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Education Homelessness Policy Reflection

Commercial Sexual Exploitation.

I recently attended a presentation given by one of the founders of The Organization for Prostitution Survivors (OPS).

If you or your organization want to hear a compelling, educational, and thoughtful talk about commercial sexual exploitation, I encourage you to contact OPS.

The talk did not necessarily alter the way I go about my work as a psychiatrist, but it did challenge my assumptions about prostitution, highlight the different perspectives men and women have about sex (to be clear, the talk was not at all “anti-male”), and encourage me to reconsider the influences of our culture on commercial sexual exploitation.

I’ve included my notes and reactions from the presentation below. Any errors and lack of clarity are entirely mine.


The speaker (a man) began with a discussion about the social construction of gender. What does it mean to “act like a man”? The stereotype is that a “man” excels at sports, fights well, doesn’t show emotions (particularly sadness, fear, etc.), is dominant, and is skilled at and knows a lot about (heterosexual) sex.

Boys learn these stereotypes throughout their youth. Boys are eventually introduced to pornography, which may actually serve a means of male bonding (passing around a copy of Playboy, sharing links to online pornography, etc.). Pornography doesn’t teach boys how about sexual relationships, but instead offers flat, two-dimensional representations of women solely in the context of sex. Masturbation leads to orgasm, which is a potent reward for viewing women as sexual objects (instead of actual people).

The speaker then asked the audience for adjectives attributed to “good girls” and “bad girls”. The assumptions about “bad girls” are often the same for prostituted women[1. The speaker used the phrase “prostituted woman” instead of “prostitute” for the same reason that I use “man with a diagnosis of schizophrenia” instead of “schizophrenic”. Let’s please remember that we are talking about actual people here.] (they have multiple sex partners; they drink alcohol and use drugs; etc.). The words we use to denigrate women are synonyms for prostituted women: whore, slut, etc.

As a consequence, prostituted women become a legitimate target group for male violence. We somehow come to believe that it is okay for men to hurt prostituted women. They are, after all, “bad girls”.

The speaker discussed Gary Ridgway (the “Green River Killer”), who sought out prostituted women and murdered them. Nearly half of the women he killed were under the age of 18. The speaker asked why the media consistently describes these women as “prostitutes” and omits that nearly half of them were, in fact, “children”? What if we described Gary Ridgway as the “most prolific killer of children” in American history?

The speaker then described how a former pimp would find and select women (girls). His strategy was essentially this: If he spoke to a woman and she responded with any direct eye contact (even if she was flattered), he would walk away and end the “grooming” process right there.

Why? Because he knew that those women who made no eye contact with him already had life experiences that would make the pimp’s job easier. “Someone else has already beaten her down so I don’t need to do as much to make her work.”

The speaker then noted that researchers often wonder about the mental health of prostituted women… but why hasn’t anyone examined the mental health of buyers and pimps (mostly men)? Prostituted women often develop PTSD, which is unsurprising given the chronic trauma they endure while working. What is wrong with us as a society that we haven’t shown the same interest in what is “wrong” with the johns?

A discussion followed about the words we use to describe men viewing women. In the US, we often say that men “ogle” or “leer at” women. Those words have a “hubba hubba hubba!” quality to them; men who want an interactive, romantic relationship don’t “ogle” or “leer at” women. When was the last time you heard of a man “beholding” a woman?

One of the most striking points the speaker made was when he asked, “To the men in the audience: What do you do to protect yourself from rape?”

Silence ensued. Some men in the audience were perplexed.

“To the women in the audience: What do you do to protect yourself from rape?”

Many women answered immediately: “Travel in pairs.” “Keep my drinks with me at all times when I’m out.” etc.

Both men and women in the audience were stunned at the disparity of responses.

The speaker then discussed the issue of consent: Consent for sex should be an “enthusiastic yes!”, not something that requires negotiation. In prostitution, the exchange of money for sex is coercion. Economic coercion is never true consent.

The speaker also commented that buyers aren’t paying to learn the reality of the prostituted woman. If the girl is 16 years old and the buying man asks her age, of course she is going to say that she is 18. If he asks her if she has a pimp, of course she will deny it.

The speaker then challenged the audience to speak up even when someone tells a sexist joke against women. Doing so helps to construct a world of equality where women aren’t reduced to sexual objects. He commented that a sexist joke is on a continuum that also includes a man forcing his wife to have with him (“why did I get married if I couldn’t have sex with her whenever I wanted?”), paying a prostituted woman for sex, rape, and murdering women.

The speaker shared that prostitution “is like domestic violence on crack”. The cycle of abuse applies to both. He reported that prostituted women leave and return to their pimps between seven and ten times before leaving for good. It is often difficult for the women to leave because they often identify with their pimps due to something like Stockholm syndrome, though “trauma-bonding” is probably more precise. Prostituted women also frequently develop drug and alcohol problems as a means of coping with the ongoing trauma associated with the work. (Imagine getting into the cars of buyers multiple times a night without knowing if you will get hurt; imagine a pimp beating you because you did not bring back sufficient earnings; etc.)

The speaker also discussed the “bad date list”, which has historically been a paper list that prostituted women have passed around with names and identifying information of buyers who don’t pay, hurt the women, etc. He said that they hope to develop a “bad date” app because of the ubiquity of smart phones.

The speaker closed by discussing different models of managing prostitution in societies. He said that he is strongly opposed to legalized prostitution. He cited some data where states and countries with legalized prostitution often results in more sex trafficking and prostitution. He gave the example of Germany: The demand for prostitution has gone up since it has become legal, so Eastern European women are often lured and trafficked into Germany to work as prostitutes.

He expressed hope in the “Swedish model“: Sweden has taken the approach that women working in prostitution are victims and, thus, the selling of sex is not considered a crime. However, buyers, pimps, and traffickers are prosecuted to the fullest extent of the law. Some data suggests that, as a consequence, there is less visible prostitution and fewer women working in prostitution.


Categories
Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Informal Curriculum: Lesson 1.

It’s been over a year, but I haven’t forgotten about the Informal Curriculum.

The first recommendation in the informal curriculum in medicine, which I still believe is “paramount, the most difficult to define, and often challenging to implement”[1. It is no coincidence that a topic that is “paramount, … difficult to define, and … challenging to implement”, is also difficult to write about.] is to be a person.

What does this mean?

Be the best professional person you can be. Be a person who actively listens to patients, who shows empathy and emotions. Be courteous. Show humanity. Be a person.

Non-psychiatrist physicians seem to have an easier time with “being a person” than psychiatrists. Psychiatrists, as a population, can be weird. We can demonstrate exceptional skills at not being people. Sometimes we come across as intrusive, awkward, and odd.

I get it. I’ve had peculiar interactions with psychiatrists who knew I work as a psychiatrist. That might explain why the conversations were even more uncomfortable than expected. (Those are stories for another day.)

Do note that this recommendation exhorts you to be a professional person. This doesn’t mean that you tell your patients about your relationship or health problems, how crappy of a day you’re having, or why your political views are correct. That stuff makes you a person, too, but that doesn’t make you a professional person.

If patients are telling you things that worry them, be a person and acknowledge their worry. If they tell you something funny and it’s not inappropriate to laugh[2. Being a person does not mean that you toss clinical judgment and boundaries away. There are times when you shouldn’t smile and laugh, even if you want to. That topic is beyond the scope of this post.], smile and laugh. Talk with them like they’re people, not diseases or case studies.

Be a person.

Patients often want to share a connection with their physicians. Patients suffer and worry. They want to know that you care about their suffering or worry. That’s what actual people[3. Yes, there are anecdotes that people will share their woes with and find comfort in a computer program.] do: They care about the suffering and worry of others.

Be a person.

Why is this paramount? Why is this my first recommendation in the informal curriculum?

Because relentless forces exist in medical training and work that can transform you into a non-person.

You use words that most people don’t use. Most people don’t talk about MELD scores, Glasgow Coma Scales, or HIV classification systems. You see a lot of emotional and physical anguish. You see people who are ill. Sometimes they cry. Sometimes they scream. Sometimes you see parts of them that they will never see. Sometimes you see them die.

These are the things that can make you turn into a non-person.

So make an effort every day to be a person. If you’re not, none of the other suggestions in the informal curriculum will matter.


Categories
Education Observations Policy Reading

DSM-5: Post-Traumatic Stress Disorder (PTSD).

This is another post from my DSM-5 e-mail list. If you find the information below useful or interesting, you are welcome to join.


(747 words = 5 min read)

The essential feature of PTSD is the development of reactive symptoms following exposure to a traumatic event. The diagnosis of PTSD has notable changes in DSM-5.

One difference is that, according to DSM-5, a person no longer needs to experience emotional reactions (“intense fear, helplessness, or horror” described in DSM-IV) to the trauma.

The authors provide a long list to describe criterion A (“exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways”). Note that sexual violence is now included in the definition.

Criterion A also allows for the diagnosis of PTSD for individuals who have had only indirect exposure to the trauma, though the trauma must have occurred to “close relatives or friends”. There is also a clause for repeated and extreme exposures, such as what paramedics and other first responders witness. The events of September 11, 2001, have influenced this diagnosis.

Criterion B, previously the “re-experiencing” sphere, is now the “intrusion” sphere. These symptoms include memories, nightmares, dissociation, and distressing reactions to internal and external cues related to the trauma.

Criterion C remains the “avoidance” sphere (avoidance of both internal and external reminders), though patients only need to meet one of two criteria in DSM-5 (versus three of seven in DSM-IV).

Criterion D encompasses “negative alterations in cognitions and mood”, which includes memory problems, negative thoughts (think Beck’s cognitive theory of depression), and resulting distressing emotions. This criterion helps capture the “comorbidity” of depression seen in PTSD.

Criterion E is the “hyperarousal” sphere that describes the irritability, “jumpiness”, and paranoia often seen in PTSD.

The authors note that these symptoms must persist for at least one month and cause “clinically significant distress or impairment”. As usual, they ask that the reader ensure that these symptoms are not due to a medical problems or a substance use disorder. There are only two specifiers:

  • with dissociative symptoms (depersonalization or derealization)
  • with delayed expression (full criteria are not met until at least six months after the event… the authors state that there is “abundant evidence” to support the delay in symptom appearance, but do not offer any explanations as to why)

The authors also include PTSD criteria for children ages six and under (which I will not review here, since I only work with adults… child psychiatrists, I direct you to page 272).

The authors note “auditory pseudo-hallucinations, such as having the sensory experience of hearing one’s thoughts spoken in one or more voices”, as well as paranoid ideation, can be present in PTSD. I find this useful because, previously, I’d give a primary diagnosis of PTSD and a secondary diagnosis of “psychosis NOS”, though it was clear that these were not “organic” psychotic symptoms.

The authors also note that prolonged exposure to trauma can result in emotion dysregulation, problems with stable interpersonal relationships, and dissociative symptoms… which sounds a lot like borderline personality disorder.

DSM-5 states that the projected lifetime risk for PTSD is only about 9%. This speaks to the resilience people possess, as much more than 9% of the population experiences trauma described in criterion A. Complete recovery is within three months for about half of adults. This again is a testament to the resilience people have.

PTSD is also diagnosed much more in the US than in other Western countries. (Paul McHugh has written a lot about the amplification of PTSD in the US.) Women are more likely than men to receive a diagnosis of PTSD. Those at highest risk of developing PTSD include survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.

The authors divide risk factors for PTSD into three groups:

  1. pretraumatic factors (temperament; childhood adversity; racial minority; etc.)
  2. peritraumatic factors (severity/dose of trauma; interpersonal violence; etc.)
  3. posttraumatic factors (“negative appraisals”; exposure to upsetting reminders; etc.)

The differential diagnosis for PTSD is one of the largest in psychiatry; it includes other stress disorders, mood disorders, personality disorders, psychotic disorders, and neurocognitive disorders. PTSD also has many “comorbid” conditions as already noted above; DSM-5 states that 80% of people diagnosed with PTSD are likely to have symptoms that meet criteria for another mood, anxiety, or substance use disorder.

Anecdotally speaking, people wrestling with homelessness and poverty often have a significant history of trauma. We might assume that the homeless caused their own problems. When you start asking clarifying questions, however, you often learn that they had horrifying childhoods. Just some food for thought.

Next time: Probably bipolar disorder.

Categories
Education Lessons Medicine Observations Reflection

On Being a Person.

Upon looking at me, there’s no doubt about it: I am Asian.

My ethnicity occasionally becomes a topic of conversation with patients. Some immediately ask me, “Yang… that’s Chinese, right?”

Others take a different approach:

“Where are you from?”

“Where am I from?” (This is meant to clarify the question, as it can mean different things….)

“I mean, where did your family come from? What part of Asia?”

Patients with significant psychotic symptoms occasionally start conversations with me like this:

“Konnichiwa! Ichiban? Teriyaki?”

or they might say things like this:

“God has a good recipe for kim chi. Do you want to know what it is?”

For the most part, it is completely clear that these conversations arise from benign intentions: Patients are trying to make a connection.

Even if I speak English with a perfect California accent or wear clothes that blend in with the fashion of Seattle, I cannot mask that I am Asian. It is a significant part of my identity and I bring it with me wherever I go.

While in training psychiatrists are often encouraged to present oneself as a “blank slate”. This psychodynaimc argument states that the more neutral you are—in speech, attire, manner etc.—the more you can analyze the “transference”, or what reactions (emotions, thoughts, behaviors) patients have upon interacting with you. These reactions are the grist for the therapeutic mill.

We, however, can never present ourselves as blank slates. Patients—people!—notice both what we bring to an interaction and what is absent. People might have opinions about my ethnicity, my facial expressions, the tone of my voice, or the scribbles I make during the conversation. They might also have opinions if I make few utterances, maintain an expressionless face, and answer questions only with questions (as demonstrated above).

Instead of being a “blank slate”, sometimes the best thing we can do as psychiatrists is to be a person.[1. To be clear, a psychiatrist should be a professional person; this is no time for sloppiness or disregard for a patient’s wellbeing and dignity. Being the best professional person you can be is still being a person.]

If people have relationship difficulties, we can be an actual person so that the patient can learn how relationships with people can be different. If people come to treatment because they have challenging relationships with themselves, we can be an actual person so the patient can learn how these views of self affect not only them, but also other people. If people have tenuous connections with reality, we can be an actual person who provides accurate feedback about “reality” (and make very clear that we’re not trying to steal their internal organs, etc.).

Being an actual person can be scary. We might worry what people (colleagues, patients, others) think of us. However, that vulnerability and authenticity we bring as people to the clinical interaction might be the most healing and inspiring to our patients.


Categories
Education Lessons Medicine Policy

Involuntary Commitment (VI).

Recall in the second scenario the man who was throwing his furniture out of his apartment due to concerns that someone or something was trying to take over his room. How would you apply involuntary commitment criteria here?

1. Does this person want to harm himself or someone else?

There isn’t compelling evidence that he wanted to harm himself—if anything, he suggested that his behaviors were attempts at self-preservation.

Though he never said that he wanted to harm someone else, his behavior was inadvertently putting other people in danger: He had already thrown stuff out the window, where it could have injured people on the sidewalk. He also threw a guitar in your direction, though, thankfully, it didn’t hit you.

2. How imminent is this risk of harm to self or others?

Imminent. He does not appear to be responding to direction to stop throwing things and perhaps it is only luck that the items he has thrown has not hurt anyone.

3. Are these behaviors due to a psychiatric condition?

Probably.

Given what we know about his history and the timeline of events, it seems likely that these behaviors are due to a psychiatric condition. However, these behaviors could feasibly be due to drug use or medical problems.

Related: Will hospitalization help treat the underlying psychiatric condition?

Probably. Hospitalization has historically helped this man recover from his acute symptoms.

What actually happened?


After the guitar crashed into the wall, other people—neighbors, staff—arrived. The man had retreated back into his room and continued to shout: “People don’t UNDERSTAND none of this is MINE how did this even HAPPEN why did I think it was OKAY I won’t let it happen again I won’t let it happen again—”

After tucking myself around the corner, I shooed away the neighbors; they needed to get out of there for their own safety. A social worker used her hands to mime making a phone call, her eyebrows raised as if asking a question. I nodded.

“Hey,” I said in a quiet voice[1. The next time you’re trying to lower the volume of someone else’s voice, try lowering the volume of your own voice. It’s hard to yell when the other person is barely audible.], “I’m sorry you’re feeling overwhelmed. Just so you know, though, we’re calling 911. I’m worried about you.”

He grabbed the clock off of the wall with one hand and a framed photo of his sister and him with the other and threw both out the window. Both shattered when they hit the sidewalk.

“I DON’T CARE you can do whatever the F@#$ you want I just NEED to get rid of all this SH!T—”

The rest of us waited.

Before the police and paramedics arrived, he had thrown a floor lamp, more silverware, and much of his clothing out the window. Papers were scattered on the floor. He smashed all the mirrors in his apartment. He tore the curtains from the walls. He threw several pieces of fruit, one remote control, and his pillows out into the hallway.

I braced myself as the police appeared in the hallway. Please cooperate… please cooperate… I hope the cops won’t be jerks…

The social worker had already briefed the police and paramedics about the situation.

“You Dr. Yang?” an officer asked. I nodded.

“And that’s the guy?”

“Yes.”

“We’ll take it from here. Can you write an affidavit?”[2. An affidavit is a written declaration that is used in court, in this case to hospitalize this man against his will. The police were asking me to write the affidavit because of my credential and because of my relationship with the patient. This affidavit included my opinion that he was a danger to others, given that he had thrown a guitar at me and had continuously thrown items out of his window.]

He was rummaging through his closet when the officers knocked on the door. He looked over his shoulder and paused as the officers greeted him. A few beats of silence followed.

“OH GOD WHY WON’T THEY LEAVE ME ALONE?” the man suddenly bawled. He fell to the ground and began to weep. After glancing at each other and then me, the officers and paramedics walked in.

He initially balked at their overtures about transport to the hospital, though he ultimately agreed. He choked on his sobs on the gurney as the paramedics wheeled him down the hallway.

He was in the hospital for over a month.

At our next appointment, he sat in the chair, his eyes glazed over, his body twenty pounds heavier.

“I’m sorry about what happened that day,” he said.

“That’s okay,” I murmured. “I’m glad you’re here.”