Masturbation does not cause prostate cancer

It is difficult to imagine a health warning that would generate more fear than the announcement that masturbation leads to prostate cancer. Over 100 newspaper articles trumpeting the findings of a new paper on the subject have generated a wave of embarrassment and concern. That’s why it is important to analyze the paper very carefully to determine whether the evidence supports the authors’ claims. In my judgment, the paper has some very serious drawbacks that render its conclusions suspect.

The paper is titled Sexual activity and prostate cancer risk in men diagnosed at a young age. The paper only looked at a subset of men with prostate cancer, the 25% who are diagnosed before age 65. It is unclear why they chose to look only at this group and whether they believe there are any differences in prostate cancer occurring before age 65 and prostate cancer occurring after.

The way the study was conducted (the methodology) raises questions about the validity of the conclusions. The study is a case-control study, in which men with prostate cancer were compared to a control group of similarly aged men without cancer. According to the Oxford Centre classification of studies, a case control study is among the weakest forms of study, rating a 3 on a scale of 1-5; the two lower grades apply to descriptions that make no comparisons and to opinions.

This is also a retrospective study, meaning that the participants were asked to recall events that took place as many as 45 years before. Not surprisingly, these types of studies are often weakened by inability to properly recall details.

Finally, this is a very small study, looking at only 400 men with prostate cancer and 400 controls. A smaller study is less likely to generate valid results.

What were the authors expecting to see? The authors were hoping to determine if there is a relationship between sexual activity and the risk of developing prostate cancer before the age of 65. They looked at two types of sexual activity, masturbation and sexual intercourse.

What would such a relationship look like? In general, if a relationship exists, you would expect to see a “dose-response” effect. In other words, if increased sexual activity increased the risk of prostate cancer, you would expect that the lowest sexual activity levels would lead to the lowest risk, moderate levels of activity would be associated with moderate risk, and high levels of activity would be associated with high levels of risk.

What did the authors find? They found that there was no relationship between overall sexual activity and prostate cancer risk. The proportion of men with low, medium and high frequency of sexual activity were equal.

It’s difficult to publish a study that doesn’t show anything, so the authors went back and reworked their data. First, they looked at the relationship of sexual activity in each decade (20’s, 30’s, 40’s, 50’s) to the risk of developing prostate cancer before the age of 65. There was a suggestion that increased sexual activity in the 20’s was correlated with an increased rate of prostate cancer, but that relationship did not hold for any other decade. In fact, increased sexual activity in the 50’s was actually correlated with a decreased rate of prostate cancer

Then they further sub-divided the data into sexual intercourse frequency and masturbation frequency per decade. There was no relationship between sexual intercourse frequency in any decade and risk of prostate cancer before age 65.

Finally, they looked at the relationship between masturbation frequency per decade and the risk of prostate cancer before age 65. There was no relationship there, either BUT they noticed that low frequency of masturbation in the 20’s and 30’s was associated with a higher rate of prostate cancer, but masturbation in the 50’s was associated with a lower rate of prostate cancer.

What should we conclude from this? We should conclude that there is no overall relationship between sexual activity (whether intercourse or masturbation) and risk of developing prostate cancer before age 65. The few, random associations that appeared in the data are almost certainly anomalies, reflecting the small sample size, and the limitations inherent in any case-control studies. These findings are consistent with multiple previous studies that showed both positive and negative associations, as well as no association at all. The fact that there is no consistent pattern among all the studies taken together further reinforces the conclusion that there is no relationship between sexual activity and risk of prostate cancer.

That’s not what the authors decided to conclude, however. They chose to assume that the random associations they found were real, and not artifacts. They provide no explanation for why or how masturbation could increase the risk of prostate cancer in some decades and also decrease it in other decades, while at the very same time intercourse had no effect at all.

Does masturbation increase the risk of prostate cancer? There is no evidence in this paper that it does, and, a survey of previous papers on the topic provide no evidence of a consistent relationship of any kind. The conclusions of this paper are weak and unjustified, and the publicity campaign waged by the authors and publishers is disingenuous at best, if not outright irresponsible.

Give me back my kidney or pay the consequences

We’ve become inured to the spectacle of bitter public divorce battles over assets or children, but how about body parts?

Richard Batista is demanding, as part of a divorce settlement, that his estranged wife Dawnell return the kidney that he donated to her. This is something new, and the press has been busy analyzing the implications. Discussion has centered on the ethics of organ donation and the commodification of body parts. They are missing the point. This has nothing to do with ethics or money; it is about spousal abuse. Specifically, this is an example of the all too common phenomenon of abusive, controlling men trying to continue abusing and controlling the women who leave them.

There is neither ethical nor legal justification for demanding the kidney or compensation. An organ donation is a gift. We have specifically prohibited the selling of organs for just this reason. Ethically, we believe that the only acceptable reason for donating an organ to another person is altruism. You give the organ because you want the other person to get it. What happens after that is irrelevant. If you cannot sue to get your kidney back because you now have a medical need for it, you certainly do not have grounds to sue to get it back simply because you are angry with the recipient.

This case is not about the commodification of organs, either. No only do we prohibit the selling of organs, but we hold both the donor and recipient harmless in the action. The donor cannot sue the recipient for the costs associated with the donation, and the recipient cannot sue the donor if the donor had an undiagnosed medical problem that was transmitted with the organ.

Experts in both law and medical ethics are in agreement that there is no legal basis for Batista’s demand, and the chance that it will be granted is nil. So why did Batista do it? He did it for revenge.

Batista has publicly acknowledge that this is nothing more than a tactic. Batista’s lawyer, appearing with him on CNN, told Larry King:

…[Y]ou mentioned the demand for the kidney or the value. Really, that's not what's going on. We use that as an example of what the doctor wants.

What the doctor wants is, A) health to be taken into consideration in the division of the assets, whether or not she'd be entitled to maintenance or not. But most of all, (what's) being done so he can be part of the children's lives. That's what really this case is all about…

He doesn't want the kidney… No, what he wants the court to do is take into consideration what he's done, what a wonderful thing it is he's done and some understanding from the court.

You know, it's so strange; here he does this, and when he says he's allowed to see his children, well, legally he is, but these children have been so alienated from him.

…It was out of desperation that he did it.

No doubt he was desperate … desperate to control the woman who was trying to extricate herself from his control.

Batista expresses awareness of the tawdriness of his demand, and insists that there is an additional, selfless, motivation:

… to draw light to the lack of kidney availability, to the number of poor and dying patients across the country who are yearning to live. I hope, and it's my prayer, that this fallout will help enlighten those people who have any question about organ donation come forward, because there are so many people who are dying as a result of not having an organ.

Oh, sure. He wanted to encourage people to donate organs by suing to get back the organ he donated.

Dawnell Batista has not spoken to the press. According to the facts of the case, though, it would be difficult to find someone more sympathetic. The kidney that Bautista gave her was actually her third transplant. Two previous transplants, from other family members, had eventually stopped working. She has undergone a double mastectomy. Nonetheless, her husband thought that she had time to conduct an affair with her personal trainer (an allegation that she denies), going so far as to examine her lingerie for “evidence” that she was lying.

Richard Batista, who claims to be doing this for his kids, seems to have little consideration for them. According to the children’s court appointed guardian:

"The children are distressed and embarrassed… It's hard for them to go to school. They believe their teachers and friends know everything that is going on. The family's life is in the public now."

When Batista demanded that his estranged wife be jailed for not letting him see his children, the guardian pointed out that he did have visitation rights with his children "as long as nothing derogatory was said about their mother," he claimed that they had been turned against him.

Almost certainly, Mrs. Batista has negative feelings toward her estranged husband, but as for turning them against him, it sounds like Mr. Batista has done just fine on his own. A man who demands that a sick woman return a kidney donation or pay more than a million dollars, and then publicly acknowledges that it is merely a tactic, to retain control over assets and children should not be surprised that his children have turned against him. He shouldn’t be surprised if the public and the court turn against him as well.

When good diaphragms go bad

 

Theoretically, a diaphragm is an excellent form of female contraception. Consisting of a latex dome covering the cervix, and held in place by a flexible ring, it provides protection against pregnancy in two ways. It forms a mechanical barrier over the cervix, keeping the sperm from reaching it and heading up the uterus to fertilize a waiting egg. In addition, the space between the dome and the cervix is filled with spermicidal jelly. Any tenacious sperm that manage to get behind the barrier are killed on contact by the jelly.

In reality, the diaphragm is far less effective than it might be. That’s because it is highly user dependent. A woman must remember to use it, must insert it correctly, and must care for the diaphragm properly so it will not develop holes or tears. I learned early on in my GYN training to ask women not only what form of birth control they were using, but, if they reported using the diaphragm, asking detailed questions about its use. That was especially important when seeing patients in the emergency room, women who might be unknowingly be pregnant, having a miscarriage or suffering pain from an ectopic pregnancy.

Most people think that immaculate conception is unique or impossible, but in the emergency room, you learn differently. You can be waving a positive pregnancy test in front of a woman and she will still insist that there is no possible way that she got pregnant. As a corollary, women who have obtained birth control believe that it is impossible for them to become pregnant, even when not actually using the birth control. Whenever a woman told me that she was using a diaphragm for birth control, I would always ask a follow up question: “When you have sex, is the diaphragm in you or in your nightstand?” A substantial portion of women would smile sheepishly and acknowledge that they hadn’t used the diaphragm the last time they had sex, or perhaps the last 10 times they had sex, or perhaps not since they had picked it up at the drugstore.

Even women who are committed to using it properly can have failures (unwanted pregnancies) if the diaphragm is fitted properly. How do you fit a diaphragm? There are diaphragm-fitting sets, with different types of flexible rings, in graduated sizes. That way the provider doesn’t have to estimate the correct type and size. He or she can insert the ring and check to be sure that it fits snuggly, is not uncomfortable, and will not fall out when a woman stands or coughs. Then the woman can practice in the office with the ring, under the guidance of the provider who can check to be sure that the woman knows how to place it properly to provide complete protection. The rings don’t have latex domes on them because it isn’t necessary for fitting, and it would make it more difficulty to sterilize them after each use.

Given that effectiveness is so closely related to motivation and understanding of the patient, it is not a good method for women who have been unreliable in the use of other methods in the past. Some times, though, particularly for women who cannot tolerate hormones (ruling out birth control pills, DepoProvera shots, and IUDs), the diaphragm is the only reasonable effective method that you can offer. In that case, it is critical to counsel the patient on how the diaphragm works, how it must be used every time, and especially how to insert it properly.

That’s what we did for a young woman who had two small children already as the result of birth control failures. She could not tolerate the Pill and her boyfriend would not use a condom. The nurse practitioner who was most experienced in patient education fitted her and watched her insert it multiple times until she could do it with ease. The nurse practitioner counseled her for an hour on the need to use it reliably, the need to apply the spermicidal jelly inside the dome before inserting it, and how to care for the diaphragm properly. She scheduled an appointment for the patient to return in 3 months, to be sure that the diaphragm did not irritate the cervix or surrounding tissue.

Six weeks after the fitting, the patient called to say that she had missed her period, and the nurse practitioner agreed to see her that day. A pregnancy test was positive, another unintended, unwanted pregnancy. The nurse practitioner was stern. Why hadn’t the patient used the diaphragm? The young woman insisted emphatically that she had used it every time, that she had inserted it correctly and that she had cared for it properly.

The nurse practitioner was mystified and told the patient so. The patient thought that she knew what the problem might have been. When she picked up her diaphragm at the pharmacy, it was broken. The nurse practitioner was puzzled. Broken? Did she mean that the diaphragm had a hole in it?

“Oh, no.” the patient replied, “That was the problem. It didn’t have a hole in it, but I remembered that the one I used in the office was only a ring, so I cut a hole to make it look the same!”

Are face transplants ethical?

Arthur Caplan has changed his mind about face transplants. Who is he and why is that important? Caplan is a bioethicist, and “public intellectual” on issues of medical ethics. He appears widely on national news and discusses ethical issues in a variety of publications, including a regular column for MSNBC.com.

Caplan’s change of heart reflects a change in the ethical understanding of face transplants. Simply put, face transplant was originally viewed as a way of changing identity, sort of like the strikingly “realistic” face masks of old Mission Impossible TV series. Now, there is a greater appreciation of face transplant as a form of reconstruction for those who have suffered catastrophic facial injuries.

Caplan documents the change in his thinking in a recent MSNBC column:

When face transplants were first proposed 10 years ago I thought they were unethical…

A transplanted face is biologically like any other transplanted organ: There is always a risk that the recipient’s body will reject it. The immunosuppressive drugs that must be used to try to prevent such a disaster are powerful, but can cause fatal cancers and other serious side-effects, such as kidney failure. Normally, transplant surgeons don’t worry much about these risks because they pale in comparison to the certain death that awaits someone whose heart or liver have stopped working. But a face transplant is intended to improve the quality of life rather than save a life, as a heart, lung, kidney or liver transplant does…

If the woman who received her new face from a cadaver were to begin to lose it due to tissue rejection that could not be stopped, what will happen? There are no second chances with face transplants — the damage of rejection makes that impossible. What if someone facing this horrendous prospect – life with no face at all — says no to artificial feeding or breathing? What if they beg for morphine to help them die painlessly and more quickly? Any team undertaking face transplants must be ready to manage a failed experiment.

What caused Caplan to reconsider?

After talking to some people with severe facial disfigurement, I realize it makes ethical sense to offer a form of surgery that might kill the patient, because the suffering of the afflicted is so great that they are willing to risk death. We don’t hear much about those with facial deformities due to birth defects, burns, trauma, cancer or violence. That’s because the stigma of severe facial deformity is so enormous, so staggering, that many simply withdraw from society. Others find that, despite the best efforts of reconstructive surgeons, they are unable to eat, breathe or speak comfortably, and are condemned to lives of suffering and pain.

A face transplant, despite its very real dangers, might bring relief. The science has reached the point where trying to help those who are beyond the help of current medical treatments is not just ethical, but almost obligatory.

I agree with Caplan’s new understanding of ethical justification for face transplant. However, previous claims by Caplan and others that face transplantation is unethical rested on a the fact that face transplant has been misnamed. A transplant (as in the case of kidneys, for example) involves the complete exchange of a failing organ for an entirely different organ with better function. Face transplantation is not an exchange.

Face transplant is simply an advanced form of reconstruction. In most cases of severe facial injury, parts are taken from the patient herself and used to reconstruct her face. Bone may be harvested from one part of her body, and skin in another, both in an attempt to replace missing features and rebuild the face that existed. Sometimes the damage is so extensive that the patient herself cannot donate enough tissue to complete the reconstruction. In that case, parts can be harvested from a cadaver to replace what cannot be rebuilt.

Medical ethicists viewed face transplantation as an actual transplant of one persons “face” to replace another person’s face. Even if that is accomplished technically, it can’t really change identity, because the underlying bone structure and placement of features like eyes and mouth always remain. Advanced facial reconstruction by harvesting missing parts from cadavers, in contrast, deliberately attempts to rebuild the face as it existed before the injury. Caplan and others worried about face transplantation as an opportunity to change identity. In reality, it is an opportunity to regain identity.

Sex chips

No, not these chips,

 

but these chips … the implantable kind.

 

When I recently read about this technology on Bioethics.net, I thought it was a joke:

Scientists in the UK are working on methods to stimulate the brain, specifically in the orbitofrontal cortex, the part of the brain that feels pleasure from eating and sex. According to The Telegraph, implantation of a chip into that area of the brain is expected to result in increased sexual pleasure. Previous studies in one woman with very low sex drive becoming one with a very active sexual appetite. However, the scientists reported, "She didn't like the sudden change, so the wiring in her head was removed."

But when I surveyed the scientific literature, I found out that these electronic stimulation projects are legitimate, are based on technology used to treat neurological problems, and that the primary research group is quite prolific its attempts to apply this technology to different parts of the brain, with very good results.

The best known researcher in the field of chip implantation technology appears to be Dr. Morten Kringlebach. He has done pioneering work in determining the location within the brain of various sensations and drives, including smell, taste, thirst and painful touch. He has also worked on the implantation technology, which is known technically as deep brain stimulation (DBS).

To date, the most well known application of DBS technology is in the treatment of Parkinson’s Disease. You can watch the technology in action at Dr. Kringelbach’s website. As he explains in an article in this month’s issue of Scientific American Mind, Sparking Recovery with Brain “Pacemakers”:

…A man in his mid-50s, affable, articulate, faces the camera and talks a bit about a medical procedure he’s had. He holds in his hand what looks like a remote control. “I’ll turn myself off now,” he says mildly. The man presses a button on the controller, a beep sounds, and his right arm starts to shake, then to flap violently. It’s as if a biological hurricane has engulfed him … With effort, the man grasps the malfunctioning right arm with his left hand and slowly, firmly, subdues the commotion …With an almost desperate gesture, he reaches out for the controller and manages to press the button again. There’s a soft beep, and suddenly it’s over. He’s fine.

In Parkinson’s, DBS technology is used to dampen the erratic brain impulses that cause the visible symptoms. Kringelbach and others reasoned that if you could use DBS to dampen undesirable brain impulses like those of Parkinson’s and certain chronic pain syndromes, you could use DBS to evoke desirable brain impulses.

In a highly technical paper, Affective neuroscience of pleasure: reward in humans and animals, Dr. Kringelbach reviews two famous cases of DBS used to evoke pleasure:

… a much-cited case is “B-19”, a young man implanted with stimulation electrodes in septum/accumbens region by Heath and colleagues in the1960s. B-19 voraciously self-stimulated his electrode and protested when the stimulation button was taken away. In addition, his electrode caused “feelings of pleasure, alertness, and warmth (goodwill); he had feelings of sexual arousal and described a compulsion to masturbate”…

Similarly, a female patient implanted with an electrode decades later compulsively stimulated her electrode at home. “At its most frequent, the patient self-stimulated throughout the day, neglecting personal hygiene and family commitments”. When her electrode was stimulated in the clinic, it produced a strong desire to drink liquids and some erotic feelings, as well as a continuing desire to stimulate again.

But popular descriptions of the technology as “sex chips” may oversell its effects:

… B-19 never was quoted as saying it did; not even an exclamation or anything like “Oh—that feels nice!”. Instead B19’s electrode-stimulation-evoked desire to stimulate again and strong sexual arousal—while never producing sexual orgasm or clear evidence of actual pleasure sensation. And the stimulation never served as a substitute for sexual acts. What it did instead was to make him want to do more sexual acts, just as it made him want to press the button more…

When [the female patient’s] electrode was stimulated in the clinic, it produced a strong desire to drink liquids and some erotic feelings, as well as a continuing desire to stimulate again. However, “Though sexual arousal was prominent, no orgasm occurred” (Portenoy, 1986)... Clearly, this woman felt a mixture of subjective feelings, but the description’s emphasis is on aversive thirst and anxiety—without evidence of distinct pleasure sensations.

Dr. Kringelbach points out that the technology definitely has potential:

Of course, to suggest that such pleasure electrodes failed to cause real pleasure does not mean that no electrode ever did so, much less that future pleasure electrodes never will. But it does mean that, if even the most prototypical and classic cases of ‘pleasure electrodes’ from the past are open to doubt, closer scrutiny of deep brain stimulation (DBS) electrodes may be needed in the future: Do they really cause pleasure? (Green et al. 2008; Kringelbach et al. 2007b).

So don’t bother looking for “sex chips” in your local drugstore just yet, but they are almost certainly on the horizon.

100,000 women demand more breasts on Facebook

Breastfeeding is obscene. At least that’s what the social networking site Facebook appears to believe. Evidently, it is only appropriate to display breasts for sexual reasons. There are literally thousands of photos of women exposing their assets to greater or lesser extent. But we need to draw the line somewhere. It might be damaging for Facebook members, including many high school and college student, to see women using breasts for their primary purpose, to nourish their babies.

Talk about a boneheaded public relations move. As was only to be expected, women whose pictures of breastfeeding were removed promptly formed the Facebook group “Hey Facebook, Breastfeeding is Not Obscene.” The group has 100,000 members and counting. Here’s their “manifesto”:

Recently, Facebook has started 'pulling a myspace' by not allowing people to post profile pictures of babies nursing. The pictures have been reported as 'obscene' and have been removed- their posters warned not to repost or fear being kicked off of Facebook.

We're wondering: what about a baby breastfeeding is obscene? Especially in comparison to MANY other pictures posted all over Facebook that really are obscene.

Facebook, we expect more from you, and we expect you to realize that nursing moms everywhere have a right to show pictures of their babies eating, just like bottle-fed babies have a right to be seen. In an effort to appease the closed-minded, you are only serving to be detrimental to babies, women, and society.

**Facebook, allow breastfeeding pictures, and stop classifying them as obscene!**

According to tech website, ars technica:

As per site policy, Facebook does not allow images depicting female nipples or areolas anywhere on the social network, though this does not include breastfeeding photos. Facebook does, however, remove photos that are reported by users as obscene, which is apparently what happened in Farley's (and other mothers') cases. Farley says that the baby covered the nipple and areola in her photos, but that apparently didn't stop other members from reporting the pictures to Facebook.

Here’s one of the offending photos, so you can judge for yourself.

Yup, that’s obscene. Sure there’s no visible nipple or areola, but OMG there is a baby eating from that breast! Small children could be emotionally scarred by just one peek.

Facebook has jumped head first into a no win situation. It is almost inevitable that the phenomenon of 100,000 women demanding more pictures of breastfeeding will lead to even greater public pressure for them to relent. The ban is unjustifiable on its face, but it is instructive about societal attitudes. Evidently no amount of cleavage is too much if it is displayed for sexual purposes, but when it comes to drinking from a breast, that’s just going too far.