Thursday, November 05, 2009

A Painful Lesson

This happened 8 years ago. I have changed details where necessary.

I was working in the north of England. We had been on 'take-in' for 24 hours. I met my team of junior doctors at 0745 to do the 'post-take' ward round which ended our duty period, after which the juniors would be free until 0900 the following morning.
Some 2 hours later we had seen and made management decisions for the new admissions, maybe 12 or 14 in number. I thought we had finished.
But there proved to be one more to see, in a side-room, usually used to isolate cases where infection was feared.

Before we went in the registrar warned me the patient was a man who had undergone surgery for 'gender reassignment'. The patient had wanted admission to the female ward, but had to go in the side ward, for obvious reasons.
A warning bell should have sounded in my head, but it didn't.

The name on the bed-notice was 'Barbie' - no surname. The cover of the notes had 'Barbra' written in marker pen across the top.
The patient was heavily built, plump faced, with broad shoulders and big hands. The hair was long, platinum blonde, loose, but carefully combed and clipped. Heavy make-up did not completely conceal a dark beard area. Large filigree gold rings hung from each ear-lobe. There was a whiff of perfume, which did not disguise a smell of tobacco.
Barbra was wearing a white cotton sleeved bed-gown: breast development could be seen. Nearly every finger had a ring; the nails were painted purple, and manicured.
Barbra was taking daily doses of an oestrogen preparation, and several other preparations of vitamins, minerals and tonics.
Barbra was unemployed, living with a male partner in social housing.

The clinical problem was chest pain, and suspicion of angina pectoris. The pain had lasted several hours the previous afternoon, but had resolved after admission. There was a previous history of hospital attendance for similar pains, but no heart or chest disease had been identified.
On this occasion ECG's taken on admission and 16 hours later had shown no abnormality. Blood values on admission had been in the normal ranges; the results of a second set of blood tests were awaited. Chest X-ray was unremarkable.
Examination revealed a normal pulse, blood pressure a little increased, normal heart sounds, and no other significant signs.

The clinical evaluation was that this was unlikely to be heart disease. Barbra could go home that evening, provided there were normal results from the third set of tests and ECG at 24 hours after admission, as the hospital protocol required.
I discussed the findings with Barbra. It is difficult to be totally confident that such chest pain is not angina, so I asked for an appointment for out-patient review in a week's time. The atmosphere was friendly, reassuring and good-humoured, or so I thought.
Barbie failed to attend follow-up.

Instead the hospital received a furious letter of complaint ten days letter. Both sides of a foolscap sheet, written by hand in small neat capital letters. While discussing Barbra's chest pain I had used male personal pronouns - he, not she; his, not hers.
There were complaints of severe emotional distress in consequence, threats of litigation, and of a complaint to the General Medical Council. There was a demand that I should attend counselling for my attitude problem to transsexual people.

I was horrified. This torrent of anger was totally unexpected, and unreasonable.
I spent several days - and nights - worrying. The threats caused little anxiety. but the ferocious personal accusations did. How could an unintended impoliteness cause such fury, especially as it went unremarked at the time?
In the end I sent a bouquet of flowers with a brief note of apology: I heard no more.

I subsequently learned there had been a previous, similar incident. Barbra came before with chest pain, and had made a scene in the ward when a colleague had used the wrong personal pronoun. "I think", said my colleague, "Barbra gets a kick out of aggrievement and outrage. You walked into a trap".  
Maybe: maybe people like Barbra have powerful psychological stresses relieved by an outburst of anger. Victim status brings rewards, too.

But there remains a difficult issue for the physician. Male sex is in the Y chromosome in every cell in a man's body. Genitalia can be amputated and some simulation of female parts created by plastic surgeons; female sex hormones can be taken; womens' dress can be worn, and womens' behaviour emulated: still the genetic reality remains. The white cells in the blood will lack the Barr bodies which identify a blood specimen as female.
Does the male pattern of disease prevalence persist when female hormones are taken for years? Do oestrogens protect men against coronary heart disease, as they do women? I don't know.
What is the chance of cancer in an oestrogen-stimulated male breast? I don't know.
If Barbra came complaining of difficulty passing urine would I be wrong to suspect prostate problems?

I'm glad I'm retired.

1 comment:

Dr Grumble said...

This was a bad mistake as a comment to this post reveals.