Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, October 14, 2006

Surgery and Rape

Sid Schwab is a semi-retired surgeon, a medical blogger and an amazing writer. He recently wrote a powerful piece called Taking Trust, about his experience of the intimacy (his word) of surgery.

Why then did I find myself profoundly disturbed as I came upon this part:
I will reach in gently and caress the liver, the stomach and spleen. Slide over the top, into the recesses, curl the fingers enough to sense the texture, the fullness. The bowels move away and under, and over the top as I direct my hand. I can describe your kidneys now, I've circled the top of your rectum, held your uterus, measured your ovaries between my fingers. Part of you is gone at the moment, but I'm here, I know you now. You trusted and let me in, you opened your belly to me, and I entered with force. I'll stay until it's right. It's what I must do. You think you'll never touch me so intimately as I've touched you. But you have. You have.

The word-image he had drawn so skillfully -- a female (as this patient happened to be) immobilized, unable to respond, carefully positioned, and then invaded -- reminded me of another powerful blog entry I had read. Although this other post described a very different situation, I was stunned by the similarity of my visceral response to each:
He ran his hands all over me, inside and out … gently at first, and then rougher and rougher. After what seemed like an eternity of having his hands prying, pinching, pressing … he positioned me the way he wanted me … and did what I knew he was going to do. I remember thinking that it was never going to end. Rough doesn’t even begin to describe it. I hurt for a long time afterward in places I didn’t even know I had.

For anyone who may not recognize this, it is part a description of a rape. I almost got the feeling that I was reading about the same incident, but from the other side (since no one knows what the rapist was thinking.)

Surgery is not rape. I do not mean to imply in any way, shape or form that it is. I am well aware that these are two paragraphs taken out of context, and juxtaposed. (Please read the two posts again in their entirety. The links are here and here.) But what am I supposed to do when two skilled wordsmiths describe such different things and evoke the same disturbing picture in my head?

There is no getting around the subliminal ways in which surgery resembles rape. There is bodily violation by one person of another; and there is pain. Obviously all resemblences end there. Every effort is made to minimize the violation (laparoscopy) and the pain. The intentions are polar opposites: service, not subjugation. But I submit it is that visceral resemblance which engenders the trepidation, the unease, the fear with which surgery is approached by the patient. And I confess it bothered me to sense the surgeon's enjoyment of it.

I have exchanged emails with Dr. Sid, and I understand that he was trying to convey surgery's mystique, the reverence with which he undertakes it, and the respect he has for the patients who allow him to do this to them. I don't believe he feels any differently from generations of surgeons, but I do think he has a gift for words and more courage than most as he tries to share his feelings with us.

Perhaps more explicit acknowledgement of these superficial similarities -- even if just in our own hearts -- will allow us to better assure our patients that our caring and concern sometimes requires actions with roots of brutality.


At Sat Oct 14, 03:27:00 PM, Anonymous Anonymous said...

Dr. Dino ... I saw your comment on Dr. Schwab's web site, and his reply to you. I'm not surprised that you wrote this post.

Having been in both positions - one in the recent past, an invasive exploratory lap, and in the distant past, the "rape" you quote in your post - I feel that I could perhaps try to comment on this ...

When I read Dr. Schwab's post, it knocked the wind out me - quite literally. I was left gasping for air as I tried to wrap myself around what he was saying. You're quite right that the post felt - invasive, intimate, almost sexual. When he touches on the same subject in his book, he leaves his readers with the same impression.

However, his post (and book) left me with a feeling of safety ... of being a willing, albeit unconscious and passive at the time, participant ...

I had to analyze why it made me feel like that, because as you say, it was disturbing. This is the conclusion I came to ...

Dr. Schwab is right when he says that the intimacy is taken ... however it's taken with actions, however violent at the time, (since what scalpel does not do violence?) which are yet actions of love, and of respect.

... Love of other human beings which is deep enough to enter sacred places no one else is allowed ... and try to undo whatever went wrong ... to bring goodness and healing through the invasion ... to return the trust which is sometimes taken with a labor of healing. It leaves wholeness, or an effort to bring wholeness, behind as a gift.

The other violation may not reach as deeply into a person ... but it takes away far more, because it does so for its own animal gratification. It takes what it wants, and leaves despair behind as a gift.

To be honest, looking toward the future, should I ever need surgery again, I would far prefer to trust myself to a surgeon who sees surgery as an intimate sacrament ... rather than to one who sees it is a clinical procedure. Both have the same ends, perhaps, but one is like relinquishing myself to the care of cold hard steel while the other is more like entrusting myself to a warm, beating heart.

At Sat Oct 14, 07:54:00 PM, Blogger Sid Schwab said...

Even great writers have been misinterpred or have failed adequately to express what they had in mind; and I'm anything but a great writer. I am a surgeon who frequently felt in awe of what he does, in ways I've been trying to express. Even though communication is a two-way process, I'll accept full (or at least much more than half) blame for the failure here, even though it seems, based on comments, that the majority of people saw my words more closely to the way they were intended. I think I may have overestimated my gifts as writer, and perhaps should have written more for my own consumption before hitting the "post" button.

There's an obvious difference between surgery and rape. It is certainly a violation: cutting into the abdomen is nothing if it's not that. But there's the matter of consent.

I do realize, as I've explicitly stated, that the patient is at a disadvantage: he or she is the one that has to make the leap. Yet I am there because of mutual assent. I'd venture that in some sense all doctors force themselves on patients: at least it might be a subject of quandary. It's why I called the post "TAKING trust." That I find operating exhilarating (when it's not terrifying) does not, I think, cheapen it. I'd also point out that whereas the paragraph you chose is indeed strictly female, in the post I shifted back and forth, sometimes in the same sentence, between the sexes. In suggesting a parallel between operating and some aspects of sex (which was, I thought, a vehicle of description, and may have been ill-advised from a writing technique point of view) I was trying to express that I realize the violation implicit in surgery, and I respect it. I know not only the boundaries, but the obligations. And that's the ultimate point: by your allowing me such a violation, and by my accepting it, I have assumed a nearly incalculable obligation. And I wanted to say: I know this, I'm in awe of it, and I won't break the trust that's implicit therein.

A surgeon, I am. A poet, I guess, I'm not.

At Sat Oct 14, 11:29:00 PM, Anonymous Anonymous said...

Dr. Dino...You and I just don't agree on much it seems. But, as Moof says, the big difference is that what Dr. Schwab does, he does with complete consent from the person he is doing it too. We are willingly laying there and have turned ourselves over to him...We are allowing him to "Take trust"

A rapist TAKES what is not his, what he has been told he cannot have. Further, he takes pleasure from the pains he is causing another human being.

A surgeon takes pleasure from knowing he is healing another human being. Fixing what has gone wrong with them.

If we have to put a sexual connotation on this (which we should not be doing) then the comparison would be.. being violently assulted during an act of rape vs making sweet long love with a person you care about. NO COMPARISON WHATSOEVER!

This kind of reminds me of those hits we all get from google. You know.. where someone keys in "Fat grandmother having sex with the dog in front of the grandkids" and somehow google sends them to you. They take bits and pieces, of totally innocent posts, maybe combining key words from 10 different one's, to make up their own sentence, when they send these perverts to your site.

I don't think you should do this to Moof or to Dr. Schwab. They both had written posts on two completely different topics. Not related in any way, shape or form. Shame on you.

At Sun Oct 15, 09:02:00 AM, Blogger #1 Dinosaur said...

Thanks to all for your thoughtful comments.

I need to point out that I really do *get* where Moof and Sid are coming from. What I'm describing is a sense of visceral discomfort that I got IN SPITE OF my recognition of what each was talking about. Haven't you ever had more than one reaction to the same thing? It's called ambivalence.

Cathy: I don't think I "did" anything to Moof or Sid. I've had email conversations with each of them (with Moof about intimacy and Sid about this post before it appeared) and have repeatedly expressed my respect for each of them, their experiences, and how they've expressed them. I hope they don't feel I've taken their words out of context to attack them, because that's not what I meant to do.

Here's an ugly reality: although the examples here by Moof and Sid paint the picture about as black and white as it comes, in the real world there are shades of gray; and more opportunities than we may like to admit for overlap.

Date rape, for example; how often does the victim sense she may have been "asking for it"/"consenting"? I'm not saying she was by any means, but it's a common feeling and a source of great distress.

And how often is a surgeon less reverent than Dr. Sid? He's set the bar pretty high; I don't know many like him. How often is post-operative pain suboptimally controlled? It happens.

So how often does a surgical patient experience distress similar to that of a rape victim? ("Similar"; not "identical.") All I'm trying to do is reduce the number of times that happens by drawing attention to Sid's reverence for what he does, in the hope that some surgeon/trainee/etc. is moved to sufficient introspection to make sure his patients experience his actions as care and not as violation.

At Sun Oct 15, 10:49:00 AM, Blogger Sid Schwab said...

I guess I don't know how much further to go with this. On the one hand, it's a very interesting and challenging subject; on the other, in matters of perception, there's only so far one can go to change minds. I'm somewhat taken aback by the question above:"So how often does a surgical patient experience distress similar to that of a rape victim?" I'm trying to figure that one out: does it say more about the person asking the question than it does about the subject of the question. I remember doing a vasectomy on a man who (despite my usual long prior discussions about it and mutual assurance that it's what he wanted) remaining in the office OR weeping for some time after. He was weeping, he said, for the loss, not for the decision he'd made. So I suppose there are some that, for their own reasons, will see surgery as "similar to" a rape no matter what. And I'd guess neither I nor the most sensitive surgeon in the world (surely I'm not he) would be able to alter or prevent that perception. Surgery is a violation that we must try to understand and respect; it obliges us to regard the patient as an equal, and not from on high as some surgeons do. But the same can be said for any medical intervention; and non-surgeon physicians need to be just as mindful of it. How often will people see surgery as like a rape? Pretty rarely I'd say. Only if the most basic rules of human interaction or ignored; or if the perceiving person has very singular issues. More than mere wordplay, I see a huge difference, in the terms we are using here, between violation and rape. Really huge.

At Sun Oct 15, 02:11:00 PM, Anonymous Anonymous said...

"I would far prefer to trust myself to a surgeon who sees surgery as an intimate sacrament ... rather than to one who sees it is a clinical procedure."
I have to diagree with Moof; I'd rather have the cold, technical clinical procedure over a surgeon who caresses my liver and measures my ovaries between his fingers while I am totally unconscious; I trust him to go in and fix a problem, not have some kind of disturbing epiphany over my organs. LOL

At Sun Oct 15, 02:54:00 PM, Blogger Sid Schwab said...

Well, I guess I've said all I'm going to say on the subject. Disturbing epiphany?? Geez.

At Sun Oct 15, 04:12:00 PM, Anonymous Anonymous said...

I'm sorry ... I wasn't going to say anything else, but "anonymous" has me wiping my eyes from tears of laughter.

Ahh Dr. Schwab, your poetry is like music in some ears, all the while jarring other sensibilities to the core! That's the mark of a true poet - don't apologize for it! :o)

The things I remember best are those that disturbed me ... the more profoundly I was "disturbed," the deeper the impression. Some things disturb in a negative sense, while others disturb in a pleasant way ... and we don't all have the same tastes.

Dr. Dino, thank you for so kindly hosting this thread. It's made a very definite "splash" across the blogosphere.

At Sun Oct 15, 05:33:00 PM, Anonymous Anonymous said...

Aah, the power of words. Once you interpret it the way you want it to be and not seeing what the author sees, there's bound to be some trouble.

It's better to stick to our own stories rather than picking up people's stories and dissect their words in our own blog. Especially if it's sensitive personal issues.

At Mon Oct 16, 09:11:00 AM, Blogger Sid Schwab said...

Something just occurred to me. It's one of those slap in the forehead realizations: there was a time, before CAT scans, laparoscopy, and teeny incisions, that "exploration" was considered an obligitory part of any abdominal operation. Before getting to whatever the work was, you'd run you hand eround the entire abdominal cavity, deliberately feeling each organ, to make sure that nothing else was going on. Also, when doing an operation for most abdominal cancers, it's a good idea to check all the areas to which it might have spread; so, far from "taking liberties," surgeons of my era were trained to do just that. I have done so, and included the findings in hundreds -- thousands -- of operative reports. Perhaps not knowing that is part of what made some readers feel creepy when they read my attempts to descibe it.

At Mon Oct 16, 06:20:00 PM, Anonymous Anonymous said...


I am anonymous 11:10PM.
You are absolutely correct: I know nothing about science and have absolutely no idea what you are referring to in your description. It does not even matter.
However, our English Department was quite amused - as I was - by your attempts at literary grandeur.

Sorry to have teased you. I hope this does not thwart you from creating more composition. It was all in jest. :-)


At Mon Oct 16, 07:35:00 PM, Blogger Sid Schwab said...

Michele: glad I was able to provide amusement for the English majors. It was a one-way street, although I did get a little amusement from your saying it was all in jest.

At Tue Oct 17, 06:55:00 AM, Blogger #1 Dinosaur said...

Dear Sid;

Don't sweat the small stuff. Most English teachers' concept of "literary" is about as narrow as a Frostian Road in the Wood. There's more than one way to express things beautifully, whatever a given group of critics may consider amusing. Besides, most of them couldn't write their way out of a paper bag.

At Tue Oct 17, 01:52:00 PM, Anonymous Anonymous said...

Hmmmm, I'd like to see the English major's blog . . . It's too bad she chose to comment anonymously. It is easy to criticize when a person knows they cannot be criticized in return.

At Tue Oct 17, 03:43:00 PM, Blogger #1 Dinosaur said...

Be fair, Ripple. She did give her name the second time (at the end.)

At Thu Oct 19, 04:42:00 AM, Blogger Barbados Butterfly said...

#1 dinosaur, I enjoy your blog (especially the Laws of the Dinosaur), but I'm compelled to comment on the question "So how often does a surgical patient experience distress similar to that of a rape victim?"

Very rarely, I would say.

In my experience the two events create very dissimilar emotions.

I think this question demonstrates a lack of understanding of either the experience of rape or that of surgery.

At Thu Oct 19, 06:41:00 AM, Blogger #1 Dinosaur said...

I've counseled post-surgical patients very upset because their results failed to meet expectations (pelvic reconstruction for incontinence, where the incontinence was much worse post-op; complications after vaginal hysterectomy; etc.) They're pretty upset; distraught; and refusing to have anything further to do with "that bastard", even to the point of letting the surgeon know of their discontent. "I'm ruined"; "I can't ever have sex again"; "I feel so violated."

Your words, Anon: "In my experience [emphasis mine] the two events create very dissimilar emotions."

I respectfully submit that others have other experiences.

At Thu Oct 19, 04:33:00 PM, Blogger Barbados Butterfly said...

This issue has previously been explored at Dr Crippen's blog.

The type of medical experience involved tends to be gynaecological or obstetric.

Yes, there are issues of loss of control or violation in both experiences. But likening surgery to rape trivialises rape and is offensive to rape victims.

It is also offensive to surgeons, although I am not making these comments with my surgical hat.

At Fri Oct 20, 06:12:00 AM, Blogger #1 Dinosaur said...

I don't intend to "liken surgery to rape." I just wanted to explore my feelings about one person's description of surgery striking me as similar to another person's description of rape.

To the extent that my remarks are offensive to surgeons, I understand and apologize, but would like to point out that those surgeons who need to hear what I'm saying are not those who carefully read and thoughtfully comment on internet blogs.

Again, I apologize to all surgeons and surgical patients for any offense I have inadvertently caused.

At Fri Jul 27, 11:06:00 PM, Blogger Miranda5 said...

I would like to say something here, just an aside...

I was an English major--I am NOT Michele.

There, I feel much better. And I discussed this very issue on my blog, without knowing about all this until Sid mentioned it and I did some digging.

I'm adding you to my blogroll, #1 Dino, if that's okay.

At Mon Aug 25, 03:50:00 AM, Anonymous Anonymous said...

"So how often does a surgical patient experience distress similar to that of a rape victim?"

Well I am one. But then my procedures were acts of medical rape. That is I strongly insisted that all care providers including students be female for a mastectomy, GYN surgery, and a colonoscopy. All three times males students, techs, and other staff came in after I was drugged. Given that I said NO MEN more than once, was drugged and then they did what they wanted (per medical records, witnesses, a spotted memory). I was also left with men (no women supervision in room) while still under anesthesia. All, against my will. Yes, to me it is not only the same as rape it was rape. Furthermore, given the fact that I now am infected w/ Herpes 2 that my husband of 20+ years does not have; the medical rape may well have inspired a sexual assault. It all centers around consent. No informed consent for intimate exams or procedures=medical battery in the form of medical rape. It is vial, irresponsible, and I am sick of arrogant doctors thinking they have the right to abuse patients for the sake of education, their convience, or sick power rush. I have lost all respect for the proffession and those that practice.


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