On asking the clinically-relevant questions

There's a question out there in medical land that apparently asks whether you are racist or not. The question is: "Do you identify as of Aboriginal and/or Torres Strait Islander background?" Now, the response to this question  – which in Australia IS of clinical relevance – is not what matters, but the fact that some people are unwilling to ask this question in this first place for fear of "offending" a person who isn't of this background.

Fear of offending a racist person is the reason some people give as to why they feel uncomfortable asking the question. They imagine they may encounter a racist person who'll take offense at not clearly being identified as non-indigenous. More specifically, though, they fear that they'll meet a non-indigenous person who they will offend by implying the negative stereotypes associated with people of Aboriginal and/or Torres Strait Islander backgrounds. But who's given this question that connotation? The racist person who holds those prejudices – and that is the person fearing to ask the question! You don't know the strangers mind that you'll be asking, only that you imagine it may believe what you (either consciously or subconsciously) believe yourself.

And briefly before I leave this topic, let me explain why I say that it is clinically relevant to know whether a person is of Aboriginal and/or Torres Strait Islander background. In Australia, there is difference in the life expectancy, the mortality rate, and the burden from disease between indigenous and non-indigenous Australians. This difference is commonly referred to as “the gap” between indigenous and non-indigenous Australians. Clinically, a person may be more likely to suffer from one or another illness (e.g. diabetes mellitus) if he comes from an indigenous background than if he doesn’t, and his/her symptoms may be more likely to be caused by a disease that is more prevalent in those of indigenous background than those that aren’t. This is turn is relevant to both the adequate diagnosis and treatment of this person’s illness. Further to that, the government may have incentive programs aimed at “closing the gap” in the health of indigenous and non-indigenous Australians, some of which can be quite helpful in allowing indigenous persons to overcome some other indirect/social difficulties in accessing adequate health care. So, asking whether a person is of Aboriginal and/or Torres Strait Islander background needs to remain a relevant clinical history-taking question, and one devoid of prejudice from the person who has been tasked with the job of looking after the health of a community consisting of people of all types of backgrounds. And perhaps we should stop fearing to encounter a racist person if it will only make us become the racist one ourselves.

On "the Jews"

I'm on holidays at the moment so here's just a few lines on things I've been thinking about recently.

I just finished reading a book called "Outliers" by Malcolm Gladwell, which I at first thought was about the absolute opposite of what my core beliefs about success are: that everyone has the same innate capacity. And, yes, at first glance it appears to be saying that you can expect to be in low-skill service jobs if you're Latino, you can expect to be good at maths if you're Asian, and you'll probably be a doctor or a lawyer if you're Jewish. And if you're of African descent you'll probably want to kill and physically hurt others for minor slights. Generalizations? Stereotypes? Actually, it deals more on examining the roots of why people turn out to be the way they are based on specific things that happened to the ancestors of their culture, and that for the most part continue to imprint on their futures. An interesting note was made of New York's Jewish community.

In the last week I made my mum visit the Museum of Jewish Heritage in New York with me. Now, she's a very humble woman with a primary school education who can barely pick out the location of countries on a map of the world (e.g. not long ago she was surprised to find out that Spain is in Europe and not in South America like she assumed for a long time). You get my point: she's a humble woman with not a lot of knowledge of what is not essential to her survival. At the Jewish museum while we were looking at concentration camp uniforms and learning about the disgusting things that happened to so many people during WW2, mum asked me, "why did all this happen to the Jews?" I thought it was an excellent question! There's probably no single answer why that did, and there's definitely nothing in this universe to justify it.

What I find even more fascinating, though, is how a great majority of the Jewish community post-WW2 became so prosperous. They were always an oppressed and abused people. They were workers and they had to learn skills. Since thousands of years they've been working (even under slavery conditions) - they had to learn! So the theory goes that around the time of WW2 when dislike of the Jews was quite overt and common, even in the new lands they settled in they were discriminated against for many reasons. So to escape this oppressive environment, Jews after some time used the skills hey had learnt previously, textile and garment industry, for example, and started up their own operations. They hired other Jews. They taught their children the importance of work to better yourself and aiming to equalize opportunity (I maintain that this is the true value of education). The story goes that the children of garment workers went on to become lawyers and doctors and business people at the insistence of their parents - but after they became lawyers (for example) their gentile counterparts still discriminated against them. They ended up working the legal cases nobody wanted, working the medical fields nobody else considered worthy at the time (things like psychiatry and neuroscience, for example). And then, something happened: the Jews had created niches of industry for themselves - which as fate or history would have it, soon became the most sought out niches in industry.

Why did the holocaust happen? I guess there's no valid or all-exhaustive answer to that. But you know what, I believe the best thing the Jewish people ever did was 1) acknowledge their position as others viewed them, and 2) used it not as an excuse to become victims of oppression but to motivate forward action. They were people who once they left the concentration camps, they left the concentration camps. They didn't sit down and feel sorry for themselves for their dreadful pasts and suffering. They began to build instead their prosperous futures. Can't we all learn from that? Once the suffering is done with, let's stop suffering and start building a future we desire.

On theism

The letter released by Yulia Tymoshenko  from her prison cell reminded me of that common saying that “there are no atheists in fox holes”.  Here’s a link to the letter which is an interesting read if you get the chance. In my case this got me to thinking about theism and why we either believe or don’t believe in God (or Gods).

I believe in God, as in that there is a non-human “thing” that started off the universe and still exists in a metaphysical form with power to intervene in anything that occurs in this universe. That’s how people commonly think of God, right? Then there’s, of course, differences in between what people attribute to God in terms of his powers, things he cares about, his opinion and judgement on human behaviour, things he intervenes in, and how he does so. Can I prove the existence of God or can anyone? No. People may raise certain arguments to support the belief in the existence of God, but there is no definitive proof in the way we commonly think of “proof”.

There are people who deny even the possibility that there may exist this metaphysical being who started off the universe. We call these people atheists. There are very few atheists in this world. I respect an atheist who will live his life according to his belief in the same way I respect a person with a spiritual belief in God who is not ashamed of his belief. There are, however, many people who claim to be atheists who mean only to say they don’t belong to any particular religion. But, then, what exactly is an atheist? It is a person who is self-reliant, who in his time of needs has only himself, his fellow humans, and our physical surroundings to rely on.  What’s wrong with that? Nothing! But what usually happens is when those things fail, most atheists become “believers”.

Why do we believe in God or gods? Because we don’t understand evolutionary theory well enough, because we’re ignorant and uneducated, because we lead empty lives and our spiritual beliefs make us feel like we have a purpose or our actions are relevant, because creationism for some reason makes more sense to us than the alternative, because our parents taught us to believe, because our government dictates we must follow religious doctrine, because believing in God seems right, etc., etc. And why do we not believe in God? Because we’re more than self-reliant – we’re arrogant in believing that we don’t need of anyone or anything , because we’re arrogant in the belief that humanity is the most superior being in the universe and don’t need of an external being or belief in an imaginary creature to survive, because we’ve been blinded and can’t appreciate the benevolence of God, because we’re more intelligent than believing in fairy stories any more, etc., etc. … You would have heard or maybe used any of these statements in the past, no doubt, but who’s right? What’s right?

Does it matter? Knowing whether a person believes in God or not tells you nothing beyond whether a person believes in God or not!  Actions, not beliefs, show our true character.

On courageous conversations

Last week I attended an education session on Aboriginal and Torres Strait Islander cultural awareness. The intent was to help health professionals engage better with this subset of the Australian population, and as such “close the gap” between the health of non-indigenous and indigenous peoples (who fair terribly worse in morbidity and mortality). The session was run by a man who identified himself as an aboriginal man and he explained various aspects of what is culture from a psychosocial and semantic perspective. It was interesting and he spoke of a thing called “courageous conversations” – you know, all those touchy subjects on elements of our society which if we comment on we’ll be called racist or bigoted or misogynist or otherwise prejudiced. Racism and the history of Australia (or the U.S.A or South Africa or so many other nations) is one of those touchy subjects. So we all listened to the discussion he presented and he played Professor Michael McDaniel’sreconciliation speech and made passing reference to Kevin Rudd’s “Sorry”speech. The things spoken by these two men are along the same vein, but stated quite differently.

On the 13th of February, 2008, Kevin Rudd, the then Prime Minister of Australia gave a speech to acknowledge the past evils that had been afflicted systematically on the indigenous peoples of this nation. The other purpose of the speech was to apologize to aboriginal peoples of past, present, and future who had been (or will be) disadvantaged or hurt as a consequence of the shameful government policies that existed to purposely suppress aboriginal peoples. The speech was symbolic and groundbreaking, intent on paving the way to improving things in future and learning from past mistakes. This very loud gesture was meant to benefit not only the Australian indigenous people who for decades had had their history and rights suppressed, but also of benefit non-indigenous peoples by empowering them with knowledge and freeing them from the guilt of knowing that their ancestors had done something wrong but they now had the chance to right their wrongs. It was by all accounts a very admirable gesture by the leader of a nation.

Professor Michael McDaniel, an aboriginal man who is also Dean of Indigenous education at the University of Western Sydney, also gave a speech related to the reconciliation process that was occurring in Australia. He told one story of a non-indigenous solicitor who met some elders of an indigenous community and tried to tell them that he was aware of the unfairness and mistreatment indigenous peoples had suffered and he had a plan to propose some “reconciliation”, in this case something akin to acknowledging the land rights of the indigenous first occupants of that land. The aboriginal elders when he had finished his courteous and respectful talk, retold him the history of the Aboriginal people. They told him how his ancestors had raped, stolen, killed, desecrated, abused, and hurt their people in previous generations and how the current generation of their people is still suffering because of his people. The young solicitor was taken aback, surprised, and feeling blamed! What do you say to that? You say sorry. And when you say sorry the better man forgives, right? Right. That’s what we do in our culture, but not everyone’s culture is apparently the same in this respect.

Now, I have varying notions of what a sense of responsibility is, but for a while you have to consider yourself in the young solicitor’s shoes also. Prof. McDaniel explains that to the elders they were simply telling their story in their way, that they needed to do this, to vent, if you will. And at that second when the elders meet this young successful non-indigenous man, “For that moment you are Captain Cook. You are Arthur Phillip. You are the Mission Manager. You are the representative of everyone who did those things”. But you may wonder, why should he be designated the “representative of everyone who did these things”? The logic goes that it is because it is as an acknowledgement that the system and society we currently live in was built to ensure the success, exactly as he has, of a non-indigenous person like him and not of an indigenous person like the elders. So is he at fault because he is successful? Prof. McDaniel doesn’t state it quite like this, but he states that the systems that exist are at fault, they’re the “bad” ones. And yet in the middle of all this is a young man trying to do the right thing given what he has. Prof. McDaniel states he just has to “cop it, because it’s part of the healing process”. I know, I was outraged at his logic too. But you know what? Apparently it's hard for us to understand, he says, because (and I am paraphrasing here) ‘as a young non-Indigenous person, we’ve never had a sense of belonging to a society. We’ve never had “a collective sense of responsibility”’.

Honestly, I liked Kevin Rudd’s speech better. I liked it better for two reasons. As a Christian I always remember that scripture in Ezekiel 18:20 that says, “The one who sins is the one who will die. The child will not share the guilt of the parent, nor will the parent share the guilt of the child. The righteousness of the righteous will be credited to them, and the wickedness of the wicked will be charged against them”. Acknowledging our ancestors sins is one thing, we can even apologize for them and regret it on their behalf, but as for being “punished” or held accountable for it, I believe is a bit rich. My second reason can be summarised in this quote by Antoine de Saint-Exupery: “To be a man is to be responsible. It is to feel shame at the sight of what seems to be unmerited misery. It is to take pride in a victory won by one's comrades. It is to feel, when setting one's stone, that one is contributing to the building of the world”. Guilt is a useless thing unless it motivates forward action. It is honourable to take responsibility for righting wrongs even if they weren’t committed by us. It is not honourable to use punishment unless your aim is for retraining. If your camel is already walking to where you want it to go, it is only cruel to continue to beat it.

On pride and prejudice... (not the book)

I have previously discussed aspects of the discrimination against people with mental illness. Specifically, I have spoken about it in the context of romantic relationships, how remaining together “in sickness and in health” means in health and in most other illnesses expect psychiatric ones. And of course, intimate relationships are not the only context this occurs in. Even in the health industry there is a deep-seated contempt of those coming into hospital medical departments with wounds that are related to a psychiatric disturbance. But what I find even more bizarre is how people can discriminate against themselves, often denying themselves a better existence, because of a connotation to mental illness!

In my job I meet a lot of people, people who we as medical professional often create. Almost every health professional can tell you a story about “some junkie”, a person with a substance addiction that they met along the way. But there’s a particular sort of person that we at times encounter and we don’t immediately think of as “a junkie” but we know that they’re addicted to prescription medication. In my experience, it’s usually the benzodiazepines class of drugs, the Valium-type medications. There’s a few main reasons why benzos are particularly good to get yourself hooked on: 1) they work, 2) gives you immediate ‘results’, and 3) doctors have fewer qualms about prescribing it than other dependence-forming drugs.

A scenario I see very often, and which I admit frustrates me to my core every time, is the young man coming in to see me for his repeat valium (diazepam) prescription. I ask why he’s on it. He says anxiety. I ask how long he’s been on it. He says years. I ask why. He says for anxiety; it’s really “good” at “treating” it. I ask how much he takes. He takes it “only” 2-3 times a day. I do the sums – he is taking huge amounts of it! I ask why he never had his “anxiety” treated, why he didn’t get proper treatment, why he never had counselling, why he isn’t on more appropriate medication. He says it’s because he doesn’t get “anxiety” that often or that it is not very severe; he only uses the tablets every 5 or 6 of the 7 days in a week, 2-3 times a day.

Usually at this stage my heart sinks because the next part of the conversation is also very predictable. I ask does he know it is very addictive. Yes, he knows, but he only takes it when he needs it, those 2-3 times a day on those 5-6 days a week. Again I ask why he takes it (yes, I always pray the patient will have an epiphany – and no, they never do). He takes it for anxiety, of course. I tell him that it must be pretty devastating to be feeling anxious to the point of needing external relief 2-3 times a day almost everyday; surely that would be very uncomfortable. Yes, he tells me, it is pretty unfortunate – but luckily the drugs are so good at “treating” it that as soon as he takes one, within minutes he feels better. I offer a friendly suggestion: wouldn’t it be better to be able to function without having to feel so anxious almost all the time, wouldn’t it be great to be free of the anxiety? Yes, he concedes. Good, I am relieved he agrees! I say ‘ok, let’s get rid of the anxiety then’ (usually I’ll have figured out by this stage that this guy has no time or patience for psychotherapy, he prefers a pill, even a bandaid if that would do it). I suggest this tablet, you take it only once a day, it’s safe, not addictive, and it has a longer time of action so you need only take it once and you won’t have those flare ups of anxiety at random times during the day or week. He doesn’t believe that’s possible. I assure him, it is; in fact if he takes it everyday he won’t even need the valium for those random daily attacks of anxiety because he just won’t be having them anymore!

He has a question for me now: is the medication I am talking about also called an antidepressant? I say, well, it is an SSRI medication which are classed as such, but has a mode of action that will relieve him of his symptoms. At this point he says No!.. But, but, why? He tells me the story again about his anxiety not being that bad, he doesn’t get the symptoms that often (only 3 times a day, 6 days a week), he’s not depressed, he doesn’t need an antidepressant tablet, he’s not crazy, why change what is working, etc., etc. I explain in vain that what he is taking currently, the valium, isn’t working because if it was he wouldn’t need it everyday, multiple times a day. He assures me it does work, because he takes it and he feels better… and eventually I realize that no-one has ever made a person addicted to a substance rationalise about their dependency. It’s the very nature of addiction, there are no great epiphanies – at least not about why ‘feeling good’ is bad. And it breaks my heart that this person would rather take a tablet with much less stigma amongst prescription pills, almost with the status that alcohol has compared to illegal substances, than take the one he really needs. And he makes his choice because of the association this other medication has to “bad things”: a mental illness such as depression. Apparently it’s a matter of shame to have ANY association to mental illness.

Let me now tell you of another class of patient. He also doesn’t want to be thought of as mentally ill. Luckily for him, he isn’t! He has this condition, a complex pain syndrome, a condition that is very difficult to treat. I met a man once who had been diagnosed as having fibromyalgia. The poor guy, was such a shame to see him; he was in discomfort and pain all the time. He had seen a lot of GPs, a few specialists, spent hundreds on natural remedies and iridologists, spoke to anyone that might be interested and asked for help. Eventually one medical specialist got him started on a medication he hadn’t tried before. He didn’t get his hopes up because he had tried many many medications with no relief. But, amazingly, this one worked! He was free from pain; it’d been months, maybe years since he felt so ‘normal’. And then one day he picked up his tablets from the pharmacy and started to read the consumer information page in the pack. And then he read in there that this drug was a TCA – and that the A in that means antidepressant! He was furious, disgusted, so angry at the doctor that told him to take it. It didn’t matter that the tablet alleviated his symptoms; what was intolerable about it was its name, its association. He stopped taking it immediately and attended his doctor to express his disgust.

I spoke to him a few months afterwards, his face was all cringed and he seemed in a lot of pain. He told me the story of what had happened and about how disgusted he was that the doctor had offended him by giving him an antidepressant for his fibromyalgia. He imagined that the doctor thought he was “crazy”, that he was only pretending to be in pain, etc. I let him speak and then I asked it the medication had worked, though. Yes, he said it had – but that was not the point. My heart again sank a little and I explained to him (gently, not trying to tell him what to do), that the TCA type of drugs are commonly used for some types of pain, and that they are very effective. I said they are called tricyclic antidepressants because their original purpose was to be used as an antidepressant but this new use for them had been found and it was great for pain of that particular sort. Yep, good story, Vanessa; he believed me because he knew I have a medical degree, but pride isn’t always about having rational or accurate information. Poor guy, I still see him in so much pain.

Now I’m going to deflect a little to tell you about something I initially thought about when I was at university. There was a ‘gay rights’ rally and in response to someone’s judgement that homosexuality is a disease and a social evil etc., someone had made a banner saying “homophobia is a disease”. It was like the perfect comeback. Only I’m a nerd who probably overthinks things and I was at the time studying medical microbiology and infectious diseases, so I immediately thought: cancer is a disease too. The point is no-one chooses to suddenly grow a cancer because they want to endanger their life or a limb or organ, or because they like to suffer. Most of us can at least empathize on seeing a person sick with cancer, ravaged either by disease or chemotherapy. I have never met anyone who would discriminate negatively against someone with cancer, someone with a disease they did not ask for, a disease that is beyond their control. Mental illnesses are a disease also, something no-one asks for or can internally control. Why should we accept that it is OK to discriminate against those suffering an illness? It’s sad that almost any reference to mental illness, whether people, disease processes, and even the medications used to treat it, still attract such great discrimination. Maybe the time for a new human rights movement is arriving.

On prejudice

One particular group of people that are often targeted by prejudice and discrimination are those we commonly refer to as lesbian, gay, bisexual, transgender, transsexual, intersex, and the newest category, “questioning”. Essentially it could be said that non-exclusively-heterosexual people are often discriminated against. Well, they’re not the only ones and any “minority” group within a society is prone to the effects of prejudice, stereotyping, and discrimination. One thing I have found extremely interesting in the past few weeks, though, is the prejudice towards bisexual persons on behalf of exclusively homosexual persons.

I know, I know, in our personal non-politically-correctedness-contaminated dialogues we would call all people who aren’t exclusively heterosexual, gay. Whatever. Let’s not get into the semantics of these labels. However, do let me get back to the prejudice towards “bisexual” people I’ve noted in the past few weeks.

I remember an episode of ‘The L Word’ where one of the girls who was exclusively homosexual was deriding another female who was bisexual. The argument was something like ‘just make up your mind already’, ‘just decide’. Seriously? Sexuality is a choice now? I found that ironic given the common arguments homosexual persons raise in counter to the religious heterosexual calls to “be normal”.

What’s even more ironic is that a group of people who are passionate to defend from discrimination and claim their rights as the same to any other member of society can also be so equally discriminating of another group of society who face many if not all their same challenges. For example, as I pointed out above, one of the stereotypes often peddled about bisexual people is that they are ‘undecided’ in terms of their sexual preference/identity. The majority of proponents of these and many stereotypes about bisexual people are people who are exclusively homosexual. In reality, both these subsets of people form a larger group of people most commonly banded together as ‘gays’. The banding together is in fact a blessing to these same people, forming greater majorities in the fight for the things that are often fought for: freedom of speech, representation, and other basic human rights. However, once you take away the common struggle, us human beings prefer to struggle against each other, smaller minority groups, the next person lower in the rank, the poorer, the more unfortunate, the weaker in the pecking order.

Just as an educational exercise I’d like to relate some of the other prejudices I hear banded around about bisexual persons:

-They’re not really gay, they’re just promiscuous and would have sex with anyone who was willing.
-They not really gay, they’re just with a homosexual partner at the moment until they find what they really want: a heterosexual partner.
-Bisexual people are promiscuous, they have no loyalty, and they’ll always leave you for the next best thing.
-They’ll always leave you for an opposite gender person.
-They’re just experimenting; they’ll go back to being heterosexual eventually.
-They only care about sex.
-They can’t commit because they can’t even “commit” to either being gay or straight.
-They’re actually just straight people.
-They have to like either men or women MORE.... this more often comes up in the form of a question.
-They just haven’t decided (or figured out) yet whether they’re gay or straight.... They NEED to make this DECISION!
-They’re bad people who only want sex from you.
-They’re just plain bad people...

Sound familiar? Wherever a group of people congregate, smaller cliques of people will form. Why? It’s human nature. It’s part of the process of self-identity. Often we define things for what they’re not. We define ourselves similarly by what we’re not. We’re not like that other group of people, those bad people. Our own societal group is better, it’s right, it’s better than all other alternatives. As we do this we define ourselves: we’re good people, we’re consistent people, we’re loyal people, we are good and worthy human beings. We overlook our flaws: the prejudice, the discrimination, the often derogatory language we use towards the “other” groups. And yet, it is absolutely essential to form our own identity, to define ourselves, to believe we are good and just human beings. The important thing is that once we reach this level of identity we continue to challenge our perspective - to be truly open-minded!

...A quote:

"AIDS. Homosexual. Gay. Lesbian. You think these are names that tell you who a person sleeps with, but they don't tell you that. No. Like all labels they tell you one thing, and one thing only: Where does an individual so identified fit into the food chain, the pecking order? Not ideology or sexual taste, but something much simpler: clout. Not who I fuck or who fucks me, but who will come to the phone when I call, who owes me favors. This is what a label refers to. Now to someone who does not understand this, a homosexual is what I am because I have sex with men, but really this is wrong. A homosexual is somebody who, in 15 years of trying cannot get a pissant anit-discrimination bill through the city council. A homosexual is somebody who knows nobody and who nobody knows. Who has zero clout. Does this sound like me, Henry? I have sex with men. But unlike nearly every other man of whom this is true, I bring the guy I'm screwing to the White House and President Reagan smiles at us and shakes his hand."  -Roy Cohn in Angels in America, by Tony Kushner.

On "coming out"

One of my favourite quotes in the world is one by Gore Vidal that says “There is no such thing as a homosexual or a heterosexual person. There are only homo- or heterosexual acts. Most people are a mixture of impulses, if not practices”. He also said, “Actually, there is no such thing as a homosexual person, any more than there is such a thing as a heterosexual person. The words are adjectives describing sexual acts, not people”. Okay, so some of this argument is about semantics, but it is also about labels.

If you know me, you would know that I have a hatred of labels— and so comes this ambivalence about the whole concept of “coming out”. I do understand that the whole movement started as a way to counter discrimination against certain people because of their sexual practices, to claim back the respect and human rights owed to every human being. I understand how it is empowering, especially to individuals who have been oppressed, to claim with pride the person they are and their right to be. I understand that identifying with a group, coming together for camaraderie, is a very human thing and it is often the only way to bring about societal change. I understand how it came about, what I don’t like, however, is the expectation that is now placed on many people to “come out”, to label oneself as gay, lesbian, bisexual, transgender, or ‘questioning’.

One reason I don’t like the concept of “coming out” is that I find it biased that a person who has sex with a same-sex individual has to tell people about it, yet there is no expectation that a person who only engages in heterosexual acts do so. There are things about the sexual practices of my friends, my family, acquaintances, celebrities, politicians, and many other people that I don’t know about – and quite frankly couldn’t care less about. How old where they when they first had intercourse? What is their favourite sexual position? Are they multi-orgasmic? Do they prefer shaven or hairy genitals on their partner? Do they use toys? These are extremely personal and intimate questions about a person’s sexuality and we rarely are even bothered to know these things about people, so why should we care to know other intimate things like whether they have sex with men, women, or both. Does it change anything? No, it shouldn’t, especially if they’re your friends or family. Seriously, who would like to know all the sexual details of their friends or family? Not me. So why does there need to be this expectation that if you have sex with someone of your same gender that you have to tell the whole world about it? Quite frankly I have friends who are probably virgins, others that may or may not have had same-sex intercourse before, but I just really don’t care to hear about their sexual exploits one way or another. Sexual expression is a very intimate thing, usually only between two people, and that’s the way I am happy for it to stay.

And the other reason I am passionately against declaring your sexual preference is because of my hatred of labels. See, because once you tell the world you’re “gay” or “bisexual” that is all the world tends to see. You in fact lose a lot of your identity and become just a label, often described by a multitude of stereotypes. You may have sex with same-sex persons, but it’s probably not all you do. Maybe you have a job you’re very good at, maybe you follow a certain spiritual belief system, maybe you play an instrument or have a large family; but the moment you label yourself, that to me is like the death of the rest of you. And imagine being known for and described in terms of the things you like to do sexually! We would meet a lot of people, some of them our friends and family members, that were known as masturbators, others dildo-lovers, others anal-lovers, etc. But this is what some of our friends do and yet we think of them as friends, not as “straight” friends or “dildo-loving” friends, just our friends. The things our friends do and enjoy sexually is a personal matter for them and they aren’t and shouldn’t be expected to tell everyone about it, to “come out” as a dildo-lover or anal-bead enthusiast... So to “coming out” as gay or bisexual or transsexual, I say no (unless you consciencelessly choose to label yourself for whatever reason, for whatever secondary gain). To me, labelling isn’t creating equality. Labelling, putting up a division between “us” and “them”, isn’t creating equality between “us” and “them”, it just perpetuates the myth that people who have sex with same-sex individuals are purely defined by the sexual things they do. For me, to say a person is gay is a denial of everything else they are – and they may just be the best human being I know.

On being a foreigner

I once walked into an exam room and the first question I was asked was how I ended up with an Australian accent and a last name like mine. Common question; I don’t mind it all, it’s a great conversation starter. But when I was asked if I ever wanted to go home, I didn’t know what to answer. My home across the river? Yes… but that wasn’t the question.

Milan Kundera wrote a book called ‘Ignorance’ about a girl born in the Czech Republic who moves to France and lives there for about 20 years. Here’s a quote about her experiences as an émigré:

“Oh, the French, you know – they have no need for experience. With them, judgments precede experience. When we got there, they didn’t need any information from us. They were already thoroughly informed that Stalinism is an evil and emigration is a tragedy. They weren’t interested in what we thought, they were interested in us as living proof of what they thought. So they were generous to us and proud of it. When Communism collapsed all of a sudden, they looked hard at me, an investigator’s look. And after that, something soured. I didn’t behave the way they expected…. They had done a lot for me. They saw me as the embodiment of an émigré’s suffering. Then the time came for me to confirm that suffering by my joyous return to the homeland. And that confirmation didn’t happen. They felt duped. And so did I, because up till then I’d thought they loved me not for my suffering but for myself.”

‘Ignorance’ talks about nostalgia. At different times in my life, in particularly the last few years, I have been asked whether I have ever considered returning home. Home? I am home! Home is where my mum is. I guess I’m a foreigner and nothing can change that, not even time. Does it bother me, the expectation that I should long for a place I actually feel no connection to? Yes, the expectation bothers me. My discord comes from not being about to understand why I should not consider this — Australia — my home? Because others were born here and I wasn’t? Home is where I raise up my tent, the place I long for when I’m away. The place I long for is the one that inhabits the people I love, my family. That home is not in Central America; what is there is a memory, not my present or the future I choose. But people have this expectation that is separate to my desires, and this expectation renders me a traitor – a traitor for betraying an ideal that is not my own!

Sometimes people ask me if I remember much about El Salvador since when I left I was around 9 years old. I remember, of course; children remember by the time they’re nine. I remember the things that are of value to me, the good or bad things that shaped me. Some memories are still like photographs and seem distant; some more vivid and play over and over. But yes, I remember. It wasn’t all bad. War was almost always background for us (my family). Family, Antoine de Saint-Exupery’s books, school, and Mexican soap operas on TV were in the foreground (for me, at least). It wasn’t all rosy, either, as some people choose to believe, landscapes which they imagine are irreproducible. And although the war was real, it was something you get around by living your everyday life. People do that, we weren’t the only ones. We weren’t specially apt or adaptable; we were common people living in a place where a lot of common people also lived. Sometimes when there’s a big crack in the ground, people learn to walk around it and pretty soon it’s accepted as part of the landscape which isn’t questioned and you can’t suffer over it. Romanticism is for the memories of the past, you can’t suffer from it in the moment.

Yes, I remember El Salvador, certain places and certain people. Why do people doubt that I would remember? Because they (both “romantics” from my country and people born here who insist my home is elsewhere) don’t understand how I could remember El Salvador and yet not long for it again. Memory is not the same as nostalgia. Patriotism doesn’t and shouldn’t rule memory.

Maybe it’s time I write my own version of my story:
I was born in El Salvador, lived there until I was nine. There was a civil war; I was a kid, I didn’t know the reasons for it and I didn’t have a view either way. My uncle was killed by a land mine and my best friend was killed by a bomb; our family was one of the least affected by the war. We immigrated to Australia with all my family. All of it: mum, grandmother, brothers, sister, cousins and aunts. I didn’t know my father very well, I still don’t. If he is still alive, it is highly probable he is still living in El Salvador. My whole family and my whole life, most of my friends, and my ambitions live in Australia. I am Salvadorian; I live in Australia. I am at home.

On "becoming" beautiful

I recently bought a new camera and I’ve just been taking photos of all sorts of random things and people. One of the things most people will often say to me when I ask to take their photo, though, is “not now, I look horrible”... Now, to myself I think “but this is how these people have chosen to present themselves today, why would that be ‘horrible’?” As I was thinking this, it reminded me of something I noticed a while ago – and maybe it has something to do with self-identity or the human concept of “beauty”. At the same time, I don’t want to be a hypocrite, and I’ll admit I once thought like those people.

Beauty is a very difficult to define concept, of course. You could say a rose is beautiful and say a woman’s face is beautiful, and not mean that the woman’s face looks like a rose. Also, one man’s wife may be beautiful to him but another man who has just met her may think nothing of her. There’s subjectivity involved, history and knowledge of a thing’s other than physical attributes involved, circumstance, and relativity of one thing to another of its kind.

I’ve always liked to take photos of things – just for fun. When I was younger I started to notice how some of the best photos to take are of children. Not all children, but children who are young enough to recognize themselves in a mirror, but not so young as to be too easily distractible when they’re awake. And when I say “the best photos”, I mean those that are most close to reality, the one’s that replicate a moment in time a little closer to the truth. I took so many photos of one of my nieces at one stage because with this childhood innocence came this absolute sincerity that even a camera (in my unskilled hands) could capture. Now, this little girl was just being herself and making it so easy for me to capture that “self”, so I took so many photos because I knew that the day would come where she would ask me if she looked ‘good’ in a photo. In fact what happened was that she then went to school and was taught to smile whenever a camera was in front of her. Don’t get me wrong, she was still beautiful, her appearance evolving with age (as it never ceases to do during our lifespan), but she had lost that sincerity that once came so naturally to her – and all because someone taught her that an attractive – and so photo-worthy face – must have a smile on it. A smile can make any face beautiful, that’s true, but that was probably first said about sincere smiles.

Before this period, though, my niece went through a stage where she figured out that the thing looking back at her in the mirror was herself. She had learnt before that what the general concept of a human face was: two eyes, nose, two nostrils, ears, mouth, hair, and attached to the rest of a body with arms, legs, etc. We first learn by stereotype, it’s essential; the world is just too difficult to comprehend otherwise. The fun times were standing in front of the mirror, her and me, pointing at this little person in the mirror and she realising it was herself because she is standing next to a person that looks exactly like me. Then she would laugh for ages. Most children will do that. They don’t notice that their clothes are all stained from when they spilt food on themselves, that there is things in their hair that came from the grass in the backyard. All these things are inconsequential details, the reality is that there in the mirror are two human beings, one which is herself, and one someone other than herself. This is self-awareness.

To return to photos, though. What is the first thing you notice when you look back at old photos? Yourself! Inevitably that is what you notice, it’s probably instinctual. You disregard the surroundings and the other people in the photo, and it’s not vanity, it’s just constancy to recognize yourself as you once were (because all moments are always in the past). Everybody has a self-image, a physical image and also a cognitive one that would recognize your own style of reasoning or speaking, for example. So the next thing we do with photos is to compare the image in the photo with our internal self-image, but also to this other image about “beautiful” human beings we have been conditioned to believe. So, often the internal thought process goes “does this look like me? does it look like me at my best physical appearance? and, does it look like those models in magazines and film actors?” When we were children the thought process was, “what is it? is it human?” and “who is it?”. Things were much simpler then. So, I won’t go on about how this “beautiful human being” mental image came to be formed because most people can probably guess it already.

My niece grew up, and she still likes photos; she even knows how to pose now. The skill difference between professional models and the rest of us is that the pros know how to look natural in a completely staged environment. That “natural” look and certain biometric features that some scientists with lack of better things to study have found is what we usually define as beauty. But my niece is beautiful too. She is beautiful because she’s my little girl, because she is a child, because there’s this sincerity about her, and because I love her. I’ve said nothing of her appearance, but you get the concept of a beautiful child like the hundreds we’ve all seen before. She is confident in herself and of her appearance. She’ll always let you take her photo, as long as you know she will always smile on cue for you.

But now, as adults, a lot of the people I come across don’t want their photo taken because they don’t look “beautiful” enough. I didn’t want a photo of a “beautiful” person, if I did I’d have cut it out of a magazine; I wanted a photo of the person who I’m asking. Has this image of un-beauty been so deeply ingrained in us or is it a universal lack of self-esteem that makes us shy away?

You know what else I’ve noticed in the last few years also? That the people that make good photos to take of are, other than children, the elderly and indigenous people with little exposure to western society. People of poor countries also have a tendency to view a request from a friend for a photo as a gesture similar to asking for a glass of water: ‘gladly, my friend, if I have enough to give’. And why do they care less than the average person about their appearance? I think because they think of a photo just as that, a thing that eventually will just come to be on a piece of paper as a representation of an event in time. But what about the elderly? Well, then I started thinking that perhaps they have had more time to have also come to this same reasoning, but also to accept their own physical appearance and it’s changing nature.

I was twenty-six by the time I finally stopped feeling ashamed of my own body. My weight has fluctuated since I was young, and since about the age of 12 I was ashamed of it. I’ve always struggled with low self-esteem despite my family thinking that I was OK because I got good grades at school, inside there was this loathing of myself from the core to my very skin. I felt ashamed of my body, to be who I was and how I was, and the last thing I wanted was to look at myself and let alone let anyone else see me. Mirrors were extremely uncomfortable places for me to stand in front of. Having to have a photo taken was almost an offensive gesture made at me. I didn’t want to look at myself. Anyhow, the whole thing made my life not very interactive and lonesome when I was young, though with study commitments I gradually expanded the number of things I became comfortable doing.

When I was 26, in my final year of med school, I finally came to the realisation that this was it, that this was my body, that this is who Vanessa was and I would just have to accept it. I finally realised that the people who spoke to me, who befriended me, or who were otherwise associated with me had chosen to do so despite of what horribleness I thought I looked like. If others could interact with me so easily, accept me as I was, then why should I not? The realisation sounds so simple now, but it had taken me 26, almost 27, years to reach. After that, it made romantic relationships easier to conceive, both in my mind and physically. I felt more at ease with being my true self. And even though 26 (or since) was probably not my best year in terms of physical appearance, I finally also accepted the changing nature of my appearance. And guess what? I finally stopped caring about what I looked like in photos.