The very thought of a surgery gone wrong is a nightmare in itself. A 32-year-old mom of three waded through a similar misery at the start of the New Year. Abigail Fernandez, who hails from Newquay, Cornwall signed up for a tummy tuck surgery in Tunisia, which almost cost her life.

Fernandez, who seemed to have body image issues post the delivery of her children, admitted to going under the knife to get back in shape. While most cosmetic surgeries are expensive, Fernandez came across a cheaper alternative via an advert. The procedure which costs about 10,000 euros in the UK, seems to have cost only 2,500 euros in Tunisia. Soon after, Fernandez called up the clinic which flooded her with information, including how she’d recover in a five-star hotel post-surgery. She wanted a breast lift as well but stuck to just the tummy lift owing to budget constraints.

But, much to her dismay, things seemed a little amiss right from the start. Far from what it looks like at a star hotel, the accommodation offered bore a dilapidated appearance—the tiles were broken, the floor was dirty and the bedsheets were dirty. And, the horror had just begun. The clinic, however, seemed spotless. She went ahead with the surgery which lasted for about four hours. When she woke up, she felt just fine. But, the next morning was far from what she imagined.

“My body felt like it was on fire and I begged nurses for painkillers,” said Fernandez, while recollecting the nightmare.

“They told me I was being discharged that day, I was horrified,” she added.  

The staff finally agreed to let her stay for one more day after Fernandez alleged that she was unable to move. Despite the pain having persisted the next day, Fernandez was discharged by the hospital staff the very next back and dropped back into the same hotel.

On her return, Fernandez remembers feeling dizzy and her vision was blurry. And well, her tummy had swollen to the size of a basketball. What unfolded in the next couple of days were plain ghastly. A green puss-like liquid oozed out of her tummy. While repeated attempts were made to bring this to the clinic staffs’ notice, they overlooked it and termed the condition as “normal.”

Unable to take it any longer, Fernandez was rushed to the doctor after being in acute pain. The excruciating pain was so bad, that she had to call for an ambulance.

At the hospital, doctors examined her condition only to discover that swelling was due to a hematoma – a clot of blood that had formed outside of Abigail’s blood vessels. The swelling was eventually busted and revealed that if she had left it longer, it could’ve cost Fernandez her life. The young mother was hospitalized for four weeks and the infection was cut out to stop it from spreading.

Currently, her stomach bears a nine-inch scar. She will also have to shell out 3000 euros to repair the damage in a specialty hospital in the UK. And, yes, she has a word of advice for all the young women out there: “Don’t go for surgery abroad, I wish I hadn’t. It seemed like I was getting a good deal, but I’ve paid a high price.”

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A new peer-reviewed commentary published in the January issue of the American Journal of Public Health argues for new metrics to evaluate the public health response to HIV in the United States. The U.S. Department of Health and Human Services (HHS) has announced plans to reduce the number of new HIV infections by 75 percent in the next five years and 90 percent in the next 10 years. “Ending the HIV Epidemic” (EtHE) efforts will focus initially on 48 high burden counties; Washington, DC; San Juan, Puerto Rico; and seven states with substantial rural HIV burdens, before moving on to all U.S. counties.

Dr. Denis Nash, Distinguished Professor of Epidemiology at the CUNY Graduate School of Public Health and Executive Director of the CUNY Institute for Implementation Science in Population Health, notes that because ending the public health threat of HIV requires intensification and more focused targeting of implementation, there is a need for new metrics to inform and evaluate EtHE initiatives. Nash argues that newer metrics should complement the current metrics that focus on new HIV infections, individuals successfully being treated for HIV, and coverage of pre-Exposure Prophylaxis (PrEP), a drug which can prevent HIV infection.

The HHS plan should develop metrics that track the deployment and uptake of specific intervention delivery strategies, which would provide data regarding plan goals. Nash contends that HIV-related health disparities in both implementation outcomes and health outcomes require special attention.

Finally, Nash underscores the need for HHS to develop a public facing web-based dashboard system that more rapidly disseminates actionable information based on the new metrics needed to inform the implementation of the HHS plan.

“We have made substantial strides in getting useful data into the hands of those that are in a position to act in support of New York’s Ending the Epidemic initiative,” he said, referring to New York’s Ending the Epidemic Dashboard system. “The national EtHE Plan needs a timely dissemination system like the one we have here in New York in order to accelerate impact and share lessons learned within and across those jurisdictions aiming to end HIV as a local public health threat.”

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When the U.S. Supreme Court in 1994 decided a case involving a transgender individual’s rights, it looked to the American Medical Association to medically define the plaintiff who asked the court to protect her.

Dee Farmer was assigned at birth male, but identified as female. She wore women’s clothing, underwent estrogen therapy, received silicone breast implants and underwent an unsuccessful “black market” testicle-removal surgery. Farmer, who was serving a federal sentence for credit card fraud, sued federal prison officials for violating her Eighth Amendment rights to not be subjected to cruel and unusual punishment while in prison.

Farmer had continued hormone therapy and presented as female in prison, according to court records. She was generally separated from the male population at the first prison she was housed, in part for behavior and in part for safety. After being transferred to another prison, she was placed in a general population where she said she was beaten and raped.

The Bureau of Prison’s medical personnel had diagnosed Farmer as transsexual and justices in their opinion turned to the AMA’s 1989 Encyclopedia of Medicine for the medical definition quoting that it was “[a] rare psychiatric disorder in which a person feels persistently uncomfortable about his or her anatomical sex,” and who typically seeks medical treatment, including hormonal therapy and surgery, to bring about a permanent sex change.

The Litigation Center of the American Medical Association and State Medical Societies and 10 other medical organizations noted that this definition was out of date in an amicus brief they filed in a 2017 case, Adams v. School Board of St. Johns County, Florida.

“It is now understood that being transgender implies no impairment in a person’s judgment, stability, or general social or vocational capabilities,” the brief stated. “Gender dysphoria is a condition characterized by clinically significant distress and impairment of function resulting from the incongruence between one’s gender identity and the sex assigned at birth.”

The court in Farmer v. Brennan sent the case back to the lower court for further consideration of whether prison officials knew the risk, with the high court justices ruling that prison officials could be found liable for denying an inmate humane conditions if they knew of or disregarded an excessive risk to the inmate’s health or safety.

Farmer ultimately lost the case during the retrial, but the Supreme Court ruling was precedent-setting.

AMA Litigation Center gets involved

Since 1994, the AMA on numerous occasions has stood up for transgendered individuals’ rights in court, with the Litigation Center filing friend-of-the court briefs.

The AMA Litigation Center gets involved in cases when the AMA has policy on an issue. The Association has a number of policies involving LGBQT rights, including that public and private health insurers cover treatment of gender dysphoria as recommended by the patient’s physician. Policy the House of Delegates adopted at the 2018 AMA Interim Meeting calls on the Association to, among other things, oppose any efforts to deny an individual’s right to determine their stated sex marker or gender identity and to affirm that gender for many individuals may differ from the sex assigned at birth.

Advocating in Penn., Wisc.

In 2018, the AMA Litigation Center joined other health care organizations in filing an amicus brief asking the 3rd U.S. Circuit Court of Appeals to uphold a policy that allows Pennsylvania high school students to use a bathroom or locker room that matches their gender identity rather than their sex assigned at birth can be left in place.

The appellate court in its ruling in Doe v. Boyertown Area School District upheld the policy. The students who filed the lawsuit seeking to have the policy thrown out are now asking the U.S. Supreme Court to consider the case.

The AMA Litigation Center also advocated on behalf of transgender individuals’ rights in 2011 when it joined with other health care organizations in filing an amicus brief in the 7th U.S. Circuit Court of Appeals in a case that asked whether a Wisconsin law prohibiting prison doctors from using hormonal therapy or sex reassignment surgery to treat inmates with gender identity disorder was legal.

In Fields v. Smith, the 7th Circuit upheld a lower court decision that withholding treatment was cruel and unusual punishment under the Eighth Amendment and deprived inmates of equal protection guaranteed under the 14th Amendment.

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