Archive for the ‘ Medical ’ Category

On conscience-based medical exemptions

The College of Physicians and Surgeons of Ontario is currently reviewing its Human Rights Code policy on conscience-based exemptions for medical professionals, and their effect on access to medical services.

This review was sparked by a number of news reports of doctors in Ontario and Alberta refusing to prescribe birth control because of their religious beliefs. In some of those cases, patients were refused in clinics where there was only one doctor on duty.

Concurrently, south of the border, the United States Supreme Court ruled in favour of a corporation’s right to deny medical insurance to its employees when doing so would violate the owners’ religious beliefs — a case that was specifically about access to contraception. The Hobby Lobby case has been followed by several new attempts to widen the exemption, and calls to extend it to other sectors and in ways that would allow businesses to refuse service to LGBT people.

These events reflect a major shift in the way that conscience rights are being seen and applied in North America.  It is my hope that the experiences of trans* people in Alberta with conscience-based medical exemptions might provide some insights for those considering a conscience policy review in Ontario.

Alberta has had a policy for some time which allows a doctor to refuse to prescribe treatments that violate their religious beliefs in non-emergency situations. However, they are required to state that the refusal is because of their religious beliefs, and to provide a timely referral for patients to someone who will provide care, so that patients still receive service and experience a minimum of undue hardship (although to be fair, having to jump through referral hoops can be considered an undue hardship of itself, especially when one factors in the difficulties in scheduling time off from work and other real life concerns).  Ontario’s policy is similar, though not identical.

Alberta’s policy was created to protect medical professionals from having to participate in any situation that might lead to an abortion.  But in the past year, there has been an upsurge of discussion about the need for a religious or conscience-based exemption in every sector and every practice.  Access to birth control is one of the pivotal issues in play in that discussion, although it is not the only one.

As an advocate for transsexual and transgender people, I’ve needed to assist a great number of people over the years who’ve been denied medical services because they’re trans* under Alberta’s conscience exemption policy.  Sometimes people have even been denied services for things like urinary tract infections, routine checkups and cases of the flu.  To be fair, the conscience exemption is not the only factor: denials are sometimes made by doctors who say they’ve never been trained in trans* health — although this complaint is made not only in regard to trans-specific health concerns, nor does there appear to be a willingness to learn from many of those doing the refusing.

Most often, trans* people who are refused care are also not provided a referral to anyone else.  This exploits the public’s unfamiliarity with this part of the law, and that they’re entitled to a referral.  It is certainly not every medical professional who refuses to assist, but it occurs frequently enough that the trans* community has had to try to keep a list of “trans-friendly” doctors — a list that is constantly plagued by doctors no longer being able to accept new patients, or making changes in their practice or habits.  I’m always happy to add doctors to the list, with the only requirement be that they adhere to the WPATH Standards of Care (which is also the policy of Alberta Health Services).  Two years ago, someone obtained a copy of our records and stormed into the offices of several listed clinics in Calgary, raising a ruckus about doctors’ willingness to treat trans* patients, and this resulted in several requests to be removed from our list.

Although commentators sometimes note theoretical possibilities like a Jehovah’s Witness practitioner denying blood transfusions, I can say from experience that conscience policies already can and do result in people being denied access to the care they need… and are not always given “timely” alternatives.

I am sensitive to a person’s right to opt out of something because their conscience, and not just a religious-based conscience.  However, in practical experience, exemptions tend to be abused, and marginalized people pay the heaviest price.  If there is to be a conscience-based exception to medical care, a province also needs to have a much better way of coordinating timely and accessible care alternatives, and better enforce the responsibility to provide those alternatives.  In Alberta, this is difficult, since there is no centralized means of communicating with medical professionals and provide some forms of training after they’re already in the field, short of making laws — so strengthening things at a policy level proves difficult.

With the recent shift of thinking among the religious right toward making provinces “abortion-free” and denying access to previously uncontroversial things like birth control, this issue will worsen in coming years.  If there is to be a conscience-based exemption to medical care, provinces need to seek a solution to the policy quandaries this creates now.  For example, if a walk-in clinic’s only physician on duty  will not prescribe contraception, then it’s worth investigating what responsibility the clinic should have in providing a doctor who will, and in a manner that suits the patient’s needs, rather than the doctor’s.

Or what responsibility the province is taking upon itself by sanctioning health care exemptions.

(Crossposted to Rabble.ca)

Nova Scotia Extends Health Care Coverage for Reassignment Surgery

After originally saying that it would not fund genital reassignment surgery, the Nova Scotia government has now said that it would extend health care funding coverage for the procedure.

Health Minister Dave Wilson is quoted as saying, “This is the right thing to do.”

I’ve written previously about why GRS is recognized as being medically necessary by medical experts, specialists in trans health, social agencies and human rights organizations.  Here is a snippet:

… There is more. Current legislation asserts that most forms of identification and legal documentation can only be changed to reflect one’s new gender after surgery has been verified. Without GRS, many pre-operative transsexuals experience severe limitations on employment, travel beyond Canada’s border, and treatment in medical, legal and social settings in which verifying ID is necessary. Prior to GRS surgery, transsexuals also face limitations on where they can go (i.e. the spa or gym, or anywhere that involves changing clothes) and difficulties in establishing relationships — as well as being in that “iffy” area where human rights are assumed to be protected, but have not yet been specifically established as such in policies and legislation. In hospitals, prisons and such, they are housed by physical sex rather than their gender identity, creating potentially risky situations, unless the authorities directly involved choose to keep them in isolation instead. And at the end of the day, without GRS surgery, one’s gender is always subject to being challenged or stubbornly unacknowledged by those who don’t realize that a transsexual’s gender identity was not a matter of choice. There is also an extremely high risk of violence faced upon the accidental discovery that one’s genitalia does not match their presentation.  No other supposedly “cosmetic” issue so completely affects a persons rights, citizenship and safety…

This is the fulfillment of several years of work for Nova Scotian trans people.  While details of the program are not yet known, the community had been advocating for comprehensive trans health coverage:

This points to a trans* health care model that includes, but is not exclusively reliant upon, SRS; that is driven by the individual and their particular requirements; that serves all of the trans* community, including those who do and those who do not seek SRS. This is exactly the kind of culturally competent, patient driven, community health care model that both Minister Wilson and his predecessor, the Hon. Maureen MacDonald, have been advocating for Nova Scotians. This is exactly the model that we, as a community, should be asking for.

Nova Scotia also recently added trans people to that province’s human rights legislation.

In a note on Facebook, Kevin Kindred and the Nova Scotia Rainbow Action Project are encouraging people to contact their MLA and send letters of thanks and support.

Most Canadian provinces provide some form of funding for GRS, now (albeit sometimes imperfect) — only New Brunswick and PEI do not.  Attempts to defund GRS have been met with sustained pressure from the public and human rights complaints, with Ontario delisting coverage in 1998 (restoring it ten years later), and Alberta delisting funding in 2009 (restoring it in 2012).

(Crossposted to Rabble.ca)

The non-operative word is not “sorry.”

I’m going to be writing about transition regrets and/or reversal of transition (sometimes from folks who remain trans-identified).  Before I do, though, it seemed necessary to finish and put this article out there, as it lays the groundwork.  I’d written about the decision to be non-operative previously, and had intended to leave it at that, but it remains one of the most hotly-contested and misunderstood subjects that I touch upon.

When it comes to genital reassignment, the non-operative word among trans people should not be “sorry.”

That’s not a very popular statement in transsexual communities.  But as much as I don’t like “rules” for being trans, I have arrived at one guideline:

Do as much or as little as you need to achieve the peace that you need.

It’s not quite that clear and simple, of course, especially given the pressures to conform and integrate as either male or female, which have been idealized as binary opposites in society.  Trans (that is to say, both transitioning from one sex to another and/or living between genders) challenges those absolutes, but it’s also a lot to ask, for someone to remain a life-long challenge to society.  And phrasing it as a “pressure to conform” oversimplifies something that also includes fears about going swimming or to public places of semi-nudity, going through airport scanners and traveling internationally, being in sex-segregated spaces like homeless shelters or correctional facilities, or the possibility of being challenged in a public restroom.

Relationships can also factor into the equation.  Genital reassignment surgery is inevitably going to change a dynamic within intimate relationships, and raise questions about our sexualities and those of our partners.  While the decision for or against GRS shouldn’t be dictated or coerced by our partners, when we love someone, it’s inevitably going to be on our minds.  Some individuals will be able to consider foregoing surgery as an act of love and sacrifice, while for others it would be far too much to ask — we’ll see why, shortly.

Another factor that blurs the lines is the fact that we live in a nation where our enfranchisement in society is largely affected by our identity documents.  In Canada, only the Province of Ontario has a provision to change a birth certificate without multiple verifications of surgery — and in many provinces, the same is true of lesser documents like driver’s licenses.  While our Social Insurance card does not display a gender marker, potential employers can do an S.I.N. check which displays a gender marker in the resulting report — and that, too, cannot be changed without a new or amended birth certificate.  When our ID is incongruent, it potentially exposes us to harm and/or discrimination when we’re carded, and at many other stages of just trying to live and work and access services.  At no other time is a person’s enfranchisement in society dependent on them having surgery.  But because that is the status quo in Canada and most parts of the U.S., it will inevitably be a point of consideration, for the time being.

Medical issues can also be factors affecting whether one can or can’t obtain surgery.  This might take the form of a serious health condition that precludes undergoing other procedures (some of these — such as diabetes or HIV — can be worked around by finding surgeons with better hospital access, but other conditions can be completely prohibitive).  It might also refer to fear of undergoing a major invasive surgery, an aversion to the medical process overall, a desire to wait until techniques improve, or living in a province where GRS is not funded and not being able to afford it.  Occasionally, health care funding is an influence for GRS, such as situations where vaginaplasty or phalloplasty are funded by insurance while orchiectomy, metoidioplasty or other options are not.

But for the moment, let’s put all of these things — health, cost, relationships, social pressures, legal identification and enfranchisement — aside.  In an ideal world, the decision to have surgery should hinge on an individual’s needs and the advice of their doctor.

This may seem a little confusing for people who have read my writing about surgery being a medical necessity.  I still maintain that its availability is, and that when surgery is necessary for an individual, it is an absolute necessity.   Relationships and legal enfranchisement obviously underscore this need, and there is also an economic benefit to resolving gender identity conflicts, so that a person is better-able to function and be productive.  But it’s also important to remember what GRS is designed to do:  alleviate distress.

Gender dysphoria encompasses a number of aspects: body dysphoria (in which genital configuration causes anxiety, revulsion, discomfort, or simply unease), social dysphoria (in which the social dynamic that we experience with people is ill-fitting), and self-identification (the inner core of who we are and the face we need to present to the world).  Each of those can vary in degree, and trans individuals can experience an emotional, psychological and/or even physical distress and anxiety about their body.  Living as the gender we identify with will often alleviate the social dysphoria and self-identification conflicts… only surgery addresses the body squick.

Body dysphoria is not always a conscious thing, but can be experienced as a discomfort or aversion to the genitalia, or a sense that those parts are out of place and don’t make sense to be there.  At the most extreme, this aversion becomes even violent, driving a person toward self-harm or self-destructive behaviour.  For people who experience it less severely, it can be a discomfort toward sexual intimacy in general, or a feeling of being out of place, without being completely clear on why.  Obviously, in these situations, it makes sense to align the body with what a person understands that they need to be.

At the lower end, the stress may not be as urgent, although a sense of closure might still be needed.

Not everyone experiences this.  Sometimes transition alone, minus surgery, is enough to resolve a person’s dysphoria, while other factors pose more significant reasons not to have surgery.

Non-operative trans women are sometimes considered button-pushing because they challenge the traditional trans narrative (there is often an exception made for trans men because of the limitations of phalloplasty and metoidioplasty procedures), in the same way that some bisexual people are unfairly seen as a challenge to the “born this way” narrative of sexual orientation.  The idea that we are fixing a predominantly medical condition seems undermined by the existence of people who don’t want to completely “fix” their bodies through surgery.  And yet, individuals exist who genuinely need to transition and live as their identified sex, but don’t urgently need or want GRS.

In transsexual culture, there seems to be this perspective that all roads lead to the holy grail of GRS, and that after one has the surgery, one has “arrived.”  Part of the reason that so many post-operative trans women and trans men leave the community is because once they’ve reached that point, the weighty discussion about GRS is no longer relevant to them.  The GRS-heavy direction has also tended to exclude non-operative and other trans people, because of the implication (intended or not) that they “must not be real” if they choose not to pursue surgical methods.

Yet GRS was only ever supposed to be one step toward self-resolution.  It’s neither all-completing, nor is it always a final endpoint (and this calls for a discussion of post-traumatic / minority stress), although it does have the ability to bring closure when that body distress exists.  By comparison, cissexual (non-trans) women never stop discovering what it means to them to be a woman; cissexual men likewise.  One does not “arrive” simply from the flick of a scalpel.

The basic reality of the trans condition is that our bodies do not define us.  If we allowed that to happen, we’d have never been able to start a transition — we would still be living in the misery and shame of having to live up to everyone else’s expectations.

The trouble with a heavy (or exclusive) focus on GRS as the “endpoint” of our transition is that we can become so intent on becoming “wholly” female or “wholly” male that we abandon, hide or feel ashamed of characteristics and histories which make us truly unique, perhaps instead embracing stereotypes.  It’s important that surgery does not become a case of simply trading one mask for another.

The overarching focus on surgery also does people an injustice, as it means that we fail to talk about bodies, hygiene issues, sex, the down-sides of post-operative care, and those things that we fear might cause a person to stray from the One True Path™ of GRS, or have doubts.

And sometimes –oh, not for everyone, but sometimes — non-operative-by-choice trans people arrive at a point of personal resolution from transition alone, and find that they can take pride in how unique they’ve become.  That perspective is hard-won.  It’s a shame to bury it.  Once in awhile, it’s important to embrace one’s uniqueness, and take pride in it.

Anyone who fails to understand this needs to take themselves out of the comfort zone of their own experiences, for a moment, to remember that one size rarely fits all.  Because the non-operative word is not “sorry.”

In the end, we are who we need to be.  Nothing else matters.

(As I was wrapping this up to post, Helen at en|Gender pointed to Non-Op.  For those who want to know more, it looks like an interesting resource.)

(Crossposted to The Bilerico Project)

About that “GID is removed from the DSM” thing…

Oh god, please make it stop.

Yesterday morning, I woke up to a rash of headlines proclaiming that transexuality was no longer considered “disordered” by the American Psychiatric Association. This morning, it grew worse, with a rash of panicked emails from people who were wondering if their medical access would be jeopardized, after some LGBT and even mainstream news sites and blogs reported this as meaning that “Gender Identity Disorder” (GID) will no longer be considered in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), or had been “removed” from the DSM altogether.  No, it hasn’t.  That’s not true at all.

I hate to be a wet blanket, but the change that’s being heralded is mostly just in name, and “Gender Dysphoria” remains in the DSM — and in the “Sexual and Gender Identity Disorders” category (although that name may change too), if I recall correctly, of a manual that governs mental health.  The parallel being drawn to when homosexuality was removed from the DSM wildly overstates this change.

And because it has not been completely removed (something I’ve previously cautioned about the risk of doing too hastily, regarding both the DSM and ICD volumes), peoples’ medical processes are not affected in any way.  The panic I’ve heard from some people wondering if their medical treatment will be hindered is unfounded.

There is something to see here, though:

There is a positive in this, though, in that people are finally paying attention to the problems associated with another DSM category: Transvestic Disorder (formerly Transvestic Fetish). When the alarm was raised about Drs. Ray Blanchard and Ken Zucker having administrative roles in the DSM revision, that protest lost some steam when the APA announced that Zucker would be in an oversight position rather than hands-on, and Blanchard would be working on a separate category not related to GID (Paraphilias). Some of our allies decided we were making much ado about nothing.  Now, people are perhaps realizing the problem with that arrangement, in that it gave Blanchard full license to develop Transvestic Disorder (TD / TF).

A few trans advocates (including Kelley Winters, Julia Serano, and myself) have cautioned about the problems with regard to TD / TF and what could happen if that diagnosis is expanded in scope while GID diminishes or is eliminated.  Well, indications thus far are that Transvestic Disorder has certainly been expanded, and evolved to encompass Ray Blanchard’s theory of “autogynephilia” as a subcategory (plus the addition of “autoandrophilia,” to make it an equal-opportunity pathology).  All that anyone really needs to do to technically qualify for this diagnosis, as Serano notes, is to be “sexually active while wearing clothing incongruent with their birth-assigned sex.”

This diagnosis sexualizes and invalidates, and frankly, it has become a wide, sweeping pathology encompassing a significant amount of non-harmful behaviour.

Backgrounder: The Little Case Study That Autogynephilia Forgot

(Crossposted to The Bilerico Project)

One More Thing.

Oh, and, uh, here’s one more thing.

This is for Albertan trans folks who filed human rights complaints following the delisting of GRS funding in 2009 and on into 2012,

Who’ve been lobbying through up to (I think it’s) five tries to pass trans-inclusive human rights legislation at the federal level,

Who called or visited your MP,

Who called or visited your MLA,

Who joined us on the Legislature steps,

Who told your stories despite the risk of being out,

Who showed Alberta people, instead of myths,

Who wrote letters,

Who allied and mobilized even if you’re not trans and don’t fully understand the experience,

Who took the time to read and find out more, rather than stick to old misconceptions,

Who organized,

Who worked behind the scenes and may or may not get public credit for it,

Who gave us the opportunity to speak,

Who supported us in the Legislature and Parliament from the beginning,

Who came to understand how our minority issues intersect with and run parallel to others’,

Who rode the ups and downs and tried not to lose hope,

Who marched.

You did this.

This is how a movement begins.

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