In which it’s nothing like matryoshka dolls.

My last three months have been mother-and-child heavy, with six weeks of Ob/Gyn and six weeks of Pediatric rotations. Sorry, the positive sides of Ob/Gyn and my time on Pediatrics will have to wait for the next post. Too many words, too many long-brewed ideas.

[sidebar for the prescriptivist in all of us] Lots of people pronounce Ob/Gyn as “oh-bee-gee-why-enn”, as if it were an initialism, rather than a shortening of both obstetrics and gynecology. They also insist on spelling it OBGYN, OB-GYN, and Ob-Gyn. But no one ever pronounces it like the parts of their constituent words, like “obb-gyne”. It’s hard to settle on a middle ground that sits well with me. Do I compromise my morals and pretend with everyone else that OBGYN is an initialism (Ideas: Only Babies, Girls, [and] Your Niece. Ouch, Birth? Get Yourself [to a] Nunnery! Oh, Better Get Your Netherlands…), or pronounce them obb-gyne with integrity and look the fool, or straddle both and win neither with oh-bee-gyne?

I took the third option and got many a bemused double-take. [/sidebar]

I had started out this rotation with my own misgivings about birth, pain, gender roles, systemic injustice, etc. I spent my Gyn weeks meeting patients dealing with the long-term sequellae of childbirth, many decades after all the action was finished. I met a woman, in her mid-seventies, with her uterus prolapsed so far that it peeked out of her body whenever she stood up. I met women who were fecally incontinent in their thirties, and had to wear diapers. I met teenagers, suggested social work consults for them so they could get resources to finish high school while caring for their newborns. Even not getting pregnant — I met a girl, 16, with periods so painful she threw up every month for the first two days, missed school, and was laid up in bed. I met a woman, not yet 20, her body shaking uncontrollably with rigors, sweating and tearing up, gripping her boyfriend’s hand, apologizing for her sounds, as she got an IUD inserted through a cervix that had never had anything pass through it before. “The procedure is not supposed to be that painful,” a male gynecologist told me a week later at an IUD removal, just after he deftly used a tenaculum (look it up, it looks medieval) to pierce through the flesh of his patient’s cervix, holding it in place. I later looked up the research on the IUD — the data gathered about the painfulness of the procedure was collected only on parous women — women who have already passed an entire baby through their cervices. And through it all were so many female apologies — “sorry to bring this up again, but I still have that pain.” “Sorry about moving during the procedure.” “Sorry, it just hurts.” “Sorry, I don’t just want to complain.” “Sorry, this sounds really dramatic.” Because even with all this pain, I had yet to learn in my medical education how much female pain was normal. How much of it should be treated, let alone can be treated. How much pain threshold, age, experience, culture, attitude, shame, expression of pain, stigma, or taboo affected what I ended up hearing as the provider. And at the end of experiencing the pain, reporting the pain, trying treatments with less than perfect efficacy or relief, so many women also have to deal with not being believed: being written off as a hysteric (etymologically from the word for uterus-caused-distress, I kid you not, I love the English language but wow are we children of the devil), as an exaggerator, a complainer, a weakling, a psychosomatic.

When I started on labor and delivery, I kept hearing the word “uncomfortable.” We’d ask a woman coming in, sweat beaded on her upper lip, thirty-nine weeks pregnant, with a torturous waddling gait, “Are you feeling contractions?” “Yes.” “Are they uncomfortable?” “Yes! It really hurts!” Or I’d hear it in the board room, where all the nurses and doctors sat. “Room 7 is very uncomfortable, requests epidural.” “Room 2 says she’s uncomfortable but she’s barely dilated to 2 and is on her phone, so I think she’s alright.” Where was the word pain? Is there a stigma with it? Do we want to shroud childbirth in euphemisms of comfort? For whose sake? For doctors, struggling or grown calloused to the idea of never fully treating patient pain? For women who have yet to give birth, to keep them from being discouraged from, frightened by, averse to the idea? For the mothers themselves, like a thorn by any other name would cut less deeply? For the fathers, to assuage their guilt for not sharing in the trial, or to shelter them once more in their lives from the idea of female suffering?

I still don’t know.

Then there’d be the offhand remarks. “That girl in Room 8 is such a drama queen. She was wincing and squirming and making noise when I put in the Cervidil. Does she know she’s gonna give birth?” “That girl in 5, she wants an epidural ALREADY, she just got in here! She can’t handle the tiniest bit of pain!” “I just cannot tonight with the girl in 3, she read somewhere that the Foley is really painful so she wants Cervidil first. Every single room is full and she wants to take her sweet time getting dilated, doesn’t she?” My own sister works in Labor and Delivery. I had so much respect for the people I worked with there. But there was an undeniable tension and urgency to the place; even at 4 AM, it had an expectant hum. Where was the next emergency to arise? Anything could happen at any minute. And often after years of existing in constant stress, it was hard for the staff to remember that this was possibly the most difficult, harrowing experience of many young women’s lives.

My working theory is that the paradigm of pain as pathology, and medical treatment thereof, is based on the male experience. In a normal male’s life, lasting pain is the body’s indicator of something going wrong: a broken bone, an inflamed appendix, an obstructed bladder, food poisoning, an internal bleed. There is no physiologic pain, or pain that is a sign of good, healthy changes in a body, besides maybe growing pains for some people. Medicine then was made to assess the level of that pain, the source of that pain, aid in its healing and treatment, and alleviate the pain (ideally while the source was also treated).

I think this medical paradigm fails the female body. So many pains of the female body (particularly the reproductive system) are physiologic: menstrual cramping, ovulation pain (Mittelschmerz), breast tenderness/hyperaesthesia, anemia, pregnancy aches and pains and pulls and pinches and punches and kicks, nausea in great rolling quotidian waves, and then, of course, childbirth. Haha wait then there’s recovery from childbirth, nursing (babies bite! Dang!), incontinence, menopause, hot flashes, the list goes on and on. I’ve learned so many conditions of female physiology that are “uncomfortable”, but there are so few treatments for these symptoms, probably due to the fact that the woman’s body is technically doing nothing “wrong”. So many women learn to grit their teeth and bear with it, knowing this too, will pass. There is a season for everything, and this is the season. And the road they travel is paved with health care providers providing “reassurance and close follow-up.”

I still don’t know.

Is the problem that we as a culture are viewing pain the wrong way? In this life, male or female, pain is inevitable. But is suffering truly optional? Is it a matter of our attitude towards pain and the experience of pain? Are we overtreating men, or undertreating women? Are we adequately treating both? Are we inadequately treating both? What if the answer for me is different from the answer for my patient?

These last few months, I’ve been experiencing chronic pain and chronic nausea. Sometimes I try to really live it in the present and work through it to build my pain tolerance. If I’m going to go through it, I might as well become stronger through it, right? I look for the Lord as my Shepherd, holding my hand. I try my best to hide in Him. If that doesn’t work, I try to stay busy and distract myself. But sometimes I just can’t. I writhe in my seat, in my bed. I rage against it. I ask the question we should never ask, “why, God?” I know “fairness” is a construct, but it’s just not fair that I get dealt this particular hand, without answers, with reassurance and a handful of NSAIDs.

What does help is that when I talk about the pain, people believe me. Some days it makes me feel better when people try to brainstorm remedies with me. Other days I’m just too frustrated with everything I’ve tried to try something more. It helps when people stay there in the painful space with me, even if they don’t know what to say. Even if they can’t make it better at all. But they don’t pretend it doesn’t exist, or that it’s not a big deal. They wish they could make it better, and somehow, that does make it better. I’ve been trying to do this for all of my patients who talk about their pain. Maybe the solution for some kinds of pain is the spiritual remedy, the human one: to acknowledge, to walk that mile with the patient, to strengthen the patient to walk many miles more.

At this point in my doctoral gestation, I don’t know anything more than what the books say. But I have a feeling there are many more books to write. And many more voices to be heard that have never been heard before.