Category Archives: Suicide

I’m Asexual, and LGBTQIA should have a letter for me…

I wrote the bulk of this piece back in Connecticut in 2013, when i still believed in the concept of mental illness yadda yadda.  i am adding this preface in Vermont, from a place of somewhat greater stability and even more firmness.

Asexuality is not a common orientation but it is not unknown or in any fashion abnormal. As i note below, a good 1% of the human population may be asexual all their lives and many, many more may find themselves “asexual” at some time in their lives. I put the quotations around the word because i believe that those who find themselves suddenly asexual while taking certain psycho-tropic drugs may not quite understand that it is the medications that have induced this change in them, but sometimes the state is an unnatural change from their native orientation and not a natural state of affairs.

if you happen to be asexual, as i am, you surely know that it is not a state of being without discrimination. For one thing, people make assumptions about us that are almost always to our detriment, and they never bother to inquire first who or what we are about. For instance, i am 64, childless, unmarried, and unpartnered…and yet i like to contribute to the well-being of young people, either by teaching them or by assisting them in other ways. If i were married with children, i believe my intentions would not be regarded with suspicion, but as it is, i feel frequently suspected as some sort of sexual predator. An asexual friend of mine evinced similar feelings, saying that he could not invite a friend from work out for a drink without that person clearly fearing that he was being “hit on” when all my friend ever wants is friendship from anyone, male or female!

I dont understand why the A in LGBTQIA stands for “allies” not for “asexual” and why there is still no place for us within it.

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Let me state this plainly so there is no misunderstanding: I am tired of people thinking there is something wrong with me just because I do not have a husband or boyfriend/lover or even a girlfriend/lover or a love-interest of any kind. I am not interested in sex and have never been interested in sex for whatever reason. This does not distress me and it never would have in the past, had others not insisted that it ought to. I have finally come to the conclusion that being asexual — definition: having no interest in a sexual relationship with another person — is okay.

I am not unhappy. I get a lot done and I am likely more satisfied by my life as an asexual than someone who is sexual and without a partner. I am never lonely. And I have tons of friends. (At least 16 friends — all of whom I adore — came to my 60th birthday party!)

It has taken me, via a tortuous up and down path, a long time to come to this position. And there may well be those who shake this foundation yet, as other people’s opinions, alas, still manage to have a strong effect on me. I have never told openly the story I am now going to relate, but I think it is time. It should be an eye-opener and a warning to those who believe they have the right, even the duty to “help” a young person discover “her true identity…”

As some of you know, a very long time ago, I was a student in a medical school in Connecticut. The two years I attended med school were extraordinarily difficult ones for me and I admit now that even as I matriculated, I “knew” at an almost conscious level that I would never get through. I didn’t honestly want to be a physician. Not really. Oh, yeah, I thought I could be a good psychiatrist. I knew that I understood people and mental illness enough to empathize and help others. But the notion that I could successfully get through four years of med school and four years of residency in order to achieve that goal was something I also knew would be impossible, even as I nominally attempted to undertake it. I had no choice. It was what you did in my family. And there was no question in my mind that I could work at a “regular 8-hour a day job.” I simply didn’t have the stamina either interpersonally or physically. I didn’t know why, I just didn’t. (I also didn’t understand that I had narcolepsy, so I construed my constant drowsiness as “boredom” for everything.)

So there I was in med school, without the ability to make friends or any interest in relationships, especially having just broken up with Bruce, the one boyfriend I had had and with whom I had sex (because he pushed it). I hated it…which was why I broke it off. I know I was noticed. I felt noticed. Possibly because I made little effort to be friendly, possibly because my narcolepsy made me noticeable. I don’t know. It is not that I was or am a striking person at 5′ 3″ and 105 lbs…hardly! Perhaps it was my mere aloneness that struck people. I dunno.

Things were hard to start with, but then the voices started up telling me to hurt myself and I acted on their commands, frequently. I had horrific nightmares nightly. And I could not stay awake in class or to study no matter what I did. People had all sorts of advice and jokes for me but no understanding. They gave me No-Doz and Vivarin for my birthday, which precipitated a caffeine-toxic all-night-up of horror. They took photos of “Rip van Winkle” sleeping on the med school lobby couch and published it in our newsletter. No one knew what was really going on, at home, at night, in my bedroom when the voices took over.

I had a run-in with the student health doctor, Dr E, to whom I had gone about possible Reynaux (sp?) Syndrome. When she saw certain scars on my body she became concerned and spoke with the psychiatrist I was seeing at the time. Dr S, who was a cold man who seemed to dislike me from the start, was angry at our next appointment for “parading” my wounds and warned me against ever doing so again.

I went back to Dr E and told her what Dr S had said. She seemed perturbed and gave me the name of a therapist that she said she often referred “troubled students” to. I might consider seeing Tamara instead of Dr S. The other students liked her a lot, Dr E said. What were their problems? I asked. Dr E shook her head and responded, Not so very different from yours.

I sit nervously in the waiting room, hoping that Tamara will be so late she won’t have time to see me today after all. I feel sick to my stomach and wonder why I’ve come. Five minutes late, ten minutes late. I am just about to leave when a very pregnant woman opens the door to the office and welcomes me in. I do not look at her face but whisk myself inside, trying not to guess how many more weeks she has.

Before she asks me anything, Tamara says, “Now, I see girls who like girls and boys who like boys. You’re okay with that?”

What is she talking about? I don’t understand. Girls who like girls? I like girls, I like boys. Why shouldn’t I be okay with it? So I say, yes. And assume that even so, she sees people whose issues are very different…

I didn’t ask her. I simply assumed that she had other interests. And went on from there. But it was critical, because I did not get that she was conducting therapy as if I had agreed that I was a lesbian, and yet I had made no such admission. I did not even understand what she was getting at. Why was she so coy? Why didn’t she just come out and ask me whether or not I was gay and then tell me that she only treated lesbians and gays with issues around their sexuality?

As it turned out, she had no idea that I was not in fact assenting to her coy proposition that I “liked girls.” On the contrary, if she had asked me point blank, I would likely have said, “Me? No way. I am not even interested in boys. I couldn’t care less about sex. I like, but don’t love, boys and girls…so to speak.” But the operant word, clearly, was not “like” at all, but love, as in “making love.”

Actually, in point of fact, I would not have been able to respond at all, if I remember my former self accurately. I was nearly mute much of the time, esp in therapy, and when I did speak it was often very cryptically and with difficulty making myself clear. This may account for the misunderstanding that so horrified me in what follows.

It was a crazy-making psychotherapy for about 6 months. I had no idea what notion she was operating under, because I didn’t know what kind of therapy she “did.” Likewise, if she knew the least thing about me, it was completely mis-colored by her mis-understanding of me as a lesbian. So when one afternoon she “told” me that she empathized with me, because I had had a sexual relationship with my previous psychiatrist…I hit the roof.

“WHAT? What the F— are you talking about?!” I nearly leapt out of my chair.

“It’s okay Pam, I understand,” she soothed me.

“It is NOT okay! I never said anything of the sort! This is YOUR filthy mind! I’m out of here. Go to hell!” And with that I got up and walked out. I realized then that she was nuts. Somehow she had gotten the entirely wrong idea, but I didn’t understand how. It made no sense to me. Where on earth had she fashioned that notion? I certainly had never said any such thing…

Then her statement “I treat girls who like girls…” came back to me. And I understood more. Dr E surely knew Tamara’ orientation, her clinical expertise, so Dr E must have believed that I needed to talk about conflicts about my “homosexuality,” about coming to terms with being a lesbian, unbeknownst to me. So she had set it up that I see Tamara, believing that she knew me better than I knew myself. But what right had she to do that? And how would she know whether or not I was a lesbian? Just because I was a conspicuous loner? How dare she? She knew nothing about me! What she had done was a violation of me as bad as any man who wanted to have sex just to prove he was Mr Right!

I spent a lot of time after that utterly paranoid that I might be gay, feeling that I must be gay, certain that I was gay…I even came to the point that I accepted it eagerly. But it was never true. It was just another identity forced on me by others who would not let me be. Who would not accept that I simply have never had interest in sex or sexuality beyond a pervasive non-sexuality. My libido, my psychic energy, is invested in other things, in art, in science and in life, but not in erotic interests. And you know what? Being non-sexual or asexual doesn’t make me an amoeba or less than human.

At least 1% of humanity is asexual, has always been asexual, permanently. That’s a LOT of people. We may not be the norm, but there are enough of us out there to rate your acknowledgement and the respect you would pay to any other human being. That’s all we ask, that’s all I ask. And for you not to try to change me just because you do not like it or understand my way of being. Thank you.

 

To Kill or Not to Kill: Physician-Assisted Suicide?

 

My brother visited me recently and for some reason we got into a discussion about whether or not we supported physician-assisted suicide. We differed on the fundamentals: Phil, aka Chip, supports assisted suicide in every sense of the word. He thinks that it should be legal for a physician to prescribe a lethal medication essentially for anyone who asks.

 

This horrified me. Wait, he went on to explain. In his opinion, everyone should have to push a button upon waking in the morning in order to stay alive. If you failed to push it, you die. Meaning that the day would begin with everyone choosing to live, thus having to take responsibility for making that choice. We would start with the premise that every person who “wakes up alive” has chosen to live and cannot claim rightly to be suicidal…I guess that Chip as a psychiatrist, feels too many of his patients do not want to live, but also do not sincerely want to die, and he thinks that they need to acknowledge the latter. That might be good, but I also know that there are those who are so depressed that in their involuntarily mentally incapacitated state, they might not be able to press the “I want to live” button, and thus would die, even though in a healthier frame of mind, they would have chosen to live…

For me, I agree that when terminally ill, a person should have the right to end his or her life, and should be able to do so without interference from authority, legal or medical. I also think that in certain cases, palliative or hospice care helps with this, and already has done, silently and as it were secretly for years: the administration of a sedating dose of morphine when the time is right goes a long way towards assisting a person’s “dying process.” Not a lethal dose mind you, but a dose to “ease breathing” and one from which the physician and all witnesses understand the person will likely never awaken.

(My friend Joe is another case entirely. They turned off his ventilator and dosed him with morphine after 4 years with ALS. I firmly  believe that they murdered Joe outright, against his will…But no more will be said of that at the present time.)

 

On the other hand, let’s face it, if you really want to commit suicide, it is easy to do so if you are able-bodied and not terminally ill: just jump in front of a bus, or out of a tall building’s window. There are a dozen sure-fire ways and they have been used for millennia as an easy way out. The problem is for those who are physically so debilitated that they literally cannot “jump” or swallow the pills or whatever. Yet  unless they are forcibly nourished and hydrated through a feeding tube, they can always refuse food or liquid, which it seems is not agonizing after all. That is according to what recent research and personal witness (my own) have indicated. When my friend Lynn L died – essentially from not a refusal to take liquids– she did not suffer acutely from deprivation but seemed slowly to cross into a never-never land. She simply drifted off to an endless sleep and passed away.

 

The idea that a physician could freely prescribe an overdose of a lethal drug to any someone who came asking for it, that just strikes me as the height of 1) irresponsibility and 2) cruelty, by someone whose job, after all, is characterized by the Hippocratic Oath: primum non nocere or “First do no harm.” If killing  a patient is not doing harm, then I do not know what is. I simply do not understand how bloodying one’s hands in the act of killing, no matter how good one’s intentions, cannot but badly affect any so-called healer.

 

Surely there are other ways to deal with a person’s pain and suffering than to throw up one’s hands and say, well, I cannot help you feel better or live longer, so I will simply shoot or poison or – whatever – you so you feel nothing and don’t have to deal any longer.This completely disregards the inherent value of the struggle itself, and the promise of something worthwhile, if only at the very end  at the moment of dying, in having faced the suffering and undergone it fully.

 

Look, I do not like or want anyone to suffer agony in the last stages of life, and am all for morphine use, liberal or sparing, depending on the patient’s desires and needs. But there is no absolute value in complete suffering or pain relief, not in my book. For me, I insist that I must feel my own feelings, and in that quest, I must decide to feel the pain, emotional or otherwise, rather than dull it with drugs or anything else. Yes, it hurts, but the hurt somehow feels better because it is mine and real, and not the forced dull nothingness of being drugged out of it.

 

If you have other thoughts about this, do feel free to share them in the comments section. In the meantime, I found this article on the very same subject at Medscape Psychiatry. It was written by ethicist and psychiatrist, Ronald  W. Pies, MD and may be found in its original form at this link:

 

http://www.medscape.com/viewarticle/771274

Medscape Psychiatry > Ethics in Psychiatry

 

Do We Need ‘Thanaticians’ for the Terminally Ill?

 

Ronald W. Pies, MD

 

Posted: 09/26/2012

 

The Ethical Dilemma of Physician-Assisted Suicide

My 89-year-old mother had been losing ground for some years, experiencing what geriatricians sometimes call “the dwindles.” Toward the end of her life, she was beset by a deteriorating heart; an inability to walk; and occasional, severe gastrointestinal pain. My family got her the best medical treatment available — eventually including home hospice care — and she generally maintained a positive attitude throughout her long downhill slide.

 

But one day, as I sat beside her bed, she seemed unusually subdued. “Honey,” she said, “How do I get out of this mess?” I had a pretty good idea of what she was really asking me, but I deflected her question with another question: “Ma, what ‘mess’ do you mean?” I asked. “It’s all right,” she replied, smiling sadly, “I’ll manage.”

My mother was doing what she had always done: sparing her children from pain. In this case, it was the pain of dealing with the waning days of her life and the frustration of knowing there was no easy escape from the burdens of dying slowly. “Ma, I’ll always make sure you are getting enough treatment for your pain,” I added, taking her hand — knowing that the prospect of unremitting pain is often an underlying fear of terminally ill persons.

 

Yet, unspoken in my mother’s question was the issue of so-called physician-assisted dying, sometimes called “physician-assisted suicide” — an enormously heated controversy both outside and within the medical profession. In my home state, Massachusetts, the issue has come to the fore, owing to a November ballot initiative for a measure that would allow terminally ill patients to be prescribed lethal drugs.[1] A closely related bill (H.3884) has also come before the Massachusetts Legislature’s Joint Committee on the Judiciary.

 

Similar to laws already on the books in Oregon and Washington state, the proposed Massachusetts law builds in numerous “safeguards”: For example, patients would be required to submit their request in writing twice, and those requests must be 15 days apart. As reported recently in the New York Times,[2] fears regarding widespread overuse or abuse of the so-called “death with dignity” laws in Oregon and Washington have largely failed to materialize, at least according to some studies.

 

Nevertheless, the Massachusetts Medical Society (MMS) has long been opposed to physician-assisted suicide. In March 2012, the MMS President, Dr. Lynda Young, testified before the Joint Committee[3] and did not mince her words. Allowing physicians to participate in assisted suicide, she stated, “…would cause more harm than good,” and she argued that “…physician-assisted suicide is fundamentally incompatible with the physician’s role as healer.” Instead, Dr. Young asserted, the physician’s role should be to ensure that the terminally ill patient “…continue[s] to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.”

 

With considerable ambivalence, I agree with Dr. Young. In my view, terminally ill but mentally competent patients should be at liberty not only to refuse further medical treatment, but also to end their own lives — for example, by refusing to accept liquid or solid food. Contrary to a widespread belief, voluntary refusal of food and fluids does not result in an agonizing or painful death, according to a2003 report in the New England Journal of Medicine.[4] Indeed, medical ethicist Dr. Cynthia Geppert informs me that voluntary refusal of food and drink is now considered an accepted approach to dying in palliative care.

 

As Dr. Thomas Szasz has argued in his book, Fatal Freedom: The Ethics and Politics of Suicide,[5] a liberty is not the same as a right, because the latter entails a reciprocal obligation on someone else’s part. (If I have a right to free speech, the state has a reciprocal obligation to protect that right.) Moreover, the liberty to commit suicide does not entail the “right” to have one’s physician prescribe a lethal dose of medication. Indeed, Dr. Szasz believes that “physician-assisted suicide” is really a euphemism for “medical killing” — more technically, “heterohomicide” on the part of the physician.

 

While I disagree with Dr. Szasz on many issues in psychiatry, I think his analysis here is essentially correct. Physician-actuated heterohomicide, in my view, is “fundamentally incompatible with the physician’s role as healer.” I believe that permitting physicians to write prescriptions for lethal drugs will eventually erode the trust that all patients should place in their physicians. More than a euphemism, “physician-assisted suicide” may be a contradiction in terms. And in my view, the very concept violates both the implicit ethical contract between physician and patient, and that between the physician and society.

To be clear: None of this means that physicians should collude in the cruel and unnecessary prolongation of dying, as is often seen in hospital settings. As physician and ethicist Dr. Fred Rosner has argued,[6] “To prolong life is a [commandment], to prolong dying is not.” Thus, in the Jewish medicoethical tradition, “removing impediments to death” is sometimes acceptable — that is, discontinuing treatments that needlessly prolong the dying of a suffering, terminally ill patient, but without actively bringing about the patient’s death. (The distinction between “letting” someone die and “making” someone die was supported in the 1997 US Supreme Court case of Vacco v Quill,[7]which upheld New York State’s ban on assisted suicide.)

 

But what about those suffering, terminally ill, mentally competent patients who will not choose to end their lives by refusing food and drink and instead seek out “assistance” from healthcare professionals? Again, I do not believe that medical professionals should participate in assisting a patient’s suicide. But I sometimes wonder whether society ought to permit somebody to do so.

 

For lack of a better term, let’s call such a hypothetical individual a “thanatician.” Let’s posit that carefully trained and closely monitored thanaticians would be permitted to provide medically screened, dying patients the same type of lethal medication now prescribed by physicians in Oregon and Washington — under essentially the same restrictions and safeguards.

 

But wait: Isn’t this proposal a cop-out? Doesn’t it merely place the moral issue of assisted suicide in the lap of the nonphysician, allowing the dying patient’s physician to shuffle off with a clear conscience? Even worse: Would the use of such death-dealing personnel amount to abandonment of the patient, as Dr. Geppert recently suggested to me?

 

Still other questions arise. As my colleague Dr. James L. Knoll has suggested, might not the training, monitoring, and supervising of thanaticians create more problems and headaches than it would solve? Finally, doesn’t the very notion of “thanaticians” suggest that we have lost faith in what Dr. Knoll rightly calls “the intensely personal journey” of doctor and patient?

 

I, too, struggle with these questions and find no easy answers. I suspect that at present, the best approach to the dying patient is through the skills of the palliative care physician. Palliative sedation, for many terminally ill patients, may be a viable alternative to managing suffering without ending life. Moreover, a careful psychiatric assessment of patients requesting physician-assisted death is always indicated, because major depression may distort the patient’s judgment as death approaches.

 

How we deal with terminally ill patients is a painful topic that I never discussed with my mother, who was fortunate enough to have excellent home hospice care in her final days. But I believe this is a discussion we urgently need to have.

 

Acknowledgment: I wish to thank Cynthia M.A. GeppertMD, PhD, and James L. Knoll IV, MD, for their valuable comments on earlier drafts of this article. The views presented here, however, are solely my own.