Consented, p.15
Consented, page 15
Today, we call these practices sexual orientation and gender identity change efforts (SOGICE). We now have overwhelming evidence that SOGICE leads to severe psychological distress, depression, substance abuse, and a lifetime of suicidal ideation and attempts.38 Because of this, every major medical and mental health organization in the United States has condemned it as unethical and dangerous.39 Despite its dark history, medicine as an institution now stands against the pathologization of sexual and gender diversity.
But the fight against conversion efforts was never just medical. As the title Pray Away implied, SOGICE has always been sanctioned by religion. Despite its banning in many parts of the world,40 SOGICE remains widespread in conservative religious communities.41 This includes over half of US states, where SOGICE is still legal, even for children.42 In 2023, the Trevor Project identified more than 1,320 SOGICE practitioners across forty-eight states and DC.43 Many operate under the guise of “spiritual counselling”—in 2018, a large British survey revealed that 8% of LGBT teens aged sixteen to seventeen had been offered some form of SOGICE, over half by faith-based organizations.44
In recent years, the fight has shifted into the political realm. In his 2024 book Free to Be: Understanding Kids & Gender Identity, Dr. Jack Turban, director of the Gender Psychiatry Program at UCSF, warned that rising political challenges to SOGICE bans could lead the courts to overturn them nationwide.45 That warning is already materializing. In 2025, a Christian therapist, backed by a conservative religious advocacy group, challenged Colorado’s ban, arguing it violated her freedom of speech. At the time of writing, the Supreme Court has agreed to hear the appeal in June 2026.46
It has been well over two hundred years since medicine and religion parted ways, when illness ceased being divine punishment and healing was no longer exclusively spiritual.47 Yet thanks to regressive politics, if the Court overturns the bans, we will take a huge step backward in history. More importantly, we will fail to protect our children.
In a 2019 study, Dr. Turban found that individuals exposed to SOGICE were twice as likely to attempt suicide. If the exposure occurred in childhood, that risk quadrupled.48 In other words, lives will be lost. And young people’s lives will be lost faster. Some, like Sean, might survive against the odds. Others, like Kirk, won’t.
And yet, do SOGICE practitioners disclose these life-threatening risks before subjecting people to their so-called therapy? I highly doubt it. By definition, then, these treatments operate under inadequate consent, if not forced consent (see Chapter 2). While religious SOGICE practitioners hire lawyers to argue for their freedom of speech, who will defend families’ right to informed, trust-based care? And when will we stop wondering if our children will have the freedom to be?
“Some guy stopped our car on this country road, Dr. Zha, and guess what he asked?” Sean’s eyebrows wiggled like they were auditioning for a dance-off.
“What?” I leaned in, matching his eyebrow choreography. Whatever this punchline was, I was ready to laugh out loud.
“He asked if Isaac and I could help him change his tire!” Sean threw a hand in the air, his shoulder-length hair whipping like he was on stage.
“No way!” I gasped, laughing but still waiting for the punchline. I had been Sean’s doctor for two years by then, and I’d never seen this playful, teasing, alive side of him. Whatever made this guy on the road so outrageous, I was all in. “What did you say to him?”
Sean’s eyes twinkled as if he’d been waiting for this exact setup. “I said: ‘Honey, I’m gay and Isaac is Amish. Do we look like we know how to change tires?’”
We both burst out laughing until our stomachs hurt and our eyes watered. Sure, it was a funny story. But what truly brought me joy was that, after everything Sean had been through, there was still light behind his eyes. Maybe he was going to be okay.
Before I left the practice, Sean brought cupcakes with rainbow frosting to our last visit. I made him a gift in return: a Chinese calligraphy piece I had written in running script style that read 傲雪寒梅—The plum blossom stands proud in the snow. While other flowers wait for spring, the plum dares to bloom in winter, unbending in the face of cold.
If winter must come, then let us stand with our patients when the snow falls. Because history will always uncover who betrayed the truth, and who refused to be converted or consented away.
A Genital Emergency
As medicine shifts from pathologizing LGBTQIA+ individuals to affirming them, one group remains largely overlooked: intersex people.
When a colleague consulted me about treating acne for a nonbinary transmasculine patient, she was specific: “They are taking testosterone, which has worsened their acne. Can you help?”
“Sounds good,” I replied, expecting a straightforward case.
But when I opened the patient’s chart, I was confused. Their demographic information listed: Intersex–Non-binary (Intersex). Intersex and nonbinary are distinct concepts. Nonbinary individuals have a gender identity outside the binary of man or woman, but their biological traits typically fit one category. Intersex individuals, however, are born with physical and biochemical characteristics that do not conform to traditional definitions of male or female. For acne treatment—which is often hormonally driven and can affect reproductive health—precision matters. Misclassifications in medical records can lead to incorrect prescriptions and additional complications for patients who have fought to have their identities accurately represented.
When I met the patient, who presented as masculine, I approached the topic cautiously. “I’m sorry to have to ask, but your chart lists intersex.”
Their eyes widened, and they leaned forward. “What? Why does it say that?”
“I don’t know,” I admitted. “My understanding is that your birth-assigned sex was female, and you identify as nonbinary and transmasculine. Is that correct?”
“Yeah,” they confirmed, sitting back, then leaning forward again. “But why does my record say intersex?”
It turned out that in Epic, a widely used electronic medical record system, intersex is not recognized as a standalone category for sex, gender identity, or assigned sex at birth, and therefore is automatically grouped under nonbinary identities.49 The very fact that intersex is not acknowledged as a standalone category in medical documentation speaks volumes. It gives us a sneak peek of how the care we give the I in LGBTQIA+ has long lagged behind, ignored in advocacy, and erased in medical records.
Not a sex or a gender, then what is intersex? Anne Fausto-Sterling, a leading expert on intersexuality, defines intersex as any biological variation that diverges from the idealized male (XY chromosomes, testes, penis, typical male hormones, and secondary sex characteristics) or female (XX chromosomes, ovaries, vagina, typical female hormones, and secondary sex characteristics). Intersex traits can involve chromosomes, hormones, gonads, internal or external genitalia, and even neurological differences.50 For example, an intersex person might be a man born with ovaries, a woman with XY chromosomes, or a baby with “ambiguous genitalia”—external traits that don’t fit typical male or female categories.51 Many intersex individuals are completely healthy, but some conditions, like congenital adrenal hyperplasia (CAH), can be life-threatening.52 In medical training, the response to such cases is clear: First, stabilize the baby’s health; second, surgically “correct” the genitalia. Both are treated as emergencies.
My mentor and friend Dr. Dennis Costakos, chair of pediatrics at Mayo Clinic Health System in La Crosse, Wisconsin, has treated over twenty thousand newborns. Neonatologists like him are trained for life-and-death situations. Airway, Breathing, Circulation—the ABCs of neonatal resuscitation—are second nature. When a complicated delivery occurs, everyone holds their breath until specialists like Dennis arrive. But one such “emergency” Dennis was called to attend was different.
Dennis’s pager went off at 2 a.m. Like any on-call physician, he blinked awake, kicked off his blanket, and bolted to the scene of the emergency. He slowed to a walk just before entering the room, signaling his team to stay calm. The neonatologist had arrived. Yet inside, there was no flurry of nurses, no tangled wires, no beeping monitors. Instead, one physician and two nurses stood silently around a peacefully sleeping baby wrapped in a hospital swaddle.
“I focused on the ABCs, but the baby was fine!” Dennis recalled. “Then the delivery physician pointed to the baby’s scrotum. That’s when I understood. Ambiguous genitalia. There seemed to be an empty scrotum draped over either a small penis or a large clitoris. Later, we determined that this was a genetic boy, and it was indeed a penis. It was just positioned differently, a condition called penoscrotal transposition (PST).”
PST is a rare condition where the scrotum is mispositioned to be in the front, at the sides, or below the penis, sometimes considered an intersex trait.53 Typically, this condition is not a crisis, evident by the peacefully sleeping baby whose room Dennis walked into.
“They woke me up at 2 a.m. for a completely normal baby!”
But normal wasn’t the term used in the medical record or the mindset of the team that summoned Dennis out of bed in the middle of the night. This case exemplifies how medicine’s understanding of sex is fixated on genitalia. Within this rigid framework, only two norms exist: stereotypically male and stereotypically female. Anything outside those bounds is seen as a deviation that must be fixed before the world labels the child a “freak.” So, while it wasn’t a medical emergency by the ABCs of neonatal care, it was a social emergency across the rest of the alphabet. It was a genital emergency. And surgery, in the name of sex assignment, was there to save the day.
After Dr. Anne Fausto-Sterling published “The Five Sexes” in 1993, she received a letter from Cheryl Chase, founder of the Intersex Society of North America. Chase pointed out that “[m]edical dogma on sex assignment of intersexuals centers on the ‘adequacy’ of the penis.” She was right. Since a large penis couldn’t be constructed from a small one, intersex infants with an “inadequate” penis had to be reassigned as female. If their clitoris was deemed too large, it was trimmed or removed, prioritizing a socially acceptable cosmetic appearance over the child’s physical and emotional well-being.54 Despite their so-called abnormal genitalia, intersex infants are natural, fully capable of normal erotic sensations. Yet sex-assignment surgeries, often multiple and requiring revisions over the span of years, leave many in lifelong pain.55 Perhaps more blurred than the boundaries of stereotypical sexes was the difference between healthcare and mutilation.
Beyond the physical scars are deeper wounds: the mismatch between assigned sex and innate identity, the trauma of repeated exams, and the secrecy enforced by parents and doctors. Many intersex patients are never told the truth about their bodies, fostering self-rejection, depression, and even suicide. Chase captured this brutality in her letter: “The capacity to inflict such monstrous ‘treatment’ on children, who cannot consent, is ultimately a clear expression of the hatred and fear of sexuality which predominate in our culture.”56
Worldwide, intersex traits occur in an estimated 0.018% to 1.7% of births.57 The average American adult knows 611 people by name.58 Let’s assume the higher figure in the intersex prevalence range is accurate, then there may be as many as ten intersex individuals in our social networks. And they could have been people you interacted with today! Yet we treat them as anomalies. Even if the true prevalence is closer to the lower number, it still doesn’t justify how we treat intersex people in society or in medicine. Just think about how we celebrate people born with perfect pitch—an ability with a prevalence of just 0.01%—as gifted. Yet those born with naturally different genitalia, which is more common than perfect pitch, are often deemed pathological. Even the insanely broad statistical range of intersex traits, over a hundredfold, is telling: Medicine still lacks a fundamental understanding of the natural variation in human sex. Should we, then, be so quick to cut?
In recent decades, the practice of intersex infant surgery has come under increasing scrutiny. In 2013, the United Nations condemned forced genital-normalizing surgery as a human rights violation, urging all nations to ban it.59 Since then, twelve countries, including Malta, Iceland, Germany, and Kenya, have outlawed these procedures. The US, by contrast, still allows them in all states except New York.60 The irony? Many of the same states that are banning gender-affirming care for trans youth continue permitting sex-assignment surgeries on intersex infants.61 In 2021, a Global Public Health article concluded that intersex care in the United States enforced an outdated definition of sex by privileging medical opinion over human rights.62 Intersex people have challenged these practices for as long as they’ve existed, which is to say, as long as humans have existed. Unfortunately, science is still too much in its infancy to meet them halfway.
But don’t worry; where science hesitates, politics rushes in. On January 20, 2025, President Trump signed an executive order declaring that the US government would recognize only two biological sexes. The still-unfolding order claimed to “defend women’s rights” by defining them as “biologically female” and men as “biologically male.”63 Simple? Yes. Accurate? No. As discussed earlier, sex goes beyond external genitalia to include variations in chromosomes, hormones, internal reproductive structures, and brain development. Each of these categories offers a spectrum of possibilities. But for the sake of simplicity, let’s assume there are only two options—male or female—in each category. With five categories, this still yields thirty-two possible combinations of biological sex. If we slightly expand the options to include “more male than female” and “more female than male,” the combinations exceed a thousand. In other words, even in an oversimplified world, there are mathematically endless ways to be human.
“What happened to the child with PST?” I asked Dennis eagerly.
“The poor kid got a massive workup—genetics, endocrinology, urology, even a psychological evaluation for the parents!” Dennis continued, “and nothing was wrong with this child! It was a perfect, nine-pound baby!”
“Did urology rush to operate?” I braced myself.
“Luckily, no. I told them not to make rash decisions, because . . . ” Dennis chuckled, knowing I’d finish his sentence.
“It was a completely normal baby.”
When we reduce human diversity to medical anomalies in need of correction, rather than recognizing its place in the natural range of existence, we do harm. Only when we acknowledge and affirm that every body, in its own form, is whole, can we truly deserve our title as healers.
It’s time we stop forcing bodies to fit narrow definitions, for I should never stand for isolation. I is infinite.
A Gendered Emergency
Shortly after being abruptly taken off testosterone, Robin developed severe heart palpitations. “You are now at an abnormally high risk for heart attacks,” the doctor’s emotionless warning echoed in his head. But no one knew exactly what that meant for him.
With his high health literacy, Robin was well aware of the gender differences in heart attack symptoms (see Chapter 4). “Do I have a female heart or a male heart?” he asked during our Zoom meeting.
“That’s . . . ” a good question, I wanted to say. But no words came out. Because unlike other good questions my patients ask, this one I didn’t have answers to, nor had I even thought to ask.
“My blood thickens on testosterone, but my blood vessels are thinner. And my heart is smaller,” Robin continued. “Structurally, chemically, hormonally. So, if I had a heart attack, what symptoms do I get? What about a stroke? A blood clot?”
Robin’s rapid-fire questions challenged my knowledge, which admittedly needed to be challenged. But they exposed how much medicine falls short in its fundamental understanding of the human body beyond the binary. And I joined him to ask a few questions of my own: Just as critical as clinical presentation, what about the quality of care trans patients receive? And what discriminatory forces shape their outcomes?
Luckily, Robin didn’t have a heart attack that day. After six hours of waiting in the ER, he was told “Everything is fine.” Only it wasn’t. Once again, he was left to look for answers on his own, feeling abandoned by his medical team and a system that wasn’t designed for him.
Sex hormones impact our bodies in profound ways, including our cardiovascular health. Testosterone can raise cholesterol, thicken blood, and increase blood pressure. Estrogen promotes clotting and alters cholesterol levels as well.64 Yet, for decades, medicine has treated male bodies, often male mice bodies, as the standard, assuming their data applies universally.65 Now, emerging research is dismantling this flawed approach, revealing sex differences across every organ system: cardiovascular, renal, endocrine, immune, gastrointestinal, nervous, and musculoskeletal.66 Uncovering these differences is a good start. But the real question is: Do they translate into different disease prevalences and symptoms?
The short answer is: We don’t know. Existing studies are severely limited by small sample sizes, inconsistent treatment protocols, and follow-up periods too short to yield meaningful conclusions.67 While we now finally acknowledge that cisgender women experience heart attacks differently than cisgender men, trans people still remain virtually absent from the research. But we can’t first fix cis women’s healthcare, then address trans health disparities. The redesign of medicine simply can’t afford such a sequential process. In fact, the opposite is true, because the most urgent needs always exist within the most marginalized communities. Just like the antidote to patriarchy isn’t cisfeminism but a movement rooted in intersectionality, the cure for medical misogyny isn’t a broader gender hierarchy—it is radical gender equity. And equity cannot exist without true inclusivity: of cis, trans, nonbinary, intersex, and every identity in between. Not in that order, but all at once.
Rather than serving as another tactic for medical rape culture, healthcare professionals and organizations have fought hard to depathologize gender diversity. Activist physicians and scientists continue to serve as strong voices for health equity against exclusionary politics. But we are not doing enough. When Robin was uninvited by his primary care doctor to discuss his own gender, it wasn’t enough for medicine to simply acknowledge diversity. When his endocrinologist reduced him to a checklist, it wasn’t enough for doctors to quietly resist Big Pharma or Big Insurance. When Robin was told his numbers were too high to accommodate who he truly was, it wasn’t enough to follow rigid treatment protocols. And when he was left to wonder whether he was having a male heart attack or a female one, it wasn’t enough for science to categorize sex-specific data into neat little boxes.
