Why Gratitude can be difficult for Immigrants and International Adoptees

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Rep Ilhan Omar has recently been criticized for her lack of gratitude to America, a country that took in her parents as they were fleeing war-torn Somalia. The reasoning is that she should not criticize America because this country “saved” her family and provided her with the educational tools to become a legislator.  Further, Rep Omar should be more humble and refrain from criticizing the injustices that she sees in our country as well as our policies abroad, especially when it concerns Israel.

These criticisms have brought back memories of similar conversations that I have heard in international adoption circles. Some adult adoptees have coined the term “toxic gratitude”.  International adoptees are expected to be grateful to their adoptive parents as well as the US for saving them from a life in their birth country.  How can you be grateful for losing not only your birth family but also a birth culture, growing up in a country as a minority rather than the majority? Gratitude implies choice. Adoptees don’t have a choice in their circumstances, in the family or countries that become their forever home. They should not be burdened with the additional weight of gratitude.

Similarly,  immigrants often don’t have choices. If their home country was stable they wouldn’t be looking for a different country to call home. They wouldn’t be leaving a language, culture, food and family to relocate to a place where all of these items present new and difficult challenges. When they arrive in America, they are expected to embrace all that is America without hesitation or criticism. How dare immigrants be ungrateful for the material wealth and opportunities that America can provide.

A recent patient shared her immigration story from an African country with me when she was discussing her post partum low mood. If she had had her baby back in Africa, she would be surrounded by friends and relatives that dropped by daily to visit, often without calling first. Food would be prepared for her and household duties completed. She moved to this country years ago to provide a better future for her children. Now she is questioning that decision, as the lack of community in this country seems too large a price to pay. Would we call this ungrateful or constructive criticism of our culture?

Many adult women in the Somali culture have undergone female circumcision prior to their arrival in this country. Western terminology used to describe this practice include mutilation, illegal, abhorrent and disfiguring. Should Somali women now be grateful that they have escaped this practice for their daughters, only to be raising their daughters in a culture that accepts breast implants and labiaplasty?

Many medical professionals that immigrate to America do not have financial resources to commit to redoing their education in this country. I have worked with many medical interpreters who were esteemed physicians in their home country. Are they to be grateful that their years of medical training and language skills only allow them to explain medical visits to more recent immigrants?

When there is dysfunction within a family, often it takes an outsider to provide better insight and allow each of us to examine what we value in our relationships. Immigrants have the ability to bring the best ideals from their countries and mix with the best traditions from America. We are and have always been a country of immigrants. We should allow immigrants to be a reflection of what is best in this country and acknowledge that we are not perfect but can strive to do better. I am grateful that I have the opportunity to learn from them and share their stories.

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Vagina: The Original Self-Cleaning Oven

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I often use the phrase “self-cleaning oven” when discussing vaginal hygiene practices with my patients. This refers to the fact that the vagina takes care of itself and the use of outside products often cause more problems than benefits. The vagina contains millions of bacteria, most of which are beneficial, just as the bacteria in the intestine. Disrupting the balance of the micro flora by outside products (antibiotics and douching) allows for the overgrowth of yeast and other bacteria that can cause bothersome discharge and irritation. My colleagues and I recently compiled a list of objects that we have seen women place in their vagina that we would not recommend.

  1. A “Lost” tampon – Tampons themselves are perfectly fine, but when they become lost it means you forgot to remove it and the vaginal bacteria are loving their new friend as they multiple in huge numbers trying to remove the offending object. The result is a foul smelling discharge that doesn’t abate until the tampon is found and removed. No further antibiotic treatment needed. Realize the term “lost” is not appropriate, as the vagina is a blind ending tube with sperm being the only object capable of going any farther.
  2. Vegetables. Although not recommended, these are used as inexpensive and easily available sex toys. I will never forget the reeking smell of cucumbers when I was called to the Emergency Room to remove a partially shredded cucumber from the vagina of a very embarrassed young woman. Even if they are removed intact, vegetables are porous objects that can leave behind bacteria that do not belong in a warm and moist environment. And garlic, although technically not a vegetable, just becomes more funky smelling.
  3. Women love to use dress up their fingernails with fake nails, but these can become a problem when you are trying to remove #1. Luckily the bright painted colors are easy to locate when your gynecologist looks with a speculum.
  4.  The natural probiotic properties of yogurt have headlined numerous health articles recently. This does not mean that those probiotics are beneficial to vaginal flora. Trying to get the yogurt from the refrigerator container into your vagina seems like an ill-fated adventure that only ends with the yogurt quickly making an exit and creating a odoriferous mess. Be content with eating the yogurt for breakfast.
  5. Topical skin products. One of my patients noted that since aloe lotion or the plant was beneficial in providing relief to a sunburn, inserting a branch of an aloe houseplant into the vagina would be a quick all-around fix for the vaginal irritation that she was experiencing. Another patient tried a gentle douche with tee-tree oil. Once these patients arrive in the office, it is impossible to determine if the vaginal irritation is due to an underlying infection or to the inappropriate product that was used.
  6. Christmas ornaments, especially the glass kind. With even gentle force, they can easily shatter in a million pieces. You may never celebrate the holiday again if you associate the holiday with an ER visit.
  7. Although you phone can be set to vibrate rather than ring, it should not be used as a vibrator.
  8. Pencils and pens. The ends are sharp and can cause abrasions and trauma, as well as small parts that break off. Keep their function to writing instruments.
  9. Panti-liners. Although I have never found anyone who has mistakenly stuffed these in her vagina, I do have many patients that think the daily use of liners is cleaner than just underwear. The opposite is true as a liner holds moisture next to the perineum and allows for overgrowth of some of those millions of bacteria as well as serving as a highway for bacteria to travel from the rectal area to the urethra, increasing the risk of a bladder infection.
  10. Vaginal Steaming and Jade Eggs. The completely falsified claims of both of these expensive practices have been pushed by Gwyneth Paltrow to financially benefit herself. Not only will they not do what she purports (spiritual detox and balance female hormones etc), but your cash balance will be significantly lower.

The good news is that the healthiest treatment for your vagina is…..NOTHING.

 

Not in my Backyard

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Summer is here, a time when many churches send their youth on mission trips both in the US and abroad. My family is sharing in this experience as my husband and youngest daughter leave in a few weeks to travel to an under-served area in the Midwest. Many youth that travel outside of the US visit areas south of our border in Mexico and Central America. Days are spent painting, teaching arts and crafts to young kids and sleeping on the floor while sharing a single shower at the end of a long hall. Camaraderie between youth group members is built, selfies with cute kids are shared with friends back home, and youth hopefully learn to be more appreciative for the lifestyle that they enjoy. Upon returning home, testimonies are relayed about the difference a smile or a helping hand can make in the life of an impoverished child.

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Unfortunately, when those same citizens of Central America show up on our southern border we are not as generous with our time or our money. In a recent poll, 67% of white evangelicals did not believe that America had any responsibility to house refugees. These refugees are the same parents and kids that youth groups may have visited the year previous on their church mission trip, but when the refugee parents take an active stance in their children’s lives and advocate for their future safety by making the dangerous journey to the US, they are separated from their children, and the children placed in camps without adequate food or hygiene. Where did all those friendly American faces go who were only to happy to provide coloring books and games when visiting  Central America? Now the US government argues whether soap and toothbrushes are part of basic hygiene.

Some churches are doing the work that Jesus commanded when he exhorted his disciples to care for the poor and forgotten. They have opened their doors to refugees and help families find their relatives and become resettled.  But these are the minority and more are needed. What if we used the millions of dollars that is expected to be spent on church mission trips over the next 5 years and research programs that will allow many of these refugees to make a living wage and stay safely in their homeland. For example, a recent article by the NYTimes details the falling price of coffee beans as a driver of Guatemalan immigration when families are unable to support their children in rural parts of the country. The primary exporter of these beans, Caribou and Starbucks, are making even larger profits as their cost of supplies is lower. Putting people over profit would mean that part of the increased profit be used for community development to keep families together… in their own country.

Individuals are not corporations with large profits but we can make small contributions that make a difference. If we don’t want to stare at pictures of refugees on the southern border that pepper our news-feed daily, we should research organizations that are working to improve the daily lives of these people and contribute. Spend the hundreds of dollars that would pay for a youth trip abroad on a tax deductible organization working in Central America and then volunteer with your youth at a local homeless shelter or food bank. You might both learn a few lessons and share a memory for the future.

 

Girlfriends are like a box of chocolates. You never know what you’re gonna get.

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Girlfriends have always been difficult for me.  In high school, I was the nerdy, science loving girl who would rather have my nose buried in a good book rather than the latest Teen magazine. While I moved on to college and then medical school, my high school friends attended trade schools, got married and started families. My friends in college had a more expansive view of the world than my limited scope incurred from a rural small town childhood, making it difficult to connect.  Their summers/school breaks involved vacations and unpaid internships while I was constantly scrambling to find multiple well paying jobs that allowed me to live in the city while earning enough for books and pocket money.

Once I arrived in medical school in 1983, only 1/3 of the class was women and most of my classmates had well established relationships with friends from college and high school. Developing friendships was fraught with the knowledge that we would soon be moving out of touch as we started residencies across the country. I met Lisa, a fellow medical student, during our third year of medical school when we shared a internal medicine rotation. I think we connected because we had both grown up in southwestern MN and shared many of the same high school experiences. Other shared rotations allowed us to reconnect but then we lost track of each other when I moved to Colorado for residency and she moved to Bangladesh after her residency to work. Social media connections had yet to be conceptualized, which is why I love when circumstances occur that connect us to someone from our past. 20 years later, while working in the kitchen as a parent volunteer at Korean culture camp, we reconnected while chopping vegetables for lunch. We shared a family structure that included both birth and adopted children and each of us were working full time in our physician careers. Since then, our adopted daughters have become best friends and despite living 3 hours apart, talk to each other more than they talk to their mothers.  It seems like it was meant to be.

 

 

Moving to Colorado for residency was a major physical and psychological move for me. I had barely traveled outside of MN during my 26 years and although I hadn’t lived at home since I left for college, I always knew my family was a 3 hour drive away. My co-resident, Marie, was the opposite. She had moved across the country for college and had a thirst for international travel as well as women’s reproductive rights. I admired her convictions and activism, as well as her spontaneity and community spirit. Following residency, we kept in touch by an occasional phone call and yearly Christmas letters. I was intrigued by her ongoing activism for women’s reproductive rights and became more involved in numerous organizations on her recommendations. Because of her involvement in an international organization that was promoting a new method of cervical cancer screening in developing world countries, I saw the need in Haiti and started teaching this method to Haitian providers as well as implementing a screening program. I heard about Dining for Women via her Facebook posts and was motivated to start my own group. Marie continued to be involved in these groups as well as advocating at the legislative level until her untimely death last year due to complications following a heart transplant. At the same time as her illness, I was contemplating a sabbatical from work that involved teaching in Haiti and Vietnam. She was upset that I was “considering” this option, rather than executing the plan. If possible, she would have been next to me on the plane, oxygen tank between us as we shared a drink and laughs. Instead, I spent one of my nights in Haiti mourning and celebrating her wonderful spirit as her family celebrated her life in a memorial service a hemisphere away.

 

 

Some obstetric patients become more than just patients.  Hieu is much younger than I, but we connected over mutual interests (ethnic food, rural roots, 3 sons) and given her close proximity, my daughters were included in her babysitter list. After her last child was born, I was mournful that I wouldn’t see her again.A few years later when she was seeking a change from full time to part time work as a surgical PA, she applied for a job at our clinic and has become our second set of hands in the operating room. She was not about to let me travel to Vietnam (the country of her birth) without offering to act as translator and cultural guide. Lisa offered to be our third wheel, craving the adventure that she had experienced years earlier in Bangladesh.

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The sheer joy that I experienced with these 2 women for a week in a foreign country is difficult to describe. It took Lisa and Hieu only one shared meal to feel that they had known each other far longer than the time it took to eat. These were friendships that had I had made, lost and then reformed. Marie was watching all of us from the other side, accepting thanks with a smile as I realized  it was her nurturing spirit that had brought all of us together on the other side of the world. At the beginning of each of these friendships, I never could have imagined the life path I would take that would eventually bring all of us to the same destination. That box of chocolates has been bittersweet, but well worth the experience.

President Trump – I don’t execute babies.

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Dear Mr Trump,

This weekend you spoke at a rally in Wisconsin and referred to physicians in my profession (Obstetrics and Gynecology) in an untruthful manner. A few weeks ago on this blog, I tried to educate elected officials about women’s bodies and how they work.  Words matter and so do facts. It is why women depend on an unbiased discussion with their physicians when they are at their most vulnerable…. dealing with an unanticipated pregnancy outcome. The situation you describe never happens.

“The baby is born, the mother meets with the doctor. They take care of the baby. They wrap the baby beautifully. Then the doctor and mother determine whether or not they will execute the baby.” President Donald Trump, April 27th, 2019.

Since I am sure that you have never been in this medical situation, and I have, let me inform you as to what really occurs. When a determination is made that an infant has an anomaly incompatible with life, multiple discussions occur with the mother, her family and physician experts before the birth. While a family is not able to change the eventual outcome,  they are provided with choices as to how they wish to proceed. Some families chose to end the pregnancy soon after the diagnosis, others continue to wait for labor to ensue. Sometimes the infant passes away while decisions are being made. At all times, the mother and her family are provided with non-judgmental support and ongoing medical care. The entire medical team (nurses, ob/gyn, pediatrician) at the hospital are aware of the level of care that the parents have determined they would like to provide for their infant after delivery. Sometimes this involves no monitoring during labor so that difficult decisions about operative delivery do not need to be made, other times parents want to do everything possible to make sure that their child is alive at delivery. Some parents want to hold their child for the few minutes or sometimes hours before the child passes away, saving every last memory with pictures and mementoes of their child’s short life on this earth. Other mothers are too grief stricken to hold their infant and choose some other family member or nurse to comfort their child. I have had some families change their plan midway thru delivery. That is their right – it is my job as their physician to honor that decision.

Obstetricians want what is best for their patients to heal from this enormous loss. We don’t want the memory of a child hooked up to IVs in an NICU when it won’t change the outcome. That child deserves to be held by a human for their last breaths.

Unlike what some would have you believe, these situations are rare. The few times I have attended such a delivery, I often have as many tears as the parents. We arrange for babies to stay in the room long after they have passed so that parents can say a long good-bye if that helps them to grieve. Mementos are created with hand and footprints, locks of hair, tiny hats and booties. No one ever conspires to commit infanticide or execute an infant. Words matter. Please don’t insult the families who have experienced such losses with your conspiracy theories. These families have been thru a personal hell and only need our support as they heal.

 

 

A letter for Elected Officials

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Dear Senator, Representative, Governor, State Officials,

It has recently become noticeable that many of you are trying to pass laws that affect women’s bodies, without the knowledge of how women’s bodies work.  As an Ob/Gyn for 25+ years I feel that I am somewhat of an expert on this topic and would like to set the record straight on a few common misperceptions.

  1. On average, women start menstruating at age 12-13 and finish around age 52-53. The lifetime cost of pads and tampons is estimated to cost a woman approximately $1800. Most women I know do not consider bleeding for 7 days each month a luxury, but many of you have legislated the addition of a luxury tax on feminine hygiene products. Women already pay more for our clothing than similar clothing choices for men, so an additional tax on a product that only women use seems to be singling women out for monetary punishment. Not only should the luxury tax be abolished, but we should provide tampons/pads in every bathroom that has toilet paper.
  2. We also bear the financial burden of contraception. Short of permanent contraception with a vasectomy, the only method of contraception available for men is a condom, which is relatively inexpensive and does not involve an office co-pay to obtain. With the implementation of the Affordable Care Act, contraception is provided free of charge under the majority of insurance plans and has markedly increased the use of the more expensive, but vastly more reliable, long acting contraceptive methods such as IUD’s and Nexplanons. Abolishing the ACA will allow insurance companies to retract this coverage.
  3. Contraception does not cause a pregnancy to abort. Please educate yourselves on the scientific facts behind contraception and don’t spread false information that makes it all the more difficult for those of us who care for women to do our jobs. Birth control methods such as pills, Depo-Provera, Nexplanon, rings and patches work by preventing ovulation (the release of an egg from the ovary). IUDs thicken cervical mucous and provide a hostile environment to sperm, killing them before they get far in their journey to the egg. Plan B, or the morning after pill, also disrupts ovulation and prevents fertilization.
  4. A “normal” menstrual cycle is considered 25-34 days. As most women will tell you, sometimes our cycles can be shorter or longer than average. This accounts for the reason we have stashes of tampons/pads in interesting locations outside of our homes (car, purse, backpacks, office desks, suitcases etc). We have busy lives and are not always counting the days until our next menses and may not realize that we are late until a few weeks have passed. Thus, the 6 week heartbeat bill that many of you have passed does not allow us time to recognize we have missed a period, take a pregnancy test (also paid for by women at an approximate cost of $20) and then make an appointment at a clinic to confirm that double blue line that appeared on a pee stained stick at midnight when our long day was finished.  All of this usually occurs while our partner is clueless as to what his plans are for the upcoming weekend.
  5. Responsibilty.  Pregnancy happens when a man AND woman have sex. The “and” is the important part. Texas has introduced a bill that would allow for the death penalty if a woman seeks an abortion, with no mention of a penalty for the other sex. Our society needs to start holding men as accountable as women for an unintended pregnancy and the decision to end that pregnancy.
  6. Hormonal methods of contraception can provide long-term health benefits to women. 5 years use of birth control pills decreases the risk of ovarian cancer by 50%. Because of the obesity epidemic, the rate of endometrial cancer is soaring and Mirena IUDs can be used for both prophylaxis and early treatment in those women who are not good surgical candidates. The recent federal funding of anti-abortion clinics in California that are opposed to any form of contraception outside of natural family planning, do not provide “comprehensive women’s health care” as advertised in that they have no resources for treating women’s health problems outside of reproduction.
  7. Sex Education. Just as you as an elected official should educate yourselves, we also need to provide sex education for our children so that they can best take care of themselves. Abstinence only education has been proven not to reduce teen pregnancy. Comprehensive sex education not only reduces teen pregnancy but also decreases the rate of abortion as there are fewer unintended pregnancies. Seems contradictory to be both pro-life and anti-sex ed, but that is what many of you embrace.

Women have trusted me with their health and bodies for years and I have respected that trust by staying up-to-date on the changes in health care as well as offering each patient the full spectrum of choices without judgement. I would expect that our government officials would do the same. Please feel free to contact me if you have questions.

Sincerely yours,

Leslee Jaeger, MD

 

The life of a woman in Vietnam

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International Women’s Day, a day to celebrate the accomplishments of women both past and present, was celebrated earlier this month.  During my recent trip to Vietnam helping to care for women patients, I had the opportunity to hear many women’s stories, see their hard work both in the hospital and in the shops and visit the Women’s Museum in Hanoi.

Each day on my walk to the hospital I encountered women that had arisen before dawn to start food preparation at their street-side restaurant or had traveled to the wholesale market to purchase fruit for sale at their sidewalk stall during the day. Many of these women have husbands and children who live hours away in a rural location who they only have the opportunity to visit a few times each month. The income earned in the city makes it possible for their children to attend school, as public school carries fees of $25-30 each month.

Women who remain in rural locations closer to their families are responsible for all the domestic work in addition to working in the families rice plot. The rice plot is a source of not only food for the family, but also cash income as some of the rice is sold. While Communism has afforded women the opportunity to be employed outside of the home, it has not coerced men into assuming any of the household responsibilities. A Vietnamese meal is delicious, but time-consuming to prepare as it contains no processed components. Due to lack of refrigeration, prepared food is consumed immediately and there is not the availability of saving food for a future meal.  In the urban areas, many of the married men in their 30-40’s helped with some of the food prep and child care. This cooperative marriage model has not filtered out to the 65% of Vietnamese who live outside of the cities.

 

 

Similar to China, Vietnam has a 2 child policy that was implemented in the late 1980’s to control population growth. A patriarchal society that depends on a son to carry on the family name often comes into conflict with the reality of a family that consists of 2 daughters. This has led to utilizing abortion for sex selection and upsetting the gender balance of the society. Although contraception is free there is a lack of sex education and general taboo against pre-marital sex, resulting in many unplanned pregnancies outside of marriage. Young girls bear the brunt of these cultural beliefs, often visiting clinics or hospitals in secret to have an abortion.

Approximately 1/3 of the ob/gyn residents I worked with were women, most unmarried and living at home with their parents. Only a few of the attending physicians were women, a prevalence that was familiar from my early residency days. One of the attending physicians lamented the dual roles that Vietnamese culture places on professional women – achieving personal high educational performance and job status in addition to perfection in raising children and household responsibilities. Young women physicians worried that their “advanced age” of 25-27 years was making them less eligible for marriage. It seems that women in Vietnam and the US share many of the same concerns regarding careers and home.

Family is very important to Vietnamese, influenced by the Confucius culture of China. The most important job for a woman is to bear children and her worth within the community is influenced by this ability. Having sons is considered the highest praise. Adoption is only considered if a couple is unable to have children of their own. Each day as we saw many women in clinic, one of the first items discussed in their health history was whether or not they had children. It was assumed that all women wanted 2 children, without asking the woman. For this reason, there seems to be an unwritten taboo against birth control, as even health professionals falsely believe that it may influence a woman’s future ability to become pregnant. Unfortunately this mindset has resulted in Vietnam having the highest abortion rate in Asia. Abstinence only education doesn’t work in either America or Asia!

Walking the crowded hallways of the hospital on the obstetrical floor afforded me a brief glimpse into the world of women as they supported each other during the process of childbirth. Sisters, mothers and mother-in-laws often surrounded the pregnant women as she labored on a narrow cot or weaving her way down the packed hall. Food was cooked at home and brought in, urine buckets were taken away and emptied, arms were offered for support. Older women help new moms to breast feed and care for newborns. After a 7 day stay in the hospital (compared to 2 days in the US), moms are proudly escorted home by their husbands on the back of a scooter – the primary means of transportation in Vietnam. If employed, they are eligible for 6 months maternity leave.

Compare this family centered care to the medical care of women in labor or gynecology. Acquisition of technology to advance medical care has markedly improved in the past 10 years, but there has not been a similar interest in developing patient centered care. Women deliver their babies on a unpadded metal table with no family or friends nearby and nurses and doctors that are too busy to provide comfort. During gynecology clinic, patients are led into a room containing 10-15 students/residents/attending physicians that are all discussing her medical record. The nurse helps her climb up onto the exam table, again unpadded, so that she can undergo 4-5 pelvic exams while everyone continues to watch and discuss. Sometime after she leaves the room, a physician has a brief conversation with her and her family in the crowded hallway with a treatment plan. Most of these women feel privileged to be able to afford this care as it is only available to those who can pay the yearly fee for health insurance.  They have the opinion that “the doctor knows what is best for me” and don’t question recommendations. This is changing as patients in private hospitals are demanding more interaction with their physicians and lawsuits have started to climb.

As in many parts of the world, the power and influence of women is changing age-old traditions. The overall rapid progress of change in Vietnam elevates the voice of women as they advocate for change that benefits their role as well as that of policies that benefit their families. Our role in the West is to provide educational support while allowing leaders within Vietnamese health care to create systems that work for their people.

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