Bloody Hell

Introduction

I am 72 years old. I have a wonderful husband, three beautiful daughters and seven fabulous grandkids. For much of my career I have either run my own business or co-directed businesses as well as completing various degrees. These days, I chair a company, participate in an active transport advocacy group, sing in a choir, paint, attend poetry appreciation sessions, concerts, plays and films, frequently travel interstate and internationally, and generally enjoy my life. I am relatively fit in that I regularly exercise by swimming, walking, attending a gym and riding my bike.

However, from 1994 to 1997 my quality of life was significantly diminished because of my failing uterus.

I believe that the series of events that led to the ultimate removal of my uterus in early September 1997 were probably not unusual. When I first wrote about my experiences just after the hysterectomy, I was angry at the way I had been treated but also disappointed and flabbergasted at my own role in the experience. But life was too busy and so I never did anything more than document my frustrations.

And today, perhaps women feel more empowered and confident to gain the care that they need to maintain their gynaecological health, and hopefully clinicians are far more respectful of those needs than I think they were 30 years ago. Nevertheless, I am sharing my story as a reminder to women of my daughters’ and grand daughters’ generations of the importance of standing your ground and making sure that you get the clinical care that you need in order to live a healthy life.

While the last three years of my relationship with my uterus were not pleasant, this piece focuses on a series of events that occurred during the twelve months that led up to and culminated in me having a hysterectomy in September 1997. In writing about this time of my life, I would like to stress that my intention is not to blame but to encourage a more balanced understanding of the issues surrounding the advice given by doctors, and decisions made by women, in determining how to best deal with this aspect of their health.

Background

I always had very regular and I think comparatively heavy periods, generally lasting between six and seven days. From the age of 17 through to when I was about 41, except for when I was pregnant, I was on some form of oral contraception. Initially, the pill was prescribed by the family GP to help reduce period pain and what my mum thought was heavy blood loss. When I turned 41, I decided that I had had enough of the pill – probably because it dawned on me that I had been on it for a very long time and was unsure about its long-term effects on my body. After that, each period became increasingly unignorable – being occasioned by heavier blood loss and more pain.

The Events

October 1996

I visited my GP for a regular check-up including a pap smear test a couple of weeks before leaving for a business trip to India. The GP picked up a polyp on the cervix and organised an appointment with a gynaecologist in the next few days. The polyp was removed and proved to be harmless. The gynaecologist nevertheless suggested an ultrasound would be a good idea just to make sure that there were no other problems with my uterus.

November 1996

On my return from India, I had the ultrasound, and after another two weeks, having not heard from the gynaecologist, I contacted his surgery to get the results. The receptionist told me that the ultrasound showed a fibroid and another polyp in the uterus. Wanting to understand these results, I asked if I could either speak over the phone with or organise a consultation with the gynaecologist. The receptionist queried my request, asking me why I would need to talk with him. I told her that I would like to understand the implications of the ultrasound results: what they actually meant. I pressed her again and she reluctantly had the gynaecologist speak with me on the phone. He told me that there was really no problem, that there was no need to see him unless I’d like to, perhaps in another three to six months. So, I followed his advice.

December 1996

Blood on the grey velcro of the car seat cover looked shockingly red – especially in the presence of my 20-year-old nephew who politely pretended to not see it.

Early January 1997

By my calculation my period was due on the weekend that I was supposed to be in Perth for my brother’s wedding. I decided that I couldn’t handle the hassles of bleeding on my mother’s sheets or risking waking her with my frequent visits to the toilet throughout the night, so I booked into a hotel, much to the chagrin of my family and in particular, my mother. As it turned out, it was a good decision. The period was a ripper and lasted ten days. Thank goodness for the relative anonymity of hotels.

30^th January 1997

Within minutes of the beginning of an all-day meeting in Sydney with an interstate client, I bled suddenly and very heavily. Fortunately, the purple jacket was long enough and the purple trousers dark enough to camouflage the stain on my trousers, which no amount of protection could have prevented. However, it was difficult to camouflage my embarrassment at having to slip out of the meeting hourly to sort myself out. This is not the first time this had happened.

My colleague with whom I had worked for nearly three years, told me that every month my frequent departures from meetings must have been very obvious to our clients, most of whom happened to be men. Every month over the previous three or so years had been marked by some similarly awkward or embarrassing event, like the time I walked the streets of Hobart early in the morning trying to find an open shop because I had gone though a pack of tampons and sanitary pads over night. Stuffed with wads of toilet paper, I made my way to the office at 8.30 am and sought the assistance of my female client who lent me a government car, which I drove around Hobart to locate a pharmacy.

Every month was the same. No amount of sanitary protection could stop me bleeding on the sheets, or ruining my clothes, or leaving stains on seats. Nothing would absorb clots. I wondered whether this what it was like for other women my age? Did the gynaecologists really believe that this was a normal loss. I kept picturing a thimble and recall once being told that most women lose no more than a thimble full, but I couldn’t see how a thimble could possibly hold what I would regularly lose.

February 1997

Without any trouble I walked the Milford Sound, a three-day, 55-kilometre hike through some fairly rugged terrain. In the six weeks leading up to the hike I trained every week and took a daily dose of the iron and folic acid supplement Fefol to manage my low iron level. However, if my period had fallen during the time that I was to go on the walk I would not have been able to do it. Apart from the inconvenience and embarrassment, there would not have been enough room for all my sanitary requirements in the little backpacks we carried.

March 1997

I took one of my daughters to Sydney. By the time I had reached Newtown, I was in trouble. Thank goodness for McDonalds. The loo was clean, but it felt so damned uncomfortable placing clean sanitary gear on blood saturated underclothing and denim.

March/April 1997

I received a letter from an insurance company rejecting my application for an income protection policy. My broker had tried to get me a better policy than the one I already had. The reason for the rejection was that the gynaecologist had written that a hysterectomy was imminent. This information shocked me. Had the gynaecologist withheld some information from me about my health? How did his report to the insurance company fit with his comments to me that I had no problem; that my heavy periods were normal; that the fibroid was very common and nothing to worry about or to take action on; that there was no need to see him – unless I’d like to. Never once had the possibility of a hysterectomy been discussed with me.

To seek a clarification, I went to see him. With eyes focused on papers that he was shuffling on his desk, he clearly demonstrated his confusion about who I was, why I had ever come to see him, and which report he had written. After a quick scan of the paperwork from the insurance company he apologised by saying that he didn’t realise that the insurance policy being sought was an income protection policy. He thought it was for life insurance. I still don’t really see the difference.

I later realise that I left his surgery without having found any real answers about my health. I think that what he told me was that I was all right: that eventually I might want to consider alternatives to a hysterectomy, but that at the moment I was all right. Nevertheless, this new advice was still quite different from what he had told me when I spoke to him on the phone in November, and not the same as his recommendation to the insurance company.

In retrospect I find my lack of assertiveness with this gentleman about his report to the insurance company puzzling. All I can put it down to is that I did not want to embarrass him or cause a fuss. More importantly, however, I recall being amazed at the fact that I walked out of his consulting room, having failed to reconcile his dismissal of the results of the ultrasound test with his report to the insurance company.

Mid-April 1997

I went to my GP to discuss options for contraception. I did not want to go back on the pill, but I was sick of using condoms. She suggested I could try a three-month injection that might also stop my periods. At the same time, however, she suggested that the bleeding might not stop completely because of the fibroid. Realising that I was again going to Perth, this time for my mother’s 70^th birthday, I decided to have the injection.

That I was period-free for the 20th April when I was with my family in Perth was good news. However, by the 22nd April I had developed abdominal heaviness and pain (which basically stayed with me until I had the hysterectomy), and I resumed bleeding on 27th April.

At this stage I was becoming aware that even though I was taking Fefol, my iron level was falling. Some familiar symptoms were returning. I was becoming increasingly breathless, and my legs were going into spasms when I sat or lay down. Nevertheless, I tried to be patient about the bleeding, thinking that, as the gynaecologist had suggested, it was likely to abate after a while. I recall him saying this as if it was not a problem, not a huge deal, and nothing to concern myself about – when I had gone to see him about the insurance report.

Mid-June 1997

Feeling frustrated at the fact that the bleeding had not stopped, I visited my GP who suggested that a hysterectomy was really my best option. With this advice I organised a visit to another gynaecologist to organise a date for the operation.

I recall the gynaecologist asking me why I wanted a hysterectomy. I said that I had had enough of uncontrollably heavy periods and two and half months of continuous bleeding. I remember rationalising at the time that the reason he showed me no reaction to the fact that I had been bleeding for so long, was that he had heard the story hundreds of times before; that therefore there was nothing unusual or untoward about my condition. I recall concluding that perhaps I was making a fuss about something that was not much more than a social nuisance.

A discussion with him six weeks after the operation threw some light on his reaction. According to him, women’s estimation of their own menstrual loss varies greatly, and sometimes is significantly at odds with reality: typically, he said, women believe that they have heavy periods.

To his credit he explained all the risks of surgery, allowing me the opportunity to make my decision in the light of all the facts. It seemed to me that from his perspective I was making a lifestyle decision that would eradicate a problem that had been a nuisance. According to this gynaecologist, after all, 40 % of women have a hysterectomy. Hearing this information made me feel like a fake. But, having come this far I decided to book in for surgery at the end of July.

Understandably, I became disappointed when my husband Steve asked me to change the date because he would be overseas and wanted to be at home – just in case something went wrong. We both accepted the change of plans as a nuisance, not thinking for a moment that waiting another four months would really make much difference to my health.

August 4 – 10 1997

I travelled to Sydney for an important meeting with a prospective client who had brought together his management team to meet me. The trip was accompanied by uncomfortable pain in both my bowel and my uterus. As I stepped out of the car at Central Station, blood exploded from my body and splashed onto the bitumen. No amount of plugging and sandbagging could have prevented the flood from breaking. I made my way across Pitt Street and into the building where I was to meet my clients. With only ten minutes to spare I raced into a toilet where I counted six clots as they fell into the toilet bowl. I then used toilet paper, tissues and spit to clean myself up before meeting my clients.

Having haemorrhaged only minutes earlier, the situation seemed almost surreal as I participated in apparently – hopefully – intelligent dialogue about the organisation’s need to bring about change and how my company might be able to help them to do so. Internally, I laughed at my cheek.

After this episode, I decided that perhaps I shouldn’t have to tolerate so much bleeding and so asked my GP for some help. She put me on a program of Primolum: three a day for three days, two a day for three days and then one a day for three days.

August 11 – 15 1997

I worked in Melbourne conducting wall-to-wall seminars for the whole week. Steve was worried, but I assured him that I would be OK: that the Primolum had started to work, making my bleeding still heavy but manageable.

Friday 15th – Sunday 17th August 1997

Conveniently my body behaved well while I was in Melbourne and I only started to bleed heavily again when I made it back home to Wollongong. A change of sheets, pyjamas, eight or nine trips to the toilet: I just let it flow away. Clots, bleeding, overnight pads and super tampons, don’t leave much time for sleep. All weekend I felt weak, with any physical exertion being hard work.

Monday 18th August 1997

Early on Monday morning before leaving for Sydney to catch a flight to the Nhulunbuy in the Northern Territory, I made a frantic trip to my GP. The weekend had been terrible. I bled very heavily. The doctor gave me a new prescription of Primolum, advising me to maintain the dose at three per day. Suspecting that my haemoglobin level might be very low, she also prescribed two additional iron tablets per day and persuaded me to have a blood test before leaving for the airport.

Wednesday 20th August 1997

By this time the increased Primolum dosage had proved moderately effective: my bleeding had subsided to a level that had been familiar over the last few months (32 super tampons and about 15 overnight pads over about 7 days), complete with fist size clots.

On Wednesday morning work didn’t start until just before 9am, so I went for a walk through the back streets of Nhulunbuy. Regular exercise is an important part of my life and so one of the frustrating aspects of my physical condition during this time was that while sometimes I could do anything I wanted to, on other occasions I would really have to push myself. At the same time, once started, strenuous exercise tended to make me feel good. But on this Wednesday morning I was a bit concerned because it was difficult to pick up any speed without my legs feeling like lead and my heart palpitating. In hindsight it is easy to understand why this was happening with less than a full quota of blood. However, the symptoms were always confusing.

On that particular day I was struggling to walk at my normal pace, but only four days earlier I had swum a kilometre with ease. So, I found my experiences on that Wednesday a little frightening. Was it because I was carrying too much weight? Was there something wrong with my heart? (Two years earlier a check–up with a heart specialist for similar symptoms suggested I was OK.) I couldn’t understand how I could keep going with a challenging workload – sometimes 12 or 13 hours a day, complete a strenuous circuit at the gym but still feel breathless when I walked up stairs, or frequently wanted to just drop to the floor with weakness.

The results of the blood test showed that my iron level was normal but red cells and haemoglobin levels were both below minimum levels. The doctor’s advice was that I continue to take the iron tablets and then have another blood test in a month.

A walk the next day along the coast of the Arafura Sea felt better, so I picked up the pace and did a few sit ups and push ups. I felt refreshed afterwards, but the iron tablets didn’t take long to exacerbate my troublesome haemorrhoids, so I gave the tablets up because the pain was too much.

Friday 22nd August 1997

At Cairns Airport carrying a briefcase, my laptop and a shoulder bag – stop start, stop-start up the walkway to the plane tested my strength. I was aware that I was stretching the friendship with my body by lifting my gear into an overhead locker. Heart palpitating, legs aching, I fell into my seat, only to be told by another passenger that I was in the wrong seat. A double-booking meant that I had to stand and wait for a flight attendant to find me another seat. Seconds later I fainted. I felt embarrassed, and a bit of a fake or prima donna. From another perspective, it was a rather dramatic way of getting an upgrade to business class.

By the time I had reached Sydney, I was feeling particularly tired and weak. Another delay at the Thrifty counter at Sydney Airport had me waiting for a car to become available. Standing was too strenuous, so I sat on my luggage.

Having driven into the city centre, I had a two-hour wait for two of my daughters Domenique and Bronwyn who I was meeting for my third daughter Tessa’s Rock Eisteddfod grand final. The night was just great, but of marathon length. The eisteddfod finished at around midnight, and locating Tessa was chaotic and not to be achieved quickly among the thousands of excited kids there. Domenique and Bronwyn laughed at me for lying on a bench outside the Entertainment Centre. I was just too tired and weak to stand or sit. I must have looked a tad silly, but I was trying to save some energy for the drive back to Wollongong, which we reached at about 2.00 am.

Monday 25 – Friday 29 August 1997

For these days the bleeding was tolerable, with the Primolum[1] apparently doing its work. By this I mean my blood loss was about as heavy as a pretty heavy period – one that I had become accustomed to experiencing for the previous three years.

By Friday night the haemorrhoids had at last subsided; however, the bleeding picked up its pace. I counted 8 trips to the toilet throughout the night.

Friday 29 August 1997

During the day in Melbourne, I needed to rush off to the toilet probably every hour and a half to change my usual sanitary protection of a super tampon and an overnight sanitary pad. This was OK. I never thought about it; It was just a normal part of my routine that had been with me for the previous four months, day in day out. The 3 Primolum seemed to be working – I suppose this is what is meant by working. I was aware that my key preoccupation on this day was with painful haemorrhoids that had kept me out of bed most nights while in Melbourne. I surmised that the constant bleeding was just too much for my troublesome haemorrhoids, no matter how much Scheriproct ointment I used every day.

Saturday 30 August 1997

Heavy bleeding. By heavy I mean going through 16 super tampons and a packet of 10 overnighters.

Sunday 31 August 1997

When I collapsed in the kitchen just after breakfast, I was amazed at the contradictory feeling I had; on the one hand I felt frightened because I was at home by myself. Steve was away and all the kids were out. On the other hand, I felt stupid. For God’s sake pick myself up. The weakness in my legs and the palpitations were probably because I was frightened, I reasoned. All I had to do to stop trembling was to keep active, but for the next hour I found this very difficult to accomplish. I climbed into bed. Then I climbed out of bed thinking that there was nothing wrong with me. But when I tried to walk, I was overcome by limpness. This was getting a bit scary. What if something was wrong? What if it was not just bleeding? The specialists never indicated that there was anything significant in my bleeding, I reasoned. So, what is wrong? Do I have a heart problem? Why do I pant so much when I walk, get up, talk on the phone, or rush?

I worked from bed but because I became frightened at having collapsed, and at feeling very weak, I rang Wollongong Hospital Emergency Department and explained that I had been bleeding heavily for a number of months and had just collapsed. The doctor suggested that it was likely that I needed a transfusion and I ‘could be’ at risk of having a heart attack, but that I would have a long wait because the hospital was busy. The ‘could be’ along with the knowledge that I would have a long wait at the hospital, led me to decide to wait until the next morning to see my own GP, thinking that this would be a more efficient way of getting a transfusion.

Monday 1 September 1997

I decided to go ahead with a meeting I had organised with a prospective employee. This was too good an opportunity to miss. Besides talking with her was not going to affect my health. I recall being breathless in talking with her, and afterwards she told me that my lips were blue and my face grey. My breathlessness bemused me because the weekend before I swam a kilometre comfortably and afterwards felt refreshed.

I finally hit the sack at about 11.30 pm after spending time talking with my daughters and helping one of them to clean out her bedroom.

A strange sensation came over me as I tried to fall asleep. I could feel and hear my heart beating; my whole body seemed like a heavy drum beating. I try to turn over, thinking that I might be pressing on a sensitive part of my ear. I sit up. I lie down again and try lying on my back, but nothing seems to work. I get out of bed and pace up and down the bedroom. This works but I am becoming frightened. It is 1.30am and I can’t get to sleep because of the palpitations. And I am too frightened to fall asleep because I just don’t know what is happening to me. The words of the casualty doctor are coming back to me. I oscillate between fear and self-reprimanding that I am over-reacting, talking myself into something terrible.

t 2.00 am I rationalise that if I am over-reacting then I can cope with the embarrassment of Wollongong Hospital staff telling me so. But to try to ignore the palpitations which in any case are not allowing me to fall asleep is not particularly clever. So, I wake my 18-year-old daughter, Domenique and ask her to take me into casualty. I feel a nuisance for waking her. It is only a few weeks before her HSC exams and I am concerned that she gets all the sleep she can. On the way in I change my mind a couple of times, as I do again when I see other people with obvious distress sitting opposite me in Emergency. But when I am asked to get on the hospital bed I can’t make the climb and collapse on the floor.

I spend the rest of the night wandering in and out of sleep, the haemorrhaging continuing as usual, and my chest palpitating with every attempt to move.

The results of a blood test indicate that I need a blood transfusion which I receive throughout the next 24 hours, and I am booked in to have a hysterectomy at the end of the week, on 5^th September, my second daughter Bronwyn’s 17th birthday.

Observations and reflections

Something needs to be said about the apparent irrationality of my procrastination. Why did I not take notice of the doctor at Wollongong Hospital that I spoke to on the phone on 31 August?

I am reasonably intelligent. A core part of my work at the time was helping managers to solve organisational problems, and teaching people in various industries how to effectively negotiate, so how did this happen to me? How come for more than two years and intensively for about another twelve months I tolerated, mostly taking for granted, sometimes not even noticing:

Breathlessness

palpitations

spasms in the legs

constipation

haemorrhoids

heavy and eventually continuous bleeding

sleepless nights

embarrassment

social inconvenience

loss of sexual opportunity and libido

loss of strength.

I offer the following suggestions as a starting point in understanding not just my procrastination prior to finally taking myself to hospital, but how I responded, and how gynaecologists behaved in response to my physical symptoms particularly in the year before my hysterectomy.

I wonder whether gynaecologists see so many women with menstrual problems that there is a tendency for them to lack appreciation or empathy for the impact that these problems have on our lives. A good start would be to listen more effectively to what the patient is saying in order to find out precisely what they are experiencing. Not once did a gynaecologist make a comment to me about the significance of blood loss on iron levels or haemoglobin or the level of oxygen in the blood.

I suspect that as soon as the gynaecologist has established that we do not have an immediately life-threatening condition, such as a cancerous tumour, he – or less often she[2] – dismisses any other condition as unimportant. While I understand that some hysterectomies may be carried out for the purpose of removing what clinicians might describe as quality of life annoyances, I am concerned that there is a lack of attention to conditions that if left will eventually have a significant impact on a woman’s ability to live her life in a physically and mentally normal way.

I am now convinced that in the 1990s there was a lack of reliable and clear information about how much blood loss was normal. One question I was asked was whether my blood loss had become heavier over the last two or so years. Until the last four or five months I just found it too difficult to make a reliable judgement. I had been told so many times that my loss was probably not as heavy as I imagined – that I just lost the confidence to make a reliable judgement. Besides any attempt to tell a gynaecologist that I thought my periods were very heavy, was always met with blank faced indifference. Would this happen today?

Over the last two or three years before my hysterectomy, my GP would frequently tell me that my body would not be able to cope with a low iron level indefinitely, and so I would take frequent courses of iron tablets. But as sympathetic and convincing as her messages sounded, they lost their impact and authority whenever I went to either of the gynaecologists. When I told them that I had suffered from low iron for more than two years, there was simply no response, no reaction. This led me to believe that low iron was not a big deal.

I recall my own mother suffering for years from periods that seemed to last for weeks at a time, and indeed for the last two or three years before she had a hysterectomy, she would spend hours most days in bed. This was 1969 and she was 43. To put her experience in context, Mum had given birth to six children, and she also had three other pregnancies, two of which had resulted in a miscarriage, and one that had sadly ended with my sixth brother being stillborn.

It was only happenchance that the gynaecologist on duty at the hospital that Mum arrived at in the middle of the night after a massive haemorrhage was not a Catholic. By contrast with the many Catholic specialists that dominated the sector in Perth at the time, he was not bound by the belief – implicit or explicit – that a woman should simply tolerate her condition. For Mum and the many Catholic women in Perth at the time, anything gynaecological including menstruation and childbirth and their impact on your physical and mental health were simply your moral – and sacred– duty to accept. Mum may have been tired, weak and irritable but never complained.

But when I was in my early 40s it had been 20 years since I had walked away from Catholicism. However, I sometimes wonder whether the cultural norms that I had grown up with in my home and in the community still lingered in my unconsciousness.

When I started menstruating at the age of 11, I was expected to comply with Mum’s no-fuss code. I recall once – I think I was about 14 – standing on the kitchen table while she used an old T Square to measure the hem on a dress that she had just made for me. It was the first or second day of my period and I was jiggling my legs as I tried to deal with painful cramps. Irritated, Mum whacked me on the legs with the T Square, insisting that I keep still so that she could accurately measure the hem.

Mum’s insistence that I silently and privately deal with my periods was no doubt intensified by her own personal history: she spent her three high school years living as an impoverished boarder at a Catholic girls school run by the Irish Mercy nuns, and prior to this as a small child during the Great Depression she was in their care for three years in an orphanage also run by the Mercy nuns who had brought their extremely narrow minded and moralistic understanding of a woman’s role with them from Ireland. So, the influence of their rigid norms about feminine modesty, piety and stoicism ran deep in her and would have rubbed off onto me, no doubt supported by my own 10 years at a girls’ school in Perth run by the Mercy nuns.

Hopefully my personal experiences have liberated my attitudes to my daughters’ menstrual experience and their gynaecological health, and in turn their confidence in dealing with this fundamental aspect of their humanity.

But I am not entirely sure that they and my granddaughters are completely free of the taboos that affected me. I suspect that this is the case for their peers too: that deep seated cultural norms, perhaps religious in their origin or simply just social – and with not much to do with Catholicism – still prevent women from seeking and gaining adequate health care related to their periods.

Nor am I confident that women can assume that their gynaecological problems will be treated with the seriousness that is appropriate.

The Period Pride survey in 2021 showed that the majority of respondents never felt embarrassed (59 per cent) when they talked about their periods. Nevertheless, that means that another 40% of women do feel some form of embarrassment and that ‘Long-held menstrual taboos of shame and secrecy can also prevent people from seeking adequate health care…’.[3]

Consistent with this reality, a survey of 1000 women aged 18 to 60 years, commissioned by healthcare company Bayer in 2022 found that ‘despite the high number (32%) of women who experience heavy bleeding, only 14% of the total surveyed have received a formal diagnosis of heavy menstrual bleeding (menorrhagia) from a health care professional.’ [4]

Astonishingly, the same study found that ‘19% of women felt uncomfortable, 7% felt ashamed, and 16% felt embarrassed to discuss their symptoms with a doctor.’

A number of recent studies and surveys suggest that women in Australia are treated less seriously than men by clinicians, and not just for gynaecological issues.

For example, the Inquiry into Women’s Pain conducted by the Victorian Department of Health and based on consultation with 13,000 girls and women in Victoria in 2024, delivered five key learnings:

1. Unmet healthcare needs

While most women seek medical care, many respondents stated their needs are not met. Experiences of dismissal, disrespect, and inadequate treatment are widespread, leading to distrust in the system.

2. Gaps in research and representation

Limited local and international research available on sex and gender disparities contributes to inconsistent and inequitable pain management, leaving many women and girls without appropriate care.

3. Gender bias in healthcare

Bias in pain perception leads to women’s pain being underestimated and inadequately treated. Cultural norms, language barriers, and stereotypes about women’s biology contribute to limited access and engagement with healthcare services.

4. Barriers across communities

Women living in regional and rural Victoria, Aboriginal and Torres Strait Islander women, LGBTIQA+ communities, and women with disabilities face greater challenges in accessing and navigating healthcare, often travelling long distances or experiencing systemic discrimination.

5. A call for change

Women want to be heard without bias or judgment, treated with empathy and respect, empowered to make informed decisions about their health, and access affordable, effective care easily.[5]

And in March 2024, a survey of ‘Almost 3,000 women, healthcare professionals and peak stakeholder groups’ conducted by the National Women’s Advisory Council and the Department of Health and Aged Care suggested that two out of every three women ‘reported health care-related bias and discrimination’. ‘Consistent themes included feeling dismissed and disbelieved; being stereotyped as ‘hysterical’ and a ‘drama queen’. Women reported that their symptoms and pain were often attributed to other causes such as menstruation, lifestyle factors or even ‘faking it’.’[6]

If there is any truth to these claims of gender bias in the way that men and women are treated by our health system, and more importantly, that women are still disinclined to be treated seriously by clinicians, especially in response to their menstrual experiences, then I hope that this memoir helps them to advocate for themselves and for each other.

[1] a prescription medicine containing norethisterone, a synthetic progestogen used to manage menstrual disorders, endometriosis, and to postpone menstruation

[2] In 2025 44% of gynaecologists and obstetricians are women, and 56% are men. In 1997, females made up just 17% of these professions. Australian and New Zealand Journal of Obstetrics and Gynaecology: Volume 59, Issue 2, Pages: 169-324, E5-E8, April 2019, Gender equity in obstetrics and gynaecology – where are we heading? Melanie Angstmann, Cindy Woods, Caroline M. de Costa

[3] Dr Jane Connery, July 2021, Period Report, Bloody Big Survey Findings, commissioned by Share the Dignity, Swinburne University of Technology, with data analysis by WhyHive

[4]‘The 2022 Period Perspective’ Survey of 1,000+ Australian women aged 18-60.
Commissioned by Bayer; executed by Researchify. https://www.bayer.com.au/en/the-menstrual-load-1-in-3-australian-women-surveyed-believe-they-may-have-undiagnosed-heavy#:~:text=THE%20UNSPOKEN%20IMPACTS%20OF%20A,mental%20impact%20on%20my%20performance.

[5] Department of Health Victoria, Bridging the Gender pain Gap: The Inquiry into Women’s Pain 2025, https://www.health.vic.gov.au/inquiry-into-womens-pain

[6] National Women’s Advisory Council, Department of Health and Aged Care, #EndGenderBias Survey Summary Report, March 2024, https://www.health.gov.au/sites/default/files/2024-03/endgenderbias-survey-results-summary-report_0.pdf

My Car Accidents

My first car accident occurred in 1976. A young teacher, I was driving home from Hampton High School in Western Australia in our first car, a Fiat 850 sports car, which we had bought just before we married in January 1973. When we exchanged our nuptials, Steve was 21 and had just completed his engineering degree at the University of Western Australia WA. I was still six months short of 20 and was two years into my Arts degree.

The Fiat was our pride and joy, and in keeping with the fashion, we had the white duco repainted bright yellow. We felt very sophisticated; very cool when we drove our little sports car to Denmark on the south coast of WA for our honeymoon. We also felt very adventurous in February 1974 when we packed all our clothes into it and drove across the Nullarbor to Sydney where Steve took up a scholarship to complete a one-year master’s program at the University of NSW.

For West Australians, the trip across the Nullarbor to the Eastern States was legendary. I recall as a small child, ‘slide’ evenings in which friends far wealthier than us proudly showed images of them standing in the red dust on the side of the highway next to their Holden, with tarpaulin covered luggage sitting on the roof, and the vehicle covered in a thick layer of the gritty red stuff. ‘This is us having a morning cuppa somewhere between Balladonia and Caiguna. The pot holes were amazing’.

Originally ‘built’ in 1941, the Eyre Highway was the only road connection between Western Australia and the Eastern States. A deeply rutted gravel and red sand track, it was only sealed in sections during the 1960s and 70s. When we made the journey in 1974, about 200 kms were still unsealed.

The Fiat was the quintessential city car: tiny, close to the ground and definitely not designed to float over the deep corrugations. On the contrary, a long-standing joke between Steve and me is that I enjoyed the vibrations. Fortunately, our adventure was just about incident free. The exception occurred at a camp site in Eucla where we were assailed by the thundering sound and vibrations of two or three motor bikes that circled our two-person tent a few times as we lay in it. Probably just a lark intended to frighten us a bit, which it certainly did, but we survived without any material damage.

On that day home from Hampton High School in 1976, I was turning right onto a busy road and failed to give way to a car that was driving towards me. Neither the other driver nor I was injured, but his car was damaged, and ours was a write-off. That was the end of our beautiful little car, which we replaced with a Hillman – one of the more modern minx models, probably from the early 1960s, which we gave to my young brother some months later when we departed for a year of backpacking overseas.

I was very embarrassed by this accident, because I do not consider myself a reckless driver. I was once stopped by a policeman who pointed out that I was driving too slowly. Judgement or inattention has probably been my problem, and so I have responded to this by giving myself plenty of time to enter traffic.

It would be fair to say that I am a three-state offender. In 1984, our Mazda traveller van – a nine-seater – was sideswiped by another car as I attempted to veer from the right to the left lane on a busy roundabout in Hobart. The driver of the other car was an off-duty policeman, and while neither of us was injured, both our cars were very slightly damaged. Apart from the opprobrium with which he took the opportunity to let me know that I was in the wrong, I also endured the embarrassment of Steve’s colleague Burt witnessing the accident from his desk in the Department of Transport office which overlooked the roundabout. For many years later, we all laughed at the fact that it was impossible to get away with doing something wrong in Hobart. However, before I had had a chance to ring Steve – these were pre-mobile phone days – I contemplated the wisdom of having not shared with the policeman the fact that the occasion was accompanied by two possible mitigating factors. The first was that having only recently weaned our third child, this was the first day of my first period in five years. The second was that I was – quite uncharacteristically – listening to ABC FM classic and immensely enjoying Vivaldi’s Four Seasons. Not ever since this experience have I listened to music on the radio while driving; I am too fearful that doing so will be an unsafe distraction.

Fast forward to Wollongong in 1996. I attempted to turn right out of a busy T junction and failed to see a car approaching from the right. Hers, a brand new mid-blue sedan, the make of which I cannot remember was slightly damaged. Mine, a black Citroen Xantia, and perhaps a couple of years old was, perhaps appropriately, was so damaged that it was un driveable. Having exchanged contact details, I sat on the curb to wait for the tow truck to take my car to the panel beaters.

This was an extremely busy time of my life, in which managing three kids and a business had me driving long distances every week, and probably far too often trying to avoid running late. The accident earned me the final three of my twelve demerit points, and thus resulted in me making a trip to court and losing my licence for three months.

I don’t remember my defence, but I clearly remember the magistrate’s swift and merciless dismissal of it, when he said that any defence would be worthless if I killed myself or others on the road. While I couldn’t argue with his rebuke, I later wondered whether his impatience was a result of the fact that his son was the sole survivor of a recent head-on collision that had killed his mates, and all the occupants of the other car. The accident occurred late at night on a quiet, narrow road. The vehicle in which the magistrate’s son was a passenger was travelling at high speed: apparently the young guys were engaging in a bit of a youthful, but reckless lark.

Fortunately, apart from my guilt and my wounded pride about yet another failure of judgement, my accident was injury free. But, the incident will always have a special place in my memory. As I sat on the curb with my head in my hands and feeling like an idiot, I suddenly heard my eldest daughter calling me. Dressed in over-the-knees, blue, red and white pleated check uniform, black leather shoes and white socks and an untidy mess of gorgeous honey blonde hair, Dom swooped down and threw her arms around me. ‘Yes, I’m ok’, I said, as I sank into her comforting embrace. Seventeen and in year 11, Dom was among a group of kids being given a lift by another mum on their way back to school after an excursion to the conservatorium when she noticed me and my mangled car.

As a teenager Dom was romantically optimistic, feisty and probably even a bit reckless at times. But, this was the first of two occasions on which she gave me a taste of the compassion and selflessness that I have loved about her ever since: the second was a year later just a few days before her HSC, when she drove me to hospital in the middle of the night. Apparently, on average, we can anticipate having 3-4 accidents in a lifetime of driving. That is according to an American calculation and I don’t imagine that the figure will be much different in Australia. So, lets hope that I stay at this point on the bell curve for the rest of my life.

June 2019

A Lumpy Letter

A few days ago, a lumpy letter arrived in the mail. I say lumpy because I could feel something soft bulging inside the envelope, and not unusually the message on the front of the envelope let me know that there was a special gift inside for me. This was a promotional letter from a charity encouraging me to become a donor, the socks apparently intended as an inducement. I wonder how the charity’s marketing staff decided that this would work with me. Perhaps they thought that I would consider the gesture a kind one that makes me feel like reciprocating the kindness by making a one-off donation or even better becoming a regular donor.

Alternatively, a less sympathetic view is that the gift is designed to induce a sense of guilt and obligation in me: an ‘oh bugger, I suppose I had better donate’ feeling.

Or does the marketing team think that a vague combination of these anticipated emotional responses will lead me to hesitate before I discard the accompanying letter and instead read it and perhaps then decide to become a donor?

But none of these scenarios was the case. Instead, I thought, oh, please not again, why is yet another charity wasting money by sending me stuff that I don’t need and don’t want? Furthermore, what do I do with it? Forewarned with the knowledge that the envelope contained an object that I don’t want, I was tempted to just throw it unopened straight into the rubbish bin. However, I am reluctant to do that because the envelope and letter should be thrown in the recycling bin and the plastic window of the envelope and the gift, complete with the plastic bag in which it was packed, need to go into the general waste. Aside from the nuisance of having to complete this tedious sorting and disposal process, which in turn forces me to see and handle the gift, I feel guilty and exasperated at wasting the socks and adding to land waste. So, the best I could do was to discard the envelope, its plastic window and the letter appropriately, and drop the socks into a charity bin at our local shopping centre. Ok, done!

No, here we go again. This time it was an A4 envelope, sans the clear window but with a picture of a cloth shopping bag and words saying ‘Can you help us with the heavy lifting? Your free gift inside…’

My strategy this time was to return the package to the sender. In the past I have done this and placed the package inside another envelope which also contained a letter describing my concerns. Returning the package doesn’t really solve the problem but it does let the charity know that the strategy didn’t work with at least one person.

Let me be clear. I do not resent charities reaching out to me for donations. As it happens, I am a regular donor to a number of charities and give one-off donations to others each year. In doing so, my decisions are based on local and international causes that I think warrant support and that I care about the most.

I just wish that charities would stop using this dubious method to promote their causes and to encourage me to become a donor or to increase my commitment to them. For me at least, the strategy is counterproductive.

May 2026

The Kindness of Strangers

We arrived at the Riverside Café and found a seat on the wide wooden floored verandah overlooking the Hunter River. To our right was a man seated alone, seemingly self-absorbed as he ate his bacon and eggs and scrolled his mobile phone. To our left were the only other people in the café – a group of about five blokes all in their 60s or older. Given their relaxed demeanour and that this was a Thursday morning, I reckon they were all more or less retired. Dressed in a motley array of T shirts, shorts and runners – the sort of attire that’s fine for hanging around the house in or working in the garden, my guess is that their visit to the café had been preceded by a walk, probably along the riverside path that stretched in front of the café and partly hidden by low scrubby gum trees.

With our bikes loaded onto the back of our car we had left Wollongong the previous afternoon to travel to Brisbane. After attending a play – a Christmas gift from our three girls – at Sydney’s Belvoir St Theatre in the early evening, we drove to Raymond Terrace where we stayed the night at a little motel: a red brick box-like structure that was simple but clean and quiet – perfect for our need for a good night’s sleep.

Keen to reach Brisbane in daylight, we were up bright and early the next morning, but our first port of call was somewhere to grab breakfast. Google search suggested Riverside Café as the nearest place on offer, and it had the advantage of being an easy place to park our car.

The blokes’ friendly relaxed banter, interspersed with occasional outbursts of laughter suggested a sense of familiarity with each other and the cafe: this was where they meet after their walk. Every now and again one or other them would call out a G’day, ‘How ya goin mate?’ or a friendly message of encouragement to a passing walker or jogger.

One of the joggers was a woman – I think the blokes called her Sue – very likely also in her 60s. Wearing a long, sleeveless white T shirt, black three-quarter length tights and old joggers, Sue shuffled past the café in a heavy sideways gait that suggested protection of wonky hips or knees.

Having cleaned up our scrambled eggs and skinny flat whites we returned to our car parked across the road from the café and next to the riverside path. Steve and I were checking that the bikes were securely locked onto the carrier at the back of the car when we suddenly heard Sue.

‘Going on a cycling trip, are ya?’ she asked as she stopped just beyond the car.

‘Yes’, I said, ‘we are headed for a three-dayer – the Brisbane Valley Rail Trail’.

‘Good on ya’, she replied her face spreading into a bright toothy smile. After a moment’s hesitancy, I added, ‘Actually, it’s our first post cancer cycling trip since my diagnosis two years ago. trip, so it’s sort of special.’

‘Oh’, she said, ‘that’s awesome’, and held my gaze for just a second before throwing her big bare, sweaty arms and drenched T shirt around me in a huge body warming hug. As we embraced, I felt utterly loved. ‘Thanks so much,’ I said. ‘Enjoy the rest of your run’.

March 2026.

Christmas Shopping in Sydney: December 2014

I stepped out of St James Station onto Elizabeth Street to face a police barricade blocking off the street from just beyond the station down as far as I could see east of the station. My first thought as I wandered across the street was that a Christmas parade was about to take place. So, along with a few others, I found my way to the edge of the pavement and glanced into the distance, wondering where all the action was. Less than 30 seconds later, bored with the absence of anything apparent on the empty street, I decided to get on with my Christmas shopping.

Pulling out the scribbled list of items that I intended looking for, I checked the time. It was 10.45am. This meant that I would have about four hours before I would need to make my way back to the airport to meet Steve’s flight. He had flown down to Melbourne early in the morning for a meeting with a client and, unusually, I had decided to accompany him the night before on the trip from Wollongong to Sydney, or more precisely to a hotel across the road from Sydney Domestic Airport. He was particularly tired because he had been working long hours on a number of large projects and I was worried about him driving to Sydney alone.

It was also extremely unusual for me to shop in Sydney as an intended, planned action. Shopping for anything other than food, tends to occur for me almost accidentally or at least incidentally, and Sydney has been the location of this activity perhaps three or maybe four times in the last 28 years that we have lived in Wollongong.

David Jones was the first shop that I visited. Within a few seconds of having made my way to the Clinique counter to purchase cosmetics for my youngest daughter Tessa, the sweet sales assistant, perhaps in her early sixties, and all bonhomie, reached for two jars of moisturising creams, and midway through a comment about the benefits of Youth Dew for a young complexion, dropped her voice to a barely audible level and asked me whether I knew about the ‘hostage situation’.

‘No’, I said in surprise.

‘A Muslim is holding a group of people hostage at the Lindt Café in Martin Place’, the word Muslim expressing a you-know-what-I-mean sense of terrorist.

‘Oh’, I replied with a mixture of shock and surprise, ‘that must be why the police are manning a barricade across Elizabeth Street’.

‘Yes’, she said, ‘you need to be careful. That’s a lovely pendent you are wearing.’

‘Yes’, I said, ‘it’s a gift from my choir friends in the ‘Gong’. And on our conversation went until she wished me merry Christmas, and having given me instructions for getting to the nearest Sussan shop, encouraged me to be careful. Why, I wondered for a fleeting moment, before remembering that there was a hostage situation just a couple of streets away.

A few minutes later I found my way to the Pitt Street mall, stopping for a few seconds to take a photo of an enormous Father Xmas display made out of Lego. The photo I thought would make a good conversation piece with my four grandchildren who would be spending a few days with us over Christmas. ‘Wow, Lulu that’s huge. Is it really all made out of Lego? I reckon I could do that if we had enough pieces’, were some of the comments I imagined them making when I showed them the photo. I walked around the Lego display to take in whatever else was happening.

To one side a strange agglomeration of dogs sitting in a cart was attracting a fair bit of attention. They were there to raise awareness and money for Assisting Wellbeing Ability Recovery Empowerment (AWARE) Dogs. A metre or so away from them on another corner of the giant Father Christmas was an old man playing a Christmas carol on a violin, his tune struggling to compete with the piped music – another vaguely familiar Christmas tune – that pervaded the air, and frustrated me because I could not locate where it was coming from.

Glancing to the right I realised with a touch of surprise that King Street was closed, and I noticed a number of police officers purposefully striding along and across Pitt Street. And, all the time, I could sense the growing unease among other shoppers: the comments about the hostages.

‘Have you heard any more news?’

‘No, nothing more; just that there are 40 hostages. One has been forced to hold up a flag with Arabic script on it; others are standing with their hands up against the front window of the café. Well, I think he’s from ISIS.’

My thoughts returned to Christmas shopping. I checked my watch: it was 12.30. Yes, there was enough time before Steve’s return to Sydney airport to pick up some books from Abbeys in York St. Books are a standard favourite Christmas – and birthday – present for him, and I wanted to also get a few for the grand kids. Half an hour later I emerged onto York St. The load of Christmas presents in my little backpack had now been made considerably heavier by a couple of novels, and a couple of non-fiction books for Steve and a pile of young readers’ books and colourfully illustrated story books for our grandchildren.

Then it suddenly dawned on me. What if the trains are cancelled? Shit, how would I get back to the airport? What if the roads are closed and I can’t get a taxi? Picking up my pace, I made my way to the Queen Victoria building, navigated a path through the crowds of people shopping, drinking coffee, and eating lunch and headed down the stairs to the Town Hall Station. Ok, which train will get me to the airport? Should I just jump on any train and get to Central or find out which one goes directly to the airport? Pulling my phone out of my shoulder bag, I quickly searched for the city timetable, completed the Plan Your Trip details, and with 2 minutes to spare, tapped on and walked as briskly as I could down the stairs to Platform 2, conscious all the time of avoiding a fall.

Stepping onto the train, it was surprisingly easy to find a seat. I gazed around only to be met by a silent sea of down-turned heads, most of them nonchalantly focused on mobile phone screens, some reading the newspaper, a few quietly dozing. Twenty-two minutes later I made my way up the escalator to the arrivals area at Sydney airport. Just as I downed the last mouthful of a coffee, Steve appeared. ‘Have you seen the news?’ he asked.

‘Yes’, I nodded. ‘Isn’t it awful’ I added, not sure what else to say.

‘I’ve been worried about you. I am so glad to see you. Let’s go home.’

Shit

My brother-in-law Tony warned my husband that he might not want to visit the gents’ toilet. We were on a cycling trip in the UK and had just finished morning coffee at a lovely café overlooking the River Tone in a little town called Taunton. Ignoring his advice, Steve returned with a wry smile and agreed that the turd in the toilet was indeed very large. Much merriment was shared as we contemplated the difficult task that lay ahead for the café staff in attempting to clear the toilet of its hefty load. Would they need a knife or perhaps blast it with hot water to break it up?

Toileting in India was always a challenge in 1977, when Steve and I backpacked our way through south east and central Asia to Europe and the UK, but one experience stays with me more than any other. We travelled on an overnight bus from Bangalore to Goa. Early in the morning, a comfort stop dropped us in a small barren looking town called Hubli next to an open field at the far end of which was a toilet block. We descended from the bus, weary from the muscle-aching half sleep that comes with travelling at speed on pot-holed roads, and started to walk along a debri-laden path that ran alongside the field. As we did so, we were confronted by the image of a noisy, angry mob of men who chased and killed a mangy dog on the field. Gaunt and dishevelled, the men hit the dog repeatedly with heavy blocks of woods, the creature’s body bouncing up and down with each deadly strike. Perhaps the dog had done something to make them angry, but there was something about their vicious determination which made me wonder whether it might be their next meal.

With eyes turned away, and my heart still pacing from this shocking scene, I made my way to the women’s toilet block. One hand clutching toilet paper in my pocket, I tentatively stepped into the L shaped concrete building. A shaft of sunlight cutting across the entrance revealed sloppy piles of shit lying on almost all of the available floor space. My second hand went straight to my nose to offer some protection from the nauseating smell, and I tightened my toes in my shoes in an instinctive but futile attempt to protect my shoes from treading on the squishy brown mess.

By this time, we had been on the road for a couple of months and had become accustomed to the awful smells and sights on offer in public toilets. However, nothing could have prepared me for what I saw as I turned the corner into the main area of the toilet block.

Squatting on the footholds of each of the five door-less cubicles were old women. Each was gently swaying backwards and forwards, her bare feet gripping the porcelain beneath her, in order to keep her balance. Each was sound asleep. With grey hair pulled back in a neat bun, each was wearing a simple white and spotlessly clean cotton sari.

This was a perfectly awful personification of the utter hopelessness of poverty; it was also a picture of grace and beauty.

During this trip we discovered that toilets came in a number of forms in Afghanistan. Our entry into the country was via Peshawar, Pakistan from where we travelled to Kabul in an old truck that was laden with a miscellany of plastic and wooden wares that bulged over the sides of the vehicle and doubled its height. Although the distance along the Jalalabad Highway through the Khyber Pass is only 200 kilometres, the trip took about 8 hours. The terrain was rugged, the road narrow, steep and winding, and at times the driver needed to edge the truck through highway passages that threatened to disgorge its precariously packed load.

Our driver had offered us the lift ‘baksheesh’, and his generosity extended to also inviting us to have some of his hashish. While we didn’t share this part of the journey with him, we somehow managed to engage in congenial conversation for most of the way, using hand and facial gestures, about Afghanistan, his truck, the Khyber Pass, his wife and kids, our relationship, our travels, Australia.

Half way through the journey, we stopped to eat, and shared a steaming hot chicken stew and flat bread with him and an afghan policeman who was also passing through the area. The place was a lone mud brick structure, just big enough for the four of us to sit on the straw covered earthen floor. The meal was cooked by a local tribesman on a woodfire, and its aroma and taste were gently delicious and restorative. I was just recovering from a bout of Delhi belly and this was the first real meal that I had been able to eat in about a week. The conversation, challenged by our lack of a common language, was again halting but warm, the situation strangely free of any sense of menace that the policeman’s uniform and gun or the truck driver’s supply of hashish could have created.

Toilets were a rarity in this rugged, arid, mountainous terrain, and along the Jalalabad Highway there were few places behind which to easily hide. In addition, we did not see many other women travellers and there were certainly no women in this tiny outpost on the Khyber Pass. But on this day, there was a toilet. So, before having the meal, I made my way along a narrow rocky path to it. Located about 50 metres behind the café, the toilet was a rickety wooden box with a hole in the floor and two concrete footholds, just within reach of which was a tub of water. There was no door, and yet, as I squatted, I felt solitary, and strangely safe and private. All I could hear was the wind blowing furiously. All I could see was a wall of mountains.

Herat was a fascinating city and, while it was just as smelly, dirty and chaotic as Kabul, we found it more attractive. We walked along dusty, noisy streets and crowded alleyways, where most of the buildings were simple mud brick structures with cut outs in place of windows and doors. We made our way between colourfully decorated horse carts and clapped out old cars, a wheat grinder driven by a camel, and fly infested sheep and goat carcases hanging from hooks on the side of the road. Narrow alley ways revealed noisy, messy bazaars full of all sorts of household paraphernalia from gaudy plastic goods to wool blanket shawls and densely patterned rugs, exotically engraved brass ornaments and leather goods, including a sturdy rectangular leather bag that we bought for Steve.

The city also indulged our taste buds with the country’s own form of mouth wateringly delicious roti – long narrow lengths of flat bread baked by being slapped onto the wall of a mud brick oven. Ours was purchased fresh from the oven – so it was piping hot, and the baker placed a huge chunk of sweet fibrous halva on it. But the highlight of the city was the magnificent 800-year-old Friday Mosque, covered in intricate geometric patterned blue mosaic tiles.

Although our practice was to choose, not quite the cheapest, but the Lonely Planet Guide’s second cheapest recommendations, our options for accommodation were often fairly spartan. The bathroom, laundry and toilet ‘amenities’ at the hotel we stayed at in Herat consisted of one grey concrete floored room with water supplied to a long trough which sat along one of the walls. Turds, large, deep brown and firm lay in neat piles on the floor. I recall staring at them – there were so many they were impossible to ignore – and wondering whether their dark brown colour, solidity and sickly, pungent smell were a result of the high meat content of the Afghani diet. On the floor near the trough stood a few bright red long-spouted plastic pots from which water was poured in lieu of toilet paper and flowed onto the floor. No doubt, at some other time of the day somebody would have the job of washing the turds away to become part of the local sewerage system. But in the meantime, we found a safe foothold at the troughs to wash ourselves and our clothes.

More than 30 years later, Steve and I did a six-week trip to South America. By contrast with our year of backpacking, this was not a $20 per day adventure: it was our reward to ourselves after having sold our company. As well as spending ten days cruising around the Galapagos Islands, and exploring the wonders of Ecuador, and a little of Chile and Argentina, we joined a small group of other travellers to walk the Inca Trail, a four-day trek through steep, rugged terrain to Machu Pichu.

According to the strict government regulations a maximum of 500 people that can be on the Trail at any one time, and they must also be accompanied by government qualified and licenced guides. Ours was a highly competent and wonderfully supportive woman called Maria. As well as providing an ongoing commentary about the Incas and their travails at the hands of the invading Spanish, Maria also indulged my delight in the complex and changing landscape. This was our first trip to South America and I knew next to nothing about any of the countries including Peru. So, while I was excited to discover the history and culture of the country, and enjoyed the novelty of seeing lamas nearby, including a huge one that prodded me in the back as I stood looking at an ancient Inca settlement, I was also gobsmacked by the natural beauty of the rainforests and the open rocky terrain through which we walked. And, an unexpected bonus was discovering that some of my favourite plants that grow in our garden at home are indigenous to Peru. I enjoyed the novelty of seeing fleshy-leaved begonias with delicate red, orange, pink or white flowers, and bright pink and purple edged flowers that protruded proud and strong from the centre of huge bromeliads, at each turn of the path.

Among the government regulations affecting the trek was one limiting camping to specified locations, all of which had toilets, or access to nearby villagers’ toilets. Most of these could be flushed; some just made use of a bucket of water located inside or just outside the cubicle. One of the peculiarities of the toilets was that soiled toilet paper was not dropped into the toilet bowl but was instead put into a bucket that sat next to the squatting footholds.

When we arrived at each of the three campsites in early evening, the toilets were relatively clean. However, a visit by torchlight in the middle of the night was more problematic. And, by the following morning when the serious task of shitting typically took place, the toilets were breathtakingly awful. Once the door was closed, and the benefit of sunlight lost, the challenge was to disrobe without letting your trouser legs touch the floor. Imprisoned in this tiny dark chamber, thankful for the protection provided by hiking boots, the senses were assaulted by a thick smelly stew of screwed up sheets of wet, soiled toilet paper as well as ruddy, used tampons and sanitary pads, all of which spilled over the bucket and onto the floor.

The fourth and final day of the trek began in the cold darkness at about 3.00am. This was to enable us to reach Machu Pichu in time to see the wondrous ruins emerge from the mist with the rising sun. Keen to avoid missing out on this experience, Steve and I secured a spot towards the front of the queue, which, within minutes, swelled to about 100 trekkers, all of us donned in familiar brands of warm clothing and hiking boots and carrying day packs, ready for the final stage of our pilgrimage.

Shivering with cold and nervous excitement, we eagerly waited for the signal to start walking, when I was suddenly gripped by stomach cramps. Reluctant to lose our place in the queue, I nevertheless realised that I just had to find a toilet as quickly as possible.

Even with the light cast by head torches, it was difficult to find any of the campsites carefully hidden from the trail. After about 200 metres, the twinkling of torchlights to my right revealed the first toilets. These were the men’s and would have been fine, but they were all occupied, as were the adjacent set that were for women. My stomach cramps threatening to explode, I was desperate to find a loo, when I suddenly saw a huddle of young women standing near a third block. They were American, I would say in their early to mid-twenties, and from their new colour coordinated trekking gear, and refined hairdos and makeup, almost certainly city girls – and probably university students.

‘Are any of these free?’, I anxiously asked. ‘Well, yes’, one of them said squeamishly, ‘but you can’t use them. They’re disgusting’. ‘Ok’, I said and raced past them into the nearest cubicle. It was awful. The floor was awash with putrid stinking shit mixed with soiled paper and urine. The toilet seat was a mess of muddy shoe marks. But with the finesse of a trapeze artist, I squatted over the bowl and gave my erupting intestines full flight.

In India, Afghanistan and Peru, shitting was – and probably still can be – difficult to deal with. Often, toilets are at least uncomfortable, and sometimes seriously challenge not just our senses but also our perceptions of hygiene and cleanliness. To a considerable degree, however, I have taken for granted that the ugly, smelly presence of human waste – along with dilapidated housing, dirty streets and disfigured bodies – is almost inevitable in an underdeveloped country.

To many travellers, San Francisco is an exotic place but perhaps not a place that one would expect to have to worry about public sanitation. However, an article in a recent edition of The Economist[1] provides a stark reminder of how powerful and yet fragile human waste management is as a measure of societal wellbeing, and more fundamentally, our understanding of the hallmarks of a civilised society.

Because of a complex array of market factors there is a shortage of housing, and in particular social housing, in the city. As a result, about 7500 people or nearly 1 % of the 871,000 that live in the US’s second most expensive city, are homeless. Last year, there were 16,022 complaints to the City and County of San Francisco about human waste on the streets. This represents a 2.5-fold increase in the number of complaints since 2011.

People are revolted by the presence of the stuff; some avoid sidewalks in fear of seeing it, smelling it or treading in it. To local residents and visitors alike – those that have places in which to live – it is an affront to their expectations of a civilised society. The homeless that defecate on the streets, probably wouldn’t disagree. However, they very likely also feel desperate, hopeless and abandoned by society.

[1] The Economist, June 2^nd-8^th 2018, page 30