Monday, November 06, 2006

Lunacy. Or Not.

Last night was the full moon. The ED folks I know swear by the "lunar effect;" one nurse tells me that both the ED and Labor & Delivery are busier during the full moon than at other times of the month.

Yesterday morning, I told Gary, "Tonight will probably be really busy at the hospital." I said the same thing to my father on the phone, and he immediately went into skeptic mode. "Has anyone studied this? Are there statistics?"

Well, it turns out that yes, there are, and they debunk the belief. The lunar effect, say the skeptics, is merely the effect of people knowing that there's a full moon and ascribing things to it that would go unnoticed otherwise.

But when I went to the hospital, lo and behold, it was really busy, and it was the kind of really busy that had the hallways crowded with security guards, police officers, and corrections personnel. I'm pretty sure that's the highest concentration of uniforms I've ever seen at the hospital. Patients were in beds in the hallways because the rooms were full, and a row of four hall beds was occupied by psych patients waiting to be evaluated. There were at least three other patients, in the ED for medical reasons, who seemed to me to have definite psych issues.

Note: I'm defining "definite psych issues" as location-inappropriate behavior. Example 1: Not answering direct questions directly, and then giving long, winding, involved speeches about Scripture that don't make grammatical or logical sense, that simply don't parse. Example 2: Asking the chaplain for a prayer while you have your hand stuck down the front of your jeans, making suspicious pumping movements. Perhaps this is just rude, but the fact is that most people would recognize this as inappropriate behavior and wouldn't do it. (I would have prayed with that patient, by the way, but then he changed his mind and screamed at me to go away. Let me add that last night's ED population also featured an unusually high number of people with really bad manners.)

So was I just noticing all that because I knew it was a full moon?

The staff definitely noticed it. "Yeah, the full moon brings out all the crazies."

And this is where things get tricky, because not one but two nurses made derisive comments to me about a patient they put in the "crazy" category, "that guy wearing women's clothing."

This patient was in for scary physical reasons. When his symptoms started, he was in a place where his attire wouldn't have been considered inappropriate. I only managed to talk to him for a few seconds, because medical staff were with him almost every time I went by his bed, and he couldn't talk very well because of his condition. But he made eye contact, and the little he said made perfect sense, and he came across as someone who knew where he was and what was happening to him, and who was very appropriately frightened.

I desperately wanted to be able to spend more time with him. I desperately wanted to say, "I hope the medical staff here have been nice to you." I wanted to hear him say that yes, he'd gotten kind treatment; I hope and pray that the inappropriate comments from staff were made where he couldn't hear them. (To their credit, most staff who talk trash about patients are careful to do so out of the patients' earshot.)

I tried to educate the first nurse. "Is he a cross-dresser, or transsexual? It's not the same thing. Please ask him what he wants to be called; pronouns are important to people."

The nurse stared at me like I was crazy. Okay, I get it: a frantically busy ED isn't the place for a teaching moment.

I tried to model compassion for the second nurse. "You know, he may feel really self-conscious in that outfit here."

In response, I got a sniff. "Well, that's the thing: I don't think he does."

That nurse was as busy as everyone else, so I didn't get a chance to say, "Maybe that's because he's too busy worrying about his medical symptoms. Maybe he'd have changed clothing to protect your delicate sensibilities if he'd known that he was going to wind up at the hospital; he didn't exactly plan this visit, you know. And if he doesn't feel self-conscious, if he knows that your response to his clothing is your problem and not his, good for him."

Even if I'd been able to say that, I doubt it would have done anything except annoy the nurse. (Have I mentioned that I can sometimes be less than tactful?) I suspect this patient would have been labeled "crazy" by some staff even if it hadn't been a full moon. And now I'm wondering how much education emergency-medical personnel receive about sexual orientation and sexual difference.

ED staff: If a patient with acute medical symptoms unrelated to sexual behavior comes to the hospital and responds appropriately to staff questions and requests, that person's attire, sexual orientation and recreational hangouts are none of your business. You aren't paid to pass judgments on people's lifestyles, and you aren't paid to be the fashion police. You're paid to help people who are sick. Judging people who've had the temerity to become ill in places or outfits of which you disapprove will not make those patients feel better.

Cross-dressers can be gay or straight; they may be transsexuals who identify as women, but they may also simply be men who like to dress up. None of these conditions automatically qualifies as a psychiatric disorder. Please educate yourselves. The Wikipedia entry on transsexuality is a fine place to start.


Eagle-eyed Gary just sent me this link to a New York Times story that begins: "Separating anatomy from what it means to be a man or a woman, New York City is moving forward with a plan to let people alter the sex on their birth certificate even if they have not had sex-change surgery."

If you aren't registered with the Times and don't want to be, here's a link to the story in The Advocate.

Later still:

Please see my follow-up post here.


  1. Interesting post; and one I'm going to have to think about for a little while.

    Not the full moon part. I, too, have read the "science" that says it doesn't make a difference, but I've also walked a mile in my moccasins on full moon nights...

    I agree nurses can be a judgemental lot. Sadly, when you deal with some of the people we see in an ED on a daily basis, rude, dumb jokes (hopefully out of earshot of the patient) can be an excellent way to dump stress. Nothing raises the mood better than a little laughter; it's just ED nurses are a little warped...

    As for the sexual orientation, behaviors and hangouts not having anythng to do with the patient's present condition being none of our business, I can't get fully on board with that. I'm still coming up with a good way to put what I'm thinking into words. Knowing a person's "behaviors", "hangouts" and "moral values" does help us, and shape how we treat, teach, and care for a patient. It also helps us to evaluate the symptoms our patient presents with, as well as guide our medical decision making. Wearing a dress for sexual gratification may not have anything to do with the heart attack they are having. Knowing the individual is hanging out at a local sex club, where drug use, unprotected sexual contact, and unsterile conditions are common place does indeed affect how we treat, teach, and help the patient...

  2. Thanks for the thoughtful response, John. If the comments had been made in the context of "we're concerned about possibly unsafe activities," I'd have felt a lot better about them, but they were just making fun of the patient.

    And if the patient had come in wearing a three-piece suit, would anyone have even considered the need to lecture him about unsafe sex etc.? How much do you really know about most of your patients' activities?

    I've heard doctors tell patients in no uncertain terms to stop drinking or stop smoking, but I suspect such messages lose some impact when the patients feel stigmatized instead of cared about. And patients usually know when they're being stigmatized, believe me, even when nothing's said in earshot.

  3. Whoever collected the statistics has never worked in any institutions dealing with the severely cognitively impaired - at least, that's according to Cathie who does and has read that (and other) research.

    So, who do you believe - the PhD with the clipboard or the PhD with the syringe?

    I know I'm biased, but I don't think there's a choice.

  4. Susan, you have inspired me to write a post....tonight!

  5. Hi, Kim. Uh-oh! Should I be afraid? LOL!

  6. Hi Susan,
    I followed the link back from Kim's page. There was a really horrible situation here in my area about 2 years ago. Ottawa is across the river from Gatineau-Hull, Quebec. A woman (former transgender MTF) sought care in one of the Gatineau hospitals. She recieved horrible care including being discharged early and having to seek care in Ottawa.

    I remember one element of the story initially that is similar to your post: one of the nurses made horribly disparaging remarks at the nurses station thinking (rightly) that the patient did not speak french. What she didn't account for was her partner being bilingual.

    The care recieved was awful and action is being taken. You can read the full story here at the link at the end. (There are elements of the story that don't quite add up (why she had to pay for care in Ontario if she had Quebec insurance, for example)).

    I think this really shows how much ground there is to make up on transgender issues. Gays and lesbians in Canada are far more readily accepted than transfolk.


  7. Thanks for the link, Jen; that's indeed a horrible story. And, by the way, thank you for the work you're doing with Insite. I'm a big fan of safe-injection programs (or anything else that will help stigmatized populations address health issues).


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