E108: The Physical Domain of Risks

Kirtly: Most of you know the video, and some of you may have experienced it. The rider and the horse are approaching a fence. A jump for the horse, and they are coming at speed. They get just to the fence, and the horse pulls to a full stop. The rider does not and goes over the horse's head and lands on the ground or on the fence.

The horse has calculated a risk of going over the fence and said, in horse psychology, "No way." The rider has not calculated the risk the same way and went over the top onto the ground.

We are starting the seven-part series on the 7 Domains of Risk. Risk assessment involves many of the things we do in our lives every day. We'll be talking about emotional risk, social risk, and financial risk. We'll talk about the mathematical expressions of risk that are given to you when you sign a medical consent form and about the risks of where we live and play and environmental risk. And we'll talk about spiritual risk. Today, we're talking about the physical domain of risk.

I'm Dr. Kirtly Jones from obstetrics and gynecology at the University of Utah. I have spent much of my career trying to explain risks and benefits and chances to women who are choosing a procedure or a contraception. The chance of pregnancy, the risk of pregnancy, or infertility like IVF, the chances of getting pregnant.

I think I am sort of risk averse. In fact, I know I am risk averse. I'm so lucky in that sort of risk assessment to have with me Dr. Katie Ward. She's a specialist. It was risky, but I have so much dopamine surges every time we come and do this. So it was worth every bit of the risk. She's a specialist in women's health and has a doctorate in nursing practice and is a professor in the School of Nursing. She also has a PhD in anthropology.

So, Katie, where would you put yourself on the risk-taker/risk-averse scale?

Katie: Well, clearly, I'm a calculated risk taker. I took the risk to be on the podcast. But my risk is domain-specific for sure. So my love of bungee jumping doesn't mean that I can stand to see my investments plummet. But I think we're going to get into all of that.

Kirtly: You have to know your triggers.

Katie: I can plummet, but not my money.

Kirtly: You may have lived without much money at one time, and so now it's very scary. But you've never crashed on your bungee jumping, so you're still jumping off cliffs.

Katie: Exactly.

Kirtly: Oh my god, it makes my stomach hurt.

Well, looking back on my life . . . which isn't over yet, according to the chances of me living a long life, risk calculated by the Northwestern Mutual Life Insurance Company, their sort of risk assessment. So anyway, looking back on my life, I think the riskiest thing I ever did was crossing a very steep snowfield while I was backcountry skiing. I think we call it ski mountaineering in these days.

And I talked about it with a friend who was guiding me when we did the emotional domain of exploring. So you might want to check out the emotional domain of exploring, the 7 Domains of Exploring if you're looking at our podcast.

It was no risk to him, but I thought I was going to die. I mean, I was up there, so I didn't have a choice. I could wait for a helicopter to come get me. But I didn't die and had the most amazing day. And my memories of the beauty of the blue sky and the white snow and the steep peaks and the fact that I was alive will be with me forever. The fear and adrenaline of the ascent and ski down and the dopamine rush afterwards were all part of the neuroendocrine response to risk.

In reality, looking back more carefully, the riskiest thing I ever did, physically, emotionally, socially, financially, intellectually, and spiritually, was to get pregnant. There's a quote from a writer, Elizabeth Stone, that says, "Making a decision to have a child, it's momentous. It's to decide forever to have your heart go walking around outside your body."

Luckily, I didn't know that part, but it was risky enough for me as an obstetrician that I went out with my husband and got life insurance when I was pregnant, because if anything happened to me, and pregnancy is risky, I would have a newborn and a husband with no money and a ton of debt.

So I was doing the risk calculation, the tiny risk that something awful would happen to me, and I couldn't tolerate that risk to leave my husband with nothing.

Katie, what's the riskiest thing that you've done so far that you're willing to share?

Katie: Oh my goodness. So the list is long. I did a 21-day float trip in the Grand Canyon in 1984, which was the second highest water year ever through the Grand Canyon, with a bunch of amateurs.

Kirtly: Were you scared when you were there, or you weren't even scared?

Katie: I didn't know enough to be scared.

Kirtly: That's like pregnancy then.

Katie: Yes. But like your mountaineering trip, once I was in it and we were floating, having to navigate these enormous rapids in some of the highest water on record, then I was scared. But I also still have this kind of crystal memory of being in this amazing place that stays with me. It's wonderful.

Kirtly: Yeah, it's what dopamine does. It brightens everything, and it makes you want to do it again.

Katie: Exactly. And so I have. I've gone paragliding. I do a lot of solo hiking. I tried taking flying lessons. I mean, I think driving my car might actually be the most dangerous thing that I do regularly. But I never think of it as risky. And the things that have turned out badly also were things I didn't know enough to be afraid of.

So I think that's the trouble with risk sometimes, is you don't know where to assess it or how to assess it.

Kirtly: Yeah, we're not always very good at risk assessment, really.

Well, let's get back to the horse, or probably better, our best research friends, the mice. I'm going to geek out here a little bit on mice, so bear with me.

Animal behavior psychologists say that all animals do risk assessment. And if I were to define risk, it would be the analysis of fear of an activity based against the probability of reward.

Fear is an adrenaline-based emotion, a primary emotion that can be immediate or it can come after some assessment. Reward is the dopamine-mediated phenomena and it is a powerful stimulator of good memory and wanting to do that activity again.

Risk is an assessment of chances that a bad thing will happen if an activity is taken or not taken, weighed against some benefit of that action or inaction.

Our mice friends can be studied with reliable scary stimuli, like having to walk out onto an open runway over water to get to a well-known reward like food. You can study wild mice and look at their behaviors, you can study genetically identical mice and their behaviors, and you can study genetically identical mice raised with different mothering behavior, so under different stress conditions.

So risk-taking behavior in mice involves balancing foraging or exploration, which mice don't really want to do because they're at risk. They're food for everybody else. So there's the risk of foraging against the dangers of predators, with roughly 27% of mice showing high risk-flexible strategies, meaning 27% of mice are willing to go out and do tough stuff, while others are more cautious.

Now, chronic stress, adolescent development, and neurochemical factors like high dopamine in the hippocampus, that's the memory center of the brain, increase risk-taking, which can be adaptive in unpredictable environments. So if your environment is unpredictable and difficult, you might be better to take some more risk to get to a different environment. And that would be an advantage for risk-taking.

There are suggestions that mice from moms who were stressed during pregnancy might engage in what, for mice, is high-risk behaviors afterwards. Meaning those babies, when they grow up, might be more risk takers. These aren't genetic changes, no changes in mouse genes, but epigenetic changes, meaning how the genes work.

Having a very risky environment, starvation or predators, may lead the next generation of mice to take bigger risks. But just rolling the genetic behavioral dice, about 44% of mice are scaredy mice. They prefer a safe strategy. And 29% prefer a flexible strategy. Sometimes take risks and sometimes they don't. And 27% have risky behaviors, risky for lab mice.

Well, what about humans? You've met me, and I'm a wuss. I'm a risk scaredy cat, even when I was a kid, and I'd bore someone who really isn't a risk taker. And I have a grandchild who isn't really a risk taker.

You've met my amazing co-host, Katie, who admits to being a calculated risk taker, and she also admits to being an adrenaline junkie of sorts. Maybe she said that on our 7 Domains of Adventuring.

Katie: On a previous podcast, I have.

Kirtly: Yes, you have. Maybe she gets more dopamine bang for her risky buck than I do.

So some people, when they do something risky and don't get hurt, they get a huge dopamine surge. And some people don't, so they don't really want to do it again.

But all of you listeners who've been around a bunch of little kids, even in the same family, know that there are those who run and fall at a very early age and those who won't walk until they're very sure they won't fall down. And there are those on the playground who climb up the slide as soon as they can walk and those who are years into their walking until they can be coaxed up the slide.

Humans who are gestated in the tummy of a mom who has experienced significant stress, or babies and small children who experience significant stress, seem to be more likely to attempt activities that could be considered risky.

Of course, adolescents are known for their imbalance of risk assessment and exaggerated reward response. You've seen it. They just all jump up and down when something happens they did that was risky, and then they get so excited. Not like us older folks. They often don't have the frontal lobe assessment apparatus at its full maturity.

By the way, did you see those Olympian ski aerialists? Whose mother ever let them do that?

Katie: Right? Paid for those lessons.

Kirtly: Who paid for those lessons?

Katie: "Fall down. Do it again."

Kirtly: They're wired to have increased dopamine responses, and you see them when they get down. They jump up and down. They're screaming and screaming. So this is what makes them more likely to be addicted to scary physical stuff, to drugs, alcohol, nicotine, porn, etc.

Katie, do you have thoughts about that?

Katie: Of course I do. I'm about to take the geeking to the next level. I mean, I think the practical challenge for parents is providing safe alternatives to the dangers of the modern world that you just mentioned. Alcohol, nicotine, porn, these were not things we necessarily evolved to have around us. So I think that dopamine reward system, it's been an advantage for humans, and now the world is scary in a different way. 

So as a parent, you've got to sort of think about, "What is my child's temperament? Are they the ones that go up the slide?" And how do you provide them some safe risks that work into that temperament versus your child that wants to hold back a little bit?

So I think practically, as a parent, thinking about this and thinking about where your child is comfortable and finding them safe expressions is probably a great idea.

Kirtly: Oh, yeah. I have a brother who's a skier, runs ski areas, and his wife is a skier, and their two kids did some pretty risky skiing. But their philosophy as parents was they wanted to create an environment where it was more fun to be with their parents than it was to be with their friends.

Their parents were doing more fun stuff than their friends were, and so they would be with their parents and do amazing things that were even a little risky but under supervision, rather than heading off with their friends and doing scary stuff. That was very clever.

Katie: Yeah, it is.

Kirtly: So, we are risk takers as humans. We walked away from good food in the rainforests and the savannas of Africa to the cold and glacial period of Europe and just kept going.

As Americans, we're all immigrants. Our Native Americans came over the frozen Bering Strait to populate North and South America. The Europeans were escaping hard times and famine in Europe, and the potential benefit of going to the unknown new place outweighed the perceived risk of staying back where we were starving or landless or persecuted. We're genetically refined risk takers.

Katie: Yeah. And I think evolutionarily, what looks like risky or impulsive behavior is actually an adaptive strategy, right?

You were talking earlier about the mice and if their mothers are stressed. So if signals from your gestational environment or your early childhood environment tell you that the world is unpredictable and resources are scarce, then developing a nervous system that's tuned for that kind of bold, fast, reward-seeking behavior is probably smart preparation. Sort of that live fast, die young, leave a good-looking corpse idea.

Kirtly: I blame my parents. I was just too coddled.

Katie: You were talking about the mice. The epigenetic flexibility isn't damage or the reason we all should get therapy. It's the genome's way of not overcommitting to a single strategy across generations, right? I think this has served us well, that we have that caution and we have that propensity to explore and take risks and follow the megafauna to the new landmass. And so it's served us well.

So yeah, I think we are risk takers, and we're cautious. Fear might be what prevents you from taking a risk, and reward compels you not to notice or not to listen to the fear.

We're going to talk about this in lots of domains throughout this series. So I think it's going to be fun to explore that our brains evolve to do . . . And I think this is a really important point too, that our brains kind of evolved to do these calculations in the moment, in activity.

You were talking earlier about explaining risks of treatment or the chances of getting pregnant. Those are so theoretical. They're really just brain activity, where our bodies, we were kind of built to do this in the moment, getting all that information from the environment. And so I think it's why theoretical risks are kind of a little harder for people to make decisions about.

Kirtly: It's also difficult because we're in Western tradition. There's actually the concept of choice in Protestant religions, and in fact, in some Eastern religions, there's no risk because God has already decided. It's kismet, meaning what will be will be. They still probably take physical risks assessment, meaning, "Am I going to jump off this cliff or not?" But in terms of longer things, it's difficult to explain randomization and risk benefit to people who have a very strong sense that their future is ordained.

Katie: Yeah. I'm looking forward to getting into all of this.

I want to come back to, since this is the "7 Domains of Women's Health" and hormones are all the rage . . . And there's a pun intended there, I think. But I want to talk about hormones and risk. This is where I'm going to geek out for a minute.

I think there's kind of this assumption that males take risks, and therefore testosterone must be what makes you bold and risk-taking, and estrogen and progesterone make you cautious. But I'm not sure that's the whole story.

So I want to start with testosterone in males. We know that males with higher testosterone are associated with being greater risk takers. But one of the things that I think is interesting is that testosterone actually fluctuates more in response to competitive situations. And so it may actually be part of the reward loop rather than the thing that drives you to take the risks, that you get that little testosterone jolt in response to doing something risky.

So I think we should sort of be asking, "Do males take risks because of the testosterone, or are they pursuing risk partly for that surge that comes along with it?"

You mentioned risk-taking increases in adolescents and teenagers, and that's true for both boys and girls. It is when girls are making the most testosterone. But it may also have to do, as you said, with ability to think through those decisions.

And then just as we geek out on the hormones a little bit, the thing that gets changed by your gestational environment or your early childhood experiences is how cortisol sort of responds to those hormonal shifts.

The hormone part of it is complicated, and it's probably not just hormones because we're socializing kids well before puberty, before their hormones are meaningfully different. So we certainly praise little boys for doing dangerous things more than we praise girls. We kind of praise them for being careful. So we've established a pattern before the hormones are even having anything to do with that.

But because it's an area of research for me, I think I want to talk about the menstrual cycle because I think that's another place where this is interesting.

My own research and that of others before me is that fear is enhanced during the second half of the menstrual cycle when progesterone is elevated. So it does look like fear. Progesterone might have something to do with how you perceive fear. "How high is the fence, and should I stop?" if you're a horse or a rider.

And there's actually this some fascinating research that shows that women in the luteal phase are measurably better at detecting snakes than those in the follicular phase.

Kirtly: Oh, Freud would go so far with that one.

Katie: I think it's fascinating and slightly suspicious. I mean, how many snakes do you really see in the real world? So it might be that snakes are this ancient threat, that we're really tuned to recognize snakes, and that's why they use it.

But it also raises for me this reason to always kind of interrogate this research, because it's such an artificial construct, right? Are you better at snake identification in the first half of your cycle?

Kirtly: I just see the research meeting, sitting around with a bunch of guys and saying, "Well, let's just see if women are more afraid of snakes." Not mice.

Katie: Why cockroaches?

Kirtly: Why not mice, or cockroaches, spiders?

Katie: I don't like them all the time, but it does tell us something about the hormones probably do play a part. Maybe not in our risk calculation exactly, but in the fear component of that, which, as you were saying, risk is this calculation between "How afraid am I?" and "What's the reward in it?" There's just not a reward in a snake.

So that's looking at fear and not at risk, which I think is also an interesting thing to just disentangle that, that risk-taking and fear aren't exactly the same thing.

Pregnancy is kind of a different story. So in pregnancy, that hormone environment is really elevated, and it's sustained rather than cyclical with the menstrual cycle. And it seems like there are probably a lot of pathways that are going on at the same time. So there's the hormonal state, but also a psychological state and a social state, and fear of childbirth and concerns about your baby.

What we do see is, by the third trimester of pregnancy, a lot of women, 40% of women, have clinical levels of anxiety that are kind of being activated by all these different directions.

Kirtly: Oh, yeah. I never had anxiety until after I had a kid.

Katie: Until after? I know a lot of women that are ramping this up throughout their pregnancy.

Kirtly: Well, I could have been, but I was too busy to know when I was pregnant. 

Katie: You were working pretty hard.

Kirtly: Yes.

Katie: Pregnancy is the most dangerous thing that women have done throughout human history, so you're right about that. More women have died in childbirth than any other single event, including bungee jumping. So somehow that weighs in my calculation. I've survived a couple births.

But we continue to get pregnant, and repeatedly, and we don't necessarily connect the risk of . . . and this goes back to that counseling . . . getting pregnant from any given act of intercourse nine and a half months ago with the threat of dying in childbirth later.

Kirtly: Right. In fact, it's often not a calculated risk, although for patients who are infertile, they are definitely making that decision every time because it's a big deal every conception time. Yeah, they just want a baby. And even women with desperate medical conditions, which means that the pregnancy could kill them, the reward is so huge that they want a baby that they're willing to take any risk.

Katie: Or you don't know what the risk of that giving your heart away is going to be, either. I love that Elizabeth Stone saying that you brought up earlier. It's certainly true.

And then you set these kids on the face of the earth and let them take their own risks. There's another saying I like somewhere. You sort of set them loose, and then you pray. I don't know who to attribute that to, though.

I think one of the things I was thinking about in preparing for this episode, though, is just how much our bodies are sort of designed to analyze these things in the moment.

And I think it's part of the reason that I can go bungee jumping and I don't necessarily think of that as this terribly risky thing. But if my retirement account is losing money, I want to start moving it back into safer places. So how my body responds to certain situations is different than how I think about those things.

I think it's always funny when the financial advisors give me a list of questions and ask me about bungee jumping and flying and parachuting and whatever those screening questions are, and then think I'm going to tolerate my account fluctuating wildly, and I don't. So I think we've got some research approaches we need to probably think about a little bit harder. 

Kirtly: Well, that becomes a typical . . . When we start talking about the intellectual domain of risk-taking, how do we as clinicians assess what the triggers are for the people that we care for?

I mean, if you had someone who died after a hip replacement, then a relatively low-risk procedure becomes a very risky procedure. It's a trigger for things and bad things that happen to them. We don't always know the platform of memories and emotional stuff that's in a person when we start to talk about risk.

Katie: I want to come back to the horse for just one second. I want to tell a quick little story.

One of my risky things, I took a solo hike to the bottom of the Grand Canyon. When you are hiking, the burros that go up and down the canyon every day have priority. So they tell you as a hiker, if the burros are coming, you have to stand to the side and let them go by.

And so I was hiking down a very steep trail, and the mule train of burros with riders on them was coming up the trail. I'm standing to the side, and I'm watching these people on top of the burro, and they're all sort of toddling back and forth from side to side and just sitting there. And some of them look like they could even fall asleep in all of that motion.

One of them walked past me and told me I was brave for doing this on my own feet. And what came out of my mouth . . . I didn't think about it. I just was like, "I trust my feet." And that became a meditation for me for the rest of the hike. I would say this phrase to myself with the emphasis on a different word. And then I would think on that. "I" trust my feet. I "trust" my feet. I trust "my" feet.

But I spent a lot of time thinking about sort of the difference for me of being in control. I was walking. Although it was hard and steep and I might have fallen down off the side and all the things, I feel much safer when I have my feet on the ground. And the idea to me of sitting on a burro on a ledge with the Grand Canyon down below where I might fall asleep and tip off, that was frightening.

Kirtly: God, I'd be throwing up the whole way.

Katie: So it was very interesting, both my assessment of what was risky . . . Being out of control was the thing that felt riskiest to me. But I liked the meditation, too, and I've kept that . . .

Kirtly: Yeah, that's lovely.

Katie: . . . as a thing that I say to myself. "I trust my feet."

Kirtly: Well, at the end of the day, or at the beginning of the day, we make decisions about scary stuff and reward every minute. I want a breakfast burrito, but it's a jillion calories and fat, and it will make me too sleepy for work. Just yogurt and berries. But there's no dopamine reward of yum to that. There's no dopamine reward.

Katie: In berries?

Kirtly: But I make that calculation. Nah, I don't like that stuff. But I know what the downside is of having a burrito anyway.

There's a big snowstorm. Should I drive and get to work on time and be a snow hero, or call in and wait until the plows come to my street and my boss thinks I'm a wuss?

Your financial advisor meets with you to talk about your risk tolerance for investments, or you take a date with someone who's a little outrageous, and it might be really fun or a little scary.

And of course, there are healthcare screenings and surgical procedures and medications with risks and benefits. How do we begin to assess our patients' risk tolerance and which risks are triggers for them?

We're going to talk about all of these in the coming episodes. So please join us. You can follow the 7 Domains of Risk and all of our other "7 Domains of Women's Health" wherever you get your podcasts, or at womens7.com. It isn't risky at all, at least not for me.