“Medicine and health sciences don’t exist in isolation from their broader social, cultural, and political contexts,” said Chelsea Clinton, vice chair of the Clinton Foundation, and adjunct assistant professor at the Columbia University Mailman School of Public Health, to Dr. Randi Hutter Epstein, the writer-in-residence for the Yale Program for Humanities in Medicine.
The two were speaking during a lunchtime conversation on Sept. 27 about Epstein’s new book, “Aroused: the History of Hormones and How They Control Just About Everything.”
“One of the things I think you do a really excellent job of in your book is teasing out how culture has influenced what questions were asked, what research was done, and also what wasn’t done,” Clinton said.
In front of a packed auditorium at the Yale School of Medicine, Clinton and Epstein spent an hour discussing “Aroused,” pulling out topics and themes from the book that were particularly relevant to the audience of current and future doctors. Anna Reisman, director of the Program for Humanities in Medicine and associate professor of medicine, introduced the two speakers.
Culture influences medical practice, research
Clinton asked Epstein to give an example of the ways cultural concerns have shaped research questions for the medical field. Epstein pointed first to the 1920s and 1930s, when researchers were asking not only “What are ovaries and testes secreting?” but also — which perhaps got at what they really wanted to know, she noted — “What makes a man a man and a woman a woman?”
The scientists directed their research with the idea of difference between sexes in mind, explained Epstein, so when they discovered the sex hormones during these decades, “it became estrogen equals woman, testosterone equals man.” She emphasized that the division drawn nearly 100 years ago created a “false binary that has stuck with us.”
In the 1950s, scientists identified human growth hormone (HGH), the hormone secreted by the pituitary gland that stimulates growth, cell reproduction, and cell regeneration. Epstein raised this as another example of science and culture mutually obsessing over a new discovery.
“What drove the interest in HGH?” she asked. “It wasn’t just doctors saying, ‘I’m going to dump all this growth hormone on kids.’ It was people reading magazines that said, ‘Your short boys are doomed. They’ll never get married, they’ll never get hired.’ The term ‘inferiority complex’ was coined at this time, as applied to short men.”
In examining each generation from the 20th century through today, Epstein said, she’s seen the discussion around hormones influenced by a combination of what scientists and doctors are doing plus how everyone — scientists and doctors included — is being swayed by the culture and the common fears of a particular time.
The need for certainty gets the best of us
For Epstein, fear is also the root of why so many medical frauds throughout American history have been so successful. Clinton asked her why she thought these deceitful products, particularly as they relate to hormones, have fooled people over time and even continue to fool us today.
“Because we love certainty,” said Epstein. Speaking directly to the audience members, she explained that unlike people who’ve gone through medical school training — which teaches that “nothing is ever 100% sure, that everything in life has a side effect” — charlatans are comfortable selling this certainty to their patients. To be a good swindler, Epstein said, “you have to take someone by the hand and tell them their doctors are too worried with all these numbers and facts and data.”
For example, in the case of non-FDA approved supplements, Epstein says that the lack of warning label with its list of “scary” side-effects makes some patients feel safer. “They can have the notion that, ‘Oh, well this is 100% healthy,’” she said. “People want surety. They want someone to hold their hand and say, ‘Here’s exactly what you have to do.’”
Epstein also cited personal testimonies as another way that hucksters peddle their suspect cure-alls. “People will say, ‘I don’t believe what I read,’” she said. “But it’s interesting because many people really do believe what’s in the media.”
During the audience Q&A portion of the talk, when asked how providers might talk with their patients about pseudo-science trends, Epstein advised that doctors should actually take the time to flip through magazines and keep themselves apprised of the latest fad remedies in popular media. Additionally, she emphasized the value of listening.
“Your patients want you to have an open mind,” she said. “Take a few moments just to say to them, ‘I get it. I know where this is coming from, but here’s what I’m worried about if you do that …’ It sounds trite, but so much of this does come down to doctor-patient relationships.”
Great leaps and grey areas move research forward
Clinton highlighted how much she appreciated Epstein’s ability to portray medical history in “Aroused” as populated by doctors and scientists who were “doing the best they can with what they know or believe to be true, even if sometimes they went sideways or backwards” in regards to advancing research about hormones.
Epstein agreed: “One of the points of the book is that we can’t just say that these are the bad guys and these are the good guys. There’s a grey area in between. Some of our leading scientists are the ones who see the data and then make a leap, and sometimes people leap in the wrong direction.”
Epstein then told the story of Eugen Steinach, an Austrian endocrinologist, who made one of those “leaps in the wrong direction.” He’s the scientist now credited with starting the vasectomy craze of the 1920s, based on a widely held misunderstanding that vasectomies would boost the male libido.
Although Steinach never performed those operations himself, he promoted the theory that justified them, explained Epstein. “He wasn’t a charlatan quack who was trying to make his surgeon friends a lot of money,” she said. “His original research was saying that the interstitial cell produced male hormones, which he was right about, but then he had a theory that sounds good — it’s just not right — that if you kill off cells in an area or block them, the others will proliferate like weeds.”
This was why Steinach believed vasectomies, which he presumed would cause the proliferation of testosterone-producing interstitial cells, thereby boosting the libido of the patient who had the procedure. Epstein said that, of course, personal testimony fueled the trend further when celebrities of the day like Sigmund Freud and W.B. Yeats had the procedure done and claimed afterwards to feel younger and more virile.
More hormones on the horizon
Clinton closed the conversation by asking Epstein what discoveries in the field of hormone research loom close on the horizon.
“I think what’s really on the cutting edge now is hormones and behavior,” said Epstein. She gave the example of lectin, the hormone now known to suppress appetite, and praised the work that Yale’s own Sabrina Diano, the Richard Sackler Family Professor of Obstetrics, Gynecology, and Reproductive Sciences, is doing on this topic.
“People with lectin defects… it doesn’t actually affect their metabolism but drives them to eat, compels them to eat,” said Epstein. “When I spoke to the scientists who are doing that research on lectin, their feeling was that they’re excited about what they can learn not only about obesity but also about behavior. This is showing us that hormones are controlling not just our growth and metabolism but our behavior too.”
Epstein concluded by reflecting that even though there have certainly been some “wacky” scientists in the course of history, there have been many “wonderful” ones too, many of whom are still advancing our knowledge about hormones and just about everything else.
It is the stated mission of the Yale Program for Humanities in Medicine to “use the medical humanities as a springboard to raise the critical consciousness of our community. … Through a wide variety of opportunities, both curricular and extracurricular, we strive to stimulate thought and discussion about the narratives we tell about our patients, ourselves, and the systems we work in; the traditions we have inherited; the role we play in questions of justice; and what futures we imagine for ourselves as a profession.” The Clinton-Epstein conversation was the program’s first event of fall 2018. To learn about the program’s upcoming events, visit its calendar online.