Authors: Atul Gawande
For as long as Drury could remember, she had been a blusher, and, with her pale Irish skin, her blushes stood out. She was the sort of child who almost automatically reddened with embarrassment when called on in class or while searching for a seat in the school lunchroom. As an adult, she could be made to blush by a grocery-store cashier’s holding up the line to get a price on her cornflakes, or by getting honked at while driving. It may seem odd that such a person would place herself in front of a camera. But Drury had always fought past her tendency toward embarrassment. In high school, she
had been a cheerleader, played on the tennis team, and been selected for the prom-queen court. At Purdue, she had played intramural tennis, rowed crew with friends, and graduated Phi Beta Kappa. She’d worked as a waitress and as an assistant manager at a Wal-Mart, even leading the staff every morning in the Wal-Mart cheer. Her gregariousness and social grace had always assured her a large circle of friends.
On the air, though, she was not getting past the blushing. When you look at tapes of her early broadcasts—reporting on an increase in speeding-ticket fines, a hotel food poisoning, a twelve-year-old with an IQ of 325 who graduated from college—the redness is clearly visible. Later, she began wearing turtlenecks and applying to her face a thick layer of Merle Norman Cover Up Green concealer. Over this she would apply MAC Studiofix foundation. Her face ended up a bit dark, but the redness became virtually unnoticeable.
Still, a viewer could tell that something wasn’t right. Now when she blushed—and eventually she would blush nearly every other broadcast—you could see her stiffen, her eyes fixate, her movements become mechanical. Her voice sped up and rose in pitch. “She was a real deer in the headlights,” one producer at the station said.
Drury gave up caffeine. She tried breath-control techniques. She bought self-help books for television performers and pretended the camera was her dog, her friend, her mom. For a while, she tried holding her head a certain way, very still, while on camera. Nothing worked.
Given the hours and the extremely limited exposure, being an overnight anchor is a job without great appeal. People generally do it for about a year, perfect their skills, and move on to a better position. But Drury was going nowhere. “She was definitely not ready to be on during daylight hours,” the producer said. In October of 1998, almost two years into her job, she wrote in her journal, “My feelings of slipping continue. I spent the entire day crying. I’m on my way to work and I feel like I may never use enough Kleenex. I can’t figure out
why God would bless me with a job I can’t do. I have to figure out how to do it. I’ll try everything before I give up.”
What is this peculiar phenomenon called blushing? A skin reaction? An emotion? A kind of vascular expression? Scientists have never been sure how to describe it. The blush is at once physiology and psychology. On the one hand, blushing is involuntary, uncontrollable, and external, like a rash. On the other hand, it requires thought and feeling at the highest order of cerebral function. “Man is the only animal that blushes,” Mark Twain wrote. “Or needs to.”
Observers have often assumed that blushing is simply the outward manifestation of shame. Freudians, for example, viewed blushing this way, arguing that it is a displaced erection, resulting from repressed sexual desire. But, as Darwin noted and puzzled over in an 1872 essay, it is not shame but the prospect of exposure, of humiliation, that makes us blush. “A man may feel thoroughly ashamed at having told a small falsehood, without blushing,” he wrote, “but if he even suspects that he is detected he will instantly blush, especially if detected by one whom he reveres.”
But if it is humiliation that we are concerned about, why do we blush when we’re praised? Or when people sing “Happy Birthday” to us? Or when people just look at us? Michael Lewis, a professor of psychiatry at the University of Medicine and Dentistry of New Jersey, routinely demonstrates the effect in classes. He announces that he will randomly point at a student, that the pointing is meaningless and reflects no judgment whatever about the person. Then he closes his eyes and points. Everyone looks to see who it is. And, invariably, that person is overcome by embarrassment. In an odd experiment conducted a couple of years ago, two social psychologists, Janice Templeton and Mark Leary, wired subjects with facial-temperature sensors and put them on one side of a one-way mirror. The mirror was then removed to reveal an entire audience staring at them from the other side. Half the time the audience members were wearing
dark glasses, and half the time they were not. Strangely, subjects blushed only when they could see the audience’s eyes.
What is perhaps most disturbing about blushing is that it produces secondary effects of its own. It is itself embarrassing, and can cause intense self-consciousness, confusion, and loss of focus. (Darwin, struggling to explain why this might be, conjectured that the greater blood flow to the face drained blood from the brain.)
Why we have such a reflex is perplexing. One theory is that the blush exists to show embarrassment, just as the smile exists to show happiness. This would explain why the reaction appears only in the visible regions of the body (the face, the neck, and the upper chest). But then why do dark-skinned people blush? Surveys find that nearly everyone blushes, regardless of skin color, despite the fact that in many people it is nearly invisible. And you don’t need to turn red in order for people to recognize that you’re embarrassed. Studies show that people detect embarrassment
before
you blush. Apparently, blushing takes between fifteen and twenty seconds to reach its peak, yet most people need less than five seconds to recognize that someone is embarrassed—they pick it up from the almost immediate shift in gaze, usually down and to the left, or from the sheepish, self-conscious grin that follows a half second to a second later. So there’s reason to doubt that the purpose of blushing is entirely expressive.
There is, however, an alternative view held by a growing number of scientists. The effect of intensifying embarrassment may not be incidental; perhaps that is what blushing is for. The notion isn’t as absurd as it sounds. People may hate being embarrassed and strive not to show it when they are, but embarrassment serves an important good. For, unlike sadness or anger or even love, it is fundamentally a moral emotion. Arising from sensitivity to what others think, embarrassment provides painful notice that one has crossed certain bounds while at the same time providing others with a kind of apology. It keeps us in good standing in the world. And if blushing serves to heighten such sensitivity, this may be to one’s ultimate advantage.
The puzzle, though, is how to shut it off. Embarrassment causes blushing, and blushing causes embarrassment—so what makes the cycle stop? No one knows, but in some people the mechanism clearly goes awry. A surprisingly large number of people experience frequent, severe, uncontrollable blushing. They describe it as “intense,” “random,” and “mortifying.” One man I talked to would blush even when he was at home by himself just watching somebody get embarrassed on TV, and he lost his job as a management consultant because his bosses thought he didn’t seem “comfortable” with clients. Another man, a neuroscientist, left a career in clinical medicine for a cloistered life in research almost entirely because of his tendency to blush. And even then he could not get away from it. His work on hereditary brain disease became so successful that he found himself fending off regular invitations to give talks and to appear on TV. He once hid in an office bathroom to avoid a CNN crew. On another occasion, he was invited to present his work to fifty of the world’s top scientists, including five Nobel Prize winners. Usually, he could get through a talk by turning off the lights and showing slides. But this time a member of the audience stopped him with a question first, and the neuroscientist went crimson. He stood mumbling for a moment, then retreated behind the podium and surreptitiously activated his pager. He looked down at it and announced that an emergency had come up. He was very sorry, he said, but he had to go. He spent the rest of the day at home. This is someone who makes his living studying disorders of the brain and the nerves. Yet he could not make sense of his own condition.
There is no official name for this syndrome, though it is often called “severe” or “pathological” blushing, and no one knows how many people have it. One very crude estimate suggests that from 1 to 7 percent of the general population is afflicted. Unlike most people, whose blushing diminishes after their teenage years, chronic blushers report an increase as they age. At first, it was thought that the problem was the intensity of their blushing. But that proved not to be
the case. In one study, for example, scientists used sensors to monitor the facial color and temperature of subjects, then made them stand before an audience and do things like sing “The Star-Spangled Banner” or dance to a song. Chronic blushers became no redder than others, but they proved significantly more prone to blush. Christine Drury described the resulting vicious cycle to me: one fears blushing, blushes, and then blushes at being so embarrassed about blushing. Which came first—the blushing or the embarrassment—she did not know. She just wanted it to stop.
In the fall of 1998, Drury went to see an internist. “You’ll grow out of it,” he told her. When she pressed, however, he agreed to let her try medication. It couldn’t have been obvious what to prescribe. Medical textbooks say nothing about pathological blushing. Some doctors prescribe anxiolytics, like Valium, on the assumption that the real problem is anxiety. Some prescribe beta-blockers, which blunt the body’s stress response. Some prescribe Prozac or other antidepressants. The one therapy that has been shown to have modest success is not a drug but a behavioral technique known as paradoxical intention—having patients actively try to blush instead of trying not to. Drury used beta-blockers first, then antidepressants, and finally psychotherapy. There was no improvement.
By December of 1998, her blushing had become intolerable, her on-air performance humiliating, and her career almost unsalvageable. She wrote in her diary that she was ready to resign. Then one day she searched the Internet for information about facial blushing, and read about a hospital in Sweden where doctors were performing a surgical procedure that could stop it. The operation involved severing certain nerves in the chest where they exit the spinal cord to travel up to the head. “I’m reading this page about people who have the exact same problem I had, and I couldn’t believe it,” she told me. “Tears were streaming down my face.” The next day, she told her father that she had decided to have the surgery. Mr. Drury seldom questioned his daughter’s choices, but this sounded to him like a bad
idea. “It shocked me, really,” he recalls. “And when she told her mother it shocked her even worse. There was basically no way her daughter was going to Sweden and having this operation.”
Drury agreed to take some time to learn more about the surgery. She read the few articles she could find in medical journals. She spoke to the surgeons and to former patients. After a couple of weeks, she grew only more convinced. She told her parents that she was going to Sweden, and when it became clear that she would not be deterred her father decided to go with her.
The surgery is known as endoscopic thoracic sympathectomy, or ETS. It involves severing fibers of a person’s sympathetic nervous system, part of the involuntary, or “autonomic,” nervous system, which controls breathing, heart rate, digestion, sweating, and, among the many other basic functions of life, blushing. Toward the back of your chest, running along either side of the spine like two smooth white strings, are the sympathetic trunks, the access roads that sympathetic nerves travel along before exiting to individual organs. At the beginning of the twentieth century, surgeons tried removing branches of these trunks—a thoracic sympathectomy—for all sorts of conditions: epilepsy, glaucoma, certain cases of blindness. Mostly, the experiments did more harm than good. But surgeons did find two unusual instances in which a sympathectomy helped: it stopped intractable chest pain in patients with advanced, inoperable heart disease, and it put an end to hand and facial sweating in patients with hyperhidrosis—uncontrollable sweating.
Because the operation traditionally required opening the chest, it was rarely performed. In recent years, however, a few surgeons, particularly in Europe, have been doing the procedure endoscopically, using scopes inserted through small incisions. Among them was a trio in Göteborg, Sweden, who noticed that many of their hyperhidrosis patients not only stopped sweating after surgery but stopped blushing, too. In 1992, the Gotebörg group accepted a handful of patients who complained of disabling blushing. When the
results were reported in the press, the doctors found themselves deluged with requests. Since 1998, the surgeons have done the operation for more than three thousand patients with severe blushing.
The operation is now performed around the world, but the Göteborg surgeons are among the few to have published their results: 94 percent of their patients reported experiencing a substantial reduction in blushing; in most cases it was eliminated completely. In surveys taken some eight months after the surgery, 2 percent regretted the decision, because of side effects, and 15 percent were dissatisfied. The side effects are not life-threatening, but they are not trivial. The most serious injury, occurring in 1 percent of patients, is Homer’s syndrome, in which inadvertent damage to the sympathetic nerves feeding the eye results in a constricted pupil, a drooping eyelid, and a sunken eyeball. Less seriously, patients no longer sweat from the nipples upward, and most experience a substantial increase in lower-body sweating in compensation. (According to a longer-range study that surveyed hand-sweating patients a decade after undergoing ETS, the proportion who were satisfied with the outcome drops to only 67 percent, mainly because of the compensatory sweating.) About a third of patients also notice a curious reaction known as gustatory sweating—sweating prompted by certain tastes or smells. And, because sympathetic branches to the heart are removed, patients experience about a 10 percent reduction in heart rate; some complain of impaired physical performance. For all these reasons, the operation is at best a last resort, something to be tried, according to the surgeons, only after nonsurgical methods have failed. By the time people call Göteborg, they are often desperate. As one patient who had the operation told me, “I would have gone through with it even if they told me there was a fifty percent chance of death.”