The Serpent’s Egg

We all see the world through our own experiences, paint it with our own colours, fly our own flags. They seem real to us –unique and even necessary to our identities. As if it’s enough to be simply what we wear; as if we are only what we’ve been taught to show. But sometimes we need distance to understand that there are other equally compelling ways of defining ourselves. Other less travelled roads.

I say this, of course, as an unwitting member of a large club in which I was enrolled without being required to read the rules. But I guess most of us say that, don’t we? Male privilege –it’s something that’s hard to see if it’s all you’ve known. Easy to deny –and certainly easier to excuse- if you’re the privileged one. Especially if you can’t even understand the claim; to a sock, everything is a foot. It’s why we have them…

I worry that it is a learned attitude, however –like assuming all girls want to play with dolls, and all boys want to play with cars. A self-fulfilling prophecy if it’s taught early enough –valid only because we know it’s how it should be. Harmless, perhaps, if it does not disadvantage either side, but untenable unless dispassionately assessed. Unfortunately, we all tend to bring our own agendas to the analysis. Our own talking-points. Our own pasts…

A state in Australia is making a brave attempt to bring some historical context to the issue, and create some early awareness of the challenges of gender perspective and gender stereotypes: http://www.bbc.com/news/world-australia-37640353 ‘Students will explore issues around social inequality, gender-based violence and male privilege.’ This is not to suggest that Australia is any different in its treatment of women, but it is a welcome departure from many countries that don’t even acknowledge the problem. ‘Primary school students will be exposed to images of both boys and girls doing household chores, playing sport and working as firefighters and receptionists. The material includes statements including “girls can play football, can be doctors and can be strong” and “boys can cry when they are hurt, can be gentle, can be nurses and can mind babies”.’ And it doesn’t stop with primary school education. ‘A guide for the Year 7 and 8 curriculum states: “Being born a male, you have advantages – such as being overly represented in the public sphere – and this will be true whether you personally approve or think you are entitled to this privilege.” It describes privilege as “automatic, unearned benefits bestowed upon dominant groups” based on “gender, sexuality, race or socio-economic class”.’ Good on them!

But I think we have to be careful to walk the middle path. Accusations are seldom neutral; they often engender anger and even retaliation from those accused. So, perhaps predictably, in Australia ‘a report on a 2015 pilot trial accused it of presenting all men as “bad” and all women as “victims”.’ It’s one thing to illuminate the entire stage for a play, but still another to spotlight only one particular area. Decontextualize it…

*

Jeannette seemed like a fairly typical young woman as she sat relaxed in her seat and talking to several other women in the waiting room. Her long auburn hair danced lightly on her shoulders when she laughed, and her eyes sparkled as she leaned over to accept a toy from a little boy who had toddled over to her on a whim. Dressed in a loose grey sweatshirt and faded jeans, she wore a fresh, newly-pregnant smile that every woman in the room could see. And even the older ones followed her with their eyes –memories of bygone years. Her joy, theirs to enjoy -if only vicariously, and for too brief a time.

But her smile faded as soon as she sat across the desk from me in my office. Her eyes were predators shackled for the moment, the cage doors open nonetheless.

“I understand congratulations are in order, Jeanette,” I said, looking at my computer screen, and missing the change in her face. “Your family doctor says this is your first pregnancy…”

“The father doesn’t want me to keep the pregnancy,” she said tersely, her lips thin and tight, and as I looked up, she sent her eyes to savage my smile, and her forehead seemed to pucker as they left.

I had never met Jeannette before, although I had apparently seen her mother as a patient several years ago. That was all the GP said  -maybe it was why he had sent her to me for her pregnancy. I took a deep breath and leaned forward in my chair. These are always difficult conversations. “And how do you feel about that, Jeannette…?”

I could see her face relax a bit, as if my response had caught her by surprise. “I… I don’t think it’s fair!” She searched in her pockets for something, and then grabbed a tissue from my desk and dabbed her cheek. “I mean he’s blaming me for getting pregnant…” She took a deep, stertorous breath and sat back on her chair. “He refused to wear a condom –he said it would show I didn’t trust him…” I could see her squeezing her hands. “I didn’t, actually… I mean we’d never slept together before, but we were good friends… and…” Her eyes had softened with tears so she dropped them onto her lap and grabbed a handful of tissues. “Well, we were both drinking –he kept filling up my wine glass and…”

I remained silent and waited for her to continue.

“And he doesn’t even believe it’s his anyway… I was too easy he said!” Her face hardened again and her eyes dared me to agree. “I got really angry. ‘You were pretty easy, yourself’, I told him. And that’s when he punched me in the stomach and left…”

I have to admit that my mouth fell open. “Did you report him, Jeannette?”

She looked at me with a puzzled expression on her face. “He’d just deny hitting me, doctor!” she said through gritted teeth as if it were obvious. “And he’s already telling my friends it was consensual sex…”

I took a deep breath and tried to keep my expression neutral. “Did you tell your GP all this?”

She shook her head. “He wouldn’t understand. I just said I was pregnant…”

I sat quietly for a moment, wondering how to proceed, when she suddenly smiled warmly at me. “Can I ask you something, doctor?”

I nodded with a smile –sometimes it’s all you can do.

“If I were your daughter, what would you say to me?”

I thought about it for a bit, then looked at her and sighed. “When you do dance, I wish you
a wave o’ th’ sea, that you might ever do nothing but that.”

Her face brightened even more and her eyes sparkled in the sunlight from the window behind me. “That’s from Shakespeare’s ‘Winter’s Tale’ isn’t it?”

I nodded, surprised both that I quoted that line of all things, but also that she knew what I meant.

“Better start filling in that antenatal form on your screen, don’t you think?” she said, barely able to contain her face.

And we both laughed. Sometimes poetry has the privilege, I realized –not gender…

 

 

Unquiet Meals

I suppose Age has blunted me –or at least made me suspicious of fads, curious about recent phenomena that wear the clothes of certainty, vogues that hitchhike on the backs of something else never meant to carry the weight… But one must not be caught rubbing the poor itch of one’s opinion, to paraphrase Shakespeare. One must seek either corroboration or refutation in equal measure; one must make the time and effort to critically analyze what one would fain discard. So it was with no little frisson of excitement that I read just such an attempt in the BBC News. Gluten allergy, and its social and physiological disguises, was the subject: http://www.bbc.com/news/magazine-37292174

I have never denied the existence of true gluten allergy, Celiac Disease. Its prevalence obviously varies with the group being measured, but it averages to around 1% of the population and is a true auto immune phenomenon where the body detects the presence of –in this case, gluten- and views it as hostile. It then produces some countermeasures –autoantibodies- which, in turn, can have effects on various organs, the small bowel often being the one that results in the diagnosis.

The existence of a non-celiac gluten sensitivity, however, is more controversial. Studies –including the one the BBC reported- seem to vacillate wildly, so I suppose it is merely another example of confirmation bias as to which one you choose to believe. Me? I remain skeptical, firmly encamped in the valley floor between the two hostile mountains that glare and threaten each other from a safe distance. And if some of my patients choose to avoid gluten in their diets, so be it -I’m an obstetrician/gynaecologist, not a dietary immunologist. But sometimes my concerns peek above the mischievous gluten dust.

You know, you can’t tell the gluten-free apostles from the gluten abusers in the average waiting room. I can’t, anyway. Geraldine looked, well, normal as she sat slouched in her chair in the corner. Although my day sheet said she was in her thirties, my eyes said forties. Her blond hair was streaked with silver –although nowadays that may just be a whim- but her face was folded into little wrinkles like previously crumpled paper that had been hurriedly smoothed. She was dressed in black jeans that belied any definite attempt at ironing for the appointment, and her oversized grey sweatshirt matched her face for creases. The very idea of needing to avoid gluten apostasy did not spring unbidden to mind, I have to admit.

And yet the sullen face that watched me as I extended my hand in greeting did suggest that Geraldine was unhappy with her referral. In my practice, this is usually an indication that the patient was hoping that, contrary to what they Googled, I would still turn out to be a female. Although I am quick to disavow them of this, I find it still takes a few minutes more to gain their trust.

Once she had reslouched herself in a decidedly less comfortable seat in my office, I brought up the note from her doctor on my computer screen. It was a one word note –not terribly unusual from this particular GP, but not terribly helpful, either: ‘IMPOSSIBLE’ it said in bolded and underlined capital letters –rather striking, really.

“So, Geraldine,” I said, feeling my way along my words, “how can I help you?”

She glared at me for a moment, and then withdrew her eyes to the safety of her lap. “Didn’t my GP tell you?” It was at once hostile yet tinged with resignation –as if the GP was simply passing a rather complicated buck onwards. As if I were only one more stop on the journey.

Her answer was so uncomfortable it caught me unprepared. “Well…”

“He just wanted to get rid of me…” she said, venom dripping from the corners of her mouth at first. But she thought about it for a moment and neutralized her face. “He never listens, anyway.”

I tried to smile –sometimes it works. “Listen to what, Geraldine?”

Her eyes rose quickly from her jeans, like two birds flushed from a bush. “He doesn’t believe in gluten,” she said, a little too quietly for me to judge the temperature of the insinuation.

“How do you mean?” I walked right into it.

The cage door of her eyes flew open, and her mouth unlocked like Pandora’s box. “He refuses to believe that gluten is alive and flourishing in the world…” I’d heard similar words from religious acolytes proselytizing on street corners; maybe gluten was now another proxy for the devil.

“So…” I said, but before I could finish my thought –well, actually before I could even develop one, she interrupted.

“He doesn’t believe me. For years I was plagued with diarrhea and bloating so he sent me to a GI doctor who tested me but couldn’t find anything. All she could say was that it wasn’t Celiac Disease.” She stopped for air. “And now, whatever I tell my GP he just shrugs and says, it’s not the gluten.”

I pretended to type something on my computer screen, but I was just doodling.

“Anyway, I decided to cut out gluten in my diet, and the bloating stopped. The diarrhea stopped… But, then I started…” she added cryptically.

“Started what?” It wasn’t the most gynaecologically phrased question of which I am capable, I admit, but it was all I could think of in the moment.

Once again her face contracted like an animal about to spring. Or flee… “Started having sex!” she said, italicizing the last word. And then, mercifully, before I could gather my thoughts about why anything she’d had to say had anything to do with sex, she explained. “You can’t have sex when you’re bloated all the time, doctor! You can’t have sex when at any moment you might have to get up to go to the toilet!”

Okay, call me naïve, but I hadn’t thought of it quite like that before. It was a different world out there. “But eliminating the gluten in your diet helped, you said.”

She nodded her head vigorously. “I was a new woman.” She stared disconsolately out the window behind me for a second or two. “So I decided I’d better up my birth control method. I hate condoms and diaphragms… and I refuse to wear an IDU…”

“An IUD, you mean?” I said, attempting a gentle correction, but her eyes tried to ravage my face immediately.

“Whatever! So my GP put me on the pill!” she said, italics and contempt now mixing freely with the original venom on her lips.

“And…?”

“And I got bloating again, doctor!” Her eyes executed a predator roll somewhere near the ceiling before heading for me again. “So I did some computer research and discovered that the pills contained lactose and cellulose as fillers…” She folded her arms across her chest and waited to see what I thought of that.

“You’re wondering if they are code words for gluten, Geraldine?”

“Wondering?” she said between clenched teeth, the word only barely able to squeak through at the last moment. “Wondering?” she repeated more loudly and forcefully, articulating each syllable as if maybe I hadn’t heard her correctly the first time. “Are you another gluten atheist, doctor?” she asked scornfully.

“No, gluten exists, Geraldine,” I said, conscious of falling into her religious idiom. “But so do common side effects of the birth control pill.”

She tilted her head like a cat figuring out the best way to attack the mouse. “Nope, I know this was the same kind of bloating I got with the gluten.” Her fists clenched, daring me to contradict that.

But there was something about her face… “How long did you take the pill?”

She shrugged and then played around with her eyes, uncertain where to roost them. “A month maybe… And then I took them on and off for a while to see if they made a difference.”

“And…?”

Another shrug. “And yes, stopping them got rid of the bloating for a while.” She stopped and decided to stare at me. “And then it came back, even though I wasn’t taking them.” She took a deep breath and then sat up straighter on her chair. “I asked my GP if it could be some residual effects of the gluten and he decided to send me to you.”

“When was your last period, Geraldine?” Common things are commonest, eh?

A smile managed to crinkle its way onto her lips, and her eyes softened like sponges in water. Her expression turned almost mischievous. “I thought you’d never ask, doctor.” Even her voice, now, was pleasant.

“You’re pregnant?”

She nodded happily. “And it’s going to be a gluten-free pregnancy…” And then as a concession, “Is that all right with you?”

I smiled and nodded. No matter what I said, she’d do it anyway, so I thought it’d be safer to do it under supervision. “I’ll send you to a dietician to help you choose the proper foods for the pregnancy.”

She rolled her eyes again –but this time it looked more like a victory role. “Sorry about the theatrics, doctor –I just had to be sure where you stood on all this.” And then her face fell, if only just for a second. “Funny,” she added, “I thought you’d be more of a challenge…”

 

 

 

 

 

 

The Obstetrical Celibate

Celibacy seems so counterintuitive and aberrant to me that I’m constantly amazed how close to the surface it seems to float. Its etymology comes from a Latin word meaning ‘unmarried’ and that, in turn, is an amalgam of two proto-Indo-European words meaning ‘to live alone’, but its exact definition seems contextually influenced. For example, despite the fact that it is not the exclusive prerogative of one sex, we tend think of male Catholic priests as the prime examples, even though nuns –their female counterparts- also live a celibate life.  It is also variably regarded as being either the condition of living alone and being sexually abstinent, or merely sexually abstinent. In the Catholic church, although it was only mandated for priests in 1130 A.D., it included both lack of partner and sexual gratification of any kind.

Celibacy is usually seen in a religious context, but it need not be. A more contemporary view tends to focus on the sexual abstinence aspect or on the lack of a regular partner. It may be a temporary phenomenon and not one that is intended to be pursued, or a lifestyle choice. It is seldom related to the condition of asexuality in which the reason for the abstinence is one of indifference or lack of sexual drive –as I have discussed in a previous essay: https://musingsonwomenshealth.wordpress.com/2014/07/03/the-asexual/

Now I don’t wish to sound so dismissive as to reject the concept of celibacy out of hand. We all make decisions based on our wants and needs, often guided by doctrines or beliefs which make sense to us at the time. In a free and open society, what the rest of us may think of the decisions should be of little consequence so long as adhering to them has no adverse effects on any except the participants. Witness the spate of publicity surrounding the late Pope John Paul II and his relationship with the married Polish-born philosopher Anna-Teresa Tymieniecka, before and during his papacy: http://www.bbc.com/news/magazine-35552997  That a very human side was able to successfully coexist with his deeply religious beliefs is both touching and laudable –especially in a pope.

But this prologue was by way of an introduction to Ann, a patient of mine shortly before I retired.

As she sat in my office that first time, she seemed unusually nervous. She had short brown hair and was smartly dressed in a white blouse and grey pant suit. Ann seemed the perfect model of a corporate executive on her lunch break –which indeed she was. But she was perched bolt upright on the edge of her chair like a bird about to launch from a branch. Her face was taut and unnaturally shiny; her lips were frozen in a straight line as if she were trying, unsuccessfully, to fabricate a smile. Only her eyes betrayed a profound mistrust, bordering on aggression.

“You seem rather nervous, Ann,” I said with a smile of my own to break the ice.

She nodded politely, but remained silent. Only her proximity to the edge of her chair changed. I wondered how long she’d be able to stay balanced on it.

I have to say that the laptop screen on my desk is a wonderful tool. It not only provides me with information –consult letters, lab data, and so on- it also gives me something to hide behind when the patient has sent her eyes on a predatory mission. It is a type of blind, I suppose. I pulled up the consultation note from her GP on the screen more for something to do than for information –the day sheet from my secretary had already disclosed the secret: Ann was pregnant.

The note from the GP was rather terse I thought: ‘Pregnant. Angry’. I took a deep, albeit disguised, breath and peeked out from behind the screen. “So, your family doctor says you are pregnant, Ann. Congratulations!” This initial praise for the achievement usually disarms patients -well, confuses them, anyway. But it did nothing to Ann but harden her expression. She mouthed the obligatory ‘thank you’ silently and with barely a movement of her lips. This wasn’t the easiest consultation I’d ever been sent.

I decided to be more direct. “Are you angry about being pregnant, Ann? Or are you angry with me?”

That obviously caught her by surprise, because she suddenly dropped her eyes onto the table –her armour had been chinked.

Then, she broke her fast of silence. “Doctor, I have to explain something to you,” she said, slowly and disdainfully, again with lips that barely moved. I began to wonder if they’d been botoxed, or something. “I am 37 years old, unmarried, and unattached!” She said the last word carefully and slowly, lest I misunderstand. I could feel the exclamation mark from right across my desk. “Further, I am not in a lesbian relationship, nor am I ever intending to be dependent upon a partner for assistance.”

At this point her face actually narrowed and I could sense its muscles trying to avoid spasm. She liberated the predatory falcons of her eyes once again. “I am a celibate by choice, not necessity, doctor,” she said, this time between obviously clenched teeth. “My career is paramount…”

Her minute pause emboldened me to ask the obvious: “And the pregnancy isn’t…?”

It was not intended to be a profound rejoinder, merely an question, but her eyebrows immediately jumped up as she recalled the falcons to their home roost. They watched me from the shadows of their cage as her face gradually softened. An embarrassed smile crept slowly across the once angry lips and I thought I even detected a blush.

“I’m sorry, doctor,” she said, after a rather reluctant sigh. “It’s just that the men at work have been giving me a hard time.” She stared up at a picture hanging on the wall for a moment. “Word somehow got out that I was considering becoming pregnant…” She closed her eyes briefly to decide how to explain. “Men don’t seem to understand that…” She glanced at me quickly, and then corrected herself. “Many people –not just men- don’t seem to understand that wanting a baby is not the same as wanting sex, or a partner, or even a calculated one-night stand.” She retreated inside herself again to pick the words she wanted. “I don’t hate men, and I don’t disparage relationships, I have simply chosen to live my life differently from most: a celibate life…”

She took a deep and stertorous breath before continuing. “You wouldn’t believe the whispering in my office when the rumour spread that I was going to pay for IVF when there were so many willing donors around… The men would wink suggestively whenever I passed by, the women would get that silly smile on their faces…

“Anyway, I decided to take a few weeks off for the in vitro fertilization process, only half expecting it to succeed on the first cycle. But when it did, I didn’t know if I could stand the censure that most men would exhibit when they hear that I did it voluntarily -in other words, without them.” She shrugged and looked out of the window behind me for a minute or two. “So, I asked my GP if she knew of any female obstetricians she could send me to, but for some reason she chose you.

I hate this kind of situation –being blamed for something over which I have no control. A false negative, as it were. I linked eyes with her for a moment. “Sorry,” I said, smiling innocently. “I can probably find you a female Ob if you’d like.”

She sat back in her chair and thought about it. It almost felt like I was at a job interview and my CV was being inspected. After a few seconds, she smiled –warmly, for a change- and sent out her eyes again –this time rather than circling for a kill, however, they perched softly on my face. “After all that anger, would you still be willing to see an obstetrical celibate?”

I nodded. “I’ve always been nonpartisan.”

Fertility options

Some people would do anything to become pregnant: undergo painful procedures, borrow money, mortgage their homes –anything, it seems, to have a child. While this is certainly understandable –parenthood is perhaps the raison d’être of our genes- it seems a shame that fertility would be something denied to some while granted to others. Arbitrary at first  glance, it sometimes remains so even after extensive investigations. And yet there has been a lot of progress in understanding the mechanisms that both allow fertilization to occur and, maybe even more importantly, implantation of the egg and subsequent successful development of the pregnancy.

Obviously, there is a whole cascade of events each having to unroll in the proper order –such things as development of a viable and healthy egg in the ovary; its ovulation and successful encounter with a (hopefully) normal sperm; a clear and unimpeded route to an appropriately developed uterine lining… And these are just the early requirements for the long journey to l’accouchement. But, like a planning a trip, it is more likely to arrive at its destination if the car is sound and there is gas in the tank.

There are many roadblocks along the way, however, not the least of which are the body’s defence mechanisms which try to destroy foreign proteins that might pose a risk to the health of the organism. A fertilized and developing egg contains a mixture of just such foreign material from the male, and so in some cases might be construed as an attack. Although the uterine cavity is designed as an immunologically privileged site to thwart such a mistaken identity, for some reason it doesn’t always work. While this can be a subtle issue and difficult to detect, it can be an even more difficult thing to correct. There have been attempts to do this with medications to increase success during IVF (in vitro fertilization), but with few breakthroughs so far.

Sometimes my patients know more about this than I do, or perhaps pay more attention to disparate media reports that view every paper published, even in obscure journals, as fodder -landmark achievements. The job of journalists is to interest their readers, not to critically analyze the data and research whether or not the findings were merely a one-off that has not been validated by others in the field. A crash is news; a non-crash is not. Or am I being too cynical?

Last year, I remember seeing Janice, a woman who had been trying to become pregnant for several years. She told me that all of her tests that her GP had ordered had been normal as were those of her partner. Because she was already approaching 40, I immediately suggested that she would likely benefit from being assessed at an infertility clinic to see if they could expedite things. I wasn’t sure that I could help.

She shook her head. “I’ve already been to a clinic…” she said, with a sad expression on her face. “They wouldn’t listen to me.”

“Listen to you? What do you mean?”

She probed my face with her eyes for a moment to see if I was likely to listen to her. Then, apparently reassured, she sighed and sat back in her chair. “Well when they saw the normal test results they added their own versions of the same things but still couldn’t find anything wrong. So they suggested IVF. Time’s running out, they said.” She straightened in the chair and uncrossed her legs. “We can’t afford IVF,” she said, all the while staring at her lap where she was alternately wringing her hands and straightening the fabric of her dress. “They basically shrugged and told me to think about it and come back if I changed my mind.”

I waited for her to continue. There must have been some reason her doctor had referred her to me.

“Anyway,” she said after a long thoughtful pause and a quick gulp of air, “I went on the internet to do some research on other options…”

I managed to stop my eyes from rolling but I have to admit she caught me holding my breath. I never know how to react when a patient innocently offers a totally unorthodox and largely un-researched idea that they’ve found on some website lying in wait in a dark corner of the web.

But she noticed my expression and chuckled at my obvious discomfort. “You must get this all the time from desperate women, eh?” I smiled, embarrassed at being caught. “I’d been trolling through some weird stuff and then noticed a reference to a paper published in the journal Science –it was dated 2015, so not very old. It was only the abstract, though, and I wasn’t really all that sure that I understood it correctly…” she said, no doubt to head off any criticism before I could formulate it. “But there was also a reference to a BBC article talking about it so I looked at that as well.” She handed me a piece of paper with its address so I could look it up as well:  http://www.bbc.com/news/health-34857022  and then to show she meant business, the abstract from Science: http://www.sciencemag.org/content/350/6263/970

When I didn’t immediately punch it in on my computer, she decided to explain. “There’s a parasite that increases a woman’s fertility, doctor,” she said, now intently studying the panoply of expressions that flitted, untended, in quick succession across my face. “Not all of them do, of course,” she added quickly, to show me that she wasn’t that foolish. “I mean, I don’t want to try one, or anything. I just wanted to know what you thought of the idea.”

While I gathered my thoughts, she explained. “I went back to the fertility clinic and asked their opinion about the worm… Ascaris lumbricoides –I memorized the name,” she said and immediately blushed. “Anyway, when I mentioned it to the clinic doctor, he just laughed at me. I don’t think he meant to, but it just kind of escaped from his face before he could stop it…” Janice suddenly leaned across my desk with a serious look on her face. “Of course I thought the doctor was being rude and dismissive, so I walked out on him and headed over to my GP’s office. At least she was more patient with me, but I could still read the disgust in her eyes. We managed to talk about it for a few moments, and then she decided to refer me to you. You’d listen, she assured me and then walked me out of the room…escorted me, almost. I think she just didn’t know how to handle the idea so she passed the buck.”

There was a sudden twinkle in Janice’s eyes that I almost missed –a mischievous expression that flirted briefly with her mouth, then disappeared. “My GP obviously didn’t think I needed an urgent appointment –although I did remind her of my age- so it took me a while to get in to see you.” She smiled a more ordinary smile this time, although it was still nuanced. “Several months, in fact.” I could hear the italics around the word from across the desk. “You’re a busy man, doctor.” I think I blushed.

She waited for a moment to let the thought embed itself in the desk. “So, what do you think of the worm idea?”

I struggled for words initially. It was an unusual idea, but I remembered a brief flurry of rumours when I was in medical school about fashion models infecting themselves with intestinal parasites to help them to stay thin. Perhaps they were just that: rumours, but the idea at least was not without precedent. “Well, I suppose if we could be sure that it wouldn’t affect the developing baby in any way… or you!” I paused for effect. “And that we could reliably get rid of the parasite when it had done its job –again without harming you or the baby- then…” I had run out of words. I had no intention of endorsing the idea, but I didn’t want to dash her hopes entirely. Hope is what keeps us going. I leaned across the desk towards her and smiled. “Let me just say that if you were my daughter and you had honoured me by asking for my opinion, I would have to say that some things are just not worth the risk.”

“You mean you’d advise against it?” She seemed relieved.

I nodded carefully, sensing I was being led into a trap.

A smile almost split her face in two and her eyes lit up and sparkled like lights on a Christmas tree. “Well, I’m pregnant now,” she said, italicizing the important word again and leaning across the desk as well. “It took so long to get to see you, I thought I’d use the time constructively.” My eyes must have betrayed something, because she suddenly extended her hand and grasped my arm. “Don’t worry, doctor, my husband and I decided against the worms. He said he was really worried about them…”

I relaxed my expression and was about to say something about a caring partner, when I noticed another twinkle in her eyes. “Yes,” she added before I could open my mouth. “He was afraid of getting them from me.”

The Mistaken Identity

Communication is a fascinating thing. It enables descriptions of the world in different sounds, different gestures, different expressions. A shrug of indifference in one culture is a greeting in another. A nod can convey a myriad of intentions -context is everything. Only the smile seems a common currency. As a gynaecologist, I am ruled by boundaries, beyond which I dare not venture without, at the very least, the permission of a smile.  It is a sign hung upon the face that needs no words -the Rosetta Stone that unlocks the mysteries of culture and walks the unfamiliar language like a bridge.

My office is a tiny United Nations, with a rainbow range of clothes on display, and skins to match. The waiting room is impossible to ignore, but equally difficult to understand. Words are encrypted by language, and intent masked by the panoply of expressions encoded in millennia of habitual use. It is a place of pleasant noise. Expectant. Pregnant, if I may say, with expectations both imminent and anticipated. Now is just a passing fancy; it is the future they await: a baby, a diagnosis, or just the reassurance that they are in not imminent need of help. It is a place of smiles, both nervous and shy -signals that they understand their different reasons for sitting side by side.

But it is sometimes a more confusing world once they have entered my consulting room. Words matter there. Meanings are crucial, explanations need context, symptoms require a modicum of description. Except for the more flagrant and visible aberrations of bodily integrity, diagnoses require detail. Language. And patients who are adept at simple conversations in English often struggle with words they would not encounter in the home. What is hidden from sight, is usually hidden from discussion: there is seldom a need to talk about an ovary nor, for that matter, a vagina -even in their own language. It is more often passed over with a blush, or an anxious smile.

I tell the referring doctors to ask their patients to bring a translator with them if they think it may be a problem, but too often it is a family member with similar language skills who accompanies them -a daughter who is too embarrassed to say the words, or a husband in front of whom she is ashamed to admit the problem. Everyone smiles, but often with incomprehension or discomfort.  I love the challenge.

Sometimes the challenge is of a different sort, however; sometimes it is me who is embarrassed.

There were just two of them in the waiting room -sisters, likely, and not too far apart in age. As I walked into the room to greet them, they were huddled together whispering loudly about something and didn’t notice me until I was standing right beside them.

“Wei?” I said in a rather tentative voice, reading the name off the referral letter that was written on a piece of paper, but not certain I had pronounced it  correctly.

I was immediately greeted by a smile -two smiles- and they both stood up. Neither made eye contact, but they followed me down the corridor to my office -normally a good sign. I felt confident that one of them was Wei.

“Wei, you sit in this chair by the desk,” I said, addressing the space between them, and hoping for clarification in the assigned seat. But instead, they seemed confused and I could almost feel the mental flipping of coins as to who sat where. I addressed the Wei seat first. “Wei?” I said, to cement the relationship.

They both smiled -nervously, I thought. The Wei seat answered for them both. “Wai,” she said -by way of correction I assumed. Even though I’d taken conversational Cantonese many years before, I never mastered even the rudiments of the many variations of pronunciation, let alone meanings of words that seemed otherwise identical. But I was happy at the confirmation of identity and smiled my acknowledgement.

“So why are you here today, Wai?” I said, careful of my pronunciation. And careful to differentiate her from her sister. Apart from the name, the referral letter was illegible.

They exchanged glances, apparently trying to decide who should answer. Obviously one of them was better at English, and they wanted to make sure I understood. It was Wai in the assigned patient chair who answered. She seemed pleased that she was able to speak, but she, too, seemed to need to clarify the situation before proceeding any further. “She my sister,” she said pointing at the other chair.

I smiled and nodded at the information. “How do you do?” I said to each of them. Clearly there was a series of preliminary introductions and small talk that were deemed necessary. Polite. I decided not to rush things, but after conferring briefly with her sister, she got right to the point.

“Me?” she said, pointing to herself. I nodded in assent. She smiled broadly and looked at her sister. Proudly, I thought. I could see her struggling to find the correct words. “Baby,” she said, and her smile almost split her face in two. “First baby!”

I could tell this was going to be a difficult. Her sister stayed quiet, merely nodding whenever Wai said anything. “Do you speak English?” I said, politely turning to the sister. Hope springs eternal. But she shook her head smiled. “Only little,” she added after a moment and an inquisitive glance at Wai.

It was Wai’s turn. “I the good English,” she said confidently and not without an ill-disguised condescending glance at her sister.

I wasn’t really sure how to proceed. Taking an adequate history was impossible -even finding out if there were problems with the pregnancy so far seemed remote. But Wai appeared so enthusiastic and happy, I thought I’d try for a few basics. “So, when is the baby due?” I immediately regretted the word ‘due’ because her face fell. I decided to try a more basic form: “When baby come?” I felt embarrassed to say it like that -it too, seemed condescending- but Wai understood and smiled again.

“Seven,” she said, holding up seven fingers.

Encouraged, I considered pressing on with more detail. I thought I’d try for the date of her last period -that would  help me plan what to do next in terms of ultrasounds, blood tests, and so forth. “When did your last period start?” I said as slowly as I could without sounding silly. But I quickly realized I’d framed it poorly. “When last bleeding?” I tried, blushing at the clumsy attempt.

Again the smile. “June one,” she said, this time holding up one finger confidently.

Great, I was getting somewhere at last.  But when I then tried to ask her if she’d had an ultrasound yet, it became immediately apparent that I had reached the bottom of the well. I shrugged and put on my best smile. “I’m going to need more information…” I sighed to show I knew how difficult it must be for her. “You’re going to need to bring an interpreter next time, Wai…” She looked disappointed, so I think she understood. She turned unexpectedly to her sister and quickly said something to her that sounded like she was confused. They both looked at me for a moment, and then huddled together in quiet conversation, occasionally risking a puzzled stare and then submerged themselves in words again.

“So, you not talk to Wei?” she said, pronouncing the name as I had in the waiting room and pointing to her sister.

“Are you not Wai?” I said, confused at the pronunciations, then glancing at my watch.

She nodded vigorously and smiled. “I Wai; my sister Wei,” she said, touching her sister gently on the arm. Then they both began to laugh. “You make mistake..?” said Wai -I think it was Wai; I was becoming quite confused. But I have to admit I blushed all the same.

I managed to chuckle along with them; they seemed quite amused by the whole encounter.

“Not problem,” said Wai, glancing at her watch. “We come back.”

And so began another day at the regional section of my own United Nations Gynaecology division… Do you see why I love what I do?

Pregnancy Stress

Curiosity is a curse sometimes. It strikes in the most unusual circumstances and often with little warning. Some little thing will set it off and bang, you’re hooked. I’m an obstetrician, so procreative issues are constantly surfacing in my life. Environmental stressors and reproductive failure also seem to be de rigeur in the social media nowadays so there’s no escaping it. The worry may have started with animal data -animals are the easiest to study so we often look at what evidence they provide and then extrapolate. I’m thinking of those dark mysterious star-filled nights at summer camp when there is howling in the distance, and everybody huddles together with questions.

And worst of all are those important things that don’t have ready answers, or the answers have different explanations each time you look for them. Different causes. The secondary sex ratio has always been that type of enigma for me: why isn’t the ratio exactly 1:1 in humans? Well, first of all, some definitions. The primary sex ratio is the ratio between the sexes at fertilization, and the secondary sex ratio is their ratio at birth. There’s even a tertiary ratio -the sex difference in mature organisms.

In the past, the gender ratio at conception was unknowable, so the only useful ratio was the one at birth -and that seemed to favour males (1.1 males for every 1.0 female). So did that mean that male sperm somehow outswam the female ones or damaged them on the way to the egg? Did it speak to the quality of the gametes or merely suggest that to balance tertiary sex ratios (the ratio in sexually mature organisms, remember) more males were needed because, unlike females, they were less able to make it through childhood..? Until recently, as I mentioned, there was no way to measure the primary sex ratio, so it remained a mystery. Now it seems there is, and, surprise surprise, there would appear to be an equality of sexes -at conception at least: http://www.pnas.org/content/112/16/E2102.full.pdf  This fascinating study tracks gendered mortality during development in the uterus. There is a theory (the Trivers-Willard hypothesis) which posits that more males are born in a favourable environment and more females in an unfavourable one because just one sex will be better at ultimate reproduction under those differing conditions.

So what conditions might effect the secondary sex ratio? Well, amongst other things, there is some evidence that major stressors may influence it. Large disasters have certainly been implicated -earthquakes, for example: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881738/  And then, of course, there were the changes in secondary sex ratio immediately after the 9/11 World Trade Center attack in 2001… One explanation that has been offered to explain how this could occur is that males typically attain a critical fetal weight earlier than do females (the average weight of newborn males, for example, is ∼100 g greater than females) and this might exert a higher metabolic demand on mothers. So, depending on the gestational age and the extent of the stress, the mothers may be able to abort the male fetuses, but maintain the less physiologically demanding female ones. In other words, evolution would seem to have selected for those females that can regulate the sex of their offspring… Really?

That explanation seems rather contrived to me. Exactly how would the mother accomplish this feticide? And avoiding direct maternal involvement by referring it back to changes in placental function merely pushes the question back another layer. Of course, some have tried other approaches -for example citing the epigenetic environment (factors influencing the functionality of genes): http://humrep.oxfordjournals.org/content/20/9/2662.full But even when I force myself through the commentator’s words, the explanation still seems a little strained.

And yet, statistically, there does seem to be reason to believe that something is happening that relates to stress.

Of course pregnancy itself is a stress -levels of stress hormones increase as pregnancy unfolds: (http://www.jogc.ca/abstracts/full/201505_Editorial_1.pdf) -although, as the editorialist explains, ‘as a pregnant woman approaches term, environmental stress has less effect in triggering the usual response in the hypothalamic-pituitary-adrenal axis, and she becomes less responsive to the effects of stress’. Uhmm… So, pick your answer from a hat?

Well, in the rubble of destroyed answers and ever blossoming questions, what are we left with? Is there something special about violence that triggers it? Or does any stress threaten the ratio? And what constitutes a stress anyway? All imponderables, I suppose, but at least a recent article in the JOGC (Journal of Obstetrics and Gynaecology of Canada) brings it closer to home: http://www.jogc.ca/abstracts/full/201505_WomensHealth_1.pdf  And in an ‘Only in Canada, eh?’ fashion it demonstrates that we, too, can participate in the secondary sex ratio debate -on our own terms, of course. I mean, who would have thought that our two referenda on Quebec secession from Canada could provoke such a response? I’m almost proud that it did –it shows how involved we are in our country. How much it matters. And how we don’t need earthquakes, either.

And maybe the slight increase in female births that the worries about the referenda caused says something about our growing appreciation of women in Canadian society as well… I live in hope. But you gotta love this stuff, eh?

To Have, or not to Have

There are two worlds out there, two Magisteria. Two contrasting inclinations that pass each other on the street without a wave. Strangers who sometimes know each other well. They sit, unwittingly close to each other, in the waiting room of my office. They chat and smile obligingly, trusting that their ignorance of the other is no impediment to friendship, however brief. Indeed, there is no barrier, only a perspectival boundary: Weltanschauung.

And yet, I don’t want to make too much of the difference; it is often in flux, and can mutate even as we watch –Time has a way of adjusting viewpoints,  justifying decisions. We all try to vindicate ourselves in the end. Validation requires exculpation, does it not? Absolution in the eyes of those who matter…

So the stronger the tradition, the societal apologue, the more the justification and guilt assigned to those who stray from it. There is a sort of canniness in the collective –or at least strength. Acceptance… And it is easier to regress to the mean, than defy the group. Especially when it comes to attitudes towards pregnancy –or more specifically, the decision whether or not to have a baby.

I’ve just read an incredibly powerful  book, whose title captures some of the agony and guilt attending those who dare to deviate from societal expectations: Selfish, Shallow, and Self-Absorbed. It is a collection of 16 well-written and generally thoughtful essays -13 from women, and 3 from men- about choosing not to have children. None are from paedophobes; and only a few are from those who decry the notion of pregnancy in others. They are not outliers –except perhaps on a carefully constructed Bell Curve- nor could they be construed as deviant. Each has merely made a personal decision not to accept the tyranny of the Norm.

The essays took me back to the early days of my practice, when, as a newly minted obstetrician, the very idea that someone would not want to have a child at some stage in her life, was anathema… Well, perhaps curious would describe it better –memorable, at any rate. And yet, it was not unknown. It was always a difficult decision in those faraway times to accede to a request for sterilization in a young woman. Contraception, yes, and although this closed the door effectively, it did not lock it. We were suffocatingly parental in those days: we knew she might change her mind –she was young and inexperienced, after all. Like a child, she had to be protected; it was our responsibility to keep her future mutable and open. We –society- were the guardians of that door…

But there are surely two issues at play here. It is one thing to criticize a decision made prematurely –before the kaleidoscope of life has fully displayed, when the future is more chiaroscuroid, more obscure and uncertain- and another developed in that fullness of time when a considered, even retrospective analysis of the factors leading to the choice can bear fruit.

This, too, can seem arbitrary, I realize. Is there a difference between a thoughtful twenty-five year old woman who -in her mind at any rate- has weighed the risks and benefits of having a baby and decided against it, and a forty-five year old who, on looking back at the way her life has unfolded, is grateful and reconciled to never having a child? It is a vexing question on several levels, I think.

In these days of autonomy and non-maleficence when it is considered medically paternalistic and politically incorrect to suggest that a decision need not be vetted by experience, we forget the other ethical duty of a health care provider at our –her- peril: beneficence –serving the best interests of the patient. It seems to me that this entails both a mature and non-directive dialogue and a list of other, more malleable options that would not only adequately serve her needs, but would also allow for change at any stage. Some form of reliable and non-intrusive contraception, for example, might respect her desire to avoid pregnancy, and yet enable some flexibility should she change her mind, or harden her decision for a permanent solution.

But I have to confess that I am still troubled. On the one hand, it seems to me that wisdom is the ability to judge a situation based both on knowledge of what it entails, as well as experience of how it usually turned out in the past. It is why elders were revered in the days before the plethora of information technology that assails us today. I am trying not to be Ludditic here but what the elders contributed, that Google often does not, is digestion. Analysis over time and place. Evaluation. Information can be coloured by current trends and bent by traditional assumptions –but of course so can needs. We must not forget that.

I have always been leery of ‘facts’ divorced from context. Are they then still facts or do they inhabit some terra incognita we have yet to fully occupy? A territory of collation, a thesaurus that is able to list endless variations on whatever theme we decide applies to us, so we can pick and choose the reality we prefer?

It is not the decision to have, or not to have a child that should preoccupy us, but rather the reason it has been chosen. And for such an important life-changing resolution, the depth and –dare I say- maturity of  thought that has gone into the consideration is paramount. It is not, nor should be allowed to fall under, the purview of political correctness and thereby escape a more cautious and examined approach. There is no correct answer, no unquestionable myth that can justify any position. We may have a spur to prick the sides of our intent, to paraphrase Hamlet, but it is a different one for each of us. We must take care that we, and those we counsel, are not –Hamlet again- hoisted with our own petards.