Gender and Stress

Even the most ardent proponents of gender parity will admit that equality of opportunity does not imply equality of physiology. ‘The worst form of inequality is to try to make unequal things equal,’ as Aristotle said. Homogeneous –likeness, if you will- is not necessarily homogenous (a biological term meaning structurally similar due to common ancestry). Admittedly a semantically fraught distinction, it nonetheless suggests that there may well be differences that do not transcend gender.

For example, there seems to be a sexual discrepancy in the acquisition of post-traumatic stress disorder (PTSD)  http://www.bbc.com/news/health-37936514 -women tend to be more vulnerable to its development than men. A research team from Stanford University published a study in Depression and Anxiety (the official journal of the Anxiety and Depression Association of America) and it suggests that ‘[…] girls who develop PTSD may actually be suffering from a faster than normal ageing of one part of the insula – an area of the brain which processes feelings and pain. […]the insula, was found to be particularly small in girls who had suffered trauma. But in traumatized boys, the insula was larger than usual. This could explain why girls are more likely than boys to develop post-traumatic stress disorder (PTSD), the researchers said. The insula, or insular cortex, is a diverse and complex area, located deep within the brain which has many connections. As well as processing emotions, it plays an important role in detecting cues from other parts of the body. […]This shows that the insula is changed by exposure to acute or long-term stress and plays a key role in the development of PTSD.’ And as I quoted, the changes seem to be different in the two sexes.

The point of all this somewhat detailed background, is to submit that, as the study suggests, ‘it is possible that boys and girls could exhibit different trauma symptoms and that they might benefit from different approaches to treatment.’ Perhaps a sensitive counsellor would recognize this as the sessions continued, but it’s helpful to have some corroboratory evidence to justify any proposed changes.

I have to say that I was woefully ignorant of any sex difference in the development of PTSD. I’m embarrassed to admit that, if anything, I thought of it as largely a male condition –perhaps because of its association with war, and combat -traditionally at least, arenas of male predominance. But of course that is naïve. PTSD is not something confined to combat; it can be equally prevalent in other situations of distress or upheaval. Trauma is trauma, and long term issues can result from such things as natural disasters, car crashes, and certainly sexual or physical assaults, to name only a few. Because the symptoms can be confusing or even disguised, the diagnosis is best left to qualified practitioners, and yet I can’t help but wonder if a greater and more sensitive awareness of the possibility of the condition might encourage more sufferers to seek professional help.

As a gynaecologist, I feel uncomfortable and indeed far out of my depth in discussing most issues pertaining to PTSD, and yet thinking back over my years in practice, it seems to me that I may have suspected something of the sort, but lacked both the vocabulary and training to assign it a label –especially in those women I saw for conditions they suspected may have been attributable to previous sexual abuse: fears that they occasionally admitted to re-experiencing in unrelated events; things about which they still had nightmares; situations that led to unprovoked irritability and anger.

PTSD, by whatever name, has no doubt afflicted humans from time immemorial. Male hubris dictated that it be disguised or denied no doubt –it was a sign of weakness- and therefore unlikely to be mentioned in contemporary accounts. But signs of its presence occasionally snuck into mainstream literature -Shakespeare’s Henry IV being a likely candidate, for example. Perhaps more germane to my specialty, however, was the recognition of the lasting effects of trauma on people other than those involved in traditional conflict: women. The US Department of Veteran’s Affairs in its National Center for PTSD pamphlet states: ‘Most early information on trauma and PTSD came from studies of male Veterans, mostly Vietnam Veterans. Researchers began to study the effects of sexual assault and found that women’s reactions were similar to male combat Veterans. Women’s experiences of trauma can also cause PTSD.’ In fact they maintain that ‘The most common trauma for women is sexual assault or child sexual abuse.’ http://www.ptsd.va.gov/public/PTSD-overview/women/women-trauma-and-ptsd.asp

For too long have the lasting effects of sexual assault been ignored, or at best, trivialized and examined through male eyes in a still-male world. I don’t mean to sound like an overzealous feminist who pins all problems on male dominance, but I think age and a career spent in women’s health grants me a unique –if still masculine- perspective. As with all things, specialists run the risk of deconstruction, overanalyzing the events often with the consequent subversion of their apparent significance -almost a form of historical revisionism, an unintentionally biased and often contextually barren interpretation. One bridge, when crossed by a thousand people, becomes a thousand bridges –we all see the world through our own experiences, our own expectations, our own prejudices.

I think the fact that we can now demonstrate that there are valid reasons to question those often unconscious assumptions is a cause for hope. Much as we have finally realized that the results of many studies carried out only using men cannot necessarily be mindlessly extrapolated to women, so it is becoming increasingly apparent that trauma and its effects may also be non-generalizable. Although not its prisoners, we are after all, creatures of a chromosomal lottery, divergent physiologies, and certainly of different past experiences, so why wouldn’t there be a spectrum of responses to stress?

So, is there a ‘man-cold’? Well, maybe… I know that’s the kind I get, anyway.

 

 

 

 

 

 

 

 

 

 

 

Folk wisdom sometimes gets it right: there is a man-cold… Well, maybe.

 

Forget it?

Memories are tricky things. Sometimes they’re not around when you want them, only to arrive later, when you don’t; sometimes they surround you, pester you, like wasps at a picnic. And other times you can’t find them at all no matter where you look. But the really tricky ones are those that never happened and yet they stand up and wave at you from the crowd as if they’ve known you for years. Sometimes they convince you…

The idea of false memories –or let’s be kind… mistaken memories- is not a new one, but several well-publicized instances recently have brought it to public attention. In the age of social media, of course, the cases are instant hits. Take the hyper-publicized example of Brian Williams, the popular NBC news anchor who claimed he remembered being shot down in a helicopter in Iraq 12 years ago. When this was disputed by veterans at the scene, he was forced to step down from his job. http://www.bbc.com/news/world-us-canada-31220600

Because most of feel we can rely on our own memories, the feeling was that he had obviously lied –perhaps to enhance his own role and bravery in the combat, or because of the notorious ‘fog of war’ –that state of confusion that arises in states of extreme stress and chaos on a battlefield.

So which was it? Fog, or lie? Or maybe post traumatic stress disorder (PTSD)? Well, the matter is more complicated than it might seem on the surface. There has been a lot of work done on ‘false memories’ of late –how and why they form. For example: https://blogs.brown.edu/recoveredmemory/files/2015/05/Loftus_Pickrell_PA_95.pdf  Memories, as one of the psychologists explained, are not like videos recorded on a DVD –the same pictures, the same information each time you play them. They are more like the material on Wikipedia –able to be modified or even changed completely depending on the need or as a result of any new information that might come along. They are, in a word, mutable. Unreliable.

And yet, unconfronted, the memories seem infallible and in most of our experience it seems counterintuitive that they would be otherwise. After all, why have memories if we can’t rely on them? I suppose the simplest explanation is that if we remembered everything that happened throughout the average day –let alone a lifetime- there would be insufficient storage to say the least. Our brains must pick and choose relevance, perhaps adding or subtracting things for efficiency or continuity as information and situations change… It used to be termed ‘retrospective falsification of memory’. Or, as the authors of the above mentioned paper describe it: ‘Relatively modern research on interference theory has focussed primarily on retroactive interference effects. After receipt of new information that is misleading in some ways, people make errors when they report what they saw. The new post-event information often becomes incorporated into the recollection, supplementing or altering it, sometimes in dramatic ways. New information invades us, like a Trojan horse, precisely because we do not detect its influence.’

This type of situation is certainly not unknown in the medicolegal kingdom. In the course of frightening and unexpected events, there is sometimes a variation of perception –especially if the event is associated with injury or seems to be the result of negligence or incompetance. Totally understandable, obviously, and yet there are often variations of what actually occurred that are remembered.

But the issues are not always of putative malfeasance. Sometimes they have a more personal tone.

I hadn’t seen Joanna for several years, the computer said. I have to admit that nothing about her was familiar. I had no record of seeing her for the pregnancy, but apparently I’d delivered her baby so I must have been on call for consultations that day for my colleagues. She’d not come back for a post partum check, so I assumed she had simply gone back to her regular doctor or midwife. And now, six or seven years later, she was sitting in the waiting room staring at the wall. She didn’t look at all happy to be there. The referral letter said she just wished to talk about a problem. Referral letters are not always helpful…

I smiled at her as I crossed the carpet to where she was sitting and extended my hand. The one that reached out to me was sweating, limp, and tentative –as if, given a choice and not witnessed by the others in the room, it would have stayed rooted in her pocket. Joanna was a small woman with short, tightly curled black hair, held in place by a yellow ribbon so tightly wound around her forehead that the skin in the immediate vicinity seemed blotched and ill. I wondered for a moment if that was why she didn’t return my smile –she couldn’t. It only let her frown.

In the office, she sat in the uncomfortable captain’s chair across from me like a post with knots for eyes. They didn’t move, but instead seemed fixated on something half way across the desk. I tried to put her at ease by asking her how she was but was met with a wooden silence; not so much as a splinter moved. I let the silence lie fallow for what seemed an eternity and then, feeling her anger, asked her as gently as I could, why she’d come back to see me after all these years.

The knots on her face moved upwards a few degrees, and the post shivered. “This is not easy for me, doctor. I didn’t want to come, but my family doctor said I should talk about it with you…”

I leaned my forearms on the desk to show I was listening, and asked her what she wanted to talk about.

She sighed and shifted uneasily in her chair. Suddenly the knots became eyes and they stared at me like the barrels of two guns. Her face tightened and her jaw clenched for a moment. “The delivery!”

I waited, but she remained silent. I wasn’t sure what she wanted me to say. I couldn’t remember it at all, although my secretary had been able to get the delivery note I’d dictated. I skimmed through it quickly, but apart from a ten pound baby and a vaginal tear as she apparently pushed it out before I could control it, I could find nothing else. “Was there something about the delivery you wanted to ask me?” I said when it was clear she was waiting for me to comment on it.

Her eyes grew larger and angrier. “The forceps! I told you I didn’t want forceps! My first baby was large and I didn’t need them for her…” She was almost shouting and little strands of saliva escaped with every word. “I told you..! And then because of the forceps, I got that tear in my vagina that took weeks to heal. We couldn’t have sex for almost 2 months!” Suddenly, tears appeared and ran down her cheeks. “I told you I didn’t want you to use forceps! I told you… But you wouldn’t listen. You kept telling me the baby’s heart was too low and she had to be delivered right away.”

I could see her clenching and unclenching her fists as she talked. “My secretary has managed to find the report I dictated on the delivery. I’m sorry I don’t remember more, but let me read it again…”

“I’ll bet you don’t remember it!” she said between clenched teeth. “The nurses told me about you before my midwife consulted you. Apparently you like forceps and are pretty good at it…” She shook her head sadly and looked at her lap for a moment. “But I told you I didn’t want forceps and yet you went ahead and used them on me!”

I pulled up the delivery report and read it carefully. I’d been exceptionally detailed in my dictation that night, so perhaps I had been concerned that the baby’s condition might have warranted it. I’d been called by her midwife in the middle of the night because she had been pushing for three and a half hours without much progress. The head was not coming down the vaginal canal and the baby’s heart rate was beginning to show signs of distress. I had examined her, explained the situation, and then told her the options: continue to push, although I didn’t recommend this because she hadn’t made any progress after all that time, and the baby’s heart rate was beginning to show decelerations indicative of distress; caesarian section; or trial of forceps (a concept meaning if the forceps weren’t successful after a reasonable try, that caesarian section would be the fall-back option.) She hadn’t wanted a Caesarian, so I’d asked the nurse to get the forceps ready –just in case. Then, when the nurse had entered the room with the forceps, Joanna had become angry and said she would not accept forceps for delivery.

There followed a sudden, profound, and prolonged fetal heart rate deceleration and something had to be done to help the baby right away. The situation demanded an immediate judgment call, and that meant the forceps. But just as I was reaching for them, she gave a mighty push and delivered the baby. Unfortunately I’d been unable to control the head on such unexpectedly short notice, so she’d sustained a vaginal tear. It hadn’t been terribly large, and I’d been able repair it without much difficulty. Baby seemed fine, and there were smiles all around.

As I was finishing reading the report, I could hear her voice repeating again and again “Why did you use the forceps, doctor. I told you not to use them…”

I forced a smile. “I didn’t, Joanna. The baby was in trouble and I needed to get her out quickly, but I didn’t get a chance to use them. You pushed her out as I was turning to get them ready.”

“But I heard them! I heard them clanking…”

Forceps are metal and as the two sides are assembled they often make a metallic clanking noise. (They superficially resemble salad tongs, although unlike tongs, they don’t actually squeeze the head in anything like the same way. They fit more like a helmet over the head and guide it down the vaginal canal like a dilating wedge in front.) I shrugged politely. “It was an emergency for the baby. She needed to be delivered right away, so I was probably getting them ready when you had that really strong push.” I chuckled at something and she stared at me. “Sometimes I think that just the threat of using them is as good as using them. Nothing motivates stronger pushing than clanking the forceps!”

First I saw her teeth and then a smile worked its way slowly into the space around them. “But I distinctly remember you putting them on… I think…” Her eyes wandered to the window behind me for a moment. “Can I see your report?”

I smiled as much in relief as at the dissolution of the tension in the room. “Of course.” I punched a couple of keys and the report chugged its way out of the printer. I handed it to her and sat back while she read it. Actually, she must have read it several times, each time shaking her head in steadily diminishing disbelief. Finally she folded it up and put it in her purse. “All this time…” Her eyes sought mine and I could see they had softened from birds of prey, to… the prey itself. “But I remembered it so differently…”

“Would you like me to see if I can get a hold of the nurses reports as well?”

A large, genuine grin spread across her head dividing her eyes from her chin as she shook her head a final time. “I’m so sorry, doctor… All this time…” Suddenly a thought occurred to her. “Tell me one thing, though.” She tore her eyes away mischievously and they flitted briefly about the room. “Were you wearing an earring that night?”

I must admit I blushed at the question and nodded my head. “It was a phase,” I added quietly.

She giggled and reached for my hand. “Well at least my memory didn’t screw everything up…”

PTSD in Gynaecology?

Post Traumatic Stress Disorder (or PTSD) is an anxiety disorder caused by being exposed to a traumatic or frightening event. It has been described in various guises since antiquity: http://www.bbc.com/news/health-30957719, but although we have traditionally ascribed it to military veterans, it is by no means confined to those who have been in the midst of battle. Paramedics, police officers, and various other sorts of first-responders are also exposed to frightening and traumatic events. The DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders) has even allowed a variant for those emergency workers even if they are only exposed to disturbing videos in the conduct of their jobs.

So I suppose it should not come as too much of a surprise that someone would take the leap and wonder whether the public, exposed as we all are to social media, would be at risk as well: http://www.bps.org.uk/news/viewing-violent-news-social-media-can-cause-trauma   There followed the usual offence at what seemed like an attempt to demean the diagnosis of PTSD in those felt more worthy of its acquisition, and in conditions far more important and deserving, but nonetheless there is a spectrum of manifestation inherent in most diagnoses.

The BBC posted a helpful primer on PTSD http://www.bbc.com/news/health-26867615 but in brief, the diagnosis requires: flashbacks to the event, avoidance behavior, sleep disturbance, and mood changes.

I have to say I was skeptical that we should even consider that anything found on social media could have such an important impact that could in any way be considered PTSD –however attenuated. It seemed almost an insult, a belittling of those who had undergone real trauma. Until, that is, I remembered Lucille.

She was a young lady visiting from another province who had been sent to me for a second opinion from the emergency department at the hospital across the street. Her problem was abdominal pain –chronic and unexplainable pain in the pelvic region, for which she had been thoroughly investigated elsewhere with ultrasounds, CT scans, an MRI and even –no doubt in desperation- a laparoscopy four or five years ago to view the area more directly. And all, said the accompanying note, were normal.

She was not what I was expecting; rather than an anxious woman sitting quietly in the waiting room with her face locked in pain, instead I found a smiling, smartly dressed young lady happily talking to the pregnant woman in the seat beside her. She smiled when I walked over and immediately extended her hand for me to shake.

“I’m so happy you could see me on such short notice,” she said as I led her down the corridor to my office. And she did indeed seem cheerful and, well, normal as she seated herself across from my desk by the window. “What a wonderful view of the ocean from here,” she almost purred, staring past the buildings and traffic at the almost-invisible water far in the distance. “Vancouver is such a wonderful city…”

I sensed her cheer was other than completely genuine, as her words wound down and slowed. Sometimes, with chronic conditions like pain, I like to wait until the patient is ready to speak -unprovoked, as it were. Unencumbered by a line of questioning known all too well to her that leads… nowhere. She was silent for a while as she turned her attention to the office itself, her eyes alighting like sparrows first on a painting on the wall, then on a wooden carving from Ethiopia I had placed on the desk so it looked out between the leaves of a plant. They stopped no place for long, revisiting their favoured twigs almost at random.

“Offices are all different, aren’t they?” I said, to begin the conversation.

She nodded thoughtfully. “I suspect they reveal a lot about the doctors…”

“And the patients who notice.” It provoked another smile.

Her face became serious –a major change. “Look, I don’t want to waste your time, doctor. I’m certainly grateful you could see me, but maybe I should wait until I get back to Ontario to get it checked out.”

“It..?” She looked down at her lap, as if the little sparrows were tired of flitting about. “The note from the ER said you were having some pain… Care to tell me a bit about it?”

She still seemed reluctant to look up. “Oh, I get these pains every now and then. No big deal, though.”

She risked a glance and I immediately seized the opportunity. “Well, suppose I just take a brief history and then if you feel you want to wait till you get back to Ontario, I can fill your doctor in as to what happened while you were here in paradise.”

She nodded her assent and for the first time, her eyes didn’t flee from my face. Was it hope? Or merely resignation that it was beginning again?

We all expect that we will be able to find the treasure where nobody has succeeded before, but the only thing I could discover in her history that might be remotely related to her pain was an episode of Chlamydia –a sexually transmitted condition- several years before. It had been treated and subsequent cultures had demonstrated cure. “When did the pain start?” I asked, almost as an afterthought, but I think she could see through my strategy.

The memory seemed uncomfortable to her, and she looked out the window again.

After an awkward moment of fidgetting silence, I said, “Sexual diseases are always difficult to talk about, I think…”

“My friend didn’t think so,” she suddenly blurted out before I could even finish my poorly worded attempt to console her. “She got an STI and had to be hospitalized when it spread through her abdomen… They even had to operate to remove the pus. She sent me a picture of her tubes they took during the operation…” She looked as if she were about to cry, but grabbed a tissue from the desk and dabbed her eyes to recover. She lapsed into a morose silence and turned her head so she could see the door.

“You know, I’d been fond of the guy who gave it to me; I’d gone out with him for a couple of years… And yes we used condoms!” She stabbed me with a sudden glare and turned her head away again. “I did everything right, but I still got it.” She sighed heavily and stared at her lap again. “I mean, how do I know I don’t still have it -but without symptoms? Or that I haven’t gotten it again from somebody?” Her hands were nervously clasping and unclasping. “They did a laparoscopy shortly after the infection and it was normal, but that was years ago…”

The time for my questions was over; I let her talk.

“I read that PID [pelvic inflammatory disease] can be silent after an infection and the damage can be going on even without symptoms…” She considered that for a second or two. “I suppose I twisted my doctor’s arm to do the laparoscopy. But anyway, she didn’t find anything. Nothing abnormal.” Another sigh. But my girlfriend kept warning me about it, so of course I read as much about it as I could online. I even looked at videos of operations for PID…” Her eyes teared up immediately. “I couldn’t stop looking at them,” she managed to whisper between sobs. “They were terrible! Frightening: great slimy fat tubes stuck to bowels and everything… And in some of the videos, when they tried to dissect them, there was blood everywhere! And pus oozing out of dark little spaces the tubes had walled off…” She considered the implications of what she’d said and closed her eyes briefly. Hid behind her face. “I’ve hardly had sex since that Email and I’m never going to trust anybody again,” she blurted out abruptly with her fists clenched. “I mean I keep thinking about those videos; I wake up in the middle of the night, and there they are, running through my mind!”

She stared at my face for a second. “You think I’m stupid for watching all those videos, don’t you?” she yelled at me. “But I couldn’t help it! I just knew that it was going on inside of me: big fat greasy sausages filled with sticky white ooze..!” And then, just as suddenly she stood up and pinned me to the wall with venomed eyes. “You’re the same as all the rest, you know. And I know you don’t believe me!”

She turned and walked to the door. “And don’t bother sending anything to my doctor in Ontario, either. I’m gonna find another one.”

She disappeared through the door leaving me wondering how I could have handled things differently. But in a moment a head poked around the door again –but only briefly. Awkwardly. “I’m sorry doctor… You’re really great! Honestly.” And then it disappeared into whatever hellish world it was forced to inhabit.

Did she have PTSD? A variation of it somewhere on the spectrum? Or was she just embarrassed that she’d disclosed so much to a stranger? I suppose I’ll never know, but I hope that somebody, somewhere, takes her seriously. She, just like anybody else with PTSD has a life to live. Deserves to live.