Let shame say what it will

Call me overly sensitive, but I don’t like to be shamed. There, I’ve said it. I suspect it is because shaming causes me to think less of myself: to feel humiliated, demeaned. And yet, there is another side to humiliation that seems to hide in the shadows: the feeling of humility – ‘This amounts not to thinking less of yourself but to thinking of yourself less. The person so ‘humiliated’ becomes less self-centred: her ethical concerns bear witness to a kind of revolution through which her own private and peculiar desires lose credence and authority, a diminution that finally allows her to take notice of what is positively owed to others.’- so writes Louise Chapman, a PhD candidate at the time in Philosophy at Pembroke College at the University of Cambridge in an essay on shaming in Aeon. https://aeon.co/essays/on-immanuel-kants-hydraulic-model-of-moral-education

‘Has the behaviour of another person ever made you feel ashamed? Not because they set out to shame you but because they acted so virtuously that it made you feel inadequate by comparison.  If so, then it is likely that, at least for a brief moment in time, you felt motivated to improve as a person.’

Perhaps, in the embarrassing circumstances of the moment of humiliation, I never stopped to think about it very deeply, but operating behind the scenes was a type of hydraulic system whereby ‘the elevation of one desire in a closed system causes a proportional diminution in another… the 18th-century German philosopher Immanuel Kant presents it as a useful metaphor for capturing the seesawing nature of real psychological forces. In his view, the subordination of self-interest removes, or at least diminishes, hindrances to willing the good. For Kant, the denigration of one’s pathological interests is thus tantamount to removing barriers to acting well. This pivotal mechanism of moral education could be classed as a form of sublimation or diversion, whereby inappropriate desires are channelled into higher pursuits.’

In more recent times, it was Sigmund Freud ‘who claimed that psychic energy can be redirected from lower aims to higher ones, at least when the patient herself recognises that the desiderative drive imperils her.’

This is where exemplary individuals come into the picture. ‘These are people who have the ability to cause profound shifts in the motivational landscapes of their spectators.’ But the exemplars should not serve as a model but only as proof that it really is possible to act in a better way.

Social Media nowadays provides an instructive example. It is tempting to rid ourselves –unfollow– those who continually post their successes, and yet ‘while they can stir up the pains of comparative humiliation, in so doing they strike down our tendency towards intellectual and physical torpor, thereby inspiring us to action.’ This could be termed a form of ‘appraisal respect’. We don’t have to engage with them, only to bear witness -and appreciate that we are not being manipulated if we see some merit in their success as an example for ourselves. In theory, at least, ‘Once the spectator has been shamed by the exemplar’s behaviour, external examples of morality are no longer necessary for continuing moral progress.’ Moral hydraulics.

Comparisons with others merely remind us of what we ourselves are capable of, and with continuing practice, can find ourselves achieving. But we do need reminders from time to time.

Take the old man I saw leaning against a lamppost on a main street in downtown Vancouver. It was a typically cool, wet, and windy day in autumn and I was snuggling into my umbrella trying to make the best of it. I almost bumped into him, but when a gust of rain suddenly tore at the umbrella, I jumped to the side in time. Dressed in a dirty brown baseball cap, a torn cloth jacket, and -judging by the cuffs that were rolled up many times- jeans that were obviously too large for him, he still managed a smile at the near collision.

It’s sometimes hard to judge the age of people who frequent the streets, but he looked old, and frail -someone who would have been sitting in a warm room somewhere, had Life not been so harsh on him. He did not have the look of a dissipated life -just an unfortunate one that had dealt him all the wrong cards.

“Spare some change…?” he rasped with an old man’s voice, then coughed as if the effort involved in speaking was too much for him. He sent his eyes to inspect my face, and they hovered over my cheeks like hopeful sparrows looking for a roost, then flittered away when they saw my expression.

I suppose his words caught me off-guard -embarrassed me, perhaps- and I merely pretended to listen, shook my head, and fought another gust of wind as I walked away. My first impression was distrust of the neighbourhood, and yet when I turned, warily -and, in truth, with guilt- to check behind me a few moments later, he was still there, the smile clinging to his face: a default expression – hoping, like its owner, for a reason to survive.

He looked so delicate, and elderly that I stopped, uncertain what to do. I was ashamed I had brushed him off so quickly, to tell the truth. His smile, I think, was what had disarmed me -that and the fleeting hope I’d seen written on his face at our chance encounter: an unexpected gift on a cold and blustery day on the street.

Something -perhaps his eyes, still heavy on my shoulders- made me turn to face him. His smile grew and his face crinkled happily at my change of heart. And when I reached him, his hand did not extend as if he expected a reward- just his eyes: two souls searching for my own to touch; two minds joining, if only for a moment in greeting.

I struggled for words, and all I could manage was an apology for being so insensitive. “I’m so ashamed,” I mumbled, reaching into my pocket. “It can’t be easy on the street…” I felt myself blushing as I pulled out the only bill I had -a crumpled ten- and handing it to him. I didn’t want him to think I was just expiating my guilt.

“Don’t be ashamed,” he said, evidently also embarrassed. “You came back… Most people don’t.” And he reached out and shook my hand like a long lost friend.

Looking back, I think he was what we all fear we might become some day. He was my face, in another’s mirror.

Death, Thou shalt Die

Just when you think that Age has afforded you a full panoply of experience, another one comes along that you are forced to fit into the bookcase. It may be sufficiently unique as to require an entirely new shelf, but more likely, it will be something so obvious that you’re embarrassed you hadn’t thought of it before, and can squeeze it in beside another thing you’ve already read.

The internet does stuff like that -to me anyway. Permutations and combinations of issues I had always believed were immutably fixed in time and space unravel at warp speed making me question the wisdom of any assumptions it was thought safe to trust when I was growing up.

Like Death, for example. It used to be that after someone died, all that remained were memories, and perhaps a few of their possessions. ‘Dead and gone’ was a relatively intuitive reality in those days; ‘Dead and present’ was an oxymoron. Now, most of us have digital feet that continue to walk the screen no matter our corporeal substance. And, apart from the nuisance algorithms that track me from app to app, I had not given those footfalls much thought -until, that is, I came across an article in the Conversation on digital grieving by Jo Bell, Senior Lecturer, Faculty of Health Sciences, University of Hull: https://theconversation.com/how-the-internet-is-changing-the-way-we-grieve-100134

She writes that ‘These days the dead are now forever present online and digital encounters with someone who has passed away are becoming a common experience. […] Each one of us has a digital footprint – the accumulation of our online activity that chronicles a life lived online through blogs, pictures, games, web sites, networks, shared stories and experiences. When a person dies, their “virtual selves” remain out there for people to see and interact with. These virtual selves exist in the same online spaces that many people use every day.’

When I first thought about this -the idea of inadvertently coming across someone, or something from whoever had died- I worried about the effect, and how I would react. But, as the author reports, ‘Yet for some, these spaces have become a valuable tool – especially so for the bereaved. An emerging body of research is now looking at the ways the internet, including social media and memorial websites, are enabling new ways of grieving – that transcend traditional notions of “letting go” and “moving on”.’

I was, of course, aware of the concept and probable value of memorials, but I have to confess that I hadn’t thought of them in terms of lasting online tributes. To be sure, I was weaned in another epoch when, apart from an obituary notice in the local paper, or flowers on a tombstone, there were precious few options to show that you remembered someone. But, of course, people today use the modalities they are used to.

Suicide is a devastating act, not only for the victim, but especially for those who are left behind. It makes sense that the friends would need to process the act as best they could. ‘For many mourners, the most important motivating factor seems to be the need to stay connected to the deceased and to “keep them alive”. And keeping a Facebook page going by actively maintaining the “in life” profile of the deceased, or creating a new “in memorial” profile, allows users to send private or public messages to the deceased and to publicly express their grief. […] The use of social media in this way goes some way towards answering the question of where to put one’s feelings – such as love, grief, guilt – after a death. And many people turn to the same sites to promote awareness raising and fund raising for various charities in memory of their loved ones.’

‘Unlike sentimental objects, social media pages and online spaces allow people to explore grief with others from the comfort of their own home. Talking to people online can also help to free up some of the inhibitions that are otherwise felt when talking about loss – it enables forms of uncensored self-expression that are not comparable with face-to-face conversations.’ Indeed, as they evolve, perhaps ‘online memorial sites and social networking spaces help the bereaved to see how events in the past can continue to have value and meaning in the present and the future.’

I was sitting in a dark corner of my usual Starbucks a few weeks ago thinking more of shadows than of death, when a couple of middle aged women sat down at the next table. Normally, I wouldn’t have paid them much heed, but one of them, a rather buxom lady was wearing a loose white turtle neck sweater that kept snagging one of her hoop earrings. Still waiting for my sausage-and-egg breakfast sandwich to cool, I have to admit I was searching for a divertissement, and her ear seemed as good as any.

‘I visited Krissy again today, Helen,” she said matter-of-factly to her similarly attired and equally Rubenesque friend.

Helen looked up from her still steaming espresso macchiato “That’s nice, dear. Anything new?”

Her friend shrugged and cuddled her cinnamon dolce latte in two serviettes folded to dissipate the heat, I suppose. “Well, a few others must have visited her earlier, because I saw some collars, and a milk bone…”

Helen nodded, but she sat back a little in her chair and left the macchiato to cool in front of her. I could see her staring at her friend, even in the dim light. “Julie, it’s been, what, two months since…”

“Seventy-eight days,” Julie interrupted her with an intensity that made me wonder if her latte had just burned through the napkins.

Helen nodded sympathetically and reached over the table to stroke Julie’s free hand. “I know dear… but…”

“But Krissy loves the attention, don’t you think?” Julie sighed at the thought.

“Loved, Julie. Loved…” Helen corrected her gently, and I could see her begin to stroke her friend’s wrist.

Julie’s face suddenly winced as her earring grappled with her sweater once again.

Helen seemed to think it was more than a simple entanglement. “There comes a time when you have to let her pass, dear,” she said, and squeezed Julie’s hand before letting it go.

“You mean take it down, don’t you…?” There was a look of desperation in Julie’s eyes, although in the shadows it was difficult to be sure. “But people are still leaving bones…” She was almost pleading now.

Helen smiled and reached across the table again, but Julie was already standing up.

“I… I need some air, Helen,” she said stiffly and began to walk away.

Helen shook her head slowly, gulped down her macchiato, and rose to follow her out of the door.

My breakfast sandwich seemed pleasantly warm in the sudden silence, so I took an experimental bite and sat back in my chair to enjoy it. For some things, I realized as I chewed contentedly, memory is enough. I felt no need to Facebook the disappearing sausage and egg…

 

 

 

 

When the wheel has come full circle…

What’s it like to live on the other side? As far as I can tell, I’m neither trans nor bi; I do not have any genderqueer feelings or aspirations, and for as many years as I’ve been in this body, I’ve been happy with my gender assignation. I’m merely curious about things I have not experienced –about things that I am not, I suppose. Is a rose by another name really the same -really a rose as we have come to experience it? Or would it be more appropriate to phrase it as the converse: does calling something else a rose, make it a rose? Even if it feels it is? It begs the question ‘what is a rose’, doesn’t it? And is the answer –even culturally contextualized- relative, temporal, or in fact, meaningless? Perhaps for someone invested in linguistic definitional stability, the idea of reassigning nouns is more confusing than helpful –notwithstanding the in-your-face examples of homophones and homographs… But I think it is worth exploring.

Jiddu Krishnamurti, the Indian philosopher, argued that naming the Divine -and therefore essentially defining­ it- confined what that concept meant, limited it. I can see parallels with gender appreciation and denotation. But this is certainly problematic for many of my generation who seem to be invested in the immutability of anatomically assigned gender –or perhaps merely question the wisdom of reallocating something that already is, to something it does not appear to be…

Confusing? An interregnum usually is. When those things to which we have become accustomed are swept aside –or, more disturbingly, simply ignored as if their validity had always been in question- there is often a feeling that some moral law has been violated. An ethical boundary crossed. No matter that the boundaries were themselves arbitrary, templates from a different paradigm, to borrow from Kuhn –a different time. It’s not so much that they were wrong, as that they saw the world from a different perspective –much like we might view the customs of another country as being quaint, if not inimical. But, hopefully, when analyzed carefully, there are usually negotiable commonalities. Values which transcend differences, attitudes which, on reflection, are not that hard to accept. Not that different from those we had come to trust.

So, in time, the misgivings fade, and it becomes not only uncomfortable to deviate from the new norm, but to wonder how we had ever thought otherwise –the subtle memory readjustment that neuroscientists tell us occur with time and circumstance.

Many years ago when I first opened my specialist practice in gynaecology, attitudes were different from today. I was asked to consult on conditions that would now be referred to sub-specialists –doctors who have gained added expertise in specific fields. But in those distant times, we were left to deal with things we had never seen in our training as best we could.

It’s when I first met Jo. There were few computers then; my day sheet was typed and the name seemed to have been left purposely vague. But Jo sat straight and proud in the chair, anything but vague -beautiful, in fact. Dressed in a full-length light blue dress, and large, dangling earrings, I wondered how she avoided getting the slowly swaying waves of her long black hair entangled. I could see her bright brown eyes following a little diapered baby crawling erratically across the rug, both of them smiling at each other, both of them obviously delighting in the moment, however fleeting. Another newly pregnant mother, I thought, although in those days, my day sheet was just a list of names and times of appointment –no other details.

Her eyes lit up when she saw me coming across the floor to greet her, and a warm smile surfaced on her face as if it had been carefully wrapped and stored for just this occasion. For me.

I led her into my office down the hall and showed her a seat across from my desk. I have to admit I was smiling broadly by that stage as well –her face was contagious. “So what can I do for you today, Jo?” I started. I hadn’t yet learned the value of the small-talk that often helps to dispel the initial anxiety before having to confront the reason for the visit.

For a brief moment, her smile disappeared, and her eyes examined the window beside her. “I guess my doctor’s note didn’t arrive…” She summoned her eyes and promptly dropped them in her lap. The smile tried to reassume it’s command of her lips, but I could see it was having some difficulty. “It’s a bit complicated,” she said, shooing her eyes from her lap.

I smiled, picked up a pen from the desk and opened her chart to show that I didn’t mind. That I would judge just how complicated it was. It was then that I saw the note from her GP.

But before I could read it, I could feel her gaze leaning heavily on me so I looked up. I remember her expression was almost pleading with me to listen –not write.  Begging me to understand. I put the pen down and leaned forward in my seat.

“I…” she hesitated, clearly wondering how to begin. Wondering if the explanation she had memorized would suffice. “…I’m not what I seem, doctor,” she said, her voice trembling slightly.

I said nothing; I sensed it was a time for silence, even though I had not yet learned its value.

“I don’t think I’ve ever been what I seemed… But I’m 23 now, and I realize that I can’t live like this.”

I watched her face slowly dissolve into tears, so I reached for the tissues I kept on the desk, and handed her one.

She accepted it with a wrinkled smile she found somewhere and wiped her cheeks. “Sorry,” she said, the smile disappearing again despite her efforts to pin it to her lips. “It’s just that my GP didn’t know what to do with me. He said he didn’t know anybody who could help –apparently there’s nobody here in Vancouver…” She took a deep stertorous breath and grabbed another tissue from my desk. “Anyway he said you might know more about it.” Her eyes suddenly perched on my cheeks and stared at me. Through me, as if my eyes were only guardians of the doors into my head. “I’m a man, doctor…”

She –he– waited to see how I would react. She –I couldn’t help but regard Jo as a ‘she’- had obviously had uncomfortable reactions to the revelation in the past. And I couldn’t disguise my expression, I’m afraid –this was not a time of social media or tolerance of any egregious flaunting of norms. Homosexuality was beginning to evince some token acceptance in many circles, perhaps, but transsexuality was still felt to be beyond the pale. Cross-dressing was a deviance that needed to be closeted away.

Jo shrugged and sank further into her seat, as if my reaction had somehow punctured her only hope. “You know, I’m only Jo, doctor. I’m really no different from the person you met in the waiting room… I want to be that woman you greeted so innocently.” Her eyes sought mine again, like supplicants before a judge.

But in that moment, I could not judge. She was the Jo I had first met moments before –the delightful woman in the waiting room engaging with the trusting toddler. “I know,” I said with a reassuring smile, my heart taking over my words. “Let me see what I can do to help.”

And with that simple acknowledgement, Jo straightened in her chair again, her eyes alive as she adjusted an errant strand of hair that had wandered onto her now hopeful face.

Sometimes, there are surprises in all of us just waiting to be discovered.

Grapple them unto thy soul with hoops of steel.

What is a friend? I think I could parallel St. Augustine’s answer about Time: ‘What then is time? If no one asks me, I know what it is. If I wish to explain it to him who asks, I do not know.’ Friendship is such a universal concept, such an acknowledged need, I’m not sure why it is difficult to define. Perhaps it is so much a part of our Umwelt that the only aspect of it that becomes consciously discernible is its absence. It is our air…

But of late, it seems to me that its meaning has been further eroded, further diluted, by its use in social media. It is now a verb as well as a noun –all well and good if we are willing to enrol people as friends much as we might solicit them to join a political party, or consider anybody that smiles at us as worthy of the designation.

Obviously, friendship is a spectrum and simply because we use the same word to designate the entire range does not reveal much about the meaning or the importance of its constituents to us. In a sense, if used generically and without a more descriptive adjective, the word is an empty shell –‘Full of sound and fury, signifying nothing’ as Macbeth said of Life. And that life is actually not so full of friends -‘Which the poor heart would fain deny and dare not.’ to quote Macbeth out of context once again. We do not have as many friends as we think –nor is it even possible to sustain the emotional effort necessary to acquire and succour more than five, or so, close friends. http://nyti.ms/2baJQPL

So, I suspect we should be careful how we use the term and in what context –for what purpose. The number of ‘friends’ we think we have are akin to the denominator of a fraction. It’s the numerator –the number of close friends- that determine the size. The value… I would have thought this was so obvious as to be almost trite. Uninteresting. But maybe the idea that a friend is someone requiring at the very least, an ongoing personal, non-virtual, interaction is a generational thing. Am I just having a semantic argument with myself; am I merely a Cassandra unable to understand that it is only my opinion that is being contested, and that its tenets have already been superseded? Food for thought…

And yet, there are consequences. Sometimes it is best to check in the rear-view mirror from time to time.

*

I’ve always liked Jennifer. She is a twenty-something year old woman I have known for several years now. I first met her because of a minor abnormality of her pap smear, and have seen her every year or so since then. I think she sits in the same place in the waiting room each time, too; I always associate her with the seat in the corner by the window –the one partially hidden by the Areca palm. She’s a small person, and her never-varying outfit of jeans and sweatshirt seem to blend beautifully with the green of the plant. Even her dark, shoulder-length hair sometimes resembles the type of shadow I imagine the plant would cast if it could… I don’t know why I think that; maybe because they’re both quiet. Both still. Both background.

The other day when I saw her in her usual spot, she was typing away furiously on her cell phone. She looked on edge, and the troubled expression did not disappear even when she saw me smile and walk across the carpet to greet her.

There’s often an easy-to-spot anxiety in some patients –the kind I usually can’t hide when the dentist ushers me into his chair- but I knew Jennifer, and the referral note just said she was back for a repeat pap smear.

“You look worried today, Jennifer,” I said when we were both seated in my office. “Are you concerned about the pap smear?”

She’d put the phone in her pocket and was staring absently at a terra cotta woman sitting on an oak stand with her begging bowl. I’d had it there for years, so Jennifer had certainly seen it before. She shook her head, but left her eyes gently stroking its contours. “She always makes me relax… I’m glad she’s still here.” I could see her trying to disguise a sigh. “It’s nice that some things stay the same…” She was quiet for a moment as she thought about it. “…Stay the way they’re supposed to be,” she added to herself as she moved her eyes slowly over to my desk like sleeping birds and left them lying there. They didn’t see me, I don’t think.

I waited for her to continue, but she merely repositioned her attention onto her lap. “What do you mean?” I asked, when it became clear that she needed to talk about it.

Up flew the eyes to the box of tissues on the desk and she grabbed a handful to wipe away some tears. “It’s nothing about my pap smears,” she said in a hoarse voice. “I don’t need to take up your time…”

“The pap smear talk can wait for a bit, Jennifer. Tell me what’s upsetting you.” I smiled reassuringly, but her eyes never reached my face.

She took a deep and stertorous breath and then decided to send them on a reconnaissance flight in my direction. “Oh, it’s just my ‘friends’,” she said, making sure I understood that there were quote marks around the word. “I invited all 147 of them to like a business website that I’m starting…”

I have to admit that I was a bit confused. “Like? As in Facebook ‘like’ you mean?” I had no idea what message that sent. A friend had once asked me to ‘like’ her barbershop on Facebook and I had duly complied –it seemed simple enough… and if it made her feel good, what the heck, eh?

She nodded, although I could tell by her face that perhaps I shouldn’t have needed to clarify such an obvious point.

“And…?”

She took a deep breath and shrugged. “And, well I guess I don’t really have 147 friends.”

I didn’t ask her how she knew -I figured that was probably obvious, too. But I must have looked surprised, because she giggled at the notion. “I mean I didn’t really think they’d all like the page, but…”

I had to chuckle –I couldn’t help myself. “I don’t even know that many people, Jennifer. I mean not counting patients…” I quickly corrected, as her face interrogated me in disbelief.

“How many friends do you have on Facebook, doctor?”

I shrugged. “I don’t know… I mean, counting my kids and a few close friends… twenty, maybe…?”

She thought about that for a few seconds. “I don’t know how I got so many.” She glanced at the statue again. “Sort of like collecting tee shirts, I guess. They look so nice in the store, but I hardly ever wear them.”

A thought suddenly occurred to me. “Do you know how many ‘liked’ your… uhmm, page?” I tried to sound knowledgeable about the words, but to tell the truth, I was on slippery ground and I think it showed.

She caught her eyes, before they completed a roll and managed to salvage a serviceable smile out of what I’m sure was headed for a smirk. Then her eyes twinkled without her planning on it, and she giggled with delight at my expression. “Only seven, so far…”

It was my turn to nod, and I sat back in my chair as I did so. “Well maybe you come out the winner, then…”

She tilted her head, as cute as a button, and I could see the adult stirring behind the mirror of her eyes.

“Now you know what ‘friend’ really means…” I said, smiling.

Her eyes hovered around my face for a moment before they returned to their owner, and I think she blushed.

Trust in the Tameness of a Wolf?

Okay, enough is enough! All these years I have been an advocate of cultural relativism. Ethical parity when societal mores and folkways are accounted for. I still am a staunch defender of freedom of belief and societally derived variations from what might be seen as a Western norm, but there are times when I must step back and shake my head. Some things beggar all tenets of humane behaviour. Beggar belief, for that matter… Beggar all conceptions of canon, doctrine, creed… They are ethically and philosophical bereft!

The example -the proximate cause of  this jeremiad- is one that was reported in a BBC News article entitled The WhatsApp Suicide: http://www.bbc.com/news/magazine-37735370 ‘A 40-year-old woman from northern India killed herself in January after a video of her being raped was circulated on WhatsApp.’ And, as if this madness itself weren’t sufficient to turn the country inside out, the article goes on to say ‘At village level, many are more bothered about women using mobile phones at all than they are about men using them to intimidate rape victims or to share videos of sexual assaults. A number of local councils in Uttar Pradesh, concerned with what they see as technology’s corrupting effect on traditional moral values, have prohibited girls from owning mobile phones.’ This follows from what seems to exist in some villages -at least in the region of northern India: ‘[…]in the patriarchal and honour-bound culture of the village, she could be blamed for “inviting” the sexual advances of a man – even if those advances were unwelcome, intimidating, or violent.’

It’s a two-edged sword, really, isn’t it? The women are able to use the phone and its network both for business and, presumably, to call for help, but the same phone can be used to shame and intimidate her. Blackmail her.

‘In August 2016, the Times of India found that hundreds – perhaps thousands – of video clips of sexual assault were being sold in shops across Uttar Pradesh every day. One shopkeeper in Agra told the newspaper, “Porn is passé. These real life crimes are the rage.” Another, according to the same report, was overheard telling customers that they might even know the girl in the “latest, hottest” video.’

But lest we delude ourselves into thinking that India is somehow unique in this regard, consider the case of a young woman in Egypt named Ghadeer: http://www.bbc.com/news/magazine-37735368 She shared the enthusiasm of youth throughout the world –they are, after all, young and although as privy to the social constraints as their elders, not necessarily as wedded to them. She was 18 and videoed herself dancing –fully clothed, mind you, but too clearly enjoying the freedom. It ended up being shared on YouTube by a former boyfriend in an attempt to shame her in ‘a society in which women were required to cover their bodies and behave with modesty.’ But, unlike many, Ghadeer decided to fight back.

‘[…] in the years since she had sent the video, Ghadeer had also taken part in the Egyptian revolution, taken off her hijab, and started to speak out about the rights of women. Outraged that a man had attempted to publicly shame her, she took legal action. Although she succeeded in having him convicted for defamation, the video remained on YouTube – and Ghadeer found herself attacked on social media by men who sought to discredit her by posting links to it. In 2014, sick of the abuse and tired of worrying about who might see the film, Ghadeer made a brave decision: she posted the video on her own Facebook page. In an accompanying comment, she argued that it was time to stop using women’s bodies to shame and silence them. Watch the video, she said. I’m a good dancer. I have no reason to feel ashamed.’

But as the article goes on to note, ‘Most cases of this form of abuse go unreported because the same forces that make women vulnerable also ensure they remain silent.’ Just being photographed in defiance of the prevailing dress code –a hijab, for example- could be used by the unscrupulous for blackmail or intimidation.

Or another example –one of too many, unfortunately: ‘the 16-year-old victim of a gang rape in Morocco, set herself on fire in July this year, after her rapists threatened to share images of the attack online. The eight accused were trying to intimidate the girl’s family into dropping the charges against them but instead drove her to suicide, as she suffered third-degree burns and died in hospital.’

Enough examples! That anyone would disparage the ebullience of youth is in itself despicable, but to turn that same scorn on the most vulnerable of that demographic –the culturally disadvantaged status of females in many countries- smacks of almost terminal insecurity on the part of the (largely male) perpetrators. It’s still unclear to me what it is that renders them so fearful. Surely our very identity as males derives from our difference from –not inferiority to- females.  Much as ‘up’ is only so, in relation to ‘down’, there is an ‘inside’ only if an ‘outside’ exists. These are not value-laden; not better or worse –they merely mark a difference. We are mutually needful of the contrast.

And yet, the two have come to be pitted in an almost eternal battle within both myth and reality alike -the Givers of Life against the beneficiaries… As if Oedipus had turned on his mother or sided with the Sphinx rather than killing his father -all equally pointless. Meaningless.

In a way, I’m reminded of the Fool in Shakespeare’s King Lear: ‘He’s mad that trusts in the tameness of a wolf…’ –or the excuses so readily proffered by those who, in any sane world, should have none.

A question might well be asked about the state of our domestication.

 

 

The Mote in Thy Sister’s Eye

We all live in different worlds, don’t we? I suppose that’s what makes travel so interesting: to see how widely dissimilar regions and disparate societies recognize and deal with comparable problems. How, for example, they might attempt to solve the ever-growing dilemma of urban pollution. The Chinese, remember, shut down many polluting factories for part of the Olympics they hosted. It was a short term fix, to be sure, but the effects were visibly evident.

Activists, or even cities in other countries have attempted different, longer term solutions with varying success. A common one seems to be restricting the amount of vehicles on the roads, whether by licence number, type of vehicle, or on certain days of the week. The success depends on whether or not it strikes a chord in the society but, probably more importantly, whether or not it is voluntary or officially mandated. And by whom…

There is always the possibility of unintended, unforeseen consequences however bold and thoughtful the concept. Consider the deceptively simple idea of ‘car-free Tuesdays’ in Iran: http://www.bbc.com/news/world-middle-east-37430493 ‘[…] campaigners in Iran began marking “car-free Tuesdays” to encourage people to leave their cars at home in the hope of cutting down on pollution.’ The BBC article was reporting on a story in the Tehran Times, and I’ve included the link. ‘Tuesday was chosen because it is in the middle of Iranian week when traffic congestion is high and air pollution at peak.’

All well and good, even if unofficial and as yet unsanctioned, ‘the campaign was kicked off by Mohammad Bakhtiari, 25, who has majored in architecture and is a member of a local NGO with 1,000 members known as “the guardians of the environment of Arak city.’ It seemed like a good idea –it is a good idea- but there are issues… The idea was to encourage people to use alternate, less polluting forms of transportation –buses, or perhaps car-pooling, but especially bicycles to get around the city. Iran is a very conservatively run theocratic society, and women have long had to conform to various religiously mandated restrictions. And yet, ‘It had been understood women that [sic] could cycle as long as religious concerns were respected. But when asked recently, Iran’s Supreme Leader, Ali Khamenei, said women were not allowed to cycle in public or in the presence of strangers.’

Of course I’m not from Iran, nor do I even pretend to understand Islamic legal opinion, but I think that this fatwah –if such it is- involves a fair amount of cognitive dissonance even in a society that is used to seemingly arbitrary restrictions being imposed upon it. Presumably atmospheric pollution was not something anticipated in religious jurisprudence –it’s barely appreciated in civil law even today. A Fatwah, I’m given to understand however, is expected to break new ground –otherwise it might be considered simply a ruling –a considered opinion on the interpretation of existing writings. So I’m puzzled as to why, given the chance to become responsible caretakers of the Divine Creation which all religions purport to acknowledge, that the opportunity would not be seized and glorified. It might even go a long way towards mollifying some of the public antipathy about some of the more obviously capricious restrictions.

Just a thought, though… Why can’t women do their parts? If they adhere to religious codes of dress and conduct, aren’t they as much stewards as anybody else? Of course it’s now gone Twitter… And the social media campaign founder Masih Alinejad has said, “It is unacceptable in 2016 when you hear that a group of female cyclists have been arrested in Iran for the crime of riding a bike in a public place and made to sign a pledge promising they will not cycle in public again.” She is speaking out from the relative safety of New York, however. And I am writing from the relative safety of New Zealand… I ask myself why that should matter.

 

 

 

 

 

 

 

 

 

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?

Treemail?

Treemail? You’ve got to be kidding… Or is this simply a natural progression from Emailing your fridge, or telling the front door of your house to lock when you’re at work -something that in four or five years will be so banal and unsurprising that pointing it out as interesting will ensure that you are similarly categorized?

http://www.bbc.com/news/magazine-33560182 is the BBC News article that first brought this intriguing idea to my attention.

The original idea was to help preserve the trees in Melbourne, 40% of which were either struggling or dying in the regional drought. The authorities mapped all the trees and gave each one a specific ID. Then they decided that if they put these online, people could Email the city if they noticed any problems with a particular tree. Great idea: digitize something and it you’ve reified it; make it accessible and voila: an individual accorded all of the rights and privileges of anything else with which you can communicate.

Individuation, the process of distinguishing one thing from another thing -how, in other words we know that an individual is one thing and not someone or something else- is a fascinating subject. There are several fields that have adopted the idea. Jung, for example used the concept to describe how an individual becomes a unique subjective entity out of all the potential that existed subconsciously before he or she did so. And of course, social media long ago tapped into it to customize news to match the preferences of the reader (for example, see my essay https://musingsonwomenshealth.wordpress.com/2015/05/15/the-polarization-bias/ ).

But I have to say that, for me, the most thought provoking aspect of the notion is the philosophical one. If I can delve into some rather abstruse background, it may help to explain what I mean. In medieval philosophy, one could ask what something was –what group it belonged to and what it shared with others of its kind (plant or animal, for example) and this was known as quiddity –Latin for ‘what it is’. This grouping into categories, as it were, was contrasted with the uniqueness of a particular thing in that group –the thisness of an individual. In other words, that which caused it to be this particular thing, and nothing else. This concept goes by the name –stay with me for just a moment- Haecceity, from the Latin haecceitas, meaning thisness.

If nothing else, you have to love the words…

So the distinction would be something akin to the difference between the concept of a woman -quiddity- and the concept of Indira Gandhi (a specific woman) –haecceity.

What makes something unique, though? Surely not simply a name. There were apparently around 77,000 presumably unnamed trees in Melbourne when they decided to individuate them. Few of them were previously noticed as individuals, unless perhaps they exhibited some feature that stood out from the rest. Most were probably beautiful in their own ways, and each was certainly, on closer inspection at any rate, unique. But they were still trees –quiddities: background, shadows in the larger Gestalt, by and large- until they were granted numbers. Identifiers. First names, if you will.

And why is that so exciting? Because each has suddenly become real. Each emerged like a crystal precipitating from a previously undifferentiated matrix. Each is now recognizable, like a friend in a crowd -someone you know. And in a world of faceless, anonymous strangers it is nice to be able to smile at something familiar –the climate-friendly helper you’ve finally met. As Polonius says to Laertes in Shakespeare’s Hamlet: ‘Those friends thou hast, and their adoption tried, Grapple them unto thy soul with hoops of steel

Haecceit them, I guess…

PTSD in Gynaecology?

Post Traumatic Stress Disorder (or PTSD) is an anxiety disorder caused by being exposed to a traumatic or frightening event. It has been described in various guises since antiquity: http://www.bbc.com/news/health-30957719, but although we have traditionally ascribed it to military veterans, it is by no means confined to those who have been in the midst of battle. Paramedics, police officers, and various other sorts of first-responders are also exposed to frightening and traumatic events. The DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders) has even allowed a variant for those emergency workers even if they are only exposed to disturbing videos in the conduct of their jobs.

So I suppose it should not come as too much of a surprise that someone would take the leap and wonder whether the public, exposed as we all are to social media, would be at risk as well: http://www.bps.org.uk/news/viewing-violent-news-social-media-can-cause-trauma   There followed the usual offence at what seemed like an attempt to demean the diagnosis of PTSD in those felt more worthy of its acquisition, and in conditions far more important and deserving, but nonetheless there is a spectrum of manifestation inherent in most diagnoses.

The BBC posted a helpful primer on PTSD http://www.bbc.com/news/health-26867615 but in brief, the diagnosis requires: flashbacks to the event, avoidance behavior, sleep disturbance, and mood changes.

I have to say I was skeptical that we should even consider that anything found on social media could have such an important impact that could in any way be considered PTSD –however attenuated. It seemed almost an insult, a belittling of those who had undergone real trauma. Until, that is, I remembered Lucille.

She was a young lady visiting from another province who had been sent to me for a second opinion from the emergency department at the hospital across the street. Her problem was abdominal pain –chronic and unexplainable pain in the pelvic region, for which she had been thoroughly investigated elsewhere with ultrasounds, CT scans, an MRI and even –no doubt in desperation- a laparoscopy four or five years ago to view the area more directly. And all, said the accompanying note, were normal.

She was not what I was expecting; rather than an anxious woman sitting quietly in the waiting room with her face locked in pain, instead I found a smiling, smartly dressed young lady happily talking to the pregnant woman in the seat beside her. She smiled when I walked over and immediately extended her hand for me to shake.

“I’m so happy you could see me on such short notice,” she said as I led her down the corridor to my office. And she did indeed seem cheerful and, well, normal as she seated herself across from my desk by the window. “What a wonderful view of the ocean from here,” she almost purred, staring past the buildings and traffic at the almost-invisible water far in the distance. “Vancouver is such a wonderful city…”

I sensed her cheer was other than completely genuine, as her words wound down and slowed. Sometimes, with chronic conditions like pain, I like to wait until the patient is ready to speak -unprovoked, as it were. Unencumbered by a line of questioning known all too well to her that leads… nowhere. She was silent for a while as she turned her attention to the office itself, her eyes alighting like sparrows first on a painting on the wall, then on a wooden carving from Ethiopia I had placed on the desk so it looked out between the leaves of a plant. They stopped no place for long, revisiting their favoured twigs almost at random.

“Offices are all different, aren’t they?” I said, to begin the conversation.

She nodded thoughtfully. “I suspect they reveal a lot about the doctors…”

“And the patients who notice.” It provoked another smile.

Her face became serious –a major change. “Look, I don’t want to waste your time, doctor. I’m certainly grateful you could see me, but maybe I should wait until I get back to Ontario to get it checked out.”

“It..?” She looked down at her lap, as if the little sparrows were tired of flitting about. “The note from the ER said you were having some pain… Care to tell me a bit about it?”

She still seemed reluctant to look up. “Oh, I get these pains every now and then. No big deal, though.”

She risked a glance and I immediately seized the opportunity. “Well, suppose I just take a brief history and then if you feel you want to wait till you get back to Ontario, I can fill your doctor in as to what happened while you were here in paradise.”

She nodded her assent and for the first time, her eyes didn’t flee from my face. Was it hope? Or merely resignation that it was beginning again?

We all expect that we will be able to find the treasure where nobody has succeeded before, but the only thing I could discover in her history that might be remotely related to her pain was an episode of Chlamydia –a sexually transmitted condition- several years before. It had been treated and subsequent cultures had demonstrated cure. “When did the pain start?” I asked, almost as an afterthought, but I think she could see through my strategy.

The memory seemed uncomfortable to her, and she looked out the window again.

After an awkward moment of fidgetting silence, I said, “Sexual diseases are always difficult to talk about, I think…”

“My friend didn’t think so,” she suddenly blurted out before I could even finish my poorly worded attempt to console her. “She got an STI and had to be hospitalized when it spread through her abdomen… They even had to operate to remove the pus. She sent me a picture of her tubes they took during the operation…” She looked as if she were about to cry, but grabbed a tissue from the desk and dabbed her eyes to recover. She lapsed into a morose silence and turned her head so she could see the door.

“You know, I’d been fond of the guy who gave it to me; I’d gone out with him for a couple of years… And yes we used condoms!” She stabbed me with a sudden glare and turned her head away again. “I did everything right, but I still got it.” She sighed heavily and stared at her lap again. “I mean, how do I know I don’t still have it -but without symptoms? Or that I haven’t gotten it again from somebody?” Her hands were nervously clasping and unclasping. “They did a laparoscopy shortly after the infection and it was normal, but that was years ago…”

The time for my questions was over; I let her talk.

“I read that PID [pelvic inflammatory disease] can be silent after an infection and the damage can be going on even without symptoms…” She considered that for a second or two. “I suppose I twisted my doctor’s arm to do the laparoscopy. But anyway, she didn’t find anything. Nothing abnormal.” Another sigh. But my girlfriend kept warning me about it, so of course I read as much about it as I could online. I even looked at videos of operations for PID…” Her eyes teared up immediately. “I couldn’t stop looking at them,” she managed to whisper between sobs. “They were terrible! Frightening: great slimy fat tubes stuck to bowels and everything… And in some of the videos, when they tried to dissect them, there was blood everywhere! And pus oozing out of dark little spaces the tubes had walled off…” She considered the implications of what she’d said and closed her eyes briefly. Hid behind her face. “I’ve hardly had sex since that Email and I’m never going to trust anybody again,” she blurted out abruptly with her fists clenched. “I mean I keep thinking about those videos; I wake up in the middle of the night, and there they are, running through my mind!”

She stared at my face for a second. “You think I’m stupid for watching all those videos, don’t you?” she yelled at me. “But I couldn’t help it! I just knew that it was going on inside of me: big fat greasy sausages filled with sticky white ooze..!” And then, just as suddenly she stood up and pinned me to the wall with venomed eyes. “You’re the same as all the rest, you know. And I know you don’t believe me!”

She turned and walked to the door. “And don’t bother sending anything to my doctor in Ontario, either. I’m gonna find another one.”

She disappeared through the door leaving me wondering how I could have handled things differently. But in a moment a head poked around the door again –but only briefly. Awkwardly. “I’m sorry doctor… You’re really great! Honestly.” And then it disappeared into whatever hellish world it was forced to inhabit.

Did she have PTSD? A variation of it somewhere on the spectrum? Or was she just embarrassed that she’d disclosed so much to a stranger? I suppose I’ll never know, but I hope that somebody, somewhere, takes her seriously. She, just like anybody else with PTSD has a life to live. Deserves to live.

The Loneliness of Social Media

There comes a time when solitude is not enough. When weekends are deserts that must be crossed to get to people on the other side. Where there are eyes that welcome, ears that hear, voices that desire a response. When your own voice is not rusty with disuse and your mind not imprisoned inside a page you’ve just read twice.

That, almost word for word, is what a patient told me recently after a routine gynaecologic examination at my office. She’d had no need to visit me other than getting a pap smear that wasn’t due for another year. She’d asked her family doctor for a referral but I’m not sure what she told him –there was no letter. I suspect she simply took up too much time. Was too vague to slot into one diagnostic category or another.

Doctors are busy; we deal in diagnoses, descriptions we can place in algorithms that lead to conclusions and thence to prescriptions… We are computers, but not as fast. And without recognizeable data to input, goal-oriented analyses, interpretation and even investigations are difficult to devise. Especially in the fifteen or so minutes usually alloted for their resolution.

I don’t mean to disparage my colleagues with this quick dissection –I, too, am prey to its siren song. But sometimes, the scramble for parsable phrases, or attributable words, leads nowhere but to confusion. Sometimes the only thing necessary is listening. Patience. Time.

Strange isn’t it? The answers usually surface, bubble to the top, when you least expect them. When you haven’t even asked. When you yourself are often at risk of capsizing in the turbulent sea of emotive misdirection. No, not misdirection exactly –the patient truly wants help- but more like multidirection. Stochastic: random observations from the maelstrom in which they are living.

And the diagnosis for my patient? Well, I am certainly no psychiatrist and pretend no background in psychology, but from what I could gather, she wasn’t clinically depressed (a selective differentiation I’ve never really understood)–or any more so than anyone else in her situation at any rate. If I were listening as her friend and not her doctor, I would be fairly convinced I knew what the problem was: loneliness. I certainly wouldn’t honor it with a DSM-5 categorization –even if I knew how to use the manual. Some things are just obvious. Or become obvious if you simply listen. Hear.

Her problem troubled me and I suppose one of the reasons was that although she had tried the usual methods of meeting people at work and at clubs, she had been singularly unsuccessful. A friend had suggested an online dating site and that’s where her real problems had begun. It was not that there hadn’t been an over-abundance of interesting profiles –apparently a buzz-word in that community for acceptable suitors- but that the ones she had agreed to meet were lies. Is that the right word? People who had misrepresented themselves in the categories that had most interested her. She had become disillusioned with the whole process. Exasperated. And other websites seemed no better.

While I’m sure that some dating sites are better than others –more reliable, more responsible and trustworthy- she seemed to think they all attracted the same clientel –or at least the same type of person. She had even done a reverse look-up of some of the pictures submitted (I have no idea how you do this) and discovered the same pictures on different sites –some with different names.

I had no solution for her, obviously, but it got me thinking about the issue of loneliness. It has always been with us, of course, but the prevalence in this age of ubiquitous, omnipresent social media surprised me. I had assumed –naively- that our almost universal and continuous interconnectedness would have banished loneliness to a locked, unroutered closet somewhere off the grid. But I was wrong.

If anything, social media as a solution to loneliness is an illusion, a bedtime story meant to lull us into complacency. There is an existential reality it simply does not confront: although it allows –indeed fosters- communication, it does so once-removed. You need eyes to communicate. Faces with expressions to analyse and judge. You need to be able to touch and maybe to hug in order to communicate meaningfully. That is really what socialization implies.

You can say or declare anything online, but there is still a gap. It’s the very same space where loneliness lives. And where people –real people- don’t. I wish my patient well, and all the others who come to me with masks. It is my job to look behind them, coax them off. But even after all these years, I still may not recognize what they hope I’ll see; sometimes I can only look for clues, or wait with patience painted on my face, and trust they’ll understand. We can communicate in the old way…

I can’t help but remember what Iago said in Shakespeare’s Othello: “How poor are they that have not patience! What wound did ever heal but by degrees?” Isn’t loneliness a wound?