The students sat at a long table in a classroom, wearing their best clothing on one of the most important days of their lives — graduation day from medical school.
I had been invited to be the commencement speaker for the Wayne State University School of Medicine in 2014, one of the largest medical schools in the nation. As part of the commencement day activities, I was asked to meet with student leaders to discuss my career in medicine prior to the official ceremony. I expected to answer questions on career choices and successes keeping in sync with the optimism of the day. However, their first question was on what medical decision I most regretted.
The saying that we learn from our mistakes was literally at the core of this discussion. So often we block uncomfortable situations from our memory. Yet, in an instant, images of what happened in my clinic when I was a young endocrinology fellow in training roared back into my consciousness. It was a teaching moment that I knew they would remember probably more than my commencement speech.
A boy came into the clinic with his father. What caught me off guard is that he was complaining of pelvic pain since the start of puberty. He had been diagnosed with congenital adrenal hyperplasia, a genetic disorder that affects the adrenal glands which make hormones including androgens, the hormone which masculinizes the body. Female infants with this disorder may have ambiguous external genitalia which can look more like male genitalia, but still have a uterus, fallopian tubes and ovaries. They may go through early puberty, have a deepening voice, acne, excessive facial or body hair and menstrual irregularities. They may also have gender dysphoria. This patient identified as and was raised as a boy.
I knew he needed a pelvic exam, but my clinic was not set up for this type of exam I called the Department of Obstetrics and Gynecology (OB/Gyn) and asked for him to be seen. They told me to send him upstairs to their clinic and they would fit him into the schedule. I did just that. It never dawned me on at that moment that I was sending a boy with his father to sit in a clinic filled with women. No one around me — from the attending physician overseeing the fellows’ endocrinology clinic, our nurses, or the gynecologist told me not to do this. I was actually relieved that my patient was going to be seen and helped.
Years later as an older female patient, sitting in an OB/Gyn clinic surrounded by young pregnant women, I felt out of place, like I didn’t belong. It was then that I recalled what my patient, the boy with his father, must have felt. A profound sense of sadness filled my heart and I hoped that that traumatic experience didn’t cause significant psychological harm to either of them. I should have demanded that the gynecologist examine my patient in my exam room.
In medicine, as in life, we make decisions that can cause harm to others. We have to stop and ask if these actions are due to benign neglect or out of malignant intention. What is the reasoning behind these decisions?
In the case of my patient from decades ago, decisions were made out of a lack of knowledge and experience to provide not just competent, but also compassionate care for this individual and his family. Fortunately, many advancements in medicine have revolutionized how we see and treat our patients.
For example, since 2001, the National Academy of Sciences refers to sex as a biological construct based on physiological and anatomical traits and gender as the societal identity. These overlapping constructs exist on a wide spectrum.
Programs such as the National Centers of Excellence in Women’s Health, established and supported by the Department of Health and Human Services Office on Women’s Health from 1996-2007, transformed the healthcare landscape by advocating for interdisciplinary services’ “one-stop shopping approach.” Services were defined by intersectionality and interprofessional care and the importance of sex-and gender-based differences in medical research, health education and clinical practice. It’s now time to build upon these advancements toward a National Centers for Gender and Health Equity, a proposal that I designed to foster equitable and personalized healthcare for patients of all sex and gender identities.
One community that has faced significant discrimination and harm has been the transgender community. Attacks by elected officials and others have escalated over the years to a point where there are those who vow to punish educators who discuss gender-related issues and even doctors and hospitals that provide gender-affirming care to transgender minors. One has to ask what is the motivation behind these actions. Why is this community being singled out?
I’m the daughter of a Holocaust survivor who was tortured in concentration camps and lost generations of relatives — including his parents and all of his siblings — because he was Jewish. The Nazis categorized people by race and used the word ‘Aryan’ for their idea of a pure German race, which they considered to be superior to everyone. It was a way to unite people against those that didn’t look or act like them. In addition to Jews, Romas, Black people, the disabled and gay people were also persecuted and killed.
I often asked my father how he could have any love for human beings after what he endured, but he would always tell me that those who tried to destroy him and our family were his teachers. They taught him how not to treat others, to learn how to offer compassion not punishment, to learn how to share empathy, not apathy or hatred. He believed that he survived to now teach others to not ignore or harm the needs of those who don’t have a voice. We have so much more to teach, so much more to learn.
Saralyn Mark, MD is the founder of SolaMed Solutions, LLC, host of the “Always Searching” podcast and founder of iGIANT (Impact of Gender/Sex on Innovation and Novel Technologies). She is the American Medical Women’s Association’s COVID-19 lead and a former senior medical and policy advisor to the White House, the Department of Health and Human Services and NASA.