Extreme Makeover: Vagina Edition

Last fall, a group of activists from New View Campaign staged a protest outside the office of the Manhattan Center for Vaginal Surgery. According to Time Magazine:

Appalled at the popularity of so-called designer vaginas, a grass-roots organization called the New View Campaign staged its first-ever protest on Monday outside New York City's Manhattan Center for Vaginal Surgery. Two dozen women … handed out index cards and held up orange poster boards with the message "No Two Alike," while two members of the group donned giant cloth vulva costumes. New View, which was created in 2000 … is trying to fight what it calls "the medicalization of sex,"…Says the group's leader Leonore Tiefer, a sexologist and psychologist at New York University: "Promoting a very narrow definition of what women's genitals ought to look like — even for those women who don't want surgery, it harms them."

I was unable to find picture of the cloth vulva costumes (and believe me, I tried), but I did find the group’s website with an extensive and thoughtful exposition of their philosophy. I was intrigued by their response to arguments about a woman’s right to choose genital plastic surgery:

The focus of our concern is on the cosmetic surgical procedures and the promotion of these by some doctors. Real choice is important, but choice does not exist in a cultural vacuum. In campaigning against genital cosmetic surgery we are calling for critical attention to the cultural conditions that lead women to choose these operations. We want to encourage debate about what is going on in contemporary western society that could produce a woman’s desire to surgically alter her genitals? We see the scene being set by trends such as the medicalization of women’s sexuality and the way women’s bodies continue to be objectified… [A]ggressive marketing … enlarges the market by normalizing and expanding women’s dissatisfaction with their bodies.

Although individual choice is an important cultural value that we endorse, the ethics of this issue cannot be reduced to ‘an individual’s right to choose.’ This is because the promotion and normalization of these practices has implications for all women. The business opportunity afforded by genital cosmetic surgery rests on creating, inflaming and inflating genital discontent among the wider population of women…

I am very wary of any argument that claims that an issue of choice cannot be reduced to an individual’s right to choose. That is nothing more than excuse to value some people’s choices (like the women of the New View) over the choices of other women with whom they disagree. The members of the New View may not like the fact that women choose genital plastic surgery, but they have no philosophic basis for interfering with that right.

The New View is correct, though, in its assertion that marketing and cultural values profoundly influence a woman’s desire to have genital cosmetic surgery. Here’s the marketing message of the Manhattan Center for Vaginal Surgery:

Labia Reduction & Cosmetic Enhancement: Labiaplasty is a cosmetic genital surgical procedure that will reduce the size or change the shape of the small lips on the outside of the vagina (the labia minora).

Many women are born with large or irregular labia. Others develop this condition after childbirth or with aging. The appearance of the enlarged labia can cause embarrassment with a sexual partner or loss of self esteem. Some women just want to look "prettier" like the women they see in magazines or in films.

They want to look “prettier” like the women they see in magazines or in films? Just what magazines and films offer up-close views of women’s labia?

If anyone is in doubt about the impact of cultural values, consider this scientific paper on the practice of labial elongation among Rwandan women. According to Rwandan female genital modification:

…In Rwanda, the elongation of the labia minora and the use of botanicals to do so is meant to increase male and female pleasure. Women regard these practices as a positive force in their lives… Research was carried out in the northeast of Rwanda over the course of 13 months. Semi-structured interviews were conducted with thirteen informants. Two botanicals applied during stretching sessions were identified as Solanum aculeastrum Dunal and Bidens pilosa L. Both have wide medicinal use and contain demonstrated beneficial bioactive compounds…

While there is extensive natural variation in the appearance of female genitalia, individual cultures have created appearance “norms,” and women within those cultures attempt to modify themselves to achieve these “norms.”

Is genital surgery the inevitable result of cultural values that create “norms” for sexuality and objectification of women’s bodies? Or are groups like the New View over-reacting? Can they really argue that genital cosmetic surgery is qualitatively different from other forms of cosmetic surgery in allowing women to take control of their appearance and enhance their self esteem?

These are difficult ethical questions without easy answers. I just hope there is no reality show in our future entitled Extreme Makeover: Vagina Edition. I’m not willing to rule that unfortunate possibility just yet.

They killed my patient. Then they tried to hide it.

A maternal death is an extraordinary tragedy. Until recently, it was all too common. In 1900, almost 1% of pregnant women died in and around childbirth. The advent of modern obstetrics has dropped the maternal mortality rate by 99% since then, so most people have no direct acquaintance with a woman who died in childbirth.

Most maternal deaths are due to serious complications of pregnancy, or serious underlying medical problems, such as heart disease, that are exacerbated by pregnancy. Like any obstetrician, I’ve been involved with several maternal deaths, though never as the primary physician. Each one has been a searing experience, but in retrospect, an unavoidable event.

All but one, that is.

The patient died because of a series of unfortunate anesthetic complications, compounded by inadequate medical response. I cannot tell you when, where or how, since the case is so unusual that any details might lead to identification and compromise of privacy.

Because maternal deaths are now so rare, my state, like most states, mandates an official investigation. The investigation is conducted by the hospital, and evaluated by the Department of Health. As a participant at a critical juncture in this woman’s care, I was interviewed extensively by a senior member of the obstetrics department and a member of the hospital administration.

I was very angry at the care the patient received from the anesthesiologists, because I believed that her death had been entirely avoidable. I did not hide my anger during the interview, going to so far as to say that I felt that the anesthesiologists had essentially killed the patient. The people who interviewed me seemed uncomfortable with my conclusions and with my anger. They repeatedly suggested alternative explanations for the unfortunate incident, but I was not swayed. Others might reach different conclusions, I acknowledged, but this was my conclusion.

Several years later I was contacted by my medical malpractice insurance carrier and advised that a malpractice case had been filed against the anesthesiologists. This was not surprising. Virtually every maternal death is followed by a malpractice suit, even when the death was unavoidable. As a participant in the patient’s care, I would be deposed by the patient’s lawyer. Consistent with its obligations, the malpractice insurer had hired a lawyer to defend me during the deposition.

Shortly thereafter, I heard from the lawyer’s office. The deposition was scheduled in several weeks, and I was given an appointment with the attorney for “deposition preparation” a few days in advance of the deposition itself.

At our meeting, the lawyer seemed both competent and affable. First, he wanted to hear the story directly from me, in as much detail as I could recall. I carefully recounted the events of that day. When I finished, the attorney was frowning.

“Do you realize,” he asked, “that your recollection is very different then the testimony you submitted at the time?”

“No, it isn’t,” I replied. “It’s exactly the same story.”

“Well,” he continued, waiving a sheaf of papers, “I have your testimony right here, and that’s not what you said.”

I was stunned. I knew that was exactly what I had told the interviewers. If anything, I had been much harsher back then, because I was closer to the event and very angry about what had happened.

I held my hand out for the papers, and re-read my testimony. By the time I finished, I must have been ashen.

“This is not what I said! This is nothing like what I said.”

The lawyer was dubious.

“No one is going to believe that,” he warned. “Unless you have proof, it’s as if it never happened.”

On the day of the deposition, we met in a conference room where the patient’s lawyer, the anesthesiologists’ lawyers, the hospital lawyer and the court stenographer were waiting. Everyone seemed friendly and relaxed. This was just a small, routine part of the case. I was only one of a dozen doctors they planned to depose, and not even a subject of the lawsuit.

I had been told to plan for a deposition that was several hours in length, but it didn’t take nearly that long. After recounting my memories of the day in question, I was met with the inevitable accusation.

“But that’s not what you said when you testified for the official investigation,” the patient’s lawyer said sharply, holding up the official report.

“Actually,” I replied, “that is what I said. The report you are holding is not my testimony.”

Every lawyer in the room was now alert. The deposition was not longer the routine task they had expected.

The patient’s lawyer looked very eager.

“Do you have proof?” he demanded.

“Yes, I do have proof,” I replied.

My husband is a lawyer, and he makes me keep everything I have ever signed. Shortly after the official interview, the interviewers had sent me a transcript of my testimony, beneath which was a place to sign acknowledging that this was a true representation of what I had said. My husband had insisted that I make a photocopy for my records before I sent it back.

After my meeting with my lawyer, I had gone home and dug it out from the bulging file cabinet. I had given the photocopy to my lawyer before we entered the conference room, and now he produced it and handed it to the patient’s lawyer.

Despite the somber nature of the proceedings, the patient’s lawyer looked gleeful. The lawyers for the anesthesiologists and hospital looked shell shocked. The lawyers handed my photocopy around. Not only did it have my signature at the bottom, but it also had the signatures of the senior department member, and the hospital administrator who had interviewed me. The document that the hospital had represented as my testimony had no signatures at all.

The patient’s lawyer was so happy, that it took several minutes for him to pull himself together and continue the deposition. The rest of the questions focused on my original testimony and my discovery that the testimony in the hospital report had been altered.

If I had been angry about what happened to the patient, I was even angrier after learning of the deception. The hospital had deliberately lied to protect its staff members. They lied to cover up medical negligence, with the assumption that the doctors in question would continue to practice at the same hospital, free to make similar mistakes.

The hospital had been remarkably foolish. In a malpractice case,  an attempt to alter the record is practically an admission of guilt. There was no limit to the millions of dollars that a jury would be willing to award in a case of avoidable death of a young mother where the hospital had attempted to hide the truth. The lawyers for the anesthesiologists and the hospital knew this, too.

My lawyer called me several days later.

“There isn’t going to be a trial,” he said. “The hospital offered the patient’s family an 8-figure settlement, and they have accepted.”

Cosmo and the zipless f*ck

 

I love Cosmopolitan Magazine, I really do. Where else can you find so much information on how to be an unpaid prostitute?

Founder Helen Gurley Brown intended Cosmo to be sexually liberating for its women readers, a feminist sexual manifesto. The Cosmo of 2009 has evolved to extol the benefits of women being unpaid sex slaves. How did we get from there to here?

In many ways, Cosmo has simply reflected changing attitudes toward sex. Originally meant to demonstrate to women that there was more to sex than satisfying a husband, Cosmo has turned a full 180 degrees to demonstrate that there is nothing more to sex than satisfying a boyfriend. At least in the presumably repressed early 1960’s sex promised a husband, children, and lifelong economic support. Now sex promises nothing more than an evening’s activity, that, if done the Cosmo way, will leave the man satisfied and the woman happy that she satisfied the man. So much for feminism.

The ideal Cosmo sexual encounter is Erica Jong’s “zipless fuck.” In her 1973 book, Fear of Flying, Jong described the zipless fuck.

The zipless fuck is absolutely pure. It is free of ulterior motives. There is no power game. The man is not "taking" and the woman is not "giving." … No one is trying to prove anything or get anything out of anyone. The zipless fuck is the purest thing there is.

Sex without strings. The original “friends with benefits.” Jong has said that she meant the zipless fuck as an expression of feminism: sex for no other reason than the protagonists wanted to have sex. But people often forget that Jong said of the zipless fuck: “And it is rarer than the unicorn.” Or that Jong’s heroine did not feel liberated by her sexual relationship with a man other than her husband.

Even the protypical zipless fuck did not work out as planned. According to reviewer Christina Nehring, writing in The Atlantic:

But here’s an irony: Fear of Flying demonstrates the unavailability of the zipless fuck. Far from being an inspirational story (as it is routinely billed) of a woman’s escape from a dead marriage and discovery of erotic pleasure and independence, it’s the tale of a woman who ditches her husband only to find in the arms of a lover first impotence and frustration, then heartbreak and abandonment. The end of the novel has Jong’s protagonist returning ruefully to her spouse …

Cosmo seems to have missed the news that sex without strings is not all it’s cracked up to be. Moreover, Cosmo appears to define “sex without strings” as “without strings for the man.” Cosmo is all about “catching” a man, but the underlying assumption is that men don’t want to be tied down. Therefore, in order to have a boyfriend, or even a casual sexual encounter, Cosmo instructs women to sublimate any needs and desires that they may have.

The April 2009 issue is a case in point.  The cover article, Just Do This on Date #1 (and he’s yours), is basically a compendium of “relationship tips” that involve emphasizing that “he” has no obligations to you. It advises not to tell him too much about yourself (TMI is a sexual turnoff) and not to text him simply because you’ve had sex; sure he had sex with you, but it’s texting that implies a more serious commitment.

Another cover article, What Guys Crave After Sex, advises acting like nothing more than an unpaid prostitute: compliment him, bring him a drink of water because he might be thirsty from his heroic performance. Most importantly, let him know that you’ve got to leave soon. That lets him know you aren’t foolish enough to believe that the fact that he had sex with you means that he wants to be with you.

Cosmo is dismally similar to 1950’s attitudes about sex. It’s a woman’s job to “put out” for her husband, whether it serves her needs or not. That was her part of the bargain; she provided sex in exchange for children and economic security. Then there was the prostitute. It was her job (literally) to “put out” for the customer in exchange for money. The Cosmo 2009 attitude toward sex is that it’s a woman’s job to “put out” for a man. And what does a woman get in exchange? Nothing of course.  Merely hinting that she might have needs is enough to drive any man away.

Cosmo was founded by a woman, but it’s difficult to believe that it wasn’t founded by a man whose ideal of womanhood was the star of a porno movie: always available, always sexually satisfied, never demanding anything other than more sex. That view of women, the view espoused by Cosmo, is profoundly misogynistic. Women are nothing more than sex toys. They may have thoughts, feelings and needs for interaction other than sex, but they should be sure to keep that to themselves.

 The zipless fuck doesn’t exist, as even Erica Jong’s heroine found out. Women don’t want or need sex without strings. Too bad the folks at Cosmo have not yet figured that out.

Your genital piercing got infected? Bummer.

 

If you’re freaked out by eyebrow piercing, the kind of person who can’t look directly at your Starbucks barrista,  stop reading now. Even if you are a devotee of “body art,” you may reflexively cross your legs as you read this.

The latest craze is genital piercing. If you can imagine it, you can pierce it. Even if you can’t imagine it, you can pierce it. Aficianados of genital piercing like to claim that they widely used among indigenous peoples, but the reality is much more prosaic. According to WebMD:

…[G]enital piercing is largely a recent and Western phenomenon. This may be disconcerting to a few ill-informed proponents of the practice, who might prefer to imagine that they are rediscovering a venerable and ancient rite of passage, rather than practicing a newfangled invention. But … most of the exotic sounding names for different types of genital piercings were actually made up in the 1970s in the U.S. and Europe…

Genital piercing is believed by some to enhance sexual satisfaction. The existing scientific evidence (yes, someone has actually studied this) is equivocal. According to one paper, First glimpse of the functional benefits of clitoral hood piercing, which studied arousal, desire, lubrication, pain, orgasm, and overall sexual satisfaction:

 … We observed significance in only 1 of the domains, desire (0.414, P = .017). Other sexual functioning indexes were negligible. We expected to see a change in the orgasm frequency and/or satisfaction. Yet, contrary to popular belief, we saw no dramatically significant difference in orgasm.

Devotees of genital piercing, both female and male, are nothing if not creative. The About.com guide to female genital piercing lists no fewer than 8 different piercing sites including clitoral hood (two types) and inner and outer labia. The guide to male genital piercing also lists 8 separate types, many known by exotic names such as Ampallang and Apradravya.

Most of the scientific literature on genital piercing deals with complications, and there are quite a few. All body piercing has risks, the most common being infection and transmission of disease:

…  [T]he procedure has the potential to pass on any number of diseases, including leprosy, tetanus, tuberculosis, hepatitis, HIV, and other STDs.

But there are additional risks specific to genital piercing:

… More invasive kinds of piercing, such as a piercing that runs through the head of the penis, should only be done by experienced piercers if by anyone at all…. Such piercings can result in serious bleeding and "the risk of impotence caused by hitting the erectile tissue by mistake is simply too high," … Piercing the clitoris itself, rather than the clitoral hood, is also a potentially risky procedure…

Once you decide that you want a genital piercing, and you decide which piercing you want, the most important step is choosing piercer. The Association of Professional Piercers, the professional organization of the piercing industry, publishes guidelines to choosing a safe piercer. These guidelines range from the obvious, choose a studio that is licensed and clean, to the esoteric, ask to see the autoclave (sterilizer) and the spore count test results.

In addition, they suggest looking at the piercing portfolio:

… Are piercings placed to accent the anatomy or do they look awkward and poorly matched to the individual? If the portfolio features unusual looking placements, are there pictures of healed piercings, showing the actual viability of the placement?

The other key to safe genital piercing is scrupulous aftercare, including cleaning and handling of the piercing, as well as sexual limitations.

Do not allow your piercing to come in contact with any bodily fluids for the first few weeks while it is healing. This includes saliva as well as semen. So, you are not restricted from sexual activity, but a condom or dental guard must be used for any and all sexual contact, or you are putting yourself at risk for infection. This includes masturbation and/or the use of sex toys.

Whether genital piercing is ancient or modern, whether it does or does not enhance sexual satisfaction, one thing is clear: it is critically important to follow all guidelines in order to avoid infection. Contrary to what you might expect, the piercing itself is reported to involve little pain. However, an infection, and its complications can be very painful, as well dangerous and possibly threaten your fertility or your life.

Sorry, Mom, no praise for getting your 12 year old the Pill.

No one likes unsolicited advice. It doesn’t matter if it’s good advice and it doesn’t matter if it’s well meant. Patients are no exception, even though part of the provider’s job is to counsel patients about their lifestyle choices. Smokers don’t want to be told not to smoke; overweight people don’t want to be told about the risks to their health.

That’s why I always tried to confine myself to the unadorned facts, and carefully excise any value judgments from my comments. Every now and then, though, I couldn’t help myself.

Any gynecologist is depressingly familiar with sexually active young teens and preteens, and the dreadful consequences. I often saw these girls in the Emergency Room in the middle of the night, unaccompanied or accompanied only by teenage friends. Certainly, no one came in with her mother. Perhaps that’s why I was not expecting a discussion of birth control when an affluent mother brought her 12 year old to the office for a consultation.

Improbably, the mother was beaming. Very few people are beaming at their gynecology appointment.

“We’re here for the Pill,” she announced cheerfully.

“The Pill,” I was shocked and it must have showed. “Who’s here for the Pill?”

The mother plowed ahead. “I brought my daughter to get the Pill. She’s sexually active.”

I turned to the daughter. She nodded her head slightly in affirmation.

“I’ve explained,” the mother continued, “that when you are sexually active, you always have to use protection, and the Pill is the best protection there is. That’s why I brought her myself.”

“Well,” I started tentatively, “the Pill is the best protection against pregnancy, but it doesn’t offer any protection against sexually transmitted diseases. Before we get to that, though, I’d like to talk a little more about sexual activity. I turned to the daughter again. “What grade are you in?”

“Seventh.”

“How old is your boyfriend and what grade is he in?”

“He’s 17 and he’s a senior in high school.”

“Yes,” the mother confirmed proudly, “she’s dating a senior.”

“Have you considered,” I ventured, “that might not be such a good thing?”

“What do you mean?” The mother was clearly annoyed.

“I mean,” I said, “that 5 years is a big age gap. There’s a big difference between a seventh grader and a high school senior.”

“So?”

“So, the needs and desires of a 17 year old boy are very different from the needs and desires of a seventh grader. A sexual relationship might seem like a good idea for a 17 year old, but it’s inevitably a bad idea for a 12 year old.”

“But she wants to date him,” the mother responded.

“Yes, she may want to date him, but that doesn’t mean that there might not be an element of coercion involved. Let’s think about this for a minute; what kind of 17 year old boy dates a 12 year old? It’s usually someone who has no success with girls his own age, and has to reach down to much younger children to have a sexual relationship.”

The mother was clearly growing angry. “But I thought you’d be impressed that I brought my daughter in for birth control,” she said, “My mother wouldn’t have done anything like this. She didn’t even tell me the facts about sex.”

“Sorry, I’m not impressed that you brought your sexually active 12 year old in for the Pill. I’m worried that someone is taking advantage of her.”

I kept looking in the direction of the daughter, but she made no response.

“We didn’t come here for your dating advice,” the mother replied heatedly. “Are you telling me that you won’t give her a prescription for the Pill?”

“No, that’s not what I’m saying. If her exam is normal, and she has no risk factors, I’m certainly going to give her a prescription. She’s sexually active and she needs to be protected from pregnancy. And I’m going to talk about condoms, too, since the Pill does not protect against sexually transmitted diseases.”

The mother was not mollified. She sat stonily through the rest of the interview and exam. When I finally wrote the prescription for birth control pills, she snatched it from my hand.

“Thank you,” she said coldly. “That’s what we came for. And by the way, the next time we want your opinion, we’ll ask for it.”

Video game let's you get in touch with your inner rapist

From Japan, the font of video game technology, comes a new game that is possibly the most offensive video game ever produced. The game is RapeLay, a rape simulator game. Yes, you read that right. RapeLay allows you to play a sexual predator in the subway.

RapeLay is surprisingly realistic in its portrayal of the rapist as power hungry sexual deviant. Gaming journalist Leigh Alexander (of websites Gamasutra and SexyVideogameland) thoughtfully downloaded and played the game, so you don’t have to:

The game begins with a man standing on a subway platform, stalking a girl in a blue sundress… Once she's on the train, the assault begins. Inside the subway car, you can use the mouse to grope your victim as you stand in a crowd of mute, translucent commuters. From here, your character corners his victim—in a station bathroom, or in a park with the help of male friends—and a series of interactive rape scenes begins.

… Although the interactive assaults are difficult to endure if you have a conscience, the game's text actually provides the most unsettling material. RapeLay relies on the horrendous, wildly sexist fantasy that rape victims enjoy being attacked. After the exposition, the game essentially becomes a simulator of consensual intercourse. There's kissing. The women orgasm.

The game is realistic in yet another way. It portrays the Japanese phenomenon of the chikan, the subway pervert. The details of chikan, a real practice, not a video game, are horrifying. According to the book The Japanese Disease: Sex and Sleaze in Modern Japan, by Declan Hayes:

… The molestation-minded men get together through the Internet, brazenly advertising for interested parties to join their ranks in chikan associations…

The chikan groups are incredibly thorough, picking out a particular target and trailing her for months until they have a minutely detailed knowledge of her commuting habits. Once they decide to implement their plan to molest her, group members are instructed to board the crowded train at different stations and stand in the particular part of the carriage that … target normally occupies… Once they’re all in the same carriage, they immediately set about surrounding the target and shutting off all possible avenues of escape… [M]embers of the group with go hell for leather groping, poking and molesting the target they have surrounded…

The back-story of RapeLay is that you are a wealthy man out for revenge after being outted as a chikan. As a result:

The objective … is for your "character" to stalk then brutally rape women, as many as possible. Wait, there is a catch: before your character can go into "free mode" to rape other women in the game, he must first rape a mother and her two young daughters, who have "falsely accused you [him] of raping them." Now the big twist: you cannot get any of the women pregnant. If you do impregnate a woman, you must force her to have an abortion because if she has the child you will be thrown under a train… With several users playing the game, it is possible to gang rape the women …

Not surprisingly, the video game offers politicians an irresistible opportunity to grandstand. New York City Council Speaker Christine Quinn has publicly called for all US video game distributors to refuse to sell Rapelay. Considering that the game has not been released in the US market, the call for a ban is unnecessary. Potential distributors such as Amazon.com and Overstock.com have already announced that they will not carry it. Moreover, a ban is meaningless, since the game is widely available over the Internet.

Will Rapelay encourage players to commit rape in real life? Clearly there is a connection between sexual predation (chikan) and a video game that glorifies rape. The game makers are explicit about this connection. Undoubtedly, those who belong to chikan associations will be drawn to the game, but there is far from obvious that playing the game will turn men into sexual predators. Rapelay is offensive, appalling and worthy of condemnation, but is it harmful? That remains to be seen.

Mister Rogers was wrong; children can go down the drain

Fred Rogers soothed the fears of several generations of children by explaining why they cannot go down the drain. Mister Rogers was thinking of the bathtub drain, which relies on gravity to empty the tub. Evidently there was no swimming pool in his Neighborhood, certainly not one that relied on a powerful filter system to pull water from the pool.

From 1997-2007, 9 children died after become entrapped in pool drains, and an additional 63 were injured, some grievously. Abigail Taylor, 6 years old, died almost exactly one year ago. In June of the previous summer, Abbey had been playing in the wading pool at the Minneapolis Golf Club when she sat on the wading pool drain. The pool suction was so powerful that it literally disemboweled her, tearing out a large part of her intestinal tract.

According to TwinCities.com:

She survived the initial incident, but the weeks and months that followed were filled with surgeries to try to repair her damaged internal organs…

Abbey got her nutrition through a tube, but that created its own problems. The formula damaged her liver, requiring an organ transplant.

In December, she received a new liver, small bowel and pancreas. There were complications from the surgery, though, including raging infections and a transplant-related cancer that required her to endure chemotherapy.

The accident did not have to happen. Had the wading pool been properly fitted with an anti-entrapment drain cover, Abbey would not have been harmed.

In December 2007, Congress passed the Virginia Graeme Baker Act, named in memory of the granddaughter of former Secretary of State James Baker III. In 2002, the 7 year old girl known as Graeme was entrapped by the drain of a hot tub at a friend’s house and drowned. Her mother tried to save her, but literally could not break the force of the suction holding her to the bottom of the hot tub. It took two men, who broke the drain itself, to remove the little girl from the grip of the suction.

The Virginia Graeme Baker Act required that drains in all public pools and spas be retrofitted with anti-entrapment covers. However, three months after the deadline, approximately 70% of public pools and spas have not undertaken the repair. According to the New York Times:

One reason compliance has been slow is … the safety commission didn't issue final regulations until just six months before [the law] took effect. Lachocki [head of the National Swimming Pool Foundation] said that left little time for manufacturers to design and ramp up production of drain covers and pumps that meet the new specifications, or for pool owners to line up contractors. He said many pool owners and local authorities are still confused.

But the Pool Safety Council says the equipment is getting easier to find. Spokesman John Procter said the group recently surveyed manufacturers and found they're catching up. And while the industry cites costs of $10,000 to $15,000 to retrofit some pools, he said most can be fixed for $1,000 to $1,500.

How can parents protect their children?

…The main sign of a faulty drain or drain cover is a continuous swirl of water created by a drain indicating excessive suction. Keep your children away from such whirlpools…

Refuse to swim in pools that do not meet safety standards. Never allow children to swim or sit in a Jacuzzi or spa tub that has not had the drains and their covers safety inspected…

Mister Rogers was right when he declared that children cannot go down the drain completely. He did not realize that they don't have to go down the drain completely in order to be harmed and that what applies to the bathtub might not apply to the local pool. The deaths and injuries caused by pool drain entrapment cannot be undone, but there is every reason to believe that we can prevent further deaths and injuries. If parents watch for signs of faulty drains, and demand that public pool owners comply with Federal standards, the terrible tragedies suffered by Abbey Taylor and Graeme Baker will not have been in vain.

The devil's baby

Working in a hospital is an education in itself. Not just a medical education, although that is the primary purpose of being there, but an education in the human condition. Anything can happen in a hospital. There is nothing too strange, too bizarre or too outlandish. Human frailty and foibles as well as indomitable strength are constantly on display.

Consider the case of the devil’s baby.

The chief resident in obstetrics is responsible for the care of patients who don’t have a doctor of their own. Therefore, when the warden of the state women’s prison called the hospital with a problem, he was put through to the chief resident, and that was me. A patient in the prison was currently nine months pregnant and very upset. She was convinced that she was pregnant with the devil’s baby. They were sending her in by ambulance for evaluation.

“Evaluation?” I was dumbfounded. “What do you want me to evaluate?”

“Just make sure the baby is normal,” he replied. “Show her that she’s not carrying the devil’s baby.”

I couldn’t believe it. “I don’t have to examine her to know she’s not carrying the devil’s baby.”

“Well, she’s already on her way,” he responded. “Just do … something.”

Unfortunately, it was a very busy day. There weren’t any exam rooms available to see her. She was placed in the doctor’s lounge and was forced to wait hours while I dealt with other medical problems before I could get to her, since “carrying the devil’s baby” did not seem to be a medical emergency.

The patient was not perturbed at the wait. In fact, she was enjoying it. She was shackled to the stretcher, but in all other respects, the surroundings were far superior to the woman’s prison. The nurses had gotten her a meal. (“Yes,” I had exasperatedly replied when asked if she was allowed to eat. “We don’t really believe that she is carrying the devil’s baby.”) She was watching television and enjoying a glorious view of the city from her tenth floor quarters.

I swept in with a medical student in tow. “What seems to be the problem?”

She remembered why she was there and her brow furrowed. “I’ve got the devil’s baby inside of me, and I’m afraid.”

The delusions of mental illness are not likely to be changed by reality, but I was obligated to try. I affected a cheerful demeanor. “Oh, I’m sure that your baby is a normal baby and not the devil’s baby at all. How about if I get the ultrasound machine and show you the baby?”

“I don’t know,” she replied. “I’m afraid.”

“No reason to be afraid,” I responded briskly. “You’ll see that everything is okay.”

I got the ultrasound machine and proceeded with a careful examination and explanation of what we were seeing. I traced the baby’s body parts on the screen, all the while feeling extremely foolish.

I traced the baby’s head. “See, no horns.”

I showed her the baby’s body. “No sign of a tail,” I announced cheerfully. “Perfectly normal in every way!”

“I don’t know,” the patient seemed extremely doubtful.

“Now that I’ve shown you that the baby is healthy and normal, I’m going to invite a very nice man to talk to you about your worries. He has lots of experience with people who are afraid of being pregnant with the devil’s baby,” and I headed off to call the psychiatry resident on call.

The psychiatry resident visited with her and decided to hold off on any psychiatric medication until after the baby’s birth, since the patient currently did not seem distressed. We gave her another meal, let her watch her favorite shows on television, and call the ambulance to take her back.

I phoned the warden’s office to inform them. I emphasized to them that she was perfectly fine (except for her delusions) and that the baby appeared to be normal and growing well. “She’s not carrying the devil’s baby,” I admonished, “and if she complains about it again, you should not send her back.”

I thought the matter was settled.

Several weeks later, the secretary on the labor floor paged me to the phone. The prison was on the line again. It was the warden.

“Remember the lady you saw a few weeks ago? Um, well, we have another little problem.”

“Another problem?” I was not in the mood for riddles. “Now what’s wrong?”

“Well, this morning she complained of pain in her stomach, but we didn’t believe her. Oh, no, we weren’t going to fall for her tricks. Last time we sent her to the hospital because she said she was carrying the devil’s baby and she wasn’t!

I could immediately see where this was going.

He continued. “She kept calling us, but we just ignored her. She tricked us before, so we didn’t believe her.”

He finished in a rush, “So she lay down on the floor of her cell and had the baby all by herself. We just found her and called for an ambulance.”

The warden had summoned a nurse from the prison infirmary, who had tied off and cut the umbilical cord. They bundled up the baby, who seemed healthy and content, and the mother, who was not bleeding very much, and sent them in.

She was glad to be back, and thrilled that she could stay for several days. The nurses ordered her favorite foods and arranged for a nice room. I arranged for the visit from the psychiatrist, and pondered the strange way that prison officials manage medical problems. They sent the patient in for “evaluation” when she claimed that she was carrying the devil’s baby, but ignored her cries for help when she was in labor. It’s amazing what you can learn about the human condition when you work in a hospital.

A last gift of love: the night before my father died

I am very proud of my profession. There is probably no other profession that has done so much to save lives and ease suffering. However, I have no illusions about the very real problems in contemporary medicine. I’ve experienced most deficiencies in medicine, either directly or through family and friends, but my father’s story is probably the one that burns most brightly in my mind.

Elsewhere, I have recounted how my own colleagues in the hospital where I worked diagnosed my father’s cancer but neglected to tell him. A small lung cancer had been seen on a routine chest X-ray more than 7 months before he coughed up blood. By the time he had his first symptoms, the cancer in his chest was the size of his fist.

If that weren’t bad enough, the doctors, my personal friends and professional colleagues, attempt to deceive us about the findings on the original X-ray. It was only because I worked at the hospital, and could access the X-ray myself, that we learned about the original mistake. And that’s not even the worst part of the story.

My father received the diagnosis on November 1. It was a complete shock since he had never smoked, but approximately 10% of lung cancers occur in non-smokers. After the debacle of unearthing the original chest X-ray and confronting the doctors involved, everyone did their utmost to try and cure him. Nothing worked. Despite multiple types of chemotherapy, the tumor continued to grow and press against his lungs. The tumor produced large amounts of fluid that made breathing difficult. Gradually he developed air-hunger, a sensation that is reported to be worse than pain. He felt like he was suffocating even when he was working as hard as he could to draw breath. By December 25th he was back in the hospital again.

Late that evening my mother called me at home. She was in tears. “You must come to the hospital,” she said. “Your father is in such pain and no one will help him.” I nursed my infant son to sleep and headed for the hospital, my hospital, the one where I had trained, where I worked, where I knew everyone and everyone knew me.

My mother was right. When I saw my father, I was appalled. He was sitting bolt upright in bed, gasping for air, and clutching his chest. I paged the intern myself and demanded his presence. He must have run at a brisk clip because he appeared immediately. We were standing in the doorway of my father’s room. I pointed to my father.

“What is the meaning of this?” I demanded.

The intern, to his credit, was abashed. He acknowledged that my father was clearly in terrible pain, and he acknowledge that my father was suffering from air-hunger and was therefore even more uncomfortable. We agreed. Everything seemed settled.

“Go get him some pain medication, “ I insisted.

“Oh, no, I couldn’t possibly do that,” the intern replied. “He’s dying and pain medication might hasten his death.”

I could not believe what I was hearing. Obviously he was dying. Every treatment had failed and there was nothing left to try. There was no hope of recovery. And we were going to withhold pain medication … why? To prolong his death?

“You’ve got to be kidding,” I barked, although he did not look like he was kidding at all. “I insist that he get pain medication this minute.”

“I couldn’t possibly do that,” he said. “I don’t have the authority. I’ll have to call my resident.”

“Fine. Call!” I demanded.

It was well after midnight at this point and he woke up his resident. I could hear that the resident was unwilling to order the pain medication, and I grabbed the phone. The resident insisted that he didn’t have the authority, only the oncology fellow could decide.

So I called the oncology fellow myself and woke him up. “Oh, no,” he declared. He couldn’t possibly order pain medication in this setting, because it might slow my father’s breathing and thereby hasten his death. Only the attending physician on call had the authority to issue that order.

Then I called the attending at home and woke him up. He listened and replied, “Look, Amy, I know you’re upset, but it’s the middle of the night. Why don’t we wait until morning when your father’s own doctor will be back and he can make the decision.”

At this point, I was screaming into the phone, and a crowd of nurses and support personnel had gathered to watch from a discreet distance. “You get in here and tell me that to my face,” I hissed. “ I will not accept it unless you come here and look at him and then dare to tell me to wait.”

I heard him sigh. “All right, all right. What do you want me to do?” I gave instructions for the amount of morphine I thought he needed, and handed the phone over to the nurse so she could record the order. I started to relax.

The nurse hung up the phone and I looked at her expectantly.

“I can’t give that morphine,” she said. “I’m not comfortable with giving medication to a patient so near death.”

At that point I was transformed into Shirley McClaine in the film "Terms of Endearment", when she was told that her daughter couldn’t have her pain medication just yet because the nurse was busy.

“You’re not comfortable?” I screamed. “Not comfortable? Do I look like I care about your comfort? I don’t think so.

You go get that morphine or I will break into the narcotics cabinet myself and get it, and then I will report you to the hospital administration for failing to follow an order!”

She hesitated. “Oh, all right. If you’re going to be that way about it.”

“Yes,” I said. “I’m going to be that way about it.

She got the morphine and hung a morphine drip. Within 5 minutes my father began to ease back against the pillows. After 10 minutes, he looked at me and smiled. “I feel great!” he said. “I haven’t felt this good in months. This is terrific.”

He slept then, and I wept. He died less than 24 hours later. Throughout the day, he kept telling everyone how wonderful he felt. His last words to me, before he lost consciousness and died:

“Don’t worry, I’m going to be fine. I’m just going to rest for a bit.”

 

She tried to flush the baby down the toilet; then it gets weird

 

Working in a hospital brings exposure to the human condition in the way that no other job can. Of course you see birth and death, but you also see the results of human foibles like rage, anger and despair. All too often, mental illness plays a (usually harmful) role. Eventually, patient behavior, no matter how bizarre, loses the power to shock. That does not apply to the behavior of the staff. It’s still shocking when they begin to behave like they are crazy.

The story of The Baby in the Wonderbread Bag begins like so many stories of teen pregnancy, with a young girl who has successfully concealed her pregnancy from family and friends. In this case, the 16 year old girl also had a history of mental illness. She appeared in the emergency room complaining of intermittent abdominal pain. Because she looked well, she was advised to wait while patients who were seriously ill were seen before her.

No one paid her much attention until she went to the Ladies Room and blood was seen to flow from beneath the door. When Security broke down the door, the doctors found that the girl had given birth to a premature baby. She had stuffed the baby in a Wonderbread bag, and, at the moment Security had broken in, she was attempting to flush the baby down the toilet.

They rescued the baby from the toilet bowl and pulled him out of the plastic bag. The neonatologist rushed down from the neonatal intensive care unit and resuscitated the baby. He appeared to be about 7 weeks premature, and smaller than expected for this stage of pregnancy. Nonetheless he was healthy and vigorous, despite his brief time in the toilet, and was swept off to the NICU for further care.

That’s when the story gets weird.

Several days later, in my capacity as a chief resident in obstetrics, I was called to the weekly Social Service meeting to provide my input in difficult cases. When I arrived, I found that the Social Service staff calmly discussing whether the Wonderbread Baby should go home with his mother, as if it were perfectly reasonable that she had tried to flush her baby down the toilet. That shocked me.

It’s not that the Wonderbread Baby was the most bizarre thing we had ever seen; it didn’t even come close. The combination of youth, concealed pregnancy and mental illness is all too common at an urban hospital and the results are usually far more deadly. Indeed, even during my years of medical school and residency, the results of this toxic combination had been getting steadily worse.

When I started medical school, a baby born addicted to cocaine had been a standard reason for removing the child from the mother’s care. During the intervening years, cocaine addiction had become so common that it was no longer considered a reason to remove a child. We had been, in the words of a famous sociology essay, “defining deviancy down.” As abuse and neglect of babies had become more common, we kept readjusting the definition of abuse and neglect, so we could continue to send babies home instead of into the foster care system.

Even so, I was not prepared for a staff meeting with participants calmly discussing flushing a baby down the toilet as if it were some sort of reasonable response to an unwanted pregnancy. They asked for my input, and they got much more “input” than they had bargained for. I had been on call and awake for most of the previous night. Therefore, I exhibited somewhat less restraint than I might have otherwise.

“My input? MY INPUT?” I replied, my voice rising in volume, “Have you people lost your minds?”

“This teenager put her baby in a plastic bag and tried to flush him down the toilet!” I continued, “Is it really that hard to figure out that she should not be allowed to take this baby home?”

The lead social worker seemed defensive.

“You don’t have to get so angry about it,” she chided.

I wasn’t finished with my tirade.

“Evidently I do have to get angry, since you don’t seem to realize how bizarre it is to ask for input about whether flushing a baby down the toilet is a risk factor for abuse.”

The whole team looked hurt.

“It is a risk factor. It is a very big risk factor!” I went on. “I’m going to put myself on the line here and state unequivocally that anyone who tries to flush their baby down the toilet should not take that baby home.”

“Well, if you feel that way about it,” the team leader huffed, “then we won’t send the baby home with her.”

“Yes, I feel that way about it,” I huffed back.

The meeting ended on that less than cordial note.

Looking back on it, I can see that what filled me with anger and despair was not the fact that a teenager had tried to kill her baby. Mental illness and desperation are often a lethal combination. What filled me with despair was that seemingly sane people were discussing whether or not flushing a baby down the toilet was acceptable, as if the conclusion might be in doubt.

Don't get screened for prostate cancer

What’s worse than being rendered impotent and incontinent by prostate cancer treatment? Being rendered impotent and incontinent by prostate cancer treatment that was unnecessary.

Two large, well-conducted studies revealed what doctors have suspected for quite some time. Screening for prostate cancer using the PSA (prostate specific antigen) blood test does not save lives. In fact, PSA screening for prostate cancer does more harm, including impotence and incontinence, than good. Due to their importance, both studies were released online today by the New England Journal of Medicine, in advance of their publication next week.

According to the study, Mortality Results from a Randomized Prostate-Cancer Screening Trial:

From 1993 through 2001, we randomly assigned 76,693men at 10 U.S. study centers to receive either annual screening(38,343 subjects) or usual care as the control (38,350 subjects).Men in the screening group were offered annual PSA testing for6 years and digital rectal examination for 4 years. The subjectsand health care providers received the results and decided onthe type of follow-up evaluation. Usual care sometimes includedscreening, as some organizations have recommended. The numbersof all cancers and deaths and causes of death were ascertained…

Results … After 7 yearsof follow-up, the incidence of prostate cancer per 10,000 person-yearswas 116 (2820 cancers) in the screening group and 95 (2322 cancers)in the control group. The incidence of death per 10,000 person-yearswas 2.0 (50 deaths) in the screening group and 1.7 (44 deaths)in the control group …

Conclusions After 7 to 10 years of follow-up, the rate of deathfrom prostate cancer was very low and did not differ significantlybetween the two study groups.

The two graphs below present the results of the study. The graph on the left represents cases of prostate cancer and demonstrates that PSA screening was much more effective in diagnosing prostate cancer than examination alone. The graph on the right represents deaths from prostate cancer. Despite a significant increase in diagnosis of prostate cancer in the PSA group, there was minimal if any reduction in deaths from prostate cancer.

 

While deaths from prostate cancer were not decreased by PSA screening, serious side effects were dramatically increased.

Risks incurred from a screening process can result from thescreening itself or from downstream diagnostic or treatmentinterventions. In the screening group, the complications associatedwith screening were mild and infrequent… Medical complications from the diagnostic processoccurred in 68 of 10,000 diagnostic evaluations after positiveresults on screening. These complications were primarily infection,bleeding, clot formation, and urinary difficulties. Treatment-relatedcomplications, which are generally more serious, include infection,incontinence, impotence, and other disorders…

Why did the PSA screening test fail to save lives? The PSA screening test did diagnose more cancers than routine examination, so the test definitely works. The apparently paradoxical outcome is due to the nature of prostate cancer itself.

Most men will develop prostate cancer if they live long enough. However, most prostate cancers are very slow growing and usually do not kill the patient. A man with prostate cancer generally dies of some other cause long before the prostate cancer becomes life threatening. Therefore, the PSA test diagnoses many cases of prostate cancer that do not need to be treated as well as a few cases of prostate cancer that are very aggressive. Not only is there no benefit to diagnosing the slow growing prostate cancers, but there seems to be very little benefit to diagnosing the aggressive cancers early, since some do not respond to treatment even when administered in the early stages.

The second study,  Screening and Prostate-Cancer Mortality in a Randomized European Study, showed a very small decrease in deaths associated with PSA screening. That decrease came at a very high price:

To prevent one prostate-cancerdeath, 1410 men (or 1068 men who actually underwent screening)would have to be screened, and an additional 48 men would haveto be treated.

For every death prevented, 1068 men had unnecessary biopsies, and 48 men had unnecessary treatment. That’s a problem, and it is made far more serious by the life altering side effects of treatment, impotence and incontinence.

Taken together, both studies provide convincing evidence that PSA screening for prostate cancer should be stopped. Too many men are seriously harmed, and very few if any men derive any benefit. The take home message for patients: Don’t get PSA screening for prostate cancer.

Condoms are not the answer? Only if you're asking the wrong question.

On the long running game show Jeopardy, contestants are given the category and the answer, and they have to provide the correct question. So, for example, if the category were HIV/AIDS, and the answer was “condoms,” the correct question would be “What is the safest, most cost effective way to prevent the spread of the deadly disease?”

Evidently the Pope does not know how to play Jeopardy. MSNBC, reporting on the Pope’s arrival in Cameroon at the start of a trip to Africa:

Condoms are not the answer to Africa's fight against HIV, Pope Benedict XVI said Tuesday as he began a weeklong trip to the continent. It was the pope's first explicit statement on an issue that has divided even clergy working with AIDS patients…

"You can't resolve it with the distribution of condoms," the pope told reporters aboard the Alitalia plane heading to Yaounde. "On the contrary, it increases the problem."

That is simply flat out false. Extensive research has shown that condoms are the most effective, the safest, and the least expensive way to prevent transmission of the deadly virus. According to Effectiveness of HIV Prevention Strategies in Resource-Poor Countries, published in the journal AIDS:

Studies overwhelmingly demonstrate that condoms are highly effective in preventing HIV transmission. A workshop co-sponsored by four government agencies responsible for condom research, condom regulation, and HIV/AIDS and sexually transmitted disease prevention programs (US Agency for International Development, Food and Drug Administration, Center for Disease Control and Prevention, National Institutes of Health, Bethesda, Maryland, USA) was held in June 2000 to evaluate the published evidence establishing the effectiveness of latex male condoms in preventing HIV/AIDS and other STDs. The workshop panel concluded that consistent users of the male condom significantly reduced the risk of HIV infection in men and women. In fact, condoms appear on average to be at least 90% effective in preventing HIV when used consistently and correctly…

A 90% effectiveness rate is very effective indeed. In contrast, sexual abstinence, the Pope’s preferred method for preventing transmission of HIV has been found to be totally ineffective. A 2007 paper in the British Medical Journal reviewed the effectiveness of abstinence programs in several countries:

…Compared with various controls, no programme affected incidence of unprotected vaginal sex, number of partners, condom use, or sexual initiation. One trial observed adverse effects at short term follow-up (sexually transmitted infections, frequency of sex) and long term follow-up (sexually transmitted infections, pregnancy) compared with usual care, but findings were offset by trials with non-significant results…

Moreover, the use of condoms is safe, easy to teach, and cost effective. In contrast, not only is abstinence ineffective, it is impractical because many HIV positive people are married to HIV negative partners. Abstinence would mean that sex was impossible even within marriage.

The Pope’s response “abstinence” is clearly the answer to an entirely different question: “What method of HIV prevention (which doesn’t even work) is consonant with Catholic doctrine?” The Pope is obviously not interested in the actual effectiveness of the method, and he does appear to be disturbed that millions are dying for lack of effective prevention strategies. That has not escaped the professionals who are striving to decrease the horrific impact of AIDS in Africa:

Rebecca Hodes with the Treatment Action Campaign in South Africa said if the pope was serious about preventing new HIV infections, he would focus on promoting wide access to condoms and spreading information on how best to use them…

"Instead, his opposition to condoms conveys that religious dogma is more important to him than the lives of Africans," said Hodes, head of policy, communication and research for the organization…

The Pope is entitled to his own agenda, but he is not entitled to be intellectually dishonest. Condoms are clearly the answer to Africa’s fight against HIV, if the concern is preventing transmission and death. When is abstinence the answer? Only if the question is how to die Catholic in the midst of an AIDS epidemic.

We lied and the patient died

While I have lots of unpleasant memories of my training, I don’t have a lot of regrets. There is one case, though, that I cannot forget: I went along with care that I believed to be unethical. I can rationalize it by taking into account that I was the most junior member of the team, with no authority to countermand the patient’s primary doctor or anyone else. I can rationalize it by acknowledging that even today, decades later, I don’t have any better idea of how I should have handled it. Nevertheless, I can’t help thinking I will always regret my participation.

I was on the medical service at the time and was taking call on a Saturday. I was paged to the Emergency Room to bring up a new patient. Mr. Rivera (not his real name) was a 38 year old Hispanic man who had come to the ER for a simple sore throat, and gotten a devastating diagnosis.

Mr. Rivera had had lymphoma when he was 18 and had been treated aggressively with chemotherapy. He was a success story; the chemotherapy had put him into remission and he had lived the intervening years free of any health problems. That’s why he was not particularly worried about his sore throat. He thought it might be due to strep.

The sore throat was caused by strep, but during the evaluation, a routine blood count was dramatically abnormal. Mr. Rivera had a very aggressive form of leukemia, a known long term side effect of his lymphoma therapy. Given the nature of his leukemia, the chances of remission, let alone a cure, were very remote.

Mr. Rivera had always known that leukemia was a potential side effect of his successful treatment. He also understood that it was an extremely serious disease. That’s why, in our very first meeting, Mr. Rivera wanted to discuss his prognosis and insisted on making clear his wishes about treatment and death.

Mr. Rivera had lived through multiple rounds of aggressive chemotherapy to treat his lymphoma. He dreaded more chemotherapy, but if there was a reasonable chance that he would go into remission, he was willing to undergo more chemotherapy. However, if, as he suspected, the prognosis was grim, he would refuse chemotherapy so he could return to the Caribbean island where he had been born, and, as he put it, “die on the beach with his family around him.”

I was not encouraging in the least about his prognosis, but I would not make a definitive statement because, as an intern, I was not allowed to interfere with the primary physician’s relationship with the patient. All information about treatment recommendations and prognosis was to be left to the primary physician. In this case, since the patient had had no contact with any oncologist in the previous 15 years, he was assigned an oncologist from our staff.

I was relieved that I was under no obligation to give the patient the grim news. It was early in my career, and I had no experience telling a patient that he was probably going to die. In my naivete, I assumed that the oncologist would tell the patient the truth, and that the patient would soon be heading to the Caribbean to live out his remaining days with his family.

I had not reckoned on the fact that oncologists can often be very unrealistic. Some oncologists believe very strongly that even the most remote chance of a remission should be pursued aggressively. That generally dovetails nicely with the fact that most patients are desperate to live and are willing to undertake any treatment, not matter how painful or difficult.

Mr. Rivera had already made it clear, though, that he was not desperate to pursue any chance. He understood what it meant to have a potentially fatal illness; it had happened to him before. He understood was aggressive treatment meant; he had already experienced it once before. He was adamant that this time he was not willing to grasp at a tiny chance or remission and probably die in the hospital due to the effects of the cancer and the chemotherapy. If the chance of remission was very small, he wanted to go home and die with his family.

Visiting Mr. Rivera the next day I intended to discuss his plan to forgo chemotherapy and return home. I was completely unprepared to learn that his oncologist had told him that he had an excellent chance to be treated successfully and that it would be a mistake to refuse treatment. As Mr. Rivera recounted this information, he watched my face carefully to see my reaction. He was clearly suspicious of the information he received from the oncologist.

I knew what was coming next and I dreaded it. Mr. Rivera asked if I agreed with the oncologist. Remaining carefully impassive, I told Mr. Rivera that I didn’t know nearly as much as the oncologist and therefore, I couldn’t really answer the question. He seemed unsatisfied, but he did not press me.

I sought out the resident physician, my immediate superior, and confronted him. Wasn’t it true, I demanded, that Mr. Rivera’s prognosis was exceedingly grim? The resident acknowledged that the chance of remission was remote. I wanted to know what we should do next. The resident was shocked. What did I mean by “what we should do?” We shouldn’t do anything. It was not up to us to correct the oncologist or, worse, to undermine him. This oncologist was known to be extremely aggressive and there was nothing we could do about it.

I argued, but he had an answer for every argument, reminding me that we could only get into trouble for pursuing this issue. To my everlasting regret, I took his advice.

Mr. Rivera had a rough time with his first course of chemotherapy. He was very sick and his immune system virtually shut down. As a result, he developed an abscessed tooth, and despite powerful antibiotics, the infection spread deep into his jaw. He was in terrible pain, poorly controlled with large amounts of narcotics.

As the days went by, Mr. Rivera spent his time vomiting, shaking with chills, and writhing in pain. Because of his damaged immune system and the chemotherapy, he was unable to fight the infection and it spread further even though we were treating it as aggressively as we possibly could. Ultimately, the infection spread to bloodstream, and three weeks after he was admitted, Mr. Rivera died without ever leaving the hospital and without ever saying goodbye to his family.

The oncologist felt that we had treated Mr. Rivera appropriately. We had given him every chance to go into remission and have a longer life. I thought we betrayed Mr. Rivera in the worst possible way; we lied to him and we deprived him of the opportunity to die the death he wanted, surrounded by the people who were important to him. What really happened is that the oncologist had substituted his preferences for Mr. Rivera’s preferences. The oncologist simply could not imagine or understand that Mr. Rivera could want something different than he would want in the same situation, and so he ignored him.

In the grand scheme of things, Mr. Rivera would have died anyway, and I was a minor character in the drama that played out. But I cannot help but think that I colluded in a theft. We stole Mr. Rivera’s dream of a peaceful death and replaced it with vomiting, fever and pain. We had no right to do what we did; we were guilty of a terrible crime, not a legal crime, but a crime all the same.

She used WHAT as a dildo?

An amazing thing about practicing medicine is that every time you think you’ve finally seen everything, you see something new. Not just something that you’ve never seen before, either, but something that you could not have even imagined.

Consider the case of the young woman who came to the urgent care clinic at our health center one evening. The woman was complaining of severe genital pain; so severe, in fact that she could only walk with her legs widely spaced a part.

That walk is a classic sign of a Bartholin’s gland abscess, a fairly common infection of the glands at the outer edge of the vagina. Bacteria can take up residence in the gland and cause an abscess. Even though the abscess is small, it is extremely painful. The wide stance walk is almost a guarantee of the diagnosis. The triage nurse explained the likely diagnosis to the patient and the fact that the abscess could be easily treated. Rather than looking relieved, the patient appeared embarrassed.

A PA (physician’s assistant) saw the patient, took the history, which was unremarkable, and started the exam, which was quite remarkable. The patient did not have an abscess; she had what appeared to be shallow, but extensive burns around and extending into her vagina. The physician’s assistant was so flustered that she excused herself to call me.

I could not leave the hospital to go to the clinic, because I had a patient in labor who would deliver soon, so I had to rely on the PA’s description. The description certainly fit with that of burns, but I had never seen burns of that kind in any area. Yes, I had seen chemical irritations of various kinds, but it didn’t seem like an injury of this sort was likely to be caused by a new bath soap or detergent.

The PA insisted that the patient’s history was unremarkable, and I insisted that she had not gotten the complete history. It wasn’t her fault; the patient simply didn’t want to reveal what happened. I suggested to the PA that she question the patient about domestic violence, since I had certainly seen vaginal injuries related to violence in the past. I also pointed out that it was important to explain to the patient that we needed to know what happened in order to treat her appropriately.

I was dreading the return phone call, and I imagined all sorts of horrible things that might have happened, but I failed to imagine what really did happen. When the PA called again, she was laughing.

“You’re not going to believe this,” she said, “but the patient accidentally did this to herself with a dildo.”

She was right. I couldn’t believe it. What could the patient have used? I’d heard of all sorts of things in the past: fruit, candles (unlit), and glass bottles, among others, but nothing that could cause burns.

“She used a deodorant stick!”

The patient had used the actual stick of deodorant, which she had pried out of the container (for who knows what reason) and the burns she had were serious chemical burns. We treated her by washing the area to remove any trace of the chemicals and applying the salve typically used for treating burns from gynecologic laser surgery. Oh, and lot’s of pain medication, too, for obvious reasons.

Her treatment plan included her medications, an appointment for follow up, and a recommendation: should she feel the need to use a dildo in the future, she should avoid deodorant, or at least leave it in the container with the cap still on.

The organic food scam

It’s the holy grail of contemporary marketing: getting consumers to pay more for something that is worth less. When it comes to organic food, marketers have hit the jackpot.

How have consumers have been enticed to pay more for products that are potentially less safe than their conventional counterparts? The organic food scam depends on tapping into cultural myths about nature, playing upon widespread misunderstanding of risk, and flattering consumers into believing that those who choose organic food are “empowered.”.

The word “natural” is widely used to sell products. In Packaging as a Vehicle for Mythologizing the Brand researchers explore the connotations of “natural” in contemporary culture and the ways in these connotations are exploited to sell products.

Marketers of organic products depict the modern world as a deeply distorted reflection of what it originally was - the garden before agro-chemical technology. While the values of the past include family, tradition, authenticity, peace, and simplicity, the current era is associated with broken family ties that need to be restored, scientific "advances" that pose threats, constant pressure on the well-being of humans, and unnecessary complexity in everyday life.

Consider the concept of "naturalness":

Naturalness appears as a rich emotional construct that connects with positive contemporary images of nature... People do not want to remember that nature can also be destructive as in deadly hurricanes and poisonous mushrooms ... In a natural health context, Thompson also finds nature to be a positively framed powerful mythic construction; and his informants attribute magical, regenerative powers to nature. They firmly believe that aligning with what nature has to offer for one’s health lets them assert control over their lives and bodies versus losing control by being complicit in a scientized medical system.

There is nothing inherently better about “natural,” but contemporary mythology assumes that there is. The organic food industry exploits this mythology to imply that organic food is inherently better.

In addition, marketing professionals exploit the lack of understanding about risk. We routinely panic about insignificant health risks (high tension wires, X-rays) and routinely ignore large health risks (driving without a seatbelt, tanning). Hence, consumers routinely obsess about insignificant health risks that have never even been shown to occur (pesticides, hormones) and routinely ignored large health risks (foodborne illness caused by bacteria like E. coli and salmonella in the animal waste used as fertilizer) that have been associated with widespread outbreaks of illness and even death.

David Ropeik discusses the causes of misperception of risk in his article The Consequences of Fear. Two factors, control and origin, are especially relevant for understanding the misperception of food risks.

Risks over which we feel as though we exercise control are routinely perceived to be smaller than risks that are imposed from outside.

… Roughly 20% of Americans still do not wear safety belts in motor vehicles… [T]his is, in part, because we have a sense of control when we are behind the wheel, and the risk of crashing is both familiar and chronic—factors that make risks seem less threatening...

In other words, people not only tolerate the substantial risk of not wearing a seatbelt, but they perceive the risk to be relatively small, when, in fact, it is relatively large compared to risks that evoke more fear, like the risk of a plane crash or a terrorist attack. Similarly, consumers of organic food tolerate the real and substantial risk of illness from pathogens in manure, but fear the effects of pesticides, which have never been shown to cause illness.

Origin is important to consumers, too. The risks of technology are widely perceived to be greater than risks from nature, neatly dovetailing with the culture mythology surrounding “nature.” For example:

...many people fail to protect themselves adequately from the sun, in part because the sun is natural … However, solar radiation is widely believed to be the leading cause of melanoma, which will kill an estimated 7,910 Americans this year.

Hence the imagined and undocumented (and possibly non-existent) risk of pesticides in food are perceived as greater than the real and documented risks of serious illness and death associated with the bacteria found in manure fertilizer.

Ultimately, these myths are joined in service of the over-arching myth, that of the "enobled and empowered" consumer:

... [A]ll the significance attached by [marketing professionals] to the products transforms otherwise powerless consumers into the powerful marketplace players. As a result, newly empowered consumers can temporarily escape imposed world conditions by shaping their personal myths and servicing their individual lives. Thus, myths of the past are meaningfully used to serve the present.

Marketers of organic food are not allowed to claim that the food is safer or more nutritious, since it is neither. However consumers are led to believe that by choosing “natural” food grown with “no pesticides,” they are making an “empowered” choice of safer and healthier food. In that way, they can be induced to pay more for food that may actually be worth less.

No, Ma'am, your 5 year old did not get gonorrhea from you

Sometimes an event is so ineffably sad that it almost defies comprehension. That was how I felt after a phone call on a bright Saturday morning in my last year of medical training.

As a chief-resident in obstetrics and gynecology, I was responsible for handling phone calls from patients who did not have a gynecologist of their own. On that Saturday morning, I took a call from a local women who was in her early 20’s. She sounded distraught, and at first, I couldn’t understand why she was calling.

“It’s about my 5 year old daughter,” she said. “I’m having a disagreement with her doctor and I want you to talk to him.”

“Okay,” I replied warily, “but I’m a gynecologist, so I’m not sure I could be very helpful.”

“No, no, you’re the right kind of doctor,” she insisted. “It’s a female problem.”

The mother proceeded to describe her daughter’s symptoms, vaginal itching and a greenish, malodorous discharge. The little girl’s pediatrician had examined her and gently taken a sample of discharge to look at under the microscope. When he returned to talk with the mother, he was very grim.

The microscopic evaluation of the discharge had reveal that the little girl was suffering from gonorrhea. It would not be difficult to treat; a simple shot of antibiotics should do the trick, but it could not end there. The pediatrician enquired if the mother knew where her daughter had contracted gonorrhea. It could only have come from sexual contact, which meant that someone had been sexually abusing the child.

The mother was aghast. She insisted that there was some mistake. There was no way her daughter could have been abused by anyone. The doctor disagreed.

The pediatrician informed her that, under the law, he had no choice but to file a “51A.” The mother understood that a 51A was a legal document alleging child abuse. It would set in train an investigation by child protection officials, and might result in her child being removed from her custody. The mother protested, but the doctor was adamant.

Now she wanted to know if it were possible that her daughter’s vaginal infection was something other than gonorrhea. I explained that seeing the bacteria under the microscope was quite reliable, but, in any case, the doctor had taken a culture. That meant that the laboratory would also identify the bacteria. The culture results would be virtually 100% accurate, and, I cautioned her, would almost certainly confirm the diagnosis of gonorrhea.

“Well, even if she has gonorrhea,” inquired the mother, “couldn’t she have picked it up from a towel or a toilet seat?”

I explained that that was highly unlikely. The gonorrhea bacteria could not survive outside the body for very long. Neither towels nor toilet seats were likely to be the source of gonorrhea.

Suddenly, her voice brightened.

“I know, I know,” she said, “My little girl got it from me!”

“From you?” I didn’t understand.

“Yes, from me,” she replied. I had gonorrhea a few weeks ago. My daughter and me, we take baths together all the time. That’s how she must have gotten it.”

She was quite relieved. “I knew it,” she declared. “No one has been messing around with her. She caught it from me.”

I wasn’t so sure.

“You had gonorrhea?” I asked with trepidation. “How did you catch gonorrhea?”

I knew what was coming.

“Oh, I caught it from my boyfriend. He had it and he gave it to me. We both got antibiotic shots and now it’s gone.”

My heart sank.

“No, Ma’am, your daughter didn’t get gonorrhea from you.”

“She didn’t? Of course she did,” the mother protested. “Who else could have given it to her?”

I tried to be gentle, but how can you gently tell someone that her boyfriend has been sexually abusing her daughter?

The mother burst into tears. “That means the doctor is right, doesn’t it?”

“Yes, he is probably right.”

The mother continued sobbing. “I’m sorry,” she said. “I’m so sorry I bothered you. I just thought that there had to be some other way.”

I assured her that it had been no bother, though I had been shaken to the core.

“I’ve got to go now,” she wept. “I can’t talk anymore. I don’t understand. I just don’t understand. What am I going to do now?”

What if the screening test hurt more people than the cancer?

Every so often I get an e-mail forwarded to me recounting the story of a friend or acquaintance recently diagnosed with ovarian cancer. The cancer is almost always far advanced, and the prognosis is very grim.

The e-mail reveals that the cancer might have been diagnosed much earlier if only the woman had been given a simple blood test (CA125 test) or had an ultrasound. Readers are exhorted to press their doctors for both tests, so that if they develop ovarian cancer, it can be diagnosed early, when treatment is more likely to be successful. The e-mail makes it sound like the means of diagnosing ovarian cancer is here, but doctors are ignoring the possibilities.

The situation is far more complicated. Yes, a simple blood test or an ultrasound can lead to early detection of ovarian cancer. Unfortunately, though, it also leads to tremendous numbers of unnecessary surgeries and the complications that result. In fact, it is entirely possible that screening for ovarian cancer is more dangerous than not screening for ovarian cancer.

That is the central message of a new study published today in Lancet Oncology, Sensitivity and specificity of multimodal and ultrasound screening for ovarian cancer. You might not realize that if you read newspaper accounts of the study, which emphasize the number of cancers diagnosed. Many newspaper accounts don’t mention that for every woman diagnosed with ovarian cancer, many more had unnecessary major surgery and quite a few suffered serious complications as a result.

The study screened more than 100,000 postmenopausal women for ovarian cancer. Half had ultrasound and CA125 tests (multimodal screening); the other half had ultrasound alone. Ovarian cancer was detected in 87 women, 42 in the multimodal group and 45 in the ultrasound alone group. That sounds pretty good until you learn that in order to make those diagnoses, 942 women had surgery. In other words, 855 women had major abdominal surgery for no reason. Of those, 24 experienced major complications including perforation of an organ (requiring surgery for repair), hemorrhage, deep vein thrombosis, and pulmonary embolus.

There was a big difference in unnecessary surgery between the multimodal group and the ultrasound group. Of the 942 women who had surgery, 845 were from the ultrasound group. In other words, adding the CA125 blood test made the screening more accurate. Even so, for every woman in the multimodal group who had ovarian cancer, 2 additional women had surgery that they did not need. In the ultrasound group, for every case of ovarian cancer diagnosed, approximately 19 women underwent major abdominal surgery that was unnecessary.

Screening hurt far more women than were helped. For every woman who was diagnosed with ovarian cancer, 9 more had surgery that they didn’t need, and 2.8% of women who had unnecessary surgery sustained serious, life threatening surgical complications. That is a pretty dismal record for a screening test.

If we leave aside the ultrasound only group, the results in the multimodal group are far more encouraging. Only 97 underwent surgery, of whom 42 had ovarian cancer. As mentioned above, for every case of ovarian cancer diagnosed in the multimodal group, 1 woman had surgery that she didn’t need. Of those women who had unnecessary surgery, 4.2% sustained serious, life threatening complications.

What would happen if we instituted multimodal screening for all post menopausal women. For every 1 million women screened, 866 cases of ovarian cancer would be diagnosed, 1034 women would have unnecessary major abdominal surgery, of which 43 would sustain major, life threatening complications.

In addition, we do not know if the early diagnosis of ovarian cancer in these patients would improve outcome. Over half of the women diagnosed by screening already had advanced disease, so it is unlikely that screening improved their prognosis. Moreover, even early stage ovarian cancer is a dangerous disease, and many of these women are going to die anyway.

The ultimate value of a screening test is in lives saved, and that information is beyond the scope of this study. It is already clear, though, that for every life saved, 4 or more women will have unnecessary major abdominal surgery, some women will sustain life threatening complications, and inevitably, some women will die from complications of surgery that they did not need.

This study is large, comprehensive and well done, but it does not support mandatory screening for ovarian cancer. It demonstrates that large-scale screening is possible, and that early ovarian cancer can be diagnosed by screening. Unfortunately, it also shows that large-scale screening efforts results in substantial harm to more people than are helped. When the screening test is potentially more dangerous than the disease, it makes no sense to implement mandatory screening.

Does statutory rape discriminate against boys?

A sharply divided Massachusetts Supreme Judicial Court recently issued a ruling with head spinning legal and ethical implications. The question at issue: do statutory rape charges discriminate against boys? According to the SJC, that claim can be raised in a defense against the charge of statutory rape.

The facts of the case are not in dispute. According to The Boston Globe:

The case … involved a high school freshman football player who is accused of engaging in various sex acts from August to October 2007 with three girls. Two were 12, and the other was 11.

"None of the complainants reported being afraid of the boy's behavior," Chief Justice Margaret Marshall wrote for the majority.

The law on statutory rape is quite clear:

Whoever unlawfully has sexual intercourse … [with] a child under sixteen years of age shall … be punished by imprisonment in the state prison … [or] any term in a jail or house of correction …

Additional case law has further refined the requirements of the statute:

The offense of statutory rape … may be committed with or without any knowledge on the defendant's part of the age of the victim.

Consent is not a defense to a charge of statutory rape.

The only elements the Commonwealth must prove are (1) sexual or unnatural sexual intercourse with (2) a child under sixteen years of age.

Based on the facts of the case, and the law, the District Attorney charged the boy with statutory rape. There is no question that the acts occurred, no doubt about the age of the girls, and no defense in claiming that the acts were consensual. Therefore, the boy’s lawyer offered a novel assertion: Since all parties were under the age of consent, prosecuting only the boy is sexual discrimination.

The boy’s lawyer should be commended for offering a novel defense. The SJC should have their collective heads examined for agreeing with it.

The theory behind statutory rape law is that children under the age of 16 are incapable of giving legal consent to sexual activity. They may desire such activity, and they may be willing participants, but their consent carries no legal weight. That’s because they are too young to understand the implications of sexual activity, and, by virtue of their age, are easily manipulated by those who are older. Although the law traditional was originally intended to protect young girls, it has been extended to protect boys as well.

In recent years, the dramatic increase in teen sexual activity has led to a reappraisal of statutory rape laws. So called, “Romeo and Juliet” exceptions have been added in many states. Generally, these exceptions allow consensual sex between partners over age 15, provided that one partner is not substantially older than another. In states with “Romeo and Juliet” exceptions, sex between a 15 year old girl and her 17 year old boyfriend is not statutory rape, but sex between a 15 year old girl and her 45 year old softball coach would still be considered statutory rape, regardless of whether the girl consented.

The statutory rape laws are gender neutral. Sex between a 15 year old boy, and his 45 year old coach is also statutory rape. Most prosecutions for statutory rape are against men and boys, because the male is usually the older party and because the male often initiates the sexual contact. The Massachusetts SJC has essentially ruled that this disparity in charges is evidence of sexual discrimination.

The boy’s defense received the support of an amicus (friend of the court) brief filed by the Women's Rights Project and the Reproductive Freedom Project, which are part of the American Civil Liberties Union. According to ACLU lawyer Sarah Wunsch:

"We should not be enforcing the law based on stereotypical notions about girls as not being capable actors in the same way that boys are... They are doing what teenagers are doing today. They are fooling around sexually, and the girls are participants in the same way that boys are."

Wunsch said statutory rape laws are rooted in an old concept that a daughter was the property of her father. Echoes of that thinking can be found today when prosecutors criminalize sexual activity involving girls, she said.

"Our view is that there is still a very strong pattern of district attorneys charging based on the notion of having to protect girls," Wunsch said. "But girls can enjoy sex and be sexually active. They are not simply victims."

Have these people lost their minds? The three girls in this case are in elementary school! Claiming that girls in elementary school  “can enjoy sex and be sexually active” is a willful misrepresentation of everything we know about children and their decision making abilities.

It is instructive to consider why lawyers for the Women’s Rights Project are willfully misrepresenting the ability of young girls to give consent to sexual activity. In their minds, they appear to believe that they are striking a blow for women’s rights. Hence Wunsch’s mention of outmoded ideas of girls as the father’s property and women as incapable of enjoying sex.

In an effort to protect women, Wunsch, and the SJC are willing to sacrifice young girls. Both willfully ignore the contemporary pressure toward early sexualization of young girls, and the cultural pressure for girls to accede to the demands of boys, whatever those demands might be.

Moreover, the SJC and Wunsch willfully ignored the ages of the girls and the age difference between the girls and the boy. The boy was charged because he was older, significantly older. He was in high school; they were in elementary school. He was not charged because of repressive ideas about female sexuality, and it is disingenuous at best to make that claim.

This case is about child protection, not about female sexuality. Elementary school girls are incapable of giving consent to sexual behavior, period. Elementary school girls can and should be protected against the sexual advances of older boys and men, period. It is astounding that the majority on the SJC could not tell the difference. In their misguided attempt to advance women’s rights, and fight sexual discrimination, the SJC has willingly sacrificed young girls to the predatory advances of older boys and men.