Following on from my post the other day (No sex please, we’re physiotherapists), I thought I would recount one of my favourite stories that illustrates just how implicit sexuality is in the work that physiotherapists do.
A few years ago, I interviewed Brian Mulligan, the famous Kiwi physiotherapist, whose work has made him one of the world’s most well known and well regarded practitioners. His Mobilisation with Movement approach to musculoskeletal physiotherapy, developed in the 1980s, is now followed by thousands of physiotherapists, and he is still teaching and examining all over the world. More than that though, he is one of nicest people you could care to meet; genuinely charming and a great storyteller.
I was interviewing him as part of New Zealand’s physiotherapy centenary celebrations (you can hear Brian talk about his work and practice life here), and as part of that interview I asked him about two quite famous pictures that appeared in the 4th edition of his book ‘Manual Therapy: “NAGS”, “SNAGS”, “PRP’S” etc.’ If you turn to pages 64 and 82 of that edition, you will be confronted by these two rather arresting pictures:
By 1998 Brian’s books had become incredibly popular, and he was in demand as a speaker all over the world. His American publishers asked him if he would consider a slight change to the next edition, including a couple of images with female models, where the technique was, shall we say, ‘sensitive.’ Brian’s books almost exclusively used male models, and American physical therapists – fearing law suits – wanted visual evidence of how one was supposed to perform a “SNAGS” technique for anterior chest pain with extension. They wanted evidence that you really do need to place your hands across the breasts to perform the technique safely and effectively.
Brian agreed, but not wanting to use a relative for the pictures, decided to phone a local massage parlour and hire a prostitute for the pictures.
The woman arrived with her minder (the man holding the leg in the picture on p. 82), took off her clothes and posed for the pictures. These were her ‘working clothes’ as Brian put it, and so they took the pictures in situ and thought nothing of it.
Brian had long held the view that we were too prudish about images of naked bodies, and knew that some skin-to-skin contact was essential if one was going to be effective with some techniques. Little did he realise the fuss these images would cause.
Suffice to say, the images were removed from the 5th edition and replaced with a picture of a male model who caused no-one any offence.
One thing that always struck me about these ‘scandalous’ pictures is the use of black boxes to hide the model’s appearance. They have the effect of making the pictures seem really seedy. It doesn’t help that Brian’s face is hidden behind the model in the first picture, and that she is looking away from the camera. I imagine that if you took this picture out of the book and showed it to people who didn’t know any better, they would say it had been lifted from an old pornographic magazine.
The second picture is even more strange. Not only was no effort made to change the model’s ‘working’ clothes, but a black box has been placed over the right cheek of her buttocks. I was totally confused by this, until Brian told me that it was because she had a tattoo on her bottom and the publishers didn’t think that it would be appropriate to show this in the book. It’s surprising, given their sensitivity, that they didn’t feel the same about having a half-naked prostitute being manipulated by two men in a photo shoot that took 20 minutes and resulted in a financial transaction that bore all the hallmarks of her normal day-job.
I find it deeply ironic, given how we have to be so careful about how we regulate the sensuality of touch, that Brian should have chosen to use a prostitute to demonstrate a technique that is used every day by practitioners around the world. Brian did a fine thing in printing these photographs because he inadvertently raised a question about how physiotherapy views the sensuality of its practice. I’m not sure if he’d do it again, if he knew how people would react, but I think that says more about some of the people in the profession than it does about him.
David I have always been intrigued by the 4th edition of MWM for those very reasons that you pointed out. Thanks for the excellent telling of the back story. Some time ago I found this video on youtube demonstrating a slightly provocative technique muddled in biomedical rationale.
https://www.youtube.com/watch?v=jB9-zPYd8ns&feature=youtu.be&t=2m49s
In short there is a lot to observe in this video, but I think the key point here is that with any discussion of sensuality there must also be a discussion of power. Our patients’ lots in life places them in a particular relationship to power structures. Behind the seemingly innocuous (positions that Mulligan placed the women photographed) there is a life story of that woman and her role which is unfortunately ignored in the written record and occluded by the story of the technique. Why was she there? What is her relationship to her minder? Did she consent to these pictures? Obviously her minder did as he probably received a portion of the payment. Why is it acceptable to photograph a storyless prostitute but not one’s relative in the buff? This last question would be the appropriate rebuff to Mulligan’s misgivings about American sensibilities.
In watching the above video I am struck with these same feelings. What woman (or man) would subject themselves to such a treatment? What biological plausibility does this technique adhere to? The technique demonstrator states that one should pay attention to the dura–what does that mean? Can one actually see, touch or feel the dura in vivo? Why not pay closer attention to the relationship you have with the patient and the fact that you place them in vulnerable position and the only difference between the ‘technique you are applying’ and abuse is the context which surrounds and leads up to the execution of that technique. It is precisely this last point where pseudo knowledge derails from reality when there is a poverty of humanistic discourse to refine the use of that knowledge in humans.
Eric Kruger @EkrugerDPT
Excellent response, Eric. I’m not giving Mr. Mulligan a pass on this, either, particularly now having knowledge of the backstory. It’s inexcusable for a therapist to subject another human being to this potential invasion of their inherent autonomy and denigration of their self-worth. I’m aware of the statistics in the US on history of sexual abuse, and I don’t doubt that they vary all that much from what occurs in New Zealand. The ongoing assault on the sense of self from such a history is profound.
I’m disgusted by both the photographs in the original post and the video you provided. This is not therapy, its a power grab-literally and figuratively.
Hi John
I can appreciate your disgust, but I’d like to point out that I’m using Brian’s story and the Youtube video only as an illustration of a question about asymmetrical power and innate sexuality that is redolent throughout physiotherapy. In other professions where touch is mandated, there is a much greater engagement with these questions. The fact that our ethical frameworks entirely fail to examine this conduct suggests that they are serving only to mask it further.
I totally agree that it is an ongoing assault on the sense of self, but what is more concerning for me has always been the banality of it all – the way it has been normalised by practitioners so that it no longer seems out of place.
Agreed, the more immanent and widespread issue is the utter lack of consideration for – for lack of a better term- the sanctity of the so-called “third space” (nod to Quintner and Cohen). The vast majority of PTs have a lack of appreciation for the treatment context, including whatever previous experiences, ideas and beliefs are currently impacting the patient’s pain experience. The term “reification” comes to mind: PTs feel compelled to make pain a “thing”, with discrete causes esoterically tucked away somewhere in the patient’s tissues. This is, after all, how we are trained. Well, the training is substandard at best, derelict at worst.
I recall that it was Eric Kruger who once used the term “bourgeois” to refer to the lack of sophistication of current PT practice in the treatment of pain problems. That term stuck with me. “Banal” works, too. In any case, it’s all embarrassing. Sometimes we PTs seem like the Beavis and Butthead of health care, and images like this floating around out there only seem to promote that. Hope that image doesn’t offend.
P.S. Thank you for allowing me to comment on your blog space.