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.”
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.
As for her mental illnesses, all were consistent with her background. People with multiple personality disorder tend to have suffered some of the most horrible abuse imaginable. Their minds adapt or escape by repressing their identities and creating new ones. Bulimics have terrible self-esteem, often resulting from a lifetime of abuse, which results in the indulgence of binge eating followed by the punishing correction: purging one’s guts of their contents. And why shouldn’t Joanne have the mania and depression of bipolar affective disorder also, since that just requires inheriting the appropriate genes?
So Joanne led and I danced along with her intense mood swings, severe pains, and adolescent devil-may-care high-risk behaviors, trying to find an appropriate mix of medications, psychiatrists, and therapists to keep her as balanced as possible. We scheduled appointments once or twice weekly to help her manage each new crisis. In the beginning I had help from her psychiatrist, Dr. Sheehy (pronounced SHE-hee; I’m not kidding) and a therapist named Kay. As so often happens to the primary-care physician of such a difficult patient, I ended up on my own after she destroyed her relationships with all her other caregivers. All, that is, except for her fiancé Paul, to whom she became engaged in 1994.
Mary’s entire life had been chaos; her center did not hold. Her stepfather, a physician, had violated her on an examination table. She had changed her gender twice. Just a few months after I became her doctor, she changed her name to Joanne. She went through several therapists and psychiatrists, firing and rehiring them several times until each would get fed up and tell her to find someone else. She broke up with Paul at least ten times in three years, but as far as I know, they’re still engaged. Given all this, I decided from the first visit that my job would be to provide society’s one consistent influence on her, one thread of continuity that might prevent a few suicide attempts, emergency room visits, anonymous sexual contacts, and psychiatric hospitalizations.
I hadn’t figured her out, though. I think my first clue came about 11 months into our relationship when, before I went into the exam room, Rhonda, my medical assistant, told me today Joanne was adamant her name was now Tammy. I entered to find Joanne sitting in a hunched over, not-quite-fetal position on a chair in the corner of the room, saying she was Joanne; she was frustrated that she couldn’t stay in one personality for any length of time during the past week. It was then that she explained that her stepfather was a doctor and had abused her on an exam table, so she refused to get on mine, although she had never shown any problem doing this before. The exam table, she said, was a symbol of the satanic altar. She had given me a copy of the satanic calendar so I would know when their holidays occurred, because those were the days she was most likely to go nuts.
And just like that, she began slamming her head against the wall and saying she was Melissa. Ten seconds later, she was over that and Joanne reemerged. She cowered in the corner for most of the rest of the visit, complaining again that her personalities were so disruptive; she claimed she couldn’t remember coming into my office and exam room. But just before we finished, she asked whether my staff knew she was “multiple” because they had such funny expressions on their faces when she came in as Tammy.
She treated me to a “switch” only one other time. She was sitting on the edge of the exam table and talking to me as Joanne, then, without any warning, threw herself backward so that she was flat on her back on the table. She lay motionless for a few moments, then jerked herself upright and began talking in an altered voice. I can’t remember who she said she was; what I remember was feeling that awkward, nauseated sensation that comes when you’re watching an acquaintance try to sing, act, or tell a joke and instead he or she looks like an idiot.
After hearing her lie about her memory loss, I reframed my clinical approach a bit. Joanne had never matured, so I could expect her to lie and say outrageous things just to see what would happen or to get a little attention. I had become weary of sifting through her barrages of physical symptoms — many of which could, in the right context, have been symptoms of serious disease and therefore require careful evaluation — so I began to look for some comic relief in her fabrications.
She gave me many. During that first year under my care, she told me she was a premed student and had enrolled for the fall semester at a local community college to begin her pursuit of this goal. As her doctor, not her career counselor, I avoided passing judgment on her choice of academic paths. I knew from the psychological testing she underwent during one of her hospitalizations that she had an IQ of about 90, which meant that, no matter what anyone might say about the validity of IQ tests, she wasn’t going to get anywhere near a medical degree. I chose instead to counsel her about the need to keep her goals realistic and not set herself up to fail. She dropped out during a mental breakdown about two weeks after school started. I don’t think she was taking premed courses; she just wanted to be able to say she was.
She also wanted to be wild. When I asked her about use of alcohol or other recreational drugs, she would chuckle or smile and “admit” to using enormous quantities and varieties of substances, although there never was any evidence or consequence of this behavior. I shouldn’t say never; at the time of one of her psychiatric admissions, she had a urine-toxicology screen turn up positive for amphetamine use. But she didn’t have positive tests on many other occasions when her stories said she should have.
Most of all, she wanted to be a real woman. On many visits, I listened with interest as her voice filled with anger when she railed against the scores of men who looked at her “as though I were just a sex object.” With her frilly white dresses, pink ribbons, and tinted-blond hair, Joanne does her best to ooze femininity, but I have observed that when she enters a room, the only heads that turn do so out of morbid curiosity, not animal magnetism.
The story that became the beginning of our end was her version of the history of her sexuality. She told me early in our relationship that she had lived as a boy through her early teens and had used supplemental testosterone injections to ensure her emerging manhood. Because of her allegations against her stepfather, she claimed reluctance to having any examinations below the waist, and I, fearful of reviving her terrible memories, was not eager to go there. A complaint of rectal bleeding in October 1994 led her to insist that I look down there. I found what I expected: a circumcised penis with small testicles, the latter atrophied from the influence of estrogen supplements. She had told me when we first met that she was hoping to undergo a sex-change operation at some later date.
But this wasn’t simple gender dysphoria. Six months earlier, the police had taken her in handcuffs out of an incest-survivors’ group meeting because, she said, she switched personalities and became Kristin, the seven-year-old who killed Joanne’s baby during a satanic-ritual sacrifice. At the meeting, Kristin viciously stabbed a doll with a pencil. But this alleged sacrifice was years ago, and Joanne was Mark then. How could he have had a baby? And why did he need testosterone supplements in his teens if he was a boy?
I didn’t pursue this at the time of the doll-stabbing incident because we had so much work to do just to get her through each day. But when I examined her six months later, it was clear that she had always been a boy. I chose not to confront her with this. My explanation was that the memory of the satanic-ritual sacrifice was false, as such memories from people suffering severe mental illness often can be. She was a he, had always been a he, and that was that.
Which was fine until she started complaining of menstrual cramps. Her periods were getting heavier and more painful. She alleged that the blood came out of her penis. My attempts to collect evidence always ended in futility; her periods had always just finished or were late. One day she wanted a pregnancy test, but I dissuaded her. Rather than risk getting tangled in a mess, I pretended to believe she had menstrual cramps. I asked detailed questions about her symptoms, their severity, their timing, etc., and treated her with prescription-strength ibuprofen. I assumed this would be another of her fleeting but recurrent symptoms.
I had underestimated her need to have a woman’s disease.
“The medicine’s not helping, so I’m going to see a gynecologist tomorrow,” she reported at her next appointment.
Glancing at my watch and seeing that it was 4:45, I got a little anxious. “Who will you be seeing?” She told me. “Excuse me for a minute,” I said, and left the room to use the phone.
“She has an appointment with the nurse practitioner tomorrow morning,” the cheerful front-office person on the other end of the line confirmed. I told her I needed to speak to the nurse practitioner, who found the situation intriguing. She agreed to see Joanne, “discover” her anatomical secret, and inform her that there was nothing she could do.
Joanne came back to me. “I want an ultrasound.” As she said this, I thought, “Oh, this will look good. I can see the radiologist asking the technician, ‘So Dr. Eichel’s sending men in here for pelvic ultrasounds. Why don’t we just do a mammogram while we’re at it?’ ”
I told Joanne I couldn’t order an ultrasound because she didn’t have a uterus. She insisted that she did. She said she was born a girl but had undergone a sex-change operation in Canada at age seven to stop her stepfather’s rapes. That’s why she needed the testosterone injections. The more questions I asked, the more obvious it became that she believed what she was telling me.
She offered to get me in contact with the surgeon who did the surgery; once she said he would be sending me a fax that day. Of course, it never came. I had seen her anatomy, and it wasn’t the work of a surgeon.
I had learned from past experience that I couldn’t believe many of the things she had told me. I knew now that I couldn’t believe anything she had told me. Ever. The sexual abuse, the cult rituals, the multiple personalities, the bulimia — she may have invented it all. I had a patient who was a complete black box. I chose to believe that some awful stuff did happen to her, which she has repressed so much that she doesn’t know the difference between what was real and what her mind created. But I will never know the truth, and perhaps no one ever will.
She never was satisfied with the way I dealt with her periods, and a few months before I dismissed her from my practice, she began asking for names of other primary-care doctors, and I obliged. At the end of August, she sprained her ankle, a catastrophic event to someone who has so little ability to cope with even the slightest problem. On the day of her final visit seven weeks later, she came with a new accent for an old personality (Sara, whom I believe Joanne used as an excuse to act like a sociopath). She swore at me and at my patients in the waiting room and punctuated her exit with a most unladylike act: she urinated on our bushes.
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 several weeks later when she tore flesh off her arm with her teeth before throwing one of our chairs and overturning a trash can. The police had to come and haul her off to the psychiatric ward that day. As the yellow drops paused and plunged from the green leaves of our hibiscus plant, I knew I had ridden the bronco as long as I could; it was someone else’s turn.