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The Nonbinary Physician Activist: “Do No Harm” Implies Equity as the Outcome

By Mackenzie, P, Lerario, MD, NYS CRPA/CPS-p

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Citation

Lerario M. The nonbinary physician activist: “do no harm” implies equity as the outcome. HPHR. 2021;42.

The Nonbinary Physician Activist: “Do No Harm” Implies Equity as the Outcome

Abstract

Gender nonconformity and outspoken nonbinary voices are stigmatized in medical professionalism.  Anti-LGBTQ climates in healthcare and research settings are psychological iatrogenesis which require structural changes to avoid further malpractice.  Academic medicine should take largescale and immediate action based on lessons learned from the lived expertise and the paid work being performed by activist and social justice thought leaders.  Intersectional, community-based participation, autonomy, and ethical representation should be standard in all components of clinical care and research.  This is especially true in post-pandemic practice, in which historically-oppressed communities’ trust in our healthcare system continues to decline.  We must move focus of translational care “from bench to bedside to embrace,” and we should target equity as our main quality assurance outcome.

Introduction

“Do no harm” is one of the first messages a medical student is taught.  I never had the full experience to test whether this idealized metric was reached by my profession until I became a patient and provider myself within the United States healthcare system as a transfeminine person of nonbinary experience.

 

 
Scientific evidence is growing that anti-LGBTQ climates increase self-harm and suicidality in transgender patients, and these rates of suicidal ideation may reach as high as 40% in some samples.12345678  As a board-certified vascular neurologist, if a medical intervention I gave to patients had a 40% chance of harm, with near-death or death as the outcome, we as a profession would immediately stop that practice.  Anti-LGBTQ climate in healthcare clinics and hospitals may seem benign, or “just a mistake,” to the oppressors.  However, healthcare mistakes, also known as iatrogenesis, are typically met with rigorous review and quality assurance initiatives to prevent further mistakes.  Why then do we tolerate ignorance of a culture and lack of community representation which could result in sweeping harm to historically-oppressed patients across the country? 9 We need to reframe social justice issues as quality assurance issues. Non-inclusive practice and research are more than bad bedside manner; they are psychological iatrogenesis and require immediate and largescale structural review.1011

Discussion

On my first day of medical school, the dean stood before our entire class and stated: “We no longer have the smartest applicants coming to medical school; but we have the ones who care the most.”  These words have impacted me for over a decade, but I no longer find them true.  Indeed, declining reimbursement and loss of professional autonomy devalue the M.D. degree, as a clinical practice is no longer as lucrative and trusted as it once was prior to the implementation of managed care.1213 As a result, talent in the STEM professions is being siphoned off to higher paying careers due to low employment satisfaction, which will likely be accelerated by the COVID-19 pandemic.14  Still a physician wields great– and often unrecognized– privilege in terms of power, wealth, influence, and authority.  For example, a psychiatrist has the legal ability to temporarily remove a person’s basic human rights.15  Regardless of the intention to protect that person from harming themselves or others, this is a power that may only be paralleled by imprisonment.  However, no crime has been committed, just foretold by the provider.  And the provider, like the rest of us, is a fallible human.

 

Historically, I do not see this professional authority as being used responsibly.  From early psychiatric institutions placing chained patients on display in return for payment to the Tuskegee syphilis experiments, the harm the medical community has perpetrated on the disabled and black communities has been substantial.1617  Now, we have LGBTQ physicians volunteer to tokenize themselves and work unpaid to create diversity, equity, and inclusion initiatives to end their own oppression within their institutions, which in turn increases that institution’s wealth, influence, and authority at minimal cost and resource expenditure.18  The normal biological diversity of sex and gender are not represented accurately in the medical profession, and the terms are often conflated with each other in original research publications, in contrast to what we know is biologically accurate as scientists.192021  These microaggressive mistakes continue to slip past peer review, even though they are a couple of the most commonly-used, categorical demographic variables in healthcare research.  These scars on our humanity remain clearly visible to this day in our healthcare and research institutions’ longstanding structures.

 

On my first day as a student in training as a certified peer specialist, we discussed how clients are disenfranchised within the healthcare system.  We learned how clients can lose their rights if we do not advocate fiercely for each other.  Bravely candid self-disclosure is taught as a tool to aid in healing, and not a sign of weakness to be avoided.  And often, a peer with similar lived expertise can help a fellow human in ways no amount of medical training can provide.

 

On my first day as a student in social service, I noted that pronouns were normalized in practice, and there were many transgender and nonbinary peers in my classes.  We discussed justice and equity as important outcomes.  Non-binary identities were included in discussions of gender.  I learned about settlement houses and how social workers chose to work in some of the harshest conditions to provide services to clients who were ignored or lost to the healthcare system.

 

I create these comparisons, not to undermine the benefits and good that modern science and medicine can provide to our species.  Instead, my intention is to deconstruct the “hierarchy of professions,” which are based on outdated standards of colonization, white supremacy, and patriarchy.  The power, privilege, and authority within medicine is hoarded too much within the hands of the few.  Where are the nonbinary voices in academic medicine and research? 

 

I dream to follow the lead of progressive-minded giants within our activist communities who championed their intersectional identities.  Some of the bridges we need to continue to build include those: between neurology and mental healthcare, between social service and medicine, between peer and professionalism, between ethical representation and clinical research, between patient autonomy and advancing medical science, between activism and professional duty, between psychiatric survivor and neurodiversity movements, between values and action in healthcare and research practice. 

Conclusions

Anti-LGBTQ climates need to be reframed as to what they are: harmful psychological iatrogenesis.  If such institutional climates are continued without timely and largescale quality assurance review, they should be considered professional malpractice with consequential legal liability.

 

From bench to bedside is no longer the end of translational practice.  We need to push ourselves farther as healthcare professionals to embrace the patient, their autonomy, their values, their culture, and their communities.  Because if our patients do not trust our profession, then bench and bedside work becomes meaningless and unadopted by those we treat.

 

Let’s start thinking ahead to the future of what it means to be nonbinary activists in academic medicine.  And let’s be humble enough to learn from activists and social justice spaces, which house people whom we have far too undervalued for far too long. 

Acknowledgements

Copy-editing performed by Xavier Alejandro Solis Rubio, The National LGBT Cancer Network.

Disclosure Satement

The author(s) have no relevant financial disclosures or conflicts of interest.

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About the Author

Mackenzie P. Lerario, MD, NYS CRPA/CPS-p

Mackenzie P. Lerario, MD, NYS CRPA/CPS-p (they/them/Doctor) is an Italian-American, disabled, pansexual, nonbinary physician and activist for the gender expansive community.  They are the founding Director of the NewYork-Presbyterian Mobile Stroke Unit Program.  Dr. Lerario is currently a MSW candidate at Fordham Graduate School of Social Service with their field placement at the National LGBT Cancer Network.  They are a founding member of the Gender Equity Working Group within the LGBTQI Subcommittee of the American Academy of Neurology and are a member of the 2021-2022 cohort of the Academy’s Emerging Leaders Program.  They are currently performing clinical research on the transgender community with a national team of multidisciplinary healthcare providers.  They are on the editorial board of Neurology: Clinical Practice and on the peer review team at the Harvard Public Health Review Journal. They are a member of WPATH and GLMA.  They are the Founding Director of Greenburgh Pride, and their blog can be followed at greenburghpride.org.

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