Lauren A. Mitchell // I am helping a group of medical students learn how to take a comprehensive sexual history with a colleague, inspired by the interview template that Fenway Health in Boston uses. This interview model expands on the usual “5 Ps of Sexual History Taking” (Pregnancy, Practices, Partners, Past History of STIs, Prevention of STIs). This is the list of questions that, while important to ask, foreground all the risks of having sex—the unintended pregnancies, the STIs, the dangers of inconsistent condom use. Joking, we call these the “Punitive Ps,” punitive because they offer veiled reminders that sex can lead to gnarly bacterial infections and traumatic abortions and kids you didn’t want and death. (Perhaps unsurprisingly, one of our course directors asked us to stop calling them the Punitive Ps in front of students.) We encourage the students to use this newer, better, “cutting edge” interview model that also asks about Preferences, Partner Violence, and Pleasure.
Pleasure is the sticking point for a lot of people, whether they are students or seasoned physicians. Pleasure is a topic that seems to move away from the issues of disease and pathology that so much of sexual history taking is attached to and inadvertently demands that students place their patients’ erotic lives into view. We tell them that this is the sexual history template that we, people who worked in sexual and reproductive health, wish we had learned, simply because who doesn’t yearn for pleasure? Pleasure is a basic need; it’s the most human thing we could want. But because of the conversational nuance that the Fenway interview model can demand, we have arguably thrown the students into the deep end of the pool. Several ask, in almost the exact same wording, “Who am I, a twenty-something-year-old medical student, to be asking such personal questions?”
I appreciate their humility, and I empathize. When I first became a birth doula at the ripe age of 21, I was terrible at it for the similar discomfort that the students describe—very worried about encroaching on my client’s privacy, nevermind the fact that I signed up for it by asserting that I had the capacity to be in a caregiving role. It takes me a while before I am able to come up with a satisfying answer.
“Well,” I reply slowly, “For many of us, our romantic and, subsequently, our erotic lives take up a lot of space. Try framing the sexual history questions as wanting to develop a greater understanding of the relationships your patients have with others, and the ways that their relationships impact their lives as a whole.”
They nod. Something in that seems to resonate with them. Of course, as I say this, I am also in the distracted haze of my own recent heartbreak, and it is through this loss and the heavy weight of his absence that I am able to identify just how much space one’s romantic or erotic life can take up.
I could wax philosophical to you about love and its place in psychoanalytic discourse, and therefore its place in medical discourse. For now, I will say something I find myself repeating to my students often when they encounter patients who are self-sabotaging: “If we were only logical beings, our lives would be a lot easier. But we aren’t. We are made of emotions, often driven by them, even when (especially when) we say we are being intellectual.”
I am a highly emotional being and an ugly crier in equal proportion—call it vanity, but this and a life-long habit of threading my thought patterns so that I am often not the center of my own story have helped me keep my composure in times of duress. Less so, lately, when I am in a new city surrounded by a new community and a new purpose in life, all things that I wanted and continue to want, but also change is hard. Now, in an unexpected period of grief, I leak all of the time: watching people cross the street. A passing thought of my cats. It doesn’t take much for me to get emotional and weepy, and it would be funny were it not also kind of humiliating. In times of big emotions, I need the space to think through them slowly, and so much of my love language tends, indeed, to be in language, in writing, a process that Maggie Nelson describes in The Argonauts as clarifying above all.
An inventory of the trail I’ve left behind me: texts and emails to lovers that state clearly my emotional inner workings in ways that paralyze me in person; love poems so bad that I shudder to think of them; astrological chart readings; ribbons that I’ve worn as necklaces attached to notes; books by writers who have moved me to some kind of ecstasis; 46 love poems for a 46th birthday, all hidden around his apartment to serve the pleasure of surprise; a copy of Roland Barthes’ A Lover’s Discourse that I annotated myself. These things were all uniquely created in the light of love and care to show these beloveds a piece of myself, and a piece of themselves, too. I wonder with no small amount of melancholy how many of these meaningful things have since ended up in the trash.
Among all of them, the annotated copy of A Lover’s Discourse may be the most on-the-nose insofar as it was offered as a grand romantic gesture from a broke graduate student (me) to someone I would later see clearly as a dangerous person to my well-being, but it is not really a romantic text at all. It’s an extended meditation on neurosis that wears the cloak of love, a treatise on the writhing uncertainty that comes from desire, which Lacan posited only desires itself in a recursive, self-fueling loop. Maggie Nelson wrote The Argonauts inspired by A Lover’s Discourse to make sense of the life she has co-constructed with her partner and their sons. I admire the way she lays claim and, indeed, clarity to the fragmentation that arises from the intimacies with lovers, with having children, with the medical establishment, all unnervingly similar in their vulnerability, their splayed bodies.
When I ran Narrative Medicine (close reading and reflective writing) workshops with residents at Bellevue Hospital a number of years ago, many of them featured their partners and their families in their writing as what gave them hope to go on. These were, after all, the people who would care for the caregiver after hours, the ones who would help them “feel themselves beloved on this earth.” At this time, my long-term relationship, effectively a marriage, was burning to ash because we were not co-evolving well. My life was in constant conversation with other people’s trauma, and I was always in close proximity to becoming a vessel for their pain. I came home night after night haunted by stories and lives that were not mine so much so that I could feel them alive inside of me almost more than I could feel myself, haunted by every failure to fix their complicated misfortunes or mistakes. I obsessively tried to reverse-engineer everything I could have done to have saved the day, without realizing what an arrogant fool’s errand this was. I’ve since come to terms with some of the yield of this years-long caregiving experience with phrases like, “survivor’s guilt,” “provider trauma,” and “shades of PTSD.” Once my un-marriage ended, I would nose-dive again and again into the bold, stupid optimism of hope and a bottomless yearning for the pleasure of love directed at the wrong people. I can’t imagine it was easy for those close to me to watch.
I try to remind the students, and remind myself: you are years away from any real ability to claim diagnostic powers to treat your patients. What you can do is to find a way to be a calm, clarifying force while they cross the River Styx of their own neurosis, the stories they tell themselves when they are trying to make sense of situations that make them feel abandoned or rejected. “Your role is to hold these stories with both hands, maintaining the boundary of yourself as best you can, because you will not take their pain away.”
You will not take their pain away.
Inhale, desire; exhale, doubt and neurosis. Repeat.
Opening oneself up to love means opening oneself up to forms of inter-dependence, shaped and formed by another person’s presence in a way that is so intimate it is almost familial. In Naomi Wallace’s play, One Flea Spare, a young woman who has been quarantined with an elderly couple during the medieval plague epidemic says, “Like water on a stone, I have loved them, and they have marked me.”
During my unexpected last conversation with my now-former-partner, he told me that his past romantic traumas made him pessimistic about future relationships, especially our paths that he felt would not re-align, and I sobbed into the phone, “But we’re all covered in scars.”
I don’t want to be in this place, hurt and alone and vulnerable. It is always, always easier to be the caregiver, inadvertently on a high horse, unclouded by grief and confusion. I have been nearby many friends and thousands of patients in almost as many fucked up, complicated relationships. Humans are so fragile and tender, so emotional and reactionary. A student, angry, discusses a written case study about a woman who uses drugs and alcohol during a pregnancy she didn’t want and refuses to use birth control once she has an abortion. He, and others, are openly disturbed by her behavior. With no sense of irony, they are exasperated by what they call her “irrational” decision making process.
But rationality is a fickle framework when life happens—when love and desire come to interrupt what we should or shouldn’t do if it is in conflict with what we want. This is part of what is so hard to be human and to take care of humans, and if we knew how hard it really could be, would we still want to do it? To keep going forward? (If I knew how hard the ensuing six years would be after I left New York, left my job, left my partner, my friends, my family, would I have still done it?) Love and medicine aren’t tied together solely through an affective register—they are part of the way that we decide what stories are important to us. There are no heroes here.
If I am able to offer any wisdom, it’s this: the only way to lean into the hard work of caring for someone’s physical body is to be willing to lean into the trembling, vulnerable mess that lives in all of us when we love or hurt. If you are lucky, maybe you can shepherd them through it; yourself through it, too. You will love them, and they will mark you.