In Stirrups, Silences, and Cells
Undressed from the waist down, she lay on the examination table, shimmying her backside up and down the upholstery until her feet fit snugly into the stirrups. She had been having pap tests regularly for years, and her body remembered how to glide and adjust her limbs into a position for the doctor to be able to explore her female outsides and insides. Alone in the room, she turned her head to look out of the window at the trees and mountain and sky that lay beyond.
“I wonder what this doctor will be like,” she mused. The last doctor who examined her in this way had doubled as her general practitioner and HIV specialist. She remembered her first visit to see him. He had entered the room saying, “Oh! I thought you would be Haitian, given your name and the type of HIV you have.” She met his surprise with her own: she had not thought very much, if at all, about the precise sort of infection she had picked up along the way. At her last check-up with him, which was to be her final, she remembered his comment “vaginas are not really my thing,” which he had joked about to explain why, in his view, women could feel comfortable with him examining them intimately. She had felt disappointed, and outside of what was perhaps an inside sort of joke. She changed HIV physicians, only to learn that from then on she would have to see a specialist gynecologist for pap tests. And in trading one doctor for two, she had ushered in more patient work for herself.
As she searched for something to fix her gaze on, the new doctor entered, greeting her cheerily. He asked quick questions about her sexual and reproductive history, and then, after manually cranking the table into position, he traded his ballpoint pen for metal tools coated in plastic and got to work: poking organs, scraping flesh, and removing tissue. She wondered how the instruments were managing among what were surely sinewy snags of skin and a messy maze of muscles inside her.
Pushing back from the table, coming out from beneath the paper canopy draping her legs, he said, “Everything seems all right. I will send the swabs to the lab for testing.” She thanked him and he turned away to take notes at his desk. She dressed.
With his back still to her, he asked what she did for a living. She liked this sort of banter with her doctors because it diverted the focus from medical terminology that tended to obscure what was going on in her body. “I work in community services, and I interact with immigrant and refugee women with HIV infection,” she said. He turned to face her, interested, and sitting down behind his desk, they began to discuss their work with women with HIV.
“It always surprises me that, when I ask women patients how they were infected with HIV, they do not seem to want to tell me,” he said.
“What does their hesitation, or reticence, look like, exactly?” she asked.
“Well, they commonly look down, or out the window. They might mumble. They might stay silent, not answering. I don’t know why they don’t just tell me, straight, but they rarely do.”
She listened and watched his gesturing hands. In the soundless space that hung between his thoughts and hers, she reflected. In truth, she was surprised that he could be surprised at women’s silences. After all, he was an older man bearing a surname that rang Gaelic to her ears. The women had family names that marked them as descendants of everywhere in the world except Western Europe. He was but the most occasional of figures in their lives. He was a chief inspector: recording and reporting on the unseen-to-them places that might well have been the same chasms and creases through which the virus snuck in, turning their blood from good to bad for all times.
“When we are with our doctors, we might have nothing to say. We might have a great deal to say. We might not want to say anything,” she thought. Silence, in her experience, is often a deliberate way to communicate. These pauses offer opportunities to consider the ill person’s quiet as action, matters of choice. What happens when we focus attention on non-verbal moments? What does this demand of us as a listener and also as an observer, especially when stakes are high, or the setting is implicitly or overtly adversarial? Power relations organize what we do, and their consequences are real, but they need not be total.
“And yet, withholding or deciding on silence is not the same thing as lying,” she said.
As a patient, she had seen doctors aghast that people in their care would, as they understood it, lie. Ironically, they seemed unaware of how they might shape their patients’ responses. A white lab coat and a nametag noting a professional pedigree are not neutral signifiers; they reinforce social difference between doctor and patient. It is hardly perplexing that conversation about leisure time pursuits and vacations in foreign countries and summer cottages are met with pregnant silence. These are not topics that people with limited spare time, who often lose wages during visits to the doctor, discuss. Where doctor and patient tread on the ground matters, since this place shapes how they relate to one another. The working poor, people without wages, and individuals receiving social assistance lack the luxury to read this foreign alphabet or speak this foreign tongue.
“How did you get HIV?” he asked.
“Why do you want to know?” she replied.
“Well, knowing this helps me understand, or gives me clues about, a woman’s life outside the clinic.”
“While I am not against telling you, I will do so knowing that you don’t actually need to know this about me to do what you need to do as my gynecologist.”
She was an experienced patient. She had heard this type of reasoning before from doctors. Doctors and others in healthcare are not entitled prima facie to know everything about a woman’s biography, including details of her intimate existence. Whether and how she shares details is up to her. Our life stories belong to us.
In the stillness of the office, she looked at him looking back at her. He was anticipating her next statement. Meanwhile, she was thinking about what she wanted her doctor to hear. His need to know, she knew, was code for wanting to take charge medically.
At this moment, she was all too aware of being at once a woman living with chronic illness and a carer to women, some of whom were colleagues and friends, experiencing this same illness. The so-called objective world was merging with the subjective.
Again she looked out of the window, beyond the institution, to see nature’s greens, blues, and greys. From what was now a sitting position on the examining table, she caught sight of the tiled roofline of the medical school, a short distance away.
A short time before, she had been invited to give a guest lecture to doctors, nurses and social workers-in-training. She had been happy for the opportunity. Hundreds of students looked at her as she stared into the dimly lit auditorium. She had prepared a talk that invited them to think about how law and medicine overlap. It was a topic she had anticipated would hold their attention, and she was right.
She wanted to bring the session to life through an experience that they could carry with them through their professional careers. She opted to show them a video-recorded interview with a colleague with HIV.
In the video, her colleague described her formative years and education, characterized by social privilege. She discussed a career in humanitarian assistance that took her to half a dozen countries. She talked about how the law in one country where she was working demanded annual mandatory HIV testing for foreigners renewing their visas. She told of being terminated—and then deported—when she was diagnosed with HIV. She was escorted out of the office by police, handcuffed, and brought to jail. She was then confined in a series of solitary cells in several countries. It was two weeks before she was able to reunite with her family.
Her colleague looked directly into the computer’s camera, and held the health workers-in-training in her sharp gaze. She asked them to acknowledge that she was more similar than dissimilar to them. She urged them to think about how their future work might involve the justice and law enforcement systems. She encouraged them to respect people with HIV, and recognize that they live complex lives under heavy surveillance by justice, law enforcement, and medical systems.
The health workers-in-training sat still and listened attentively to her colleague’s video; she watched them watching the screen. Their silence continued after the video was turned off. She organized her thoughts, jotting down ideas about possible questions.
She doubts that any prior planning would have prepared her for the lead question.
“Right, okay, but just how was she infected by HIV?”
More than a few students wanted to know the answer. She fell into silence at the podium, unable to say anything. The details of the story they had just heard were harrowing. The human suffering was significant. The institutional encounters were excruciating. The affective costs had long-term effects for her colleague, as she knew. All of this had been on raw display. But what mattered to the students were details of intimate life and sexual history.
Her attention returned to the gynecologist and their conversation. And when she resumed speaking, she did so slowly. She had decided to use the moment to educate.
“What if you walked into an examination with the idea that the world beyond a woman’s body, all of our bodies, is the ‘thing’ that is problematic?” she asked.
“I mean, since caring practices are set within society, we cannot misstep by assigning individual responsibility for what are actually socially produced and sustained ills.”
He nodded his head, continuing to listen. She paused and took a breath before suggesting that he endeavour to talk to women not in the angular vernacular of medicine, or with an infection-infused agenda, but rather,
“Be curious about how women live their lives everyday. Consider the wider societal arrangements that govern their lives. This would mean taking society as pathological rather than the women you encounter as healthcare seekers,” she said.
She said that for her a focus on the material circumstances of women’s lives is more valuable than the mode of infection. How one acquires HIV infection is often moot in the bearer’s life. “We know what makes us ill,” begins Bertolt Brecht’s A Worker’s Speech to a Doctor, and the poem’s purpose and power buoyed her in that moment. Our bodies bear the imprint of where we live and work, and how we are governed; poets are sentinels who remind lest we forget.
“Where there are medicines, people with HIV, like everyone else, get up everyday and get on with living. Where there are no medicines, and where laws are punitive, they get on with dying,” she mused aloud.
She also knew from experience that medical training and practice are rife with demands that practitioners manage financial resources carefully. If knowing how the virus is acquired does not change a doctor’s actions, then it is not worth a physician investing time or money to gauge intimate histories.
She extended her arm to touch and shake hands with her gynecologist. As she did so, she hoped that they might succeed in recognizing each other as humans first and as professionals second, holding at bay the medical categories that colonize, reorganize, and repurpose. Caring for one other, as she knew well, happens when personhood is mutually recognized.
As she spoke ideas that traveled from brain to heart to tongue and out through her lips, she thought of her women friends and colleagues with HIV and, in the same moment, what might make it more possible for them, for her, to experience care in all of these ways.