A Feminist Doctor on Gender Identity Policies, Institutional Capture and Medicine
La Scapigliata is a feminist writer and medical doctor. She is outspoken on the harms of gender identity policies, sharing medical expertise to debunk various myths and writing passionately in defense of women’s sex-based rights. FiLiA caught up with her to discuss her work investigating how ideas prioritising the concept of gender identity have become embedded in various UK medical institutions.
“I receive confidential messages from colleagues and medical students all the time. They tell me they are afraid of being falsely accused of transphobia and face discrimination and bullying in their place of work/study if they openly question these policies. My feeling is that, the vast majority of healthcare professionals are concerned with the lack of evidence.”
What was your initial assessment of how medicine understands or manages patients who identify as other than their biological sex?
Working in psychiatry, I encountered several transsexuals who became acutely suicidal following sex-reassignment surgery. They were homosexual males with a diagnosis of Gender Identity Disorder (GID), who had undergone a thorough assessment and counselling to ensure their suitability for these procedures and to help them manage their expectations. When their psychological distress didn't go away following surgery, they described feeling mutilated and wanting their old bodies back, which was unfortunately not possible because these operations were irreversible. I had a great deal of empathy for these patients, but I also understood the impulse of a doctor to do something, anything, as a last resort to help alleviate a patient's distress at being born male. I wasn't convinced that sex-reassignment was the best way to go about achieving this, but I trusted my colleagues, who were experts in this area, to have solid science behind what they were doing.
When I started examining this issue in detail, I first wanted to familiarise myself with the scientific rationale for sex-reassignment. To my surprise, I couldn't find any studies that showed long-term improvements. Instead, the biggest study on sex-reassigned individuals showed significant increase in mortality, morbidity and suicide over time. Despite this, a whole new population of patients, mainly girls but also some boys, were being diagnosed with "gender dysphoria" and instead of being offered counselling, they were fast-tracked to a medical pathway to “gender reassignment," that involved hormone blockers, cross-sex hormones and eventually, irreversible surgeries such as double mastectomies, hysterectomies and surgical castration.
I looked up Gender Dysphoria (GD) and found that it had replaced GID in the diagnostic manual for psychiatrists (called DSM-V). The criteria appeared very similar in spirit, but the persistent discomfort with one's biological sex and identification with the opposite sex, that I have seen in my patients, was now redefined as a mismatch between one's "experienced/expressed gender," and "assigned gender."
The criteria never define "gender," but judging by the description of boys and girls as "assigned genders" it is safe to assume they are referring to biological sex.
But if this was the case, why do they also talk about "desire to be of the other gender (or some alternative gender different from assigned gender)"?
What did you think about the phrase “assigned gender” in this context?
Biological sex is binary and observed at birth with 99.98% accuracy. The remaining 0.02% of the babies have Disorders of Sex Development (formerly known as intersex), and while they might need genetic testing to determine their biological sex, they are still either male or female. There are no other or in-between sexes.
In the past, children with DSDs were operated on in order to make their bodies appear more sex-typical, and sometimes, the decision was made to raise them as the opposite sex. This procedure was known as "assigning sex," but because we know that socialisation of males and females is heavily influenced by gender stereotypes, and that biological sex can't be changed, it could be argued that this constituted "assigning gender" instead. However, this language relates to a very specific, rare set of circumstances where doctors found it difficult to classify a child’s sex based on “ambiguous” physical features, so medics may have “assigned” those children as girls or boys and surgically altered their genitalia to look more “normal.” This practice is not the same as in 99.98% of cases, where doctors simply observe a child’s biological sex and note it on a birth certificate.
The vast majority of children and adults who were diagnosed with GD were correctly and easily recognised as their biological sex at birth. We know this, because when doctors screened for DSDs in patients who have GD, they found it was very rare: the incidence of DSDs is the same as in the general population.
Therefore it appeared that the terminology used to describe DSD patients' unique experiences was being misapplied to give an air of scientific legitimacy to a linguistically convoluted and scientifically imprecise diagnosis of gender dysphoria.
How does a feminist lens complement your understanding of the medical approach to gender dysphoria?
GD criteria talk a lot about gender stereotypes, which feminists consider to be socially constructed and designed to disadvantage females. Females are supposed to be submissive and perform free emotional, domestic and sexual labour (femininity) while males are supposed to be aggressive, dominant, and have a leading role in society (masculinity). Seen through this lens, it was easy to understand the surge in referrals of girls and young women to gender identity clinics, and how replacing "sex" with "gender" in the wording of the diagnosis shifted the narrative from distress with one's biological sex, to distress with gender non-conformance. But instead of advocating for greater acceptance of gender non-conformity, and offering counselling as the first-line treatment, with gender reassignment as a last resort, the treatment was changed to an "affirmative model", whereby patients' "gender identity" had to be validated by offering gender reassignment as the first-line treatment, while counselling was likened to "conversion therapy" and it fell out of favour.
This practice of "affirmation" has a particularly negative impact on women and girls, because most young patients with gender dysphoria in the UK now are females, who have other factors such as autism, sexual trauma or emerging homosexuality that could explain the discomfort they feel about their bodies and restrictive social norms.
The mantra of "affirmation without exception" is also used more broadly, to deny that females have different needs and experiences than males, to accuse women of being "exclusionary" for wanting to retain single-sex spaces and to portray males who identify as women/girls as "victims" of female boundaries.
What do you mean by gender identity policies, and to what degree do you think such ideas are scientifically sound?
Policies prioritising gender identity are based on a postmodern belief system that asserts primacy of gender identity (one's internal sense of being male or female) over biological sex. When gender identity is congruent with biological sex the person is said to be "cisgender," and when it is incongruent, they are "transgender." This set of ideas around the concept of gender identity maintains an old-fashioned belief in traditional sex-roles, or gender stereotypes, but adds a modern twist to it. Women and girls are still "inherently feminine" and men and boys are "inherently masculine," but a man who likes to wear dresses and make up "could really be a woman," while a girl who hates dresses and likes to climb trees "could really be a boy".
As a feminist I am all for dismantling the gender binary. Nobody conforms to stereotypes of masculinity and femininity perfectly. These gendered boxes are restrictive and they enforce a social hierarchy that disadvantages females. This is why feminists see gender as means by which women are oppressed.
Women can try to identify as men in order to escape oppression. They can take testosterone, remove their breasts and uteruses, change their names and pronouns and even get certificates that say they are legally male. But they still won't be able to dominate men the way males, even those who identify as women, can physically overpower females.
Therefore, to say that women are oppressed due to some hypothesised inner identity of womanhood would require any analysis of sexism, misogyny and male violence to become uncoupled from the material reality, whereby women’s oppression is and has always been linked to them being biologically female in a male-supremacist world.
As far as science is concerned, I always like to keep an open mind so I welcome more research into the transgender phenomenon. So far it seems that we are dealing with a pseudoscientific set of ideas which relies on misuse of language to justify transgression of laws and existing social norms, rather than some groundbreaking new science that has turned our understanding of what it means to be male or female on its head.
Why is resisting certain policies related to gender identity so important to you?
I think it is important to resist any pseudoscience, especially if it seeks to influence medical treatment. As doctors we have the responsibility to be truthful and to first do no harm. Considering that sex can't be changed, and that masculinising females and feminising males with drugs and surgeries has no evidence to support it, whilst these interventions have risks and some reported experiences of significant harm, then why are we offering these treatments in the first place?
Statistics also indicate that males who identify as women retain male-pattern criminality. If we change policy to segregate spaces such as prisons, healthcare, domestic violence shelters, toilets and sports, based on gender identity, rather than biological sex, we are introducing males into women's single-sex spaces, which increases the risk of harm. So I think we need to be highly sceptical of any practice that gives primacy to beliefs over observable facts, as this constitutes a departure from evidence-based policies into faith and peer-pressure driven decisions.
What is your view on the medical profession’s general relationship to the concept of gender identity?
In medicine "masculine" and "feminine" have biological connotations. For example, exposure of a foetus to testosterone is said to "masculinise" them, and in the field of gender reassignment, we talk about masculinising females and feminising males to make them look like the opposite sex.
This is quite different from the social constructs of masculinity and femininity, which vary across cultures and time.
I think that these two meanings got conflated in practice of gender reassignment, and this conflation is now spreading to other areas of medicine under the guise of "equality, diversity and inclusiveness."
Throughout history, males who were deemed to be insufficiently masculine were speculated to have a "feminine essence." Medicine later described this essence as "a woman trapped in a man's body", and attempted to "free it" with hormone blockers, cross-sex hormones and surgeries. And now, this essence is known as a "female gender identity" and scientists are trying to capture it with brain scans. I suspect that the reason why it hasn't been captured yet is because this "essence" is just a projection of society's discomfort with gender non-conformity.
What is the problem if we replace the category of sex with gender identity in medicine?
Biological sex is the most fundamental piece of information clinicians need in order to deliver safe and effective medical care. Male/female sex differences impact everything, from the likely diagnosis and lab reference ranges to reactions to medication, choice of treatment, dosage and prognosis.
Despite this, the General Medical Council (GMC) has issued guidance that asks doctors to "respect patient's request to change sex on their medical records." This process, which is facilitated by doctor's surgeries and Primary Care Support England (PCSE), involves issuing new NHS numbers with opposite sex markers and it removes all references to patient's true biological sex (referred to as "previous gender identity") from the new record. According to the GMC, it is also "unlawful to disclose a patient’s gender history without their consent."
Patients who decide to take advantage of these new rules risk not receiving invitations for sex-appropriate screening, they can be misdiagnosed, and even denied appropriate medical treatment.
These new rules also restrict clinicians' autonomy to truthfully record and communicate relevant information pertaining to a patient's biological sex. All this seriously jeopardises healthcare of the very patient population these gender-identity-driven policies are meant to be benefitting.
Healthcare of course exists in a broader social context. For example, there's currently a push to use "gender neutral" language, so women are being referred to as "pregnant people," "menstruators" and "cervix-havers," however there are no corresponding descriptions such as "impregnators," "ejaculators" or "prostate-havers." Males are still referred to as "men," regardless of their gender identity.
Women are already underrepresented in clinical trials. Their pain is taken less seriously, and due to atypical patterns in relation to males, their diagnoses, such as a heart attack, can be delayed or missed, all of which affects long-term health outcomes. Replacing sex with gender identity in medicine would make sex-based research very difficult.
As many as one in four women is a survivor of male sexual violence, and in a medical setting, where we are all vulnerable, many women require access to single-sex spaces and same-sex healthcare providers in order to feel safe. When the GMC allowed doctors to self-identify as the opposite sex on their professional register they made it very difficult for female patients to challenge male doctors who identify as women. In practice, patients who find themselves in this situation report being labelled "transphobic" and "difficult" when they complain. Many were worried that they would be refused medical care if they didn't keep quiet.
Abuse of females in a medical setting manifests in many different ways, from misogyny-driven medical scandals and obstetric abuses, to sexual abuse of female patients by both male practitioners and male patients.
Replacing sex with gender identity in healthcare not only removes the protections women's sex-based rights give all females, it puts us in an impossible position where we can no longer use sex-based language to analyse and address root causes of violence that is committed against us.
Many might assume that doctors are not susceptible to cultural or political influences. However, your work uncovers that parts of the medical establishment may have been persuaded to abandon some of their usual principles. Could you briefly outline some of what you discovered in your research on medical institutions and gender identity policies?
Replacing biological sex with gender identity in healthcare is a fundamental departure from mainstream scientific understanding of human biology. Therefore such policies should have been a result of prolonged debate among clinicians. However, looking at the situation in the UK, policies that allow mis-sexing of patients and clinicians appear to have been imposed from above, by institutions who have signed up for various "equality, diversity and inclusiveness" schemes run by organisations such as Stonewall UK.
In some cases there is no electronic or paper trail of how these policies were developed and approved. Typically, no impact assessment was done to see how they would affect other protected characteristics, such as sex, disability, age, religion etc. Women are not routinely consulted. Instead, transactivists are seen as the sole stakeholders and allowed to influence administrators and small committees to make unilateral, belief-driven decisions.
Whenever I approached medical institutions, or their representatives, with concerns that women's sex-based rights were being breached by these new policies, I got stock replies that dismissed my concerns. The few colleagues who openly campaigned for gender self-identification would simply claim that "transwomen are women," call me a "transphobe" and refuse to engage further.
To what extent do you believe most doctors know what is going on?
I think doctors are increasingly aware of what is happening but they are under huge pressure due to the current public health crisis, the stressful nature of the job as well as chronic understaffing and underfunding. Our institutions have implemented policies that would see you accused of bigotry and question your fitness to practice if you stated, quite correctly, that males aren't women. Most doctors' livelihood depends on not falling foul of these frameworks.
I receive confidential messages from colleagues and medical students all the time. They tell me they are afraid of being falsely accused of transphobia and face discrimination and bullying in their place of work/study if they openly question these policies. My feeling is that, the vast majority of healthcare professionals are concerned with the lack of evidence. They can see the many ways in which replacing sex with gender identity compromises patient healthcare and safety. However, the culture of dismissal and bullying has quashed all dissent, and this is being used by transactivists to claim that the medical profession fully endorses biology-denialism.
Why do you think some respected medical organisations have been vulnerable to these influences?
Institutional capture was carried out quite systematically, using various tactics outlined in Denton's report titled "Only Adults? Good Practices in Legal Gender Recognition For Youth", such as avoiding debate, tying gender identity centering proposals to less controversial policy suggestions (such as reforms to support LGB rights) and using youthful voices to portray these changes as “progressive.” This has worked equally well at the GMC, British Medical Association (BMA), Care Quality Commission (CQC) and Royal Colleges as well as the Crown Prosecution Service (CPS), prison service and women's aid sector.
Clawing back from this will be difficult, because the gender identity lobby has had free reign for over a decade and now our institutions are riddled with policies made "in advance of the law". This makes lawful single-sex provisions all but impossible to enforce. Furthermore, free speech is under threat with increasingly Orwellian "hate crime" legislation and policing. However, with several Judicial Reviews under way, that seek to examine the lawfulness of these policies and their effect on individual service users, as well as growing public opposition, I am hopeful.
What are the duties of a doctor to their patients (especially women and girls) when it comes to understanding sex-based rights? For example, what would you see as the responsibilities of a medic who was born male but identifies as a woman when seeking consent from a female patient to perform a breast examination?
Humans are sexually dimorphic, and we have evolved to instinctively recognise each other's biological sex. This instant recognition least relies on clothes, make up hair length or mannerisms. Our brains can be alerted to true biological sex by facial structure, voice, shoulder width, size of hands and feet, gait, scent, and as soon as any inconsistency is noted, the disguise no longer works. This is why even with the best cosmetic, surgical and hormonal interventions, transgender individuals rarely completely "pass" as the opposite sex, and this is especially true for males who identify as women.
Furthermore, sex recognition is context-dependent. We don't pay as much attention to biological sex of people we casually pass on the street or interact with online, as we do in situations where we are vulnerable, such as being alone in a women's toilet or receiving a breast examination.
This is why it's problematic that some male clinicians who identify as women report they might feel validated when female patients decline chaperones. The imbalance of power between doctor and patient makes it unlikely the patient would challenge the doctor, and the apparent lack of insight about this is worrying.
Should a medic’s sex be explicitly disclosed to the patient? Does such information impact a woman’s ability to make an informed choice? Do you believe there are any conflicting rights for professionals to try to keep those details private?
I see biological sex as self-evident and gender identity as equivalent to any other belief system a doctor might hold, such as religion or membership in a political party. Belief systems, just like sexual orientation and other private information that isn't immediately apparent, don't need to be disclosed as long as they aren't negatively impacting treatment. Because biological sex is obvious, it cannot constitute private information and it should be stated correctly.
If a female patient can recognise that a doctor is male despite his documents stating otherwise, but due to various policies she is not allowed to challenge him or demand a female practitioner without being accused of "transphobia", than she is being gaslit when she is in need of medical care and that is unacceptable.
Transactivists try to liken single-sex spaces and services to racial segregation or discrimination based on sexual orientation, but that is a false equivalence. Men being violent toward women is a well-documented problem in our society. We have no evidence that people of certain races or sexual orientations are more dangerous than others. Therefore, a woman requesting a female doctor is both reasonable and justified in light of male-pattern violence, while discrimination against a lesbian or a Black doctor would clearly be wrong.
Speaking both as a female patient and a survivor of male violence, any male doctor who disregards my concerns over this is automatically unsafe. The burden of proof needs to be on these doctors to demonstrate that they can put their belief systems aside, and focus on delivering safe and effective care to all patients, including women. That would mean a promise not to lie about their biological sex, declaring their biological sex correctly on all documents and respecting women's single-sex spaces and boundaries.
Yours seems one of few voices of dissent from the medical profession. Why do you think this is?
When I first became aware of these issues, the only perspectives I could find were either medical or feminist, so I thought I could contribute by combining the two. Male violence was already rife online, so I chose the nickname "la scapigliata", which means "head of a woman", to symbolise my free thoughts, spoken with no fear of death and rape threats, cyber stalking and other types of intimidation men are engaging in to silence women. I had hoped things would improve and that eventually I would be able to write under my own name, but unfortunately the violence toward women and feminists has since escalated.
In medicine there's also a risk of appearing "biased" if one should advocate for women's sex-based rights, even though the profession regards male body and male authority as a default, which in practice means that male interests are heavily prioritised. This medical sexism is so deeply entrenched, that even in healthcare settings, the very concept of male-free spaces and women being allowed to say No to males is still very controversial.
How has writing about this issue affected you?
Since I started writing about cognitive and policy capture of the medical profession by the concept of gender identity, the stakes have risen and I would lie if I said that this hasn't taken a toll on me. Seeing how far our profession has departed from "first, do no harm" and evidence-based decision making, and having to conduct this debate in an extremely hostile environment, is very stressful.
This work has also taken a lot of time and energy away from other projects. I have not received any payment for the countless hours of intellectual work I have undertaken, and I am not the only one. Women and men from all walks of life - lawyers, teachers, doctors, counsellors, parents, sports coaches - are doing the work our institutions have failed to do. We are identifying pitfalls, analysing and challenging gender identity policies in the media, with the institutions directly and through the courts, and at best, we can hope that some of these dangerous policies are reluctantly withdrawn with no reflection or apology. It feels daunting.
What is your advice for any other concerned doctors or medical students, particularly those who might be afraid of engaging with this subject?
Medical students need to learn how to be safe and competent doctors, a task that is that much harder in an environment where language and science are being compromised by the introduction of thought crimes and pseudoscience. My advice to them is to focus on evidence-based information and on learning to critically appraise research, because these skills will be most helpful in separating scientific fact from belief-based assertions.
Doctors have a job to do and families to feed, so don't do anything that would jeopardise that. But do write to your College, Trust, BMA, GMC, MP, the papers, whenever you feel able, and do what you can to avoid mis-sexing the patients in the medical notes. Connect with like-minded colleagues at work and spend more time with your children, to make sure they aren't being groomed to uncritically accept unscientific ideas around gender identity. Go to Mumsnet feminist sub-forum and gender-critical Twitter. Look at the work of the Society for Evidence Based Gender Medicine (SEGM), Fair Play for Women and Transgender Trend. Soon, UK doctors will have their own group and website that will offer an alternative to affirmation-only approach. The tide is turning so come and join us if and when you can.
What are your hopes for the future? Any bright spots on the horizon?
One huge bright spot is that, if we can expose false equivalencies between transgender and intersex, then awareness of DSDs, how people are affected by them and all the medical harms inflicted on this patient population may become more mainstream knowledge. This will help this marginalised patient population receive better medical care and experience less social stigma.
Another benefit is that gender identity policies have exposed weaknesses in systems designed to provide child safeguarding and sex-based protections for women. We cannot fix what we don't know is broken, so this gives us an opportunity to improve.
Finally, I think these policies of gender identity have put gender stereotypes under a magnifying glass and I hope we will emerge from this with far greater tolerance toward gender non-conformity. Our culture is still sexually exploitative of women, as well as homophobic, and this set of ideas around gender identity amplifies these prejudices to an absurd degree. It is my hope that, going forward, we can move away from gender stereotyping. This will improve health and wellbeing of everyone, including people who identify as transgender.
Where can women find your work, and what can they do to support you?
You can find me on twitter as @lascapigliata8 and on my blog http://www.lascapigliata8.wordpress.com. I have been fortunate to receive a lot of support from feminists, colleagues and members of public. There is safety in numbers, so the best way to support us, is to join us.