Notes from a gender clinician

In my family practice, we care for people, not ideologies. I greet my patients and ask, "What concerns do you have?" I listen and ask clarifying questions. I inquire about each patient's biological, psychological, and social circumstances. I examine their bodies. I reflect on the stories I hear, uncovering hidden truths within them.

Years ago, Bella, a six-year-old girl, visited my office with her mother. She requested to speak with me alone.

"What concerns do you have?" I asked Bella.

"I'm here to help my mom," she said. "She's having a hard time with my gender. When I was born, my mom thought I was a boy because I have a penis. I'm not a boy. I'm a girl. But people say things to Mom, and she gets upset."

"Are you upset?" I asked.

"No. Well, yes, but just when my mom is upset. And when the police came. I didn't like that."

"How do you know you're a girl?" I asked. Bella looked surprised and shrugged. "Because I know! I've always been a girl." She met my gaze. "You look like one too. Are you?"

I nodded. "How do you know you're a girl?" She asked.

As a cisgender woman, I don't know what it feels like to experience gender dysphoria. I also don't know how it feels to be ninety or to work from a wheelchair. I don't have diabetes or a porcine valve in my heart. I do have experience worrying about my children, but they were adopted. I don't know how it feels to be pregnant or what it's like to labor and bring a child like Bella into the world.

No matter. I can still be a doctor. I listen to and trust my patients when they tell me about their experiences.

As I spoke with Bella and her mother, I learned that Child Protective Services, not the police, visited Bella's home. One of Bella's kindergarten teachers had reported her mother for "making her son wear dresses to school."

"It was causing problems," the teacher said. "Even the other kids think he's a girl." Child protective services threatened to take Bella away from her mother.

"I can't make her wear boy clothes," Bella's mother said.

"She breaks down. She refuses to leave the house. She knows who she is–always has–since she was two. Nothing I say or do changes how she feels about her gender." Tears filled her eyes. "I love my child. How can I help her survive in this dangerous world?"

When I began caring for transgender patients, I read as much as I could about gender. I discovered that sexual and gender diversity thrives in the animal kingdom—a realm rich with biological rainbows that thwart the classification of creatures into distinct male and female categories.

In her book Evolution's Rainbow, Joan Roughgarden describes bullfrogs that exhibit two male genders: larger ones that call at night and smaller ones that remain silent. The bluehead wrasse (a type of fish) has three genders, one starting as female and transitioning to male, with sex changes triggered by alterations in the ecological system or social dynamics. Sunfish possess three male forms and one female. Male Sunangel hummingbirds exhibit feminine plumage to different extents. Female spotted hyenas mate and give birth through penile canals. Sixteen percent of kangaroo rats are intersex, possessing both sperm and egg-related parts within a single individual. The all-female species of whiptail lizards don't require a male—they engage in clonal or asexual reproduction. This process includes elaborate same-sex courtship and genital contact. I recall the male penguin pair that hatched and nurtured their chick. I gaze at the gorgeous seahorse fathers, gestating their young.

These creatures encounter no stigma. In their world, diversity simply is what it is. It’s normal. Given the wondrous mix within animal species, is it any surprise that humans exhibit gender diversity, too?

Transgender individuals have lived in our world since ancient times. They existed long before Trump was born and will continue to thrive beyond his midterms. Trans adults often share stories like Bella's, expressing that they felt something was different from a young age. They sensed a disconnect between their internal selves and their physical bodies. They describe their pain as ever-present and bewildering, making it difficult to function or connect with others in meaningful ways. "I'm not presenting as me." They reveal their despair, stemming from societal stigma. Trans people experience higher rates of depression, substance abuse, risk-taking behaviors, and suicide. With treatment, gender dysphoria may abate or resolve.

As a doctor, how could I fail to provide life-saving treatment for those seeking my care?

On January 20th, Donald Trump signed an executive order asserting that "ideologues who deny the biological reality of sex . . . permit men to self-identify as women, [depriving them women] of their dignity, safety, and well-being." The order outlines policies declaring that the U.S. government recognizes only two sexes, male and female, which are "not changeable and are grounded in fundamental and incontrovertible reality." This order strips our language of the nuanced terms developed over the last century to describe gender and gender-diverse people, words aimed to guide understanding and treatment. It prohibits changes to the government-issued identification documents, allowing Bella to live and work as her true self. It overlooks the safety concerns of incarcerated transgender women, denying them essential medical care; they must live as men and will be as vulnerable as any other woman.

A friend asked if I felt afraid after reading Trump's executive orders. I do feel frightened.

I worry for Bella's safety. She's in college now, pursuing a degree in neuroscience. Bella received care at the onset of puberty. She's not visibly trans and won't be ‘clocked’ in the girls' bathroom. But because Bella's mother stood by her side, Bella is thriving—she's out, and she's proud to be a transgender woman.

Will someone hurt Bella? I'm concerned about a colleague in Texas; she's facing a lawsuit led by Texas Attorney General Ken Paxton for following the same evidence-based treatment guidelines clinicians use worldwide. I worry that our hospital will be unable to support our program due to a loss of federal funding, forcing our clinic to close.

Trump's executive order fails to recognize the undeniable fact that gender is complex. Gender-diverse individuals exist alongside us—hidden or visible—as our family members, neighbors, educators, religious leaders, elected officials, and mail carriers. How do I know? Because I am their family physician. I listen to their truths, provide medically necessary treatment, and witness their journeys toward wholeness. I watch, breathless, as they blossom and bloom.

To bear witness in this way has been the most incredible privilege of my career. And at the end of the day, I ask myself, how am I doing at living my truths? Have I been authentic?

Many have tried to alter another's gender identity, but none have succeeded. Gender diversity is normal; humans share this remarkable truth with the animal kingdom. We cannot erase transgender people, but we can choose how we respond to their joy, suffering, and human experience: with respect or contempt, compassion or hatred.

I condemn Trump's executive orders aimed at restoring the "biological truth" about gender; they inject hate into our already fractured nation and will harm the people I care for and love. My role as a physician is clear. I choose respect and compassion. I follow the World Medical Association's pledge. I dedicate my life to the service of humanity and keep the health and well-being of my patients as my first consideration. I vow to make Bellas's world safer. I will cheer when Bella becomes a neuroscientist.

You, too, are now faced with a choice. How will you choose to respond?

Dr. Carolyn Wolf-Gould is the Founder of Bassett Healthcare Network’s Gender Wellness Center, a rural-based interdisciplinary center for trans health in upstate New York. She attended Yale University School of Medicine and completed her residency in family practice at the University of Rochester. She is coeditor and contributor the book A History of Transgender Medicine in the United States: From Margins to Mainstream, published by SUNY Press in February 2025. She has been providing gender affirming care to patients across the lifespan since 2007.

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