Words Matter: The Impact of COVID-19 on Gender-Affirming Surgeries

“Due to the COVID-19 pandemic, we have been advised to cancel all elective procedures. Your surgery will be rescheduled when conditions allow.”

This is the kind of message that millions around the world have received over the past year as the pandemic has ravaged our health systems. After reading through a list of steps to take if they find themselves experiencing life-threatening symptoms of the virus, patients are once again reminded that their care is elective and has been deemed nonessential. Expansive resources have been dedicated to determining the effects of these cancellations, but one continuously overlooked group is the transgender and gender nonconforming (TGNC) community who have had their gender-affirming procedures indefinitely postponed or even cancelled.

Gender-affirming surgeries include a wide range of procedures that are designed to align an individual’s body with their gender identity. The American Medical Association (AMA) has classified gender-affirming services as medically necessary in an effort to reduce barriers to care for TGNC patients [1]. (That said, it is important to note that not all members of the community choose to undergo medical procedures.) Despite being deemed a necessity, these procedures are still classified as elective, which has left them vulnerable to blanketed cancellations throughout the pandemic.

An AMA panel comprised of LGBTQ health experts weighed in on the impacts that the COVID-19 pandemic has had on TGNC individuals. The cancellation of surgeries has led to major disruptions in people’s lives and has compounded upon the effects of social isolation, leaving this population especially vulnerable to adverse outcomes in both their physical and mental health [2]. To be clear, these issues weren’t brought on by the pandemic. They were simply exacerbated and illuminated by it. While this panel highlighted several systematic issues related to gaps in insurance coverage, it also forced me to consider a larger issue in our classification system as a whole: our language.

From a societal standpoint, the term “elective” is often equated with “cosmetic” and perceived as frivolous and unnecessary. In reality, most hospitals classify elective surgeries as those “that can be scheduled in advance” and can include anything from the removal of a mole to the treatment of a cancerous tumor [2]. This gap in understanding between the medical community and the general population is especially damaging to members of the TGNC community who may interpret the classification of their life-saving care as “elective” to mean that it is unimportant.

The classification system, as well as general cost and insurance coverage, are all long-standing barriers to gender-affirming care that we ought to work towards dismantling, but they are reinforced by policies and loopholes that will take time to overcome. That being said, our language and its perception in the general population are sizable ethical concerns, but ones that can be easily addressed. Even if we can’t immediately change the surgical classifications themselves or ensure that access to these life-affirming surgeries won’t be interrupted in the future, we at the very least have the responsibility to make sure that our language is clear and isn’t causing harm to those we are trying to help.

In these times of uncertainty when so much feels that it is out of our control, the one thing that can be certain is that our words matter.

References [1] American Medical Association. (2019). Talking Points: Health insurance coverage for gender affirming care of transgender patients. Retrieved February 21, 2021, from https://www.ama-assn.org/system/files/2019-03/transgender-coverage-talking-points.pdf [2] American Medical Association. (2020, June 15). How gender affirming surgeries have been impacted by the pandemic. Retrieved February 21, 2021, from https://www.ama-assn.org/delivering-care/population-care/how-gender-affirming-surgeries-have-been-impacted-pandemic [3] Johns Hopkins Medicine. (2021). Types of surgery. Retrieved February 21, 2021, from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/types-of-surgery

The Opioid Epidemic: a multi-faceted crisis

Drug overdose is a pressing issue in the United States, being one of the leading causes of death. In 2019, more than 70,000 Americans died from drug overdose, including illicit drugs and prescription opioids(1). Overdose of opioids has adversely affected the entire country, but certain demographic groups have been affected more than others. Data has revealed that overdose is rising rapidly for minority groups in particular. In 2017, non-Hispanic Blacks had the highest percentages of opioid-related overdose deaths and total drugs deaths attributed to synthetic opioids compared to other race and ethnicities (2). These disparities are intimately linked to psychosocial determinants of health including racism, poverty, limited access to treatments and services, and socioeconomic status. Furthermore, there exist ethical problems related to prescription practices, naloxone availability, and clinician regulations. Prescription of opioids by clinicians, while used to ease the suffering of patients, is a source of potentially dangerous and addictive drugs.

In order to tackle the opioid crisis on a public health level, greater attention to the ethics of opioid prescription and regulation is necessary. Furthermore, the social determinants underlying this issue must be thoroughly analyzed and assessed. Factors such as economic conditions and social conditions create problems of accessing drugs in a proper manner for many minority populations (2). This then results in drugs being administered in an unsafe environment, which increases the likelihood of a negative outcome. Drug behavior can be heavily influenced by the drug use context, such as the setting or location under which it is administered. The stigma surrounding opioid use and addiction can also increase negative health outcomes. Stigma often prevents people from seeking help, due to fear of the social and legal repercussions. In order to address this issue, the discourse surrounding this topic needs to change. Those with opioid addiction need to have access to a safe, judgement-free space to share their experiences and spread awareness. Furthermore, the language used to describe opioid users needs to incorporate more person-centered language and acknowledgement of addiction as a disease requiring medical intervention. In order for the opioid crisis to be improved on a population level, there needs to be a social shift towards spreading awareness and destigmatizing addiction—factors not necessarily directly related to disease condition itself.

References

1. National Institute on Drug Abuse. Overdose Death Rates. [internet].; 2021 Jan 29 [cited 2021 Feb 20]. Available from: https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates

2. Centers for Disease Control and Prevention (CDC). 2019 Annual surveillance report of drug-related risks and outcomes —United States. [internet]. Atlanta, GA: CDC National Center for Injury Prevention and Control; 2019 Nov 1 [cited 2021 Feb 20]. Available from: https://www.cdc.gov/drugoverdose/pdf/ pubs/2019-cdc-drug-surveillance-report.pdf

The COVID-19 Publishing Paradox

Hundreds and thousands of scientific papers are published each day, communicating progress in medicine and up-to-date results to both scientists and the eager public eye. We turn to these articles and journals for reliable information on the latest advancements, with the assurance that the author is an expert in their field and that each work undergoes a rigorous editorial process often spanning months. Indeed, most of the publications we read are the result of months and years of work and a rigorous peer-review process. However, in recent years, light has been shed on the existence of a minority of flawed or even fraudulent publications that lack careful editing and review by publishers.

The discussion of the issue of publication ethics at this time is crucial, as the quantity and speed of publications have skyrocketed during the months of the COVID-19 pandemic. Researchers have suddenly found themselves faced with an overwhelming demand for medical research to be carried out and disseminated rapidly to the concerned public. As a result of these demand pressures, turnover rates of papers related to COVID-19 have increased extraordinarily. For example, journals available on PubMed are now averaging publication only 6 days after the time of submission, with an average of over 350 COVID-19 article publications per week including retractions of select publications.

Rapid publication provides us with new, much-needed evidence and knowledge during this fast-evolving pandemic, but how heavily should the pressure for speed be weighed against the need for extensive peer review and quality control? This paradox must be reconciled. The speed of this research has the ability to save lives, but we must ensure that the credibility of these publications is not put on the line for the sake of urgency alone. We must ensure that the sheer quantity and expedited nature of COVID-19 publishing does not plant doubts about scientific integrity or dilute the pool of evidence that is critical for experts and directly translates to public policy discourse and decisions. Ethical concerns of misinformation are being raised by scholars and they cannot be overlooked—trust is fragile, and at this time, to lose it is a dangerous thing.

What can be done to protect and reinforce the ethics of publication amid the surge in scientific literature? Measures such as the transparent labelling of non-peer-reviewed publications as preprints may help prevent news outlets and the general public from misusing these works or being misled. Given the volume of articles, we must also question the general public’s ability to identify the substance of these articles and their limitations. Requiring a simple summary for a nonprofessional audience on findings, applications, and their limits may help prevent public confusion. Select journals have begun to raise the conventional bar for publications to ensure the vigor of the review process and to refine the growing sea of articles that the general audience is drowning in.

The ethics of publication is central to integrity in research, and now more than ever it must be safeguarded.

References

Q. Chen, A. Allot, et al. “Publishing Volumes in Major Databases Related to Covid-19.” Scientometrics, Springer International Publishing, 28 August 2020, link.springer.com/article/10.1007/s11192-020-03675-3.

Palayew, Adam, et al. “Pandemic Publishing Poses a New COVID-19 Challenge.” Nature News, Nature Publishing Group, 23 June 2020, www.nature.com/articles/s41562-020-0911-0.