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

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

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

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

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

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

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

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

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

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

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

Wow, how scientific!

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

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

Why?

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

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

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

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

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

Dear Ms. Block,

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

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

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

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

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

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

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

Sincerely,
Amy Tuteur, MD

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

According to Brady Swenson of RH Reality Check:

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

Here’s what I wrote in response:

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

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

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

As one such service explains:

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

Evidently, we believe in socialized nursing home care.

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

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

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

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

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

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

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

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

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

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

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

You might be a Birth Junkie …

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

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

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

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

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

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

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

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

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

Drum roll, please.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Some of the electives are truly bizarre:

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

and my personal favorite:

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

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

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

EU midwife————————- homebirth midwife

100 —– pre-natal examinations—– 75

40 —– deliveries—– 25

40 —– caring for high risk patients—– none

100 —– postpartum patients—– 40

40 —– newborns who need special care—– none

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

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

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

You can’t make this stuff up.

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

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

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

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

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

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

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

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

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

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

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

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

The authors end with a flourish of outright stupidity:

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

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

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

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

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

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

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

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

“I’m sorry, but I have to pee.”

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

“Just pee in the bed. I’ll clean it up later.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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