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…

Gender and Stress

Even the most ardent proponents of gender parity will admit that equality of opportunity does not imply equality of physiology. ‘The worst form of inequality is to try to make unequal things equal,’ as Aristotle said. Homogeneous –likeness, if you will- is not necessarily homogenous (a biological term meaning structurally similar due to common ancestry). Admittedly a semantically fraught distinction, it nonetheless suggests that there may well be differences that do not transcend gender.

For example, there seems to be a sexual discrepancy in the acquisition of post-traumatic stress disorder (PTSD)  http://www.bbc.com/news/health-37936514 -women tend to be more vulnerable to its development than men. A research team from Stanford University published a study in Depression and Anxiety (the official journal of the Anxiety and Depression Association of America) and it suggests that ‘[…] girls who develop PTSD may actually be suffering from a faster than normal ageing of one part of the insula – an area of the brain which processes feelings and pain. […]the insula, was found to be particularly small in girls who had suffered trauma. But in traumatized boys, the insula was larger than usual. This could explain why girls are more likely than boys to develop post-traumatic stress disorder (PTSD), the researchers said. The insula, or insular cortex, is a diverse and complex area, located deep within the brain which has many connections. As well as processing emotions, it plays an important role in detecting cues from other parts of the body. […]This shows that the insula is changed by exposure to acute or long-term stress and plays a key role in the development of PTSD.’ And as I quoted, the changes seem to be different in the two sexes.

The point of all this somewhat detailed background, is to submit that, as the study suggests, ‘it is possible that boys and girls could exhibit different trauma symptoms and that they might benefit from different approaches to treatment.’ Perhaps a sensitive counsellor would recognize this as the sessions continued, but it’s helpful to have some corroboratory evidence to justify any proposed changes.

I have to say that I was woefully ignorant of any sex difference in the development of PTSD. I’m embarrassed to admit that, if anything, I thought of it as largely a male condition –perhaps because of its association with war, and combat -traditionally at least, arenas of male predominance. But of course that is naïve. PTSD is not something confined to combat; it can be equally prevalent in other situations of distress or upheaval. Trauma is trauma, and long term issues can result from such things as natural disasters, car crashes, and certainly sexual or physical assaults, to name only a few. Because the symptoms can be confusing or even disguised, the diagnosis is best left to qualified practitioners, and yet I can’t help but wonder if a greater and more sensitive awareness of the possibility of the condition might encourage more sufferers to seek professional help.

As a gynaecologist, I feel uncomfortable and indeed far out of my depth in discussing most issues pertaining to PTSD, and yet thinking back over my years in practice, it seems to me that I may have suspected something of the sort, but lacked both the vocabulary and training to assign it a label –especially in those women I saw for conditions they suspected may have been attributable to previous sexual abuse: fears that they occasionally admitted to re-experiencing in unrelated events; things about which they still had nightmares; situations that led to unprovoked irritability and anger.

PTSD, by whatever name, has no doubt afflicted humans from time immemorial. Male hubris dictated that it be disguised or denied no doubt –it was a sign of weakness- and therefore unlikely to be mentioned in contemporary accounts. But signs of its presence occasionally snuck into mainstream literature -Shakespeare’s Henry IV being a likely candidate, for example. Perhaps more germane to my specialty, however, was the recognition of the lasting effects of trauma on people other than those involved in traditional conflict: women. The US Department of Veteran’s Affairs in its National Center for PTSD pamphlet states: ‘Most early information on trauma and PTSD came from studies of male Veterans, mostly Vietnam Veterans. Researchers began to study the effects of sexual assault and found that women’s reactions were similar to male combat Veterans. Women’s experiences of trauma can also cause PTSD.’ In fact they maintain that ‘The most common trauma for women is sexual assault or child sexual abuse.’ http://www.ptsd.va.gov/public/PTSD-overview/women/women-trauma-and-ptsd.asp

For too long have the lasting effects of sexual assault been ignored, or at best, trivialized and examined through male eyes in a still-male world. I don’t mean to sound like an overzealous feminist who pins all problems on male dominance, but I think age and a career spent in women’s health grants me a unique –if still masculine- perspective. As with all things, specialists run the risk of deconstruction, overanalyzing the events often with the consequent subversion of their apparent significance -almost a form of historical revisionism, an unintentionally biased and often contextually barren interpretation. One bridge, when crossed by a thousand people, becomes a thousand bridges –we all see the world through our own experiences, our own expectations, our own prejudices.

I think the fact that we can now demonstrate that there are valid reasons to question those often unconscious assumptions is a cause for hope. Much as we have finally realized that the results of many studies carried out only using men cannot necessarily be mindlessly extrapolated to women, so it is becoming increasingly apparent that trauma and its effects may also be non-generalizable. Although not its prisoners, we are after all, creatures of a chromosomal lottery, divergent physiologies, and certainly of different past experiences, so why wouldn’t there be a spectrum of responses to stress?

So, is there a ‘man-cold’? Well, maybe… I know that’s the kind I get, anyway.

 

 

 

 

 

 

 

 

 

 

 

Folk wisdom sometimes gets it right: there is a man-cold… Well, maybe.