Gynecology in Japan

The incident

At the time of the incident I was living in Japan with my husband. I went to the hospital for a gynecological consultation with my husband. The nurse took me into a small changing room; my husband was not allowed to enter with me. At that time, I did not speak Japanese very well. I had to undress myself and lay legs apart on the gynecologic table.

There was a curtain at the level of my abdomen, separating the room and I could not see what was happening behind the curtain. I opened the curtain; a nurse passed on the other side, she said something I did not understand and closed the curtain, I opened it again.

A doctor came in and started speaking to me however I did not understand him and there was a long negotiation: I asked if my husband could enter and the doctor allowed this. The doctor told me that during the consultation the curtain must stay closed and that he will explain to me what he’s going to do. I categorically refused: I wanted the curtain to be opened so I could see the doctor.  He was very surprised, however he finally accepts.

1. Identities of the actors in the situation

Narrator: 27-year-old French woman married to a Japanese man, has been in Japan for two and a half years, married for 3/4 months, has lived in other countries before and a teacher at the Franco-Japanese institute in Tokyo.  She speaks some Japanese.

Assistants, nurses: Female, Japanese, only speak Japanese.

Doctor gynecologist: Japanese, only appearing at the end, male, around 50 years old.

2. Context of the situation

The physical disposition is a key element in this situation.  The situation takes place in a hospital, at the department of gynecology. The waiting room gives access to several doors one next to the other. All these doors give entrance to narrow rooms where there is only space for undressing and for accessing the gynecologist chair. A curtain goes across the chair around waistline; beyond the curtain there is an open space from which all the chairs disposed in parallels can be accessed.

The narrator thinks that there were other women in the chairs next to hers, but she could not see them.

She could hear movements, steps on the other side of the curtain, at least 3 nurses and about 2 gynecologists.

Everything was white, the curtain white or green. The chairs were simple gynecologist chairs with support for the feet. There was a smell of disinfectant characteristic of hospitals.

3. Emotional reaction

“I felt not recognized, I felt ignored, my individuality was ignored. I was also scared a bit. I felt resistance and some apprehension.”

4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock.

In France the profession of gynecology happens to be more taken by women than men. The professional culture– which is also the preference of the narrator – is one dominated by the following practices:

Doctor-patient relation

Consultation starts with a face-to-face encounter, which happens in a room that looks more like an office than a hospital room. Doctor and patient usually seat across a table in and at this point the patient is fully dressed.  It is important that the first contact is a verbal one, but which is also accompanied by eye contact. It is a private encounter between the two, the doctor and the patient, there are no other protagonists. A personal relationship is established via the verbal and visual contact before the undressing and physical examination takes place. Also, there are separate spaces for the verbal interaction and the physical examination.

Level of medicalization

In France the gynecologist consultation does not bear the accessories of a medicalized encounter: the gynecologist does not wear white, does not have a mask, and may not posses complicated instruments such as ultrasound machines.

A core value underneath the differences is a tendency of individualism

It is important to reassure the patient, to recognize her as an individual, and in particular as a person, who is more than the flesh, the biological entity with a physical symptom. The symptom cannot be accessed only physically; it goes through discussion with the person.

Direct communication

In France the preferred communication style is based on more symmetry and equality than in Japan and direct verbal communication has a stronger role than indirect. Even in situations where there are strong power asymmetries, efforts are taken to diminish and compensate these differences by restating equality. Accordingly it is very much acceptable for a patient to ask the doctor to do certain things, such in this case to put the curtains apart.

5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, "stigmatized", positive, very positive, real, unreal) etc?

Bizarre, a different relationship to the body, a different conception of “shame”.

6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator.

Collectivism: InJapanese society a tendency toward collectivism or interdependence dominates rather than individualism. This may explain that the patients do not feel as threatening the idea that they sit in one of the many gynecologist chairs, with their intimate organs exposed to doctors that see all the vaginas at the other side of the curtains.

Relationship to the body: there is more reserve concerning the body in Japanese society, in any case the rules of the ritual erasure of the body are different than in western society. In Japanese society it is less likely that women talk about intimate aspects of their body, physical contact is rarer (i.e. the western ritual of handshake is replaced by the bowing not requiring any physical contact).  Traditional Japanese society is also more discrete concerning hiding parts of the body.  Male – female contact is also more regulated, in fact gender roles are more marked, even in language where there is a separate male and female form of speech.

Communication style: preferred communication style in Japan is more contextual (i.e. using objects, disposition of furniture to communicate) and more indirect (less focused on direct verbal messages, more on non-verbal, para-verbal) that in France.  Also, less emphasis is put on direct visual contact, which is considered impolite when extended and fixed. Accordingly, communication through a curtain is acceptable, even desirable in some circumstances.

Orientation towards the face of the other: when embarrassed people from most cultures would direct the view away from the other person source or witness of the embarrassment, as a direct visual contact would confirm or aggravate the embarrassment and induce a loss of face of the other. Japanese communication style is more oriented towards saving the face of the other than saving one’s own face. In a potentially embarrassing situation (such as observing the private parts of a woman) the avoiding of even the possibility of having eye contact gives reassurance and helps saving the face of both parties.

Relationship to hierarchy:  in Japanese society the general tendency accepts more hierarchical relationships than in France.  A profession such as doctor / gynecologist is also adds to status, thus a relationship between doctor and patient by definition can be more asymmetrical.  Instructing someone of a higher status (i.e. asking the other to change the behavior, do something) is considered quite impolite. Rituals such as talking seemingly at equal levels such as in the French practice are not required.

7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?

This incident illustrates the importance of contextual communication, or how the disposition of furniture, objects, the organization of space can support very important values and norms related to body, communication, gender roles and politeness.

A more subtle conclusion concerns two different representations and relationship towards the body.  On a superficial level Japanese cultural approach is more restricted, reserved (with more regulations, taboos) concerning the body (less physical contact, more hiding, more hygiene rules etc). However in western cultures such as French are also meet the practice of “ritual erasure of the body” that we can catch in such practices as the taboos of body noises (burps, farts).  In a way in both cultures there is a demand desire for hiding the body, but the strategies on how to do this differ radically. In Japan the choice is to separate the body (the intimate part of the body) physically with a curtain and not bring the eyes as witnesses, while in the occident the viewing of the intimate part is compensated by an introductory dialogue between patient and doctor, where the viewing of the intimate part can only come as secondary.