The Doors of Persuasion

The Doors of Perception, by Aldous Huxley -I loved that book; I read it when I was a teenager and was intrigued by the idea that there could be doors to abstractions as well as to rooms -doors to other areas, other places. Invisible portals that existed alongside more tangible things, and yet magical, somehow -like the door to Communication.

Communication is such an obvious and basic requirement to enable us to function that it is often invisible until pointed out. Almost everything we do is a form of communication; writing, creating, building -perhaps even imagining- are all done for someone else to notice –despite our ego-dominant protestations to the contrary. We, none of us, live in a vacuum –nor would we be able to, even if we mistakenly thought we might like to try it for a while.

No, the need to communicate is a given; we are social creatures. And there are many reasons for it: to reach out and feel the presence of another is a major one -to share the solitude we all inhabit and reassure ourselves that we are not alone.

And yet the other main purpose of communication –the imparting of information- can be more difficult. Is more difficult. We are all unique, and we guard the differences behind a variety of walls: culture, education, gender… There are so many ways. So many reasons. So many locks on so many doors. The art of communication has always involved the art of persuasion; to open a door, you must first want to open it -and trust that what is on the other side is neither harmful, nor antithetical to what you have become accustomed to, or are able to accept. Willing to accept.

In medicine, to open doors, we have often relied on the magic of arcane knowledge. But although communication through authority can force, it cannot persuade. Cannot convince people that what we advise is necessarily in their best interest, especially if the advice flies in the face of what they have always believed, what those around them have always lived, or what their culture or milieu has always prohibited. There is always other advice, other authorities they can consult that harmonize more readily with what they have been taught, so why should Western Medicine, as we have come to classify ourselves, be specially privileged?

I’m not convinced that in all cases, and in all circumstances it should be. There is usually not one answer that suffices, not just one approach to a problem. But if someone has come to a doctor for advice, or more unfortunately, has been swept into his purview through circumstances not of her choosing, it would be helpful to approach the issue with all the respect it demands. The trust one engenders as the doctor is assigned; it has not yet been earned on that first encounter. Authority of the sort we as doctors possess breaks down rapidly when it attempts to enforce an opinion. Contradicts a belief.

If I, for example, say that something is my belief, I may be closing a door unless the person to whom it is addressed already shares that opinion. Especially if uttered in a fashion or in a circumstance that negates the other person’s opinion -makes them lose face, or does not allow for a compromise that permits their own beliefs, and makes allowances for their own cultural practices. I am not talking life-and-death situations where emergency surgery is required to remove a ruptured appendix, say, or an antibiotic is needed to rescue the body from an overwhelming sepsis… More the situation where there may well be other options –some, perhaps not as appropriate or effective, but where the choice could still be construed as a matter of opinion –mine.

Each of us is the agent of our own lives and we should be free to decide for ourselves what path to walk. Some choices may be unwise and later we may wish we had chosen something else, but wherever possible, the choice should not be forced upon us. And indeed, one of the major premises of medical ethics forbids just that: the principle of autonomy –we should be free to choose whatever option we wish, even if the doctors disagree.

So, if we feel persuaded about the validity of our own beliefs, our own view of the world, it behooves us to unlock the doors of persuasion, not coercion. We are not always right –and that is surely not the point- but we have the best interests of our patients at heart and believe we can help. We do that by earning their trust, their respect, and their confidence. The object, after all, is not to prove that they are wrong and we are correct, but rather to help them to see that, in the face of the legion choices they could make, the one we suggest is most likely to produce the results we both desire.

I sometimes find that is the hardest part. It is difficult for me to listen sensitively to a monologue on ‘cleansing’, say, when I do not accept the thesis that disease is caused by toxins in the gut that need to be removed. It smacks too much of bloodletting, or leeches, of purgatives and enemas, of spells cast on the unwary… Attestations that the poor heart would fain deny, yet dare not. Even placebos help for a while, after all -it is the kingdom of Hope.

But it is not enough to merely try to keep an open mind -as the King says in Hamlet: My words fly up, my thoughts remain below: Words without thoughts never to heaven go. The object, where ever possible, is to stop for a moment to listen -no matter what is said. There is often fear in the other voice. And it’s a dare of sorts that the patient issues: ‘Prove me wrong; convince me if you can -I need something- but first, listen, then explain your point of view. Let me believe I have been heard…’

I want to believe that hope springs eternal in both our breasts.

 

Trust in the Tameness of a Wolf?

Okay, enough is enough! All these years I have been an advocate of cultural relativism. Ethical parity when societal mores and folkways are accounted for. I still am a staunch defender of freedom of belief and societally derived variations from what might be seen as a Western norm, but there are times when I must step back and shake my head. Some things beggar all tenets of humane behaviour. Beggar belief, for that matter… Beggar all conceptions of canon, doctrine, creed… They are ethically and philosophical bereft!

The example -the proximate cause of  this jeremiad- is one that was reported in a BBC News article entitled The WhatsApp Suicide: http://www.bbc.com/news/magazine-37735370 ‘A 40-year-old woman from northern India killed herself in January after a video of her being raped was circulated on WhatsApp.’ And, as if this madness itself weren’t sufficient to turn the country inside out, the article goes on to say ‘At village level, many are more bothered about women using mobile phones at all than they are about men using them to intimidate rape victims or to share videos of sexual assaults. A number of local councils in Uttar Pradesh, concerned with what they see as technology’s corrupting effect on traditional moral values, have prohibited girls from owning mobile phones.’ This follows from what seems to exist in some villages -at least in the region of northern India: ‘[…]in the patriarchal and honour-bound culture of the village, she could be blamed for “inviting” the sexual advances of a man – even if those advances were unwelcome, intimidating, or violent.’

It’s a two-edged sword, really, isn’t it? The women are able to use the phone and its network both for business and, presumably, to call for help, but the same phone can be used to shame and intimidate her. Blackmail her.

‘In August 2016, the Times of India found that hundreds – perhaps thousands – of video clips of sexual assault were being sold in shops across Uttar Pradesh every day. One shopkeeper in Agra told the newspaper, “Porn is passé. These real life crimes are the rage.” Another, according to the same report, was overheard telling customers that they might even know the girl in the “latest, hottest” video.’

But lest we delude ourselves into thinking that India is somehow unique in this regard, consider the case of a young woman in Egypt named Ghadeer: http://www.bbc.com/news/magazine-37735368 She shared the enthusiasm of youth throughout the world –they are, after all, young and although as privy to the social constraints as their elders, not necessarily as wedded to them. She was 18 and videoed herself dancing –fully clothed, mind you, but too clearly enjoying the freedom. It ended up being shared on YouTube by a former boyfriend in an attempt to shame her in ‘a society in which women were required to cover their bodies and behave with modesty.’ But, unlike many, Ghadeer decided to fight back.

‘[…] in the years since she had sent the video, Ghadeer had also taken part in the Egyptian revolution, taken off her hijab, and started to speak out about the rights of women. Outraged that a man had attempted to publicly shame her, she took legal action. Although she succeeded in having him convicted for defamation, the video remained on YouTube – and Ghadeer found herself attacked on social media by men who sought to discredit her by posting links to it. In 2014, sick of the abuse and tired of worrying about who might see the film, Ghadeer made a brave decision: she posted the video on her own Facebook page. In an accompanying comment, she argued that it was time to stop using women’s bodies to shame and silence them. Watch the video, she said. I’m a good dancer. I have no reason to feel ashamed.’

But as the article goes on to note, ‘Most cases of this form of abuse go unreported because the same forces that make women vulnerable also ensure they remain silent.’ Just being photographed in defiance of the prevailing dress code –a hijab, for example- could be used by the unscrupulous for blackmail or intimidation.

Or another example –one of too many, unfortunately: ‘the 16-year-old victim of a gang rape in Morocco, set herself on fire in July this year, after her rapists threatened to share images of the attack online. The eight accused were trying to intimidate the girl’s family into dropping the charges against them but instead drove her to suicide, as she suffered third-degree burns and died in hospital.’

Enough examples! That anyone would disparage the ebullience of youth is in itself despicable, but to turn that same scorn on the most vulnerable of that demographic –the culturally disadvantaged status of females in many countries- smacks of almost terminal insecurity on the part of the (largely male) perpetrators. It’s still unclear to me what it is that renders them so fearful. Surely our very identity as males derives from our difference from –not inferiority to- females.  Much as ‘up’ is only so, in relation to ‘down’, there is an ‘inside’ only if an ‘outside’ exists. These are not value-laden; not better or worse –they merely mark a difference. We are mutually needful of the contrast.

And yet, the two have come to be pitted in an almost eternal battle within both myth and reality alike -the Givers of Life against the beneficiaries… As if Oedipus had turned on his mother or sided with the Sphinx rather than killing his father -all equally pointless. Meaningless.

In a way, I’m reminded of the Fool in Shakespeare’s King Lear: ‘He’s mad that trusts in the tameness of a wolf…’ –or the excuses so readily proffered by those who, in any sane world, should have none.

A question might well be asked about the state of our domestication.

 

 

Eeny Meeny

I have always been fascinated by the idea of choice –the philosophy of choice. What does it mean to choose? Does the act of embracing one thing necessarily exclude the other, or merely prejudice it? Blemish it? Dishonour it? Alternatively, given an either/or situation, is it possible to throw the pair into a box and merely choose the box? After all, that’s (sort of) what Set Theory allows mathematicians to do –group together unlike things with common properties for analysis.

It seems to me there are several types of choice that range from necessary to frivolous, each with its own particular reason for being made, and each with its own particular set of consequences. Some choices are imposed from without, and some from within; some have to be made, while some are voluntary. Personal. The most compelling ones –for me, anyway- are those in that box –that set

The issue surfaced again for me after reading another BBC news article on non-binary gendering: http://www.bbc.com/news/magazine-37383914  I published another essay on this topic in July, but there I was more concerned with managing its language eccentricities: (https://musingsonwomenshealth.com/2016/07/13/non-binary-gynaecology/ ) I realized even then that there was much more to it than language, but the more recent BBC article really brought that home. How can you choose between two things when you are both? It would be like choosing between your son and your daughter –a Sophie’s Choice.

And yet, it would seem that Society feels more comfortable with identifiable categories –in this case, they’re usually anatomically assigned, so from that perspective, they’re not exactly arbitrary… Just unfair. Insensitive. Closed…

Perhaps my long career as an obstetrician/gynaecologist has blurred the gender boundaries as thoroughly as it has the social, economic and ethnic ones. When you get right down to it, we’re all more alike than we might like to think, and categories eventually leak like unwaxed paper cups.

I take the bus a lot nowadays –I’m not sure why, really, except that I enjoy watching those around me. And listening. Sometimes I feel a little like Jane Goodall, only my country is the bus, and my subjects, are people, not chimpanzees in deepest Africa. The other day, I happened to be on a rather crowded vehicle just after the local public schools had opened their gates. Standing next to me in the aisle were two young girls, both around eleven or twelve years old judging by their looks. Each was wearing jeans, sneakers, and coloured ski jackets, and both were hugging their backpacks to their chests, for some reason. One, a rather tall girl with short, brown hair and horn-rimmed glasses, was rummaging in her pack for something while her friend –a blond with hair that she had tied into a rather messy ponytail, watched with interest.

“Do you have any gum in there, Cindy?” the blond said, peering into the caverns of her own pack.

“No… I was just looking for some lipstick,” she said proudly, glancing at me as she said it.

“What! Your mom lets you wear lipstick?”

The tall girl blushed at the response. “Well it’s just reddish Chapstick, but it, like, reddens my lips, too…”

The blond nodded collegially, and then pointed at the two seats in front of me that had just been vacated. After that, only scattered bits of their conversation filtered back to me.

“Yeah… sometimes, I do Cindy,” the blond said, nudging her friend.

“But you said…”

“I said sometimes!”

Then Cindy elbowed her softly, as if she understood completely. “I’ve sometimes wondered what it would be like…”

“It’s kinda confusing -every so often, anyway…”

“You mean choosing which…?” Cindy seemed puzzled.

I could tell that the blond had to think about that. Then she shook her head thoughtfully. “No, more like who I am when I try to think about it…”

Cindy looked at her for a moment and then straight ahead, as if she was suddenly embarrassed. “Aren’t you just ‘Connie’? I mean no matter what you feel like, aren’t you still a Connie?”

Connie was quiet for a moment. “I guess…” They were both silent for a bit. “I don’t think names really matter though, do you Cindy?”

Cindy shrugged and looked at her. “I suppose as long as you answer…”

I could hear Connie giggle at that. “I’m still Connie… But whatever you call me, it’s still me inside.

Cindy nodded slowly but I could tell she was still perplexed about her friend. “Have you…Have you told Father Simms?”

Connie immediately shook her head vigorously and the little ponytail almost came undone. “No way! He’d just tell my parents.”

“How about your mom and dad then?”

“Mommy thinks it’s just a phase –hormones kicking in or something…”

“Well…”

“Cindy I’ve always felt like this; I just didn’t say anything.” She glanced out the window and nudged Cindy again. “Better pull the cord. It’s the next stop.”

Cindy looked up and then obliged. But as they passed me, I could hear Cindy’s concerned whisper -as if it wasn’t something she dared to say it in a normal voice. “But how come you don’t think like the rest of us in the church?”

“How do you know I don’t?” Connie said with a laugh, and they both stepped off the bus, giggling.

I thought about it for a while before my stop came. If I hadn’t just read the BBC article on non-binary gender, I would have assumed they were simply talking about God. But now that I’ve had more time to replay the conversation in my mind… I’m not so sure. Maybe I was granted a privileged audience with someone very special.

 

 

An Even More Modest Proposal

How many of you remember being presented with Jonathan Swift’s ‘A Modest Proposal’ in English 101? It was a not so subtle satire of 18th century British treatment of the Irish, in which he hyperbolically –and anonymously- suggested that the Irish might be able to ease their economic distress by selling their children for food to English gentry. It was clearly so outrageous and inflammatory that it was intended to make the readers see how wrong the then-prevailing treatment of fellow human beings could be. To alter, in other words, the perspective, and facilitate the shift to a different world view. To allow people to see what they had hitherto ignored and perhaps make them want to improve it.

My own modest proposal is less preposterous and certainly not satirical, but it does fly in the face of what we in the richer nations have come to expect and accept: only the use of professionals in our health system; and discount: the adjunctive use of non-professionals to help with some aspects of that care. It was engendered by a segment in an October 2016 PBS program and has intrigued me ever since: http://www.pbs.org/newshour/bb/can-ordinary-citizens-help-fill-gaps-u-s-health-care/ The idea that health care is becoming increasingly expensive and that even with universal coverage, there are still a lot of gaps that are unlikely to improve even with the addition of more doctors and nurses. Training and equipping them is expensive, and still does not usually solve the problem of their accessibility to those most in need –the poor and disadvantaged in our societies.

Professionals are viewed as part of a power structure that is often alien to a population all too frequently ignored, isolated and denigrated by the mainstream. Issues of cultural safety frequently play a role in this –lack of understanding and respect for cultural or economic disparities may make them unwilling to engage with professionals until the problem is untenable or even irremediable. Prejudices don’t need to be stated; they are too often felt. So the idea that there may be bridges into this demographic –keys, however counterintuitive, that could unlock barred doors- is worth exploring.

The idea of using trained volunteers to talk to those in society that are often ignored until in extremis is certainly not new. Think of the ‘barefoot doctors’ working in rural villages in China, for example. Or, ‘In sub-Saharan Africa, community health workers have long formed the backbone of health systems, filling in gaps where doctors and nurses are in short supply.’ The key concept for the acceptance of these para-medical workers, of course, was the relative lack of other facilities and professionals to fill them.

So why should we, in our relative affluence, consider the use of non-professionals? Especially here in Canada where, in 2003 at least, there were 2.14 doctors and 9.95 nurses per 1000 population? Perhaps in Malawi, where there is 1 doctor per 50,000 people (2004) the need is more readily apparent, but Canada…?  Well, it seems to me that the gap is not so much one of professional numbers as engagement. As one of the patients interviewed in the PBS program said of the volunteer that talks to her about her severe diabetes condition: ‘With your doctor, you don’t really want to say what you eat, so I’m able to tell her like, really, if I’m not going well, or, you know, if I sneaked and cheated. I tell her the right things, and she helps me.’

In other words, the volunteer is not attempting to take the place of the doctor or nurse and give medical advice, but is acting almost as a translator of patient concerns that are not verbalized in front of the doctor or nurse. We sometimes forget the power discrepancies on display between doctor and marginalized patient.

The addition of trained community volunteers should not be seen as a threat to the professions, but rather as a helpful, and essential, adjunct to expand the reach of healthcare beyond its present boundaries. Nor should it be seen as creeping multi-tiered medicine with the poor being relegated to substandard care –swept under a carpet where they can be safely ignored until they become seriously ill and show up in Emergency Departments across the land -an expensive way to provide health care, not to mention wellness-promotion. It is simply not cost-effective, no matter the system.

The volunteers can be used to penetrate the layers and develop relationships with people who otherwise might not seek help until they had no other choice. Help them to know when to seek professional advice. Check to see if they are following whatever recommendations were given; make sure they take their medicines as directed. Emergency care is expensive and its facilities limited; timely, early intervention is both preferable and, ultimately, more humane. I know that our Social Service is already doing a sterling job in this regard -especially in our larger cities- but they are stretched pretty thinly nowadays; I would think they might appreciate a little help. Doctors and nurses in the various walk-in community clinics or in smaller towns could suggest clients who might benefit from some additional help, and the word would spread from there… As I have suggested, there are layers within layers to penetrate in a neighbourhood.

And if we agree that the volunteers would be better prepared and more useful if they received an appropriate basic training course to equip them for what they are likely to encounter, why not fund this? For that matter, why not pay them? Or am I being naive?

It’s a modest proposal, though… Isn’t it?

 

 

 

 

 

 

 

 

 

From the Mouths of Babes

We take a lot for granted, don’t we? As parents we assume responsibility both for the wellbeing of our children and also their voice. Somebody has to, and obviously we, as their adult guardians, are better able to decide what’s best for them than they are –especially when they are young and inexperienced. It’s hard to argue with that, of course… At least I thought so until I happened upon an article in The Guardian newspaper that started me wondering whether the arrogance of age blinds us to a conceit that should be re-examined. https://www.theguardian.com/lifeandstyle/2016/sep/26/should-children-be-able-to-give-consent-for-medical-treatment?CMP=share_btn_link

I’m not advocating the abrogation of our responsibility to make the decisions –especially in the very young- nor to neglect to act in what we consider to be their best interests. I think it’s more about soliciting their opinions and perhaps incorporating these, where feasible, in the ultimate decision. Clearly, age is a major factor in how engaged the child will be –in the UK, at least, ‘Anyone over the age of 16 can consent to treatment, but so can younger children if doctors think they can understand and are competent to make medical decisions. Neurobiological research shows that the prefrontal cortex, home of balancing risks and rewards, is the last area of the brain to mature. So can adolescents – who are often impulsive risk-takers – be trusted to make decisions about their health?’

There was an interesting 1982 study that addressed the issue of the competency of children and adolescents to make informed treatment decisions: https://www.ncbi.nlm.nih.gov/pubmed/7172783?dopt=Abstract   In it, ‘9-year-olds appeared less competent than adults with respect to their ability to reason about and understand the treatment information provided in the dilemmas. However, they did not differ from older subjects in their expression of reasonable preferences regarding treatment.’

And indeed, there has been some effort to accommodate the child’s wishes in the latest policy statement on Informed Consent of the American Academy of Pediatrics: http://pediatrics.aappublications.org/content/pediatrics/early/2016/07/21/peds.2016-1484.full.pdf  For example: ‘When defined as agreement with proposed interventions, assent from children even as young as 7 years can foster the moral growth and development of autonomy in young patients. This consideration is based on an understanding that, starting around 7 years of age, children enter the concrete operations stage of development, allowing for limited logical thought processes and the ability to develop a reasoned decision.’

Of course, I am a gynaecologist with an adult practice, so I rarely have occasion to delve into the ethical minefield of paediatric consent, but occasionally I am exposed to its intricacies vicariously. These are frequently related to childhood vaccinations. In my Canadian province of British Columbia, vaccinations for hepatitis B and chickenpox as well as HPV (to females only –at the time of this writing) are offered to all children in grade 6 –in other words, to 11 year olds. https://www.healthlinkbc.ca/healthlinkbc-files/grade-6-immunizations Of course, ‘It is recommended that parents or guardians and their children discuss consent for immunization.’ But under some circumstances, even an eleven-year old might be considered a ‘mature minor’ and could potentially consent to the vaccination on her own: ‘In B.C., immunizations for school aged children are given in grade 6 and grade 9. Most of the time, the vaccines are given by nurses at immunization clinics held at schools. Children may also get vaccines at a health unit, youth clinic, doctor’s office, or pharmacy. In all of these settings, a child can consent to the vaccine on their own behalf if the health care provider has determined that the child is capable of making this decision.’

Ruth, a thirty-six-year-old woman whose daughter I had delivered eleven years ago, returned faithfully to my office each year for a pap smear. She had a history of several increasingly abnormal smears, eventually necessitating a minor excision procedure three or four years ago for an HPV-related pre-cancerous lesion on her cervix. Fortunately there had been no evidence of recurrence since then.

She’d always been a nervous woman -her pregnancy no exception- and the subsequent abnormality on her cervix had done nothing to alleviate her anxiety. Even her clothes seemed adjectival to the noun of her angst. Exquisitely ironed white cotton sweatshirts and similarly fussed black jeans over highly polished black leather pumps were her inviolable uniform on each visit. She wore her long blond hair tied in a pony-tail so tightly pulled from her forehead, I imagined I could see tiny fissures opening up on her scalp where it was tearing. And she constantly clenched and unclenched her fists as if she were training for some hand-shaking marathon.

Everything about her usually screamed stress. And yet, when I saw her recently, she had relaxed her hair so it danced freely on her shoulders, and was actually wearing a pale blue silk blouse and a pretty black skirt. At first I didn’t recognize the smiling woman who seemed so comfortable as she sat chatting with one of my young pregnant patients. But as soon as she saw me, she stood and grinned at me as if I were a cherished friend. I suppose I was…

“Doctor,” she said, even before she sat down as I closed the door to my office. “Remember Trish?” she pronounced the name slowly, in case I didn’t remember delivering her.

I nodded and tried not to roll my eyes. She was always telling me about Trish –every visit she had something new to report –and A in spelling, or a Silver in some race she’d entered.

“Well, she’s in Grade 6 in school now…” She stopped and scanned my face to see if I could guess what she was about to tell me. She often played this game and, sadly, I never succeeded.

This time, however, she prolonged it sufficiently long that I began to wonder if she’d forgotten what she was going to tell me. “…And you’ll never guess what happened,” she finally added -probably to tease me.

I knew it would continue like this until I said something. “What?” It wasn’t a very profound response, and I think she was a little disappointed –especially in my evident lack of excitement.

“My little Trish has grown up,” she bubbled with obvious pride. And then, when I didn’t say anything, she continued. “This is the year they all get their vaccinations…” She fixed me with a suspicious stare as she tried to decide whether or not I knew that.

I held my expression to an anticipatory smile and a nod.

“Well, she decided to have the vaccination, doctor!” I could hear the exclamation mark as it rebounded off the walls. “I mean, I’d discussed it with her beforehand and everything, but it was her decision!”

I took a deep, but silent breath. “Was there ever any question about it, Ruth?”

I could see her withdrawing into her face as her eyes took turns jousting with mine.

“She had a lot of questions at first.”

“Questions…?”

She nodded –warily, I thought. Carefully. “Mainly about the HPV one, though.”

“What did she want to know?”

I felt another probing jab with from her eyes before she called them off and sighed. “It was about the boys.” I waited patiently. “She wanted to know why they didn’t have to get the HPV vaccination.”

It was a common complaint, and one that I shared. Although several weak arguments have been made for male exclusion, none of them are convincing.

“She thought boys would have the same risk as girls, and it was so unfair she wondered whether she should refuse to be vaccinated as a protest,” Ruth said proudly.

I wondered where that idea had come from –Ruth was a zealous supporter of HPV vaccinations, I knew. “So you convinced her to change her mind?”

She shook her head. “I tried, believe me. I even phoned the school to make sure they knew I wanted her to have the vaccination.” But I could tell she was pleased that her daughter had evaluated the matter so carefully. I was certainly impressed.

“So what changed things?”

She rolled her eyes and smiled. “One of the boys in the class made a face at her.” Then she sighed. “Perhaps not the most persuasive of arguments…”

All I could do was nod. If someone makes the right decision for the wrong reasons, it’s not really a teaching moment, I suppose…

 

 

 

 

 

 

 

 

 

The Serpent’s Egg

We all see the world through our own experiences, paint it with our own colours, fly our own flags. They seem real to us –unique and even necessary to our identities. As if it’s enough to be simply what we wear; as if we are only what we’ve been taught to show. But sometimes we need distance to understand that there are other equally compelling ways of defining ourselves. Other less travelled roads.

I say this, of course, as an unwitting member of a large club in which I was enrolled without being required to read the rules. But I guess most of us say that, don’t we? Male privilege –it’s something that’s hard to see if it’s all you’ve known. Easy to deny –and certainly easier to excuse- if you’re the privileged one. Especially if you can’t even understand the claim; to a sock, everything is a foot. It’s why we have them…

I worry that it is a learned attitude, however –like assuming all girls want to play with dolls, and all boys want to play with cars. A self-fulfilling prophecy if it’s taught early enough –valid only because we know it’s how it should be. Harmless, perhaps, if it does not disadvantage either side, but untenable unless dispassionately assessed. Unfortunately, we all tend to bring our own agendas to the analysis. Our own talking-points. Our own pasts…

A state in Australia is making a brave attempt to bring some historical context to the issue, and create some early awareness of the challenges of gender perspective and gender stereotypes: http://www.bbc.com/news/world-australia-37640353 ‘Students will explore issues around social inequality, gender-based violence and male privilege.’ This is not to suggest that Australia is any different in its treatment of women, but it is a welcome departure from many countries that don’t even acknowledge the problem. ‘Primary school students will be exposed to images of both boys and girls doing household chores, playing sport and working as firefighters and receptionists. The material includes statements including “girls can play football, can be doctors and can be strong” and “boys can cry when they are hurt, can be gentle, can be nurses and can mind babies”.’ And it doesn’t stop with primary school education. ‘A guide for the Year 7 and 8 curriculum states: “Being born a male, you have advantages – such as being overly represented in the public sphere – and this will be true whether you personally approve or think you are entitled to this privilege.” It describes privilege as “automatic, unearned benefits bestowed upon dominant groups” based on “gender, sexuality, race or socio-economic class”.’ Good on them!

But I think we have to be careful to walk the middle path. Accusations are seldom neutral; they often engender anger and even retaliation from those accused. So, perhaps predictably, in Australia ‘a report on a 2015 pilot trial accused it of presenting all men as “bad” and all women as “victims”.’ It’s one thing to illuminate the entire stage for a play, but still another to spotlight only one particular area. Decontextualize it…

*

Jeannette seemed like a fairly typical young woman as she sat relaxed in her seat and talking to several other women in the waiting room. Her long auburn hair danced lightly on her shoulders when she laughed, and her eyes sparkled as she leaned over to accept a toy from a little boy who had toddled over to her on a whim. Dressed in a loose grey sweatshirt and faded jeans, she wore a fresh, newly-pregnant smile that every woman in the room could see. And even the older ones followed her with their eyes –memories of bygone years. Her joy, theirs to enjoy -if only vicariously, and for too brief a time.

But her smile faded as soon as she sat across the desk from me in my office. Her eyes were predators shackled for the moment, the cage doors open nonetheless.

“I understand congratulations are in order, Jeanette,” I said, looking at my computer screen, and missing the change in her face. “Your family doctor says this is your first pregnancy…”

“The father doesn’t want me to keep the pregnancy,” she said tersely, her lips thin and tight, and as I looked up, she sent her eyes to savage my smile, and her forehead seemed to pucker as they left.

I had never met Jeannette before, although I had apparently seen her mother as a patient several years ago. That was all the GP said  -maybe it was why he had sent her to me for her pregnancy. I took a deep breath and leaned forward in my chair. These are always difficult conversations. “And how do you feel about that, Jeannette…?”

I could see her face relax a bit, as if my response had caught her by surprise. “I… I don’t think it’s fair!” She searched in her pockets for something, and then grabbed a tissue from my desk and dabbed her cheek. “I mean he’s blaming me for getting pregnant…” She took a deep, stertorous breath and sat back on her chair. “He refused to wear a condom –he said it would show I didn’t trust him…” I could see her squeezing her hands. “I didn’t, actually… I mean we’d never slept together before, but we were good friends… and…” Her eyes had softened with tears so she dropped them onto her lap and grabbed a handful of tissues. “Well, we were both drinking –he kept filling up my wine glass and…”

I remained silent and waited for her to continue.

“And he doesn’t even believe it’s his anyway… I was too easy he said!” Her face hardened again and her eyes dared me to agree. “I got really angry. ‘You were pretty easy, yourself’, I told him. And that’s when he punched me in the stomach and left…”

I have to admit that my mouth fell open. “Did you report him, Jeannette?”

She looked at me with a puzzled expression on her face. “He’d just deny hitting me, doctor!” she said through gritted teeth as if it were obvious. “And he’s already telling my friends it was consensual sex…”

I took a deep breath and tried to keep my expression neutral. “Did you tell your GP all this?”

She shook her head. “He wouldn’t understand. I just said I was pregnant…”

I sat quietly for a moment, wondering how to proceed, when she suddenly smiled warmly at me. “Can I ask you something, doctor?”

I nodded with a smile –sometimes it’s all you can do.

“If I were your daughter, what would you say to me?”

I thought about it for a bit, then looked at her and sighed. “When you do dance, I wish you
a wave o’ th’ sea, that you might ever do nothing but that.”

Her face brightened even more and her eyes sparkled in the sunlight from the window behind me. “That’s from Shakespeare’s ‘Winter’s Tale’ isn’t it?”

I nodded, surprised both that I quoted that line of all things, but also that she knew what I meant.

“Better start filling in that antenatal form on your screen, don’t you think?” she said, barely able to contain her face.

And we both laughed. Sometimes poetry has the privilege, I realized –not gender…

 

 

The Mote in Thy Sister’s Eye

We all live in different worlds, don’t we? I suppose that’s what makes travel so interesting: to see how widely dissimilar regions and disparate societies recognize and deal with comparable problems. How, for example, they might attempt to solve the ever-growing dilemma of urban pollution. The Chinese, remember, shut down many polluting factories for part of the Olympics they hosted. It was a short term fix, to be sure, but the effects were visibly evident.

Activists, or even cities in other countries have attempted different, longer term solutions with varying success. A common one seems to be restricting the amount of vehicles on the roads, whether by licence number, type of vehicle, or on certain days of the week. The success depends on whether or not it strikes a chord in the society but, probably more importantly, whether or not it is voluntary or officially mandated. And by whom…

There is always the possibility of unintended, unforeseen consequences however bold and thoughtful the concept. Consider the deceptively simple idea of ‘car-free Tuesdays’ in Iran: http://www.bbc.com/news/world-middle-east-37430493 ‘[…] campaigners in Iran began marking “car-free Tuesdays” to encourage people to leave their cars at home in the hope of cutting down on pollution.’ The BBC article was reporting on a story in the Tehran Times, and I’ve included the link. ‘Tuesday was chosen because it is in the middle of Iranian week when traffic congestion is high and air pollution at peak.’

All well and good, even if unofficial and as yet unsanctioned, ‘the campaign was kicked off by Mohammad Bakhtiari, 25, who has majored in architecture and is a member of a local NGO with 1,000 members known as “the guardians of the environment of Arak city.’ It seemed like a good idea –it is a good idea- but there are issues… The idea was to encourage people to use alternate, less polluting forms of transportation –buses, or perhaps car-pooling, but especially bicycles to get around the city. Iran is a very conservatively run theocratic society, and women have long had to conform to various religiously mandated restrictions. And yet, ‘It had been understood women that [sic] could cycle as long as religious concerns were respected. But when asked recently, Iran’s Supreme Leader, Ali Khamenei, said women were not allowed to cycle in public or in the presence of strangers.’

Of course I’m not from Iran, nor do I even pretend to understand Islamic legal opinion, but I think that this fatwah –if such it is- involves a fair amount of cognitive dissonance even in a society that is used to seemingly arbitrary restrictions being imposed upon it. Presumably atmospheric pollution was not something anticipated in religious jurisprudence –it’s barely appreciated in civil law even today. A Fatwah, I’m given to understand however, is expected to break new ground –otherwise it might be considered simply a ruling –a considered opinion on the interpretation of existing writings. So I’m puzzled as to why, given the chance to become responsible caretakers of the Divine Creation which all religions purport to acknowledge, that the opportunity would not be seized and glorified. It might even go a long way towards mollifying some of the public antipathy about some of the more obviously capricious restrictions.

Just a thought, though… Why can’t women do their parts? If they adhere to religious codes of dress and conduct, aren’t they as much stewards as anybody else? Of course it’s now gone Twitter… And the social media campaign founder Masih Alinejad has said, “It is unacceptable in 2016 when you hear that a group of female cyclists have been arrested in Iran for the crime of riding a bike in a public place and made to sign a pledge promising they will not cycle in public again.” She is speaking out from the relative safety of New York, however. And I am writing from the relative safety of New Zealand… I ask myself why that should matter.