Handbook of Clinical Gender Medicine. Группа авторов
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including women and nature and ‘every creeping thing’. If we are to survive as a species, this dualistic and power-over thinking must change. Now that we know that we have to do things differently, the obvious place to begin is by embracing what men and women have to offer collaboratively and unpacking the ways of the feminine with reverence instead of horror.
What can we know when we include the feminine? Einstein wrote that no problem can be solved from the same level of consciousness that created it. The possibilities that have been held in the unconscious for thousands of years are re-emerging in the science of gender and medicine.
One example is the exciting concept of biomimicry, which takes inspiration from nature to solve human problems. It is based on the realization that instead of dominion over nature we need to understand her if we are to survive as a species. Nature has been problem-solving for billions of years, and every life form in existence today is the product of those billions of years of experimental research. It is an example of the power of paradigm shifts in thinking, one that coincides with the emergence of the feminine.
It has taken thousands of years to create the thought systems that we know now. It will take just decades to build on this accumulated wisdom with the new tools that come with understanding the clinical implications of sex and gender. That is the work that is described in this textbook. Within a decade, the scientists and clinicians of the Western world will ask, ‘how could we have missed that?’.
In their rigorous pursuit of knowledge, scientists and doctors will join with social scientists to gain the benefits of hybrid vigor. Gender is a concept of the social sciences and it takes the epistemologies and methodologies of the social sciences to unpick the meaning to improve clinical care. The creative insights that are released when the two thought forms are employed together will astound with their discoveries.
Jo Wainer, AM, PhD
Eastern Health Clinical School
Faculty of Medicine, Nursing and Health Sciences
Monash University
Wellington Road
Clayton, VIC 3800 (Australia)
Tel. +61 3 9094 9573, E-Mail [email protected]
Introduction
Schenck-Gustafsson K, DeCola PR, Pfaff DW, Pisetsky DS (eds): Handbook of Clinical Gender Medicine.
Basel, Karger, 2012, pp 5–7
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Biological Sex and the Genome: What Makes Us Ourselves?
Marianne J. Legato
Partnership for Gender-Specific Medicine, Columbia University, New York, N.Y., USA
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Abstract
The last three decades have witnessed a revolution in our concept of the importance of biological sex in determining phenotype. More and more we are successfully meeting the challenge of studying females directly at all levels of research rather than making males normative for the entire population. As a consequence, we have discovered fascinating and completely unanticipated differences between the sexes.Those differences exist not only at the macroscopic level and in the organism as a whole, but also at the molecular level: for example, we now know that the same genes are expressed differently as a function of gender. Gender-specific biomedical investigation has helped us formulate questions about normal function and the pathophysiology of disease we never would have otherwise asked and has deeply enriched and expanded our notion of precisely what makes us ourselves.
Copyright © 2012 S. Karger AG, Basel
Heraclitus, the philosopher of change, pointed out that the only thing of which we can be completely certain is that everything in the world around us is in flux and that nothing endures but change itself [1]. Medical science and medical opinions are no exception: as scientific data accumulate, we construct theories and formulate paradigms that we inevitably and constantly alter. The evolution of the concept of ‘gender-specific medicine’ is a classic example of that principle.
The notion that all human biology, with the exception of that of our reproductive systems, is essentially the same for men and women dominated medicine for centuries. In fact, the idea that what we know about males cannot be extrapolated to females without direct testing of female subjects is less than 25 years old. Suggesting that what we found in males might only be true of one sex and could not be extrapolated without separate testing in females met with tremendous skepticism and even outright opposition. In fact, it is astounding to think that centers of medical research tolerated and indeed promulgated the idea that sex was not a significant determinant of normal function and of the experience of disease.
Thus, scientists themselves are imperfect; they do not spring fully and perfectly formed like Athena from the brow of Zeus: one’s style in shaping a method of scientific inquiry is not wholly objective: basic talent, the caliber of training, and, importantly, prejudices, all influence investigative style and substance. A whole variety of other factors impact medical investigation. Public interest is one: money drives the research engine, and the public is the source of that money and the ultimate arbiter of what it will pay for. The prevailing wisdom of the research community dictated that to repeat research protocols that had been completed in men to women seemed an unnecessary waste of funds. History is another factor: it shapes attitudes in medicine as in all sections of society. After the abuses of World War II were exposed to general scrutiny at Nuremberg, a determination to protect the more vulnerable members of society from exploitation under the guise of furthering medical knowledge was forged and dominated the American research enterprise for decades. Women, particularly premenopausal women, were considered more vulnerable than men and shielded accordingly from sharing the risk of being subjects of clinical investigation. This attitude was, however, countered by the effective lobbying of the feminist community (itself a direct result of the experience of the war), which petitioned the government to support the direct investigation of women’s physiology.
The Task Force on Women’s Health, sponsored by Dr. Edward Brandt at the Public Health Department, spearheaded an effort by the National Institutes of Health and the Congress itself to fund and support direct research on women. The Office of Research of the NIH, headed by Doctor Vivian Pinn, played a major role in guiding and shaping efforts to comply with that mandate. In the decade that followed, a dedicated coalition of feminists, physicians, and medical researchers stabilized and expanded the idea that women were significantly different from men and profited from a direct investigation of their physiology and their experience of disease. The rich bonanza of data that resulted, however, was completely unanticipated: to our growing amazement, we found that every system of the body was different in significant ways between males and females. The differences extended to the molecular level: thousands of identical genes are expressed differently in males and females [2]. Furthermore, gene expression is modified by the parent of origin in the process called imprinting and, even more significantly, the loci and number of parentally imprinted genes vary with the sex of the offspring. The impact of sex on the genome is far more extensive than was ever anticipated [3, 4].
Another revolution in our concept of gender-specific medicine was the old debate of whether our sex-specific differences are cast in biological stone or rather our environment is in fact more important in shaping the phenotype. Many have speculated that if men and women were subjected to environments that were utterly identical, sex-specific biology would disappear. This extreme view is a distortion of what is, in fact, correct: experience plays a direct and essential role in altering biological properties and cannot be ignored or separated