The Custom that dare not speak its name

The custom that dare not speak its name… Not until recently anyway. Now it seems all the rage to study the practice –expose it, as it were. And while I confess to paraphrasing the famous euphemism used in the trial of Oscar Wilde in 1895, I’m talking about something completely different. I’m talking about… well, grooming, as it’s prosaically termed.

Not grooming, you understand, but grooming…

I suppose ‘they’ (a nice term to offload responsibility) had to come up with a suitably un-nuanced descriptor for something hitherto off limits -although it’s not meant to conjure up images of what you might do to the coat of a horse or the fur of a cat; it’s meant as more of a tidying up process…

Still, even as an older gynaecologist, I have to admit to a little surprise at it being a subject worthy of publication in the prestigious Journal of American Medical Association’s (JAMA) Dermatology: http://archderm.jamanetwork.com/article.aspx?articleid=2529574 -the title of which, I blush to confess, immediately caught my eye: Pubic Hair Grooming Prevalence and Motivation Among Women in the United States. And then, after digging around for a more popular media source from the same time period, I found an article in the Guardian that references it: https://www.theguardian.com/lifeandstyle/2016/jul/11/should-groom-pubic-hair-shaving-trimming?CMP=share_btn_link

The practice of shaving the pubic region is certainly not new. It has been practiced in some cultures for hundreds of years, and early documents have suggested that it was an occasional practice amongst prostitutes in the middle ages, presumably for ease of maintenance as well as any aesthetic benefits. But the custom, at least in North America, seems to ebb and flow in its popularity. The JAMA study suggests that currently, it seems to be most popular in younger women –especially those between 18 and 24- and to some extent, those women with more education. ‘Race was also significantly associated with grooming, with all groups reporting less grooming when compared with white women. No association was found between grooming and income, relationship status, or geographic location.’

Over my many years in women’s health, I can’t say I even notice the grooming status anymore –unless, that is, there is a problem.

I had seen Janice before; in fact, both she and her mother came to see me from time to time, but seldom together –I don’t think they got along very well, to tell you the truth. Each of them were pleasant enough to me, but I suspect that her mother may not have understood her need to develop an independent identity. That’s what Janice told me that day in the office, at any rate.

A very active 19-year-old, she usually arrived in bike gear –helmet, tight lycra shorts, and a flush on her face both in apology for being late, and as the inevitable result of both cycling from her home several kilometers away, and running up four flights of stairs. This time, however, she’d not only been on time, but was also wearing the only dress I’d ever seen her in. And she seemed very uncomfortable as she sat fidgeting in the chair across from my desk.

“Took the bus in today,” she said –in response to my expression, I suppose. “Michael thought I should.”

“Michael?” I asked, and then immediately regretted it –I’m expected to remember these things. But I never can; it’s like trying to remember what colour socks I wore on a patient’s last visit.

“Yes… my guy.” She watched my face for a moment and then capitulated. “I told you about him a few months ago when I saw you for the birth control pill, remember?”

I pretended to remember –unconvincingly, judging by her expression.

“Mom still doesn’t approve of him, though…” She noticed a tiny movement in one of my eyebrows and smiled. “She thinks he’s too controlling,” she explained, but with eyes that told me I should have remembered that as well. “I mean she should talk, eh?”

I could feel another memory accusation coming up, so I decided to smile and change the subject. “Why have you come in to see me today, Janice?” I said.

She seemed relieved that the small talk was over and she could finally talk about it. But then, quite uncharacteristically, she blushed and looked at one of the paintings hanging on the wall as if it had suddenly called to her. “I… Uhmm, I’ve got a problem in my vagina.” She closed her eyes tightly to think more about the location. “No, not really the vagina, more the area around it, I guess.”

I waited for her to continue, but she seemed to have decided that she already told me enough. “And so, what…?”

“Little cuts,” she interrupted, almost as if I should have known right away. “Michael noticed them right away,” she added, to validate her claim.

“When do…?”

Her embarrassment was making her irritated at my repeated questions, I think.

“I’ve had them now for two or three days, and Michael is getting worried about them.” She stared at the picture again. “I told him they’d heal on their own, but I think he’s afraid of catching something…” she whispered to the wall. “I’m sure that’s why he insisted I come in for a check,” she said, turning to me again.

“Well would you like me to examine you?” She’d been sending her eyes out on little excursions while we talked and I got the impression that she only wanted to discuss her problem, so she could tell Michael about it. It was her choice.

She examined me with a puzzled expression on her face, her eyes firmly perched. “Well… I feel a little awkward about them,” she said slowly.  “They’re just cuts, I’m sure.”

I kept my face neutral. “And does Michael have any of these ‘cuts’?” Sometimes sexually transmitted diseases have unusual manifestations.

She kind of cocked her head and stared at me with a wrinkled forehead. I was obviously asking silly questions. “No, of course not! Why would he?”

I was about to answer her when she pre-empted me. “I mean he shaved me,  I didn’t shave him.” Her eyes suddenly twinkled. “I’m gonna suggest it next time, though.”

It dawned on me that George Bernard Shaw was right: ‘It is all that the young can do for the old, to shock them and keep them up to date.’

 

The Grief that does not Speak

How weary, stale, flat, and unprofitable seem to me all the uses of this world!

Like Hamlet, we all recognize this mood: the black dog lying in the noonday sun, the cloud that even hides the moon. It is the tear that defeats the wavering smile –and yet… And yet, there is often something more behind the grief, something that is hidden beneath the first impression. Shakespeare, again, understood this over four hundred years ago: ‘Give sorrow words. The grief that does not speak whispers the o’erfraught heart and bids it break.’

I suppose we all impose our own reality; we all see the world through our own experience. But, sometimes we see through that glass darkly. Things are not always what they seem.

Alethea looked calm and happy as she sat in my waiting room. In fact, she was smiling and talking with a little child who’d toddled over to her in his diapers with a toy. She was bending over in her seat, her long black hair almost reaching the little boy, as she tried to make him laugh. Her full-length black, cotton skirt and her blue silk blouse contrasted sharply with his bulky white diapers –a chiaroscuro worthy of a picture, but he waddled off to another woman as quickly as he’d arrived. The waiting room is like that here: a work in progress; an evanescent scene of fleeting beauty.

Alethea smiled again when I greeted her, and examined me with friendly eyes. I had anticipated avoidance, or at least timidity from a woman referred to me with recalcitrant depression. A woman, according to a rather extensive explanatory note, who seemed refractory to multiple attempts at treatment. But I’m a gynaecologist, and although we’re sometimes involved on the edges of depressive illnesses, most of us lay no claim to the territory. We’re adjuncts –often last-minute guests- invited to the therapy just in case; we’re seldom primaries.

But in my office, she seemed less at ease, her eyes flitting from the plants in their pots to the eclectic pictures hanging on the walls. They spent some time inspecting a terra cotta sculpture of a woman begging with a bowl that I’d positioned on a little oak table.

“You certainly have wide-ranging tastes, doctor.” I don’t think she meant it as a criticism, so I took it as the long missing compliment I have yet to hear from my staff.

I smiled, and opened up the computer.

“I’m afraid my GP wrote a rather long note justifying the referral to you; she seems quite worried –or maybe frustrated with me.” Alethea rested her eyes on me for a few seconds. “I asked to see you rather than a psychiatrist.” And then she chuckled. “She was not happy about that, I’m afraid.”

I pushed the computer to one side and sat back in my chair. “Do you mind if I hear your version, first?” I asked.

“Thought you’d never ask,” she said as she made herself more comfortable in the sturdy, old wooden captain’s chair that I insisted on keeping across from my desk, her eyes twinkling with amusement at my suggestion, but still cautious.

“Well,” she started, obviously trying to place the events in their proper order, “A few months ago, I went to see my GP because of some problems I was having –you know, coping stuff,” she added when I wrinkled my forehead. “Anyway, I was in tears when I sat down in her office and had trouble even talking to her without crying.

“She got very clinical and I could tell she was trying to remain an objective observer.” Alethea rolled her eyes and sighed. “She does that sometimes when all I need is a hug or something.” She risked a quick glance at my expression. “But I realize that’s not what doctors are supposed to do…

“Anyway, she asked me all the usual questions about my work, and my home life…” Alethea blinked and looked away. “I think she felt a bit uncomfortable with that part because my partner also used to go to her.” Suddenly she stared at me and I could feel the anger in her eyes. “I really don’t know why that would matter…”

She quickly snatched a tissue from my desk and wiped her eyes. “I’m sorry, doctor, I guess my GP is not the only one who gets frustrated.” She took a long, deep breath and exhaled it slowly. “She said she’d never seen me like that before, and that whatever might be going on, I was seeing it through the lens of depression.” She glared at the begging lady statue for a moment. “She actually said ‘lens of depression’ for god’s sake! Like no matter what I said, or experienced, it was somehow misinterpreted through that bloody lens, or whatever.”

Alethea seemed uncomfortable and kept readjusting her body on the hard chair so I pointed to a more comfortable one nearby. That got her smiling again, but I could tell she was still angry.

“She insisted I go on one of those new antidepressant medications –you know, the ones that aren’t supposed to make you tired. The ‘no side-effects pill’ she called it. ‘Just try It for a few weeks and let me know if it helps,’ she said and escorted me to the door, all buddy-buddy.”

She brought the comfortable chair close to the desk and helped herself to a handful of tissues. “But it only made things… worse.”

I leaned forward on my chair, detecting something she was implying in the way she said that word. “How do you mean, Alethea?”

A tear rolled down her cheek and she dabbed it with the tissue. “I didn’t feel at all like sex, when I was taking it and…” She hesitated for a moment. “And that really made her mad.”

I was confused. “Made who mad?”

She was staring at her lap, but her eyes wandered up to my face for a brief look before she called them back. “My partner.” She sighed again. “So I decided to go off the antidepressants after a while and went back to the GP. She seemed upset that I had only given them a month, and said I was still acting depressed. At that point she said I needed to see a psychiatrist, but I refused. ‘You have a chemical imbalance,’ she almost screamed at me, and implied that if I didn’t get help soon, there might be dire consequences.” Alethea glanced at me again. “I suppose she thought I might try to off myself or something.” She giggled at the thought and when I looked puzzled, she smiled and continued. “Maybe it’s your birth control pill, Alethea. I don’t know why you insist on taking them anyway.’” Alethea’s face turned mischievous and her eyes twinkled like when she first came in. “Because I’m Bi, you stupid woman!” she said and laughed. “Well, I didn’t actually say that to her, but I felt like it…

“Anyway, I convinced my GP to send me to you.”

I squirmed a little uncomfortably in my own, soft chair. “Why me?”

A playful smile emerged. “My aunt and cousin see you… They said maybe you’d listen.”

I think I blushed. “And what about your partner? Did she think you were… depressed?” I hesitated before using that word. “Did she listen?”

Alethea’s face suddenly tensed. “She was abusive,” she said between gritted teeth, and sent her eyes to scout my face again. “She used to scream at me and throw things around. I hated going home after work.”

“Did you tell that to your GP?”

She shrugged. “I told you, she felt uncomfortable about it. And anyway, she had a diagnosis –and a treatment,” she added, with a wry smile. “That’s what medicine is about nowadays, isn’t it?” The smile disappeared, to be replaced by a sweet grin. “And once you have a treatment, it’s… Next!” she said, rolling her eyes, and we both laughed.

“And so what’s happening now? Are you still with your partner?”

Her face beamed and her eyes sparkled. “Now, I’m back with my old boyfriend -it takes a long time to get in to see you,” she explained with a chuckle. “We’re even planning to have a child soon, maybe.” Her eyes hovered under the ceiling for a second or two. “I guess I wasted your time, doctor, but my aunt was right -it does help to talk about it… And I thought I should meet you anyway,” she added, and decided to make eye contact again. “You delivered my cousin last year…” The twinkle returned. “Care to see me again –in a while?”

I think my smile told her I’d love to see her again.

And as she left, I couldn’t help but think of that wonderful metaphor of Khalil Gibran: ‘Sadness’, he said, ‘is but a wall between two gardens.’

It certainly is.

Biding the Pelting of this Pitiless Storm

Hubris –the extreme arrogance that was so offensive to the old Greek gods that they reacted with punishment and an exile from grace- is that what this is? I’m not sure anymore… It’s not, perhaps, so obvious as the vaulting ambitions of a Macbeth or the arrogance of a Caesar, nor even the overweening pride of an Oedipus in the Sophoclean plays, and yet… And yet, viewed from a distance, it’s hard not to notice the similarities that inhere in the attitude that End justifies Means, that intentions trump consequences, that methodology is the servant of results –however narrowly beneficent we define them. And it’s important that we not be so blinded by those touted benefits that we ignore other, perhaps less harmful routes, to achieve them.

And what, you may reasonably ask, prompted this jeremiad? It was a study reported in the New England Journal of Medicine (NEJM) on the addition of a second and possibly more powerful prophylactic antibiotic during non-elective Caesarian Sections to reduce post-operative infection rates: http://www.nejm.org/doi/full/10.1056/NEJMe1610010?query=gynecology-obstetrics -certainly a worthy aim, to be sure. Who could possibly take issue with that? Well, in this era of increasing antibiotic resistance, and the unfortunate dearth of replacement antibiotics in the wings, I think not only the study, but also the idea demands more than a cursory analysis. This is not to criticize the intent, so much as to explore alternative roads to the same destination.

Few would argue that antibiotics, when they are deemed necessary, should be used according to the infecting bacterial sensitivities if they are available –or considered expectations as to sensitivities if they are not. It’s why we can no longer use penicillin for everything –not all infections would respond. Surgical prophylaxis (where there is not yet an infection) is one of the few exceptions, and even there, the antibiotics are chosen in anticipation of the type of bacteria that might reasonably be expected in the surgical field (although there are some who believe that their effect is merely that of decreasing the total bacterial load in the area whether or not the expected ones have been targeted). But, nevertheless, we toy with resistance at our peril.

I’ve chosen to link the editorial rather than the study itself because of the insights it offers. The full-length study to which it refers can be accessed via a link in that editorial, however.

As I mentioned, the study by Tita and colleagues, in a randomized trial, attempted to reduce post-operative infections by adding another broad-spectrum antibiotic (Azithromycin) to the usual antibiotic (cefazolin) in non-elective Caesarian sections (i.e. there was some condition in mother or baby that required urgent delivery) where the current infection rate was 12% -and it worked! Compared to the usual group that just received the cefazolin alone, they dropped the infection rate to 6.1% -not zero, but at least an improvement. And, ‘Neonatal outcomes, which were tracked up to 3 months, were similar in the two trial groups.’

But on closer analysis, 73% of the population in the study was obese -and that, plus the fact that the Caesarians were unplanned, certainly added to their risk of infections. So far, so good.

But, as the editorialist wonders, could the fact that these women were obese have meant that the usual dose of cefazolin was inadequate: ‘[…] should the potential pharmacologic benefit of higher doses of cefazolin alone be evaluated further before the addition of a second agent?’

Another consideration leading to the study of adding azithromycin to the regimen, was that it may be useful for eliminating a potentially  infective organism in the vagina –ureaplasma– that cefazolin doesn’t touch. Unfortunately, there are no prospectively adequate data for the contention that the organism was even present in the studied women.

And finally, the azithromycin was more beneficial in those women whose incisions were closed with staples, and there seems to be evidence that staples, themselves, may increase the post-operative infection rate.

So why, you may ask, have I chosen to comment on this rather obscure study –especially since it seems to have demonstrated the benefits it expected? First of all, I think we have to be careful that we don’t lose sight of the forest as we wend our way through the undergrowth. There do seem to be other options that could be explored before the addition of yet another antibiotic –and indeed should be anyway, given the non-zero infection rate even with the addition of azithromycin. Such things as more ‘stringent adherence to infection-control protocols’, avoiding the use of staples in this high-risk population, or even re-calculating the dose of the standard prophylaxis (cefazolin) to account for differing patient weights before deciding to add the new antibiotic.

I don’t mean to be the new Cassandra, issuing thundering prophesies of doom that will not be heeded anyway, or aspersing well-intentioned attempts to improve our lot… And yet we must not forget that consequences follow actions, not precede them. To be fair, we do try our best to anticipate and thereby avoid, or at least minimize them, but history is riddled with examples of unintended outcomes. The road to disaster is paved with should’ves –only seen with clarity, after arrival.

It seems to me that, wherever possible, we should be exploring options that reduce the likelihood of incurring bacterial resistance. And the answer may not lie in the reliance on new antibiotics -new guns for our on-going war with the microscopic world. It’s a battle in which we cannot hope for more than a temporary truce while we search for peace. Without that, as the map makers of old were said to write on unexplored regions, Here be dragons.

 

The Impossible

So, Trump has convinced his country that he should lead. I did not think America had drifted so far; I did not realize it was so out of touch with us -and me… It brought to mind a poem I wrote years ago, not ever believing the impossible could come to pass:

 

The Impossible

Is not something

I can understand,

Or even compute

With words.

Like infinity,

It is defined in terms of what

It is not

Or ever could be,

Realistically.

Even Maybe does not cover it

Completely,

Although it paints a kind of curtain

That lets through

Light,

Almost.

Sometimes briefly,

Like our attempts

To conceive what lies behind,

It is

A labyrinth of smoke

Forever weaving new patterns

From the old.

No,

What cannot be

Is often locked away

In arguments

And definitions –

Words whose meanings

Are not cast in stone,

But trapped in sentences

By the years.

Impossible

Is what is not

Now,

And by default

Will lose,

Perhaps,

Even before

It has begun.

Is Beauty really skin deep?

Although love looks not with the eyes but with the mind, as Shakespeare reminds us, there is a redness of the cheek that is not as kind as a simple blush. So may the outward shows be least themselves, he also says. The world is still deceived with ornament.

Acne arrives at the wrong time of life; it usually declares itself around the same time a teenager is trying to establish her identity; trying to acquire independence; experimenting with relationships outside the family. It is a time of uncertainty when self-esteem and confidence may be suspended, like the Sword of Damocles, on that single hair of outward appearance.

Acne is nothing new; it has probably been around as long as there has been skin with hair follicles to get blocked. Oil from glands is one of the culprits and these are more common on the face and upper body. The hormonal changes of puberty may result in changes in activity of these glands -that, plus genetics, and excessive growth of the bacterium Propionibacterium acnes, all contribute to the unfortunate timing.

An article last summer in the BBC News reminded me of the consequences that affected a patient I once saw in my office for gynaecological consultation.  http://www.bbc.co.uk/newsbeat/article/36712810/doctors-warn-acne-could-become-resistant-to-antibiotics

The waiting room was full that day and I saw Janice sitting quietly in the corner, her face almost buried in a magazine. She was a tall, thin, sixteen-year-old wearing tight designer jeans with a cream-coloured baggy sweater and beautiful deep blue hijab that she wore sufficiently loosely around her head that, even when she looked up, seemed to cover most of her face.

At first I wasn’t sure what to make of this. I wondered if it might be a cultural, or religious requirement for seeing a male gynaecologist -or merely a teenage affectation. But apart from her continuing reluctance to expose her face, she seemed more at ease once she was seated in my office.

The consultation note from her GP was one word: Contraception!! -with two exclamation marks. I took that as a sign.

“So, what can I do for you, Janice?” I usually like to let the patient tell me why they were referred; it’s sometimes different than what the family doctor thinks.

She shrugged. “Birth control, I guess…” But she seemed rather unsure.

I smiled and tried to make eye contact, but she continued to look away, first to a painting on the wall beside her, and then to the other wall where I had placed a terra cotta statue of begging woman on an oak stand. Janice seemed to favour the statue.

“Is that for tips?” she said, indicating the bowl the woman was holding in front of her. It was filled to overflowing with coins.

I laughed and shook my head. Everybody seems to ask the same question, and then puts a coin on the pile. “I’m not sure why some people do that, but I empty it from time to time and give it to real people begging on the street. I like to think that’s what my patients want me to do with it.”

She turned her head to look at me and I could see a smile peeking from the shadows inside the hijab. “I didn’t bring any change…”

My smile broadened. “That’s okay, I’ll put a coin in the bowl later for you if you like.”

The hijab nodded.

I settled back in my chair. “So you want to discuss contraception, Janice?” Another nod. “What have you been using so far?”

She shrugged. “Condoms at first…” She hesitated and then sighed. “Then when we got to know each other better, I went on the pill.”

“Is that what you’re on now?”

She shook her head. “They didn’t work. Well…” She lowered her head, so all I could see was the top of her hijab. “Actually, I kept forgetting to start them again after my period…” Two eyes peeked timidly from the shadows on her face. “So I had a couple of… accidents.”

She said the last word in a whisper I could hardly hear as she lowered her head to look at her lap. Suddenly, her head jerked upwards to face me and she pulled the hijab back so I could finally see her face. Both her cheeks were rough and jagged seas of red nodules, some weeping and moist, some merely little cysts about to burst. I could understand why she had chosen to wear her hijab as she did.

“My GP tried me on several kinds of treatments for the condition, but none of them helped. In fact, it was getting worse, so she sent me to a dermatologist. And she just put me back on higher doses of some antibiotic I’d already been on: mino-something.

“Minocycline?”

She nodded, and her eyes filled with tears, so I handed her a tissue from the desk. “But she said it was dangerous for a developing baby, so I had to stay on the birth control pill.” She looked up at the ceiling for a moment, shaking her head. “I told her I kept forgetting to take them, but the doctor just shrugged and told me to write little notes for myself… Stupid woman!

“After the second abortion, my boyfriend and I decided the birth control pills didn’t work so I stopped them. When I told my GP about it, she took me off the antibiotics, too… I guess because she thought I might get pregnant again…” She wiped her eyes and grabbed another tissue from the box I kept on the desk. “And now look at me!”

Her eyes flitted around my face for a moment, and then she summoned them back. “They wanted to put an IUD in me at the time of the second… procedure, but I wouldn’t let them.” Her eyes found mine again. “They recommended the hormonal one.” She seemed on the verge of tears again. “But they told me it might worsen the acne.”

All of a sudden, she leaned over the desk towards me –as if she wanted me to really see what she had to deal with. “I can’t stand my face like this!” She sat back in her seat again. “My boyfriend has already left me; my friends whisper behind my back. Everybody is afraid to look me in the face…” She grabbed a handful of tissues this time and dabbed her cheeks when she’d dried her eyes. “I’m really confused, doctor. Nobody seems to know what they’re doing; they keep changing their minds…

“I can’t go on like this! I can’t…” She took a deep ragged breath. “I need somebody to tell me what to do before I fall off the edge… Or jump,” I heard her whisper into the folds of her hijab.

And then her eyes almost bored into my skull. “Can you help me, doctor?”

Her expression worried me; she was desperate and clearly in crisis -obviously at that edge. I had to do something.

“Tell me, Janice, when you were on both the pill and the antibiotics that last time, was your acne improving?”

She nodded vigorously. “The doctor told me the hormones in the pill sometimes help.”

I smiled in agreement, although I didn’t feel comfortable dealing with acne; I suspected she needed to go back on the antibiotics and her GP was right, she needed absolute protection against pregnancy while she was on them. Minocycline is a class D drug –meaning there is positive evidence of human fetal risk.

And then something occurred to me. “Was it only when you were restarting the birth control pill after your period finished that you forgot to take them?”

She nodded, obviously embarrassed. “There was a lot going on in those days…”

“But you were happy with the pill? I mean it wasn’t giving you any problems?”

“No… except for the pregnancies.”

“So, if you didn’t have to stop the pill for a period, would that work for you?” I watched her closely. “I mean, do you think you would remember to take them?”

She nodded carefully, and stared at me. “Yes… But you mean I wouldn’t have any periods?”

I nodded. “You can take the birth control pill every day for three or four months at time –or even more- then stop and have a period.” Sometimes the simplest solutions work the best.

She thought about it for a moment. “Uhmm… But if I didn’t get my period, how would I know I wasn’t pregnant?”

A good question. I smiled what I hoped was a reassuring smile. “Well, it’s true that Minocycline can interfere with the absorption of the pill, but the risk of pregnancy is still low. And you should supplement the pill with a condom.” I waited till she made eye contact again. “In fact, if you’re starting a new relationship, wouldn’t condoms be a reasonable precaution anyway?”

The acne made way for a face-swallowing smile. “I’ve sworn off sex… Well, at least until I get my face back.” I could tell she was blushing, even under the hijab. Even under the acne.

But I could finally hear some hope in her voice, and I was reminded of another verse from Shakespeare: ‘I will go wash; and when my face is fair, you shall perceive whether I blush or no.’ It seemed fitting, somehow…