Theoretically, a diaphragm is an excellent form of female contraception. Consisting of a latex dome covering the cervix, and held in place by a flexible ring, it provides protection against pregnancy in two ways. It forms a mechanical barrier over the cervix, keeping the sperm from reaching it and heading up the uterus to fertilize a waiting egg. In addition, the space between the dome and the cervix is filled with spermicidal jelly. Any tenacious sperm that manage to get behind the barrier are killed on contact by the jelly.

In reality, the diaphragm is far less effective than it might be. That’s because it is highly user dependent. A woman must remember to use it, must insert it correctly, and must care for the diaphragm properly so it will not develop holes or tears. I learned early on in my GYN training to ask women not only what form of birth control they were using, but, if they reported using the diaphragm, asking detailed questions about its use. That was especially important when seeing patients in the emergency room, women who might be unknowingly be pregnant, having a miscarriage or suffering pain from an ectopic pregnancy.

Most people think that immaculate conception is unique or impossible, but in the emergency room, you learn differently. You can be waving a positive pregnancy test in front of a woman and she will still insist that there is no possible way that she got pregnant. As a corollary, women who have obtained birth control believe that it is impossible for them to become pregnant, even when not actually using the birth control. Whenever a woman told me that she was using a diaphragm for birth control, I would always ask a follow up question: “When you have sex, is the diaphragm in you or in your nightstand?” A substantial portion of women would smile sheepishly and acknowledge that they hadn’t used the diaphragm the last time they had sex, or perhaps the last 10 times they had sex, or perhaps not since they had picked it up at the drugstore.

Even women who are committed to using it properly can have failures (unwanted pregnancies) if the diaphragm is fitted properly. How do you fit a diaphragm? There are diaphragm-fitting sets, with different types of flexible rings, in graduated sizes. That way the provider doesn’t have to estimate the correct type and size. He or she can insert the ring and check to be sure that it fits snuggly, is not uncomfortable, and will not fall out when a woman stands or coughs. Then the woman can practice in the office with the ring, under the guidance of the provider who can check to be sure that the woman knows how to place it properly to provide complete protection. The rings don’t have latex domes on them because it isn’t necessary for fitting, and it would make it more difficulty to sterilize them after each use.

Given that effectiveness is so closely related to motivation and understanding of the patient, it is not a good method for women who have been unreliable in the use of other methods in the past. Some times, though, particularly for women who cannot tolerate hormones (ruling out birth control pills, DepoProvera shots, and IUDs), the diaphragm is the only reasonable effective method that you can offer. In that case, it is critical to counsel the patient on how the diaphragm works, how it must be used every time, and especially how to insert it properly.

That’s what we did for a young woman who had two small children already as the result of birth control failures. She could not tolerate the Pill and her boyfriend would not use a condom. The nurse practitioner who was most experienced in patient education fitted her and watched her insert it multiple times until she could do it with ease. The nurse practitioner counseled her for an hour on the need to use it reliably, the need to apply the spermicidal jelly inside the dome before inserting it, and how to care for the diaphragm properly. She scheduled an appointment for the patient to return in 3 months, to be sure that the diaphragm did not irritate the cervix or surrounding tissue.

Six weeks after the fitting, the patient called to say that she had missed her period, and the nurse practitioner agreed to see her that day. A pregnancy test was positive, another unintended, unwanted pregnancy. The nurse practitioner was stern. Why hadn’t the patient used the diaphragm? The young woman insisted emphatically that she had used it every time, that she had inserted it correctly and that she had cared for it properly.

The nurse practitioner was mystified and told the patient so. The patient thought that she knew what the problem might have been. When she picked up her diaphragm at the pharmacy, it was broken. The nurse practitioner was puzzled. Broken? Did she mean that the diaphragm had a hole in it?

“Oh, no.” the patient replied, “That was the problem. It didn’t have a hole in it, but I remembered that the one I used in the office was only a ring, so I cut a hole to make it look the same!”

Arthur Caplan has changed his mind about face transplants. Who is he and why is that important? Caplan is a bioethicist, and “public intellectual” on issues of medical ethics. He appears widely on national news and discusses ethical issues in a variety of publications, including a regular column for MSNBC.com.

Caplan’s change of heart reflects a change in the ethical understanding of face transplants. Simply put, face transplant was originally viewed as a way of changing identity, sort of like the strikingly “realistic” face masks of old Mission Impossible TV series. Now, there is a greater appreciation of face transplant as a form of reconstruction for those who have suffered catastrophic facial injuries.

Caplan documents the change in his thinking in a recent MSNBC column:

When face transplants were first proposed 10 years ago I thought they were unethical…

A transplanted face is biologically like any other transplanted organ: There is always a risk that the recipient’s body will reject it. The immunosuppressive drugs that must be used to try to prevent such a disaster are powerful, but can cause fatal cancers and other serious side-effects, such as kidney failure. Normally, transplant surgeons don’t worry much about these risks because they pale in comparison to the certain death that awaits someone whose heart or liver have stopped working. But a face transplant is intended to improve the quality of life rather than save a life, as a heart, lung, kidney or liver transplant does…

If the woman who received her new face from a cadaver were to begin to lose it due to tissue rejection that could not be stopped, what will happen? There are no second chances with face transplants — the damage of rejection makes that impossible. What if someone facing this horrendous prospect – life with no face at all — says no to artificial feeding or breathing? What if they beg for morphine to help them die painlessly and more quickly? Any team undertaking face transplants must be ready to manage a failed experiment.

What caused Caplan to reconsider?

After talking to some people with severe facial disfigurement, I realize it makes ethical sense to offer a form of surgery that might kill the patient, because the suffering of the afflicted is so great that they are willing to risk death. We don’t hear much about those with facial deformities due to birth defects, burns, trauma, cancer or violence. That’s because the stigma of severe facial deformity is so enormous, so staggering, that many simply withdraw from society. Others find that, despite the best efforts of reconstructive surgeons, they are unable to eat, breathe or speak comfortably, and are condemned to lives of suffering and pain.

A face transplant, despite its very real dangers, might bring relief. The science has reached the point where trying to help those who are beyond the help of current medical treatments is not just ethical, but almost obligatory.

I agree with Caplan’s new understanding of ethical justification for face transplant. However, previous claims by Caplan and others that face transplantation is unethical rested on a the fact that face transplant has been misnamed. A transplant (as in the case of kidneys, for example) involves the complete exchange of a failing organ for an entirely different organ with better function. Face transplantation is not an exchange.

Face transplant is simply an advanced form of reconstruction. In most cases of severe facial injury, parts are taken from the patient herself and used to reconstruct her face. Bone may be harvested from one part of her body, and skin in another, both in an attempt to replace missing features and rebuild the face that existed. Sometimes the damage is so extensive that the patient herself cannot donate enough tissue to complete the reconstruction. In that case, parts can be harvested from a cadaver to replace what cannot be rebuilt.

Medical ethicists viewed face transplantation as an actual transplant of one persons “face” to replace another person’s face. Even if that is accomplished technically, it can’t really change identity, because the underlying bone structure and placement of features like eyes and mouth always remain. Advanced facial reconstruction by harvesting missing parts from cadavers, in contrast, deliberately attempts to rebuild the face as it existed before the injury. Caplan and others worried about face transplantation as an opportunity to change identity. In reality, it is an opportunity to regain identity.

No, not these chips,

but these chips … the implantable kind.

When I recently read about this technology on Bioethics.net, I thought it was a joke:

Scientists in the UK are working on methods to stimulate the brain, specifically in the orbitofrontal cortex, the part of the brain that feels pleasure from eating and sex. According to The Telegraph, implantation of a chip into that area of the brain is expected to result in increased sexual pleasure. Previous studies in one woman with very low sex drive becoming one with a very active sexual appetite. However, the scientists reported, “She didn’t like the sudden change, so the wiring in her head was removed.”

But when I surveyed the scientific literature, I found out that these electronic stimulation projects are legitimate, are based on technology used to treat neurological problems, and that the primary research group is quite prolific its attempts to apply this technology to different parts of the brain, with very good results.

The best known researcher in the field of chip implantation technology appears to be Dr. Morten Kringlebach. He has done pioneering work in determining the location within the brain of various sensations and drives, including smell, taste, thirst and painful touch. He has also worked on the implantation technology, which is known technically as deep brain stimulation (DBS).

To date, the most well known application of DBS technology is in the treatment of Parkinson’s Disease. You can watch the technology in action at Dr. Kringelbach’s website. As he explains in an article in this month’s issue of Scientific American Mind, Sparking Recovery with Brain “Pacemakers”:

…A man in his mid-50s, affable, articulate, faces the camera and talks a bit about a medical procedure he’s had. He holds in his hand what looks like a remote control. “I’ll turn myself off now,” he says mildly. The man presses a button on the controller, a beep sounds, and his right arm starts to shake, then to flap violently. It’s as if a biological hurricane has engulfed him … With effort, the man grasps the malfunctioning right arm with his left hand and slowly, firmly, subdues the commotion …With an almost desperate gesture, he reaches out for the controller and manages to press the button again. There’s a soft beep, and suddenly it’s over. He’s fine.

In Parkinson’s, DBS technology is used to dampen the erratic brain impulses that cause the visible symptoms. Kringelbach and others reasoned that if you could use DBS to dampen undesirable brain impulses like those of Parkinson’s and certain chronic pain syndromes, you could use DBS to evoke desirable brain impulses.

In a highly technical paper, Affective neuroscience of pleasure: reward in humans and animals, Dr. Kringelbach reviews two famous cases of DBS used to evoke pleasure:

… a much-cited case is “B-19”, a young man implanted with stimulation electrodes in septum/accumbens region by Heath and colleagues in the1960s. B-19 voraciously self-stimulated his electrode and protested when the stimulation button was taken away. In addition, his electrode caused “feelings of pleasure, alertness, and warmth (goodwill); he had feelings of sexual arousal and described a compulsion to masturbate”…

Similarly, a female patient implanted with an electrode decades later compulsively stimulated her electrode at home. “At its most frequent, the patient self-stimulated throughout the day, neglecting personal hygiene and family commitments”. When her electrode was stimulated in the clinic, it produced a strong desire to drink liquids and some erotic feelings, as well as a continuing desire to stimulate again.

But popular descriptions of the technology as “sex chips” may oversell its effects:

… B-19 never was quoted as saying it did; not even an exclamation or anything like “Oh—that feels nice!”. Instead B19’s electrode-stimulation-evoked desire to stimulate again and strong sexual arousal—while never producing sexual orgasm or clear evidence of actual pleasure sensation. And the stimulation never served as a substitute for sexual acts. What it did instead was to make him want to do more sexual acts, just as it made him want to press the button more…

When [the female patient’s] electrode was stimulated in the clinic, it produced a strong desire to drink liquids and some erotic feelings, as well as a continuing desire to stimulate again. However, “Though sexual arousal was prominent, no orgasm occurred” (Portenoy, 1986)… Clearly, this woman felt a mixture of subjective feelings, but the description’s emphasis is on aversive thirst and anxiety—without evidence of distinct pleasure sensations.

Dr. Kringelbach points out that the technology definitely has potential:

Of course, to suggest that such pleasure electrodes failed to cause real pleasure does not mean that no electrode ever did so, much less that future pleasure electrodes never will. But it does mean that, if even the most prototypical and classic cases of ‘pleasure electrodes’ from the past are open to doubt, closer scrutiny of deep brain stimulation (DBS) electrodes may be needed in the future: Do they really cause pleasure? (Green et al. 2008; Kringelbach et al. 2007b).

So don’t bother looking for “sex chips” in your local drugstore just yet, but they are almost certainly on the horizon.

Breastfeeding is obscene. At least that’s what the social networking site Facebook appears to believe. Evidently, it is only appropriate to display breasts for sexual reasons. There are literally thousands of photos of women exposing their assets to greater or lesser extent. But we need to draw the line somewhere. It might be damaging for Facebook members, including many high school and college student, to see women using breasts for their primary purpose, to nourish their babies.

Talk about a boneheaded public relations move. As was only to be expected, women whose pictures of breastfeeding were removed promptly formed the Facebook group “Hey Facebook, Breastfeeding is Not Obscene.” The group has 100,000 members and counting. Here’s their “manifesto”:

Recently, Facebook has started ‘pulling a myspace’ by not allowing people to post profile pictures of babies nursing. The pictures have been reported as ‘obscene’ and have been removed- their posters warned not to repost or fear being kicked off of Facebook.

We’re wondering: what about a baby breastfeeding is obscene? Especially in comparison to MANY other pictures posted all over Facebook that really are obscene.

Facebook, we expect more from you, and we expect you to realize that nursing moms everywhere have a right to show pictures of their babies eating, just like bottle-fed babies have a right to be seen. In an effort to appease the closed-minded, you are only serving to be detrimental to babies, women, and society.

**Facebook, allow breastfeeding pictures, and stop classifying them as obscene!**

According to tech website, ars technica:

As per site policy, Facebook does not allow images depicting female nipples or areolas anywhere on the social network, though this does not include breastfeeding photos. Facebook does, however, remove photos that are reported by users as obscene, which is apparently what happened in Farley’s (and other mothers’) cases. Farley says that the baby covered the nipple and areola in her photos, but that apparently didn’t stop other members from reporting the pictures to Facebook.

Here’s one of the offending photos, so you can judge for yourself.

Yup, that’s obscene. Sure there’s no visible nipple or areola, but OMG there is a baby eating from that breast! Small children could be emotionally scarred by just one peek.

Facebook has jumped head first into a no win situation. It is almost inevitable that the phenomenon of 100,000 women demanding more pictures of breastfeeding will lead to even greater public pressure for them to relent. The ban is unjustifiable on its face, but it is instructive about societal attitudes. Evidently no amount of cleavage is too much if it is displayed for sexual purposes, but when it comes to drinking from a breast, that’s just going too far.

Everyone has heard of weight lifting with weigh machines or free weights, like barbells, dumbbells and even kettlebells, but now there’s a new kid on the block. Vaginal weights are coming to a store near you. No, I’m not making it up. Just like traditional weights, vaginal weights exist to exercise and build up muscle groups. In this case, the muscle group in question is a rather intimate one. Vaginal weights were created to exercise the pelvic muscle groups responsible for tone in the vagina and surrounding structures.

While vaginal weights may sound like a joke, the problem they are designed to treat is anything but. The weights, used in conjunction with special exercises, are designed to treat stress urinary incontinence (SUI). SUI is leakage of urine when the pelvic muscles are stressed such as when coughing, sneezing or laughing. It is much more common among women than men, and some estimates suggest that as many as one in three women will suffer from SUI at some point in her life.

SUI is often associated with pregnancy, but in that case, it is usually self-limited; after the baby is born, the incontinence will stop. More commonly, it is associated with aging, particularly in women who have given birth in the past. The ligaments and muscles that support the pelvic organs stretch in response to pregnancy and childbirth. After menopause, when the ligaments and muscles tend to weaken even further, the bladder and uterus may slip down (prolapse) into the vagina, distorting the normal relationships necessary to control bladder function. The difference is typically not noticeable at rest, but anything that increases pressure on the bladder, like coughing or sneezing, allows urine to leak out beyond muscles that are too weak to hold it in.

As you might imagine, SUI is embarrassing and inconvenient. When actress June Allyson made those television commercials encouraging women to “get back into life with Depends,” she was talking to women with SUI. In the intervening years, pads of all different types and sizes have been introduced. SUI is so common that the pads are sold next to the tampons in the feminine hygiene section of the grocery store. Many women find pads an unsatisfactory compromise. These women, and women who develop more severe SUI, oft opt for surgery to repair the weakened ligaments. The uterus is usually removed because it is often dragging down the bladder with it, and it is much easier to permanently prevent incontinence after it is gone.

Surgery is, of course, the most drastic treatment. Before women opt for surgery, they are often advised to perform Kegels, exercises designed to strengthen the pelvic muscles surrounding the vagina, uterus and bladder. Kegel exercises, named after Dr. Arnold Kegel, involve contracting and relaxing the muscles of the pelvic floor, as described on the Mayo Clinic website:

To make sure you know how to contract your pelvic floor muscles, try to stop the flow of urine while you’re going to the bathroom. If you succeed, you’ve got the basic move. Or try another technique: Insert a finger inside your vagina and try to squeeze the surrounding muscles. You should be able to feel your vagina tighten and your pelvic floor move upward. Then relax your muscles and feel your pelvic floor move down to the starting position…

Once you’ve identified your pelvic floor muscles, empty your bladder and sit or lie down. Then:

·         Contract your pelvic floor muscles.

·         Hold the contraction for three seconds then relax for three seconds.

·         Repeat 10 times.

·         Once you’ve perfected three-second muscle contractions, try it for four seconds at a time, alternating muscle contractions with a four-second rest period.

·         Work up to keeping the muscles contracted for 10 seconds at a time, relaxing for 10 seconds between contractions.

Women are advised to perform sets of 10 Kegels, 3 times a day. That’s where the vaginal weights come into the picture. The reasoning is that if contracting the pelvic muscles builds muscle tone, contracting them against resistance (the vaginal weight) should build muscle tone more effectively. According to GlysBy, the makers of a particularly colorful set of vaginal cones:

If a cone is inserted into the vagina, it tends to slip out again. It is then prevented from slipping out by repeated muscular reflexes (“bio-feedback phenomenon”) and, throughout the course of exercising, by increasingly conscious muscular contractions. Drawing together and tensing the muscles of the pelvic floor trains and strengthens these muscles, similar to body building with weights. Exercising may thus at first give rise to sensations of pain in the pelvic area (muscular soreness). At the same time, however, awareness of the pelvic floor will be improved.

How does a woman use the vaginal weights?

The woman starts by testing the strength of her pelvic floor. This can be done by inserting the yellow (lightest) cone deep into the vagina. Should she be able to keep this cone in place for approx. 1 minute in a standing position, she may try the next heavier cone (green first, then blue and purple last). The cone that she can only just hold shows you how strong your pelvic floor is and she should start exercising with this cone.

The woman should exercise at least twice a day in a standing position or when walking. At the beginning she may only be able to hold the cone for a very brief period. The exercising time should be increased gradually until the cone with which you are exercising can be held for approx. 10 minutes per exercising session for several days in succession. Once this stage has been achieved, she may exercise with the next heavier cone.

In theory, using the vaginal weights should be more effective than Kegels alone, but the reality has proven somewhat disappointing. According to a 2007 Cochrane Review, Weighted vaginal cones for urinary incontinence:

Fifteen studies, involving 1126 women of whom 466 received cones, were included. All of the trials were small and in many the quality was hard to judge. Outcome measures differed between studies, making the results difficult to combine. Some studies reported high drop out rates with both cone and comparison treatments… Cones were better than no active treatment. There was little evidence of difference between cones and PFMT [pelvic floor muscle training/Kegels] … There was not enough evidence to show that that cones plus PFMT was different to either cones alone or PFMT alone.

Despite the lack of improvement over muscle exercises alone, vaginal weights have become a big business, with many different manufacturers and websites selling the cones. According to the makers of the Stepfree vaginal cones: “It’s never too soon to start a program of prevention with vaginal weight.” That’s almost certainly an exaggeration. There appears to be very little scientific evidence that Kegels or vaginal cones can prevent the development of SUI. There is evidence that one or the other can improve symptoms of mild SUI. So women who truly want to exercise ALL muscle groups, might consider adding vaginal weights to their exercise routine.

We’ve already got a cure for a problem most of us didn’t know existed: short eyelashes. On December 5, a panel of independent eye and skin experts convened by the FDA voted unanimously that the benefits of the drug Lumigan (bitamoprost), making lashes longer and fuller, outweigh the risks. The drug’s maker, Allergan, may soon be able to add this as a companion to its blockbuster cosmetic drug Botox. Allergan plans to re-introduce the drug under the name Latrisse, and claims that the market for it could eventually reach $500 million. Allergan stock rose 3.7% in the wake of the announcement.

Allergan did not set out to find a drug that promotes eyelash growth. The effect of Lumigan on eyelash growth was a serendipitous discovery. Lumigan was brought to market as a treatment for glaucoma, one of the leading causes of blindness worldwide. Lumigan belongs to a class of drugs known as prostaglandin F2α analogues. When given as eye drops, they act to reduce the elevated pressure inside the eye caused by glaucoma. Lumigan is among the most effective medications in the class.

After Lumigan went into widespread use, side effects were observed. These were particularly remarkable in patients who needed glaucoma treatment in only one eye. It became obvious that Lumigan cause increased pigmentation in the iris, and led to excess eyelash growth, making eyelashes on the affected side noticeably longer and fuller. The use of Lumigan seems to be quite safe, as well. According to The side effects of prostaglandin analogues, in the January 2007 issue of Expert Opinion on Drug Safety:

In the last decade topically applied prostaglandin F2α analogues … have become widely used as a means to reduce elevated intraocular pressure in patients with glaucoma and ocular hypertension… [T]he systemic side-effect profile is favourable for all the prostaglandin analogues, and some of the local side effects are only of cosmetic significance. Numerous clinical studies suggest that discontinuing treatment with prostaglandin analogues on account of their side effects is rare in clinical practice.

That was all it took. As soon as this side effect was recognized, dermatologists began prescribing it “off label” for eyelash enhancement.

Once a drug is approved by the FDA for one use, it can be prescribed by any physician for any use. That’s known as “off label” prescribing, and is sanctioned by the FDA. Google “Lumigan eyelashes” and you will find hundreds of entries as well as multiple Google Ads. Allergan did not have to seek approval from the FDA for the use of Lumigan, because it already has FDA approval for use in glaucoma. However, the FDA specifically prohibits a drug company from marketing a drug for an off-label use. Allergan wants to exploit the market for cosmetic Lumigan with an advertising campaign similar to its wildly successful campaign for Botox. That is why it is willing to do the additional work and submit the additional data needed for approval as a cosmetic agent.

Lumigan represents a bonanza for Allergan. All of the development work and most of the testing have already been done. It is already a successful product, and by rebranding is as Latrisse, the market can be dramatically increased. Best of all, the eyelash effects of Lumigan are only temporary. Unless it is applied once a day (with a mascara wand), the effect wears off. There’s nothing better for a drug company than a product that must be used every day.

Are there any ethical objections to bringing a drug to market for the sole purpose of promoting eyelash growth? In effect, it is too late to ask that question. The FDA has approved Lumigan for medical use, and it can be and is being prescribed for cosmetic use already. Asking the FDA for cosmetic approval commits Allergan to conducting additional studies on the effect of using Lumigan for purely cosmetic reasons, which will ultimately provide consumers with more information on risks and benefits.

Most importantly, we can rest soundly, knowing that no one will need to suffer from the heartbreak of short eyelashes anymore.

There’s a serial killer on the loose, a killer of libidos. No it’s not stress, or overwork, or even relationship difficulties, though all have been implicated in the deaths of desire. This killer is a commonly prescribed medication: Prozac and its cousins the SSRIs.

Consider:

A 35-year-old woman was referred by her therapist for an evaluation of her sadness, irritability, fatigue, and poor concentration despite cognitive behavior therapy. She was happily married and had a fulfilling, enjoyable sex life. She was diagnosed as suffering from depression, and treatment with Prozac was started. At a follow-up visit, she reported complete relief of her depression and irritability. However, she complained about marital problems. Detailed questioning revealed a lack of sexual desire and difficulty in achieving orgasm. It was apparent that the dysfunction was related to the treatment with Prozac. (adapted from Balon, SSRI Associated Sexual Dysfunction)

Stories like these are repeated over and over again in therapists’ offices, or worse, not repeated but kept secret by patients who are embarrassed. And these stories are more common than previously thought. In a 2007 article, Depression, Antidepressants and Human Sexuality, Balon reported that sexual side effects of a class of antidepressants known as SSRIs (selective serotonin re-uptake inhibitors, like Prozac, Zoloft and Paxil) impact anywhere from 30% to 70% of people who take these medications. It is particularly unfortunately that these side effects are often not shared with physicians, because there are ways to prevent, minimize and treat sexual side effects.

Why is it so difficult to pin down exactly how many people are affected by side effects of SSRIs? Part of the problem is that depression itself has many sexual side effects. Approximately 70% of people suffering from depression report some impairment of sexual functioning, particularly loss of libido. Assessing the sexual side effects of SSRIs is further complicated by the fact that many patients have additional medical conditions that effect sexuality or take non-psychiatric medications that can impair sexual functioning.

Nonetheless, years of experience with SSRIs have made it plain that they can and often do cause sexual side effects. Interestingly, the main reason why sexual side effects have risen to the fore in connection with SSRIs is because older antidepressants had many more serious side effects that overshadowed the effects on sexuality. Paradoxically, newer medications with fewer side effects have raised the relative importance of sexual side effects.

What are the sexual side effects of SSRIs? According to Sexual Dysfunction Associated with Antidepressant Therapy:

The major side effect is anorgasmia or delayed orgasm, which seems to occur in 30% to 40% of patients depending on the threshold set for the diagnosis. Clinicians have used this side effect to treat premature ejaculation. These problems usually occur within 1 to 2 weeks of starting the agent and well before the antidepressant effect is evident… Problems with decreased libido and erectile impairment occur less frequently, perhaps in approximately 20% and 10% of patients, respectively

Not all SSRIs are equally likely to cause sexual side effects.

Controlled clinical trials and large prospective clinical series have established that the SSRIs … as a class, are all are associated with sexual dysfunction. There is some evidence that paroxetine has a higher rate of sexual dysfunction than the other SSRIs and that fluvoxamine may have a lower rate of sexual dysfunction …

… Antidepressants with a low incidence of sexual side effects are … Bupropion, Nefazodone, Mirtazapine, [and] Duloxetine.

This variability in the frequency of sexual side effects suggests ways to prevent and treat sexual side effects. To prevent sexual side effects, patients can be started on SSRIs that have a lower incidence of side effects. In the event that side effects develop, switching to a different SSRI may solve the problem.

There are many other strategies for dealing with sexual side effects, including:

          Waiting for the side effect to resolve spontaneously

          Scheduling sexual activity around dosing of the medication

          Temporarily going off the medication

          Adding medications that counteract the sexual side effects of SSRIs (e.g. Wellbutrin)

What do people taking, or contemplating taking SSRIs need to know? First, it is important to be aware, even before starting treatment, that SSRIs can and often do have sexual side effects. Second, it is critical to bring up the issue of side effects with your physician, both before starting treatment, and if any symptoms develop. Third, if the medication is helping with depression, don’t stop treatment because of sexual side effects; they can often be minimized or cured by strategies like those mentioned above. Fourth, if side effects do develop, you can share information with your partner that the side effects are due to the medication and not the relationship itself.

The search is on for newer SSRIs that have fewer or no sexual side effects. In the meantime, for those who need them, SSRIs can be literally life saving. Many sexual side effects can be prevented, minimized or treated, so no one has to choose between a sex life and a life free of depression.

In an ongoing effort to keep readers apprised of the latest, the most interesting, and most unusual stories in medicine, I have come across a medical procedure that fits all three criteria. In addition, this is undoubtedly the grossest medical procedure ever.

Be warned! If you are squeamish, do not read any farther. I say this with a certain amount of authority; I have spent many years immersed to the elbows in people’s internal organs, and covered in bodily fluids, but I was shocked by this. Even the name of the procedure is repulsive, but it is a real procedure that has been successful in treating a very serious problem. What is it?

Fecal transplant … (yes, it’s just what you think it is).

Before we get to the mechanics of the procedure, a digression is in order to explain the disease it is designed to treat. The problem is also unpleasant, but a serious, and growing, danger to our health. The technical name is Clostridium difficile enteritis, but is more commonly known as C. diff infection.

C. diff bacteria are everywhere in our environment, and many of us carry it in our intestines. Normally, it is kept in control by the many other forms of bacteria that reside in our gut. However, when a person takes powerful antibiotics, the majority of bacteria in the gut may be killed off. This allows the C. diff bacteria, which are hardier, to overgrow and produce large amounts of a toxin that inflames the intestines. In effect, this is similar to what happens to many women when they take antibiotics and end up with a yeast infection. The antibiotics kill the normal bacteria of the genital tract, allowing the yeast to take over and cause an infection. Yeast infections, while very unpleasant, are usually not dangerous. C. diff, on the other hand, can be very serious.

Some cases of C. diff infection are mild, causing diarrhea and abdominal cramping. But new strains of C. diff are emerging that produce more powerful toxins and can cause severe, even deadly illness. A severe infection with C. diff can lead to profuse diarrhea, severe abdominal pain, fever and debilitating illness. That’s what happened to Vicki Doriot, profiled in and MSNBC article about the new procedure:

“When those toxins are in your body, you kind of feel like you’re close to death,” said Doriott, 52, an accountant from Eau Claire, Wis., who spent nearly six months battling recurrent bouts of the nasty intestinal bug known as C. diff…

“At its worst, I’d have diarrhea every 15 minutes,” recalled Doriott. “I’d be going for two or three days. I’d have a 103-degree fever. I couldn’t make it two steps from the couch.”

C. diff is caused by powerful antibiotics, but it can be cure by other, equally powerful antibiotics. Unfortunately, a new dimension of C. diff disease has emerged: drug resistant C. diff. Up to 20% of new case of C. diff illness are caused by drug resistant bacteria. There has been some success in treating drug resistant C. diff by using newer antibiotics, but there remain some patients who cannot be cured with antibiotics.

Since C. diff infection is invariably the result of antibiotic treatment that destroys the normal bacteria of the intestines, some scientists and doctors have reasoned that restoring the normal bacteria could allow the body to heal itself. Yet it is not as simple as isolating one or two different kinds of bacteria to use for replacement. It is the complex interaction and interrelationship between many different kinds of bacteria that prevents the overgrowth of C. diff. And where can you find a combination of the right bacteria in just the right proportions? You guessed it … in the gut of someone who does not have a C. diff infection.

That’s how they hit upon the idea of a “fecal transplant.” Not surprisingly, only those patients who are desperately ill are willing to try fecal transplant. That’s what happened to Doriott:

After months of exhaustion and illness, Doriott became desperate enough to consider the fecal transplants she’d heard about through research…

Typically, patients ask a close household member, usually a spouse, to produce a sample of stool, which is tested for disease and infection. In Doriott’s case, her husband, Jerry, 50, a civil engineer, was on tap.

On the day of the transplant, donors provide the feces, which is blended and filtered. A tube is fed through the patient’s nose into the stomach and several teaspoons of the sample are injected through it.

“I refused to look at it,” said Doriott. “All I felt was a coolness. It didn’t smell.”

Doriott said she felt better immediately and hasn’t suffered a C. diff relapse since the treatment…

There have been enough patients willing to undergo the procedure that a formal study has been published:

A 2003 case study of 18 patients who received fecal transplants found that two patients who were very ill died shortly after transplant. But of the remaining 16 patients, only one developed C. diff again, according to the study published in the Journal of Clinical Infectious Diseases.

The use of fecal transplant is reminiscent in some ways to the early treatment of other serious illness. Before insulin was identified as the missing component in diabetes, scientists showed that an extract from ground up pancreas was able to cure diabetes in dogs. Eventually, insulin was isolated from the extract, and that became the standard treatment.

Ultimately, doctors and scientists will probably be able to determine the most important intestinal bacteria that need to be replaced in order to treat C. diff infection, and fecal transplant will be replaced by biotherapy with bacteria grown in sterile culture. Until then, though, this primitive form of biotherapy will have to do. It may be gross, but it is a literally life saving therapy, based on sound biologic reasoning, that allows a body to ultimately heal itself.

 Mothering is marked by transcendent moments. I’ve had those moments while nursing my infants, watching my children in school plays and sports, and looking on proudly as they crossed the stage for graduations. This, however, is not about those moments. This is about teaching children the facts of life.

As a gynecologist, I always vowed that I would not subject my children to agricultural theories of human reproduction. None of that “daddy plants a seed” stuff for us. I planned on anatomically correct, age appropriate, completely truthful answers to any questions about sex. Each of my children learned where babies come from as soon as they asked, and each child got some version of “the talk.”

There were occasional complications; one child received his “talk” in a car at highway speeds. He was so embarrassed by the entire issue of sex that he always ran away when I attempted to discuss it. Only by giving him no option of escape could I make sure he learned the basics.

I was also motivated by my experiences as a practicing gynecologist. I have seen first hand the results of the mistruths, half truths and outright lies that pass for “information” among teens. The staggering toll of this misinformation is measured in unplanned pregnancy and sexually transmitted disease. Often teens lack basic information because no one ever bothered to tell them the truth about sex, about birth control or about protecting themselves.

Whenever I talked about sex with my young children, I had the best of intentions. So why did I often end up answering completely unanticipated questions while struggling desperately not to laugh?

***

While cooking dinner one evening, I was approached by the youngest of my four children. She asked, “Mommy, do you remember all four times you had sex?” I tried to look thoughtful while biting the inside of my cheek in an effort to avoid laughing.

“Actually,” I said, I’ve had sex more than four times.”

Her eyes widened. “Why would anyone do that?”

“Sex is not only for making a baby,” I explained. “Most of the time people have sex because they enjoy sex itself.

She thought for a bit and made a face. “Really? I can’t imagine why.”

***

I wasn’t the only one to have awkward moments. When one son related misinformation he learned from friends at school, my husband pulled out the children’s book “Where do I Come From?” He sat the two youngest children down to read it with him. The book contains excellent explanations that made it clear to my son that what he had heard at school couldn’t possibly be correct. My husband was very proud of how he had handled the situation … or he was until “the question.”

Our son, an angelic boy of eight at the time had a big smile on his face. “I understand now,” he said happily. “I just have one question.”

Pointing to his little sister, he asked: “Can she and I practice this at home, so we’ll know what to do when we get married?”

***

My favorite story, though, is not my story at all. It was told to me by two friends, both physicians, who shared the philosophy that sex should be described truthfully in an anatomically correct way. They carefully planned the “talk” with their youngest daughter and were pleased at how well it had gone. She, too, appeared to understand, and she, too, had only one question.

“I just want to know,” she declared, “how after the man takes off his penis and puts it in the woman to make a baby, how does he stick it back on his body?”

Last May, our small town was roiled by what, for us, was a scandal of major proportions. A new and attractive high school teacher checked her cellphone to find a message from a student. The student was known as a practical joker, but that did not prepare the teacher for what she found: a sexually explicit photo of the student accompanied by a text message that seemed menacing.

The teacher was so frightened that she approached the local police and requested a restraining order against the student. Once that process was put in motion, the high school was forced to act in accordance with legal guidelines. The student, popular and accomplished, was suspended from school and prohibited from attending graduation, planned for the following week. In addition, the college he was planning to attend was notified, as well as the scholarship committees that had awarded him scholarships. Those scholarships were promptly withdrawn.

The student had a defense; he couldn’t have done it because he had lost his cellphone several weeks before during a trip down South. It contained nude photos he had taken of himself to send to his girlfriend. Whoever had retrieved the phone had sent those photos to his contact list. Why had the teacher’s number been in the student’s phone? He had an answer for that, too. He was the president of a school club and the teacher was the faculty advisor. She had given him the phone number to discuss club matters.

Many parents found the explanation absurd. “Who keeps nude photos of themselves on their cellphones? I asked my college age children. “Lots of people,” was the response. That’s how I learned about sexting.

According to the study, Sex and Tech, released today by The National Campaign to Prevent Teen and Unplanned Pregnancy in collaboration with Cosmogirl.com:

One in five teen girls (22%)—and 11% of teen girls ages 13-16 years old—say they have electronically sent, or posted online, nude or semi-nude images of themselves…

Teen girls are not the only ones sharing sexually explicit content. Almost one in five teen boys (18%) say they have sent or posted nude/semi nude images of themselves. One-third (33%) of young adults—36% of women and 31% of men ages 20-26—say they have sent or posted such images. 

Teens are notorious for their poor judgment, and one reason for this deficiency is the inability to perceive both short and long term consequences of their actions. According to a local Virginia ABC affiliate:

The risque game has very real consequences. “The phones these days are like very good so they can just like send it to the Internet and they can put it on MySpace and other people can save it so it’s like all over the place,” said a seventh grader… 

The kids said very often it starts as a girlfriend sending a boyfriend a picture, but then they break up, he shows a friend and it quickly gets forwarded around…

Who could have seen that coming?

The long term consequences can be even more severe. According to an article in today’s Boston Globe:

Two cheerleaders near Seattle were suspended recently when nude pictures of them spread through their school via cellphone, and last week a Wisconsin teenager was charged with exposing a child to harmful material for showing classmates nude cellphone pictures of his former girlfriend and other girls. At least 10 students were suspended from a Michigan high school in October for spreading a nude cellphone picture of a classmate.

In Salem, principal William Hagen did not discipline any students involved, but warned that future infractions would carry sanctions…

“We educated the kids about the long-term and short-term consequences,” Hagen said. “Once they’re posted electronically, they’re out there forever. They’re available to colleges and universities. They’re available to employers…”

In addition, it’s a felony for children under 18 to receive sexually explicit pictures on their phone, and taking sexually pictures and sending them could lead to charges of pornography production and distribution.

The Sex and Tech campaign has published a list of “5 things to think about before pressing ‘send’.”

1.      Don’t assume anything you send or post is going to remain private.

2.      There is no changing your mind in cyberspace— anything you send or post will never truly go away.

3.      Don’t give in to the pressure to do something that makes you uncomfortable, even in cyberspace.

4.      Consider the recipient’s reaction.

5.      Nothing is truly anonymous.

The resolution of our high school’s sexting incident was sobering. The boy’s family hired a lawyer who obtained the phone company records for the day in question. The call had originated down South several weeks after his phone had been reported stolen, just as the boy had claimed. The principal wrote a public letter of apology to the student; his college was informed and his scholarships were reinstated.

Despite the apparently successful conclusion, there has been a legacy of bitterness. Friends of the student lashed out at the teacher, claiming that she overreacted. The teacher felt that the school had not provided her with support during her ordeal. The student was left angry, embarrassed and in possession of large legal bills.

Sexting exists at the intersection of poor teen judgment, sex and technology. These days, that’s a dangerous place to be.