A Response to the NICE Menopause Consultation (Plus! What happens when you get into bed with patriarchy)
Photo by Scott Graham on Unsplash
a welcome NEW CONSULTATION ON MENOPAUSE
The UK’s National Institute for Health and Care Excellence (NICE) has recently done a consultation (now closed) about the management of menopause. A bout of pre-Christmas Covid meant I wasn’t able to give it much time, so my comments refer solely to the Draft Guideline and the Equality Impact Assessment.
(1) The new menopause guideline USES GENDER INCLUSIVE LANGUAGE!
The phrase ‘trans men and non-binary people registered female at birth’ appears on 12 pages. ‘Trans men’ and ‘non-binary’ and around 42 times each in the Draft Guideline. (There was no gender inclusivity at all in the original 2015 document.)
This is a great start for normalising inclusion. Now we need both practitioner education and research to help put words into practice. It is harmful to exclude a population group from both menopause healthcare and from education about their own bodies. [Is this an example of therapeutic nihilism?]
GPs and gender clinics need to work together to create care pathways for trans and non-binary people who are in, or coming into, peri/menopause. An obvious example where more education and support is needed is when trans men experience Genitourinary Symptoms of Menopause and would be helped by topical vaginal oestrogen.
(2) But why use an infantilising WORD like ‘troublesome’?
This word was used at least 50 times in the document. (It’s better than ‘bothersome’, I guess.) As one responder pointed out, we need to refer to different levels of impact caused by menopause symptoms. How about a scale of, say, (1) ‘inconvenient’, (2) ‘worrying’, and (3) ‘incapacitating’? Or a numerical scale, like 1-3? (I’m aware that number scales are not perfect either, particularly in terms of neurodivergent experience.)
It feels unserious and part of the wider idea, fed by pronatalism and ageism, that anything that happens to someone who cannot bear children is somehow not very significant.
(3) THE ever present fear of Cancer
The word cancer appears on 59 of the 99 pages, often multiple times per page. I lost count but it’s mentioned well over 100, maybe even 200 times. Now, there are many very good reasons to be mindful of cancer, but remember how the Women’s Health Initiative study in the 2000s erroneously scared so many people away from taking, and prescribing, HRT?
Fear of cancer in the long term may cause a person in menopause to suffer unnecessarily in the short term. Using cancer to scare someone away from taking hormones, before you know anything of their health history - it still happens - is nothing less than gatekeeping (see further down).
Connectedly, the fear of cancer has often been used to scare Intersex people into having unnecessary surgeries, to retrospectively justify these surgeries, or to scare their parents into allowing them. (Pidgeon Pagonis’s memoir Nobody Needs to Know is worth reading on this.) I note the word Intersex does not appear in the main document, but is mentioned in the Equality Impact Assessment. The Intersex experience of menopause is another subject that needs far greater research and discussion.
(4) CBT (Cognitive behavioural therapy) - danger of gaslighting
The big new thing in this consultation is the idea that CBT (Cognitive Behavioural Therapy) could be offered to menopausal patients. There is some evidence that CBT has been beneficial for hot flushes and other symptoms.
The guideline states that ‘CBT is not a risky intervention’ but I disagree. As a therapist, I have long been aware of the concerns about how CBT has been implemented. It is usually short-term, so quicker and cheaper to research than longer-term therapies or medications, so therefore claims a greater evidence base. Some have benefited from it, and others harmed, and it seems unsuitable for some people when given as a standalone treatment.
Above all, the short-term nature of CBT means it can be used as a substitute for proper help, which makes it an individualised neoliberal sticking plaster for what are actually systemic top-down social ills. (Plus, the background work culture for mental health practitioners often replicates this.)
Where menopause is concerned, the red flag here for me is that encouraging someone struggling with menopause to try CBT is actually a way of saying ‘It’s all in your head, dear.’ Ultimately I fear that some clinicians will enforce its use by saying someone can only access hormones if they have had a course of CBT first. Is this a worst case scenario? I hope so.
Because if this should happen, how will the system tackle the CBT practitioner waiting lists? I imagine a desperate patient, who is struggling with night sweats, insomnia, anxiety and/or fatigue, being told to queue up for CBT - for what, six months to a year? - before being ‘allowed’ to come back and ask for hormones. Actively dystopian? I am not so sure.
We know that hormones are not the answer for everyone. Some do not wish for them, some don’t find them helpful, and others cannot take them. Hormones cannot fix the intersectional harms caused by getting older in a misogynist and ageist society. But everyone has the right to be offered them.
(5) the perils of RUNNING to patriarchy FOR HELP
In brief: You can draw a direct line between high-profile transphobia and the substitution of CBT for Menopause Hormone Therapy.
Think this is a stretch? Let’s take a look.
Cast your mind back to early 2023 when the UK Parliament rejected a number of major proposals regarding the rights of menopausal people in the workplace. After all that work, it was incredibly disappointing but not really surprising. As I wrote back then, ‘...if you appeal to patriarchy to save you it will play you for a while and then smash you to the ground.’ And here we are again.
In the UK, you may have already experienced gatekeeping if you have ever tried to get support with a hormonal transition - whether relating to gender affirmation or to menopause. For example, if you are a cis woman seeking testosterone for menopause you may have to fight for it - even though bodies with ovarian systems literally make it.
You will also have noticed that we have had several years of HRT shortages. For some people, frantic phoning around pharmacies for the right brand has become normalised. Incidentally, this is also the experience of people who are desperately seeking their ADHD medication. People with ADHD are being increasingly gaslighted in the media and told they are part of a fashion or trend - can you see the connection? While I have no doubt that Brexit has contributed to all this, I can’t help joining the dots.
Patriarchy knows that enforcing a strict essentialist gender binary, by generating both scarcity fears and a sense of threat, is an effective vote catcher (see also nationalism). Look at what has already been happening to trans rights in the US - whatever happens over there will come here, where things are already bad enough.
OK, so let’s say you are a cis woman in age-related menopause and you are publicly anti-trans. You throw yourself at the feet of patriarchy, begging it to save you from those terrible people who are spoiling your toilet experience and corrupting your children. You know what’s going to happen, don’t you? Patriarchy will thank you for your support - and then it will turn on you.
To be even clearer, if you wish for gender expansive members of the population to be denied access to what they need, which for some people is hormones so that they may transition (as well as basic human rights), don’t be surprised when patriarchy, bolstered by ageism and misogyny, does the same to you.
It starts with offering CBT for menopause, but where does it end?