But will Medicare pay for lube?

You might have missed the part about the penis pumps. It was in a New York Times article about Medicare overpaying for things like oxygen tanks. Apparently Medicare, despite its potentially enormous bargaining power, spends more for many items than they would cost in your neighborhood pharmacy or surgical supply store. In the midst of the article is this paragraph:

For example, last year Medicare spent more than $21 million on pumps to help older and disabled men attain erections, paying about $450 for the same device that is available online for as little as $108. Even for a simple walking cane, which can be purchased online for about $11, the government pays $20, according to government data.

The article doesn’t comment at all on whether penis pumps are a legitimate Medicare expense, which I think is interesting. Given our government’s very conflicted attitudes about sex, I find the news both heartening and irritating. I am glad that Medicare takes the needs of aging men seriously and considers sex a part of healthy living. We were just discussing that when we were discussing Pepper Schwartz’s book Prime. TracyA linked to a great post by Supercrone about sexual desire in her 80s, Mimi of Sexagenarian in the City writes about her own re-entry into dating and sex, and so I’m glad that the US takes the sexual needs of the elderly — at least elderly men — seriously. I wonder why it denies the sexual needs of so many of the rest of us. Our own internal contradictions around sexuality are pretty amazing. Medicare, an entitlement program for older folks, will pay for penis pumps. Medicaid, the program that provides health care for poor people, does not cover abortion services (thanks in large part to Henry Hyde, who died the other day) though states are apparently free to provide such coverage. (For example, in New York State residents enrolled in Medicaid are entitled to “Free access” family planning — including contraception and abortion — even if their Medicaid Managed Care Provider does not cover those services.) We see inability to have intercourse as an illness for the elderly but don’t want to teach young people about safer sex.We spend our tax dollars foolishly in either case, overpaying for penis pumps or paying at all for abstinence-only education.But back to the penis pumps again: is this an example of sexism in health care again? I mean, older women are less likely to be in need of contraception or other family planning services, but does Medicare pay for lube? Or are women expected to deal with the changes in their sexual function on their own while men’s physical changes get medical attention? (And if Medicare does cover lube, what are they paying for a bottle of Astroglide, do you think?)And is Medicare paying for condoms to keep these older men from getting and transmitting STIs? Or are we again in a situation where we’ll pay to address the disease (inability to maintain erection) but not to prevent disease?If, like me, you were wondering about the efficacy of penis pumps in the first place, here is a link to Corey Silverberg’s piece on them from About.com. He points out that penis pumps are pretty reliable at generating erections but that unless well aroused, or if the man has a problem maintaining erections, that the erection created by the pump might not last. He mentioned that better penis pumps, of the sort sold by medical professionals (which he says run about $200, not the $450 that the US pays) come with “constriction rings” (read: cock rings) that help maintain the erection.I wonder if Medicare would cover the cost of cock rings alone for men who have no trouble getting erections but do have trouble maintaining them.And what about sex ed for older folks so that they know that there is plenty of good sex to be had without erections and penis-vagina penetration? What about some workshops on manual sex? Oral sex? Sex with toys? Training in orgasm without intercourse, anyone?Meanwhile, lets make sure that all government provided health care treats sex as an important component of healthy living. Lets make sure that Medicaid and Medicare cover sexually-related health care costs, whether those be penis pumps or lube, or contraception or abortion. If sex is a party of a healthy life, those things are all important.Lets make sure that private insurance plans do the same!And lets pay for smart sex education for sixty-year-olds and for sixteen-year-olds!Illustration, “Penis Pump,” by Derek on Flickr, and used under a Creative Commons Attribution, Noncommercial, Share alike license.NOTE: This is also published on our community site, SexInThePublicSquare.org. Join us there!

Technorati Tags: government, health, news and politics, sex, sex and age, sex education, sexuality

Prevention bill(s)* still stuck in committee while Democrats increase Abstinence-Only Funds

File this under “with friends like these…”

What has happened to the Prevention First Act (H.R. 819/S. 21)? Why are these bills stuck in committee while the Democrats are INCREASING funding for abstinence-only education? Don’t they at least have an obligation to hold the line on such misappropriate of funds? We’re talking about the spending of 141 million dollars on programs that we know don’t work and that actually put our communities at risk. And we’re talking about the party in control, the one that is supposed to be friendly to smart sexual health policy, granting this increase in spending and as a result teaching kids that abstinence-until-marriage is the only legitimate approach to sexuality and that condoms don’t work well.

James Wagoner at RH Reality Check, expresses his outrage about this far more articulately than I could express mine. He writes:

I am constantly told that it’s not “politic” to call out our friends on an issue like sex education. There are bigger fish to fry. I’m not buying that anymore. Not when ten thousand young people get an STD, two thousand become pregnant and fifty-five contract HIV every single day in this country. Not when poll after poll shows this issue to be a political winner, not a loser, for Democrats. Not after Democrats exploited this issue in opposition and now, with control of Congress, act like it’s an insignificant chit to be bartered away at the whim of a recalcitrant committee Chairman.

It is now time to call this what it truly is. A stunning disgrace.

A stunning disgrace, indeed. And this is not a new story. We wrote about this here back when the Dems in the House of Representatives voted to approve the increase when they passed the Labor/Health and Human Services appropriations bill. But its in the news again because the bill has just come out of the Democrat-controlled conference committee and the increase is intact. And the increase is outrageous. SIECUS reports that the Senates version of the bill would have reduced funding for abstinence-only programs. Why didn’t they hold that position in the conference committee?

We’re nearing election day and it is important to remember that the Democrats are not so clearly our friends. And they ought not be allowed to continue to get away with hurting us just because the Republicans might hurt us worse.

You know, it really starts to feel like an abusive relationship, doesn’t it? You know, the kind where you are being beaten but feel trapped because if you leave you’ll be worse off?

We need shelters for the battered body politic. I think they’re called multiple-party systems. You know, where real choices are possible.

Maybe that would be a truly “pro-choice” system.

I think we need to start building one.

Now.

*The Prevention First Act is only one of a slew of bills that were introduced to try to make sane sex ed and contraception policy. The REAL (Responsible Education About Life) Act is another that is stuck in committee. For a look at the whole list, depressing though it is that none are moving, click here.

Note: This piece is also published on my blog at our community-building site, SexInThePublicSquare.org. Drop by and join in!

Photo of “Condom Police” sign not taken in the US no matter how much it may feel that way. The sign was photographed in Vanuatu by “Phnk“, posted on Flickr and used here under a Creative Commons Attribution-Noncommercial license.

Technorati Tags: abstinence-only, Congress, health, news and politics, sex and age, sex education, sexuality

Because mastectomy should never be an outpatient procedure!

It’s been kind of quiet around the Public Square on WordPress and that’s mostly because I’m back full time at the college after a year of sabbatical and am just getting up to speed with classes, students, committee work while trying to keep an active hand in at SexInThePublicSquare.org (our very exciting community-building site).

One of the wonderful things about being back in the classroom, though, is that students share information that I wouldn’t necessarily have heard about. Just today a student passed along to me a link to a petition sponsored by Lifetime that calls for passage of legislation to guarantee that health insurance companies pay for at least two days of hospitalization for women who have mastectomies. This is to guard against the health insurance companies’ desires to limit coverage to one day or even to outpatient classification.

Outpatient mastectomies? We’re talking major surgery here. Removal of a breast is not an uncomplicated thing, nor is the aftercare required in the days immediately following the surgery.

And this year’s legislation isn’t the first time the issue has been raised in Congress. Not by a long shot. Not by a decade, in fact. For the past 10 years Rep. Rosa DeLauro (D-CT) has been trying to get legislation passed in Congress that would mandate insurance companies to pay for at least two nights of hospitalization for women having mastectomies. She has introduced her bill, called the Breast Cancer Patient Protection Act, five times. Each time it has been consigned to languish in committees.This year she has agan reintroduced the bill. It is HR 758 this time around, and again it has been assigned to several committees. In fact, here’s the list of committees to which it has been referred before action can be taken:

House Energy and Commerce

House Energy and Commerce, Subcommittee on Health

House Education and Labor

House Education and Labor, Subcommittee on Health, Employment, Labor, and Pensions

House Ways and Means

House Ways and Means, Subcommittee on Health

The corresponding Senate bill (S. 459 ) has also been assigned to committees: Senate Health, Education, Labor, and Pensions

Lifetime has a petition in support of this legislation and of course I encourage you to sign it. But sometimes petitions are not enough. Clearly this is one of those times. What we need now is a direct call-in, letter-writing, and email campaign.

Click here to locate your Senators and Representatives. Call them or email them to tell them, very simply, that you don’t think that mastectomy should ever be an outpatient or overnight procedure and that insurance companies should not be allowed to override doctors when it comes to providing proper care for a patient.

Mastectomy surgery is major surgery. Women need the kind of care that can best be provided by nurses and doctors in the days immediately following a mastectomy.

These bills will be allowed to expire in committee again, for the fifth time, if we don’t loudly draw attention to the issue.

If you do write, I encourage you to leave a copy of your letter as a comment here. That will help others who want to write but aren’t sure how to get started.

Democrats vote to increase funding for abstinence-only “education”

I don’t know how I missed this item posted on the Advocates for Youth web site last week:

Democrats INCREASE Funding for Discredited Abstinence-Only Policy
Ignore Findings that Programs Don’t Work

WASHINGTON, DC (July 19, 2007) Today, by a vote of 276 to 140, the House of Representative passed the Labor-HHS Appropriations Bill which included an unprecedented $27.8 million increase for failed abstinence-only-until-marriage programs, bringing the total annual funding for Community-Based Abstinence Education (CBAE) to $141 million.

“In one spectacularly cynical move, the Democrats turned their backs on science-based public health and chose political expediency over the health and well-being of young people,” said James Wagoner, president of Advocates for Youth. “With friends like these, who needs conservative Republicans?”

Democrats who have been ardent critics of abstinence-only voted to increase the very programs they opposed when Republicans controlled the Congress.

“With this vote, reproductive health ‘champions’ like Representative Nancy Pelosi and Nita Lowey have aligned themselves with ultra-conservative abstinence-only proponents,” added Wagoner. “They are now complicit in funding programs that promote ignorance in the era of AIDS.”

Since 1982, Congress has allocated over $1.5 billion for abstinence-only-until-marriage programs that censor information about birth control and the health benefits of condoms in the prevention of sexually transmitted diseases. A 10-year congressionally mandated evaluation conducted by Mathematica Policy Research, Inc. and released in April, 2007, found that “youth in the [abstinence-only] program group were no more likely than control group youth to have abstained from sex and, among those who reported having had sex they had similar numbers of sexual partners and had initiated sex at the same mean age.”

“It’s becoming increasingly difficult to tell our friends from our opposition these days,” concluded Wagoner. “The majority of Democrats say they oppose these ineffective programs because they withhold life-saving information, yet they failed to act on those beliefs. Shame on them!”

Cynical? Cynical doesn’t even come close.

Now I know these provisions are buried in huge appropriations bills. And this one is interesting because in at least some states (New York, California, I haven’t checked them all!) it is the Democrats who tended to support the bill and Republicans who tended to it. So clearly the vote wasn’t “about” abstinence-only “education.” It was more likely about the funding of things like public schools and hospitals, for museums and libraries, public broadcasting, programs for the blind, for Medicare, for the National Labor Relations Board, and other important stuff. (Click here for the text of the bill, its provisions, and the programs it funded.)

But Democrats certainly had an opportunity in moving the spending bill through the House to amend it or alter provisions to which they objected, and they certainly could have cut funding for abstinance-only programs and allocated money instead for comprehensive sex education programs (which, by the way, also promote abstinence as the best policy for teens).

Here is the section of the bill that deals specifically with “abstinence education”

Provided further, That $136,664,000 shall be for making competitive grants to provide abstinence education (as defined by section 510(b)(2) of the Social Security Act) to adolescents, and for Federal costs of administering the grant: Provided further, That grants under the immediately preceding proviso shall be made only to public and private entities which agree that, with respect to an adolescent to whom the entities provide abstinence education under such grant, the entities will not provide to that adolescent any other education regarding sexual conduct, except that, in the case of an entity expressly required by law to provide health information or services the adolescent shall not be precluded from seeking health information or services from the entity in a different setting than the setting in which abstinence education was provided: Provided further, That within amounts provided herein for abstinence education for adolescents, up to $10,000,000 may be available for a national abstinence education campaign: Provided further, That in addition to amounts provided herein for abstinence education for adolescents, $4,500,000 shall be available from amounts available under section 241 of the Public Health Service Act to carry out evaluations (including longitudinal evaluations) of adolescent pregnancy prevention approaches: Provided further, That up to $2,000,000 shall be for improving the Public Assistance Reporting Information System, including grants to States to support data collection for a study of the system’s effectiveness.

We are now spending almost 137 million dollars to teach teenagers that abstinence is the only acceptable method of preventing STDs and pregnancy, and we are prohibiting organizations that accept grants from this allocation from offering “any other education regarding sexual conduct.”

Ironically, or not, this same bill in Title V section 517 b provides that “None of the funds made available in this Act may be used to disseminate scientific information that is deliberately false or misleading.”

Click here to find out how your legislators voted (once there, click on your state to see each of your legislators’ votes) and then call them or email them and let them know you’re outraged that they didn’t address the problem of abstinence-only funding but instead voted to increase funding for the very programs they claim are harmful to kids. You can use the “Speak Out!!” box on the left side bar to find contact info for your representatives.

By the way, this same bill in Title V section 507, continues the ban on spending federal money to provide abortions (so they aren’t covered for poor women, or for women insured under federal health insurance programs).
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This is posted here and also at SexInThePublicSquare.org

Technorati Tags: childhood sexuality, Congress, news and politics, public discourse,  sex education

The good news and bad news about the new teen birth rate data

A new study by the Federal Inter-agency Forum on Child and Family Statistics reports that the teen birth rate is at an all time low. The current birth rate for teens between 15-17 in the US according to the study is 21 per 1000.* (That’s down from a high of 39 per 1000 in 1991). The same report gives a teen pregnancy rate of 44 per 1000 in 2002, the most recent year for which they give a rate, and some of the drop is attributable to an increase in condom use. You can see a PDF version of the report here.

Any drop in the teen pregnancy rate, the teen birth rate, and any increase in the rate of condom use is certainly very good news. But the good news is hardly unqualified. There is a fair bit of bad news that surrounds those important bits of good news.

One bit of bad news is that the teen pregnancy rate in the US is still much higher than it is in other western postindustrial societies. In the Netherlands and in Switzerland there were only 5 births per 1000 women between 15 and 19 in 2002 according to UN data. (There were 53 per 1000 young women in the US that same year according to the UN figures). The UN data I found did not report pregnancies, only births. Data from the Guttmacher Institute indicate that the pregnancy rate in the Netherlands was 12 per 1000 in 2001.

Another bit of bad news is that in the US there are significant differences in birth rates for girls of different racial and ethnic groups. The lowest teen birth rate is found among Asians (including Pacific Islanders). That group has 8 births for every 1000 girls between 15 and 19. For non-Hispanic White teens, the rate is 12 per 1000, for Native Americans (classified as American Indian/Alaska Native) the rate is 31 per 1000, for non-Hispanic Blacks it is 35, for Hispanics it 48 per 1000.

These differences must reflect, at least in part, access to health care, contraception, accurate sex education, and abortion services. The differences are not likely to be primarily related to differences in sexual activity between groups. A study published by the National Center for Health Statistics reporting on National Survey of Family Growth data from 2002 finds that Hispanic girls between 15-17 are less likely than their non-Hispanic black or white counterparts to have had sex. The same is true for 18-19 year olds. In the first age group 30% of non-Hispanic white girls, 41% of non-Hispanic black girls, and 25% of Hispanic girls report having had sexual intercourse with a male. In the second age group 68% of non-Hispanic white girls, 77% of non-Hispanic black girls, and 59% of Hispanic girls report having done so (p. 24). And, of those girls who had had sex in the previous four weeks, 19% of non-Hispanic white girls had had sex 4 or more times in that period compared with 13% for both black girls and Hispanic girls.

Why do white girls have lower pregnancy and birth rates if they’re having sex more frequently? This same study found inequality in use of contraception (which may provide some support both for the observation of unequal access and also of the observation of cultural barriers to use). White girls were more likely than either other group to be on the pill at the time of their first intercourse (18% compared to 13% of black girls and 10% of Hispanic girls), and were also more likely to use both pills and condoms together during their first time (15% compared to 9 % for black girls and Hispanic girls). This may speak at least in part to their access to multiple methods of contraception and to their ability to gain access to birth control pills before becoming sexually active.

In fact, when asked whether they had ever used specific methods of contraception, the study found that only 37% of Hispanic girls had ever used birth control pills (compared to 68% of white girls and 55% of black girls). Given an intersection between ethnicity and religion, and the prohibitions against contraception by the Catholic church, some of this difference might be explained by religion and culture. But given that Catholics around the world use birth control pretty regularly, I think that inequality of access to health care and prescriptions is a big part of the story.

There is no teen sex crisis in the United States, but there is a sex education and sexual health care crisis in the United States. If we want to bring our levels of teen pregnancy and teen births down to rates that are in line with those of countries like the Netherlands, we need to start addressing teens sexual health as a serious matter, treating teens with respect, and giving them the tools they need to make smart decisions and creating an environment in which those decisions are respected.

We need to do this while paying attention to race, class and ethnic inequality. Teen parenthood is associated with long term disadvantage for parents and for their children. Girls who become parents in high school are less likely to finish high school, and less likely to go to college. Children who start their lives in poverty are less likely to make it into the middle class. They’ve got all kinds of structural factors working against them.

The answer is definitely not to continue promoting abstinence-only sex education. The answer is complicated, but it certainly requires promoting sound, accurate sex education where the values of abstinence are taught in conjunction with the importance of contraception, relationships skills, and emotional well-being. It involves providing support for teen parents so that they are not so disadvantaged. It involves making sure that access to emergency contraception is secured for everyone, and that abortion remains a legal option for young women. It involves providing equal access to health care. And it involves the acknowledgment that we can’t talk about inequality without talking also about sex.

*The original version of this post incorrectly labeled that rate as the “teen birth rate” which would have been the rate for girls between 15-19. The error was brought to my attention by a very careful reader, Carole Joffe, of UC Davis, who continued:

“…the overall figures from 15-19 (birthrate) was 40/thousand–in fact, nearly identical to the year before. This fact aside, I think your analysis of the Report is right on. I look forward to reading more of your postings. Best wishes from a fellow sociologist, Carole.”

Return to the corrected sentence.

A quick update on the Holsinger confirmation hearings

The AP filed a story this afternoon that was then run on the New York Times web page. It’s a disconcerting story in its utterly bland representation of the 1991 paper that Holsinger wrote on homosexuality. Here’s a quote:

Committee Chairman Edward M. Kennedy, D-Mass., said he was worried that Holsinger would let his own ideological beliefs cloud his scientific judgment. He referred to the paper that Holsinger wrote on homosexuality for a study committee of the United Methodist Church.

”Dr. Holsinger’s paper is ideological and decidedly not an accurate analysis of the science then available on homosexuality,” Kennedy said. ”Dr. Holsinger’s paper cherry picks and misuses data to support his thesis that homosexuality is unhealthy and unnatural.”

Holsinger said the 1991 writing was not intended to be a scientific paper and relied on the information available to him at the time.

”First of all, the paper does not represent where I am today. It does not represent who I am today,” Holsinger said.

Holsinger said he was personally troubled by allegations that he harbors bias against gays.

”I’ve worked diligently to provide quality health care to everyone regardless of personal characteristics including sexual orientation,” he said.

As I wrote two days ago, the problems with Holsinger’s paper go beyond the views he expressed on homosexuality, and go beyond what Kennedy claims is a cherry-picking and misusing of data. The problem in that paper, which Holsinger says was not intended to be a scientific paper, is that he doesn’t even cherry pick the data well, nor does he misuse the data in a way that really supports his arguments. The whole paper (which you can find here) is poorly reasoned and weakly written. Whatever it’s intended purpose, it does not represent the quality of work I’d have expected of a 52-year-old doctor (Holsinger’s bio on Wikipedia indicates he was born in 1939).

The article goes on:

Holsinger’s paper is interpreted by gay groups and others as saying that homosexuals face a greater risk of disease and that homosexuality runs counter to anatomical truths.

In the paper, which focuses extensively on human anatomy and the reproductive system, Holsinger said the ”varied sexual practices of homosexual men have resulted in a diverse and expanded concept of sexually transmitted disease and associated trauma.”

Health and Human Services officials said Holsinger wrote the paper when he was asked more than 17 years ago to compile a survey of peer-reviewed scientific data on health issues facing homosexuals.

”Since then, the science has deepened with continued research on these issues. Dr. Holsinger remains focused on addressing the health of all in need, including gay and lesbian populations, consistent with sound science and the best medical practices,” said Health and Human Services spokeswoman Christina Pearson.

It isn’t that gay groups and others interpret the paper to say that homosexuals face greater risk of disease or that homosexuality runs counter to anatomical truths. The paper does say those things. Explicitly. It isn’t a question of spin or interpretation. It’s a question of basic reading comprehension.

And it isn’t okay to explain the paper away by saying it was written more than 17 years ago as a review of peer-reviewed literature on homosexuality, and that the science has deepened since then. Of course the science has deepened since then, but Holsinger’s use of the science that existed when he wrote the paper is poor at best and ideologically driven at worst. It’s nice to say that Holsinger is committed to “addressing the health of all in need…consistent with sound science and the best medical practices” but his paper doesn’t instill confidence in his ability to parse sound science or appropriately evaluate medical or scientific literature.

Meanwhile, HRC reports on the organization’s blog that Holsinger was temporarily stumped today when asked about the Don’t Ask Don’t Tell policy that keeps gays in the military closeted, or fires them if they come out:

Got this email a little while ago from Lara Schwartz, our legal director, on Holsinger’s stance on Don’t Ask, Don’t Tell:

Sen. Sherrod Brown mentioned the 52 fired linguists and asked Holsinger whether homosexuality is more dangerous than untranslated documents and he actually floundered! He eventually stumbled to Al Qaeda being more dangerous, but it took a while.

It’s disconcerting to say the least that a nominee who knows his views on homosexuality are going to be questioned would be unprepared for such a question. It is even more disconcerting that a doctor could possibly believe, or be tempted to believe, that the presence of openly gay members of the military could cause more harm to the military or to the country than might the presence of untranslated intelligence.

It’s not too late to call the Senate switchboard and encourage your senator to support science, intelligence, expertise and experience over loyalty and ideology.

P.S.: According to the AP/NYT article linked above, Holsinger did say he’d resign rather than submit to political pressure to censor his science and his public health program agenda. But he hasn’t convinced me his science-and-health agenda isn’t already in line with the politicians that have done the censoring in the recent past.

 

 

Questions for Dr. James Holsinger, or those in charge of his confirmation hearings

Quick: name the Surgeon General of the United States. Can you do it? I couldn’t. I know all about the guy who is being nominated and nothing about the one who is currently serving. I had to look him up on Wikipedia. He is Rear Admiral Kenneth P. Moritsugu PHSCC, M.D., M.P.H., and he has been acting Surgeon General since his boss, Vice Admiral Richard Henry Carmona, M.D., RN, M.P.H, F.A.C.S., finshed his term in 2006. (For the record, David Satcher is the last surgeon general I have a clear memory of!)

On Thursday, the man selected to replace Moritsugu and take on the full mantle of surgeon general will have his confirmation hearings in the Senate. His name is James Holsinger and it’s a good bet you’ve heard of him. You may have heard that his nomination is a controversial one because he is a conservative Christian or because he has expressed the view that homosexuals are diseased and pathological, and both of those things are true. But he is controversial mostly because he used weak science and faulty reasoning to try to back up his view that homosexuality is pathological. It is that use of unscientific argument disguised as science that makes him an upsetting candidate to take on the job of top public health educator in the US.

This is a link to the paper that is the basis for all this criticism (PDF, hosted on ABCnews.com). Holsinger wrote it in 1991 for the United Methodist Church’s Committee to Study Homosexuality. The main text is only 6 pages long so go ahead and read it. I’ll be here when you get back.

~~~

Done? Good. So you probably have some questions, and so do I. Let’s lay some of them out. My first question comes after reading the second paragraph, which begins, “There is absolute concensus in the scientific community concerning the structure and function of the human alimentary and reproductive systems.” Holsinger goes on to explain that they are entirely separate systems in humans (as we do not possess cloacas, something he returns to later), and then explains how the reproductive systems of men and women interact to produce baby humans.

Now, I’d bet that there is no debate in the scientific community that the two systems are separate, nor that only one of them functions in a way that absorbs nutrients into the body while only the other functions in a way that causes reproduction when properly combined with the right other reproductive organs. But, how many scientists would agree that each system has only one function? And how many would deny that both systems can function in ways that create pleasure? Or would contend that pleasure is not an important part of human existence?

So one question I would ask at Dr. Holsinger’s nomination hearing on Thursday is this:

Dr. Holsinger, do you believe that public health policy and health education should ignore the ways that we use our bodies for pleasure, and should omit information about how we can do so safely?

My second question comes after a description of how the anus and rectum do not lubricate in the way that a vagina does, and so can be damaged by penetrative sex. From this observation he argues that “the varied sexual practices of homosexual men have resulted in a diverse and expanded concept of sexually transmitted disease and associated trauma.” He cites a study that I wont attempt to evaluate because I haven’t read it yet. The section he sites notes findings that bisexuals, heterosexuals, and homosexuals had different rates of assorted sexually transmitted diseases. Without commenting on the quality of the research, I can say about this is that his use of the study, whatever its own merits, doesn’t support his argument. He is trying to argue that homosexual sex is pathological and heterosexual sex is not, and he presents evidence that every group gets STDs, but that those STDs are distributed differently across groups. In the study, more homosexuals than heterosexuals get things like amoebiasis and giardiasis while heterosexuals are more likely than homosexual to have urethral gonorrhea and or chlamydia. Unless he’s willing to argue that only some STDs are signs of pathology while others are just fine, I don’t see how this helps his argument.

So, my second question for Dr. Holsinger at his nomination hearings would be this:

Dr. Holsinger, would you say that some diseases are markers of pathology in a person while others are not? If so, which diseases are markers of heathly lifestyles and which are markers of pathological lifestyles?

My third question comes from a strange quote he uses to support the claim that “trauma and tumors are the primary problems related to the anorectum in homosexual men.” He quotes a study that found that women who engaged in “anal-receptive intercourse” did not suffer from anal-sphincter dysfunction and rarely suffered from anorectal problems in general, partly because “consensual penile-anal intercourse can be performed safely provided there is adequate lubrication.” Ignoring that finding even though he cites it, Holsinger then goes on to decry the dangers of fisting and of unlubricated forceful anal sex.

So my third question would be this:

Dr. Holsinger, is it safe to say, based on your writing, that you only think homosexuality is pathological if it does not involves enough lube? In other words, would it be a key part of your public health policy to educate people about the value of proper lubrication? Or, rather, would you suggest that no sex that requires lubrication not supplied by the body itself can ever be healthy sex?

Last, I am puzzled by Holsinger’s claim that squamous-cell anal cancer, which is associated with HPV virus strains that cause genital warts is further evidence of the pathology of homosexuality. After all, those same strains cause genital warts in women, and lead in some cases to cervical cancers (for which we are all supposed to be screened annually or every two years, and which are often contracted through heterosexual contact).

So my fourth question would be:

Dr. Holsinger, how can a disease that occurs frequently in women who have heterosexual sex be used as evidence that homosexual sex is pathological, but not used as evidence that heterosexual sex is pathological?”

He ends his paper with an analogy to pipe fittings in order to illustrate just how taken-for-granted the sense of male-fitting-into-female is in our culture, and notes that injuries and diseases result “when the complimentarity of the sexes is breached.”

I do not want a man who reasons this way to be my Surgeon General. It is not his private views on homosexuality that are the problem, though I strenuously disagree with them. It is certainly not his privately held religious convictions, so long as could keep them separate from his scientific evaluation of evidence.

No, it is his inability to weigh scientific evidence to come to logical conclusions that is the problem. Perhaps Holsinger has gotten smarter in the 16 years since he wrote that article. I hope that difficult questions are asked during his confirmation hearings so we can discover whether he can now reason more logically than he could in 1991.

For updates during the confirmation hearings on Thursday, check the HRC web site’s blog.

To let your Senator that you oppose Holsinger’s nomination, you can use this HRC Action Form.

“Do it ourselves” Abortion Reduction Policy

Atul Gawande had a very clear, concise, mostly very smart and only partially problematic op-ed in yesterday’s New York Times about how to reduce the number of abortions in the US (TimesSelect registration required). He started out by dispelling some of the myths we have about who has abortions and why. For example, on the upsetting side, roughly half of pregnancies are unintended, and four in 10 unintended pregnancies end in abortion. On the optimistic side, teens are getting the message about contraception:

“Pregnancies at age 15 to 17 are down 35 percent since 1995, according to federal data; one-fourth of the drop is from delaying sex, and three-fourths is from increased use of contraceptives. Today, just 7 percent of abortions occur in minors.”

and

“Forty-five percent of abortions occur in adults ages 18 to 24; 48 percent occur after age 25. Most are in women who have already had a child. The kids are all right. We are the issue.”

Consistent and correct use of contraception appears to be the biggest problem:

“92 percent of abortions occur in women who said they used birth control. Six in 10 used contraception the month they got pregnant. The others reported that they had used birth control previously but, for one reason or another, not that month. (Many, for example, say they didn’t expect to have sex.)

Gawande then asserts that the “trouble appears to be blindness to how easy it is to get pregnant and what it takes to make birth control really work.” I would disagree: the trouble is not blindness to how easy it is to get pregnant. It is wishful thinking of the “it won’t happen to me” variety, and a difficulty accepting one’s own likelihood of having sex. It is also fear of the stigma attached to being willing to have sex without a committed relationship. Another problem is the difficulty women have with requiring their male partners to use condoms, and the difficulty some men have using them. Then there is the forgetting of the many ways to have sex that can’t result in pregnancy in the first place! Lets get more creative with our hands and our mouths and the rest of our bodies! Lets buy sex toys. (Wow, did I actually just recommend a consumer-based solution to a problem? Yikes!)

Gawande is right, though, that the number of unwanted pregnancies in the United States — and thus the number of abortions — could be dramatically reduced if we were a more sexually honest and open society. If we — men and women — were honest with ourselves and with each other about the situations in which we are willing to have sex, and about the degree to which we do not want to be responsible for a child, I think we would have an easier time consistently and correctly using contraception. Imagine….

…if we were more honest with ourselves about how the contraception we do use makes us feel, and more willing to talk to each other about our contraceptive methods, we would be better able to find the methods that would work best for us.

…if we were more willing to admit that we simply won’t stop having sex just because we aren’t ready, able or interested in raising children.

…if we could acknowledge sexual pleasure as a basic human right and not a privilege for the middle and upper classes.

Then perhaps we would — as a society — realize our moral imperative to improve access to contraception and safer sex education and supplies for those who need them.

Gawande believes that politics precludes government from helping to create that society and that ultimately we need a “do it yourself” approach. I’m not willing to let government or the politicians who control it off the hook quite so quickly, but I agree that there is much we can change about this society if we “do it ourselves.” And among the things we can change through grassroots community-based activism is, in fact, the government.

Among the things the government could do better, or do at all:

• Offer incentives for research and development of long-lasting contraceptives that have fewer risks and side effects.
• Provide contraceptives free, and without any burdensome monitoring, to women and men who want them.
• Require that sex education programs offer clear, accurate information about the effectiveness of contraceptives and about their correct use.
• Support programs that help parents learn how to talk to their kids about sex.

But Gawande is right that, absent some sea change in what we as individuals and communities demand of our government, these things are not going to happen quickly. We need to take up the lead of organizations like Planned Parenthood which already offer workshops on how to talk about sex, and start branching out in our communities and among our friends to “do it ourselves.” Imagine if we each had at least one conversation a week with someone about the right to sexual pleasure, or he right to sex without fear of pregnancy or disease.

Try it out. Start with yourself and make a list that honestly accounts for the ways you like to have sex, the people you like to have it with, and your own risks of pregnancy. (Yes, this applies to men too. Women don’t get pregnant on their own!) Any unpleasant surprises on your list? If so, acknowledge them and make a plan to reduce your risks. Then, be courageous: share your list with someone. And share this post. Next week try a conversation with someone else. Ask someone how they feel about the right to have sex because it feels good. Discuss whether we should take a punitive attitude toward sex for pleasure.

And stay tuned here. This blog has been part of my attempt to create more open space for reasonable and productive conversations about sex. But you’ve inspired me to do more, and I’ve decided to expand the public square:

Coming soon to a computer near you: SexInThePublicSquare.org!

The New Anti-Abortion Law — Bad News For Women’s Health and Doctor’s Ethics

In an earlier post I discussed the Supreme Court’s analysis of the so-called Partial Birth Abortion Act, concluding that the Court’s decision to uphold the Act was intellectually dishonest and inequitable. This post is about the purposes of the Act, as described by Congress, and the Act’s probable consequences for the practice of medicine and the health of women.

Understanding the Act requires some minimal understanding about abortion procedures. (This explanation is more or less lifted directly from my earlier post on the Carhart decision.) The Act targets the procedure used in essentially all abortions taking place after first trimester and before viability. (Viability is the point in pregnancy when, given the current state of medicine, a premature infant has a fifty percent chance of survival. At present, viability occurs around the 23rd week.) The procedure is referred to as “dilation and evacuation” or “D&E”. A D&E is performed by first dilating the patient’s cervix for a period from a few hours to a few days. The physician then removes the fetus, placenta and related material from the uterus through the cervix, and out of the body. Often, the fetus must be removed from the uterus in pieces. Sometimes, though, the fetus can be removed from the cervix intact (called an “intact D&E” by the Court). Because the fetus is not destroyed during the intact D&E process, the physician must ‘kill’ (the word used in the Act), the non-viable fetus. The loaded term “partial-birth abortion” is thus an obvious mischaracterization of this procedure. The nonviable fetus cannot be “born,” either partially (whatever that might mean), or otherwise.

The Act makes it a crime for a physician to knowingly perform an abortion using the following procedure:

1. The physician removes the intact fetus from the woman’s body to a particular point:

In a head-first position, to the point where the entire head is outside the woman’s body;

in a breech (foot-first) position, where any portion of the fetus past the navel is outside the woman’s body; and,

2. The physician then takes an overt act that kills the fetus.

(This is my summary of the Act. The full Act can be found here.)

The Act provides no exception to preserve the health of the woman undergoing the procedure.

The Act won’t stop a single abortion from taking place. Justice Ginsburg noted during oral argument, “[W]e’re not talking about whether any fetus will be preserved by this legislation… It doesn’t preserve any fetus because you just [terminate fetal life] inside the womb instead of outside.” The US attorney defending the Act agreed with Justice Ginsburg. In other words, in order to be compliant with the Act, a physician must terminate the fetus’ life prior to delivery, even in cases where the physician believes it is safer for the mother to do otherwise.

Whether an intact D&E’ is considered medically necessary depends on a number of factors, including the age and health of the woman, especially if the woman has an underlying medical problem; the condition of the fetus; and the sophistication of the medical facilities available. Under the Act, a doctor is no longer allowed to make this decision. With the Act, Congress has overruled the the physician’s medical judgment, as well as her ethical obligation to provide the best possible medical care. Is appears the Hippocratic Oath has joined the Geneva Conventions as “quaint” obligations our government has decided can be ignored.

The trade-off Congress made in the Act and the Supreme Court appears hardly rational: Physicians must choose between following the law, on one hand, or providing the best possible care to preserve the health of the mother. What exactly has Congress achieved in return? Nothing, it seems. Abortions will not be reduced. But the Act will make abortions more dangerous and more difficult to obtain. Some physicians will likely withdraw from the practice of performing intact D&E’s rather than risk criminal charges. The health of some women will be harmed as a result, because they will not be able to obtain the best possible care. And, perhaps most troubling, those seeking to limit reproductive rights have established that their political agenda can override concerns about privacy, personal autonomy, and women’s health.

Tom Joaquin

TheFreeLance

Will New York Stop Treating Teen Prostitutes as Criminals?

Keep tabs on these two bills making their way through the New York State Senate and the New York State Assembly. Assembly bill A.5258, the Safe Harbor For Exploited Youth Act passed last year but didn’t make it to a vote in the Senate. It’s up again this year (its bill number in the Senate is S.3175), and I hope the Senate takes it up and passes it.

If it were to pass it would mean, as the New York Times pointed out in an editorial this morning, that we would treat American born teen prostitutes much the way we treat internationally trafficked teens caught working as prostitutes: that is, we would treat them as people in need of protection and services rather than as criminals. Here’s the lead paragraph from this morning’s New York Times editorial:

Sexually exploited children can be helped by the law or victimized by it, depending on where they are from. An Eastern European child smuggled into this country as a sex slave is offered protection under the federal Trafficking Victims Protection Act. An American child who flees abusive parents and ends up selling her body on the streets is labeled a criminal and sent to the juvenile equivalent of prison.

That statement is important because it points out one reality of young prostitutes: they are sometimes engaged in prostitution because, as runaways, there are few options open to them that will allow them to remain free of the homes they are trying to escape. The National Runaway Switchboard sites a 1998 study published in the journal Child Abuse and Neglect, indicating that 34% of runaway youth (girls and boys) reported sexual abuse before leaving home and forty-three percent of runaway youth (girls and boys) reported physical abuse before leaving home.

In addition to offering treatment and care to teen prostitutes (instead of detention and punishment) the law recognizes that the needs of sexually exploited “boys, girls and transgendered youth,” may be different from each other, and should be treated as distinct where necessary. The inclusion of transgendered youth is important because transgendered youth are at high risk of family conflicts that are often behind running away in the first place, and the needs of transgendered youth certainly are distinct from those of other youth in important ways, and need to be met in appropriate ways.

Services mandated by the bill are to be provided in safe houses specifically for sexually exploited youth and will include: “housing, diagnostic assessment, individual case management, medical services including substance abuse services, counseling and therapeutic services, educational services including life skills services and planning services to successfully transition residents back to the community.”

The law is not without its problems. For one thing, the youth in question would not have a choice about participating in the state’s protection. Services would be “made available” to them whether they are “accessed voluntarily, as a condition of an adjournment in contemplation of dismissal issued in criminal court,” or through other court proceedings. In other words, if picked up for prostitution, protective services will be mandatory if not chosen voluntarily. This is likely to be a good thing for many youth engaged in prostitution, but not all teen prostitutes are operating in the same conditions nor do they all have the same needs. In addition, state care is not always effective, and until we know more about the quality of the services to be provided, and the culture of the safe houses, it is hard to have an unrestrained enthusiasm for the program. If the treatment options pathologize teens and their developing sexualities, they will not be helpful, and they may do more harm than good. Not only that, the law still separates sexual exploitation from other kinds of exploitation, and quite possibly will result in the release of youth “back into the community” where they are forced to choose some other kind of exploitation as a way to earn an independent living. Until we solve the fundamental economic problems of our society, exploitation would seem to be a necessary condition of many lives. We should not be concerned only with exploitation of a sexual nature.

Lastly, the comprehensive needs of abused or neglected youth will not be met by this bill alone. This bill makes an important step in the direction of humane treatment for young people in desperate circumstances, but we need to continue to work to solve the problems that lead teens to run away in the first place. Those reasons sometimes, themselves, have to do with sexuality. Teens are thrown out of their homes or run away from home because their sexual orientation or gender expression is rejected by their families. They are abused (whether sexually or otherwise) and run away to escape their abuse. They sometimes run away to be with boyfriends or girlfriends or lovers they have been barred from seeing. In other words, the denial of teens self-hood and sexuality is, itself, sometimes what leads to the sexual exploitation this bill is trying to address. If it does nothing more than offer treatment instead of punishment, this bill will have helped. I hope, though, that it will do more than that: I hope that the discussions generated by this bill will encourage us to move further down the road toward recognizing and affirming teens’ developing sexualities, and toward treating young people in our society with greater dignity.

~~~~~

Links:

• NY Senate Bill 3175
• NY Assembly Bill 5258
• OutProud (National Coalition for GLBT youth)
• National Runaway Switchboard