Clare Dimyon and breast screening: whatever happened to ‘patient choice’?

mammography

Ask any woman about going for a mammogram and she is likely to wince. These screening procedures are not pleasant, no matter what the situation. Try having your boobs painlessly squeezed and flattened into the scanner as you are manhandled by the operative. This can take several attempts and is often the most time-consuming section of the procedure. It’s not an agreeable experience. For those of us who are somewhat challenged in the size department, it can be even more uncomfortable, having what little there is pulled and shoved into the machine. As one of my colleagues said to me years ago, ‘I’ve only got two fried eggs at the best of times and it just isn’t possible to shove them into the scanner’. Quite. One of the only reassuring things about breast screening is the sign outside the scan room that says something like ‘No men in here’.

And that’s before we even get onto cervical smear procedures. These can be downright painful. Let alone humiliating. For any men reading this and wondering what all the fuss is about, try to imagine lying down with your nethers completely exposed while someone inserts a metal duck-bill into your orifice and then cranks it open before scraping your insides with a spatula. Lovely.

Stuff like this is women-only. It is uncomfortable, can be embarrassing and is only mitigated by the fact that women expect other women to be doing the manhandling and the scraping. Maintaining your dignity is a major issue for most women. We often have to give it up in childbirth but there is no reason why we should have to give it up in screening.

But wait, apparently there is…and guess where it originates?

According to a health trust in England last year, any woman who had been raped (or even one who has not) was required to submit to having her breasts manhandled (literally) in the mammogram suite by someone who says he is a woman but is actually a ‘natal male’ (or ‘man’). Why were her choices and feelings ignored in favour of the rights of the ‘trans-woman’ who may be doing the procedure?

Clare Dimyon, 54, who was raped as a teenager, apparently wrote formal letters to Brighton and Sussex University Hospitals NHS Trust asking to be seen by a ‘natal female’ when she went for a mammogram on Christmas Eve last year. Why we now have to call ourselves ‘natal females’ or ‘cis-females’, is another argument, but let’s get on with this one for now.

Brighton and Sussex University Hospitals NHS Trust subsequently used Clare Dimyon’s letter – anonymized – in guidelines to support trans staff, as an example of ‘unacceptable’ and ‘highly discriminatory’ communications. There was no reference in these guidelines to the fact that the letter-writer had formally requested a female mammographer in writing prior to the appointment, or to the fact that she was a survivor of a sexual crime.

The Trust said, ‘It is not possible to guarantee to any patient that they will only be treated by a clinician assigned to a specific gender at birth and, as an organisation that prides itself on our commitment to diversity and inclusion, nor would we wish to do so.’

So there we have it.  Again. Apparently diversity and inclusion only work in one direction.

They went on to say, ‘We have a duty to apply the same principles here as we would if a patient requested clinicians from particular backgrounds/ethnicities or any of the nine characteristics protected by law.’

Did you get that? According to this hospital trust, a woman client asking for a woman staff member to carry out an intimate medical procedure was the equivalent of a client/patient refusing to be ‘served’ by a black person, a gay person or a Muslim person (for example).  Except it isn’t.  The terminally-PC committee (I assume) which made this decision had clearly not read the actual wording of the Equality Act.

The Trust’s response referred to the Equality Act (2010) that states it is illegal to discriminate against someone on the basis of nine characteristics. These are age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation.

Don’t you just love it when authorities lay claim to their legal credentials by simply hanging onto the headlines without reading the small print? We used to get this all the time with the old Data Protection Act – now we have it with the Equality Act.

Is a public service authority right to claim that it cannot allow discrimination against A or B based on the provisions of the Equality Act? Yes and no, is the answer. What is required is a careful reading and assessment of the Act and of the scenario in question.

The Act actually states that there are circumstances where apparent ‘discrimination’ is allowed. Many of these relate to the issue of ‘harassment’, which is a key concept within the Act.

Under Prohibited Conduct – Section 26Harassment, the Act states that Person A harasses Person B if Person A ‘engages in unwanted conduct related to a relevant protected characteristic, and the conduct has the purpose or effect of violating Person B’s dignity, or creating an intimidating, hostile, degrading, humiliating or offensive environment for Person B’.  

So harassment is defined here are having the effect of violating a person’s dignity or creating a specified negative situation to a person. Just replace ‘Person A’ with ‘medical professional’ and ‘Person B’ with ‘client’ or ‘patient’ and there you have it. Clare Dimyon’s protected characteristic was related to sex – both hers and the mammographer’s – yet her rights to protection were considered secondary (if at all) to those of a trans medical professional, had such an individual been there to carry out the procedure. We should also argue that Clare’s case was compounded by her own traumatic past, which was directly related to the kind of medical screening she was to undergo.

The Act also specifically addresses harassment in relation to the provision of public services.

Under Services and public functions – Section 29 – Provision of Services, it states that ‘A service-provider (A) must not, in providing the service, discriminate against a person (B) as to the terms on which A provides the service to B or by subjecting B to any other detriment.  A service-provider must not, in relation to the provision of the service, harass a person requiring the service, or a person to whom the service-provider provides the service’.

It is already clear how Clare Dimyon’s situation comes under ‘the effect of violating Person B’s dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment for Person B’ (above). Now we can see that, at the very least, her case is also surely covered by the requirement not to subject her to ‘other detriment’. Plus, the Act requires in Section 29 (7) that a service provider should ‘make reasonable adjustments’ in the provision of the service – which is exactly what Clare Dimyon was asking for.

The last point to make about Clare Dimyon’s case is the fact that she is a lesbian. This is, of course, entirely irrelevant to the provision of healthcare for her in itself. But, and here is the worrying point, she is protected herself under the Equality Act because she is a lesbian (sexual orientation) and because she is a woman (sex).  That is two grounds for protection if I have counted correctly. Yet, her entirely reasonable request, given in writing in advance of an appointment, to only have a female medical professional attend her, was deemed to be offensive and discriminatory to trans people. Not only was her request dismissed as offensive and discriminatory, there was no desire to make reasonable adjustments for her based on her traumatic experiences in the past. More than this, her letter was used as an example of discriminatory and offensive communications.

What have we now come to? Once again, women’s rights are thrown under the bus in favour of protecting the rights (i.e. feelings) of trans people.

Brighton and Sussex University Hospitals NHS Trust has since apologized. However, this is an inadequate response. Who is/was making decisions like this in the first place? And why? Has all sense of balance flown out of the window? Did nobody at the Trust even think to consider that Clare Dimyon had a point in her request? What are the consequences now for people being treated by trans medical professionals? Or indeed by trans people working anywhere?  Do all women now have to submit themselves to treatment by trans people, with or without original genitalia in place, if they do not wish to be exposed to an intimate procedure by that person?

And what of the risk element in all this?  Unlikely as it is statistically, there is a possibility, however small, that some female patients may be at risk from trans-women staff with male genitalia in the medical setting.  We’ve seen what has happened in women’s prisons when some trans-women have been placed in them while still in possession of male appendages. What is to say that similarly-intentioned trans-women may not choose to access the health sector as a means of getting up close and personal with female patients? If we know that paedophiles have actively sought out roles in child-centred settings in the past to facilitate their offending and we now know that some trans-women have sought places in female prisons to facilitate theirs, why do we assume that some trans-women may not have the same idea in the health setting? Are trans-women required to have a chaperone when in a room with a female patient? No?  Do we have to await the first sex assault case in a hospital or surgery before this risk is taken seriously?

If one Trust can think this is acceptable, how many others are already acting in the same way? Are elderly ladies now supposed to accept intimate treatments or screenings from men, or men who say they are women? Are rape and other sexual assault survivors now supposed to subject themselves to examinations by men when they don’t want that? Outside the hospital setting, are women now to be frisked at airport security points by male staff? Are women to be body-searched by men in police stations?

Of course, the vast majority of trans-women have no intention of perpetrating sexual crimes. But we know that some do. We also know that the medical setting is one in which all women are particularly vulnerable. Just look at the dozens of past cases in which male nurses, doctors and others have been found guilty of misusing their healthcare role in the pursuit of inappropriate and criminal behavior. Women want other women to do certain tasks for them. In the hospital where I trained as a nurse years ago, women were not allowed to catheterize men – although of course, men were allowed to catheterise women. Where we are now with this, I don’t know.

On the NHS website there is a section about Patient Choice.

‘The NHS Constitution sets out the NHS commitment to benefiting the whole community, making sure that nobody is excluded, discriminated against or left behind. This means that the individual is at the heart of the NHS and services must be coordinated around and tailored to the needs and preferences of patients, their families and their carers. As a user of the NHS you have the right to receive care and treatment that is appropriate to you, meets your needs and reflects your preferences’.

It seems that this is disingenuous, to say the least. Firstly, when I was a nurse, we had to put our own rights aside in favour of the patient. The notion of me saying that I did not want to treat a certain patient or carry out a certain procedure was a non-starter (apart from being allowed to refuse to assist at an abortion, which I believe is no longer an option). Nowadays, it seems that the ‘carer’ has rights which may trump those of the sick person. This is crazy when it is applied to intimate procedures.  As a woman, I do not want a male person to do my mammogram or my cervical smear test.  I don’t particularly want a man to deliver my baby either but as there are fewer obstetricians than screening staff and midwives, I may have to put up with that.  But this is all a far cry from expecting women to submit their bodies to intimate handling by men for screening purposes.

Clare Dimyon has asked, ‘The NHS is spending a lot on trans training, so when is the awareness training going to start for survivors of rape and sexual violence?’

A good question. To which we might add, ‘When is awareness training going to start for those female patients who do not wish to be intimately seen or touched by men?’

 

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