Acknowledging the Mind’s Eye

Sometimes, in the midst of a problem –in the midst of an era- the resolution derives not so much from the answer as from the acknowledgement that there is an issue to begin with. I find it interesting that Nature has given us an ability to adapt more efficiently -to ignore, I suppose- that which arises gradually than that which falls upon us as an event –interesting, because that allows us to discount something until it results in complications. Difficulties. It is the Janus view of evolution, I suppose.

An article in the BBC news alerted me to one novel approach to encourage acknowledgment of an issue that has plagued some societies for what seems to be millennia: sex selection –or perhaps, more honestly,  destruction:  www.bbc.com/news/world-asia-india-37034444

It got me thinking… We tend to cherish and preserve what we value; we neglect, or abandon that which we don’t. Denigrate it, even. Perhaps an occasional nudge in the ribs may cause us to look around and see where we have wandered –realize that there is really no need to stand so close to the edge.

But it does give one pause for thought –how do some of these things become imbedded in a culture? Surely they don’t start out as intentionally malevolent. Or is that being revisionist and unduly naïve? I’d like to think that some of the customs, however egregious we find them now, were products of a different time when other priorities required precedence. Confusing times, perhaps, when we barely knew who we were in our overarching need to identify and fend off them. Troubling times beneath the roiling waters in which we are just beginning to be able, however slowly, to surface for air.

And the problem, as always for those of us less afflicted, is acknowledgement –recognition that there is more to do. There is always more to do…

Despite being a gynaecologist for more years than I can remember, I suppose I have always lived in a man’s world. It’s hard not to wear the clothes you were assigned. And yet, every so often, that usually-locked door is knocked ajar briefly, and the light from within is blinding. Unintentionally heuristic.

I was sitting in a busy coffee shop recently and managed to find a tiny unoccupied table against a windowless and shadowed wall in the corner. Perhaps it camouflaged me -made my presence less noticeable, my gender less obtrusive- but as I sat there staring silently at the busy room, fragments of conversation from the next table floated past like dust motes in the feeble light. Two women were catching up on their lives. I didn’t mean to listen, but sometimes words are beacons: currents, vacuuming up the air between –meant to be heard, meant to inform. It’s hard to ignore words when you sit in shadows.

“And so how is Janice doing now?” a grey-haired woman in pigtails wearing black track pants and a yellow sweat shirt asked between gulps of coffee and grabs for the oversized chocolate cookies she had balanced precariously on her plate. She clearly had little need of more calories, but the presence of her more sizeable friend likely justified the debauch in her mind. It works for all of us, I think.

Her friend just shrugged amicably. “You know what it’s like, Dory,” she said, and launched into her bagel as if she were packing a box. “Kids are kids…”

Dory munched softly on a cookie and considered the issue. “She’s hardly a kid, now, Alice. She’s, what, seventeen?”

Alice nodded her head equally thoughtfully and her long dark hair slid back and forth over her shoulders like a wash cloth. Although considerable larger than her friend, she carried her weight gracefully, and with the gravitas that suggested a person of authority. Dressed in what seemed in the dim light to be an expensive white silk blouse I could make out little ruffs on each wrist. I don’t normally notice such things, but with each movement of her arms, they risked coating themselves with cream cheese from an impertinent bagel, now lying in fragments in front of her. “Eighteen…” She took a delicate sip from her coffee and sat back on her chair as if the subject required a little more thought.

“Still, she should know where she’s headed by now…” Dory left the question of direction open, but her eyes betrayed her opinion. “I mean, who she is…” she added, italics begging for attention.

Alice sighed and leaned forward again to pack another item into her waiting mouth. “I think she’s always known.”

“And how about you?”

Alice smiled and nodded. “Some things a mother just knows, Dory.”

Dory was obviously trying to understand, but her confusion was apparent, even to accidental eyes watching from the shade. She shook her head, disapproval hovering over her like a cloud. “Did you ever to speak to her about it, Alice?”

Alice’s eyebrows both rose at the same time. “Whatever for, Dory?” she said, genuinely puzzled at the remark.

It caused Dory to sigh rather more loudly than necessary. “Well, I would have thought…”

Alice refurbished the smile she’d sacrificed to the bagel and leaned an elbow on the table. “Thought what?”

Dory straightened her back like a boxer ready to receive a blow. “Well… that…”

“That my daughter would think the same way as her mother? She learned the Theory of Mind when she was five, Dory.” Her friend visibly winced at that. “The world is different for each of us, Dor,” she said, reaching out and grasping Dory’s hand. “And the question should not be why, but rather, how can I best negotiate it…?”

Dory tried to smile, but even from the shadows I could see her lips twitching with the effort. “Do you think if…” But she was clearly too embarrassed to finish her thought –and anyway, I could see Alice shaking her head and squeezing her hand affectionately.

“Somethings just are, Dory. And my main duty as a mother is to help her to accept them.” She let go of Dory’s hand and picked up her coffee for a sip. “And to help others to accept her…”

“But…” There was a hint of helplessness in that one word.

“But what’s not to love, eh?” she said, glancing towards the door and standing up to wave at a smiling teenager gliding towards them like a boat about to dock. And then Janice waved back, just like anybody else…

Medical Revisionism

Words -that’s all they are: sounds that by their very presence magically communicate meaning. They are more than mere noise or background. They are not the wind rustling through the leaves, nor the sounds of a frog in a pond; in a way, they are entities that resolve uncertainty, and in as much as they can be interpreted, contain information. Data. So, in a sense, they transcend Time: the information in the words of an ancient document still exists. But information is subject to interpretation; the same data may be seen as having different meaning as time and societal norms change. But does that change the information conveyed? I think not.

I’ve covered this topic in previous blogs (for example: https://musingsonwomenshealth.wordpress.com/2013/11/01/whats-in-a-name-cancer/ ) but the topic is a source of continuing intrigue for me, so I was once again interested in seeing it broached in an article in the BBC News last fall: http://www.bbc.com/news/blogs-ouch-34385738  It seems we are constant and insatiable revisionists. It’s as if by changing the descriptor, we somehow alleviate the pejoration its ancestor accumulated. And yet the information remains; only the colour changes.

I suppose that this is useful, but I can’t help but wonder if there is some other way of doing it. Of course, some words seemed to have been coined originally with a belittling intent -Cripple springs to mind- and even without our penchant for viewing the machinations of history through modern eyes, the word is disparaging; it is simply not fair. It derives from the Old English word crypel which has the suggestion of creeping. It was a condition in clear need of a new term.

Other words were more naively-attempted descriptions –designations that were no doubt thought to help others picture what was being named. There was unlikely to have been any attempt at denigration -despite how they might now offend or upset us. Mongolism is one such term. According to the New Oxford American Dictionary:mongol, or Mongoloid, was adopted in the late 19th century to refer to a person with Down syndrome (named after John L. H. Down [1828–96], the English physician who first described it), owing to the similarity of some of the physical symptoms of the disorder with the normal facial characteristics of eastern Asian people. The syndrome itself was thus called mongolism.’ But the problem remains –what happens when the term ‘Down Syndrome’ itself also becomes offensive?

Sometimes, it seems to me, the words will also change for no apparent reason. Think of the various expression changes for sexual diseases over the years and the somewhat clumsy attempts to strip the prejudice out of them. When I first started medical school, the expression was ‘venereal disease’ –or VD. Then, when that became too pejorative, or at least discriminatory, it morphed into STD (‘sexually transmitted disease’), and currently STI for ‘sexually transmitted infection’… Or am I already out-of-date? The reason for any of these transformations, however, is totally beyond me.

Words, it seems –or maybe it’s me– just can’t keep up. Maybe, like Fashion, they’re bound to change because of user-boredom or a need for novelty, but I think it’s probably deeper than that. I suspect that it relates more to societal attitudes than societal ennui. And I think that it may be a lost cause to expect consistency of usage. As we change our approach to issues and our opinions, so we change our words to describe them. It starts off with the more curmudgeonly amongst us –usually those for whom tradition provides a stable and secure platform- proclaiming the changes to be ‘political correctness’- to use the current phrase. But then, gradually, sometimes imperceptibly, the expression achieves a common parlance and not using it courts sideways glances, or even incomprehension. It is, perhaps, an aurally measurable example of society’s changing attitudes, if not its mores.

My biggest complaint, however –although minor in the scheme of things- is that it seems a waste of perfectly good words. One of my favourite ones ‘awe’ and its brother ‘awesome’ which used to bespeak a form of reverence, was ripped from my useful vocabulary only a few years ago and I’ve never really gotten over it. The words now have little value -they’re the scrapings from a different, grander time. Crumbs. Leftovers.

I am reminded of the words of Moth, the page of the soldier Don Armado in Love’s Labour’s Lost by Shakespeare: ‘They have been at a great feast of languages, and stol’n the scraps.’ 

Affairs of State?

What is it about les affaires d’amour that seem to capture our interest? Wave for our attention?  I am reassured by the activity in the world’s blogs -not to mention its press- that I was not alone in noticing the recent fuss around the alleged affair of the president of France. Adam Gopnik’s piece in the BBC News is, I think, one of the best reports:

http://www.bbc.co.uk/news/magazine-25756961

It suggests, at the very least, that I was not born with an unusual amount of prurience -if one can think of it as a personal quality akin to, say, courage, or agape. But is it just curiosity that attracts my attention to activities I have hitherto been unwilling to perform -and, now that I am not in a relationship, perhaps even definitionally unable- or something more basic? Primal? Contemptible?

It has been argued that sexual affairs mainly pique the interest of those who have not yet had the chance to indulge in them -those whose consciences are clear not because it is beyond their pale, but more beyond their skill. Or opportunity… Being somewhat virginal in this respect -or perhaps naïve would be a better term- I imagine I can be allowed to comment on them, albeit from a position of ignorance… and yet I don’t suppose there are any rules, are there? It seems to me that only someone with an absolute and unquestioned possession of what is right and wrong should be qualified to judge. We usually assign this role to a deity. None of my friends fit into this rather narrow slot; no one in political office for sure…

For that matter, are there any absolutes when it comes to morality? Apart from such obvious things as murder or child molestation -I’m only short-listing things, not closing the door- why do there seem to be so many societal discrepancies? Is it simply a ‘Well they’re not like us, so don’t listen to them?’ or something more profound?

‘When in Rome, do as the Romans.’ I grew up with this aphorism, for some reason. It was certainly not geography -Winnipeg and the vast Canadian prairies were my childhood homes- and yet what I interpreted it to mean was that if you were living in a place where they did things differently, try to fit in even if you didn’t understand. Even if you didn’t agree. They likely had a reason to which you were not -yet- privy. Hollande -being French- has been variously caricatured as ‘typical’, ‘selfish’, or even ‘amoral’. But it is as if the Romans -read the French- always behaved a certain way. Or worse, being told by a non-Roman that Romans behave a particular way. And even worse: being informed by a non-Roman who has never even been to Rome (but has read about it)… I don’t know, it’s too much ‘third-cousin-twice-removed’ information for me.

I think we have to divide the Media’s interest into two parts. First, is it acceptable to cheat on someone; and second, should people in authority be somehow exempt from such intimate and personal scrutiny? Is this merely -I used the word before- prurience? The answer to the first question seems self-evident: no. There may be circumstances where cheating is easier, circumstances where it just ‘happens’, even circumstances where it might be possible to keep it secret, but I’m struggling to think of circumstances where it is the correct thing to do. Full disclosure: I’m an avowed, life-long ethical relativist, and yet even my relativism sees a problem with this. For that matter, even a liberal interpretation of Kant’s Categorical Imperative (an action is correct only if you could accept everybody doing it) suggests that sexual affairs might be problematic. And I have to come down somewhere, don’t I..?  Or is it permissible to obfuscate? Delay until the subject is forgotten.. or at least until something else is front and center?

How about the need to examine those in power more carefully than their flock? Well, not more carefully –as carefully. We are, none of us, above criticism; none above personal scrutiny -not because of who we are so much as that we are. Whether a public figure should be judged for things outside of the public realm is not the issue. If whatever doesn’t effect performance or obligations, then it must be assessed separately. Judged separately. But like it or not, agree with it or not, it will be analyzed. We do not live in a vacuum and we all cast shadows that follow us around as long as there is light; it is in darkness where ambiguity proliferates and context is muddled. Mistakes are made in the dark… and rumours lie like fields of mud. Waiting.

And then there is the rather insulting question of whether the French are somehow… different. Do the French really have a societal acceptance of ‘affairs’? Are they somehow less titillating there than elsewhere? It seems to me more appropriate to ask the questions differently. All of us that are not French ask them from the framework of our own belief systems, our own closets. No matter their answers, we will interpret them as members of different Magisteria where words, not to mention values, imbue them with different colours, different shades of relevance. We all see the world through different parents, and tempered backgrounds. We braid our opinions with fragments of ‘other’ to be sure, but in the final analysis we are seldom them, as much as us… Our judgements can rarely be extracted from the warp and weft of where we live and how those around us think.

Most of us are still, sadly, prisoners in Plato’s Cave. Have the French alone escaped? Would we know?

The dangers of perceived wisdom

The Court of Public Opinion -an interesting phrase to be sure. It implies the judgemental assessment of an action, an idea -an opinion- by society at large. An interpretation, not necessarily impartial or even appropriate. A reaction, really, to something that stands out as different in some way from that Public’s perceived norms.

A Culture’s value system is usually encapsulated in what sociologists have termed its folkways -unconscious guides of conduct and thinking- and its mores -its more important customs. These have an even greater significance than may seem obvious at first glance: they are assumed, taken for granted and thus largely unexamined. And of course they vary from country to country, culture to culture -although less so nowadays with our ubiquitous interconnectedness; they are what have always made foreign travel so exciting. So broadening: that others espouse something terribly alien to what we have been acculturated to accept… to expect…  Epiphanous that our own customary behaviour is actually heretical somewhere else. That norms, in fact, aren’t necessarily normative.

All of this suggests that societal expectations can vary; not all values transcend geography; ideas that once held sway are ultimately mutable -inevitably changing as society itself evolves. But existent mores are powerful creatures nonetheless; they channel behaviours and engender punishments for perceived transgressions. When an act conflicts with canon, there are consequences -if only those of guilt and remorse, or the necessity of an obsequious denial of responsibility.

And once an act is deemed aberrant, anomalous -or just plain wrong– it is anathema to be seen or suspected of performing it. Think of our current attitude to, say, drinking and driving: years ago it was a subject of humorous tolerance; now it incurs not only societal, but also legal penalties. The same with such diverse things as domestic violence, or even animal abuse: once occasioning an uncomfortable averting of the eyes, they are now subject to intervention and prosecution.

It is difficult to know or predict what will fall within the purview of acceptable behaviour, but moralists are not without hope that their particular vision will be thus incorporated and often actively pursue campaigns to that end. Smoking is perhaps the quintessential example. While there is little debate about the adverse health issues visited upon the smoker, this was generalized to include his immediate vicinity in an ever-expanding circle that soon came to include the room where he smoked, the adjacent rooms, the floor, the building, and finally the grounds upon which the entire complex rested. Now, with a few disgruntled cynics it is largely accepted as appropriate and well within the bounds of common sense.

Public Health authorities have long recognized the value of trying to convince their public that certain issues should not be ignored. They are so important that to allow the behaviour is tantamount to endangering the health of innocent bystanders: vaccination for example and its benefit of ‘herd immunity’ whereby the more people are protected from some communicable disease, the less of them are available to transmit it. And for some reason while the reliability of vaccination seems to vacillate between acceptable and questionable in some populations, other health issues have been more thoroughly encapsulated into popular wisdom. Smoking in pregnancy, for example, or excessive alcohol consumption -indeed any alcohol consumption- by an obviously pregnant woman, are now behaviours that draw critical glances from friends and even uninvolved strangers. These have apparently slipped into the unconscious mores of a more-observant Society. They are unhealthy acts, selfish acts. We all now know this to be the case… How dare anybody disagree?

And there are even deeper levels of disapproval directed towards illicit drug use in pregnancy. Never tolerated or understood by most of us at the best of times, their use is so unacceptable in pregnancy as to engender almost universal anger and condemnation of the individual and her unfortunate circumstances.

I make these observations, not to deride what most of us would be willing to tolerate in a society, but more to draw attention to what this bias -however appropriate and well-meaning- is likely to do to someone caught on the other side of the equation. The opinions of others -their respect and approbation- is deeply influential, even required by most of us. So much so, the offending behaviour is often hidden or denied in an attempt to be seen to adhere to what is considered ‘proper’. To admit the deviance is to be excluded, criticized, judged.

How then, to help someone who is reluctant to admit to something of which she is ashamed? Something she might feel would prejudice your opinion of her? Your willingness to accept her without contempt? Alter the way you deal with her..?

An obviously thorny issue in obstetrical care, it is also a delicate one. Printed, official-looking prenatal forms with multiple tick-off boxes of questions go some way to alleviating her concerns: her issues might seem to be only a small part of a general interrogation aimed at all pregnant women -not just her… And yet concerns about who might have access to the information in the hospital setting might impede accurate answers. If she admits to drug use, will the hospital social worker take action to apprehend her baby, for example? Will she be treated differently if it is known that she was consuming alcohol in the pregnancy? If she was smoking? If she was the subject of ongoing domestic violence..? Will her personal integrity and wishes be questioned, or even disregarded in the name of some perceived Greater Good? With unknowns like these, would denial be her best option?

And how should the care-giver react? If the patient admits to something unhealthy, something seen as unacceptable, is the greater good to be realized by trying to change her behaviour and perhaps not writing it in the chart to protect her ‘secret’, or by alerting the appropriate authorities: pediatricians, medical specialists, and the like? It is an obvious choice for most of us, I suspect. But if a well-intentioned cover-up is initially chosen at the mother’s behest, suppose despite all efforts, her behaviour persists -does one then direct one’s attention to the baby, the mother… Society? And at what point? Is it a betrayal? It is a decisional labyrinth with untoward consequences down every path.

Ultimately, trust is probably the most likely factor affecting the honesty of the response for both parties. Trust that the person she has delegated to care for her in the pregnancy will honour her; trust that the route taken will be chosen with care and understanding. Trust does not always end at the expected destination of course, but hopefully it will be a fully explained and acceptable compromise. A place where she and her baby can live without regrets: in society… Where else is there, after all?

Gender

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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