Thursday, September 24, 2009

Shame on Who?

Caster Semenya, an 18 year old track star from South Africa who won the 800 meter race in Berlin in August has been the object of intense media scrutiny ever since she ran. Not because she outran her competitors by a few seconds, but because the sports world has been weighing in on whether it is fair for her to run as a woman.

Caster is intersex. Some 0.5 to 1% of the general population is thought to have characteristics that are intersex. In Caster's case she has typical-appearing external genitalia of a woman but the internal gonads (sex organs) of a male and therefore produces testosterone and not estrogen. This explains her flat chest, her deeper voice, her facial hair, and maybe her muscular build (she also works out and trains a LOT to get that body). As hard as it is to make the mental leap to understanding that sex is not necessarily a binary, either-or phenomenon, we must stretch our minds and get educated. It is not ok to sit back and pass judgment or gawk at a variation of nature. Semenya is different but she is not a freak and she is not alone. As Lisa Belkin blogged in the New York Times, we need to tell our children about this; it's a matter of tolerance.

I believe Caster when she says that she just learned about this from the media and the recent tests that the International Athletics Associations Federation have put her through. I believe her father that he thinks of her as a girl. I believe the reports that she has withdrawn and is depressed over having her life and gender identity exposed publicly. For gender identity is something we each decide for ourselves;no test can make that choice;it is a psychological phenomenon. Usually gender identity is in harmony with one's body as it most likely was for Caster until she entered puberty and developed external male characteristics.

What I have trouble believing is that no one in a professional capacity--counselor, coach, physician, nurse--ever questioned the pubertal development of Caster. By most standards a young woman without a period by age 16, who was developing hirsutism and had no breast development deserved an evaluation. If that evaluation was done and not shared with Caster in the most competent, delicate, compassionate and informed sort of way, well shame on them!

Because someone did not do his or her job with complete competence, this young woman is having her body dissected on the world stage and in the blogosphere and her achievements diminished by sceptics who do not understand the science behind it all. Let's keep the legitimate debate about athletic competition separate from the discourse about Semenya's sex.

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If this piques your interest and you want to read a moving novel, extremely well researched and written of the life of an intersex adolescent, try Middlesex by Jeffrey Eugenides.

Thursday, September 17, 2009

Don't pass down your depression

It looks like it might actually be possible to "immunize" our children against one of the afflictions most feared by all parents--mental illness. A recent study by Judy Garber, PhD of Vanderbilt University that was published in the reputable journal JAMA(Journal of the American Medical Association) provides some hope.

It is known that adolescents with depressed parents are more likely to develop major depression themselves. Whether there is a genetic component to this or can be attributed to environmental factors is not what matters here. What matters is that Dr Garber's work shows that a group of adolescents who have been depressed in the past and were considered at risk for serious depression could be taught techniques that helped to significantly lower their symptoms when studied nine months later.

The techniqes are called cognitive behavioral therapy and can be as simple as teaching a patient to "think positively." They are also taught problem solving skills, and ways to recognize and "re-frame" negative or potentially self-destructive thoughts. Cognitive behavioral techniques are often just a translation of age-old ways of looking at the world and helping people manage daily stresses.

The Vanderbilt treatment program included eight weeks of 90 minute group sessions and then monthly "booster" sessions for small groups of students. Parents were also involved in two informational meetings.

What Garber's work suggests to me is that we should probably start thinking of mental health prevention as part of our plan for our children in the same way that vaccinations and "physicals" are. Kids deserve a "mental" at every visit to their health care provider. I might even go so far as to say that our schools should begin to consider "emotional education"(Emo-Ed, can't you see it now?) as well as physical education in our curricula. Good mental health is not a given, but it can be taught.

Tuesday, September 8, 2009

Insurance morass

Back from vacation! Springing into Fall!

Although it was never my intention to use my blog as a way to complain, I saw Julie and Julia last night and Amy Adams' blogging inspired me to share a story that is only a thinly veiled gripe.

In these times of debate about health care, I have been struggling with the idea of joining insurance plans to make myself more accessible to a wider range of patients than I can see otherwise. In addition to the New York State plan for low income families and children (Child Health Plus), I have been on the Aetna panel for over a year. About nine months ago I decided to apply for four other plans in the hopes that their reimbursements would be reasonable enough to sustain my practice.

The way the application process works is the doctor applies (many documents, reams of paper, phone calls) and time goes by. We did that in January. Eight months later (this July) Blue Cross sent a letter announcing my acceptance. At this stage (and not until then)an applicant is able to know what the reimbursement schedule will be. So, once I saw the numbers ($52.16 for a thirty minute visit; $63.84 for forty-five minutes) and did the math, I decided not to join. HOWEVER, Blue Cross put me on their roster without my approval and listed me on their website in August.

So what difference does it make? The problem is that patients who may be on Blue Cross now submit their superbills from my office to Blue Cross and are told that they only owe me the co-pay because from the company's point of view I am a BC provider. So now, I am struggling to try to get someone to answer the phone at Blue Cross and cancel my listing which I never authorized in the first place.

This one tiny example serves to demonstrate the monolithic, bureaucratic, and confusing nature of the insurance system we work under.

I honestly wish for Blue Cross employees that they find meaningful work one day. Work that does not involve arguing with doctors' offices; refusing care to patients; nitpicking over whether a doctor asked ten questions or twelve; denying claims for routine procedures (eg urine tests); wasting paper, ink and postage; and breaking patient confidentiality by looking over the shoulders of doctors and pharmacists.

And now I am off to look up the recipe for boeuf bourguigon.