About two years ago, a 25-year-old, second-year dental student came to me for help. On his intake form, he described his problem as pain in the groin region and circled the gonad/groin area on his pain chart.
During the interview, he was reticent but finally revealed that he was having pain when walking or standing. I thought he meant something like a groin sprain. He said he had experienced this pain since high school and denied having had any injury that could have caused it. He denied perineal pain, urinary difficulties or sexual dysfunction. He said he had been to numerous doctors, where the physicians examined him and found no reason for his pain. They found his labs to be normal, including hormone levels.
He seemed nervous and avoided eye contact during the interview. He tended not to volunteer information. I had the feeling he was not being open with me. It was a little hard to imagine he was a dental student because he seemed to not have thought through the musculoskeletal issues that could produce groin pain. My impression was that he felt very awkward while talking with me.
At this point, I felt he was simply uncomfortable in the clinic atmosphere with the acupuncture procedure or the fact I was female. He also might have been embarrassed about discussing anything remotely sexual in nature. I wondered if there were issues involving sexual abuse or identity.
He appeared to be very healthy: excellent weight-for-height condition; athletic build, but not overly muscular; and no signs of acne, hair loss or changes in skin pigment. His pulse was 65, large, slippery and somewhat superficial bilaterally. All pulse positions were equal in strength and depth. The tongue was a healthy red color, very thin white coat with no peeling or cracks, indented along the Liv/GB area, slight depression in the kidney area, sublingual veins not enlarged.
My first treatment attempts were based on the assumption there was a musculoskeletal origin to the problem. Notable was the fact that he could barely tolerate my palpating or needling his abdomen. To me, this was more evidence of sexual issues being involved. I discovered he was wearing an athletic cup. He said that it felt better to wear one when he was having pain.
By his report, a variety of acupuncture approaches failed to help him. After about four treatments, I asked if there were any other symptoms related to this pain. He told me he also was worried about "shrinkage," which I understood to mean his genitals. It was difficult, but I finally got him to say it was the testicles in particular that he was concerned about. He said the doctors did not agree with his concern. I wondered if he had some kind of irrational concern about the size of his testicles; if he was somehow obsessed with testicle size. However, I did not feel comfortable doing any kind of examination and chose to let the doctors do that.
At this point, I felt the ethics nudge and examined the situation. I was fairly certain he had not been completely honest with me from the beginning, and there could be sexual trauma issues, that my being female could complicate things, and that acupuncture might not be helpful for this problem. I was uncomfortable continuing his treatment.
I told him at the conclusion of the next session that acupuncture might not help much more and sent him to my friend and chiropractor for a more detailed evaluation of physiological and structural elements related to the problem. He only went there twice and did not follow the suggested treatment plan. He called me again about three months later, and I found I was feeling pretty uncomfortable and uncertain of how to handle things. I decided I had to be completely honest with him before I could go any further with the treatment. I scheduled a visit for him and planned to have a frank discussion with him about my impressions so far before doing a treatment.
At his appointment, I tried to "renegotiate the contract" so we were on the same page. I told him I could not guarantee results, but we could try a few more treatments. I also informed him that I was in a difficult position because he had not been completely specific about his problems from the start.
At the end of the treatment, I noticed a patch, such as those used for transdermal drug delivery, on his gluteal area. I said nothing at the time but at the close of the visit, I told him I had noticed it. I asked him about the patch, to which he responded, "That is none of your concern." This made me angry, but I stayed calm and told him I assumed it was from some kind of drug. He said it was herbal and admitted it was of a hormonal nature. He did not volunteer anything further.
I told him I did not feel comfortable treating a patient who was not willing to tell me what they were taking, especially if it could be causing the problem or working against my treatment. He acted like he didn't understand. I gave him an example of a dental patient in the same situation and asked him what he would do. He said, "Oh, I guess I see what you mean." It seemed like he was using me in some way that I didn't understand. I also was concerned that I was somehow in collusion with him by allowing things to get this far.
I didn't see him for about a year. He recently called again for treatment. I scheduled a visit but had to cancel. Finding that I was relieved when I didn't have to see him was a good sign that I needed to clarify my thoughts about working with him and decide on what terms I would do so. I knew he was near graduation and would be leaving town soon to begin his dental practice. I decided to go ahead and meet with him and be very frank about my thoughts on his case.
When he came in, he said the pain was better but the shrinkage still was a concern. He said there were no changes in his health. His tongue was mainly the same but a little more bright red, and his pulse was still large and superficial.
At the treatment, I told him I had not felt good about what had happened before and that I was concerned about the terms of our agreement. He said he just wanted to try acupuncture a few more times before he left town. I told him he had to be honest with me about any medications he was taking or any other symptoms he might be having. He agreed to do this.
During the treatment, I used some points on the abdomen, among other things. He could barely tolerate being touched on his abdomen - again reminding me of my prior concerns about sexual trauma. When I examined his ear with the point detector, I found an active point in the area relating to gonadotropin. A lightbulb went off in my head. I then found active points all through that area relating to endocrine and reproductive physiology. A brief look at Oleson's Auriculotherapy manual reminded me of the protocol for testitis. He was positive for most of the indicated points, which I treated. When I explained this, he was pleased to hear it and said he'd like to have weekly treatments until he left town in a month. I agreed to this, reminding him that we would just have to see how it would work.
Ear assessment indicated that endocrine involvement was present and acupuncture might not be likely to help this in the short run. However, auricular therapy might be supportive to the endocrine system along with body acupuncture. I felt it would be good to continue to treat him now that I had more data and what seemed to be a useful protocol.
Just after that visit, I consulted with a colleague about this who said, "He's juicing," meaning that he was using anabolic steroids. Another acquaintance said that testicular atrophy in steroid abusers is very common. Suddenly it all became clear. I felt a little dumb for not seeing this all along. Based on the research I have now done, I understand that testicular atrophy from steroid use can be reversed. He was probably looking to reverse the damage. I don't believe he was "juicing" at the time, but if he was, this would explain why he was so reluctant to talk about it. Even if it had happened previously, he might not want any record of it, due to the fact that he would soon be granted a license to prescribe medications. I am now confronted with the main ethical issue of the case, although there have been several along the way.
At his last visit, I treated him with body and auricular acupuncture. While he was on the table, I spoke to him about my concerns in a roundabout way so that I clearly communicated my thoughts before he left treatment. I asked if he had done much research into the issue of testicular atrophy. He said, "Quite a bit." I said, "All a person has to do is go on the Web and Google testicular atrophy and tons of stuff comes up. Like how it can be a side effect of certain drugs." I felt that he had gotten my drift.
After much consideration, it became clear that one major ethical dilemma for me is how I feel about treating someone for the side effects of illegal drug use. He probably was not forthcoming with all the information because either he was ashamed of having used steroids or feared negative consequences. He may even have been trying to protect me in some way.
If he had been honest from the beginning, I probably would not have felt so uncomfortable so many times. I might even have been able to help him more. I wonder if it is appropriate to treat someone under these circumstances. I feel like I have been used in some way. Certainly, I feel disrespected and disempowered because my patient was not completely honest with me during this whole process.
This case was a very good lesson for me about trusting my gut. It was helpful to take time to think things over each time I felt uncomfortable. In some ways, I think I should have dismissed him earlier on. Overall, however, I think I handled everything well and I was glad for the opportunity to learn.
This case is interesting because it demonstrates the type of situation that an acupuncturist or other complementary medicine practitioner might come across. We so often work with people who are not successful in the conventional medicine system or who are looking for something other than Western medicine. Some of these people may inaccurately report symptoms or otherwise manipulate the situation. Most of us want to help our patients, even sometimes so much as to be blind to situations that are tricky. We must be very clear in our thinking about our own boundaries and limitations, and stay true to that inner voice. Being honest and direct with clients whom we suspect of these things is sometimes tricky and uncomfortable, but if we are clear with ourselves first, we can be more at ease in the process. Sometimes, the way I can help the most is to gently confront a patient, even if it means losing them as a patient.
Discussing our feelings with other colleagues or teachers is critical in this process. Clearly stating our viewpoints and boundaries to the client, as well as documenting our concerns in the chart, also are helpful in negotiating the winding road in such cases.
Click here for previous articles by Laura Christensen, MA, LAc, MAc.