Another day, another gun massacre.

In Louisiana last night:

A “drifter” sat silently in a movie theater for 20 minutes before shooting 11 other patrons in an incident that was over in matter of seconds, witnesses and police in Louisiana said early Friday.

[He] 59, was seated in the theater “just like everybody else” before firing 13 rounds, killing two people and wounding nine others with a .45 caliber handgun, Lafayette Police Chief Jim Craft told reporters. Houser later took his own life.

The proximate cause is obvious to everyone in the world but gun aficionados; the proximate cause is the easy access to guns brought to us by a corrupt legislative process orchestrated by the National Rifle Association and its mounds of cash.

[pullquote align=”right” color=”#86081d”]Gun rights advocates are denialists just like anti-vaxxers are denialists, and they are every bit as dangerous to public health.[/pullquote]

Americans favor gun restrictions [edited to replace “strict gun control”]. Gun restriction is associated with decreased gun violence. Yet, the NRA opposes gun control and their cash contributions to legislators trump the will of the American people, the victims of American gun violence, and common sense itself. The truth is that the NRA is a group of gun violence denialists who have an amazing amount in common with science denialists of all stripes from creationists, to climate change denialists, to anti-vaxxers, to purveyors of “alternative” remedies.

Don’t believe me? Consider this definition of denialism offered by Andrew Dart in an chapter from Building your Skeptical Toolkit:

Denialism … is driven by ideology rather than evidence. Now denialists may claim they care about the evidence and will happily display any that supports their point of view, but in most cases they reject far more evidence than they accept. Furthermore, denialists will cling to evidence no matter how many times they have been shown that it is flawed, incorrect or that it does not support their conclusions; the same old arguments just come up again and again. Denialism also tends to focus on trying to generate a controversy surrounding the subject at hand, often in the public rather than scientific arena, and does so more often than not by denying that a scientific consensus on the matter even exists.

Pretty much nails gun violence denialism, right?

1. Denialists start with a conclusion and work backwards.

It doesn’t matter how much evidence you show to climate change deniers, creationists or anti-vaxxers. They’ve embraced a conclusion and they’re sticking to it, regardless of what the evidence actually shows. Similarly, there’s no evidence that you could show gun violence denialists that would cause them to even question their beloved conclusions about guns, let alone change those conclusions.

2. Denialists love denial.

Who you gonna believe, the NRA or your lying eyes?

Like the climate change deniers who will still be in denial as the water rises above their heads, and the evolution deniers who insist that dinosaur bones were planted by God to test our faith, or the anti-vaxxers who can still claim with a straight face that vaccines don’t prevent disease, gun violence denialists are still denying the dangers of easy access to guns as the pile of dead bodies mounts beside them.

3. Denialists love conspiracy theories.

As Dart explains:

So the vast majority of the scientific community and an overwhelming mountain of evidence is aligned against you, what are you going to do? Well you could always claim that there is a conspiracy to suppress the truth …

The favorite conspiracy theory of gun violence denialists is that the government wants to take away people’s guns in order to stage a fascist takeover.

Conspiracy theories, whether blunt or subtle, are nothing more than evasions of the actual evidence that easy access to guns leads to massive numbers of gun deaths, as well as the absence of any evidence of any kind that gun control is the first step to a fascist take over the of the US.

4. Denialists love cherry-picking.

Cherry picking is the act of selecting papers and evidence that seem to support your point of view, whilst at the same time ignoring the far greater body of evidence that goes against your position.

Gun violence denialists claim that research shows that easy access to guns makes us “safer,” when the evidence is all around us that in countries with easy access to guns life is more dangerous for everyone, particularly innocent people.

5. Denialists love echo chambers.

They seek support and validation for their views at NRA conventions and on Fox News and refuse to directly address the concerns of victims of gun violence and public safety experts.

The inevitable conclusion is one that anyone who cares about scientific integrity and intellectual honesty should keep in mind:

It is not the topic that makes someone a denialist, it is how they the handle evidence that contradicts their cherished, immutable beliefs, in this case, the rising tide of the blood of innocent people injured and killed in gun rampages. Do they deny the evidence that is right in front of their eyes. Do they invoke outlandish conspiracy theories? Do they cherry pick the data and only present those findings that agree with them? And do they congregate in echo chambers that always validate and never question their beliefs?

Gun rights advocates are denialists just like anti-vaxxers are denialists, and they are every bit as dangerous to public health.

As I wrote yesterday, Katie Tietje (Modern Alternative Mama) claims that natural remedies work to cure disease.

She provided no evidence for that claim, but that doesn’t mean that it is impossible.

Let’s look at what Katie would need to know in order to determine whether natural remedies work:

The study of drug efficacy and safety is pharmacology. Pharmacology can be roughly divided into two areas: pharmacodynamics, how the substance acts on the body, and pharmacokinetics, how the body acts on the substance.

[pullquote align=”right” color=”#762b1d”]What are the pharmacodynamics and pharmacokinetics of natural remedies?[/pullquote]

Here are some basic questions that must be answered to find out how the drug works on the body:

• How does the drug work? What is the active ingredient? What effect does the active ingredient have on the body?
• What is the dose-response? In other words, as the dose of drug increases, does the response increase?
• What is the ED50, the dose that produces a response in 50% of subjects, also known as the median effective dose?
• What is the maximum effect that can be produced by the drug, also known as efficacy?
• What is the therapeutic window? For every drug, there exists some concentration which is just barely effective and some dose which is just barely toxic. Between them is the therapeutic window where safe and effective treatment will occur.

Here are some basic questions that must be answered to find out how the body interacts with the substance:

• What is its half life?
• What is its bioavailability?
• How is it removed from the body?
• Does it have effects on other parts of the body besides its stated therapeutic effect?

What does Katie Tietje know about the pharmacology of the natural remedies that she recommends? Generally nothing. She doesn’t know the mechanism of action, the dose response or the side effects. Therefore, she has no evidence that the natural remedies that she peddles are either safe or effective.

Determining drug efficacy and safety is complex. It is absolutely imperative to study the pharmacodynamics and pharmacokinetics of a substance before anyone can claim that it is effective or safe. In the case of Katie Tietje’s natural remedies, these questions have not even been asked, let alone answered.

Katie Tietje (nom de quack Modern Alternative Mama) continues to grace us with her own charming brand of scientific illiteracy. Because, really, who doesn’t consider someone with no scientific knowledge and no medical training to be an excellent source of medical advice?

Recently she offered 10 reason for using natural remedies. Paradoxically they are actually reasons why you SHOULDN’T use natural remedies.

To wit:

1. Natural remedies don’t work.

I’m a skeptic. The definition of a skeptic is not someone who is skeptical in the colloquial sense. A skeptic is someone who demands proof. If natural remedies actually worked, there would be studies that show that they actually work, but there aren’t any. And it’s not because no one has looked.

According to Mielczarek and Engler in Measuring Mythology: Startling Concepts in NCCAM grants:

[pullquote align=”right” color=”#565592″]Since herbs are natural, they must be safe. Kind of like heroin, cocaine and tobacco.[/pullquote]

Using data from the NIH website,we studied all NCCAM funding awards from 2000 to the present. We found no discoveries in alternative medicine that justify the existence of the center; Congress has mandated into the health care bill the tax burden of paying for myths and commercial interests.

Billions of taxpayer dollars have been spent on testing botanicals, yoga, magnets, and distance healing as interventions for serious medical problems such as diabetes, HIV/AIDS, and cancer…

Did Americans really need to spend millions of dollars to learn that“distance healing” cannot cure brain cancer or HIV/AIDS; shark cartilage does not affect the survival rates of cancer patients; vitamin E and selenium do not mitigate prostate cancer; magnets are not useful for fibromyalgia or carpal tunnel syndrome; and clinical trials using coffee enemas combined with heavy vitamin supplementation for patients with pancreatic or prostate cancer are unsafe?

2. They’re not safe.

Tietje operates on the delightful misapprehension that because herbs are natural, they must be safe. Kind of like heroin, cocaine and tobacco.

3. You get what you pay for.

According to Tietje:

Here’s another cool thing — herbs are very affordable. They’re often $1/oz. or less (and an ounce of dry plant material is a lot). Even prepared remedies are often $20 – $30 for a small bottle, which usually will last for months to years. Herbal remedies can be stored longer than most OTC medicines, and can be taken by multiple family members…

Amazingly, they cost no more than food because that’s all they are.

4. Altie-shills like Tietje make them easy to buy.

This is not an advantage for anyone except altie-shills like Katie who profit from selling ground up leaves to gullible people.

5. You can pretend that they are customized just for you.

That’s not especially compelling when they don’t work in any formulation, regardless of whether the formulation was customized for you.

6. A sure sign of quackery is a treatment advertised to cure many different unrelated types of pathology.

Katie says:

Ginger can be used for colds, flu, inflammation/pain, upset stomachs, cancer, and more! Lavender can be used for burns, promoting relaxation, headaches, and more. Herbs are so versatile that it’s possible to have only a few common ones around and still be able to treat many different things.

And if you believe that, I have a bridge in Brooklyn that I’d like to sell you.

7. Anyone who believes that curing cancer is a do it yourself project is a fool or worse.

According to Katie:

I love knowing that if someone isn’t feeling well, I have what I need in the kitchen to whip up something to make them feel better in minutes. That’s just awesome.

No, that’s just moronic.

8. It makes no difference that you control the ingredients when none of the ingredients are efficacious.

9. If it sounds too good to be true, it is.

Such as:

I know — when you’re brand new to natural remedies, it can seem really intimidating. But I promise, they are easy. Most only require a few ingredients, and come together in just a few minutes. Even the ones that take longer really only need time to sit — not active time from you.

But Katie saved the best reason for last.

10. Katie can profit from your gullibility!

See!

In about a month, Natural Remedies For Kids is coming. It’s a beautiful, full-color guide to making and using your own natural remedies (and despite the title, they’re for the whole family). It’s also my first traditionally published book. 🙂

See, I once was totally intimidated, too. I wished I had an experienced mama to come alongside me and show me how to get started. That’s why, after 6+ years of experience with using and preparing natural remedies, I wrote this book!

You’ll learn all about the basic preparation methods — teas, decoctions, infusions, tinctures, salves, lotions, and more. Plus, which herbs to start with in your natural medicine cabinet.

My advice? When contemplating buying and using natural remedies, keep in mind that famous ancient saying:

A fool and his money are soon parted.

Those are truly words to live by.

I no longer practice medicine, but I sometimes miss it.

One of the reasons is that the amazing thing about practicing medicine is that every time you think you’ve finally seen everything, you see something new. Not just something that you’ve never seen before, either, but something that you could not have even imagined.

Consider a case that came to my attention when I was an attending physician. A young woman came to the evening urgent care clinic at our health center one evening complaining of severe genital pain; so severe, in fact that she could only walk with her legs widely spaced a part.

That walk is a classic sign of a Bartholin’s gland abscess, a fairly common infection of the glands at the outer edge of the vagina. Bacteria can take up residence in the gland and cause an abscess. Even though the abscess is small, it is extremely painful. The wide stance walk is almost a guarantee of the diagnosis. The triage nurse explained the likely diagnosis to the patient and the fact that the abscess could be easily treated. Rather than looking relieved, the patient appeared embarrassed.

[pullquote align=”right” color=”#e80000″]She was right. I couldn’t believe it.[/pullquote]

A physician’s assistant (PA) saw the patient, took the history, which was unremarkable, and started the exam, which was very remarkable. The patient did not have an abscess; she had what appeared to be shallow, but extensive burns around and extending into her vagina. The physician’s assistant was so flustered that she excused herself to call me.

I could not leave the hospital to go to the clinic, because I had a patient in labor who would deliver soon, so I had to rely on the PA’s description. The description certainly fit with that of burns, but I had never seen burns of that kind in any area. Yes, I had seen chemical irritations of various kinds, but it didn’t seem like an injury of this sort was likely to be caused by a new bath soap or detergent.

The PA insisted that the patient’s history was unremarkable, and I insisted that she had not gotten the complete history. It wasn’t her fault; the patient simply didn’t want to reveal what happened. I suggested to the PA that she question the patient about domestic violence, since I had certainly seen vaginal injuries related to violence in the past. I also pointed out that it was important to explain to the patient that we needed to know what happened in order to treat her appropriately.

I was dreading the return phone call, and I imagined all sorts of horrible things that might have happened, but I failed to imagine what really did happen. When the PA called again, she was laughing.

“You’re not going to believe this,” she said, “but the patient accidentally did this to herself with a dildo.”

She was right. I couldn’t believe it. What could the patient have used? I’d heard of all sorts of things in the past: fruit, candles (unlit), and glass bottles, among others, but nothing that could cause burns.

“She used a deodorant stick!”

The patient had used the actual stick of deodorant, which she had pried out of the container (for who knows what reason) and the burns she had were serious chemical burns. We treated her by washing the area to remove any trace of the chemicals and applying the salve typically used for treating burns from gynecologic laser surgery. Oh, and lot’s of pain medication, too, for obvious reasons.

Her treatment plan included her medications, an appointment for follow up, and a recommendation: should she feel the need to use a dildo in the future, she should avoid deodorant, or at least leave it in the container with the cap still on.

The books are flying off the shelf.

The hangers-on are making a fortune.

And the reputation of the author — elderly, frail, suffering from memory, vision and hearing loss — has been destroyed.

Simply put, the publication of Harper Lee’s Go Set a Watchman (the discarded first draft of her iconic novel To Kill a Mocking Bird) appears to be a spectacular case of elder abuse.

I find it both appalling and inexplicable that critics are debating the merits of Watchman and asking whether Atticus Finch, the beloved main character of Mockingbird, is actually a racist and what that means for literature and for us. Frankly, to the extent that we enrich those who plundered Ms. Lee’s legacy for their own benefit, we are complicit in that abuse.

[pullquote align=”right” color=””]Does anyone truly believe that Harper Lee had the capacity to decide to publish a first draft manuscript that she swore for 50 years she would never publish?[/pullquote]

In the the 50 years since the publication of To Kill A Mockingbird, Lee both acknowledged the existence of a first draft and steadfastly refused to publish it. Presumably it would have passed to whatever library or institute that Lee has chosen to bequeath her personal papers and could have been made available for academic study to provide insights into how a great author creates a great work. Yet after the December death of her closest living relative and caregiver, her sister, the manuscript was suddenly “rediscovered” and Lee suddenly “agreed” to its publication.

To put these events in perspective, imagine if an 88 year old individual had designated a Rembrandt in her possession to be donated to a famous museum after her death. Imagine if she had publicly acknowledged the planned donation and publicly insisted that she would never sell the painting for profit. Then suddenly, at age 88, after the death of her closest living relative and caretaker, suffering from memory, vision and hearing loss she “changes her mind” and gives the painting to her new caretakers to sell, despite the fact that she does not need the money.

We would (hopefully) recognize that the new caretakers were committing elder abuse, which encompasses exploitation:

… taking, misuse, or concealment of funds, property, or assets of a senior for someone else’s benefit.

In the case of a previously written bequest, there would be a museum who would file suit to execute the owner’s original wishes. The entity that stood to benefit from the original intention would take legal action to uphold the original bequest. Unfortunately, in the case of Lee’s first draft, there was no entity besides Ms. Lee who stood to benefit from her original intention and, therefore, no one with any stake in following her original wishes.

There were those who tried, however.

According to The New York Times:

Now the State of Alabama has been drawn into the debate. Responding to at least one complaint of potential elder abuse related to the publication of “Watchman,” investigators interviewed Ms. Lee last month at the assisted living facility where she resides. They have also interviewed employees at the facility, called the Meadows, as well as several friends and acquaintances…

With an investigation involving Monroeville’s most famous resident underway, friends and acquaintances who have come forward in recent weeks have offered conflicting accounts of Ms. Lee’s mental state, with some describing her as engaging, lively and sharp, and others painting her as childlike, ornery, depressed and often confused. Several people said that her condition varied depending on the day.

Ms. Lee — known to many as Nelle, her legal first name — had a stroke in 2007 and has severe hearing and vision problems. But friends who visit her regularly say she can communicate well and hold lengthy conversations if visitors yell in her ear or write questions down for her to read under a special machine. (A black marker is kept in her room for this purpose.)

But, of course, whether or not she can communicate well tells us nothing about whether she is competent to make decisions. Many elderly people communicate just fine with telemarketers who swindle them.

Lee’s literary reputation is on the line:

A lot is at stake, including the legacy of one of the country’s most beloved authors. Many wonder whether “Watchman,” which was rejected by a publisher in the mid-1950s and then rewritten as “Mockingbird,” will turn out to be a flawed, amateur work when it is released in July, and a disappointing coda to a career that has been defined by one outsize hit.

Jason Karlawish, M.D., a professor of medicine and medical ethics, weighed in at Philly.com:

How would we know that Lee was capable of making the decision to publish a novel she long ago swore not to publish?

Cases such as hers are an immense public-health problem. Changes in older adults’ cognition and need for help with daily tasks, together with accumulated lifetime wealth, make them easy prey for those who want to exploit or abuse them…

For Lee, publishing Watchman will reshape her carefully lived legacy. Is she, in some sense, mistakenly killing her own mockingbird?

The answer to this question engages decades of scholarship at the intersections of ethics, law, medicine, and psychology. We no longer use broad generalizations about a person, such as whether her decision was “reasonable,” or whether she has dementia. Instead, capacity is grounded in an assessment of an adult’s abilities to make a specific decision.

Karlawish points out that being able to communicate does not indicate capacity to make major life decisions.

Classic cases include the older adult who always avoided financial risks, but who now wagers large sums at casinos, or sends bank account information to strangers to collect a share of an alleged lottery payout, or who revises a will to support a new and much younger and needy partner. Or, in the case of Lee, who swore that her first novel was her last novel, but who now has changed her mind.

People do change, and they truly can have new values. In some cases, however, these changes reflect impairments in brain function. The classic causes are conditions that damage the frontal lobes, such as from an uncommon dementia called frontotemporal lobar degeneration, or a type of traumatic brain injury.

Studies of older adults’ decision-making in risky situations, or their capacity to distinguish between trustworthy and untrustworthy sources show that some older adults perform poorly on these tasks and as a result are liable to make poor decisions…

Does anyone truly believe that Harper Lee had the capacity to decide to publish a first draft manuscript that she swore for 50 years she would never publish? Does anyone actually believe that Lee underwent the fundamental change in values that would be required to support that decision? Or was the “decision” to publish Watchman akin to the “decision” to share bank account information with strangers to collect an alleged lottery payment?

It seems to me that Harper Lee’s “decision” to destroy her legacy by publishing a discarded first draft of her literary masterpiece is a spectacular example of the all too common phenomenon of elder abuse. And by buying the new book and analyzing it for “insights” on the real Atticus Finch, we have made ourselves complicit in Lee’s tragic exploitation.

Debra Pascali-Bonaro and Christiane Northrup, inquiring minds want to know:

If, as you claim, women have orgasms at the moment of birth, shouldn’t they be having orgasms during speculum exams?

As Dr. Northrup explained:

“When the baby’s coming down the birth canal, remember, it’s going through the exact same positions as something going in, the penis going into the vagina, to cause an orgasm.

Right, and when a speculum is inserted in the vagina (and again when it is removed), it is going through the exact same positions as the penis going into the vagina. So why don’t women have speculum orgasms?

Could it be because you can’t profit from the idea?

Most people (myself included) dismiss orgasmic birth as a lucrative figment of your imaginations, complete with the hucksterism attendant on all form of quackery. And certainly, Pascali-Bonaro’s website Orgasmic Birth does nothing to disabuse them. You can’t even get to the home page without being barraged with a plea for your email address:

You deserve to give birth with Dignity, Love and Pleasure! Learn how to move from Pain to Power. Subscribe now to receive my Pleasurable Birth Tips PDF & Free Weekly “Keys to Unlock Your Pleasure” enews!

[pullquote align=”right” color=”#af937b”]If women women can have birth orgasms, shouldn’t they be having speculum orgasms too?[/pullquote]

According to you, orgasmic birth is the best kept secret. Indeed, it’s so secret that it has only been described in Western, white, well off women who have read the natural childbirth literature within the past 40 years. It is so secret that it apparently never happened before then in all of recorded human history, and so secret that it never happened among African and Asian women. And it is so secret that for all of recorded human history childbirth was routinely described as excruciating and agonizing.

Who knows the secret? Ina May Gaskin, of course.

In the film, world-renowned midwife Ina May Gaskin helps us to understand the normal rhythms of labor and women’s ability to have ecstatic birthing experiences…

Women can experience birth as sensual and pleasurable, and can enter a natural state of ecstasy. New research shows that the intimate experience of birth affects a woman’s life profoundly. Babies are also affected emotionally and physically, and over the long term, by their birth experience.

Gaskin is the lay midwife who wrote this:

Sometimes touching her very gently on or around her button (clitoris) will enable her to relax even more. I keep both hands there and busy all the time while crowning … doing whatever seems most necessary.

And this:

Sometimes I see that a husband is afraid to touch his wife’s tits because of the midwife’s presence, so I touch them, get in there and squeeze them, talk about how nice they are, and make him welcome.

As well as this:

I might want to have a cunt one day and a twat the next. On the third day I might decide that pussy is my favorite word.

These quotes, taken from the 3rd and 4th editions of Gaskin’s book Spiritual Midwifery, sound immature, foul mouthed, and sexually inappropriate.

What is the purported key to having an orgasmic birth?

The key to having an orgasmic birth is spending money on lay midwives like Gaskin and their natural childbirth associates.

What a coincidence!! Who could have seen that coming?

But if birth has been described, in every time, place and culture as excruciating and agonizing, how could any woman possibly have an orgasm at the moment of birth, when the vaginal opening is being stretched to 10 times its resting size, often tearing as a result?

Pascali-Bonaro is graciously willing to talk by phone to you or me for the low, low price of $195 an hour.

Or, if you book before July 31, you can join Pascali-Bonaro at her woman’s retreat on Italy’s Amalfi Coast from August 30th to September 6th ($3500 if you book after July 31).

But I prefer to ask Pascali-Bonaro and Northrup publicly:

If women women can, as you claim, have birth orgasms, shouldn’t they be having speculum orgasms too?

Suppose I told you that research shows that the ideal C-section rate — the lowest rate compatible with the lowest rates of perinatal and maternal death — is 75%.

You’d balk, right? That couldn’t possibly be true.

Suppose I told you that research shows that the ideal C-section rate is 15%?

Most people, particularly non-obstetricians, would probably nod their heads in agreement. That sounds about right to them, confirming what everyone already “knows,” that that C-section rates in industrialized countries are “too high.”

Now let me tell you the truth:

There is no more evidence for an ideal C-section rate of 15% than there is for an ideal C-section rate of 75%. Indeed, there’s no evidence at all for ANY ideal C-section rate, a fact that has been acknowledged by the World Health Organization. Buried deep in its handbook Monitoring Emergency Obstetric Care, you can find this:

Although the WHO has recommended since 1985 that the rate not exceed 10-15 per cent, there is no empirical evidence for an optimum percentage … the optimum rate is unknown …

[pullquote align=”right” color=”#c94242″]There no evidence for an ideal C-section rate of 10-15% because no industrialized country with low levels of perinatal and maternal mortality has a C-section rate of 10-15%.[/pullquote]

So why did the World Health Organization recently reaffirm its commitment to a C-section rate no higher than 10%?

The answer is white hat bias.

As I explained recently, white hat bias was first described in reference to obesity research, including purported preventive effects of breastfeeding on subsequent obesity. White hat bias is a form of confirmation bias, the natural tendency of people to accept information that confirms what they believe. Confirmation bias is why Tea Party members watch Fox News. They want to have their beliefs, prejudices, and wishes always confirmed, never challenged.

White hat bias is confirmation bias in service of what are seen as laudable goals:

‘White hat bias’ (WHB) [is] bias leading to distortion of information in the service of what may be perceived to be righteous ends… WHB bias may be conjectured to be fuelled by feelings of righteous zeal, indignation toward certain aspects of industry, or other factors.

White hat bias leads scientists, doctors and public health officials to substitute what they fervently believe for what the actual scientific evidence shows. For example, obesity researchers, doctors and public health officials routinely claim that normal to low BMI is “healthiest.” But the scientific evidence shows, and has always shown, that people with higher than normal BMI, overweight but not morbidly obese, are the people who live the longest. So why don’t scientists, doctors and public health officials advise people that being slightly overweight is healthiest? Because white hat bias leads them to ignore the scientific evidence in favor of what they deeply believe: being overweight must be bad for your health.

Their motives are pure. They ignore what the scientific evidence shows because it doesn’t comport with what they are absolutely, positively certain must be true. Moreover, they believe, with some justification, that the current US epidemic of morbid obesity (which isn’t healthy at all) is the result of corporations placing profits ahead of creating healthy food options.

But if science teaches us anything it’s that what we believe may be very different from the truth. Paraphrasing Thomas Henry Huxley: The highest duty of scientists lies in submitting to the evidence however it may jar against their inclinations.

The problem of white hat bias in regard to C-sections is, if anything, worse than the problem of white hat bias in obesity research. Everyone “knows” that the C-section rate is too high despite the fact that the existing evidence for this belief is circumstantial at best. It goes something like this: if historically high C-section rates don’t lead to historically low mortality rates, there must be too many C-sections. In other words, since perinatal and maternal mortality rates haven’t dropped remarkably as the C-section rate has increased remarkably, those increases C-sections were unnecessary.

The belief that there is an ideal C-section rate, and that it is considerably lower than the C-section rates in contemporary industrialized countries is white hat bias at its most basic, resting as it does on other deeply held beliefs: The cost of health care is too high; we need to find a way to rein it in. Midwives are cheaper than obstetricians; we need to find a way to employ more of them and less obstetricians. C-sections are surgery; we should always avoid surgery whenever possible. But regardless of the pure motives of many of those promoting an idea C-section rate, their beliefs are a reflection of their biases and thoroughly ignore the scientific evidence.

As it happens, I also believe that the C-section rate is too high. I say this as a clinician who had a 16% C-section rate (and 0% forceps rate) during my years of private practice. But there’s a difference between what I might believe and what the scientific evidence actually shows.

There is simply NO EVIDENCE that a C-section rate of 10-15% is ideal because NO industrialized country with low levels of perinatal and maternal mortality has a C-section rate of 10- 15%! Indeed, the average C-section rate for countries with low rates of perinatal and maternal mortality is approximately 22%.

That’s an exceedingly inconvenient fact for those arguing that an ideal C-section rate of 10-15% will yield low levels of perinatal and maternal mortality. It’s just like the inconvenient fact in obesity research that those who are healthiest don’t have normal BMIs, but are actually overweight. However, as Neil de Grasse Tyson has noted:

The good thing about science is that it’s true whether or not you believe in it.

That applies equally to scientists as well as to purveyors of pseudoscience.

There is no scientific evidence for an ideal C-section rate and certainly no evidence for a C-section rate of 10-15%. Anyone who tells you otherwise, including the World Health Organization, probably has his, her or its heart in the right place, but that doesn’t make it true. It makes it white hat bias.

Shame is integral to the contemporary lactivism movement.

Indeed, it is so integral that there’s actual a blueprint on how lactivists can shame other mothers. Entitled Watch your language it was written by lactation consultant Diane Wiessinger and published in the Journal of Human Lactation in 1996. It is a primer on how to mobilize language to shame women who bottle feed.

Wiessinger identifies the problem for those wishing to shame mothers. Merely telling them that “breast is best” leaves open the possibility that you can still be a good mother if you formula feed (also known in Wiessinger’s parlance as artificial feeding):

When we … say that breastfeeding is the best possible way to feed babies because it provides their ideal food, perfectly balanced for optimal infant nutrition, the logical response is, “So what?” Our own experience tells us that optimal is not necessary. Normal is fine, and implied in this language is the absolute normalcy and thus safety and adequacy-of artificial feeding…

So what if that’s the truth and women deserve accurate information in order to make informed decisions? We shouldn’t allow the truth to get in the way of manipulation:

Artificial feeding, which is neither the same nor superior, is therefore deficient, incomplete, and inferior. Those are difficult words, but they have an appropriate place in our vocabulary.

Actually, they are ugly, shaming words and Wiessinger is just getting started:

Because breastfeeding is the biological norm, breastfed babies are not “healthier” artificially-fed babies are ill more often and more seriously. Breastfed babies do not “smell better”; artificial feeding results in an abnormal and unpleasant odor that reflects problems in the infant’s gut.

[pullquote align=”right” color=”#ef6aa7″]The shaming of mothers for the ostensible benefit of babies benefits only those who profit from the shame.[/pullquote]

Wiessinger has the temerity to insist:

When we fail to describe the hazards of artificial feeding, we deprive mothers of crucial decision-making information. The mother having difficulty with breastfeeding may not seek help just to achieve a “special bonus”; but she may clamor for help if she knows how much she and her baby stand to lose. She is less likely to use artificial baby milk just “to get him used to a bottle” if she knows that the contents of that bottle cause harm.

Since when is deliberately inducing shame a form of decision making information? It has never been before, and it isn’t now.

Why would anyone undertake shame as a deliberate effort to promote breastfeeding. For Weissinger, it isn’t about babies or mothers it’s about promoting a “breastfeeding culture.”

We cannot expect to create a breastfeeding culture if we do not insist on a breastfeeding model of health in both our language and our literature.

And:

All of us within the profession want breastfeeding to be our biological reference point. We want it to be the cultural norm; we want human milk to be made available to all human babies, regardless of other circumstances. A vital first step toward achieving those goals is within immediate reach of every one of us. All we have to do is…watch our language.

Maybe that’s what those who profit from lactivism want, but it’s not what those in the health professions want. We want babies to be healthy, fed to satiety and not left to cry in hunger. We want mothers to be healthy and not in pain or struggling to manage a fraught breastfeeding relationship while dealing with new motherhood.

Over the past 20 years Wiessinger’s dream of using shaming language to browbeat women into breastfeeding has succeeded. The breastfeeding initiation rate has reached a 100 year high. And the impact on infant health has been … negligible to non-existent.

In contrast, the impact on maternal mental health has been profound. Simply put, there is an epidemic of guilty mothers who are ashamed that they cannot breastfeed exclusively.

The authors of a recent paper, Shame if you do – shame if you don’t, explain:

The message frequently summarised as ‘breast is best’ reflects scientific knowledge on the nutritional and immunological benefits of breast milk for infants as well as carrying moralistic dimensions. In many cultures, breastfeeding is synonymous with ‘good mothering’. When mothers make a decision not to breastfeed, they may experience guilt, blame and feelings of failure. Taylor and Wallace, in their theoretical framework aimed at understanding maternal responses to infant feeding, argue how formula feeding mothers may experience shame (as opposed to guilt) through ‘failure’ to live up to ideals of womanhood and motherhood…

Shame is considered to incorporate affect (e.g. fear, anger, humiliation, self-disgust, anxiety, low self-esteem, depression), cognitions (e.g. feelings of rejection, inferiority and inadequacy) and actions (e.g. withdrawal and isolation or retaliation). Although shame is often used interchangeably with guilt, these are considered to be two distinct emotions. Shame is believed to occur when there is a breach between the cognitive evaluation of the ideal self and that of the actual self. The self-evaluation giving rise to shame emerges through an awareness of a deficiency or feelings of not being good or good enough: a global negative feeling about the self in response to a goal not reached, or some shortcoming…

Just what Wiessinger was hoping for!

Interestingly, the sense of shame was precipitated or intensified by exposure to those who were supposed to provide breastfeeding support:

The quote[s] below suggests that what professionals may view as a positive approach may in fact augment the experience of shame due to the inherently judgemental nature of language used:

I got fed up of people telling me I was doing a good job. […] I wanted somebody to help me and actually find a solution to the problem I was facing. I think it is underestimated how vulnerable you feel and how much of a failure you feel and that is not really the right thing to say to people.

Some of the women who formula fed from the early post-natal period or after a period of breastfeeding also reported marginalisation through a lack of support:

When you bottle-feed you don’t get as much help. I did try so hard [to breastfeed] I kept blaming myself that I couldn’t do it. […] it was too painful and however much I tried I couldn’t get him on, and wasn’t feeding properly. […] But when you decide ‘I don’t want to do it anymore’, it seems the support goes out the window. […] It did get me very very down, it felt like they turned against me because I was bottle-feeding.

Restrictions or inhibitions on discussing substitute feeding methods (both on the post-natal ward and in the community) left women feeling dejected and isolated:

Bring the choice back for god’s sake, when breastfeeding doesn’t work, bottle feeding is a good alternative. I didn’t have a clue what I should be using.

The enforced dependency of mothers on the medical model was also in evidence when women experienced incapacity to breastfeed, perceived or otherwise:

They wouldn’t allow me to cup feed her, so I had to wait for a midwife to be free […]. I did ask as it was distressing that I couldn’t feed my child.

In The concept of shame and how understanding this might enhance support for breastfeeding mothers, Leeming and Marshall note:

Previous discussions of the potential for breastfeeding promotion to cause distress for women who do not breastfeed or who struggle to do so have tended to assume that the problem is guilt. In response to this a frequently made point has been the importance of recognising that apparent ‘failures’ to breastfeed are not best understood as the mother’s omission or ‘choice’ but instead as a consequence of the many barriers to breastfeeding in Western societies… However, as Taylor and Wallace point out, women’s emotional responses may be more complex than has sometimes been assumed and for many mothers who struggle with breastfeeding or turn to formula milk, shame may be as much if not more of an issue than guilt.

… When we are ashamed we experience ourselves as inferior or flawed before a more powerful critical ‘other’, whether this is an actual person we perceive as devaluing us or a sense of a generalised ‘other’ in front of whom we are inadequate and lesser. With shame the focus is on a sense of a damaged and unable self, rather than on specific actions. Therefore an example of shame would be a mother whose distress about feeding difficulties arises from the possibility to her that these difficulties mean she is fundamentally flawed or inadequate as a mother, and possibly exposed as such before critical others…

So if babies don’t benefit in any measurable way from breastfeeding promotion through shaming and mothers are actually harmed by it, who does benefit?

Lactivists benefit and they benefit in a variety of ways.

First, lactation consultants benefits by increased employment and income. If every women is shame into attempting breastfeeding, and shamed if she attempts to stop, and shamed if she combo-feeds with formula, and shamed when she is seen bottle feeding, there will be greater need for lactation consultants.

Second, lactivists benefit in the same way that those inflicting shame on others always benefit, by enhanced self-esteem through feeling superior to the shamed.

Finally, lactivists benefit by enjoying ugly behavior that is usually forbidden but is actually encouraged in the case of formula feeding. There is simply no limit to the cruelty of lactivists toward women who don’t or don’t want to breastfeed, and no limit to the delight that lactivists experience in sanctioned cruelty to other mothers.

Wiessinger’s blueprint for lactivists, promoting careful choice of shaming language in order to browbeat women who choose formula is an ugly document, and the result, inevitably, has been a rise in ugly feelings of shame among those mothers.

So now the rest of us need to ask ourselves if we have been duped into harming women for the benefit of a lactation consultants and lactivists who have been preying on them. Wiessinger was on the mark when she pointed out that “breast is best” leaves open the possibility that you can still be a good mother if you formula feed and that our personal experiences tell us that optimal is not necessary. We need to make it clear, in the strongest possible terms, that formula is an excellent substitute for breastmilk, that you can definitely be an excellent mothers if you formula feed, and that the shaming of mothers for the ostensible benefit of babies benefits only those who profit from the shame.

You want to become educated about pregnancy? Whom should you believe, an obstetrician with 4 years of college, 4 years of medical school, 4 years of hands on obstetric training delivering hundreds of babies, multiple years of clinical practice, having read hundreds or thousands of obstetric papers from the scientific literature or altie-shill Katie Tietje, Modern Alternative Mama, a legend in her own mind, a layperson who shills for “natural” products by fear mongering about obstetrics? Only a fool could imagine that Katie Tietje has any idea what she is talking about.

Like many altie-shills, Katie is most concerned about making money for herself and her friends. There is tremendous financial incentive for her to ignore preventive testing and care, ignore risks, and demonize doctors who want to reduce risk. The key factor for homebirth/natural childbirth altie-shills is the ongoing ability to bill women and sell them products. Acknowledging that risk factors necessitate obstetrician care and puts patients beyond Katie’s ability to shill products to them, so they must be ignored.

Katie and other homebirth/natural childbirth altie-shills behave like ostriches. They know that they can make more money by putting their heads in the sand and ignoring warning signs, so that’s what they do.

[pullquote align=”right” color=””]Altie-shills behave like ostriches. They know that they can make more money by putting their heads in the sand and ignoring warning signs, so that’s what they do.[/pullquote]

Case in point, Katie’s latest example of her profound ignorance: 12 Mainstream Pregnancy Lies You Likely Believe and her ostrich like bahavior.

Don’t see it? scroll down from the multiple products for which Katie is shilling and you’ll find it next to the additional products for which Katie is shilling. Those who think her blog is anything other than marketing for her shill products are touchingly naive.

Alti-shill Katie demonstrates her special recipe for combining money grubbing with mistruths, half truths and out right lies.

Let’s debunk Katie’s lies one by one, shall we?

1. Internal exams are beneficial and necessary.

They are if you believe that knowledge is power and that preventive medicine is better than treating emergencies.

How will you know if a cord has prolapsed if you don’t do vaginal exams? You’ll know when, in the classic tradition of homebirth, the baby drops dead into the hands of the clueless midwife.
How will you know if a baby is breech or a face presentation that is undeliverable? You’ll know when the baby’s head gets stuck and the baby suffers brain damage.
How will you know if a labor has stalled? You won’t know, silly! That’s a trick question since homebirth midwives don’t want to know. They would rather wait until a mother is exhausted and a baby is in distress and necessitating a C-section rather than transfering to the hospital when timely use of Pitocin can effect a vaginal birth.

2. Ultrasound Measurements Are Accurate

Ultrasound is used to measure two different things, gestational age and weight. In the first trimester, ultrasound is extremely accurate (+ or – one week gestational age). As the baby grows individual variation plays an ever larger part; although all pregnancies start out exactly the same size (one cell), at birth babies can normally weigh anywhere from 6- 11 pounds. Not suprisingly, ultrasound for gestational age is less accurate in the second trimester (+ or – two weeks gestational age) and the third trimester (+ or – three weeks gestational age).

Ultrasound for fetal weight is known as estimated fetal weight because it is always an estimate. Once again the same principles that apply to gestational age apply to estimate fetal weight. It is highly accurate in early pregnancy, much less accurate (+ or – 2 pounds) at term, but it still provides valuable information that allows mothers to make informed decisions.

3. GD Testing is Accurate and Necessary

Testing for gestational diabetes IS accurate and IS necessary. The glucola test is a very accurate screening test for gestational diabetes, and the 3 hours glucose tolerance test IS accurate in diagnosing gestational diabetes.

4. You Can’t Breastfeed While Pregnant

You can breastfeed when pregnant, but it’s unnatural. Tandem nursing does not occur in humans or animals anywhere in nature.

5. Repeat C-Sections are Safer Than VBACs

Repeat C-sections ARE safer … for babies, but they are slightly more dangerous for mothers.

The issue that mothers contemplating VBAC need to decide is whether they wish to carry the risk by electing a repeat C-section or whether they wish to place the risk on the baby by attempting a vaginal birth.

6. “Baby is Too Big” is a Reason to Induce Early

Macrosomia is a serious medical problem. It increases the risk to the baby of brachial plexus injury, fractured clavicle, brain damage and death. Because of the limitations of ultrasound at term, it is difficult to perfectly predict macrosomia. That doesn’t mean that we should just give up and let the baby get injured. That’s a decision best left to the mother and in order to make that decision she needs the same information that the doctor has. Estimated fetal weight is an important piece of information needed to make that decision.

7. Elective Induction is Safe

Elective induction IS safe. It lowers the perinatal mortality rate and does not raise the C-section rate.

8. Eating Junk Food is Safe or Beneficial for Weight Gain

Who ever said that it was?

9. Herbs are Dangerous in Pregnancy and Should be Avoided

9. Herbs ARE dangerous in pregnancy and should be avoided.

10. Vaccines in Pregnancy are Safe and Well-Tested/Necessary

Not all vaccines in pregnancy are safe, but pertussis and flu vaccines are safe, well-tested and life saving.

11. “Your Fluid is Low” is Accurate

Low fluid (oligohydramnios) is a risk factor for poor neonatal outcome when accompanied by other signs of poor fetal growth.

12. Going “Overdue” is Dangerous

If you think death qualifies as a bad outcome, going overdue is. There’s simply no question about it.

Look again at the 12 recommendations. Fully 9 of them are about ignoring risks (from prolonged labor, undiagnosed breech, undiagnosed cord prolapse, gestational diabetes, ruptured uterus, macrosomia, postterm pregnancy, herbs, and oligohydramnios) so that homebirth/natural childbirth altie-shills can continue to bill them for services and products. It is rather obvious that these “lies” are fear mongering to promote the financial health of altie-shills, mothers and babies be damned.

Katie insists that because screening tests and risk factors are not 100% predictive, they are useless. That’s the equivalent of saying that there’s no point in looking both ways before crossing the street if your vision isn’t 20/20. Sure, your ability to see approaching vehicles is less than 100% accurate if you don’t have perfect vision, but that doesn’t mean that the imperfect information is useless.

Anyone who gets their pregnancy information from a clown like Katie Tietje is both profoundly ignorant and profoundly gullible.

Rank the following in order of dangerousness:

• Term infants exposed to A have a death rate of 5.6/1000.
• Term infants exposed to B have a death rate of 0.5/1000.
• Term infants exposed to C have an excess death rate of 0.

They’re already ranked in order of dangerousness, right?

What if I pointed out to you that in all cases the death rates are low so it doesn’t really matter? Would that change your assessment of dangerousness? Probably not.

What are we looking at?

• A is planned homebirth with a licensed homebirth midwife.
• B is vaginal birth after C-section.
• C is infant formula.

If homebirth is more dangerous than VBAC and VBAC is more dangerous than formula feeding, why do advocates of natural parenting promote homebirth and VBAC as safe and formula feeding as dangerous?

Because they are biased.

According to Wikipedia:

Bias is an inclination of temperament or outlook to present or hold a partial perspective, often accompanied by a refusal to consider the possible merits of alternative points of view. People may be biased toward or against an individual, a race, a religion, a social class, a political party, or a species. Biased means one-sided, lacking a neutral viewpoint, not having an open mind.

Those who promote natural parenting are biased in favor of allowing nature to take its course and against technology. They lack a neutral viewpoint and don’t have an open mind. They are innumerate, lacking awareness of or interest in the real dangers of various natural and technological choices. Their bias leads them to label formula feeding as dangerous and homebirth as safe even though there has never been a single reported death associated with properly prepared formula, but dozens of babies who die each year from homebirth.

That’s personal bias on the part of natural parenting advocates, but breastfeeding science is also afflicted with many other kinds of bias.

The actual research on the benefits of breastfeeding is surprisingly weak, filled with conflicting studies and plagued by confounding variables. That is well known by anyone who reads and analyzes the breastfeeding literature. But breastfeeding science suffers from another form of bias that is less well known: white hat bias. Indeed breastfeeding research was identified as a paradigmatic example of white hat bias in the seminal commentary by Cope and Allison, White hat bias: examples of its presence in obesity research and a call for renewed commitment to faithfulness in research reporting.

What is white hat bias?

‘White hat bias’ (WHB) [is] bias leading to distortion of information in the service of what may be perceived to be righteous ends… WHB bias may be conjectured to be fuelled by feelings of righteous zeal, indignation toward certain aspects of industry, or other factors. Readers should beware of WHB and … should seek methods to minimize it.

Cope and Allison note that researchers have been so anxious to establish a connection between formula feeding and obesity that they have ignored or misrepresented what the scientific evidence actually shows.

Certain postulated causes have come to be demonized (… formula feeding of infants) and certain postulated palliatives seem to have been sanctified. Such demonization and sanctification may come at a cost…

Whether WHB is intentional or unintentional, stems from a bias toward anti-industry results, significant findings, feelings of righteous indignation, results that may justify public health
actions, or yet other factors is unclear. Future research should study approaches to minimize such distortions in the research record. We suggest that authors be more attentive to reporting primary results from prior studies rather than selectively including only part of the results, to avoiding PB, and to ensuring that their institutional press releases are commensurate with the studies described…

In other words, breastfeeding researchers are so sure that breastfeeding is beneficial, and are so angry at the infant formula industry that they exaggerate findings that place breastfeeding in a positive light and ignore findings that the benefits of breastfeeding in industrialized countries are actually trivial (approximately 8% of breastfed infants have one fewer cold or diarrheal illness in the first year).

White hat bias is bias in the service of what are perceived to be righteous ends, but it’s bias nonetheless and it’s wrong. When breastfeeding research is presented in biased fashion, we deprive women of the right to make informed decisions about infant feeding choices, and we substitute the beliefs of lactivists for the actual data.

Breastfeeding is great. I breastfed four children without too many difficulties and I (and they) enjoyed it. But it’s simply one of two excellent ways to nourish infants, and anyone who attempts to convince you otherwise is likely to be righteously but regrettably biased.