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女性为何生活在“不适区”?

更新时间:2014-3-20 21:35:12 来源:华尔街日报中文网 作者:佚名

Why Women Are Living in the Discomfort Zone
女性为何生活在“不适区”?

Several years ago, my neck suddenly went bonkers-bone spurs and a long-lurking arthritic problem probably exacerbated by too many hours spent hunching over a new laptop. On a subjective scale of zero to 10 (unfortunately, there is no simple objective test for pain), even the slightest wrong move-turning my head too fast or picking up a pen from the floor-would send my pain zooming from a zero to a gasping 10.

Sitting in a restaurant was agony if the table was too high; it forced my arms and shoulders up. So was sitting in the movies, looking up to see the screen. Shifting from sitting to lying down in bed was excruciating; there is simply no way to do it with a bad neck. Even stupid little things like bending forward to paint my toenails became impossible.

I had been inducted, apparently, into the growing army of American adults living in chronic pain. I discovered that there are 100 million of us, according to the Institute of Medicine. That was surprise No. 1. Surprise No. 2 was that most of us are women. Nobody really knows why.

There are cultural factors, to be sure. Women are 'allowed' to be emotional about their pain, and men often aren't, so perhaps women's pain gets noticed more. There are complicated hormonal factors too. There are research biases at work as well, including the absurd fact that most basic neuroscience work on pain pathways is done not only in rats but in male rats. Go figure.

What is clear is that women and men can react so differently to both pain and pain medications that, as the McGill University pain geneticist Jeffrey Mogil only half-jokingly puts it, we may someday have pink pills for women and blue pills for men.

Here's what we do know. Clinically, women are both more likely to get chronic painful conditions that can afflict either sex and to report greater pain than men with the same condition, according to studies over the past 15 years. (Women also have more acute pain than men even after the same surgeries, such as wisdom tooth extraction, gall bladder removal, hernia repair and hip and knee surgery.)

In 2008, when researchers looked at prevalence rates in 10 developed and seven developing countries, in a sample that included more than 85,000 people, they discovered that the prevalence of any chronic pain condition was 45% among women, versus 31% among men.

In a 2009 review, researchers from the University of Florida found that, all over the world, women get more irritable bowel syndrome, more fibromyalgia, more headaches (especially migraines), more neuropathic pain (from damage to the nervous system itself), more osteoarthritis and more jaw problems such as TMD, as well as more musculoskeletal and back pain. In a large 2012 study (the biggest of its kind), Stanford University researchers confirmed this picture.

And it isn't just clinical pain conditions that reveal an unequal burden of suffering. Sex differences have also shown up in lab experiments in which people voluntarily let scientists test their responses to pain stimuli, though recent research suggests that these differences are more complicated than once thought.

Historically, women have repeatedly been shown to be more sensitive to experimental pain stimuli than men-with lower pain thresholds (that is, they report pain at lower levels of stimulus intensity) and lower tolerance (they can't bear intense painful stimulation as long). More recent work shows that the type of pain stimulus-heat, cold, mechanical pressure, electrical stimulation, ischemic pain (from tourniquets cutting off blood supply) and other methods-matters a lot in the attempt to tease out gender differences.

In a recent systematic review of 10 years' worth of data from pain labs, Canadian researchers found that men and women have comparable thresholds for cold and ischemic pain but that women have lower pain thresholds for pressure-induced pain than men. It's unclear why. With tolerance, there is strong evidence, the team found, that women tolerate less heat and cold pain than men, but that tolerance for ischemic pain is comparable in men and women. Again, it isn't clear why.

The more pressing question, of course, for millions of women in chronic pain is how well their pain will be managed once they seek help.

A few studies suggest that when women in chronic pain seek care in emergency rooms, they are offered comparable doses of opioids ('narcotics') as men and sometimes are actually offered more aggressive treatment. Chronic pain, by the way, isn't just acute pain that doesn't go away after a few months; it's a transformation of the nervous system that can literally shrink the brain.

But many other studies point to undertreatment of women's chronic pain-a pattern that fits an overall picture of differential care for men and women. With heart attacks, for instance, a team of Canadian researchers reviewed the charts of 142 men and 81 women with comparable symptoms and reported in 2002 that men were more likely to be given lipid-lowering drugs, to get angiograms (to detect potentially clogged blood vessels) and to have coronary-artery bypass surgery.

Other data suggest that women are also less likely than men to be admitted to intensive care units and to get certain procedures, such as being put on a respirator, once they arrive there; they are also more likely to die in the ICU, in the hospital or within a year of admission. A 2007 Rhode Island study looked at 30 men and 30 women who had just had coronary-artery bypass surgery and tracked the medications they were given. The researchers were astonished to find that men got pain medications, while women got sedatives.

With chronic pain problems, women's symptoms are often minimized.

In a clever 1999 study, researchers from Georgetown University videotaped professional actors portraying people with chest pain. The researchers showed the videos to more than 700 primary care physicians and gave them data about each hypothetical patient. The doctors were much less likely to believe that the women with chest pain had heart disease. Similarly, when European researchers looked at the records of 3,779 heart patients, 42% of them women, they found that women weren't worked up as thoroughly. It was the same story in a 2000 Mayo Clinic of 2,271 men and women who went to the emergency room with chest pain.

To be sure, chest pain and heart attacks can be especially tricky to diagnose because women and men tend to exhibit somewhat different symptoms. But less complicated medical problems, such as the knee pain of osteoarthritis, exhibit the same pattern of differential treatment.

Women are three times less likely to get the hip or knee replacement they need, according to Mary I. O'Connor, a former Olympic rower who now heads the orthopedic surgery department at the Mayo Clinic in Jacksonville, Fla. And when they do finally have the surgery, they often don't do as well as men, a problem she calls the 'never-catch-up syndrome.'

Part of the problem is that women usually wait longer to have surgery, Dr. O'Connor has found, in contrast to men, who tend to seek surgery before their pain becomes extreme. The surgery itself is equally beneficial for both sexes, but because a woman typically has more advanced disease by the time she gets surgery, the result often isn't as good.

Another factor may also be at work here: an unconscious bias that can make doctors less likely to recommend surgery to a woman with moderate knee arthritis.

In a 2008 study, Canadian researchers looked into this very question, asking 38 family physicians and 33 orthopedic surgeons to evaluate one 'standardized,' or typical, male patient and one 'standardized' female patient with moderate knee arthritis. ('Moderate' means a degree of arthritis in which it's a judgment call whether surgery is necessary or not.)

The odds of a surgeon recommending knee replacement were 22 times higher for the male patient than the female, the Canadian team found.

Women are under-treated for abdominal pain, too, a 2008 study showed. In Philadelphia, emergency room doctors kept track of 981 men and women who arrived with acute abdominal pain. The men and women had similar pain scores, but women were significantly less likely to get any kind of pain medication and were 15% to 23% less likely than men to get opioids specifically. Women also had to wait longer before they got any pain medicine-65 minutes on average, compared with 49 for men. Cancer and AIDS patients have displayed the same pattern, with women much less likely than men to get adequate pain treatment.

And consider this: In Sweden, researchers used a modified version of a national exam for young doctors in which hypothetical patients with neck pain were described. Some of the hypothetical patients were male and some female; all were described as bus drivers who were living in tense family situations. The interns taking the exam were more likely to ask female patients psychosocial questions (implying a psychosomatic origin of the pain) and more likely to request lab tests in the males. Female interns were just as biased as males.

So if women have more chronic pain than men-and they do-the obvious question becomes: Why?

At the most basic biological level-the expression (activation) of genes, including genes that control responses to pain stimulation-gender has a very significant effect.

In fruit flies, for instance, researchers from North Carolina State University have shown that males and females are different in the expression of a whopping 90% of all their genes. In other words, for almost all the genes in the fly's genome, sex plays a significant role in how active a particular gene is-that is, how much it is 'turned on' and how much of a role it plays in the animal's physiology and behavior. Exploring such sex differences in gene expression could help researchers understand sex-related differences in pain processing.

Sex hormones also play a major role in the different ways men and women experience pain, though the hormonal connection is proving nightmarishly tricky to unravel.

It's clear that, as young children, boys and girls show comparable patterns of pain-until puberty. Once puberty hits, certain types of pain are strikingly more common in girls. Even when the prevalence of a pain problem is the same in both sexes, pain severity is often more intense in girls than boys. That is especially true with migraines. Before puberty, boys and girls get roughly the same number. After puberty, the prevalence becomes 18% for women and 6% or 7% for men. A similar pattern holds for TMJ, temporomandibular joint disease (now called TMD), as University of Washington researchers have shown.

Overall, many researchers think that testosterone generally protects against pain, an idea shown in some rat studies. If newborn male rats are castrated, they are unable to produce testosterone later, during puberty. The result? The animals become less sensitive to the pain-reducing effects of the opioid, morphine, and thus more susceptible to pain. If newborn female rats are given testosterone, they get better pain relief from morphine. (A word of caution, though: It isn't clear how well pain findings in rats translate to people.)

But if the role of testosterone in pain is relatively straightforward (more testosterone, less pain), the role of estrogen is anything but.

Genetics research suggests that estrogen reduces the activity of one of the leading 'pain genes,' called COMT. The job of the COMT gene is to get rid of stress hormones such as epinephrine. That means that if COMT activity is too low, the body can't get rid of stress hormones as well. And since stress hormones act directly on nerves to rev up pain, the net result of estrogen acting on COMT is more pain, according to researchers at the University of North Carolina.

Other research, too, supports the 'estrogen is bad ' pain theory. Consider what happens when transsexuals take hormones to enhance the sexual characteristics of their new sex. In one preliminary study, Italian researchers tracked male-to-female human transsexuals, who must take estrogen to enhance female sex characteristics. They found that approximately one-third develop chronic pain, especially headaches. The researchers also looked at female-to-male transsexuals, who must take testosterone to enhance male characteristics; their chronic pain went down.

But often, things aren't that simple. At menopause, for instance, women's ovaries stop pumping out estrogen. To combat the symptoms caused by this drop in estrogen, many women begin taking exogenous estrogen-that is, estrogen not made naturally in the body but taken as a drug. If the general theory-that estrogen increases pain-is true, you would expect that taking exogenous estrogen (hormone-replacement therapy) would make pain worse. But in truth, sometimes exogenous estrogen makes pain worse, sometimes it doesn't, and sometimes it makes it better.

And then there is the 'catastrophizing' problem. In general, studies suggest that women are more likely than men to catastrophize-that is, to imagine worst-case scenarios and to believe that the pain will be unending. The tendency to catastrophize even shows up on brain scans called fMRIs. In one University of Toronto study, for instance, researchers showed that while catastrophizing didn't affect how the brain processed the sensory aspect of experimental pain, it did make the emotional regions of the brain light up.

Catastrophizing may actually be a learned behavior; girls, more than boys, seem to pick up verbal and nonverbal catastrophizing cues about pain from their mothers, says Lonnie Zeltzer, a pediatric anesthesiologist at University of California, Los Angeles. The good news here is that studies show that cognitive behavioral therapy can help reduce the tendency to catastrophize.

Where does all this leave women in pain?

To some extent, in the same boat as men in pain. Both men and women often have to be extremely persistent in the search for a physician who can help with their suffering. That is because most doctors don't get enough basic education about pain in medical school-a sad but well-documented fact.

But women, I believe, have to be extra-persistent, particularly if they feel their pain is being dismissed as emotional.

I know, because this happened to me with the first physician I went to for my neck pain. When she seemed to imply that there was an emotional trigger for my pain, it felt like she was literally adding insult to injury. I left that doctor and found another-a man, as it happened-who believed me and set me on a path of treatment that ultimately worked. Thankfully, I am much better now.

几年前,我的脖子突然出现了严重的问题──长时间伏在新笔记本电脑前可能加重了骨质增生和潜伏已久的关节炎。按照从0到10的主观分级量表(可惜的是,检验疼痛程度没有简单客观的方法),最轻微的不当之举──转头过快或者从地板上捡起笔──也会让疼痛感从零迅速升至令人痉挛的10级。

在餐厅吃饭时,桌子太高会让我非常难受,因为我不得不抬高胳膊和肩膀。坐在电影院中仰头看屏幕也是如此。从坐着换成躺到床上去也让我痛苦不堪,脖子不好的话,简直是做什么都不行。连往前弯腰涂脚趾甲油这样的无聊小事也做不了了。

显然,我被拉进了越来越庞大的生活在慢性疼痛中的美国成年人的队伍。根据美国医学研究所(Institute of Medicine)的数据,我发现像我们这样的人有一亿之多。这是最让我吃惊的事情,其次就是当中的多数人为女性。没有人真正了解原因。

当然,这其中有文化因素的影响。女性对疼痛的情绪化表达是“被允许的”,而男性往往就不行,所以女性的疼痛可能更会受到注意。复杂的激素因素也是原因之一。此外,研究中的偏见也会产生影响,比如大多数对痛觉通路的基础性神经学研究不仅是以老鼠、而且是以公鼠为实验对象,这真是荒唐。你想想吧。

明确的一点是,女性与男性对疼痛及止痛药的反应非常不同。加拿大麦吉尔大学(McGill University)研究疼痛问题的遗传学家杰弗里·莫吉尔(Jeffrey Mogil)就半开玩笑地说道,某一天我们或许会给女性开粉色药片,给男性开蓝色药片。

有些事情是我们确实了解的。过去15年间的研究表明,从临床上说,女性更容易患上无论男女都会患的慢性疼痛,她们所报告的疼痛程度也高于患同样病症的男性。(在做过相同的手术,如拔智齿、切除胆囊、疝修补术及髋膝关节手术后,女性会出现比男性更剧烈的疼痛。)

2008年,研究人员调查了10个发达国家及七个发展中国家的疼痛患病率,涉及的抽样人群有85,000多人。他们发现慢性疼痛病症在女性中的发病率是45%,而男性的比例为31%。

在2009年的一项研究综述中,佛罗里达大学(University of Florida)的研究人员发现,从全世界范围来看,女性患肠激惹综合征、纤维肌痛、头痛(尤其是偏头痛)、神经病理性疼痛(因神经系统本身受创造成)、骨关节炎、如颞下颌关节紊乱症(TMD)之类的下颌病症、肌肉骨骼疾病以及背痛的比例更高。在2012年的一项大型研究(该类研究中规模最大)中,斯坦福大学(Stanford University)的研究人员证实了这一发现。

反映出男女疼痛程度不同的不只是临床上的疼痛病症。性别差异也在实验室的实验(受试者自愿让科研人员检验他们对疼痛刺激的反应)中体现出来,尽管近期的研究表明这些差异要比以前认为的更为复杂。

过往的实验反复表明,女性对实验性疼痛刺激的敏感度高于男性──她们感受疼痛的起点较低(也就是说她们在刺激强度较低时就报告出现疼痛),忍受能力也较低(她们能忍受强烈疼痛刺激的时间不如男性长)。最近的研究还指出,疼痛刺激的类型──热、冷、机械压力、电流刺激及缺血性疼痛(用止血带阻断血液供应来刺激),以及其他方法造成的刺激──在研究出性别差异的实验中有很大的影响。

在最近一项对疼痛研究实验室10年数据的系统性综述中,加拿大的研究人员发现男性与女性对寒冷与缺血性疼痛的忍耐起点大致相当,但女性对压力诱发的疼痛的忍耐起点要低于男性。其中原因并不明确。该团队还发现,关于对疼痛的忍耐度,有很强的证据表明女性对热和冷诱发的疼痛的忍耐度低于男性,但她们对缺血性疼痛的忍耐度与男性相当。其中的原因也不清楚。

当然,更迫切的问题是,对于数百万患慢性疼痛的女性而言,她们的疼痛在她们寻求帮助时得到了怎样的控制。

有一些研究表明,患慢性疼痛的女性在急诊室寻求治疗时,她们获得的阿片类药物(“麻醉剂”)的剂量与男性相当,实际上有时候还会得到更激进的治疗。顺便说一句,慢性疼痛不仅指几个月都不会消退的剧烈疼痛,它还指真的会使大脑萎缩的神经系统的转变。
不过,许多其他研究指出女性的慢性疼痛治疗不足──这一模式符合男性与女性的治疗存在差异的总体情况。以心脏病为例,一群加拿大研究者核查了症状类似的142名男患者与81名女患者的病例,后来他们在2002年报告称男患者获得降血脂药、拍血管造影片(用于检测出可能阻塞的血管)以及进行冠状动脉绕道手术的几率更高。

其他数据显示,女性被送进重症监护室(ICU)以及送入后受到某些治疗(如戴上呼吸机)的几率也更低。此外,她们在ICU、医院中以及入院一年内死亡的几率高于男性。罗德岛2007年的一项研究调查了刚刚做完冠状动脉绕道手术的男女各30名患者,并跟踪了医生给他们开的药物。研究人员震惊地发现男患者获得的是止痛药,而女患者得到的是镇静剂。

在慢性疼痛问题上,女性的症状往往被按最低程度估计。

乔治城大学(Georgetown University)的研究人员在1999年实施了一个巧妙的实验。他们拍下了伪装成胸痛病人的专业演员,然后把录像展示给700名全科医生并给他们提供了每位假冒患者的信息。结果是,医生不大相信胸痛的女性患有心脏病。同样地,欧洲研究者查阅了3,779名心脏病患者(42%为女性)的病例,发现女患者受到的治疗不如男患者周全。梅约医院(Mayo Clinic)在2000年对2,271名因胸痛去往急诊室的男女患者的调查发现了同样的结果。

当然,胸痛与心脏病发作特别难诊断,因为男女患者往往会表现出不同的症状。不过,一些复杂程度较低的医学问题,如骨关节炎引发的膝痛也表现出同样模式的差异化治疗。

前奥运赛艇选手、目前于佛罗里达杰克逊维尔市(Jacksonville)梅约医院矫形科担任主任的玛丽·I.·奥康纳(Mary I. O'Connor)称,女性获得所需的髋关节或膝关节置换手术的几率比男性低两倍。即使她们最终做上了手术,效果也往往不如男性好,这一问题被她称为“永远追不上综合症”。

奥康纳发现,部分问题在于,与男性相比,女性等待做手术的时间常常更长,而男性往往在疼痛变得难以忍受之前就寻求手术。手术本身对男女患者同样有益,但由于女性的病症在做上手术前一般都更严重,手术效果往往也就不如男性好。

另一个或许也有影响的因素是,无意识的偏见会促使医生不大可能会推荐患中度膝关节炎的女患者做手术。

在2008年的一项研究中,加拿大研究人员调查了这一问题。他们请了38名家庭医生及33名骨科医生评估均患有中度膝关节炎的一名“标准”或典型的男患者与一名“标准”女患者。(“中度”表示关节炎的程度,用以评判是否有必要实施手术。)

该组研究人员发现,医生推荐男患者做手术的几率比推荐女患者做手术的几率高出22倍。

2008年的一项研究显示,女性的腹痛问题也存在治疗不足。费城的一些急诊室医生持续跟踪了981名因腹部剧痛来就诊的男女患者。这些患者的疼痛程度类似,但女患者获得止痛药的几率低得多,特别是获得阿片类药物的几率比男性低15%至23%。此外,女患者要比男患者等待更长时间才能拿到药──女患者的等待时间平均为65分钟,男患者为49分钟。癌症与艾滋病患者的治疗也表现出了同样的模式,女患者获得充足疼痛治疗的几率要低得多。

再想想这项研究:瑞典研究人员借用一项修改过的年轻医生全国考试进行的实验。他们在考试中对杜撰出的颈痛患者进行了描述,其中一部分假定患者为男性,另一部分为女性,但他们全被描述为生活在关系紧张家庭中的公交车司机。参加考试的实习医生向女患者询问心理社会问题的几率更高(这暗示疼痛的源头是心理压力),而要求男患者进行实验检验的可能性更高。女实习医生与男实习医生同样存有偏见。

那么,假如女性的慢性疼痛多于男性──而且确实如此──明显的问题是:为什么呢?

在最基础的生物学层面──基因(包括控制对疼痛刺激的反应的基因)的表达(激活)──性别起着非常重要的作用。

以果蝇的情况为例,北卡罗来纳州立大学(North Carolina State University)的研究人员指出雄果蝇与雌果蝇有多达90%的基因的表达模式不同。换句话说,就果蝇基因组的几乎所有基因而言,性别在决定某个基因的活跃程度──即它有多“兴奋”以及它在果蝇的生理与行为方面发挥多大作用──上扮演着重要角色。探索基因表达模式中的此类性别差异有助于研究人员了解疼痛处理与性别有关的差异。

性激素也在男性与女性不同的疼痛感受方式中发挥着重大作用,尽管事实证明激素方面的关联异常难以解开。

很明显,在年龄较小时,男孩与女孩表现出的疼痛模式大致相似,直到青春期为止。一旦到了青春期,某些类型的疼痛在女孩当中就明显变得更常见。即使某类疼痛病症在男孩与女孩中的发病率相同,女孩的疼痛剧烈度也往往比男孩强。这一情况在偏头痛问题上尤为明显。在青春期前,男孩与女孩的患病率基本相同。在青春期后,女性的发病率变成18%,而男性的比例只有6%或7%。华盛顿大学(University of Washington)的研究人员指出,颞下颌关节病(TMJ,现称为TMD)的模式也类似。

总的说来,许多研究人员认为睾丸素普遍可抵御疼痛,这一观点在某些针对老鼠的研究中有所体现。刚刚出生的老鼠如被阉割,接下来它们在青春期期间就无法产生睾丸素。结果是什么呢?它们对阿片类药物和吗啡减轻疼痛的作用变得更不敏感,因此更易感到疼痛。刚出生的母老鼠如被投喂了睾丸素,它们在服用吗啡后疼痛得到了更大的缓解。(不过此处还是要提醒:针对老鼠的疼痛研究发现在多大程度上适用于人还不明确。)

如果说睾丸素对疼痛的作用比较直接(睾丸素越多,疼痛越轻),雌激素的作用则完全不然。

遗传学研究显示,雌激素会减轻最主要的“疼痛基因”之一──COMT的活跃度。COMT的作用就是消除肾上腺素之类的压力激素。这意味着如果COMT的活跃度太低,身体也无法消除压力激素。北卡罗来纳大学的研究人员称,由于压力激素通过对神经直接产生作用来加剧疼痛,雌激素对COMT产生作用的最终结果就是疼痛加剧。

其他研究也支持了“雌激素不利”的疼痛理论。想想变性人服用激素来增强新性别的性别特征时会发生什么。在一项初步研究中,意大利的研究者跟踪了从男性变为女性的变性人,这些人必须服用雌激素来增强自己的女性特征。他们发现约有三分之一的人患上了慢性疼痛特别是头痛。这些研究人员还调查了从女性变为男性的变性人,这些人必须服用睾丸素来增强男性特征,他们的慢性疼痛有所减轻。

不过,事情常常没那么简单。例如,女性到更年期时卵巢不再分泌雌激素。为了抵抗由雌激素下降引发的症状,许多女性开始服用外源性雌激素,即并非由身体自然产生、作为药物服用的雌激素。假如认为雌激素加剧疼痛的普遍说法是正确的,你会认为服用外源性雌激素(激素替代疗法)会加剧疼痛。不过,事实是外源性雌激素有时候会加剧疼痛,有时则不会,有时候还会缓解疼痛。

此外,还存在“疼痛灾难化”的问题。通常说来,研究显示女性比男性更倾向于把事情想得很糟糕,即想象最糟糕的状况并认为疼痛不会休止。这种做最坏打算的倾向甚至在名为“功能性核磁共振成像(fMRIs)”的脑部扫描中也体现出来。比如说,在多伦多大学(University of Toronto)的一项研究中,研究人员展示尽管做最坏打算并未影响大脑处理实验性疼痛的感觉方式,但它确实让大脑的情绪区出现活动。

加州大学洛杉矶分校(University of California, Los Angeles)儿科麻醉师朗尼·泽尔策(Lonnie Zeltzer)指出,”疼痛灾难化”实际上可能是个后天习得的行为;女孩似乎比男孩更容易从母亲那里习得以语言或非语言形式表现的对疼痛的灾难化。。好消息是研究显示认知行为疗法可减轻这种倾向。

那么,这一切让承受疼痛折磨的女性处于什么境地?

在某种程度上,她们与承受疼痛折磨的男性处境相同。男女患者往往都得以极大的毅力坚持寻找能缓解他们痛苦的医生。其原因是大多数医生在医学院没有受到足够的关于疼痛的基础教育──这是一个可悲但证据充分的事实。

不过,我相信女性还得付出更多毅力,特别是如果她们感到自己的疼痛被医生淡化为情绪原因的话。

我之所以了解这一点,是由于我因颈痛找到的第一个医生就是如此。当她似乎在暗示我的疼痛是由情绪诱发时,给我的感觉是她简直是让我的伤痛雪上加霜。我离开了那个医生,并找到了另外一个医生──碰巧是位男医生,他相信我并为我制定了一个治疗方法,而且它最终产生了效果。谢天谢地,现在我感觉好多了。

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