When I qualified as a GP, I moved to a practice in small, intimate Hemingway. Watching patients carefully, closely, over years makes an art out of diagnosis and prognosis. I am my patients’ first point of contact for diagnosis, and I provide continuing treatment, advice and evaluation for all their medical conditions. Perhaps, if I tried, I could predict the health of Hemingway’s individuals over the course of their lives. I could tell you who might be at high risk of cancer or diabetes or liver failure. I could tell you which children will become obese, which might develop eating disorders, and which might have problems with drugs.
Due to my experience, I take most of the patients who are under twenty-one. It has become evident to me, after twelve years at Hemingway, that I have most contact with my young patients before the age of five and between the ages of thirteen and eighteen. I see the under-fives for vaccinations, chicken pox, colic, whooping cough, scarlet fever, the mumps, diarrhoea and parental hypochondria. I see the teenagers because of sex.
Thirteen seems young to start talking about sex, but I have heard it said that children are getting older. I think adults are getting younger. I also suspect, however, that the sexuality of adolescents has not changed in nature since we were apes. In fact, I am certain that in medieval times, in Hippocrates’ days and through the somewhat conservative Victorian era, thirteen-year-olds have been engaged in sexual activity, teenagers have procreated, and the LGBT issues we think of as contemporary existed in all their variations and multiplicity.
What has changed, perhaps, is that our ability to connect with these people in our society has grown via the internet. Some policy has advanced because of this, and is clearly outlined in best-practice documents and in medical school curricula, but some areas are still being debated. In particular, medical approaches to trans, intersex and asexual people can vary greatly between jurisdictions.
I know that our practice is ahead of most in our approach to these teenagers, but there are some areas where I do not know enough, and we need to improve. Like most clinics, like the curricula, like the policy-makers, we are struggling to keep up with scientific advancements, and also with our patients.
Between my list of patients and the adolescents who come to the drop-in sexual health sessions I run after hours at the clinic on Tuesdays and Thursdays, I look after about 700 adolescents, five of whom I know to experience some degree of gender dysphoria. About thirty have discussed a non-heterosexual preference with me. A number have come in to the after-hours clinic upset because they don’t ‘get’ sex. One hundred and thirteen are on the pill. Three have had abortions in the past year. I treat the occasional sexually transmitted disease. About eighty per cent of all my patients come to the clinic for free condoms.
As I run the late night clinics, I often work from 2 p.m. until 10 p.m. Today I pull my car into the drive in the early afternoon and the leaves crunch as I walk towards the doors.
Ahead of me reception is busy as always. A blond boy, a Hemingway teen, dressed in the high school’s uniform of suit trousers, white shirt, a black V-neck jumper, black tie and blazer, leans in close to the service window, his hand on the frame. The warmth of the low autumn sun is caught in his fair hair and on the skin of the other patients next to him, creating a blinding glow that makes it difficult to see. I lift my hand up to shade my eyes. As I move nearer a few of them turn hopefully towards me. To my left, the cluster of heads in the waiting room lifts, and I feel, as I usually do, bad that I can’t see all of them, that I will only be taking one person through to my office to release them from the long wait and bland magazines. Then the blond boy steps forward, out of the light.
He moves towards me purposefully and his lips part.
‘Can I help you?’ I ask.
He smiles and glances at my nametag. ‘Dr Verma? Can I talk to you?’
‘Have you made an appointment? What’s your name?’
He hesitates, then whispers softly as I pass by, my step brusque, ‘Max Walker.’
I stop and turn around to look at him. As an older couple pass, Max ducks his head down and hair falls over his face.
The Walker family is a mainstay of the Hemingway Post, and all the local press. Max’s father and mother both frequently appear on the evening news. His mother advises people who call in on legal matters and his father often gives statements about current cases. They are both lawyers of some kind, and Max’s dad, particularly, is something big in local law enforcement. But I cannot recall having met Max before.
‘Are you a patient of mine?’ I ask.
‘The receptionist says so.’
I look towards the waiting room. People watch Max over their magazines.
‘It’s urgent? Will it be quick?’
Max nods emphatically.
‘Alright then,’ I say. ‘Let’s be quick.’
‘Thanks.’ He smiles, visibly relieved.
I slip into the office and murmur to the receptionist, ‘Hold my list, OK? And I need Max Walker’s file.’
I escort Max briskly to my room and close the door, just as the office phone starts ringing. ‘Let me just get that,’ I say to Max, slinging my bag on the table. It’s the receptionist.
‘No, I said Max Walker.’
Max sits down in the chair opposite me.
‘No, Walker. W-a-l-k-e-r.’
I roll my eyes at the phone for Max’s benefit. He gives a weak grin and looks ready to burst into tears.
‘Yes, that’s it,’ I say into the phone, and replace the receiver.
Max is staring worriedly at an appointment slip left on my desk and wriggling uncomfortably on the chair.
I sit in my chair opposite him. ‘Now, what have you come to talk to me about today?’
Max takes a deep breath, but falters. ‘Is this confidential?’
‘Yes.’
This is not strictly true. There are various grounds on which I am able to break confidentiality, and I have done so before. But, by and large, confidentiality is key to being trusted, so I don’t explain the nuances of that statement. Particularly when it comes to helping young people.
He looks doubtful, but swallows, attempting to smile. I watch it fading gradually from his face, beat by beat, coming back as he pushes for it, fading away as he loses faith.
‘OK, um . . .’ he says, wetting his lips. ‘I need a morning-after pill.’
The click of the door interrupts us, and we are silent as the receptionist slips in and places Max’s file on my desk. She leaves, closing the door behind her.
I nod. ‘May I ask why?’
He swallows and shifts forward then backward in the chair.
‘Is it for a girl? Because I’m afraid she has to come in.’
He shakes his head. ‘No, it’s for me.’ He pauses. ‘You should probably read my file.’
I reach for his file. The cover reads: Max Walker, D.O.B 25 September 1996. I look up.
‘It’s alright, I’ll wait.’ He looks over at the window. I watch him struggling to smile to himself, to grin, like it’s a drag, like it’s an irony. I close the file without reading it.
‘Don’t you just want to tell me what is relevant?’
He looks back at me, alarmed, then breathes out slowly, calming himself. ‘Alright.’ His hand brushes his hair behind his ear and he blinks. ‘I’m intersex.’
‘I see.’
‘Like, a hermaphrodite.’
‘I understand. I haven’t seen you before, have I? We run a clinic on Tuesdays and Thur—’
He interrupts me. ‘I had specialists. I mean, I have specialists. So I haven’t seen you about . . . anything to do with this before. I came in once when I had a stomach bug, but I think you weren’t here. I saw a nurse.’
I nod. ‘Wouldn’t you prefer to see your specialists now?’
‘Well . . . I can’t drive. They’re in London. On Harley Street.’
‘Do you want me to arrange for someone to take you to the train station in Oxford?’
‘I don’t want
to see them. They’re . . . they ask a lot of questions and stuff.’
‘I see.’
‘Can’t I just see you?’
‘Yes, of course you can. I deal with all sorts of conditions. I have to warn you, I haven’t had too much experience with intersexuality.’
‘Have you had any?’
‘Yes, I have. I’ve worked with some cases featuring genital variations when I was training. But if you like we can talk about anything you want to and then if I feel I don’t know enough to advise you, we can look at specialists – with your permission. Does that sound good?’
Max tucks a leg underneath himself, shifting nervously, and nods.
‘I’m just going to scan your file, now I know what I’m looking for.’
‘’Kay,’ he whispers.
I look down at his file again and open it. Max is quiet while I flip through. Most people have fairly slim A5 files. Max’s is bulging out of the cardboard folder, most of it faxed over from several NHS hospitals and, later, a private clinic on Harley Street. The papers include: possible diagnoses from his birth, then final diagnosis with several addendums added in later years, advice and opinions of a number of doctors on operations, what should be done, what could be done, preserving fertility, later references to a consensus statement on management of intersex patients with a redefined diagnosis for Max, then a list of hormones advised and then used for treatment, including documentation of injections and courses of pills. Then there are the photos. Max as a baby, Max as a toddler, Max as a four-year-old with a piece of paper held in front of his face for anonymity, while green-gloved hands prise apart his legs. The photographs cease. There is a full page of notation on parental reaction to the diagnosis, starting from birth and ending two years ago, just before Max’s fourteenth birthday. Most records seem to end at that time.
I make a note to scan Max’s file into the computer. It’s much too cumbersome in paper form, and we are trying, slowly, to make the move over to digital.
In my peripheral vision I notice Max watching me curiously and I look up from the files.
‘Max, are you sure you need this pill?’
He nods, biting his fingernail. He notices me looking at it and lowers his hand. ‘Sorry.’
I smile. ‘I don’t mind if you bite your nails.’
He shrugs.
‘Did your specialists say you were fertile?’
‘They said there was a slim chance.’
‘You get periods?’
He blushes. ‘Not very often.’
‘This says you have a uterus?’
He shrugs. ‘Yeah.’
‘And you haven’t had it removed at any time?’
Max shakes his head.
‘Are you on any type of contraception?’
‘No.’
‘Just condoms?’
‘No,’ Max replies miserably. He opens his mouth, as if to say something, then shuts it firmly.
‘Do your specialists know you’re sexually active?’
‘Um . . .’ He does not continue, instead morosely ripping the top of his thumbnail off.
‘Didn’t they ask you about it?’
‘I haven’t seen them in ages and I . . . wasn’t then. They usually talk to Mum, not to me, anyway.’
I point to the file. ‘These notes seem to run out almost two years ago. Is that perhaps when you last saw them?’
‘Maybe.’
‘Right.’ I nod and scan the last few pages.
Suddenly Max pipes up, louder than before, ‘I’m not fertile in the . . . guy way.’
I frown, not understanding. ‘So—’
‘No!’ Max is suddenly upset.
‘What do you mean, “No”?’ I ask, confused.
‘It’s not . . . I didn’t . . . I can’t self do it!’
‘Self-fertilise? No, of course you can’t, Max. I wasn’t suggesting that.’
‘Um, OK.’ He swallows, calming down. ‘Sorry. You . . . you can’t be both, can you?’
‘Fertile in two ways? I’ve haven’t heard of it. Medicine isn’t often a finite science, but I don’t think it’s possible. In humans,’ I add.
I make a mental note to drag out my old textbooks at home and look up intersex diagnoses online. There are many, with many different causes. While most are classified as ‘disorders’, some are, to a certain extent, reversible, some are defects, caused by the body’s lack of hormones, or faulty hormone receptor, and some are to do with the sex chromosomes. Studying for a medical degree in England, our curriculum never went into much depth about intersex disorders. In fact, I recall when training that, on the odd instance they came up, we referred to them as hermaphroditism. The words have changed, and I wonder why.
I frown at the file. It is true that I have dealt with some patients with ambiguous genitalia, but not to this extent. I flick through it again, trying to find the notes on fertility, but nothing jumps out at me.
Max pulls his jumper over his fingers and wipes his face. His cheeks are red.
‘Max? Are you OK?’ I say to him. ‘I’m sorry to ask all these questions, I’m just trying to ascertain—’
‘I just need a pill! Can’t I get one?’
‘Of course you can. Of course.’
‘Can I have the thing that makes you not get an STD too?’
‘Excuse me?’
‘Isn’t there something that stops that?’
‘You mean HIV prevention medication?’
‘Yeah.’
‘Do you think you might have been exposed to HIV?’
Max looks confused. ‘I don’t know. Probably not HIV.’
‘There’s nothing else that we have preventative medicine for.’
‘Oh.’
‘Would you like the medication?’
Max thinks. I can’t see his eyes properly, behind his hair. He’s looking down at his knees. He rubs an eye with his sleeve again. ‘Probably not.’
‘OK. Alright, let me get a Levonelle pack.’
I stand up and he looks at me, lost.
‘The emergency contraceptive. I’ll just be a minute.’
I put my hand reassuringly on his shoulder and sweep out the door.
Max
This is the most embarrassing, horrible day of my life, and if I can just get through it, stay blank, breathe in and out, keep smiling, keep nodding, it’ll be over, and tomorrow will be better, and the next day will be better than that and soon it’ll be like it never happened.
I’m never going to hang around with Hunter again and in less than two years he’ll have gone to uni and I won’t see him at all. Maybe our parents will stop being friends and drift apart. Maybe we’ll move away. You never know what will happen in the future. Things often work out even when you really, really think they won’t, like that time when I was little and I was convinced, utterly convinced, that Mum wasn’t going to come home, and I didn’t know why at the time but I knew she wasn’t, whether she was dead, or had left us, I don’t know, but she did come home, she did. Dad was angry at her, and I shouted at him not to be because I thought she would leave again, but she didn’t, she stayed and everything I thought would happen didn’t happen. Sometimes things just aren’t what you think they are, and even when things seem really bad, it can work out. Everything can work out and go back to normal. If I can just get the pill, then I’ll buy some more Ibuprofen on the way home at the chemists, or in Sainsburys, because then I can go through self-service and I won’t have to talk to anyone to explain why a Walker kid is out of school during school time, then I can get home, say to Mum I’m ill and go to sleep.
Then maybe tomorrow I’ll call in sick. No, I don’t want to miss school tomorrow! I’ve been looking forward to tomorrow for ages. Fuck Hunter, I’m not going to let him ruin my day. OK, so tomorrow will be good and then I’ll forget about it, minute by minute it’ll trickle out of my brain until it means nothing, and it just hasn’t happened.
So. First I get the pill, then Sainsburys. What if the pill is
too late? No, it works up to twenty-four hours after, that’s what they said in class. It’s been . . . fourteen hours. That’s OK. Besides, Dr Verma seems to think I’m not fertile. I think she thinks that anyway. She’s a bit brusque and clinical. She’s like, let’s get to it, matter of fact. I guess that’s good in a doctor but it makes me feel more shitty. I thought I’d be able to talk about everything, but I can’t bring myself to tell her about Hunter.
I just have to get through today. Then things will go back to normal. Until next year, when maybe all the other guys will have facial hair, and then in two years, when everyone will be having sex but me, and then in ten years, when everyone will be getting married and having kids but me, and over the years, the kissing will dry up because I won’t have sex with people, because I won’t go out with people, because if I have sex with someone, they’ll see, and then they won’t want to go out with me anyway. Because I’m a freak. Because I’m freakish.
Archie
‘Right. I have to ask you a few questions before I can give you the pill.’
The door swings shut and I take my seat opposite Max.
‘’K,’ he mumbles.
‘Oh!’ I turn to face him and speak softly. ‘Don’t cry, it’s OK.’
Max puts both hands, gripping sweater sleeves, over his face. His skin is red and tears fall onto his lap. He sobs something into his palms.
‘Pardon?’
‘I hate it.’
I hesitate, not knowing what to do. I end up reaching out and squeezing his arm. ‘Do you mean being intersex? Do you get upset about your condition a lot?’ I ask.
He shakes his head and his light hair swings back and forth. ‘It never comes up.’
‘At home?’
‘Well, we never talk about it but . . . it’s never been an issue. It’s just a thing. I don’t know. It’s one of those things you just have to accept.’
‘Haven’t your doctors ever talked to you about operations or medication?’
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