Slam dunk? No thank you!

Posted by on July 9, 2015

In the past year, I have started to hear an alarming number of health care providers (therapists, doctors, surgeons) refer to trans people seeking gender-affirming medical services (such as surgeries or hormone replacement therapy) as “slam dunks”. I am not new to trans health care, so I don’t know exactly why I just started hearing this term used in this way just recently. The first time I heard it, I was taken aback but thought it was just one provider’s idiosyncratic way of speaking about a trans client. But then I heard it again, and again, and again. Over time, I have come to realize that this concept of a “slam dunk” is actually quite pervasive in the field of trans health. It is a term used and perhaps commonly understood by providers to imply that the trans patient in question has a very “straight forward” case, i.e., presented with an acceptable approximate of the medicalized narrative of trans experience. If you’re not familiar with what this narrative is, it sounds something like this:

I was born as a girl trapped in a boy’s body. I played with dolls and I hate my penis. I won’t be complete as a woman until I have surgery.

I’m not saying this isn’t an authentic narrative for some, possibly many, trans people. It’s just that the people for whom this narrative does not apply are often excluded from gender-affirming health care that could provide them a better quality of life. These people are not members of the slam dunk club. slam dunk catIn conversations between providers evaluating whether a trans person is a suitable candidate for whatever the desired medical procedure is (e.g., top surgery, genital reconstructive surgery, hormone replacement therapy), this term is used in a way that is perplexing to me. I’ve been having difficulty placing my finger on it, but after hearing it more than a several times I reached my limit. This is a common pattern. Sometimes microaggressions just need to add up over time and across different contexts to be seen and named for what they are. So these are my thoughts.

  1. When we call people “slam dunks”, we are implying that some trans people are somehow more real or authentic than other trans people. Trans people already face the challenge of being seen as authentic in their genders (as women, as men, as neither, as both, as in between). Let’s not add on another layer of pressure to be a “real” trans person. There is no one way to be trans, the same way there is no one way to be a man or a woman or a genderqueer person, etc.
  2. The concept of “slam dunk” immediately brings to mind the picture of a basketball and a hoop. Yes, we are talking about the hoops that trans people have to jump through and we aren’t even trying to hide it. In fact, when I hear people use the term “slam dunk”, it almost sounds celebratory, with great pride. Are trans people basketballs? Are health care providers basketball players? Is another point scored for every surgery approved for someone we don’t have to worry about?
  3. Let me explain about #2 regarding worry. Health care providers are worried. We are worried about liability. We are worried about the guilt we would face if we allowed someone to make a bad decision about their (third person singular gender neutral pronoun intentional) life trajectory. We are worried that if the person we pass through these barriers to care were to ever (gasp!) REGRET and (gasp!) de-transition, we would lose the game.
  4. More about #2 regarding worry. The concept of a “slam dunk” (like other terms and concepts that perpetuate the medicalized narrative of trans experience) puts providers at ease. It quells the anxiety that they may have about unintelligible gender. It gives them a sense of security much like the relief one might feel after they are given an answer to “Is it a boy or a girl?” Cisnormative? Phew! We can understand that. We don’t have to expand our notions of gender when these patients walk into our offices.
  5. Let me explain about #3 regarding bad decisions. People make bad decisions all the time. People regret their decisions all the time. I don’t believe it is my job as a therapist to stop someone from making a bad decision. We don’t stop people from getting married, and we all know that is sometimes a very, very bad decision! My job as a therapist is to help someone to understand the implications of the decisions they are making, the risks, the benefits, all foreseeable challenges and what options they would have to deal with them. And, of course, the feelings! Don’t forget about those! I’ll point out that I’m writing about adults because that’s the population that I’m qualified to work with. Trans people are often infantilized and judged to not possibly know what they truly want.
  6. Are the people who aren’t slam dunks ever in the game? Are they the long shots that just might make it into the net if they’re lucky? Or are they just shit out of luck?
  7. Another problem with the concept of “slam dunk” is that it pits trans people against each other. Sometimes it implies a scarcity of resources (which is sometimes real) and that the most deserving trans candidate wins. It negates the possibility of a world in which trans people of all genders, all gender histories, binary or nonbinary have an equal chance of being taken seriously. This should have never become a competition or a game. We are talking about people’s lives.
  8. Slam dunk becomes shorthand. It leads to assumptions. It cuts a very important, meaningful conversation short and has the capacity to inflict more harm when people aren’t given the space to share their stories, not one that they learned they needed to adopt in order to survive or access health care. We want to have these conversations. We should mostly be on the listening end, and then we can ask the right questions to help someone come up with their own answers. This is generally my approach as a therapist.
  9. The “slam dunk” archetype has certain characteristics. I cannot say this is true across the board, but a “slam dunk” usually has the following characteristics:
    • Is White, has White skin privilege, or approximates the White/Western ideals for masculinity or femininity.
    • Has access to financial resources.
    • Is mainstream educated.
    • Is articulate in speech.
    • Adequately meets criteria for Gender Dysphoria (thus having a mental illness) but is not too mentally ill (no suicidality or hysterics please).
    • Does not have cognitive disabilities.
    • Has a very binary articulation of gender identity.
    • Already has passing privilege and perhaps even is perceived as a “beautiful” man or woman.
    • Is persistent, insistent, and consistent: Privilege really helps in asserting these characteristics.
    • Plays nice, acts sweet, is compliant and agreeable with doctors.
    • Uses the word “complete” repeatedly.
    • Displays none of the above but aware of the medicalized narrative and can play the part (“I’m not a slam dunk, I just play one on TV…”).

There are health care providers I really respect, some who are incredible allies and do affirming work with trans people, yet who have adopted the language and rhetoric of “slam dunk” in their practice. It usually comes out of the mouths of people who are well-meaning and consider themselves advocates and allies, but it can have a harmful impact. Maybe we chalk it up to bad habit – in any case, it’s time to unlearn it. Let’s all “slam dunk” this term (and all that it represents) into the trash!

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