Why are women more predisposed to autoimmune conditions?

 Since the age of 17, I have been curious about autoimmune conditions. I had experienced drug lupus in the past. I was told that it was due to my acne medication at the time; however, I always wondered if maybe there was a correlation to my biological sex. Furthermore, in medical school we were told that women were more predisposed to autoimmune diseases. But why? Why did having two XX chromosomes make you a risk factor for conditions like RA or Lupus?

 Well.. did you know that researchers have speculated a correlation with having two XX chromosomes and autoimmune diseases? There are genes on one X that can initiate an autoimmune reaction, and females happen to have two of those. They are essentially getting a double dose of that specific gene. Since males have X and Y, they do not get that double exposure from the X chromosome. Furthermore, Females go through something called X inactivation. One of their X chromosomes will be inactivated in a cell causing the other one to be predominant. The X that is inactivated can now be seen as foreign to the body and provide itself as an antigen. When this happens, the body can form an immune response and hence a possible autoimmune disease. In fact, the process I just described is suggested to a potential cause for Lupus

 There are other possible causes for Lupus. I will describe one more. It is suggested that there are genes expressed on one X chromosome, CD40LG and CXCR3, that become overexpressed when one of those X’s fails to inactivate. There are still studies being done to further assess this theory. It is speculated that proper X inactivation may help decrease disease progression.

 It is also suggested that hormonal changes can exacerbate an autoimmune disease. Hormonal changes may not be the cause of a skin condition like Psoriasis; however, it is speculated that hormonal changes can make the skin more sensitive. The endocrine system and skin are closely linked, and an imbalance could increase the severity of Psoriasis.

 In addition, Rheumatoid arthritis and Sjogren’s syndrome are thought to be linked to hormonal changes as well. With RA, there are issues with the bones and joints. It is suggested that around menopause, a decrease in estrogen and progesterone can decrease protection of the bone and joints making RA more severe. Sjogren’s Syndome is also thought to be linked to a decrease in estrogen.

Now that hormones are thought to be a link, pregnancy and puberty are a concern. These are times where hormonal imbalances occur. With pregnancy, those changes can last until at least one year post pregnancy. It is also thought that a mother carry a baby could face a decreased immune system making autoimmune issues more likely. As far as puberty goes… a study done in Taiwan observed an increase in juvenile SLE in girls compared to boys. It is also suggested that there is an increase of multiple sclerosis for girls after the onset of puberty.

I’ve learned something new today, and I appreciate the review article on the prevalence of autoimmune disorders in women that was published in the Cureus Journal of Medical Science in May 2020.

 Sabrina Billings MS4

Drexel University College of Medicine

 

 

 

Angum F, Khan T, Kaler J, Siddiqui L, Hussain A. The Prevalence of Autoimmune Disorders in Women: A Narrative Review. Cureus. 2020;12(5):e8094. Published 2020 May 13. doi:10.7759/cureus.8094

 

Miscarriage: The deafening silence that follows

I remember like it was yesterday. The tiny fingers that curled up into fists, fists literally clinging onto life. The tiny baby was delivered at 22 weeks, a stillborn. I was helping with the delivery and was able to cut the umbilical cord. Never would I imagine my first time cutting the cord would be in this situation. I remember hearing the mother’s pain through her screams and tears. As the healthcare providers, we helped in the delivery and aftercare of the labor. Afterwards, I was struck how there was no discussion or conversation with the mother who just lost her child. We closed the doors after the delivery and in turn closed the door on the traumatic experience that just occurred. I remember when my aunt herself had a miscarriage. Her family and friends all empathized with the loss but could not understand why my aunt was still feeling sad and depressed after many months after the incident. I saw my aunt spiral into a deeper depression as she could not find any support after miscarriage. Unfortunately, these are not isolated reactions to miscarriage in society.

            Miscarriage is one of the most common complications of pregnancy, occurring around 15% of all clinically recognized pregnancies. One in four women experience miscarriage in their lifetime. Many women following the loss of their child feel grief, sadness, and depression. These mental health issues are only exacerbated by society’s lack of consideration and belief that no loss has occurred. Mental health issues that these childless mothers face are perpetuated in this way. As healthcare professionals, we must do better and continuously monitor our patient’s moods and behaviors following their loss. Mental health services should immediately be offered to women who experience the loss to normalize their feelings and help mitigate any long-term consequences.

Ammarah Spall, MS4

Drexel University College of Medicine

Intimate Partner Violence And The Role Of The Healthcare Professional

Intimate partner violence is characterized by behavioral patterns that include physical abuse, emotional/psychological abuse, sexual abuse, threats, intimidation, stalking and deprivation5. These behaviors are normally perpetuated by one’s former or current intimate partner. According to the national coalition against domestic violence, an average of 20 people are physically abused by their intimate partners every minute. This means that approximately 10 million people in the US experience some form of intimate partner abuse annually3. Statistics shows that 25% of women and 7.6% of men will be victims of domestic violence in their lifetime4. IPV can happen to people of all ages, educational and cultural backgrounds.

The consequences and prevalence of intimate partner violence nationally makes it a health crisis that needs to be addressed and prevented. Unfortunately, most victims of intimate partner violence do not report the case to the appropriate authorities but often find excuses to justify the actions of the abusers. Research shows that health care professionals, especially Physicians can play an important role in detection, intervention and prevention of IPV due to the unique relationship they have with patients4.This is why it is important that physicians screen their patients for domestic abuse. Screening creates an opportunity for healthcare workers to educate their patients on the dangers and consequences of domestic abuse on their health.

Due to the sensitivity of domestic abuse, it is essential for physicians to be very discreet in their assessment when screening for it. Studies have shown that patients are more likely to open up about their feelings if asked in confidence away from family and in a nonjudgmental, respectful manner. There are two different ways of screening- written survey and oral screening using either direct or indirect questions. Since some people may be offended when isolated to be screened privately for domestic violence, it is recommended that physicians introduce the conversation with statements such as “Because violence is very common, I ask all my patients about their experience with violence”. Direct questions are preferred mostly in a situation when domestic violence is already suspected based on the observations made by the physician.

The response from the physician after a patient opens up about domestic abuse, is also very important. A nonjudgmental and supportive statement is essential to create a congenial atmosphere for the patients to explore solutions. The immediate concern for a physician should be the safety of the patient. Victims of domestic violence are at higher risk of death when they leave their partners, so it is important that they determine the best time to leave the relationship in order to ensure their safety. In states that physicians are not mandated to report intimate partner violence, the best way to help patients is to offer them resources that can help them plan for ways to ensure their safety, educate them on the physical and psychological effects of IPV and refer them to access services that are available to them.

Akua Boadu (MS4)

Drexel University College of Medicine

 

Resources

1. Lizdas C Kristen, Durborow Nancy, O’flaherty Abigail, Marjavi Anna; Compendium of State Statutes and Policies on Domestic Violence and Health Care, 2010, https://www.acf.hhs.gov/sites/default/files/fysb/state_compendium.pdf
2. Pennsylvania Coalition Against Domestic violence, 2018, http://www.pcadv.org/Learn- More/
3. National Coalition Against Domestic Violence, 2018, https://ncadv.org/statistics?gclid=Cj0KCQjw1q3VBRCFARIsAPHJXrFq0k5XaHQoXI W0zdld_NG1rMC02xsc1JPcPViYv65UafLDOe8NXwcaAtgBEALw_wcB
4. Cronholm Peter, Fogarty Colleen, Ambuel Bruce, Harrison Leonard Suzanne; Intimate Partner Violence, 2011, https://www.aafp.org/afp/2011/0515/p1165.html
5. Guidelines for the Health Care of Intimate Partner Violence, 2004, http://domesticabuse.stanford.edu/screening/law.html
6. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/index.html

Honoring Marilyn J. Smith and the 35th Anniversary of ADWAS

 March 25, 2021 marks the 35th anniversary of the first organization created to support and empower survivors of domestic and intimate partner violence within the Deaf community. Abused Deaf Women’s Advocacy Services (ADWAS) started in the basement of Marilyn J. Smith, a hearing survivor of rape, following the murder of a local d/Deaf woman by her spouse. Smith was inspired to act after learning that many in the Deaf community had known of this woman’s abuse but had not known how to get help or report it. Since then, ADWAS has grown into a nationwide model to address the needs of male and female survivors of abuse in the Deaf community and to educate the general public about related issues. In honor of the 35th anniversary of ADWAS, I’ve included 30 facts and 5 resources on domestic and intimate partner violence in the Deaf community, highlighting the continued importance of their work.

• There are at least 500,000 members of the American Deaf community, a culturally distinct group of people who share American Sign Language (ASL) as their primary language.

• To be Deaf (capital D) is to be a part of a cultural identity, not simply a person with deafness and not a person with a disability.

• American Sign Language (ASL) does not have the same grammar and sentence structure as English; thus the importance of having a certified interpreter is paramount, especially of instances of healthcare and legal matters.

• Individuals who are deaf and hard of hearing are 1.5 times more likely than their hearing counterparts to be victims of relationship violence, including sexual harassment, sexual assault, psychological abuse and physical abuse, in their lifetimes (Porter & Williams, 2011).

• Although it is commonly reported that 25% of women in the general population experience domestic violence in their lifetime, estimates within the Deaf community are closer to 50% (Anderson & Leigh, 2011).

• Since the beginning of the COVID pandemic and stay-at-home mandates, the number of domestic and intimate partner violence cases have risen in both the hearing and Deaf communities. According to statistics from The National Deaf Domestic Violence Hotline (NDDVH), contacts between the months of January and May 2020 had already surpassed the total number of contacts received during the entirety of 2019.

• Emotional abuse is the most common form of intimate partner violence reported by people who are deaf, with lifetime rates exceeding 25% (Pollard, Sutter, & Cerulli, 2013).

• Reports of physical abuse are at least as common among individuals who are deaf, if not slightly more so, than in the general population.

• Pollard et. al (2013) also noted that sexual violence and forced sex is much more frequently experienced by individuals who are deaf than their hearing counterparts. This is consistent with previous findings regarding sexual abuse among d/Deaf adults.

• According to Pollard et. al (2013), there was a higher proportion of males that reported experiences of intimate partner violence in the Deaf community than in the general population.

• Anderson and Leigh’s (2011) survey of deaf female college students resulted in surprisingly high rates of intimate partner violence perpetration reported by these women.

• Domestic and intimate partner violence in the Deaf community often includes isolation (from friends, family, and appropriate services), intimidation (aggressive or threatening signing style), shame (showing disgust toward Deaf culture), and manipulation (gaslighting).

• Economic abuse can occur by abusers withholding survivors’ Social Security Disability Income checks, creating financial reliance on the abuser for survival.

• Within the Deaf community, there is a “double code of silence” related to domestic and intimate partner violence because services are typically not culturally sensitive or accessible for deaf survivors and because the deaf community has historically misunderstood or minimized these issues (Rems-Smario, 2007).

• A recent study on intimate partner violence among deaf female college students found that more than 50% of survivors did not label their experiences of psychological aggression and physical assault as abuse, even when these experiences included severe harm (e.g., death threats, choking) (Anderson & Kobek Pezzarossi, 2012).

• Anderson & Kobek Pezzarossi (2012) also noted that a majority of deaf intimate partner violence survivors did not label sexual coercion by a partner as an abusive act.

• Healthcare providers often omit screening for intimate partner violence along with sexual histories of women with disabilities due to the incorrect assumption that individuals with disabilities are not sexual (McRuer & Mollow, 2012).

• Under the Americans with Disabilities Act and Rehabilitation Act, hospitals and other medical facilities are required to provide appropriate in-person and/or remote sign language interpretation services as well as textual English communications to patients and/or companions who are deaf or hard of hearing.

• Many deaf and hard-of-hearing people do not know sign language, and they comprise populations that also experience inequities in access to health communication, health care, health research, and health-related careers.

• Most d/Deaf individuals experience obstacles to understanding written health materials due to differences in language and development compared to hearing individuals (Glickman, 2013).

• Research suggests a fourth-grade median English reading level among d/Deaf high school graduates (Gallaudet Research Institute, 2003), significantly below the average seventh-to-eighth grade reading level among hearing high school graduates.

• In addition to these general English literacy concerns, nearly 50% of d/Deaf individuals also have inadequate health literacy—6.9 times more likely than hearing individuals due to insufficient health education (McKee et al., 2015).

• Health-related vocabulary among d/Deaf sign language users is similar to non–English-speaking US immigrants (McEwen & Anton-Culver, 1988), and “many adults deaf since birth or early childhood do not know their own family medical history, having never overheard their hearing parents discussing this with their doctor” (Barnett et al., 2011)

• Survivors may avoid seeking treatment due to valid concerns about confidentiality  including reduced anonymity within the Deaf community and unease about Deaf providers or ASL interpreters who belong to the same social circles as their clients (Barber, Wills, & Smith, 2010).

• Members of the Deaf community have also been subjected to historical mistreatment by behavioral health researchers and providers. Early literature on the “psychology of deafness” described d/Deaf people as emotionally and cognitively deficient compared to hearing people (Pollard, 1970)

• Historically, individuals with deafness have also been described by individuals in the medical community as “language impaired, immature, impulsive, concrete, aggressive, [and] less intelligent” (Pollard, 1970).

• As recently as the 1970s, the majority of mental health practitioners working with d/Deaf individuals were practicing without special training or knowledge of Deaf culture or ASL.

• Despite recognition that this practice was unacceptable, to this day the number of resources for d/Deaf survivors of domestic and intimate partner violence are limited. Currently, there are approximately fifteen deaf–specific organizations for survivors of abuse in the U.S., with goals of expanding numbers and locations.

• For that reason, many survivors who are deaf or hard of hearing continue to seek assistance at local organizations where providers are likely unfamiliar with ASL and d/Deaf cultural norms, thus putting them at a disadvantage when trying to establish healing relationships.

• By educating ourselves on the specific obstacles facing survivors of domestic and intimate partner violence among the d/Deaf community, we as providers can begin to work towards more equitable and just care for some of our most vulnerable patients.

If you or someone you know is a survivor of domestic or intimate partner violence, the following resources are available, with specific emphasis on those that are equipped to support survivors in the d/Deaf community:

1. Abused Deaf Women’s Advocacy Services, an organization that empowers Deaf and DeafBlind survivors of domestic violence, sexual assault and harassment to transform their lives, while striving to change the beliefs and behaviors that foster and perpetuate violence. https://www.adwas.org/
2. DeafHope, a grassroots organization whose goal is to provide accessible support and empowerment to Deaf women who are survivors of domestic and sexual violence. http://www.deaf-hope.org/
3. Deaf Anti-Violence Coalition (DAVC), a national organization committed to ending power-based personal violence, including but not limited to: domestic violence, intimate partner violence, sexual violence, stalking, and human trafficking within Deaf communities. https://www.deafantiviolencecoalition.com/
4. The National Domestic Violence Hotline (NDVH): Email: deafhelp@thehotline.org; TTY: 1-800-787-3224; Video Phone: 1-855-812-1001; Live Chat: www.thehotline.org
5. National Resource Center on Domestic Violence has operated https://vawnet.org/, an online network focused on violence against women and other forms of gender-based violence.

 

Resources:

-       Anderson ML, Leigh, IW. Intimate partner violence against deaf female college students. Violence Against Women. 2011;17(7):822-834.

-       Anderson ML, Kobek Pezzarossi CM. Is it abuse? Deaf female undergraduates’ labeling of partner violence. J Deaf Stud and Deaf Edu. 2012;17(2):273-286.

-       Barber S, Wills D, Smith MJ. Deaf survivors of sexual assault. In Leigh IW (Ed.), Psychotherapy with deaf clients from diverse groups, 2nd ed, 2010. Washington, DC: Gallaudet University Press.

-       Barnett S, Klein JD, Pollard RQ, et. al. Community participatory research with deaf sign language users to identify health inequities. Amer J Pub Heal. 2011;101(12): 2235-2238.

-       Gallaudet Research Institute. Literacy and deaf students. 2003. [web] http://gri.gallaudet.edu/Literacy/reading.

-       Glickman NS. Introduction: what is deaf mental health care? In Glickman NS(Ed.), Deaf mental health care. 2013. New York, NY: Routledge.

-       McEwen E, Anton-Culver H. The medical communication of deaf patients. J Fam Practice. 1988; 26(3): 289–291.

-       McKee MM, Paasche-Orlow Mk, Winters PC, et al.  Assessing Health Literacy in Deaf American Sign Language Users. J Health Comm. 2015; 20 (2): 92–100. doi:10.1080/10810730.2015.1066468.

-       McRuer R, Mollow A (Ed.). Sex and disability. 2012. Durham, NC: Duke University Press

-       Pollard RQ Jr. 100 years in psychology and deafness: A centennial retrospective. J Amer Deaf and Rehab Ass. 1970;26:32-46.

-       Pollard RQ Jr, Sutter E, Cerulli C. Intimate partner violence reported by two samples of deaf adults via a computerized American sign language survey. J Interpers Violence. 2014;29(5):948-965. doi:10.1177/0886260513505703.

-       Porter JL, Williams LM. Auditory status and experiences of abuse among college students. Violence Vict. 2011;26(6):788-98. doi: 10.1891/0886-6708.26.6.788.

-       Rems-Smario, J. Domestic violence: We can’t ignore it anymore. NADmag. March/April 2007;16-18.

Samantha Innis, MS4

Drexel University College of Medicine