Working in a hospital brings exposure to the human condition in the way that no other job can. Of course you see birth and death, but you also see the results of human foibles like rage, anger and despair. All too often, mental illness plays a (usually harmful) role. Eventually, patient behavior, no matter how bizarre, loses the power to shock. That does not apply to the behavior of the staff. It’s still shocking when they begin to behave like they are crazy.

The story of The Baby in the Wonderbread Bag begins like so many stories of teen pregnancy, with a young girl who has successfully concealed her pregnancy from family and friends. In this case, the 16 year old girl also had a history of mental illness. She appeared in the emergency room complaining of intermittent abdominal pain. Because she looked well, she was advised to wait while patients who were seriously ill were seen before her.

No one paid her much attention until she went to the Ladies Room and blood was seen to flow from beneath the door. When Security broke down the door, the doctors found that the girl had given birth to a premature baby. She had stuffed the baby in a Wonderbread bag, and, at the moment Security had broken in, she was attempting to flush the baby down the toilet.

They rescued the baby from the toilet bowl and pulled him out of the plastic bag. The neonatologist rushed down from the neonatal intensive care unit and resuscitated the baby. He appeared to be about 7 weeks premature, and smaller than expected for this stage of pregnancy. Nonetheless he was healthy and vigorous, despite his brief time in the toilet, and was swept off to the NICU for further care.

That’s when the story gets weird.

Several days later, in my capacity as a chief resident in obstetrics, I was called to the weekly Social Service meeting to provide my input in difficult cases. When I arrived, I found that the Social Service staff calmly discussing whether the Wonderbread Baby should go home with his mother, as if it were perfectly reasonable that she had tried to flush her baby down the toilet. That shocked me.

It’s not that the Wonderbread Baby was the most bizarre thing we had ever seen; it didn’t even come close. The combination of youth, concealed pregnancy and mental illness is all too common at an urban hospital and the results are usually far more deadly. Indeed, even during my years of medical school and residency, the results of this toxic combination had been getting steadily worse.

When I started medical school, a baby born addicted to cocaine had been a standard reason for removing the child from the mother’s care. During the intervening years, cocaine addiction had become so common that it was no longer considered a reason to remove a child. We had been, in the words of a famous sociology essay, “defining deviancy down.” As abuse and neglect of babies had become more common, we kept readjusting the definition of abuse and neglect, so we could continue to send babies home instead of into the foster care system.

Even so, I was not prepared for a staff meeting with participants calmly discussing flushing a baby down the toilet as if it were some sort of reasonable response to an unwanted pregnancy. They asked for my input, and they got much more “input” than they had bargained for. I had been on call and awake for most of the previous night. Therefore, I exhibited somewhat less restraint than I might have otherwise.

“My input? MY INPUT?” I replied, my voice rising in volume, “Have you people lost your minds?”

“This teenager put her baby in a plastic bag and tried to flush him down the toilet!” I continued, “Is it really that hard to figure out that she should not be allowed to take this baby home?”

The lead social worker seemed defensive.

“You don’t have to get so angry about it,” she chided.

I wasn’t finished with my tirade.

“Evidently I do have to get angry, since you don’t seem to realize how bizarre it is to ask for input about whether flushing a baby down the toilet is a risk factor for abuse.”

The whole team looked hurt.

“It is a risk factor. It is a very big risk factor!” I went on. “I’m going to put myself on the line here and state unequivocally that anyone who tries to flush their baby down the toilet should not take that baby home.”

“Well, if you feel that way about it,” the team leader huffed, “then we won’t send the baby home with her.”

“Yes, I feel that way about it,” I huffed back.

The meeting ended on that less than cordial note.

Looking back on it, I can see that what filled me with anger and despair was not the fact that a teenager had tried to kill her baby. Mental illness and desperation are often a lethal combination. What filled me with despair was that seemingly sane people were discussing whether or not flushing a baby down the toilet was acceptable, as if the conclusion might be in doubt.

What’s worse than being rendered impotent and incontinent by prostate cancer treatment? Being rendered impotent and incontinent by prostate cancer treatment that was unnecessary.

Two large, well-conducted studies revealed what doctors have suspected for quite some time. Screening for prostate cancer using the PSA (prostate specific antigen) blood test does not save lives. In fact, PSA screening for prostate cancer does more harm, including impotence and incontinence, than good. Due to their importance, both studies were released online today by the New England Journal of Medicine, in advance of their publication next week.

According to the study, Mortality Results from a Randomized Prostate-Cancer Screening Trial:

From 1993 through 2001, we randomly assigned 76,693men at 10 U.S. study centers to receive either annual screening(38,343 subjects) or usual care as the control (38,350 subjects).Men in the screening group were offered annual PSA testing for6 years and digital rectal examination for 4 years. The subjectsand health care providers received the results and decided onthe type of follow-up evaluation. Usual care sometimes includedscreening, as some organizations have recommended. The numbersof all cancers and deaths and causes of death were ascertained…

Results … After 7 yearsof follow-up, the incidence of prostate cancer per 10,000 person-yearswas 116 (2820 cancers) in the screening group and 95 (2322 cancers)in the control group. The incidence of death per 10,000 person-yearswas 2.0 (50 deaths) in the screening group and 1.7 (44 deaths)in the control group …

Conclusions After 7 to 10 years of follow-up, the rate of deathfrom prostate cancer was very low and did not differ significantlybetween the two study groups.

The two graphs below present the results of the study. The graph on the left represents cases of prostate cancer and demonstrates that PSA screening was much more effective in diagnosing prostate cancer than examination alone. The graph on the right represents deaths from prostate cancer. Despite a significant increase in diagnosis of prostate cancer in the PSA group, there was minimal if any reduction in deaths from prostate cancer.

 

While deaths from prostate cancer were not decreased by PSA screening, serious side effects were dramatically increased.

Risks incurred from a screening process can result from thescreening itself or from downstream diagnostic or treatmentinterventions. In the screening group, the complications associatedwith screening were mild and infrequent… Medical complications from the diagnostic processoccurred in 68 of 10,000 diagnostic evaluations after positiveresults on screening. These complications were primarily infection,bleeding, clot formation, and urinary difficulties. Treatment-relatedcomplications, which are generally more serious, include infection,incontinence, impotence, and other disorders…

Why did the PSA screening test fail to save lives? The PSA screening test did diagnose more cancers than routine examination, so the test definitely works. The apparently paradoxical outcome is due to the nature of prostate cancer itself.

Most men will develop prostate cancer if they live long enough. However, most prostate cancers are very slow growing and usually do not kill the patient. A man with prostate cancer generally dies of some other cause long before the prostate cancer becomes life threatening. Therefore, the PSA test diagnoses many cases of prostate cancer that do not need to be treated as well as a few cases of prostate cancer that are very aggressive. Not only is there no benefit to diagnosing the slow growing prostate cancers, but there seems to be very little benefit to diagnosing the aggressive cancers early, since some do not respond to treatment even when administered in the early stages.

The second study,  Screening and Prostate-Cancer Mortality in a Randomized European Study, showed a very small decrease in deaths associated with PSA screening. That decrease came at a very high price:

To prevent one prostate-cancerdeath, 1410 men (or 1068 men who actually underwent screening)would have to be screened, and an additional 48 men would haveto be treated.

For every death prevented, 1068 men had unnecessary biopsies, and 48 men had unnecessary treatment. That’s a problem, and it is made far more serious by the life altering side effects of treatment, impotence and incontinence.

Taken together, both studies provide convincing evidence that PSA screening for prostate cancer should be stopped. Too many men are seriously harmed, and very few if any men derive any benefit. The take home message for patients: Don’t get PSA screening for prostate cancer.

On the long running game show Jeopardy, contestants are given the category and the answer, and they have to provide the correct question. So, for example, if the category were HIV/AIDS, and the answer was “condoms,” the correct question would be “What is the safest, most cost effective way to prevent the spread of the deadly disease?”

Evidently the Pope does not know how to play Jeopardy. MSNBC, reporting on the Pope’s arrival in Cameroon at the start of a trip to Africa:

Condoms are not the answer to Africa’s fight against HIV, Pope Benedict XVI said Tuesday as he began a weeklong trip to the continent. It was the pope’s first explicit statement on an issue that has divided even clergy working with AIDS patients…

“You can’t resolve it with the distribution of condoms,” the pope told reporters aboard the Alitalia plane heading to Yaounde. “On the contrary, it increases the problem.”

That is simply flat out false. Extensive research has shown that condoms are the most effective, the safest, and the least expensive way to prevent transmission of the deadly virus. According to Effectiveness of HIV Prevention Strategies in Resource-Poor Countries, published in the journal AIDS:

Studies overwhelmingly demonstrate that condoms are highly effective in preventing HIV transmission. A workshop co-sponsored by four government agencies responsible for condom research, condom regulation, and HIV/AIDS and sexually transmitted disease prevention programs (US Agency for International Development, Food and Drug Administration, Center for Disease Control and Prevention, National Institutes of Health, Bethesda, Maryland, USA) was held in June 2000 to evaluate the published evidence establishing the effectiveness of latex male condoms in preventing HIV/AIDS and other STDs. The workshop panel concluded that consistent users of the male condom significantly reduced the risk of HIV infection in men and women. In fact, condoms appear on average to be at least 90% effective in preventing HIV when used consistently and correctly…

A 90% effectiveness rate is very effective indeed. In contrast, sexual abstinence, the Pope’s preferred method for preventing transmission of HIV has been found to be totally ineffective. A 2007 paper in the British Medical Journal reviewed the effectiveness of abstinence programs in several countries:

…Compared with various controls, no programme affected incidence of unprotected vaginal sex, number of partners, condom use, or sexual initiation. One trial observed adverse effects at short term follow-up (sexually transmitted infections, frequency of sex) and long term follow-up (sexually transmitted infections, pregnancy) compared with usual care, but findings were offset by trials with non-significant results…

Moreover, the use of condoms is safe, easy to teach, and cost effective. In contrast, not only is abstinence ineffective, it is impractical because many HIV positive people are married to HIV negative partners. Abstinence would mean that sex was impossible even within marriage.

The Pope’s response “abstinence” is clearly the answer to an entirely different question: “What method of HIV prevention (which doesn’t even work) is consonant with Catholic doctrine?” The Pope is obviously not interested in the actual effectiveness of the method, and he does appear to be disturbed that millions are dying for lack of effective prevention strategies. That has not escaped the professionals who are striving to decrease the horrific impact of AIDS in Africa:

Rebecca Hodes with the Treatment Action Campaign in South Africa said if the pope was serious about preventing new HIV infections, he would focus on promoting wide access to condoms and spreading information on how best to use them…

“Instead, his opposition to condoms conveys that religious dogma is more important to him than the lives of Africans,” said Hodes, head of policy, communication and research for the organization…

The Pope is entitled to his own agenda, but he is not entitled to be intellectually dishonest. Condoms are clearly the answer to Africa’s fight against HIV, if the concern is preventing transmission and death. When is abstinence the answer? Only if the question is how to die Catholic in the midst of an AIDS epidemic.

While I have lots of unpleasant memories of my training, I don’t have a lot of regrets. There is one case, though, that I cannot forget: I went along with care that I believed to be unethical. I can rationalize it by taking into account that I was the most junior member of the team, with no authority to countermand the patient’s primary doctor or anyone else. I can rationalize it by acknowledging that even today, decades later, I don’t have any better idea of how I should have handled it. Nevertheless, I can’t help thinking I will always regret my participation.

I was on the medical service at the time and was taking call on a Saturday. I was paged to the Emergency Room to bring up a new patient. Mr. Rivera (not his real name) was a 38 year old Hispanic man who had come to the ER for a simple sore throat, and gotten a devastating diagnosis.

Mr. Rivera had had lymphoma when he was 18 and had been treated aggressively with chemotherapy. He was a success story; the chemotherapy had put him into remission and he had lived the intervening years free of any health problems. That’s why he was not particularly worried about his sore throat. He thought it might be due to strep.

The sore throat was caused by strep, but during the evaluation, a routine blood count was dramatically abnormal. Mr. Rivera had a very aggressive form of leukemia, a known long term side effect of his lymphoma therapy. Given the nature of his leukemia, the chances of remission, let alone a cure, were very remote.

Mr. Rivera had always known that leukemia was a potential side effect of his successful treatment. He also understood that it was an extremely serious disease. That’s why, in our very first meeting, Mr. Rivera wanted to discuss his prognosis and insisted on making clear his wishes about treatment and death.

Mr. Rivera had lived through multiple rounds of aggressive chemotherapy to treat his lymphoma. He dreaded more chemotherapy, but if there was a reasonable chance that he would go into remission, he was willing to undergo more chemotherapy. However, if, as he suspected, the prognosis was grim, he would refuse chemotherapy so he could return to the Caribbean island where he had been born, and, as he put it, “die on the beach with his family around him.”

I was not encouraging in the least about his prognosis, but I would not make a definitive statement because, as an intern, I was not allowed to interfere with the primary physician’s relationship with the patient. All information about treatment recommendations and prognosis was to be left to the primary physician. In this case, since the patient had had no contact with any oncologist in the previous 15 years, he was assigned an oncologist from our staff.

I was relieved that I was under no obligation to give the patient the grim news. It was early in my career, and I had no experience telling a patient that he was probably going to die. In my naivete, I assumed that the oncologist would tell the patient the truth, and that the patient would soon be heading to the Caribbean to live out his remaining days with his family.

I had not reckoned on the fact that oncologists can often be very unrealistic. Some oncologists believe very strongly that even the most remote chance of a remission should be pursued aggressively. That generally dovetails nicely with the fact that most patients are desperate to live and are willing to undertake any treatment, not matter how painful or difficult.

Mr. Rivera had already made it clear, though, that he was not desperate to pursue any chance. He understood what it meant to have a potentially fatal illness; it had happened to him before. He understood was aggressive treatment meant; he had already experienced it once before. He was adamant that this time he was not willing to grasp at a tiny chance or remission and probably die in the hospital due to the effects of the cancer and the chemotherapy. If the chance of remission was very small, he wanted to go home and die with his family.

Visiting Mr. Rivera the next day I intended to discuss his plan to forgo chemotherapy and return home. I was completely unprepared to learn that his oncologist had told him that he had an excellent chance to be treated successfully and that it would be a mistake to refuse treatment. As Mr. Rivera recounted this information, he watched my face carefully to see my reaction. He was clearly suspicious of the information he received from the oncologist.

I knew what was coming next and I dreaded it. Mr. Rivera asked if I agreed with the oncologist. Remaining carefully impassive, I told Mr. Rivera that I didn’t know nearly as much as the oncologist and therefore, I couldn’t really answer the question. He seemed unsatisfied, but he did not press me.

I sought out the resident physician, my immediate superior, and confronted him. Wasn’t it true, I demanded, that Mr. Rivera’s prognosis was exceedingly grim? The resident acknowledged that the chance of remission was remote. I wanted to know what we should do next. The resident was shocked. What did I mean by “what we should do?” We shouldn’t do anything. It was not up to us to correct the oncologist or, worse, to undermine him. This oncologist was known to be extremely aggressive and there was nothing we could do about it.

I argued, but he had an answer for every argument, reminding me that we could only get into trouble for pursuing this issue. To my everlasting regret, I took his advice.

Mr. Rivera had a rough time with his first course of chemotherapy. He was very sick and his immune system virtually shut down. As a result, he developed an abscessed tooth, and despite powerful antibiotics, the infection spread deep into his jaw. He was in terrible pain, poorly controlled with large amounts of narcotics.

As the days went by, Mr. Rivera spent his time vomiting, shaking with chills, and writhing in pain. Because of his damaged immune system and the chemotherapy, he was unable to fight the infection and it spread further even though we were treating it as aggressively as we possibly could. Ultimately, the infection spread to bloodstream, and three weeks after he was admitted, Mr. Rivera died without ever leaving the hospital and without ever saying goodbye to his family.

The oncologist felt that we had treated Mr. Rivera appropriately. We had given him every chance to go into remission and have a longer life. I thought we betrayed Mr. Rivera in the worst possible way; we lied to him and we deprived him of the opportunity to die the death he wanted, surrounded by the people who were important to him. What really happened is that the oncologist had substituted his preferences for Mr. Rivera’s preferences. The oncologist simply could not imagine or understand that Mr. Rivera could want something different than he would want in the same situation, and so he ignored him.

In the grand scheme of things, Mr. Rivera would have died anyway, and I was a minor character in the drama that played out. But I cannot help but think that I colluded in a theft. We stole Mr. Rivera’s dream of a peaceful death and replaced it with vomiting, fever and pain. We had no right to do what we did; we were guilty of a terrible crime, not a legal crime, but a crime all the same.

An 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 the case of the young woman who came to the urgent care clinic at our health center one evening. The woman was 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.

A PA (physician’s assistant) saw the patient, took the history, which was unremarkable, and started the exam, which was quite 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.

It’s the holy grail of contemporary marketing: getting consumers to pay more for something that is worth less. When it comes to organic food, marketers have hit the jackpot.

How have consumers have been enticed to pay more for products that are potentially less safe than their conventional counterparts? The organic food scam depends on tapping into cultural myths about nature, playing upon widespread misunderstanding of risk, and flattering consumers into believing that those who choose organic food are “empowered.”.

The word “natural” is widely used to sell products. In Packaging as a Vehicle for Mythologizing the Brand researchers explore the connotations of “natural” in contemporary culture and the ways in these connotations are exploited to sell products.

Marketers of organic products depict the modern world as a deeply distorted reflection of what it originally was – the garden before agro-chemical technology. While the values of the past include family, tradition, authenticity, peace, and simplicity, the current era is associated with broken family ties that need to be restored, scientific “advances” that pose threats, constant pressure on the well-being of humans, and unnecessary complexity in everyday life.

Consider the concept of “naturalness”:

Naturalness appears as a rich emotional construct that connects with positive contemporary images of nature… People do not want to remember that nature can also be destructive as in deadly hurricanes and poisonous mushrooms … In a natural health context, Thompson also finds nature to be a positively framed powerful mythic construction; and his informants attribute magical, regenerative powers to nature. They firmly believe that aligning with what nature has to offer for one’s health lets them assert control over their lives and bodies versus losing control by being complicit in a scientized medical system.

There is nothing inherently better about “natural,” but contemporary mythology assumes that there is. The organic food industry exploits this mythology to imply that organic food is inherently better.

In addition, marketing professionals exploit the lack of understanding about risk. We routinely panic about insignificant health risks (high tension wires, X-rays) and routinely ignore large health risks (driving without a seatbelt, tanning). Hence, consumers routinely obsess about insignificant health risks that have never even been shown to occur (pesticides, hormones) and routinely ignored large health risks (foodborne illness caused by bacteria like E. coli and salmonella in the animal waste used as fertilizer) that have been associated with widespread outbreaks of illness and even death.

David Ropeik discusses the causes of misperception of risk in his article The Consequences of Fear. Two factors, control and origin, are especially relevant for understanding the misperception of food risks.

Risks over which we feel as though we exercise control are routinely perceived to be smaller than risks that are imposed from outside.

… Roughly 20% of Americans still do not wear safety belts in motor vehicles… [T]his is, in part, because we have a sense of control when we are behind the wheel, and the risk of crashing is both familiar and chronic—factors that make risks seem less threatening…

In other words, people not only tolerate the substantial risk of not wearing a seatbelt, but they perceive the risk to be relatively small, when, in fact, it is relatively large compared to risks that evoke more fear, like the risk of a plane crash or a terrorist attack. Similarly, consumers of organic food tolerate the real and substantial risk of illness from pathogens in manure, but fear the effects of pesticides, which have never been shown to cause illness.

Origin is important to consumers, too. The risks of technology are widely perceived to be greater than risks from nature, neatly dovetailing with the culture mythology surrounding “nature.” For example:

…many people fail to protect themselves adequately from the sun, in part because the sun is natural … However, solar radiation is widely believed to be the leading cause of melanoma, which will kill an estimated 7,910 Americans this year.

Hence the imagined and undocumented (and possibly non-existent) risk of pesticides in food are perceived as greater than the real and documented risks of serious illness and death associated with the bacteria found in manure fertilizer.

Ultimately, these myths are joined in service of the over-arching myth, that of the “enobled and empowered” consumer:

… [A]ll the significance attached by [marketing professionals] to the products transforms otherwise powerless consumers into the powerful marketplace players. As a result, newly empowered consumers can temporarily escape imposed world conditions by shaping their personal myths and servicing their individual lives. Thus, myths of the past are meaningfully used to serve the present.

Marketers of organic food are not allowed to claim that the food is safer or more nutritious, since it is neither. However consumers are led to believe that by choosing “natural” food grown with “no pesticides,” they are making an “empowered” choice of safer and healthier food. In that way, they can be induced to pay more for food that may actually be worth less.

Sometimes an event is so ineffably sad that it almost defies comprehension. That was how I felt after a phone call on a bright Saturday morning in my last year of medical training.

As a chief-resident in obstetrics and gynecology, I was responsible for handling phone calls from patients who did not have a gynecologist of their own. On that Saturday morning, I took a call from a local women who was in her early 20’s. She sounded distraught, and at first, I couldn’t understand why she was calling.

“It’s about my 5 year old daughter,” she said. “I’m having a disagreement with her doctor and I want you to talk to him.”

“Okay,” I replied warily, “but I’m a gynecologist, so I’m not sure I could be very helpful.”

“No, no, you’re the right kind of doctor,” she insisted. “It’s a female problem.”

The mother proceeded to describe her daughter’s symptoms, vaginal itching and a greenish, malodorous discharge. The little girl’s pediatrician had examined her and gently taken a sample of discharge to look at under the microscope. When he returned to talk with the mother, he was very grim.

The microscopic evaluation of the discharge had reveal that the little girl was suffering from gonorrhea. It would not be difficult to treat; a simple shot of antibiotics should do the trick, but it could not end there. The pediatrician enquired if the mother knew where her daughter had contracted gonorrhea. It could only have come from sexual contact, which meant that someone had been sexually abusing the child.

The mother was aghast. She insisted that there was some mistake. There was no way her daughter could have been abused by anyone. The doctor disagreed.

The pediatrician informed her that, under the law, he had no choice but to file a “51A.” The mother understood that a 51A was a legal document alleging child abuse. It would set in train an investigation by child protection officials, and might result in her child being removed from her custody. The mother protested, but the doctor was adamant.

Now she wanted to know if it were possible that her daughter’s vaginal infection was something other than gonorrhea. I explained that seeing the bacteria under the microscope was quite reliable, but, in any case, the doctor had taken a culture. That meant that the laboratory would also identify the bacteria. The culture results would be virtually 100% accurate, and, I cautioned her, would almost certainly confirm the diagnosis of gonorrhea.

“Well, even if she has gonorrhea,” inquired the mother, “couldn’t she have picked it up from a towel or a toilet seat?”

I explained that that was highly unlikely. The gonorrhea bacteria could not survive outside the body for very long. Neither towels nor toilet seats were likely to be the source of gonorrhea.

Suddenly, her voice brightened.

“I know, I know,” she said, “My little girl got it from me!”

“From you?” I didn’t understand.

“Yes, from me,” she replied. I had gonorrhea a few weeks ago. My daughter and me, we take baths together all the time. That’s how she must have gotten it.”

She was quite relieved. “I knew it,” she declared. “No one has been messing around with her. She caught it from me.”

I wasn’t so sure.

“You had gonorrhea?” I asked with trepidation. “How did you catch gonorrhea?”

I knew what was coming.

“Oh, I caught it from my boyfriend. He had it and he gave it to me. We both got antibiotic shots and now it’s gone.”

My heart sank.

“No, Ma’am, your daughter didn’t get gonorrhea from you.”

“She didn’t? Of course she did,” the mother protested. “Who else could have given it to her?”

I tried to be gentle, but how can you gently tell someone that her boyfriend has been sexually abusing her daughter?

The mother burst into tears. “That means the doctor is right, doesn’t it?”

“Yes, he is probably right.”

The mother continued sobbing. “I’m sorry,” she said. “I’m so sorry I bothered you. I just thought that there had to be some other way.”

I assured her that it had been no bother, though I had been shaken to the core.

“I’ve got to go now,” she wept. “I can’t talk anymore. I don’t understand. I just don’t understand. What am I going to do now?”

Every so often I get an e-mail forwarded to me recounting the story of a friend or acquaintance recently diagnosed with ovarian cancer. The cancer is almost always far advanced, and the prognosis is very grim.

The e-mail reveals that the cancer might have been diagnosed much earlier if only the woman had been given a simple blood test (CA125 test) or had an ultrasound. Readers are exhorted to press their doctors for both tests, so that if they develop ovarian cancer, it can be diagnosed early, when treatment is more likely to be successful. The e-mail makes it sound like the means of diagnosing ovarian cancer is here, but doctors are ignoring the possibilities.

The situation is far more complicated. Yes, a simple blood test or an ultrasound can lead to early detection of ovarian cancer. Unfortunately, though, it also leads to tremendous numbers of unnecessary surgeries and the complications that result. In fact, it is entirely possible that screening for ovarian cancer is more dangerous than not screening for ovarian cancer.

That is the central message of a new study published today in Lancet Oncology, Sensitivity and specificity of multimodal and ultrasound screening for ovarian cancer. You might not realize that if you read newspaper accounts of the study, which emphasize the number of cancers diagnosed. Many newspaper accounts don’t mention that for every woman diagnosed with ovarian cancer, many more had unnecessary major surgery and quite a few suffered serious complications as a result.

The study screened more than 100,000 postmenopausal women for ovarian cancer. Half had ultrasound and CA125 tests (multimodal screening); the other half had ultrasound alone. Ovarian cancer was detected in 87 women, 42 in the multimodal group and 45 in the ultrasound alone group. That sounds pretty good until you learn that in order to make those diagnoses, 942 women had surgery. In other words, 855 women had major abdominal surgery for no reason. Of those, 24 experienced major complications including perforation of an organ (requiring surgery for repair), hemorrhage, deep vein thrombosis, and pulmonary embolus.

There was a big difference in unnecessary surgery between the multimodal group and the ultrasound group. Of the 942 women who had surgery, 845 were from the ultrasound group. In other words, adding the CA125 blood test made the screening more accurate. Even so, for every woman in the multimodal group who had ovarian cancer, 2 additional women had surgery that they did not need. In the ultrasound group, for every case of ovarian cancer diagnosed, approximately 19 women underwent major abdominal surgery that was unnecessary.

Screening hurt far more women than were helped. For every woman who was diagnosed with ovarian cancer, 9 more had surgery that they didn’t need, and 2.8% of women who had unnecessary surgery sustained serious, life threatening surgical complications. That is a pretty dismal record for a screening test.

If we leave aside the ultrasound only group, the results in the multimodal group are far more encouraging. Only 97 underwent surgery, of whom 42 had ovarian cancer. As mentioned above, for every case of ovarian cancer diagnosed in the multimodal group, 1 woman had surgery that she didn’t need. Of those women who had unnecessary surgery, 4.2% sustained serious, life threatening complications.

What would happen if we instituted multimodal screening for all post menopausal women. For every 1 million women screened, 866 cases of ovarian cancer would be diagnosed, 1034 women would have unnecessary major abdominal surgery, of which 43 would sustain major, life threatening complications.

In addition, we do not know if the early diagnosis of ovarian cancer in these patients would improve outcome. Over half of the women diagnosed by screening already had advanced disease, so it is unlikely that screening improved their prognosis. Moreover, even early stage ovarian cancer is a dangerous disease, and many of these women are going to die anyway.

The ultimate value of a screening test is in lives saved, and that information is beyond the scope of this study. It is already clear, though, that for every life saved, 4 or more women will have unnecessary major abdominal surgery, some women will sustain life threatening complications, and inevitably, some women will die from complications of surgery that they did not need.

This study is large, comprehensive and well done, but it does not support mandatory screening for ovarian cancer. It demonstrates that large-scale screening is possible, and that early ovarian cancer can be diagnosed by screening. Unfortunately, it also shows that large-scale screening efforts results in substantial harm to more people than are helped. When the screening test is potentially more dangerous than the disease, it makes no sense to implement mandatory screening.

A sharply divided Massachusetts Supreme Judicial Court recently issued a ruling with head spinning legal and ethical implications. The question at issue: do statutory rape charges discriminate against boys? According to the SJC, that claim can be raised in a defense against the charge of statutory rape.

The facts of the case are not in dispute. According to The Boston Globe:

The case … involved a high school freshman football player who is accused of engaging in various sex acts from August to October 2007 with three girls. Two were 12, and the other was 11.

“None of the complainants reported being afraid of the boy’s behavior,” Chief Justice Margaret Marshall wrote for the majority.

The law on statutory rape is quite clear:

Whoever unlawfully has sexual intercourse … [with] a child under sixteen years of age shall … be punished by imprisonment in the state prison … [or] any term in a jail or house of correction …

Additional case law has further refined the requirements of the statute:

The offense of statutory rape … may be committed with or without any knowledge on the defendant’s part of the age of the victim.

Consent is not a defense to a charge of statutory rape.

The only elements the Commonwealth must prove are (1) sexual or unnatural sexual intercourse with (2) a child under sixteen years of age.

Based on the facts of the case, and the law, the District Attorney charged the boy with statutory rape. There is no question that the acts occurred, no doubt about the age of the girls, and no defense in claiming that the acts were consensual. Therefore, the boy’s lawyer offered a novel assertion: Since all parties were under the age of consent, prosecuting only the boy is sexual discrimination.

The boy’s lawyer should be commended for offering a novel defense. The SJC should have their collective heads examined for agreeing with it.

The theory behind statutory rape law is that children under the age of 16 are incapable of giving legal consent to sexual activity. They may desire such activity, and they may be willing participants, but their consent carries no legal weight. That’s because they are too young to understand the implications of sexual activity, and, by virtue of their age, are easily manipulated by those who are older. Although the law traditional was originally intended to protect young girls, it has been extended to protect boys as well.

In recent years, the dramatic increase in teen sexual activity has led to a reappraisal of statutory rape laws. So called, “Romeo and Juliet” exceptions have been added in many states. Generally, these exceptions allow consensual sex between partners over age 15, provided that one partner is not substantially older than another. In states with “Romeo and Juliet” exceptions, sex between a 15 year old girl and her 17 year old boyfriend is not statutory rape, but sex between a 15 year old girl and her 45 year old softball coach would still be considered statutory rape, regardless of whether the girl consented.

The statutory rape laws are gender neutral. Sex between a 15 year old boy, and his 45 year old coach is also statutory rape. Most prosecutions for statutory rape are against men and boys, because the male is usually the older party and because the male often initiates the sexual contact. The Massachusetts SJC has essentially ruled that this disparity in charges is evidence of sexual discrimination.

The boy’s defense received the support of an amicus (friend of the court) brief filed by the Women’s Rights Project and the Reproductive Freedom Project, which are part of the American Civil Liberties Union. According to ACLU lawyer Sarah Wunsch:

“We should not be enforcing the law based on stereotypical notions about girls as not being capable actors in the same way that boys are… They are doing what teenagers are doing today. They are fooling around sexually, and the girls are participants in the same way that boys are.”

Wunsch said statutory rape laws are rooted in an old concept that a daughter was the property of her father. Echoes of that thinking can be found today when prosecutors criminalize sexual activity involving girls, she said.

“Our view is that there is still a very strong pattern of district attorneys charging based on the notion of having to protect girls,” Wunsch said. “But girls can enjoy sex and be sexually active. They are not simply victims.”

Have these people lost their minds? The three girls in this case are in elementary school! Claiming that girls in elementary school  “can enjoy sex and be sexually active” is a willful misrepresentation of everything we know about children and their decision making abilities.

It is instructive to consider why lawyers for the Women’s Rights Project are willfully misrepresenting the ability of young girls to give consent to sexual activity. In their minds, they appear to believe that they are striking a blow for women’s rights. Hence Wunsch’s mention of outmoded ideas of girls as the father’s property and women as incapable of enjoying sex.

In an effort to protect women, Wunsch, and the SJC are willing to sacrifice young girls. Both willfully ignore the contemporary pressure toward early sexualization of young girls, and the cultural pressure for girls to accede to the demands of boys, whatever those demands might be.

Moreover, the SJC and Wunsch willfully ignored the ages of the girls and the age difference between the girls and the boy. The boy was charged because he was older, significantly older. He was in high school; they were in elementary school. He was not charged because of repressive ideas about female sexuality, and it is disingenuous at best to make that claim.

This case is about child protection, not about female sexuality. Elementary school girls are incapable of giving consent to sexual behavior, period. Elementary school girls can and should be protected against the sexual advances of older boys and men, period. It is astounding that the majority on the SJC could not tell the difference. In their misguided attempt to advance women’s rights, and fight sexual discrimination, the SJC has willingly sacrificed young girls to the predatory advances of older boys and men.

I’m surprised to find myself upset about a reality TV star having a very uncomfortable brush with reality. The incident could an unexpected benefit, though. The embarrassment of having a personal failing caught on camera might cause Jon to consider how his eight children feel about their televised lives.

Jon Gosselin, of Jon and Kate Plus Eight, has been photographed partying with young women, none of whom are his wife. Evidently, while visiting his mother, he crashed a local college party to play beer pong and was also seen in local bar with some of the college girls. An apparently very drunk Jon was photographed with two of his “fans.”

Jon is not a friend of mine, but I feel like I know him. After all, he and his wife invite me into their home on a daily basis to watch the trials and tribulations of raising twins and sextuplets. My kids love the show and I often watch it with them. The children are terrific, it’s easy to sympathize with the parents, and they leave their fundamentalist Christianity out of the show (though not out of their book, website, etc.). Admittedly, I find it a little tough to take the way that Kate is constantly berating Jon; but I figure that if it works for them, it shouldn’t matter to me.

Why is the incident so upsetting for a total stranger? Jon and Kate surely have their problems, like all married couples, but in an extraordinarily stressful situation, they appear to have created a happy marriage and a loving home. They emphasize their partnership and they clearly dote on their children. In short, they present the ideal of family life: challenging, complicated, but ultimately rewarding and satisfying.

It is disappointing to learn that the stress has become too much, that the ideal is no longer ideal and to imagine the resultant pain for Kate, their children, their families and their friends. It would be bad enough if the incident were relatively private, but Jon is a celebrity, and the news is being flashed from coast to coast, dramatically escalating the humiliation potential for Jon, for Kate, and for the children.

Yet if the incident has a bright side, it may be that it brings home for Jon and Kate, the price of the celebrity that they sought and enjoyed. When you are a reality TV star, the entire reality of your life is fair game, not just the carefully manicured part presented to the public. Jon and Kate consciously chose the life of celebrities, and have created some clear boundaries around themselves, even within the context of a reality show. Their eight children, on the other hand, couldn’t possibly give consent, and can’t possibly understand the ramifications of being displayed on television on a daily basis.

Jon and Kate have been honest about the fact that they agreed to the show in order to make enough money to support eight children and provide them with all the extras of a middle class life, while allowing Kate to remain at home. Yet they have made the children celebrities without their consent, and they have allowed their lives to be displayed in intimate detail without considering the ultimate consequences to the children themselves.

As Jon and Kate have just learned, probably to their great shame, fame comes with a very high price. You cannot go anywhere without being recognized. You cannot make mistakes without being photographed. And you cannot keep your transgressions private, to be resolved between yourself in whatever way you deem best.

The children are still small. The embarrassment of having their toilet training broadcast to the public may bother them when they are preteens, but it is unlikely to have any lasting effect. However, as they grow older, the foibles and issues may become more serious, and they will surely become more invested in their own privacy.

Jon’s drinking and partying with young girls is now public knowledge. Jon and Kate will not be able to protect them from it, as they might have done if they were any other couple. That is going to have a harmful impact even though they were not the perpetrators of the deed. How much more harmful will it be to have their own lives laid bare to the public?

I love the television show Jon and Kate Plus Eight, but the life of Jon and Kate and their children should not be on display for us, no matter how much we enjoy watching. Jon’s recent experience has illuminated in sharp relief the consequences of opening your life to public scrutiny. Jon and Kate made that choice, and they will live with the consequences, good and bad. The children never chose to be celebrities, and beyond the money, there appear to be no benefits for them in this arrangement.

In addition to reflecting on their marriage, this may be an opportunity to reflect on what they are doing to their children. Surely it would be difficult to walk away from the fame and marketing bonanza, but maybe it’s time to do just that. This could recent incident could have been a sign of problems, in more ways than one.