When the doctor walked in and immediately asked me about my prostate during an appointment I’d made about an issue entirely unrelated to my gender, I knew things weren’t going to go well.
“I don’t have any reproductive organs,” I answered.
He fumbled with his clipboard. “Oh.”
We tried to recover a neutral mood in the room, but the visit remained tense and awkward. I couldn’t feel fully comfortable with him.
Trans patients face polar struggles in seeking medical treatment: We need doctors to diagnose us with gender dysphoria in order to receive trans-related treatments that align us with who we are, while general practitioners express total ignorance of our basic health needs and mishandle our gender identities and bodies instead. Close medical scrutiny, which is supremely important in making effective individualized care possible, is still taxing, complex, and draining to navigate.
I am a trans boy with chronic back and neck pain that has worsened over time. After my ability to drive to and stand at work deteriorated, I left my apartment, friends, and job to move across the country so my mom could help with my care as I sought a diagnosis. With so much lost and even more at stake, it was especially frustrating when doctors focused on the fact that I’m trans instead of my symptoms—like in the visit where I had to explain my lack of reproductive organs.
By the time I turned to the healthcare abyss in search of answers, I was a veteran of the system, having undergone hormone replacement therapy and two surgeries over the prior four years. Navigating my medical transition was exhausting, expensive, and complicated, but the surgeons, therapists, and physicians I saw specialized in trans-related treatment. They gave me the naïve belief that, with decent insurance, emotional support, and the willingness to complete a thousand forms, I could receive adequate care.
But needing non-trans-related care meant dealing with doctors who had little to no experience treating trans patients, who often conflated my gender with my wider health. Over the span of two years, many medical professionals immediately questioned if my gender-confirming surgeries were responsible for my pain. One doctor read my chart and cross-examined me about my genetic material. “So, if we were to test your DNA and chromosomes, you’d actually be a woman?” she interrogated. A rheumatologist asked me if I believed in God, which apparently would give me the strength I needed to—I don’t know—survive this appointment? I was sometimes asked when I first “felt” I was trans, and whether I was considering further surgeries.
After ruling out these concerns, providers brushed me off with a painkiller prescription and the recommendation to see a psychiatrist. I did, and she helped me understand and handle the toxic cycle of pain and stress familiar to many chronically ill folks. But my pain never went away. I wondered if doctors’ suggestions for me to “see a psychiatrist” were informed not only by my symptoms or behavior, but by my previous medical record of gender-related therapy.
I underwent countless appointments, misdiagnoses, and stressful tests in search of a cause: MRIs, CT scans, X-Rays, corticosteroid shots, antibiotics, four rounds of physical therapy. Nearly a year after the onset of my pain, I remarked to one physician’s assistant that doctors didn’t seem to believe I had a legitimate health problem and asked inappropriate questions about my gender. The PA told me straight out, firmly but sympathetically: “You’re young, transgender, and have a mental health diagnosis,” he said, referring to the gender dysphoria diagnosis I’d needed in order to transition. “Most doctors will think you just want drugs or have psychological problems.”
His candor was shocking. Throughout six years of working with doctors during my transition, I jumped through hoops to prove my mental stability in order to access the gender-confirming procedures I needed. Yet, regarding my chronic pain, the body I’d worked so hard to align with was used against me—evidence that I was prone to “psychological problems.”
Doctors have always been trans people’s biggest allies and biggest antagonists. Doctors made it possible for trans people to access new levels of harmony in their own bodies, and doctors helped dispel the stigma that trans people are inherently mentally disturbed. But doctors were also the very people who determined that being trans was a mental illness in the first place.
In the 1940s and 50s, during the early years of trans medicine in the U.S., doctors instituted a system of gatekeeping to sort the “real” trans people from the rest. They prized trans folks’ ability to “pass“—to move through society undetected as trans—and patients needed to play the game if they wanted approval for treatment. In Julia Serano’s queer classic Whipping Girl, she describes how trans women learned to “show up for their psychotherapy appointments wearing dresses and makeup,” stick to a narrative about being “trapped” in a man’s body, and deny being sexually active.
The functions and language of this system of control linger: When I had top surgery in 2012, my insurance listed my diagnosis as “true transsexual,” a term from endocrinologist Harry Benjamin’s 1966 “Sexual Orientation Scale.” Just this May, the world’s two gold-standard diagnostic tools, the World Health Organization’s International Classification of Diseases (ICD) and the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), de-categorized transness as a mental illness. Until then, trans patients were labeled as suffering from “gender identity disorder” (GID). The new ICD terminology is “gender incongruence,” and the DSM replaced GID with “gender dysphoria.”
Susan Stryker highlighted medical science’s power to “regulate” society in Transgender History , writing , “Medical practitioners and institutions have the social power to determine what is considered sick or healthy, normal or pathological… to transform potentially neutral forms of human difference into unjust and oppressive social hierarchies.” Still today, doctors play god with trans bodies, deciding who does and doesn’t deserve access to care—as I found out, this time around, in my experiences with general practitioners.
The doctor who cluelessly asked about my prostate was, ironically, the doctor who gave me the best advice about subjecting myself to doctor after doctor: “You have to prepare yourself to go through this for a long time.” By “this,” I think he meant not only physical discomfort, but the very process of seeking care itself, of dealing with the unpleasant assumptions, of being profoundly disappointed and dismissed.
I finally received a diagnosis when a friend recommended a rheumatologist close to home. His office didn’t take insurance, but I was desperate. The doctor himself actually received me on time from the waiting room—a first. He went over my trans-related treatment briefly, but spent nearly all of the appointment directly addressing the actual symptoms I was there to discuss. He determined I have undifferentiated spondyloarthritis, an auto-inflammatory disease that affects the spine, joints, and where tendons and ligaments attach to bone. I will most likely struggle with pain for my entire life, although medications and physical therapy can help. I felt dejected, but grateful to regain a modicum of understanding and control. And I’d found a doctor who made me feel believed.
This should not have taken as long as it did, especially given the amount of specialists I saw. 2016 data suggests around 1.4 million people in the U.S. identify as trans, which means we can bust once and for all the myth that the average American (and doctor) has not met a transgender person. Trans healthcare is no longer a niche business, and with unprecedented media visibility for trans folks this decade, a lack of basic knowledge about trans identities and healthcare needs is more inexcusable than ever.
My doctor didn’t specialize in trans healthcare, but he could provide tailored care for my specific body with kindness and respect. I’m certain my positive experience at this practice was directly correlated to the fact that I paid out of pocket for the care, a more-lucrative exchange for doctors which subsequently incentivizes a more hands-on approach, but there are things all medical care providers can do to educate themselves and make trans patients feel more welcome.
We can’t fix the outdated, for-profit healthcare system overnight, but we can start by advocating for the humanization of disenfranchised patient populations. Practices should prioritize having at least one doctor with some experience treating trans people and have all of their staff take full advantage of free resources about how to offer respectful and effective care, like the University of San Francisco’s “Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People.” Healthcare professionals with an online presence can openly list their trans-friendliness in order to help clients find them (and avoid doctors who aren’t aware or respectful of trans health). Even seemingly small things, like “safe space” stickers and LGBTQ health brochures are always appreciated. It is an anomaly for anyone to have reliable access to good healthcare in America, but for trans patients like me, especially ones seeking care for chronic issues, it’s, devastatingly, even rarer.
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Hey, Insurers and Employers: Put Up or Shut Up About Mental Health Support
It’s undeniably expensive to be sick in the United States. The U.S. population spends literal trillions on healthcare every year, paying into a system that hemorrhages money annually, and accruing a staggering, life-altering amount of medical debt in the process. Insurance (which, obviously, not everyone has) helps decrease the cost of being and staying alive,…
It’s undeniably expensive to be sick in the United States. The U.S. population spends literal trillions on healthcare every year, paying into a system that hemorrhages money annually, and accruing a staggering, life-altering amount of medical debt in the process. Insurance (which, obviously, not everyone has) helps decrease the cost of being and staying alive, but often falls short, especially when it comes to out-of-network care. According to a new study, the Americans who are most often let down by insurance providers are those who seek out behavioral treatments for substance use disorders, despite a cultural push towards greater accessibility for mental health services.
Researchers at Ohio State University compared the healthcare spending of more than 3 million patients with either mental health issues (like depression and anxiety), drug use disorders, or alcohol use disorder to the spending of patients with either diabetes or congestive heart failure. The analysis found that mental health patients who sought behavioral treatments, particularly those with substance use disorders, spent more money out of pocket and received more out-of-network care than their counterparts with chronic physical ailments, even though the mental health patients spent less money on healthcare overall. Those with drug or alcohol use disorder ended up spending over $1,000 more than patients with diabetes, which is especially striking given the fact that diabetes patients are literally dying because they can’t afford insulin. Lead author Wendy Yi Xu attributed the pay disparity to insurance participation rates for mental health care providers. “Much of this disparity is likely due to the limited availability of behavioral health care providers in insurance plans—the participation rates by these providers are generally low, a problem that is fueled in large part by low reimbursement rates for clinicians, including psychiatrists,” Xu said in a press release. It’s a blind spot that feels pretty related to reports predicting millennials will die from mental health issues at a rate that’s disproportionate from the rest of the American population.
The care deficiency when it comes to mental illness, particularly substance use disorders, makes a morbid amount of sense when you consider the way people with substance use issues are treated in every other realm of American life. One in every 16 Americans (around 20.3 million people) has a substance use disorder, and a little less than half of those people (around 9.2 million) have a co-occuring mental health disorder, according to the 2018 National Survey on Drug Use and Health. But the misconception that these patients are to blame for their addiction issues persists, as does the stigma surrounding substance use disorders. There’s no easy fix under our current, inept healthcare system, but in the meantime it’s worth considering and being compassionate how and why other people are suffering.
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Is Sex Addiction Real?
Taylor, a 31-year-old in Los Angeles who asked that only her first name be used for privacy, started having casual sex several times a week in college. Her friends warned her she could be a sex addict. At age 21, she was a victim of revenge porn, which her therapist considered evidence that her friends’…
Taylor, a 31-year-old in Los Angeles who asked that only her first name be used for privacy, started having casual sex several times a week in college. Her friends warned her she could be a sex addict. At age 21, she was a victim of revenge porn, which her therapist considered evidence that her friends’ sex addiction theory had merit. “I thought it was all my fault,” she said. “That’s when I surrendered and accepted the ‘diagnosis’ of sex and love addict.”
For four years, Taylor attended volunteer-run Sex and Love Addicts Anonymous (SLAA) meetings, which follow the 12-step model of Alcoholics Anonymous. Members suggested she had repressed childhood sexual trauma and urged her to be celibate for a year. Once she’d made it nine months, she followed the other women in the group’s example and committed to only having sex within monogamous relationships. Whenever she felt desire, she said, “I berated myself and dragged myself to a meeting in fear of falling back into ‘old habits.’ I felt like a zombie.” Over time, Taylor wondered why she was being encouraged to think of sex like a disease. At meetings, she asked, “Who decides how much sex is too much? How do we know if we’re addicts?”
After receiving unsatisfying responses, Taylor saw a sex therapist. “Is it possible that you’re not a sex addict, and maybe you’re just a woman who enjoys sex in a society that shames women for enjoying sex?” he asked. She cried with relief on his couch.
Sex addiction has never been a formal diagnosis. Though treatment centers and books like Patrick Carnes’s 1983 Out of the Shadows: Understanding Sexual Addiction have popularized the term, the mental health field is increasingly critical of it, based on research suggesting that sex does not affect the brain like an addictive substance. A 2016 study by sex researcher Nicole Prause in PLOS One, for example, found that people who engaged in risky sexual behaviors were more sensitive to genital stimulation, not desensitized, as the sex “addiction” model would predict.
The American Psychiatric Association repeatedly rejects proposals to add sex addiction or “hypersexual disorder” to the Diagnostic and Statistical Manual. In the 2018 edition of the International Classification of Diseases, the World Health Organization also rejected the label of sex addiction and instead included “compulsive sexual behavior disorder.” Many psychologists favor the latter label because it describes a behavioral pattern, not an addiction, and focuses on treating the underlying issues rather than directly changing sexual behavior itself.
Before he was trained as a sex therapist, psychotherapist Joe Kort adopted a sex addiction treatment model due to sex-negative cultural messages he’d received earlier in his life and career. But as he saw this approach repeatedly fail, he abandoned it. “The training is loaded with addiction and trauma information and education, but not sexuality,” he said. Kort feels the term is over-applied to people simply because they enjoy sex without emotional attachment. “The sex addiction therapist misunderstands sexual health and imposes their own bias and moral beliefs onto what could be completely natural for the client,” he said.
LGBTQ people may be more frequently mislabeled as sex addicts, says Prause. A 2014 review in Current Sexual Health Reports found a lack of scientific evidence for porn addiction—which is often studied for sex addiction research because it’s easier to show people images of sex than to sexually stimulate them—and pointed out that a disproportionate number of those who report it are LGBTQ people with religious conflicts. “Assessments claiming to help diagnose ‘sex addiction’ are well-replicated to discriminate against gay men,” said Prause. “Questionnaires identify more gay men as having a problem than is statistically reasonable. I think the overrepresentation of homosexual men in sex addiction centers is strong evidence that the diagnosis is primarily used for social control of sexuality, rather than treating any actual disease that should affect all men equally.”
Sex workers are also pathologized. Daniella Valenti, a 32-year-old legal sex worker in Hawaii and Nevada, was put into therapy by an anti-trafficking program and diagnosed with sex addiction. “Sex is my job, and I am super safe with it. I’m not addicted to anything, and I’m not a danger to myself or anyone else. I don’t display any type of compulsive behavior,” she said. “I think my psychologist was judging me for enjoying sex work and labeling it as a disorder because it’s a reality he didn’t want to accept.”
Prause said issues involving sexual behavior should be addressed individually, rather than grouped together as an addiction. “If you are failing to consistently use condoms when you should, there are excellent empirically supported interventions to improve condom use,” she said. “If you are engaging in sex outside your monogamy agreement with a partner, there are excellent empirically supported interventions to treat infidelity that include risk reduction. If you are having sex to deal with depression, there are dozens of excellent empirically supported treatments for depression.”
Nevertheless, some women believe in the value of the sex addiction model. Erica Garza, author of Getting Off: One Woman’s Journey Through Sex and Porn Addiction, said SLAA meetings—which prompted her to give up sex, porn, and masturbation for various periods of time—and other sex addiction treatments helped her replace her compulsions with healthier behavioral patterns. “I’m less likely to seek out the shame-and-pleasure combo I was hooked on,” she said. “I have revised my learned beliefs that sex is something dirty and bad […] so that I can engage in healthy, honest, safe, yet still open-minded sex.”
Alexandra Katehakis, sex therapist and Clinical Director for the Center for Healthy Sex, argued that sex addiction is real, pointing to a study in JAMA Network Open showing that 8.6 percent of Americans report “clinically relevant levels of distress and/or impairment associated with difficulty controlling sexual feelings, urges, and behaviors.” She isn’t against alternative labels like compulsive sexual behavior, but she believes they are separate from sex addiction. Sex addiction is characterized by feelings of withdrawal when someone ceases certain sexual behaviors, desensitization, and always seeking the next “high,” according to her approach, while sexual compulsivity is more about problems with impulse control.
If someone thinks they’re a sex addict because of a conservative upbringing or gender norms, Katehakis won’t treat them for sex addiction. But if their sexual behavior causes harm or feels out of control to them, she will use cognitive behavioral therapy to help them stop whatever behaviors they feel are destructive. “Both sides have to be careful about either minimizing the problem, or making something into a problem that’s not really a problem,” she said.
Today, Taylor has a happy sex life that has included an open relationship and multiple casual partners. The solution to using sex to cope with anxiety and depression was not to have less sex, but to begin seeing a therapist and learning to communicate with others about her mental health and reduce shame around sex. “My relationship to sex is beautiful because it’s so authentic, but most important, because it’s mine,” she said. “I have the kind of sex that I want to have, with men that I want to have sex with, as little or as often as I please, and I don’t see any need to explain it to anyone who doesn’t understand.”
‘Detox Pearls’ Absolutely Do Not Belong in Anyone’s Vagina
The idea that vaginas need to be detoxed by some external force is as persistent as it is wrong. Doctors, journalists, and sexual health experts have repeatedly debunked the vaginal detox racket, essentially screaming from the hilltops that the vagina is a “self-cleaning oven,” meaning there are natural, biological mechanisms to keep it pH balanced…
The idea that vaginas need to be detoxed by some external force is as persistent as it is wrong. Doctors, journalists, and sexual health experts have repeatedly debunked the vaginal detox racket, essentially screaming from the hilltops that the vagina is a “self-cleaning oven,” meaning there are natural, biological mechanisms to keep it pH balanced and and in tip-top condition and healthy. But companies that prey on the insecurities of vagina-owners continue to peddle douches, vaginal steaming, “purifying” (and porous, aka bacteria-friendly) crystal and jade dildos, scented washes for people to use… all in the pursuit of a “tolerable” vagina, I guess. But one of the sketchiest entries into the vaginal “health” canon has just been banned in Canada as a result of a CBC Marketplace investigation. The makers of Goddess Vaginal Detox Pearls were banned from selling their products by Health Canada, the country’s public health department, after making particularly noxious claims about their ability to help users heal from sexual trauma, among other health-related “benefits.”
Vaginal detox pearls, small herbal balls inserted into the vagina with an applicator and removed up to 48 hours later, are insidious because they’re presented as a holistic, natural solution. Dr. Jen Gunter, noted evangeliser of keeping all this trash out of your vagina, called out the logic behind vaginal detoxing in this fashion in an interview with CBC: “You don’t need to detox … anything at all. There’s nothing in your reproductive tract that needs to be detoxed. Your whole body, you’ve got liver and kidneys — they take care of that.” Gunter also called the claim that Goddess Vaginal Detox Pearls could “cleanse” past sexual trauma “predatory,” “offensive,” and “harmful,” which sounds about right. “The idea that there is any kind of remnant in your vagina from sexual trauma is simply not true,” she said. The pearls also contain borneol, an ingredient utilized in some traditional Chinese medicine practices and flagged by Health Canada as toxic back in 2002. Exposure to borneol may cause skin and eye irritation, nausea and dizziness in small doses, and restlessness, irritability, and seizures in larger amounts, according to the New Jersey Department of Health and Senior Services.
It’s great that Canadian consumers won’t have to deal with the toxicity of this particular product anymore. But the mere existence of the vaginal detox market makes it clear that there’s still an overarching ignorance when it comes to gynecological health that’s a lot more difficult to address. Basically, a good rule of thumb is if a product is marketed to make vaginas smell, taste (ugh), or look cleaner or better, proceed with extreme caution. Barring some kind of medical condition like an STI, a fungal overgrowth, or a bacterial infection, everything necessary for maintaining vaginal health is already available in-house, no accessories required.
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