Tuesday, May 16, 2017

Can I Find a Partner?

It occurred to me that there are ways to find out if we can fall in love, whether we can sustain a relationship and how close we can be to others. We can enter into our physiology for answers to these questions; for in that physiology lies our history, our emotional past that can help predict the future. We can slice into the problem from many different perspectives but for now I will choose only one: oxytocin. I call it the hormone of love. When we make love our oxytocin levels mount; if we rub an animal’s belly levels rise. Making love tells us the importance of oxytocin since that act is the origin of life.

Oxytocin is a neuro-hormone that is a key hormone of love. When the level of oxytocin is low there is less emotional attachment, less interest in social engagement, less caring and bonding, and less touch ... in short, less love. "Less love" has a physical base. Less love early in our lives can be found in an imprint, which affects many systems. These effects are measurable. In some respects, love is a measurable entity. The imprint affects sexuality, particularly how key brain structures such as the amygdala and hippocampus translate pain into sexual behavior.

Oxytocin is found only in mammals. When it is high, one experiences a sense of relaxation, rest, and growth, repair and healing, loving behavior and emotional-attachment. Love and nurturing early in our lives are necessary for optimum health, and healthy brain development cannot take place without it. It isn’t just that low oxytocin levels are an indicator of early neglect and lack of touching, it also indicates a dysfunction of the entire system, and serves as a prognosticator of our later mental and physical health. Its presence says, "I was loved and could develop normally,” its lack says, “I was unloved and my system is skewed.” It is one of the key indices of how much love we received in infancy and around birth.

In the same way that we may increase sexual drive in males with testosterone injections, it may well be that we can "inject love" into people, or at least inject a hormone that encourages it – give people a shot of love, so to speak. This shot may help us attach to others and bond with partners, allows us to feel close to someone else, to feel and empathize with their feelings and pain. Bonding is a strong emotional attachment that helps us want to be with one another, to help and protect one another, and to touch and become sexual with one another. High levels of oxytocin encourage and strengthen bonding. Because early trauma and lack of love affect the output of this hormone, the ability to relate and have good sex later is determined even before birth and just after.

Someone can swear she is full of love, only to find herself very low in the essential hormone of love – oxytocin. It is actually good news that "less love" has a physical base, for there may be something we can do chemically to alter that state, and there is certainly something we can do psychologically to change it, as well. At sometime in the future we may be able to determine what proper love from a parent to a child is through the measurements of various hormones, not the least of which is oxytocin, which, as I state, has been in wide use to help birth along, affecting contractions in the mother. (Pitocin).
Early parental love is a permanent painkiller. Rats who were able to self-administer painkillers by pressing a lever did not do so when given oxytocin. Oxytocin (OT) inhibits the development of a tolerance to drugs such as morphine, and also decreases the painful withdrawal symptoms that occur when one is taken off these drugs. The degree of addiction can be measured by the severity of one’s withdrawal, yet oxytocin reduces the severity of these symptoms. Love will do the same thing; early love calibrates the system for life. A current shot of love, such as someone hugging and kissing us, may well change the levels temporarily. If we rub the belly of an animal the oxytocin levels will rise immediately, but once the initial critical period of the system’s development has passed, every change we can effect will be transient. Once we arrive at adulthood, oxytocin levels are fairly set. One can be given a shot of it, but it will not have a permanent effect, for once low levels of oxytocin or high levels of stress hormones are registered early in life, it is difficult to re-establish normal set points. After the critical period to receive love is over, the only way to normalize the system is to neuro-chemically relive the early events that dislocated the set points. The “critical period” is the time when a need must be fulfilled. It can never be recaptured. After that period all we can do is play catch-up.

If we are to ever have any chance at normalization we must feel again "unloved." That enables us to go back to the point of deviation or dislocation and rewrite the scenario and return the body to its correct set-points. . In that way only can we right the ship and return to the original biologic settings. It is that agony with all its concomitant biochemical components, that, when fully experienced, helps normalize the system. And when I mention “normal,” it seems to me that one of the key indices of normality is the ability to give and receive love. This is what patients should expect out of a psychotherapy.

We do know that in our measurements of the salivary cortisol (the stress hormone) there was a return to normal levels after one year of Primal Therapy. (see Primal Healing for a full discussion). In various other avenues we find the same phenomenon. True of heart rate and blood pressure. We assume it will be true with oxytocin levels. We make that assumption because our patients state over and again how they finally could relate to a partner and feel comfortable in an emotional relationship after the therapy.

There are many kinds of hormones that play into love and sex; I am extracting these for discussion and to show how early experience affects adult behavior. Many years ago we studied testosterone in our male patients. We also classified those who were low on testosterone as parasympaths – those dominated by the passive, reflective, healing nervous system. Those, who were high in testosterone, tended to be sympaths, meaning they were more aggressive, goal seeking, optimistic and ambitious (looking ahead, an analogue of the birth process). After one year of Primal Therapy, those who were low on testosterone tended to rise, while those who were very high tended to come down a bit; in brief, their systems would normalize.

When it comes to love, however, oxytocin is by far the most important hormone. The question we now face is what came first: lowered oxytocin and then the inability to love and to bond, or the lack of early love, which lowered the set points of oxytocin? I would choose the latter. Because hormones are so sensitive to early trauma, we must take care not to blame high or low levels to genetic factors. We must never forget the critical nine months of life in the womb.

Bonding is the most positive aspect of human relationships. We learn how to bond emotionally in adulthood through early bonding in childhood, as simplistic as that sounds. It cannot be taught! And it certainly cannot be taught in later life. Attachment is pretty well set in our childhood. It is not something we learn; it is something we feel. It is also something biochemical. Those who did not bond very early on with their parents may well be condemned to a lifetime of broken, fragile, tenuous relationships. It may be in large part due to deficits in the hormonal wherewithal such as oxytocin. Oxytocin researcher Thomas Insel has remarked that, "Many of the affectional ties to the mother observed post-natally (after birth) could be laid down by pre-natal experience." Life in the womb may determine life outside the womb for decades to come. If the early relationship with one’s parents was distant, alienated and glacial, it may be a harbinger of the love relationships we have or don't have later in life. The earlier the alienation from one's parents, the more trouble there may be in relationships later on. I have seen it in hundreds of my patients. It approaches a biologic law – if my sampling of our patients is any index.

In certain mountain rodents such as the mountain vole, a species that lives an isolated life (as differentiated from the prairie vole, which is more social), a shot of oxytocin proved to encourage bonding and pairing between voles. After repeated injections there was a long-acting anti-stress effect, which calmed overall behavior and gave rise to a strong tendency to bond. This again indicates that early love supports calmness and serenity. Those humans who are able to bond with others have high levels of oxytocin. Love seems to be the ultimate painkiller and a permanent one. It prepares us for the challenges of life and is the ultimate survival tool.

Need a good sex life? Be loved early on by your parents. That means, inter alia, right after birth and for the few months afterward. By that I mean plenty of hugging and kisses. Touch is ne plus ultra. Suffer from perversion? It may be because early in life, you were twisted by your parents in the quest for love. Parents whose personalities made implicit demands on the child to be someone else—non-coomplaining, passive, listening never speaking.

There is enough evidence to show that a newborn's heart rate, body temperature, and respiration rate are governed by the mother; when she is loving and nurturing towards the baby she carries, there is a positive affect on the baby and the set points of heart rate and blood pressure become normal. Any neglect she inflicts changes the biochemistry of the baby, perhaps permanently. Her anxiety and depression during pregnancy may very well alter the offspring's sex hormone levels. We know, for example, that anxiety in the mother can and does alter the sex hormone level of the fetus and can feminize infant males. So what we see is that once a male is feminized he is vulnerable, more vulnerable to a lack of love during infancy and childhood. He may become homosexual as a result of a cold, distant father, while the one who is not vulnerable will remain heterosexual. We need to understand that at certain levels of vulnerability, stress, trauma or pain can produce an overload and channel them into a symptom. In this sense, homosexuality could be considered a symptom, in the sense that there is a latent tendency, a feminizing, which only becomes overt homosexual behavior due to trauma; i.e., the lack of a father’s love. If the father’s love is there, it remains a latent tendency.
The female prairie vole, when treated soon after birth with steroid/stress hormones, showed an increase in masculine behavior, such as mounting. Most of us don't have to be injected with stress hormones; stress in the womb and just after birth accomplish the same thing, and may indeed masculinize females.

Although we may think that an injection is something special, the same chemical process takes place naturally. We can inject oxytocin, or we can massage the animal, and increase oxytocin levels that way. We can create stress for a pregnant woman, or inject her with steroids – the psychological effect is precisely the same as from a needle. A mother can be kind and loving and raise the serotonin levels in her offspring so that he can better handle adversity or a doctor can inject serotonin into the offspring and produce a temporary calming effect that is no different than that created by a loving look from the mother. A mother can "inject" oxytocin into her baby through her milk, which contains high levels of the hormone. Love, or what looks like it, can be injected. When "injected" naturally and at the proper time it will produce a loving human being.

Oxytocin means "quick birth." A synthetic oxytocin known as Pitocin, is given to mothers who need stimulation for contractions. I surmise that some mothers who need oxytocin to expedite the birth process may have had a history of pain that lowered their levels so as to make giving birth difficult. Statistics indicate those mothers who give birth by cesarean have lower levels of oxytocin. Additionally, when oxytocin is given to mothers to facilitate the birth process, it also enhances the love they feel for their child; they nurse better and are more relaxed with the baby. Conversely, a chronically anxious mother may leave her offspring with low oxytocin levels, which will contribute to the child having trouble later in life with bonding and forming attachments, as well as harboring a latent tendency to addiction. Thus, lack of early love translates into inadequate chemicals with which to bond, creating a vicious cycle of misery – unhappy relationships, poor sexual function, and failed marriages with suffering, abandoned children who bear the brunt of something that had its root causes in the infancy of the mother.

Loving feelings are transmitted to the fetus through the biochemistry and oxytocin levels of the pregnant woman, and then later through physical contact, which again raises oxytocin levels. If we were not loved early on, looked at, touched, listened to, nuzzled and adored, those biological changes, subtle though they may be, follow us throughout our lives. Yet a mother who takes good care of herself, is not depressed or anxious, does not take drugs, and eats properly, will produce a loving child.

If the traumas of birth, pre-birth and early childhood are inundating the system there will be an eventual overload and breakdown of the neuro-inhibiting, suppressing systems – serotonin, as well as oxytocin. There are many chemicals that live in the gaps between nerve cells, neurons; some push back and while others facilitate the message of pain. They are either information blockers or enhancers. Supplies of neuro-inhibitors will be used up over time in the fight to keep pain down. These supplies are not inexhaustible. It is the very earliest pains that have the highest valence and require the greatest amount of inhibition. These biochemicals will be used in the battle against emotional deprivation. The system will eventually be less sexual as the hormones of love become transmuted into the job of holding down pain.

A therapist can ask us, "Were you loved?," and we may insist, "Absolutely," yet we are betrayed by our oxytocin levels, which are far too low, and by our stress hormone levels, which are far too high, and also by our hormone levels which may be quite deviated. They speak too. The body and its physiology do not lie. Indeed, we may have been loved after birth, but suffered severe traumas in the womb of which we remain completely unaware. Our physiology will tell us the truth.

Monday, May 8, 2017

The Difference Between Romantic Love and Sex

Romantic love exists. Emotional attachment exists. Yet they involve different brain structures and different biochemistry than what drives pure, lustful sex. Once there is attachment or love, a separation can cause pain. Oxytocin helps to quiet this pain and can function very much like other neurotransmitters and inhibit suffering. To listen to my patients is to understand the terrible pain of a child separated from his parent; the cry of separation is an attempt to bring that parent back close again; it is true in nearly all animal forms.

There is a structure within the brain known as the cingulate cortex, which is responsible for that cry. This cortex is like an arc overlaying the limbic/feeling area and also deals with aspects of emotion. This area plays a role in maternal care and loving. The cingulated cortex is responsible for making the chemicals of comfort, and is also involved in inducing a sense of empathy, the ability to feel what others are feeling.

The cingulate cortex is endowed with endorphins, internally produced painkillers. When animals cry (as a result of separation from their mothers), these painkillers surge forth to ease the pain. When such a separation is abrupt and goes on for a long time, the baby’s pain becomes imprinted in the brain and remains. It is more pain than what a young body can tolerate.

Mother Nature knows that a baby needs two parents to care for him. Pair bonding is the result of two adults becoming attached, having sex, having a child, and loving that child. With the love these parents themselves received early in their own childhoods, they have the oxytocin and vasopressin that enables them to love their own child. Love is the foundation, therefore, for survival because when it is lacking, the child does not get the love he needs and he suffers, and the system becomes skewed and dislocated. Later, there may be disease and premature death as a deviated system is forever out of whack. A baby needs to be caressed and feel the sense of touch, which is the baseline of love. Without it, the brain changes and is less adaptive.

Alterations inside a pregnant woman, who does not want her baby, can affect the brain development in the womb so that the frontal cortex of the fetus becomes impaired. This has implications for later learning and adaptation. The mother's attitude, if not loving, adversely affects her fetus. It is one reason that we cannot be taught to love later on, though we can be taught to behave in a sociable manner. Love is not something to be taught. It is something we learn through our experience.

When the stimulating hormone, dopamine, and the repressive hormone, serotonin, are both at proper levels, there can be feeling and love. When serotonin is too high, there is too much repression and the ability to love is less. When dopamine is too high there is too much agitation and not enough cuddliness to allow love. A proper balance is needed among all the hormone systems. This is particularly true with oxytocin in females and vasopressin in males. After sexual orgasm, both of these levels rise by hundreds of percent in both parties, as if to say that attachment and closeness are part of sex or perhaps "should be," according to nature. It's nature's way of saying that sex should be taken seriously and is part of the syndrome of romance.

Constant random sex has nothing to do with love and is more or less a release of tension. It actually contradicts nature. However, there are two different brain/biochemical systems involved – one for pure sex and the other for attachment. We can be attached to someone and still have sex with someone else without love. There is evidence that in the latter case – sport-sex – the oxytocin and vasopressin levels are lower.

What are we to make of all this? That love exists and it is has physical effects. It can sculpt our brains early on. It is an intimate part of sex, and it ensures healthy development, both physically and mentally. Love is not an ethereal entity, but something we can measure. It may be a more accurate gauge of our state of being than all the protestations of love we might make. Love really does make the world go round.

Monday, May 1, 2017

On Why We Can't Express Our Feelings

Having feelings and expressing them are two different animals; and I choose those words carefully because having feelings means having access to the feeling structures of the limbic system in the brain. Expressing feelings means access to the thinking neocortex. The only time expressing feelings is important is if the state of having feelings precedes the expression of them. Then the comprehension is an evolutionary outgrowth of those feelings.

Unfortunately, when I was doing insight/psychoanalytic therapy I thought that expressing feelings in a session was tantamount to having them. Not the case. In fact, too often expressing feelings can act as a defense against experiencing them; smothering feelings in a flurry of abstract ideas. When I say “it is two different animals,” it literally is: the primate (monkey) feeling brain versus the human thinking one. Animals feel even when they have no means to expressing them.

I have been writing about this for the last forty years, and just now, new research is coming to the fore to verify this. Early on I posited the notion that one aspect of expressing feelings was the proper connection between the right and left brain hemispheres. Now it turns out that this is basically true; (see Science Daily, May 27, 2008. “Why Are Some People Unable to Express Their Emotions.”) Italian investigators have found that there is a deficit in interhemispheric transfer with those who cannot express their feelings. What that means is that the feelings lying on the right lower brain do not make the trip across the corpus callosum (where emotional information is transferred from one side to the other) to the left understanding, comprehending verbal side. Since eighty percent of all emotional information cross the corpus callosum from one side to the other, it seems logical that there is one key locus for the problem of alexithymia, or the inability to express emotions. It seems obvious now that for help in expressing true feelings one needs access to right side lower brain sites. It does not help to engage oneself in a therapy that is primarily intellectual; an interaction through the realm of ideas. Expressing feelings in words is not feeling those feelings. One can express feelings precisely but cannot necessarily feel them. What is required is a therapist who has access to her feelings and who can know when someone has access or not. So we need a therapy of feeling; one that takes feelings into account, and just as important, a psychological theory based on need.

What seems to be the problem is a dysfunctional cortical frontal-limbic circuits. In particular, the orbitofrontal area. As I have written elsewhere the right orbitofrontal area (behind the orbits of the eye) contains a map of our emotional life and emotional history. It is internally oriented. The left, on the other hand, is externally focused. It is interesting that panic attacks often accompany this condition (alexithymia). These attacks usually emanate from deep in the brain (the brain stem) and are associated with trauma in the first few months of gestation.

A new study (Brain’s Gray Cells Appear to be Changed by Trauma of Major Events. Science Daily June 4, 2008) indicates something I have maintained for decades: “ This suggests that really bad experiences may have lasting effects on the brain.” I believe that the earlier the trauma, (especially during gestation) the more widespread and long-lasting the effects. It seems that the set-points for many physiologic functions are established in gestational life. These dislocations of function remain fixed and unalterable; whereas trauma after birth can often be compensated for. In short, there is a permanent deficit in gray matter when traumas occur while we are being carried in the womb.

We can’t get well just expressing our feelings; we can only get well by experiencing them.

Review of "Beyond Belief"

This thought-provoking and important book shows how people are drawn toward dangerous beliefs.
“Belief can manifest itself in world-changing ways—and did, in some of history’s ugliest moments, from the rise of Adolf Hitler to the Jonestown mass suicide in 1979. Arthur Janov, a renowned psychologist who penned The Primal Scream, fearlessly tackles the subject of why and how strong believers willingly embrace even the most deranged leaders.
Beyond Belief begins with a lucid explanation of belief systems that, writes Janov, “are maps, something to help us navigate through life more effectively.” While belief systems are not presented as inherently bad, the author concentrates not just on why people adopt belief systems, but why “alienated individuals” in particular seek out “belief systems on the fringes.” The result is a book that is both illuminating and sobering. It explores, for example, how a strongly-held belief can lead radical Islamist jihadists to murder others in suicide acts. Janov writes, “I believe if people had more love in this life, they would not be so anxious to end it in favor of some imaginary existence.”
One of the most compelling aspects of Beyond Belief is the author’s liberal use of case studies, most of which are related in the first person by individuals whose lives were dramatically affected by their involvement in cults. These stories offer an exceptional perspective on the manner in which belief systems can take hold and shape one’s experiences. Joan’s tale, for instance, both engaging and disturbing, describes what it was like to join the Hare Krishnas. Even though she left the sect, observing that participants “are stunted in spiritual awareness,” Joan considers returning someday because “there’s a certain protection there.”
Janov’s great insight into cultish leaders is particularly interesting; he believes such people have had childhoods in which they were “rejected and unloved,” because “only unloved people want to become the wise man or woman (although it is usually male) imparting words of wisdom to others.” This is just one reason why Beyond Belief is such a thought-provoking, important book.”
Barry Silverstein, Freelance Writer

Quotes for "Life Before Birth"

“Life Before Birth is a thrilling journey of discovery, a real joy to read. Janov writes like no one else on the human mind—engaging, brilliant, passionate, and honest.
He is the best writer today on what makes us human—he shows us how the mind works, how it goes wrong, and how to put it right . . . He presents a brand-new approach to dealing with depression, emotional pain, anxiety, and addiction.”
Paul Thompson, PhD, Professor of Neurology, UCLA School of Medicine

Art Janov, one of the pioneers of fetal and early infant experiences and future mental health issues, offers a robust vision of how the earliest traumas of life can percolate through the brains, minds and lives of individuals. He focuses on both the shifting tides of brain emotional systems and the life-long consequences that can result, as well as the novel interventions, and clinical understanding, that need to be implemented in order to bring about the brain-mind changes that can restore affective equanimity. The transitions from feelings of persistent affective turmoil to psychological wholeness, requires both an understanding of the brain changes and a therapist that can work with the affective mind at primary-process levels. Life Before Birth, is a manifesto that provides a robust argument for increasing attention to the neuro-mental lives of fetuses and infants, and the widespread ramifications on mental health if we do not. Without an accurate developmental history of troubled minds, coordinated with a recognition of the primal emotional powers of the lowest ancestral regions of the human brain, therapists will be lost in their attempt to restore psychological balance.
Jaak Panksepp, Ph.D.
Bailey Endowed Chair of Animal Well Being Science
Washington State University

Dr. Janov’s essential insight—that our earliest experiences strongly influence later well being—is no longer in doubt. Thanks to advances in neuroscience, immunology, and epigenetics, we can now see some of the mechanisms of action at the heart of these developmental processes. His long-held belief that the brain, human development, and psychological well being need to studied in the context of evolution—from the brainstem up—now lies at the heart of the integration of neuroscience and psychotherapy.
Grounded in these two principles, Dr. Janov continues to explore the lifelong impact of prenatal, birth, and early experiences on our brains and minds. Simultaneously “old school” and revolutionary, he synthesizes traditional psychodynamic theories with cutting-edge science while consistently highlighting the limitations of a strict, “top-down” talking cure. Whether or not you agree with his philosophical assumptions, therapeutic practices, or theoretical conclusions, I promise you an interesting and thought-provoking journey.
Lou Cozolino, PsyD, Professor of Psychology, Pepperdine University


In Life Before Birth Dr. Arthur Janov illuminates the sources of much that happens during life after birth. Lucidly, the pioneer of primal therapy provides the scientific rationale for treatments that take us through our original, non-verbal memories—to essential depths of experience that the superficial cognitive-behavioral modalities currently in fashion cannot possibly touch, let alone transform.
Gabor Maté MD, author of In The Realm of Hungry Ghosts: Close Encounters With Addiction

An expansive analysis! This book attempts to explain the impact of critical developmental windows in the past, implores us to improve the lives of pregnant women in the present, and has implications for understanding our children, ourselves, and our collective future. I’m not sure whether primal therapy works or not, but it certainly deserves systematic testing in well-designed, assessor-blinded, randomized controlled clinical trials.
K.J.S. Anand, MBBS, D. Phil, FAACP, FCCM, FRCPCH, Professor of Pediatrics, Anesthesiology, Anatomy & Neurobiology, Senior Scholar, Center for Excellence in Faith and Health, Methodist Le Bonheur Healthcare System


A baby's brain grows more while in the womb than at any time in a child's life. Life Before Birth: The Hidden Script That Rules Our Lives is a valuable guide to creating healthier babies and offers insight into healing our early primal wounds. Dr. Janov integrates the most recent scientific research about prenatal development with the psychobiological reality that these early experiences do cast a long shadow over our entire lifespan. With a wealth of experience and a history of successful psychotherapeutic treatment, Dr. Janov is well positioned to speak with clarity and precision on a topic that remains critically important.
Paula Thomson, PsyD, Associate Professor, California State University, Northridge & Professor Emeritus, York University

"I am enthralled.
Dr. Janov has crafted a compelling and prophetic opus that could rightly dictate
PhD thesis topics for decades to come. Devoid of any "New Age" pseudoscience,
this work never strays from scientific orthodoxy and yet is perfectly accessible and
downright fascinating to any lay person interested in the mysteries of the human psyche."
Dr. Bernard Park, MD, MPH

His new book “Life Before Birth: The Hidden Script that Rules Our Lives” shows that primal therapy, the lower-brain therapeutic method popularized in the 1970’s international bestseller “Primal Scream” and his early work with John Lennon, may help alleviate depression and anxiety disorders, normalize blood pressure and serotonin levels, and improve the functioning of the immune system.
One of the book’s most intriguing theories is that fetal imprinting, an evolutionary strategy to prepare children to cope with life, establishes a permanent set-point in a child's physiology. Baby's born to mothers highly anxious during pregnancy, whether from war, natural disasters, failed marriages, or other stressful life conditions, may thus be prone to mental illness and brain dysfunction later in life. Early traumatic events such as low oxygen at birth, painkillers and antidepressants administered to the mother during pregnancy, poor maternal nutrition, and a lack of parental affection in the first years of life may compound the effect.
In making the case for a brand-new, unified field theory of psychotherapy, Dr. Janov weaves together the evolutionary theories of Jean Baptiste Larmarck, the fetal development studies of Vivette Glover and K.J.S. Anand, and fascinating new research by the psychiatrist Elissa Epel suggesting that telomeres—a region of repetitive DNA critical in predicting life expectancy—may be significantly altered during pregnancy.
After explaining how hormonal and neurologic processes in the womb provide a blueprint for later mental illness and disease, Dr. Janov charts a revolutionary new course for psychotherapy. He provides a sharp critique of cognitive behavioral therapy, psychoanalysis, and other popular “talk therapy” models for treating addiction and mental illness, which he argues do not reach the limbic system and brainstem, where the effects of early trauma are registered in the nervous system.
“Life Before Birth: The Hidden Script that Rules Our Lives” is scheduled to be published by NTI Upstream in October 2011, and has tremendous implications for the future of modern psychology, pediatrics, pregnancy, and women’s health.
Editor