Science often demands that her adherents do odd and peculiar experiments to advance knowledge; when it comes to studying a sexually transmitted infectious disease, this is doubly true. I’m fairly confident that among my pharmacist peers, excluding those within our research group, I’ve assisted with more pelvic exams than any of them. Possibly more than all the rest of them combined, even, or at least the rest of the PharmDs licensed in the United States.
On Day 3 of my fellowship training in HIV pharmacology, our first study visit is scheduled. Sink or swim, right? I can swim. I’m not quite sure what I’m doing, and frankly, I’m scared to death, but, I’m here to learn, right? Right. I dosed toxic medications without killing anyone. I survived a year of residency hell before this, where I cried every day, and drank every day, often at the same time. Surely this cannot be as hard as those things were. This is the place that’s going to help me realize my full potential and former glory as the Smartest Girl in the Room, unlike those goobers at my small-time, miserable residency site. A major academic research center, famous researchers with big grants and excellent publications: this is the big time I’ve wanted ever since the most famous pharmacy residency program rejected me and my wounded pride went after a sure thing rather than risk another rejection. And my new mentor chose ME, so I swallow my anxiety and walk over to the research unit, clutching my little blue Igloo cooler full of tubes and supplies.
My co-fellow, a slick guy from the Northeast desperately out of place in the South, and I prepare to do the visit. We start off well. We’re on time. We remembered all of our supplies. None of the nurses are yelling at us. The participant is patient with us newbies; Mr. Slick’s dark good looks probably help with that a bit. Our study physician arrives.
We’ve done all the question-asking and assessing part of the visit before she got there. Now it’s time for the specimen collection, which happens during a pelvic exam. We’re studying HIV drug concentrations in cervicovaginal fluid and cervical cells, so I understood the basics of collecting and processing the samples. Somehow I’d missed that I would actually be the person directly assisting with that until we’re all waiting in the hall while the participant undresses. “Ready?” the physician asks. Oh … ok.
Mr. Slick looks more surprised than I do. There’s a totally ridiculous screen for him to stand behind so he can hear what goes on in the visit and watch what I’m doing with the specimens, but not see the participant … except that he’s tall and has to turn around, with an “Oh, Jesus!”, because the top of the screen is right at his eye level, and there’s no way he can watch me without seeing the participant on the exam table, naked from the waist down, feet in the stirrups. (This will become fodder for many, many jokes over the next two years of our shared experience, and we still occasionally joke about it when we see each other at meetings, more than 10 years later.)
I’m standing there handing over speculums and cytobrushes and aspirators, dear sweet baby Jesus. The thoughts milling about my mind went something like this: I’m a pharmacist, man! I don’t touch people or see them naked or play with their bodily fluids. What have I done? How did I not realize I had to do this? You need to learn to ask better questions. You’re an idiot. This is weird.
And it was weird. And then it got less weird. And then I became so inured to it that I couldn’t have normal conversations with people not also involved in HIV research. I spent a lot of time thinking about cervicovaginal fluid, semen, vaginal tissue, rectal tissue, and antiretroviral concentrations in each of them. Our research goal was to characterize drug behavior over time, i.e. pharmacokinetics, in these areas that contain the virus and are important to preventing HIV transmission, hoping if we could understand the behavior, we could manipulate it to our advantage against the virus. That’s the science; and talking about the science with my peers, all mostly well-educated researchers and clinicians, lead to many amusing, unscientific conversations.
My male best friend and I loudly argued about the number of semen samples the average man could produce in a day while dining in a very small, very expensive restaurant in the cellar of an inn in a quaint North Carolinian mountain village. It’s possible we may have been well into our third bottle of very nice wine at this very nice establishment when this occurred; and he may have been trying to impress his date, my across-the-parking lot neighbor, an oncology researcher. The dignified older crowd at the other five tables was not amused. Dirty looks pierced our backs upon our visit to the ladies’ room. I forgot that most people don’t talk about these things, period, and probably not in public, or at least not outside of a dark bar.
Phone screening healthy volunteers to participate in a pharmacokinetic study of a still-investigational HIV drug that involved a vaginal biopsy was fun. “Are you currently sexually active?” is a yes or no question; this is not one of those times when I’m working on my communication skills with my patients and want a detailed answer to an open-ended question. Yes or no, ladies, yes or no.
“What form of birth control are you using?” garnered some interesting answers. I misheard “I only have sex with women” as “I only have sex with children.” My mind was running through my potential legal and ethical responsibilities to the children in this scenario and wondering if pharmacists are mandatory reporters of child abuse, while I continued asking questions, trying not to sound judgmental. The rest of the conversation and other context clues helped me determine that I was talking to a woman having sex with other (adult, consenting) women; or at least, that’s what I told myself to rationalize not taking any further action to investigate.
Birth control pills, thyroid supplements, and antidepressants are indeed prescription medications. Commonly used, yes, but still prescribed by a medical provider and still obtained from a pharmacy, and their use governed by both federal and state law. And exclusionary for most healthy volunteer pharmacokinetic studies, where we only want you to be on our drug, lest there be drug-drug interactions. Thus, their omissions may also be partially intentional for the more seasoned volunteer pool in our research-intensive college town.
Later, working with men to collect semen and attempting to isolate immune cells from it brings a whole new level of weird. Collecting fluid or tissue from women is not sexual in any way; cervicovaginal fluid is always there waiting to be aspirated, and the biopsies, while not intensely painful, are not exactly comfortable. Semen collection, the exact opposite; semen as we know it doesn’t exist until ejaculation occurs. IRBs don’t let us anesthetize human men and shock their prostates into producing samples, as is done for research monkeys. (If you believe in reincarnation, pray to whatever god you honor that you don’t come back as a rhesus macaque.) The men collect the samples by masturbation into a urine cup, alone, using whatever they need to get the job done. When I started my fellowship, we had VHS porn tapes in our desk drawers donated from Adam and Eve. Unfortunately, they gave us heterosexual porn, which was of limited usefulness to our mostly gay participants; turns out gay porn is kind of pricey and they were not going to give it away for free to a bunch of weirdo scientists. Nowadays, the research unit has wireless, and everyone’s got a phone to access whatever materials they prefer, so that part at least involves less intervention from us. If you have a sense of humor about it, it makes things go much more smoothly for all involved. If you’re nervous and embarrassed, like a couple of the nurses in the research unit, it’s much more awkward for everyone. It’s always a little awkward; how could it not be? My cure for awkward is levity.
After collection, processing the samples is difficult, especially from older, HIV-infected men, because there’s usually not much volume to work with and the samples are sticky. Did you know semen liquefies after sitting at room temperature for 45 minutes or so? Watching sperm swim under a microscope is actually pretty cool, like the videos you watch in high school biology come to life. Semen has a more consistent odor to it across men; cervicovaginal fluid smells different from woman to woman since we have an entire bacterial garden that shifts species depending on a host of factors—also a very active area of research.
After doing the lab work for a while, I can almost guess how old the donor is based on the volume and consistency of the sample. We needed practice samples; I have a husband who’s willing to support my career. I felt a strange mix of pride and possessiveness when his samples were comparatively larger in volume, with more sperm and more immune cells, and less difficult to handle compared to other men in his age range. In other experiments, we needed to make sure we had the right cells, which originate in the seminal vesicles, and I was sad on multiple occasions that we’d elected “vasectomy” as our birth control method after the birth of our last child, excluding him from further semen donations. He’s still scientifically useful, though, as he’s the only person I know that goes through life willingly un-caffeinated, coupled with being an easy blood draw, so he remains our preferred source of caffeine-free blood. (And don’t worry, he’s been properly consented, by someone other than me, to an IRB-approved sample collection protocol and is compensated for his time.)
Ultimately, I got what I wanted from this training: a couple of (relatively) highly-cited papers in high-quality medical journals read by other biomedical researchers, and not just pharmacists. I felt like I belonged in the upper echelons of my profession again, no longer tarnished by my lack-luster experience at a low-wattage institution. I was back on top, the Smartest Girl in the Room, at least until I cowered from the perceived pressure of a tenure-track position and took a teaching job.
I love to teach; I feel the most alive and most fully myself in front of a classroom, a feeling I’ve never replicated during a research study visit. I didn’t love the geographical area of this job, though, and I missed the intense research focus, despite enjoying teaching and finally inserting myself into HIV clinical care there whether they liked it or not, dammit, through a calculated campaign of dogged persistence, the likes of which I had not shown the world since I decided my husband was the man for me, years prior. And so I returned to my fellowship institution, working with my fellowship mentor, to relearn all those fellowship lessons about taking risks and stretching yourself to learn and grow and get better and do good science, and especially the kind of science that challenges your personal sense of self and extends your capabilities, while advancing knowledge for the good of the patients we serve.
The rest of it is just generating good stories to tell in dark bars and at scientific meetings, and in dark bars at scientific meetings.