Exhaustive Study Notes: Non-Maleficence for LGBTQIA+ Patients by Jensen Fisher
Speaker Introduction and Personal Background
Jensen Fisher is an Assistant Professor in the Medical Humanities department at Rocky Vista University (RVU).
Fisher specializes in scholarly communication as a research librarian and is involved in various tracks and special programs, including evidence-based medicine.
Fisher identifies as a transgender man and shares his lived experience navigating the healthcare network as a person within the LGBTQIA+ community.
The lecture was requested by Doctor Thornock to address the clinical and ethical nuances of caring for LGBTQIA+ patients.
The Ethical Foundation: Non-Maleficence in LGBTQIA+ Healthcare
The primary ethical focus is non-maleficence, the principle of "do no harm."
Jensen Fisher emphasizes that the existence of LGBTQIA+ people is not a debatable topic for agreement or disagreement; they are human beings deserving of safety, dignity, and care.
Physicians are bound by an ethical duty that transcends personal beliefs. Personal beliefs must never justify neglect, mistreatment, or denial of care.
Harm in a clinical setting occurs through: - Action: Refusal of treatment, judgment, or treating patients as "problems to be solved." - Inaction: Ignoring pain, delaying care, or withholding compassion.
The standard for medical professionals is not merely tolerance but the dedication to protect the well-being of all patients with equal skill and respect.
The Narrative of Transition and the Search for Authenticity
Fisher identifies as a "late transitioner," beginning his transition journey at age .
He references a quote by Alexander Leon: "Queer people don't grow up as ourselves. We grow up playing a version of ourselves that sacrifices authenticity to minimize humiliation and prejudice. The massive task of our adult lives is to unpick which part of ourselves are truly us and which parts we've created to protect us."
Fisher describes his previous life as living in a "hollow" manner, wearing an uncomfortable costume as a woman for years to survive socially.
The transition "click" or "egg cracking" moment occurred in at RVU while Fisher was the faculty advisor for Medical Students for Choice and assisting Doctor Rachel Linger with a production of the "Vagina Monologues" for Safe House Denver.
Watching women connect deeply with their femininity made Fisher realize he did not relate to it at all; he describes his social survival as being like a "gay man dressing up as a woman" to endure the world.
Five years later, Fisher reports feeling "at home in my skin" for the first time, noting that transition is about becoming the person one was meant to be rather than following a trend.
Fundamental Concepts: Gender, Sex, and Sexuality
Fisher advocates for avoiding assumptions of heteronormativity (the assumption that being straight and cisgender is the universal norm).
Inclusive Language: - Avoid gender-specific terms like "husband" or "wife," which assume heterosexual dynamics. - Use gender-neutral terms such as "partner," "parent," or "relationship" to hold space for LGBTQIA+ individuals.
Three distinct concepts: - Gender: A social construct regarding how one understands themselves and interacts with others; expressed through behavior or physical appearance. - Sex: Biological characteristics historically categorized as male or female, though intersex variations exist. Fisher notes that even biological markers are not static (e.g., a woman remains a woman after a mastectomy or oophorectomy). - Sexuality/Sexual Orientation: Who a person is romantically or sexually attracted to ("who you love").
Gender Identity Terms: - Transgender: Coined in the early s; describes people living in a gender not associated with their birth genitals. - Cisgender: Coined within the transgender community; the prefix "cis" is Latin for "on this side of." It describes individuals whose gender identity aligns with the sex assigned at birth. Fisher clarifies it is not a slur, but a descriptive label.
Historical Context and the Statistical "Spike" (The Left-Handedness Analogy)
Critics often view the rise in LGBTQIA+ identification as a "social contagion."
Gallup Data (): Approximately of Gen Z identifies as LGBTQIA+.
Left-Handedness Analogy: - Approximately of the world population (roughly people) is left-handed. - Historically, the Latin "sinestra" (left) was associated with the "sinister" or witchcraft. - Children were often forced to write with their right hands until social acceptance grew in the s and s. - When the stigma decreased, there was a statistical spike in left-handedness that eventually leveled off. This was not a contagion, but a reflection of safety for people to exist as they are. - Fisher argues the same phenomenon is happening with LGBTQIA+ youth: it is not a trend, but a result of it no longer being a "death sentence" to be out.
The Landscape of Discrimination and Legal Inequalities in the United States
There is no comprehensive federal law protecting LGBTQIA+ people from discrimination based on sexual orientation or gender identity.
Discriminatory State Statistics: - Public Accommodations: states allow refusal of service; affects of LGBTQIA+ Americans. - Housing: states allow eviction or denial based on identity; affects of the population. - Credit/Lending: states allow denial of loans/mortgages; affects of the population. - Adoption: states lack protection; states allow agencies to refuse service. - Fostering: states lack protection; states allow rejection based on identity. - Parental Leave: states lack protections for LGBTQIA+ parents. - Youth in Schools: states lack anti-discrimination laws; states ban protections outright; states lack anti-bullying policies; states ban anti-bullying protections. - Conversion Therapy: states have no ban; have partial bans. Those exposed to it have the odds of lifetime suicidal ideation and greater odds of planning a suicide attempt. - Crime/Defense: states do not classify identity-motivated crimes as hate crimes; states allow the "gay panic" or "trans panic" defense in violent crimes/murder. - Healthcare Access: states lack shield laws for transgender care; states do not protect against insurance exclusions for gender-affirming care.
Systemic Failures in Healthcare: Case Studies and Clinical Experiences
of transgender Americans lack regular access to healthcare.
LGBTQIA+ health disparities (Bisexual/Lesbian women): - more likely to smoke; higher rates of alcohol abuse, obesity, depression, and anxiety. - Significantly less likely to get regular mammograms or pap smears due to fear of provider discrimination.
Case Study: Yiwong Chung: - A transgender man diagnosed with Stage breast cancer after top surgery. - His doctor did not know how to code him in the system, leading to initial misses. - His roommate (also a trans man) simultaneously suffered from undetected ovarian cancer because doctors weren't checking biological female organs in patients perceived as male.
Case Study: Cameron Whitley: - Needed a kidney transplant. His severity was measured by EUGFR (Estimated Glomerular Filtration Rate). - Because he was registered as male, doctors used the male cutoff; however, based on the female cutoff, he would have qualified for a transplant immediately. - This misalignment delayed his placement on the transplant list for over a year, nearly costing him his life.
Personal Anecdote (Jensen Fisher): - Fisher received a panicked call from a nurse at the UC Integrated Transgender Health Clinic regarding "dangerously high" testosterone levels. - The nurse had failed to realize the levels were perfectly normal for a male range, which was intentional for Fisher's transition. - Fisher emphasizes the exhaustion of having to be an advocate and educator for your own doctors in every appointment.
Understanding Gender Affirming Care (GAC)
Definition: Treatment intended to improve quality of life by facilitating a physical state representing the patient's sense of self.
The "Double Standard" of GAC: - Fisher argues most plastic surgery is "gender-affirming care": hair plugs, jaw surgery, breast implants, waxing, and electrolysis for cisgender people. - Society accepts these interventions when they affirm the sex assigned at birth but creates moral/ethical quandaries when used to affirm a different gender.
Models of Care: - Informed Consent Model: Patients are informed of risks/benefits and make their own decisions. Common in Colorado, but often resisted by insurance providers. - Gender Dysphoria Diagnosis (DSM-V): Requires psychiatric evaluation and often letters of recommendation. Fisher describes this as "gatekeeping" and a "mental diagnosis that's not a mental diagnosis."
Historical context of DSM: Homosexuality was classified as a mental disorder until .
Fisher provides the example of a cisgender female friend with PCOS (Polycystic Ovarian Syndrome) who took Aldactone (a testosterone blocker) to conform to female beauty standards. This is considered acceptable medical care, yet identical treatment for trans women is often scrutinized.
Pediatric Care: Puberty Blockers and Transgender Youth
WPATH Guidelines: Puberty blockers can start at Tanner stage . - Typical ages: to (AFAB) and to (AMAB).
Original Purpose: Developed for cisgender children with "precocious puberty" (starting before age or ) to prevent short stature and social distress.
GAC Purpose: Provides a "pause" for youth to explore their identity without the trauma of transitioning through the wrong puberty. Results for binary trans people are often better if they start before bones fuse and secondary characteristics fully develop.
Statistics of Youth Care: - Only of transgender youth have undergone any form of surgery (Pediatrics, study). - Transgender people make up only of the US population. - Most "top surgery" (reduction of breast tissue) is performed on cisgender males with gynecomastia.
Detransitioning and Mental Health Consideration
Detransitioning is complex and affects approximately of the transgender population.
Reasons for detransitioning often include lack of support, lack of funding, or realizing a non-binary identity rather than a complete reversal of identity.
Mental Health and Violence: - High suicide rates in the community are attributed to society's reaction to transition and the lack of safety, rather than intrinsic mental illness. - Black transgender women face the highest levels of murder and violence in the US.
Fisher notes that medical regret rates for GAC are significantly lower than regret rates for common procedures like heart implants or knee/hip replacements.
Concluding Philosophy: First, Do No Harm
ACLU Quote: to of Americans claim to have seen a ghost, while only claim to know a transgender person directly.
Medical providers must engage with and seek to understand this population to treat them effectively.
Final takeaway: Primum non nocere (First, do no harm). Harm is the direct contrast to healing, and healthcare providers must be prepared to deliver quality services to all people, regardless of personal agreement or understanding.