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 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.”
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.
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…”