Coming In As Transgender

I recently spent the better part of a week at the American Association of Clinical Endocrinologists’ annual meeting, where I picked up some fascinating pearls of wisdom. I realize this is shocking to alternative medicine enthusiasts who believe that doctors stop learning after medical school and are practicing medicine that is 20 years out-of-date. Before they even finished the preceding sentence, they were already shouting at their screens, “Yeah, sure you learned new things – whatever the makers of Synthroid wanted you to know!”

Misinformed skepticism notwithstanding, there’s one particular topic from the meeting you might find enlightening. Don’t worry – I’m not going to expound on new data showing that SGLT-2 inhibitor drugs are the greatest thing for type 2 diabetes since sliced bread – that would be boring. And, upon further reflection, I probably should have chosen a more keto-friendly idiom to describe an advancement in the field of diabetes. My apologies to the Low Carb Cardiologist and Virta Health, two of my favorite low-carb proponents.

Coming In As Transgender

Many of you know that helping transgender folks transition is one of my favorite things to do in the entire field of Endocrinology. It is incredibly gratifying to see a person progress on their path* to becoming who they were meant to be in the first place. Gender care has become a significant portion of my practice, which provides an interesting contrast to the rest of what I do – in that most of Endocrinology is a highly evidence-based field. Though the body of evidence for transgender care is increasing and improving, much of what we do in clinical practice is guided more by clinical experience and the patient’s goals, as opposed to a standardized pathway.

With that in mind, I like attending sessions – at the national level – about transgender care, because there aren’t many doctors in my region who specialize in this field. At AACE, there was a session featuring a Mayo Clinic Endocrinologist, followed by the famous Dr. Marci Bowers (a surgeon known for expertise in Genital Reassignment Surgery), then anchored by Aydin Olson-Kennedy – a Licensed Clinical Social Worker discussing the social transition.

To be completely honest, I thought the final talk was likely to be a whole lot of obvious. Since it was the last lecture of the day, I figured if it wasn’t breaking new ground, I might squeeze in a workout and shower before dinner with an old friend. Imagine my surprise when this social worker’s talk turned out to be my favorite of the entire conference. Shame on me.

Though much of what I learned is probably going to elicit a collective duhhhhh from all my transgender readers who are living this, Mr. Olson-Kennedy presented complexities of the social transition in ways that never occurred to me. I can’t reproduce his whole talk here, and I’m sure I won’t do his message the justice it deserves, but I will share a few take-home points that helped me greater understand what it means to transition.

First, transgender people need to “come in” long before they ever “come out.” As soon as he said this, it felt absurd that I hadn’t thought of it this way – especially since I see people exploring the possibility of hormone therapy for the first time in their 60s and even 70s. There are data showing that the average time span between identification and disclosure of one’s gender identity is 14 years. Family, friends, colleagues, and doctors tend to view the disclosure as some sort of starting point; they don’t necessarily appreciate the years of angst that preceded the disclosure.

This lack of understanding leads to incredibly misguided statements like: “You’re too young to make such a big decision,” or “If you’re really a boy/girl, then why didn’t you tell us when you were younger?” This places transgender people into a Catch-22 situation in which there is never a right time to come out.

Next, Aydin discussed the concepts of certainty and regret. During the coming in process, the person has a sense of what they’re feeling, but they may not know exactly how to express it, how to define it, or what to do about it. The idea that a transgender person should have absolute certainty about every aspect of transitioning with a 0% chance of regret is a fallacy.

The social and medical transition is a process that involves trial and error, like just about anything else in life. For example, I see an older patient – assigned male at birth – who is exploring a transition to female. One of his (he prefers male pronouns) paramount concerns is to not go so far as to irreparably damage his marriage. We have tried various combinations and doses of medications to help him feel more feminine, without causing significant physical or adverse psychological changes. Of course, this has resulted in a two steps forward, one step back approach. He continues to question whether he should continue with hormone therapy; if he finds that he can’t thread the needle, he is likely to choose his marriage over his gender expression. Lesson: the transition doesn’t have to be a linear process.

The last part of the social worker’s talk really blew my mind. The first 2/3 mostly presented concepts with which I was familiar, but were couched in a novel way that enhanced my understanding. The last 1/3 dealt with how it feels to bump up against society’s assumptions and expectations of you now that you’re a man/woman.

For example, a transgender male will acquire status and authority, just for walking into the room male. Sounds great, right? Isn’t it awesome that one can be respected simply for being, as opposed to one’s merits? Well, slow down, because it’s not all unicorns and rainbows. According to Aydin, the transgender male must also learn how to navigate rape culture, our patriarchal society, and male privilege.

Think about that for a minute. You’ve spent your life to this point presenting and being regarded as female. You are now presenting as male and, happily, society views you as male. But this makes you a member of the same club that has the intrinsic power to make a woman fear for her safety when you’re walking behind her on a deserted street late at night. Consider how jarring it must be to have to acclimate to these assumptions and expectations.

Along those lines, consider this quote presented during the talk, attributed to a black transgender male:

I went from the most invisible form in our society – a black female – to the most feared form in our society – a black male.

And this one from the actress Laverne Cox, a black, transgender female:

When I was perceived as a black man I became a threat to public safety. When I was dressed as myself, it was my safety that was threatened.

Again, it seems obvious to me now, but I never thought about this aspect of the social transition. So what do I want you to take away from all this? If you are a cisgender layperson, you probably have a transgender family member, friend, or colleague. Perhaps this will give you greater insight into their struggle, which can engender empathy and build better relationships – I’m pretty sure that’s what life is all about. If you’re a cisgender healthcare provider who cares for transgender individuals, awareness of this stuff should make you better at your job and help you connect with your patients on a deeper level. Finally, if you’re transgender – regardless of your profession – I hope it’s a small comfort to know that there were a lot of doctors at this AACE session. I think the medical profession wants to do a whole lot better for the transgender community than we have in the past.

*I almost used the word “journey” instead of “path,” but The Bachelor(ette) TV franchise has completely ruined the word journey for me. I’m pretty sure there must be drinking games that involve tossing back a shot every time a contestant says something to the effect of, “I’m just so excited to be on this journey and see where it takes me!” That said, after having renounced my status as a fan of the franchise and refusing to watch Becca’s season, I somehow got pulled back in for Colton’s season. It got really good toward the end, guys. Seriously.

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Image Credit: Photo by Kyle Nieber on Unsplash

7 Replies to “Coming In As Transgender”

  1. I hope you read this and will interact regarding the following issue I have been made aware of by a colleague who is a lawyer…

    [HD: I have redacted the rest of this comment, as my blog is not an appropriate forum for this type of discussion.]

  2. Dr. HD,

    Thank you so much for your recent post. As you know, I’m a transitioned trans woman and your writings and feedback have helped me so much. You’re appreciated more than you know.

    I am not sure how to say this or even if I should: I wish you’d consider removing Ms. Figaro’s comment. I considered responding directly to her but decided not to. Your blog is hardly the place for debates about the Equality Act.

  3. Thank you for this article! It sounds like that was an incredible talk. Certainly much of what you have relayed here I have heard from my trans friends. I wonder, now that people have been receiving hormone therapy for a number of years, is there any research about increased risk for comorbidities that are typically associated with cis- gendered people of the same gender as the trans person? Ie: heart disease in trans-males or breast cancer in trans- females?

  4. “If you’re really a boy/girl, then why didn’t you tell us when you were younger?” That is not so easy when you are age 5 and are holding another boys hand and are gleeful that you finally have somebody to play with. Gleeful until your mother makes a homophobic remark about you holding his hand. There are little signs that you are different. The first one might be wishing that you had your own saddle shoes and plaid skirt like your sisters. The second might be boys in the first grade calling you pansy or sissy before they even know your name. If you are non-binary I believe it makes it more difficult to zero in on what you are feeling in your younger years.

  5. “ There are data showing that the average time span between identification and disclosure of one’s gender identity is 14 years.”

    This isn’t anything I’ve heard about before and I am insanely curious about it. Do you have any recommended further reading? Heck what would I even use for terms to find this kinda of data and studies? Thanks for any response, public or private.

    1. Rachael, this is a great question. I have to admit that I don’t remember where I pulled this from, but I will assume it was from notes I took during the lecture I describe in this post. It makes intuitive sense to me, as many of my patients describe knowing “something was off” from a very early age. But they typically don’t come out to family and friends until their late teens or later.

      This may be changing nowadays, for multiple reasons, so I wonder if the time-to-disclosure will naturally decrease as the environment becomes more hospitable for transgender people to talk about what they’re feeling.

      I will also assume that the data referenced in the lecture and my post will probably be a bit “squishy,” in that these things are hard to study, due to recall bias and other inaccuracies inherent to this type of social science research.

      If I were to search Pub Med for this kind of thing, I would use terms like gender dysphoria and gender identity, for starters, and I would filter for review articles, initially. Then I would read a couple of review articles and look at the references in those articles, selecting the studies that look like they would address the time to disclosure issue.

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