Joseph, a thin man with a delicate bearing and soft gray eyes, has a mellifluous accent that is hard to place – evidence of growing up in the United States but in a world apart. Until 2009, he was living in a religious enclave of upstate New York as a Belzer Hasidic Jew. He worked as a travel agent, spending his days arranging flights to far flung places, often for people with more freedom than he could ever dream of.

Like many Hasidim, Joseph (who, like several of the people interviewed for this article, requested that his real name not be used here) married at twenty. His wife was the first woman he had ever touched, and she got pregnant soon after their wedding. But their sex life left much to be desired for both partners, and then petered out altogether. Joseph says his wife would sometimes decide not to go to the mikvah, the ritual bath required of Hasidic women after they menstruate to “purify” them, making them once again sexually available to their husbands. According to Jewish law, if Joseph’s wife had not gone to the baths, he was forbidden from touching her, much less having sex with her. After their fourth child was born, Joseph says she stopped going altogether.

Joseph grew desperate for intimacy. After two years of celibacy, he finally went to a strip club, Stiletto, on Route 59. A stripper asked him if he wanted a dance and a confused Joseph told her he didn’t know how to dance – was she going to teach him? “She meant a lap dance,” he told me when we met in his Brooklyn apartment, shaking his head with an embarrassed smile. “I had no clue.”

Joseph at home in Brooklyn, New York.
Joseph at home in Brooklyn, New York.

About once a month, Joseph would go back to the strip club. Sometimes there would be other Hasidic men there. Fearful of being recognized, he learned to ask the bouncer before entering if there were others like him inside, and if the bouncer said yes, Joseph would go to Lace Gentleman’s Club, on Route 303.

One day Joseph sold a ticket over email to a Hasidic woman planning a family trip. A mild flirtation developed when she got her ticket and made a throwaway comment about the airport code listed at the bottom of the itinerary – something most customers never noticed. Joseph remembered their first interaction fondly: “I was like, ‘Wow, a chassidishe woman, you know airport codes? You go, girl!’ And she was like, ‘You bet I know!’” The woman, who I’ll call Dini, managed a store. She had an open-mindedness and a brassy confidence that Joseph found intriguing; her curiosity about the world mirrored his own. “I liked her power,” he remembered, and for her part, Dini was drawn to Joseph’s gentleness.

After a week of email flirting, they arranged to meet at a movie theater. When Joseph saw Dini, he was very attracted to her. “Her face was a raving beauty, and still is,” he told me. But he was struck by something else, too. “There was a presence,” he remembered. “She’s not someone who gets lost in a crowd,” a unique quality in their little village. For someone like Joseph, who had always struggled to stand up for himself, struggled to identify his needs and desires, this quality of Dini’s was intoxicating. The two continued to see each other, and fell in love.

But two Hasidim married to other people don’t just get a divorce and start a new life together. The community got involved. A rabbi and what’s known as an askan, a person of influence in the Hasidic community, were given Joseph’s “case.” The role of an askan – collectively called askanim – is part politician, part good Samaritan, and part busybody. Together, Joseph’s rabbi and the askan appointed by the community to his case staged an intervention. Joseph says they got involved in every level of his life, in order to prevent him from leaving his family and starting a new one. They took away Joseph’s BlackBerry. The askan started monitoring Joseph’s computer, a mirror image of Joseph’s screen under surveillance at all times. Joseph’s brother-in-law started tracking Joseph’s car, where he went and whom he saw.

Joseph was faced with a choice: surrender to the will of his community’s leaders, or risk public shaming, and worse – losing his children and friends. He capitulated, and promised never to see Dini again. But that was not enough. The askan chose a psychologist to provide Joseph with talk therapy, and then a psychiatrist for medication, who started Joseph on a course of chemical treatment for sex addiction.

* * *

The Hasidic movement began in the eighteenth century in Western Ukraine. Legend has it that the founder, Rabbi Yisroel ben Eliezer, known as the Baal Shem Tov or Master of the Good Name, performed miracles – that he cured the incurable. He urged his disciples to develop a personal relationship with God through mystical teachings. Today, there are about a quarter of a million Hasidim in the U.S., up to 95 percent of whom live in the New York area, according to population consultant Jonathan Comenetz’s 2006 “Census-Based Estimation of the Hasidic Jewish Population.” There are nine major sects, each named for the town in Eastern Europe from which its adherents came – Satmar, Bobov, Belz, Munkatch. After the Holocaust, the remnants of these communities made their way to the United States, where they began to flourish, exhorted by their leaders to repopulate the Jewish people and to radically separate from the secular world that had caused them so much loss. Many of these communities are now all but self-sufficient; they have their own ambulances, police forces, businesses and Yiddish-speaking schools. They have internal economies based on deluges of charity that cascade from the richest to the poorest. In each sect, fealty is paid to the leader – the “Rebbe” – whose position is inherited.

The focus of these communities is on securing the collective good. Conformity is strictly enforced. There is also strict separation of the sexes: Men and women, who typically marry between eighteen and twenty, are kept apart before and after their arranged marriages. While sex is a taboo subject, masturbation is often discussed, absolutely verboten, and rigorously policed. A man from the Satmar community in Williamsburg, Brooklyn, told me that he knew of two rabbis with cabinets full of medications that they dispensed to boys who had been caught or confessed to masturbating, as well as to couples having marital difficulties. “Listen, a boy who masturbates is depressed,” he explained, “because he knows he’s not following God’s commandments.”

Religious deviation – especially of a philosophical or sexual nature – may be interpreted as a sign of mental illness, which, for many years, has carried a serious stigma among Hasidim. Perceived aberrations are punished in the arena that matters most – the marriage market. If word got out that someone were on medication, that information could hurt her chances of making a good match, and those of her immediate and even extended family members.

But recently, non-Hasidic psychologists and psychiatrists have been making inroads on topics like post-partum depression and trauma therapy through workshops and ultra-Orthodox publications. Dr. Ayala Fader, an anthropologist at Fordham University and author of Mitzvah Girls: Bringing Up the Next Generation of Hasidic Jews in Brooklyn, told me in an email, “Over the past fifteen years or so, there has been a shift in perceptions and uses of therapy among Hasidic Jews. When I did research in the 1990s, many were reluctant to go to therapists and prescription drugs were stigmatized. These days, therapy is more accepted. Therapists and rabbis may work together, and like for so many in the secular world as well, prescription drugs for certain diagnoses are not uncommon.”

With the increased acceptance of those subjects has come a recognition that psychiatric medications might have off-label uses that serve the community’s goals. Joseph is one of many Hasidic Jews in the United States and Israel who are taken by community operatives like askanim to see psychiatrists for what are essentially religious, rather than psychiatric, difficulties. I spoke to twenty individuals in the New York area who had all been sent to the same five or six psychiatrists (and all knew others who had been through the same thing, often cycling between them), where they say they were prescribed anti-psychotics, hormones, or anti-depressants for masturbating, questioning the tenets of the community’s faith principles, experimenting with or even fantasizing about same-sex partners, or displaying “too high” a sex drive. The “symptoms” that psychiatrists take as evidence of disorders can vary, according to their patients. One woman told me that, when she confessed to an askan and later to a psychiatrist that the strictures of her life made her feel stuck, she was prescribed anti-depressants. When that didn’t solve anything, her askan took her to a second psychiatrist, who told her that she was getting a sexual high from her job, where she interacted with men, and diagnosed her with bipolar disorder. She was prescribed Abilify, an anti-psychotic medication. Another young woman, who had kissed a girl at school, was compelled by the principal to see the same psychiatrist. She was prescribed anti-psychotic medications, “to make you feel better and to decrease your temptations,” the doctor told her. “You’re not going to want to misbehave as much.”

This may sound shocking. But taken in a different light, these off-label uses are consistent with a current American mentality that uses medical interventions as technologies for optimization. Think for example of the use of growth hormones to enhance height, or Ritalin to optimize concentration, or plastic surgery to enhance beauty, or even amputations to optimize expressions of sexual identity. Are the uses of psychiatric medications to enhance religious performance so different from these practices? And are they necessarily unethical?

“The very idea of what we call a psychiatric disorder is strongly influenced by different norms,” Dr. Jonathan M. Metzl, a professor of psychiatry and the director of the Center for Medicine, Health and Society at Vanderbilt University, told me. Doctors over-prescribe anti-anxiety medications to women, and they over-diagnose African-American males with schizophrenia, he explained, because doctors themselves live with cultural biases. “If the psychiatrists are Orthodox, they may share some of the same belief systems,” he went on. “Is the critique of the doctor, or is the critique of a culture that doesn’t have an outlet for talking about different kinds of sexuality and calls everything deviance?”

* * *

In the course of their affair, Joseph and Dini never had intercourse. According to Jewish law, a woman who commits adultery is barred from marrying the man with whom she cheats on her husband, and Joseph and Dini wanted a future together. When a psychologist diagnosed Joseph with sex addiction, he tried to correct him. “I said, ‘It wasn’t just about sex! It was love, it was passion, it was fun, it was a different lifestyle, it was everything else,’” Joseph recalled. “But I was at the point of surrendering, so I said, ‘OK, I’m a sex addict.’”

The askan sent Joseph to Sexaholics Anonymous meetings in nearby White Plains every Wednesday and Sunday. His sponsor, a Christian, confessed to Joseph that he didn’t really see the manifestations of Joseph’s sexual addiction. The askan also made Joseph an appointment with a psychiatrist named Dr. Richard Price. Before they went to the appointment, Joseph says that the askan coached him in what to say and how to say it in order to procure the treatment that the askan thought was appropriate. According to Joseph, the plan in mind was that Dr. Price would prescribe Lupron Depot, a hormonal shot used to treat prostrate cancer by lowering the patient’s testosterone; it’s also a controversial treatment for sex offenders. Perhaps this would lower Joseph’s desire for Dini. (When I reached the askan by phone, and asked him if he had arranged for a man having an affair to get Lupron Depot shots, he interrupted me. “No, no, I don’t speak about such things,” he said. “No, no, it’s a mistake,” and he hung up.)

Dr. Richard Price in his Monsey, New York, office.
Dr. Richard Price in his Monsey, New York, office.

Joseph’s medical records name the askan who brought him to Dr. Price’s office, where Joseph told Dr. Price that he could not stop thinking about sex and running after women. Joseph said that he was “addicted” to his Blackberry and to the internet. He told Dr. Price that, since being married, he had had sex with five women, including prostitutes, and that he was seeking help “by all means necessary.” Dr. Price initially prescribed a small dose of Risperdal, an anti-psychotic medicine, and recommended that Joseph go back to talk therapy. After that, he prescribed Lupron Depot. Joseph got the shot four times over a period of three months. “Patient here Lupron injection,” read the nurse’s scrawled notes. “Administered R buttocks.”

“This askan took me to a psychiatrist and coerced me into saying that ‘yes, I am a sex addict,’ and that I need Lupron Depot,” Joseph told me, sitting hunched over on a couch in his Brooklyn apartment and staring at the floor. He paused, shook his head, and went on, “Thinking back on it now, it was very humiliating to me. I went to Refuah [Health] Center to have a nurse stick it up my ass. I had to drop my pants, turn around, and have her put it in.”

* * *

Dr. Price was eager to talk when I called to ask about his work as a psychiatrist catering to the Hasidic community. He invited me to his private practice, situated in the upstate New York town of Monsey, where there is a large Orthodox and Hasidic population. His office is in a two-story building at the edge of a strip mall that also houses a kosher restaurant, a kosher candy store, a Jewish bookstore, and a pharmacy. On his door was a plaque that read “Rabbi Richard Louis Price, M.D.”

Dr. Price is a tall man with a childlike, clean-shaven face and jet-black hair cut across his forehead in a straight line. He wore a black yarmulke and a crisp navy suit and tie. When I arrived, he told me excitedly about a treatment he had come up with for autism, which he said has high rates in ultra-Orthodox communities. Dr. Price determined that, in high enough doses, the chemical compound inositol could counteract “antisocial” symptoms. He had tried the treatment on his son, and is now having the powder baked into cookies at a local kosher factory. The cookies, called “Ostreicher’s Calmintol Cookies,” can be found on the shelves of Monsey’s supermarkets alongside the rugelach and babkas. He showed me a bag: it has a purple mountain landscape, with a blue stream flowing into two round cookies.

Dr. Price’s office.
Dr. Price’s office.

Dr. Price was raised as what he calls a “traditional” Jew – the family kept kosher and observed the Sabbath, and the young Dr. Price went to a Jewish day school. He played a lot of basketball, grew up listening to R&B, and enjoyed smelling Philly cheesesteaks, even if he was not allowed to eat them. After college and medical school, he earned his rabbinical ordination from Ohr Somayach, a non-Hasidic ultra-Orthodox institution. This gave him the cultural knowledge he needed to treat Hasidim, he says, though he is not himself Hasidic. He serves as the medical director of the Bikur Cholim of Rockland County, a mental health clinic that serves the ultra-Orthodox community. In addition to his private practice, he also works at clinics, and is an assistant professor of clinical psychiatry at the Weill Cornell Medical College in White Plains, where, last year, he was awarded the American Psychiatric Association’s highest honor for medical education, The Roeske.

Two thirds of Dr. Price’s Monsey practice is ultra-Orthodox. Most of those patients are being treated for symptoms that he attributes to “cultural issues,” as he calls them, from masturbation to homosexual desires to obsessive thoughts (“I do believe in God, I don’t believe in God,” they will think, day in, day out). Sometimes, he uses medication to treat the symptoms, if he determines that they are psychiatric in nature. Other times, he sends the patient to a rabbi for a dispensation to eliminate the religious cause. Psychiatric medication addresses symptoms, not root causes, Dr. Price told me; symptoms like anxiety, depression, paranoia, and overall distress can coincide with living a life of strict religious practice.

He sees many teenage boys struggling with the prohibition against masturbation, a challenge that is often accompanied by “a lot of anxiety and obsessive thoughts and compensatory compulsive rituals,” he said. He talks to them about what’s “normal.” To avoid masturbating, he recommends keeping their eyes cast downward; sometimes he’ll prescribe anti-depressants called selective serotonin re-uptake inhibitors, or SSRIs. “They might end up on medication, which is ostensibly used for the anxiety and the OCD, but all the SSRIs have the side effect of lowering the libido and making it difficult to ejaculate,” he explained. I asked whether he prescribes SSRIs to prevent masturbation. “I’m not going to say that,” he replied. “I’m saying, I’m prescribing it for the main intent of lessening their anxiety and lessening their OCD, but the side effect of all the SSRIs, some more than others, is that it reduces libido and delays ejaculation, which is really almost the primary benefit for what they seek, so it’s like an all in one!”

When he is treating kids, the school is involved. When he is seeing adults, he has the askans – “do-gooders,” as Dr. Price describes them. “You’re not working alone,” he explained. “People come in with an entourage, for good or for bad.” I wondered whether someone would feel uncomfortable being honest with a community operative in the examination room. “The askan is not the agent of anybody,” Dr. Price said. “The askan is kind of like the mentor, the buddy.” They play a valuable part in the treatment plan, he added. “Some of these askanim are very astute and savvy and well-trained, by myself or other professionals, and as cultural facilitators they can really help you not only refine the diagnosis but implement the plan.” Without askans, many Hasidim would not have access to medical care at all; adults are used to having their needs mediated through community channels, and children under the age of eighteen often don’t speak English, only Yiddish.

The first time I asked about Joseph, Dr. Price didn’t remember him by name. In general, when dealing with patients considering infidelity, he said, “It’s a catch-22. If you’re going to take away their libido for this woman, you’ll take away their libido for their wife.” To the contrary, helping couples maintain a healthy sex life requires supplementing, not suppressing, their libidos. He fondly patted a large and ornately embellished chest next to his chair. “In this box is a whole stash of Viagra.” He admitted to prescribing Lupron Depot, but “that’s a last resort,” he said, for people trying to avoid hurting others, or criminal behavior. In psychiatry, since so much of the discipline relies on the subjective experience of the patient’s pain, Dr. Price said, a psychiatrist can do very little to guard against a patient who may have been coached on what to say. “To not take their pain and their request seriously is to really minimize and be insensitive to their subjective distress,” he said.

Later, I returned to Dr. Price’s office with a signed medical release from Joseph, and he agreed to take out the chart. He read me the notes he had written neatly across a yellow paper. Joseph’s patient history also included sexual abuse; he had been molested by multiple people as a child and teenager, while hitchhiking in Monsey, while in the mikvah, in a grocery, and by a teacher. He blamed himself, and he never told his parents. The notes didn’t indicate if Joseph had asked for the Lupron Depot directly or merely consented to it. Dr. Price stood by the treatment. “I would never put it upon him without his consent,” he said of the Lupron Depot. “But if someone is asking for it,” – for help controlling their sexual desires by all means necessary – “that is all means necessary.”

Joseph at home.
Joseph at home.

When I told Joseph about my conversations with Dr. Price, he asked, “Which patient comes to a doctor with the most intimate stuff with another person in the room?” He sighed heavily. “There’s no medication for affairs.”

* * *

I met another patient of Dr. Price’s, who I’ll call Moishe. Moishe told me that he suffered from religious doubts, which he believed caused him to become manic. “I was yelling at everyone,” he recalled. “No one was able to talk to me, no matter what subject. I was completely off my rocker.” He considered leaving the Hasidic world, until he met an askan known for dealing with psychiatric illness. The askan took Moishe to see Dr. Price, who Moishe says put him on Lamictal, a bipolar medication, and Vyvanse, for ADHD. Moishe believes that Dr. Price saved him from a terrible fate. “It’s a valid treatment, in my opinion,” Moishe said. “If someone is stuck in a bad job and it’s making them depressed, the doctor won’t tell them to leave their job. He would give them medication.”

Metzl, the psychiatrist at Vanderbilt, told me that evaluating the ethics of this kind of treatment – when medications are being prescribed for off-label uses – depends on the patient’s relationship with the “deviant” behavior. There are “egosyntonic” behaviors, he explained, which the patient views as acceptable within his own value system, and there are “egodystonic” behaviors, which the patient finds shameful. In the latter situation, like Moishe’s, the patient may experience mental anguish over their inability to stop. “In the case of an egodystonic behavior, you could conceivably say, these acts are causing these people to feel depressed or worthless,” Metzl said. “From a textbook perspective, it would fall under the guidelines of the kinds of things psychiatrists would ethically treat.” As to establishing red lines in terms of treatment, Metzl said it’s all about context. “Is the problem a chemical imbalance in someone’s brain that’s amenable to psychiatric medications? Or is the problem with the religious context? I think it’s very difficult for psychiatrists because you don’t want to get into a situation where you are treating the individual when the problem is the context. I see it as a very, very complicated problem. It really takes an exploration of broader contextual issues.”

According to the Food and Drug Administration, physicians may administer a drug for purposes not approved in the label; it’s the doctor’s responsibility to make sure that the usage is based on sound scientific rationale and to maintain the appropriate records. “Off-label medications can help patients when current FDA approved treatments aren’t working,” Dr. Renée Binder, former President of the American Psychiatric Association, told me.

“A huge percentage of what physicians do is done off-label,” said Paul S. Appelbaum, a professor of psychiatry, medicine, and law at Columbia University and a past president of the APA. In fact, most physicians would not do a very good job of distinguishing on-label and off-label uses of medications they prescribe regularly, says Appelbaum. The real issue, he explained, is not whether the treatment is on- or off-label, but rather, what are the limits of medical intervention? Should doctors be restricted to correcting acknowledged pathologies? May they help patients deal with difficult life situations that would not be classified as illnesses? Can they aid in one’s personal enhancement? “It’s a tough question to answer because the lines are pretty blurry,” Appelbaum said. “We’re in this somewhat unchartered territory of trying to figure out where the boundaries are.”

I asked Dr. Appelbaum about treating young men who masturbate with SSRIs. “It is a decision that is neither ipso facto right to do, or wrong to do,” he said. “One has to take into consideration a lot of factors particular to any given context and to the person who’s sitting in front of you. In principle, if you have a young man who’s distressed about excessive – or what he thinks is excessive – masturbation in a community that discourages that, it’s not really easy to see a distinction between treating that with a cognitive behavioral therapeutic approach and treating that with medication. The question is more: Is intervention appropriate?”

To others I spoke to, like Dr. Dinesh Bhugra, president-elect of the World Psychiatric Association and a professor of mental health and diversity at the Institute of Psychiatry at King’s College London, the APA’s approach represents a tendency to over-diagnose. “We should not be medicalizing normal human reactions and normal human emotions,” Bhugra said. “I understand and take into account the role religion plays, but from a psychiatric point of view, there is no clinical indication to be able to treat masturbation with anti-depressants.”

The APA does draw a clear line on so-called conversion therapy, or the “treatment” of same-sex attraction, which can involve nausea-inducing drugs and electroshock. In 2009, the organization adopted its “Resolution on Appropriate Affirmative Responses to Sexual Orientation Distress and Change Efforts,” which condemns stigmatization and states that attempting to change someone’s sexual preference is unlikely to work. Conversion therapy for minors has been outlawed in five states and the District of Columbia; in February, New York Governor Andrew Cuomo announced regulations to restrict its use on minors.

But doctors tend to make a distinction between gay conversion therapy on the one hand, and treating patients for anxiety or depression that comes from not fitting the right religious mold on the other.

“For people who are distressed about their sexual orientation and seeking relief from depression and anxiety, it is perfectly appropriate for a psychiatrist to provide treatment to alleviate those symptoms,” explained Dr. Appelbaum in an email. “That’s very different than suggesting to a person that a psychiatrist can help them change their sexual orientation, when there’s no evidence that’s true. By analogy, a psychiatrist may not be able to change the behavior of a mean boss or a difficult spouse, but can help relieve the symptoms that ensue from that situation, hopefully rendering the patient able to deal with the situation on his or her own.”

* * *

I went to visit Dr. Alfredo Nudman, who, like Dr. Price, has built his career treating Hasidic and Orthodox Jews. His office is on Madison Avenue in Manhattan. When we met, he wore a gray suit and a blue shirt open at the collar; a black velvet yarmulke covered a balding head. He was tall and thin and confident. Nudman, who is from Chile, was raised in a family that was “very Jewishly identified” but not very religious, he said, and he became Orthodox in college. His Hasidic patients found him after he became the Unit Chief of inpatient psychiatric services at the Weill Cornell Medical College, which, he explained, was the destination hospital in Hasidic circles. “I ended up being the go-to doctor,” he said.

Now, Nudman says, eighty percent of his practice is Hasidic. (A sign on the door to the women’s bathroom warns, “Bathroom is for WOMEN ONLY” in English, Hebrew and Yiddish.) Most of Dr. Nudman’s patients don’t have the money to see him, so their bills are paid by community charities. “Most of the rabbis know me really well and trust me,” Nudman said. He speaks their language, literally and culturally. “I don’t just decide what’s necessary medically,” he explained. “I take into consideration their particular needs.”

Dr. Price speaks with a colleague in his office.
Dr. Price speaks with a colleague in his office.

As for the ban on conversion therapy, Nudman is skeptical. “I happen to think that’s insane, because who is the State or the American Psychological Society or anyone for that matter to dictate to a person what that person wants to do with their life?” He allows that they are trying to prevent abuse. “But to say that it’s illegal to try to help somebody who wants that?” He shook his head. “The decision to take homosexually out of the list of psychiatric illnesses was by vote, not by science.”

“Is homosexuality an illness?” He went on. “I don’t know. It’s not for me to decide, it’s not my specialty. But if someone comes to me and tells me they come from a Hasidic background and they’re married and they have three kids and they have severe same-sex attraction and this is killing them and all they want is to be happily married with their wife and have sex with their wife and be a father and an upstanding member of the community and this thing is not letting them, I’m going to help them.” If there are psychiatric symptoms, Nudman will treat them. If there’s anxiety, depression, insomnia, he’ll treat it. But it’s not conversion therapy, he says. Nudman admits that there’s no medication to make someone straight.

At the same time, Nudman told me that he faces pressure from Hasidic leaders to do things he is unwilling to do. When I asked whether he had a business interest in complying with the requests of askanim, he said, “I do!” But he added, “I probably just lost another askan today because I yelled at him.” He says he doesn’t let the business incentive influence his treatment. “There are psychiatrists who will do whatever they are told,” Nudman says. He says he isn’t one of them. “My responsibility is to the patient – morally, ethically, medically, legally.”

Nudman insisted that the motivations of the askuns are honorable – they believe that the only way a person could wish to deviate from the religious mores of their community is because such a person is unwell. In his opinion, while not everyone who leaves an ultra-Orthodox community does so for a psychiatric reason, “It’s always a personal issue.” He added, “I’m still waiting to see one person that ran away from the Hasidic world and they come from a loving, caring family.”

* * *

Luzer Twersky joined the Satmar sect in upstate New York in his teens. He told me of an askan who dispensed medication to a house full of “problem” children from around the community to whom he gave pills and coached through doctors’ visits. Twersky was raised in a Hasidic home in Monsey, where he’d had a difficult childhood. When he was eight, he’d been the class clown; he was always in trouble at school. He also shoplifted, and stole from his parents. He worried that no one liked him, and feared that his parents didn’t love him. He joined Satmar because he wanted to “be better” than his parents, who he felt weren’t religious enough, and he was married before his twentieth birthday.

But a year in, he wasn’t happy. Twersky was plagued with religious doubt, and his marriage wasn’t satisfying his sexual desires; in violation of religious law, he masturbated and went to strip clubs. The rabbis he consulted told him that he was depressed, that these were emotional problems, not religious ones. They said he would not be happier if he got divorced and left the strict religious life.

A Hasidic counselor recommended that he go see Dr. Nudman, and Twersky made an appointment. (According to Twersky’s chart, which he signed a release to allow me access to, the counselor told Dr. Nudman that Twersky had mood swings, and that he was angry, depressed, and dysphoric.) When Twersky met with Dr. Nudman, he told him about his unhappy childhood and his religious doubts, about his unfulfilling sex life and his high sex drive.

During the consultation, Dr. Nudman found no evidence of a mood disorder or a psychiatric condition. But, he told me later, as he looked over Twersky’s chart, “there was a vast history of severe personality disorder symptoms, starting at a very young age.” According to the notes Dr. Nudman had taken during their consultation, Twersky had been married for a year when he started “sabotaging” himself and his marriage, by not coming home or engaging with his wife. Twersky told Dr. Nudman that he felt he was acting out a self-fulfilling prophecy: if he can’t be perfect, he’d rather ruin everything. Dr. Nudman prescribed a small dose of Prozac, and a small dose of Risperdal, which “technically is an anti-psychotic,” he told me, “but at very low doses like that, we use it to control mood swings and anger and impulsivity in patients with personality disorders.”

Twersky hid the medications in his locker at synagogue so his wife wouldn’t find them. But they made him feel numb; his libido was so diminished that he couldn’t have sex with her anymore. After two months, he gave up on the pills, and a year later, he went OTD, or Off the Derech – off the path – and on to a secular life.

Twersky moved to Los Angeles, where he is now enjoying success as a film and TV actor. He’s on no medication. “I don’t think OTD is in the DSM,” he said, referring to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. “I’ve had rough times, sure. I’ve been depressed. I lived in a tent in Bushwick. I was a transient trying to be an actor. But I haven’t needed psychiatric drugs to get by.” Recently, he has appeared in the film “Felix and Meira,” and the show “Transparent.”

When I spoke with Twersky about what went into Dr. Nudman’s treatment plan, he told me, “It’s hard to say where does weird end and personality disorder begin. Are the things he’s saying about the way I behaved true? Of course. But how much of that was because I was in a marriage I wasn’t happy about, or a religion I wasn’t happy about, and how much is about my troubled childhood? Once I left the community and once I left my wife, I’m doing very well.”

* * *

Joseph eventually gave up the hormone treatment when Dini, who he had not seen for nine months, called to tell him that she and her husband were expecting a child. Joseph told her about the Lupron Depot shots, and Dini was shocked and outraged. She told him to stop taking them immediately, which he did. She wanted to keep talking, but Joseph was unwilling to maintain contact with her. Dini, who missed Joseph terribly, persisted. As her pregnancy wore on, Dini’s husband finally relented. “I don’t want to keep you hostage,” Dini remembers him saying. The next day, Joseph and Dini were on a flight to the Bahamas, and soon after, they got divorced from their respective spouses.

They have now been married for five years. They live in Brooklyn and Joseph calls himself “neo-Hasidic.” He is on a spiritual journey, one facilitated by his relationship with Dini.

Nearly every single one of his previous friends has stopped talking to him. Recently, his entire extended family got together; Joseph was invited but only if he came without Dini, so he stayed home. “The book was written and I was excluded,” he said sadly. He gets to see his children once a week, and talks to them on the phone every day. The oldest is currently in the marriage market, having trouble finding a good match because of his father’s choices.

To this day, Joseph struggles to understand how he let himself be talked into the hormone treatment. He also is dealing with erectile dysfunction, which he believes to be the result of the Lupron Depot shots. “I did not have any idea when I was in that place that there is a notion that you have the power of change,” he says. This was the reason he wanted to share his story, to empower others in the same position. “They can make a decision, they can decide what to do, they can make their own research, they can go to their own doctors. They shouldn’t be, I don’t know the right word, katzon latevach – like a sheep to the slaughter,” he said. He seemed both defeated and hopeful.

Joseph with his old journal.
Joseph with his old journal.

When I first met Joseph, he and Dini were living in an apartment in Borough Park, a Hasidic enclave in Brooklyn. Walking from the train to their home, the men I saw on the street all wore hats and side curls, the women stiff wigs and traditional mustard-colored stockings. As I mounted the stairs to the apartment on one of the occasions I visited, their upstairs neighbors, ultra-Orthodox Jews who disapproved of the couple, called me a prostitute.

But the last two times I visited, I went to see Joseph and Dini at their new home, a spacious house on a leafy, tree-lined street in a gentrified, more diverse neighborhood. On the door hung a sign with Joseph’s last name, over which was embossed the message: “The heart of a happy home is family.” A neighbor in a black yarmulke and a plaid shirt and jeans bid me a nice day when I left.

The couple’s new home is a hub for a community of seekers, where Dini and Joseph host Shabbat meals for up to forty people at a time, each guest at a different stage of religious observance. Almost every night, people drop by for support, or just to talk. “For the first time, I feel I can breathe,” Joseph said. “I couldn’t foresee how life is going to be.” He was still walking through the rooms of his new home with a look of amazement and a big smile on his face. Even his posture seemed to have changed.

I remembered my first conversation with Joseph, after which he had dug up a journal he kept during his treatment. He hadn’t opened it in years.

“Hello, addict,” he had written across the top of the first page in block letters. “Today I took the shot for the first time,” he wrote in one entry. And then, on a later date, “I’m being forced to do it. I’m not sick.”

On the last page, he wrote, “Decision: I am no addict.”

Joseph turned the pages slowly, reading out the entries with amazement, as though they had been written by someone else.

Batya Ungar-Sargon

Batya Ungar-Sargon is an award-winning journalist whose work has appeared in the New York Times, the New Republic, and Foreign Policy.
Pearl Gabel is a staff photographer and multimedia journalist at New York Daily News. On Twitter as @PearlGabel.