The Audacity of Poop

Published / by rmaddy / 3 Comments on The Audacity of Poop

“We should be guided by what works.”  –Barack Obama, The Audacity of Hope

It’s flu season again–our annual lesson in biological humility.  A tiny capsule of protein and RNA, 1/20,000,000th our size manages to break through our admirable system of defenses and actually turn them against us, killing a half million people worldwide every year, and leaving more than a billion of us utterly miserable and worthless for 7-10 days.  Medically, our best hope to treat the disease is not to get it at all, a strategy which requires a new vaccine every year, some of which work better than others.  All of this is compounded by the fact that the majority of the population has somehow convinced itself that the flu is no big deal, certainly not worth taking 15 minutes out of one’s schedule and enduring 1 second of mild pain, to prevent.  It’s the perfect recipe for a pandemic, and nearly every year it rises to the occasion.

Today I take a break from transgender education and advocacy to talk about another deadly infection which continues to adapt its defenses, rendering  the treatments which, until 15 years ago, worked in the vast majority of cases, substantially less effective.  This disease, caused by a bacterium named Clostridium difficile–or “C diff” for short–now infects 500,000 Americans per year, causing approximately 30,000 deaths.  In the waning days of November 2017, I very nearly was one of them.  This is the story of a deadly disease which already lies quiet in your intestines and challenges the way we think about bacteria in general.  And, it’s a story where the best hope of cure lies not in medicine, but in shit.

I recently posted regarding my experience with FFS–facial feminization surgery.  I was about 5 days post op at that point, and still really swollen, but optimistic about a rapid recovery.  It turned out to be anything but rapid.  I developed infections in my cheeks which required multiple courses of antibiotics and surgical revision.  Before the dust settled, I had been on antibiotics for nearly 8 weeks.

Four days after taking my last dose of cipro1, the diarrhea started.  C diff most commonly strikes after antibiotic use, when the normal bacteria of the intestines are disrupted.  I was ready for the possibility of C diff.  I had a full bottle of metronidazole–an antibiotic used to suppress C diff2–at the ready.  I started taking it immediately, and the diarrhea lessened as long as I took it.  No tests were done, but I was pretty sure I had it.  I finished my course of metronidazole on Thanksgiving day.

Three days later, my symptoms were back with a vengeance.  This time, the diarrhea came with intensely burning rectal cramps and high fever.  I was at work at the time, and ended up becoming my own next patient in the ER.  Holding off as long as I could stand it, I ended up just flopping onto the cot in Room 4 an hour before my shift ended.  My temperature was 105, my white blood cell count was 4x normal and it took three liters of IV saline to get my blood pressure back above 90.  I had sepsis and there was some concern that my colon had perforated.  This time a stool specimen was collected, and I was started on another antibiotic–vancomycin.  I felt better after IV fluids, but I was admitted to the hospital for a couple of days.  The test result confirmed that I had C diff.

Vancomycin seemed to resolve the symptoms better.  I ended up taking it for ten days–long enough to get some R and R in Hawaii.  I felt like a limp dishrag, but it is better to be sick in paradise than sick at home.  While there, I saw a T-shirt that I liked, but unfortunately not in my size:  Salt Water Cures Everything.  Unfortunately this was not true.  Two days after returning home and taking the last of the vancomycin, the diarrhea returned.

I restarted vancomycin again, and this time got permission from my insurance to go on a new medicine tailor made to treat C diff–fidaxomicin.  I was on the good stuff this time–$100 per pill of pure healing.  I still have half a bottle of it in my purse.  I was sick again within five days and switched back to vancomycin, which at least suppressed the symptoms a little better.  I resigned myself to the fact that antibiotics were not getting rid of the infection, and there was only one treatment left to try.

About six years previously, I had given a medical lecture for our hospital staff on emerging infections.  I covered the latest on Ebola and resistant Staph infections (aka MRSA), but mentioned that an old infection, C diff, was making a resurgence and seemed to be suddenly less susceptible to antibiotics.  The change seemed to happen abruptly in 2003-4.  The disease had literally evolved in front of our eyes.3  I mentioned a new therapy–stool transplantation from a healthy donor–to the audience, who mostly, like me, laughed it off at the time.

Now I found myself desperate enough to try it.  The problem was that it was now Christmas Day and nothing much was likely to happen until after the holidays.  My doctor said she would refer me to a gastroenterologist at Mayo Rochester.  It would probably take about 3-4 weeks to get an appointment.  They did have a stool transplant–aka Fecal Microbiota Transplantation–program.  If I were accepted as a patient I should be able to get the procedure done within another 2-3 weeks.  She would be happy to supply with more vancomycin in the meantime.  Quick math suggested that I was looking at early February, and meanwhile I was still sick, never able to do any better than suppress the symptoms somewhat.  Hope delayed is hope denied.  I wondered what I should do.  More to the point, I wondered what would Angus MacGuyver would do.

I gathered supplies and read up on potential complications.  Most hospital based FMT programs require you to supply your own donor, and subject that person to a lot of testing to prevent exposure to other infections.  My donor and I have shared a bathroom for nearly 30 years, and was not concerned in the least about catching anything from her.  Hospital programs also typically use a colonoscope to deliver a mixture of stool and water carefully prepared and homogenized in their microbiology lab.  I don’t have a colonoscope or a microbiology lab.  I decided to settle for an enema bag and some kitchen tools4.  There is a surprisingly robust DIY community of fecal transplanters online.  I read all that I could from them and from the medical literature about FMT.

One day before the main event, I stopped eating.  I laid out everything in the bathroom and even rehearsed the sequence, practicing shifting from position to position in a manner which would allow my mixture to follow gravity back through the length of my colon.  I drank magnesium citrate to empty out what was left in my gut and waited for shit to happen.  Once it did, the procedure was done in an hour including clean up.  I held the mixture internally for 5 hours.  That night, everything exploded back out.  For good measure, we repeated the transplant the next morning.  This time, nothing came back.  For days.  I have not had a single episode of diarrhea since, nor have I taken a single tablet of vancomycin.

For decades, doctors have prescribed antibiotics for increasingly flimsy reasons to satisfy a patient population that has largely come to expect them.  In so doing, we have created a host of emerging diseases which are resistant to treatment.  The hope has been that even better antibiotics would come along to treat the tougher diseases.  That hope is starting to wear a little thin.  In this particular case, antibiotics gave me C diff, or more precisely, they killed off the normal bacteria that usually keep C diff in check.  I took more antibiotics to kill the C diff, but they could not eradicate the infection.  What finally cured me was not better drugs, but better bacteria, specifically those of my healthy spouse.

C diff may be unique in its ability to be cured by bacteria.  I suspect that it is not.  Regardless, in the long run, we will need to be more prudent, both as physicians and as patients.  Doctors should take the time to explain why antibiotics do not help in viral illnesses (including bronchitis, sinusitis and other upper respiratory infections).  Patients should become savvy consumers, not pushing for medication where time and rest will suffice.  We hope that diseases will become less resistant to antibiotics if we use them less frequently.  Unfortunately, that is only one possible outcome.  The other may be the emergence of a deadly post-antibiotic era, where antibiotic treatment is no longer works at all.

FFS

Published / by rmaddy / 4 Comments on FFS

Image credit David Tenant, Hamlet, 2009

 

The arc of a ball through the air can be described mathematically.  For each fraction of a second, the ball approaches you at a certain rate, drops slightly due to gravity and perhaps curves in one direction or another due to spin.  In a second, the ball moves so far.  In a half second, less.  It is possible to consider smaller and smaller increments of time.  In fact, if you consider an instant, an infinitesimally small increment of time, you may still describe the position and motion in that moment.  To do so requires a branch of mathematics known as calculus.  Odds are, you don’t understand calculus.  Nevertheless, through practice and experience you catch the ball.  Your brain gets calculus even when you don’t.


Something parallel happens regarding gender.  The senses give input to the brain which turns this information subconsciously into complex ratios and estimates of probability.  Men tend to be taller than women, but height alone does not distinguish between them.  Similarly, women tend to speak in a higher pitch, but there is sufficient overlap that pitch alone does not reliably allow for gender recognition.  At any given moment, nearly instantaneously, we measure thousands of parameters in order to classify our human companions with regards to gender.  Most of the time, we are unaware that we are doing it.  In fact, if we try to consciously measure and process data in order to make a gender determination, we suddenly get very, very bad at it.  Our brains are really good at making gender determinations that cannot easily be made if we set our attention to it.

Consider the face.  You recognize the difference between male and female faces, but if asked why you think a face is male or female, you either draw a blank or tend to mention things (shape, for example) that are not particularly potent predictors of gender.  At any given moment your eyes are picking up subtle details and your brain uses this information to calculate ratios which you have probably never considered.  There are nearly 4 billion male and 4 billion female faces on the planet.  They are so unique that even genetically identical twins can be recognized by close contacts.  Somehow, your brain recognizes them as male or female, familiar or unfamiliar and may instantly assign a biographical file to a face before you have a moment to think of it.  And, to today’s topic, you assign gender to a face almost instantaneously, despite the fact that there are four billion men’s faces that don’t look all that alike and four billion women’s faces with the same degree of variance.

Certain patterns tend to hold.  Women on average have smaller heads with smaller features.  The male hairline is a relatively higher “M” to the female’s upside down “U”.  The male forehead slants backward subtly compared to the relatively vertical female counterpart.  The female mandible is narrower, culminating in a somewhat more v-shaped chin.  The male nose to lip distance tends to be longer.  Without even considering the relatively obvious marker of facial hair, there are patterns and ratios which, taken together, help to form a gender impression.

I write today five days post facial feminization surgery,1 still a bit bruised and sore from 6 hours under anesthesia during which dozens of millimeter scale adjustments were made to my features.  When next we meet, you will still recognize me, but your brain will tend to classify me differently.  Some of the changes (higher brow, smaller nose) will already be present, whereas some (lower hairline, narrower chin) may take six months or more to settle.  Although most people have never heard of it, FFS is often the surgery most coveted by male to female (MTF) transsexuals.  It is expensive, painful, and unlike GCS, aka “The Operation,” impactful in day to day social interactions.

Unfortunately, it is also widely considered to be purely cosmetic and elective.  Insurance rarely picks up the tab, and it can run anywhere from $15,000-$50,000 depending on what is done, by whom and in what facility.  Personally, I opted for a fairly limited course, concentrating on the upper part of the face, particularly the forehead, which seems to play a crucial role in how the brain processes gender.  Most transwomen never get the opportunity.  I write this fully cognizant that I am a woman of great privilege.

I also had the procedure done in a local office, which given the length and intensity of the surgery was not the sort of caution I would have preferred, but I am not immune to the economic argument.  And, I seemed to have escaped death, for at least the period of time that I would likely have been hospitalized elsewhere.  It is not my intention to review here the care of my surgeon, but Kathy and I were drawn to him for his reassuring demeanor, his thoughtful listening, his artistic eye and ultimately, his training in complex craniofacial procedures.  I appear to have won the bet, and saved thousands over what the same care would have cost in my hospital system, which as I mentioned, wouldn’t financially support it anyway.

The bruises and swelling are still too extensive to permit much of a look, but I like what I can see.  Mostly, I see my eyes, but the way I think they were meant to look.  The pain is intense, but I was never particularly afraid of that–a few butterflies the day before at most.  My biggest fear was that I would wake up with regret, thinking that I had made some sort of a mistake.  I don’t.  Not one bit.

I hope that my surgery will help you to see me differently, but ultimately it was more about greeting the person I see in the mirror each morning.  I want, in the words once given to me by my friend Anne, to feel at home inside my skin.  Time will tell, but the deed is now done, I am convalescing, and I am feeling very grateful.  I do hope that you will not think me vain.  I am of course, but it’s still uncharitable to think that.  This fixes for me something that was existentially broken for 50 years.

Perhaps my new lines will persuade your brain to accept my femininity.  Nevertheless, I remain ever hopeful that you will accept it for the best reason of all…because I asked.

Sweet Anonymity

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It’s the closest thing to a high holy day for me these days, not that this is saying much.  I don’t have much use for the concept of holiness anymore, with its haughty sense of untouchability, distance and separateness.  Are you apt to swear by “all that is holy”?  Name-dropping of the highest order, IMO.  Perhaps we ought to swear by more verifiable commodities like the greenness of grass, the jerk in accounting or Amazon Prime.™ But I digress…

The (un)holiday to which I refer is, of course, Pride, which also stretches the definition of holiday by extending for the entire month of June.  Practically speaking, though, it amounts (in Minnesota anyway) to a two-day festival of which the most popular event is a roughly half-mile parade down Hennepin Avenue.  Depending on the mood of the LGBT community and the weather, it can be a raucous affair indeed, drawing hundreds of thousands of people.  In 2013, the parade came on the heels of the legalization of same sex marriage.  I remember stepping out into the street at the end, and being one of a somewhat tall disposition, I was able to look far up and down the street, revealing a sea of people that simply dwarfed the crowd of a large stadium, decked out, for the most part in epic rainbow.  Last year, a similar number gathered, yet palpably in the shadow of Orlando.

This year, clouds and wind better suited for late-April provided a tangible reminder of turbulent times.  Stung by the acquittal of a police officer who gunned down a man for calmly complying with instructions to produce a driver’s license, we were forced to reconsider the role of the police our festivities.  Those of us more recent to the festivities have typically experienced  the police as a benign presence at Pride, marching alongside us and dispensing a seemingly limitless supply of smiles.  Still, we recall that Pride started at Stonewall, a direct result of systematic discrimination and police violence, particularly against transwomen of color.  Polite applause greeted a cadre of protesters claiming to represent Black Lives Matter.  Nevertheless, viewers in my immediate vicinity expressed frustration as the parade stalled for more than 60 minutes.

By the time the parade resumed, I was freezing, despite having layered up.  Dykes on Bikes led the procession as always with a roar, producing the usual response of thunderous applause.  The various flags were next.  As the transgender flag passed by, I saw a chance to warm up.  I walked out into the street, grabbed a handle, and marched the rest of the way to Loring Park.

From then on, it was business as usual, as in Target, Delta, Best Buy, health organizations (including those that still deny transgender benefits) and dozens of churches.  I got my 30,000 steps in.  I ate corn dogs and gyros.  I kissed a daschund.  I kept hoping for some great random conversation, but mostly I just made small talk with the various shopkeepers.  Whether there were more present this year or not, police seemed to be ever present, most of them grinning from ear to ear and many with dogs.  And why not?  Pride is always crawling with canines.  I regret that Scooter did not make the trek this year as he has in the past.  Most of all, I reveled in the annual opportunity to walk around and garner no reaction whatsoever.  Sweet anonymity!

I meant to post this summary before June slipped away, but better late than never.  Belated Happy Pride to my readers, who sometime within the past few months hit my pages for the 10,000th time.  I am honored by your clicks and comments.  I do apologize for the slacking pace of this blog.  Chalk it up to a combination of things–at some point one feels that there is very little to say, and at some point the desire to recount my transitional thinking starts to feel like performance art.  I intend to continue writing, but a growing impulse for privacy is competing with my desire to disclose, slowing me down somewhat.  Until next time…

 

Dunsinane. Within the Castle.

Published / by rmaddy / 1 Comment on Dunsinane. Within the Castle.

His elbow caught me more or less in the center of my abdomen.  Instantly, accident scene reconstruction commenced.

Option #1.  I walked into somebody.  Sure.  I do this, particularly but not exclusively when I am lost in thought.1 Ordinarily my well-honed reflex to beg pardon would engage at this point, but paradoxically the moment of contact found me unusually dedicated to interpersonal spacing.  Specifically, I had chosen an opening at the luggage carousel where I would have the best chance of extracting my heavy ass suitcase without risk of jostling or be jostled.  The elbow did not compute.  My brain sought more information.  It came as I made eye contact with the other party and noted that rather than registering the expected surprise, he was smiling.

Option #2.  I must know this person.  Memories of past chance encounters in the airport begin to percolate towards the surface, only to be superseded by the frantic urgency of identifying the face before me.  This is not a talent for which I am recognized.  I feel a bit queasy, whether from the potential embarrassment of being recognized without recognizing or an increasing insistence by my usually passive abdominal wall that I suddenly pay attention to it.

He is short.  Slightly built.  Blond.  Roughly twenty-five.  The only friends I have in this age group are musicians and wannabes.   A patient perhaps…then why the touchy-feely familiarity?  A co-worker’s spouse?  Dammit.  No match.

The encounter approaches the ripe old age of four seconds.  He starts circling to my left, eyes locked, smile shifting ever so slightly into a display of teeth, holding a distance of 20-25 feet. I recall the elementary school playground and those TV specials about hyenas.  Option #3 begins to take shape.

I voice it first as a question:  “Oh my God…did he just hit me?”  My subconscious runs with this, and starts laying the groundwork for a shift from “What?” to “Why?”  It will have precious little time to proceed.  He is about to speak, thereby signaling the end of the internal inquisition.

Good luck with the operation.

He continued to my left, and while I considered whether to believe my ears, he repeated it, so as to register his preference that I do.  Well, thanks…I suppose…although I didn’t recall bringing it up.

That’s as far as the story goes.  If the dissection of my thoughts seems overly detailed, it is only because there is nothing else to report.  In striking me in the center of my spare tire, he chose the one target where he was least likely to do much damage, his elbow bouncing harmlessly away like a pebble on the roadway.  Parenthetically, this happened not in the ruby red state of Texas, from which I had presently returned,2 but in brilliantly purple Minnesota.

I don’t know what impression will linger in the months to come, but the early verdict is that I had no good options.  Whereas my youthful self was directly and indirectly trained to resist a bully, it now occurs to me that most often resistance really is futile.  I am aging and recently, quite achy.  My size no longer protects; it only identifies me as a target.   I have also acquired just enough wisdom to know that answering petty violence with more petty violence would put me on level with this little cretin.  There was nothing whatsoever but to wait for the end of the scene.

I offer this story with no moral attached unless it is that shit happens.  I’ll brood, and verbally process and move on.  Eventually something else like this will happen and I’ll go right back to Square Fucking One.  Repeat until you can’t.

Life’s but a walking shadow, a poor player
That struts and frets his hour upon the stage
And then is heard no more: it is a tale
Told by an idiot, full of sound and fury,
Signifying nothing.

 

Check the Math

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[There are] lies, damned lies and statistics.  –Mark Twain

It will not surprise you to hear that I follow a number of transgender news feeds.  Staying abreast of happenings within one’s broader demographic requires some discipline, particularly when one’s “broader demographic” is rather narrow.

As with news in general, transgender news reads a bit dark.  Violence makes good television, at least if ratings are any clue.  Following this trend, it has become increasingly common for transgender murders to be not only reported, but counted, as in, “This marks the ___th murder of a transgender person this year.”  The final tally last year, according to The Advocate, was 27.

I understand what The Advocate and others are trying to do.  Shining a light on anti-transgender violence is part of the process of curtailing it.  Further, each death represents a grim loss–first and foremost for the individual, then outward to their families, friends and society in general.  I applaud that they are individually remembered and lamented.  I feel their deaths somewhat more closely than the average murder because I identify with the class struggle which often lies beneath it.

But let us not too quickly get lost in the numbers or gloss over ridiculous phrases such as “the average murder”.  The reason that some of you might not have choked on these words the first time I used them owes largely, in my opinion, to the fact that murder is anything but rare.  In 2015, there were 16,000 murders in the USA, and by all accounts the final numbers for 2016 look to be higher.

Each one of the victims reflects an epidemic of violence that we, as a nation, have done little if anything to address.  Indeed, we tend societally to respond to rampant violence by buying guns, a remedy which has been proven to double the likelihood of being murdered and triple the chances of dying by suicide.  Of course those stats don’t apply to us, right?

Let’s do the numbers:  27 transgender murders.  16000 total.  This means that, if reported accurately, transgender people, who represent perhaps 0.3% of the population, account for less than 0.2% of US murder victims.  The problem isn’t necessarily that we have a transgender violence problem specifically, but rather that we have a violence problem in general.

By all means, let us mourn and remember the dead, not just as numbers, but as individuals bursting with unrealized promise and potential.  Let us feel the outrage inherent in the fact that someone was killed for being who they are.  Nevertheless, let’s not get too parochial about it:  Trans people really are killed for being trans, but likewise children are killed because they are children.  Women are killed because they are women.  The poor are killed because they are poor.  Murder is the ultimate affront to egalitarianism.  Somehow, somewhere, someone was deemed to be expendable.

That.  Let’s stop that.

 

Unfinished Business

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Occasionally a patient or family member will call the ER to say that they are on their way in to see us.  Similarly, radio traffic alerts us to the dispatch of ambulances in the surrounding communities.  I refer to potential patients not yet within our walls as “lurkers”.  Thus, when asked if I am busy, I might respond, “3 here, 2 lurking.”  The lurking patient has already entered into my problem-solving calculus, and perhaps not in the manner you might expect:  lurkers count double.1

Why, you might ask, should this be the case?  Is not a bird in the hand worth two in the bush?  Quite the opposite, as far as I am concerned.  There are many words that might be used to describe what I do at work:  diagnostician, comforter, risk manager, explainer, and so forth.  In order for me to be an Emergency Physician, however, something else must be in the mix.  I am someone who finishes shit.  I meet people, enter into their dilemma and, to whatever extent possible, solve the problem.  At the very least, I figure out how it is going to be solved.  Quickly.  Perhaps you have a physician who knows you like a neighbor and who will walk with you through decades of sickness and health.  That’s not me.  I’m the one who checks out at 7:30.  I do as much as I can as well as I can, then I go home.  I am a specialist of the first hour, sifting through the problems of the day and always trying to be maximally prepared and available for the next bad thing that happens.  You need me to have such an outlook–the next disaster might befall you, and you will want my full attention at that time.

A lurker is a person I cannot yet help, a problem I can not yet solve.  If the lurker would kindly arrive, then we might make some progress together.  A job begun really is half done, as far as I am concerned.2  Until then, I have unfinished business.

I dislike unfinished business.  I paid off my 30 year mortgage in 12.  Don’t ask me to pledge x number of dollars for every mile you walk.  Tell me rather how much you want and how I can complete the transaction online right now.  No, I’m not interested in a wine-of-the-month club, and hell yeah–I belong to Amazon Prime.

By now you’ve guessed the segue, and if it sounds familiar, I think it is because I have riffed on it before:  transition is seemingly endless.  Whether it is actually endless, I cannot say.  I have met plenty of people that speak of completing transition in such and such a year, but the very fact that I have met them usually owes to their presence in transgender support groups.  Maybe they are Bodhisattvas, remaining among the transitioning to help us along our way.  Following that analogy, though, I wonder if transition, like enlightenment, is more something that you habitually do than a place you arrive.3  Use it or lose it.

But oh, how I hope it is a destination!  I even know what it would look like:  a state of happiness and coherence.  In this respect my goals are not much different than those of anybody else.  It doesn’t really matter how one gets there, so long as one gets there.  If the journey  itself is the reward, however, then I could end up nearly anywhere.  One can get in decent shape even by running after nothing, but in line with my introduction, I have always proceeded under the assumption that the point of a race is to break the tape at the end.

There you have it–a perfect recipe for my restlessness and a plausible explanation for why I intermittently flip out.  For me, there is not a reliable degree of joy in the journey, only the sense of not having arrived.  A friend of mine bears a tattoo stating, in oriental script, “Not all who wander are lost,”4 but I secretly suspect a healthy percentage actually are.  I certainly am.  This is hard…really hard, and I don’t know if I’ll ever, as the Scots say, “Get on wi’ ae.”

I believe people who say they have completed transition.  They own their stories, just as I own mine.  The sense I have gotten from speaking to several who have said so and from reading the blogs of others though is that they are referring very specifically to gender confirmation surgery (GCS), i.e. when they had their fun bits rearranged.  This is certainly understandable, since society in general thinks is what transition means.  Apparently, at least for some,  this really can be the end of the road.  The tricky part is that we are all on different roads and I don’t think we can infer too much from the experience of others.  The end of my road, you recall, is primarily defined by a mental state–happiness and coherence.  There doesn’t seem to be any guarantee that these things follow surgical transition.  The people I know post-GCS appear to fill a broad spectrum between happy and miserable.  Having major surgery because someone else said it helped them is flawed process.5

I experience transition as a mental phenomenon.  It is in my mind that I envision happiness/coherence and in my mind that I suffer its absence.  When you ask me how I feel, I think I can safely assume that you refer to my mental state, not my genitals.6  I publish my story largely to help me “think things through”–now there is a metaphor–hoping along the way to help the next transgender person do the same.  When I blew an emotional circuit breaker last month, I called my psychiatrist, not my endocrinologist.  It is in my mind where my demons lurk7, and it is there that I go to fight them.

I was raised this way, taught that my mind would “take me far.”  In some sense, it has, and yet I recognize that my religious upbringing thoroughly stigmatized “the flesh” as corrupt.  I often wish that I had recognized myself as transgender when I was younger, but I don’t see how that would have been possible.  I didn’t have the tools.  Speaking to another issue, but with great eloquence, my sister once remarked, “We were raised without bodies.”  She has since found hers back but I am still looking.

I have moved on, but I still tend to forget that the mind/body dichotomy is a metaphor.  It is often a useful metaphor, but metaphors have their limits.  We ought not to eat the menu.   Humans do not think, octopus-style, with their arms, but the brain is nevertheless thoroughly embodied.  When I deal with depression, I experience physical pain in my upper abdomen strong enough to wake me from sleep.  In my summary of a year on estrogen, I recounted what I was hoping it would do to my mind, and how surprised I was by how quickly it was messing with my body and that the things it was doing to my body were affecting my mind.  Well, duh…I need to stop being shocked by the obvious.  The term transgender would be meaningless if I had no body.

I have a body.  It’s that tall thing that glares at me from the other side of the mirror, every damned time I look.  It knows that I don’t like it and I can tell that the feeling is mutual.  Lately, just to piss me off further, it has been getting older.  Perhaps someday we will call a truce, but for now, we scowl at each other like old enemies, each demanding that the other surrender.

Unfinished business.

 

 

There are no happy endings.
Endings are the saddest part, 
So just give me a happy middle
And a very happy start.

Shel Silverstein, Every Thing on It

Footnotes

This or That?

Published / by rmaddy / Leave a Comment

My name is Renae Gage8 and I am a binary thinker.

If I was ever anything else, it was far away and long ago, lost even to memory.  Not 100% of the time of course.  It do hate peas and carrots more or less equally, and I observe that some folk really are a little bit country and a little bit rock and roll.  Nevertheless, binary thinking is my tragic flaw, the pit into which I regularly fall.  “As a dog returns to its vomit,” offers the scriptures, “so fools repeat their folly.”

Speaking of which, I blame religious indoctrination for this rut in my thinking.  I was raised on Heaven and Hell, good and evil, darkness and light, blessings and curses.  The stripe of Christianity which I was force-fed does not do nuance well.  Whether this only amplified some innate tendency within me or produced it out of whole cloth, my reflexes are honed to a razor’s edge.  Where others see similarity, I see difference.  My contrast knob 9 is dialed to the maximum.

The fact that I have rejected the crucible in which I was fired is of no consequence–the pattern is etched in my brain, and there isn’t a hell of a lot I can do about it.  In fact, the manner in which I extracted myself from religion looks just as binary–some people just file their faith on a dusty back shelf and ignore it.  I sent mine packing, barred the doors and secured a restraining order lest it ever contemplate a return.

Being a binary thinker is a serious bummer as a transgender person.  It has taken a Herculean effort for me to understand, for example, gender as a spectrum or, even more, as a social construction.  To be sure, I understand it up here, but not so much in here.   Note to self:  add head/heart to my list of artificial binaries.

It seems that the difficulty is primarily internal.  I have friends who reject gender completely and I think I am able to take their assertions at face value.  Nor would I think any less of another trans person who told me that they don’t fit neatly into the boy or the girl box.  I thoroughly accept that people are, so long as they are honest, exactly who they say they are.

For me, however, the binary tyrant lives.  I am unable to shrug at my variance.  Every day, I run into people who are ostensibly 100% male or 100% female with the singular exception of my morning encounter with the mirror.  I can opine until I am ROYGBIV10 in the face about gender as a spectrum, but waiting for me around every corner are two little boxes labeled “M” and “F”.

Nor is it just me, society.  I hear your “Good night, ladies.  Good night, Renae.”  I feel your hand-crushing handshakes and bro hugs.  I notice the angle of your lip when you stare at me in the checkout line.  Nevertheless, I recognize the steep discount I am getting.  In some places, the price is much, much higher.

I don’t believe in a world without gender.  I don’t feel genderless.  I feel feminine.  While the younger generations may be starting to chip away at the moulds, most of us were already hardened in them.  I’m told that I need to let go of the binary.  What if I can’t?  What if this also is simply something that is?

I’ve had the privilege of meeting more and more trans people.  Some are happy and others not so much.  Almost none of them are “embracing the broader gender continuum”.  To an individual, they all seem to be crawling into the “other box” and closing the lid.  The ones who fit in the box better seem to be happier.  Maybe that’s all you can do.  You can’t beat everybody.

Into the darkness

Published / by rmaddy / 6 Comments on Into the darkness

The first storm of winter is upon us.  The early indications predict that we will escape the heavy snow this time, but we have already been treated to gusting winds, steeply dropping temperatures and some sort of snow/sleet/hail thingie that didn’t do any damage, but produced an absolutely deafening roar on my windshield as I headed into work this morning.  Twas the witch of November come stealin’, as the prophet Gordon1 once intoned.

As much as I hate winter, I love a good storm.  Any storm.  I love “sheltering in place,” as they say, looking across the hills and fields out the back (southwest) windows of my home.  I don’t cower in the basement.  I grab a camera.  I step out of the front door to welcome the arrival of the new wind, to take in its measure and flavor.  In my formative years, I loved to go for a run during the height of a downpour, especially when the streetlights were knocked out.2  Like Lieutenant Dan, I climb to the top of the proverbial mast and taunt the sky:  “Is that all you’ve got?”

But not all storms are weather.

There are other kinds of storms which terrify me.  They paralyze–stunning me with a dizzying barrage of emotional lightening and pounding me with the thunder of confusion.  The very foundations of my life erode and I cascade downstream into Mare Crisium–the Sea of Crisis.3  It is there that, for the last several weeks, I have been treading water, at times with some success, but occasionally sinking beneath the waves of doubt.

Enough with the metaphor?  I suppose, but then again, you have never known me to be a particularly linear writer, and, as I have found myself saying more than once recently, I am not at my best.

I prefer to narrate the storm from the relative safety of its aftermath.  “Hey, things got bad, but look at all the nifty rainbows now!”4  I seem to be okay with vulnerability, but usual only with a certain degree of retrospect. I am not immune to shame.

I struggle to find a pathway into describing my whereabouts, but I think the storm is the best place to start.  I am prone to disruptions.  They strike without much warning and make a tangled mess of my thoughts and self-confidence.  If there are warning signs in advance, I am blind to them.  They are infrequent enough lull me into the delusion that they are done and gone.

Almost exactly three weeks ago, I was beset by crippling doubts about my identity.  True, there has always been a “female gravity” bending the trajectory of my life in the direction with which you have become familiar, but this crisis began with an overwhelming sense that, wherever I seem to be headed or feel I need to be, where I am isn’t identifiably feminine to most people, nor, during these dark hours, to me.

The disruption seems to be centered on two perceptions which still loom large in my present state of mind.  First, it is far more than the physical which separates me from other women.  I have been denied (or spared) the particular rhythms and discomforts of feminine physiology, but perhaps even more significantly, I have missed out on so many formative experiences:  I did not grow up in a world which devalued my gender.  I have not been groped or ogled by predatory men.  My size has conferred upon me a degree of protection from conflict.  I have been rewarded, not chastised, for “speaking out”.  I have made one dollar on the dollar.  I have not been asked on a date, nor spent any time worrying that this would never happen.  I have not spent a lifetime being conditioned to fret about my beauty.5  Not only did I get math (many women do, of course); I learned early that I must get math.  Though I have always made friends with women far more naturally than with men, have I ever truly convinced either them or myself that I am one of them?

I am unsurprised that this hit me so hard during the run up and run off of the election, whether or not this was actually the trigger.  Misogyny offends the hell out of me, but have I ever actually felt it?  As much as I desired the election of HRC, would it have produced any sense whatsoever of existential validation for me?  I was born into nearly every privilege imaginable.  What right do I have to see myself as a citizen of Pantsuit Nation?

The second perception was that my identity seems to be largely aspirational.  Am I female or do I simply experience intense conviction hat I ought to be?  I was trained to believe the unbelievable–is this simply the latest version?  Yes, masculinity took effort for me, but does femininity take less?  Without imaging that other women sail from moment to moment free of self-doubt, I observe that they never have to spend a moment convincing anyone else, let alone themselves, of their gender.  I do not think that this is merely to say that I don’t pass in society.  The question is whether I even pass to myself.  I fit the typical profile of a late transitioning transsexual–white, XY socialized male, melancholic, above average intelligence6.  Is there any sense in which transphobic critics, who see my identity as a sustained delusion, have a point?

Suffice it to say, the last several weeks have sucked mightily.  For the first 4-5 days, I was back to being a squirrel in the road, unsure which direction to run and consequently immobilized in front of the approaching headlights.

“Forward?  I can’t go forward!  Back?  I can’t go back!  Oh God, I definitely can’t stay here…”

My brain flip-flopped rapidly, wanting desperately to decide or better, to do something, and yet I knew there was nothing to do.  I just wanted to go back to bed so I could shut it out for a bit.

Fast forwarding a couple of weeks, the intensity has dialed down a little, but I’m still “dazed and confused”, and worse, worried that I won’t ever be able to un-think some of the thoughts of the last couple weeks.  And there is no resolution, no personal victory to report.  I still feel the wind and hear the thunder.

More ominously, this is the first time I have gone through this post-hormonal therapy.  There is certainly a lot more to the sense of calm and general well-being I have tried to convey beyond freedom from crisis, but until now, I really did have freedom from crisis.  For 18 months.  Even more, it had the feeling of resolution.  Peace was the benefit of therapy that justified the various downsides.  What now?

I don’t really know, and I don’t know when I will find out.  Sorry, there is no moral to this story.  Sometimes there isn’t.

 

 

Notes:

Out of the Woodwork

Published / by rmaddy / Leave a Comment

Minnesota…ever a blue state.

We’ve doubled, it seems.  In 2011, the William Institute (UCLA School of Law) estimated that 3 out of every 1000 Americans–a total of 700,000–identified as transgender.  Now, their most recent study suggests that the actual figure is twice as high.  1.4 million, or 0.6%, of Americans identify as transgender.  The vivid blue color of my home state, above, indicates that Minnesota has the highest proportion of transgender residents in the midwest.7

I see this as very, very good news.  At this rate, we will take over the world in less than 40 years, well ahead of schedule.  Long live the transgender agenda!  Chill the champagne and check to see if Lady Gaga is busy in the summer of 2055…

Of course, it might just be possible that the doubled estimate has nothing whatsoever to do with an increase in transgender people.  More mice crawling out of the woodwork could owe to a bumper crop of pinkies,8 but it might also mean that the cat has gone on vacation.  Translation:  it is likely that more transgender people are being identified because they are less afraid to be out.


Being transgender in a small town can be a lonely business, but not everything is as it seems.  Before I came out (somewhat before the 2011) survey, I could have never imagined that there were 20 other trans people in my little hamlet.  If this were the case, why wouldn’t I have already met some?  Such is the ironic reasoning of the closeted individual.  Invisible at the time myself, I wondered that others were not more apparent.

Eventually9 I realized that I hadn’t met other transgender people because I had never tried, and I really wasn’t paying much attention.  Further, I came to grips with the fact that I was afraid to meet others like me.  What if I didn’t like them?

I got out more.  I tried a couple of support groups.  Most of all, I stepped out into the open myself.  There is simply no better way to meet transgender people than to be openly transgender10  Fairly quickly I discovered that belonged to a largish cohort of people that I had never even noticed before.

Additionally, I found that the skill of noticing gets better with practice.  Walking through my town festival last week, I spotted several transgender people in the crowd.  There is sort of a secret nod that increasingly happens.  In my medical practice, I meet upwards of 1000 people every year.  I suppose that my social interactions add a few hundred more.  The current research suggests that about 1 out of every 170 are trans.  I do directly experience that proportion, but I no longer doubt that it is the case.  Not everyone who is trans is noticeably so.  Some are not out at all and are performing their expected gender.  Others have the privilege of passing,11.  And, if I’m honest, most of the time I’m still not paying attention.

I still feel like a zebra among horses, but there really is a degree of strength in numbers.  Besides, one could do far worse than to be a zebra.

Vote Trans 2016

Published / by rmaddy / 1 Comment on Vote Trans 2016

What a difference a year makes.  At this point last fall, I predicted that anti-transgender bills would continue to proliferate (as they did in 2015) and that transgender rights would remain a contentious issue in state and national politics.  Instead, 2016 has become a referendum on economic and racial grievance as well as an increasingly nauseating contest of personalities.  Yippee!  We’re off of the hot seat, at least for the time being.

I’m sure that your political views, like mine are a conglomeration of a variety of opinions to which you give degrees of weight as you approach election day.  Trans issues, as you might expect, are weighted rather strongly in my calculus.  That you are reading this at all leads me to expect that you assign some importance to transgender politics, but what, if anything, does that mean in a practical sense as one enters the voting booth?  In other words, what might it look like to “vote trans” in November if nothing else mattered to you?

Presidential

Four candidates remain for the Presidency.  Reading “from left to right”, their positions on transgender issues are as follows:

Jill Stein–thoroughly on record in favor of LGBT rights, she also states explicitly that transgender rights fall under the heading of existing protections against discrimination based on sexual identity (similar to the declaration in the Minnesota Human Rights Act of 1993, which defines transgender identity as a sexual orientation).  Some trans advocates chafe at this designation.1  Nevertheless, this approach works has resulted in durable human rights protection for trans people wherever it has been enacted.  In other words, there is a semantic quibble, but no broad concern on policy direction.

Hillary Clinton–consistently supportive of transgender rights and inclusive of trans people within her circle of advisors.  As Secretary of State she changed changed the internal policies to prevent anti-trans discrimination and re-wrote the procedures for issuance of a passport such that trans people do not need to prove a history of genital surgery prior to changing their gender marker.

Donald Trump–apparently personally disinterested in LGBT rights as a political issue.  There is no evidence that he discriminates against LGBT employees in his business.  His only public comment on trans rights during the current campaign indicated a belief that transgender people should be allowed to use the bathroom facilities with which they felt comfortable.  Due to a reaction from his party, he subsequently walked this back, saying that he would “leave it up to the states.”

Despite managing to insult nearly everyone during this campaign, he has not made any truly inflammatory remarks against trans people.  He somewhat famously said that if Caitlyn Jenner came to his hotel, she could use the women’s room.  During primary season, his relatively easy-going attitude about the LGBT community stood in stark contrast to the nearly daily anti-trans pronouncements of his closest Republican rival, Ted Cruz.

That said, trans people have some cause to be wary of Trump’s candidacy, if not his personal opinions.  First, trans people aren’t generally comfortable with dealing with transgender rights at the state level.  During a recent business trip, my stopover was changed from Phoenix to Dallas/Ft Worth.  On landing, I could not recollect whether using the women’s room was illegal, and I believed (with some cause) that the local culture in which I found myself was substantially more hostile than the Land of 10,000 Lakes.  When, in the past, we have left civil rights up to the states, the end result has tended to look like a historical re-enactment of the Confederate succession.

Second, Trump nominated Mike Pence to serve as VP.  Pence was the pioneer of so-called “religious freedom laws” at the state level (as governor of Indiana) which were written in such a way as to open the door for sanctioned discrimination against LGBT people.  True, he ended up walking back this stance after threats of a national boycott, but he established the template that North Carolina, Mississippi  and others would subsequently follow.  The media have tended to interpret the appointment of Pence steadiness to counterbalance Trump’s erratic nature.  LGBT people see Pence as a dog whistle to culture warriors.

Third, Trump’s publish list of potential judicial appointments (which was lifted wholesale from a pre-existing RNC list), includes a number of justices who have already voiced opposition to gay and transgender rights.  Whatever Trump’s personal tolerance toward LGBT people, he shows no reluctance whatsoever to throw us under the bus to appease his base.

Gary Johnson–supports LGBT rights in general, stating a libertarian desire to “keep government out of the bedroom.”  Although he has not said much about transgender rights, he was early, at least among conservatives, to support marriage equality.

In summary, a voter prioritizing candidate stances on transgender rights above all else would have most cause to trust Clinton, but might comfortably end up backing Johnson or Klein as well.  Trump the man doesn’t seem to harbor any personal animus against trans people,2 but Trump the candidate has taken on associates and policies far more hostile to the advancement of LGBT rights in calculated moves on the pathway toward his election.

In the grand scheme of things, however, the trans-conscious voter probably would not sweat the Presidential election too much, if at all.  The reason for this you have already guessed:  the battle lines in the battle for transequality are drawn not so much in Washington DC as in the state houses, city councils and school boards.

As I mentioned, the wave of specifically anti-trans legislation (mainly bathroom bills) we saw last year seems to be losing a bit of energy.  There are a few reasons for this.  First and foremost, the corporate response to such legislation was swift and unambiguous.  Companies will halt expansion or worse in states that pass bigoted laws.  Transphobia, like homophobia is bad for business.

Second, in anything beyond the reddest of states, voter backlash is a real problem for those facing election.  I have previously written about the 2012 Republican implosion in Minnesota after their bigoted crusade of 2010.  More recently, Governor McCrory, the architect of North Carolina’s anti-trans bathroom law is poised to lose his re-election campaign, and there is concern within that state’s GOP that the backlash against McCrory might spill over into the Presidential election, essentially blocking Trump from any chance of victory.  If McCrory loses, which seems increasingly likely, his political career is over.

Finally, state and federal courts are ruling against such laws.  There is a growing sense that the issue of transgender equality will be resolved much in the same way that marriage equality was in 2015.  Both pro- and anti-equality advocates suspect that a game-changing ruling is coming, making expenditure of political capital on what will likely prove to be temporary legislation does not make sense.  Instead, each side is nationalizing the fight, hoping for a more favorable court.  Meanwhile, trans-conscious voters can become more savvy voters by carefully listening for the dog whistles within the broader campaigns.

The most shrill is that religious freedom is under attack.3  Of what does this attack consist?  If the “corrective” legislation is any indication, the threat is that it is becoming more difficult to discriminate against others with impunity.  In addition to anti-trans proposals, there are growing movements to favor “European”4 and Christian immigration despite the fact that the most severely oppressed refugees are brown and Muslim.  Churches still pay no taxes, enjoy broad protections to discriminate in their hiring/firing practices even when it violates federal law, and polls regularly demonstrate that Republicans would sooner vote for Democrats and vice versa far more readily than either would vote for an atheist.

Lately, an even louder chorus is booming: we must protect our children.  Not from poverty, inadequate education, measles, air pollution, racism or school shootings.  No–our children are threatened by transgender kids, who are willing to subject themselves to anxiety, social ostracism and daily abuse in hopes of seeing your kid partially naked before gym class.  Be afraid.  Be very afraid.


At the beginning of this post, I enjoined you into a thought experiment in which you would vote based on transgender issues alone.  Let us put that thinking aside once again.  I do not advocate one-issue voting.  Nevertheless, if someone you know is transgender, or if trans people simply matter to you in general, elections are a time of great angst and greater opportunity.  I would ask you simply to factor our concerns into your electoral calculus.  Whatever your political assumptions, please do not leave your voting decisions until the afternoon of November 8.  Read.  Ask.  Contact.  Consider.

Vote.