The award-winning film Emilia Perez addresses a central question in gender medicine. When a patient wants to transition, is it because they want to change their gender or because they want to change their life? If the later, a gender transition may be effective approach, but it may not be necessary. Instead, sometimes, other approaches may better help the patient reach their goals.
The movie addresses the complexities inherent in this question by telling us the story of a man who clearly wants to change his life but, for complicated reasons, may not be able to change his circumstances. Manitas, the brutal boss of a ruthless Mexican drug cartel, is in trouble. Rival cartels are muscling in on his territory. His life is in danger. He is depressed and having thoughts of suicide. He tells his doctor, “I can’t take it anymore... I’ve thought about killing myself, about ending up as a few lines in a newspaper. But then I thought it wasn’t fair, I couldn’t die without living... I was entitled to another life, a life of my own.”
Patients’ motivations are complex. They don’t want to be the person they are in the world they are in. They world will not change. For Manitas, as for most people, the barriers to change are embedded in the particulars of his life and the choices that he has made. Gender transition may be the only way to escape the life in which they are trapped and to stop being the person they have been.
How will Manitas find that other life? He wants the drug-lord to disappear. He will fake his own death while he is secreted off to Tel Aviv to become a woman. To implement his plan, he kidnaps a clever and corrupt lawyer, Rita, and offers her millions to arrange his disappearance, his surgery, and his new identity. He asks her to set it up in a way that will protect his wife and children and allow him to keep control over his money. When he tells her this, she asks the key line in the movie, “Do you want a new life or a new gender?” His reply illustrates the ambiguity: “Is there a difference?”
The ambiguities are further explored as the movie shows us two different types of surgeons, each representing a different approach to gender transition therapies. The first, in Bangkok, is a glitzy clinic in which transition services are offered as luxury consumer goods. The shimmering white walls and silver metal are bathed in cold fluorescent light. The clinic’s offerings are described in an upbeat song and dance number, the chorus of which happily describes “vaginoplasty,” “mammaplasty,” and “laryngoplasty.” There is a flow of bandaged patients sending selfies of their new faces and bodies. Here, gender medicine has nothing to do with the idea that gender dysphoria is a potentially fatal disease. One can buy and wear a new body like one could buy a new suit. Rita rejects this approach. Manitas needs something more personal.
Rita finds another surgeon who offers a very different approach. Dr. Wasserman works in Tel Aviv. Rita thinks he is the right guy because “he doesn’t try to be nice and he’s not pushing his wares.” Wasserman is also realistic about what his interventions can achieve. He warns Rita that he can only fix the body, not the soul, a view that explains in a song. He sings,”If he’s a he she’ll be a he/If he’s a she she’ll be she.” For Wasserman, gender surgery is a complicated choice that may or may not achieve the patient’s goals. He needs to understand Manitas in order to judge whether his reasons for wanting treatment and his hopes are consistent with what Wasserman thinks is achievable. That requires a probing conversation with Manitas.
Manitas’ reasons, as noted, are not straightforward. Clearly, his life is stressful and there are many reasons why he would like to fake his death and disappear. But Manitas also talks about his longstanding sense of gender dysphoria. He compares himself to Vito, a mobster-character on the television show The Sopranos, who was gay and closeted. He tells the doctor that, “To keep his true nature hidden, Vito had to be the worst fucking scumbag of them all...” Vito was not conflicted about being gay. He was conflicted about the need to hide it. We sense that Manitas has similar conflicts.
This conversation and Wasserman’s psychodynamic approach seem more patient-centered and beneficent than the Bangkok approach, even though the Bangkok approach offers a more unconstrained deference to the patient’s own choices. In Bangkok, though, they seem like consumers, not patients. Wasserman is portrayed as the doctor with genuine integrity. He is honest, doesn’t raise unrealistic hopes, and establishes a trusting doctor-patient partnership.
After hormonal and surgical treatment, Manitas emerges as Emilia Perez, supposedly a distant cousin of Manitas to whom he left all his money.
The second half of the film addresses an even more complicated question. Has Manitas really disappeared? Externally, he clearly has. The world thinks him dead. He has become Emilia. She is not a new person. She is a sort of mirror image of Manitas who wants to not just be free to live her own life but also, in a way, to atone for his sins. She does that by starting a Foundation whose goal is to helping the families of people who were murdered by the drug cartels. Transition, this suggests, allows bad people to become good, selfish people to become altruists, sinners to become saints. This is a lot to ask of a medical intervention.
The film can help doctors locate some sources of tension in gender medicine today. We can endorse the approach that sees doctors as technicians peddling hormonal and surgical interventions without inquiring into patients’ motivations or expectations. Or we can insist that evaluation, shared decision-making, and informed consent are essential to decisions about whether the benefits of intervention outweigh the risks. These tensions flare up in the differences between, say, the WPATH recommendations that psychological evaluations are an unnecessary barrier to care and those of the UK’s Cass report which insists that all patients receive psychological and neurodevelopmental assessments. The tensions flare up when a clinics debate their policies about the appropriate type of evaluation for patients seeking transition.
These two approaches to gender transition reflect serious debates about gender that are going on within society today. On one side are those who believe that our gender is not something that we choose. Instead, by this view, we are born with a single true self that is of one gender or the other. If there is discordance between that true gender-self and the biological body into which a person has been born, the mismatch causes great psychological distress and medical interventions to decrease the discordance are essential. Hence, evaluation must determine whether someone’s sense of gender incongruence is real and persistent. Such beliefs were the basis of early gender medicine services, sometimes called “the Dutch model.”
Another view, recently articulate by non-binary journalist Masha Gessen, is that gender is inherently fluid. “Wouldn’t it be wonderful,” she says, “if we could think of transition as a lifelong option? Some people transition more than once. Some people transition from female to male, and then transition from male to female, and then maybe transition again. That doesn’t tell us that their first transition was wrong. Some people are truly binary. Some people are truly nonbinary. Some people are still in negotiation with their identity.”[i]
A question that unites the two is whether gender-dysphoria is a medical condition. If so, then it is essential for doctors to define eligibility criteria and evaluate outcomes. For many people, it is not a medical condition. It is not a disease. Gessen puts it like this: “Being trans is not a medical condition, but it marries you for life to the medical system. It almost always—not always—involves some kind of medical intervention.” Perhaps it is medical, in the sense that it can lead to life-threatening complications, and in the sense that doctors are needed to provide interventions, and that medical insurance should be for it. Perhaps it is not medical in the sense that doctors should not determine eligibility criteria.
How can the movie help today’s practitioners. As with so many bioethical dilemmas, the arts are providing important analyses of what is at stake in the choices doctors and patients make. Amy Herzog’s play Mary Jane explored the dilemmas faced by the parents of a child with a complex, chronic, neurodegenerative disease. Cormac James’ novel Trondheim explored the complexities of caring for a young adult with a stroke during the week when he was in a phenobarb-induced coma in the ICU. Pedro Almodovar’s film, The Room Next Door, based on Sigred Nunez’s novel, What You Are Going Thru, explored the complex dance of loyalty and fear that we go through in trying to care for dying friends. Emilia Perez can help doctors think about the questions at the heart of gender medicine – questions about patients motivations, the nature of gender identity, and the goals of medicine for doctors who care for patients who are struggling with such issues.
[i] Remnick D. What we talk about when we talk about trans rights. New Yorker, March 11, 2023. https://www.newyorker.com/news/the-new-yorker-interview/what-we-talk-about-when-we-talk-about-trans-rights. Accessed Jan 8, 2025.
Comments