Volume 212 Issue 4

Misgendering negatively affects the mental and physical health of trans individuals

Irene J Dolan · Penelope Strauss · Sam Winter · Ashleigh Lin

Before prescribing tafenoquine, clinicians need to request a quantitative G6PD test to exclude patients with either severe or intermediate enzyme activity

Robert J Commons · James S McCarthy · Ric N Price

A 74-year-old Caucasian woman was referred for hirsutism over the abdomen and was incidentally found to have a 21 × 25mm ulcerated nodule over the umbilicus

Tom Kovitwanichkanont · Shoba Joseph · Leona Yip

The skin has more disease processes than any other organ system in medicine, with over 3000 dermatological conditions described

Kirsty JL Wark · Saxon D Smith · Deshan F Sebaratnam

The balance between benefits and risks could be improved if effective risk-based screening protocols were developed

David M Roder · Elizabeth Buckley

Ongoing population- level strategies are needed to further reduce lead exposure

Mark P Taylor · Bruce P Lanphear

Cancer overdiagnosis is a substantial problem that urgently requires changes in public health policy

Paul P Glasziou · Mark A Jones · Thanya Pathirana · Alexandra L Barratt · Katy JL Bell

Blood lead levels in the pre-school children in our sample were lower than in previous surveys

Christos Symeonides · Peter Vuillermin · Peter D Sly · Fiona Collier · Victoria Lynch · Sandra Falconer · Angela Pezic · Nicole Wardrop · Terence Dwyer · Sarath Ranganathan · Anne‐Louise B Ponsonby

Since the publication of the previous guidelines in 2015, further evidence has emerged that has led to a change in management of paracetamol poisoning

Angela L Chiew · David Reith · Adam Pomerleau · Anselm Wong · Katherine Z Isoardi · Jessamine Soderstrom · Nicholas A Buckley

Compared with age-matched men, women tend to have poorer health status but longer life expectancy

Emily H Gordon · Ruth E Hubbard

To the Editor: Amyotrophic lateral sclerosis (ALS) is a rapidly progressive and fatal neurodegenerative condition with no cure. Only two treatments with class I evidence exist — riluzole1 and edaravone2 — both with unclear mechanisms of action and modest survival benefits. In Australia, riluzole remains the only treatment approved by the Therapeutic Goods Administration. The Pharmaceutical Benefits Scheme limits initiation of riluzole to patients with at least 60% of predicted forced vital capacity, although facial weakness may make this an unreliable target. Initial and continuing treatment requires patients to be ambulant; or to have good upper limb function or to be able to swallow; and not to have respiratory failure. A recent retrospective study classified patients into different disease severity stages, ranging from 1 (one region involved) to 5 (death); patients with respiratory and nutritional failure were assigned to stage 4.3 The study identified that patients in stage 4 receiving 100 mg of riluzole daily did not progress to the next clinical stage (ie, death) as rapidly as those in milder stages. This suggests that the modest survival benefit experienced by patients taking riluzole comes about by extending the time spent at this stage. A quarter of patients present with bulbar or respiratory onset,4 making many ineligible for treatment, despite data suggesting they may benefit most.5 Mean survival in these forms of ALS is particularly short, meaning the modest survival benefit offered should be considered, as a majority of patients with advanced ALS do not wish to hasten death.6 A recent study of over 4000 trial participants confirmed benefit in both early and late stages,7 supporting use of riluzole throughout the disease. Few prospective studies on late‐stage treatments exist; patient choice in continuing treatment during advanced stages therefore remains paramount. Prospective studies are needed to establish whether the benefit of riluzole is weighted towards more advanced disease. However, recent studies, along with the recognition of the clinical spectrum of ALS, indicate that the current Pharmaceutical Benefits Scheme criteria are too stringent. As we move towards precision‐based medicine, different profiles of therapeutic response are likely. Regulators will be required to rapidly respond to emerging data to ensure the right patients can access the right medications.

Colin J Mahoney · Matthew C Kiernan

To the Editor: We applaud the astute perspective of Teede in relation to gender equity in medical leadership.1 Organisational culture that promotes male leadership styles is self‐perpetuating and this has implications for our specialty of endocrinology, which is rapidly becoming “feminised”. About 80% of physician advanced trainees in endocrinology are female and yet only 20% of heads of endocrinology departments in Australian training hospitals are women (Royal Australasian College of Physicians Advanced Training in Endocrinology Program, unpublished data). Waseem and colleagues2 documented significant under‐representation of women at higher academic levels in endocrinology societies internationally. Only 23% of full professors and 31% of board members were female. Women have fewer publications or research citations, but their skill sets are diverse and they bring value to executive boards through negotiation and problem solving skills. The historical biases around the expectations of women are perpetuated by male powerbrokers. Unconscious bias can be subtle. Duma and colleagues3 reported that when introducing female speakers at an international conference, men were more likely to use a woman's first name alone, but male speakers were introduced with full professorial title and surname. This undervalues the women who already tend to underplay their own skills. Part‐time employment may be supported in theory, but it is left up to the woman to find a solution. Women fear that part‐time work may challenge perceptions of competence. A healthy endocrinology training scheme must support our significant female workforce and serve the 70% of endocrinology outpatients who are women. We have wonderful male colleagues who are willing to support progress, but they may be deterred by the stigma attached to issues such as paternity leave. The current chair of the Royal Australasian College of Physicians Advanced Training Committee and the coordinator of the Advanced Training in Endocrinology Program are both women, so we do see a bright future ahead. This is an important issue for our patients, for women and for men.

Diana L Learoyd · Jane Holmes‐Walker

To the Editor: Teede's inspirational, forward‐looking review1 should also prompt scrutiny of the philosophical constructs underpinning gender equity. “Unconscious bias” is raised four times but does not appear to be supported by referencing, apart from a qualitative survey which reports the perception of unconscious bias.1 Some critics have argued2,3,4 that implicit (unconscious) bias as a factor in creating gender or other types of societal inequity is not proven, and that the Implicit Association Test, which has been used to support the concept of implicit bias, does not meet criteria for reliability and validity.2,3 Substantive equality allows different groups to be treated differently to enable members of these groups to enjoy equal human rights. It is the philosophical justification for the legal instrument of “special measures”, as described in the Australian Human Rights Commission guidelines on special measures under the Sex Discrimination Act 1984 (Cth).4 Special measures allow for “lawful” discrimination, without which, for example, leadership programs for women and quotas would be unlawful under anti‐discrimination legislation. However, there is no strict legal definition of special measures and the guidelines do not provide a definitive legal clarification of the special measures allowed under the Sex Discrimination Act.5 This leads to the question of how individuals, institutions and the legal system can determine if substantive equality has been achieved and whether this has led to gender equity. Although statistics are frequently used to support either the attainment of gender equity, as they are in Teede's article,1 or the lack of it, the concept of “disparate impact” needs to be considered. This describes the situation where groups which have protection under the law (eg, for race or gender) experience disadvantage despite all the rules being formally neutral. The United States Supreme Court6 found in 2015 that a “disparate‐impact claim relying on a statistical disparity must fail if the plaintiff cannot point to a defendant's policy or policies causing that disparity”. That is, a statistical variation alone cannot prove discrimination. Such findings are also likely to partly shape debate in Australia. In summary, justifying otherwise discriminatory means of redress using the unjustifiably blunt dichotomous test of “gender” creates untenable rankings of individual disadvantage.7 How does this deal with the situation where, for example, a man wishes to make career sacrifices for childrearing. Should this situation be included in special measures?

Michael Keane

In reply

Mariam Mousa · Jacqueline A Boyle · Helena J Teede

Dr Allison Hempenstall left herself open to all career possibilities and so far, things are working out well …

Cate Swannell