Archive for the ‘ Commentary ’ Category

Que reste-t-il du « transsexualisme » après le rapport de l’IGAS ?

Introduction

En 2012, l’IGAS (Inspection Générale des Affaires Sociales) rendait disponible son rapport portant sur une « évaluation des conditions de prise en charge médicale et sociale des personnes trans et du transsexualisme »1. Attendu par les décideurs comme par le monde associatif, ce rapport fait suite à l’abandon des réunions ministérielles débutées en 2010 et avortées en 2011, qui avaient pour but d’entendre à la fois les associations d’usagers et les praticiens protocolaires sur la question des transidentités (toujours réduite à la question « transsexuelle »). Un premier rapport, rédigé par la HAS2 (Haute Autorité de Santé) n’était pas parvenu à pacifier la question des modalités de prise en charge des transidentités en France. Le rapport de l’IGAS répond-il aux interrogations autour de la question Trans ?

Le constat des antagonismes.

Le rapport rappelle les enjeux de cette évaluation : l’établissement d’un nouveau PNDS (Plan National de Diagnostic et de Soins). Pour ce faire, le rapport préconise la création d’un « cadre législatif » ainsi que d’une « organisation adaptée » du processus de transition. Toutefois les auteurs du rapport reconnaissent les « difficultés de conciliation » entre les différents acteurs de la question Trans. Il s’agit en réalité d’antagonismes frontaux. Après avoir rappelé le « flou » qui entoure les définitions actuelles, les auteurs soulignent la conviction conjointe des praticiens protocolaires d’assurer un « acte thérapeutique » en même temps qu’une « mutilation ». La question de l’extension du nombre de praticiens, de manière à assurer notamment un meilleur « libre choix » du médecin, semble être exclu par les psychiatres hospitaliers. Sur tous ces points, le rapport n’oublie pas de rappeler les critiques des associations concernant le « real life test », la qualité des opérations, la main mise psychiatrique sur les transitions, la question des délais ou bien encore les « ambigüités » du changement d’ALD (devenu une ALD « hors liste » depuis 2009).

31 propositions.

Au-delà de ces antagonismes, le rapport pointe du doigt les angles morts des précédentes consultations : la question des mineurs, des interactions entre hormones et antirétroviraux, de l’automédication, etc… Au total, le rapport procède à l’écriture de 31 préconisations, dont certaines reprennent très précisément les revendications militantes : réduction des délais, fin du real life test, élargir les conditions de prises en charge ainsi que le nombre de praticiens sur le territoire, constituer des relais d’informations (personnes Trans, sites internet, formations), reconnaissance de l’identité de genre…

Proposer de nouvelles pistes de réflexion

Comme le souligne le rapport lui-même, la question Trans ne se limite pas aux questions médicales. C’est pourquoi la question de la déclassification, de la dépsychiatristion et de la dépathologisation ne se couple pas d’un déremboursement. Cependant il faut envisager une démédicalisation des procédures du changement d’Etat Civil, sur le modèle de ce qui a été fait dans d’autres pays (Espagne et plus récemment Argentine) ou suivant les préconisations européennes. Les auteurs, qui en appellent à de nouveaux rapports insistent néanmoins sur l’importance de ces éléments juridiques et sociaux. Contrairement au rapport de la HAS qui s’était dédouanée de toute responsabilité quant au chapitre intitulé « transsexualisme et société », écrit par Marcela Iacub, le rapport de l’IGAS écrit « ne pas ignorer que de nombreux problèmes, en dehors du champ médical, sont à résoudre »

Conclusion

À la suite de ce rapport, que reste-t-il du « transsexualisme » ? Plus grand-chose. L’optique semble être libéraliser les parcours, tout en maintenant la prise en charge et en modifiant les cadres de la pratique actuelle d’une clinique « transsexuelle » jugée comme maltraitante par les personnes concernées.

 

Arnaud Alessandrin

Docteur en sociologie, université Bordeaux Segalen

Coresponsable de l’O.D.T. (Observatoire Des Transidentités)

Andreas Killen: “Hypnosis and Medical Ethics”

Apparatus for measuring hypnotically-suggested arm movements. Clark Hull (1933). Hypnosis and suggestibility: an experimental approach (New York: Appleton-Century-Crofts). Image from: http://www.hypnose-kikh.de/museum_en/saal9.htm#a

Hypnosis and Medical Ethics

by Andreas Killen

Andreas Killen is Associate Professor of History at the City College of New York and the CUNY Graduate Center. He has held fellowships at the UCLA Humanities Consortium and the Max Planck Institute for the History of Science. He is an editor and co-founder of H-Madness.  This essay was posted earlier for Psychiatric Times.

When Leo Alexander, the psychiatrist who served as advisor at the Nuremberg doctors’ trial, helped draft the articles of the Nuremberg code, his attention was drawn to two earlier episodes in German medical history. One of these occurred in 1931, when, following the deaths of 75 children in Lübeck by means of a contaminated TB vaccine, the Reich Health Council issued guidelines spelling out the principle of voluntary consent. Galvanized by the Lübeck affair and others like it, prominent physician Julius Moses had publicly condemned the “experimental mania” in German medicine, and by the time it met to discuss Moses’ charges, the Health Council was responding to considerable public outrage. Noting widespread popular belief that experimentation served the interests of scientific knowledge rather than those of healing, Council members agreed on the necessity of clearly defining the boundaries of permissible human experimentation. Yet these boundaries were by no means self-evident to the Council.

In an effort to clarify the issue, Council member Alfons Stauder suggested that the distinction between experiments for therapeutic purposes and those purely for research purposes could be illustrated by reference to the practice of hypnosis. In the hands of a trained physician this method of treatment was invaluable, although it exercised such a “profound influence over the patient’s mental life” that it could only be used with due caution. Very different, Stauder continued, was the use of hypnosis by lay-practitioners, whether for the purpose of healing or for the sake of gratifying public interest in mysterious or unconscious forces. He stressed the danger such experiments posed and the disrepute such practices could bring to medicine.

On the face of it, Stauder’s illustration of the general problem addressed in this session by reference to hypnosis seems surprising, even bizarre. Why did hypnosis appear in these deliberations? And why was it seen as so transgressive? Closer examination shows that, however seemingly tangential to the controversies surrounding the Lübeck affair, Stauder’s comments allude to a wider history of debates concerning the ethical and professional boundaries of medicine, in which hypnosis figured as a recurring theme.

Another key moment in this history concerns an earlier scandal that erupted in 1898, when several people experimentally injected with serum from a syphilitic patient contracted the disease. One participant in the resulting controversy was Albert Moll, a specialist in neurology and hypnosis, whose book Medical Ethics (1902) Leo Alexander cited as a key source. Moll argued that this case was not an isolated one but indicative of wider abuses, including frequent instances of experimentation on patients in public hospitals. He identified several possible causes of such lapses: medical overspecialization and the resulting narrowness of doctors’ outlook; the growing knowledge-gap between doctors and patients as medicine was revolutionized by the natural scientific method; the greater prestige accorded research over treatment. He also suggested that physicians’ social status blinded them to the power differential between them and their often poor, under-age, or mentally handicapped patients. To prevent abuses, Moll suggested the need for a contract between physician and subject-patient spelling out, among other key issues, the principle of voluntary informed consent.

Not surprisingly, given his own professional interests, Moll referred often to hypnosis in his discussion of medical ethics. Indeed it is quite central to his treatment of the doctor-patient relationship. The opening pages of his text included a warning concerning the dangers of hypnosis at the hands of lay practitioners, illustrating these dangers by citing the case of a woman who had to be institutionalized following treatment by a Hungarian hypnotist. Though he regarded such occurrences as unusual, Moll conceded in his text Hypnotism (1898) that the hypnotized subject was in fact “completely devoid of a will of his own,” and reiterated this view in his book on medical ethics. In Moll’s eyes, the hypnotic procedure carried clear risks, involving not just its apparent ability to penetrate deeply into the subject-patient’s psyche, but, in effect, to turn the subject into an object. A corollary to this was the great power it placed in the doctor’s hands.

Hypnosis thus raised significant issues concerning the doctor-patient relationship. A precondition for the contract between doctor and patient, he wrote, was the existence of a relationship of trust: a consent given by the patient or patient’s guardian. This was precisely what hypnosis, by disabling the will and thus the very basis of voluntary consent, called into question. This special feature of the hypnotic procedure, therefore, was symptomatic of a larger problem plaguing modern medicine: that patients all too often were treated as objects — a fact raising questions about “the so-called voluntary nature of the consent that patient-subjects gave their physician-researchers.” In touching here on the issue of physicians’ treatment of their patients, Moll linked the problem of ethical violations to larger questions of public trust. Absence of trust harmed hopes of medical progress both by hindering public health policies and by strengthening the popularity of alternative medicine.

Moll’s effort to find a middle ground between the patient’s interests and those of science initially found little resonance. Meanwhile, the critique of the natural scientific orientation in medicine spawned a lively medical counter-culture of alternative and esoteric healing, against which German doctors campaigned vigorously. This proved, however, no easy task, and became less so as a result of subsequent developments. During World War I, thousands of shell-shocked soldiers were treated with hypnosis. German military doctors’ discovery of its therapeutic properties gave hypnosis new validity. At the same time, the war amplified many of the issues that had surfaced in earlier debates. In some hands, the hypnotic treatment took on authoritarian features, making the patient’s submission to the physician’s absolute authority a part of the cure, and leading to conflicts between medical authorities and soldiers. Such conflicts were re-enacted in postwar films like The Cabinet of Dr. Caligari (1919), which portrayed the hypnotist as a figure of intense fear and fascination.

During the 1920s, debates about hypnosis proceeded along several tracks. On the one hand, many doctors incorporated it into their clinical practice. On the other, controversies persisted concerning its still poorly understood workings, benefits, and risks. Malpractice charges were not infrequently filed against the many unlicensed hypnotists who flourished in the war’s aftermath. The campaign against lay medicine, or quackery, continued throughout the Weimar period. At the same time, in the polarized political climate of this era, many politically conservative physicians cultivated an image of themselves as charismatic leaders, claiming the right to administer ambitious, and sometimes radical, solutions to many social problems. Moreover, doctors continued to resist encroachment on their prerogatives, resisting efforts to impose stricter guidelines on experimentation, claiming that – as opposed to the problem of quackery, where intervention was justified – prospects for scientific progress demanded complete freedom.

It was in this context that Julius Moses launched his attacks on the “experimental mania” in German medicine. In referring polemically to the Lübeck case as an instance of “medical quackery,” Moses challenged the claims of physicians like Alfons Stauder, the doctor who brought hypnosis into the 1930 Health Council deliberations, that German medicine stood on solid scientific foundations. Stauder was the head of two leading medical associations who had long used his position of influence to campaign against lay-healers. Convinced that his profession had adequate safeguards in place, Stauder argued that the worst abuses occurred in natural medicine circles. Nevertheless, in the outcry following the Lübeck affair, the Health Council issued new guidelines spelling out the limits of permissible experimentation and the principle of voluntary informed consent. These guidelines, however, had limited impact before the Nazis repudiated them in 1933. With the passage of laws legalizing involuntary sterilization of the mentally handicapped, the systematic violation of patient’s rights became institutionalized under the rapidly Nazified medical profession.

What conclusions may be drawn from this story about hypnosis and its place in the history of debates about medical ethics? Though the issues surrounding hypnosis do not warrant comparison with the Lübeck case or the crimes tried at Nuremberg, the persistence with which German doctors wrestled with them over a period of decades suggests that these issues touched a deep nerve in the medical community. Hypnosis represented a special category, one that threw several problems confronting the profession into relief. Debates about hypnosis exposed a general lack of clarity surrounding the boundaries between treatment and experiment, as well as the boundaries between science and non-science, in other areas of medicine. Perhaps more importantly, hypnosis raised significant questions concerning the relationship between doctor and patient. Efforts to establish this relationship, and the wider relation between medicine and public, on the basis of the principle of voluntary, informed consent proved, in the deeply fractured political climate of the early 1930s, short-lived. It would take the verdict of the Nuremberg doctors’ trial, and the subsequent efforts of the psychiatrist Leo Alexander, to establish this principle at the center of modern medical ethics.

Hans Pols: “Treating Mental Illness Before It Strikes”

As we have mentioned before, H-Madness publishes an essay every month for the online magazine Psychiatric Times.  We know, however, that many H-Madness readers do not subscribe to the magazine (although, it is free).  In order to be sure that you don’t miss any of the pieces there, we will be making a point of posting those essays and reviews here on H-Madness as well.  What follows is a commentary posted last month at Psychiatric Times, written by co-editor of H-Madness, Hans Pols.

Treating Mental Illness Before it Strikes

by Hans Pols

Hans Pols is senior lecturer at the Unit for History and Philosophy of Science at the University of Sydney. He is interested in the history of psychiatry and the mental hygiene movement in North America and Europe, psychiatric war syndromes, and colonial psychiatry, in particular in the Dutch East Indies.

Psychotic episodes are devastating for the individuals who have them, their friends, and families. Wouldn’t it be wonderful if individuals could receive treatment before the first psychotic episode strikes, so that it could be avoided altogether? After all, an ounce of prevention is better than a pound of cure. Unfortunately, in psychiatry, we are a long way from achieving primary prevention—there is no vaccine for psychosis, nor have clear genetic markers for severe and persistent forms of mental illness been identified. Throughout the twentieth century, psychiatrists have therefore focused their attention on the early detection of signs and symptoms of mental ill health, assuming that early treatment will stop conditions from becoming worse. However, the ideal of secondary prevention can only be realized if these early signs and symptoms, or a “pre-psychotic syndrome” can be identified successfully. During the twentieth century, psychiatrists have defined many of these “pre-mental illness syndromes”; unfortunately, it has not always been demonstrated that they indeed constitute the early phases of severe and persistent forms of mental illness.

In June 2011, a number of Australian newspapers reported that a high-profile medical trial targeting psychosis in young adults would not go ahead. It was to be conducted by Prof. Patrick McGorry, who had been Australian of the year (an honorary and mostly symbolic title bestowed by the Australian government on an unusually deserving citizen advocating worthy causes). In the proposed trial, youths as young as 15 would receive Seroquel when they were first diagnosed, not with psychosis but with attenuated psychosis syndrome (previously called psychosis risk syndrome). Treating young adults with this syndrome would nip the danger in the bud—their potential psychosis would be treated before it even arose. The trial was to have been sponsored by the drug’s manufacturer, AstraZenaca, which, like many pharmaceutical companies, was probably eager to test its medication on a younger age group to expand the market for its medications. What could be wrong with such a commendable initiative?

Attenuated psychosis syndrome is proposed for inclusion in DSM-V and has attracted an unusual amount of discussion (and dissent). In particular, its relation to psychosis is unclear. Emeritus professor Allan Frances, who chaired the task force which produced DSM-IV, is a fierce critic of the concept. According to him, there is hardly any evidence that attenuated psychosis syndrome, if left untreated, will ultimately develop into a full-blown psychosis (current estimates state that this will happen in merely 10 to 20% of cases). The number of “false positives” is therefore staggering. According to him, treating a group of individuals of whom 90% would never become psychotic appears to be a waste of resources and a rather risky proposition.

McGorry’s proposed trial was widely criticized by psychiatrists world-wide, raising a number of significant ethical problems. First, there is the high number of false positives who would receive medication for a condition they would never develop if left untreated. The trial would not target incipient psychosis but probably address more or less unrelated conditions. This leads to the second ethical problem: a great number of young people would therefore be put on a medication they do not need. This would not matter so much if only aspirin or vitamin tablets were tested. Unfortunately, Seroquel has many highly undesirable side-effects including extreme weight gain and diabetes. One should only prescribe it when it is absolutely necessary.

Last April, AstraZeneca settled a lawsuit by the U.S. government after allegations it paid kickbacks to doctors while promoting the drug for unapproved uses by children, the elderly, veterans and prisoners for $525 million (New York Times, July 28, 2011). It has also settled, for $647 million, product liability cases for misleading patients about the risks of diabetes and weight gain associated with the use of the drug. Total expenses in legal fees associated with Seroquel are now $1.9 billion, which constitutes less than five months of Seroquel sales. Not a great medication to prescribe to individuals who do not need it.

McGorry’s proposed research has attracted (unfavorable) media attention (in Australia); I highlight it here not because it is exceptional or unusual in any way, but instead because it illustrates ways of thinking that have been part and parcel of twentieth century psychiatry. The most important of these is the ideal of secondary prevention in psychiatry: it is imperative to treat psychiatric conditions when they first appear and when they are not as serious as they could become if left untreated. This prevents them from becoming worse and less responsive to treatment. This strategy is of course commendable when there is a proven link between these less serious conditions and more serious ones. In most cases, it has been assumed that such a link exists; it has hardly ever been demonstrated.

The emphasis on prevention is not unique to psychiatry but characterizes developments in several (if not all) medical specialties. In days long since gone, one would see a dentist when one’s toothache became unbearable—today, dentists fill cavities and polish our teeth so that we will never end up in this situation. They also whiten and straighten our teeth although this prevents neither toothaches nor tooth decay. Today, the demands we make of physicians (and dentists) far exceed those of average patients a hundred years ago. Today, physicians do a lot more than treating serious illness—and we expect them to do that.

Most historians of psychiatry have discerned two themes in the history of twentieth century psychiatry. First, there has been a broadening of the definition of what constitutes mental ill-health. A wide range of conditions in between mental health and severe and persistent forms of mental illness have been identified and investigated. The formerly almost absolute distinction between mental health and mental illness has been replaced by a wide spectrum of conditions, which has led to the blurring of the distinction between the normal and the abnormal. Second, conditions on this spectrum have increasingly become the target of psychiatric intervention; psychiatrists now treat a variety conditions less serious than severe and persistent forms of mental illness but definitely in need of treatment. During the twentieth century, prevention has been the most important argument to hold both themes together: treating less serious psychiatric conditions prevents these from becoming worse—because it has been assumed these conditions will inevitably become more serious over time. It was well into the twentieth century before any effective medical treatments for severe and persistent forms of mental illness were developed. Mental hospitals were severely overcrowded while little could be done for their inmates. Therapeutic nihilism reigned. Any type of intervention that promised to prevent mental illness from developing or becoming worse was therefore worth considering.

The blurring of the distinction between normal and abnormal is generally associated with Sigmund Freud: according to psychoanalysis, nobody is entirely normal, although some individuals are better in keeping their unconscious desires in check than others, thereby maintaining an appearance of mental health and normality. Despite differences in appearance, we are all to a certain extent mad. Views like these open up unexpected vistas for psychiatric attention: behind the everyday veils of normality, happiness, and adjustment hides psychopathology, lust, and perversion. Nevertheless, the blurring of the distinctions between the normal and the abnormal is not unique to psychoanalysis. The historian of psychiatry Elizabeth Lunbeck has analyzed (in The Psychiatric Persuasion, 1994) how, in the 1910s, American psychiatrists proposed psychopathy as a category to designate forms of psychopathology that had previously been unrecognized because they had been able to pass as normal. No longer would mental illness, as insanity, be limited to insane asylums, where it could be contained successfully. On the contrary, the widespread presence of psychopaths everywhere, hiding under the veil of normality, threatened the social fabric of American society. These views made psychiatric intervention even more compelling: not only would it remove sick individuals from public life, it could also protect the social order.

In my own work on the history of the mental hygiene movement, similar themes appear. In the 1920s, mental hygienists launched a major project on the treatment of juvenile delinquency to prevent children from developing life-long criminal careers. The concept of adjustment as an essential marker of mental health, central to the philosophy of mental hygiene, brought a great range of human behavior under the purview of psychiatry. Instead of treating maladjustment in adults (for example, adults with mental illness), mental hygienists argued that treating maladjustment in children (for example, children with enuresis or temper tantrums) would prevent serious forms of mental illness arising later in life. By labeling all forms of undesirable behavior as maladjustment, it became self-evident to expect relatively innocent forms of maladjustment to become serious forms of maladjustment later on. Rather than punishing delinquency, the therapeutic treatment of children with “pre-delinquent syndrome” could be expected to bear fruit. Unfortunately, the central assumptions of this approach were never put to the test, and would most certainly not hold up when investigated properly. Led by their convictions, psychiatrists and mental hygienists were not bothered by this. They focused on lesser complaints, while neglecting the plight of the mentally ill in increasingly overcrowded mental hospitals (leaving them to somatic psychiatrists who experimented with insulin therapy, metrazol shock therapy, ECT, and lobotomy).

The mistaken impression could arise that the two themes in the history of psychiatry identified thus far (blurring the distinction between normal and abnormal, and targeting less serious states for psychiatric intervention) were a characteristic of psychoanalysis or other psychiatric approaches focusing on mental and behavioral factors. It would be too easy to dismiss them because, with psychiatry becoming increasingly biological and scientific, such trends have been reversed today. Nothing could be farther from the truth, however. During the last twenty years or so, we see these trends developed in an unprecedented way in psychopharmacological psychiatry. In the 1950s, only individuals with severe and persistent forms of mental illness received medication such as Thorazine. Today, fidgety and distracted kids as well as shy adults are portrayed as individuals who could benefit from psychopharmacology. Increasingly, a wider range of psychiatric medications are prescribed to young children, with the idea that early intervention will prevent problems from getting worse. It is this mind-set, now more than a century old, that made McGorry’s research project appear innovative and cutting edge.

McGorry has introduced a slight modification to his study, which will now go ahead. Instead of Seroquel, he will now test the efficacy of fish oil.

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