What We Value

I think it’s about time I revisited the concept of ‘disability’, both in its description and in society at large. It seems to me that the word itself is too value-laden to accept at face value. We are all disabled in one way or another and yet we may not see ourselves like that. And why should we? Disability, like beauty, is in the eye of the beholder –or in this case, the beheld. I first wrote about this several years ago: https://musingsonwomenshealth.com/2012/08/31/antenatal-genetic-testing/

The concept is embedded in context, and like two colours mixed together, can result in something totally different. Totally unexpected –even if innocently mixed. I was reminded of this by another  BBC article on Down Syndrome and antenatal screening: http://www.bbc.com/news/magazine-37500189  Once again there was an acknowledgment that ‘”The whole essence of a good screening programme is the counselling you have before you even have the blood test done or the scan done,” says Alan Cameron, foetal medicine consultant at Queen Elizabeth Hospital in Glasgow.’ And, of course, ‘[…] all experts agree that the way a diagnosis of Down’s syndrome is presented can influence whether parents choose to continue with the pregnancy.’ Even unconscious biases affect the way counsellors present the evidence, and none of us is free of these, I fear. We are all tinted by the colours that surround us, after all.

And I suspect there’s no better place to experience colours than riding in a bus.

I happened to be sitting behind two young women, both of whom were carrying their babies in those little vertical hammocks on their chests that tend to wax and wane in popularity. They evidently were strangers, but as newly minted parents, they seemed anxious to brag and peek at each other’s baby.

“She’s gorgeous,” said the one sitting beside the window, glancing at the closed-eyed head breathing quietly in its tight little container on her seat-mate’s chest. I’m not sure how she ascertained the sex so easily, but maybe new mothers are more adept at that than the rest of us.

“Thank you,” said the other, risking a peek at the sleeping baby beside her. “So is yours,” she cooed, cuing a smile and a flutter of her eyes.

“His name is Joshua,” the window lady responded, as if it was essential to establish that from the start. “Names are important,” she added, more seriously. “It means ‘God is generous’, or something…” To be honest, she didn’t sound too certain.

Aisle-woman was silent for a moment. I couldn’t see her face, obviously, and it might have been rude to look, but I thought it seemed an awkward response. “That’s nice,” she said in a carefully neutralized tone, but that kind of thing is hard to determine when you’re sitting behind someone in a noisy bus. “My little sweetie is called Elizabeth…” I could hear the hesitation in her voice. “I don’t actually know what it means,” she admitted.

“It means God is satisfaction, I think,” window-woman said without a pause. “We were going to name him that –if he’d been a girl, I mean.”

“Oh.” Aisle-woman seemed stumped about how to reply, but her neck-language suggested she was none too comfortable with the God references in both names.

They were silent for a few streets, and then, window-woman, unable to contain herself, peeked at the other baby. “They all look so peaceful when they’re asleep, don’t they?”

The woman nodded and felt forced to reciprocate with a fleeting inspection of Joshua as he snored. I assume it was snoring, at any rate, because it was rhythmic and his mother didn’t seem to be doing it. Elizabeth’s mother reached over and loosened Joshua’s hammock with a finger, thinking that might have been the cause. It was an innocent gesture, meant to be helpful –a mother’s instinct in action- but Joshua’s mother immediately grabbed the offending finger.

“He’s okay,” she said, embarrassed at her protective reflex. “Joshua’s just a noisy sleeper, that’s all…”

Elizabeth’s mother stole another glance at Joshua and I could see the edge of her smile, even from behind. “I’m so sorry, I didn’t mean to interfere,” she said, and adjusted Elizabeth’s little hoodie, just in case. “I thought he looked a little puffy… I wondered if maybe it was the hammock.”

Joshua’s mother forced a smile and then turned to look out of the window. “He isn’t puffy; he looks just like yours,” she said in a soft little voice that I found hard to hear.

“I’m sorry,” Elizabeth’s mother said, touching the other’s shoulder gently. “I… I thought I was helping…”

When Joshua’s mother turned her head to respond, I could see a tear rolling down her cheek. She stroked Josh’s little cheek and the snoring stopped for a second or two. “They told us he’d be…different,” she said slowly, “But he’s really a very good baby, you know…” She stroked Joshua again when he seemed to be rousing, and he immediately relaxed and made some sucking sounds with his lips. “I know he meant well, and everything, but the doctor always looked so sad when he saw me during the pregnancy. You know, like he was trying to console me or something…”

I could see a little tear beginning to form in the eyes of Elizabeth’s mom now. “I’m so sorry,” she said as softly as she could over the rattle of the bus. “I didn’t mean…”

But the window-lady had already pulled the cord for the next stop and was starting to rise from her seat. “God really has been generous to us both,” I heard her say as she reached out and gently stroked her neighbor’s baby as she passed. “It’s just that I’m always going to be reminded of that, I guess…”

She hurried through the opened door and I could see her standing out there as the vehicle pulled away, caressing little Joshua but otherwise not moving… As if maybe the answer was another bus…

 

 

 

Eeny Meeny

I have always been fascinated by the idea of choice –the philosophy of choice. What does it mean to choose? Does the act of embracing one thing necessarily exclude the other, or merely prejudice it? Blemish it? Dishonour it? Alternatively, given an either/or situation, is it possible to throw the pair into a box and merely choose the box? After all, that’s (sort of) what Set Theory allows mathematicians to do –group together unlike things with common properties for analysis.

It seems to me there are several types of choice that range from necessary to frivolous, each with its own particular reason for being made, and each with its own particular set of consequences. Some choices are imposed from without, and some from within; some have to be made, while some are voluntary. Personal. The most compelling ones –for me, anyway- are those in that box –that set

The issue surfaced again for me after reading another BBC news article on non-binary gendering: http://www.bbc.com/news/magazine-37383914  I published another essay on this topic in July, but there I was more concerned with managing its language eccentricities: (https://musingsonwomenshealth.com/2016/07/13/non-binary-gynaecology/ ) I realized even then that there was much more to it than language, but the more recent BBC article really brought that home. How can you choose between two things when you are both? It would be like choosing between your son and your daughter –a Sophie’s Choice.

And yet, it would seem that Society feels more comfortable with identifiable categories –in this case, they’re usually anatomically assigned, so from that perspective, they’re not exactly arbitrary… Just unfair. Insensitive. Closed…

Perhaps my long career as an obstetrician/gynaecologist has blurred the gender boundaries as thoroughly as it has the social, economic and ethnic ones. When you get right down to it, we’re all more alike than we might like to think, and categories eventually leak like unwaxed paper cups.

I take the bus a lot nowadays –I’m not sure why, really, except that I enjoy watching those around me. And listening. Sometimes I feel a little like Jane Goodall, only my country is the bus, and my subjects, are people, not chimpanzees in deepest Africa. The other day, I happened to be on a rather crowded vehicle just after the local public schools had opened their gates. Standing next to me in the aisle were two young girls, both around eleven or twelve years old judging by their looks. Each was wearing jeans, sneakers, and coloured ski jackets, and both were hugging their backpacks to their chests, for some reason. One, a rather tall girl with short, brown hair and horn-rimmed glasses, was rummaging in her pack for something while her friend –a blond with hair that she had tied into a rather messy ponytail, watched with interest.

“Do you have any gum in there, Cindy?” the blond said, peering into the caverns of her own pack.

“No… I was just looking for some lipstick,” she said proudly, glancing at me as she said it.

“What! Your mom lets you wear lipstick?”

The tall girl blushed at the response. “Well it’s just reddish Chapstick, but it, like, reddens my lips, too…”

The blond nodded collegially, and then pointed at the two seats in front of me that had just been vacated. After that, only scattered bits of their conversation filtered back to me.

“Yeah… sometimes, I do Cindy,” the blond said, nudging her friend.

“But you said…”

“I said sometimes!”

Then Cindy elbowed her softly, as if she understood completely. “I’ve sometimes wondered what it would be like…”

“It’s kinda confusing -every so often, anyway…”

“You mean choosing which…?” Cindy seemed puzzled.

I could tell that the blond had to think about that. Then she shook her head thoughtfully. “No, more like who I am when I try to think about it…”

Cindy looked at her for a moment and then straight ahead, as if she was suddenly embarrassed. “Aren’t you just ‘Connie’? I mean no matter what you feel like, aren’t you still a Connie?”

Connie was quiet for a moment. “I guess…” They were both silent for a bit. “I don’t think names really matter though, do you Cindy?”

Cindy shrugged and looked at her. “I suppose as long as you answer…”

I could hear Connie giggle at that. “I’m still Connie… But whatever you call me, it’s still me inside.

Cindy nodded slowly but I could tell she was still perplexed about her friend. “Have you…Have you told Father Simms?”

Connie immediately shook her head vigorously and the little ponytail almost came undone. “No way! He’d just tell my parents.”

“How about your mom and dad then?”

“Mommy thinks it’s just a phase –hormones kicking in or something…”

“Well…”

“Cindy I’ve always felt like this; I just didn’t say anything.” She glanced out the window and nudged Cindy again. “Better pull the cord. It’s the next stop.”

Cindy looked up and then obliged. But as they passed me, I could hear Cindy’s concerned whisper -as if it wasn’t something she dared to say it in a normal voice. “But how come you don’t think like the rest of us in the church?”

“How do you know I don’t?” Connie said with a laugh, and they both stepped off the bus, giggling.

I thought about it for a while before my stop came. If I hadn’t just read the BBC article on non-binary gender, I would have assumed they were simply talking about God. But now that I’ve had more time to replay the conversation in my mind… I’m not so sure. Maybe I was granted a privileged audience with someone very special.

 

 

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…”

 

The Unexpected

What I like about the unexpected is that you never expect it. It’s a surprise. A gift. And the world is filled with this stuff. Each day at work –I’m a gynaecologist- there are little treasures hidden within appointments, presents in names. Especially the unpronounceable Persian names that unravel when I try to work at them one syllable at a time to call some nervous woman from the waiting room. But she inevitably understands my bumbled attempt, smiles, and when she sees my embarrassment, immediately forgives.

And there are cross cultural surprises that don’t anymore. Surprise, that is. There are some people for whom a question has to be asked with a lot of forethought. It cannot merely trip off of the tongue; it must be planned well in advance. A simple query in taking her history such as “You’re not married, are you?” might elicit ‘yes’ –meaning either ‘Yes I am married,’ or ‘yes, you are correct in saying I am not married.’ I love it.

Or consider the argumentative patient who doesn’t want to tell you why she is there. Her name provides no advance warning, nor does the note from the referring doctor. The first clue is usually the defiant, silent stare, and the arms tightly enfolded across her chest as if to prove that coming to see me was definitely not her idea. I suspect the behaviour is a punishment, although for whom I’ve yet to determine. And what do I usually do? I ignore the theatre and simply ask her why her doctor sent her. If that doesn’t work, I sit back in my chair and smile at her, hoping the time will allow her to acclimatize. Relax. Sooner or later, of course, she realizes she has to do something  or pay for extra parking, so she will sigh, undo her arms, unlock her eyes and either apologize or leave. I never know which way it will go.

But sometimes I am caught off guard. Something unexpected happens that even I did not anticipate. That something happened only a few months ago in fact: a movie star. Well, sort of…

It was just before lunch, and my stomach was rumbling. I had only one patient to see before I could escape for the morning, so I quickly glanced at the referral note. ‘Pain’ was all it said. Damn! I suppose the family doctor was in a hurry, but even an adjective, a descriptive, might have pointed the word in a more helpful direction. I shrugged mentally and then let it go –after all I was the detective, not him.

I walked down the corridor to the waiting room rehearsing her name. “Jojo?” I said with a little uptick at the end to indicate that I wasn’t entirely sure I’d got the name right, or whether it was a name only her closest friends used.

An unsmiling woman with short hair stood up and walked over to me. She shook my hand, but I could tell she didn’t really want to touch me. She wouldn’t make eye contact either. That made me a little nervous, but I assumed that she was just shy and understandably anxious. But I have to confess that apart from that, my initial impression of her was, well… absent. Nothing about her cried out for attention. She was average height, average build, with a pleasant but decidedly unstriking appearance –we are all beautiful in our own ways, but sometimes it is easier to notice, I suppose. I dislike the adjective ‘plain’ when applied to people, but occasionally it’s difficult to find another word without seeming patronizing. Let us just say she was neither attractive, nor unattractive but somewhere on that hazy continuum verging on, well, average.

She sat rather primly on the chair opposite my desk, eyes fixated on something on the wall to the left of my head. I fought the temptation to turn and see what she was looking at and distracted myself by asking her why she’d come to see me.

“Pain,” she said simply, without moving her eyes.

I waited what I thought was a polite interval for her to continue, but when she didn’t  I fidgeted with a pen on my desk -a signal, I hoped.

She glanced briefly at her hands and then her eyes flew back to their accustomed branch on the wall. “It’s been interfering with work lately,” she said, as if she had unlocked a door.

I felt I was getting somewhere. “In what way?” I asked, smiling to reassure her that I would understand.

She stared even harder at the wall and said, without a hint of embarrassment, “I get terrible pain when he…” I could actually see her adjusting words in her head. “When he enters…” She seemed pleased with the word she’d chosen and smiled for the first time –at the wall, mind you, but I figured it was a rapport starter. Suddenly she appeared to reconsider. “No, not ‘enters’ exactly… when he’s, uhmm…” -this seemed to be a real challenge for her- “…you know, in there and looking around.” I could tell she wasn’t exactly happy with her description, but she didn’t offer any more metaphors and resumed the neutral expression she had worn coming into the office.

I assumed I had simply misinterpreted the temporal juxtaposition of  her personal life and work, so I let it pass without further comment, although I did make a few mistakes typing it into the computer. The rest of the history was easier for her and even the subsequent physical examination, despite the pain, didn’t appear to bother her unduly. After she had come back into the office from the examination room, she seemed more relaxed than I’d seen her. “You found it, eh?” she said after sitting down and making more comfortable eye contact with the now familiar space on the wall behind me. “The part he hits,” she added to make sure I knew what she meant.

I smiled and nodded in agreement.

“So, what do you think?”

I’d felt a rather large and tender ovarian cyst in her pelvis -probably from endometriosis, judging from the rest of her history. “Well…” I tried to frame my response in a non-frightening fashion, but it was difficult. Ovarian cysts are always frightening. Threatening. “The area that was the most tender was around your left ovary. It seems larger than it should be –a cyst, maybe…” I thought the ‘maybe’ might diffuse the fright I could see in the eyes that now sought mine. “I’d like to get an ultrasound first, though, before we decide what to do.”

“You mean, like it might be… cancer?” I could tell it was difficult for her even to fashion the word in her mouth.

I smiled disarmingly. “No, more probably endometriosis.” I was about to elaborate on the word when her face turned sour and her eyes fled to the wall again.

“So, if it is a cyst, what are you going to have to do about it?” She sounded angry, but her face grew expressionless.

“Well, if it is a cyst, we’ll have to remove it.”

Her eyes immediately saucered and focussed on the front of my shirt. “You mean surgery?” I could almost see the italics. “Sorry, I don’t do surgery, doctor!” Her face changed; it was no longer unreadable.

“Why don’t we just wait to see what the ultrasound finds and then decide what we…”

But she was already putting on her coat. “You don’t understand, doctor.” She was having trouble fitting the two sides of the zipper together, so it gave me time to ask why she seemed so upset. She sighed, left the zipper for a moment and actually looked at me. Me -not the wall, not my shirt, not her hands- me. “It’s my work… I can’t have any scars for my work.” She stood up and walked to the door, still unzipped.

“The scars from a laparoscope are really quite small, Jojo. I…”

But she stopped at the door and turned to face me as she interrupted irritably. “Any scars. I can’t have any scars! That’s what they told me…”

“Who told you?”

“My producers.” I couldn’t keep the concern off of my face, so she continued. “No scars –that’s what they said.”

My face relaxed. “Producers? So you’re an actor? In the movies?” I must have looked impressed because she nodded modestly and leaned seductively on the door frame. “But… they’d be tiny little scars. And most of them would be lower down on your abdomen. Even the skimpiest little bathing suit would hide them.”

She cocked her head and allowed herself a tiny smile before she left. “I never get to wear one for very long,” she said as she disappeared down the hallway.

Words and Names

Words are important, let’s face it; they help us address those most existential of all entities: concepts. They describe things, modify things, name things. Without them, we’d no doubt be reduced to gestures -limited descriptors at best. The richness that is reality would still be there, but unexpressed, identified perhaps, but somehow unrepresented. To an extent then, we, the world -everything- is partly  how it is described. Words are powerful.

By now I’m sure you’re wondering what all this has to do with women’s health. Why is an obstetrician pretending he’s a philosopher? Words again, you’ll notice… Well, when we name something -a process, a condition- it engenders a certain expectation. If you name an experience, the name comes to represent what was experienced. Pain comes to mind. Or laughter. We know how it felt to experience these and if someone were to suggest that they were going to occur again, we’d probably have a pretty good idea what to expect. It’s what names are for, after all. Of course, what we call pain might be different from what someone else experienced, but we know what that experience meant for us. We would be able differentiate it from, say, tingling, or maybe fatigue. And if someone were to say you were going to experience pain, the very word would likely engender an expectation of something fairly identifiable and even relatively specific.

Okay, how about ‘labour’? You are a woman in your second pregnancy; your first labour was terrible. Maybe the contractions were deemed inefficient despite their pain, and augmentation with oxytocin was necessary. It seemed slow and interminable, punctuated with frustrations you could never have anticipated, delays that seemed unnecessary, maybe even resulted in something you wanted to avoid: forceps perhaps, or a Caesarian section. You have all that to look forward to (backward to?) again.

But do you? Well, we use the same word for second labours, sixth labours, whatever. So with minor variations on the theme, you expect the same thing. You know what to expect; you know what mindless suffering awaits, and if there was some trouble with the actual birth process, you know it will repeat: you haven’t changed. Your pelvic measurements are the same and this baby measured even bigger than your last baby on the ultrasound you had a month ago. So if anything, it’s going to be worse. Your midwife or obstetrician has tried to reassure you that second labours are quicker, more efficient creatures than first labours. Different creatures, in fact. But despite the rhetoric, something tells you they’re wrong. After all it’s still called ‘labour’ isn’t it? And you know what that means; you’ve experienced ‘labour’…

So why don’t we call subsequent labours by a different word if they really are different? Like the apocryphal description of different kinds of snow by the Inuit using different words: not all snow is the same, obviously, so if you were to hear a different description, a different word, you would expect that what you were going to see and experience was going to be different as well. Words are powerful.

I tell this to my patients and they usually laugh, politely to be sure, but secure in their knowledge that it’s all going to turn out the same no matter what I say. For one thing, I’m a man, so how would I know? And for another, and an even more convincing certainty, if it were truly different, there would be a different word for it.

I have struggled for years to come up with another word, but alas, with no success -no Nobel Prize for advancement of women’s psychological health, no media attention whatsoever.  I suspect I’ve not even been particularly convincing, coming at it as I do from the ‘other side’… But Hope springs eternal, eh?

Any suggestions?