Eenie Meenie Miney

I’ll be the first to admit that I have been left far behind in the vocabularic peculiarities that are now used to describe non-normative sexuality. Perhaps it’s Age, but more likely naïveté, that has led to this deficiency rather than lack of exposure.

I entered medical school in the mid-sixties when the youth were beginning to out themselves, and when some of the gloves were starting to come off -or maybe there was a growing awareness that a few of them had actually been wearing gloves. At the time -at least in my  school- Medicine seemed bicameral and only accepted two genders, male and female, with perhaps the door held slightly ajar for babies born with ambiguous genitalia or other genetic syndromes that made classification difficult.

For some of us, at least, it was a simpler time. Gender and sexual assignation were one and the same; preference as to which was really which was non-negotiable. But times and self-designation began to change; Medicine and the Law limped behind until the rift started to expose the consequences of their inaction.

I’d like to pretend that I saw these coming but, alas, I had no idea of the scope of the issue. In fact, in my mind, this straying from the norms was at best a marginal fashion. Anatomically, at least, we were what we had been assigned, and I assumed that perhaps the fullness of time and the machinations of society would iron any deviations into the acceptable crease. I had not reckoned with the discontent that enforced conformity might produce. When one has not experienced qualms, when one accepts the way the chromosomal dice have landed, it is not easy to grasp the uneasy restlessness of those few who will not play the game… or were not willing to join either team.

I say ‘few’ because I did not know; I did not understand. In time, of course, the discrepancies became too obvious to ignore in practice. At least in my gynaecological practice…

At first, there was confusion, I suppose -mine at first, perhaps- but theirs too. Not about their role, but mine. Initially, my lack of training forced me merely to listen, to empathize and then to help when and where I could. And, naïvely, I thought that was likely all that was required -and maybe all that they could reasonably expect. There was much psychological turmoil and disbelief that there was so little I could do, and yet I was relieved that I had heard them without disparaging their distress, or trivializing their problems.

But it soon became apparent that the eventual ramifications of their choices had the potential for far deeper consequences than either side had anticipated. And I’m not sure that I even appreciated the extent of the consequences of this disparity until after I retired. Only then, for example, did I come across an essay in the BBC Future series that touched upon some of the problematic issues. In an essay, Zaria Gorvett, a freelance science journalist for BBC, addressed the problem of why transgender people are ignored by modern medicine and what that might mean for their health: https://www.bbc.com/future/article/20200814-why-our-medical-systems-are-ignoring-transgender-people

‘[T]here are thought to be nearly a million transgender people living in the US… Rather than devising new ways to cope with changing social norms, transgender people are often shoehorned into inappropriate boxes instead.’

And the example she starts with is ‘a transgender man – he identifies as male but his biological sex is female. He has been living as a man for around 20 years… he is registered as a man on all his legal documents, from his passport to his medical records.’ All along, he had been taking small doses of the male hormone testosterone, but he suffered kidney failure and his condition deteriorated, therefore necessitating a kidney transplant. The criteria, for consideration of transplantation, however, differ between men and women and he lost valuable time in sorting out what criteria would apply to him.

As Gorvett points out, ‘When you factor in the large data gaps in everything from the average life expectancy of transgender people to the right dosages of medications for their bodies, along with the widespread lack of knowledge among doctors about how to address them – let alone treat them – and the high chance of them being refused treatment outright, it soon becomes clear that transgender medicine is in crisis.’

Indeed, in the UK, ‘“You can register as male or female, but you can still only choose between these two options – you can’t say if you are transgender or non-binary,” explains Kamilla Kamaruddin, a doctor who works for the National Health Service (NHS) and transgender woman. “So that’s quite difficult.” Or, if gender issues seem irrelevant to the visit, the patient may choose not to mention it, because of perceived stigma.

And, ‘The gender you’re registered as also dictates which screening tests you are invited to, meaning that thousands of transgender men could be missing out on potentially life-saving cervical (Pap) smears and breast exams, while transgender women could be missing out on abdominal aortic aneurism check-ups (or prostate cancer screenings, if they live in the US).’

Male and female physiology are different and many medications behave differently in each. ‘Females also have more sites for certain drugs to bind to, and are therefore more sensitive to them. They tend to clear them more slowly, so they are more susceptible to overdoses.’

Perhaps because of the stigma and subsequent lifestyle, ‘The group has higher rates of heart disease, certain cancers, mental health problems, suicide, smoking, and substance abuse than the general population – as well as an HIV prevalence which is  up to 42 times the national average. Transgender people are not only more likely to get sick, but less likely to seek treatment when they do.’

Still, I think we’re beginning to understand the problems they face. This gender dysphoria is an ancient condition, though, and actually gender fluidity may go back farther still. Gorvett writes about more enlightened recent attempts at assisting both with surgery and with hormonal replacement. The problem, however, is in the continuing stigmatization of those who are not mainstream. Those who do not fit neatly into societally condoned roles.

Maybe my age is tempering my reaction, or clouding my judgment, but I do wonder why there continues to be such marked antipathy to those who do not look like us, behave like us, or (gasp) think like us. Are we so insecure in who we are that we are threatened? And is it redress for the difference that we seek, an expectation of contrition? Do we really demand repentance, or is it homogenization?

I, for one, have come to think that the world would be a poorer place if we -the cis creatures- and we alone, were all that was on offer…