Moving Medicine
"How do you prove that you're trans?"
Oct 5, 2023
Featured topic and speakers
Family medicine physician Kathleen Bock, MD, shares their personal story receiving care as a non-binary person and poses important questions for physicians on delivering care to transgender and gender-queer patients.
Speaker
- Kathleen Bock, MD, family medicine physician, Northwestern Medicine
Host
- Todd Unger, chief experience officer, AMA
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Transcript
Dr. Bock: What if my psychiatrist doesn't feel comfortable commenting on my gender? Will I need to wait 18 months to establish with a psychiatrist, who will assure everyone else, "Oh no, they're for real. They're definitely non-binary. They're trans enough. It's fine."
Unger: That was Dr. Kathleen Bock, family medicine physician at Northwestern Medicine. In this episode, Dr. Bock passionately shares their personal experience receiving care as a non-binary person and gives voice to the many challenges transgender and gender-queer patients face in the medical system.
Dr. Bock: Hi. I'm Kathleen Bock. My pronouns are they/them. I'm a family medicine provider who also practices HRT. But I am not here today so much in that capacity as I am as a non-binary person attempting to offer some insight into the patient experience. This is one experience of neurodiversity and gender identity in as brief as I can make it. So, here's the story. I'm a non-binary person and sometimes I think about what it would be like if I tried to access care, without my knowledge that I have of the medical system and without my knowledge I have as a doctor, because doubt is the functioning word in the discussion of transgender and gender-queer patients.
Are we being rushed into this? Do we really know who we are? Are we being groomed into this, manipulated? Are we being forced? Are we moving too fast? We really ought to take our time and be sure that these people are really trans before we treat them. And how do you prove that you're trans? Especially if you're autistic and anxious. How many seconds uninterrupted do you get in a doctor's visit when they ask, "So tell me, why do you want HRT?" And I think I might say when asked that, "Well, when I was three years old, I used to pretend that graham crackers could turn me into a boy. And then in 2020, I saw a meme and a lot of things started to make sense and it wasn't right at first, but now I've been thinking about it a lot and it is right. It's time.” A provider faced with that brief explanation might feel some doubt. Am I trans enough for health care?
So, I'm going to take the opportunity that no patient ever has, which is that I have 15 uninterrupted minutes to make my case. I'm only going to spend 10 of it on me. And I hope by the end of it you'll understand my approach to doubt and how I open conversations with my patients about HRT. When I was three years old, I pretended that graham crackers, specifically cinnamon graham crackers, could turn me into a boy. I have a very specific memory of my tiny, gnarled fingers going, "I am changing." I was also an autistic three-year-old. I was a weird kid. When I was eight years old, and at various times throughout my youth, I would position myself so that only the upper half of my face was reflected in the skylight of our living room at night. And I would stare at it until I could imagine what I would look like if I had been born a boy. I would do this in other various times throughout my youth. All you have to do is, you just cover the lower half of your face with your hand and stare in the mirror.
Everyone ... doesn't do that. Oh my. In 2020, it became very fashionable to have the lower half of your face covered, but we'll get to that. Middle school was as middle school universally is, miserable. I wanted to play with the boys and the boys didn't want to play with me, and I didn't really get how to interact with the other girls. And my voice cracked, my voice changed. I sing tenor, so I went through the voice squeaks that everyone knows only happens to boys. But I wasn't a boy, I was a girl and it was embarrassing and it was frustrating. Of course, I felt awkward and strange and incorrect in my body. I was in middle school. I was an autistic middle schooler. No surprises there. In high school, there was a bit of a game changer, which was when we did the school play and we had to wear poodle skirts and high heels and there's video of me twirling and I saw how good my legs looked and I was like, "Wait, wait, wait. We've got a game changer here. That's attractive.”
"I could be an attractive woman. Okay, wait, we can do this. Okay, we got this." And I clung to that knowledge that I had good legs. And that made me feminine, I was a woman, it's fine. We're going to be okay. And in the meantime, at school dances I commanded boys to dance with me. God knows they wouldn't say yes if I asked. I still didn't understand the relationships. Especially the intricate stuff. Of course, I was autistic. And of course, I didn't feel right in my body. Sometimes I felt beautiful, but other times I felt misshapen, and something was just profoundly, fundamentally wrong. Of course, I felt that way. There's an entire industry in making teenage girls feel fundamentally unwell in their bodies. Cross-Dress Day senior year, I was so convincing that people kept calling me by one of my classmates' names. And I loved it. It's one of my favorite memories of high school. And I know why that was.
I had been reading a book where someone was really good at disguises, and I was really good at disguises. That's why it felt so good to be called Luke. In college I dated a chauvinist, much to the distress of my friends. "Katie, how can you date him? You're a flaming feminist." And I didn't really have a good answer. Except what I wrote it off was, "Well, he's just wrong. So, I don't even really worry about that part. He thinks the sky is green, we don't talk about it." There was something about his presence that I found so magnetic, and I always wanted to be around it. And again, we vary. We have the moments feeling beautiful in dresses. We have the moments feeling misshapen and horrible, young woman in America. Again, there's an industry. Feeling awkward with my peers, not quite fitting in with the girls, not being allowed with the boys. Autistic. My senior year, I dressed up as a boy to audition for my friend's all-male acapella group and I passed for like 45 seconds, and it was amazing. That is also one of my favorite memories. Because I'd played a prank. That's why I cherished that memory, I love pranks.
I started therapy in college, and I kept waiting for it to turn out that I was gay, because I felt like clearly something was being suppressed within me. And if I could just come out and realize like, "Oh, I'm gay," it would all make sense and everything would click and I would be fine, but that didn't happen. My intern year of residency, I did realize I was bisexual, but that really wasn't a game-changer. It was more of a, "Oh great, now I get to feel awkward around girls too." And then in April of 2020, when the world was falling apart, I was working in an ICU and a friend posted this meme. As we all know, the Scooby Doo gang, whenever they're chasing one thing, it turns out they were chasing something entirely different. So, in this, Fred is looking at his high school crush and he removes the hood, it's transition goals. He didn't have a crush. It's transition goals. You didn't have a crush on that girl in high school, you wanted to be her. And I thought about the chauvinist and a lot of things started to make sense.
If I could snap my fingers tomorrow and appear as he appears, I would, I still would. Before we get the wrong idea here, it's not that he was stunningly attractive, I happen to know he despised his own body, but when he walked into a room, everybody turned to look and said, "That is a man." I wanted that. I still want that, but not permanently, because have you seen my legs? They're great.
I had had trans friends in college, and I wondered, "Oh, maybe I'm trans," but I'm a woman, I know I'm a woman. I saw this meme and I realized, "Wait, can you be both?" I texted one of my non-binary friends and I said, "Yo." It was before rounds, again, ICU April, 2020, weird time and place. Can you be both? They texted me back. "I mean, yeah. I'm not, but you can be if that's what you are." A lot of things made sense, that fluctuation between belonging and not belonging, the sensation of something being profoundly incorrect but impossible to describe.
The last three years have been spent making sense of that, getting more serious about using my pronouns even with my parents. Listen, right now, HRT isn't right for me. I want to start a family. Testosterone and pregnancy are incompatible. Frankly, as I've said, my own identity sort of waffles between the two. I don't know that I'm totally ready to give up my feminine traits, but that might change. In six or eight years when I'm done building my family, fingers crossed, knock on wood, will I decide that it's time for HRT? When I go to that cisgender doctor and explain about graham crackers in a meme, will I be trans enough for them? Or more likely, will they need a note from a therapist?
Well, I've had a therapist since I was in college, but what if my therapist isn't comfortable commenting on my gender, because she doesn't do gender care? I need to see another therapist for a year. That'll be, what? At least a six-month waiting list and then another year so that I can talk to a therapist about my gender, which frankly is not what I need therapy for, talk to anyone who knows me. Similar with psychiatry. What if my psychiatrist doesn't feel comfortable commenting on my gender? Will I need to wait 18 months to establish with a psychiatrist, who will assure everyone else, "Oh no, they're for real. They're definitely non-binary. They're trans enough. It's fine."
Doubt. As though I hadn't already lived currently 32 years in this body making sense of confusion and disconnect, which cannot be extricated from my autistic experience. There's a reason it's so confused. Of course, I feel awkward and wrong all the time, which is why when my patients come to the office, the conversation is very simple. I look at the young woman in front of me and I say, "Here's the thing. The cis are terrified that a cis person is going to get confused, stumble into my office and ask for estrogen, so I'm going to ask you some questions that don't really matter, but I'm expected to document, to show that I've been thorough. When did you realize you were a woman? Does your family know? Do your friends know? Does your job know? Have you socially transitioned?" Whatever that means. "What is it exactly about your body that gives you dysphoria? What are your goals for transition?"
Then once we've had a bit of a chat about that, I say, "Listen, there's only one question that really matters. Are you a woman?" She looks at me and she goes, "Yes?" I go, great. You're estrogen deficient. Let's talk about the risks and benefits of estrogen therapy. That is where our thoroughness should lie. You cannot prove that you are trans, any more than you can prove that you are left-handed. It just is. Oh, but maybe there was an influencer who uses their left hand all the time, so you've been practicing and made yourself think that you're left-handed. How would you ever prove otherwise? By the time someone is in my office, they have done so much internal work, they have been thinking and fighting and trying to figure something out for so long. They have deeply, deeply considered. By the time someone says, "I'm ready for HRT," there is no place for doubt about their identity. I understand, because of the political climate we live in, we do need to put on a good show, we need to pretend that somehow there's a medical way to determine transness, because if we don't do that, think about the poor children.
When I was three years old, I pretended cinnamon graham crackers could turn me into a boy. HRT wasn't right for me then, but my experience is only one experience. There is no place for doubt. There is a place for thoroughness. There is a place for compassion. There is a place for ensuring that people are aware of the profound consequences that HRT can have, but there is no place for doubt for a thing you cannot hope to understand unless you have lived it yourself. We should disabuse ourselves of that obligation.
Unger: This episode was recorded at the AMA Annual Meeting in 2023. Join the AMA today to gain access to events like this one and all the benefits of membership. I'm Todd Unger and this is Moving Medicine.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
