Gemma Parramon i Puig: "Hormones have been used to discredit women and justify inequalities"

Hormones have often been used to explain any discomfort in women. But, according to psychiatrist Gemma Parramon Puig, head of the psychiatry section at Vall d'Hebron Hospital, this perspective has hidden another reality for decades: a medicine built by taking the male body as the standard and biases that have delayed diagnoses, medicalized social problems, and made women's health invisible. In "It must be the hormones (Vergara), argues that incorporating the perspective of sex and gender is essential for better medicine.

The book argues that too often we have attributed to hormones problems that actually have other causes. What have we misunderstood?

— It's the hormones is a phrase that all women have heard at some point. It has been used to devalue our discomfort, to question it, or to tell us that we have to put up with it. Or to cast doubt on our discomfort. Even today, there are gynecological procedures, such as an endometrial biopsy, a hysteroscopy, or a cervical biopsy, that many women endure with minimal or no analgesia. It's hard to imagine that equally invasive procedures, if they affected men's genitals or reproductive organs, would be performed with such a natural assumption that the pain has to be endured.

When did she start questioning this gaze?

— Liaison psychiatry, my specialty, has allowed me to view women's health from many disciplines. I have worked primarily with women during pregnancy and postpartum, and also with hormone therapy for breast cancer. I was surprised to find that, in very different situations, very similar psychopathology appeared. Psychosocial factors play a large role, but there is also an evident biological fact: major hormonal changes.

Does medicine continue to carry many gender biases?

— We think that science is objective, but it is an illusion. Whoever poses the research questions and whoever interprets the data also has biases. We have a science with very little gender perspective. For many years we have hardly had studies differentiated by sex. And when there have been, the results often shame us: recently, an investigation showed that women wait longer on public healthcare waiting lists. There are even female doctors who do not know that heavy bleeding during theperimenopause affects the vast majority of women. This says a lot about the training we receive in faculties. Furthermore, it is important to ensure that these women do not end up with anemia.

Has medicine been built primarily thinking about men?

— Yes. Notice that we all have a reference gynecologist because historically medicine has been organized around reproductive function. On the other hand, we do not have a reference cardiologist, even though cardiovascular diseases are one of the main causes of mortality among women. Furthermore, for decades, man has been the model on which clinical studies have been based or diseases have been studied, and this has had negative consequences for women.

As which ones?

— There is a Danish study with millions of people that analyzes 1,400 diseases. In more than half of them, there are significant diagnostic delays in women, sometimes several years. And these are not rare diseases, but common conditions like diabetes, and when this happens it is very serious, because arriving late to the diagnosis conditions all subsequent health.

Does this also happen in mental health?

— In mental health, two realities coexist. On the one hand, there is underdiagnosis in many disorders, but on the other hand, there is also overdiagnosis of depression and anxiety. It is a way of trivializing what happens to women. Many times they present symptoms derived from a very high level of stress, not necessarily a mental disorder. But these symptoms end up receiving the same treatment. There is no population group in which women and men receive the same degree of stress. Even in studies with university students from very affluent families, we find that society treats them differently based on gender. With the same context, men and women have the same psychopathology.

Now?

— Postpartum depression, although I don't like talking about postpartum depression in men because partners don't give birth. But there are indeed more and more men very involved in childcare, who share responsibility. And these men are at much higher risk of having depression in the period after the birth of a baby, because they are subjected to the same stressful conditions as women. Although they don't have the hormonal context, they do suffer the rest of the conditioning factors. I remember the first time I saw a man who had just become a father and who became depressed during his wife's postpartum period. She had debuted with mania.

What is a phobia?

— Bipolar disorder is a disease that can debut and decompensate greatly in the postpartum period. This is crucial, although, unfortunately, there are few studies that have investigated the relationship between hormonal changes in this vital phase of women and mental illness. Mania is the opposite of depression: it causes a state of hyperactivity, of overestimating one's own abilities. That woman disappeared, she did not take responsibility for the baby's care. She slept little, did not feel tired, initiated many activities. During a manic episode, the ability to assess the consequences of one's own decisions can be altered. Increased impulsivity and disinhibition can favor behaviors that pose risks to the person. Her husband had to take complete care of the baby. He was subjected to the same environmental conditions as most mothers. And he had a depression.

Why is there more women diagnosed with depression?

— Two major factors are involved here. The first is all the social conditioning: the double burden of responsibility, caregiving, aesthetic pressure, self-demand... All of this falls much more heavily on women. The second is biological. There are brains that are particularly sensitive to hormonal fluctuations. It's not so much a question of having more or fewer hormones, but rather how some brains respond to hormonal changes. This is why we see a higher incidence of affective disorders, such as premenstrual dysphoric disorder, which causes depressive symptoms with irritability approximately a week or a few days before menstruation.

But doesn't this reinforce the stereotype that women are emotionally more unstable?

— What oppresses us is not biology, but society. Gender is a cultural construct. If it were socially normalized for some women to experience emotional changes before menstruation, it probably wouldn't have been pathologized so much. Furthermore, we know that women who have suffered situations of violence are at higher risk of developing premenstrual dysphoric disorder.

Does epigenetics also change mental health?

— A lot. And it helps us explain things that were difficult to understand until now. We know, for example, that experiences can activate or deactivate genes throughout life. Our history, our biography, ends up becoming biology. Children who suffer violence, for example, may show changes in the receptors for cortisol, the stress hormone, and this makes them more vulnerable to stress throughout life, less resilient. That is why it is so important to act from pregnancy and during the first years of life, to prevent mental problems in adulthood. Unfortunately, perinatal mental health programs remain very underfunded.

He also argues that women are more medicalized.

— Yes. When a woman goes to the doctor, it is very likely that she will end up taking a benzodiazepine or an antidepressant. It is a personal hypothesis, but I believe that one of the factors that can influence this is the way women and men have learned to express and explain discomfort. On the other hand, men tend to describe a specific symptom: I have pain here, without going into more contextual explanations. This can condition the clinical interpretation.

Have you seen cases where this bias has had important consequences?

— I remember a patient who had been diagnosed with depression since adolescence because she always complained of fatigue. For years she was diagnosed with anxiety and prescribed psychotropic drugs. She attributed that tiredness to work, to perhaps working too much, or to perhaps being married to a peculiar man –this is literal– whom she had to put up with his whims. When she became pregnant at 30, she suffered a very serious heart failure and it was discovered that she had a rare heart condition that had never been diagnosed. That heart condition was what caused her fatigue, and not any anxiety. If it hadn't been for the pregnancy, she would probably have continued to be treated for a depression she didn't have. It was a miracle she didn't die in pregnancy. Now the child is 12 years old and she and I continue to see each other, because I know that if I stop accompanying her, she will end up on antidepressants again, which she doesn't need right now.

Women's distress is associated with mental disorders.

— When women express discomfort, it is easier for it to be interpreted in psychological terms. In men, on the other hand, some depressions can be masked behind alcohol consumption. These are biases, often unconscious, that medicine carries.

Hormones have also been used to explain male behaviors, especially testosterone.

— Hormones often serve to penalize women and excuse men. For a long time, women were excluded from studies because it was said that hormones introduced too much variability. But there are also hormonal variations in men. We know, for example, that fatherhood and involvement in childcare can be associated with a decrease in testosterone levels. Hormones do not act in isolation from context: experiences, relationships, and behaviors can also modify their levels. The brain is extraordinarily plastic and continues to be shaped throughout life according to the experiences we live.

There are no ‘Pélicot’ women.

— The Pélicot case cannot be explained solely by the individual characteristics of a man. It was possible in a social context in which dozens of men considered that they could participate in the rape of an unconscious woman. This tells us about a culture that trivializes sexual violence and that still associates masculinity with dominance and the exercise of power. Hormones do not cause these behaviors on their own. Testosterone can influence the search for status, but the way it is expressed depends largely on what each society allows or rewards.

The word "hysteria" has practically disappeared from medicine. What about prejudice?

— They have changed the name, but not always the gaze. This word, hysterical, was a euphemism used to place patients who you don't quite know where to put, when there are difficulties with emotional regulation. When I was a resident at the hospital, I still heard professionals who qualified some women as "hysterics". I remember one in particular who told me that he already knew, when a pregnant woman entered through the door, just by looking at her face, whether she was a hysteric or not. Today this term is hardly used, but many patients continue to receive diagnoses that do not really explain what is happening to them.

Is borderline personality disorder the new hysteria?

— We increasingly understand better that many women labeled for years with borderline personality disorder, in reality, present with complex post-traumatic stress disorder derived from years of sustained violence. Many women we now see in consultation have been subjected to situations such as abuse by their husbands for a long time. And they develop the same disorder that was seen in war veterans, as psychiatrist Judith Herman detected in 1992, who revolutionized the understanding of trauma by demonstrating that sexual assaults and gender-based violence caused post-traumatic stress in women. It is a paradigm shift. If we want to understand women's mental health, it is not enough to look at hormones; we also have to look at their history.