Archive for February, 2009

On Medicine and Objectification

Usually when we women’s studies types worry about objectification, we mean sexualized objectification: a (usually male) gaze that sees the other as a means to an end, where the end is sexual pleasure. I think sexualized objectification is actually more complex and ambivalent, but for now I’d like to set that aside. Sex is by no means the only area where objectification occurs, and insofar as means-to-an-end logic is always part of it, those other areas ought to draw our concern, too. And so I’ve been thinking about the relationship between medicine and objectification – partly in honor of today being Rare Disease Day (h/t Shakesville) but mostly in light of my recent experiences.

Modern, scientific medicine has historically objectified people as patients. Indeed, the “modern” and “scientific” elements of it rely on objectification. Modern medicine is founded upon objectification: People become case studies. Their complicated life stories are aggregated into statistics. They’re assigned to control or experimental groups, and their individuality melts away.

Medical research as we understand it would be unthinkable without objectification. The techniques I just mentioned are necessary to doing science right, following professional standards. The alternative – drifting in a sea of anecdata – would yield few useful results.

Actually, the alternative might look a lot like the journal articles written a century ago by long-dead German gynecologists. (For my dissertation research, I happily squandered months of my life leafing page-by-page through all the major German medical and gynecological journals and some of the minor ones, spanning about 1905 to 1935.) Typical articles included:

  • An outline of a new (and by our lights, scarily unsuccessful and brutal) technique for cesarean section or symphysiotomy.
  • Case reports of a needle left behind during surgery.
  • Descriptions of rare deformities of the pelvic organs.
  • Pictures of pickled uteri.

In other words, the journals reflect a fair amount of objectification but with very little systematization or, well, science. This started to change after 1900. By the 1920s there were more statistical analyses and fewer appeals to the author’s “experience.” Patients were still objectified, but there’s an occasional glimmer of scientific method. We’d still consider most of these studies piss-poor science, but the trend, at least, was toward research beginning to yield benefits for patients, as opposed to mostly boosting the author’s career.

(And yes, I joined the objectification party while I was working on these journals. I got so I could distance myself from even the photos of disembodied organs, which were mercifully in black and white. I could down a Snickers bar while looking at this stuff. So I experienced from the inside how medical training can create a distance from the suffering person and at least temporarily suspend empathy.)

Singling out medical research would distort the picture, because patients also came to be treated as objects in ordinary practice. This was especially true in teaching hospitals. I’ve written about how pregnant women in early-twentieth-century Germany were forced to undergo repeated exams by clumsy medical students, and how they were paraded naked in front of a whole auditorium full of observers while in labor. American obstetrics was no better: Women were strapped down while in labor and knocked out, whether they wanted it or not.

Over the past 40 years, under pressure from consumer advocates, feminists, and medical ethicists, medical researchers and practicing doctors have become a lot more sensitive to problems of objectifying patients. Patients with cancer are no longer kept ignorant of their diagnosis and prognosis. These days, expectant mothers are often encouraged to write birth plans – and yes, I realize those plans aren’t always heeded, but that doesn’t negate the sea change.

One index of objectification is condescension. They’re not the same thing, but condescension generally grows out of the practitioner’s conviction that he’s in a hierarchical relation to the patient; that he’s the subject and the patient is the object. And personally, I’ve seen a major decline in patronizing attitudes among medical practitioners. In the late 1980s, as a young graduate student, I went to my family doctor with complaints of fatigue, nausea, and dizziness. He told me, dismissively, that I was neurotic and overambitious and just needed to chill. (Another doctor diagnosed me with chronic fatigue syndrome, and after roughly 18 months I felt substantially better.) He projected the person of a folksy old-time GP, but I was just a case to him, and as such, he felt free to load me up with stereotypes about smart, ambitious young women. This doctor ultimately got in trouble for inappropriately touching young female patients – demonstrating that medical objectification and sexual objectification can occasionally overlap. He’s now long retired, thank goodness.

My recent experiences at the Cleveland Clinic and the OSU MS clinic were the polar opposite. The doctors listened to me and took my complaints seriously. No one implied that I was hysterical or tense or simply a head case. Overall, I’d describe my relationship with my family doctor, ob/gyn, endocrinologist, and the kids’ pediatricians as a partnership. We talk to each other frankly, and they listen to me just as much as I listen to them. The kids’ doctors are also wonderful about addressing the kids directly and asking them about their preferences. (A penicillin shot or liquid antibiotics? Gee, that’s a tough choice for a four year old!)

I realize I’m likely to get better care than average because I’m white, educated, medically literate, fully covered by insurance, and (heaven help me) sometimes a little pushy. But that’s not the whole story. For instance, there’s one doctor in our pediatricians’ group practice who’s still completely old-school. He was on duty in the hospital the day the Tiger was born, and he would not shut up about circumcision. In the end he had to respect my refusal to snip. I know he’s very condescending toward people who he assumed are less educated. But this fellow is the exception that proves the rule. He’s slouching toward retirement, and all the parents I know avoid him whenever possible. He’s a relic of the medical past. Patronizing doctors like him are on a gradual path toward extinction.

One notable exception to this general trend away from objectification is medicine’s ambivalence toward sexuality. As I’ve argued before, too many doctors are embarrassed to discuss sexual problems with their patients. This weekend’s Well feature in the New York Times offers a fresh example: a prominent ED specialist reports that one in four of his patients who’ve had a prostatectomy was not aware until after the surgery that he’d never ejaculate again! This embarrassed silence also interferes with patients getting the full scoop on the sexual side effects of antidepressants. The failure of medicine to deal with sexuality is an effect of shame, embarrassment, and ignorance, as these examples show, but it’s also a legacy of medical objectification. Seeing someone as merely as a “case” makes it very difficult to view a patient as a whole person with complex needs and desires. The result is condescension, fragmentation, and silence.

While pressure from our culture as a whole are pushing medicine away from condescension and objectification, there are countervailing structural forces. The most obvious of these is pressure to contain costs, which comes from all directions: insurers and HMOs, employers, and the state. Spending time really listening to the patient – as my doctors have done for me recently – doesn’t come for free. The specialists will be better able to recoup this; the MS neurologist I saw, for instance, routinely budgets an hour and a half for new patients, and I assume he’s got a billing mechanism that will cover his time. I’m pretty sure my family doctor, by contrast, will not be able to bill for all of the time he’s given me. Adding insult to injury, just yesterday my university (the only big employer in town) announced they won’t consider his clinic in-network anymore as of July 1. While this is likely a gambit to negotiate new rates, the net effect will be to place even more pressure on local primary-care doctors to curtail the time they spend with patients. Rushed appointments are not conducive to seeing the whole “case,” much less the whole person.

Another structural counterweight to more enlightened, anti-objectifying medical attitudes is the march of medical technology. Again, the history of obstetrics provides lots of examples. Chief among them is the fetal monitor. Quite apart from the large body of evidence that suggests routine fetal monitoring increases interventions without improving outcomes, fetal monitors also objectify the laboring woman. Her experience – and the well-being of her child – are reduced to lines and squiggles. I’m not a Luddite about this, because I know that fetal monitoring has legitimate uses, even though it’s vastly overused. Yet I know it’s not just doctors and nurses who sometimes fixate on a mere artifact – the monitor’s output – rather than on the whole person. Laboring women and their partners sometimes do the same.

The MRI is a further example of medical technology that can supplant the person, substituting a series of images that risks turning the person into an object. One example of this, ironically enough, is that study of sexual objectification that made a splash in the media earlier this month. While I’m fascinated with functional MRI, I also know that fMRI just shows brain activity in certain areas. What that means is still up to interpretation. And if the researchers are reducing their volunteers to mere images and not conducting lengthy interviews with them (only a questionnaire was mentioned in the media reports), then we can confidently saw that the research subjects are being rendered objects.

Does all of this mean medicine is evil and we should reject medical objectification whenever and wherever it occurs? Not at all. I’m in favor of medicine being more evidence-based. As I mentioned at the start, today is Rare Disease Day, and all of those orphan diseases cry out for more research. (My dad has had Crohn’s for 50 years; my husband had an encounter with an obscure but devastating autoimmune neurological disease called MADSAM. My recent brush with the possibility of MS taught me that the unknowns still vastly outweight the knowns, even for such a relatively common disease. So I hope for more research, not less, and I recognize that scientific approaches to medical research will always tilt toward objectification.

But I also favor acknowledging the legacy of unexamined objectification in medicine. We can look at how it operates in specific contexts and weigh whether its costs are worth its benefits. We can analyze the potential of new technologies to fragment and objectify the patient. Simply bringing objectification out of the shadows tends to mitigate its effects: talking about it can make both doctors and patients more aware of it, and this will tend to promote more equal partnerships. And finally, we can hope and lobby for meaningful health-care reform that would limit the power of insurers to dictate that doctors practice medicine in five-minute increments guaranteed to obscure, fragment, and objectify the whole person.

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Caturday, Philip Glass Style

I don’t know how I missed this. Apparently over 12 million viewers have seen Nora the Piano Cat, and yet – despite my 100% Felinity rating – I was totally ignorant of her existence, until now.

Just in case you missed her, too, here’s Nora performing what seems to be an original composition. I’m guessing Philip Glass was one of her formative influences.

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Has anyone else noticed this irony: that a lot of the people who reject well-grounded science (evolutionary theory, climate change, etc.) hold exactly the same stereotypical ideas about gender that pop up repeatedly in evolutionary psychology? Obviously many of the denialists have religious reasons for rejecting sound science, while evolutionary psychologists and sociobiologists are overwhelmingly secularists. Yet they share the idea that men are the pursuers, women the pursued; that men are naturally dominant; that homosexuality is somehow aberrant.

Strange bedfellows, huh? Logically, we can be pretty sure no one working in the field of ev psych or sociobiology believes in creationism. These are disciplines that have spawned some of our most outspoken atheists. Many of these scientists them see their work as progressive, in fact. Many believe their research exposes the roots of human nature, allowing us to mold a kinder, more ethical society. In The Caveman Mystique, Martha McCaughey portrays this impulse as a quasi-religious reformist zeal that arose as practitioners of ev psych and sociobiology moved into the void left by the post-Darwin decline of religion.

To be fair, ev psych and sociobiology often look more regressive than they are because the media skews their findings to match existing gender stereotypes. However, the actual science is still too often rife with speculation and gendered assumptions (as figleaf shows today in a smart post on how these assumptions skew findings). And so it meshes all too easily with the stories that religious fundamentalists tell about our gendered “nature.”

On the flip side, I’d be interested to know if there’s a subset of creationists who also embrace ev psych. Seems to me that the “ev” part of it would be anathema to them. But otherwise the “psych” half would work pretty well for them, if they could only find a way to compress it into the past 6000 years.

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My First Shivering Crocus

Here’s my first lonely crocus of the year. It popped up a day ago, rising above the brown and trodden grass. This morning, it refused to open in the damp grey air. It’s holding out for a few more rays of sun, and I can’t blame it. My daffodils, too, are sending up their first tentative shoots, but they’re still nothing but hope and promise.

And then there are my ornery pansies, under ice ten days ago, now stubbornly trying to bloom. They’re not a thing of beauty, are they? But that’s beside the point. The point is, they’re still here. They persist. Despite sub-zero temperatures.

Just because a metaphor is obvious doesn’t mean it’s any less true.

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Stymied milk-slurping kittehs from I Can Has Cheezburger?

So the Denny’s in Asheville, North Carolina, is just the latest in a long line of businesses where some twit took it upon himself to tell a nursing mama she couldn’t feed her baby where everyone else was dining. Daisy at Daisy’s Dead Air reports on the brouhaha – in which the restaurant manager threatened to call the cops! – and the resulting protest. North Carolina law guarantees the rights of mothers to breastfeed anywhere and anytime, but I guess lactophobia trumps the law.

Among all this absurdity, what jumped out at me is that the manager was going to call the police unless the mother covered herself.

In my experience, the demand for “discretion” while nursing may sound like a compromise, but in fact it’s completely unreasonable.

My two little creatures partook of mama-milk until they were each about ten months old. As newborns, they wiggled a bit while nursing but mostly concentrated at the business at hand. It can’t be easy to drink and breathe at the same time, but they practiced and practiced (oh, did they practice! about every hour and a half! for weeks on end!) until they’d mastered the task and grew large and fat. (Each of them gained about 5 1/2 pounds in their first six to seven weeks. Seriously.) Even as novices, they weren’t exactly inert, but I could usually arrange a blanket around them and not feel too exposed.

And then one day, they discovered that mealtime was for socializing, not just for sustenance. They’d drink a little, and then blop! They’d pop off the nipple, look around, smile, drool, and flirt with everyone in the room. I’d be left with my breast waving at the world, chilly and exposed, until their Royal Babyness deigned to latch on again. If we were in a public place, I could be grateful if a jet of pressurized milk didn’t spray any innocent bystanders.

Now, I’ll admit I never went in for those “nursing” clothes that promise discretion. You know, those goofy, dowdy shirts with flaps and buttons that oh-so-discreetly announce “I’m lactating.” That didn’t matter, though, because once a baby pops off the boob, no flap in the world is gonna hide you.

There are blankets, you say? And the mama can artfully drape her nursing baby in flannel and fleece? My guys saw the mealtime blanket as a fun challenge. Grabbing and wadding up and throwing it probably did wonders to develop their motor and visual skills. But coverage? The net effect of a blanket was probably negative, because if you relied on it, you’d end up flashing even more skin once the kid wrestled it to the ground.

Besides: In order to fully cover your breast, you’ve got to swaddle your baby’s entire head, too. Last I checked, infants need air as much as they need milk.

The standard feminist response to lactophobia is to say that men have issues with naked breasts that aren’t displayed for their express pleasure. There’s surely some truth to that. Prudery and prurience are often two sides of a single coin.

But the other thing about naked lactating breasts is that they bluntly remind us of our animal nature. Mammaries make it impossible to deny that we’re mammals. There’s no way to cover that up when you’ve got a baby at the breast, no matter how uncomfortable it may make some folks.

Update 12 noon, 2-27-09: Vanessa at Feministing alerts us to an example of how these two forms of lactophobia can intersect: Milwaukee hate-radio talk-radio host Mark Belling recently called breastfeeding mothers “sows” on his program, saying, “It’s..it’s what a pig does and it does it in public, right?” Just goes to show that misogyny and disgust at our animality make a happy, harmonious match.

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So here’s what I made for dinner tonight:

That’s, um, aluminum soup on the burner. I’d had a burst of energy and decided to make quiches for dinner – one with artichoke hearts, the other with asparagus. I put the pot on the burner, cranked it up to high, chopped the asparagus, and went to dump it into the pot.

That’s when I saw the pot was empty. I’d neglected to add water. (What was that about my beautiful brain?)

I picked up the pot to rescue it from the heat, and the aluminum soup spilled out in a big glop. The aluminum layer sandwiched between two layers of stainless steel had liquified, expanded, and popped the bottom off the pan.

The blobular aluminum was shiny and pretty, in a perverse way:

Now, the good news is that this stove is 25 years old. It bakes unevenly and I’ve been jonesing for a new one ever since we bought this house nearly seven years ago. I know we could just replace the burner, but maybe this is the nudge I need to do a little research and buy a new range. Any suggestions? Past negotiations on this have always hit a stalemate because I long for a gas stove, while my husband wants something like a ceramic top that’s easy to clean. As you can see, he’s not being unreasonable – not at all.

The other reason I can’t be upset about this is that I’m ecstatic about the surge of energy behind this kitchen fiasco. Yesterday I rode my bike to work and was pretty useless for the rest of the evening. Today I felt strong enough to bike to work again, and I still had enough oomph to embark on cooking a real dinner for just the second time since I fell sick on January 20.

As for the quiches? They were delicious.

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My Beautiful Optic Nerve

I learned two things at OSU’s MS clinic this morning:

1) My optic nerves are beautiful.

2) I almost certainly do not have multiple sclerosis.

I feel like my life was just handed back to me, in its entirety, fresh and new.

(Gratuitous daylily from last July’s garden, just because I am so happy.)

As in Cleveland, I had a wonderful experience with the doctor at OSU. He was smart and kind. He had a great sense of humor. His wife studies the social history of medicine (which is my research field, too); I’d love to have dinner with both of them.

He spent an hour talking with me and performing a neurological exam that involved vibrating tuning forks and the Ministry of Silly Walks. All normal except that my reflexes are a bit exaggerated.

He looked at my brain MRI and told me that I also have a beautiful brain – and that my scan is normal. Normal. Those extra spots? A mystery of nature. He showed me pictures of brains afflicted with MS, and the difference was evident even to me.

I don’t have to go back again unless I have a repeat performance of my symptoms, which the doctor thinks is extremely unlikely. I don’t have to get a spinal tap. I’ll get a repeat MRI sometime six or twelve months from now, just to be safe. That is all.

I feel incredibly lucky. Incredibly blessed.

So what went kaflooey with me? Maybe a virus; maybe the Bactrim after all; maybe something wonky with my thyroid (and I’ll still talk to an endocrinologist about that). As long as I keep getting slowly better, I can live with the mystery.

I may still blog about some of the thoughts I’ve had lately about disability, “passing” as normal, and the relation between body and mind. But I hereby declare an end to blogging about my day-to-day health (unless I get an answer someday, after all).

You can assume, along with me, that I’ll keep getting better, and that I’m wallowing in the amazing good fortune of having a beautiful brain.

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