Tuesday, October 25, 2011

Modesty, A Woman's Perspective
by Nicole Lee

From their website.  Click on to read.
Nicole Lee is the creative director of Stirrups and Stories.   She has worked in the area of sexual and reproductive health for over five years: taking sexual histories, training others to do the same, working in HIV prevention, and providing quality control for clinic and agency management.

The word “modesty” is loaded with too much emotional and cultural connotative meaning to be a neutral concept.  Who is saying the word, and how, and to whom, and for what purpose?  Is “immodesty,” with all of its attendant frightful connotations, the shadow defining the edges of modesty?

In the context of health care provision, modesty is a double-edged ideal:  on one hand, respecting patient-initiated modesty enhances our ability to serve patients.  Some of the ways we do this include:  acknowledging and responding to the cues our patient gives us about her level of comfort; by asking for permission and consent before touching her; by echoing the language she uses; by avoiding unnecessary, invasive procedures; by acknowledging the legitimacy of her family structure.  We do this by listening – and hearing – what she is saying to us.  By explaining in language she understands why we are asking intrusive questions, and working with her to procure the necessary information.  By respecting a denial of consent and fully honoring the process of informed consent.  By seeking training on cultural competency specific to the populations we see.    

Such a type of respect requires our acknowledgement of the wholeness of the patient in front of us, including the soul and the heart that embraces that modesty.  No longer is she a composite of parts and organs and symptoms, a medical puzzle waiting for construction (or deconstruction):  her embodied self is not our disembodied medical task.  When we as health care workers are respecting a woman’s own sense of modesty, we are helping to make more visible the value system in which she functions.  Significantly, that value system is fundamental to the context in which our palliatives, prevention, and education must succeed, and is a potentially key part in identifying pathogens or risk.

On the other hand, if a health care worker or policymaker enforces modesty, the relationship between patient and provider is inhibited.  Such a dynamic can silence a patient, leaving health care workers without knowledge that may prove vital to providing care for a given woman. 

The enforcement of modesty is rarely overt, but instead typically a thoughtless perpetuation of a set of cultural norms that liken immodesty to being unladylike.  It provides a prescription of acceptable behaviors and appearances for women to assume, and defines the dimensions of space women are allowed to occupy.

Is it immodest and unladylike for a woman to disclose the number of sexual partners she has had?  To choose not to shave any particular body part?  To use abrupt or rough language to describe her experiences?  To talk openly and unashamedly about her partner(s), who may be of the same sex?  To speak of her abortion with sadness and no shame, or with no sadness at all? 

Is it unladylike for a woman to challenge our authority as medical care providers?

Women are faced with a variety of messages that often boil down to one – the feminine ideal is to be a lady, so avoid an immodest exposure of self.

Are our offices spaces where women can expose the necessary parts of themselves without fear of sanction?

If they are not safe because we (or our staff) judge our female patients for not abiding by the standards that we, possibly unconsciously, have for women, it is nearly impossible to conceal.  Our biases are conveyed in a plethora of ways both subtle and overt, including how we ask questions (and which questions we choose not to ask), our body language, our double standards for men and women.

Conversely, by ignoring a woman’s own unique modesty and sensibilities, we are imposing on her an authoritarian message of subservience and disrespect.  Without thinking, we risk telling her that “her body is ours” and that she has given up certain rights merely by seeking health care.  This encourages a retreat from visibility for many women and a reduced ability to successfully communicate with her health care provider.

What and how we communicate, and how we receive information given, can contribute to a woman’s reluctance to seek prevention or cure for any number of health concerns.
By respecting her values and that which she chooses to conceal or protect, we are inviting her to reveal more of herself to us.  In that exposure is the human for whom we are charged with caring, and in this new relationship is the true potential for health and healing.

By refraining from imposing our own values of modesty on our patients, we open up the possibility to clearly see our patient in her own context.  In that exercise of self-awareness and self-restraint, we lay the groundwork for a respectful and deeply therapeutic relationship with her.

The narrow channel between what we subscribe to and what we prescribe for others is a tricky space to navigate, but that is exactly what we must do. 

Wednesday, October 5, 2011

Feathered Boas and Your Dignity

It is our pleasure to introduce Steven Z. Kussin, M.D. to our blog. He is the author of, Doctor, Your Patient Will See You Now: Gaining the Upper Hand in Your Medical Care, (2011) published by Rowman & Littlefield. Dr. Kussin was a practicing physician in New York for more than thirty years. He has published several journal articles, and has taught at Albert Einstein Medical College and Columbia College of Physicians and Surgeons. He has founded The Shared Decision Center, one of the only free standing independent community based Shared Decision Centers in the country. Dr. Kussin blogs at MedicalAdvocate.com.

Feathered Boas and Your Dignity
by Steven Z. Kussin, M.D.

“In war, truth is the first casualty.” (Aeschylus, celebrated Greek dramatist)
“In medical care, dignity is the first casualty.” (Kussin, unknown American physician)
Whether critically ill in the hospital, or fit as a fiddle in a doctor’s office, an individual’s dignity is an issue dear to me because of a memory. The memory of a mentor. Doctors learn from journals and texts. The best of us also learn from mentors. Rivaling only the military, medicine is a highly hierarchical system. When young doctors find a senior physician who has fulfilled the dreams of how we someday wish to be and be seen, they become our mentors. These role models, properly chosen, can influence not only our knowledge but our attitudes. Most doctors will identify only one or two whose impact is so significant, that their lessons are destined to last a life time. One of my mentors left a circle of young physicians in awe of his knowledge and in shock in the wake of his death. We all knew he had cancer and was to die. But to me, it was his treatment near death that left the lasting message.
During his final hospitalization, I entered his room often finding him fully exposed. His gown thrown aside and with sheets askew he lay there for all to see. Dementia had claimed the mind all were in thrall of. I spoke with the staff and his doctors. Could we close the door? Could we pull the drapes? Could we secure his gown beyond his ability to remove it? Apparently not. So, a cadre of his acolytes, including me, guarded him during his final days.
And so it is today. So let’s talk a bit about your dignity, privacy and how it is so casually and gratuitously subtracted from your care. You may need your own night’s Knights Templar when you are stricken. Neither your family nor your doctors should restrain you physically or chemically when you already have enough to deal with. To maintain the dignity you will surely lose, you need what, in my book, I have called ‘Designated Sitters’. Family who are constant and consistently present. To protect your body from soulless comments delivered in your ‘absence’ demands their help.
But how about when you are well? Gowns that are side tied (available at your hospital supply store or on line) prevent the world from regaling in either of your nethers. Better yet, bring your own PJs and robe.
You should demand a private room because they are, well, private. Privacy is where dignity starts. Privacy increases the quality of your consultations. The bonus is the possibility of entering your doctors’ circle of empathy. Your doctors would prefer death to a semi-private room. When you are bivouacked in a private room, your domain becomes bespoke. Fill it with photos of you when you were your doctors’ age and litter the room with upscale magazines. Architectural Digest or even the Robb Report comes to mind. Let them see themselves in you. Being stared at, jaw agape, by your providers, let alone the ten year old guest of your roommate just adds to your woes.
And the physical examination? Enter the pictured feathered boas. How can it be when physical examinations are almost a relic of the past you nonetheless find yourself with your sundry body parts needlessly defying gravity, dangling in front of your providers? Breasts, gonads and penises swinging free for all to see. Well it’s precisely because physical exams are a lost art that you get to show your parts. Back in the day, boa dancers could remain fully demure even when they had nothing but diaphanous throws to throw about their bodies. The art of using examination sheets as skillfully as boas is a rarely used remnant of a lost medical culture. Moving these drapes down the torso artfully and gracefully leaves nothing unseen, while paradoxically, leaving nothing revealed.
“Strip to your underwear. Leave your socks on.”
Why, is there something wrong with my feet? And I refer to both the modern and biblical use of the word feet. Cotton gowns that are clean only by inference and as threadbare as dishrags do you no service. Paper contrivances that, when you sit, bend or recline, ride up and down like a roller coaster prevent any attempt at preserving your status much less hiding your quo.
What to do? What to say?
“Doctor, right at this moment, if I was examining you I’d make sure I’d be seeing a lot less of you than you are seeing of me. Can you spare a drape? Thanks.”
It’s kind of funny, kind of pointed and kind of you too. Let the doctor know that you are being dissed and dismissed by being needlessly and carelessly revealed.
Will you say that? Wait, you’ll find out the next time it happens. When is your next appointment?