Healthcare Blogger Code of Ethics

Welcome to anyone who is finding this blog for the first time through the Healthcare Blogger Code of Ethics. I am proud to have been accepted into the HBCE community. I am using this recognition to renew my commitment to protecting patient confidentiality and the ethical use of health information, and I welcome dialogue on this subject or whatever other feedback you have for me. Thanks for reading.

 

“Steeling Their Courage”

This made me cry a little… and then giggle a lot, when I looked out of a window the other day and spotted Sponge Bob the Construction Crane. I hope that will be true of my future career in pediatrics: a little crying, a lot of giggling, and a very warmed heart.

And check out this insightful take on it from Joe Wright’s Hemodynamics.

 

Quick Disclaimer

WordPress has a new feature in which they put links to “possibly related” posts below each entry. These links are to other people’s blogs, not mine, so just know that they don’t originate from or represent me. That being said, traffic to and from those links is very much welcome.

 

Advent

Growing up, of course, I thought of Advent in terms of counting down until Christmas. We would get out the advent calendar with its twenty-four little wooden figures, and mark the days as we got closer and closer to the main event. The box marked 24 was always the largest, and the most important, and from the minute we opened it on Christmas Eve morning the anticipation just accelerated until Christmas Eve dinner with the family and then, finally, waking up on Christmas morning to begin the ritual of stockings, then kringle, then… presents! I once wrote myself a note saying “It’s Christmas!” and put it in the bars of my canopy bed over my head, so that it would be the first thing I saw when I woke up and I wouldn’t lose a second of knowing it was that special day.

Now, of course I still love the counting-down aspect of Advent, the focusing on what is to come; the number of days has just become somewhat more flexible. I am counting down with a cheap advent calendar with unpalatable chocolate, but the little images in each window of airplanes and ornaments remind me that I am marking the days until I fly home to my family and to the world of Christmas as we practice it on the 21st. I may even have to open doors 22, 23, and 24 in advance, before I leave Boston. And I sent my long-distance boyfriend a calendar as well, to count down the days not only until Christmas but, by implication, until we get to see each other again on the 27th.

But I no longer just love Advent for what happens when it is over. I have come to love it as a celebration of waiting itself, an honoring of the time-before-the-happening. This time of year is by its nature a time of waiting and uncertainty and always has been: once the last harvest is in, wondering whether stores will last until the spring, and as the sun sets earlier and earlier in the day, waiting for the night to slowly begin to shorten again. Personally, the last few wintry weeks have been difficult for me as my emotional energy flags and as I struggle to stay engaged in my schoolwork at a time when professional competence and rewards feel very far in the future. I am also struggling with uncertainty, with the inescapable fact that I cannot have complete mastery of the infinite amount I could want to know about medicine. Moreover, I am facing an overall paradigm shift as I come to recognize that much of my success before medical school was rooted in the availability of answers, but that my future success as a doctor and as an adult will be rooted in my ability to make the right decision based upon incomplete information.

So I resonate with Advent all the more. The metaphor of being in darkness and waiting for the light, being uncertain and waiting for an answer or a solution, is incredibly powerful. Whether the awaited light is the solstice or the Messiah or the lifting of sadness or worry, the waiting itself is worthy of recognition. It is even worthy of celebration, especially as it already is by faith communities, because it is part of the essence of faith. Believing in troubled times that a child will be born to change the world and that a star will bring light where there was darkness. Believing that the laws of the universe mean the Earth will continue to turn on its axis and bring back the daylight, without ever being able to see it move. And acting on that belief by continuing to put one foot in front of the other and continuing to go forward, and preparing the manger. The Maccabees did so, as I understand the Hanukkah story: expecting the oil in the temple to last only one night, they lit the lamp anyway, out of a need to express their joy at their victory and to show that their lives and their culture would continue on despite persecution. And sometimes the answer to faith is unexpected happenings: a great miracle happened there, the oil burned for eight days. Centuries later, as I gathered together with friends around a menorah in my classmate’s apartment and mumbled through the candle blessings then talked earnestly with them about our dreams and our fears, I felt surrounded by love and light, and the holiday season became a time of brightness for me even in the face of my uncertainty and the darkness of the winter.

O come, O come, Emmanuel
And ransom captive Israel
That mourns in lonely exile here
Until the Son of God appear
Rejoice! Rejoice! Emmanuel
Shall come to thee, O Israel.
…
O come, Thou Day-Spring, come and cheer
Our spirits by Thine advent here
Disperse the gloomy clouds of night
And death’s dark shadows put to flight.
Rejoice! Rejoice! Emmanuel
Shall come to thee, O Israel.

 

Grandparents

Something I wrote back in August, originally as an email to a friend that I never sent. It’s more personal than other entries here and many of my readers already know about the context – I hope it’s not too hard for you to read it. I put it on this blog because the second part says something important about end-of-life experiences in medicine, and the two parts together are about me consciously and subconsciously trying to make some sense of the changing of the generations: the feeling of no longer being the third living generation of my family, but now the second, and of how time can change the roles of caregiver and cared-for…

I had a dream last night that I have to believe was inspired by your talk at the panel about caring for people at the end of their lives… I dreamt I was with my paternal grandmother, who died several years ago after a long period of being ill and not really herself. We were talking as if it was before her illness, but I think I somehow knew – as one does in dreams – that she was dying, or that she had already died. I can’t remember exactly what was said, but they were loving things, and it felt good to be close to her. She was upset for a while about a trip she regretted we had not taken together, but otherwise was at peace. And she wasn’t just lying in a bed with me at her side: I was holding her. I felt very clearly the warm, loose skin on her arms, and the softness of her curled white hair. It was unlike any moments we had shared in life except for the reversed situation when she would hold me on her lap to comfort me when I was little. She would rock us back and forth shushing gently, and saying, “there there, bubbe.”

My grandfather, her devoted husband, passed away a few weeks ago. He was in fact alone at the moment of his death, but only after all of his close family had been able to gather around him and say goodbye. Of all the ways that it could have happened, I think his death was a blessing. My plane reached Seattle in time for me to join the others at the hospital. We all sat with him as he breathed quietly, sedated and comfortable, until the end of his beloved Mariners baseball game on TV. Then we each had our moment to say the things that we hoped he knew already. We came back in smaller groups to sit with him in the day or two after that that he held on, but each day his body somehow seemed to contain less and less of him. I had the profound sense that he stopped looking like himself – once his eyes had closed and his smile had been smoothed away. And then he was gone. His death was expected, peaceful, quick, and surrounded by love.

 

Maple Leaves

For a change of pace, a poem I workshopped tonight (still very much a work in progress) at the HMS Writers’ Group:

Maple Leaves: A Responsive Prayer
October 3, 2007

The week we got the diagnosis,
we heard from all over – Texas and Canada.
Cancer… it was a big word.
My husband’s whole family said prayers
and lit candles.
Like a big shrine,
as wide as the spread of my arms.
They are very Catholic.

(I can see the candles shining.)

That was three years ago, and now it is October.
In Boston, it is still summer-warm,
but we know the frost is coming,
and the paper snowflakes in the windows.

(Your husband stays, sitting quietly behind me.)

More than anything, I am tired.
The medicine makes my skin itch and peel.
My stomach is sick,
my head aches,
my mouth is full of sores.
But I am so proud that I made it through twelve times,
and now thirteen,
and tonight will be fourteen.

(I hope you get to go home soon.)

No, not too soon,
because I want to get more treatments.
And I hope that I will be back in a few months
to go through it all again,
because that will mean it is working.
Cross your fingers for me.

(I will.)

It affects my brain too.
Neurotox-… I can never think of the word.

(Dreams, your husband says, then falls silent again.)

Yes, vivid dreams.
And once
I saw maple leaves falling.
They were everywhere.
Maple leaves falling, and behind them everything was gray.

(What has been helping you get through this?)

Oh, I’m not religious, but I’m spiritual.
And I’ve got God right here with me,
everywhere I go.

(Amen.)

---

I started out intending to write a little background and it turned into a lengthy reflective essay. So be it, I’m writing-starved.

This poem is based on my interview with a mid-50s patient with metastatic renal cell carcinoma. The neurotoxicity from her interleukin-2 therapy had in fact once caused her to have the hallucination of falling maple leaves, and I was struck by the beauty of the image and by her bravery and confident spirituality in the face of her devastating illness.

I wrote the poem more or less as a creative reworking of our verbatim interview, and it was only afterwards that I recognized its resemblance to the form of Christian responsive prayer, and changed the title accordingly. We sometimes use responsive prayers or litanies at First Parish, and admittedly I don’t like them much – they tend to be too scripted and impersonal to meet my spiritual needs and they feel too “high church” (yet simultaneously lacking in the mystery and comfort of high church ritual). But when the form of this poem emerged, it showed me the similarities between the medical interview and the responsive prayer in a way that has made me appreciate both forms more.

First, the parts in the medical interview are largely scripted: there is always room for adapting the questions to the patient, but in general there are certain ways that certain questions are always asked, wordings that we are taught from the very beginning of our clinical skills curriculum. The introductory question “what brought you into the hospital today?” is simple on the surface, but is actually carefully scripted to elicit the so-called chief complaint while avoiding launching prematurely into the history of present illness and the past medical history (which one might get if one asked a very slightly different question like “what is your medical problem?”). Yes, there are some patients who respond “an ambulance brought me, obviously!” but other than that it is a very effective question.

This scripted quality of the medical interview, in which theoretically the doctor knows exactly what information they need and what to ask to get it and the patient knows the role he or she plays in response to the doctor, can be off-putting for some people and yet simultaneously comforting… like, for me, responsive prayer. I bristle at it because I have trouble setting aside my own ego, identity, and agenda, spiritual or otherwise – I think “My concerns aren’t being addressed” or “I would have phrased this differently.” I’m sure patients often feel the same way, and it’s a huge issue for otherwise caring physicians who sometimes need to get just the facts, ma’am, in a very constrained period of time. But if I were able to let go of clinging to my ego (this is where Buddhism interjects briefly into the conversation) and accept that responsive prayer is not about me as an individual but about voicing the nature and needs of the religious community and my participation in it, I might find responsive prayer – as many people do – to be comforting precisely because it is so scripted and ritualistic, while simultaneously potentially very powerful. Similarly, if patients otherwise are happy with their care and feel that their concerns are being addressed (which is definitely possible within the interview script, something I proudly feel I achieved in today’s Patient-Doctor II interview), then the script can become a reassuring part of the “therapeutic environment” I wrote about in a previous post.

I have to acknowledge two failings in the analogy between medical interviewing and responsive prayer. First, it goes without saying that the purposes are very different. I have tried to focus my comments here in true writers’ workshop fashion on form rather than content, although when it comes to poetry (like architecture), form and function are closely intertwined. The analogy also breaks down in that the response portions of responsive prayers are typically voiced by the community as the community (using “we” rather than “I”, or even speaking for all of humanity) whereas medical interviewing is much more one-on-one. That being said, especially with the presence of the husband in the room in this patient’s case and in the future the knowledge that I will be asking the interview questions on behalf of my entire team and everyone else who will be involved in this patient’s care and have access to her medical record with my writeup, the sense of community should never go away. It is a strange sort of intimacy, to speak so deeply with another person sometimes, but to be doing so on behalf of so many.

That’s enough overanalyzing of this poor poem (you know you’re in post-college literary criticism withdrawal when you overanalyze your own works). I very much welcome comments and feedback on the poem itself and on what I’ve written afterwards.

---

The HMS Writers’ Group is a small group of students, faculty, and other HMS affiliates who meet every few weeks to share and workshop our work, read the work of other writers both medical and non-medical alike, do writing exercises, and generally “live the writer’s life on the side,” as our poet-teacher-guru Sophie Wadsworth put it tonight. It has been a real blessing to have this group exist, even though I can’t always attend or contribute, because it reminds me of my longstanding love for writing and provides a community of kindred spirits who also confront the harsh and sublime realities of medicine through words.

I love readership, but this poem is copyrighted and may not be copied or reused in any form without my permission. Please leave your contact information in a comment if you would like me to get in touch with you about its use.

 

Tools of the Trade

Our diagnostic equipment came in today! I have a brand new – and yes, shiny – Welch-Allyn Harvey Tycos Elite stethoscope (burgundy, with a little interchangeable pediatric head ) and Welch-Allyn PanOptic Ophthalmoscope and Otoscope, as well as the various tuning forks, reflex hammers, penlights, and so on that make a white coat look well-stocked. In other words… I’m equipping myself with the tools of the trade. Not that I know how to use any of it yet, but that will come with time and practice this year. I am excited about learning to do a good physical exam because, even in this era of modern diagnostic technology, you can learn so much about the body just by looking and listening with a little assistance. And I very much appreciate the idea of therapeutic touch – the doctor’s reassuring hand resting on the patient’s shoulder when listening to the lungs is not just a part of the traditional Norman Rockwell image of the doctor-patient relationship, but a very real way to forge connections in moments in the midst of a busy hospital or clinic. Ironically enough, the stethoscope was invented to make possible a more distant doctor-patient relationship: the first one was a paper cone improvised to distance the ear of the male doctor from the heart (and, therefore, bosom) of his demure lady patient. Nevertheless, its use is a huge part of the therapeutic environment we create to improve the health of our patients, both because of its direct observational and diagnostic benefits and for the patients’ general sense of being taken care of by a medical professional (call it the placebo effect). Therefore, the arrival of the stethoscope in particular marks another important if surrogate milestone on my path into medicine: have stethoscope, will doctor.

Speaking of tools of the trade, I am greatly enjoying our first course as second year students, Principles of Pharmacology. While the course has been dramatically shortened from eight weeks to two by the curriculum reform (don’t get me started), we are still expected to cover all of the fundamental principles of drug action, dosing, metabolism, and so on. I like the problem-solving aspects, and I love the immediacy of the potential application of this knowledge: we will be using these lessons to someday improve the health of patients. The connection is much less abstract than the implications for clinical practice of much of the first year material, signaling a transition that I think will make second year very rewarding if challenging. Moreover, I am having my first glimpses of what it will be like to “think like a doctor.” A classmate asked me a question about a hypothetical case involving both warfarin (an anti-clotting agent) and tuberculosis treatment; the principle at issue has to do with the metabolism of both drugs by the same particular set of enzymes, such that they interact with each other’s metabolism and change the effective dosages. I found myself quickly putting together an answer that incorporated both the pharmacological principles and the implications for the patient. It wasn’t a particularly complex situation to analyze, but I realized right then that it was exactly the sort of question I would need to answer every day in my own future clinical practice. Even just the first forays into that kind of clinical decision-making make the clinical years feel much closer and clinical success more achievable.

 

The Fascinating Sea

I began writing this entry at the end of last year and never quite got around to finishing it, so I didn’t make it “public” until now, but I think it’s a worthwhile – if rough – snapshot of where my mind was at the end of my first year in medical school. Much more to come as I continue the reentry process. My mood at this moment approaching second year is somewhat apprehensive as I realize how much I will need to learn in the next seven months, but it helped me a bit to reread this entry and remember why I’m doing this in the first place.

“Journalists and doctors tend to think modestly in terms of their own personal contribution to society, and consider the world at large to be a fascinating sea of untapped knowledge and possibility. Businessmen, entertainers, politicians and lawyers think modestly about the world at large and feel their own personal contributions to society are fascinating seas of untapped knowledge and possibility.”
–comment on “When Doctors Write”

You, reader, may or may not agree. The commenter did add: “(And if you can’t make a sweeping generalization in public every now and again, what’s the point of blogging?)” I do think though that the comment – in response to Stephen Dubner’s question “So why do these doctors write so well, and so much better…than other non-writers?” – taps into something very interesting. Do we bring to our profession a sense of wonder and curiosity that perhaps other people do not? And is the difference in us, the people who choose to become doctors, or is it in our subject matter itself?

Dubner continues eloquently, “Perhaps there are elements of doctoring that lie in harmony with writing: peeling back the layers to get to the core of an issue; confronting the obvious but being willing to look beyond it; learning where to “cut in,” of course; and, more than anything, recognizing that this object before you – in one case a human body, in the other a manuscript – is on a certain level a miraculous object with the power to astound, and on another level is a complex, dynamic system which can (and must be) reduced to a schematic, laid out on paper or x-ray film.”

I am going to claim the difficulty of the reduction of complex systems to schematics as an excuse for my lack of posting lately… Actually, life has just gotten busy as we approach the end of the year. Final projects and papers are done or soon due, and we have two more exams before we end on June 8. Along with and among the flurries of work have come a network of interrelated things-that-are-fascinating, any of which could be a post in itself, but I’ll try to address in a nutshell here for now.

Cluster one: AIDS, its sociocultural context, and narrative medicine, which by the end of the month will lead to a massive product encompassing the Casebook itself and four appendices, as this project will now have formed the basis for final products for five classes (Mentored Clinical Casebook Project, Mind-Body Medicine, Role of Discovery in Medicine, Introduction to Social Medicine, Patient-Doctor I). While I originally intended to be more broad in the subject matter for these various projects, and I regret missing the opportunities to do some other interesting work while recognizing that it was not feasible in terms of time and effort, working on my Casebook patient’s story from all these various aspects has been an incredibly rich experience (even beyond that of just learning his story in the first place). I am turning in and presenting tomorrow the narrative medicine piece for PD1; I advocate for the power and importance of narrative medicine, the application of narrative analysis techniques to patient stories, and do a first-pass analysis of my patient’s story. The social medicine piece has a long way to go yet, but I just finished reading the book And the Band Played On, a journalist’s contemporary account of the early years of the AIDS epidemic, and it opened my eyes to so much that seems like it should be long ago and far away (stigma, ignorance, hatred, prejudice…) but isn’t.

Cluster two: abortion, HPV, sex education, women’s health, ob-gyn, contraception, sexuality, sexual orientation. education and ignorance and prejudice. Outrage and sadness, and fear for the future of reproductive health. Also not entirely unrelated to cluster one. more on this soon, but one of these days I’m hoping to do something about it, in my own small way.

…

 

Reflection and Remembrance: Virginia Tech

What would I do if I was a doctor, and someone like Cho Seung-Hui walked into my office needing medical care? The code of the medical profession, like the path of the bodhisattva, calls us to extend help and care and compassion to all beings. Unitarian Universalism calls us to radical inclusivity; how much more radically inclusive can you get than being compassionate towards a senseless murderer? And yet that is what I have found myself trying to do since I first heard the news on Monday. Of course I was moved to first say a prayer for the victims, their families, and the university community, though recognizing that there is nothing that can change their incredible losses. Then, I found myself wondering about the killer – asking why and how he could have come to that level of violence and desperation. As a future medical professional, I found myself wondering about his psychiatric and psychosocial problems, and whether any additional services and support could have been provided to him – for his own good, as well as for the prevention of this horror. I am not trying to absolve him of guilt for this crime; far from it, the majority of my being wants to wall him off from the species I call mine. But difficult as it is, I am trying to cultivate a level of compassion for him as well. Because as soon as we choose who is deserving of compassion and why, rather than extending it to all people (Buddhism says: sentient beings), the limitless compassion of the bodhisattva and the ideal medical provider becomes limited compassion, and loses its radical power, and is mired in judgment, and gives up its capacity to heal those who are in need.

I got choked up several times in the last few days as the news continued to come in, the number of dead and injured increased, and more and more bizarre and awful things about the behavior of Cho Seung-Hui were reported. But when I really cried, I wasn’t thinking about him, but about Liviu Librescu. He was the professor who physically barred the classroom door to give his students time to escape; he was shot, but saved their lives. I cried when I read that he, a Holocaust survivor, died on Yom HaShoah – the Jewish Day of Remembrance for the Holocaust. The fact that he survived one senseless killing only to lose his life in another hit me hard. However, with help from my boyfriend, I’ve been able to turn it around and see that his action is a reminder that even within incredible darkness, some light can be found. People who represent such points of light enable me to believe that there is a higher power of good and love and creation – one that moves within us – that can overcome the evil that is its absence.

[And I'm not far from the only one who has been so moved: in our own strange children-of-the-new-millenium way, young people by the thousands have been showing their respect and appreciation for Professor Librescu on Facebook.com, as well as sending their hearts out to the victims and the survivors at Virginia Tech.]

In closing, an incredible testament to the possibility of human goodness and compassion: a prayer from beliefnet.com that was posted for Yom HaShoah but on April 14 – who could have foreseen it would have an additional meaning after this April 16?
Lord, remember not only the men of good will, but also those of ill will. But do not remember all the suffering they have inflicted upon us. Remember rather the fruits we have brought, thanks to this suffering: our comradeship, our loyalty, our humility, the courage, the generosity, the greatness of heart that has grown out of this. And when they come to judgment, let all the fruits we have bourne be their forgiveness.
source: Found on a scrap of paper at the liberation of Ravensbruck Concentration Camp in Germany

 

Affirmed

Newsflash: “miracle cure” eliminates depression, bipolar disorder, and suicidality nearly overnight; formerly institutionalized child is now a happy, healthy 11-year old baseball-playing boy; teenager with three suicide attempts recovers completely and is now a successful art school student

Sounds pretty appealing, right? Something that you would expect the medical community to be behind 100% and doctors would be lining up to try? An intervention insurance companies would trip over themselves to pay for? Unfortunately, no. Only a handful of doctors administer this treatment in the United States, and some patients have to go to Thailand to find it. A negligible fraction of insurance companies provide any coverage for any part of it. It’s controversial among medical professionals, and many of them tend to avoid at all costs patients who seek it.

This seemingly miraculous, life-restoring treatment is… gender reassignment.

We had an amazing set of speakers today in our Human Sexuality in Medicine elective: Dr. Norman Spack, a pediatric endocrinologist who specializes in gender identity and intersex, and two of his patients, one a young adult and the other an elementary schooler. The endocrinologist didn’t use exactly these words, but he basically made it clear that he felt he had been called to this career path (after many years in other areas of pediatrics) out of a desire to help patients that had few people to turn to. He was an inspiring person not only because of what he does but also because of how he obviously had worked so hard to understand where his patients were coming from and what they most needed in terms of medical care and emotional support.

The patients themselves were even more amazing. I have heard from one other person who I knew to be transsexual, but he emphasized his experiences with the medical system as an adult more than the process of transitioning, so this was the first time I really got to hear about what it’s like to grow up in the wrong body. The endocrinologist mentioned that transsexual children and adolescents are frequently diagnosed with bipolar disorder, when really “it’s more like post-traumatic stress disorder” from the unbelievable trauma of feeling that your brain doesn’t match your body, and of course all the stigma and other emotional issues other people cause these children.

The 19-year-old woman, an art student, was born as a boy. She had suffered extreme anger and depression, and had attempted suicide multiple times; 50% of transgender adolescents do. She talked about going through puberty and feeling intensely hostile to the changes in her body. All the messages about transgender she initially got were on Jerry Springer or porn sites she found when she tried to search the internet. Fortunately, she eventually came into the possession of some legitimate information, and she lit up when she talked about the immediate identification with all the feelings the materials talked about – “this is me.” From that moment on, her emotional life completely turned around. She came out as transgender to her parents at age 14; not an easy process, but one that ultimately resulted in them being extremely supportive. While they went to bat for her, she has also been an incredible advocate for herself, including educating people like therapists who were supposed to be helping her, and doing extensive research on “every surgeon in the world” who does gender reassignment surgery, ultimately traveling to Thailand for it. Now that she is transitioned and in college, she says, being transgender isn’t even a big part of her life. She broached the topic with her boyfriend, but most other people don’t know, and she no longer goes to support groups or conferences. Her identity can now be defined by other things: a woman, a college student, an artist, and all the other things she does and is.

The younger patient was a sweet, goofy, buzz-cutted boy in a Red Sox shirt who was volleying teasing back and forth with his dad and confidently interjecting his views into the conversation. Hard to believe that earlier in his young life he was aggressive, depressed, possibly suicidal, diagnosed bipolar, given lithium, and institutionalized… but that’s when he was living as a she. According to the dad, practically from the moment their daughter started to walk and talk, it was obvious that she did not identify as a girl. When asked after watching the Disney movie Pocahantas if she wanted to dress up as Pocahantas, she replied adamantly “No! John Smith!” and marched around the house with swords tucked into a belt. She refused to wear girls’ clothes, and made it clear in many other ways that she didn’t want to be a girl. So, these incredible parents agreed to let their child transition… and it was clear from the way the father glowed when he talked about “my son” that he felt he had gotten his lost child back. The mother attends a yearly transgender conference, where the son can hang out with two friends who are the same age and also female-to-male transgendered. The boy seemed to take it all in stride, reflecting a patience and maturity well beyond his years. He left school for spring break as a girl and returned two weeks later as a boy. The school had been incredibly supportive, fielding calls from parents and making accommodations. I could only think how lucky this boy was to have been taken care of so well and so early; compared to people who have to spend most or all of their lives hiding their true selves, he can spend nearly his entire life as the person he truly is and wants to be. And he truly embodied the idea of looking “happy in his own skin”.

I won’t go into details here, but suffice to say that the endocrinologist talked about a new treatment pioneered in the Netherlands that, for kids identified before puberty, can not only delay puberty’s irreversible changes into the genetic gender that the child wants to reject, but can also basically buy some time for the child to mature emotionally/psychologically before making the decision to mature physically. It was one of those simple interventions, perfectly in harmony with the workings of the endocrine system, that can only be called “elegant.”

One other thing of note was the language used throughout the talk, particularly calling the gender to which patients transitioned the “gender of affirmation.” I hadn’t heard this usage before, and the more I think about it the more I love it… It is so positive, but without any notion of normativity (not “the right gender”). More importantly though, it implies a very different concept than the phrase “gender of choice”, to which one might be more inclined to gravitate. Because as these patients’ miraculous turn-arounds after transitioning indicate, their birth genders were not even an option; just as gay people do not choose to be gay, transgender people do not choose another gender, but rather find ways to affirm the gender that they feel they have been all along. They did not somewhere along the way choose to change. Their birth gender is, basically, a pathology… one that can lead to intense crises that, while yes they have psychiatric as in “in their head” implications, also pose very real physical risks and certainly prevent the total health and wellbeing of transgender patients. Studies have shown significant gender-related brain differences in transgender people, for those who look for physical findings to establish something as a medical problem. And yet gender reassignment surgeries are considered elective and cosmetic… As I tried to communicate with my admittedly leading beginning to this article, there is so much potential here for making positive changes in the health of these patients and yet gender identity disorders and “disorders of sexual differentiation” are regarded by the American medical institution as psychiatric maladjustment-like issues and therefore not eligible for insurance coverage.

I look forward to the day when any person could have access to the quite literally transformative services of gender reassignment should it be appropriate for them, as well as to a time when anybody who doesn’t fit stereotypical social molds has greater rights to self-determination. I just kept feeling tonight that this is a new frontier of acceptance and ability to change a life for the better, for both the medical community and American society as a whole.

–

Disclaimers: I know this post is opinionated and incredibly controversial, and I am not looking to pick a fight or criticize anyone who disagrees for being closed-minded.  When I talked to my mother about this, she wisely encouraged me to look back and think about how I came to this acceptance.  The truth is I don’t know, and I really wish I did, because then I could help others along that path towards tolerance and understanding.  I think I have been blessed to live and work in environments where tolerance of many kinds of differences was the norm, or at least where expressions of intolerance were not acceptable.  This enabled me, when I did finally come into contact with people that I knew to be transgender (or gay, for that matter), to listen to their stories with an open mind and heart, and after being open to someone in that way it’s hard to go back to being closed off.  If you are interested in learning more, the Intersex Society of North America seems like a good place to start, and the book True Selves is now on my reading list.