Inclusivity In Healthcare Should Not Be Valued Above Our Paramount Mandate: First, Do No Harm

In the spring of 2022, a 50-year-old grandfather in North Carolina decided that he wanted his daughter’s newborn to suckle at his nipple.

Rather than keep this thought to himself, he opted to confide in his doctor.

You may wonder what happened next. Was the doctor a mandated reporter? Did Child Protective Services show up at his house to investigate a possibility of child sexual abuse? After all, the CPS is so vigilant that they investigate 37% of American children. Or perhaps he was referred to a therapist?

Well, no. Because this particular man identified as a transgender woman, doctors and academics from Duke University wholeheartedly supported his “unique desire”. Indeed, they published a research paper in Breastfeeding Medicine, providing details of the cocktail of hormones and drugs they used. With these, he was able to produce secretions, that were administered to his grandchild. The paper does not have a single sentence about the potential impact on the grandchild.

It is an unimaginable breach of ethics. An adult male’s desire to be affirmed as a woman should never be met by feeding an experimental drug-infused substance to newborns with no capacity to consent. Compelling one individual to undergo medical treatment to benefit another is an ethical minefield, especially in the case of minors. Most societies are strongly averse; market-based solutions for blood and organ donations are routinely banned, even if many lives would be saved.

This is not an isolated instance. There are several research papers on inducing lactation in males¹, sometimes called ‘chestfeeding’². To secrete fluid from the nipples, these males consume high doses of hormones like progesterone and oestradiol, along with drugs with known side effects for infants, like domperidone.

Nor is it an edge case confined to academic hospitals. Supporting chestfeeding is the official position of La Leche League - the world’s oldest and most famous international breastfeeding organization. Trustees who objected were suspended. Directors resigned. And their 94 year old founder, Marian Thomas, walked out over it, 68 years after its founding.

Experimenting on newborns, just to affirm adult identities, is egregious. Such experiments are possible only because medicine, in the push towards inclusivity, is forgetting our own core value: first, do no harm.

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I work in maternal and newborn health. In 2019, I founded Aastrika, a public health organization in India whose mission is to increase access to high quality, respectful, ethical, and evidence-based maternity care.

Aastrika’s private maternity hospital, Aastrika Midwifery Centre, aspires to be a centre of excellence in evidence-based obstetrics, women’s healthcare, reproductive care, and paediatrics.

Our non-profit arm, Aastrika Foundation, focuses on capacity-building and on advocacy. We conduct multi-year training programs for professional midwives in Karnataka, along with short-duration courses for over 150,000 frontline healthcare workers in states like Bihar and Uttar Pradesh.

Aastrika was inspired by my own experiences. In 2016, I was a Public Policy PhD student in the US, conducting a randomized controlled trial in south India. I was also pregnant and toggling between Indian and American hospitals for maternity care.

In the US, caesarean section rates hover around 32%. In Indian private hospitals, caesarean section rates are 70-95%.

Profitability and operational convenience are routinely prioritized by hospitals, despite the potential harms to the mother and baby. These excessive c-section rates are possible in large part because of what I call ‘fear-based consent’. That is, consent obtained from patients by misrepresenting the risks and benefits of surgery, or even via outright fear-mongering.

I founded Aastrika because I wanted Indian women to have access to the kind of ethical and evidence-based care that was available to me in the US, as well as to informed consent and shared decision making.

So it is with deep dismay that I have watched Western medical institutions abandon these principles under the influence of gender-identity theory.

Acknowledging that reality is gender-critical is neither hateful nor bigoted

In the United Kingdom, gender-critical feminists have won a series of legal and political battles. One of the earliest of these was the Forstater judgement that gender-critical beliefs are legally protected. British feminists celebrate the anniversary of the judgement as WORIADS day – the day that UK caselaw established that gender-critical beliefs are Worth Of Respect In A Democratic Society.

Specifically, the UK protects the belief that “biological sex is real, important, immutable and not to be conflated with gender identity.”

This is protected as a ‘belief system’ only because gender-identity theory³ has become so dominant. Arguably, each point is a fact.

Sex is real. It cannot be assigned. It is inherent.

It is not a social construct, as activists sometimes claim. If humans were to go extinct overnight, taking all social constructs with us, sex would still exist, because life on earth has used sexual reproduction for over a billion years.

Sex is important. It is important for women’s rights, because women and girls suffer from sex-based oppression. India struggles to prevent female foeticide because of sex discrimination, not because of identities. It is absurd and offensive to claim, as Amnesty did, that “Under the Taliban, women and girls were discriminated against in many ways, for the ‘crime’ of identifying as a girl.” Females in Afghanistan do not have the option of identifying out of sex-based discrimination.

Sex is important for gay rights, because without sex, you can’t have same-sex attraction. Lesbians who reject trans-identified males in their dating pools are accused of transphobia, genital fetishism, and worse. For these reasons and others, gay and lesbian people are at the forefront of gender-critical movements around the world.

Sex is important for healthcare, because sex is present in every cell of your body. Sex affects how your heart attack symptoms will present. Sex affects your risk of vaccine-related myocarditis. Sex affects how practitioners interpret your laboratory tests, such as for triglycerides, HDL, haemoglobin, cardiac enzymes, and more.

Sex is immutable. We are physically embodied in sexed bodies, from the moment of our conception. We cannot change this material reality. Hormones and surgeries can modify appearances and sex-affected traits such as height or breast size, but you cannot change sex itself. In other words, you can change form. You cannot change function. No procedure can create a female who produces sperm or a male who produces eggs.

Sex should not be conflated with gender identity. People should be free to express themselves how they wish, without conforming to gendered stereotypes. We should strive to ensure that those who identify as transgender have full civil rights, along with protection from discrimination, harassment, and victimisation. But every human has a biological sex. In healthcare, allowing gender identity to override biology can be deadly.

Maternity hospitals do not ‘assign’ sex - and yes, sex is binary

Among gender-identity advocates, maternity hospitals are often the bad guys. Apparently, we go around ‘assigning’ the wrong sex at birth. The best-selling children’s book “It Feels Good to Be Yourself”, rated “Exceptional” by Kirkus, describes our work like this: “See, when you were born, you couldn’t tell people who you were or how you felt. They looked at you and made a guess. Maybe they got it wrong, maybe they got it right. What a baby’s body looks like when they’re born can be a clue to what the baby’s gender will be, but not always. When people guess wrong, it’s okay to let them know.”

Just to clarify, maternity hospitals do not ‘assign’ sex. And we definitely don’t look at babies and make a ‘guess’. Rather, we observe and record sex.

Because the sex of the foetus is determined at conception, we can observe it via blood tests as early as 10-12 weeks of gestation, or by ultrasounds at 16-20 weeks.

In India, to reduce female foeticide, sex-determination by blood tests or ultrasounds is illegal. So, for Aastrika babies, sex is visually observed at birth.

Sex is binary in mammals. Males are those who follow the developmental pathway to producing small gametes. Females are those who follow the developmental pathway to producing large gametes. There is no third sex because there is no third gamete. There are no intermediate sexes because there is no hybrid gamete.

There is definitely much confusion about this, though. Babies can occasionally be born with congenital Disorders of Sex Development (DSDs), caused by chromosomal abnormalities. These babies are sometimes called intersex, but that is an inaccurate term. Sex is still binary, because each disorder is sex-specific. A very brief explanation is that there are genetic disorders that affect the reproductive system of a baby, but the baby is still either male or female. Less briefly, here is a post-length explanation, and here is a book-length one.

When an Aastrika baby is born with a congenital DSD, we provide evidence-based treatment and compassionate counselling, just as we do for babies born with heart defects or any other congenital condition.

Genetic disorders should not be falsely recast as healthy variations of a supposed human sex spectrum. Some DSDs can be fatal if they are untreated. Many adults with DSDs are tired of their health conditions being used as a political weapon.

The damage from gender-identity theory in healthcare goes well beyond youth gender medicine

History will look back on gender-identity theory’s takeover of medicine as a shameful scandal. Many of us already do.

Ideological pressures are overriding basic principles of evidence-based medicine. Iatrogenic harm is widespread. The lawsuits from detransitioners have started; I expect a tsunami in the coming years.

To date, public discussion is extremely focused on paediatric transition treatments - on the quality of evidence for youth gender medicine, on social contagion among teenage girls, on parental rights, on whether minors should have medical autonomy for irreversible procedures, and so on.

That is only one part of the problem.

Gender-identity theory is harming patient care across specialities, not just in paediatrics. It is also impairing medical schools, teaching hospitals, and professional associations.

I am particularly disturbed by how badly research has been affected. Prioritizing gender identity over sex in healthcare affects individuals. Prioritizing gender identity over sex in research affects the entire body of human knowledge.

When the UK government commissioned Professor Alice Sullivan to do an independent review of research on sex and gender, the verdict was damning. There are barriers at every stage of the research process. Whether research gets produced or published is heavily influenced by activism. As just one example from an extensive catalogue: Professor Baxendale, a neuropsychologist, authored a review which documented the negative impact of puberty blockers on cognitive development. The review was repeatedly rejected, not because the reviewers disliked the methods, but because they disliked the outcomes.

If the process of knowledge generation is so corrupted, evidence-based medicine becomes an impossibility.

Are we respecting someone’s identity, or are we treating gender dysphoria?

There are many strands of gender-identity theory. Broadly, these can be bucketed into the gender-identity school of thought and the gender-dysphoria one.

In the gender-identity school of thought, the concept taught to children often portrays being a girl or a boy as a series of preferences and consumer choices. In I am Jazz, for instance, Jazz explains that he “hardly ever played with trucks or tools or superheroes. Only princesses and mermaid costumes. My brothers told me this was girl stuff. I kept right on playing… I had to put on my boy clothes again. This made me mad!” After a doctor explained the idea of ‘transgender’ to his parents, they allowed him to wear girl clothes and grow his hair. He is very happy to be considered a girl at last.

The concept understood by adults is more sophisticated. Gender identity is “a person’s internal sense of being male, female or something else”. It is self-determined, and it can be fluid over time.

The gender-identity school of thought often delinks biological sex and gender altogether. Take the ‘genderbread person’, which is widely used as an educational tool. This concept involves gender identity (how you self-perceive), gender expression (how you outwardly present), anatomical sex (being male, female, or ‘intersex’), and sexual/romantic attraction (who you are attracted to). These may not align, and each of them is a spectrum.

So, as someone recently explained to me, a ‘gender non-conforming transgender woman’ is a biological male, who identifies as a transgender woman, but is gender non-forming to the adopted gender, i.e. prefers to present as a man. This person is considered a woman as it is his gender identity.

In the gender-dysphoria school of thought, people may suffer from the mental health condition of gender dysphoria, as defined by psychiatrists. Medical intervention and social transition are treatment modalities to resolve the feelings of distress.

The ideas of ‘being born in the wrong body’ and ‘brain sex’ broadly fall into this school of thought. As Jazz explains, “I have a girl brain but a boy body. This is called transgender. I was born this way!” ‘Being born in the wrong body’ is something out of your control, something that is pre-determined.

In politics, transgender is seen as an umbrella term. The ACLU, for instance, defines transgender as “a broad range of identities and experiences that fall outside of the traditional understanding of gender. Some of those identities and experiences include people whose gender identity is different from the sex they were assigned at birth, people who transition from living as one gender to another or wish to do so (often described by the clinical term “transsexual”), people who “cross-dress” part of the time, and people who identify outside the traditional gender binary (meaning they identify as something other than male or female). ”

In healthcare, this umbrella term is unhelpful. The implications of gender-identity theory and gender-dysphoria theory are radically different. A transsexual seeking medical interventions is very different from a part-time cross-dresser.

When we are treating gender dysphoria, then of course we should follow regular principles of evidence-based medicine

I don’t think this is complicated. It is just that the issue is so politicised, it’s tough to openly say it.

To fully delve into this topic would require a whole post. For now, briefly:

We should choose treatments using the best evidence available, including systematic reviews.

We should explore all potential diagnoses for gender-related distress, including autism, sexual abuse, internalised homophobia, co-morbid mental health conditions, etc., rather than jump to the conclusion of gender dysphoria.

We should use our routine toolkit for medical decision-making, including cost-benefit analysis, Bayes theorem, and the Number Needed to Treat framework.

We should stop blocking research on gender medicine. As a matter of urgency, we should do retrospective analysis of data from gender clinics. Gender clinics that are wilfully hiding data should be penalized.

When gender identity is a self-determined inner perception of one’s gender, it doesn’t need any healthcare at all

Let us go back to the children’s book I mentioned earlier, It Feels Good to Be Yourself. This tells kids that “You might feel like a boy. You might feel like a girl. You might feel like both boy and girl – or like neither. You might feel like your gender changes from day to day or from year to year… No matter what your gender identity is, you are okay exactly the way you are. And you are loved. It feels good to be YOURSELF, doesn’t it?”

I agree with this message! This is how I parent my 8-year-old son. I endorse telling children that whatever they feel like internally is okay. That they are loved. That they should feel free to be themselves. That they can play with dolls or trucks, footballs or mermaids. That they can wear their hair long or short.

Unfortunately, putting children on puberty-blockers, and giving people of any age cross-sex hormones, mastectomies, castrations, and various other surgeries is the complete opposite of “you are okay exactly the way you are”.

For every child to feel loved exactly the way they are, we need to encourage parents, playground bullies, and society to be more accepting of kids who are gender non-conforming.

For adults, we need protection against discrimination for gender presentation, along with civil rights in housing, employment, marriage, etc.

But we don’t need any medical interventions.

Respecting beliefs in healthcare is commendable… to a point

Often, the patient may not be directly seeking gender medicine, but his gender identity or belief that he is a woman is still impeding the management of his health. As I noted earlier, biological sex is important throughout healthcare, for procedures as routine as interpreting lab tests.

What do we do then?

Well, this is not a new challenge. Hospitals and doctors have to constantly decide how much to defer to metaphysical, cultural, and religious beliefs.

At Aastrika Midwifery Centre, we try to accommodate culture as much as possible. Some requests are simple, like the Assamese lady who wanted to give birth facing east. Some requests are logistically complicated but doable, such as ensuring all-female staff for some of our Muslim clients.

But healthcare will throw up dilemmas in which beliefs clash with protocol-based healthcare, potentially causing harm to patients.

A few months ago, I was arguing with a to-be Aastrika grandmother in our triage room at 2am in the morning. This lady’s daughter was about a month away from her due date. The family wanted us to admit and induce the pregnant lady before the baby was full term, so that the baby would be born before the inauspicious period of amavasya, which was a few days away.

Multiple of my colleagues had already counselled them on the health risks faced by premature babies.

Nonetheless, I once again explained the NICU⁴ risks, the chances of iatrogenic harm, the possibility of long-term consequences, and so on.

They were adamant. The to-be grandmother told me that “I cannot only think about the NICU and his short-term health concerns. I have to consider the next twenty years of harm to my grandchild if he is born during amavasya. If you don’t induce her today, can you promise me she won’t go into labour next week? You cannot, right? So admit her now.”

I was equally adamant, and this argument went on for a while.

Eventually the pregnant mother, who was listening quietly, said “What if we sign all the consent forms, acknowledging that the baby may go to NICU, etc.?”

I tried to be gentle, but I also told her the truth. She didn’t have our consent.

And she didn’t. Aastrika and I are not willing to use medications, hormones, or surgeries to deliver a premature baby and put the child in the NICU, to accommodate his grandmother’s metaphysical belief. Perhaps being born at the wrong time will burden him for decades. Perhaps it won’t. How would we know? This sort of belief is unfalsifiable.

I expected them to walk out and have a c-section at a competitor’s hospital. I was pleasantly surprised when they instead decided to follow our advice! The pregnant lady even sent a private message thanking me. My stubbornness had probably increased her bargaining power in her intra-household dynamics. And luckily for us, amavasya came and went before the baby was safely born full-term.

My decision was not necessarily correct. Perhaps I should have been more respectful of the woman’s choice and less paternalistic. Perhaps I should not have put so much weight on the foetus’s right to be born full-term. I may have ignored other ethical considerations.

But ultimately, we have to have some ethical stance of our own, to decide what we will do if accommodating a personal belief will cause harm to our patient.

You have a right to refuse treatment, not a right to demand it

Bodily autonomy and the right to informed refusal is one of my core beliefs. Aastrika was founded in part because Indian women rarely have that right, and I wanted that to change.

But the right to bodily autonomy is a negative right to refuse intervention, not a positive right to demand treatment.

Suppose the situation with the amavasya-fearing grandmother had been flipped. Suppose Aastrika was recommending an induction or c-section for the health of the child, and the family was refusing to be admitted until amavasya got over. In that case, I would have documented their refusal and accepted it. The pregnant lady always has the right to refuse treatment. But they were demanding that we give them treatment, although it would have violated our oath to do no harm. In those situations, we too have the right to refuse.

I am not saying that people should never get elective medical treatments. But they are not a right, and they should be evaluated through regular frameworks in medicine. What is the potential harm of the procedure? Is there adequate informed consent? What is the financial burden? Are there alternative procedures that are less invasive? And so on.

Wrong-sex language is often harmful to patients

Thankfully, the civil rights component of the transgender political movement is popular in Western democracies. In the UK, the Equality Act protects people with ‘gender reassignment’ from discrimination, harassment, and victimisation. In the US, there is strong public support for protecting trans people from discrimination, and the Bostock Supreme Court decision reflects that.

I fully support these civil rights protections. No one should be discriminated against in housing, employment, and so on, for their health conditions, their clothing, their behaviours, or their personal beliefs.

In 2025, disputes in trans politics are more about healthcare, women’s rights, and single-sex spaces.

When it comes to healthcare, the current moderate position is roughly that “We can debate the pros and cons of various medical treatments for gender dysphoria, but of course society, doctors, and hospitals should always respect someone’s gender identity and pronouns”.

This moderate position is reflected in the remarkably strong social norm about deferring to preferred pronouns. Particularly among college-educated Americans, ‘misgendering’ is very stigmatized. Preferred pronouns are so unquestioned that even the conservative US Supreme Court uses them in Skrmetti.

Friends who read drafts of this article urged me to add a line on “of course, we should always respect someone’s pronouns”.

Anyone who hasn’t cancelled me yet may be about to, but… I don’t agree.

When a transgender person is someone who is suffering from gender dysphoria, then using preferred pronouns is not benign

If a doctor uses preferred pronouns for a patient who says they have gender dysphoria, they are agreeing with the patient’s self-diagnosis. Gender distress can arise due to gender dysphoria. It can also arise because of autism, depression, sexual abuse, bullying, social contagion, discomfort with being gay, and so on.

A doctor’s role is to consider all possible diagnoses, not confirm the patient’s suggested one. If needed, further diagnostic testing and detailed evaluations can be used.

Even if a patient does meet the criteria for a clinical gender dysphoria diagnosis, social transition may not be an appropriate treatment. Using preferred pronouns, along with other elements of social transition, is an active medical intervention, not a neutral position. There are recognized harms in social transitioning.

When doctors use preferred pronouns from the very first visit, it is like affirming an anorexic teenager’s belief that she is fat. Not only is affirming the teenager’s belief directly harmful, but it also makes it harder to later withhold inappropriate bariatric surgery.

When a transgender person is someone seeking affirmation, doctors and hospitals should be courteous and respectful of his language preferences, but also evaluate the possibility of harm

Healthcare professionals should respect beliefs and preferences if it doesn’t impact treatment. Patients should be free to change their names or gender presentation. Wrong-sex language, on the other hand, is often actively harmful.

It is one thing to use preferred pronouns as a courtesy, for instance to older transsexuals who understand that biological sex is real and affects their medical care.

It is quite another thing to use wrong-sex language with patients immersed in gender-identity theory, who don’t seem to understand that biological sex is real, important, immutable, and not the same as gender identity. Gender identity is a perception, unlike the material reality of sex. I am deeply uncomfortable with endorsing this perception as fact in healthcare, which deals with physical bodies, not with a “person’s internal sense of being male, female or something else”.

Respecting metaphysical, cultural, and religious beliefs cannot be the sole criteria in medical decision-making. We understand this perfectly well in other contexts. For instance, male circumcision for religious considerations is accepted but female circumcision is not, because the health consequences are very different. Patient beliefs are an important input to decision-making, but they are not the only factor.

Wrong-sex language is definitely harmful to healthcare culture

Alarmingly, wrong-sex language has thoroughly muddled the thinking of healthcare professionals.

As just one example, consider the Duke researchers who administered drug-infused male nipple secretions to a newborn. They are so steeped in ‘trans women are women’ that they forgot that trans-identifying males are not actually females.

As an analogy, an adoptive mother is a mother. But will you do a c-section for her?

Healthcare professionals are vilified and penalized for recognising reality, even when sex is integral to patient care

Consider Dr. Victor Acharian, the French gynaecologist who refused to treat a male who identified as a woman, saying that he didn’t have any relevant expertise. Did he deserve his month-long suspension?

Consider Jennifer Mille, the English nurse, whose story really sounds like a parody. She was caring for a convicted paedophile, temporarily released from a high-security men’s prison to the NHS to resolve his urinary problem. She referred to the patient, who identified as a woman, as ‘mister’ and ‘he’ while discussing the patient’s catheter with a doctor. He responded violently, yet, she was the one who was disciplined.

Consider the situation in the Scottish NHS Fife trust, where acknowledging biological reality is so professionally dangerous, that a nurse – a nurse! – prefers to testify in court, under oath, that she is not sure if results of a DNA test will be changed by hair, clothes, or make-up.

Consider Dr. Carole Hooven, the human evolutionary biologist and Harvard lecturer. All she did was explain that the scientific definition of sex is inherently binary, and share her view that we should respect gender identities while also understanding facts about biology. For this, she was hounded out of her prestigious role at Harvard.

Dragging medical institutions back to non-ideological medicine feels like a distant aspiration. For now, gender-critical healthcare professionals just want to be able to acknowledge the truth.

So much of this is a tragedy

When I think of how gender-identity theory is damaging public faith in healthcare, I feel worry. When I think of how chestfeeding exploits the newborn’s inability to voice her refusal, I feel rage.

But when I think of children being taught that they are born in the wrong body, I feel grief.

Perhaps because I am the mother of an 8-year-old boy, it feels too personal. India is not a feminist country, let alone a post-feminist one. I try hard to raise my son to feel free of gendered Indian expectations. It is acutely distressing to know that children in other parts of the world are medicalised if they don’t conform to stereotypes.

It is also bewildering. When I moved back to India after a dozen years in the US, and started an organization to provide Western-style ethical and evidence-based medicine, I could never have imagined that the West would give up those principles. I am still in shock. It feels unreal.

Healthcare professionals have a duty of care to our own patients and to society at large.

We are entrusted with the physical bodies of our patients. Perhaps other fields can afford to prioritize gender identity over biological sex. In healthcare, we cannot.

Doing so is a failure of our paramount duty - to first, do no harm.

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Janhavi Nilekani is the Founder and Chairperson of Aastrika Foundation and Aastrika Midwifery Centre. She has a PhD in Public Policy from Harvard, and a Bachelor of Arts from Yale.

The views expressed in this piece are those of the author and not any institution she is affiliated with. She is deeply grateful to all those who helped her build the confidence to write and publish this essay.

1. See, for example, here, here, here, here, here, and here.

2. The term chestfeeding is also used for females who are breastfeeding infants but identify as fathers or non-binary. Such females may have intact breasts, may be using binders, may have had mastectomies, or may be on testosterone. Each of these situations has different clinical implications in maternity care.

3. I use the Sullivan Review’s definition of gender-identity theory as “the negation of at least one of the four aspects of gender-critical belief: in other words, the assertion that biological sex is not real and/or not important and/or not immutable, and/or that gender identity and sex cannot be clearly distinguished.”

4. Neonatal intensive care unit