Naturopathic Medicine and Gender Affirming Healthcare.
By Jill Corey ND
Naturopathic medicine has five principals listed here:
- First do no harm: using treatments that have low side effects.
- Prevention: working with the patient to prevent future health conditions.
- Supporting the body’s own ability to heal: help remove blocks to healing.
- Treat the whole person: understanding the patient and providing an individualized plan that includes physical, emotional, environmental and spiritual aspects.
- Docere (teaching): providing knowledge to the patient in order to help them feel empowered to take responsibility for their health.
One of the principals of naturopathic medicine is to treat the whole person. This principle ties in perfectly with gender affirming healthcare. Many of my patients are seeking to express outwardly what they identify as on the inside. We just want to feel more like themselves. Naturopathic Medicine provides many avenues to facilitate this process. For example, many people feel that they need hormone therapy (HRT) to feel more comfortable. HRT is a wonderful tool for gender affirming healthcare. However, hormone therapy can have undesirable side effects. That is why when I provide HRT for my patients I also make sure to keep in mind the whole person. For example, HRT can cause be taxing on the liver. The liver is the organ that process hormones and toxins in our body. That is why certain herbs and supplements can be taken to help the liver function optimally. I will sometimes recommend Milk Thistle, Artichoke or Glutathione for support. Also, if our liver is not functioning optimally the toxins processed by the liver can also cause skin issues such as acne or eczema. Furthermore, HRT can also cause mood fluctuations. Remember going through puberty as a teenager and how moody you were? Well, fortunately there are lots of herbs like St. John’s Wort or Lemon Balm. That can ease the emotional roller coaster that HRT can cause. There are also many lifestyle changes such as exercise and meditation that can have profound effects on mood. As a naturopathic doctor I typically provide recommendations for diet, lifestyle modifications, exercise and herbal medications to ease the transition for all of my patients seeking gender-affirming care.
We are social animals with nervous systems that have developed over time to keep us alive. One of the reasons that I love Polyvagal Theory is that it provides a useful way to understand our nervous system responses. Deb Dana, one of the main scholars and writers about Polyvagal Theory calls it, “the science of connection.” The job of our nervous system is to collect information about and process cues of safety and danger. It rules our impulses toward survival and even our longing to connect with others.
What are nervous system responses? I’m sure you’ve heard of fight and flight. Perhaps you’ve heard of freeze, appease, or collapse? People keep adding to the list because our nervous systems do so many things. Polyvagal Theory organizes these different responses into three categories: ventral vagal, sympathetic, and dorsal vagal. These three nervous system states, or pathways, developed over a long long time throughout our evolution into the humans we are today.
As you read the following responses, notice if there is one you feel more familiar with:
The first nervous system state to develop in our evolutionary journey is the “dorsal vagal” response. We are in a dorsal vagal response when we are scared to death. Sensations associated with this state are feeling shut down, frozen or collapsed. We might feel foggy and disconnected, dissociated, despairing, and hope feels unreachable. Our heart rate slows and our breathing becomes shallow.
The next oldest pathways is the “sympathetic” response. The sympathetic response is about mobilizing us to action, like fight and flight. It can feel like a rush of adrenaline, or anxiety. Our hearts pound faster, our focus narrows as we listen and look for danger in our environment. We may misread cues from other people. For example, a neutral face or body posture of someone nearby may register as dangerous.
We needed a prefrontal cortex in order to develop the most recent of the evolutionary nervous system states: ventral vagal. In this state we have a regulated heart rate and are able to take full deep breaths. We feel that we have access to choices for ourselves. We can experience curiosity and connection with others. We can reach out for support and also offer support. We have access to feelings of altruism. When we are squarely located in ventral vagal we feel safe and connected to ourselves and to others.
Were you able to recognize any of these states from your own experience? We are actually going in and out of these states all the time, every day, even moment by moment. Our nervous systems are incredibly flexible. We move into disregulation (sympathetic or dorsal vagal), and then back into regulation (ventral vagal) all the time. We are constantly sending and receiving cues of safety and danger from and with those around us. Basically our nervous systems are talking to other nervous systems all the time. As we move about our days our bodies are collecting and responding to this information totally outside of our conscious awareness. This is called “neuroception.”
Neuroception is our body’s unconscious assessment of either danger or safety. This information is gathered from inside our bodies, our external environment, and in our relationships with others. When we have a neuroception of danger, our nervous system responds by affecting physiological changes inside our bodies to mobilize us into sympathetic, or take us into the collapse response of dorsal vagal. Because our brain is always in conversation with our nervous system, the brain makes up a story in order to make sense of the state our body is in. The story follows the state change. When we can bring conscious perception to our neuroception, then we can start to become a student of our own system.
Our nervous systems are shaped and toned over time through relationships. This means that if we grew up in a family where we rarely, if ever, felt safe, we may develop a habitual response of disconnection. We may feel that being seen is dangerous so we try to disappear. Some people find themselves habitually in a state of sympathetic arousal, or in dorsal vagal. I want to stress here that our nervous systems shape our responses so that we can survive. Every nervous system response we have is in service to our survival. Understanding the science behind our survival responses can sometimes help reduce shame we feel about those responses. When we can begin to reduce the shame, we can begin to get curious. When we can get curious then we can begin take a more active role in getting to know our particular nervous system. We can begin to notice what our thoughts, behaviors and beliefs are when we are in each state. It’s an empowerment process that we can participate in with ourselves, with a therapist, or with a safe and compassionate other.
Just like neuroplasticity shows us that we can change our brains, Polyvagal Theory shows us that we can re-shape our nervous systems over time through becoming active and conscious in our own response patterns and experiencing repeated interactions with safe others. We can become active in re-shaping our nervous system to bring greater flexibility, and build our capacity for regulation and connection.
Training: Integrating Polyvagal Theory into Clinical Practice with Deb Dana
Therapy can be gross. What I really mean is, therapy can make you feel less ok about things then you felt before you sat down and started talking. A colleague of mine describes this feeling as “stirring up the gunk.”
We all have coping mechanisms that help us move through our day to day. We all deal with our emotions and struggles in *some* way. And often what happens in therapy is that we are asked to think about finding different ways to cope. Maybe we have enough self-awareness to say to our therapist in an early session, “This way I’ve been coping isn’t working, I need a new one.” Many people – including myself when I first started going to therapy as a client – don’t start there. We start with something like, “I don’t know, I guess I’ve been really anxious.” We’ve heard talking to a therapist can help, so we try it. And then at some point in therapy we reach this meme-able moment:
We realize – or our therapist gently tells us – that our coping mechanisms could use some work. And that is why therapy can be gross.
Learning new ways of doing things is hard. It takes work and practice. It brings up all the feelings of not being good at something because you haven’t tried it before. Gross, gross, gross. It can ask us to examine where we learned how to cope like this, maybe from family dynamics or traumatic events. It can require us to be really vulnerable with naming the emotions we’re coping with. And vulnerability often feels super gross. Vulnerability feels hard and uncomfortable because we hide things really well from ourselves that we can’t hide as well with another person. Dr. Brene Brown defines vulnerability as “uncertainty, risk, and emotional exposure.” Just what we all want to do with a stranger on a Thursday morning!
But here’s the thing about vulnerability in therapy. When we open ourselves up and let whatever “gunk” we maybe didn’t want stirred up come to the surface, our therapist knows what to do next. As a therapist, the moments when a client can be vulnerable with me feel like sinking three-pointers. Except I don’t feel like the Steph Curry in that scenario. I feel like the Steve Kerr. Because my client has ability and skill and wisdom and experience that have nothing to do with me. And those things – they’re part of the gunk. What we’ve been taught, as therapists, is to be able to say “look at that gunk, isn’t it neat!” We’re here to help you consider that maybe that gunk, those gross feelings, are actually important and valuable. We’re trained to encourage your understanding that this coping mechanism you had, while it was helping you get through your day to day, also involved feeling feelings and saying “gross” to yourself, instead of saying, “I feel really disappointed right now, because this thing I wanted isn’t going to work out.”
That is a hard thing to do. Harder for some feelings than others. Harder at some points in our life than others. The difficulty doesn’t always go away, but therapy helps us get better at. Weights don’t get lighter, muscles get stronger. The basket doesn’t move closer, we get more skilled. Practice doesn’t make perfect, especially in therapy. Practice just makes it easier to do the hard thing. We still feel the way we feel. The things that have happened to us don’t magically evaporate. But stirring up the gunk becomes a thing we know how to do, even if we find it gross.
This article is not all inclusive and is meant to explain the basics of how most USA health insurance policies work in regards to your out patient care appointments. You will need to look at your individual policies for confirmation and details where your policy may differ from the general description below.
First you choose a health insurance policy.
Most of the policies presently consist of a premium, a deductible, and co-pays.
Premium is the amount you pay every month to the company to be able to have a month to month policy. If you don’t pay this premium, they can cancel your insurance. If your premium is $250/month, this will cost you $3000 per year whether or not you use your insurance and does not apply to your deductible.
Deductible is the annual amount set up by the company that you/your family must pay before the company pays out any substantial payments to your providers. For example, you have a $5,000 deductible. You must pay the first $5,000 of medical services before the company pays. Depending upon your policy, there may be some visits that are covered before the deductible is met such as annual physicals, but that will vary from policy to policy. Otherwise, you are responsible for covering office visits, labs, and procedures up until the deductible is met.
Co-pays are paid at each office visit in accordance with your plan’s policy. Not every policy requires this, but most do and it is applied to your deductible.
What happens when you are seen in the clinic and you have not met your annual deductible?
The clinic takes your co-pay, which the company will apply to your deductible. It is illegal for any clinic to not collect a co-pay if your insurance requires you to pay one, so please do not ask for the clinic to waive your co-pay. If you do not pay your co-pay at the appointment, insurance requires you be billed for this and you are responsible for this amount, not your insurance.
At the end of the visit you have the option to pay then or be billed.
Paying at time of service often gives you a discount with the clinic, ask if this is possible. You should receive a receipt and a billing slip which will allow you to send to your insurance company for reimbursement. The funds you paid for your visit are then applied to your annual deductible.
If you are to be billed, the clinic will submit the bill to your insurance first. If you have not met your deductible, the insurance company will notify the clinic and then the clinic must send you a bill for that visit. If you have met your deductible, the insurance will send a portion of the clinic fees as their payment to the clinic, and then the clinic must bill you for the remainder. Typically, many insurances use an 80-20 split. They pay 80%, you pay 20%. This varies from policy to policy and you must always know your own policy to know for sure what your coverage is and what amounts you will be responsible for.
If you are receiving care at a cash only clinic, i.e. one that does not accept insurance, the process is the same as if you were choosing to pay cash instead of billing your insurance up front: you pay the clinic, they give you a receipt and billing slip for you to submit to your insurance company, and then your insurance company reimburses you. Best to confirm with your insurance prior to your visit to make sure they will cover the care.
Those with this type of insurance do not have a deductible. Medicare and Medicaid only pay to clinics that are signed up with these insurance plans. Cash only clinics are not in this group. If you have Medicare or Medicaid you may use a cash only clinic and pay the clinic, but you will not be reimbursed from the insurance company.
Some people choose to get care at a cash only clinic even though they have insurance if the clinic offers services their own PCP doesn’t or if they prefer the provider(s) in the cash only clinic. If they have insurance that is not Medicare/Medicaid, these visits may be reimbursed by their insurance companies and applied to deductibles. This is money that you would need to pay to the clinic taking insurance anyway if your deductible was not met. So, this can potentially not cost you any more to use a cash only clinic.
If you have an HMO such as Kaiser Permanente, you must get all your care through the HMO unless there is a written agreement/contract between the HMO and your chosen non-HMO provider. You will need to discuss using a non-HMO provider with your HMO prior to seeking care outside the HMO if you want to be reimbursed for care outside the HMO.
This information is provided to help potential patients in our clinic since some of the providers are cash only and do not take insurance. Some providers do take insurance but recall from the explanation above, you may still be billed for the visit if your deductible is not met. If you have questions about your policy, always review your policy or talk to your insurance representative.