Patricia P. Rieker

Gender matters: an integrated model for understanding men's and women's health

Health research has failed to adequately explore the combination of social and biological sources of differences in mens and womens health. Consequently, scientific explanations often proceed from reductionist assumptions that differences are either purely biological or purely social. Such assumptions and the models that are built on them have consequences for research, health care and policy. Although biological factors such as genetics, prenatal hormone exposure and natural hormonal exposure as adults may contribute to differences in mens and womens health, a wide range of social processes can create, maintain or exacerbate underlying biological health differences. Researchers, clinicians and policy makers would understand and address both sex-specific and non-sex-specific health problems differently if the social as well as biological sources of differences in mens and womens health were better understood.

Complications after treatment with external-beam irradiation in early-stage prostate cancer patients: a prospective multiinstitutional outcomes study.

PURPOSE To use data from a prospective quality-of-life study to assess differences in disease-specific and general health-related quality-of-life changes after treatment with different external-beam irradiation techniques for prostate cancer. PATIENTS AND METHODS Patients were divided into three groups based on their pretreatment field size and planning technique: whole pelvis, small field, or conformal. Measures of bowel, urinary, and sexual function and of global health-related quality-of-life parameters (from the Health Survey Short Form [SF-36] and the Profile of Mood States [POMS]) were obtained from self-report questionnaires completed before initiation of therapy and at 3 and 12 months after therapy. RESULTS Irritative gastrointestinal and genitourinary side effects were frequent 3 months after treatment, but were substantially improved at 12 months. Sexual dysfunction increased steadily over the study period. The POMS and the SF-36 did not demonstrate significant changes over time. Despite small patient numbers, we found trends in favor of conformal therapy across several symptom measures, including sexual function. In the fatigue, energy, and vigor subscales, patients who received whole-pelvis treatment fared significantly worse than those in the other two groups. CONCLUSION Prospective, detailed data from a feasibility study allowed us to assess the effect of technique on quality of life following external-beam irradiation. Although limited by the small planned sample size, these results suggest that smaller radiation fields limit treatment-related complications, including, unexpectedly, sexual dysfunction. However, confirmation in a larger study is necessary.

Rethinking Gender Differences in Health: Why We Need to Integrate Social and Biological Perspectives

The complexity of gender differences in health (i.e., mens lower life expectancy and womens greater morbidity) extends beyond notions of either social or biological disadvantage. Gaps remain in understanding the antecedents of such differences and the issues this paradox raises regarding the connections between social and biological processes. Our goals in this analytic essay are to make the case that gender differences in health matter and that understanding these differences requires an explanation of why rational people are not effective in making health a priority in their everyday lives. We describe some salient gender health differences in cardiovascular disease, immune function and disorders, and depression and indicate why neither social nor biological perspectives alone are sufficient to account for them. We consider the limitations of current models of socioeconomic and racial/ethnic health disparities to explain the puzzling gender differences in health. Finally, we discuss constrained choice, a key issue that is missing in the current understanding of these gender differences, and call on the social science community to work with biomedical researchers on the interdisciplinary work required to address the paradoxical differences in mens and womens health.

Curative testis cancer therapy: psychosocial sequelae.

We examined the long-term impact of advanced testis cancer and its curative therapies on emotional states and outlook on life, employment, intimate relationships, and sexual function. The sample consisted of 74 nonseminomatous and seminomatous tumor patients who had completed treatment two to ten years ago. The majority of men felt that surviving the debilitating treatment(s) was both an accomplishment and worthwhile trade-off. Neither the rate of unemployment (7%) nor divorce (10%) was remarkable. The most critical outcome was in the area of sexual functioning. One fourth to one half of the men reported some type of sexual impairment. Multiple regression results indicate that ejaculatory dysfunction, a side effect of the retroperitoneal lymph node dissection, is significantly associated with distress about both infertility and sexual impairment. Men with sexual impairment report more psychological symptoms, strained intimate relationships, and negative changes in other areas of life functioning. These data, while not definitive, suggest that there are delayed effects and that the subgroup of men, who are least likely to disclose these problems to physicians, are at greater risk for the deleterious outcomes.

Changes in quality of life following treatment for early prostate cancer

OBJECTIVES To explore the effects of urinary, bowel, and sexual symptoms following treatment for early (nonmetastatic) prostate cancer on health-related quality of life through an examination of the responsiveness of the Medical Outcomes Study Short Form Health Survey (SF-36). METHODS We conducted a prospective observational cohort study of 125 men with early prostate cancer who underwent either radical prostatectomy or radical, external beam radiotherapy. Patients completed questionnaires, which included assessments of urinary, bowel, and sexual symptoms and the SF-36 at the time of their clinical consultation prior to deciding on primary therapy and at 3 and 12-month follow-up. RESULTS Although cross-sectional analysis showed substantial associations between symptoms and the eight scales of the SF-36 12 months after the initiation of treatment, longitudinal analyses of changes in these scales showed only modest effects. Three scales registered changes associated with the development of new symptoms: General Health Perceptions, Vitality, and Social Function. Role Performance with Emotional Limitations demonstrated a surprising response: slight improvements in men with new symptoms, compared with substantial gains in men who survived treatment without developing new urinary, bowel, or sexual symptoms. Overall, the SF-36 demonstrated a pattern of decline at 3 months and recovery to baseline at 12 months. Rather than registering declines in response to increasing symptoms, negative changes occurred primarily in men who presented symptoms prior to treatment and whose symptoms were unchanged 12 months later. CONCLUSIONS The SF-36 is associated with the presence of physical symptoms but demonstrates a complicated pattern of change following treatment and the development of new urinary, bowel, and sexual problems. Multidimensional approaches to the outcomes of treatment for early prostate cancer help to clarify the magnitude of both gains and losses in quality of life.

THE VICTIM‐TO‐PATIENT PROCESS: The Disconfirmation and Transformation of Abuse

The victim-to-patient process is reconceptualized as an interplay among abuse events, family relationships, and other life contexts, emphasizing the fragmented identity deriving from accommodations to the judgments of others about the abuse. Original defenses are seen to form the later core of the survivors psychopathology. This schema helps clinicians to understand obstacles to treatment and recovery and to recognize the behavior reflecting disconfirmation and transformation of abuse.

Gender Differences in Relationships and Stress of Medical and Law Students.

A small-scale, comparative study of medical and law students was undertaken at a large, southern state university to examine the sources and consequences of stress during professional training. Specifically, the impact of stress on personal relationships was explored. The authors of the study reported here found gender differences in the source and degree of stress perceived by students. Women reported significantly more stress than men. Unlike the men, women found sexism and difficulties with partners to be particular sources of stress. Although both men and women reported that the stress of their professional training had resulted in strained personal relationships, proportionately more women than men stated that their personal relationships had ended.

Finasteride and flutamide as potency-sparing androgen-ablative therapy for advanced adenocarcinoma of the prostate.

OBJECTIVES Androgen ablation with luteinizing hormone-releasing hormone (LHRH) agonists, orchiectomy, or oral estrogens has significant untoward sexual side effects. We evaluated a combination of finasteride and flutamide as potency-sparing androgen ablative therapy (AAT) for advanced adenocarcinoma of the prostate. In addition, we evaluated whether finasteride provided additional intraprostatic androgen blockade to flutamide. METHODS Twenty men with advanced prostate cancer were given flutamide, 250 mg orally three times daily. Serum prostate-specific antigen (PSA) values were measured weekly. At a nadir PSA value, finasteride, 5 mg orally every day, was added. PSA values were then measured weekly until a second nadir PSA value was achieved. Sexual function was evaluated at baseline, at the second nadir PSA value, and every 3 months thereafter. Testosterone, dihydrotestosterone (DHT), and dehydroepiandrostenedione (DHEA) levels were measured at baseline and at the first and second nadir PSA values. RESULTS The median follow-up period was 16.9 months. Therapy failed in 1 patient with Stage D2 disease at 12 months, but an additional response to subsequent LHRH agonist therapy was observed. One patient developed National Cancer Institute grade 3 diarrhea and was withdrawn from the study. Seven of 20 men developed mild gynecomastia, and 3 of 20 developed mild transient liver function test elevations. Mean PSA levels were 94.6 +/- 38.2 ng/mL at baseline and 7.8 +/- 2.7 and 4.7 +/- 2.2 ng/mL at the first and second PSA nadir values, respectively (P = 0.034). Mean percent decline in PSA value from baseline was 87.0 +/- 3.1% with flutamide alone and 94.0 +/- 1.9% with both flutamide and finasteride (P = 0.001). Eleven of 20 men were potent at baseline. At the second nadir PSA value, 9 (82%) of 11 were potent, whereas 2 (18%) of 11 were impotent. With longer follow-up (median 16.4 months), 6 (55%) of 11 men were potent, 2 (18%) of 11 were partially potent, and 3 (27%) of 11 were impotent. With flutamide alone, testosterone rose a mean of 77 +/- 14.7% of baseline (P = 0.0001), DHEA fell a mean of 32.4 +/- 4.6% (P = 0.0001), and DHT was unchanged. With the addition of finasteride, testosterone rose another 14 +/- 6% (P = 0.06, not significant), DHEA was unchanged, and DHT fell a mean of 34.8 +/- 4.7% (P = 0.0009). CONCLUSIONS Finasteride and flutamide were safe and well tolerated as AAT for advanced prostate cancer. Finasteride provided additional intraprostatic androgen blockade to flutamide, as measured by additional PSA suppression. Sexual potency was preserved initially in most patients, although there was a reduction in potency and libido in some patients on longer follow-up. Further evaluation of this therapy is needed.

Pediatric bone marrow transplantation: psychosocial issues for parents after a child's hospitalization

Bone marrow transplantation (BMT), once a highly experimental procedure performed in only a handful of medical centers, has become increasingly common and is now considered to be the treatment of choice for some diseases. Although a growing number of pediatric patients undergo this life-saving procedure, psychosocial research has focused primarily on adult BMT patients. This article presents data from an exploratory study of 73 parents whose children successfully completed the transplant. The study identified the major concerns and needs of this unique population as they coped with life after a childs transplant. The results indicated that although most parents coped adequately, certain problems such as financial strains and fears of relapse remained.

Job stress and satisfaction among the staff members at a cancer center

Although it is evident that working with cancer patients can be stressful, explanations have differed as to why this is so and little attention has been paid to the rewards of this work. One hundred ninety clinical staff members at a comprehensive cancer center representing 91% of eight disciplines studied were interviewed using a semistructured format about the factors influencing their job satisfaction. The fact that the staff members almost uniformly rated their satisfaction as high (8.2 on a scale of 1 to 10) precluded the detection of discriminating variables. Satisfaction with the way they met their goals also was high; most identified potentially achievable goals, relied heavily on the interdisciplinary team, and experienced changes in their attitudes and approach during their first 2 years in the field, primarily increased realism. A major discomfort for physicians was the inability to provide optimal care. Ethical issues were a major discomfort for nurses. Death itself and staff conflict were less important sources of discomfort than in previous reports.