Game of Bones: Finale (Part 7) Live Free or Die

The day started out with blue skies, but then scudding across a milky sky, charcoal clouds closed in on the farm on that day, the first week of November.

Farmer Brown did not arrive with the morning feed and the turkeys clustered along the fencing which faced the farm house, where the lights were on.  The feeding always took place at 9 AM, but not this day, and by 11 AM the birds were becoming irritable and several fights broke out. A hungry bird is a testy bird.

Just before noon a low rumbling began and grew louder and louder until its source appeared: A fifteen foot silver truck ground slowly down the road and pulled up in front of the pig barn. It had a huge red and gold star painted on its long walls: "Gold Star Market." 
Seeing that, Brooks remarked, "That is the same logo that man had on the back of his jacket. The man Farmer Brown was talking to the other day."
None of the other turkeys could make that connection.

Members of Farmer Brown's family, his three teen aged daughters, walked out of the farmhouse, wearing blue jeans and brown rubber aprons which reached below their knees and they walked to the far side of the van and disappeared behind it. 

The hired men, wearing similar aprons, drove up in a pickup truck and jumped down and several entered the silver truck from the door on the near side, and one stood in the door and three formed a line in front of the truck from the door to the road.

Finally, Farmer Brown walked out of his front door, down the road to the turkey field and he spoke in a booming voice. 

"You are all winners today!" he shouted. "So white and big breasted. This farm has had its best year in history. Believe me.  And we want to mark  the greatest flock of turkeys ever with a special celebration. Come one and all, the lines are wrapping around the block!"

The troika turkeys, Sean, Rush and Rupert led the procession, walking across the road and down toward the covered bridge to the silver truck and up the stairs where each turkey was hoisted through the door by the hired men.

Toward the end of the long line Brooks, Chamberlain and Will straggled along behind. As they passed the goat pen, the goats seemed most intent on not looking at them, not even Delphi, who was normally the most responsive goat, met their eyes. 

Only the old goat looked up and followed the line of turkeys with his eyes, and he met the eyes of each of turkeys who had visited the goats with a strange and steady look.

The pigs were gathered in their sty. They had their own field on the north side, but this day, they remained corralled. They looked at the turkeys pass by and grunted amongst themselves in a low, not unfriendly, but not a happy murmur. 




















The chickens were nowhere to be seen, which was unusual, as they were always underfoot.

From behind the truck Rush, Rupert and Sean emerged and headed back up the road toward the turkey field. 
"Oh, you'll love it," Rush cackled.
"Best party ever"  said Sean.
"Winners," Rupert said. "Every one."

But from within the truck a grinding, whirring sound was audible.
And a stench gradually filled the road. 
The closer Brooks and his two friends got to the truck, the more intense the the smell and the louder the whirring sound, almost like the grindstone Farmer Brown occasionally used to sharpen his scythes. 

The line of men lifted the birds and handed them along, until they finally reached the man at the front door to the truck, who handed the birds inside to unseen hands. The three friends, Brooks, Chamberlain and Will had not quite reached the line of men. Then Brooks noticed a large rubber hose running from the unseen side of the truck down to a barrel below.

Two of the daughters were struggling to lift the hose out of the top of one barrel and place it into a new, fresh barrel, but as they did, the hose gushed a crimson stream, which splashed on the ground between the barrels. 

Brooks saw Chamberlain's eyes focus on the scarlet tide and then back to Brooks.

Just then, a shadow crossed over the faces of Brooks and his two friends. They realized the shadow was from a bird flying over them. They looked up and there, a hundred feet above them, sailed Thomas and three of his wild turkey friends.

The wild turkeys did not look down upon Brooks, but flew on, wings beating rhythmically, voices clear, plaintive, keening. They did not form a line as geese would do, but lumbered along in the air, heavily, working hard. They were slow, but  they were up there, on their own power, moving steadily, untouched by the scene below them.

The hired man seized Brooks, smiling and handed him to the next man in line, and he was passed along until he reached the final man at the door to the silver truck, who handed him inside, where the whirring sound had grown louder.

Game of Bones: Part 6

Indian summer is like a woman. Ripe, hotly passionate, but fickle, she comes and goes as she pleases so that one is never sure whether she will come at all, nor for how long she will stay. In northern New England, Indian summer puts up a scarlet-tipped hand to hold winter back for a little while. She brings with her the time of the last warm spell, an unchartered season which lives until Winter moves in with its backbone of ice and accoutrements of leafless trees and hard frozen ground. Those grown old, who have had the youth bled from them by the jagged edged winds of winter, know sorrowfully that Indian summer is a sham to be met with hard-eyed cynicism. But the young wait anxiously, scanning the chill autumn skies for a sign of her coming. And sometimes the old, against all the warnings of better judgment, wait with the young and hopeful, their tired, winter eyes turned heavenward to seek the first traces of a false softening.
--Grace Metalious, Peyton Place

October opened with heat which in the 20th century would have been called, "Indian Summer," but the animals and people of New Hampshire had, for some years, come to expect summer would shift into winter without pausing for autumn.

The wild turkeys pecked and hunted the sere, the yellowed fields abutting the fenced in yard for the white turkeys.  The wild turkeys looked parched and their muscles had gone stringy and their voices cracked.

Standing along the fence between them, Brooks, who had grown ever fatter, his plumage whiter and his breast muscles bulging, called out to Thomas who raised his head to listen.

"You know, Thomas," Brooks said. "If you wild turkeys flew in here at dusk, there is always feed left in the bins. We cannot eat it all. Nobody would say anything and Farmer Brown goes off to the north fields in the afternoon."

Thomas smiled as much as a turkey beak will allow for a smile and said, "That is very kind of you. But I don't think we will take you up on that generous offer."

"It must be hard to recall the death of your friend," Brooks said. "But I do think it would be safe and we could post look outs for Farmer Brown. You would have plenty of time to escape, should he approach."

"We're struggling; it's true," said Thomas, "But we are getting by. Once the heat passes, we'll do better."

"It just seems a waste, all that feed uneaten at the end of the day," Brooks persisted.
"This is New Hampshire," Thomas said, "Live Free or Die. In our case, in yours as well, ever true."

"You are still the Cassandra," Brooks said. "Sounding the alarm for the approaching apocalypse." 
"And you still cleave to Farmer Brown."

Later, that same day, Farmer Brown arrived with a man who wore a silver jacket which had printed in big red and gold letters on its back, "Gold Star Market." The two entered the fenced in turkey grove and walked slowly among the birds. One of Farmer Brown's daughters trailed behind, in dungaree overalls and pigtails. 
"I raise the best and most beautiful and whitest turkeys in the entire country!" Farmer Brown told this man. Farmer Brown waved his arms about and as he did some of the turkeys approached, in hopes he had feed in his pockets. "Look how they love me!" Farmer Brown told the man. "They are the happiest, fattest, biggest, strongest, healthiest, most beautiful birds who ever existed! Right here."

The birds preened and strutted and fluttered their stubby, flightless wings and they all felt like winners. 

"Any one of these birds would win first prize at the County Fair, if I would enter them. But I keep them right here. I wouldn't risk taking any off the farm, exposing them to those other birds from other places."

The man with the silver jacket shook Farmer Brown's hand. They ambled back out, trailed by Farmer Brown's daughter.
"I just feel so good every time he sets foot in the compound," said Chamberlain. 
"He is so charismatic," Will said. "I'd follow him anywhere."


"He has kept us safe," Brooks agreed.  "We eat well, all we can eat and more. His fence has kept the fisher cats and foxes and coyotes away.  We have never had it so good."

Thomas was just beyond the fence, with two other wild turkeys.

"But you are not free," Thomas reminded Brooks.

 "If this is not freedom, whatever it is feels pretty good. You may say that we ain't free, but it don't bother me," replied Brooks.
"That sounds like a line from a Robert Altman movie."
"Sometimes," Brooks said, "If we hop up on the hay bales, we can see across the road and through the window and see the big screen TV in Farmer Brown's living room. We saw 'Nashville' the other night."
"Ah," said Thomas.
"Farmer Brown really cares about us. Did you notice the new gate he put up at the entrance?"
"Yes. But I could not read the words."
"They are German," Brooks said. "The old goat told the other goats. Arbeit Mach Frei."
"Meaning?" asked Thomas.

"Something about freedom, I think. We are free range turkeys. Farmer Brown has set us free. We live so much better here than on other farms. We have no coops here."
"What is freedom, really?" asked Thomas.
"Just another word for nothing left to lose," laughed Brooks.
"I've heard that one."
"We can walk where were want to."
"As long as you stay on the right side of that fence."
"We can eat as much as we like."
"I can fly wherever I like," said Thomas. 
"Why should I want to go anywhere else? I'm fine here. What more do I need to know?"

"Ah!" Thomas expostulated, "That's just it, isn't it? What more do you need to know? What is the use of exploration? Why ask what is on the other side of the fence, the stream, the salt marshes?"
Brooks looked across the fence at Thomas and Thomas looked back at him. They were not more than five feet apart, but they lived in different worlds entirely.

Transgender Medicine: Abigail Schrier and Paul McHugh

Sometimes things just coalesce.  

Some weeks ago, the Phantom attended his annual Endocrine Society meeting and underwent his ritual plunge into icy water, and this weekend he read Abigail Shrier's most excellent WSJ piece on Paul McHugh.  Then a twitter post by Paul Krugman and the lightbulb went off above his head: Even in dark times, a conflagration can sometimes, for all its destruction and despair, clear a field so new growth can occur.

Dr. Paul McHugh

First, the meeting. 

Every year the Phantom attends sessions on his favorite hormones for updates from leaders in research and clinical practice.  He attended one session on "Androgen Abuse Update," where a man who runs a clinic at the University of Michigan described the patients he sees and the Phantom recognized these patients immediately, as he sees many similar folk in his clinics in Massachusetts and New Hampshire: They come to the clinic looking like Arnold Schwartzenager, huge trapezius, pectoralis, biceps, asking for prescriptions for industrial doses of testosterone.

They are never big enough. Never the incredible hulk they want to be. Of course, their testes have shrunken to the size of raisins, but that does not bother them. They are in pursuit of bigger deltoids.

The lecturer showed a cartoon of a heavily muscled man looking in a mirror seeing a skinny 98 pound weakling. 

"These men are like the anorexia nervosa patients who see themselves as fat and can never get thin enough," he said. 

A doctor from the Netherlands got up and told about his clinic where psychiatrists and endocrinologists work together with the patients, who are treated very much as people addicted to heroin are treated, with programs to taper them down and off the agents to which they are addicted. 

"Wow," an America doctor said. "I wish we could do that here. But we have to worry about the FDA and lawyers."

"Well," the Dutch doctor replied, "Everything is easier in the Netherlands."

Which is likely true, except when money is involved. Cash does grease the wheels in America.

The next session, which the Phantom makes himself attend every year was on "Transgender Medicine" where the heads of some of the biggest "Transgender Medicine" clinics report on their experience and practices and present cases to illustrate various clinical problems.

At a glance, it was clear these programs, which involve patient visits, prescriptions and often complicated surgeries, are big business at the institutions where they thrive. Careers are made and hospital budgets balanced.

One of the experts on the stage mentioned the doses of testosterone he uses to achieve the results the patient is looking for, in some cases, two or three times the usual dose used for replacement in men who lack testosterone.

On the other hand, the expert said, he had some patients who were not looking for increased musculature or facial hair, but just a deeper voice, so he "touched them up" with lower doses of testosterone. A sort of Botox approach to medical care: show me where you want that wrinkle dissolved and I'll deliver that. 

" I know in some cases these doses and blood levels  are higher than what androgen abusers attain," said the director of the transgender clinic, "But we need these to achieve results in our patients."

The Phantom, sitting in the audience,  quickly emailed the University of Michigan professor who had given the session on "androgen abuse" with what the transgender doctor had said.

 "Are we, in transgender medicine, not inducing androgen abuse in our patients?" the Phantom asked.

The professor replied, "In this case, the higher doses are used to achieve gender affirmative therapeutic goals." 

In other words, as an Endocrine Society approved expert, he was not about to criticize standard practice in transgender medicine circles.

"So, if a man who is not transgender requests an  industrial dose of testosterone so he can see bigger muscles, that is abuse. But if a transgender person requests industrial doses of testosterone so hair grows on an XX lip, well that's just 'gender affirmative'?" I asked the professor. 

One year, long ago, the Phantom had stood up in the audience during the transgender session and asked: "What is the suicide rate among your transgender clinic patients?"

The speaker blandly replied, "About forty percent," as if that were just another statistic. (The Phantom did not remark: "One death is a tragedy; a million deaths is a statistic," showing uncharacteristic restraint.) 

But the Phantom had persisted, "Suppose you had a cardiology clinic which did some procedure and it reported a 40% mortality rate. How long do you think that clinic would be allowed to stay in business?"

A blizzard of resentment and loathing swept from the audience toward the microphone where the Phantom stood, and the Phantom slunk back to his seat, chastened, not having the courage or the folly to persist.

Portrait of an Artist: Abigail Shrier

Paul McHugh on the other hand, saw what the Phantom saw and he did not slink away.

 As Abigail Shrier reported, at Johns Hopkins, where McHugh is a professor, medical students will not speak to him. 

"They think that my views must be motivated by hatred," he says.

In this one paragraph Shrier speaks volumes about where we are in "transgender medicine." The very people who ought to look at problems dispassionately, who should ask the hard questions, fail to do so. When it comes to "transgender medicine" all rational thought goes out the window. Suddenly a medical problem has been politicized and emotion rules, even among medical students, at Johns Hopkins School of Medicine. And in the audience at the Endocrine Society.

Schrier has done the journalistic equivalent of painting St. George and the dragon.

McHugh arrived at Hopkins in 1975 as chief of psychiatry, and was asked to coordinate the participation of psychiatry with urology and endocrinology and plastic surgery in the Hopkins transgender program. 

Being an actual physician and scientist he asked the requisite questions: What is the success rate of the clinic? What are the goals? How do you measure the achievement of these goals? And what are the risks? 

What he found was a 40% suicide rate among patients in the transgender clinic.

He thought of the dictum every medical student learns first day: Primum non nocere (First, do no harm.) 

He closed the clinic. In 1979. He did not do this immediately. He took time to gather facts. Facts he could not avoid. Facts are stubborn things. What he did had to take courage. So many jobs and dollars depended on that clinic. But he slew the dragon. And he has been paying for it ever since. 

He was trying to protect patients, but he was accused of hating the patients, of not accepting them as suffering human beings who needed care. 

In fact, he asked, at least by implication, "Would you respond to patients with anorexia nervosa by trying to help them find ways to lose more weight?"

But we all agree anorexia nervosa is a disease, that is, we agree the patients are wrong in their assessment of what they need. And we agree that heterosexual men who seek high doses of exogenous testosterone are wrong to do so. In fact, our state legislatures have called them not just wrong, but criminal for doing so. Testosterone is now classed with codeine as a drug with abuse potential in the criminal code. (Unless, of course, you are using it for "gender affirmation.")

McHugh has suggested in some cases, anorexia nervosa for sure, and very likely "gender dysphoria" have a disorder of an "over valued idea." For the anoretic, that idea is thinness. For the gender dysphoria patient, it may be that if only the right gender could be found, all would be right again.

A year ago, after one such Endocrine Society transgender session, the Phantom emailed Dr. McHugh about a case which had been presented. A male to female transgender had a lesbian partner and they wanted to have a baby. 

The male to female transgender had not had surgery, only estrogen therapy, but the estrogen therapy had reduced the sperm count.  They sought in vitro fertilization (IVF). The clinic was moving ahead with IVF just as soon as they could be sure insurance would pay for it.  The Phantom asked McHugh if this did not sound somehow wrong.

McHugh replied, "You have to ask, what sort of sex, exactly, is this couple having?"

That had not actually occurred to the Phantom. If the male to female was having erections, it was possible they were having penis in vagina intercourse, so why would they need IVF? Just reduce the estrogen, allow the sperm count to rise.

This year, another case presented:  A female to male transgender with an intact cervix and uterus on testosterone therapy was still menstruating and likely ovulating and the clinic thought an IUD would work best. But objections were raised that offering an IUD to this female to male person would be "emotionally traumatic" because it would remind the patient of her persistent female organs, and would not be "gender affirmative."

The Phantom thought of Dr. McHugh's email and emailed him again. 

"This couple is clearly having penis in vagina intercourse, and the female to male is receiving this penis, which is somehow not destructive of her 'gender affirmation' and yet an IUD would be?"

This time Dr. McHugh did not reply.

He may not have got the email.

Or maybe, at age 87, he had wearied of the battle or at least wearied of the questions from an exasperated Phantom.

Or maybe he just thought it's time for some other saint to slay the dragon.

As pernicious and nasty as Trump and his willing accomplices have been, it is possible a brush clearing fire might be possible. Trump is clearly hostile to the whole idea of transgenders, and has rescinded military codes in their respect. Would his FDA now be willing to look at these "transgender clinics" and all those who profit from them: the endocrinologists employed there, the plastic surgeons, the urological surgeons, the nurses, ancillary staff, the hospitals all of whom profit from this transgender industry? It may be that, at least in this one area an ogre will do the right thing.