Trolling for a Cause

Okay, full disclosure: in my day, ‘trolling’ was either dropping a baited fishing line in the water behind the boat as you cruised, or watching out for Billy Goat Gruff villains under the next bridge. I didn’t realize just how much I was in need of a more recent update. I mean why does everything now seem to have an online reference? A diktat. That which was once perfectly happy as a denotative word, complete with papers as an official definition, has since wandered onto the wild side beyond the tracks and reinvented itself as a ‘connote’ –or whatever the noun for its once respectable verb might be. I suppose I could look upon their ilk as metaphors, but I suspect they are a little too slippery to be confined like that.

Maybe what has drawn my interest this time is an article I saw a while back on my BBC news phone app: http://www.bbc.com/news/world-asia-38267176 That I am being critical of matters to which I may, online at least, be naively party, has not escaped my notice. Irony, if not denotatives, can sometimes coexist, I suppose.

At any rate, it’s the issue of media advice I wish to address here. And the issue, I must confess, is problematic to say the least. In brief, a young London woman, Dami Olonisakin, began to write a sex and relationship blog, Simply Oloni, in 2008 because she felt that a lot of women didn’t have anyone to speak to. ‘It began as a personal lifestyle blog and she wanted to be the person that someone could speak to without being – or feeling – judged.’ Fair enough. She wanted ‘to give out impartial advice – something she believes can be more valuable than the opinion of a friend or a relative, who could be too emotionally involved.’ The identities of the participants and their problems were kept confidential and indeed she did not set herself up as an expert, merely an intermediary, as it were. She posted the problems on her Twitter account for her ‘26,000 followers to also share their advice and tips on the dilemma.”

It became quickly apparent, as she herself admits, that not every reader was happy with reporting the sorts of problems she receives. ‘”Not everyone has accepted that women are allowed to talk about sex freely, and we are allowed to embrace our sexuality; whether it’s choosing to keep your virginity until you’re married, or wanting to have casual sex, or wanting to be friends with benefits,” she says. “Your sex life is not a decision for other people to dictate.”’ And the critics were apparently not kind in their responses -they ‘trolled her’, to lapse into the vernacular for a moment: ‘”I’ve had trolls online telling me I’m ‘disgusting’ for suggesting that girls dating more than one man [at a time] is fine,” she says.’

A lot of things can be said under the cloak of online anonymity, to be sure and I suppose venting it serves some purpose or other… but as the inadvertent recipient of ‘trolling’ for writing a supportive comment on a news item a friend had posted online, I can attest to the concern –and even fright- that the vitriolic response elicited. It was almost as if someone had entered my house while I slept and spray-painted a hateful epithet on the bedroom wall. Perhaps I deserved it for daring to evince support for something in public -sorry, online; nobody agrees with everything, after all, but it was the emotions, the hatred, oozing from the words that felt threatening. And yet, maybe that’s just my age talking -presumably most youth today have evolved an internet shell under which they can shelter. But as the devastating effects of internet bullying have demonstrated, the shell is far from impervious. Far from universally distributed.

As bad as ‘trolling’ and internet bullying may be, however, I am more drawn to the courage of Oloni in recognizing the need that women –all of us, really- have a desperate wish to be heard. And to be heard impartially, non-judgmentally. Friends, clergy, and even doctors have the unfortunate habit of diagnosing and then advising; sometimes the person doesn’t want a diagnosis, let alone a treatment –she just wants someone to listen. Often the simple act of describing something to a dispassionate ear, is in itself a cure –or at least a relief. We don’t always require advice either –sometimes just a respectful silence. An acknowledgment.

This is often readily apparent in the privacy of my consulting room. I am a gynaecologist by trade, but occasionally ‘sounding board’ would describe it better. Deborah, a normal-appearing 38 year old Caucasian woman, was a good example.

She had been sent to me by a worried family doctor because of her heavy periods. Nothing the GP tried seemed to be working, so in desperation she had sent her reluctant patient to me to see what I could do for her. All of her tests were normal –iron stores, haemoglobin level, ultrasound of the uterine lining, and even a biopsy of those same cells (just in case) as she put in brackets.

On taking her history, Deborah assured me that her periods were quite regular and predictable, and on the whole, not any different from what she had experienced for years.

“I shouldn’t have mentioned them to Dr. Cameron,” she said once I had finished the history. “My mother and her sister both have heavy periods, so neither of them seemed at all worried when I was a teenager. But my GP seemed adamant: they were too heavy. In fact, she put me on all sorts of pills to decrease the flow…”

“And did they work?” I’m not sure why I interrupted her at that point, except for her eyes. They kept wandering to the pictures on the wall, or out the window to the tree outside. It was almost as it they feared to seek shelter on my face.

She shook her head at first, and then grinned. “Well, actually I didn’t take them -they were samples anyway, so…” She thought about it mid-sentence, and then suddenly revised it. “Well, actually I did take one and it made me feel sick, so that was it for the pills, I figured.” She shook her head sadly and then sent her eyes to explore the wooden carving of a woman holding a baby I’d positioned on my desk behind a plant to make it look as if she were hiding. “I felt like that woman,” she said, pointing at the carving. “You know, like I needed to hide from all her well-meaning advice.”

She was silent for a moment, so I waited. “I think Dr. Cameron had a thing about periods, actually. Each time I’d return for follow-up, she would smile and shake her head in that conspiratorial way women have –you know: ‘what a life we have to live’, and all that. She tried several contraceptives that I never took. And then she suggested a progesterone IUD that I refused.” Deborah finally allowed her eyes safe passage to my cheeks. “I only let her do the biopsy because she felt so upset about her treatment failures. She needed to find something. An explanation. Or better still, a solution.

“But I started to get really worried when she began to hint that I might need surgery. ‘Maybe just an ablation to get rid of the lining cells of the uterus,’ she added –probably because my face went pale.”

Deborah sat back in her chair and scrutinized my face, obviously more relaxed than when she’d entered the office. “Dr. Cameron suggested I see a gynaecologist that she was going to recommend, but I didn’t recognize the woman’s name. And anyway, I wasn’t so sure I wanted to discuss it with another woman…” A mischievous grin surfaced on her lips. “I figured I needed a non-participant… Neutral territory,” she added, her eyes twinkling. “And anyway, my mother sees you and she’s still got her uterus at seventy-three, so…” She blinked; it was my turn, apparently.

I shrugged and tried to suppress chuckling at her posture. She was comfortably ensconced –slouched, actually- in the far-from-comfortable wooden captain’s chair across from my desk, looking like she didn’t have a care in the world. I couldn’t remember anybody owning the chair –owning the office– like she did at that moment. “Well, Deborah, I have to say that I’m not worried about you.”

“No ablation? No hysterectomy…?” She pretended to pout. “Nothing?”

I smiled. “Well, if the periods get worse, you could always come back…”

The mischievous look returned. “Don’t worry, my mother would make me.”

 

Time Out, eh?

Time-outs to wring behavioural change from naughty children are all the rage nowadays. Everywhere you go there seem to be men sitting near their tantrum-laden little boys in the parking lots of stores, or women standing outside of cars fastidiously ignoring the screams of alternately pounding and pouting children confined within. Perhaps this has been going on for years, but only recently have I begun to notice the ritual. In fact, it seems so ubiquitous, that I am beginning to suspect a flaw in my own upbringing. I don’t remember being an easy child; maybe I just had easy parents. Or maybe the Encyclopedia Britannica of the age didn’t cover that aspect of childrearing.

It might be investigating the obvious, but I had to look it up at any rate. Time-outs are more acceptable attempts at behaviour modification than corporal punishment –spanking comes to mind- especially in public, where the difference between remonstration and child abuse is uncomfortably opaque. The idea of social exclusion was likely popularized in a paper by a Dr. Montrose Wolf at the University of Washington in the mid 60ies, drawing on the work by his mentor, Dr. Arthur Staats (who called it ‘time-out’).

But, unless you grew up in Winnipeg in the 1950ies, you might now regard time-outs as such an intuitively obvious way of treating both the child’s misbehaviour and the resultant parental frustration, that you would be forgiven for assuming it had been hard-wired in our DNA. Perhaps it was, but with variable penetrance, and probable mid-prairie epigenetic modification –anyway, there seem to be some issues with its application: http://www.cbc.ca/news/health/time-outs-study-parenting-1.3888166

By default, I suppose I’m an educationally impoverished repository of doctrinal wisdom when it comes to children. As an obstetrician, for years -until my own arrived, at least- my responsibilities ended with handing the freshly-liberated, and usually screaming newborn to the mother, tidying things up, and then congratulating the smiling, emotionally overcome parents before I left the room. I didn’t expect to be confronted with any of their subsequent behavioural peccadillos. But, as Shakespeare’s Cleopatra remarked, those were ‘my salad days, when I was green in judgment’.

Usually, I enjoy seeing children in the waiting room –they lend a kind of friendly family air to the office. Sometimes, however, there are things I need to discuss with the mother, procedures I need to perform, or even examinations that might alarm the child, so my enjoyment is often that of seeing the child stay in the waiting room. It’s not called that for nothing.

Clara was already a harried teenage mother of a two year old when I first met her several years ago, and I delivered three more for her in the following years. Now in her late twenties and recently divorced, she had been sent to see me for permanent birth control.

I heard the excited screaming even before I reached the front desk, and I have to admit that I hid behind a wall to assess the situation more fully before I ventured into the open. The first of the children I delivered -Edward, now around five- was stirring the pot by running around the room clutching a toy to his chest so the dauphin, despite the obvious entitlement of age, could not get it.

Clara’s long auburn hair, now partially liberated from whatever restraints she’d attempted at home, was hanging forlornly around her shoulders, while her eyes followed the action around the room like a hockey game. A large lady now, she sat uncomfortably on the edge of her seat, no doubt hoping to catch Edward and the toy if he was so unwise as to come anywhere near grabbing range. The youngest, still breast feeding, was the only one over whom she exercised even temporary dominion.

I glanced nervously around the room from the shelter of the alcove, hoping she had brought a friend or older family member with her, but Clara was the last patient of the day and the room was otherwise empty.

“Clara,” I said, face prepared, and hoping she hadn’t noticed me behind the wall. “Nice to see you again.”

The children immediately stopped running and flocked to my side to tug on my clothes. Jamie, the oldest, grabbed the toy from Edward, who was now too busy trying to reach my stethoscope to notice.

“I… I saw you… watching from the alcove, doctor,” Clara said, blushing a deep crimson because she almost said ‘hiding’. “I tried to get my sister to take care of the kids, but she had to work today…” She shrugged and reached out with lightning speed to grab Jamie’s arm before he could swat his brother. “You behave yourself, Jamie, or you’re gonna do a Time-out, eh?”

Jamie immediately akimboed his arms and made a face at his brother. “He grabbed my car…!”

Clara glared at him and frowned, but from the defiant face with which Jamie greeted the threat, I could see the battle lines hardening.

I glanced at my secretary sitting behind the front desk, but she was on the phone and I realized that I was on my own. “Let’s go into my office,” I said, with a worried look at the boys, and the little girl, Janice, who by now had decided that the way to recapture some attention was to stick her tongue out at Jamie. Only the baby seemed compliant, but that was probably because Clara was still nursing her.

My office, unfortunately, was not designed for children –there are simply too many things that could tip over or break if handled indelicately. On the way down the hall to the office, I even thought of getting my secretary to fake a call from the hospital requiring my immediate assistance, but she was still on the phone and merely winked at me as I passed. I got the impression she was just holding the receiver for show.

As soon as the troupe entered the office they began to explore, and Jamie, who had probably never seen pennies before, made a quick exploratory lunge for the penny bowl that sat in front of a terra cotta statue of a begging lady precariously balanced on a little oak table. Edward, on the other hand, was reaching for the carved wooden statue of a woman holding a child that I had put behind a plant on my desk, and Janice was trying to extract the contents of the shelf where I keep my medical journals. It was a multi-pronged attack worthy of an Alexander.

“I’m not sure this is going to work, doctor,” Clara said, trying unsuccessfully to reposition the baby onto a breast while glaring at all three of her children now crawling along the floor scooping pennies into their pockets.

I called my receptionist to come in with us. “Laura,” I said as she opened the door a crack and peeked in. “Please put the phone on hold, or something…  I need your help.” Actually, I needed a time-out.

I could feel Laura’s eyes rolling behind the door. She was the mother of three young children, so she knew what I was going to ask.

“I want you to take the kids and… occupy them for a few minutes while I talk to Clara.”

She shrugged, but I could tell from her face that she thought it might be an interesting challenge as she gathered the tribe -minus the now sleeping baby- and led it out of the door. The office felt so peaceful suddenly that Clara and I just looked at each other for a moment. I managed to gather a more complete history and when I opened the door to lead her across the hall to the examining room I could only hear quiet giggles.

Finally, after Clara and I had discussed her needs, we both tiptoed down the corridor to the waiting room. But it, too, was quiet except for Laura’s voice telling a story as the children sat around her in a little circle on the floor.

Each of them had a plastic speculum with a sticker face stuck on the top and when Laura asked a question, one of the children would make the speculum talk. They were loving it and didn’t even look up when we crossed the rug. But Laura did, her eyes glistening from quiet laughter.

Clara just stared at them, unable to speak.

Laura chuckled and then shrugged. “I gave each of them a choice of those little funny face stickers we always give to the kids and showed them how to attach them to the top of the speculum.” A contented sigh escaped as she watched them all talking quietly to each other through the specula. “From then on, it was just role playing…”

“How did you ever think of that, Laura?” I asked when they’d all left.

She shrugged again. “The specula have always reminded me of quidnuncs… you know, snoops -those who insist on sticking their noses in other people’s business.”

I had to sigh in admiration -Laura has a name for everything. I just hope she doesn’t expect me to name the specula now… But I looked up quidnunc just in case.

 

 

 

 

 

Gender and Stress

Even the most ardent proponents of gender parity will admit that equality of opportunity does not imply equality of physiology. ‘The worst form of inequality is to try to make unequal things equal,’ as Aristotle said. Homogeneous –likeness, if you will- is not necessarily homogenous (a biological term meaning structurally similar due to common ancestry). Admittedly a semantically fraught distinction, it nonetheless suggests that there may well be differences that do not transcend gender.

For example, there seems to be a sexual discrepancy in the acquisition of post-traumatic stress disorder (PTSD)  http://www.bbc.com/news/health-37936514 -women tend to be more vulnerable to its development than men. A research team from Stanford University published a study in Depression and Anxiety (the official journal of the Anxiety and Depression Association of America) and it suggests that ‘[…] girls who develop PTSD may actually be suffering from a faster than normal ageing of one part of the insula – an area of the brain which processes feelings and pain. […]the insula, was found to be particularly small in girls who had suffered trauma. But in traumatized boys, the insula was larger than usual. This could explain why girls are more likely than boys to develop post-traumatic stress disorder (PTSD), the researchers said. The insula, or insular cortex, is a diverse and complex area, located deep within the brain which has many connections. As well as processing emotions, it plays an important role in detecting cues from other parts of the body. […]This shows that the insula is changed by exposure to acute or long-term stress and plays a key role in the development of PTSD.’ And as I quoted, the changes seem to be different in the two sexes.

The point of all this somewhat detailed background, is to submit that, as the study suggests, ‘it is possible that boys and girls could exhibit different trauma symptoms and that they might benefit from different approaches to treatment.’ Perhaps a sensitive counsellor would recognize this as the sessions continued, but it’s helpful to have some corroboratory evidence to justify any proposed changes.

I have to say that I was woefully ignorant of any sex difference in the development of PTSD. I’m embarrassed to admit that, if anything, I thought of it as largely a male condition –perhaps because of its association with war, and combat -traditionally at least, arenas of male predominance. But of course that is naïve. PTSD is not something confined to combat; it can be equally prevalent in other situations of distress or upheaval. Trauma is trauma, and long term issues can result from such things as natural disasters, car crashes, and certainly sexual or physical assaults, to name only a few. Because the symptoms can be confusing or even disguised, the diagnosis is best left to qualified practitioners, and yet I can’t help but wonder if a greater and more sensitive awareness of the possibility of the condition might encourage more sufferers to seek professional help.

As a gynaecologist, I feel uncomfortable and indeed far out of my depth in discussing most issues pertaining to PTSD, and yet thinking back over my years in practice, it seems to me that I may have suspected something of the sort, but lacked both the vocabulary and training to assign it a label –especially in those women I saw for conditions they suspected may have been attributable to previous sexual abuse: fears that they occasionally admitted to re-experiencing in unrelated events; things about which they still had nightmares; situations that led to unprovoked irritability and anger.

PTSD, by whatever name, has no doubt afflicted humans from time immemorial. Male hubris dictated that it be disguised or denied no doubt –it was a sign of weakness- and therefore unlikely to be mentioned in contemporary accounts. But signs of its presence occasionally snuck into mainstream literature -Shakespeare’s Henry IV being a likely candidate, for example. Perhaps more germane to my specialty, however, was the recognition of the lasting effects of trauma on people other than those involved in traditional conflict: women. The US Department of Veteran’s Affairs in its National Center for PTSD pamphlet states: ‘Most early information on trauma and PTSD came from studies of male Veterans, mostly Vietnam Veterans. Researchers began to study the effects of sexual assault and found that women’s reactions were similar to male combat Veterans. Women’s experiences of trauma can also cause PTSD.’ In fact they maintain that ‘The most common trauma for women is sexual assault or child sexual abuse.’ http://www.ptsd.va.gov/public/PTSD-overview/women/women-trauma-and-ptsd.asp

For too long have the lasting effects of sexual assault been ignored, or at best, trivialized and examined through male eyes in a still-male world. I don’t mean to sound like an overzealous feminist who pins all problems on male dominance, but I think age and a career spent in women’s health grants me a unique –if still masculine- perspective. As with all things, specialists run the risk of deconstruction, overanalyzing the events often with the consequent subversion of their apparent significance -almost a form of historical revisionism, an unintentionally biased and often contextually barren interpretation. One bridge, when crossed by a thousand people, becomes a thousand bridges –we all see the world through our own experiences, our own expectations, our own prejudices.

I think the fact that we can now demonstrate that there are valid reasons to question those often unconscious assumptions is a cause for hope. Much as we have finally realized that the results of many studies carried out only using men cannot necessarily be mindlessly extrapolated to women, so it is becoming increasingly apparent that trauma and its effects may also be non-generalizable. Although not its prisoners, we are after all, creatures of a chromosomal lottery, divergent physiologies, and certainly of different past experiences, so why wouldn’t there be a spectrum of responses to stress?

So, is there a ‘man-cold’? Well, maybe… I know that’s the kind I get, anyway.

 

 

 

 

 

 

 

 

 

 

 

Folk wisdom sometimes gets it right: there is a man-cold… Well, maybe.

 

A Flicker of Hope

It’s interesting what catches our attention when we surf the apps on our smartphones nowadays. Some of the more provocative articles have dubious sources, of course, but with a little digging the original study can often be found and the claims checked. The problem, however, is that even these results need to be reproducible in case either the methodology or the results were unreliable –and also the conclusions drawn from them. That’s why it’s often unwise to believe everything you see reported –or, on the other side, to report everything you want to believe… Fear and Hope are wonderful incentives, and so the issues in the study need to be thoroughly researched and vetted for bias and innuendo and references to the original study need to be included.

Perhaps because I am now retired, any article about time-related changes catches my eye more easily. So I find myself particularly interested in studies that suggest progress is being made -not with respect to age itself, but more the evolving process of aging: the gerund. It was with considerable interest that I read the BBC news on the use of flashing light therapy for Alzheimer’s http://www.bbc.com/news/health-38220670

I also attempted to read the original paper from MIT (entitled Gamma frequency entrainment attenuates amyloid load and modifies microglia) published in the December 2016  issue, of the journal Nature should you wish to struggle though it, but I have to confess that for me, even the title was difficult…

At any rate, the article suggested that flashing light in the eyes of mice that were genetically engineered to have Alzheimer’s-type damage in their brain, ‘encouraged protective cells to gobble up the harmful proteins that accumulate in the brain in this type of dementia. The perfect rate of flashes was 40 per second – a barely perceptible flicker, four times as fast as a disco strobe.’ And ‘Build-up of beta amyloid protein is one of the earliest changes seen in the brain in Alzheimer’s disease. It clumps together to form sticky plaques and is thought to cause nerve cell death and memory loss.’ Research has focused on ways to prevent this plaque formation using drugs, but with limited success so far. If a non-invasive method like a flickering light can activate the immune system to do it by itself, so much the better. ‘The researchers say the light works by recruiting the help of resident immune cells called microglia. Microglia are scavengers. They eat and clear harmful or threatening pathogens -in this instance, beta amyloid. It is hoped that clearing beta amyloid and stopping more plaques from forming could halt Alzheimer’s and its symptoms.’ Fine with me.

I did, however, initially wonder about how bothersome the flickering would be –news reports on television usually caution their audience whenever even flash photography is found in the report, presumably because of the risk of triggering epileptic seizures. But, as the article discussed: ‘For the patient, it should be entirely painless and non-invasive “We can use a very low intensity, very ambient soft light. You can hardly see the flicker itself. The set-up is not offensive at all,” they said, stressing it should be safe and would not trigger epilepsy in people who were susceptible.’ Better and better! It’s just preliminary stuff, of course, but at least it opens up new pathways and ideas for further research.

As if even reading about the concept was in itself therapeutic, the article immediately triggered what, at first blush, would seem to be a non-sequitur memory of a patient I saw many years ago. The issue as I recall was not so much about mental aberration -although the patient herself was apparently suffering from paranoid schizophrenia- but more about her speculation on the possible effects of flickering light on mental function.

I was, I think, in my first year of residency training in the gynaecology program and was doing a rotation in one of the older teaching hospitals in the city. In those days, things were very busy on the wards and so our tasks were apportioned according to our seniority, the senior residents doing the lion’s share of new consultations, while we juniors were given those jobs that, while important, required less experience -pap smears, usually.

My senior’s name was Sara, I remember, and she decided I should be the one to go to the psychiatric ward to do a pap smear on one of their more ‘unusual patients’ as she said to tease me.

“What do you mean ‘unusual’?” I asked. Sara didn’t like to go onto that ward, for some reason, so she usually made some excuse.

She stared at me for a moment before answering, I remember. “Oh, you know, she has paranoid delusions and hallucinates, or something…” But it was clear that Sara really had no idea why our department had been asked to do the pap, nor had she any intention of doing it herself.

I was beginning to suspect this was merely another sluff. Sara fancied herself a consultant now and able to delegate things she didn’t want to do. “But if she’s paranoid and hallucinates, wouldn’t it be better if the doctor doing the pap smear was female?”

Her expression turned angry at that point, and I recall her almost attacking me with her eyes. “Oh for god’s sake, there’ll be a nurse there with you the whole time… Or maybe they said two…” she added, uncertainty softening her glare, but not her resolve to send me to that ward.

I showed up at the psychiatric area and was allowed in only after identifying myself via the phone just outside the door. Then I was led to the brightly lit nursing station, and a rather large matronly nurse handed me the chart of the woman needing the pap.

“She hasn’t had a pap smear in years,” the nurse said in a soft voice, so it couldn’t be heard in the corridor outside of the station. “And her voices told her she has cervix cancer…”

“Her voices?” I should have been more professional, but I was already feeling a bit apprehensive about being inside a locked ward. “I mean, shouldn’t we wait until she’s feeling a bit better before we…”

“We can’t seem to find any good medication for her yet,” the nurse interrupted. “The doctor thought that we could at least calm her by checking her cervix.”

Greta –I still remember her name- was already in the examination room, sitting in her gown on a little table that had a set of rickety old metal stirrups at one end. They’d apparently had to borrow everything from another ward for the job. As soon as I entered with the nurse, Greta examined me from top to bottom with suspicious eyes.

“You’re a man,” she said before we were even introduced.

The nurse, whose name I forget, walked over to Greta and held her hand. “You remember we talked about this, Greta,” she said in the same soft voice she’d used before. “And you said it was okay…”

Greta nodded, smiled and lay back to put her feet in the stirrups. “They said I should show you my cervix,” she said, the italics staring at me between her knees. “Not the one with cancer, though…  I’m supposed to keep that one hidden.”

“Her voices,” the nurse quickly whispered in my ear as I sat on a little stool they’d also borrowed for the occasion along with a light on a long, flexible metal pole. It looked as old as the stirrups.

I got the speculum and the pap smear paraphernalia ready as the nurse readied the light. The bulb kept flickering, though. I fiddled with the bulb to see if it was loose, but it seemed tight enough. And it was obviously plugged into the wall. On, off, on, off… the light was beginning to annoy me. I snapped the switch a few times, but still, it insisted on flickering. On, off, on, off…

“I’ve got a flashlight,” the nurse said, but when she turned it on, it was so weak, I knew I wouldn’t be able to see cervix high up in the vagina with it.

“Well, maybe I can do the pap smear with the flickering light,” I said and shrugged.

Suddenly Greta raised her head and stared at me again. “Sometimes the prongs don’t make good contact in the wall. Everything’s so old in this place,” she added, shaking her head. “Take the plug out and squeeze the prongs.”

By this time I had the speculum in my hand, so I nodded to the nurse to try Greta’s suggestion. Sure enough, squeezing the prongs stopped the flickering.

Greta was still staring at me through her legs. “I may be crazy, doctor, but I’m not stupid…”

I put the speculum down on the medical tray I had on my lap. I sensed Greta wanted to explain something. “It’s a signal, you know.” I didn’t think I should reply. “The light’s always trying to tell you something –sometimes it’s angry, but more often it’s just trying to help…” Her feet still in the stirrups, she raised herself onto one elbow and continued. “It gets right into the brain to help, you know. It doesn’t stay there long enough, though, and that’s why it has to keep going in and out, in and out… And each time it tries, it flickers…” Then she stopped talking for a moment and stared at the nurse with an amazed expression on her face. “That’s what the doctors should be trying –not all those horrible pills…”

Maybe that incident stands out because it was the first pap smear I’d ever done. I don’t remember the result in Greta’s case –I was near the end of my rotation in that hospital- but I do remember Sara asking me what I’d done with that patient.

“Why?” I asked, afraid Greta had accused me of doing something improper.

“The ward told me that your patient seemed much calmer after you left and she apparently kept telling everybody you’d come up with a new treatment, or something…” And then I remember Sara smiling condescendingly at me, as if to say that junior residents could never do anything of the sort.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Happily Ever After?

I suppose we all revisit our childhoods from time to time –those memories have a special hold on us. But they are stories thick with varnish, and when analyzed too closely, soon fall apart in our hands like dreams. And yet, handled gently, stories are what we are –they are our names- and that we awaken the same person from day to day is like reading further in the book.

Maybe that’s why fairy tales can have such a fascination for children –escaping into an imaginative narrative that is as magical and surprising as their own. A time to believe we can become the story –maybe even are the story. For most of us, it was an enchanting time of fairies, and wishes coming true; of escape from tragedy, or finding a special person in the deep, dark forest; of finding happiness in the midst of sorrow.

Well, at least that’s what I thought was happening as I snuggled in the arms of my parents when one of them read to me before I went to sleep each night. But we only know what we are told, I suppose; we only understand the world that is laid out for us. I certainly never suspected an agenda; I never thought to ask if what I heard was only a manifestation of the time of writing. And I certainly neither questioned my mother’s world-view, nor my father’s integrity –I assumed I was being told the truth about the once-upon-a-time days.

And yet, viewing them through a modern lens, I suppose their faults were obvious. Not my parents’ –they, too, were products of their own times. No, I mean the stories that I found so innocent and sweet, had rougher underbellies than I had reason to suspect. In fairness, I think we acclimatize to the things to which we are habitually exposed. Who can smell the garlic on their own breath? And so, the undergarment of sexism in many fairy tales came as a revelation to me. https://www.bustle.com/articles/149098-5-fairy-tale-tropes-that-perpetuate-sexism

And I have to say that on first glance, I suspected this was yet another example of historical revisionism –the reinterpretation of the umwelt of another time through the sensitivities and biases of our own. There is some of that, to be sure –we do not easily appreciate the perils and depravities that were rampant in medieval Europe- but even so, we can no longer blindly accredit tales of infanticide or child abuse, nor turn a blind eye to attitudes like misogyny or tropes like the evil inherent in non-conformity that may have been prevalent and believed in that time. And, indeed, it often seems to be women that are treated unfairly in these tales, when appraised by modern eyes.

The danger is that by ignoring the hidden message, we risk normalizing it. Condoning it by not pointing out that we no longer sanction that kind of behaviour.

Of course, it can also go too far -come too close to serving an agenda that seems more retributive and spiteful than merely corrective. Some of the fairy-tales –Cinderella, or even Sleeping Beauty (despite the apparently more malevolent early versions)- have a sweetness and charm that, at least when examined only superficially -as might be the case by a child- spin a message of hope and rescue for even the poorest among us.

But that said, I have to confess that I never really thought about the main character -in most of the ones I remember, at any rate- being almost always a girl. Think of Goldilocks, Little Red Riding Hood, Rapunzel… Even Gretel in the Hansel and Gretel story. And the frequent portrayal of old and eccentric women as witches, or at least as malicious step-mothers. I suppose that Jack in the Beanstalk was a refreshing exception, but nevertheless, point taken.

Perhaps it’s my age, or a comment on my epoch, but have to say that I didn’t realize the extent to which these stories were recognized as violating the currently prevalent societal ethos.

A few years ago I remember seeing Ada, a young twenty-something woman for antenatal care. It was her first pregnancy and she was bursting with dreams and bubbling with questions about problems she hoped to avoid in the pregnancy. But one of the things that made her stand out in my memory was her hair. She had incredibly long shiny black hair that hung down to her waist when she didn’t try to confine it in a messy bun on top of her head. She was extremely proud of it, and told me she rarely had to work at keeping the sheen that was so striking to everybody in the waiting room. She was used to stares, she would tell me with a big smile on her face.

And yet, as the pregnancy progressed, she found that not only was the length starting to annoy her, but she was also beginning to find clumps of it on her brush each morning. I tried to reassure her that, although not the rule by any means, it is not uncommon to lose some hair in the course of a normal pregnancy. This usually corrects itself three or four months after delivery.

“So I’m not gonna go bald, then?” she said with a twinkle in her eye. I shook my head and smiled. “My husband says it’s probably because the long hair weighs so much it’s pulling on the roots and weakening them or something.” Her expression suddenly changed and instead of twinkling, I found her eyes wandering over my face like robins listening for a worm. “He even jokes about me being a black-haired Rapunzel…” A look of concern appeared, and her eyes immediately flew home. “He says maybe I should cut it shorter while I still have some left. ‘Remember the witch’ he says.

“We had a big fight about how unfair that was…” She glanced at me for my reaction, and seeing the puzzled expression I was unable to hide, she shrugged. “The story hides behind the idea that long hair not only allowed her captor, but also her rescuer to reach her in the tower.” Suddenly her look was a glare. “In medieval times, men were the oppressors –they had the towers- so why make some old woman the villain?”

I wanted to say it was just a story, but she beat me to it. “Ted says it’s just a story –a way to allow a prince to rescue her…” Ada turned her eyes into predators and suddenly unleashed them on my face. “I told him it seemed a bit contrived to me. An example of assumed male privilege, and Woman’s desire to be rescued. Of course he was a prince, and of course that’s what she needed…”

I suppose my face said I still didn’t follow her logic, because she immediately softened her expression and touched my arm. “I majored in medieval European literature in university –Ted was messing with the wrong woman…”

She smiled and sighed at her reaction to her husband. “Poor guy. I really gave it to him,” she confessed with a chuckle. Then she twinkled her eyes again. “So, doctor, was Ted right? Should I cut my hair shorter?”

I shrugged to indicate that I wasn’t at all sure. “Are you certain Ted wouldn’t miss it?”

She sighed. “That’s the problem with princes, isn’t it?”

 

 

 

 

 

For my Pains, a World of Sighs

What does pain look like? An intriguing question to be sure, but one I hadn’t even thought to ask until recently. Pain is one of those things that, like St. Augustine’s quandary over Time, presents a similar difficulty in defining. The International Association for the Study of Pain made a stab at it: ‘Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,’ but somehow, it seems to lack the immediacy of its subject matter –it stands, like an observer, outside the issue. Poets have done a better job, I think. Emily Dickinson, for example: After great pain, a formal feeling comes. The Nerves sit ceremonious, like tombs’; or Kahlil Gibran: ‘pain is the bitter potion by which the physician within you heals your sick self’; or even Oscar Wilde: ‘Pain, unlike Pleasure, wears no mask.

But I was reminded of another of Wilde’s observations -‘We who live in prison, and in whose lives there is no event but sorrow, have to measure time by throbs of pain, and the record of bitter moments.’- when I read a CBC article from November, 2016 entitled ‘Indigenous children, stoic about their pain, are drawn out with art’ http://www.cbc.ca/news/health/aboriginal-youth-art-pain-hurt-healing-1.3852646

‘”Aboriginal children feel and experience pain just like anyone else. It’s just that they express their pain very differently,” said John Sylliboy, community research co-ordinator with the Aboriginal Children’s Hurt and Healing Initiative.

‘”They don’t necessarily verbalize their pain, or they don’t express it outwardly through crying or through pain grimaces,” he told CBC News.’

‘These children are socialized to be stoic about their pain, to hold in their pain.’- Margot Latimer, Centre for Pediatric Pain Research, IWK Health Centre in Halifax. ‘”We noticed we weren’t seeing any First Nations youth referred to our pain clinic at the IWK hospital and wondered why that was so.”‘ It didn’t make sense, she thought — especially since research shows that chronic illness in First Nations communities is almost three times higher than in the general population. Aboriginal children are especially vulnerable, says Latimer, with higher rates of dental pain, ear infections, and juvenile rheumatoid arthritis.’

I found it very moving, and yet disturbing, that ‘[…] cultural traditions, and lingering effects from the residential school system, are some of the reasons Indigenous kids pull on their suit of armour against pain and hurt.’ But they’re children, and perhaps not yet completely shackled to all the subtleties of culture. ‘A group of Indigenous children and teenagers from four First Nations communities in the Maritimes were asked to paint their pain, to express their hurt through art. Researchers were hoping to tease out emotions from a population more inclined to show resilience to pain.’ But soon after, the children began to depict not just physical pain, but emotional pain as well. As Sylliboy points out, ‘”These kids told us about loneliness, sadness, darkness, bullying, hopelessness. It’s not the typical anxiety [or] depression. It is more complex than that.” “To these clinicians who are just asking about physical pain and not looking at emotional pain as well, it is important, because Aboriginal kids are showing us that there is no difference between emotional and physical pain”, said Sylliboy. “It’s just pain.”‘

And I learned another thing about pain –or maybe about children – ‘It’s all about creating a safe space for the children when they come to the hospital, says Latimer.  She says it’s about learning a bit about them and gaining their trust. “When they come to the health centre, or a physician or a nurse practitioner, they want to tell their story, but we do not train health professionals to assess pain that way.”’

It reminded me of a patient I first met in the Emergency Department at the hospital when I was the gynaecologist on call one night. Edie, an aboriginal woman arrived with heavy bleeding –she was  apparently in the throes of miscarrying an early pregnancy- and had brought her eight year old son to the hospital because she had no one to take care of him at home. The bleeding settled shortly after her arrival and an ultrasound in the department revealed that there was no further tissue left in the uterus, so fortunately we didn’t have to take her to the operating room. But the process of diagnosis and decision was not instantaneous. Although the little boy, Timmy, was clearly frightened, his face stayed neutral. And yet it seemed as if he was peeking through hole in a fence, and I could see his eyes carefully following my every move. One of the nurses volunteered to sit with him in the waiting room while I examined his mother, but I was the last one he stared at before leaving; I was the thing he didn’t understand.

I decided to let Edie rest on the stretcher for a while before discharge, and I thought I’d reassure Timmy before I left. He was sitting on the too-big chair as quietly and unmoving as an adult and when I approached, he stared at me like a deer hiding in a forest.

“Your mom’s going to be okay, Timmy,” I said with a big smile.

But he still seemed just as frightened, and stayed silent for a moment. “There was blood on her pants,” he mumbled, perhaps making sure I’d noticed. He allowed his eyes to venture out further into the open and he examined me again. “And she was hurting…”

What do you tell a little boy about his mother’s suffering? I knelt down on one knee in front of him so our eyes were on the same level and put a hand on his knee. I couldn’t  think of anything else to do. “She’s not hurting now, Timmy,” I said and smiled again.

He looked at my hand and then he finally smiled. “Can she go home now?” When I nodded, he reached out and carefully touched one of my fingers, and then when I didn’t pull away, he patted my hand.

I never saw little Timmy again, but a few weeks later, Edie came to my office for a follow-up visit and to thank me for seeing her in the hospital in the middle of the night. “Timmy was really impressed,” she said and smiled. She ruffled through her purse and brought out a rumpled piece of paper she’d nonetheless folded carefully. “He drew this for you, doctor,” she said proudly, and handed it to me.

When I opened it up, it was a drawing of a hand in red crayon.

“He said it was to thank you…” She seemed embarrassed, and hesitated before continuing. “I asked him why he drew it in red…” she said.

She still seemed embarrassed, so I stayed silent until she felt ready to continue.

Edie studied me for a moment with her big brown eyes, still uncertain. Then her face relaxed and a big smile appeared. “He said maybe you were one of us, now…”

I could have cried.

Baa Baa Black Sheep…

Okay, I’ll admit I’m intrigued by investigations that attempt to prove things the rest of us simply take for granted. Things that seem so obvious, that I wonder why they ever extracted them from the background for analysis. When you live in a forest, why would you single out a tree?

Do babies do better when they are loved? I can’t even imagine the need to ask that question, but I suppose we only see the world through the filter of the prevailing ethos of our society. It was not so very long ago, for example, that the psychologist Harry Harlow devised an experiment that, although cruel to contemporary eyes, was an honest attempt to explore what it is that infants need. He separated infant monkeys from their mothers and placed them in isolation in little cages. He then gave them a choice between a metal dummy holding a bottle of milk, or a soft, fuzzy cloth dummy without milk. And, no surprise, the babies chose the soft cloth dummy so they could cling to it. A mother is more than a source of food –much more.

An article in the BBC news last year caught my eye. It posited ‘[…]that babies need to feel safe, secure and loved for brain connections to be properly formed to enable them to learn effectively.’ http://www.bbc.com/news/science-environment-38002105

This was suggested by a study from Cambridge University in England that utilized brain scans. The researchers scanned the brains of babies and their mothers while the two were interacting in learning activities. ‘The early indications are that when the brain waves of mothers and babies are out of sync, the babies learn less well. But when the two sets of brainwaves are in tune they seem to learn more effectively. Dr Victoria Leong, who is leading the research, has discovered that babies learn well when their mums speak to them in a soothing sing-song voice which she calls “motherese”. Dr Leong’s research shows that nursery rhymes are a particularly good way for the mums in her study to get in sync with their babies.’

Fascinating, but taking it even further, ‘[…] babies respond better when there is prolonged eye contact. Mums who sang nursery rhymes looking directly at their babies held their attention significantly better than those who gazed away, even occasionally.’

I recognize how important it might seem to subject the intuitively obvious to some form of scientific scrutiny –just in case, as it were- and I am all for it. Who would dare question what is plain to see and even easier to hear every day in my waiting room? Certainly not me. But sometimes I am, well, surprised at the venue.

I first met Janice in the delivery suite late one night when I was the obstetrician on call. The midwife was concerned about the progress of labour and had asked me to consult on her client. After examining Janice, I had reassured them both and counselled patience and then, with smiles all around, had left to attend to other matters. The midwife later informed me that she delivered a healthy baby boy only a few minutes after I’d left, and so I assumed I’d probably never see Janice again.

So I was surprised when, a month or so later, Janice showed up in my waiting room. At first I didn’t recognize her, but she was singing to her baby and the voice sounded familiar. It’s funny how some things seem inextricably linked to people –a mannerism for one, or a facial expression for another… For Janice, it was undoubtedly her voice. As a small, even petite, woman, I suppose my expectation would be for her sound to match –thin, soft, fragile, perhaps- but like the Pacific wren, the volume far exceeded the source. As did the duration and enthusiasm with which she serenaded her infant. In fact I stood, in thrall, just behind the front desk, not wanting to interrupt her song by inviting her into my office.

Eventually, and not without some concern about interfering with the obvious bonding process, but seeing the baby snuggled contentedly in her arms with his eyes closed, I decided to intervene.

“Janice,” I said, walking over to where she was sitting, and the baby seemed to stir.

She knifed me with her eyes, and a finger flew to her lips to caution me to be silent. She wound down the nursery rhyme slowly and deliberately, all the while gazing intently at her sleeping baby. She seemed to be assessing his breathing pattern and only when she had decided that it accorded with her expectations did she rise and follow me into my office down the hall. I could tell by her subsequent shrug that she hadn’t meant to be rude, or to keep me waiting, but was merely trying to stay in sync with her sleeping infant. That, of course, was fine with me –it’s hard to talk with a patient when her baby is crying.

She settled in a chair by my desk almost by brail; she was so intent on her baby, her eyes never left his face. “I’ve just fed him,” she explained with a smile that only caressed the infant, so I’m not sure whether I was supposed to share. “I think he’ll sleep now,” she added with another misdirected smile.

I decided to respond with a smile of my own, this one directed at Janice, however –a sort of ‘teach by example’, I suppose.

But before it even reached her, the baby opened his eyes and stared quietly at his mother, contentment written across his face like a tattoo. It immediately galvanized her into action, however, and she began to sing another nursery rhyme and rock him in her arms. He obviously enjoyed it and stared lovingly into her eyes as if there were no other reality. No other world. He seemed to be spellbound by the endlessly repeated ‘Baa baa black sheep’ song although after a few minutes, I have to say I became more interested in the rhythmic, hypnotic nodding of her head and felt myself occasionally fighting to focus my eyes.

I began to wonder what the end point of her singing would be. The baby seemed content, he wasn’t crying, or squirming and yet on and on she sang. I tried a few times, unsuccessfully, to ask her why she had come to visit me in the office; the midwife usually follows her clients post-partum unless there is a problem. But each time I spoke, the baby would open his eyes, and Janice would risk a quick glare at me and resume rocking him with yet another song.

Finally, she stood up and looked at me with an embarrassed smile. “I’m sorry, doctor,” she said, heading for the door. “I just can’t seem to settle him today… I’ll have to make another appointment,” she added before launching into ‘Three Blind Mice.’

As she disappeared down the hall, and the song faded into the distance, I realized I never did discover why she’d been sent to see me. But I felt grateful for that final smile, however. Sometimes it’s the little things that matter…