From: Headley, Shannon
Sent: Sunday, July 26, 2020 3:25 PM
To: Vercellini, Paolo
Cc: FertStert Editorial Office
With the recent events and public shaming of The Journal of Vascular Surgery regarding their publication of Prevalence of Unprofessional Social Media Content among Young Vascular Surgeons, and specifically the outcry from women surgeons regarding the implicit bias and gender discrimination using the word "bikini," I wanted to bring an article to your attention privately since I am not in the business of shaming, but rather, educating.
A colleague contacted me today regarding Attractiveness of Women with Rectovaginal Endometriosis: A Case-control Study, and the stated conclusion of "Women with rectovaginal endometriosis were judged to be more attractive than those in the two control groups. Moreover, they had a leaner silhouette, larger breasts, and an earlier coitarche." DOI:https://doi.org/10.1016/j.fertnstert.2012.08.039
Although your methodology includes 4 independent female and male observers, I can foresee this article causing another outrage where women feel objectified or discriminated against and I wanted to bring this to your attention.
My hope is that the editors-in-chief and corresponding author will consider my feedback and make the best decision for your journal.
All the Best,
Shannon Headley, MA LPCStudent Doctor | MSIV
Hello Mrs Headley,
The issues and the approaches of the two articles you are referring to seem very different.
We dealt exclusively with a pathogenic hypothesis regarding the most severe endometriosis form, that is, rectovaginal endometriosis.
A vast amount of data suggests that rectovaginal endometriosis may have a different pathogenesis with respect to ovarian and superficial peritoneal lesions. In particular, several investigators are focusing their attention on the intrauterine environment, theorizing that women with deep infiltrating endometriosis might have been exposed to an unbalanced hormonal environment, characterized by an estrogen excess, during the first trimester of pregnancy.
Moreover, independent groups consistently observed associations between endometriosis and particular phenotypic characteristics. To give you an example, our data demonstrated a strong association between blue eye colour and rectovaginal endometriosis (https://academic.oup.com/humrep/article/29/10/2171/646008).
This suggests a genetic basis for this disease form. An interaction has been hypothesized also between specific genetic profiles and the intrauterine hormonal environment. Endocrine disruptors might here play a role.
Face attractiveness is being studied for decades in females and males in different fields of medicine and research in general. It is also known that genes influence facial attractiveness and that those genes are associated also with some secondary sexual characteristics (https://journals.plos.org/plosgenetics/article?id=10.1371/journal.pgen.1007973).
In addition, there is no evidence in support of different serum estradiol levels in adult women with endometriosis compared with controls in the general female population of corresponding age. The same is true for attractiveness in young adult women (https://www.sciencedirect.com/science/article/pii/S0306453018300039?via%3Dihub).
Thus, early intrauterine rather than adult life might be the decisive phase for the future development of severely infiltrating endometriosis, be it due to genetic predisposition, unbalanced hormonal exposure, or both.
We studied facial attractiveness to verify whether differences existed between women with rectovaginal endometriosis, women with other disease forms, and women without endometriosis. A statistically significant difference was observed. Several other demographic, clinical, and phenotypic variables were also assessed. Among the latter ones, breast size was larger in women with rectovaginal endometriosis, thus providing further support to the study hypothesis.
The study investigated many variables in addition to phenotypic characteristics, and age at first intercourse (coitarche) was among the data that women indicated in the section of the questionnaire focused on sexological aspects.
All the women were evaluated exclusively by female examiners except for the rating of facial attractiveness, that was performed, after the end of the visit, by four other investigators (two females and two males) who were unaware of the woman’s condition.
I understand that this article has generated disappointment, and most of the criticisms were raised several years after its publication (it appeared online in October 2012). The study was designed in 2004 and started in 2005. Fifteen years ago, we had no awareness of the possibility of being misinterpreted. Despite this, I still do not feel that this study objectified or discriminated women, and nobody involved in the study even raised the suspicion that our behaviour could be disrespectful or discriminating. Several co-workers participated and, again, almost all were females. Nobody thought that assessing facial attractiveness could be interpreted as objectification. And all the female investigators that are still working in our hospital are very surprised by the concerns raised.
Even the wording might be badly received. As an example, the word coitarche (from Latin coitus plus ancient Greek ἀρχή, i.e., beginning) that you also included in your email has been criticized. However, a search of “coitarche” in PubMed retrieved many articles published even recently in English-language journals. Indeed, in Italy, we frequently use this type of terminology for other phenomena also, such as thelarche, pubarche, and menarche.
In conclusion, our group discussed the hypothesis to be tested after a thorough literature examination, designed and conducted this study with enthusiasm and according to what we considered a sound methodological approach and analyzed the results carefully.
Despite the above consideration, when we understood that our article could have caused discontent, we abandoned completely this line of research. I am very sorry, but everything was done in good faith. We thought we had found another piece of evidence in favour of the genetic/intra-uterine life theory.
I hope my words have clarified the context in which our idea was developed, and the theoretical premises underpinning our study. Rest assured that we take respect toward our patients very seriously.
I appreciated the kindness of your email.