#writeups just take more time thanks to all the footnotes and links

[tomatograter]

If he has internalized homophobia then why he has no problem telling Dave he used to date a guy? Like, as you said, he cares about his reputation, and we know he really wanted Dave to like him, so that prolly means he was quite careful with what he could or couldn't say in front of him, specifically after he discovered that Bro abused him. So what I'm trying to say, if he cared about being gay, I think he would have avoided telling him he dated Jake? Or at least give it a second thought? I don't see what's the problem with Dirk being against labels, he seems that type of person, he prolly thinks that makes him more intellectual or some stupid thing like that

Hmmm thats not exactly what I said. I don't think Dirk has internalized homophobia so much as <he's afraid of the outside reception to the fact that he's gay, and how people will perceive him based on it>. Dirk knows that he's gay. We know Dirk is aware of that since he was at least 13, because he's already throwing undeniably romantic advances at Jake by then to test the waters. Dirk isn't in cutesy denial about anything here, he doesn't have the time or luxury for that. His problem is more that once you state 'Yes I Am Gay' as a definition of your character, that comes with a Lot of historical baggage and expectations- and from dirk's perspective, both the expectations and historical baggage are something so incredibly divorced from his reality in a future where no human society exists that he's waaaayyyyyy too careful of making that association. It could potentially bust the image he's trying to project.

Again, Dirk's thing is performance. Esp the performance of masculinity. He is the one homestuck character that truly, genuinely, wholeheartedly cares about putting up an image of what it means To Be Masc. He does this because he likes it. He's not forced to do it, he's not under societal pressure to do it, he's not whinning about how much he hates it, he's not doing it at gunpoint; this is a set of parameters he came up with for himself, even in complete isolation. They are a statement and holy boypledge he's making.

He thinks it is Very Cool, and he would like it if you thought it was Very Cool Too (especially if that transmits an image of how strong and reliable he "totally" is). And, again, when you think about our early 2000-10's context of GAYNESS, because homestuck is an extremely time-bound comic, the image "being gay" summons is... really not the one I described above. We're talking about gay men being stereotyped as catty & cowardly & effeminate, about the constant punchlines around 'useless fairies' (a term that was used to refer specifically *to* feminine, submissive, oft gender-transgressive gays ) not incidentally, Dirk's godtier is revealed to him in-comic through a drawing that depicts him as a fairy. He's immediately put off by it. Dirk and Jake's godtiers were called Fagtiers by more than a portion of the fandom. Relics of this are still high up on google images if you search for pictures of their godtiers, lol. Essentially, to admit to his gayness openly and broadly in that timeframe is to be stereotyped as something he doesn't entirely identify as, in an environment that is far from welcoming.

I am pretty open about reading Dirk as a trans man, and what I think is happening here is that together with Roxy's constant insinuations that Dirk Should Have Her Babies, Dirk is ultimately afraid that his claim to being a homosexual paints him as innately womanly. He either gets to be a man or he gets to love men. There's no middleground, or else these social features will cancel eachother out like pemdas. What we see in Homestuck is his haphazard attempt to keep both things intact. His courtship of Jake is only allowed if it is strictly masculine, if it seems like he has a semblance of control, if it looks like they are both just Dudes being Bros throwing it down like Fellow Action Men. This is harmful for Dirk and gives him extreme emotional constipation; not to speak of how tiring it is for Jake to try to keep up with this months-long improv game of Xtreme Axe Bodyspray Marathon when they could just... date. Jake really wouldn't mind if they decided to paint each other's nails or have stereotypical sleepovers or just chill out and have fun like Jane and Roxy are obviously doing. Jake would be fine with being soft so long as he's not being made fun of. But Dirk struggles with letting any sign of dangerous sensitivity show under the assumption that it will be read as a weakness, an inadmissible vulnerability in his set of armor.

Which becomes all the more relevant once you note that when Dirk's trying to convince Dave that he's not a threat and certainly not a monster, one of the first things he admits to is "I like men."

[healthserv]

The Solution Never Works If You Haven’t Identified the Problem

By the DARK GODDESS OF REPLEVIN

I have a bias, I admit it. I am sensitive to studies with a subtext of “those stupid patients, what are we going to do about them?” Read the following rant with that in mind.

A pharmacy benefits manager a/k/a PBM funds a study of patients nonadherent to chronic prescription medication. The premise of the study, Effect of Reminder Devices on Medication Adherence: The REMIND Randomized Clinical Trial (hiding behind a paywall, by the way), is that “forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices.” Thus, the intervention consisted of sending a population which included folks taking meds for schizophrenia and bipolar disorder either “a pill bottle strip with toggles, digital timer cap or standard pillbox” along with their mail order meds. There was of course a control group who received neither notification or a device. Surprise, surprise! Getting a prize in your Crackerjack box from your PBM does not improve medication adherence. Those stupid patients! Why won’t they do what’s good for them?

Well, let’s take the most basic first step and look at the evidence that the REMIND paper cited in its very first footnote to support its premise that patient “forgetfulness” is the problem. The paper cited is not, thank you very much, behind a paywall. Its very title should have been a tipoff: “Unintentional non-adherence to chronic prescription medications: How unintentional is it really?” This study concluded that “For our study sample, unintentional non-adherence does not appear to be random and is predicted by medication beliefs, chronic disease, and sociodemographics. The data suggests that the importance of unintentional non-adherence may lie in its potential prognostic significance for future intentional non-adherence. Health care providers may consider routinely inquiring about unintentional non-adherence in order to proactively address patients’ suboptimal medication beliefs before they choose to discontinue therapy all together [sic]” (emphasis added]

Reading further in the paper I’ve just linked to (which I highly recommend you do), “medication beliefs” include such things as “perceived need for medication”–statins, anyone?–and perceived medication affordability.

Let’s go a little further and consider something obvious about clinician-patient dynamics in an era of managed care. How many clinicians take the time, or have the time, to initiate a thoughtful discussion with a patient regarding the benefits and risks of a course of long-term medication being recommended? A statin, say, or low-dose aspirin for primary prevention, in someone who feels just fine? How many patients will push through the clinician’s subtle (or not-so-subtle) signals that s/he is pressed for time to initiate and then persist in a discussion, which might persuade a patient on the fence about the recommendation that there is an actual need for the medication? Or might even lead the patient and provider to jointly conclude that this long-term medication is not, after all, warranted?

Consider this: the more important you believe something to be, the easier it will be to remember to do it. “I forgot” is a convenient excuse we offer, after all, to our doctors. It is more polite, and less time-consuming, than initiating an uncomfortable conversation by saying, “I don’t see the point of this/I am experiencing unpleasant side effects/I cannot afford this/I am overwhelmed by the ‘treatment burden.’ ” Such comments can be taken as a direct challenge to the provider’s authority, although they might stem from the provider’s failure to communicate with/empathize with/educate the patient adequately in the first place.

A patient on insulin therapy is unlikely to forget to use insulin. It’s obvious that insulin is important. This suggests another possible flaw in the study design. It excluded patients taking more than three medications, apparently because their dosing regimes are just too complicated (math class is tough!). It would be interesting to learn if patients taking more medications might actually be more adherent because they feel that the stakes are higher. Alas! We will never know, at least from the authors of this study hellbent on reminding these silly patients who just cannot remember what is good for them. Although the study design notably did not include smartphone apps such as Mango Health that “gamify” taking medications and could use more investigation.

I feel compelled to point out as well that patients getting their meds mailed from their PBMs are by definition not in regular contact with an overlooked, underrated member of the patient’s care team: a flesh-and-blood pharmacist who reinforces dosing instructions, and provides that human touch. Yes, it is possible for a patient to make contact with an actual pharmacist at a PBM, but I wonder how many nonadherent patients are aware of that.

I should finally note that many patients view PBMs as an arm of their insurance company (which in fact they are) and may have viewed what appeared to be medical advice coming from their insurer as inexplicable and suspect. Indeed, “[b]ecause the study devices are currently available for commercial use and because participants received the devices by mail and could choose not to use them, patient-level consent was waived by Chesapeake Institutional Review Board.” Not obtaining consent may have made the study less useful, but I’m sure it was cheaper, amirite?

The writeup of the REMIND study grudgingly concedes towards the end that “because nonadherence is a multidimensional problem, addressing forgetfulness alone may have been insufficient to improve actual medication taking.” This spectacularly misses the boat. Because it’s not truly a problem of forgetfulness at all.

The Solution Never Works If You Haven’t Identified the Problem published first on http://ift.tt/2sUuvu3