I recently received an invitation to attend the national conference of the Society for Intercultural Education, Teaching, and Research. The conference theme was “Inclusive Interculturalism.” The implicit message was simple: in order to be inclusive, interculturalists need to make a conscious effort . Inclusivity doesn’t come naturally.
In my last month’s ADR column I addressed a similar issue about the development of multicultural education. I argued that multiculturalists need to be cognizant about whom they may be excluding as well as including. The more that you exclude categories of people, the less inclusive the curriculum becomes.
It’s easy to be misled by your own language. The DEI triad — Diversity, Equity, and Inclusivity — conveys the idea that those three ideas are natural partners. Maybe even inevitable partners. If you pursue one of those goals, you automatically are pursuing all three. Not so fast.
This fall I began my sixth year as co-director of the Health Equity, Social Justice, and Anti-Racism curriculum of the University of California, Riverside, School of Medicine. The more I unpack health care, the more I recognize that, without continuous reflection, the noble idea of inclusivity can degenerate into an empty buzz word. This is particularly true when the pursuit of equity for some leads to the exclusion of equity for others. Let me share one such thorny example that has proven perplexing, controversial, and publicly explosive: gender affirming care for transgender people.
Gender affirming health care has been around for centuries. That is, when it is used for cisgender people. Consider mastectomies, penile implants, hormone replacement therapy, and hair removal. Transgender people deserve similar consideration. After all, they are human beings, too.
That said, once we move beyond the superficiality of moral proclamations about transgender affirming care, we encounter a perplexing question. What if some types of gender affirming care can also can exclude if used for the wrong people? What if, under certain conditions, such treatment can undermine the physician’s oath: First, do no harm?
Consider two broad dimensions of gender affirming care. One set of gender affirming strategies is physically non-invasive. For example, take counseling and other forms of emotional support.
Then there are those gender affirming strategies that involve physical interventions, such as puberty blockers and non-reversible surgery. What if those strategies are used with people who later choose to detransition? That is, at one point in their lives they identify as transgender but later change their minds? For them, non-reversible physical interventions can effectively do harm by excluding them from the full benefits of health care.
How many detransitioners actually exist? There is anecdotal evidence of individual cases, but I have yet to encounter much in the way of robust and statistically-compelling analysis. Some gender affirming care aficionados proclaim that detransitioners are rare. However, even if such cases are relatively rare, those rarities are still people who deserve inclusive, non-harmful health care.
Mohandas Gandhi adopted a “last girl first” principle. Through that proposition Ghandi argued that we should consider the most excluded members of the community to guide our legal and social choices. In current discussions of gender affirming transgender care, detransitioners often get overlooked, thereby falling within Gandhi’s “last girl first” principle. But how should that work out in practice? Let’s start with cultural humility.
When addressing gender affirming care, cultural humility is vital. Any of you who have raised children know that 8 year olds think differently than 18 year olds and even more distinctly than 28 year olds. Non-reversible health care interventions with an 8 year old may restrict that person’s options when they reach 18 or 28. Therefore, while providing gender affirming care, health care professionals need to consider how their decisions, recommendations, and actions might unintentionally exclude those who, down the line, decide to return to their assigned birth sex.
This dilemma has perplexed and sometimes divided health care professionals around the world. In general, European public health institutions are becoming more skeptical than the U.S. medical establishment when it comes to the use of puberty blockers and hormone treatment for young people. The 2024 Cass Report of the United Kingdom National Health Service embodied this more nuanced European stance.
I realize that addressing gender affirming health care from such an inclusivity perspective creates challenging complications. If you withhold physical interventions for people with firm and permanent transgender identities, you may be denying full and equitable health care. Conversely, if you engage in physical interventions with those who later change their minds about their gender identity, you have effectively limited their future options.
So what’s the answer? I wish I could provide it. I wish that we had more a more solid diagnostic basis for predicting the permanence of transgender identity transitions. Many experts seem cautious.
Dr. Scott Leibowitz, co-lead author of the 2024 adolescent care standards of the World Professional Association for Transgender Health, argues that transgender adolescents “come to understand gender at different times and in different ways.” Therefore, deciding on care for transgender individuals should include experts in adolescent identity development and what is known as “naturally occurring sexual fluidity.” Comparably, the Cass Report recommends “proper screening and assessment before medical interventions are undertaken.”
Whatever one’s general stances on these recommendations, the rubber really meets the road when it comes to determining gender affirming care for individuals. That’s where the lack of firm and replicable diagnostics becomes an inclusivity issue. How do I, the physician, provide equitable treatment for the human being in front of me while doing justice to both the transitioner and the potential detransitioner?
The more that I work and teach in health care, the more I encounter such complexities and dilemmas within the pursuit of inclusivity. Buzz words and glittering generalizations provide only partial guidance when addressing individual health care challenges involving race or ethnicity or religion or language or disability or sexual orientation. At this point the best advice I have to offer is to remain humble in addressing these dilemmas. If diversity advocates do not seriously contemplate the humility-challenging dilemmas of inclusivity, they risk falling into the trap of picking winners and losers in life’s health care journey.
He also edited the four-volume Multicultural America: A Multimedia Encyclopedia (2013).