Dr. Elizabeth Stier is a gynecologist at Boston Medical Center who studies cancers related to the human papilloma virus (HPV). Most people associate HPV with genital warts and particularly with cervical cancer, which is much more common in women who have been infected with HPV.
But HPV also causes other cancers. There was a flurry of stories on throat cancer recently, when celebrity Michael Douglas said that his throat cancer was caused by HPV contracted through performing oral sex (it was probably caused by smoking, but whatever). And HPV can also lead to anal cancer, which (as with oral cancers) can affect either women or men.
Because HPV’s effects are most common in women, however, the people who know most about it are often gynecologists. Although anal cancer is relatively rare, its rates have been rising, as shown here in a table from The National Cancer Institute:
As anal cancer became more common, gynecologists increasingly began treating men for the condition. Sounds good, right? Doctor knows about the cancer, patient has the cancer, doctor treats the patient.
But apparently that’s not how it works. According to a New York Times article by Denise Grady, the American Board of Obstetrics and Gynecology, which certifies ObGyns, refuses to allow gynecologists to treat men:
Dr. Larry C. Gilstrap, the group’s executive director, said the specialty of obstetrics and gynecology was specifically designed to treat problems of the female reproductive tract and was “restricted to taking care of women.” Of the 24 medical specialties recognized in the United States, he said, it is the only one that is gender-specific, and it has been that way since 1935.
There are a number of problems here.
First of all, how does one define a man vs. a woman? Though gender often lines up with biological sex, it doesn’t always, and some people change genders. If a person lives as a man but still has female genitals, can he see a gynecologist? If a biological man becomes a woman, is a gynecologist allowed to see her, even if her genitals were fabricated? Can a pregnant man go to an obstetrician? The American Congress of Obstetricans and Gynecologists (ACOG is a professional organization, not a licensing board), said in a committee opinion that its members should treat transgender patients, but does not indicate how one defines the transgender person as female:
Obstetrician–gynecologists should be prepared to assist or refer transgender individuals for routine treatment and screening as well as hormonal and surgical therapies. Basic preventive services, like sexually transmitted infection testing and cancer screening, can be provided without specific expertise in transgender care.
Some people are intersexed, with ambiguous genitalia, and sometimes with “mosaic” chromosomes, in which some cells are XX and others XY. Do gynecologists have to decide an intersexed person is at least 51% female before providing care?
Finally, some gynecologists have been treating men with anal cancer for a decade or more. They are not only the experts in the field, they have important relationships with their patients. As the Times article reports,
[Dr. Stier worries] what will become of the men she has been treating. Those who had precancers need to be examined once or twice a year, because the growths tend to recur. Dr. Stier said the procedures are embarrassing and uncomfortable for patients, and it takes time for a doctor to gain their trust. Many of her patients are poor, from minority groups and infected with H.I.V. Some live in shelters, some have histories of drug use. And anal disorders add more stigma. “My main issue here is that I don’t think my patients are going to get the follow-up that they need, and I think they’re going to be lost to care, and we take care of a very vulnerable patient population,” Dr. Stier said.
Most of all, why is gynecology the only specialty that is gender or sex specific? Does ABOG even know the difference between sex and gender? It seems that doctors are trained to treat people first and foremost, and issues surrounding sex and gender are relevant to all medical subspecialties. There is nothing paticularly sex specific about the anus or about oncology (the study of cancer). Humans are one species. If women are humans, aren’t doctors trained to treat women competent to treat all humans?
Update 11/27/13: ABOG reversed its decision and now says that gynecologists may treat men, particularly for anal cancer screens and sexually transmitted infection screening and treatment. Read more here.
Other posts in the (un)Privileged Body series: