Religious Freedom in an Emergency Department

I worked as a staff nurse in a pediatric emergency department from the time I graduated nursing school through when I received my master’s degree in nursing, in total between 6-7 years. I started at age twenty-two.

I enjoyed being twenty-two. I lived in a left wing land with Obama soon to be entering office and even though I attended school in very conservative upstate New York I never really internalized the level of conservatism that abounds in most of the country. I was working in an inner city hospital in the Northeast happily back in my liberal bubble.

The Emergency department was a hodgepodge of characters. Attendings, residents, nurses, techs, EMTs, police, security, administration, social workers, psychiatrists, surgeons, pharmacists…you name it and we had them at some point working in the emergency department. At that age and in that geographical area I basically assumed every one was pro-choice, pro-LGBT rights, and pro-healthcare for all.

I was wrong.

One day I was taking care of a patient who was raped. She was young (children’s hospital being under 18), and scared, and traumatized. The physician spoke to her mom and her about all the options available to her. Rape kit, medications, etc. One of the options was the morning after pill which prevents pregnancy from occurring. The mom and the patient wanted to discuss it and they agreed to certain things but initially did not want the morning after pill. No one pushed it, as that’s not our role.

Later, after all the tests and interviews and near time for discharge the mom approached me and said they decided she would take the morning after pill. I said sure, and went to the desk where the physicians were sitting. The Attending and the resident were sitting next to each other making my life easier. I told them the patient changed her mind and wanted the morning after pill.

The Attending looked awkward and said, “Okay, but I can’t order it,” and he looked at the resident, and she looked awkward and said, “Yeah I can’t order it either,” I stared at both of them like they had two heads and genuinely asked, “Is there something wrong with your computers?” They both shook their heads and avoided eye contact with me. I stood there staring at both of them and said, “Well some one has to order it because this kid was raped and she doesn’t want to get pregnant. So what’s the freaking problem?”

It still had not penetrated my head that they couldn’t order it because their religious beliefs prevented them from ordering it. I literally was still thinking there was a technical issue and for some reason the system was not allowing them to order it. I know it sounds so stupid, but I was young and naive and hopelessly liberal.

Another Attending overheard our exchange and likely heard my statement, and saw me standing there with my hands on my hips glaring at the computers and the doctors, and quietly said, “I’ll do it.”

That’s when I got it.

I remember walking away silently to the medication room. Later I was with the Attending who ordered it and I asked what would have happened if it was night shift and they were the only two doctors in the ED? He told me they would have ordered it. But I wasn’t so sure. I’m still not. I’m thinking if it was night shift and they were the only ones in the ED I’d be trekking up to the ICU and finding one of their Attendings to place the freaking order.

This happened eleven years ago. I still remember it vividly. For many reasons.

For starters I never envisioned patient care being affected by some one’s religious beliefs. I remember we had a travel nurse from North Carolina. She told me they don’t even offer it to rape victims where she worked down south. I thought that was shitty. Still do.

If birth control is against your religious belief I would hope that murder, rape, pedophilia, burglary, tax evasion, etc. are also against your religious beliefs. Do physicians regularly screen their patients for committing tax fraud? Because let’s be real, everyone in America who owns a business probably has kept cash for themselves and not reported it as income. Do you not treat them because they are stealing and committing tax evasion? Do you not treat men who’ve committed rape when they arrive in the ED for a heart attack? Do you not treat the man who arrives in the ED after having a heart attack while he is screwing a prostitute who also arrives with him, but quickly exits when she hears the wife is on the way (Yes that’s happened)? Why is it that you can pick and choose what religious beliefs you follow at work and which you don’t?

You shouldn’t, hence why religious beliefs should not affect the delivery of healthcare.

Here’s one that will totally trip you up- would you refuse to treat a pregnant transgender man who wants to have the baby? What about all that pro-life chatter? Or does pro-life mean you’re only going to treat the lives that matter to you? 

The Health and Human Services Department recently formed a committee to explore religious freedom within healthcare. Per LamdaLegal article the aim of the committee is to protect from consequences health care providers who refuse services to patients due to religious beliefs. It makes me sick that in the United States we have one of the highest Maternal mortality rates in the Western world, but no we aren’t going to form a committee to save women’s lives during childbirth.

In 2009 a study out of Harvard wrote that about 45,000 deaths in one year were attributed to people not having health insurance. But we are focused on decreasing access to care instead of increasing it. Psychiatric hospitals are losing funding, states are shutting down facilities, families with severely autistic individuals have no long term plans for placement. The United States has one of the highest infant mortality rates in the Western world. But we can’t focus on that. Our current administration is instead focusing on restricting care.

But I digress. My patient got her medication preventing pregnancy. Thanks to an Attending who was not conflicted about ordering it.

My heart aches for the number of people within the LGBT community, who if this committee actually makes progress, will hesitate to receive healthcare services because they are fearful of being refused services.

Religious freedom is a beautiful component to American society and the foundation on which our country was built. But religious beliefs do not belong in healthcare delivery. Science, education, and clinical experience should be the basis of medical decision making.


LGBTQ in the Days of #45

The FBI published data last year that hate crimes were on the rise. According to their report entitled, 2016 Hate Crime Statistics, there were roughly 1400 hate crimes directed toward the LGBTQ community defined as crimes perpetrated due to sexual orientation or gender identification. Now in the grand scheme of our population 1400 may not sound like a lot. But those are 1400 individuals who were attacked and/or assaulted and/or murdered due to their sexual orientation or gender identification. That is 1400 too many.

That is also a 5% increase from 2015.

When this was published in 2017 the rate of murder of transgender individuals was already increased from the previous year.

I believe the actual number of hate crimes is higher, but many are not reported.

I personally don’t think it’s a coincidence that there is an increase in hate crimes toward the LGBT community after we elected officials who are openly anti-LGBT.

In my clinical practice I’ve heard many individual’s stories of discrimination and being victim to assaults due to sexual orientation or gender identification. I’ve heard from clients and in my own personal life that they have been spit on, punched, thrown against walls, jeered, followed, etc. I’ve yet to meet some one who has reported any of these experiences to the authorities.

I’ve met people who have come away with black eyes and broken bones or dislocated joints, and they have not reported these crimes. I’ve actually never met someone who has pressed charges. This is why I think this is a gross underestimation of actual hate crimes.

The saddest stories are those where the perpetrator is a family member who reacts with violence when their child comes out to them. I have spoken to individuals who have walked away with broken bones after coming out to their parents.

This happens in the United States. Not just in the South. But also in the Northeast. It happens in towns and homes right next door to you.

I’ve been questioned by transgender clients in the past year about what my medical record will say and who it could be released to. They have said they live in fear of our new administration and they don’t want to be put on a list somewhere by the government.

I thought it was cool when my medical record system added gender identification as an option. But to my clients it is a vulnerability.

The Queer community feels unsafe. I see and hear it daily.

Nothing will change this uncertainty and fear unless we vote. Vote in the 2018 elections. Vote in the 2020 elections.

Don’t turn a blind eye to the hatred fostered by this administration. It is real, we are feeling it, and it hurts.

Holding Hands with my Wife

Before I dated my wife I dated men. I went on dates in public places with men including places like the beach and the movies. At all of these places I engaged in public displays of affection otherwise known as PDA. This could be as simple as holding hands or as much as kissing, or cuddling. I never thought twice about it.

I have been with my wife for ten years. A full decade. In that time I can probably count on both hands the number of times I’ve held hands in public or engaged in any type of PDA.

I am by nature private and am not one to be extremely affectionate in public. But being married to a woman has made me even more cautious.

Recently a friend who I hadn’t spoken to in awhile messaged me on facebook and told me how much they were enjoying my blog and how much they really had no idea what my wife and I went through to be together. That’s not the first heterosexual friend to tell me that since I started this blog. Many have told me they had not idea that I didn’t dance at their wedding because it was a heterosexual wedding full of heterosexual people, or that they didn’t know about the decisions we made when selling our home in terms of our family pictures, or about the decision to be an “out” provider. That’s basically the point of my writing. Heterosexual individuals including some of my dearest friends and beloved family members, take for granted the hetero-normative culture we live in.

I vividly remember my wife and my first date. It was at a restaurant. I felt like we had a big neon red sign flashing over our table, “Lesbian Date Here” and I was terrified. I had witnessed too much discrimination with my friends and sister who were gay to be relaxed. I waited for someone to peg us as being on a date and start making comments.

We didn’t go on another date for a long time. I mean, we went out places, but I kept it very neutral in public. I still do to some degree.

In a decade we’ve been on countless dates to the movies, the beach, vineyards, hikes, etc. As I’m sure any couple who has been together a decade can attest to, we’ve spent a lot of time together privately and in public spaces. I can say that unless we were in a gay bar though, we were not holding hands, we were not putting our arms around one another, we were not pecking on the cheek if she dropped me off a coffee at work, or any other hundreds of reasons why we interact on a daily basis in public.

Not all lesbian couples are this way. Many don’t give a shit and more power to them. I personally am generally hyperaware of other people and I just don’t want to deal with discrimination. If we are with another lesbian couple we are more likely to feel comfortable holding hands, and definitely if we are in a gay space.

Something that has brought this to the forefront for me lately is our sons. We are a very affectionate family in general. Our sons are all over us and we are all over them. Since we had them and since we started venturing out in public with toddler twins I’ve realized that I still care about facing discrimination as a result of PDA, but I also don’t want my sons to see me acting differently than they are used to. They’ve sort of turned our world upside down in every possible way.

I’m not going to turn into a PDA slut, and the point of me writing this is not to be some major transformative moment for me. It is to bring awareness to my hetero-audience.

You take for granted your freedoms.

If you know a lesbian couple who has been together a long time you should take stock of what you’ve witnessed in terms of PDA and recognize if there’s a general lack of PDA that it’s not because they are not or do not want to be affectionate.

It’s because they don’t feel safe being affectionate. 

Straight people have privilege to be natural all the time. If you want to reach out and touch your spouse’s hand as they walk by you in a crowded room, out of reflex, you can. I have been with my wife for ten years. I have literally held her hand in public less than ten times. If I really sit here and think about that it brings tears to my eyes. Next time you hold someone you love in public think about the freedom that gives you the opportunity to do so and don’t take it for granted.


Why Strong Women are B*#%&’s and how I was compared to a woman stabbing a head.

My cousin and I often send each other interesting cards or postcards randomly through the year. One I got from her this Fall took me some time to process. If you don’t know the story of Judith and Holofernes allow me to give a short version. Holofernes invades the city Judith resides in. He decides he wants Judith’s body. She enters his tent, he gets drunk, and she beheads him. It’s kind of awesome. I mean she takes on an Assyrian General who is literally laying siege to a city.

This story has been portrayed in numerous paintings over the ages including one by Francesco del Cairo. It was during the Baroque period, and since I took Humanities in high school I have a minimal idea what that means. The only lighting is to draw the viewer into Judith’s face. The rest is very dark. It takes a minute or two to look away from her bad-ass expression to realize she’s holding a dagger in a head. Holofernes’ head. There is also a servant girl who is trying to whisk her away from the scene.

Now my own back-story. If you’ve read the blog you know I’m feisty. I stand my ground, and I’ve been described as a bitch, hard-headed, stubborn, and most recently like a “gnat that will just keep coming and coming until she figures out what the hell is going on,”. The gnat comparison was actually positive because it was some one who was telling a client I would be relentless in trying to find an answer.

My cousin wrote, “Her face just says ‘are you going to piss me off too.’ You are also a glorious bad-ass who doesn’t take shit from anybody and you’ll do whatever it takes to protect your people.” The stamp was a Disney villain- Maleficent.

I called my cousin.

“You compared me to a woman stabbing a head.”

We laughed and she reiterated her original point. I ended with, “There’s a blog post here somewhere, fair warning.”

All of the qualities I have been criticized for over the years would be praised in a man. If I had a penis I would be called  a “go-getter” or my favorite, “Boys will be boys.” Standing my ground and holding to ethics when others waver and bend is looked down on in me because I’m a woman.


I also work in a female dominated field (nursing) and have had to go toe to toe with male physicians and psychiatrists. For voicing my opinions in healthcare I have been told to “Smile more” “take the weekend off because you may not be thinking clearly” “I know this is because you’re pregnant” “Is this because you are still breastfeeding?” “You just seem sensitive to this right now” “I’m not saying this because you’re a woman.” “You didn’t do anything wrong, but” “So I need to talk to the real person in charge now.”

What I have had to say because I’m a woman, “My face is up here.” “So me bringing up the fact that the resident made a bad call and this was done under the Attending is now translating to me not thinking clearly?” Message received. “That patient grabbed my ass, and you laughed, I don’t think I’m being overly sensitive, I think I was sexually groped and the staff present, a physician laughed.” “MY FACE IS UP HERE!!!!”

Healthcare is hard. Corporate structures are hard. Being a female in any field is hard. Being a lesbian pregnant or nursing female is even harder. Some days the fight doesn’t seem worth it. I did take that weekend off several years ago, and I came to some very important conclusions. I could not change that system unfortunately. I had to work there, bide my time, and leave. Sometimes we have to work in places we don’t like to get to the light on the other side. Without my time in the darkness fighting and learning to not fight, and learning about “old boys clubs” and bureaucracy I would not be where I am today. Some of my hardest lessons personally and professionally have been learning that I can’t fight every battle even when every atom in my being wants to. Staying silent takes more strength and more inner turmoil sometimes than speaking up.

I worked in the hospital settings for ten years as a staff nurse and an advanced practice nurse. I experienced sexism in almost every possible way. It’s hard to not come through healthcare and have some sort of resentment build toward men. There are also constant power struggles that are hard to not engage in especially as a younger less experienced provider. I came through the last decade less naive, more cynical, but if anything I am now more passionate about my patients and providing quality care and that’s I think what is important for me to hold onto.

The thing that really gets me is if I were a man all of the traits that have been admonished in me by previous bosses in healthcare would have been praised if I were male. The bitch in me would be seen as authoritative and somewhat attractive in a male. But because I’m female and have been pregnant or worse menstruating I am just a bitch.

I used to bristle at male qualities being pointed out in me as negative. Now I’m like fuck it. I’ll stab the head and hold it up and roar. I’m direct, I have a dry sense of humor, I smile only when it’s truly warranted, but that doesn’t mean I don’t care. Our country and our youth have gotten into a situation where by being nice we have allowed monsters into power. We allow our LGBT youth to die from suicide and homelessness and drugs and hatred. If standing up demanding for the tenth time you look at my face and not my tits makes me a bitch, so be it. If standing up and demanding action and pointing out the negatives in our society without a pretty smile on my face makes me a bitch, so be it.

If putting females into a villain role is the only way we as a society are comfortable with them being strong, fierce, loyal, fighters, then so be it. I’d rather be Maleficent spewing fire than laying back with my eyes closed living in a fairy tale.

Psychostimulants…the Good the Bad and the Ugly.

Stimulants first arrived on the market back in the 1950’s. Prior to that they were given to soldiers in World War II in order to keep them awake and focused. There’s a great novel- ADHD Nation- that outlines the history of stimulants so I will not go into that here. What I do want to talk about is my clinical experience in prescribing stimulants.

I have a lot of thoughts about ADHD as outlined here. For this blog post I’m going to try and stay off my soap box and stick to clinical experience only.

The Good. 

I don’t prescribe Adderall. I will limit my discussion to Ritalin LA, Ritalin (methylphenidate), Focalin XR, Focalin, Vyvanse, and Concerta. There are short acting stimulants (Methylphenidate and Focalin are the ones I prescribe most, however I have also prescribed Dexedrine) and long acting stimulants (Concerta, Vyvanse, Focalin XR, Ritalin LA). There is also a patch called Daytrana- I have never prescribed it. I know prescribers who have and they report mixed results. The good about Concerta is that it’s cheap and usually covered by insurance. The good about Vyvanse is it is less addicting and has a slower onset as well as less of a crash. Focalin XR I’ve had mixed results with, it doesn’t last as long as Vyvanse or Concerta but when it works it does really work for people. Some people who couldn’t tolerate Vyvanse or Concerta were able to tolerate Focalin XR. Ritalin LA same results, doesn’t last as long but generally well tolerated when it works. The benefits of stimulants for teenagers with ADHD can be quite astounding. They report feeling like they can focus better, having improved short term memory, improved organizational skills, and many of my clients report feeling better and more confident socially. To be clear, these are all subjective reports from my clients and what I have observed in my practice. None of the above should be substituted for your own practitioner’s recommendations and clinical experience.

The Bad.

They all reduce appetite and I’ve had to stop them or not even be able to start them in teenagers who are already underweight. There often is a crash of some sort. People report feeling very tired when it wears off or having onset of significant headaches. Some people just don’t tolerate long acting stimulants in general and feel crappy and in a fog when they take any of them. They can cause hypertension, and yes I’ve seen that happen in multiple cases hence why I check blood pressure. They can cause increase in irritability and anger. They can interfere with sleep. The worst is when a teenager is taking a stimulant and doing much better in school, and then they start to not be able to sleep. They come in for a medication visit with their parent and they both ask for a sleep aide. This is something I don’t do. I’m not going to prescribe an “upper” during the day and a “downer” at night to mitigate the side effects of the “upper”. If there are adverse effects such as poor sleep then we need to take a break from the stimulant. Many people do not like this answer.

The Ugly. 

Stimulants (and non-stimulant Strattera) can cause auditory and tactile hallucinations. I have seen this in clinical practice and it’s very scary for the client and their family. Stimulants can stunt growth. I’ve had clients on stimulants throughout their adolescence who grow to be over six feet. I’ve also had clients in their adolescence who stop growing and who need to be off stimulants and obtain growth hormone injections in order to reverse these effects. The growth stunting is very rare, but I’ve only been prescribing for four years and I’ve seen it happen. There is no predicting who will be in which category. Stimulants are absolutely addictive and they have a street value and you can snort them. I’ve even had clients who injected them.

The ugliest part of stimulants to me as a prescriber are instances when they are sought for the wrong reasons. I’ve done intakes on kids who are absolutely brilliant. They are referred by teachers for being “too fidgety” or “off in space” but they are getting straight A’s. These kids are bored. They need more challenging work at school, but in a class of 25-30 kids the teacher teaches to the average or below average so the kid only has to pay attention for the first five minutes to understand the lesson. I don’t prescribe to these kids, but their parents can easily take them to some one who will. Or the kids who are angry all the time and acting out at home so they must have ADHD. Then you talk to the kid and find out about a trauma history. These kids don’t need stimulants they need trauma therapy. The worst are the drug addicts who seek them to abuse or to sell or both. The addiction to psychostimulants is rampant and it’s something that no one talks about because drug companies are making billions of dollars.

Fun fact- the volume of Adderall that can be produced in a single year is regulated by congress. Guess who endorses the continued increase in the volume of Adderall that can be produced yearly? Our representatives and senators in congress. In one breath our politicians are speaking out against opiate addiction while in the next they are advocating for increase in production of stimulants. As a prescriber who sees the abuse of these medications daily I feel this is a problem.

My take home message is there can be vast benefits for people who truly suffer from ADHD and for who it is impairing their functioning socially and academically. But there are also adverse effects, long term effects, and addiction which all need to be considered carefully before writing out a prescription.

When I was told to breastfeed on a toilet.

Pre-babies I had a lot of thoughts about breastfeeding. Some of them still hold true. I don’t need to see other people breastfeed. I am a very modest person in terms of nudity and seeing other people’s boobs is not something I’m into. However, I would never put another mom down for breastfeeding wherever and however they need to do it. It’s my issue so I look away. If I ever heard any one give a mom a hard time for breastfeeding in public I would immediately come to their defense.

Some stuff I learned about breastfeeding twins for twelve months is important. As a society we don’t talk about breastfeeding because it has to do with boobs and we as a society are extremely closed to these discussions because apparently we only like talking about boobs if they are sexualized.

There is a lot of pressure on new mom’s to do things certain ways. And the right way varies depending on who you talk to. People become very judgmental and invalidating. I’m writing this blog post to hopefully provide some encouragement and validation to new mom’s.

I decided to breastfeed my kids because I work in healthcare and I knew it was the healthy choice to make. I was not going to put a lot of pressure on myself to “make” it work though. Because I knew my mental health was more important when starting a journey as a twin mom. So here’s my breastfeeding story.

Immediately after being cut open and having two babies taken from my uterus and while I was still intermittently puking I had two beautiful little beings put onto my boobs. One of them took it to it right away, the other was not very interested.

They were born at 36 weeks, they were both 5 lbs. Having been a pediatric nurse I knew they were at high risk for weight loss and feeding issues. That is what would keep them in the hospital. So I was determined to make this breastfeeding thing work. I also agreed to supplement with formula until my milk came in. I wanted to bring them home.

Enter in pre-eclampsia. I had high blood pressure which is why we did the emergent C-section. The next morning I lost all peripheral vision in both eyes. I was put into maternal special care and started on a magnesium drip as they thought I was having full blown eclampsia. The next twenty-four hours sucked ass. I got no sleep. They check vitals every hour on a Magnesium drip. I was on bed rest, so I had the freaking catheter still in. My incision freaking hurt, and they would still come in every two hours and throw the boys onto my boobs. They also encouraged me to pump between feedings to help bring in milk supply.

So I had no vision, I was on a drip that made me feel shitty, and I was fresh post-op. People were texting us wanting to come to see the boys. I wanted everyone to go away and leave me to die. It sounds so dramatic but it was totally awful.

So that was my introduction to breastfeeding.

Luckily after some force-feeding of the boys with medicine droppers and the 24 hours of Magnesium we were all cleared for discharge. One of my boys was breastfeeding like a champ, the other one not so much. Every two hours it was an ordeal. One boy on each boob, and extra attention to the one boy who needed it.

About five days in my nipples felt like they were going to fall off every time they nursed. I’m not exaggerating. I actually had nightmares where they fell off. Because they didn’t get a break. There was no switching boobs, it was one baby on each boob every time they nursed. No breaks. Around this time we realized both my sons could not tolerate formula. We tried milk based, soy based, anti-allergy etc. The only thing they could keep down and sleep after having was my breast milk. No pressure.

After the first two weeks of me crying through every feeding because my nipples hurt I wanted it to be over. Now. But we literally tried every formula and it was not happening. They were both in pain afterward, up for twelve to twenty-four hours sometimes just miserable. So onward we went with breastfeeding. I did get my lazy feeder to start nursing well, so by about five weeks in they both were at least nursing easily but I was living life as a milk machine. I was always crazy about my supply. If I took six hours to sleep at night, I would wake up in the middle and pump. We were building up a freezer supply which thank God we did because we needed every last drop to get us through to a year.

Enter blocked ducts. I was making milk for two babies. My boobs were overloaded so I continuously would get blocked ducts. It feels like a hard lump in your boob. It’s extremely painful. The solution- nursing. One of my sons was a very vigorous nurser so he’d have to nurse on that side until the duct cleared. He did clear it every time. But it took a few tries sometimes.

Then we had family and friends over and they were sad they couldn’t give the boys bottles. They wanted to know why I couldn’t just not breastfeed them one time. It made me want to scream. I was working so hard physically and emotionally to keep up with twin supply. Every time they had a growth spurt my supply had to keep up with them. I also knew I was going back to work at eighteen weeks and we needed a freezer supply. I was working all the time on making breast milk to feed my sons. I didn’t want to hear it from anyone about giving them a damn bottle.

Breastfeeding twins who are not on the same schedule meant I was breastfeeding upward of eighteen hours a day. Mostly they were on the same schedule. But they never had growth spurts at the same time which meant those weeks were rough. Then one of my sons cut his first tooth at ten weeks. Yes that is rare. Yes it totally sucked. They didn’t use pacifiers at that time, and instead he was gnawing on my boob.

I couldn’t leave the house because if we left the house one of them needed to nurse. They weren’t the quiet nursers. They made a lot of slurping noises, they looked around all the time, and unless we were sitting alone on the couch at home it was not relaxing for me or them. Thus it was an incredibly isolating eleven months. The twelfth month we made it through on all frozen milk.

Had I not had two babies who were extremely sensitive to formula would I have stopped breastfeeding? Yes. Did I receive many opinions about my breastfeeding journey from many different individuals? Yes. Did this want to make me isolate even more? Yes.

Around the tenth month I was back at work already and had been sharing a double office with another new mom. We would both hook up our boobs to our pumps and do our notes while we pumped. It was a nice set-up because we could lock the door and we were both going through the same thing. But then there were some major office changes and we were told we would be put into a group room with three other employees, some males. When I asked my boss and the woman in charge of office space where I would pump they said well we don’t have a space. I said you have to provide me a space, and they said, “Well you can use a bathroom.” I said, “You want me to pump milk, food for children, sitting on an open toilet in a nasty public bathroom?” They both said “yes.” I informed them that this was against our state and federal labor laws to suggest I pump on a toilet. I ended the meeting, waited until I walked out and burst into tears. I was still pumping three times a day at work at that point.

I worked for a hospital, and both of those individuals were women one a mother. I could not believe I was being treated this way and I felt violated. I had come so far in this breastfeeding journey and put so much work into it and it literally was how we fed our children. I was angry and stressed and hormonal and I also knew it was illegal. So then I had to set up meetings with human resources and our executive director. I couldn’t believe that the three men I spoke to (while crying) about my whole experience were more understanding and more willing to help me than the two women.

The psychiatrist I worked with at the time and our chief resident immediately came up with a solution for me to use in the interim until the hospital got it’s shit together. I remember feeling so angry though that I had to even involve them. That my breast-feeding journey became this spectacle and source of gossip at work.

The whole experience was incredibly eye-opening for me. The more I talked to other women at work and online and in my life the more stories I was told about women being told there would be no accommodations made for them to pump at work. Teachers and nurses had it the worst or maybe that’s just who I was surrounded by. Women came forward having been told they could not take pump breaks or there was nowhere for them to pump, or use their car, the bathroom, etc. It was shocking to me.

Why do women not make a stink about this? Why are women treated this way by employers? Why as a society do we not empower women to feed their children in any way they want instead of making it impossible for them to do so without it being a battle? My place of employment should not dictate how I feed my kids. I should.

By the time the boys were eleven months they were big, healthy, eating solid food, and the last time I nursed them one of them bit me (he had a full mouth of teeth by twelve months) hard, and I was done. One of them was clearly ready to be done, one of them would probably still be nursing if I let it go on, but it was time. They went from 5 pounds at birth to over twenty pounds each by one year. My boobs will probably never look the same but it was worth it. There were moments when we would be nursing and they would cling their little hands together or hold onto my fingers. They would sigh and fall asleep on my chest. They would look at me and really see me with their big blue eyes. There were beautiful moments I wouldn’t trade for anything.

When a friend became pregnant with twins they asked me for advice. I said the number one thing I’d do is not stress about nursing. If it works it works, if it doesn’t and they tolerate formula just move on, the first year will be happier and easier and less isolating. Do I regret nursing? Never. Do I wish I was less isolated for the first eleven months? Yes. Do I wish I never had that experience at my job? Absolutely. It was horrible. But it also made me more aware of a problem our society has.

Breastfeeding is an incredibly vulnerable act. It exposes our bodies, it exposes our babies. It puts us into the position of not being able to defend ourselves if needed. It also makes us vulnerable to people’s judgements. Any mom who breastfeeds for any length of time deserves a medal. She deserves encouragement, pride, support, and NO judgement.

It’s taken me a long time to write this blog post. I stopped breastfeeding one year ago. But it still causes me to feel raw when I think about those eleven months. It was so hard for so many reasons. I could not have made it through without the support of my wife. I also would not have made it through if my son’s hadn’t absolutely loved nursing. That’s what kept me going. But I’m not going to lie. I’m very happy it’s over.

Bigotry down the street buying a Christmas Tree. 2017.

This holiday season brought a lot of decisions for us. We always celebrate Christmas. We were both raised Christian though our religious experiences left us with different tastes in our mouths for sure. We agreed on Santa Claus from the start. We sort of agreed on Advent breakfasts. That’s just a thing my family does every Sunday in Advent we have a nice breakfast at the dining room table and light an additional candle each week until we have five on Christmas day. I grew up reading certain passages from the Christmas story in the bible, so we do that too. However we also have the “Yule” book at the table, written by a Wiccan, and flip through that to find blessings and legends outside the Christian tradition.

Our advent breakfast sounds so austere when I read what I wrote above, but in reality it was me flipping pancakes, the boys screaming because they don’t do well without eating first thing upon opening their eyes. Waiting the ten minutes for pancakes is torture. But they do love pancakes. Then we served them their pancakes in their highchairs at the dining room table, we brought out the coffee, placemats, then by the time my wife and I sat down the boys were basically done. I read the passage from Luke and the boys babbled the entire way through with my wife “shh-ing” them, and telling them to be quiet, and me telling my wife to be quiet. Then they got down and wanted to help us eat our pancakes and one of my son’s knocked over my water bottle…the chaos just goes on. So in reality our peaceful advent breakfast was a clusterfuck but we don’t regret it. Traditions start out as clusterfucks I’ve decided, or maybe that’s just in my family.

The one tradition my wife and I never disagree about is the Christmas tree. We get one every year. We cut it down fresh, drag it to the parking lot, watch them wrap it in twine, struggle and swear at each other as we lift it onto the car, tie it down. Then the ENTIRE way home I ride the breaks and make my wife practically hang out the window to make sure it’s not going to fall off (it never has. I’m just a freak). My wife meanwhile bitches about hanging out the window and tells me to drive faster and the tree is fine.

This year is the first year the boys had any clue what was going on. All four of us went out into the field, the boys frequently falling and tripping over all the stumps and holes. We finally found “the tree” thinking it wasn’t too big, when in fact it was the biggest freaking tree we’ve ever gotten and literally would not have fit in our living room if there was furniture in there. Which there isn’t because we just moved in, thank God, so it’s still unfurnished. Well except the big ass tree.

So we are out in the field, I’m chasing the boys around, we are all getting trapped in prickers, my wife is sawing down the tree yelling at me to push it, I’m yelling at her that I have to watch the two boys. It finally comes down. We try and get it onto the cart. We fail miserably. It’s not going on the cart. Then she’s yelling at me that we picked a tree that’s too freaking big, and I’m like I wanted the little one back near the car. And we are losing the boys.

So I take the empty cart, and yell to the boys who follow me like little ducklings, still tripping over every hole in the freaking field. My wife drags the tree that’s literally five times her size, and then a very nice gentleman sees our struggle, and probably hears me scream at her “I hate doing this with you every year!” And she screamed back “I hate doing this with you too!” then we both are cracking up, and one of the boys is stuck in a hole.

Anyway the nice man helps my wife carry the tree to the twine thing. The boys and I and the empty cart make it out alive. Covered in scratches from the prickers. The lady by the twine says the tree is too big for their twine machine and has to be brought to the “main farm” for their “industrial twiner”. I’m like Motherfucker. At least they transported it there in a pick-up.

We put the boys in the car, we drive up to the main farm, and see the ginormous twiner. Now back at the tiny twiner we put a tag on the tree with our last name. Pretend our last name is Smith. We are hanging out at the big twiner. The boys are drinking “cider” (it was warm apple juice, gross, but it was free), and sucking on candy canes, watching the trucks and dogs and everything. The four of us are standing together watching our tree go through the big twiner, it’s kind of a kodak moment. It’s bitter cold and we are all snuggled together loving life.

There were three middle-aged white guys working the twiner. And one woman supervising the “cider”. They put the Smith tree through then looked around and only saw the four of us. The guy in charge looked at us, and said “Are you the…uh…” and he looked back and forth between my wife and I, pointed at me directly, “Are you Smith?” he says. Kodak moment broken. Stupid bigot alert. It wasn’t what he said, it was the hesitation, the understanding that flickered in his eyes as he was putting it together, and the downturn in his expression when he did.

I gestured toward my whole family, and smiled and said, “Yes, we are the Smith’s” (in my head it continued with some profanities). He took us all in. The boys had on fleece hats. I mean come on. Cutest thing ever. And one had a cut on his cheek from the prickers. Battle wound. We just survived a family bonding outing from hell. And we wanted our damn tree twined up and put on our car. It was an awkward moment, and the other men  there were clearly sizing us up and deciding whether they would help us or not. I think because we were the only people there and they had literally no escape and my eyes did not leave them for a second, they gave in.

They helped us put it on the car. But they weren’t nice. They didn’t interact with our sons and barely with us. They essentially acted like we had lesbian germs and they wanted to throw the tree at us and run. Which of course made me want to slobber all over them, but now that I have kids I can’t be that annoying lesbian calling every person out on discrimination.

Takes family bonding to a whole new level. Because all of the sudden we were not safe, and we were only a mile from our home. Suddenly I didn’t give a shit about the tree. I wanted to protect my sons. Because those guys could have spit on us, could have thrown the tree at us, could have destroyed our car. They could have followed us home and realized we were practically neighbors.

Some day the boys will be old enough to notice. Some day they might have a mouth like mine. Some day I hope middle aged white guys who live on farms will be nice to us.

And some day I’d like to actually estimate the size of the tree correctly.

The Challenges of Treating ADHD as a Prescriber

I receive around two or three calls weekly for evaluation of ADHD in children and adults. Generally people have done some sort of questionnaire online and self diagnosed after answering six general questions. Or they have been receiving stimulants from their pediatrician, PCP, or other psychiatrist or APRN who is now requesting they transition care to psychiatry for whatever reason. They could have been on stimulants for years, having only completed a basic questionnaire at the time of the first prescription.

Diagnosing ADHD is hard. There are a lot of false positives because our brains and bodies are not supposed to sit for eight hours a day listening to lectures or working on a computer. So kids in high school and college who find lectures challenging often come to me stating they can’t pay attention to a three hour lecture. I’m thinking yeah but who can?

Depression is pretty straightforward. For a true severe depressive episode there is weight loss/gain, poor ability to function in daily life (decrease in showering, poorly groomed, missing work etc.), sleep increase or decrease, irritability…the list goes on. I’ve sat with enough depressed people on the spectrum from mild to severe with psychotic features that it in general fits a picture and there is overt evidence of impairment in functioning of the individual.

ADHD, especially in adults, is more subjective. Sometimes it takes a few sessions for me to see the full disorganization of their thought process. These are people who could be getting a 3.5 GPA telling me they can’t focus and can’t organize themselves. It’s hard for me to believe that when they are doing well academically. There’s also a lot to rule out. Anxiety disorders often present with difficulty focusing as do depressive disorders. Bipolar disorder has a high co-morbidity with ADHD and many times when bipolar patients are treated with mood stabilizers their focus improves. Trauma/abuse in children presents often as behavioral difficulties and difficulty focusing. I can’t tell you the number of kids I’ve assessed who have been diagnosed with ADHD but no one asked them about being sexually assaulted and how that is on their mind all the time making it impossible to focus.

I have adults who come to see me who are working two or three jobs, raising kids, getting maybe four hours of sleep per night telling me they have trouble concentrating and completing tasks. Chronic sleep deprivation can cause cognitive impairments. In other words without enough sleep you can’t think straight. Taking a stimulant would enhance anyone who is chronically tired. Taking a stimulant honestly would enhance anyone in general too.

What I look for in an assessment is thorough testing of some sort. Neuropsychiatric evaluation, or at the most basic a Conners Behavioral Rating Scale. Anything beyond a Vanderbilt really. Then I need to figure out how functioning is impaired. It needs to be impaired for me to offer medication. In the midst of all of this I have to assess for those who are drug seeking: those who would potentially sell their medications to others, and any other co-morbid substance abuse issues.

Then if I get through all of that and decide this person could benefit from some sort of medication for ADHD I have to warn about all the adverse effects. Because they exist. For real. I’ve seen stimulants make kids psychotic (visual hallucinations), more angry, irritable, lose weight due to decrease in appetite, stunt growth (yes I measure height and weight at every visit and rarely kids have needed Growth Hormone injections), and yes I’ve seen people who are addicted to stimulants. It’s a real thing.

Then we have to pick the stimulant to trial. There’s a bunch. I point blank don’t prescribe Adderall- it has a high, then a crash, and a wicked withdrawal, it also had a major street value and is the “most addicting”. Yet Adderall is the cheapest and the one all insurance companies want me to prescribe first. So for every stimulant prescription I write that’s a new prescription, new medication, I have to do a prior authorization. It’s a pain in the ass.

This is a side note. Adderall is supposedly the “cheapest” available. But Ritalin has been out on the market since 1952. So I’m confused as to why it is still wicked expensive. It’s generic now, yet pharmaceutical companies keep the price of stimulants jacked up. Read ADHD Nation. It’s a good book.

So, I do a thorough assessment, I provide drug education for my patient and/or their parents, I potentially send a urine toxicology screen, I fight the insurance company to cover the stimulant I feel is safest to prescribe. I call the pharmacy and the patient to tell them they can now pick up the stimulant. They try it. We do a follow-up. They don’t like it. “I just don’t feel like me.” “It makes me too tired.” “I have no appetite.” “It makes me angry.” “It makes me cloudy.” “My friends notice something’s not right.” The list goes on.

Round 2. We try another one. I have to do another prior authorization. I have to do more education. If it’s a college kid I have to make sure they get the old stimulant out of their dorm room and off the college campus to a place that destroys old medication.

Potential success with second medication trial. Or we go onto the third.

In my experience it can take 1-3 tries to find the right ADHD medication. I do prescribe non-stimulants as well.

We find the right medication. Then we have to taper to the right dose. Then it’s only lasting 6 hours they want it to last 8 or 10 or 16.

Then we have to have the discussion- my goals are to medicate someone to last a school day. My goal is not to have a person’s brain on a stimulant for sixteen hours a day. That’s not healthy. Then we may have to have the discussion of why they are running out of their medication early- because they are doubling their dose, or taking an added afternoon or evening dose to get through work or night classes. Then we have to revisit goals of treatment, misuse of medication….it goes on.

I don’t want people to think I don’t love treating ADHD. Because I do. When a thirteen or fourteen year old comes to me and is suffering and being made fun of at school and says the one thing they want to fix with medication “is to give me friends” well that just about breaks me and when I see them respond to ADHD medication and therapy and a year or two down the line they are functioning beautiful teenagers with friends and a social life and good grades, well that’s just about the best feeling in the world.

I’ve been in outpatient practice now for three and a half years. Some of the patient’s have been with me since day one. I started treating them as gangly and awkward thirteen year olds and they are now applying for college and asking me advice about sex and if they can smoke pot with their medications. It’s frightening watching these babies turn into men and women but it’s also amazing forging relationships with them and being a safe space for them to ask any question about anything. It’s also heart-melting to see them now have friends when a few years ago they felt like the most lonely kid in the world.

Those are my success stories and those are the reasons I still treat clients with ADHD. But there have been a lot of problems along the way too. I’ve seen clients who became irate and verbally aggressive because I wouldn’t prescribe them stimulants, specifically their Adderall. I now screen clients over the phone for intakes and am clear that I don’t prescribe that particular medication to weed out those issues.

Prescribing psychiatric medication is hard. Diagnosing psychiatric illness is hard. I take that responsibility very seriously and I try and be exceptionally thorough. Because for those suffering with ADHD I do want to help. But it can be exhausting and it is one of the few fields where patients come often thinking they know more than their healthcare provider about their diagnosis and course of treatment because of the tests they’ve taken online and subsequent research (many pharmaceutical companies are tricky and link ADHD questionnaires with websites about stimulants- you have a problem? Here’s the answer!).

For those truly suffering from ADHD I’m not trying to invalidate your experience. Because like I said, there are clients I treat with true ADHD who improve with therapy and medication and allowing me to be part of their journey is an honor. But to everyone else, you may not have ADHD- don’t jump to conclusions and please ask for a thorough evaluation before agreeing to the diagnosis. Also note that behavioral and cognitive therapy does help ADHD in addition to medication. Naturopath doctors also are around who treat ADHD if you are looking for an alternative approach.

Read legitimate sources and articles. ADHD Nation is great, the American Journal of Psychiatry has excellent articles about ADHD. Don’t depend on WebMD and pharmaceutical company websites. Be truly informed and don’t get mad when your healthcare provider recommends a thorough evaluation before jumping to a stimulant. Instead be thankful.


“You mean the sperm donor?” “Yes the biological dad.”

I am going to preface this blog post with the statement that I love my pediatrician group. They are very smart and very professional and I’ve met all of the doctors in the large group practice over the past two years. Twin boys in daycare catch just about everything and then we also have the physicals. We spend a lot of time at our pediatrician’s office. A lot.

At their two year physical we were asked for health history (and not for the first time) we were asked for information about their “biological dad” also stated as “bio father” throughout the dialogue. The first time it was asked my wife and I both kind of stopped and stared and then the dialogue went something like this….

I said, “You mean the sperm donor?”

“Yes, the bio father.”

“You mean the sperm donor?”

“Yes their biological dad.”

“You mean the sperm donor?”

“Yes, do you know any of the history of their biological father?”

“You mean the sperm donor?”

This all was said in less than thirty seconds. Then I said we don’t know much and we all moved on. I think by now you can see where I’m going with this.

Something about the term Dad or Father being placed into my children’s vocabulary when it really has no place there at all pissed me off. It also made me feel vulnerable and protective. Was this person messing with me? Were they being deliberately obtuse or worse deliberately hurtful? Or were they, as I suspect and my wife concurs, just not educated on caring for a two mom family?

My sons are two. They don’t know yet what a dad is. But at some point they will. I don’t want the anonymous sperm donor placed as a father figure in their lives. Because he’s not. We don’t know anything about him except his height, eye color, and age at the time that he donated the sperm. The boys have the option of contacting him when they turn eighteen. And that will be their choice. But I hope at that time it is not out of some longing for a father they never had.

When caring for a two-mom or two-dad or whatever kind of family is presenting in a healthcare provider’s office it would be polite if you ask how they refer to one another. Because there are some two-mom families who do know their sperm donor and do refer to him as the “biological Dad” or whatever. But that’s not my family.

Wherever we take the boys for healthcare we are going to face these vocabulary issues. We are going to have to answer potentially rude (intentionally or unintentionally) questions and we are going to have to do this all in front of our sons. We have to model behavior and vocabulary for them. Because I can’t freak out on every health care provider or secretary who makes assumptions. But I don’t want to sit back and not address the issue.

After that exchange in the pediatrician’s office I thought about my response. I was caught off guard, even though it’s happened there before, so I needed to think of my response next time. I need to overtly say, “We don’t refer to him as the dad or father, the sperm donor is our preferred term. Thanks.” Set the boundary in the moment instead of engaging in this back and forth with some one who thinks sperm donor is synonymous with biological dad. It’s not.

I also contacted their office and gave the feedback that perhaps with diverse families they could ask about preferred names and terms.

Entering a healthcare provider’s office is scary and vulnerable for any one. Add in that we are a minority with our young sons with our own narrative and it makes me instantly defensive mostly because I want my son’s protected and I want the people caring for them not to care for them differently because they have two mom’s.

Dad is a protected term to me. It depicts an individual who has a vested interest in a child’s development. I have a Dad. I know what it’s like. He was and is a good Dad. The boy’s don’t have a dad. They have a sperm donor. They also have two Mom’s. If I donated my eggs and never met the resulting child I would not expect to be referred to as the Mom. I would be the egg donor. The child would hopefully have either a Mom or Dad or two of each. But I would not have a vested interest in that egg’s development into a child, therefore would not presume to be named a parent.

The moral here is if you work in healthcare and care for diverse families, just ask how they want their roles to be referred to or defined as. It makes life for us much easier.

When therapists “don’t want to get involved”.

I’ve seen enough LGBT youth now in my private practice to unfortunately have heard many times, “Yeah my last therapist just didn’t want to get involved.”

Here’s the story.

I see people for therapy and/or medication management. When I see clients for medication management I still do a thorough assessment. I ask all the tough questions and find out why someone is really depressed or anxious or whatever. I poke and pry because I don’t want to prescribe medication if there is actually a deeper issue that just won’t respond to medication.

Case in point- every LGBT youth whose family is not accepting of their sexuality. That would make me depressed too. And anxious. Because they fear that if they are “out” their parents will kick them out, stop supporting them financially, but most of all they fear their parents will stop loving them.

I tell my patients that no amount of medication I prescribe will take that fear away. Then I ask how we can address this issue with their family. They usually look at me through tears and tell me no previous therapist wanted to insert themselves into this issue in the family.

For a little bit I started questioning if I was doing the right thing. But then I saw their relief, and I’ve met with parents and processed their fears and feelings around their children’s sexuality. I’ve never met with parents without extensive processing with the kids first, and I’ve never done it in a way that would out my client if they do not want me to do that. I am extremely respectful of their boundaries and where they are at in their own journeys.

But I can’t ignore the elephant in the room. I can’t continue to increase an anti-depressant dosage knowing the depression comes from feeling rejected and not address that in some way.

As a therapist and as a nurse I feel it is my duty to provide support not only to my client but to the family system. And my teens and young adults are grateful to have someone speak up for them and be heard in ways by their parents that maybe as “the kid” they cannot be. It’s a fine dance to be sure though. Balancing where my client is at and where their family is at and what each needs from the other in the moment.

Therapists are in a position to be incredible advocates for LGBT youths. Why would we not seize the opportunity? And if you are not comfortable for whatever reason to do the family work then refer them to someone who is.

Many clients come to me feeling stuck. The best part of the work is helping to unstick them from the fear and secrecy and move their whole family forward into the light.

It’s incredibly difficult and requires good supervision as a clinician and continuing education specific to the LGBT community. But it’s doable and as difficult as it is it’s the most rewarding aspect of my work. Too many LGBT youth face high rates of depression and higher rates of suicide to ignore this issue and to not insert ourselves.