Health rationing and Covid

Over 30,000 people are in hospital in England with Covid. What does this mean?

The British Medical Association says doctors are stressed, anxious about their own health and that of their families, working more than normal hours and possibly beyond their competence in order to avoid serious harm. Final year medical students are fast-tracked, retired doctors are returning to practice. Doctors are working outside their normal specialty. The BMA drily states, ā€œThe skills of these professionals may not meet pre-pandemic expected standards of fitness to practiseā€.

The General Medical Council, appointed to govern doctorsā€™ fitness to practise, reassures doctors that their careers will not necessarily be affected. They will take into account ā€œthe stress and tiredness that may affect judgment or behaviourā€.

Hospitals lose their ability to admit patients for other matters. It is a terrible time to have a heart attack, stroke or cancer. GPs will be dealing with most health need, and so will cancel non-essential services, and use telephone or video consultations.

Where all facilities, equipment and staff that could be used to meet patient need are at capacity, ā€œresource allocation decisions between individuals would become inescapableā€. Rather than meeting individual need, the health service has to ā€œmaximise overall benefitā€. This means refusing treatment to some patients. Normally, there is an ā€œobligation to persevere in the face of an extremely ill patientā€, leading to breaking ribs attempting to resuscitate a patient on ventilation. Some patients may have treatment withdrawn, even if they are slowly improving, to enable others to be treated, who have a ā€œhigher survival probabilityā€.

It is lawful and ethical for a doctor to refuse potentially life-saving treatment where someone else is expected to benefit more from it. Doctors are not assessing the suggested value of a person to the community- younger or older, family responsibilities, work eminence- but their capacity physically to benefit. Individual doctors should be making these decisions according to rules set by their employers. The rules should be open and transparent.

Where care is withdrawn, patients will receive symptom management and end-of-life care for the dying. These decisions have a significant emotional effect on health workers.

Triage is a form of rationing of scarce resources. It sorts patients according to needs and probable outcomes. It can identify those who are so ill they are unlikely to survive, who will be given symptom relief. Priority ā€œwill be given to those whose conditions are the most urgent, the least complex, and who are likely to live the longestā€.

These decisions should not solely be based on age or disability but likelihood of benefiting from available resources. Where patients cannot be admitted to intensive care they will not receive cardio-pulmonary resuscitation (CPR).

Where large numbers of people have apparently equal chances of survival and length of stay in ICU, at first there will be a queuing system- first come, first served. If patients are not improving, there may be a time-limited trial of therapy, and treatment withdrawn. In overwhelming demand, where a patientā€™s prognosis worsens care may be withdrawn.

Sometimes a patientā€™s contribution to essential services, where the workforce is severely depleted, may be taken in account. This means that sick doctors may be prioritized. Well, I would not object to that.

Hospitals are reporting shortages of oxygen. Blood oxygen saturation of 95% is considered normal, but in Southend the target was reduced, to 88-92%.

Cases in England are still rising, because of the Conservative governmentā€™s ridiculous promises of association indoors over Christmas, and failure to implement lockdown until after schools were opened on Monday 4th January. Deaths will continue to increase for four weeks. Hospitalisations will continue to increase for two weeks. Hospitals in London are overwhelmed. People who could have been saved with normal health resources will die.

The BMA’s FAQs are here. Their detailed guidance is here.

DSM V Gender dysphoria

What do you need, to get a diagnosis of gender dysphoria? This is the Diagnostic and Statistical Manual of the American Psychiatric Association definition of gender dysphoria:

A marked incongruence between oneā€™s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:

1. a marked incongruence between oneā€™s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics).

2. a strong desire to be rid of oneā€™s primary and/or secondary sex characteristics because of a marked incongruence with oneā€™s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).

3. a strong desire for the primary and/or secondary sex characteristics of the other gender.

4. a strong desire to be of the other gender (or some alternative gender different from oneā€™s assigned gender).

5. a strong desire to be treated as the other gender (or some alternative gender different from oneā€™s assigned gender).

6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from oneā€™s assigned gender).

Under “Diagnostic features” it notes that “There must also be evidence of distress about this incongruence. Experienced gender may include alternative gender identities beyond binary stereotypes… Adults feel uncomfortable being regarded by others, or functioning in society, as members of their assigned gender.”

Medicine is practical. Doctors don’t make people conform to a particular ideal Wellness, but help us continue to function. This definition is focused on the patients, and what we believe, desire and experience.

You don’t need to desire to change sex characteristics. Secondary sex characteristics include facial hair, or the lack of it, so a desire to change that, rather than gonads or genitals, is enough. So the attempt of some gender critical feminists to distinguish between transsexuals (acceptable) and transgender (not) is not backed up by the APA.

Alternative gender identities: the diagnosis recognises non-binary people. It does not state that the appropriate treatment will be hormones or body alteration, but at least recognises they exist. Private doctors may be more keen to give the patient what they want, so recommend surgery or hormones.

The evidence of “distress” is a fudge. Many of us are not distressed by our gender, but by society’s (perceived) response to it. I know I am a woman, but other people rejecting that distresses me. And, I decided that to be distressed by others’ responses gave them too much power over me. I accept that some people think I am a man. I am not going to waste any energy trying to persuade them otherwise, and I am not going to get upset about it. And, being seen as a woman is not necessary for friendship or politeness: they could see me as a transwoman but think that’s OK.

Yet, if you are not distressed, you are not ill. Being trans is not an illness, it is just a way people are. That means the diagnosis would change to something like gender incongruence in the proposed ICD, as it is only necessary for psychiatrists to intervene if someone wants genital surgery. You might like the backing of a psychiatrist- yes, I really am like this, I am a trans woman- but that is more the province of social scientists than of doctors.

The conviction that one has the feelings and reactions of the other gender does not fit me either. I am a gender critical feminist. I don’t think either gender is so limited, and the feelings of both are the same. I believe the reactions are culturally conditioned rather than innate. I believe my feelings and reactions fit the feminine stereotype far better than the masculine.

The convictions need to have lasted six months for diagnosis. There is no need for The Script, a claim that the feelings have lasted since childhood. But the longer the feelings have lasted, the more likely it is that they will persist, so treatment is less risky.

DSM V estimates prevalence at 0.005% to 0.014% in natal males and 0.002-0.003% in natal females. Other estimates go from 0.1-1%.

It’s all a botched job. It is trying to create a working definition for a varied human phenomenon, and people may try to fit that definition to get what we want.

Righteous anger

When I go to see my doctor, I hope we will be discussing my issues rather than hers.

I told her I was tired all the time, and she sent me for blood tests. The practice wrote to me telling me to make an appointment, so I did. I was ambivalent about discussing antidepressants. I have not found them useful in the past, and feel that my depression is caused by circumstances rather than any brain chemical imbalance, particularly by a series of traumas.

-Why have you come to see me today?
-The practice wrote asking me to make an appointment.

She looked blank for a moment. “Well, you remember I told you that your thyroid reading was slightly lower than normal range.” It took me several tries to convince her. Eventually I said, “I have not seen any doctor at this practice since the blood tests. I made the appointment after getting a letter from the practice. Perhaps you wrote a note of what you were going to say, before requesting the letter.”

That got through to her. My thyroid is very slightly below normal range. It could cause various symptoms- heavy periods was one she mentioned, she knows I am trans surely. Not regulating temperature. Putting on weight. She recommended another blood test in 3-4 months, and if it showed a similar result she might try me on a very low dose of thyroid medication.

No, I don’t want to discuss depression after that. She, however, has something to ask me. Her lesbian friend, who she trained with, asked on facebook whether friends thought the word “queer” had been reclaimed or not. She commented, “Yawn,” and some disparaging reference to “political correctness”, and all the queers piled on her. She wondered what I thought, she said.

Well, I feel the word “queer” has been reclaimed: we do “Queer Studies”, after all. But that’s not what she’s asking: she wants me to say the queers should not have rebuked her.

-You’re straight, aren’t you?
-What’s that got to do with it, she blazed. I am taken aback. She says they would not know that. I am too nonplussed to explain that she does not get the nuances around the word. It has been used to belittle and attack people, including some who might be on that facebook thread.

She says being Jewish she understands all about being part of a minority. Now, me being queer means I want to be a good ally to Jews, BAME etc, and I might say that, but she is saying something different, that being Jewish is enough to understand. Her children are so terribly left wing and right on. She wants pensioners to get enough benefit so that they can afford food, rent and heating, but her children are concerned about things like transgender bathrooms.

“Well, I would love to stay chatting but I have patients to see,” she says, dismissing me.

What would be the point of complaining? I don’t really want to make trouble for her, and I don’t think it would achieve useful change.

I was being sympathetic, but the moment I started to hint that they might have reason to object to her comment she became immediately defensive and struck back. Why should it matter that she’s straight? She does not want an answer, only to be assured that she is right to be aggrieved; and perhaps to take out her grievance. I love her righteous anger. I wish I could do it myself, instead of being quiet then resenting.

-Where’s the hurt, you ask, and I answer in that quiet voice which I think shows my most vulnerable self in our conversations.

It’s just hurt. I don’t think it’s anger, or resentment. There’s some perplexity. I feel disrespected and this feels unfair, and my sense that it’s unfair I immediately judge as pointless, worthless whining. I admire her going on the offensive like that, I don’t think I would.

I noted how easily my mood can go up and down. I was worried about that conversation, “you don’t seem depressed”, and then meeting Mr Corbyn got me feeling so much better. Then something happened and I got down, then I started talking about something I was looking forward to- I said “I will do that well”, and knew in the moment that what I said was true- and felt good again. Being able to say to myself that it was just a mood, like dreich weather, would be a good skill.

Identities II

I feel powerless with doctors, and wanted something to communicate my value: how can I show that I am a worthwhile person, and should be treated well? This shows a lack of trust in the medical profession. Well, I have had particular experiences with doctors.

My medical practice wrote to arrange a medication review. I take prescription hormones, and wondered about just ignoring it; but they might not give me a repeat prescription. I have a named GP but don’t like him. He did not know what it was when I described my retrograde ejaculation, and did not seem to care. So I did not want to see him again. I made an appointment with the first GP available, a woman in her forties. The male GP then got the receptionist to phone me up: I had been discharged from the gender identity clinic, was I happy with that? Yes, happy enough, thanks for asking two years after it happened. Then he wanted my blood pressure taken. I was happy to see a nurse to do that but did not want to go twice to the practice. We established that the female GP could probably do that.

She has a small fan just directed at her, but barely strong enough for the airflow to be noticeable, though the whine was. The motor had overheated. So that it just points at her is incompetence getting a decent fan in this heatwave, not discourtesy. I am a middle class person. Don’t fob me off. I was delighted to notice the booklet from “All too human”, a Tate exhibition, lying about her room. I said how much I loved the show.

She started telling me how much she had enjoyed it, especially the Lucien Freud. I loved the- can’t remember the name, Cookham man, entirely different view of him. [Stanley Spencer, of course.] She knew a woman who had curated the — gallery, which had done a retrospective of David Bomberg and showed a lot of the Jewish artists who escaped the Holocaust to London. After, I thought, yes, Germanic surname, Biblical first name, she is Jewish, I would not have considered it but for what she said. Is that why Jewish artists specifically appealed to her? Freud could be the greatest artist in that show. I would be interested in a Quaker artist, or a Scot, there.

Later, I thought of what I might have said- that Jewish refugee immigration did a great deal of good for this country- something I believe, something that fits with my attitude to refugees now, something that might have built connection there. I want to build connection. I sympathised as the fan died. She did some standard tests for why I might be TATT (Tired All The Time) from physical causes, and noted my blood pressure is within normal range. Under 140/90 is OK.

I started it, and am not sure she should have been so open to small talk. She wants to be able to relate to me, as well as I to her. I liked her as a human being and want her as an equal. I went off to the phlebotomist, who had to hunt for a vein, waggling the needle inside my arm. Piercing the skin was the most painful bit of that.

Trans children and adolescents in Australia

Australian doctors affirm trans children, and show why affirmation works: Trans or gender diverse children with good health and wellbeing who are supported and affirmed by their family, community, and educational environments may not require any additional psychological support beyond occasional and intermittent contact with relevant professionals in the childā€™s life, such as the familyā€™s general practitioner or school supports. Others need a skilled clinician working with the family, to help them support their child. Where there are other mental health problems, they should be treated together with GD.

Parents who do not support their child’s transition may make their mental health worse. “Do no harm” does not mean refusing gender-affirming treatment:

Withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including increasing depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications.

Social transition improves emotional functioning. It should be the child’s decision, and may be just at particular times or particular places. Social transition brings trans children’s depression, anxiety and self-worth to the same level as cis children’s. Doctors may need to be advocates, telling schools this is what the child needs. An endocrinologist should see the child before puberty starts.

Children referred in adolescence need different treatment. The child may have spent a long time coming to understand their gender dysphoria, and considering how to explain it to parents, so will want immediate support and medical help, but a parent might see this as sudden, and have difficulty adjusting. The child needs a comprehensive exploration of the adolescentā€™s early developmental history, history of gender identity development and expression, emotional functioning, intellectual and educational functioning, peer and other social relationships, family functioning as well as immediate and extended family support.

Once there is significant breast growth and menstruation in a trans boy, puberty suppression is not recommended. Gender dysphoria around menstruation can be reduced with norethisterone. Testosterone in trans boys may produce irreversible facial and body hair growth and scalp hair loss. Deepening of the voice is irreversible. Clitoral enlargement and vaginal atrophy may be reversible, but this is unknown.

Oestrogen in trans girls will reduce muscle mass and strength, soften skin, and decrease libido and spontaneous erections. These effects are probably reversible. Breast growth is irreversible. The testicles will shrink, and sperm production decrease: it is unknown if these effects are reversible.

Teenagers vary in their maturity, and ability to make decisions with complex risks and benefits. However delaying hormone treatment in trans girls means increased masculinisation of face and body, and suppressing puberty without starting stage 2 treatment (gender-affirming hormones) can weaken bones. Refusing treatment reduces an adolescent’s sense of their own autonomy and agency.

GPs should give an initial assessment, including of the family support and functioning, and advise on the effect of treatment on sexuality, sexual pleasure, and fertility.

A trans boy may have chest masculinisation surgery as young as 16. There should be a joint decision with child, parents and clinicians coming to consensus, taking account of the child’s maturity. However the guidelines advise delaying genital surgery until adulthood, because it will make the patient sterile, and may reduce sexual pleasure and interest.

The New Zealand Adolescent Health Survey suggested that 1.2% of adolescents identify as transgender. The guidelines suggest that this means referrals will continue to rise. Only an atmosphere of support and acceptance will enable a child to make a proper decision.

Guidelines pdf.

Gender incongruence

Is the ICD-11 (International Classification of Diseases) redefinition of “Gender incongruence” a progressive change to the medical treatment of trans people? Almost too progressive. Trans people are accustomed to seeing psychiatrists. What will we do when we can’t?

Gender incongruence, in the new ICD, in effect from 1 January 2022, is not a mental illness. Desire for physical alteration is the diagnostic criterion. To be diagnosed with gender incongruence, you need to want rid of your primary and secondary sexual characteristics, or to want those of the opposite sex to your birth gender.

This is the definition: Gender incongruence is characterized by a marked and persistent incongruence between an individualā€™s experienced gender and the assigned sex. Gender variant behaviour and preferences alone are not a basis for assigning the diagnoses in this group. Gender incongruence of adolescence and adulthood is characterized by a marked and persistent incongruence between an individualĀ“s experienced gender and the assigned sex, as manifested by at least two of the following: 1) a strong dislike or discomfort with the oneā€™s primary or secondary sex characteristics (in adolescents, anticipated secondary sex characteristics) due to their incongruity with the experienced gender; 2) a strong desire to be rid of some or all of oneā€™s primary and/or secondary sex characteristics (in adolescents, anticipated secondary sex characteristics) due to their incongruity with the experienced gender; 3) a strong desire to have the primary and/or secondary sex characteristics of the experienced gender. The individual experiences a strong desire to be treated (to live and be accepted) as a person of the experienced gender. The experienced gender incongruence must have been continuously present for at least several months. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.

So thinking you are a woman, though you have a penis, would not fit this definition. The desire to be accepted socially as a woman is not enough, even though most people only show off their genitals to sex partners. There is a separate diagnosis for childhood, but it too requires dislike of ones own sex characteristics and desire for the target gender’s. We will have to just accept ourselves, without long agonising sessions with counsellors and psychiatrists!

Gender Incongruence comes under ICD-11 17, conditions related to sexual health, which includes physical illnesses but also paraphilic disorders. It uses “desire” as a diagnostic criterion. That desire will be assessed by a psychiatrist. Might there be a similar desire which was a mental illness, such as a psychotic delusion? I can’t find the appropriate treatment in ICD 11: it does not exclude an attempt to reconcile the person to their physical characteristics.

For me, the role, expressing myself as a woman, was more important than the physical changes. It liberated me to be myself. I now believe my passionate desire for the physical changes came from social pressure, the idea that the “true transsexual” wanted these changes, and only “true transsexuals” should transition. I regret my physical alterations, probably in part because the operation was not as successful as it was in others I have talked to. I have had a significant loss of sensitivity.

The Guardian correctly reported that GI no longer comes under “mental, behavioural and neurodevelopmental disorders”, and quoted Lale Say, co-ordinator of the WHO department of reproductive health and research, who said, “We think it will reduce stigma so it may help better social acceptance for these individuals”. I am glad not to be called mentally ill. That is a relief. I am concerned that there might be greater pressure to have surgery and hormones. I am not convinced they are necessary, or that they would improve our happiness if we were not told they were necessary.

There should be two rigorously separated approaches to gender incongruence. One is the medical approach: really, those of us who want to present in the other sex without surgery or hormones should not need to see a doctor, so that reasonably concerns itself with medical treatment, but some might need help with other mental conditions. The other is the legal/social approach: those of us who transition, intending to live life long in the acquired gender, should be treated like others of that gender. Those who intend to transition or manifest as non-binary should not suffer discrimination because of it. As long as the legal definition does not require medical diagnosis, people may not be pressured into unnecessary medical treatment. We might benefit from support, even though we are not ill: transition is difficult. Hair removal and voice training might be available.

It is necessary to define a medical condition to say what a health service or health insurance should pay for, and what doctors should do. The desire to alter your body in this way is not a mental illness. The health problem, for those who desire the changes, is that the changes are necessary.

The desire to transition may involve mental distress- can I manage it? How will work, family, community react? Am I deluded in wanting this? Psychotherapists could be part of helping a trans person resolve these issues. Gender dysphoria- distress arising from others’ expectations of us based on sex- exists and is mentally debilitating. Mental health services have a role in helping with it. The mental illness is not a deluded belief that you are part of the true gender. The mental illness is the difficulty you feel realising that, given the social pressure you suffer to conform to the assigned gender. Gender dysphoria, discomfort with gender role, exists and is debilitating, and one cure is transition. Internalised transphobia could be a medical condition.

The document will be sent to WHO member states, and will take effect from 1 January 2022 if adopted.

The definition was amended.

Gender incongruence is characterised by a marked and persistent incongruence between an individualā€™s experienced gender and the assigned sex. Gender variant behaviour and preferences alone are not a basis for assigning the diagnoses in this group.

I am not sure how or when. According to wikipedia the “stable version” was issued on 18 June 2018, with the initial, longer version, and officially endorsed on 25 May 2019. The shorter version is now on the WHO website. Member states must decide when to implement ICD 11.

 

Trans children II

Which would you prefer? To be always noticeable as a trans woman, to be subject at any time to others’ prejudices, but to be fertile and able to father a child, or to be indistinguishable from any other woman, albeit one without a womb, but sterile? Can you decide, aged even 18, whether you will want children at some time?

It is possible to defer puberty until a child makes the decision whether to transition permanently, and then give cross-sex hormones. Many adult trans women would like to have been so treated. Passing matters. We flourish better if we are not constantly worried about other’s real or imagined prejudices. You can adopt, or foster. Clever things might be done with stem cells: ordinary skin cells may be converted into stem cells.

Any use of cross-sex hormones, even with a natural puberty, might affect fertility. Never using cross-sex hormones might make passing more difficult.

Doctors do not make people “well”. They have a number of treatments which might improve a person’s condition. They do plastic surgery where there is no medical need. I do not believe in a discrete group which is transsexual, which will clearly benefit from transition. Our circumstances and our resilience affect whether we can make a go of life, and whether that should be as male or female. I can imagine a regret of either course. A doctor might want their patient to fight for puberty-blockers, so that the doctor could not be blamed later for loss of fertility.

An adult knows it will not grow back.

The Royal College of Psychiatrists position paper acknowledges the need for better evidence on the outcomes of pre-pubertal children who present as transgender or gender-diverse, whether or not they enter treatment. Until that evidence is available, the College believes that a watch and wait policy, which does not place any pressure on children to live or behave in accordance with their sex assigned at birth or to move rapidly to gender transition, may be an appropriate course of action when young people first present.

That says nothing. “First present”- what about after? It gives discretion to the doctor involved, to suppress puberty if they decide it is appropriate. Doctors might want a wide range of options, but not to be blamed for any of them. I do not blame doctors for the treatment which I wanted, and want them generally free of blame- it means that others can choose what I chose. If we blamed the doctors for wrongful treatment, we make their gatekeeping more onerous on those who follow us. We have to make these decisions for ourselves.

The mood of the paper is limiting treatment. “Better evidence on outcomes”- we fear this means, no puberty blockers. Parents and children can be particularly keen on puberty blockers.

I like the idea of the child following their own desires. Let them find what way suits them. I would like children to be able to experience both presentations side by side- to be able to go to school as boy or girl as they wished on the day. The RCP will not say that: The Department of Health and Social Care and the Department for Education should ensure all schools provide appropriate staff training and have clear policies that support transgender children. These include tackling bullying, effective safeguarding, parental concerns, and practical considerations (such as appropriate language, use of toilets and changing rooms, and uniforms). They make no suggestion what that policy might be.

We want the best for children- and not in some ideal world but the world they must navigate, now and throughout life. That I regret a decision does not mean that I would be happier had I decided the other way. Life will be hard on gender diverse people whatever choices we make. Life is difficult for everybody.

A feminist

I love what Dr Jen Gunter writes, on abortion, empathy, privilege, feminism, and incidentally on trans people.

An advert on facebook led me to an article from last month’s NYT on vaginas. Male partners sometimes criticise healthy vaginas as too loose, or smelling wrong, or tasting wrong, as a way of controlling women and making us feel insecure. This is not OK. I decide how I want to look. Women may actually harm themselves trying to make their vaginas acceptable. As a gynaecologist, Jen Gunter hears a lot of women describing the men’s manipulation.

In the comments here, I see different lines on “Not all men”. It gets clearer to me how that is offensive. Indeed, not all men rape women, and perhaps some men have never pushed women’s boundaries or wronged them in any way, but when a woman complains of shitty male behaviour, why should a man feel the need to say not all men? That’s irrelevant, she is not complaining of all men, but some men. The man may not be saying it never happens, but is derailing: it happens, it matters, and we should consider the experience of it, rather than judging the way it is shared. And, why feel any need to protest, if you do not feel guilty? What she wrote was “This is a form of control men often use”- not, all men; not, women don’t do something similar, though women may have less power in a relationship so might not, so much; but, men do it. Let us agree it is a bad thing, and try not to ourselves.

I dislike the line that “men suffer the same way”. Yes; but she was not claiming a right of retaliation, only saying it happens and is wrong. Someone signing a woman’s name accused Dr Gunter of an offensive, gross mischaracterization of an entire classification of people based on gender. That was not what I perceived. “Not all men” becomes a way of saying SHUT UP rather than a reasonable response.

She is worth reading for the facts on late abortions: after 25 weeks, a woman with a wanted pregnancy but health problems making continuing pregnancy too dangerous would have a C-section or induced labour. The child would be cared for. Concealed pregnancies, perhaps of a frightened teen or a rape survivor, are very rare. Sometimes a foetus has severe defects but the mother elects to carry anyway; but a foetus lying horizontally cannot be delivered vaginally.

She continually calls for our empathy. Some women donā€™t want a C-section in this situation for baby who canā€™t live. I think you can understand that. And Some women just canā€™t bear continuing. Imagine everyone touching your belly asking if you are having a boy or a girl and you know your baby has no brain? I have heard that story. It breaks people.

This post is particularly good on empathy, privilege, and thinking your way into someone else’s situation. You can’t experience the same situation, every situation is different, yet you should be able to imagine theirs. Assuming what someone else felt or might have felt based on your own experience (or wanted experience) is the opposite of empathy.

Once as a resident I rolled by eyes when discussing a woman who was presenting for her third abortion. I mean really, I thought. Sheā€™d been sent home after both of her previous abortions with 4 months of free birth control pills and here she was just six months later. My attending, an older man, took me aside and reamed me for that display of privilege. Iā€™ve never forgotten that. In fact, it prompted me to design a study to look at that very question, why do women have repeat abortions? Guess what it turns out is a big factor? Domestic violence. Though empathy may be too much of a stretch for Republican authoritarians concerned for their own moral rightness.

I checked whether she had anything on transgender. She mentions it in passing, but always in a friendly way. The agency tasked with enhancing the ā€œhealth and well-being of Americansā€ now believes that certain religious beliefs are more important than health care. This could apply to contraception, abortion, vaccines, addiction medicine, sexually transmitted infection screening, and transgender care just to name a few… government planning will be all based on some non science ideas such as life begins at conception, pre marital sex is wrong, anything but marital sex between cis women and men is wrong. If we think too much about the hostile people it colours our view of humanity. Here is a woman working for the rights of women, who is positive about trans people, and uses our words such as “cis”.

Pressure to change sex

Scare story in the Daily Mail: NHS pressured our kids to change sex: Transgender backlash as desperate parents accuse overzealous therapists of ‘blindly accepting’ children’s claims to have been born in wrong bodyDoctors fear being sued after the NHS signed a ā€˜memorandum of understandingā€™ banning staff from challenging patients who believe they are born the wrong sex. YouTube, Instagram and Tumblr make trans cool, encourage teens to threaten suicide or self-harm if their parents oppose them, show where to find binders and hormones “and other sex change aids”, whatever those might be, and spark a social contagion. Adolescents are “heavily influenced” by messages they send to one another. NHS Scotland and NHS England have signed a Memorandum of Understanding banning staff from challenging patients who believe they are born the wrong sex. Doctors fear being sued, and a psychotherapist called Bob Withers cautioned that the memorandum could prevent therapists from exploring patients who say they are transgender but are suffering from other mental health conditions. He says it means the psychotherapist cannot look at the psychological reasons for the gender dysphoria.

So much for the Daily Mail. What is the truth? Here is the Memorandum. It commits the NHS and other bodies to ending conversion therapy, defined as the assumption that any gender identity is preferable to any other, leading to attempts to change or suppress gender identity or sexual orientation. Gender identity includes all binary, non-binary and gender fluid identities.

Personally I find non-binary and gender fluid identities preferable, as they give people more freedom. My identity as a TS liberated me to be myself, at the cost of undertaking the transition I understood an M-F TS would undertake. Non-binary or gender fluid permits maximum variation in gender expression without preventing any surgery or hormone treatment. It’s not “I am trans therefore I want hormones” but, given that I have this identity and these desires, might I want to transition, or to have medical treatment? What desirable or negative effects might that have? We move beyond one size fits all- I am TS, therefore I have hormones then surgery- because that is restrictive.

The memorandum goes on, gender identity is not a mental disorder; but people uncertain of their gender identity might seek psychological help. Some people may benefit from the challenge of psychotherapy and counselling to help them manage dysphoria and to clarify their sense of themselves. Clients make healthy choices when they understand themselves better. Withers and the Daily Mail are wrong: counselling for self-understanding is still possible.

There may be grounds for exploring therapeutic options to help people unhappy about their transgender status live more comfortably with it, reduce their distress and reach a greater degree of self-acceptance. So professionals may explore hormone or surgical treatment, within the guidelines for that. The real problem is that there is little funding for specialist assessment or mental health treatment. Adolescents get referred to the Tavistock clinic, whose waiting lists grow.