Popular Dysphoria by Pat Conrad MD
“Were the doctors in attendance saying how they felt so sick inside,
Or was it just the scalpel blade that lied?”
– “Tower of Babel”, Elton John/Bernie Taupin
Years ago when a third year resident, the first breast exam I was directed to perform was on a man, semi-balding, beard, hairy chested, and former female impersonator. In his working days, he had gotten estrogen shots (his story) in his breasts to make them grow, and now he was worried about a lump. Not how I thought the day was gonna go, but any of us former med students have had similar surprises. Later in residency, I was assigned an HIV-positive “married couple”, one of whom was an egregious cross-dresser, both very male. Oh well, professional decorum, stick to the problem list, do your best, try not to be overtly judgmental, and treat the patients the best way you can.
Perusing the American Medical Association’s website, I chanced a look at their current topics page, which confirmed yet again that the AMA is ever the refuge of the dull-witted and easily led. Consecutive topics included their efforts to create a list of LGBT groups in organized medicine (Earlier this year, the AMA wrote that “the only effective treatment of [gender dysphoria] is medical care to support the person’s ability to live fully consistent with one’s gender identity.”) and announcing that another state is covering “gender reassignment” surgery for employees.
Maryland has become the third state, following California and Oregon, to offer such coverage that includes hormone and surgical therapies. Now that the newly released DSM-5 has decided to de-stigmatize this sad affliction, their criteria of “must exhibit a strong and persistent cross-gender identification…” will surely encourage more takers. The Obama Administration has already weighed in with an executive order extending new protective emphasis to the transgendered in federal employment.
We should all be sincerely, and truthfully compassionate toward these unfortunates. But that does not include lying, either to patients or to ourselves. We can’t pretend that there is an easy answer to this problem, and it is the height of dishonesty to pretend that buckets of hormones and surgical mutilation affords such an avenue. The L, G, and B demographics as a subject of public policy, psychiatric consideration, diversity celebrations, or societal acceptance are one thing; externally altering someone and assuring them that they are what they wish to be simply because they wish it will only add new conflicts to their already serious inner turmoil. Now that both governments and the AMA are bowing to media-fed political pressures, more physicians will be called upon to accept and perpetuate these deceptions. Is it now a doctor’s ethical duty to refer a would-be transgender to a psycho-endo-surgical team offering corrective therapies? Will a physician refusing to do so be subject to legal sanction or board of medicine scrutiny, with the AMA policy used as evidence? Authentic medicine means compassion and looking for answers. It means trying to be kind to those who seem strange, different, uncomfortable with themselves, or even creep the hell out of you. It also means admitting when you are unequal to a problem, and not selling a lie as a substitute. Policy that endorses someone’s psychopathology is neither good medicine, nor authentic.
At last, someone willing to speak out about this issue. It would be nice if there was or had been a debate, dialogue ,discussion or forum on this topic. How did the T get mixed in with the L G B ? So the DSM experts concoct a diagnosis for a serious, real life problem and then a “cure” is created ?? A “cure” with real, serious side effects. Oh, and if they become “normal” will a TG gender dysphoric be deemed cured and lose SSD eligibility ?
Nonsense camoflaged as “science”
A vitriolic rant masquerading as concern for the practice of authentic medicine. Thankfully this blog is usually free of such prejudicial rubbish. If any physician feels uncomfortable or unqualified to treat a condition then that physician can simply refer the patient to someone with the necessary expertise. There are well-established protocols for evaluating and treating gender identity problems which may or may not involve hormones and surgery. The last thing these patients need is a physician who views them as creepy psychopathologies.
I really don’t see any vitriol in Pat’s writing, Kristzina. “The last thing these patients need is a physician who views them as creepy pathologies.” Agreed. I believe that was part of Pat’s point. Insisting that people always behave in a perfectly conscientious manner is like telling someone to calm down – most likely to cause the opposite.
The underlying question is very interesting – and will be, as usual, ignored.
The AMA has published new guidelines for physician behavior in 2014:
1) A doctor may not injure a patient or, through inaction, allow a human being to come to harm.
2) A doctor must obey the orders given to it by patients, except where such orders would conflict with the First Law.
3) A doctor must protect its own existence as long as such protection does not conflict with the First or Second Law.
That’s actually satire about the AMA – these rules are simply Asimov’s rules for Robotics, published many years ago in the 40’s. I left the “it” word in for impersonality.
Transgender persons are persons, and so are doctors. Transgender persons, as persons, expect to be respected and liked by their medical providers. Some doctors, as persons, cannot care empathetically and humanely for transgender persons. Some transgender persons are furious when they perceive a lack of genuine caring from a provider.
These are all behavioral habits of human beings, persons. In general, the unspoken ethics of medicine allow the referral of a patient by a doctor based on the doctor’s own perception or ability to care empathically for a patient. The expectation is that the referral be genuine and humane; the reasons for it are allowed to be private and not intruded upon.
A physician who has been raped has a societally-recognized cause for referral of a rapist; a person who hates Jews does not have a societally-recognized cause for referral of a Jewish patient. Nevertheless, the weight of societal recognition should have no sway in the matter. If you cannot treat fully, refer genuinely.
Some doctors are delighted to care for a transgender patient; many are unconcerned; a few are repelled. Is it the duty of society to force the doctor to attempt something that is, on self-reflection, ethically beyond their capacity?
I am not a surgeon, and do not do appendectomies; the only conceivable circumstances when I would, would be when an incompetent attempt would be better than no attempt at all. Nobody would question that ethical certainty.
Are doctors allowed to contradict societal wisdom, and opt out of non-emergency treatment that bothers them? Should a doctor be obligated by a sense of duty to the social authorities to pursue bothersome treatment? Abortion? Sterilization of the intellectually feeble? Racial purification?
Can doctors dare state that what is politically wise and solemnly mandated by the “social conscience” may be, in fact, wicked and inhumane?
Or are we demanding a new version of Doctor 2.0, a new edition of the “I, Robot” series for medicine? What about developing eDoctors, the marriage of CGI faces with Big Data and “Guidelines” to make the Perfect Robot Doctor? Is that our Nirvana that we seek?
And yet – everywhere – human patients want their doctors to be humans. This insistence will guarantee a clumsy fit, until all human beings instinctively love and cherish all other human beings unquestioningly. What then? Will “genuine humanity” simply mean “all aspects of humanity which have been authorized by the Agency?” Is the ultimate goal of Perfect Humanity simply the development of IT to the point of Turing’s Doctor?