“Gender is sickeningly important in our culture”

What is the status of trans people in Israeli society? An interview with Dr. Shochat, who runs a gender reassignment clinic in Tel Aviv.

The question of transgender rights and identity is one of the most acrimonious issues in the Anglophone world. In Israel, however, the topic hardly comes up. What, then, is the status of transgender people in Israel, and what sort of medical options are available to them? Dr. Daphna Shochat, who runs the Keshet Clinic, a clinic for gender reassignment at Wolfson Hospital, weighs in.

Alex:  Hi Dr. Shochat. It’s great to have you here today. Can you first of all introduce yourself and tell us a bit about your work?

Dr. Shochat: I’m an endocrinologist, that’s a doctor who specializes in hormones. So in my day job for Maccabi, I treat all sorts of hormone problems like thyroids, etc. But I also run the Keshet Clinic, a clinic for gender reassignment at Wolfson Hospital.

Alex: How many trans people are there in Israel and how many people come to see you on a regular basis?

Dr. Shochat: There isn’t up-to-date data on the number of transgender people in Israel, and I think that data that is older than five years isn’t relevant because the number of people who identify as transgender have really risen. What has caused this increase is a whole different topic of conversation, obviously. But there are thousands of transgender people in Israel, and three clinics dealing with them in the country. For the last year or so I’ve had about 10 new patients a month, with hundreds of patients in total.

Alex: Tell us about the patients. First the profile, who they are, and what’s their background? And second, what’s their trajectory with you like? What’s the treatment they get, and what’s the common outcome?

Dr. Shochat: There are transgender males and transgender females. Transgender females are people who were born with a male body but who feel that they are women. Transgender men go through the opposite process. And there are lots of in between cases, especially in patients born with a female body. People also define themselves as not having any gender. They can be anywhere on the spectrum between feeling like they belong to the female gender or the male gender. This especially happens with female-to-male patients.

We have a lot of patients who were born with a female body and do not feel like they can align with the role that society expects from females. They define themselves as being nonbinary and they usually have dysphoria regarding certain features of their bodies which define them, in the eyes of society, as having a certain gender.

So if somebody who does not really define themselves as male or female has breasts, then the world treats them as female, with all the implications that arise from that. That would cause dysphoria and often the only thing they want is to get rid of the breasts. Others really want to have as male a body as possible, and there’s a whole spectrum in between. So people often find that there’s one part or more of the body that they feel uncomfortable with. It can be also the voice and the way they speak, aspects that identify them with a certain gender.

There’s a lot of confusion between sexual orientation and gender, and there’s no connection between the two. You can be a transgender woman and be attracted to other women, and you can be a transgender man and be attracted to other men, and vice versa.

Alex: What is the division in terms of transgender men and transgender women? And can you tell us about the demographic profile of the people who come to you?

Dr. Shochat: It’s about 50-50, transgender male and transgender females. I haven’t seen much data about socioeconomic status between the two, but I can tell you, based on my personal experience, they’re very different.

When people think of transgender people, they tend to think of trans women, at least until recently when celebrities like Elliott Page started defining themselves as transgender men. There was a stigma towards transgender females which was connected to the idea of a very exaggerated female figure. There was a lot of confusion in popular culture between transgender women and drag queens, and a lot of hostility and transphobia was directed against transgender women. Drag queens are people who are male. For various reasons, they dress in a stereotypical female way for various periods in their lives, often for performance purposes, but they’re not females. Transgender females see themselves as women. I see them as women. The problem is that society doesn’t see them as women.

Transgender women were marginalized socially for many years, and they were often stereotyped as prostitutes. The stereotype was rooted in reality, because transgender women were often alienated from the places that they came from, kicked out of their homes, not accepted by their families and ended up having to work in prostitution. They therefore also did not have access to medical care.

In the past, the identity of transgender males was more ambiguous. A lot of people who were born as females were seen as tomboys, which was socially accepted. So while if someone born with a male body started dressing as a woman or identifying as a woman, it would be frowned upon, for a woman to be boy-like or man-like, was more acceptable.

We don’t hear the term tomboy much anymore because it’s a misleading term. It implies that a female is someone who adheres to a gender stereotype of being girly and being sexy in a certain way; being delicate. And more and more people now say no, I’m not a tomboy, I’m not a lesbian who is a bit manly, I actually feel myself to be a man or non-binary. I don’t feel like a woman at all. And then they start getting the treatment.

The socio-economic status of transgender men is, broadly speaking, higher than that of trans women; it’s often people who are much more grounded within middle class society and have the knowledge and education and support to theorize about it, to think about it in a more intellectual sense.

A lot transgender women are in terrible distress about having to live as a male within a very stereotypical male identity. I have people who have been soldiers in Golani, famous businessmen, all with a gang of male friends. And then they say, “I just don’t feel like I belong.”

Recently we have seen transgender women from middle class backgrounds who have lived their lives up to a certain age (50s or 60s) with every privilege that society has to offer white men. These are big things to give up.

Alex: What about the classic sectoral divisions of Israeli society, Jewish, Arab, religious, secular, Haredi, etc?

Dr. Shochat: It’s definitely everyone but I see a surprisingly high number patients coming from the Haredi community and peripheral areas in Israel. This population has many more transgender females. I have one transgender male who comes from the Haredi community, but I have several transgender females from this community. It’s very interesting, and I’ve had this conversation with them and I asked them why they think that is.

If somebody is just born with a mind that doesn’t match their body, then it doesn’t make sense that there would be a socioeconomic division. So we have to think that the misalignment has a lot to do with society rather than just with an individual.

Someone can be born with or develop certain characteristics, but if these characteristics don’t fit the expected stereotypical gender identity, they won’t be able to survive. They won’t be accepted by society, whether they define themselves a certain gender or not.

Within certain socio-economic groups, a very feminine male is not going to be accepted. And they might as well go all the way and “choose” the different gender, because sometimes it’s easier for us in society to accept a transition in gender than it is to accept that maybe the way we distinguish between male and female is not real, but is in our imagination and our culture.

It’s really surprising to me when I think about it, that there is much more acceptance now of the whole concept of being transgender than there is an acceptance that maybe gender doesn’t matter at all; maybe we should just stop mentioning it as something that defines a person.

Alex: Does everybody who comes to see you transition?

Dr. Shochat: Some people want to transition but they change their mind because the price they will have to pay socially is too high. Some people, especially trans men or asexual people who do not define themselves as a certain gender, may be going through a process of defining themselves. So not everybody transitions and some people start and then stop. But most people do. We usually start with hormonal treatments because hormonal treatment is essentially reversible. Even if there are some residual effects, they are very minor.

The main point of it is to allow the person to feel the way they want to feel within society. Their body may not look the way they want it to; they may still feel terrible when they look at themselves in the mirror, but when they get dressed, and they go outside, society behaves towards them according to the gender that they have chosen. That enables them to consider more deeply whether they’re willing to pay the price of continuing with their treatment and whether they are happy with the gender role that they have taken upon themselves. And only then, once someone has been living like this for at least one year, do we start even to think about operations, because this is an irreversible process.

But at the end of the day, my role is to guide and advise but it is not my body and not my choice. Anyone who has the capacity to make an informed choice should be able to have access to all the procedures at the time that feesl right to them.

Alex: So nobody can come and say straightaway, “I want the operation”? What’s the process?

Dr. Shochat: It is different between male and female. Transgender females usually come to an endocrinologist. There are very few endocrinologists who deal with this in Israel – about three or four. Transgender females can start endocrinological treatment, hormone treatments, without any committees or legal approval. It’s up to me as the doctor.

However, it is recommended that there is some psychological or psychiatric assessment beforehand. The reason for this is that some people are still questioning their identity. Some people may not be able to deal with the consequences with their families, their jobs and with society in general.

Recently I encountered a patient whose wife had committed suicide when she became aware that her husband wanted to transition to female. Some people don’t understand what’s going to happen when they come out and it’s really important to allow them to assess their capability of dealing with the consequences. It is vital that they have the right support.

We like to have a psychological assessment for various reasons. One reason is that according to the guidelines, we are supposed to have a diagnosis of gender dysphoria. This is controversial as a psychiatric definition. Why should someone have to feel dysphoria before they can change their perceived gender? The definition involves the stereotypical gender roles that people need to fit into. I think it’s very bizarre to have a psychiatric definition of gender dysphoria.

This is what the guidelines say but I tend to ignore it. I think if someone is an adult, and they want to go through the process, then they should be allowed to. As long as they understand all the consequences.

Sex reassignment surgery for transgender men is not available in Israel at all due to lack of skill, and due to the fact that it almost always results in complications. A lot of transgender men have decided not to have this surgery (even abroad), at least until better techniques become available.

Alex: Do you have to approve it?

Dr. Shochat: I have to approve it and a psychologist is supposed to approve it. In practice this doesn’t really happen.  The problem is that there aren’t enough psychologists or psychiatrists in Israel who know how to make this diagnosis or how to deal with transgender people.

But ideally, what we would like to have is a psychiatric assessment or psychological assessments. One reason for this is to make the diagnosis, but I think this is the least important reason. More importantly, people who transition often have other psychiatric illnesses – not gender dysphoria, but other illnesses deriving from whatever they have had to endure in their life as a result of being different.

I can’t tell you what is the cause, and what is the effect, but there’s comorbidity. With someone who’s transgender, there’s often a lot of PTSD, personality disorders, anxiety and depression, which, among other things, is caused by life circumstances. Transgender patients often receive medications, and they need to be supervised to help with this transition, which is very hard, both in terms of the way society perceives them, and because hormonal treatment can change your mood and change your personality.

Ideally, we would like a psychiatric assessment. Sometimes, there are other diagnoses, for example, someone can have a dysphoria about a certain part of the body that is not related to their gender.

People often feel disassociated from various parts of the body. We had a patient, for example, who was not a transgender female but who had dysphoria about his penis, which he wanted to remove. He presented himself as if he wanted to become a woman, but we had a feeling that something was a bit off, and the psychiatric assessments said the same. Eventually this person ended up cutting off their own penis with a kitchen knife. So there are psychiatric illnesses that can look like gender dysphoria, but are actually nothing to do with gender. It’s quite rare, but it would be nice to have somebody assessing this.

In reality, though, it’s basically me assessing this because there aren’t enough professionals. There are clinical social workers who often give us a letter saying if someone is fit psychologically for the process. But it’s a rubber stamp rather than anything else. And then we start the hormonal treatments.

Alex: Could you ever theoretically say no? And if you were to say no, would that person not be able to proceed? Does someone need a doctor’s approval in order to transition?

Dr. Shochat: A doctor’s approval is required for any medical treatment. If we feel uncomfortable with any treatment, we don’t have to give it.

Alex: Have you ever been in that situation?

Dr. Shochat: I have never been in a situation where I didn’t want to help someone transition. I have been in a situation where I felt that it was premature; that the person was not ready for it; that the drugs have too many side effects, and that was a very difficult decision to make. If you go to a doctor with a different medical problem, then you can always go to another doctor, but in Israel, there are very few doctors dealing with this issue.

Personally, I tend to give treatment to everyone. And the reason why I do this is because if I don’t, then they just take the oral contraceptive pill. They’ll just have treatments illegally, without being supervised. Also because the suicide rates among transgenders is sky high.

But to have a sex change surgery, which is genital surgery, in Israel, you must have the legal permission of a committee. This is the only medical treatment that requires legal permission apart from abortion.

Alex: Is it a rubber stamp or do they sometimes say no?

Dr. Shochat: I have never seen them say no, but I don’t think it’s a rubber stamp because it’s a process. It’s not like an abortion committee where, when if you go privately, you can just say what you want even if you are lying. Here the process takes nine months (previously it took 18 months) and patients are required to see several psychologists, endocrinologists.

It has its positive aspects, because when somebody goes through such a significant surgery, they should be accompanied and get support. The question is, though, should we be allowed to regulate people’s body with a legal committee? You can say the same thing about abortion; when I had an abortion in England, I was forced to see a counselor. They said I was forced to see a counselor because otherwise I might make a life-changing decision that I would regret.

Right now, this is the law and you can’t go through genital surgery without the committee, which is under the auspices of the Ministry of Health.

Alex: Can you talk about the difference in the process to the United Kingdom and America?

Dr. Shochat: I really don’t know what the law is regarding genital surgery in the UK, but I know that even to start the treatment is a much harder process in England than it is here in Israel.

It’s not that hard to start the process in Israel. I’m here and there is Dr. Yaish in Ichilov Hospital and several other endocrinologists. So long as a patient knows about this, they will be able to start the process. In America, for example, I don’t know about the approval process but some drugs that we use are not approved by the FDA.

Alex: How come you’re allowed to use those drugs?

Dr. Shochat: We are generally allowed to use drugs even if they have been approved with a different goal in mind. For example, some drugs used to treat prostate cancer block the hormone testosterone in various ways. I use them in order to block it in transgender females.

Alex: What about children?

Dr. Shochat: A child who wants to change gender goes to a pediatrician. And the pediatrician gives the approval or not. There’s only one place in Israel that deals with transitioning children.

Alex: Do the parents have to approve?

Dr. Shochat: Parents need to approve (unless a judge rules otherwise,), but more than that,  it’s a kind of multidisciplinary approach with psychologists and more. How does a child say that they’re transgender? How do they know? After all, cross-gender behavior is not uncommon in children. Young children may ask to be called by a different name or dress in clothes traditionally worn by the other sex but that doesn’t necessarily mean that they’re transgender. It means they’re exploring their gender roles, which is something which we all do.

It can change as they grow up. Children don’t have testosterone and they don’t have estrogen. When we’re children, our bodies are identical hormonally and in almost every other way. The important thing is what to do when someone goes through puberty. When someone goes through puberty, as you may know yourself, it can be traumatic. It’s a process of change that is drastic and life-changing, and the psychological implications of it are confusing. You don’t need to be transgender to go through dysphoria with your body. You suddenly have breasts and don’t know what to do with them; you have hair; you can be really disgusted by your own body, all without belonging to the opposite gender. And so doctors need to make this distinction and must be careful and to know the whole history and context, in order to decide what to do.

There’s some evidence that children who define themselves as the opposite gender sometimes change during puberty. Somehow, the physical changes enforce the existing gender they were born into. But we don’t know. It’s a controversial issue because once a child starts producing testosterone, a lot of irreversible changes happen. The bones become much bigger, the hands, the feet, the height, the way the face looks. If I prevent this from happening, then, apart from the genitalia, the child can grow up looking exactly like a female.

There’s a film – I can’t remember what it’s called, but it followed identical twins. One of them went through the process at a young age, before puberty, and she looks exactly like a cisgender woman, because her facial features are totally different from her brother’s, even though they’re identical twins. Starting treatment at a young age tends to have a much better outcome. On the other hand, how can one know how the physical changes will affect someone’s sense of identity? What doctors do now is to block puberty.

The treatment is an injection that blocks the whole process from the brain. It gives someone time to see how their peers develop. It gives someone time to develop emotionally so that they can decide whether they want to start hormone treatments. I think it’s the best thing to do when you don’t know what you want – to just stop everything and wait.

One clinic in London did treat children before puberty – the Tavistock Clinic. However, one person who went through the process of becoming a transgender male regretted it. As a result of this, the treatment on children in the UK was banned with the reasoning that children cannot make the decision for themselves and parents can’t make the decision for them.

The UK has a beautiful law called the Gillick competence, which determines whether or not someone under 16 is able to consent to their own medical treatment without the need for parental permission or knowledge.

If a person demonstrates that they understand the consequences of the treatments, then they can be given to a child. There was massive controversy in the UK, and the High Court concluded that the answer should always be “no” in the case of under-16s with gender dysphoria, before the decision was reversed in late 2021. But until recently there were no treatments for children in the whole of the UK. So I think the situation here is much, much better in that sense. I think, comparatively to other countries, we are in a much better place.

Aside from the question of children, our problem is with the operations. If you want to have breast enlargement or reduction, you can have it privately. But if you want to have genital surgery, you’re not allowed to have that privately because you’re dependent on the committee. And there’s just one surgeon in the whole country who does that. His name is Dr. Alon Liran. He’s a fantastic surgeon, a fantastic human being, but he’s just one person. And as far as I know he does it once a month.

The wait for an operation is currently three to four years. So a transgender woman has to live with a penis for three to four years until she can get the surgery. And the only way to bypass this is to go abroad.

Alex: You said there’s been an increase in the last five years, what do you ascribe that to?

Dr. Shochat: I don’t think that people have changed, I think there’s more acceptance socially. Some people who have lived their lives in a marginalized place didn’t really have a choice. In my childhood the only prominent transgender figures were Zalman Shoshi and Dana International. They were very exceptional back then.

Alex: It seems in the Anglosphere, particularly on social media, particularly in popular media and culture, the debate surrounding transgender people and their identities has become a key focal point of the culture wars. The only thing I can think of that gets people as animated is the argument over the Israeli-Palestinian conflict. Why is that?

Dr. Shochat: Because gender is sickeningly important in our culture, and people are very, very threatened by any challenges to that concept. When you go back to the classical feminism of Germaine Greer and Simone de Beauvoir, they said that gender was a social construct.  That gender and sex are not the same thing was a massive revelation. You’re born into such and such sex, but you’re not born into your gender. Gender is something that society does to you; it’s a violent act.

Feminism has made progress on women’s rights, but I don’t think this conception of gender has penetrated on a popular level. When someone is pregnant, the first thing you ask them is whether they’re having a girl or a boy.

In research, when you take a small child and dress them in pink or blue, and give them to a nanny who doesn’t know them, causing her to think that they’re of the opposite sex, she behaves totally differently with them. She gives them different toys to play with, she tells them off for different things. It’s something that is so embedded in society that I think any playing with these roles is very difficult for people to handle.

Alex: My five-year-old daughter refuses to go into male bathrooms. Which is tricky when I’m on my own with her. And I’ve always wondered how she absorbed that.

Dr. Shochat: It’s present in every Western society. And I think the toilet is actually not a very extreme example, because it involves the sexual organs. There was an excellent BBC program, No More Boys and Girls: Can Our Kids Go Gender Free? It explored the socially imposed differences between girls and boys from a very, very young age, showing how difficult it is to eliminate them.

A girl has different genitals, but is she worse at math? Is she weaker physically? Because she isn’t. Her peers who are boys have the same level of muscle strength, but still girls are perceived to be weaker, even before puberty.

If you speak to people about this, they can really become angry and resistant. People from the most liberal backgrounds say, “I have a boy and I have a girl and I have seen differences. And I didn’t say anything to them. It didn’t come from me.”

But it did come from them as well. They’re just not aware of it. Or it came from all of society. When they say, “I have a boy and a girl and they’re completely different, so I’ve proved this,” they have a complete misunderstanding of statistics and scientific research.

Alex: So we get to the burning issue. Is a transgender woman a woman? Perhaps more importantly, the argument surrounding that question. What’s interesting to me is that we hear more people talking about whether a transgender woman is a woman than whether a transgender man is a man. It always seems to be on one side of the spectrum. Why is that? And why is this such a bitter and acrimonious issue? Is there any hope for harmony? Is there a way out of this dichotomy?

Dr. Shochat: There’s always this discussion about what makes a woman a woman. Germaine Greer writes about it a lot. We can’t say a woman is someone who has a womb because a woman can have her womb removed and still be a woman. The same goes for other parts of the body.

Even biologically, we don’t really know what a woman is because you can have various chromosomal differences. There’s a lot of in-between biologically. So there’s nothing that really defines us in some dichotomous way.

Is a transgender woman a woman? Yes, I think she is. She’s just a different type of woman, she’s a transgender woman. A lot of transgender women say this, they say, “Yes, I’m a woman; I’m a transgender woman. It doesn’t make me the same as a cisgender woman. I will never be a cisgender woman, but I am a woman.”

The arguments around transgenderism will only become less acrimonious if we stop regarding gender as the defining element of identity.

I understand both sides of this argument but telling anyone who they are is a violent act and the real issue here is about feminism and the perceived undermining of feminism.

And this is why feminists are rightfully scared. It’s divide and rule. It shouldn’t be feminists against transgender women, it should be both of us against the patriarchy.

The reason nobody talks about transgender men is because nobody cares. And the reason why nobody cares is because being a man is not precarious in the way that being a woman is. It is not necessarily the case that everybody who sees a transgender man thinks that he is masculine, but transgender men pose less potential threat to males and masculinity. Men have not had to fight to obtain power and influence in the way that women have. The power that men have is taken for granted by those who wield it and it is not threatened by transgender men in the same way.

On this question, I love JK Rowling, but I think the way she phrases her arguments is very offensive. She does, though, come from a feminist perspective that says gender is a social construct. I strongly agree with this and I think there’s something about some of the ways in which transgenderism is understood that undermines this. The reason why I treat transgender people is not because I believe that someone is born into the wrong body.

I don’t think anyone can be born into the wrong body. I treat transgender people because I believe that people are forced by society into behaving in a certain way. Society demands that people’s sex and genders align. For people where this is not the case, their lives become intolerable.

Alex: Do you think if society wasn’t as obsessed with gender that fewer people would transition? Would they find an accepted place on the gender spectrum?

Dr. Shochat: To be a woman is a very violent existence. Perhaps I’m wrong but I think many more things are forced on women than on men. It’s therefore much more common not to be able to cope with the accepted gender roles of being a woman. I think it’s much more common for women to resist the gender roles prescribed by society, because these roles are so limiting and oppressive. Many transgender men tell me that that they don’t want to be like a cisgender man. What they want is not to be a woman in the way that society has prescribed.

It doesn’t happen the opposite way. You don’t get transgender women who say, “I don’t want to be a man, but I don’t know if I’m a woman.” Why you don’t get this is interesting to me. Why are those transitioning from male to female are so much more accepting of gender stereotypes and gender dichotomy?

The lived experiences of being a woman are something that transgender women need to consider. I ask them if they want to transition into the weaker sex and whether they want to transition from a position of power to a position of someone who is less lucky in society.

Transgender women often say to me that people bug or harass them in the street. I wonder, is this because they are transgender? Or is it simply because they are now female and have just never experienced this before.

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