Monthly Archives: January 2017

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The Bicameral Mind

Time to unwrap the Jeremiad again, I’m afraid; I’m getting tired of this. Really tired. I know it’s an American thing, but stop it will you? Or can you? Every time there’s a bicameral shift it tears the fabric a little more and unravels what I want to believe about your country. Yes, I’m Canadian and watching with unvetted eyes I guess, and yet sometimes it is good to hear from the other side of the mirror. To listen to the indrawn breath and pause to look around. Sometimes acumen travels in disguise: the dusty traveller leaning on the fence, the unwashed face of Vishnu. Wisdom does not always wear a flag.

One of the things I’m referring to, of course, is the perpetually probationary status in the United States of both family planning and pregnancy termination. Women’s rights seem contingent upon the prevailing ideology, their status as stable as the government in power -guaranteed only conditionally, and as changeable as the pen that underwrites them.

As a non-combatant, I suppose I should only listen with firmly closed lips; perhaps the border should be a closed curtain so I cannot see through. And maybe I should apologize for being so critical, but when is this vacillation going to stop? I accept that there are valid differences of opinion, and that any decision is inevitably temporally adjudicated. Times change, and so do populations and their ethnic and cultural compositions. It’s happening to us all. But surely the answer isn’t to retreat behind the doors and barricade the walls.

And defunding organizations that seek to address the issues of involuntary overpopulation would seem unduly parochial and even internationally misunderstood. It is the special duty of an enlightened nation to accept that there are many roads and many destinations. It has, it seems to me, the burden of reasonable neutrality, grounded observation, and judicious guidance.

The issue, I think, should be one of choice not fiat. Conscience, not doctrine. To offer alternatives is not to coerce, nor to prejudice the selection; it is surely to achieve the goal for which the options were offered in the first place. Not all things are equally acceptable; not all choices are politically or culturally permissible, to be sure. So a variety of solutions might have a greater likelihood of admissibility. A greater possibility of success.

Several years ago, I travelled to the States to attend a gynaecological convention and discovered that not only was pregnancy termination still an inflammable topic for many delegates, but even the provision of Family Planning counselling for whoever requested it. I found this hard to understand, especially at a meeting of specialists in the field.

I remember questioning one of the doctors I met there and she rolled her eyes at my Canadian naïveté. “Do you remember that fable of Aesop called ‘the Belly and the Members’?” Now I felt really naïve because I had to shake my head.

She seemed surprised. “Well,” she said, after interrogating my face for a moment to make sure I wasn’t kidding her. “The version my daddy told me when I was young went something like this. One day, after carrying the body through a long day of heavy work, the feet complained that they seemed to be the only ones in the body who had to work. Of course the hands argued with them that they were the ones who should complain -the feet may have carried the body, but they had to carry and even balance the load. The only thing they could agree on, after a long argument, was that although the four of them worked all day, in the end it was the stomach who got all the food.

“So, they devised a plan. The feet refused to walk to the stove, and the hands refused to pick up any food.”  The doctor smiled at this point and pierced me with her eyes. “And you can guess what happened after a while… They all got weak and finally had to agree to work together. Only the stomach could give them the strength they needed.”

She giggled at the end and touched my arm playfully. “I can’t believe you didn’t know that one, doctor.”

I hate it when a colleague calls me ‘doctor’, but I let it pass. “And I take it the fable is telling us that we all have to work together, no matter that we’re different? And that we can all have different opinions?”

Her expression changed and a puzzled look crept onto her face. “Never thought of that, actually… My daddy said it meant that we all have our jobs, but need someone –something- watching over us to give us strength and direction… Reminding us of what we should do. He said the Stomach was our Conscience… But I think he really meant the President… Or maybe the Lord…” She shook her head in apparent disbelief at my interpretation. I blinked, because it didn’t make sense to me. I wondered if she’d remembered it wrong.

“You must have similar fables even up there in Canada…” I could tell she was trying to understand my confusion. Transcend boundaries.

“Well,” I started, just like she had, “I do remember one about chopsticks…” She smiled at my multiracial example –so Canadian. “It was something one of my Chinese patients told me after giving me a little gift for delivering her baby. She said her father had told her this when she was a child.

“’There was an old man,’ she said, ‘who was close to death, and worried about what would happen after he died. He decided to ask the wise village elder if he knew what it would be like in Hell. The elder smiled and told him to imagine a large room filled with people. ‘They are all thin and hungry,’ he said ‘even though there is food everywhere.’

“’Then why are they so thin,’ the old man asked?

“’Because their chopsticks are each ten feet long,’ was the answer.

“The old man thought about it for a minute. ‘And Heaven,’ he asked, ‘What’s it like in Heaven, then?’

“The elder laughed. ‘Imagine another large room. There is food everywhere, but the people are fat and happy in spite of their ten foot long chopsticks…’

“The old man was puzzled. ‘But… I don’t understand.’

“The elder smiled and put his arm around the old man. ‘In Heaven, they feed each other…’”

Perhaps, I thought, after watching my colleague’s reaction, perhaps there is something more profoundly different about our two countries than simply the colour of our mailboxes…

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Scrambled Eggs

Great! Test tube mothers now, is it? Not enough to eliminate the Fallopian tube, or the on-egg dating site where potential sperm candidates meet, are scrutinized, profiles scanned and competition held for first across the zona (pellucida, that is) … Oh no, now we have to eliminate the entire coffee shop. What is happening out there… or do I mean in there? It’s so confusing.

There was a time when it was simple. Well, maybe it wasn’t, but at least we were used to it. You met somebody and expectations and hormones took over. No need to put in a special request for stem cells, or people in white lab coats and masks. No need to take out a loan –although flowers and dinners aren’t that cheap anymore, either. But it was the excitement of the chase, the hunt –searching for clues about the other person that weren’t all tied to their DNA; picking them because they were funny and considerate, cute and snuggly. They had histories. Stories. Isn’t that why we get together? Wasn’t it? http://www.bbc.com/news/health-37337215

Okay, I’m leap-frogging here. We’re not there yet –I mean they are not there yet; I suspect that, despite the occasional slip-up, most of us are still going to prefer to stick to the traditional court-and-impregnate model that has served us so far. I mean, fun is fun, eh? And to be fair, there’s a lot to deal with if you want to bypass natural stuff -ingredients, for example. Right now, you need a minimum of two things to make babies: a sperm and a receptive egg (sperm always seem to be in the mood…). Yes, and you need a place for them to meet and grow together, but there are any number of uteri out of work at any given time, so, with the rise of things like Airbnb, I suspect they won’t be a problem.

And everything that is alive has DNA and its instruction manuals closeted away somewhere… Do you see the opportunities I’m suggesting? Trick some skin cell, or whatever, into thinking it’s a sperm or an egg, and poof –reproduction-lite. Better still, why not hoodwink that ordinary cell into thinking it’s pregnant? I mean, it’s got all the necessary assembly instructions squirrelled away, hasn’t it? Your argument just has to be convincing. Persuasive. It doesn’t necessarily need to be, well, necessary. You could just be doing it for fun. A prank. Or to prove that you can, I guess. Isn’t that why a lot of stuff gets done? When you tire of trying to justify something that would fly in the face of current needs and desires, you simply create a niche product. Create a want. Wants usually evolve into needs –mutate into needs, at any rate. Look at Selfies and their requirement for sticks. Or bell-bottomed trousers –no, wait, that was a while ago…

My point, I think, is that gender may be rendered redundant not by increasing social awareness of its variations, but rather because of its dispensability. Why keep something you don’t really need? History will decide, of course, but hindsight tends to come down hard on things that outlive their time. Consider phlogiston. It was the postulated fire element that was contained by combustible things and was released when they caught fire. Of course! But who, apart from old people, have even heard of it? Or want to?

And then, in keeping with the air theme, there is the Miasma Theory which just assumed that disease was caused by ‘bad air’. Simple. Elegant. No need to bring in a lot of accessory stuff like animalcules and other things you couldn’t see anyway. Germs, let alone viruses prions and the like, were simply unnecessary and unduly complicated. Why dump many unknowns into an equation that could be solved by one charming known? Why mess with E = mc 2 when it isn’t a theory of everything, especially if it needs Quantum? Explanation isn’t everything, either…

Okay, so I’ve non sequitured again, but hopefully you see my concern. Obsolescence is one thing –we often persist past our best-before dates- but unplanned obsolescence is another creature entirely. It smacks of blundering about in dark corners hoping there are no unpleasant surprises -nothing that will sting in retrospect.

I am as excited as the next person about the prospects for the future, but experience teaches caution. The principle of unintended consequences is a favourite historical topic –almost as seductive as the ‘what if’s’ so popularized in historical fiction nowadays. Maybe there is nothing enchanted about that first introduction between egg and sperm. Nothing magical. Nothing necessary. Maybe life will carry on much as before and procreation will still scratch out a living between the sheets. And maybe it’s always good to have options -choices freely made and understood. Even needed, occasionally. We have always been condemned to live in interesting times –the Past was never an Eden.

And yet…

 

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Digital Naivete

I suppose it was inevitable; I suppose I should have guessed… When you are charged with consulting on a generation that seeks its information online, there are issues that are only apparent in that venue. And treatment algorithms which don’t take that into consideration are woefully naïve. Doomed to fail.

There are smartphone apps for everything I guess, but in an Ob/Gyne practice like mine, there are only two that my patients seem willing to share with me: obstetrical dating apps that disclose the expected date of baby’s arrival, and period tracking apps. In an age of constant immersion in information sharing and with an understandable need for inclusion in any decision making, I think that both of these programs -especially the menstrual tracker- would be considered especially useful to any women at risk of pregnancy, particularly so if they also suffered from irregular periods. A natural extension of that, then, might be to extend its use. To adapt it for another purpose for which it was not originally intended -a technological exaptation.

But an article a while ago in the BBC news (also an app, by the way) looked at some of the pros and cons of menstrual tracking apps: http://www.bbc.com/news/health-37013217 that raise some serious concerns.

The idea of being able to follow one’s periods without the need to carry a marked calendar around is appealing, to say the least. It might also allow the recognition of a pattern in an otherwise seemingly random sequence. And even with a predictable cycle, other discernibly helpful patterns may become obvious. As one English singer put it: “When you are starting your period or you’re pre-menstrual, the hormones that rush around your body affect your larynx in ways that are detrimental to your singing voice. I use the app to avoid auditions, premieres or really important performances on those days if I can.” And, ‘The app also helps her identify connections with changes in her emotions, eating habits and headaches’.

So far, so good. As that English singer put it: “Being able to chart what happens to you and how you uniquely respond to your cycle is a great way of taking ownership of something that really sucks – but is completely necessary.” Perhaps the more you know about how unique you are (or aren’t) the more likely you are to feel in control –not simply a table of random numbers, a caster of dice… But there is a danger in relying too heavily on a reading and analysis of an app that merely calendarizes a menstrual cycle –especially an irregular one.

Yes, it is generally true that one usually ovulates about two weeks (or so) before the period starts, but each cycle has been exposed to a different set of conditions –stress, exercise, illness, and so on- so the rule is not reliable. Especially for contraception. The time period before ovulation (the follicular phase) while the egg is being readied in the follicle can be quite variable. If not using serial blood tests, or the like, one needs at least temperature charting and/or mucous testing to discover more reliably when ovulation has occurred… and then, of course, it’s probably too late to take precautions to avoid pregnancy.

The phase after ovulation (secretory phase) is also variable –although often less so- for a variety of reasons, so it won’t reliably predict the exact timing of an oncoming and expected period either.

The whole tracker app thing can be thought of as a digital rhythm method. And if you subscribe to that philosophy, a period tracker app may help you to remember when your last period started, so you can practice periodic abstinence. The Mayo Clinic suggests that with dedicated and consistent observance of this method, one might expect a failure rate of perhaps 13%. Although we all must decide what risk is acceptable given our circumstances, it does seem high in comparison with most other forms of contraception. And, ‘[…] the Royal College of Obstetricians and Gynaecologists has warned they [period tracking apps] should not be used as a form of contraception.’

Another thing that worries me about many of these apps –especially the downloadable free ones- is security of the information that you need to submit. As a privacy campaigner for medConfidential –a British privacy advocacy group- points out: ‘[…] if an app is free, consider whether you are paying for it in effect by giving away your data – and investigate where it might be going.’

With the blooming crop of digital savants, I suppose the posting of a cautionary list is merely an annoying Jeremiad from an older, and more naïve generation. And yet, there is more than a tittle of necessity to the reminders. Sometimes even the young need to step back and critically examine what they have come to believe is commonly accepted and practiced amongst their peers. The wisdom of the crowd differs markedly from the wisdom of the individual and although we may wish something to be so, as Plato observed: ‘Real knowledge is to know the extent of one’s ignorance.’

Or, put another way, with all due deference to the digital generation, Shakespeare’s immortal line in Julius Caesar: ‘Your wisdom is consumed in confidence’. Don’t let it be so…

 

 

 

 

 

 

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Pleasing Her: sexual evolution?

I came across an interesting article in the magazine Science a while back. I am always intrigued when a paper tries to place an issue in its ontological context, although I have to confess that the title had something to do with catching my eye. It was a scientific theory from seemingly reputable sources about the evolutionary significance of the female orgasm. http://www.sciencemag.org/news/2016/08/new-theory-suggests-female-orgasms-are-evolutionary-leftover  The article to which it refers is more detailed and helpful, but somewhat difficult to read; to get a more comprehensive description of the process however, I will include it here for reference: http://onlinelibrary.wiley.com/doi/10.1002/jez.b.22690/full

Orgasm is a topic that seldom surfaced through all the years of my gynaecologic practice; it was something that many women felt too embarrassed to mention –especially to a male doctor. It was also a subject that I felt ill-prepared to tackle –apart from standard psychological advice of dubious merit, the only benefit seemed to be that of a sympathetic, nonjudgmental hearing. Little was known about either the function or the physiology of orgasm, so advice about its production was more anecdotal than beneficial; it was therefore usually the purview of sexual dysfunction clinics rather than that of the general gynaecologist.

The only thing that seemed on a firm basis with regards to orgasm was that it was essential in males for sperm transfer. Clitoral stimulation is usually required for the production of female orgasm, and since the penis and clitoris share a homologous origin perhaps it was simply a fortuitous consequence of this –a secondary adaptation (exaptation) for the purposes of bonding, or the like.

But to place female orgasm on a more secure footing, the authors have looked at reproduction in other animals. ‘The essential condition for the success of internal fertilization is the timely maturation and release of the oocytes from the ovary into the female reproductive tract, that is, ovulation, for the egg to be accessible to sperm. These events need to be coordinated with the availability of males and favourable environmental conditions for raising the young.’ And for such, there are roughly three factors that might influence induction of ovulation in mammals: environmental –cues that suggest it would be a favourable time for successful rearing of offspring such as weather, food sources, etc.; copulation induction –only produce valuable eggs when they’re needed –i.e. when a mate is available; and spontaneous ovulation –no matter the availability of mate or suitable environment. Humans, it would seem, utilize the latter option –spontaneous ovulation.

In copulation-induced ovulation, a surge of two hormones in the female are required –prolactin, and to a lesser extent oxytocin. Interestingly, these are also produced during human female orgasm, although with spontaneous ovulation in humans, they are not specifically required. As the authors suggest: ‘The orgasm in women does not obviously contribute to the reproductive success, and surprisingly unreliably accompanies heterosexual intercourse. Two types of explanations have been proposed: one insisting on extant adaptive roles in reproduction, another explaining female orgasm as a byproduct of selection on male orgasm, which is crucial for sperm transfer.’ In other words, ‘Human female orgasm is associated with an endocrine surge similar to the copulatory surges in species with induced ovulation. We suggest that the homolog of human orgasm is the reflex that, ancestrally, induced ovulation. This reflex became superfluous with the evolution of spontaneous ovulation, potentially freeing female orgasm for other roles.’

There is another aspect of the study that fascinated me –something that had not registered despite my years as a gynaecologist: ‘With the evolution of spontaneous ovulation, clitoral stimulation lost its role in ensuring fertilization simultaneously with the removal of clitoris from the copulatory canal, likely causing a variable association between copulation and orgasms for the female.’

Think about it. Why would the homologue of something important for ovulation in some species, and so important for orgasm in ours have moved away from the action? The clitoris is now located quite a distance from the vagina and is only inadvertently stimulated with human heterosexual intercourse. I think the Science article expressed it well: ‘Humans and other primates don’t need intercourse to trigger ovulation—they evolved to a point where it happens on its own—but the hormonal changes accompanying intercourse persist and fuel the orgasms that make sex more enjoyable, the biologists hypothesize. And because those hormonal surges no longer confer a biological advantage, orgasms during intercourse may be lost in some women. This explanation “takes away a lot of stigma” of underwhelming sexual relations, says one of the authors, Mihaela Pavlićev, of Cincinnati Children’s Hospital in Ohio.’

And also: ‘Pavlićev and Wagner’s theory helps explain why female orgasms during intercourse are relatively rare. “It is new to use [this] innovative, Darwinian approach to understand one of the mysteries of human sexuality—why the male orgasm is warranted, easy-to-reach, and strictly related to reproduction and the female counterpart [is] absolutely not,” says Emmanuele Jannini, an endocrinologist at University of Rome Tor Vergata. The nonnecessity of orgasms for reproduction may also explain why women’s reproductive tracts vary a lot more than men’s—there are fewer constraints, he adds.’

I have to admit that this was all terra incognita to me. And a clarification and reassurance for those few women who confided concerns about their difficulties or even inability to achieve orgasm with heterosexual intercourse seemed impossible if it was supposed to be part of the process. Surely they weren’t all psychologically liable… So-called foreplay was clearly important –if only to stimulate both the clitoris as well as interest in the procedure- but was there something wrong with them if he couldn’t be persuaded?

Satisfactory sexual experience is clearly important and helps to provide the glue that bonds a relationship. But does the changed anatomy tell us anything? Might we be permitted a secular Darwinian postulate that pleasure may, after all, be divorced from the procreative imperative? A sort of anatomical excuse? Much can be done to wrap this in a more attractive package -the counselling of both partners as well as suggestions on technique- but at least from an evolutionary perspective that seeks to propagate our species, we’re doing just fine. Maybe too fine, in fact…