Difference and Identity (review)

Difference and Identity is a collection of essays intended to give the reader a sense of how "differences" are perceived by those who are different (physically, spiritually, or socially). In this way it expands on those concepts conventionally thought of as contributing to identity. The first section of the book ("Dis-Ability") focuses on the impact of physical disability; the second ("Dis-Sexuality") explores the impact of sexuality, including both gender and sexual orientation; and the third ("Dis-Embodiment") examines the interface between the physical and spiritual or emotional selves. The result is a book that turns the reader's perspective 180 degrees: instead of starting with the assumption that most people are "normal" and that minority populations are "different," in this book those who are "different" define what is normal—it is the rest of us who are abnormal or different. The book thus paves the way to a discussion of how physicians should approach patients who are different from them.

The uniqueness of each person who is "different" not only distinguishes him from his "normal" neighbors, but also from others with whom these "normal" neighbors might tend to clump him. When a member of an identifiably different minority group interacts with the world at large, society defines that person by his or her membership in the group. When the individual is surrounded (physically or emotionally) by other members of his or her community, however, a fuller collection of attributes comes to define that person in the eyes of his or her peers. For example, at the Special Olympics, it is not a physical disability that makes a person unique. Similarly, in a synagogue on a Saturday morning, being Jewish does not uniquely define individual worshippers. Difference, then, is a relative concept.

In a medical context, this perspective on difference forces caregivers to consider that in order to treat a patient in a culturally competent manner, they must not limit their view of the patient to the characteristics that define the patient in the majority's view. Instead, the patient must be understood as having a unique set of insights and expectations as a result of a unique set of cultural and experiential inputs. A person's culture can be seen as analogous to his genetic code: some cultural inputs are dominant, some are recessive, and most demonstrate partial penetrance.

Difference and Identity highlights several factors that complicate efforts to treat patients in a culturally competent manner, including the phenomenon of "passing." Treating physicians who view their patients through the majority perspective may find surprisingly few differences between themselves and their patients because, in order to mitigate potentially uncomfortable differences, members of minority groups may try to pass as majority. Contributor Tobin Siebers explains in "Disability as Masquerade" that passing is fairly common: "When in the minority and powerless, Jews pass as Christians, blacks pass as whites, and gay, lesbian, and transgendered people pass as heterosexuals. Similarly, people with disabilities find ingenious ways to conceal their impairments and pass as able-bodied" (p. 2). Siebers describes the experience of Jaclyn Stuart, who wears a rubber hand for cosmesis when she wants to avoid stares: "I wear it when I go dancing because otherwise [if I wear my hook] the whole dance floor goes crazy!" (p. 13). David Kirby also explores passing in his essay "GATTACA," which analyzes the science fiction film of the same name. The movie describes two types of individuals inhabiting a future society in which an individual's genetic makeup is as visible to others as his or her skin color: those who are genetically modified before birth enjoy a privileged position in society, and those who remain genetically unmodified are oppressed. Vincent, a genetically unmodified individual, is not hired for work he is qualified to perform because of his genetic profile. To improve his social position, he rents genetically modified DNA, which enables him to pass as genetically modified and thus obtain a position as an engineer...