When identity is not a question

The chief complaint written on the young woman’s chart was typically vague -- “personal concern.” It’s a catch-all phrase used at check-in with patients who are uncomfortable talking about private issues with reception or nursing staff.

Many patients with such problems -- often involving sexual health, proctology, gynecology or urology -- feel isolated, reluctant to talk with friends and family for advice or reassurance. Influenced by their own discomfort, they also can fear that their doctors will see their symptoms as unusual or shameful as well.

So I was determined to approach the patient with empathy and sensitivity, acknowledging her hesitation and encouraging open communication. A nonjudgmental, supportive environment would be most likely to lead to effective diagnosis and treatment.

I entered the waiting room and greeted her with a warm smile. The young woman looked like a typical college student of the mid-’90s, dressed in a casual jacket and jeans. Welcoming her into the office, I began with a general question, “How can I help?”

Her direct manner and her answer surprised me -- she did not feel like a woman, but a man in a woman’s body. She was hoping that I could coordinate her physical transition from female to male with hormone treatments and eventual sex reassignment surgery.

It was I who hesitated, who stammered out a response. Of course, of course, I would be happy to help, but I honestly had little experience or information about her needs. I would have to research the necessary resources before I could be of further assistance.

As I tried to discover the life experiences that had brought her to this decision, I could draw only upon lay articles about famous cases of gender change, such as those of Renee Richards and Christine Jorgensen, not my medical training. Was she sure that this change was what she wanted? Had she talked with someone? Had she considered counseling first?

Again, she answered confidently. An international student, she had explored these questions in her home country and had even begun a short course of hormone treatments at a local clinic until leaving the year before for the United States. Though she was attracted to women, she didn’t see herself as a lesbian, but a heterosexual male. She expressed comfort with her decision to transition and a commitment to proceed.

She politely declined my offer to have her consult with a psychologist at our counseling center. I could only assure her that I would try to assist her and find a clinic that could provide the requested services. We ended the visit with a promise to follow up with each other within the week.

I was clearly beyond my depth in terms of medical training and experience and, in those pre-Internet days, I was at a loss how to begin my research.

My textbooks and fellow primary care doctors had little to offer, so I turned to a colleague specializing in men’s health and to our local lesbian and gay resource center. Together we were able to locate a clinic in our state that could meet the patient’s expectations. We referred her for evaluation and a long-term protocol of hormone therapy and counseling that could culminate in her choice of surgery to reassign her gender.

Still ...

As a progressive physician, I had prided myself on being up to date on medical issues for a diverse community. I had worked to build an atmosphere of inclusion in my office, where, for example, my queries about sexual history were not worded to imply only heterosexual possibilities.

Yet despite my commitment to maintain a nonjudgmental perspective, I found myself questioning her decision. My training had taught me to maintain a professional distance and serve as a sounding board and resource for my patients. Now instead, I struggled with doubts as to the wisest course, even as my patient’s conviction never wavered -- were years of endocrine treatment and elective surgeries a positive choice?

I resolved to learn as much as I could about gender identity issues.

The American Psychiatric Assn. in its DSM-IV (1994) estimated prevalence of male to female transsexuals at 1 in 30,000 and female to male transsexuals at 1 in 100,000, but some recent researchers have argued that the true prevalence of gender identity concerns may be more than 10 times higher.

Over the last 10 years, substantial resources and training have become available that can help make every doctor’s office a welcoming environment for patients with gender identity concerns. For many people, the decision is clear -- they wish to live as the gender with which they identify. My patient looked like a woman to me, but the image she saw of herself -- no, he saw of himself -- was a man’s.

I came to realize that my patient’s chosen path would not bring more pain -- but a profound relief.

A few years later, the patient returned to my clinic. The chief complaint once more read “personal concern.” But this time the young person who entered my office greeted me with a broad smile and a strong handshake. Still dressed in the student’s uniform of jacket and jeans, my former patient now sported a dark beard and firm muscles. He had completed his sexual reassignment surgery and was living comfortably as a male.

I asked about the gold ring I spotted on the fourth finger of his left hand -- yes, he told me in a deep voice, he had recently married a woman from his country and was very happy. Close to graduation, he had a job lined up that he hoped would support his plans for a family.

Finally, he asked if I could help him once again. I agreed, and to his delight, was able to provide him with a new resource list -- of local adoption agencies.

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Dr. Yolanda “Linda” Reid Chassiakos is director of the Klotz Student Health Center at Cal State Northridge and a clinical assistant professor of pediatrics at UCLA.