Tag Archives: Medicine

Posts that relate to medicine in some way.

Sex and stigma (part I)

I recently had a discussion with a friend regarding the stigma surrounding sexually transmitted infections and around sex in general. Given the puritanical foundation of our largely paternalistic Judeo-Christian country it is understandable that rigid sexist ideals and social taboos prevail. However, it is also important to note that just below this whitewashed facade lies an occult but rich and gooey truth: humans love sex and few live up to the standards that society attempts to impose. Just look at all the fallen poster boys and girls of the so-called “Moral Majority” (Ted Haggard, Mark Sanford and Iris Robinson to name a recent few). I’ve done a little digging to bring some of that goo to the surface and with the rest of this blog I intend to demonstrate the hypocrisy of the current moral code.
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According to George Michael:

Sex is natural, sex is good
Not everybody does it
But everybody should
Sex is natural, sex is fun
Sex is best when it’s
One on one

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Britney Spears disagrees:

1, 2, 3
Not only you and me
Got one eighty degrees
And I’m caught in between
Countin’
1, 2, 3
Peter, Paul & Mary
Gettin’ down with 3P
Everybody loves ***
Countin’

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But Salt-N-Pepa hits the nail on the head:

Let’s talk about sex, baby
Let’s talk about you and me
Let’s talk about all the good things
And the bad things that may be
Let’s talk about sex
Let’s talk about sex
Let’s talk about sex
Let’s talk about sex
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Consider Abstinence Only education. A 2008 comparison study of 3440 nationally representative middle and high school students aged >15 years who, when surveyed in 1995, had never had sex or taken a virginity pledge found the following: (Rosenbaum JE. Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers. Pediatrics. 123(1):e110-20, 2009 Jan.)

  • The US government spends more than $200 million annually on abstinence promotion programs, including virginity pledges
  • >90% of abstinence funding does not require scientific accuracy
  • 81.9% of pledgers denied taking the pledge 5 years later
  • Pledgers did not differ in the average lifetime sexual partners (3) nor in the age of first sex (21)
  • 73% of pledgers and 76% of nonpledgers had had sex at the 5 year mark
  • Fewer pledgers than matched nonpledgers used birth control and condoms in the past year and birth control at last sex

A 2007 prospective study of 240 heterosexual 18–20-year-old male university students in Tucson, AZ found the following: (Partridge JM. Hughes JP. Feng Q. Winer RL. Weaver BA. Xi LF. Stern ME. Lee SK. O’Reilly SF. Hawes SE. Kiviat NB. Koutsky LA. Genital human papillomavirus infection in men: incidence and risk factors in a cohort of university students. Journal of Infectious Diseases. 196(8):1128-36, 2007 Oct 15.)

  • Only 25% of men reported 4 or fewer lifetime sex partners
  • 25% reported >16 lifetime sex partners
  • Only 20.7% of men reported consistent use of condoms during sexual intercourse
  • 41.0% reported never having used condoms

So what happened with all that unplanned, unprotected sex?

The fact of the matter is that while abstinence may be a lofty ideal for some people it is clearly not a viable option for the vast majority of humans. The insistence on abstinence education only is not only ludicrous but clearly dangerous. It has been nothing more than a complete and utter failure to American youth and a waste of tax payer money.

So just what are our real sexual habits anyway? When do people actually become sexually active? According to the 2002 NSFG data as presented by the CDC (MMWR: Sexual and Reproductive Health of Persons Aged 10–24 Years—United States, 2002–2007)

  • % of teens reporting having had sex:
    • Females aged <15 years: 13.1%
    • Females aged 15-17 years: 30.0%
    • Females aged 18-19 years: 70.6%
    • Males aged <15 years: 14.8%
    • Males aged 15-17 years: 31.6%
    • Males aged 18-19 years: 64.7%
  • Females aged 18-24 years who have experienced involuntary intercourse in the past: 9.6%
  • Females who have experienced forced intercourse in the past:
    • Females aged 18-19 years: 14.3%
    • Females aged 20-24 years: 19.1%
  • 3 in 10 adolescents aged 15-19 years reported having had 2+ sexual partners
  • Among never-married sexually active adolescents aged 15-19 years, 75.2% of females and 82.3% of males reported using a method of contraception at first intercourse
  • Among adolescents aged 18-19 years, 49.8% of females and 35.1% of males had talked with a parent before reaching age 18 years about methods of birth control
  • Among females aged 15-17 years, 88.0% of births were from unintended pregnancies

Yes, virgins do exist but they are few in number. A 2009 case-control study of 210 college-aged men aged 18–23 years in Baltimore, MD found the following: (D’Souza G. Agrawal Y. Halpern J. Bodison S. Gillison ML. Oral sexual behaviors associated with prevalent oral human papillomavirus infection. Journal of Infectious Diseases. 199(9):1263-9, 2009 May 1.)

  • Among college-aged men
    • 9% never engaged in open-mouthed kissing
    • 28% never performed oral sex
    • 30% never had vaginal sex
  • Among the control patients
    • 24% never performed oral sex
    • 2.6% never had vaginal sex

For the rest of us, surprise, surprise! Humans LOVE to fornicate and few of us are virgins on our wedding/commitment days. A 2007 study of the four most recent cycles of the National Survey of Family Growth (NSFG) of men and women aged 15-44 found the following: (Finer LB. Trends in premarital sex in the United States, 1954-2003. Public Health Reports. 122(1):73-8, 2007 Jan-Feb.)

  • By age 20, 77% of respondents had had sex, 75% had had premarital sex, and 12% had married
  • By age 44, 95% of respondents had had premarital sex
  • Among those who abstained until at least age 20, 81% had had premarital sex by age 44

Screw procreation. Straight couples like oral and anal sex almost as much as their gay and lesbian counterparts and are just as neglectful with condom use. A 2007 survey of 12,571 heterosexual men and women aged 15–44 years found the following: (Leichliter JS. Chandra A. Liddon N. Fenton KA. Aral SO. Prevalence and correlates of heterosexual anal and oral sex in adolescents and adults in the United States. Journal of Infectious Diseases. 196(12):1852-9, 2007 Dec 15.)

  • 3/4 of heterosexual men and women have had oral sex
  • 1/3 of heterosexual men and women have had anal sex
  • Condom use during last oral or anal sex was relatively uncommon

Likewise, a 2009 study of heterosexual anal intercourse in 1348 adolescents and young adults aged 15 to 21 years in 3 US cities found: (Lescano CM. Houck CD. Brown LK. Doherty G. DiClemente RJ. Fernandez MI. Pugatch D. Schlenger WE. Silver BJ. Project SHIELD Study Group. Correlates of heterosexual anal intercourse among at-risk adolescents and young adults. American Journal of Public Health. 99(6):1131-6, 2009 Jun.)

  • 8% of boys and 6% of girls aged 15-17 years have had anal sex
  • And 33% of men and 30% of women aged 20-24 years have had anal sex

Finally, it is important to recognize the work of Alfred C Kinsey in bringing the discussion of actual sex experience into the open. His 1948 landmark study on sexual behavior in the human male revealed the following: (Kinsey AC. Pomeroy WR. Martin CE. Sexual behavior in the human male. 1948. American Journal of Public Health. 93(6):894-8, 2003 Jun.)

  • About 60% of pre-adolescent boys engage in homosexual activities
  • At least 37% of the male population has some homosexual experience (physical contact between other males who were brought to orgasm as a result of such contact) between the beginning of adolescence and old age

So in conclusion to part I of Sex and Stigma, humans are social, sensual and sexual beings. We are not very good at abstaining from sex even though socially conservative political forces continue to try to keep sex education in the Dark Ages. If we are truly going to make a difference in decreasing our shameful number of unintended pregnancies (we have the highest rate in the entire industrialized world) and at least slow the transmission of sexually transmitted infections we need to foster an environment where we can be at least honest with ourselves and our kids and have educated discussions about sex. Our middle school and high school students deserve better than abstinence only education. We cannot continue to allow our youthful generations to suffer the consequences of heavy handed pious ideology. Advocate for youth and oppose federal funding of abstinence-only education!

Throwing wrenches at the gears

I just finished my first week back on the labor and delivery service and happened to be on call on Saturday. As we were discussing patients in the workroom my senior resident inquired if I had asked a patient whether or not she wanted her son circumcised. I replied that I had not asked and that I would not be asking that question of anyone in the future.  Well sparks flew!

At this particular hospital infant male circumcision has become so institutionalized that it is treated almost as casually as a fast food worker asking, “Do you want fries with that?” “So you had a boy, huh? You want a circ with that?” On one hand we are appalled at the female circumcision that so many of our Somali patients have undergone yet we barely bat an eye at the other. Why are we so horrified by the surgical modification of female genitalia by another culture when we are so flippant about surgically modifying the genitals of our own infant boys?

So what is female circumcision anyway? It is a procedure done in parts of Africa, Asia and the Middle East where as little as the clitoral hood to as much as the entire clitoris and labia are excised. What little tissue remains after this procedure grows together (often aided by leg binding) sometimes leaving  a hole so small that sexual intercourse is physically impossible. In the U.S. we code it as “female genital mutilation” but of course no such verbiage is used with infant male circumcision. Now granted, I completely understand that cutting off some penis skin is not nearly as morbid as cutting off a clitoris. But less bad is still bad! Both procedures are forcefully performed without the consent of the individual receiving it and both have permanent consequences.

Many physicians and new parents justify their decision to participate in infant male circumcision for social or religious reasons. Others speak to its public health merit in reducing the transmission of HPV (the virus that causes cervical cancer in women) and HIV (the virus that causes AIDS). Yet all of these excuses (and yes, they are excuses) fail to consider the rights of the people involved. Infant boys are clearly unable to provide informed consent. Period.

One of the four ethical principles to which we prescribe as physicians is “Autonomy” – the right of each patient to make informed medical decisions regarding his/her own care. Also within the Hippocratic oath we take is the principle “First, do no harm.” It is impossible to honor these guiding ideals while performing circumcision or any other elective cosmetic genital surgery on infants and children.

And why are OB/GYN providers doing circumcisions anyway? For a specialty that prides itself on treating women only it is quite surprising how many providers perform this little side gig on infant boys. What infant penises have to do with women’s health I’ll never understand.

So what happened with my refusal to participate? Well I met with the residency program director today who affirmed my right to refrain from participating in procedures I am morally opposed to. I will not be forced to ask patients if they want us to maim their sons. I will continue to wear my Genital Autonomy badge with honor and I will continue to throw wrenches at the gears of status quo.

Related posts

For some teens, puberty brings unexpected changes

recent article published on CNN discusses the lives of two teens in Palestine raised as girls but transformed by puberty into boys. These teens most likely have a condition called 5-alpha-reductase deficiency (5-ARD), one of several intersex conditions (disorders of sex development) that alters the masculinization of XY fetuses before they are born. Unfortunately, the article uses outdated words and phrases such as “pseudohermaphrodism” and “sex-change operations” that should no longer be used because they are offensive. However it does raise awareness and give face to a group of people who are usually hidden away.

All fetuses have the same internal and external genitalia until about 8 weeks of gestation. Then various hormones act to differentiate the sexes by developing some parts and regressing others. But there are many steps involved and DNA mutations can modify this outcome. I suspect that Caster Semenya, the recently contested 2009 gold medal winner of the 800 meter race at the World Athletics Championships, has androgen insensitivity syndrome (AIS). If this is so, her XY chromosomes and testes were unable to masculinize her body as it formed; a defective hormone receptor prevents her body from responding appropriately to the male hormones it produces. However, her receptors may be only partially impaired and thus give her, in some people’s view, an unfair advantage over her competitors. The allegations, the subsequent gender verification studies and the fallout therefrom continue to embroil her in international controversy. But what makes a woman a woman? If she isn’t a woman than what is she? She certainly isn’t a man.

The Palestinian teens discussed in the article have a different mutation. Like Caster, they probably have XY chromosomes, testes and appeared just like any other girl when they were born. Yet while their hormone receptors work, they lack the enzyme needed to convert testosterone into its more powerful form, dihydrotestosterone (DHT). Their bodies appeared female before puberty because the amount of testosterone produced was insufficient to make up for the absent DHT. After puberty began their testosterone levels went through the roof just like every other adolescent boy. This brought along the changes the go with it including facial hair, deeping voice and musculoskeletal changes. Their clitorises probably enlarged significantly just as penises do. But do these teens really feel that they are now men or do they still feel that they girls inside of bodies that have betrayed them?

“Only my appearance, my haircut and clothing, makes me look like a boy,” Ahmed says, gesturing with his hands across his face. “Inside, I am like a female. I am a girl.”

Why do we care if Caster and these teens are men or women, one or the other? Is it right for society to force them to change to uphold the myth of binary gender? When you really think about it, no one fits the stereotype completely; no one is or every was the ideal man or the ideal woman. They are only fantasies. Instead we are all composites, not one of us pure in form. We exist somewhere in the middle leaning this way and that in varying degrees depending on which attribute we consider. Gender is so much more than the 2 little check boxes “male” and “female.” Maybe someday we will learn to allow each other the space to simply be who we are. A world without labels and boxes, without simplification and alteration. We will finally see the world as it already is.

Poison in the water

According to a recent article the New York Times you may want to think twice about drinking water from the tap.

“Only 91 contaminants are regulated by the Safe Drinking Water Act, yet more than 60,000 chemicals are used within the United States… hundreds associated with a risk of cancer and other diseases at small concentrations in drinking water.”

Some of them are arsenic, chromium (movie: Erin Brockovich), perc and uranium. To see if you live in a higher risk area click here.

So what to do? Don’t contribute to landfills by buying bottled water every day. Instead, buy filtered water from the grocery in refillable containers for all of your potable needs.

IAAF offers to pay for Caster Semenya’s gender surgery if she fails verification test – Telegraph

IAAF offers to pay for Caster Semenya’s gender surgery if she fails verification test – Telegraph. This article was recently addressed in the Organisation Intersex International (OII) Forum and someone asserted that the reason why doctors remove testicles from women with androgen insensitivity syndrome (AIS) is because we want to prevent women from having them. So, I did a little research and this is what I found out:

There really isn’t a conspiracy to prevent women from having testes. The issue is that mammalian testes need to be cooler than core body temperature; thus testes have evolved to hang outside of the body in scrotums. Internalized testes are a cancer risk for both men and women. And the risk of cancer is greater in women with AIS than in men with undescended testes (UDT).

According to HM Wood (1):

  • The incidence of testicular cancer in men is 0.9 to 7.8 per 100,000 men per year
  • 1.1 to 1.6% of boys have unilateral or bilateral undescended testes
  • Among men with testicular cancer, 5-10% have had a history of UDT
  • Men with a history of UDT have 2.75 to 8 times the risk of testicular cancer compared to men who don’t; the risk is even higher in men with bilateral UDT, associated genitourinary anomalies, or late (after age 10-12 years) or uncorrected UDT
  • Orchiopexy (repositioning testes outside the body) by age 10 to 12 years results in a 2 to 6-fold decrease in relative risk of cancer compared with orchiopexy after age 12 years or no orchiopexy

According to SJ Robboy (2):

  • The incidence of complete AIS is 1 in 20,000 live births
  • There is a risk for malignancy in AIS gonads owing to the occurrence of germ cell tumors. The cumulative risk for a germ cell tumor is greater than 30% by 50 years of age
  • The risk of malignancy in patients with testicular feminisation is only 4% by the age of 25 years, but reaches 33% by 50 years

Thus, women CAN have testes, but they should be removed if they aren’t located in a scrotum.

References:
(1) Wood HM. Elder JS. Cryptorchidism and testicular cancer: separating fact from fiction. Journal of Urology. 181(2):452-61, 2009 Feb.
(2) Robboy SJ. Jaubert F. Neoplasms and pathology of sexual developmental disorders (intersex). Pathology. 39(1):147-63, 2007 Feb.

Gene discovery could make FTM gender reassignment easier

Jessica Green of Pink News is reporting that researchers at the National Institute for Medical Research have discovered that switching off a single gene, FOXL2, is all that is needed to make ovarian cells turn into testicular cells. This discovery could lead to the development of a new drug that would allow trans-men to essentially convert their ovaries into testes and to develop male characteristics such as facial hair and a deepened voice without hormone therapy.

Talk to your kids about sex

Alice Park reports on Time.com that parents are talking with their kids too little too late according to a 2009 study in Pediatrics. In fact, approximately 40% will have sex before their parents finally bring up the subject of “the birds and the bees”. It certainly was true in my case.

I can remember being a teenager and one ordinary day my mother taking up the subject of sex. She just kept going on and on about how important it was to stay a virgin until marriage in spite of my protests “I know, Mom” and attempts to change the subject. Eventually I tired of her lecture and finally blurted out, “Mom, just stop. I’m not a virgin.” I still remember the look of shock in her eyes as she muttered, “I’m so disappointed in you” before walking away.

Frankly, I was disappointed in her. Waiting until your kid is 16 before having this conversation is way too long. I remember kids talking about sex on the playground in elementary school, don’t you? Kids aren’t dumb and kids are curious.

I took a different approach with my kids. Beginning in their toddler years I began addressing the subject of body parts using their correct anatomic names — a penis is not a “peepee” or “junk” nor is a vagina “private parts”. Eyes are eyes and noses are noses, why should sexual organs be any different? As their minds developed I added more to their knowledge, always addressing the subject in a matter of fact way and answering all of their questions. If a child is able to comprehend and formulate a question then s/he is mature enough to receive an answer.

I recently had a conversation with my son who is 11. He told me that now that he is in 6th grade he has to have health and sex education. He seemed rather annoyed by the idea and said, “I really don’t know why I have to learn about it in school, you’ve already taught me all about it.” I just listened and smiled.

Tylenol® Terror!

Most people think of Tylenol (generic name: acetaminophen) as a safe medication for pain. After all, you can buy it without a prescription. While it is relatively safe when taken as directed, acetaminophen is also toxic to the liver when taken in excess. If the liver dies so will the body unless a replacement liver is transplanted.

The liver is an essential organ that helps keep the body’s chemistry in balance. It also makes important proteins so that blood will clot when we bleed. When the liver dies, toxins build up in the body causing altered mental function, eventual coma, and death. This is complicated by worsening unstoppable bleeding. All in all it’s a horrible way to die and is certainly not quick and painless.

The maximum dose of acetaminophen anyone should take is 1000mg (1 gram) at a time and a total of 4000mg (4 grams) in one day. If you drink alcohol, have bad kidneys, or have a bad liver, you will have to take less and should be under doctor supervision.

Please check your medications carefully! Acetaminophen has been added to many other medications and you may not even realize that you are taking it unless you pay attention. Some over-the-counter medications that have acetaminophen are Excedrin, NyQuil, Pamprin, Sudafed, and Theraflu. Some prescription medications that have acetaminophen are Lortab, Percocet, and Vicodin. When in doubt, ask a doctor or pharmacist for help.