The vociferous response to my post Should we lament the disappearance of Down Syndrome? advocating choice in terminating a Down Syndrome pregnancy alerted me to an organized effort by DS parents to “educate” everyone else. It reminds me of, and shares many characteristics in common with, efforts by pregnancy “crisis centers” to “educate” women experiencing unwanted pregnancies. In both cases, the efforts are rather transparent attempts to get women to change their minds.

The movement was profiled in a 2007 piece in The New York Times.

Convinced that more couples would choose to continue their pregnancies if they better appreciated what it meant to raise a child with Down syndrome, a growing group of parents is seeking to insert their own positive perspectives into a decision often dominated by daunting medical statistics and doctors who feel obligated to describe the difficulties of life with a disabled child.

Their concern is hardly selfless:

A dwindling Down syndrome population, which now stands at about 350,000, could mean less institutional support and reduced funds for medical research. It could also mean a lonelier world for those who remain…

“If all these people terminate babies with Down syndrome, there won’t be programs, there won’t be acceptance or tolerance,” said Tracy Brown, 37, of Seattle, whose 2-year-old son, Maxford, has the condition. “I want opportunities for my son. I don’t know if that’s right or wrong, but I do.”

Interestingly, the vast majority of parents who elect to terminate are not complaining about being “uneducated” either at the time of termination or years later. And certainly no one in the community of DS parents is complaining about the “education” of those who were encouraged to continue the pregnancy. In fact, the only complaint emanating from the community of DS parents appears to be that people who make different decisions must be receiving inadequate education.

The approach, on view in the comments section of my previous DS post, is fairly formulaic:

… [T]he richness of their children’s lives, parent advocates say, is poorly understood. Early medical intervention and new expertise in infant heart surgery stave off many health problems; legally mandated inclusion in public schools has created opportunities for friendship and fostered broader social awareness of the condition.

The effort to “educate” other is remarkably intrusive:

… [P]arents are arranging to meet with local obstetricians, rewriting dated literature and pleading with health care workers to give out their phone numbers along with test results.

The medical community has been unimpressed. They understand that their obligation is to present unbiased information, not to present false hope in an effort to sway their patients’ choices.

Genetic counselors, who often give test results to prospective parents, say they need to respect patients who may have already made up their minds to terminate their pregnancy. Suggesting that they read a flyer or spend a day with a family, they say, can unnecessarily complicate what is for many a painful and time-pressured decision…

There is certainly no objective evidence that Down Syndrome counseling is inadequate. There is only the conviction of some DS parents that people who make a different choice are making the wrong choice. Their effort to “educate” other parents is nothing more than an attempt to pressure them, and, as such, it is wrong.

I first noticed difficulty with my vision in the early spring of 2000. Sitting at Little League Games I often had trouble focusing on the action. Over time I realized that the problem was intermittent double vision.

As the weeks went by, the double vision got worse. My optometrist suggested that adjusting my contact lens prescription; that didn’t seem to work. Over time it became apparent to me, despite my vigorous attempts to pretend otherwise, that this was not a problem with my eyes, but almost certainly a problem inside my head. I made an appointment a highly regarded neuro-ophthalmologist, a hospital colleague.

I read up on double vision. There were three principle causes of double vision in otherwise healthy patients: idiopathic, which is the technical term for unknown cause; multiple sclerosis, and, least likely, a brain tumor. I convinced myself that I had idiopathic double vision, distressing because there was not cure, but certainly better than having multiple sclerosis or a brain tumor.

I arrived for my appointment on time. I had to spend an hour and a half in the waiting room because the doctor was “running behind,” but, as an obstetrician, I’m hardly in a position to complain about waiting. Finally, the doctor flung open the exam room door and swept into the room.

“I can’t see you today,” he announced. “My secretary is an idiot. You have double vision and double vision requires an extra long appointment. She booked you for a regular appointment. You’ll have to come back another time when I have more time to see you.”

“I don’t think so,” I responded. “I’m here now and you can start the exam in the time we have available. If we need more time, I’ll make another appointment.”

The doctor looked irritated, but after learning I was a colleague of his, he seemed mollified. From that point forward, he was on his very best behavior. Considering how he treated me, I feel very sorry for his patients who are not doctors.

The doctor did a few simple tests, asked me to look up and down, side to side and follow his finger. In less than 5 minutes he announced findings.

“You don’t have to come back,” he said. “I already know what you have. You have a sixth nerve palsy. The nerve that controls one of the muscles of your eye (the sixth cranial nerve) is not working. You can’t move your left eye to the left, that’s why you have double vision, and why it happens intermittently. You only get double vision when looking to the left.”

“There are three main causes of double vision,” he continued. “Idiopathic, but I don’t think it’s that; multiple sclerosis, but your story is wrong for multiple sclerosis; and brain tumor. You must have a brain tumor. I’m sure of it.”

That was it. That was how he broke the diagnosis. I had known about the possibility, of course, but I was stunned nevertheless.

“How are we going to find out whether I really do have a brain tumor?” I asked.
“Oh, you have a brain tumor,” he responded emphatically. “We need to get an MRI to find out how big it is and where it is located. I suspect that it’s benign, and based on its appearance on the scan, we should be able to confirm that.”

He continued, “You can have an MRI on Monday, then you can come back on the following Monday and I’ll tell you what it showed.”

“Wait a minute,” I was beginning to recover from the shock. “What do you mean that I find out the results the following Monday? The radiologist can see the findings during the scan itself. Why can’t you get the results from the radiologist by phone on Monday?”

“You know those radiologists,” he confided. “They’re all foreigners, Pakistanis, Indians; who can understand what they say? I can’t, so I’ll just wait for them to write me a letter.”

Even in my shocked state, I recognized that it was pointless to try to deal with this doctor. I determined to deal with the radiologists directly.

I told my husband what had happened. I related the doctor’s comments about the foreign radiologists. He was appalled by the blatant racism, but then he smiled.

“As it happens, I know those radiologists. I am one of their lawyers. My contact person in the group is Dr. Z, He’s Pakistani, but I have no trouble understanding him. He speaks better English than we do.”

My husband called Dr. Z who assured him that he would come down and read my scan after it was done, and tell us the results immediately.

On the day of the scan, as I slid out of the MRI machine, a radiologist approached and stuck out his hand.

“Hi, I’m Dr. Z and I’ve already looked at your scan. Come out to the computer and I will show you what I found.”

He was warm and engaging. He spoke perfect English with a slight British accent. I had no trouble understanding him. I followed him to a large computer screen.
“Good news,” he said, with a smile. “Your brain tumor is benign.”

The room started to spin. I asked for a chair and sat down with a thump.

“I can’t have a brain tumor,” I said stupidly. “My son is having his Bar Mitzvah in two months and now is not a good time.”

He looked at me kindly. “I’m not sure what that is, but it doesn’t prevent you from having a brain tumor. But look at the scan. The tumor is small and well contained. It looks like a meningioma, a very common type of benign tumor. See how it is pressing on the sixth nerve. That’s why you have double vision. Don’t worry, though, a neurosurgeon will be able to remove it, and you’ll be fine. They typically don’t come back.”

I wasn’t counting on brain surgery, and this did not seem like good news to me. However, when I realized that Dr. Z was genuinely happy to be sharing this news, I understood that he had worried that the scan might have showed something far worse.

Later that afternoon, I got a call from the neuro-ophthalmologist. Dr. Z had informed him that I already knew the results of the scan. I’m not sure why he called since he did not impart any helpful information.

“I’ve looked at the film,” he reported, “and you have a small tumor that is almost certainly benign. It’s only a half inch across, but it is located deep inside your brain and pressing on lots of important structures.”

Then he added: “I’d hate to be the neurosurgeon doing your case. That sucker is sitting in a lake of blood. The surgery’s going to be a mess.”

To be continued

This piece originally appeared on Open Salon in October 2008.

Homebirth advocates have a fallback position when presented with reams of data that homebirth increases the risk of neonatal death. They declare that the evidence is “conflicting” and that “there’s no way we can solve this.” But, of course, there are neutral ways to establish the truth, and I’d like to offer them publicly to homebirth advocates.

The following was originally posted on RH Reality Check in response to a piece by Amie Newman entitled What’s So Scary About Home Birth? I offer this proposal to her, and if she doesn’t accept, to any and all homebirth advocates:

“I’m sure you would agree that American women deserve to know the truth about homebirth. The best way to do that would be to present the information from both sides in a way that everyone could understand and make their own decisions.

I propose that RHRealityCheck sponsor a homebirth debate. I am willing to debate any professional homebirth advocate at any time. I would welcome the opportunity to present my claims side by side with those of homebirth advocates. I am very confident that when women see the actual data, they will realize that professional homebirth advocates have not been completely honest about the safety of homebirth.

Of course, the real problem will be finding a professional homebirth advocate willing to debate. They know what I know and they know that if they are forced to publicly defend their claims, they will be unable to do so. Hence they will do anything possible to avoid a debate.

Last year I was invited to participate in a childbirth conference by the organizers of the conference. They thought that my controversial status in the homebirth community would be an excellent draw. I agreed that I would attend the conference, but with one condition attached. I would only appear in a debate with a professional homebirth advocate, many of whom were already planning to attend.

The conference organizers thought this was a great idea. I warned them that no one would agree, including those who were already planning to attend. Professional homebirth advocates never appear in any forum where they can be challenged by people who are equally knowledgeable. Sure enough, much to the surprise of the organizers, they were turned down by almost everyone. Ultimately they managed to cajole a very prominent homebirth advocate into participating and I made plans to attend the conference. Then, predictably, the homebirth advocate announced that he had changed his mind and would not participate. I did not attend the conference.

I’m hoping that you could be more persuasive, but I am not optimistic. Professional homebirth advocates are afraid of me, and anyone else who has command of the data and scientific literature. They cannot afford to appear in any type of debate because their claims would be eviscerated in short order.

Second, since it is highly unlikely that any professional homebirth advocate would participate in a debate, I offer an alternative way of settling the controversy. Let’s hire a professional statistician to analyze the data and present his or her findings to the public. We could find a mutually agreeable statistician who has no previous connection to the homebirth issue. I am so confident about the results that I am willing to pay for the analysis by any mutually agreed upon professional statistician.

We may not be able to solve the controversy by arguing with each other, but you, in your role as a professional journalist, are capable of presenting a public analysis of the evidence, either by sponsoring a debate or by agreeing to publish the results of an independent statistical analysis.

Check with the executive staff of RH Reality Check and see what they think. It seems like the perfect forum. RH Reality Check is committed to providing women with accurate information on reproductive health topics. This is a chance to inform the public and get lots of publicity and traffic as a result. And, as I said, I’d even be willing to pay for it.”

Is Down Syndrome disappearing? Is that a bad thing? Brian Skotko asks these provocative questions in a recent article in the journal Archives of Childhood Diseases, With new prenatal testing, will babies with Down syndrome slowly disappear?.

The proportion of children born with Down Syndrome is declining rapidly. That’s not because the incidence of Down Syndrome is declining. The cause is the dramatic increase in prenatal testing and the high abortion rate for Down Syndrome babies. As Skotko explains:

…[W]omen are waiting longer to have children. Because advanced maternal age is associated with increased chances of having a child with DS, the birth incidence of DS would have been expected to climb. However, the worldwide birth incidence of DS has actually decreased from what it could have been … For example, in the U.S., there would have been a 34% increase in the number of babies born with DS between 1989–2005, absent prenatal testing. Instead, there were 15% fewer babies born, representing a 49% decrease between the expected and observed rates.

Down Syndrome is a chromosomal anomaly with a straightforward cause. Human beings have 23 pairs of chromosomes for a total of 46. Individuals with Down Syndrome have an extra chromosome for a total of 47. Chromosomes pairs are numbered and Down Syndrome is the result of an extra chromosome 21. The extra chromosome leads to effects of varying severity throughout the body. Down Syndrome individuals have mental retardation, distinctive facial features, low muscle tone and medical problems such as congenital heart defects.

A major genetic defect like an extra chromosome is relatively easy to diagnose by amniocentesis. More recently, we have developed less invasive methods of screening for Down Syndrome such as the triple test or quadruple test. Further improvements in prenatal testing are on the horizon. Skotko wonders if improved testing will further decrease the proportion of Down Syndrome children:

…Several factors suggest so. First, the new tests will be offered in the first trimester … Consequently, women will be able to receive a DS diagnosis and make a decision about the continuation of their pregnancies in private… Second, the new tests are noninvasive, carrying no risk to the fetus …

Thirdly, in countries like the U.K., where women are only offered CVS or amniocentesis if their screening test is deemed “high risk,” the new tests would afford everyone an opportunity to know definitively if their fetus has DS … Lastly, the new tests are projected to cost less than amniocenteses …

Stotko, who has a sister with Down Syndrome, laments these advances, under the dramatic heading “our genetic future.”

While DS might be the first genetic condition that can be definitively diagnosed in the first trimester on a population basis, others will undoubtedly follow… ACOG issued an opinion opposing obstetric practices that perform terminations based on fetal sex alone. Barring work-up for sex-limited genetic conditions, sex selection could be interpreted as “condoning sexist values” and creating a “climate in which sex discrimination can more easily flourish.” By contrast, in its support for DS prenatal screening, has ACOG endorsed a climate in which disability discrimination could more easily flourish?

Skotko has strong feelings on the subject, dramatically concluding

…Parents who have children with Down syndrome have already found much richness in life with an extra chromosome. Now is the time for the rest of us to discuss the ethics of our genetic futures.

Richness? The use of that term is patronizing to both parents and to people with Down Syndrome. It is patronizing to parents because it implies that the lifelong burden of caring for a disabled child should be perceived as “enriching.” It is patronizing to people with Down Syndrome by suggesting that their primary value is to enrich the lives of others.

Interestingly, Skotko pays very little attention to the myriad of genetic diseases for which testing and termination are also available. He does not advocate the “richness” of life with a child who has a terminal neurologic condition like Tay-Sachs, or the “richness” of life with a child who has similar but more serious chromosomal abnormalities like Edward’s Syndrome (extra chromosome 18) or Patau’s Syndrome (extra chromosome 13). Evidently these disorders are not “enriching” enough to justify his concern.

Skotko is right to raise these issues, but he is wrong to substitute his judgment for the parents who face these decisions. Raising a child with a serious genetic anomaly is a major burden, one that never ends and one that often gets harder as the years go by. It should be up to those parents to make the decision, and they should be entitled to the most advanced and least invasive technology with which to do so.

On the face of it, it sounds like an idea that everyone can love, patients, doctors and insurers. I’m talking about “evidence based medicine,” the idea that treatment decisions should be determined solely by the scientific evidence. In practice, though, evidence based medicine can harm or even kill patients. That’s because the evidence may be conflicting and various third parties like drug companies and insurers may have undue influence in determining what qualifies as the “evidence” in evidence based medicine.

The recent findings about diabetes and tight control serve as a stark reminder of the drawbacks of evidence based medicine. Good control of blood sugar levels in adult onset diabetics improves long-term health outcomes. Therefore, it seemed reasonable to assume that tight control (very strict control of blood sugar levels) would provide even better outcomes. When drawing up the guidelines for management of adult onset diabetes, the National Committee for Quality Assurance deemed tight control to be the evidence based treatment guideline.

A recent large-scale study of tight control showed that, contrary to assumptions, tight control actually increased the death rate for adult onset diabetics. In fact, the results were so dramatic that the study was ended early to prevent harm to any other patients. This unexpected finding prompted a deeper look at how the standard had been promulgated and the story is not pretty.

First, it quickly became apparent that the guideline for tight control was approved over the protests of many diabetes experts. They had cautioned that the evidence for tight control was lacking and that the difficulties of maintaining tight control often led to unexpected side effects, poorer compliance, and poorer outcomes.

Second, there was a third party that would benefit from a guideline for tighter control, whether that guideline helped or harmed patients. That party was the pharmaceutical companies that sold insulin, the cornerstone of blood sugar control. Tighter control automatically means using more insulin than less rigorous control. A guideline insisting on tight control would immediately and dramatically benefit drug companies.

Third, the National Committee for Quality Assurance, a supposedly impartial organization that sets the standards used by insurers to determine whether a treatment qualifies for payment, had received money from the drug industry. Indeed, last year the NCQA received approximately $3 million from drug companies, fully 10% of its revenue.

This story is a cautionary tale about the dangers of evidence based medicine. In theory, evidence based medicine is the ideal. In practice, the evidence is often unclear, or leads to the need for personalized recommendations in place of a universal standard. Since the evidence is often unclear, third parties like drug companies and insurers may have motives for promoting one view of the evidence over another and can exert undue influence over supposedly impartial organizations that set the evidence based standards.

This does not mean that we shouldn’t use evidence in determining care. It just means that we need to be sensitive to the fact that the evidence for specific treatment recommendations in specific cases is often lacking or conflicting. Sometimes there really is no evidence based standard and we shouldn’t try to create one simply to fill the gap.

Moreover, acknowledging that the evidence is lacking or conflicting minimizes the chance that the standard will be influenced by third parties. When a treatment standard is set, there are often third party winners and losers like device manufacturers and drug companies. A specific standard may represents millions of dollars in profit or loss, and it is only to be expected that the winners and losers will try to influence the choice of standard.

Finally, the entities that promulgated evidence based standards must be thoroughly insulated from the influence of third parties. Those organizations must be prohibited from taking money from companies who stand to benefit or lose based on the standards.

Evidence should always guide treatment decisions, but evidence based medicine often doesn’t reflect the evidence accurately, leading to injury or even death of patients.

Natural vision advocates are planning rallies at DMV (Department of Motor Vehicle) offices around the country today. They are protesting what they believe to be the coercive tactics of the DMV in mandating vision correction for drivers with less than perfect vision. Simply put, anyone applying for a license must submit to a vision test, and anyone who has been diagnosed with nearsightedness must wear glasses or contacts while driving. Members of the group Vision Junkies United think that is wrong.

According to their spokesperson Mr. Jayden Kayden Hayden:

Human eyes are designed by nature to see perfectly. Are we really supposed to believe that 25% if the population needs vision correction? That’s simply laughable. We wouldn’t be here if nearsightedness were so common. We would have died out long ago.

Ms. I. C. Yu, the president of Vision Junkies United, explains the ten point manifesto prepared by her organization:

Eyeglasses and contacts are unnatural. Nature never intended human beings to have vision correction.

Relying on natural vision instead of giving in to glasses is empowering. Anyone can drive safely wearing glasses. It is a true achievement to drive safely without them.

The requirement for a vision test is absurd. All you have to do to drive it to see; it is hardly necessary to test every single person for vision impairment.

We need to trust vision. It’s time for us to reject the notion that human eyes are broken and need to be “fixed” by artificial means.

People should rely on their intuition about vision. If they believe that it is safer to drive without glasses, then they should drive without glasses.

Vision affirmations lead to better outcomes. Drivers should continually remind themselves, “I can see the car in front of me” and that will naturally improve their ability to see.

The decision to wear glasses is a choice. The DMV has no right to interfere with individuals’ right to make their own choice about whether they will wear glasses or contacts while driving, or even whether they will submit to the vision test when renewing their license.

Vision junkies are far more educated on the topic of vision than others. Most people behave like sheep when told that they need glasses for vision correction. They just go out and buy them, without ever questioning whether they are truly necessary.

There’s no scientific evidence that driving with glasses is safer than driving without. No one has even bothered to study it. Those in authority simply assumed that correcting nearsightedness is safer.

No one should underestimate the influence of “Big Glasses.” The vision industry is a multi-billion dollar industry. No one profits by declaring that you have perfect vision. Eyeglass manufacturers, contact lens manufacturers, optometrists and opticians only profit if you need vision correct. Is it any wonder that so many people are told they need glasses?

According to Ms. Yu, the American people need to “take back vision” from those who have tried to intimidate us into believing that our eyes are broken. We should stop giving in to the perceived need to actually see the road and return to our natural roots. We must learn to see the way nature intended, without glasses and without contacts, and we will surely feel empowered as a result.

It’s not enough for Christian Fundamentalists to keep their own compatriots ignorant of science; now they want you to be ignorant, too. And they are bringing their traditional technique, mob rule, to a movie theater near you.

The producers of a widely acclaimed British film about Charles Darwin’s life have revealed that they cannot find an American distributor for the film because it is “too controversial.” Not the substance of the film Creation; that’s true and that, of course, is the problem. The movie reveals that Charles Darwin could not reconcile his scientific discoveries with the Bible, and like millions of people since, was forced to conclude that the religion he was taught is directly contradicted by scientific discoveries.

In many ways this movie represents a more critical challenge than the scientific facts of evolution. Religious fundamentalists fear evolution, but for a very specific reason. If evolution is true than the Bible is not, and Fundamentalists will not, cannot, acknowledge that.

If this conflict sounds familiar, that’s because it is. As I wrote in When it comes to science, religion is always wrong:

The “debate” over evolution is almost an exact recapitulation of the “debate” over Galileo’s demonstration that the sun is at the center of the solar system, not the earth. The Bible had located the earth as the center of the entire universe, to literally represent the role of man as the center of God’s concern. When it became apparent that the earth wasn’t even the central planet in our little solar system, religious authorities felt compelled to prevent anyone from learning the truth.

If it became widely known that the Bible was wrong about something as straightforward as the location of the earth within the universe, then it might be wrong about anything. Church leaders reacted as conservatives often do; they attempted to suppress knowledge…

What is particularly frightening for Fundamentalists about this movie is that it focuses specifically irreconcilable aspects of science and the Bible. Darwin was not irreligious. He was a religious man who could not reconcile the tenets of his faith with the scientific discoveries he had made.

What’s especially frightening for the rest of us about the Fundamentalist reaction is that it is no longer enough for them to make sure that their compatriots, and especially their children, never hear the scientific truth. They are exerting their political power to make sure the rest of us don’t hear the truth.

Fundamentalists could easily avoid the film, and they could ensure that their children do not see the film. They don’t want anyone to see the film and they plan to exert political and economic leverage to punish anyone who makes it possible for others to see the film.

Don’t get me wrong. They are well within their political rights to speak out against anything they want to speak out against. Nonetheless, it is chilling when any group tries to exert political power to suppress the truth.

As I have written before, over the last two millennia, religion has opposed science on many different occasions. And every time religion has opposed science, regardless of the topic, religion has been spectacularly wrong, every single time. Evolution is no different. Religion has never vanquished science and it isn’t about to start now.

Religious efforts to suppress scientific facts are harmful to society. Those efforts make our children ignorant and prevent progress. They make us the laughingstock of the world. Most countries are trying to solve contemporary problems. Americans are still fighting about issues that were definitively settled 200 years ago.

Hopefully, Americans who care about the truth will step forward and bring the movie to this country. It is up to us to resist the public promotion of ignorance.

Officials of the American grocery industry have announced that they are preparing a two pronged attack against soup kitchens for the poor. They plan an advertising campaign to alert the public of the dangers of soup kitchens, and a lobbying effort in Congress.

A spokesman for the grocery industry, I. M. Greedy, declares:

“Americans are compassionate people and on the face of it, a soup kitchen is a compassionate attempt to help the poor. Dig a little deeper, though, and you’ll find that the soup kitchen option is both unfair competition and will hurt all Americans.”

The grocery industry is concerned, first and foremost, that the soup kitchen option represents unfair competition. As Greedy explains:

“We have to make a profit, but soup kitchens do not. Therefore they can charge less for their soup.

Let’s be honest here. When poor people are given a choice between buying their soup in the grocery store or heading to the soup kitchen, they’ll pick the soup kitchen every time. The only way we could make the grocery store more attractive is to lower the price of soup and that is unfair.”

Greedy emphasizes that they are not the only ones who will be harmed. Though the government insists that the soup kitchen option will be just one among many options for obtaining soup (citing the continuing availability of soup in grocery stores, restaurants and food courts, the industry is convinced it is only a matter of time before everyone is forced to get their soup in soup kitchens.

According to Greedy:

“Sure, they say that you will still be able to choose where to get your soup. That’s what they want you to believe. The reality is that it is only a matter of time before the government bans soup in grocery stores, restaurants and other places, forcing everyone who wants soup to get it from a soup kitchen.”

The grocery industry believes that the worst thing about the soup kitchen option, from the point of view of the general public, is that it takes away choice. Rather than selecting any soup from the grocery store shelves, consumers who select the soup kitchen option will be restricted to eating only the soup available that day.

Greedy says:

“Americans are not going to tolerate any situation in which they are deprived of choice. You go to a soup kitchen, and can you choose your favorite soup, the one that you have loved for years? No, you cannot. At the soup kitchen you are forced to accept whatever they are offering. Suppose it’s chicken soup and you don’t like chicken soup? Too bad.”

The grocery industry also plans an extensive lobbying effort on Capitol Hill. They have already contributed millions to the re-election campaigns of several Senators and Congressmen. One of those Congressmen has introduced legislation to ban soup kitchens.

Greedy explains:

“We in the grocery industry are gratified that several Senators and Congressmen already understand what it is at stake here. That’s not enough, though. We want to meet with even more Senators and Congressmen to impress upon them the unfairness of the soup plan option. American is a great nation because it won’t countenance socialism. And what are soup kitchens but a socialist attempt to benefit the poor at the expense of the rich? Real Americans refuse to accept schemes that redistribute money from those, like grocers, who work for a living, to the undeserving poor.”

Mr. Greedy is optimistic about the eventual outcome.

“Once Americans understand what is at stake here: government forcing people to get their soup through soup kitchens; government restricting people’s choice of soup; government stifling honest American competition; they will reject the soup kitchen option.”

Mr. Greedy is modest:

“I don’t think that Americans will ever realize that the grocery industry, through a successful advertising and lobbying effort, will have protected them from the harms that would occur if the soup kitchen option were allowed. That’s okay. We in the grocery industry are content to let people believe that they thought of opposing the soup kitchen option instead of being incited to do so by a relentless barrage of fear mongering.”

Mr. Greedy smiles:

“We don’t need the public to thank us. Banning the soup kitchen option will be thanks enough.”

Narcissistic injury is a term from psychoanalysis. A narcissist in psychoanalytic theory is different from our colloquial use of the word. Rather than being a person who is obsessed with herself, a narcissist is a person who suffers a deep sense of inferiority and masks it by projecting an air of grandiosity and excessive self regard. A narcissistic injury occurs when reality threatens the narcissist’s carefully constructed facade of perfection.

In reading the work of homebirth and natural childbirth advocates, I am repeatedly struck by the assumption that a not having an uncomplicated vaginal birth is viewed as an imperfection. Hence the use of words like “failed” and “broken”, the insistence on comparing birth to competitive sports, and the use of goofy birth “affirmations” that are all variants of “I can do it.”

I suspect that some homebirth and natural childbirth advocates experience a C-section as a narcissistic injury. A narcissistic injury is not simply an imperfection. It is an imperfection that threatens the narcissist’s protections against feelings of inferiority.

For example, many people need vision correction, but the overwhelming majority are able to accept that their eyes are not perfect without viewing it as a fundamental deficiency. Similarly, many women have C-sections and view the surgery as nothing more than one of many acceptable ways to have a baby. In contrast, a small proportion of women have such a fragile sense of self, and have constructed such elaborate defenses to protect against these feelings, that a C-section is experienced as a “failure,” a sign of being “broken,” and an insupportable assault on a very fragile sense of self-regard.

Experiencing C-section as a narcissistic injury can explain many confusing aspects of homebirth and natural childbirth advocacy, particularly among advocates who have already had a C-section. The refusal to see a doctor (with some women even refusing to see a midwife) can be explained as the inevitable result of regarding even the possibility of pregnancy complications as personal criticism, combined with the inability to tolerate criticism of any kind.

It can also explain the seemingly inexplicable reactions to the death of a baby at homebirth. Reacting to a baby’s death by being “proud” of oneself for having a vaginal birth is extremely bizarre. However, it makes sense if the mother’s overriding preoccupation is to preserve her narcissistic mask of perfection and keep feelings of inferiority at bay.

The real problem, then, for women who view C-section as “failure” is not the C-section, but the outlook of the women themselves. C-section is experienced as a narcissistic injury, not because it really is an injury, but because women with carefully constructed defenses that keep feelings of inferiority at bay feel those defenses threatened by the lack of perfection.

I don’t expect homebirth and natural childbirth advocates to acknowledge this. Narcissists are notorious for their lack of introspection and their insistence on blaming everything on everyone else. They could never acknowledge that the source of their distress comes from within; they are compelled to externalize it to others who are supposedly criticizing them or disrespecting them.

This piece originally appeared on Homebirth Debate in November 2008.

Homebirth and natural childbirth advocates are incensed that anyone might think a healthy baby is compensation for a less than ideal birth “experience.”

The piece by Kathy at Woman to Woman Childbirth Education, At least you have a healthy baby, is typical of the genre bemoaning C-sections and other life saving methods of modern obstetrics.

Many women, on telling stories of how they felt abused or traumatized during birth — or some other negative feeling, like having failed as a woman after having a C-section, or something — have their feelings dismissed with, “at least you have a healthy baby…” [I]t only makes her feel worse, because then she has the added guilt of not being able to “just be happy” that her baby is healthy. Certainly she is happy that her baby is healthy… but can she not also be sad that it came at the cost of severe bodily trauma?

I especially like the picture of the “mutilated” apple. That apple was torn apart and left ruined just to get at the seeds.

Certainly, not every woman who had a C-section is going to feel this way … otherwise there would be at least 31.7% of women last year who were as traumatized in body and spirit as this apple was brutalized …

So, the next time you hear someone process her negative birth experience, and you’re tempted to say, “At least you have a healthy baby,” remember the picture of the mutilated apple, bite your tongue, and if you can’t think of anything else, just say, “I’m so sorry.”

Is a healthy baby merely a “silver lining” after a C-section? Let’s do a little thought experiment and consider the converse. Imagine a courtroom during a malpractice trial, a trail that alleges that an obstetrician did not perform a C-section in time to save a baby’s life. The mother is on the stand and being questioned by the doctor’s lawyer:

Yes, Mrs. Smith, your baby is dead, but at least you had a great birth experience. You didn’t have surgery; you didn’t have an epidural; the baby was born vaginally and put immediately on your chest for bonding. Sure the baby was dead, but consider the experience.

And look at the picture of this mutilated and brutalized apple. Is this what you would have preferred? Dr. Jones has saved you from a psychic wound that would never have healed. You ought to be grateful.

People would be horrified by the lawyer’s complete lack of perspective. The health of the baby and the quality of the “experience” are not remotely comparable, and it is absurd, and even cruel, to suggest they are.

Similarly, the idea that a healthy baby is merely a “silver lining” after C-section is indicative of the complete loss of perspective on the part of homebirth and natural childbirth advocates. The picture of the “brutalized” apple is particularly telling. The implication is that physical perfection is critical, and a surgical incision leaves a woman mutilated and incapable of healing.

There is another, deeper implication that is both unexamined and unjustified. The implication of the picture is that the removal of the seeds could have and should have occurred without changing the apple. The reality in nature is far worse that the “brutalization” of the apple. In nature, the apple must desiccate and die in order for the seeds to live.

The reality of childbirth in nature is far more brutal than a C-section. In nature, the mother often dies while the baby lives. Or the baby must die in order for the mother to expel it and live. Thousands of women and millions of babies around the world die each year for lack of C-sections.

A live baby is not the “silver lining” of a C-section. It is the entire purpose of pregnancy and childbirth.