One of the dirty little secrets of healthcare is that most preventive medicine does not save money. Sure, it saves lives, and it improves worker productivity, but it costs a lot more. That’s because those whose lives are saved live longer, thereby incurring increased Social Security benefits, and live to develop chronic diseases, thereby consuming increased Medicare resources. This unfortunate fact is revealed in an article on MSNBC:

Willard Manning, a professor of health economics and policy at the University of Chicago’s Harris School of Public Policy Studies, was lead author on a paper published two decades ago in the Journal of the American Medical Association that found that, taking into account tobacco taxes in effect at the time, smokers were not a financial burden to society.

“We were actually quite surprised by the finding because we were pretty sure that smokers were getting cross-subsidized by everybody else,” said Manning, who suspects the findings would be similar today. “But it was only when we put all the pieces together that we found it was pretty much a wash.”

Expert witnesses for tobacco companies in their endless stream of litigation have seized on this fact.

Vanderbilt University economist Kip Viscusi studied the net costs of smoking-related spending and savings and found that for every pack of cigarettes smoked, the country reaps a net cost savings of 32 cents.

“It looks unpleasant or ghoulish to look at the cost savings as well as the cost increases and it’s not a good thing that smoking kills people,” Viscusi said in an interview. “But if you’re going to follow this health-cost train all the way, you have to take into account all the effects, not just the ones you like in terms of getting your bill passed.”

This dirty little secret calls into question the proposed financing of universal healthcare plans. The conventional wisdom about healthcare costs is that preventive medicine saves money. During the recent presidential election campaign, candidates relied on the assumed savings from preventive medicine to either control healthcare costs or to provide the money to extend healthcare coverage.

Smoking is a case in point. Although the calculations of the Centers for Disease Control (CDC) estimates that smokers cost the country $96 billion a year in direct health care costs, and an additional $97 billion a year in lost productivity, another less publicized calculation calls any cost savings into question. However, since smokers die approximately 10 years earlier than nonsmokers, each smoker forgoes 10 additional years of savings to Medicare, Social Security, and pensions.

According to The economics of tobacco: myths and realities published in the journal Tobacco Control in 2000:

Most societies devote a significant proportion of their health care resources to treating people made ill by smoking … It is certainly reasonable that a country should want to reduce smoking produced disease so that it could devote these resources to other health and social welfare needs.

It is also true, however, that non-smokers live longer than smokers, and thus that the health care costs of non-smokers during the “extra” years of their lives (compared to smokers) balance, at least to some extent, the higher costs smokers experience during each of their (fewer) years of life…

…[T]o appeal to the high medical costs of smoking as a fundamental reason to reduce smoking seems at least a bit disingenuous.

The cost of caring for the elderly in this country has been rising dramatically. According to a recent estimate by the Congressional Budget Office (CBO):

… the federal government will spend roughly three and one-third times more on the elderly this year than it did three decades ago (in constant dollars, excluding the effects of inflation). Since 1971, per capita spending on older people (in 2000 dollars) has risen at an annual rate of 2.4 percent a year, although over the past decade that rate of growth was 1.5 percent.

This year, spending on the elderly will account for more than one-third of the federal budget, up from about 22 percent in 1971 and 29 percent in 1990. That draw on the federal Treasury is projected to climb to nearly 43 percent by 2010 (according to CBO’s April 2000 baseline budget projections)…

Should people quit smoking? Of course they should. The cost to them and their families is very high, in terms of lives lost and productivity reduced. The cost to society, however, is not particularly high, and the premature deaths of smokers may actually represent a cost saving. So those who continue to smoke despite the myriad health warnings at least have one consolation. They may die early, but they’ll save the US government money.

Patients say the darndest things.

Sometimes, a doctor asks a routine question, one that she’s asked to others many times before, and gets a completely unanticipated answer. That’s why it’s important for any provider to ask questions as clearly and completely as possible, and clarify answers. Otherwise, the patient might be answering an entirely different question than the one you asked.

Occasionally that would happen to me when I saw gynecology patients in the emergency room. I asked every woman whether she was sexually active. Most answered either yes or no, but every now and then, I would ask, “Are you sexually active?” and the patient would say “No, I don’t move around much during sex.” or “Not active enough, if you asked my boyfriend.”

Questions asked and answered are important, but sometimes what is not asked is even more important. That’s why any provider should go through what is called a “review of systems” when taking a history. A review of systems means asking specific questions about most major aspects of body function. You can ask, “Do you have any medical problems?” and the patient will say no, but a review of systems often reveals a great deal of important information that may have been left out..

The typical case from my internship was a woman I was interviewing prior to her scheduled surgery. She insisted that she had no medical problems. I was in a rush and did not go through a review of systems. When I began her exam, I was surprised to find a large scar in the midline of her abdomen.

“What’s that from?” I asked.

“Oh, I forgot. That’s from my hysterectomy.”

“When did you have the hysterectomy?”

“Hmmm. Let’s see. That was last February. No, wait. I was supposed to have a hysterectomy last February, but they had to postpone it because of my heart attack.”

“Your heart attack?”

“Yes, I had a heart attack, but then they did angioplasty and I felt a lot better.”

“Angioplasty?”

“Yes. Then they rescheduled my hysterectomy, but I broke my leg …”

It is truly amazing what patients will forget to tell the doctor. A colleague admitted a woman who was 25 weeks pregnant to the hospital because she had a fever of 105. When giving her history, the patient insisted that she had no known medical problems. When the doctor examined her, she was shocked to find a very large incision extending from the base of the patient’s neck to the bottom of her breastbone.

“What’s this from?” the doctor asked.

“Oh, that. That’s from my heart transplant.”

The doctor was incredulous. “Your HEART transplant.? Don’t you think that’s a medical problem?”

“Sure,” said the patient, “you asked me if I have any medical problems, but I don’t any more. The heart transplant fixed them all.”

Not surprisingly, the heart transplant was a relevant piece of information. The patient was taking immunosuppressive drugs that left her vulnerable to serious infection. Knowing that, the doctor started her on broad spectrum antibiotics, and she recovered quickly. Sometimes, what you don’t say it just as important as what you do say.

Everyone should keep a list of their past medical history, past surgeries, current medical problems and current medications. Be sure to share that information with your providers at the beginning of any consultation. The recommendation that your doctor offers is only as good as the information that she has available. Ensuring that your doctor has accurate and comprehensive information about you and your health is the first step toward getting the best possible care.

Telephone triage is a skill that every doctor must acquire. Many patients initially present over the telephone, and it is important to be able to tell the difference between those who need to be seen right away, those who can wait for an appointment, and those who don’t have to be seen at all. Office staff usually handles the calls on weekdays, but on nights and weekends, the doctor on call takes them herself.

Most calls are about distressing symptoms, but occasionally there are calls due to simple curiosity (“I have a sunburn; do you think my baby is hot?”), and even less commonly, some women call simply because they are lonely or depressed. Every now and then, there are calls that defy categorization. Such was a call that blindsided me on a blustery Saturday afternoon in early spring. I was the chief resident, and therefore, took all the OB and GYN calls that came directly to the hospital. I was sitting in the Emergency Room where I was already caring for a patient having a miscarriage.

The caller sounded like a self possessed woman in middle age.

“I’m calling,” she announced, “because I need some information.”

“Okay,” I said. “How can I help you?”

“My son got his girlfriend pregnant,” she continued, “and I think she had an abortion. I have reason to believe that she had it done at your hospital.”

“That may be,” I replied. “But I cannot share that information with you.”

Every hospital has strict privacy requirements. Although this was in the days before the strengthened provisions of HIPAA (the Health Insurance Portability and Accountability Act), no hospital or provider could share medical information about a patient unless authorized to do so by that patient.

“Let me tell you her name,” the caller coaxed, “and you can tell me if you took care of her.”

“It doesn’t matter if you tell me her name, or whether I took care of her,” I answered. “I simply cannot tell you.”

“Don’t I have any rights?” she demanded. “After all, that could have been my grandchild.”

I tried to explain that her relationship to the baby or to the mother did not matter.

“Just look in the computer,” she begged, “and tell me if she was at the hospital. You don’t have to tell me what treatment she had.”

I explained that I was not allowed to do that either. The woman on the other end of the line now sounded agitated.

“You don’t understand,” she insisted, “I have a very special reason why I need to know.”

I tried to explain yet again. “There is no reason that would allow me to give you the information that you want. It is literally against the law for me to disclose that information.”

“Please,” she pleaded. “You have to help me. The baby needs me.”

“Excuse me,” I was startled. “Did you say the baby needs you?”

The caller exhaled a sigh of relief at finally being understood. “Yes, the baby is calling me. Every time I try to go to sleep, I hear the baby calling me: ‘Grandma, Graaaandmaaa, help me, help me, I’m stuck in this bottle.'”

“What?!”

“Yes, I hear the baby’s voice every time I close my eyes. I know he’s trapped in the basement of a hospital, maybe your hospital. I have to come get him. You have to help me.”

“Oh,” I said, “I see.” And now I did. “That must be very upsetting to you.”

“It is,” she sounded very tired. “I can’t sleep, I can’t eat, I have to rescue the baby.”

“You must be very uncomfortable and upset,” I agreed.

“Can you help me?” she sounded desperate.

“I can’t tell you about your son’s girlfriend,” I acknowledged, “but there is a very nice doctor here with me in the emergency room and I think he might be able to help you feel better.”

“You do?”

“Yes, I do. I’m going to let him know what you told me, and tell him that you are coming to see him right now. I’m certain that he can help you feel better.”

“Will he take me to the baby? The baby is calling me,” she repeated.

“He won’t be able to take you to the baby, but he will be able to help you with the voice that you hear,” I responded truthfully. “Will you promise me that you will come in right now?”

“Yes. Yes, I’ll come in. Let me get dressed and I’ll be there in an hour or so,” she agreed.

And that’s just what happened. Within an hour or two, she was visiting with the psychiatrist on call. He couldn’t help her find the baby in the bottle, but he was able to help her make the voice stop calling.

The Alzheimer’s Association recently released a report that attempt to quantify the financial and personal burden of Alzheimer’s care.

… [M]edicare payments alone are almost three times higher for people with Alzheimer’s and dementia than for others age 65 and over; Medicaid payments alone are more than nine times higher.

“With the country facing unprecedented economic challenges and a rapidly aging baby boomer population, now is the time to address the burgeoning Alzheimer crisis that triples healthcare costs for Americans age 65 and over,” said Harry Johns, Alzheimer’s Association CEO.

“It is widely understood that addressing health care is key to the country regaining its financial footing,” continued Johns. “And there is no way this can be done without improving Medicare and Medicaid which Alzheimer’s directly impacts…”

The report of the Alzheimer’s Association assumes that the enormous cost of Alzheimer’s care is a morally necessary burden, but it’s far from clear that the assumption is justified. The report ignores the most fundamental question: Is Alzheimer’s care a waste of money?

The report is quite clear on the financial burden to taxpayers and insurance companies, and the personal burden on caregivers. Alzheimer’s boosts the total cost of healthcare for the elderly from $10, 603 to $33,007 per year, each and every year. As the above excerpt from the report indicates, taxpayers bear the bulk of that increase.

The personal toll is equally high:

… According to Facts and Figures, in 2008, nearly 10 million Alzheimer caregivers in the U.S. provided 8.5 billion hours of unpaid care valued at $94 billion. In addition to the unpaid care families contribute, the report also reveals that Alzheimer’s creates high out-of-pocket health and long-term care expenses for families.

Alzheimer’s care doesn’t simply cost more. In a healthcare system that cannot afford to provide care for all its citizens, Alzheimer’s care diverts massive amounts of resources away from caring for the young and curable toward caring for the elderly and incurable. As a matter of justice, such a diversion cannot be defended. Every individual deserves the opportunity of a healthy childhood, and, indeed, Alzheimer’s patients have by definition already survived childhood. The moral claim of children carries far more weight than that of the elderly who have already lived a complete life.

I’m hardly the first person to raise this question. As I wrote last fall, British medical ethicist Baroness Warnock, noted for her willingness to address controversial issues stated in an interview in the TimesOnline:

“If you’re demented, you’re wasting people’s lives – your family’s lives – and you’re wasting the resources of the National Health Service,” she said…

No one could accuse her of being reticent. The Baroness elaborates:

“With 700,000 people suffering, it really is a problem that has got to be faced. The fact is we have to take a fairly unsentimental view. Care may get better, but if so, at huge cost. There’s no point saying we ought to spend more, because we can’t.

“People talk about it as if the only respectable motive for wanting to die is for your own sake. But it seems to me just as respectable to want to die partly for the sake of others, and for the sake of society.”

The Baroness gets to the heart of the matter and does not flinch:

“If society has an obligation to look after them, I really want to know what for? For whose benefit? It’s not for the benefit of society, as the person is not in a position to contribute, and it’s not for the benefit of the person, so it must be something abstract about our being unable to bear saying ‘We can’t do this any longer’.

“If I were in a state of acute misery or pain, or an insufferable degree of dependency, I don’t see why I should feel an obligation to others to let them keep on changing my nappies.

“It sounds very callous, but most people I know dread being kept alive in a state of mental incapacity, more than cancer or anything else. If so, then I don’t see why society should force them to go through with something they fear the most.”

Her questions are the key questions: If society has an obligation to look after them, I really want to know what for? For whose benefit?

I can think of a few more questions:

Does anyone benefit from our perverse insistence on indefinitely extending the lives of the senile elderly? Are we fulfilling the wishes of the elderly people involved? Would they want to be kept alive, incapacitated, incontinent, and incapable of participating in the most basic tasks or social interactions? It’s difficult to imagine that anyone would want that.

Does it make any sense to spend a major proportion of the healthcare budget on people who are virtually insensate and will never recover? Does it make any sense, financially or morally, to divert resources from young people, who may not even have access to the healthcare system, to elderly people who have already received a lifetime’s worth of benefits from that same system?

The Alzheimer’s Association, not surprisingly, starts with the assumption that we can and should continue to provide care regardless of the cost. Considering that it is we the taxpayers who are paying, it is both financially and morally incumbent upon us to question that assumption.

Last fall, a group of activists from New View Campaign staged a protest outside the office of the Manhattan Center for Vaginal Surgery. According to Time Magazine:

Appalled at the popularity of so-called designer vaginas, a grass-roots organization called the New View Campaign staged its first-ever protest on Monday outside New York City’s Manhattan Center for Vaginal Surgery. Two dozen women … handed out index cards and held up orange poster boards with the message “No Two Alike,” while two members of the group donned giant cloth vulva costumes. New View, which was created in 2000 … is trying to fight what it calls “the medicalization of sex,”…Says the group’s leader Leonore Tiefer, a sexologist and psychologist at New York University: “Promoting a very narrow definition of what women’s genitals ought to look like — even for those women who don’t want surgery, it harms them.”

I was unable to find picture of the cloth vulva costumes (and believe me, I tried), but I did find the group’s website with an extensive and thoughtful exposition of their philosophy. I was intrigued by their response to arguments about a woman’s right to choose genital plastic surgery:

The focus of our concern is on the cosmetic surgical procedures and the promotion of these by some doctors. Real choice is important, but choice does not exist in a cultural vacuum. In campaigning against genital cosmetic surgery we are calling for critical attention to the cultural conditions that lead women to choose these operations. We want to encourage debate about what is going on in contemporary western society that could produce a woman’s desire to surgically alter her genitals? We see the scene being set by trends such as the medicalization of women’s sexuality and the way women’s bodies continue to be objectified… [A]ggressive marketing … enlarges the market by normalizing and expanding women’s dissatisfaction with their bodies.

Although individual choice is an important cultural value that we endorse, the ethics of this issue cannot be reduced to ‘an individual’s right to choose.’ This is because the promotion and normalization of these practices has implications for all women. The business opportunity afforded by genital cosmetic surgery rests on creating, inflaming and inflating genital discontent among the wider population of women…

I am very wary of any argument that claims that an issue of choice cannot be reduced to an individual’s right to choose. That is nothing more than excuse to value some people’s choices (like the women of the New View) over the choices of other women with whom they disagree. The members of the New View may not like the fact that women choose genital plastic surgery, but they have no philosophic basis for interfering with that right.

The New View is correct, though, in its assertion that marketing and cultural values profoundly influence a woman’s desire to have genital cosmetic surgery. Here’s the marketing message of the Manhattan Center for Vaginal Surgery:

Labia Reduction & Cosmetic Enhancement: Labiaplasty is a cosmetic genital surgical procedure that will reduce the size or change the shape of the small lips on the outside of the vagina (the labia minora).

Many women are born with large or irregular labia. Others develop this condition after childbirth or with aging. The appearance of the enlarged labia can cause embarrassment with a sexual partner or loss of self esteem. Some women just want to look “prettier” like the women they see in magazines or in films.

They want to look “prettier” like the women they see in magazines or in films? Just what magazines and films offer up-close views of women’s labia?

If anyone is in doubt about the impact of cultural values, consider this scientific paper on the practice of labial elongation among Rwandan women. According to Rwandan female genital modification:

…In Rwanda, the elongation of the labia minora and the use of botanicals to do so is meant to increase male and female pleasure. Women regard these practices as a positive force in their lives… Research was carried out in the northeast of Rwanda over the course of 13 months. Semi-structured interviews were conducted with thirteen informants. Two botanicals applied during stretching sessions were identified as Solanum aculeastrum Dunal and Bidens pilosa L. Both have wide medicinal use and contain demonstrated beneficial bioactive compounds…

While there is extensive natural variation in the appearance of female genitalia, individual cultures have created appearance “norms,” and women within those cultures attempt to modify themselves to achieve these “norms.”

Is genital surgery the inevitable result of cultural values that create “norms” for sexuality and objectification of women’s bodies? Or are groups like the New View over-reacting? Can they really argue that genital cosmetic surgery is qualitatively different from other forms of cosmetic surgery in allowing women to take control of their appearance and enhance their self esteem?

These are difficult ethical questions without easy answers. I just hope there is no reality show in our future entitled Extreme Makeover: Vagina Edition. I’m not willing to rule that unfortunate possibility just yet.

A maternal death is an extraordinary tragedy. Until recently, it was all too common. In 1900, almost 1% of pregnant women died in and around childbirth. The advent of modern obstetrics has dropped the maternal mortality rate by 99% since then, so most people have no direct acquaintance with a woman who died in childbirth.

Most maternal deaths are due to serious complications of pregnancy, or serious underlying medical problems, such as heart disease, that are exacerbated by pregnancy. Like any obstetrician, I’ve been involved with several maternal deaths, though never as the primary physician. Each one has been a searing experience, but in retrospect, an unavoidable event.

All but one, that is.

The patient died because of a series of unfortunate anesthetic complications, compounded by inadequate medical response. I cannot tell you when, where or how, since the case is so unusual that any details might lead to identification and compromise of privacy.

Because maternal deaths are now so rare, my state, like most states, mandates an official investigation. The investigation is conducted by the hospital, and evaluated by the Department of Health. As a participant at a critical juncture in this woman’s care, I was interviewed extensively by a senior member of the obstetrics department and a member of the hospital administration.

I was very angry at the care the patient received from the anesthesiologists, because I believed that her death had been entirely avoidable. I did not hide my anger during the interview, going to so far as to say that I felt that the anesthesiologists had essentially killed the patient. The people who interviewed me seemed uncomfortable with my conclusions and with my anger. They repeatedly suggested alternative explanations for the unfortunate incident, but I was not swayed. Others might reach different conclusions, I acknowledged, but this was my conclusion.

Several years later I was contacted by my medical malpractice insurance carrier and advised that a malpractice case had been filed against the anesthesiologists. This was not surprising. Virtually every maternal death is followed by a malpractice suit, even when the death was unavoidable. As a participant in the patient’s care, I would be deposed by the patient’s lawyer. Consistent with its obligations, the malpractice insurer had hired a lawyer to defend me during the deposition.

Shortly thereafter, I heard from the lawyer’s office. The deposition was scheduled in several weeks, and I was given an appointment with the attorney for “deposition preparation” a few days in advance of the deposition itself.

At our meeting, the lawyer seemed both competent and affable. First, he wanted to hear the story directly from me, in as much detail as I could recall. I carefully recounted the events of that day. When I finished, the attorney was frowning.

“Do you realize,” he asked, “that your recollection is very different then the testimony you submitted at the time?”

“No, it isn’t,” I replied. “It’s exactly the same story.”

“Well,” he continued, waiving a sheaf of papers, “I have your testimony right here, and that’s not what you said.”

I was stunned. I knew that was exactly what I had told the interviewers. If anything, I had been much harsher back then, because I was closer to the event and very angry about what had happened.

I held my hand out for the papers, and re-read my testimony. By the time I finished, I must have been ashen.

“This is not what I said! This is nothing like what I said.”

The lawyer was dubious.

“No one is going to believe that,” he warned. “Unless you have proof, it’s as if it never happened.”

On the day of the deposition, we met in a conference room where the patient’s lawyer, the anesthesiologists’ lawyers, the hospital lawyer and the court stenographer were waiting. Everyone seemed friendly and relaxed. This was just a small, routine part of the case. I was only one of a dozen doctors they planned to depose, and not even a subject of the lawsuit.

I had been told to plan for a deposition that was several hours in length, but it didn’t take nearly that long. After recounting my memories of the day in question, I was met with the inevitable accusation.

“But that’s not what you said when you testified for the official investigation,” the patient’s lawyer said sharply, holding up the official report.

“Actually,” I replied, “that is what I said. The report you are holding is not my testimony.”

Every lawyer in the room was now alert. The deposition was not longer the routine task they had expected.

The patient’s lawyer looked very eager.

“Do you have proof?” he demanded.

“Yes, I do have proof,” I replied.

My husband is a lawyer, and he makes me keep everything I have ever signed. Shortly after the official interview, the interviewers had sent me a transcript of my testimony, beneath which was a place to sign acknowledging that this was a true representation of what I had said. My husband had insisted that I make a photocopy for my records before I sent it back.

After my meeting with my lawyer, I had gone home and dug it out from the bulging file cabinet. I had given the photocopy to my lawyer before we entered the conference room, and now he produced it and handed it to the patient’s lawyer.

Despite the somber nature of the proceedings, the patient’s lawyer looked gleeful. The lawyers for the anesthesiologists and hospital looked shell shocked. The lawyers handed my photocopy around. Not only did it have my signature at the bottom, but it also had the signatures of the senior department member, and the hospital administrator who had interviewed me. The document that the hospital had represented as my testimony had no signatures at all.

The patient’s lawyer was so happy, that it took several minutes for him to pull himself together and continue the deposition. The rest of the questions focused on my original testimony and my discovery that the testimony in the hospital report had been altered.

If I had been angry about what happened to the patient, I was even angrier after learning of the deception. The hospital had deliberately lied to protect its staff members. They lied to cover up medical negligence, with the assumption that the doctors in question would continue to practice at the same hospital, free to make similar mistakes.

The hospital had been remarkably foolish. In a malpractice case,  an attempt to alter the record is practically an admission of guilt. There was no limit to the millions of dollars that a jury would be willing to award in a case of avoidable death of a young mother where the hospital had attempted to hide the truth. The lawyers for the anesthesiologists and the hospital knew this, too.

My lawyer called me several days later.

“There isn’t going to be a trial,” he said. “The hospital offered the patient’s family an 8-figure settlement, and they have accepted.”

I love Cosmopolitan Magazine, I really do. Where else can you find so much information on how to be an unpaid prostitute?

Founder Helen Gurley Brown intended Cosmo to be sexually liberating for its women readers, a feminist sexual manifesto. The Cosmo of 2009 has evolved to extol the benefits of women being unpaid sex slaves. How did we get from there to here?

In many ways, Cosmo has simply reflected changing attitudes toward sex. Originally meant to demonstrate to women that there was more to sex than satisfying a husband, Cosmo has turned a full 180 degrees to demonstrate that there is nothing more to sex than satisfying a boyfriend. At least in the presumably repressed early 1960’s sex promised a husband, children, and lifelong economic support. Now sex promises nothing more than an evening’s activity, that, if done the Cosmo way, will leave the man satisfied and the woman happy that she satisfied the man. So much for feminism.

The ideal Cosmo sexual encounter is Erica Jong’s “zipless fuck.” In her 1973 book, Fear of Flying, Jong described the zipless fuck.

The zipless fuck is absolutely pure. It is free of ulterior motives. There is no power game. The man is not “taking” and the woman is not “giving.” … No one is trying to prove anything or get anything out of anyone. The zipless fuck is the purest thing there is.

Sex without strings. The original “friends with benefits.” Jong has said that she meant the zipless fuck as an expression of feminism: sex for no other reason than the protagonists wanted to have sex. But people often forget that Jong said of the zipless fuck: “And it is rarer than the unicorn.” Or that Jong’s heroine did not feel liberated by her sexual relationship with a man other than her husband.

Even the protypical zipless fuck did not work out as planned. According to reviewer Christina Nehring, writing in The Atlantic:

But here’s an irony: Fear of Flying demonstrates the unavailability of the zipless fuck. Far from being an inspirational story (as it is routinely billed) of a woman’s escape from a dead marriage and discovery of erotic pleasure and independence, it’s the tale of a woman who ditches her husband only to find in the arms of a lover first impotence and frustration, then heartbreak and abandonment. The end of the novel has Jong’s protagonist returning ruefully to her spouse …

Cosmo seems to have missed the news that sex without strings is not all it’s cracked up to be. Moreover, Cosmo appears to define “sex without strings” as “without strings for the man.” Cosmo is all about “catching” a man, but the underlying assumption is that men don’t want to be tied down. Therefore, in order to have a boyfriend, or even a casual sexual encounter, Cosmo instructs women to sublimate any needs and desires that they may have.

The April 2009 issue is a case in point.  The cover article, Just Do This on Date #1 (and he’s yours), is basically a compendium of “relationship tips” that involve emphasizing that “he” has no obligations to you. It advises not to tell him too much about yourself (TMI is a sexual turnoff) and not to text him simply because you’ve had sex; sure he had sex with you, but it’s texting that implies a more serious commitment.

Another cover article, What Guys Crave After Sex, advises acting like nothing more than an unpaid prostitute: compliment him, bring him a drink of water because he might be thirsty from his heroic performance. Most importantly, let him know that you’ve got to leave soon. That lets him know you aren’t foolish enough to believe that the fact that he had sex with you means that he wants to be with you.

Cosmo is dismally similar to 1950’s attitudes about sex. It’s a woman’s job to “put out” for her husband, whether it serves her needs or not. That was her part of the bargain; she provided sex in exchange for children and economic security. Then there was the prostitute. It was her job (literally) to “put out” for the customer in exchange for money. The Cosmo 2009 attitude toward sex is that it’s a woman’s job to “put out” for a man. And what does a woman get in exchange? Nothing of course.  Merely hinting that she might have needs is enough to drive any man away.

Cosmo was founded by a woman, but it’s difficult to believe that it wasn’t founded by a man whose ideal of womanhood was the star of a porno movie: always available, always sexually satisfied, never demanding anything other than more sex. That view of women, the view espoused by Cosmo, is profoundly misogynistic. Women are nothing more than sex toys. They may have thoughts, feelings and needs for interaction other than sex, but they should be sure to keep that to themselves.

 The zipless fuck doesn’t exist, as even Erica Jong’s heroine found out. Women don’t want or need sex without strings. Too bad the folks at Cosmo have not yet figured that out.

If you’re freaked out by eyebrow piercing, the kind of person who can’t look directly at your Starbucks barrista,  stop reading now. Even if you are a devotee of “body art,” you may reflexively cross your legs as you read this.

The latest craze is genital piercing. If you can imagine it, you can pierce it. Even if you can’t imagine it, you can pierce it. Aficianados of genital piercing like to claim that they widely used among indigenous peoples, but the reality is much more prosaic. According to WebMD:

…[G]enital piercing is largely a recent and Western phenomenon. This may be disconcerting to a few ill-informed proponents of the practice, who might prefer to imagine that they are rediscovering a venerable and ancient rite of passage, rather than practicing a newfangled invention. But … most of the exotic sounding names for different types of genital piercings were actually made up in the 1970s in the U.S. and Europe…

Genital piercing is believed by some to enhance sexual satisfaction. The existing scientific evidence (yes, someone has actually studied this) is equivocal. According to one paper, First glimpse of the functional benefits of clitoral hood piercing, which studied arousal, desire, lubrication, pain, orgasm, and overall sexual satisfaction:

 … We observed significance in only 1 of the domains, desire (0.414, P = .017). Other sexual functioning indexes were negligible. We expected to see a change in the orgasm frequency and/or satisfaction. Yet, contrary to popular belief, we saw no dramatically significant difference in orgasm.

Devotees of genital piercing, both female and male, are nothing if not creative. The About.com guide to female genital piercing lists no fewer than 8 different piercing sites including clitoral hood (two types) and inner and outer labia. The guide to male genital piercing also lists 8 separate types, many known by exotic names such as Ampallang and Apradravya.

Most of the scientific literature on genital piercing deals with complications, and there are quite a few. All body piercing has risks, the most common being infection and transmission of disease:

…  [T]he procedure has the potential to pass on any number of diseases, including leprosy, tetanus, tuberculosis, hepatitis, HIV, and other STDs.

But there are additional risks specific to genital piercing:

… More invasive kinds of piercing, such as a piercing that runs through the head of the penis, should only be done by experienced piercers if by anyone at all…. Such piercings can result in serious bleeding and “the risk of impotence caused by hitting the erectile tissue by mistake is simply too high,” … Piercing the clitoris itself, rather than the clitoral hood, is also a potentially risky procedure…

Once you decide that you want a genital piercing, and you decide which piercing you want, the most important step is choosing piercer. The Association of Professional Piercers, the professional organization of the piercing industry, publishes guidelines to choosing a safe piercer. These guidelines range from the obvious, choose a studio that is licensed and clean, to the esoteric, ask to see the autoclave (sterilizer) and the spore count test results.

In addition, they suggest looking at the piercing portfolio:

… Are piercings placed to accent the anatomy or do they look awkward and poorly matched to the individual? If the portfolio features unusual looking placements, are there pictures of healed piercings, showing the actual viability of the placement?

The other key to safe genital piercing is scrupulous aftercare, including cleaning and handling of the piercing, as well as sexual limitations.

Do not allow your piercing to come in contact with any bodily fluids for the first few weeks while it is healing. This includes saliva as well as semen. So, you are not restricted from sexual activity, but a condom or dental guard must be used for any and all sexual contact, or you are putting yourself at risk for infection. This includes masturbation and/or the use of sex toys.

Whether genital piercing is ancient or modern, whether it does or does not enhance sexual satisfaction, one thing is clear: it is critically important to follow all guidelines in order to avoid infection. Contrary to what you might expect, the piercing itself is reported to involve little pain. However, an infection, and its complications can be very painful, as well dangerous and possibly threaten your fertility or your life.

No one likes unsolicited advice. It doesn’t matter if it’s good advice and it doesn’t matter if it’s well meant. Patients are no exception, even though part of the provider’s job is to counsel patients about their lifestyle choices. Smokers don’t want to be told not to smoke; overweight people don’t want to be told about the risks to their health.

That’s why I always tried to confine myself to the unadorned facts, and carefully excise any value judgments from my comments. Every now and then, though, I couldn’t help myself.

Any gynecologist is depressingly familiar with sexually active young teens and preteens, and the dreadful consequences. I often saw these girls in the Emergency Room in the middle of the night, unaccompanied or accompanied only by teenage friends. Certainly, no one came in with her mother. Perhaps that’s why I was not expecting a discussion of birth control when an affluent mother brought her 12 year old to the office for a consultation.

Improbably, the mother was beaming. Very few people are beaming at their gynecology appointment.

“We’re here for the Pill,” she announced cheerfully.

“The Pill,” I was shocked and it must have showed. “Who’s here for the Pill?”

The mother plowed ahead. “I brought my daughter to get the Pill. She’s sexually active.”

I turned to the daughter. She nodded her head slightly in affirmation.

“I’ve explained,” the mother continued, “that when you are sexually active, you always have to use protection, and the Pill is the best protection there is. That’s why I brought her myself.”

“Well,” I started tentatively, “the Pill is the best protection against pregnancy, but it doesn’t offer any protection against sexually transmitted diseases. Before we get to that, though, I’d like to talk a little more about sexual activity. I turned to the daughter again. “What grade are you in?”

“Seventh.”

“How old is your boyfriend and what grade is he in?”

“He’s 17 and he’s a senior in high school.”

“Yes,” the mother confirmed proudly, “she’s dating a senior.”

“Have you considered,” I ventured, “that might not be such a good thing?”

“What do you mean?” The mother was clearly annoyed.

“I mean,” I said, “that 5 years is a big age gap. There’s a big difference between a seventh grader and a high school senior.”

“So?”

“So, the needs and desires of a 17 year old boy are very different from the needs and desires of a seventh grader. A sexual relationship might seem like a good idea for a 17 year old, but it’s inevitably a bad idea for a 12 year old.”

“But she wants to date him,” the mother responded.

“Yes, she may want to date him, but that doesn’t mean that there might not be an element of coercion involved. Let’s think about this for a minute; what kind of 17 year old boy dates a 12 year old? It’s usually someone who has no success with girls his own age, and has to reach down to much younger children to have a sexual relationship.”

The mother was clearly growing angry. “But I thought you’d be impressed that I brought my daughter in for birth control,” she said, “My mother wouldn’t have done anything like this. She didn’t even tell me the facts about sex.”

“Sorry, I’m not impressed that you brought your sexually active 12 year old in for the Pill. I’m worried that someone is taking advantage of her.”

I kept looking in the direction of the daughter, but she made no response.

“We didn’t come here for your dating advice,” the mother replied heatedly. “Are you telling me that you won’t give her a prescription for the Pill?”

“No, that’s not what I’m saying. If her exam is normal, and she has no risk factors, I’m certainly going to give her a prescription. She’s sexually active and she needs to be protected from pregnancy. And I’m going to talk about condoms, too, since the Pill does not protect against sexually transmitted diseases.”

The mother was not mollified. She sat stonily through the rest of the interview and exam. When I finally wrote the prescription for birth control pills, she snatched it from my hand.

“Thank you,” she said coldly. “That’s what we came for. And by the way, the next time we want your opinion, we’ll ask for it.”

From Japan, the font of video game technology, comes a new game that is possibly the most offensive video game ever produced. The game is RapeLay, a rape simulator game. Yes, you read that right. RapeLay allows you to play a sexual predator in the subway.

RapeLay is surprisingly realistic in its portrayal of the rapist as power hungry sexual deviant. Gaming journalist Leigh Alexander (of websites Gamasutra and SexyVideogameland) thoughtfully downloaded and played the game, so you don’t have to:

The game begins with a man standing on a subway platform, stalking a girl in a blue sundress… Once she’s on the train, the assault begins. Inside the subway car, you can use the mouse to grope your victim as you stand in a crowd of mute, translucent commuters. From here, your character corners his victim—in a station bathroom, or in a park with the help of male friends—and a series of interactive rape scenes begins.

… Although the interactive assaults are difficult to endure if you have a conscience, the game’s text actually provides the most unsettling material. RapeLay relies on the horrendous, wildly sexist fantasy that rape victims enjoy being attacked. After the exposition, the game essentially becomes a simulator of consensual intercourse. There’s kissing. The women orgasm.

The game is realistic in yet another way. It portrays the Japanese phenomenon of the chikan, the subway pervert. The details of chikan, a real practice, not a video game, are horrifying. According to the book The Japanese Disease: Sex and Sleaze in Modern Japan, by Declan Hayes:

… The molestation-minded men get together through the Internet, brazenly advertising for interested parties to join their ranks in chikan associations…

The chikan groups are incredibly thorough, picking out a particular target and trailing her for months until they have a minutely detailed knowledge of her commuting habits. Once they decide to implement their plan to molest her, group members are instructed to board the crowded train at different stations and stand in the particular part of the carriage that … target normally occupies… Once they’re all in the same carriage, they immediately set about surrounding the target and shutting off all possible avenues of escape… [M]embers of the group with go hell for leather groping, poking and molesting the target they have surrounded…

The back-story of RapeLay is that you are a wealthy man out for revenge after being outted as a chikan. As a result:

The objective … is for your “character” to stalk then brutally rape women, as many as possible. Wait, there is a catch: before your character can go into “free mode” to rape other women in the game, he must first rape a mother and her two young daughters, who have “falsely accused you [him] of raping them.” Now the big twist: you cannot get any of the women pregnant. If you do impregnate a woman, you must force her to have an abortion because if she has the child you will be thrown under a train… With several users playing the game, it is possible to gang rape the women …

Not surprisingly, the video game offers politicians an irresistible opportunity to grandstand. New York City Council Speaker Christine Quinn has publicly called for all US video game distributors to refuse to sell Rapelay. Considering that the game has not been released in the US market, the call for a ban is unnecessary. Potential distributors such as Amazon.com and Overstock.com have already announced that they will not carry it. Moreover, a ban is meaningless, since the game is widely available over the Internet.

Will Rapelay encourage players to commit rape in real life? Clearly there is a connection between sexual predation (chikan) and a video game that glorifies rape. The game makers are explicit about this connection. Undoubtedly, those who belong to chikan associations will be drawn to the game, but there is far from obvious that playing the game will turn men into sexual predators. Rapelay is offensive, appalling and worthy of condemnation, but is it harmful? That remains to be seen.