Gender Transition a Question of Ethics?

Transition (literary journal)

I read an article by an ethicist who answered a question in the New York Times about the morality of gender transition pitted against the harm it may cause a family.  It is a Hobson’s choice, really, as there is no good answer in the end.  But, I guess that’s why ethicists get paid the big bucks.

Gender transition is selfish. No doubt about it.  But,  so is just about any medical treatment, alcohol recovery for instance.  Gender dysphoria might just as surely kill you as alcoholism in my experience.  Yes, I had both, and after several years of living in the proper gender and in recovery with all of the attendant hardship, heartbreak and happiness, I am perhaps uniquely qualified to say that both are a means of survival.  I had to do both, or neither would have saved me from myself, so bad was my sense of demoralization and hopelessness.

Yet, behind me lies a trail of loss, separation and broken relationships.  My decision to transition hurt other people whether or not their reaction may be perceived as just or warranted.  Thus, I might be rightly asked whether it was the right thing to do.  Was it just?  Was it ethical?  Or was it merely necessary irrespective of the consequences?

In reverse order, my need to transition was more than manifest at the time, so frail was my grasp upon a life not hell bent on personal destruction. Some may rightly conclude that my transition should not matter to others if I was going to be dead anyway, even if by my own hand.  At the time, and for all the years since I have believed that I would not have made it, but for transition and recovery.  But what if . . . ?

What if I had found recovery and reserved transition for later in life, if at all?  Of course, I was already 48 when I began.  But, might I have learned a way through recovery to live a sober life as a man, and still kept my job, my friends, my family and my marriage?  Is that possible?  Of course it is?  But is it likely?  That is a much more germane question, given the level of dysfunction following nearly half a century of gender confusion, fear, guilt, shame, ambiguity, etc., which was merely masked and drown out through alcohol dependancy.

The answer, then, is that it is much more likely that as the masks of dependency were stripped away, the difficulty maintaining the duality of self would have only grown worse, not better, and continually threatened the chances of recovery taking hold.  But, even If I could have made it through reliance on God, a sponsor and a recovery group, what difference would it have made.

Would I have kept the relationships and people I lost in my transition – my children, friends, colleagues and acquaintances who have all turned away?  Probably, but I must believe that those relationships would be strained as ever, particularly because recovery involves rigorous honesty.  It is our secrets which often make us so sick.  At some point, I would have had to tell my truth to the people in my life.  I could not have continued to live vicariously through cross-dressing in private, for it would seem ever more the lie.  And what then?  What purpose does it serve to tell the truth and not live it – to be honest, but not authentic?  Forgive me for waxing apologetically.

I never meant to hurt the people in my life, but, I still believe to my core that I did the right thing.  Moreover, I could not foretell a person’s reaction, and, though I knew them well, predictions and expectations of how a person will take the news of gender dysphoria are pure and painful folly.

Therefore, I had to step out in faith, reveal the dysphoria and prescribed treatment and then deal with the reaction.  It does not work the other way around, as there is no way to sort of test the waters before jumping in.   People have no frame of reference, no experience to fall back on when a trans person reveals themself, and they can no more control their reaction than I can.  It is a gut level, sometimes gut rendering response that typically involves either rejection or openness, if not confusion.  If a person can be open and willing to accept the trans person, there is a chance at a continued relationship.  However, if the knee jerk reaction is rejection the door may be firmly closed.  And I have second guessed myself enough times to know that the process of revelation makes very little difference in the long run.  Either a person gets it, or they don’t.  And there is simply no way to know ahead of time which it shall be.

Thus, the trans person can take only one of two paths.  They can remain forever inside their secret gender box with all the dueling emotions and resulting pain and dysfunction that hiding brings for the sake of their family and friends and to avoid the risk of emotional harm to others.  Or, they can stumble blindly and uncertainly along the path to authenticity, assuming the risk that not all will choose to go along.

Gender transition is not a question of right or wrong, per ‘se, but rather it is one of possibility, necessity and risk.  Can the trans person live without transition, and are they willing to assume the risks inherent in either choice – a life forever locked in dysfunction and incongruence, or one without the ones they love who also lose someone dear.

The Girl Effect

The infographic below was created by the Girl Effect which is a movement about leveraging the unique potential of adolescent girls to end poverty for themselves, their families and the world. It highlights the problem of child marriage which leads to pregnancy and childbirth which can be fatal for young girls- not to mention damaging to a country’s economy.

Infographic_Girl-Effect

 
Read more: http://www.care2.com/causes/6-infographics-about-being-a-woman-that-will-make-you-want-to-take-action.html#ixzz2Hrij8zMw

Identification of LGBT Needs in the Exam Room

A physician performs a routine checkup on a pa...

A physician performs a routine checkup on a patient at the medical clinic. (Photo credit: Wikipedia)

Last time you were in an exam room, did you feel that the attending physician received all the information needed to gain an accurate perspective of your plight? Did you share everything you felt you should, no matter how personal? Did said physician even ask about anything, aside from the usual short list of inquiries we are all too familiar with in that particular setting?

If you are a physician, do you really get the answers you need from your patients? Or perhaps it is just too uncomfortable when talking about sexual health and behaviors. More likely, they do not disclose the details out of discomfort, or even fear.

LGBT persons have shown to have some unique healthcare needs, sometimes experiencing disparities in care. LGBT patients are often uncomfortable or inhibited from talking openly with healthcare providers about sexual orientation, gender identity, and sexual behaviors. Certain sexual behaviors do not automatically define that patient as LGBT, and not all LGBT patients are going to have similar sexual behaviors. Truthfully, it’s not about whether a person is a member of the LGBT community or not. It’s about the individuals choices and behaviors that could be putting their health at risk, as well as the health of others. In order to cover everyone’s needs, patients must speak openly with providers. Providers must delve into the patients behaviors and understand where the risk behavior is at for each patient. I am going to lay out a few examples, ideas, and suggestions for physicians, as well as patients.

In any healthcare position, you will find people from diverse backgrounds and lifestyles. Different interests, tastes, and mindset. The right approach will reassure patients that the provider is knowledgeable, genuine, concerned, confidential and accepting. This enables the patient to open up and discuss the very private matters of sexual behavior, often in this society a ‘taboo’ subject.

Ask the patient to tell a bit about themselves. As the patient, make sure you indulge your sexual partner(s), safe sex practices, and concerns. Some behaviors have an amount of risk attached to them that is often unknown to the patient.  A physician might ask “Do you have any questions or concerns about your sexuality, sexual orientation or sexual desires?”. Use gender-neutral terms and mirror the patient’s terminology to better understand how they identify. For example, asking “do you have a partner or spouse?” “Are you currently in a relationship?” “What do you call your partner?” are all good ways to decide how the patient will identify without offending them with clinical terms which may sound cold and ‘labeled’. From here the in-depth sexual questions begin: “Are you sexually active?” “When you have sex, do you have sex with men, women or both?” “Are you and your partner monogamous?” “How many sexual partners have you had in the past year?” “Do you have vaginal sex, anal sex, or both?”. These and many more are the key to finding out just what unique needs your particular patient might have.

It is important to differentiate between sexual identity and sexual behavior. Providers need to discuss sexual behavior with patients regardless of sexual identity in order to define risk-assessment, ascertaining what activities they engage in and to learn what they are doing to prevent the transmission of disease.

And for the majority of readers, as  patients we have a personal responsibility to find the courage to openly discuss in confidence all of our behaviors and desires with our doctors, nurses, therapists and counselors, etc. This is extremely important. We cannot rely on someone to read our thoughts and know the truth.

Stand up and be proud of yourself. I can almost guarantee that the person treating you has heard it all. And if they haven’t, they will soon enough.

Hard Truths (About Gay Men & HIV)

From NAPWA’s Positive Voice Newsletter:

National Gay Men’s HIV/AIDS Awareness Day – NGMHAAD – is coming September 27, three months to the day after National HIV Testing Day, and hard on the heels of July’s landmark International AIDS Conference (IAC) in Washington, D.C. We have two messages this year: Be aware, know your risk, and, Let’s end this epidemic! Because we matter – and we can.

Speaker after speaker at IAC returned to this year’s good but challenging news: yes, we still need more science to stamp out HIV – more and better antivirals, an effective vaccine, and a functional cure – but we already have all the biomedical tools we need to make new HIV infections a thing of the past. The hard part is reaching “key populations” – groups with high rates of existing infections and new infections because they have been marginalized, stigmatized, denied civil rights, and excluded from health care.

NGMHAAD is for one of those “key populations:” this country’s men who have sex with men (MSM). NAPWA founded NGMHAAD in 2008 because we want them to know the epidemic isn’t over. We want them to know how high their HIV risk really is – because so many are already infected, and too many don’t know it. And we want them to know that we’ve come a long way since AIDS was first reported in 1981, and even further since Stonewall, but stigma is still driving this epidemic and gay men don’t have to take it anymore.

So let’s look at some numbers and see what that the gay men’s HIV epidemic looks like in the U.S.

The July 28 issue of The Lancet opened an admirable series of articles on HIV among gay men worldwide with a look at epidemiology, and reported that HIV prevalence among men who have sex with men in its North American region is a jaw-dropping 15.4% – almost one in six. The real prevalence may be a little lower – The Lancet assumes that only 3.7% of American men are MSM, a number we think is too low, and raising the estimated number of MSM would reduce the calculated prevalence a little – but it’s still clear that prevalence is breathtakingly higher among MSM than in the rest of the population.

Let’s calculate just how much higher.

About 251 million Americans are 15 or older. If 5 percent of the men are MSM, we have 6.3 million MSM and 245 million “others” 15-and-older in this country. We’re all familiar with the CDC’s estimates that 1.2 million Americans are living with HIV, and 60% of them are MSM. That gives us 480,000 infections in 245 million “others,” for a prevalence of 0.2% – one in five hundred. It also gives us 720,000 infections in 6.3 million American MSM, for a prevalence of 11.5% – just shy of one in eight. HIV prevalence among American MSM is almost 60 times what it is in the rest of the population.

That means HIV-negative MSM who are active with partners whose status they don’t know are at much higher risk than many realize. So the first and most important message of National Gay Men’s Awareness Day is – simply – be aware. Know your status. Know your risk. If you aren’t absolutely sure you know your own and your partner’s status, keep your condoms handy.

In September 10’s Positive Voice, we’ll write about how we got to where we are and what’s needed to deal with the MSM epidemic on the ground. Why near-universal testing is so important when prevalence is already so high. The need to confront stigma and talk frankly about sex in communities where this is deeply uncomfortable. The need for pride and love. The need to have culturally competent and welcoming health care for MSM.

And in the September 24 issue, just three days before NGMHAAD, we’ll remember the quarter-million (at least) American MSM who have died of AIDS and examine our responsibility as their survivors to demand action to end this epidemic once and for all. Now that we can, we must.

Gay Men’s Wives, Homophobia and HIV

(click for source)

Discrimination and homophobia are often more prevalent in rural areas. Outreach workers in Montana know that there are certainly barriers for men to being tested for HIV. One of the most significant is the fear of being harshly judged, labelled and dismissed. It’s one of the reasons some gay/bi men get married to women and start families- they want to be ‘normal’- even though they already are. The sense of shame and guilt can be overpowering- and it’s adding fuel to the fire as far as HIV is concerned.

Rural outreach workers have known this for years- it may be one of the reasons that HIV is spreading so rapidly in the south. It’s almost certainly one of the reasons that HIV is spreading in the African American population. But we haven’t paid much attention- at least scientifically- to this issue. Now it looks as if science is actually catching up to reality. From The Sobering Truth About HIV Among MSM by Gregory Trotter, Chicago AIDS Foundation blog (July 25):

The idea of “turning the tide” against the AIDS epidemic will prove to be no more than a slogan if more is not done to address the growing number of gay/bisexual men infected with HIV worldwide, experts said today.

Speaking at an afternoon press conference today, a panel of experts presented new research – recently published in a series in the medical journal, The Lancet – that confronted the reality of HIV prevalence among MSM (men who have sex with me).  The series concluded that, in addition to medical and scientific advances, more must be done to eradicate the cultural and societal impediments of homophobia and discrimination. Until that happens, ending the AIDS epidemic is unlikely, said Chris Beyrer, a professor at Johns Hopkins Bloomberg School of Public Health. (emphasis mine)

We routinely encounter discrimination in dealing with MSM in Montana- some of whom do not openly identify as gay. In fact, some are married- with children- and do not plan on leaving their families. But they’re having sex with other men- and some are not using condoms with their wives. “If I did, she’d know I was having sex with someone else,” one client told me.

The fear of being exposed for these men is great. One man told me, “I can’t afford to be seen as gay. It would kill me- it would kill my wife.”  Shame from society, churches and social groups abut being gay have forced men to create false lives. But they haven’t stopped sexual behavior. This type of internalized shame is not uncommon here- and the wives of these men could be put at risk as a result.

Shame, homophobia and discrimination are fueling the epidemic- so are apathy and denial (see my essay Gay Men Are Flunking The Test). Part of me wonders when we’re going to start seeing a rise in HIV infection among rural women- the wives of gay/bi men. Back to Mr Trotter:

On average, MSM are 19 times more likely to be infected with HIV than the general population in low- and middle-class countries, according to Dr. Kevin Fenton, director of the National Center for HIV/AIDS.

Many African countries do not accurately report numbers of MSM and some do not even acknowledge they have MSM among their population, said Paul Semugoma,  Uganda physician who serves on the steering committee for the Global Forum on MSM &HIV (MSMGF).

Homophobia is rampant in such countries, he said.

“If we don’t start solving these impediments for MSM, we’re not going to do much about the epidemic,” Semugoma said.

In a recent study in Jamaica, 82% of Jamaicans self-identified as homophobic, largely out of fear of HIV prevalence among gay/bi men, said Maurice Tomlinson, legal advisor on marginalized groups for AIDS-Free World, an international advocacy group.

Such homophobia has engendered a climate where gay men are afraid to buy condoms for themselves, Tomlinson said. Their female friends often buy condoms for them, he said, but refuse to buy lube, as that would imply a female “deficiency.”

And so many gay/bisexual Jamaicans use petroleum jelly, saliva or even hairspray as a lubricant, he said.

“In those cases, it would be better if they used nothing at all,” Tomlinson said.

To learn more about how HIV affects MSM throughout the world and possible solutions to problem, read the full series in The Lancet titled HIV in Men Who Have Sex with Men.”

HIV Is In Montana- It’s No Bull

The second video in the Montana social marketing campaign for HIV Awareness:

This HIV prevention animation targeting the MSM population is a playful look at a young bull elk that is looking for a relationship in Montana. As the party music plays he searches the herd for another bull who has been “Checked” (tested) for HIV. This is a creative project that was created by Laura Dybdal and Amber Bushnell as a part of Montana’s HIV Prevention Social Marketing Campaign. It also directs viewers to getcheckedmt.org, a resource to find the nearest HIV testing location in Montana.

The first one was posted yesterday….

Study: Incarceration Increases Risk Of STI’s, HIV Infection

Something nobody ever seems to want to talk about: sex, prison and STD’s.

The study’s objective was to assess the link between incarceration and sexually transmitted infection, including HIV, from a social network perspective.

Data collected from a social network study in Brooklyn (n=343) were measured for associations between incarceration and infection with herpes simplex virus-2, chlamydia, gonorrhea and syphilis or HIV and sex with an infected partner, adjusting for characteristics of respondents and their sex partners.

“Infection with an STI or HIV was associated with incarceration of less than one year (adjusted prevalence ratio=1.33; 95 percent confidence interval=1.01, 1.76) and one year or longer (adjusted PR=1.37; 95 percent CI=1.08, 1.74). Sex in the past three months with an infected partner was associated with sex in the past three months with one partner (adjusted PR=1.42; 95 percent CI=1.12, 1.79) and with two or more partners (adjusted PR=1.85; 95 percent CI=1.43, 2.38) who had ever been incarcerated,” the results found.

There is a need for STI and HIV treatment and prevention for current and former prisoners, concluded the authors. The results provide preliminary evidence to indicate that incarceration may influence HIV and other STIs, “possibly because incarceration increases the risk of sex with infected partners.”

I love it when science follows common sense. Well, at least informed common sense…