Stereotypes in Medicine

I suppose we are all, at times, seduced by stereotypes. They are, after all, a simplified way of processing the other world –underlining how they are different from us. Even the etymology of the word, derived from Greek, seems as if it would be helpful: stereos –firm, or solid; typos –impression. But unfortunately it has wandered from its first use in the printing field as something that would reliably duplicate what was engraved on the master plate, to its use in 1922 in a book entitled Public Opinion that suggested a ‘preconceived and oversimplified notion of characteristics typical of a person or group’.  It has grown and metastasized, cancer-like, from there. Now, any attribution is suspect. Any observation, coloured. What was once felt to be useful is now recognized as impossibly simplistic. Naïve.

We are far too complex to fit into labelled baskets that purport to describe our essence or predict our opinions. Indeed, to stereotype a group is to consider it different –perhaps not unreasonable as an observation, but also dangerously close to slipping into an us/them perspective with its risk of discrimination and prejudice. As Wikipedia (sorry!) summarizes it: ‘Stereotypes, prejudice, and discrimination are understood as related but different concepts. Stereotypes are regarded as the most cognitive component and often occurs without conscious awareness, whereas prejudice is the affective component of stereotyping and discrimination is one of the behavioral components of prejudicial reactions. In this tripartite view of intergroup attitudes, stereotypes reflect expectations and beliefs about the characteristics of members of groups perceived as different from one’s own, prejudice represents the emotional response, and discrimination refers to actions.’

So, the stereotyping of an individual, or worse, the group to which she presumably belongs, can have consequences well beyond the initial encounter –‘unintended consequences’, as we are so fond of saying in retrospect- and yet we still seem genuinely surprised that things would turn out like that. I am always heartened, therefore, when I read about those who are able to pierce the curtain and see what lives outside the window: http://www.bbc.co.uk/news/technology-34359936

I like to tell myself that all my years in practice have dissolved the last dregs of stereotypes from my psyche, and yet my guilt, my terror of succumbing, is still alive and well –if tucked away. But, if stereotyping can occur without conscious awareness, the very act of trying to avoid it suggests that there is something there in the first place…

Manipulation always reminds me of the danger. Not my manipulation, you understand (and besides, I don’t call it that); no, my patients’ attempts at beguiling me. My mother was a masterful manipulator and I’ve always noticed similar attempts by others. Perhaps the very labelling of their actions as manipulations is itself a stereotype, but I’m getting ahead of myself.

I still remember a time, several years ago now, when I was discussing the pros and cons of vaccination against HPV, the sexually transmitted virus responsible for cancer of the uterine cervix. The woman, a well-educated software engineer at a local start-up company, had asked me what I thought of her daughter being vaccinated in school.

“She’s only in grade six, doctor -11 years old! She hasn’t even thought about…” Loretta hesitated briefly as she sorted through her vocabulary. Clearly, even the thought of her daughter as a sexually active individual was uncomfortable for her. “…being intimate.” She immediately blushed at the word.

It’s a delicate topic for parents and I nodded sympathetically. “Not intimate yet, I’m sure,” I said and smiled to diffuse her embarrassment. “But when she gets older, it would be nice to know she will be protected against the virus, don’t you think?”

Loretta’s face hardened at the thought –or maybe at the fact that I needed to bring it to her attention. Her expression was adamant: her daughter was not like that. She studied my face for a moment, her eyes made short angry excursions onto it, then, finding nowhere to roost, hurried back to safety. “I think I will decide when she is older and more able to understand.”

I tried to disguise a sigh. “Sometimes our children understand a lot more than we suspect, Loretta…”

I could see her stiffen in her chair. “I know my daughter. You may be a parent…” She paused to run her eyes up and down what she could see of me from where she sat, obviously trying to decide whether even that was possible. “But you are not a woman, doctor; you couldn’t possibly understand the mother/daughter bond!”

My only possible response was a smile, so I parried with the best one I could muster under attack. “You did ask for my opinion, Loretta,” I managed to reply in an even voice.

She unleashed her eyes on my face again, this time as birds of prey, and as they circled for the kill, she managed to answer in a polite monotone. “You health practitioners are all the same, aren’t you? You think you have all the answers. You, my GP, the school doctor –even the school nurse- prattling on about anticipated behaviours and how you want to deal with them as if you were all decanting untasted wine from the same expensive bottle.”

My smile broadened at her use of the simile but my reaction only seemed to fluster her more. I shook my head slowly. “Most of us certainly don’t think we have all the answers, Loretta.” Her eyelids fluttered as if I were a politician trying to convince a wary population. “But I suppose we do try to prevent problems when we see them coming. Cancer of the cervix used to be a major problem until we recognized it was caused by a common sexually transmitted virus. The obvious next step was to see if we could develop a vaccine to protect against it like we did with small pox –or polio…” I shrugged as if I had just made an irrefutable point.

She stared out the window for a moment, undecided, and then I could see her body language change. Soften. Her eyes were sparrows again –finches, maybe: curious, but playful. “I just stereotyped you didn’t I?” I hadn’t thought of it that way, I have to admit; the accusation usually comes from the opposite direction. I nodded in pleasant agreement. “But it’s a two way street isn’t it?” she added with an impish smile, obviously unwilling to let me off unscathed. “I saw you rolling your eyes at the mother-daughter bond thing.” She could hardly talk for her smile. “Over-protective mother meets omniscient doctor, right?” She settled back more comfortably in her chair. “Both of us using our unique and non-reciprocable roles to pull rank. To manipulate each other –ad hominem stuff…” she added and then chuckled.

Suddenly she became serious and I could sense she needed an answer. “Tell me, doctor,” she said, carefully choosing her words, “If I were your daughter, would you advise me to have your granddaughter vaccinated?”

A serious question; a personal question -and I didn’t hesitate to respond. I nodded my head immediately.

She relaxed again. “Then I have my answer, don’t I?” she said and started to put on her coat. She stopped at the door and turned to me with a little smile waving for attention on her face. “Did I just get swept up in another stereotype?”

I had to shrug. I’m just not sure anymore.

The Asexual

Well the annual Pride Toronto Festival has come and gone again; we had one here in Vancouver as well, but this year’s Toronto iteration apparently broke all records for attendance, parade, and participation. I have to admit to my own feeling of pride that Society is making such progress in accepting –even welcoming- diversity. Especially, it would seem, in Canada.

The LGBTQ (have I got those initials in the right order?) community has done a wonderful job of publicizing and integrating their orientations in the public’s mind. Gay marriage –an unthinkable concept only a few years ago- is now accepted in most areas with barely a glance. That a loving couple should be able to legally dedicate their lives to each other with all the rights normally accorded to a marriage seems now so obvious and compelling that it is hard for many of us to countenance a time when it was restricted to heterosexuals.

But the orientation diversity has not run its course; there are other voices finally audible now that the din of battle has dimmed somewhat –voices that I, at least, had not heard before. Readers of this blog may recall my essay on Gender in January 2013, when I had to admit to an age-dependent naïveté concerning gendered public washrooms –you know, designating separate rooms for male and female toilets. I had always thought of the arrangement as being eminently sensible until disavowed of this by a patient, indignant that she had to accept the arbitrary (she felt) assignation of the female room by the accident of her (unchosen) chromosomal array. So I felt that I had witnessed the final frontier of the orientation choices: none. No-name toilets for the sexually unassigned.

I was wrong –again. My innocence was dragged to the surface once more when I heard a CBC radio interview with a woman who was feeling unaccepted even by the LGBTQ group because she identified herself as asexual –i.e. none of the above. Well, to consider oneself as a non-participant is fair enough I suppose, but the absence of something really doesn’t give one much to identify with I would have thought. How ignorant of me; how unsophisticated! I mean there was an unfilled niche there just begging for attention… And there is a growing community of asexuals, some of whom apparently marched in this year’s Toronto Pride Festival parade.

But I suppose I shouldn’t have been surprised. As with most issues, I am often exposed to them first in my office. And under those circumstances, they don’t seem odd or aberrant –just interesting.

Thinking about it now, I suppose I was first introduced to asexuality several years ago -during an investigation of infertility of all things.

There are many causes of infertility. Some are complicated and require referral to a specialized infertility clinic for more intensive investigation and treatment. Others are less onerous, less worrisome and after taking a thorough history and doing a detailed physical exam need only a few simple investigations followed by a large dollop of patience and reassurance. Needless to say, it is this latter group that I prefer, if only because I feel that dialogue is still useful; I get a chance to show that listening, interacting and empathizing is part of Medicine.

Of course, sometimes the reasons for infertility seem blindingly obvious -like the frequency of intercourse. Infrequency, I mean…

“Oh, we don’t have sex very often, doctor,” the sweat shirt and blue jean clad woman said almost proudly. And when one of my eyebrows crept up involuntarily –I try to stay neutral, but sometimes I am weak- she scowled and explained that she didn’t really like sex. “It’s not who I am,” she added, staring at me defiantly. “Once a month is plenty…”

I intended to follow up with a question about whether or not she found the act painful, or whether there might be some impediment to her enjoyment of sex but I felt the mood change in the room. Or at least the mood on her face changed.

I thought maybe I should play the ‘please clarify’ card rather than the ‘I don’t understand’ one which seems to annoy people nowadays. I pretended to read from the notes I had just written. “You say you are only sexually active once a month…?”

“Only when I’m ovulating.” She interrupted before I could finish the question. “That’s when the best chance to conceive exists,” she continued, as if perhaps this was a thought about fertility that hadn’t occurred to me.

I nodded in agreement, but my expression must have remained puzzled because she sighed and sat back in her seat as if exasperated. “Not everybody enjoys sex, you know. For some of us it is simply a means to an end: a baby.” She continued to stare at me –defying me to disagree. “I don’t enjoy washing dishes either, but if I want to have dinner…” she added somewhat cryptically.

I put my pen down on the chart and decided to sit back in my seat as well.  “Well, so far everything seems completely normal,” I said helpfully, hoping to diffuse the tension. I was trying to reassure her that she would likely be able to conceive –but with such infrequent exposure to sperm, might have to be patient or change her frequency. “You may just have to start washing more dishes,” I added carefully. I thought it was a humorous and inoffensive rejoinder to her example. I said it with a smile and with what I hoped was a twinkle in my eye. But to tell you the truth, I couldn’t resist. 

She shot forward in her seat, her eyes narrowed, and I could see her face hardening like concrete. “I had hoped you of all people would understand, doctor!” She said the ‘doctor’ word through clenched teeth.

“I’m sorry…” It slipped through my mouth involuntarily as it often does when I’ve inadvertently crossed some line or other. I actually meant it as a query –as in, ‘Pardon me?’- but when her face relaxed a little from my apparent capitulation I decided to lie fallow. I had no idea what had enraged her, however. Had I been Aspergerially inappropriate and insensitive? Or had she wanted some other more easily acceptable regimen?

She got up from her chair, picked up the little backpack she had worn on arrival and walked to the door. There she hesitated and I could see her tension dissolving. She turned to me and almost whispered, “I’m sorry, too, doctor. It’s just that I’m an Asexual.” She said it as if it were a noun rather than an adjective. And then she left –not angry, not frustrated… More sad that I hadn’t known.

I never saw her again, and I may never understand what she was going through, but I hope things have worked out. I hope she eventually had the child she so desperately wanted and that they went to this Toronto Pride Festival to watch the parade. And I hope that she has at last achieved the recognition and validation of her orientation that she obviously needed. The one that society evidently needs to offer.