"I base my life on sadness": Apparently paradoxical sources of resilience among young Haitians

Haitian expressions of resilience also hold deep knowledge of human vulnerability. This longitudinal, qualitative study with young Haitians from urban shantytowns combines ethnographic and participatory methods to explore the complexities behind such idioms. Artistic and creative products made by or with the youth facilitated interviews, focus group discussions, and workshops. Through the life stories of participants and rich ethnographic material, this study presents locally situated idioms of resilience (and distress). By including local social ecology, the idioms were framed as historically and culturally rooted, thus shaping contextual, pragmatic, and gendered coping strategies grounded in embodied experiences of vulnerability and resistance. The study adds essential insights into Haitian resilience, revealing the local logics behind seemingly paradoxical statements. By drafting a conceptual framework for further studies on idioms of resilience, the study also makes a theoretical contribution to international resilience research.

Adverse life experiences among patients with morbid obesity

BACKGROUND

The association between highly stressful life experiences and morbid obesity is well documented internationally, but this knowledge is not incorporated to any great extent in Norwegian clinical practices. We have studied the reports of previous life stresses from a sample of Norwegian patients under assessment for morbid obesity at a centre where the topic of life experiences was included during the recording of patient histories.

MATERIAL AND METHOD

In the summer of 2018, an invitation to participate in the study was distributed to the last 200 patients to have been examined at the Regional Centre for Morbid Obesity in Bodø. Information on lifetime adversity was collected in clinical interviews. Data were retrieved from the patient's discharge summaries, and these texts were analysed using a qualitative approach. Stressful life experiences were divided into twelve categories.

RESULTS

The study recruited 70 participants (57 women) with morbid obesity. Of these, 64 (91 %) related at least one significant and stressful life experience, and 39 (56 %) reported three or more different types. The most frequent types included serious relationship ruptures, parental neglect and other negative childhood experiences.

INTERPRETATION

In a sample of Norwegian patients who were undergoing examination for morbid obesity there were many who reported distressing life histories. Lack of existential security in childhood, often linked to complex traumas, was prominent. In light of international research on the association between trauma and obesity, our results indicate that the patient's life history should be included in an assessment of patients with morbid obesity.

From wholes to fragments to wholes-what gets lost in translation?

The highly demanding and, in a certain sense, unique, working conditions of general practitioners (GPs) are characterized by two phenomena: First, they involve an increasing familiarity with individual patients over time, which promotes a deepening of insight. Second, they enable the GP to encounter all kinds of health problems, which in turn facilitates pattern recognition, at both individual and group levels, particularly the kind of patterns currently termed "multimorbidity." Whereas the term "comorbidity" is used to denote states of bad health in which 1 disease is considered to predate and evoke other ailments or diseases, the term multimorbidity is applied when finding several presumably separate diseases in a person who suffers from them either sequentially or simultaneously. Encounters with patients whose suffering fits the biomedical concept and terminology of multimorbidity are among the most common which GPs face, presenting them with some of their most demanding tasks. The term multimorbidity needs to be examined, however. As it alludes to a multiplicity of diseases, it rests on an assumption of separateness of states of bad health that might not be well founded. An adequate determination of what to deem a "separate" state of bad health would require that the biomedical concept of causation be scrutinized.

Creating chronicity

An authentic sickness history is the vantage point for juxtaposing a biomedical and a biographical-phenomenological reading. What, in a biomedical framework, appears to be a longstanding state of comorbidity of different and unrelated types of diseases is rendered transparent in a biographical reading. This particular reading, evidencing the shortcomings of a biomedical framework regarding identifying the social sources of an increasingly complex burden of disease, is reflected upon in light of recent research in the neurosciences. Thus, the biomedical contribution to a sickness history is demonstrated, with its resultant multimorbidity, chronification, and complete incapacitation of a woman despite the continuing and nearly excessive involvement of the health care system.

Does 'existential unease' predict adult multimorbidity? Analytical cohort study on embodiment based on the Norwegian HUNT population

OBJECTIVES

Multimorbidity is prevalent, and knowledge regarding its aetiology is limited. The general pathogenic impact of adverse life experiences, comprising a wide-ranging typology, is well documented and coherent with the concept allostatic overload (the long-term impact of stress on human physiology) and the notion embodiment (the conversion of sociocultural and environmental influences into physiological characteristics). Less is known about the medical relevance of subtle distress or unease. The study aim was to prospectively explore the associations between existential unease (coined as a meta-term for the included items) and multimorbidity.

SETTING

Our data are derived from an unselected Norwegian population, the Nord-Trøndelag Health Study, phases 2 (1995-1997) and 3 (2006-2008), with a mean of 11 years follow-up.

PARTICIPANTS

The analysis includes 20 365 individuals aged 20-59 years who participated in both phases and was classified without multimorbidity (with 0-1 disease) at baseline.

METHODS

From HUNT2, we selected 11 items indicating 'unease' in the realms of self-esteem, well-being, sense of coherence and social relationships. Poisson regressions were used to generate relative risk (RR) of developing multimorbidity, according to the respondents' ease/unease profile.

RESULTS

A total of 6277 (30.8%) participants developed multimorbidity. They were older, more likely to be women, smokers and with lower education. 10 of the 11 'unease' items were significantly related to the development of multimorbidity. The items 'poor self-rated health' and 'feeling dissatisfied with life' exhibited the highest RR, 1.55 and 1.44, respectively (95% CI 1.44 to 1.66 and 1.21 to 1.71). The prevalence of multimorbidity increased with the number of 'unease' factors, from 26.7% for no factor to 49.2% for 6 or more.

CONCLUSIONS

In this prospective study, 'existential unease' was associated with the development of multimorbidity in a dose-response manner. The finding indicates that existential unease increases people's vulnerability to disease, concordant with current literature regarding increased allostatic load.

Primary care emergency team training in situ means learning in real context

OBJECTIVE

The purpose of our study was to explore the local learning processes and to improve in situ team training in the primary care emergency teams with a focus on interaction.

DESIGN, SETTING AND SUBJECTS

As participating observers, we investigated locally organised trainings of teams constituted ad hoc, involving nurses, paramedics and general practitioners, in rural Norway. Subsequently, we facilitated focus discussions with local participants. We investigated what kinds of issues the participants chose to elaborate in these learning situations, why they did so, and whether and how local conditions improved during the course of three and a half years. In addition, we applied learning theories to explore and challenge our own and the local participants' understanding of team training.

RESULTS

In situ team training was experienced as challenging, engaging, and enabling. In the training sessions and later focus groups, the participants discussed a wide range of topics constitutive for learning in a sociocultural perspective, and topics constitutive for patient safety culture. The participants expanded the types of training sites, themes and the structures for participation, improved their understanding of communication and developed local procedures. The flexible structure of the model mirrors the complexity of medicine and provides space for the participants' own sense of responsibility.

CONCLUSION

Challenging, monthly in situ team trainings organised by local health personnel facilitate many types of learning. The flexible training model provides space for the participants' own sense of responsibility and priorities. Outcomes involve social and structural improvements, including a sustainable culture of patient safety. KEY POINTS Challenging, monthly in situ team trainings, organised by local health personnel, facilitate many types of learning. The flexible structure of the training model mirrors the complexity of medicine and the realism of the simulation sessions. Providing room for the participants' own priorities and sense of responsibility allows for improvement on several levels. The participants demonstrated a consistent, long-term motivation to strengthen safety, both for their patients and for themselves.

Patients' 'thingification', unexplained symptoms and response-ability in the clinical context: in response to 'Patients' substantialization of disease, the hybrid symptom and the metaphysical care', by Alexandra Parvan

The types of diseases, or categories of suffering, referred to as medically unexplained symptoms or syndromes (MUS) are the focus for the following commentary. Such cases seem to invite reflection. The very nature of such complex patterns of disease and suffering raises a number of fundamental epistemological and ontological issues. Furthermore, such health challenges can serve as the basis for an exploration of how the suffering person as well as the medical caretaker comes to grip with disease, incapacitation or suffering. We have structured our comments into two parts: first, we will describe medically unexplained health problems as the background for an inquiry into a process wherein patients reify their suffering in order to meet their doctors on equal terms, which carries a potential for alienation. Second, we will reflect on Alexandra Parvan's text as regards patients' 'substantialization' of their disease, the resulting 'hybrid symptom' and a proposed model for care and healing.

Medicine's perception of reality - a split picture: critical reflections on apparent anomalies within the biomedical theory of science

Escalating costs, increasing multi-morbidity, medically unexplained health problems, complex risk, poly-pharmacy and antibiotic resistance can be regarded as artefacts of the traditional knowledge production in Western medicine, arising from its particular worldview. Our paper presents a historically grounded critical analysis of this view. The materialistic shift of Enlightenment philosophy, separating subjectivity from bodily matter, became normative for modern medicine and yielded astonishing results. The traditional dichotomies of mind/body and subjective/objective are, however, incompatible with modern biological theory. Medical knowledge ignores central tenets of human existence, notably the physiological impact of subjective experience, relationships, history and sociocultural contexts. Biomedicine will not succeed in resolving today's poorly understood health problems by doing 'more of the same'. We must acknowledge that health, sickness and bodily functioning are interwoven with human meaning-production, fundamentally personal and biographical. This implies that the biomedical framework, although having engendered 'success stories' like the era of antibiotics, needs to be radically revised.

Is childhood stress associated with shorter telomeres?

BACKGROUND

It has been shown that severe stress in childhood is harmful to later health. New research aims to ascertain whether – and if so, how – the telomeres, the protective caps at the end of our chromosomes, may be one of the links between this type of experience and later morbidity. Here we present an overview of studies which have examined the association between stress in childhood and length of telomeres.

METHOD

The review encompasses 26 original studies found through a literature search in PubMed. We included studies of the relationship between length of telomeres and various stress-inducing factors from conception throughout childhood and adolescence.

RESULTS

The studies were grouped into four topics. The empirical research base for mother's stress in pregnancy and parents' ability to care for their children is too small to draw any conclusions. Psychosocial stress in childhood was associated with shorter telomere length in 12 of 14 studies. Socioeconomic status in childhood was not unequivocally associated with telomere length.

INTERPRETATION

Shorter telomeres are possibly associated with psychosocial stress in childhood. This field of research is still new, and more longitudinal studies are needed with an emphasis on childhood experiences and coordination of measurement variables and results measurement in order to confirm this association.

Self Reported Childhood Difficulties, Adult Multimorbidity and Allostatic Load. A Cross-Sectional Analysis of the Norwegian HUNT Study

Background

Multimorbidity receives increasing scientific attention. So does the detrimental health impact of adverse childhood experiences (ACE). Aetiological pathways from ACE to complex disease burdens are under investigation. In this context, the concept of allostatic overload is relevant, denoting the link between chronic detrimental stress, widespread biological perturbations and disease development. This study aimed to explore associations between self-reported childhood quality, biological perturbations and multimorbidity in adulthood.

Materials and Methods

We included 37 612 participants, 30–69 years, from the Nord-Trøndelag Health Study, HUNT3 (2006–8). Twenty one chronic diseases, twelve biological parameters associated with allostatic load and four behavioural factors were analysed. Participants were categorised according to the self-reported quality of their childhood, as reflected in one question, alternatives ranging from ‘very good’ to ‘very difficult’. The association between childhood quality, behavioural patterns, allostatic load and multimorbidity was compared between groups.

Results

Overall, 85.4% of participants reported a ‘good’ or ‘very good’ childhood; 10.6% average, 3.3% ‘difficult’ and 0.8% ‘very difficult’. Childhood difficulties were reported more often among women, smokers, individuals with sleep problems, less physical activity and lower education. In total, 44.8% of participants with a very good childhood had multimorbidity compared to 77.1% of those with a very difficult childhood (Odds ratio: 5.08; 95% CI: 3.63–7.11). Prevalences of individual diseases also differed significantly according to childhood quality; all but two (cancer and hypertension) showed a significantly higher prevalence (p<0.05) as childhood was categorised as more difficult. Eight of the 12 allostatic parameters differed significantly between childhood groups.

Conclusions

We found a general, graded association between self-reported childhood difficulties on the one hand and multimorbidity, individual disease burden and biological perturbations on the other. The finding is in accordance with previous research which conceptualises allostatic overload as an important route by which childhood adversities become biologically embodied.

The quantified self: closing the gap between general knowledge and particular case?

RATIONALE, AIMS AND OBJECTIVES

This paper addresses the movements 'evidence-based' (EBM) and 'personalized' (PM) medicine. The former is being criticized for failing to do justice to clinical complexity and human individuality. The latter aims at tailoring medical knowledge for every patient in a personalized fashion. Instrumental to this effort is the technological development engendering unlimited amounts of data about bodily fragments. The aim of this article is to stimulate a debate about the notion of the body and knowledge in medicine.

METHODS

An authentic sickness history is used as a vantage point for a more comprehensive account of biomedicine.

RESULTS

The analysis of the sickness history demonstrates how biomedical logic guided all approaches in the care for this particular patient. Each problem was identified and treated separately, whereby neglecting the interaction between body parts and systems, and between the woman's bodily condition and her experiences. The specialists involved seemed to look for phenomena that fit categories of disorders 'belonging' to their field. These approaches engendered unintended effects: chronification, poly-pharmacy and multi-morbidity, leading to an unsustainable increase in medical costs.

CONCLUSIONS

The article elucidates how the status that professionals ascribe to the body has vital implications for what they regard as relevant and how they interpret the information they have collected. On this ground, we challenge both the prevailing and tacitly accepted separation between the physical body and human experience and the view of knowledge underpinning EBM and PM. The growing molecularization of the body veils decisive sources of human illness.

Co- and multimorbidity patterns in an unselected Norwegian population: cross-sectional analysis based on the HUNT Study and theoretical reflections concerning basic medical models

Rationale and aims: Accumulating evidence shows that diseases tend to cluster in diseased individuals, so-called multimorbidity. The aim of this study was to analyze multimorbidity patterns, empirically and theoretically, to better understand the phenomenon. Population and methods: The Norwegian population-based Nord-Trøndelag Health Study HUNT 3 (2006-8), with 47,959 individuals aged 20-79 years. A total of 21 relevant, longstanding diseases/malfunctions were eligible for counting in each participant. Multimorbidity was defined as two or more chronic conditions.Results: Multimorbidity was found in 18% of individuals aged 20 years. The prevalence increased with age in both sexes. The overall age-standardized prevalence was 42% (39% for men, 46% for women). ‘Musculoskeletal disorders’ was the disease-group most frequently associated with multimorbidity. Three conditions, strategically selected to represent different diagnostic domains according to biomedical tradition; gastro-esophageal reflux, thyroid disease and dental problems, were all associated with both mental and somatic comorbid conditions. Conclusions and implications: Multimorbidity appears to be prevalent in both genders and across age-groups, even in the affluent and relatively equitable Norwegian society. The disease clusters typically transcend biomedicine’s traditional demarcations between mental and somatic diseases and between diagnostic categories within each of these domains. A new theoretical approach to disease development and recovery is warranted, in order to adequately tackle ‘the challenge of multimorbidity’, both empirically and clinically. We think the concept allostatic load can be systematically developed to “capture” the interrelatedness of biography and biology and to address the fundamental significance of “that, which gains” versus “that, which drains” any given human being.

Can person-free medical knowledge inform person-centered medical practice?

We have taken great pleasure in reading the comprehensive and detailed review of the latest development in biomedical clinical practice presented by Miles & Mezzich [1]. We hereby respond to the invitation implicit in the authors’ categorization of their paper as “for discussion”. We feel an urge to add some reflections regarding a core topic not addressed in the paper. But initially, we present our condensed interpretation of Miles & Mezzich’ s text, prior to setting out the ground for our subsequent reflections. 

Standardization meets stories: contrasting perspectives on the needs of frail individuals at a rehabilitation unit

BACKGROUND

Repeated encounters over time enable general practitioners (GPs) to accumulate biomedical and biographical knowledge about their patients. A growing body of evidence documenting the medical relevance of lifetime experiences indicates that health personnel ought to appraise this type of knowledge and consider how to incorporate it into their treatment of patients. In order to explore the interdisciplinary communication of such knowledge within Norwegian health care, we conducted a research project at the interface between general practice and a nursing home.

METHODS

In the present study, nine Norwegian GPs were each interviewed about one of their patients who had recently been admitted to a nursing home for short-term rehabilitation. A successive interview conducted with each of these patients aimed at both validating the GP's information and exploring the patient's life story. The GP's treatment opinions and the patient's biographical information and treatment preferences were condensed into a biographical record presented to the nursing home staff. The transcripts of the interviews and the institutional treatment measures were compared and analysed, applying a phenomenological-hermeneutical framework. In the present article, we compare and discuss: (1) the GPs' specific recommendations for their patients; (2) the patients' own wishes and perceived needs; and (3) if and how this information was integrated into the institution's interventions and priorities.

RESULTS

Each GP made rehabilitation recommendations, which included statements regarding both the patient's personality and life circumstances. The nursing home staff individualized their selection of therapeutic interventions based on defined standardized treatment approaches, without personalizing them.

CONCLUSION

We found that the institutional voice of medicine consistently tends to override the voice of the patient's lifeworld. Thus, despite the institution's best intentions, their efforts to provide appropriate rehabilitation seem to have been jeopardized to some extent.

The medically unexplained revisited

Medicine is facing wide-ranging challenges concerning the so-called medically unexplained disorders. The epidemiology is confusing, different medical specialties claim ownership of their unexplained territory and the unexplained conditions are themselves promoted through a highly complicated and sophisticated use of language. Confronting the outcome, i.e. numerous medical acronyms, we reflect upon principles of systematizing, contextual and social considerations and ways of thinking about these phenomena. Finally we address what we consider to be crucial dimensions concerning the landscape of unexplained "matters"; fatigued being, pain-full being and dys-ordered being, all expressive momentums of an aesthetic of resistance.

[A different cardiovascular epidemiology]

BACKGROUND

Cardiovascular diseases constitute the leading cause of sickness and death in Western countries. They are therefore embraced with much attention in medical research, treatment and preventive programmes for which quantifiable biological risk factors comprise the common conceptual basis. We want to demonstrate that the current narrow biological focus may prohibit a deeper understanding of the sickness expressions. THEORY, MATERIAL AND METHOD: The present paper is grounded in a theory of human beings as self-reflecting and capable of creating and conveying meaning affected by culture, time and relationships with others. From such a perspective, the human body is seen as a lived body, a centre for expression of experience. Two cases are interpreted in light of more recent epidemiological evidence of associations between traumatic experiences and cardiovascular disease.

RESULTS

Research shows that traumatic experiences in general and early trauma in particular are potent pathogens. Different types of trauma are, however, not consistently related to specific diseases, but rather to complex patterns of so called co-morbidity. These patterns blur the mind-body-distinction and thereby the classification systems for somatic and mental diseases. When such patterns are interpreted as expressions of embodied life, insight is provided into how traumatic experience informs the lived body.

INTERPRETATION

Correlations between traumatic experience and cardiovascular disease challenge the dominating biological framework of cardiovascular epidemiology. An analysis of the evidence by means of two cases opens up new perspectives. Knowledge about the path from particular and painful experience to particular and painful disease is an inevitable premise for an adequate treatment of the individual. It is also a prerequisite for development of adequate preventive measures.

Inscriptions of violence: societal and medical neglect of child abuse--impact on life and health

OBJECTIVE

A sickness history from General Practice will be unfolded with regard to its implicit lived meanings. This experiential matrix will be analyzed with regard to its medico-theoretical aspects.

METHOD

The analysis is grounded in a phenomenology of the body. The patient Katherine Kaplan lends a particular portrait to the dynamics that are enacted in the interface between socially silenced domestic violence and the theoretical assumptions of human health as these inform the clinical practice of health care.

RESULTS

By applying an understanding of sickness that transcends the mind-body split, a concealed and complex logic emerges. This logic is embedded in a nexus of the impact of childhood abuse experience and the medical disinterest in subjective experiences and their impact on selfhood and health. Its core is twofold: the violation of embodiment resulting from intra-familial abuse and existential threat, and the embodiment of violation resulting from social rules and the theoretically blinded medical gaze.

CONCLUSION

A considerable medical investment, apparently conducted in a correct and consistent manner as to diagnostic and therapeutic measures, results in the complete incapacitation of a young physician.

[Heavy burdens and complex disease--an integrated perspective]

Complex chronic diseases require an increasing proportion of society's resources and represent a growing challenge. Valid biomedical models of etiology, pathogenesis, treatment and prognosis are inadequate for understanding these diseases. The article discusses current knowledge about the impact of stress on the immune-, hormonal - and central nervous systems, and integrates this knowledge with a phenomenological understanding of the body in an attempt to explain the complex chronic fatigue syndrome. The medical significance of the individual's biography is highlighted, and the inadequacy of statistically grounded biomedical research when aiming to understand complex disease is presented. By regarding human beings as persons who experience bodily and who both create and convey meaning, we claim to have transgressed the mind-body-dichotomy in complex disease development. The dichotomy converges in the living body.

Estimating the high risk group for cardiovascular disease in the Norwegian HUNT 2 population according to the 2003 European guidelines: modelling study

OBJECTIVE

To estimate the high risk group for cardiovascular disease in a well defined Norwegian population according to European guidelines and the systematic coronary risk evaluation system.

DESIGN

Modelling study.

SETTING

Nord-Tröndelag health study 1995-7 (HUNT 2), Norway.

PARTICIPANTS

5548 participants of the Nord-Tröndelag health study 1995-7, aged 40, 50, 55, 60, and 65.

MAIN OUTCOME MEASURES

Distribution of risk categories for cardiovascular disease, with emphasis on the high risk group.

MAIN RESULTS

At age 40, 22.5% (95% confidence interval 19.3% to 25.7%) of women and 85.9% (83.2% to 88.6%) of men were at high risk of cardiovascular disease. Corresponding numbers at age 50 were 39.5% (35.9% to 43.1%) and 88.7% (86.3% to 91.0%) and at age 65 were 84.0% (80.6% to 87.4%) and 91.6% (88.6% to 94.1%). At age 40, one out of 10 women and no men would be classified at low risk for cardiovascular disease.

CONCLUSION

Implementation of the 2003 European guidelines on prevention of cardiovascular disease in clinical practice would classify most adult Norwegians at high risk for fatal cardiovascular disease.

Ethical dilemmas arising from implementation of the European guidelines on cardiovascular disease prevention in clinical practice. A descriptive epidemiological study

OBJECTIVE

Our first objective is to describe total, age- and gender-specific prevalences of subjects in a well-defined population for whom medical follow-up is indicated due to unfavourably high blood pressure and/or cholesterol levels, as defined by the 2003 European guidelines on cardiovascular disease prevention in clinical practice. Our second objective is to highlight scientific questions and ethical dilemmas relating to implementation of the guidelines.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional population study comprising 62104 adult Norwegians aged 20-79 years who participated in The Nord-Tröndelag Health Study 1995--97.

MAIN OUTCOME MEASURES

Total, age- and gender-specific point prevalences of individuals with total cholesterol > or =5 mmol/l and/or systolic blood pressure > or =140 mmHg and/or diastolic blood pressure > or =90 mmHg, or taking antihypertensive medication.

MAIN RESULTS

In total, 76% of individuals aged 20-79 years have an "unfavourable" cardiovascular disease risk profile, according to guideline definitions. The point prevalence of individuals with cholesterol and/or blood pressure above the recommended cut-off points increases with age. By age 24, the prevalence reaches 50%. By age 49, it reaches 90%. Men below 50 years of age have higher combined risk prevalence than women.

CONCLUSIONS AND IMPLICATIONS

Implementation of the 2003 European guidelines on CVD prevention would label a large majority of Norwegian adults as having unfavourably high cholesterol and/or blood pressure levels. The current biomedical standards appear to invalidate demographic health statistics. The theoretical basis on which the guidelines rest should thereby be scrutinized with regard to scientific methodology and consistency. Important ethical dilemmas arise at the point of guideline implementation, relating to risk labelling and medicalization, as well as resource allocation and sustainability within the healthcare system.

[Inscribed in the body]

BACKGROUND

Accumulated general practice experience from numerous encounters with sexually victimized persons motivated this study of childhood sexual abuse with regard to its longterm impact on life and health. THEORY, METHODS, AND MATERIAL: Phenomenology is its theoretical frame of references, and its methodological tools are hermeneutics, 34 adult users of two Norwegian incest centres consented to being interviewed in depth about their encounters with the health care system. The audiotaped interviews were transcribed verbatim. Relevant medical records filled out 16 of the interviews. Likewise, extensive field notes from interview setting were collected.

RESULTS

The experiences linked to violation, illness and treatment clustered around seven phenomena present in every interview in at least one modality. These were termed sensory imprints, confused judgements, maladaptive adaptations, strained relationships, recognized memories, unheard messages, and reactivated experiences.

INTERPRETATION

The impact of childhood sexual abuse was shown to transgress linear time, cause-effect relationship, categorical distinction and individuality. Since these four central preconditions for a correct medical judgement were not provided, harmful, though presumably correct, medical treatment was a frequent result. Consequently, the abused persons were revictimized in medical contexts when asking for help for sickness in the wake of socially silenced sexual violation.

["It is difficult to move a writing pen"--an interpretation of subtext in Agnar Mykle's work]

This article embarks from knowledge gained from dialogues with adult men and women in a phenomenological-hermeneutical study of the long-term health impact of sexual boundary violations in childhood. All published texts by the Norwegian novelist Agnar Mykle have been reviewed for the purpose of a reinterpretation, together with scholarly work on his oeuvre and biographical accounts of the author and his first wife. The interpretation has been guided by the assumption that the essays, novels and letters may represent a double text with an embedded coded message. The suggestion is offered that Mykle's work can be read as an attempt at acknowledging and surmounting a basic conflict in the author's own life between, on the one hand, his memories of experiences of boundary violations in childhood and, on the other, a scientific theory of infantile sexuality. It is also claimed that Mykle was silenced by the experience of being tried on pornography charges against one of his novels. The impact of this public humiliation may, in Mykle's perception, have reactivated earlier boundary violations and, as such, have been experienced as a revictimisation.

[Medical research on patients' experiences--structured questionnaires result in worthless answers]

The patient's expectations, wishes, judgments, and opinions have recently become a topic of interest in medical research. This is partly due to the physician's increasing awareness of an inadequate impact of medical measures, be they preventive, informative, or even curative, on the patient and the general public. It may also be partly due to an increasing criticism on the part of the patient and the general public of the failure of the medical service to respond adequately to the information provided. Consequently, there has recently been increased interest in gaining knowledge about the social aspects of human life relevant to medicine. The measures for securing validity, however, are the traditional rules of reductionist methodology. The author argues that by exploring the domain of culturally constructed meaning with tools based on naturalistic epistemology, the knowledge obtained will be invalid.