Crybabying

I remember (sort of) my days in Elementary School, when one of the most devastating insults a little boy could receive was to be labelled a crybaby. I’m not sure why, really. Maybe it meant you didn’t fit in with the prevailing umwelt –with what you were supposed to be as a little boy- or maybe it was just a talisman raised to guard against the fear that despite its undesirability, it might be hiding in us all –even the accuser. Children are inherently superstitious, don’t you think?

It never occurred to me to wonder about the expression at the time, nor even later when I had children of my own. Babies cry, often too much, and perhaps more to the point, often at inconvenient times: during the nights. But I never suspected that it was sufficiently upsetting that it would transmute into folklore as a children’s curse. In fact, as childhood made way for my adult clothes, I didn’t think much about it at all -let alone as an imprecation- until I happened upon an article in the CBC News: http://www.cbc.ca/news/health/babies-crying-health-study-warwick-university-1.4052932 ‘Researchers at the University of Warwick conducted a meta-analysis of studies involving about 8,700 infants in countries including Canada, Germany, Denmark, Japan, Italy and the U.K.’ and guess what? ‘[…]babies in Canada, Britain, Italy and the Netherlands cry more than babies in other countries.’ And not only that, ‘On average, Canadian babies cried 30 minutes more than babies from other countries.’ Great! There goes our long held patriotic claim to be the ‘polite nation’ -the one usually definable by what we are not: (not American, not greedy, not pushy, not… Well, you get the point). ‘Canadian babies had some of the highest levels (peaking at three to four weeks at 34.1 per cent of infants), followed by the U.K. (peaking at one to two weeks at 28 per cent) and Italy (peaking at eight to nine weeks at 20.9 per cent).’ ‘Germany, Japan and Denmark had the least amount of crying and fussing babies.’ Damn.

Mind you, if you actually look at the article reported by the CBC:  http://www.jpeds.com/article/S0022-3476(17)30218-4/fulltext – s0070, ‘Overall, fuss/cry durations were high across the first 6 weeks of life, then reduced significantly over the following 6 weeks. All studies found a “universal” reduction in fuss/cry duration between 6 and 12 weeks of age.’ The reasons for the differences were not at all clear: ‘[…] we can only speculate on the reasons why there are country differences, in particular between Denmark and the rest of Europe and North America. These could range from economic conditions, such as less social inequality, to caretaking patterns such as responsiveness, carrying behavior and management in Denmark that have been shown to differ from the United Kingdom. However, there may also be population genetic differences, and the infants both inherit their parents’ genes and are reared by them (gene-environment correlation). […]Feeding type was a further moderator of fuss/cry duration. Bottle or mixed feeding was associated with reduced duration of fussing and crying or colic from 3-4 weeks of age onward. Switch in feeding type is one frequently adopted method by parents dealing with a crying baby and has been found to reduce crying regardless of what formula change is instituted, suggesting a placebo effect.’

Unfortunately, ‘[…]this is a review of studies in North America and parts of Europe with only 1 study from Japan. No studies from threshold or developing countries were available, but these would be needed to provide adequate feedback to parents on other continents. Feeding type information was also not available for some studies.’

And what about ‘colic’ the catch-all word for persistent crying? ‘The most widely used definition for colic is the “Rule of Three’s”: an infant is considered to have colic if the infant fusses or cries for >3 hours, >3 days per week, for >3 weeks.’ Unfortunately it is, apparently, often a diagnosis of despair with no readily identifiable cause. Indeed, ‘The rapid developmental change in fuss/cry duration has implications for treatment and interpretation of treatment studies. Colic is the extreme of normal fuss/cry behavior, self-limiting, and, thus, the vast majority will spontaneously remit. Adequate management of fussing and crying in the first 3 months rather than treatment may be required. However, if excessive fuss/cry persists beyond the first 3 months, there is increasing evidence that this may indicate regulatory problems with adverse consequences for future development and may require treatment.’

But, bringing it back to Canada, my terre natale, ‘Psychology professor Dieter Wolke, lead author of the study, says Canadian parents need not worry. […] He pointed out that babies in Canada peaked around the three-four week mark but fell into a more normal range around week six.’ …Damned by faint praise again…

And what about Germany, Japan and Denmark? Especially Denmark –why does it always seem to win everything? ‘”In Denmark, it seems to be they’re more relaxed about it,” Wolke said. “They might have a little bit more support because of maternity and paternity laws … the father in the first few weeks can stay at home, too.” It’s worth noting that Denmark regularly falls at or near the top of the “best countries to live in” lists. Wolke speculates that this may foster a population that feels good about itself, and those emotions can transfer to the baby.’

Uhmm, excuse me! ‘”Babies are already very different in how much they cry in the first weeks of life,” the researchers said. “There are large but normal variations”’. So let’s not dump on les petits Canadiens, eh? It’s a squeaky wheel that gets the grease, after all. Right? …I mean that’s right isn’t it…?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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The Stealing Steps of Age

Elderspeak. We’ve all heard it: baby-talk for seniors, an almost unconscious reaction to those we deem cognitively impaired, or hopelessly out of date. It’s a kind of pretend-communication with those who seem unreceptive, or beyond the pale of verbal comprehension.

Although the term is aptly descriptive and eerily evocative of rows of beds with wrinkled heads whose staring eyes peek out from where their bodies are tucked, I have to admit I had not heard the word before seeing an article in the CBC News. It described a study published in The Gerontologist about the way a group of nuns cared for their elderly colleagues from their convent: http://www.cbc.ca/news/health/nuns-elderly-1.4039508

‘The sisters caring for cognitively impaired elderly nuns in a Midwestern convent spoke to their care recipients in a way that sounded strikingly different to linguistic anthropologist Anna Corwin. The nuns rarely used “elderspeak” — a loud, slow, simple, patronizing and common form of baby talk for seniors. Instead, Corwin reports, they told jokes, stories and blessed the sick nuns, all the while speaking to them like they were completely capable, even though their ability to communicate was significantly diminished.’

‘The nuns in the infirmary suffered from dementia, Alzheimer’s disease, aphasia, stroke and neurological deterioration, and all had limited or impaired communication abilities. Sometimes the caregiver nuns held the sick nuns’ hands, and sometimes they massaged their legs, Corwin said.’

It all sounds so… sensible. So empathetic. And yet, so often we are frustrated by our apparent inability to effectively communicate that elderspeak becomes a sort of default –almost as if those to whom we are speaking are not really listening, or, depending on their condition, are minimally aware of our presence. And this can be especially prevalent among overworked care providers in geriatric wards.

‘Kristine Williams, a professor at the University of Kansas School of Nursing in Kansas City, trains nursing home providers to use less elderspeak. Her studies found that communication training can reduce the number of diminutives, terms of endearments and collective pronouns senior caregivers use.’ But training to do what?

The nuns offer an interesting option. ‘The caregiver nuns had long-established deep relationships with their elder charges, Williams noted. “They are in almost a family-like relationship, as opposed to someone who’s a nursing assistant in a home,” she said.’ And what they offered, was not condescension or inadvertent humiliation. Not patronage or mere toleration. ‘”They see these older adults, even when they’re lying in bed moaning and can’t move, as not being reduced by these chronic conditions but still as whole individuals.”’

The study was an interesting one, and yet its findings should not surprise us. ‘Beauty doth varnish age, as if newborn, and gives the crutch the cradle’s infancy’ as Shakespeare said. In other words, finding beauty in old age can transform it and make it bearable –in this case both for the aged as well as the caregiver.

Now that I think about it, I suspect I learned that years ago when I was a beginning medical student and visiting my aunt Shirley who was hospitalized after a stroke. She was stored –that’s the only word to describe it- in an older part of an already-old hospital on a ward –a large room, really- lined on both walls with beds like a dormitory. And for the most part, as I described above, all one could see looking down the rows were heads peeking out from neatly tucked bedsheets, white hair splayed across the pillows or stuck to the scalp with sweat. Some had eyes that moved, but mostly it was a room of mouths –none speaking, all busy with just the chore of breathing.

Shirley was one of the exceptions, propped as she was by a series of pillows and a cloth bib whose tethers kept her from tipping over the bed railings and onto the floor. Her voice was slurred and indistinct, so I had trouble hearing what she had to say, but I could tell she was getting better because she was complaining about the woman in the bed next to hers.

“There’s nothing there,” she kept saying, her eyes pointed at the head beside her that was staring, unblinking, at the ceiling. “They’ve put me in an empty room, dear, and I don’t like it.”

My aunt had always been gregarious, some might even say nosy, so to be confined to a room where she couldn’t extract vital gossip and life histories, was a type of exile for her. A punishment.

“You seem to have improved each time I come here,” I said, trying to cheer her up. For my part, the ward depressed me. “They’re obviously treating you well,” I added, quickly running out of small talk.

Part of her mouth smiled, but most of her face seemed still asleep. Not at all happy.

“Your aunt is improving, sir,” a soft voice said from behind me.

I turned and saw a short, smiling, grey-haired nurse dressed in white trousers and a white shirt buttoned up to his neck. His eyes were twinkling, and he was gazing at my aunt as if he, too, was proud of what she’d accomplished. There weren’t very many male nurses then, so I was surprised. “I expect they’ll be transferring you to another ward, soon, Shirl,” he added locking her eyes in his and ignoring me for a moment. “So quit complaining, eh?” He chuckled when he saw her smile broaden and the rest of her face follow suit. He reached out and squeezed her toe through the sheet and wandered off to check on the next bed. Shirley giggled, obviously pleased.

I could hear the nurse talking to that unresponsive woman in the next bed, although he spoke quietly. First, he tilted his head to stare at the ceiling above her bed. Then, he smiled. “You know, Liz, I figure you must have much better eyes than me…” He liberated a skeletal arm whose flesh hung from it like curtains on a window and held it tenderly. “…Because no matter how often I look, I still can’t see whatever it is that you find so interesting up there.” He gently squeezed her hand. “We’re gonna have to discuss this over a beer someday, eh?”

Her face didn’t change, but her breathing seemed a little less laboured. A little slower. More even. “Anyway, is there anything you need me to help you with today?” he said as he ever so gently massaged her arm then flexed and relaxed her fingers. When he’d finished with that arm, he tucked it under the sheets again and repeated the exercise on the other. “I’m going to come back and move you into a different position in a few minutes, Liz, so don’t get too comfortable like that, eh?” He loosened the sheets around her and raised the railings around the bed again that guarded her from falling. “And I’m going to make sure that physiotherapist you like comes with me to massage your legs.” He winked at her flirtatiously and gave her leg a squeeze through the sheet.

“He might as well be talking to the pillow,” Shirley whispered, as he busied himself with the railing. “All she does is stare at the ceiling. She doesn’t seem to notice when I talk to her…”

“So wait for me, Liz. I don’t want to have to go looking all over the ward for you again,” he said, laughing, and wandered off to yet another bed.

“I do like Bill,” Shirley said when he was out of earshot. “He treats us all like family –like we matter.” She was silent for a moment and then, just when I was about to leave, she managed to snag me with her good hand. “But I don’t know how he stays so cheerful here. I think half of the patients don’t even know he’s talking to them.” And her eyes wandered over to the woman in the next bed again. “It must be terribly discouraging for him, don’t you think?”

I glanced at the woman, and for a moment, I thought I saw her eyes flicker as if they were searching for something. Someone. And then, a tear? But maybe it was just a trick of the light, because, as her face relaxed a tiny bit, they closed and she began to snore. Not loudly, not as if she couldn’t breathe –but quietly, comfortably, and slipped from the waking dream, into yet another more peaceful one further inside.

 

 

 

 

 

 

 

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.

 

 

 

 

 

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.

How Ethical is Ethical Compromise?

What to do with a minefield? Once it is there, is it sufficient to avoid it while we investigate and map it –mark it off as terra incognita- or must we act immediately to attempt to remove all mines even if we do not fully understand their distribution or destructive capabilities? Even if we may miss some and our initial enthusiasm was deemed naïve?

This is an admittedly inadequate metaphor when applied to ethics, to be sure, but in many ways is illustrative of the pitfalls of being too quick to judge; or, alternatively, of assuming there is only one approach –and that the one chosen is perforce the correct and appropriate one.

Unfortunately, majority opinion often quietly assumes the mantle of indisputability in a culture, no matter its importance or suitability elsewhere. And even to question the legitimacy of the assertion is to question the legitimacy of the social norms to which its members unconsciously adhere. It may not necessarily intend to negate them, or overtly dispute them, but by subjecting them to investigation, it may seem to disparage their sanctity.

It is difficult to step out of our societally condoned patterns of thought and our long-hallowed mores; it is troubling to observe customs that seem to violate what to us are ingrained standards of morality. It is difficult indeed, to accept that we may not be in sole possession of moral rectitude –that there may be alternate truths, alternate moralities, even alternate equally valid perspectives.

I raise this with regard to the increasing awareness and condemnation of female genital mutilation (FGM). To be clear from the start, I do not condone FGM nor feel that it should be perpetuated; indeed I have to confess that I have great difficulty viewing it as anything other than a culturally-imposed abomination -misogyny writ large. I was, however, intrigued by a paper published in the Journal of Medical Ethics that sought to assess the issue in a more critically constructive fashion than I have seen before: http://jme.bmj.com/content/early/2016/02/21/medethics-2014-102375.full  It is really a very thoughtful and enlightening paper and I would strongly suggest that it is worth reading –if only to learn more about FGM and its cultural significance stripped of any pre-loaded societal baggage.

I was impressed by several things in fact. They sought to classify the procedures in terms of degree, medical issues, the ethical underpinnings of FGM, cultural sensitivity, and whether or not any form of the procedure would constitute gender discrimination or the violation of human rights. I will let the reader judge how thoroughly these fields were covered, but caution against our usually self-imposed wall of confirmation-bias that often precludes a dispassionate consideration of views that don’t fully accord with what we ‘know’ to be the correct ones… http://www.cbc.ca/news/health/female-genital-mutilation-legal-1.3459379 -this brief article from the CBC is perhaps a more assimilable and balanced –albeit nuanced- summary of the arguments.

I suppose the issue is not so much whether the practice should ever be acceptable –although neonatal male circumcision seems to have made it through the gate- as whether by outlawing it, the procedure will be driven underground as seems to be happening currently. If it is so important to a culture –whether justified by mores, or religion- that there seems to be an imperative to have it performed to allow an individual’s acceptability to be confirmed in the community, then wouldn’t it be better to acknowledge this, but mitigate the harm?

The authors have attempted a classification of FGM into 5 categories, the first two of which are thought to have minimal if any permanent effects on the girl -no effects on sexual pleasure, functioning, or reproduction. And, of course, if accepted, could be done under an anaesthetic, rather than by test of courage. Its acceptance could serve to assuage the cultural imperatives while essentially eliminating the greater severity and mutilating effects of the more complicated forms of the practice. It would be an intermediate –and hopefully temporary- step on the road to complete elimination of the procedure.

To be sure, the objection raised is often the one of argumentum ad temperantiam –the fallacy of assuming that the truth –the resolution- can be found in the middle ground between the two conflicting opinions. The problem, of course, lies in the validity of the opposing claims. Should one really be looking for the middle ground between information and mis (or dis) information? Sometimes the distinction is easy, but sometimes it is the minefield I discussed above. Primum non nocere –first of all do no harm- is the guide. As the authors state: ‘… analysis of issues in medical ethics generally regards principles as being prima facie in nature, rather than absolute. Therefore, important emotional and social considerations can trump minor medical considerations.’ In fact, because of the extreme and negative connotations of the term female genital mutilation, the authors even propose an alternative, less pejorative name: FGA (female genital alteration).

Without trying to push the concept and its acceptance too strongly, let me quote the summary of their intent: ‘Since progress in reducing FGA procedures has been limited in states where they are endemic and the commitment of people from these cultures to these procedures has led to their persistence [even in] in states where they are legally discouraged, alternative approaches should be considered. To accommodate cultural beliefs while protecting the physical health of girls, we propose a compromise solution in which liberal states would legally permit de minimis [a level of risk too small to be of concern] FGA in recognition of its fulfilment of cultural and religious obligations, but would proscribe those forms of FGA that are dangerous or that produce significant sexual or reproductive dysfunction.’

Compromises are always difficult; no one gets all they want, and yet each gets something. I raise the issue of female genital mutilation/alteration mainly for information but also for discussion. Sometimes, we need to know something about what we oppose. Always, in fact…

Is there really Something in a Name?

What’s in a name? That which we call a rose, by any other name would smell as sweet.

So said Shakespeare’s Juliet. And yet even then –especially then- it mattered. Tribes have always mattered; we have always been known by our tribes: we are all either us or them aren’t we?” And little has changed despite the agglutination of the numberless tribes into tightly knit societies; there are still passwords.

I suspect I have lived in a bubble somewhere all these years; I really did think things were improving –that we were becoming less prejudiced- but I suspect it is just one more of those parochial shadows obscuring our vision here in Canada. Names, religions, skin colours, gender –appearance– all are code words for acceptance or rejection. We may fantasize that we live in a meritocratic land where Justice is blind and deaf, where we are all judged by our abilities and not our backgrounds, but alas we are deceived –or, rather, we deceive ourselves.

And so, more thoughtful societies have cast about for solutions to those biases so deeply ingrained, and often so hidden that we scarcely notice them anymore. The idea of ‘blind recruitment’ might offer one way to help resolve unconscious (or not) biases that plague many employers. Symphony orchestras were among the first to try it as the following CBC news article points out: http://www.cbc.ca/news/business/blind-recruitment-marketplace-1.3462061 -‘When the Toronto Symphony Orchestra began to audition musicians blindly in 1980, putting them behind a screen, the result was profound. While the hiring committee could hear an applicant’s performance, they not see what he or she looked like. They even put down a carpet so high heels couldn’t be heard. Now the orchestra — which was made up almost entirely of white men in the 1970s — is almost half female and much more diverse.’ Another news article, this time in the BBC News echoes this: http://www.bbc.com/news/magazine-34636464

Talent will out, if that is the sole criterion; but it isn’t. Unfortunately, our judgments are not entirely determined by merit; we sometimes are distracted by other, unrelated issues. Gender, seems an obvious one, but topping the list, is race. Foreign-sounding names seem to discourage interest in the further exploration of a CV: ‘Studies in the U.S. and Canada reveal that job applicants with ethnic-sounding names are less likely to get a response than more Anglo-Saxon names, despite having the same experience and credentials.’ So, unless ‘name blind’ applications are mandated, applicants with foreign-sounding names are at a distinct disadvantage in the job market. This is such a blatant waste of talent and opportunity that –at least anecdotally- some career advisers have suggested that their clients harmonize the names they use on job applications to more societally acceptable ones. Or more pronounceable: ‘Luxshiani Ganeshalingham says her friends automatically change their names when they’re looking for jobs. “We shorten our names to get a better response, or more responses.”’

Hiding things on the initial application may allow people the chance for an interview, but it is obviously far from the solution to racial, gender, or religious bias in hiring, however. ‘”… the reality is that people carrying out interviews, at the next stage on from applications, are humans,” says Azmat Mohammed, director general of the Institute of Recruiters. “The thing is for them to be able to analyze their own biases. Everybody has them and businesses are working to address this issue.”’

And nowadays in most Western countries, where discrimination is prohibited by law, or even discouraged by popular media, the biases have been driven underground. ‘”Modern prejudice is the transformation of our biased attitudes,” says the students’ professor Michael Inzlicht. “[About] 40, 50 years ago, one could express overt hostility or antipathy toward a group — ‘No, I’m not going to allow a black person into my golf club,'” he says. “You politically can’t say that any more.” Modern racism is less overt, Inzlicht says, but we see “very clear” biases. “It’s more dangerous … if you’re not aware of it,” he says.’

I can remember sitting on a rather crowded bus last year and feeling grateful that I had found the last unoccupied seat. A young woman with sparkling brown eyes in the adjacent seat seemed to be absorbed in reading and writing notes on some loose papers in a folder, and as she read I could see her sigh, or at times, chuckle at their contents.

Although I tried to be discreet, she obviously noticed my interest and turned to me with a smile. “Students nowadays are so funny,” she said, glancing first at my face, and then back at one of the papers. “They think they are inventing the wheel each time they answer… But, you know, sometimes they come to the question with such an innocent perspective, they really are… The world is different for them –new, exciting… They’re not muddied by the old methods we bring to questions -the old thoughts that channel us like pipes.”

I looked at her more closely when she said that. She was a young woman, in her late twenties perhaps, with dark hair, and a nut-brown complexion. She was actually excited by what she was reading. I smiled at her enthusiasm and, as strangers will, we began to talk of other things as the bus honked and jolted its way through rush-hour traffic. Just before the journey’s end, we exchanged names. Hers was Alice. I smiled at the name –it has always been one of my favourites and I told her so.

She returned the smile. “I have always liked it, too,” she said, almost wistfully. “Maybe it was Lewis Carroll’s influence –sorry, I mean Charles Dodgson’s,” she corrected herself academically with an embarrassed grin. “My mother always read to me in English at night when I was a little girl growing up in Tehran, and I used to ask for Alice in Wonderland all the time…”

“So you mean Alice was a name you chose for yourself? It’s not your birth-name?”

Again, she seemed embarrassed. “No, my real name is Aza; Alice is pretty close though, don’t you think?” The almost childish delight returned to her face and she smiled so brightly, her teeth seemed to sparkle in the sun coming through the window.

“But…” I was confused. “But Aza is such a beautiful name. Why would you want to change it?”

Her expression changed for a moment and she looked puzzled. She tried to disguise it, but her eyes inspected me to determine if I was patronizing her. As if I, of all people, should know why she’d changed her name. For that brief moment, I was one of her less gifted students. But it passed like a cloud and suddenly her smile returned.

Her stop was coming up so she reached up and pulled the cord. Then, in an effort to atone for her doubts about me perhaps, she touched my hand. It was a gesture of friendship at the very least. “Names, not credentials, get you interviews,” she said with a sad smile as she stood up to leave. “And I wanted to teach…”