Body image and the brain - Our brains have "neural pathways" for our thoughts. It’s like a field of tall grass, with some pathways tramped down. Those pathways that are the most well-worn are thought patterns that are more established. For example, when someone thinks of their fistula, they may think "Ugh. It is so gross." And that may be a really established pathway. So, anytime that person thinks of their fistula, they start feeling badly. However, it is not a "fact" that the fistula is gross, that's a subjective value that the brain is assigning the fistula and we believe it because we trust our brains (which, honestly, is hit or miss). The good news is that we can change our neural pathways. But just like a field of tall grass, it takes a while for the old pathway to grow over and for a new pathway to be established. And how do we make a new pathway and let the old one grow over? We have to consistently start using the new pathway, while avoiding the old one. Which is tough at first, because the old one is so well worn, and easy to walk through. But it is doable, and here is how:

1. Notice and stop our negative neural pathways. Next time you catch yourself in a negative thought pattern about your fistula, say "stop!" You can even say it out loud, if it won't cause too much social awkwardness. This is important because if you keep going down that negative neural pathway, you are only tramping that grass down more, making it easier for your brain to take that path next time. Changing your activity or your surroundings can help get you out of that thought spiral. For example, get up and go for a walk to get you in a different headspace.

2. Be curious and challenge what your brain tells you. As mentioned earlier, our brain is not always the best reporter. Our brain is a tool that is there to help us anticipate and navigate dangerous situations, but sometimes it gets a little too into its job and ends up creating problems (like stress, anxiety, self-esteem issues) rather than solving them. An example: Someone's brain may be trying to protect someone from the pain of rejection. So it starts running scenarios of the reasons they will be rejected (like a fistula scar), and practices what that rejection would feel like, so you are prepared for the worst case scenario. Unfortunately, a side effect of this is that person will begin to anticipate rejection and focus on the "problematic" aspects as failings that prevent successful relationships. So, that person may need to check in with curiosity.

3. Mindfulness - it's the cure for everything. Mindfulness is the practice of being present, in the moment, without judgement. It's a great way to compassionately notice the stories our brains are creating, and gently challenge them. Here's an exercise that could be helpful:

1. Get into a comfortable position, preferably with your back straight, shoulders back, and eyes closed.

2. Take a couple deep breaths, focusing on slowly and completely filling your lungs with air, and slowly and completely releasing the air. Feel the sensation of your lungs expanding. Notice where you feel you the air passing through your nose, throat, chest, and belly. If you catch yourself having thoughts, smile at your brain for being so busy and gently redirect focus back to your breath.

3. Take a moment to notice your body. Starting at the top of your head, begin "scanning," noticing any tension, tightness, pain, thoughts, or emotions that may be hanging out in your forehead, then your eyebrows, the folds of your brain, your scalp, etc as you slowly bring your awareness down your body, all the way out your arms and eventually ending in your toes. Try not to fall down any thought spirals, and if you notice your brain starting to get busy, re-focus on your breath and then continue the scan.

4. Ideally, you are now feeling more settled into your body and present in the moment. You can open your eyes, and begin to explore your fistula with the spirit of mindfulness - deeply noticing, without judgement. This means, using all your senses and avoiding value-based assessments (good, bad, ugly, pretty, etc). You might touch your fistula and notice the skin is warm, cool, firm, or soft. Write these descriptors down. You might look at the fistula and notice it is bumpy, pink, dynamic. Write these down, too. By focusing on non-judgmental descriptors, you are moving from that "negative" neural pathway into more neutral, and maybe even positive pathways, that will help you feel more comfortable in your body.

4. Own your special, unique body. We all have things going on with our bodies, that other people may find confusing or different. And often, the way people respond is influenced by how we present it. Some examples include folks who have amputations that create dating profiles like "Looks 9/10, personality 10/10, legs 1/2" or breast cancer survivors who get elaborate and beautiful tattoos over their mastectomy scars. How can you own and celebrate your body, exactly as it is?

**There are some ideas out there for fistula scar tattoos, NKF has some information on tattoos post-transplant: https://www.kidney.org/content/heart-your-kidneys-tattoos and as always, talk with your nephrologist, transplant team, and fistula surgeon before deciding on if or where to put a tattoo.

5. Finally - commit to not dating or hooking up with people who don’t deserve you. There will be people who will reject you because of your fistula. Or your height. Or you weight. Or your hair color. Or your income. Or the fact that you have the same name as their parent. The best relationships and hook-ups will be with people who can co-create a space where you feel sexy, safe, and adventurous. So if someone is coming in with judgements and hang-ups, and isn't interested in growing themselves enough to understand that bodies and humans are dynamic, then move on. They aren't sexy enough for you.