THE BLOG
04/03/2014 02:57 pm ET Updated Feb 02, 2016

Harm Reduction, Covering , and a Voice for the Voiceless

"It only takes one person, one patient, one moment, to change your life forever. To change your perspective, color your thinking, to force you to re-evaluate everything you think you know. To make you ask yourself the toughest questions: do you know who you are, do you understand what has happened to you, do you want to live this way?"

This is a quote from a fictional character, Dr. Christina Yang, of the medical drama, Grey's Anatomy. I'm presenting it not because I enjoy Shonda Rimes' programs -- which I do -- but because that episode, and that quote, caused me to break out into a cold sweat. It shocked my memory, taking me back over thirty years to a similar episode in my life, which changed me forever as well. It was not the first such event, nor the last, but it had a profound impact upon me, and seeing it fictionalized in a popular drama was startling.

The first law of medical practice is, "Primum Non Nocere -- First, Do No Harm." Whether the phrase derived from the Hippocratic Corpus or from Dr.Thomas Sydenham, "England's Hippocrates," in the 17th century, it has become the "Prime Directive" of modern medical practice. On its face, it seems easy enough to follow. On deeper examination, though, one begins to grapple with the meaning of the word, "harm."

In this episode, the question manifests as, "Is keeping this man, who has suffered a devastating spinal cord injury leading to quadriplegia, alive against his wishes doing harm, or would letting him die be the greater harm?" In such an acute setting, can any human being make such a life or death decision? Is it fair to wait, until a time the patient has been able to really think it over, but when few physicians would feel comfortable acceding to a patient's request to be allowed to die? Whose comfort is at stake, and whose takes priority? Of course, there are then the issues of the law, which may supersede the ethical decisions.

Such a crisis can happen to any one of us. Given the number of traffic accidents every day, as well as the epidemic of gun violence, such crises do happen on a regular basis. It's worth pondering, and over the decades such thinking has led to the creation of living wills and other health care directives to deal with just such an occurrence. The challenge for the physician, and other health care providers, though, remains the same, and is ultimately a very personal and lonely decision.

Monday, March 31st was International Transgender Day of Visibility. A recent addition to the LGBT calendar, it is a counterpoint to the much more somber Transgender Day of Remembrance. When it popped up on one of my lists the other day, it got me to thinking about visibility, and its meaning for both gay and trans people. It reminded me of the superb memoir and analysis by Professor Kenji Yoshino, now at NYU Law School, called Covering: The Hidden Assault on Our Civil Rights. Professor Yoshino's theme deals with the damage "covering" does to people who are otherwise "out." The drive for assimilation in and of itself causes existential damage, and is a major problem under the surface of the successful campaign for ever greater gay equality in this country. The repeal of Don't Ask, Don't Tell, and the marriage equality victories, are victories of aggressive assimilation.

As Professor Yoshino puts it:

"In the new generation, discrimination directs itself not against the entire group, but against the subset of the group that fails to assimilate to mainstream norms. This new form of discrimination targets minority cultures rather than minority persons. Outsiders are included, but only if we behave like insiders -- that is, only if we cover... This covering demand is the civil rights issue of our time. It hurts not only our most vulnerable citizens but our most valuable commitments. For if we believe a commitment against racism is about equal respect for all races, we are not fulfilling that commitment if we protect only racial minorities who conform to historically white norms."

For decades it's been the trans community which, almost by definition, has been the subset that has failed to assimilate to either mainstream straight or gay norms. Many of those who transitioned gender before the current decade of trans visibility intentionally disappeared from view, for safety's sake, and because it was what they wanted to do anyway. Once the danger began to slowly fade, more came out to their circles as trans, and began to build a life that wasn't specifically trans but which didn't involve any covering. Assimilation could be substantially accomplished, but needn't come at the cost of one's past or, on occasion, one's soul.

Creating a unified LGBT community became possible when covering began to fade, but it's been a very arduous climb. Trans persons have long been dependent on gay support, both social and financial. Trans persons have long been weakly represented, when not completely ignored, in the media. Trans persons, without a seat at the table, have long been at the whim of legislators unfamiliar with the community to obtain their rights. There is a long history of interaction between the trans and gay male communities, but RuPaul, a cis gay male reality media star, actor and singer, who thinks using terms like tranny and shemale is appropriate, and refuses to apologize, sets the wrong example and projects a profoundly harmful image of the trans community.

Being an ally requires acting with integrity, and respecting the community for which you claim to speak. First, do no harm, and if you have nothing positive to say, stay silent. Make the community for which you speak, not your media or political ratings, your priority.