The birth of the Roman Republic, which would soon transform into a vast empire with a monumental legacy, has brutal origins all beginning with a rape victim. It’s no secret the Romans were excellent storytellers; the proof is longevity. Roman myths, passed down for generations, outlived their society and continue to echo off the tongues of modern storytellers.
The story of Lucretia is a mythological and historical tale that has survived since the early origins of Roman history, over two thousand years since its believed origins in 509 BCE. It was narrated and criticized in several different versions of works by prolific Roman writers such as Livy, Ovid, and Dionysius. Gaining popularity immediately after her death, Lucretia became a legendary symbol of beauty, virtue, and chastity. Subsequently, Roman society encouraged women, and especially young girls, to view her as a matron for model behavior.
As the victim of the story, the glorification of Lucretia’s story after her death reveals deeper insight into the sexist roles women were expected to conform to in ancient Rome.
In Book 1 of Ab Urbe Condita, “From the Founding of the City,” Titus Livius, or Livy, a Roman historian whose works are largely viewed as reliable historical sources, recounts Lucretia’s story. Livy narrates the events leading up to the climax of her rape, as well as the aftermath and her impact on the founding of the republic. The story begins with Lucius Tarquinius Collatinus, Lucretia’s husband, and his companions drinking at the house of Sextus Tarquinius, son of the king Tarquinius Superbus, one night. The men drunkenly argue on the subject of wives, each man praising his own, and Collatinus decides that the mere sight of his wife at such late hours would put an end to the debate altogether. They mount their horses and head to Collatia, a Roman town governed by Collatinus, and into the quarters where Lucretia resides. Upon entering, Lucretia is seen weaving wool by herself by the lamplight with only the company of slave girls, unlike the other wives who had spent their night mingling and drinking with each other. This alone is meant to portray her legacy as a woman of the utmost chastity and virtue. Lucretia wins “the prize of this contest in womanly virtues”1 for her devotion to her husband and home. Sextus, intrigued by her beauty, is “seized by wicked desire”2 to conquer her modesty.
A few days later, he returns to Collatia again, this time without Collatinus. His motives unsuspected, Sextus is welcomed to dinner in their home and is provided guest chambers for his seemingly innocuous visit. Late into the night, he enters Lucretia’s room while she is asleep. A knife in one hand, Sextus holds her down while clasping onto her breast with the other, and threatens her to comply with his wishes, otherwise he would lay the dead naked body of a male slave next to her corpse and frame her for adulterous acts. Sextus then rapes her.
Afterwards, Lucretia, frightened and upset, sends a message to her father and Collatinus to return home with trusted companions so that she can recount all of this. All of the men are enraged by Sextus’ actions. They reassure her that “it is the mind that sins, not the body.”3 This part of the story is particularly interesting as it challenges the norms in Roman society by unexpectedly diverting blame onto the perpetrator rather than the victim who was raped. In the end though, Lucretia deeply fears that her virtue has been “ruined” by Sextus and does not wish to be an “impure” example to Roman wives. She admits that although her heart does not hold any guilt, and that she absolves herself of blame from the rape, she still cannot free herself from punishment. Lucretia reveals a knife she hid under her dress and thrusts it into her chest out of shame as Collatinus, her father, and their companion named Junius Brutus bear witness. Just before committing suicide, she urged the men to decide Sextus’ fate. It is evident she herself prefers to die before being seen as a role model to unchaste women.
Lucretia’s rape was also the impetus of political revolution in Rome. Collatinus and Brutus led the overthrow of Sextus’s father and exiled the Tarquins from Rome. A new form of government was established in 509 BCE, with Collatinus and Brutus serving as the first pair of consuls of the Roman Republic.
Lucretia’s suicide was socially viewed as honorable by Romans, and she was subsequently immortalized as a heroine. Given that her story serves as thematic for proper behavior for women in Rome, it further reveals incredibly sexist ideals present in Roman society. Lucretia’s position as the embodiment of pudicitia, a term used to describe virtuous women, would only grow after she died. Sexual ethics were deeply conceptualized in ancient Rome; there were several intricate terms to describe one’s social as well as physical position regarding male and female sexuality. Pudicitia was a distinctly feminine descriptor of one’s character, predominantly in relation to morality and sexual fidelity.
It is important to recognize that the male equivalent of this quality did exist in the form of virtus, meaning virtue, although not nearly to the same extent women were judged. Pudicitia was not praised as a positive ideal in men, rather, it was viewed as a neutral trait for males, and could sometimes be simply reduced to whether they acted in the dominant role in sexual relations with other men.4 Much of the explanation as to why a woman’s chastity held so much value in ancient Rome was due to the fact that it ensured they were kept “pure” for men until marriage. Lucretia’s virtue and sexual modesty was promoted as a feminine ideal through “deeply conservative and patriarchal impulse.”5 It is important to address the emphasis on virginity as men were certainly not scrutinized to the same standards. Roman girls were purposefully married young, the legal age twelve, to “ensure an undefiled body and mind.”6 This view alone amplifies the misogynistic logic used by the ancient Romans to control female sexuality and restrict freewill.
As expected, Roman societal structures continued to subjugate women throughout the longevity of the republic and empire. The specific reasons for this perceived inferiority of women thrived on their generalization as “fragile and fickle, therefore in need of protection.”7 A plausible explanation for these rigid social structures is the historical dichotomy of men as “protectors” and women as “childbearers.” Additionally, it was a widespread belief that women were “emotional, irrational, and intellectually less capable than men”8 to the point where objections to such beliefs were controversial. In a speech written by Livy, capturing the thoughts of Cato says: “Our ancestors decided that women should not handle anything…they should always be in power of fathers, brothers, husbands. If once they get equality, they’ll be on top.”9 In contrast, Musonius, a Stoic philosopher, argued that women possessed reason and logic, were inclined towards good virtue just like men, and that “men should have as high a standard of sexual virtue as women.”10
Marriage was beyond a sufficient reason society deemed it unworthy for girls to continue their education, instead prioritizing domestic tasks and tending to the wishes of their husbands. It is also dire to address the fact that the majority of the available information about the daily lives of Roman women is provided through the lens of men, often incidental in orations or letters or poems.11 It is clear the ancient Romans did not prioritize women’s education nor urge them to contribute to literature or philosophy. The already lacking information about the daily lives of women is focused on upper class women, with scarce information about common women. In the study of classics, a field that has traditionally been dominated by men, studying the lives of ancient women was an academic priority until recent feminist perspectives concerning historical analysis emerged.
It is known that Roman women were established as subservient to men in all aspects of life; their names were technically not even their own. A Roman woman’s name was the feminine form of her father’s gentilicium during the early republic, which was passed down to all of the sisters, and also shared with aunts and cousins on her paternal side.12 Marriage was largely an social and economic proposition for both parties since the Romans rarely married for happiness and romantic love; the latter was usually reserved for extramarital affairs.
Additionally, women had limited citizenship status, meaning they could not vote or run for public office, and in many cases their properties were under control of their father and eventually husband. Specific terms evolved for circumstances of marriage: cum manu, “with the hand,” and sine manu, “without the hand.” A woman who was married cum manu was no longer under her father’s authority, but under the legal control of her husband.13 This meant that she was under potestas, “power,” of her husband rather than her father. If she was married cum sine, which was common in the late republic, she remained under her father’s control. She needed his approval to make important financial transactions, and “might have her marriage ended by him even against her wish.”14 In a divorce, which women were allowed to bring forth under legally valid conditions, children were no longer left to her, but rather to her husband’s family.
A woman’s influence was not acknowledged in the public sphere; they were restricted to domestic matters concerned with running the home. Such partially demonstrates why Lucretia was glorified above the other wives from the moment Collatinus and his companions found her tending to her weaving, historically one of the most domestic chores, instead of away socializing with other women. A “virtuous” Roman wife influenced by the precedent of Lucretia behaved modestly, felt great devotion to her husband and tended to his needs, and most importantly valued her chastity, and in this legendary case, above her own life.
The widespread idealization of Lucretia in ancient Rome provides insight into the way Romans viewed the social structures of gender, family life, law, and marriage. Often portrayed as a docile victim, it is clear Lucretia embodies the submissive traits women were expected to display in order to fit the status quo. Although in modern times her story is often regarded as a mere puzzle piece in the larger image of ancient Rome, it continues to raise questions regarding the position of women in a society where they were severely oppressed.
People have always been interested in learning about influential people’s lives — through both gossip and the media. Whether we’re learning about Jennifer Aniston’s new fling, Kim Kardashian’s pregnancy, or Harry Styles’s secret vacation, we often interest ourselves with other people’s lifestyles, namely celebrities, because we feel as if we personally know them through our powerful admiration and devotion. We see celebrities as heroes; people we aspire to be like. But why are we so drawn to the lives of villains as well?
Recently, women have developed a strong obsession with true crime, a literary and film genre in which the author examines an actual crime and exposes the actions committed by real people; specifically, there has been a sudden fascination with serial killer crimes. This infatuation with evil reveals our desire to uncover the secrets and truth behind those who commit the horrific acts we abhor. Perhaps it fascinates us that these famous perpetrators hold such obvious disregard for morality and societal values; we feel obligated to witness the dramatic scenes unfold as a means of “preparation” for any real-life danger.
From Ted Bundy to Charles Manson, women often find themselves deluded into romanticizing famous serial killers. We find it hard to accept that attractive people are just as capable of committing grotesque crimes as ordinary people. Recently, the Joker movie played by Joaquin Phoenix, though fictional, has captured the attention of young girls infatuated with his depressing life story and motivation to commit heinous crimes that are similar to real killers. Though women are more likely to be victims of a major crime, for some reason they feel increasingly attracted to the vile and twisted side of history, intrigued to learn about the ways in which they can face danger.
Psychologists conducted a 2010 study at the University of Illinois to investigate the relationship between gender and the true-crime audience. Psychologist R. Chris Fraley and their team discovered that women wrote 70% of the true-crime book reviews on Amazon, while men felt a greater connection to war books, writing 82% of reviews (Yates). The researchers hypothesized why women may feel an increased inclination to read more true crime and suggested that such stories can provide useful information that may help readers avoid or escape potential attacks such as murder or rape. To investigate this claim, the psychologists reviewed the summaries of the books most often reviewed by women. Further study revealed that women were more likely to read a true crime book if the victim used a clever ‘psychological trick’ to deceive and escape from their perpetrator. Unsurprisingly, women also felt attracted to true crime books with female victims. Thus, evidence strongly suggests that women tend to read more true crime books with clever female survivors because they provide a ‘guide’ of instructions as to how to avoid deadly encounters in real life. If women consume as much violence as they can in art, maybe they can escape the true violence that unfortunately lingers in our reality.
Recently, the producers of All Killa No Filla, a British podcast dedicated to exploring the lives of serial killers, found that roughly 85% of listeners are female (Woman’s Hour). BBC Radio 4’s Woman’s Hour considered why their listeners consisted mostly of women, and invited Dr. Gemma Flynn, a criminologist at Edinburgh University, and Rachel Fairburn, co-host of the famous podcast, to explain their theories. Dr. Flynn believes that a major explanation for female true crime listeners includes women retaining an extensive fear of crime. According to Fairburn, “women love true crime because pretty much from the time that we’re very small, we’re told to be careful, look after ourselves, watch out for bad people, make sure we get home safely” (Woman’s Hour). The host suggests that society constantly attempts to protect women from danger, instilling in their minds that as long as they’re alone, they can be attacked. Thus, women tend to leave their house with a constant target on their back and safety on their minds, attracting them to true crime out of self-preservation. With the stereotype and widely held belief that women cannot walk alone at night because of possible attacks, women feel the need to protect themselves as much as possible, consuming true crime stories at the top of their list.
The constant fear society holds regarding women as potential victims of brutal crimes stems from the media’s infatuation with blood and murder. According to a 1992 study conducted at SUNY Oswego,mass media “serves as the primary source of information about crime for up to 95% of the general public,” with approximately 50% of news coverage devoted exclusively to crime stories (Mann). With this extensive reporting on crime and violence, Americans fall victim to their availability heuristic, a mental shortcut that relies on immediate examples that come to a person’s mind when thinking of an idea or event. Because of the increased attention presented towards crime on-air, Americans may not believe that the crime rate has actually decreased over the years since all they hear about is murder, rape, and violence when they turn on their televisions. While murder rates decreased by 20% from 1993 to 1996, reporting on murder on television rose by 721%. (Mann). This affects women especially as the constant fear perpetrated by the media regarding crime and murder may be a key reason in females’ attraction towards true crime media.
Now that we understand why women tend to reach for books labeled with the true crime genre, the compelling question needed to be answered is why women romanticize these vile human beings. After the release of Extreme Wicked, Shockingly Evil and Vile, a film on the life of Ted Bundy based on the perspective of his girlfriend, viewers went to Twitter to express their newfound admiration for the ‘misunderstood’ villain. Ted Bundy was portrayed by attractive and talented Zac Efron, only attracting more fans to the Ted Bundy “fandom,” a group of teenage girls infatuated with the killer (Donaldson). Some tweets include: “Love that conservative masculinity #TedBundy,” and “Ted Bundy is so hot… wish he killed me” (via Twitter). The women who romanticize serial killers like Ted Bundy and Charles Manson can be described as having hybristophilia, or sexual arousal “over someone committing an offensive or violent act,” as described by Dr. Katherine Ramsland, a forensic psychology professor at DeSales University. These women admire the idea of being the ‘exception’ for a damaged person; they feel the need to ‘nurture’ and ‘protect’ their powerful and evil lovers. These women fantasize about “changing” the broken part of serial killers; they want to “fix” them; usually, women who admire such behaviors have trouble with conventional relationships due to insecurities. If she dates a serial killer in jail, at least she’ll know where he is all the time (Psychology Today).Additional research indicates that women feel attracted to masculinity and may interpret serial killers’ unchecked aggression as ‘protective’ or ‘manly.’ Women may feel that these attributes will keep them safe and secure, and thus may prefer more violent mates (Perrett).
Whatever may be the reason behind women’s fascination with serial killers, this infatuation proves fatal. When Charles Manson and Ted Bundy awaited death, thousands of female fans lined up, expecting to marry these vicious men, refusing to believe their crimes simply because of their attractiveness (Sutton). The never-ending fame of attractive serial killers depicts the true danger: our inclination as human beings to automatically trust and like attractive people, simply because of their looks. Many women fell prey to Bundy and Manson’s traps simply because they might’ve misjudged them for being kind, respectable people because of their beautiful smiles or bright eyes. Though Netflix and other entertainment providers may attempt to raise awareness of real tragedies, it is important to also consider the danger of awareness. Today’s generation may be too infatuated with Zac Efron’s looks and appearance in Extreme Wicked, Shockingly Evil and Vile to realize that his charm was what allowed many to overlook his apparent misogyny and objectification of women: “Women are possessions… Beings which are subservient, more often than not, to males. Women are merchandise” (Wyman).The tales of these serial killers should serve as a warning to many women, rather than favorable romantic heroes; we really don’t know what people are like behind closed doors. We need to remind ourselves who these serial killers actually are: vile, immoral men disguised as educated, charismatic professionals; they are not compassionate or need protection – they do not feel. We must not grieve or sympathize with men that never existed.
My phone lies face down on the table beside me, buzzing sporadically, but insistently. I ignore it, fanning myself against the mid-July heat as I attempt to concentrate on an assignment for my summer class. I drum my fingers against the desktop and whisper the words aloud to myself, trying to make sense of the convoluted sentences of the essay as the buzzing continues. What do they want? I think exasperatedly, assuming my friends are simply spamming me with memes from Instagram and funny Tiktoks. As I finish the reading passage and move on to the multiple choice questions that accompany it, I decide to spare a glance at my phone. Expecting to see Instagram direct messages (DMs) and text messages headed by my friends’ familiar usernames and contact names, I am shocked to instead see hundreds of Instagram comment notifications from unfamiliar usernames, all beginning with the common header “[Instagram user] mentioned you in a comment.” My heart racing in anticipation, I open the Instagram app and quickly scroll through my notifications. I had left a comment criticizing France’s April 2021 ban on hijabs (headscarves worn by women for religious reasons) for Muslim women under the age of 18 on a post advertising travel to the Eiffel tower, and now I see that all these comments are in response to mine. Some of them back me up, but others range from applauding France’s actions, to blatantly calling Islam backwards and incompatible with Western civilization, to attacking me as a young Muslim woman myself. I exit the app without bothering to respond to anyone and close my eyes for a second, my heart still pounding as the hate words flash through my mind repeatedly. Like me, young Muslims everywhere are exposed to Islamophobic rhetoric on the social media sites they use most, and chronic exposure to such hate inevitably takes a toll on their mental health. Online hate is not given the same coverage or attention that street-level hate crimes get, but the effects of the former may be exponentially more profound due to the wide reach of users that are present on online platforms. Actions should be taken to limit such hate speech on public platforms like social media to preserve the mental-wellbeing of users that are targeted by these remarks, even if it means limitations on the First Amendment right to free speech.
In a case close to home, a Muslim student recently graduated from my high school in the summer of 2021 and was chosen to deliver a speech at the commencement. In her speech, she advocated for the need for understanding and peaceful coexistence during difficult times, and briefly mentioned the ongoing conflict between Israel and Palestine. This part of the speech incited infuriated outcries from the audience, rude remarks shouting at her to “go back to Pakistan” as she walked off the stage, and the creation of a Facebook group as a space for angry parents to vent and express mildly Islamophobic sentiments. Due to the convenience and ease of access, social media is frequently defaulted to as a platform for these polarizing conversations. Certain social media sites, such as Twitter, are “better-designed,” in a sense, to perpetuate hate speech and to facilitate radicalized expression. Dr. Nigel Harriman, professor at the Harvard T.H Chan School of Public Health, and a group of researchers found that 57% of students that actively used the social media sites Youtube, Instagram, and Snapchat had come across hate speech, and 12% had encountered a stranger that tried to convince them of racist beliefs (this was especially common on Youtube). Additionally, exposure to hate messages was significantly correlated to Twitter use and Houseparty use (Harriman et al., 8531). Twitter is a particularly convenient hotbed for such rhetoric, as victims that come forward to tell their stories to Twitter are simply told to block the hating account or delete their own account. In 2014, Twitter issued a statement claiming that it “cannot stop people from saying offensive, hurtful things on the Internet or on Twitter. But we can take action when content is reported to us that breaks our rules or is illegal” (“Updating Our Rules Against Hateful Conduct”). Twitter more recently updated its rules against hateful content in December 2020:
In July 2019, we expanded our rules againsthateful conduct to include language that dehumanizes others on the basis of religion or caste. In March 2020, we expanded the rule to include language that dehumanizes on the basis of age, disability, or disease. Today, we are further expanding our hateful conduct policy to prohibit language that dehumanizes people on the basis of race, ethnicity, or national origin.
(“Updating Our Rules Against Hateful Conduct”)
Although Twitter has taken some necessary steps to limit hate speech, this form of harassment nonetheless still exists on this and countless other platforms, and more action must be taken to counter this.
As someone that frequents social media sites like Instagram and Facebook, I understand how detrimental the algorithms themselves can be to one’s self-esteem, but coupled with exposure to hate speech, mental health for those targeted is more likely to plummet. Although I ultimately ignored the hate comments on Instagram under the post about France, the occurrence bothered me for several days afterward, leaving me anxious, unsettled, and dealing with mild sleep difficulties to the point where I deleted Instagram for a few months. Research by Dr. Helena Hansen at NYU Langone found that victims of online hate speech are found to have elevated levels of the stress hormone cortisol, leading them to exhibit a blunted stress response as well as higher rates of anxiety, sleep difficulties, and substance use (Hansen et al. 929). Dr. Brianna Hunt at Wilfrid Laurier University found that exposure to Islamophobic rhetoric is also a predictor of social isolation and loneliness, particularly among Muslim women in Waterloo, Canada. Furthermore, the dehumanizing aspect of hate speech also incites conflicts of identity in Muslim women of color, who feel that neither their religious nor their racial ingroups accept them fully, calling for the need to address mental health for more complex cases of intersectionality as well (Hunt et al.).
In an effort to mitigate the destructive effects of hate speech on mental health, individuals have advocated for limiting such speech, but opponents of these limitations have expressed their concerns and dissatisfaction with this movement. In the 2017 case Matal v. Tam, the Supreme Court of the United States ruled that hate speech, like regular speech, is protected under the First Amendment under the justification that “giving offense is a viewpoint” (as long as it does not directly incite violence) (Beausoleil 829). Thus, individuals opposing limitation of hate speech on social media argue that doing so would be an infringement on their First Amendment right. There is also the danger that limitations of this sort would be a step in the direction of mass surveillance and abuse of power, ultimately resulting in a power dynamic of large digital companies﹣and potentially the government﹣in stifling any and all dissent (Beausoleil 2124). Other supporting evidence includes the notion that some exposure to counter speech is needed for the development of stable mental health and that various studies have shown that limitation of hate speech does not correlate to improved social equality (Beausoleil 2125). In fact, Dr. Stephen Newman of York University points out that expression of this sort of dialogue may be integral to human personality development, and that exposure to robust forms of speech may actually improve societal dynamics by influencing democratic policy (Newman). Lastly, there is limited existing literature proving that hate speech limitation is beneficial, as regulations of this magnitude have not been implemented anywhere yet. Thus, this argument is largely based on studies that have shown the harmful effects of hate speech.
In a growing digital age, where social media use is a part of daily life for adolescents, young adults, and even middle aged individuals, chronic exposure to hate speech such as Islamophobic rhetoric cannot be tolerated. The longer online sites and social media platforms delay addressing such sentiments, the more widespread and normalized they will become and the more detrimental the effects will be on affected individuals’ mental health. In regards to opponents’ concerns over First Amendment compromise, the First Amendment cannot be applied perfectly to the digital age, which allows for unprecedented and unanticipated reach of communication across borders, continents, and time, as posts can always be viewed and interpreted so long as they are not deleted (Beausoleil 2127). Restrictions on the right to free speech are warranted in this case, where the mental health of countless targeted individuals on a global scale are at stake. To limit the likelihood that these companies abuse their extended powers of speech limitation, restrictions should be placed on the companies’ extent of power as well (ie. restrictions should be placed on the restrictions). Rather than immediately deleting all posts and comments including hateful rhetoric (which may be impractical), social media platforms should specifically aim to disband or deactivate groups, chat rooms, and accounts specifically devoted to or frequently posting Islamophobic﹣and other hateful﹣rhetoric. On particular posts where the comment section becomes overwhelmingly belligerent and hate-fueled, social media platforms should either delete the post, delete the inflammatory comments, or disable the comment section entirely. Lastly, these social media platforms should issue public statements against hate speech like Twitter did, include them explicitly in their terms and conditions of use, and send automated warnings to users who violate conduct rules multiple times with the intent of suspending their accounts if hateful activity continues.
Ideally, the extent to which media companies can regulate inflammatory speech should be overseen by the federal government. However, complications may arise due to matters of jurisdiction: for example, the US government may have limited say on regulation of content posted on the social media platform TikTok, as this company was founded in China. Thus, for the time being, regulations should remain on a company-to-company basis. In the short-run, it can be expected that consumer use and feedback will let companies know how effective and acceptable their policies are.
Though many praise the advent of cyberspaces and the beginning of the digital era as a way of bringing the world closer together with connections never known before, it is difficult to fathom how connected we really are amidst the divisive and discriminatory rhetoric that is often perpetuated on the very same platforms. Hate speech is present in several different forms, including anti-Semitism, racism, homophobia, gender discrimination, and prejudice against disabled individuals. As a Muslim woman, the recent increase in Islamophobic sentiments on social media have made me realize how pervasive their effects on young Muslims’ mental health are. Therefore, I strongly encourage social media platforms to limit hateful speech and promote civil and constructive dialogue instead using the methods outlined above, even if it means a slight compromise on First Amendment rights. By merely limiting and not completely eradicating hate speech, the extent of social media companies’ power is kept in check and the potential societal benefits of exposure to antagonistic speech mentioned previously may still be experienced. Taking actions such as deleting the Instagram post about France with the barrage of inflammatory comments would be steps in the direction of greater coexistence as the Muslim high school graduate’s speech earnestly called for and promoting the benefits of global connection that the digital era originally promised.
Beausoleil, Lauren. “Free, Hateful, and Posted: Rethinking First Amendment Protection of Hate Speech in a Social Media World.” Boston College Law Review, vol. 60, no. 7, 2019, pp. 2101–2144.
Hansen, Helena, et al. “Alleviating the Mental Health Burden of Structural Discrimination and Hate Crimes: The Role of Psychiatrists.” The American Journal of Psychiatry, vol. 175, no. 10, 2018, pp. 929–933, doi:10.1176/appi.ajp.2018.17080891.
Harriman, Nigel, et al. “Youth Exposure to Hate in the Online Space: An Exploratory Analysis.” International Journal of Environmental Research and Public Health, vol. 17, no. 22, 2020, 8531, doi:10.3390/ijerph17228531.
Hunt, Brianna, et al. “The Muslimah Project: A Collaborative Inquiry into Discrimination and Muslim Women’s Mental Health in a Canadian Context.” American Journal of Community Psychology, vol. 66, no. 3-4, 2020, pp. 358–369, doi:10.1002/ajcp.12450.
This essay examines maternal healthcare practitioners’ perspectives about and experiences with incorporating sex- and gender-based medicine (SGBM) into healthcare training at Stony Brook University, a leading medical institute in the United States. SGBM refers to the style of clinical practice that accounts for the ways in which biological sex characteristics and social constructions of gender affect healthcare outcomes. This method is particularly critical for women’s and reproductive healthcare providers because they routinely treat patients that experience gender and its unique interactions with other sociocultural factors. Within the wide range of literature discussing the need to integrate an SGBM lens into medical education, only a handful of scholars have examined why it is so difficult to actually accomplish. Building on this emerging body of evaluation research, I conducted several oral interviews with faculty at the Stony Brook Schools of Medicine and Nursing, discussing how they have reacted to this relatively new but essential field of medicine from the early 1990’s to today. The university has recently claimed that its health institutions are progressive both politically and practically, but I argue that “progressive” is an exaggerated description. Based on the interviews, instructors continue to face institutional as well as logistical barriers to incorporating an intersectional gender lens into their didactic and practical curricula. Furthermore, this case study offers insight into how practitioners can improve the ways they currently teach gender in order to produce more equity-conscious and diversity-respecting maternal care providers.
“Learning is not attained by chance, it must be sought for with ardor and diligence.”
– Abigail Adams (“Abigail Adams,” 2019).
Medicine, particularly medical education, has historically ignored the humanities and social sciences, especially intersectional gender and sexuality studies. Maternal and reproductive health scholarship that actually includes women as its subjects and researchers did not emerge until the women’s health movement rooted itself in American academia just over two decades ago. However, the field’s first fifteen years or so focused on biology-based differences between men and women with minimal regard for any individuals identifying outside the cisgender, heterosexual norm. Gender and sexuality only entered the conversation in the last five years, and even now, intersectionality is barely acknowledged. Medicine continues to primarily use the additive model, which considers various forms of oppression (sexism, racism, ableism, etc.) separately rather than examining how they operate inseparably (Kang et al., 2017).
And yet, intersectionality is more important than ever before, especially in the United States. The number of Americans who identify as a person of color and/or LGBTQ* grows every day (Jones et al., 2021; Jones, 2021). Therefore, it is imperative that medical providers understand how to treat their patients with respect for diversity in all its forms. As with any sustainable change, the process of removing heteronormativity from medical practices must begin with medical training. In this essay, I aim to provide a snapshot of where American medical education stands on the inclusivity stage. I will accomplish this by examining maternal, reproductive, and family healthcare practitioners’ perspectives about and experiences with incorporating sex- and gender-based medicine (SGBM) into education at Stony Brook University, a leading medical institute in the United States. These perspectives reflect the larger institution’s state of inclusiveness and progressiveness.
For reference, SGBM refers to the style of clinical practice that accounts for the ways in which biological sex characteristics and social constructions of gender affect healthcare outcomes. This method is particularly critical for women’s and reproductive healthcare providers because they routinely treat patients that experience gender and its unique interactions with other sociocultural factors. Building on this emerging body of evaluation research, I conducted several oral interviews with faculty at the Stony Brook Schools of Medicine and Nursing, discussing how they have reacted to this relatively new but essential field of medicine from the early 1990’s to today.
Stony Brook University has recently emphasized its “progressive” approach to healthcare, especially regarding women’s and LGBTQ* populations. In response, I argue that while the Schools of Medicine and Nursing are certainly more aware of SGBM than they were two decades ago, the university still lacks clear intersectional gender- and sexuality-inclusive training and approaches the education they do have in a non-inclusive, binary way. In this essay, I will provide historical context for my analyses by briefly summarizing key events in the trajectories of feminism, the Women’s Health Movement, and sex- and gender-based medicine (SGBM) in the late twentieth century. I will then conduct an in-depth analysis of my case study research and its implications. Finally, I will conclude by proposing potential ways for practitioners to improve how they currently teach gender in order to produce more equity-conscious and diversity-respecting maternal care providers.
How maternal and reproductive medicine evolved with American politics
When Betty Friedan’s groundbreaking book The Feminine Mystique was published in 1963, America began to realize that many of its women were dissatisfied with simply being housewives (Churchill, 2020). After World War II, women were not especially keen on relinquishing the professional and financial freedoms they had found in the factories while the men were fighting overseas. Simultaneously, the Stonewall Riots in 1969 marked the birth of what is now commonly referred to as the modern LGBTQ* rights movement (Duberman, 1993). In the following decades, both of these marginalized groups would find themselves at the center of the global political and health stages.
Policy and health were particularly inseparable during this era. The 1990s saw what is now known as Third Wave Feminism, placing women’s experience at the center of American politics and “integrat[ing] an ideology of equality and female empowerment into the very fiber of [American] life” (Walker 400, 1992).Women delayed marriage into their mid-twenties, felt sexually liberated, and entered male-dominated careers (Yarrow, 2018).Yet, the fight for equality raged on in the political and medical arenas, clashing in landmark health-related historical events such as the Anita Hill sexual harassment hearings (Gross, 2021), Planned Parenthood’s fight against conservatives over abortion rights (Prescott, 2019), and the Violence Against Women Act of 1994 (“History of VAWA”).
In the same decade, the Women’s Health Movement was progressing with full-force activism: reproductive endocrinologist Florence Haseltine co-founded the Society for Advancement of Women’s Health Research in 1989, which helped to pass the Women’s Health Equity Act one year later and created the Office of Research on Women’s Health at the National Institutes of Health. In 1993, following the groundbreaking discovery that the HIV virus can pass from pregnant parent to fetus, Congress required the inclusion of women in NIH-sponsored clinical research trials (Liu and Mager, 2016). Prior to this mandate, women of childbearing age were considered too high-risk to participate in clinical research due to the possibility of pregnancy, severely inhibiting knowledge production about sex and gender in healthcare (Participant 3, 2021). It was these socio-political and medical paradigm shifts within women’s health research that gave rise to what is now referred to as sex- and gender-based medicine (SGBM). Within the wide range of literature discussing the need to integrate an SGBM lens into medical education, only a handful of scholars have examined why it is so difficult to actually accomplish.
How sex- and gender-based medicine was born
In the midst of this emerging field of women’s health intervention evaluation, Lorena Alcalde-Rubio et al. reviews 22 articles that evaluate clinical interventions aimed at “reduc[ing] variability in healthcare,” five of which focus on sexual and reproductive health (Alcalde-Rubio, 2020). The majority of the 22 evaluations supported standardizing protocols as a feasible method of systemic change, which is consistent with the faculty’s opinions during my interviews. However, Alcalde-Rubio’s review does not specify what types of protocols should be standardized and importantly notes that 15 out of the 22 evaluations did not utilize gender perspectives adequately. Further, the review significantly reflects a larger fault in medical academia: researchers often focus too much on the purely clinical aspect of change. When it comes to destabilizing social constructions that are ingrained in us and impact every aspect of human life both inside and outside of medicine, education plays a, if not the most, critical role in producing systemic change. In other words, we cannot fix the problem without addressing its roots. As such, I will primarily address the education aspect that Alcalde-Rubio et al. does not.
A 2005 Dutch study (Verdonk et al.) attempts to explore the potential for long-term change in medical education. Researchers concluded that a lack of guidelines, political ideology conflicts, and the educators’ own levels of dedication contribute to the gap between what should be taught and what was actually being taught. Further, certain factors must be present to successfully incorporate gender into medical training, including faculties’ personal experiences and motivations, practical support, and “executable” proposals for adjustment. This suggests that the Western medical educators were generally aware of the need for gender education in the 1990s, the decade during which many of my interviewees were medically trained here at Stony Brook. However, Verdonk, like many others in the field, conceptualizes gender as binary and essentialist.1 To make any meaningful progress, modern medical educators need to start deconstructing the gender binary and validating identities and sexualities beyond the cisgender, heteronormative ones.
Like Verdonk et al., Mary Rojek and Marjorie Jenkins (2016) examined medical schools, but this time in the United States. They surveyed faculty from medical schools that had already successfully integrated SGBM into their education. Their results suggested “it was important to involve all stakeholders… linking curricula to experiential learning and research. It was important to support faculty by providing them with educational resources” (Rojek and Jenkins, 2016). The majority of schools, though, are still behind in adding a sex- and gender-based lens to formal medical education. My research supports Rojek and Jenkins’ conclusions that formal institutional support is a crucial factor in determining integration success.
Also similar to Verdonk et al.’s case study, Hsing-Chen Yang examined the Eastern (Taiwanese) medical world’s perspectives about gender. Asian beliefs and social norms about gender are significantly different from Western ones, and even between individual Asian cultures themselves. Because Stony Brook’s Renaissance School of Medicine began accepting international applicants in 2014 (Medical School (MD) Applicant Profile, 2021), along with the majority of graduate students across the university identifying as people of color (Stony Brook University Fall Headcount, 2021), it is crucial to consider a diverse set of approaches to medical education. Because patient populations are now increasingly diverse—fueled by immigration and globalization—healthcare providers need to have a basic understanding of how gender functions in different cultures. Yang’s surveys found that healthcare professionals and teachers generally believe that sexism, gender awareness, gender equity, and patriarchy are among the most important to teach but this prioritization is not reflected in practice. However, the study omits two key factors: historical context and sociocultural context. Sexism, gender, and patriarchy have various meanings depending on the patient’s and the provider’s respective backgrounds. Therefore, Yang’s conclusions may be limited to predominantly Asian regions.
To see if Yang’s results holds true in Western medical culture, I came upon a 2010s-era study that revealed that American students also lack sex- and gender-based medical (SGBM) training, Majorie Jenkins et al. (2016) surveyed 1097 medical students across five major medical student organizations in order to examine institutional response to these findings. Jenkins’ survey suggests that while medical students are generally aware of SGBM’s existence, the majority do not receive adequate SGBM education at their respective medical schools. While it provides a solid look at what other American healthcare schools are doing about SGBM in relation to Stony Brook, Jenkins focuses solely on students’ perspectives rather than those of faculty, not accounting for logistical and institutional obstacles instructors face that students may not be aware of. I aim to fill this knowledge gap in this case study.
Stony Brook University
Stony Brook University (SBU) grew alongside the women’s movement. The university was founded in 1957 (“History and Mission”), and its Renaissance School of Medicine (RSOM) opened in 1971 (“History,” 2019). The RSOM currently houses 25 professional departments, including “Obstetrics and Gynecology,” which is an influential player in university progressive politics (“Departments,” 2019; Participant 5, 2021). One year after the RSOM admitted its first class, the SBU School of Nursing (SON) opened in 1972 (Strategic Plan 2016 to 2021, 2017). Graduate-level programs were gradually added in the following years, and the school’s first doctoral-level program, the Doctor of Nursing Practice (DNP) program, admitted its first cohort in 2007 (Participant 2, 2021). Now, Stony Brook’s Hospital is considered one of the best in the United States and boasts progressive and inclusive practices. This makes it an ideal institution to study the emerging field of sex- and gender-based medicine, especially considering its diverse student and faculty profile.
While gender undoubtedly affects all areas of health, obstetricians (OBs), gynecologists (GYNs), and nurses typically have the most direct patient contact with populations where gender is uniquely related to healthcare outcome (Participant 5, 2021). For example, maternal care and reproductive care specialists may see pregnant trans patients, same-sex couples with fertility concerns, and Black cisgender women, who have disproportionally higher rates of maternal mortality in the United States (“Working Together,” 2021). For this reason, I individually interviewed a total of six faculty at Stony Brook University, including three OB-GYNs from the Renaissance School of Medicine and three from the School of Nursing. Participants were recruited via email outreach based on whether they attended Stony Brook University for their undergraduate degree, graduate degree(s), residencies/fellowships, or any combination of those three. Each interview was approximately thirty minutes long and conducted over Zoom or phone call between the months of September 2021 and November 2021.
Table A. Participants’ Educational Backgrounds
Type of Clinician
Highest Degree Earned
Nurse practitioner and midwife
Pediatric nurse practitioner
Family and acute care nurse practitioner
Key DNP – Doctor of Nursing Practice MD – Doctor of Medicine PhD – Doctor of Philosophy *Completed at Stony Brook University
I asked the participants five main questions about various gender- and sexuality-related topics. The first question asked about the participants’ educational backgrounds, including where they earned their undergraduate degree(s), graduate degree(s), and where they completed their post-doctoral residency and fellowships if applicable.
Gender & sexuality education as a student
The second question asked about the participants’ experiences – or lack thereof – learning about gender as a student, including as a medical or nursing student and graduate-level nursing student or medical resident.
Current gender & sexuality education
The third question asked participants to compare their own student experiences to what current SBU students learn about gender. The fourth question asked about their experiences and opinions about teaching gender as a professor, including what challenges they may face and how they address them.
The fifth question asked participants if the university has offered and/or currently offers opportunities for faculty to further their own knowledge about gender and sexuality in healthcare, and if so, what types of opportunities and how helpful they were.
Results & Discussion
Participants’ own gender and sexuality training
None of the participants had any formal education about gender nor sexuality, with the exception of studying purely biological sex differences, when they were medical/nursing students. All participants received their first clinical degrees (BSN or MD) in the 1990s or early 2000s. At the time, SGBM was just beginning to grow as a legitimate field of medicine and was more commonly referred to as “gender-based biology” (Madsen et al., 2017).
For example, a few of the participants from both the RSOM and SON recalled learning about sex differences in symptom presentation and risk levels for certain conditions, such as the fact that men are more likely to have a heart attack while women typically show less obvious signs of a heart attack like pain similar to that of severe indigestion (Participant 3, 2021). Participant 2 recalled learning absolutely nothing about gender, especially its interactions with race and ethnicity. As a Black woman, she did not feel supported by the School of Nursing while earning her degree. Therefore, diversifying nursing education is particularly important to her, so a tremendous portion of the efforts to update the midwifery curriculum comes directly from her. This aligns with Verdonk’s 2005 findings, where a specific professor of Women’s, Gender and Sexuality Studies was an “important stimulus” and “trigger” person for SGBM integration. For Stony Brook’s midwifery program, Dr. Findeltar-Hines is the “trigger” person.
Another important consideration is that in the 1990’s, patients were often quite hesitant about revealing their gender identity and/or sexuality to practitioners (Participant 6, 2021). Furthermore, gender-affirming care standards, mostly relating to gender-affirming surgeries, did not exist until 1979 (Frey et al., 2017). The first major case study in hormonal puberty blockers, now a major treatment option for transgender, non-binary, and gender non-conforming pediatric patients, was not published until nearly twenty years later in 1998 (Cohen-Kettenis et al., 2011). Clinical progress took decades, and the curricula were trailing far behind as a result. This aligns with the Verdonk et al. case study of the Dutch medical center (2005), in which faculty’s personal experience and motivation was found to be a key factor in ensuring the success of gender education integration. Unlike the Dutch case study, though, Participant 2 acknowledges that gender exists on a spectrum and does not conceptualize it in mere binary terms, perhaps contributing to the Midwifery program’s progressive success in recent years. According to Participant 2, the program’s instructors have created a trans patient case study, use gender-neutral pronouns whenever possible, and are currently working on implementing gender/sexuality- and race-specific lectures.
This level of dedication to building gender-inclusive training is not consistent across the nursing and medical schools, however. While some participants recalled learning about “special populations” (Participant 4, 2021), which include trans and gay patients, it was from a very “cisgendered” perspective (Participant 1, 2021). This special population education was also added to the curriculum out of political pressure rather than student/faculty motivation. In the 1990s, HIV and AIDS awareness skyrocketed to the top of major health institutions’ priority list as the AIDS epidemic entered its “Middle Era” and gained international attention (Durvasula, 2018). This increased public health attention to women’s and reproductive health disparities, but commonly used terminology like the “4H Club [homosexuals, hemophilliacs, heroin users, and Haitians]” were homophobic and racist, essentially doing the opposite of increasing gender and sexuality awareness (Participant 3, 2021). In fact, prior to the AIDS epidemic, those who identified as female were prohibited from participating in medical research, so it’s not surprising that health practitioners and academics ignored gender education.
What current SBU students learn
Current SBU students learn more than participants’ did but the integration of gender and sexuality into the curriculum is slow. Challenges include time constraints (Participant 1, 2021), disparities in instructors’ own knowledge about the topics (Participant 1, 2021), and resistance from more traditional faculty (Participant 2, 2021). Ultimately, it is up to individual faculty to decide how much they want to adjust their curricula to include diversity education.
The Renaissance School of Medicine did not start internally pushing for inclusive education until two to three years ago (Participant 1, 2021; Participant 6, 2021), and since then, progress has been very slow. The majority of interviewees recognized the need for specialized gay and trans* education, but that was about the extent of their reported knowledge. Only one or two faculty mentioned non-binary and gender-nonconforming patients (Lian, 2021; Participant 3, 2021), and one mentioned the relationship between race, socioeconomic/citizenship status, and healthcare outcomes (Participant 6, 2021). None offered evidence of education that focuses on the vast variety of other gender and sexuality spectrums, including sexualities that are not strictly straight/gay/bisexual. Only one doctor mentioned how clinical placement affected patient populations. For example, attending physicians working at a Flushing, NY clinic might see more Asian patients while someone working in a “resident clinic” would typically see patients in less privileged socioeconomic groups. The resident clinics have more Hispanic and non-English speaking patients “by default” (Participant 6, 2021).
It is also worth noting that while a few participants mentioned race, gender, sexuality, socioeconomic status, and ability status separately, it was evident that all of them viewed gender and sexuality using an additive lens. The additive model considers systems of oppression to be individual entities rather than structures that cannot operate without one another. Intersectionality was undoubtedly an unfamiliar term, so interviewees were largely unable to answer questions about the intersections of identity factors like gender and sexuality. A potential cause of this issue is the lack of precise terminology in the broader field itself (Madsen, 2017).
The School of Nursing, however, began adding diversity and inclusion to its branding in 2017, which, coincidentally, is the same year the Midwifery Program appointed the first woman of color as its Director. In its academic success goals, the Strategic Plan 2016 to 2021 (2017) specifically lists “recruit diverse nursing faculty” and “expose [nursing students] to global health and healthcare disparities.” Since then, the midwifery program has been adapting lectures to use more inclusive terminology, such as saying “patient” instead of “woman” and “parent” instead of “mother.” Additionally, the program was the first in the SON to add a transgender-specific case study to the curriculum. As the program director noted in her interview, “Education is always evolving… We [educators] have to stay creative and innovative in order to get the basic education things that we want learned [by the students]” (Participant 2, 2021). This is both in agreement and in direct contrast with Yang’s Taiwanese survey of healthcare professionals and teachers regarding gender education expectations. Yang claimed that workplace sexism is a primary cause of the disparity between what instructors believe should be taught and what is actually taught about gender. She also argued that this same sexism prevents educators from viewing gender as a human issue rather than a “woman issue” (Yang, 2020). Participant 2 suggests that all educators must address gender education, including the traditionalists, and simultaneously expresses that workplace discrimination is not an excuse for lack of progress.
All faculty are required to retain clinical practice while teaching, and all participants hold additional leadership positions within their respective schools (Participant 4, 2021). Combined with minimal access to formal training, some traditionalists would say that faculty simply don’t have the time to educate themselves about gender so it is much harder for them to teach it (Participant 1, 2021). However, integration does not necessarily need to involve revamping the entire curriculum (Participant 3, 2021). Faculty could also incorporate gender diversity education into existing training, such as making a simulated patient a woman of color or a child with two mothers. Additionally, instructors could use case studies to emphasize a wide variety of lessons, such as Participant 2’s pediatric case study with a transgender (assigned female at birth) patient named “Timmy” (2021). This case study provides opportunities to practice using proper gender pronouns, learn about hormonal gender affirming treatments, and how to interact with parents of gender-diverse children. Across all interviews, participants said that they would like to improve the time dedicated to gender and sexuality education, so the motivation is there. These sentiments align with those of the students that Jenkins et al. surveyed in 2005, meaning formal course offerings have not improved much since then.
According to the participants, the students are the main driving force behind integrating gender and sexuality training into their healthcare studies. This result was also expected based on the Jenkins et al. survey (2005). On top of being very receptive and eager to learn about diversity, they even provide feedback asking to learn more (Participant 2, 2021; Participant 1, 2021; Participant 4, 2021). Depending on clinical placements, students also have the opportunity to interact with diverse patient populations (Participant 4, 2021), and at Stony Brook Hospital, residents consistently see high levels of diversity (Participant 5, 2021; Participant 1, 2021). While not all healthcare practitioners will work directly with gender-diverse patients, it is still extremely important for all medical providers to understand and be able to apply gender-inclusive theories. According to a recent 2021 Gallup poll, 5.6% of American adults, and one in six adults in Generation Z alone, identify as LGBT (Jones, 2021). Furthermore, the U.S. Census estimated that in 2019, over 36% of women were women of color, and this proportion is projected to grow to over 55% by 2060 (“Women of Color in the United States,” 2021). These statistics are particularly relevant to maternal and reproductive healthcare; therefore, it is critical that these healthcare providers are trained, at least on a basic level, in gender and sexuality studies (Participant 5, 2021).
Based on Verdonk’s 2005 study of a Dutch medical center, institutional support must be present in order to successfully incorporate sex- and gender-based education into healthcare curricula. This may be in the form of financial resources, guest lecture support, accessible educational resources, and visual/presentation support (Verdonk, 2005). With this in mind, I asked participants about how Stony Brook University supports its healthcare faculty in diversifying the curricula, if at all.
Using a binary gender lens
SBU as an institution provides some structured learning opportunities for faculty specifically about using an intersectional gender lens when practicing healthcare, but students and faculty want more. In terms of gender education, because the topic is so relevant to daily patient care for OB GYNs, a few formal lectures have been offered, and OB GYN residents discuss gender- and sexuality- related cases during grand rounds (Participant 5, 2021). For medical students, as of 2020, all SBU medical and dental students are required to take a “Transition to Medical and Dental School” course that talks about gender and diversity issues (Participant 1, 2021)
Using a heteronormativeLGBTQ* lens
In terms of LGBTQ* inclusivity, two of SBU’s major medical institutions, Stony Brook Medical Center and Stony Brook Southampton Hospital, scored a 100/100 on the Human Rights Campaign (HRC) Foundation’s 2020 Healthcare Equity Index [HEI] and were named LGBTQ Healthcare Equality Leaders (Healthcare Inequality Index 2020).2 According to Stony Brook, “[t]he HRC is the largest national lesbian, gay, bisexual, transgender and queer civil rights organization” (“Health Equality Leader,” 2021). However, the HRC has received a substantial amount of criticism for, despite its claims, failing to represent and advocate for LGBTQ* folks of color. Much of this controversy surrounded the Don’t Ask, Don’t Tell Repeal Act of 2010 (“H.R.2965,” 2010). In the months leading up to its official passing, the HRC used a disabled, gay veteran of color to promote fake inclusivity while it simultaneously “profited from the practice of diversity management” (Montegary, 2015). Further, the HRC has been called “cisgenderist” and white supremacist for several years (Johnson, 2011; Rosen, 2021). As such, their HEI rating may not have as much practical weight as Stony Brook claims.
Stony Brook University released an LGBTQ+ Health Needs survey in early summer 2021 and received over 1,218 responses from Long Island, NY residents as of September 30th, 2021. Its purpose is to “provide information critically needed by healthcare providers, social service providers, government officials and public health staff to expand service offerings and serve as effective advocates for LGBTQ+ people” (“LGBTQ+ Health Needs Survey”). Moreover, the survey was made available in both English and Spanish, increasing access to non-English speakers. Suffolk County alone is 20% Hispanic/Latinx, according to the U.S. Census Bureau estimates (“Quick Facts”).
Both the Stony Brook Medicine [SBM] and the School of Nursing [SON] have recently created committees to educate practitioners and spread awareness about gender-informed care. The SBM LGBTQ* advisor committee meets monthly and aims to establish a set of priorities for LGBTQ* patient care, as well as create a more welcoming environment for patients, practitioners, and staff (“Two Stony Brook Hospitals;” Participant 1, 2021). Additionally, the SON’s brand new IDEA committee [Inclusion, Diversity, Equity, and Access] aims to use student feedback to build a more inclusive learning environment (Participant 4, 2021; Participant 3, 2021). Faculty veterans accustomed to traditional academic politics may argue that committees are a poor use of resources, especially in higher education; however, as university administration researcher David Farris writes in “Not Another Committee” (2017), with regular communication, perceived equality among members, and actively focused leaders, committees can actually be quite effective. Nonetheless, it is still important to note that the learning opportunities produced by these committees, particularly at Stony Brook, are created for clinician audiences and are less advertised to didactic instructors (Participant 1, 2021).
Hiding behind generalized health inequity
Pre-COVID, nursing faculty went on a few retreats that focused on diversity inclusiveness, but it was addressed in a very general manner (Participant 4, 2021). Recently, Stony Brook Medicine ran a two-day conference entitled “The Long March to Equity,” which covered general healthcare disparities and their historical trajectories into modern day medicine (Participant 3, 2021). This was the only example mentioned by multiple participants, and I was unable to find any other examples.
One OB-GYN did mention Women’s Health Day, an annual conference at the Renaissance School of Medicine that focuses on various health issues (cardiovascular, eyesight, muscle, breast cancer, etc.) and is exclusively targeted at an all-female audience (Participant 6, 2021; “Women’s Health Day,” 2019). This participant noted that the OB-GYN department also hosts a women’s health clinic on the same day at which anyone can get a routine check-up for free. The department has also started a bi-weekly clinic that provides discounted services for uninsured patients (Participant 6, 2021). However, she also explained that basic needs such as transportation already inhibit many of their regular patients from accessing necessary healthcare appointments. While treating women for free or at lower rates is somewhat helpful, it does not address the issue of inequitable access in an intersectional way; essentially, these clinics are just a Band-Aid solution to a deeper, more complex problem.
Distinct differences between medical and nursing education
The next result I will discuss was unexpected but certainly worth noting. I found clear differences between the perspectives/openness of the medical doctors and nurses. While the medical and nursing models have been known to be incredibly separate for decades (Reed and Watson, 1994), I was surprised by how much the models impacted the providers’ perspectives on sex- and gender-based medicine. For reference, the medical model focuses on “diagnosis, treatment, and cure” and has been widely criticized for its “narrow and unsatisfactory view (Reed and Watson, 1994). On the other hand, the nursing model “offers a more humanistic approach to patient care” (Reed and Watson, 1994).
The Medical Model’s Shortcoming
During the interviews, OB-GYNs consistently steered their responses towards healthcare outcomes, while I found the important connection between education and patient experience to be missing. For example, medical doctor participants mentioned “sobering” maternal mortality statistics, grand rounds3 (Participant 5, 2021), and student feedback being important (Participant 1, 2021), but only one explicitly said they prioritized making patients “feel more comfortable… and heard” (Participant 5, 2021). Yet, is the entire reason for improving medical education to benefit the patients?
Additionally, all three of the OB-GYNs discussed referrals4 as a way to support gender- and sexuality-based diversity. While having and being knowledgeable about sufficient resources is absolutely necessary, it does not address the alarming fact that many maternal and reproductive care providers are entirely unfamiliar with the concepts of intersectionality and non-binary gender and sexuality spectrums. Patients should not need to see another doctor in order to be treated with bare-minimal respect and dignity.
The Nursing Model’s Humility
On the contrary, nursing faculty were much more open to discussing how their personal experiences and medical training affects the quality of care they deliver. For example, Participant 3 took a few gender studies courses during her undergraduate career at Stony Brook, which exposed her to “thinking about other cultures, other health belief systems that wasn’t just coming out of a textbook” (2021). This, she said, impacted both the way she teaches and the way she cares for her queer5 patients, particularly helping her grasp new concepts like non-binary genders and different cultural understandings of disability. Here, the connection between the importance of inclusive education and patient experience is clear. Further, Participant 4 explained how crucial it is for students to work with diverse patient populations during school so that when they enter the workforce as licensed providers, they will already have achieved at least a basic level of intercultural competence.
One final point I must discuss is that all six participants identified as women, and four identified as women of color (see Table A on page 9). This sample is not representative of the Renaissance School of Medicine’s and School of Nursing’s faculty at all. The School of Medicine’s Obstetrics and Gynecology department has 42 physician faculty, of which only 13 (about 30%) are women of color. Furthermore, not a single woman is a full professor (with tenure). The department Director and Chair, the two highest leadership positions in the department, are also both white men (“Our Providers,” 2021). Within the School of Nursing, there are 32 faculty, of which 27 (about 84%) are white women and 4 (12.5%) are women of color. There is only one woman of color who holds a director-level position (“Faculty & Staff Directory,” 2021). It seems, then, that the School of Nursing has not yet met its goal to “Recruit diverse nursing faculty” (Strategic Plan 2016 to 2021, 2017).
With these numbers in mind, it is not surprising that Stony Brook University is lagging behind when it comes to incorporating SGBM into healthcare training. The key “trigger person” suggested by Verdonk’s 2005 study is hardly present, which may be why the Midwifery Program is the most progressive program within the School of Nursing (Participant 2, 2021). Verdonk also notes that personal experiences are significant contributors to SGBM’s successful incorporation into medical education (2005). Therefore, because the School of Medicine’s OB-GYN department has two white men occupying its highest leadership positions, and because the School of Nursing only has one woman of color in a leadership position, gender-inclusive training may be extremely difficult to accomplish with the existing faculty structure.
In summary, when the participants, the majority of whom were initially medically trained in the late 1990s to early 2000s, were students, they did not receive any education about SGBM with the exception of purely medicalized topics. Today, Stony Brook medical and nursing students are taught more gender-inclusive curricula but not as much as faculty nor students would like. Participants expressed facing challenges such as finding time to create new content, lacking personal knowledge and familiarity with SGBM, and lack of institutional support in the form of formal, specific training opportunities. Overall, Stony Brook’s “progressive” practices and curricula continue to use a heteronormative lens and show no intentions of trying to dismantle it.
This case study provides a snapshot of the American medical system, which currently faces discrimination and disparities on both clinical and educational fronts. With more Americans openly identifying as LGBTQ* than ever (Jones, 2021), and with populations of color continuing to grow (Jones et al., 2021), addressing gender- and sexuality-based healthcare disparities is an essential piece to improving the health of the nation. If the COVID-19 pandemic has shown us anything, it’s that we are in a deep crisis, and we have been for decades, leaving marginalized groups with inexcusably inequitable care. One of the most effective ways to produce long-term, sustainable change is by educating future generations of providers. This is why it is so important to ensure our healthcare students are receiving, at bare minimum, adequate training on these topics.
Potential ways to improve SGBM education and ensure competency is 1) provide formal, structured training for educators; 2) incorporate SGBM into the didactic and clinical curricula using updated lectures, new case studies, more diverse patient populations, and inclusive simulations; 3) appoint more (qualified) individuals from marginalized groups to leadership positions; 4) allot more funding to gender- and sexuality-inclusive educational initiatives; and 5) continuously assess, collect feedback, and adjust accordingly.
To form a more robust understanding of the medical educators’ attitudes towards SGBM education, future research could involve more individual case studies of academic medical institutions and/or comparing multiple universities. Faculty and student demographics differ between schools and geographic regions, which may affect attitudes as well as financial and socio-political ability to incorporate SGBM into formal medical education.
1 Essentialists believe that certain groups (categorized by race and sex especially) have traits and behaviors that are determined by biological factors. Gender essentialism inherently supports gender inequality by viewing gender as a binary concept, i.e. man versus woman (Hepburn).
2 HEI LGBTQ scores were calculated based on four major criteria: 1) quality LGBTQ patient-centered care, 2) “Patient Services and Support,” 3) “Employee Benefits and Policies” including “transgender inclusive healthcare benefits,” and 4) Patient and Community Engagement” (Healthcare Inequality Index 2020 14).
3 “A grand round is a formal meeting at which physicians discuss the clinical case of one or more patients. Grand rounds originated as part of residency training wherein new information was taught and clinical reasoning skills were enhanced. Grand rounds today are an integral component of medical education” (Stöppler, 2021).
4 A referral is when a healthcare provider does not have sufficient expertise in a particular field and suggests that the patient see a more knowledgeable specialist in that field (“Referral,” 2021).
5 Here, I use the term “queer” to mean “not aligning with the norm” rather than the more conventional “non-heterosexual” meaning.
Acknowledgements & Disclosures
Thank you to Liz Montegary for providing guidance for my research process, and thank you to all faculty who interviewed with me. This research was not funded in any way by any institution and was a fully independent project.
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Women and men across the world use eye pigments, blushes, lipsticks, eyeliners, and lip liners as a way to express themselves, enhancing their natural features. From a little pop of glitter in the inner corner of the eye to make the eye look bigger to a hint of shiny blush to give the cheeks a fuller look, glitter is a fundamental ingredient in a lot of makeup products. But how does the $500 billion makeup industry manage to shine all that glitters? The answer lies in a mineral found in nearly every continent, mica. Mica is utilized in makeup, but it is also used in the automotive, medical, and defense industries, making it a widely used inexpensive ingredient. The mica industry is forecasted to be worth over $700 million by 2024, yet the workers who mine and dig as a group all day in some of the poorest states of India can only hope to collectively make two dollars per day in total (Schipper and Cowan). This contrast is possible because some of these states, namely Jharkhand and Birpur, have indigenous communities living in the outskirts of the city who sieve through mud and dirt all day in the hopes of finding as much of the shiny rock as they can, and it is their only source of income. Geographically these communities live remotely and have limited access to job opportunities, basic services, schools, and businesses. Agriculture used to be another source of income, but due to increasing infertility and drought-prone soil, the only viable option is to work for long hours, digging and mining for mica and that too without any safety equipment. The conditions have irreversible consequences on adults, yet children accompany their elders to provide a helping hand, leading to a systematic cycle of poor health and poverty. Since it is the only way to earn bread and butter, an estimated 20,000 children have to work to support the multi-billion dollar industry (Schipper and Cowan). However, the problem of child labor can be significantly improved with awareness which will then promote the proper implementation of laws, economic growth, and education. Therefore, when it comes to survival and child rights, child rights should be chosen not only because it is morally right but also because in the long run, it will prove more beneficial.
Child labor has effects that are cyclical and long-lasting. However, one of the most effective ways to combat this issue is through awareness. Awareness through different means, especially social media, can be helpful in terms of putting pressure on governments to acknowledge issues, put light on issues, and create fundraisers and donations for important causes. Makeup gurus, some of whom have millions and even billions of followers, have the immense potential to start the change. Realizing there is an issue in the first place is what will initiate the change because as a beauty influencer remarked after finding out the truth about the deadly industry, “I’m very embarrassed to only be finding out about this now” (“The Dark Secret Behind Your Shiny Makeup”). A study on social media found out how the “Red Cross received eight million dollars in donations directly from texts” in two days, illustrating the power of social media (Gao 10). Although Makeup gurus can use their influence to raise donations for these children, they can also use it to simply show their viewers how the most important ingredient in many makeup products is supplied. Influencers hold a lot of power as proven by a survey conducted by Statista which reported how “58 percent of the brand strategists and marketers surveyed report that influencer marketing will become integrated into all of their forthcoming marketing activities” (Stubb and Colliander). Makeup products that are used every day, wasted, redesigned thousands of times, without considering how this ingredient ends up in almost every makeup product. However, by simply informing viewers of the way these things happen, people can become more conscious.
This consciousness can then in turn help pressurize companies to trace the supply chain. A major reason why child labor and abuse that is utilized to supply Mica is virtually undetected is that traders can legally get licenses to sell the mineral (Bliss 21). The supply chain goes from miners, collectors, traders, processors, exporters (Bliss 25). Therefore, since the mineral is technically purchased legally from the exporters, the rest of the process that happens behind it goes unseen. A lot of companies report that tracing the supply chain of the mineral is hard and ambiguous, but the truth is that these companies are simply not interested in tracing the origins of the chain. However, if awareness is raised amongst people, then consumers can demand greater supply chain transparency and traceability. A local activist in Jharkhand urges consumers to “Write to them [companies] and request that they disclose the source of their mica… after all, if they manage to procure the specific grades of mica required for their various products, they should be able to find out who is extracting it” (Zuckerman). Makeup buyers can usually find out if Mica is being utilized sustainably in specific products by reading the ingredients or by searching online for the brand’s sustainable-sourcing policies. Consumer awareness can make companies realize that it is worthwhile for them to start a due diligence trajectory specifically for Mica. Tracing the whole chain is difficult since these companies are not sourcing directly from the mines, but if companies and NGOs collaborate on working to end child labor, it can drastically improve the situation.
The supply chain of Mica poses its hardships, but there are alternate resources companies can resort to which makes the eradication of child labor more possible. L’oreal, for instance, has taken an initiative to source Mica from only “legal” and “fenced” mines (Bliss 29). Similarly, other companies have resorted to Mica mines in more developed countries such as America, which comes with a higher price but a transparent supply chain. Moreover, there is also synthetic Mica, which is developed in labs. Lush, the British cosmetics company, proudly presents itself as the leader of supplying its ingredients ethically; however, in 2016 it “discovered natural Mica in a range of mica pigments it had been told were synthetic” (Bliss 30). Therefore, the development of synthetic Mica is a field that requires further research; however, it can still prove to be worthwhile putting efforts by the billion-dollar companies as it can eliminate the need for natural mica in the first place.
Awareness is imperative because it will then bring attention and aid to all the other things that need drastic changes. People will be more conscious of their actions, and they can also donate. Furthermore, NGOs and other organizations can come to these poverty-stricken areas to better the situation. One of the ways this can be achieved is through improving the traditional ways of livelihoods, specifically the agriculture system. A sustainable agriculture system ensures food security and environmental safety; it provides livelihood by providing a source of income. Given that the farming situation in these areas has suffered due to drought and ineffective and primitive techniques, NGOs can initiate a change by teaching non-traditional farming techniques which will not jeopardize the availability of the resources for future generations and still provide an alternate source of income for the villagers. These change initiatives could include innovations on water scarcity, multiple-use schemes or other community resilience, extreme water vulnerability mapping in the area, and technical options on water demand management. These initiatives can equip farmers to effectively mitigate droughts, stop using urea and DAP fertilizers, and teach methods like crop rotation, so the same nutrients are not drained from the soil throughout the year. The revival of these lands might seem unworthy; however, a UNEP report has found out that “for 42 countries of Africa the benefit of intervening to conserve is 3-26 times greater than the cost of inaction,” and those interventions came through the help of NGOs (Kumar). NGOs are very prominent and effective in implementing sustainable agriculture programs, but, on the other hand, governments can also play their role by implementing state-led land reform programs and buying crops from the local farmers at a fair price. State-led land reforms take a big piece of land and assign sections to different farmers; this leads to greater independence and possible profits for the individual farmers, avoiding the monopoly of one person controlling the lands. Government buying crops at a certain price will ensure that despite any other inconveniences that might occur, such as price drops or crop failures, the crops the farmers were able to produce are sold at a predictable and fair price.
Eradication of child labor cannot be achieved only through the improvement of farming techniques but also through the implementation of laws and regulations. India already has laws that forbid children under the age of eighteen years from working in mines, and it is also against the UN Child Conventions (“Act now: end child labor!”). Awareness of the abuse of children in these states will urge governments to go beyond simply stating these laws in law books and implementing this law. One law that can potentially prove beneficial in this case is the legalization of mining Mica, which was made illegal in 1980 under the Forest Act. Mica is a forest resource and in efforts to conserve the environment, this law made it illegal to extract this mineral. 24,000 people who once relied on a stable source of income were left jobless (Bliss 24). Repealing this law will not only enable to formalize something which is already happening but also regulate the sector thus addressing the issues related to working conditions, minimum wages, and protective equipment. Enforcement of this law should include setting a minimum age for the mineworkers through proper documentation processes like unique identification numbers or birth certificates. The legalization of these mines would also mean that the workers do not have to work in fear of being caught all the time and illegal operators will not be holding control of the mines. Villagers get forced to work under these operators because they depend on unlicensed lenders when they need money for medical treatments or other reasons (Zuckerman). The only way to pay off the loan is by agreeing to work in these mines; hence, people get stuck in an intergenerational cycle of poverty. Furthermore, deaths in these mines usually go unreported and people are compensated with “blood money” (Makower). Therefore, the legalization of this law could also mean that deaths will be reported as there will be less fear of pursuing illegal activities under illegal operators who assert their dominance through force and brutality. However, these resolutions can only potentially occur if the law is properly enforced.
Eradication of child labor cannot be achieved only through the implementation of laws but also to create alternate sources of income. Besides agriculture, supporting small and medium scale enterprises (SME’s) through soft loans or micro-credits (on the model of Grameen Bank in Bangladesh), promoting local cottage industries, and local, national, and international tourism can be some examples of job creation and economic activities. Skills the indigenous people already possess can be utilized to their advantage. Research conducted found that women in Jharkhand possessed skills such as “sari-making”, painting mud houses, “sewing”, and “tailor-making” (Dagar 6). However, Suyamukhi, one of the indigenous women, remarked “These items don’t sell for much” (Dagar 7). This is where awareness can be used so these products are sold on a national and international scale. Furthermore, NGOs and the government can provide further assistance to this marginalized group by teaching ways for starting a business, applying for microcredits, and navigating the market. Supporting such potential small local businesses will lead to gradual independence from the dependence these people have on mining Mica as their only source of income.
In addition, the government also needs to play its role by providing facilities to these citizens. Citizens and governments have social contracts whereby each has roles and responsibilities. If it is expected that citizens will abide by the law, then the government is responsible for providing them not only safety and security but also sources of income and provision of social services. Besides health and education, water supply and sanitation, infrastructure development particularly farm-to-market roads and broader connectivity with other parts of the state and country are important ingredients in fostering this vertical social cohesion. It would be highly recommendable that the government look into this with a different lens i.e. not only provide these services but also use it as means to create jobs for youth and unemployed persons from various strata and skills sets. Consumers and the international community can play their role by urging the government to abide by their side of the social contract so villagers then do not need to resort to unlicensed lenders or other such resources.
Education is another imperative aspect that would again need the government’s attention and involvement to truly support the eradication of child labor. Besides traditional education, vocational and technical education needs not only to be promoted but also attractive. This can include incentivizing through free education, free books, and perhaps stipends for the students who attend and perform in their respective educational areas. However, Dr. Kumar, who researched education in Jharkhand, concluded that “doling out some incentives does not do much” (9). It is true that only providing incentives will not eradicate the overall issue of lack of education; on the other hand, there have been instances that have illustrated the effectiveness of incentives. Anjali Sinha, a researcher who has been to Jharkhand sites to collect data, witnessed in 2014 how some of the villagers willingly converted to Christianity for incentives such as certain amounts of food per month (Sinha). It is important to note though that this conversion is not only because of the incentive but also because these people want to escape India’s brutal caste system. Additionally, research in Nicaragua on poverty eradication illustrated how “school breakfasts were implemented to attract children,” which after three weeks resulted in “all eligible children” attending “school” (Blandon et al. 5). Therefore, incentives can become a channel that makes children less desperate to leave education and earn money instead. Simply providing children with a school will not solve the problem, children need to be taught in their mother tongue, at least in the primary years, in efforts to keep dropout rates low. Respectful and sensitive teachers, who are patient towards the first-generation learners, are needed. Awareness needs to be raised amongst the villagers to assure parents why sending children to school, especially girls, is beneficial for them and it will become a chief way to break the cycle of poverty. It is both in the government’s and villagers’ interest to pay attention to this aspect as education has proven to be “essential to a country’s development” (Kiross et al. 10). Many studies have proven how literacy has “been a major determinant in the rise or fall in other indicators” such as “growth rate, birth rate, death rate, and infant mortality rate”(Kiross et al. 10).
Awareness of the child labor situation in these mines has the potential to create a platform which in turn will result in consumer awareness, urging companies to either resort to alternative resources or trace the supply chain; additionally, consciousness regarding this matter can also urge government and NGOs to provide these people with different sources of income, by, for example, improving the agricultural state, and overall the government should be pressurized to play its role by providing proper facilities. However, these are all long-term initiatives that require enforcement and solving the problem from the very root. The main concern that can arise against such potential implementations is that the eradication of child labor “could increase the cost of commodities, harming the economic “comparative advantage of countries with cheap labor” which will eventually negatively impact the “poor people” (D’Avolio). Nevertheless, it is important to realize that the overall problem of child abuse in this area is complicated and deeply rooted; hence, it is going to take time and in the short term it might seem futile to pursue these actions. On the contrary, not initiating a change will keep these neglected groups of people fixated on a meager lifestyle.
Child labor is so easily utilized in India because poor children are vulnerable and easily exploited. Children cannot form unions, go on strikes, demand breaks, and set minimum wages because children are not meant for such pursuits. They are meant for school, for playing. They are not meant to worry about whether they will be able to see tomorrow or will there be enough food on the table tomorrow. India and the global community have a responsibility to give this oppressed group of people and their children their basic rights, facilities, and resources; furthermore, the international community should not lose sight of this cause till these goals are fulfilled. The situation of this problem is difficult, deeply rooted, and complex; however, through awareness, the right resources and resolutions can be passed so the rights of the children can be chosen without hindrance by this neglected group of indigenous people.
Blandón, Elmer Zelaya, et al. “Breaking the Cycles of Poverty: Strategies, Achievements, and Lessons Learned in Los Cuatro Santos, Nicaragua, 1990–2014.” Global Health Action, vol. 10, no. 1, Jan. 2017, p. N.PAG. EBSCOhost, doi:10.1080/16549716.2017.1272884.
Dagar, Preeti. “Vocational education and training for indigenous women in India: Toward a participatory planning approach.” International Journal of Training Research, Aug. 2021. doi:10.1080/14480220.2021.1959379.
D’Avolio, Michele. “Child Labor and Cultural Relativism: From 19th Century America to 21st Century Nepal.” Pace International Law Review, vol. 16, no. 1, 2004. digitalcommons.pace.edu/pilr/vol16/iss1/5.
Gao, Huiji, et al. “Harnessing the Crowdsourcing Power of Social Media for Disaster Relief.” IEEE Intelligent Systems, vol. 26, no. 3, 2011, pp. 10–14. doi:10.1109/MIS.2011.52.
Kiross, Girmay Tsegay, et al. “The Effect of Maternal Education on Infant Mortality in Ethiopia: A Systematic Review and Meta-Analysis.” PloS One, vol. 14, no. 7, 2019, e0220076. doi:10.1371%2Fjournal.pone.0220076.
Kumar, Anant. “Universal Primary Education among Tribals in Jharkhand: A Situational Analysis.” Xavier Institute of Social Service, 25 Mar. 2008, files.eric.ed.gov/fulltext/ED500704.pdf.
Stubb, Carolina, and Jonas Colliander. “‘This Is Not Sponsored Content’ – The Effects of Impartiality Disclosure and e-Commerce Landing Pages on Consumer Responses to Social Media Influencer Posts.” Computers in Human Behavior, vol. 98, Sept. 2019, pp. 210–222. doi:10.1016/j.chb.2019.04.024.
Spending time between Pakistan and the United States as a child, I have learned about different receptions to the LGBTQ+ community in two cultures. I thought that the first time I met a transgender individual was as a 14-year-old in America. After reading Jeffrey Gettleman’s article “The Peculiar Position of India’s Third Gender,” I realized I have met transgender individuals as early as age 8 (and possibly even earlier) in Pakistan. Similar to the Fa’afafine in Samoan culture, Hijras are individuals in Pakistan’s and India’s Muslim history who do not subscribe to a single identity as male or female.1 “Hijra” in Hindi translates to eunuchs, who are sexless individuals. They are castrated to eliminate the desire for love or lust and are meant to be sexless beings who are sexually receptive to men.1 It is important to note that not all transgender individuals in India identify as Hijras. Hijras are an entity that exists under the umbrella identity of transgender.1 During my visits to Pakistan, my family would donate money to Hijras whenever they stopped by our home or knocked on car windows. Gettleman finds that the identity of Hijras stems from a Hindu myth that Lord Rama, a Hindu god. Gettleman describes that Lord Rama “was exiled from Ayodhya and his entire kingdom began to follow him into the forest.” Lord Rama told men and women to leave him and regroup in Ayodhya.1 Hijras were known for their loyalty as they awaited Lord Rama’s return for 14 years in a folktale.1 Scholars of Hindu mythology discount the anecdote, claiming it is not in early versions of ancient Hindu texts. Regardless, the devotion of the Hijras demonstrated by the folktale is a significant characteristic of the Hijra identity.1 Before Britain’s colonization of India, Hijras were “revered as demigods.”1 Britain stripped Hijras of their identity upon colonization and enforced the binary gender system of female and male by suggesting they existed against the “order of nature” and thus criminalized “carnal intercourse.”1
In the modern-day, Hijras dress in sparkly saris and makeup while dancing and offering blessings in the streets. Indians perceive Hijras as beings with the power to bestow blessings or curses on those they meet. Radhika, a 24-year-old Hijra, shared that they were uncomfortable with resigning to a single-gender while in school. Her mother condemned these thoughts and told Radhika to “stick to” the gender binary.1 Soon after this interaction, Radhika’s parents split and her mother died. With no one else to turn to, 8-year-old Radhika met an older sex worker who made her a sex worker in a park.1. Radhika continues sex work today, as there is no other source of income. Hijras are still essential to the hierarchy of harems, which often operate like street gangs. They rely on gurus, also Hijras, who “fulfill the hybrid role of den mother, godfather, spiritual leader and pimp.”1,3 Beneath Hijras in the pyramid are chelas (disciplines) who are used to increase cash flow to the guru. For Hijras, there is not much social mobility due to restrictions placed on education and employment.2 Their rights as humans are often violated; these factors contribute to the cycle of being exploited through sex work and facing humiliation through castrations and social isolation.1 For a majority of the time following colonization, there were no modes of medical care that are easy to access. Countless deaths occurred as a result of the castrations by unqualified individuals.1 In recent years, however, India has recognized being transgender as another gender. Hijras can now undergo gender-affirming surgeries in some hospitals and access government benefits including welfare.1,2 Although this is a step in the right direction, Hijras are still considered inferior oddities who are not respected. The attitudes of society on their roles as sex workers have yet to change.
The following is a paper written for Stony Brook University’s Research and Writing in Psychology course (PSY 310) in which students were required to design an experiment and write a research paper based on it. It should be noted that all results and accompanying graphs, tables, and discussions, are imaginative and not based on conducted experimentation.
The current study aimed to examine the effects of the congruence of parenting and teaching styles on adolescent students’ academic achievement. Teaching styles mirrored the parenting styles of authoritarian, authoritative and permissive. Sixty eighth grade students were randomly sorted into three different classes, each of which utilized a different style of teaching. It was hypothesized that students who experienced the same teaching style in the classroom as parenting style at home would achieve higher levels of academic success than those students who experienced different parenting and teaching styles. Academic achievement was measured by proctoring identical final exams to all students and analyzing the exam scores. Results showed that students who experienced the same parenting style and teaching style achieved higher final exam scores than students who experienced different parenting and teaching styles. These results support that students’ academic achievement in schools are affected by the similarity and differences that exist between their home and school environments.
The many adults present in a child’s environment heavily influence their development and growth. Studies have aimed to look at the ways in which the style of parenting that a child’s guardians choose to follow may impact the child’s mental, emotional, and social development. Such parenting styles were typically identified as either authoritarian, authoritative, or permissive, whereby authoritarian parents show high control and little warmth, authoritative parents show high control and high warmth, and permissive parents show low control and high warmth towards their children (Walker, 2009). Additionally, besides the daily interactions children may have with their parents, their perception of and relationship with teachers while they are students have been shown to play a large role in their academic success (Alvidrez & Weinstein, 1999). It is on this premise that researchers have explored the extent to which parenting styles utilized in children’s home environments have impacted teacher-student relationships (Paschall, 2015). One study explored the effect of parenting styles in home environments on attachment issues and negative versus positive relationships with teachers, especially at a young age (Paschall, 2015). Studies such as this one have suggested that there may be an interconnected effect of different adults’ supervision approaches on children.
Teaching styles that instructors adopt in the classroom have shown many similar characteristics to the three types of parenting styles (Bassett, 2013). The ability to use the definitions of parenting styles to evaluate teaching styles was shown in one study in which college students were asked to evaluate teachers using the 30-item Parental Authority Questionnaire, also known as PAQ, which was a survey used to assess parenting styles in home environments. A few changes were made to the original PAQ; although the PAQ was created with the intention of analyzing parenting styles, scores using this survey were extended to teachers (Bassett, 2013). In a similar study, university students from Lander University were asked to read vignettes and describe the teachers in them as authoritative, authoritarian, or permissive, and then describe whether or not they would hire them. The students were also asked to identify the parenting styles they experienced at home, and the results were then analyzed to examine whether students’ preference in hiring teachers with different styles were related to the parenting styles the students experienced in their home environments (Bassett & Snyder, 2013). This study takes a more subjective view by asking the students for their perspective on which teaching style is preferable based on the students’ background.
When describing parenting styles, an authoritative approach to parenting has often been seen as most effective in regards to yielding positive results such as higher levels of social and emotional maturity (Bassett, 2013). Similarly, an authoritative teaching style was observed to be the most effective at increasing academic success in students (Walker, 2009). A study conducted by Walker in 2009 using fifth grade students and teachers described higher levels of success and even preference for teachers using an “authoritative” style. An important aspect to note is that while authoritative teaching styles were generally seen as more effective, there is not much research that exists analyzing how this effectiveness is impacted by the students’ home environments. The current study aimed to explore the connection between students’ experiences with parenting styles and teaching styles to determine whether or not experiencing the same or different styles at home and at school is most beneficial to the student.
The purpose of the current study was to determine how the relationship between parenting and teaching styles can influence adolescent students’ academic achievement at the end of an academic year. The teaching styles, categorized as either authoritarian, authoritative, or permissive styles, were designated to each experiment group with guidelines on how to maintain these definitions. Such guidelines included varying levels of leniency in regards to deadlines, supportiveness or consolement during struggles, and acceptance levels of disruptions in the classroom. Student achievement was measured using the final exam score at the end of the academic year. It was hypothesized that students who are instructed by a teacher adopting the same teaching style as the parenting style that student experiences at home will have excellent or high achievement while students who experience different teaching and parenting styles will experience acceptable or low achievement. By examining how similarities and differences in the student’s home and school environment impact their academic achievement through an objective lens, school environments can adapt to be better suited to students’ preferences and can more uniquely and effectively nurture their success.
Sixty students, 30 males and 30 females, entering eighth grade in September 2021 were recruited on a volunteer basis for this study. All participants were in the age range of 12-14 years old and were selected from Nassau County, Long Island, New York. Each participant also came from a household that contains two parents (or similar parental figure or guardian). Three mathematics professors from Stony Brook University’s Mathematics department were recruited to teach the classes. Participants were sorted randomly into three groups consisting of ten males and ten females each. All three classes of students were taught mathematics in accordance with the New York State mathematics curriculum, and all participants had to be able to read, write, and communicate proficiently in English.. All classes were held year-round at Garden City High School located in Nassau County.
Parental Authority Questionnaire (PAQ). All students were provided with a modified version of John R Buri’s Parental Authority Questionnaire (PAQ) from 1991 in order to gauge students’ assessments of the parenting style they experienced at home (Buri, 1991). The 30-item questionnaire asked students to rank statements regarding their parents using a 5 point Likert scale (Buri, 1991). While Buri’s questionnaire aimed to provide results regarding the mother and father’s parenting styles individually, the current study grouped the parents as a single entity and asked all 30 questions as they pertained to both parents or parental figures. For example, “As I was growing up I knew what my mother expected of me in the family and she insisted that I conform to those expectations simply out of respect for her authority” was modified to read “As I was growing up I knew what my parents expected of me in the family and they insisted that I conform to those expectations simply out of respect for their authority” (Buri, 1991).
Each of the three groups of students were assigned to one of three teaching styles: authoritarian, authoritative, and permissive. Each of these styles was used by a predetermined teacher who was provided with guidance on how to implement their assigned teaching style as it pertained to leniency, supportiveness, and tolerance. For example, the permissive teacher was instructed to employ high levels of leniency with assignment deadlines, high levels of supportiveness when students expressed having trouble in class, and high levels of tolerance when students created disruptions during class time. The authoritative teacher was instructed to demonstrate low levels of leniency, high levels of supportiveness, and low levels of tolerance. The authoritarian teacher was instructed to display low levels of leniency, low levels of supportiveness, and low tolerance for disruptive behavior. Besides these guidelines, all three teachers were given identical lesson plans and content to teach each class.
In September 2020, all students were asked to complete the Parental Authority Questionnaire. Results were compiled and each student was then categorized into one of two groups without their knowledge. Group A consisted of students who were about to experience a similar teaching style to the parenting style they experienced in their households, and Group B was composed of students who would be experiencing different teaching and parenting styles in the classroom and at home.
All three classes of students were taught mathematics using the same lesson plan, co-developed by each of the three teachers. Throughout the school year, monthly observations of the class were conducted, during which the observers would note details regarding leniency, comfort, and tolerance demonstrated by each teacher for a day.
On June 10, 2021, all sixty students were presented with an originally created, cumulative 50-question multiple choice final exam in mathematics with answer choices A-D. Every test was taken on a Scantron sheet for unbiased grading purposes. All students, regardless of class, were provided with the same exam and took the exam in identical testing conditions at the same time and location. Individual scores from the exam were blindly calculated and measured on a scale in which scores higher than 90% showed excellent achievement, between 75%-90% signified high achievement, between 65-75% indicated acceptable achievement, and below 65% represented low achievement. These results were then analyzed as they related to each student belonging to Group A or Group B.
In assessing students’ academic success it was predicted that students who experienced the same teaching and parenting style would display higher achievement than students who experience different teaching and parenting styles. Students were randomly placed into one of three classes (authoritarian, authoritative, and permissive), and students who reported having a parenting style similar to their teacher’s style were categorized as Group A, and those with parenting styles different than their assigned teacher’s styles were categorized as Group B. Results were compiled in order to support whether or not students who experience the same type of teaching style in the classroom as parenting style at home perform higher academically as shown by final exam scores.
Figure 1 shows a comparison of Group A and Group B students’ final exam scores in each of the three classes. A two-way ANOVA was used to examine the effect of group assignment in the three differently taught classes on academic achievement in eighth grade mathematics. Results showed a significant main effect of group assignment. Students who experienced the same teaching style in the classroom and parenting styles at home — Group A — achieved significantly higher final exam scores (M = 90.23, SD = 5.55) than students who experienced different styles in the classroom and at home (M = 77.87, SD = 5.73) classified as Group B F (1, 59) = 5.32, p <.05. Furthermore, based on the predetermined scale, a mean of 90.23 showed excellent achievement for Group A (falling between the 90th and 100th percentile), while students in Group B obtained a lower average final exam score of 77.87, signifying high achievement (falling between the 75th and 90th percentile). Additionally, results were calculated to analyze final exam scores for each teaching style classroom. Students in the authoritarian class obtained an average final exam score of M = 79.75, SD = 4.03. Students in the authoritative class obtained an average final exam score of M = 83.95, SD = 2.43. Students in the permissive class obtained an average final exam score of M = 83.5, SD = 4.47. No main effect was found for the style of teaching on academic achievement F (1, 59) = 2.36, p <.05.
Average Final Exam Scores Across Three Math Classes
Note. This bar graph displays the comparison of Group A and Group B students’ final exam scores in three differently taught math classes.
The present study was conducted in order to examine the effects of similarity or difference of teaching style and parenting style on students’ academic performance. It was hypothesized that students who were placed in a classroom with a similar teaching style as the parenting style they experienced at home would result in higher academic achievement. It was predicted that students with similar teaching and parenting styles, or Group A students, would show excellent (90-100%) or high achievement (75-90%) on the final exam in mathematics, while students who experienced different teaching and parenting styles, Group B, would exhibit acceptable (65-75%) or low (below 65%) achievement. Results showed that students in Group A showed excellent achievement while students in Group B demonstrated high achievement. These findings supported the hypothesis by showing that the level of similarity between teaching styles in the classroom and parenting styles at home (same or different) influenced students’ academic performance.
The current study used a novel approach to understanding the effect of different adult figures in adolescent students’ lives and how they work together to impact students’ success in education. Previous research has examined the relationship between the two styles, often focusing on the influence of parenting styles on teacher-student relationships, or vice-versa, showing support for the idea that the two are inter-connected (Paschall, 2015). Studies have also highlighted the success of one type of style over the other, often concluding that an authoritative style is seen as being more effective for the classroom and at home (Walker, 2009). While previous research has used a more subjective approach to understanding teaching and parenting styles and how they influence students by asking students to provide insight on preference and evaluation of the different styles, the current study aimed to take a more objective approach (Bassett & Snyder, 2013). The current study showed that students who experienced similar teaching and parenting styles had higher average test scores than those students who experienced different styles at home and in the classroom, providing quantitative support for the idea that both parents and teachers’ methods of supervision can impact students’ achievement together. While less focus was given on highlighting one style as more effective than the others, the study instead examined the relationship between school and home environments.
One strength of the current study was that it analyzed comprehensive success levels of students by examining average scores of a cumulative final exam rather looking only at final averages or at individual test scores throughout the year, which could be impacted by other factors such as homework completion or class participation, which may not accurately reflect content understanding (as it could be reflective of time constraints or student personality, respectively). Final exams were identical for each student, as was the curriculum, in an aim to make the content of the three classes uniform. Another strength of the study was categorizing students into Group A or Group B — depicting that the students were either going to experience the same or different parenting and teaching styles, respectively — without informing the teachers or students of these placements. This allowed for minimal influence or bias on the teachers’ or students’ parts in regards to academic performance or teaching methods.
One limitation of the study was the decision to make mathematics the subject to be taught by the three classes. Varying degrees of skill may have been present in each of the three classes, and no additional support classes (extra help, tutoring) were provided, thereby causing there to be a discrepancy between students who were previously skilled at mathematics and students who previously struggled with mathematics. Additionally previous research has shown that authoritative teaching styles were most effective in the classroom (Walker, 2009). This could mean that both Group A and Group B students could have been provided with the most ideal situations in the authoritarian style classroom when compared to permissive and authoritarian classes, indicating that an interaction may exist between the congruence of parenting and teaching styles and the specific parenting or teaching style itself.
The current study brought to light the importance of examining the many environments children and adolescents find themselves in and how they are connected to each other in impactful ways. This study suggests that students may be more comfortable and successful when they are learning in a familiar environment, and that the continuity that exists between home and school can impact students’ academic performance. Further research is needed to analyze other factors that can impact the students’ success, such as physical setting or other members of the environment (i.e., siblings vs. peers). These further studies can also incorporate the significance and effectiveness of home-schooled students and how the education system can be molded to better suit each individual child’s unique needs.
Nearly 800,000 people die from suicide every year (Suicide Data). Approximately seventy percent of the American youth that struggle with depression requires treatment (The State). People with depression have a daily battle with themselves to prevent those feelings of despair and loneliness from taking over. Those living with mental health disorders may develop effective coping mechanisms to deal with their issues. Music therapy, a method of therapy and a de-stress technique for which the positive effects are not yet highly known, involves “the professional use of music and its elements as an intervention in medical, educational, and everyday environments with individuals” (Wang and Agius 595). Music therapy not only involves listening to music but also consists of thinking, analyzing, and playing it. Many people view music as a means of amusement and frivolity for those involved. Both mental health issues and the fine arts are often stigmatized in our society. In regards to mental health, several people feel the need to downplay their problems since many illnesses do not manifest with obvious physical symptoms. Hence, society issues out old cliches, suggesting that people need to learn how to ‘deal with their problems.’ In actuality, mental health can affect not only one’s mind but also one’s body and, if left untreated, can severely affect one’s quality of life. Over recent years, many have come to view the fine arts as an impractical endeavor since several jobs in this field may not lead to a stable job or income. Historically, humans have always turned to the arts to express their feelings, through music, visual arts, or the written word. Music can have a profound effect on the biochemical as well as the physiological aspects of the brain. More and more researchers today find that psychotherapeutic drugs are not as effective in treating mental health patients as they used to be, partly due to drug tolerance. As a society, we must alter our mindset away from treating psychological problems exclusively through psychotherapy and drugs and must instead leverage the nontraditional method of music therapy for those who experience daily stressors and mental health disorders.
The standard practices of mental health treatment today involve two significant methods – psychotherapeutic drugs and psychotherapy – both of which, given the statistics of how the rate of mental health diagnosis is accelerating, are not enough. People with mental health disorders nowadays have a lot more options as to how to treat themselves: psychotherapy, medication, case management, hospitalization, therapy groups, alternative medicine, electroconvulsive therapy, and peer support (Mental Health Treatments). In the early- to mid-1900s, methods of curing mental health ailments involved lobotomies and shock therapy. Even with all of the progress made today, a recent study shows that approximately 10 million adults in America have suicidal thoughts, have not been able to seek treatment or have experienced both. In the past six years alone, the population of youth (ages 12-17) with depression has gone up by 4.35%, and two million kids now have major depressive episodes and need to seek treatment (The State). A team of neuroscientists from Naples, Italy found that antidepressant drug treatments are mostly ineffective for major depressive disorders. (Fornaro e. al. 494). Inefficacy can be attributed to tolerance, an anomaly that occurs when depressive symptoms reappear after previous treatment with antidepressants” with the return of depressive symptoms of MDD occurring in 9–33% of patients across published trials” (Fornaro et al. 494). Drug tolerance can build over time as the body requires higher doses of the drug in order to have the same effect as the initial dose once did, ultimately resulting in other biological side effects. Many antidepressant drug trials tend to last shorter than 52 weeks, contributing to the lack of understanding as to how effective these drugs will be long-term. The National Institute of Mental Health stated that 25% of 103 patients had depressive episodes. Further these patients were found to have 43 out of 171 following depressive episodes and experienced drug tolerance after a 20 year follow up (Fornaro et al. 496).
In the book, Music Therapy in Mental Health for Illness Management and Recovery, written by Michael J. Silverman, the director of the music therapy program at the University of Minnesota, he states that “ even when medications are effective in alleviating the symptoms of mental illness, they do not necessarily facilitate psychiatric recovery as pharmacological treatments do not contribute to the development of knowledge and skills necessary for a successful transition back to the community” (Silverman 55). The state of mental health is worsening – therapies previously used for decades are now proving to be not enough in curbing the rampant increase in prevalence of depression and other mental health disorders. Psychiatric treatment needs to implement a new type of therapy, like music therapy, that includes psychological interventions to analyze how people’s behavioral and thought processes have improved over time. By seeking new methods of treatments, specifically music therapy, society will move closer towards respecting rather than ostracizing mental health patients.
Music therapy was developed post World War I and II as a way to ease the minds of many soldiers with PTSD (Craig). Since then, this field has led to a wide range of studies, all seeking to answer the questions of how music therapy works and its purpose. If we have many different types of psychotherapy, why are neuroscientists and psychologists seeking more holistic treatments for their patients that are not guaranteed to work? Let us start with what precisely music therapy is and the basis behind it. Music therapy includes two main facets: psychoacoustics and the appreciation and hearing of music. Psychoacoustics refers to how someone perceives and comprehends music. In contrast, the brain’s mechanisms of appreciation and hearing of music is something that is developed across an entire lifespan and is influenced by many environmental factors (Craig, para. 19-20).
There are two main methods of music therapy: listening and active playing. When listening to music, therapists will put on music for the patient, recommended by medical experts who know about the patient’s specific case (Craig, para. 41-42). Some therapists will go down the more analytical route of listening to music. Therapists may ask questions that evoke personal thought analysis and insight. Some may also follow the Bonny method of guided imagery and music. Bonny methods consist of a patient listening to a song and seeing an image. This leads to the therapist asking specific guided questions that lead to the patient talking about their thoughts and emotions (Craig, para. 43-44). Music therapy can change a person’s attention, emotion, memory processing, behavior, and communication. A combination of all of these changes can result in changes in neural processing that can effectively change the biochemical state of depressed minds and improve their lives
Many studies prove that music therapy has been effective in treating people with mental disorders. In a study done by Sergio Castillo-Pérez MD and his team, he states that “depression remains a major health problem and, despite using pharmaceutical agents, patients continue to report high levels of unrelieved depression” (Castillo-Perez et al. 390). This group of researchers decided to study a group of low to medium depressed people receiving psychotherapy treatment compared to music therapy. A group of 79 patients between the ages of 25 to 60 years old were split into the two groups of therapy. The subjects chosen have never taken any psychotherapeutic drugs or have any other neurophysiological problems. All subjects were asked to self-report their level of depression with a well-known survey known as the Zung depression scale (Castillo-Perez et al. 387). The subjects self-reported how they were feeling age week for eight weeks. The music therapy itself involved a 50-minute self-administered music session, and once a week the participants would have a group session with doctors and other patients to provide a comfortable environment. The study controlled for stressful environmental variables that may occur such as sudden noises, changes in temperature, any environmental change or trigger (Castillo-Perez et al. 389).
The psychotherapy administered in this study was standard conductive-behavioral therapy (CBT). At the end of the tests, the researchers quantitatively analyzed the patients’ progress with the Hamilton scale (another type of depression scale) based on their behaviors and their self-reported scores of the Zung scale. The people with significant improvement meant they had to have a Hamilton scale of 0 to 7. The Hamilton scale was used after the 3rd, 5th, 7th, and 8th weeks. After only three weeks, within the music therapy group, one person improved; however, none improved within the psychotherapy group.. By the end of the study, 29 subjects improved with music therapy, and only four did not. For psychotherapy, only 12 subjects improved with 16 people showing little to no improvement. These data from the Zung and Hamilton tests were also cross-referenced with the Friedman test, and showed to be statistically significant with a p-value as little as 0.0356 (Castillo-Perez et al. 389).
As we can see, psychologists and neuroscientists today are doing more and more research regarding music therapy. Castillo-Perez’s study is just one of many examples in which music therapy has proven to improve the quality of life for people with depression more than psychotherapy. The three main methods of treatment for depression today are psychotherapy, antidepressants, and electroconvulsive therapy for severe cases. However, Perez and the rest of his team say, “Pharmaceutical treatments […] make no difference in the odds ratio of suicide attempts” (Castillo-Perez et al. 387). That is what needs to fundamentally change in how we treat and understand therapy for depressed patients. Pharmaceutical drugs will not influence the likelihood of someone committing suicide because there can be many sudden environmental circumstances and triggers. Musical therapy, on the other hand, aims to help depressed patients by trying to invoke the mesolimbic system, which correlates to positive and rewarding thoughts. As people living in the 21st century, we can understand that there is something special about listening to new music by our favorite artists, or dancing and singing to a high energy song that can affect our minds positively. Songs can reflect how we feel and can heighten our current emotions, and this is something that medicine and therapy at a certain point cannot do as effectively as initially administered.
As with many people who learn music from an early age, I found that playing a music instrument helped me relax and de-stress, especially after a long day of school and tests. After my piano lessons on Sundays and six-hour days at high school, I would hop on that leather bench and play Emile Pandolfi and feel my heartbeat slow down and my cheek muscles tense from all the grinning. Playing the theme from Harry Potter on the piano was my mode of artistic expression and relaxation. It is easily accessible, then, to imagine how music can help those who have severe emotional or mental disorders. To the parents of kids with mental health disorders, understand that music can be an outlet for kids to release their emotions and can have a tremendous effect on their functioning and behavior; to the kids who never seemed interested in playing music, that is okay. Part of music therapy merely involves passively listening to music in a relaxing setting. Society needs to alter its perspective on music from being misconstrued as a way of wasting time to a way of elevating one’s moods and taking a mental break.
To truly get an insight on a student’s perspective of music and its effects on mental health, I interviewed a bandmate of mine from high school who has been playing trumpet since the fifth grade. Her lifelong appreciation of music started when she began taking piano lessons in the second grade. She then began taking trumpet lessons and joined the band in the 5th grade and has continued primarily with trumpet since then. When I asked her about her mental health, she said, “As someone who has depression and anxiety, a part of me is always anxious, and the daily fight is not letting it become a 100% of me, and using coping mechanisms to get out of it.” She had to move 350 miles for college and said that it was a difficult transition due to the workload and having to meet new people, making it difficult to find time to relax. Being a part of the wind ensemble at her college allowed her to ease into the transition of a college student. When asked how music has helped her with her mental state and journey, she stated, “playing music was definitely a double-edged sword. Although I had stress and anxiety from the responsibilities that came with being on the band e-board, the intrinsic joy I got from getting together with people I cared about and playing amazing music was amazing” (Anonymous). She found that listening to music gave her a sense of solace and tranquility. It allowed her mind to focus on just the music, and in the process, she forgot all of her anxieties and elevated her mood. The lyrics, instrumentation, and many other aspects of music therapy can reflect the emotions we feel and can elevate how we feel. Music can alter the state of chemical neurotransmitters in our minds and change our emotions – this is something drugs and psychotherapy cannot do as effectively.
Due to social media today, music has become much more prevalent in students’ lives and has influenced the way college students handle stressful situations.A significant reason explaining music therapy’s lack of usage is because there are many misconceptions about the way music therapy works. Music therapy Director of University Minnesota Dr. Silverman, discusses the ill-conceived notions of music therapy, stating that “a common misperception of music therapy is that it is used exclusively to treat musicians” ( 55). Silverman emphasizes that music therapy was always used to help treat people with a broad range of neurological and psychological issues among a variety of adults, children, and seniors. Another common misconception is that music therapy is not as effective because it is merely the act of passive listening to pre-recorded music. However, music therapy is not just listening to music. Director Silverman says that in a study done comparing two groups of depressed patients who underwent passive music therapy and active music therapy, the active music therapy patients stayed throughout the sessions. Active music therapy involved lyric analysis, recreation music playing, and percussional music therapy (Silverman 55). All of this active participation served as psychological interventions that helped alter the person’s mood, behavior, and mindset.
In a survey I administered to fellow Stony Brook Students and my fellow high school alumni who have taken part in music since a young age, I discovered their opinions on the use of music in a therapeutic way. Of the 57 people who responded, 79% played an instrument, 22% of people said they listen to jazz or a variety of orchestral or classical music while studying, 80% of people listen to music when stressed out, and 73% of people found music to be therapeutic overall (“Music As Therapy”). 28% percent of the people I surveyed have mental health disorders such as anxiety, depression, and eating disorders. Even though the majority of people surveyed did not have disorders, 80% of the people who deal with everyday environmental stressors choose to listen to music to cope. When asked on a scale of one to five (five being complete improvement in mood and one being mood unchanged), 31 people said they felt better after listening to music when they felt anxious, sad, depressed, or other negative emotions. 12 people say their mood completely changed for the better (“Music As Therapy”). Although these results are biased because many of these people have played an instrument, they show that a majority of students understand that music has therapeutic qualities and utilize it as a coping mechanism or a tool when experiencing stress, anxiety, or depressive thoughts. Music is a type of escapism that allows people to avoid focusing on their current troubles and gives them the ability to focus all of their energy on one thing only – music.
Having said all of the above, why do people still believe that conventional treatment methods are effective and do not want to change? Discussions of new treatment methods lack because people only know what is largely acknowledged in society. Mental health was and still is stigmatized because it affects one’s mind and does not often manifest with physical symptoms like cancer. Only in the past few years has the topic of mental health been brought to the forefront. If many Americans do not wish to discuss their mental health problems, then how can new and more productive methods of treatment be used? Therein lies the existing problem that needs to change. Currently, in the time of self-quarantine, anxiety can run high even with people who have not been diagnosed with a mental health disorder because we live in a time of uncertainty. In a time when the fear of virus spread is high and ‘stay at home’ orders are strict, quarantine serves as an obstacle for people who need weekly in-person therapy sessions. People need to utilize resources at home that are easily accessible to cope with their anxiety, like music resources. If people are privileged enough to have access to the internet, there are a plethora of resources that can be used for music therapy, such as YouTube, Spotify, or an instrument if one has it.
Society needs to acknowledge that music therapy is a method that has proven to be successful amongst a wide range of people with varying disorders and varying levels of depression. Well known music therapist Dr. Dany Bouchard eloquently describes how to handle anxiety during the time of COVID: “Music has a connection with memory, brings us emotions, all kinds of stuff. It is how you use it now in order to make it a music prescription” (Rowat, para. 15). Music can help with COVID-related anxiety by serving as a focusing tool that allows our mind to target what is going on now rather than worrying about an uncertain future (Rowat, para. 18). Being open to trying new modes of therapy can be much more effective for anyone. As time goes on, some people with mental health disorders may have to increase their drug dosage due to drug tolerance that inevitably develops. At times, people who go to therapy may feel that it is not working, and can revert to unhealthy habits and coping mechanisms. Mental health overall is something that affects people every day through their actions and their emotions. Treatment of mental health disorders is an important aspect of healthcare that needs to be improved; it is a series of actions and behaviors one takes in order to see an actual result. Music can alter the state of someone’s mood and change someone’s behavior after prolonged daily music sessions. Additionally, the collaborative nature of music therapy allows people with mental disorders to have a massive support system on their path to recovery. Music therapy moves away from the idea persisting in mental health recovery that it is up to the person to improve themselves, and it is a solitary journey. Take 10 or maybe even 20 minutes per day to actively take part in something that involves music, whether it’s through such as playing, writing, singing, or listening. People with mental health problems are in a daily battle with their minds to prevent feelings of depression and anxiety from overcoming their thoughts. While psychotherapeutic drugs and therapy are helpful to an extent, music therapy can provide long term positive effects.
Anonymous. Personal interview. 15 April, 2020.
Castillo-Perez, Sergio, et al. “Effects of Music Therapy on Depression Compared with Psychotherapy.” The Arts in Psychotherapy, vol. 37, no. 5, Nov. 2010, pp. 387-90. ScienceDirect, doi:10.1016/j.aip.2010.07.001. Accessed 15 Apr. 2020.
Craig, Heather. “What Is Music Therapy and How Does It Work?” Positive Psychology, 18 Mar. 2020: par 1-101, positivepsychology.com/music-therapy/. Accessed 15 Apr. 2020.
Fornaro, Michele, et al. “The Emergence of Loss of Efficacy during Antidepressant Drug Treatment for Major Depressive Disorder: An Integrative Review of Evidence, Mechanisms, and Clinical Implications.” Pharmacological Research, vol. 139, Jan. 2019, pp. 494-502. ScienceDirect, doi:10.1016/j.phrs.2018.10.025. Accessed 15 Apr. 2020.
Sankaran, Sanjana. “Music As Therapy.” Survey. 15 April. 2020.
Silverman, Michael J. “An Overview of Music Therapy as a Psychosocial Intervention for Psychiatric Consumers.” Music Therapy in Mental Health for Illness Management and Recovery, Oxford UP, 2015, pp. 60-67. doi:10.1093/acprof:oso/9780198735366.001.0001.
Theatre is universally considered an art form, a way to embody the trials and tribulations of human emotion and virtue, and a way to speak the truths of those far too silent. Konstantin Stanislavski, for instance, was known for being a visionary of emotional discovery. He taught his actors to become the character, almost to the brink of no return (Cohen-Cruz, 2010). Bertolt Brecht then had a completely different approach: isolate the audience from emotion, and ask them to judge the conflict from the viewpoint of logic and objectiveness (Cohen-Cruz, 2010). Both became the introductory means to using theatre as a form of social change, while one man became the true pioneer: Augusto Boal. Boal — a Brazilian theatre actor, director, and playwright — created a beautiful mesh of Stanislavski and Brecht he called “Theatre for the Oppressed.” His plays were interactive and discussion-based, emotional yet objective. He is known today for opening these forms of theatre all across Europe, North and South America, and even Africa, all of which have the unique ability of creating a sense of change through critique and unity (Cohen-Cruz, 2010). For those who know him well, it is easy to admire his groundbreaking take— but for those who know Brazil, it is far easier to view him (and his methods) as revolutionary.
Boal’s popularity unfortunately (not coincidentally) rose right alongside Brazil’s difficult transition to a dictatorship in the 1960s— so that at the height of his career in Brazil, he was assaulted and exiled for his controversial practice (1971). It’s important to acknowledge, however, that his popularity rose for a reason: his styles and methods were skillfully designed to combat the political and social turmoil within Brazil, and continue to target those issues today.
The dictatorship, supported financially and politically by the United States, seemed ideal for many wealthy citizens who agreed with the coup. They were relieved to feel as though they could walk the streets without the fear of crime, protected by guards on every corner. For the poor or the dissidents, this was a different story entirely. People could not speak against the dictatorship, promote unity amongst the people, or offer critiques about the state of affairs. Anyone who chose to do so would be exiled, killed, or tortured for more information. (The dictatorship’s style of choice was the “macaw’s perch”, which involved tying and hanging the person upside down to wear out their limbs and rush the blood right to their head.) (Rejali, 2009). The dictatorship was not fair, not strategical, and chose personal profit over people at every given opportunity. Pablo Uchoa, whose father was a detainee, recalled these stories in a 2014 BBC article: “Many prisoners were also subjected to electrical shocks to their fingertips, genitals, and wherever else the sadistic imagination of their torturers would choose” (Uchoa, 2014). This was the setting from which Boal’s methods developed, which made them evolve from “How can we make theatre more entertaining?” to “How can we use theatre as a conduit to make a difference?” The concern of the people at the time was not entertainment— it was the pain and suffering they wished to fight against.
Boal’s theory is very involved, both mentally and physically. He wanted his audience to imagine themselves as the main character, just as many great directors do—to feel the pain, happiness, or desire that drives that person forward. Stanislavski reserved the right of “becoming the character” solely to the actors, whereas Boal wished to make everyone sense this feeling, so that the emotion became collective. His most famous method is known as “forum theatre,” during which the audience will watch the play once, consider how it could have occurred differently, watch it again, and—at their own discretion—interrupt it to suggest (or become) that change. That is, they may tell the actors how they wish for the play to be modified, or they may replace and become one of the actors themselves. The true embodiment he encouraged, it seems, is the perfect promoter of anti-military upheaval. The body’s connection to theory is what makes it powerful, as a symbol for dedicated change and action. It gives the audience a recognition of their body as power, each motion and act a new subjective lens to a complex situation. He not only wanted his people to become the characters, but to also become their own proposed solutions. In this sense, he wished for his audience to gain autonomy and independence in the context of the story and within their own lives. The Brazilian people subjected to the rule of the dictatorship—fearful of the outcome of disagreement—would have used Boal’s practice as not only a way to feel more comfortable, but also as a way to confront issues long gone unspoken. It was a way to unite the people in their mistrust, maltreatment, and dissatisfaction— all the while motivating action through reaction.
Today, Brazil’s social and political situation has not improved by much. After its shift to democracy in 1988, the nation has faced many issues with corruption, poverty, sexism, and racism. Each is as divisive and dangerous as the last, most particularly in the case of politics and corruption. In 2003, Lula da Silva ran for president, known for having had a very limited educational background and a very unfortunate life of pain and family death. This grew into a resentment of capitalism and worker treatment, and passion for politics. As a presidential candidate, he attracted people for his kindness, charisma, his humble background, and most importantly, for being someone they could trust. After years of allegations and suspicions, he was arrested for corruption in 2018 for accepting bribes worth a total of 3.7 million reais, equivalent to 1.2 million USD (Britannica, 2021). This led to riots and protests all across Brazil arguing about the validity of those allegations. They would spray paint it, scream it, put posters up, have custom door knockers, make it their wifi password, their phone case— everything: Lula Livre, they’d say. Free Lula. Or, if they disagreed, Lula Ladrão. Lula the Criminal. Jair Bolsonaro, the current president, is passionate about strong militarism and obsessed with returning to the Brazilian dictatorship (Reeves 2018). He has done countless things to incite anger from the public and believes criminals that live in favelas should “die on the street like cockroaches” (Phillips 2019). Many citizens, including Uchoa (whose father experienced it first hand) are terrified of this new reality—that Brazilians must fear the return of a dictatorship—but it is the reality of a politically, economically, and racially divided people.
Methods such as Forum Theatre, then, never cease to become useful in their capability to not only change the flaws of society in the crux (government), but also the people. Boal would find random sample sizes of individuals at the park, restaurants, etc., and motivate them to theorize and discuss together, regardless of their opinions, beliefs, race, sex, sexuality, etc. They would become immersed in the theatre and feel a newfound sense of unity with one another, particularly after Boal’s “Games for Actors/Non-Actors” (Paterson 2013). During the dictatorship, the Brazilian people could discuss these issues with the cloak of just games or petty acting, coerced into developing a new sense of community identity and revolution against a dysfunctional government. These same people now, who struggle with polarization of class systems and racial exclusion, tend to remain silent and act as though they live in a racial democracy, incapable of racial tension or injustice. These same people more than ever do not understand each other’s lives and debate constantly on how to create a better future. The Augusto Boal Institute, made in his honor, continues to encourage constant reproductions or inspirations based on his work, holds panels of Boal’s relatives and colleagues, and shares important stories of his life and his time during exile. It keeps his message alive, his impact longlasting, and most importantly, it creates a space where theatre is synonymous with critique and release, with love and change, with power and unity— the very theatre Boal knew would never rest.
Cohen-Cruz, Jan. Engaging Performance: Theatre as Call and Response. Routledge, 2010.
In 2008, a seven-year-old boy complained that his stomach was in such pain that he could not sleep. The boy’s parents took him to see his pediatrician. In due time, the boy found himself in a hospital in Long Island. He was missing an entire school day, which would have otherwise been a happy occasion if it were not for the IV in his arm and the impending endoscopy—a procedure in which a small camera is inserted down his esophagus and into the stomach to check for gastrointestinal issues. The doctors could not find any explanation for the stomach pain.
Eventually, the boy’s parents brought him to a specialist in Manhattan, who did his own tests. When all the tests seemed to be futile, the specialist asked if lactose intolerance had been considered as a possible cause. After a few days of avoiding milk, the boy’s stomach pain went away. In the end, he had no gastrointestinal issues, no infections, no serious complications; he simply could not digest dairy. Silly, right? I know. The boy was me.
Lactose intolerance is not only very common, but it also runs in my family. All my signs and symptoms indicated lactose intolerance. The evidence was there. As the saying goes, “When you hear hoof beats, think horses, not zebras.” It should not have taken three doctors and a camera down my throat to reach the proper diagnosis. So why did it?
Did my parents’ urgency for their child create a dramatic flare for the doctors? Was there a desire to take action so quickly and intensely? Maybe the doctors thought a simple answer was not satisfactory enough for my concerned parents? Maybe the multiple lab tests and procedures done on me were just the doctors’ gesture that they were trying their hardest to get an answer, no matter how convoluted and unnecessary the gesture. While this may seem ridiculous that a doctor would offer excessive medical services just to make patients happy, it is not unheard of. In fact, it is quite common. To the detriment of the medical profession, the interpersonal dynamics of the clinic can become tangled with a physician’s fear of lawsuits.
The Power of Patient Expectations
Some doctors find symbolism in providing medical services they know are unnecessary. The doctors see their actions as doing everything they can for their patient (Rowe et al. 5). To them, the issue of overtesting and overprescribing their patients can be overlooked. Doctors have even reported that if their patient left an appointment without some kind of prescription, the doctors felt as if they had not done their job (Butler et al. 639).
More often than not, patient expectations for their medical care are communicated to doctors implicitly rather than explicitly (Stivers 1127). Since patients are not always making their wishes clear, doctors decide to follow their gut instinct on what they believe their patients want. University of Newcastle researchers Jill Cockburn and Sabrina Pit found that if a doctor perceived their patient to be expecting medications, then the patient was ten times more likely to get a prescription (Cockburn and Pit 521).
Now, one may say, ‘Maybe the doctor is correct. Maybe the doctor is just really perceptive, and they can tell what the patient wants without the patient saying it.’ Unfortunately, doctors are frequently wrong on this occasion. A study published in Patient Education Counseling observed that when doctors predicted a patient’s expectation for medication, the doctors were correct only 53% of the time (Jenkins et al. 276). Medications can have harmful side effects and high costs. Lab tests also bear negative consequences, especially if the tests involve radiation or high risks of false-positives. Medical services should not be given on gut instinct just to make patients happy.
However, the demand to meet patient expectations is both compelling and draining for doctors. In the short term, doctors may receive some relief in believing their patient walked away feeling fulfilled, but in the long term, the reality of not complying with standards of their medical training may kick in. In interviews with Dr. Theresa Rowe et al. of Northwestern University, doctors spoke about prescribing unnecessary antibiotics because they felt the patients desired them. One doctor remarked, “You spend 15 minutes trying to educate [patients], when they will go out disillusioned, come back the next day and see someone else, making you feel 5 minutes would be better spent just giving them a prescription and getting rid of them.” Another doctor admitted, “I do feel as though I’ve been slightly used. Sometimes slightly abused as well” (639).
When doctors put an emphasis on patient expectations, they lose the motivation to limit medical excess, preferring to cater to customer satisfaction. Ironically, the physician makes the medical profession more mentally taxing for themselves. Now, they must walk a fine line between customer service and patient wellness. And to keep customers coming back for business, sometimes it pays to think of zebras, not horses.
Looking for Liability
When we think of the healthcare we receive, we hope physicians run their medical practice faithfully, not defensively. However, an unfortunate reality is that the threat of malpractice lawsuits and mentalities such as “more is better” have made doctors weary of acting according to their medical training. Doctors would prefer to safeguard themselves with defensive medicine, ordering multiple tests or procedures that do not always make the patient feel better, but will definitely make the doctor feel better. Doctors can use tests or prescriptions as evidence that they did their job correctly and were extensive in their examination of a patient.
At times, some of these numerous tests may alert doctors to a hidden, life-threatening illness. If we think in terms of “more is better” or “earlier is better,” then maybe the cost of defensive medicine is acceptable. However, if we prioritize the moral integrity of the medical profession, then we should not accept that some doctors direct our medical care by threat of lawsuit. Then our treatment plans are not designed exclusively for patients. Rather, doctors will begin to merge the clinic with the court, and legal opinion with patient outcome. As Johan Bester, director of bioethics at the University of Nevada Las Vegas, writes, “[Defensive medicine] represents an egregious breach of professionalism and of ethical obligations to the patient and to society” (418-419).
We should hold doctors liable for their mistakes, but we should be mindful of where the threat of liability is steering doctors’ decisions. Current trajectory suggests more defensive medicine. It would be ironic if the tool we use to hold doctors responsible for isolated incidents encourages doctors to have an irresponsible approach to treating every patient.
If we would like to have patient-oriented medicine, we should consider the realities in which doctors exist today. There is no magical wand to stop doctors from engaging in defensive medicine. This is more than just a patient-doctor issue. It is one that affects our economy and healthcare system: from longer wait times to more expensive medical bills. Bill Clinton said he wanted to get rid of defensive medicine in 1992. So did George Bush in 2004. And Barack Obama in 2009.
But there are realistic steps that we can take to clarify the line between patient and customer. We should be more upfront with our doctors: let them know what we expect, what our presumptions are, and what we would like done. We should not be worried about sounding stupid or wasting the doctor’s time with questions. Doctors undergo many years of medical training to give you an answer. So ask away and be frank. We cannot risk our doctors making an inaccurate assumption of our needs and then treating us accordingly. Not all of us are doctors, but all of us at some point will be patients. We do not need to be over-tested nor overprescribed. We should take up our side of the effort to prevent medical excess and preserve our doctors’ attention to us.
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