Dr Cary Gabriel Costello

Dr Costello writes in his blog entry, Intersex Fertility, that “My daughter was not of woman born. That is a concept that has fascinated people through the ages. My daughter’s gestation was perfectly ‘natural,’ I should point out–but I carried her, and I was never of the female sex; I am a so-called ‘true hermaphrodite.’ I was assigned female at birth, and was living as such when I gave birth to her, but I never identified as a woman, and am now legally male.”

He continues, “I’m glad that I was able to become a parent, but believing that this should have ‘cured’ me of my distress with my assignment is magical thinking along the lines of believing that procreating will ‘cure’ a lesbian or gay man and make them heterosexual. Gender identity, sexual orientation, and procreative status are independent characteristics. Lesbians and trans men and intersex individuals aren’t mystically “converted” by pregnancies. Gay men and trans women and intersex individuals who inseminate someone aren’t thereby made straight or cis or dyadically-male-sexed.”

He concludes: “Most of us who do reap the rewards of fertility do this in private, with no medical journal articles trumpeting a star in the east. In fact, some medical ‘corrections’ of our physical differences render us infertile, and I don’t see why that’s treated as unimportant when doctors are so very willing to write articles about their ‘cases’ who do prove fertile. And the magical thinking behind the idea that doctors can validate a sex assignment through the intersex person contributing the ‘correct’ component, egg or sperm, to a conception just boggles my mind. It’s time for some more sophisticated thinking about intersex fertility.”

I couldn’t agree more. Ready more about Dr Costello, his experiences and his scholarly opinions regarding intersex and trans issues on his blogs:

• http://intersexroadshow.blogspot.com/
• http://trans-fusion.blogspot.com/

Here’s an excerpt:

The concert hall at the Syndey Opera House holds 2,700 people. This blog was viewed about 14,000 times in 2011. If it were a concert at Sydney Opera House, it would take about 5 sold-out performances for that many people to see it.

Click here to see the complete report.

“My Little Buster,” the distraught mother writes, “I’m so sorry. How else do I begin this?… As a parent, there will be a million things you will look back on and think ‘Gee… I wish I would have done that differently…’… But how in the hell do I apologize for having part of your genitals amputated for NO MEDICAL REASON? When you were less than 24 hours old!… So for all of the parenting moments I look back upon, wishing I could re-do, having you circumcised is the only one I have utter remorse for. With much, much love, Your Mommy.”

The post struck a cord in me because I too carry this burden, and I echo the sentiments of this mother.

When my son was born in 1998 — in my former life as a closeted, gay, married, mechanical engineer — my ex-wife and I had little discussion on the matter. I am circumcised, my father is circumcised and her father and brother are circumcised. Why wouldn’t we do to our son what was a norm for our family? We didn’t understand the risks. We didn’t understand the permanent damage that we were condoning. We did not understand the history of circumcision in the U.S. nor its root in puritanical aims to deter masturbation. We were simply uninformed and did not understand the gravity of our decision to circumcise our son.

Now it is too late. We stole that choice from him and his body is permanently altered. I have apologized to him. The tears ran down my cheeks. He has forgiven me but at his young age he cannot comprehend the consequences of that decision. Do not repeat our mistakes. Leave your sons whole as nature/god intended them to be. Allow them the autonomy over their bodies that is rightfully theirs alone. Let’s end this barbaric custom of infant genital mutilation!

- James Pate, MD

American Grotesque posted The Genocide of Intersex People on 11/28/11. I recently came across it while catching up on twitter and facebook during my holiday break (a true luxury for a resident!). In this post the author discusses the damage perpetuated by the myth of binary gender, its social construction and legal ramification. The author places hir-self in the place of “patients” whose bodies defy the myth and without consent are reconstructed to appear to confirm it. Yet in spite of appearances they remain outside of the binary and their shame and scars and are shrouded in secrecy and silence. Is this moral? Is this fair? Is this just?

“Our lives begin to end the day we become silent about things that matter. [And] In the end, we will remember not the words of our enemies, but the silence of our friends.” ―Martin Luther King Jr

Dear Dr Pate,

I was born with a DSD. Is penoscrotal hypospadias with severe chordee an intersex condition? Am I intersexed?

- J

Dear J,

Your questions are more difficult to answer than one would think. The term “intersex” has changed in meaning over time, more so among doctors than perhaps many who consider themselves to be intersex. From a medical point of view, your condition would not necessarily have been considered an intersex disorder in the past. However, an international consensus reclassified disorders with either abnormal sex chromosomes (ie XO, XXY) or atypical genitalia under the umbrella term “disorders of sex development” (DSD) in 2006. Given that hypospadias is a condition where development of male external genitalia is halted prematurely, this is indeed a DSD. The term “intersex” however is no longer considered to be a contemporary medical word and has been replaced by DSD.

Adults who consider themselves to be intersex generally have a history of ambiguous genitalia, may or may not have been subjected to “normalizing” genital surgeries in infancy and/or childhood, but do not feel that they fit neatly into the binary boxes of male or female. They usually feel that if surgery occurred that it was undesired and destructive. Their gender identity may be the same as their sex of rearing, opposite, a combination, or something else. Adults who identify as intersex are generally offended by the new medical nomenclature “DSD”; they do not feel that their sex is disordered but rather a natural occurrence within the human spectrum. They are also quick to point out that they are not transgender or transsexual and do not feel that they are a part of those communities. Unlike the trans communities, they feel that their gender identities match(ed) their bodies, though they may not match their surgically altered bodies nor the sex of rearing that was chosen for them. The intersex community is still rather small given the shame, embarrassment and mistreatment individuals were subjected to while growing up as well as the continued ignorance of society regarding their existence.

People that continue to be born with chromosome abnormalities and/or varying degrees of genital ambiguity may feel that they are either truly male or truly female with a DSD medical condition, not intersexed. On the other hand, if their gender identity is the opposite of their sex of rearing then they may consider themselves to be trans. Others feel more comfortable with an intersex identity. Thus the matter of what is considered an intersex condition and who considers themselves to be intersex remains quite murky.

There are intersex groups that exist online and occasionally meet in person. If you are interested in chatting with others like you I would recommend checking out Organisation Intersex International (OII). They are “devoted to systemic change to end the fear, shame, secrecy and stigma experienced by children and adults through the practice of non-consensual normalisation treatments for people born with atypical anatomy, and the arbitrary assignment of a particular gender without an informed consultation with the individual concerned.”

Hope this helps and good luck to you. Happy holidays!

Sincerely,

James Pate, MD

Ob-Gyns: Prepare to Treat Transgender Patients

Washington, DC — To address the significant health care disparities of transgender individuals and to improve their access to care, ob-gyns should prepare to provide routine treatment and screening or refer them to other physicians, according to The American College of Obstetricians and Gynecologists (The College). In a Committee Opinion published today, The College also states its opposition to gender identity discrimination and supports both public and private health insurance coverage for gender identity disorder treatment.

Although the total number of transgender people in the US is unknown, studies suggest they make up a small, though substantial, population. Transgender is a broad umbrella term that includes people whose gender identity and/or gender expression differs from their assigned sex at birth. Female-to-male, male-to-female, crossdressers, bi-gendered, and intersex are the major groups that fall under the term transgender.

“Transgender patients have many of the same health care needs as the rest of our patients,” said Eliza Buyers, MD, former member of The College’s Committee on Health Care for Underserved Women who helped develop the new recommendations. Health outcomes for the transgender community are very poor due to their lack of access to health care, noted Dr. Buyers. “It would be wonderful if all transgender patients had the resources to be seen in a specialized clinic, but the reality is that many forgo care because they don’t. By increasing the number of ob-gyns providing care to transgender patients we can help improve the overall health of the transgender community.”

Transgender individuals who were assigned female sex at birth but are now living as a male will continue needing breast and reproductive organ screening, unless they’ve had mastectomy or had their ovaries, uterus, and/or cervix removed. Male-to-female individuals who have had genital reconstruction may need cancer screening of the neovagina and breast cancer screening if taking estrogen hormones.

“Services that ob-gyns should be able to offer transgender patients include preventive care, Pap tests, sexually transmitted infection (STI) screenings, and hysterectomy for standard indications like heavy bleeding or pain,” said Dr. Buyers. The College recommends ob-gyns first consult with transgender experts before performing hysterectomies as part of gender affirmation surgery. “Hormone replacement can be managed in consultation with experts in transgender care, as many patients will seek hormones on the black market if unable to obtain them from their providers.”

Many, if not most, transgender people face social harassment, discrimination, and rejection from family and society in general. Many of them are homeless, particularly youth who identify as transgender. Transgender individuals are at an increased risk for sexually transmitted infections (STIs), including HIV, and physical abuse.

“We need to make our offices settings that treat all patients with respect,” said Dr. Buyers. The College offers ob-gyns suggestions on how to create an office environment that is welcoming to transgender patients. For instance, asking patients their preferred name and pronoun, posting non-discrimination policies, ensuring confidentiality, and offering sensitivity training for staff are all steps that signal acceptance and let patients know that they will be treated with dignity. “We want the transgender community to know that we, as ob-gyns, care about their health.”

Committee Opinion #512 “Health Care for Transgendered Individuals” is published in the December 2011 issue of Obstetrics & Gynecology.

The Rio Political Declaration on Social Determinants of Health was subsequently adopted with “five key action areas critical to addressing health inequities:

1. To adopt better governance for health and development
2. To promote participation in policy-making and implementation
3. To further reorient the health sector towards reducing health inequities
4. To strengthen global governance and collaboration
5. To monitor progress and increase accountability

“We, Heads of Government, Ministers and government representatives, solemnly reaffirm our resolve to take action on social determinants of health to create vibrant, inclusive, equitable, economically productive and healthy societies, and to overcome national, regional and global challenges to sustainable development. We offer our solid support for these common objectives and our determination to achieve them.”

As healthcare continues to evolve in the U.S., more and more “midlevel practitioners” are taking on roles formerly provided by physicians. Examples of midlevel practitioners include the physician assistant (PA), doctor of pharmacy (PharmD) and advanced practice registered nurses (APRN) such as the certified nurse midwife (CNM), nurse practitioner (NP), certified nurse anesthetist (CNRA) and doctor of nursing (RN, PhD). Some of these providers may be unintentionally called “doctor” or request that their patients refer to them as such, however it is very important to recognize that they are NOT equivalent to — or substitutes for — the traditional physicians of Western medicine.

What is a doctor?

According to Merriam-Webster, the word “doctor” literally means “teacher”. Given that around 700 years have past since its first use in the 14th century, its modern meaning includes both the academic doctor of philosophy (PhD) as well as the healing art doctors of medicine (MD), osteopathy (DO), podiatric medicine (DPM), dental surgery (DDS), chiropractic medicine (DC), naturopathic medicine (ND) and veterinary medicine (DVM).

What does it take to be a physician?

As delineated above, there are many paths to gaining the title but the training involved and the credentials earned are not equivalent. In Western Medicine there are only 2 types of physicians: the MD and the DO. While they arise from independent roots (allopathy vs osteopathy respectively), the training involved is essentially the same except for minor details that occur during medical school. To become a physician we all must take the same arduous path.

• Pre-medical school
• Completion of a Bachelor’s Degree – A 4+ year process in any field of study including the sciences (BS) as well as the arts (BA or BFA). A competitive GPA is generally felt to be 3.6 or higher.
• Prerequisite course work – Must be completed in biology, chemistry, physics and math in addition to regular course work.
• The Medical College Admission Test (MCAT) – Administered by the Association of American Medical Colleges (AAMC), the MCAT “is a standardized, multiple-choice examination designed to assess the examinee’s problem solving, critical thinking, writing skills, and knowledge of science concepts and principles prerequisite to the study of medicine. Per the Princeton Review, it is a “5-1/2 hour, computer–based test that has the reputation of being one of the most challenging standardized tests.” Over the past 2 years (2010-2011) the average score has been 25 out of 48 possible points. A competitive score is generally felt to be 30 or higher and only around 1/3 of test-takers will achieve this score.
• Other considerations – Competitive GPA and MCAT scores alone are not enough to ensure admittance to medical school. Other considerations include experiences in leadership, community service, medicine and research as well as letters of recommendation, your personal statement and of course how well you interview.
• Chances – According to the American Medical Association, “For the 2010-2011 entering class, U.S. medical schools received 580,304 applications from 42,742 applicants, an average of 14 per applicant. There were also 31,834 first-time applicants—up 2.5 percent from 31,063 in 2009-2010.” The AMA also noted that, “American allopathic medical schools enrolled 18,390 first-year students for 2009″ and “nearly 13,000 applicants competed for 5,100 available slots” in osteopathic medical schools. So given 23,490 total positions and 55,742 applicants, the chance of acceptance based on these numbers alone is 42%.
• Medical school – Another 4+ year process for those fortunate enough to gain admittance. Medical school serves to form the foundation of medical knowledge that we build upon in residency. It costs an average of $30,000 per year for tuition alone; it does not include books, supplies and living expenses. Can you drink water from a fire-hose? That’s what it feels like being deluged with information, struggling to retain it and continuing to compete against peers. How well we do has a direct effect on our ability to obtain a residency position not only in a location of our choosing but also in the field of our choosing – surgical residencies (general surgery, OB/GYN, urology, etc) are more competitive than medical residencies (family medicine, internal medicine, pediatrics, etc). In addition there are 2 more standardized tests we must complete — the United States Medical Licensing Examination (USMLE) steps 1 and 2 — that along with yet another personal statement, more letters of recommendation and interviews are evaluated for residency positions. We obtain either the MD or DO degree when we graduate from medical school depending on the program.
• Residency – All residents are doctors given that we have completed 8+ years of higher education and have graduated with the degree from medical school. First year residents are commonly referred to as “interns”. Residency serves as a kind of apprenticeship or on-the-job-training and thus, in spite of our extensive education, we actually make less money than the nurses with whom we work. Residency can be as short as 3 years or greater than 5 years depending on the chosen specialty.
• Fellowship – For those of us who want to sub-specialize, yet another level of training awaits (the fellowship) with its own process of evaluation and competition. Those of us who do not complete a fellowship are loosely referred to as “generalists” and those who do so are called “specialists”.

All in all to become a physician you are looking at a minimum of 11 years of rigorous higher education: a bachelor’s degree (4+ years), medical school (4+ years), residency (3+ years) and possible fellowship (1+ years). Now that we have explored what it means to be a physician of Western medicine, let’s discuss the process of becoming a midlevel practitioner.

Types of degrees

• BA/BFA/BS – Bachelor of arts/fine arts/science (4+ years)
• MA/MS – Master of arts/science (2+ years following a BA/BFA/BS)
• PhD – Doctor of philosophy (4+ years following a BA/BFA/BS)

Physician extenders

• Physician assistant (PA) – 6+ years (BA/BFA/BS plus MS in physician assistance).
• Nurse practitioner (NP) – 6+ years (BS in nursing plus MS in nursing).
• Certified nurse midwife (CNM) – 6+ years (BS in nursing plus MS in midwifery).
• Certified nurse anesthetist (CNRA) – 6+ years (BS in nursing plus MS in nurse-anesthesia).
• Doctor of nursing (RN, PhD) – 8+ years (BS in nursing plus PhD in nursing).
• Doctor of pharmacy (PharmD) – 8+ years (BA/BFA/BS plus PhD in pharmacology).

Now I’m really not trying to dis on my fellow healthcare providers. In truth PAs, APRNs and PharmDs are needed to improve the accessibility of healthcare to citizens around the country. I am merely trying to point out that large differences remain between midlevel providers and physicians: their training is less comprehensive, less rigorous and certainly less competitive. To compare the two is to compare a Lexus with a Kia: both are cars but their builds are very different.

Why does this matter?

A recent data brief from the National Center for Health Statistics (NCHS) arm of the Centers for Disease Control and Prevention (CDC) noted that over the past 8 years (periods 2000-2001 to 2008-2009):

• Outpatient visits attended only by APRNs have increased by 50%
• People that live outside of major cities are 6 times more likely to be seen by a midlevel practitioner
• Midlevel practitioners are utilized heavily by general medicine (21%) and OB/GYN (19%) compared to pediatrics (8%) and general surgery (6%)

Summary

As we move forward in the improvement of healthcare delivery in the U.S., it is important that we don’t lose sight of quality as we push for quantity. Most aches and pains and even chronic conditions can be (and probably should be) managed by physician extenders, however under the supervision and guidance of the physicians from whom they extend. To permit the practice of medicine without the physician is egregious and frankly dangerous. The next time you see your “doctor”, make sure you understand what kind of “doctor” s/he is. If you are seeing a midlevel provider, inquire about the supervising physician and how s/he is involved in your care. If there is no physician involved I highly suggest that you find yourself a real “doctor” or be prepared for the increase in medical error that will inevitably come. And in response to Mr Riley, quoted above, I would caution: Beware the decoys! They have become quite sophisticated.