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Another dirty book


Charlotte Roche

<em>Fourth Estate, 229pp, £12.99</em>

A warning: do not, as I did, start reading this book in your lunch break. The writer introduces the protagonist's haemorrhoids in the very first sentence, and by the second page some lucky man has his nose in them ("I call this position 'stuff your face'"). The gross-out genre, happily bestowed upon us by the Farrelly brothers and Chuck Palahniuk, has a new star in Charlotte Roche, an elfin, English-born, German-bred television presenter whose fictional debut, Wetlands, has sold half a million copies since its publication in Germany last year. It is interesting to see how differently this kind of subject matter is received when it is written by and/or about a woman. While Palahniuk and the Farrellys are filed under "comedy", the jacket of the English translation of Wetlands announces that this novel has the "feminist agenda of Germaine Greer's The Female Eunuch".

Such a reception in itself lends weight to the book - it is clearly still political, rather than funny, for a woman to write about shit, piss, slime and other entertaining bodily functions. But the focus on gender diverts attention from what Wetlands actually does well: it is a sharply written, taboo-busting black comedy, both gross and engrossing. If you are looking for a manifesto for 21st-century feminism, on the other hand, you will be disappointed.

The novel is set in a proctology ward (or "ass unit") where 18-year-old Helen Memel has been admitted, following an unfortunate accident while shaving her bum. (Roche said in a recent interview that the book had originally been conceived as a non-fiction tirade against hair removal. She also maintained that bum-shaving is a common practice among females. At the risk of giving away far too much information, I have to ask - really?) In between the various agonising medical interventions to which she is subjected by the sinister Dr Notz, she flirts with a male nurse, ponders her colourful sex life and lets readers in on some of her choicest grooming habits. "Hygiene's not a major concern of mine," she announces, and she's not kidding: from deliberately wiping her "lady fingers" on the seats in public toilets to fashioning her own tampons from whatever happens to be lying around, this girl is Florence Nightingale's worst nightmare.

I can't help but find it depressing that Helen has been understood as some kind of feminist icon. Far from being liberated, she is imprisoned by her preoccupations with sex, dirt, blood and hair. She has rebelled against her prim-and-proper mother's obsessive cleanliness ("Her dying thought at the scene of an accident would be: How long have I been wearing these panties?"), only to construct her own set of obsessions, many of which are more damaging to herself and to those around her. She is promiscuous and sexually adventurous - we are treated to several pages on her preparations for anal sex - but surely we have progressed beyond mistaking these for sexual empowerment? Roche makes the point neatly by allowing Helen to be "rescued" in traditional knight-on-a-white-horse fashion by Robin, the male nurse.

There is an interesting argument to be made against hygiene fascism, and many times during the course of her narrative Helen hits the target: "If you find cocks, cum or smegma disgusting you might as well forget about sex"; "What [well-kept women] don't know: the more effort they put into these little details, the more uptight they seem . . . those type of women would never let themselves get all messy fucking". However, after 229 pages in her company, I was just as tired of the tyranny of uncleanliness, and probably more drawn to obsessive-compulsive hand-washing than ever before.

None of these is a criticism of Helen as a character. She is charismatic and full of contradictions: obsessed with mascara and curling her eyelashes but pathologically opposed to washing her face; proud of her pussy yet ashamed of her ass; strong and independent-minded, but still reliant on men to bolster her self-esteem. For all her tough talk she is, by her own admission, "neurotic, deranged and depressed", the product of a broken home and a suicidal mother. Wetlands, in the tradition of Plath's The Bell Jar, is a remarkable novel about mental illness that has been mistaken for feminist literature.

Alice O'Keeffe is an award-winning journalist and former arts editor of the New Statesman. She now works as a freelance writer and looks after two young children. You can find her on Twitter as @AliceOKeeffe.

This article first appeared in the 09 February 2009 issue of the New Statesman, Revolution 2009

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Want to know how you really behave as a doctor? Watch yourself on video

There is nothing quite like watching oneself at work to spur development – and videos can help us understand patients, too.

One of the most useful tools I have as a GP trainer is my video camera. Periodically, and always with patients’ permission, I place it in the corner of my registrar’s room. We then look through their consultations together during a tutorial.

There is nothing quite like watching oneself at work to spur development. One of my trainees – a lovely guy called Nick – was appalled to find that he wheeled his chair closer and closer to the patient as he narrowed down the diagnosis with a series of questions. It was entirely unconscious, but somewhat intimidating, and he never repeated it once he’d seen the recording. Whether it’s spending half the consultation staring at the computer screen, or slipping into baffling technospeak, or parroting “OK” after every comment a patient makes, we all have unhelpful mannerisms of which we are blithely unaware.

Videos are a great way of understanding how patients communicate, too. Another registrar, Anthony, had spent several years as a rheumatologist before switching to general practice, so when consulted by Yvette he felt on familiar ground. She began by saying she thought she had carpal tunnel syndrome. Anthony confirmed the diagnosis with some clinical tests, then went on to establish the impact it was having on Yvette’s life. Her sleep was disturbed every night, and she was no longer able to pick up and carry her young children. Her desperation for a swift cure came across loud and clear.

The consultation then ran into difficulty. There are three things that can help CTS: wrist splints, steroid injections and surgery to release the nerve. Splints are usually the preferred first option because they carry no risk of complications, and are inexpensive to the NHS. We watched as Anthony tried to explain this. Yvette kept raising objections, and even though Anthony did his best to address her concerns, it was clear she remained unconvinced.

The problem for Anthony, as for many doctors, is that much medical training still reflects an era when patients relied heavily on professionals for health information. Today, most will have consulted with Dr Google before presenting to their GP. Sometimes this will have stoked unfounded fears – pretty much any symptom just might be an indication of cancer – and our task then is to put things in proper context. But frequently, as with Yvette, patients have not only worked out what is wrong, they also have firm ideas what to do about it.

We played the video through again, and I highlighted the numerous subtle cues that Yvette had offered. Like many patients, she was reticent about stating outright what she wanted, but the information was there in what she did and didn’t say, and in how she responded to Anthony’s suggestions. By the time we’d finished analysing their exchanges, Anthony could see that Yvette had already decided against splints as being too cumbersome and taking too long to work. For her, a steroid injection was the quickest and surest way to obtain relief.

Competing considerations must be weighed in any “shared” decision between a doctor and patient. Autonomy – the ability for a patient to determine their own care – is of prime importance, but it isn’t unrestricted. The balance between doing good and doing harm, of which doctors sometimes have a far clearer appreciation, has to be factored in. Then there are questions of equity and fairness: within a finite NHS budget, doctors have a duty to prioritise the most cost-effective treatments. For the NHS and for Yvette, going straight for surgery wouldn’t have been right – nor did she want it – but a steroid injection is both low-cost and low-risk, and Anthony could see he’d missed the chance to maximise her autonomy.

The lessons he learned from the video had a powerful impact on him, and from that day on he became much more adept at achieving truly shared decisions with his patients.

This article first appeared in the 01 October 2015 issue of the New Statesman, The Tory tide