Arthur or Martha or neither–how cultural intelligence can help untangle the transgender knot

By Roger G McDonald, Mahana Culture’s roving blogger

When doctors deny one in five members of a community medical care, and 41 per cent of that group attempt suicide, a cloud hangs over our cultural intelligence on two essential issues — health and gender.

Push the pause button on that for a moment. First, look in the mirror and ask yourself that existential teenage question: who am I? For most of us, at least one basic response is pretty clear. I’m a male, or a female.

However, for a small but expanding sector of humanity, the answer is anything but plain.

Dr Ada Cheung has three parallel healthcare careers. She’s an internationally recognised and awarded endocrinologist, and a full time medical science researcher at the University of Melbourne. She also heads an organisation probing and promoting the health and welfare of Australia’s transgender community.

Her interest in transgender issues stems from her research at the University of Melbourne. She is the recipient of a prestigious National Health and Medical Research Council (NHMRC) fellowship. NHMRC is one of 17 portfolio agencies under the auspices of Australia’s Federal Department of Health. The council is one of the world’s most respected medical research administrators with, by international standards, a disproportionately high number of Nobel laureates among its researchers.

Her research project focuses on improving the lives of people with hormone-related conditions. As well as in-depth probing into the influence of testosterone and oestrogen, she has a particular interest in the physical and mental health status of transgender and gender diverse people.

Straddling three cultures

Dr Cheung’s personal and professional lives straddle all three cultures, though they’re not always complementary and not all in constant accord. As a medical specialist, she represents and connects to a culture she loves and respects, but sometimes struggles to fully endorse.

She describes on the one hand a strong, intensely historical culture that gives us the Hippocratic oath, with its passionate respect for human life and dignity. On the other, she portrays the same culture as represented by a male doctor in a white coat standing over a compliant patient confined to a hospital bed.

Dr Cheung thinks of our contemporary Western medical culture as an embedded, hierarchical tradition. Universities and teaching hospitals make sure students receive inoculations of medical and moral expectations that can cause serious side effects for both practitioner and patient.

In an environment where doctors cannot be seen to be fallible, to falter or to fail, bullying remains a significant issue. Mental illness and suicide are rife, she says, but slide under the radar in a culture that struggles with overt signs of vulnerability. Who would not recall the New Testament warning: ‘Physician, heal thyself’?

A new approach to medical cultural intelligence

The prestigious Psychology Today magazine confirms her contention. In the United States, physicians are at higher risk of suicide than non-physicians. Suicide is responsible for a quarter of young physicians’ deaths annually. The profession needs a new approach to cultural intelligence, she believes.

Her second culture, scientific research, is both quizzical and sceptical. She jokes that scientists don’t trust or believe anything, and that nothing is true except for the data they so minutely examine. Unlike medical practice, the research is clinical and bloodless. Emotion is all but removed from the equation in favour of the facts. Yet its relative remoteness from the lives its discoveries and conclusions are meant to treat can make scientific and medical research seem almost one-dimensional.

She believes devoted researchers must work hard to design protocols and conduct research programs that do more than provide solutions to some of our most baffling physical and mental puzzles. Unravelling scientific, medical, and therapeutic mysteries may be a wonderful first step. But without a corresponding shift in cultural call and response — the marginalised pleading to the mainstream — no reformative or lasting societal change can occur.

Dr Cheung says she didn’t choose her research field, it chose her. The stigma members of the transgender community constantly endure blights our humanity because it occurs at the most fundamental level.

Biological, not psychological

She and her team face a remorseless, though not unwinnable battle to counter one of our most prevalent myths: people outside the conventional male and female boundaries go and remain there by choice. The truth of gender assignment is radically different: it’s biological, not psychological. Our hereditary DNA determines our gender just as it ordains other physical characteristics such as eye colour, finger prints, right or left handedness, and a host of other attributes and functions.

More critically, gender is not a one-or-the-other choice — for any of us — between masculine and feminine. Biologically standard infants of course display a tell-all penis or vagina at birth. While the newborn’s external sex organs might seem a give-away for her or his likely sexual orientation in puberty and beyond, it’s far from the end of the story.

We now know that conditions like autism, anxiety, depression, and dozens of other life-defining and life-altering states occur across a spectrum. Experts can measure them from barely noticeable to profound and severe. Which makes it all the more surprising that something as basic as gender ambivalence and ambiguity has taken so long to achieve recognition.

Transgender studies are still in their relative infancy, but a wealth of terms for different gender identities has already sprung up. Dr Cheung’s Trans Medical Research organisation lists nine categories but there are many more:

  1. Trans man or trans male: a female at birth but who identifies fully as male
  2. Trans woman or trans female: male at birth but identifying fully as female
  3. Non binary: identifies as neither trans male or trans female, preferring to identify along the gender spectrum
  4. Gender fluid: a person whose gender identity changes
  5. Gender queer: someone who doesn’t identify with either of the two main genders, or gender binary
  6. Agender: not identifying with any gender at all
  7. Demi boy or demi girl: a person who identifies only partly as a male or a female
  8. Trans masculine: identifying as more male than female on the gender spectrum
  9. Trans feminine: identifying as more female than male on the gender spectrum.

Dr Cheung says the trans community suffers doubly, first through the ignorance and bias of the wider population and health professionals, and then through division within its own ranks. Marginalised and stigmatised for decades, transgender people tote unenviable baggage compared to the rest of the gender-assured population. She cites some disturbing research figures:

  • 41 per cent of transgender people in Australia have attempted suicide
  • 54 per cent suffer from depression, five times the national rate
  • 20 per cent have been denied treatment by a medical professional
  • 50 per cent report having to educate their healthcare professionals about their status
  • 28 per cent have experienced harassment in a medical situation
  • 49 per cent put off medical care because they didn’t have enough money

With these kinds of odds against them, transgender people feel sidelined and have a mostly lower socio-economic status than the rest of the population. Some profess a distrust of the medical and scientific profession, a minority of which has shown an historic discrimination, even if unintentional.

Transgender people have to live with the enhanced sensitivities that come with gender ambiguity. Dr Cheung says she has inadvertently caused transgender people offence, even as a sympathetic researcher specialising in the field. Much work remains to be done by health professionals to gain or recover the transgender community’s trust.

She sees it as a collision of cultures. She describes a muddled conflict zone where tradition and an unconscious bias in doctors meet a difficult to grasp gender fluidity that cannot express itself in a unified voice. Further education and research, combined with enlightened goodwill on the part of the medical profession, will go a long way to easing that cultural tension.

If you would like to learn more about transgender culture or associated issues affecting you or someone you know, contact Dr Ada Cheung MBBS (Hons) FRACP PhD, Department of Medicine (Austin Health), The University of Melbourne E:

If you would like to know more about straddling cultures and untangling cultural knots to maintain cultural dignity, contact Tavale Ilalio, on 0428 504 240 or visit