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Volume 13, Number 3

ON CARING
Sexuality, the Patient, and the Doctor

Ghislain Devroede, MD

On January 29, 1997, Le Devoir noted that in Egypt some people have mounted a crusade against a dance-the macarena-that President Clinton danced after his re-election. They believe it is linked to a cult of the devil. Nil novo sub sole, or "nothing new under the sun." Five hundred years ago, the Inquisition was also chasing the devil in all his manifestations. However, the real reason for the Inquisition was probably sex or, better said, fear of sex.

Humanity has had a hard time separating sexuality from procreation. All religions have devised codes of ethics that at times are highly invasive of the person. During the Islamic fast of Ramadan, the faithful cannot have intercourse during daytime. Beyond that, social control of population growth was desirable "for the glory of God." However the French philosopher Luc Ferry notes that today men and women vacillate between the humanization of God and the divinization of Man.

When life expectancy was brief, men and women barely had time to reproduce themselves. Thus, the main purpose of sexuality was to procreate, and natural impulses were uninhibited largely through the fear of handicapping function. Initially, no taboos against incest existed because the population was small and there was no concern about the concentration of undesirable recessive genes. Progress occurred when the landlord decided to sell his right to bed any bride in his fiefdom on her wedding night.

When the pill became available, women finally had the chance to behave like men. Today, La casa chica (the house of the mistress and her offspring) is still a national institution in Mexico. It was present everywhere in Europe 50 years ago. However, religion played a role, as the phrase, "And the word became flesh" (that is, the incarnation of love) illustrates. In an attempt to promote love, these forces refrained from sex and tried in vain to control it. The less permissive a society, the more perverse it was also, especially when groups of women and men were reserved for sexual use without love. If a man had two women in his life, he had a very prudish relationship with one, whose destiny it was to rule the house and raise children, and with the other he had a much more intensively sexual relationship. Thanks to the pill and other means of contraception, women can now also have two separate lives. My old mother of 82 often says that there are many mates, but few couples around. In her view (which I share), these couples are in equilibrium and share an incarnated love. Spirituality cut off from sexuality is a flight away from life, and conversely sexuality cut off from spirituality is mere "genitality." More and more women seem to consume sex as if it was a market commodity. Yet, throughout this first sexual revolution and through the feminist gains of equality, humankind is evolving, albeit slowly, from having sex to making love.

To contemplate love, one must remember this evolution of sexuality because one can not separate today's behaviour from that of the past. I have in mind two issues in this essay: the doctor-patient sexual relationship, and the presence of sexual abuse in the past history of patients. The two go together; they echo one another.

No equality exists in a doctor-patient relationship unless the patient, well and satisfied, dismisses the doctor for good. This is better than the reverse. Yet because of the power of transferential links, neurotic elements may persist even after the patient has left. Many people do not know what transference is. The image I use with students and patients alike is this: "When we are two, we are not two, but six." I project my parents on you, and you project your parents on me. If we have a perfect, quasi-mystical relationship, there is just you and me. If we have a lousy relationship, we are not there at all. Most cases are somewhere in between. As long as the two partners are not separate and equal, love viewed broadly, is virtually impossible between a patient and a doctor, particularly if a sexual component exists. Puritan and Anglo-Saxon elements have begun to react against the mixing of sexuality and caring, particularly in North American society. At times, the rules which govern interactions between doctors and patients have almost created "witch hunts." This is because on this continent, much more than in the Latin countries of the Old World, women are at war with men, but exert powerful emotional pressure at the same time. Of course, even today many women are still oppressed financially, emotionally, and sexually. And the war goes both ways. However, we should stop this war. The rules that currently govern the doctor-patient relationship make no distinction between rape, emotional blackmail, and acting out in the relationship. True, any of these actions would be wrong and deleterious. But the system should not encourage irresponsibility. Raping, or blackmailing a patient to have sex, is not the same thing as falling in love with the seductive patient who is desperately trying to seduce the doctor to recover from sexual abuse. Such behaviour indicates that the physician is weak emotionally and insecure sexually. Yet, in this society nurtured on the promise of mistake-proof warranties, doctors are expected to be perfect even though they grew up in the same sort of families as their patients. We all know doctors are not perfect, and passing medical students on the basis of high marks provides no guarantee that they will be strong emotionally. If the students are particularly obsessive, they may even score the best marks, yet be perfectly cold with their patients. Beware if they open up! To the watchdogs of propriety I say, "A little compassion for all is in order, and lots of education."

At the same time, we know how prevalent sexual abuse is in the past history of many patients who consult us. For instance, reliable studies have shown that 50% of women with irritable bowel syndrome have been abused, mainly in their youth. This is true in North Carolina, in Minnesota, in California, and in Quebec. Ten years ago when I was lecturing on this subject in Paris, a French professor explained the situation by saying, "It is too cold in Quebec and winters are too long." Ten years later, with more data collected, another professor in France jokingly said that we were perverted in North America. Fortunately, he did his own study and was honest-France is no better. Although a history of abuse is often part of a hidden agenda, 90% of the treating physicians remain quite unaware of this occult drama. Of course, they are also unaware that predating and underlying much abuse are major gender-identity conflicts. This confusion has important practical consequences as these patients unnecessarily consume a large volume of health resources. Worse, they have a lot of unnecessary operations, such as negative laparoscopies and laparotomies, normal appendectomies, and castrating procedures such as ovariectomy and hysterectomy. At times, it is like a bad psychodrama in which the surgical procedure is a feeble attempt to imitate the sexual trauma.

Finally, although doctors are now being asked to be human and not cold-hearted, they are also asked to be careful about touching their patients. I recently read in a Canadian medical journal that one had to be careful in shaking hands with the patient! Can you imagine a doctor who is so insecure sexually that shaking hands becomes dangerous for the patient, presumably because of the doctor's projection? Such a physician will not only be cold-hearted, but will also miss vital scientific observations about the temperature of the hand shaken, its degree of humidity, the duration of contact, its strength, the associated symptoms, and changes in these indicators after the doctor-patient encounter. Of course, if a doctor shakes hands and expresses interest and a caring attitude toward a patient who has been sexually abused and is trying to recover, this couple is at risk of "an acting out." Indeed, a doctor who has a high sense of ethics and morality, which is merely learned intellectually and is not a part of his real "self," could therefore be easily aroused sexually by shaking hands, but censor this unacceptable behaviour and say that shaking hands is dangerous.

In the last issue I wrote about love in general. This time, I have focused on sex. Much sexual intercourse is like mutual masturbation and has nothing to do with making love. Doctors need a lot of education in this regard. Patients too. Here, a little indulgence and much compassion is required. The act of punishing physicians who are guilty of sexual misconduct will definitely prevent episodes of acting out and rapes. But this is also likely to scare off many potentially good doctors, even if they were never guilty of any such misconduct. An undesirable side effect is that many physicians are likely to brace themselves and strengthen their protective shields. Therefore, patients are likely to be frustrated, and abused patients will not recover without warmth and love.

Correspondence and reprint requests: Ghislain Devroede, Centre universitaire de sante de l'Estrie, Pavilion Fleurimont, Département de chirurgie, 3001-12e Avenue Nord, Fleurimont, Quebec J1H 5N4, Canada.

Meditation

If a man speaks in the forest and no woman is there to hear him, is he still wrong?