sex and gender

The third gender

Your Health DR GITA MATHAI

The terms sex and gender are often interchanged, even in official forms, under the erroneous impression that they mean the same thing. Actually, “male or female” is the sex, “masculine or feminine” the gender. Gender is the self-identified perception of the individual. This can be different from the sex medically assigned at birth. People can choose to identify themselves as male, female or the “third gender.” Most people are “cisgender” or comfortable with the sex they are born with. One in 1,000 people exhibit a dissociation between the genetic sex, psychological gender, and social sex. They may be uncomfortable with the roles they have to play in society. Sometimes the physical attributes signifying a sex get interchanged. A woman may be hairy with a deep voice and a man may have scanty facial hair and a high-pitched voice. This makes it difficult for the person to psychologically identify with their attributed sex. One in a hundred persons may have intersex characteristics. This may result in them trying to change the sex through entensive surgery. Men who have changed themselves into women do not menstruate and cannot have children. Women who transform themselves into men usually have their uterus and ovaries removed. They can also call themselves the “third sex,” neither male nor female. They can just “cross dress” as a person of the opposite sex without undergoing surgery. They can take hormones for masculinisation or feminisation. A woman may develop a deep voice, facial hair and male pattern baldness. If these changes occur in adolescence, they may have difficulty determining which sex to identify with. This is increasingly common with the widespread occurrence of PCOS (polycystic ovary syndrome). It may occur as a result of tumours of the adrenal gland or ovary or as a side effect of medication. In men too, facial hair may be scanty, there may be breasts and a high-pitched voice. This can be the result of liver disease, tumours or medication. Psychological and social confusion may be created in the minds of children because of cross dressing by parents. Boys dressed as girls is a social “no no” for whatever reason. Girls dressed in pants and shorts, on the other hand, is totally acceptable. They usually wear feminine accessories such as earrings, necklace, bangles and hair clips. The Supreme Court of India, in a landmark judgment, has recognised the existence of a third gender. You can “declare” yourself any gender (male, female or the third). No surgical procedure needs to be performed nor any medical or legal proof provided. If we can declare our gender as whatever we are comfortable with, it opens up many questions. Does it mean that men who perceive themselves as women can occupy the “reserved for women areas”, participate in sports in the female category and get jobs in the women’s quota? Or, is everything going to be changed into “male, female and NOTA” (the third gender)? Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

loo breaks

Take a loo break Your Health DR GITA MATHAI Most people attain bladder control by the age of two and stop soiling themselves or wetting the bed except on rare occasions. Some people (particularly boys) may take a few years more. A return of these childhood symptoms with dribbling of urine, inability to control the urge to go to the bathroom, urgent evacuation of urine when the toilet is sighted, (not necessarily after reaching it) or a total loss of control while coughing, laughing, sneezing or having sex, can be acutely embarrassing. Urine is formed as a continuous process in the kidney. It passes down two pipes called ureters and reaches the bladder. From there it passes out through a short pipe called the urethra. The outflow is controlled by a sphincter under voluntary control. It relaxes to release urine only when the brain signals it to do so. This occurs when the bladder is full, and the area (toilet) socially acceptable. The bladder can hold 350-500ml of urine when it is full. The sphincter may be weak and give way involuntarily, causing small amounts of urine to leak out, especially if the bladder is full. This situation is commoner in women. After vaginal childbirth, the pelvic muscles around the urethra may become weak. The birth process itself can cause injury. The vagina may be lax and the bladder and rectum may prolapse into it. Weight gain also increases the abdominal pressure on the bladder. In these conditions coughing, sneezing or even laughing vigorously may cause an accident. A stone, tumour or some other obstruction in the bladder neck can prevent free flow of urine. Constipation causes hard motion stuck in the rectum to press against the bladder, preventing free urine flow, causing overflow, incontinence and even dribbling. Men have a gland called the prostrate at the neck of the urethra, which can enlarge after the age of 40. This is usually non-cancerous and called “benign prostatic hypertrophy” (BPH). If untreated, it can eventually cause obstruction and dribbling. The prostrate can also enlarge due to cancer. The bladder may be “irritable” — there is an urge to empty it even if a little urine gathers. Sleep is disturbed as the person has to get up to pass urine. This can occur because of urinary tract infection, stress, or a central nervous system disorder such as a stroke, Parkinson’s disease, or multiple sclerosis. It is important to determine the cause of the urinary symptoms. A physician can usually make a diagnosis, with the help of the history, a general, pelvic and rectal examination and a few tests. In women, pelvic floor muscles can be strengthened by doing Keegle’s exercises. This means tightening the pelvic muscles for 20 seconds several times a day. Also, when going to the toilet, do not pass all the urine immediately but try to control the flow by stopping and starting. Lean back while urinating, not forward. As long as the exercises are done the symptoms remain controlled. An irritable bladder can be controlled by bio feedback. Note down the number of times you visit the toilet and the interval between visits. Consciously increase the interval. Also, restrict the quantity of fluid consumed to a minimum required — around 2-2.5 litres a day. Some groups of medications, such as anticholinergics and antidepressants, can be used along with these techniques for better results. Train your bladder. Do not visit the loo until you simply have to. This will increase bladder capacity. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in Share on emailShare on printShare on facebookShare on twitterMore Sharing Services

cramps

Cramped up

Your Health DR GITA MATHAI

We humans can perform highly complex and coordinated actions. We have muscles under voluntary control, which obey commands relayed by the brain. Movements are smooth and synchronised as opposing groups of muscles work in tandem. However, muscles occasionally fail to obey the commands of the brain. They contract and go into a painful “spasm”, refusing to relax. The agonising discomfort prevents further movement. After a few minutes (which seem like an eternity) the muscle relaxes. The cycle may or may not recur. If cramps occur during a sport, the competitor may be massaged on the field or led off it. If they occur in the night, the pain wakes the person up. About 95 per cent of the population experiences cramps at some time in their life. They occur in all age groups (including children) but become more common with increasing age. Diagnosing a cramp is not difficult. The sufferer knows he has developed a cramp. The severe pain makes him stop the activity or wakes him up from sleep. The muscle is tight, sore and a hard tender knot can be felt. Although the cramp disappears in a few minutes, the soreness may persist for days. Cramps can occur due to: • Fracture of the underlying bone. Overlying muscles tend to go into an unrelenting protective painful spasm. • Overuse injury like in writing, typing or computer use. The fingers assume abnormal painful positions from which they cannot voluntarily be straightened. • Excessive sweating because of the heat — with or without exercise — which depletes the body of salt (sodium). • Electrolyte imbalances and shift of body fluids due to liver (cirrhosis) or kidney disease (renal failure) or the hormonal changes of pregnancy, with hyperventilation or vomiting. • Withdrawal from alcohol, sleeping tablets and anxiety agents like valium in addicts. • Deficiencies of the B group of thiamine (B1), pantothenic acid (B5), and pyridoxine (B6) and vitamin E. The exact mechanism is not known but these vitamins are thought to stabilise the nerve membranes • Medications such as diuretics, statin group of drugs raloxifene, parkinson’s disease medications, nifedepine, asthma medications like terbutaline and ventorlin. Cramps usually occur due to the levels of minerals and electrolytes in the body going “out of sync”. This is because unbalanced or low levels (particularly of sodium, calcium or magnesium) cause hyper excitability of the nerve endings going to the muscles. They are unable to obey commands from the central areas of the brain to relax. Low levels of calcium and magnesium can occur in pregnancy and with increasing age unless they are supplemented. Calcium can be taken as tablets. Supplements work well provided the level of vitamin D3 in the body is adequate. Aerobic physical exercise helps ingested calcium get into the system. The safest way to supplement magnesium is with an adequate intake of greens, grains, meat and fish, bananas and nuts. Sometimes the calf muscles pain when walking. After a period of rest the pain disappears and walking can be continued. This is not true cramps but claudication. It occurs as a result of inadequate blood supply to the muscle. It requires medical evaluation. Cramps can usually be stopped if the muscle is stretched in the opposite direction. For calf cramps that means placing both feet flat on the ground, keeping the leg straight and rocking back on toes and heels. Alternatively you can stand half your height distance away from a wall, stretch arms out and balance against the wall. If still in bed and unable to move, keep the feet straight and stretch the toes towards the head. For “writer’s cramp”, place hands flat against a wall with fingers facing downward. Gently massage the cramped muscle. Then apply warmth with a heating pad or hot water. This will help the muscle to stay relaxed. If the cramp is associated with fluid loss, water and electrolyte replacement is needed. Salted buttermilk, lime juice, commercially available electrolyte solutions, or ORS (oral rehydrating solution) packets can be used. Caffeine containing beverages (coffee, tea and colas) aggravate dehydration. Exercise, (even in the elderly) should start and end with stretching. Hydration should be adequate. The amount of water required depends on the intensity of the exercise and the weather. If thirst develops it means that dehydration has already set in. Older people and young children do not experience appropriate thirst. Muscle cramps usually disappear on their own and do not require specific medication. If they occur frequently without exercise or dehydration and are accompanied by severe discomfort, and skin colour or texture changes, then they may be due to some other disease process. This requires medical evaluation. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

Bitter truth Your Health DR GITA MATHAI Sweet measure The amount of sugar found in regular food Tea/coffee with a spoon of sugar – 4gm or 20 calories A 335ml can or bottle of cold drink – 35gm or 175 calories A regular bar of chocolate – 30gm or 150 calories Two small gulab jamuns – 25gm or 125 calories A rasgulla – 30gm or 150 calories A cup of cornflakes – 18.75gm or 94 calories A glass of milk (250ml) with health drink (3tbsp) – 40-50gm or 200-250 calories A cup of grapes – 15gm or 75 calories A teaspoon of tomato sauce – 5gm or 25 calories Almost all of us have a “sweet tooth” and it doesn’t help that as a culture we serve sweets enthusiastically on all occasions — births, engagements, marriages, success in an endeavour. And it is considered rude to refuse. Unfortunately, sugar works on the same areas of the brain and is as addictive as tobacco or drugs. Constant high intake can trigger withdrawal symptoms with craving, binge eating and mood changes. It is emerging as the actual cause of our present epidemic of obesity, diabetes and metabolic syndrome X. Three out of the following five conditions need to be present to diagnose metabolic syndrome X. • Central abdominal obesity, which is present if the waist:hip ratio is greater than 0.90 in males; greater than 0.85 in females. The waist circumference alone can be used and should be less than 94cm (37 inches) in males and 80cm (32 inches) in females. • Blood pressure is 130/90 or more on three or more occasions. • High blood sugar level, with a fasting blood glucose test result of 100 milligrams per decilitre (mg/dL), or 5.6 millimoles per litre (mmol/L), or more. • High cholesterol, with a level of triglycerides of 150 mg/dL (1.7 mmol/L) or more and a level of high-density lipoprotein (HDL) cholesterol — the “good” cholesterol — of less than 40 mg/dL (1.04 mmol/L) for men or less than 50 mg/dL (1.3 mmol/L) for women. • A BMI of 30 or more. Additional findings which should raise suspicions of metabolic syndrome are fatty liver, gall stones and high CRP (C reactive protein). Continuous overindulgence in sugar can result in polycystic ovarian syndrome, heart disease and cancer. Sugar contains 20 calories in 4gm (1 teaspoon is approximately 5gm) but these are empty calories, which provide no nutritional benefit. If it is not immediately required to provide energy (which is usually the case), it goes straight to the liver where it is deposited as fat. An ultrasonogram will often show a “fatty liver” even in a person who appears lean and has a BMI (weight divided by height in meter squared) less than 25. It causes an elevation of bad cholesterol (TGL) and a fall in the level of good cholesterol (HDL). This leads to a fatty plaque build up in the arteries and eventually, heart disease. You may think that only a teaspoon of sugar (4gm) in your tea or coffee can’t be harmful but if you drink three cups a day that is 12gm. Also, you may be inadvertently consuming “unseen sugars” such as honey, high fructose corn syrup, fructose or “liquid glucose”. A can or bottle (355ml) of an aerated beverage contains seven teaspoons of sugar; a regular bar of chocolate around six teaspoons, two small gulab jamuns five teaspoons, a rasgulla six teaspoons and a cup of cornflakes three-fourth teaspoon. Indian gravies often call for sugar or jaggery. There is 5gm of sugar in a teaspoon of tomato sauce. Many mothers add flavoured health mixes to children’s milk. As much as three tablespoons (90gm) may be added to a tumbler (250ml) of milk. This is with the mistaken impression that the child receive essential nutrients, grow taller and become more intelligent. Half of this, 40-50gm or 10 teaspoons is pure sugar. The child receives a “sugar boost” offering no nutritional benefit and which is detrimental in the long run. The WHO-recommended intake of refined sugar is 10 per cent of daily calorific intake. That means an adult male on a 2,000-calorie diet can have up to nine teaspoons (45gm) a day from all sources and women, with a lower caloric intake, can have about six teaspoons (30gm). Children actually need less sugar than adults; pre-school children need four teaspoons (20gm), those aged four to eight years three teaspoons (15gm) and teenagers five teaspoons (25gm). This month WHO has proposed recommending that sugar provide only five per cent of daily calorific intake as even 10 per cent was high enough for some harmful effect. As processed sugar enters the blood stream, the pancreas secretes insulin in an attempt to keep the sugar within normal limits. The sugar is pushed into the liver and converted into fat. As these episodes become frequent, “insulin resistance,” (a condition where secreted insulin is ineffective) develops. This is the first step in a cascade that leads to metabolic syndrome and eventually diabetes. As more insulin is released, a compound called “insulin-like growth factor” is also released. The two together promote tumour growth and play a role in the growth of cancer cells. Refined sugar has all these effects, but when sugar from natural sources such as fruits (not honey) it is not as harmful. This is because natural food contains fibre, which slows digestion and the absorption of sugar, protecting the body from a sugar boost. The one exception to this is grapes. One cup of grapes has three teaspoons of sugar and very little fibre. Naturally sweet food also contains micronutrients (vitamins and minerals) and antioxidants, which have a protective effect on the body. But before you reach for that “sugar fix” consider — is it worth it? Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in Share on emailShare on printShare on facebookShare on twitterMore Sharing Services