Category Archives: human rights

The Authoritarian Personality and the National Divide

‘In talking to right-wing authoritarians (RWAs) — in any situation — the first and greatest challenge is to reduce the level of fear and increase the level of trust. They cannot hear or see you at all until this happens.’ — Sara Robinson

I think it’s fair to say that a majority of Americans are completely boggled that so many of our fellow citizens are willing to believe so much crazy crap that is so utterly disconnected from reality. Just saying that they’re nuts is not helpful. Strangely enough, there is actual research to help explain why and how they are able to continue living in their alternative reality and steadfastly fend off any facts that might attempt to intrude. And it’s been around since before the last period of far-right fantasy hegemony.

I came across a very useful set of posts by Sara Robinson, who was raised fundamentalist and closed-minded but was able to transcend her upbringing, and who has a lot of understanding about how to communicate with those who are still inside the “Wall” of insulated post-factual unreality. So much became clearer for me. (Scroll down for links.)

Robinson was summarizing the work of John Dean— yes, that John Dean, from Watergate— who wrote Conservatives Without Conscience, which is based on the work of social psychologist Robert Altemeyer.

“Research into ‘authoritarian personalities’ began in the aftermath of WWII, as scientists tried to figure out how otherwise civilized people succumbed to the charisma of Hitler and Mussolini and allowed themselves to be willingly led into committing notorious atrocities. The inquiry continued through Milgram’s famous experiments at Stanford in the early 60s; later, some of it became subsumed in the work of The Fundamentalism Project convened by Martin Marty at the University of Chicago in the 1980s and early 90s. Long story short: there is now over 50 years of good data on these people coming from every corner of the social sciences; but since almost none of this has been common knowledge outside the academy, nobody on the progressive side has really been putting it to use.”

The bully leads

The description of authoritarians who are on the leader side of the equation sounds eerily familiar in our present environment:
“High-SDO [social dominance orientation] people are characterized by four core traits: they are dominating, opposed to equality, committed to expanding their own personal power, and amoral. These are usually accompanied by other unsavory traits, many of which render them patently unsuitable for leadership roles in a democracy:
“Typically men
Intimidating and bullying
Faintly hedonistic
Vengeful
Pitiless
Exploitative
Manipulative
Dishonest
Cheat to win
Highly prejudiced (racist, sexist, homophobic)
Mean-spirited
Militant
Nationalistic
Tells others what they want to hear
Takes advantage of ‘suckers’
Specializes in creating false images to sell self
May or may not be religious
Usually politically and economically conservative/Republican”

“Dean notes: ‘Although these collations of characteristics…are not attractive portraits, they are nonetheless traits that authoritarians themselves acknowledge.’ In other words, these guys know what they are, and are often quite unabashedly proud of it.”

But these leaders wouldn’t get very far unless there were legions of authoritarian personalities on the follower side, and unfortunately there are. It seems that there are all too many people who want to be told what to think and what to do. Ms. Robinson postulates that while the bullying leader types may be beyond the possibility of redemption, a lot of followers may have some openness to communicating across the divide.

I can easily sympathize with the desire to be given simple answers and clear directions. The world is so overwhelmingly complex nowadays, and our path forward seems so uncertain. Sadly, I expect that fundamentalism and authoritarianism will continue their ascent in the near future as climate change and population growth create even more conflict and pressures for water and other resources. They may even provide some sort of genuine protection against chaos, at least temporarily and in limited areas. However, this kind of mindset works against the innovative drive and mental agility that is needed most under fast-changing and stressful conditions.

Dedicated to the cause


“RWAs are sadly accustomed to subordinating their own needs to those of their superiors; in fact, one of the struggles we often see in recovering fundies is a complete inability to even acknowledge that they have needs of their own, let alone identify them, let alone act to meet them. They simply don’t know where to begin. Also, because their own authorities use guilt and shame to control them, they’ve seldom been allowed to see themselves as truly good and moral people.
“Giving an RWA permission o recognize, give voice to, and take action to satisfy his or her own needs is a powerful act. In affirming that they are not just allowed, but entitled (in the name of fairness) to feel their own emotions, own their own goodness, indulge a few harmless appetites, enjoy themselves, assert their boundaries, or stand up and say ‘no’ to overweening authority, you are being an enlightened witness to their true self — something many of them have seldom if ever had. In the process, you are also giving them a direct view over the wall. Often, it’s a view that they never forget, and will keep coming back to until they’re persuaded to go over it for good.”

Red Family, Blue Family

“The best writing on this I’ve seen comes from Unitarian writer Doug Muder, who has taken George Lakoff’s model of ‘strict father’ versus ‘nurturant parent’ politics one step further, and uses it to explain precisely how the right wing came to believe this preposterous notion…. Muder asserts that, while Lakoff’s right that family models are the right frame, the real dialectic is between families of ‘inherited obligation’ versus those based on ‘negotiated commitment.’ Go read the article, then come on back. We’ll be here.”

Here’s the article: “Red Family, Blue Family” https://www.gurus.org/dougdeb/politics/209.html
I strongly recommend that you read this. In fact, I implore you to read it. Lights will go on for you. For example:
 “The Inherited Obligation model, on the other hand, is ambivalent about the social safety net. On the one hand, it is good that people don’t just die when they have no one to take care of them. But on the other hand, the safety net weakens the network of familial obligations. A young adult who moves to the big city to seek his fortune doesn’t come home when he fails, he draws unemployment. Social Security and Medicare may provide an excuse not to take care of aging parents.
“…The Inherited Obligation model is likewise ambivalent about freedom. Freedom to fulfill your obligations according to your best judgment is a good thing. But the kind of freedom that releases people from their obligations is not. In the Negotiated Commitment model, a life without commitments is empty, and there can be no commitment without freedom.”
“Their demonic liberal is a person with no moral depth or seriousness. Convenience is his only true value. Words that we revere, such as freedom and choice, rebound against us: We like these words because we want to be free of our obligations and choose the easy way out.
“Just as married people sometimes imagine the single life as far more licentious and libidinous than it ever actually is, so people born into life-defining obligations imagine a life free from such obligations. The truth about liberals – that we more often than not choose to commit ourselves to marriage, children, church, and most of the other things conservatives feel obligated to, and that we stick by those commitments every bit as faithfully, if not more so – easily gets lost.”

Sometimes those on the left are accused of attempting to control and tyrannize others in the same way that the right does. That isn’t really characteristic of liberals, with their tendency toward fluidity and emphasis on choice:
  “As a final point: Dean’s book puts to rest once and for all the right-wing shibboleth of ‘liberal fundamentalists’ and ‘liberal authoritarians.’ Altemeyer and his colleagues have found, through decades of research, that authoritarians almost universally skew toward the far reactionary right on the political scale. This very much includes Stalinists and other ‘left-wing’ totalitarians: though these men used socialist rhetoric to create ‘Communist’ political orders, they’re classic examples of high-SDO leaders taking control by whatever means they had at hand, and using them to create archetypal far-right authoritarian states. Dean and Altemeyer make it clear that authoritarianism is, by long-accepted definition, overwhelmingly a right-wing personality trait.
“Dean is also emphatic that authoritarianism, in all its forms, is completely antithetical to both classical conservatism (he still considers himself a Goldwater conservative), and to the founding ideals of America. We must be clear: when right-wingers threaten liberals, they are directly threatening the seminal political impulse that created our nation. An operative democracy depends on having a populace that is open to new ideas, able to think for itself, confident in its abilities, willing to take risks, and capable of mutual trust. America was founded as the world’s first radically liberal state. History has shown us that the nation’s best moments, past and future, are created by people with a strong liberal orientation.”

(Note that standing up strongly for principles, such as equality of opportunity in jobs and housing, does not constitute tyranny.)

“Alt” authoritarians

Then there are those who reject established authority but believe in “alt” authorities without question. It’s easy and seductive to see oneself as part of a persecuted minority, a group that’s in the know and smarter than all those “sheeple.” Robinson’s “A Short Detour” section is about them:
“I’ve known way more than my share of these guys, since Silicon Valley is one of their primary native habitats. And my take is that they’re at least as driven by their burning desire to fit in as any other RWA. In fact, their feelings of victimization may be rooted in the belief that they were promised an acceptance in liberal intellectual circles that they intensely wanted but never really found. The most extreme ones were frighteningly bright and well-read, and usually also from very religious family backgrounds. Those two qualities alone guaranteed that it was going to be hard to find a niche among the better-rounded, more secular big city liberals. So they decided that, if they were going to be outcasts anyway, they could at least claim moral superiority. I may be a nerd, but I am RIGHT — the possessor of Ultimate Truth! — and that’s what really matters in the end.”

Why so many of them?

I’ve wondered why the authoritarian-follower trait has been so persistent in the human population, being that it involves so much unwillingness to face facts and thus to deal with real and immediate threats. There must be some advantage, or it wouldn’t exist. Authoritarians do know how to organize and come to agreement, for good or ill, and perhaps that confers an ability to respond more quickly to danger than a dithering, contentious group could, despite their propensity to live inside their imaginary constructions. (Even more than the rest of us, I mean.) Black and white thinking is faster and easier than taking all the grey into account. Perhaps group cohesion has been historically favored over innovation under adverse circumstances?

(Since to be a Christian is to see everyone as your neighbor, and to love your neighbor as yourself, it’s particularly perplexing to me to see that right-wing fundamentalists are so invested in being part of an in-group and demonizing everyone else.)

The most depressing thing about all of this is that Robinson wrote it back in 2006, so hopefully, but nothing seems to have changed, except to get worse. At least, that’s how it looks. I would love to see evidence to the contrary. Please tell me if you’ve got some.

 

Sara Robinson’s posts:

Cracks In The Wall, Part I: Defining the Authoritarian Personality
http://dneiwert.blogspot.com/2006/08/cracks-in-wall-part-i-defining.html

Cracks In The Wall, Part II: Listening to the Leavers
http://dneiwert.blogspot.com/2006/08/cracks-in-wall-part-ii-listening-to.html

Cracks in the Wall, Part III: Escape Ladders
http://dneiwert.blogspot.com/2006/08/cracks-in-wall-part-iii-escape-ladders.html

Tunnels and Bridges, Part I: Divide and Conquer
http://dneiwert.blogspot.com/2006/08/tunnels-and-bridges-part-i-divide-and.html

Tunnels and Bridges, Part II: Nothing to Fear But Fear Itself
http://dneiwert.blogspot.com/2006/08/tunnels-and-bridges-part-ii-nothing-to.html

Tunnels and Bridges, Part III: A Bigger World
http://dneiwert.blogspot.com/2006/08/tunnels-and-bridges-part-iii-bigger.html

Tunnels and Bridges, Part IV: Landing Zones
http://dneiwert.blogspot.com/2006/09/tunnels-and-bridges-part-iv-landing.html

Tunnels and Bridges: A Short Detour
http://dneiwert.blogspot.com/2006/09/tunnels-and-bridges-short-detour.html

 

 

 

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Filed under human rights, history, politics, psychology

“You know my heart.”

About a week ago I heard that the pastor of one of our local megachurches, Steve Smothermon, had referred to my city councilor as a “militant homosexual.” The exact quote was: “Pat Davis, I think that’s his name, City Councilor Davis on the city council, he come out and said it’s the greatest thing, ‘cause he’s a militant homosexual.”

It kept popping back up in my mind, especially since I have friends who go to that church, and they wouldn’t say such a thing. The issue, if I understand it, was that Councilor Davis was trying to defend LGBTQ kids against some school board members who were trying to remove protections that had previously been put in place.

I must be more sheltered than I think, because I didn’t realize that the term “militant homosexual” is used all the time by a faction of religious extremists who believe that gay people are trying to destroy Christianity, indoctrinate their children, and take over the whole country and perhaps the world. As I write this, the image that is running in my mind is that of my kind, gentle lesbian colleagues and their wives, doing their gardening and puttering around the house. It’s pretty hard to square with the fire-breathing monsters these folks are warning everyone against.

This same pastor has gotten notoriously entangled in politics a number of times. He spoke out against Gov. Susana Martinez a few years ago when she appointed an openly gay man to the PRC. ‘Smothermon told NMPolitics.net last month that Martinez “looked me in the eye personally and said she’s socially conservative… she wouldn’t espouse the homosexual agenda.” He said Howe’s appointment “goes against that.”’ http://nmpolitics.net/index/2012/02/pastors-comments-spark-protest-online-debate/

Ah, now we are on familiar ground— “the homosexual agenda.” Hiring the most qualified candidate, who happens to be gay, is “espousing the homosexual agenda.” Because apparently gay people shouldn’t be allowed to work and therefore have food and a place to live. Or maybe they just shouldn’t be paid with tax dollars? The pastor continued: ‘”These aren’t the people we voted for you to appoint. We voted for you to appoint people who think like we do,” he said, adding that he is “not against the human being, but the lifestyle and the political power that the homosexual agenda has today, as a lobbying agenda, that’s what I begin to come against.”’

“We voted for you to appoint people who think like we do.” Separation of church and state does not seem to mean much to such pastors (and indeed, I have heard a few voices on the right say that it should not exist).

If wanting to avoid being killed or beaten in the street, wanting to be able to work and survive economically, and expecting the fundamental respect accorded to any other member of society— just wanting to live— makes us “militant,” I will be happy to count myself as militant and stand up for that “agenda.” In fact, this crap is making me feel more militant by the day. I fly under my bisexual cloak of invisibility most of the time, for good or ill, so these guys don’t see me. If they did take notice of me, though, they would probably be just as happy to attack me as they would my gay friends. I am taking all this extremely personally.

I could go on with a lot more obvious points, such as the propensity of so many religious folk to harp on their favorite few lines taken out of context, and in translation, from the huge literary tradition that constitutes the Bible. But you know all that. I do want to add a word from someone who comments at liberal pastor John Pavlovitz’ blog, a religious person herself, who stated this at least as well as I could: “If we believe God doesn’t make mistakes and that God it is love and that God made humanity in God’s image, then it stands to reason that if God created someone to be homosexual, then it must have been because it delighted God to do so.”

I will not even engage with the contention that people “choose” to be gay. Everyone should know better by now.

And I should know better than to give all this garbage any space in my brain, but it’s amazing what can worm in there and take up residence. I’m going to tell you about an experience I had nearly three years ago and wrote about then but never dared to share with you because it seems an order of magnitude farther out than anything else I’ve posted. It isn’t, really— that’s probably just my inner insecurity talking. As intense spiritual experiences go, it may even be fairly mainstream. Anyway, it changed everything for me. Here goes:

 

*************************************************************************
Events of 9/30/14

A friend told me with great excitement about a channeler she had discovered, who was giving messages from Jesus, as many do. She felt that his work was what she had been trying to find for a very long time, and said that she had at last discovered real peace. The messages she described sounded very much like what I had heard from Hania Stromberg’s channeling [see my old post “An Appointment with Jesus”] and what I had picked up myself, a real antidote to the controlling, limiting, shaming version of Christianity my friend and so many of us had grown up with.

I went to the channeler’s website to find out more. There were a number of messages that seemed worthwhile and helpful. I was a little put off by the fact that the channeler had been associated with the I AM Movement, which has a number of problematic aspects and was founded by questionable and deceptive leaders. He still uses much of their terminology. But I don’t care about the channeler’s background so much as the content of the messages themselves.

I scanned the sidebar of the home page for subjects. One entry was “Teachings on Homosexuality.” My heart sank. “Oh, crap,” I thought. “Here it comes.” I had a pretty good idea what I was going to find— and what I found was even worse than I expected. Not only was it judgmental in the most insidious and damaging manner I had ever seen, it was couched in language that insisted the speaker wasn’t being judgmental at all. The effect was, “I would never judge anyone, but you’re horrible beyond redemption.” It also came off as “I’m only telling you this for your own good.” I will not repeat what I saw there, because it doesn’t need to be given any validation, and my readers don’t need the trauma. The sanctimoniousness was thick and sticky, and so very familiar.

If this had been written by any typical yahoo wingnut preacher, I would have shaken my head sadly, closed the page, and moved on. But my friend’s reaction to the channeler, and her typical level of depth and thoughtfulness, gave it far more impact in my mind. I felt deeply ill, sick to my stomach. The idea that people, especially young people, would read this and let it get into their systems was horrifying. I knew this wasn’t the Jesus I had met, not remotely, but I couldn’t just leave it alone.

This was one of my piano lesson/lunch and writing/walk on the ditchbank days, and as I strolled under the cottonwoods that afternoon, I quizzed myself very rigorously, just in case, on whether I might be rejecting an actual truth because it wasn’t what I wanted to hear. (That sounds silly now, that I could consider accepting anything so insane even for a nanosecond.) No. Every molecule of my being told me it was utterly, evilly wrong. I sent out distress calls. Normally I don’t have conversations with Him, and don’t have a clear “phone connection,” but I hoped to get a reply. After all, he had told me years earlier that I could always come to him for comfort if I needed to.

A little later, when I got home, I felt his presence. As soon as the contact began, I knew there was really nothing I needed to ask. The answers were in the presence itself. A fountain of love and acceptance rushed down through the top of my head and filled me everywhere. Being me, though, I had to ask for clarification in words.

He did not say that he had nothing to do with this man or that the messages were wrong; he said that the channeler was getting only the surface of what he was trying to say. He showed me a view of an ocean full of creatures, and explained that while there were a great many fish living in the water, this man saw only the few fish that swam toward him and presented themselves to his vision. This image formed clearly in my mind, one fish after another swimming forward, turning, and moving away into the darkness beyond. It was an odd metaphor, it seemed to me, but the meaning was easy to understand.

At the end of that sequence, I heard, “I am the ocean.”

I realized that the reason I had been so upset by the channeler’s presentations was that some part of me believed he might be right. “I need reassurance,” I went on, chattering nervously, along these lines: “I, and people I know, do feel in a way that we are broken or unbalanced or wrong. I don’t really think it’s true, but I feel it. You know that I feel something’s wrong with me because I fall in love too much. I guess you probably think that’s silly, and it is, but I feel it. Anyway, I need a hug!” I was getting seriously teary by this time.

I’d been getting a lovely cosmic hug the whole time already. He said something that surprised me: “You know my heart.” Yes, I did. “And I know yours,” he continued. I was both feeling much better about everything and dissolving further into weepy, overwhelmed jelly.

And then he said something even less expected, something so large that it doesn’t fit in these words: “My heart is yours.”

I felt the meaning, far beyond the words. He had told me Tat tvam asi, Thou art that. We are one. I already partake of Christ Consciousness and I am in my rightful place in the universe of humanity. I am not unacceptable, not wrong, not broken. I am loved, and I always will be. (You are too.)

 

In the weeks that followed this experience, my friend kept sending me more material from that website. None of it was particularly problematic or offensive. I wondered if she had even seen the part that had upset me so, and was afraid to ask. She wanted to know my reaction to what she sent, and I couldn’t figure out how to talk about any of it without bringing up what I saw as a central issue that invalidated the whole body of work. At last I couldn’t avoid it any longer, and I found a way to discuss it with her. She didn’t like that section any better than I did, but she wasn’t worried about the validity of the channeling overall. She reminded me that even the channeler himself had written about the difficulties of getting messages through without having them colored by our own biases and expectations. That was good enough for her. It wasn’t for me.

I was left feeling that I would rather listen to Source Itself than to what anyone else says. To whatever small extent my antennae can receive it, that is. All I can tell you, as usual, is, “This is what I heard. Make of it what you will.”

So what’s the difference between me and others, like the wingnut preachers or this channeler, who claim they know what Jesus is saying? Maybe not much. But I can truthfully state that I am not trying to get any power over others.
****************************************************************

Perhaps the people I am complaining about have tapped into a pervasive field of fear and judgment, just as I connected with a field of love and acceptance. I would suppose that it is absolutely real to them. I know where I would rather live, and I know which is more likely to generate a world that is better for all of us.

More recently, I found myself in a lengthy and eye-opening discussion with a Catholic priest who reminded me that a traditionally religious viewpoint does not necessarily require a narrow, judgmental attitude. I think I’ll save that story for another day.

 

While looking for background about Pastor Smothermon’s comments, I found a couple of other articles of interest:

http://www.paulholtministries.com/2012/02/10/homosexuality-steve-smotherman-and-the-torah-observant-jesus/
This is an argument against those who point out that Jesus didn’t say anything about homosexuality one way or another. Holt writes that Jesus didn’t need to say anything about matters that were already covered in the Torah because he was an observant Jew and so must have agreed with everything in it. Pastor Holt apparently believes that not only does he understand everything Jesus said, he understands everything Jesus did not say as well.


http://nmpolitics.net/index/2012/02/forgiving-smothermon-praying-for-those-his-words-affect/

“Pastor Smothermon does not need to apologize. I have already forgiven him. I pray for him, but more importantly I pray for those his words affect.
“The kids that are bullied on the playground because Pastor Smothermon says being gay is wrong. The individual that continues to seek God’s love but can’t find it because Pastor Smothermon says there is no love, and in essence gays should not hold any job.”

For some perspective on the centrality of the fight against “militant homosexuals” among members of the religious right, check this out:
https://www.youtube.com/watch?v=_Gf4jN1xoSo
“True Origins of the Religious Right”
  The emphasis on homosexuality and abortion, issues not brought up in the gospels, turns out to be surprisingly recent. In contrast, although the gospels say that Jesus did speak against divorce, repeatedly, most evangelicals seem happy to let divorce go on. They would like to keep it available for themselves, so it’s perfectly fine. It’s those other people who are doing all the evil.

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Filed under channeling, human rights, spirituality

Another Human Being’s Identity Is Not Yours to Dictate

(Rant Advisory! I am as upset about this as if it pertained to my own child, or to me.)

So very often I am reminded of the old song that goes “None of us are free if one of us is chained.” It adds, “And if we don’t say it’s wrong then that says it’s right.”

Sometimes the chains are kept locked by those who think of themselves as far beyond bigotry or intolerance.

In the past week I have encountered two attacks against transgender people that appeared on the surface to have some higher intention. Both were warmed-over versions of old arguments.  One came in the form of a supposedly spiritual look at gender identity through the lens of reincarnation, and the other purported to be a principled defense of the rights of women by a feminist group.

GIVE. ME. A. BREAK.

I could call out the “spiritual” thinker by name, but I’m not going to, because his presentation is not just his own but represents a turn of thought that is all too common. It’s been used against gay people, too. The idea is that if you are not comfortable twisting yourself to fit into a gender-binary, heteronormative life, it’s because you were a different gender in a previous life, and either through confusion or through willful stubbornness, you are still clinging to identification with that gender. If you persist, you are stupid and bad. You should just get over it and move on, and then you’ll be fine.

This is the exact same paternalistic crap promulgated by religious groups who insist that God made you either male or female and that’s that. God doesn’t make mistakes, and so if you don’t feel right in your body, you are going against God, and therefore you are sinful and bad.

I’ll get to the so-called feminists later. First, I want to take a look at exactly what God/nature/biology did make. Because we do have some actual facts to work with.

While it would be nice to have human reproductive biology all wrapped up in a neat, understandable package, the more we learn, the more we see that things are complex and fuzzy. “Male” and “female” are not definite categories with hard edges. I’m sorry if someone dislikes this, but it’s reality. Some easily accessible sources of information follow.

http://www.isna.org/faq/ten_myths/rare
According to this, about 1 in 2000 humans are intersex. Another source estimated 1.7% of births. That’s a lot of people. Some may never realize they are anything but typical male or female, or may only find out late in life. One person I’ve read about was a seemingly ordinary middle-aged man with a bunch of kids, who had an abdominal surgery and was found to have a uterus in addition to his full set of male reproductive parts.

https://medlineplus.gov/ency/article/001669.htm
There are a variety of possible intersex conditions, with varying appearances and health considerations, briefly summarized in this article.

If that’s not enough, take a look at the fascinating case of the guevedoces. A few weeks ago I learned about them in an excellent PBS program, Nine Months that Made You. In the Dominican Republic, about one in 90 boys have this condition, which has also been found in Papua New Guinea. They have XY genotypes like “regular” boys, but they lack an enzyme that is needed to develop male genitalia in the womb, so their parents think they are girls and raise them that way. At puberty, they have the usual surge in testosterone and become obviously male all of a sudden. Of course, they were biologically male all along.
http://www.pbs.org/show/9-months-made-you/
http://www.newsweek.com/rare-condition-causes-girls-become-boys-puberty-374934

So are we clear now that external genital configuration does not equal gender? Likely we’re not clear at all and I’m still going to get a big argument from those who insist on a binary world, but in that case, they’re going to have to register their objections with God, because this is the way nature is put together. A religious and/or spiritual viewpoint, it seems to me, would have to say that there must be a good reason for things to be this way. A purely materialist viewpoint would say the same— that nature has shaped human bodies and brains in a dazzlingly diverse variety because it’s been helpful to our survival.

Some might then point out that transgender people are not the same as intersex people, and that most probably have clear male or female genotypes or phenotypes. But there appear to be differences from cisgender folk in those cases too, albeit subtler ones. As far as we can tell, transgender people have brains that function more like the gender they say they are rather than the one indicated by their genital apparatus— though this too is complex and a bit fuzzy.
http://www.scientificamerican.com/article/is-there-something-unique-about-the-transgender-brain/

Here is a link to another useful PBS program.
http://www.pbs.org/wgbh/frontline/film/growing-up-trans/
What struck me most about it was that the kids decidedly look like the gender they say they are. That’s not a hard scientific fact, but to me, it reinforces the concept that there is a physical basis for being transgender.

I don’t pretend to understand much about these aspects of our biology, nor how they fit with how we become who we become when we enter a new life on this planet, or what choices we have or don’t have about our embodiment. My conjecture is that gender exists as a spectrum so that we can experience every permutation of it, but that’s not fact. What I know for sure is that it makes no sense to tell others how they feel inside themselves— either how they do feel or how they should feel. It’s illogical and it’s just plain mean. And when it’s coupled with a holier-than-thou or more-enlightened-than-thou message, it’s positively sickening.

Now, to the lawsuit filed by the Women’s Liberation Front, or WoLF. It’s the bathroom thing again, same as the extreme right’s fearmongering, strangely enough. They are insisting that “men” in women’s restrooms are a threat to women’s safety. I’m not going to rehash the reasons why trans women are no threat to cis women in this context (or anywhere else, really). You can find those all over. I’m only going to point out that trans women are not men. In their brains, the part of the human body that matters most, they are women. So denying ordinary human rights to those women cannot be feminism. Not in any way I can recognize it.

The latest post on WoLF’s Facebook page, in reference to the rule allowing kids to use school facilities consistent with their gender, states: “Girls’ rights to personal privacy and freedom from male sexual harassment, forced exposure to male nudity, and voyeurism have been eliminated with the stroke of a pen.” This makes my stomach churn. I am of course not a trans girl trying to navigate high school (which is hard enough for the rest of us), but reading this, I can viscerally relate to what they experience. It is terrifying. To be just a kid and know that others assume you are a sexual predator, when all you want to do is attend PE class and not get beaten up… to be hated and censured by “righteous” people one has never met… it boggles the mind and even more the heart. Imagine being, say, a second grader, too young even to have a concept of voyeurism or anything like it, having no idea why people are saying these terrible things about you.

(Please note that I don’t mean to ignore trans boys.  It’s just that WoLF seems to be targeting trans girls and women specifically.)

WoLF’s lawsuit clearly contradicts two of their main stated goals, and they seem to have no clue that this is the case. The home page of their website says: “WoLF is a radical feminist organization dedicated to the total liberation of women. We fight to end male violence, regain reproductive sovereignty, and ultimately dismantle the gender-caste system.” The total liberation of women has to include ALL women, not just the ones who look a certain way. Dismantling the gender-caste system (a laudable goal) has to mean completely dismantling, so that no gender is discriminated against.

Why should we settle for anything less?

 

It’s a great song:
http://www.altheaknight.com/None-of-us-is-free-if-one-of-us-is-chained
https://www.youtube.com/watch?v=JC2mmeA9CA8

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Wibbly-Wobbly Sexy-Wexy

don't existA few months ago I wrote a post entitled “Identity and the True Self,” in which I alluded to the concept that none of us truly exists.  The “not existing” referred to in this meme is something else– it’s a deliberate attempt to erase or marginalize someone, in this case someone who identifies as bisexual and thereby makes someone else uncomfortable.

I was halfway through another planned post about being treated as if I don’t exist because my entire profession is considered by some to be nonexistent, to deal in the unreal.  Then it came to my attention that this is Bisexual Awareness Week, and that today, September 23, is “Celebrate Bisexuality Day (often abbreviated CBD), an international awareness day that is also referred to as Bi Visibility Day and Bisexual Pride Day. Three bisexual advocates– Wendy Curry, Michael Page and Gigi Raven Wilbur– conceived of the event as a way to combat bisexual invisibility. CBD, which began in 1999, is celebrated with events around the world celebrating bisexual culture, community and history. In 2013, the White House held its first bisexual community issues roundtable on Celebrate Bisexuality Day.”  http://www.bisexualweek.com/about/

We have a day?  We have a whole week?  We have White House roundtables?  How did I not know this?  Until last year, I didn’t know we had a flag, either.  (It’s what you see behind the words in the meme above.)  I’m honestly not sure why none of this came to my attention, especially since I’m very much interested in gender politics and I follow gay and transgender rights issues assiduously.  Is my ignorance simply my own, or could it be in part a measure of that erasure and invisibility?

What also had not come to my attention until the past year or so was the fact that people who identify as bisexual are often seen as untrustworthy, disease-ridden, greedy, sexually voracious, shallow, unable to commit, confused, actually gay but afraid to say so, actually straight but looking for attention, and/or basically lying cheating creeps.  In addition to not really existing, that is.  We sure have a lot of awful qualities considering that we’re not supposed to exist.

I must admit that I’ve lead a rather sheltered life in some ways.  I’ve been with my husband for 36 years, since I was 19.  I never really was part of the dating market and I am blissfully ignorant of its workings.  I have not been much pursued by members of any gender, and those I would have liked to pursue have tended to run the other way.  So I can’t claim to have a complete picture of what’s going on out there.

I’ve also been extremely lucky in not being given much guff about my 360-degree sexual orientation.  Some guff, but relatively little.  As a teenager, I knew other people who had attractions to both males and females, so I felt, if not normal, not too terribly outré.  My husband has always been fine with me being me.  I haven’t remotely experienced the oppression that a great many people have.  (There was that one woman I had a youthful crush on for years, who, when I told her how I felt, looked at me as if I’d crawled out from under a rock and refused to ever speak to me again.  That was the worst of it.)  The straight world has been pretty gentle to me for the most part.  The gay world has been too, in terms of my interactions with individuals.  I didn’t know that there was a deep prejudice about people like me.  Here’s someone’s take on it, which may or may not reflect what any specific person thinks:

oppressed

Well.  Perhaps people would have had more of a problem with me if I were trying to date them?  Then I’d be rejected by all sides?  I decided to ask some trusted gay friends for their point of view and what they were hearing out in the world.  I’m not going to quote them directly, because I want to preserve their privacy, but what I was told was eye-opening, to say the least.  In one case it was positively vicious.  Even the more compassionate statements concerned why the person would never want to get into a relationship with a bisexual.  I was taken aback.  No wonder a lot of people like me want to use some other label.

If it’s necessary to use a label at all, that is.  I hear that the young whippersnappers increasingly are saying what I’ve always said, that they are interested in the person, not the plumbing, that sexuality is fluid, and that labels are too limiting and they don’t want them.  Maybe at some point all of this distinction-making will seem quaint and outdated, and people will just be who they are and feel how they feel.  That day isn’t quite here yet, but there’s hope.

I do “pass” and that has probably been a benefit to me– a degree of “bisexual privilege” for real.  I’m not trying to pass, though, and don’t particularly want to.  I’m still using the old-school label bisexual, understanding its limits*, because it is what I’ve always called myself, what I’ve known myself to be ever since I was aware of having any sexuality at all.  But now I’m beginning to think of myself as:

wibbly-wobbly

*“Pansexual” might be better but doesn’t feel quite right.  And I haven’t come up with a word for someone who is in love with a person who has been dead since 1849, or who is almost exclusively attracted to musicians, or who thinks pianos are a turn-on.  “Sapiosexual” is a great word and fits me well– someone who is attracted to intelligence.  Mary Oishi expanded this to “sapiocardiosexual”– attracted to a fine brain and a good heart.  Far more important than the organs lower down.


Whovians may very well have a word for those of us who think the Tenth Doctor was seriously hot.  He’s the one who explained that time is not linear, but instead is more like “wibbly-wobbly timey-wimey.” 

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Identity and the True Self

By Mike Luckovich. http://www.gocomics.com/mikeluckovich/2015/06/02 (I did my best to look into getting permission to use this cartoon, but could not find out how. Go Comics does allow free sharing on Facebook etc., so I hope this is OK.)

 

 

So much has happened in the past couple of weeks! Looking at the news optimistically, despite the horrifying attacks that have occurred, I see tremendous opportunities for healing in the national conversations about race, gender, and sexual orientation. That is, the fact that we’re having the conversations at all is extremely positive.

I usually try not to jump into any of the rings of the media circus. I am way behind the news cycle with this post, because I’ve been cogitating for quite a while about what I want to say. All the headlines lately have to do with identity in one way or another, and that’s my subject today. It’s complicated, as you know, and I’m afraid that someone may come away from reading this feeling insulted or minimized, which is certainly not my intention.

I started on this back at the time earlier in June, which seems like ages ago, when everyone was talking about Caitlynn Jenner and Rachel Dolezal,* and we were endlessly treated to analyses of those two cases of identity change. I don’t normally pay any attention to celebrities-for-celebrity’s-sake; it wasn’t that long ago that someone had to explain to me who Kim Kardashian was, and I wasn’t clear how Jenner was related. (Argus Hamilton quipped that before Dolezal identified as black, she identified as a Kardashian-American.) But there has been some real usefulness in the confusion people have been expressing and in their attempts to work their way through it.

It seems like the group mind has concluded that it’s pretty much OK to change your appearance and who you say you are in order to fit with who you feel you are on the inside, but that it’s not OK to lie. That’s fairly simple. There’s nothing simple about identity, though.

The fact that same-sex marriage is now legal and recognized in all 50 states (Lord, what fun it is to type those words!) is one sign that our view of human identity is more flexible and tolerant than it used to be. The lowering of the army of northern Virginia’s battle flag in some Southern states is another. The burning of African-American churches—six of them in four states in just the past week— following the murders at the church in Charleston is a sobering sign that the opposite is still true.** We have a long, long way to go.

From a biological viewpoint, race is nonexistent, and gender is fuzzy. Each of us contains multiple lines of ancestors and multiple genetic potentials. Why shouldn’t identity be large enough to contain those multitudes? I am so accustomed to switching roles in the course of a day or a week that it’s hard to imagine being limited to existing as any one thing. I wonder if we can or will get to a point where being intentionally multiple will be seen as normal.

In the matter of race, it seems inevitable; there are more and more mixed-race people all the time (all of us are mixed-race, of course, but I mean those for whom it’s an overt identity), so surely everyone will get more and more used to that. Genetic studies have shown how closely everyone on the planet is related, and that fact will most likely become more widely known.

With regard to gender, I wonder what would happen if our concepts of male and female expanded enough that a boy who feels like a girl could be comfortable remaining identified as a boy while expressing feminine aspects without restriction. That is, I wonder if trans people would feel less pain and less need to transition if society got over the idea of gender being binary and opened up the possibilities. But I am fortunate in that my own identity is not painful and is not being forced on me in any way, and I cannot speak for anyone else.

I read an impassioned essay from June 9 by Fr. Robert Barron, who strongly criticized trans people for saying that they are mentally one thing and physically another.+ He wrote that the Church has always seen the material body as good (which doesn’t sound to me like the Catholic Church I was brought up in), with identity being a characteristic of the body and not just the mind. “Moreover, the mind or will is not the ‘true self’ standing over and against the body; rather, the body, with its distinctive form, intelligibility, and finality, is an essential constituent of the true self.”

Since I am very much aware of the existence of human beings who are not currently living in bodies, I find this point of view astonishing. I wonder what in form Fr. Barron imagines humans to exist in his version of heaven, where physical bodies must be irrelevant. I don’t mean to say that the mind should be set against the body, but it is clear that the body cannot be the “true self.”

Speaking of a council that was apparently convened in Rome the week before, he said that he was particularly bothered by “the claim that the secret council was calling for a ‘theology of love’ that would supplant the theology of the body proposed by John Paul II.++” Christians espousing a theology of love? Shocking! Certainly no basis in the New Testament. No idea where they could have gotten such stuff.

If I had the chance to converse with Fr. Barron, I might ask him how his body-centered spirituality deals with the fact that the body is always changing and does not have “distinctive form” or “finality.” The many, shall we say, gifts of middle age put this fact in front of me every day. For example, my vocal range has changed enough to cause a new label to be applied to my voice, one that feels like it doesn’t belong to me, and I am trying to gracefully let go of the old one. It would be silly to get overly involved with concepts of having to sound a certain way or having a certain hair color or even being a certain height, because those are going to be different, and sooner rather than later. My mother, at age 90 1/2, has been expressing surprise that her body is changing so quickly and dramatically. My elderly patients and friends often say things like that, but add that they feel exactly the same on the inside as they always did.

On the spiritual level, none of our outer identifiers, the things other people see when they look at us, have any real meaning at all. I don’t have to tell you that body shape, size, color and the like are not who you really are. But let’s go a bit further. Some philosophers say that there is no “real you” at all.

Brian Hubbard, husband of Lynne McTaggart, wrote the book Time-Light, describing his theory that what we think of as our personality is nothing more than an accumulation of experiences we have not sufficiently understood, that stick to us and make us “time-heavy.” He claims that he got over his persistent depression by letting go of the past and returning to a state much like that of a small child.

Brent Phillips, a healer and teacher whose work I encountered a few months ago, is one who insists that the you that manifests in the physical world is only a kind of fictional character— he likes to use Harry Potter as the example. When you look further and further inward, he says, you find that “no one is home.”

I have been very uncomfortable with this concept that there is nothing and no one at the center of a person. Not because I particularly want to cling to my own existence; in fact, I feel empty of it much of the time, as if there is someone talking and doing various things, typing this right now, but “I” am not particularly identified with that being, and even the “I” that is observing its activities does not feel fundamental. The problem is that I, whatever I that means, directly experience a something in a human being, some irreducible spark behind all those characters in their shifting roles. That something exists in animals as well. At the core of all is an awareness. That is what’s home.

A long time ago I heard a talk by the Dalai Lama in which he was asked what the nature of consciousness really is. I remember him saying that it is a “luminous I.” Now I can’t find that quote anywhere, but I’ve found standard Buddhist references to consciousness as being “luminous and knowing.” Consciousness is the thing that illuminates, meaning that it lights its objects so that they can be apprehended, and it is the thing that knows, independent of what is known. At least, that is my best effort at understanding this. And the awareness that is found at the center of everyone is the same awareness that is found at the center of everyone else. This gets tougher to grasp. If one follows along through Phillips’ teachings, it becomes apparent that he too is talking about this universal awareness, not truly saying that there is no one home anywhere.

Universal awareness has found a staggering variety of ways to express itself, and I find that to be a tremendous joy. The “luminous I” is free to manifest as any physical appearance, any set of interests and talents, any gender or sexual orientation. The objective human mind sets limits, but in reality there are none.

 

*For those who have been living on Mars or who may read this in the future when these names have faded into history: Caitlynn Jenner is the name of the person who used to be the Olympic athlete Bruce Jenner before she transitioned. Rachel Dolezal is a white woman who changed her appearance and identified as black, and who led a chapter of the NAACP before she was outed as white by her parents.

**http://www.splcenter.org/blog/2015/06/26/string-of-nighttime-fires-hit-predominately-black-churches-in-four-southern-states/

+http://www.wordonfire.org/resources/article/bruce-jenner-the-shadow-council-and-st-irenaeus/4785/
Fr. Barron uses Jenner as a reason to attack his real target, Gnosticism, which he trashes viciously, and which he appears to understand poorly, as seen in his use of the term “the Gnostic heresy” at this late date. It seems, also, that he has more of an issue with dualism than with Gnosticism; he conflates the two, and this is misleading. But all that is a subject for another day and probably a very long post.

++ http://www.jp2.info/Theology_of_the_Body.pdf
Here is a summary of Pope John Paul II’s “theology of the body.”  I had not heard that term before, but I was all too familiar with his resistance to contraception and to any kind of sex outside of marriage (not to mention an equal role for women within the church).  I always admired John Paul II overall, but he went much further than I realized with these ideas, which seem to me to dismiss and denigrate the body’s biological needs just as Catholicism has done for centuries.  I am deeply saddened by words such as this:  “Therefore, in such a case, the conjugal act, deprived of its interior truth because it is artificially deprived of its procreative capacity, ceases also to be an act of love.” “If the procreative aspect of conjugal union is excluded, then that truth of the person and of the act itself is destroyed.”   There is no room at all for those who are anything other than heterosexual and monogamously married, nor even for those of us who have been sterilized for medical reasons or who have undergone hysterectomies!  This does not reflect the reality of nature on this planet.
  And for a celibate old man to suggest that since I had a tubal ligation in my late 20s, in all these years my husband and I have not experienced “an act of love,” is beyond offensive.  I am well and truly ready for a theology of love to replace this one.

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Killer Copays

Most of us seem to enjoy complaining about our so-called health care so-called system, but not a lot of clear paths for improvement have been put forth. I have come to think that above all, we have a failure of imagination. We cannot envision another way of doing things, or at least a way out of the present situation, and so we continue to put up with a reality that is increasingly insupportable. We tinker around the edges, but nothing more. As Dr. Dean Ornish put it, “We spend so much time in medicine mopping up the floor around the sink that’s overflowing without ever turning off the faucet.”

Much of what I’m writing today will focus on a small aspect of the system, copays, and will not offer grand visions for the future, but I would like to drop this idea into your head so you can let it grow in the background: We created the present situation. We can create something else. What we have now is not ordained by God or nature. It hasn’t even existed for a very long time, only a few decades.

After you’ve read this post, please look up the 2012 film Escape Fire, which outlines just how completely screwed we are and what we can do about it. You can find it here:  http://www.escapefiremovie.com/  It’s also available through Netflix.

Escape Fire is based on a book by Donald Berwick, MD, the former head of Medicare and Medicaid. He wrote it early in the 2000s, and you’d think that a decade later we would have figured a few of these matters out, but as far as I know we haven’t made a single one of the changes he recommended. The idea of an “escape fire” is that if one is about to be overtaken by a forest fire, one can burn an area on purpose to provide a path to escape. The film recounts the story of a group of firefighters who were in this type of situation. Their leader dropped a match on the ground and burned a circle around their position, using up the fuels that would have fed the fire. He told the others to stay in the circle with him, but they took off, insisting that they could get out safely. Guess who survived. Dr. Berwick’s point is that we have obvious paths to escape right in front of us, but we refuse to take them, or even to see them.

Dr. Berwick pointed out that people within the health care industry do exactly what makes sense to them where they find themselves. It’s just that the system contains such incredibly perverse incentives that they often do things that have ill effects for the country as a whole.

Recently one of my elderly patients canceled her appointment for the next day. The reason was that she had to see her eye doctor, and the copay for that is $45, meaning that she wouldn’t have the money to pay even the extremely reduced price I would have charged her as a low-income senior who doesn’t have insurance that covers my services. This lady lives in a subsidized retirement apartment complex. Some of the people who live there have income of less than $1000 per month, and few have much more than that. A copay of $45 is huge for them, possibly even requiring saving up over a couple of months. These folks have Medicare and often other coverage, but strangely, it’s still quite possible to face daunting copay amounts.

A few weeks ago, an insurance company representative told me that high copays do not prevent access to care. Clearly, they do. Copays and deductibles* are both going through the roof. I wrote to her company, one of the major insurers in our area, one which pays only 2/3 of usual and customary fees for acupuncture, as follows:

“Copays keep increasing in general. I understand that at least in part this is caused by attempts to limit increases in premiums. What is troubling is that in many cases copays are equal to or greater than the amount insurers actually reimburse for a given service. As copays continue to go up, this situation is likely to keep getting worse.

“Within the ____ system, the most extreme case I’ve seen involves City of Albuquerque employees. They have a $55 copay for acupuncture, but ___ only pays $43.73 for acupuncture. [Your representative] said that she thought in this case the member would only be expected to pay the $43.73, but that is not how it works. EOBs show clearly that the full $55 copay is expected. And providers are not allowed to discount copays and can get into trouble for doing so.

“It is more typical these days to see a $40 copay for ____ members, and has been for a couple of years now. That means that much of the time ____ is paying a princely $3.73 for acupuncture, and the patient is paying nearly the entire charge. When you include the fact that ____ limits members to 20 treatments per year, the total paid for the year can be as little as $74.60, less than the price of a single appointment for most medical services.

“In both of these types of cases, the member and the employer (often through the taxes we all pay) are paying for coverage for acupuncture, but they don’t get anything that can really be called coverage, and in the case of the highest copays, they have a kind of negative coverage. It’s an advantage to me as a provider to have the patient pay a larger copay, but it’s still painful to see them treated so unfairly.

“I imagine that when the HR department or whoever set up these copays were in discussions about how their plans would work, the amounts sounded quite reasonable to them. Perhaps someone said, ‘I don’t know, what does acupuncture usually cost?’ and someone replied, ‘Well, my acupuncturist charges $70.’ It might not have occurred to them that $55 would be higher than the reimbursement amount.

“(After all, usual and customary insurance payments for acupuncture alone are in the range of $62-65, not counting any amounts for E & M codes or other services. ____ is unusual in paying only about 2/3 of that— an amount that has not changed for a number of years even as patients pay more and more. This exacerbates the issues with copays.)

“I don’t know about how other types of providers are affected. I do know that chiropractors have some similar issues.

“Copays are charged for us DOMs at the ‘specialist’ rate, but since we are not reimbursed at anything like the amounts cardiologists, etc. get, the copays are a much larger percentage of the price. I understand that PCP visit copays are kept lower because insurers want members to see their PCPs to try to catch problems early, but often the PCP can’t do anything and simply makes a referral anyway, meaning that the PCP visit is a waste. Visits to DOMs, DCs and PTs are relatively discouraged by the higher copays, even though we are saving insurers money by helping patients avoid more expensive interventions such as surgeries— not to mention helping the patients relieve their suffering and improve their overall health, which ultimately reduces costs as well as being worth doing in itself.

“[Your representative] said that members have far wider benefits than just acupuncture, which obviously is true, and a member who has a major health problem may end up with much more value paid in benefits than they pay in premiums in a given year. However, this does not change the fact that members with high copays for acupuncture are being sold a benefit that they don’t truly receive. It’s rather like going into a store to buy a shirt, and being told that although the shirt normally costs $45 and most people pay that or less, you have to pay $55 for it.”

So costs to consumers and the country at large keep going up and up and up. In what aspects of the system are those costs increasing so persistently? Let me tell you, payments to doctors are not the problem. We’ve been seeing flat or even decreasing rates of reimbursement. Medicare and Medicaid in particular squeeze providers, and as shown in a heartrending segment of Escape Fire, often the only way a clinic can stay in business is to pack in more and more patients. Again, providers are doing what appears to make sense from their perspective in their corner of the system. But not only is this compression of appointments terrible for patients, especially those with more complex needs, it can actually raise costs. Primary care doctors who don’t have enough time to figure out what’s going on with a patient are likely to refer that patient to a specialist, costing dramatically more, whereas with more time to think, the PCP might well have solved the problem and come up with a treatment plan without making a referral.* So reducing payments for primary care to absurdly low levels is classically penny-wise and pound-foolish. “There is no more wasteful entity in medicine than a rushed doctor.”
http://www.nytimes.com/2014/07/21/opinion/busy-doctors-wasteful-spending.html?contentCollection=opinion&action=click&module=NextInCollection&region=Footer&pgtype=article&_r=3

I would like to propose a simple rule that copays may not be more than 50% of the amount reimbursed for a given service. Period. I truly believe that there is more than enough wasted money, far more than enough, to make this happen. I would also like to propose that resources be redirected into primary care and especially accessible clinics for the most vulnerable portions of the population, like the ones being seen by the frustrated PCP in Escape Fire. Continuing to cut already-thin payments to practices like that makes no sense.

These of course would only be stopgap measures. Next time, I’ll take up some thoughts about self-care and our responsibilities toward our own health. Meanwhile, I offer you one more pithy post to chew on: 
http://rolwingjames.wordpress.com/2014/04/13/the-intervention-fallacy-part-i-how-it-starts/

*https://elenedom.wordpress.com/2014/02/04/health-care-access-and-why-pcps/

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Health Care Access, and Why PCPs?

Grant's rainbow 2.2.14A friend posted this picture of a rainbow that appeared two days ago in our area, a most welcome sight since we had had no moisture at all for over 40 days.  The rainbow showed up just after her neighbor died after a long illness, giving its benediction to the family.  Last night we had a fair amount of rain and snow, and it feels like we will not dry up and blow away just yet.

I am trying to keep up some hope for our health care system as the conflicts over so-called “Obamacare” continue and costs keep spiraling upward.  There does seem to be some lucid thinking going on in at least scattered spots among those in the medical field and those making policy, and I want to encourage that.  There’s also a lot of the same old thinking that got us where we are today.  Here is my current take on some aspects of the situation, which I sent to the Albuquerque Journal today:

The Journal has published some useful articles lately on problems with access to health care, and I’d like to add my perspective as a provider out in the field.  There are three main issues with access to care for New Mexicans: distance, cost, and scarcity of providers.

I don’t have to tell you that for many of our residents, most everything is far away.  Even in our smaller cities, there are not a lot of services.  In Grants, where I see patients once a week, medical specialists come in from Albuquerque or elsewhere, as I do.  People who need VA services must go to Albuquerque, no matter how elderly or disabled they are.  It’s bad enough in a small city like Grants, but people who live in more rural areas, as some of my patients do, may be completely out of luck if they lack transportation.

Getting more New Mexicans insured is necessary and commendable.  However, this does not remotely solve all the problems with the direct cost of medical care to consumers.  As those who are shopping on the state exchange have no doubt noticed, many plans have deductibles in the thousands of dollars.  Also, with some plans patients pay as much as 90% of the cost of the service themselves, even after their deductible is met, because their copays are so high; they are paying for coverage that they don’t get. The ACA was intended to bring deductibles and copays into the realm of reason, if I understand correctly, but as it is, cost limits access even for those who are insured.

For those on Medicaid, at least, copays are low or nonexistent.  However, very basic and critically necessary care may not be covered.  For example, one of my elderly patients needs drops for an unusual and painful eye condition caused by her recent case of shingles.  The cost is low compared to most of her care, but Medicaid is not covering this medication, and on her extremely limited Social Security income, this lady can’t afford enough of it to last through the month.  For all the millions we spend as a state, we still can’t get people simple things that they need badly.  And while the myriad costs add up to so many millions, Medicaid and Medicare payments to providers are so unsustainably low as to keep providers out of the programs, exacerbating the access problems all the more.

Our state’s lack of health care providers has multiple causes, but it also has the potential for multiple solutions.  Making better use of mid-level practitioners, as many have suggested, is certainly necessary, and any efforts which will attract more health care workers are worth trying.  However, there are other available health care forces which are only partly being tapped.  One of your editorials did refer to “traditional community health workers,” by which I assume you mean people like curanderas/os and Native healers.  Encouraging greater use of their abilities would be a definite help– but how is that going to be funded?  For the most part our insurance system has ignored the existence of these valuable resources, as it has ignored herbalists, homeopaths, and those who do energy healing such as Reiki.  Most federal dollars will also bypass all those practitioners and the people who rely on them.

New Mexico has a formidable and growing health workforce in the members of my profession, Doctors of Oriental Medicine.  We too are being used far less efficiently than we could be, even though most commercial insurance in the state does cover our services.  Decision makers don’t seem to realize how much primary care we do– and we have not yet managed to get the word out to them sufficiently.  We are lumped in with “rehabilitative medicine” by insurers, but that is only one aspect of our medicine.  Patients walk in to acupuncturists’ offices with everything from flu to IBS to sciatica, and we treat them effectively.  We are well placed to help take the strain off of primary care MDs, and we are ready and willing to serve.  However, provider groups organizing “patient-centered medical homes” have generally not included us in their planning.

Medicare does not cover acupuncture, and under most circumstances Medicaid also does not, largely because the federal dollars are not available to make that happen.  Attempts to fix this in the state and federal legislatures have failed thus far.  So immediately a huge proportion of our population is left out of a major form of effective and cost-effective medicine.  And while our NM-based insurers do offer coverage, as I mentioned before, in many cases reimbursement is slim and patients are left to pay as much as 90% of the charges, so that this “coverage” is not very meaningful.  (Fortunately, there are also many plans with much better coverage, I must add.)  Yet, many patients do use us as their front-line care providers, and that could be expanded.

There are still other possible providers as well.  In some situations a chiropractor may be the best choice to see first, and access can be a bit easier than that for DOMs, with so many chiropractors available and a good number of them accepting Medicare.  For at least some conditions these practitioners could also help to ease the burden on primary care MDs.  Physical therapy is usually given limited coverage, and patients tend to be referred to PT only after they have failed to get better for a long period of time.  That is inefficient and leads to unnecessary suffering.  We could use PTs more as the first choice, go-to practitioners for injuries, back pain, and the like.

There is one access problem that would be very easy to solve, IF those who are in charge were willing.  That is the system of HMO and PPO networks.  It was unconscionable when Lovelace ended its relationship with ABQ Health Partners and tore hundreds of thousands of New Mexicans (including my family) away from the doctors they knew and trusted.  Now Presbyterian has stopped coverage to the UNM providers, again leaving patients in the lurch.  We could stop this kind of abuse, I expect, legislatively or perhaps through actions of the state insurance department.  I am not holding my breath, but as the provider crunch gets more and more serious, I hope access will be broadened across insurance networks.  There is no good reason for things to be this way; we all pay and we all deserve to have the best providers for our needs.  HMOs were supposed to reduce costs and improve health outcomes.  Neither has happened.  Time for a different approach.

And we do have a different approach waiting in the wings: the home-grown, NM-specific Health Security Act is still here and has been gathering more and more support over the years, though so far it hasn’t made it past all the Powers That Be.  In the next few years we will have the opportunity to improve upon the current health insurance exchange and enact this more efficient plan.  We can choose to do it– it’s just a matter of willingness.

 

OK, that’s what I sent off to the newspaper a moment ago.  Continuing:

Let’s say that a patient has jumped through all the hoops of distance and cost and gotten the coveted access to care, and is now sitting in the doctor’s office.  Now the main barrier is time.  The patient may have waited months for this appointment, but she is going to be very lucky to get more than 10 minutes of the doctor’s time.  And maybe even that pittance may soon be a luxury.  An editorial written by two local executives with Presbyterian Health care and published a few days ago stated that because of the pressures on PCPs, we have to find some alternative to the standard 15-minute appointment with the physician, such as group appointments for people with common conditions like diabetes.  Wait just a MRSA-contaminated minute here!  We pay more and more and more for our supposed health care every year, we are totally breaking the bank, we are stressing the whole country out trying to fix all this, and we can’t even get a measly 15 minutes with the Minor Deity?  Seriously?  (Meanwhile, the Deity is struggling to stay afloat in a world of shrinking reimbursements and greater pressures on his or her business.)

I must say that on the fairly rare occasions when I’ve gone to an MD, as for my yearly OB-GYN checkup, I’ve had more like a 25-minute appointment.  I hear that this is not usual, but it has been the norm for me thus far, perhaps precisely because I’m not there all the time– I’m having more than just brief followup appointments.  So I have a little bit of hope, but again, as the provider crunch gets worse, that hope is likely to evaporate.

(Appointments with me as the doctor, in contrast, are still normally scheduled for an hour or more.  My patients who have gone to community acupuncture or to other colleagues who see multiple patients in an hour tell me that they appreciate the difference.  I find trying to treat more than one person at a time very stressful, in addition to feeling that I can’t be as effective, and I have no intention of doing that on a regular basis, but the squeeze on insurance reimbursement may force me to change my ways eventually.  I hope not.)

Now let’s think about what actually happens during that 10, 15, or possibly 25 minutes.  What are primary care physicians for, and do they fulfill that purpose?  One of the main things they do is to prescribe and authorize refills of medications.  In the case of chronic illnesses, they should be able to help the patient maintain well and deal with any changes in their condition that come up.  Well, last week one of my patients, who has been taking Synthroid for decades since she had thyroid surgery, went to see her new PCP, who had been forced upon her by the issue I mentioned above, Presbyterian ending its relationship with the UNM system.  Her last PCP had reduced her dosage, and she had done extremely poorly until she figured out the problem– herself– and started taking the higher dose again.  She explained all this to the new guy, but he flat-out refused to consider prescribing the dose she needs.  Total failure both at paying attention to the patient and at delivering the treatment.  Especially at paying attention!  I wish I could say this was unusual, but it’s what I hear from patients over and over and over, and it seems most common with regard to thyroid issues.*  In this case, there was an out– I sent the patient to a colleague of mine who specializes in endocrinology and can prescribe natural thyroid extract.  Not everyone has such an alternative, and many patients go without effective treatment.

The other main thing a PCP is “for” is to be on the lookout for problems and do something about them before they get worse.  Often they really shine in that role.  A few weeks ago we got my mother’s PCP appointment moved up because she was getting markedly weaker and often short of breath.  The PCP (Ann Jones, MD, about whom I have few complaints) didn’t like the way my mom looked either, and sent her for extensive testing at the ER space across the parking lot.  They didn’t find much, but my mom came home– after an exhausting 9 hours– with a clear diagnosis and a prescription that has been noticeably helpful.  That’s more or less how things should work.**

On the other hand, a patient who has recently entered the Medicare age group went for her first ACA-mandated Medicare yearly wellness checkup around the same time.  This lady has had a chronic cough and severe fatigue for months, following a period of extreme stress, and although she’s improving, no clear cause has been found and the problem has been hard to treat.  The idea of these yearly exams for Medicare is supposed to be to give the patient a thorough going-over so that any problems will be found and dealt with appropriately, keeping them from getting worse and causing more cost and suffering.  My patient reported that the appointment lasted less than 10 minutes, she barely had the opportunity to ask any questions, her main complaint was not really addressed, and no treatment was suggested.  And this is a very assertive and articulate patient.  So it didn’t seem like the purpose of the exercise was fulfilled at all.

The PCP is often the most accessible and cost-effective person for performing minor, in-office surgeries.  And of course the PCP can order tests, which will either show that there’s no problem or perhaps guide the path to more specialized care.  When I had that health scare back in August, I ended up with Bob’s PCP, Oswaldo Pereira, MD, who had no more idea what was going on than I did, but could send me for further testing.  We ruled out a number of possibilities, and that was helpful and quite necessary; I needed to know that I didn’t have a cardiac issue, for example.  However, Dr. Pereira never came up with either a diagnosis or a treatment.  Since we couldn’t find anything dire, and since I was gradually getting better, we both dropped the matter.

I had the most significant improvement with a structural approach, under the care of my friend Christine Dombroski, PT.  Dr. Pereira, thoughtful and knowledgeable as he is, would never have thought to send me there, and didn’t really understand why this helped.  It’s just not part of the way MDs are usually trained.

I love the PCPs of the world and feel sympathetic toward them, but the more I consider all this, the more I think our typical use of them is a bit misguided.  I’d like to end with some fairly obvious statements about when to head for your PCP’s office, and how to use that system appropriately.  First, please do not see the PCP when you have a cold!  You will accomplish nothing except to waste time and money, tire yourself out when you need to rest, and spread viruses around the office.  Even a run-of-the mill case of flu is not a good reason to go to the PCP, unless you have an underlying condition that makes it more dangerous; all they can do is give you Tamiflu, which works poorly if at all, and tell you to rest and drink fluids, which you already know.  (Do feel free to see me or my colleagues, as we can actually treat you!)

Do head for urgent care or the ER if you have severe unexplained pain, trouble breathing, or other scary symptoms that are not resolving in a reasonable way at home.  And of course if you are having any signs of a possible heart attack or stroke (I should write another post on those), you should call 911 as soon as you can reach the phone.

 

*It doesn’t have to be that way.  Both my last PCP and my OB-GYN tend to dose thyroid replacement on the basis of symptoms rather than strictly by blood test results.  They are not unique, fortunately, just not the rule. 

**Update, later in the day:  This morning my mother saw Dr. Jones again, and she is leaving most medication issues up to the specialists.  So I ask again, what is the PCP for?  It’s not easy for 89-year-olds to get to appointment after appointment, nor for their families to get them there.

 

As I was writing this, I came across a great Medscape article by a doctor who has a vision of what a true health care system could be like.  You may have to sign up with Medscape to read it, but if you have any interest in medical matters, it’s well worth it.
http://www.medscape.com/viewarticle/819947?nlid=46863_1521&src=wnl_edit_medp_wir&uac=167278MR&spon=17

Here the author imagines an idealized school health teacher:
‘”She sat down with all of the physical-education, biology, and health-education teachers in her system, and together they outlined a plan to change the curriculum such that health education starts in kindergarten. In their system, by the time children reach the 12th grade, they know which side hurts when their appendix is about to rupture. They know the warning signs of a heart attack. They know when to start screening for colon cancer, and they know when it’s appropriate to access the doctor’s office, the urgent-care clinic, or the ER. They understand the basic dangers and positives of over-the-counter medications. In other words, by the time someone puts a high school diploma in their hands, they are as well equipped to take care of their bodies as they are to find their favorite iPhone app.

“They understand the difference between a carbohydrate and a fat and which foods fuel their systems to fight cancer, heart attack, and stroke. They are not going to be obese because they know to exercise at least 150 minutes per week. Mrs J’s students are going to cost us less and live longer. They will live better with more money in their pockets, because they won’t have to buy a laundry list of prescription medications every year until they die prematurely from a preventable illness.’

And here’s her imaginary doctor who figured out a fix for electronic health records:  ‘Then, there’s Dr P [for practical]. Although we acknowledge the necessity of electronic health records [EHR], our earliest efforts have failed the patient. A doctor’s daily work has ground down to a snail’s pace. Patients complain about the basic lack of eye contact during an office visit because the doctor is focused on a screen. Dr P revolted against that practice. He designed a system where there are shorter updates at each visit and there is a symptom-limited entry into each subsequent visit. You don’t have to go through 900 reviews of systems that have nothing to do with why this particular patient has come to see you. He does only a positive review of systems. He took the time away from his EHR and gave it back to his patients, and his patients are more satisfied and better taken care of because of it.’

All this could happen.  There’s no reason why it couldn’t.

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