Tuesday 24 December 2019

The Medical Profession is Female

A man and his son are terribly injured in an accident. They are taken to hospital requiring surgery. A surgeon is called, but looks at the boy and says "I can't operate on this boy: he's my son!" How is this possible?

Does this riddle perplex you? If so, you may be demonstrating your innate gender bias, that surgeons ought to be male, and therefore you expect the surgeon to be the boy's father. Of course, the common answer is that the surgeon is the boy's mother (though it's becoming increasingly possible that the boy is the child of a gay couple).

My media feed this week sparked my interest with its announcement that the "Medical Profession is Female", and I followed the link.

Professor Elizabeth Loder is a professor of neurology at Harvard, and the head of research at the British Medical Journal. She writes (my italics):
Loder: Soon, most doctors in the US, the UK, and Europe will be women; this is already the case in many countries (...) The stereotype that doctors are men persists at a time when almost half of physicians are female—and it has been internalised by women physicians like me—so it’s a problem that needs to be fixed. How to do this? It would help to retire “he,” “him,” and “his” as the default pronouns for doctors and make a deliberate switch to “she,” “her,” and “hers.” Pronouns are in flux, and it’s possible that “they,” “them,” and “theirs” will become standard. Until that happens, I have a proposal: when in doubt, and the gender of the doctor is unknown, let’s use female pronouns to send a message and open minds.
Professor Elizabeth Loder
There is no doubt that she is right. Women outnumber men at admission to medical school already, and my own belief is that more than half of all doctors are already women.

Loder's piece was prompted by a paper recently published in the BMJ which shows that female scientists are less likely to use positive terms to describe their research findings compared to male scientists. The men tend to use positive-sounding words like novel, unique, or unprecedented, and papers with this more positive language get cited more often.

Academic papers are usually cited in a way which masks the first name of the authors. They are usually given by their initials only: (Lennon J, McCartney P, Harrison G, Starr R), which makes it pretty hard to infer anyone's gender. I had always considered that this made academic publishing encouragingly gender-neutral, but the BMJ paper shows that there is a measurable male-female difference.

As an amusing aside, those of you who are familiar with British English will know the expression "old Uncle Tom Cobley and all", meaning "everyone imaginable". I was delighted to discover that there are several listings in academic journals where Cobley UT has been listed as a co-author!
Loder: Using female pronouns for doctors would force everyone, on a regular basis, to remember that women can be doctors. Soon the default use of female pronouns will make sense for the same reason we’ve defaulted to male pronouns: it will be the best reflection of reality and the new gender makeup of the physician workforce. Furthermore, in situations where most doctors are male (surgical subspecialties, for example), it’s then even more desirable to use a default pronoun of “she” to expand people’s ideas of who can be a doctor.
I'm already doing this very deliberately in my Quora answers, and at work I am careful to deliberately avoid assuming male pronouns for doctors (instead I tend to use they). The very first post I ever wrote on this blog, back in 2011 (!) was about pronouns, although I must say that the invented, gender-neutral pronouns still grate with me wherever I see them.

What I saw, twenty or more years ago, is that to succeed in medicine, women had to outperform the men. That meant that the few female consultants and professors, that I knew then, tended toward the ferocious spinster archetype. I got the impression these were women who had sacrificed a lot (personal life, family life) to get their positions. Many seemed to me to be bitter and battle-hardened: sick of proving themselves right in front of mansplaining men who were not as good as they were.

Before she was that doctor, she was this doctor.
It was considered acceptable for women to do the “touchy-feely” specialties, such as general practice or psychiatry. But women found it very difficult to succeed in the “tougher, harder” specialties such as surgery (especially orthopaedics). The following quote comes from my favourite dark medical drama, the wonderful Cardiac Arrest:
Just because surgery involves a bit of sewing doesn’t mean it’s any job for a housewife!
I personally witnessed the deliberate, ritualised bullying of a highly capable surgical trainee who had committed two grave sins: being a woman, and having brown skin.

But things have changed, and are still changing. Those battle-hardened spinsters have blazed the trail, and women are streaming into specialties which have previously been off limits. And they no longer need to do battle with the boys, which means they are more relaxed and able to express themselves. Some female surgeons operate with little feminine touches: fabulous pink surgical boots (instead of boring white) or operating spectacles with little sparkly bits glued onto the legs and rims. These sound like little things, almost trivial, but they represent ground which was hard-fought for, inch by inch.

The men are, in general, much more respectful and better-behaved. Some of the older ones have ascended to higher echelons, which means that Medical College councils and presidents still tend to be mostly men. But even here I am hearing new dialogue. The president of my Medical College (a man) announced that, considering all the Annual Scientific Meetings our College has ever held, over 100 keynote speakers have presented, and only six were women. Imagine, he said with genuine sincerity, all the talented speakers we have missed out on. (This year nearly all the keynote speakers were women).

That talented surgical trainee I knew back in the day has made it; she was far too talented not to. But she lost something along the way: her compassion is far less now than it was when I knew her. She too has been battle-hardened.

I remain hopeful that these trends continue, and I remain certain that medicine (and hence patients) will benefit from improved gender balance.

But there is one thing still missing: where are the trans doctors? If, as I suspect, there are just as many transgender doctors as there are in the general population, where are they all? This is a subject I intend to explore more fully in a later post, because I've been doing a lot of looking. Meanwhile, if you have a story or viewpoint to share, please leave a comment.

Friday 6 December 2019

Shifting Sands

Although it's over a year since its release, I came across this amazing publication, and I wanted to give it wider recognition.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) is the medical college responsible for setting training standards for doctors specialising in the field of Obstetrics and Gynaecology in Australasia. So it's a very large, prestigious, academic organisation.

As most medical colleges do, it publishes a flagship academic journal; but also a more informal publication, O&G Magazine, which I admit I had never come across until I saw a pile of them lying in my hospital. The top one caught my eye, because it was colourful, and because it looked like Tetris (which is one of my favourite games). When I looked closer, I saw that the theme of this particular issue was "LGBTQIA", so I picked it up to have a read. I was immediately captivated. Best of all, the entire issue is available free online here.

Let's start with the editorial, from incoming RANZCOG President Dr Vijay Roach:
Roach: This issue of O&G Magazine addresses an important aspect of social, cultural and clinical life in Australia and New Zealand. Members of the LGBTI community have experienced a long history of marginalisation and discrimination, often to the detriment of their physical and mental healthcare. While the College acknowledges a diversity of opinion in the community and among our members on many issues, on one thing we are united: RANZCOG believes that every person, independent of their sexual orientation, has the right to high-quality medical care. 
In 2017, the RANZCOG Board issued a statement on same-sex marriage which read, in part '… the Board affirms its support for marriage equality and calls upon the Australian Parliament to ensure equal opportunity for lesbian, gay, bisexual, transgender and intersex (LGBTI) Australians in same-sex relationships and their families …' I was proud to be a member of that Board and grateful to then-President Prof Steve Robson for his leadership.
In this issue, the O&G Magazine editors have assembled a diverse series of articles relevant to the care of the LGBTI community. It is compelling reading and relevant to everyone’s practice.
The list of articles is impressive:
Fertility options for gender and sexually diverse people (Bronwyn Devine)
Rainbow IVF (Sarah van der Wal)
Gender dysphoria (Simone Buzwell)
Gender dysphoria: a paediatric perspective (Noel Friesen)
Fertility preservation in the transgender child and adolescent (Tamara Hunter)
Intersex: variations in sex characteristics (Jennifer Beale)
What do intersex people need from doctors? (Morgan Carpenter)
Hormonal treatment of the transgender adult (Rosemary Jones)
Surgery for transgender individuals (Charlotte Elder)
LGBTQIA gynaecological screening (Kimberley Ivory)
Takatāpui (Elizabeth Kerekere)
Tekwabi Giz National LGBTI Health Alliance (Rebecca Johnson)
Glass closets and the hidden curriculum of medical school (Amy Coopes)
Australia's queer history (Robert French)
I read these articles with two sets of eyes. The first were my medical eyes: was this the sort of thing that, as a doctor, would be helpful for me to read? The answer is clearly yes. The second were my transgender eyes: was this the sort of thing that, as a trans person myself, I would want doctors to read and know? The answer is also a clear yes. There is no doubt that transgender people are becoming more and more visible; their care has been, in the main, not that great; most doctors have very little training in care of transgender people, and reliable resources for doctors to draw upon are few.

The various authors all have special expertise and interest in their various fields, which is commendable. But it's the range of subjects which strikes me as particularly noteworthy. I've sometimes felt that the T is kind of tacked on to the end of LGB as an afterthought. But here we are, right in the middle, with articles dealing with not just hormones and surgery but issues like fertility and childhood and emotional wellbeing. Amazing.

I was pleased to note that the tone of all the articles was spot on, from the acceptance of the individuals, to recognition that care matters but is frequently lacking, to pragmatic information and guidance for practitioners.
There are several points which are very much worth making about a publication of this type.

(1) First, it's great that a major medical college is being so overtly inclusive. That alone is magnificent. RANZCOG is setting an example for others to follow. There has been lots of Twitter support for the issue.

(2) Second, most medical colleges publish guidelines for the care of patients with X condition. What strikes me about this one is a subtle but powerful shift in tone: not "this is what these patients are like" but "this is us, and that's OK". As Amy Coopes points out in her article, there is still great stigma in medicine if you are gay or non-binary. So a publication like this is extremely affirming. As a transgender person with a medical degree myself, I immediately wanted to reach out and make contact, so I wrote to RANZCOG and congratulated them on their magazine (and I’m not the only one: there is a very heartfelt response from a gay obstetrician in the following issue here).

(3) I wouldn't have necessarily expected O&G to be the specialty which would deal with the care of transwomen. Post-transition, care could potentially be complex, since O&G specialists are more used to the care of people with a uterus and vagina than a prostate gland. But this issue seems to be saying to its readers: don't panic, you can do it! It's started me discussing these issues with some of my colleagues much more openly than previously.

Whether you are medical or not, it's well worth having a browse through this magazine. If you're aware of any other medical organisations being explicitly rainbow-inclusive, please let me know.

Thursday 10 October 2019

Vivienne at large!

In the last few weeks my desire to express Vivienne has risen enormously, culminating in a series of public outings over the last couple of weeks, which have been unbelievably successful and affirming.

Having Vivienne time isn't easy. We both have full-time jobs, and between us we have a bunch of kids that have all sorts of things on: school, sports, music, social lives, you name it. However, there has been a series of days where I have managed to get some completely free time. It was time--it was past time--for Vivienne to get out and about.

My partner Missy could see that I had been getting cranky because I was feeling increasingly feminine, but had no opportunities to express it. So she asked me what I wanted to do. The top item on the bucket list was to go dressed to the cinema, so that's what we did.

Please turn your phone to silent.
There were a few matinees which I wanted to see. Normally I like thrilling action-adventure blockbusters--but as Vivienne, I feel much more comfortable to watch more emotional, dramatic or historical films, and in my town there is a cinema which specialises in arty-type films. We settled on a historical costume drama, which had no lightsabres or giant robots to be seen anywhere.

Missy helped me to pick out an outfit which would work. My tendency is to do more. More makeup! More nails! More shoes! She suggested that I tone it down to an outfit which a woman would actually wear, and she had a really good point. I've pointed out before how I tend to become voracious when dressing after a drought.

I am naturally aiming for a compromise with both my outfit and makeup. In one direction, there is too much, and I look like a clown, or a bad drag queen, or a caricature of a woman. In the other direction, there is too little, and I look like a man. Somewhere in the middle is a sweet spot, where I can look, if not exactly like a woman, at least like someone who is trying to make a go of looking like one. Previously I only had my own frame of reference to guide my choices; now I have Missy's sensible viewpoint.

Day One

I felt completely comfortable until we got to the mall and I got out of the car. Suddenly I was aware that everyone's eyes would be on me. This wasn't a frightening sensation, but probably the sensation that the meerkat has when out on the Kalahari desert. We walked into the cinema. Missy ordered the tickets, and I stood behind. The attendant (a woman) spotted my nails, and said they were lovely. I was taken aback by this sudden compliment, having been out for a total of about ten minutes. "Thank you!" I responded. Then she looked at me, having not really looked at me at all. She must have clocked my man-voice, and I braced myself for some sign of discomfort, but there was none. (Missy chided me jokingly for my deep manly voice, but I don't have a fem voice, and I was totally unprepared!)

We made our way into the cinema, which of course was dark and quiet. We got the luxury seats and watched the film. I couldn't believe how lovely it felt. I wanted to pinch myself. None of the other people paid us the slightest attention, though I felt as if I had a huge flashing neon sign above my head.

I came out of the cinema floating on air. This is the sensation some people call the pink fog; others gender euphoria. I drank it all in. I wanted to absorb as much of it as I possibly could.

Still getting used to the handbag thing.
Missy had an appointment for about an hour. I could retreat home, or I could go to a cafe and wait for her. Cafe of course! This meant two new things: going somewhere on my own (already!) and also visiting the ladies' room. But I felt pretty comfortable and pretty confident, and I walked into the cafe. The ladies' room was near the entrance, so I went straight in. It was empty, so I just used a stall, straightened up my clothing, checked my makeup, and came out. I took a table, ordered a drink, and sat looking out of the window, unable to believe this was actually happening. My interactions with the wait staff (male and female) were pleasant and ordinary; again they must have clocked me instantly, but they seemed completely comfortable with me for a customer. When Missy came back to pick me up I was still happy and floaty, and this feeling lasted for the rest of the day and into the evening.

Day Two

The following day, Missy was at work. I had the option to dress again--or I could do ordinary stuff (as if!). I decided to dress and go out on my own. I wore the same outfit as I had before, and I went back to the same mall. It was much more crowded than the day before!

I was so nervous at first that I decided to just stroll around. I was extremely self-conscious! There were so many things to remember, including a whole new way to walk and carry myself. I had, of course, been practising, but it's one thing to practise when there is nobody looking, and it's a different kettle of fish if you feel like everyone is looking at you!

At first I jumped at every noise. As I passed a sports store, I heard a burst of male laughter from within. At the time I was sure it was directed at me, but in retrospect, there is no reason at all to think it was. I began to look up and take notice of the people around me more. A woman coming the other way caught my eye, and smiled. I smiled back. Was it because she clocked me, and was being reassuring? Or was it because women sometimes smile at one another when they make brief eye contact in the mall? I was especially fearful of large, muscular men. I fear that, of all people, they are the ones who would express their discomfort most vocally.

I braced myself for strange looks; for weird expressions; for expressions of distaste. Nothing. Nothing at all. Nobody seemed to pay me the slightest notice. Was that, I wonder now, because they were silently sniggering and pointing behind my back? Maybe. Or maybe I just didn't stand out enough for people to notice me (and I am sure most people are wrapped in their own business, so that if you mostly blend in, you become effectively invisible). Or maybe (and here's the kicker) they did actually notice, and clock me, but were not bothered in the slightest?

Hot as any Hottentot?
My self-imposed task was to buy sunglasses for Vivienne. The weather has been bright and sunny lately. I could hardly buy sunglasses for Vivienne in male mode ("Do you think these would look good on me if I was wearing a wig and a frock?"). And sunglasses add a layer of disguise.

I went into the sunglasses shop, and approached the counter. The assistant, a young woman, said "Can I help you?" I smiled and said "Yes, I'm looking for sunglasses to go with this look," and indicated myself. She didn't seem fazed in the slightest, but asked me how much I wanted to spend, and then showed me lots and lots of frames, several of which I tried on.

Every time--every time--I looked in the mirror, it was a surprise to see Vivienne's face looking back out at me. The assistant was lovely. I told her I wanted large round lenses, but she suggested a few alternate frames. Some of them didn't work at all, but some of them looked really good. Eventually, I settled on a pair, and bought them. She asked me if I had shopped there before, and I laughed and said "Yes, but I didn't look like this!" and she laughed too.

When it came time to pay for my parking ticket, the attendant smiled and asked if I was having a nice day, and I said "Yes, it's lovely, thanks!"

In the afternoon I went for a long stroll round the park. With my sunglasses on, nobody looked at me at all, and I seemed to blend right in. I went into the little cafe next to the park and ordered a drink, and sat writing my journal with my lovely fountain pen and its lovely sparkly ink. Other patrons came and went, and nobody seemed in the least troubled. I once wrote in this blog I considered this simple activity to be pie in the proverbial sky, and here I was, doing it and loving every moment.


You would think that no human being could stand this amount of pink fog, and perhaps you would be right. There is a definite sense in which Vivienne time seems to stand apart from ordinary time; no work, no commitments, no obligations. It's probably the same sense of "getting away from it all" that some men enjoy when golfing or fishing--but surely it's much more pleasurable than either of those activities? In any case, after a couple of days, I had to come back down to Earth.

But my reflections are these. First, going out as Vivienne seems to be OK. That is, nobody seems offended or horrified. The people of my town seem very tolerant, which is extraordinarily gratifying to me. Why should this come as a surprise? Perhaps because I've had about 20 years of being told how disgusting crossdressing is (by my ex-wife), and though I knew that her view was very skewed, some of it had inevitably sunk in. To discover that it isn't right; that people are apparently totally fine with it, has come as a revelation, and a delightful one. My biggest goal, in all of this, is simply acceptance, as I have written before.

Second, I think for me, the key is to not pretend to be a woman: I shall surely fall short. Instead, I can simply be myself, and let people make of me what they will. The woman in the sunglasses shop didn't seem remotely uncomfortable with my attitude or presentation. I am hopeful that with time and practice the anxiety will fade and the pleasure and comfort will grow, but even if it doesn't, where I am right now is fabulous.

So far, everything has been completely wonderful. I fear that there may yet be an event, which in my mind I am calling The Puncture, where I have a truly unpleasant encounter with someone, or some other experience which really puts me off going out like this. The reason I think such a thing will happen is that a part of me thinks that moments of bliss must be balanced out somehow, for the universe to keep turning. But the reason I think it might not, is that very few people (and I've read a lot of stories) mention events like this.

In any case, for each time I go out, and meet smiles and acceptance, it adds to the store of goodwill and optimism in the bank. As these experiences accumulate, it will become harder and harder to demolish the pile, and easier and easier to accept that an occasional uncomfortable encounter represents the exception, not the norm.

Sunday 6 October 2019

Vivienne-- The Next Steps

It's been a little under three years since I wrote this post, about the end of my marriage. During that time I've been going through a tremendous reframing of my life. There were several things which happened which were quite surprising, and I wanted to put them down here.

Meeting someone new

It will come as no surprise at all that I adore women. I always have. I'm more comfortable in their company, and I just feel better being around them. It was therefore inevitable that I would start dating again.

To get a few things out of the way, this was not about "sowing wild oats". I've never been that person before, and I am not that person now (even though one of my male friends, with the best of intentions, but without much delicacy, told me it was time to get shagging). So I was just looking forward to dinner, wine, and pleasant company.

Actually neither of us drinks coffee!
To my surprise, on one of my very first dates, I really clicked with a woman from work. We found we had a lot in common, and we were texting each other constantly. This presented a problem: to tell, or not to tell?

On the one hand, Missy was lovely, and funny, and had a host of good features. I was enjoying feeling attractive again, and I was looking forward to spending more time with her. On the other, I had escaped from a previous relationship which had been ruined, in large part, because of cross-dressing. I didn't think it was fair on this woman to take the relationship further without her knowing. I didn't think it was fair on me, to have to keep hiding who I am. So, on our second date, I told her there was something important she needed to know.

She blanched immediately. If you ask her about it now, she will tell you that the expression on my face made her think it was something dreadful, such as terminal cancer. But I slid my phone across to her, and showed her some pictures of Vivienne. She was surprised, of course, but her response was basically "Is that all?" And she was completely fine with it.

Having got that out of the way, the relationship blossomed. We moved in together a year ago, and things are looking great. I am enormously fortunate.

Vivienne went away

Missy wanted to meet Vivienne. I was incredibly nervous, but again, it was a lovely encounter. She didn't laugh. She didn't wince. She gave me makeup tips and bought me thoughtful gifts, including perfume, and a lovely handbag.

Vivienne in the kitchen
We went out together for a stroll round the town. I was unbelievably nervous, but I can't tell you how much I wanted this experience. I wanted to know what it would be like--for me, for her, and for other people. Amazingly, it was completely fine. We hosted a dinner for friends at home. It was bliss.

Having spent nearly 20 years being told that Vivienne was grotesque and perverse, I struggled to process all these feelings. I couldn't believe, at first, that being Vivienne was suddenly OK. One night I was in the bath, with lots of bubbly foam, and shaving my legs. Missy texted me to ask what I was doing, and I told her, and she responded very positively and said she hoped I was enjoying it. I was!

I found myself dreading, at any moment, that she was going to turn round at some vulnerable moment and say "Ha! Fooled you, you horrible tranny freak!" And of course she hasn't done this. After 3 years, it's beginning to sink in that she isn't going to. The trust is building, and it's a feeling which doesn't get old.

But the next part was another surprise: the compulsion to dress nearly vanished. I didn't change who I was. I continued to be Vivienne online. I continued to buy nice Vivienne things when I saw them. But the drive to dress, to express myself openly, seemed to go away nearly completely.

I wondered why this was. Was it because Vivienne was forbidden fruit, which, when suddenly available, lost some of its sweetness? Was it because I was so wrapped up in a new relationship that Vivienne was forgotten? Was it because there was so much else going on, with kids and work and school? Was it because all of us wax and wane with time; that we are not constant in our feelings and wishes?

There have been times when this has happened before, and I reasoned that Vivienne would return in time. Meanwhile, I wanted to be ready! I had new clothes, cosmetics, accessories. Not grabbed off the rail in the back of gloomy charity shops, but carefully considered to be part of a look that works well; these shoes would look great with that skirt.

Vivienne came back

And then, Vivienne came back. I gradually became aware of an insistent nagging feeling, which became more and more prominent with time. I realised that the feeling was unstoppable, and that it was time. So I've just gone with it. And there has been an explosion of experiences; more Vivienne time in the last month than there has been in the past three years put together. It's been amazing, and intoxicating, and it's still going on. Where will it lead to next?