Different Flavours

There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy –so says Shakespeare’s Hamlet. I suppose as one ages, there is a tendency to become, if not indifferent, then less surprised at the plethora of variations that exist when they are sought, less amazed at the range of combinations just waiting for discovery. Like ice cream, the world does not come in only one flavour.

But perhaps it is not just the array that so bedazzles, but that we could ever have presumed to define what is normal in anything other than in a statistical way. A Bell Curve distribution confronts us wherever we look –reality is a spectrum no less than the rainbows we all profess to admire. So, then, why is it that in some domains we are less than accepting of mixtures, less tolerant of difference? Why is there the overwhelming need to categorize things as either normal or abnormal? Natural, or unnatural? A macrocosm of only us and them?

Is it just the benefit of retrospection that allows me to notice that no one of us is the same? Or a corollary of Age that lets me thank whatever gods may be that it is like that? That not only do we differ in our tastes and thoughts, but that the discrepancies in our appearance, if nothing else, allow us to recognize each other?

At any rate, I have to say that, as a retired gynaecologist, I was pleasantly surprised to rediscover a world I thought I had left behind –intersex. It was an article in the BBC News that caught my attention: http://www.bbc.com/news/world-africa-39780214 In my day, however, we still hewed to the label ‘hermaphrodite’ if both male and female gonads were present, or even more insensitively, to something like ‘disorders of sex development’, with the medical community taking it upon itself to assign and surgically ‘correct’ the anatomical features at variance with some of the more prominent features of the melange. All this often before the person was able to decide whether or not to identify with either or both traditional sexes. I don’t for a moment believe that this was done malevolently, however, and I think we have to be careful not to apply current sensitivities to another era. Historical revisionism is always a temptation…

But the spectrum of variation is so wide in both anatomy and physiology, not to mention time of discovery, that assignation of gendered roles is fraught. For some, the worry has been that of acceptance –acceptance of any divergent anatomy, any dissonance, by society at large, but also acceptance by the individual themselves (even pronouns become problematic –assigned as they usually are by gender).

It is common nowadays (UN Office of the High Commissioner for Human Rights) to use the (hopefully) neutral term of intersex to define people who ‘are born with sex characteristics (including genitals, gonads and chromosome patterns) that do not fit typical binary notions of male or female bodies. Intersex is an umbrella term used to describe a wide range of natural bodily variations. In some cases, intersex traits are visible at birth while in others, they are not apparent until puberty. Some chromosomal intersex variations may not be physically apparent at all.’

Of course attitudes are as disparate as societies themselves. Not all have been as tolerant or accepting of difference as one might hope. The BBC article, for example, describes the attitude in some rural areas in Kenya that a baby born with ambiguous genitalia should be killed. ‘Childbirth is changing in Kenya. Increasingly, mothers are giving birth in hospitals, rather than in the village. But not so long ago the use of traditional birth attendants was the norm, and there was a tacit assumption about how to deal with intersex babies. “They used to kill them,” explains Seline Okiki, chairperson of the Ten Beloved Sisters, a group of traditional birth attendants, also from western Kenya. “If an intersex baby was born, automatically it was seen as a curse and that baby was not allowed to live. It was expected that the traditional birth attendant would kill the child and tell the mother her baby was stillborn.”’ The article goes on to say that ‘In the Luo language, there was even a euphemism for how the baby was killed. Traditional birth attendants would say that they had “broken the sweet potato”. This meant they had used a hard sweet potato to damage the baby’s delicate skull.’

‘Although there are no reliable statistics on how many Kenyans are intersex, doctors believe the rate is the same as in other countries – about 1.7% of the population.’ But the thrust of the article was really to discuss how  Zainab, a midwife in rural western Kenya defied a father’s demand that she kill his newborn baby because it was intersex. She secretly adopted the baby –and indeed, even a second one a couple of years later. ‘In Zainab’s community, and in many others in Kenya, an intersex baby is seen as a bad omen, bringing a curse upon its family and neighbours. By adopting the child, Zainab flouted traditional beliefs and risked being blamed for any misfortune.’ But she represents a slow, but nonetheless steady change in attitudes in rural Kenya.

‘These days, the Ten Beloved Sisters leave delivering babies to hospital midwives. Instead, they support expectant and new mothers and raise awareness about HIV transmission. But in more remote areas, where hospitals are hard to reach, traditional birth attendants still deliver babies the old-fashioned way and the Ten Beloved Sisters believe infanticide still happens.’ But, ‘It is hidden. Not open as it was before’.

I suppose it is progress… No, it is progress –however slow, and frustrating the pace may be, as long as there are people like Zainab there is hope. But it still leaves me shaking my head.

For some reason Robert Frost’s poem, The Road Not Taken, springs to mind, in a paraphrase of its last verse: I shall be telling this with a sigh somewhere ages and ages hence: two roads diverged in a yellow wood and she, she took the one less traveled by, and that has made all the difference

Please.

Acknowledging the Mind’s Eye

Sometimes, in the midst of a problem –in the midst of an era- the resolution derives not so much from the answer as from the acknowledgement that there is an issue to begin with. I find it interesting that Nature has given us an ability to adapt more efficiently -to ignore, I suppose- that which arises gradually than that which falls upon us as an event –interesting, because that allows us to discount something until it results in complications. Difficulties. It is the Janus view of evolution, I suppose.

An article in the BBC news alerted me to one novel approach to encourage acknowledgment of an issue that has plagued some societies for what seems to be millennia: sex selection –or perhaps, more honestly,  destruction:  www.bbc.com/news/world-asia-india-37034444

It got me thinking… We tend to cherish and preserve what we value; we neglect, or abandon that which we don’t. Denigrate it, even. Perhaps an occasional nudge in the ribs may cause us to look around and see where we have wandered –realize that there is really no need to stand so close to the edge.

But it does give one pause for thought –how do some of these things become imbedded in a culture? Surely they don’t start out as intentionally malevolent. Or is that being revisionist and unduly naïve? I’d like to think that some of the customs, however egregious we find them now, were products of a different time when other priorities required precedence. Confusing times, perhaps, when we barely knew who we were in our overarching need to identify and fend off them. Troubling times beneath the roiling waters in which we are just beginning to be able, however slowly, to surface for air.

And the problem, as always for those of us less afflicted, is acknowledgement –recognition that there is more to do. There is always more to do…

Despite being a gynaecologist for more years than I can remember, I suppose I have always lived in a man’s world. It’s hard not to wear the clothes you were assigned. And yet, every so often, that usually-locked door is knocked ajar briefly, and the light from within is blinding. Unintentionally heuristic.

I was sitting in a busy coffee shop recently and managed to find a tiny unoccupied table against a windowless and shadowed wall in the corner. Perhaps it camouflaged me -made my presence less noticeable, my gender less obtrusive- but as I sat there staring silently at the busy room, fragments of conversation from the next table floated past like dust motes in the feeble light. Two women were catching up on their lives. I didn’t mean to listen, but sometimes words are beacons: currents, vacuuming up the air between –meant to be heard, meant to inform. It’s hard to ignore words when you sit in shadows.

“And so how is Janice doing now?” a grey-haired woman in pigtails wearing black track pants and a yellow sweat shirt asked between gulps of coffee and grabs for the oversized chocolate cookies she had balanced precariously on her plate. She clearly had little need of more calories, but the presence of her more sizeable friend likely justified the debauch in her mind. It works for all of us, I think.

Her friend just shrugged amicably. “You know what it’s like, Dory,” she said, and launched into her bagel as if she were packing a box. “Kids are kids…”

Dory munched softly on a cookie and considered the issue. “She’s hardly a kid, now, Alice. She’s, what, seventeen?”

Alice nodded her head equally thoughtfully and her long dark hair slid back and forth over her shoulders like a wash cloth. Although considerable larger than her friend, she carried her weight gracefully, and with the gravitas that suggested a person of authority. Dressed in what seemed in the dim light to be an expensive white silk blouse I could make out little ruffs on each wrist. I don’t normally notice such things, but with each movement of her arms, they risked coating themselves with cream cheese from an impertinent bagel, now lying in fragments in front of her. “Eighteen…” She took a delicate sip from her coffee and sat back on her chair as if the subject required a little more thought.

“Still, she should know where she’s headed by now…” Dory left the question of direction open, but her eyes betrayed her opinion. “I mean, who she is…” she added, italics begging for attention.

Alice sighed and leaned forward again to pack another item into her waiting mouth. “I think she’s always known.”

“And how about you?”

Alice smiled and nodded. “Some things a mother just knows, Dory.”

Dory was obviously trying to understand, but her confusion was apparent, even to accidental eyes watching from the shade. She shook her head, disapproval hovering over her like a cloud. “Did you ever to speak to her about it, Alice?”

Alice’s eyebrows both rose at the same time. “Whatever for, Dory?” she said, genuinely puzzled at the remark.

It caused Dory to sigh rather more loudly than necessary. “Well, I would have thought…”

Alice refurbished the smile she’d sacrificed to the bagel and leaned an elbow on the table. “Thought what?”

Dory straightened her back like a boxer ready to receive a blow. “Well… that…”

“That my daughter would think the same way as her mother? She learned the Theory of Mind when she was five, Dory.” Her friend visibly winced at that. “The world is different for each of us, Dor,” she said, reaching out and grasping Dory’s hand. “And the question should not be why, but rather, how can I best negotiate it…?”

Dory tried to smile, but even from the shadows I could see her lips twitching with the effort. “Do you think if…” But she was clearly too embarrassed to finish her thought –and anyway, I could see Alice shaking her head and squeezing her hand affectionately.

“Somethings just are, Dory. And my main duty as a mother is to help her to accept them.” She let go of Dory’s hand and picked up her coffee for a sip. “And to help others to accept her…”

“But…” There was a hint of helplessness in that one word.

“But what’s not to love, eh?” she said, glancing towards the door and standing up to wave at a smiling teenager gliding towards them like a boat about to dock. And then Janice waved back, just like anybody else…

Menstrual Taboos

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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