Go back to California, the physician at a minor emergency center in a suburb of Tulsa told me. The words were flung — practically vomited — at me. I had gone to the center, a relatively new building that was beautifully decorated, on a Sunday morning in 2010. I was in terrible pain because of complications from surgery.
The receptionist was pleasant, and the physician had entered the exam room smiling. He was about 50 and seemed friendly. But when I explained why I was there, the smile disappeared, and his face contorted into an expression of revulsion.
Two days earlier, I had returned to Tulsa from a week-long stay in California, where I had undergone a secondary labiaplasty — a procedure that refines the shape of the inner labia of the vagina.
For this procedure, I had returned to the surgeon who performed my original genital reassignment surgery in 2005, confident that she could make some minor improvements. She was one of the leading specialists in the world, a gynecologist who had traveled the same medical journey as I had: from male sex assigned at birth to female. After returning home from this second surgery, I had developed a minor abscess around one suture. It was extremely painful and terribly frightening.
The emergency center doctor’s words reverberated in my head: “Go back to California.” He fled the exam room soon after he’d uttered them, without examining me or obtaining any further history. I was devastated, angry, scared, embarrassed … and ashamed. It wasn’t the first time a physician had made me — also a physician — feel this way. And it’s a problem in health care that must change.
I am a transgender woman, meaning that I was identified at birth as male but I have known since my earliest memories that I am a woman. When I was growing up in small-town Kansas during the 1950s and 1960s, there was no internet and there were no books, television shows or other media that could affirm for me that I was not the only person who felt this way.
My only sibling, a younger sister, was my main playmate before my school years began. We played with dolls during the day when my father wasn’t around. I learned quickly that in the evenings when he was home, it had to be trucks and toy guns, cowboys and Indians. He was the gender police for me.
“You walk like a girl,” he would tell me. Or, “You throw a ball like a girl.” “You stand like a girl.” “You get dressed like a girl.” “You blow your nose like a girl.” (Yes, he even said that.) These were behaviors that were to be eliminated.
I quickly learned to be ashamed of the woman inside me and became fearful of showing any suggestion of femininity lest I be punished. At night, I would pray for God to let me wake up as a girl, but I intuitively knew that I could share my true feelings with no one else.
Suppression and denial became my daily ritual. I spent decades living as society expected me to, and hid my true female self behind a veneer of masculinity. I went to college and medical school to become an osteopathic physician. I got married and helped raise four children.
Yet in moments when I found myself alone, I would put on women’s clothing. It just felt so right. I would look at myself in a mirror and be so disappointed in the reflection. Sometimes I “borrowed” a few items of my wife’s clothing. Eventually, I would promise myself I would never dress up that way again. I would discard my treasured clothing in some place where it would never be discovered. This cycle repeated itself endlessly.
This common emotional turmoil is known as gender dysphoria. In some trans people, the disorder may be accompanied by substance abuse, self-harm or eating disorders as ways of coping with the inner pain. Forty percent will attempt suicide.
By the time I was in my 50s, my gender dysphoria — which would often strike me for a period of unbearable hours, days or even weeks, but then pass — had become constant. It was like a car alarm I could not silence.
One afternoon, I parked my truck in a lot next to a busy four-lane street and got out. I watched as a large red semi headed my way. I walked in front of it, hoping my death might be viewed as an accident. The driver managed to swerve away from me, somehow, and I was unharmed. It was then I knew that I had to find help. Soon.
By then, I was able to use the internet to learn more about what I was feeling.
In time, I found websites with credible information. One of the first things I learned was that there was a word for people like me: Transgender. Soon, I found other websites that provided information that probably saved my life: Lists of mental-health therapists who provided therapeutic support for transgender people, and information about successful hormonal and surgical treatments that could enable me to become my true self. Finally, I had hope.
The science of transgender
Gender identity — that internal sense of knowing oneself to be a man, woman or other — is understood to typically be fully developed by around age 4, sometimes earlier. All of us inherently know our gender identity: It is not a conscious decision, but rather one aspect of everything that makes each of us an individual. Transgender people are born with a gender identity that does not match their body.
Research has shown that being transgender is most likely due to a hormonal imbalance in utero that happens when the fetal brain is differentiating into a male or female brain. Autopsy studies, functional MRI scans and SPECT (single-photon emission computed tomography) scans suggest that some people are born with a male brain and a female body, or vice versa. (Male and female brains have been shown to be slightly different in structure.) These studies suggest that transgender people have brains that match their gender identity even before taking any cross-sex hormones.
During my childhood, teen and even adult years, transgender people were viewed as defective. Attempts to cure what was viewed as deviant behavior or mental illness included electroshock therapy, massive hormone doses, intense psychotherapy and psychiatric hospitalization.
These treatments were not effective in treating transgender children, teens or adults. Research and clinical experience gradually demonstrated that it is not efficacious to attempt to “fix” the brain; rather, it is effective to provide medical and surgical treatment (if desired) to change the body to conform with and affirm a person’s gender identity.
When I began my journey to become my authentic self, my family-practice physician of many years refused to see me. She said that I had lied to her about who I was. This was a shock — but then, I guess I had lied to myself for decades, too. On numerous other occasions, I have been refused care by physicians, sometimes because of discrimination and bigotry, but at other times because of an expressed concern that “we have no idea how to care for a transgender patient.”
Because so few physicians will treat this population, many transgender people have given up trying to find medical care or are afraid to seek routine and emergency care. A 2014 Williams Institute study on transgender suicidality showed that 60 percent of transgender patients who are unable to find physicians have attempted suicide.
Fortunately, after several years I found a family-practice physician who is accepting. I was the first transgender patient she had treated, so I have had to educate her about our treatment, follow-up care and culture. She has proved to be a wonderful learner.
Unfortunately, information about the appropriate treatment for transgender patients has not been taught in medical schools or postgraduate programs until recently, and even now it is only infrequently included in the basic few hours of LGBT education that the schools and programs provide. Most physicians now in practice have no training in how to care for transgender people.
After being refused medical care for my acute abscess at the minor emergency center, I was able to tolerate the pain until my family-practice physician could drain the abscess and provide antibiotics. I healed physically without further difficulty, but the emotional scars from this event and countless others remain.
During medical school, my peers and I were taught about obscure medical diseases, conditions that I‘ve never seen during 30-plus years of medical practice. Transgender patients, in contrast, are not uncommon. Almost every practicing physician will encounter transgender patients in his or her practice. Yet medical education in the United States is failing to teach medical students and residents how to care for this population.
This has to change. No patient meeting a physician for the first time should fear being denied care or given incorrect treatment. The expression on a caring professional’s face should be one of concern and interest, not a snarl of angry disgust.
Dr. Laura Arrowsmith is a physician, educator and advocate for the transgender community. This article is adapted from Health Affairs: https://www.healthaffairs.org/do/10.1377/hp20171019.555074/full/