Tag Archives: The Guardian newspaper

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Give Sorrow Words

It is fairly intuitive to suspect that parental mental health has an effect on both infant and childhood development. Indeed there is a widespread attempt to address the issue with the use of evaluative tests such as the Edinburgh Postnatal Depression Scale to identify or even anticipate and take action to ameliorate the problem.

It was designed, of course, to deal with the disastrous effects a mother’s depression, especially a postpartum one, might have on the health of the newborn -everything from bonding, to breast milk production, to the safety of the baby itself, could be jeopardized with an untreated depression. But, aside from the obvious issues of domestic violence, the father’s mental state is seldom accorded the same vigilance -after all, he is not the one who has undergone profound physiological and hormonal alterations as the pregnancy progresses, he is not the one who has experienced the rigours of delivery, and he is certainly not the one whose hormone levels change so drastically once again in the postpartum period.

And yet, merely to assign the paternal side of the parental equation to a largely supportive role is perhaps to assume there are few mental consequences of the changes that this newly acquired responsibility entails. It is the woman who is under the watchful eye of the accoucheur, and not the partner -even if he attends most of the prenatal visits. And postpartum period is likely even more of a black-hole for partner surveillance.

But the man, too, can undergo psychological changes after the birth, as an article in the Guardian newspaper reports: https://www.theguardian.com/lifeandstyle/2017/nov/13/can-men-get-postnatal-depression

Although not adequately investigated, previous studies suggested that only  between 4-10% of men developed recognizable post-partum depressive-like symptoms, whereas a Swedish study found that ‘28% of men had symptoms that scored above mild levels of depression. Overall, 4% had moderate depression. Fewer than one in five fathers who were depressed sought help, even though a third of those had thought about harming themselves.’ The discrepancy is likely because, unless it is serious, or obvious, the men are less frequently assessed in relation to their spouses pregnancy.

But the answer might not be as easy as asking the father-to-be to fill in the Edinburgh Depression Scale like his partner. ‘The lead author of the Swedish paper, Elisa Psouni, from the department of psychology at Lund University, says the Edinburgh Postnatal Depression Scale (EPDS) used for both women and men is not so accurate in picking up depression in fathers. Her research showed higher levels of depression in dads because it added in a score more reflective of “male” symptoms of depression such as agitation, anger, irritability, working longer hours and drinking too much.

‘Depression in fathers may be rising not just because researchers are looking for it, but because more new dads are struggling. Psouni believes fathers increasingly face the same dilemmas that mothers do – including trying to combine parenthood with working. Fathers who got depressed often had external pressures, such as job issues, and if their partner was depressed, their own risk of depression doubled. Lack of sleep, having twins and conflict in the relationship can all contribute.

‘A depressed dad will play and smile less with his child. Children are deeply affected by paternal postnatal depression with studies showing poorer measures of wellbeing and more behavioural problems at the age of seven.’

I suppose we are all children of our eras, though, aren’t we. We usually see the world through societal eyes. Indeed, I wrote an essay in my weekly series about this back in 2013: https://musingsonwomenshealth.com/2013/08/09/postpartum-depression-just-words/

I was focussed, as were most obstetricians, on the mother of course, but even then I wondered about the effects of pregnancy on the dads.

*

Julie was sitting in the waiting room fussing with her new baby cradled ever so carefully in her arms. I recognized the older woman seated beside her -I’d met her mother several times before the delivery, and as a watchful guardian in the corner during the delivery- but I’d never seen Julie without her husband, Andrew. He’d come to every prenatal visit, and had hovered over her like a tent during her entire labour -at least those times when I was present, anyway.

They were a team, and as inseparable as a shirt from its tie -too inseparable, I sometimes thought. Each decision she had to make throughout the pregnancy -everything from prenatal supplements, types of analgesia in labour, to when to cut the umbilical cord after birth- was made after lengthy consultation between the two of them. She never seemed to be given the option of deciding for herself and yet she seemed to welcome his input. She basked in his concern; she waded in his eyes.

That day, I remember she insisted her mother stay in the waiting room with the baby while she had her routine post-partum check; it seemed a little unusual.

“You’re looking a bit tired, Julie,” I said, when I had finished my post-partum examination.

She nodded pleasantly, but she looked preoccupied. I assumed it was the usual new-mother state, though, and I was happy that her mother had agreed to stay with them for a while.

“Where’s Andrew,” I asked, more to change the subject than out of curiosity.

Her eyes suddenly surfaced from her lap and flew to my face. “Andrew?” she replied, a little too quickly, I thought. “Oh, he’s… at home…”

But there was hesitation in her answer -as if I was being invited to question her some more. “At home…?” I asked, gently. I could see some tears beginning to well up in her eyes. “Is he okay…?”

She sighed and fixed me with a melancholy shrug. “He’s been stressed a lot at work, I guess -he’s taken some time off…”

I leaned forward a bit on my desk to show her I was listening and her face collapsed.

“Soon after we got home with the baby, he began sitting around pretending to read, but he never turned the page. He didn’t want to go for walks with us, and he only played with his food… He started to argue…” She closed her eyes for a moment before resuming. “And even the baby didn’t seem to interest him anymore…” She stared out the window behind my desk, obviously uncertain how to proceed. I offered her some tissue from the box I keep on the desk and she wiped her cheeks. “He said he was afraid of hurting her…” she blurted out, uncoaxed.

Suddenly, she stared at me. “Can you imagine -he was afraid of hurting his own daughter..!”

I must have looked concerned, because she quickly sat back in her chair and almost smiled. “Yes,” she said, as if trying to reassure me. “I realized he was depressed -I’m a nurse, remember- so both of us went to his doctor a week or so ago. He was referred immediately to a specialist who put him on medications as well as enrolled him in some counselling sessions.” Just getting it off her chest seemed therapeutic, and the shadows of a tiny smile began to surface on her lips.

But nonetheless, she looked uncertain, and also perhaps a little bemused. “I didn’t think men could get post-partum depression, doctor.”

I smiled and relaxed in my chair while I riffled through my head for an explanation. “A new baby changes things for both of you, don’t you think? Only, he just doesn’t have the same hormones, Julie…” I added, not certain what more I could say about it.

She actually chuckled at the thought. “Damn! I was hoping you’d tell me he could do some of the nighttime breast feeding…”

 

 

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The Thousand Natural Shocks

I guess I should have seen it coming, but I am a creature of an epoch that craved the security of its boundaries, liked the certainty of its labels, the comfort of knowing where things stood. I am older now, and can accept the confluence of sides. I live in the wake of new ideas.

And yet, all around me, I hear echoes of Yeats: The falcon cannot hear the falconer; things fall apart; the centre cannot hold; mere anarchy is loosed upon the world, the blood-dimmed tide is loosed, and everywhere the ceremony of innocence is drowned. For goodness sakes, it’s just Fashion blinking once again.

Those of us of an age, still equate unisex clothing with the guerilla military garb of Latin American rebel groups –utilitarian, egalitarian in its camouflage if not its beauty. But these are the chains of another era, born of necessity, not fashion. Once only a whisper, a different voice now sings in the ears of a youthful culture tired of the constraints of gender, impatient with being assigned a role. And while I can’t say that I follow any particular clothing style, I suspect that I conform rather closely to the stereotypes to which I was exposed at a very early age. But I realize that nobody really cares what I wear; it is perhaps enough that I don’t object if people wear each other’s clothes.

And I don’t object, although in fairness, I can’t say I’ve really noticed. These things sometimes creep up slowly, as indistinguishable as shadows on a cloudy day. In fact, I only became aware of non-discrepant dressing a while back, when I found myself scrolling absently through an article on unisex clothing as an antidote to the troubling catastrophes that leave me sleepless in the night. https://www.theguardian.com/lifeandstyle/2017/sep/04/joy-unisex-gender-neutral-clothing-john-lewis

I won’t say it was a surprise –things evolve, and clothing is certainly in the vanguard. ‘The British designer Katharine Hamnett has a long history of exploring non-gender-specific clothing […]. She says that, in the past, when women stepped on to more traditionally male sartorial territory – wearing military-inspired clothing, for instance – this “was about appropriating male power”. Now, she says, a move towards equality means women “may be feeling more comfortable with themselves”; in other words, they may have the freedom to wear what they like. (It is still far less common for men to seek out traditionally female clothing.)’ Uhmm… Yawn… I almost stopped reading at this point –I don’t know how normal people can slog their way through stuff like this.

Still, the next paragraph did manage to snag me from torpor’s edge: ‘Chloe Crowe, brand manager for Bethnals, a London-based unisex denim brand, says that when they have run pop-up shops, men and women in couples have come in and bought jeans that they can share.’ Okay, coals-to-Newcastle perhaps, but it was a candle in a dark room that kept me scrolling.

Then, something caught my eye, something that even I have noticed over the years -the frustration of seeing some patterns or styles that I fancied, only to find they were destined for the female market. This was a view from the other side, though. ‘The shirt company GFW Clothing – GFW stands for Gender Free World– has three fits, designed to fit different bodies rather than the broad terms “men” or “women”’ and Lisa Honan, co-founder of the brand online said ‘“I’d look in the men’s aisle and see great patterns and short-sleeved shirts […]” The men’s shirts, she says, didn’t fit her “because I’ve got a woman’s body. It got me thinking why is [there] a man’s aisle and a woman’s aisle, and why do you have to make that choice?”’ I don’t buy many new clothes nowadays, but Amen to that, I suppose.

One day, not so long ago, I was on a trip in a foreign city, and happened to walk past a row of brightly-coloured clothes hanging outside a store on a rack on the sidewalk. A sign above the clothes shouted Sale! 50% -or more- Off. And just like that, I fingered my way through a few of the shirts, stopping at a pale blue one that had a white linen flower sewn on the chest near the collar. In fact, the collar was what intrigued me –instead of the standard sharp angles, it was rounded off like the railings of an escalator. But its treasures didn’t stop there –the cuffs were adorned with a row of brightly coloured decorative buttons like digital fasteners all in a little row.

It was then that I noticed the eyes. And heard the mouth. “It’s beautiful, isn’t it sir?” I traced the words to a stoutly built middle-European woman standing in the door of the shop. She looked pleased, but suspicious –there was not the usual fawning of a sales rep on commission.

Embarrassed at being caught riffling through the clothes, and determined not to be pressured into buying anything, I merely smiled at her and withdrew my hand. Then, I shrugged and walked away a few steps until she disappeared through the door again. But there was something about the shirt that appealed to me so I turned around and pulled it off the rack. I think it was the little flower, to tell the truth. It seemed so… alive.  I couldn’t find the size, so I pressed the shirt against my chest like I’d seen people do to decide if it would fit. It seemed about the right size.

“Something for the missus, sir?” a now-familiar voice said softly, almost in my ear.

I turned my head suddenly and found a pair of eyes clinging to my face; I think I blushed. “No… I, uhmm, I think maybe…” I finally noticed the sign above the door, Plus One it said, and I wondered if it meant it was a two-for-one store, or something.

“I understand, sir,” she said with a big smile and what might have passed for a wink as she studied me and then let her eyes float up and down my face. “Would you like to try it on?” she added with a practiced, friendly expression and ordered her eyes closer to home base, finally satisfied with their assessment. She glanced at the rack. “I think that green one next to it would look good on you, too…”

So, it was two-for-one, I thought, happy that I’d found the rack.

“Try the blue one on first, and I’ll let you know what I think,” she said, hurrying over to one of two flimsy change room doors but found it locked. She looked at me and sighed. “You can use the other one. Some people just can’t make up their minds,” she whispered, and rolled her eyes. “That’s why they ask for my opinion.” She smiled innocently, as if she really would tell them what she thought.

I have to say that the shop had a sweet fragrance -as if someone had just shampooed themselves in a corner somewhere- and I was about to compliment her on the ambience, when the rickety door opened and a very large woman emerged. She was wearing a rather masculine-looking olive-coloured pant suit, complete with vest and a wide red necktie. It didn’t look like the stuff from the rack outside, but apart from some obvious strain on the fabric, I thought it really looked very nice on her.

“I don’t know, Helga,” she said, eyeing me suspiciously as she spoke to the saleslady. “I wonder if the colour is right for me.” She glanced my way again, obviously embarrassed.

Helga was already shaking her head, and I could see the disappointment on the large woman’s face. She really liked the outfit -and I kind of fancied it as well.

I put on my warmest smile. “I think it looks very nice on you, ma’am. The colour goes beautifully with your complexion, and I think it highlights your eyes. It’s a man’s opinion, of course…” I thought it best to issue a disclaimer.

Suddenly the woman blushed and a grin that almost split her face in half emerged. “I’ll take it, Helga!” she almost shouted, and disappeared behind the door again.

“And I’m gonna take these as well,” I said, handing them to Helga. “I don’t need to try them on… Two for one, are they?” You have to clarify these things.

Helga looked momentarily surprised but then slowly nodded. “Ever think of going into retail?”

You know, I’m beginning to think that someone like me would do very well in the burgeoning field.

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The Venus Figurine

Pregnancy has always had a sacred place in mythology. From the Palaeolithic Venus figurines, to the various stories of deities born from virgins, pregnancy has been cloaked in mystery and draped in awe –the curious interregnum separating being from non-being. That special state when the woman is suddenly not alone in her body, and then, equally suddenly not just a person, but a mother –a transformation that is as miraculous now as it was in millennia past.

It is still a source of wonder for me, even after 40 years as an obstetrician. But I think one has to be particularly careful in its blanket ascription to every woman –To every thing there is a season, and a time to every purpose under the heaven. For many women, it has been a rite of passage, a validation of their gender, whereas for others…

I am always on the lookout for popular articles on pregnancy and its resulting motherhood –not so much for resolution of the pro-life/pro-choice conundrum, but mainly to understand the current societal prescriptions for acceptable attitudes and behaviours of mothers. How intrusive is social media in moulding conduct and beliefs? There were a few clues in an opinion piece in the Guardian newspaper: https://www.theguardian.com/commentisfree/2017/may/30/detach-myth-motherhood-from-reality-future-generations But, judging from the tenor of the piece, it would seem difficult to avoid dissenting views.

The author, Angela Saini, introduces the topic by saying, ‘It’s hard for any woman to escape the expectation to be a mother. The maternal myth suffuses every human culture, from Catholicism’s Virgin Mary to Hinduism’s goddess mother. It’s considered the most natural state of womanhood, leaving the childless woman the object of pity. Let’s not even mention the woman who doesn’t want or like children at all.’ And then she imputes an opinion to a famous restauranteuse who was criticizing the UK prime minister about something –that ‘motherhood somehow makes a person automatically care about not only her own children but everyone else’s as well; and that women who aren’t mothers don’t have the same caring sense towards future generations.’ Fighting words, as they say.

Saini goes on to write, ‘But maternal instinct is not a switch that exists in every woman, ready to be flipped as soon as she smells a baby. Relationships between mothers and their children are frequently far more fraught than the myth leads us to believe. It shocks us that mothers can be selfish. […] There is scientific evidence to suggest that the maternal instinct may even be contingent on a woman’s circumstances. […] maternal instinct may sometimes depend on whether a mother has the support she needs. We’re not a species designed to cope alone. Indeed, we’re at our most social when it comes to parenting, often recruiting many people around us to help. It really does take a village to raise a child.’

Her point, obviously, is that maternal instinct is not an all-or-none phenomenon –it can exist in degrees, and like a flower, it may take a while to fully bloom. ‘[…] motherhood is not always an against-all-odds epitome of selfless caring. Sometimes it can involve emotional calculation, weighing the needs of both parent and child. We all assume that a mother always wants the best for her child, above her own needs. What we seem to deliberately ignore is that a child’s welfare can also depend heavily on the mother’s own needs being met.’

And so, ‘For the sake of both mothers and children, we need to begin detaching the myth of motherhood from the reality. It’s unfair of any society to expect women to be the best mothers they can be without economic or emotional support, just because they should love their children. Not all women are happy to be mothers.’

She concludes by observing that ‘Many mothers will know that birth doesn’t always signal a rush of immediate love. The maternal bond may build slowly over time. For a small few, it may never appear. And some never experience the urge to have children. We think of all these as unnatural exceptions, bucking the normal trend of how a woman is supposed to feel. But the scientific and historical evidence shows that none of it is strange at all. […]The most unnatural thing of all is forcing a woman into motherhood in the anticipation that she will biologically fall into line when a baby arrives.’

As an obstetrician, my responsibilities ostensibly end with the birth of the baby, and yet how can a duty ever end? Delivery is seldom the last time I see the woman and her baby, and it is certainly not the last time I hear their stories. We are all stories.

Jennifer sat in my office crying inconsolably. It started out as most other visits start, as I remember. She was seeing me for her post-partum checkup, six weeks or so after the normal delivery of a healthy baby boy. It was her first pregnancy and everything had gone well in hospital. She had left smiling, if a little stunned at the rapidity of her labour.

When she came into the office she was the picture of contentment, although I did wonder why she hadn’t brought the baby. I don’t deal much with babies, but the mothers usually bring them to show them off. It’s always nice to see how they’ve changed since birth, and marvel at the almost constant eye contact between the two of them. Usually, I get the impression the mother is only half listening to my questions –she is completely involved in a world I cannot really enter.

But when I asked Jennifer how the baby was, her face changed. “Jonathan was marvelous for the first day or so…” she said, her voice trailing off. “But I was so amazed at him, so involved in his every move, of course he seemed perfect.”

The first tear slid down her cheek and she stared out the window behind me for a moment, as if she were afraid I’d ask her more. Then, she grabbed for a tissue from my desk and wiped her cheeks. “Doctor, he never sleeps! I feed him, I burp him, I change him, I rock him… And so does Tony, but it only works for a while, and then he starts again. We took him to the pediatrician, but she just smiled and reassured me. Some babies are like that, she said. It’s not colic, it’s not something Tony and I are doing wrong… And it will settle.

“But it hasn’t! Neither of us are getting any sleep and now Tony and I are fighting… I wish we’d never decided to have a baby…” She stopped talking and suddenly stared at me in terror as if she’d admitted to some unspeakable crime… And to the doctor who’d seen her excitement for her entire pregnancy…

She began to sob. “I don’t think I’m a very good mother, doctor. My friends seem able to manage with their babies… They don’t need any help!”

I waited to hear her out, but she just sat huddled in front of me weeping inconsolably. “Did your mother stay with you?” I said softly. “I remember she was with you in labour.”

She shook her head sadly. “Tony and I figured we could manage.” She wiped her cheeks again and grabbed another tissue. “She wanted to stay and help, but I’ve always been her independent child.” She sighed with a deep stertorous gulp of air. “I was kind of embarrassed to admit I might need some help, to tell the truth…” She stared at me with wide red eyes, like a doe peering out of the woods.

I smiled and sat back in my chair. “There’s an African proverb I’m sure you’ve heard, Jennifer: It takes a village to raise a child. I think it also takes a mother to help her child…That’s what mothers are for, isn’t it…?”

She stared at me for a second or two, a weak and wobbly smile fighting to control her lips. “You mean…?”

“Phone her,” I said.

And she did –right there in the office.

 

 

 

 

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Zealandia?

Sometimes things are not as they seem and we see, as the biblical Paul wrote, ‘through a glass darkly’. Sometimes there is more than meets the eye; it is what makes the world so interesting. Maybe it’s why we wrap gifts –or give them, for that matter. They are such stuff as dreams are made on…

I have always loved New Zealand; to me, it is a gift, and so is what I’ve recently learned about its origins. To think that Aotearoa –the land of the long white cloud- is more than the ribbon I can see today, more than the Maori seafarers could see even a thousand years ago when they first arrived, is astonishing, and not a little intriguing. An article in the Guardian (https://www.theguardian.com/world/2017/feb/17/zealandia-pieces-finally-falling-together-for-long-overlooked-continent?CMP=Share_iOSApp_Other) reports on a paper published in GSA Today -the journal of the Geological Society of America: ‘Zealandia covers nearly 5m square km, of which 94% is under water, and encompasses not only New Zealand but also New Caledonia, Norfolk Island, the Lord Howe Island group and Elizabeth and Middleton reefs. The area, about the same size as the Indian subcontinent, is believed to have broken away from Gondwana – the immense landmass that once encompassed Australia – and sank between 60m and 85m years ago.’

Of course, even with satellite-derived bathymetric data, it’s hard to appreciate. And the skeptics, largely silent in their apathy, still sit in the shadows wondering what difference knowing  this  makes. After all, it’s almost all underwater, some of it way underwater –one edge of it ‘can be placed where the oceanic abyssal plains meet the base of the continental slope, at water depths between 2500 and 4000 m below sea level.’ http://www.geosociety.org/gsatoday/archive/27/3/article/GSATG321A.1.htm Would we be any the worse, the unimpressed might argue, if this remained undetected? Would the ignorance handicap us in some way? Any way…?

In the conclusion to the paper, the authors assert that: ‘As well as being the seventh largest geological continent Zealandia is the youngest, thinnest, and most submerged. The scientific value of classifying Zealandia as a continent is much more than just an extra name on a list. That a continent can be so submerged yet unfragmented makes it a useful and thought-provoking geodynamic end member in exploring the cohesion and breakup of continental crust.’ But it seems to me that questioning the value of this discovery misses the point entirely. Misses, perhaps, the point of gifts and the wrapping in which they are concealed.

Although I am now retired, I am reminded of something that happened late in my career as a gynaecologist and which continues to intrigue me. It makes me wonder just how many other assumptions limit our vision…

Sometimes in medicine, we feel the need to step back from the fray, to attempt an objectivity denied to those whom we treat. It allows us, we explain, to adopt another, more reasoned perspective -one which is unadulterated by their pain and emotion. ‘A thought which, quarter’d, hath but one part wisdom’ as Hamlet said.

And yet, looking out from the forest of my age, I realize that sometimes people don’t want to be treated as patients, but as people. Fellow travelers. What they want is a knowledgeable friend, not a textbook to which they can turn. One has to learn to gauge the needs…

Jean was not a new patient, but her visits were erratic and unpredictable. Sometimes it was for a pap smear, but more frequently it was for what she would only characterize as an ‘infection’ –“The usual one,” she would inevitably add with an embarrassed laugh. But neither I, nor any of the other doctors she had seen were ever able to find the infection, so it had become a sort of standing challenge as to who would find it first.

Jean was a very fit woman then in her early fifties, who taught both English and drama at a nearby high school. Meticulous about her appearance, I would see her in the waiting room sitting bolt upright, shoulders back, head perched on her shoulders like it was suspended on fine wires to keep it from despoiling the immaculately dressed body below. Her hair was brown and short with each strand assigned an immoveable location lest it be chastened with the brush she kept on her lap in a little purse.

That day, however, I noticed she had added another weapon to the arsenal on her lap –a little pump action plastic bottle, the content of which she would surreptitiously spray on her hands from time to time, followed by a vigorous rubbing as if she had just applied some soothing lotion.

She smiled when she saw me and extended a just-sprayed hand in greeting. “I think I’ve solved my problem, doctor,” she said as soon as we were settled in my office. “I just wanted you to check and see if there was any difference –you know, down…” She blushed before she could finish her sentence. She immediately produced the little bottle and sprayed her hands again. “No infection,” she added, regaining her composure after the little entr’acte.

“And the little bottle?” I had to ask.

“Sanitizer,” she answered proudly. “It’s antibacterial,” she added, and dived into the purse to read the label to me. “It contains triclosan… For some reason it’s really  hard to get nowadays.” Her face suggested that puzzled her. “I mean it kills bacteria doesn’t it? And they’re the troublemakers…”

I suppressed a sigh and sat back in my chair. “It also encourages bacterial resistance, Jean. And it doesn’t seem to be any more effective at cleaning than good old soap and water.”

She blinked, but whether in surprise, or disbelief I couldn’t tell. “But…” She gathered her thoughts before continuing. “We pick up bacteria from our environment and dirty hands are how we transmit a lot of diseases. We have to keep them clean… Bacteria” –she said it as if the word itself were dirty- “Bacteria are everywhere.” She pointed to an alcohol-based hand sanitizer I kept on my desk. “And I see you don’t take any chances either. ”She relaxed in her chair as if she’d proved her point.

I allowed myself the sigh I had avoided earlier. “An interesting dichotomy, isn’t it?” She raised an eyebrow. “That we live in a world jam-packed with so many bacteria that they are virtually ubiquitous…” I continued, “…and yet so few cause us trouble.”

“But…” She leaned forward on her seat.

“But we seem to want to malign them all; we act as if they were all our enemies. And yet, our own microbiome –the bacteria living in our intestines- are absolutely essential for our health in ways we are just discovering. And apparently the number of bacteria normally living in and on a healthy human body outnumber our own cells by ten to one.” I stopped and smiled at her incredulous expression. “We –our cells- are only the tip of the iceberg.”

I suppose I thought I’d just be reminding her of something she already knew, but her eyes were saucers. “Zealandia,” she said after a moment’s reflection.

“Pardon me?” I’d never heard the word, and wondered whether she was referring to the title of some obscure novel she was teaching at school.

“Zealandia,” she repeated as if she were surprised I didn’t recognize the term. “You know, doctor, the continental landmass of which New Zealand is a part? It’s 95% underwater so you can’t see it and therefore don’t appreciate it’s importance. We usually only judge what we can see, don’t we…?” she added with a wink and a big winning smile.

We all have our blind spots.

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From the Mouths of Babes

We take a lot for granted, don’t we? As parents we assume responsibility both for the wellbeing of our children and also their voice. Somebody has to, and obviously we, as their adult guardians, are better able to decide what’s best for them than they are –especially when they are young and inexperienced. It’s hard to argue with that, of course… At least I thought so until I happened upon an article in The Guardian newspaper that started me wondering whether the arrogance of age blinds us to a conceit that should be re-examined. https://www.theguardian.com/lifeandstyle/2016/sep/26/should-children-be-able-to-give-consent-for-medical-treatment?CMP=share_btn_link

I’m not advocating the abrogation of our responsibility to make the decisions –especially in the very young- nor to neglect to act in what we consider to be their best interests. I think it’s more about soliciting their opinions and perhaps incorporating these, where feasible, in the ultimate decision. Clearly, age is a major factor in how engaged the child will be –in the UK, at least, ‘Anyone over the age of 16 can consent to treatment, but so can younger children if doctors think they can understand and are competent to make medical decisions. Neurobiological research shows that the prefrontal cortex, home of balancing risks and rewards, is the last area of the brain to mature. So can adolescents – who are often impulsive risk-takers – be trusted to make decisions about their health?’

There was an interesting 1982 study that addressed the issue of the competency of children and adolescents to make informed treatment decisions: https://www.ncbi.nlm.nih.gov/pubmed/7172783?dopt=Abstract   In it, ‘9-year-olds appeared less competent than adults with respect to their ability to reason about and understand the treatment information provided in the dilemmas. However, they did not differ from older subjects in their expression of reasonable preferences regarding treatment.’

And indeed, there has been some effort to accommodate the child’s wishes in the latest policy statement on Informed Consent of the American Academy of Pediatrics: http://pediatrics.aappublications.org/content/pediatrics/early/2016/07/21/peds.2016-1484.full.pdf  For example: ‘When defined as agreement with proposed interventions, assent from children even as young as 7 years can foster the moral growth and development of autonomy in young patients. This consideration is based on an understanding that, starting around 7 years of age, children enter the concrete operations stage of development, allowing for limited logical thought processes and the ability to develop a reasoned decision.’

Of course, I am a gynaecologist with an adult practice, so I rarely have occasion to delve into the ethical minefield of paediatric consent, but occasionally I am exposed to its intricacies vicariously. These are frequently related to childhood vaccinations. In my Canadian province of British Columbia, vaccinations for hepatitis B and chickenpox as well as HPV (to females only –at the time of this writing) are offered to all children in grade 6 –in other words, to 11 year olds. https://www.healthlinkbc.ca/healthlinkbc-files/grade-6-immunizations Of course, ‘It is recommended that parents or guardians and their children discuss consent for immunization.’ But under some circumstances, even an eleven-year old might be considered a ‘mature minor’ and could potentially consent to the vaccination on her own: ‘In B.C., immunizations for school aged children are given in grade 6 and grade 9. Most of the time, the vaccines are given by nurses at immunization clinics held at schools. Children may also get vaccines at a health unit, youth clinic, doctor’s office, or pharmacy. In all of these settings, a child can consent to the vaccine on their own behalf if the health care provider has determined that the child is capable of making this decision.’

Ruth, a thirty-six-year-old woman whose daughter I had delivered eleven years ago, returned faithfully to my office each year for a pap smear. She had a history of several increasingly abnormal smears, eventually necessitating a minor excision procedure three or four years ago for an HPV-related pre-cancerous lesion on her cervix. Fortunately there had been no evidence of recurrence since then.

She’d always been a nervous woman -her pregnancy no exception- and the subsequent abnormality on her cervix had done nothing to alleviate her anxiety. Even her clothes seemed adjectival to the noun of her angst. Exquisitely ironed white cotton sweatshirts and similarly fussed black jeans over highly polished black leather pumps were her inviolable uniform on each visit. She wore her long blond hair tied in a pony-tail so tightly pulled from her forehead, I imagined I could see tiny fissures opening up on her scalp where it was tearing. And she constantly clenched and unclenched her fists as if she were training for some hand-shaking marathon.

Everything about her usually screamed stress. And yet, when I saw her recently, she had relaxed her hair so it danced freely on her shoulders, and was actually wearing a pale blue silk blouse and a pretty black skirt. At first I didn’t recognize the smiling woman who seemed so comfortable as she sat chatting with one of my young pregnant patients. But as soon as she saw me, she stood and grinned at me as if I were a cherished friend. I suppose I was…

“Doctor,” she said, even before she sat down as I closed the door to my office. “Remember Trish?” she pronounced the name slowly, in case I didn’t remember delivering her.

I nodded and tried not to roll my eyes. She was always telling me about Trish –every visit she had something new to report –and A in spelling, or a Silver in some race she’d entered.

“Well, she’s in Grade 6 in school now…” She stopped and scanned my face to see if I could guess what she was about to tell me. She often played this game and, sadly, I never succeeded.

This time, however, she prolonged it sufficiently long that I began to wonder if she’d forgotten what she was going to tell me. “…And you’ll never guess what happened,” she finally added -probably to tease me.

I knew it would continue like this until I said something. “What?” It wasn’t a very profound response, and I think she was a little disappointed –especially in my evident lack of excitement.

“My little Trish has grown up,” she bubbled with obvious pride. And then, when I didn’t say anything, she continued. “This is the year they all get their vaccinations…” She fixed me with a suspicious stare as she tried to decide whether or not I knew that.

I held my expression to an anticipatory smile and a nod.

“Well, she decided to have the vaccination, doctor!” I could hear the exclamation mark as it rebounded off the walls. “I mean, I’d discussed it with her beforehand and everything, but it was her decision!”

I took a deep, but silent breath. “Was there ever any question about it, Ruth?”

I could see her withdrawing into her face as her eyes took turns jousting with mine.

“She had a lot of questions at first.”

“Questions…?”

She nodded –warily, I thought. Carefully. “Mainly about the HPV one, though.”

“What did she want to know?”

I felt another probing jab with from her eyes before she called them off and sighed. “It was about the boys.” I waited patiently. “She wanted to know why they didn’t have to get the HPV vaccination.”

It was a common complaint, and one that I shared. Although several weak arguments have been made for male exclusion, none of them are convincing.

“She thought boys would have the same risk as girls, and it was so unfair she wondered whether she should refuse to be vaccinated as a protest,” Ruth said proudly.

I wondered where that idea had come from –Ruth was a zealous supporter of HPV vaccinations, I knew. “So you convinced her to change her mind?”

She shook her head. “I tried, believe me. I even phoned the school to make sure they knew I wanted her to have the vaccination.” But I could tell she was pleased that her daughter had evaluated the matter so carefully. I was certainly impressed.

“So what changed things?”

She rolled her eyes and smiled. “One of the boys in the class made a face at her.” Then she sighed. “Perhaps not the most persuasive of arguments…”

All I could do was nod. If someone makes the right decision for the wrong reasons, it’s not really a teaching moment, I suppose…