This article originally appeared in the National Post.
By Shawn Whatley, October 18, 2022
Every day, patients tell their doctors what they think is wrong. Well-informed people self-diagnose heart attacks, broken ankles and dozens of other things. And patients are often right. A second heart attack can feel like the first one. Even so, doctors ask and probe. Physicians must challenge themselves and their patients.
No diagnosis is beyond dispute or review. Blood clots and panic attacks can mimic MIs (myocardial infarctions). Missing a clot can cause death. Missing a panic attack risks unnecessary treatment. Doctors never simply affirm a patient’s self-diagnosis for a new condition, except for gender dysphoria.
For every other condition, a patient’s self-diagnosis presents a place for physicians to start collecting a medical history. Tests and treatment follow. Multiple specialists might need to review a challenging case.
Sherwin Nuland, surgeon and best-selling author, wrote in The Uncertain Art: Thoughts on a life in medicine, “The process is one of sifting, weighing, and judging … Disease never reveals all of itself; the path toward healing may appear visible, but it is always poorly lit and subject to changes in direction.”
Gender-affirming care inverts this paradigm. Doctors must not probe or ask. Questions could be construed as unsupportive, even subversive. Gender is identity, not diagnosis. Asking about gender could be a sneaky way to inject “conversion therapy” on the sly.
Most doctors have little knowledge or interest in conversion therapy. It plays no part in modern medical education. The vast majority of physicians would shudder at accusations of trying to convert, no matter how unfounded the charge.
Even so, when patients tell their family doctors that their gender observed at birth is wrong, doctors today tend to play it safe and refer. No questions asked.
Gender dysphoria has a well-documented association with mental illness. With other mental illnesses, counselling helps patients learn to limit symptoms, develop coping skills and maintain a productive life.
Counselling for gender dysphoria seems to aim at opposite ends. It offers guidance for “coming out as transgender,” help finding “resources to assist with changing outward appearances,” or referral for “speech therapy to help match vocal characteristics … with gender identity.” This approach presupposes, with scant evidence, that it will help long-term. What if it causes harm?
With medical therapy, there also seems to be only one treatment path. Asking about untreated mental illness has become verboten.
Federal law bans conversion therapy. It was designed to quash the (alleged) pandemic of conversion therapists. Instead, it quashed questioning in clinics — doctors have gone silent.
Social and legal pressure has a profound impact on physician practice. The College of Physicians and Surgeons of Ontario thinks we need more. The College is seeking consultation on a draft policy: Human Rights in the Provision of Health Services. Consultation aside, the message is clear. Doctors must endorse and affirm and avoid any hint otherwise.
The social, legal and regulatory pressure around gender affirmation might be reasonable, even necessary. We have clear protections for religion, sexuality, language, skin colour and much more. But affirmation should follow debate, not moral dictates.
Gender transition requires potent medications and irreversible surgery. Every other medical treatment involves discussion about risks and benefits: the bedrock of informed consent. Even before referral, physicians have a duty to inform patients about what they might expect.
Dr. David Zitner, retired physician and former director of medical informatics at Dalhousie University, tackled these issues at length in a new piece for the Macdonald-Laurier Institute: Gender dysphoria in children: Risking harm from well-intentioned parents and doctors.
Never mind whether or not we should transition minors. What ethical principle supports transition with so little evidence available about long-term side-effects? Outside Canada, people have shifted away from unvarnished affirmation to sober reflection. The shift led regulators to shut down the flagship Tavistock Gender Clinic in the U.K. this year.
Gender theory and treatment is an exciting and evolving area of research. We should embrace exploration armed with all the habits and norms that got us here: asking questions, following evidence, and changing course as we learn.
Tom Sowell, economist and author, famously said, “There are no solutions. There are only trade-offs.” A lack of solutions does not condemn us to decisional paralysis. We should just be aware of the trade-offs involved with changing course.
The current zeitgeist of social, legal and regulatory pressure around gender issues has made doctors go quiet on gender. Affirmation carries the day. When doctors stop being doctors, it never turns out well for patients.
Shawn Whatley is a practicing physician in Mount Albert, Ont., and a fellow at the Macdonald-Laurier Institute. He is the author of When Politics Comes Before Patients: Why and How Canadian Medicare is Failing.