Blood Matters

by Masha Gessen

  “This is probably what your brother would tell you,” David suddenly said. “If your brother were an economist.”

  It was already dark outside, and pouring rain, when we left the building. My babysitter had stayed longer than planned. David had had two guilty phone conversations with his wife. He opened his umbrella and ran for his car, and I jumped on my bicycle and sped home, making currents in the puddles, getting soaked, feeling strong and a little silly and generally like my life had a utility of 100 a year, possibly even more, now that I also felt that much more competent for being able to put a number on the value of riding in the rain.

  ***

  Nancy Etcoff studies the important things in life. She wrote a book called Survival of the Prettiest: The Science of Beauty, and when I met her she was working on a book on happiness. She was also teaching at Harvard Medical School and at the college itself, where I was auditing her class on the psychology of happiness. It was a wonderful class, one that made me very happy—not a surprising result of an hour of talking about nothing but what makes people happy. In my state, the distraction of discussing happiness with a roomful of very bright twenty-year-olds was nearly a lifesaver.

  In her book Nancy wrote that breasts are one of the things that distinguish humans from other animals: We are the only mammals who, starting at puberty, have rounded breasts all the time, whether or not we are breast-feeding. We are also the only species that views breasts as sexual. American culture, she argues, is as obsessed with breast size as it is with penis size.

  No wonder the genetic counselors mentioned ovarian surgery so much more easily than the preventive-mastectomy option. Plus, having one’s breasts removed is a much more difficult surgery than an oophorectomy. The ovaries are small and invisible from the outside, and the surgery can be performed as a laparoscopy—a tube is lowered into the abdomen through a tiny incision and the ovaries are snipped and pulled out through the tube, all in under an hour, leaving only a miniature scar. In another light, choosing whether to lose breasts or ovaries was choosing between the visible expression of femaleness and its invisible essence. “The visible always trumps the invisible,” said Nancy—meaning, the visible is harder to sacrifice.

  I asked her what makes a woman—or, rather, a beautiful woman. Breasts, she said. Also, the shape of the torso (narrow waist, wider hips), skin tone (women’s skin is less ruddy than men’s), lips (fuller than men’s), hair (no male-pattern baldness). In other words, it is the ovaries—or more specifically, the estrogen they produce. Without her ovaries, a woman will often gain weight, especially around the midsection (there goes the torso), her skin will lose elasticity, her lips will lose their fullness and color, and her hair will thin (though not necessarily the same way a man’s hair does). Hair and skin, Nancy writes in her book, are essential to our idea of beauty and attractiveness: They are “polymorphically arousing and primal in their appeal.” There follows a breathtaking sentence: “Within each inch of skin are sweat glands, oil glands, hairs, blood vessels and nerve endings through which we shiver, shudder, sweat, blush and quiver.” An organ like that could not be jeopardized lightly.

  Another sexual attribute that goes out with the hormones is the libido. It occurred to me that I was facing a choice between feeling desire and being desired. I would need my ovaries for the former and my breasts for the latter. I said I would rather be desirous: I figured I could always find one person to desire me—my actual partner, with any luck—but that would bring me nothing but frustration if I could not feel desire myself. Nancy seemed skeptical of this idea: She said it could be devastating to feel that there was no one in the world who wanted you. And worse, to see the reason in the mirror every time you took off your shirt.

  In her book on beauty Nancy writes a lot about what makes a woman attractive to a man. As its title suggests, the book is an attempt to apply Darwinian interpretations to today’s realities—an extraordinarily convincing attempt. In pondering why female medical students state a preference for men who will make even more money than they will, while male medical students seek the opposite in a mate, Nancy suggests it had to do with the hunter-gatherer division, which mating heterosexuals seek to maintain in some form. When she writes about women’s attractiveness, she focuses on the signs of her fertility. In fact, she notes, men are most drawn to women who look like they have never been pregnant, an attraction that can be seen as a form of intelligent investment, from the point of view of procreation: Women who have not yet hit their peak fertility (women under twenty, in other words) have their most fertile years ahead of them. Of course, we live in a time when the visual signs of the most attractive age are easily and frequently faked—and when fertility itself is manipulated more and more successfully—but human instincts, Nancy argues, trail well behind progress.

  Books like Nancy’s—and it is a wonderfully written book that sold well—serve a dual purpose. Those of us who read them get to feel superior to those who are described within: We can always cite our alternative priorities, unorthodox family structures, and advanced fertility techniques as proof that we are not governed entirely by Darwinian instincts. At the same time, they justify our less refined feelings—in my case, my reawakened vanity and deepening concern with sexual desire. I was not single; I was not particularly young; I was not even a practicing heterosexual. Nancy cites studies showing that lesbians pay youth and other traditional features of female attractiveness no heed; I was pretty sure the respondents were lying. Many of the women I had interviewed played the wise adults. They said things like, “I already have a mate.” Then they also sometimes said that they were happy with having had the surgeries—despite the fact that they had no libido and no longer liked looking at themselves in the mirror, ever. This struck me as counterintuitive, which is to say, utterly insane.

  But Nancy also writes about something else: Beauty does not guarantee or even significantly increase the probability of being happy. “Beauty gets you a mate,” she said, “but it doesn’t make you happy.” That is very strange, because beauty yields any number of everyday advantages, of the romantic and the purely social sort, and beautiful people do have higher self-esteem—and both self-esteem and small daily pleasures and satisfactions are known to matter a lot in happiness. Still, beautiful people, on the whole, are not happier than those who do not look as good. There are two possible, complementary explanations. First, one can always be more beautiful, so good-looking people are not immune to feeling dissatisfied with their looks. Second, happiness—like beauty, but quite separately from it—may be genetic.

  In 1996 two University of Minnesota psychologists, David Lykken and Auke Tellegen, published a new study of twins in a series of studies of twins that they had undertaken. The state of Minnesota maintained a twins registry—including twins that had been reared apart—that allowed these researchers to compare everything and anything about them. Their method was classic for geneticists: They collected data on both monozygotic and dizygotic twins, issuing questionnaires to various pairs of twins twice, at intervals of either ten or four and a half years, and then compared it. Whenever the results for monozygotic twins indicated a markedly higher correlation than for dizygotic twins, the researchers theorized that the trait had a genetic component. In general, virtually anything they set out to study seemed to have a genetic component—with the notable exception of choice of romantic partner, which, Lykken and Tellegen concluded, was entirely a matter of chance.

  Their conclusion that happiness is largely heritable did not mean that one was either happy throughout life, starting at birth, or unhappy forever. The people they studied got less or more happy over time. Only half of the people interviewed were equally happy at the age of twenty and the age of thirty—but monozygotic twins were much more likely to be as happy as their twin either was or had been. The psychologists concluded that happiness was roughly 80 percent heritable. In other words, they wrote, “It may be that trying to be happier is as futile as trying to be taller and therefore is co
unterproductive.”

  The idea of happiness as a genetic trait appealed to me. First, it affirmed my sense of reality: I generally felt as if I had been born to be happy. Second, it seemed to restore a kind of fairness: I might have inherited the cancer mutation from my mother, but I had lucked out of whatever unhappiness genes she seemed to carry. When I was much younger, our relationship veering between mutual torment and cold indifference, my undefeated ability to enjoy life had sometimes felt like revenge. Something of that old feeling resurfaced now.

  But then the mathematics of chance in happiness genetics are even less solid than in cancer genetics. “If the transitory variations of well-being are largely due to fortune’s favors, whereas the midpoint of these variations is determined by the great genetic lottery that occurs at conception, then we are led to conclude that individual differences in human happiness—how one feels at the moment and also how one feels on average over time—are primarily a matter of chance,” Lykken and Tellegen write at the conclusion of their paper. In other words, a predisposition to being happy is like a predisposition to being healthy or thin: Lousy lifestyle choices and plain bad luck can spoil the best of chances.

  So what do we know about happiness? Scholars of happiness have offered a number of definitions and ways of measuring happiness, but have largely settled on the concept of subjective well-being, which boils down to the simple premise that people generally know when they feel contented. Some people are more likely to feel happy than others. Religious people are a bit happier than nonreligious people. People who feel optimistic about their future are happier than those who do not, but though this was an important consideration for someone in my genetic boat, it posed a clear chicken-and-egg problem. Married people are happier than those who are not—though this, too, may confuse cause and effect: Happy people may be more likely to get and stay married.

  Here I was, considering doing drastic things to myself in the hopes of making myself live a longer and healthier life. But could I do violence to myself in the interests of longevity and still be reasonably sure that the person who came out the other end would be someone worth having around?

  Health is important to happiness—but not as important as one might think. People can be extraordinarily resilient in the face of shocking damage to their health. People rendered partially or completely paralyzed by accidents have a way of regaining their sense of well-being within eight weeks. Burn victims, who can suffer profound physical and psychological consequences, tend eventually to reach a good quality of life. In this sense extreme misfortune has as little lasting impact as great fortune: Winning the lottery, like getting a new job, being promoted, or even getting married, improves our sense of well-being only briefly. In the long run, people confined to wheelchairs are as happy as those who can walk unaided, wealthy people and good-looking people are as happy as those less fortunate, and even elderly healthy people are only marginally happier than their peers whose health is failing.

  Did that mean I had nothing to fear? Could I count on the genetics of happiness to keep me level as I battled the genetics of cancer? Nancy pointed out that cutting off apparently healthy breasts and ovaries would be strange. She might have been trying to avoid calling it insane. After all, people generally aim to fake youth and beauty, not purposefully to annihilate them.

  There are only a couple of things that have been found to make people profoundly less happy for a long time. One is being widowed—and this was certainly an argument for doing anything I could to prolong my life. The other is developing a degenerative disabling condition. Surgical menopause could well turn out to be just such a condition, at least for a few years.

  Nancy pointed out that for some women, menopause actually brings a sense of liberation. No more mood swings. No more unwanted sexual attention. “As women get older, they broaden their definition of beauty,” she said, “to emphasize aspects of strength, confidence—intangibles.”

  “What do those look like?” I asked.

  Nancy was momentarily stumped. “I think it’s more about self-presentation and style—projecting more than meeting signals.” She then suggested that genetic counseling for a woman in my position ought to include a computer model of how she would change with age—or as a result of premature aging brought on by surgical menopause. I liked the idea of giving shape to the suggestion of surgical tinkering—creating a visual expression in place of a statistical model.

  Much harder to grasp was what it would feel like. The few available studies of women who had undergone preventive mastectomies seemed to show that they were happy with their choice. There were a couple of problems with these studies, however. First, women who were likely to have been most conflicted might simply have refused to participate. Second, once the results were unpacked, they looked far less positive. Take a British study that concluded that “for a majority of women there is no evidence of significant mental health or body image problems.” In fact, only 21 percent of the women in the study said their body image had not changed for the worse as a result of the surgery. More than half said they felt less physically and sexually attractive, and a third said they felt less feminine.

  On the other hand, the women said these were slight changes, not profound ones. And it did seem that they paled in comparison with the psychological benefits of the surgery. Several studies concluded that women were much less anxious about their health and their future, and much less likely to become depressed than mutation carriers who chose not to have surgery. In other words, it seemed, cutting off her breasts could make a woman happy.

  ***

  When it came to menopause—early surgical menopause, to be precise, caused by the removal of the ovaries—my efforts to pin down the probability of specific outcomes appeared very nearly doomed. Most doctors seemed reluctant even to discuss some of the possible side effects that worried me most, such as cognitive difficulties and memory loss.

  I interviewed a number of women who had undergone surgical menopause. My sample was unrepresentative and almost certainly skewed toward those who had handled the surgery well enough to be willing to discuss it, for publication, with a complete stranger. As it was, I heard everything from “It’s no big deal” to accounts of debilitating effects ranging from depression to utter physical collapse. My own doctor assured me that depression, in most cases, stems from sleep deprivation, which is treated successfully with hormone-replacement therapy. “But word recall is never recovered,” she added matter-of-factly. Word recall, as it happens, is essential to my craft. Would my professional competency and, to some extent, my identity be too much to sacrifice for a couple of years’ increase in life expectancy? Would my mind be too much to give up in exchange for peace of mind?

  I may have been exaggerating. Most specialists dismiss any discussion of the cognitive consequences of surgical menopause as “anecdotal”—which, generally, is medicalspeak for, “We haven’t studied it, so it can’t be considered proved.”

  It is remarkable how little the effects of surgical menopause have been studied. Hysterectomy is the second most frequently performed surgery in the United States (following cesarean section). For the last two decades of the twentieth century, about 60 percent of American women had their uterus removed by the age of sixty-five—and the average age at hysterectomy was a mere 42.7 years. In more than half of the cases, the ovaries came along for the ride. A groundbreaking study published in 2005 found that these unnecessary oophorectomies caused women’s deaths from heart disease and hip fracture. But what actually happens to the lives—or, rather, to the minds—of the roughly four hundred thousand American women who have their ovaries removed each year? No one really knows.

  A study of the effect of surgical menopause on women who did not have cancer found that they suffered a significant decline in all the mental functions that were measured: digit span (the number of digits a person is capable of memorizing at one time), visual memory, logical memory, and mental control (essentially, the ability to concentrate).
This study was conducted at the University of Egypt and involved just thirty-five women who had an oophorectomy and another eighteen who served as a control group. Another study, carried out in California, failed to find any clear negative consequences of oophorectomies—but it compared women’s test scores to those of other women rather than to their own presurgery test results, as the Egyptian study did. A third study, in Italy, looked specifically at the effect of oophorectomy on memory and concluded that surgical menopause was “a critical negative event within the female brain, in particular when it occurs prematurely.” I loved the wording—“a critical negative event”—like an earthquake or a hurricane in the brain, coming in an instant and leaving devastation in its wake. This certainly seemed to add up to more than anecdotal evidence—except that three studies, one of which was inconclusive, is pitifully little proof in medicine.

  It took a while to find someone willing to discuss the effects of surgical menopause with me. I finally located Susan Bauer-Wu, a nurse scientist at the Dana-Farber Cancer Institute. She stressed that she was not an MD but rather a doctor of nursing, “which is important, because I have a whole-body perspective.” The jab at MDs, who view bodies as the sum of spare parts, may have been unintended, for Bauer-Wu did not seem the type of woman who would jab anyone on purpose. Bauer-Wu turned out to be a thoughtful woman who spoke very carefully and softly, but in well-formed, nonspecific phrases that gave me little to latch onto.

  We spoke in a fake exam room: Dana-Farber, which attracts constant media coverage, has one set up for taping television interviews with doctors. Once again I heard everything I feared I would. Bauer-Wu enumerated the certainties of surgical menopause: depression, memory loss, difficulty with word recall, and that feeling I remembered so well from the postpartum year, the feeling of having all your senses padded with cotton. She also left me no doubt about the loss of libido: “It just happens to everyone.” There would not be an exception in my case.