The combined number of cases of chlamydia, gonorrhea and syphilis reached an all-time high in 2015, with young adults accounting for most cases of sexually transmitted diseases, according to the Centers for Disease Control and Prevention.
The CDC’s annual report on sexually transmitted diseases, which came out earlier this month, found that people ages 15 to 25 accounted for one-half of all gonorrhea cases last year and two-thirds of all chlamydia cases. And while Yale Health officials continue to make STD prevention a top priority, national STD diagnoses continue to rise.
Andrew Gotlin, chief of student health and athletic medicine at Yale Health, said he could not release the number of STD diagnoses at Yale in 2015 due to confidentiality stipulations. However, he did confirm that Yale Student Health was aware of the CDC’s report.
“My impression is that we as a country are not doing as good a job at prevention as we should and could,” Gotlin said. “Given this rise, we need a strong message that screening and testing is necessary for preventing [sexually transmitted infections].”
Still, Gotlin said that Yale Student Health will not change its STD awareness and treatment practices in response to the report.
David Roth, chief of Yale Health’s Obstetrics and Gynecology Department, said that although his department does not collect the statistics of STD cases in the Yale student population, he has not observed a rise in STD diagnoses in the department’s female patients this year. He also confirmed that aside from human papillomavirus, chlamydia was the most common STD he observed among members of the Yale community. While Yale has not experienced an apparent rise in STD rates in line with national trends, Roth said that his department is always looking for ways to help STD prevention.
“We already know this is a really important topic for us to address, so we are doing a lot for prevention and screening,” Gotlin added.
But while Yale’s resources are abundant, Roth acknowledged that outside Yale, STDs are more prevalent in underserved areas where state and local governments are often cutting funding for health clinics. The CDC’s report made a similar claim, attributing the significant increase in STDs in part to budget cuts for more than half of state and local STD programs nationwide.
“Luckily, that’s not an issue at Yale for us,” Roth said.
Roth said it is often difficult to determine whether students are not coming for routine checkups because they seek medical care at home, or because they are simply avoiding seeing the gynecologist entirely. He added that when students do see a Yale Health gynecologist, Yale doctors screen for chlamydia and gonorrhea, which are the most common STDs among young adults.
In recent years, Yale Student Health has developed a sexual health initiative involving STD “screening parties,” to encourage Yale students to get tested. Every semester, Yale Health partners with organizations across the Yale community to host a mass screening event at the Yale Health Lab. Pizza and games are provided to students while they wait to get tested. This initiative allows students to get a full and comprehensive STD testing with blood and urine samples without the hassle of scheduling an appointment at Yale Health.
“[The STD screening parties have] been really, really successful because we partnered with various student groups to make sure that students feel they have some ownership of this and we really want them to be involved,” said Tracy George GRD ’15, a Yale student-wellness health educator.
George also helps plan the annual Valentine’s Day “Sex and Chocolate” event for graduate and professional students. The event, which features chocolate desserts and drinks, allows students to anonymously submit sexual health questions via text message. The questions are then projected onto a large screen with both the questions and the answers from Yale health professionals. This program is meant to facilitate conversation and education about sexual health issues such as STD transmission and pregnancy in a fun and safe environment, George said.
“With programs like the [Community and Consent Educators] … the conservations around sexual health are really ramping up and there’s much more access to safe sex supplies, so I feel really good about what we’re doing here and love how much we’re partnering with students rather than it just being a top down kind of program,” George said.
George’s office works with the Office of Gender and Campus Culture, the CCEs, the Yale College Dean’s Office and the Freshman Counselors to distribute all the condoms, lubrication, internal condoms and dental dams throughout Yale’s campus.
“It looks different at different universities but we’re one of the universities that actually offers all of these supplies for free. Luckily, we do have a good portion of our budget set aside for these medical supplies so that students can get any sort of supplies they need,” George said.
STD tests at Yale Health are free to all Yale students, even those who have waived the Yale Health Hospitalization/Specialty Care Coverage.
Columns like this one usually have a format. They tend to go: funny anecdote; expand on anecdote; serious moral musings; bite-sized takeaway. This week, let’s scrap all that and get right down to the bite-sized lessons, because I have two, and you should listen up.
Lesson number one: Karma exists. Remember this, if you are ever tempted to put off planning something special for your two-year anniversary until the half hour before you meet up with your loved one.
Lesson number two: Make sure you have proper dental insurance. The Yale Health Plan does not cover you. This is not a drill. Do it right now.
Here is what will happen if you do not follow these lessons. First, you will scramble to find transportable food for the last minute picnic that you have half an hour to assemble in order to prove your significant other that you, too, are capable of romantic gestures. Sushi! you will think triumphantly, as you send time-buying texts like “Could you please look to see if I have lost an earring anywhere in your entryway?” Next, you will tear down York Street flailing wildly. Meanwhile, deep in the shadows, Karma is starting to flex her muscles.
An hour later, as you and your beau romantically feed each other wilted fish, you will suddenly have the daunting realization that Sushi on Chapel cuts its New York rolls into giant, fist-sized pieces. To avoid dribbling rice down your shirt, you will try to eat these in one bite. Hubris! In so doing, you will inadvertently tear open the half-healed incision over what used to be your wisdom teeth. You will wake up the next day with a face the width of a basketball, gently oozing. Karma: 1; You: 0.
If you’ve already followed lesson two, at this point you can pass go and collect $200. If, however, you have foolishly assumed that the Yale Health Plan will pay to fix a gaping hole in your mouth, you are in trouble. At this point — because this is how Karma works — it will definitely be a Saturday. So, you will reluctantly drag yourself to Acute Care, where, after a four hour wait spent watching a documentary on the History Channel about toilets, a physician will literally Google your symptoms and then give you an antibiotic recommended by the internet. A week later, another doctor will tell you that the medication you have been given is actually intended for gastro-intestinal infections, and that you must pay out of pocket to see an oral surgeon immediately. Karma: 5; you: 0.
At this point, you may realize Karma has it in for you, and start doing good deeds to try to change her mind. Apparently working at the soup kitchen is not enough: your cheek will continue to fester. You might have job interviews; when you go to them, and smile at recruiters, they will ask if you need a second to finish your mouthful before you start the interview. A friend, alarmed by the radical asymmetry of your face, will force you to consult Yelp for an oral surgeon.
This is how, at 8 a.m. on a Friday morning, you will find yourself 20 minutes up Whalley Avenue, in a building between a car parts wholesaler and a desolate wasteland of broken paving stones. You will feel nervous. The waiting room you are sitting in may in fact go so far as to display a plaque saying “Voted New Haven’s 12th best oral surgeon in 2009.” Strangely enough, this will not make you feel much better. The oral surgeon will then pull a scalpel out of a drawer of what seems to be a desk purloined from a Vandy dorm room. His syringes wait in a pen pot. The radio is playing the Spice Girls. He will ask if you need to call your parents. He will ask, no joke, if you folks have phones in England. Karma: 10; you: -1.
You think I’m exaggerating. But this would be a good moment to go put all your loved one’s birthdays (and any anniversaries) into your iCal, because, believe it or not, every word of this has actually happened to me over the past two weeks. So be nice to people — and, if you don’t plan to — get full dental insurance. I’m serious. Otherwise, this really and truly will happen.
The story ends where all regrettable actions do: in the neon corridors of Yale New Haven. There, if you, like me, haven’t treated others quite as you might like to be treated, Karma will make sure you are given an X-ray by a doctor with unbelievably long finger hair. When you look at who’s next to you, you will, no joke, see a convict in beige scrubs handcuffed to the machine, flanked by two particularly no-nonsense members of the NHPD.
The two of you will catch each other’s eyes. Karma, you’ll both think.
55 Lock Street, commonly known as Yale Health among the University’s students, overlooks New Haven’s Grove Street Cemetery like the Death Star hovered in George Lucas’s night sky.
Black and jagged, the building was completed in 2010 after three years of construction. According to a newsletter released by Yale Health that fall, the new health center was 60 percent larger than its predecessor, “with more than double the examination rooms, more space in the diagnostic imaging area, and increased space for minor procedures.” The same pamphlet touted the relocation with the headline: “From a ‘hole in the ground’ to ‘wow;’ Yale Health Center continues great service in a new home.”
The inside of Yale Health suggests a more complicated reality. At the end of a brightly lit hallway on the building’s third floor is the Mental Health and Counseling Department (MH&C), which addresses the psychological concerns of Yale’s almost 12,000 total students. Inside the waiting room, there are 11 brown chairs, a modern-looking coat tree, and a barrier of opaque glass that separates the department from the building’s other facilities.
More than 50 percent of undergraduates will find themselves in this room during their time at Yale. Lorraine Siggins, the department’s chief psychiatrist, reported in a publically available memo in September that MH&C sees about 20 percent of undergrads each year. (Siggins declined to comment for this article, citing “time constraints” in a November email.)
The numbers are even higher for Yale’s graduate and professional school students, 25 percent of whom visit MH&C yearly. They are also growing; visits have doubled since 1998, now surpassing 20,000 per year. All Yale students are entitled to 12 individual counseling sessions annually, and a mental health clinician can always be reached for emergencies through the Acute Care Department.
With the rise in appointments have come longer wait-times and more reports indicating insufficient quality of care at MH&C. Based on more than two dozen interviews with University officials, student leaders and alumni, these concerns about Yale’s mental health services finally seem to be making waves within the administration.
As pressure mounts to reform MH&C from every level of the student body, the 2013-14 academic year appears to present an opportunity for Yale to more actively address mental health. Still, such reforms may take longer than many students are willing — or able — to wait.
“Negative Perceptions Are Prevalent”
On December 12, the Office of the Secretary and Vice President for Student Life, headed by Kimberly Goff-Crews ’83 ’86 LAW, sent an email to all Yale students, which said “discussions and collaborative efforts have been underway at all levels” to improve mental health on campus.
“Living and working in this type of environment, it is normal for students to feel anxious about academic and social pressures,” the email stated. “However, the culture at Yale seems to discourage acknowledging vulnerability; rather, many students feel additional pressure to be ‘effortlessly excellent’…This expectation is not realistic and not healthy.”
The email did not specify measures for reform beyond updating the MH&C website with more information about mental health care, nor did it mention students’ most pressing concern of all: meeting patient demand in a reasonable amount of time.
Yale Health employs 28 mental health clinicians — including social workers, psychologists, and psychiatrists — 22 of whom work full-time. Given Yale’s student population, this means there are approximately 425 to 550 students for every clinician at MH&C. This means Yale has about twice the number of mental health professionals per student than do schools of similar size, based on 2012 data from the Association for University and College Counseling Center Directors (AUCCCD).
A Yale College Council (YCC) report on mental health published last October revealed that this ratio, while favorable, doesn’t tell the whole story. Authored by three Yale College students, the report compiled data from what it called 50 “structured interviews” with student leaders and administrators, and from a campus-wide, anonymous survey, to which roughly 20 percent of undergrads responded.
The report included findings about Yale’s campus culture and resources surrounding mental health. Of students who completed the survey, 39 percent said they had sought the services of Mental Health and Counseling — the reasons for their visits ranged from depression and anxiety to eating disorders and academic stress.
“We do acknowledge the limitations of the data we’ve collected,” Reuben Hendler, one of the YCC report’s authors, says, referring to sampling biases in the survey and interviews. “But that in no way means we can’t learn a lot from it.”
The report also contained data on students’ perceptions of the quality of care offered at Yale Health, with 31 percent of students rating their experiences as “poor” or “very poor.” Moreover, over half of respondents said they would be “unlikely,” “very unlikely,” or “unsure” about approaching MH&C if they wanted professional counseling.
“Negative perceptions of MH&C are prevalent,” the report stated. “Some students fall through the cracks.”
Paul Genecin, director of Yale Health since 1997, acknowledges that students’ experiences of MH&C vary, but says Yale Health has quality control measures in place, such as an annual review of clinicians, a member services department, and yearly accreditation by the Joint Commission — a non-profit organization that certifies roughly 20,000 health care programs in the United States.
“It is a fact of student health across the land: If you ask students what they think, you will find a number of people exercising their critical faculties,” Genecin says. “You can trade out us and put in ‘Athletics,’ ‘Dining,’ ‘Libraries’ — there’s always a seeming disconnect between how people look at a service versus how it actually is.”
In order to assuage students’ expressed concerns, the YCC report outlined three major recommendations for MH&C: communicating more effectively about appointments, expectations, feedback, and mental health education; hiring additional therapists; and possibly referring certain students to outside clinicians.
Specific measures included allowing students to schedule appointments over email, instituting mandatory telephone check-ins with students who miss an appointment or wait more than a week to be assigned a therapist and creating “an accessible, well-publicized way for students to provide feedback.” Hendler, one of the authors, says he is confident the report will be given “serious consideration” by the University.
Genecin states the YCC report did “a good job” of addressing some of the misinformation among students about MH&C’s services. He admits Yale Health should do more public outreach, but adds that his staff is primarily dedicated to patient care, and so cannot focus on outreach as much as they would like. When asked about the long wait times some students experience, Genecin responded that “no health care system can have perfect access to resources” and that doctors must prioritize patients based on the severity of their conditions.
“I’m much more concerned with treating students who need serious intervention,” he explains. “The question is not what percentage of students did you see in x number of days, it’s what percentage of students did you see who really needed help.”
But such an approach has led to a dissatisfaction with MH&C that extends well beyond the College: on the same day the YCC released its report, Yale’s Graduate Student Assembly (GSA) and Graduate and Professional Student Senate (GPSS) released their own mental health report, according to which 32 percent of participants in an annual GPSS survey said they were “somewhat dissatisfied or worse” with the University’s mental health services. Ultimately, this was “the strongest student concern with the Yale Health Plan” in 2013.
Yale: “A Rough Place To Be Sometimes”
For Julie Botnick ‘14, scheduling an appointment at Mental Health and Counseling was a daunting task. In an October 21 Yale Daily News opinion column, “Don’t neglect us,” Botnick wrote that she sought treatment at MH&C during her sophomore year for a chronic mental disorder.
Botnick became frustrated, however, when she waited over a month to be assigned a permanent clinician after her “intake” appointment — an hour-long evaluation session typically made within three days of a student contacting MH&C.
When Botnick finally saw someone, the clinician was a social worker and not a psychiatrist as she had requested, whom she said seemed “bored and unresponsive.” She stopped visiting MH&C after “two or three sessions,” and was never contacted afterwards to see if her condition had improved.
“It was a waste of my time,” Botnick remembers. “I can’t believe they had never been so busy before and didn’t know what volume of people to expect. They need to meet the demand, no excuses.”
Multiple factors may explain why students like Botnick experience long wait times and variable quality of care at MH&C. Notably, Yale Health’s triage system prioritizes students who feel they are in dire straits and can articulate it. According to Genecin, those who express suicidal thoughts or the intention to harm themselves are “seen immediately,” which necessarily delays other appointments.
Nonetheless, as Genecin himself acknowledges, these are rare cases; most students present with an “extremely broad” range of concerns that do not require emergency treatment.
After intake, each patient is given the contact information of a MH&C clinician, and a schedule is created that is reviewed within five weeks, Siggins, the head of the department, stated in the September memo. Students on medication are scheduled a check-in appointment after four to five weeks of treatment, and Siggins reported that only “about 10 percent” of patients wait longer than two or three weeks to see a clinician.
Additionally, in her September presentation to the Yale Health Member Advisory Committee — a feedback group composed of about 20 undergraduate, graduate and professional school students, and Yale Health staff — Siggins said her department offers group therapy to students waiting for individual appointments, with about a dozen groups currently running.
But Genecin concedes that many students are uncomfortable with group treatment because they would prefer confidential, one-on-one therapy. Moreover, students can only join groups in which they do not know anyone else. While in line with clinical best practices, this requirement poses significant logistical problems for a student body as well connected as Yale’s.
Anna North ’13, a first-year student at Yale’s School of Public Health and a former Freshman Counselor (FroCo) in Silliman College, says although she was offered group therapy after her individual appointments ran out as an undergrad, she was ultimately disappointed with her experience.
“Hardly anybody will be able to benefit from [group therapy] because they start at a random time and are really disorganized,” North says. “Last year, I tried to join a group, finally got into one, and then found out one of my friends was in it so I wasn’t allowed to join.”
However, Stephanie Tubiolo ’14, a current FroCo in Silliman College, believes group therapy helped her cope with depression and an eating disorder, which developed after her work supervisor, John Miller MUS ’07, a School of Music employee, committed suicide in 2011. Tubiolo says everyone in her therapy group received the attention they needed, adding that the counselor in charge facilitated discussions without interfering with the group dynamic.
“It was a really rewarding experience to say I had this issue and someone else would say, ‘That happens to me all the time,’” Tubiolo explains. “Especially at Yale where so few people are willing to show their weaknesses. It’s a rough place to be sometimes.”
Tubiolo also speaks highly of individual counseling sessions, which she says taught her to “pick [herself] up” on difficult days and now seem like “one of the best decisions [she has] ever made.”
She says she was surprised by the YCC report’s findings about variable quality of care at MH&C, but admits that not everyone feels immediately comfortable with their clinician because of therapy’s subjective nature.
Siggins reported that 25 percent of students start to feel better after three or four visits to MH&C. But inevitably each year, the department sees busy times, such as between Thanksgiving and winter breaks, when the stress of final exams and papers may negatively affect students’ mental health.
“I feel like it’s gotten a bit worse in recent years,” University Chaplain Sharon Kugler maintains. “Students are now stressing two weeks into the semester rather than six. Then we get into Reading Week and everything goes to black.”
Addressing the Information Gap
Administrators like Kugler play an important role in getting certain students to receive treatment at Mental Health and Counseling. In an environment with a high demand for services and a limited supply of clinicians, residential college masters, deans, freshmen counselors and chaplains can significantly accelerate the intake process by advocating for students.
“If something gets to a level where day-to-day support from deans, administrators, and friends is not going to help, then we contact MH&C,” Jeffrey Brenzel, Master of Timothy Dwight College, says.
Many undergraduates do not know where to go until they face an acute situation. As the YCC report outlined, students may be “confused about how to navigate [Yale’s] extensive network of resources.
Such confusion is unsurprising: Yale resources include everything from student organizations like Walden Peer Counseling, Queer Peers, Peer Liaisons (PLs), Communication and Consent Educators (CCEs), Freshman Counselors (FroCos) and Mind Matters — a mental health awareness group — to institutional resources like MH&C, the Sexual Harassment and Assault Response & Education (SHARE) Center, the Chaplain’s Office, the Resource Office on Disabilities, the Office of LGBTQ Resources and the four cultural centers. Currently, comprehensive information about campus resources is not centralized.
“I felt like FroCo training was the first time where I fully knew about Yale’s mental health resources because it was my job to know,” Margaret Coons ’14, a Silliman FroCo, recalls. “People going through emergency situations might not have the luxury to wait.”
Five current FroCos said freshman orientation should include more information about Yale’s mental health resources and campus culture. Although every FroCo must meet with the staff of MH&C and participate in mental health role-plays before freshmen arrive on campus, Michael Sherman ’14, a FroCo in Pierson College, says he was disappointed with this year’s training.
“When we did the role-plays,” — simulations of students approaching FroCos with mental health concerns — “the professionals who were there gave almost no feedback and left it up to the group,” he says. Sherman added that a mandatory tour of Yale Health was part of orientation, but because it was scheduled on Labor Day, there were no officials present to greet and guide freshmen. “We quickly realized we were the tour guides and we didn’t know the adequate information.”
Anna North ‘13, the alumna at the School of Public Health and former FroCo, agrees with Coons’s assessment of the information gap, adding that she was “extremely nervous” the first time she visited MH&C during her sophomore year because she didn’t know what to expect. North, who was experiencing regular anxiety attacks, only approached MH&C once she felt she was on the verge of leaving Yale if nothing changed.
The result of general ignorance about MH&C is that rumors circulate among undergrads regarding the consequences of receiving treatment, North claims, which may deter some students from seeking help. Such rumors include being sent to the Yale-New Haven Psychiatric Hospital, where treatment could become expensive, and being asked by the University to take a medical leave of absence, which could threaten a student’s chances of graduating on time.
It’s no wonder then that for many students, a certain deal of anxiety surrounds scheduling an appointment at MH&C. Robert Peck ’15, a former staff reporter for the News, had a Kafkaesque experience there during his sophomore year, when he had to wait over three months to be seen by a permanent clinician.
Now a YCC representative on the Yale Health Member Advisory Committee, Peck says he was told he would get to see a clinician within a month of his intake appointment in November 2012. When that did not happen and he returned home for winter break, Peck emailed his intake counselor but received no response. And when he called MH&C in early January, he was simply told that December was always a busy time.
It was not until his dean called MH&C several weeks into the spring semester that he had an official appointment scheduled for February.
“You would think that was the end of it, but then the therapist I was assigned decided not to show up for work on the day of my appointment,” Peck remembers. “I was so thoroughly poisoned by the experience that I left and didn’t go back.”
Peck admits his condition was not as severe as those of others he has spoken with, but says it would be unacceptable for Yale Health to define success only in terms of treating its most pressing patients.
“Of course Yale Health is probably better than many [university health care] programs in the country, but that doesn’t get them off the hook for not fully helping the student population here,” he asserts. “If we’re to have faith in our university, for a service we pay for through tuition, there has to be some legitimate reason they can’t meet demand in a timely fashion. So far, I haven’t heard what that is.”
“A Legitimate Reason”?
A potential answer to Peck’s question may involve how the University determines Yale Health’s annual budget, which Stephanie Spangler, deputy provost for health affairs and academic integrity, currently oversees. She previously served as Director of Yale University Health Services from 1990 to 1995.
In November, Spangler declined to comment on the magnitude or percentage that Yale Health’s expenses make up of the University’s overall budget, but said Yale Health’s four biggest costs are medication, staffing, hospital expenses and those to outside providers and delivery systems.
Genecin and Lorraine Siggins are the two people primarily responsible for managing the budget for mental health, Spangler said. Although Genecin declined to provide specific budgetary figures, which total in “the millions of dollars,” he notes that a significant amount of MH&C’s funding comes from the endowment, through donors who specifically want to support Yale’s mental health services.
However much money is allocated to MH&C, the University’s limited finances and budget priorities may impede changes to Yale Health for some time. As of June 2013, Yale faced a $39 million budget deficit, which University President Peter Salovey and Provost Benjamin Polak announced in mid-November would need to be reduced through cuts to administrative departments. At the time, Genecin told the News that Yale Health is always looking for ways to contain costs, and that budget pressures fluctuate throughout the year.
Reuben Hendler, one of the YCC report authors, admits that hiring extra clinicians at MH&C would cost more than other reforms, but says it would be “the silver bullet” to lowering student wait times. In turn, Hendler explains, undergrads would have more positive perceptions of Yale Health. “It’s simple: If there are more therapists, then people can be seen more quickly,” he says. “Obviously that takes resources. We think those resources are well spent.”
“Barring unforeseen circumstances, I expect we’ll be talking about adding more staff as the new residential colleges are built,” Genecin says. The two new colleges are scheduled to be completed in August 2017, which will allow Yale to admit roughly 15 percent more students each year, bringing total undergraduate enrollment to more than 6,000.
Genecin declined to speculate as to whether the ratio of mental health clinicians to students would also change.
Ernest Baskin GRD ‘16, chair of the Yale Health Member Advisory Committee, says he is optimistic that mental health resources on campus will improve, but maintains that it will take “broad student initiatives” to make the Yale Corporation aware that mental health is such an important issue. “It needs to be heard by the trustees who control the purse strings and can influence the allocation of funds, at the very highest level of decision-making,” he asserts.
For now, at least, those hopes may not be far off.
“One thing in the [YCC] report that concerned me was the observation that students could be unhappy here and feel they have to hide it,” Spangler says. “We have a great opportunity to change that.”
I don’t remember when I first started to notice, but it was hard to stop hearing these things once I did. I was hearing this word, I was hearing it everywhere and I had next to no idea what it actually meant. On a campus full of people with bizarre study habits and sleep schedules, what does it take to get called “crazy”?
In an unscientific survey conducted in Blue States and dining halls, students told me they think we’re all very sensitive when it comes to talking about our peers’ mental health. Conversations about mental illness take place in hushed tones, full of sympathy and euphemisms. They do not involve big, loud words like “crazy.”
“I think in my experience when I talk about people with mental illnesses, it’s pretty sympathetic,” said Maggie Zhou ’15, a member of my random sample. “The enemy is always Yale Health.”
Students I spoke with had a wide range of horror stories about Yale Mental Health Services: waiting up to four months for an appointment, encountering therapists who didn’t recognize their patients, who cut them off in the middle of sentences when their time was up, who pushed medication on them after two sessions, who prescribed the wrong kind of medication, who made them feel judged.
On the surface, we’re trying to fix this. Every Yale College Council presidential candidate in recent memory has made improving Yale’s mental health resources a prominent part of his or her platform. When Cameron Dabaghi ’11 jumped off the Empire State Building in the March of 2010, we wrote op-eds and talked about boosting access to mental health services. When Zachary Brunt ’15 committed suicide two years later, we did much the same thing.
We hear that Yale’s mental health services are failing us. The failures are big and gaping and scary.
But we also hear about the stigma that makes so many students reluctant to seek help, or even articulate their suffering in the first place. The source of this stigma seemed a little mysterious to me at first. Yale is famously inclusive, extremely PC. But then there’s the hard truth that based on the numbers, at least one in every two people we have no problem calling crazy on this campus have visited Yale Mental Health at least once during their Yale careers.
We hear that we don’t talk about mental health enough. But maybe we need to listen to what we’re saying.
* * *
Abigail*, a junior who has struggled with clinical depression, insomnia and anxiety during her time at Yale, can describe, immediately and at length, the kinds of qualities that comprise craziness here.
“I hear the words ‘chill’ and ‘crazy’ so much at Yale, and it’s a problem I have had for a very long time,” she told me. “Crazy has the connotation of a girl who doesn’t really have a handle over her emotions … and chill is the positive way to be, if you can be chill and act like things don’t affect you.”
Thirteen students interviewed were unanimous about one aspect of “crazy”: Girls get called crazy more often and more casually than boys do. Many identified strikingly similar characteristics that mark a “crazy” Yale woman. Eleanor Michotte ’15 said it can mean going out too much or not enough. But she said that it’s applied especially often to girls who exhibit too much “clinginess” in romantic situations. Andrea Villena ’15 told me “crazy” is typically used to refer to girls who seem overly dramatic in dealing with their relationships. Abigail said these are girls who seem immature or insecure, who publicly and dynamically react to things. They are clearly socially anxious. They don’t seem chill.
Jay Pabarue ’14 said the word is used so much and so generally that it’s hard to identify just one meaning. But he too associates the term with girls who seem to have a “pathological way of dealing with social scenes.”
The only guy Abigail has heard called crazy at Yale is “legitimately crazy,” she said. Several students said that calling a boy crazy is more serious than calling a girl crazy: It suggests more about their actual psychological state. When asked why they think so many girls do get called “crazy,” many blamed unjustified cultural stereotypes about girls being more neurotic and hysterical.
But the World Health Organization tells us women are far more likely to be afflicted with anxiety and depression. And they are twice as likely to develop generalized anxiety and panic disorders as men, according to the Anxiety and Depression Association of America.
These disorders are also more tied to external influences than any genetic or internal predisposition, which means the environment we collectively create on campus each day matters. Psychology professor Tyrone Cannon, who is presently teaching a course on the neuroscience of mental disorders, said that depression and anxiety are only 35 percent determined by genetic factors, with environmental influences accounting for the remaining 65 percent. He contrasted this with disorders not particularly associated with one gender over another, such as schizophrenia and bipolar disorder, which are 85 percent determined by genetic factors.
“I think the mechanisms are similar across men and women,” Cannon told me. “The question is, are those environmental factors experienced differently by genders, and the answer is probably yes.”
According to June Gruber, one of Cannon’s colleagues in Yale’s Psychology Department, girls begin to experience the social world differently at a very young age. Their parents encourage them to express their emotions. Girls mature more quickly and develop a strong social orientation earlier. They tend to be more ruminative. But all this introspection comes at a cost: Girls are much more likely to become depressed as they grow.
All through high school, 2013 grad Jessica* dealt with anxiety and insomnia. The summer after her freshman year at Yale, she found herself having panic attacks and even more extreme anxiety. She took a year off. Jessica doesn’t think her experience of depression and anxiety can be divorced from her gender and the way she grew up because of it. It’s something she’s been thinking about a lot post-Yale.
Jessica began feeling “very body conscious” at age 10 — and the feeling never went away. She believes those concerns helped feed her anxiety at Yale. When she was 20, she went to the beach and a male friend made a rude comment about her body. Jessica remembers going home, sitting on the floor of her bathroom and crying for hours.
“I think there are these social expectations for girls to be a certain way, to act a certain way, to not be weird, to be attractive. A part of the education as a preteen girl is to learn how to be attractive to boys. A lot of my friends and I are going through this experience where we’re unlearning that,” she said. “Definitely there is a direct physiological connection to my mood and my body consciousness and anxieties about being a woman.”
Such feelings may be exacerbated on campus. Michotte said people at Yale, and girls especially, seem much more intense about their appearance than in her native England (an issue she discussed in one of her “Crit from the Brit” columns for WEEKEND). “I think there’s appearance inflation. As everyone grooms more, works out more … suddenly everyone falling short of that standard stands out, and the collective average creeps up and up,” she said.
Abigail thinks a lot of the girls she knows who get “crazy” thrown at them probably have mental health issues that people too easily overlook. She doesn’t think she’s crazy; she thinks she’s someone who feels things deeply and has problems with her brain chemistry that she’s working hard on.
“I’m sure people call me crazy, though no one’s ever called me crazy to my face,” Abigail tells me suddenly, 20 minutes into our conversation at the Hall of Graduate Studies dining hall. She sounds as though she is articulating this thought to herself for the first time.
In a culture where there’s so much silence about people’s diagnoses, it’s hard to know who might be suffering. Pabarue cited one girl he knows who often gets called crazy in an unsympathetic way by people not aware that she has a problem.
After a bad breakup her freshman year, Abigail found herself breaking down and crying multiple times a day, for several months. It never occurred to her that she was “actually depressed”; she thought she was just another girl who had been dumped. She’s always been someone who experiences higher highs and lower lows than other people, and the line between grief and illness wasn’t obvious.
“When your boyfriend and you have a really bad breakup, the time when you’re crying and mourning that’s not called clinical depression,” she said. “I thought I was just really sad.”
But though few students interviewed believed girls were legitimately at a greater risk for developing any mental disorder, society has no problem making judgment calls based on gender when it comes to one commonly reported disorder: eating issues.
When Sally*, now a junior, developed Crohn’s disease her freshman year, she lost 18 pounds in a month and was constantly vomiting. Yet as she sought treatment, she found herself under attack from all sides.
“Everyone was saying I was anorexic,” Sally said. “People at Yale Health, people at Yale. People just wouldn’t believe me when I was saying I was in pain.”
Sally had friends trying to force her to eat, commenting on how skinny she was and telling her that it “didn’t look good.” She knew that people were talking about her behind her back. The experience made her close down and withdraw into herself. She began simply avoiding people altogether.
Pabarue experienced the opposite problem when he developed anorexia as a freshman in high school. For months, he saw his pediatrician in a clearly unhealthy state. He remembers being told to drink more Boost and Ensure and that it seemed like his metabolism was simply getting faster. He was 6 foot 1 and 112 pounds when he fainted in the shower and was rushed to the emergency room.
* * *
In her first year at Yale Law School, Elyn Saks LAW ’86 remembers thinking that she could kill hundreds of thousands of people with her thoughts alone. The TV was giving her commands. Throughout all this, she believed that she alone had a “special premium on the truth.”
For years, she struggled against receiving medication for her schizophrenia. She was very reluctant to accept the diagnosis of being mentally ill and “needing a crutch,” but now she looks back on accepting her diagnosis as the key to liberating herself from the disease.
“For me, a schizophrenic episode is like a waking nightmare, but you can’t just open your eyes and make it go away,” Saks said.
As a law professor at the University of Southern California studying the treatment and rights of the mentally ill, Saks lives a life her diagnosis had once seemed to preclude. There’s nothing she prefers about her unmedicated state.
But for others, navigating the threshold between normal and not normal is much less clear, and accepting a diagnosis an ongoing struggle. The language we use to discuss mental illness — or the lack thereof — only makes this process harder. “People who are sensitive and well-meaning and would never use racial slurs, use the words ‘nutcases’ or ‘looneytunes,’” Saks said. “I’m happy to be called a patient. I have an illness; the words people use are hurtful. Even just changing that would be a small change to changing the culture around mental health disorders.”
Having more precise language to talk about mental health isn’t just about sensitivity — it’s also about helping inform people who may be vulnerable. Jessica did not have the words to describe what was wrong the first time she started crying for no reason. It was the middle of the day and she was sitting in a café. The experience terrified her. After searching her symptoms online, she concluded that she was probably bipolar. This diagnosis did not prove to be correct.
“I felt like my feelings weren’t justified, and I didn’t have the language to express that,” she told me says. “I didn’t know what was happening, I didn’t have a language for understanding it. I thought something was wrong with me, that something was very, very wrong.”
Now she realizes that her diagnoses are not at all uncommon. The more she talks to people, the more she realizes how many people have similar stories. She doesn’t feel so abnormal anymore.
Alison Greenberg ’14, who has struggled with depression at Yale, said the prevalence of terms like “crazy” has to do with the fact that people’s ideas about mental health are vague at best.
“Crazy is sort of a catch-all term for not normal, and normal at Yale is I think very different from normal in the real world,” Greenberg told me.
While Jessica was struggling with depression and anxiety at Yale, she found herself constantly worried about trying “to appear normal.” She felt she was doing everything she could to hide: She was seeking help, she was accepting all kinds of medications and therapies. At one point, she was on five types of medication. It seemed excessive, but she did what her doctors told her to so as to appear “alright.”
Ellen*, a junior who has received many diagnoses over the years, said that the social norm at Yale is to appear high-functioning even when we’re “hanging by a thread.” In a culture of glory tales and desperate work ethics, it’s easy for someone who is really suffering to think that their suffering is normal, too. Among her group of friends, a normal state of mental health could include low-level depression, or mania or suicidal thoughts.
Within these standards, labeling someone as “crazy” ends the conversation about him or her, Pabarue said. It’s a way to explain someone else’s behavior without engaging with what might be driving it. It lets you put a label on them, and move on with your own, non-crazy life.
“I think a lot of the failings are among us or born out of the way we talk about things,” Pabarue said. “It’s too easy to blame the institution alone.”
Ellen says she won’t get offended when someone sad tells her that they’re feeling depressed. She understands words can take on different meaning in a casual context. Still, she has occasionally been upset by the glib way many at Yale discuss mental health.
“The casual context mental health is treated can hurt, anything that’s internal, anything people can’t see on the outside, can make you feel undercover in enemy waters,” she explained.
Crazy sets up a dichotomy between normal and everything else. For many at this school, deciding where you fall on this spectrum can be very difficult. Ellen said she feels herself intellectually and emotionally pushing back against the idea that the various mental health diagnoses she has received over the past four years — clinically depressed, bipolar 1, bipolar 2, anxiety — are legitimate. She doesn’t like the idea of the boxes these words create.
Some abandon the pursuit of normal altogether. For his entire freshman year, Charles* said he threw himself into the prescribed way of experiencing life at Yale. He described buying into the “cultural hegemony” of what a weekend is supposed to look like, of how he should be dealing with drinking, sex and drugs.
“There’s kind of a dominant narrative of what your first year is supposed to be,” he said. “You’re shopping classes, you’re shopping friends, you’re shopping organizations. You’re kind of walking around the campus consuming everything. … It’s very oppressive. I’m saying all this because I was the first to do it.”
All through freshman year, Charles was also taking medication which treated his narcolepsy and hypomania (a milder form of bipolar disorder). The medications made him feel dull, productive and “sterile” throughout the year. He did his reading. He did what he was told to do. But when he ran out of pills one week his sophomore year, he decided to see what would happen.
That spring semester Charles wrote all five final papers — about 80 pages — without sleep, as though in a trance. He described the papers he wrote that semester as “the greatest work I’ve ever done.”
When he’s in a low phase, he can barely bring himself to do any schoolwork at all.
Still, he prefers this to the “stale,” consistently productive feeling he had on medication.
“It makes for a really intense form of existence. I know I suffer because of it. I know I could have a more tranquil, sterile kind of life,” Charles said. “I don’t want to be told that I’m sick; I think my life is so beautiful.”
After going on and off multiple medications, Ellen said she has come to accept that medicine can improve her quality of life. Now she is on a daily medication that changes her mood and behavior. She said she has had to learn to accept some degree of uncertainty in not knowing if what she’s doing is right.
“A lot of us have been given diagnoses … but not too many of us trust those diagnoses. There’s this terrible uncertainty in terms of if what you’re doing is right when it comes to your own mental health,” Ellen said. “Finally settling down with a treatment and accepting that as part of who you are is a really adult struggle, one that people don’t really talk about.”
In a campus-wide email this afternoon, Yale Health announced new supplemental coverage called the Approved Academic Travel Rider that is designed to meet the medical needs of students traveling within the United States but outside the Yale Health service area.
The Rider will provide coverage for non-emergent illness and chronic care.
“The motivation [for the update] was to make it possible for these students to get health insurance coverage for routine care if they are far away for a semester or a year,” said Paul Genecin, director of University Health Services. “There was already a good option for students abroad, but we needed one for this country as well.”
Students must enroll in the supplemental coverage for the fall term between June 1 and June 30 at a price of $250 per semester. Genecin said the service is likely to be used by graduate and professional students more than undergraduates, particularly in terms of conducting academic research in other parts of the country.
Without purchasing the additional coverage, students are covered by Yale Health Hospitalization/Specialty Coverage for emergency care, acute care and pre-authorized short-term follow-up care.
The announcement of the Rider supplement follows multiple changes to the Yale Health plan made at the end of April. Those updates include the extension of sex-reassignment coverage, the combination of Hospitalization/Specialty Coverage with Prescription Coverage, and two revisions to mental health policies.
Yale Health will now offer coverage of gender-reassignment surgeries
In a Thursday email to the student body, Yale Health announced that it will cover expenses related to medically necessary sex-reassignment surgery “subject to pre-authorization based on widely accepted standards of care.”
The expanded coverage is part of a series of updates to student coverage announced by Yale Health in an email to the campus this afternoon. The coverage changes, which will go into effect Aug. 1, also include two changes to mental health policies — the removal of a waiting period between inpatient care days covered by Yale’s insurance plan, and an increase in mental health coverage for enrolled children from 16 daytime visits to 25 annually.
Additional expanded coverage items also include:
Prescription coverage included in hospitalization/specialty coverage.
There is no longer an annual dollar limit for durable medical equipment.
$25 copay for Yale Health Allergy Department office visits.
Copay for specialty services outside of the Yale Health Center increases from $10 to $20.
Director of University Health Services Paul Genecin was out of the country and could not be reached for comment at the current time. In an interview with the News last month, Genecin confirmed that Yale Health has hired one additional staff member in its Psychiatry Department.
The changes come from recommendations by Yale Health’s Student Coverage Task Force, a committee convened in 2008 that makes recommendations for improvements to student coverage annually.
In February, Brown University joined 36 other universities in covering gender confirmation surgery for students on its medical plan. Yale was not among the 36.
Seizing upon an article in The Brown Daily Herald, hosts on “Fox and Friends” told their viewers, “Don’t date anyone from Brown without reviewing medical records.” Although the comment echoes now-disparaged rhetoric on gay and lesbian issues from three decades ago, no apology was ever offered.
The episode, however, revealed something more than the leanings of Fox News. It showed that to most Americans, transgender issues are defined by gender confirmation surgery, which many wrongly believe to be a single procedure, and in what many transgender individuals would consider offensive, referred to it as a “sex change.”
The language of transgender issues is fraught. Is it sex reassignment surgery or gender confirmation surgery? Is it FTM (female-to-male) man or transgender man? Transgender issues, like gay and lesbian issues, lie at the intersection of sexuality, politics and religion. But unlike gay and lesbian issues, transgender issues have stayed in the shadows of national and campus discussion, perhaps because of the size of the transgender population and perhaps because they continue to appear too fraught to broach.
At Yale, policies on gender confirmation surgery remain contradictory. While covered under the faculty medical insurance plan, the procedure remains explicitly excluded from procedures covered by the student plan.
Although the surgeries, of which there are many, can cost anywhere from $7,000 to $50,000, utilization rates, says transgender student Gabe Murchison ’14, would be so low as to make the cost to the University “a drop in the bucket.” Activists, including members of Resource Alliance for Gender Equity, of which Murchison is a part, are pushing the University to cover the procedures, although major change in the near future appears unlikely. In covering the procedures for faculty and most employees, Murchison says, Yale Health has already stated that they are medically necessary for transgender individuals. It is unclear, then, why they remain excluded from the student plan.
As prospective Yalies pore over admissions materials throughout April, few are likely to make their way onto the Yale Health website to download the Student Handbook, which describes, point by point, what is and what is not covered by Yale’s student health plan. But for the University’s transgender students, a small minority that receives even smaller consideration, the policies contained in the handbook make all the difference in how they live their lives and how they are regarded by the University as an institution.
Public narratives emphasis gender confirmation surgery over any other medical treatment sought by transgender individuals. But hormone therapy, in part because of its low cost and in part because of the ease of treatment, plays a role in transitions from one gender to another more than any surgery. The University recently altered the student plan to cover hormone therapy — in which individuals born as one gender take hormones associated with the other — which Murchison says is a major step forward in providing necessary medical care.
The change in the University’s policy on hormone therapy is the sum of many small pushes, by transgender and gender-conforming students alike, the kinds of small pushes that are the only way for transgender students to receive necessary care in the labyrinthine Yale Health bureaucracy.
Students’ experiences reflect a frustratingly complex system that poses significant obstacles to transgender students seeking health care specific to their transition from one gender to another. When Jake Hodge ’15 tried to access gender-specific care at Yale Health, including endocrinology, which would prescribe appropriate hormones, he found the experience “hellish,” a not-uncommon sentiment.
“I was given contradictory information from multiple departments, my psychiatric and endocrine referral papers were lost in the system, and my care was delayed by almost a month so that an ‘interdisciplinary board’ within the hospital could approve it, which I was outright informed by my physician as a completely unnecessary protocol,” Hodge said of his attempt to see an endocrinologist.
Once Hodge made it through the bureaucracy, though, he found the staff at Yale Health helpful and sensitive.
“After jumping through an absurd number of arbitrary hoops, the Endocrinology Department itself has been nothing but supportive and competent,” Hodge said.
In cultivating a good relationship with an endocrinologist, Hodge cultivated the same thing that defines all good relationships between patients and doctors: trust. The ability to trust health care providers, several transgender students say, is rooted in cultural competency: In this case, the ability to knowingly and sensitively address, or at times not address, a student’s gender status.
But such competency can be elusive at Yale Health.
“Some providers know enough to do a good job, while … others clearly do not. I have heard of more bad experiences than explicitly good ones,” Murchison says.
Transgender students describe experiences of doctors dragging their gender status into otherwise unrelated medical conditions, doctors appearing visibly uncomfortable or stumbling over how to appropriately refer to a student.
Angel Collie DIV ’14, who identifies as a man, recollected a visit to Yale Health in which doctors continued to use female pronouns, even though he identified as a man. It took speaking to a younger nurse, whom Collie felt to be more likely to accept his gender identity, to slowly disseminate the word that male pronouns were correct, after which Collie said doctors exercised appropriate sensitivity in discussing his gender.
“On file, it must be female, so that’s what they assume,” Collie said.
At a personal level, expanding cultural competency, at times through as little as a conversation, appears within reach. Yet there remain institutional barriers that make widespread change difficult.
Paperwork poses a significant problem. On the intake form, three options are offered: male, female and transgender, which, Murchison says, betrays an underlying misunderstanding of what being transgender is.
“The term transgender describes the fact that they have moved from one gender to another, not their gender itself. Thus, making male, female and transgender mutually exclusive options makes little sense,” Murchison says, suggesting that a better option would be to ask if a student is transgender in a separate question.
There is no silver bullet for a lack of cultural competency, but a combination of education and generational turnover might do the trick. Collie and others interviewed believe the best way to improve cultural competency is through continuing education for staff at Yale Health, adding that the University needs to create incentives for its employees to actively pursue more knowledge on the topic.
“Anyone who’s going to be coming in contact with trans folks should be educated about what that means,” Collie said.
Any organized push for that kind of continuing education on transgender issues among medical practitioners will be part of a long-term battle. Yet any current or future efforts will find themselves closer to the beginning of a movement’s history than the end. At Yale, Murchison says, there is little to no student organizational history around transgender issues, beyond Trans Week, which has brought artists and speakers to campus to discuss the issue for the past 10 years.
The first attempts to actually change University policy to reflect greater sensitivity have an even shorter history.
In 2006, the Yale College Council pushed the administration to include “gender expression” in its nondiscrimination clause, after a transsexual dining hall worker sued the University for harassment. And three years later, non-transgender and transgender alike proposed that the University permit mixed-gender housing. Like all institutions, Yale moves at its own pace: In 2011, the University allowed seniors to live in mixed-gender suites, and then, in 2012, the policy was expanded to cover juniors.
Today, some activists on campus are asking Yale to liberalize even further, and extend the same option to sophomores.
But the trajectory of transgender activism at Yale runs alongside — and at times separately from — the history of transgender activism in the nation at large, which has sought to address issues faced by few, if any Yale students. America’s transgender population is marked by disproportionately high rates of homelessness, violence and suicide. According to a 2010 study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, 41 percent of transgender individuals have attempted suicide. In addition, a 2010 study by the Center for American Progress put the percent of homeless and at-risk youth who identify as gay, lesbian or transgender at 40 percent.
Reconciling what could easily be described as two different worlds, the one inside the University and the one beyond it, is no easy task for transgender activists, Murchison says. In one sense, the knowledge that transgender individuals, some as nearby as downtown New Haven, are frequent victims of homelessness and targets of violence, makes fighting for insurance coverage appear relatively trivial.
But at the same time, perhaps those changes that within the scope of a University are small, and within the scope of a nation even smaller, will together constitute small pushes on a grand scale. And perhaps those pushes will yield larger results — precisely the way Hodge’s push to receive the medical care he needed at Yale Health did.