Building Bridges

'25 de Abril' Tagus Bridge by Alvesgaspar - Own work, CC BY-SA 3.0,

’25 de Abril’ Tagus Bridge (Lisbon, Portugal) by Alvesgaspar – Own work, CC BY-SA 3.0,

The old Roman emperors, between Julius Caesar and the beginning of the Christian rule, had as one of their titles Pontifex Maximus, a title which later was used by the head of the Church of Rome. Even today it is one of the titles of the Pope; His Holiness uses @pontifex as his handle on Twitter.

Pontifex literally means ‘builder of bridges’. In the case of the heads of the Roman Empire, and, later, of the Church of Rome, this didn’t mean that they built a lot of bridges (although that certainly happened during the Roman Empire), but rather that symbolically they forge ties between different factions. They somehow represent the moderate faction which tries to bring all others to the common ground. They are the ones that recognize that a river has two margins, but you’re only aware of the margins when a bridge connects them (I learned that from my wife, an architect!). It also means that, no matter how different we might be, we can always have a ‘bridge’ to join us together.

It is for that reason that the European Union features a lot of bridges on the Euro banknotes. The bridge symbolically shows how the European countries, in spite of their historical antagonism, and different languages and cultures, are at least making an effort to come together. And, of course, it shows the heritage from the old Roman Empire (which bound almost all of Europe together under a common rule) and the Church of Rome (which replaced the Roman Empire in forging ties across all European countries, imposing a certain cultural uniformity through religion, at least until the 16th century or so).

We might not agree with the symbolism, or its necessity. Some might even find the symbol offensive in a way, especially when set in the context of those who have claimed the title of ‘bridge builders’: after all, the Roman Empire was a well-oiled bureaucracy supporting a tyranny, with an economy that flourished mostly thanks to slavery; and the Church of Rome most certainly emulated some of the worst aspects of the Roman Empire, at least in wielding power through oppression, exercised ‘in the name of God’. So the bridge as a symbol also has negative aspects — but that is true of almost all symbols. Remember the swastika, a traditional ‘good luck’ symbol across Indian and Chinese cultures, but absolutely forbidden in the West because of its unfortunate connection to Nazism? There will always be good reason to accept or reject ideas and symbols, although the whole point of the bridge symbolism is to show that, through human skill and labour, we can endeavour to join opposing factions and always find some middle ground. It might just take time and a lot of patience.

Identity as a fundamental right

Who, me?But this essay is not about symbolism or history; it’s about the next upcoming battle for the transgender community, one that is being spearheaded by a few countries, where activists have been successfully pushing for the recognition of ‘identity’ (specifically in this case: gender identity) as a fundamental and inalienable human right.

The reasoning behind this ‘demand’ is relatively easy to understand (even if so many people might disagree with it, or with the need of having it as a fundamental right). Right now, in most countries in the Western world, ‘gender identity’ is something that is, at best, validated by a doctor. In other words: someone who identifies with a specific gender is not allowed to get it legally recognized, unless a doctor agrees with that identification. Because ‘identity’ is something uniquely individual, and happens inside one’s mind, it’s hard to understand why exactly an external entity — namely, a doctor — needs to ‘validate’ it.

Consider some stupid examples, where the issue makes no point. We don’t need a veterinary to call a dog ‘dog’. We can all look at a dog and claim it to be a dog. We don’t need to register our dog at a veterinary, just because we might have confused it with a cat somehow. But we also don’t need a mechanic to tell us that our car is, indeed, a car, and not a motorcycle; we can tell the difference, even if we’re not experts in the field. And the same happens to a lot of things, where we do not need ‘expert advice’ to identify something for us. In general, we can be rather good at identification, even in the absence of an expert.

There are other fields where this is not true. The ‘flu (caused by the influenza virus), the common cold (caused by the rhinovirus, quite different from the influenza virus), and a rhinitis (usually not caused by any virus, but merely allergic) all have quite similar symptoms. The difference is mostly in the quality or intensity of some symptoms over others. But all of them are easily ‘cured’ with home medicine — hot tea, lots of liquids, staying in a warm bed, etc. — which will eventually help to alleviate some of the symptoms. In general, however, all these diseases will ‘cure themselves’, and only in extreme cases they need medical assistance. But we’re quite aware that this is not the case for a lot of diseases, where we really need a specialist to diagnose our ills and to give us some prescription for medicine. The same, of course, happens in most fields. We might be able to build our own single-floor house by ourselves, but if we wish to build a 50-floor skyscraper, we certainly require architects and civil engineers to tell us what to do. Anyone can do simple maintenance on their cars (or motorbikes), but if the engine refuses to start because we forgot to regularly put lubrication oil in it, then we really need an expert to repair it. We can easily quench the flames on a frying pan left too long on the stove, but if the whole house catches fire, that’s beyond our ability to stop — we need to call the fire brigade. And so on, and so forth.

Civilization, indeed, is the movement towards a society that can afford people that become specialists in several different fields — from artisans and craft workers to bankers and university professors. That doesn’t mean that we have to abandon all efforts to solve even the simplest things! It just means that when we reach a certain threshold, we need professional advice from specialists to help us.

It’s rather easy to understand that, and most people will have no trouble in accepting that this is how our society works best (except perhaps for a few survivalists!).

Therefore, we’re socially conditioned to think that it’s up to doctors to diagnose complex conditions, which, these days, mostly means pretty much everything beyond a sore throat, a cold, or a stomach ache. Self-medication is actively discourage, because we all know that the incredible longevity of the human species, achieved in merely a century or so, has come from scientific research — specifically in areas related to medicine and nutrition — which enabled us to survive well beyond the expected average lifespan for humans (roughly 40 years). Note that these advances in medical science do not affect humans only. Our own pets also live far beyond their natural lifespan: a cat, for instance, will usually live 6-7 years on the street, but properly taken care of at home, they easily live twice that long (and it’s not unusual for them to live up to two decades). It’s not surprising, therefore, that cats mostly die from diseases quite similar to our own ‘old age’ diseases, i.e. kidney failure, cardiovascular failure, several types of cancers, and so forth.

But back to doctors. They have achieved a certain ‘mystical’ status — one that the class as a whole actively promotes! — because medical science, in general, has prolonged life by curing almost all common diseases (and working on curing the uncommon ones). This, in turn, led us to take their word on a lot of ‘recommendations’ they make. We might disagree with many of those recommendations, but at least we implicitly accept that they have the ‘right’ to make recommendations.

Gibson's Law (Image by Jim Hartley @ Zazzle)

Gibson’s Law (Image by Jim Hartley @ Zazzle)

Medical science is also the field of science that researches more and publishes most, compared to other fields. This should not be so surprising — after all, it’s the result of such research that directly benefits the whole of humankind, by allowing them to get rid of most ailments and achieve a long, healthy life. But this tremendous output of research results also shows that in many cases, researchers do not agree with each other — something which is perfectly normal in science!

The point here is: just because doctors might be experts in their respective fields, do we really want them to dictate ethics and morality?

The question, of course, is loaded — if PhDs do not always agree with each other in terms of science, how can we trust that they will agree when they are stepping outside their field of expertise?

Effectively, this is pretty much the argument made by those who are fighting for the right of affirming one’s gender identity without any need of having doctors confirming that identity.

The problem of perceptions

The recently Oscar-awarded movie Room (2015) shows how one’s perceptions are completely changed by one’s environment, and of course this is not the only movie that shows that. We might be absorbed by completely ‘alien’ ways of thinking following the deranged mind of Dr. Hannibal Lecter in The Silence of the Lambs (1991): even though we might not empathize with such a mind, we can at least get a small glimpse on how this mind works, and understand things from its perspective.

Gender dysphoria, as I wrote on an earlier article, rarely comes alone by itself. Rather, it is often accompanied by mental disorders such as depression, anxiety, trauma, and so forth. While all these other disorders can be cured with relative ease (in the sense that they do respond well to medication and therapy), what they all have in common is that they change the way the brain works. I’m deliberately re-stating this, over and over again, because many people simply think that those disorders are like a ‘flu that eventually will disappear and leave your body as it was before. Many classes of mental diseases are not like that: they are actively changing things at the neuronal level, forcing the brain to work under a completely different chemistry, which makes neurons recombine differently, or synapses fire under strange circumstances, and so forth. The brain is supposed to be able to change the way it works by itself (that’s what happens, for example, when we are under an adrenaline rush, as I also described earlier on this blog), and this still seems very odd for us who are not trained neurosurgeons: it’s as strange as if our doctor told us that we have grown a fifth heart chamber, or that our intestines have grown an extra metre or two overnight. While, in fact, many of our organs can change themselves, and we might even accept that, when we talk about the brain changing itself, we usually feel queasy about it. After all, the brain is where our mind resides, and our mind is tied to our self, so we’re not exactly happy to know that something we see as being ‘stable’ over all our lives can suddenly be affected by a change of brain chemistry and structure. How will that affect our perceptions, most notably, our perception of self?

We can all have the experience of what happens to our perceptions (and even our perceptions of self) when we drink alcohol, a typical (and easily available!) drug which also changes the way the brain works. Our perceptions get clouded, and our sense of self changes — in some cases, dramatically so, like with certain very introverted and shy types who, under the influence of alcohol, become extroverted and bold. Alcohol diminishes social awkwardness, and makes us lessen (or even lose) the ability to evaluate risk — that’s why we do bold and reckless things when drunk — all of which are clearly changes of perceptions, both of the ‘exterior world’ but also about ourselves.

Because of that, we are supposed not to make serious decisions when drunk. We’re not supposed to come to our jobs drunk, exactly because our altered perceptions and abilities might render us unable to do our jobs (and instead pick fights with fellow colleagues!). Judges don’t pronounce sentences when drunk. And we’re not supposed to drive cars — or accept marriage proposals! — while drunk. In other words: because our society has long ago established the link between altered perceptions and being drunk, we have created a lot of social conventions to deal with that state of mind — in essence, making sure that our decisions made when drunk are not taken seriously.

The same applies to certain severe mental disorders, where we have created means to disallow those people to participate in society (in other words, we have to lock down psychopaths, for example, because they are unable to function in our society due to their deluded perceptions and a non-functional mind which believes such perceptions), either temporarily (until they get cured) or even permanently (in such cases where no treatment exists for them). But we also consider that elderly people who have contracted any sort of dementia might slowly progress to a mental stage where they are unable to take care of themselves and make valid decisions. So, once again, society creates mechanisms to deal with such people. For example, a psychopath suffering from mania and paranoia still remains a citizen even if they have been locked up (for their own safety and for the safety of others), but they cannot vote in the next free elections, much less be a candidate (because we know we cannot trust their judgement). People with dementia are not allowed to drive a car, but they certainly deserve all the rights and protections granted by laws to assure they get proper care and treatment.

It becomes harder with things like trauma, depression or anxiety (just to name a few examples). These mental conditions are not always ‘extreme’ in the sense that they become a menace to society (or themselves), unless these conditions push them to suicide thoughts or self-mutilation, in which case they will very likely have to be transferred to an institution to take care of them until they recover. But otherwise, we actually treat them as if they had a common cold: a bit of medicine, a bit of therapy, and eventually they will feel better again. In the meantime, we allow them to participate as full members of society and expect them to fulfill their roles as such. A little bit like the common cold, we admit and recognize that it’s a disease caused by the rhinovirus, but it’s not lethal, just a nuisance, and we expect people to go on with their lives if they just suffer from a cold — since it will go away by itself anyway, after a few days, no matter what kind of treatment we follow.

I must confess I was in the same category of people believing such things. It was for me an eye-opener when, under the influence of depression, I was experiencing things in quite a different way than others around me — not only that, but I was actually experiencing things differently from what I used to experience. And that, once realized, was truly weird.

How did I notice those things? I was lucky — my wife is very straightforward with me. She simply told me things like ‘you used to take half an hour to do that; now you take an hour’. I would argue with her that only half an hour had elapsed, but she was right — the clock didn’t lie. What happened? My mind was tricked in believing one thing, when the so-called conventional reality was quite a different thing. And the more I started observing, the more I noticed that my mind was… ‘unhinged’. The closest analogy I can give is like being drunk, but fully conscious that what you’re experiencing while drunk is not what you experience when sober. With the difference, of course, that sooner or later you’ll get sober again, once the alcohol was flushed out of your system and stopped affecting your brain. Under depression, of course, you wake up every day with those altered perceptions.

Some of those perceptions are clearly delusional; others are merely annoying (like being aware that you’re taking much longer than usual to complete simple tasks). You can cope with the latter — for example, making sure that in your schedule you put some extra time on all those tasks that you used to do much faster — but it’s much harder to cope with the former. In essence, it means asking yourself: how much of what I’m experiencing is actually true?

Really? Maybe. Probably. I don't know.

Really? Maybe. Probably. I don’t know.

That led me to be brutally honest with the psychologists (and some doctors) I’ve consulted with. I have no doubts about depression, because anyone can list the symptoms they observe in me, and independently validate them. But I also suffer from gender dysphoria, and I can list those symptoms as well. The problem is that I know that a lot of what I currently believe in is delusional, because the depression is affecting my perceptions and the way I reason about them. So when someone asks me, ‘are you male or female?’ my most honest answer is ‘I don’t know’. In other words: my current altered perceptions tell me that I’m ‘female inside’, but can I seriously trust my own perceptions in this state?

The dilemma

So we come to the point where we reach a paradox.

On one hand, we should listen to the doctors with an open mind, but also with a healthy dose of skepticism: they might be experts in many fields, but they cannot ever know what people really think inside their minds. Letting doctors handle all the legal requirements for someone to affirm their gender is probably not a good idea. After all, in all other cases — affirming one’s age, ethnicity, skin colour, religion, political affiliation, whatever — we do not need any doctor to tell us that!

On the other hand, those who are afflicted with gender dysphoria might have their perceptions so skewed — not necessarily because of gender dysphoria itself, but from other mental conditions usually associated with gender dysphoria — that their self-identification might simply be wrong. How can they tell? We can always look at the extreme case: someone who is paranoid will believe anything that convinces them that ‘they’ are out there. If you’re paranoid and reading this, you might be thinking right now: ‘Sandra is one of them. That’s why she’s writing these things to persuade me that my mind is not working right. I know I’m fine. It’s people like Sandra who are really, truly after me and use sophisticated arguments to trick me in trusting them… but I’m much more clever than that and refuse to be tricked!’

Gender dysphoria, by itself, is not truly a ‘disease’, but merely a condition that cannot be ‘cured’ (except with transition). But it comes so often together with many other afflictions that it might be impossible, for a person who is suffering from so many conditions, to be absolutely sure about what they are ‘inside’. The job of the doctors, in this case, is to eliminate all other (treatable) conditions and see what remains.

We have very good research on this subject since the sad ‘experiments’ made in the 1950s to attempt to try to change one’s sexuality/sexual orientation and gender identity. We know quite well that you can get pumped up with hormones and be subject to electroshock therapy, aversion therapy, or any kind of torture, that the ‘inner feeling’ of your gender (and sexuality) will not go away. The best example of this happens every day, when a MTF transexual completes their transition: the reduction of testosterone levels will affect their libido strongly — to the point that it might completely disappear — but their inner sense of being female will not fade, much less disappear. In fact, one of the possible diagnosis for gender dysphoria is to submit the person to hormone therapy, beginning with chemical castration. If the gender identity remains solidly firm, then it’s quite clear that the person does, indeed, identify with that gender. If the gender identity becomes more and more questioned, as chemical castration progresses, then one might consider very strongly to question if that gender identity is actually correct or not (for example, a male identifying as female might actually be merely gender fluid, and a full transition to female might make them ‘lose’ the ability to continue to present themselves as a gender fluid person).

On the other hand, of course, we have had a long history of misdiagnosis — either due to outdated ethical/morality issues (an attitude that prevailed pretty much until the 1960s at least), or, more recently, because doctors, in their eagerness to help their transgender patients, misinterpret their symptoms. Thirdwaytrans is a typical case of doctors failing to diagnose his condition correctly, confusing symptoms caused by trauma with gender dysphoria, and, as a result, thirdwaytrans had to endure half his life of suffering in the male gender, and the other half of his life was spent suffering in the female gender — until finally his condition was correctly diagnosed and he de-transitioned, apparently with great success (at the mental level at least, since it’s obvious that his twice-modified body might be a mess…). So we cannot fully trust doctors to be able to figure out things. In spite of many suggestions to the contrary, there is no ‘magic’ test that you can perform to be sure that you are ‘male’, ‘female’, a mix of both, or none — many tests exist to help doctors to establish a profile that might be helpful, but, ultimately, only you can know what you feel deep inside yourself… assuming that your perceptions are not clouded for some reason!

A solution?

One of the biggest problems with all surveys that are published about crossdressing and transgenderism/transexuality is that they rely on self-diagnosis. Psychologists, psychiatrists, neurologists, sociologists, anthropologists, and many other researchers, are well aware of the limitations of such surveys. The very wording of the questions can subtly induce the participants to answer not according to what they truly feel and think about themselves, but according to what they believe that the researchers might wish to hear. There is this old adage spread among medicine students: ‘Patients LIE!’. I would not be so hard on people who are suffering: they might not even be ‘lying’ at a conscious level. But they can certainly give wrong answers — even to themselves! — which come from either deluded perceptions, or peer pressure, or social conformity.

Here are a few typical examples. On older surveys (and this form is still very popular today!) it was customary to ask, at the very beginning, the age, gender, and ethnicity. This immediately conditions the person to answer subsequent questions based on the social stereotypes for a person of that age, gender, and ethnicity. This was discovered — and scientifically proved! — around 2007 or 2008 (I forgot the name of the article published about that research, and it has been notoriously hard to retrieve it again), which means that practically all research before that, which include intimate/personal questions at the very beginning, are highly likely all wrong. Even today I keep getting surveys, questionnaires, and interviews, where they still follow the old model of asking those questions at the beginning. I always raise an eyebrow when reading them — and make a note on the comments section.

Specialists in clinical sexology treating transexual individuals have been well aware of this problem for a few decades — at least since the mid-1990s. There are a lot of reports and books studying trangenderity in that decade when it was very clearly found out that transexuals desiring transition would know very precisely what to answer to the doctors’ questions, in order to get an approval. Back then it was not universally accepted that someone who only starts to question their gender in adulthood was really gender dysphoric — in most of those cases, the doctors might just view the obsession with transition exactly like that: an obsession, one that can be cured by conventional means, and never with transition. As a consequence, late onset transexuals had no choice but to completely (and consistently) lie about their whole lives, presenting themselves as having ‘always’ felt as ‘women trapped in male bodies’, since early childhood, and having repressed those feelings for decades. Thanks to the emerging World-Wide Web, and social networks established between those who were transitioning and those who were seeking advice, it was rather easy for people to exchange information about what kind of questions would be asked, and what would the appropriate answers be in order to get an approval for transition. Many managed to transition that way — to regret it afterwards, to great bafflement by the scientific community.

Nowadays doctors are much more clever, and they are trained to understand that transgender people will come to their appointments well prepared. They will have read everything they could about their condition — a typical ‘symptom’ of transgenderism is the obsessive need to find information about one’s condition  — and are probably active in many online transgender communities. They have exchanged their views with others who also have gender dysphoria, and know what they feel, and how to express those feelings when talking to a doctor. So, unlike other conditions, in this particular case — diagnosing gender dysphoria — doctors are aware that their patients will be often as well informed as their doctors, and that ‘earning’ the diagnosis of gender dysphoria is almost like a trophy to be displayed among the community. Gender dysphoric people are often narcissistic, or at least require some peer validation/confirmation with regularity, and, as such, they wish others to know that they, too, are ‘officially’ gender dysphoric. So they will work hard to ‘earn’ that trophy. It’s like those games with their ‘achievement badges’: when transgender people talk to doctors, they see it as a sort of competitive game, where they hope to get diagnosed as quickly as possible, and be submitted to as many treatments as possible, to show the rest of the community about how committed they are, and how much they have progressed.

Doctors know all about this, too.

I remember that one of the very first questions that my psychologist asked me, not surprisingly, was if I felt that I was a woman. I knew it would be stupid for me to blatantly lie about it. So I answered: ‘Yes, I think that I’m female, but, because I’m also depressed, I cannot trust my feelings and thoughts; so my primary motivation to come here is to get rid of the depression, and then we can talk about my gender dysphoria’. This made my psychologist delve deeper in the subject, and ask me if I thought that after the depression was cured, I would be willing to undergo transition.

Again, I was honest with her. I told her that there would be nothing that I wouldn’t love more to do; but I have to be a realist and a pragmatist. I don’t look nowhere near like a woman, and I would never pass, no matter how much surgery I do and how many hormones I take. I would ruin my life, lose my job (I still had a job back then), get ostracized by wife, family and friends, and had to start my life from scratch, probably in a different city or even country. And face transphobia no matter where I lived, since clearly there is no ‘magic’ that can turn me into anything remotely looking like a woman — not even a very big-boned, large-framed, ugly woman. So I had to be honest with myself and say that this is truly not an option for me.

My psychologist just probed deeper and more stubbornly, and asked me to imagine a scenario where I would be universally accepted after transition, and assume that medical technology could do wonders with my body. Would I transition?

I answered that I’m very fond of science-fiction scenarios (being a humble SF writer myself, with a published book and some short stories), and although her scenario was utterly utopian, I would most certainly never hesitate and sign the papers for transition right there. But I was aware that the welfare state would not even give me a stipend during a jobless (and unemployable) transition, so I had to forget all about those utopian ideas and work with what I got, in the real universe.

Was that the right approach for me? Probably not, but what would be the point of creating a false narrative about myself? My business is not to be happy because I ‘tricked my doctor’, which is pretty much pointless. I wish only to be cured from depression, be able to work again, and enjoy life. I would enjoy it so much more as a woman, of course, but I’ve managed to drag myself through half my life pretending to be a male, and survived it so far. With a little help from the doctors, I might manage to continue my pretense until I die.

Ok, enough personal information! After all, it’s just anecdotal evidence; every transgender person talking to their doctors will have a different approach — all I recommend is to be absolutely truthful with them. In all honesty, after that first session, I thought that I would have blown any chance of being labeled as ‘gender dysphoric’, and, frankly, it wasn’t so important for me any more: all I wanted was to get rid of the depression, and as quickly as possible, and if that means being stuck in this body forever, because I’d never ‘qualify’ for transition, then so be it. Ironically, it was almost a year after the first session that my psychologist slipped out that I was, indeed, being flagged as ‘transexual’ for all legal and medical purposes, even though there are a lot of things to work out first before anything gets done about that ‘label’.

My whole point here is that my case illustrates well the difficulty in establishing a valid ‘confirmation’ of one’s gender identity. On one side, I feel I’m a woman inside, so something went wrong inside my brain at some point. On the other hand, I’ve been acting the role of a male for so long that I’m actually relatively good at it; even when I do something that is outright unmale-ish, nobody will notice. They just look at my body and assume I’m male, no matter what I do. So, from my personal point of view, what cross should I check on my legal documentation? F or M? I don’t know. I play it safe and always check M.

Looking at the other side of things, it seems that the doctors take me more seriously than I do myself, and allegedly they have concluded that I exhibit symptoms of gender dysphoria, but because this particular institution never applies a ‘one-size-fits-all’ solution to their patients, they might have something in store for me (I’ve got a few surprises in the past year!). But if they had the sole authority in deciding for me what checkbox to tick, what would they do in my case? F or M?

Now let’s take the opposite case, and, again, I can draw from experience. A couple of good friends of mine, like me, are not especially ‘female’ — not in their behaviour for sure, but also physically they are not very female-ish. They have several advantages over me — they’re shorter and much thinner, and that always helps! — but their minds work in a clearly male way. Nevertheless, both strongly feel ‘female inside’. One of them has completed her transition, which she demanded from doctors as quickly as possible, and now struggles every day with being misgendered, which erodes her self-esteem, while looking for a job (and facing transphobic refusals). Was that a wise decision? Is my friend happier now? It’s hard to say.

The other friend wishes as eagerly to be legally labeled as a ‘woman’ and start HRT as soon as possible. But she has a little more wisdom and has told her doctors not to ‘rush’ things. In order to test her, the doctors created a scenario where she would be able to transition in half a year and start her life as a woman — in fact, they were already looking for dates for surgery six months in the future! My friend, very wisely, told them that she didn’t want to rush things at all. She could wait five, six years. Even though she’s excited about the whole idea, and very happy to have found such understanding doctors who apparently wish her to transition as quickly as possible, she has heard about many ‘failures’ in the past, and can afford to go more slowly through her own transition. Is she happier now that she started transition? Well, I would say ‘yes’. For her, it’s more important to be doing something about her condition than the actual result (and I will address this singular way of thinking in my next article!).

In both scenarios, we see the problem of having gender being labeled by the self and/or by the doctors. Are the doctors right in labeling my second friend as ‘female’? Are they right in rushing her through transition? How can they be so sure that they’re doing the right thing to her, after only one session of therapy?

Again: anecdotal evidence is not worth much. There are hundreds of thousands of successfully transitioned people out there in the world, fully enjoying their lives. There are probably millions more following their steps, or at least looking for a way to achieve a better life. Looking at just a handful of cases and trying to make a judgement based on that is simply not ‘scientific’. At best, it allows me to formulate some hypothesis, but I cannot make any claims for sure.

My point here is that neither the person itself (because their judgement might be clouded due to other mental conditions), nor the doctors (because they can make mistakes and sometimes be ‘persuaded’ or ‘convinced’ by clever transgender people, who know what doctors wish to hear), are good at figuring out what gender one person ought to be labeled at. However, if both work together, they might achieve something that is greater than the sum of the parts!

The right to affirming one’s gender identity is…

… fine, if one can be guaranteed to be making that decision of their own free will, full in power of all their mental faculties, and being able to understand all issues and consequences of their decision.

What this mostly means, in practice, that I’m proposing a slightly different approach to what activists are suggesting (or have actually implemented in countries like Malta, Ireland or Argentina), but also a profound change from what the current situation is in most countries where transition is allowed.

Activists demand total freedom. That means that it’s up to each individual (as long as they are adults!) to decide, on their own, and without any way to stop them, what gender they belong to. Period.

As said, this is fine if and only if that person has an unclouded judgement about the consequences of their decision. But let’s assume three different scenarios. In the first scenario, someone who is suffering from either depression or trauma ‘decides’ to change their gender legally (and even refuses to get treatment for their depression/trauma/whatever mental condition they might have). In the second scenario, someone who is a MtF crossdresser decides to legally change gender, ‘just for the fun of it’ (i.e. because they can), but have no intention to live as women whatsoever. And in the third scenario, a male who finds himself jobless applies for a legal gender change because there are positive discrimination laws to keep a more fair and balanced number of men vs. women in the workplace; by changing their legal gender to female, even though they have no intention to transition or even to dress/behave like women in the workplace: the ‘legal gender change’ is just a sneaky way to get access to jobs (or other positive discrimination laws, like financing new small businesses for women, and so forth).

And no, I’m not even going into the situation of a clearly male person jokingly changing their legal gender to female to be able to enter women’s bathrooms legally, without them having a chance to exclude them — after all, being ‘legally women’, they are entitled to use the women’s toilets and bathrooms (they might also use the men’s toilets anyway, since they will present and behave like males anyway, and nobody will check their ID in a male toilet if they look male…).

Let’s see the hidden flaws of the scenarios. The first one, of course, is pretty much what the advocates for the freedom of right to decide one’s gender are fighting for: they don’t want doctors to have a saying in one’s personal decision. No matter if whole panels of sexology experts ‘decide’ that such a person should get treated first, and transition later, activists nevertheless want the power of decision in the hands of the transgender person — no matter what.

Do I look male to you?The danger here, of course, is that such a person might not be able to live as the gender they identify with at all. Sure, as said, in the case of misdiagnosis, some people might definitely be able to sustain the ordeals of living as a different gender than the one they were assigned at birth, but let’s be honest here: not all doctors are incompetent idiots. A few may make mistakes. A few (especially in the US) might have moral and ethical grounds for preventing transition. But, in general, most doctors in this field will have a reasonable good background and experience and be able to figure out what’s best for their patients — together with them. Ignoring that means that untreated conditions will simply haunt the person forever. A MtF transgender person suffering from anxiety/irritation will continue to be aggressive after changing the letter M to F on their ID cards — the legal change will have absolutely no effect in their behaviour. It might just make things even harder: someone who is aggressive (due to anxiety), refuses treatment, and tries to get a job — being constantly kicked out because of their attitude — might believe that the problem is the ID card. Once they change M to F on the ID card, they now believe that they will have no more problems in holding a job. But, of course, they continue to be aggressive, because that condition did not change — and they get fired over and over again. Now this person will turn her hate and aggressivity towards transphobes, and miserably complain about them (eventually even trying to sue former employers — but to no avail, because I’m pretty sure any company will be able to demonstrate with witnesses that the problem is not the person’s perceived gender, but rather their aggressivity and attitude towards others — colleagues and clients alike).

What this means is that blindlessly following the route of transition without any medical support whatsoever just leads to a life of nightmare — assuming the person already had previous mental conditions before their transition. Those will not go away. At some point in life, they will wonder why their lives are so miserable — even if they actually got the desired letter on their ID card! That is unfortunately one reason (out of many!) for the very high suicide rate among transgender people — lack of medical care, in this case, psychological and psychiatric support before, during, and after transition. It is necessary for a vast majority of transgender people. Although almost all of them will deny the need — and those are the ones who are most vocally ‘demanding’ a change of the laws.

The second scenario (as well as the third) exemplify a different issue, which is what exactly is meant by the letter F or M on the ID card. We could endlessly argue what makes someone ‘masculine’ or ‘feminine’ and never reach a conclusion; obviously there are genetic females who behave in very masculine ways, and males with XY chromosomes and a normal phenotype development for their biological sex who nevertheless exhibit a lot of typical (or should I say stereotypical?) traces of feminine personality and behaviour. Gender is a spectrum, no matter how people deny it — even in the strictest Muslim fundamentalist countries, women hiding behind their burqas will have both so-called masculine traits and feminine traits — and so will the males in those societies.

The point here is that nobody is ‘forced’ (nor even ‘pushed’) into fully accepting a role that is congruent with the F or M on their ID cards! Nobody can prevent an F to wear T-shirts, jeans, sneakers, and a baseball cap, if they wish — after all, genetic women all over the world do that every day without anyone paying attention to them. Similarly, just because someone has an M printed on their ID card, they are not forbidden to wear a dress in public — or wax their legs. After all, hundreds of millions of men in the whole world wax their legs (or even their whole bodies), take care of their eyebrows, and paint their fingernails (even if only with a transparent polish). There is nothing in that M or F on the ID card that magically changes the rules.

If in my country I would be allowed to simply go to an office, present my ID card, and ask the clerk to change the M to an F, ‘just for the fun of it’, and nobody could prevent me from doing that, then what’s the point? The M or F become completely pointless. They don’t mean nothing. They are just a convention, but by allowing everyone to tick the box they prefer, it becomes irrelevant what is one’s choice: we would empty gender of its whole meaning.

That might be indeed the whole point of gender activists, i.e. forcing society to become officially genderless. And why not?

Well, because mostly of the third scenario. Women, at least in our slightly-more-enlightened-than-average societies, are in the majority — but continue to be discriminated in countless ways. This is naturally getting better and better since at least the 1960s, but it’s still not enough. There are still more unemployed women than men. They also earn, on average, less than men — when doing the same jobs. They have less chances to compete for the same job vacancy — or for promotion — even if they have exactly the same qualifications and experience: on average, the men will be picked first. So what did our societies do? We establish laws that discriminate women positively, i.e. that allow them access to some benefits that are not available to men. And no, I’m not thinking merely of the issues related to childbirth (or breastfeeding in public), but things like job quotas per company (or public services; or even political parties), or special lines of credit for investing in their own businesses. There are a lot of tiny things like that which we have been promoting to give women a fairer chance to compete.

Now imagine, for instance, a country where single mothers are given a special subsidy to take care of themselves and their children. A man, having a child at their care, could simply apply to change their legal gender from M to F, becoming legally the child’s ‘mother’, and therefore being allowed to apply to that special subsidy. What would be the consequences of that?

I know the outcry this would generate among feminists! They would go haywire, seeing how suddenly hordes of men would start changing their legal gender (even though they would continue to present as males, of course) just to get access to benefits that were intended for genetic women. Imagine a huge bank, where 90% of the staff is male, and the board is not interested of hiring women, because of a misguided, chauvinistic, and sexist ‘belief’ that men are better at banking than women. So they could simply ask half of their male staff to legally change their gender. Now for the purpose of the statistics, they would suddenly have 60% of ‘women’ and 40% of men in their staff — and probably even be able to apply for benefits from the state for employing so many ‘women’ — when in fact they would all be genetic men who had just changed their legal gender to ‘female’.

This would simply stop making any sense. The issue about having an F or a M on the ID card is not merely a question of ‘implying’ a certain type of social convention upon those who have the F or the M. It is important for statistical purposes, and it is also meant to allow positive discrimination laws to be passed to give women a fairer chance in this male-dominated world. We can argue if there is any real progress being done (I seriously believe there is!), or what could be done better (or more!). My point here is not to criticise if enough is being made to make our society more fair towards women; I just wish to point out that getting rid of the F/M marker on the ID card makes no sense as long as inequalities between the genders exist. And these will be with us for a long, long time! So we must be pragmatic: we do not live in a genderless society yet, so we need to protect women (yes, transwomen too). And in the particular context that we’re talking, we have to make sure that the ‘privilege’ of changing one’s legal gender freely is not abused.

How can we prevent that abuse? Well, unfortunately, that means that someone needs to validate the legal gender change first.

Working with doctors, not against them

I propose a simple and straightforward strategy. Remember, the premise is that people who are in full command of their abilities ought to be able to freely change their gender at will, through a simple bureaucratic procedure, so long as they affirm upon word of honour that they will present and behave themselves according to the appropriate gender role.

What this means in practice is that it would require a medical examination first resulting in a medical report confirming that the person has been found medically without any condition. Such a report would then be presented to the clerk making the legal name and gender change.

But wait! — I hear you crying — isn’t that exactly what we wished to prevent? Doctors might, after all, make mistakes, persuade people against their will, and so forth? Isn’t that precisely what activists do not want to happen?

Actually, no, there is a subtle difference. Under this proposed scenario, the person doesn’t even need to tell the doctor what they are intending to do. All they need is an evaluation of their mental situation. I’m pretty sure that it would not be tremendously hard to get a full exam of one’s mental abilities; after all, a lot of companies submit their employees regularly to such exams – for example, air traffic controllers and airplane pilots have to routinely get a mental health check, and I’m sure there are many others which do the same. Therefore, such exams might be seen as ‘routine’ and not really very hard to do.

With that document in hand, the transgender person would simply go to the nearest office to change their names and gender on the ID cards and other legal documentation. They would also have to sign a declaration of honour that they would agree to present themselves according to the gender they identify with, assuming the gender role appropriate for that gender. Why a declaration of honour? Well, that simply means that if this person intended to abuse the system, and get caught at doing so while clearly presenting themselves as a gender that does not correspond to what they have on their ID card, then they would be liable to criminal charges (impersonation, fraud, whatever…).

Of course this raises a problem: what if such a person wears gender-ambiguous clothing? Or unisex clothing — a pair of jeans, a T-shirt, sneakers? Well, I generally have a straightforward way to deal with ambiguity: just leave it in the hands of the court. Judges and lawyers exist because laws are ambiguous; if they were not, then we would not need a judicial system at all. I mean, if someone who is labeled ‘F’ on their ID card, but usually presents as male, and then enters a female bathroom dressed in jeans, T-shirt, and sneakers, and the women inside complain — upon which this person shows that they have the ‘F’ on their ID card and therefore are allowed to enter this particular bathroom — then it would be up to the courts to decide. There would be a complaint; and the judges would need to determine what the intent was to enter a female bathroom clearly not looking female at all. And, of course, the defendant’s lawyers would try to prove in court that ‘clothes do not make the gender’ (which is absolutely correct!). I believe, however, that if such a law was passed, then the courts would be very harsh in dealing with so-called ‘ambiguous’ presentations, when the intent is clearly to abuse the system.

So far, so good on the legal aspect. I’m well aware that my proposal is not ‘perfect’, and it still allows several loopholes to be exploited, and is certainly possible to abuse the system that way. But at least it provides some safeguards. People who are clearly transgender would not even need to tell that to the doctors making their evaluation, the doctors would only need to confirm that the person had no incapacitating mental condition. So the doctors, if they were ‘kept in the dark’, could not be influenced negatively (due to personal morals, etc.) by transgenderity. On the other hand, a person who assumes that they are clearly transgender, and wish to present themselves as the gender they identify with, would have absolutely no problem in signing the declaration of honour. In fact, they would probably even love to do so and religiously keep a copy of it…

Then there is the other aspect: the clinical side of things.

The most radical advocates want to turn doctors in simple clerks signing papers to do what they want. The argument here is that doctors are the ‘gateway’, the obstacle to their desired transition, and that gender dysphoric patients usually know much better what they want and what they need to reach their goals than doctors; so doctors ought to get completely out of the picture.

In a sense, this is a bit what already happens if you are rich enough: there will always be a doctor, somewhere in the world, which will provide you with what you want, so long as you can afford the long trip and the price they charge. So, effectively, if you really want to transition, against the better judgement of your doctors, you just need to switch countries — or countries — to find the ‘right’ doctor.

This, naturally, is socially unjust, because poor people who suffer from gender dysphoria are unable to access the same kind of treatments, and have to submit to the will of their doctors. Activists therefore wish for doctors to automatically prescribe whatever hormonal treatments (or surgery) the patient wishes, independently of their own (expert) opinion on the subject.

As you might imagine from the rest of this article, I have some serious issues with this approach.

There is, to my knowledge, no area in medicine where the patient ‘demands’ a specific treatment from the doctor, just because they — the patient — ‘know best’. While it’s true that many doctors might have prejudices and be transphobic (or merely uninformed), it’s also true that the majority of doctors will be in a much better position to diagnose a patient, and recommend the appropriate treatment. The argument here is that a cisgender doctor is unable to ‘fully understand’ what a transgender patient really ‘feels’, so they will never be able to recommend the ‘right’ treatment. But that argument is flawed; after all, on one hand, there are transgender doctors too, and they adhere to the same medical standards; and, on the other hand, the doctor does not need to ‘have’ a condition in order to know how to treat it — they don’t need to have, say, cancer, or suffer from depression, to be able to recommend the best treatment.

Taking hormones wildly, without knowing what interactions they will have with other medicine we might be taking, or with other clinical conditions that we might have (but which are unknown and therefore left untreated) is very dangerous. No matter how much information one might have read on the Internet, or talked about with other transgender people on hormones, each case is a case. There are objective — not subjective! — blood tests and other exams that can be made before one starts hormone replacement therapy, and these tests have to be repeated, and the dosage adjusted for each case. A certain article I read about HRT, some years ago, claimed that there is always some type of HRT that can be followed, no matter what clinical conditions one might have. It’s just a question of adjustment. Sure, in many cases, the desired effects might take much, much longer to achieve — but the negative effects can be averted that way.

Now, such a precise adjustment of dosage, according to one’s clinical profile, really requires a doctor to evaluate. I agree that the ultimate decision ought always to be made by the patient — that seems obvious to me. But the doctor ought to be doing a bit more than blindingly signing papers. They ought to be allowed to do some exams and design a proper treatment, informing the patient of what is reasonable to expect, and what potential side-effects the treatment might have.

The same, of course, also goes for surgery — perhaps even more so. Someone who is 70+ and has a weak heart might not be the best candidate for sex reassignment surgery; unlike more common procedures, SRS still requires being fully anesthetized for several hours. It is a very demanding surgery with a relatively long (and painful!) recovery — which requires a healthy body to start with. And making sure that the risks of the surgery are diminished (as well as that the recovery period is as short as possible) requires that the doctor knows the patient well, and knows their medical history and background — something which often requires a few years of many exams. The theory that if your local doctor is unable to provide you with what you wish, and you just need to fly to Thailand or Brazil to get your surgery, is a flawed theory — no matter how competent those surgeons might be (after all, they have the experience of many thousands of cases), they will know next to nothing about the patient’s history. And, of course, like Dr. House used to say in the TV series, ‘Patients lie’. As a result, there can be serious complications, even if they aren’t immediately apparent.

In short: all these procedures are extremely dangerous and potentially lethal if not well done. In order to evaluate the safety of those procedures, and to minimize the risks, the doctors and surgeons need to know a lot about their patients, and that means following them for a relatively long time. There is no ‘magic’ nor any ‘miracles’ in this area — the more knowledge you acquire from your patient, the more likely the treatments will succeed. Sure, we all know of success stories of those who did their surgeries or hormonal treatments abroad and had no complications whatsoever. I would say that they are the lucky ones. Interestingly enough, I have been following a few transgender people on YouTube and other social media, and many, once they announce that they would be undergoing surgery, they simply… disappear. Weird, huh? And some of them were very popular, with lots of followers, etc. The usual explanation is that they have started their new lives as women and want to forget about their past as ‘transexuals’, and sever all their connections with the ‘community’, since they don’t want to remain associated with them. Maybe that’s true. I have no way to know!

And the conclusion?

A large portion of the transgender community and the doctors are at odds with each other. In most cases (and of course there are good exceptions!), this comes mostly from resentment. Most transgender people in dire need of a quick transition will have lots of roadblocks ahead of them — many, of course, coming from the deterioration of their own mental health (due to stress/anxiety/depression/trauma, etc.), but many more coming from doctors recommending ‘patience’ and a ‘slow transition’, after a series of protocols are completed. For someone who has been contemplating suicide as the only option besides transition, this is not what they want to hear. Transition takes at least some 2-3 years to complete; but in my country I have heard of cases taking more than one decade until completion.

Of course those people are very angry at the system (especially those who are already affected with anxiety, which manifests itself as extreme irritation and annoyance with other people), and the only solution they wish to hear about is the complete abolishment of the role of the doctors in the identity/transition process.

I can understand that approach perfectly. It’s only natural that you get angry when you don’t get what you want — and we are, literally, talking about life-or-death situations here. I think that those who wish the doctors out of the picture are genuinely and legitimately believing that this is the only fair and just way of dealing with transexuality — by making gender identity a free choice, and, to complete a transition hormonally or surgically, force doctors to automatically sign all papers, once the gender identity is legally recognised.

But I nevertheless recommend prudence. As said, I have lost count of those transexuals I’ve met who refused to get treatment for their anxiety — because they could not possibly see what benefits they would get from that medication, along their road to transition. It seemed to be just a stupid pretext to stall and delay the process even more.

In fact, the problem is that people who are anxious, and as a consequence, angry at everybody and everything, will have deluded perceptions about themselves and the others. Anxiety is not merely a nice word; it is a mental condition, but one that is surprisingly easy to treat, since people respond usually quite well to modern anxiolytics, and the latest generation don’t have many side-effects, nor do they cause habituation. So when doctors start to deal with aggressive and/or hyperactive transgender people who come to their offices desiring to transition quickly, the first thing they get handed out is a prescription for some anxiolytics.

Once anxiety is treated, we experience things differently. Suddenly, what seemed urgent and overly important a month ago, seems now pointless and stupid — and we can even laugh at ourselves for being so obsessive about that. This is not to say that gender dysphoria is just a form of anxiety! It isn’t — in fact, you can lessen the anxiety that comes with gender dysphoria, but that doesn’t make gender dysphoria go away. It doesn’t even diminish the gender dysphoria in any way. It just ceases to become something that you’re anxious about — and that means you can also think much more rationally about it.

So the first step ought always to be getting rid of deluded perceptions that come as part of the baggage, when one is gender dysphoric. That requires trusting the doctors — understanding that they evaluate our desires and needs from a neutral, objective standpoint (assuming, of course, that they are not transphobic moralists…). Our minds and perceptions are clouded and confused, even though we truly feel that we are thinking correctly. The old adage applies — when do you know that you have a mental condition? It’s when you think that everybody in the world is crazy except you.

I’ve been there 🙂 so I know exactly how it feels…

Obviously, if someone mistrusts doctors to evaluate them, then they won’t trust them in planning a successful transition using HRT and surgeries, either. You need to trust doctors as a class first. This is what is currently missing from the most radical activists: they see doctors as the enemy to beat. And, in a sense, they are winning small victories. I’m not sure if all of those are really ‘progress’, though.

Let’s see a few good points. In most places, you can now transition to your gender without requiring surgery or hormonal therapy; in some countries (like mine) you can even change the gender and name on your ID card during the early stages of the real life test, so long as you’re willing to go ahead with your life in your new role. This facilitates a lot of things, like the ability to get a job under a name and gender that are consistent with your appearance. But because you don’t need to go through HRT or surgery, it means that you can still ‘go back’, if things don’t work out.

What this ‘real life’ test will determine is how well you can deal with transphobia. Quoting a book I’ve recently read (I will write more about it on the next essay 🙂 ), the vast majority of transgender males will never look like cisgender women, no matter how many surgeries they do and the hormones they take. There are certain tell-tale signs in the several ratios in their face — size of eyes compared to the rest of the face, for example — some of which are very tiny indeed, but come from the differences in skeletons between males and females. And we humans are very good at picking those differences.

There is an illusion created by the glamorous transgender women on the social networks who look gorgeous after their transition. In fact, for every one who looks absolutely stunning there will be 99 others who simply look like ‘men in a dress’ — no matter how many surgeries they have done. Unfortunately for us, our society puts a lot of importance in appearance, so it’s only natural that we wish to look like the mental image we have of ourselves — which more than often is completely and utterly irrealistic. Sure, some will be lucky — they will have been androgynous from the very beginning and will just need a little push in the right direction. Most of us, however, will simply have to live with the idea that we will always be ‘read’, and, as a consequence, misgendered. It makes no sense getting angry at the whole society for not treating us ‘correctly’. We might never give them a fair chance. When wearing our complex makeup and best dresses, we might almost look great; but in truth we won’t be going through that routine every day, most certainly not just to buy something quick at the supermarket and get back home — we’ll wear something casual and probably just brush our hair, just like cisgender females do all the time. And on those occasions, of course, we will be ‘read’.

Now, for those who have no choice but transition (i.e. suicide is their only choice), they will worry little about their appearance — living in the gender they identify with, no matter how they look like, is fundamentally important for their mental health, and outweighs any considerations. Such people will always prefer becoming laughing stocks in public, but still stick to their preferred gender roles, than considering the alternative — a life being stuck in the ‘wrong’ body and the ‘wrong’ role for their brain and mind.

Many, however, still give a lot of importance to how they look and how they are perceived by others. There are ways to deal with that, of course; but that requires trusting doctors to aid them along their transition. The whole purpose of the real life test is not to exercise some form of masochism upon transgender people; but truly see how well they cope with their new reality, and provide counselling in order to successfully overcome all challenges and obstacles. Many might even conclude that they don’t need to modify their bodies at all, once they understand how to give less importance to their appearance, and show that they can endure all sorts of transphobic comments. Others might see that hormones and surgery will not change much in the way they will be accepted in society, but will still desire those changes, because they wish their bodies to be more in harmony with the gender they identify with. So one could say that they are doing those treatments for themselves, to better deal with their gender dysphoria, and not really for others (even if so often they will claim that they will do those to ‘be better accepted’ or to ‘look more like cisgender women’).

It’s not really just about ‘identity’ and ‘transition’: we humans are much more complex than that. There are now very interesting studies showing that, although most transgender people (across the spectrum) will remember occasional episodes in their early youth where they clearly affirmed their preferred gender, such episodes were far less, and much more scattered, that they like to admit — even to themselves. There is obviously the other end of the spectrum: those who have been chronically depressed since their infancy because they were ‘forced’ to belong to a gender that they did never identify with, and have constantly rebelled against it. Transition is open to both kinds, of course — just because one cannot remember many episodes in their youth (transgender people, in general, have few memories of their infancy, compared to cisgender people — mostly because they did not wish to have that infancy, but the infancy of the gender they identify with, and, as a consequence, the brain erases those painful memories), that doesn’t count against the right to transition. After all, most transexuals have been repressed, their emotions suppressed, for uncountable decades, and this means that they will naturally have few memories of those short periods when they could ‘be themselves’.

But to distinguish between the many nuances in the vast spectrum really requires an objective, detached mind to analyse everything. I can give another example of myself: I often felt very sad for not having transitioned earlier on, because I have this nagging feeling that the older I get, the less people will ‘believe’ that I’m transgender — after all, they will say that I managed to live half my life as a male, why shouldn’t I be able to bear a few more decades until my life is over? By contrast, I strongly envy the young people of today, who can have access to doctors in their tender youth, and at least suppress adolescence until they are legally of an age when they can make decisions about their future — but without having to deal with the burden of having acquired the ‘wrong’ secondary sexual characteristics. This is an awesome technological leap — but one that definitely requires the intervention of doctors along all steps.

In other words: in the future, in not many decades, we will not have ‘late on-set transexuals’ as we have today. Transgenderity will be something that doctors will diagnose very early on, and, at least in more liberal societies, parents will be properly advised and informed about what to do with their kids. They will have plenty of time to explore whatever gender they identify with, and delay puberty for as long as necessary, until they can make a decision. Because that decision will be made with an androgynous body, hormonal treatments will make true wonders, and the results will be indistinguishable from cisgender males or females. We are already having lots of people who are fortunate to have started early and, yes, they become the glamorous and gorgeous beauties — male and female alike — that we see on popular YouTube channels or Facebook/Instagram pages. Such people will be much less exposed to transphobia, since they will never truly have lived their role as the ‘wrong’ gender, and they will have bodies (almost) perfectly matching their chosen gender identity. Only doctors examining them will know the difference — and in that future, enlightened society they will treat transgender people as merely someone who had the ‘wrong’ genes at birth, but, fortunately, thanks to advancements in medical technology, we are able to give them a successful, fulfilling life.

In the meantime, we’re stuck with a couple of generations of those who unfortunately were unable to transition at a young age, and, as a consequence, developed more extreme cases of gender dysphoria, and, even worse than that, they developed a lot of trauma/depression/anxiety symptoms associated with a lifetime of constant repression and suppression not only of their emotions and feelings, but of their actual identity. These people naturally need a lot of help, and I’m talking about help from doctors. Now what activists wish to do is to get doctors out of the picture completely.

For me, this doesn’t make sense. Gender dysphoria is not like the common cold, where you can buy some off the counter medicine to get some relief for its symptoms. Gender dysphoria is a serious and potentially debilitating condition, which has no cure except transition, and it attracts all sorts of other mental conditions as well — all of which can be cured, but that requires doctors to make a diagnosis and propose a treatment. Merely removing a clouded mind and give the transgender person a way to look objectively at their gender dysphoria is a huge step — and one that would be completely eliminated if activists around the world manage to get doctors out of the picture.

There are obviously cases where someone only has gender dysphoria and nothing else, and all they wish for is the transition that will provide them the ultimate relief. For those, obviously, having doctors with their prejudices dictating how and when they ought to transition, and under which conditions they are allowed to legally change their name and gender on the ID card, there is a sense of profound humiliation, and of giving doctors way too much power over one’s life and pursuit of happiness. But the simple truth is that most transgender people do not suffer only from gender dysphoria — even if they think they do, it’s highly likely that other mental conditions are clouding their minds to make them believe that gender dysphoria is the only issue they have to deal with, and therefore refuse to see doctors at all. The trouble here is that such people will make decisions that will affect all their lives without being able to make objective judgements — because they are unaware that their perceptions are distorted due to undiagnosed and untreated mental conditions.

I know that this debate is highly polemic, because at some point there will always be people defending the right to decide over one’s own lives — even if that decision is a bad one. In other words, we expect that, as adults, nobody is allowed to interfere in the way we lead our lives, and that certainly includes the right to manifest one’s identity freely. But on the other hand, we also protect those who are unable to have lucid thoughts and correct perceptions from harming themselves, because they see the world in a twisted way — instead, we provide medical and mental care in order to relieve them from symptoms that might be influencing the way they think and perceive the world.

Now please don’t misinterpret my words. I do not believe that ‘gender dysphoria’ is merely an illusion, or even that it is a ‘disease’. The simple and plain fact that it does not react to any kind of known treatment (and people have been at least objectively trying to ‘cure’ it since the 1950s — and by ‘objective’ I mean that there is published research about those attempts at a ‘cure’) is more than enough proof that it is not a disease, and it is plainly stupid to insist or demand that transgenderity is pathologised — even if in the future we might have ways to rewrite a brain so that it identifies with the same gender as the rest of the body, there will always be the ethical question about the right of doctors to ‘change’ one’s identity that way. We ought to learn something about the intersex individuals for whom the doctors ‘decided’ which gender they belong to — well before those individuals were even able to formulate rational thought.

What I’m saying is that it is very rare for a gender dysphoric individual to be ‘merely’ gender dysphoric. In general, they will, at the very least, be anxious as well. Most will also be depressed or suffer from childhood trauma which still affects the way they think and behave as adults. Such secondary mental conditions can and should be treated, before the individual makes any permanent decision about their gender identity — mostly because those conditions do, indeed, twist one’s perceptions, and no rational decision made on facts can be made. So my advice, in this issue, is to demand people to be ‘cured’ from everything that might impair their judgement first. That requires putting doctors in the picture. And afterwards there might be a hormonal treatment, or surgery, which can be incredibly dangerous (and potentially lethal) if made without a proper medical evaluation over a long period of time. We simply shouldn’t allow people to ‘step outside the system’ just because they want to do dangerous and lethal things to themselves; in general, most legislations do not allow self-harm to be inflicted, especially if that self-harm comes from distorted perceptions of reality.

It’s tough to say this, but I believe that many of the most aggressive activists are actually working hard for what they believe is the best for the community — but that aggression comes from a twisted perception of reality, one most likely produced by anxiety, and which places the doctors as the obstacle to freedom. Obviously doctors are humans and make mistakes. Obviously there ought to be better screening to make sure that doctors with misconceptions, erroneous or insufficient information, personal prejudices and moral backgrounds that promote transphobia, are all excluded from the system. That ought to be something that activists should be pursuing — and that would, indeed, bring much better benefits. We have seen in the case of abortion how so many doctors refused to perform it on the grounds that their religion forbids abortion. But this is actually a good thing: it means that the remaining doctors are not clouded by their religion, and will instead help out mothers, to the best of what medical technology can offer, to deal successfully with their desired abortion. They will be neutral, not passing any moral judgements, and simply do their jobs as professionals.

We need the same to happen in the realm of clinical sexology — not excluding doctors from the process as a rule of thumb, but just making sure that the doctors that are ‘part of the system’ are those who are open-minded, non-judgmental, non-transphobic, and more interested in helping out transgender people than trying to affirm their prejudices. I’m pretty sure that the medical class will certainly agree that the system would only benefit more people if all doctors adhere to these guidelines — instead of bringing their prejudices to the discussions with their patients.

Maybe that way we can forge better bridges among the transgender community and the medical community — working together to achieve what is best for transgender people, safeguarding the whole process and reducing its risks — instead of being at odds with each other for no rational reason.