Hamilton

And biding your time

The musical Hamilton premiered in 2015, the film version on Disney+ was released in 2020. I worked in the pediatric transgender center at Washington University School of Medicine from July 2018 until October of 2022. 

In traditional gay fashion, I love musicals, Hamilton included. In liberal fashion, I also gleefully sang along with lines like, “for the revolution” and “immigrants we get the job done.” Hamilton was a loved and discussed musical within the team at the pediatric gender center where I worked. 

Photo by R.D. Smith on Unsplash

I received my first poor performance review in 2021. I was given a plan to improve my performance which included the instructions to “stop challenging the doctors, stop asking too many questions, and, especially in a way that wasn’t sufficiently nice”. By this time I had been consistently bringing forward case after case of patients being rushed into puberty blockers and cross-sex hormones. I explained in meetings with supervisors that the ethical concerns about the care model were growing; that we were drowning in the patient volume; and that the patients we were seeing were incredibly challenging and well outside of anything that WPATH addressed. 

Performance reviews were still important. They dictated the percentage of salary increases and one could not apply for any other positions within the university with a poor score. My position at the university came with a benefit that we referred to as “golden handcuffs.” Once an employee passed the 7 year mark of employment our children would be allotted what is essentially free college tuition at nearly any university in the United States.  

This performance review was telling me in so many words that: They wanted me out of there; I had become the squeaky wheel; and, they had no more grease to offer me to silence myself.

But I am stubborn and I also thought that my ethical concerns were valid. So I didn't leave. Instead I wrote a Post-It note and taped it prominently on my work laptop. 

From the song, “Aaron Burr, Sir,” from Hamilton. “While we’re talking, let me offer you some free advice. Talk less. What? Smile more. Ha. Don’t let them know what you're against or what you’re for. You can’t be serious. You wanna get ahead. Yes. Fools who run their mouths off wind up dead.” 

Those who know me will know that “talk less” is a huge challenge for me. Smiling is easy, silence is death. But I tried. So in the clinic I would use Hamilton as a reminder as I tried to bide my time. 

I would also think of the song “Yorktown.” “Take the bullets out your gun! The bullets out your gun! We move undercover and we move as one. Through the night, we only have one shot to live another day. We cannot let a stray gunshot give us away.” 

Was I successful? Barely. I tried to find less abrasive ways to voice my concerns. I tried to not raise my voice or snap at superiors. I tried to spell out the case directly from the guidelines, clearly stating how patients did not meet criteria according to WPATH. This is not easy to do when you are discussing permanent changes to young peoples’ bodies, when you are discussing “top surgery” and puberty blockers. 

I wasn't always able to contain myself. I was screamed at on a Wednesday morning over a patient who we had prescribed feminizing hormones (including bicalutamide). The patient told me that they wanted biological children but that they had not been referred to a sperm bank. I told the doctor this and he did nothing. I insisted that the long term use of this protocol could lead to the patient being sterilized. I was yelled at by the doctor in the clinical pod space and told that I was using inflammatory language. I pulled back my tears and ignored the huge lump in my throat as I let it drop and the patient left without proper care or referrals. 

On another clinic day we were, once again, discussing that none of the parents were signing written consents. I advocated for the position that parents should be signing and that they should be given a written copy of any consent form. I was told that asking parents to do this would be “too burdensome” and that some parents would no longer agree if it was put in writing. I was told it would be a ‘barrier to care.” I told them that I would be happy to donate the pens if that was part of the barrier.

I am not proud of how I behaved. It was the worst year of my professional life. I knew I was complicit in harming children and adolescents. I knew just how reckless we were being. I knew we were lying. I knew everything was wrong, yet all I could do was “talk less and smile more.” 

Every single day I was in the clinic with patients was a day that I wish I could take back. Every single intake call that I completed where I scheduled a patient to be seen, I knew I was just lining up lambs for the slaughter. 

I was stuck. I had a mortgage to pay, I had to feed and clothe my kids. This was my salary but also my family's health insurance, my retirement, my masters degree, and my golden handcuffs. So I did what I did. You are welcome to judge me. Some of you would have quit immediately. Some of you would have never taken the job in the first place. Some of you still say on X, that they just don’t understand.

But I stayed. 

As I said on Gender: A Wider Lens, I would draw an ethical line in the sand and find that it would be crossed, time and again. I was the frog being boiled alive. At first I was not aware. Once I was, though, I can report that it was fucking terrible. Morally nauseating. Emotionally scarring. Once you see it you can't unsee it. Part of me thought that I deserved to boil.

It took me one year to get out from under that performance review. But I did. As soon as I was able, I applied to transfer from that department. The Hamliton strategy succeeded. I worked myself free to transfer and—I thought—free to stay at the university so that my children could still receive their tuition. Someday I hope I can discuss why I eventually had to leave. 

During that year I bided my time. I data mined every patient I could. We had no database so I created it. We had no solid numbers so I tried to count them all: one by one. I took the bullets out of my gun, but crept closer. 

I think back on that time whenever a song from Hamilton plays. I think back to that Post-It note: “Talk less, Smile more” and I think that it served a purpose. 

“You think it's impossible to be a passive fighter? Well, sometimes fighting just means existing. Existing, not going away, and quietly biding your time”