Jan Bergstra & Laurens Buijs
Amsterdam Gender Theory Research Team
The Amsterdam UMC published a position statement on the Cass report on transgender care on its own website this week. Last week, pediatrician Hilary Cass published the long-awaited review of British care provision for transgender youth. Her report revealed fundamental problems with the diagnosis and treatment of these youths (see AGTRT-BF78).
By and large, the AUMC agrees with Cass it seems, but there are caveats. Most of the comments concern the provision of care, and we have no opinion on that in principle; we are not medics. But there is a final comment that we quote below, which we do explicitly criticize. We quote from AUMC’s website:
“
Carefulness and nuance
In England, there is what the Cass Review describes as a “culture war. Cass describes a debate around transgender care that has been poisoned by polarization. According to the Cass Review, this is detrimental not only to patients but also to clinicians and research on transgender care. The Netherlands has long been characterized by a climate of acceptance and tolerance of transgender youth, an important factor in the much better well-being of Dutch transgender youth compared to other countries. Unfortunately, Amsterdam UMC increasingly recognizes the polarizing climate described by Cass also in the Netherlands.
Amsterdam UMC therefore calls for the debate around transgender care to young people in the Netherlands to be conducted with nuance and care. The same care and nuance with which care is currently provided in the Netherlands.“
The suggestion is that transgender care is provided with care and nuance. We see this differently and have written about it several times. In the medical field, there is absolutely no interest in the social function of the concept of gender.
As far as we can tell, it is widely assumed in the medical literature that a person is transgender when gender incongruence occurs. A person is already transgender (in most cases) according to the APA when the gender identity differs from the GAAB(gender assigned at birth, see also AGTRT-BF80).
The correct term here would be that the person has a transgender identity. Indeed, about the person’s gender, transgender status says nothing yet. The medical profession is also not about that at all, because that is a matter of legislation, civil and administrative law.
This matters because the language used in the medical angle suggests that, for example, an opponent of the proposed new transgender law would necessarily have something against “better acceptance of transgender youth,” and that is absolutely not the case. Much criticism focuses solely on the definition of transgender and the growing role of self-identification therein (see AGTRT-BF76).
The medical profession, by so visibly neglecting this aspect, pretends that legal gender transition is a minor side effect of medical procedures that resolve gender incongruence and possibly remedy gender dysphoria. This removes sight of the most controversial aspects of transgendering.
Read more about the relationship between the medical profession and the legal position of transgender people:
Separating gender dysphoria from gender incongruence is essential to the legal position of transgender people
Across the board, the medical profession relies on a notion of bodily gender that has not been made explicit (see AGTRT-BF41 and AGTRT-BF42 for this concept) but at the same time in no way bears the burden of the societal battle for upholding that concept. And that is precisely what gender is about. With the language used, the medical system is co-essentialist when it comes to transgender care and essentialist when it comes to other care. This falters, and we see the obvious lack of reflection on it as a lack of nuance.
When a patient enters a hospital, whether that person is male or female still matters. Thereby, the idea that that is determined by what the person himself thinks of it in practice is not an issue, because it then actually goes without saying that physical gender is meant.
Three controversies play out interchangeably in the gender debate:
- Essentialism (gender = GAAB) versus co-essentialism (gender = gender identity), and beneath the surface: is gender primarily physically determined or is it primarily socially determined. This controversy is now complicated by the increasing prevalence of individuals who claim to have a neutral gender.
- Allowing gender erosion (the irrelevance of the male/female distinction) versus avoiding (or even fighting and undoing) gender erosion.
- The medical practice of treating gender incongruence (see also AGTRT-BF83, in which we criticize a WHO definition of gender incongruence) and gender dysphoria. Here there is disagreement (controversy) about how and the timing of addressing these problems in youthful clients/patients.
Read more about our critique of the WHO definition of gender incongruence:
WHO does not have sharp definition of transgender, and creates ambiguity with term “experienced gender”
Only point 3 is a matter for medics; points 1 and 2 are not, initially. There is, however, a medical aspect to point 1, namely when the possibility of legal gender transition (and in particular the application of that possibility to a specific person) is deemed medically necessary as the capstone of a medical phase of gender transition.
That state of affairs is by no means a foregone conclusion, and it is critical to maintaining the option of legal gender transition that the medical community be aware of the theoretical background of this matter. If that is condescended to because, after all, it is “not really medical,” then in time the possibility of gender transition is lost is our expectation.
But points 1 and 2 do involve sharp social controversies, both nationally and internationally. Thus, on both issues, the positions of Russia and Iran are explicitly opposed to Western positions, and it cannot be ruled out that the upcoming elections in the United States will be decided through these themes. The future of the German coalition is also very sensitive to this.
The Roman Catholic Church, the Russian Orthodox Church and a number of Evangelical Christian groups hold largely essentialist views. The Islamic world is divided on point 1 but not on point 2: The importance and necessity of combating gender erosion is quite universally endorsed in Islam. Leftist movements today, on the contrary, tend to be co-essentialist. Within feminism, both point 1 and point 2 lead to division and controversy.
The medical profession does not give sufficient consideration to the fact that the correct course of action is not to implicitly presuppose controversial positions on 1 and 2. So in our view, this is explicitly not done to a sufficient degree: there are implicitly such assumptions. In doing so, transgender care does contribute to the polarization around gender.
In any case, to improve practice, the relationship between gender and gender identity must be made explicit. If this is done really well, then it will also become clear why we believe that the word nuance is too easily used to describe AUMC’s position. By the method used, AUMC is unnecessarily contributing to polarization around the issue of gender.