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First, the OMGWTFBBQ. Via Pharyngula, the Hastings Center Bioethics Forum, and TIME Magazine: pediatric endocrinologists Maria New and Saroj Nimkarn are advocating prenatal treatment with the glucocorticoid dexamethasone to "reduce behavioral masculinization" of female children.

Yes, you read that right: they want to expose pregnant mothers to one of the most potent, adverse-effect-prone steroids out there in the hopes of molding unborn girls into models of femininity.

I'll give you a few minutes to find where your lower jaw rolled off to and get a glass of water -- throwing up in your mouth a little is bad for your teeth. When you get back, I'll expand a little on the current standards of practice, and then we're going to go over some organic chemistry.

Back now? Great. First, PZ got one important fact wrong: the American Academy of Pediatrics and other noteworthy medical organizations have absolutely not condoned or endorsed this practice. The "consensus" to which PZ refers is an agreement that the study of dexamethasone as a preventative for congenital adrenal hyperplasia due to 21-hydroxylase deficiency should be conducted "via IRB-approved clinical trials through research centers large enough to obtain meaningful data" and with follow-up studies. This is, in my opinion, a reasonable position. CAH gets press because one of its effects can be ambiguous genitalia, sometimes aka "intersex", but its effects on aldosterone (one of the steroids your body produces) can lead to dehydration, hyponatremia, hyperkalemia, metabolic acidosis and death, in infancy. "Ambiguous" is also used, erm, ambiguously; it doesn't only mean "large clitoris", it also includes things like the urethra and vagina opening into a common cavity and causing severe urinary tract problems.

If there is sufficient reason to believe that prenatal dexamethasone can keep children whose genes prevent them from producing 21-hydroxylase alive, or make it possible for them to avoid difficult, expensive and painful surgery to restore urinary function, that is a valid avenue for research conducted under the auspices of an institutional review board. Attempting to tweak girls' personalities to make them more girly is way, way out of bounds, and New and Nimkarn should be censured for even suggesting the idea.

But what I really want to talk about is steroids, and what you, dear reader, do and don't already know about them.

"Steroid" is a really, really broad term. It's as broad as "sugar" or "alcohol". (The categories also overlap, which can be confusing; there are sugar alcohols and steroid alcohols.) When you think of "sugar" you probably think of that grainy white stuff you put in your coffee, and when you think of alcohol you probably think of booze -- but the picture is actually much bigger. All monosaccharides and disaccharides are sugars, including the ribose and deoxyribose that form the backbone of your RNA and DNA. Ethanol is the alcohol we drink, but it's just one of the aliphatic alcohols, which also include isopropanol (rubbing alcohol), methanol (can blind or kill you if you drink it!), xylitol (used to sweeten chewing gum), mannitol (baby laxative), ethylene glycol (antifreeze!), and glycerol (aka glycerin). I won't bore you with all the various non-aliphatic alcohol families, but there are a lot of them. So, also, with steroids.

Steroids are emphatically not just what dumb jocks inject to get really ripped really fast. (Those are certain anabolic steroids.) Just as "alcohol" refers to organic molecules with an -OH bound to a carbon atom and "sugar" refers to a particular type of carbohydrate building block, "steroid" specifically means "molecule with three six-carbon rings and one five-carbon ring in a particular arrangement". (That four-ring core is called a sterane, if you were curious.) And, wow, are there ever a lot of them. Cholesterol is a steroid. So are androgens (including testosterone), estrogens (there's more than one), and progestagens (humans only have the one, progesterone). But unless you're on hormonal birth control, taking estrogen or testosterone replacements, taking progesterone as part of fertility treatment, or otherwise tweaking your own sex hormones, if your doctor prescribes you a "steroid" it is almost certainly going to be one of the corticosteroids.

Dexamethasone is, as I said above, a glucocorticoid -- a member of the family of corticosteroids that can affect immune function. (In the interest of space, I'm going to skip the other family, the mineralocorticoids.) It is, not to put too fine a point on it, the nuclear option of corticosteroids. Long-term use -- which, for glucocorticoids, means more than a week -- causes the adrenal glands to start shutting down; stopping glucocorticoids abruptly after this has happened can cause an Addisonian crisis, which can be fatal. Even long-term use as directed frequently causes Cushing's syndrome, which has a whole raft of nasty symptoms including rapid weight gain, high blood pressure, insulin resistance, severe anxiety, and psychosis. As if that weren't enough already, long-term use also causes osteopenia, a lowering of bone density that is the precursor to osteoporosis.

Given the degree of side effects involved with long-term dexamethasone usage -- and the several weeks of treatment involved in the New and Nimkarn study constitutes "long-term" -- the "behavioral masculinization" paper rolls over from "horrible" to "sheer, unrestrained evil". They are literally advocating putting pregnant women through multiple weeks of chemical torture -- not to save lives, but in pursuit of a behavioral "ideal".

If you think this is anything even remotely resembling right, I invite you to spend a month on dexamethasone -- without medication to mitigate side effects, remember we can't give benzos to pregnant mothers because they might adversely affect the fetus! -- and find out what it does to you. The stretch marks alone -- which look more like "I lost a fight with a cage full of tigers" than "boo, cellulite" -- will last a lifetime; the psychological damage from finding out just how deep your capacity for violence and self-hatred can run may fade, eventually.

All that said, there is one extremely valid prenatal use for dexamethasone. If you're about to give birth to a premature baby younger than 34 weeks, one injection of dexamethasone 24-48 hours prior to birth will help the baby's lungs produce the surfactant which it needs to be able to breathe. (Multiple doses used to be the standard, but -- big surprise -- it turns out that the beneficial effects of multiple doses are no higher, in any statistically significant sense, than of a single dose, and the adverse effects on both mother and fetus with multiple doses are worse.) Consider the difference, though: one injection versus several weeks of dosing, sharp increase in likelihood of survival versus reinforcing social norms. It's like day and night.

What it all comes down to, in the end, is this: be an informed patient. Ask questions. When you're prescribed a medication, the minimum you need to know is:
  1. What exact medication is this? Don't accept a category as an answer. You wouldn't hire a contractor who told you she was going to build your cabinets out of "wood"; you wouldn't hire a florist who told you he would make your anniversary bouquet out of "plants".
  2. How long will you be on it?
  3. What is the intended benefit of taking this medication?
  4. What are the potential or likely adverse effects for the timeframe in which you'll be on it?
  5. (if applicable) What are the potential interactions with any other prescription medications, over-the-counter medications, supplements, herbs, &c you take?


Doctors have a lot of training, and they do learn how to perform risk analysis, but at the end of the day, you are the one who gets to decide whether the potential benefits of any medication are worth the risks involved. You can't know the benefits or the risks unless you know exactly what you're putting in your body. Ask, and don't put up with bullshit non-answers.
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So apparently a guy decided to show up today to an Obama speech in Arizona while carrying a pistol and a semiautomatic rifle. (He didn't want to give reporters his name, but that's him in the foreground in the picture over there.) Good for him! He and William Kostric have both conducted themselves admirably, declaring for all to see, "I am a citizen who is well-informed of my rights and responsibilities under the law, and I will acquit myself in a law-abiding fashion." We need more upstanding citizens like these guys.

This afternoon, on Twitter, I was reminded of why.

See, although I've never hidden the fact that I love the Second Amendment and believe that it's one of the most important founding principles of American government, I've never really gone out of my way to engage people about it like some of y'all are wont to do. I prefer to do my activism on a one-on-one basis, by shaking up people's expectations. If you've never been around guns, if none of your friends are gun owners, if your only exposure to guns has been violent movies and reports on the six o'clock news about people being shot during robberies, it's easy to think of gun owners as Those People who Aren't Like Us. It's easy to conflate gun owners with closed-minded rednecks who would rather put a bullet through a queer or a feminist or an anti-war protestor than have to live in the same society as them.

It's a bit different when you find out that the woman who just walked three miles through the streets of San Francisco with you in the Trans Pride March, who goes to raves with you and wants drug laws to be completely overhauled and blogs in favour of gay rights, is just as proud of being a responsible gun owner.

I found out about the fellow in Arizona through someone I don't actually know: some guy on Twitter who started following me yesterday. He had some interesting links, so I followed him back, and he tweeted a link to an article about the guy in Arizona. I tweeted back that as long as he conducted himself peacefully, that was great news. This kicked off an hour-plus-long debate which, apart from a couple of interchanges with antagonistic people at a Diversity Fair at the University of Iowa where some friends and I had a booth representing the gun culture, was really the first frustrating conversation about guns I've ever had. I guess I'm lucky.

See, in the Sassaman household we have two rules for houseguests: if you use the stove, make sure you turn it to the "off" position that really is "off" and not the "off" that leaks gas, and you must understand the four rules of firearm safety and show us that you can safely unload the guns we keep in the house. That's it. You can use our shampoo, if it's in the fridge it's fair game, we don't mind if you walk out of the shower in the altogether -- but we expect and require you to know how to be safe with the two dangerous things in the house. We'll teach you basic gun safety and step you through all the physical stuff, as many times as you need or want, but if you're not willing to do that, you're going to need to find somewhere else to crash. (We'll help with that too.)

It's pleasantly surprising just how much this opens people's eyes: discovering that wow, there actually are People Like Us, people who share Our Values and fight for the same things we fight for, who are also passionate about gun rights. I don't know exactly what goes through their heads, but I like to think it's something along the lines of, Huh. Maybe guns aren't as scary and alien as I always thought they were. Maybe they really are just tools, just inanimate objects that take on meaning only in the context of whoever's holding them.

You know, like a dude in Arizona carrying a pistol in a holster and a semiautomatic rifle in a resting position over one shoulder with the barrel pointed safely at the ground.

What I didn't expect, today, was just how much context some folks want to assume, even in the absence of any evidence whatsoever to support those assumptions. Twitter-guy ranted, angrily and at length, about a "greasy redneck cowboy" he'd seen in a grocery store the other day, openly carrying while doing his shopping. He accused this man -- who he didn't exchange a single word with -- of being "afraid" and "paranoid", and said that he "was sorely tempted to grab it and make him shit his cowboy pants."

I was flabbergasted. "Wait," I said, "so you think it's OK to just walk up to some dude in a supermarket and assault him if you don't like what he's holding?" Well, yeah, apparently he did. That blows my mind. If you wouldn't walk up to some dude in a supermarket and snatch his backpack off his shoulder, why on earth would you walk up to some dude in a supermarket and snatch his gun off his hip? (Uh, or try to. Good luck with that, by the way.) 

The conversation continued, with Twitter Guy launching invective left and right, while I did my level best to answer his rhetoric with reason, his anger with level-headedness. I won't recap the whole thing here -- you can go read it on Twitter if you really want to -- but the one thing that really struck me, throughout the conversation, was the sheer depth of his conviction that those of us who support gun ownership and the right to carry in public do so out of fear. He labelled me "insane", he labelled gun owners of his acquaintance as "paranoid" and "nutcases". I shrugged off the name-calling -- dignifying it with a response never helps -- but he kept coming back to it, again and again, demanding to know why someone would carry a gun in public if they weren't afraid of something.

At the end of the conversation, just before I called a halt and went to dinner, we were on the subject of when it would or wouldn't be appropriate to use a firearm in self-defense in a built-up area. "If there's a rapist in my face," I said, "I'll take that chance." And when I got back from dinner, what do you know, a snarky response about "See, you claim you're not afraid, but your words say differently."

That, ladies and gentlemen, pissed me the hell off. I don't know about the rest of y'all, but I do know women who have been violently raped by complete strangers. (I won't out them here; that's their choice, not mine.) I'd trade my right arm for the chance to go back in time and make sure they had a loaded handgun and the skills to use it on the night they were raped. You know why? Because trying to frame the discussion about self-defence rights in terms of "fear" versus "lack of fear" is more than disingenous, it's an out-and-out lie. English has words like "concern" and "qualm" and "doubt" and "dread" and "paranoia" and "unease" because fear is not a binary, it's a continuum. We have the phrase "healthy concern" because there is such a thing. I'm "afraid" of being in a situation where I might need to defend myself with deadly force the same way I'm "afraid" of having my bad ankle go out under me and dump me on my keister in the street: I wear stiff boots to keep my ankle from buckling, and when I'm in a situation where it's lawful for me to do so, I carry a handgun. 

So I told him his male privilege was showing, and that was the end of that.

I support gun rights because I support civil rights, plain and simple. I cheer every time a woman plugs a would-be rapist, every time a PoC plugs someone trying to assault them because of the colour of their skin, every time a queer plugs a would-be gay-basher. It's not that I especially like violence; the bare truth of it is that some people will listen to nothing else. Some people hear "it's wrong to physically harm people because of the colour of their skin, or what's between their legs, or because of who they love" and it just slides right off as if they'd never heard it. Am I saying "let's go shoot all the racists"? If you think that, you haven't been listening: firearms are a tool for self-defence, and I don't mean "the best ~ is a good offence". Nobody likes to admit it, but if you're a minority in the United States, there are people who believe, as surely as they believe that the sun will come up in the east tomorrow, that your mere existence is a killin' offense. These people are wrong, and if one of them attacks your person, then for God's sake just shoot the motherfucker. If just ten percent of the gays and lesbians in America were to learn how to shoot and carry handguns, there'd be a lot fewer Matthew Shepards or Paul Broussards or Brandon Teenas or ... well, you can read up for yourself if you don't already know.

This is what William Kostric means, by the way, when he says "an armed society is a polite society." And so do I.

But I wonder, because I know some of you reading disagree with me -- what is it you think we're afraid of? 
maradydd: (Default)
Worth exactly what you paid for it, so hey, if I piss you off, all you wasted was your time.

Anyway. I recently read some discussion in a trans* community about the following excerpt from an HRC newsletter:
Getting the truth in front of the American public is no small undertaking. Extremist groups are not only attacking equal rights we've already won – they are raising millions to shut down progress on victories yet to come.

Backed by supporters like you, here's how we're making a stand:

* In Maine, preparing to defend marriage equality at the ballot – sure to be a major fight;
* In California, rolling out a massive initiative to organize clergy and religious communities in support of marriage equality;
* In New Hampshire, building grassroots pressure behind the marriage bill now making its way to the governor's desk;
* In New York, working with state groups to organize support for a marriage bill scheduled for a vote in the state Assembly today;
* In Iowa, ensuring elected leaders continue standing strong against the radical right's relentless campaign to overturn the recent court ruling;
* In Connecticut and Vermont, ensuring that marriage equality is protected forever.

Every single one of these efforts is being threatened. The truth is on our side, but we need YOUR support to broadcast it, talk face-to-face with Americans, and win hearts and minds.

The discussion was critical of the fact that transgender rights were not being addressed by the HRC's efforts at all. Now, this is a thing worth being concerned about, because there are some major issues going on in the US with respect to access to health care, access to housing, fair treatment in the workplace, fair treatment by the State Department, &c with respect to trans* persons. As an organisation which deals with sexuality-based discrimination issues, it is reasonable to expect the HRC to engage with trans-rights issues.

The HRC also has a lot of money, and it is tempting to assume that it can take on any goal it wants to. Making this assumption can lead to the conclusion that HRC is therefore deliberately ignoring trans* issues in favour of same-sex marriage. However, I submit that it is flawed reasoning to assume that the HRC's resources are unlimited; in fact they most certainly are limited compared to, say, the aggregate resources of the Republican Party and its supporters. This means that the HRC must pick its battles.

It is presently the case that there is legislation related to gay rights, and in particular to same-sex marriage, being considered in several state legislatures at this time. It is also the case that there are ballot issues and judicial issues related to same-sex marriage coming up that immediate, decisive action -- often in a grassroots fashion, as in the case of making sure people get to the polls in order to vote on important issues, or encourage their friends in areas of important ballot measures to get to the polls -- can make a major difference on.

Now, here is my question. What are some major trans* issues currently in front of the courts or the legislatures that I can have some impact on?

I ask that in all seriousness as a US citizen who maintains a residence in California. Offhand I can think of several government issues that I can affect, in California and in the United States as a whole, some of which have to do with same-sex marriage, some of which have to do with other issues with which I concern myself (e.g., privacy, copyright, open-source biology). For instance, if the petition for a rehearing in Strauss v. Horton is granted, I can write an amicus curiae brief -- a "Friend of the Court" letter. Is there a trans-rights case currently going before a state or federal court that I can research and submit a brief about?

How about a trans-rights referendum in some upcoming municipal, county, or state election? Is there, say, a proposition in San Francisco to require the City and County to cover HRT and SRS for trans* government employees? If so, I could encourage all my San Francisco readers -- and there are a lot of them -- to get out the vote. And they'd do it. That's the kind of people I make friends with. I could do the same for Houston, Austin, Iowa City, Chicago, Washington DC, Seattle, Miami, NYC, Boston, just by speaking up and getting the word out, thanks to my diverse group of friends. I can also write letters and make phone calls to Congresscritters, state and local representatives, and ask people in all sorts of places to do the same and get the word out themselves.

So I ask you, what are some time-critical issues that I can help spread the word about? Because HRC is going to have to focus on things that it can affect immediately, and really, that's the kind of thing I can help with too.

Is there a website I can go to that tracks trans* issues before the courts or legislatures? When I go to GovTrack and search using the keyword "transgender", I get seven results for the current session of Congress, six of which are memorial resolutions of one kind or another, the other of which is the National Hate Crimes Hotline Act of 2009. That's nice, but GovTrack only follows the US Congress, not state issues, and it doesn't do elections or courts. Is there a centralised repository of up-to-the-minute (-day would be fine, actually) breaking trans* political issues? Preferably one where I can send emails to my representatives with a convenient dropdown menu?

And finally, if there aren't any trans* issues before the courts or on the ballots at the moment, I strongly recommend putting some there. The issues exist, but in order to get them the attention they need in order to be addressed, they're going to have to be forced in the spotlight by someone taking a discrimination issue to trial, or by getting a legislator to propose some form of legislation, or by grassroots effort to get a proposition on a ballot somewhere.

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September 2010

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