[DRAFT] Hormone Replacement Trouble

[Galway-Dublin]

The context to this is the ability for HRT, Hormone Replacement Therapy, to be prescribed to Transgender persons who seek it. In many places, long waiting periods for public healthcare systems can restrict Trans people from as quickly starting the medical aspect of their transition. Meanwhile, some Trans people are unable to be prescribed hormones without being first diagnosed with gender dysphoria, or in more restrictive circumstances being mandated to live in a "real-life experience", that can prove they are comfortable with their gender identity before they start hormones. This forces many trans people to either start HRT themselves without bloodwork or proper medical observation, which can be very dangerous.

The gist of all this context is that while some issues already cover HRT in particular form of sex-assignment surgery, none yet particularly focus on my intent, which is to allow nations to opt for an informed consent model, continue with the status quo, or to outright ban hormone therapy in the country and criminalize its usage, and I add this context to properly furnish the intent of the options in this issue in case they come off as overbroad or confusing.

[Name] Hormone Replacement Trouble
[Validity] Only valid for nations that allow Transgender persons to live freely, though I'm unsure if it should be open to those who are allowed medical care or not as the issues around the subject are very broad.
[Desc] A rally outside your office formed this morning in response to medical slowness to provide hormones required for Transgender hormone transition in @@NAME@@.

[option]"Hormones are too darn difficult for Transgender people to safely get their hands on in this country!" Shouts @@RANDOMNAME@@ from their loudspeaker, "Some people have to wait months just to get their first dosages and bloodwork! In the name of Transgender rights, we demand the government remove such reactionary medical regulation on hormones and adopt informed consent! We already allow prescripton of dozens of medication to be properly provided this way, so why not hormones?"
[effect] the nation is transitioning to a better tomorrow

[option]"Absurd!" Shouts @@RANDOMMALENAME@@, your medical advisor, salad dressing dripping from his mouth. "If we don't mandate trans people to go through rigorous courses to confirm their identified gender, what'll stop any old sod who thinks they're trans from starting hormones and causing irreversible changes to their body? In the name of safety, we must continue to adhere to our current policy, no matter how slow it may be. That said, we should try to grease the wheel a bit to help these people more quickly, so how about a bit more funding, @@LEADER@@?
[effect] @@DEMONYMNOUN@@ medical professionals insist that slow and steady cures the dysphoria

[option]"We should be outright reactionary!" Wails @@RANDOMFEMALENAME@@, founder of the "Wreal Womyn's Wrath" party. "In all my years of supporting the rights of REAL womyn, I will not let this country delve into a path of acceptance and medical support of these unnatural degenerates. Estrogen should only be for real womyn! To my movement, what defines a womyn is her biology; Our wombs! We must not bend to these men trying to INVADE our spaces! In the name of real womyn, we must outright ban hormone replacement therapy throughout @@NAME@@!"
[effect] a black market has erupted for estrogens and testosterone

[Name] Hormone Replacement Trouble
[Validity] Only valid for nations that allow Transgender persons to live freely, though I'm unsure if it should be open to those who are allowed medical care or not as the issues around the subject are very broad.
[Desc] While hormones for Transgender people in @@NAME@@ are subsidized by the government, there has been growing discontent with the current medical requirements in order to be safely prescribed medication, reaching a breaking point with a huge rally outside of your office.

[option]"Hormones are too darn difficult for Transgender people to safely get their hands on in this country!" Shouts Madeline Roem from her loudspeaker. "The current system requires months of therapy before we even get the ability to have our first doses and bloodwork done. In the name of Transgender rights, we demand the government remove such reactionary medical regulation on hormones and adopt an easy model of informed consent! We already allow dozens of prescription medication to be provided this way, so why not ours?"
[effect] the nation is transitioning to a better tomorrow

[option]"Absurd!" Shouts @@RANDOMMALENAME@@, your medical advisor, salad dressing dripping from his mouth. "If we don't mandate trans people to go through rigorous courses to confirm their identified gender, what'll stop any old sod who thinks they're trans from starting hormones and causing irreversible changes to their body? In the name of safety, we must continue to adhere to our current policy, no matter how slow it may be. That said, we should try to grease the wheel to help a bit quicker, so how about you throw a few more doctors in our direction?
[effect] @@DEMONYMNOUN@@ medical professionals insist that slow and steady cures the dysphoria

[option]"We should be outright reactionary!" Wails @@RANDOMFEMALENAME@@, founder of the "Wreal Womyn's Wrath" party. "In all my years of supporting the rights of REAL womyn, I will not let this country delve into a path of acceptance and medical support of these unnatural degenerates. Estrogen should only be for real womyn! To my movement, what defines a womyn is her biology; Our wombs! We must not bend to these men trying to INVADE our spaces! In the name of real womyn, we must outright ban hormone replacement therapy throughout @@NAME@@!"
[effect] a black market has erupted for estrogens and testosterone

[Candlewhisper Archive]

I don't think this issue covers much that isn't covered by 66.1.

@choice: "I have gone through twenty years of internal pain about my external appearance, and I've put so much effort and money into finally having the world see the real me!" blogs the model. "Gender isn't a binary proposition: gender identity is not necessarily the gender assigned at birth. I was fortunate to have private funds and supportive parents, but not all are so lucky. Please recognise my right to self-determination of identity, and help those like me get the surgery and medicine they need."

Medicine includes hormone treatments. Getting bogged down in the availability of individual treatments isn't issueworthy: rather the big decision to be made is the broad principle of the state's role in helping transgender transitions.

[Galway-Dublin]

I don't think this issue covers much that isn't covered by 66.1.
Medicine includes hormone treatments. Getting bogged down in the availability of individual treatments isn't issueworthy: rather the big decision to be made is the broad principle of the state's role in helping transgender transitions.

One of the reasons I decided to draft this issue was based on the idea that the government already providing hormones as stated in that issue, but perhaps seeking to draft and enforce legislative restriction for security purposes, something that is at best implied to be diminished through the broad and vague nature in which that issue's first option explains, and this is also why the first option does not mention costs, as that is not the issue here. The issue is imposed regulation on medication by the government in the name of safety of those who may wish to prescribe to it.

Many developed countries that would seek to subsidize the costs for hormones do this, for example with the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, which has been criticized for its restrictiveness. In the UK, which provides HRT through its NHS, a legal name change is required before one can start hormones. Meanwhile, in Germany, there's a requirement of being on therapy for 6 to 12 months, and a mandated "Real life experience" to familiarize a person with their identified gender.

It's true that 066 has similar options, however neither of its options are a "Legalize and fund hormones and restrict them unless the person seeking them meets medical criteria" or funding them and doing away with a potential restriction. It isn't unusual for public healthcare systems to offer hormones but withhold them if the requesting person fails to meet requirements needed, and it's for that reason that I feel the underlying basis for this issue remains relevant in NS; the government can fund HRT all it wants, but whether or not it seeks to impose restrictions on it in the name of safety or not would easily find itself a debatable public policy decision that might be opposed by those who see it too restrictive.

If possible, I could redraft the issue to make the conflict people who want to restrict hormones, if 066 is indeed to be taken at its word for being an all-inclusive and deregulating issue through its broad, vague generalities.

[Candlewhisper Archive]

For sure, as a GP I've battled the underfunded system on this myself, in particular the ridiculous notion that the NHS won't continue hormonal treatments that weren't commenced on the NHS.

However these are funding minutiae in the grand scheme of the nation, something for health department officials to work out, rather than being on the desk of the leader. There's vast numbers of small health economic decisions to make, like whether you fund social care or geriatric medicine, or whether you emphasise safe hospital discharge teams or community nursing support, whether you offer PSA screening or not, and so on.

Within a sim like NS, where exact balancing of the books isn't done and where spending is more or less inconsequential, there's simply not the granularity for the question of "do you put additional funding for hormonal treatments for transgender people to reduce treatment waiting times?" The detailed costing framework doesn't exist to make it a significant question, and the stats aren't precise and small-scale enough to measure the difference in healthcare provision and outcome for the speed of delivery of a single intervention for a small proportion of the population.

Very much an important issue for a clinical commissioning group deciding how to allocate funds, but not right for NS.

[Galway-Dublin]

For sure, as a GP I've battled the underfunded system on this myself, in particular the ridiculous notion that the NHS won't continue hormonal treatments that weren't commenced on the NHS.

However these are funding minutiae in the grand scheme of the nation, something for health department officials to work out, rather than being on the desk of the leader. There's vast numbers of small health economic decisions to make, like whether you fund social care or geriatric medicine, or whether you emphasise safe hospital discharge teams or community nursing support, whether you offer PSA screening or not, and so on.

Within a sim like NS, where exact balancing of the books isn't done and where spending is more or less inconsequential, there's simply not the granularity for the question of "do you put additional funding for hormonal treatments for transgender people to reduce treatment waiting times?" The detailed costing framework doesn't exist to make it a significant question, and the stats aren't precise and small-scale enough to measure the difference in healthcare provision and outcome for the speed of delivery of a single intervention for a small proportion of the population.

Very much an important issue for a clinical commissioning group deciding how to allocate funds, but not right for NS.

My issue's primary focus isn't funding, and to an extent it's not particularly about waiting times. It's whether the state's existing medical regulations and prerequisites for Trans people to begin HRT should be changed to a consent-based model or if the current regulation on hormones should remain.

As I mentioned in the examples with the UK and Germany, it's not so much so that there's a wait in the latter's case, it's the fact that a Transgender person has to be provided numerous clearances in order to be provided with proper hormone therapy, unrelated to how much funding their public medical provider is allotted; This issue's proposition is not government funding on the matter, but whether or not there should restrictions on Trans people who seek hormones from getting them as easily.

[Australian rePublic]

Option 2- This is not something people change their minds about

[Galway-Dublin]

Option 2- This is not something people change their minds about

As I mentioned earlier, regardless of the quality of the policy, in countries like Germany, UK, an at many medical providers in the US, there exist length time requirements in order for Trans people to get proper bloodwork alongside monitoring during their transition, such as the German example for 6 months of meetings with a therapist or the whole RLE requirement.

[Ab Humanitatis Scientiam]

My issue's primary focus isn't funding, and to an extent it's not particularly about waiting times. It's whether the state's existing medical regulations and prerequisites for Trans people to begin HRT should be changed to a consent-based model or if the current regulation on hormones should remain.

As I mentioned in the examples with the UK and Germany, it's not so much so that there's a wait in the latter's case, it's the fact that a Transgender person has to be provided numerous clearances in order to be provided with proper hormone therapy, unrelated to how much funding their public medical provider is allotted; This issue's proposition is not government funding on the matter, but whether or not there should restrictions on Trans people who seek hormones from getting them as easily.

So, just to clarify, you're envisioning this issue being primarily about Standards of Care/Real Life Experience versus informed consent:

The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC) require psychological counseling and for the patient to live a period of a time in the desired gender role, in order to assure that they can psychologically function in that gender role.[2] This period is sometimes called the real-life experience (RLE). While this standard was widely followed in the 20th century, a growing number of physicians refuse to follow the Standards of Care, insisting that they are too restrictive and that inhibiting patient access to hormone therapy does more harm than good.

Some LGBT health organizations (notably Chicago's Howard Brown Health Center[3]) advocate for an informed consent model where the patient must only prove that they understand the risk[4] and consent to the procedure in order to access hormone therapy.

https://en.wikipedia.org/wiki/Transgend ... ne_therapy

I think we can see the beginnings of such a debate in your issue options to date:

[option]"Hormones are too darn difficult for Transgender people to safely get their hands on in this country!" Shouts @@RANDOMNAME@@ from their loudspeaker, "Some people have to wait months just to get their first dosages and bloodwork! In the name of Transgender rights, we demand the government remove such reactionary medical regulation on hormones and adopt informed consent! ...

[option]"Absurd!" Shouts @@RANDOMMALENAME@@, your medical advisor, salad dressing dripping from his mouth. "If we don't mandate trans people to go through rigorous courses to confirm their identified gender, what'll stop any old sod who thinks they're trans from starting hormones and causing irreversible changes to their body? ...

ButI think the (at least implied) general focus on waiting times in the description might muddy things a bit. Perhaps try changing the issue description to more explicitly make the debate about Standards of Care/RLE vs. Informed Consent. The underlying issue is really about individual autonomy in the context of a medical system where practitioners have a duty of care which may or may not limit individual autonomy. Not just "medical slowness."

Perhaps something like:

[validity] selected #66.1

[description] Since @@NAME@@'s legislature recently committed itself to recognizing it's citizens right to self-determination in gender identity, some medical practitioners have insisted upon a waiting period to ensure individuals are psychologically capable of adapting to physical transition. Others argue, however, that patients should be permitted to proceed immediately once informed consent is provided. The debate has reached your office, etc.

This is too awkwardly worded and long, but hopefully might illustrate the general idea.

EDIT: Spoilered most of this post, since I've only just now noticed and read the "context" spoiler in the OP, and you've said all that already. Although folks might want to read the Wikipedia article (and links and such) I linked to for additional info; I found it helpful in rediscovering everything that was already explained to me :\ I still recommend the above unspoilered course of action -- rework the issue description to make the debate specifically about SoC/RLE vs. informed consent and not just "slowness."

[Galway-Dublin]

ButI think the (at least implied) general focus on waiting times in the description might muddy things a bit. Perhaps try changing the issue description to more explicitly make the debate about Standards of Care/RLE vs. Informed Consent. The underlying issue is really about individual autonomy in the context of a medical system where practitioners have a duty of care which may or may not limit individual autonomy. Not just "medical slowness."

Perhaps something like:

[validity] selected #66.1

[description] Since @@NAME@@'s legislature recently committed itself to recognizing it's citizens right to self-determination in gender identity, some medical practitioners have insisted upon a waiting period to ensure individuals are psychologically capable of adapting to physical transition. Others argue, however, that patients should be permitted to proceed immediately once informed consent is provided. The debate has reached your office, etc.

This is too awkwardly worded and long, but hopefully might illustrate the general idea.

Thanks for the advice, I've tried to interpret as much as this could be reasonable within the limitations of the issues as possible in my latest draft, and kinda-sorta killed the third option, as the issue should be primarily between the Informed Consent and RLE models (also bump).

[Ab Humanitatis Scientiam]

Thanks for the advice, I've tried to interpret as much as this could be reasonable within the limitations of the issues as possible in my latest draft, and kinda-sorta killed the third option, as the issue should be primarily between the Informed Consent and RLE models (also bump).

Better, but the description still strikes me as a bit vague. It's better than the rambling textbook block that was my suggestion, certainly. I still feel that an issue description should set out a "X vs. Y" type debate, then have the issue options make good-faith arguments for each side.

I read "...growing discontent with the current medical requirements in order to be safely prescribed medication" and immediately want to know what these requirements are. Without a tiny bit more detail, I'm still left wondering what makes this issue different from #66. It seems like the essential debate in re: informed consent vs. RLE is who gets to determine when/if an individual is psychologically fit to undergo hormone therapy: the said individual, or their doctor. The description should address this basic question at the very least.

Also, I'd keep the third option, since it's a side in the debate one is likely to see and it serves the more practical function as a reversal of #66.1. I might make it a coalition of some sort, however. "Real Womyn," various religious concerns, and haberdashers afraid of losing business, or some such.

[Palos Heights]

How are you guys going to make all these posts without even telling them that they spelled Replacement wrong?

Personally, I think you could also make a play here to talk about how HRT education is substandard in some countries, even amongst medical professionals.

[Feria-Alkaline]

How are you guys going to make all these posts without even telling the poor man he spelled Replacement wrong?

Personally, I think you could also make a play here to talk about how HRT education is substandard in some countries, even amongst medical professionals.

Palos. Did you even read Galway's sig..?

[Palos Heights]

How are you guys going to make all these posts without even telling the poor man he spelled Replacement wrong?

Personally, I think you could also make a play here to talk about how HRT education is substandard in some countries, even amongst medical professionals.

Palos. Did you even read Galway's sig..?

I did not!

[Chan Island]

Palos. Did you even read Galway's sig..?

I did not!

*shuns Palos*

[Feria-Alkaline]

Palos. Did you even read Galway's sig..?

I did not!

Good job, mate, good job...

[Palos Heights]

I did not!

Good job, mate, good job...

I hardly find this continued line of posting to be constructive to the issue draft at hand, especially considering the innocent nature of the mistake (which has been corrected) made. If you have time to give me steam for an honest mistake, then you have time to actually give this person (and others) feedback on their draft(s).
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As for the draft at hand, the second option could do without that last line about greasing the wheels. As it stands, the option itself seems unnecessarily large, so I would recommend finding a way to get your point across with fewer words.

Also, why are you capitalizing transgender? Transgender isn't a proper noun and shouldn't be capitalized.

Aside from that, I'd tidy up your dialogue and make sure that the characterization and word choice synergize.

Also remove darn from option one. You can say damn on NationStates.

[Galway-Dublin]

How are you guys going to make all these posts without even telling them that they spelled Replacement wrong?

Oh my God how did I not catch that earlier

I read "...growing discontent with the current medical requirements in order to be safely prescribed medication" and immediately want to know what these requirements are. Without a tiny bit more detail, I'm still left wondering what makes this issue different from #66. It seems like the essential debate in re: informed consent vs. RLE is who gets to determine when/if an individual is psychologically fit to undergo hormone therapy: the said individual, or their doctor. The description should address this basic question at the very least.

I figured that I could leave the particulars of the requirement up for explanation in the issue options, though I could try to strike an equilibrium in its explanation between the description of the issue and options about it.

Also, I'd keep the third option, since it's a side in the debate one is likely to see and it serves the more practical function as a reversal of #66.1. I might make it a coalition of some sort, however. "Real Womyn," various religious concerns, and haberdashers afraid of losing business, or some such.

I'm split on such, I agree that it'd make the issue generally more in line to other issues on the matter, but at the same time I can't help but feel that a nation that already legalized and is funding SRS and HRT isn't probably demanding to retract the privileges so quickly, but I could be wrong.

[Candlewhisper Archive]

I still feel this just isn't a controversial or interesting enough topic to make for a good issue. Essentially, if you're in favour of state healthcare provision for transgender medical care, then you're likely in favour of it being timely and properly available. However, achieving those things is a question of health economics priorities and budget balancing, not a grand ethical dilemma, and NS just isn't set up to look at those things.

It essentially comes to:
You've already said you're in favour of transgender medical care. Do you now want to increase your health spending stat to get a bonus to inclusiveness and health?

Answer: obviously yes.

Maybe something with more edge and debate to it:

The question, for example, of what age hormone treatments should begin at is a really interesting one. If a child comes to a firm pronouncement of transgender identity at age 10, do you seek to induce puberty changes appropriate to their identity, or do you seek to suppress puberty till they can decide as an adult, or do you say no messing with hormones at all until they're an adult? What about if the parents want one thing and the child wants another?
Something like that is a much deeper ethical dilemma!

[Galway-Dublin]

I still feel this just isn't a controversial or interesting enough topic to make for a good issue. Essentially, if you're in favour of state healthcare provision for transgender medical care, then you're likely in favour of it being timely and properly available. However, achieving those things is a question of health economics priorities and budget balancing, not a grand ethical dilemma, and NS just isn't set up to look at those things.

It essentially comes to:
You've already said you're in favour of transgender medical care. Do you now want to increase your health spending stat to get a bonus to inclusiveness and health?

I hope it's clear that it's ostensibly not a budgeting problem, the intent and basis is whether or not state provided hormones should be withheld from individuals if they are unable to pass certain tests that do exist in the real world between Trans persons and their hormones. The second option asserts a budget/staffing increase, but with the intent of smoothing the stagnant wheel of the bureaucratic medical process.

The question, for example, of what age hormone treatments should begin at is a really interesting one. If a child comes to a firm pronouncement of transgender identity at age 10, do you seek to induce puberty changes appropriate to their identity, or do you seek to suppress puberty till they can decide as an adult, or do you say no messing with hormones at all until they're an adult? What about if the parents want one thing and the child wants another?
Something like that is a much deeper ethical dilemma!

This seems like a good potential option/options, if not an entire issue in it of itself; i.e. whether trans children should be provided the whole set of HRT-associated drugs or only just T-blockers or be distrusted entirely.

Inb4 this becomes like my other issue draft on robberies and I totally rewrite the basis of it.

[Ab Humanitatis Scientiam]

I'm split on such, I agree that it'd make the issue generally more in line to other issues on the matter, but at the same time I can't help but feel that a nation that already legalized and is funding SRS and HRT isn't probably demanding to retract the privileges so quickly, but I could be wrong.

I'm in the United States, so gigantic reactionary swings are unfortunately not an alien concept to me perhaps.

(But mostly -> )

[The Marsupial Illuminati]

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Deleted by The Marsupial Illuminati on Sun May 32, 2008 13:11 pm, deleted 1 time in total.

[Feria-Alkaline]

Good job, mate, good job...

I hardly find this continued line of posting to be constructive to the issue draft at hand, especially considering the innocent nature of the mistake (which has been corrected) made. If you have time to give me steam for an honest mistake, then you have time to actually give this person (and others) feedback on their draft(s).
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As for the draft at hand, the second option could do without that last line about greasing the wheels. As it stands, the option itself seems unnecessarily large, so I would recommend finding a way to get your point across with fewer words.

Also, why are you capitalizing transgender? Transgender isn't a proper noun and shouldn't be capitalized.

Aside from that, I'd tidy up your dialogue and make sure that the characterization and word choice synergize.

Also remove darn from option one. You can say damn on NationStates.

XP I was gonna but time and stuff...

Right, so, Galway. Honest region-mates, good friends, heart-to-heart here, okay? I consider myself relatively okay-versed in LGBT+ stuff. I'm not saying I know what skoliosexuals are (for the record, they're attracted to non-binary people), but I kinda get, more or less, the basics of LGBT World.

I would dismiss this issue because I'd have no idea how to respond to it. So, too, would a lot of people. I don't think many, if any, would choose option 2, because those who have trans policies and stuff would want to help trans people even more. It's on the side of the line where it's pretty technical...

First of all, if you're not making an easy reference, use @@RANDOMNAME@@. Like for my draft "The Lottery Ticket", several names are not randomised - because they reference Shirley Jackson's short story The Lottery. Others, the ones I couldn't ref back, are. I, personally, understand Madeline Roem, but the vast majority of NSers will not, and it'll be weird for them. Also, you can do @@HIS@@ and @@HE@@ to have both guys and gals random-name.

Now, the title could use a lot of work. It's kinda bland as is. "Hormone Replacement Trouble" sounds like a Max Barry issue. Please don't write Max Barry issues...

Nit-picking, in both your options, you used "shouts", so grab a thesaurus and look up some obscure replacement xD

Both effect lines, as well, are a bit bland. Like, I get them, but they're not really funny. Like a lot of people say, the effect is the punch line, and the option is the joke leading up to it. There's no real punch line - this is quite the serious issue, and it could use a lot more lightening up, too...

And maybe more options? Two (or three, but I think two) is a bit low, and barely shows all of the sides of this issue. There's so much more you can do with this draft.

Here's my tip - maybe start your description with a trans person being denied hormones, then run through that trans person, the doctor, the counter-trans, and the wacky everyone should be trans?

[Candlewhisper Archive]

The question, for example, of what age hormone treatments should begin at is a really interesting one. If a child comes to a firm pronouncement of transgender identity at age 10, do you seek to induce puberty changes appropriate to their identity, or do you seek to suppress puberty till they can decide as an adult, or do you say no messing with hormones at all until they're an adult? What about if the parents want one thing and the child wants another?
Something like that is a much deeper ethical dilemma!

I wrote an issue with a similar premise (children transitioning) and you told me that such a topic was too complex to present in Issue format.

Yes indeed, I thought that your issue WAS too much about technical details to be workable.

I said:

I see!

So why would a small penis stop sex reassignment surgery? There's techniques for SRS which don't involve penile inversion, for example use of scrotal sac material, and honestly, if female hormones have made the area more female in appearance to start off, then that's a surgical boon, not an impediment. There's always ways around this, so the issue premise is essentially non-believable.

Plus, let's not forget that primarily what happens in most jurisdictions that support transition is that puberty blockers are applied that will delay puberty, not promote gendered changes, and that only when a child reaches a stated age of consent competence are they able to initiate hormonal treatments that will allow gender expression.

I think there's a strong issue to be explored about what age you let people initiate hormonal treatments, but I think the surgical question is too technical and too inaccurately portrayed here to be an inclusion in this issue. In fact, honestly, I think the whole topic is one that belongs in medical ethical debates by professionals and engaged parties, and is too complex to present in Issue format.

That is, I don't think the issue of penis size prior to transitioning surgery causing technical impediments to the operation was a good national issue.

However I do think that the question of the age you can begin transitioning IS a good national issue.