Different Flavours

There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy –so says Shakespeare’s Hamlet. I suppose as one ages, there is a tendency to become, if not indifferent, then less surprised at the plethora of variations that exist when they are sought, less amazed at the range of combinations just waiting for discovery. Like ice cream, the world does not come in only one flavour.

But perhaps it is not just the array that so bedazzles, but that we could ever have presumed to define what is normal in anything other than in a statistical way. A Bell Curve distribution confronts us wherever we look –reality is a spectrum no less than the rainbows we all profess to admire. So, then, why is it that in some domains we are less than accepting of mixtures, less tolerant of difference? Why is there the overwhelming need to categorize things as either normal or abnormal? Natural, or unnatural? A macrocosm of only us and them?

Is it just the benefit of retrospection that allows me to notice that no one of us is the same? Or a corollary of Age that lets me thank whatever gods may be that it is like that? That not only do we differ in our tastes and thoughts, but that the discrepancies in our appearance, if nothing else, allow us to recognize each other?

At any rate, I have to say that, as a retired gynaecologist, I was pleasantly surprised to rediscover a world I thought I had left behind –intersex. It was an article in the BBC News that caught my attention: http://www.bbc.com/news/world-africa-39780214 In my day, however, we still hewed to the label ‘hermaphrodite’ if both male and female gonads were present, or even more insensitively, to something like ‘disorders of sex development’, with the medical community taking it upon itself to assign and surgically ‘correct’ the anatomical features at variance with some of the more prominent features of the melange. All this often before the person was able to decide whether or not to identify with either or both traditional sexes. I don’t for a moment believe that this was done malevolently, however, and I think we have to be careful not to apply current sensitivities to another era. Historical revisionism is always a temptation…

But the spectrum of variation is so wide in both anatomy and physiology, not to mention time of discovery, that assignation of gendered roles is fraught. For some, the worry has been that of acceptance –acceptance of any divergent anatomy, any dissonance, by society at large, but also acceptance by the individual themselves (even pronouns become problematic –assigned as they usually are by gender).

It is common nowadays (UN Office of the High Commissioner for Human Rights) to use the (hopefully) neutral term of intersex to define people who ‘are born with sex characteristics (including genitals, gonads and chromosome patterns) that do not fit typical binary notions of male or female bodies. Intersex is an umbrella term used to describe a wide range of natural bodily variations. In some cases, intersex traits are visible at birth while in others, they are not apparent until puberty. Some chromosomal intersex variations may not be physically apparent at all.’

Of course attitudes are as disparate as societies themselves. Not all have been as tolerant or accepting of difference as one might hope. The BBC article, for example, describes the attitude in some rural areas in Kenya that a baby born with ambiguous genitalia should be killed. ‘Childbirth is changing in Kenya. Increasingly, mothers are giving birth in hospitals, rather than in the village. But not so long ago the use of traditional birth attendants was the norm, and there was a tacit assumption about how to deal with intersex babies. “They used to kill them,” explains Seline Okiki, chairperson of the Ten Beloved Sisters, a group of traditional birth attendants, also from western Kenya. “If an intersex baby was born, automatically it was seen as a curse and that baby was not allowed to live. It was expected that the traditional birth attendant would kill the child and tell the mother her baby was stillborn.”’ The article goes on to say that ‘In the Luo language, there was even a euphemism for how the baby was killed. Traditional birth attendants would say that they had “broken the sweet potato”. This meant they had used a hard sweet potato to damage the baby’s delicate skull.’

‘Although there are no reliable statistics on how many Kenyans are intersex, doctors believe the rate is the same as in other countries – about 1.7% of the population.’ But the thrust of the article was really to discuss how  Zainab, a midwife in rural western Kenya defied a father’s demand that she kill his newborn baby because it was intersex. She secretly adopted the baby –and indeed, even a second one a couple of years later. ‘In Zainab’s community, and in many others in Kenya, an intersex baby is seen as a bad omen, bringing a curse upon its family and neighbours. By adopting the child, Zainab flouted traditional beliefs and risked being blamed for any misfortune.’ But she represents a slow, but nonetheless steady change in attitudes in rural Kenya.

‘These days, the Ten Beloved Sisters leave delivering babies to hospital midwives. Instead, they support expectant and new mothers and raise awareness about HIV transmission. But in more remote areas, where hospitals are hard to reach, traditional birth attendants still deliver babies the old-fashioned way and the Ten Beloved Sisters believe infanticide still happens.’ But, ‘It is hidden. Not open as it was before’.

I suppose it is progress… No, it is progress –however slow, and frustrating the pace may be, as long as there are people like Zainab there is hope. But it still leaves me shaking my head.

For some reason Robert Frost’s poem, The Road Not Taken, springs to mind, in a paraphrase of its last verse: I shall be telling this with a sigh somewhere ages and ages hence: two roads diverged in a yellow wood and she, she took the one less traveled by, and that has made all the difference

Please.

The Doors of Persuasion

The Doors of Perception, by Aldous Huxley -I loved that book; I read it when I was a teenager and was intrigued by the idea that there could be doors to abstractions as well as to rooms -doors to other areas, other places. Invisible portals that existed alongside more tangible things, and yet magical, somehow -like the door to Communication.

Communication is such an obvious and basic requirement to enable us to function that it is often invisible until pointed out. Almost everything we do is a form of communication; writing, creating, building -perhaps even imagining- are all done for someone else to notice –despite our ego-dominant protestations to the contrary. We, none of us, live in a vacuum –nor would we be able to, even if we mistakenly thought we might like to try it for a while.

No, the need to communicate is a given; we are social creatures. And there are many reasons for it: to reach out and feel the presence of another is a major one -to share the solitude we all inhabit and reassure ourselves that we are not alone.

And yet the other main purpose of communication –the imparting of information- can be more difficult. Is more difficult. We are all unique, and we guard the differences behind a variety of walls: culture, education, gender… There are so many ways. So many reasons. So many locks on so many doors. The art of communication has always involved the art of persuasion; to open a door, you must first want to open it -and trust that what is on the other side is neither harmful, nor antithetical to what you have become accustomed to, or are able to accept. Willing to accept.

In medicine, to open doors, we have often relied on the magic of arcane knowledge. But although communication through authority can force, it cannot persuade. Cannot convince people that what we advise is necessarily in their best interest, especially if the advice flies in the face of what they have always believed, what those around them have always lived, or what their culture or milieu has always prohibited. There is always other advice, other authorities they can consult that harmonize more readily with what they have been taught, so why should Western Medicine, as we have come to classify ourselves, be specially privileged?

I’m not convinced that in all cases, and in all circumstances it should be. There is usually not one answer that suffices, not just one approach to a problem. But if someone has come to a doctor for advice, or more unfortunately, has been swept into his purview through circumstances not of her choosing, it would be helpful to approach the issue with all the respect it demands. The trust one engenders as the doctor is assigned; it has not yet been earned on that first encounter. Authority of the sort we as doctors possess breaks down rapidly when it attempts to enforce an opinion. Contradicts a belief.

If I, for example, say that something is my belief, I may be closing a door unless the person to whom it is addressed already shares that opinion. Especially if uttered in a fashion or in a circumstance that negates the other person’s opinion -makes them lose face, or does not allow for a compromise that permits their own beliefs, and makes allowances for their own cultural practices. I am not talking life-and-death situations where emergency surgery is required to remove a ruptured appendix, say, or an antibiotic is needed to rescue the body from an overwhelming sepsis… More the situation where there may well be other options –some, perhaps not as appropriate or effective, but where the choice could still be construed as a matter of opinion –mine.

Each of us is the agent of our own lives and we should be free to decide for ourselves what path to walk. Some choices may be unwise and later we may wish we had chosen something else, but wherever possible, the choice should not be forced upon us. And indeed, one of the major premises of medical ethics forbids just that: the principle of autonomy –we should be free to choose whatever option we wish, even if the doctors disagree.

So, if we feel persuaded about the validity of our own beliefs, our own view of the world, it behooves us to unlock the doors of persuasion, not coercion. We are not always right –and that is surely not the point- but we have the best interests of our patients at heart and believe we can help. We do that by earning their trust, their respect, and their confidence. The object, after all, is not to prove that they are wrong and we are correct, but rather to help them to see that, in the face of the legion choices they could make, the one we suggest is most likely to produce the results we both desire.

I sometimes find that is the hardest part. It is difficult for me to listen sensitively to a monologue on ‘cleansing’, say, when I do not accept the thesis that disease is caused by toxins in the gut that need to be removed. It smacks too much of bloodletting, or leeches, of purgatives and enemas, of spells cast on the unwary… Attestations that the poor heart would fain deny, yet dare not. Even placebos help for a while, after all -it is the kingdom of Hope.

But it is not enough to merely try to keep an open mind -as the King says in Hamlet: My words fly up, my thoughts remain below: Words without thoughts never to heaven go. The object, where ever possible, is to stop for a moment to listen -no matter what is said. There is often fear in the other voice. And it’s a dare of sorts that the patient issues: ‘Prove me wrong; convince me if you can -I need something- but first, listen, then explain your point of view. Let me believe I have been heard…’

I want to believe that hope springs eternal in both our breasts.

 

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…

As I Age

As I age, it becomes increasingly clear to me that Life is far more complicated than I could ever have suspected. It is like a stew where I keep finding new ingredients –some to my liking, and some… Well, let’s just characterize them as unexpected -mysterious strangers that surface from time to time, wreak havoc, then disappear again like shadows on a moonless night.

Social movements are often like that –or, rather, social solutions. Society changes over time and it has been the fashion of late, to see this as an evolutionary adaptation to underlying conditions –the slow but steady metamorphosis of caterpillar into butterfly. And yet, sometimes the change is more abrupt -a mutation- and we are forced to deal with the consequences. When things around us change, we attempt to keep up –or at least, like the Red Queen in Carroll’s Through the Looking-Glass, find ourselves running faster and faster to stay in the same place.

And one manifestation of this is the need to preserve a thin weft of values as a template during the inchoate and often thread-bare interregnum. I’m thinking, of course, about the age-old philosophical conundrum of whether we should tolerate the intolerant –and if so, then how? And at what price the compromise? One example from many: the need to establish special female-only transportation in the city of Zhengzhou in eastern China to help women feel safe from sexual harassment. To guard them. http://www.bbc.com/news/blogs-news-from-elsewhere-36169029  Of course, the problem is by no means unique to China -other countries have discovered the same need and arrived at similar solutions.

But it seems to me that the issue is far more complex than these solutions might suggest. This gender issue, in some ways is not dissimilar to the racial problems that surfaced so violently in the last century in America. To think that having different buses for people of colour would salve the problem was proven to be naïve, and in itself discriminatory.

It comes down to the difference between toleration and acceptance: putting up with something that might not actually be approved of –enduring it: ‘toleration is directed by an agent toward something perceived as negative. It would be odd to say, for example, that someone has a high tolerance for pleasure’; versus  Acceptance: acknowledging and welcoming something as itself; permission versus approval. A power struggle either deferred, or shared.

To equivocate for a moment, should we tolerate mere tolerance, or accept it…? As an interim solution, of course. In other words, is it better to have the segregated buses for women, say, than groping and intimidation on more inclusive public transit? To say that there should not be sexual harassment is all well and good, but it ignores the present reality –there is, and to ignore it would therefore be akin to tolerating it. So are we  trapped in a never-ending game of chase-your-tail, forever condemned to wander the Mobius strip looking for an exit?

Perhaps it might be helpful to distinguish the component parts of the issue (I have adapted some principles from the peer-reviewed Internet Encyclopedia of Philosophy: http://www.iep.utm.edu/tolerati/#SH4a).  It seems to me that there is a difference between the more superficial and emotional response to whatever is being tolerated (Let’s call this the Reactive Stage) –the need to separate the aggrieved from the aggressor, for example- and the Rational Stage: the more dispassionate and reasoned analysis of the problem –if indeed such an analysis is feasible, or could even be rationally justified. In other words, on what grounds does the prejudice in question continue to exist? Is it remediable, or inevitable? Should we be forced to retreat behind our own societal boundaries and accept the relativistic excuses proffered that we simply can’t superimpose our own values on those who are not like us? That we, in fact, do not understand –nor likely ever will, since we are other?

Or, closer to home, can we ever hope to change attitudes such as disrespect and insensitivity to aspects of personal autonomy that have been entrenched –and indeed accepted- for countless unquestioning generations -that, until recently, were not even considered problems requiring solutions?

Well, societies do alter as time and members change; I’m not sure we could characterize the alterations as necessarily evolutionary, or teleologically driven, but certainly the initial reactive and then the more rational stages can often be discerned. The societal attitudes towards Gay rights, for example, have undergone major shifts within the past few years –even the initial toleration, which was rare in past decades, is now remodelling itself as acceptance.

So what -if anything- has Age taught me? What has the passage of years and the successive unfolding of events disclosed? Well, it has become clear that in the long run, our enemies become our friends; that we seek and find compromises satisfactory to each –bargains that in due course cease to be seen as concessions by either party, but rather as amicable balance; that Force only suppresses while it is being applied; and that discussion is inevitable and infinitely preferable to confrontation. We may not be able to evince our much-touted rationality in all things, but we are all eventually susceptible –amenable even- to accommodation.

Omnia vincit amor, I suppose.

 

 

Barbie in the Mirror

As an Ob/Gyn specialist I have been, I suppose, more than a passive observer of women over the years. But society has not been passive, either. Depending on where you live and in what cultural milieu, issues such as our sizes and shapes have become sources of real anxiety. Unrealistic expectations of morphology no doubt arise from multiple origins, but the end result is often the same -many of us don’t even come close to meeting them.

And as if that worry wasn’t enough, there has now been added the perhaps more troublesome issue of health. Despite the euphemism ‘plus-sized’ there is no disguising the stigma of the special term for many women –particularly when it comes wrapped with innuendoes of obesity and diminished well-being… not to mention beauty. Shakespeare would have us believe that ‘Love looks not with the eyes but with the mind.’ But does it? https://blogs.harvard.edu/marianabockarova/2014/05/29/the-science-of-beauty/ Once again, morphology rears its stilted head.

But we are a curious lot, we humans, influenced as we are by fashion and culture. Fickle in our choices, mercurial in our attitudes to those who fall outside the norms, we deride those who fail to satisfy the arbitrary boundaries –temporal though they may be.

Some have argued that one of the barometers of expectation is the shape of dolls –Barbie dolls in particular. They become, after all, the matrix of imaginary play and serve as proxies for the roles the children are trying to understand. http://www.bbc.com/news/magazine-35670446

A fuss seems to have been engendered by the release of three new types of Barbies: curvy, petite and tall. There are also skin colour differences, presumably to reflect the diversity in modern societies. But also, one could argue, to deflect the criticism of pandering to the thin, blond phenotype so prevalent in their models up to now. ‘Mattel [the makers of the doll] argues Barbie shouldn’t be expected to represent average proportions in the first place. “Barbie is a doll. She is not meant to reflect a real woman’s body,” says Sarah Allen from Mattel UK. “The purpose of introducing three new bodies into the range is variety and differentiation. When you look at the dolls collectively you can see the range in relationship between the dolls. “’ It’s a start, I suppose.

Therein lies the problem, of course, and it seems to me that it is hydra-headed. On the one hand to portray a doll that is truly representative of the reality that the child sees around her, would be to normalize –legitimize, really- the scourge of the 21st century: obesity and all of the health risks that entails: ‘[…]were Mattel required to accurately reflect the average British and American woman across all ages, the dolls would be overweight or obese.’ And yet, from a more modulated perspective, ‘Lenore Wright, from Baylor University, Texas, conducted a study in 2003 that explored the role of Barbie. She found Barbie’s shape didn’t really matter to children – her function was more important.’ Dolls, in other words, are just pretend –they’re substitutes that are merely assigned the role the child is exploring. The child knows they are not real.

But ‘Wright adds that Mattel’s new line has been criticized by some feminist scholars for reinforcing an old stereotype – that women are defined by their bodies.’ As I suggested, there are many divergent perspectives but remember that a Minotaur waits at the center of the labyrinth. We must be careful not to wander too far in our approach; we must not let our zeal mislead us.

It seems to me that children have always played with dolls and represented them according to their needs. To criticize a stick-doll, for example, or to confuse it with the reality the child apprehends is to stray dangerously far into revisionism. We are not children and we do not think as children. In a world where dolls are doctors, and dogs are patients, we are now strangers. Adults. Other… Forgive me for referencing Corinthians, but I think its advice was prescient: ‘When I was a child, I spake as a child, I understood as a child, I thought as a child: but when I became a man, I put away childish things.’

Amen to that.

 

 

 

 

 

Menstrual Taboos

Culture shapes behaviour, attitudes and beliefs -or is it the other way around? The chicken or the egg? This has puzzled me since I was a child wondering why everybody I knew wore jeans but in pictures the people living in, say, India did not. And the members of my family –uncles, aunts, grandparents, cousins- all went to church and sat in seats. None of them prostrated themselves on little rugs on the ground. Did each of us have to be Protestant? Was there a choice? Or, was there something about my family that made them that way? I don’t remember choosing.

Why do we end up believing or doing something that seems arbitrary when compared with other parts of the world? Why do we often think that only the way we do things is appropriate? Correct? How many correct ways are there..?

Could imitation be something akin to an infection? If everybody we know does the same thing, why would we even suspect it? Maybe it’s contagious and causes a psychological compulsion to fit in –like fashion, or expresssions in language that identify us as a member of a group or region. We seldom question it, but then again, there is no reason to: everybody around us is doing the same thing so it infrequently rises to a conscious concern. It’s an outrageous thought experiment of course and yet such curious congruity does give one pause for thought.

But in our islands of similarity we do notice difference; it makes us feel uneasy –as if perhaps there was a choice. Another way to do something. Another way to be in the world. And depending on the status of the innovator, we may see the novelty as interesting but peculiar –perhaps even something we should adopt for ourselves- or we may consider it simply wrong. Strange. Evil. Something to be shunned, avoided at all costs -even at the expense of the defector. Even if the apostate is tolerated under other circumstances when seemingly adhering more closely to the accepted norms.

I use the word apostate advisedly. Society is a religion, and one that is often disdainful of heretics, aberrations that tug at the pattern in the fabric. Anomalies. Discrepancies sometimes strain cohesion and make us question who we are and why we have come to behave the way we do. We are creatures of custom.

Of course I realize it is difficult, if not impossible, to apprehend difference without judgment. Even curiosity suggests analysis: comparison and evaluation. Some things, however, seem difficult to assign merely to custom; the difference is more appropriately attributable to fear. Unintended ignorance. Naivete.

The menstrual taboo is a case in point. There have been some recent articles in both the BBC News: http://www.bbc.com/news/world-asia-29727875?print=true and the Huffington Post:   http://www.huffingtonpost.ca/sabrina-rubli/menstrual-education_b_5689072.html that discuss problems surrounding menstruation and how it interferes with education for young girls especially. Menstruation is a natural process for renewing the uterine lining every month: shedding the old cells to make way for new ones that may be required to grow a baby. But natural does not necessarily mean acceptable or discussable for everybody.

Culture deems some things embarrassing, things best kept private or at least not shared outside a family or circle of friends. Bodily functions and intimate relations probably top the list. And yet necessity sometimes trumps personal feelings; where adequate facilities do not exist, an accommodation, a compromise usually springs up to fill the need. So while communal ablution may never rise to the level of a societal norm, a variation of it may be tolerated under some circumstances. Safety and vulnerability constrains many compromises, with strict gender separation often necessitating extreme measures such as waiting until the relative safety of darkness for a woman to relieve herself. Even this atrocious compromise is fraught with danger, as recent reports of rape and sometimes murder in parts of rural India attest. That the practice should even need to exist is unconscionable to most of us; that those with the authority and power to change it in the region have not managed to remedy it is worse.

But let’s not allow the unreasonable social diminution of women in one area blind us to an even more pervasive inequity in many developing nations around the world: the cultural taboo about menstruation. Femme International has documented some of the more egregious offenders in its website http://www.femmeinternational.org/the-issue.html

Culture is a tricky thing. Both intriguing and covert, it exerts an inordinate amount of influence on thought and action. The sources of its traditions are often historical, bound in a delicate weave with myth and legend, and are at best opaque. To question it, therefore is difficult and usually seen as insulting and provocative –it is what separates us from them, precluding further analysis, further understanding. “It’s just how we do things,” is the usual response to questions from foreigners. “You wouldn’t understand.”

The menstrual taboo is like that… and not. Attitudes are seldom fodder for experimental investigations, and yet occasionally there are aspects that are historically discoverable. The enforced seclusion or restrictions on the activity of menstruating women are usually ascribed to ignorance –lack of education about the function and meaning of menstruation- or fear of some theological punishment.  And yet Femme International, political correctness notwithstanding, has intimated there may be a more obvious, historical reason for the concern, albeit uncomfortable to state.

Traditionally, menses have been a source both of embarrassment as well as inconvenience for a woman –especially if she is required to be in public places such as the market -or school in more modern days- for any extended period of time. How to cope with the menstrual blood? Only recently have effective measures been available, but even these are priced beyond the means of many girls in isolated villages. In Kenya, for example, the BBC article reveals that the cheapest package of sanitary pads costs almost half the average daily wage, so they may be seen as more of a luxury item than a necessity. ‘As a result, girls will resort to using alternative methods of menstrual management, such as rags, leaves, newspaper, bits of mattress stuffing, even mud.’ The Femme International again: ‘Menstruation is the number one reason why girls miss school. Sometimes girls will attend school on their periods, but will refuse to sit down, or once seated, refuse to move. Many schools do not have appropriate latrine facilities, and girls are unable to wash themselves during the day. When latrines are shared between boys and girls, they are teased and mocked during their period.’ Indeed it has been suggested that because of some of these practices, the odour alone may have given rise to some of the fear of contagion and restrictions placed on the menstruating woman.  For example, the BBC reports than in ‘regions of Kenya, girls are forbidden from touching livestock, preparing food or consuming animal products for fear of contamination.’ And in India ‘there is generally a silence around the issue of women’s health –especially around menstruation. A deep-rooted taboo feeds into the risible myth-making around menstruation: women are impure, filthy, sick and even cursed during their period.’

Femme International has suggested at least one acceptable option: menstrual cups. ‘Menstrual cups provide an affordable and sustainable solution to menstrual health management. A menstrual cup is made of medical grade silicone and is worn inside the vagina during menstruation to collect fluid. Menstrual cups are more cost-efficient and environmentally friendly than tampons as they can be washed and reused for up to 15 years. Unlike [expensive] pads and tampons, the cups only need to be emptied every 12 hours. Thus girls can attend school without worrying about the availability of private washroom facilities, or revealing their period to peers.

There are other remedies of course and they, too, need to be pursued. Once again the Femme International: ‘Young women who lack the knowledge and resources to safely and effectively manage their periods not only miss school but face stigma and shame from their male and female peers. When girls do not understand why their body menstruates each month, they easily believe that it is something to feel shame about, something to keep hidden and something that is a source of humiliation. This type of behaviour is strongly influenced by the widespread stigma that surrounds menstruation in the majority of communities. When women are unable to manage their periods, they are less able to participate in daily life. Addressing the issue of menstruation through health education, positive reinforcement and the provision of management materials reduces these gender specific barriers.’

Yes, it’s a step to be sure, but one that may require a generation to succeed. We must not give up because the progress seems slow and the task insurmountable. Attitudes do shift, cultural mores and folkways change, governments fall. And with the almost ubiquitous availability of social media, one hopes the results might be noticeable even in our time. The curtain of mystery that has always separated the two sexes need not be rent asunder, though –mystery, after all, can be a source of awe and wonder. And not all mysteries have to be solved -sometimes just acknowledged and appreciated for their charm and excitement. No, the fabric need not be torn -merely parted enough to reveal that what differences do exist between the sides -between males and females- are nothing to fear. We were made for each other, after all.

 

The Stand

“So, do you have a stand on that, then?” She was smartly dressed in jeans and what looked to be an expensive white silk blouse and divided her eyes between my face and a little notebook in her lap. Whenever I said something she liked, she would scribble furiously and noisily in it. Otherwise it was silent -a non-attributable form of media manipulation? The noise amused me more than anything.

“I thought we’d already established that I like to hear what the patient is saying and then try to diagnose…” -I thought I’d sprinkle a few medical terms at her- “… what it is that she is trying to tell me.” I stared at her silent notebook and then added: “There’s more to conversation than words.” Her face took on the look of a dog that hears a noise it can’t locate. I could tell I was losing her. “You know: tone of voice, cadence of speech, body language…”

Her expression softened, and there were a few cursory scratches of pencil on paper. “A bit wish-washy. I’m trying to get at what you actually believe.” She said the word as if there were discrepancies in my answers so far.

“I believe…” –I thought I’d italicize the word as well- “…that it’s important to understand what my patient believes -read between her lines, if you will.”

“Her lines?”

Well, that metaphor was lost on her. “The lines, then.” Silence: pen gripped tightly but motionless, eyes fixed, breath held. More was expected: an addendum. “I mean that sometimes a person says one thing , but actually means something else that they’re afraid to say… Or maybe haven’t really decided what they think.”

Her brow crinkled -rather cute,  I thought. “But you’re the doctor! Wouldn’t you have an opinion on what she was telling you?”

I took a deep breath but tried to disguise it in case that would somehow get translated into pencil scratches. “If I knew what she was telling me, I suppose it might help me to direct my subsequent questions more appropriately…”

“But,” she interrupted, pencil at the ready, “let’s say the woman has already come in to see you with… a situation…” I suspect she thought she was being sensitive with that choice of words. Politically neutral. “Wouldn’t that in itself give you the information you need?”

I shifted into my bland I’m-not-sure-what-you-mean mode that I often find helpful in the office. “Information, yes; solution, no.”

“But…”

I’m still not sure why I had agree to be interviewed. Not really. Superficially I suppose it was because one of my colleagues was doing abortions and had a recent complication with the procedure -through no fault of his own, I might add. The woman had tried to self-induce a termination of her pregnancy, failed, become seriously infected, and then sought medical help from my colleague. He performed his job admirably and saved her life through his own skill and knowledge, but someone had leaked the ‘complication’ to the press and the whole event had been misconstrued. So perhaps I’d wanted to set things straight. But that’s not what this journalist saw as her mission. I suspect she actually wanted to know the opinion of a gynaecologist who worked in an ostensibly Catholic hospital.

I’d tried to dissuade her from that approach at the start, but to no avail. Now I was becoming a little annoyed at her persistence. But if the truth be recognized, it was her agenda that bothered me the most. I put on my best doctor smile and sat back in my chair. “Perhaps it might be a good time for you to be more specific. What is the question that you are leading up to?” Somewhere inside I blushed at my ending the sentence with a preposition and wondered if that might be one of the few sentences that she would quote in her article.

She gripped the pencil tightly; I could see the bones in her hand standing at attention just under her skin. “Doctor, you work at a Catholic hospital, do you not?” I nodded, but it was one of her conditions for the interview in the first place. “What do you think of abortions, then?”

My smile continued without interruption. I knew that was what she wanted, and had expected it at the beginning. And yet the question, at least for me, was irrelevant: where I work does not determine what I think. And what I think does not interfere with how I manage a patient with a problem. The journalist was staring at me, pencil poised, a subsequent question rolling around in her mouth just waiting for my answer. “Would you care to contextualize that?” I said, knowing full well she would have no idea what I meant.

“Pardon me?”

I crossed my arms and leaned forward on the desk that I had been careful to sit behind at the start of the interview. “You asked me what I thought of abortion. You might as well have asked me what I thought of fibroids…”

“I… I don’t see…”

“No, you don’t do you? Well let me put things into context for you, then. Abortions? I wish they were unnecessary. But then I also wish that people only became pregnant when they chose. And if they chose. In life, things happen, and not always for the best. I don’t much approve of smoking either, but that doesn’t mean that if a person were to become ill because they smoked I wouldn’t try my best to help them. Or in my own field, if they were to develop chlamydia or gonorrhea that I wouldn’t help them because they hadn’t used a condom, or maybe adhered to my own person moral preferences.

“Am I an ethical relativist? You might better ask me if I am a doctor. If you were to walk through that door looking for help, my first question would not be whether we had the same belief systems or the same cultural norms. No, it would be what can I do to help you? In other words, how are you suffering? And if I asked you about your sexual practices, or preferences it would not be to criticize, but to help in the diagnosis and treatment of the condition for which you had sought my help.”

“Are you Pro-Choice then?” I could see the words forming on her lips before she uttered them.

“We all have choices and I respect that. It’s not for me to interfere; I am not the person who has to make them. But I prefer to think of myself as Pro-Help… Perhaps I am the sounding board that helps you to make the Choice for yourself.”

With that she tucked her pencil and the notebook in a little shoulder bag and stood up. She sighed deeply and demonstrably. I had wasted fifteen or twenty minutes of her time. Now she was going to have to find another doctor to interview, I supposed. I stood up and extended my hand to shake, but she took it somewhat reluctantly, I think. “I’m sorry you decided not to commit yourself, doctor.”

I’m assuming it was a subtle put-down, but I allowed my smile to dance a moment longer on my face until I tucked it carefully away. “Actually, I think I did,” I said, and ushered her out of the room.