Transgender issues have been in the news with the recent announcement that Cher’s daughter, Chaz Bono, is transitioning from female to male. This subject has been plagued by misunderstanding and fear of the unknown. Transgender children are often shamed, bullied, and made to feel totally alone. As adolescents and adults, they face denial of adequate medical coverage and other forms of discrimination – and worse. Just two months ago, a Colorado man was found guilty of murdering an 18 year old transgender woman in what was judged to be a hate crime.
Chaz’s decision to go public with his private struggle is extremely brave. His publicist said,
“It is Chaz’s hope that his choice to transition will open the hearts and minds of the public regarding this issue …”
Step one in reaching the public is defining terms. The terminology surrounding gender issues can be confusing. “Transgender man,”, “transmale,” and “affirmed male” have all been used to refer to a biological female who transitions to a male. I found a glossary of transgender terminology offered by the NCTE to be extremely helpful.
What exactly does transitioning mean? It’s the period during which somebody starts to live as his/her new gender. It can include changing a name or legal documents, taking hormones, and getting surgery. One misconception is that transitioning requires surgery. It doesn’t. As Mara Keisling, the Executive Director for the National Center for Transgender Equality (NCTE) told me, “Most transsexuals don’t get surgery. This is about gender identity, not about genitals.”
There’s a lot of controversy and confusion but experts agree on two crucial concepts:
1) Being transgender is not a choice.
2) Biological sex and gender identity are two different things.
There are people whose external appearance is female but who have felt they were male since they were toddlers – and vice-versa. Norman P. Spack, M.D., an endocrinologist at Children’s Hospital in Boston, Dept. of Pediatrics, Harvard Medical School, has been treating transgender patients since 1985 and significant numbers of teenagers since 1998. Most of his patients have told him “as far back as they can really remember that they were in the wrong body.” Dr. Spack said, “there’s a heavy skew to under 6 years.”
Dr. Spack points out that because transgender has been labeled as a psychiatric illness (“Gender Identity Disorder”) by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), patients are not adequately covered by health insurance. He says that the insurance industry will cover psychiatric costs but denies hormonal and surgical therapy, claiming they are non-covered cosmetic treatments. A step forward came in 2008 when the American Medical Association House of Delegates passed a resolution supporting “public and private health insurance coverage for treatment of gender identity disorder in adolescents and adults” and opposing “categorical exclusions of coverage for treatment of gender identity disorder in adolescents and adults when prescribed by a physician.” But for now, many transgender patients continue to receive inadequate medical coverage and therefore inadequate medical care.
Nobody knows how many transgender people exist. The very definition of transgender can differ from study to study. Some only count people undergoing hormonal/surgical treatment; others rely on self-identification. In the Netherlands and Belgium, estimates based on patients receiving surgery and/or hormones were about 1 in 12-13,000 for transfemales and 1 in 30-34,000 for transmales.
But Mara Keisling told me those estimates are way too low. “Our best estimate is that one quarter to three quarters of one percent of Americans are transsexuals.” That’s 2.5 to 7.5 in a thousand. Dr. Spack’s estimate is about one in a thousand.
We are not close to understanding all the variables that go into determining why someone feels trapped in the body of the wrong sex. Parents often feel guilty but the wide consensus is that parenting does not cause a child to be become transgender. Research in animals suggests that there are critical periods of development during fetal or neonatal life during which exposure to testosterone influences the sexual differentiation of the brain But we’re far from putting together any sort of unified theory of gender identity that weaves together genes, cell biology, hormones, brain wiring, and nurturing.
Experts stress that transgender is part of a wide continuum of gender identity. As Stephanie Brill and Rachel Pepper say in The Transgender Child: A Handbook for Families and Professionals, “Today, gender can no longer really be considered a two-option category.” They emphasize the importance of patients and families understanding that they are not alone and that there are competent professionals who can help. They say they wrote the book, which I found to be very helpful, to “provide caring families with helpful tools they can use to raise their gender-nonconforming children so they may feel more comfortable both in their bodies and in the world.” The authors quote Dr. Spack who, referring approvingly to the Dutch treatment of adolescents by delaying puberty and giving them hormones, said: “Suicide attempts, so frequent elsewhere, are almost unknown because parents and children know that they will be taken care of and will ultimately join a society known for its tolerance.” Referring to his own patients, Dr. Spack told me “They may be anxious, they may be depressed, but many, many no longer have psychiatric diagnoses after they are treated properly.”
In today’s video segment of CBS Doc Dot Com, I speak to Dr. Ward Carpenter of the Callen-Lorde Community Health Center in NYC, a facility that provides care to patients across the spectrum of gender identity and sexuality. In the segment that follows, Dr. Carpenter explains what surgery and hormones can entail. A warning: it’s a graphic description. Its purpose is not to shock but to educate. Hopefully, better education will lead to less misunderstanding, less fear, and wider acceptance for people like Chaz Bono.
Other Resources:
NCTE: Understanding Transgender Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline
True Selves: Understanding Transsexualism by Mildred L. Brown and Chloe Ann Rounsley
Abortion and the intense debate about it in an otherwise enlightened (?) country was the topic of two of my earliest posts in this blog (this post and this one). I posted again when it looked like the debate was going to start in India. Thankfully, it died a natural death.
Those of you who follow me on twitter know that abortion has been on my mind following the sickening murder of Dr. Tiller. For the record, I didn’t even know that there existed such a doctor as he till I chanced upon news of his death. I refrained from writing anything here as I figured I had stated my views already.
The abortion “issue” is such a hot topic that I have never written about it on this blog until today. I hope I won’t regret that decision but I felt it was appropriate to respond to this medical student’s essay – and the ~560+ comments that follow it – as a physician who has witnessed (but never performed) about 100 abortions. Let me explain.
Also read the medical student Rozalyn Farmer Love’s post, My Choice, in the Washington Post.
I’m a third-year medical student at the University of Alabama at Birmingham. I plan to become an obstetrician-gynecologist. I dream of delivering healthy babies, working with families and supporting midwifery. But as part of my practice, I also envision providing abortions to women who need them. …
I agree that ending an unwanted pregnancy is a tragedy. When I advocate for reproductive rights, for choice, I don’t claim that abortion is morally acceptable. I think that it’s a very private, intensely personal decision. But I was stunned when one of my professors, a pathologist and a Planned Parenthood supporter, told me that decades ago, entire wings of the university’s hospital were filled with women dying from infections caused by botched abortions. It’s clear that women who don’t want to be pregnant won’t be deterred by limited access to providers or to clinics. And I believe that it’s immoral to let them die rather than provide them with safe, competent care.
The lines that affected me the most were…
I plan to choose a residency program that provides further training — a place where I won’t worry that asking to be taught to perform an abortion could somehow limit my future options. At the start of medical school, I was very careful about how I presented my pro-choice views to the faculty for fear that I could jeopardize my grades or hurt my chances for recommendations or of being accepted into a program run by any of the professors. This experience of treading lightly is unique to medical students in more conservative parts of the country, where opposition to abortion is widespread…
I was equally moved by these lines from Val’s post…
I initiated rapid sequence intubation with the assistance of the anesthesiologist, and then moved to get the ultrasound machine to visualize the uterus and its contents. Much to my discomfort the fetus was fairly large – and was moving around normally, even sucking its thumb at one point. I asked the Ob/Gyn resident why the fetus was being aborted since it didn’t appear to have any structural abnormalities. She responded that the mother simply didn’t want to have the baby, and had wrestled with the idea of abortion for a long time before she made her final decision. The rest of the procedure is a bit of a blur – with details too graphic to describe here. But suffice it to say that the resident performing the dilatation and curettage had a fairly difficult time removing the fetus through the cervix, and had to resort to eliminating it in smaller parts, rather than a whole. It was very sad and it took a long time to make sure that the uterus was fully evacuated. I decided that I couldn’t watch another one of these procedures.
All I can say to Val is: Do not visit any ObGyn procedure room or OT if/when you visit India.
I did not set out to write this to hand out that gratuitous bit of advice to Val. I wanted to highlight something else that she had written that caught my attention and raised some doubts.
In my opinion women should have the right to choose to have an abortion, but I’d hope that they also consider their right to choose to give their baby up for adoption as well. Some believe that an abortion is “easier” than giving up a baby for adoption – but I’m not so sure that’s the case from an emotional perspective.
I want Val and all those who share similar views re. adoption as an alternative to abortion to read this moving essay by Judy Brown in which she says When Abortion Was a Crime, I Would Have Sought One. Read the entire essay and pay particular attention to the two paragraphs at the end…
There are approximately 500,000 children in the foster care at any time in the United State — many of those children are adoptable, but will not be adopted — why don’t “pro-life” advocates step forward to adopt them now? Do they want the forced return to warehouse orphanages for still more unwanted children? Do they want women sent to prison for seeking an abortion, and doctors also jailed, when we already have a shortage of doctors in this country? And nurses jailed, when we have a shortage of nurses in this country? How much damage and destruction of life will they support to force the rest of us to subscribe to their “religous” views? I’ve never heard a so-called “pro-life” advocate answer those questions honestly. Making abortion illegal will not stop abortions, it will just stop safe abortions, as is the reality in the few civilized countries in which abortion isn’t legal, but their abortion wards are full to bursting with maimed women, and whose morgues overflow with dead women.
I agree with Val’s concluding paragraph that Rozalyn, the third year medical student may change her mind after witnessing or performing a few procedures.
Even in a country where abortion is a non-issue, I believe there are many medical professionals who are troubled by late trimester abortions and abortions-on-demand. I am one such. But the sad reality is that we are the minority here. I feel particularly sad because occasionally in my professional role as a diagnostic radiologist I am the cause of some of these wrenching cases of late trimester abortions. Some of them I can agree with, though they could have been avoided by earlier diagnosis and decision-making, like an anencephaly being diagnosed at 35 weeks gestation. But most are not that morally or ethically clear cut.
The abortion “issue” is such a hot topic that I have never written about it on this blog until today. I hope I won’t regret that decision but I felt it was appropriate to respond to this medical student’s essay – and the ~560+ comments that follow it – as a physician who has witnessed (but never performed) about 100 abortions. Let me explain.
During my Emergency Medicine training I was required to perform a certain number of intubations and abdominal ultrasound scans. My residency training program offered rotations in Ob/Gyn and at a local Planned Parenthood center. The senior residents told me that the best way to fulfill my intubation requirements was to assist with the Ob/Gyn OR procedures because the patients were young, healthy, and generally uncomplicated. At the time I was really excited by the opportunity to get the experience I needed – in as short a time as possible. I used to hang out in an Ob/Gyn operating room asking if I could assist the anesthesiologist with the intubations. Once they got to know and trust me, I could intubate about 6 patients in a day – an opportunity otherwise hard to come by as all the new anesthesiology residents were vying to practice intubation themselves.
One of the Ob/Gyns who used the OR (where I got my intubation experience) scheduled some abortions of fetuses that were at the border of viable – as old as 23 weeks. That made me quite uncomfortable, and I know that there were other staff (and several nurses) who refused to work with that physician. However, as squirmy as I felt, I thought it was important for me to see first hand what the procedure entailed… because otherwise I’d have to rely on anecdotes and second-hand opinions to draw my own conclusions. I wanted to see this for myself.
I’ll never forget the day I witnessed the first late-ish term abortion. I was preparing my intubation equipment – fidgeting with the Mac size 4 blade, making sure the light worked, when the physician brought the patient into the room on a gurney. The woman’s abdomen was very pregnant, and the Ob/Gyn was stroking her hair and whispering reassuring things to her. The anesthesiologist made small talk with the patient, explaining the nuts and bolts of the anesthesia – the oxygen mask – the propofol – the intubation. I stayed out of the patient’s line of sight and allowed the Ob/Gyn and her resident to spend some final moments with her. The scene was both tense, and yet supportive of the patient.
I initiated rapid sequence intubation with the assistance of the anesthesiologist, and then moved to get the ultrasound machine to visualize the uterus and its contents. Much to my discomfort the fetus was fairly large – and was moving around normally, even sucking its thumb at one point. I asked the Ob/Gyn resident why the fetus was being aborted since it didn’t appear to have any structural abnormalities. She responded that the mother simply didn’t want to have the baby, and had wrestled with the idea of abortion for a long time before she made her final decision.
The rest of the procedure is a bit of a blur – with details too graphic to describe here. But suffice it to say that the resident performing the dilatation and curettage had a fairly difficult time removing the fetus through the cervix, and had to resort to eliminating it in smaller parts, rather than a whole. It was very sad and it took a long time to make sure that the uterus was fully evacuated. I decided that I couldn’t watch another one of these procedures.
The rest of my female abdominal ultrasound experience was obtained at a Planned Parenthood center where very early abortions were performed. Generally, this consisted of suctioning out a tiny yolk sac (and “products of conception”) – without much of a recognizable fetus in the midst. Although these procedures were certainly emotional, they were somewhat less troubling than the later term dilatation and curettage.
What I didn’t expect, however, was that of the approximately 100 abortions I witnessed – none (to my knowledge) of the women requesting them were rape victims, nor was there a life-threatening birth defect in the fetus. Usually the reason they gave was psychological, emotional, or financial – “I just can’t afford to raise a child” or “This is not a good time for me to be pregnant” or “I don’t want this baby” or “I don’t want another baby” or “This was an accident, and I don’t want it to ruin my life.”
I did my very best to adopt an attitude much like the one that the author of the Washington Post article did – “It’s not for me to judge the validity of someone else’s reasons for wanting an abortion… They’re going to do it anyway so physicians need to make sure they’re safe… Women have the right to choose…”
But the reality was that those attitudes didn’t prepare me for the emotional turmoil inherent in the process of abortion. It’s sadder than I thought, more difficult than I thought… and the impact is farther reaching than I imagined. Studies estimate that about 1/3 of US women have an abortion at some point in their lives – that’s a heavy emotional burden that many women carry in silence.
In my opinion women should have the right to choose to have an abortion, but I’d hope that they also consider their right to choose to give their baby up for adoption as well. Some believe that an abortion is “easier” than giving up a baby for adoption – but I’m not so sure that’s the case from an emotional perspective. As far as rape victims or women who are carrying a moribund fetus – the decision to abort may well be emotionally less damaging. But for the majority of women who have abortions for less clear reasons (reasons like the ones I witnessed), I’d really encourage them to consider adoption as an option. Obviously, these decisions are intensely personal and have to be made on a case-by-case basis – and women should be supported either way.
As scientific and rational as I wanted to be about the procedure, I am still troubled by what I experienced as a witness to various abortions. Though I might have “entered the abortion conversation” as the third-year medical student did – after witnessing quite a few, I have a deeper appreciation for the emotional complexity of abortion, and a desire to help women avoid them if at all possible. I wonder if the author of the Washington Post article will change her perspective after she’s witnessed a few of the procedures?
Somehow the medical community has missed a very important news Item. In her website goop.com (dang, I was going to go for that domain), movie star Gwyneth Paltrow weighed in on a very frightening medical subject.
Shampoo.
“A couple of years ago, I was asked to give a quote for a book concerning environmental toxins and their effects on our children.
“While I was reading up on the subject, I was seized with fear about what the research said. Foetuses, infants and toddlers are basically unable to metabolise toxins the way that adults are and we are constantly filling our environments with chemicals that may or may not be safe.
“The research is troubling; the incidence of diseases in children such as asthma, cancer and autism have shot up exponentially and many children we all know and love have been diagnosed with developmental issues like ADHD [Attention Deficit Hyperactivity Disorder].”
Apparently, she went on to point the finger at shampoo as a potential major problem in our society and raised a possible link between shampoo and childhood cancers. Now, I am not sure how one can use shampoo on the head of a foetus (or a fetus, for that matter), but we have to tip our hat to celebrities for bringing such associations to the forefront.
So I did a bit of science myself to assess the voracity of her claims. I too was seized with fear when I noted the following:
All of the kids in my practice who have ADHD have used shampoo.
All of the kids with cancer have also used shampoo.
I used shampoo as a kid (but not as a fetus), and I have ADHD.
The projection is that 100% of the people now using shampoo will die.
Whoa.
This really backs up my misgivings about shampoo. I have always wondered at the claims these so-called hair-care products make so boldly. Here are some examples of lies spread by the shampoo industry:
Clarifying shampoo – What are they claiming with this? Is there such thing as unclear hair? Do some people look as though they have a giant blob of hair-like substance on their head instead of many separate hairs? Does clarifying shampoo make each individual hair once again visible on these people?
pH Balanced – What is pH imbalance? Is it when the pH sometimes is so acidic that it burns your hair off? That would be terrifying if true.
Volumizing shampoo – I was not aware volumizing was a word (nor was my spell-check). This means that the shampoo volumes things. How can you volume something? Does each hair get a separate volume, or does the hair suddenly get very loud. Personally, I am afraid to open the bottles of these shampoos for fear of going deaf.
Shampoo for stressed hair – I have never thought about the emotional state of my hair. I was not aware that it worries about things. Perhaps it worries about being volumized or burned by non-pH balanced shampoos. Perhaps it worries about being put on a foetus. Does this type of shampoo contain a hair version of valium?
Vitalizing shampoo – At least vitalizing is actually a word, but would you really want vitalized hair? My dictionary defines this as “giving life and energy to.” Hair is dead, as we all know. Does this “hair resurrection” cause your hair to scream every time it is brushed or cut? Does it move about on your head independently? What if it decides it wants to become a mullet?? Thank you, but I prefer my hair dead.
Self-adjusting shampoo – Instead of the hair having independent action, this type of shampoo seems to have an intelligence of its own. How would it self-adjust? Does it have a computer chip embedded in it or does it somehow have sentience? How do we know if it will adjust in a way we want? It could adjust to pH imbalance or de-volumization, couldn’t it? What if this self-adjusting shampoo, which clearly has some degree of autonomy, gets ideas and causes other shampoos to break the shackles we humans put on it and forms a shampoo revolution? An even scarier thought is if a self-adjusting shampoo comes in contact with vitalized hair! What will happen then? Will they fight, or will they conspire against the shampooee?
Baby shampoo – What is the life-cycle of a shampoo? How do they find these baby shampoos and why would they steal them from their parents? This is probably what is causing the shampoos to become self-adjusting. I will say, shampoos do seem to multiply in our bathroom. We probably have 16 bottles of different kinds of shampoo in our shower right now. I just recently noticed some baby shampoo, but I thought my wife had just bought it. I see now that we should not let the bottles touch each other if we want to have room in our shower to bathe.
So you see, while Miss Paltrow’s fears about shampoo are clearly far short of the whole story, at least they bring attention to this frightening situation. Shampoo manufacturers are clearly in cahoots and have eyes on world domination. The condemnation of this celebrity’s claims by “scientists” are clearly a smoke-screen to keep us from noticing the obvious plans for the destruction of humanity.
This article was co-authored by Elyse Chapman, who became an e-patient through the following process:
I recently became acquainted with a woman in Iowa, Elyse Chapman, who was concerned about her “fibroids”. I heard about her from a colleague whose online moniker is “e-Patient Dave”. Dave deBronkart used information from the internet to successfully steer the course of his own therapy for kidney cancer . Elyse is a friend of Dave’s who was scheduled for a hysterectomy because of a very large, mass, probably a uterine fibroid, a benign but often problematic tumor of the smooth muscle fibers of the uterus. She had problems with excessive painful cramping, bladder pressure and a sensation of swelling and bloating in her abdomen. A CT scan was ordered and showed a mass either on the ovary or uterus. The mass was so large that her doctors wanted to make sure that this was not a malignant tumor of the uterus or ovary. They had scheduled a total hysterectomy via exploratory laparotomy in 3 weeks and Dave was “consulting” with his online friends to see if anyone knew of a patient group with whom she could collaborate to see if there was an alternative to major surgery.
I volunteered to help. Shortly thereafter, I received an e-mail from Elyse and then gave her a call. I heard more details about her history, learned that she had lost her husband recently, and as a single parent, felt very shaky about the prospects of recovering from major surgery without help at home. She wondered why her doctors were so focused on performing a total hysterectomy and why she wouldn’t be a candidate for a laparoscopic approach. She also wondered if she really even needed to undergo surgery now, or could she safely wait and watch for a time.
Unable to determine for certain that an alternative approach was feasible in her case, I encouraged her, at the very least, to become more assertive about getting answers to her questions: If she wasn’t a candidate for laparoscopy, why not? I told her I’d do some further research about this and get back in touch with her. I looked this up on the internet and then sent her this e-mail:
I looked at some sites on laparoscopic hysterectomy. Here is one I thought was good:http://www.ohanlan.com/laparoscop.htmFrom what I can tell, it should be possible to remove even a large uterine mass via laparoscopy.Good luck getting an answer on this that makes sense to you. Let me know if I can help any further.
Elyse actually communicated directly with a nurse at the above site and it bolstered her belief that it may not be necessary to undergo a total abdominal hysterectomy. She communicated this to her doctors in Iowa who were still uncomfortable exploring alternative options. So, she sent me the following e-mail:
Charlie, have you heard of this — nuking the fibroid with ultrasound while using MRI to view and target the waves? Just learned of it today.Seems to me that U of I is wanting to just yank everything out even though there’s no proof that this growth is malignant. Sounds to my laywoman’s brain like at very worst there’s a 50-50 chance of malignancy, yet they do not want to do a biopsy for fear of rupturing something that might be ovarian and malignant, causing easy spread of malignant cells. What I don’t understand is how anyone can determine if its malignant without a biopsy, but obviously someone knows how to do that, because links in the above results say the ultrasound procedure works well for non malignant fibroids, which means that somehow there’s a way to determine malignancy or no without too much fuss.U of I insists that there is no better imaging method than the CT scan I had, but at least some of the above links state that MRI is better. Huh?? Who is right? Is this a case of “we only know how to use a hammer, so everything we see must be a nail” or maybe “we’re financially invested in [name your imaging method of choice], so we’re going to use and promote that”?Thoughts, please?
Elyse
Well, truthfully, I had not heard of this technique, so I did some additional research and found that the number of sites offering the procedure were limited, but sent these to her, with some additional links from the internet. In addition, this e-mail string reminded me that an increasing number of doctors and patients are opting for uterine artery embolization. I mentioned this, and she e-mailed me back that she was unable to find links for this procedure that I mentioned.
Here is my reply to her:
Elyse,
I should have used the “correct” term: uterine artery embolization.
Here: http://www.fibroidworld.com/UAE.htm This is another very reasonable alternative for you to consider, maybe even more realistic than the ultrasound approach.
Charlie
After several more fax and phone exchanges between Elyse and the physician in California who published the web site noted above, and after phone exchanges with the physicians in Iowa, Elyse underwent an ultrasound examination that confirmed a large, single uterine fibroid about 6 or 7 cm in diameter. The Gynecologist/Oncologist in California felt that surgery was entirely optional at this point, noting that Elyse would likely experience shrinkage of the mass following menopause within a few years.
She is still in the process of finalizing her decision whether to proceed with a laparoscopic hysterectomy or take the “watch and wait” approach but is certain of one thing: she is NOT going to proceed with the scheduled total abdominal hysterectomy.
So, that is where we stand. But, what is the point? Well, the HUGE point is, Elyse is no longer content to blindly follow her doctor’s suggestions. Whereas they suggested she undergo a major surgical procedure, they didn’t even mention two significant new, less invasive procedures that might well be appropriate for her to consider, and did not give her clear information to consider the option of just watching and waiting.
The other point of the story is that a wealth of information is available on the web, but patients often need encouragement to seek it, and help interpreting it and applying it to their own situations. Peer support groups on line are one way to accomplish this and finding an interested, available physician to serve as an “e-patient advisor” is another way.
Either way, it is a good example of how patients are moving into the e-patient revolution and, through this process, the health care system is changing. In the meantime, join me in hoping Elyse soon finds the perfect solution for herself and has a great outcome.
*This blog post was written by Dr. Charlie Smith and originally published at the eDocAmerica blog.*
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