In this emerging hot seat state, where major university hospital centers and "queer" identifying providers are in federal and state legal/investigation/whistleblower trajectories - from criminal to civil courtrooms and where legislative "battle lines" are increasingly being clearly marked I have to offer this to the rest of us.... there is a third option being overlooked in the provision of mental health care services across the entire United States. Gender affirming care is only one area - but frankly in all lifelong mental illness care provision, severe and often life long permanent disorders are generated everyday in our country, by diagnosis. Everday, masters level providers (I am in this category) not doctor level providers, in initial appointments lasting 60 minutes (maybe 75 or 90) label (by clinical and now legal documentation) people, children and adults - lgbtq and straight - with permanent mental disorders - to effect care. That is to say almost every severe disorder (and oftentimes permanent ones) diagnosed in the mental illness category can be documented, and then billed to insurance payors by a licensed provider in minutes...very very few of these diagnoses' are made with labs, scans, genetics, and valid testing instruments. Minutes to permanence for billing - often.
Forget the hotbed gender affirming topic for a moment and let that sink in - for both children and adults - a lifelong disorder can be made in a one hour conversation. And outside of the specialty topic of gender, it is noteworthy to say that very few diagnostics, particularly lifelong ones are withheld from family members under the guise of privacy and confidentiality. And, if safety (suicide, homicide, self injury, self harm, abuse) is at risk, mandated reporting of some kind and duty to warn laws and or ethics of some kind will require disclosure to caregivers (or other providers) who can generate a higher level of care.
Going back to the hotseat of Missouri and controversies over gender affirming care I would take the above variables (notice there are not only two) and summarize a treatment consideration that would be ethical, legal and reasonable: permanent or near lifelong diagnostics of children should not be done without a disclosure to the parents/caregivers - and - where abuse concerns exist mandated reports are required such that those other systems need to be activated. Anything else may lead to the perpetuation of increased risks of harm to all involved. This case is, if nothing else, proving the point of perpetual harm by omitting necessary party involvement where permanent illness, lifelong care and safety risks must be equally and adequately treated.
I've written about treating children for many years and most providers know that to be critical for overall improved outcomes in treating children families must be treated. Family treatment is needed in children's services, and it is more medically necessary in serious mental illness diagnostics (and rule outs) where lifelong and life threatening variables exist (particularly with a child and his/her/their families).
So, why and how does any of this (short term diagnostics with lifelong and often permanent outcomes) happen? Because of something else I've also written and spoke about: the third party payor system, health insurance and standards of care that are shaped by timed billing related to short and long term diagnostics to facilitate "medically necessary" care and payment. There is much room for improvement right here...in insurance. To focus on providers, patients, politics, gender, hospitals, educational systems, mental illness, laws, religion, parents, children, and healthcare as a whole - and NOT on the payors - to me is the biggest travesty of the conflicts between them that keep us all in court sadly off the treatment focus. Another complex consideration: insurance payors may be hurting us all ... and they too do not intentionally do so - even if we want to blame them as well. Money cannot be omitted from costs of care, even by an idealist who wishes it, "rightly" so.
While this article does a wonderful job of identifying the moving parts in gender affirming practices and concerns, labeling affiliations and biases of the players who are making the ruckus - in gender laws and education of children and parental rights - (including identifying another hotseat place I've lived and worked - Tallahassee - oh and where DeSantis also sits) - the drama of winning over the politic aside - too many variables are overly generalized. A good problem identification article it is indeed - but the focus of generalizing omits context. The children AND their families is the context.
You see each child and family scenario can be considered via a clinical and peer review lens (something that is not well/often funded by third party payors either). And in the whole "don't say gay" drama - I've said it this way ... "but the children" ... we are talking about need to be talked to and included (patients are supposed to be asked what they want in treatment and in treatment outcomes - this is in fact often an insurance mandate, if not an ethical and professional one).
You see, children need treatment - big time in the US. And if the children do - so do their parents. To exercise confidentiality as a mechanism to engage a child in keeping secrets from their parents may be a misstep in the provision of care. And to say that "privacy" between child/patient/provider/professional (excluding parents/family) is being done to ensure the child is not abused, suggests collusion out of fear with suspected abusers whereby mandated reporting is being avoided. That is, in my estimation a significant clinical error in the diagnosis and treatment trajectory that occurs when both the patient and the family are not included. This is phenomenally true in the case of children. Lgbtq and otherwise.
Why do treatment trajectory errors of this magnitude (lifelong, often life threatening mental health treatment processes) also happen? It goes back to providers who work in 45 minute sessions, limited by federal, state and private payors where care is limited by time and diagnosis related to "need" and reducing costs in "effecting care".... aka insurance.
I do not believe these topics are solved in the blue or red, right or wrong, all or nothing, evil or good paradigms. Nor do I believe class action lawsuits where members are compensated in ten's of dollars while tens of millions/billions only go to to or stay with a few. The scenarios highlighted in this one example of a mental healthcare system in some disarray - and child welfare too (I've written about this topic as well) - are not limited to any group of children and parents and schools and gender and mental healthcare workers and laws and insurance ... but these many variables are what mental health providers must navigate everyday. Often in 45 minute windows with multiple suicidal and risk of harm scenarios and with as many as 6 to 10 patients in an 8 hour day mental health providers must conclude many impactful stories of people - well - quickly. Add lifelong disorders, if accurately diagnosed with or without gender affirming issues - these same kinds of case scenarios (highlighted directly and indirectly in the gender affirming care article referenced) also occurs with drug use, bipolar, schizophrenia, autism, ptsd, eating disorders, depression, anxiety, domestic violence, bullying ..... on and on I could go....in 45 minute sessions a provider has allot to consider.
"But the children."
Clinicial assessments of children must include families and family systems. Risk of harm does not strengthen confidentiality it mandates reporting for safety sake. Secrecy for safety is secrecy that will increase a child's bind and increase risk of negative acting out and self injurious behaviors. Moms, dads, guardians, systems to prevent child abuse and mental health providers cannot operate in secrecy - and in health. Lgbtq or otherwise - secrecy in severity, lifelong disorders and safety risks require involving others in the family (and larger) systems.
Lifelong, lifethreatening, permanent disorders and treatment needs are not going to be resolved in generalized legal and political hotbeds (Florida, Missouri, The United States). They are going to be resolved one case at a time. Somehow.
Informed consent, neurobiological training, education, cultural inclusion, cultural reframing and comprehensive care is possible. These variables are already in place in our mammouth systems of "care." Accessing them is largely provider dependent, patient navigated, and funded in some way - whether there is sufficient time to do so or not.
Now children, families, providers, institutions, politicians are going to fight it out for some next big change?
If you're reading this, and you've made it this far - I think you must care ... so if you have time, give a long read to the entire article linked below and then also give a long read to my website Talkifuwant.com. Search child welfare, children and mental illness, types of providers, lgbtq, nutrition, couples, anxiety, stress, school counseling, adult welfare, - all of this "stuff" is covered there ... problems and solutions.
If you're a parent or guardian or a social services caregiver, a child too (these folks have voices and opinions too by the way) or if you're in law enforcement and politics - you are a part of the system. All of us are. Know that what you do with the person sitting across from you matters. And keep trying.
You/we/they can help - as exhausting and frustrating and maybe even as impossible as it is - one person at a time.
More talking. More bias training. More education. More time with people. More time with systems. More inherently healthy focussed advocates ... you/we/they/I can do and get better.
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