The Questions in Gender-Affirming Medicine Aren’t What You Think
We asked providers and researchers what the open questions in gender-affirming medicine were. Their answers might surprise you.
by Veronica Esposito
In the mainstream press, conversations around gender-affirming medical care for trans people currently focus on whether young people should be granted access to medical interventions such as hormone therapy or puberty blockers, and if so on what terms. However, among medical and mental health professionals who specialize in this care, this is largely a resolved issue. A recent research paper found that, of the medical organizations who issued an opinion on gender-affirming care for minors, almost all of them (33 out of 35) were unambiguously in favor. When it comes to the experts, there’s less “debate” in this debate than it seems.
If those who specialize in serving and improving trans people’s medical care aren’t focused on questions occupying the mainstream, then what do they think about? When it comes to the future of transgender medical care, what are the most interesting questions for people in the field?
Question: How can transgender medicine be better integrated into mainstream medical systems?
For researcher Eric Plemons, the most interesting questions revolve around making gender-affirming care less of an outlier, and folding it more into the mainstream of medicine. Plemons, who describes himself as a “medical anthropologist” and who has written extensively on transgender surgeries, has centered his research around the politics and practice of trans medicine and how institutions shape this care.
Plemons takes an institutional look at the recent history of transgender medicine. According to him, major moments in gender-affirming care since 2000 occurred when the Harry Benjamin Standards of Care—which were the original guidelines for medical professionals seeking to support a gender transition—transformed into the World Professional Association for Transgender Health in 2006, and when the Affordable Care Act was enacted into law in 2010. He sees these events as creating an unprecedented expansion of trans people accessing medical care. “The passage of the ACA was super significant in expanding insurance coverage,” he told me via video call. “It’s a big reason why we’re seeing this explosion in youth in hospitals. That’s a piece that I think people never really talk about when they say things like, ‘oh, it’s the teenagers making each other trans.’”
As Plemons tells it, the influx of funding occasioned by the passage of the Affordable Care Act dovetailed with a destigmatization of trans identities, leading to a dramatic expansion of clinical capacity, which Plemons believes will define the near future of transition medicine. “We’re working past the bubble of people who wished they could access this care for 20 years. As things level out, that’s really going to help insurers and institutions anticipate costs. That predictability, and making it usable and accessible, is really important for long-term stability.”
This is also an era that Plemons hopes will be characterized by the medical world learning to create a cohesive narrative around trans surgeries. “Learning to tell a single story about what surgeons are trying to achieve by doing these procedures is going to be the most important thing for surgery going forward,” he said. “Medicine doesn’t like nuance. On the justice side, it’s awesome for people to be able to pursue the bodies they want, but on the medicine side that’s a really dangerous situation to be in, because there’s no way to tell if you’re helping or harming people. It doesn’t fit with our medical system.” As an example, Plemons noted that gender-affirming care might be more comprehensible to the medical system if the current panoply of treatment outcomes could be more narrowly tailored toward a few specific benefits.
Doctor Dragana Vagic, a Los Angeles–based internal medicine physician who has specialized in serving trans people in various medical capacities for over a decade, has also seen an influx of trans people seeking medical care. According to her, the larger numbers of trans people medically transitioning has led to much more widespread training and competence in the basics of providing all sorts of medicine to trans people, a trend that she expects to continue in upcoming years. “There’s much more interest and desire to provide this care, and also an increase in competence,” she said. Vagic believes that the medical profession will continue to integrate an understanding of trans people into its basic competencies, and that larger and larger numbers of professionals will come to collaborate, offering more holistic care to trans people.
Question: How will best practices for surgeons and endocrinologists change as options expand, younger people transition, and non-binary transitions become more common?
Sam Davis, a Bay Area–based Licensed Clinical Social Worker who has a research background in gender-affirming care, agreed that the depathologization of trans identities has been a major development in trans medicine that will resonate for years to come. “There has been a huge explosion in the availability of information to younger people,” they said. “That plus the education and growing acceptance of parents has been mind-boggling.”
These major changes in depathologization and the spread of information may very well impact the kinds of surgeries that are offered to trans people. For instance, when it comes to vaginoplasties, the gold standard has typically been the penile inversion method, where skin from the penis and scrotum is used to line the inside of the newly formed vagina. But as patients begin their transition earlier, that might change, as transfeminine individuals who have not had significant levels of testosterone do not possess anatomy appropriate for the penile inversion method. “You’re going to see more colon section vaginoplasties, or taking skin from other parts of the body,” Plemons said. “So that is going to make a shift in vaginoplasty practice. That’s definitely something that surgeons are talking about.” This could, in turn, alter the forms of surgeries offered to those who are transitioning as adults.
Plemons also believes that uterine transplants could become a possibility one day, arguing that—insofar as transplants for trans patients are concerned—these surgeries are the closest to becoming a reality. He noted that such transplants are already underway on cisgender women in 18 nations, although he described the science around uterine transplants on transgender individuals as currently “unsettled.” “There are some people who think, yes, there would be no anatomical reason why a trans woman couldn’t receive a uterus transplant to become pregnant,” he said. “And there are other people who disagree.”
In the past, gender-affirming care has revolved around medicine that helps individuals reach either a binary male or female appearance, but the increase in non-binary identifying trans people has created a demand for more options for those who do not desire cis-normative bodies. Plemons noted that, thus far, there are very few surgeons offering genital reconstruction that diverges from the binary mainstream (for example, a phalloplasty constructed while leaving a patient’s natural vagina intact, or vice versa), but he expects that to change. “More surgeons will be willing to produce so-called atypical genitalia,” he said.
Question: Can understanding gender diversity have a positive impact on research dealing with aspects of biology and sex?
In the realm of hormones, Davis also argued that future directions in trans medicine could move away from centering binary identities. They pointed to research spearheaded by Krisha Aghi, a disabled, trans woman of color working out of UCLA, who has sought to deconstruct the concept of sex at a hormonal level. Specifically, Aghi argues for an understanding of sex not based on physical characteristics such as genitals or things like beards, breasts, and similar markers, instead basing sex designations on circulating hormonal levels in the person’s body. Citing Aghi’s research, Davis argued that, “sex is currently a binary variable. It completely ignores the idea that there are different hormone levels and different genes. You can look at hormonal levels instead of dividing everything into male and female. That lets you do much more sophisticated research, which starts to include trans and nonbinary people.” Davis added that such research could also yield considerable benefits for cisgender individuals, as most medications are currently only tested on cisgender men, leaving out dosages and efficacies for cisgender women.
Regarding hormones, Vagic stated a hope for studies to win FDA approval for hormone replacement therapy, which is currently prescribed “off-label.” (Around 10 - 20% of all medications prescribed are done so via off-label practices, according to research published in JAMA.) She wants to see better research into HRT both to win FDA approval and to offer more tailored approaches for trans individuals. This would include research as to the impacts of progesterone administration and of various testosterone-blocking medications, both of which currently lack research. “We still don’t have enough studies into optimal doses,” she said, “because not everybody has the same, BMI, same height, same weight, same race, right?” FDA approval would also have the benefit of offering more protections to trans people against legislative attempts to cut off access to HRT.
Question: Will regional differences in ideological influence on medicine and legislation create oases of high quality care?
Regarding recent legislative attacks on trans people, Plemons believed that access to gender-affirming care would concentrate in certain areas, following a path similar to abortion providers. He also argued for the importance of insurers to the equation. “There’s a lot more social acceptance of trans people than the political landscape would make it seem. As long as that’s the case, insurance will continue to cover it.” He also noted the importance of Catholic hospitals, as the Catholic Church recently issued guidance contrary to providing gender-affirming care. “There are some states where 70% of the hospitals belong to Catholic hospitals,” he said. Ultimately, Plemons imagined a world in which gender-affirming care continued to be provided by public and private medical insurance, but where trans people might have to seek out a willing provider. “You might get sent around to places that have become inaccessible, or if you needed aftercare or something acute, you may not receive the care you desire.”
Ultimately, among the professionals consulted for this piece, the story being told was one of the ongoing fallout of trans people presenting for medical services in numbers and ways that have never been seen before. This is a story about how the medical system understands bodies, as it makes room for those that are not cis-normative, as well as about the backlash among those who do not believe such bodies are inherently legitimate. Given these considerations, the next few years are likely to be characterized by continued negotiation of these questions, as some parts of the medical system attempt to incorporate trans needs into the mainstream, while other parts perhaps find ways to exclude the aspects of trans medicine that they feel opposed to.
Veronica Esposito (she/her) is a writer and therapist based in the Bay Area. She writes regularly for The Guardian, Xtra Magazine, and KQED on the arts, mental health, and LGBTQ+ issues.