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.

 

Medical Revisionism

Words -that’s all they are: sounds that by their very presence magically communicate meaning. They are more than mere noise or background. They are not the wind rustling through the leaves, nor the sounds of a frog in a pond; in a way, they are entities that resolve uncertainty, and in as much as they can be interpreted, contain information. Data. So, in a sense, they transcend Time: the information in the words of an ancient document still exists. But information is subject to interpretation; the same data may be seen as having different meaning as time and societal norms change. But does that change the information conveyed? I think not.

I’ve covered this topic in previous blogs (for example: https://musingsonwomenshealth.wordpress.com/2013/11/01/whats-in-a-name-cancer/ ) but the topic is a source of continuing intrigue for me, so I was once again interested in seeing it broached in an article in the BBC News last fall: http://www.bbc.com/news/blogs-ouch-34385738  It seems we are constant and insatiable revisionists. It’s as if by changing the descriptor, we somehow alleviate the pejoration its ancestor accumulated. And yet the information remains; only the colour changes.

I suppose that this is useful, but I can’t help but wonder if there is some other way of doing it. Of course, some words seemed to have been coined originally with a belittling intent -Cripple springs to mind- and even without our penchant for viewing the machinations of history through modern eyes, the word is disparaging; it is simply not fair. It derives from the Old English word crypel which has the suggestion of creeping. It was a condition in clear need of a new term.

Other words were more naively-attempted descriptions –designations that were no doubt thought to help others picture what was being named. There was unlikely to have been any attempt at denigration -despite how they might now offend or upset us. Mongolism is one such term. According to the New Oxford American Dictionary:mongol, or Mongoloid, was adopted in the late 19th century to refer to a person with Down syndrome (named after John L. H. Down [1828–96], the English physician who first described it), owing to the similarity of some of the physical symptoms of the disorder with the normal facial characteristics of eastern Asian people. The syndrome itself was thus called mongolism.’ But the problem remains –what happens when the term ‘Down Syndrome’ itself also becomes offensive?

Sometimes, it seems to me, the words will also change for no apparent reason. Think of the various expression changes for sexual diseases over the years and the somewhat clumsy attempts to strip the prejudice out of them. When I first started medical school, the expression was ‘venereal disease’ –or VD. Then, when that became too pejorative, or at least discriminatory, it morphed into STD (‘sexually transmitted disease’), and currently STI for ‘sexually transmitted infection’… Or am I already out-of-date? The reason for any of these transformations, however, is totally beyond me.

Words, it seems –or maybe it’s me– just can’t keep up. Maybe, like Fashion, they’re bound to change because of user-boredom or a need for novelty, but I think it’s probably deeper than that. I suspect that it relates more to societal attitudes than societal ennui. And I think that it may be a lost cause to expect consistency of usage. As we change our approach to issues and our opinions, so we change our words to describe them. It starts off with the more curmudgeonly amongst us –usually those for whom tradition provides a stable and secure platform- proclaiming the changes to be ‘political correctness’- to use the current phrase. But then, gradually, sometimes imperceptibly, the expression achieves a common parlance and not using it courts sideways glances, or even incomprehension. It is, perhaps, an aurally measurable example of society’s changing attitudes, if not its mores.

My biggest complaint, however –although minor in the scheme of things- is that it seems a waste of perfectly good words. One of my favourite ones ‘awe’ and its brother ‘awesome’ which used to bespeak a form of reverence, was ripped from my useful vocabulary only a few years ago and I’ve never really gotten over it. The words now have little value -they’re the scrapings from a different, grander time. Crumbs. Leftovers.

I am reminded of the words of Moth, the page of the soldier Don Armado in Love’s Labour’s Lost by Shakespeare: ‘They have been at a great feast of languages, and stol’n the scraps.’ 

A Medical Dilemma

Here’s an outrageous assertion: there are some things that we just cannot control. Worse, sometimes they are undefineable – or at least so vague as to defy placing them on some scale or other. Ranking them in terms of importance either to us, or to others. Naming them for future reference. And if we cannot even assign a name, categorization is slippery, too.

All of us experience these uncontrollables. Sometimes we are suddenly enveloped –a fog that obscures direction so completely that we are lost, abandoned in a terrifying limbo- but as often, we wade in from familiar territory until, over our depth, we panic.

Doctors, among others, seem to gather these fractious elements like apples in a basket we scarcely notice we are carrying. Its not that we are incompetent –although circumstances often determine competency, don’t they? It is that situations pile up like obstacles -and detours, of necessity, require changes in direction. Unintended changes. Routes that, until they are explored and charted, make regaining the original destination difficult, if not time consuming.

A recent example from my practice: suppose, for a moment, you are a gynaecologist who has been referred a young woman with a benign tumour, a uterine fibroid, say. Even though fibroids –benign overgrowths of uterine muscle tissue- are fairly common in middle age, fibroids of significant size are unusual in young women. You are reassured by many factors in your investigations thus far, however: the ultrasound appearance, the blood tests measuring tumour markers, and her general good health. She has no pain; she has no symptoms, and the fibroid is small -only 1 cm in diameter. And, as important, a clinical examination does not hint of cancer, or demonstrate a lack of mobility of the lump in her pelvis that might indicate malignant attachments. She has simply been plucked from the realm everyday existence by a test done for something else but which found a tiny mass on her uterus.

She is barely out of her teens and as yet unattached, but dreams of a relationship and children –the proverbial girl next door. Her life has been turned upside down in an instant, and intimations of mortality that should not be collecting outside her door for years are suddenly apparent -a tree branch scratching her window in the night.

You discuss the features of fibroids, show her what she has on a diagram, then answer her questions and attempt to calm her down. Finally, after considering all the factors in her case, you speak to her of what you would recommend: observation and reassessment with another ultrasound in 6 months. Perhaps sooner if she develops any symptoms –pressure, or pain with sex, for example.

But she is worried, and all of your explanations have only served to reify the alien lump, hitherto hidden and unnoticed. It is real for her now, and it shouldn’t be there. The fact that her mother required a hysterectomy for them in her forties after years of heavy periods and pelvic pressure, has always weighed heavily on her.

You put down your pen, and listen as she tells you how she has researched the various therapeutic options online. You have already discussed them, of course, but have counselled against their use because of the small size of the lump. She smiles at you, because she agrees she is not a candidate. No, she wants the lump surgically removed –a myomectomy- before it gets too big. Before it causes symptoms. Before it interferes with becoming pregnant.

It is always difficult to disagree with a thoughtful person who presents her arguments in a cogent and reasonable fashion, but one always has to help the patient weigh the risks and the benefits more objectively. More contextually. Especially when you feel that surgery is not indicated. There are risks to surgery –major risks. Risks that are obviously assimilable under certain circumstances, but in your expert judgment, not hers. Fibroids grow slowly, so there is certainly time to consider less invasive options. Some sort of a compromise is in order.

You attempt to do this, to help her stand back and consider her request within the landscape of her actual needs. You try to help her to separate her concerns about the fibroids her mother had to have treated when she was much older, and her own situation.

But she is adamant. It can be done laparoscopically –belly-button surgery- so she will not even need much time off school, she points out.

When you still are hesitant, she breaks down in tears and heads for the door, sobbing. You relent and say you are willing to refer her for a second opinion, secretly hoping the other surgeon will be able to convince her to wait. But she is not listening any more; you have failed her.

But have you? At what point can failure be assigned? Does a reluctance to acquiesce to demands which are predicated on fear and misunderstanding constitute failure? Or is failure actually the opposite: going against your considered judgment to please the patient?

Years ago, I saw a very similar person –the daughter of a doctor in another part of the country she immediately informed me. She was adamant about wanting surgery –felt she was entitled to it, in fact. And encapsulated in the trappings of my recent specialist status, I was equally certain of my opposition to it. She was quite verbally abusive to me when I wouldn’t change my mind and also walked out of the office, but not in tears… She had a smirk on her face.

She was a heavy woman, a smoker, and although in her twenties, not in the best of health. We weren’t doing many difficult laparoscopies in those days, so any surgery would have required a large incision –her abdomen was obese and pendulous- and several days in hospital to recover. In her case the fibroid was only 2 cm in diameter –still small. Still observable over time.

I was puzzled by the expression on her face until I learned from my secretary that she was actually scheduled for a myomectomy with another surgeon in another town –but not for a month or two. She had been hoping I could schedule it sooner in my hospital.

I felt guilty, although I couldn’t really understand why. She was a poor operative risk despite her age, and the surgery was unnecessary anyway. I wondered whether I had made the correct decision, or whether I had been unduly influenced by her being rude to me when I’d tried to present the reasons for my opinion. Had pride clouded my judgement? Had she been right all along?

So, did I fail her? Or did the other surgeon? Were we both manipulated?

There is a condition called pulmonary embolism that occurs when a clot formed in a vein breaks free of its source and travels to the lungs to obstruct the blood supply. Some factors increase the risk of forming clots –major surgery, obesity, smoking, immobility… An embolus can kill if not treated immediately. Nowadays, we recognize these risks more readily and will prophylactically employ anticoagulation –blood thinners- to decrease the likelihood of clot formation. We ambulate patients more quickly and educate them about the risks.

In those days, I think we were more concerned with the risks of anticoagulation –bleeding internally, for example- than we are today. And so, especially in the non-teaching hospitals in small towns, prophylactic anticoagulation was not a routine standard of care. In fact, it was usually only considered in patients with more extreme and identifiable risks –cancers, for example. The regimens and even the choices of medication were limited then; surgeons were rightly as afraid of the treatment as of what it prevented. Risks had to be balanced. Managed.

I mention pulmonary embolus, because that patient died from one. I only found out weeks later when the surgeon phoned me after he discovered my consultation letter that the referring GP had forwarded to him. He was devastated, as were we all.

It’s easy to be revisionist in retrospect –especially years hence when protocols have changed, not to mention knowledge and available medications. We see the world through modern lenses and judge in the light of current knowledge. Things change. It was –and is- a tragedy that it happened. And it’s a burden which that family –and that surgeon- will carry forever. But in fairness, how critical can we be? Should we be? The assimilability of risks varies over time and things we might consider preventable nowadays, were understandably viewed differently then. Not only do things change, things happen.

Hopefully we learn from them.