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 men's and women's 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 men's and women's 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 men's and women's 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.

How should a man with testicular cancer be counseled and what information is available to him?

The peak incidence of testicular cancer occurs in early adulthood (between the ages 19 to 34) when men are physically robust and actively formulating social and sexual identities. This is also a time when they are pursuing career and family goals. The disease not only interrupts these pursuits but its very location threatens the integrity of the body and an organ that is associated with self-esteem, sexuality, fertility, and masculinity-psychosocial issues of importance to both ill and healthy men alike. This paper discusses approaches to counseling these men. Effective counseling depends on understanding the illness itself and four psychosocial domains: the context of patients' lives, the assault on the sense of self, the impact on intimate relationships, and treatment options and psychosexual effects.

Home antibiotic therapy for low-risk cancer patients with fever and neutropenia: a pilot study of 30 patients based on a validated prediction rule.

PURPOSE: To assess the feasibility of early discharge to home therapy with standard intravenous antibiotics in 30 patients with fever and neutropenia at low risk by a validated clinical decision rule. PATIENTS AND METHODS: Newly admitted outpatients with fever and neutropenia were evaluated for home therapy during 2 days of inpatient observation. To evaluate enrolled patients' acceptance of home care, we assessed patient attitudes and quality of life before and after home therapy. To assess economic effects, we compared the medical charges of patients treated at home with those of medically eligible patients who remained in the hospital. RESULTS: Of the first 84 patients, 50 (60%) were medically ineligible, and neutropenia was resolved in another eight (10%) during the observation period. Only nine patients of the remaining 26 who were medically eligible (35%) were enrolled in the home-therapy trial. Thereafter, 21 of 31 medically eligible patients (68%) were enrolled. The 30 patients treated at home were neutropenic for a median of 6 days (mean, 8.2). Four had medical complications, and five others were readmitted for observation. Patients' quality of life improved during home therapy, and favorable attitudes toward home care persisted after treatment. Medically eligible patients not enrolled had briefer neutropenia than patients treated at home, but had 44% higher daily medical charges and equivalent overall charges despite treatment half as long. CONCLUSION: We conclude that early discharge of low-risk patients to home intravenous antibiotic therapy is feasible, is well received by patients, and may prove to be cost-saving. However, these conclusions must be validated in a large randomized trial.

Perceptions of quality of life and quality of care for patients with cancer receiving biological therapy.

This retrospective, descriptive study was undertaken to identify patient and family perceptions about quality of life (QOL) and quality of care (QOC) after experimental biological therapy. A mail survey that included instruments designed to measure QOL (the Profile of Mood States [POMS] and the Linear Analogue Self-Assessment [Lasa]) and QOC was sent to patients (response rate, 60%) and to relatives of deceased patients (response rate, 70%). Bivariate and multivariate statistics were used to analyze the data. Patients reported a relatively good quality of life, as measured by POMS and LASA scores. The majority of living patients and of family members of deceased patients were positive about the QOC received; relatives were significantly less positive than patients. Four components were significant in respondents' assessment of QOC: adequate symptom control, availability of support services, communication with the medical team, and receiving information about response to treatment. The findings suggest that there is a need to supplement survival data and biomedical outcomes with information about patient and family perceptions about care and treatment.

Adaptive behavioral responses to potential infertility among survivors of testis cancer.

In a retrospective study of 153 testis cancer survivors, we examined the sociodemographic and clinical determinants of attitudes and behaviors toward illness-induced infertility. Five fertility adjustment responses were identified: sperm-banking awareness (SBA); adoption awareness (AA); fertility testing (FT); trying to father children (TFC); and fertility distress (FD). Although responses to infertility are multidetermined, these data demonstrate there is a distinct sociodemographic and clinical profile for the subgroups of men who engage in different fertility-related behaviors. Multivariate analysis results show that men most likely to be concerned with banking sperm are those who at diagnosis are younger (less than 35 years), childless, college educated, and whose relationships have become strained. Men who sought fertility tests were childless, college graduates, and able to ejaculate. The only factor predicting adoption was childlessness. Those married men attempting to father children were also less than 35 years of age at diagnosis and without ejaculatory dysfunction. The men at greatest risk for continued distress about infertility were those who remained childless and had posttreatment ejaculatory dysfunction. Residual infertility distress also was significantly associated with treatments that included extensive retroperitoneal lymph node dissection (RPLND) surgery, indicating that the latter is a "risk factor" in survivors' long-term distress. These data, while not definitive, show that the prerogative to have children is very important to men and that losing it sets into motion a range of both adverse emotions and adaptive responses. Adjustment to infertility is a complex process that begins at diagnosis and extends long after treatment is completed.

Psychosocial factors, curative therapies, and behavioral outcomes. A comparison of testis cancer survivors and a control group of healthy men.

In a retrospective study of 223 testis cancer survivors and 120 controls matched sociodemographically, we examined the relative impact of sociodemographic and clinical factors on long-term outcomes in the areas of sexual function, relationships, employment, and mental outlook. For most of the survivors, testis cancer did not lead to unemployment (4.5%), divorce (6.8%), or disabling psychological problems. Multivariate analysis results confirm that cancer survivors report significantly more infertility and sexual performance distress, but not more desire distress, than the control group. Survivors' sexual impairment varied according to treatment received (and therefore histologic factors) and sociodemographic variables. Parental status (not having children) and education (college or less) independently predict infertility distress, whereas education and lower occupational level independently predicted sexual performance distress. Adjusting for socioeconomic status (SES), the men with advanced testis cancer who received chemotherapy and standard retroperitoneal lymph node dissection (RPLND) had significantly more infertility and performance distress than those men who received other treatments. Neither the treatment or SES variables predicted disrupted relationships or a deteriorated mental outlook. However, men with sexual impairment distress were more likely to report strained relationships and a pessimistic mental outlook. These findings have implications for treatment decisions and can be used to identify subgroups of survivors who could benefit from counseling and sexual rehabilitation services.

A psychosocial model of the victim-to-patient process. Implications for treatment.

The psychosocial model of the victim-to-patient process explains how chronic abuse damages the self and sets into motion psychological processes that may evolve into various forms of mental illness. This model emphasizes the fragmented identity that derives from victims' attempts to accommodate to the judgments of others about the abuse, namely, it didn't happen; it happened, but it wasn't important and has no consequences; (s)he provoked it; and it wasn't abusive. Victims thus repress and deny the trauma and associated feelings in order to survive. The behavioral and psychological legacy of this adaptation forms the core of survivors' psychopathology and becomes an obstacle to treatment and recovery. The link between the damaged self and AIDS risk in adolescent runaway, homeless, and mentally ill survivor populations is underscored, along with recommendations for urgently needed clinical interventions.

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.

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.

Victims of violence and psychiatric illness.

The authors investigated the relationship between physical and sexual abuse and psychiatric illness. The life experiences of 188 male and female psychiatric patients were reconstructed through an in-depth examination of psychiatric inpatient records. Almost half of the patients had histories of physical and/or sexual abuse; 90% of the abused patients had been victimized by family members. The abused patients' responses to chronic victimization included difficulty in coping with anger and aggression, impaired self-esteem, and inability to trust. The authors compare male and female victims and discuss the clinical implications of abuse.

Teaching value clarification: the example of gender and psychotherapy.

The authors describe an effective model for teaching and evaluating a one-semester course on gender and psychotherapy for psychiatry residents. Clarification of values and attitudes about gender involves learning at both intellectual and affective levels. The authors conceptualize this cognitive-affective interplay as a series of stages or turning points in the process of value change and professional resocialization. The process may also be viewed as a microcosm of the inevitable gender-based conflicts that occur in the daily lives of the participants and in the wider social context. The course evaluation demonstrates that residents are able to translate the new knowledge into clinical practices.

Social science in medicine: the question of 'relevance'.

Social science differs from the other basic medical sciences in that its perspective for understanding illness is not centered on processes within the individual. For this reason the relevance of social science knowledge to clinical practice is not obvious to many medical educators and students. Initial efforts at the University of North Carolina to develop a social science curriculum that is obviously relevant are described. Strategies include the use of small-group seminars taught by social-scientist/clinician teams and an organizing framework which links social science knowledge to clinical practice. Response to the curriculum from faculty and students has been encouraging.