A woman's history of vaginal orgasm is discernible from her walk

It's the lie that will not die. I'm referring to the notion that there are two types of female orgasm, vaginal and clitoral, and that vaginal orgasm is "superior." Not superior in the sense of being preferable to the woman experiencing orgasm (evidently a woman's opinion on the subject does not count), but "superior" in authenticity and intrinsic value.

I've seen a lot of supposed scientific research on this topic, some of it inane, some of it offensive and some of it simply amusing. After 25 years of regularly reading the woman’s health literature, I think I have identified the most ridiculous paper of all.

A woman's history of orgasm is discernible from her walk was published last year in the Journal of Sexual Medicine. Conducted jointly in at universities in Belgium and Scotland, the authors claim to have found:

The discerning observer may infer women's experience of vaginal orgasm from a gait that comprises fluidity, energy, sensuality, freedom, and absence of both flaccid and locked muscles. Results are discussed with regard to previous research on gait, the effect of the musculature on sexual function, the special nature of vaginal orgasm, and implications for sexual therapy.

And just what is the “special nature” of vaginal orgasm that inspired the research? The authors apparently believe:

Compared to women who have had vaginal orgasm (triggered solely by penile–vaginal stimulation), vaginally anorgasmic women display more use of immature psychological defense mechanisms, are less satisfied with their relationships, mental health, and life in general, and are more likely to suffer from global sexual dysfunction.

Really? If those claims were not absurd enough, the authors make a claim that is even more ridiculous:

The primary hypothesis in the present study is that clinical sexologists appropriately trained in the relationship between personality, sexology, and body movement will be able to differentiate between women with and without a history of vaginal orgasm purely on the basis of observing the women walking.

How did the authors test their hypothesis? They recruited 16 female psychology students who agreed to fill out a questionnaire and then consented to be videotaped walking 100 meters. According to the questionnaires, 7 women were vaginally orgasmic and 9 were vaginally anorgasmic.

Then (and this is the hard part), the videotapes were analyzed:

The basis for judgment was a global impression of the women's free, fluid, energetic, sensual manner of walking (with an emphasis on energy flow through the rotation of the pelvis and the spine). The raters conferred and agreed on the vaginal orgasm status of the women, and the results were recorded.

Wow, how scientific!

I am trying to stop laughing long enough to type the results. Here goes: The authors "diagnosed" 8 of the 16 women as vaginally orgasmic and they were only wrong 25% of the time. But, don't worry, they were probably right even though it appears they were wrong:

Although the couple of incorrect diagnoses could simply be that, it is also possible that in the case of the two false positives, it might be that the women have the capacity for vaginal orgasm, but have not yet had sufficient experience or met a man of sufficient quality to induce vaginal orgasm.

Why?

In addition to the possible anatomical issue of whether her man has a penis of sufficient length to produce cervical buffeting, and the issue of whether the man maintains his erection for a sufficient duration .., studies have indicated that women are most likely to have an intercourse orgasm with men displaying indicators of greater genetic fitness ...

Congratulations to the authors are in order. They have managed the rare feat of a stupidity trifecta. They concocted a stupid study to test a stupid theory and stupidly interpreted the results.

Hmmm, I wonder if you can discern the stupidity of certain sexologists by their walk. Maybe we could do a study to find out.

An open letter to homebirth advocate Jennifer Block

Homebirth advocate and author Jennifer Block just posted a long screed on RH Reality Check asking why homebirth midwives are not taken seriously as components of a reformed healthcare system. The reasons are obvious. Homebirth increases the risk of neonatal death. Homebirth midwives are grossly undereducated. Moreover, the Midwives Alliance of North America (MANA), the trade union for homebirth midwives, is doing everything legally possible to hide their own safety data from the public.

I posted a long comment on RH Reality Check. I have repeated it here in the form of an open letter since I'm not sure whether the comment will be allowed to remain on the RH Reality Check website:

Dear Ms. Block,

As you well know, homebirth increases the rate of neonatal death. When you interviewed me for several hours the summer before last, I provided you with the evidence, and I will provide it now for your readers.



1. All the existing scientific evidence, as well as all the state and national statistics show that homebirth increases the risk of neonatal death to almost triple the rate for hospital births of comparable risk. In fact, the most dangerous form of PLANNED birth in the US is homebirth with a direct entry (lay) midwife.

As this chart shows, the neonatal mortality rate for DEM (direct entry midwife, another name for homebirth midwife) assisted homebirth is almost double the neonatal mortality rate for hospital birth with an MD. This is all the more remarkable when you consider that the hospital group contains women of all risk levels, with all possible pregnancy complications, and all pre-existing medical conditions. An even better comparison would be with the neonatal mortality rates for CNM assisted hospital birth. The risk profile of CNM hospital patients is slightly higher than that of DEM patients, but CNMs do not care for high risk patients. Compared to CNM assisted hospital birth, DEM assisted homebirth has TRIPLE the neonatal mortality rate.

The chart shows the data for 2003-2004, but the data for 2005 has recently become available. Homebirth death continues to be far higher than death in the hospital for comparable risk women. In 2005 the neonatal death rates were CNM in hospital 0.51/1000, MD in hospital 0.63/1000 and DEM attended homebirth 1.4/1000.

2. Certified professional midwives (CPM) are grossly undereducated and grossly undertrained. Unlike certified nurse midwives (CNM), American homebirth midwives do not do not meet the standards of midwives in the Netherlands, Great Britain, Canada or Australia, or anywhere else. Indeed, American homebirth midwives including CPMs do meet the standards for licensing in ANY industrialized country in the world.

3. The Midwives Alliance of North America (MANA), the trade union for homebirth midwives, has been collecting its own safety data from 2001-2008. They have publicly offered that data to those who can prove they will use it for "the advancement" of midwifery. Even then, you have to sign a legal non-disclosure agreement not to show the data to anyone else. The data is NOT available to the public. It does not take a rocket scientist to suspect that MANA's OWN DATA shows homebirth with a CPM increases the risk of neonatal death.

Homebirth kills babies. It's as simple as that. And no amount of pretending or hiding the data from the public changes that fact.

Sincerely,
Amy Tuteur, MD

addendum: RH Reality Check removed this data from the comment section, as I suspected that they would. It's all true, and they know it. I guess they figured that it was more important to hide the data from the public than to acknowledge it.

According to Brady Swenson of RH Reality Check:

"You have posted this exact same comment many times on this site. The views contained in it have been debated many times. This post that you are copying and pasting onto any post that touches on the subject of homebirth is now being considered spam and thus has been removed..."

Here's what I wrote in response:

Indeed I've posted the same information before. That's because I believe that women deserve to know it. However it has never been debated. That's because there's nothing debatable about it. It simply a recitation of the facts.

Obviously, you are frightened by the truth. Rather than address the data and statistics that I posted, you simply deleted them. That's as good as acknowledging that I am correct. Thanks for the validation.

Those who condemn socialized medicine expect to get socialized nursing home care

While driving I listen to the local news station. Several times each hour there are commercials for financial services designed to protect the assets of “you or your loved one” should nursing home care be necessary. The advertisements mention the extraordinarily high cost of nursing care, and raise the specter that your money or your future inheritance might (gasp!) be used to pay for it. The planners offer guaranteed ways to protect (i.e. hide) your assets so “you or your loved one” can enter a nursing home, but still keep the money.

As one such service explains:

The Process of Nursing Home Planning is the formulation of a plan that provides for a loved one’s nursing home care while preserving their assets for either their spouse’s use or their beneficiaries' inheritance.

Evidently, we believe in socialized nursing home care.

We believe that nursing home care for the elderly should be free and the government should pay for it. Not just free for those who cannot afford to pay, but free for those who can afford to pay. And not just free, but unlimited in both price and duration. How is that to be accomplished? Why the government will pay, of course.

According to CDC data, the government already does pay. Close to two thirds of elderly nursing home residents are supported by Medicare and Medicaid.

This curious notion rests on several assumptions. We apparently assume that nursing home care for the elderly is a right. We know it is extraordinarily expensive so we assume that no one can or should pay for it out of pocket. And finally, we assume that the taxpayer should foot the bill.

Wait! That reminds me of something. Ahhh, yes, the dreaded “socialized” medicine.

Many Americans cannot abide the idea of a health care system predicated on the notions that healthcare is a right; that it is extraordinarily expensive so no one can or should pay for it out of pocket; and the bill should be sent to the taxpayer. Yet they expect that the care of the dependent elderly should be fully socialized.

It’s ironic that in attempting to craft a more equitable healthcare system and one that holds down costs, the most socialized and one of the most expensive aspects of medical care is entirely off the table. No one even dares to question the astronomical government expenditures on nursing home care or the fact that the system is essentially socialized.

The elderly are not more deserving than the rest of us. If they are entitled to healthcare than everyone is entitled to healthcare. In fact, as a justice issue, those who have not yet grown old are more entitled to the healthcare that will allow them to grow old than the elderly are entitled to the healthcare that allows them to grow older.

To those who oppose "socialized" medicine, consider: If your mother is entitled to socialized care, why aren’t your grandchildren deserving of the same benefit?

Birth junkie

What is a birth junkie and why is she obsessed with other women's births?

Many if not most homebirth midwives, doulas and, sanctimommies are quick to tell everyone that they are "birth junkies." They consider it a boast, but in reality, it is evidence of serious shortcomings.

Kathy at Woman to Woman Childbirth Education explains proudly that a birth junkie has "an infatuation bordering on addiction (if not actually there) for birth and all things related to it." She continues:

You might be a Birth Junkie ...

·if when you’re discussing something related to birth, you receive those polite but puzzled looks… right before your conversation partner moves away ...
·if you have birth-related artwork somewhere in your house (includes placenta pictures and belly casts, etc.)
·if you currently have or ever did have a placenta in your freezer
·if you have ever consumed placenta ...
·if you've ever gone to the bookstore and hidden "What to Expect When You’re Expecting" (or some other similar non birth-junkie book) and replaced it with some pro natural-birth book ...
·if someone tells you she "had to have" a particular intervention and you can come up with several alternatives that were never mentioned to her ...
·if someone tells you her baby is breech and you give her names (bonus points if you know phone numbers) of chiropractors skilled in the Webster technique or people who can perform moxibustion
·if you encourage your children, especially young children, to watch birth videos ...

That's not even the complete list. It's less than half, but it highlights the serious problems with the concept.

1.Being a birth junkie (like being a Sanctimommy) involves butting into other women’s lives inappropriately. Birth junkies relish demeaning other women; she insists (without any evidence, of course) that any interventions another woman had were unnecessary, and any that she might be contemplating, such as C-section for breech, are unnecessary, too. As a special touch, they cheerfully recommend idiocy. Moxibustion for breech (I am not making this up) involves burning a small bundle of leaves at the tip of the 5th toe; this is supposed to cause the baby to turn to the head down position.

2.Birth junkies fetishize certain aspects of the birth process, and the weirder the fetish, the better. As Kathy makes clear, birth junkies fetishize the placenta. That includes making ink prints of it, keeping it indefinitely, and, or course, eating it.

3.Birth junkies insist on foisting their obsession inappropriately on others. They bore and offend other adults, and they insist that their children "especially young children" be exposed to the object of their obsession.

Others have noticed the pathological nature of the obsession. Barbara Katz Rothman, and sociologist and supporter of homebirth, spoke at last year’s conference of the Midwives Alliance of North America (MANA). The presentation was "Birth Junkies: Working Through Our Relationship to Birth: Who owns the birth experience? Strategies for maintaining a non-addictive relationship with midwifery, responding to clients concerns about their own birth addiction, and ways of responding to the “birth junkie” term in the birth/midwifery community."

Being obsessed with birth, one's own births and the births of others, is pathological. And being a birth junkie has nothing to do with birth, with babies and certainly has nothing to do with helping other mothers. The women who are birth junkies suffer from a crippling lack of self-esteem. Their only "achievement" is the faux achievement of having an unmedicated, and preferably an outlandish, birth. Like the adult still talking about his SAT scores 20 years after the fact, birth junkies need to continually remind themselves of their "achievement" by obsessing about it, demeaning other women, and controlling other women’s births.

Homebirth midwives are just birth junkies who took it a step further. They are birth junkies who couldn’t manage to get into or through a college level midwifery program, so they decided to simply pretend that they were midwives. They made up their own certification, heavy on the inanity, and entirely lacking the education and experience that are necessary to be a competent midwife.

Most have no interest in a real midwifery program because being a birth junkie is not about birth and has nothing to do with preventing and managing complications. It’s all about them and their constant need for validation. Rather than being proud of their obsession, homebirth midwives who are birth junkies should be questioning it. If they truly care about women and babies, they owe it to them to get real midwifery training (the kind that would be recognized in other first world countries) instead of simply pretending that they are midwives. And if all they care about is boosting their own self-esteem, they should still get real midwifery training. That is a real accomplishment to be proud of.

The most important thing I learned in medical school

Drum roll, please.

After 4 years in medical school, 4 years of internship and residency, the single most important thing I learned had nothing to do with physiology, sophisticated tests, or complex surgical procedures. The most important thing I learned is ...

Some people have good luck and some people have bad luck.

I was reminded of it yet again while reading Michael Winerip’s piece, My Heart Messed With My Head, in yesterday's New York Times. Winerip writes about his efforts to avoid his family history of heart problem, and his recent angioplasty to clear a blocked coronary artery:

I'm ... confused. I've had so many advantages my father's generation did not — medication, diet, exercise, not smoking — and yet, my first heart episode came at almost the same age as Dad's.

It's not surprising that Winerip is confused. The deeply entrenched conventional wisdom about health is that our health is under our control. Eat right, exercise a lot, practice preventive care measures, and you can live virtually forever. The dirty little secret is that our health is not under our control. The single most important factor is the one that people don't want to talk about: luck

No one wants to die, so we have created the comfortable fantasy that preventing death is within our power as individuals. We pretend that we can prevent cancer and heart disease. We pretend that most health problems are caused by behaviors like smoking and drinking alcohol to excess. We pretend that the bad things that happen to other people won't happen to us because we don't smoke, we don't drink, we eat right and get plenty of exercise.

The sad and scary fact is that many aspects of our health are beyond our control. Even the behaviors that have been demonized, like smoking and drinking, are not as amenable to control as we like to pretend. Most adults who are smokers wish that they could stop. Most alcoholics are filled with self-loathing about their drinking. They don't stop those behaviors because they are addicted, and addiction, too, can be a matter of luck.

Winerip asks Dr. Alice Jacobs, cardiologist and professor of medicine, why he hasn’t been able to avoid heart disease even though he did everything that was supposed to prevent it.

Innovations that boomers like me have benefited from — cholesterol drugs (20 years); blood pressure medication (25 years); stress test/nuclear scan (25 years); stents (15 years); medicated stents (5 years) — have all most likely contributed to improved mortality rates, Dr. Jacobs said.

In 1950, according to the Centers for Disease Control and Prevention, 587 Americans per 100,000 died of heart disease; by 2006, the number was 200...

But on the micro level, individual by individual, it's more fuzzy. "You can modify the major risk factors, but you can't modify family history," Dr. Jacobs said. The presence of coronary disease in a close relative younger than 55 for men increases heart disease risk.

In other words, Winerip could not escape the bad luck of having a strong family history of heart disease.

The deeply held conviction that most if not all disease can be prevented by personal behavior strikes me as the updated version of old belief that disease is God's punishment. Both are medical versions of blaming the victim. The person who is sick deserves to be sick, either because God willed it or because he brought it upon himself by his own bad behavior.

But Michael Winerip did not cause his own heart disease and he could not prevent it. That’s because our genes are not under our control. He was unlucky to have a family history of heart disease and he could not escape it, not matter how fast or how far he ran.

Of course behaviors can be risk factors, and those risk factors should be modified whenever possible, but most diseases are not caused by modifiable risk factors. Genetics, or viruses, or bacteria, or other non-modifiable factors cause them. Despite the ongoing hysteria over environmental causes of cancer, it is almost certain that cancer is caused by genetic errors that are inherited or occur naturally as a result of living a long life. People do not get multiple sclerosis, juvenile diabetes, polycystic kidney disease or a plethora of other diseases because of their behavior. They get them because they have bad luck.

It’s time to give up the notion that people "deserve" their illnesses and that the rest of us can prevent illness if we just try hard enough. We should stop taking credit for good health, and thank our lucky stars.

The education of a homebirth midwife

Homebirth midwives like to trade on the excellent reputation of American nurse midwives and European midwives. It is a deception because it implies that homebirth midwives have the same education and training as other midwives. Nothing could be further than the truth.

The American nurse midwifery degree is a masters level degree. The European, Canadian and Australian midwifery degrees are college level degrees. Homebirth midwifery is a post high school certificate.

Consider the curriculum for certification at Birthingway School of Midwifery. Required courses include:

Botanicals I and I
Plant Medicine I, II and III
Homeopathy
Chinese Medicine
Other Modalities: Introduction to a variety of alternative healing modalities including chiropractic, flower essences, and aromatherapy.

So out of 42 required courses, 8 are complete garbage, unscientific, and inane. The remaining 34 required courses include:

Medical terminology - simply learning definitions.
Midwifery culture
3 courses about communicating with patients
Running a midwifery practice

Of 42 required courses, 14 (of which 8 are a total joke) have nothing to do with delivering babies.

Some of the electives are truly bizarre:

Birth Stories in Life and Literature - Read, write, and tell birth stories while learning and exploring effective storytelling techniques.

and my personal favorite:

Introduction to Vibrational Healing - Discussion of vibrational medicine and how it relates to health and health from the center outward to the planet. Course focus is on astrological medicine and gemstone energy within midwifery. Didactic knowledge is integrated with experiential, hands-on learning and observation.

The course requirements for a degree in midwifery are pathetically inadequate and nothing short of appalling. Plant medicine? Homeopathy?? vibrational healing??? It sounds like some sort of joke. Unfortunately, this is what passes for "education" among direct entry midwives.

How about clinical experience? The following is a comparison of the clinical requirements for European midwives and homebirth midwives:

EU midwife------------------------- homebirth midwife

100 ----- pre-natal examinations----- 75

40 ----- deliveries----- 25

40 ----- caring for high risk patients----- none

100 ----- postpartum patients----- 40

40 ----- newborns who need special care----- none

So when it comes to clinical requirements, homebirth midwives have 25-60% LESS experience caring for healthy women, and NO experience caring for pregnancy complications and NO experience caring for newborn complications. This illustrates one of the central shortcomings of homebirth midwifery training; there is no experience diagnosing and managing complications.

Anyone can catch a baby; no special training is required. The most critical function of a birth attendant is to diagnose, prevent and manage complications. Homebirth midwives have literally no clinical training in doing so.

American homebirth midwives are grossly undereducated and undertrained. They cannot meet the licensing requirements in ANY first world country. It is hardly surprising, therefore, that the neonatal death rate for planned homebirth is almost triple the death rate for comparable risk babies in the hospital.

Homebirth midwives wonder why no one takes them seriously

You can't make this stuff up.

This piece of psychobabble is what passes for research in the world of homebirth midwifery, Including the nonrational is sensible midwifery, by Jenny A. Parratt, and Kathleen M. Fahy, was recently published in the Australian midwifery journal Women and Birth. This piece has a very simple premise and conclusion: Many principles of midwifery are not supported by science. Rather than modify midwifery to reflect scientific knowledge, it is personally more satisfying to midwives to justify and celebrate their ignorance. Hence, we celebrate!

In many ways, the article resembles religious rationales for maintaining belief in creationism in the face of the overwhelming scientific evidence that creationism is nothing more than wishful thinking. It is striking how the language of the article resembles that used in justifications of religious belief:

Much of life cannot be apprehended or comprehended on a purely rational basis... Consider, for example, the sensations that may arise when watching a sunset, hugging a loved one, hearing a bird's song or delighting in a sense of bodily capability... Similarly a midwife's ordinary practice of being with the woman can be experienced by the midwife in quite extraordinary — nonrational — ways...

The centrality of emotion is similar; the nonrational beliefs must be good because they help people feel better about themselves; interestingly, the "people" in question are not laboring women, they are midwives. This article is a justification of irrational midwifery beliefs on the basis that they make midwives feel good about themselves.

Experiencing the nonrational may include sensations of inner power and/or inner knowing... These experientially grounded, nonrational aspects of life have been described variously as mysterious, sacred, spiritual and intuitive... Experiences that are nonrational are experiences of unity and wholeness; ...

And, of course, no discussion of religious justification is complete with reference to the "soul".

Our soul is our own particular organic expression of the spiritual milieu of nonrational power. The soul moves in parallel with spirit: thus soul is nonrational, ethically neutral and idiosyncratic... Through our soul we may interpret and experience the power of spirit in diverse and contrasting ways: e.g. liberating, oppressive, joyous, peaceful or challenging...

The central claim of the paper is that the inclusion of the non-rational is midwifery "enhances safety", although the authors' explanation seems to show nothing of the kind.

When the concept of 'safety' is considered in childbearing it can illustrate how insensible rationality can be and how negative consequences can occur. Safety is an abstract concept because it is difficult to define and can only be considered in general terms. Rational dichotomous thought, however, provides 'safety' with the following defining boundaries:

- 'safe' has a precise opposite called 'unsafe',
- every situation/person/thing must be either be safe or unsafe,
- a situation/person/thing cannot be both safe and unsafe,and
- it is not possible for a situation/person/thing to be anything
other than safe or unsafe.

The authors have created a straw man. Perhaps they understand safety to be an either or dichotomy, but real medical professional recognize safety as existing on a continuum. Some techniques, treatments and situations are safer than others, but there is no single technique, treatment or situation that is "safe", rendering everything else "unsafe". The authors complain:

...What is deemed as safe is aligned with what is rational and what is unsafe is aligned with what is irrational. As irrationality is not acceptable this essentially forces the definition of safety to be thought of as 'true' even though it may not fit with personal experience and all situations... As the standard birth environment is the medicotechnical environment of the hospital this is presumed to be the safest. Its 'opposite', the home environment, is therefore rationalised to be unsafe. To argue otherwise would define the rational person as irrational... In the purely rationalist way of thinking there is no other option except to consider that honouring the nonrational variabilities of individual bodily experience is irrational and unsafe.

The authors end with a flourish of outright stupidity:

For example, when a woman and midwife have agreed to use expectant management of third stage, but bleeding begins unexpectedly, the expert midwife will respond with either or both rational and nonrational ways of thinking. Depending upon all the particularities of the situation the midwife may focus on supporting love between the woman and her baby; she may call the woman back to her body; and/or she may change to active management of third stage. It is sensible practice to respond to in-the-moment clinical situations in this way... Imposing a pre-agreed standard care protocol is irrational because protocols do not allow for optimal clinical decision-making which requires that we consider all relevant variables prior to making a decision. In our view all relevant variables include nonrational matters of soul and spirit.

Evidently, even if the woman bleeds to death for lack of pitocin, the decision to "support love between the woman and her baby" is still the correct one because her "soul" is "safe". In summary:

Being open to the nonrational in midwifery practice makes room for midwives to self-reflexively acknowledge aspects of themselves, such as their fears, in a way that does not interfere with their practice. During birth, making room for the nonrational broadens both midwives' and women's knowledge about trust, courage and their own intuitive abilities including the changing capabilities of bodies. And by including the nonrational midwives can then most honestly be with the woman's own fears as she opens her embodied self to her own unique process of childbearing.

At least these people are honest, even if completely inane. A fundamental (perhaps, the fundamental) goal of homebirth midwifery is to make midwives feel good about themselves. Coming face to face with their own ignorance makes homebirth midwives feel bad about themselves. Fortunately, there is a way to pretend that there is no such thing as ignorance. If a midwife thinks it or "feels" it, it automatically becomes knowledge. If the ultimate goal of midwifery is to make midwives feel good about themselves, then the inclusion of the nonrational is indeed "sensible".

Her dying wish was for a bedpan ... and they ignored her

The problem of medical staff failing to treat patients respectfully is a very old one. Eventually, many doctors and nurses just get used to seeing it. The first time you see it, though, it makes a big impression on you. I can still remember the first such incident that I observed. It has stayed with me for more than 25 years.

I was in the first weeks of my general surgery rotation at a small suburban hospital. The chief of surgery used to take the medical students around to see the patients. Mrs. D. was a middle aged woman suffering from a severe complication of alcoholism, distended and bleeding blood vessels in the gastro-intestinal tract.

Mrs. D. was scheduled for surgery and the chief told us that the surgery was very complicated and the chances of survival were small. The odds were high that in the aftermath of surgery, because of the fragile state of her damaged liver she would be progressively poisoned by waste products from her liver and never regain consciousness. I had this in mind when the resident called me to observe him putting in a central line prior to surgery. A central line is a monitor placed inside the heart after being threaded down an IV in the neck.

I pressed myself into a corner where I would be out of the way. The central line placement was difficult and the resident struggled over and over again. He was sweating and everyone in the room was tense. I could not see the patient's face from where I stood. It seemed that Mrs. D. was incredibly stoic as she was stuck in the neck repeatedly. Eventually, her voice emerged from beneath the drapes,

"I'm sorry, but I have to pee."

The nurse looked at the resident, and the resident shook his head no. He was already frustrated and he did not want to stop to let the patient use the bedpan. So the nurse told the patient,

"Just pee in the bed. I'll clean it up later."

I was shocked and evidently Mrs. D. was, too. Was it really that much trouble to take a few minutes to let her pee into the bedpan? The patient said she would try to wait.

Again the resident was unsuccessful and again Mrs. D asked for the bedpan. This time she was pleading.

"Please, I don't want to pee in the bed. I've never had an accident before. Please, please just let me use the bedpan."

By this time, no one was interested in the patient's distress. She wept as she eventually peed into the bed.

"I am so embarrassed," she kept saying over and over again.

It only took a bit longer and her central line was finally placed. She was wheeled off to the operating room, weeping. The surgery did not go well. She survived, but she never regained consciousness and died a few days later.

Mrs. D.'s last conscious thought had been embarrassment because no one could be bothered to give her a bedpan. She was going to her death. Everyone in the room knew it, but no one cared enough to honor her dying wish for a simple bedpan.

Sanctimommy

There's a new mother on the block and she's cheerfully terrorizing everyone else. The sanctimommy is here!

The sanctimommy knows how you should raise your children. Specifically, she knows what foods they should eat, what toys they should be allowed to play with; heck, sanctimommy even knows how you should have given birth.

The best part about sanctimommy is that she is always ready to share her wisdom with the rest of us. She doesn't hesitate to point out the deficiencies of your parenting practices (in other words, how your parenting choices differ from hers). She doesn’t hesitate to make dire predictions about what the future holds for your children ("You give him a pacifier? You know he's never going to be able to ..."). She never hesitates to bemoan your lack of understanding of the key issues of childrearing, letting you know that you are not as "educated" as she is.

My personal observation on the behavior of sanctimommies in their natural habitat is that they tend to suffer from overwhelmingly from ostentatious "sadness". They are so "sad" for you that you don't do everything their way. They are so "sad" for your children that you are not parenting the way they prescribe. They are just so "sad" that everyone in the world does not recognize their incredible superiority and their expert status on every aspect of parenting at every age.

Sanctimommy has lots of all purpose rules for parenting. No need to tailor your parenting choices to the personality and needs of the individual child. All childbirth should be unmedicated; all children should be breastfed for the prescribed amount of time, all children should be carried, every child should sleep in the family bed. There’s a rule for every behavior and every situation.

Despite her apparent self assurance, sanctimommy needs constant validation and she intends to get it from you. Your parenting choices serve as the perfect foil for sanctimommy since she can criticize them and you.

Sanctimommy is quick to take offense. In fact she is always sure that she is being "disrespected" by those who don’t make the same choices.

Sanctimommy is sure that she is being persecuted. Mothers who don't agree with her are accused of interfering with her choices even if you have no interest in her choices at all.

Fundamentally, Sanctimommy cannot abide uncertainty, and if there ever was it job fraught with uncertainty it is motherhood. It is difficult to get feedback on job performance from children. Children live in the moment, are overwhelmed with their own needs, and don't take the long view.

Children don't tell you whether being allowed in the parental bed promotes security or inability to manage separation. They don't tell you whether limiting television is crucial to wellbeing or merely an affectation that has no impact on them. They don't thank you for discipline and they don't applaud your performance. In fact, it often turns out that your best moments as a mother were the ones that they appeared, at the time, to hate the most.

All mothers must cope with this uncertainty, but some are more challenged than others. Sanctimommies deal with uncertainty by pretending that it doesn't exist. They adopt all purpose rules for parenting and insist that following them demonstrates unequivocally that they are doing the right thing (and, inevitably, if you don’t agree, you are wrong).

And because they are so insecure, they cannot resist interrogating other mothers and demeaning their choices. Had an epidural? Too bad you gave in to the pain. Stopped breastfeeding before age 2 (or 3 or 4)? How sad that you didn’t try hard enough. Your children’s food is not 100% organic? How unfortunate that you don’t care enough about your children to serve the very best.

Ironically, Santimommy's choices don't necessarily reflect what is best for her children. They don't reflect the fact that children are individual human beings with individual needs and desires. There is no one-size-fits-all parenting formula and pretending that there is ignores the specific needs of a specific child. Sancitmommy's choices are all about her, her need for reassurance and her inability to tolerate uncertainty.

Premature ejaculation: Withdrawal is not an effective method of birth control

Premature ejaculation. In this case it refers to making claims about the effectiveness of withdrawal before there is any proof.

No doubt every gynecologist is cringing. We have spent years counseling patients that withdrawal is an ineffective method of preventing pregnancy, only somewhat better than nothing. Now researchers from the Guttmacher Institute have published a study that claims that to show that withdrawal is as effective as condoms, but actually shows nothing of the kind.

According to the paper Better than nothing or savvy risk-reduction practice? The importance of withdrawal (Contraception 79 (2009) 407–410):

Withdrawal is sometimes referred to as the contraceptive method that is "better than nothing". But, based on the evidence, it might more aptly be referred to as a method that is almost as effective as the male condom—at least when it comes to pregnancy prevention. If the male partner withdraws before ejaculation every time a couple has vaginal intercourse, about 4% of couples will become pregnant over the course of a year. However, more realistic estimates of typical use indicate that about 18% of couples will become pregnant in a year using withdrawal. These rates are only slightly less effective than male condoms, which have perfect- and typical-use failure rates of 2% and 17%1, respectively.

In other words, when used improperly, both withdrawal and condoms are not very effective. When you consider what that means, it is only to be expected, and hardly an endorsement of the effectiveness of withdrawal.

The reason there is a vast gulf between typical use and perfect use in the case of both condoms and withdrawal is that in both cases "typical use" means that the method is not used all the time. It's supposed to be used all the time, but in practice, condom users forget to put it on or put it on too late. For a significant portion of the time, real world condom users have sex without any protection against pregnancy.

Real world withdrawal users are often unprotected too. That’s because many men and boys who use withdrawal don't have the self-control to withdraw in time. They intended to do so, but they couldn’t do so. For a significant portion of time, real world withdrawal users have sex without any protection against pregnancy.
It is hardly surprisingly that the study found couples who claim to be using condoms but are using nothing intermittently have the same pregnancy rate as couples who claim to be using withdrawal but are using nothing intermittently. That was only to be expected.

The real question is not what happens when you don't use the method properly, but what happens when you do use the method properly. When used perfectly (in other words, every time) withdrawal (4% pregnancy rate) has double the pregnancy rate of condoms (2% pregnancy rate). It may sound like a trivial difference, but for couples who faithfully use either method (instead of intermittently using nothing), it makes a big difference because condoms are inherently more effective in preventing pregnancy … twice as effective.

The take home message is not that withdrawal is as effective as condom use. The study merely showed that regardless of method, if you don't use it consistently, it will have an extraordinarily high pregnancy rate. That's not news and it's not helpful information for people trying to determine the safest method of contraception.

Alternative health: Longing for a past that never existed

There once was a time when all food was organic and no pesticides were used. Health problems were treated with folk wisdom and natural remedies. There was no obesity, and people got lots of exercise. And in that time gone by, the average lifespan was ... 35!

That’s right. For most of human existence, according to fossil and anthropological data, the average human lifespan was 35 years. As recently as 1900, American average lifespan was only 48. Today, advocates of alternative health bemoan the current state of American health, the increasing numbers of obese people, the lack of exercise, the use of medications, the medicalization of childbirth. Yet lifespan has never been longer, currently 77.7 in the US.

Advocates of alternative health have a romanticized and completely unrealistic notion of purported benefits of a "natural" lifestyle. Far from being a paradise, it was hell. The difference between an average lifespan of 48 and one of 77.7 can be accounted for by modern medicine and increased agricultural production brought about by industrial farming methods (including pesticides). Nothing fundamental has changed about human beings. They are still prey to the same illnesses and accidents, but now they can be effectively treated. Indeed, some diseases can be completely prevented by vaccination.

So why are advocates of alternative health complaining? They are complaining because they long for an imagined past that literally never existed. In that sense, alternative health represents a form of fundamentalism. Obviously, fundamentalism is about religion and the analogy can only go so far, but there are several important characteristics of religious fundamentalism that are shared by alternative health advocacy. These include:

The desire to return to a "better" lifestyle of the past.
The longing for a mythical past that never actual existed.
An opposition to modernism (in daily life and in medicine).
And the belief that anything produced by evolution (or God, if you prefer) is surely going to be good.

Advocates of alternative health bemoan the incidence of diseases like cancer and heart disease without considering that they are primarily diseases of old age. That both cancer and heart disease are among the primary causes of death today represents a victory, not a defeat. Diseases of old age can become primary causes of death only when diseases of infancy and childhood are vanquished, and that is precisely what has happened.

Alternative health as a form of fundamentalism also makes sense in that it has an almost religious fervor. It is not about scientific evidence. Indeed, it usually ignores scientific evidence entirely. All the existing scientific evidence shows that all of the myriad claims of alternative health are flat out false. None of it works, absolutely none of it. That's not surprising when you consider that it never worked in times past; advocates of alternative health merely pretend that it did, without any regard for historical reality.

Alternative health is a belief system, a form of fundamentalism, and like most fundamentalisms, it longs for a past never existed. It is not science; it has nothing to do with science; and it merely reflects wishful thinking about the past while ignoring reality.

Why lie about childbirth pain and bonding?

The theory of the "big lie" is that if you say it loud enough and long enough, people will believe it regardless of how ridiculous it is. Such is the case with Dr. Michel Odent's claim that childbirth pain is necessary for mother-infant bonding. It is ridiculous, there is no evidence for it, which is not surprising since he made it up.

Odent went public with his fabrication in July 2006:

Women who choose to have Caesarean sections may be jeopardising their chances of bonding properly with their babies, a leading childbirth expert has claimed.

Obstetrician Michel Odent said that undergoing the planned procedure prevents the release of hormones that cause a woman to 'fall in love' with her child.

Speaking at a conference in Cambridge, Dr Odent warned that both C-sections and artificial inductions with drugs somehow interfere with the natural production of the hormone oxytocin.

The French expert said: "Oxytocin is the hormone of love, and to give birth without releasing this complex cocktail of love chemicals disturbs the first contact between the mother and the baby.

"The hormone is produced during sex and breastfeeding, as well as birth, but in the moments after birth, a woman's oxytocin level is the highest it will ever be in her life, and this peak is vital.

"It is this hormone flood that enables a woman to fall in love with her newborn and forget the pain of birth."

He added: "What we can say for sure is that when a woman gives birth with a pre-labour Caesarean section she does not release this flow of love hormones, so she is a different woman than if she had given birth naturally and the first contact between mother and baby is different."

Why is this a big lie?

1. There is no evidence that oxytocin is required for bonding.
2. There is no evidence that a complex interaction like maternal-infant bonding is mediated simply by hormones
3.If oxytocin were the source of bonding, women who received pitocin would be more bonded to their babies than anyone else.
4. Odent and his supporters get around this difficulty by claiming that pitocin is different from oxytocin (false) or that the only oxytocin produced within the brain can have an effect on the brain (there's no evidence for that).

The claim that childbirth pain is required for bonding is nothing but an offensive smear. No doubt Odent and his supporters wish it were true, so that simply asserted it.

Interestingly, this is not the only time that Dr. Odent has made up a theory to support his personal prejudices. Evidently, he could not stand to support his own wife when she was in labor, so he has made up a theory that the presence of fathers at birth is "dangerous."

In April 2008, Odent declared:

That there is little good to come for either sex from having a man at the birth of a child.

For her, his presence is a hindrance, and a significant factor in why labours are longer, more painful and more likely to result in intervention than ever.

As for the effect on a man - well, was I surprised to hear a friend of mine state that watching his wife giving birth had started a chain of events that led to the couple's divorce?

What is the genesis of this theory? Dr. Odent's personally discomfort with attending the births of his children.

As it happens, at the exact moment our son arrived in the world, the midwife was on her way down the street and I, having made my excuses realising he was about to be born, was fiddling with the thermostat on the central heating boiler downstairs.

My partner did not know it, but I had given her the exceptionally rare, but ideal situation in which to give birth: she felt secure, she knew the midwife was minutes away and I was downstairs, yet she had complete privacy and no one was watching her.

I raise the issue to point out that Michel Odent fabricates his theories about childbirth out of thin air. In this case, as in the case of his offensive claims about childbirth and bonding, he announced a brand new scientific theory without any research and without any evidence. He seemed to think that it was enough that the theory made sense to him and confirmed his personal preferences.

It is easy for lay people to understand that Odent's "theory" of fathers at birth is nothing more than a projection of his own anxieties and prejudices. It is important for lay people to understand that his "theories" of natural childbirth, waterbirth, and bonding are also nothing more than projections of his own anxieties and prejudices.

The feminist critique of "natural" childbirth

There has been considerable furor surrounding midwifery professor Denis Walsh's assertion that women benefit from the pain of childbirth. It is important to understand that although Walsh attempts to ground his claim in science, the scientific evidence does not support him. That's because "natural" childbirth has nothing to do with science; it is a philosophy, not an impartial result of scientific facts.

From it's origin in Biblical injunctions that childbirth pain is punishment for women's inherent sinfulness, to it's modern adaptation by eugenicist Grantly Dick-Read, preoccupied as he was with racist, sexist fantasies, it has never had any basis in science. That didn't stop 19th Century opponents of anesthesia for childbirth from insisting that it was "unnatural;" it didn't stop Grantly Dick-Read from making up "science" to support his racist and sexist claims; and it certainly does not stop contemporary advocates of "natural" childbirth from insisting that unmedicated childbirth is better, despite the fact that the scientific evidence shows that unmedicated childbirth is not better, safer, healthier or superior in any way to childbirth with pain relief.

So if "natural" childbirth has no basis in science, what about it's validity as a philosophy?

There are quite a few problems there, too. That's because "natural" childbirth makes assumptions about the nature of women, science and pain, assumptions that most people do not support. Indeed the most powerful critique of the "natural" childbirth movement is to be found in feminist philosophy. Feminist philosopher Katherine Beckett, in Choosing Cesarean: Feminism and the politics of childbirth in the United States, (Feminist Theory, 2005, vol. 6(3): 251–275) writes:

..[Feminist] critics argue that the idealization of 'natural childbirth' rests on the assumption that both women and childbirth have a true essence or nature that is respected by the natural childbirth movement but violated by the medical establishment: birth activists then 'assert a nature to which birthing women must conform'...

Beckett points out that the claim of "natural" childbirth advocates that pain relief is pushed on women to their detriment is in direct contradiction of actual historical fact:

...[H]istorical scholarship indicates that women had long expressed a great deal of fear and trepidation about the potential pain (and danger) of childbirth. Indeed, many first wave feminist activists saw the right to pain relief as an important political issue and argued strenuously for women's right to relieve their suffering ... through the use of drugs, and specifically, scopolamine. These activists were outraged by obstetricians' reluctance to provide pharmacological pain relief ...

Beckett also addresses belief that childbirth pain is good for women, the belief that Walsh promotes.

Pain is a recurring issue for feminist analysts of childbirth ... First wave feminists saw the right to pain relief during childbirth as an important political issue... [T]hird wave scholars, drawing on their experiences with alternative 'birth culture', have criticized the alternative birthing community's knee-jerk rejection of (pharmacological) pain relief and understand this rejection as indicative of a kind of machisma, a belief that birth is 'an extreme sport'. 'Isn't it interesting', one such writer comments, 'that the movement that's supposedly feminist is the one that insists on women feeling pain?'. Another suggests: 'Today’s natural childbirth purists don't see moral punishment in pain but they do see moral superiority in refusing pain relief'.

The idea that women do (or should) savour, enjoy, or feel empowered by the experience of labour and delivery, they argue, romanticizes women's roles as lifebearers and mothers, and assumes an emotional and physical reality (or posits an emotional and physical norm) that does not exist for many...

In short, some feminists perceive the alternative birth movement as rigid and moralistic, insistent that giving birth 'naturally' is superior and, indeed, is a measure of a 'good mother'. The perceived moralism of this stance is quite troubling to some; according to one feminist critic, the 'natural' philosophy ... is as tyrannical and prescriptive as the medical model, but pretends not to be ...

It is against this background that Walsh's claim should be evaluated. It is not science; it is philosophy and even as philosophy it has serious problems. The obsession with unmedicated birth is based on flawed assumptions about women and about pain. It is inappropriately moralistic, and consciously or unconsciously serves only to elevate the personal choices of "natural" childbirth/homebirth advocates, while denigrating the choices of most women.

Fat, black and female

She has been called "an angel in a white coat." She is a doctor and the first black woman and youngest person elected to the board of the American Medical Association. She received a MacArthur Foundation "genius" grant. She's been honored for her medical work on behalf of the poor by both Nelson Mandela and the Pope. The President has just appointed her to the job of Surgeon General

And around the web from the blogosphere to mainstream publications people are discussing ... her weight!

There's no quicker way to diminish the achievements of a powerful woman than to talk about her body. But don't worry, it's okay because prejudice against the overweight is the socially acceptable prejudice. It's socially acceptable because it masquerades as a health issue although it is really a class, race and gender issue.

Let's be completely clear on one point first. Those piously declaiming on Dr. Benjamin's potential influence as a health role model are ignoring the scientific evidence. Decades of scientific evidence have already demonstrated that, contrary to the conventional wisdom, overweight people live longer than people of "ideal" body weight.

The hysteria about weight sweeping contemporary America is just that, hysteria. Of course morbid obesity is a serious health problem with potentially deadly consequences. However, simply being overweight is not only safe, but actually appears to be protective compared to "ideal" weight. That's what the data really show.

Why is the conventional wisdom about weight completely unhinged from the actual scientific evidence? The answer, I believe, is prejudice. Weight has become a proxy for social class. And, as we all know, it's always open season when it comes to criticizing the bodies of women, particularly black women.

When poor people were thin because they didn't have enough to eat, being overweight was a sign of status. That’s changed now. Thin is a sign of wealth. Achieving and maintaining the favored body type requires access to healthy food and special diet foods. It also requires exercise equipment or membership in a gym or, most exclusive of all, a personal trainer. All these things cost money, so weight has come to be viewed, accurately, as a sign of economic class.

Much of this is perceived only on the unconscious level. Nonetheless, it leaves people feeling free to criticize those who are overweight, supposedly on "health" grounds, but in reality as a proxy for social class.

Let's be brutally honest here: Regina Benjamin looks like the stereotypical fat, black welfare queen and therefore, a socially acceptable target for our class, race and gender prejudices.

The hypocrisy about health concerns is glaring. Did anyone dare to discuss C. Everett Koop’s weight when he was appointed Surgeon General? Has anyone declared President Obama unworthy of being a role model because he smokes? Of course not, but it socially acceptable to muse about the "suitability" of Regina Benjamin as Surgeon General because she is an overweight black woman.

I am so angry I could spit. An extraordinarily brilliant, compassionate, gifted individual has been nominated to take control of an important health organization in disarray and the mainstream media is talking about her body. Salon Magazine ran an article about it yesterday, and MSNBC has Arthur Caplan discussing the "bioethical" implications of Dr. Benjamin’s weight today. Have people lost their minds?

No, of course not. They're just enjoying the socially acceptable occupation of criticizing black women's bodies; there are so few politically correct forms of prejudice left that no one can refrain from indulging.

Suicide: A Love Story

There are not many heartwarming stories about death, and even fewer about suicide. That small number is destined to grow with the addition of the true story of Sir Edward and Lady Downes, and elderly couple who chose to end their lives together as she faced imminent death from terminal cancer.

From The New York Times:

...[O]ne of Britain's most distinguished orchestra conductors, Sir Edward Downes, [flew] to Switzerland last week with his wife and joined her in drinking a lethal cocktail of barbiturates provided by an assisted-suicide clinic.

Although friends who spoke to the British news media said Sir Edward was not known to have been terminally ill, they said he wanted to die with his ailing wife, who had been his partner for more than half a century.

According to their children:

Sir Edward, who was described in a statement issued earlier on Tuesday by [their son and daughter] as "almost blind and increasingly deaf," was principal conductor of the BBC Philharmonic Orchestra ... [and] a conductor of the Royal Opera House at Covent Garden in London, where he led 950 performances over more than 50 years.

Lady Downes, who British newspapers said was in the final stages of terminal cancer, was a former ballet dancer, choreographer and television producer who devoted her later years to working as her husband's assistant.

"After 54 happy years together, they decided to end their own lives rather than continue to struggle with serious health problems," the Downes children said in their statement.

What could be more natural or more romantic? An elderly couple who had an unusually long and happy life together faced only debility, decline and life apart. They viewed this prospect as insupportable and chose to take control of their destiny by ending their lives now instead of suffering longer. Their deaths were quiet and peaceful, just as they had planned

...[T]he children said, they watched, weeping, as their parents drank "a small quantity of clear liquid" before lying down on adjacent beds, holding hands.

"Within a couple of minutes they were asleep, and died within 10 minutes," ... the couple’s 41-year-old son, said in the interview after his return to Britain. "They wanted to be next to each other when they died..."

Of course Britain, like the United States, does not permit an elderly couple to control the timing and method of their own deaths, even when those deaths are inevitable. Sir Edward and Lady Downes were forced to leave their home and travel to Switzerland, where the organization Dignitas helped arrange the suicides.

Predictably, the news of the deaths has ignited controversy back home. The British Medical Association, in their wisdom, voted recently to deny the terminally ill the option of assisted suicide.

Not surprisingly, though, in a society that forces the terminally ill to live even if they are suffering, it is Sir Edward's death that has sparked the most outrage. He may have been 85 years old, almost blind and losing his hearing, he was not terminally ill. He had lived a long time, longer than most men, and was satisfied with his length of life, but the British, like Americans, believe that death is far too serious a matter to be controlled by the person who is dying.

That's the source of the outrage. It is certainly not about the deaths of this elderly couple for natural deaths at the very same moment would have provoked no concern. The outrage is directed at the temerity of Sir Edward and Lady Downes in arranging the time, place and manner of their deaths instead of taking their chances with cruel fate.

The concern is not for them, of course, but for us. As Rod Dreher writes on Beliefnet:

We shall very soon proceed from the "right" to die to the "duty" to die, when one is seen, or made to see oneself, as a burden on the living.

In other words, Sir Edward and Lady Downes' continued suffering is a regrettable necessity to protect the rest of us. If they are allowed to die, the inevitable next step would be to force others to die. It's the classic slippery slope argument. But as students of logic know, the slippery slope argument is an intellectual fallacy. The slippery slope is a fallacy because it denies the possibility that a middle ground can and does exist.

It does not follow logically that allowing people to control their own deaths will lead to forcing people to die. It is possible, but those who wield the slippery slope argument are obligated to prove a connection, and thus far, no one has done so.

Moreover, the slippery slope argument in this setting is incredibly cynical and selfish in the extreme. The underlying supposition is that any amount of suffering of any number of other people is allowed in order to prevent the chance that one of us may suffer inadvertently in the future. In other words, for Dreher, the Downes' suffering is the price they have to pay to protect Dreher from a theoretical future where he might be forced to die.

But his fear of theoretical future suffering is not a justification for the very real and ongoing suffering of terminally ill and elderly people who are ready to die but are forced to live. I applaud Sir Edward and Lady Downes for having the strength of character and purpose to make their own most intimate decisions and carry them through. And I have deep respect and admiration for the intense love that makes surviving alone an unbearable prospect.

Updating the sexist claim that pain is good for women

The blogosphere is abuzz with the news that Midwifery Professor Denis Walsh has declared that labor pain is good. According to the Daily Mail:

In an article for Evidence Based Midwifery, published by the Royal College of Midwives, Dr Walsh said the NHS was too quick to give in to requests for pain-killing injections.

He said: "A large number of women want to avoid pain, but more should be prepared to withstand it. Pain in labour is a purposeful, useful thing which has a number of benefits, such as preparing a mother for the responsibility of nurturing a newborn baby."

Dr. Walsh recycles an entirely fabricated claim:

[Epidurals] also led to lower rates of breast-feeding. He added: "Emerging evidence showsthat normal labour and birth prime the bonding areas of the mother's brain more than Caesarean or pain-free birth."

The belief that pain in labor is beneficial has a long and sordid history. A large body of scientific literature shows that women’s pain (of any kind) is much less likely to be taken seriously than men’s pain.

The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain (Journal of Law, Medicine & Ethics, 29 (2001): 13–27) provides a disturbing description of the ways in which the pain of women is systematically devalued, disbelieved and undertreated.

...Women who seek help are less likely than men to be taken seriously when they report pain and are less likely to have their pain adequately treated...

The study by McCaffery and Ferrell of 362 nurses and their views about patients’ experiences of pain found that while most of the nurses (63 percent) agreed that men and women have the same perception of pain, 27 percent thought that men felt greater pain than women… The same study also found that almost half of the respondents (47 percent) thought that women were able to tolerate more pain than men ...

These erroneous attitudes are particularly prevalent in regard to childbirth:

Bendelow found that "the perceived superiority of capacities of endurance is double-edged for women — the assumption that they may be able to 'cope' better may lead to the expectation that they can put up with more pain, that their pain does not need to be taken so seriously." Crook and Tunks point to the influence of the psychoprophylaxis movement in the United States with its implicit assumption that it is good to experience childbirth without the aid of analgesia... [A]ccording to the authors, "these attitudes imply that we have a value system ... that suggest women should be encouraged to keep a stiff upper lip."

The authors believe that people discount women's expressions of pain.

A deeper examination of why women are treated this way is explored by several feminist authors. They attribute it to a long history within our culture of regarding women's reasoning capacity as limited and of viewing women's opinions as "unreflective, emotional, or immature." In particular, in relation to medical decision-making, women's moral identity is "often not recognized..."

...These findings are consistent with studies reporting that female pain patients are less likely than their male counterparts to be taken seriously or are more likely to receive sedatives than opioids for the treatment of their pain.

It is not a coincidence that the philosophy of "natural" childbirth was promulgated by men steeped in the ethos that women's pain was not worthy of serious consideration. Their claims that women can and should manage childbirth pain through psychological means, that women are "empowered" by pain or that the pain is "beneficial" are simply elaborate justifications for not acknowledging and not treating the pain of women.

Walsh's claims are just the 21st Century version of the willingness to dismiss the pain of women. He has dressed up his claims in scientific jargon to make them more palatable to a more sophisticated audience, but there is no scientific basis for his claims. There's NO scientific evidence that unmedicated childbirth is better, safer, healthier or superior in any way than childbirth with pain relief. And the claim about endorphins and bonding is entirely fabricated; it was made up by Michel Odent.

Walsh is merely the latest update in an endless string of men (and sometimes women) who discount, dismiss and disbelieve women's suffering. The original reaction was to claim that pain was all in a woman’s head; the updated version is to claim that if she cared about her baby and herself she would gladly embrace the pain and be a better mother and woman for the experience.

Curiously, no one has been able to find a form of male pain that supposedly benefits men. I suspect that it is more than mere coincidence that the only pain that is supposedly beneficial is pain that only women can experience.

Doctor, I've read ...

Many years ago I regularly received a free monthly publication called "Doctor, I've read ..." Unlike much of what doctors receive for free, it was both interesting and extremely useful. It was a compendium of excerpts from newspapers and women's magazines about women's health. It alerted me to what my patients were reading so I would be prepared for the inevitable patient questions, and because I had read the same article, I could explain to the patient whether it was reliable or not.

I often thought that there should be a similar publication for patients, showing them how they could evaluate medical claims found in newspapers and magazines. Such information is even more important today when medical claims are widely disseminated on the web. There is a great deal of excellent medical information available on the web, but far more information is erroneous and even dangerous.

Unfortunately, there is no magazine like that, but there are publications for lay people explaining how to evaluate scientific claims. One of the best is Risk in Perspective: A Consumer Guide to Taking Charge of Health Information prepared by the Harvard Center for Risk Analysis. Although it's geared specifically toward risk, it has valuable information about any health claims.

It's worth reading in full, especially because the cartoons are very funny. The text is serious, though.

Health information can be based on untested claims, anecdotes, case reports, surveys, and scientific studies. Scientific studies, which take samples and apply the results to the whole population, often provide the best clues about health. Nonetheless, many studies are needed to be confident about an answer. The following are some factors that might help you judge information:

Less reliable (less certain)	More reliable (more certain)
One or a few observations	Many observations
Anecdote or case report	Scientific study
Unpublished	Published and peer reviewed
Not repeated	Reproduced results
Nonhuman subjects	Human subjects
Results not related to hypothesis	Results about tested hypothesis
No limitations mentioned	Limitations discussed
Not compared to previous results	Relationship to previous studies discussed

If you read these guidelines, it is not difficult to understand that most of the "alternative" health literature falls into the category of less reliable, and is almost always superseded by scientific evidence that is more reliable.

So, for example, anecdotes, the mainstay of vaccine rejectionists, are not reliable since they tell us nothing about what happens to most people. Those ubiquitous "clinical studies" not published in peer review scientific journals, often used for touting herbs and "natural" remedies, are not reliable compared to information that has been published in a peer reviewed journal. Bits of information scavenged from a variety of studies that were unrelated to the claim being discussed, a favorite of "natural" childbirth advocates, are far less reliable than actual studies of the specific claim.

The first step in evaluating any claim is to ask some basic questions. Is the claim based on a few observations or a scientific study? Was the study published in a peer reviewed scientific journal? Have the results been repeated by anyone else? Do the authors discuss the limitations of their own study? How do the results of this study compare with other, similar studies?

If the claim is supported only by anecdote, has not been reported in the scientific literature, has not been repeated by others, and it inconsistent with existing scientific literature, the claim deserves the deepest skepticism.

Beware Socialized Mail

Lobbyists for private package delivery services have been wining and dining members of Congress in an effort to undermine support for the US Postal Service.

"It's an outrage, actually," declares their spokeswoman Louise Harry. "The US Postal Service is practicing socialized mail delivery."

A Republican Congressman agrees: "Because of its monstrous size, the Postal Service has an unfair competitive advantage. They can deliver mail from one coast to the other for less than 50¢ per letter. There's no way that private enterprise can compete with that."

A Republican Senator concurs and warns, "Socialized mail is just the first step to destroy America as we know it. No one can deny that the US Postal Service has taken choice away from consumers. Can you choose any stamp you want? Oh, no. Every American is forced to use only government-approved stamps to send their letters. It's an outrage!"

In an effort to fight what it perceives as an unfair competitive disadvantage, private delivery services are rolling out a new program of mail insurance, ChoiceMail. For a flat monthly fee, private delivery services will provide all the mail service you need, subject to a few minor restrictions.

"As the name indicates, we feel that the most important component is choice," explains Louise Harry. "The consumer will be free to affix any stamp of his choosing, and we will deliver that letter!"

We were able to obtain a copy of the ChoiceMail contract to share with our readers. For a flat monthly fee, ChoiceMail provides unlimited delivery from coast to coast, and you are not required to use only government-approved stamps. You can use any stamp of your choosing. We asked Ms. Harry about the restrictions.

"Yes, ChoiceMail does reserve the right to determine whether your letter needs to go to the address on the label. We've found that a consumer may think that a letter should go to Aunt Irma in Oregon, but cross country mail service is expensive. It's more cost efficient to send the letter to Uncle Ed who lives in the consumer’s own state. If the news is important, he can call Aunt Edna to tell her."

Ms. Harry emphasizes that ChoiceMail can offer unlimited choice for a flat monthly fee because they do their utmost to control costs. As Ms. Harry explains:

"You might think that you want to send a letter to your old high school friend Billy to tell him about your new baby, but that's wasteful. After all, you'll see Billy at the high school reunion next year and you can tell him then. That's why we check every letter and send only the ones that we feel need to be sent."

Ms. Harry is particularly proud of ChoiceMail's most innovative form of cost cutting, charging the mail recipient:

"Sure, Grandma Sue wants you to send a birthday card. It costs her nothing to receive that card, and she benefits from every card she gets. Why should we pay for the consumer to send a card to Grandma Sue? Let Grandma Sue eat the cost if she thinks getting a birthday card is so important."

Ms. Harry concludes:

"The most important thing is choice. The US Postal Service is socialized mail and it restricts consumers’ choice to government-approved stamps. ChoiceMail allows consumers unlimited choice of stamps. Sure, we might not deliver your letter to the person you specify in the address or we might decide that it doesn’t need to be delivered at all. But you’ll rest easy knowing that you have sent your mail by private enterprise, the patriotic way, the American way."

What's the safest C-section rate? Higher than you think.

This post originally appeared in September 2008.

Critics the current C-section rate often quote the World Health Organization recommendation of an ideal C-section rate of 10-15%. Unfortunately, the WHO appears to have pulled those numbers out of thin air. Its own data shows that a 15% C-section rate does not result in the lowest possible levels of either neonatal mortality or maternal mortality. Indeed, Dr. Marsden Wagner, who has probably done more than anyone to promote the notion of a 15% C-section rate as ideal, is a co-author of a study that actually demonstrates the opposite.

The paper is Rates of caesarean section: analysis of global, regional and national estimates (Paediatric and Perinatal Epidemiology, 2007; 21:98–113.) The article explicitly acknowledges that the 15% C-section rate recommendation was made without any data to support it. This paper is actually the first paper that attempts to compare international C-section rates with maternal and neonatal mortality.

Since publication of the WHO consensus statement in 1985, debate regarding desirable levels of CS has continued; nevertheless, this paper represents the first attempt to provide a global and regional comparative analysis of national rates of caesarean delivery and their ecological correlation with other indicators of reproductive health.

The data regarding C-section rates below 10% is stark:

...[T]he majority of countries with high mortality rates have CS rates well below the recommended range of 10–15%, and in these countries there appears to be a strong ecological association between increasing CS rates and decreasing mortality.

How about the data on C-section rates above 15%? The authors claim:

Interpretation of the relationship between CS rates and mortality in countries with low mortality rates is more ambiguous; nevertheless, the sum total of the evidence presented here supports the hypothesis that, as has been argued previously, when CS rates rise substantially above 15%, risks to reproductive health outcomes may begin to outweigh benefits.

Not exactly. Indeed, not even close. The data show that low maternal mortality and low neonatal mortality are associated almost exclusively with high and very high C-section rates.

The article contains a variety of charts that make this clear. Of note, the charts are of an unusual kind. Rather than graphing C-section rates against mortality rates, the authors chose to graph the log (logarithm) of C-section rates against the log of mortality rates. A log-log graph has the advantage of exposing tiny differences when all the values are bunched close together, but all the values are not bunched together in this situation. C-section rates occur along a broad range, and mortality rates occur along a broad range. As a consequence, the log-log graph magnifies the effect of tiny differences and minimizes the effect of large differences. Therefore, you need to be very careful in interpreting the graphs.

addendum: This is an adaptation of the chart that appears in the paper. The area representing a C-section rate of 10-15% has been highlighted in yellow. The vertical blue line represents a mortality rate of 15%. Lower mortality rates are left of the blue line and higher mortality rates are right of the blue line.



The data themselves are quite clear. There are only 2 countries in the world that have C-section rates of less than 15% AND low rates of maternal and neonatal mortality. Those countries are Croatia (14%) and Kuwait (12%). Neither country is noted for the accuracy of its health statistics. In contrast, EVERY other country in the world with a C-section rate of less than 15% has higher than acceptable levels of maternal and neonatal mortality. There nothing ambiguous about that.

The authors claim:

Although below 15% higher CS rates are unambiguously
correlated with lower maternal mortality; above this range, higher CS rates are predominantly correlated with higher maternal mortality.

No, that's not what it shows at all. It shows that all countries with high C-section rates have low levels of maternal and neonatal mortality EXCEPT Latin American countries (represented on the chart by open diamonds) with high C-section rates. The only conclusion that you can draw is that high C-section rates for medical indications are associated with low rates of maternal and neonatal mortality, and high C-section rates for social reasons (as in Latin America) do not lead to low rates of maternal and neonatal mortality.

What the data actually shows is this: The only countries with low rates of maternal and neonatal mortality have HIGH C-section rates (except Croatia and Kuwait). The average C-section rate for countries with low maternal and neonatal mortality is 22%, although rates as high as 36% are consistent with low rates of maternal and neonatal mortality.

The authors claims are not supported by their own data. There is simply no support for a C-section rate of 15%, since virtually none of the countries with low rates of maternal and neonatal mortality have a C-section rate of 15% or below, and most have rates that are far higher. There is also no support for the claim that "the sum total of the evidence presented here supports the hypothesis that ... when CS rates rise substantially above 15%, risks to reproductive health outcomes may begin to outweigh benefits". When C-sections are performed for medical indications, there is no evidence that rising C-section rates lead to rising rates of maternal or neonatal mortality.

The authors own data indicate that a C-section rate of 15% is unacceptably low, and that the average should be at least 22%, with rates as high as 36% yielding low levels of maternal and neonatal mortality.

The organic food scam

This post originally appeared in March 2009.

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.

Father arrested for smoking near infant?

Consider:

A young rural father was recently arrested and charged with felony child endangerment for smoking in the presence of his infant son. Police called to the home to investigate a domestic disturbance observed the father smoking cigarettes although a 6 week old infant was present in the same room.

Officers responding to the home reported that the smoking was a chronic problem. One noted that the home positively "reeked" of stale smoke indicating an long term, ongoing habit.

Parental smoking is known to increase risk of infant wheezing, respiratory disease and even death. As the police chief pointed out, "increasing the risk of infant death is clear evidence of felony child neglect. Our officers had no choice but arrest the father and file charges."

If convicted, the father faces up to 5 years in prison.

This incident never happened, but it ought to happen all the time if the case of Stacey Anvarinia, the woman arrested for breastfeeding while drunk, is a precedent. I was quoted in a recent Associated Press article about this case, expressing outrage that a young woman was arrested for a made-up crime. The reaction to my comments indicate that many people feel that Ms. Anvarinia got what she deserved.

Why then would the same people would probably recoil in horror at the idea of arresting men who smoke in the presence of their infants? Fundamentally, it is the result of the American inability to understand relative risk.

Most Americans unthinkingly accept all sorts of risks that are familiar, while simultanously expressing outsize alarm at risks that are trivial in comparison. We like to pretend that we would never expose our infants to risk, but simply putting them into a car to drive to the store represents a risk far larger than the risk posed by breastfeeding while drunk (which is merely theoretical) or the risk of smoking in the presence of an infant (which is an all too real risk of illness and death).

Simply put, some risks, though large, are judged to be acceptable, while others, trivially small or non-existant, excite outrage. Those who throwing proverbial stones at Ms. Anvarinia for breastfeeding while drunk are living in glass houses. Many routinely expose their own infants to the far greater risk of travelling in a car.

Unfortunately, there's an element of discrimination, too. The risk that smoking poses to an infant is far greater than any theoretical risk of breastfeeding while drunk. Yet I suspect that people would react with outrage at the idea of a smoker being arrested for smoking in the presence of his or her infant. Smoking is socially acceptable, while breastfeeding, for all its known benefits, is still considered slightly strange and suspect.

We need to be honest with ourselves about our own prejudices. When it comes to children and risk, we cannot pretend that we are unwilling to accept risk, because the reality is that we consider some risks, even large risks, acceptable. Moreover, we treat some risks as acceptable because they are socially acceptable. Smoking in the presence of an infant is more dangerous than breastfeeding while drunk. Unless we are willing to arrest and charge parents who smoke in the presence of their infants, we should stop self-righteously condemning Ms. Anvarinia.

"The mother is the factory"

I'll be traveling intermittently for another week, and will occasionally repeat an old column. This article originally appeared on my Open Salon blog in August 2008.

Who said: "the mother is the factory, and by education and care she can be made more efficient in the art of motherhood"?

That was written in 1942 by Grantly Dick-Read, widely considered to be the father of modern natural childbirth. Most people don't realize that natural childbirth was invented by a man to convince middle and upper class women that childbirth pain is in their minds, thereby encouraging them to have more children. Read’s central claim was that “primitive” women do not have pain in childbirth. In contrast, women of the upper classes were “overcivilized” and had been socialized to believe that childbirth is painful.

Grantly Dick-Read's theory of natural childbirth grew out of his belief in eugenics. He was concerned that "inferior" people were having more children than their "betters" portending “race suicide” of the white middle and upper classes. Read believed that women’s emancipation led them away from the natural profession of motherhood toward totally unsuitable activities. Since their fear of pain in childbirth might also be discouraging them, so they must be taught that the pain was due to their false cultural beliefs. In this way, women could be educated to have more children.

According to Read: "Woman fails when she ceases to desire the children for which she was primarily made. Her true emancipation lies in freedom to fulfil her biological purposes"..

The comparisons between "overcivilized" white women and "primitive" women who gave birth easily was not merely the product of racism, but reflected the anxiety that men felt about women's emancipation. This anxiety was expressed in medicine generally, and in obstetrics and gynecology particularly, by the fabrication of claims about the "disease" of hysteria and the degeneration of women's natural capabilities in fertility and childbirth compared to her "savage" peers. Simply put, the result of women insisting on increased education, enlarged roles outside the home and greater political participation was that their ovaries shriveled, they suddenly began to experience painful childbirth and they developed the brand new disease of "hysteria", located in the uterus itself.

Pain in childbirth served a very important function in this racist and sexist discourse: it was the punishment that befell women who became too educated, too independent and left the home. The idea that "primitive" women had painless childbirth was fabricated to contrast with the painful childbirth of "overcivilized" women.

Grantly Dick-Read was issuing a warning to women of a certain social class: if you step beyond the roles prescribed for women, you will be punished with painful labor. And if you have had painful labor, you should understand it as a punishment for ignoring your "natural" duty to stay home and procreate.

In light of this, the contemporary popularity of natural childbirth is more than a bit ironic. The central claims of natural childbirth, that childbirth is not inherently painful, and that if you "prepare" properly, your birth will be painless, too, were utter fabrications. Read would be delighted that these fabrications have been embraced by many women and that his philosophy has been propagated so successfully that most women don't even realize that the central tenets of natural childbirth are racist and sexist lies.