Angelina Jolie Pitt, since publicizing her decision to undergo a prophylactic double mastectomy around two years ago, has become a fascinating cypher between the medical field and the lay world. Found through genetic testing to carry a mutant of the tumor suppressor gene BRCA1, Jolie’s estimated risks of breast cancer and ovarian cancer were 87 percent and 50 percent, respectively. In the face of such overwhelming risk, and having witnessed her mother ultimately succumb to these devastating conditions, Jolie refused to sit idly by while the demons of her past and potential future festered within her.
In Tuesday’s New York Times, she wrote another tender, intimate and inspiring piece titled “Diary of a Surgery.” In it, she discusses her second bout of preventative intervention — this time, a laparoscopic bilateral salpingo-oophorectomy. In other words: the complete removal of her ovaries and fallopian tubes.
Her assumption of this role, of matriarchal medical translator to the masses, is far more profound than simply following in the cancer-fighting footsteps of health activist Mary Lasker. Long perceived as the very social symbol of feminism, estrogen is the fundamental “female” hormone that is produced in the ovaries. Jolie, in this recent procedure, has had the primary endocrine essence of her womanhood removed: estrogen.
So, in the wake of her procedure, Jolie asks us: What does it really mean to be female?
This is a tremendously difficult question; one that doctors and patients have struggled with enormously. William Halsted, as a stalwart advocate of the radical mastectomy, at the break of the 20th century, represented one side of the continuum. The surgery, which called for the complete eradication of cancerous tissue in the breast, often resulted in horrifying disfigurement of the female body (given the uncertain anatomical proliferation of the cancer). Halsted thus submitted that womanhood was a virtue that was to be declared under the microscope.
The alternative end of the spectrum surfaced with the May 1960 FDA approval of the first oral contraceptive drug, Enovid. The drug had been previously approved by the FDA for menstrual disorders. “The Pill,” biochemically, is a humble combination of the two essential female hormones, estrogen and progesterone. It acts by manipulating the menstrual cycle to prevent ovulation. In other words, women could now elect to alter their chemistry to control their biology, causing a revolution in sexuality. In contrast to Halsted’s thesis, women were much more than how they looked under the microscope.
Now, back to Jolie’s question: What does it mean to be female?
Her answer is subtle. I read it as the following: so long as you feel female and are comfortably so, you are female. In any case, the interpretation is subjective — a sea change in the history of social medicine. This is quite a message from the sex icon of a generation. One imagines that this resonates with the cohort of those who have felt the need to change their gender.
I would, however, be remiss if I did not extrapolate the themes of this piece out a little further, such that they may also apply to my own life, and to that of my fellow males. (Actually, I feel there is an entire library of books to be written on the themes here, but I’ll do my best.)
I read Jolie’s broader question to society is as follows: If you knew a piece of information that could change your future, would you do something about it? What cost would you bear?
This too is an extraordinarily important question. As advancements in genetic medicine give us the potential to know more about ourselves than we ever thought possible, we must ask such difficult questions. If you were at risk for diabetes, would you change your diet? If you were at risk for lung cancer, as I am, would you stop smoking? If you were at risk for prostate cancer, would you do the extra colonoscopy?
And yet, among these immensely hard questions, perhaps the most profound of all of them are the three Jolie alludes to at the end of her article: Who do I want to be in the future? Who do my genes say I am going to be? What can I do about it?
If nothing else, Jolie illustrates that there is something to be done to be who you want to be.
The landscape of medicine is changing dramatically; we, as patients, will be more informed and more capable to make our own decisions than ever before. “Fate” is more malleable than it has ever been. Medical options have never been greater. Genes have never been more visible. They have also, in some sense, never been less powerful. What a wonderful thing.
It’s our prerogative to learn about our medical options in order to carve out the futures we desire for ourselves. As Jolie says, “knowledge is power.” How very sweet this irony is, given that the power to know and shape the future is the very fulcrum of the first “Tomb Raider” movie. Truly, the good guys can win after all.
Eli Cahan can be reached at emcahan@umich.edu.