For years I have bemoaned the fact that there is no accountability for doctors in the way that they treat patients. Make patients wait for 2 hours for a scheduled appointment? Who cares? Offer only clipped, curt answers to questions? Why not? Rush patients through as if they were cattle? What are they going to do about?

I have periodically joked about the need for a Zagat guide to doctors, where patients could contribute evaluations of the doctor’s bedside manner, office policies, and overall treatment of patients. Evidently someone else had the same idea. As a matter of fact, Zagat itself had the same idea.

As reported in today’s New York Times, Zagat has partnered with the insurance company WellPoint to bring WellPoint customers a new guide rating doctors. Predictably, the reaction from doctors has ranged from anger to outrage. As a physician myself, I want to go on record as applauding the move. It is long over due.

The doctors’ criticism can be summed up as the claim that patient evaluations do not take into account the diagnostic and clinical skills of the doctor. A patient with an excellent bedside manner can be an incompetent practitioner, and a nasty doctor can be an excellent clinician. That claim is true, but it is beside the point. Patients are not being asked to evaluate their doctor based on his clinical skills; they are evaluating the doctor on how he treats patients as human beings. The Times quotes Nina Zagat:

Ms. Zagat, who founded the Zagat Survey company with her husband, Tim, said the reviews were not meant to be the main factor in the choice of a doctor. Rather, she said, they could help a patient choose among specialists recommended by her primary physician.

“One patient might say I care more about communications skills,” she said. “To somebody else, having a very modern, attractive office may lead to a different choice.”

The doctors’ whining is depressingly predictable:

“It is curious that they would go to a company that had no experience in health care to try to find out how good a doctor is,” said Dr. William Handelman, a kidney specialist in Torrington who is president of the Connecticut State Medical Society. “It certainly is very subjective.”

In addition, the doctors preemptively blame patients for bad ratings that a physician might receive:

“Patients notoriously ignore their doctor’s advice to eat well and exercise,” he said. “Often they quit taking their pills when they’re feeling better. They usually don’t understand the technologies and skills needed for treatment.”

Those complaints are, in the words of a classic expression, “true, true and unrelated.” Yes, Zagat has no experience in healthcare, but they have tremendous experience in collecting, collating, and disseminating customer opinions. Yes, patients often ignore the advice of doctors, but that has no bearing on whether they are entitled to have an opinion about the manner in which the doctor treated them.

The sad fact is that at this moment, patients currently have no way to evaluate doctors. Internal evaluations by insurance companies and rating agencies tend to be useless for everyone involved. Evaluating doctors by whether they order enough Pap smears, but not too many doesn’t tell us who is a good doctor and who is incompetent. It also doesn’t tell us who is a compassionate caring physician, and who is a mean SOB.

The Zagat rating system will not provide much information about the diagnostic and clinical skills of physicians, but then it is not designed to do that. It will provide information about the other factors that matter a great deal to patients and often seem to be of no consequence to physicians.

Make patients wait for 2 hours for a scheduled appointment? That’s inexcusable and reflects and complete disregard for the value of the patient’s time. A Zagat guide to doctors will let patients know who cares enough to create a realistic daily schedule and who has no idea or interest in how long patients wait.

Offer only clipped, curt answers to patients’ questions? That’s simply unacceptable, and it has a major impact on whether patients comply with their treatment, not to mention a major impact on how patients experience their care. If doctors knew that their behavior would be broadcast to all potential patients, they would give more thought to their responses.

Rush patients through as if they were cattle? Now they will be able to do something about it; they will be able to tell other potential patients. For the first time ever, there will be real consequences for physician actions.

I have a great deal of sympathy for the terrible time pressure under which doctors operate, and I understand how that leads to long waits and short tempers. But there should be consequences for doctors in how they treat their patients. At the very least, it will cause them to take notice of something they now routinely ignore.

A Zagat Guide for doctors? This doctor says, “Bring it on!”

Kidney transplantation was pioneered in Boston, at the Peter Bent Brigham Hospital. The first transplants were performed only on identical twins because immunosuppression treatment had not yet been discovered. The donor and the recipient had to be literally identical in order for the transplant to have any chance of success. For the early recipients, it was a case of bad luck and good luck. Bad luck that to have a fatal kidney disease. Good luck that you had an identical twin able to give you a spare.

For the Marsden brothers, it was a case of bad luck, good luck, bad luck. Leon had the bad luck to have a fatal case of glomerulonephritis. He had the good luck to have an identical twin, Leonard, who was eager to donate a kidney. But, more bad luck, because Leonard, at the age of 19, did not meet the legal age of majority in Massachusetts, and, Leon was not expected to survive until they turned 21.

Because Leonard was not old enough to give legal consent, and because he desperately wanted to donate his kidney to his brother, his parents petitioned the courts for help. In Marsden v. Harrison, the court sided with Leonard in his desire to donate. The transplant was successful and both brothers did well. The case highlights the stringent standards that were used in the 1950’s to be sure that donors were not being pressured into giving kidneys against their own desires.

By the time I started my medical training in the 1980’s the pendulum had swung in the other direction. Kidney transplantation was relatively routine and the dangers were smaller. Family members often came under intense emotional pressure to donate even when they were, in truth, quite reluctant.

Chris* was a 17 year old with blond, curly hair, admitted for a kidney transplant early in my internship year. He had a long history of a degenerative kidney disease and had been undergoing thrice weekly dialysis for years. Despite the dialysis, his health continued to deteriorate. His parents vied with each other to donate one of their kidneys, but neither was a match.

His only sibling, his brother Steve* was in his early twenties and just starting out in a demanding career. He had an excellent relationship with his brother and his parents, but he was very reluctant to donate. He was so reluctant, in fact, that the transplant surgeon suggested that they put Chris on the waiting list for an unrelated donor kidney in the hope that Chris could get a kidney without involving Steve.

In the following two years, Chris continued to deteriorate until he was facing death, and still no matching kidney had become available. At that point, everyone began looking to Steve. Steve was still reluctant. Steve was frankly scared about the risks. Kidney donation carries a small, but real risk of death. In addition, no one could honestly tell Steve that he might not come to need, and regret the loss of, his second kidney. Steve balked.

Steve endured unrelenting pressure from his parents. As Chris became increasingly ill, his parents became increasingly desperate. They simply could not understand how Steve could hesitate at giving his brother what was his only chance to live any life, let alone a life free of dialysis.

Faced with his frantic parents, and frightened by Chris’ precipitous decline, Steve relented and agreed to donate. Both Chris and Steve sailed through their surgical procedures. To the great joy of everyone, Steve’s kidney in Chris’ body began to work immediately. For the first time in years, Chris could make urine. A mundane physical process, peeing, became a source of joy for Chris, Steve and their parents. The first few days after the transplant were days of happiness and celebration.

Then, inexplicably, Chris became suddenly and seriously ill. The kidney did not appear to be infected. It was still working well, but Chris developed high fevers, chills and lapsed into delirium.The family’s joy turned to fear, and the fear was compounded by the inability of the doctors to figure out the cause of Chris’ life threatening illness.

Chris slipped into a coma around the time that tests of spinal fluid revealed the cause, cytomegalovirus (CMV) encephalitis. Chris had developed a brain infection caused by a virus that infects those who are severely immunocompromised. Chris certainly fit that description; he was taking massive doses of immunosuppressive medication. CMV had spread throughout Chris’ body and attacked his brain. The chances of recovery were extremely slim.

How had Chris acquired CMV? CMV is transmitted from person to person through close contact with bodily fluids. Special immunologic tests indicated that Chris had acquired CMV only recently. It had almost certainly been transmitted with Steve’s kidney.

How had Steve gotten CMV? The first thought was that Steve, like many people, had had a mild infection of CMV in the past, and the virus had remained dormant in his bloodstream. However, blood tests on Steve revealed a completely unexpected finding. Steve, too, was immunocompromised. That’s because Steve was HIV+.

It was then that the truth came out. Steve was gay. That had been the source of his reluctance to donate. This was at the very beginning of the AIDS epidemic. Most people had not yet heard of AIDS, but Steve, like many members of the gay community, was aware that a new disease was striking down young, gay men. He did not know exactly how AIDS was transmitted, but he did know that he was at risk. But Steve was ashamed that he was gay and he strove to conceal his sexuality from everyone, particularly his parents.

Nowadays the requirements for informed consent have become almost as stringent as they were in the 1950’s. In an effort to prevent tragedies like those of Chris and Steve, potential organ donors are cared for and counseled by doctors who have no role in the care of the recipient. Most importantly, potential donors can choose to opt out for any reason or no reason, and the family will simply be told that the potential donor is not a match. In that way, we can ensure that donors are giving organs of their own free will, and not because of intense emotional pressure from family members or the recipient.

Of course that came much too late for Chris, Steve and their parents. Chris was promptly started on anti-viral therapy that brought the CMV infection under control, but he had already suffered massive brain damage. He lingered on for several months and died, his new kidney still working fine. Technically, he died of CMV encephalitis, but in reality, he died of shame, Steve’s shame. Steve had been so ashamed of his sexual orientation that he felt compelled to conceal it, even from the doctors who cared for him and Chris.

Steve developed full blown AIDS two years later. In the days before protease inhibitors, there was little treatment for AIDS, and inevitably, Steve died after struggling with the disease for several years. Two elderly parents, who for a few brief days in the aftermath of the transplant dared to believe that both sons would live to old age, lost everything.

Our country may be fractured along political and economic lines, but we can all agree on one thing: we’re mad at Nadya Suleman, the mother of the newborn octuplets.

Ann Curry, who recently interviewed Suleman on the Today Show, referred to her as the “most vilified” mother in America. That’s a bit hyperbolic; most people will readily concede that they consider the actions of women who deliberately harm or kill their children to be far worse than what Suleman has done. However, Suleman has become a lightning rod for anger, resentment and disgust. There are a number of reasons why this has happened.

The first and most obvious is that Suleman expects, indeed feels entitled to, massive financial support for her children. Suleman has already bankrupted her enabling parents, and is making a good faith effort to bankrupt the rest of us. Such behavior would be unacceptable at any time, but in harsh economic times such as these, it adds insult to existing financial hardship.

Suleman is surprisingly childlike in her approach to money. She just assumes it will come from somewhere, as if by magic. Evidently, it always has. She seems to have no sense of what it will cost to raise her children, let alone any realization that she will never be able to support them, even if her fantasy of getting a master’s degree ever comes true.

One of the most difficult tasks of adulthood is to support oneself and one’s children, particularly if you are a single parent. An adult has to go to work whether she feels like it or not. An adult has to take and keep a job that she may despise because she and her children need the money. An adult has to put up with a bullying boss, annoying colleagues and boring tasks simply to continue putting food on the table for her children. Those are the basic rules of life for the millions of parents trying to survive in this economy. Nadya Suleman obviously thinks those rules don’t apply to her.

The resentment of Suleman’s indifference to the basic rules of adult life are increased exponentially by the fact that she clearly expects that the rest of us are going to support her family. The estimated $1.5-3 million cost to hospitalize the octuplets for 6 weeks or more? California will just have to suck it up and pay, or the hospital will just have to write it off. They money needed to buy food for 14 children? No problem; the taxpayers will just have to send more food stamps than they already do. Early intervention and educational support for any delays or disabilities her children might have? Nothing to worry about there either; there are mandates in place that will force the taxpayers to provide those services to her for free.

Second, Suleman has behaved in an extraordinary reckless way, ignoring the well being of her existing children, and the octuplets that she deliberately conceived. Children are separate, individual human beings and they deserve to be treated as such; Suleman clearly does not understand that.

Her stated reason for having so many children is both bizarre and narcissistic. She has been creating and accumulating children in an effort to make up for a childhood that she describes as lonely and dysfunctional.

People have children for many different reasons, good and bad, or no reason at all. But after having one child, most parents realize that the child is a person, separate from themselves, with his own needs that must be acknowledged and met. Suleman has failed to make this basic transition to responsible parenting. Her children are merely collectibles who exist to satisfy a psychological hunger that cannot be assuaged. Simply put, it’s all about her.

Third, and most importantly, Suleman exists in a fantasy world where actions and consequences are entirely disconnected.

Suleman hired publicists to improve her image, with the ultimate hope of profiting from her story. It is difficult to imagine that any public relations people, no matter how gifted, could extricate her from the hole that she has dug herself into. Neither Suleman or her family realized how their actions would be received by other people who live in the real world. While Suleman may have hired publicists, she is apparently ignoring their advice.

Eclipsing the foolish and bizarre statements she has already made, Suleman claimed that she has never been “on welfare.” When, as was inevitable, the press found that she has been receiving Food Stamps for the 6 children she already has, Suleman compounded her mistake, and revealed her penchant for fantasy, by asserting that Food Stamps are not welfare.

Suleman does not feel responsible for her choices, because she refuses to acknowledge the connection between her choices and the consequences: Yes, she has had 14 children, but that’s not her fault because she was lonely. Yes, she has no means to support those children, but that’s not her fault because she is going to get a master’s degree that will magically allow her to support them. It’s true that she receives Food Stamps, but that’s not a problem, because they are not “welfare” and she is entitled to them.

Nadya Suleman is not the most vilified mother in America, but she is sparking anger, resentment and disgust. That’s not because of her mothering, though. It is because of her narcissism, irresponsibility, and penchant for fantasy. As the financial hardship of these tough economic times impacts ever increasing numbers of families, as more and more parents give up their dreams and desires to provide whatever they can for their children, it is painful to listen to the prattle of an immature, selfish woman and it is almost unbearable to consider that we are paying for her folly.

The film “Reefer Madness” became a cult classic more than a generation ago. Originally produced as a graphic warning against the use of marijuana, it was so overwrought it produced the opposite reaction to that intended. The film tells the story of teenagers lured into trying marijuana and, ending up involved in manslaughter, rape, suicide and an eventual descent into “madness.” By the 1970’s, it had become a cult classic, shown to great enjoyment and acclaim across college campuses.

The transformation from dire warning to joke is well known in the world of advertising and prevention campaigns. It is called the “boomerang effect” for obvious reasons. Typically it occurs when warnings are so dire that they are no longer believable. In fact, people take away the opposite message: the disfavored behavior could not possibly be as harmful as depicted, and therefore is probably safer than previous thought.

That phenomenon may be responsible for the paradoxical results of the Montana Meth Project (MMP). The MMP, the largest advertiser in the state of Montana, may not only fail to decrease meth use; it may actually increase it.

The MMP website proudly reports:

The Meth Project is the largest advertiser in Montana, reaching 70-90% of teens three times a week. This is saturation-level advertising.

The research-based messaging campaign—which graphically portrays the ravages of Meth use through television, radio, billboards, and Internet ads—has gained nationwide attention for its uncompromising approach and demonstrated impact. The campaign’s core message, “Not Even Once®,” speaks directly to the highly addictive nature of Meth.

Wikipedia groups the 16 television ads by director:

Tony Kaye’s spots feature themes of meth-addicted teens’ moral compromises and regret, and certain teens’ false confidence that they can use meth without becoming addicted… Just Once, That Guy and Junkie Den feature teens who promise themselves that they will only try meth “once”…

Each of the spots directed by Darren Aronofsky features a voice-over spoken by the teen featured in the spot. In voice-over, each teen talks about how strong their relationships are with their friends and family, and how important those relationships are to them. The action on screen demonstrates that if a person becomes addicted to meth, their addiction will destroy even their strongest relationships.

Each of the spots by Alejandro González Iñárritu features a teen or teens who appear to be normal and healthy in the beginning of the spot, but who appear pockmarked, bleeding, and addicted at the end, despite the fact that time passes normally. As each teen encounters their downfall—prostitution, robbery, or overdose—a narrator intones the simple phrase: “This isn’t normal… but on meth, it is.”

The MMP claims is has produced impressive positive results:

Teen Meth use has declined by 45%

Adult Meth use has declined by 72%

62% decrease in Meth-related crime …

…As a model prevention program for states nationwide, the Meth Project has expanded into Arizona, Idaho, Illinois and Wyoming. Additional states are expected to launch in the coming year.

A new study in the December 2008 issue of the journal Prevention Science takes issue with those claims. According to Drugs, Money and Graphic Ads: A Critical Review of the Montana Meth Project, by David Erceg-Hurn, the campaign has actually resulted in increases in the acceptability of using meth, and decreases in the perceived danger of using drugs. The key finding of the study, though, is that meth use had been declining before implementation of the campaign and there is no evidence that the campaign is responsible for the continued decline. According to Erceg-Hurn:

“Meth use had been declining for at least six years before the ad campaign commenced, which suggests that factors other than the graphic ads cause reductions in meth use. Another issue is that the launch of the ad campaign coincided with restrictions on the sale of cold and flu medicines commonly used in the production of meth. This means that drug use could be declining due to decreased production of meth, rather than being the result of the ad campaign.”

As the paper concludes, after an exhaustive analysis of each of the projects claims that the existing data that support or do not support those claims:

The MMP has successfully portrayed its advertising campaign as a resounding success to the media, politicians, and even some researchers. However, claims that the MMP’s advertisements have been associated with positive changes in attitudes to methamphetamine are, for the most part, not supported by evidence. In some cases, the MMP’s claims of efficacy are directly contradicted by data in their own reports. It is very worrying that the MMP has ignored and misrepresented several negative findings, such as increases in the acceptability of methamphetamine use, and decreases in the perceived dangers of drug use.

The Montana Meth Project has had an impact far beyond Montana. It’s approach to drug abuse is consonant with the beliefs of the Bush administration on preventing drug abuse, and it’s report of positive results has encouraged the government to extend the program to other states. Yet the Government Accounting Office (GAO) has reported that despite $1.5 billion spent since 1998 on large scale programs warning of the dangers of drug abuse, there has been no evidence of any impact on drug use. Indeed, some campaigns appear to have increased the use of drugs after repeated exposure to such campaigns.

Methamphetamine abuse is a serious problem, with widespread ramifications for communities across the country. The government should try to prevent drug abuse through public health campaigns. However, there is a danger that graphic and exaggerated advertising will have precisely the opposite effect of that intended. Instead of reducing meth use, the Montana Meth Project may go the way of “Reefer Madness,” becoming a cult classic for a new generation of teens and young adults.

 I’ll admit it right up front. I fell for it.

I was standing in line at the drugstore when I noticed the cover of the March issue of Cosmo. The bottom right hand corner declared, “An Orgasm Almost Killed Her.” I’m a gynecologist, and I couldn’t think of what the mechanism might be for an orgasm to be fatal, but they included the subtitle “We Are Not Kidding” so it must be true. Medicine is constantly changing, and perhaps Cosmo might be the first to provide this important new information.

The article detailed the story of a young woman who had a stroke immediately following intercourse. Is it accurate to say that orgasm caused the stroke? It could have, but it is far from clear that there was a direct link between the orgasm and the stroke.

When the young woman who developed symptoms of a stroke shortly after sexual intercourse, her boyfriend rushed her to the hospital. Doctors found that a blood clot had blocked off part of her brain, causing the stroke symptoms. A review of her medical history revealed that she was at particular risk for blood clots because she was on the birth control pill. The Pill increases the risk of blood clots developing in the legs, and anyone who has other risk factors for blood clots should not take the Pill.

This patient had no contraindications to taking the Pill, and had she been like most other people, the blood clot in her leg should not have posed a threat of stroke. Unbeknownst to her, however, the young woman also had a small hole in her heart.

Everyone is born with a hole in the heart, called the foramen ovale (oval opening). The hole is there because the fetal circulation, when oxygen comes in through the umbilical cord instead of the lungs, is very different from the circulation after birth. In the first few moments after birth, the foramen ovale is supposed to be closed off by a flap of tissue. In this woman’s case, the flap did not cover the hole completely.

Because of this small hole within her heart, the blood clot that broke free of her leg vein traveled up to the heart, where it should have stopped, and crossed over to the other side of her heart and began the journey to her head. It lodged there, cutting off the circulation to a small part of her brain and causing the symptoms.

So the Pill caused the blood clot, and the hole in her heart allowed the blood clot to reach her brain, but is it true to say that an orgasm caused the clot to break free? It is possible, but then so are a lot of other things. Change in position like rising from a long period of sitting to standing can cause a clot to break free. Increased intra-abdominal pressure, like that caused by cough, could have also detached the clot. In fact, something as unglamorous as straining at a bowel movement, could also have caused the clot to be released into her bloodstream.

A blood clot is not the only way that you can die from sex. Anyone who has an abnormal blood vessel in the brain is at risk for bleeding into the brain if the blood pressure rises, and sex can cause a temporary rise in blood pressure. For those with heart problems, sexual activity can lead to a heart attack. For those with heart problems who are cheating on a spouse, the risk of a heart attack appears to be even higher. It must be the added effect of guilt on the blood pressure.

I feel a little embarrassed for being tricked by the headline into reading the magazine. However, on further reflection, I’ve decided that Cosmo has performed a public service, in the way that only Cosmo can. Blood clots in the leg are a rare side effect of the birth control pill. Patients receive written information about this side effect, but most probably pay no attention. After reading this story, it’s unlikely that anyone will forget the association between the Pill and blood clots.

That’s Cosmo for you: selflessly searching out stories of sex related medical problems in an effort to keep young women up to date with the latest health news. An orgasm almost killed that young woman. Don’t let it happen to you.

Our daughter recently gave us a very fine compliment. Discussing her day over dinner one night, she reported that her high school “Issues” class was studying marriage. The teacher had told the students that a successful marriage has three elements: friendship, intimacy and passion.

“That’s you guys,” she said, looking toward her father and me. “I raised my hand,” she continued, “because I had lots of examples to share.”

I was thrilled, both because of the compliment, and because she has been observing what her parents are trying to teach to her and to her brothers. My first, greatest, and longest lasting joy in life is my husband.

My children, of course, are my heart. They are as much a part of me as an arm or leg. Their joys are my joys; their sorrows are my sorrows (generally multiplied by a factor of two) and their fears are my fears (generally multiplied by a factor of ten). But my husband is the source of most of the good things in my life, and has been for more than the past 30 years.

As the “Issues” teacher said, the basis of a successful marriage is friendship. According to the late, great Ann Landers, “Love is friendship that has caught fire.” That is indeed what happened in our case. We met sophomore year of college as part of a large group living in the same dorm. When I started making my interest known, it was his fear for our valued friendship that made him hesitate. However, after throwing myself at him (there is no more glamorous way to describe it), I wore down his resistance.

Yet as our relationship grew, the friendship remained at the very core. He has been at my side through medical school, residency, work, the births of four children, the struggles we have shared with our children over their challenges, not to mention countless Little League games, Back-to-School nights, and dance recitals. Eight years ago when I stepped out of the MRI scanner and told him that I had brain tumor, his first words were, “I wish it were me.”

There is no one I would rather be with, talk to, read with, or watch football with. We are about a micron apart on the political spectrum, but have managed to have countless heated discussions about it, nonetheless.

Intimacy is also a vital quality for a successful marriage. I can share anything with my husband, including every fear and every embarrassment. He is always in my corner. I can also expect good advice. Although I’d like to tell you that he agrees with everything I do, the truth is a bit different. He’s not afraid to gently chide me, or counsel me to approach a situation differently. He’s a much nicer person than I am; in fact, he’s the nicest person I know, so that makes his advice and criticism easier to take.

There are additional components beyond the three that the “Issues” teacher discussed. Commitment and compromise are vital. A lifetime together involves a lot of momentous decisions, and the ability to compromise is necessary to smooth the way. For example, my husband thought he wanted two children, and I wanted four. So we compromised on four and he is very happy that we did.

That issue aside, there have been a lot of compromises: about careers, about work hours, about whose needs will be met when. If you can’t compromise, a marriage can be sunk. And when compromise seems very distant, commitment to the relationship, to making sure that everything works out, and to hanging on even when it seems like it might not, can tide you over to better times.

Everyone knows about the passion part of marriage. What I didn’t know 30 years ago was that the passion only increases. The boy I married because I liked, loved and was attracted to him is now the man who held my hand in labor, who tenderly nurtured our children, who supported me through my personal crises and who has become a respected and admired professional. I still like him, I certainly love him, and I am more attracted to him than ever, but even that does not adequately express the passion I feel for him more than 30 years after he captured my heart.

I am the luckiest woman alive, and I know it. He made all of my dreams come true, including the most the most important one. He showed me that true love is real.

The lyrics from the old standard, I Remember You,  convey my feelings best:

When my life is through,
And the angels ask me to recall
The thrill of them all.
I will tell them I remember you.

I have been working on the internet as a freelance writer since before the advent of the World Wide Web. I had one of my most interesting jobs in 2000. That year I went to work for a new start-up called iEmily.com, a health website for teenage girls. I wrote the column Ask the Ob-Gyn.

In advance of the site going live, I prepared a variety of sample questions that I thought might come my way, and I collected research papers on conditions that I though the girls might ask about. I figured that in addition to questions about sex, I’d be asked about weight, about drugs, about drinking and about self-harm.

Surprisingly, over the 12 months or so of the project, virtually all the questions I received fell into one of two categories. The first, and smaller category was weight, specifically “am I fat?” Almost all the girls who wrote had a BMI (body mass index) in the normal range, so it was easy to offer reassurance.

Far more common were questions like this:

Dear Dr. Amy,

I’m 14. I’ve been going out with this cute guy. We just had our one week anniversary yesterday. He wants me to go down on him. I’m not sure what to do. What do you think?

Or

Dear Dr. Amy,

I’m 15 and there’s this guy I really like. All his friends say he will go out with me if I sleep with him. Should I do it?

I always said no. I never said yes. At first I was concerned that the girls would stop writing in because they would think I was too judgmental, but I couldn’t in all honesty say anything else. I was startled to find that the more I said no, the more girls would ask me for my opinion.

There were a variety of reasons why I always said no. First, I figured that if a girl needed to ask a stranger on the computer about such an intimate decision, it reflected the fact that she didn’t really want to do it. Second, I could not and cannot envision a situation in which sexual activity among young teen acquaintances or strangers is ever a good idea. Third, I was concerned about the risks. I developed a little riff on the risks and benefits that went something like this:

Let’s consider the risks: You could get pregnant; you could get gonorrhea; you could get herpes; you could get genital warts and risk cervical cancer down the road.

Now let’s consider the benefits. I personally cannot think of any benefits, can you?

Keep in mind that all the questions and all the answers were visible. Yet every time I said no, girl after girl would write in to ask me whether I thought that she should sleep with her boyfriend despite the fact that I had told the previous 10 girls no. Sometimes I would get 12 or even 15 questions in a row that were all asking the exact same question.

At first, I thought they were checking to see if I would ever give a different answer. Gradually I realized that something else was going on. They wanted me to say no. They wanted someone to give them permission to do what they had wanted to do all along, refuse the demands of acquaintances or strangers. Evidently there was no one in their lives whom they could count upon to watch out for their interests, to remind them that they were worthy of respect, and to tell them that they deserved to be healthy, which meant not taking health risks.

As a clinician and mother, I found the seemingly endless stream of girls asking for permission to say no both touching and horrifying. It was touching that they were so desperate for guidelines that they would ask a woman they didn’t know for advice, and it was horrifying that they did not feel that they had a right to speak up for themselves.

The job ended after a year when the start-up ran out of money. Ever since, I have pondered how it is that we tell our daughters that they can be astronauts or soccer stars, yet when a boy asks them to drop to their knees and “service” them, they don’t feel entitled to refuse. While aiming for career achievement is a worthwhile goal, we should start with the basics.

Every girl should know:

Your body is yours, and being a teen girl does not mean that you must lend it to any boy who asks.

You deserve to be healthy and sex poses serious health risks, especially if you and your partner are unwilling to obtain protection.

A relationship revolves around mutual interests, caring and concern. Any boy who is pressuring you into oral sex or intercourse does not really care about you.

Any boy who refuses to protect you by using a condom does not really care about you.

You are not in a relationship if the boy does not care about your feelings and your health.

 Almost all discussions about reproductive ethics are invariably deformed by analogizing to abortion. The train of thought goes something like this: the conclusion of an ethics discussion must result in confirming the right to abortion; anything that limits a woman’s reproductive choices could potentially impact the right to abortion; therefore, there can never be any limits to women’s reproductive choices.

That argument is weak, wrong and does not consider what the “choice” in pro-choice actually means. The “choice” is the decision to have an abortion, and it does not extend to any possible choice in reproductive ethics. That’s why Nadya Suleman had a right to get pregnant, a right to terminate the pregnancy and a right to carry it to term. She had no right to deliberately conceive octuplets, however, and it is a misunderstanding of reproductive rights to claim that she did.

Ultimately the protection for the choice of abortion is rooted in the right to bodily autonomy. No one can interfere with a person’s right to control his or her own body. No one can force an individual to donate a kidney, to accept a particular medical treatment, or even to accept lifesaving care. The individual has no obligation to do any of those things, and always has a right to say “no.” But that does not mean that the converse is true. Bodily autonomy is the right to refuse various measures, but there is no concomitant right to undergo whatever medical procedures one might wish.

Similarly, the right to an abortion is rooted in the right to refuse to continue a pregnancy, particularly because pregnancy has a small but real risk of death. No woman can be forced to remain pregnant against her will.

Bodily autonomy allows the individual to refuse to donate a kidney. It does not allow the individual to have a doctor remove his kidney to sell to someone else. It also does not confer the right to have a leg amputated or an eye put out, simply because the patient might desire it.

  Bodily autonomy means that patients have the right to refuse cancer care even if that might lead to death from cancer. It does not mean that they have the right to receive chemotherapy when they don’t have cancer, because they want to see what chemotherapy is like. Nor does it mean that they have the right to demand unapproved medical treatments or inappropriate medical treatments, no matter how much they believe that they might work, or how desperately they want them.

The right to an abortion implies a concomitant right to get pregnant spontaneously and to carry a pregnancy to term. Yet women who cannot get pregnant have no “right” to infertility care. Moreover, even if they are paying for infertility care, they have no right to dictate inappropriate fertility treatment or unapproved fertility treatment. That means that there is no right to demand an excessive number of embryos to be transferred even if that’s what the patient might want. The current medico-ethical recommendation for women under the age of 35 is two embryos. There is no “right” to demand more, and the right to control one’s own body does not confer the right to demand more.

Nadya Suleman had no “right” to conceive octuplets. She had no “right” to demand that 8 embryos be returned to her uterus, and the doctor had no “right” to put them there. If, as seems more plausible, she conceived octuplets using fertility medication, she had no “right” to take excessive doses of medication, and certainly no “right” to take fertility medication if she did not meet the medical definition of infertility.

In the rush to protect abortion rights, people should not ignore the rest of medical ethics. The right to end a pregnancy does not confer the right to begin one using artificial means. The right to selectively reduce a multiple pregnancy does not confer the right to create a multiple pregnancy of any number of embryos. In fact, the right to control one’s body does not confer the right to demand medical treatment of any kind if it is not medically indicated.

 The “right to choose” is the right to choose to terminate a pregnancy; it does not confer a right to choose anything, even if it is a reproductive choice.

It is difficult to imagine a health warning that would generate more fear than the announcement that masturbation leads to prostate cancer. Over 100 newspaper articles trumpeting the findings of a new paper on the subject have generated a wave of embarrassment and concern. That’s why it is important to analyze the paper very carefully to determine whether the evidence supports the authors’ claims. In my judgment, the paper has some very serious drawbacks that render its conclusions suspect.

The paper is titled Sexual activity and prostate cancer risk in men diagnosed at a young age. The paper only looked at a subset of men with prostate cancer, the 25% who are diagnosed before age 65. It is unclear why they chose to look only at this group and whether they believe there are any differences in prostate cancer occurring before age 65 and prostate cancer occurring after.

The way the study was conducted (the methodology) raises questions about the validity of the conclusions. The study is a case-control study, in which men with prostate cancer were compared to a control group of similarly aged men without cancer. According to the Oxford Centre classification of studies, a case control study is among the weakest forms of study, rating a 3 on a scale of 1-5; the two lower grades apply to descriptions that make no comparisons and to opinions.

This is also a retrospective study, meaning that the participants were asked to recall events that took place as many as 45 years before. Not surprisingly, these types of studies are often weakened by inability to properly recall details.

Finally, this is a very small study, looking at only 400 men with prostate cancer and 400 controls. A smaller study is less likely to generate valid results.

What were the authors expecting to see? The authors were hoping to determine if there is a relationship between sexual activity and the risk of developing prostate cancer before the age of 65. They looked at two types of sexual activity, masturbation and sexual intercourse.

What would such a relationship look like? In general, if a relationship exists, you would expect to see a “dose-response” effect. In other words, if increased sexual activity increased the risk of prostate cancer, you would expect that the lowest sexual activity levels would lead to the lowest risk, moderate levels of activity would be associated with moderate risk, and high levels of activity would be associated with high levels of risk.

What did the authors find? They found that there was no relationship between overall sexual activity and prostate cancer risk. The proportion of men with low, medium and high frequency of sexual activity were equal.

It’s difficult to publish a study that doesn’t show anything, so the authors went back and reworked their data. First, they looked at the relationship of sexual activity in each decade (20’s, 30’s, 40’s, 50’s) to the risk of developing prostate cancer before the age of 65. There was a suggestion that increased sexual activity in the 20’s was correlated with an increased rate of prostate cancer, but that relationship did not hold for any other decade. In fact, increased sexual activity in the 50’s was actually correlated with a decreased rate of prostate cancer

Then they further sub-divided the data into sexual intercourse frequency and masturbation frequency per decade. There was no relationship between sexual intercourse frequency in any decade and risk of prostate cancer before age 65.

Finally, they looked at the relationship between masturbation frequency per decade and the risk of prostate cancer before age 65. There was no relationship there, either BUT they noticed that low frequency of masturbation in the 20’s and 30’s was associated with a higher rate of prostate cancer, but masturbation in the 50’s was associated with a lower rate of prostate cancer.

What should we conclude from this? We should conclude that there is no overall relationship between sexual activity (whether intercourse or masturbation) and risk of developing prostate cancer before age 65. The few, random associations that appeared in the data are almost certainly anomalies, reflecting the small sample size, and the limitations inherent in any case-control studies. These findings are consistent with multiple previous studies that showed both positive and negative associations, as well as no association at all. The fact that there is no consistent pattern among all the studies taken together further reinforces the conclusion that there is no relationship between sexual activity and risk of prostate cancer.

That’s not what the authors decided to conclude, however. They chose to assume that the random associations they found were real, and not artifacts. They provide no explanation for why or how masturbation could increase the risk of prostate cancer in some decades and also decrease it in other decades, while at the very same time intercourse had no effect at all.

Does masturbation increase the risk of prostate cancer? There is no evidence in this paper that it does, and, a survey of previous papers on the topic provide no evidence of a consistent relationship of any kind. The conclusions of this paper are weak and unjustified, and the publicity campaign waged by the authors and publishers is disingenuous at best, if not outright irresponsible.

We’ve become inured to the spectacle of bitter public divorce battles over assets or children, but how about body parts?

Richard Batista is demanding, as part of a divorce settlement, that his estranged wife Dawnell return the kidney that he donated to her. This is something new, and the press has been busy analyzing the implications. Discussion has centered on the ethics of organ donation and the commodification of body parts. They are missing the point. This has nothing to do with ethics or money; it is about spousal abuse. Specifically, this is an example of the all too common phenomenon of abusive, controlling men trying to continue abusing and controlling the women who leave them.

There is neither ethical nor legal justification for demanding the kidney or compensation. An organ donation is a gift. We have specifically prohibited the selling of organs for just this reason. Ethically, we believe that the only acceptable reason for donating an organ to another person is altruism. You give the organ because you want the other person to get it. What happens after that is irrelevant. If you cannot sue to get your kidney back because you now have a medical need for it, you certainly do not have grounds to sue to get it back simply because you are angry with the recipient.

This case is not about the commodification of organs, either. No only do we prohibit the selling of organs, but we hold both the donor and recipient harmless in the action. The donor cannot sue the recipient for the costs associated with the donation, and the recipient cannot sue the donor if the donor had an undiagnosed medical problem that was transmitted with the organ.

Experts in both law and medical ethics are in agreement that there is no legal basis for Batista’s demand, and the chance that it will be granted is nil. So why did Batista do it? He did it for revenge.

Batista has publicly acknowledge that this is nothing more than a tactic. Batista’s lawyer, appearing with him on CNN, told Larry King:

…[Y]ou mentioned the demand for the kidney or the value. Really, that’s not what’s going on. We use that as an example of what the doctor wants.

What the doctor wants is, A) health to be taken into consideration in the division of the assets, whether or not she’d be entitled to maintenance or not. But most of all, (what’s) being done so he can be part of the children’s lives. That’s what really this case is all about…

He doesn’t want the kidney… No, what he wants the court to do is take into consideration what he’s done, what a wonderful thing it is he’s done and some understanding from the court.

You know, it’s so strange; here he does this, and when he says he’s allowed to see his children, well, legally he is, but these children have been so alienated from him.

…It was out of desperation that he did it.

No doubt he was desperate … desperate to control the woman who was trying to extricate herself from his control.

Batista expresses awareness of the tawdriness of his demand, and insists that there is an additional, selfless, motivation:

… to draw light to the lack of kidney availability, to the number of poor and dying patients across the country who are yearning to live. I hope, and it’s my prayer, that this fallout will help enlighten those people who have any question about organ donation come forward, because there are so many people who are dying as a result of not having an organ.

Oh, sure. He wanted to encourage people to donate organs by suing to get back the organ he donated.

Dawnell Batista has not spoken to the press. According to the facts of the case, though, it would be difficult to find someone more sympathetic. The kidney that Bautista gave her was actually her third transplant. Two previous transplants, from other family members, had eventually stopped working. She has undergone a double mastectomy. Nonetheless, her husband thought that she had time to conduct an affair with her personal trainer (an allegation that she denies), going so far as to examine her lingerie for “evidence” that she was lying.

Richard Batista, who claims to be doing this for his kids, seems to have little consideration for them. According to the children’s court appointed guardian:

“The children are distressed and embarrassed… It’s hard for them to go to school. They believe their teachers and friends know everything that is going on. The family’s life is in the public now.”

When Batista demanded that his estranged wife be jailed for not letting him see his children, the guardian pointed out that he did have visitation rights with his children “as long as nothing derogatory was said about their mother,” he claimed that they had been turned against him.

Almost certainly, Mrs. Batista has negative feelings toward her estranged husband, but as for turning them against him, it sounds like Mr. Batista has done just fine on his own. A man who demands that a sick woman return a kidney donation or pay more than a million dollars, and then publicly acknowledges that it is merely a tactic, to retain control over assets and children should not be surprised that his children have turned against him. He shouldn’t be surprised if the public and the court turn against him as well.