Bedside Manners

With the new PBS Frontline documentary Hunting the Nightmare Bacteria premiering this week, I hope that the American public is finally becoming aware of what many in the U.S. and around the world have seen coming for years.  I encourage readers to check out the film and the links available online through PBS. However, I feel ethically bound to issue a ‘trigger warning’ for those who do not want to view a child and young adult being ravaged by diabolical infections.

Are we ready for the post-antibiotic era?  Supposedly, we were all alerted last March when the CDC sounded an alarm – “Action needed now to halt spread of deadly bacteria” – but how many of us heard it?

We’re still in the dark when it comes to nightmare bacteria.  At this point, I’m less convinced that anyone is “hunting” these antibiotic-resistant bacteria and more convinced that these microorganisms are hunting us.  We need to be on the defensive, taking steps to protect ourselves, our loved ones, and our society.

Reading the PBS documentary’s link to “Eight Ways to Protect Yourself from Superbugs,” I found tips that are not new but are important reminders for public health.  I’m a big believer in their recommendation to question the necessity and effectiveness of all prescriptions of antibiotics (e.g., that they cannot cure viral illnesses).  That said,  I’m sad that we still need to teach people how to properly wash their hands, and I’m even more dismayed that we have to recommend that everyone asks their medical providers to wash their hands.  Unfortunately, promoting hand-washing is only a small improvement when proper drying methods are unavailable: studies continue to show that air hand dryers add more bacteria to clean hands.

In the documentary, Arjun Srinivasan, M.D., Associate Director of CDC, warns, “…the more antibiotics we put into people, we put into the environment, the more opportunities we create for these bacteria to become resistant….”  However, the environmental components – government funding for research and surveillance, public health policies, and medical norms – are not fully addressed by this film.  In addition, the causal link to meat and poultry policies/practices is completely absent.  As a medical sociologist, my critique of this documentary is that it spends a lot of time on horrific case studies and too little time on the structural and social causes, consequences, and solutions to this crisis.

For a more complete picture, see the CDC’s report with graphics that illustrate the dynamics of drug resistance.  I was stunned by chilling estimates: annually, antibiotic resistance will cause over 2 million Americans to become ill and will result in at least 23,000 deaths.  In the early years of the HIV/AIDS epidemic, activists rallied public support and political action with the message that “Silence Equals Death” – what message will wake up Americans to the realities of our new nightmare?

This month’s guest column* by Tristan Bridges, Ph.D., deals  with a recent research publication on a correlation between testicle size and nurturing instincts/behaviors in men.  Bridges, a sociologist at The College at Brockport, State University of New York, is currently working on a project dealing with the meanings of “man caves” in contemporary U.S. households.

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So…I’m going to go ahead and say that this is the wrong question to be asking. This question proceeds from a belief that testicles CAN tell us something about dads. A new study is making the rounds in the news that addresses the relationship between testicle size and parenting behavior among men (well… 70 men… not randomly sampled…). The paper is entitled “Testicular Volume is Inversely Correlated with Nurturing-Related Brain Activity in Human Fathers” in the Proceedings of the National Academy of Sciences of the United States of America. I can think of more than a few titles that might have been catchier (and clearly, journalists reporting on the research had a similar idea).

In fairness, I don’t have access to the complete study (though I’ve requested it). But the problem is also in how this study gains attention in the media. It’s a great example of how a correlation combined with cultural stereotypes and assumptions can run wild. When correlations combine with popular stereotypes concerning a particular topic (like, say, the relationship between testosterone and any number of socially undesirable behaviors), questions about the science sometimes get lost because it looks like something was “scientifically proven” that we already wanted to believe anyway.

So, here’s the relationship the researchers found: men with smaller testicles tested more positively for nurturance-related responses in their brains when shown pictures of their children. The study reports that men with smaller testicles had roughly three times the level of brain activity in the area of the brain associated with nurturing. These men (with smaller testicles) were also men with lower levels of testosterone—something that has previously been shown to be associated with nurturing behavior among men.*

Side Note: Just for fun, I’d love to know how to measure testicular size. Is it a measure of circumference (in which case I’d want to know: width or height)? Is it a measure of total tissue volume? And, how is the measurement taken? There’s probably a great “How many grad students does it take to….?” joke in here somewhere. But, I’ll rise above the temptation.

The researchers, then, have found a correlation between nurturing-related brain activity and testicular volume (and, to be fair, this is right in their title). But, off the top of my head, I can think of more than a few ways of explaining this correlation differently than they have. And, if you’re not up on your research methods, a correlation simply means that two (or more) trends, variables, etc. can be shown to vary together. So, age an income might be an example. But proving that one variable or trend is actually causing another is more difficult. To prove a causal relationship, you need three things (to convince the scientists anyway):

1. Correlation—you’ve got to be able to show that the two things you’re saying have a relationship actually have a relationship with one another.
2. Time Order—you’ve got to be able to show that the thing you’re saying is “causing” the other thing happens prior to the change you’re claiming is “caused.”
3. Rule Out Other Possible Explanations—even when you’ve established a correlation and can show time order in a way that favors your interpretation of the relationship, you still have to consider alternative ways of explaining the same finding.

Okay, back to the testicles. So, the study shows a correlation. And, there are really three explanations for the correlation. Either: a. testicle size is causing (or inhibiting) nurturance, b. nurturing behavior (or lack thereof) is causing testicular volume, or c. something else is to blame for both nurturing behavior and testicular volume.

Stanford neuroendocrinologist Robert Sapolsky wrote a great essay on the relationship between testosterone and violence. Sapolsky argues that there is a huge cultural bias favoring an understanding wherein higher levels of testosterone are seen as responsible for increased violence (especially in men). But, research actually favors the opposite understanding: violence causes spikes in testosterone levels (see, time order really is important). My sense is that a similar misstep is taking place in the debates about testicular volume, testosterone and nurturing behavior among men.

The authors of the testicular volume study are upfront in claiming that they are unable to actually demonstrate that testicular size is a “cause or a consequence of male life-history strategies”. However, like the relationship between testosterone and violence, they have cultural bias on their side in suggesting the relationship is causal. Cultural stereotypes surrounding testosterone create an environment in which testicle size (and associated levels of testosterone) are much more likely to be framed as the culprit.

So, a possible interpretation of this study (and the one that the media has been quick to adopt) is that some men seem biologically better suited to be fathers—to actually participate in nurturing and caregiving. But, a more complex implication could be that caregiving and nurturance are not qualities for which people are more or less biologically suited. Engagement in nurturing and caregiving behaviors causes changes in both women and men—emotional, behavioral, and, yes, physiological as well. If I had to guess what the actual relationship is between testicular volume and nurturance, I’d guess that testicular volume is a consequence, not a cause, of nurturance among men. While they haven’t proven causation, this is, biologically speaking, the interpretation with more evidence.

Why does this matter? In a culture in which women are culturally understood as responsible for the caregiving of children, it’s easy to assume that women’s nurturing qualities are somehow hardwired. Similarly, in a cultural environment in which men have (in recent history) done relatively little caregiving, it might be easy to similarly assume that they are somehow naturally ill-suited to nurture. Correlations like this let men off the hook for being bad parents. It sounds like they can’t help it. But, there are plenty of factors that work against men’s active involvement in their children’s lives in the U.S. today. They just aren’t biological.

*To be fair, this study is longitudinal and does acknowledge time order. What’s problematic is the assumption that parenting activity is the only behavior that might have this effect on men’s testosterone levels, as well as the assumption that men’s testosterone levels are naturally high prior to “partnering.” To prove that these differences in testosterone levels are naturally occurring and biologically determined, we’d need to show cross-cultural universality in men’s pre-parental and post-parental testosterone levels. I’m not aware of any research on this topic.

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Note: this column was originally posted on Inequality by (Interior) Design and is reposted with the author’s permission.

Thanks to Chloe Bird, Ph.D., Senior Sociologist at RAND Corporation, for sharing this new health podcast.

For nearly 30 years, heart disease has killed more women than men in the United States. Yet women continue to face lower rates of diagnosis, treatment, and survival. Many other diseases are disproportionately prevalent among women and may affect them differently, requiring gender-specific approaches to diagnosis and treatment. The disparities in care might have developed unintentionally, but the time has come to narrow them deliberately. In this recording, a panel of experts discuss women’s health, heart health, and the potential effects of gender on health.

This month’s column features a new guest author: Adrienne Trier-Bieniek, Ph.D. is a sociologist and author of the new book Sing Us a Song, Piano Woman: Female Fans and the Music of Tori Amos (Scarecrow Press).

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I have spent the better part of the last five years trying to understanding how women use music to heal after  experiencing trauma.  When I was interviewing women for my book, Sing Us a Song, Piano Woman, one comment stuck in my head from a woman named Madeline.  Madeline talked about how she used to be into music by hair-metal bands.  She said, “Growing up, all my favorite bands were male artists.  Um, maybe it’s just that now I see that their message is from their point of view.  And I internalize that and maybe that’s why I made all the shitty choices that I made.  I think that maybe the reason that I only listen to female artists is because I just would rather have their messages in my head.” And this comment wasn’t rare.  Many women said that they found empowerment/comfort/salvation in music written and performed by another woman.

Now, I am totally aware that women can listen to male bands to feel support and vice versa.  However, one thing that I think it missing from conversations about feminism and pop culture is how women use music by feminist musicians as a way to heal after they have experienced trauma. This was the premise of my research for Sing Us a Song, Piano Woman.  The women I spoke with selected Tori Amos’s music as their self-care guide.  They were very much aware that this help was coming from a feminist performer and, because of that, found her music to sit close to home.

From this study I took away a few helpful tips for connecting feminism with music and healing that I would like to share.  In no particular order:

– Find an anthem:  I don’t think it gets much better than listening to powerful women belt out songs like it is the last time they will have the opportunity to sing in their lives.  Whether it’s Sister Rosetta Tharpe, Aretha, Tori Amos, Ani DiFranco, Janelle Monae, Beyonce etc.  Feminist musicians approach their songs with an eye toward empowerment, equality and expressing the experiences of women.  One of the reasons many of the women I spoke with enjoyed Tori’s song “Spark” was because it addressed her experience with miscarriage.  Healing from the loss of a child is hard, but hearing a performer address her emotions can be helpful.  So find your feminist anthem.  (I have many.  Some, like Aretha’s “Respect” and Ani’s song “Alla This” I will gladly cop to.  Others are embarrassing but help me get through the day!)

– Create While you Listen:  In 2007 I was a grad student at Virginia Tech  when my college became the site of the worst school shooting in U.S. history.  One activity that got me through was creating art while listening to Tori’s music and trying to use the lyrics to illustrate my feelings.  Many of the women I spoke with did the same thing with writing, crafting, singing and dancing.  Song lyrics became immortalized through their bodies, art and voices.  What is even more important is that this exercise requires you to think about the lyrics you are repeating to yourself.  What do they mean?  Are they empowering?  Of course we all can rattle off songs meant for entertainment.  But if there was ever a chance to think about the impact of music on our identities, it is when we are expressing ourselves through art and being vulnerable.

– The Feminist Standpoint:  Ok, stick with me.  In sociology (my field), the feminist standpoint basically says that women’s stories are often ignored in a culture.  So, I would encourage you to take an anthem song and use it to tell your story.  Anthems are great backdrops for activism.  They can help with speaking out about being raped, having an eating disorder, having a miscarriage etc. And, speaking out is a huge step toward breaking the culture of silence that surrounds these experiences.  I, like many of you, have found a new hero in Wendy Davis (the Texas legislator who stood for 11 hours to strike down anti-abortion laws).  She used her voice and inspired the band The Bright Light Social Hour to record this song called “Wendy Davis.”

Finding feminism in music (for both female and male artists) is key to changing the ways pop culture stereotypes women.  Finding feminism in music to help us heal from trauma is key to finding empowerment in vulnerable moments.  What do you listen to?

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– Crossposted from Feministing with permission –

Having written about sexually transmitted HPV (human papillomavirus) for 13 years, I’ve been waiting for the day when  celebrity would lend his or her fame to spotlight the realities of HPV infection, especially of HPV-related oral cancers. My hopes were that big news could bring about big change.  Today is that day, but it remains to be seen if it can be long-needed catalyst for change.

When news first broke, about three years ago, that Michael Douglas had oral cancer, my gut instinct was that it had been caused by HPV, likely one of the same types of HPV that has been causally linked to cervical cancer. The mucus membrane tissue of mouth and throat are similar to those of genital skin, so researchers have known for some time that, like herpes, HPV could be transmitted oral to genital, as well as genital to oral.

Back in 2009, the research findings were already clear: oral transmission of cancer-causing HPV means that almost all of us are more likely at risk than we are safe from risk.  For my 2010 feature article in Ms. Magazine, I focused on the importance of not only educating the public about HPV-related cancers in men but also about the HPV-oral cancer link. In addition, I advocated for the need to destigmatize all STDs: my research and book have shown that STD stigma makes it more likely for at-risk/infected  individuals to put off getting tested and treated. STD stigma also makes it less likely for individuals to disclose their sexual health status to partners, placing those partners at greater risk for infection.  In addition, negative stereotypes about the ‘types’ of women and men likely to be infected distort our ideas of who is at risk.

I’ll wrap up this post with a call: for us to come together, to learn the facts and not be swayed by incomplete media coverage and confusing pharmaceutical claims.  We must support significant funding increases to investigate exactly how we can prevent HPV-related oral/throat cancers, which research shows to be steadily on the rise and more fatal than cervical cancers in the U.S.

Update (6/3/13): I was not surprised to read reports which broke today — that the actor’s rep is correcting one aspect of yesterday’s breaking news: “He did not say cunnilingus was the cause of his cancer.” All any cancer survivor probably knows is that his/her cancer was caused by HPV (viral tests and typing can be done in lab tests of biopsied tissue samples). Researchers have found that cancer-causing HPV can be transmitted to oral/throat area via oral sex. The point remains: Michael Douglas did a good deed by helping raise awareness that serious (often fatal) oral cancers can be caused by sexually-transmitted HPV which is likely contracted by oral sex….

In the wake of Angelina Jolie’s NYT op-ed about undergoing a preventive double mastectomy, many experts have weighed in — to critique, to analyze and to correct misconceptions.  I’m keeping this month’s column short to encourage readers to explore some well-researched analyses.  I’m particularly inspired by a past guest-author for this column, Gayle Sulik, Ph.D. (author of Pink Ribbon Blues and Research Associate, Department of Women’s Studies, University at Albany – State University of New York).  Sulik’s guest post for Scientific American is a must-read for those who have questions and concerns about what Jolie’s story may or may not mean for themselves and their loved ones.  If you prefer a podcast, then listen to KCRW’s interview with a panel of experts, including Dr. Sulik along with Alice Park (author of The Stem Cell Hope and health reporter for Time magazine), Joanna Rudnick (BRCA activist and documentary filmmaker), and Ellen Matloff, M.S., C.G.C. (Director of Cancer Genetic Counseling at Yale Cancer Center).

I leave you with this quote from Sulik:

…we all deserve quality information, evidence-based medicine, and access to comprehensive and coordinated health care that is free from conflicts of interest and the profit motives of commercial enterprises that are eager take advantage of our fears while selling us superficial “solutions” to our problems.

New controversy about free condoms inspires this month’s column, a critique about student health and public health by Chloe E. Bird, Ph.D., senior sociologist at the nonprofit, nonpartisan RAND Corporation and co-author of Gender and Health: The Effects of Constrained Choices and Social Policies (Cambridge University Press).

This month’s column features one of our past guest authors: Chloe E. Bird, Ph.D. is a senior sociologist at the nonprofit, nonpartisan RAND Corporation and co-author of Gender and Health: The Effects of Constrained Choices and Social Policies (Cambridge University Press).

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In the past two months, two of my friends–both seemingly healthy women–became unlikely victims of cardiovascular disease. One, a woman who by any textbook definition would be considered at low risk for heart problems, nonetheless suffered a heart attack. Thankfully, she is recovering. The other, a longtime friend and a mentor of mine, tragically passed away after suffering a stroke. These experiences left me wondering how we can accelerate efforts to reduce cardiovascular disease risk and mortality in women.

As a women’s health researcher, I am concerned about how long it is taking to bring attention and resources to this problem. After all, it has been decades since we’ve learned that cardiovascular disease affects women every bit as much–or even more–than it does men. Indeed, since 1984, cardiovascular disease has killed more women than men in the United States. When it comes to women’s health, cancer gets a good deal of the attention; somehow, it hasn’t fully registered that so many of our mothers, sisters, friends and daughters are being affected by another, often silent killer.

Commonly referred to as heart disease, cardiovascular disease includes both heart disease and other vascular diseases. When tallied separately, stroke is the third leading cause of death among women. Both strokes and cardiac events are all too common in women over 40 and, sadly, so are deaths.

Consider a few statistics:

• In the U.S., women account for 60 percent of stroke deaths, and 55,000 more women than men suffer a stroke each year.
• Worldwide, heart disease and stroke kill 8.6 million women annually–accounting for one in three deaths among women.
• Whereas one in seven women develops breast cancer, more than one in three women has some form of cardiovascular disease.

Although the American Heart Association’s Go Red for Women campaign has done much to raise awareness, there is still too little attention devoted to preventing heart disease in women and improving the quality and outcomes of their care.

While we should celebrate the significant improvements in the care and survival of men with cardiovascular disease, those gains began decades ago, and the death rate among men has fallen more quickly than it has for women. Unfortunately, women continue to face lower rates of diagnosis, treatment and survival. The new Million Hearts campaign aimed at preventing a million heart attacks and strokes by 2017 has partnered with WomenHeart, a national coalition for women with heart disease. This effort is essential and represents progress, but prevention is not the only challenge.

Why are outcomes worse for women? Even if biomedical research on cardiovascular disease had not traditionally focused almost exclusively on men, these conditions would likely still be harder to recognize and treat in women. Women don’t tend to have the “TV heart attack”–the familiar image of a man clutching his left arm or his chest in pain. Rather, for women, the symptoms of a heart attack are often more subtle and less specific. Women can present with symptoms like throat pain or a sore back. In fact, 64 percent of women who die suddenly from heart disease had no previous symptoms at all.

Furthermore, tests that are mostly reliable in assessing men’s cardiac risk are not as accurate in women, largely because they are aimed at identifying major coronary artery blockage. At least half of heart attacks in women are caused by coronary microvascular disease, which involves narrowing or damage to smaller arteries in the heart. This not only makes the diagnosis challenging, but it poses problems for treatment as well. Women often go undiagnosed or incorrectly untreated after major blockages have been ruled out, and optimal treatment of microvascular disease remains unclear. Consequently, 26 percent of women over age 45 will die within a year of having a heart attack, compared with 19 percent of men. The deficits in women’s cardiovascular care may have developed unintentionally, but our efforts to address them need to be both intentional and focused.

Fortunately, we know what it will take to close the gap and get women better diagnosis and treatment for cardiovascular disease. We can start by looking to the fight against breast cancer. Our first task is to call for increased public and private funding for public-health, biomedical and health-services research to reduce women’s risk and improve their outcomes. Second, on the private side, there are many foundations dedicated to addressing cardiovascular risk in women. But they and the women they serve would benefit from more collaboration and better coordination of effort. Finally, doctors and medical clinics need to do more to improve assessment and the quality of women’s cardiovascular care. Otherwise, women’s care and outcomes will continue to lag behind men’s.

Our bodies are complex systems. So, if we want to take on women’s health in a way that truly moves the needle on outcomes, we need a comprehensive approach. Women’s health care in general needs to become a primary focus for research and practice. And improving women’s health and longevity will require us to expand our focus beyond sex-specific reproductive cancers and predominantly female diseases, such as breast cancer. This doesn’t mean that we should divert resources from other areas of study, of course. But we need to recognize that woman-specific health care should not be confined to conditions that don’t (or don’t often) affect men.

The stakes for women are high, but we can and must bring greater attention to women’s cardiovascular health. Personally, I am not willing to let go of another friend, colleague or relative to a condition that could have been caught and treated if women routinely received appropriate preventive care, diagnostic testing and treatment.  It’s time for feminists to take on heart disease as a women’s issue.

— Crossposted with permission from the Ms. Blog —

With this coming Tuesday marking the 40th anniversary of Roe v. Wade, I’m inspired to post this month’s column early.

I encourage readers to check out the work of ANSIRH (Advancing New Standards in Reproductive Health), a UCSF research program “dedicated to ensuring that reproductive health care and policy are grounded in evidence.” So, rather than cover the breadth of political and social dynamics related to abortion policies, I’m focusing on one specific new study which has important implications for protecting women’s health:

A newly published landmark study by ANSIRH demonstrates that trained nurse practitioners, certified nurse midwives, and physician assistants match physicians in the safety of aspiration abortions they provide. We hope that these results will give policymakers the evidence they need to move beyond physician-only restrictions in order to enable more women to have their reproductive health care needs met in their local communities by health care providers they know and trust.

The results of this study are significant because PAs, NPs and CNMs have been shown to be important and accessible health care providers for rural and low-income women. ANSIRH’s new findings support policies which would reduce health care disparities and increase continuity of care because a larger group of health care providers would be able to offer early abortion care. For more on this topic, read the latest post by Tracy Weitz, Director of ANSIRH.  This research should inform health policy across the U.S.

For more on the realities of abortion in the U.S., watch Abortion in the United States, a short video from the Guttmacher Institute.

On Sunday, I was enjoying a nice dinner with my family at a new local restaurant that actually features produce from local farmers’ markets.  All was good, until my 8-year-old daughter decided to ask our waitress, “Who are you going to vote for to be President of the United States?”  Too young to know that it’s not ‘polite’ to ask strangers about politics, she was surprised to hear the waitress reply, “I’m not going to vote.  I’m 28 years old, and I’ve never voted because I don’t know enough about the issues to vote.”  That answer stunned my daughter into confused silence because she’d watched the debates and had her own clear ideas about at least a few of the issues.  In the awkward silence, my 70 year-old dad (a pro-choice feminist) gently suggested to our waitress, “Well, you don’t have to know a lot about every issue to know who to vote for — even if you just know about where the candidates stand on one issue….”  At that point, I knew he was hinting strongly at Obama’s and Romney’s clear differences on the topic of women’s reproductive rights, and I did not want to go there — not with our waitress, in the middle of a family-friendly restaurant.

As uncomfortable as that conversation was, I almost wish my dad would have made his point…almost.  While it’s not the best voting strategy to be a single-issue voter, the facts about the differences between the two candidates (and their two parties) on this one issue are fairly astounding and have long-reaching consequences for the health of girls and women throughout the U.S.  Today, I had a chance to catch up on my twitter feed and came across the perfect illustration for this post — impressed by the clarity and distressed by the facts presented, I give you The Republican Party Rape Advisory Chart: