Letters to the Editor

TPJ,

I read, with interest, the Ethics article "Engendering Differences: Ethical Issues about Intersex" in the Fall 2001 Journal. I was impressed with the logic behind waiting to assign gender to these children, especially given the uncertain effects of prenatal and early neonatal hormone exposure on sexual differentiation of the brain. It may be easier to offer that advice from an ethical standpoint than a parental one, as the reality of having ambiguous genitalia and gender would be a difficult one for any family. I was disturbed, however, to see the recommendation on Dr Fausto-Sterling's part regarding management of the presented case of a child with XY/XO dysgenetic gonads. Her advice to wait until after puberty to see how the child develops and to what extent the Y-chromosome-bearing dysgenetic gonads can produce hormones ignores the real risk of gonadoblastoma. Although the data set is not complete, numerous peer-reviewed articles^1-3 describe a risk of malignancy of 5% by the age of 14 and 16% by the age of 20 in children with mixed gonadal dysgenesis, such as the case presents. The chance that any meaningful hormone production would result from these gonads is small, and I am aware of no reports that evaluate the potential of dysgenetic gonads to contribute to bone density or development of secondary sexual characteristics. I believe that the correct ethical argument would be that the parents must be informed of the risk of malignancy and the uncertain role of the gonads in sexual differentiation of the external genitalia, bone density, and gender preference. In addition, parents need to know that the majority opinion, based on the evidence that currently exists, remains that children with dysgenetic gonads containing a Y-chromosome-bearing cell line have bilateral prophylactic gonadectomy prior to the onset of puberty.

Kenneth A Faber, MD
Chief, Reproductive Endocrinology and Infertility
Colorado Permanente Medical Group

References

1. Gourlay WA, Johnson HW, Pantzar JT, et al. Gonadal tumors in disorders of sexual differentiation. Urology 1994 Apr;43(4):537-40.
2. Trouche V, Hernadez E. Neoplasia arising in dysgenetic gonads. Obstet Gynecol Surv 1986 Feb;41(2):74-9.
3. Verp MS, Simpson JL. Abnormal sexual differentiation and neoplasia. Cancer Genet Cytogenet 1987 Apr;25(2):191-218.

The Permanente Journal,

I haven't found time to invest much thought to The Permanente Journal
until now, but this issue (Fall 2001) is outstanding, informative, interesting, and some entertainment with nice photo-art. I especially enjoyed the article on patient profiling by Renate Justin. Dr Justin, who is 'retired,' obviously combines a keen sense of observation and reflection with a fluid style of expression. I hope she will be encouraged to continue her medical writing.

Yossef Aelony, MD
Internal Medicine, Harbor City, CA

Dr Brian Alman,

I enjoyed your article on Medical Hypnosis in The Permanente Journal
(Fall 2001). It surprised me that positive change took place in the case studies without delivering commands. I, like many others, assumed hypnosis was a matter of repeating commands to the subject until they were ingrained in their subconscious. How wrong I have been.

I plan to read the book you recommended, "The February Man," to understand more about this captivating subject. I also want to read your book
on self-hypnosis so I can use it to remove some of my blocks. I practice in Internal Medicine for Kaiser Permanente in Atlanta, Georgia and receive The Journal at my office in Atlanta. I hope you continue to contribute your expertise.

Gail Gibson Vest, MSN, FNPC
Internal Medicine, Alpharetta, GA

Dear Dr Alman,

I enjoyed your recent article in The Permanente Journal (Fall 2001). It reminded me of when, as an Internist, I used hypnosis in my practice at Kaiser Permanente (KP) many years ago. I was trained to use hypnosis by Jack Watkins while in my residency at the VA hospital, so when I started practice at KP, it was just one of the tools I used.

In 1991, I published an article¹ that showed a 25% increase in the time the cardiologist was able to keep the balloon inflated compared to the controls. More interesting, was the fact that Norepinephrine levels were higher in the hypnotized group. I think further studies are needed in this area.

In 1970, with Stan Abrams, I published an article² on the validity of polygraph tests with the use of hypnosis. It proved that hypnosis could fool the lie detector.

As an aside, an interesting patient of mine was having trouble selling her artwork. What she liked to paint didn't sell; what she didn't like to paint did sell. I asked her to bring in her art materials. In a trance I asked her to do a drawing from the left side of the brain and later to do a drawing from the right side of the brain. Her drawings were completely different, as was the way and the tools she used to draw them. I didn't tell her what to do with her art, but on her next visit she told me those two art forms combined in her mind and she was now happy selling her art. I imagine I was more relaxed then with my patients than the doctors are now.

Edwin J Weinstein, MD, PhD
Retired
Northwest Permanente

References

1. Weinstein EJ. Use of hypnosis before and during angioplasty. Am J Clin Hypn 1991 Jul;34(1):29-37.
2. Weinstein EJ, Abrams S. Gibbons D. The validity
   of polygraph with hypnotically induced repression and guilt. Am J Psychiatry 1970 Feb;126(8):1159-62.

Permanente Journal,

I am an internist at KP MAPMG. Just loved the photos in the Fall 2001 issue. Wow!

Susan Houseman, MD
Internal Medicine, Washington, DC