I remembered the day three years before when she had come in, armed with a stuffed tyrannosaurus, singing George Thorogood’s “Bad to the Bone.”
  • I remembered the day three years before when she had come in, armed with a stuffed tyrannosaurus, singing George Thorogood’s “Bad to the Bone.”
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When she first visited my office, Joanne was Mary, and I was not surprised when she told me that not long before she had been Mark. She had a linebacker’s 5´10˝, 246-pound blocklike frame and bull neck, but her insecure voice quavered with a softness that matched her long sandy-blond hair. Her Converse high tops and face full of pimples could have belonged to any ordinary adolescent. My family practice in Berkeley that day in 1993 was only eight months old, which meant that many of my new patients came to me for one of two reasons. Some had seen but for some reason rejected the other primary-care physicians in town. For others, I was the only private doctor in town accepting MediCal-insured patients. I think Mary fell into both categories.

She told me a lot about herself during that first visit. A victim of multiple episodes of childhood-sexual and cult-ritual abuse, she outlined a smorgasbord of consequent mental illnesses. Since age seven, bulimia nervosa had led her to binge on high-calorie foods and later purge them from her system by vomiting and abusing laxatives. She had at least seven personalities, which would take control of her at different times. Mania, depression, and panic attacks further disrupted her day-to-day existence; scars from suicide attempts wove lacy patterns on both of her wrists and forearms. And, of course, she had “gender dysphoria” — living as a woman in the body of a man.

With so many tidal waves pounding her emotional landscape, her physical health displayed the damage. She came to me that first day for a follow-up visit from two trips earlier in the week to the local emergency room for abdominal pain, chest pain, shortness of breath, and a bowel movement covered with blood. The pains in the chest and abdomen were so severe, she said, “they cut off my breathing.” As she spoke these words, her mouth and face went through a series of contortions that would become so familiar I would cease to notice them. People who take phenothiazines, the powerful emotion-blunting tranquilizers of which chlorpromazine (brand name Thorazine) is the most infamous, can develop uncontrollable movements, often including rhythmic sucking and lip-smacking motions of the mouth, called tardive dyskinesias. Mary’s expressions were a mixture of these and pain-laden grimaces.

The emergency-room physician did not find a physical cause for any of her pains but did detect a rectal fissure, the result of either too much straining from constipation or trauma during sex. He therefore gave her new prescriptions for Colace, to soften her stool, and Zantac, to reduce stomach-acid secretion in the hope of alleviating her chest and abdominal discomforts. Emergency rooms are set up to treat acute problems quickly; their job is to stabilize the patient as much as they can before someone else takes over his or her care in the hospital or, more often, in the doctor’s office. People with lives as unstable as Mary’s need thorough investigation of their medical complaints by someone who knows them well; therefore, the emergency room is ill-suited to their needs. But such dysfunctional people are almost always poor; they either have no insurance and cannot afford a private doctor or they have government insurance, which many private doctors will not accept. Instead of developing a useful, long-term relationship with one doctor who knows them well, they must wait for a crisis and go to the emergency room for treatment.

So Mary wasn’t feeling much better that day when she met me. I say she met me; it would be more accurate to say that he met me, but I made a habit of using feminine pronouns to refer to Mary so I would not offend her. On a few occasions I — more often my staff — slipped and accidentally said him or his in Mary’s presence, infuriating her. Now, as I read over the chart note from that first encounter, I see that I interchanged feminine and masculine pronouns throughout, so I didn’t know what to call her then. My closing comment on that date was, “Her management will be very challenging given the severity of her psychiatric illness.” I got that one right.

Between that day, March 24, 1993, and the last time Joanne came to my office on October 17, 1997, she made more visits than anyone ever has, before or since. Once, when I spoke of her to a colleague, I compared my relationship with her to that of a rodeo rider with a bucking bronco. I hung on as best as I could for as long as I could, trying to keep both of us from getting hurt.

After the first few visits, I dared to think that I had pretty well figured her out. Victims of physical and/or sexual abuse adapt by losing touch with their bodies and feelings, and the profound emotional pain that they need to let out often manifests as physical pain. Early in our relationship, it became clear that the severity of her pain symptoms was out of proportion to any physical ailment she may have had. For example, her recurrent chest pains and shortness of breath did not reflect any disease of her heart or lungs but instead were her body’s way of expressing profound anxiety. Panic attacks like this are common in people functioning at a much higher level in society than she was and often respond to treatment with anti-depressant medications, which Joanne used for most of the four years she spent under my care.

Her abdominal cramping mixed in with intermittent diarrhea and constipation turned out to be another stress-related condition: irritable bowel syndrome. Our brains and our guts have a relationship, the intimacy of which varies from person to person. There are firefighters and inner-city trauma surgeons who encounter unimaginable stress every day whose bowels are as predictable as the calendar. There are people who if someone slips a drop of cream in their oatmeal or an unexpected bill in their mailbox, their bowels turn to water or stone. Most of us are somewhere in between. Again, given Joanne’s tumultuous emotional constitution, it would have been shocking to me if she had normal bowel function. Irritable bowel syndrome causes over one-third of the U.S. population’s visits to doctors for abdominal complaints, so Joanne had plenty of company.

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