Sheep in Wolf Clothing

I suppose it has always happened -there’s very little that’s really new around; I still wonder why it’s necessary, though. Even through the lens of my white male privilege –my through-a-glass-darkly upbringing- I continue to wonder about these things. Why, for example, do I even have a lens? Was it necessary simply because in the chromosomal lottery, I got the Y? Or is it rather because others lack one? Others? There’s a difference, I guess: one side brings children -even the Y’s- into the world, and nourishes them until they are old enough to be independent; the other side… what, fears  that ability, despite experiencing it themselves? I’m sorry, I don’t understand. Call me naïve, but does that not make us interdependent? Partners in survival?

Anyway, despite my anguished jeremiad, and notwithstanding my somewhat childish credulity, I love it that people have always pressed against boundaries. Crossed borders. Transcended gender constraints. Limits which have been arbitrarily imposed have been challenges from time immemorial.

Until we searched, records of past successes were unfortunately few in number -hidden, or at least difficult to access- not necessarily because they failed, but more often I would suspect because history is written by the dominant. Controlled by those who commanded the prevailing power structure and had greater access to whatever educational resources were available at the time. Military and church, after all, were predominately unisexual, so it seemed rare to read about females that stood out for things other than pandering to male needs, or gaining fame as consorts to royalty.

A few exceptions proved the rule, of course. To pick only a few of my favourites of the many historical examples we were once offered: the fourth century Greek mathematician and philosopher, Hypatia; Lady Li, an artist in tenth century China; the twelfth century polymath Hildegard von Bingen. She was not only a Benedictine abbess, but also a philosopher, natural historian and writer -and she first came to my attention for her musical compositions; Fanny Mendelssohn, a composer and pianist, the talented sister of the more well-known Felix. And then there was the nineteenth century novelist Georges Sand, albeit perhaps more famous for her association with Chopin (and other famous men of the time) than her writings.

The list has recently become much, much longer -and growing- as we begin to delve into historical documents more thoroughly. It would seem that our knowledge of the past is directly proportional to the prevailing ethos –the effort expended… There have always been women who’ve excelled, but there have not always been people who wanted to hear about it…

I do, though; I’m always inspired by anyone who is able to critically assess that which represses them, and come up with a solution. I suppose most of the answers are variations on the same methodology, and yet they still make me want to cheer. An article I found in the BBC news was particularly heartening I think –especially its little twist:

It’s the story of a woman in Tanzania who ran away from an abusive husband and ended up in the ‘small Tanzanian town of Mererani, in the foothills of Africa’s highest mountain, Kilimanjaro – the only place in the world where mining for a rare, violet-blue gemstone called tanzanite takes place.’

Only men were allowed in the mine so, like in a fairy story, she disguised herself as a man and went to work. She called herself ‘Uncle Hussein’. ‘”I acted like a gorilla,” she says, “I could fight, my language was bad, I could carry a big knife like a Maasai [warrior]. Nobody knew I was a woman because everything I was doing I was doing like a man.”’

And, just like in a real fairy story, ‘after about a year, she struck it rich, uncovering two massive clusters of tanzanite stones. With the money that she made she built new homes for her father, mother and twin sister, bought herself more tools, and began employing miners to work for her.’

But, as in all parables like this, ‘her cover was so convincing that it took an extraordinary set of circumstances for her true identity to finally be revealed. A local woman had reported that she’d been raped by some of the miners and Pili [Uncle Hussein’s real name] was arrested as a suspect.’

Of course, the truth was soon revealed and she was released. ‘But even after that her fellow miners found it hard to believe they had been duped for so long. […] Pili has built a successful career and today owns her own mining company with 70 employees. Three of her employees are women, but they work as cooks not as miners. Pili says that although there are more women in the mining industry than when she started out, even today very few actually work in the mines. “Some [women] wash the stones, some are brokers, some are cooking,” she says, “but they’re not going down in to the mines, it’s not easy to get women to do what I did.”

She has married again, although ‘Finding a husband when everyone is accustomed to regarding you as a man is not easy, Pili found, though eventually she succeeded. “The question in his mind was always, ‘Is she really a woman?'” she recalls. “It took five years for him to come closer to me.”’

‘Pili’s success has enabled her to pay for the education of more than 30 nieces, nephews and grandchildren. But despite this she says she wouldn’t encourage her own daughter to follow in her footsteps. “I’m proud of what I did – it has made me rich, but it was hard for me,” she says. “I want to make sure that my daughter goes to school, she gets an education and then she is able to run her life in a very different way, far away from what I experienced.”’

I love the kind of story of someone encountering and then overcoming seemingly overwhelming odds. I suppose we all do –it’s a classic fable, isn’t it? A veni, vidi, vici episode to be sure. But I am still saddened that it has to be like this. Not that there have to be challenges, you understand –it would be a boring world that offered none- nor even that only a few manage to see it as an opportunity, a fence that needs climbing. No, I’m sad that after all this time, whether out of fear or mistrust, there are still walls like this.

And yet, I remember lines from a poem by William Ernest Henley –‘Invictus’: ‘In the fell clutch of circumstance I have not winced nor cried aloud. Under the bludgeonings of chance my head is bloody, but unbowed’. And, more especially, the last stanza: ‘It matters not how strait the gate, how charged with punishments the scroll, I am the master of my fate, I am the captain of my soul.’

Let us all hope so…






Teenage Sexuality

It seems like every time I turn around nowadays, I learn something new about what my colleagues are doing -or not… A recent article published online in JAMA Pediatrics, Dec. 30/13 (abstract: ) suggests that we in the medical profession are not doing enough to disseminate information about sexual health -especially to teenagers. The study was from the USA (North Carolina), and so might not be universally applicable, but it got me thinking.

I suspect the problem is not confined to the study area reported; it is all too probable -if not understandable- in most countries, but Canada is the one with which I have the most experience, so let me begin with it. Teenagers in any country, are a difficult group: they are usually healthy and often unaccustomed to visiting a doctor except with a specific complaint to be resolved. The age difference between a teen and her doctor, or nurse, is usually significant and often an impediment to easy and trustful communication. And sometimes her world-view and experience clouds the risk and her own consequence-assessment of her behaviour -especially if others are engaging in it. Many have yet to learn from their mistakes…

Another not insignificant factor -at least in this country- is the frequent accompaniment into the doctor’s office of the teen by her mother. A totally understandable and laudable practice, at least a priori.  Sometimes it is to give the young girl confidence on her first visit, or to make sure that she asks the right questions and of course receives the correct answers. But it does make it difficult to delve more than superficially into the sexual history, contraceptive needs, and more particularly, issues surrounding normal, healthy sexual functioning: such things as pain, lubrication, orgasm or even partner expectations. There are a lot of questions that are both embarrassing and difficult for her to raise, let alone answer, with a parent present. A mother can be a two-edged sword…

And I suppose that one of the cardinal rules of medicine –Listen first, talk later– is also turned on its head with teen sexuality: teens seldom ask about it, in my experience. They’ll ask about contraception (sometimes) or sexually transmitted diseases -and more specifically whether or not I think they have one- but almost never about other sexually related concerns unless I ask them. Whether it’s because I am a male and generationally distant, or because they are too embarrassed to raise the subject -especially when the answers so obviously lie just a mouse-click away- I’m not sure. But I can say that when I do raise the subject, after a short, suspicious period of feigned indifference, most seem relieved.

As a male gynaecologist dealing with often nervous, and bashful teenage girls, the problem is usually finding a way to work into the subject of sexual health without alarming or further embarrassing the patient -the younger ones in particular. Indeed, wherever possible I try to have them seen by my female associates instead, recognizing that they may feel more comfortable dealing with another woman. No doubt this could be seen as an abdication of my responsibility to a patient in need of care, but in many cases it’s a more sensitive approach, and one that may ultimately prove more valuable and helpful to the teen at a particularly impressionable -not to mention vulnerable- stage of her life.

But in reality, and given the exigencies and problems inherent in finding available specialists, I realize that sometimes we -the patient and I- must attempt to transcend both the gender and the generational gap as best we can. And so, with regard to inquiries about sexual health, I try to fall back on experience and advice from my more seasoned colleagues. It’s usually inappropriate to inquire without a reason -it smacks too much of prurient curiosity even from a health professional. But sometimes it can be a careful addendum to questions about contraception. Or perhaps during the queries about some other problem for which they have sought help -pain, for example. I am often asked to see a young patient discovered to have an ovarian cyst (a not uncommon, but often painful result of irregular or absent ovulation in younger teenagers -benign, but nonetheless frightening). The discussion lends itself to asking if she gets pain with such things as exercise, bowel movements… or intercourse -a natural progression of embarrassing yet understandably relevant questions that allows further pursuit of the topic. A rather different approach is to embed the sexual questions in the lengthy and detailed initial history that allows the girl to see that you are being thorough -not intrusive. It is unabashed subterfuge, I admit, but in many such circumstances, the end does justify those means. Or is it just me?

So I can understand why it may seem that the sexual health inquiry appears to be absent or minimal -in the study at mentioned at the beginning, at any rate.  One must first achieve rapport -a relationship deemed to be both trustworthy and private- and this takes time; it seldom occurs on the first visit, and almost never with the mother present. It is a long-term goal and cannot be hurried. Even those admittedly tentative answers to the thorough and hopefully sensitive consultation history may need to be reconsidered -re-approached as it were- once she has come to know and trust you.

I think all of us in the position of health care advisers wrestle with these challenges and recognize that our goal in promoting teen sexual health should be to interfere less and to educate more; to facilitate her ability to make informed choices; to help her to recognize and avoid risks; and perhaps most important of all, to be sensitive to her growing independence and to let her understand that we celebrate it. Criticism will only turn her away. 

But we are all learning; communication between age groups and genders is often riven with inadvertent blunders and unplanned insensitivity. Words -questions- can be met with sullen withdrawal or sudden suspicion and mistrust. Anger. Rejection. Embarrassed silence… It was Oscar Wilde who said: Experience is the name every one gives to their mistakes. And yet we must never forget that experience teaches -even across generations. Rapport is not often given freely, it must be won, and its path frequently winds through a dark, mysterious forest of little mistakes.