Me and Mr. Kline

I just called Mr. Kline's office and left a message for him to get in touch with me. I mentioned I was a blogger and I would like to ask him a few questions. Not sure if he'll get back to me [he'll be able tell from my area code I don't live in Kansas]. I'll update if he does.

U.S. Says Women Are Not Guaranteed a Right to Medical Care

Under the auspices of the United Nations, the Fourth World Conference on Women was held ten years ago in Beijing. The purpose of the conference was to advance the goals of equality, development and peace for all women everywhere in the interest of all humanity. More than 180 governments signed its Platform for Action, an agenda for women's empowerment.

The areas of Strategic Objectives and Action identified in the Platform are:

1) Women and Poverty

2) Education and Training of Women

3) Women and Health

4) Violence against Women

5) Women and Armed Conflict

6) Women and the Economy

7) Women in Power and Decision-making

8) Institutional Mechanism for the Advancement of Women

9) Human Rights of Women

10) Women and the Media

11) Women and the Environment

12) The Girl-child

In 2000, a follow-up meeting to the Beijing conference (the Beijing +5), a special session of the United Nations General Assembly, was convened at United Nations headquarters in New York to review progress achieved and obstacles remaining to full implementation of the Beijing Platform for Action.

The participating governments reaffirmed their commitment to the goals and objectives contained in the Beijing Declaration and Platform for Action and to the implementation of the 12 critical areas of concern in the Beijing Platform for Action....

A document was issues after this follow-up meeting on [f]urther actions and initiatives to implement the Beijing Declaration and Platform for Action:

The Beijing +5 Outcome Document strengthened commitments to eradicate harmful traditional practices, including so called 'honour killings', forced marriages and female genital mutilation. Among other things, it also called upon governments to eliminate gender discriminatory legislation by 2005 and create greater access to affordable treatment and care for women and girls living with HIV and AIDS.

In particular, in the area of Women and Health, the Beijing +5 declaration (.pdf, page 9) notes:

Achievements. ... There is: increased attention to high mortality rates among women and girls as a result of malaria, tuberculosis, water-borne diseases, communicable and diarrhoeal diseases and malnutrition; increased attention to sexual and reproductive health and reproductive rights of women as contained in paragraphs 94 and 95 of the Platform for Action, as well as in some countries increased emphasis on implementing paragraph 96 of the Platform for Action;

and

Obstacles. ... While some measures have been taken in some countries, the actions contained in paragraphs 106 (j) and 106 (k) of the Platform for Action regarding the health impact of unsafe abortion and the need to reduce the recourse to abortion have not been fully implemented.

That was then. This is now:

Starting Monday, a high-level U.N. meeting attended by over 100 countries and 6,000 advocates for women's causes will be taking stock of what countries have done to implement the 150-page landmark platform of action adopted at the 1995 U.N. women's conference in Beijing to achieve equality of the sexes.

But even before the two-week meeting began, delegates were wrangling behind closed doors Friday on a draft declaration that the U.N. Commission on the Status of Women put forward - and had hoped to have adopted by consensus before Monday's opening session.

The short declaration would have nations reaffirm the Beijing platform and a declaration adopted with it, welcome progress toward achieving gender equality, stress that challenges remain, and "pledge to undertake further action to ensure their full and accelerated implementation."

And this is were the U.S. government runs into a problem:

But at an informal closed-door meeting on Thursday, the United States said it could not accept the declaration because of its concerns that the Beijing platform legalized the right to abortion as a human right, according to several participants.

On Friday, the United States proposed an amendment to the draft declaration that would reaffirm the Beijing platform and declaration - but only "while reaffirming that they do not create any new international human rights, and that they do not include the right to abortion," according to the text obtained by The Associated Press.

Since abortion is a basic medical procedure, it appears the United States government is saying that it cannot accept a declaration affirming women's right to proper medical care. Surely this can't be right. Or can it? You be the judge.

Here are the references to abortion in the Women and Health section of the original Beijing declaration (emphasis mine):

Adolescent girls are both biologically and psychosocially more vulnerable than boys to sexual abuse, violence and prostitution, and to the consequences of unprotected and premature sexual relations. The trend towards early sexual experience, combined with a lack of information and services, increases the risk of unwanted and too early pregnancy, HIV infection and other sexually transmitted diseases, as well as unsafe abortions.

Unsafe abortions threaten the lives of a large number of women, representing a grave public health problem as it is primarily the poorest and youngest who take the highest risk. Most of these deaths, health problems and injuries are preventable through improved access to adequate health-care services, including safe and effective family planning methods and emergency obstetric care, recognizing the right of women and men to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.

Recognize and deal with the health impact of unsafe abortion as a major public health concern, as agreed in paragraph 8.25 of the Programme of Action of the International Conference on Population and Development;

In the light of paragraph 8.25 of the Programme of Action of the International Conference on Population and Development, which states: "In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women's health, to deal with the health impact of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family-planning services. Prevention of unwanted pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion. Women who have unwanted pregnancies should have ready access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for the management of complications arising from abortion. Post-abortion counselling, education and family-planning services should be offered promptly, which will also help to avoid repeat abortions", consider reviewing laws containing punitive measures against women who have undergone illegal abortions;

Since unsafe abortion is a major threat to the health and life of women, research to understand and better address the determinants and consequences of induced abortion, including its effects on subsequent fertility, reproductive and mental health and contraceptive practice, should be promoted, as well as research on treatment of complications of abortions and post-abortion care;

It would be instructive to know what exactly the government finds unacceptable:

-- A desire to reduce the risk of unsafe abortions?

-- A desire to prevent the grave public health problem of unsafe abortion through improved access to adequate health-care services?

-- Recognizing and dealing with the health impacts of unsafe abortion?

-- An effort to reduce the recourse to abortion and even to eliminate the need for abortion?

-- Insuring women have access to quality services for the management of complications arising from abortion?

-- Services aimed at helping women avoid repeat abortions?

-- A proposal to review laws containing punitive measures against women who have undergone illegal abortions?

-- Research efforts to understand and better address the determinants and consequences of induced abortion, and on treatment of complications of abortion care?

So much access to proper medical care to restrict, so little time.

Your Medical History--Private or Public Information?

Thank you to Dr. Charles and Ms. X (here, and here) for alerting me to the latest attempted abuse of power by our beloved leaders.

I only had time to listen to the NPR report, and to read a couple of articles. My hurried summary:

Kansas State Attorney General (AG) Phill Kline is seeking to obtain access to the medical records of 90 women who underwent an abortion in 2003 at 2 clinics.

The Kansas attorney general, a staunch opponent of abortion, has demanded the medical records of nearly 90 woman and girls who had late-term abortions, saying he needs the material to investigate crimes.

and

On Oct. 21, state District Judge Richard Anderson ruled that Kline could have the files. The clinics then filed an appeal with the high court. No hearing has been scheduled.

The AG says it's not about abortion, but about sex crimes against minors.

But Attorney General Phill Kline insisted Thursday he needs the records because he has "the duty to investigate and prosecute child rape and other crimes in order to protect Kansas children."

Sex involving someone under 16 is illegal in Kansas, and it is illegal in the state for doctors to perform an abortion after 22 weeks unless there is reason to believe it is needed to protect the mother's health.

Investigation was begun last year, in October 2003; conducted in secret; all court records sealed; subpoenas and 30 motions all sealed.

Kansas law allows secret inquisitions as part of a criminal investigation.

Case become public because attorneys for the two abortion clinics asked State Supreme Court to get involved.

The clinics said Kline demanded their complete, unedited medical records for women and girls who sought abortions at least 22 weeks into their pregnancies in 2003. Court papers did not identify the clinics.

The records sought include the patient's name, medical history, details of her sex life, birth control practices and psychological profile.

The clinics are offering to provide records with some key information, including names, edited out.

and

In their brief, the clinics' attorneys said a gag order prevents the clinics from even disclosing to patients that their records are being sought.

Under Kansas law MDs are required to report suspected cases of sexual abuse. The AG has interpreted this law to apply to any [?female] sexual activity (in the under 16 age group). [This is from the NPR report and it's not too clear.]

AG's interpretation was challenged by health care agencies.

Federal Judge issued a restraining order blocking AG's interpretation.

Kline in 2003 began pushing to require health care professionals to report underage sexual activity. Kline contends state law requires such reporting, but a federal judge blocked him. The case has yet to be resolved.

All records requested by the AG are for abortions performed at an estimated gestational age (EGA) 22 weeks or older.

AG cited a law requiring MDs to determine gestational age, and if EGA is 22 wks or older, if it can survive outside womb. [Also from the NPR report; not too clear.]

I'll try to look up some of these Kansas laws, but, even before I do that, I can already tell you two things:

1) This is not a secret inquisition [why are the citizens of Kansas allowing secret inquisitions?] motivated by the duty to investigate and prosecute child rape and other crimes in order to protect Kansas children.

If you don't have any actual allegations, and you are going on a prosecutorial fishing expedition*, what you need to know is how many teenagers under the age of 14 are pregnant. [I know several articles list 16 as the age of consent in Kansas, but the AG says it's 14, so that's the number I'm using.]

The gestational age is irrelevant. Unless, of course, under Kansas law only certain Kansas children deserve protection--those who have an abortion at an EGA 22 weeks and over--while all the rest [those who have an abortion at an EGA under 22 weeks, and/or those who give birth] may be raped at will?

*My understanding of the lawspeak in the AG's statement: Sexual intercourse with a child 14 years of age and younger is a crime in Kansas. The crime is child rape. A pregnant 14 yo and younger represents probable cause that child rape has occurred.

OK, I couldn't resist. I had to look up some numbers (.pdf). [Sorry, I didn't have time to organize the material.]

In 2003 there were 40 live-births (.pdf) in the 10-14 age group. The father's ages were: 1 (10-14 age group); 14 (15-19 age group); 3 (20-24 age group); and 22 age group not specified.

Of course what we really need to know is the number of pregnancies (not just live-births) in the 10-14 age group. The best data I could find [Table 19 (.pdf)]:

In 2003 there were 73 pregnancies in the 10-14 age group (live-births + reported abortions + stillbirths). So, the number of reported [not sure if this means spontaneous and elective, or only elective] abortions and stillbirths for the 10-14 age group is 33**.

Interestingly, the number of teenage pregnancies [10-19 age group] in Kansas has been steadily decreasing from 1995 (6,552) to 2003 (5,174).

**From this data (.pdf) it looks like, in the under 15 age group, there were 33 reported abortions for Kansas residents, and 45 for non-residents.

But the most interesting [as in extra disturbing] bit of information I found is this. In 2003 there were 78 reported abortions--33 for residents, 45 for non-residents--in the under 15 age group. In only 14 of these cases was the EGA 22 and over. [No residency breakdown available.]

So, for the under 15 age group the majority of abortions, or ~82%, occurred at EGAs of under 9 weeks to 21 weeks.

The Kansas AG states that rape is a serious crime and when a 10, 11 or 12 year old is pregnant - they have been raped under Kansas law and [a]s the State's Chief Law Enforcement Official I have the duty to investigate and prosecute child rape and other crimes in order to protect Kansas children. Hence, the reason for his demand to, secretly, have unrestricted access to patients' medical records. Yet his request only covers the records of patients who had an abortion at 22 weeks and over, a minority at ~18%. Moreover, those in the 10-14 age group who gave birth (um, you know, as a result of a pregnancy) aren't even mentioned in the AG's request.

Bottom line: If this is about child rape and other crimes, and it's done to protect Kansas children a) why are the majority of pregnant 10-14 yo excluded (the majority of patients under the age of 15 who have had an abortion, and all the 10-14 yo who gave birth?; and b) why are non-residents and/or patients over the age of 14 included? [I am making an assumption here, based on the number of records (90) requested. From the data, for all age groups, in 2003 there were only 46 Kansas residents who had an abortion with an EGA 22 and over.]

2) With the exception of the Kansas AG and a couple of legislators, for everybody else--resident/non-resident of Kansas, female/male, young/middle-aged/old--this is not about abortion. It's about the government demanding secret and unrestricted access to your medical history, details of your sex life, birth control practices, and psychological profile. (Anything in your chart you wouldn't care your state's politicians or AG to have access to, and to share, without your knowledge, with perfect strangers, your employer, your acquaintances, and/or members of your family?)

Of Democrats, Abortion, and Human Life

Sorry for the lack of posting; I'm way behind and still trying to catch up. While I do that, here's some material you might find interesting.

Start with feministing's post Dems & Abortion: The New Republican Light? Jump to Zed's blog for a discussion on When cells become a person (make sure not to miss the comments). Then read this (lengthy) article, titled When Does Human Life Begin?:

The question of when a human life begins is a profoundly intricate one, with widespread implications, ranging from abortion rights to stem cell research and beyond. A key point in the debate rests on the way in which we choose to define the concepts of humanity, life and human life. What does it mean to be alive? What does it mean to be human? Is a zygote or an embryo alive? Is a zygote or an embryo a human being? These are intricate philosophical questions that often incite intense debate, for their answers are used as evidence in the answers to questions about the moral status of a zygote, embryo or fetus.

Unfortunately, I didn't have time to finish reading the article, but I definitely plan to. I got as far as this passage [and had some (hurried) thoughts*]:

The current Catholic Church doctrine maintains the belief that immediate animation, the instant at which the zygote is endowed with life including a soul from God, is concurrent with the moment of fertilization (Shannon and Wolter 1990).

1) Except, fertilization is not a momentary event. There is no moment of fertilization but rather a lengthy process.

Fertilization usually occurs in the [WARNING, graphic; path specimen] fallopian tube at the end closest to the ovary. It begins with contact of the sperm and the outer layer of the egg, continues with the gradual penetration of the sperm into the various layers of the egg, and is completed when the pronuclei of the sperm and egg lose their nuclear membranes and fuse to form a new cell called a zygote.

An interesting aside: The majority, up to 78%, of fertilizations do not result in live births. [Up to 60% of fertilized eggs are spontaneously aborted before they can cause a missed menstrual period. For clinically recognized pregnancies, 10-15% end in spontaneous abortion.]

That last stage of fertilization, the fusion, is called syngamy: the sperm chromosomes (23) fuse with the egg chromosomes (23) and form the zygote (46 chromosomes).

2) Also, the product of fertilization is not a cell/s designated to become a specific entity (e.g., a human), or even a particular part of an entity (e.g. an eye, or a leg). Rather, it is a bunch of distinct totipotent cells.

After syngamy, the zygote undergoes a series of divisions (preembryo stage). [About 3 days after syngamy we're at the 8 cell stage.] The newly divided cells are called blastomeres. These blastomeres are the totipotent cells. [Briefly, each one of these cells can develop independently along any line--from a preembryo to an extra-embryonic structure; they are not yet committed to a/any particular pathway.]

Another interesting aside: Once fertilization is complete, there is an entity with a new genotype. [The egg/sperm has only 23 chromosomes, but the zygote has 46--a new genotype.] However, this new entity isn't capable, at its earliest stages, of expression (transcription) of the new genotype, being regulated instead by information from the egg for continued growth and development.

3) Last, but not least, the product of fertilization doesn't have individuation. In order to be able to develop into a human person, the preembryo needs to acquire it.

From 4 to 5 days after syngamy, the blastomeres start to adhere more closely to each other, and form a morula. [During all this time, the fertilized egg has been traveling from one end of the fallopian tube towards the uterine cavity.]

Next, the morula undergoes a few changes--a central cavity appears, a distinct inner cell mass organizes--and becomes a blastocyst. The blastocyst reaches the uterine cavity where it floats around for about two more days.

After this [5-7 days after syngamy] the process of implantation begins:

As the blastocyst is in the process of attaching to the uterine wall, the cells increase in number and organize into two layers of cells. Implantation progresses as the outer cell layer of the blastocyst ... invades the uterine wall and erodes blood vessels and gland. Having begun 5 or more days after fertilization with the attachment of the blastocyst to the endometrial lining of the uterus, implantation is complete when the blastocyst is fully embedded in the endometrium several days later.

The inner cell mass is the progenitor of all the cells and cell types of the future embryo. But, at this time, these cells don't yet have the concrete potential to become a human person. They are not yet set for development as a single being.

The implanted preembryo acquires individuation about 14 days after fertilization, with the development of the primitive streak.


*ACOG's Ethics in Obstetrics and Gynecology [2002;70-4] is the reference. I tried to adapt most of the material, but I couldn't eliminate the medspeak entirely. So I included the glossary; hope it helps.

Glossary

Blastocyst: A sphere of cells containing a fluid-filled cavity forming about 4 days after fertilization and prior to the beginning of implantation.

Blastomeres: The cells derived from the first and subsequent cell division of the zygote.

Diploid (in humans, 46): A cell having two chromosome sets, usually one maternal and one paternal, twice the haploid number.

Embryo: The stage in human development starting from about 2 weeks after fertilization, with organization around a single primitive streak [band of cells], and continuing until the end of the 8th week after fertilization when all the major structures are represented.

Fertilization: The process which renders gametes capable of further development; it begins when sperm contacts the plasma membrane of the egg and ends with the formation of the zygote.

Gametes: Mature reproductive cells, usually haploid in chromosome number [ovum (egg) or sperm].

Haploid: The chromosome number of a normal gamete [egg or sperm]. In humans, the haploid number is 23, representing one member of each chromosome pair. [Egg (23) + Sperm (23) = Diploid cell (46)].

Implantation: Attachment of the blastocyst to the endometrium [uterine lining] and subsequent embedding in the endometrium. Implantation begins at about 5-7 days after fertilization and may be completed as early as 8-9 days after fertilization.

Inner cell mass: The centrally located cells within the blastocyst; these cells will develop into the embryo.

Morula: A compact sphere of 16 blastomeres that forms at about 3-4 days after fertilization.

Oocyte: An immature female reproductive cell, one that has not completed the maturing process to form an ovum (gamete).

Preembryo: The developing cells produced by the division of the zygote until the formation of the embryo proper at the appearance of the primitive streak [band of cells] about 14 days after fertilization.

Primitive streak: The initial band of cells from which the embryo begins to develop. The primitive streak is present at about 15 days after fertilization.

Pronuclei: The egg and sperm nuclei after penetration of the sperm into the egg during fertilization.

Spermatozoa: Mature male germ cells (gametes).

Syngamy: The final stage of the fertilization process in which the haploid (23) chromosome sets from the male and female gametes come together following breakdown of the pronuclear membranes to form the zygote.

Totipotent: Able to differentiate along any line; the capacity of a cell or group of cells to produce all of the products of conception--the extra-embryonic membrane and tissue, the embryo, and, subsequently, the fetus.

Transcription: Transfer of genetic code information from one kind of nucleic acid to another.

Zygote: The single cell formed by the union of the male and female haploid (23) gametes at syngamy.

"Unborn Child"--Arizona Style

Our favorite B.Ph.D. links to an article about an Arizona bill (SB 1052), and comments:

A bill, ostensibly to punish the killing of pregnant women, that makes a fetus legally equal to its mother. The law explicitly makes an exception for abortion.

After reading the bill, titled protection of unborn children, I'll have to disagree with her a bit. This is not a bill about pregnant women, but rather about "unborn children".

In case you're not exactly sure what "unborn child" means [I wasn't], the Arizona legislature provides the definition. Actually, they provide several definitions. Feel free to select the one that strikes your fancy [I'm going with B. I find not having to couple giving birth to uterine location (in utero, ex utero, makes no difference) irresistible.]:

A) ..."UNBORN CHILD" MEANS AN UNBORN CHILD AT ANY STAGE OF ITS DEVELOPMENT. (scroll to bottom of page)

B) ...an unborn child shall be considered to be a child who is under twelve years of age (scroll to the middle of the page).

From the surface of the woman's and man's kidney (that's the area where the earliest sign of a gonad appears) when they are embryos themselves [the woman and man having gonads is an essential stage in the development of any child they might have], to a child under 12 years of age, it's all the same in Arizona.

See, this is what happens when you make up terms ("unborn child", "partial-birth" abortion)--reality tends to get in the way. In real life, a genital ridge, a fertilized egg (zygote), blastomers, a morula, a blastocyst, an embryo, a fetus, a neonate, and a child, under 12 years of age, are not interchangeable.

My take on SB 1052: There are enough reality-based problems we need to tackle, both in society in general, and in the reproductive health arena, in particular. It would be most helpful if assorted politicians would refrain from making up medical terms.

Regulating Reckless Sex?

Allow me to point you to this lawyerly debate about regulating reckless sex [you go ahead and read, while I take a moment to suppress my gag reflex]:

Sexually transmitted diseases can't be outlawed, but can the law slow their spread? In a forthcoming article in the University of Chicago Law Review, Ian Ayres and Katharine Baker propose adding the crime of "reckless sexual conduct" to the books. Citing data that shows that STDs are transmitted with disproportionate frequency the first time two people have sex, Ayres and Baker argue first-time intercourse without a condom should be punishable by putting the perpetrator in prison for three months.

But critics are skeptical about the ability of the proposed law to deal with a range of issues, from consent (What if a woman insists a man not use a condom?) to privacy (How will courts avoid the he-said/she-said problem that plagues rape prosecutions?).

Can the law regulate reckless sex?

This, in conjunction with proposals for a national ID card, is enough to prompt one to consider moving to ... Iceland! [I don't actually know how free Iceland is, comparatively, but I'm starting to get perturbed by what's happening in our country, and I'm grasping at straws. I mean, if the U.S. ceases to be a free country, where does one move to?]


(via Instapundit)

Grand Rounds

One advantage of having the Grand Rounds hosted in India--it allows me to blame my tardiness in alerting you to a great read on the time difference.

Put the Consumer in Charge

While I'm on the topic of informed patients, here's an interesting question for you about the American healthcare system: Why Not Put the Consumer in Charge?

Dr. George D. Lundberg, Editor-in-Chief of Medscape General Medicine, has this to say:

Many Americans are pushing the concept of consumer-driven care. Most healthcare already is self-care. So, why not empower consumers with good information so that they can take charge of their health? After all, it is their health! Why not let individuals make the purchasing decisions directly, spending their own money, so as to inject free-market components into the otherwise skewed medical marketplace? I like this idea as far as it goes, and I believe it is worth doing. But it contains fundamental flaws that prevent it from being a panacea.

Federal Refusal Clause

Speaking of reproductive health education, and making information available to women, here's an interesting article about the refusal-to-treat law (aka federal refusal clause):

A new law making it easier for health professionals to withhold reproductive health information from patients made its way into the courtroom in January amid concerns that it undermines the nation's family planning programs and risks the health and lives of women.

The law, known as the federal refusal clause, was inserted into fiscal year 2005 omnibus appropriations legislation that was signed by President Bush in December 2004. The clause, inserted by Rep. Dave Weldon, R-Fla., allows a federally funded "health care entity" to deny women information on abortion services, even if state laws mandate that such information be given upon request. States that attempt to enforce their laws can be accused of discrimination, and be denied all of their health, education and labor funding as appropriated under the omnibus bill.

"The overarching principle is that this is a backdoor attempt to gag referrals for abortion, to gag health care providers and to basically intimidate states away from having anything to do with abortion," said Judith DeSarno, president of the National Family Planning and Reproductive Health Association, which filed suit to stop enforcement of the refusal clause. "The precedent here is that you can withhold any kind of information and still get federal dollars."

According to the association, the refusal clause is at odds with numerous regulations attached to the Title X program, the nation's only federal program solely dedicated to providing family planning and reproductive health care to low-income and uninsured women. Organizations that receive Title X funding must agree to a number of requirements that range from blood pressure screenings to sexually transmitted disease testing to giving abortion referrals upon request. Those who violate the terms of Title X grants, DeSarno said, can then be sued or have their federal funds withdrawn. But with the Weldon clause, such requirements can be rendered unenforceable.

"There's a bitter constitutional question here: Can Congress mandate state law through the appropriations process?" DeSarno told The Nation's Health.

The Cost of PMS

Sorry for the lack of posting; real life, and all that. An encouraging observation from my offline activities. I was interviewed by a reporter from Organic Style magazine, who was working on a piece on PMS. One thing she mentioned she learned from my book, and something she found most useful, was the fact that women who use the Pill no longer menstruate, for as long as they use the Pill. [I was recently wondering if it's true that a majority of Pill users aren't familiar with menstrual suppression. The reporter opined that's true.]

It's great that readers are picking up on this information.

It's one thing to have a patient "trapped" in an examining room while you're trying to explain something. You can persist until you make sure she understands [or, until she's had enough and manages to extricate herself, and run away from all your hand-outs, and schematics. Yes, as hard to believe as that is, some women just don't find the minutia of reproductive organs or contraceptives as fascinating as I do.]. It's another thing to throw the information "out there" in the form of a book, and not know if the main points are getting across. [And you wonder why I have a blog; can you say instant feedback?]

Speaking of PMS, while Australians are considering a menstrual leave, researchers in the U.S. looked at a sample of regularly menstruating women aged 18-45 and estimated the cost of PMS:

A total of 29.6% ... of the participants were diagnosed with PMS. A PMS diagnosis was associated with an average annual increase of $59 in direct costs ... and $4333 in indirect costs [days of work missed and lost productivity at work] per patient ... compared with patients without PMS.

If we extrapolate from these results, we can get an idea of the magnitude of the problem. If about 1/3 of all the reproductive age women (60,201,000 women aged 15-44), or 18,060,300, are diagnosed with PMS, we have an average annual increase of $1,065,557,700 in direct costs, and $78,255,279,900 in indirect costs. Hm, either I need to update my calculator [I don't; I checked my numbers], or these are some impressive estimates.

What would be interesting to know is how many of the estimated 18,060,300 women diagnosed with PMS [about 2% to 9% suffer from PMDD] 1) contact their physician for treatment [?self-medicate], and 2) suffer in silence.

Unfortunately, for the first group, the news isn't that good. One survey revealed that, in a majority of cases, women sought help from multiple physicians for more than 5 years before a diagnosis of PMS was made. For the second group, it would be instructive to learn if the women a) don't know there are treatment options available, or b) they do know, but elect not to use them.

One more interesting number: [T]he average woman experiences 7-14 symptoms premenstrually every month, and ... this amounts to a staggering 1680 symptomatic days every decade!

And since I gave you all these numbers and projections about PMS, here's a good review article on the evaluation and treatment of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). Since the author is a pharmacist, the article has a good Treatment section, covering:

Lifestyle modifications

Antidepressants (Sarafem)

Anxiolytics (Xanax)

Combination birth control pills

Progesterone

GnRH agonists (Lupron)

Danazol

Diuretics

Bromocriptine

Nonsteroidal anti-inflammatory drugs (Ibuprofen)

Alternative Therapies: vitamin B6, calcium, magnesium, manganese, vitamin E, combination supplements, evening primrose oil, other herbal products.

Acupuncture

The Morning Arts Report

The metal frames of Christo's gates (orange) are up all over the place. The fabric parts will be unfurled later.

The Gates

On the plus side, it's good for tourism. And I can report there were tons of them this morning, furiously snapping pictures right and left, and up and down. On the minus side, 5 police helicopters hovering, a strong police presence; not to keen on the use of resources.

And on a personal note, I really hope the gentleman I passed on one of the alleys wasn't the artist. That's because he caught a certain dog in flagrante delicto. He was nice about it "You can now say your dog was the first one [I didn't have the heart to disabuse him of that notion] to pipi on my work". Still, just for the sake of appearance, one would like one's dog to show more appreciation for a work of art.

Of course, no post about park art would be complete without a mention of one of my fave exhibits, the Cows.

Menstrual Leave

Menstrual leave:

Providing female car workers with paid menstrual leave would improve a company's productivity and quality, Australian Manufacturing Workers Union (AMWU) secretary Doug Cameron said.

Production line jobs were tough on some women during their monthly cycle and their problems should be recognised, he said.

A claim for 12 days menstrual leave a year for women is one of 600 improvements being sought by the AMWU from carmaker Toyota.

Take it or leave it?

(via feministe)

Women Want More Information

Somehow I missed this report on women's attitudes about skipping [fake] periods. Here are some interesting nuggets:

Women like the idea of menstrual suppression -- skipping or eliminating monthly periods -- but want their health-care providers to tell them more about it...

The study shows that the concept of changing menstrual patterns is popular among patients and practitioners alike, but their awareness of the topic differs significantly.

"...most women have never heard of using birth control pills to skip a period, while eight out of 10 clinicians -- 90 percent of whom were female -- have heard of it and seven out of 10 of them have prescribed it to suppress menstruation,"...

...women and providers disagree on the need for having a period every month,".... "Fifty percent of the women surveyed and only 7 percent of providers think a menstrual period is necessary every month. This translates to a big information gap between what the providers know about menstrual suppression and what they tell -- or don’t tell -- their patients." [Heh, the "Secrets of the Menstrual Sisterhood/Brotherhood", depending on your Ob/Gyn's gender.]

Nearly three-fourths of the women sampled had never heard of menstrual suppression with oral contraceptives. Nearly two-thirds of them would be interested in not menstruating every month, and one-third would choose never to have a period. Nearly half the clinicians thought that menstrual suppression is a good idea, with only 7 percent of them thinking it was physically necessary to have a period every month. [That's ~57% of clinicians. What happened to the rest, no opinion/not familiar with period control?]

The study results demonstrate that clinicians should discuss this option with their patients...

I know I keep mentioning this, but it's important: menstrual suppression is not the same thing as skipping a monthly fake period. For example, if you ask "Is menstrual suppression a good idea?", in effect what you are asking is "Is using the Pill on a regular [3 weeks on/1 week off] regimen a good idea?"

I don't have hard data, but I'm not convinced that most women who use the Pill for birth control don't already know that they don't have a menstrual period for as long as they use the Pill.

Bottom line: Good thing a very informative book* on this very topic allows women to educate themselves.

*Disclosure: I'm the author.

Women's Health

A useful review of the key 2004 issues in obstetrics/maternal fetal medicine, gynecology, reproductive endocrinology, and women's health:

In 2004, the National Women's Law Center and the Oregon Health & Science University released a report finding that not a single US state currently meets basic federal goals for women's health set by the US Department of Health and Human Services' Healthy People 2010 agenda. Moreover, the nation as a whole fails except in 2 areas -- mammograms and dental check-ups.

Topics covered include:

Women's Health-Obesity

Women's Health-Sexual Health

Gynecology-Hormonal Contraception

Gynecology-Menopausal Hormone Therapy

Urogynecology-Pharmacologic Treatment of Overactive Bladder [using drugs, as opposed to surgery]

Sexually Transmitted Infections and HIV/AIDS

Reproductive Endocrinology-Polycystic Ovary Syndrome, Infertility, and Assisted Reproduction

Pregnancy-Depression During Pregnancy

Pregnancy-Preeclampsia [high blood pressure during pregnancy]

What's In Store for 2005 for Obstetrics and Gynecology

Breast and Gynecologic Cancer

The End of Tamoxifen? [a breast cancer drug]

Reproductive Rights Threatened in the United States

Lack of Access to Healthcare

Violence Against Women

Early Motherhood May Shorten a Woman's Life

A Finish study finds an interesting correlation:

Women who start a family early in life tend to die younger, a study of childbirth and longevity has revealed.

A trawl through thousands of church records in Finland dating to the 17th and 18th centuries has found a correlation between the age at which a woman had her first child, the number of children she had, and the age at which she died.

The scientists behind the study - one of the biggest on pre-industrial society - believe the findings indicate that women who delay starting a family and have fewer children may have a natural tendency to live longer than women who become mothers at a young age.

Obviously, we need more information before we can draw any conclusions.

Grand Rounds

I'm late for Grand Rounds (for shame). Good thing it's never too late to read great posts.

Georgia On My Mind

Feministing takes a closer look at Georgia and shines the light on attempts to legislate informed consent and medical care:

Senate Bill 77 and House Bill 197 would require physicians to give women seeking abortion information on the medical risks of abortion, the probable gestational age and development of a fetus, fetal pain and alternatives to abortion, including adoption. It would require women to wait 24 hours after receiving the information before proceeding with an abortion. The bill also would require that only a parent or legal guardian be notified when a minor younger than 18 seeks an abortion. Currently, Georgia law allows certain people, such as a grandparent or other relative caring for the minor, to act as a stand-in for a parent or legal guardian.

...

Senate Bill 93 would outlaw abortion in Georgia, with no exceptions for rape or incest.

With all due respect to The Atlanta Journal-Constitution (AJC), I just couldn't believe they summarized Senate Bill 93 accurately. So, I read the bill (House Bill 93) and, I must say, I stand corrected. Actually, AJC's characterization of the bill errs on the side of caution. The fact that there's no exception for rape or incest is but the tip of the iceberg:

We know that life begins at conception.

...

(1) Justice Blackmun, writing for the majority in Roe v. Wade, 410 U.S. 113 (1973), wrote: 'when those trained in the respective disciplines of medicine, philosophy, and theology are unable to arrive at any consensus, the judiciary, at this point in the development of mańs knowledge, is not in a position to speculate as to the answer [to the question of when life begins].' Now, 30 years later, the General Assembly knows the answer to that difficult question, and that answer is life begins at the moment of conception;

...

(3) Even if the answer to the question of when life begins were unclear, the Georgia Constitution, at Article I, Section I, Paragraph II, provides: 'Protection to person and property is the paramount duty of government and shall be impartial and complete. No person shall be denied the equal protection of the laws.' Because a fetus is a person, constitutional protection attaches at the moment of conception. It is therefore the duty of the General Assembly to protect the innocent life that is currently being taken;

[Logic, people! Is the answer to the question clear, or isn't it?]

(4) As a direct result of three decades of legalized abortion on demand, the nation has seen a dramatic rise in the incidence of child abuse and a dramatic weakening of family ties, with the infamous Roe v. Wade decision pitting mothers against their children and women against men;

[Where is the evidence for a direct link between elective abortion and the incidence of child abuse and weakening of family ties? And how are the terms (e.g., weakening of family ties) defined?]

(5) Studies of the three decades since Roe v. Wade have revealed that women have been deeply wounded psychologically, with one researcher reporting that 81 percent of the women who have had an abortion had a preoccupation with an aborted child, 54 percent had nightmares, 35 percent had perceived visitation with an aborted child, and 96 percent felt their abortion had taken a human life;

(6) Studies have shown that women who have had an abortion require psychological treatment of such symptoms as nervous disorders, sleep disturbances, and deep regrets, with 25 percent of one test group of women who have had abortions visiting a psychiatrist while only 3 percent of a control group did so;

(7) Another random study showed that at least 19 percent of women who have had an abortion suffered from diagnosed post-traumatic stress disorder, with 50 percent suffering from many, but not all, symptoms of that disorder, and 20 to 40 percent of the women studied showed moderate to high levels of stress and avoidance behavior relative to their abortion experience;

(8) Approximately 60 percent of women who have had an abortion and who reported post-abortion trauma also reported suicidal tendencies with 28 percent actually attempting suicide, of whom half attempted suicide two or more times;

(9) Abortion results in increased tobacco smoking, and women who have had an abortion are twice as likely to become heavy smokers and suffer the corresponding health problems as women who have never had an abortion;

(10) Abortion is linked to alcohol and drug abuse, with a two-fold increase in the risk of alcohol abuse among women who have had an abortion and a significant increase in drug abuse;

(11) Most couples find abortion to be an event which shatters their relationship, causing chronic marital troubles and divorce;

...

(13) Thirty years of abortion on demand have resulted in an increase in breast cancer, and a study has shown that women who had an abortion in the first trimester of pregnancy before experiencing a full-term pregnancy may be at increased risk for breast cancer;

(14) The practice of abortion has had a profound detrimental effect on the health and well-being of the citizens of this state as well as the health of the economy; and

[Where is the scientific evidence for 5-11, 13, 14?* And it's a "randomized" study, not a "random" study. Big, huge difference between the two.]

(15) The practice of abortion has caused the citizens of this state an inestimable amount economically including, but not limited to, the costs and tax burden of having to care for individuals and their families for the conditions cited above, as well as a significant reduction of the tax base and of the availability of workers, entrepreneurs, teachers, employees, and employers that would have significantly contributed to the prosperity of this state.

[Where is the evidence for the costs and tax burden? And if the amount is inestimable, how do we know it's a debit and not a credit? Also, how did abortion cause a significant reduction of the tax base and of the availability of workers, entrepreneurs, teachers, employees, and employers that would have significantly contributed to the prosperity of this state? I'm not sure, but if this refers to the potential of aborted fetuses, where is the evidence that abortion didn't cause a significant increase of the tax base and of the protection from thieves, criminal masterminds, pedophiles, rapists, and murderers? (I'm probably off on this one; it's impossible this would be the level of argument in a piece of legislation.)]

The depth of misinformation in this bill is too profound for me to believe its proponents are truly familiar with the facts. I understand politicians have agendas, but it's just not possible to be this divorced from basic reality.

You can read a good review of the abortion/breast cancer politics and studies here (.pdf). And here's the analysis of data from 53 studies (83,000 women).

The U.S. National Institutes of Health, National Cancer Institute has this to say about the link between reproductive events (pregnancy, breastfeeding, spontaneous and elective abortion) and breast cancer:

On March 3, 2003, the National Cancer Institute's (NCI) Board of Scientific Advisors and Board of Scientific Counselors reviewed and unanimously accepted the findings of an "Early Reproductive Events and Breast Cancer Workshop." The workshop, convened by NCI, brought together a cross-section of experts to discuss available scientific data on reproductive events in a woman's life that may impact her subsequent risk of developing breast cancer.

Some of the population-based findings in the report that were presented as supported by evidence that was well-established were:

Early age at first full-term birth is related to lifetime decrease in breast cancer risk.

Increasing parity (number of live births) is associated with a long-term risk reduction, even when controlling for age at first birth.

The additional long-term protective effect of young age at subsequent term pregnancies is not as strong as for the first term pregnancy.

A nulliparous woman (someone who has never given birth to a live infant) has approximately the same risk as a woman with a first term birth around age 30.

Breast cancer risk is transiently increased after a term pregnancy.

Long duration of lactation provides a small additional reduction in breast cancer risk after consideration of age at and number of term pregnancies.

Induced abortion is not associated with an increase in breast cancer risk.

Recognized spontaneous abortion is not associated with an increase in breast cancer risk.

An interesting aside. We know that having frequent menstrual periods--late age at first full-term birth, low parity/nulliparity, etc.--is associated with an increased risk of developing breast cancer. But we don't yet know exactly why having fewer periods reduces the risk. As I note in my book:

...the increased number of menstrual cycles increases the breast cells' exposure to the estrogen made by the body. Because estrogen accelerates breast cell activity, there is a greater risk of random genetic errors that can lead to cancer.

*The literature does not support the contention that abortion causes longterm trauma. I remember last time this came up, Emily sent a link to a list of citations, and the Elliot Institute. I can't find my specific comments, but I do recall the studies I looked at were either off topic, or methodologically flawed. A more detailed analysis of the list by DonP, in the comments to one of Trish Wilson's posts.

So Many Bills, So Little Time

Feministing finds an article, and asks "What's up in Georgia?"

Newly empowered Republicans in the Georgia Legislature are setting their sights on another anti-abortion measure.

Under a bill filed Thursday by freshman Sen. Jim Whitehead (R-Evans), pharmacists who oppose abortion on "moral or religious" grounds and who refuse to dispense emergency contraceptive drugs would be immune from lawsuits or disciplinary action by employers.

Emergency contraceptives, sold in the United States under the name Plan B, can prevent a pregnancy if taken within 72 hours of having unprotected sex. The drug works as birth control pills do, by preventing ovulation, or fertilization and implantation of an egg.

But some pharmacists throughout the nation have refused to dispense the medication because they believe it amounts to abortion. Last year in Texas, an Eckerd drugstore fired a pharmacist for refusing to sell Plan B to a rape victim. Whitehead said some pharmacists in his Augusta-area district asked him to push the legislation.

"We're just trying to protect some pharmacists who feel the way we do as far as having to issue the contraceptive pill — that have Christian values that want to stand up against abortion," Whitehead said.

Pharmacists in Georgia already may refuse to fill a prescription on any grounds, said Flynn Warren, a University of Georgia professor and chairman of the Georgia Pharmacy Association's board. But pharmacists should give the prescription back to the patient and offer suggestions on how to get it filled elsewhere, Warren said.

Fred Vincy comments on the article, and notices a real gem (emphasis mine):

Senate President Pro Tem Eric Johnson (R-Savannah) is one of the bill's co-sponsors.

Whitehead and Johnson said in interviews Thursday they had concerns about the drug RU486, which causes abortion once a pregnancy is confirmed. The bill, however, does not specify that drug by name; it refers to "emergency contraceptive" drugs.

A Planned Parenthood fact sheet on the drugs notes that there is "considerable public confusion" over the difference between emergency contraception provided by Plan B and medical abortion provided by RU486. Reis said RU486 was administered by abortion providers, not pharmacists.

"The bill is not intended to prevent pharmacists from providing contraception, only from participating in an abortion," said Johnson, who acknowledged he was not clear on precisely how either drug worked.*

I read the article and become inspired by Senate President Pro Tem Eric Johnson!

I decide I must write (off the top of my head, without consulting any sources) the protocol for performing the most complex type of surgery there is, one totally outside my area of expertise.

I also decide to grant as many interviews as possible and acknowledge I'm not clear on precisely how the procedure is performed.

I then realize, just in the nick of time, that I'm not actually qualified to emulate Johnson. Unlike him, I at least have an understanding of the basics of a surgical procedure. I am also, at least minimally, responsible--I wouldn't write about, let alone perform, a surgical procedure I'm not familiar with. But then again, I'm not an elected official.

It's becoming clear that, when it comes to politicians, the less you know, the more you can legislate.

I know of at least three bills--HB 1677, HB 1807, and HB 2088 (.pdf)--either stricken from docket, tabled [check out my newly acquired poli lingo!], or in need of revision simply because the sponsor's lack of familiarity with the fundamentals of the bills rendered them irretrievably flawed.

One way to address this problem, and motivate our beloved politicians to, at a minimum, understand what they're proposing, before the urge to legislate strikes: find out the costs associated with drafting a particular bill. [Is there a standard formula used? Something like: it costs the taxpayers x for a one page bill to be drafted, proposed, acted on, etc.?] Then deduct that amount from the politician's salary.

Just being a politician shouldn't be justification enough for being incompetent and irresponsible.

*Briefly: Plan B is a birth control method in the Emergency Contraception (EC) group; it's a hormone, a progestin (a synthetic progesterone, just like the one used in the regular birth control pill). It has the same mechanism of action as the Pill, but a different dosage, and regimen. Mifepristone (Mifeprex) [RU-486] is an antiprogesterone. Depending on the mechanism of action, dosage and regimen, it's either a birth control method in the EC group, or an abortifacient, in the Medical Termination of Pregnancy group.

The Pre-Fertilized

This week, a pre-embryo is a human being:

A couple whose frozen embryo was accidentally destroyed at a fertility clinic has the right in Illinois to file a wrongful-death lawsuit, a judge has ruled in a case that some legal experts say could have implications in the debate over embryonic stem cell research.

In an opinion issued Friday, Cook County Judge Jeffrey Lawrence said "a pre-embryo is a 'human being' ... whether or not it is implanted in its mother's womb."

He said the couple is as entitled to seek compensation as any parents whose child has been killed.

The suit was filed by Alison Miller and Todd Parrish, who stored nine embryos in January 2000 at the Center for Human Reproduction in Chicago. Their doctor said one embryo looked particularly promising, but the Chicago couple were told six months later the embryos had been accidentally discarded.

In his ruling, Lawrence relied on the state's Wrongful Death Act, which allows lawsuits to be filed if unborn fetuses are killed in an accident or assault. "The state of gestation or development of a human being" does not preclude taking legal action, the act says.

Lawrence also cited an Illinois state law that says an "unborn child is a human being from the time of conception and is, therefore, a legal person."

"There is no doubt in the mind of the Illinois Legislature when life begins," Lawrence wrote.

Another judge had thrown out the couple's wrongful-death claims, but Lawrence reversed that decision, partly because that judge did not explain his decision at the time.

Next week: All hail to the pre-fertilized!

Update: Also, make sure no to miss the microscopic American:

The U.S. government says embryos aren't "donated" to infertile couples -- they're "adopted." How language has become a front line in the abortion wars.

Scare quotes are fast becoming superfluous.

(via Mouse Words)

Fewer Periods. More Possibilities Part Deux

Just saw the new version of the Seasonale ad. Basically, the same model, same white dress, and four redish dots. The change [notable mostly because I was listening for it]: the text the announcer was reading. Now it's, and I paraphrase "Seasonale extends the time between periods", "Can cause bleeding like a period", and an emphasis on the few rare SE of using the Pill.

Overall impression: If you don't already know about period control, you'd be hard pressed to figure out from the commercial what Seasonale does. [It shifts the frequency of your fake period.] The ad isn't very helpful; it confuses more than it teaches.

What I found interesting was the mention that over 250,000 women are using it. Considering that there are tens of millions of women who menstruate, and millions who suffer from period-related problems, this is a tiny, tiny number.

Bottom line: I don't think Barr Labs is doing a very good job educating women about menstrual management. [I should talk! When is the last time I had an instructive post about period control?]

More on HB 2088

Here's the latest on the Kansas HB 2088 (.pdf), introduced by Rep. Peggy Mast (background here).

On January 31 I sent Rep. Mast an e-mail, and today I received a response from her.

My e-mail:

Greetings Representative Mast,

...

It would be most helpful for your constituents if you could clarify several outstanding issues raised by HB 2088.

According to the Department of Health and Human Services' (DHHS) estimate, nationwide in 1997 there were 105 discarded infants. [How many of these cases were in Kansas?] As you are probably aware, Kansas already has a "safe heaven" law (HB 2838) aimed at addressing the problem of discarded infants.

As tragic as each individual case is, given the small number of cases of discarded infants, and the fact that Kansas already has a law aimed at dealing with this problem, why is it necessary to introduce new legislation (HB 2088)?

Also, according to the DHHS, when it comes to strategies aimed at decreasing the number of discarded infants:

"At present, public education about resources available to pregnant women and alternatives to discarding an infant remains the primary method for addressing this issue."

Your proposed legislation (HB 2088) does not follow the DHHS' recommendations for addressing the issue of discarded infants. Why not? Moreover, on what do you base your assumption that HB 2088 will be effective in reducing the number of discarded infants?

Finally, a few specific questions related to the text of the bill:

1) Applicability limited to hospital births. If the intent is to reduce the number of discarder infants, why does HB 2088 only cover hospital births? [See the bill's definition of "[u]nlawfully giving birth without medical assistance".]

2) Criminalizing strangers. How intrusive are strangers permitted to be in order to comply with HB 2088? In order for them to determine the fetal estimated gestational age, will they be permitted unrestricted access to a woman's medical records on demand? Perhaps ad hoc bimanual pelvic exams?

3) Criminalizing unattended deliveries. Why is a woman giving birth (livebirth or stillbirth) without medical assistance presumed guilty?

4) Creating an obligation to seek medical assistance. Why is a woman giving birth obligated to seek medical assistance?

5) Infringement on personal/patient autonomy. Why isn't a woman giving birth allowed to refuse medical assistance?

6) Requirement to predict the future, and act based on that prediction. How is a woman to determine how long the newborn will survive for, immediately after giving birth?

7) Incorrect definition of "fetus". Why does the bill contain an incorrect definition of "fetus"?

8) Requirement to diagnose fetal age. How is a woman (or a stranger) expected to estimate fetal age?

Thank you for your time, and I shall look forward to your reply.

Rep. Mast's reply:

As you can see there has been a great deal of comment about the Baby Doe bill. I have received comment from several fronts. People have vilified me as uncaring. Some have been compassionate about the purpose of the bill and have realized that finding dogs dragging a 9 lb. baby boy around the neighborhood can have a tramatizing [sic] effect on some people. One person seems horrified about the death of whales, but seems to have little concern for the horrible death suffered by some newborns. One woman even went so far as to name the number that occurs in the nation on an annual basis and think that it cannot be such a big deal in the state of Kansas if you spread it out. My answer to that woman is four. Four deaths reported last year were the result of women who gave birth without medical assistance and discarded the baby (hope that you do not find that term offensive) in such a way as to have the body discovered later. That is four deaths in Kansas. I guess if you compare that number to all of the whales killed it may seem small to some, but to me and to other women who have lost their babies for some reason or another, it seems uncounsciousable [sic].

Well, I probably won't change any of your minds by telling you about the testimony of law enforcement who responded to 911 calls last year (4) in Kansas regarding the discovery of a little baby that its brothers and sisters were carrying around town after they found it buried in the back yard, or KBI having to retrieve one from a septic system that had been thrown in there. To some of you who wrote, there will be only dismay that an investigation had to take place to try to determine the cause of death.

But we all don't think alike do we. Some people think that a woman who has had an unattended birth may need support and help. Some people probably actually think that she can go on with the rest of her life without any haunting feeling about seeing the eyes blinking up at her or the muffled cry coming from that plastic garbage bag.

For those of you who think that I have any anger toward those women, let me tell you now that it is not true. I care deeply about those women and whatever circumstances took them to the place that made them try to hide that traumatic event in their lives. I care about society that seems to think that it is far better for that woman to continue to hide behind drug abuse, alcohol, or other desperate measures to cope.

The bill was not intended to have women implicated for not having hospital births. It did not require women to be interrogated by the police if their baby did not survive. The bill attempted to require that medical personal, including midwives, be allowed to determine the cause of death within a certain amount of time after the birth. For the woman who spoke of loosing twins; it is hard for me to understand that you would not want to know the cause of death, or that you would not confer with a physician after a loss like that.

The bill is in the Revisor's office and I am trying to address the valid concerns about the language. I agree with many that the language is flawed. But I do not agree with those of you who feel that it is ok to kill infants. Nor do I agree with you if you feel that is in the best interest of the mother - whether it be a mother whale or not.

The Representative seems unclear about the purpose of HB 2088:

Some have been compassionate about the purpose of the bill and have realized that finding dogs dragging a 9 lb. baby boy around the neighborhood can have a tramatizing [sic] effect on some people. One person seems horrified about the death of whales, but seems to have little concern for the horrible death suffered by some newborns.

The bill's purpose is to decrease the number of discarded infants by criminalizing unattended deliveries. Its purpose is not to protect the psyche of some of the neighborhood people, or to address the concerns of one person.

The Representative's comprehension also seems to be impaired:

One woman [I assume that would be me] even went so far as to name the number that occurs in the nation on an annual basis and think that it cannot be such a big deal in the state of Kansas if you spread it out.

Two points:

1) The impertinence of me nam[ing] the number! [In my defense, I hadn't realized this statistic was some sort of national secret, to be known, and interpreted only by exalted politicians.]

Seriously now, here's how legislation is supposed to work. You identify a problem [newborns are being abandoned], study the data [how many, where, why, what works, what doesn't, what's been done so far, what are the results, etc.], and then, and only then--after you have a firm grasp of the facts--do you propose legislation aimed at correcting the problem [reducing the number of discarded infants].

The reason I went so far as to name numbers is because, before I'm able evaluate if a solution to a problem works, I need to understand what the problem is. I cannot speak for Rep. Mast, but as far as I'm concerned, I need to know the number of discarded infants, before I can figure out how to reduce it. [The number also comes in handy when it's time to evaluate if my solution is/isn't working.]

2) Rep. Mast claims that because I state the national number of cases of discarder infants, I think that it [the number of cases] cannot be such a big deal in the state of Kansas if you spread it out.

This is what I said:

According to the Department of Health and Human Services' (DHHS) estimate, nationwide in 1997 there were 105 discarded infants. [How many of these cases were in Kansas?] As you are probably aware, Kansas already has a "safe heaven" law (HB 2838) aimed at addressing the problem of discarded infants.

As tragic as each individual case is, given the small number of cases of discarded infants, and the fact that Kansas already has a law aimed at dealing with this problem, why is it necessary to introduce new legislation (HB 2088)?

I've already addressed the reason I mentioned the number of national cases.

I offered no comment about the number of cases in Kansas, since I didn't know what that number was. [How many of these cases were in Kansas?]

I specifically offer my opinion that each and every case where a newborn is discarded is a big deal. [As tragic as each individual case is....]

I stated the fact that 105 cases nationwide = a small number of cases. Based on the available* data, I stand by my statement.

*In 1997 there were 3,880,894 (.pdf) live births and 105 cases of discarded newborns. Interestingly, of the 3,880,894 births, 92.4% were attended by a physician, 7% were attended by a midwife, for a total of 99.4% of births occurring under medical supervision. Of the remaining .07%, or 24,207, 1,800 had an "unspecified" birth attendant.

I questioned the need to introduce new legislation, when legislation is already in place to deal with however many cases, out of the small, 105 nationwide total number of cases, occur in Kansas.

Rep. Mast continues:

My answer to that woman is four. Four deaths reported last year were the result of women who gave birth without medical assistance and discarded the baby (hope that you do not find that term offensive) in such a way as to have the body discovered later. That is four deaths in Kansas. I guess if you compare that number to all of the whales killed it may seem small to some, but to me and to other women who have lost their babies for some reason or another, it seems uncounsciousable [sic].

I would like to thank Rep. Mast for providing the information about the number of cases in Kansas--four. So, now we have a better understanding of the problem. If we use the available data (2003) for the total number of births in Kansas, we have 39,353 live births, and 4 cases of discarded infants (~0.01%).

I would also like to caution Rep. Mast that this comment (emphasis mine) ...and discarded the baby (hope that you do not find that term offensive)..., leads one to believe she is not familiar with the most basic terms one needs to know in order to draft a bill like HB 2088. If true, this is a serious dereliction of duty.

According to the Department of Health and Human Services (DHHS, 2001) the following terms are used (emphasis mine):

Boarder babies are infants under the age of 12 months who remain in the hospital past the date of medical discharge. Boarder babies may eventually be claimed by their parents and/or be placed in alternative care.

Abandoned infants are newborn children who are not medically cleared for hospital discharge, but who are unlikely to leave the hospital in the custody of their biological parents.

Discarded infants are newborns who have been abandoned in public places, other than hospitals, without care or supervision.

The prevalence, characteristics, financial and social implications, as well as the best way to combat the problems of each group are distinct. If a bill intended to decrease the number of discarded infants (those abandoned in public places) only covers hospital births, that bill is ineffective.

One more thing. With all due respect to Rep. Mast, enough with the whales! We are discussing discarded infants and criminalizing unattended deliveries, not whales. When it comes to public policy, the magnitude of the number of discarded infants in Kansas shouldn't be based on a guess (that number [4]...to me...it seems unconscio[nably high]), or an interspecies comparison. It should be based on facts, e.g., the number of births in Kansas.

Moving on, we have this:

Well, I probably won't change any of your minds by telling you about the testimony of law enforcement who responded to 911 calls last year (4) in Kansas regarding the discovery of a little baby that its brothers and sisters were carrying around town after they found it buried in the back yard, or KBI having to retrieve one from a septic system that had been thrown in there. To some of you who wrote, there will be only dismay that an investigation had to take place to try to determine the cause of death.

The way to change people's minds is to show how HB 2088 will be effective in reducing the number of discarded infants. It is troubling that an elected official isn't aware that personal testimony, even if it's from law enforcement, and even if it's about an extraordinary case, cannot substitute for hard data. Law enforcement testimony will *not* cause an ineffective law to reduce the number of discarded infants. Neither will gratuitous digs about what the reaction of some people might be when finding out that an investigation had to take place to try to determine the cause of death.

And this:

But we all don't think alike do we. Some people think that a woman who has had an unattended birth may need support and help. Some people probably actually think that she can go on with the rest of her life without any haunting feeling about seeing the eyes blinking up at her or the muffled cry coming from that plastic garbage bag.

Rep. Mast's suppositions in this paragraph may, or may not be correct. After all, some people think that we've been visited by extraterrestrials. The question is: what is the relevance of her speculation to the topic at hand? The intent of HB 2088 is to decrease the number of discarded infants, not to offer support and help to women who have an unattended birth, and/or to force these women to undergo psychiatric counseling.

Next, we have:

For those of you who think that I have any anger toward those women, let me tell you now that it is not true. I care deeply about those women and whatever circumstances took them to the place that made them try to hide that traumatic event in their lives. I care about society that seems to think that it is far better for that woman to continue to hide behind drug abuse, alcohol, or other desperate measures to cope.

I mentioned earlier that it is crucial to be familiar with the basic facts in order to be able to propose an effective bill. In this paragraph Rep. Mast provides us with a clear example why:

I care about society that seems to think that it is far better for that woman to continue to hide behind drug abuse, alcohol, or other desperate measures to cope.

Except, according to the Department of Health and Human Services [under Characteristics]:

Substance abuse continues to be the most common factor in cases of abandoned infants and babies boarding in hospitals.

...

Available literature indicates that individuals who commit acts of neonaticide and public abandonment are predominantly young, unmarried, physically healthy women who are pregnant for the first time and not addicted to substances (Kaye, Borenstein, & Donnelly, 1990; Oberman, 1996).

Once again, abandoned infants and boarder babies, and discarded infants are not one and the same thing.

If you care deeply about those women and whatever circumstances took them to th[at] place, you ought to, at a minimum, make an effort to have a basic understanding of what those circumstances might be.

Moving on, we have Rep. Mast making a direct statement about the intent of HB 2088. Not about what the text of the proposed bill actually says, mind you, but what Rep. Mast intended it to [not] say:

The bill was not intended to have women implicated for not having hospital births. It did not require women to be interrogated by the police if their baby did not survive. The bill attempted to require that medical personal, including midwives, be allowed to determine the cause of death within a certain amount of time after the birth. For the woman who spoke of loosing twins; it is hard for me to understand that you would not want to know the cause of death, or that you would not confer with a physician after a loss like that.

Again with divining intent! Here's a suggestion: When discussing a bill's intent, always use the bill's actual text. If you are a politician, know that it makes no difference what you say the intent was. The only thing that matters, especially when the affected citizens are hauled into court and charged with a felony, is what the text of the bill says.

We've already dissected the bill, so briefly: HB 2088 specifically mandates contacting law enforcement.

Unless a legal requirement to call the police can be construed as placing a call to have law enforcement act as a doula or pizza delivery service, the assertion that the bill did not require women to be interrogated by the police is disingenuous. And so is [t]he bill attempted to require that medical personal, including midwives, be allowed to determine the cause of death within a certain amount of time after the birth. Among other things, the bill specifically, and repeatedly demands action immediately after ... birth....

Apropos the woman who spoke of loosing twins; it is hard to understand that Rep. Mast would be so presumptuous as to assume that a woman, who just moments before lost her pregnancy, would not want to know the cause of death, or that the Representative would want to force the woman, under threat of becoming a felon for noncompliance, to confer with a physician immediately after a loss like that.

Finally:

The bill is in the Revisor's office and I am trying to address the valid concerns about the language. I agree with many that the language is flawed. But I do not agree with those of you who feel that it is ok to kill infants. Nor do I agree with you if you feel that is in the best interest of the mother - whether it be a mother whale or not.

After such a lengthy reply, heavy on speculation, dubious accusations [who says infanticide is ok?], and mentions of whales, and light on data, facts, and bill particulars, we have a nonspecific admission that the bill's language is flawed.

Unfortunately, Rep. Mast does not deem it necessary to share with us what the valid concerns about the language might be. So, after reading Rep. Mast's reply I'm still not edified. Actually, more than that; I'm even more troubled now than I was before I read her muddled e-mail.

Rep. Mast doesn't appear to have a grasp of the fundamentals: how to establish, as opposed to guess, the magnitude of the number of cases of discarded infants in Kansas; the difference between abandoned infants, boarder babies, and discarded infants; the concept of anecdotal evidence; the characteristics of women who discard their infants; and last, but not least, the actual text of the HB 2088.

"Nurturant Parent" vs. "Strict Father"

An interesting suggestion to reframe the abortion debate in accordance with the "Nurturant Parent" - "Strict Father" model (via Anne):

This debate is not about "choice" or "life". It is not even about being "anti-abortion" or "pro-abortion". This debate is how we approach the issue of unintended pregnancy: Prevention or Punishment. The Prevention Approach is about supporting policies that prevent unwanted pregnancies and decrease abortions while the Punishment Approach is about supporting policies that increase unintended pregnancies and increase abortions in order to punish people for having sex. The difference in approach reflects the difference in our values.

...

The vast majority of Americans harbor discomfort concerning the act of abortion. It is unlikely, however, that most believe that all women should be made to suffer when faced with an unintended pregnancy. I believe that if one were to pose the question: "Are you willing to deliberately increase the number of abortions, unintended pregnancies, and sexually transmitted diseases in this country in order to teach people the lesson that sex is wrong?" most people would answer no. In fact, many people would find this tactic to be inhumane, cruel and unethical.

My objection to allowing the honesty, beliefs, humanity, benevolence, and/or ethics of strangers to play a determining role in a woman's medical decisions aside, the strategy advanced by this article might have merit.

I don't think redefining the terms to allow for an honest debate, the kind that we can win, will have any effect on the true believers--those who wish to impose their system of belief on others at any cost. For example:

Stacey Emick, legislative director of the Texas Right to Life Committee, said being offered emergency contraception is one more traumatic thing for an already traumatized person to think about.

"If they're just throwing a pill at her and saying, 'Here's how you get rid of the problem,' that's not an informed decision," she said. "You are putting her in a more vulnerable position."

To a person willing to bend reality to this degree to fit their dogma,
no amount of data will be persuasive. For this segment of the population (hopefully a minority), ideology will always trump reality.

On the other hand, those who hold a personal belief that abortion is unacceptable, and are thus truly committed to decreasing the number of elective abortions, should find the facts about "pro-life" policies--e.g., that increasing the risks of sex has never, in any democratic society, worked to decrease unintended pregnancies and abortions--most useful.

Tabled in Courts of Justice

Via missmeridian, we find out that Virginia's HB 1807 has been Tabled in Courts of Justice.

HB 1807 is the bill proposing penalties for providing birth control to a minor in certain circumstances (see here, here, and here).

So, isn't this great news? Or is it? I ask, because the first time I read "Tabled in Courts of Justice" I had no idea what that meant. I looked it up, and I'm still not convinced I know what it means: either 1) the bill was shelved, or 2) the bill was postponed due to some legal action (?in Courts of Justice).

Remind me again, why is it not the politicians' duty to make sure legislation is written in clear, accessible language? [No, no, this question was not at all prompted by me being miffed at the double standard. Political and/or legal communication--the more obscure, the better. Medical communication: if the patient doesn't end up knowing at least as much as you do, you've failed to give informed consent.]

Grand Rounds

This week's edition of the Grand Rounds is up.

Repro Health News

Cervical cancer

Steady progress on the development of a cervical cancer vaccine:

A vaccine that could prevent young women from developing most cases of cervical cancer could be on the market within a few years.

Researchers are testing dozens of vaccines against different types of cancer but those that protect women against strains of the human papillomavirus (HPV), which are linked to more than 70 percent of cervical cancer cases, are the most advanced.

"I believe there will be an HPV vaccine sometime in the next few years," Anne Szarewski, a clinical consultant at Britain's Wolfson Institute of Preventative Medicine, told journalists.

Results from early trials of two separate vaccines developed by drugs giant GlaxoSmithKline and Merck, which protect against HPV infection, have been promising.

...

Szarewski said an HPV vaccine would have enormous potential in poor countries where screening is not available.

She is beginning Phase III trials of one of the vaccines in 300 women aged 15-25. The women will be given three doses of the HPV vaccine or a hepatitis A vaccine, which will act as the control.

Abstinence-only sex education

Study finds abstinence-only sex education programs in Texas do not work:

Abstinence-only sex education programs, a major plank in President Bush (news - web sites)'s education plan, have had no impact on teenagers' behavior in his home state of Texas, according to a new study.

Despite taking courses emphasizing abstinence-only themes, teenagers in 29 high schools became increasingly sexually active, mirroring the overall state trends, according to the study conducted by researchers at Texas A&M University.

"We didn't see any strong indications that these programs were having an impact in the direction desired," said Dr. Buzz Pruitt, who directed the study.

The study was delivered to the Texas Department of State Health Services, which commissioned it.

...

The study showed about 23 percent of ninth-grade girls, typically 13 to 14 years old, had sex before receiving abstinence education. After taking the course, 29 percent of the girls in the same group said they had had sex.

Boys in the tenth grade, about 14 to 15 years old, showed a more marked increase, from 24 percent to 39 percent, after receiving abstinence education.

Amanda has more, and a good discussion in the comments section.