The Blue Cotton Gown

by Patricia Harman

  We deal with alphabet soup nowadays. HSV (herpes simplex virus), HPV (human papillomavirus), HIV (human immunodeficiency virus). They’re all sexually transmitted. Only one of them can directly kill you. The rest are just uncomfortable and with you for life.

  I sit and wait for Shiana’s tears to stop so I can ask her why she thinks she has herpes.

  She’s wearing the regulation thin cotton gown, sitting on the end of the exam table, with her dark hair pulled back under the pink baseball cap. I roll my stool up and hand her the tissues.

  Shiana wipes her face, glances at me, then starts crying again. I pat the girl’s knee and say something soothing. “It’s okay now, sweetie. It’s okay, hon. Tell me what’s happening.”

  The young woman wipes her face and takes a deep breath.

  “Why do you think you have herpes? What’s going on?” I ask again softly.

  Shiana swallows hard and lets out some air. Then her almond eyes water and it seems for a minute like I’m losing her again. I reach out and take the young woman’s hand. “Let me take a look. Let’s see what’s going on down there. Maybe we can do cultures to find out for sure. Sometimes I can tell by examining you.” I want to cut to the chase, but the girl doesn’t lie back or put her feet in the footrests.

  “Do you remember me?” Shiana asks. “I know you meet a lot of patients … I’m the girl with the condom. The blue one.”

  “I remember.”

  “Well, it’s been downhill since I saw you. I got your nurse’s call about the positive chlamydia test and I took the antibiotics like you told me, but then I got a yeast infection.” She’s talking fast now. Trying to get it all out. “I’d never had one before, but they said it was common after taking antibiotics … Now I’m all swollen and have little blisters down there. I checked on the Internet and I don’t know what else it could be. It has to be herpes.”

  She starts leaking tears again, but before she gets too far, I say, “Shiana, stop now. I need your cooperation. I want you to lie down. I can usually tell by looking, but if I can’t, I’ll send cultures to the lab. Have you been sick with a fever or had any difficulty peeing?”

  “It burns awful. It hurts so bad that I try not to pee. All I did yesterday was stay in bed. I didn’t even tell my roommate what was wrong. I’m so ashamed.”

  I spread the young woman’s outer labia with my gloved fingers. I don’t need cultures, but I’ll get them anyway. Along the right side are a row of white ulcers, tiny moist craters. There’s no question.

  “It’s herpes,” I say. “I was hoping it wasn’t.” Shiana puts her arm over her eyes and begins to sob again, this time silently, but her whole body shakes. It’s hard to tell if it’s sadness or anger.

  “Shiana, I know you’re upset, but I want you to sit up and listen to me. I’m going to tell you what we need to do.” Shiana wipes her face and sits up, her hands folded in her lap on the blue exam gown, like a schoolgirl in the principal’s office. She blows her nose on the tissues I give her.

  “The first thing is, I’m going to give you medicine to make the sores go away. I want you to stay on the pills for two weeks. I’ll get you something for the pain, and you’ll probably need to take a few days off school. I know you’re upset, but this isn’t the end of the world.” Shiana squints like she doesn’t believe me. “No, really. I see two or three women a week with herpes.” This is a lie, but sometimes I exaggerate to make the patients feel better. Really it’s more like two or three cases a month.

  “Will the medicine cure it?”

  “No, it can’t, but it can control the virus and dry up the sores. I had a herpes outbreak once.” Shiana stops crying, paying close attention now, her brown eyes still shining with tears.

  “You?”

  “Yeah. I was about your age, nineteen or twenty. We didn’t know about chlamydia then, or herpes, or HIV. This was back in the hippie days.”

  Shiana watches me, no doubt picturing the young Patsy Harman with hair to her waist, a long calico skirt, and maybe a flower behind her ear, like girls on a PBS special about the protest days. She wouldn’t be far off.

  “I had it much worse than you, and there weren’t any antiviral medicines. I was at home on spring break and I got sores all over down there, and in my mouth too.” For a second, I wonder if I’m being too graphic. I can’t picture Tom or any other health-care provider telling a patient something like this, but I continue. Maybe it will help Shiana to know that someone else has been through this. “It stung so bad when I had to go to the bathroom, I had to stand up in the tub to urinate.”

  “That’s what I did too.” The girl smiles. “I stood in the shower and tried to get the water to spray on me while I was peeing. It didn’t help much.”

  I write my patient a script for acyclovir ointment and tablets and give her a pamphlet on living with herpes. “In seven days I’ll see you again and we can discuss how you’ll need to protect yourself and any future partners.”

  Shiana regards me, startled. I can tell she hadn’t thought about what she would tell a new boyfriend. She’s dressed now in a loose gray Torrington State University sweat suit. For a minute, I think of taking her to my home. The sweet young woman could use some mothering. But I resist. Like most professionals, I try to draw a line between my relationships with patients and my personal life. Though I’ve thought of doing it many times, I don’t take them home.

  “Well, I won’t be telling any partners. I’m planning on being celibate from now on,” the girl says, and the tears well up. This time there’s no smile.

  I give her a hug. I’ve said that myself. More than once.

  KASMAR

  Straightening the stethoscope around my neck, I take a deep breath and then open the door. “Hi, Kasmar.” I reach out my hand, hoping I won’t regret my decision to help her become a man. There are so many things I haven’t thought out. Will the nurses object and refuse to give her the injections of testosterone? Will the other patients be offended to see someone who appears to be a man sitting in the waiting room?

  The tall, thin woman sits in the guest chair; she’s wearing neatly pressed gray slacks with a light green checkered shirt, the long sleeves rolled up. This time her dark hair is cropped even shorter and the neck shaved; no makeup, no earrings or jewelry, only a large square-faced gold watch with a leather band. Kasmar looks at me expectantly.

  “So, how are you today?” I ask. It’s been more than a month since her last visit.

  “Fine, thank you.” Kasmar shifts her ankle up on her knee and leans forward, waiting.

  “Well, I suppose you’re wondering what we’ve decided, so I might as well get to the point.”

  Kasmar watches my face.

  “Dr. Harman and I had a discussion. We’ve decided that though your request is out of the ordinary, it’s something that we can help you with.”

  She swallows hard, relief in her blue eyes.

  I go on. “We’ll help you so long as the testosterone injections aren’t hurting your health. If we start to feel the situation is out of our league or requiring too much time, we reserve the right to stop treatment. I’ve also drawn up a consent form for you to sign in which you acknowledge that there are possible side effects to the—” I haven’t finished my sentence but Kasmar is reaching for the heavy black ballpoint clipped in her front shirt pocket.

  “Thanks so much,” she says, signing the document after glancing over it, her tanned, freckled face flushed with excitement. “This is great.” She’s grinning from ear to ear. “This is just great.”

  I go over the potential side effects again. “Most of them are minor and reversible, like acne, cessation of periods, headaches, mood change, and masculinization.” We both smile at that. “But some might be irreversible, like hair loss, liver problems, hypertension, or elevated cholesterol.” Kasmar nods. She knows all this. Then I write the first script for the testosterone injections. Kasmar will pick up the syringe at the pharmacy and bring it to the clinic every two weeks.
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  If the patient had been born with a deformity, some error of nature such as a cleft lip or a clubfoot, someone would help her. To Kasmar, her female body is just as much of a mistake.

  Kasmar stands, reaches for my hand, and pumps it firmly, still beaming. “This is great. Just great,” she says again.

  Her voice is already a few notes lower.

  HOLLY

  On sunny summer days, everyone at the clinic, from Dr. Tom to Junie, our junior secretary, is eager to go home early. Sometimes we close at four, but not often. We find ourselves dreaming of what we could be doing outside: working in the garden, biking, swimming, or just reading a book out on the porch.

  Today’s that kind of day. It’s lunch break, and having finished my charting, I gaze for a minute out the window at the billowy white clouds being swept across the blue sky. Last night was that kind of night too! I smile, remembering.

  Tom and I had our first skinny-dip of the season. The air was warm, the dark waters of Hope Lake a little cold, just enough to make you holler when you dove in, although two minutes later you were swimming around and saying, “This is great!” “Not too bad.” “Actually pretty warm.”

  In the cove below the house, skinny-dipping has the added benefit of being a little risky. How would it look if a well-known middle-aged physician and his wife were caught naked in the spotlight of a motor boat?

  We swam on our backs, looking up at the stars. Dark sky, no moon yet. We dog-paddled into the streaks of silver and gold that floated over the black water from the cottages on the other side of the cove. We swam together, our bare bodies wrapped around each other. We played like little kids, grabbing each other’s private parts. Well, I grabbed his, anyway, and joked about a snapping turtle.

  There’s a tap at my door, and I snap back to the here and now. “Your first patient is ready, chickie,” says Celeste, my nurse for the afternoon, handing me a yellow chart. “Time to go back to work. Sure would be nice to leave early today.” I know what she’s really saying: Try to keep up so we can leave on time, maybe even early. I’ll try. I always try.

  I knock my usual greeting—dum-de-dum-dum—and enter exam room 1.

  “Do you think this microdermabrasion would do me any good?” Holly Knight asks before I even get through the door. She inspects her face in the small gold-framed mirror mounted in the dressing corner.

  “I think it does good for everyone. For you, it would take off the dry skin and some of the fine wrinkles. It would fade the sun damage.” I turn Holly’s face to the light. “It would clean out the pores … And it feels great.”

  It strikes me as odd that I, an ex-hippie who rarely wears makeup, promote medical cosmetic microdermabrasion, but I’ve come to feel that if a person can afford it, she should have her interest encouraged. In Torrington, because of the university, there are plenty of female professionals who travel, who read. They’re curious how such procedures can help them.

  Women don’t do enough nice things for themselves. They give to their kids, their husbands, their parents and families. Sometimes they volunteer in the community or at church, but they rarely give to themselves. Whenever a patient signs up for a package, it’s a celebration for us all.

  I pat Holly on the back. “You should try it. Abby, our nurse, does a facial massage afterward and she has soft music playing. Every time I get one I think, I’ve got to take better care of myself. It makes me want to eat healthier, to exercise, to begin doing yoga again. We started doing the treatments when we stopped delivering babies. It helps pay the bills, and it’s fun to help women feel good.”

  Holly sits down in the guest chair. Today she’s dressed in a sleeveless aqua tunic, linen cropped pants, and taupe slides. Her highlighted hair is held back with a clip, but there are circles under her eyes and she looks tired.

  I wonder how her daughter, Nora, is doing but hate bringing it up. The last I’d heard, she was in the ICU for bulimia. “So, how you been?” I start out, opening the chart.

  “Oh, not too bad.” Holly slides down in her chair with her long legs stretched out. “I think I need to change my antidepressant, though. It’s not working. I’m so cranky I can hardly stand myself. Maybe I just need to increase the dose.” She looks at me.

  “Are you on it for perimenopausal symptoms, stress, anxiety, or depression?”

  Holly laughs. “All of the above.” That’s what I like about this woman. She isn’t a whiner, and except when it comes to her issues around her daughter, she can make fun of herself. We’re quiet for a moment.

  “So, how are you doing with your hormone replacement? Do you have enough to get you through till your annual gyn visit?”

  “Yeah, I’m okay. I stopped taking the medication for a while. Did I tell you? But I went back. I started hot flashing and sweating all day. I thought I could make it naturally, but I can’t and I don’t know how some women do. I feel like a wimp.” She waits for reassurance.

  “We’re all different, that’s for sure. Some women’s menopausal symptoms aren’t that bad, others are so affected they can’t work, they can’t sleep, they can’t make love, they can’t remember their own kids’ names.” We laugh, both knowing how that is.

  I laugh a lot with my patients. I joke with them about constipation. I kid about periods. We poke fun at aging, at looking in the mirror and seeing our mothers looking back at us. “We’re being silly,” I say when our laughter gets too loud, but sometimes if you don’t laugh you might cry.

  I open Holly’s chart to her history. “You have no personal or family experience of breast cancer or early strokes, so the risk, if there is one, is worth the improvement in the quality of your life. You know what Dr. Harman says about hormone replacement, don’t you?” Holly shakes her head no. “There’s a risk in getting in a car and going across town too, but that doesn’t mean you stay home.” I raise my eyebrows to make the point. Holly grins.

  “I always feel better when I come to see you, Patsy. I feel almost normal, like you understand.”

  I smile and nod. We are all almost normal. “So how’s your stress level? Stress makes hot flashes worse, you know.”

  “Better, I guess. Nora’s home from the treatment center and taking classes at State. I think she’s still vomiting but she’s holding her own. I told you she went to Atlanta to a treatment center for a month, didn’t I?”

  I shake my head no. “Did it help?”

  Holly continues. “It seemed to at first, but then she comes home and starts puking again. My husband tells me I can’t save her. I know he’s right. She has to save herself.” The patient’s husband is the vice president of First Mountain State Bank. I met him once at a United Way fund-raiser.

  “Why does she do it? The vomiting. Is it insecurity? Is it pressure at school?” I lean back against the cool white wall, wanting to understand. I wish I could take Holly home with me and have tea. We’d sit in my living room with our feet on the coffee table and talk about our kids and where we’d gone wrong. We’d eat brownies and maybe drink Stress Relief tea. I’d get out the pictures of Mica and Orion and Zen, and she’d open her wallet and show me her boys and Nora.

  “I don’t know why she vomits. I don’t even think she knows anymore. It started when she was in junior high school. Now she can’t stop. We have a new counselor but I’m afraid to hope. It’s been such a struggle. I try to be optimistic, but if she gets really sick again I’m clueless what we’ll do next, where we’ll go.

  “Thank God we have health insurance. I don’t know what people do who don’t have coverage. Do you know how much it costs to stay at a center for eating disorders? Fifteen hundred a day.” Holly widens her eyes, waiting for my reaction. She gets what she expected.

  “Fifteen hundred a day?” I know I heard right, but I can’t comprehend it. “That’s forty-five thousand for a month. Did you look around? Is that the going rate? Forty-five thousand!”

  “Of course I did. Are you kidding? I got on the Internet to investigate and called every program.
And there’s only a limited amount of reimbursement on most health insurance plans for mental health, anyway. Did you know that?” the mother continues. “When you use it up, you’re done, there’s no more. Some of the centers will give you a break if you don’t have coverage, but there’s so much demand and so many young women with bulimia and anorexia. What would you do if she was your child? Mortgage your house? What would you do?” Her voice breaks. “You couldn’t let your own daughter starve.”

  I nod. I know the passion mothers have for their children, and I wonder where Tom and I would get that kind of money if one of our kids were dying and we didn’t have insurance. I would sell everything we own for one of my boys. You give birth to them in pain. You nurse them at your breast. You hold them at your heart forever.

  I write Holly a script for her increased dose of antidepressants, give her a couple months’ worth of samples of hormone replacement, then hold out a pamphlet on coping with stress. “Maybe this will help,” I say, smiling. We both know it won’t. I put my arms around Holly, saying a silent prayer for her daughter. Sometimes the mother needs mothering. We’re almost the same height, both tall, big, capable women. Both little girls.

  Shame

  Okay, I’m ashamed about the alcohol … but not about the insomnia. I know from talking to so many women that half of them don’t sleep well either. I’ve come to think of the sleeplessness as a disability, something I just have to live with. I never tell my patients about my sleep medicine. I don’t tell Holly or Trish or Nila. I don’t know why.

  Okay, I do know. It’s the shame of not being able to turn off my thoughts, of using a drug that, though legal, when taken too long and in excess can destroy your liver and maybe your mind.

  I’m a midwife. When I discuss sleep problems with my patients, I talk about herbal teas, relaxed deep breathing, leaving their troubles out of the bedroom. Those things don’t work for me. I doubt they work for them. Sometimes I prescribe pills for my patients or refer them to the sleep clinic. I went there myself a few years ago, but it was a waste. And I’ve tried sleeping pills too. I’ve never found one that both works and doesn’t make me too groggy in the morning.