How Different is Dangerous

I saw a transgendered inmate today, and it caused me to inquire how she fared in an all-male prison. She said, "I'm really harassed by the Neo-Nazis, but I have a group of people who watch out for me, and I draw strength from them." Hmm. Yea, I kind of feel the same way about the Neo-Nazis. But what was most disturbing was her discussion of how she is treated by staff, given the circumstance of the Plata decision that placed the CDC medical system in receivership. This patient has chronic hepatitis B and hepatitis C, leading to cirrhotic asceties and esophageal varicies from Portal hypertension (This was of notable interest to me after a recent seminar on HCV/HCC/HIV that I recently attended - who would have thought...). He was vomiting blood one night, and no staff would believe anything was seriously wrong. He bled for several hours before his cellmate "acted the fool" to draw attention and they took her to an outside hospital. This reminded me of the story of Jennifer Sutton.

I attended safety training ("Block Training") at a prison that is a medical facility. It is always a mixed group of employees - from physicians to gardener's - and you sit through discussion that have no application to your duties (you may know how fond I am of such occasions), such as 2 hours of "Weapons and the Use of Deadly Force." Whatever... At some point in my wilting afternoon, a person from HR came in to do a presentation regarding sexual harassment. Now, for an environment known for the harassment of women, this was a truly lame presentation (and God bless all female CO's and Clinkshrink). Lame enough that some support staff broke into a discussion of transgendered inmates: "If one talks to me, could that be considered sexual harassment?" Yikes! This quickly evolved into hostility, religious belief, and discrimination. I suffered this as long as possible before, in a polite & professional manner (and you know I am), discussed the conflict with these "opinions" and California law. Yea, there are definitely some conflicts. The HR person stood there without comment. I left the training watching my back.

I cannot say I conceptually grasp the developmental transgender, or for that matter, gender assignment and sexual orientation. Is it genetically influenced, bio-psych-social-environmental as is evidenced-based medicine? On the single occasion a patient came to me for therapy, required for gender re-assignment, as is living as the other gender and receiving hormones, I had to honestly say that I was unqualified to provide what I believed to be and appropriate treatment, and made a referral. I will not end this without commenting on the issue of countertransference & prejudice. Since this is an unconscious process, it would seem incumbent upon a clinician to become aware of their operation and influence. Further, I recall once asking Dr. Otto Kernberg why I had felt increasing anger as I evaluated an abused woman, given that countertransference is classically thought to be based in personal experience (and I've never abused a woman - thought I'd throw that in), he described the phenomenon of projective identification, whereby an individual will "project" a feeling, thoughts, or beliefs onto another, and the other will feel or act as if they share the feeling or thought. As with countertransference, projective identification is an unconscious process..

All of this is to say that the difference between countertransference and prejudice is that, while the former is unconscious and the latter is conscious, both are equally capable of destroying therapeutic relationships. Likewise, the former is discoverable & correctable, and the latter is ignorant and ugly.