I was at one time a medical student. I am on hiatus, indefinitely, having been forced to step away when my school’s administration created and perpetuated an unsafe environment for me as its first transgender student. Hundreds of thousands of dollars gone, along with a future career I may have loved, remains a sore and unresolved point, but the universe had other plans. I would never have had time to become as active in the recent transgender zeitgeist, had I not freed myself from another path first.
My transition in medical school started over the Jewish holiday of Passover, which I used as the thematic platform for an essay I wrote to a Jewish-affiliated school. First year students were assigned a reflective essay for our Introduction to Cultural Competence “soft skills” course. Nothing about the course itself was memorable, and if the word “gay” came up twice at most, that was the extent of our LGBTQ-competency curriculum. I was already taking female hormones, resulting in smoothing skin and budding breasts, but despite these changes and growing out my hair, my trajectory was only rumor and hearsay.
More could be done, so I challenged myself to write a crash-course curriculum. It was also, subconsciously or overtly, my means to break the ice with the faculty members I hoped would be my allies moving forward. I am excited to publish this in its entirety as a blog post. It’s long form, but snapshots of my own coming out and how I approached identity early in my own transition. It is part guide for medical students, part Jewish sermon, and part, “Call me Hannah... soon.”
The plagues are a symbol of divine intervention, but they are also a test of strength and fortitude. The struggles of the gender non-conforming can be envisioned through each plague, and represent key points to consider while assessing a patient’s well-being. Blood is the awkwardness of coming out to friends and close family at the risk of their rejection. Frogs are the ugliness or disconnect one might feel with their own mirror reflection. Lice are the plague of infections, for which this group has increased risk. Flies and diseased cattle mark poverty and loss of one’s livelihood respectively, perhaps from discrimination at school or work. Boils require medical attention, from which this group faces distinct barriers. Hail strikes painfully; the world to any gender non-conforming person can be downright violent. Locusts represent the infinite swarm, among which it is inevitable to feel lonely. Darkness is the fear and depression, from which far too many find no escape. Taking away the first-born is accepting infertility—explicit or de facto—the realization that starting or sustaining families will be considerably more complicated now.
Where the Parted Sea Collapses
Exploring health care barriers and possible solutions for the trans and gender non-conforming populations through the Passover Seder -April 11th, 2013
Preface:
A complete disclaimer for this paper could in fact turn out longer than the paper itself. The topic I have chosen to discuss is regretfully as controversial to some as it is fascinating to me, but as A. T. Still, the founder of Ostepathic Medicine, once said, “I have no desire to be a cat, which walks so lightly that it never creates a disturbance.” The ideas are my own, although due to their sensitive nature, anecdotes are kept general and I am not citing the individuals who have confided information in me, some over many years.
I have elected to fulfill this assignment in part as a creative thought exercise. I firmly believe that, as future physicians, we must never talk above or below the patient, but rather with them, in terms and cadence commensurate to their understanding and need. The use of relatable analogy can be a powerful engine upon which to start or sustain any discussion, especially with uncomfortable or unfamiliar topics. However creative, this paper is merely a glimpse into a much larger topic and makes no attempt to encompass every perspective. Lastly, this topic is a minefield of ever-changing thought and parlance, so I will simply do my best to offend nobody, or at least everybody, equally. This paper is dedicated to dear friends of mine: KJ, RR, MB, and KH, who I am proud of and thankful to have in my life.
Part 1: Why is this Night Different?
Earlier this week, I was invited to attend a unique Passover Seder, hosted by old Hebrew school friends of mine who are part of the self-proclaimed “radical queer” community in Brooklyn. A number of individuals around the table identified as trans or gender non-conforming to one degree or another. The Hebrew word for Egypt, Mitzrayim, which means, “from the narrows,” represents not so much a geographic location, but a state of mind, from which each of us seeks liberation in our own way. It is fitting and timely context through which to learn from the challenges of my queer and gender-variant friends face in receiving medical care. Each section of my paper will thus begin with and relate to a key concept from the Passover narrative and customs.
For the purposes of this paper, I will be focusing on the barriers faced by trans and gender-variant individuals, loosely speaking, those who fall under the “T” in LGBT. The queer community’s needs were only superficially and inconsistently discussed in our recent Introduction to Cultural Competence course, something that could certainly be enhanced. To many people, queer health care brings to mind providing the gay and lesbian populations with a non-judgmental atmosphere, STI prophylaxes and treatment, and lately, in-vitro reproductive options for partners forming families. Beyond that, their needs are not so different from the general population. Proper care for the gender-variant population however, has numerous notable differences, which should be considered on their own.
Comprehensive services for the trans-identified patient will certainly include all of the above, as well as: copious mental health services; gamete storage or reproductive therapy; hormone replacement and endocrinologist supervision; and any variety of affirming surgical procedures. As physicians, we may be called upon to support an individual through this process, or we may just be treating their common cold.
From the medical student’s perspective, the study of gender non-conformity and its treatment touches upon every specialty from pediatrics to geriatrics, psychiatry to gynecology, and also triggers debate over nearly every third-rail issue in the medicinal and societal vernacular: bioethics, legislative reach, insurance exclusions, hate crimes, discrimination, and medical tourism, just to name a few. For the osteopathic student in particular, the promise to treat each patient as a whole – body, mind, spirit, and circumstance alike, must remain steadfast. Our task is to find each patient’s health, along no preconceived template and however it may manifest.
I am writing this paper to encompass what I personally believe is a baseline level of background that all future physicians should possess to best serve the trans and gender- variant patient population, much of which is applicable to the entire queer population. I hope to have the chance to distribute it as such one day as training for others. This paper will attempt to delve into to some of the specific nuances of the trans and gender-variant experience, as I understand them, and the barriers they face to medical care. Very often, it is the fear of negative reaction that prevents individuals from seeking care they need, both specific to their identity and for any unrelated issues. It will then go on to suggest ways in which the medical community can become more accommodating, from the individual exam through infrastructural changes. Lastly, this Passover night is different because it is a call to self-reflection. New physicians are taught to check their own biases at the exam room door, but in reality we are charged with continuously challenging our own truths, and using our rational, respectful approach to shape the public discourse.
Part 2: The Chosen People were Enslaved
We can’t all be chosen, is how my good friend sarcastically depicted his coping mechanism for the sensation of knowing from an early age that he was not exactly the little girl others saw overtly, even if he could not quite put his finger on how. To write a paper about impediments faced by any minority population, one must be able to define it, or in this case, at least highlight the difficulty in doing so. A tremendous barrier faced by this chosen people is the lack of adequate vocabulary to capture the diversity of experience in ways that are respectful yet adequately descriptive when medically necessary. I will go through some examples with trans, gender-variant, and queer.
As I have personally learned through relentless correction, every word or label contains a history that may resonate or alienate, often depending on generation, socio- educational background, a person’s self-identity, or even who is saying it. Trans (and many words that start with that prefix), imply a state of flux or “crossing,” from the Latin. Not all gender-variant people consider themselves trans. Some because they wish to exist between or without gender, while others use that word only in past tense to recall a stage of life before they achieved their desired expression.
Gender-variance likewise, is also an umbrella term, yet implies existing outside of established cultural binaries to one degree or another. Many in this population in fact, live much of their lives within one of the iconic pillars of masculinity or femininity. Either they have taken on a role opposite to their natal features, or societal pressure and fear of rejection keep them from ever exploring the full expanses of their consciousness and potential at all, or at least not for many, many years.
Queer, genderqueer, and even LGBT(Q) have nuances too. A previous generation hid from this shameful slur, which today, in places like radical Brooklyn, has been reclaimed as a self-affixed badge of distinction. While today a colloquial umbrella term, queer still bears the heritage of ascribing sexual orientation. Not all trans people consider themselves queer, many take on heterosexual partners (from their new vantage), and go so far as to say that label degrades the new normalcy they strive to achieve.
LGBT..., which gains appended letters almost weekly, can be equally contentious. Not all believe the association between the realms of LGB and T are beneficial to either side, and I learned from my friends of at least two examples where this becomes evident, as per the stories I was told. The first is the concern over homophobia by the religious zealots of the world. For better or worse, many leading holy texts have a few vague lines each prohibiting acts of non-normative sexual orientation. None of the ancients however, say much that pertains to medically altering one’s phenotypic gender. True zealots seldom require facts or logic to substantiate an argument, but the close association of LGB to T in use like LGBT further blurs the differences to the uniformed citizen, not that persecution of any population is tolerable. A similar example comes from the recent repeal of Don’t Ask, Don’t Tell, the United States’ policy banning openly homosexual armed service members. This was considered by many to be a tremendous “LGBT” victory, when in reality, being of trans experience is in fact a military physical exam exclusion which was unrelated to DADT and remains in effect.
For the care provider, the directive is not to use specific terms, but to have a basic understanding of the major ones while learning to listen to and mimic each patient’s own expression. Physicians must employ these skills every day; this is merely an unfamiliar context to most. Over the years, people of African descent have been referred to as African American, Black, Negro, and a variety of other terms. Each one has a story, a context, and a connotation. As native African and Caribbean immigrants are common to meet walking down the street, it would be unjust and non-productive to ascribe the same cultural narrative and parlance to a member of these communities as to a descendent of the Southern slave trade, even if people from these groups appear superficially similar.
Part 3: The Baby Boy in the Basket
The Egyptian Pharaoh decreed that all the newborn boys of the Israelite slaves be thrown in the river, but how would he have known who actually identified as boys? A physician who might work with the queer and gender-variant population, or more precisely, every physician, should have an understanding of preferred names and pronouns. In short, you can affirm your respect of an individual’s self-defined first person via your third person speech. It is impossible to look at someone and know their name until it is told to you, and once told, you never question it. With pronouns, we instinctively make assumptions. We see people on the street and can categorize them as “he(s)” or “she(s).” Biological sex can often be determined from a single skeletal bone or histologic slide in isolation. Gender identity is an entirely different story.
Gender-variant individuals face barriers to health care, because they are embarrassed by having to enter into a system that very often ascribes them a sex with which they may or may not agree. This is in part due to the limitations in the English language, but these are not insurmountable. In fact, other languages make it much worse. Some people have suggested new pronouns like ze and hir for individuals who defy the gender binary, but most likely, society will settle on they, them, and their. These are already used as the third person plural pronouns (which are coincidentally gender-nonspecific), so it may simply become a singular neuter as well. There is even archaic precedent for this usage. While grammatically incorrect, it still prints and sounds better than s/he, he or she, or any other politically correct concoction we scribble to denote inclusivity within formal writing. This paper is intentionally written in this style.
Grammar is negotiable; respecting others’ identities is not. A great way to address this particular barrier is to use neutral language and ask a patient’s pronouns whenever possible. The standard intake form for all new patients should include “legal name,” “preferred name,” and “preferred pronouns.” If the physician happens to know a patient is actively in transition, they can periodically ask, “Are these still your preferences,” the same way they might ask about any update in overall health. Throughout a physical exam, asking a patient’s preferred words for different parts of their body, and directly explaining the medical relevance to the chief complaint of that visit for any question related to their sexual past, are great ways to ensure a comfortable and beneficial experience. Hopefully, whatever answers they give never again determine whether or not they are thrown into a river.
Part 4: The Plates of Coal and Gold
It is said that baby Moses was presented plates of gold bars and hot coals to determine whether he sought to usurp the riches of the throne. Like any baby, he gazed toward the shiny objects and reached outward. At the last second, an angel is said to have descended from the heavens, just to sweep his hand into hot coals. Baby Moses retracted his burnt his fingers toward his mouth, singed his tongue, and forever spoke with a lisp.
A fundamental sticking point to the debate over sexual orientation, as well as gender identity, is whether or not the uninformed citizen believes these characteristics are the result of conscious “lifestyle choice.” Why would Moses choose the coals? When considering the hassles gender-variant individuals endure, not unlike homosexuals, it is hard to believe anyone would willingly take them on. In fact, quite the opposite, too many individuals choose to hide their feelings and suffer mental anguish while feigning normalcy.
There are various theories on the etiology of gender identity changes, ranging from genetic factors to hormonal changes in utero, through defining experiences in early childhood. This is my own conjecture, but I prefer to explain gender-variance to my peers along the lines of intersexuality. Intersexuality is the blanket term for overt, variations or incomplete sexual differentiation. Certain simplistic scenarios are mentioned in our physiology and embryology coursework, such as androgen insensitivities, enzymatic deficiencies, or chromosomal abnormalities, which result in the partial or alternative development of the typical internal and external reproductive structures. Gender-variance is perhaps a discrete subset of the same mechanics that lead to overt intersex births, where the processes that fail—or trip inadvertently—are localized within the developing brain.
Ninety-nine percent or more of the time, things fall into place as expected. The vast majority of the world takes agreement of their natal sex and gender for granted, yet this phenomenon of variance is seen across races, religions, and cultures. There are many historical accounts, which in modern context are also suspect. As healers, etiologies are helpful if understood, but deference to the wonder and diversity of the human species will do more for our patients now than waiting for that answer. Autism, if identified early, can be aggressively treated with tremendous results. Nobody denies it exists or would dare to suggest it is the patient’s lifestyle preference, yet it too lacks definitive explanation. Being dealt in life a handful of coals, a handful of gold, or autistic arm spasms, comes down to chance—or the occasional angelic intervention—but is decidedly not a choice.
Part 5: The Bitter Herbs
Passover’s bitter herbs remind those participating in the Seder of our ancestors’ sorrow. Yet as our sinuses drain in discomfort, we might also recall that herbs have had medicinal use for thousands of years. This is an excellent symbol from which to consider the barriers faced by trans patients to receiving such medicine. Three examples I will touch upon in this section, out of many, will be age, insurance exclusions, and imprisonment. Barriers this population faces in every day life, to activities so otherwise innocuous as the use of public restrooms, are not to be downplayed, but are beyond this piece’s scope.
As I have learned from trans friends and through periodic news media coverage, care for the trans patient gets extraordinarily tricky when considering minors. Regretfully, for those who do hope to transition and live in an opposite-natal-gendered role, this is actually the best time in their lives to provide modern pharmacology to achieve the desired results. Today, children with access to the most progressive standard of care can elect to receive puberty blocking treatments to buy them time as they solidify their identities in early adolescence. Only if desired, they can progress onward to cross-sex exogenous replacement without enduring consequences of undesired natural masculinization or feminization first. Neither a natural, nor an assisted puberty is reversible, so the goal should be to help guide the patient through the correct one exclusively. Some children naturally exhibit gender non-conforming behavior, which they later outgrow, but others are stalwart. Only a handful of clinics in the world offer this expensive screening process and treatment option, which in itself is a barrier to care. By contrast, most providers will not prescribe medicinal intervention, especially lacking parental consent, to those under the age of majority in their region, which is generally well after peak pubescence. As care providers, especially in pediatrics, we must be advocates for our patients first and foremost, even when systemic or societal constraints obfuscate the process.
A second systemic barrier to trans care is specific exclusions listed in many private insurance policies, particularly in the United States, that prevent payouts for hormones, mental health services, or surgical options. Insurance companies often classify these treatments as elective, experimental, or cosmetic, despite literature and endorsements from leading medical and physician’s organizations debunking those assertions. There are certain expensive procedures, but the total lifetime additional expenditure consequent to a trans-identification is not probably much different than what gets spent on an individual with a “preventable” disease like diabetes. Having the cash on hand to pay for procedures equivalent in price to a midsize sedan is a tremendous burden to many trans individuals, especially if they are young, or lack familial support. Many fly overseas where US dollars go much further, but this places them at considerable risk of difficulty attaining follow-up care if they experience complications. Supportive care providers already use many tactics to maximize coverage on existing plans, such as use of generic language in billing and service reports. Insurance, I have learned, is likely to cover an office visit to “assess progress on hormone therapy,” whereas a more specific claim might get rejected. This is also not unique to the gender identity case; all physicians are increasingly subjected to scrutiny at every level, potentially undermining our prerogative to determine the medical necessity of any treatment to a particular patient, yet also demanding enhanced confidentiality.
Lastly, I will touch upon the interesting case in the news not that long ago, of an imprisoned woman in Massachusetts who sued to have her gender affirming procedures covered by taxpayer dollars. The details of the case are not important, but she was convicted as a male, and will not be leaving prison soon, if ever. At the time, there was debate over the perceived frivolity of such a procedure for a felon, which enhances misunderstanding and taints the legitimate discourse over all queer issues. This is where, as physicians, we can reduce barriers to care for every patient by correcting misconceptions whenever and wherever we hear them, even after work in our private lives. We must remember that it is not for us, and certainly not the press, to question the medical necessity of any procedure for a patient not directly under our care. Furthermore, we must assert ourselves to reframe the debate. Rather than ask, “Why should money be spent so prisoners can change their genders?” a better question would be, “How did we construct a country in which inmates receive public health coverage, while the working, law-abiding poor often cannot afford it?” Some forms of bitterness are entirely justifiable.
Part 6: The Ten Plagues
The plagues are a symbol of divine intervention, but they are also a test of strength and fortitude. The struggles of the gender non-conforming can be envisioned through each plague, and represent key points to consider while assessing a patient’s well-being. Blood is the awkwardness of coming out to friends and close family at the risk of their rejection. Frogs are the ugliness or disconnect one might feel with their own mirror reflection. Lice are the plague of infections, for which this group has increased risk. Flies and diseased cattle mark poverty and loss of one’s livelihood respectively, perhaps from discrimination at school or work. Boils require medical attention, from which this group faces distinct barriers. Hail strikes painfully; the world to any gender non-conforming person can be downright violent. Locusts represent the infinite swarm, among which it is inevitable to feel lonely. Darkness is the fear and depression, from which far too many find no escape. Taking away the first-born is accepting infertility—explicit or de facto—the realization that starting or sustaining families will be considerably more complicated now.
Part 7: Wading into the Water
Passover is not a story about succumbing to plagues; rather it is a story of faith, overcoming adversity, journeying into the unknown, and choosing to do more with your life than just herding sheep. The ability to provide comprehensive and compassionate care to queer individuals, particularly those of gender-variant and trans experience is a tremendously unmet need for the coming generation. Just as shifting public acceptance of homosexuality has prior, the tide of taboo will ebb here too, and uncover many new individuals from the sea banks who never mustered courage to address these issues before. Furthermore, the advent of digital cameras, internet, and YouTube video diaries have helped make accurate information and positive encouragement accessible to queer and questioning youth in a way that was unfathomable even a decade ago.
These will be our patients, and we will encounter them among every social majority, minority, economic class, status, national origin, and religious persuasion we treat. Anything we have covered in our Introduction to Cultural Competence Class still applies, and then some. We have the opportunity to provide a caring, professional, supportive environment, or ignorance will further alienate them from receiving future attention. As osteopathic physicians in particular, we recognize that health consists of a sound body, stimulated mind, and encouraged spirit. We treat to better expose all three, and we respect our patient’s inner truth above all, even if elements within one facet might surprise us in relation to the others.
A sea is intrinsically fluid, capable of filling all voids. The parted sea however, defying its own nature, is inherently unstable. Hopefully from this guide you have learned the basics of queer, trans, and gender-variant cultural competence. You will know how to swim when a new patient enters your care and the parted sea of the gender binary collapses around you.
Hannah Simpson is a transgender advocate, writer, educator, comedian, marathoner, traveler and unabashed nerd based in NYC. She speaks to schools, businesses, and even military bases on embracing trans and nonbinary identity. You might have seen her as a guest on Melissa Harris-Perry on MSNBC, or on WNYW Fox 5’s Good Day New York. Follow her on Facebook, Twitter @hannsimp, or Instagram @hsimpso.