Did You Heat The One About The Bearded Lady?

August 3rd, 2009
I encountered her at a clinic in a different city that had asked me to consult on some tricky cases. She bonded with me, even though I told her I would not be her permanent doctor and somebody else would be attending her soon.
Her diagnosis is bipolar. She may be schizoaffective, for she does have some eccentric ideas and may have had some delusions. But right now, I think she looks pretty good. There is only one problem. She wants to feel more like she belongs in society. She wants to work.
Her first problem, she told me, was her advanced age. We determined she was almost exactly the same age as me. I was exactly, to the day, two months older than she. She looked at me and could not believe it. She accused me of looking young because I had all the advantages. A middle class upbringing. Lots, yes whole lots, of education. And this patient had been on the streets, living the hard life. But now she had a place of her own, and disability. She wanted to work, first volunteer maybe, then, maybe, someday, a paid job. She said she did not expect much, did not have the stomach for education, just a little job doing filing, or something.
We could get her some clothes, get her hair cut. I do not think she looked badly at all. But she knew there was something about her, which the minute people looked at her, they did not seem to want her around.
Nobody else would tell her. I was her favorite person in the clinic. I was nailed. I did not know she would later thank me for my candor.
I told her how the public was fickle; there was no accounting for taste, etc. I finally got to the heart of the matter.
"Some people might think you have a beard."
She was not stupid. She had suspected it was the beard. She had also had some problems with a discharge from her breasts, a while before.
She had been on the antipsychotic drug risperidone (Risperdal) for some years long before she met me. Nobody had tested her prolactin, a substance secreted in the brain as a side effect, pretty well known, of risperidone. Whatever. She was in menopausal age now, and had no interest in any kinds of tests. I cannot establish for 100% certain that her beard had anything to do with the risperidone, but I do know that risperidone has been associated with impotence in males. She had been on plenty of drugs over the years, had never had any desire or inclination to be anything other than female, but could have lived with her beard if it had not seemed to disturb others.
The fact remained that the Risperdal had worked. Her mood was fairly well controlled. She may have had some odd thoughts, but she did not have any psychotic (hallucinatory or similarly alternate-reality kinds of symptoms), and risperidone is known for getting rid of that. It had worked for her.
Some menopausal women just get beards, but it is usually a few hairs. Hers was impressive in its coverage of her chin, but reached no further. It had been there long enough that she thought it was a side effect, and she was probably right. When you tinker with a hormone system, all kinds of things happen.
I suggested shaving.
She suggested waxing. She told me that real women don't shave, they wax.
I told her that real women prefer pleasure over pain. I would always choose something that did not hurt over something that did hurt.
She told me that I was a wimp, wimp, wimp.
I told her people would look at her and never know how she had gotten her beard off. They would only know if she had one or not.
This is a lot to deal with for anybody. It is a very lot to deal with for someone chronically mentally ill, coming into a work force for the first time.
It is always an interesting exercise, trying to get an informed consent from someone who has not taken psychiatric drugs before. I tell them the known side effects, of course. But for all drugs, there is the possibility of something being a side effect if it happened when you are on the drug. You never know, really, no matter what other people say. We are so different in our personal physiology that what happens in one person may not happen in another.
Her beard is an issue of some complexity and she has not decided how it will be resolved. I suggested a razor might be cheaper than repeated waxing, if that was a factor.
With psychotropic medications, it is not impossible to find complex issues with a simple prescription.
Side effects are common. In the years when I was in residency training for psychiatry, we had mostly the older "tricyclic" antidepressants, which are now used less often, most specifically for difficult cases. Then, the major determinant for which drug was used to treat which depressed person seemed to be the side effect profile. Now, there are advances in psychopharmacology, such that side effect profiles look, and are, far more benign.
I am hearing rumors, and seeing accounts on the net, about the possibility of drug company-repressed research results regarding drugs brought to market. A pharmaceutical manufacturer has a tremendous investment in bringing a prescription drug to market, so I can understand - without condoning - why some people may be motivated to do this.
All these things are happening on levels way before data and medications get to me.
Anything and everything might be a side effect. Side effects can touch peoples' lives in ways we have not yet considered.
This is one of the reasons I love natural substances as much as I do.