Making Space

What If the Clinician Forgets to Ask?

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Vital Subjects
by Keiko Lane, MFT

[dropcap]M[/dropcap]y partner sits on the table in our gynecologist’s office undressed for her annual exam. The hospital gown is flapping open around her back when our gynecologist says that given my partner’s age, health history, and low risk factors, she can skip the pap smear. I’m a little irritated; and it takes me the rest of the day to figure out why.

Let me fill in a few details: We’ve been seeing this gynecologist for a decade. We actually enjoy our appointments with her. She’s funny, a dyke, and a woman of color. My partner and I accompany each other to most medical appointments because we like our doctors and feel that when we go to each other’s appointments we are all reminded that they are treating us as a family. But it’s also an old habit of mine from the early years of HIV treatment not to let anyone go to the doctor without an advocate.

As I was finishing up case notes in my psychotherapy practice, I realized that I was disappointed in our doctor for her assumption that my partner has remained low risk. Our doctor had asked, as is her routine, about any sexual or medical issues we wanted to talk about with her, but she did not ask about whether our arrangements around monogamy, or any other risk factors, have changed.

The first time I had an HIV test almost twenty-five years ago, I was still seeing the doctor who had been my primary care physician through my adolescence. When I asked for an HIV test, my doctor looked at me—young, femme, queer, Japanese American, good student—and said, “Why? Someone like you isn’t at any risk.” Well, this was during the ACT UP years, and I had lovers who were HIV-positive, and more than once I had helped friends who had been beaten by police at demonstrations hold compresses to their wounds. We usually had gloves with us. But not always.

For more than a decade after that exchange with my doctor, I only got tested through free testing programs at LGBTQ centers in the cities where I lived. In those HIV testing programs, test counselors began with the assumption that if you were walking in the door, you knew you had a reason to be there. They respected that it took courage to sit down in the waiting room with an anonymous number and hold your arm out to a gloved phlebotomist you had never met.

As a community engaged with HIV/AIDS, we have had more than twenty years of “Knowledge Is Power: Know Your Status” campaigns. I believe in those campaigns. They have become part of the landscape of queerness and sex education in large urban centers that have visible LGBTQQI populations and communities affected by HIV. They’ve become code—something we can nod toward as a signifier of HIV education and knowledge.

Sometimes things happen to remind me that code isn’t enough. We need more than the shorthand of cultural signifiers to make sure we are explicitly inviting everyone to participate and take up space. Recently in my psychotherapy practice, a gay man in his early twenties came to see me. As I got to know him over the first few sessions, he talked about his family, his friends, and the men he dated and hooked up with. He had come to the Bay Area from a small town in a Midwestern state. This was the first time he had a community in which he could be out in all parts of his life. It wasn’t until he told me about feeling guilty about a drunken hookup that I asked him about his safer sex practices. He said he was relieved that I asked, and we were able to talk about what he believes about when he protects himself, and when and how he takes risks, and what his feelings are about those experiences.

I realized after my partner’s appointment with our gynecologist that she had done to us a version of what I had done to my client—not asking specific and direct nonjudgmental questions unless (or until) there was a story told that elicited some concern. In other words, it had not been a casual question I asked early into his psychotherapy, the way I ask about any other part of someone’s history. It isn’t that I’m uncomfortable talking about sex, and, in fact, the problem may be the opposite: I’m so used to talking about sex and teaching about sex and gender in the communities that I move through that I can forget that clients who come from different cultural contexts may have difficulty initiating conversations. Making space is not enough.

And now I wonder, how can I expect my clients to be able to advocate for themselves if I am not advocating for myself and my family? I think about how hard—impossible—it was for me to pause and question my beloved doctor of a decade. Regardless of whether anything has changed in my epidemiological HIV risk, or my partner’s, next time I will stop my doctor and question her assumption. It’s good practice. Necessary. I can’t ask it of my clients without asking it of myself. This is my challenge to myself and to my clinical colleagues in mental health, community health advocacy, and physical medicine.

Self-advocacy is a revolutionary act of self-love. I teach that to my psychotherapy students and I offer it as a possibility to the clients in my practice. Saying what is difficult often enough so that it ceases to be difficult is one way we erase stigma.

I apologized to my young gay client, and together we are exploring his embodied experience of sex, risk, desire, and fear. We are finding his language. Sometimes signifiers aren’t enough. We need to find new and more words. Again. Still. Always.

In all case examples from my clinical practice, clients’ identities and details are changed significantly to disguise their specificity and identity. The issues raised are actual questions and issues from my clinical practice, clinical supervision, and teaching.


Keiko Lane, MFT, is a Japanese American writer and psychotherapist. She writes about the  intersections of queer culture, oppression resistance, racial justice, and liberation psychology. She has a psychotherapy practice in Berkeley, California, specializing in work with queers of all genders, artists, activists, academics, people affected by HIV/AIDS, asylum seekers and other clients self-identified as post-colonial. Keiko also teaches graduate and post-graduate psychotherapy courses on queer and multicultural psychotherapies, the psychodynamics of social justice, and the embodied literature of exile. She is a long-term survivor of ACT UP/Los Angeles. Visit: www.keikolanemft.com.