I know I say this a lot, but:
If there’s one thing I’d like the public to know about medicine in the US, it’s that it is not standardized. For the same condition, one doctor will recommend surgery, another will send you to physical therapy, a third one will put you on painkillers, a fourth one will give you steroids, and a fifth one will say “there’s no effective treatment but it will get better on its own.”
Each one of these doctors will say “this is the evidence-based standard of care, I have studies backing me up, and everyone who’s up-to-date with the research does it this way.” (The studies will be real, too. There’s just other studies showing other things.)
This isn’t true for every condition, nobody’s going to prescribe PT for strep throat*, but for something like chronic pain or mental health issues it’s especially important to keep in mind.
*I… think. I’ve worked with some weird doctors.
@slatestarscratchpad can you comment on this?
Agreed, though with some caveats.
(like: all doctors are weird doctors)
There are a few things that are really obvious and almost universally agreed, like the strep throat example.
But other things are total judgment calls. Should a depressed patient
be treated with antidepressants, therapy, or both? Well, it depends.
How bad is their depression? What kind of exogenous stressors
contributed to it? Are those exogenous stressors solveable? Is the
patient “psychologically minded”, ie smart and self-critical enough that
she can understand complicated therapy concepts like “self-esteem”?
Does she have poor coping strategies and self-defeating beliefs? Does she have an hour per week to devote to therapy? Has she had very
positive or very negative experiences with medication or therapy before
in the past? Is she taking ten medications already that would interact
with antidepressants? Does she have some other condition that the
antidepressants would coincidentally solve (eg if she is underweight, we
can give her Remeron which is an antidepressant that causes weight
gain). Does her insurance cover one but not the other?There is no
guideline that can possibly consider all of these factors, so it comes
down to the doctor consulting their Vague Intuitions. That means even
with a single perfectly-consistent doctor, they’ll prescribe different
things for superficially-similar patients. And if by chance doctors have
different Vague Intuitions, they’ll prescribe different things for the
same patient without either of them necessarily doing anything terribly
wrong.Other times the correct treatment is “the one you’re most familiar with”. With very rare exceptions, I only prescribe four benzodiazepines – Ativan, Xanax, Klonopin, and Valium. I know there are like two hundred others, but they really have no advantage over my four, and I’m not that familiar with them – I might get the dose wrong, or forget about a side effect. I know some other doctors who trained in weird places and are really familiar with Serax or something, and they should use Serax rather than switch to something they don’t understand. Likewise, as a psychiatrist I (claim to) understand all sorts of weird antidepressants, and I might give you a weird antidepressant perfectly tailored to your situation, but I don’t want a random primary care doctor prescribing clomipramine because he heard it’s good sometimes. I don’t even want a psychiatrist who specializes in schizophrenia and hasn’t really worked with clomipramine doing that. In return, I don’t use clozapine, even though I know it’s great, because I don’t have enough schizophrenia experience to use it properly (I also don’t have the support from labs and nurses it would take to monitor it well). If there’s a patient who really needs it, I’ll refer them to a clozapine specialist. But if they can’t go to the clozapine specialist for some reason, I’ll probably use one of the few antipsychotics I’m super-comfortable with. If I were a Dr House level genius, I would know all of these drugs and use them all confidently, but almost nobody is that great. In some fields, I’m not even good enough to fully know what I don’t know. There are two thousand different schools of therapy. I know about three of them well enough to feel comfortable practicing them, and another ten well enough to feel comfortable knowing when to refer someone for them, but if one of my patients could benefit from Gestalt Therapy or something else I have barely even heard of, they’re just screwed.
(keep in mind that when a doctor says they’re “comfortable” with a certain treatment, they don’t just mean “I heard about this one time in medical school and mostly remember it”, they mean “if I screw this up, you will die, but don’t worry, I’m confident I know it well enough not to screw up.” This can be a high bar, and not always a level of confidence everyone can maintain about everything)
Still other times, doctors have different values and experiences. I usually trust my patients, and I believe informed people who understand the risks and benefits should have the choice about what to do with their own bodies. I also coincidentally have met a lot of people whose lives have been devastated from having the medications that helped them taken away by gatekeepers on grounds of “we’ve got to fight addiction!” So I am more likely to prescribe (and especially continue) potentially addictive substances than some other doctors I know are. I have had generally good luck with these, so I continue to prescribe them. I think a doctor who works in an area devastated by drug addiction, and who was more temperamentally conservative and less temperamentally libertarian, would be more careful with these, as would a doctor who got unlucky and their first benzo patient became a junkie and overdosed and died. Some doctors value patient satisfaction/comfort more or less compared to getting results. Some doctors are more worried about the risk of side effects that haven’t been discovered yet and so more conservative about supposedly-provably-safe medications. Some doctors value patient autonomy more or less compared to giving the most effective treatment. Some doctors value being absolutely sure something works more or less compared to being willing to try promising experimental treatments. Guidelines aren’t always going to help here.
(a particularly common place I see this come up is in pain management. If there’s a condition that will go away on its own after two weeks, but be really painful until then, how aggressively do you treat it? What if the aggressive treatment has risks or side effects? You can find a doctor with basically any conceivable philosophy on this question.)
And finally, is this really that surprising? Or is every profession like this? Will two financial advisors always recommend the same investments? Will two computer programmers always write programs with the same structure? Will two lawyers always try the same argument? I think it’s pretty common in skilled professions for there to be multiple different ways of handling something, none of which are wrong. Medical students often get asked to make lists of the top five things to do in a certain situation, and often everyone makes a different top choice but has approximately the same five choices on their list. I think this is normal and not necessarily incompatible with people being basically reasonable.
I don’t want to claim there aren’t a lot of doctors who are incompetent, or who disagree with the guidelines just because they’re contrarian. I often disagree with the guidelines just because I’m contrarian (did you know the sleep guidelines say melatonin doesn’t work?), and I am very likely incompetent in some ways I don’t currently understand. But it’s not 100% that.
I’m reblogging this because it’s important context and I don’t want my original post to sound like “care isn’t standardized because doctors are all just stubborn jerks.” Two doctors who are both caring and knowledgeable can still have very different recommendations, and that’s important for patients to be aware of.
Month: July 2018
so apparently some people feel like it’s annoying when someone engages with a lot of stuff from the same person, like going through their ship tag and liking all the content there.
hearing about this, i was immediately paranoid about reblogging literally anything from anyone i don’t talk to on a regular basis.
so to save others from the same paranoia, i’m gonna say that if you like every single post on my goddamn blog it is okay. i might be kind of concerned about your level of time management, going through 23,000 posts, but it wouldn’t bother me.
I may find it a little weird and possibly creepy if someone goes through liking pretty much my entire archives. A few posts at a time, every single day, for months on end. And it’s someone I have never seen before, who isn’t even following me. That actually happened once elsewhere, with at least 95% certainty that it was an actual human and not a bot.
Other than that level of unusual behavior? Go right ahead, and I likely wouldn’t even register it as odd.
the thing about the “why can’t we say pregnant WOMEN instead of pregnant PEOPLE, PC gone mad!” discussion going on right now is that even the “cis ally” side is kind of not understanding why, exactly, “official” stuff about pregnancy needs to use gender neutral language.
the use of gendered language, whether in law or in company guidelines, has been used as an excuse to exclude trans people from various kinds of reproductive healthcare. there have been stories of abortion providers pointing to the use of “pregnant women” in all clinic literature to justify not giving trans men assistance. there are issues where “women’s health clinics” will refuse to accept referrals for anyone who doesn’t have “F” on their records, which of course includes many trans women. there are in turn stories of trans women being unable to access “male” prostrate cancer screening.
language in this sort of capacity needs to be as factual and neutral and carefully constructed to avoid loopholes as possible. at this stage in my life, as a non-woman capable of pregnancy, i don’t really CARE anymore if you talk casually about pregnancy as something that happens to women. but i DO care if the medical system writes out some guidelines that, in only acknowledging pregnant women as a possibility, open me up to the possibility of being denied care by transphobes who can claim they’re just following the rules.
this is a real issue for us, the gendering of health care leading to single-sex guidelines which are actively used by assholes to say “no, we only treat [gender] here”. it’s not a matter of nitpicking over everyday language; it’s about ensuring we are safe from loopholes that can be used to exploit us.
So, I don’t see me getting anything, but I’d greatly appreciate if someone could drop me some money for food, my gf and I are broke and hungry, and we would adore you if you sent us something to order food with
My paypal is paypal.me/corakitty
If you help us out, I can send you some nudes or something in return if you’d want
Hey, I know I posted this a few days ago, and I really hate to be asking again, but money is still really tight and we would greatly appreciate the help if anyone can
No lie. I went to college in Syracuse, and they closed the campus one time because of a ridiculous blizzard. It was during Spring Break, cuz Central New York.
Physician, know thy own queer history
I’ve come to suspect that a lot of LGBTQ+ discourse these days is conservative Protestantism with a gay hat because it’s pushed by people who literally are conservative gay Protestants whose worldview hasn’t been broadened beyond “now you can have 2.5 kids in a house in the suburbs… with a spouse of the same gender.”
My girlfriend Marna has been a queer activist since the late 80s. She’s told me about the incredible deliberation and debates LGBTQ+ activists had, in the late 90s and early 00s as the community began to see past the AIDS crisis and immediate goals of “surviving a plague” and “burying our dead.” There were a lot of things we wanted to achieve, but we had to decide how to allocate our scarce reserves of money, labour, publicity, and public goodwiil. Those were the discussions that decided the next big goals we’d pursue were same-sex marriage equality and legal recognition of medical gender transition.
From hearing her tell it, it seems like it was actually a wrenching decision, because it absolutely left a lot of people in the dust. A lot of people, her included, had broad agendas based on sexual freedom and the rights of people to do whatever they wanted with their bodies and consenting partners—and they agreed to put their broader concerns aside and drill down, very specifically, onto the rights of cis gays and lesbians to marry, and the ability to legally change your sex and gender.
As a political tactic it was terrifically effective. In less than two decades, public opinion in many countries has totally reversed on gay marriage, and we’ve won some truly enormous legal landmarks. Gender transition has entered public consciousness and the first landmark battles allowing people to define their own gender have been won. Marriage equality means that husbands and wives are protected from being banned from their dying spouse’s bedside, being forcibly separated from their children, or not being recognized as an important part of their spouse’s life.
The LGBTQ+ community knew they were taking a gamble, focusing so exclusively on marriage equality, and trans activists knew that they wouldn’t be able to achieve anything else until they’d gotten basic medical transition recognized. By and large, prioritizing things this way paid off. But they knew going in that there would be costs—and we’re reaping them.
Activists of 20 years ago chose to sideline and diminish efforts to blur and abolish the gender binary. Efforts to promote alternative family structures, including polyamorous families and non-sexual bonds between non-related adults. Efforts to fight the Christian cultural message that sex is dirty, sinful, bad, and in need of containment. Efforts to promote sexual pleasure as a positive good.
Those efforts have been going on for the last 20 years, but they’re marginalized—activists who had to decide where their finite time, money, publicity, and social capital went literally sat in committee meetings and said, “Marriage equality is our top priority. Legal gender transition is our top priority. Everything else will have to wait.”
This happened especially because sex education, sex positivity, and youth outreach were incredibly dangerous areas. Our enemies have been saying for years that all LGBTQ+ people are pedophiles, perverts, seeking to corrupt and recruit children to our cause; anyone trying to teach children basic facts about how to avoid disease, what’s happening to their own bodies, or what possibilities they have for identity and orientation, risks having their name, career, and life ruined. As a sex educator in the 90s, Marna had to tell teenagers, “I can’t answer your questions about safe sex now. Come back when you turn 18.”
So kids who grew up being told that girls and boys are different and ought to lead different lives, and sex is dangerous and sinful and gross, and you definitely shouldn’t want sex UNTIL you get married to your One True Love, only had that message tweaked a little bit. Now you can cross the floor from the Girl Side to the Boy Side or vice-versa. Now your One True Love doesn’t have to be a different gender from you. But those kids could survive with the rest of their worldview relatively intact. And I think that’s what we’re seeing in fandom, with an emphasis on “pure” OTP ships, on only including LGBT+ identities that use crisp, clear gender binaries and result in nuclear family life. The rest of those cultural messages about sex and love remain: men’s and women’s worlds are and should be different, “impure” sex degrades and defiles you, sexual urges that do not contribute to your One True Love and family life should be repressed, shamed, or destroyed, and sexual thoughts are every bit as bad as acting on them.
This isn’t because kids today are bad or stupid. It’s because as a community, we had to decide where our effort was going, and now we need to pay down the debt we’ve racked up over years of prioritizing marriage equality and legal trans recognition over sex positivity, sex education, and deconstructing gender.
TERFs, SWERFs, exclusionists, and transmedicalists have stolen a march over liberal queers because they’re doing the work to educate youth. While liberal queers have been staging protests and lobbying politicians, half a dozen of my undergraduate professors were radical feminists. Communities of exclusionists and anti-sex activists have honed their expertise at engaging teenagers with their ideas and theories. They’re the ones writing the FAQs, answering the asks, and doing the groundwork of saying, “Here is a basic framework of sexual ethics for you to follow.”
If we want to win back the culture wars, we have to step up our own efforts. Go back to the sex educators and gender activists whose good work has been ignored or underfunded for all this time and support them. Let major LGBTQ+ activist organizations know that their work so far is very nice, but it’s time to renew our focus on youth outreach and mentoring young activists. Brainstorm a way to help angry, isolated, disenfranchised young people form communities based around positive action and a sense of belonging. Get into mentorship or education yourself. Help us pivot as a community, to reach out to the kids who have obviously been underserved.
People doing the good work who need our support:
San Francisco Sex Information
Sex & U
Scarleteen
Sexplanations
Making Queer HistoryWe won a few battles. That’s nice. But now it doesn’t serve us to whine that they’re not all won. We’ve still got work to do.
This is a delightful post and I’m delighted you linked it over on Dreamwidth, which is where I saw it. I’m sitting here and chewing it over and integrating it into my personal experience of being, y’know, a twenty-eight-year old who reaped many of both the victories–Coffee wouldn’t be right here, living with me, without DOMA going down; wouldn’t have health insurance without Obergefell; wouldn’t feel safe if anything happened to me without legal recognition of our relationship–and also someone who came from a really different microculture.
God, I feel like the “HI I AM BRINGING THE ACE PERSPECTIVE TO BROADER HISTORY” person these days, but here’s a thing that strikes me: my communities, growing up, were also out there having sidestepped the marriage discussion and instead having chosen to focus on youth outreach, education, and engagement. I mean, for a decade the central ace-spec community out there was AVEN, which literally chose to call itself the Asexual Visibility and Education Network.
And the thing is, the same community was also quietly but heavily influenced by a lot of those ideas about blurred gender binaries and new family structures. There have always been quiet but powerful sex-positive currents in ace communities, to the point that in 2011 there were quite a lot of us going “Hang on, hang on, why the hell are we the standard-bearers of how great sex is?” in frustration. Ace communities are such a haven for nonbinary folks that in 2011 fully 40% of the surveyed community for one widely published study found that people ticked their gender identity as something other than “male” or “female.” (This is counting folks who put down identifications along the lines of “male-ish” or “female-ish”, which was a viable option.) And anyone who has looked at an ace community for five minutes or listened to ace folks talk about fantasies of family has seen how much focus these communities place on alternative family styles.
A lot of that sort of burst back all over mainstream queer communities again circa 2010-2012ish, as AVEN shattered and ace communities sprang up without necessarily referencing it. But those discussions and those currents and those feelings go right back to the roots of what AVEN was, and more to the point they go back to the roots of those older activism strains that were deliberately unfed by many “mainstream” queer activists: for example, asexual folks probably didn’t come up with romantic orientation wholesale–I ran into it described as “affectional” orientation often enough in ~2005ish that I’m pretty sure it was picked up from bisexual communities and dialogues. But it was indisputably asexual culture that burst out around 2011 and repopularized the concept within younger queer communities, to the point that I’ve run into a lot of allo folks asking if it’s appropriation to pick up the concept and borrow it for themselves.
Or–I’d ask @coffee-mage-sans-caffeine for more input than me on early nonbinary/genderqueer communities, because they know more about those spaces than me by a country mile, or maybe @xenoqueer has thoughts. But for a while there, when I met any given person who didn’t identify as male or female I could often work out whether they were coming from an ace-influenced or a non-ace-influenced background just by seeing if they used the word “nonbinary” or “genderqueer.” I’m pretty sure I wrote something about it at the time, but I haven’t got the time to go digging right now.
So I’m sitting here tilting my head and wondering: because while mainstream LGBTQ activists, for lack of a better turn, might have given this fight up wholesale while putting their muscle and their blood and sweat and tears into marriage equality, I don’t think TERFs et al. were the only pockets of queer community who were going out and focusing very specifically on youth engagement. I actually think that ace communities–and maybe the non-ace nonbinary communities of trans folks–might have been picking up and incubating many of these ideals and engaging in outreach all on their own.
It’s an interesting thought, thinking about AVEN as the vanguard of all of these older, tactically silenced priorities for queer liberation. And it makes a certain amount of sense in the context of the inclusionist/exclusionist wars c. 2003-2004 within ace communities outside of AVEN, too.
Scarleteen is run by an amazing person – Heather Corinna – who is a disabled artist and just… if I started talking today about all the good they have done for me and everyone close to me, I wouldn’t stop until tomorrow at least. They don’t just run Scarleteen, they’re the kind of person who … just…
Look, I’ll start and stop with “they were instrumental in getting me out of an extremely abusive relationship and helping @dadhoc and I get together and get on our feet.”
All of the points above are everything I’ve been screaming forever, it feels like, and the only thing I can really add is that Heather is incredible and Scarleteen is an amazing resource and you should both use it and support it and I definitely don’t talk enough about how great it is and Heather is.
Also, I had heard of the word genderqueer before @mistresskabooms was born in 2000 but didn’t hear nonbinary until she was at least in late elementary school. So.
“
So kids who grew up being told that girls and boys are different and ought to lead different lives, and sex is dangerous and sinful and gross, and you definitely shouldn’t want sex UNTIL you get married to your One True Love, only had that message tweaked a little bit. Now you can cross the floor from the Girl Side to the Boy Side or vice-versa. Now your One True Love doesn’t have to be a different gender from you. But those kids could survive with the rest of their worldview relatively intact. And I think that’s what we’re seeing in fandom, with an emphasis on “pure” OTP ships, on only including LGBT+ identities that use crisp, clear gender binaries and result in nuclear family life. The rest of those cultural messages about sex and love remain: men’s and women’s worlds are and should be different, “impure” sex degrades and defiles you, sexual urges that do not contribute to your One True Love and family life should be repressed, shamed, or destroyed, and sexual thoughts are every bit as bad as acting on them.
“
I want this on a fucking wall-print. I’ve been saying queer communities online (especially Tumblr) that focus on moral and sexual purity are a direct result of Good Christian Children who are allowed to be gay now taking EVERYTHING ELSE about toxic christian upbringings into the queer community and using it to hurt other queer folks who have more experiences and a broader worldview.
#aome interesting food for thought? #something i have to read about more to understand better tho #lgbtq history #Am I the only one who feels like the ace movement popped up in response to the ‘purity’ teachings lgbtq people received re: sex and marriage #And that like….. That’s not a good thing……
This is a very intuitive concept and unfortunately it is about 100% wrong. For one thing, ace cultures have always included heteroromantics, and in my experience it has been more common for someone to identify as ace before they add other LGBTQ identities, not after–and the main exception is folks identifying specifically as bi or pan under the theory that they’re equally attracted to multiple sexes at once. Furthermore, ace communities have been infamous as places that ignoring and repressing your sexuality is nearly impossible for decades.
The asexual community has two primary origins, depending on whether you’re interested in why asexuality would emerge as a sexual orientation or whether you’re interested in the modern asexual community as it is today. The first origin is, oddly enough, the reification of homosexuality in Western thought around the turn of the twentieth century. That sparked the reification of heterosexuality, because you need something to contrast your homosexual people (as distinct from regular ol’ people who prefer to sleep with other folks who maybe have the same sex or gender as they do) against. Note that the concept of homosexuality and sexual orientation hadn’t actually completely taken over even among what we’d today call MSM until between the 1930s and the 1950s (depending on social class; the concept of homosexuality/heterosexuality as we know it today was adopted first by middle classes and slowly spread both up and down class ladders simultaneously).
(If you’re curious about that, I highly recommend Gay New York by Chauncey. It’ll give you a lot of information about early queer history, particularly the strains of folks who would probably identify as gay men and/or transfeminine today.)
So you have homosexuality spreading as a medicalized concept, and heterosexuality pops up as a contrasting identification. Then you have a number of people who go… “hang on, this binary doesn’t actually apply to me or all these other folks?” and in the 1950s you start getting Alfred Kinsey et al. going “hold on hold on bisexuality, it’s a thing?” And early bi communities form, except that if you aren’t familiar with the history of bisexual communities you should maybe think for a minute, because early bisexual communities contained basically everyone who didn’t identify as straight or gay, including a whole lot of early nonbinary/genderqueer people, people who later would identify as asexual, quite a lot of trans people, and generally everyone who in some way violated the homosexual/heterosexual binary. Except all of that ran into a whole lot of suspicion and marginalization both in straight and gay circles, which resulted in a lot of conflict over whether or not bisexuals were welcome. These early anti-bisexual efforts resulted in the formation of the LGB and later the LGBT acronyms.
What all this conflict does is create a situation wherein, by the time the internet filters around, the concept of bisexuality as meaning “interested in/attracted to men and women” is solidifying (in large part because of cheerful straight and gay community ignoring what bi folks are saying). You also get, as far as I can tell–and the genesis of pansexual communities is not my thing, so I’d be happy to be corrected–with folks who would previously have fit in just fine with bisexual communities effectively re-inventing the wheel in a reaction to the extra-community definition of what bisexual means and there’s a whole lot of conflict there that smells like fragmentation and people talking past one another. The big thing, however, everyone is focusing on? Attraction and who you’re sexually attracted to.
So you wind up with people who haven’t spent much time in any of these communities going “well, shit, I ain’t sexually attracted to men, women, and I certainly am not attracted to both; what is happening? What box do I fit in?” People who feel lonely and isolated, and they start talking to each other because thanks to the Internet, now they can also find one another. And that’s the second half of how we got here to this modern asexual community, which tbh I’m not getting into now because it’s already been too long.
But that’s where it really came from: a reaction to the increasing hegemony of the sexual orientation model.
Of all the toads I gently held yesterday only one thought to grab a stick to stab me with
Urocyon's Jaunts 2.0 
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