Menstrual Taboos

Culture shapes behaviour, attitudes and beliefs -or is it the other way around? The chicken or the egg? This has puzzled me since I was a child wondering why everybody I knew wore jeans but in pictures the people living in, say, India did not. And the members of my family –uncles, aunts, grandparents, cousins- all went to church and sat in seats. None of them prostrated themselves on little rugs on the ground. Did each of us have to be Protestant? Was there a choice? Or, was there something about my family that made them that way? I don’t remember choosing.

Why do we end up believing or doing something that seems arbitrary when compared with other parts of the world? Why do we often think that only the way we do things is appropriate? Correct? How many correct ways are there..?

Could imitation be something akin to an infection? If everybody we know does the same thing, why would we even suspect it? Maybe it’s contagious and causes a psychological compulsion to fit in –like fashion, or expresssions in language that identify us as a member of a group or region. We seldom question it, but then again, there is no reason to: everybody around us is doing the same thing so it infrequently rises to a conscious concern. It’s an outrageous thought experiment of course and yet such curious congruity does give one pause for thought.

But in our islands of similarity we do notice difference; it makes us feel uneasy –as if perhaps there was a choice. Another way to do something. Another way to be in the world. And depending on the status of the innovator, we may see the novelty as interesting but peculiar –perhaps even something we should adopt for ourselves- or we may consider it simply wrong. Strange. Evil. Something to be shunned, avoided at all costs -even at the expense of the defector. Even if the apostate is tolerated under other circumstances when seemingly adhering more closely to the accepted norms.

I use the word apostate advisedly. Society is a religion, and one that is often disdainful of heretics, aberrations that tug at the pattern in the fabric. Anomalies. Discrepancies sometimes strain cohesion and make us question who we are and why we have come to behave the way we do. We are creatures of custom.

Of course I realize it is difficult, if not impossible, to apprehend difference without judgment. Even curiosity suggests analysis: comparison and evaluation. Some things, however, seem difficult to assign merely to custom; the difference is more appropriately attributable to fear. Unintended ignorance. Naivete.

The menstrual taboo is a case in point. There have been some recent articles in both the BBC News: http://www.bbc.com/news/world-asia-29727875?print=true and the Huffington Post:   http://www.huffingtonpost.ca/sabrina-rubli/menstrual-education_b_5689072.html that discuss problems surrounding menstruation and how it interferes with education for young girls especially. Menstruation is a natural process for renewing the uterine lining every month: shedding the old cells to make way for new ones that may be required to grow a baby. But natural does not necessarily mean acceptable or discussable for everybody.

Culture deems some things embarrassing, things best kept private or at least not shared outside a family or circle of friends. Bodily functions and intimate relations probably top the list. And yet necessity sometimes trumps personal feelings; where adequate facilities do not exist, an accommodation, a compromise usually springs up to fill the need. So while communal ablution may never rise to the level of a societal norm, a variation of it may be tolerated under some circumstances. Safety and vulnerability constrains many compromises, with strict gender separation often necessitating extreme measures such as waiting until the relative safety of darkness for a woman to relieve herself. Even this atrocious compromise is fraught with danger, as recent reports of rape and sometimes murder in parts of rural India attest. That the practice should even need to exist is unconscionable to most of us; that those with the authority and power to change it in the region have not managed to remedy it is worse.

But let’s not allow the unreasonable social diminution of women in one area blind us to an even more pervasive inequity in many developing nations around the world: the cultural taboo about menstruation. Femme International has documented some of the more egregious offenders in its website http://www.femmeinternational.org/the-issue.html

Culture is a tricky thing. Both intriguing and covert, it exerts an inordinate amount of influence on thought and action. The sources of its traditions are often historical, bound in a delicate weave with myth and legend, and are at best opaque. To question it, therefore is difficult and usually seen as insulting and provocative –it is what separates us from them, precluding further analysis, further understanding. “It’s just how we do things,” is the usual response to questions from foreigners. “You wouldn’t understand.”

The menstrual taboo is like that… and not. Attitudes are seldom fodder for experimental investigations, and yet occasionally there are aspects that are historically discoverable. The enforced seclusion or restrictions on the activity of menstruating women are usually ascribed to ignorance –lack of education about the function and meaning of menstruation- or fear of some theological punishment.  And yet Femme International, political correctness notwithstanding, has intimated there may be a more obvious, historical reason for the concern, albeit uncomfortable to state.

Traditionally, menses have been a source both of embarrassment as well as inconvenience for a woman –especially if she is required to be in public places such as the market -or school in more modern days- for any extended period of time. How to cope with the menstrual blood? Only recently have effective measures been available, but even these are priced beyond the means of many girls in isolated villages. In Kenya, for example, the BBC article reveals that the cheapest package of sanitary pads costs almost half the average daily wage, so they may be seen as more of a luxury item than a necessity. ‘As a result, girls will resort to using alternative methods of menstrual management, such as rags, leaves, newspaper, bits of mattress stuffing, even mud.’ The Femme International again: ‘Menstruation is the number one reason why girls miss school. Sometimes girls will attend school on their periods, but will refuse to sit down, or once seated, refuse to move. Many schools do not have appropriate latrine facilities, and girls are unable to wash themselves during the day. When latrines are shared between boys and girls, they are teased and mocked during their period.’ Indeed it has been suggested that because of some of these practices, the odour alone may have given rise to some of the fear of contagion and restrictions placed on the menstruating woman.  For example, the BBC reports than in ‘regions of Kenya, girls are forbidden from touching livestock, preparing food or consuming animal products for fear of contamination.’ And in India ‘there is generally a silence around the issue of women’s health –especially around menstruation. A deep-rooted taboo feeds into the risible myth-making around menstruation: women are impure, filthy, sick and even cursed during their period.’

Femme International has suggested at least one acceptable option: menstrual cups. ‘Menstrual cups provide an affordable and sustainable solution to menstrual health management. A menstrual cup is made of medical grade silicone and is worn inside the vagina during menstruation to collect fluid. Menstrual cups are more cost-efficient and environmentally friendly than tampons as they can be washed and reused for up to 15 years. Unlike [expensive] pads and tampons, the cups only need to be emptied every 12 hours. Thus girls can attend school without worrying about the availability of private washroom facilities, or revealing their period to peers.

There are other remedies of course and they, too, need to be pursued. Once again the Femme International: ‘Young women who lack the knowledge and resources to safely and effectively manage their periods not only miss school but face stigma and shame from their male and female peers. When girls do not understand why their body menstruates each month, they easily believe that it is something to feel shame about, something to keep hidden and something that is a source of humiliation. This type of behaviour is strongly influenced by the widespread stigma that surrounds menstruation in the majority of communities. When women are unable to manage their periods, they are less able to participate in daily life. Addressing the issue of menstruation through health education, positive reinforcement and the provision of management materials reduces these gender specific barriers.’

Yes, it’s a step to be sure, but one that may require a generation to succeed. We must not give up because the progress seems slow and the task insurmountable. Attitudes do shift, cultural mores and folkways change, governments fall. And with the almost ubiquitous availability of social media, one hopes the results might be noticeable even in our time. The curtain of mystery that has always separated the two sexes need not be rent asunder, though –mystery, after all, can be a source of awe and wonder. And not all mysteries have to be solved -sometimes just acknowledged and appreciated for their charm and excitement. No, the fabric need not be torn -merely parted enough to reveal that what differences do exist between the sides -between males and females- are nothing to fear. We were made for each other, after all.

 

The Begging Bowl

We all have needs; we are all mendicants at some level. Sometimes subtle: a smile that begs response, a look that hopes for more; sometimes obvious: a verbal request, or even a sign that solicits aid. But sometimes it is more blatant. Glaring. Almost rude.

I was once accused of that –of shameless, brazen panhandling. And right in my office. Near my desk.

It started out quite innocently, as I recall. I was given a clay sculpture by a Mexican patient. I don’t encourage gifts -to tell the truth I feel embarrassed by them- but she seemed so grateful for her care, her delivery, and her healthy baby, that I felt compelled to accept. The moment she struggled in with the box unannounced, her eyes shining, and her face a risus sardonicus, paralysed with joy, I realized I was trapped. No matter the contents, I was meant to appreciate it. My mind returned to Christmases past with presents of socks or itchy home-knit woolen sweaters from my aunts, and how I had to pretend not to be disappointed. So it was not an unfamiliar skill –just long-dormant.

She seemed so pleased with her choice: a poor woman in a shawl sitting on the ground holding a begging bowl. The whole figure was done in a dirty grey clay and fired so it was rough to the touch. The most striking thing about it though was her expression: depite the lack of fine detail, the face commanded attention. The eyes in particular demanded succor -redress for what Life had thrown at them; compensation for the indignity of having to beg.

Whether my patient was concerned for the aesthetic welfare of my office, or the medical system in Canada, she didn’t say. She just watched, beaming and toothful as I opened the box, hugged me, then headed for the door. She hesitated for a moment before leaving, turned her head and pinned me to the spot with her eyes. “I know you understand, doctor,” she said slowly, the smile tucked away somewhere inside.

Well, to tell the truth I didn’t at first. In fact, I didn’t know where to put the begging woman either. Eventually, I brought a little oak table from home and put the two of them in the corner by the window on the other side of my desk. The fact that my patients sit beside the bowl she proffers didn’t strike me as particularly important. In fact, I forgot about it. When you see something every day that neither moves nor changes, it becomes invisible. At least to me.

One day I was talking to an older Asian woman when I noticed her glancing at the bowl whenever I wrote something in her chart. She seemed more troubled each time she looked. At first I thought it was because of the reason for her consultation –an ovarian cyst that looked malignant on ultrasound- but she didn’t sound worried. She didn’t even look anxious. Just perplexed.

“Am I supposed to make an offering?” she said suddenly, in the middle of a question I was asking.

“Pardon me?” It was such a non sequitur, that it threw me off my line of thought.

She reached into her purse and after a moment of scrabbling the depths, her hand emerged with a two dollar coin. “Not much,” she said almost to herself as she placed it carefully in the bowl, “but the poor woman looks so sad with that empty pot.” She stared at me for a while and then smiled. “Maybe it’ll bring me good luck…”

Well, that started the deluge. The coin glinted in the bowl like a flashlight, beckoning. A single offering demanded more: Fill the bowl, it said. The begging woman said. I didn’t; I just watched with fascination each time someone saw it and felt compelled to add something. Just in case. It couldn’t hurt, was written on each face.

Occasionally, I had to empty the bowl when its contents began to spill onto the floor each time someone accidently touched the table leg with her foot. But an unfilled bowl seemed to spur even more contributions.

It was a bowl that fascinated children. Whether it was the money, or the novelty of seeing something like that in a doctor’s office, they used every distracted maternal moment to try to sneak past a knee and grab for a coin. Most mothers are quick, but some are indulgent -trusting the judgement of their experimenting child and assuming that, unlike fire or naked electrical sockets, no harm is likely to come from their curiosity.

I, who watches nervously from the wrong side of the desk, do not trust, however. I am suspicious of every lunge, every mischievous grab. I recognize my younger self and the need, the compulsion, to outwait the unusually tolerant eye and outwit the momentarily inattentive face.

But sometimes I, too, am preoccupied. Busy with the constraints of medical practice, focussed on mother not child. And so it began –softly at first, of course. A young child I apparently delivered three or four years ago while on call for my colleagues, made it past a set of knees and too-slow hands to reach the bowl. The mother caught the statue before it hit the floor, but not before the coins explored the room and the child screamed in a terrified expectation of retributive justice.

No lasting harm was done, although the little boy wouldn’t stop crying as his mother, down on her knees behind the desk, attempted to refill the bowl. I tried to reassure her, but I could see she was embarrassed and flustered. When the two of them finally surfaced from behind the desk, laden with silver, her mood had changed. She seemed more annoyed than apologetic.

“Why would you put that thing where someone could knock it over?” she said, pointing at the begging lady with anger bordering on litigany. “What’s it for, anyway? Bribes?” she added, either in a try at black humour, or more likely, threat.

I smiled in an attempt to diffuse the situation. “It was a gift from a lady I delivered,” I said, trying to remain calm now that the child, recognizing that his mother was mad at me not him, began to cry again.

“Well,” she said, huffiness creeping into her now-trembling voice, “It’s a good thing I didn’t get hurt.”

“Yes it is,” I agreed. Someone had to remain in adult mode. “Maybe I can put it somewhere else…”

Her face immediately softened. She realized she had made her point; I was listening. She lowered her eyes and took a deep breath. “I’m sorry,”she whispered. “I know it was Devon’s fault…” She burrowed into me with sad, repentant eyes. “I always get upset when he cries.” She blushed and immediately reached into her purse and put two coins into the now-overflowing bowl.

Then she looked at me for a moment before speaking. “One coin is for the one I saw him put in his pocket… ” -she glared at Devon briefly- “…the other is a bribe so you don’t tell anybody,” she said chuckling softly. “And,” -she reached across the desk and touched my hand- “I want to thank you for delivering my little boy. You had no way of knowing…”

Breast and Ovarian Cancer Screening

I am sometimes troubled by the concept of risk. I mean how can we possibly decide whether or not a risk is acceptable? No matter the statistics, if the issue under consideration doesn’t happen, then the risk assumed was acceptable. So far, so good. But of course the converse is also true: no matter how low the risk, if it does occur, well…

Ours is a culture of prediction. Statistics. Guessing. I rationalize buying a lottery ticket by convincing myself that if I don’t buy it, I won’t win -no matter how low the odds, no matter how unreasonable it would be to assume that I would be the one in –what?- ten million who wins the jackpot. Or anything, for that matter…  And no matter that without a year of such profligate spending, I could treat myself to a sumptuous dinner at a good restaurant.

Of course, we all live in hope, and if the lottery ticket funds some worthwhile government project, then it is an almost enjoyable form of indirect taxation. Assimilable because it is freely chosen. Optional.

It is a different proposition entirely if the risk is one to which we do not wish to subscribe but have no choice: genetic defects in a developing pregnancy, cancers, diseases, to name but a few. It is likely to our advantage to interrogate these, if possible. Of course, the question then becomes who should undergo the screening. Only those at the highest risk –those with a family member with the condition, say- or everybody? Just in case.

Screening always seems to be bathed in a soft, warm glow. If you can test, then why not? Just pop in to your local lab and get that PSA; find out if your prostate is betraying you. Demand yearly mammograms as soon as you feel concerned. As soon as a friend or even a friend-once-removed has a cancer scare. And at any age, because you never know…

If only screening was that good; if only all negative tests were reliable –and, for that matter, didn’t have to be repeated at intervals to keep pace with the ravages of Time wreaking its not so subtle havoc on our aging bodies.

Screening for specific inherited genetic mutations for breast and ovarian cancers are the relatively new species of Wunderkind: BRCA1 and BRCA2. These are tumour suppressor genes broadly speaking; we all have them, and they are located on chromosomes 17 (BRCA1) and 13 (BRCA2). But if they contain defects -mutations- they may no longer function efficiently and so be unable to winnow out mistakes such as tumours from proliferating. The mutations are inherited in an autosomal dominant manner and women with these particular mutated genes have a lifetime breast cancer risk of 50-85%. .

So why not screen all women for these genes? Indeed, a recent study published in the Proceedings of the National Academy of Sciences (USA) suggested just that: http://www.pnas.org/content/111/39/14205.abstract

On first reading, it sounds like a reasonable approach. But I’m not so sure. First of all let’s put the whole issue into context. Less than 10% of breast cancers (and <15% of ovarian cancers) seem to be associated with BRCA1 or BRCA2 mutations. And, although even less common, there are hereditary breast cancers associated with other genes, so there might be a false sense of security from testing only the BRCAs.

And then there’s the uncomfortable fact that there have been over a thousand different mutations in BRCA1 and 2 discovered so far. You’d have to know which one to look for. Of course, some populations have more prevalent mutations –so called Founder effects– which might simplify the search. Two per cent of Ashkenazi Jews, for example, carry specific mutations of BRCA1 or BRCA2. And there are other populations carrying unusual founder mutations that might facilitate searches in them as well: people from the Netherlands, Quebec, Iceland, to name a few. Or in still other groups -some families, for example- if the particular mutation resulting in their tumours has been identified, then the process is obviously easier.

The most successful screening is in people with identifiable risks, however. With breast cancer, such things as family history -especially a young age of developing the breast or ovarian cancers (the younger, the more chance there is a risk that can be  inherited), or a family history of so-called triple negative breast cancers –progesterone, estrogen and HER2 receptor negative. Males with breast cancer (yes it happens) are another, albeit infrequent clue to increased risk.

But screening everybody? Let’s get back to risk assimilability. Just what risk is acceptable? Less than 50%? Less than 25%? No risk at all..? Sometimes the answer is easy: a 50-85% lifetime risk of breast cancer if specific BRCA1 or 2 mutations are present is likely not tolerable. But what about the odds if only 2% of the population had that risk, as is the case for BRCA1 and 2 mutations in the Ashkenazim? Or if the chances of those mutations are even lower: 1/800-1/1000 as it is in the general population?

And what if you are not a member of a high risk population, or if there are no cases of breast or ovarian cancer in the family? Should you still be screened? And if so, with what? Remember there are many different mutations possible on the BRCAs -not all of which may result in an increased cancer risk. And there are other genes than BRCA that may play a similar role sometimes. So if you are just concerned that you might be at some risk, or worse, merely curious… Well, its best to remember that we are all exposed to dangers each day that we don’t even think about -and there’s no avoiding them: everything from tripping and falling down the stairs, to slipping on some ice; from having a heart attack, to getting hit by a car crossing the street to shop. We have to put things in perspective: life is a risk, and we are fragile creatures. Remember Shakespeare’s Hotspur in Henry IV:

‘Tis dangerous to take a
cold, to sleep, to drink; but I tell you, my lord fool, out of
this nettle, danger, we pluck this flower, safety.

So, if there is reason to believe there is a risk on the horizon, then it’s best to mitigate it. But don’t go looking for it in places it doesn’t exist.

 

 

 

Have Hypnosis, May Travel…

“You want me to do what?”

Janet’s smile never waivered; it broadened if anything. “Hypnotize my friend.”

I rolled my eyes in a maudlin attempt to emphasize my frustration at her answer. “But your friend is a male, Janet…”

She blinked slowly –her version of an eye-roll, no doubt. “Given that you are as well, I don’t see an ethical problem.”

“I’m an obstetrician, Janet. By definition, we see females. We have nothing against males; we just don’t see them as patients.”

She shifted slightly in her chair, as if this would somehow work to her advantage in the discussion. We were sitting in the hospital cafeteria by a window that mirrored the whole room in the early morning darkness. Neither of us could be mistaken for fashionable in our rumpled scrubs that still bore traces of an emergency Caesarian section.

Now a freshly minted GP, Janet had been present at a class of residents I had been assigned to teach a few years ago. I don’t even remember what I had intended to talk about, but they had taken a vote before I arrived and decided the topic would be hypnosis. I had made the mistake in a previous class of regaling them with tales of my adventures in using it to treat hyperemesis gravidarum – nausea and vomiting in pregnancy. Unfortunately I agreed and promptly managed to hypnotize myself in attempting to demonstrate it with a volunteer using a little cut-glass pendant necklace I borrowed from the student. They loved it.

“You could see him at the end of the day, if that would make it easier for your waiting room.”

I took a deep breath and let it out slowly, but noisily for effect. “Janet, you don’t seem to understand. In the Canadian medical system, we get paid a fee-for-service amount for specific items in our specialty. There are no items in it for men.”

She thought about it for a moment. “Okay, suppose I refer his female friend to you and he just happens to come with her?”

I shook my head.

“He’s willing to pay privately…”

I shook my head again, but less vigorously. I’ve never liked the idea of paying privately for medical services; it smacks of privilege. Of jumping the queue. “You still haven’t told me why he needs the hypnosis so badly. Is he a smoker, or something?”

Her turn to shake her head. “Death!”

My eyes went wide; I couldn’t stop them. “I don’t do Death, Janet.” I considered that response for a moment. “I mean, we’re all going to die…”

She smiled -a thin, made-up, wan sort of lip stretch- and turned on her eyes. “Not like he figures.”

I didn’t like where this was going. In a specialty that deals mainly with new life, I’ve always felt uncomfortable with the other end. “What sort of illness does he have?”

Her smile brightened and her eyes twinkled. “Politics.”

I decided to look at her reflection in the window; it seemed safer, somehow. “I just know that you’re going to explain.”

“He asked me not to.”

My eyes involuntarily sought the source. “Too dangerous?” I was getting into this now.

She nodded, but mischievously. Playfully.

“And might this be… foreign politics?” I asked, attemping to make my voice serious.

She tried to keep her expression the same, but I could see little microscopic worry lines beginning to gather on her forehead. “Well, his sexual orientation is domestic…”

What did that mean? Janet was exasperating and I was tired, but she still pulled out the big gun: “Look, will you do this as a favour for me?”

I stared into my empty cardboard coffee cup for a moment. “Well, make sure he brings his partner…I’ll figure out some condition for her so he doesn’t have to pay.” I thought about it for a moment. “Maybe infertility…”

“That’ll work,” she said, but her eyes were much too twinkly for me to ignore.

“Something else you’re not telling me Janet?”

She shrugged. “He’s gay.”

I shrugged back and smiled. I love twists like this. We had an understanding, however –but an agreement that I, for one at least, did not understand.

*

He seemed quite at ease in my waiting room. A short, ebony man with a shiny bald head that reflected the flickering of one of the flourescent lights above him, he was dressed in a dark suit and grey-blue tie. A similarly well-dressed woman sat beside him, quietly reading a magazine from the table in front of them while he smiled and studied the room like a text book.

“Come in Jonathan and…”

“Flora,” he responded in a deep sonorous voice that seemed to fill the room. She smiled and took his hand. The perfect couple.

I led them into my office and seated him in the least-uncomfortable chair somewhat guiltily. But he smiled disarmingly and accepted. Then he nodded to her and she touched his sleeve and left the room. “It is best she leave,” he said softly. “The less she knows…” he added, and the unfinished sentence hung in the air like the sword of Damocles.

And then… nothing. I felt unaccountably nervous and neither of us spoke. He just watched me for a moment and then closed his eyes. “You may proceed, doctor,” he said after a few seconds. “Teach me how to hypnotize myself.”

I took a deep breath to steel myself. I felt like a child chosen at random by the teacher to come and write something on the blackboard in front of the class. “Well, first I need to know a few things, Jonathan. Janet said you’d explain,” I said with as much courage as I could muster.

His eyes suddenly opened and he stared at me like a lion who’d spotted a zebra on the plain.

“Different problems require different solutions,” I lied, and then shrugged in what I hoped was a take it or leave it gesture.

A smile spread slowly over his face, but it was a condescending expression, a bored acquiescence -the smile of a king. “I am running for office in my country,” he said in a booming voice that managed to be soft, yet vibrate the leaves of the plant on my desk at the same time.

I nodded to encourage him further, but I suppose he assumed he had given me what I had requested and he closed his eyes once more. Waiting.

I tried again. “So you need hypnosis to..?” I’ve never been good at unfinished sentences. They always sound like I’ve just forgotten what I intended to say. When his face looked like he’d fallen asleep I thought I’d better finish it. “…To help you to relax when you have to make a speech in front of a large crowd?” That sounded reasonable; I’m afflicted with acute amnesia and random mispronounciations whenever I am asked to speak at a meeting.

Still nothing. Maybe he really had fallen asleep. I decided it deserved one last try, and then I would wake him up if I had to. “What is it that worries you about running for election in your country?” I said, even though I hadn’t the faintest idea what country it was. And he certainly didn’t look worried.

Then, from the depths of his chest, a regal whisper: “Death threats.”

“Oh…” I didn’t know what else to say.

I taught him to hypnotize himself -and it seemed to work. Then for weeks after he left, I scanned the newspapers for foreign political assassinations, but without knowing the country or the office he was running for, it was all to no avail. You’d be amazed at just how many people are getting shot at political rallies around the world. And Janet was no help; she was sworn to secrecy or something.

But I can’t help wondering if it actually worked. Did the hypnosis lull him into accepting danger, or allow him to rationalize his way out of it entirely? There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy… And if he did get shot in that unknown country, would would he still thank me for the lesson if he survived? Or is he angry..?

As for me, I’m much more careful where I go when I travel. Just in case…