Washington D.C. Clinical & Forensic Psychiatrist

ABOUT ME

Washington D.C. Clinical & Forensic Psychiatrist

ABOUT ME

Clinical Practice

I am a licensed, board-certified psychiatrist in adult psychiatry with training in psychosomatic medicine, which is the interface between medical illness and psychiatric illness.  Before entering private practice, I served as an Associate Professor of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine.  In my clinical practice, I see adults (age 16 and up) for a wide variety of psychiatric problems including, but not limited to mood disorders, anxiety disorders, adjustment disorders/bereavement, obsessive-compulsive disorder, and attention deficit disorder.  I have a large clinical practice which is inclusive of individuals who identify as LGBTQI+ and have experience in participating in gender-affirming care.  More information can be found on my clinical services page.

Forensic Practice

My forensic practice, research, and teaching have focused on human sexuality, sexual disorders, and problematic sexual behaviors.  I served as the academic editor of Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention.  Additionally, I was a member of the board of directors for the Society for the Advancement of Sexual Health (SASH) and the lead developer for Advanced Training in Problematic Sexual Behaviors (ATPSB).  I am a member of the Association for the Treatment of Sexual Abusers (ATSA). I routinely conduct evaluations for the court for individuals who have problematic sexual behaviors, particularly those that have occurred online.  More information can be found on my forensic services page.

Physician Health

I have 20 years of experience working with physicians who have engaged in unprofessional behaviors. At Vanderbilt University Medical Center, I helped evaluate curriculum aimed at addressing sexual boundary violations, misprescribing controlled substances, and disruptive behaviors. At George Washington University School of Medicine, I lead multiple initiatives to improve the culture and safety of medicine and to address the mistreatment of learners in medical education. I have lectured nationally and internationally on topics related to physician health, wellness, behavior and misconduct. Currently, I serve as the chair of the Medical Society of the District of Columbia's Physician Health Committee (PHC) which serves to intervene upon, monitor and advocate for physicians with mental health problems, addictions, and other behavioral issues.

Personal

Outside of medicine, I enjoy theater, travel, art, and exercise.  As a former student at Interlochen Center for the Performing Arts (Summer Programs) and intern at the John F. Kennedy Center for the Performing Arts, I spent much of my academic medical career integrating theater into my medical education.  I have produced several short plays aimed at changing the culture of medicine including a musical.  I have traveled to more than 80 countries.  I believe my background in the arts and exposure to diverse populations has played a great influence in my psychiatric practice.  More information can be found on my philosophy page.

CURRENT ACADEMIC POSITIONS

Associate Clinical Professor of Psychiatry and Behavioral Health, George Washington University School of Medicine

Associate Professor of Psychiatry (Volunteer), University of Tennessee School of Medicine

EDUCATION

  • University of Chicago (Chicago, IL) 
    Bachelor of Arts (BA); Biological Sciences with General Honors

  • University of Chicago Pritzker School of Medicine (Chicago, IL)
    Doctor of Medicine (MD)

  • Rhode Island Hospital/Brown University School of Medicine (Providence, RI)
    Pediatrics, Psychiatry, and Child Psychiatry (Internship)

    Vanderbilt University Medical Center (Nashville, TN)
    Resident/Chief Resident; General Psychiatry

    Vanderbilt University Medical Center (Nashville, TN)
    Psychosomatic Medicine (Fellowship)

  • University of Michigan School of Public Health (Ann Arbor, MI) 
    Master of Public Health (MPH); Health Behavior and Health Education

    George Washington University – School of Education and Human Development (Washington, D.C.)
    Master Teacher Leadership Development Program

PSYCHIATRIC TEACHING AND EDUCATIONAL EXPERIENCE

Educational Leadership

Psychiatry Clerkship Director, George Washington University School of Medicine

Associate Psychiatry Residency Director, George Washington University School of Medicine

Course Director and Developer, Psychopathology and Conceptual Models, George Washington University School of Medicine

Course Director and Developer, Brain and Behavior, George Washington University School of Medicine

Course Director, Human Sexuality, George Washington University School of Medicine

Course Director, Human Behavior and Development, George Washington University School of Medicine

Lecturer, Physician Assistant (PA) Program, George Washington University

Lectures Developed

    • Psychiatric Interviewing and the Mental Status Exam 

    • Building a Psychiatric Diagnosis

    • Psychotic Disorders 

    • Anxiety Disorders 

    • Substance-Related Disorders 

    • Personality Disorders 

    • Eating Disorders

    • Somatoform Disorders

    • Somatic and Emerging Therapies in Psychiatry

    • Child and Adolescent Substance Abuse

    • On-Call Psychiatry

    • Emergency Psychiatry

    • Psychopharmacology

    • Personality and Team Functioning

    • Race, Power and Authority/Implicit Bias in Psychiatry

    • Depression in Primary Care

    • Handling Difficult Patients

    • Verbal De-escalation of Agitated Patients

    • Motivational Interviewing

    • Changing Health Behaviors

    • Sexual Disorders and Paraphilias 

    • Sexual Dysfunctions

    • The Sexually Active Adolescent

    • Sex and Aging

    • LGBTQIA+ Sexual Health

    • Transgender Health

    • Sex and Disability

    • Men’s Sexual Health

    • Women’s Sexual Health

    • Sex and the Net

    • Maintaining Proper Boundaries

    • Physician Wellness and Impairment

    • Medical Student Mistreatment

    • The Top 10 Ways to Improve the Learning Environment

    • Physician Wellness is More than a Yoga Group

    • Managing the Disruptive Physician

CLINICAL EXPERIENCE

Fee-Based Physician – Nashville Veteran’s Administration Hospital – Emergency and Inpatient Psychiatric Services

Attending Physician – George Washington University Hospital – 6 South Inpatient Psychiatric Service

Attending Physician – George Washington University Hospital – Consultation/Liaison Psychiatric Service

Fee-Based Physician – Washington D.C. Veteran’s Administration Hospital – Emergency Psychiatric Service

Physician – Medical Faculty Associates, George Washington University – Outpatient Psychiatry Services

PUBLICATIONS

    • Dapueto, J; Viera, M; Samenow, C; Swiggart, W; Steiger, J. (2018) A tale of two countries: innovation and collaboration aimed at changing the culture of medicine in Uruguay. HEC Forum

    • Swiggart, W.; Ghulyan, M.; Dewey, C.; Williams, B.; and Samenow, C. (2013) Development and preliminary evaluation of a continuing education curriculum in problematic sexual behaviors.  Sexual Addiction and Compulsivity 20 (4)

    • Samenow, C.  (2013) Editorial: An Enemy of the People.  Sexual Addiction and Compulsivity. 20:3.

    • Naficy, H; Samenow, C; and Fong, T. (2013) A review of pharmacological treatments for hypersexual disorder.  Sexual Addiction and Compulsivity. 20 (1 and 2).

    • Choi, D; Toulokhonova, V, Socha, E., and Samenow, C. (2013). Brief Report: Substance Use and Attitudes on Professional Conduct Among Medical Students – Preliminary Findings.  Academic Psychiatry. 37:3.

    • Samenow, C., Worley, M., Neufeld, R., Fishel, T. and Swiggart, W. (2013). Transformative Learning in a Professional Development Course Aimed at Addressing Disruptive Physician Behavior. Academic Medicine. 88(1):117-123.

    • Samenow, C. (2012). SASH Policy Statement: The Future of Problematic Sexual Behavior/Sexual Addiction.  Sexual Addiction and Compulsivity. 19(4).

    • Samenow, C. (2012). Editorial: Why Human Research Protection is Important in Sex Addiction.  Sexual Addiction and Compulsivity. 19(3).

    • Samenow, C. (2012) Child pornography and the law. Sexual Addiction and Compulsivity. 19(1)

    • Schneider, J; Weiss, R; and Samenow, C. (2012) Partners of cybersex compulsives. Sexual Addiction and Compulsivity.  19(1)

    • Samenow C, Yabiku S, Ghulyan  M, and Swiggart W. (2011) Do Family of Origin Issues Contribute to Physician Sexual Boundary Violaton? Measuring family dynamics and boundary violating behavior among 613 physician referred to a CME course.  HealthCare Ethics Committee Forum: An Interprofessional Journal on Healthcare Institutions’s Ethical and Issues. Identifier (DOI) 10.1007/s10730-011-9171-8 

    • McGowan C., Weinstein D., Samenow C., et. al.  (2011) Drug use and the receipt of highly active antiretroviral therapy among HIV-infected persons in two US clinic cohorts.  PLOS One, 6(4)

    • Qian H, Stinnette S, Rebiero P, Kipp A, Shepherd B, Samenow C, Jenkins C, No P, McGowan C, Hulgan T, and Sterling T. (2011) The relationship between injection and non-injection drug use and HIV-1 disease progression.  Journal of Substance Abuse Treatment. 41(1): 14-20.

    • Samenow, C. (2011) Editorial: Human Sexuality and Health Professions Students – Lessons Learned from an Electronic Bulletin Board. Sexual Addiction and Compulsivity. 18(1)

    • Weiss, R. and Samenow, C. (2010) Editorial: Smart Phones, Social Networking, Sexting and Problematic Sexual Behaviors – A Call for Research.  Sexual Addiction and Compulsivity. 17(2)

    • Finlayson, A. and Samenow, C. (2010).  Editorial: A Psychiatrist's Approach to A Case of Problematic Sexual Behavior.  Sexual Addiction and Compulsivity. 17(3)

    • Samenow, C. (2010).  Editorial: A Biopsychosocial Model of Problematic Sexual Behaviors. Sexual Addiction and Compulsivity; 17(2).

    • Samenow C.  (2010) Editorial: Classifying Problematic Sexual Behaviors --- It’s All in the Name.  Sexual Addiction and Compulsivity.17(1).

    • Samenow C, et. al. (2008) A CME course aimed at addressing disruptive physician behavior. The Physician Executive. Jan/Feb. 31-40. 

    • Spickard Jr, A, Swiggart W, Manley G, Samenow C, Dodd D (2008).  A CME course to improve sexual boundaries of physicians.  Menninger Bulletin. 72(1):38-53. 

    • Swiggart, W, Samenow, C, Feurer, I and Spickard Jr, A.  (2008) Sexual boundary violation index: a validation study.  Sexual Addiction and Compulsivity. 15:176-190.

    • Samenow C (2013).  Disruptive physician behavior: myths and facts. Washington Psychiatrist. Summer, 2013.

    • Samenow C, Spickard Jr. A, Swiggart W, Regan J and Barrett D. (2007) Consequences of physician disruptive behavior.  Tennessee Medicine. November. 38 – 40.

    • Samenow, C; Worley, L; Dewey, C; and Swiggart, W. (2021) Continuing Medical Education Courses for Unprofessional Behavior.  In: Fraud, misconduct and fake news in the academic, medical and social environment. Springer.  

    • Samenow, C and Schnieder, J. (2017).  Sex Addiction and Professional Misconduct.  In: International Textbook of Sex Addiction. Routledge. London, UK.

    • Samenow, C. (2012, 2017) Human Sexuality.  In Sahler and Carr.  The Behavioral Sciences and Health Care. Hogrefe. Cambridge, MA.

    • Samenow, C. (2012, 2017) Physician Impairment. In Sahler and Carr.  The Behavioral Sciences and Health Care. Hogrefe. Cambridge, MA.

REGIONAL, NATIONAL, AND INTERNATIONAL PRESENTATIONS

    • Workshop Presenter, Update on Professional Sexual Boundary Violators.

      • Society for Advancement of Sexual Health 2007 National Conference. Las Vegas, NV. (September, 2007)

    • Presenter, A Biopsychosocial Model of Sexual Addiction

      • Society for Advancement of Sexual Health Annual Conference, Boston, MA (September, 2010)

    • Presenter, Integrating Sexual Addiction into a Human Sexuality Curriculum

      • Society for the Advancement of Sexual Health Annual Conference, San Diego, CA (September, 2011)

    • Presenter, Theoretical Conceptualizations and Treatment Approaches for Problematic Sexual Behavior

      • Society for the Advancement of Sexual Health Annual Conference, San Antonio, TX (September, 2012)

    • Presenter, The slippery slope: Tools to enhance awareness regarding physician boundaries

      • AMA/BMA/CMA International Conference on Physician Health, Montreal, Canada (October, 2012)

    • Invited Speaker, HIV and Gender Identity

      • Working and Hoping for Our Community to be Safe from the HIV/AIDS Epidemic. Providence Hospital, Washington, D.C. (October, 2015)

    • Presenter, Rethinking Sexual Addiction, DC Psychological Association (May, 2017)

    • Invited Panelist, LGBTQ Healthcare, Guidehouse Consulting (June, 2019-2021)

    • Invited Discussant, “Special Considerations for LGBTQIA+ Individuals Who Commit Sexual Offenses”  

      • Maryland Office of the Public Defender (June, 2021)

      • Pennsylvania Sex Offender’s Assessment Board (SOAB) (February, 2022)

      • Minnesota Sex Offender Program (MnSOP)  (March, 2022)

      • Minnesota Association for the Treatment of Sexual Abusers (MNATSA), Virtual (May 2021)

      • Sex Offender Civil Commitment Programs Network (SOCCPN) (October, 2022)

    • Invited Speaker, “Promoting Healthy Sexuality Among Sex Offenders”

      • Minnesota Sex Offender Program (MnSOP)  (December, 2021)

    • Discussant, Mission Impossible, “Teaching Sexual Health to Individuals Who Commit Sexual Offenses”  

      • Association for the Treatment of Sexual Abusers (ATSA) (September, 2021; October, 2022)

    • Invited Instructor, “Pharmacologic Considerations in Problematic Sexual Behaviors”

      • Problematic Sexual Behavior Certification Program (Dec 2021)

    • Invited Speaker, “Child Pornography and Online Behavior,” Zealous Advocacy in Sexual Assault and Child Victims Cases

      • National Association of Criminal Defense Lawyers (NACDL) (Nov, 2022)

    • Invited Speaker, “Debunking Myths around Risk Recidivism,” Zealous Advocacy in Sexual Assault and Child Victims Cases

      • National Association of Criminal Defense Lawyers (NACDL) (Nov, 2023)

    • Workshop Presenter, Hope for the Distressed Physician: The Good, the Bad and the Ugly

      • American Psychiatric Association Annual Meeting. Washington, DC. (May, 2008)

      • American Psychiatric Association Annual Meeting, San Francisco, CA (May 2009)

    • Workshop Presenter, Is Everyone Bipolar? How Psychiatrists Approach Sexual Addiction

      • Society for the Advancement of Sexual Health Annual Conference. San Diego, CA. (September, 2009)

    • Invited Speaker, Physician Impairment

      • Grand Rounds, GW Medical Center Department of Emergency Medicine (August, 2008)

      • GW Graduate Medical Education Chief Resident Orientation (May 2008 - 2013)

      • GW Graduate Medical Education Orientation, GW Medical Center  (June, 2008 - current)

    • Invited Speaker, Dealing with Difficult Patients

      • Grand Rounds, GW Medical Center Department of Emergency Medicine (October, 2008)

    • Invited Speaker, Disruptive Physician Behavior

      • Grand Rounds, Vanderbilt University Department of Psychiatry (June, 2007)

      • Grand Rounds, GW Medical Center Department of Psychiatry (January, 2009)

      • Grand Rounds, GW Medical Center Department of Medicine (January, 2009)

      • Grand Rounds, GW Medical Center Department of Anesthesiology (March, 2009)

      • Grand Rounds, GW Medical Center Departments of Neurology and Neurosurgery (March, 2009)

      • Grand Rounds, GW Medical Center Department of Obstetrics and Gynecology (April, 2009)

      • Grand Rounds, GW Medical Center Department of Surgery (June, 2009)

      • Grand Rounds, Capital VA Medical Center (June, 2009)

      • Grand Rounds, Holy Cross Hospital (August, 2009)

      • The University of the Republic, Montevideo Uruguay (March, 2010)

      • Risk Management Grand Rounds, Children’s National Medical Center (November, 2011)

    • Oral Presentation, Substance Use and Attitudes on Professional Conduct Among Medical Students – Preliminary Findings

      • AMA/BMA/CMA International Conference on Physician Health, Chicago, IL (October, 2010)

    • Workshop Facilitator, Integrating Professionalism and Wellness Curriculum into Graduate Medical Education (GME): A Tale of Two Countries

      • AMA/BMA/CMA International Conference on Physician Health, Chicago, IL (October, 2010)

    • Invited Speaker, Physician Wellness: It’s More than A Yoga Group

      • Faculty Development, George Washington University School of Medicine (February, 2013)

      • Grand Rounds, Pediatric Radiology, Children’s National Medical Center (February, 2013)

      • Ob/Gyn Rounds, George Washington University School of Medicine (March, 2013)

      • GME Faculty Retreat, George Washington University School of Medicine (April 2013)

      • Emed Fellows Seminar, George Washington University School of Medicine (Nov 2013)

      • Grand Rounds, Medicine, George Washington University School of Medicine (September, 2014)

      • Grand Rounds, Interdisciplinary, Sibley Memorial Hospital (February, 2020)

      • Grand Rounds, Psychiatry, Martinsburg Veterans Affairs Medical Center (October, 2022)

      • Society for Education in Anesthesia National Conference, Washington, D.C. (October, 2012)

      • Society for Pediatric Radiology Education National Conference, Washington, D.C. (May, 2014)

      • American Association of Pediatrics Section on Emed, Washington, D.C. (October, 2015)

      • National Fund of Resources Commission of Continuing Professional Development, Montevideo, UR (November, 2013)

    • Facilitator, “The Autopsy of Dr. Melinda J. Smith” – An Interactive Play About Professionalism

      • The University of the Republic, Montevideo Uruguay (November, 2013)

    • Facilitator, From Paper to Practice: Carrying out the Mental Health Technical Instructions

      • Intergovernmental Panel Physicians Training Summit, Cape Town South Africa (March, 2014)

      • Intergovernmental Panel Physicians Training Summit, Hong Kong (March, 2015)

      • Intergovernmental Panel Physicians Training Summit, Prague, CR (March, 2016)

    • Facilitator, “The Autopsy of Dr. Melinda J. Smith” – An Interactive Play About Professionalism

      • Grand Rounds, GW Medical Center Department of Psychiatry (October, 2012)

      • Leadership Development, INOVA Health Systems (October, 2012)

      • Faculty Development Seminar, GW Medical Center (October, 2012)

      • Ob/Gyn Residency Core Curriculum, GW Medical Center (November, 2012)

      • PGY-1 Resident Retreat, GW Department of Internal Medicine (November, 2012)

      • Grand Rounds, GW Department of Emergency Medicine (January, 2013)

      • Grand Rounds, GW Department of Cardiology (February, 2013)

      • Division Chair Meeting, Children’s National Medical Center (February, 2013)

      • Practice of Medicine 4, GW School of Medicine (March, 2013)

      • UHS Hospital Leadership (April, 2013; July 2013)

      • AAMC Professional Development Series (April, 2013)

      • Pediatric Fellowship Bootcamp, Children’s National Medical Center (July, 2013)

      • Faculty Development; GW School of Nursing (Jan 2014)

      • Retreat, PA Program, GW School of Medicine (Jan 2014)

      • Power Day, Yale University School of Medicine (April 2014)

      • GME, University of North Carolina Chapel Hill (October, 2014, 2015)

      • Undergraduate Medical Education, Northeast Ohio Medical University (November, 2014)

      • Graduate Medical Education, Albert Einstein College of Medicine (May, 2016)

      • New York Physician Assistant Annual Conference (October, 2016)

      • Virginia Commonwealth University – Fairfax Campus (September, 2018)

      • University of Michigan School of Medicine (November, 2018)

      • Society for Education in Anesthesia National Conference, Washington, D.C. (October, 2012)

      • Group on Faculty Affairs, American Association of Medical Colleges, Washington, D.C. (January 2013)

      • Patient Quality Health Forum, Universal Health Systems, Las Vegas, NV (October 2013)

      • American Association of Medical Colleges (AAMC) Annual Meeting, Philadelphia, PA (November, 2013)

      • Physician Assistant Educator’s Association, Washington, D.C. (August, 2014, 2015)

      • Physician Assistant Educator’s Association Annual Meeting, Washington, D.C. (Nov, 2015)

      • National Academies of Science, Engineering and Medicine, Washington, D.C. (December, 2015)

      • Alliance for the Arts in Research Universities, Denver, CO (November, 2016)

    • Presenter, Best Practices for Preparing and Assisting Physicians in Transitions

      • AMA/BMA/CMA International Conference on Physician Health, London, England (September, 2014)

    • Invited Speaker, Preliminary Data from 2,000 physicians referred for unprofessional behavior

      • Northeast Regional Physician Health Program Meeting, Waltham, MA (October, 2015)

      • Grand Rounds, Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine, Washington, D.C. (May, 2016)

      • Grand Rounds, Department of Medicine, George Washington University School of Medicine, Washington, D.C. (December, 2016)

      • D.C. Physician Health Program, Washington, D.C.  (Summer, 2017)

      • Washington D.C. Veteran’s Hospital (December, 2018)

    • Facilitator, “Bystander Intervention”

      • Anatomy Grand Rounds, George Washington University School of Medicine (Dec 2021)

      • Surgery Grand Rounds, George Washington University School of Medicine (Dec 2021)

      • Pediatrics Grand Rounds, Children’s National Medical Center (Jan 2022)

      • Neurology Grand Rounds, George Washington University School of Medicine (Jan 2022)

      • Emed Grand Rounds, George Washington University School of Medicine (Jan 2022)

      • Ob/Gyn Grand Rounds, George Washington University School of Medicine (March 2022)

      • Medicine Grand Rounds, George Washington University School of Medicine (April 2022)

      • Anesthesiology Grand Rounds, George Washington University School of Medicine (April 2022)

    • Presenter, “Top Ten Things You Can Do to Improve the Learning Environment Right Now”

      • Radiology Grand Rounds, George Washington University School of Medicine (April 2022)

      • Emed Grand Rounds, George Washington University School of Medicine (April 2022)

      • Ob/Gyn Grand Rounds, George Washington University School of Medicine (April 2022)

      • Medicine Resident Retreat, Sinai Hospital (May, 2022)

      • Medicine Grand Rounds, Anne Arundel Medical Center (June, 2022)

HONORS

    • Elected Member, Society of Distinguished Teachers

      • George Washington University School of Medicine. (Washington, DC) May 2012

    • Educational Excellence Award for an Individual

      • Presented by Caron Comprehensive Addiction Treatment (Washington, DC) October 2012

    • Golden Apple Teaching Award

      • Presented by students of the George Washington University School of Medicine

      • George Washington University School of Medicine (Washington, DC) March 2013

      • George Washington University School of Medicine (Washington, DC) March 2018

      • George Washington University School of Medicine (Washington, DC) March 2019

    • Faculty Innovation in Education Award

      • American Board of Psychiatry and Neurology (ABPN)  January 2021

    • Elected member, University of Chicago Maroon Key Honor Society

      • (Chicago, IL) June 1993

    • Elected member, Beta of Illinois Chapter of the Phi Beta Kappa Society

      • (Chicago, IL) June 1995

    • University of Chicago’s Jane Morton and Henry C. Murphy Student Leadership Award

      • (Chicago, IL) June 1998

    • Exemplary Substance Abuse Prevention Program Award. 

      • Presented on Capital Hill by the U. S. Department of Health and Human Services, General Barry McCaffrey, and the Assistant Surgeon General. (Washington, D.C.) April 1999

    • President’s Volunteer Service Award

      • Presented by the President of the University of Chicago for the most outstanding contribution to the welfare of the university community. (Chicago, IL) June 1999

    • Daniel X. Freedman Award.

      • Presented by the University of Chicago Pritzker School of Medicine for most outstanding medical school student performance in Psychiatry. (Chicago, IL) June 1999

    • American Medical Association (AMA) Foundation’s Leadership Development Award

      • Presented at the AMA National Leadership Development Conference (Miami, FL).  March 2000

    • Top Doctor

      • Washingtonian Magazine (2015, 2019, 2020, 2021, 2023)

PROFESSIONAL
SOCIETIES

Member, American Psychiatric Association (APA)

Member, Association for the Treatment and Prevention of Sexual Abuse (ATSA)

Member, Medical Society of the District of Colombia (MSDC)

Member, Washington Psychiatric Society

MEDICAL THEATER

    • Tangles - A musical about a family struggling with a loved one with dementia

    • The Autopsy of Melinda J Smith - A play exploring individual and systemic factors that challenge a culture of safety and professionalism in medicine

    • 5 Days to Friday - A play that looks at the challenges health care providers face in modern academic medicine

    • Holistic Review - Promoting diversity and inclusion in the health care professions

    • Bystander Intervention - Challenging individuals to speak-up against cultural norms and medical hierarchy