When politicians get involved, the real losers are usually ordinary, decent folk. As physicians, you are called to bring reason and science into public discussions. Again, the following "women's health issues" unit is non-testable.

ESTROGEN REPLACEMENT: In summer 2002, the first big prospective randomized study of the health effects of estrogen-progesterone replacement was stopped early because the treatment group was having more cardiovascular problems and breast cancer than the controls. Especially the cardiovascular effects were opposite to the "conventional wisdom" that replacement is beneficial. If the conventional wisdom is indeed incorrect, perhaps it reflects that women who go to the doctor more often are both healthier and more likely to receive hormone replacement. Gee whiz. Watch this business. Another study found that replacement increases the risk for venous thrombosis and gallstones (JAMA 288: 99, 2002), without much beneficial effect on fracture risk. The fact that there wasn't an impressive impact on fractures obviously results from the study covering only a few years, which was stupid, and the slightly higher mortality rate in the treated group doesn't look statistically significant. The media parlayed this into estrogens causing tremendous cardiovascular risk, and there will be trouble for the next several years over this.

THE BENDECTIN FIASCO: The United States pays the price for its tort system and ignorance of science.

In 1983, the best drug for severe nausea and vomiting of pregnancy (doxylamine, marketed with pyridoxine as "Bendectin" by Merrell-Dow) was withdrawn because of lawsuits alleging the medicine had caused babies to be born deformed.

The hoopla followed an exposé in The National Enquirer (1979). The principal researcher alleging that Bendectin was a teratogen was denounced by his own co-workers as a blatant fraud (JAMA 263: 1468, 1990). Other animal studies supposedly demonstrating teratogenicity found similar effects for sugar and tap water, but could not show a teratogenic effect for thalidomide (JAMA 264: 569, 1990). The NIH epidemiology found no link whatever (Teratology 40: 151, 1989). I found a single recent abstract (89300349) alleging a link, and it is an sorry effort from the former Soviet Block, where there has been no real biology since nature-mystic Thaddeus Lysenko oversaw Stalin's extermination of his country's honest biologists. However, as late as mid-1994, a jury awarded $19 million to a kid whose mother (Ms. Daubert) took Bendectin; the kid's only problem was common clubfoot. Last case thrown out: Science 267: 167, 1995.

Almost all the other lawsuits were unsuccessful, but had placed a tremendous burden on the corporation. The whole business went to the Supreme Count, which in 1993, in a solid, landmark decision ("Daubert vs. Merrell Dow"), required judges to bar junk science from their courtrooms (JAMA 270: 423 & 2964, 1993; Science 261: 22, 1993, thanks Mr. Justice Scalia). Good luck. Nowadays, nobody is going to market a drug for use by pregnant women, or a vaccine, or anything else that invites silly lawsuits. As usual, it is the people who are really sick who suffer.

THE PAP SMEAR FIASCO: The United States pays the price for its tort system and ignorance of the limits of screening.

The pap smear for cervical cancer was designed as an inexpensive screening test. The key was "inexpensive". The consensus among pathologists is that a 10% false-negative rate is quite acceptable, and if it's that low, probably even good practice. (College of American Pathologists, cited in Path Yearbook 1994 p. 42). The idea was that the test should be repeated frequently, in case the technician misses a few cancer cells on one slide.

Unfortunately, the lawyers and militants got into the act in the mid-1980's. ("Murderers" missed a few cancer cells on pap smears; this is likely to be fatal only if the women aren't screened as often as they should be.) The price of a "pap smear" rose from $5 to over $50 because of all the regulations; I haven't seen anything to suggest that quality is better, and "to save money", lots of gynecologists switched to a one-slide specimen, which means less sensitivity but much better cover-your-butt. The result, of course, was that the test became unavailable to the underclass women who are at greatest risk, and the rate of invasive cancer of the cervix has increased. See Med. Care. 30: 1067, 1992; Acta Cytol. 36: 461, 1992.

FEMALE GENITAL MUTILATION: ("female circumcision"); Women in the world's poorest nations suffer, while the rich nations ignored a horrible problem for ideological reasons.

The custom is most common in Africa, where some people believe it ensures a woman's chastity and, after she is married, her fidelity by reducing sexual pleasure.

-- Br. Med. J. 313: 1103, 1996.

Until 1992-4, the abominable practice of female circumcision was a taboo subject, thanks to the politics of the era. In 1994, the medical literature (until then, strangely silent) suddenly was filled with physicians saying the obvious: FEMALE CIRCUMCISION IS A CRIME AGAINST HUMANKIND.

What is female circumcision? It's a "cultural practice" to which around 100,000,000 living human females have been subjected, mostly in Africa north of the equator. For example, almost every human female in Somalia is circumcised. It involves the surgical amputation of the clitoris, sometimes with the surrounding tissue, part or all of the labia majora, and/or the labia minora. Sometimes the introitus is sewn shut with needle and string, and the new husband cuts the string when he buys the wife. It's usually performed on children, often with no anesthetic. What's the basis for this "cherished traditional cultural practice"? The intent, of course, is to make the girl less interested in sex, and less able to do it, so that she will be a virgin when she is ready to marry and will therefore get more money for her parents.

Complications include huge dermoid cysts arising in the scar, loss of sexual pleasure, inability to menstruate, inability to have intercourse, pelvic and back pain, chronic pelvic infections leading to stones and hydroureters, stitch abscesses, traumatic neuromas, reopening of the incisions, pain on intercourse, vesicovaginal fistulas (dribble continuously), and catastrophic problems with delivery of children. Every one of these is common. Unlike male circumcision, there are no health benefits whatsoever. Opposition to female circumcision comes from mainstream Islam (Saudi Medical Journal 21: 921, 2000, thanks) and Christianity, and even the WHO, which in 1992 (after knowing about the problem since its founding, of course) finally condemned it officially (Eur. J. Ob. Gyn. 45: 153, 1992). Here's a reading list on female circumcision, including a few pieces by Leftists who ask, with a straight face, whether concern for health can ever override "multicultural sensitivity":

• NEJM 331: 712, 1994 (godawful pictures, review article)
• Can. Med. Assoc. J. 148: 288, 1994 ("when medical ethics confronts cultural values"); follow-ups 149: 16 & 1382, 1994.
• Br. J. Ob. Gyn. 101: 92, 1994
• Am. J. Ob. Gyn. 169: 1616, 1994
• Holistic Nursing Practice 8: 70, 1994
• J. Postgrad. Med. 38: 136, 1994
• Soc. Sci. Med. 33: 637, 1994 (even these folks, who are generally far-left-wing, are suddenly against female circumcision)
• Lancet 352: 126, 1998: The women of Africa replace the knife with "circumcision by words", a coming-of-age ceremony for their daughters.
• KC Star May 3, 1996, front page. Women claim political asylum, saying that if they are returned to Togo, they will be forcibly circumcised. Includes some very curious statements by proponents of this "cultural practice".
• Lancet 351: 121, 1998: Egypt finally makes the practice illegal. Its "conservative moralists" are outraged.
• Lancet 356: 137, 2002. Ethiopian tribes are still doing it.

Plastic and laser surgeons are able to help these women: Am. J. Ob. Gyn. 187: 1550, 2002.

More changing times: Only during the mid-1990's did it become politically acceptable in the USA to talk about the endemic of violence against women in sub-Saharan Africa. The problem was and is unbelievable: JAMA 279: 625, 1998; Lancet 371: 15, 2008 (rape as a weapon to demoralize civilian populations in collapsed society of the former Belgian Congo); Lancet 373: 1966, 2009 (one girl in three in Swaziland suffers sexual violence before age 18, often by family, friends-of-family, or in school.) Ninety-one Sudanese women who had been rendered totally fecal-incontinent from sexual violence: Lancet 354: 2051, 1999. "What are the human rights of a teenager who is the third wife or a man the age of her grandfather who will not allow her to use contraception even though her last confinement nearly killed her?" (Br. Med. J. 321: 570, 2000). In some communities in Pakistan, it is considered "honorable" to kill your daughter if she wants to make her own choice about who she marries (BMJ 338: b1221, 2009); there are dozens of such killings each year. It seems to me that "cultural practices" or no, something is wrong if it interferes with people's health. The Taliban's oppression of women, and the resulting impact on women's health, was frightful: JAMA 280: 449, 1998. The extent of Saddam's organized violence against women, especially against Shi'a women between 1991 and 1993, is astonishing (JAMA 291: 1471, 2004).

ATTENTION TO WOMEN'S PROBLEMS: Right or wrong, it's human for each individual to interact differently with males and females, even when pursuing gender-neutral activities, and in this regard, every human being's behavior is different. Where things go wrong is when fairness is compromised, as in the old days, when medical schools wouldn't take women "because they'll just get pregnant and then never practice." That really happened, and happened frequently. Things are better since the 1950's ended, at least in this regard. Thankfully it's now possible to punish those who really commit sexual harassment, which has historically been the bane of a professional woman's existence, in the health-care setting and otherwise. But there's still a tendency by physicians to thoughtlessly ignore health problems specific to women. In one chart review (at an M.D. institution, mind-you), housestaff (male and female) doing history-and-physicals almost never asked about pap smears, mammograms, or breast self-exam, and were only half as likely to do breast exams (35%) as to do a rectal (70%). When I was a med student, I was, to my knowledge, the only one who discussed breast self-exam with every adult female patient. See Academic Medicine 68: 698, 1994. There's plenty of evidence now that women get under-treated, or at least get less treatment for the same things, as do men. See, for example, Am. J. Psych. 150: 1309, 1994 (on being human, as well as disparities in care), JAMA 268: 1872, 1994 (women alcoholics get less care than men), Arch. Int. Med. 152: 972, 1994 (women with myocardial infarcts get treated less aggressively; the latter effect might be due to women being better protoplasm and less sick than men: NEJM 330: 1101, 1994). Hip arthroplasty: NEJM 342: 1016, 2000. Reperfusion in heart attack: NEJM 342: 1094, 2000. Docs: Unless you want Uncle Sam to get involved, you need to do something about this yourselves. And this should come as no surprise: In India, where most families supposedly want sons rather than daughters, three girls die of diarrhea for every boy (Br. Med. J. 327: 126, 2003). South India has by far the highest known suicide rate of anyplace in the world; most often, it is a young woman who commits suicide rather than be forced to marry a man she hates (Lancet 363: 1117, 2004). Women in many traditional societies commit suicide to avoid forced marriage or escape domestic violence (NEJM 358: 2201, 2008). Click here for the Archbishop of Canterbury's remarks after England passed an act protecting its women from forced marriage. This was quoted out of context by outraged militants of various kinds, result in a world news story.

IN-VITRO FERTILIZATION: Some people say it's your inalienable right to have Uncle Sam pay for it, while for others, it's anathema on religious-ideological grounds. Averages: To get one born baby when all the factors are favorable, somebody will pay $50,000 if it works the first try; when there's male-factor infertility and five previous failures, the cost is $800,000 per baby (NEJM 331: 239, 1994). I bet third parties (Uncle Sam, managed care) won't pay for this.

FETAL MONITORING is fancy-tech, and since it's available, the savvy physician has to use it to cover his butt. However, the benefits to the human race are by no means apparent, and people are finally getting up the courage to say so (Can Med. Assoc. J. 148: 1737, 1994; J. Fla. Med. Assoc. 78: 303, 1994). Even the American College of Obstetricians and Gynecologists has come out with a statement that listening occasionally with the stethoscope is every bit as good as hooking up a monitor (Ob. Gyn. 76: 1130, 1994; this has held up). There are more muddy-the-waters technologies on the horizon; there's no reason yet to think they'll do much to help patients, though they'll surely increase health-care expenditures and incomes (Curr. Op. Ob. Gyn. 5: 647, 1994; Br. J. Ob. Gyn. 100: 733, 1994). One fancy intervention ("home fetal monitoring") didn't seem to do much that simply explaining things to the patient didn't (Am. J. Ob. Gyn. 164: 756, 1994). This trend has continued to the present; in the "managed care" era, the decisions of obstetrician-gynecologists about which technologies to use are a curious subject (Am. J. Ob. Gyn. 188: 162, 2003); a Canadian group points out the obvious fact that "defensive medicine" can itself generate income for physicians (Soc. Sci. Med. 51: 523, 2000), etc., etc. Especially welcome is the loss of the fetal scalp blood monitor as a standard of care.

Androgens for female sexual dysfunction / low libido: Mayo Clin. Proc. 79(4S): S-19, 2004. No joke -- when one partner loses interest in sex, the effect on a marriage is often devastating.

Goya's sketch of women resisting

For more on the vile crime of RAPE, check the current literature. There are around 20,000 convictions per year in the USA for adult rape, and 23,000 for child sexual abuse. Examining and treating the woman who has been raped: NEJM 332: 234, 1995; Ped. Clin. N.A. 46: 809, 1999. Dudes: Forcing yourself on an unwilling woman is the most un-masculine thing you can do. Most rape is committed by an acquaintance, and (despite what's below) I suspect most rapes go unreported, which is bad. "Roofies" is flunitrazepam ("Rohypnol"), which when added to her drink makes rape easy (review South. Med. J. 93: 558, 2000). One bizarre article even cites industry-specific rates for being raped by a co-worker (Am. J. Pub. Health 84: 640, 1994). Under the common law, a husband may lawfully penetrate his wife without her consent; this is changing. The serial rapist generally starts shortly after puberty, as a stupid-hurtful way of expressing anger. The first victim is usually an acquaintance. In most jurisdictions, rape means putting any part of his penis into any part of her body without her consent. He doesn't have to have an erection, he doesn't have to ejaculate, it doesn't have to be her vagina, it doesn't matter if she's known to be easy, or if she consented last night, or if she happily took off her clothes and got in bed with him, or was petting for a long time, or if she just teased him, or said she would and then changed her mind, etc., etc. A man can get raped, too. A mentally-retarded or very crazy person cannot lawfully consent, no matter what her age. Dudes: if she changes her mind later, and says you raped her, it's her word against yours. Nowadays, the law and public opinion are stacked against you in this (and many other situations, too) simply because you are a man. For example, a judge isn't even allowed to remind a jury that it's easy to bring a false accusation or rape, and hard to defend against it, and the defense may not even be allowed to present evidence that a particular woman had already made a previous false allegation "because it might inflame the jury" (Arkansas Supreme Court, Ralph Taylor). "Rape shield laws" forbidding any discussion of the accuser's previous sexual history have been interpreted to include the accuser's currently facing criminal charges for having consensual sex with minors (Charles Steadman, 1993). In some juristictions, the law specifically allows that a man can be convicted of rape solely on the uncorroborated testimony of an accuser, without any physical evidence whatsoever. This results from litigation from the 1970's prompted by militants, including the author of "Against our Will: Men, Women, and Rape", whose mentality is illustrated by her statement that rape is "nothing more or less than a conscious process of intimidation by which all men keep all women in a state of fear." Be careful, dudes, especially around people you don't know aren't "fantasy-prone" or worse. However, until 1994, the subject of "factitious rape", i.e., a woman making a false accusation, was a forbidden subject in the medical literature for political reasons, and patently false ideology ("No woman would lie about something so personal"; "The FBI has proof that only a few percent of claims are false", etc., etc.) dominated discussion. We have known about this since the time of Potiphar's wife. A major article by the US Air Force Office of Special Investigations that got no attention at the time appeared in Forensic Science Digest 11(4): 64, December 1985; of accusations of rape brought in the Air Force, a panel of three reviewers unanimously agreed 60% were false, with many of the women recanting before or after failing a polygraph. The landmark article appeared in Arch. Sex. Behav. 23: 81, 1994. Now that we have DNA testing, it's become clear, in retrospect, that plenty of men serving prison time for a particular rape didn't do it (KC Star March 13, 1993 was the first in what has now become a frequent feature of new stores.) The now-classic 1996 article from the US Department of Justice "Convicted by Juries, Exonerated by Science" cited a statistic of 25% for cases in which DNA specifically excludes the accused; this does not include those for which results are indeterminate, and of course it does not exclude the possibility that the sex was consensusal (remember the defense in the Kobe Bryant case). By 2008, there have been over 200 convictions overturned -- all men were serving long prison terms. This is in keeping with my own experience doing exams, which range from godawful cases of genuine rape to women trying to get out of a non-rape abusive situation to malicious women simply trying to get a particular man in trouble. The latter works. My reading of law articles indicates there are perhaps 33,000 false accusations of rape per year in the US, primarily against African-American men. "Rape counsellors": Before you tell her absolutely to... please be sure that.... Your lecturer doesn't take anybody's word on anything any more, in the absence of physical evidence. He also considers himself a macho-man, and hopes that the same science that should protect a man against a false claim of rape will also bring real perpetrators to justice. For "Factitious rape", see South. Med. J. 87: 736, 1994; Arch. Sex. Behav. 23: 81, 1994 (the latter found 41% of police rape accusations to be false; my informal series in 1982-3 was at least this high). Self-inflicted wounds by a women claiming to be raped: Am. J. Forens. Med. Path. 20: 374, 1999; Med. Sci. Law. 38: 202, 1998. Wood's lamp is notoriously nonsensitive and nonspecific in looking for semen: Pediatrics 104: 1342, 1999. Examining the clothing can support a claim (saving the woman a terrible ordeal) or refute a claim (saving the man a terrible ordeal) -- the authors of this paper talk about the "sensitive" politics: J. Forens. Sci. 45: 568, 2000. The false memories syndrome has produced women who accuse both family and physicians of terrible crimes -- for a case of a woman with uterine agenesis who "remembered" incest, a resulting pregnancy, and a resulting criminal abortion by a particular physician: J. Ped. Adol. Gyn. 11: 181, 1998. (A few years before, it would have been extremely difficult to defend against this accusation.) As I mentioned, you will find nothing whatsoever on this very important subject in the English-language medical literature before 1994.

Current dogma in "child sexual abuse" circles is that a normal physical exam is consistent with any manner of horrid abuse, including recent full penetration of a baby girl by an adult male's erect penis. This strange idea is based on misrepresenting the actual data from an article in Pediatrics 94: 310, 1994, rebutted Pediatrics 97: 148, 1996. The best study so far on healing of the hymen (Pediatrics 119: e1094, 2007) does document that it heals well, like the buccal mucosa, often without marks. Even an 8-month-old girl healed with only neovascularity at the site of previous transection. Of course, this makes it much more difficult to defend against a coached accusation. A problem that I have with this paper, which will be of great importance in sex-abuse trials in the years to come, is a strange selectivity in discussion of the data. Despite all the talk about how well the hymen heals, and how even the worst trauma can heal without a trace, a look at the data shows that of prepubertal girls sustaining transection/laceration (i.e., what you might expect after full penetration -- and 16 of 39 children sustained these severe injuries), the vast majority did NOT heal either smoothly, continuously, or "delicately". The medical profession needs to do something about this, now, despite the political climate.

The term "commercial sex worker", now the politically-correct term for "prostitute", was popularized by the Thai government. Free enterprise brought about "Thailand's economic miracle", which was based largely on sex tourism (Lancet 352: 246, 1998). Girls become CSW's to escape grinding poverty, and the majority pay with their lives when they contract HIV. This seems to me to be a very great evil, and not something we want to honor and dignify by changing our terminology. Thankfully, with the decline in "political correctness", the term is now changing to "trafficked women", re-emphasizing that these women lose their freedom, their dignity, and their health, especially when they are brought from the poor nations to the rich nations as sex slaves (Lancet 363: 564, 565, & 566, 2004).

Pathological Chess