“The best advice I can give you when working with trans-gender patients is, if you have a moral or religious problem with the topic, remove yourself from the situation.”

Good advice.  Sitting in a lecture about transgender medical issues – including sex-change operations – I’m looking at the trans-gender patient that came along with the lecturer so s/he could describe the travails of his/her condition.  After about 10 minutes of staring at “her” (I’ll use the gender that the patient wants to be), I realized that I had in fact seen this patient in clinic myself. 

At the time, she wanted advice and medication for severe depression and mental disturbances.  “She” was wearing Wrangler Jeans, a flannel plaid shirt, a jean jacket – dressed totally as a man and looked as tough as an axe handle.  And, I might add, she was a rather good-looking Marlboro Man, cowboy type, too. 

The patient mentioned that she wanted to live as a woman; had even tried it a number of times in Seattle, but had returned to her rural town to care for her ailing mother.  Nothing about her looked female to me in any way.  Imagine, by the way, the smack-down that kind of person would get in a rural logging town in Washington.  Whatever your feeling on the issue, I’d think you’d have at least a little respect for someone brave enough to take off the denim and put on a skirt in a small, remote logging town in rural America.  People get killed for that kind of thing.

Personally, I have no qualms about transgenderism and sex change surgery, from either a religious or moral perspective.  But I still have a pretty strong emotional reaction toward people making The Change.  In complete honesty, I’ll admit that the prevailing emotion I feel is…fear.  I can’t explain why, either.  Every rational thought in my mind on the topic is decidedly neutral – even ambivalent – about transgenderism. 

Oh, I suppose I get a little hackled when I think about some hapless transgender soul getting hazed or even killed for their sexual mores.  And I’m probably a little reluctant to support a tax-payer-funded system that provides sex changes.  But in general, I don’t really give the matter much consideration one way or the other.  Everyone has their urges, desires, whims and frustrations…and everyone is trying to change something dramatic about themselves.  So, in general I support the idea but not with much emotion one way or the other.

But there’s a fear-factor that I can’t quite shake.

The only other human that from the outset causes an irrational fear reaction in me is preemies.  I’m talking the super-early babies before 28 weeks, lying in their incubators clawing for life.  While doing rotations in neonatal units, I had to keep reminding myself that preemies are, in fact, humans.  Visually, they could be mistaken for any of a number of creatures in B-movie matinee flicks that I saw in grainy black-and-white as a teenager. 

Maybe it’s the lack of defining visual cues – in preemies and transgenders – that get me so unsettled.  Whether fair or not to these people, I’m just used to determining certain basic characteristics about all humans off the bat.  Probably the very first thing I determine about a person is if they’re female or male.  Recognizing traits of both genders in the same person – like prominent breasts and coarse facial hair – is simply unsettling, even if medically fascinating.

I should mention here that medical science on the topic has advanced remarkably in the past 20 years.  This may have largely to do with the fact that gender change is not nearly as uncommon as you might imagine.  This isn’t just some vague, bizarre mento-emotional weirdness that only the goofiest and most sexually-molested among us ever venture into. 

The fact is that many, many people deeply desire to be the opposite gender – normal, balanced people.  Some were born with ambiguous genitalia from the very beginning, and never have been able to figure things out on the sexuality front but are otherwise intelligent, competent and compassionate people.

So, the medicine has followed demand, and the results are impressive.  Men can become women, and the other way around.  The process is both hormonal and surgical.  It takes years and requires enormous effort and resources to be truly successful.  These days, hairy-chested men can grow breasts, and smooth-faced women can grow facial hair; surgeons can form a clitoris where there once was a penis and on and on. 

Of note: Medically, it is much easier to go from woman to man.  Not that I’m trying to strengthen any stereotypes here, but it’s true that hormonally-speaking, men are plain, straightforward, simple.  When it comes to hormonal and even anatomical complexity, women are in a different league than men. 

That said, altering even their anatomy has become so successful, that even doctors can’t tell the difference while performing pelvic exams, to the point of believing they are looking at not only a completely and normally-formed vagina, but the entire perineum, clitoris and cervix. (Trivia:  Do surgically-created females need Pap tests like natural-born women?  Answer: Yep.  Every year).

But to get back to my own qualms about the topic:  Should I recuse myself from a transgender case due to my own discomfort with the subject?  Upon reflection, no.  As mentioned, I don’t have a problem with the notion.  It’s more of a visual thing for me.  It’s unsettling, disturbing, yes, but not repulsive or morally outrageous.  It took me awhile to get used to seeing squirting abscesses, and compound fractures; even the beauty of new life writhing, gushing and screaming from the inner sanctum of a mother’s pelvis.  I can get used to this, too. 

I’m a doctor, and taking care of people no matter how they look or live is what I do.  If a trans-gender patient is willing to trust me with their medical care, I’d accept their outreach as a true honor.