Divide by Gender

There’s plenty of evidence here to convince modern medicine practitioners to take cognisance of gender-based health care.
DR. KESHAV RAO   New Delhi     Print Edition: March 26, 2017
Divide by Gender
Book by Marek Glezerman

The Thalidomide tragedy shook the world in 1961. Thousands of mothers took this new anti-nausea drug to control morning sickness. It led to birth of 10,000 babies with absent or stumplike limbs along with other horrifying deformities. A decade later, girls born of mothers given a drug called DES in pregnancy were found to be prone to developing genital cancer. That was it. Researchers stopped enrolling women in clinical drug trials. Even today, laments Professor Glezerman in Gender Medicine, women are disregarded or misrepresented in medical research and data gleaned from a largely male cohort is irrationally applied in assessment, investigation, diagnosis and treatment of diseases among the women of the world. At the outset, the author clarifi es that gender is not synonymous with sex. Gender refers to socially constructed roles, behaviours, activities and attributes that a given society considers appropriate for men and women. Gender medicine views an individual as having an inner core of genetic material, surrounded by a sphere of biological changes that are the result of millions of years of evolution - the male hunter, and female gatherer and child bearer, with an outer cover of environmentally-engineered attributes. All put together, men and women differ signifi cantly in their susceptibility to disease, their defence mechanisms and bodily responses to disease, the expression of symptoms, and response to therapy. As the book unravels, Glezerman presents realms of anatomical, physiological and psychological evidence to support his claim that modern medicine can no longer ignore these gender-specifi c differences, and the need of the hour is individualised gender-based health care. The book grabs one's attention from the very fi rst page where the author describes a young girl with uncontrolled epilepsy. Evaluation reveals her fi ts increased during her menstrual cycle. The natural surge of hormone progesterone that occurs during the second phase of the menstrual cycle partially neutralised her medication. An upward tweak of the dose during menstruation solved a seemingly complex problem. While discussing how gender affects the way a foetus develops in the womb, the author simplifies a complex topic - genetics, the blueprint inherited from parents, epigenetics, as the chemical changes that affect the way genes are expressed, genotype as the root, and phenotype the plant that grows into the environment. The Trivers-Willard effect is described as an evolutionary concept wherein weak male fetuses with probable low fertility are spontaneously aborted so that a pregnancy with a female or a stronger male foetus could quickly follow. Foetal programming is described, in which exposure to high intra-uterine testosterone levels may have an inverse relationship to a child's social skills or vocabulary and maternal factors like stress or diet can significantly affect behaviour, learning ability or weight. What a mother reads, the music she listens to, or the flavour of the food she eats all get transmitted to her baby by subtle alterations in the intra-uterine environment. Holistic pre-natal care, therefore, is the key to prevention of disease in adulthood. "How we are ushered into life decides how we leave it". A gender-medicine approach is the only way forward, stresses Glezerman, as he outlines with precision the nuances of heart disease as being different in men and women. A young woman is protected from heart disease by the hormone estrogen, but this protection wears off with menopause when, with the advent of obesity, hypertension and high cholesterol, a woman is as likely as a man to get heart disease. The dramatic scenario of severe central chest pain, sweating, anxiety and breathlessness that herald a heart attack in men may not be so prominent in women. A woman may feel generalised weakness and fatigue or a typical pain in jaw, shoulder or back - often leading to missed or delayed diagnosis. While a stress test or SPECT scan is suited for a man, a stress Echocardiograph is a better test for a woman. Women react differently to medication. Aspirin, which helps prevent heart attacks in men, is more effective in preventing brain strokes in women. Pregnancy offers a window of opportunity to monitor pregnancy associated high blood pressure or high sugar, which are often harbingers of hypertension and diabetes in later life. Every chapter of this riveting book is strewn with nuggets of information such as some of these - food takes twice as much time to traverse the intestine in women as in men (should women eat twice a day and men four times?); the intestinal nerve network, the second brain, has one hundred million nerve cells and can function independent of the brain except for swallowing and excretion which thankfully are under voluntary control; 40 trillion microbes live in the intestines…indiscriminate use of antibiotics or excessive artifi cial sweeteners that disturb this fl ora are deleterious to health; a man produces a hundred million sperms per day but a woman does not produce any eggs after birth; the sweetness of a kiss is not dependent on affection but on ovulation; and redheads are more sensitive to pain than blondes or brunettes, and require larger doses of anaesthesia. Gender medicine, the author says in conclusion, is still a young fi eld. There is an urgent need for education and awareness of the general public and the media. Health administrators and medical institutions need to be sensitised, and medical colleges should include gender medicine in training curricula. Only once the principles of gender medicine are established in all doctors' clinics will patients receive individualised evidence-based treatment they all deserve. I couldn't agree more.

 The reviewer is Regional Medical Director at Fortis Healthcare Ltd

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