'My Religious Trans Patients Want to Talk About Faith. What if God Doesn't Forgive?'

Dr. Iris Yaish, head of transgender health at Tel Aviv's Ichilov Hospital, talks about the challenges Israeli trans people encounter, how the army treats them and the misconceptions Israelis have

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Dr. Iris Yaish. “It’s like diving, in minutes, into the most intimate stories. About the moment they understood that they weren’t born into the right sex. I hear stories that are unbelievable.”
Dr. Iris Yaish. “It’s like diving, in minutes, into the most intimate stories. About the moment they understood that they weren’t born into the right sex. I hear stories that are unbelievable.”Credit: Meir Cohen
Ayelett Shani
Ayelett Shani

Tell me briefly about yourself.

I am a physician – an endocrinologist – and I’m the head of the Center for Transgender Health and Medicine at Ichilov Hospital. The unit seeks to provide all the relevant medical responses for trans people in Israel: hormonal therapy, gynecological treatment, fertility preservation, surgery and also the services of dieticians, psychologists, social workers and so on.

Let’s focus on the medical aspect for the moment. You’re talking here about a medical response to a diagnosis that is not medical. How would you define this sort of medicine? What is distinctive about it?

I am an internist on the staff of the hospital’s Institute of Endocrinology, and I treat people who suffer from gender dysphoria [i.e., the distress that stems from a mismatch between biological sex and gender identity], but my patients are not sick. They have a condition that requires a certain kind of medical treatment, by means of medication or surgery. It is a type of medicine that is truly different from what I routinely engage in as an endocrinologist, or from any other field of medicine one can think of.

Transgender medicine is very personal: Whether it is successful or not frequently depends on the encounter and the conversation with the patient, on the ability to create relations of trust, to maintain a dialogue that can be highly emotional. It’s not like a patient who has a blood pressure problem, and I stabilize it and the problem is solved. When I meet a new patient in this case, I know that I won’t even enter their data into the computer initially. That will have to wait. First, I’ll sit facing them, look them in the eyes; there will be a conversation, usually not an easy one.

The response is also emotional, perhaps mainly emotional.

The medical response is the smallest part of this story. The main thing is to talk with the human being sitting across from me, to understand what they are telling me, to hear their life story. It’s a full-fledged relationship for the long term, and very often the success of the treatment derives from that. Consider that already in the first meeting I hear things that are extremely personal. It’s like diving, within minutes, into the most intimate stories. About the moment at which they understood that they weren’t born into the right sex. About the alienation, the social isolation, the harassment and the ostracism, the attitude of the family. I hear stories that are unbelievable.

For example, I am now treating a patient from the Arab community. Her parents think she is at a university abroad, but she’s here in Israel, she has started the process of gender reassignment in the clinic, and her parents have no idea. Every story is a crazy movie in itself. I am learning so much in this work; every day I learn something new.

What, for example?

I have quite a few religiously observant female trans patients. The conversations with them go in all sorts of directions – issues of morality, belief and values come up. I have one such patient who brings me directly into discussions of what will happen when she dies, of what will happen if God will not forgive her for what she did. Think how they feel when they have to say in the prayers each morning, “Blessed art Thou for not creating me a woman.” Or what complexity these individuals [that is, men who have undergone reassignment as women] experience with respect to preserving their fertility, because it involves extracting semen “in vain.”

One of the most severe offenses, according to Jewish law.

Yes. It is truly a problem. For them a very acute problem. As a secular woman, I have no understanding of that, and in order to respond suitably I need to learn, to ask, to consult: This occupation is driving me to develop as a person, to realize that my role as a physician is to learn and to educate and to accept. The transgender community in Israel today is still ostracized and experiences difficulties in what for most of us are trivial matters. People don’t hire them, won’t rent them apartments.

Jessica Gold, a patient of Yaish. 'I photograph trans people. What I want to show is that they are regular people, like me and you.' Credit: Iris Yaish

The community’s interaction with the realm of medicine is also problematic. It ranges across the spectrum from physicians who refuse to treat them – and that still happens – to offensive remarks or general insensitivity.

In today’s Israel, many trans people don’t seek medical treatment, knowing that they will encounter disdain, insults, contempt. Rina Natan, who was the first known trans woman in the country, or one of the first, begged to undergo “bottom surgery.” The Health Ministry refused. There were court petitions and whatnot, and in the end she simply castrated herself and arrived at a hospital in that condition, leaving the physicians no choice but to operate. We had a case of a trans patient who arrived to start treatment, but it was repeatedly postponed because she had to cope with all sorts of bureaucracy. After a time, we were notified that she had simply gone to a different hospital after cutting off the genital organ by herself. Rina Natan’s story took place in the 1950s; this story happened last year. What do we understand from that?

Mostly the depths of despair of such individuals. I think we are underestimating the profound mental distress caused by gender dysphoria.

The distress is immense. Every day I sit with patients who tell me things like “I am ashamed to take a shower,” “I hate to look at myself in the mirror,” “I can’t stand my body, I want to throw up.” I thought how terrible it is to be imprisoned in a body you hate, with nowhere to escape to. Trans women have a hard life. As a crude generalization, I would say that it’s harder than the life of trans men. Trans men get a few injections of testosterone, they assume a masculine appearance, and it’s easier for them to pass as a man. However, trans women must undergo far more complex procedures and attract much more negative attention. People are always looking at them, making comments – everyone has something to say.

Avoiding ‘gendered toys’

You obviously identify with their pain.

Very much so. The parents of patients often tell me, “If it were your child, you would behave differently.” That is simply not true. I have two children. Twins. A boy and a girl. I try to avoid gendered toys or colors. When I buy a dress for my daughter I also buy a dress for my son. My son wears dresses and puts on makeup from a kit I bought them. I know that if one of my children is transgender, I will accept them as they are, precisely because I understand – from my personal experience as well – how hard life is for trans people, how challenging and complex and painful it is.

Personal experience relating to your own identity?

Transgender medicine is very personal: Whether it is successful or not frequently depends on the encounter and the conversation with the patient, on the ability to create relations of trust.

Yaish

Yes. I am a little late in saying this: I didn’t understand until around the age of 30 that I prefer women. For years I felt that something wasn’t exactly right, but I couldn’t put my finger on it, and even when I grasped it, I couldn’t tell anyone. I knew that for my family it would mean the end of the world. I remember that the first time I met up with a woman I only told one friend, and even that was because I was simply afraid that something would happen to me, and I wanted someone to know where I was. I’m not comparing my situation to theirs, but that loneliness, living with yourself with a certain knowledge and not sharing, the confusion, the huge fear of how the family and your circle will react – those are things I experienced myself. So, yes, I really identify with them and with their pain.

And the pain is there, even after the transition. It never ends.

Yes. Think, say, about how, after the process ends, adolescence starts over. You know, someone who is assigned female at birth, and at the age of 22 decides to start a process of gender reassignment, goes through the processes of adolescence again, this time as a man, with all the attendant emotional and physical changes: hair growth, acne, mood swings and more. It is extremely difficult, physically and emotionally. It’s very important for me to send the message to my patients that they can lead a full and successful life after the process. In the last conference we held, we brought, as speakers, an amazing trans woman from 8200 [the elite army intelligence unit], and also the first trans officer in the Israel Defense Forces. He spoke and so did his mother. It’s so important to show these examples, to demonstrate that it’s possible to integrate into society and the employment market, and also to find a partner and love after the transition.

Efrat Tilma. A photo featured in Yaish's exhibition at Ichilov Hospital. Credit: Iris Yaish

There are high rates of suicide in the community.

A study conducted in the United States found that 40 percent of the members of the trans community had attempted suicide at least once. I have two female trans patients who committed suicide. I had had a lengthy, deep, personal association with them, including ongoing WhatsApp communications, including giving them money when needed. I can’t tell you that I don’t feel I crossed emotional boundaries. Many members of the community have experienced very difficult lives. They suffer from all sorts of disorders and some of them are simply unable to overcome the ordeal in terms of their family and society. Many were thrown out of their homes and found themselves overnight without a roof over their head and without a livelihood, and sank into a state of total despair. One of my patients put an end to her life just before our appointment; we were scheduled to meet, and then that terrible news arrived.

I can’t imagine how you felt.

Awful. Just awful. There was a feeling of failure and tremendous pain. And the ever-present question: Maybe I could have done more, maybe I could have noticed, maybe I missed something. Acute and lengthy soul-searching over my place in all that.

Really? It sounds like you are doing a great deal. Possibly more than what other physicians would have been ready to do.

Yes, but even so: I can’t spend five hours with each person, and I can’t be available all the time. My email and WhatsApp are bursting. I also manage a trans health forum on Facebook, where everyone also expects an immediate response. Many times I feel it’s too much for the shoulders of one person. I need to get used to the thought that with all the good will and with my deep emotional involvement – I can’t do everything. I can only do my best.

Let’s talk a little about the medical challenges themselves.

They are also never-ending. Think, for example, of a transgender man who wants to undergo a hysterectomy and an oophorectomy [removal of the ovaries]. That is actually a lifetime change. Until his dying day he will require hormonal therapy, which has to be adjusted to his life, his needs, his medical profile. It takes time to find the right treatment, and then suddenly a test might show that he is suffering from polycythemia [increase in the number of red blood cells in the body], so the whole treatment would need to be revised. There are many challenges related to gynecology. Say, patients who did not do fertility preservation, started the process – which may affect the ovarian reserves or the sperm [quality and count] – and suddenly, at the age of 35, they discover they can’t have children. There are a great many questions about hormonal therapy. For example, does it increase the prospect of cardiovascular illness, or of cancer? We are examining its effect on sleep, on memory, on cognition, on fertility.

Other great challenges have to do with the treatment of people who come in at relatively advanced ages of 60 or 70. On one hand, I want to help them, but on the other, the body can no longer tolerate what it could tolerate at younger ages, and not everyone can afford to be Caitlyn Jenner and to undergo such a dramatic change in such a short time.

Does the body not respond to hormonal therapy at an older age?

It’s not that it absolutely does not respond, but the situation is far more complex and problematic. In addition, there are all kinds of other preexisting medical problems that also must be considered. Of course the younger one starts, the more significant the effect. Transgender men who start the treatment even before breast tissue develops can avoid a mastectomy in the future. On the other hand, at young ages, there are great fears that the patient will later have regrets. The whole business is very tricky. For example, I have a female patient who’s married and has children; she lives at home, and her wife and daughters don’t know.

What? How?

I don’t know. It’s completely wild. You look at her, and her external physical appearance is that of a man’s man, like a combat soldier. She started treatment a year ago. When she comes to see me she arrives dressed as a woman, with nail polish and makeup. She has already begun to grow breast tissue but no one seems to notice at home. Her adolescent daughters are occupied with themselves; the wife has already started to ask a few questions, but no one really knows, and that’s how she lives.

Until they start to see....

Yes. And then she will have to decide what to do. This is something a lot of people don’t get: The gender reassignment process is not done for cosmetic purposes, and also not because someone gets up one morning and feels like putting on a skirt. It’s not cosmetic surgery on the nose. It’s therapy for a problem or for deep mental distress.

Eyal Michael Orgobi, photographed by Iris Yaish.

I think most people see it as some sort of caprice.

Anyone who thinks it’s a caprice should try living their life for one day. Let them spend one day in their shoes. It’s an incredibly challenging life. No one would embark on that difficult, long road without experiencing a profound, real need. It means ingesting hormones, undergoing operations, living in a society that is simply unwilling to accept you, walking down the street and knowing that everyone is looking at you and judging you. It is such a demanding process, but the underlying distress just doesn’t allow for a different possibility.

The IDF is one of the most progressive armies in the world when it comes to trans people. It drafts them according to their desired gender, responds to their needs in terms of uniforms and showers, supports their treatments.

Yaish

What did you not understand about this world before you entered it – what is the most meaningful insight you’ve acquired?

There are many insights, and I am still learning. I think the deepest one actually relates to the attitude of the families. When I speak with the families, tremendous pain and difficulties arise – there are genuinely heartrending stories in some cases, and I respect and understand that. At the same time, it’s important for me to clarify to them that what’s most important is the happiness of their son or daughter, and not what the neighbors or grandma will say. Their children are not murderers or rapists, and wanting to live in the right gender is not a crime. These people need to be accepted and loved unconditionally, because we can never feel what they feel. I, too, of course, do not pretend to know. I try to get as close as I can. From my point of view, when a person sits down across from me, and I ask how they want me to address them, and he or she replies – from that moment everything disappears and the person opposite me has the gender they want, irrespective of their appearance at the moment.

‘I don’t stage them’

You are also a photographer – I saw photographs from an exhibition you mounted at the hospital.

If I weren’t a doctor, I would be a photographer. Maybe I haven’t yet lost hope that that will happen. I did all sorts of photography projects at Ichilov. I photographed, and I am continuing to photograph, trans people. What I actually want to show, and I hope this comes through in the pictures, is that they are regular people, like me and you. I don’t stage them; I want it to look and be experienced as naturally as possible.

I noticed that there are quite a few soldiers in the pictures. Is that representative?

Yes. We have many patients who are soldiers, and in fact, contrary to all the prejudices we have about it, the IDF is one of the most progressive armies in the world when it comes to how it treats trans people. The IDF drafts trans people, the chief of staff has an adviser on gender, and the army actually sees to their singular needs: It drafts them according to their desired gender, responds to their needs in terms of uniforms and showers, it supports their treatments. The army issues them Form 17 [payment authorization for HMOs] so they can be treated by us, no obstacles are created for them. On the contrary: Many times it’s easier for me to get the army to accede to therapy than to obtain the consent of an HMO [for a civilian]. I can tell you that the soldiers I see here [in the hospital] come from the army unscarred.

What do they tell you?

The reactions are very diverse, because these individuals are at all kinds of different stages. Some already started the process in adolescence, and they lived with terrible fear about being drafted and fitting in. Some embark on it during army service, and that is very challenging. Think about them being drafted in a particular gender, and suddenly they change, and everything has to be changed accordingly, and sometimes they also have to be posted to a different corps or given a different assignment. Now all kinds of possibilities exist in the army. A few years ago there weren’t many male or female trans officers, today there are a lot – in all the corps and in all ranks.

Nina Halevy.Credit: Iris Yaish

Let’s talk a little about the painful subject of trans people in prostitution.

That is the most painful of all. There I feel that my role as a physician is particularly meaningful. I am ready to do anything to assist trans women in prostitution who need medical treatment, and do it gladly and wholeheartedly. I am ready to receive them without forms being filled in, without bureaucracy, without their having to go through the regular channels. Trans women who work at the Central Bus Station [in Tel Aviv] and can’t get to me – I am ready to go to them.

Does that happen?

Yes. I did it in the past and I also volunteered at the clinic of Physicians for Human Rights. Every trans person in prostitution who contacts me will get a response. You have to understand that many trans people engage in prostitution simply because they have no other option. Some of them were ejected from the labor market when they started the process, some were thrown out of their homes and found themselves on the street, overnight. There are trans people from the Arab community who simply have no other way to survive in this world. It is so sad and terrible. It’s also not so simple in terms of medical treatment. Think about how they are getting hormonal therapy that is meant to transform them: It affects their sexual functioning, but they need to preserve their sexual abilities, because they make a living from sex work. They tell me, “I want to be a woman, but this is my livelihood.” Not to mention all the diseases that are transmitted via sexual contact. Medical treatment is critical for them, more than for any other population, but they obstacles they face are higher. A trans woman working on the street will not try to obtain a Form 17.

I think they also encounter a specific type of client, more dangerous.

Yes. They are more exposed to violence and abuse. They come to us with shocking cases of violence – cuts, bruises, serious sexual injuries. We are now setting up an acute care unit in the hospital and deploying specifically to receive trans women in prostitution, because we know that cases of violence there are more widespread.

It’s difficult, a heavy burden.

Indeed. They are also a tough group, in and of themselves. Dealing with them is not easy. These are people who come to us when they’re already on the edge, and every little thing throws them off balance. Sometimes it’s enough for someone to address them wrongly, by mistake, to spark immediate anger and frustration with the system.

I think that for a community that is so excluded, it doesn’t matter how good your intentions are – you still represent the establishment.

Absolutely. And the establishment, from the point of view of that community, is the person who makes all the problems. The person who demands that they fill out forms and do tests, and decides that treatment is impossible now, or surgery can’t be performed now, and there is great anger.

Everything is highly charged.

Absolutely. But that doesn’t deter me. You can be a good, professional physician and have what’s called “good technique,” but when you do something that feels urgent for you, that you feel is a mission, you’re a different physician. You need an emotional connection, and I have that. I feel that I am working with a population that needs me, that I can truly feel I am helping, changing their life. When I meet a trans woman who tells me that I helped her, that I gave her strength, that without me she might not have been able or been capable – that’s worth everything.

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