Category Archives: Women

A Lesson in Cultural Sensitivity: Assumptions

Last week, my team and I learned a valuable lesson in cultural sensitivity. Having traveled as much as I have and having been in many situations where I have been privy to privileged information, I considered myself to be well versed in culturally sensitivity. However, as I have learned countless times in essentially every aspect of life, there is always space for improvement and a seemingly endless stream of lessons to be learned.

Focus Group

 As I am currently in India studying a highly sensitive topic, in planning my research, I attempted to make every effort to ensure that my data collection was appropriate and inoffensive. I have spent years rearching this facinating culture but despite my research on these topics, I still had a lot to learn being on the ground interacting with women. Before leaving, I felt like I was constantly debriefing my team members on what to expect with Indian culture. We set up focus groups with Community Health Workers (CHWs) to refine our questions, piloted the final result, and asked our questions with well-educated Telugu translators. I knew that the women in villages would be too embarrassed to discuss their menstruation habits with men, so I arranged to conduct interviews with the only female translator that was available. The other members of my team, both male, interviewed CHWs and, unfortunately, had to take a male translator.

 

Hut in a Village

 This is where we made our first mistake–the assumption that because the CHWs interact with both male doctors and men about sensitive health information, that they would feel comfortable talking about the menstrual health habits of women in their villages with a male American medical student. However, the questions asked were still too sensitive and the situations in which they were asked brought embarrassment to the CHWs. On our first day, at the suggestion of our male translator, the male portion of our team interviewed the CHWs outside their home. The translator had a very loud and projecting voice and he spoke so loudly that I had to send my translator out from where I was interviewing to ask him to speak quietly. The next day, we realized that these questions needed to be asked in a private environment and, with the intense heat (110 F +), again at the suggestion of the male translator, this team decided to interview the CHWs in a private, air conditioned car. In making this decision, no one considered how this would appear to the villagers, and we neglected to think of having a female chaperone.    

In both of these situations, our team attracted attention to our project. As we are discussing such a sensitive and taboo topic, much of the attention that we drew was negative. In a society that is unfortunately dominated by males, the husbands of our interviewees interrogated their wives and became angry at us for asking their wives such sensitive questions. In retrospect, I see how someone might be offended if a group of men took another man’s wife into a private vehicle and asked whether she or the women in her village wore underwear… Sometimes it takes this sort incident to shift the lens and change perspective.

Some of the questions themselves that we asked were offensive. For example, we were interested in finding out about the villager’s and CHW’s general knowledge of menstruation. We quickly found that no one knew anything about the physiological process of menstruation and that this lack of knowledge made them feel uncomfortable. One question in particular, asking about the origin of menstrual blood, was extremely offensive. Even a seemly innocuous question—a question about which religion our interviewee followed–was met with extreme discomfort. Unfortunately, this question was misunderstood by the villagers, who thought that we were asking about their caste.

Unfortunately, we did not know that any of this was going on for our first two days of interviewing–we were at the mercy of our translators. We had made yet another assumption that our translators would translate the full responses, including the discomfort and the scolding that apparently went on in some of the interviews. We only learned of the trouble we caused when it was large enough to inhibit the study’s progress. One evening at dinner, we were told that the CHWs were calling each other and saying that we should not be allowed into their villages, as we were asking “bad questions”. We also were told that the husbands were particularly angry that we were asking their wives such sensitive information, and that if we proceeded with the study as is, we could be met with violence in some villages. I think that this lack of communication was due to the fact that our translators, who were also our hosts, felt obligated to proceed with our faulty and insensitive study, as they did not want to offend us. Having worked closely with people in this part of India for the last two and a half years, including one of our translators, I regretfully should have anticipated this issue and should have spoke with our translators more about giving us “bad news”.
 

Esther and BeBe (CHW)

 After learning this unfortunate and surprising news, we were all understandably upset. After all, we came to India in attempts to help alleviate some suffering, not to cause further discomfort and suffering. I felt (and am) responsible for the discomfort caused and couldn’t help but think that I could be responsible for episodes of domestic abuse, which is horrifyingly all too common in the villages. I retreated to my room, where, between several episodes of crying out of frustration and guilt, I began to brainstorm ways to salvage the study. After several Skype calls with friends and mentors, I was able to organize my thoughts and come up with a plan. In the period of about 16 hours (including about four and a half hours of sleep), I shifted the focus of the study, pulled the males (and with them, an important aspect of the study, as I do not have time to do in-depth interviews with all 25 CHWs on my own), and built in the mentorship and knowledge of key persons into the study, getting every question approved by multiple wise and influential women. 

The trouble that we faced happened because we made assumptions. We made the assumption that menstruation was less taboo of a subject, the assumption that the CHWs would be comfortable talking with men about menstruation, and the assumption that our translators would translate our interviewees discomfort and inform us if our study was not well received. As painful and frustrating as this experience was, myself and my team learned important lessons in global health and cultural sensitivity that we will take with us on future endeavors. 

  

Post Interview

  

 Currently, the newly designed study is going smoothly. The women leave the interviews smiling and many wait for all the interviews to complete to take pictures with me or walk me to my vehicle with their children. The CHWs are happy and comfortable, generously offering their home and electricity so that I can have both comfortable and private interviews. So far, my findings are interesting and my mind keeps rolling with new study ideas and possible interventions. In fact, one important finding is that many of the women in the villages suffer from painful menses and cite this as a primary reason for missing work or school. Today, I was able to present information on normal menstruation as well as an intervention for painful menstruation to 22 CHWs at the quarterly CHW training. 

In closing, I learned a valuable lesson in cultural sensitivity and in making assumptions. However difficult, this experience will undoubtedly shape my approach to future work abroad. Luckily, I was able to salvage and reshape the study and look forward to sharing the results in the coming months.

Chalagamari VIllage

India, India! (I return)

After over two years, I’m back in India. For whatever reason, this country has grabbed me more than most, and I have returned to the same place again in my travels, with plans to return for many many more visits… 

  

SNP Widows

 In the middle of an unrelenting heat-wave, I am back at the BIRDS campus in the village of Muthylapadu, in the Kurnool District of Andhra (no longer Andhra-Pradesh), India. The school children are on summer break and without them, the campus feels empty but at peace. Taking their place, are the widowed employees of Shelter International’s Sanitary Napkin Project. Visiting them in their workshop and my interactions with them have been a highlight of the last few years. Words do not begin to express my sentiments and I hope that I am able to process and share these feelings in the future.

While I am here for the widows, I am also here to research the beliefs and practices of feminine hygiene in this portion of village India. Two friends have joined me and together we are trying to create a concrete and evidence-based picture of the area’s current feminine hygiene practices. As tools, we are using focus groups and individual interviews with women and Community Health Workers (CHWs).

 

Transportation

 So far, only two days into the individual interviews, our results are quite interesting. It seems that the majority of women here already use sanitary napkins, most having adopted them recently because they wanted the “freedom” and “comfort” to move about. Previously, they used bits of cloths that restricted their movements, caused mortifying menstrual mishaps, unpleasant smells, rashes, and were embarrassing to wash, dry, and reuse. When I ask these impoverished women the maximum price that they would pay for napkins, they almost unanimously reply, “Napkins are now a necessity. Even if the cost was 100 rupees (current prices in the villages range from 26-45 rupees), we will pay it, because we will never go back to the old ways.” 

Despite this unexpected progress, many of the women still face restrictions on their behaviors and movements during menstruation. So far, none of them worship during their menses, as they feel “impure.” Several do not travel or leave the house, many restrict the foods that they eat, and some are forced to stay outside or in a corner for the duration of their period. Thus, while some women do have the freedom and comfort to go about their days normally, because of custom, many women are still restricted and stay home from work or school during menstruation.

Education is also lacking and, perhaps surprisingly, mothers do not tell their daughters about menstruation until after menarche (their first period). And, as one might expect, sex education is lacking in the Indian school system. Thus, when girls see their first drops of blood, they fear disease or death and run crying to their mothers, who then tell them that this is a normal process for girls– their entrance into womanhood. Several of the women revealed that they never had the opportunity to learn from their mothers, because they were married within a month of menarche and their mothers did not have time to explain how to manage menses. Furthermore, women have no knowledge of the physiological process of menstruation and very few women are able to identify the origin of menstrual blood.

Still early in this process, my mind rolls over future projects and mostly educational interventions. I am also dreaming up ways to expand Shelter to employ more widows, as widows frequently travel great distances hearing that we employ widows and treat them well (unfortunately, the stigma of widows is still strong). While I do have a slight bias, I have already seen the impact that Shelter has had on the lives of our employees and even on women in the villages. I feel so lucky and thankful to be able to do this work. It is what drives me and gives me the energy to succeed in my studies.

More to come as time, internet, and power allow…

 

I interviewed this widow over 2.5 years ago. She is still alive, wearing the same blouse, and is now in her 90s.

  

Raw Material and almost finsihed product

    

The BIRDS farm

 

(A Brief) On Sanitary Napkins in Rural India

Anyone that has talked to me in the last year and a half (or anyone who has read this blog) knows that I am deeply passionate about women’s health and the improvement of women’s lives worldwide. This past year and a half, I have spent my time working on various projects involving women. From my employment on the Native CARS Study, work with survivors of sex-trafficking through Save a Survivor’s Smile, my acceptance into an MD/MPH program where I plan to pursue women’s health, to the development of my non-profit organization SHELTER International, which aims to improve the lives of widows in rural Andhra Pradesh, India, it’s a wonder I ever made it outside (but I am so thankful that I did as there is just so much to hike…)!

Today, May 28th, is Menstrual Hygiene Day. As females in the developed world, menstruation is still a pain, but we simply have to make a trip to the drug store to cheaply purchase feminine hygiene products to manage our menses. In rural India (and many other parts of the world), menstruation is a whole different fiasco. Imagine having to travel a significant distance to a town large enough to have a market where they can sell feminine hygiene products. Now imagine spending half-a-week’s (or thereabouts) salary on expensive and imported sanitary napkins. Obviously, most women in this situation spend their hard-earned cash on food or school for their children and simply do without this “luxury.”

Instead of using a hygienic product, women use bits of old cloth and sometimes even newspapers or sand to manage their menses. Due to embarrassment (as I am sure you can imagine), these cloths are rarely cleaned or sanitized and have been reported to increase the incidence of disease in the reproductive track. As these solutions can hardly be considered solutions, women and girls often have to stay home from school or work so that they can manage their menses. In turn, women have just one more reason to make less money and girls often fall behind their male peers in school.

IndiegogoSo, in an effort to help the area’s widows as well as pursue my passion for feminine hygiene (I realized feminine hygiene was a problem for many Indian women when I taught health and hygiene to girls in Tamil Nadu, India), my organization is trying to raise funds to purchase a machine to manufacture sanitary napkins. The machine will employ 10-20 widows and the low-cost product will be sold to women and girls in the area. I have wanted to get this project going for a year and a half and, after much research and planning, it is happening! We (SHELTER International) are also very fortunate to have several graduate students from Pacific University heading to the project site this summer to oversee and study the project’s implementation. I personally cannot wait to go back to India at my earliest availability to see the project in action!

Anyways, after spending so much time and energy working towards something, I am ecstatic to see a project that I am so passionate about finally coming through. Check out the Indiegogo campaign page, read about widows, learn more about the importance of menstrual hygiene, and women reading this post: be thankful that you are fortuitous enough to manage your menses in a way that doesn’t completely interrupt life!

 

Blaming the Victim

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The river in Kampot

A terrible thing happened last week near Kampot, Cambodia: the body of young French woman was found in the river. Her body showed signs of sexual assault. Terrified (for I too am a single girl traveling and was in Kampot just a few days ago) and curious about the atrocity, I spoke with others to find out more.

I was shocked and a little disgusted at the replies and opinions of my fellow travelers for they all blamed the victim. I don’t know if they did this out of an unconscious fear for their own safety and a thought that, “well, I’m smarter so this couldn’t happen to me” or if they actually believed their preposterous assertions.

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Sunset on the streets of Kampot

When asking about the details of the crime, I heard several different stories. One person told me that the victim was riding her bicycle, maybe in the evening or at night, when she was attacked. This man commented on how stupid the girl was to be out alone at night and how the rape and murder was “kinda her own fault.” Would I be out on the streets alone at night if I could help it? No, and I am sure that this victim wouldn’t have either (e.i. could this girl have had a flat tire that prolonged her return home into darkness?) because as solo female travelers, we have to watch out for ourselves and realize that the world, however wonderful, has its faults.

Another woman told me that the victim was cycling out to a remote beach to sunbathe nude. Someone might have seen her, alone and exposing her body to the world, and took “the invitation” to rape and kill her. “She was kind of asking for it because it’s really stupid to be naked in rural Cambodia.”

Was she really?

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Canals in rural Kampot

What happened to this poor girl is terrible, under every circumstance. No one is asking to be raped and murdered and dumped into the river. Clearly this girl’s unfortunate end was not of her own doing. It shocks me to hear “open minded” individuals, including women, suggesting that crimes like these are the victim’s fault. Yes, perhaps her sexual assault and murder could have been prevented had the circumstances been different. We will never know. The fact is that men still view women as objects for the taking–completely disregarding their beautiful existence for a few seconds of selfish pleasure.

Shouldn’t men learn self-restraint? Shouldn’t they learn to be human?

Why do we continue to blame the victim?

Note: I have received a few comments that rape isn’t just a few seconds of pleasure. I realize that in most cases it is not and personally believe that rape stems from insecurity. Please read my post titled “Rape: Women and Society in India” for more thoughts on rape.

Redefining Sex-Education

Kama Sutra Statue

Kama Sutra Statue

Unfortunately for India’s youth (a huge proportion of the world’s population), India is afraid to teach her children and adolescents about sex or anything remotely related to sex. Due to this fear, sex-education here is non-existent (even though the majority of sex-education has nothing–or next to nothing– to do with actual intercourse). Thus, the vast majority of Indian children learn nothing about their bodies and how to properly care for them, or even about the changes their bodies undergo during puberty. When India thinks about sex-education, she miss its significance and utility, and instead thinks that her children will be taught the sexual intricacies of the Kama Sutra and other perversions.

Due to the unfortunate title, “sex education,” children all over the world are missing out on learning important and necessary material. Thus, for India and other parts of the world (including the American South), sex-education should be renamed (taking sex out of the name) to something like “Health and Personal Hygiene.” And, as these classes would be of major benefit even without the mention of actual sex, sex could be taken out of the lectures in countries with both conservative thought-processes and conservative sexual practices (the South does not align). This modification would allow children access to pertinent information about their health and bodies.

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The consequences of not having proper sex-ed in the US…

The United States has a very different sexual culture than conservative India (with the average age of first having intercourse at 17, which is much later than I thought) and thus requires a different sort of sex-education class that does involve sex, especially focusing on the importance of safe sex. (Sex education classes need to be catered to the actual sexual practices and culture of each community rather than the conservative thought processes that outline how things should be.) I remember my first sex-education class at the age of twelve while attending a boarding high-school in rural Arizona (as a day student). Luckily for the students (and completely necessary for a boarding school environment), we were all required to attend a gender specific sex-education class where were learned about our bodies (which was a review for most of us, ages 12-18), were shown slides and given graphic descriptions of STIs, and told that if we had sex without a condom, we would both get pregnant and contract STIs. Unfortunately, I still carry those images and descriptions in my mind (it forever destroyed my enjoyment of cottage cheese)…but it worked! Even at the age of 12, I knew that in the future, when I had sex, I would not do so without proper protection.

While perhaps India is not quite ready for such “forward” classes, India is in dire need of something to take its place. While studying thoughts and practices regarding menstruation in India, I came across several shocking journal articles regarding knowledge and beliefs about menstruation. In one study involving girls in the state of West Bengal, India, about 30% of the girls did not know about menstruation at the time of menarche (their first period) and a very small percentage of girls (<10) knew the source of the menstrual blood. Also, a dangerously high number of girls attributed menstruation to such things as curses from God or disease. Studies like these demonstrate this dire need for “sex-education” aka personal hygiene classes where girls are given the opportunity to learn about their bodies and dispel dangerous beliefs regarding menstruation.

The Saranalaya Home for the daughters of prisoners

The Saranalaya Home for the daughters of prisoners

Some of the little girls

Some of the little girls

I have had the opportunity to offer a few of these “modified sex-education” classes smartly titled “Health and Hygiene” to girls in orphanages in Coimbatore, Tamil Nadu, India (with the help and support of the Womens Center). My first class was at the Saranalayam home for the daughters of prisoners. I was originally told that I would be speaking to girls ages ten and up, however, when I arrived I was shocked to see that about half the girls were under ten and many were as young as five or six. As I had planned my presentation around the central theme of menstruation and still really wanted to give the older girls the opportunity to learn about their bodies and how to care for them, I had to quickly consider my options. Do I teach the five and six year old girls about menstruation even though they won’t understand it? Will I scare them if I do? They probably won’t ever have this opportunity again… These were the thoughts running through my head in the few minutes before my scheduled talk. After consulting the nuns in charge of the house, I restructured the presentation so that everyone learned about general hygiene including toilet hygiene, nutrition, “bad touch,” and exercise. The little girls then went downstairs and I spoke with the over ten crowd about menstruation.

hanna 012After the general talk, I noticed that the nuns were shuffling out adolescent girls that should be staying to listen to the talk, leaving me with just a few of the oldest girls. The nuns told me that these younger girls hadn’t reached menarche (though by the looks of it many would within the year) and therefore didn’t need to stay for my talk. With some passionate convincing, I was able to have a few more girls added to the talk. I told them that menstruation was natural and actually a sign of good health (and showed them a drawing of the uterus!), told them things they could try to alleviate menstrual cramps (exercise and avoiding salt and sugar), and about the proper care of their bodies both generally and while on their periods.

hanna 013Next, we had a question and answer session where a nun who helped care for the girls asked me many questions about normality–and thank god not the Foucauldian sort (she was probably in her late 30s, was educated enough to read and speak English, but had next to no knowledge about  menstruation). The girls themselves asked me a plethora of questions regarding menstruation and what was normal, about pimples and shampoo, weight loss and weight gain, how to grow taller, what to do for cracked heels and cracked lips… Everything. It was actually really fun.

I was able to reassure them that menstruation is normal and calmed many of their fears about their own bodies and cycles. I ended up leaving the printout outlining the key points of my talk with the nun. She was very thankful for the talk and ensured me that she would teach the younger girls about hygiene and their bodies as they came of age.

As my readers can see, my talk was completely innocent and nowhere did it mention or even allude to sex. And it didn’t need to. Yet there is a huge resistance to providing education like this as the public believes that it will corrupt and pollute the innocent minds of children. I have several more talks scheduled for orphan girls at different orphanages throughout Coimbatore. The idea is to give these girls lessons that their mothers would be giving them if they had mothers. However, many girls with mothers do not receive this information either because 1) many of mothers simply don’t know, and 2) many people are too shy to discuss such topics with their children. Thus, I am also scheduling talks at English medium schools to both provide wealthier school girls the opportunity to ask questions about their bodies and to show that “sex-education” doesn’t need to be about sex.

Note: This talk at Saranalayam was covered by The Hindu. Yet, you can see from the article that even the media is a little afraid to mention that my lesson contained a modified version of a sex-ed class (no mention of menstruation), but instead labels it as I did–Health and Hygiene.

Arranged Marriage: A Western Perspective

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My first encounter with arranged marriages (excluding story books and historical accounts of royal and political marriages) occurred about a month into a past relationship with a man of Indian origins. We somehow got to talking about the topic of marriage and how, shockingly to me, arranged marriages still sometimes happened in India (though I don’t think either of us knew to what extent). He then told me, jokingly, that he was betrothed to a girl in India whom he had never met. At first, I didn’t realize that he was joking and felt a little upset, the romantic in me thinking–why was he spending time with me when he has another (perhaps I experienced for a few short seconds the way a woman feels when she discovers that she has been seeing a married man)? I then realized that he was joking and we had more than a few a good laughs…

As one can assume from this anecdote, the concept of arranged marriages has always been foreign to me. Like many Westerners, I was brought up on fairy tales and Disney and always had the notion that people fell madly in love, dated for a while, and then married. And, if for some reason their parents didn’t approve, the couple would run off to Las Vegas or Niagara Falls to elope. The couple’s parents would eventually come around, and everyone lived happily ever after.

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A Western perspective of arranged marriage?

With this mentality, arranged marriages happening in this day and age seemed so bizarre and almost impossible. I know arranged marriages happened historically, and could accept that they happened in backward villages in developing countries (usually involving children, of course), but today?– amongst middle and upper class individuals? Doesn’t everyone want to fall in love?

When I arrived in India, I was in for quite a shock as nearly everyone that I met either had or was going to have an arranged marriage (I could accept members of my parent’s generation having arranged marriages, but my own?!). As this topic fascinated me, I questioned and probed into the lives of as many people as possible to find out the procedures, customs, and thoughts regarding arranged marriages. In this post, I hope to provide stories and share my changing insights and perspectives on the practice.

The first person I questioned about arranged marriages was an educated man in his fifties with knowledge about Western culture. He told me that in India, arranged marriages worked out well as the families would form a partnership on which they could agree. This meant that Christians would marry Christians, Muslims Muslims, and Hindus Hindus. It also meant that families would be in the same general socioeconomic class and might even run in the same social circles. There is also the idea that if the families can get along, the children (the married couple) will be able to sort out any issues that might arise. And, if the couple has problems that they can’t deal with on their own, both sets of parents offer counsel and assistance for the troubled couple. This family orientation, he insisted, is one of the main reasons that India has such a low divorce rate (divorce is also seen as incredibly taboo and, in most incidences, women cannot remarry without intense social consequences. Also, as India is so family oriented, the idea of being divorced and without a family is often worse than suffering through a troubled, unhappy, and even abusive marriage).

Next, he told me the reasons why “love-marriages” often don’t work. First, love doesn’t always follow the rules of society and an upper-caste girl could fall in love with a lower-caste boy (or the other way around) causing both families turmoil and disgrace. Similarly, a Christian could fall in love with a Hindu, and the all important extended family would argue over which religion the future grandchildren should follow, and the families would have to explain why their daughter or son did or didn’t have a Church wedding. Thus, love marriages often don’t work because the pivotal role of family in marriage. And, as family plays such an import role in the lives of Indians, eloping is often out of the question as one does not want to create distance or separation from family. Also, as parents often know their children better than the children know themselves (so the belief goes…), parents have the ability to better select an appropriate spouse than their children. Yet another problem with love marriages is that once the love runs thin and problems begin to arise, the young couple will not have the same support structure created by a partnership between two families.

So, family plays the all important role in marriage in India–and it favors arranged marriages.

After receiving this insight from a man who has arranged his own daughter’s marriage, I began probing into the lives of my Indian peers, discussing their thoughts, feelings, and experiences regarding marriage.

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Nice to meet you?! Almost…

When I asked one recently married couple about their arranged marriage, the man told me how he came to meet and marry his wife. A few months ago, the man announced that he wanted to marry a woman with an MBA degree. One of his father’s friends recalled another friend who had a daughter that was just finishing her MBA. This friend contacted the man with the daughter and gave the future-father-in-law information about his future-son-in-law. The future-father-in-law approved. The young couple exchanged photos and phone numbers, then Skype IDs, and, a few weeks later, finally met. About two months after the initial contact, the couple married. I met the couple about a month after their marriage and it was both sweet and strange to see a married couple behaving towards each other with the innocence of highschool sweethearts.

I had another interesting interaction with an unmarried Christian man of twenty-six. He was going to wait a few more years to marry so that he could settle into a career before starting a family. Discovering that Western societies had different marriage customs, he asked me how it was possible to marry without an arranged marriage. So, I censored myself as best I could to be as least offensive as possible and explained, “Well, we meet people through classes, colleagues, or friends and, if we like each other, we exchange numbers and arrange a time to meet. Then, we date for a while (generally a few years) and, if we both still like each other, at some undefined point in the future, we marry.” Knowing his conservative Indian and Christian background, I edited out all offensive and heretical topics such as pre-marital sex and living together before marriage (aka “trial marriages”). I was shocked when, after my simplistic and seemingly pious explanation of Western marriage practices, he vehemently declared that dating was a sin! I guess I had forgotten to factor in that in the vast majority of Indian marriages, couples even in their twenties and thirties go on supervised dates, thus having no unsupervised time alone until their wedding night!

However, as India is influenced more and more by the West, marriage customs are slowly beginning to change, especially in large cities and amongst the wealthy. While arranged marriages are still the norm, more and more frequently children are shipped off to other cities for university or job opportunities where they meet potential suitors. These suitors are then brought home to meet the parents, such as they would in the West. In this case, the suitor is generally of the same social class (and caste doesn’t play much of a role in educated, wealthy, city dwellers) but still has to obtain parental approval. Finally, the sets of parents meet, and, if everyone agrees, the couple is married. Someone told me that the wealthier or more educated one is, the decision to marry is made more and more by the child than by the parent, even in the case of an arranged marriage (the child has more veto power).

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Perhaps also stemming from Western influence, online dating, in the form of matrimony sites, has made it to India. These sites are very similar to the online dating sites in the West, with the exception that they are used for the purpose of selecting a spouse rather than Friday night’s date. While I am not 100% sure what happens in the selection process and after contact details are exchanged, I would not be surprised if family played an important part in both selecting and approving potential future spouses.

While I am thankful that I have been granted the opportunity to explore the hearts, minds, and bodies of potential (or not) suitors, the Indian system of marriage leaves some room for jealousy. Firstly, how many of us have dated someone our parents can’t stand? In arranged marriages where one’s parents select a partner, this nightmare isn’t an issue. Secondly, with the high divorce rates seen in the West (come on, America, over 50%!?), India’s low rate of divorce looks pretty good (although perhaps all the potential reasons behind it don’t). Thirdly, after having spent the last several weeks in and around a fertility clinic, I know more than I care to about the increasing rates of infertility and about how fertility decreases with age. As someone who might want to have a family in the future as well as a career, when combined with the elevated rates of infertility and a strong personality, the chance of finding a suitable partner during the small window between career and fertility is far from a guarantee. Where in the Western system of love marriage you may spent your life wandering aimlessly (or with unrealistic aims) never finding a partner, in the Indian system, you are practically guaranteed to find a partner by the age of thirty (or shortly after should you wish to be slightly non-traditional). Despite the advantages of arranged marriage, the romantic in me is happy to experience the ups, inevitable downs, and personal growth associated with dating.

Rape: Women and Society in India

“Senior Citizen Attempts to Rape Nine Year-Old Girl.” “Widow Gang-Raped in Uttar Pradesh.” “Delhi Gang-Rape Victim as Guilty as Her Rapists, Asarum Bapu Says.” “Two People, Including a Minor, Rape 15 Year-Old Girl.” “Puducherry Prescription: Separate Buses and Overcoats for (School) Girls.” “School Girl Raped and Strangled with Her Scarf on Way to School.” “Dalit Girl Raped by Upper Caste Boy.” “17 Year-Old Girl Repeatedly Raped by Her Father and Brother.”

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One of many recent front-pages highlighting rape

These are just a small handful of the headlines that I have read the last few weeks in the Indian papers. It seems like every morning about ten different rape cases (all equally horrible) appear in the paper. And these are only the cases that the press finds interesting enough to write about in the fraction of rape cases that are actually reported. One of the most horrible cases I read about (besides the Delhi gang-rape case that has received international press) was about an eighteen year-old girl who was expelled from her college for being raped. Apparently, she was “following nature’s call” (there are very few bathrooms in rural India, or in all of India for that matter) with two friends when a gang of men playing cricket noticed the girls and started coming towards them. The girl’s two  friends were able to escape, leaving the girl in a vulnerable position. The girl was captured and then raped repeatedly in a field, in plain view of male administrators from her school (who did nothing to stop it). After the rape, she was expelled from her college for “behaving in-appropriately with men.” This expulsion will prevent the girl from continuing her education at another school.

After returning home that day, her parents questioned her about her injuries and tears. After much interrogation, she told her parents what had happened. She was immediately taken to a doctor who treated her for her injuries and confirmed the rape. She is now fighting the administration’s decision to expel her for being raped (the administration is still arguing their case, insisting  that this girl was acting inappropriately, even when others who witnessed the crime clearly identified it as rape). As this story was one of the few stories to get attention from the press, I hope that the administrators of this school are closely examined and replaced.

(In India, virginity is a prized possession. Women, even after being raped, are fearful to report the crime as they are afraid that their rape will tarnish their reputation and keep them from being married (some Indian men even divorce their wives after their wives have been raped!). Thus, this stigma, along with the inefficient and embarrassing process of reporting rape (in 2012 in Delhi, only 2 out of 600 reported rape cases we brought to trial and many more cases were given up after victims were treated with disrespect by the investigating officers), prevents many women and girls from taking justice against their attackers. And, perhaps most disgusting of all, policemen and family members often encourage the rape victim to marry her attacker, for she is seen as unfit to marry anyone else.)

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After the brutal rape and death of the Delhi gang-rape victim, the Indian public is finally taking a stand against violence against women. Everyone from politicians, men, and women are demanding change, justice, and preventative measures against rape. Unfortunately, their solutions for the “Rape-Problem” are almost as problematic as rape itself. Politicians are demanding that women cover up more than they are already covered, insisting that women don burka-like dress and school girls wear overcoats to prevent leering eyes from feasting on those few inches of exposed skin. One, India is HOT and women are already covered up more than women in most other countries (with the exception of the Middle East and winter in Siberia). Two, “solutions” like this blame women for the misfortune and atrocity of being raped. “Solutions” such as this also avoid confronting the real issue behind rape. Furthermore, with politicians propagating such madness, women will further internalized the culturally engrained notion that rape is their fault. This will then prevent the few women that do report rape from reporting the crime, allowing more rapists to get away with it, finally resulting in an increase of rape. It is ridiculous and embarrassing that elected officials and politicians (including some women!) are spouting off such madness.

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Protesters demanding death by hanging for the rapists. Credit: WSJ

While the politicians are coming up with fantastic plans to stop rape from covering up women to banning the sale of alcohol, the public is demanding stricter laws against rape including harsher punishments and swifter trials. I am in full agreement that the process of reporting and prosecuting rape should be made more agreeable to the victim (including the call for more female police officers and inspectors) and for rapists to be brought to trial within a few weeks of the incident (rather than in 10 years or not at all). However, I do not think that chemical castration or the death penalty are the solution to stopping rape.

These “solutions” miss their mark. Preventing rape has nothing to do with the way women dress or the punishments that rapists receive. Rape will continue to happen no matter what women wear and whatever the consequence as long as men continue to disrespect women. Male ego or not, women all over the world are coming up in position. We are providing for our families and working in fields that were originally reserved for men. After thousands of years of oppression and second class citizenship with ridiculous and bizarre justifications (such as women lacking reason or being deformed-and thus less than-men), women are finally beginning to live freely as they rightfully should. Perhaps this rise in progress is being met with resistance, and men feel that women are cramping their style or taking over what they feel is rightfully theirs. Perhaps this insecurity is why men feel the need to dominate women with the display of their animalistic power. While I am no expert, I am sure that men rape women for a variety of reasons, but probably all stem from insecurity.

Whatever the cause of rape, the root of the problem is not with women but with society itself. Men need to learn to love and respect women from a young age. This means that their fathers must treat women with respect, and that politicians (our leaders) need to shift the blame of rape from women to men and to the society that allows men to be brought up devoid of such values. Society must also not neglect women, but seek to raise women who are confident and believe themselves to be the equals of men. As gender inequality has deep roots in Indian culture, India’s transformation will be long and hard. I just hope that India does not require another atrocity like the death of the twenty-three year-old Delhi gang-rape victim to initiate this change.

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Protesters. Credit: The Guardian

An Introduction to Women’s Health

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I have been kept so busy that I have barely had time to update this blog! After spending a few days as a tourist in Hyderabad, I left Andhra Pradesh and have settled in Coimbatore, Tamil Nadu, where I will spend the next six weeks working at The Womens Center. This small, private hospital is remarkable. Not only does it offer lavish interiors (it’s the most pleasant hospital that I have ever been in–I stayed in a patient room for two nights and it was the nicest place that I stayed since leaving the US), it offers remarkable services at affordable prices. But enough advertisement…

While here, I will be conducting educational outreach projects. I have been busy learning about all sorts of women’s health issues, finding statistics, and trying to figure out how to present my findings to women from a culture where private parts are kept very private and sex is a very touchy subject. My first presentation will be this Friday to a group of educated women working in IT. It will be part of a longer presentation on general health given by a female colposcopist who has just returned to India after practicing for several years in the UK.

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Dr. George Papanicolaou

My talk will be about the importance of the Pap-smear in cervical cancer prevention. India has one of the highest rates of cervical cancer and basically no prevention program, so the aim is to raise awareness around the issue. In this first talk, I will discuss the use of Pap smears in the US and the dramatic reduction in the rate of cervical cancer. For example, with screening, incidences of cervical cancer have been reduced by 75-90% depending on which journal article one reads. This figure is quite remarkable as in 2010, only 73.3% of women in the US had a Pap smear within the last three years. Also of interest is that over half of all cervical cancer cases in the US occurred in women that have never had a Pap smear, where ~25% of cases occurred in women who haven’t had a Pap smear in the last 5 years, and the remaining 25% or so of cases occurred in women who failed to follow-up properly after an abnormal Pap smear. It is estimated that if all sexually active women received Pap smears every 3 years, the incidence of cervical cancer would be reduced by 99%! So, I must find a way to present these promising statistics to women who are very fearful of both cancer and talk of sex (especially as 99% of cervical cancer cases are caused by HPV, a virus transmitted through sexual contact).

(In the US, an estimated 80-90% of sexually active women contract the virus at some point in their lives although the majority are able to clear it to undetectable levels before it becomes a problem)

In discussing these issues with the colposcopist, she told me some startling anecdotes about the female Indian patient. The body clears most abnormal growth on the cervix naturally, so in most cases patients are asked to return for another Pap smear in 6-12 months to check on the condition. However, some patients hear “abnormal,” stop listening there, and nod their heads that yes, they will come back in 6-12 months. But instead they rush to another doctor and, if they have already had their children, they demand a hysterectomy!

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Another issue with this sensitive topic is women wondering HOW they became infected with HPV in the first place. As very few women in India have had more than one sexual partner and their husbands insist that they have both been faithful and were also “pure”  at the time of marriage, this creates yet another problem. I have been thinking about how to answer the questions that I might receive on this topic with something other than  “Your husband is a liar.”

(HPV can be spread without actual intercourse but contact is necessary).

Another project that I will be working on involves visiting orphanages in the area and giving talks on feminine hygiene and sexual abuse. I just did some quick research on feminine hygiene in India and found some pretty startling results. For example, in India, only 6% (around 30 million women) use some sort of hygienic sanitary napkin during their monthly menstruation (compared to the 96% rate seen in developed countries). The remaining women use whatever they can find. Thus, women often endure embarrassment, infection and loss of workdays due to the negative social stigma and discomfort associated with monthly menstruation. Reproductive tract infections are 70% greater among women who lack access to hygienic supplies and as many as 31% of adult women in India note a drop in their productivity levels when they menstruate, resulting in missing an average of 2.2 days of work each month (click here to read more). Aside from these issues, I will also teach simple exercises to relieve menstrual cramps as well as exercises to help combat depression. These presentations will be a challenge as the customs and sexual culture are just so different from what I know (I still haven’t even figured out how people here get by without toilet paper).

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Sketch of a baby with arthrogryposis (Wikipedia)

Meanwhile, I have read about 30 journal articles and reports on different aspects of female health, evaluated sperm for male infertility tests (more observational on my end), watched mammograms and ultrasounds, watched a C-section, spent time in the NICU with preemies including one suffering from arthrogryposis, went on rounds, watched heart scans on newborns… Its been busy but I’ve learned so much and am so excited to learn more!

An update on my Widows Project:

The first widow I spoke with who was taking care of her orphaned grandson is currently making arrangements to live at the BIRDS farm where here grandson will attend the BIRDS school. On a more upsetting note, the two little boys whose parents died of AIDS and suicide, are both HIV positive. The twelve-year-old girl with tuberculosis does not have HIV. BIRDS is aware of this situation and will be doing all they can in order to get treatment for these children and support for their grandmother.

I am also still plugging along on the development of SHELTER, the non-profit sustainable women’s shelter that I am working on developing with two Indian MBAs.

(Hopefully Not) Lost in Translation

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Every act of human communication requires some form of translation. Even speaking in our own language requires translating what one person meant in his own mind into what one thinks he meant to convey. Body language as well requires translation–but perhaps body language is so engrained in our nature that it requires a bit less translation (although it can add even more confusion to the act of translating for the body often says one thing and words another).

Now move these complexities into a different language and add yet another filter and layer of translation–a translator. And now add different customs that might even obscure some body language (i.e. do people smile because they are happy or because it is their custom?). From all these complexities one can easily see the difficulties of translation–especially when one must use a translator.

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Interview with translator in a tribal village

In my interviews with widows, I had to use a Telugu to English translator. While it was incredible that I could “speak” with the widows, I did run into a few problems (really more minor annoyances) with my translator. For one, he was a man and I was interviewing uneducated women who came from a culture where women are considered less than their male counterparts–and I was asking these women for some fairly personal and gender-based information. Seeing this potential barrier, I had originally arranged for a female translator, but she had an unforseen arranged marriage and was no longer available. So, I had to make due with what I had and now must factor the male translator into the equation. Doing this, I assume that the stories that these women told me were actually more horrific than the information and translations that I received.

Some other issues that I faced with the translator involved him filtering what the women had to say and giving me only what he thought I wanted to hear. While my questions were answered somewhat directly, I had posed the questions as open ended because I wanted to get the women to talk about their lives. And, from what I could not understand but judging from the length of their answers, it worked. However, from the brevity of the translations I received, I know that my translator had his filter on high. I would constantly ask, “What else did she say?” and my translator would respond:

“She is telling me about her sorrows.”

“And…”

“Next question.”

I would receive this frustrating response to my pleas for better translation (or actual translation!) several times each interview.

Another frustration besides the filter set on high was my translator responding “same thing” instead of actually translating what the woman actually said. Yes, every woman that I spoke with suffered from neglect and discrimination. But I wanted to hear their stories and hear what they had to say.

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Interview in a village school

And yet another annoyance which I think actually did affect my research was the translation of the responses to the mental health questionnaire. These questions were a little more direct. Where the first part of my interview asked open ended questions such as “What is your opinion about widowhood in your village?”, the mental health questionnaire asked questions that were meant to get responses more along the lines of “yes,” or “no,” or “sometimes.” But, as these women wanted and needed to talk and share their sorrows, their responses were not quite so direct. For example, their responses to “In the past month, how often have you been feeling sad?” would consist of a long story about what had happened in the past month rather than a response such as “seven times.” Thus, my translator would say “sometimes” or “no” and would look annoyed when I would ask him to elaborate. As each response in this section was meant to generate a number, such inaccuracies in translation do effect my research.

In regards to inaccuracies in the mental health score, towards the end of my interviews, I realized that my translator was adding a little too much of his own translation onto the responses in regards to questions about whether the widows ever thought that life was not worth living. I discovered this issue when a women gave a long and emotional response and my translator simply translated, “No. Next question.” Here, I demanded an elaboration. It turned out that this woman had twice attempted suicide but for the sake of her children did not want to harbor such thoughts. And so, in response to the question: “Have you ever felt that life was not worth living?”, my translator translated the response of a woman who had actually admitted attempting suicide more than once as “no”. Thus, my translator failed to translate the difference between wanting to feel a certain way and actually feeling a certain way.

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Interview at the BIRDS farm

From this point on, I demanded actual translations to these questions. However, for the previous eighty-five or so widows that I had questioned, I cannot fully trust the accuracy of their mental health scores. Thus, I will have to translate and factor these inaccuracies into the mental health scores. Unfortunately, the actual scores are probably actually much higher than those that I have calculated. And, as the previous post states, the average mental health score for the one hundred and eleven widows was 4.47 on a scale from 0-8.

Despite my issues with my translator, I do feel that my research is fairly accurate and am thankful that I had a translator. Unfortunately, the inaccuracies and issues due to the gender of my translator and his actual translation only make my results even more depressing.

Something about HIV

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There is just something about HIV that makes the heart stop. When it’s mentioned (especially in close context), the whole body collapses. The throat closes, the chest sinks, the stomach drops. Time freezes or at least becomes painfully slow. This is the state that I found myself in yet again this afternoon.

(I can’t imagine what patients must go through when they get their positive diagnoses.)

I will keep this story short. It involves a thirty year old woman (I will call her Lakshmi), who came to my room and brought me ORS when I was sick my first week in India. Lakshmi’s husband committed suicide five years ago after learning his HIV status and giving up on life three years later. He was an alcoholic mason who presumably frequented prostitutes in between beating his wife. After learning that he was HIV positive, he attempted to change his ways and find God, working in a church for three years. However, his attempts failed and he instead committed suicide. He left behind his wife and two HIV positive children, who are now nine and ten and studying at the BIRDS school (the mother and children are receiving treatment). I have met both children.

When I asked Lakshmi the question concerning her future, she told me what nearly every mother that I have talked to has said: That she wants to work hard so that she can give her children a good education and better lives than she had. I don’t remember if Lakshmi cried at all during our interview. But I nearly did with her response to this question. I really struggled against the tears welling up in my eyes. And it took all effort to keep my voice strong for the next question.

I could take the sad stories of her husband beating and harassing her. Of her three-year abandonment just after her daughter was born. Of her brother-in-laws harassing her daily and stealing her land. Of the time her children found her when she had taken all those pills. But when it came to the topic of her children’s futures, I broke.

Note: please read my reply for further discussion of HIV and the stigmas facing patients.