The Mote in Thy Sister’s Eye

We all live in different worlds, don’t we? I suppose that’s what makes travel so interesting: to see how widely dissimilar regions and disparate societies recognize and deal with comparable problems. How, for example, they might attempt to solve the ever-growing dilemma of urban pollution. The Chinese, remember, shut down many polluting factories for part of the Olympics they hosted. It was a short term fix, to be sure, but the effects were visibly evident.

Activists, or even cities in other countries have attempted different, longer term solutions with varying success. A common one seems to be restricting the amount of vehicles on the roads, whether by licence number, type of vehicle, or on certain days of the week. The success depends on whether or not it strikes a chord in the society but, probably more importantly, whether or not it is voluntary or officially mandated. And by whom…

There is always the possibility of unintended, unforeseen consequences however bold and thoughtful the concept. Consider the deceptively simple idea of ‘car-free Tuesdays’ in Iran: http://www.bbc.com/news/world-middle-east-37430493 ‘[…] campaigners in Iran began marking “car-free Tuesdays” to encourage people to leave their cars at home in the hope of cutting down on pollution.’ The BBC article was reporting on a story in the Tehran Times, and I’ve included the link. ‘Tuesday was chosen because it is in the middle of Iranian week when traffic congestion is high and air pollution at peak.’

All well and good, even if unofficial and as yet unsanctioned, ‘the campaign was kicked off by Mohammad Bakhtiari, 25, who has majored in architecture and is a member of a local NGO with 1,000 members known as “the guardians of the environment of Arak city.’ It seemed like a good idea –it is a good idea- but there are issues… The idea was to encourage people to use alternate, less polluting forms of transportation –buses, or perhaps car-pooling, but especially bicycles to get around the city. Iran is a very conservatively run theocratic society, and women have long had to conform to various religiously mandated restrictions. And yet, ‘It had been understood women that [sic] could cycle as long as religious concerns were respected. But when asked recently, Iran’s Supreme Leader, Ali Khamenei, said women were not allowed to cycle in public or in the presence of strangers.’

Of course I’m not from Iran, nor do I even pretend to understand Islamic legal opinion, but I think that this fatwah –if such it is- involves a fair amount of cognitive dissonance even in a society that is used to seemingly arbitrary restrictions being imposed upon it. Presumably atmospheric pollution was not something anticipated in religious jurisprudence –it’s barely appreciated in civil law even today. A Fatwah, I’m given to understand however, is expected to break new ground –otherwise it might be considered simply a ruling –a considered opinion on the interpretation of existing writings. So I’m puzzled as to why, given the chance to become responsible caretakers of the Divine Creation which all religions purport to acknowledge, that the opportunity would not be seized and glorified. It might even go a long way towards mollifying some of the public antipathy about some of the more obviously capricious restrictions.

Just a thought, though… Why can’t women do their parts? If they adhere to religious codes of dress and conduct, aren’t they as much stewards as anybody else? Of course it’s now gone Twitter… And the social media campaign founder Masih Alinejad has said, “It is unacceptable in 2016 when you hear that a group of female cyclists have been arrested in Iran for the crime of riding a bike in a public place and made to sign a pledge promising they will not cycle in public again.” She is speaking out from the relative safety of New York, however. And I am writing from the relative safety of New Zealand… I ask myself why that should matter.

 

 

 

 

 

 

 

 

 

Acknowledging the Mind’s Eye

Sometimes, in the midst of a problem –in the midst of an era- the resolution derives not so much from the answer as from the acknowledgement that there is an issue to begin with. I find it interesting that Nature has given us an ability to adapt more efficiently -to ignore, I suppose- that which arises gradually than that which falls upon us as an event –interesting, because that allows us to discount something until it results in complications. Difficulties. It is the Janus view of evolution, I suppose.

An article in the BBC news alerted me to one novel approach to encourage acknowledgment of an issue that has plagued some societies for what seems to be millennia: sex selection –or perhaps, more honestly,  destruction:  www.bbc.com/news/world-asia-india-37034444

It got me thinking… We tend to cherish and preserve what we value; we neglect, or abandon that which we don’t. Denigrate it, even. Perhaps an occasional nudge in the ribs may cause us to look around and see where we have wandered –realize that there is really no need to stand so close to the edge.

But it does give one pause for thought –how do some of these things become imbedded in a culture? Surely they don’t start out as intentionally malevolent. Or is that being revisionist and unduly naïve? I’d like to think that some of the customs, however egregious we find them now, were products of a different time when other priorities required precedence. Confusing times, perhaps, when we barely knew who we were in our overarching need to identify and fend off them. Troubling times beneath the roiling waters in which we are just beginning to be able, however slowly, to surface for air.

And the problem, as always for those of us less afflicted, is acknowledgement –recognition that there is more to do. There is always more to do…

Despite being a gynaecologist for more years than I can remember, I suppose I have always lived in a man’s world. It’s hard not to wear the clothes you were assigned. And yet, every so often, that usually-locked door is knocked ajar briefly, and the light from within is blinding. Unintentionally heuristic.

I was sitting in a busy coffee shop recently and managed to find a tiny unoccupied table against a windowless and shadowed wall in the corner. Perhaps it camouflaged me -made my presence less noticeable, my gender less obtrusive- but as I sat there staring silently at the busy room, fragments of conversation from the next table floated past like dust motes in the feeble light. Two women were catching up on their lives. I didn’t mean to listen, but sometimes words are beacons: currents, vacuuming up the air between –meant to be heard, meant to inform. It’s hard to ignore words when you sit in shadows.

“And so how is Janice doing now?” a grey-haired woman in pigtails wearing black track pants and a yellow sweat shirt asked between gulps of coffee and grabs for the oversized chocolate cookies she had balanced precariously on her plate. She clearly had little need of more calories, but the presence of her more sizeable friend likely justified the debauch in her mind. It works for all of us, I think.

Her friend just shrugged amicably. “You know what it’s like, Dory,” she said, and launched into her bagel as if she were packing a box. “Kids are kids…”

Dory munched softly on a cookie and considered the issue. “She’s hardly a kid, now, Alice. She’s, what, seventeen?”

Alice nodded her head equally thoughtfully and her long dark hair slid back and forth over her shoulders like a wash cloth. Although considerable larger than her friend, she carried her weight gracefully, and with the gravitas that suggested a person of authority. Dressed in what seemed in the dim light to be an expensive white silk blouse I could make out little ruffs on each wrist. I don’t normally notice such things, but with each movement of her arms, they risked coating themselves with cream cheese from an impertinent bagel, now lying in fragments in front of her. “Eighteen…” She took a delicate sip from her coffee and sat back on her chair as if the subject required a little more thought.

“Still, she should know where she’s headed by now…” Dory left the question of direction open, but her eyes betrayed her opinion. “I mean, who she is…” she added, italics begging for attention.

Alice sighed and leaned forward again to pack another item into her waiting mouth. “I think she’s always known.”

“And how about you?”

Alice smiled and nodded. “Some things a mother just knows, Dory.”

Dory was obviously trying to understand, but her confusion was apparent, even to accidental eyes watching from the shade. She shook her head, disapproval hovering over her like a cloud. “Did you ever to speak to her about it, Alice?”

Alice’s eyebrows both rose at the same time. “Whatever for, Dory?” she said, genuinely puzzled at the remark.

It caused Dory to sigh rather more loudly than necessary. “Well, I would have thought…”

Alice refurbished the smile she’d sacrificed to the bagel and leaned an elbow on the table. “Thought what?”

Dory straightened her back like a boxer ready to receive a blow. “Well… that…”

“That my daughter would think the same way as her mother? She learned the Theory of Mind when she was five, Dory.” Her friend visibly winced at that. “The world is different for each of us, Dor,” she said, reaching out and grasping Dory’s hand. “And the question should not be why, but rather, how can I best negotiate it…?”

Dory tried to smile, but even from the shadows I could see her lips twitching with the effort. “Do you think if…” But she was clearly too embarrassed to finish her thought –and anyway, I could see Alice shaking her head and squeezing her hand affectionately.

“Somethings just are, Dory. And my main duty as a mother is to help her to accept them.” She let go of Dory’s hand and picked up her coffee for a sip. “And to help others to accept her…”

“But…” There was a hint of helplessness in that one word.

“But what’s not to love, eh?” she said, glancing towards the door and standing up to wave at a smiling teenager gliding towards them like a boat about to dock. And then Janice waved back, just like anybody else…

Unquiet Meals

I suppose Age has blunted me –or at least made me suspicious of fads, curious about recent phenomena that wear the clothes of certainty, vogues that hitchhike on the backs of something else never meant to carry the weight… But one must not be caught rubbing the poor itch of one’s opinion, to paraphrase Shakespeare. One must seek either corroboration or refutation in equal measure; one must make the time and effort to critically analyze what one would fain discard. So it was with no little frisson of excitement that I read just such an attempt in the BBC News. Gluten allergy, and its social and physiological disguises, was the subject: http://www.bbc.com/news/magazine-37292174

I have never denied the existence of true gluten allergy, Celiac Disease. Its prevalence obviously varies with the group being measured, but it averages to around 1% of the population and is a true auto immune phenomenon where the body detects the presence of –in this case, gluten- and views it as hostile. It then produces some countermeasures –autoantibodies- which, in turn, can have effects on various organs, the small bowel often being the one that results in the diagnosis.

The existence of a non-celiac gluten sensitivity, however, is more controversial. Studies –including the one the BBC reported- seem to vacillate wildly, so I suppose it is merely another example of confirmation bias as to which one you choose to believe. Me? I remain skeptical, firmly encamped in the valley floor between the two hostile mountains that glare and threaten each other from a safe distance. And if some of my patients choose to avoid gluten in their diets, so be it -I’m an obstetrician/gynaecologist, not a dietary immunologist. But sometimes my concerns peek above the mischievous gluten dust.

You know, you can’t tell the gluten-free apostles from the gluten abusers in the average waiting room. I can’t, anyway. Geraldine looked, well, normal as she sat slouched in her chair in the corner. Although my day sheet said she was in her thirties, my eyes said forties. Her blond hair was streaked with silver –although nowadays that may just be a whim- but her face was folded into little wrinkles like previously crumpled paper that had been hurriedly smoothed. She was dressed in black jeans that belied any definite attempt at ironing for the appointment, and her oversized grey sweatshirt matched her face for creases. The very idea of needing to avoid gluten apostasy did not spring unbidden to mind, I have to admit.

And yet the sullen face that watched me as I extended my hand in greeting did suggest that Geraldine was unhappy with her referral. In my practice, this is usually an indication that the patient was hoping that, contrary to what they Googled, I would still turn out to be a female. Although I am quick to disavow them of this, I find it still takes a few minutes more to gain their trust.

Once she had reslouched herself in a decidedly less comfortable seat in my office, I brought up the note from her doctor on my computer screen. It was a one word note –not terribly unusual from this particular GP, but not terribly helpful, either: ‘IMPOSSIBLE’ it said in bolded and underlined capital letters –rather striking, really.

“So, Geraldine,” I said, feeling my way along my words, “how can I help you?”

She glared at me for a moment, and then withdrew her eyes to the safety of her lap. “Didn’t my GP tell you?” It was at once hostile yet tinged with resignation –as if the GP was simply passing a rather complicated buck onwards. As if I were only one more stop on the journey.

Her answer was so uncomfortable it caught me unprepared. “Well…”

“He just wanted to get rid of me…” she said, venom dripping from the corners of her mouth at first. But she thought about it for a moment and neutralized her face. “He never listens, anyway.”

I tried to smile –sometimes it works. “Listen to what, Geraldine?”

Her eyes rose quickly from her jeans, like two birds flushed from a bush. “He doesn’t believe in gluten,” she said, a little too quietly for me to judge the temperature of the insinuation.

“How do you mean?” I walked right into it.

The cage door of her eyes flew open, and her mouth unlocked like Pandora’s box. “He refuses to believe that gluten is alive and flourishing in the world…” I’d heard similar words from religious acolytes proselytizing on street corners; maybe gluten was now another proxy for the devil.

“So…” I said, but before I could finish my thought –well, actually before I could even develop one, she interrupted.

“He doesn’t believe me. For years I was plagued with diarrhea and bloating so he sent me to a GI doctor who tested me but couldn’t find anything. All she could say was that it wasn’t Celiac Disease.” She stopped for air. “And now, whatever I tell my GP he just shrugs and says, it’s not the gluten.”

I pretended to type something on my computer screen, but I was just doodling.

“Anyway, I decided to cut out gluten in my diet, and the bloating stopped. The diarrhea stopped… But, then I started…” she added cryptically.

“Started what?” It wasn’t the most gynaecologically phrased question of which I am capable, I admit, but it was all I could think of in the moment.

Once again her face contracted like an animal about to spring. Or flee… “Started having sex!” she said, italicizing the last word. And then, mercifully, before I could gather my thoughts about why anything she’d had to say had anything to do with sex, she explained. “You can’t have sex when you’re bloated all the time, doctor! You can’t have sex when at any moment you might have to get up to go to the toilet!”

Okay, call me naïve, but I hadn’t thought of it quite like that before. It was a different world out there. “But eliminating the gluten in your diet helped, you said.”

She nodded her head vigorously. “I was a new woman.” She stared disconsolately out the window behind me for a second or two. “So I decided I’d better up my birth control method. I hate condoms and diaphragms… and I refuse to wear an IDU…”

“An IUD, you mean?” I said, attempting a gentle correction, but her eyes tried to ravage my face immediately.

“Whatever! So my GP put me on the pill!” she said, italics and contempt now mixing freely with the original venom on her lips.

“And…?”

“And I got bloating again, doctor!” Her eyes executed a predator roll somewhere near the ceiling before heading for me again. “So I did some computer research and discovered that the pills contained lactose and cellulose as fillers…” She folded her arms across her chest and waited to see what I thought of that.

“You’re wondering if they are code words for gluten, Geraldine?”

“Wondering?” she said between clenched teeth, the word only barely able to squeak through at the last moment. “Wondering?” she repeated more loudly and forcefully, articulating each syllable as if maybe I hadn’t heard her correctly the first time. “Are you another gluten atheist, doctor?” she asked scornfully.

“No, gluten exists, Geraldine,” I said, conscious of falling into her religious idiom. “But so do common side effects of the birth control pill.”

She tilted her head like a cat figuring out the best way to attack the mouse. “Nope, I know this was the same kind of bloating I got with the gluten.” Her fists clenched, daring me to contradict that.

But there was something about her face… “How long did you take the pill?”

She shrugged and then played around with her eyes, uncertain where to roost them. “A month maybe… And then I took them on and off for a while to see if they made a difference.”

“And…?”

Another shrug. “And yes, stopping them got rid of the bloating for a while.” She stopped and decided to stare at me. “And then it came back, even though I wasn’t taking them.” She took a deep breath and then sat up straighter on her chair. “I asked my GP if it could be some residual effects of the gluten and he decided to send me to you.”

“When was your last period, Geraldine?” Common things are commonest, eh?

A smile managed to crinkle its way onto her lips, and her eyes softened like sponges in water. Her expression turned almost mischievous. “I thought you’d never ask, doctor.” Even her voice, now, was pleasant.

“You’re pregnant?”

She nodded happily. “And it’s going to be a gluten-free pregnancy…” And then as a concession, “Is that all right with you?”

I smiled and nodded. No matter what I said, she’d do it anyway, so I thought it’d be safer to do it under supervision. “I’ll send you to a dietician to help you choose the proper foods for the pregnancy.”

She rolled her eyes again –but this time it looked more like a victory role. “Sorry about the theatrics, doctor –I just had to be sure where you stood on all this.” And then her face fell, if only just for a second. “Funny,” she added, “I thought you’d be more of a challenge…”

 

 

 

 

 

 

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…

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…

 

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…

 

 

 

 

 

 

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…