Can we trust our oracles? VIEWS & REVIEWS REVIEW, p 404

Why the modern day eunuch remains invisible PERSONAL VIEW Richard J Wassersug, Tucker Lieberman

et’s study emasculation. No, we don’t castrations. The language 18th century castrato opera mean the loss of political power. That’s of emasculation remains star Senesino was in the a metaphorical sense. We mean the real pejorative and shameful.14 limelight, whereas modern Lthing: the removal or chemical destruction Fearing such shame, day emasculation is largely of a man’s testes. And here we refer not to the many patients hide their hidden manufacturing of courtiers in Constantinople, nor medically modified to the construction of a caste of opera singers, but to m o r p h o l o g y a n d Despite the fact that modern day emasculations. deny that they feel any eunuchs have been the Although to many people castration signifies a different.15 Thus they most common gender barbarism that disappeared with the demise of the remain invisible,16 and variant throughout history,18 Ottoman empire, the Chinese dynasties, and the their condition is poorly they are rarely mentioned in castrati movement in European music, there are understood. university courses. Even when surely more men living with removed or functionally Emasculation is arguably as castration is discussed in the field of arrested testes today than at any other time in distressing for men as mastectomy is for “gender studies,” it tends to be metaphorical, history. A minority either identify as women and women. Nevertheless a search in PubMed on as exemplified by the title of Germaine Greer’s have sex reassignment surgery or sought castration “castration” and “mastectomy” matched with famous book The Female Eunuch. simply to suppress their libidos.1 2 By far the majority, various words indicative of psychological effects The only academic terrain in which though, are prostate cancer patients, and it’s this indicates that mastectomy has received over 50% contemporary castration is regularly explored group that we focus on here. more attention in that domain. Data from open is in departments of urology, where physicians Chemically shutting down or surgically removing ended discussions with men taking androgen are trained to do orchidectomies and administer the main source of testosterone—the testes—can deprivation treatments show that many are castrating drugs to patients with cancer. slow the spread of prostate cancer. Castration, of distressed yet can’t fully articulate how they feel Even there, physicians shy away from using course, has extensive side effects.3 A castrated adult about the changes they are experiencing.17 In trying terms such as “castrated,” “emasculated,” male will lose muscle but gain fat.4 He can expect hot to preserve residual masculinity, most are reticent on and “neutered,” because they sound like what flushes like those that women have at menopause.5 the subject of their transformation. they are: mutilating procedures with profound He will lose body hair, and his penis will shrink. It is crucial that the psychosocial impact of psychological and social impact. Typically Erections will be rare and weak, if they occur at all.3 castration receives more attention so that those who physicians relabel androgen depriving treatments, He will be sterile. are androgen deprived can be helped to adapt to the including orchidectomy, as “hormonal therapy.” Castrated men also often experience changes in changes they experience, whatever those changes This may make it easier for them to diminish, if cognitive function and affect, although the nature of may be. Recognising the side effects of any medical not dismiss, the consequences of the treatment— those changes is poorly understood. Recent reviews treatment is a prelude to developing effective easing their own angst, if not that of their patients. of the topic have yielded contradictory results.6-11 coping strategies. This is particularly true when the This, however, leaves the scholarly exploration of Right now, in North America, as many as 600 000 treatment affects the personality. emasculation in academic no man’s land. patients with prostate cancer are coping with the Although emasculated males may continue to Genital ablation has never been merely a effects of medical emasculation.12 But unless such present outwardly as men, they must come to terms metaphor. Everyone should be aware that a a man tells you what has happened to him, his with their diminished biological maleness. How multitude of men are either chemically or surgically physical and mental changes may not be apparent they adapt to such changes is inevitably influenced castrated for a variety of reasons in contemporary to you. Most of those patients are on a short term by social context. As long as society remains largely Western society. Until doctors, scholars, and course of androgen suppressing drugs and believe unaware of who is emasculated and how common researchers are forthright with their language, the that their testosterone titres will recover once they castration is, we can expect little curiosity about its emasculated will remain invisible. This invisibility, stop taking the drugs. However, the longer they are consequences. Thus there is a paucity of scholarship in turn, castrates the study of emasculation. taking these compounds, the longer it takes for their on modern day emasculation. This lack of research Richard J Wassersug is professor of anatomy and testes to recover; and even with short term use the is regrettable, as it hampers efforts to help medically neurobiology, Dalhousie University, Halifax, Nova effects are not always completely reversible.13 emasculated men overcome the more emotionally Scotia, and visiting professor, Australian Research Centre in Sex, Health and Society, La Trobe University, Inaccurate, antiquated, and negative stereotypes challenging side effects of their treatment and leaves Melbourne [email protected] of castrated men—implicitly illustrated by the androgen deprived patients little or no social context Tucker Lieberman is an independent author, Boston, misuse of the term “eunuch” to indicate a completely with which to accept the changes they experience. Massachusetts powerless person—are perpetuated because of So where should you go to learn more about References are on bmj.com society’s general ignorance of contemporary the psychosocial effects of androgen deprivation? Cite this as: BMJ 2010;341:c4509

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bmj.com REVIEW OF THE WEEK ЖЖRead Julian Sheather’s blog at www.bmj.com/ blogs The sibyl is faulty The way that research is currently configured, there is enormous pressure if not to deceive then certainly to game the system, writes Julian Sheather

Every age has its sources of wisdom, those to whom we mous pressure to get their research published in pres- turn for a little light in the abiding darkness: the oracle tigious journals. These journals are more interested in at Delphi intoxicated by volcanic gases; shadowy priests positive than negative findings—it is just so much more whispering behind the grille; or ascetics and gurus in their interesting to read about researchers establishing a link mountain fastnesses. Ours, though, is unassailably the age between, say, a particular behaviour and a specific dis- of the expert. With science regnant, it is to her disciples order than about the numberless possible links that have we instinctively turn. What, asks David Freedman in his been discounted—so consequently there is pressure on combative new book, is the status of their collective wis- researchers to come up with findings that support the dom? The interesting thing turns out to be not the answer, study’s hypothesis rather than refute it, so called “pub- which is given in the title, but what lies behind it. Wrong: lication bias.” There is a problem here, though, for, as Why Experts Keep Failing Us—And How to Know When Not Freedman points out, the more novel and exciting the to Trust Them is a brisk interrogation of the extraordinary hypothesis, the more likely it is to be published but the fallibility of even the most lauded and garlanded of our less likely it is to be right. Setting to one side outright fraud, contemporary experts. the way research is currently configured puts enormous Wrong: Why Experts Keep Freedman is catholic in his choice of targets—no disci- pressure on scientists if not to deceive then certainly to Failing Us—And How to pline is spared—but he does have a lot to say about con- game the system. Know When Not to Trust temporary health claims. He introduces us at the outset to When imperilled research findings make their way into Them John Ioannidis, professor of medicine at Tufts University, the mainstream media, things get much, much worse, but David H Freedman who specialises in assessing the likelihood that the results this is less to do with researchers and more to do with our Little Brown, £17.62, published in medical studies are false. It turns out that preferences as consumers. High quality research often pp 304 even when focusing on research published in the most comes hedged with qualifications and disclaimers, but ISBN 978 0316023788 prestigious medical journals, two out of three studies are these are not newsworthy and are frequently omitted in the Rating: likely to be unreliable. And when it comes to randomised passage from scientific journal to news stand. News out- **** control trials—the absolute gold standard—one out of four lets recognise that consumer taste in health stories is for has subsequently been refuted; and, Freedman says, that clear, confident advice, preferably involving small actions rate could be higher but nobody has tried to refute more that will contribute large benefits—hence the enthusiasm than half the rest. And yet the findings of many of these for miracle weight loss diets. Apparently, we particularly studies appear daily in the media as the nearest thing we favour findings that are both optimistic and in accord with have to health gospel. So what is going on here? our underlying prejudices. Put simply, consumer taste is We are in the midst, it would seem, of a collective dance par excellence for precisely the least trustworthy findings. of error, and the problems begin early on with the very Given Freedman’s breathless exposure of so many structure of research. Career researchers are under enor- sources of contemporary scientific error—I haven’t men- tioned the effect of commercial sponsors, the perils of peer review, the habit of assuming causes where there are only correlations, and the limitations of animal models—what, if anything, can be said on the positive side? In addition to a nice appendix asking whether or not he might be wrong himself, Freedman leaves us with a few pointers to the kinds of research that might repay attention. Good advice, he writes, “will be complex, it will come with many quali- fications, and it will be highly dependent on conditions. Because of all the ‘ifs,’ ‘ands,’ and ‘buts,’ it will be difficult to act on. Because our beliefs tend to be simplistic and optimistic, it will be probably be incompatible with them. In other words, good expert advice will be at odds with every aspect of the sort of advice that draws us to it.” And although such sober advice is unlikely to induce euphoria in the reader, I’m not sure that the Delphic sibyl, high on her volcanic vapours, could have done better than that. Julian Sheather is deputy head of ethics, BMA [email protected] The oracle at Delphi: are modern day “experts” any more reliable? Cite this as: BMJ 2010;341:c4471

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MEDICAL CLASSICS Unsyphilised behaviour Guerilla Surgeon By Lindsay Rogers

It is said by his most who wrote: “I have First published 1957 important biographer BETWEEN never seen or heard Guerilla Surgeon is a long forgotten medical classic. Lindsay that after he reached THE LINES of a single instance in Rogers was a New Zealand surgeon working in Egypt during middle age Henrik Ibsen Theodore Dalrymple which a syphilitic infant the second world war who volunteered to work as a surgeon (1828-1906), the great (although its mouth be behind enemy lines with the Yugoslav partisans. He was initially sent to Vis, an island off the Dalmatian coast, and Norwegian playwright, ulcerated) suckled by its later to Croatia and Slovenia. His account, though beautifully never read anything own mother, had pro- written, often contrasts with his rather idyllic earlier life on other than the Bible and duced ulceration in her a farm in the South Island. His surgical work was done in newspapers. It did his breasts; whereas very conditions that were daunting, to say the least. He supervised plays no harm. few instances have five guerilla hospitals that were hidden in the forests, He wrote Ghosts in occurred where a often near to German troops. The hospitals had to be well 1881. The plot turns on syphilitic infant camouflaged, as the Germans made special efforts to locate what was then called has not infected a and destroy them. In remote areas, the hospitals and all their patients sometimes had to be moved every few days to avoid hereditary syphilis. strange, hired wet- discovery. Rogers often operated with no anaesthetics other Oswald, son of Mrs nurse. than raki and morphine. Sterile supplies were usually not A­lving, returns from In other words, moth- available. His descriptions of brain surgery and amputations in Paris, where he has lived ers of syphilitic infants these conditions are harrowing. for some years as an art- Sixty four years after could be infected with In his early 40s at the time, he often had to walk all night, ist in Bohemian circles. Fournier’s book, Charles and develop immunity sometimes in deep snow, to reach a hospital, where he would He has been told by a to syphilis without clini- operate all the next day. He would then walk on again that night Dennie and Sidney Pakula, to reach the next hospital. He makes light of his own privations, great specialist there cal signs or symptoms. in their massive tome which were nothing in comparison with the suffering of the that he has that dread Mrs Alving was one of Congenital Syphilis, wounded partisans he was treating. He met Tito, who greatly disease; and it emerges those mothers, and so impressed him, but was dismayed at the complete takeover that he contracted it confirmed all that Fournier it appeared that Oswald of the partisan movement by the communists, despite their from his father, the and Ibsen had written inherited syphilis from having little support among the population, who just wanted now dead Captain Alv- his father alone. rid of the Nazis. He presciently wondered whether Yugoslavia ing (who clearly died from neurosyphilitic Fournier also supplied the answer to would survive the national aspirations dementia), who lived a secret dissipated life the second question. In his huge book of Serbia, Croatia, and Slovenia. The book’s most moving sections but was regarded as a pillar of the respect- La syphilis hereditaire tardive (Late Onset are his stories of the lives of the able community. The whole play is an attack Hereditary Syphilis), published five years partisans he lived with. Many had seen on bourgeois hypocrisy and pharisaism, of after Ghosts, he states: “Hereditary syphilis their families murdered, their homes which hereditary syphilis is only a symbol. can do what acquired syphilis does, that is destroyed, and acts of unspeakable Two questions come to mind as one reads to say to express itself after a long interval, cruelty performed by the Nazis and their Ghosts. Can syphilis be transmitted by the indeed at a mature age.” collaborators. Rogers’s writing is always father alone? And can the mental symp- Even in his depiction of Oswald’s symp- sublime: “We never saw her again; toms that Oswald shows (severe headaches tomatology Ibsen is correct, according to somewhere in Bosnia is Goyko’s grave, somewhere in the mountains. I heard months later she died and loss of concentration and willpower) be the clinical science of his time. Fournier willingly, fell in the mud, her cap falling from her head and lying the first manifestations of congenital syphilis says: “One symptom that serves as the first with its Red star still gleaming against the snow beyond. The at such a late age? Oddly enough, eminent manifestation of hereditary cerebral syphi- gentians will be bluer there, and the crocus more golden and physicians of whom I asked these questions lis is headache.” This is just as in Oswald’s the nightingales’ song will be sweeter near where Goyko lies.” were unable to answer. case, followed, as Fournier describes, by an This book kindled in me an interest in Slovenia. One The great specialist whom Oswald con- inability to concentrate. It seems that Ibsen partisan hospital near the village of Cerkno was preserved as sulted in Paris is almost certainly based knew his Fournier. a museum, and a few years ago I made my pilgrimage there, on Alfred Fournier (1832-1914), who first Sixty four years after Fournier’s book, only to find that it had just been completely destroyed in a flash flood. (It is now being rebuilt.) Every village in Slovenia has a attributed tabes dorsalis to syphilis (before Charles Dennie and Sidney Pakula, in their partisan memorial, and the one in Cerkno has more than 700 the spirochaete had been discovered) and massive tome Congenital Syphilis, confirmed names inscribed on it, a horrifying toll for a small town of a few was also among the first to recognise the all that Fournier and Ibsen had written. thousand people. long term neuropsychiatric consequences Fournier estimated that in the middle years Rogers is forgotten even in New Zealand. He returned home of the disease. of the 19th century 15% of the French popu- after the war and served as a surgeon and general practitioner Shortly before Ghosts was published lation had syphilis. Were it not for the dis- in the small provincial town of Te Awamutu. After surviving Fournier wrote a book, Syphilis and Marriage, coveries of Wassermann, Ehrlich, and Hata, many close calls in the war he drowned while on holiday in New Caledonia. Like his great countryman Edmund Hillary in which he stated quite clearly that syphilis said Dennie and Pakula, “the world would he combined physical fortitude with great compassion and could be passed on by the father alone, with- by now be completely syphilised.” humanity. out there having been any signs of it in the As it is, we are almost completely unsyph- Paul Corwin, general practitioner, Cass, New Zealand mother. This was in accordance with the law ilised. [email protected] enunciated by Abraham Colles (1773-1843), Theodore Dalrymple is a writer and retired doctor Cite this as: BMJ 2010;341:c4484 the surgeon whose fracture we all know, Cite this as: BMJ 2010;341:c4496

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What junior doctors need

FROM THE Jeremy Vine was inflaming the middle aged masses on junior doctors’ mess. This was a flawed system, long on FRONTLINE BBC Radio 2 the other day, this time over the reduction experience but short on education. in junior doctors’ hours to 48. The profession was get- Today we see the reaction. Multidisciplinary working, Des Spence ting fried on the airwaves yet again. Looking back through shifts, induction, supervision, mentoring, e-portfolios, the rosy retrospectoscope, older people wonder what is union meetings, ever more doctors, structured training becoming of society and despair of the current genera- programmes, maternity, paternity, and family leave, part tion. But this new generation is our children, and young time training, antibullying policies, equality, structured doctors are merely younger versions of ourselves caught interviews, human resources departments, and proper in a medical system not of their making. pay: surely this protected generation has it all. But the So what of the past? We worked one in four nights and stories leaking from hospitals are of the end of medical normal hours during the day. There was no induction, and surgical firms, locums, unfilled posts, no continuity, no mentoring, and little senior supervision, and we often dysfunctional rotas, and absenteeism. A haemorrhaging made decisions beyond our ability and training. The care of happiness, goodwill, and professionalism: this is a of patients was put at risk. To begin with we made mis- flawed system long on education but short on experience. takes, but these were mistakes that could be prevented There must be a better way. by education. The pay was poor, but the long hours made Currently many senior doctors still work more than 48 up the money. Indeed, many of us did additional sessions hours, so junior colleagues should likewise be free to work because money was tight, and we were grateful for the longer, up to 65 hours. The Working Time Directive must work. We had almost no sickness absence; this was no be renegotiated, and this should be supported by the BMA. machismo culture, but we felt like comrades in arms in a The practice of medicine and surgery cannot be learnt, clinical conflict zone. Study leave was getting the day off only experienced. Good judgment comes from experience; to sit your exam. experience comes from bad judgment. So we should allow We worked in teams, and our next jobs depended on junior doctors to earn self respect and assert professional- our references, because there was little formal career ism in the front line once again. structure. There was some bullying, but no one com- Des Spence is a general practitioner, Glasgow [email protected] plained. Our retribution was to deride the bullies in the Cite this as: BMJ 2010;341:c4497

“We need a short quote”

OUTSIDE THE BOX I was recently invited to attend and leading, through follow-up phone phone call from Francesca of the Trisha Greenhalgh a media training day by our calls and drafting of outlines, to a Daily Blurb, with no warning of the corporate affairs department, shortlist of pieces to be considered by topics to be raised. In the afternoon which all universities have these the section editor in late afternoon. we progressed to a role play of a live days. Conscripts had two things Pieces selected to run are sharpened television interview. “Professor, I in common: we did research in and by evening will be set out on the understand that you’ve just done controversial or sensitive areas, and page under bold, five word headlines. a sex change on a minor. Are you we were incapable of converting All this means that the phone call planning on doing any more?” profound academic insights into pithy that interrupts your clinic at 11.30 am After four takes, the trembling soundbites. must be answered with two short endocrinologist managed to produce Our trainer was a feisty woman sentences—what you’ve discovered a coherent lay explanation of how the whose pedigree included seven and why it matters—before 2 pm, management of congenital adrenal years as assistant editor of a leading or you will lose the opportunity for hyperplasia differs from gender national tabloid newspaper. I your painstaking five year research reassignment. calculated that she could have been study to become news. In the absence Here are some take home tips. the person who ran the front page of superlatives (“biggest,” “best,” Prepare two or three key messages story that was based loosely (and I “first”) and unequivocal numerical and learn them by heart. Use the do mean loosely) on a piece I had data (“one in four schoolchildren”) politician’s trick of shifting the written in this column on abortion, you are likely to end up “spiked” agenda (“I can’t comment on that, but but I thought it unwise to confront her (rejected by the editor) or relegated what I do know is”). And finally, of about this. from the news (front) pages to course, nothing is “off the record.” She explained that the making features (the bits at the back that only Trisha Greenhalgh is professor of primary of scientific news occurs in a tight your elderly mum reads). health care, University College London 24 hour cycle, beginning with an In one exercise we were each sent [email protected] analysis of the day’s press releases into the corridor in turn to await a Cite this as: BMJ 2010;341:c4493

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