Embrace where you are now, but don’t forget where you have been.

closeup photography of pink rose flower

I feel grateful every day just to be above ground and be reasonably physically and mentally healthy. I have a great family. I have rebuilt bridges. I have strengthened old relationships and built new ones. I am attempting to take even better care of myself and make myself a priority. I have made myself a mission of positivity that I attempt to fulfill at least once a day, no matter how small the triumph.

Wow! It seems like a lot of work doesn’t it? Frankly, it is, but so Worth IT! There are days when I get tired and don’t feel like putting in an effort. That’s when I have to stop and remember where I was even a year or two ago: somewhat depressed, frustrated, lonely despite people surrounding me, full of cancer trying to take my life, not able to work like I wanted to help support my family, mentally swirling with guilt and self-induced feelings of failure.

I have come a long way since then, but in order to keep my current path intact, I need to keep in mind where I came from and the lessons it taught me. I learned that no one can fully heal all of me but me. No one can really help assure my future without my help and driving force. I need to be mindful and grateful of the “good days” even if thrybaten’t as frequent as I would like. I learned that there isn’t always a tommorow, so I better make damn sure that today is the best I can muster. Nobody can do that for me. I’ve got to care enough to do it myself.

Dr. Katz

Man! It’s hard to feel sexy when you have cancer.

Picture the scene: Your partner gives you the let’s get frisky look. They start petting you in the way you are normally into. The sexy dance has started. The lights are dimmed aaaaaaand……nothing. You are laying there all bald and post chemo( well it has been a few days but you get the idea), fresh off your latest chemo hot flash, tired, bloated and not the least bit sexy….in your mind. You just aren’t up for it. It’s not you. It definitely isn’t your partner. It’s the freakin absence of sexiness that sometimes comes with cancer and chemo. I tell ya, the changes in appearance alone are a real confidence killer at times. My husband is the most amazing partner and best friend on the planet and regular me can’t get enough of him. But, cancer me is another story.

Cancer and cancer treatment can have a very significant impact on a woman’s sexuality in many ways. Disfiguring surgery may be required that can significantly affect your self esteem and confidence. Treatments can sometimes put you into premature menopause with hot flashes, vaginal dryness, pain with intercourse and decreased libido. Certain pelvic cancers require such extensive surgery, radiation, etc that a woman is left without proper function of her sexual organs permanently.

I get it, this sounds all doom and gloomy. The good news is that not all women are left with permanent sexual dysfunction after cancer. Sometimes the effects are temporary and things go back to normal when treatment is over. I am seriously hoping that I fall into this category.

Fortunately the data shows that if a woman was able to have satisfactory sexual experiences before cancer, she will be able to again. The American Cancer Society has a whole section of helpful tips and information for women who are having sexual issues resulting from cancer treatment. Some of these are in fact very helpful. The bottom line of all of them is that sometimes you have to get creative and you have to reinvest in your own self-love and confidence. Sometimes the same techniques for sexual satisfaction that you used before will not be successful anymore. You might not even have the same parts anymore. You may have to use more lubricant when you didn’t have to before. You may have to explore different things that excite you. You may require a vibrator for extra stimulation. You may need to try different positions. You may need to employ more fantasies into your sexual relationships. You may need dilator therapy to re-stretch the vaginal canal. These are just a couple of examples.

There is an interesting set of exercises recommended by the American Cancer Society for patients feeling anxious about sex and the way that their appearance has changed and adjusting to those changes. They suggest looking in the mirror, dressed at first, and noting the changes in your appearance: your surgical scars, ostomies, missing parts, etc. Then notice what you try to avoid looking at. Then while dressed, try to find three things that you like about your appearance. Once you are comfortable looking at yourself as a stranger might see you, then change the exercise and repeat it with you being dressed “sexy” for your partner. Finally, repeat the exercise nude with the same steps until you are able to look at yourself and adjust to the changes and feel comfortable. Don’t stop until you can give yourself 3 compliments like you did in phase one of the exercises.

The last thing to address regarding the impact of cancer on sexuality is the anxiety that goes along with it. It takes time to realize even when treatment is over that you are actually better and that life can go on, including sex. Clear communication is the absolutely paramount here. Talk openly with your partner about your fears and issues. Don’t leave them in the dark and just reject them. They can’t possibly understand what is going on in your head unless you tell them. Get therapy if you need to. Talk openly with your doctors. You be the one to bring it up. I can tell you right now that most physicians are not comfortable enough to make sure to address sexual issues at any time, much less with their cancer patients. This will be something that you really need to take charge of and advocate for if you want things to change and improve. As much as we try to deny it at time, our sexuality and sexual health are key components to our relationships and overall health. Sex is just as important for cancer patients as it is for every day folks. So, do what you can to preserve it. It’s for your health!

Dr. Katz

Nobody told me about the guilt!

I had no idea just how much guilt comes with chronic disease. This may not be true for everyone, but it is definitely true for me. I just can’t seem to balance the whole “just concentrate on getting better” side of me with the side that is worried about everybody else, my business, other people’s schedules, my patients, and just generally letting people down with all of my limitations. Sometimes I think it takes me more time and energy to process all the guilt and worrying than it would just to be sick. I get it. That sounds ridiculous, but it is the truth for me. It is just a tough balance for me.

You know what I think would be a good idea? We should sit patient’s down, after they have had a chance to digest the news of their new diagnosis, and hook them up with a mentor or counsellor to sit them down and help them start to wade through and plan for all the other complications and stuff that comes with any chronic illness. It might make it less overwhelming than just having everything smack you in the face as it comes, while you are busy trying to “just concentrate on getting better.” I get that some cancer patients have patient navigators, but the main role of these individuals is to keep the patient on track in terms of appointments, tests, and treatments. This is useful to be sure, but the real trick is managing all the outside life stuff that is on top of the tests, etc. I say we start offering life navigators too because, in most cases, the damage that is done with all the life fails, failed relationships, missed work, and unpaid bills far exceeds whatever damage the cancer inflicted.

Dr. Katz

Be your own advocate, but DON’T be your own doctor.

These are words to live by right there. I am always encouraging patients to advocate for themselves. I think that every patient should be master and commander of their own destiny. It is so important that you listen with your eyes and ears open at every doctor’s appointment. Take notes and read everything that your doctors give you. At least attempt to understand what your doctor is telling you or ask questions until you do. Insist on clarification if you don’t. Pay attention, even if you don’t like what the doctor is saying, especially if you are getting news that you don’t want to hear. If you are getting any kind of unfavorable news, it becomes even more important to buckle down and concentrate so that you can be a part of your own management plan. If you disagree with your doctor’s diagnosis and plan, communicate that, in the right way, and talk about it together. Make sure that you have given him or her ALL the necessary information that you can think of, even if you think it doesn’t matter. Ask questions! I never understand when my colleagues complain about patients asking questions. I am like bring it on! I love questions! It means that you are actually interested in your own health and what I am telling you. I am actually more concerned if you don’t ask. Plus, if I have a problem with a patient asking questions, that poorly reflects on me if anything. So, please ask away.

So we have discussed how to advocate for yourself as a patient. Now let’s discuss the difference between advocating for yourself and trying to be your own doctor. When a patient advocates for themselves, they are being an active participant in their own management. They are agreeing to a team participation relationship between themselves and their physician. They are vested in their care. This is a good thing. Sometimes, patients cross the line and try to be their own doctor. This is when things get tricky and potentially harmful. Show of hands: who has done this before? I think we all have at one time or another, myself included. There are many different strategies that we use. 1) We self- diagnose with the aid of our friends or Doctor Google and seek our own treatment. 2) Sometimes we use left-over medication instead of seeking help or advice. 3) Sometimes we are so set on our own self-diagnosis that we call the doctor’s office and insist on a particular course of treatment and refuse to come in because we are sure that we are right. Then we lash out at the doctor for not instantly responding to our requests of convenience and daring to ask us to come for an appointment. 4) Sometimes we convince ourselves that nothing’s wrong and delay our treatment because we are either afraid or “don’t have time to bother with it.” I think that physicians in particular are guilty of this last one. We spend so much time caring for others that we don’t make the time to make sure we care for ourselves. It really is self-defeating because, if we don’t take care of ourselves and assume a patient role at times, we won’t be around to care for others.

All of these strategies have the potential to bite you in the proverbial ass at the end. I strongly advise against it. Mind you, I am all about patients being aware of their own bodies and health history. On top of that, I am always listening when a patient gives me their diagnosis and I take it into consideration. However, the bottom line is, when you are too close to a situation(i.e you trying to diagnose you), it is nearly impossible to always make the right decision. The chances of you being wrong are greater than the chances of you being right. You just can’t be objective. The decisions we make for ourselves are automatically imbued with our own agenda and baggage: We are worried about missing work. We don’t have time to go to the doctor. We don’t have time to stop. There are deadlines that we are worried about missing. We are afraid. When you “let your doctor in” on the decision making process, you bring back the objectivity that is crucial in determining the right diagnosis and treatment. When a patient comes to me with an issue, I am able to evaluate it with a clear head with objective information. My initial job is to get to the root of their issue and come up with a plan. I have the luxury of not having to be preloaded with concerns about their external factors until I have come up with a diagnosis. Let me clarify. I do not mean that I don’t consider their schedules or other life issues, I just mean that I don’t have to let it slow me down in terms of their diagnosis.

Now that we have described what it means to be your own doctor, let’s talk about why it is a bad idea. First and foremost, you just get it your own way. You slow down the path to diagnosis and treatment, if not cure. Second, if you are wrong, and there is a good chance that you could be, it could literally mean the difference between success and failure, life and death, etc. Third, you are not giving your doctor a chance to actually do their job. They did go to medical school after all and it was probably a more thorough training experience that what Dr. Google or your friend has. Let them get their ( and your) money’s worth out of it! Fourth, trying to be your own doctor can be really isolating and frustrating and often you have gone through multiple incomplete treatment options first when you could have just gone to the doctor and gotten the correct treatment the first time. If the risk of wasting time was your deciding factor in not going to the doctor, you just negated it by wasting your own time. Just don’t do it!

I fully realize that doctors need to step it up and not force this situation either. We are not free of accountability here. We need to try to work with your schedule. It’s not always possible though. We need to have same day appointment availability slots if possible. We need to make sure our staff is answering phones regularly when you call with questions when we are busy with patients. We need to make sure that we answer our phones when you have after hours concerns. I get that. It’s not just a one-sided issue. I make every effort to fulfill all of these criteria. But, none of these convenience and safety steps can make any difference unless you at least try to reach out in the first place.

Have a great day everybody!

Dr. Katz

Once a manipulator, always a manipulator

There are manipulators everywhere. I am pretty sure all of us have fallen victim to their wiles at one point or another. Depending on the skill of the manipulator, the process may be so sly and so subtle that you don’t even realize that it is happening until it is too late. I personally have been on the receiving end of countless manipulations over the years. After doing a lot of research and reading, plus a side dose of life experience, I have realized a few things about manipulators that are the key to foiling their efforts and getting your life back.

First, you have to recognize a manipulator. A manipulator is a person who uses other people to seize power, influence outcomes, create scapegoats, gain control in relationships and reap the benefits of the work of others. These individuals use a lot of different tricks to accomplish these goals: deceit, guilt, false hope and last but not least, lies.

Second, master manipulators can twist any situation in their favor. They are very skilled at making you talk more about you than themselves. This is a how they gain information about you and use it to exploit potential weaknesses. They feign supreme interest in order to gain your confidence and learn all your inner most secrets. They may be genuinely interested in you, but not for the reasons you think. Their interest and your information reveals may ultimately be your undoing. Turn those questions around and ask them probing questions instead. This is like putting a deflector shield up and may result in the manipulator backing down.

Third, a manipulator is always two-faced. He or she acts differently to different people in different situations. Beware of the person that is smiling and chatting with a person one second and then talking about them to another person the next.

Fourth, a manipulator will always try to make you feel guilty for standing up for yourself and what you believe in. Anyone that tries to make you feel bad for expressing your opinion or maintaining your ground is trouble. It is said that belief can be manipulated while knowledge is truly dangerous. Knowing yourself and your boundaries and your beliefs makes you less vulnerable to someone’s efforts to put you down and undermind you.

Fifth, a manipulator’s actions never meet their words. They may tell you what you want to hear but their actions spell out something completely different. They promise to support you but fail on the follow through. They compliment you and tell you how amazing it is to be with you, but then turn around and act like it’s the biggest cross to bear in the world. This is just one more way that they attempt to mold your perception of reality of the world around you to one that works in their favor.

Sixth, a manipulator will always play the victim in every situation. They are experts at pointing the finger in every other direction but toward them. They blame everyone else for everything. They take no accountability. Nothing is their fault.

Last, they are all about intensity. Everything is too much too soon. They pretend to reveal everything right away and expect you to do the same. They pretend to be vulnerable so that you will be flattered because they “let you in.” It is all part of the plot though to make you feel sorry for them and to make you completely responsible for their feelings, regardless of what they are actually based on.

All of these attributes are important to spot, but once you do, now what? Use this awareness to maintain emotional distance from the manipulator. Refuse to participate in their guilt traps. Control the chaos. Don’t get sucked into it. Delay your responses to situations rather than offering instant gratification to the manipulator.

In the most serious cases, these manipulative relationships can progress into violence. This is a situation in which outside intervention is often needed because the victim has been so conditioned to think the interactions are normal that they cannot see their way out of it. This is where national hotlines come in.

The bottom line is, when it comes to manipulators, you need to trust your instincts. If your gut is telling you that something is off about the relationship, reassess and break away. Don’t let the worry and self doubt that they have carefully implanted in your mind take over. You have nothing to gain and everything to lose by staying in the relationship. Extricate yourself while you can.

Dr. Katz

Isn’t it strange that it’s ok that I’m human now, but it wasn’t ok before?

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Traditionally, it seems that most patients do not view their physicians as actual, potentially flawed human beings. It’s just too uncomfortable a concept. If patients viewed their doctors as humans, that would mean that they would have to acknowledge the fact that they can make mistakes, have emotions, have physical ailments, and emergencies as well. To most patients, that is an untenable thought. Their doctors need to be superhuman, infallible, and infinitely available at a moment’s notice. This kind of thinking allows patients to engage in demanding, unreasonable, and entitled behavior at times and puts a significant burden on the doctor patient relationship.

Interestingly, this seems to have turned around somewhat now in the time of COVID. Now it seems like patients are attaching themselves more to doctors who are showing their human side. The videos I post of myself at home in regular clothes or talking about how I finally figured out how to do my nails by myself get tons of views. Patients are listening with baited breath to see how I might be struggling with all of these changes. It’s as if listening to me is giving them tacit consent that it’s ok not to be ok right now. I feel like giving them a glimpse into me as a person is actually helpful right now. I can potentially help guide them through the proverbial tunnel to the other side of this thing. I get excited when I post my Facebook live daily video in the morning and all those people tune in. Knowing that I am able to reach all those people in a positive way helps me too. Personally I am loving it. If I can be myself with patients and still help them at the same time, I am all in! I would prefer to be that way all the time, within reason of course. I still stand by what I have said in previous blogs. Patients who are suffering or have just been given a terrible diagnosis do not necessarily care how I am feeling at the moment. Common sense still has to reign supreme here. I guess what I am really saying is that I hope the compassion doesn’t die out when the pandemic does. Have a great day everybody!

Dr. Katz

(Making) love hurts

So many women out there suffer from pain with intercourse…and most of them suffer in silence. The few that are brave enough to speak up and visit a doctor are often greeted with statements like “It’s all in your head” or worse, they are confronted with a physician that is just uncomfortable with the subject so they avoid it. Thus, the suffering goes on. Sex becomes something to dread, not something to enjoy, something to get through rather than something to look forward to. Relationships waiver and relations become strained. As much as we like to think that sex should not be the most important thing in a relationship, it is actually important. We cannot deny it. It is the most personal, intimate act that we can share with another person. At it’s finest, it is imbued with love and trust as well as physical satisfaction. It is the ultimate release. It is an essential part of a healthy relationship. Even the best-matched couples on the planet begin to suffer somewhat when sex becomes unpleasant or taken off the table all together.

So let’s talk about painful sex and what we can do about it. I am proud to say that I am one of the Ob Gyn physicians that is not uncomfortable with the subject. Treating pain with intercourse is a large part of my practice. I devote entire office visits just to this. Most of the patients that I see have been suffering for years and seen several doctors only to be dismissed. For whatever reason, they decide to give me a try and then are pleasantly surprised and grateful that i am wiling to embrace the subject. Some of them even bring me flowers or cards when everything goes well. That is just an added perk, but not the point of course.

What are the causes of painful intercourse? There are more than you think. Let’s break them down and what we can do about them. One of the most common causes of pain with intercourse is psychogenic pain. This occurs when the woman has real pain with intercourse but no physical cause can be found. I know what I said before about women being told that it is all in their head and how terrible that was, but let me explain. Women with psychogenic pain often have a history of trauma such as rape or rough sex or an abusive relationship. Most of the time they have never told a soul about it and have never had the opportunity to have any closure about the incident. On top of that, the trauma from those incidents was so devastating that it left a psychological scar that never healed. In their minds, even the thought of sex takes them to a dark place with pain and fear, not pleasure. Until that is addressed, some of them will never be able to have a healthy intimate relationship. Sometimes a psychogenic pain response can be triggered by a lack of trust in the relationship. They are fearful of adultery and possible exposure to sexually transmitted infections. To make matters worse, these women begin losing their sense of self worth, wondering why they are no longer good enough to satisfy their partner. Again, unless these issues are addressed, no amount of treatment will help them have a satisfying and painless sexual relationship. These are some of the first things that I privately ask about in our first interview. I get them help and counselling. We work on empowerment strategies, anything they need to process their traumas and either mend or leave their toxic relationships.

Another cause of painful sex is endometriosis. Endometriosis is a disease in which retrograde menstrual flow goes backwards up through the fallopian tubes and back out into the pelvis. In the right woman with the right environment and genetics, those implants of endometrial tissue set up shop all over the pelvis and cause pain and inflammation. The best way to diagnosis endometriosis is with a laparoscopy and actual visualization and biopsy of the implants in the pelvis. The trick is, that if you were to biopsy normal appearing peritoneum in the pelvis, up to 20% of the time you could find endometriosis. The other tricky part, is that some patients can have incredible pain with just one visible implant while others can have a pelvis full and have no symptoms whatsoever. We are ever striving for better, quality of life enhancing treatments for endometriosis. Most of them involve hormone modulation or shut down with the thought being that shutting down hormones will shut down growth of the implants and “starve them.” However, a lot of the treatments can only be continued for so long because of side effects. The only permanent treatment for endometriosis is hysterectomy with removal of both ovaries. We try to save that for the most drastic cases that have completed childbearing already.

Another cause of painful sex is pelvic inflammatory disease. Pelvic inflammatory disease usually occurs as a result of the spread of sexually transmitted bacteria from the vagina, through the cervix, into the uterus and then through the tubes and ovaries. The bacteria can spread to the rest of the pelvis and cause inflammation, abscess and scar tissue. All of these things can cause painful intercourse with cervical motion tenderness and pain with deep penetration. Once the infection is treated, there is an 88 percent+ chance that the pain will go away. Antibiotics are the way to go.

Yet another cause of painful sex is simple vaginitis or vulvitis. These occur when there is inflammation or discharge which can cause itching or pain and thus, pain with intercourse. This pain and inflammation can be caused from reactions to household things like detergent, soaps or personal cleansers or an actual bacterial infection like bacterial vaginosis or yeast. Treat the infection and the pain usually goes away. Figure out which things around the house is irritating( Tide, Summer’s Eve, Vagisil, scented soaps are common offenders for example), and get rid of it and substitute it with Cetaphil or All Free and Clear, and usually the inflammation goes away in about two weeks and so does the pain. I have made up a hand dandy “be kind to your vulva” tip sheet that helps patients get this under control faster and keep them from getting irritated again.

Another cause of painful sex is something called vulvodynia. This condition is the result of localized intense inflammation around the peri-urethral and vestibule areas of the vulva and causes intense pain with initial penetration during intercourse. This condition can be easily diagnosed with something called a q tip test. The q tip is used to touch certain points around the vulva. If a patient has this condition, they will perceive the q tip as a razor blade scratching them during the examination. Knowing this ahead of time, I always make sure to show the patient the q tip before i conduct the test, because most of them are sure that i secretly pulled out something sharp instead. That is how intense the pain can be. The pain that the patients get with vulvodynia often leads to a condition called vaginismus on top of it. Vaginismus is involuntary intense tightening and contraction of the vaginal muscles in response to penetration, which then causes a lot of deep pain with penetration. The key in these patients is to treat the vulvodynia first. We have had all kinds of theories about the cause of vulvodynia over the years, none of which have really panned out. At first we thought it was related to chronic yeast. Then we thought it was related to a high oxalate diet. The list goes on. The bottom line is that we really don’t know. I have found that a short course of a tiny amount of estrogen cream goes a long way at first. I do not use it for any longer than a month to avoid any possible unopposed estrogen effects. Then i transition the patient to any one of a number of compounded ointments that i have developed over the years. Usually these contain a small amount of an anti spasmodic, something non-narcotic for chronic pain, and a bit of lidocaine. The patients can easily use a tiny amount of this ointment up to three times a day to keep their pain and inflammation at bay. I make sure to educate them that this condition is considered chronic and we need to focus on control not cure. Most patients are so happy to not be in pain that they are happy to use a tiny bit of ointment every day. I think it is also important in these patients to remove any possibility of external irritants as well, like with the vulvitis patients so I give them the ” be kind to your vulva” tip sheet also. The vaginismus is a tougher nut to crack. Even when the vulvodynia is improved, the vaginismus sometimes still remains. I think that in these cases, the brain is so used to intercourse being painful, that it cannot allow the patient to enjoy intercouse even when the primary cause of pain is gone. That is just how our brains work. In these cases, we still have options. I like to start with vibrator therapy for example. I have the patient purchase a set of medical dilators that start all the way down to pinky size and gradually increase up to the size of an average penis. The patient starts with the pinky size dilator and coats it with a small amount of steroid cream and inserts it for twenty minutes. The goal to achieve with each size is to be able to tolerate insertion for 20 minutes twice a day before the patient can increase to the next size. After several weeks, most patients can usually increase up to the final size and then can begin enjoying sex again. For some patients, we need to incorporate biofeedback therapy in addition. Biofeedback therapy uses sensors with a biofeedback monitor. In can be used for a variety of purposes. In this case, a patient is hooked up to the biofeedback monitor and then various dilators are introduced in a sequential monitor. When a dilator is introduced, the patient is instructed to look at the biofeedback monitor. They are educated about what a relaxed muscle looks like versus a contracted muscle on the monitor. They then work to achieve a relaxed muscle every time a dilator is inserted. Over time, they learn to consciously relax their pelvic muscles with insertion. These sessions are variable in price and are sometimes covered by insurance. The number of sessions that each patient requires varies.

Last but not least, another cause of painful sex is good old menopausal vaginal dryness. We can’t forget that one. This is usually caused by something called atrophic vaginitis. Atrophic vaginitis occurs when the vaginal mucosa folds straighten out from lack of estrogen causing thinning, drying, and inflammation of the vaginal walls. We can treat this with a course of vaginal estrogen in pill or cream form. I limit this to three months if they have an intact uterus or add progesterone too if they need it for longer. We now also have medications like Osphena, which is a selective estrogen receptor modulator. It is a cousin to medicines like Evista or Tamoxifen. Osphena can be taken orally. For patients that cannot take hormones I treat their vaginal dryness with water based lubricants like astro glide. You can also use extra virgin olive oil vaginally or even vitamin e gel caps as a suppository. All of these are potential alternatives for vaginal dryness. There are others, but these are the first lines in my office. For the patients that do not respond to any of the above, we can always use small amount of topical lidocaine about ten minutes before intercourse. I have the patient apply a small amount to their vulva and that way we can at least decrease the pain, even if we cannot address the dryness.

Long story short, there are a lot of different causes of painful sex and there are options for all of them. I urge all you ladies out there to stop suffering in silence. It is not all in your head. There is something that we can do for you! All you have to do is find a physician and ask! Have a fantastic day folks!

Dr. Katz

What is a healthy relationship?

Ok I am going to say it. My husband truly is my best friend, but what does that actually mean? Are there different criteria for besties you are married to versus ones that you are not married to or in a relationship with? I don’t actually know the answer to this one, but I can define what I mean when I say it. I mean that my husband is the first person I think of to talk about my day with, to tell a secret to, to giggle with, to hold hands with, to spend the day with, or to just sit and do nothing with. He really is at the top of the list. I still get a stupid smile on my face( most of the time) when I think of him or refer to him in conversation. We still have a lot of fun. That’s my definition of a best friend. This does not mean that we never fight or argue, but we have never resorted to hitting or any other violence. This does not mean that sometimes I don’t get so pissed off at him that I don’t want to speak to him for awhile. Both spectrums are fully represented. No one can make me happier and no one can make me angrier. Gladly, these two situations don’t usually present at the same time, if you don’t count menopausal hormone swings. I still have other friends and I still lead my own independent life with my own goals and pursuits. I travel alone for business or with friends sometimes. I “do my own thing.” He is not up my proverbial butt all the time. I still consider that pretty normal and healthy.

Sometimes when people say those words, they mean something entirely different and, in my opinion, not so healthy. I know people who talk about their partners being their best friends and what I see, as an outside observer, is a relationship that is fraught with obsession, possession, and pathologic co-dependence. They are attached at the proverbial hip with their partners. They identify themselves only as a matched set. They are uncertain of who they are when their partner is not around. They have no outside friends or unshared activities. They have a habit of checking/seeking permission from their partner to do anything. They don’t speak their minds for fear of starting an argument. To me, this is unhealthy and potentially leads down a slippery slope to a controlling or even abusive relationship. I get that traditionally we think of an abusive relationship in terms of physical abuse, but emotional abuse leaves just many scars and they last longer.

So, what is a healthy relationship? I find that this is a question that seems to be getting more and more difficult to answer for both adults and adolescents. Did you know that roughly 1.5 million high school boys and girls in the U.S admit to being intentionally harmed or abused in a relationship at one point and that 1 in 3 young people will be in an abusive or unhealthy relationship at some point in their lives. That means that 33% of adolescents in America are victim to sexual, physical, verbal, or emotional dating abuse. This behavior is starting as young as six th grade! Young women who are in an abusive relationship are 6 times more likely to become pregnant or contract a sexually transmitted infection and are 50% more likely to attempt suicide. Add on top of this that most of this abuse goes unreported because of fear of exposure or just lack of knowledge about possible recourse. The stats for adults are not any better in terms of unhealthy relationships. Did you know that a woman is assaulted or beaten every nine seconds in the United States. 1 in 3 women, and 1 in 4 men, have been in abusive relationships. 1 in 5 women and 1 in 7 men have faced severe physical violence as well. 20 people are abused by an intimate partner every minute, which adds up to 10 million people each year. Just like with the teens, up to 75% of this is not reported.

Ever time I look at those statistics, I am sobered once more about the reality of them. Still, I feel that awareness is an essential ingredient in targeting this devastating issue. This is truly a situation in which putting your head in the sand can make a life or death difference. I deal with domestic violence in my office frequently. I have a confidential questionnaire that each patients fills out with her visit that starts off with some generalized questions and slowly leads up to questions about domestic violence. This way, she can fill it out confidentially and then we can open up a dialogue once she is safely back in an exam room. Sometimes, I am the first person who has ever even asked the question in her whole life. These are often women who have friends, relatives etc who have seen bruises or noticed behaviors but don’t consider it their place or are afraid to mention it for fear of repercussions and or potential danger to themselves.

I think that sometimes abuse victims face a culture of blame. Myths about domestic violence are common, particularly among those who are likely to abuse their partners. Some people say that if they get hit, they will hit back and then the next bit of twisted logic is that women who slap their partners should expect whatever violence their partner can dish out because they deserve it. I hear women say that they got ” what was coming to them” as a result of a particular behavior. This is false! There is no behavior that justifies physical violence or emotional abuse. All of these myths contribute to an overall culture of violence and victim-shaming.

People talk about the victim as being a part of the cycle of abuse and have no idea why the person doesn’t leave the relationship. This is an easy statement to make on the outside, but these same people are not intimately involved in that relationship. They don’t realize what is potentially at stake with leaving. Sometimes there are children involved and the victim feels that they will be more at risk with leaving. Sometimes there is a very real danger that the victim themselves may be killed if they try to leave. Sometimes the victim cannot leave because their partner offers financial security. Victims talk about the very strong psychological pull of the ” honeymoon period.” The honeymoon period is that period of calm when things appear good again and the abuser has apologize and made temporary changes and restored the often desperate and fleeting hope that the victim has that the relationship can be saved. I have patients tell me that this honeymoon period is all that have to live for at certain points because they are so broken by the abuse and the relationship that they can no longer see or evaluate their lives clearly.

So, how do you spot an abusive relationship? What are the signs?

1. Humiliating or embarrassing you

2. Constant put-downs

3. Hypercriticism

4. Refusing to communicate

5. ignoring or excluding you

6. Affairs with other people

7. Provocative behavior with the opposite sex

8. Unreasonable jealousy

9. Extreme moodiness

10.Mean jokes or making fun of you

11.saying ” I love you, but…

12. Guilt trips

13. Domination and control

14. Making everything your fault

15. Withdrawal of affection

16. Isolating you from friends and family

17. Using money to control

18. Constant calling or texting when you are not with them

19. Threatening to commit suicide if you leave

Ok now that you know the signs. What do you do about it? What do you do when you notice it in someone else’s relationship? If you are the victim, the obvious, but not easy, answer is to break off the relationship and leave. Call the National Domestic Violence Hotline at 1-800-799-SAFE. All phone calls are confidential. This is a 24 hour hotline to talk confidentially with anyone in the United States who is experiencing domestic violence, seeking information, or questioning if his or her relationship is unhealthy. This same hotline also provides lifesaving tools and immediate support to empower victims and survivors and also provides support to friends and family. They have an online chat as well if you do not feel comfortable or are unable to call. If you are the observer, don’t wait for the victim to approach you. Ask them in private and let them know your concerns. Tactfully point out the signs that you have noticed. Offer to be there for them to talk and promise confidentiality. Direct the victim toward resources such as the national hotline. You could save a life. Have a fantastic day!

Dr. Katz