Transgender patient with a rash: “I was going to call and ask if you knew of a dermatologist in my town, but then I realized that this was probably going to be a pants-off situation, so I decided to come see you instead.”

Me: “Glad to be of service.”

(Mental note: try to work the phrase “pants-off situation” into conversation more often!)

…for depression.  Yup, the annual holiday depression has set in for my patients.  I spent the past couple of days being as reassuring as possible, repeating “You’re not alone in this.  Many people find the holidays stressful and depressing.  Not everyone is happy, even though they all look like it on t.v.”  It’s a combo of family stress, financial worries and the omnipresent image of the happy family enjoying conflict-free togetherness that pushes people over the edge.  Let me just repeat for good measure: YOU ARE NOT ALONE IN FEELING SAD AROUND CHRISTMAS.  PEOPLE LOOK HAPPY, BUT MANY TIMES THEY ARE JUST AS SAD AND CONFUSED AS YOU ARE.  It’s ok.  The season will come to an end, and people will stop being jolly.  Hang in there a little longer.

Arrived at the clinic yesterday to find this phone message: “Patient states that he was walking outside with his dilaudid and spilled it in the snow.  Requesting refill.”

Ah yes, when I take my morning constitutional, I always bring along an open bottle of a powerful narcotic.  Good luck with that refill request.

Sometimes I miss working with adolescents.  When you work with them–as I did with a new, 18-year old patient last week–they say the most delightful things.  Like this: “So I have a question…if you have anal sex, does it still pop your cherry?”

And also this: “Um, I was wondering, when I had sex for the first time, it didn’t hurt and I didn’t bleed.  Is there something wrong with me?”

Bless her little heart.  Those comments gave me the perfect segue into discussing the STD risks of anal sex, along with the concept of the intact hymen as the basis for virginity.  (And in case anyone is wondering about my response to the cherry-popping question, I said “Good question.  If you’re asking if having anal sex will break your hymen and make you not a virgin in your vagina, then the answer is no.  But it is possible to pop someone’s cherry during anal sex, if you’re using that to describe having sex for the first time.  And if you’re asking me if I think that anal sex is really sex, then the answer is yes.  Anal sex is real sex.”)

Just one day after I wrote my last post about people still dying from AIDS, I had a surprise visit from one of my erstwhile patients.  She’s a HIV-positive woman who has struggled with substance abuse for most of her life.  The last time I saw her in clinic was a year ago.  Her last appointment with the infectious disease specialist was 18 months ago.  From what she tells me, she stopped taking her HIV meds 6 months ago–although I suspect she might have stopped a while before that.  She came in because the pain in her throat had become too much to bear.  When she opened her mouth for the exam, I wanted to weep.  Her throat was covered with thrush, and the pain in her throat and chest indicated that she had developed esophageal candidiasis.  She lost 40lbs in the past year.  I drew some labs, and today I got the results.  Her CD4 count is less than 10. Mine is probably 800.  It’s like she’s a walking illustration to my point that HIV meds only work when you can actually stick to the regimen.  Somehow it doesn’t feel good to be vindicated.

One of the things that keeps me going at work is a sort of cynical optimism.  I don’t think she’s going to survive much longer.  But that didn’t stop me from thanking her for coming in, starting her on anti-fungals and antibiotics and making plans for follow up.  As long as she’s alive, I can keep trying…as long as she does.

This is a serious post, in honor of World AIDS Day.  People still die from HIV/AIDS.  My patients still die from HIV/AIDS.  This year, 2 of our clinic patients have died from AIDS-related illnesses and a few more are going downhill quickly.  Yes, the drugs are amazing and life-saving.  But they’re only life-saving when you can get them…and take them.  Regularly.  The problem my patients faced wasn’t access–they were able to make appointments with infectious disease specialists and case managers right in our clinic, and HIV meds are free for those who meet income criteria in our state.  The problem was in the other parts of their lives.  The mental illness.  The substance abuse.  The poor coping skills.  Many people lead long, relatively healthy lives after becoming infected with HIV–but not everyone does.  HIV can still kill you.  Sometimes we forget.

New vocal hoarseness:

Move turtleneck aside and

Whoa!! Giant goiter.

Your blood sugar was

four hundred after dinner?

Happy Thanksgiving.

Got a thank you card

from a sweet, thoughtful patient.

Shed a little tear.

Overheard while sitting in the staff office:

Doctor Cuts-a-lot (he loves to do I & D’s) returns from draining someone’s abscess and states happily “Now that was some export-quality pus!” Um, yes. Our community is known for its fine, export-quality pus. Perhaps we can shore up the horrendous economy here with a side business in pus exportation.  wtf?

November is my birthday month, and it’s also the month that it starts to get really dark at 5pm. These two things never fail to put me in a reflective, somewhat melancholy mood. This year I’ve been thinking a lot about what it’s been like to have left my wild adolescence behind. I’m basically a totally respectable adult now, in my 30’s, with not just a job but a career. Frankly, it feels weird. Some part of me never thought that I would grow out of my rebellious youth, despite all evidence to the contrary that most adults do (and in fact, it’s a little creepy when adults try to maintain their youthful rebellion past their 20’s). Although you could argue that I am still fighting The Man every day with my LGBTQ-friendly community health services, it’s a very different kind of “fight the power” feeling than it was to show up at a big protest march with a bunch of black-clad anarchists. Arguably, I’m actually doing more to fight the power now, but it’s just not as dramatic.

I’m not trying to say that I didn’t want to grow up. You can only sleep on a thin futon mattress in a dirty shotgun flat for so long before it stops being exciting and starts being uncomfortable. Likewise, dancing and drinking and picking people up in bars and then going to work the next day is only sustainable for so long, and after that it gets exhausting. Now I get a good night’s sleep and march into exam rooms, wearing a white coat and authoritatively giving people instructions and diagnoses, standing in my fun-but-not-too-funky-for-work heels and pantyhose (i mean seriously, pantyhose?! i really never pictured that when i was younger), and people look at me and see someone respectable. It’s weird, I tell you. Just weird.

I feel very lucky to have made it through my adolescence and young adulthood relatively unscathed, despite some very poor choices that I made along the way. I credit a few things for keeping me on the thin line between rebellion and disaster. My parents gave me a strong foundation of literacy very early on. They may have made some mistakes in other departments, but my love of reading really took hold and kept me at least partially invested in school. I was also in a magnet program throughout my public school education–where the prevailing attitude wasn’t “IF you go to college…” but “you WILL go to college”–and lo and behold, I wanted to go to college. In fact, I wanted to go to college so much that I made damn sure I was on birth control so I wouldn’t get pregnant and ruin my life when I started having sex, and I stopped doing drugs when I got worried that I might develop a habit. Partially, this is due to genetics. I was born pretty smart, and that helped. And I must not have the genetic predisposition for addiction, because certainly I had the opportunity to develop one. I am eternally thankful that I dodged that bullet. I guess it was luck, with a little hard work and some drive to succeed thrown in, that finally brought me to where I am today. And now I sit at work–my white coat covering tattoos, facial piercings long since removed, the ghost of my youthful self marveling at at this new specter of adulthood.

Paulina Ibarra
Location: East Hollywood, California
Cause of Death: Stabbed to death
Date of Death: August 28, 2009
Paulina was found dead inside her apartment, she had
been stabbed to death. Paulina was 24 years old.

Kamilla
Location: Volgograd, Russia
Cause of Death: shot to death
Date of Death: June, 2009
Was shot to death by her boyfriend Vladmir after he discovered
that she had been born male. Kamilla was 30 years old.

Jimmy McCollough
Location: Fayetteville, North Carolina
Cause of Death: his murdered body
was found on Joseph Street behind the old Club Spektrum
Date of Death: April 14, 2009
Jimmy was a drag performer whose performance name
was Image Devereux. Jimmy was 34 years old.

Cynthia Nicole
Location: Comayaguela, Honduras
Cause of Death: Shot 3 times in the chest and once in the head by three
unknown men driving a blue car in Barrio Guaserique, Comayaguela, near Tegucigalpa.
Date of Death: January 9, 2009
News sources believe that the killing of Cynthia Nicole may be related to her legitimate human rights activities, in particular her involvement in the defense of the rights of the transgender community.

There were 91 more reported deaths of trans people worldwide. And these are only the deaths that were reported.  I am praying for the day when no trans person has to live their last moments surrounded by hatred and cruelty.