Nonbinary Femme and other Biases

Coming out, even to myself ,as a nonbinary femme has been harder than I expected. I keep waiting for someone to tell me I somehow dont “qualify.” Hell, I question my self on a regular basis, why would I expect less from anyone else?

Many years ago, in the late 90s in Toronto my soon to be best friend Aimée and I would meet for “femme coffee” once a week and talk about the politics, nuances, and intersections of femme identity. I was somewhere between 21-25 and this was all new to me. Pieces fell into place in my psyche connecting me to the this queer community. I was becoming a part of.

Fast forward at least 20 years. Words like genderqueer, nonbinary and ace have flourished in an ever expanding garden of sexual and gender personal affiliations. They/them pronouns are discussed on NPR and the spectrum of trans identity is in media, politics, elementary school and everywhere else. I am in medical school at 45 years old, advancing my personal and professional education in sex and gender health. I am married to an androgynous millennial and she says one night “Femme is not a gender. You have no gender identity.” I was so hurt and angry and erased. I fumbled through my 90s gender books trying to find some proof that I existed; i had no name for who I was.

I folded in on myself at that moment. I knew that I had a complex gender and I knew I existed but I didnt have the words to speak up with.

Current time, or 2020. I was in relationship with another millennial, spending time with their all-trans friend group many of who were GenZ. I am jealous that these humans were able to grow up in a less gendered era than I was and had the freedom to know at 15, or 19, that their internal understanding of their personal gender *as well as their visible identity* could be whatever they wanted it to be. I know in my heart that if I were 17, or 27 instead of 47 I would certainly identify as nonbinary. And maybe I would have pushed my visible boundaries further than I will now.

One friend in particular was classically femme-presenting and identified as nonbinary trans. I repeatedly used she pronouns , probably 50% of the time, as their image in my mind was so deeply ingrained as one pronoun. It felt terrible every time – for everyone involved. I changed to using they/them pronouns for everyone for about 6 weeks until I got used to it as a habit in my mouth and brain. Uncoupling the phenotypical appearance of face/hair/clothing presentation from associated pronouns was very hard work for me. I could not figure out why I was struggling so much: How could i not get this right? What Was Wrong With Me. (spoiler alert: I was struggling with my own gender identity and associated femme biases.)

I wish this friend group and I had been able to have safe gender discussions. I wanted to learn from their growing up experiences as they were obviously very different than mine. I was in a deep struggle with myself as an older AFAB person allowing myself to invoke a nonbinary truth while still presenting as the lesbian femme I have always been. Eventually the words slid into place: I finally had language for a gender that fit my folded up erased insides. I harmed this friend by not seeing their gender in the same way I was unseen. I perpetrated that bias. I am truly sorry for that.

I dont consider myself trans. Cis does not fit comfortably either. For me, nonbinary means that – actually off the binary. That includes cis and trans, masculine and feminine, as well as good/bad, right/wrong, in/out, victim/perpetrator, love/hate. Unpacking the binary has been an enormous relief on multiple levels. I have a gender euphoria at deeply knowing that I am more than people assume I am from my face. I also still struggle with the words and explanations around what gives me the right to feel like I have a different gender than, for example, my also pierced and tattooed, also radical, also queer femme friends that dont identify as nonbinary.

I have had an image of gender as a 3D nebula with us all bouncing around inside moving through our beautiful multifaceted lives as our original and authentic selves. A few people stick to one pole or another; most of us are all over and in between at any one time. I am grateful for evolving language that imperfectly and accurately outlines a frame for my complex gender despite how you may read my face, my clothes/hair and my genitals. I still feel pretty unsure of the language and philosophy to discuss this evolution though. I have no critical theory or objective framework to reference when it comes to being a nonbinary femme or themme.

I welcome communication from nonbinary femmes out there of any age. Lets have coffee and talk (missmasina@gmail.com).

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We Must Speak Up; We Must Speak OUT

I add my voice to the growing number of health care professionals and medical societies condemning the newest human rights violation by the Trump administration against our transgender community. The urgency of this issue is paramount! To deny health care rights during a global pandemic is both inhumane and absurd. Our trans patients and colleagues are already vulnerable due to the health disparities inherent in our system and biases from healthcare practitioners. Not only are out trans patients affected but all patients who fall under any part of our QUEER community in the past, present or future are at risk, making it even more difficult to be open and honest wit our health care providers.

Gender based and transphobic violence includes racism, murder and hate crime. It disproportionately affects black trans lives, especially black trans women. In the midst of the Black Lives Matter uprising and Covid19 the reversal of transgender health protections puts an immediate threat to black trans patients, and all trans BIPOC patients who identify as gender neutral or non-binary.

This recent action should be met with a call to arms from all medical professionals, including attending physicians, resident, medical students, nurses, APPs and staff. We must to do our best to provide trauma-based compassionate medicine and NEVER deny care for transgender patients nor any LGBTQ patients. The personal views of providers in any setting (outpatient, clinic, hospital or otherwise) must not be allowed to interfere with the right to health care. The recent COVID pop-up hospital in a Brooklyn park that denied transgender and LGBT care is an atrocious example of what the Trump administration is suggesting here.

There is a dearth of education for healthcare professionals from the earliest academic levels. Health disparities, intersectional oppression, and implicit biases of language, systems and structures have to be called out and addressed to stop this cycle of ignorance. Silence is clearly violence, and we cannot in good faith stay silent and allow conservative politicians to sacrifice health protection in the names of transphobia and racism – not now or ever again.

  • Kaiser Kabir OMS4 Lincoln Memorial University
  • Masina Wright, DO PGY1 University of New Mexico Hospital, Internal Medicine
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Well Hello

Its been a long time since I have posted from the medical world of Dr Wright. I am now in Albuquerque New Mexico, Land of Enchantment and Liver Disease. So many dying ciswomen in their 30s suffering of liver failure here, and transwomen too. I have been pleased with the cultural competency for trans and non binary folk in this city so far!  My hospital’s respect for the transfolk and their pronouns I have seen come through the door at UNMH has been heartwarming. The work is never done, but the foundations are in place thanks to those who have done this work before me.

There are so many things I could write about  it feels overwhelming. Like

  • how does one deal with anxiety in a productive way that does not encourage substance use?
  • how much does good food really influence health
  • and
  • the value of death: vs life. what is a life well lived
  • what is a good death

As an internal medicine doctor I know part of my life is to facilitate death. This is the job of the warrior; and as a hospitalist  I tend to those as they fight in their own particular battlefield . I have been privileged to sit with Death, and she is a  mistress no one wants to see. And yet, often such a sweet gift.

I wish that hospital medicine could embrace healing meditations and buddhist lectures. Imagine folks watching these daily in their hospital beds instead of cooking shows and NCIS? These are a few of my faves:

Anything by Pema Chodron as well: I look for ones longer than 45 minutes

I certainly haven’t mastered the art of effectively handling my own stress without turning to food, or alcohol, or any thing that distracts me from the what-feels-like intolerable levels of emotion building up inside. So, I have empathy for my patients that use this coping mechanism to get through their life. What is the difference that has me as a privileged white woman in my 40s still strong and healthy foundationally, vs their 30 year old bodies that are broken down by alcohol? Genetics is certainly a piece of it. The Navajo, Zuni and Pueblo folks here have what must be a genetic succeptibility to liver failure secondary to alcohol use disorder. They are too sick, too young, and too many of them to have it be environment alone.

I cant help but feel these women are carrying the trauma of generations of dominance, trauma and oppression and it is manifesting as this alcohol sickness – a genetic trait passed from white rapists to their progeny and concentrated in generation after generation. Tie that to poverty, a lack of fresh fruits and vegetables, and ongoing systemic depression and it makes complete sense that we have these women dying, daily, in our hospital.

It is a helpless feeling, this system oppression and individual illness. This is certainly a piece of the burnout of becoming a physician. We do our best to hold together the pieces of survival for each person, holding the hope, while also titrating the reality of recovery.

As a person very new to this state I have very little working knowledge of the cultural climate of health care here and even what resources are available. As a new resident and hospital based physician, I have basically no time to investigate and advocate for this community at the ground level. All I can do is hold the space for the sickest of the sick and even in that I don’t have time to be present for their stories or their traumas.

Dandelion and Milk thistle, turmeric are not native botanicals to this part of the country, so I doubt they are used in traditional medicines?  I wonder how much early liver protection with these herbs, as well as anger management, trauma based care, and other integrative therapies could be used to protect and heal the liver in the teens and twenties for these folks? My acupuncturist said New Mexico is the land of wind, and heat, both properties of the liver meridian. This would argue for an environmental component to the imbalance as well. Food, Water, Emotions, Genetics, Trauma, Environment, Substances – so many nuances to health and to disease. And I, as a doctor, am depressed with the minimal amount of time I have to explore these facets with each individual that may lend insight into prevention before these women end up in our hospital beds.

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A Habit is Harder to Break than a Heart

Ugh. New Years Resolutions. Worst idea ever! And yet – I had a tough end of 2018 personally so I decided to make some resolutions in an effort to bring structure and more wellness to my life.

Well, it is 13 days in and I have already failed all of my official resolutions. In fact I failed my first one in the first two days of the year:

1. spend less time on my phone, especially in the company of people I love

Excuses are bountiful. However, If you are in the same boat as me with lofty goals and a complex life, I encourage you to think about resolutions as a year long goal, not something to be abandonded by week 3. It could take even 3 years to build the structure that you need to support the foundation of your bigger dreams/resolutions like an art or writing studio and time to produce new work.

The Winter Solstice (12/21/18) is when we annually rekindle the spark of the year ahead. This tiny flame grows to a raging bonfire at Summer Solstice with our culling and tending and then dwindles down to the blue flames of Halloween and Nov-Embers. Then the cycle begins anew with the next Winter Solstice.

If you looked at your resolutions as a fire you were to tend for a 12-36 month duration, would that change your approach? Your commitment to your Self or Visions?

I have things about my lifestyle I need to adjust, and those are built on deeply entrenched habits that function as crutches that allow me to perform in my hugely challenging day to day life. I cannot just pull the supports from my foundational Activities of Daily Living; I CAN build new supports/habits to relieve the not-so-functional structures.

Building a new wellness foundation takes a team or at the very least a multifaceted approach. I failed my New Years Resolutions the first week because I did not have my new structures in place to support them. I now see who and what I could rely on to make this reality functional, and this second week of the year I was 50% more successful in my goals.

What are your NYR? What changes do you need to make this happen?

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Notes from the Road: Buenos Aires WPATH

I am in beautiful Buenos Aires at my second World Professional Association for Transgender Health. My first was held in Amsterdam in 2016 when I was a fresh faced, just-finished first year medical student. Now, as a mid-fourth year student I am significantly more exhausted and disillusioned; I also have so much more doubt about choosing this field of medicine as my calling.

I like to tell the story that I returned to medical school to practice transgender health. Specifically, to be able to prescribe transitional hormones and participate in the insurance racket to reach more people. And that is part of the story. The root truth is I have been compelled to be a full scope physician for many reasons and transgender medicine gave me a focus because it was something I could not attain as the Naturopathic Doctor that I was before.

The last session I attended at the WPATH ARGENTINA conference was an incredible and inspired panel of Brazilian intellectuals speaking on depathologizing the transfeminine and deconstructing cisheteronormativity. Fran Demetrio, a transfeminine Brazilian professor was so passionate and eloquent in her discussion of injustice, oppression, systemic violence and the colonization of knowledge imported by biomedicine. She was being translated which made some of the discourse hard to fully comprehend and I wished WPATH had provided a professional translator for her because what she had to say was so profound and important and well thought out. She framed a paradigm that took the personal out of the conversation and raised it to a social construct and human justice level. In rough translation, she explained that not including the existential experience of trans voices in episystemic medical knowledge creates symbolic violence and perpetrates the colonialism of transgender relationships. This generates mental health violence and tramples the [transgender] patients knowledge. Considering and understanding this is essential to depatholgize the trans experience.

Despite the  multiple disparities that this population faces world wide, there is a slowly increasing body of trans identified physicians and health leaders in the field. However, to date  many of the people making the decisions about gender medicine are not differently-gendered themselves. Surely, this is problematic. The numbers of trans identified health care leaders is increasing by the year, and with groups like the Transgender Professional Association for Transgender Health, they are seeking greater control around the discourse of gender medicine and claiming their place as necessary voices in the didactic.  

The tensions between cis and trans leadership has created a simmering anger within this medical community. A socialist friend of mine shared that in activism in general there is a current trend towards challenging aggressions towards advocacy leaders in many different fields with a similar theme of  – who has the power to speak and represent the cause?

I was personally attacked in this rising conflict this year when I created a transgender health elective as a third year medical student for global medical students to supplement core medical school curriculum. A variety of trans and nonbinary people on social media threatened to create a petition against the course as it does not have a transgender identified course leader and there were multiple flamings on Facebook. I personally received several vitriolic emails from different people about the course, its content, and my leadership. I was privileged to have a team of (cis and transgender) people who have been in the field for a long time holding leadership positions to assist me in creating online and email responses that were balanced, appealed to reason, and illustrated the many ways the course seeks to uphold and respect the “nothing about us without us” principle while promoting evidence based foundational medicine.

I brought up this conflict between cis and trans leadership in the didactic of transgender medicine again at one of the ethics seminars at WPATH, where leadership and authority privilege was being discussed. Unfortunately, I was emotional in my questioning of the ethics behind attacking ally’s and advocates, as I am still deeply shaken by this experience. The response from one of the panelists was that when working as a non trans person with the gender diverse community there is so much anger one must simply expect to be attacked and be ok with that.

I am a person who has been excavating emotional violence in my personal life and creating real boundaries to protect myself for the first time. I don’t think I can intentionally choose a career were the population I am exhausting myself to serve reserves the right to be emotionally violent towards me indiscriminately because of their experience of violence. That is like saying that my mother has the right to be violent towards me in any way she sees fit because of the abuse she and her mother suffered. No.

Again.

not  including the existential experience of trans voices in episystemic medical knowledge creates symbolic violence and perpetrates the colonialism of transgender relationships. This generates mental health violence and tramples the patients knowledge. Considering and understanding this is essential to  depatholgize the trans experience. “

Dr. Demetrio’s message ultimately lifted my perspective of the conflict to a healing systems approach. With this in mind, I am still recalibrating my commitment to trans health as a specialized field of medicine, while intentionally making room for the many trans identified health care leaders. As a nontrans woman and a white queer/lesbian, I devote the next phase of my medical education to the foundations of internal medicine as well as lesbian health, vaginal happiness, fertility, community health, and queer health issues like addiction and mental health. My view of women’s health includes trans and cis women, as does my passion for community wellness. I am confident that these past 11 years of studying transgender medicine and advocacy work will continue to inform the communities I serve, if in a less direct way.

I see now that when I claim my leadership vision within a paradigm that matches my own identity I can be stronger and more authentic.

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Gender Affirming Health Care: Top Ten Tips

This article was written for the American Medical Student Association journal The New Physician October 2017. The original can be found at this link: http://mydigitalpublication.com/publication/?i=445109&utm_source=webtoc&utm_medium=referral&utm_campaign=O17#{“issue_id”:445109,”page”:1}. Volume 66, Number 5.

Picture this: it’s your second day of practice. You graduated medical school, made it into a residency, and now it’s time to be a doctor …. In walks your third patient of the day – medium height, medium build, medium length black hair, charming but shy face and awkward smile and – your quick-fire practiced analysis stops there – frozen, you can’t tell if this person is a girl or a boy. You glance at your paperwork. First Name: Robin. Last Name: Also Unhelpful. The person is talking in a midrange tone, and you aren’t listening because you are frantically scanning their body to figure out what lies underneath the black tee-shirt and dark Levis. You look up at the persons face and see it start to close as they observe you floundering to see past their gender.

Transgender Medicine is a newly emerging subspecialty, but every health care professional is already seeing transgender patients. Trans people have always been a part of every culture worldwide; in the last ten years there has been a public blossoming of gender expression in social media, television, and probably your personal family or friend circle as well. Transgender people have come out as part of our modern society, and as physicians we need to be culturally and medically competent enough to provide good medicine for this community.

As of 2017, there are several epicenters of transgender medicine, research and scholarship worldwide. The Dutch are famous for their longitudinal body of evidence on transgender health, as they have been collecting research and academic scholarship on transition medicine within their socialized health care system for over 30 years. As such, they have a tried and true so-called “Dutch protocol” for male to female (MTF) and female to male (FTM) transitions that has been used as a template for most international Standards of Care.

The US has several gender specialty clinics that conduct research and offer high quality trans health care. These clinics and hospitals are also key players in this rapidly evolving area of medicine, surgery and research. The best known of these include:

  • Fenway Health Center in Boston
  • The Center for Transgender Medicine and Surgery at Mount Sinai in NYC
  • The Mazzoni Center in Philadelphia (which puts on the free Philadelphia Trans Health Conference annually)
  • The Center of Excellence for Transgender Health at UC San Francisco

For future and current physicians interested in Transgender Medicine as a specialty, the key areas for concentrated trans care are Family Medicine, Endocrinology, Psychiatry, Surgery/Urology and Pediatric Endocrinology. There is not yet a fellowship available in Transgender Adult or Pediatric Endocrinology (Coming Soon!) but the first fellowship in Transgender Surgery has been piloted this year at Mount Sinai in New York City.

Whether you want to dive into the depths of the transgender community and learn the intricacy of this rich and diverse community or not, as it was said before every physician will see trans people in their career. Take the time now to become familiar with the basics of transgender health literacy, for your professional integrity and your patients.

TOP 10 TIPS FOR BEING A TRANS FRIENDLY PHYSICIAN

DON’T GET HUNG UP ON IDENTIFYING GENDER IN THE FIRST 3 MINUTES. Gender and Sexuality Identity begin to develop at 2-3 years of age. Your patient has probably been trying to figure out their gender for a whole lot of years before they showed up in your office, so chances are their gender is more complicated than your 10 second evaluation. Once you notice you can’t confirm male or female specifically (spoiler alert: you may be wrong in your assessment) MOVE on with your objective assessment and Listen to what the person is saying.

THEY IS THE NEW SINGULAR PRONOUN: For some people, She doesn’t feel comfortable, but neither does He. Some people live in the space between male and female, and those definitive English pronouns can feel extremely uncomfortable. Being mis-gendered by pronouns is also surprisingly hurtful to trans people. “They” is a neutral pronoun that just feels more comfortable for some people. Why not use it? (Ps. Please don’t use the “it’s just not good grammar” argument because chances are your grammar isn’t perfect otherwise; and, while it may commonly be an English plural pronoun, Latin-based languages have pleural pronouns that can also be used in the formal You/singular.) Again, the use of “They” is really helpful to some people for communication purposes, so embrace it, try it on every day, and get used to it. In fact, it really comes in handy when referring to someone whose gender you can’t figure out, as in saying to your attending “I’m not sure what’s wrong, but they look really terrible, would you come take a look?”)

ACCEPT THAT SOME PEOPLE LIVE OUTSIDE THE LINES: Technically, the term is “non-binary” for people that don’t neatly fit into the sex-gender binary of male / female. This is a complex spectrum of identities that can be any shape or form and have any meaning for an individual. The non-binary space can be intentional with hormone use, or how people are born or mature. For people who have always fit within the binary, it can be hard to remember that other people LIKE THE WAY THEY ARE. It isn’t our job as physicians to try and get them to fit within a specific box. For other people, the non-binary identity may be a stepping point, a transitional space, or something they struggle with. As always it is simply our job as health care providers to create a safe place where people can talk about their health care needs, and help them get these needs met.

STATISTICS DON’T LIE: Not a lot is known about trans health care seeking behavior from an evidence based perspective, but from my community I know that many of my gender minority friends avoid health care due to bad medical experiences being misgendered, disrespected, or worse assaulted/insulted or denied care. From the research that does exist, the statistics are alarming. Dr. Angela Carter, a transgender physician from Portland, Oregon writes “One in 5 transgender people have been turned away from healthcare because of their gender, and an estimated 30% have avoided seeking care due to fear of discrimination. Reports suggest that 50% of transgender people have had to teach their physician how to care for them; 24% of trans people have been verbally harassed while seeking care; and, 2% report an actual physical assault while trying to get care.Read more of her great Trans Health 101 article here: http://ndnr.com/endocrinology/transgender-healthcare/.

PAPERWORK: What is named, exists. If you have a box for Transgender or better yet Male to Female, Female to Male, and Gender Nonbinary on your intake form or embedded in your EMR next to Male and Female, you can have that helpful self-identifying information at the first encounter. At the same time, this improves the patients visit experience, offering a named identity and acceptance from the first encounter. Make sure your staff are educated in trans cultural competency as well. Include training elements like being compassionate and respectful with patients who may have gender incongruent birth names, insurance navigation, and associated pronoun use.

EMRs – UN/NECESSARY EVILS: It will take a long time and many years of advocacy work before most hospitals EMRs are updated to contain alternate gender identities; however, having staff who are trained in ways to communicate about gender differences can soften the experience for the person who is in an acutely ill and vulnerable state needing medical care. For example, triage personnel (and med students!) could say “”So, I know this may be a difficult question right now but what is your preferred pronoun and what is your is gender designation on your health insurance?” This non-judgemental approach leaves space for the person to give an answer without an explanation and conveys compassion in a business-like open-ended manner.

DON’T JUDGE A BOOK BY ITS COVER: Many trans people “pass” for their chosen gender completely. We need to be mentally and medically prepared for providing effective and competent health care to people who physically inhabit bodies that are hormonally and anatomically complex. Doing this work AND exploring your own personal, moral, or religious complexities of feelings about trans gender and identity needs to be done BEFORE that patient walks in your door needing your professional skills as a doctor, not your human opinions.

KNOW YOUR RESOURCES: The World Professional Health Association (wpath.org) has been the guiding force and academic collective of transgender scholarship for the past 30+ years. WPATH has been at the heart of the conservation and documentation of the protocols used for transitional medicine. There is a published a Standards of Care (version 7.0) that is available online and in print. University of San Francisco also has a superior online learning center with everything you need to know to start basic primary trans care including evidence based protocols. http://transhealth.ucsf.edu/trans?page=guidelines-home. Fenway Health is the east coast online epicenter for trans health resources and reading and has great free training webinars http://fenwayhealth.org/care/medical/transgender-health/. Take an afternoon and familiarize yourself with these sites, bookmark them, and pass them on.

KNOW MORE RESOURCES: No one should have to travel beyond state lines to get competent medical care. As with most kinds of medicine, having a grasp of your local resources is essential, especially for primary care docs who just can’t do everything (contrary to popular belief.) Know who is providing competent transgender primary care and endocrinology for adults and for children in your area, who has experience with transition hormone therapy, where to refer for respectful electrolysis and other cosmetic procedures, and who is offering the basic surgeries like mastectomy in your part of the world is a great way to provide your gender minority patients with access and resources. If there isn’t anyone offering these services, consider taking a WPATH certification course and becoming that person.

DON’T BE AN ASSH**E: The best thing to do when you make a mistake is apologize. I have over 10 years of professional experience with trans health and gender non-conformity has been part of my social circle for 20+ years and I still unfortunately misgender people, use the wrong pronouns, and say awkward things. And then I apologize and learn from my mistakes. Doctor-patient relationships are built on an exchange that requires integrity and some transparency. You don’t have to be the expert in trans medicine- your patient is the expert in what their body (mind spirit) needs. Your job is to help them maintain a safe and consensual medical space where they can address health concerns and work towards their optimal self-expression. This may include transitional hormones and gender affirming surgery for some, or it may be flu shots and cholesterol testing for others. Or oncology. Or labor and delivery. Or sickle cell anemia. Who knows what the person will need, trans people are people and you have one in your office right now. What will you do?

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Balancing with Ayruvedic Medicine – from Womens Power to Heal

510fafgjdbl-_sx336_bo1204203200_I am doing an Integrative Medicine Scholars program through the AMSA and we have to do a project to explore some aspect of Integrative Health. Ayurveda is a practice of medicine I don’t know much about, so I decided to do a personal practice incorporating lifestyle, nutrition and herbal medicine principles for the month of January. My friend Cathleen Miller helped me to figure out what my Dosha is (constitutional type) and lent me this amazing book, and …. here we go! Below is an outline taken directly from this text for (my) Pitta-Vata type.

Balancing Pitta-Vata Rhythms –

  • Rise with the sun and go to bed by 10 pm – maintain steady eating and sleeping routines
  • Ease yourself out of all stressful activities and maintain only those projects that create ease – allow adequate time to complete projects
  • Take ample rest
  • East wholesome, fresh, moderately warm, moist substantial and calming foods.
  • Avoid bitter, cold, raw, hot, spicy, oily, salty, fermented or stale foods and stimulants.
  • Shield against hot, wet, humid, cold, damp, or stressful environments.
  • Embrace serenity, love, warmth, healthy rituals and calmness.

Nutrition Principles

AVOID: caffeine, refined sweets, alcohol, saturated fats, excess salt, oily and spicy foods, and commercial dairy projects, as well as highly processed junk foods, meats, additives, frozen, canned, commercially grown, bioengineered, transgenic refined salts, sugars, flours and hydrogenated oils.

CHOOSE:

VEGETABLES Broccoli Brussel sprouts cabbage Cauliflower
Artichokes Asparagus Bamboo Bitter greens Black olives
Celery Cucumber Green beans Dark greens Parsnips
Peas Potatoes Sprouts Summer squash Sweet potato
Winter squash yams Watercress Bok choy Carrots
Daikon Beets Leeks

 

FRUITS Apples Apricots Coconuts Dates
Fresh figs Oranges Pears Pomegranate Tangerines
Mango Plums Raisins Quinces Limes
pineapple Avocado Banana Grapefruit Kiwi
Lemon Peaches Tamarind Rhubarb

 

LEGUMES Aduki beans Mung beans Kidney Lima
Lentil Navy Pinto Chickpeas Tofu
Black beans

 

NUTS Coconut Roasted sunflower seeds Roasted pumpkin seeds Poppy seeds
Water chestnuts Macadamia nuts Sesame seeds Pecans Walnuts
Pine nuts Pistachios

 

DAIRY Unsalted butter Cows milk Cottage cheese Sweetened yogurt
Buttermilk Whole cows milk cheese Cream Ghee Sour cream

 

OILS Sunflower Almond Olive Coconut
Dark sesame Light sesame

 

SWEETENERS Maple syrup Dates Sucanat

 

SPICES Coriander Cumin Cardamom Cilantro
Curry leaves Dill Fresh basil Fennel Turmeric
Saffron Peppermint Spearmint Ginger Anise
Mustard seeds Sage Nutmeg Thyme Ginger
Cloves Rosemary Tarragon Oregano parsely

 

Practices

  • New moon journalling with saraswati mantra – Aim Sarasvatyai Namaha
  • Ginger compress one week before the new moon (unless bleeding)

1 gallon water

1 handful grated fresh ginger

1 lg stainless steel pot with cover

2 stainless bowls

  Bring water to a boil, and add ginger secured in a ouch with a drawstring. Squeeze the  pouch to release the ginger juice and drop into the water. Simmer 30 minutes. Let sit 5 minutes before uncovering when taken off the heat. Create a compress towel and apply to lower back for 4-5 minutes or until lukewarm. For full instructions, see text p. 264.

  • Rose Oil Pichu – for headaches, hair loss, pain in the eyes, poor vision, mental fatigue and nose bleeds. Pichu: a powerful lubricating and loving therapy that helps maintain mental calm, emotional equanimity and helps balance the doshas. Best time: waxing moon phase. C/I bleeding. Best time: morning or early evening.

¼ cup dried roses

1 c sesame oil

Bring to boil over low heat and remove from heat, Add rose flower, cover and let steep 4-6 hours. Strain and use.

PICHU instructions: need pottery bowl, 12 “ clean cotton square and cotton hand towel.

  • Wash hair a few hours before
  • Release all stressful thoughts and details from the mind
  • Assemble the supplies on the floor close by
  • Soak the cloth in oil and lie down; place the cloth ear to ear. Press down on the cloth and wipe away excess oil
  • Rest quietly for 30 minutes and rise slowly, use hand towel to wipe away excess oil and maintain a peaceful attitude for the rest of the day.
  • Shakti Mudra – should be daily but 3 times per week seems doable – enhances sense of self, reinforces femininity, self esteem and restores vital energy to the womb.

Sit facing east

Bring palms together and separate slowly

Form the Shakti mudra hand position – see p. 192 text

Breathe deeply into pelvis and breathe out slowly, tracing the exhalation from the base 0f the perineum, circulating through the uterus and belly

Maintain for 15 minutes

Take a deep breath and make a commitment to a life of non-hurting

 

  • Yoni Mudra – 3 days before the new moon and full moon to revise Shakti prana.Not when bleeding.

Sit in meditative practice with palms facing up

Create the yoni mudra hand positions – see p. 155 text

Hold the hand gesture for 5 minutes

Allow breath to flow freely throughout the body, keeping the mind centered

HERBAL MEDICINE

Herbal Teas for PMS – Vata type predominant – take for 3 days of the new moon as well as the 5 days before menses

Helpful herbs: nutmeg, valerian, triphala, ashwaganda, shatavari, cinnamon, turmeric, fennel, dill and wild yam.

CINNAMON, CLOVE AND CARDAMOM DECOCTION (VATA) for PMS

2 c water

2 c organic milk

1 tbsp cloves

1 tsp cinnamon

1 tsp cardamom

½ tsp ginger

1 pinch saffron

 

LAVENDER FENNEL GINGER TEA DECOCTION (PITTA) for PMS

I c water

1 c organic cows milk

1 tso roasted fennel seeds

1 tbsp lavender petals

1 tbsp hops

½ tsp ginger powder

1 pinch saffron

bring water and milk to a boil. Toast the fennel seeds, then add all herbs and spices and simmer on medium for 15 minutes. Remove from heat, add saffron and stand 3-5 min before drinking.

 

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Heartbreak and Heart Failure

screen-shot-2016-11-06-at-2-48-11-pmSometimes life, work and study all seem  to dovetail and everything makes sense for just a few glorious moments. Cardiology was like that for me, in between the Frank Starling curves.

Last year we had a case study of a woman with congestive heart failure (CHF.)  Her husband had renal failure and needed dialysis, and she worked at a job she didnt love. She slowly developed worsening heart failure over the course of the case, with  shortness of breath, edema, high blood pressure, and poor circulation, eventually dying from it. I was impacted by the apathy she displayed in her efforts to recover – unwilling to eat more grains and greens, decrease salt,  get outside, exercise regularly, investigate psychotherapy, or better her personal life in any way. Instead, she just declined in health, adding a new prescription per year to mange her symptoms until she  – drowned. In her grief. Of heart disease.

This. Story. Happens. Every Day.

And not only in the US, or Canada or Europe. World-Wide.

The multitudes of meta-analysis risk factor evaluations like the Framingham, Whitehall and Rekjavic studeis have concretely illustrated important evidence about the facts of heart disease: atherosclerotic fatty streaks in arteries, high blood sugar, and  inflammation are the undeniable Holy Trinity of heart disease. What is not being avidly reported is the rate of divorce, or mood disorders in these same subjects. The sexual dissatisfaction. The childhood trauma. Socioeconomics and race are sometimes studied, and African Americans and Latinos have higher rates of heart disease. Nobody is surprised. Russia has the highest rate of ischemic heart disease in the world, along with some African nations and Indonesia. These countries also have horrible human rights records, with well documented transphobia, homophobia and police brutality.

screen-shot-2016-11-09-at-9-01-58-pmIf we are going to turn around heart disease, do we not need to acknowledge the humanity of the heart? The same  epidemiological study quoted deep within the content:

“Additional reports from this study have shown inverse associations between fair and respectful treatment at work and CHD [Congestive Heart Disease],and job control with future CHD risk.

Similarly, hypertension, which is the harbinger of heart disease through its effect on cardiac structure and function,  is hugely mediated by the stress response.

screen-shot-2016-11-09-at-9-11-31-pmI was talking to Dr. Stein, an internist specializing in HIV and also our OMS II course director, about this theory that heart failure is so rampant because we have no real medicine for soul-problems like dissatisfaction, grief, sorrow, envy, loneliness and such. He said the links between depression, elevated cortisol, hypertension and CHF are well documented and clearly evidenced.

He reiterated that it is known that People of Color have higher blood pressures because their lives are more stressful due to systemic and personally experienced racism aka “stress.” It is also well evidenced that African Americans with CHF respond better to different medications than other races – Hydralazine, a vasodilator that decreases resistance,  improves survival with  isosorbide dinitrate rather than the ACE inhibitors and Beta Blockers commonly used. Ha, decreasing [systemic institutionalized] resistance as a keystone in improving survival? I need to know more about the MOA of these drugs to understand why decreasing the catecholamines isnt enough for this population; maybe its because of the deleterious and constant push and pull the sympathetic blockers have on the heart receptors of someone living in the actual adrenergic rut of an unsafe society.

3f0a8388-0078-4c4f-88ef-36078365eae5Our cardiologist professor Dr. Glass stated that the average person with hypertension is on 3.4 medications to manage it. These are usually layers of diuretics to decrease the blood volume and drain edema (decreasing preload), and beta blockers to decrease cardiac work and improve cardiac output,  and/or other meds like diphydropyridines and nitrates. But guess what – it just came out recently that hypertensive medications may be CAUSING depression/ mood disorders while working to decrease blood pressure.  What a double whammy.  This was a big study from a database of a single hospital containing 525,046 patients over 5 years. This 2016 article stated:

Major depressive and bipolar disorders predispose to atherosclerosis, and there is accruing data from animal model, epidemiological, and genomic studies that commonly used antihypertensive drugs may have a role in the pathogenesis or course of mood disorders.”

  • Patients on angiotensin converting enzyme inhibitors or angiotensin receptor blockers had the lowest risk for mood disorder admissions
  • those on β-blockers (hazard ratio=2.11; [95% confidence interval, 1.12–3.98]; P=0.02) and calcium antagonists (2.28 [95% confidence interval, 1.13–4.58]; P=0.02) showed higher risk
  • those on no antihypertensives (1.63 [95% confidence interval, 0.94–2.82]; P=0.08) and thiazide diuretics (1.56 [95% confidence interval, 0.65–3.73]; P=0.32) showed no significant difference.

To summarize the findings,  calcium antagonists and β-blockers may be associated with increased risk, whereas angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may be associated with a decreased risk of mood disorders. (Hypertension. 2016;68:1132-1138. DOI: 10.1161/HYPERTENSIONA HA.116.08188.)

It appears, the drugs that most directly affect the heart muscle itself are thus linked to more mood disorders, while those that work indirectly and decrease the work for the heart seem to have less impact on mood.

This is such a broad topic and there are so many layers to heart failure – blood pressure, kidney regulation of blood pressure, nutritional effects, blood lipids, blood volume, inflammatory mediators, free radicals and antioxidants, sleep quality and more – but I think that too often we lose sight of some of the most basic truths of happiness and heart health. And we also forget the deeply sensitive creatures that most of us are and fool ourselves that pharmacy could possibly be enough to cure a heart that is systemically broken, or the effects of a chronically hypervigilant nervous system.

imagesWIDJJQD2I am going to need to become proficient at cardiology as an Internal Medicine doc. But without a degree in psychiatry, or soul medicine, or archangel intervention, how can I possibly hope to help people recover their failing hearts when the intersections cut so deep? I am scared of all of those people that have no willingness, or ability, to look deep within and make the simple and profound choices towards life. This is the part of being a physician I most fear. The medical failures; the broken hearts.

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The Pitfall of Alcohol

I’ve been avoiding writing this post for at least a week, probably two. Mostly because it has personal meaning to me as alcoholism runs in my family on both sides – My mothers father was one of the “Mad Men” of the 50’s, worked in advertising and died of liver failure due to alcoholism. I guess he got pretty ugly in the end. My paternal grandparents didnt drink at all (which leads me to wonder if their parents were alcoholic) but all of their children have a penchant for the sauce.

Before I was a medical student, I thought the damaging effects of alcohol could be traced directly by measuring liver enzymes – and as long as those harbingers of hepatic cell death stayed within a reasonable limit, one was “getting away” with whatever one was doing. Enter: neurology. Boy was I wrong. Oh and Ps. Dead liver cells cant release ALT or AST, so good liver enzymes in the face of chronic alcoholism is actually a pretty bad sign.

The blood brain barrier is an effective barrier to most things except: nonpolar and lipid soluble molecules. Enter: CO2, O2, and ETOH (alcohol.) This means that as soon as alcohol is in your blood, it is seeping into your brain. And brain cells/ neurons are permanent cells – they don’t have the ability to divide, so they don’t replicate. You get what you started with – some axons can be regenerated, but once the cell body dies, your numbers start to decrease.

gait-ataxiaThe cerebellum is one of the parts of the brain most affected by alcohol cell death; this is why people become unsteady and clumsy anterior-vermiswhen drunk – inhibition of cerebellar function! There are multiple and complex inputs to this lower brain region from almost every aspect of the nervous system, so it can compensate for loss of neurons (when sober) for a long time. Up to 80% of cell death can happen before symptoms become noticeable! Unfortunately, once this is happening in the sober state, the cells are dead and there is no ability to recover balance or coordination.

I didn’t know that memory loss is also a component of chronic alcoholism. There are two halves to the cognitive decline that will happen eventually called Wernicke-Korsakoff syndrome, and these are from alcohol related destruction to two more areas of the brain.

confusionThe first set of symptoms is reversible, and is related to a deficiency of vitamin B1 aka thiamine. The mammillary bodies are wee nubs on the underside of the brain that are part of the social and emotional brain. They take information from the hypothalamus and hippocampus, and run it to the anterior nucleus of the thalamus. nrhpth08

 

 

 

 

This is a critical loop in emotional and social behavior integration at a cognitive level. I guess this is partially where the numbing effect of alcohol on the emotions could occur? With a deficiency of B1, the mammillary bodies hemorrhage and cause Wernickes encephalopathy, characterized by confusion and your eyes not tracking properly, as well as the unsteadiness from the damaged cerebellum. This is why in hospital treatments, alcoholics are first given thiamine/ B1 to see if it can reverse the symptoms. From a prevention standpoint, taking a good quality capsule (not tablet) daily multivitamin seems like a good idea for anyone drinking on a regular basis.

This condition can progress to irreversible memory loss for the past, with an inability to make new memories, plus psychotic symptoms. This is called Korsakoff psychosis. As people lose their ability to remember, they start making things up to fill in the blanks called confabulation. This can be really depressing for friends and family members as it becomes clearly evident that the damage is permanent.

and THEN, there is the metabolic damage that is occurring below the neck. (This next section is biochemical mumbo jumbo, but since this is my review exercise, I’m going to include it for my medical interest:)

screen-shot-2016-09-26-at-12-32-00-pmEthanol/ your drinks/ are 80% broken down by cells (cytosol) of the liver. 15% of alcohol is broken down by microsomes in the brain and liver, and this pathway is upregulated in chronic alcoholism. The remaining 5% are converted to fatty acids and phospholipids that are thought to play a role in tissue damage. Both primary pathways break down ethanol to acetaldehyde, which is metabolized  down to acetate…..Acetate, where have you heard that before? yes, NAIL POLISH REMOVER, flooding your liver and brain.

The major metabolic consequence is from the elevation of NADH that occurs in the cell and in the mitochondria in steps one and two with excessive and continual amounts of alcohol intake, because this NADH will inhibit the TCA cycle from running. No TCA = no glucose metabolism = no fuel for the cells. The brain will still need fuel, so the liver cleverly shifts the glucose from the alcohol (which can no longer be metabolized) to ketone production + free fatty acid synthesis (aka fat storage.) This explains, in painful detail, why alcohol makes you gain weight and affects blood sugar levels.

screen-shot-2016-09-26-at-12-36-56-pmFinally, I wanted to add this last slide for an important prevention note. This is the process of the 15% microsomal pathway that is upregulated with chronic high alcohol intake. Note the second step produces ROS – this is reactive oxygen species aka free radicals which are known to cause cell damage and cell death. Higher levels of ROS are bad in general and associated with greater inflammation and cellular damage across the board. This points to another potential place for prevention – with use of high dose antioxidants like CoQ10 200-300mg, resveratrol (500mg), alpha lipoic acid (200mg) and vitamins C (1000mg) and mixed tocopherol E (400IU).

screen-shot-2016-10-08-at-4-29-14-pmWhen alcohol intake gets high enough to start causing brain damage, obviously the primary treatment goal is to reduce the intake. Our first case study had a 37 yo male drinking 12-16 beers PER DAY. How many drinks, realistically speaking, are you having per day? How many does that add up to per week? Does that seem reasonable to you?

I don’t know enough about addiction to know how to address real chronic alcoholism. I imagine it is incredibly hard to quit, and even to reduce daily intake without a pure and strong internal directive to do so – no one can be told to do it,  the drive Must Come from Within. Treating underlying depression, anxiety, or life stressors are surely part of the picture, but what if you just drink to have fun? Sometimes, the party needs to stop, or gets out of control. I guess we all need to grow up sometime and learn to tolerate whatever it is we harbor inside our minds (before they get destroyed.)

Alcohol is a depressant, so withdrawal symptoms are the opposite – agitation, irritation, worse case scenario people can have seizures. Benzodiazapines, some sleep drugs and alcohol all work on the GABA-A receptor in the brain. Chronic alcohol use downregulates the expression the neurotransmitter GABA, one of the “off switches.” Once high levels of alcohol start to lower, it takes time for the brain to start making enough GABA again, resulting in foul moods, irritability and general unpleasantness.

There are medications like naltrexone and acamprosate that can help reduce the cravings for alcohol, and medications to treat the side effects of withdrawal, mostly aimed at these same parts of the brain. These are definitely worth exploring with a psychiatrist or addiction specialist to figure out what approach will work best for you. Complete abstinence does not need to be the goal. GABA as a supplement is not absorbed well, but is readily available and might be worth a try for someone who is just cutting down on daily intake, and has addictive enough a personality that switching to benzos instead of alcohol could exacerbate rather than relieve the problems. However, it is unlikely GABA alone would be enough to support sobriety. Making the very personal and often terrifying choice to look at one’s habits and face trauma/addiction is the place to begin. A comprehensive medical assessment with an empathetic and respectful health professional who has experience in addiction is next step. (if you are in Maine, I highly recommend Dr. Merideth Norris!)

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Insomnia is the Worst!

luxury-hotel-rooms-pamilla-cape-townI was on vacation with my sweetheart this past week, and spent two long nights in a hotel room when I could.not.fall.asleep! What to do? It was so exhausting, and of course set my mood and energy levels off for the remainder of the trip.

When I evaluate sleep from an Integrative Medicine perspective, I usually break it into –

  1. unable to fall asleep
  2. unable to stay asleep.

The former tends to have a different set of causes and therefore medications than the latter. Sleep is complex and involves multiple body systems working together including endocrine, neurological, immune, musculoskeletal, and mental/emotional at the very least! Each person with chronic insomnia will benefit most from individualized treatment, but here are some generalizations to improve sleep.

First, as boring and arcane as it sounds, sleep hygiene is important. Hygiene is a strange word to associate with sleep, IMHO. It sounds weird and uncomfortable, but “sleep hygeine” is a general concept that encompasses the environmental and behavioral aspects that are known to improve sleep quality and promote restful sleep. For example, my hotel room was too hot both nights. Maintaining a comfortable room temperature preferably cool with fresh air, is known to improve sleep quality. A darkened room without blinking or other lights within eyesight and a peaceful bedtime routine are also examples of sleep hygiene.

untitled     To fall asleep, sedatives are the key. Valerian is the strongest herb for sleep support. This herb was mentioned by Hippocrates in his writings, and is one of the oldest sedatives known. It has numerous studies supporting its use for sleep. The essential oils in valerian appear to provide its sedative activity, while the valepotriates exert a regulatory effect on the autonomic nervous system.  Although more than 150 constituents have been identified, none appear to be solely responsible for valerian’s effects, suggesting many compounds may act synergistically. Valerian’s mechanisms of action are not completely understood.  Valerian interacts with neurotransmitters such as GABA and produces a dose-dependent release of GABA. Valerian also inhibits the enzyme-induced breakdown of GABA in the brain.

GABA is my other secret weapon for falling asleep. There are two on switch neurotransmitters (dopamine and acetycholine) and two off switches (gaba and serotonin.) When the off switch is stuck on, sleep becomes difficult. Taking GABA as a supplement improves GABA levels in the brain, quieting the mind. Benzodiazepenes like Attivan and hypnotics like Ambian also work to increase GABA levels, as does Valerian. *Don’t use these all together as they can depress respiratory function as a cocktail.

images7OHBNK29Difficulty staying asleep can be more complicated to treat than falling asleep. Taking sedatives at 2 – 4 am can result in morning grogginess. From my experience, early waking (3am) is often related to a dysregulated cortisol clock, or, put simply, stress. Cortisol is the primary stress hormone produced by the adrenal glands. It runs on a 24 hour clock, and should be highest at 8am, and slowly drop during the day and rise at night. With emotional and/or physical stress, travel to different time zones, or shift work, the cortisol clock can become dysregulated, peaking earlier and earlier, creating an too-early wake up signal. Adrenal support is key. I often use herbs like ashwaganda, L-theanine, rhodiola, relora, and more to help regulate adrenal hormone production and heal imbalances. Cortisol is complicated, and balancing requires an in-depth look at ones lifestyle, mental health, stress coping techniques, exercise patterns, blood sugar and more. Therefore, treating stress and adrenal health in relation to sleep is best with an individualized approach, as “cookbook” medicine rarely gives optimized results.

For really tough sleep cases, NeuroScience labs makes a neurotransmitter panel to assess what is causing the night time wakefulness. Blood sugar disorders, sympathetic nervous system activation, cortisol dysregulation, hormone imbalance, anxiety, depression, grief, and more can all be part of the “perfect storm” of insomnia. Find a Naturopathic Doctor in your area to unravel the depths of your sleep mystery.

Umbrella_GraphicFinally, energetic medicines like acupuncture and homeopathy can be invaluable for unlocking sleeps depths. We are quantum physics humans, we do not operate in straightforward paradigm. Sometimes sleep issues go back to childhood dysregulation or other “never been well since” life events. These more energetic medicines can work to correct these deep imbalances by integrating unresolved issues that plague your subconscious when your guard is down. Psychotherapy and cognitive behavioral strategies can also be used to unravel sleep and stress mysteries.

I was lucky: once I was able to come down from the stress before my trip, and relax into my holiday my sleep improved, and I even got to sleep in for a change! What do you need to get that beauty sleep you so desire?

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