Before his operation, a man bunches his surgical gown around his genitals so that no one can see them. A woman tugs a blanket over her bottom to cover herself while I put an epidural in her back. Such behavior—the normal shame response—happens all the time in my anesthesiology practice. But what underlies it?
Shame is not the desire to be moral, nor is it meant to repress sexual desire. Indeed, sexual desire is the last thing on a patient’s mind when entering a cold, sterile operating room. Nor is shame the desire to hide the ugliness of one’s body, as some beautiful patients express shame when they disrobe, while some ugly patients express no shame at all.
In my experience, shame in the operating room arises when patients take the measure of themselves as individuals at the very moment they think others are scrutinizing them. It is a protective feeling. It arises out of our desire to shield the most important parts of ourselves from general notoriety. It can be likened to a feeling of imbalance or disharmony, which is unpleasant; yet its intention is to cover or veil something of value in ourselves and to defend it against the larger world, which is praiseworthy.
But that is not how many educated Americans today view shame. They focus on the unpleasant sensation, and view shame as an unhealthy feeling. They put shame in the same category as unhappiness, anxiety, and pain. In essence, they “medicalize” shame as a malady that needs to be fixed. But unlike the first three problems, shame has no pharmaceutical antidote, which makes all the difference in how it is treated. People suffering from unhappiness, anxiety, or pain can take a pill to ease their discomfort. Without a pill for shame, it is society that has to change.
Among the various kinds of shame that our society has labeled destructive and malignant, sexual shame has become the primary target. Society, especially progressive, well-educated society, has bent over backwards to make sure no one feels any shame whatsoever about his or her sexual activities. The movement to destroy sexual shame has sometimes led to new ways of life that shock us—for example, sex education in lower school, college hook-up culture, f—k buddies and “friends with benefits,” the ubiquity of celebrity sex tapes and amateur porn, the principle of gender neutrality, the policy of letting teenage girls get an abortion (but not an aspirin) without their parents’ consent, college workshops on anal sex, and courses for credit that involve masturbation and the use of sex toys. Sometimes the changes confuse us—for example, when feminists call women consumers of sex, like the men, but also “victims,” unlike the men; or when feminists encourage women to dress sexy but then criticize the “objectification” of women.
All this confusion makes sense to an anesthesiologist, for the world of anesthesiology is a world of naked patients where shame naturally abounds. Every change associated with our half-century war on shame is derivative of one of four techniques I use every day to combat feelings of shame in the operating room.
Before describing those techniques, I need to make two points. First, in combatting shame, I appear to ally with those who view shame as something unhealthy or wrong. There can be some truth in this, but as a doctor I view a patient’s shame experience as a special situation, a needless burden borne by a sick person in an unusually stressful environment. Relieving shame’s discomfort in the operating room does not detract from shame’s larger value in everyday life, just as forgiving the absence of grit in someone with the flu doesn’t mean grit lacks value in healthier circumstances.
Second, gays, lesbians, and transgendered people seem to represent the shame-smashing movement’s leading edge, but this is wrong. It is more accurate to say that the larger population of cisgendered heterosexuals has sometimes found these groups useful, and therefore pushed their agendas in pursuit of a shame-free society on behalf of themselves.
Gays and lesbians, for example, have widened the range of acceptable sex. Yet rather than push for shame-free sex, most gays and lesbians have supported sex’s most conservative institution: marriage. By highlighting the border between marital and extra-marital sex, they actually reinforce the shame experience for married heterosexuals pursuing sex on the side. In another example, the attentiveness of some gay men to their physical looks does no work for those heterosexuals fighting against “body shaming.”
Transgendered people do more work for the anti-shame movement, which may explain why “progressive,” well-educated society jumped to their defense so quickly after “discovering” them. For example, transgendered opposition to “deadnaming,” in which a transgendered person’s original biological sex is made public against that person’s wishes, complements the larger cisgendered heterosexual goal of forgiving and forgetting—and de-judgmentalizing—peoples’ sexual pasts.
In another example, transgendered people who think cisgendered people should be more open to having sexual relationships with them work in synch with the much larger cohort of obese cisgendered heterosexuals fighting against similar prejudice, as well as against “fat shaming.” The latter want a wider population of heterosexuals to overlook their weight when considering future partners. Finally, by pushing gender neutrality, transgendered people help the larger cisgendered heterosexual world rid itself of traditional norms of femininity and masculinity, which have long been sources of shame for those who fail to somehow measure up.
Nevertheless, these smaller groups are just marginal phenomena; true reality remains the much larger population of cisgendered heterosexuals pushing for a shame-free society, using some application of the four methods I use every day in the operating room.
Fighting Shame in the Operating Room—and Beyond
The first method that anesthesiologists use to fight shame is to distract scantily clad patients from thinking of themselves as individuals. I talk to these patients as if they were “cases” rather than individuals. I greet them with a face of stone. I neither frown nor smile when I address them. I inquire into their medical histories as if they were one of many semi-naked bodies to pass before my eyes, and nothing about their personal lives—their lives as individuals—could possibly interest me.
The naked patient for me becomes like an artist’s model—a lump of flesh to puzzle over as opposed to an individual with deep personal feelings. A woman who poses nude for a male artist feels no shame; she feels herself not to be an individual but an object. If the artist starts to flirt with her, she no longer feels herself to be just an object; she suddenly experiences herself as an individual, and often blushes.
It is no different with a female patient. The more I treat her like a “case,” the less she experiences herself as an individual, and the less she feels shame. Talk to her as if she were pretty or attractive and not just another case, or tell her that she reminds me of another woman, and she will quickly blush. She will feel tension between herself as an individual and what the world thinks about her, which gives rise to the feeling of shame.
This general method accounts for many of today’s shame-smashing policies and practices. Sex education has come to lower schools to keep youngsters from stumbling into a teenage pregnancy or catching an STD. But an equally important goal is to sever sex from any sense of shame. It is why educators objectify sex. Graphs and diagrams make sex a study in the behavioral traits of whole classes rather than in the liaisons of unique individuals. It is why so much emphasis in sex education is put on the mechanics of sex, since all naked bodies function more or less similarly.
Shame often arises from deeper feelings of guilt, which itself arises from an attraction to what is supposed to be resisted. There is no attraction in sex education—on purpose. The solid wealth of information presented becomes ponderous and even a little ugly to young students; the long lines of text and paragraphic numerals at the margins grow tiresome. If anything, sex education produces in young people a curious expression of stoicism—of a certain grim acceptance of the facts of life. They feel no more shame in learning about sex than do naked patients being lectured to by a doctor on the various categories of disease.
Many young people carry this objectification of sex with them into early adulthood. In hook-up culture and among f—k buddies, sex becomes an act that the body engages in, not the self. Like the artist’s model, these people behave like objects during sex, which suppresses shame. Sexual love is practically a precondition to sexual shame, for people in love feel the urge to express their sensations physically while at the same time trying to suppress them, out of self-protection, until garnering enough evidence that one’s love is returned. None of this complex dynamic occurs during a hook-up.
Given that suppressing the sex drive seems pointless, while avoiding it seems impossible, today’s educators trying to banish shame have made the calculation that it is better for young people to meet each other halfway, to satisfy their mutual bodily desires—safely, contractually, and with mutual consent—so that afterward they will not be distracted from the more important task of discovering themselves as individuals in their careers. Thus, from their perspective, the more sex education is sanitized of love the better. The result may be more sex, assuming young people retain the interest (although recent research suggests they might not), but less shame.
This method carries complications. For example, once, while still an intern, I took care of a bashful patient who came to the emergency room with a condom trapped inside her vagina. While searching for the condom, I explained to her how she and her boyfriend might avoid this problem in the future—for example, by having her boyfriend hold on to the condom when removing it after sex. It was as if I were a doctor speaking matter-of-factly about going on a diet: Nothing fried or roasted, less salt and fat, more fiber and vitamins. The woman grew so indignant toward my air of clinical detachment that at the end of the case, instead of thanking me, she said caustically: “I think you could have been more sympathetic during the whole thing.”
For this reason I sometimes use a second method to counteract shame: I make patients think of themselves only as individuals. To keep patients out of that no-man’s land between an individualizing attitude and a generalizing attitude where shame arises, I tack in the opposite direction.
Take a hypothetical semi-naked patient with red hair named “Betty.” To keep Betty from blushing I will try and make her feel that I am comparing her with no one else; that she reminds me of no one else; and that she says things that have been said by no other patient. I do this to keep her from generalizing her situation, for as soon as I stop looking at Betty as “Betty,” the unique individual, and start looking at her as a more general type—for example, Betty, “the young naked woman with red hair”—she will turn to her self, and blush.
We see this method at work in the larger world, where thousands of people recite their sex stories or confess their sex problems on social media in ways that would have embarrassed most people a mere generation ago. The anti-shame movement encourages this. Sometimes these confessions are anonymous, but sometimes they’re not—the confessors’ voices are real and even their images on screen are real. While giving their testaments, so long as these confessors feel themselves to be unique individuals and unlike any other case (even though in reality they are very much like other cases), shame lies dormant in them. For it is not the number of people watching them that poses to their minds the risk of general publicity, but whether the audience is lumping them in with others. These confessors often delude themselves into thinking the audience is not.
Social media makes this delusion possible. For example, a Yelp restaurant reviewer sometimes imagines his or her review to be singular, and the restaurant owner to be paying special attention. To a Yelp reviewer, this turns the review into a kind of personal dialogue between owner and customer. A 2015 South Park episode parodied this inflated sense of self-importance among reviewers, who, in the episode, imagine themselves to be unique, central, and all-powerful. An analogous phenomenon occurs when people tell their sex stories on the internet. While millions of people observe them, these impassioned confessors imagine their story to be special, unlike any other case, and that to others (millions of them) they are not just “one more example of such and such,” but, instead, “John” or “Betty,” stretching out a helping hand through a personal experience, while those watching them feel for them or even shed tears for them, as one might for a friend. While describing their intimate details, the confessors seem to think they remain themselves, and are read as themselves, and are acknowledged as themselves, and that those watching them would, if they could, share with equal willingness their trend of thought, the way friends do. Because of this delusion, social media sex confessors often do not feel the danger of general publicity that incites the feeling of shame.
Obviously, the first anti-shame method and the second anti-shame method are in conflict. The first method encourages objectification; the second method discourages it. It is why my patient referenced above, with the condom trapped inside her, became angry with me. She thought I was treating her like an object when she wanted to be treated like an individual. We see the same conflict in the larger world, as, for example, when feminists encourage women to give their sexuality free reign and to dress provocatively, but then resent the “male gaze” that objectifies women who dress provocatively. Although the contradiction confuses people, it merely attests to the contradiction inherent in the two methods.
Yet both methods yield the same paradox: more sex, more discussions of sex, and more confessions of sex, but less shame. It recalls the paradox of the prostitute. The prostitute feels no shame at work, but also no shame at home with her lover. At work, the customer seeks the prostitute, not the individual, while the prostitute seeks the customer. The prostitute is purely an object. At home, both the prostitute and her lover seek the individual. In neither situation does the prostitute feel herself to be in that twilight state of indecision, part-object and part-individual, that arouses the feeling of shame.
Sometimes the second method of fighting shame fails spectacularly. I once gave anesthesia to a man who needed a penile implant for impotence. I visited him afterward, along with the surgeon (a woman, I might add). We spoke with him as if we had been friends all our lives, while the man responded in ways that made us all feel closer, even if only by joking and clowning. This was no doctor-patient relationship; this was just the three of us hanging out. We wanted the man to focus on his individuality and not to see himself as a more general case of male impotence. Then two young female nursing students entered the room. Thinking the man’s easygoing nature a license for them to say anything, one of them teased lasciviously, “Can we see how it works?” The man’s lips dried instantly. Suddenly, he was no longer a unique individual; he was now the impotent man with desires who needed a funny device to make his penis grow. His situation had been generalized before an onslaught of seeing eyes. He grew ashamed and his relaxed manner never returned.
For this reason I sometimes use a third method to fight shame. I try to keep patients from thinking that others are watching them. Shame comes when people feel a disharmony between how they see themselves and how they imagine others see them. Saint Augustine said as much when he noted how a man often feels no compunction against saying the stupidest things in public but will feel terribly ashamed if caught innocently copulating with his wife. At such a moment, the man feels himself to be compared with the general class of animals. Rid him of onlookers and his shame fades.
True, one doesn’t need to be watched to feel sexual shame. Some people feel shame when masturbating alone. Nevertheless, most people do feel less shame when they are alone.
I often enter birthing rooms where pregnant women greet me with their legs spread wide apart and their private parts open for all to see. During uterine contractions most forget themselves and think only of their pain. I have never seen a birthing mother in the middle of a contraction express shame. However, once I’ve placed an epidural and rid mothers of their pain, the potential for shame returns, and these women sometimes grow embarrassed when I return to check them.
To ease a mother’s shame, I will often look down when entering the room, and walk straight over to her chart lying on the counter. With my eyes fixed on her chart I will ask her how she’s feeling as I scribble notes. When I do look up, I will stare directly into her eyes, as if there were nothing unusual about her bottom half to distract me. Indeed, if someone were to ask me at that moment why I looked only at her eyes and not at her bottom, I would feign confusion, and declare: “Why should I look down there? Is something out of the ordinary going on down there?” Because I glance away from her private parts, the mother loses the audience needed to initiate the shame cycle.
This anti-shame method takes several forms in the larger world. Most obvious is the “right to privacy” movement supported by many liberals and conservatives, which is the right to have no onlookers. Technology makes snooping on people easy. The mining of personal data by such companies as Facebook and Google is equally troubling. People risk shame and humiliation if their information gets out. The “right to privacy” pushes back against this trend.
The method takes another form in the “right to be forgotten.” Embarrassing details of a person’s intimate encounters can live forever on the internet, resulting in the potential for eternal shame. If the details get erased, there can be no onlookers and therefore no shame.
This is where privacy rights begin to merge with the opposition to “deadnaming,” and, in the larger cisheterosexual world, with the effort to get people to forget, or at least forgive, one’s sexual past.
The notion that people can start fresh at any moment is a very American one, so much so that to think otherwise is almost un-American. At the same time, people today are so desirous that their sexual history should disappear of its own accord that they barely think how all of this should come about, other than that other people should simply deny the undeniable. They are as children who want everything to be made of chocolate. They pretend to have no past, and they expect others with meek smiles to pretend with them. Sometimes a man or a woman will have a history of hundreds of sexual partners but then expect to be accepted as someone who had always been waiting for Mr. or Ms. Right. The slate is wiped clean. “Life begins now,” declares the vulnerable party—nothing to be ashamed of here.
Gender neutrality represents another application of this anti-shame method. Just as it is easier to be anonymous in a big city than in a small town, so is it easier to rid oneself of onlookers if one’s sexuality is merged into a universal type. An eye trained to the difference between two distinct genders will not easily notice something different or unusual if all people are clustered around a single mode. What is distinct is blurred or effaced altogether. With gender neutrality, people become like the customary trunks of firs and pines in a dense forest, all so similar that no particular tree stands out. Without the stark division between masculinity and femininity to serve as a standard for comparison, no tension between the individual and a larger group standard can exist. This arrests the shame cycle.
The fourth method of controlling shame works on the principle of jujitsu, where an opponent’s strength is used against him. Some semi-naked patients cannot be rescued from their shame. It is too intense. Rather than fight it, I intensify it so that the patient grows insolent toward it. In other words, I encourage the patient to become cynical.
Here is an example: When a female patient tries repeatedly to cover her bottom while I place an epidural in her back, I sometimes say in a bitter tone, “Don’t worry, I’m not thinking about bottoms. I’m thinking about high taxes and government incompetence. Our whole system, it’s so corrupt.” I become an angry curmudgeon. The naked patient ineluctably falls into my groove of thought. Indeed, sometimes she goes from being ashamed of her nakedness to rejecting civilization altogether and becoming sufficiently exhibitionist to throw off the rest of her covers.
This method transforms a naked patient’s shame into the shame of the cynic. The cynic isn’t shameless; on the contrary, the cynic has a hypersensitive feeling of shame, which he or she rebels against by protesting defiantly against prevailing expressions of shame. The cynic still feels a kind of shame—it is why sarcastic people in particular often fear ridicule; they go from being revealers to the revealed—but shame’s expression is perverted so that it no longer discomforts. It is transformed into indifference toward anything sexual—for example, toward the fact that one’s bottom lies exposed in the operating room.
Yet there is a dark side to this method. Shame is a protective feeling, but what if the cynic believes he or she has little inside himself or herself worth protecting? In such cases, expressions of indifference may pass into a love of the obscene, while the feeling of shame itself is discredited with mockery and wit.
We see this method abound in the larger world: Celebrities eager to make sex tapes and amateurs eager to defend their appearance in porn videos; comedians who poke fun at clergymen for their celibate ways; filmmakers who stereotype all suburban parents as buttoned-down, sexually repressed prudes; spokespeople for free love; spokespeople for the “culture of irony”; and run-of-the-mill critics of traditional mores, modest attire, and conventional sex relationships—in other words, many of the people who define today’s hip cultural scene.
Their teasing defines “edgy,” but it is sometimes just a protest against prevailing conventional expressions of shame used to divert attention from their own strongly felt lack of an inner life. They attack modesty, yet they themselves have no charms for modesty to conceal. Their indifference has passed into resentment; their cynicism has passed into jokes about genitalia and the desire to shock. The jokes themselves suggest an air of self-confidence; indeed, they let the jokesters form a conception of life which allows them to think well of themselves and even take pride in their outlook. But it is really all a façade. If they were to change their shameless attitude, they would lose the feeling of superiority it accorded them, and for this reason they instinctively cling to the kind of people who look upon life in the same way they do—hence, the hip cultural scene.
The jokesters’ cheeks are white with confusion or resentment rather than red with healthy shame. Yet some self-described freethinkers have cheeks that are white with anger. These people recall the very prudes they poke fun of. Old-fashioned prudes, seen in both genders, invoke their moral code to find situations that cause shame in others, thereby giving them an opportunity to express their moral indignation. This lets them enjoy a kind of sexual gratification otherwise denied to them: The more they moralize, the more pleasure they feel. Their smugness diverts attention away from deficiencies in their own lives; they replace the feeling of healthy shame with the excitement of condemning the feeling of shame in others.
Some extreme feminists behave similarly. They ferret out all sexually significant events in their surroundings and are eager to condemn them harshly if they deviate from their moral code. Cases of sexual assault obviously deserve condemnation, but the fury expressed toward perpetrators of milder incidents, involving, say, a tasteless joke in mixed company or a brief moment of unwanted hand-holding—a fury often more intense than the sympathy shown toward the “victim”—betrays a deeper feeling of pleasure, almost as if the fury itself were providing an alternative form of sexual satisfaction. As in the case of prudes, their sadistic moralizing titillates them; their criticism accomplishes the very thing it is meant to condemn.
I knew a woman who moved out of town after her divorce. Years later, when I saw her again, I asked her why she had done so. She told me it was not to find a new job or new spouse, but because people back home kept asking her about her…situation. She didn’t want to stare into their embarrassed smiles again and explain. That’s the hardest thing about a break-up, she said: explaining. It made her feel awkward, as if she had done something dirty and shameful.
Critics of shame dislike shame because it is an uncomfortable feeling. And it is. By ridding society of shame, they imagine that they are helping people rise up and revolt against some jailer. I don’t blame my friend for wanting to leave town.
Yet some critics of shame have risen up against false expressions of shame rather than true shame, and in their war against the former they have overlooked the value in the latter. Indeed, for today’s critics, the latter has no value, for to their minds there is no difference between true shame, which is universal and healthy, and false expressions of shame arising from a particular morality they despise. Today’s critics despise a traditional morality that condemns both pre-marital sex and non-heterosexual sex, that lauds only one ideal of male or female beauty, and that forces people to hide their bodies under stupid, baggy clothes. They confuse the judgments of this old-fashioned morality with true shame, as if wearing a one-piece bathing suit to avoid the wrath of an old biddy is synonymous with blushing. It is not. The former reflects the artificial urge to conform to a particular morality; the latter reflects the natural urge to shield oneself from notoriety.
To make different kinds of sex acceptable, today’s critics have risen up against uptight scolds who narrowly define respectable sex. Yet they erroneously think such scolds speak for true shame. To encourage people to discuss their sex lives with their doctors or friends without feeling shame, they have risen up against tight-lipped puritans who suppress this legitimate desire. Yet they erroneously think such puritans speak for true shame. To help people enjoy sex without feeling ashamed, they have risen up against prudes who smugly parade traditional values. Yet they erroneously think prudes speak for true shame.
Helping people to enjoy sex or talk about sex without embarrassment are positive things, but by confusing false shame with true shame, and then opposing both, the critics’ methods have also encouraged the disjunction of sex from higher feeling. They have encouraged the delusion that one’s sexual past can easily be forgotten. They have abetted cynicism and obscenity. They have poured venomous and bitter ridicule on any act of modesty. They have enabled a new kind of prude to come into being, as vicious as the old one. They have turned masculinity and femininity into dirty words.
They have confused asceticism, prudishness, uptightness, and conformism with true modesty. They have confused distended forms of behavior with a true virtue.
To tell the difference, study the color of the person’s cheeks. The cheeks of the puritan, the prude, the scold, and the conformist are invariably white with fear or anger. The cheeks of the modest are red. Those red cheeks are like a suit of armor, shielding from the outside world what the modest person believes is valuable in himself or herself. For that person, shame is a healthy reflex.
Think of a young woman in love, blushing with shame. She is brimming over with a new kind of affection. Her eyes sparkle bashfully and mischievously, as if she has an intimate secret to tell. Nature is calling her just as time cues a tiny flower to open even during a frost. She has much to give, but it still needs nurturing and protection until she knows that it will be properly received, and so she blushes in shame. She cradles her burning cheeks in her hot palms. It is a healthy instinct that masterfully and indivisibly enters her will.
True, her shame discomforts her. But it also represents almighty, palpitant life. To call this a disease and embrace shamelessness, to rid her of that discomfort and describe doing so as progress, is to kill that life. It is akin to the twisted logic that says dead people have perfect health because they never get sick.