Monday, April 25, 2016

"Chatty Cathy" and ADD: How Gender Expectations Influence the Diagnosis and Treatment of American Girls

We’ve spent a lot of time this semester teasing out the differences between how men and women are understood, and how that relates to the legal profession and society at large. A theme that keeps re-emerging is objectivity – whether it exists, how it is used by the patriarchy, and whether it is simply an idea that is used to silence “emotional women.” The subtle and persistent idea that women’s intelligence is suspect because it will be side-tracked by their unpredictable emotions plays out in the workplace and in interpersonal relationships. Recently, I was surprised to see it also crop up in another area – identification, diagnosis and treatment of Attention Deficit Disorder (ADD).

Could the fact that men are expected to be objective, focused and level-headed lead to a more quick diagnosis of a man who does not conform to that expectation? Can we expect that women who are disorganized and inattentive are more likely to be shrugged off as emotional, hormonal or sensitive? Is it possible that our societal expectations of women’s emotional instability leads to less empathy for women who struggle, and less narrative directed towards legitimate psychological conditions shared by both genders? There is evidence that suggests the answer to all of these questions, currently, is yes.

A few months ago, a friend sent me an article about under-diagnosis of ADD in women. While women are just as likely to suffer from ADD as men, they are much less likely to be diagnosed and receive treatment. Instead, women are more likely to be diagnosed with depression or anxiety, other psychiatric illnesses that can result from untreated ADD. The article explained part of the reason for the under-diagnosis:

“Girls with ADD tend to try harder than their male counterparts to compensate for and cover up symptoms. To keep up their grades, girls are often more willing to put in extra hours of studying and to ask their parents for help. In addition, girls are more likely to be “people pleasers” doing all they can to fit in – even when they know they are ‘different.’”

When ADHD was first identified, it was diagnosed in young, white boys who were hyperactive. Guidelines for identifying ADD and ADHD were geared towards these boys, leaving girls overlooked. Because teachers are often asked to identify children with ADD or ADHD, the common perception that it is a young boy’s problem leads to under-diagnosis. In her book Understanding Girls with AD/HD, Dr. Ellen Littman explains that ADHD can display much differently in girls and women – carelessness, disorganization and difficulty following instructions are more likely indicators than hyperactivity. 

Dr. Littman believes that girls with undiagnosed ADD/ADHD may “internalize their symptoms – disorganization or carelessness - as personal flaws rather than medical issues.” Self-esteem and even academic challenge brought on by struggling with undiagnosed ADD can often lead to anxiety and depression. These are more stereotypically expected to be women’s issues, and therefore may be more readily diagnosed, but may be masking a deeper struggle. (In fact, womenare twice as likely as men to be diagnosed with generalized anxiety disorder).

Situations like this gender difference in diagnosis of ADD reinforce the idea of a subtle patriarchal structure that impacts women in unexpected ways. Sure, it could be easier to diagnose a hyperactive boy than a “chatty” girl, but could that partially be attributed to our gender expectations? If we expect women to struggle with emotions more than men, we are less likely to legitimize conditions manifesting symptoms that fit gender stereotypes. Perhaps increasing education about psychology, mental illness and the human brain can ultimately impact society’s expectations for women in all aspects of their lives. 

"Feminine Products".

No, that title is not a typo. It comes from a real sign that I came across in a unisex bathroom at a winery this weekend in Amador County:

This sign was in addition to another one warning patrons not to flush said “feminine products” but instead to deposit them in the appropriately labeled receptacle. While the flush versus not-to-flush debate can be saved for another day, it takes a special level of condescension to see these signs posted over and over and over again. Women get it. I would hazard a guess that most women understand how plumbing works better than most men posting these signs understand women’s biology.

And that’s where the heart of the problem lies. As the incomparable Amy Schumer so perfectly pilloried last week on her show in the well-worth watching Dr. Congress skit, many men react to any mention of the “lady curse” with an automatic “ew.”

Much like Sonja discussed last week in her post on the medical profession’s relative inattention to heart attack risks for women, the level of national conversation on women’s health issues has a very different tone than other health issues – especially when it comes to menstruation.

This is slowly changing. Pop culture is beginning to embrace the fact that this is a natural occurrence on a roughly monthly basis for half of the population. Broad City has had not one, but two straight episodes dealing with menstruation (the genius use of “period pants” to avoid being searched for drugs at the airport, and then an epic search for a tampon on the subsequent international flight).

Kiran Ghandi, a drummer for MIA and a Harvard MBA student, ran last year’s London Marathon while on her period without a tampon. She proudly proclaimed her intent to highlight period-shaming and to raise awareness for the millions of women who do not have access to tampons and other basic necessities. The Internet being what it is, reaction was mixed – but there was a tremendous out-cry of support and solidarity that largely overwhelmed the negative reactions. Kiran put it perfectly when she defended her decision from the critics who labeled her “disgusting”: “You see, culture is happy to speak about and objectify the parts of the body that can be sexually consumed by others. But the moment we talk about something that is not for the enjoyment of others, like a period, everyone becomes deeply uncomfortable... Women's bodies don't exist for public consumption.”

I am optimistic that feminist heroes like Kiran Ghandi, Amy Schumer, and Broad City’s Ilana Glazer and Abbi Jacobson will continue to push the national conversation on women’s health into a more body-positive direction. Here’s hoping that this will also result in fewer condescending signs telling women what to do with our “feminine products.”

Sunday, April 24, 2016

Undiagnosed and under-treated: how medical professionals misunderstand women's pain

We’ve got a Janus-​faced relationship to female pain. We’re attracted to it and revolted by it; proud and ashamed of it. So we’ve developed a post-​wounded voice, a stance of numbness or crutch of sarcasm that implies pain without claiming it, that seems to stave off certain accusations it can see on the horizon—melodrama, triviality, wallowing—​and an ethical and aesthetic commandment: Don’t valorize suffering women. Leslie Jamison.
I have recently fallen into a stress-induced, Netflix-encouraged, Nurse Jackie-shaped hole. The show is enjoyable for a number of reasons beyond its distracting qualities, but my favorite parts of the show are the numerous, dynamic and multi-faceted female characters. The show more-than passes the Bechdel test and tackles complicated issues from addiction, to mental health, to sexism. A recent episode made me think critically about how women are frequently misdiagnosed and mistreated by their medical professionals.

In the episode, a woman comes into the emergency room after an argument with her girlfriend. The woman states that she thinks she has a stress-induced stomachache. When Jackie asks where the pain is, the woman points to her solar plexus. Jackie then calmly explains that the woman most likely suffered a heart attack. The patient and her girlfriend were shocked by this news. Later in the episode, a doctor confirms the diagnosis and tells Jackie, “good catch.” I couldn’t help but think that diagnosing a woman’s heart attack shouldn’t be a good catch it should be routine medical treatment. Unfortunately, it isn’t.

According to an Atlantic article titled Why Doctors Still Misunderstand Heart Disease in Women, every year thousands of women in the United States are misdiagnosed, often with fatal consequences. This statistic is especially alarming given that heart disease is the number-one cause of women’s death in the U.S.

There are several reasons for these misdiagnoses – historically heart disease was considered a men’s disease and women were omitted from textbooks and curriculum. Two of the major ground-breaking studies about heart disease involved tens of thousands of male participants and no women. Moreover, heart disease symptoms can vary by gender. When Evan Woods lost his grandmother to heart disease after her heart attack went undetected, he was told that her symptoms were unusual. His response, “how can they be unusual, when it is more than half the population?”

Woods’s question gets to the heart of the matter – why is women’s healthcare considered a niche issue when women are more than half the population?

When Joe Fassler’s wife rushed to the ER with an ovarian torsion (a literal twisted ovary), she had to wait between 90 minutes and two hours to be admitted. When a doctor finally saw her after several hours, it was too late to surgically fix the torsion and her ovary had to be removed. Fassler’s article, How Doctors Take Women’s Pain Less Seriously, chronicles his wife’s experience and how “female pain might be perceived as constructed or exaggerated.” While men and women report different levels of pain, they are also treated disparately in the pain management they receive.

Diane Hoffmann, Associate Dean and Professor at the University of Maryland School of Law, and Anita K. Tarzian, researched bias against women in the treatment of pain in their article The Girl Who Cried Pain. The authors found that “women are more likely to be treated less aggressively in their initial encounters with the health-care system until they ‘prove that they are as sick as male patients.’”

The authors also found that there are gender-based biases regarding how women experience pain.
Women’s pain tends to be viewed as more emotionally based and thus less credible — or, likewise, less credible if indeed it is emotionally based. Men’s pain is more likely to be acknowledged strictly as a physical symptom, thus reinforcing the societal expectation that men suppress their emotions, even if it impedes their pain treatment and recovery.
Biases in how women experience pain are not surprising in a society where women, in general, are perceived as the “weaker” sex.

Yet bias is not only shown in how pain is perceived, but also in the medical necessity of treatment at all. Even with strictly female medical procedures, like abortion, our society tends to flaunt it as a political battle rather than a necessary women’s medical service, as demonstrated by current SCOTUS discussions.

Healthcare bias against women in all medical services needs to be addressed, so that women are receiving adequate healthcare and pain management. Women need to be able to express pain and not be shamed for it; we need to know that we are heard and that our wounds will be treated as valid and just as serious as those of a man.

Tuesday, April 19, 2016

The fight for "space" and open discussion

I haven’t been able to shake off a NYTimes article titled, “Why Donald Trump has done worse in mostly white states.” The answer to the title’s question is that Trump does best in high diversity areas. Given Trump’s blatantly racist rhetoric, this might come as a surprise. But the explanation is simple, although perverse. Trump appeals to those “who feel a resentment toward racial, ethnic and religious ‘others.’” As the author notes, “An appeal to white identity tends to work better in areas where that identity is felt to be under threat.” Trump’s racist and sexist rallying cry serves as “an authoritarian voice of the voiceless.”

The notion that racism flourishes in areas of greater diversity is disturbing. I’d hope that, if anything, the opposite would be true. But the reason I can’t shake off the article is because it also indicates some other level of failing—failure to create an environment where people forced to confront their prejudice actually resolve to become more tolerant, rather than becoming more entrenched in hateful beliefs.

In the presence of white patriarchy, it’s hard to stomach the idea that white men are voiceless. Whether or not white men actually are is not the subject of this post. And let me make clear, I think we have to confront prejudicial beliefs head on. But how we do so, and how we have done so, is up for discussion. By bringing everyone into the serious conversations we’re having about things like race, gender, and class, we might better address prejudice rather than push alienated groups toward further extremes.

A breakdown in communication is at least partially responsible for the current wave of extremism we’re experiencing—a breakdown recently experienced at Harvard Law. According to one Harvard Law student, a recent campus protest involved putting up posters around Harvard as a way to reclaim public space. This tactic of occupying physical space, in recent years popularized by the Occupy movement, is a way for marginalized groups to engage the public and make their voice heard. According to the Harvard Law student, this protest devolved into a poster tear-down contest between Reclaim Harvard Law students and a conservative student group. Although each group had a different set of priorities (you can find Reclaim Harvard’s demands here), each was also fighting for a place to be heard. One Harvard law student observed:

It is disturbing to see one of our neighbors videotaping another one so as to provide clickbait for his political tribe’s media outlets. The events of the last two days may have created new heroes and villains, may have scored a few points for a few folks within their respective filter bubbles, and may have made most of us — and the distant readers reading about us — angry. But what these events did not do was build understanding. This is a shame, because if we are to build a moral community together, we must work to understand each other.

These fights for physical space stem from frustrations with entrenched racism and patriarchy that have silenced people for far too long. But what we sometimes fail to openly acknowledge is that these fights for space are also waged by newly alienated people facing challenges to the traditional power structure. Look no further than to the success of Donald Trump’s (racist and sexist) rhetoric in more racially diverse areas.

At Harvard, a well-intentioned movement became mired in catching students in a bad act, as opposed to fostering an environment where people could talk about racism and find ways to combat it. All over the country, public discourse often devolves into a back-and-forth, tit-for-tat, he said-she said display that ignores content and focuses on shaming and spectacle. This squeezes out space for discussion that might move an issue forward and causes people to dig their heels in further.

While many—probably most—prejudicial acts go uncorrected, other statements are publicly singled out as bigoted, not to force the person to acknowledge their own prejudice, but rather to enjoy the subsequent public shaming. While I’m not trying to be an apologist for those who hold or act on bigoted beliefs, I do recognize that many thoughtful people have been shot down for well-intentioned statements (sometimes taken out of context), or have chosen to say nothing at all—and neither of these scenarios provide any benefit to combating prejudice.

What’s missing from this picture is empathy. To facilitate better conversations about prejudice, we must recognize that people aren’t born with prejudice. Prejudice is a cultural byproduct. Racist or sexist beliefs stem from certain places, communities, and experiences. Recognizing the societal root of these ills should inspire a sense of empathy in addressing people who hold such beliefs—rather than disdain, exclusively.

I may be more amenable to calls for empathy given my white privilege. But my empathy also stems from growing up in a culturally conservative area where most people openly held intolerant beliefs. I realize that I didn’t develop a more tolerant outlook because I was born with a bigger heart. I developed values of tolerance because I was fortunate to have parents and friends who encouraged tolerance and questioned prejudice. Much like current calls to recognize crime as the product of systemic problems and one’s life circumstances, so too should we recognize that intolerance also stems from one’s surroundings. Prejudice isn’t just a symptom of “bad people,” it’s a symptom of societal failings.

At some point during an open conversation about racism or sexism, or any other systemic prejudice, someone will say the wrong thing. If we want people to change, we have to accept that the process of change exposes some problematic beliefs—the exact beliefs we're hoping to confront and transform. If we don’t create a space to work out these issues, they’ll continue festering in the dark. No person, and no cause, benefits from that.

Monday, April 18, 2016

How NOT to Write Female Characters: Reflections on the “Manic Pixie Dream Girl” Trope

As I’ve argued in previous blog posts and in class, representation in pop culture and media are pivotal to how society understands the dynamics among people and institutions. Although people seriously underestimate the value of what they write off as merely “entertainment,” those social dynamics manifest themselves in the law and how we treat one another.

Every few months, sometimes for no particular reason, I get a seething rage about the Manic Pixie Dream Girl trope (shortened to “MPDG” in some instances for the purposes of this blog post). As this article from The Atlantic discusses, the term has made its way to the Oxford Dictionary, with the definition as follows:
“manic pixie dream girl (noun): (especially in film) a type of female character depicted as vivacious and appealingly quirky, whose main purpose within the narrative is to inspire a greater appreciation for life in a male protagonist”
The annoying crux of this trope is that the female character, however interesting she may be, functions primarily to serve the male protagonist’s development arc.

(See also, the “Women in Refrigerators” and “Manpain” tropes)

As the article by The Atlantic suggests, one of the most popular examples of this trope is Natalie Portman’s character in "Garden State." Portman’s reflections on her role suggest that a female character being “interesting” is one thing, but a female character existing within the narrative for her own purpose is an entirely different matter.

One of the more specific reawakenings of my MPDG rage stemmed from the movie version of “Scott Pilgrim v. The World,” wherein the female character Ramona Flowers seems more like a prize to be won by the male protagonist, rather than a badass in her own right. As this review suggests, a lot of the MPDG problems stemmed from adapting this story from comic to screen, as the comics involved more backstory for Ramona Flowers that would have otherwise saved her from MPDG status had they been transferred over to the film version. Whether or not we accept the difficulty of transferring mediums as an excuse for how female characters are written is a hotly debated topic in itself (I personally find the excuse to be lazy and such adaptations to be sloppy).

There is a broader social critique invoked in the criticism of this trope. Sure, we’ve come a long way from Blackstone’s “doctrine of coverture” days, wherein women were legally and socially subordinated to men. However, ideas associated with the MPDG trope remind us that American society at large is a far cry away from acknowledging the autonomy and personhood of women. The MPDG trope is so criticized, specifically because female characters appear solely for the development of the male characters. If the female characters are largely portrayed for nothing more than their use to men, how will real life men view real life women? The persistent issue is that real women in real life continue to be objectified by men and valued only for how they make men feel. Men continue to assert the entitlement to control women’s bodies and destinies (highlighted in areas of law such as reproductive justice, domestic violence, and rape). The MPDG trope perpetuates this mode of thinking.

The lengthy public debate about the meaning and validity of "Manic Pixie Dream Girl" as a term is precisely the kind of conversation that we need to have to question social consciousness about different issues. As the cited articles suggest, in an atmosphere where the Manic Pixie Dream Girl trope is thoroughly discussed, such a trope becomes known and identifiable to the point that writers will have to work harder to avoid clich├ęs. Put simply, this awareness puts the pressure on writers to write female characters with the complexity that rings true to that of their female counterparts in reality.

Undoubtedly, there is a lot of work to be done in this area. Male writers continue to dominate film and television, so the accurate depiction of popular culture is largely left to men trying to convey an experience that they don’t live. Out of this process, getting a well-written female character can be hit-or-miss, but that’s why it’s important to keep the pressure on the industry and the people in charge of telling these stories. We need more women in position of power, more women writers and directors, more women everywhere and anywhere. We need to keep the pressure on male writers to write the kinds of female characters that we see in reality: the powerful, the strong, the weak, the conflicted, the complex, existing on their own terms and for their own purposes and no one else’s.

Friday, April 15, 2016

Reproductive justice, birth justice, and criminal justice

With the help of a recent grant, the University of California, San Francisco collaborated with the Birth Justice Project and Black Women Birthing Justice Collective to form a new nonprofit, the East Bay Community Birth Support Project.

In 2011, UCSF students began providing doula support for pregnant women in the San Francisco County jail through the Birth Justice Project. A doula is an experienced and trained professional who provides continuous emotional and physical support to a mother before, during, and after a birth. Doulas are also able to provide emotional and practical support during a mother's postpartum period. Additionally, birthing communities have shown an increased amount of support for abortion doulas. An abortion doula also provides emotional, physical, and informational support to a pregnant woman, however they support the woman through the process of having an abortion and after the abortion. (For an interesting read on abortion doulas, see My Year as an Abortion Doula).

Through the Birth Justice Project, doulas are able to provide support and companionship to women giving birth at San Fransisco General, the public hospital that treats women from San Francisco County jail. Because of safety concerns and regulations, when incarcerated women go to the hospital to give birth they aren't able to have friends or family visit for more than one hour. Doulas are able to provide consistent companionship and support throughout a labor. Nicole Sata, a co-founder of the Birth Justice Project, said her goal is to provide "loving, respectful and empowered birth and postpartum support to women at San Francisco's jail."

With the help of a 2014 grant from Alameda County's Innovations in Reentry, the East Bay Community Birth Support Project was able to expand their doula services to Santa Rita jail and begin a doula training program for formerly incarcerated women. Innovations in Reentry grants help to support projects that reduce recidivism in Alameda County. By offering doula training programs, the Easy Bay Community Birth Support Project hopes to ease women back into their communities upon release from jail, while also fostering strong relationships with their new babies. Additionally, the women will have a supportive space within the doula community when they are released.

The program in its entirety is a poster child for the reproductive justice movement. Not only does it focus on the intersection of both birth justice and criminal justice, but the program places women of color in positions of power within their own communities.

To date, sixteen women have gone through the doula training program and not one has returned to jail. The program's goal to "give them the skills and self-esteem necessary to earn a living and, if they chose, to further their education and purse other careers, including health care" appears to be successful. The doulas have supported over 60 births and as awareness of the program grows, the demand for their services throughout the Bay Area is ever-increasing.