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From the Townsend Letter
February / March 2012

briefed by Jule Klotter
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Breast Thermography
Thermography, which measures the amount of infrared radiation (heat) emitted by an object, has been used in medical imaging for over 50 years. Because it is low-cost and noninvasive, and does not expose sensitive breast tissue to radiation, thermography has been promoted as an alternative to mammography for breast tumor detection. Tumors usually emit more heat than surrounding tissue due to their increased blood supply (angiogenesis). In addition, cancer cells have a higher metabolic rate than normal cells. The FDA has approved digital thermography as a supplement to mammography and breast MRIs, particularly for use when the results of the initial screen are ambiguous. It is not, however, recommended for initial, stand-alone screening.

New camera technologies that record variations in skin temperature and digital software for interpreting the images have greatly improved thermography's accuracy in recent years. At this point, however, thermography's ability to identify breast tumors in nonsymptomatic women is not superior to mammography's, according to medical literature. "[Digital thermography] is limited by the fact that thermal recordings are only a physiologic measure," state Nimmi Arora, MD, and colleagues, "and therefore must be used as an adjunct to another test such as mammography or ultrasound."

Arora and colleagues at New York Presbyterian Hospital (Cornell, NY) conducted a 2009 clinical study to evaluate thermography using the Sentinel BreastScan (SBS; Infrared Sciences Corp., Bohemia, NY). They recruited 92 women with abnormal mammography or ultrasound results to undergo thermography before their scheduled biopsy. The imaging unit found 58 of 60 malignancies, a high sensitivity of 96.7%. Its specificity (the ability to exclude nonmalignancies) was only 44%; thermography indicated malignancies in 19 of the 34 women whose biopsies were benign.

A 2010 study involving 100 women scheduled for a breast needle core biopsy also used Sentinel BreastScan technology. In this study, the British researchers also employed No Touch BreastScan software to analyze the thermal images. They reported only 53% sensitivity for the Sentinel's screening mode, compared with 96.7% obtained by the New York researchers. With the software, sensitivity rose to 70%. "Sensitivity (78%) and specificity (75%) using NoTouch BreastScan were higher in women under 50," G. C. Wishart and colleagues report, "and the combination of mammography and [digital infrared breast scan], with NoTouch interpretation, in this age group resulted in a sensitivity of 89%."

How can results be so different when using the same technology? As with any assessment tool, thermography's accuracy depends upon the technician's skill, routine calibration of the machine, and correct patient preparation. E.Y.-K. Ng, a scientist at the National University Hospital of Singapore, discusses several factors that affect body surface temperature, including circulatory problems, trauma, muscular inactivity (or activity), regular cigarette smoking, stimulants, and inflammation (including sunburn). In the hours before thermography, Ng advises patients to avoid exercise, smoking, alcohol, tight clothing, physical therapy, eating large meals, and the use of lotions, creams, and powders. Because thermography measures heat, the tests should take place in a room with stable ambient temperature that is comfortable for an unclothed patient.

Ng says, "Both [infrared radiation] imaging and mammography technologies are of the complimentary [sic] nature. Neither used alone is sufficient, but when combined, each may counteract the deficiencies of the other."

Arora N, Martins D, Ruggerio D, et al. Effectiveness of a noninvasive digital infrared thermal imaging system in the detection of breast cancer.
Am J Surg. October 2008;196(4):523–526. Available at Accessed November 30, 2011.

Neubauer K. Are breast thermograms accurate enough to use?
Nat Med J. November 1, 2011. Available at Accessed November 17, 2011.

Ng E Y-K. A review of thermography as promising non-invasive detection modality for breast tumor.
Int J Therm Sci. 2009;48:849–859. Available at Accessed November 17, 2011.

Wishart GC, Campisi M, Boswell M, et al. The accuracy of digital infrared imaging for breast cancer detection in women undergoing breast biopsy [abstract].
Eur J Surg Oncol. June 2010;36(6):535–540. Available at Accessed November 30, 2011.

Mind Filters on the Internet
Without our knowing it, the Internet is shape-shifting from a tool that expands knowledge to one that simply reinforces personal biases. Eli Pariser, author of the Filter Bubble: What the Internet Is Hiding from You (New York: Penguin Press, 2011) said on the news program Democracy Now that "personalization" has become the guiding force behind the algorithms that manipulate and transfer information. Google, for example, gives search results that the algorithms say you "want," according to the constant stream of information that it gathers as you browse the web. Results from a search now vary from person to person, depending upon an individual's profile.

These new algorithms prioritize, theoretically making it easier to find the desired information; but personalization is also a boon to marketers. "What was once an anonymous medium where anyone could be anyone … is now a tool for soliciting and analyzing our personal data," Pariser writes in his book. Each of the top 50 Internet sites – such as CNN, MSN, and Yahoo – install software that tracks viewers' movements, says Pariser, citing a Wall Street Journal study. "Search for a word like 'depression' on," Pariser warns, "and the site installs up to 223 tracking cookies and beacons on your computer so that other Web sites can target you with antidepressants."

Instead of allowing diverse cultures and viewpoints to interact on the web, personalization threatens to keep us ensconced in our biases. By analyzing past usage to predict what a person wants, today's search engines create a "filter bubble," says Pariser. Pariser asked two white, female friends to Google search "BP" during the 2010 Gulf oil spill. Both lived in the Northwest and had the same political leanings and comparable education. For one, links to news about the oil spill showed up on the first search page. The other woman, however, was puzzled to find only information that promoted investing in BP – no news about the spill at all on that first page (the one that most people view). She couldn't figure out what in her profile would call up such results.

When Pariser "friended" two people with strong conservative views, Facebook deleted them because the people he had added to his friends list did not fit Pariser's profile. "You may think you're the captain of your own destiny," Pariser writes, "but personalization can lead you down a road to a kind of informational determinism in which what you've clicked on in the past determines what you see next. … You can get stuck in a static, ever-narrowing version of yourself – an endless you-loop."

Can individuals avoid the filter-bubble trap? Collecting personal data in order to target personalized advertising is big business; Google, Facebook, and others make big bucks selling this information. Nonetheless, Pariser offers several ideas in his book and on his website Erasing "cookies" that track Internet use helps – if it's done regularly. (Select "Options" or "Preferences" on your browser and then "Erase cookies.") Perhaps, more importantly, adhere to Pariser's admonition: "Stop being a mouse." Instead of repeatedly visiting the same websites each day, vary your routine. Seek out different types of websites. Exposure to diverse ideas fosters open-mindedness, mental flexibility, and creativity.

Pariser E. The Filter Bubble: What the Internet Is Hiding from You. New York: Penguin Press. 2011.

Managing Hot Flashes with Hypnosis
Researchers at Baylor University (Waco, Texas) have initiated a randomized controlled study to investigate hypnosis as a treatment for hot flashes. Hot flashes, those sudden vasodilations and volcanic rushes of heat that overtake about two-thirds of postmenopausal women, rank at the top of common menopausal complaints. Sweating, flushing, palpitations, anxiety, irritability, and panicky feelings can accompany them, disrupting sleep and decreasing quality of life. Hot flashes tend to be more severe in women who receive chemotherapy for breast cancer and/or antiestrogen therapy, such as tamoxifen. These medications decrease estrogen levels more quickly than occurs during normal menopause.

Equine-derived estrogen-progestin replacement therapy was commonly prescribed to treat menopausal symptoms until the Women's Health Initiative trial reported that these hormones increased the incidence of breast cancer and the risk of cardiovascular disease and stroke. Women and health-care providers began looking for alternatives. Antidepressants have helped some women, but the drugs tend to have negative side effects. Since hot flashes appear to be linked to an overdrive in the sympathetic nervous system, stress management techniques, such as hypnosis, may be beneficial.

In 2007, Gary Elkins, a professor at Baylor University's Psychology and Neuroscience Department, led a small pilot study that looked at hypnosis's ability to reduce hot flashes in 16 breast cancer survivors. Each of the participants received four weekly sessions and instructions on the use of self-hypnosis. At baseline and posttreatment, patients rated how much the hot flashes interfered with daily activities and affected life quality. They also kept daily records of hot flash frequency and severity. Mean hot flash score declined 70% from baseline to the end of treatment, far exceeding the 20% to 30% effect attributed to placebo. The researchers note that the reduction "… is comparable to or higher than that achieved through non-hormonal pharmacological interventions such as veralipride, methylodopa, clonidine, venlafaxine, paroxetine, citalopram, and mirtazapine." Reported interference with daily activities also declined. This pilot study is limited by the small number of participants, all of whom were interested in hypnosis, and by the lack of a control.

In a 2008 NIH-funded trial, also led by Elkins, 60 breast cancer survivors (no evidence of recurrent disease) were randomly assigned to receive hypnosis or no treatment. At baseline, the women reported having a minimum of 14 hot flashes per week for at least a month. Those assigned to the hypnosis group received weekly 50-minute sessions with a psychologist trained in hypnosis for five weeks. During hypnosis, the psychologist conveyed "suggestions for relaxation, mental imagery for coolness, and positive imagery for the future." This group also received instructions and audiotapes for self-hypnosis. "By the end of the intervention, hot flash scores had fallen 68% from baseline in the hypnosis group (p<0.001) [compared to the no-treatment group] … in which scores fell 9% from baseline. Patients in the treatment group also reported decreases in anxiety and depression and less interference in their daily activities and sleep," according to Dr. Andrew M. Kaunitz's report for Journal Watch Women's Health.

In 2011, Elkins and colleagues announced a study protocol for an ongoing randomized clinical trial involving 180 postmenopausal women (instead of breast cancer survivors) suffering from hot flashes. In this study, the women will be randomly assigned to receive five sessions of hypnosis or five sessions of structured-attention control. All participants will be followed for 12 weeks after treatment. In addition to keeping daily diaries, participants will undergo 24-hour ambulatory skin conductance monitoring to measure hot flash frequency, as well as salivary cortisol sampling (taken four times during the same day at baseline and at the end of five sessions), and complete measures of anxiety, depression, sexual functioning, sleep quality, and the Hot Flash Related Daily Interference scale. The use of objective physiological measurements adds an interesting twist to the study of this centuries-old mind-body therapy.

Elkins G R, Fisher WI, Johnson AK. Hypnosis for hot flashes among postmenopausal women study: A study protocol of an ongoing randomized clinical trial. BMC Complement Altern Med. 2011;11:92. Available at Gale Health Reference Center Academic database. Accessed December 5, 2011.

Elkins G, Marcus J, Stearns V, Rajab MH. Pilot evaluation of hypnosis for the treatment of hot flashes in breast cancer survivors. Psycho-Oncology. 2007;16:487–492. Available at EBSCO database. Accessed December 5, 2011.

Kaunitz AM. Hypnosis for hot flashes in breast cancer survivors? [abstract and commentary]. J Watch Womens Health. October 23, 2008. Available at Gale Health Reference Center Academic database. Accessed December 5, 2011.

Nuclear Accidents and Health Effects
Few, if any, environmental challenges produce the health and societal effects of major nuclear catastrophes such as Chernobyl and Fukushima. Scientists are still gathering data about the April 26, 1986, accident at the Chernobyl reactor, which released massive amounts of radioactive isotopes across the northern hemisphere. Most health effects of Fukushima's nuclear meltdown after the March 2011 earthquake and tsunami are still unknown.

Months before Fukushima, Janette D. Sherman, MD, a toxicologist who specializes in substances that cause birth defects and cancer, and Alexey V. Yablokov, PhD, wrote "Chernobyl: Consequences of the Catastrophe 25 Years Later," a 2010 article that outlines the health effects of external and internal (absorbed by ingestion and inhalation) radiation. Yablokov and colleagues Vasily Nesterenko and Alexey Nesterenko abstracted and translated 5000 primarily Slavic studies into English to produce a compendium of firsthand scientific reports about the effects of Chernobyl: Chernobyl: Consequences of the Catastrophe for People and the Environment (New York Academy of Sciences, 2009). Sherman edited their book.

Even 25 years later, no one knows the full consequences of Chernobyl. "The effects from the Chernobyl catastrophe change over time, many ongoing and some increasing in adverse effect as, for example, Plutonium-241 (Pu-241) that decays to Americium-241 (Am 241), with a half-life of 432 years," Sherman and Yablokov explain. "Am-241 is water-soluble, moves through the food chain, and emits both gamma and alpha radiation." In contrast, radioactive iodine-131, which causes thyroid cancer, degrades within months. (Iodine-129 is also released but takes millions of years to degrade.) But cancer is not the only threat. Data from Chernobyl show that "… for every case of thyroid cancer there are about 1,000 cases of other forms of thyroid gland pathology." In addition to affecting growth and metabolism, thyroid disruption that occurs in uterodecreases intelligence.

Radiation exposure, even in small amounts, damages the brains of both unborn infants and young adult clean-up workers, according to recent studies: "These organic changes are reflected in nervous system dysfunction, including perception, short-term memory, attention span and operative thinking and result in behavioral and mental disorders and diminished intelligence." A 2007 study by D. Almond and colleagues found that Swedish schoolchildren whose mothers lived in areas that received the most fallout during key times in their pregnancy were "significantly less likely to qualify for high school."

While radioisotope exposure can produce cancer, Chernobyl scientists were surprised to find that much of the morbidity so far has stemmed from radioactive destruction of endothelial tissue (inner lining of blood vessels). Heart disease claimed about 55% of the young clean-up workers who had died by 2005. Blood diseases, including leukemia, have also increased among workers, children, and the general population in contaminated areas. Other physiological effects attributed to Chernobyl include respiratory damage, immune suppression, reproductive and urogenital disorders, chromosomal aberrations, and bone and joint pain.

The meltdowns and explosions at Fukushima nuclear reactors after Japan's March 11, 2011, earthquake and tsunami created exposures equal to or greater than Chernobyl's. Health effects, however, may be more difficult to track. In a 2012 paper, published in International Journal of Health Services, Joseph J. Mangano, MPH, MBA, and Sherman state that the number of environment samples taken by the US Environmental Protection Agency (EPA) in the weeks after Fukushima were "far fewer than those taken and reported in the [comparable] period after Chernobyl." After Chernobyl, the EPA took at least 2304 milk samples and found barium-140, cesium-137, and iodine-131 in 2000 of them (86.8%). After Fukushima, the EPA took only 670 milk samples and found isotopes in just 2.2%. In addition, the EPA chose to take fallout measurements quarterly instead of weekly just three weeks after the earthquake. "Clearly, the 2011 EPA reports cannot be used with confidence for any comprehensive assessment of temporal trends and spatial patterns of U.S. environmental radiation level originating in Japan," Mangano and Sherman write.

In order to determine Fukushima's early health effect in the US – if any – Mangano and Sherman decided to use preliminary CDC mortality data for 122 cities to look for mortality changes. "Deaths rose 4.46 percent from 2010 to 2011 in the 14 weeks after the arrival of Japanese fallout, compared with a 2.34 percent increase in the prior 14 weeks," they report. Because infants are particularly sensitive to environmental toxins, Mangano and Sherman also tracked infant deaths and found a 1.8% increase during the 14 weeks after fallout reached the US (2674 during week 12 rising to 2722 during week 25) compared with a decline of 8.37% (2520 to 2309) during the 14-week period preceding fallout's arrival.

Sherman and Mangano published a controversial article in the San Francisco Bay View (June 9, 2011) and another in CounterPunch (June 10–12, 2011) describing their observations about changes in infant mortality rates in the weeks after Fukushima. These articles focused on eight Pacific Northwest US cities that had received high levels of iodine-131 (and presumably other isotopes) during the week of March 22, according to EPA measurements. (After this week, the EPA decided to take quarterly, instead of weekly, measurements.) Because of the many criticisms that Mangano and Sherman received, "accusing [them] of scaremongering and deliberate fraud," they revisited their analysis in a June 25, 2011, article: "Given the fallibility of humankind, we may have erred, and if so, will admit it. Given the delay in collecting data and the incompleteness of the collection, the criticism may be valid."

Mangano and Sherman looked at infant deaths for weeks 8–11 (pre-Fukushima) to weeks 12–21 (post-Fukushima). They also looked at data for the same weeks during the previous six years (2005–2010). When comparing the number of infant deaths that occurred during the four weeks (8–11) to the number that occurred during the 10-week period (12–21), they found a 2.8% increase in deaths in 2009 (lowest change) to a 10.9% increase in 2010 (highest change). In 2011, however, infant mortality for these eight cities rose 35.1% during the comparable time periods. Mangano and Sherman hope that this information will push the Japanese and US governments to be more forthcoming about radioactivity in the environment. They assert,
"…infant mortality is an indication of an entire population's health. When an unusual number of babies are dying, we are all at risk and must take a stand."

"'Fukushima is the biggest industrial catastrophe in the history of mankind,' Arnold Gundersen, a former nuclear industry senior vice president, told Al Jazeera [June 16, 2011]. '… The data I'm seeing shows that we are finding hot spots further away than we had from Chernobyl, and the amount of radiation in many of them was the amount that caused areas to be declared no-man's-land for Chernobyl.'" Because Fukushima's reactors are so close to the ocean, radioactive isotopes will accumulate in seafood and seaweeds. Even though cesium isotope levels declined in the months after the earthquake, July's measurements showed cesium-137 levels in Japan's coastal waters to be over 10,000 times higher than levels measured in 2010. Government agencies are willing to point out declines in external radiation but never talk about the threat of internal radiation that occurs as we eat and breathe contaminants in our food and the environment.

Will Earth experience another Chernobyl or Fukushima? Probably. Even without an earthquake, hurricane, or other natural disaster, our 40-year-old nuclear reactors are vulnerable to simple mechanical aging; and the Nuclear Regulatory Commission is extending operating licenses for an additional 20 years, according to Tom Zeller Jr. As the Fukushima tragedy unfolded last year, I wrote my senior US senator, asking him to oppose federal subsidies for nuclear energy in the US; without government support, the nuclear industry would fold. His form letter affirmed that the US nuclear industry is the best in world. What a frightening thought.

"Nuclear fallout knows no state or national boundaries and will contribute to increase in illnesses, decrease in intelligence and in instability throughout the world," Sherman and Yablokov warn. "The economic costs of radioactive pollution and care of contaminated citizens are staggering. No country can maintain itself if its citizens are economically, intellectually, politically and socially impoverished."

Almond D, Edlund L, Palme M. Chernobyl's Subclinical legacy: prenatal exposure to radioactive fallout and school outcomes in Sweden [online article]. 11, 2007. Accessed January 2, 2012.

Buesseler K, Aoyama M, Fukasawa M. Impacts of the Fukushima nuclear power plants on marine radioactivity. Environ Sci Technol. 2011:45:9931–9935. Available at Accessed December 14, 2011.

Jamail D. Fukushima: it's much worse than you think. Al-Jazeera-English. June 16, 2011. Available at Accessed December 28, 2011.

Mangano JJ, Sherman JD. An unexpected mortality increase in the United States follows arrival of the radioactive plume from Fukushima: is there a correlation? Int J Health Serv. 2012;42(1);47–64. Available at Accessed December 20, 2011.

Sherman JD, Mangano JJ. Question marks, the elephant in the room and the refusal of nuclear power defenders to consider what has happened to people and the environment since Fukushima and Chernobyl. San Francisco Bay View. June 25, 2011. Available at Accessed December 10, 2011.

Sherman JD, Yablokov AV. Chernobyl: Consequences of the catastrophe 25 years later. 2010. Available at Accessed December 10, 2011.

Zeller T. Nuclear agency is criticized as too close to its industry. The New York Times. May 7, 2011. Available at Accessed December 10, 2011.

Mouth Rinse Reduces Preterm Birth
Pregnant women with periodontal disease are more likely to give birth prematurely, heightening the infant's risk of potentially life-threatening respiratory, gastrointestinal, and other problems. At this point, researchers are still unsure whether periodontal disease actually causes preterm births, as smoking does. It may simply be an association. (Both gum disease and preterm birth, for example, could stem from similar nutritional issues.) A 2011 study, however, found that use of a nonalcohol, antimicrobial mouth rinse (Proctor & Gamble's Crest Pro-Health) decreased the number of preterm births (<35 weeks) in a group of high-risk women. The study was conducted by two researchers at University of Pennsylvania and two scientists employed by Proctor & Gamble Co.

The single-blind study involved 226 pregnant women (6–20 weeks' gestation) with periodontal disease who refused dental care, such as scaling and root planning. One-third of the participants received the test rinse, which contains the antimicrobial cetylpyridinium chloride (0.07%). The remaining two-thirds simply rinsed with water. The two groups had similar percentages of women with preterm-birth histories and smokers. All participants underwent dental and obstetric exams at baseline and additional dental exams three months and six months later (unless the baby had been born). Spontaneous preterm birth (<35 weeks) was "significantly (P<.01) lower in the rinse group (4/71, 5.6%) than in the control group (34/155, 21.9%)." Gum disease worsened in the group of women who rinsed with water; the group had a 56% increase in periodontal bleeding sites and increased probing depth, while the mouth-rinse group showed little change from baseline. The study, published in American Journal of Obstetrics & Gynecology, includes no information about other aspects of participants' oral care: which toothpaste they used, whether they flossed, how often they brushed their teeth, and so on.

Other mouthwashes may be just as effective. A 2007 study found that Crest Pro-Health and Listerine, which contains essential oils and alcohol, showed "no statistically significant difference in the anti-plaque and anti-gingivitis benefits." The group using Crest-Pro-Health, however, showed significant reduction in bleeding sites compared with the Listerine group. Cetylpyridinium chloride (CPC) has the negative effect of staining teeth. Crest Pro-Health contains a higher percentage of the chemical than other CPC mouthwashes on the market, Scope (0.045% CPC) and Cepacol (0.05% CPC).

Albert-Kiszely A, Pjetursson BE, Salvi GE, et al. Comparison of the effects of cetylpyridinium chloride with an essential oil mouth rinse on dental plaque and gingivitis – a six-month randomized controlled clinical trial. J Clin Periodontol. August 2007. 34(8):658–667. Available at Accessed December 21,2011.

Bacca LA, Doyle MJ, Macksood DM, Lanzalaco AC. Comparative effects of cetylpyridinium chloride mouthrinses on plaque glycolysis and regrowth. Presented at the 75th General Session of the IADR. Orlando, Florida, March 19–23, 1997. Available at Accessed December 10, 2011. (Note: To access, type into address http://www.)

Jeffcoat M, Parry S, Gerlach RW, Doyle MJ. Use of alcohol-free antimicrobial mouth rinse is associated with decreased incidence of preterm birth in a high-risk population. Am J Obstet. October 2011;382–383.

Lisante T, Askinazi JA, McGuire JA, Hee A, Williams KP. The staining potential of various currently-marketed mouthrinses. Presented at AADR Annual Meeting Washington, DC, March 4, 2010. Available at Accessed January 3, 2012.

Morrissette C. Common preemie health problems [online article]. August 14, 2010 (update). Accessed January 2, 2012.

Health Consequences of Sexual Violence
No single factor affects women's health and well-being more than the threat and incidence of sexual violence and rape. Worldwide, more women ages 15 through 44 become disabled and die because of physical and sexual violence in any year than from cancer, malaria, traffic accidents, and war combined, according to the World Health Organization (1997). In the US, the National Violence Against Women Survey (2000) found that an estimated 1 in 6 women and 1 in 33 men had been victims of either rape or attempted rape. The incidence of rape is even higher in the US military. One in three female US soldiers has been sexually assaulted or raped, usually by fellow soldiers, while on active duty, according to the Department of Veterans Affairs' estimates.

Contrary to prevailing beliefs, rape is not an act of sexual passion. It is an act of violence, usually premeditated and primarily motivated by anger and the desires to control, humiliate, and exercise power over another person. Neither female nor male victims "ask for it." In rape, the sex act is a weapon, a weapon commonly used in wars. Hundreds of thousands of women and girls during Rwandan genocide in 1994 and in the recent Democratic Republic of Congo war have been raped by soldiers.

Sexual violence has numerous physical and psychological consequences for the victims. Genital-anal trauma, sexually transmitted disease, pregnancy, and miscarriage (if the woman is pregnant) are physical effects that arise shortly after a rape. Other complaints that can continue for years after the trauma include chronic headaches, fatigue, sleep disturbance, recurrent nausea, decreased appetite, eating disorders, severe menstrual pain, excessive/prolonged menstrual bleeding, and sexual dysfunction. In addition, rape victims can suffer from depression, social phobia, and posttraumatic stress disorder. They are also more likely to abuse alcohol, illegal drugs, and prescription drugs. Many, many women suffer from these physical and psychological symptoms. Only a percentage of them have survived the trauma of sexual violence; but to truly heal, this percentage needs the perceptive help of health-care practitioners who will screen for sexual violence and guide them to appropriate care.

Arizona Department of Health Sciences. Sexual Violence Prevention and Education Program [Web page]. Accessed December 5, 2011.

Basile KC, Lang KS, Bartenfeld TA, Clinton-Sherrod M. Evaluability assessment of the rape prevention and education program: summary of findings and recommendations. J Womens Health. 2005;14(3):201–207. Available at CINAHL Plus with Full Text database. Accessed December 5, 2011.

Broadbent L. Rape in the US military: American's dirty little secret. The Guardian. December 9, 2011. Available at December 10, 2011.

Hamlin J. List of rape myths [Web page]. 2001. Sociology of Rape; University of Minnesota Duluth. Accessed December 5, 2011.

Martin SL, Macy RJ. Sexual violence against women: impact on high-risk health behaviors and reproductive health [online document]. June 2009. VAWnet, a Project of the National Resource Center on Domestic Violence/Pennsylvania Coalition Against Domestic Violence. Accessed December 5, 2011.

World Health Organization. Violence against women – facts and figures [Web page]. Available at: Accessed December 5, 2011.

Clinical Trials and Women
Until the passage of the National Institutes of Health (NIH) Revitalization Act of 1993, few clinical trials enrolled women. Those who conducted drug trials were concerned about effects on fetuses and flummoxed by the problem of controlling for female hormone cycles. Clinical trial researchers primarily recruited men for their studies and assumed that results pertained to women as well. But menstrual cycles and pregnancy are by no means the only physiological differences between genders. "Sex-based differences in natural history of disease, epidemiology, pathophysiology, diagnostic accuracy of tests, response to therapy, and outcomes have all been identified in a range of diseases and conditions previously thought to be 'gender neutral,'" write Sharonne N. Hayes, MD, and Rita F. Redberg, MD, MSc, in an editorial for Mayo Clinic Proceedings. Cardiovascular disease, non-gender-specific cancers, degenerative joint disease, and mental health problems are among the many illnesses that exhibit different pathophysiology according to gender.

While the number of women included in clinical studies has increased since 1997, women continue to be underrepresented. Hayes and Redberg refer to a 2008 study that shows a disparity in the research evidence used to make Medicare medical decisions. Only 25% of the studies' participants were female, but women account for 58% of all Medicare recipients (Arch Intern Med. 2008;168(8):136–140). Given the known differences in pathophysiology between genders, one has to question current evidence used to make medical decisions for female Medicare recipients.

Because of the NIH Revitalization Act of 1993, NIH-funded trials are required to include both genders whenever appropriate. (Clearly, women would not take part in prostate research.) Studies that do not receive NIH funding, however, are not required to include women. Mary A. Foulkes, PhD, reviewed the enrollment of NIH-funded phase 3 trials for her 2011 report. She found that "an overall average enrollment of 37% (±6% standard deviation) women, at an increasing rate over the years 1995-2010." She also discovered that enrolling more women in research studies is only part of the story. Despite the requirement to include women, only 28% of the articles indicated that the researchers considered gender differences. Gender-specific results are not appearing in journal articles, so practitioners cannot use the information gained, and researchers cannot use the information in designing future studies. Foulkes would like to see journal editors require an analysis of gender differences as part of their publication guidelines. Hayes and Redberg concur and suggest that, at the very least, a study's gender-specific data be available online. "Analyzing data by sex for conditions or treatments affecting both men and women is the only way we will be able to begin to provide optimal care for all patients," Hayes and Redberg assert, "and is a critical step toward the ultimate goal of 'individualized medicine.'"

Foulkes MA. After inclusion, information and inference: reporting on clinical trials results after 15 years of monitoring inclusion of women. J Womens Health. 2011;20(6):829–836. EBSCOhost Health Source:Nursing/Academic database. Accessed December 3, 2011.

Hayes SN. Redberg RF. Dispelling the myths: calling for sex-specific reporting of trial results [editorial]. Mayo Clin Proc. May 2008;83(5):523–525. EBSCOhost Health Source: Nursing/Academic database. Accessed December 3, 2011.

Women's Health – Past and Present
The 1960s was a time now thought of as enlightened and full of activism, yet it was also a time when unmarried women couldn't legally obtain birth control in many places. When men and women shied away from speaking about sexual pleasures and problems, when women were routinely excluded from clinical drug trials, and when physicians didn't think their female patients were capable of understanding detailed diagnoses. It was a time when privileged white women could only seek sterilization if they'd already had a certain number of children and when poor women and women of color might be sterilized without their knowledge or consent. (Norsigian)

In an essay adapted from her acceptance speech for the 2011 Humanist Heroine award presented by the Feminist Caucus of the American Humanist Association (April 9, 2011), Judy Norsigian talks about past and present women's health issues. Norsigian is executive director and cofounder of the Boston Women's Health Book Collective, which produced the book Our Bodies, Ourselves in 1971. Our Bodies, Ourselves, the culmination of numerous workshops and meetings, was the first health resource written for women by women to provide "firsthand, straightforward guidance about [women's] health and sexuality." The book has been the prototype for 29 foreign editions. Boston Women's Health Book Collective has also generated the books Our Bodies, Ourselves: Menopause (2006) and Our Bodies, Ourselves: Pregnancy and Birth (2008).

Although US women today have better access to birth control and are more knowledgeable about their bodies than generations before them, many challenges to women's health and well-being remain. Access to a safe abortion and young women's right to obtain reliable information about sex and reproduction continue to be controversial in some states. So far, opponents have not forced a return to unsafe backroom abortionists or to self-induced abortion attempts. Moral questions aside (and those, I believe, are the province of the individual), women throughout history have always turned to abortion when birth control methods fail and they cannot abide having a child.

Childbirth itself is another area of concern. Like other women's health advocates, Norsigian is disturbed by the increased use of medically unnecessary labor inductions and the high rate of cesarean (surgical) births in the US. Women need to be educated about the risks to mothers and babies that accompany these practices. The high cesarean rate is supported in part by restrictive hospital policies that prohibit vaginal birth after having had a child by cesarean (VBAC). Doctors and advocates are working to change these policies. Norsigian promotes the use of midwifery "both inside and outside the hospital." The midwifery model views childbirth as a natural physiological event that best proceeds without unnecessary medical intervention.

The emergence of the commercial egg donation industry poses another threat to young women. Drugs used to suppress and then hyperstimulate the ovaries' egg production can have serious and long-lasting effects. Young women, who may undergo the procedure in order to make money, need to be educated about the risks, explained in the documentary Eggsploitation.

Norsigian views the pharmaceutical industry's influence on practitioners and patients as another major threat to women's health. In order to sell more products, drug companies have engaged in "disease-mongering." The companies regularly use pharmaceutical reps, direct-to-consumer advertising, and other public-relations strategies to convince doctors and patients that one of their drugs will cure a newly recognized health problem. For example, Pfizer latched onto the results of a 1992 survey of approximately 1500 women for its widely publicized assertion that 43% of American women have female sexual dysfunction (FSD), according to journalist Roy Moynihan. Women who reported having just one of seven problems in the survey – such as lack of desire for sex, anxiety about sexual performance, and difficulties with lubrication – for two or more months within a year were categorized (but not clinically diagnosed) as having sexual dysfunction. Pfizer was seeking an expanded market for Viagra at the time. Dr. Sandra Leiblum told Moynihan that Pfizer's tactics "… contributed to an overmedicalisation [sic] of women's sexuality, where changes in sexual desire are the norm." As Norsigian explains, many factors determine women's sexual experiences, including "… understanding one's own anatomy (where the clitoris is, for example), what kind of stimulation works best for a particular woman, what kind of environment is essential to producing a comfort level that allows for the experience of sexual feelings, and so forth."

Norsigian ends her essay by talking about the ubiquitous threat of violence that women experience: "… in many surveys of women across the globe, they identify violence as the biggest threat to their health and wellbeing – not cancer or inadequate maternity care or lack of access to healthcare in general. And this is primarily about violence perpetrated by men against women." Advocacy groups such as  the White Ribbon Campaign are raising public awareness about violence against women and teaching young men and boys to "never commit, condone, or remain silent about violence against women and girls" ( Violence against women will not end without education and cultural transformation. The White Ribbon Campaign, initiated by Canadian men in 1991, has spread to over 60 countries, including the US.

Moynihan R. The making of a disease: female sexual dysfunction. BMJ. January 4, 2003;326(7379). Available at Accessed January 4, 2012.

Norsigian J. The body business: challenges facing women's health advocates today. Humanist. November-December 2011;71(6):21. Available at GALE Health Reference Center Academic database. Accessed December 5, 2011.


Jule Klotter


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