Doctor, My Breasts Are Sick
Benjamin GayedIn medical school, we are instructed that when performing a breast exam, we should reassure the patient at the end of the exam by confirming that her exam was “healthy and normal.” This particular phrase has been conceived to avoid saying such awkward things as, “Everything looks great!” or, “Feels fine!” which might conceivably lead to some uncomfortable moments and perhaps frivolous lawsuits as well. Inherent in the expression “healthy and normal” is that the two words have different meanings, assuming we are not trying to be redundant.
As Plato discusses in The Republic, the goal of any profession is the betterment of its subject. In the book, Socrates goes on to explain why a government cannot be self-interested as a result of this. I am going to back up and consider health care in these terms as a means of differentiating what is healthy from what is normal. My intention is to use this analysis to determine what is truly heath care by virtue of being chiefly concerned with health, and what may not fit so well as it is more concerned with what is normal.
Health is defined by the Merriam-Webster online dictionary as “the condition of being sound in mind, body and spirit.” The converse of this definition would lead us to say that any conditions which cause deterioration of the mind, body, or spirit comprise the object of the efforts of health care to remedy. For example syphilis causes the deterioration of the body by reducing its physical and functional integrity. Schizophrenia causes deterioration of the mind by inhibiting its function. While I agree that the spirit is an important component of health, we have largely delegated conditions which cause deterioration of the spirit to the care of the clergy. Illness of the spirit is outside the scope of what is considered here.
Normal is more difficult to define than it might seem at first glance. It might be defined by prevalence: for example, an attribute which is present in some significant portion of the population of a given society at the moment of concern. A “Gaussian” normal is defined quantitatively — those values which fall within one standard deviation of the mean on the curve of normal distribution. I think for this discussion at least it is more useful to define normal in terms of perception. Normal is that which is acceptable to the majority of the population in question at the time in question. Using this example, underarm hair on women would be considered normal in most of the world. It would probably be considered abnormal in the United States even though most women probably possess this attribute at any given time, especially if that time is in the winter months.
When considering health, the absence of many diseases is both healthy and normal. To consider syphilis again, most people do not have syphilis nor do they consider it acceptable to have syphilis. To cure syphilis with penicillin is both healthy and normal. There are some conditions which are considered the purview of health care professionals which, I would argue, are chiefly concerned with normalization, disguised as a concern for health.
Sexual reassignment surgery is a recent marvel of modern science. It was considered in a previous essay on this website by another author as a study in the meaning of freedom. A particular application of sex reassignment surgery in infants also serves as a good differentiation point of healthy and normal. There are several conditions which can cause the genitals to develop ambiguously in utero. At least one of these conditions constitutes a medical emergency in which the infant will die if not transfused with fluids and electrolytes and given replacement hormones within several days. Medical texts on the subject have also traditionally discussed the presence of ambiguous genitals in these conditions as a “psycho-social emergency” for which the appropriate therapy is immediate surgical correction. There has traditionally been no regard for the long-term sexual function of the child’s genitals after such surgery. There would be a discussion between the parents and surgeons about which sex would be easier to make the child. Applying our definition of health above, there is in fact no deterioration of the mind or body of the infant in being born with so-called ambiguous genitalia, though it is unacceptable to not fit neatly into one of the genders anatomically. Though the surgery does nothing to improve the function of the body or the mind (in fact, it is likely to deteriorate function), it is more acceptable to have normal-looking genitals.
Breast implants are also performed by health professionals. Breast size perceived as inappropriate may certainly be considered abnormal. Small breasts do not interfere with the normal function of the body or mind. An argument which is sometimes made in the defense of breast enhancement is that the perceived physical deficit causes depression. Breast enhancement would correct the depression which inhibits the function of the mind and body. There is no decisive evidence, but the news-making studies have indicated that women receiving breast augmentation are more likely to commit suicide than age-matched controls. There is certainly a chicken-and-egg element to consider here, but it seems more constructive to consider the depression as an independent disease. (As a side note, breast reconstruction after mastectomy has been shown to reduce depression rates.)
The differentiation of healthy and normal is important, not only for the superficial definition of health care field, but to understand what is true sickness and what is not. This is an important step in recognizing what kinds of help people might need, and what interventions will bring them no closer to right function. It was not my intention to actually list which areas of “health care” are not actually “health care”, but to point out the difference in the hopes of avoiding more unhelpful distractions when trying to understand why people have depression and self-esteem or other true illnesses which they might try to correct with normalization.
January 21st, 2008 at 8:29 pm
It is reasonable that the term ‘normal’ should be statistically determined, based on a physician’s experience and on Gaussian distribution, and ‘healthy’ should be a metaphysical idea which is a priori, toward which health-care strives.
‘Normality’ should probably refer only to laboratory science and measurable values, not clinical disease. Thus, a person’s hemoglobin or prostate-antigen could be ‘abnormally’ high or low, but they could show no clinical signs of disease. Alternatively, those values could be ‘abnormal’ while they are clinically very sick. A man who loses his hearing and experiences incontinence at the age of 95 is ‘normal’ but is not ‘healthy’ per se. An aymptomatic woman with no palpable lumps in her breast, but with occult breast cancer, is definitely not ‘healthy’.
But the caveat here is that, normality and health are not independent variables. Doctors define normality precisely to help track down occult diseases. Thus if you are ‘abnormal’ your chance of being ‘healthy’ is less than if you were ‘normal’. And the key point I think is relevant here is that those who vehemently resist doctor’s rights to define what is normal, are thinking too much from their ideologies, and rejecting the biologic criteria of health. For example, people born with ambiguous genitalia are not ‘normal’ statistically, nor are they healthy physiologically speaking. There is definitely a deterioration of the body, so to speak: they are predisposed to a number of anatomical and hormonal problems throughout their life. The causes of ambiguous genitalia include enzyme defects, genetic translocations, missing chromosomes, mixtures of normal and missing chromosomes (mosaicism), or maternal ingestion of hormones. I believe that the movements to ‘normalize’ these abnormal conditions are actually motivated by the ethical implications such conditions have toward homosexuality. But a disease is a disease is a disease. Anorexia is a disease, despite that there are pro-anorexia websites on the internet. Indeed, the desire for breast implants is a social disease of the mind, and often a psychological disease for individuals, probably classifiable under ‘body dysmorphic disorder’ or some such thing.
January 27th, 2008 at 5:56 pm
Well put, and I agree for the most part. You appear to be saying that ambiguous genitalia are a deterioration of the body; I disagree. I do not want to focus on that detail but prefer to keep the discussion focused on the larger issue: what is healthy versus what is normal.
To expand upon one really important point you raise, the concept of health is a metaphysical one. We can talk about what is healthy only in terms of what leads to discomfort, sadness and death. These are all relative to our own desires and perspective. We have no objective standard to define what is “right” and what is not in terms of health. If we did, then there would be no point to this discussion. But that we do know an objective standard does not mean that one does not exist.
Psychiatric illness illustrates where our empiric definition of health conflicts with our desire for a metaphysical, objective standard. A delusion is defined as a disorder of thought content, that is, the ideas one expresses. One particular type of delusion is a “religious delusion.” The example given in my psychiatry text of such a delusion is “Jesus talks to me.”
On what basis can the writers of the text claim that this is unhealthy? I would like to assume it is a claim of “unhealth”, and not just of abnormality as it is a medical text, but there is no standard that can be used to validate that claiming to talk to Jesus is an illness at all. Claiming to have conversations with a person dead 2000 years is outside the distribution of normal . Unless someone can propose an objective standard of health, this is another example of normalization as standard practice within the health-care community.
I am sure the psychiatric community thinks it is a safe-enough assumption that normalization approximates health, as you have discussed in your response. It seems that the entire field of psychiatry is really normalization in this sense, and further can be grouped with elective cosmetic surgery as technically outside of the realm of health-care. The question remains though whether, when or to what extent normalization is appropriate, and on what basis.
January 28th, 2008 at 6:02 pm
Those who talk, converse, or pray to any deity cannot even be defined as abnormal, because that’s the majority of humanity! Whenever a medical establishment defines as unhealthy something that is near the middle of the curve of normality, they are probably making a mistake. (The only exception i can think of is a pandemic plague, which is itself not temporally permanent, unlike human prayer and worship.) For example, when millions of healthy women of child-bearing years are taking oral contraceptives, something is wrong because exposing that many healthy women to a medical risk (estrogen is a carcinogen) is not warranted by any possible medical reasoning. The decrease in overall risk of cancer, as opposed to avoiding the inherent risks of pregnancy, does not play into my conception of health, because health is metaphysical, ie, it is not determined by risk-statistics alone! (As i have said however, normalization and statistics do play a role.) But think about it: we could really reduce the risk of cancer/death for all women if we prophylactically sterilized most women…
And the secular psychiatric culture is undoubtedly guilty of numerous forms of contrived normalization: for example the association between child abuse and homosexual psychology is flatly denied. In psychiatry just as in medicine, ‘primum non nocere’ is the rule: treatment and intervention should be driven only by the presence of symptoms or the anticipation of imminent symptoms or comorbid associations. But should psychiatric ’symptoms’ include thought content? Again, abnormal ‘content’ should be cautiously observed for incontrovertible comorbidites. (difficulties in formal logical deduction, change in sleep, mood, affect, diet, emotional patterns, inability to sustain ‘healthy’ relationships or jobs, etc.)
Seeing a vision of Jesus, on the other hand, is so abnormal that medical workup is probably warranted even if you are a doctor who is sympathetic to the vision! But treatment is unwarranted in the absence of comorbidity. In psychiatry, it’s especially important to judge based on a constellation of signs, not just one.