Tag Archives: gender in medicine

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The Feminine Perspective?

“Men and women think differently, doctor,” a patient said to me recently, shaking her head in response to some requested advice from me. “You of all people should know that.” It was stated with a look of smug authority, as if  to disagree would have been tantamount to an admission of professional incompetence. And while I don’t concede the point that to disagree with what seems to be a societal dictum necessitates a conclusion of medical bankruptcy, it got me thinking…

I suppose the first thing that occurred to me was to question the assumption that my specialty somehow enabled entrance into the heavily guarded sanctum sanctorum of my patients –female patients at that. It kind of invokes the Theory of Mind, doesn’t it: the early discovery by a child that others also have things going on in their heads, and that they may differ from her own thoughts or perceptions. It’s an important step in eventual integration into society; it’s also a recognition that because it’s different, we can never really know what someone else is thinking.

So, in that sense, no: I (a male) can’t know what my patient (a female) is thinking -any more than I could if that person were another male. I can suspect that it might differ from what is going on in my head, but given a common purpose -the solving of a medical need, say- I can intuit that we can communicate something meaningful about that.

“Ahh, but it’s not just that we live in different bodies, doctor,” -I could almost hear her response to my thoughts- “It’s more the way we approach the problem.” Really? Are the goals actually dissimilar, or is it more a difference in perspective -a choice of route? And is the perspective culturally assigned, or does it reflect a basic underlying gender difference in physiology and wiring? Is it just that we are supposed to think a certain way -an assumption- or that we, in fact, do -an innate, genetically driven imperative?

Are the perceived psychological differences in the sexes superficial and societally contrived, or are they more like two Magisteria -the approach Gould chose to describe the difference between religious and scientific knowledge and authority? It’s a difficult question obviously, but I sometimes think it has degenerated into more of a media-driven competition -each side trying to enlist support from an otherwise disinterested and unaffected Public.

I sat back in my chair and smiled inquisitively at my interlocutor. “And how would you approach this problem?” I asked, hoping to learn something from the encounter.

“Well, for one thing, I would offer more choices.”  She sat up straighter and crossed her arms defiantly, daring me to disagree.

Fair enough; I suspect we would all like more of a say in how we deal with a problem. I nodded my head in agreement. In medicine, even if there are no other viable therapeutic choices, there is always the option of doing nothing -seeing what will happen over the coming days or weeks. But I suspect that the choice of that option transcends gender, transcends the assignation in the genetic lottery…

But maybe I was missing something; maybe she was operating with a world-view that necessitated a different assimilation of Reality. For that matter, maybe there was a different reality for her -one that I could never hope to experience. Maybe what she experienced as Red, for example, I experienced as Blue and yet we both named it with the same word. How could I ever know? A troublesome thought indeed.

And yet, ever the pragmatist, even if we both meant something different by that word, but arrived at the same destination, wouldn’t the communication have been successful? The goal achieved?

She wasn’t finished with me. “And I think you were assuming I should just accept your opinion, doctor.” She obviously hadn’t liked any of my solutions, although I had offered her several. She had probably only heard the word ‘hysterectomy’ among them.

It occurred to me that although we both wanted to solve the same problem, her condition had a different meaning for her altogether. And it didn’t hinge on her sex as much as on the way she envisioned herself as a person, as the protagonist inside a personal history: her story.  She possessed an identity tied to what she currently was, and whose very existence was contingent on whom she might inadvertently become.

But we’re all like that: we are who we have been; the past drags behind us like a shadow. It’s company for us on our long trip; it’s our suitcase full of memories… So that alone cannot be what she was alluding to.

That we all see the world from our own perspective, and that it is different for each of us, is merely stating the obvious. That we each come to a problem with a different history is equally obvious. We have all been entangled in cultural webs that have conditioned the way we respond to issues. In the beginning, perhaps it was all engendered by biological constraints, but I think most of us now realize the artifice in that.

What, then, accounts for the difference, other than milieu?

Bertrand Russell, a philosopher mathematician of the last century had some small influence on my early development; I make no claim either to have read all of what he has written, or for that matter to have understood more than a small part of what he had to say, but I have always remembered one passage -one pearl- that made sense to me. Perhaps it was the only thing I could understand:  For my part, I distrust all generalizations about women, favorable and unfavorable, masculine and feminine, ancient and modern; all alike, I should say, result from paucity of experience.

Maybe I should have read more of him; there are many perspectives…

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Gender

I am a prisoner of my age, a hostage to my generation; I never thought I’d say that, but I suppose none of us do… We are as contemporary as our minds and experience will allow.

My own epiphany came, as I recall, when a patient engaged me in a discussion of gender. I had not intended to be controversial; neutrality -or at least impartiality- had been my intent in our exploration of her problem. I am, after all, a male meddling in female affairs so I must needs approach it as a visitor to a foreign land: respectful of its customs and willing to learn. I even used those words, I think, but it seemed they were the points of contention, however. Unbeknownst to me, I had innocently strayed into a minefield.

“Why do you have to feel as if you are a stranger?” she asked, eyes ablaze.

I thought about it for a moment, but I have to admit my response was weak. “I suppose because I am a man and was brought up as one…” I left the end of my sentence open, hoping she would not ask for further clarification. I was mistaken.

“But that’s just my point,” she said, rising briefly off her chair in her enthusiasm. “We’re both human, and despite the difference in our ages, both equally entitled.”

I could have wished she hadn’t felt the need to comment on our age difference, but entering into the spirit of the discussion, I put down my pen. “Entitled to..?”

Her face crinkled for a split second before she could rein it in. “Well, entitled was probably the wrong word; entitled implies that there is someone who is allowing, permitting, something. What I’m suggesting is that there should be no gender split…” My eyebrows must have moved, because the wrinkles reappeared on her face and stayed put. “No gender discrimination,” she added, as if that would clarify her meaning and win me over.

I don’t need to be convinced there is egregious gender discrimination throughout the world, but I suppose I assumed that the worst of it took place somewhere else: developing countries, or places still troubled by malaria -naive in the extreme, I  must confess, but a topic not often front-and-center in my everyday life. I believe in equality of opportunity for everybody, gender included, but I recognize that the platform from which I regard this is that of a white male in a position of relative authority and privilege -something so taken for granted that I no longer see it. Or don’t want to…

“I don’t see why the absence of a Y chromosome should relegate me to a particular role in society.”

She said it with such vehemence I couldn’t think of a suitable response at first. There are some things about our dealings with the world that are hard to express, much less analyse dispassionately. “How would you change things,” I asked finally, hoping she would understand my quandary.

She crossed her arms defiantly. “The very fact that you had to ask, is part of the problem,” she said, trying her best to smile politely. “How do you change things when the very institutions that you want to change, don’t think there is anything wrong?” She pinned me to the wall with eyes like spotlights. “Why should I have to behave a certain way, just because I happen to be female? Why is there an expectation that is constrained by gender? Limited by gender? Imprisoned by gender?”

She was becoming very excited and agitated across the desk from me, but all I could do was smile in what I hoped was a sympathetic way and show I was open to her indignation.

“I mean washrooms, for god’s sake!” She rolled her eyes; I remained silent, not knowing what she meant. “Why is there still washroom discrimination?”

I have to admit I hadn’t thought that was even a problem. I just go into the one with the little man sign; there is usually a woman sign right beside it, so it’s not like we have more of them. And if there’s no sign, no indication of sexual preference, I assume it doesn’t matter. End of story. “Is…” -my tongue floundered about, looking for the right question- “Is that usually a problem?” I couldn’t think of anything else to ask.

Her arms folded even more tightly across her chest. “Not usually!” she snorted, eyes locked on mine as if we were wrestling. For once I was glad my desk was so wide. “But there’s no need for two types of washrooms.” I watched her as passively as I could manage, given the tight hold she had on my face. “But washrooms are only the part of the iceberg that’s showing. Society discriminates: it assigns roles; Language discriminates -you know: chairman, fisherman, fireman…

 “I thought we’d changed those,” I said, feeling suddenly compelled to defend Society, or something. “You know: it’s Chair, and Flight Attendant… That sort of thing…”

“Yeah, but inside, you’re thinking chairman, or stewardess aren’t you?”

I shrugged. “Maybe I am, but that’s because those were the words I grew up with; younger people probably don’t even know we used to call female flight attendants stewardesses.” I decided to cross my own arms to make the point. “And besides, language evolves alongside Societal trends -Societal demands, if you will. It means a shift is occurring, however slowly, don’t you think?”

Her face softened and a twinkle appeared in her otherwise steady gaze. She had, after all, come to me with another problem for which she sought help and guidance. Perhaps coming to a male for her gynaecological issue meant that she saw me as gender neutral after all. “Would you mind if I asked you a rather personal question, doctor?”

I shook my head -affably, I hope- but with a sinking feeling in my chest; I could feel it coming.

“Would you go to a female doctor for your prostate?” I suspect I blushed, because she suddenly smiled and visibly relaxed in her seat. “It’s a very slow shift…”

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Choosing a doctor

There are age-old dilemmas in choosing a doctor, aren’t there? Choices often have a way of seeming problematic, even insoluble, when considered in the abstract and all the more so when they have to be made for real. Theoretically, I suppose, they should be made after due-diligence, as the lawyers would say. One merely sets out a series of criteria and then assesses whether or not they have been satisfied. We all do this, to some extent, but often the only criterion that has to be met is whether or not a friend liked the doctor, or perhaps had a good result from him or her. What her scar looked like -never mind what went on underneath it?

But even considering it like this suggests further and more contentious questions: should one choose on the basis of personality -bedside manner, if you will- or results? After all, you still need to interact with the doctor, explain your problem, have it considered and assessed in a sympathetic and respectful manner. A skilled surgeon may be only that – and as I’ve pointed out in previous blogs, surgery isn’t always the answer, but often merely one of many options. If you’re not given the choice, how would you even know there was one?

Do you choose the academician, or the clinician? Knowledge isn’t always translatable into skill. My senior residents usually have the academics down pat -they need to write exams to prove it, after all- but it takes time for them to master the skills that enable them to put it into practice, especially under pressure at three AM or in an emergency where conditions may not be text-book clear. Knowledge is the possession of facts about something; wisdom -skill- is the ability to contextualize them. Use them, in other words.

Oh yes, and then there’s gender -a particularly vexing problem for the male gynaecologist. It seemed especially so when I first started in practice, but I was younger then -more naive. A female colleague and I opened an office together soon after we achieved our specialist fellowships, and I remember feeling hurt (is that the right word?) that our new patients chose -insisted- on seeing her. Finally, and after what seemed like months of empty day-sheets for me, she became so busy that new appointments, even emergencies, had to be deflected. I began to get what I used to call the left-overs: patients who were initially angry that they too had been given a left-over.

Eventually, however, things settled a little and people began to choose on the basis of other criteria than merely gender. Quite simply, males often see things differently. Things that my partner had less patience for -perhaps because she had lived through some of the problems she was being asked to solve and saw them more as complaints than issues needing a solution- I  saw through inexperienced eyes and from a different perspective. I could sympathize with someone having debilitating pain that returned like the moon month after month, year after year. I could understand the need to find a contraceptive that didn’t engender mood changes, or headaches, or intermittent bleeding, or require strict adherence to a schedule so as not to forget to take it. I could sense the tiredness that would be brought on by the demands of breast-feeding, of needing to be constantly alert to the infant, or child’s needs, no matter what else my life required.

But a choice is just that: singling out one from a line up of often similar faces where even the criteria require yet other choices. I suppose if the difference between them is truly small, the choice is even more difficult, but less likely to result in later self-recrimination. One does not -one cannot- choose retrospectively, so any choice could be argued to be the correct one under whatever circumstances it was made. The fact that choice is even possible is a luxury not afforded to everyone, everywhere.

Obviously I have no answer that transcends personalities and specific needs; I would not presume to speak for someone who sees the world from a different background or a different culture. I can only suggest that respect is something that I would look for; that is usually evident on the first encounter. It is in the eyes, on the face and in the gestures. It is woven into the cadence of speech, the words chosen, the smile that, unbidden, lights up the interface between two individuals who are no longer strangers.