Male and female gender symbols. Crowd of people by gender symbol. 3d render.

Hastings Center News

Gender-Affirming Care for Cisgender People: Q&A with Theodore Schall and Jacob Moses

The term “gender-affirming care” is almost always applied to treatment for transgender people, but an article in the current issue of the Hastings Center Report argues that such care predominates among cisgender people, whose gender identity matches their sex assigned at birth. In this Q&A, the authors discuss why having a broader view of gender-affirming care matters—for respecting patients, mitigating bias, and reducing polarization in discussions about transgender and gender-diverse people. Schall is a PhD candidate in bioethics and health policy at the Johns Hopkins Bloomberg School of Public Health and an incoming assistant professor of health policy and management at the University of Massachusetts Amherst. Moses is an assistant professor of bioethics and health humanities at the University of Texas Medical Branch at Galveston.

Why is it important that doctors, patients, and the general public see gender-affirming care as something that anyone can need and benefit from at some point in their lives?

Jacob Moses: We argue that gender-affirming care is used most often by cisgender people. This suggestion may initially strike some readers as odd. After all, basically all discussions of gender-affirming care in professional and public settings have focused on trans and gender-diverse people and their ability to access this kind of care. But one effect of emphasizing the particular needs of a marginalized community has been to exceptionalize transgender medicine, disconnecting it from the kind of care provided in other areas of medicine and to other populations. To some extent, this has been a move made by both supporters and skeptics of transgender health care. We think this can obscure how many of trans and gender-diverse people’s needs are not unique. Arguments grounded on equality have been important in LGBTQIA+ health care and queer bioethics.

Theo Schall: We hope that readers will think more critically about their perspective on trans health care, especially if they (like many people) see trans gender-affirming care as less legitimate than other areas of medicine. If you support and understand gender-affirmation for cis people (for example, you think breast reconstruction after mastectomy serves an important purpose for cis woman patients), the question becomes: what’s different between cis and trans care? Why is one more legitimate than the other? We contend that at least some of the difference is likely to be anti-trans bias, which is pervasive in our society at large and in medicine. Recognizing this bias is the first step towards mitigating it.

You cite several interventions received by cisgender people as being gender-affirming, including breast reconstruction following mastectomy, penile implants following testicular cancer, hormone replacement therapy, and hair removal. In what ways are they gender-affirming, at least to some people?

Jacob Moses: My training is in the history of medicine and bioethics, so I was drawn to look at these historical cases. As we discuss in the article, it turns out many patient groups in the past have advocated for the availability of medical interventions to align their bodies to match their sense of who they are and how they present themselves in society. I was really struck by how similar justifications grounded in authenticity have been offered by both cisgender and transgender patients for why they should—or shouldn’t—elect particular interventions. And to be clear: we think either availing oneself of or declining medical interventions can be gender-affirming. This contrasts with some prior models of transgender medicine that encouraged or even required trans and gender-diverse people to pursue a whole range of interventions to “pass” as cisgender in society.

Theo Schall: These common treatments allow cisgender people to live more comfortably in their bodies and to realize authentic versions of themselves. They help people recover their full humanity after traumatic injuries and life-threatening illness. Gender is an important part of that full human experience, and giving people the gendered bodily experiences that align with who they are contributes to overall well-being.

Why did you choose cisgender reconstructive interventions as the useful analog to the interventions offered to transgender individuals, rather than cosmetic interventions like breast enlargement or, for men, the enlargement of a jaw line?

Jacob Moses: The other kinds of interventions you name could also have gender-affirming goals. One reason we focused on cisgender “reconstructive” procedures, rather than “cosmetic” ones, is the history of reconstructive surgeries shows that, not so long ago, procedures like reconstructive mammoplasty or testicular implants were not seen as medically justified interventions in the view of many practitioners and in health policies. This might come as a surprise to some readers who might assume that reconstructive interventions have always been accepted as more legitimate than cosmetic ones. The line between reconstructive and cosmetic intervention is actually blurrier than you might think. And it’s been one that’s been redrawn over time. We focus on cisgender reconstructive procedures because they’ve undergone the greatest change in health policy and these debates from decades ago strongly echo current discussions of transgender health care.

Theo Schall: Hair plugs, testosterone therapy for “low-T”, even surgeries like jaw recontouring–these help many cis men to feel more masculine. Of course, there are whole industries that help cis women feel more feminine and womanly. The marketing for these treatments is often eerily similar to the way gender-affirming surgeries are marketed to trans people, a similarity that started us down the path to writing this paper.

You emphasize that the key factor in determining whether an intervention is gender-affirming is whether a patient considers it so. Explain why it is the patient’s perspective—and not the medical provider’s—that is decisive?

Jacob Moses: That’s right. Some may think that invoking core bioethical concepts, like patient autonomy, could get you to the same place. But given the significant force gender plays in how people present in society, we thought it was important to emphasize the role of affirming gender—and we’d include here nonbinary and other expressions of gender diversity. We think it’s important to recognize that gender-affirming care is not just a set of technologies or interventions, but rather a stance that health care providers and systems adopt toward patients. Using a patient’s preferred name and pronoun are signs of respect, but also forms of social gender-affirmation.

Theo Schall: There’s a dark history of providers deciding for trans people, of limiting care to only deserving trans people who would look and act the way clinical teams thought people of a specific gender should act and look. As paternalism has given way to alternative models of patient-centered care and shared decision-making, trans medicine has become much more focused on individual experiences of gender, allowing for a greater diversity of experience. Cis people deserve the same autonomy over their bodies and their expressions of gender that trans people do. Cis or trans, the patient is the expert on their own life, and it is their experience of gender that is affirmed. There’s simply no one else who can know what an individual needs to be themselves, other than the patient.

Jacob Moses: Taking the patient’s perspective seriously is necessary because there’s not an MRI for gender identity. But even if there were, the patient’s perspective would be absolutely vital. Consider how a reconstructive mammoplasty after mastectomy operation that is gender-affirming for one patient who elects it could be wholly inappropriate for a patient who feels such intervention would be alienating. In the case of mastectomies for breast cancer, some patients elect to reconstruct and some who choose to “go flat,” perhaps because they view reconstruction as participating in gender norms they resist or simply because they find it unnecessary for them. In our view, both decisions can be gender-affirming. Similarly, there are some trans and gender diverse people who seek medical interventions while others do not. It’s important to emphasize that gender-affirming care is a mode of respecting patients as they exist in a broader social context. In many ways, the move in recent years to more affirming models of transgender health overlaps with longstanding commitments in bioethics to respect patients as people.

What effects do you hope that your ideas have on medicine? On the politicized debate over care for transgender people?

Jacob Moses: The current discussion about health care for transgender and gender-diverse people has become highly polarized. Our hope is to show that some of what’s at stake in medicine is very consequential for trans and gender-diverse people but not starkly different from the kind of respect other groups of patients have sought. I think one important role of bioethical scholarship and historical research can be to bring context and perspective to bear on discussions that have been lamentably politicized. Historical analogies alone cannot resolve every question of ethics and policy. But they can help identify commonalities between seemingly disparate groups that are not initially self-evident.

Theo Schall: I hope that providers of cisgender gender-affirming care come to see their work in these terms and to value it more highly. Gender affirmation makes a tremendous difference in quality of life for both cis and trans patients and should be more widely accepted as an ordinary part of patient-centered care. It’s usually a very rewarding practice for medical providers, too–patients are grateful to be seen and cared for in this deeply personal way–and I hope providers feel proud of their gender-affirmation work with their cis and trans patients. In the long run, my hope is that we normalize and improve gender affirmation for cis patients, leading to greater understanding of and support for trans gender-affirming care.

You call on bioethics to illuminate and attempt to mitigate bias and reduce unjust differences in access to necessary care for transgender people. What should bioethics do now?

Jacob Moses: A founding impetus of bioethics was that new technologies can raise new ethical and social questions. In addition to recognizing novelty and change, it can also be important for bioethics to appreciate connections between the past and present. In this case, recognizing the historical similarities between gender-affirming care for cisgender and transgender people can help expose forms of discrimination in health policy. Here, as in other areas of health care, there remain vast disparities and forms of injustice in LGBTQIA+ health. Structural barriers in access—whether that’s lack of insurance coverage or discriminatory laws—can hamper goals of gender-affirmation. There remains much work to do.

Theo Schall: One important role for bioethics is to clarify the values that animate opposing sides in the debate over trans lives and trans health. Many anti-trans arguments are rooted in religious values and it’s important for our pluralist country to clearly see the religious nature of many anti-trans claims, and to limit these arguments to the relevant settings. Other anti-trans arguments are essentially unfounded, or based simply in bias (transphobia), and this feature, too, ought to be clarified (and these positions heartily refuted). More pragmatically, bioethicists in medical and research institutions have an important role to play as advocates for a marginalized community that faces substantial medical discrimination. There’s always more to learn and I encourage you to spend a few extra minutes this June reading about the unmet needs of trans and gender diverse people.