Vol. 209 March 15, 2019, Jargon Update

March 15, 2019

Jargon: “special words or expressions that are used by a particular profession or group and are difficult for others to understand.”

PIV
“Penis In Vagina” intercourse.  Researchers into the sexual activities of people over 65 yo. are using this term to more accurately define a specific sexual act . . .  because they are documenting a wide variety of sexual practices without penile insertion in this age group.

Elderly” is OUT
This term is currently way out of favor. Few “older adults” want to be considered elderly. “Seniors” is acceptable, even though it implies that those under 65 are “juniors”. It may be the association of that word with “discount” that keeps it current. “Perennials”, suggested as a response to the “millennials”, has the connotation that one has to be replanted every spring so it’s failing to stick. “Olders”, “gerontos”, and “third-agers” are distant possibilities. “Older adults” has been adopted by the American Geriatric Society. The American Association of Retired Persons began referring to itself simply as AARP in the late 1990’s . . . about the time it started sending membership invitations to 50 year olds. The Boston Commission on Affairs of the Elderly just changed its name to the Age Strong Commission. (The best candidate for “Best New Politically Correct Term of the Year” award.)

GM/GF
Genetically engineered wheat that contains far less gluten for gluten-free bread that tastes and feels more like real bread has been created using CRISPR gene modifying technology. When it does reach the marketplace it will undoubtedly cause a real purchasing dilemma for a select group of tree huggers.

“Organic”, “natural”, “healthy”
All still remain relatively undefined by the U.S.  Department of Agricultural so any company can put those labels on almost any food. The USDA and the National Organic Standards Board have opposite opinions on the “organic-ness” of carrageenan, a seaweed derived thickening agent. The USDA Organic label does indicate no synthetic pesticides and fertilizers, no genetically modified crops, no chemical processing aids, and no artificial ingredients. A proposed Food Labeling Modernization Act hopes to set uniform, definitive standards in the U.S.

Computer vision
A growing domain of artificial intelligence using “deep learning”, a “type of machine learning that uses multilayered neural networks whose hierarchical computational design is partly inspired by a biologic neuron’s structure.” (1) (Took the words right out of my mouth.) Computer vision can analyze medical images like pictures of skin lesions as well as the work flow in operating rooms or the progression of patient mobility in the ICU.

Moral injury
This is a substitute term for “burn out” in describing what is happening to our physicians.  “The increasingly complex web of medical providers’ highly conflicted allegiances. . . results in the moral injury . . . of not being able to provide high-quality care and healing in the context of health care. . . . Electronic health records track productivity and business metrics, but significantly reduce face-to-face interactions.” (2)

Cisgender
Having a gender identity that is aligned with one’s sex assigned at birth. The opposite of transgender. . . usually, but some transgender persons identify with both genders or neither! (on to the next jargon item.)

Nonbinary
Identifying as neither male or female, having multiple gender identities, or having none; “a more expansive concept of gender.”

Sexual orientation
“Who you go to bed with. Gender is who you go to bed as.”

High-end lobster
Offered by a Maine seafood restaurant that pumped marijuana smoke through the tank water to sedate lobsters before throwing them into the pot. The practice was stopped by order of the state Department of Health for “dispensing of marijuana without a license.”

Standing desks are OUT
A deeper look into the 2015 research of the health benefits of standing vs. sitting while working at a desk indicates that there is little actual health benefit to standing. “Workers should not fool themselves into thinking that standing is a form of exercise.”

Pasture-raised chicken
“Cage-free” chickens may still be raised in packed buildings with no outside access. “Free-range” chickens have outside access but there is no government standard for amount of available space. “Organic” chickens are cage-free, are fed only organic feed, and have outdoor access, but it may be just a small concrete porch. “Pasture-raised” chicken require 108 square feet per bird of outdoor space to earn that label as well as the “Certified Humane” label. (3)

Geroscience
This emerging field of scientific research of longevity hopes to gain the Federal Drug Administration’s attention for reviewing drugs to retard the aging process, which recognizes aging as a natural process (outside their purview) not as a disease (within their jurisdiction for review of new drugs).  A newly formed Boston-based Academy for Health and Lifespan Research will lobby various governments world-wide to support development of drugs and other age-slowing therapies.

“Safe-school officer”
Former combat veterans wearing body armor while carrying a 9mm Glock handgun and a sawed-off automatic rifle hired to roam the halls of the Manatee School for the Arts in Palmetto, Florida. The principal hired the combat veterans because “I don’t want this to be the first time they’ve had someone shooting at them.”

References:
1. NEJM 378;14 April 5, 2018
2. Drs. Talbot and Dean, Boston Globe 8/15/18
3. Consumer Reports On Health, February 2019


Vol. 176 September 1, 2017 Sexual Anatomy, Gender Identity, and Orientation

September 1, 2017

“Sexual orientation means ‘who you go to bed with’.
Gender identification means ‘who you go to bed as’.”

 -Norman Spack, MD, Pediatric Endocrinologist,
Chief of Gender Management Service, Childrens Medical Center, Boston

Discussion about transgender people is back on the front page since President Trump tweeted his wish, and then ordered the Defense Department, to ban the enlisting of transgender persons and to ban transgender soldiers from continuing to serve in our armed forces. The ACLU notes that there are currently about 8000 transgender U.S. soldiers.

The appearance of your genitals at birth, if anatomically correct, tells everyone in the delivery room what you are; “sexual anatomy”. “It’s a boy, or it’s a girl” are the first three words an infant “hears”. In the first decade of life we begin to think of ourself as a boy or as a girl; “gender identification”. In our second decade, as we approach and go through puberty, we begin to realize that we are attracted to boys or girls, or both; “sexual orientation“. These three terms are often confused and intermixed in our discussion. which can make rational, unemotional consideration of new policy, laws, and societal changes very difficult.

When do children begin to identify themselves as a boy or a girl? (1)
Studies show that it can be as early as third grade. (7-9 yo.) By then, most children associate themselves with one or the other sexes and understand that it is permanent; “girls grow up to be women and boys grow up to be men.”

What about “cross-gender” play which is very common at young ages?
By age 2 years all children know sex stereotypes (“women are associated with lipstick”,”boys don’t wear pink tutus”) ). It is remarkable that transgender children understand and accept the same stereotypes as their peers. Studies show that “cross-gender” play (“boys wearing dresses”, “girls excelling as tom-boys”) is very common in pre-school children, is normal, and is temporary in most children. 

Where are all these transgender children?
Everywhere. Since 2007 when Childrens Hospital started its Gender Management Service as part of their Sexual Disorders and Dysfunctions Clinic, they have treated about 200 transgender children, 95% of whom came from within 150 miles of Boston.

What causes transgender identification, nature or nurture?
Both probably. No one really knows. One twin study revealed that of 23
identical same-sex twin pairs, one twin in 9 of the pairs was identified as transgender. No twin in the 21 fraternal same-sex twin pairs were transgender. The suspected genetic basis of this is completely unknown. In 1895 an article in Scientific American expressed concern that riding bicycles threatened women’s health. In 1948 only 32% of adults believed women should wear slacks in public. (1)

What is the “treatment”? (2)
The Dutch taught us that the best time to change a person’s gender is before the onset of puberty (10-12 yo. in girls and 12-14 yo. in boys).

Dr. Spack and others thought that was a pretty young age for the patients (and their families) to make such a life-changing and permanent decision. Therefore, the U.S. standard of care is to delay puberty to buy some time.

At age 12 years after extensive psychometric testing of gender identification by a multi-specialty team, treatment with appropriate sex hormones that block progression of puberty of the “birth gender” is started. This puberty “blockage” is reversible and is continued for years.

At age 16 after the repeat of extensive psychometric testing of gender identification, the decision to move on to irreversible body-changing sex hormone treatment is considered. . If the decision is to NOT GO on with the change, that hormonal treatment is stopped and normal puberty appropriate to the “birth gender” occurs. If the decision is to proceed with a change, treatment with different sex hormones appropriate to the “affirmed gender” is started. The goal is to achieve the physical appearance of the “affirmed gender”. This treatment is usually very successful (“girls develop normal sized breast and have normal heights”).

After age 18 years and years of hormonal therapy, surgical reconstruction of genitalia can be considered. (Male-to-female surgery is much easier and can be successful enough to “fool a gynecologist”.)

Are there any barriers to treatment?
Yes. Very expensive (about $1000 a month for several years of hormonal treatment), misunderstanding about the reversibility of early treatment, and continued classification in the DSM-V (Diagnostic and Statistical Manual of Mental Disorders) of “Gender Identification Disorder” as one of a dozen “Sexual Disorders and Dysfunctions” (which exempts the treatment from most insurance plans). Note: Homosexuality was removed in 1973 from the DSM-III as a mental health disorder as it is NOT amenable to psychiatric therapy. Neither is transgender identity. There is no evidence that people can be talked out of, or therapized away from, their transgender identity.

What if the transgender child is not treated?
In the scheme of things the number of transgender children is limited. But, of the 100 patients seen by the Gender Management Service by 2012, 20% had performed self-mutilation and 10% had attempted suicide. Other studies have documented a much higher-than-average suicide rate in persons with gender identity issues.

So, gender identity can trump anatomy,
and sexual orientation can be completely unrelated to either.

This can get a bit confusing, but have no fear, it may even get harder to keep track of the players without a scorecard.
N
ew research is focussing on “nonbinary” children. These children  see themselves as in the middle of the spectrum and neither male nor female.

Refrences:
1. Scientific American, “Everybody has a stake in the new science of sex and gender”, September 2017
2. TED talk, Norman Spack, MD

 


Vol. 135 November 1, 2015 “He, She, or It?”

November 2, 2015

Hub thumbnail 2015

People tend to confuse sexuality and identity, and often want to conflate these things, but being transgender has nothing to do with sexuality.

— Norman Spack, Director Emeritus and Founder of the GeMS Program, Boston Children’s Hospital

Last week one of our five-man book-and-lunch club started our monthly gathering with, “Before we start can you tell me if an infant with unclear genitalia is called transgender?” It quickly became clear during the ensuing conversation that most of us not only knew someone with gender identity issues, but also that we (all over 60 y.o) had blurry, often overlapping, and quite different understandings of gender definitions and terms.  I suspected that we might not be the only ones confused, and thought that researching a blog on the subject might be clarifying for me and others.

What’s the difference between“transsexual”  and “transgender”?
“Transsexual” was coined by a German surgeon in the 1930’s for people (usually males) who wished to have sexual reassignment surgery (SRS) and change from male to female (M2F, MTF). “Transgender” was coined in the 1960’s, was much more about who the person thought they should be rather than about sexual orientation, and was not usually associated with the desire for SRS. In 1979 Christine Jorgensen rejected “transsexual” and insisted on “transgender” (even though he/she underwent SRS). Transgender seems to be the most PC term today, and transsexual, still implying an interest in SRS, is considered to be a subset of transgender. There is a World Professional Association for Transgender Health  as well as a blue/pink/white striped Transgender Pride flag that “will always be correct, no matter which way you fly it.”Screen Shot 2015-11-01 at 5.17.07 PM

A over-simplified, and not always correct, way to remember the differences is:
“Transsexual usually implies sexual orientation, ‘who you go to bed WITH’.
Transgender usually implies gender orientation, “who you go to bed AS?’ ” (1)

An excellent illustration of the complex interplay of these two terms is the Amazon Prime video “Transparent” for which Jeff Tambour won a 2015 Emmy for Lead Actor (a term, by the way, that is now often used for both male and female). In the series of 12 episodes we met several transgender characters, some of whom appeared to have had SRS and hormone therapy and some who have not.

What’s the difference between cross-dressers, drag queens, and transvestites?
Transvestites  are people who like to dress and act like those of the opposite sex. In the 1970‘s “cross dressers” was coined by such people who disliked the implications of fetishism or homosexuality in being called “transvestite”. Cross dressers can be private and have any kind of sexual orientation (J. Edgar Hoover?). Drag queens are theatrical cross dressers who are mostly male homosexuals with great pride in their flamboyant entertainment value.

Is a hermaphrodite the same as an infant with ambiguous genitalia?
Rarely an infant may be born with genitalia that appears to be neither clearly male or female (now called “intersex”). It is important for physicians and family to quickly forge ahead in checking chromosomes, internal anatomy, external physical appearance, parental wishes, and other factors to decide quickly which sex the child shall be raised as. Surgically, it is much easier to create a functional female than a male, but many factors are involved. Even rarer is the hermaphrodite who is born with both male and female genitalia. Unlike lesser species, these human hermaphrodites can not self-impregnate, but can apparently have a future career in adult porn.

In recent years our recognition of and services for gender identity confusion in children has increased. In 2007 Boston Childrens Hospital started a Disorders of Sexual Development and Gender Management Service (GeMS). Since then that multi-disciplinary team of 12 professionals have evaluated and treated over 160 pre-pubertal teen agers for gender identity confusion; 75% of whom lived within 150 miles of Boston. (1)  GeMS considers gender identity confusion as potentially life-threatening because of the higher than expected suicide rate among those adolescents not treated. Evaluations are initiated in “gender non-conforming” children  as soon as 10 or 11 years of age. Puberty is delayed by hormonal therapy, and later the child’s gender appearance can be changed to match the child’s mental gender identity through hormones and surgery.

Even a cursory review of these terms, what they used to mean and what they mean today, suggests many PC/sensitivity potholes dotting the road of their practical use. One Boston suburb middle school teacher started the first day of school this fall with a request to her class to indicate “by which pronoun each wished to be called”.  In addition to the grammatically traditional gender neutral terms like “it”, “one”, and “they”, invented gender neutral pronouns exist and include “zhe” and “zher” and “zhem”. (2000). The medical term “gender identity disorder”, disliked by many because it implies a disease condition, is being replaced with “gender dysphoria”.

References: 1. Norman Spack, MD TED talk


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