Gender Identity Crisis

[~Zaria~]

Assalamu-alaikum,

Today I was faced with an interesting situation.

Ive actually been dreading this for some time, but I guess it was bound to happen sooner or later.....

Today, I met a 16 year old girl who was referred to our clinic by a psychologist with a 'Gender Identity' problem - and who is requesting 'Corrective surgery'.

She has been born and raised as a female thus far. However she tells me that:

- Since pre-school, she has identified herself as a boy.
- Her first kiss (in pre-school) was with a girl.
- Her friends would comment on her behaving like a boy - to which she replied: "i am a boy" (this occured at a very young age as well).
- She preferred 'male' toys as a child, and never played with dolls.

At present - even though she has developed and matured as a normal female - she has done everything possible to look like a boy:
- She dresses in masculine clothes.....including male underpants.
- She has strapped her chest wall - so that it appears flat.
- She speaks in a very deep voice.
- She exercises excessively, takes protein supplements to build muscle mass and does weight-lifting.

In fact, I was so confused when I met her initially - I had called for MS. X......then saw her and said - 'it looks like they made a mistake on your clinic folder'......then realised the situation, and tried to mumble my way out of that jam! :/

I realise that there are many possible 'Disorders of Sexual Differentiation' - which could medically explain this situation.

But I have a terrible feeling that these investigations are going to be normal - with a normal, female 46XX karyotype and normal hormonal levels.

And in this case......what do i do?

Firstly, i cant understand how a CHILD will perceive him/ herself as being of the opposite gender (without a medical reason).

And secondly - I do not want to be involved in the 'make-over' of this individual (should all work-up be negative).

Then, how do i manouevre myself out of this case?

Do I tell her: 'Ms X, you are a girl. Now start behaving as one, and hopefully you will soon feel the same'?

Even if I refer her to someone else, wont I be sinning - by 'directing' her towards those who will assist in her gender 'correction'?

What do I do?? : (((

 

[جوري]

You're not under obligation to treat a patient you don't wish to treat however you can' t abandon her and you must refer her to someone else (who that someone else is to your descretion)It can be another psychiatrist- she's not even emancipated yet to make that kind of life altering decision- I sure as hell didn't know what I wanted at age 16, you can't just up and get a sex change and take hormones, they need extensive counseling sometimes up to 20 plus years. You're a doctor you can do anything and no one can force you to do anything you're not comfortable with!
Are you in the U.S by the way? because that's part of medical ethics. I am not sure how things are run elsewhere per ethics but that's how it is here!

 

[~Zaria~]

You're not under obligation to treat a patient you don't wish to treat however you can' t abandon her and you must refer her to someone else

JazaAllah khayrun for your reply sis.

I realise Im not under obligation to treat her (if this goes against my belief system)........but neither do I feel obligated to refer her to anyone else.

Why should I refer a perfectly developed female for gender correction surgery?

The problem is, that I will most likely get a complaint laid to the superintendant if I were to I simply turn her away......:/

(who that someone else is to your descretion)It can be another psychiatrist- she's not even emancipated yet to make that kind of life altering decision- I sure as hell didn't know what I wanted at age 16, you can't just up and get a sex change and take hormones, they need extensive counseling sometimes up to 20 plus years. You're a doctor you can do anything and no one can force you to do anything you're not comfortable with!
Are you in the U.S by the way? because that's part of medical ethics. I am not sure how things are run elsewhere per ethics but that's how it is here!

She has been through a psychological/ psychiatry evaluation, and according to their assessment, they are satisfied that she is well adjusted as a male - and recommends assisting her in this regard.

Most gender-correction surgery is performed as early as possible/ as soon as the individual begins to strongly identify him/herself towards a particular gender --> this is with regards to cases where a medical condition is found e.g patients who are True Hermaphrodites (they have both male and female reproductive organs to varying degrees).

In these cases, the consent of a parent/ adult guardian would be required.

With regards to 'normal' individuals who are seeking 'corrective surgery', Im not actually sure of the protocols involved (apart from requiring a psychological assessment).

I guess my problem lies here:

How is it possible for a 4/5 year old child to identity himself with the opposite gender?

I cant imagine media influences having such a profound influence from this young.

Or what are we missing??

Is there possibly a valid biological reason for this - that we have not as yet found?

Or is this just a trial that Allah (subhanwataála) has placed on certain individuals - where they feel 'trapped' in the 'wrong' body? (Im dont feel comfortable with this reasoning though.....;/)

I kinda feel sorry for this young girl.
She has believed that she is a boy for as long as she can remember......when she was still an innocent child.

And she has gone to such drastic lengths to be able to feel like the opposite gender.

Im personally hoping that her investigations reveal some hormonal abnormality (even though this seems very unlikely from I can tell......).

At least then, I will be able to rationalise it.

Allah knows best.

 

[جوري]

Can you let me know what kind of doctor you're? that will actually play a large in the matter, if you're a GP or a GYN there's nothing you can do for her anyway. Referring her will take the responsibility off your hands and there's NO penalty for that under the law it is actually on your side. We have OB/GYn who are not comfortable performing abortions even in perfectly legitimate conditions that require them, that's why people go into partnerships and that's why we have consultants and referrals, exactly what do they want you to treat her for unless corrective and/or plastic surgery is your field of expertise I don't see how this would affect you under any circumstance? Just do what you normally would do for someone who seeks your help and set her on her way. I have had all kinds of patients I didn't like and some whom I didn't want to treat. I didn't abandon them until I made sure someone else was taking care of it, not that I had a choice anyway during my clerkships.

 

[Who Am I?]

I can relate to this in a way since I have a racial identity crisis. :hmm:

 

[glo]

What is your profession, Zaria? What I mean is, in what way would you be involved in this process?

 

[Insaanah]

Firstly, i cant understand how a CHILD will perceive him/ herself as being of the opposite gender (without a medical reason).

How is it possible for a 4/5 year old child to identity himself with the opposite gender?

I cant imagine media influences having such a profound influence from this young.

Or what are we missing??

What was the family set up like as a child?

Does she have any siblings, and if so, are they male or female, and what number child is she?

Did the parents want a boy, and subconsciously it reflected in their mannerisms? We don't give children enough credit, they do pick up on this type of thing.

Does she have brothers, who were praised more than her as a child, so she felt that's what she needed to do to gain approval? Or did she feel she didn't get on with her sisters, or that they didn't like her, and thus felt closer to her brothers?

Sometimes (but not always) you find that men with homosexual feelings are brought up in matriarchal families. Was there an extended family with grandparents, uncles, aunts?

What did she watch TV wise as a child etc?

She may say everything was fine, but most likely if there were such factors involved as mentioned above, that she picked up on then, she might not be able to pinpoint them now, looking back after all these years, and she would most likely feel that everything was fine.

On the other hand, maybe it was none of these, Allahu a3lam.

Even if I refer her to someone else, wont I be sinning - by 'directing' her towards those who will assist in her gender 'correction'?

There's normally a conscience clause somehere, that enables you to refuse, but you must refer onwards. Not just doctors, but pharmacists also, who may not want to be involved in the supply of the "morning after" pill, can refuse to supply on grounds of belief, but must signpost to other places from where the patient may obtain a supply. Professionally, not referring isn't (in most cases) an option, even though you may feel uncomfortable and may feel complicit in it. As to whether it's sinning, Allahu a3lam, but as sister منوة الخيال said, you can at least take the responsibility off your hands, that's something you can do, and perhaps within the constraints you're in, the only option you have.

 

[~Zaria~]

What is your profession, Zaria? What I mean is, in what way would you be involved in this process?

I am training as an endocrinologist (which deals with hormonal-related problems - e.g. diabetes, thyroid, adrenal, male/female reproductive problems, etc).

I work in a public sector hospital - which means that I cannot actively chose which patients are referred to me.

Unfortunately, individuals who are seeking gender correction surgery are being referred to us in increasing numbers (this is a relatively new trend in my country, and esp. in an impoverished public health sector as ours).

When such individuals are seen for the first time, we try to exclude any hormonal/ genetic basis for their problem.

For me, finding something wrong would be the best scenario (as weird as this sounds) - as it means that the person has a genuine medical cause for his gender crisis.

However, in the far majority of cases - the person is completely 'normal' both physically and biochemically......yet is requesting gender corrective surgery.

My part in this story would involve: prescribing male hormones to a female wanting to change (i.e testosterone) or female hormones to a male wanting to change (i.e oestrogen).
This would be required at mega doses and life-long, starting before the surgery even occurs --> to achieved the 'desired' outcome.

In other words - this young girl is actually asking me to prescribe testosterone (at a dose that would even exceed male requirements) - to enable her 'metamorphosis'.

If you are feeling confused right now......dont worry - so am I!

What was the family set up like as a child?

Does she have any siblings, and if so, are they male or female, and what number child is she?

Did the parents want a boy, and subconsciously it reflected in their mannerisms? We don't give children enough credit, they do pick up on this type of thing.

Does she have brothers, who were praised more than her as a child, so she felt that's what she needed to do to gain approval? Or did she feel she didn't get on with her sisters, or that they didn't like her, and thus felt closer to her brothers?

Sometimes (but not always) you find that men with homosexual feelings are brought up in matriarchal families. Was there an extended family with grandparents, uncles, aunts?

What did she watch TV wise as a child etc?

She may say everything was fine, but most likely if there were such factors involved as mentioned above, that she picked up on then, she might not be able to pinpoint them now, looking back after all these years, and she would most likely feel that everything was fine.

On the other hand, maybe it was none of these, Allahu a3lam.

Wa-alaikumsalam,

She had been consulted by both a psychologist and psychiatrist, and so I did not go into great detail with regards to her social background.

However i do know that:

- she has an elder brother.
- her parents are divorced (as is commonly seen here).
- her mum does not approve of this - hence she is now living with her gran. (her parents would tell her that she is merely 'going through a phase that would soon pass' as she was growing up).
- Im not sure what she has been exposed to in the media as a child (before 4/5 yrs)

There's normally a conscience clause somehere, that enables you to refuse, but you must refer onwards. Not just doctors, but pharmacists also, who may not want to be involved in the supply of the "morning after" pill, can refuse to supply on grounds of belief, but must signpost to other places from where the patient may obtain a supply. Professionally, not referring isn't (in most cases) an option, even though you may feel uncomfortable and may feel complicit in it. As to whether it's sinning, Allahu a3lam, but as sister منوة الخيال said, you can at least take the responsibility off your hands, that's something you can do, and perhaps within the constraints you're in, the only option you have.

In the past, I had been 'shielded' from these sorts of cases - as a collegue in our division was the 'expert' in this field......and so, the rest of us happily asked these patients to sit in front of her door.
She has now left......and Im not sure what will become of the rest of her patients either.
(It gets really disturbing......:/)

In this case, I would ideally like to tell the young girl: 'You are a normal female. Go home, put on a dress and all will be ok!'

I dont think thats going to work though!

And I also feel guilty to refer her to someone who wouldnt mind helping her.

---> Would it not be similiar to this scenario:
A man walks into your shop requesting a bottle of beer.
You tell him that you do not supply alcohol......BUT here are the details, address and phone number of where you can buy some!

I would be consciously referring her to someone who i KNOW would embark on 'turning' her into a male!

: (

 

[جوري]

In this case, I would ideally like to tell the young girl: 'You are a normal female. Go home, put on a dress and all will be ok!'

Again sis, you don't have to tell her anything by way of advise, simply refuse to prescribe the medication as it is unnecessary- and that's actually what you have to say. I don't see an organic disease that merits treatment with testosterone or any other hormones. .
I have come across two or three people like that and the doctors who refused to treat them. In fact a funny incident once where the the she male asking for treatment was denied by a lebanese doctor who was actually a maronite (christian) and this particular she male was telling me how that doctor is the 'devil' for refusing her/his 'treatment'.
I really fail to understand why refusing to prescribe hormones is a problem in this case.
Let's reverse gears a bit and say a patient came to you asking for narcotics or pain relief and they came to you as a referral from a 'pain clinic' do you not make an executive decision on whether or not this person is abusing the system or is in actual need of medications? Do you just hand out prescriptions for the asking? You can actually lose your license when audited for that!
Don't make it into something it is not. Simply refuse to prescribe it is your privilege!
You can't also be made responsible religiously for referring someone. Else practically everything you do will have some ramifications.

Mani ihtada fainnama yahtadee linafsihi waman dalla fainnama yadillu AAalayha wala taziru waziratun wizra okhra wama kunna muAAaththibeena hatta nabAAatha rasoolan​

17:15 Who receiveth guidance, receiveth it for his own benefit: who goeth astray doth so to his own loss: No bearer of burdens can bear the burden of another: nor would We visit with Our Wrath until We had sent an apostle (to give warning).
​

else simply handing someone a butter knife would be a cause to go to hell.

and Allah swt knows best,

 

[~Zaria~]

^ If I refuse to prescibe hormones to her (as is my plan) - would mean that I also tell her that she is discharged from our care (as there is no need to see her at the clinic if she is not being actively treated).

Problems with this is:

1. Im not able to discharge her, as our clinic is the only unit that specialises in the care that she is looking for.

2. If no one else is willing to assist her in my dept (which is very likely) - I need to refer her to someone who will.
--> I dont think this scenario can compare to handing someone a butter knife (which has many uses, not only for harm).
In this case - I would be sending her to someone who I know would assist her to become a male.
And i feel that i am still wound up in the process (unwillingly).

Unfortunately, to be honest, i dont think i have many other options.....

I pray I dont have to see such individuals again.
Ameen.

 

[جوري]

^ If I refuse to prescibe hormones to her (as is my plan) - would mean that I also tell her that she is discharged from our care (as there is no need to see her at the clinic if she is not being actively treated).

Problems with this is:

1. Im not able to discharge her, as our clinic is the only unit that specialises in the care that she is looking for.

2. If no one else is willing to assist her in my dept (which is very likely) - I need to refer her to someone who will.
--> I dont think this scenario can compare to handing someone a butter knife (which has many uses, not only for harm).
In this case - I would be sending her to someone who I know would assist her to become a male.
And i feel that i am still wound up in the process (unwillingly).

Unfortunately, to be honest, i dont think i have many other options.....

I pray I dont have to see such individuals again.
Ameen.

I'd treat her like I would a person with munchausen syndrome or hypochondriasis. Schedule appointments and see her give her a checkup and don't send her home with prescriptions. Usually endocrinologists here are also internists who go for a fellowship therefore you can just treat her as a general practitioner and have follow ups and don't release her until she herself decides to go somewhere else.
And as a last note. You don't know if the person you send her to will be assisting her or not, simply referring someone doesn't denote that the other doctor will take that case on. I have seen many of those unfortunately with cancer patients, who doctors with excellent 'track record' refuse to treat them because of a known morbidity/mortality rate. So you place undue burden on yourself and you have to take it easy, believe me these aren't the difficult cases that you should lose sleep over..

 

[Muhaba]

Well, since you are a Muslim, you can explain to her that as a Muslim treating her to change her gender or referring her to someone else who will do the same is a sin. Then you can explain to her about the Islamic rule of not altering God's creation.

You couold go for spiritual councelling, tell her that everything God creates is just right and shouldn't be changed; that if she were meant to be a male then God would have created her male and not female. everything that happens is according to God's knowledge and Wisdom; nothing happens randomly so there is no reason why someone should want to change their gender.

Also explain to her that we are all God's creation and equal in God's Sight, that men and women are equal in God's Sight and that both were created for specific roles to play in the world and that each of those roles are equally important; the man's role is no more important than the woman's role and the woman's role is no more important than the man's role.

Show her the verses of the Holy Quran about Mary mother of Jesus (Maryam alaiha assalaam): Mary's mother had vowed to give the child she was pregnant with to serve Allah but when she had the child it was a girl. so she wondered how a girl could serve God since a woman's work is different from a man's: But Allah said that He knew what she bore and that the male is not like the female. Yes, Allah said in the Quran that THE MALE IS NOT LIKE THE FEMALE. That is because a male cannot do the work of a female.

normally people say that the female is not like the male because they think that the male's work is better than the females. But Allah didn't say that the female is not the male but that the male is not like the female. In that particular case, a female was better suited for the work that was to be done. God gave Mary great honor. Likewise God has given all women great honor in the very important work that they have to do which is childbearing and rearing. Men no matter how strong they are, can not raise children as well as women. This is because a woman's psychology is better suited for tolerating children. most men can't tolerate children so can't raise them as well as a woman. this is why children raised by single fathers suffer more psychologically than children raised by single mothers.
furthermore, a woman's job in the world is unique and irreplaceable but not given much credit. rather it is looked down upon. but if you compare a woman's work with a factory you can see how important it is. think of how much a car manufacturing company earns and how important they are. every woman is more important than the most important manufacturing company. this is because the human being is produced inside the woman!

when your patient learns of these facts, she may look at her in a different light. If she shows interest, you can guide her to an Islamic scholar who might help her learn about Islam.

See Chapter 3, verses 35 - 37 about the birth of Maryam Alaiha assalam

 

[~Zaria~]

^ JazakAllah khayrun ukthi.

I like your approach : )

 

[جوري]

That's indeed a lovely approach, the question however remains does she see you as a doctor or as a spiritual counselor? Do you know her well enough to explore the grounds of the philosophical & religious with her and what her reaction will be with that and how that reconciles with doctor/patient ethos? I come from a place where doctors don't make house calls and call patients 'clients' I hope the situation where you're practicing differs from that for those attempts to be successful!

 

[~Zaria~]

^ I said that i like the approach.
I didnt say that I think it would work, lol ;p

Seriously though, I would like to think of myself as both: alhamdulillah, a doctor and if my patients give me the chance (and sometimes even if they dont : ) ), a 'spiritual counsellor' as well.

We cant subtract Allah (subhanawataála) from anything in life......including when we are trying to help others.

And we should be trying to include some part of dawah in our conversation, whenever we get the chance.
In fact, even if we dont get the chance in a conversation, one who is 'fluent in dawah' knows how to 'lead' a conversation towards the greatness of Allah and His Oneness.

May Allah make us all of these type of people.
Ameen.

In this case, I guess its worth a try - what can I lose by speaking about Allah? (The worst that could happen is that she lays a complaint against me for trying to educate her about Islam. My counter-argument would be: 'She thinks shes a BOY.....she needs all the advise she can get!' : ) )

From her first visit to me though, I can tell that she is quite fixated about gender-swopping (considering the lengths that she has already taken to try and convince everyone).
I dont think that she sees females as a 'weaker' gender, but rather that she has strong desire to actually be a male and that she is attracted to other females.

From my side, I think its my duty as a muslim to, insha Allah, guide her towards the right path.

(And if she doesnt want my advice, then why is she in my office?
Its a package deal : D )

 

[جوري]

In this case, I guess its worth a try - what can I lose by speaking about Allah? (The worst that could happen is that she lays a complaint against me for trying to educate her about Islam. My counter-argument would be: 'She thinks shes a BOY.....she needs all the advise she can get!' : ) )

lol.. well I am glad you understood what I was deriving at without me saying it bluntly (at least per 'worst part' of your statement) but yeah that will be interesting conversation indeed... sob7an Allah.. Good luck sis I wish you well in shaa Allah..

 

[IbnAbdulHakim]

i sincerely hope you refer this back to a knowledgeable and enlightened individual (scholar from ahlus sunnah upon a madhab) and let us know how it goes.


There is no way in high heaven I will attempt to advise you on this.

 

[Muhammad]

:wasalamex

SubhanAllaah, a very difficult encounter. It seems that you don't have much choice on the issue of referral, because if you choose not to treat someone, and you didn't refer them, would that get you into trouble?

On the issue of giving da'wah, that is a very good thought. Just be careful in the way you approach it. I am reminded of the story of the Nurse suspended for prayer offer!

In any case, remember to perform Istikharah. May Allaah (swt) guide you in making the right decision and grant you every success in your career, Aameen.

 

[Alpha Dude]

On the issue of giving da'wah, that is a very good thought. Just be careful in the way you approach it. I am reminded of the story of the Nurse suspended for prayer offer!

Yeah, I thought of something similar. It might not be a good idea to say your counter argument to them either, if it comes to it... I know it sounds logical and all, but it's the kind of thing that could be taken wrongly and used against you later.

 

[جوري]

'clients' have more right here than doctors and of course even the doctors the shrewd Zionist ones have it made.. It is always the ones in training or starting out that are treated worst than pu. They can give a written statement and revoke it verbally before going into surgery and then sue you for doing what they've requested verbally because you didn't get it in writing. In closure this is a pretty litigious society and you'd be surprised how fast you burn out.
Walhi I was so delusioned when I fought for this career like it was dear life. I remember the first thought that came to my head at the end of the very first day of my OB/GYN rotation, is ''wow it never gets better, it doesn't matter how far you think you got in life, it is going to be **** all the way'' walhi that's what I said and I always recall that when I advise people not to get into medicine plus the migraine I had that day and the juice my mom gave me when I came home which caused me to throw up.
I am sure others haven't had the crappy experience I have had and perhaps had I been in another country I'd have hated it more or loved I really can't tell and don't care at this stage.
We often think things are greener else where. But people have changed, ethics of medicine has changed and it is just a business. when I went into medicine as cliche as it sounds my biggest joy was to actually feel that I have the knowledge and the skill to help others seeing so many loved ones drop dead around me from things that could have been easily helped with the right person in the right place.
Of course now I believe in fate and divine Qadr completely. If someone didn't drop dead of that heart attack or chocking on a chicken bone they'll have been hit by a car or have an embolus somewhere.
I have lost respect for the institution, with the exception of a few doctors I can count on one hand and who are completely old school, I have lost all respect for doctors, I'd rather die than seeking medical attention and often treat myself when deathly sick and worst of all I have no feelings of care or concern for the patients which is the saddest thing of all. There were days when one case would haunt me for three months and then came days when I'd see 13-25 people per day and not remember a single one of them when I lay my head on the pillow at night, just the thought of dragging myself back there in the morning was all I could stand and yet you'd not think it would get worst and it always does.
Not to be so grim and completely go off on a tangent but Sr. Zaria try to not burn out fast it is inevitable and if you can postpone it until your fifties or sixties it is better than in your thirties.