A Pink Elephant in the Room?

You could see her waiting in the wings, peeking around the curtain, anxious for her debut on the public stage. And what a buildup; the opening acts pretty well guaranteed her a receptive audience -one that would assume that anything less than a full symphonic orchestral introduction and a dais at centre stage would be discrimination. Gender imparity. No, her time was already too long delayed; everybody had come to see Ms Pink Viagra perform –maybe even out-perform what had come before.

Well, okay, I understand the problem –I even suspect I understand the parity issues: it seems unfair to help the man with sexual dysfunction (read erectile dysfunction) while appearing to believe that any problem in the woman is just psychological… Or his fault. Beyond the Pale, in other words. The current situation is a vexing one to be sure and the answer is clearly not an easy one. But I’m hoping that we don’t merely end up prescribing medication alone for an issue that is almost certainly multifactorial.

There was a helpful, albeit preliminary, article on the subject in the Canadian Medical Association Journal this December: http://www.cmaj.ca/content/early/2015/12/14/cmaj.150705.full.pdf  At the time of publication, the American FDA had recently approved a drug (flibanserin) for the treatment of ‘acquired, generalized hypoactive sexual desire disorder’ in premenopausal women. The concern, in the Canadian context at least, was whether any company approved to market it would be able to adhere to Canadian law in advertising it: ‘direct-to-consumer advertising is not allowed in Canada, but direct-to-consumer information campaigns are legal’. One of the problems is the quality of evidence for the information supplied. For example, in the USA, the company selling it claims that ‘hypoactive sexual desire disorder affects as many as one in three women in the US’, whereas ‘reliable and independent scientific data show that only about 1 in 10 women experience distress as a result of their low desire and thus have the condition’. Suggesting, of course, that low desire does not always need to be treated; and therefore the corollary that low desire in either partner is not necessarily pathological…

I’m also concerned about the drug’s promulgation in the cause of equivalency. Fairness. If information about a product is what is allowed by law, surely neutral presentation of all that information is what was intended -expected, if not required. As the article suggests: ‘Bias is introduced if emotive campaigns that are not linked to strong evidence underpin the provision of information.’  And it goes on to say, ‘What about asking the more pertinent questions of whether the existing evidence can tell us if the condition really exists or whether drugs are the only response to a “dysfunctional” level of sexual desire?’ Indeed, perhaps the entire subject of sexual dysfunction in either sex requires a more critically based analysis.

I have to admit that, as a general gynaecologist, I have always felt very uneasy and ill-equipped for dealing with the subject of sexual dysfunction. It’s not that I find that it is embarrassing -I don’t (although the patients usually do); and I don’t mind that it is time consuming (my accountants not withstanding); it’s not even that it contains an undercurrent –often well disguised and overtly denied- of recrimination, blame, or guilt (although it can be all of those). No, I suspect that it is rather that the solution to the problem is seldom straightforward or easily solved. And, unlike an infection, it may require more than a pill to cure. It seems to me that the answer often lies with both parties –and each comes to the table with different perspectives. Different interpretations… Different appreciations of the issue, for that matter. Occasionally it may respond to empathetic listening, and the provision of impartial information along with counselling; more often it requires a multidisciplinary approach , or at least an expertise beyond that of the average practitioner, however well-intentioned. And that may be difficult to obtain in a timely fashion.

But as with depression, for example, it is often so much easier for the uncomfortable and busy practitioner to reach for a prescription pad after a brief hearing, and a subsequent cursory analysis of the complaint. And even if the medication, in the cool, reasoned glow of retrospect, turns out to be more of a placebo than a targeted and specific cure, well, that’s better than nothing… Isn’t it?

Maybe it is, but is it an example of critical thinking? Evidence-based medicine? Is it really the result of an honest and respectful consideration of the problem? If the condition is indeed often multifactorial, shouldn’t the treatment be that as well? I’m sure that the directions on the probably-pink package will make that perfectly clear, though… Right?







An Unfamiliar Worry (for some)

I don’t know how the world used to manage with just men at the helm. There are so many things –obvious things- that simply pass by us uncharted. I don’t think its intentional; it’s more likely that those things just do not affect us in the same way. They have different consequences; we assign them different priorities –if we assign them at all…

There are, of course, some issues at which men seem relatively proficient at first glance- such as dealing with the needs of refugees arriving in Europe or wherever, from war torn areas of the world. When they arrive, attempts are made to provide for their health and safety while they are being processed. Because of the large numbers arriving, this often means settling them temporarily in camps where the basic needs of shelter, food, and medical care can be provided.

But those are relatively easy things to plan for -easy things to discuss at any  rate. Add in education for the children, maybe phone service so they can communicate with their families back home, and perhaps even, as icing on their cakes, leisure activities, and… Well, apart from a chance of permanent resettlement or, of course, improving the chaos in their home countries so they could return, what else could refugees possibly need? Or want?

Full disclosure: I am a man, and despite my forty-plus years as a gynaecologist, I’m afraid my brain is still sometimes stuck in Y mode. One would have thought that if anyone could transcend gender –wear other shoes- a gynaecologist might be in the running. But I missed this one: ‘About one in four of Zaatari’s [Jordan’s largest refugee camp] residents need sanitary pads. The UN does distribute them now and again to women aged 14 to 45, but there are never enough to go round.’ Sanitary products, even if they are available, can be expensive; the temptation is probably to use whatever personal money is available for other, more survival-oriented necessities. I learned this from an insightful article in BBC News: http://www.bbc.com/news/magazine-34925238  A British woman named Amy Peake not only discovered the need, but found a simple machine in India that would allow women  to make sanitary pads cheaply and on site. ‘On top of that, Peake discovered, there is a desperate need for incontinence pads for the many wounded, elderly and disabled people – and traumatised children. “The children are really suffering,” says Peake. “The problem is that the mothers have been trying to cope for so long that basically they’ve given up. Night after night of urine and they can’t keep them clean.’

There are so many things in everyday life that most of us take for granted until they are not available –things like a clean and timely change of clothes, the ability to maintain personal cleanliness in a culturally sensitive manner, and in private if desired. Although necessary, it is simply not sufficient to provide only the obvious -food, shelter, and so on- and then assume normalcy will ensue; we are all products of societies laden with traditions and expectations –this is what it is to be human. To strip these away is not only cruel, and disrespectful, it is also degrading. Inhuman. After all, they were living lives much like us until forced by war and unspeakable danger to flee from their homes for the sake of their families. For the sake of their futures… They are not merely bodies in need of sustenance, they are mothers and fathers… children… and so are we. So the question we must continue to ask ourselves is whether we would be comfortable treating our own families in the same way as these refugees. Would we feel that we have been sensitive to their needs?

Admittedly, in times of crisis and overwhelming numbers, some things must be prioritized, while others, perhaps less important to survival, need to be relegated to the background. But not neglected. Not forgotten. The refugees, already traumatized and exhausted by the hardships of their journeys and often bewildered by the contrasts with their previous lives, are ill equipped to complain. They are initially powerless, and confused, but very soon understand that once the basics have been provided, once the threat to life and limb has receded, there is another thing they desperately require: dignity. If they are ever to be assimilated into another country, another culture, another life, they must regain their self-esteem. Their pride.

We must not forget that different societies may view the world in different ways. Things to which we in the West have long since been accustomed are sometimes still problems elsewhere. Attitudes about the management of menstruation is one such problem. In many traditions, it is not only a secretive event that must be concealed from others for fear of ridicule, but also dealt with by whatever is at hand. The stigma around menstrual periods is complicated and culturally sensitive as I have already discussed in several other blogs:

https://musingsonwomenshealth.wordpress.com/2014/11/26/menstrual-taboos/, https://musingsonwomenshealth.wordpress.com/2015/04/01/menstruation-and-sports/, and even: https://musingsonwomenshealth.wordpress.com/2015/03/13/the-tampon-tax/

So I’m not sure why this article came as such a revelation. Maybe it was a reminder that we all see the world from our own perspectives: two people crossing one bridge is really two people crossing two bridges… And yet, to a third who is watching from the edge, it’s still the same bridge.

I should have known!  ‘But every little difference may become a big one if it is insisted on.’ as Lenin said.’ so I suppose I’ll have to accept that Time is a series of tests, and you only get marked at the end… I hope.

I can only offer the words of Iago in Shakespeare’s Othello:

I will wear my heart upon my sleeve
For daws to peck at…




The Most Unkindest Cut of All

It was the best of times, it was the worst of times

I’m a surgeon, so for me, the operating room has always been a haven of sorts. It’s one of the few places where I feel safe from interference from out there. Where, for a brief but immeasurable time, there is no outside –no politics, no traffic jams, no rainy days- just the task at hand. It is a magic place where we all work as a team –all interdependent, all focussed on our mission, all oblivious to anything else. A world unto itself, it exists briefly -like Brigadoon- then vanishes as suddenly leaving only remnants glimpsed through a door: soiled sheets being secreted away into plastic bags, or paper drapes being crumpled into even noisier containers by relative strangers -a different team- busy with wiping and washing… And then the room is empty, barren of meaning –its sacred purpose subdued by the evanescently profane. A sanctuary no more.

I say ‘no more’, but that is hyperbole because it always begins again: samsara. It is an organism that cannot be fully assessed from outside the doors. In the room it is measured in the steady pulse of a beating heart, the razor thin stroke of a piece of steel, the strength and tightness of a length of string.

There are, of course, distractions inside, but they are like traffic noises in the night and soon forgotten, hidden in blood or quickly acclimatized as more urgent problems –often unexpected- surface in the morass of organs vying for attention. It is a stormy sea, the opened body, and to navigate requires immersion in the troubled waters.

But absorption, however deep, demands surfacing from time to time to take stock, to breathe deeply –to assess and plan. And it is then, when the spirit needs whatever succour it can find, when distractions finally disturb -bewilder. It is then when the team finds solace in music.

Ay, and there’s the rub. http://www.bbc.com/news/health-33771022

There are as many tastes in music and what soothes, as there are people in the room -as there are people in the world, probably. So what knits up the raveled sleave of care for one, is definitely not the nourisher of life’s feast for another (Sorry, Macbeth). The article I’ve linked is from the BBC News and suggests that music in the operating room may be counterproductive.

But it is more of a ‘Just right, baby bear’ story I think -obvious stuff that seems almost too obvious to study: if the music is too loud, people can’t communicate with each other; dance music with drums or whatever, definitely distract, although they didn’t elaborate. But the BBC report partially retracted the condemnation towards the end of the article and suggested a compromise approach that fits more closely with my own Confirmation Bias: a link to a 2011 study reported in The Journal of Anaesthesiology and Clinical Pharmacology: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3161461/ This was a prospective, questionnaire-based cross-sectional study -a survey- that tried to pin down elements of music that might be acceptable both to those who were standing or sitting in the operating room as well as the silent one who wasn’t.

For example, ‘…62% thought that music helped in reducing anxiety of patients before anesthesia’ – or to completely obfuscate the observation and clothe it in scientific attire: ‘According to the gate control theory which is based on the fact that pain is an integrated sensory, affective, motivational system that modulates noxious input and attenuates the perception of nociceptive inputs, it has been suggested that pain and auditory pathways inhibit each other. Perhaps the activation of auditory pathway by music during surgery inhibited the central transmission of nociceptive stimuli.’

And also: ‘Our study revealed that 59% of the respondents thought that music helped in reducing their autonomic reactivity in stressful surgeries thus calming them down and allowing them to approach their surgeries in a more thoughtful and relaxed manner.’

It goes on to suggest (with references) that: ‘Music has been used to achieve a wide range of outcomes not only in the hospital, but also in the community and residential care settings. It minimised anxiety levels of patients during hospitalisation and during unpleasant or invasive procedures. It helped people relax. Its effect has been measured in terms of its impact on the person’s heart rate, blood pressure and respiratory rate. It reduced the severity of pain and the need for analgesia in people with acute or chronic pain. It was found to improve cognitive function in terms of behavior, eating and minimised the need for physical restraint for people with dementia. The effect of noisy environment produced by medical equipments in OTs [Operating Theatres- or ORs] and critical care units on patients was also found to be minimal, when music was played in such settings. Patients and hospital visitors were more satisfied with the care provided. It improved mood and feeling of well being for a range of different patient groups. It enhances tolerance level of people to unpleasant or invasive procedures, such as insertion of intravascular lines, surgical interventions, burns dressings and chemotherapy.’

Then there was an attempt to prescribe tempo: ‘Tempo of music around 60-80 beats per minute was found to be the best for creating relaxation. A higher tempo acted like a “driving input”, which resulted in increased heart rate, blood pressure and respiratory rate.’ So, since I prefer the classical music I usually bring to be played in the OR, this meets with my approval, and as long as the team doesn’t nod off during the more lugubrious passages I think I satisfy those criteria.

But of course, volume is the elephant in the room. As the authors of the study put it: ‘The volume of the music played also had a tremendous effect on the mood of the OT staff. Of the total study population 59% of the respondents preferred medium volume while 41% preferred low volume of music in the OT. It was evident that the staff would not let music compromise or interfere with the technical aspects of patient care or competence.’

Although I think it’s hard to turn a symphony up too loud in an OR, I’ve found that violin or even -dare I admit it- piano passages tend to elicit angry, but accidental, elbows in my ribs if played other than sotto voce. I tried out opera once as well, only to discover that the musical device I used was missing for the next case… So I hesitate to draw any firm conclusions… Except that it kept the team awake, I guess -I mean you have to be alert to plan where to hide an iPod.

But I will leave the final words to Shakespeare again –this time from Henry IV: ‘Let there be no noise made, my gentle friends; Unless some dull and favourable hand Will whisper music to my weary spirit.’ A simple request -but this time from a king. They outrank even surgeons.