Diabetes & Miscarriage

I have LADA (Latent Autoimmune Diabetes in Adults), which is essentially Type 1 but with an extended “honeymoon” phase at onset. My doctors first noted that I had slightly elevated fasting blood sugar when I got routine blood work drawn for an annual physical in 2012, when I was 23. Though I would never had any of the telltale diabetes symptoms (excessive thirst and urination) over the next five years, my blood sugar only continued to rise further into the “prediabetes” range, and my endocrinologist started me on a low dose of basal insulin in February 2017, when I was 28, to supplement the limited insulin my pancreas was supplying. (You can read more about my LADA journey here and here.)

I went into my first pregnancy this year both worried about how my diabetes might negatively impact my pregnancy and how my pregnancy might impact my diabetes. I was warned that getting pregnant might push me out of the “honeymoon” phase or otherwise complicate my LADA into looking more and more like a Type 1 with no remaining pancreatic insulin production - then again, I was also told that this would happen regardless, either on its current gradual path or all of a sudden, triggered by an infection (including something as common as a cold, the flu, etc.) or triggered by nothing at all but the passage of time. I knew my blood sugars were in a good range for trying to conceive and for being pregnant - but I didn’t know how long that would last. My body was already requiring more supplemental insulin as the months and years went by, regardless of whether I was pregnant or not; I figured getting pregnant sooner (while my pancreas still produced some of its own insulin) rather than later (when it might no longer do so) would only make it easier to keep my diabetes well-controlled during pregnancy. And if I did end up seeing my diabetes forever altered by a pregnancy? Well, I supposed that having a baby and becoming a mother be worth the sacrifice.

Not all pregnancies have a happy ending though. In September, my nearly 9 week pregnancy ended with a missed miscarriage and a D&C, leaving me to navigate the physical process and emotional grief of pregnancy loss (which you can read all about in my previous post). And unfortunately - though that would have been more than enough - that’s not all of the story. In a matter of weeks, I was hit with a double whammy of body betrayal - first, a uterus that could not sustain a much-wanted pregnancy, and second, a pancreas that succumbed (temporarily if not permanently) to what it had been hinting at for years: a further decrease in (or at least less predictable/consistent) insulin production.

I finally purchased a medical alert bracelet when I was pregnant, envisioning a time in the not-too-distant future when my pregnancy's second and third trimester would require me to take more and more insulin. A few weeks later, my pregnancy was over and I purchased another bracelet - this one featuring half-pink/half-blue Pregnancy Loss Awareness ribbons.

In the days/weeks after my D&C I saw enough “wonky” blood sugars to worry me and prompt me to look into ways of altering my diabetes treatment plan. I made appointments with my endocrinologist and maternal fetal medicine (MFM) at Beaumont hospital. I talked to sales representatives for two different brands of insulin pumps, and looked into continuous glucose monitoring (CGM) systems. And I searched for advice or stories online about people with diabetes who saw their diabetes treatment routines impacted by miscarriage - and couldn’t really find any. I was disappointed not to find more information - or at least personal anecdotes - and so I decided I could at least write down my own, to be found by other people who might also be searching.

To be clear: this is a post about how my miscarriage affected my diabetes - NOT the other way around. My diabetes did not cause my miscarriage. My A1C while pregnant was 5.4%. Anything below 5.7% is considered “normal,” the 5.7-6.4% range denotes prediabetes, and most people with diabetes are instructed to shoot for staying under 7% as a reasonable goal. For pregnancy, the recommended A1C target is <6% - if it can be achieved without hypoglycemia - a.k.a. low blood sugar. The higher someone’s A1C (a way to measure average blood sugar over a 3-month period), the likelier the chances of birth defects, preeclampsia, neonatal hypoglycemia, and yes, miscarriage - but with an A1C of 5.4% (comparable to many pregnant individuals without diabetes), my diabetes posed no great risk to my pregnancy and could not have caused my miscarriage. My obstetricians told me that my miscarriage was likely caused by the same thing that causes at least 1 in 4 known pregnancies to end in miscarriage: unpredictable, uncontrollable chromosomal abnormalities. When I met with my MFM doctor, he repeated the same thing, launching into an unprompted 15-minute explanation of how chromosomes work and telling me over and over again: “This was not because of your diabetes.”

I lost track of the number of well-meaning but misinformed people who asked me - sometimes obliquely, sometimes point-blank - if my diabetes was the cause (or a cause) of my miscarriage. Maybe they were thinking of the film/play Steel Magnolias - for many, the only cultural resource they have for a diabetic pregnancy storyline, in which (spoiler alert!) a woman with diabetes-related kidney problems was discouraged from her doctor from getting pregnant, and then suffered the fatal consequences when she intentionally got pregnant anyway. The pregnancy put undue strain on her already-failing kidneys, to the point where she required a kidney transplant three years after her son’s birth. She died when her body rejected the transplant. The story is based on the true story of the playwright’s sister, and takes place in the mid-1980s - when portable blood glucose meters were not yet widely available, let alone the insulin pumps and CGMs (continuous glucose monitors) we have now. Diabetes was thus a lot harder to control and resulted in more complications at younger ages.

The current 2018 reality is that women with pre-existing Type 1 diabetes successfully have pregnancies all the time. None of my doctors - including my endocrinologist and my ob/gyns - ever expressed concern about my diabetes impacting my ability to get and stay pregnant. In fact, throughout my nearly 9 week pregnancy, I was the one who kept pushing for information, advice, and more appointments; I practically begged my providers to treat me like a high risk pregnancy and go over my blood sugar logs with me, and still they refused. I have only one and a half years experience taking insulin - and that experience encompassed only basal insulin (mainly to help with my fasting glucose numbers); to control post-meal blood sugar spikes I was instructed to limit my carbohydrate intake. So I had a lot of questions about what to expect while pregnant, and whether or not I should be continuing my lower-carb diet or beginning bolus (mealtime) insulin - and it was so aggravating when I struggled to find anyone in the medical profession who would answer my questions for me.

When I told my endocrinologist a year in advance that we would be trying to conceive soon, he told me that I would likely have to start bolus insulin once I was pregnant - but once I got my positive home pregnancy test and notified his office that I was pregnant, he wouldn’t give me any advice or update my insulin prescriptions. Instead, he told me that he “doesn’t see pregnant patients” and that I would need to contact MFM at the hospital to handle the ins and outs of my diabetes. Then, when I tried to set up an appointment with MFM, they couldn’t get me in until I was 9 weeks along. (I ended up having to cancel that appointment when I had my D&C at 8 weeks 6 days.) Whether it was because my insulin needs were still slight, or because having diabetes just isn’t considered much of a high risk anymore as long as it’s kept under good control, I don’t really know - but from my standpoint it was very frustrating to me that I was denied the care and reassurance I was looking for.

I work really hard to control my diabetes every day - but I especially did so while I was pregnant. As I said, I didn’t really have any guidance from any of my doctors about how to proceed (though my endocrinologist did recommend I start taking a bit more basal insulin in the morning, to supplement the basal insulin I was already taking at night). I also didn’t have a prescription or even any samples of a quick-acting bolus insulin, and no one - not my endocrinologist, not my OB, and not my MFM doctors (because they hadn’t seen me yet) - would write me one. I had to be so careful with what I ate - and how much - because all I had was basal insulin and my diet to try to keep my blood sugar levels within the impossibly tight pregnancy target ranges of <90 dL/mg when fasting and <120 dL/mg two hours after eating. When I talked to my OB at my 6-week ultrasound, I told him what some of my higher numbers were, and he condescendingly said: “Those aren’t good enough. Do you think you can do better?” It took everything in me not to start crying. I said: “I’m already doing all I can! I can’t do anything else to make these numbers better until I have mealtime insulin I can take!” He changed his tune after that. “Oh. Well you know, these numbers are actually pretty good if you don’t even have mealtime insulin to work with. You’re fine.” And still he wouldn’t give me any bolus insulin.

From the day I saw that positive home pregnancy test until the day of my 8-week ultrasound (when I learned the news that I was having a missed miscarriage), I counted calories and carbs every single day, and I started eating fewer and fewer carbs in an effort to try to hit in-target after-meal glucose numbers. There were some days when I ate only 75 total grams of carbs in 24 hours. I worried about not getting adequate nutrition by keeping such a low-carb diet, but I had no one to ask what was worse for my growing child - a lower-carb diet or higher post-meal glucose readings - because none of my doctors would advise me. (And before anyone asks - a lower-carb diet, while maybe not the best nutritional choice for pregnancy, does not cause miscarriages and also cannot be blamed for mine.)

A friend asked me, when they saw how much effort I was putting into making healthy food choices, if it was easier to stay motivated to keep my “diabetes diet” now that I was pregnant. The truth is that motivation has never really been an issue for me - I was already doing more than what my doctors had asked me to do to try to keep my glucose in check. Instead, it just made me all the more anxious and self-hating anytime I saw numbers I didn’t want to see, because now it wasn’t just going to potentially affect my health, but my baby’s as well. My pancreas doesn’t work properly, and like any person with diabetes, I am sometimes going to see too-high numbers, even when I’m doing everything I’m “supposed” to be doing. I can’t control everything. But I tried to control everything anyway, and the few times when I saw a post-meal spike approaching or even well into the 200s, I was devastated. I felt horrible and guilty and like I wasn’t doing enough - even though I was literally doing all I could do.

My endocrinologist tried to reassure me that a few high numbers here and there were not a problem, and that as long as my A1C stayed below 6, I was not as risk for any complications. When I miscarried, the OB who saw me that day repeated the same thing. “It wasn’t anything you ate or drank that caused this,” she told me. “And it wasn’t any funky sugar issue. These things just happen. There was nothing you could’ve done differently.”

If I sound a little defensive, it’s because I am. There is a difference between controlled diabetes and uncontrolled diabetes - and in 2018, diabetes can be more or less controlled, as long as someone is motivated and educated in what to do, and has access to the medication and support they need. All of the serious diabetes-related risks you hear about (kidney failure, blindness, amputations, and heart attacks/strokes) are risks for uncontrolled diabetes, and are typically associated with A1Cs in the 10-13% range; the woman with diabetes in Steel Magnolias, then, likely had an average A1C twice what mine was. People with diabetes who can consistently keep their A1Cs under 6 are essentially just as healthy as anyone else without diabetes - it just takes them more effort (sometimes a LOT more effort) and daily management to be that healthy, rather than seeing their bodies do it naturally. When people ask me if my diabetes caused my miscarriage then, it sounds accusatory to me. It sounds like they’re asking if I wasn’t controlling it enough, if I wasn’t putting in the effort and daily management. And I was. I was doing everything in power to prevent a miscarriage, and still it happened anyway.

But as I said - that’s not what this post is about. My diabetes didn’t contribute to my miscarriage - but my miscarriage did impact my diabetes, and that’s what I wanted this post to be: a testimonial of how my LADA changed in the weeks after my miscarriage, the likes of which I sought out for camaraderie and reassurance and was unable to find.

When I had my D&C on September 13, I was in the hospital for about 3.5 hours. The actual procedure took less than 20 minutes; I was under general anesthesia for about 40 minutes total. Because I couldn't eat the morning of the procedure, I went slightly low (67) while under the anesthesia. I was given apple juice when I woke up, and after drinking the juice and going home and eating lunch, my blood sugar then shot up to 325, the worst I've ever seen it - and not something I particularly wanted to see on a day when I was already anxious about the possibility of infection. Talking with my endocrinologist six days later, he said he wasn’t surprised - high sugars are apparently often part of a typical inflammatory response for a person with diabetes following an invasive procedure - but it was still frightening for me to see at the time. At that point, I still had no mealtime insulin to use to get that 325 glucose down; neither was I in a state where I could exercise or do anything else that might help, since I was supposed to be taking it easy and resting after the procedure. I checked my glucose every hour and watched impatiently, stressfully, to see it go slowly back down on its own (294, 233, 217…). I messaged my endocrinologist the next day, asking if I could please at least get some sample bolus insulin pens to use in the hopefully infrequent emergency situations where something like this might happen again. I also told him that I had miscarried, but that I wanted to try to get pregnant again. Now that I was no longer pregnant, he agreed to meet with me, and the aforementioned six days later I went in for an appointment.

First, he finally gave me the bolus insulin samples I’d been requesting for months - two pens of Humalog. Second, I noticed that on the paperwork they use to code the visit for insurance purposes, he circled “Type 1 - Controlled” for the first time; at all previous visits over the last three and a half years, including the one where he started me on basal insulin one and a half years ago, he’d circled only “Elevated Fasting Glucose.” (There is no option for “Type LADA.”) Third, he asked me if I had any interest in getting a CGM (continuous glucose monitor) and/or insulin pump, which I might find useful for a subsequent pregnancy. I don’t know if it was my glucose finally topping 300 once, or if it was my “threat” about trying to conceive again - which he was apt to take more seriously this time, now that I had already done so once; whatever the reason, I finally saw myself treated less for the “latent” part and more for the “autoimmune diabetes” part of the LADA description. I resented that I had to go through a pregnancy and miscarriage to get the attention and resources I’d been requesting all along, but I guess now I can count it as a thin silver lining in the middle of a tragedy.

My endocrinologist warned me that if I waited until 2 hours after eating (which is when I usually check my glucose), it would then be “too late” to take Humalog. It peaks 1-2 hours after eating, to counteract the food that was consumed, and so if I took it 2 hours after eating it wouldn’t peak until 4 hours after eating, and then I would risk hypoglycemia. He said if I already had high glucose (>150) before eating, then I could take 2-3 units of Humalog with my meal. I was a little disappointed in these instructions - first, because it meant I’d have to start sticking my finger even more frequently to check my glucose levels, if I had to now test before eating as well as after eating; second, because I’d seen several instances where my glucose was on or near target before eating, but then still got high after eating, and if I followed his rules I still wouldn’t be able to treat those highs. But at least it was better than nothing, and I figured it would at least be useful on a day like my D&C, where even if I couldn’t have prevented that first 325 high, I could’ve at least eaten dinner when I was hungry (instead of waiting 6 hours after lunch to eat dinner, to give that 325 time to finally get below 150 again).

It turned out, though, that I would get to use the Humalog sooner than I anticipated. I work part-time and get home around 1:45 pm, typically eating lunch around 2 pm. If I also happen to eat an early-ish dinner that day - at 5 pm or so - that makes it only three hours between meals. If I get a higher number after lunch, then, it might still be at or above 150 when it’s time to eat dinner. Lunch didn’t used to be a problem for my blood sugar - my numbers after breakfast and lunch tended to be pretty good, while I still had more basal insulin in my system; if I had a problem, it would likely be with dinner. But a few days after my endocrinologist appointment, I started seeing higher numbers after lunch - for no real reason that I could figure out. September 26 - thirteen days after my D&C - I took my first mealtime insulin. Because I was also still continuing my twice-a-day basal regimen from pregnancy, that made three times that day when I was injecting insulin - and ten times that day when I checked my blood sugar with a finger prick. I’d been researching CGMs and insulin pumps since my endocrinologist brought them up at the appointment; if my body was going to make this a regular thing of requiring mealtime insulin after all, the idea of getting both was looking better and better.

In the weeks after my D&C, I also saw several episodes of mild hypoglycemia (blood sugar less than 70), all in the middle of the night or early morning: 65 at 1:30 am on September 16, 61 at 3:25 am on September 24, 68 at 6:10 am on October 1, 59 at 1:25 am on October 3… These are just the ones I know about - the ones that woke me up feeling warm, sweaty and shaky, or feeling hungry and otherwise “off.” There was also the night of September 27 when I had several dreams about feeling hypoglycemic, and I kept waking up or almost waking up throughout the night. I don’t know if I actually went low, or if I was just worried about it (it was the night after I took Humalog for the first time, so I’d taken slightly more insulin than usual during the day), because I wasn’t conscious and aware enough to figure out if I was having hypoglycemia symptoms while awake, rather than just in a dream, and I never tested. My fasting glucose that morning was 88 - right on target - so I suspect they were just anxious dreams. But many people with diabetes experience what is called a “predawn” phenomenon, where their blood sugar rises (sometimes significantly) when they wake up, and it’s certainly possible that I was in the 60s overnight and then still got a healthy 88 when I tested before breakfast at 7 am. As far as I know, I have no hypoglycemia awareness and the symptoms always wake me up - but as I haven’t used a CGM to track my glucose overnight, and am not in the habit of setting an alarm for 2 am to wake up and check regardless of how I feel, I don’t actually know if that’s true. I might be going low even more often than I realize.

I’m not sure if my hypoglycemia was caused by a slight decrease in insulin needs once my body readjusted to a state of non-pregnancy after my miscarriage - or if I kept going low because I wasn’t eating enough. Three of the four nights listed above happened after days when my schedule deviated a bit from my norm and I ended up eating less than 1700 calories and/or less than 100 g. carbs throughout the day - but the other one was after a day when I ate nearly 2000 calories and 134 g. carbs, and there were also several other days during those first three weeks after my D&C where I ate less than 1700 calories and/or less than 100 g. carbs and didn’t go low at all (that I know of). My impulse is to always look for the pattern - but sometimes it seems like there isn’t one, which is frustrating. To make matters more confusing, there were other days - about once or twice a week - when my fasting glucose was slightly high (above 100) in the morning, making me wary to just decrease my basal insulin every day as a solution for treating hypoglycemia - because then, I worried, my fasting numbers would just grow worse.

The answer, I think, is to somehow fine-tune my insulin intake at meals throughout the day so that I’m not relying so heavily on basal insulin (and probably to change my eating habits to be more steady and predictable from day to day, as well) - but I for awhile I debated if it would be better to do that by employing more Humalog insulin injections, or by switching over to an insulin pump. With a pump, I would be able to control my basal insulin as a gradual release with a little bit every hour, which better mimics the insulin production of a properly functioning pancreas - rather than taking two blanket doses (one in the morning, one in the evening) in an attempt to cover the entire 24 hour period, like I do right now. It’s a question that depended on a lot of factors, including what my insurance will actually cover (given how low my A1C already is with my current regimen), how much my blood sugars might fluctuate in the weeks/months while I adjust to a new insulin delivery schedule, and how soon I plan to try to get pregnant again.

And in case that wasn’t enough information overload for you - there’s more! At the beginning of October, I finally got my long-awaited appointment with MFM. It was considered a “preconception consultation” now that I was no longer pregnant, and I was worried that after so many weeks of hoping and waiting to talk to them, through pregnancy and miscarriage and recovery, it would be a quick, disappointing consultation that still left me with unanswered questions. Thankfully, everyone in the MFM department was great - once I finally got in there - and the doctor talked to me for nearly an hour! (How often do they actually give you that much of their time and undivided attention??) The doctor I spoke to was adamant that with an A1C of 5.4% I was clearly doing all the right things already; still, when I brought up that I was only keeping my A1C so low because I was doing a low-carb diet, he listened to my concerns instead of dismissing them. He said that I should feel comfortable eating a healthy, balanced diet that would include 150-200 g. of carbs per day (whether pregnant or not), and that if I can’t do that without taking mealtime insulin, I needed to be taking more mealtime insulin. It was exactly what I wanted to hear - that I didn’t have to play this awful game of prolonged extreme dietary self-control anymore, denying myself even appropriately-sized portions of healthy carbs in an effort to control what my pancreas could not. (During the month of September, I ate only 60-130 g. of total carbs every day - most of which were healthy, low-glycemic carbs from vegetables, beans, and fiber bars.)

I further told him that my endocrinologist had only just given me Humalog to use “on a case by case basis,” that so far I had only used it once, and that my endocrinologist had not told me what carb-counting ratio to use, encouraging me to use “no more than 2-3 units” with a meal (regardless of how many carbs that meal included), and only then when my glucose was already slightly high before eating. Maybe that’s fine advice for someone like me in general, whose insulin needs are still relatively small and only gradually increasing. But I knew (and the MFM doctor agreed) that I would likely need to be able to employ carb-counting ratios to figure out tailored bolus doses when I got pregnant again, and that it would be better to learn how to appropriately use bolus insulin now - before I got pregnant, started developing more insulin resistance around the second trimester, and REALLY needed it. He assured me that they would be able to help me manage my diabetes while I was pregnant - no separate endocrinologist needed - and he referred me to their dietician/nutritionist for tips on how to incorporate more healthy carbs into my meal plan to get up to 150-200 g. a day.

To be clear, I don't (fully) blame my endocrinologist for my low-carb diet. For one thing, even though I listed my daily carb counts on every blood sugar log I gave him, I don't know if he ever paid any attention to that column. I don't know if he realized how much I'd pared my carb intake down to maintain on-target glucose, since it happened gradually over time and especially during my pregnancy - when he wasn't paying attention, because he “doesn’t do pregnancies.” For another thing, though - I started seeing him back in 2015, when my c-peptide levels (the amount of insulin my pancreas still produces) were still in the normal-ish range, and for a couple years I was easily able to keep a relatively good A1C just by watching what I ate. When he started me on basal insulin in early 2017, my c-peptide levels had gotten worse - but I was still clearly producing much of my own insulin, and needed only to supplement it with a little bit. When it's such a gradually declining slope like that (like it is with all LADA, but, he has said, with me especially, who's been experiencing what he has in the past called "one of the longest honeymoon periods he's ever seen"), it's hard to know when you've crossed over the line between being able to maintain steady blood sugar with diet changes alone and needing to admit that diet changes cannot cover it anymore. Furthermore, I was also (and still am) rather sensitive to insulin, which is why I get hypoglycemic so often. I don’t need much insulin at all, and there is a real risk to prescribing me too much. So it does make sense that he would hold back and want to avoid putting me on mealtime insulin for as long as possible - but it’s also been clear to me, for at least the last several weeks, if not months, that the time has come to stop avoiding it and instead embrace bolus doses as part of my everyday. And it was nice to have the MFM doctor agree with me.

I next asked my MFM doctor if I should get an insulin pump instead of doing manual mealtime injections. (I just wanted someone to tell me what to do, so I didn't have to make the decision myself.) He didn't help. He said that it was up to me - but if I wanted to switch to the pump, I should definitely do it now... and then wait at least three months before trying to get pregnant again, to make sure my blood sugars are stabilized with my new regime and my A1C is back on target for pregnancy. I didn’t know if I wanted to wait that long before trying to conceive again - especially once I factored in that it can sometimes take awhile to jump through all the necessary insurance hoops and receive a pump in the first place, which would push a potential second pregnancy even farther into the future - but I also didn't want to deny myself the opportunity to have more resources at my disposal just because I still wished my first pregnancy had never ended early, and I was impatient to be pregnant and feel hopeful again.

The doctor also said that a pump was definitely not necessary for me, given that my A1C was already so good without it and that the medical profession often takes on an attitude of “if it ain’t broke, don’t fix it,” not wanting to disrupt a good thing. Of course, I suspect that just increasing my carb intake and my bolus insulin, and likely adjusting my basal insulin down to compensate for the bolus doses, will already “disrupt” the good A1C I currently have, at least for a couple weeks while I trudge up the learning curve of figuring out how to correctly count carbs and utilize an appropriate bolus carb-insulin ratio. My gut reaction, then, was to suggest that if I’m going to see temporary problems while I fine-tune my insulin anyway, maybe switching to a pump wouldn’t be that much of a difference during the transition period, while ultimately (probably) giving me better insulin control in the end. On the other hand, I also worried that maybe skipping right to a pump and trying to do everything all at once would be overkill. It would be good to know how to figure out my bolus ratio myself first instead of jumping immediately to a pump and relying on its calculator to determine my ratio every meal - because if I don't know how to do it myself and then something were to happen to my pump, I'd be inexperienced and lost trying to figure out how to do it by myself on the fly.

At the very least, I would love to have a CGM. Then, instead of only having data of my blood sugar levels during the times of day when I can prick my finger, bleed on a test strip, and check my glucometer, I could easily just consult the CGM screen/app to see automatic readings of my glucose every five minutes. It would also alert me if I was trending toward hypoglycemia, so I could correct it faster before I went too low (and maybe catch some more instances of it if it turns out I am going lower more frequently than I realize). I would love to have access to all that data. But I couldn’t even get a CGM until I first made a decision about the pump - because getting a pump would change which brand of CGM I got.

For my needs, it seemed like the Dexcom or Medtronic CGMs would work best. The downside of the Medtronic CGM is that it requires an Apple device to see the data, and I only have an Android phone. I was told by the Medtronic representative that they expect to have their app available on Android phones “any day now” - but that “any day” could be as late as mid-2019. To use their CGM, then, I would need to switch to an Apple phone or purchase an iPod touch. The Dexcom, on the other hand, comes with its own Dexcom-specific monitor so I wouldn’t have to purchase another device - and therefore seems like the easier choice if all I’m getting is a CGM. If I did decide to get a pump, however, the Medtronic makes more sense - because the Medtronic insulin pump (which seems to be far and away the most accurate on the market) works as a hybrid closed-loop system with their CGM, meaning that the pump can automatically adjust doses or temporarily suspend insulin based on readings from the CGM.

There’s also the maintenance and aesthetic of these wearable technologies to consider… The Medtronic hybrid system has the CGM sensor (which you have to change every few days) and its rechargeable transmitter, plus the insulin injection site (which you also have to change every few days), cumbersome tubing, and the bulky pump itself, which has to either hook onto an article of clothing or fit inside a pocket - and was thus obviously invented by men who don’t understand how tight or thin the fabric often is or how small the pockets often are on women’s clothing. It sounds great in theory to have what is essentially an “artificial pancreas” (or as close as we have to that right now) - but the actual day-to-day of wearing all of those pieces seems very daunting to me, especially when it’s not necessary for me to do to maintain tight blood sugar control and my MFM doctor thinks I’ll be just fine for the entirety of my next pregnancy without it if I'd rather stick to multiple insulin injections.

It’s just all a lot to think about - and I felt like I had to make a decision relatively quickly, before I could move forward toward my goals of pregnancy and motherhood again. Because I kept going back and forth on it, my husband advised me to just get the CGM for now, and then revisit the idea of a pump in a year or so. I already have more resources at my disposal than I had last time - I’ve talked to MFM, I know who will be helping me with my diabetes during pregnancy, and I’m starting on a diet and insulin adjustment plan; it’s likely these would be enough to give me peace of mind (as much as anything could) whenever I get pregnant again next. So I contacted Dexcom and am expecting to hear back soon from them about what my insurance will cover. It's so important to me to have a CGM that I'll probably pay for whatever the out-of-pocket cost happens to be... but I obviously hope it won't be too astronomical. Once I have my CGM, I'll feel more comfortable experimenting with bolus insulin to fine-tune what my mealtime ratio should be, and hopefully I can work out something there that will work for me without too much hassle.

I know this is a lot of tedious information, especially if you aren't familiar with the ins and outs of diabetes management. I just wanted to outline all the things that have been weighing on my mind lately and the decision process I recently went through to illustrate why it's so easy to get overwhelmed and feel angry. Why can’t my pancreas just function properly so I don’t have to deal with all these issues, put in all this effort, go to all these appointments, and make these difficult decisions? Why couldn’t my first pregnancy have just worked out, so that all these decisions about my diabetes management would have been postponed for another time? I didn’t do anything to deserve any of this, and it isn’t fair.

It’s been a stressful couple of months. Sometimes I feel like I’m not allowed to admit that and show people how sad and frustrated and overwhelmed I am. I have to remind myself that that isn’t true, that my feelings are normal and valid, and that anyone would feel sad and frustrated - because these are sad, frustrating things. I’ve been (mostly) feeling a lot better emotionally about my pregnancy loss over the last few weeks (something that’s possible only when it’s no longer actively happening) but my diabetes management is still an occasional great source of stress for me, and likely will be on and off for the rest of my life. Diabetes isn’t something that just goes away. It’s always there, impacting all areas of my life and requiring a lot of my time and energy to manage - particularly in times that are already stressful, such as during and after a miscarriage, or during pregnancy. Stress makes diabetes management less efficient and predictable and diabetes itself can further contribute to stress - and I feel like people don’t talk about that enough.

Letting Marginalized Groups Speak for Themselves

I have a lot of privilege. I recognize this about myself.

I am white - very white, actually, with blonde hair and blue eyes. In high school, other people sometimes described me as Aryan. (I assumed they meant to imply that if I had lived in Nazi Germany, I would have so perfectly fit the description Hitler wanted for his new master race that not only would I have been spared, but possibly celebrated and married off to some prominent Nazi official in need of a respectable looking wife or something. The way they said it made it seem like a compliment, but it was a very strange compliment, and made me a little uncomfortable.) My point is - I could never pass for anything but white. I am so white that even among white people my whiteness is "fascinating" (or possibly intimidating). I have no way to fathom what it actually feels like to be a person of color in this country, because so much of my life experience has been that of white privilege. I can try to empathize, but there is no way I will actually ever understand.

I am female. And while this means I lack male privilege, I do still have cisgender privilege. My body and gender identity match. I also conform to many female appearance stereotypes - my hair is long, my fingernails are long and sometimes painted, and I often wear dresses and skirts, earrings and necklaces. I've never been misgendered. I can't truly understand how it would feel to have a disconnect between who I wanted to be and who I looked like on the outside.

I am straight. I am married to a white man. I never had to come out to my family or friends, or felt ostracized from my religion because of my sexual preferences, or had a stranger make incorrect assumptions about my sexual orientation, or felt that my relationship with my husband was somehow unacceptable or morally wrong. I'll never really know what it's like to be gay, bi/pansexual, or asexual.

I was raised Christian in a Christian-majority nation. My religion's holidays matched the school calendar. I was exposed to the traditions and cultural practices that remain entrenched in American society - and it was never required of me to learn any others. Though I chose to step away from Christian beliefs as I grew up, I still have that outward Christian privilege to fall back on if I chose to - unless I specifically admit that I don't believe in God and would rather identify as atheist, no one would know or assume that about me. I don't really know what it's like to belong to a different religion, a religion without privilege (though I've seen some glimpses, working as a graphic designer at a large Reform Jewish synagogue).

I grew up in a middle class family. I have never known real poverty. Even when my dad was unemployed for 15 months during the recession, I never really wanted for material things. Throughout my life, educational resources were readily available to me if I wanted them. I went to a local state school, was lucky enough to get scholarships and have a lot of my expenses paid for by family members and my (very) part-time jobs, and graduated with virtually no student loans. I'm 28 years old and my husband and I became homeowners five years ago. I don't know what it's like to lack class privilege. Even when it felt like maybe I didn't have it growing up, I really did. I've always had it, and still do.

I'm also healthy (relatively so). I look healthy from the outside. I have poor eyesight, so I wear corrective glasses - but there is no real stigma attached to wearing glasses, so that's irrelevant. And no one could guess any other chronic ailments I might have - unless I told them - because they are not noticeable, nor significant enough to impact my day to day life. I do a lot of preventive behaviors to keep the threat of LADA at bay (latent autoimmune diabetes in adults), because my glucose is slightly elevated. But it's never really been bad enough to be even officially labeled "diabetes," let alone impact my life much. And any mental health/emotional issues I'm working through also don't outwardly influence my daily functionality. I have ability privilege, and have no idea what it's really like to be discriminated against based on my ability (or appearance of my ability).

My point is that I'm not exactly an ideal candidate to talk about a lot of these issues - race, gender, sexuality, religion, class and ability - which I just spent several months addressing with colored pencil drawings and blog posts. I want to use my privilege to draw attention to these topics that warrant discussion, if I can. But I also want to be careful not to speak for these oppressed groups. I don't want my voice to drown out theirs, and I don't want to presume to know their experiences or what the best steps would be to help them moving forward.

This is perhaps the most difficult thing privileged people like myself face in trying to help the unprivileged. We want to help - but often don't quite know how to help. We spend so much time patting ourselves on the back for taking on liberal causes or doing good in the world that we neglect to recognize that we've painted ourselves as "savior" figures. Marginalized groups don't need us to "save" them - they just need us to shut up and listen. It shouldn't be up to us to give them more rights; it is instead our job to support them and help draw attention to their cause from the sidelines while they take the rights they deserve. We are meant to be allies, not leaders.

Marginalized means they have been relegated to the margins. It's our turn to stand in the margins instead, and allow oppressed groups an opportunity to assert their own voice.

I feel a bit like a fraud when I start talking about politics or social issues too much. I'm not an expert. I barely even follow details of what is going on in the world. (To be honest, there's just been too much bad news lately that it's been overwhelming. And I'm lucky enough that I have the privilege to tune all that shit out when it overwhelms me. But that is another discussion for another time.)

It is precisely this reason that my message in this "Stronger Together" series is so vague. My drawings celebrate the differences found in humanity and show a symbolic floral arrangement in which all flowers (all people) have equal weight in filling out a bouquet - regardless of race, gender, sexuality, religion, social class, or ability. It is a hopeful idea that could have just as easily been drawn a hundred years ago or a hundred years in the future as drawn today. It doesn't reference specific topical events, and it doesn't try to speak for marginalized groups. It just showcases a utopia in which all people have their own equal voices with which to speak.

It tells people where I stand - on the side of tolerance and love and acceptance, on the side of allies, on the side of hope for a better tomorrow - without presuming that I have any real answers, without taking a clear leadership role, and without even referencing many specifics. Maybe this isn't enough; maybe as an ally I could have done more. But this is where I'm at in my journey right now. I am erring on the side of Not Doing Enough out of concern for overstepping. This is the extent that I feel capable of.

I do feel more qualified to talk about gender and religion, because these are areas that I feel I have more personal experience in. I don't have male privilege and never have, and I gave up Christianity to label myself an Atheist (an Atheist who married into a Jewish family, an Atheist who works at a Reform Jewish synagogue), so I don't have as much religious privilege anymore either. I can more comfortably talk about these issues and state where the problems lie - because I've witnessed them myself and because I am one of the marginalized who deserve to have their voices heard.

But even here, I often want to step aside to let those with intersectional oppression speak. I can only speak to my experience as a white, cisgendered, straight woman; women who are black or gay or transgendered (or all of the above) face much greater oppression than anything I've lived through.

All humans suffer sometimes. But not all suffering is created equally.

I hope that my "Stronger Together" drawings are adequate at straddling that line - the line between speaking up but not shouting over those less privileged than me; the line between wanting to do something, or say something, but not knowing exactly what to do or say. I hope that their vagueness allow more people to find resonance in them. Often, the more we get into specifics, the more we start to disagree. I am hoping that despite where we are on the political spectrum, or what life experiences we've had, or what privilege we've been granted or oppression we've endured, we can all agree in this very basic premise:

Humans - ALL humans - deserve respect, love, acceptance, acknowledgement, tolerance, and to have their voices heard.

Especially those who have traditionally been denied such things, who have a lack that needs to be filled.

Why Are You So Quiet?: A Modern Double Standard

It used to be that men had no qualms about verbally disparaging (or physically abusing) womenfolk if they spoke "out of turn," voiced opinions, or socialized - with other men, or even with each other. A well-behaved woman was meek and silent; like a child, she was allowed to speak only when spoken to, or only in certain places. The specific customs varied depending on location and historic era, but a popular one was that women could only speak at home, and that their voices were unwanted in public.

In the Bible (1 Corinthians 14:34-35), for instance, Paul said: "Women should remain silent in the churches. They are not allowed to speak, but must be in submission, as the law says. If they want to inquire about something, they should ask their own husbands at home; for it is disgraceful for a woman to speak in the church." (NIV)

In some religions or cultures even today, women are discouraged from speaking. An overly loud, gregarious, or social female is seen as dangerous, unruly, and impolite. Often, it is a seen as a reflection of other "moral failings," such as sexual promiscuity. A woman who speaks freely also probably has sex freely; a sociable woman is therefore a bitch and a whore.

This is an extreme opinion. It is not usually said so harshly - at least in modern America - and yet some of this idea remains and permeates our culture more subtly. Women do not generally fear physical abuse or being called a whore if they were to voice an opinion in public or interrupt a man - and yet it's statistically observable that in many gender-integrated public spheres (classrooms, business meetings), women are less likely to raise their hands or speak up. They're less likely to be called upon to speak up. And they're less likely to interrupt their male counterparts, compared to how often women are interrupted by men. Women don't participate in public in the same way that men do - because we've been conditioned not to. We've been raised that interrupting others is impolite.

The standards of "good behavior" are different for girls and boys - "boys will be boys," we're told, and so they are allowed physical and verbal freedoms like running through the house, making a mess, interrupting each other, and speaking loudly. I could see how someone might even try to argue that it is the boys who are discriminated against with such cultural allowances - because girls are seen as more capable of good, polite, restrained behavior, at a younger age, and so are given a higher standard. A boy is going to have a hard time believing he has a capacity for patience to wait his turn or to sit still in his seat if such behaviors are not modeled for him or encouraged, or if he is met with a laugh or a shrug or a "oh well, we tried" attitude when he missteps from this desired behavior. He comes to believe instead that he can't help fidgeting, that he can't help playing rowdy, that it's in his very nature to do so. When he gets away with interrupting others, he comes to believe that his words are important, that his opinions are important. He learns that a louder voice can be heard over a softer one, and if he speaks up, if he yells, if he interrupts, people will pay attention.

Similarly, girls often learn that their gender is predisposed to politeness, to empathy. They care about others, and so they care about listening to what others say, and they're willing to put others first. They will listen to someone else complete his or her thought before voicing a response. They have the capacity to wait their turn, to be patient - and indeed embody the positive qualities of their gender when they do so.

I've said it before, and I'll say it again - gender roles hurt both genders. Boys who are not loud or rambunctious might feel ashamed for not acting like a boy is supposed to; he may then purposefully act like the other boys to fit in. And girls who are too harsh or too loud or too opinionated or too rambunctious are called tomboys or bitches.

Of course, at a certain age, these prejudices about how boys act more or less fall away. Men are expected to conduct themselves with politeness and good behavior in college lecture halls and business meetings. While they may get away with interrupting colleagues on occasion, it would be noticeable (and potentially worthy of an HR write-up, or a chat with the boss) if he interrupted constantly, or acted particularly rudely when doing so.

Furthermore, while there is an expectation that women are quieter than men in professional settings, there are other public settings where women are expected to be more talkative than their male counterparts. When surrounded by other women, women are in fact "known" for their socializing. There are myriad jokes and (derogatory or derisive) phrases about their tendency to talk: gossiping, chatting, prattling, "clucking hens." In private, it's a well-known trope that wives "nag" their husbands, or just in general try to talk to their husbands about their day. (It's no wonder men are so reluctant - they spent all day at work getting a chance to talk, and now that they're home, they only want quiet, relaxing time.) At parties, women often engage both sexes in conversation, often doing the brunt work of moving a conversation forward, trying to engage those at the fringes of conversation, prompting others with questions about how they're doing, etc. If there is a person in your family who takes on the role of keeping track of everyone and updating the rest of the family on the goings-on of the others, chances are it's a woman - a mother, a grandmother, an aunt, a female cousin.

Even as girls, females are expected to be social - but only during "social times." I went to three different elementary schools growing up, and anytime I started at a new building and had to make new friends, I would go through a period of transition where I would be particularly quiet and shy. Recess monitors came up to me that first week to ask if something was wrong. Why wasn't I talking with or playing with the other girls? I was shamed for not talking, for not being social. Yet later, after I made friends, I was told off for being too social. For those who know me now, it may be hard to believe - but my third grade teacher in particular had so much trouble keeping me quiet during class that she regularly kept my assigned seat away from those of my other friends. I have the report card to prove it - she wrote in the comments section that I talked too much in class, when I wasn't supposed to.

To be fair, I don't think this is necessarily gendered - we all have to learn growing up when we are and aren't allowed to do things. There is a time and place for socializing; this is true for everyone, regardless of gender. Additionally, I think the lines become more blurred, more subtle as we age. Men and women don't talk or act so differently as adults as they do as children. We all interrupt each other sometimes, we all speak loudly sometimes, and we all stay silent sometimes. We find our own rhythm, and it's often more individual and based on where and how we feel comfortable, than about gender specifically. I'm very reserved with strangers, or in large groups, but I'm comfortable talking a lot with my husband and other close friends and family members.

Yet what I do think is gendered is the policing of one's decision of where and when and how to socialize or speak up. A man can speak as loud and ardently as he wants with few repercussions; a woman does not have the luxury of always speaking her mind unless she's comfortable with being called a bitch. A man can also be as quiet and reserved as he wishes with few repercussions - if a man isn't social, he's painted as the "strong, silent type" (stoic, unemotional, manly), or it's assumed that he has "better things to do"; he's not talkative because he's busy, he's tired, he's been working hard all day. A woman who isn't being social is seen as out of the ordinary. "Why aren't you talking?" "Is something wrong?" "Are you unhappy?"

I would be remiss here if I didn't make this discussion more intersectional. A white man probably gets away more with voicing opinions and speaking loudly than a black man does. When a white man interrupts, he's eager and has strong convictions; when a black man interrupts, he's being a bully or a thug, or his parents never taught him proper manners.

I speak from my own experience when I write of quiet women being called out on their quietness; it happens to me all the time. It's not always a question. ("What's wrong?" "Are you okay?" "Why are you so quiet?" "Do I intimidate you?") Sometimes it's a statement. ("You're so quiet." "You're so reserved." "You don't have to be scared to speak up.") But the questions are still there, still implied. It's wrong, it's weird for someone like me to be quiet or reserved. It must mean something's wrong. I must be unhappy, or uncomfortable, or scared. Maybe I'm just shy and thoughtful. Maybe I'm more comfortable with silence than with talking just to talk, with saying nothing just to fill space; maybe you're the one making me uncomfortable now that you've pointed out my "unnatural silence." I hate when people say these things. What? You think this is news to me? I know I'm quiet; you don't have to tell me.

I suspect that many people point out that I'm being quiet because they wish to draw me into conversation. Instead, it often makes me retreat more, because pointing it out makes me self-conscious about how quiet I was being, and I turn even quieter to reflect on how I was acting or how I am being perceived.

On the other hand, other people may point out that I'm being quiet because they are uncomfortable with my silence - and, for some reason, think their discomfort is my problem. What they're really saying is: "I didn't expect someone who looks like you to be quiet, and you not being how I expect you to be is making me uncomfortable - which is your problem, not mine, so please get around to fixing it and acting more like how I expect you to act, so that I can be comfortable again."

Many women complain that they are told to smile - by complete strangers. They are policed on their apparent happiness and told to smile - not because the stranger is trying to make the woman feel better or feel happier, but because the stranger is uncomfortable and wants the woman to smile, to pretend that she is happy or at ease, so that the stranger can feel secure. I don't think this has happened to me; I can't think of a time (other than when I was child throwing a pity party or a temper tantrum) when I was told by someone to smile, or act happy. I certainly can't think of a time that a stranger has approached me to harass me about not smiling. But I do hear a lot of comments about how quiet I am (from people close to me and strangers or near-strangers alike), and I think these are related. Maybe it's a level worse than "not smiling." I'm not smiling and I'm not talking, not engaging socially with the world, and it's the worst offense that people pick up and try to call me out on.

I wonder, too, if it's not because I'm blonde. I'm a 20-something blonde woman, and young women and blonde women are particularly stereotyped as social, as extroverted, as talkative, as friendly, as perky, as happy. We're supposed to all be cheerleaders, sorority girls. I'm sure Black and Hispanic women who are quiet, introverted, shy, or bookish have similar stories. Because these groups (like blondes) are particularly seen as loud, extroverted, and social, with a love of raucous parties and/or dramatic displays of emotion, a Black or Hispanic woman who does not embody the expected stereotype might hear similar "concerns." What's wrong? Why aren't you friendly? Why aren't you talking? Asian women on the other hand, are not expected to be loud or talkative, so they probably don't see similar surprise from strangers when they act quiet and reserved. I can't imagine an American woman in a hijab being told: "You're so reserved. I hardly ever hear you talk." But someone like me does.

Being a woman - even an American woman - is not a universal experience. Double standards are going to be slightly different among different groups of women. But as a young blonde white woman, I am exposed to these double standards:

- If I talk a lot, I'm seen as gossiping and idly pilfering time on silly chats; yet if I'm quiet and choose not to take advantage of opportunities for small talk, I must be unhappy or uncomfortable, because a blonde anti-social female is unnatural.

- If I'm too friendly, I'm a social butterfly, a ditz not to be taken seriously - or, even worse, a flirt, a whore, a slut, sexually promiscuous, "asking for it," begging for attention; yet if I'm not friendly enough - if I prefer solitude to parties, if I'm reluctant to smile or share personal stories - then I'm uptight, uncool, rigid, old-fashioned, I have a "stick up my ass" or my "panties in a wad," I'm a prude, a tight ass, a virgin, a bitch.

- If I interrupt someone else (especially a man, especially in a professional setting), I'm rude, I'm selfish, I'm impolite, I'm a bitch; yet if I never speak up, I'm seen as weak, scared, intimidated, and unwilling or unable to stand up for myself: a doormat, a wimp, a pussy.

- If, in the process of continuing or sparking a conversation, I ask too many "personal" questions, I'm a nag, I'm nosy, I'm a bitch; yet if I don't play this role and inquire how others are doing - or if someone else were to ask for an update on my life and I were to give what they consider a short, unrevealing answer - I'm a brat, I'm snotty, I'm not feminine or empathetic enough, I'm rude, I'm uptight, I'm a bitch.

Double standards are, by definition, a "damned if you do, damned if you don't" situation. Because there is no way to win, I've gravitated over the years to one end of the spectrum. I decided it was safer or more comfortable for me to be thought of as uptight or unfriendly than it was to be seen as sexually promiscuous or flirty, or seen as a frivolous, vapid, unintelligent ditz. I decided I'd rather be too quiet than too loud. I was okay with being thought of as snobby or rude; I told myself I was being mysterious and unknowable, that it was a virtue, that men get away with it all the time. And so I played up my introversion more. I policed myself, I made myself quieter. I think I was predisposed to some shyness and reserve, but I definitely became more shy, more reserved, and more quiet, starting in high school and college.

I've taken the Myers-Briggs personality test a few times, and though I've nearly always come out at INFJ (and always I, in particular), for many years the amount of "I" I was on the Extroverted-Introversion spectrum only increased. I went from being like upper-60s% Introverted to high-90s% Introverted from the beginning of high school to the end of college. No wonder I seemingly lost my ability to make new friends and started giving off more austere and less friendly first impressions.

I'm not trying to be rude or impolite, and I'd rather not be called a bitch (who would?) - but what hurts me more is when my reserve is interpreted as me being a doormat, or weak, or scared, or intimidated, or sad. Maybe because there's a bit of truth in there, and that's why those words hurt more. I don't see myself as rude (on the contrary, I think I'm one of the nicest people I know); but I do worry that I don't stand up for myself enough, that I don't think enough of myself. I do worry that I'm too sad, or too anxious, or too easily intimidated. Isn't the whole reason that I became more introverted because I was afraid? I was afraid of being seen as a ditz, as unintelligent, as flirtatious, as "asking for it." Being quiet seemed like it could be my protective shell.

So to all of those who have ever asked me "Why are you so quiet?" - feel free to pick your favorite answer from the ones provided below:

- Because being quiet often feels safer to me than the alternative.

- Because being quiet often feels more comfortable to me than the alternative.

- Because by now being quiet is a habit.

- Because I'm tired of being asked why I'm quiet.

- Because I'm just tired in general.

- Because I'm mysterious and unknowable. Because still waters run deep.

- Because you wouldn't ask me that question if I were a man and I'm silently protesting your belief that you have the right to police whether or not I engage you in conversation.

- Because I'm actually not paying attention to the conversation and have zoned out and am thinking about my novel or some other much more fascinating thing.

- I actually don't owe you an explanation at all. And I suspect you weren't really looking for a thoughtful response anyway - you just wanted to get me to say something in response.

Self-Advocacy

In a previous post I talked about creating eight "daily affirmations" to remind me of the things I believe that I often forget to apply to myself. Today I'd like to share two more of those.

3. I am capable of being assertive, and deserve to speak my mind.

4. I will not let fear or anxiety or complacency make life decisions for me.

These two are very hard for me. Yes, everyone technically deserves to speak their mind - freedom of speech and all that - but is the capacity to be assertive, to speak their mind in the face of opposition (or perceived opposition), actually something that anyone can learn to do? I have a hard time believing that I am capable of being assertive. I find it easier to be assertive online - where I can hide behind a computer screen - and nearly impossible to do in person.

And the reason, I think, has several nuanced layers. (Doesn't everything?)

1) I don't always know what I feel. As I mentioned the last time I brought up these affirmations, I'm so used to "bottling up" my emotions, that I don't always know myself what those emotions are - I hide them even from myself, not taking the time to acknowledge them. It's hard to be assertive if you don't even know what to assert.

2) I don't believe it's worth it. (I don't believe I'm worth it.) I would never let anyone else get away with saying something like that - but then I often treat others better (even complete strangers) than I'm willing to treat myself.

What I mean here is that I'd rather not "rock the boat." Even if I acknowledge that I'm upset about something (or someone), I am not one to go to that person and let them know how wronged I feel. I value their happiness over my own. I am well versed in "bottling up" my emotions; what's one more to reign in?

And 3) I have so little practice acting assertively (especially acting assertively and then seeing positive results because of this), that I am not confident in my ability to do so. The solution to this seems simple - do it more often! practice makes perfect! - but it's hard to practice assertiveness when the first two points are working against me.

I had a friend in elementary school that I would often argue with. We would argue about something (something trivial, I'm sure - we were in fourth/fifth grade), and then the next day she would approach me like nothing had happened between us, carrying on our friendship as before (until the next argument). We never talked about these arguments again once they were "in the past" - not even to apologize for mean things we might have said to each other. She expected me to be okay with moving on without discussing the problem (or, perhaps, expected me to be the first to apologize). I thought I was taking my cue from her - but perhaps she was taking her cue from me. Either way, we quickly fell into a destructive pattern.

I never did speak up and tell her how much it bothered me that we never apologized to each other. I just let the pattern continue. Resentment over what I saw as her refusal to solve our arguments added to lingering resentment over the actual unsolved arguments, and eventually, when there was an argument that we couldn't just sweep under the rug, and our friendship vaporized. We had never set a precedent for talking through our disagreements, and so didn't know how to do it when it mattered most.

It stands to reason that if I can be assertive on smaller, trivial things, then I will have the confidence to be assertive over something major, if the opportunity should arise. The goal, then, is to be assertive and voice my opinions as much as possible - especially with the people I care about and trust most. In the middle of a discussion, it's easier. The real trick is to be comfortable enough to bring it back up again at a later time, to revisit a disagreement after the fact, and talk about it more rationally.

4. I will not let fear or anxiety or complacency make life decisions for me.

This is connected to the third affirmation because it is precisely those things - fear, anxiety, complacency - that might prevent me from being assertive. I'm afraid or anxious that I will offend someone, or make someone's life more difficult. It's easier to just be complacent, to "let it go." And maybe for some things, it is easier to just "let it go" - I can hardly go around pointing out every time I disagree with someone, every time I feel mildly offended, or every time I see an injustice that needs to be remarked on. I'd never get anything done! But I literally never do these things in person - only asserting my opinions online - and that's hardly nice to myself, to never acknowledge the things I'm feeling or thinking about.

Sometimes it's not about another person, but a solely internal conflict. I'm too nervous to try something new - even if I'm curious about it, even if I think it'd be good for me - and so I decide that the status quo is "fine," something I can "learn to live with." It's this situation that this affirmation is particularly commenting on. Not doing something that I want to do because I'm afraid or anxious to try, or because I've talked myself into believing that where I'm at is "fine for now," is letting fear, anxiety, and complacency make life decisions for me.

Source: http://www.merriam-webster.com/dictionary/complacent

(When I'm talking about complacency, by the way, I don't really mean that I'm satisfied with where I am, only that I'm satisfied enough to have "given up" trying to change. Maybe I'm using the word wrong, and there's a better word that means more of what I'm trying to get at here? Defeatism, perhaps?)

My point is, I'm trying not to let fear or anxiety make decisions for me, to talk me into giving up on something I want to do. Part of that is about expressing emotion to those closest to me (as I talked about in that previous post), but it's also about putting myself out there in other ways. Writing these blog posts. Promoting these blog posts - actually posting the links for these posts on social media and encouraging others to read them, something I rarely do. Writing my novels, and sharing those novels with others (letting friends and family read them, querying literary agents, etc.). Even creating art, and talking about the process of creating art, and sharing the images on here and on social media. Putting my art on Etsy and trying to attract buyers. Trying to figure out how to market myself.

These are not things that come easy to me. It takes assertion to say to strangers (or even friends/family) - "Hey, I think I've made something cool. Would you like to check it out and maybe financial support me so I can keep making these cool things?" And fear, anxiety, and complacency hold me back from being assertive.

This all comes down to self-advocacy - speaking up for myself and my interests. If I don't advocate for myself, who else is going to?

Expressing Emotion

In my effort to try to employ more daily positive thinking, I came up with a list of eight "affirmations" that I wanted to read every morning. I did not choose these words lightly; it was a process of going through old journals and figuring out the things in life that I did truly believe but often have trouble remembering - the lessons I learn over and over again because they tend not to "stick" with me (for whatever reason).

Of course, reading them every morning lasted about a week (if that). But every once and a while, I do go and reread them, and today I'd like to focus on two. (I'll get to the other six in later posts, as I have time.)

1. My emotions matter and are entitled to expression.

2. It is a relief and a joy to feel vulnerable around others.

What I mean with these is that "bottling up" my thoughts/feelings (in general or about a specific event) should not be my default. Instead, I should feel comfortable (especially around those I care about, and who care about me) expressing those thoughts and feelings.

I often downplay my emotions - to the point where I might not even understand how I feel about something, because I haven't let myself figure it out. If there's something exciting on the horizon, I don't let myself get too excited about it - just in case it doesn't work out. If there's something aggravating or distressing, I pretend I'm unaffected, that I'm "above" such things as the "weakness" of showing emotion (a topic that the novels I'm working on definitely addresses). Even if I'm happy - whether because of something I'm proud of, or because I'm sharing in someone else's happiness - I tend to "hold myself back."

I suppose this could be a genetic personality trait - there have to be some people who are just naturally less emotional than others - but in my case I definitely think it's learned behavior.

Honestly, I can't imagine anyone not learning that behavior. Men are told that "boys don't cry" and are discouraged from showing emotion (perhaps with the exception of anger, the only emotion seen as "masculine" in nature). Women not being told this does little to prevent the same result. The reason men are deterred from displaying emotion is because such action is seen as "feminine."

When "feminine" is an insult (as it is in our society), it doesn't really matter if you're a man or a woman demonstrating those traits - it's weakness. Men are supposed to be "above" that weakness because they are "above" women; but women too, if they want to be taken at all seriously, have to go to great lengths to distance themselves from such "weaknesses" and prove that they are not like "the rest of their sex" - as if all members of a sex, or any group, are ever identical.

I want to be one of the few, not one of the many. I want to be "great" - to be successful, to be understood as intelligent, to get at some core of the human existence that many fall short of finding, to "make a name for myself," to influence. In this country, in this world, in this era of history - the power tends to go to the emotionless. Our leaders are not compassionate; they're robots.

But what happens, then, when I do feel something, something that can't be buried under stoicism? More likely, it's not one thing, but a culmination of many - little daily annoyances or grievances or celebrations, all shoved down layer by layer on top of each other, until my heart is full and can't hold any more, no matter how trivial the thing. This is why I end up crying over a printer jam (it's always crying for me, whatever the corresponding emotion) - not because I think a misbehaving piece of technology is the end of the world, but because I haven't let myself acknowledge my emotions in too long, and this minor frustration is one time too many.

It is better to acknowledge my emotions as they happen. This doesn't mean crying over every little thing - because, actually, I find that little things don't warrant crying so much when they're acknowledged individually, periodically, every day. It simply means taking a moment and realizing that oh yes, this thing is frustrating me, or disappointing me, or upsetting me - or, oh yes, that is something I'm excited about, or proud of myself for, something that should be celebrated. It's not a thing worthy of a sob-fest (or a momentous party), but it's also not nothing, despite my tendency to treat it as such.

1. My emotions matter and are entitled to expression.

I word it that way so that I cannot argue it. If I were to say "I am entitled to express my emotions," it would be too easy for me to logic my way out of it on a day I was feeling down on myself. (Am I entitled to my emotions? Am I entitled to anything? Should I be? Should anyone?)

I picture "my emotions" as separate from myself, needy children that need to be acknowledged. I am doing them a favor by taking a minute out of my day and saying "Yes, I hear you. I see you. You're right - this is frustrating. You're right - this isn't fair." When I ignore the emotion, it still has power. When I confront it, accept it, acknowledge it - only then will it lose it's power so I can move on with my day. As Carl Jung said, "What you resist persists."

Of course, my emotions aren't tangible, real things that have feelings of their own. It's really myself I'm doing the favor toward. But I'm often more likely to do something if I think it'll help someone else, than I am if I think it'll help myself.

The second affirmation works in tandem with that first one - and does appeal to the idea of helping myself.

2. It is a relief and a joy to feel vulnerable around others.

If I am willing to be "selfish," and the first affirmation doesn't convince me to acknowledge my emotions, this second affirmation will do the trick.

This statement is evidence-based. Looking through old journals, it becomes clear that despite how anxious I am about "revealing" something about myself before I do so, it is always relief and joy I feel afterward - that once I am open and honest, once I allow myself to acknowledge my emotions and "be vulnerable" with my friends and family, the negative emotions disappear.

You'd think after this happening so many times, I would have realized this sooner and stopped getting anxious about sharing aspects of my life with other people. Instead, I have to reread this affirmation to remind myself; I have to use this affirmation to convince myself not to be anxious, and to just go ahead and share.

To be clear, I am not saying that "feeling vulnerable" is a positive experience - or something that should be done lightly. I am only saying that it often leads to better relationships, given that it is done in a safe, loving environment, and that looking back on the moment of vulnerability in hindsight I am always, without fail, 100% glad that it happened.

These "moments of vulnerability" take many forms. Voicing an opinion, admitting a feeling, sharing a story I've written or a favorite book that I've had a personal response to with someone that I trust, etc. Often, it is that I'm worried someone will judge me or think less of me if they know something about me - even something as mundane as "I sometimes cry when my printer jams" - but once I share, I find that others appreciate my sharing, relate to what I'm saying, and indeed, even feel the same way I do. It might seem insignificant to care about something so small, but it really is a relief to express frustration over a small, daily occurrence, and learn that I'm not alone in my reaction.