Ad-monishments

I have a confession to make -and I almost feel like it should be done behind a curtain in a soft, contrite whisper to someone who promises not to tell… It’s not something of which I am particularly proud, nor is it something that might not resolve itself over time -I honestly hope it does- but for now, it is an albatross. What I am so hesitant to disclose is that I don’t like health product ads -especially intimate ones. No, that’s too tame, too polite. They offend me. Some of them, anyway.

It could be my age: increasing frailties with their incessant demands immediately draw my attention to remedies for aching backs, or wobbly knees. Still, that’s old news, and not particularly personal. I can tolerate them, but they are the thin edge of a rather large wedge. Next in line I suppose are the legion, fail-safe bowel aids offered by actors with far more wrinkles than I could possibly fit comfortably on my face. This verges on profiling: not all older people are constipated, although I have to admit that their skin is not the best.

Some ads, despite being personal are more bearable I have to admit. I don’t notice them as much online, for example; one develops a blind spot for things that flash, and focal deafness to pictures that address you personally when the little mouse arrow happens to traverse their otherwise invisible boundaries on the screen.

Ads are far more difficult to ignore on TV, though. They appear suddenly -and purposefully- in the midst of a particularly interesting segment of the program, and unless you are constantly on guard with a thumb hovering over the mute or channel buttons, they are hard to keep subliminal. And yet, to be clear,  it’s not ads per se that I am against; companies have to survive and people have to know there are choices.

No, it’s more subtle than that. My sense is that there are some things that should be kept private, left unsaid. Of course maybe my wish to shade certain problems -certain areas- from public interrogation is merely an idiosyncrasy. Maybe the world has a right to know that there is now an effective treatment for private itch, or off-putting personal odours. Maybe people nowadays feel comfortable sharing these types of things: advocating antifungal creams on their Facebook pages, or Tweeting the ecstasy of their newly discovered intimate online depilatories. But I don’t.

Fortunately, sometimes repetition breeds indifference. I no longer shudder during those bowel commercials, although they do tend to focus my thoughts. I’m a doctor though, eh? I’m supposed to transcend emotions when it comes to the gastrointestinal system -although I hasten to add that the system in which I pretend expertise tends to produce more babies than… well, you know. Perhaps I am more tolerant as well of male hair-removal products nowadays, although I do not understand the need, nor do I personally know anybody who openly aspires to metrosexuality. I am open to face-shaving products, however, and am always on the lookout for improvements that don’t involve adding more blades. My kids have promised to text me if they come across anything.

The line begins to harden when the ads step across gender lines. I’ll admit this is probably a guy thing -an over-fifty me-thing, even- but I struggle with advertisements about stuff I would rather not think about. Maybe I’m just being delicate or old-fashioned; maybe I just haven’t travelled far enough along the information highway; or maybe I’m simply being fussy and curmudgeonly, but I have difficulty with cheery messages about such things as, say, feminine hygiene products (as they have been euphemized to get them on television). And I am annoyed when I am forced to see female incontinence clothes being modelled on the screen as if they were summer shorts. Forgive me, but it strikes me that these issues should be prime topics at the next health care visit, not vaunted, not bannered for all and sundry, not foisted upon them unawares. Unchosen. That someone can actually skate, or dance wearing retention panties is probably a plus, but come on… There are treatments that preserve dignity and don’t involve diapers -even other non-surgical approaches- that the companies would rather obfuscate.

Now I realize that industry needs to publicize its brands, and they even seem to travel a parallel road to public health at times. The inference -the message- is often: ‘Don’t just complain about your problem; try our product.’ And then the disclaimer: ‘This product may not be right for you… Ask your doctor.’ But as one of them, I would still wonder why she had come to ask my opinion about her pants if she were not also wondering about some other treatment options as well. In fact, she may already have chosen what was best for her -she may be wearing the best brand- but I wouldn’t know.

So that’s why I think I have to get over my ad squeamishness. Get over this Western Medicine scientific approach stuff. Embrace the alternatives. Decondition my antipathies. After all, some day, I might develop a personal problem I’d rather not admit to the health clinic at the Home – an embarrassing stain when I laugh, say, or maybe an undue concern over the stability of my teeth. And at that age, I don’t think I’d go to a surgeon anyway… they’d all be too young to know what they were doing. The stuff I’d see on the little silent television mounted on the wall over the card tables, though -I mean what would I have to lose? Something I could slip on and wear unobtrusively at the next sing along would be just the thing… maybe I could laugh again. Safely.

Affairs of State?

What is it about les affaires d’amour that seem to capture our interest? Wave for our attention?  I am reassured by the activity in the world’s blogs -not to mention its press- that I was not alone in noticing the recent fuss around the alleged affair of the president of France. Adam Gopnik’s piece in the BBC News is, I think, one of the best reports:

http://www.bbc.co.uk/news/magazine-25756961

It suggests, at the very least, that I was not born with an unusual amount of prurience -if one can think of it as a personal quality akin to, say, courage, or agape. But is it just curiosity that attracts my attention to activities I have hitherto been unwilling to perform -and, now that I am not in a relationship, perhaps even definitionally unable- or something more basic? Primal? Contemptible?

It has been argued that sexual affairs mainly pique the interest of those who have not yet had the chance to indulge in them -those whose consciences are clear not because it is beyond their pale, but more beyond their skill. Or opportunity… Being somewhat virginal in this respect -or perhaps naïve would be a better term- I imagine I can be allowed to comment on them, albeit from a position of ignorance… and yet I don’t suppose there are any rules, are there? It seems to me that only someone with an absolute and unquestioned possession of what is right and wrong should be qualified to judge. We usually assign this role to a deity. None of my friends fit into this rather narrow slot; no one in political office for sure…

For that matter, are there any absolutes when it comes to morality? Apart from such obvious things as murder or child molestation -I’m only short-listing things, not closing the door- why do there seem to be so many societal discrepancies? Is it simply a ‘Well they’re not like us, so don’t listen to them?’ or something more profound?

‘When in Rome, do as the Romans.’ I grew up with this aphorism, for some reason. It was certainly not geography -Winnipeg and the vast Canadian prairies were my childhood homes- and yet what I interpreted it to mean was that if you were living in a place where they did things differently, try to fit in even if you didn’t understand. Even if you didn’t agree. They likely had a reason to which you were not -yet- privy. Hollande -being French- has been variously caricatured as ‘typical’, ‘selfish’, or even ‘amoral’. But it is as if the Romans -read the French- always behaved a certain way. Or worse, being told by a non-Roman that Romans behave a particular way. And even worse: being informed by a non-Roman who has never even been to Rome (but has read about it)… I don’t know, it’s too much ‘third-cousin-twice-removed’ information for me.

I think we have to divide the Media’s interest into two parts. First, is it acceptable to cheat on someone; and second, should people in authority be somehow exempt from such intimate and personal scrutiny? Is this merely -I used the word before- prurience? The answer to the first question seems self-evident: no. There may be circumstances where cheating is easier, circumstances where it just ‘happens’, even circumstances where it might be possible to keep it secret, but I’m struggling to think of circumstances where it is the correct thing to do. Full disclosure: I’m an avowed, life-long ethical relativist, and yet even my relativism sees a problem with this. For that matter, even a liberal interpretation of Kant’s Categorical Imperative (an action is correct only if you could accept everybody doing it) suggests that sexual affairs might be problematic. And I have to come down somewhere, don’t I..?  Or is it permissible to obfuscate? Delay until the subject is forgotten.. or at least until something else is front and center?

How about the need to examine those in power more carefully than their flock? Well, not more carefully –as carefully. We are, none of us, above criticism; none above personal scrutiny -not because of who we are so much as that we are. Whether a public figure should be judged for things outside of the public realm is not the issue. If whatever doesn’t effect performance or obligations, then it must be assessed separately. Judged separately. But like it or not, agree with it or not, it will be analyzed. We do not live in a vacuum and we all cast shadows that follow us around as long as there is light; it is in darkness where ambiguity proliferates and context is muddled. Mistakes are made in the dark… and rumours lie like fields of mud. Waiting.

And then there is the rather insulting question of whether the French are somehow… different. Do the French really have a societal acceptance of ‘affairs’? Are they somehow less titillating there than elsewhere? It seems to me more appropriate to ask the questions differently. All of us that are not French ask them from the framework of our own belief systems, our own closets. No matter their answers, we will interpret them as members of different Magisteria where words, not to mention values, imbue them with different colours, different shades of relevance. We all see the world through different parents, and tempered backgrounds. We braid our opinions with fragments of ‘other’ to be sure, but in the final analysis we are seldom them, as much as us… Our judgements can rarely be extracted from the warp and weft of where we live and how those around us think.

Most of us are still, sadly, prisoners in Plato’s Cave. Have the French alone escaped? Would we know?

The Wandering Womb

The science that brought you heart transplants, kidney transplants, and even lung transplants, is at it again -with a vengeance. Well, maybe I shouldn’t word it that strongly -I’m sure the folks that thought this one up assumed they were doing some good. And maybe they are… I mean, Science is good, right?

I’ve always believed that the world is filled with answers just waiting for the right questions. If there’s a problem, grab an answer, then look around for the appropriate question; you might get lucky. That’s how it used to be done… Too random? Well then create a problem nobody’s thought of. Then solve it. I can think of several transplant problems one might want to create and then solve. It might make sense to attempt to transplant bowels, for example -you never know when a new set might come in handy. Or how about eyes? They’re useful… And then there is always somebody looking for a new pair of ovaries. For that matter, limbs would be big -entire limbs, not just their parts.  Tongues..? The list goes on. But a uterus? http://www.bbc.co.uk/news/health-25716446

I have to admit I am conflicted on this issue. On the one hand, it would seem natural for a woman without one to want one -a uterus does all sorts of important stuff: carrying babies springs immediately to mind. But hold on. A uterus placed in someone else’s body is in a foreign country. It is a stranger at a family party and after being roundly embarrassed and then exposed as someone they don’t know, it is immediately rejected and shown the door. Explanations just don’t work under those circumstances without drugging the entire family into submission. And don’t forget, the uterus doesn’t merely show up because it got the wrong address; it was likely recruited for a specific and important job. No one orders a new one just to re-create the painful periods of their youth, nor in order to keep a ready supply of fibroids on hand.

No. Odds on, it will be recruited as a biological isolette. An incubator. But fetuses are notoriously sensitive to chemicals as they are developing and so what keeps the incubator alive and well, had better have a similar effect on the incubee. And the only way to keep the body from destroying the transplanted uterus is with anti-rejection drugs -immune-suppressors- which are toxic. Swords of Damocles.

Obviously a similar situation obtains with a transplanted kidney going through pregnancy -it needs immune suppression, too. But although the demands on kidney function change with the constantly moving target of pregnancy requirements, one might argue that there are some fundamental differences that separate kidney function from uterine function in a pregnancy.

First, there is the obvious need for a fertilized egg to actually implant itself in the wall of the stranger -this is the bond that ultimately creates the placenta which in turn nourishes the developing fetus. I can’t imagine this is easy at the best of times. So, the uterine muscle must have a smoothly functioning mechanism to allow an attachment that is not impeded by any inflammatory response from the immune system, or inhibitory effect by the drugs. It has to be a strong and functional union because that union will have to allow for the growth and changing metabolic and nourishment needs dictated by it’s totally dependent passenger for the entire pregnancy: a Gordian knot…

That uterus will also have to grow as the baby grows inside it. Grow -not merely stretch. Too much stretching without concomitant growth might irritate the muscle fibers and cause them to do what muscles all over the world have been taught to do under the circumstances: contract. In obstetrical terms, this is sometimes known as labour… Admittedly, hormones from the placenta and who knows where else will normally have a role to play in keeping the uterus relaxed and quiet -coordinating things. But a transplanted uterus, already confused by its new digs and having to contend with a whole bagful of noxious chemicals may well react differently: like an already rebellious teenager in a new and (maybe) abusive foster-home… (Uhmm, okay that metaphor was probably a bit of a stretch as well…)

And if the pregnancy actually succeeded and made it to an acceptable state of viability for the baby, a Caesarian section would be necessary -I can’t see the uterus cooperating sufficiently to agree to any kind of productive and efficient labour. That’s fine, of course: under the circumstances a Caesarian delivery would likely be the safer option. Perhaps even a Caesarian hysterectomy, because I suspect the uterus would only be a single use entity after what it would have been through and so require removal anyway.

So, what am I saying? I suppose the first thing is that I congratulate the surgical teams for their success in many of the transplants so far and I wish them and the recipients the best of luck. It was inevitable that someone would try it some time, I guess. But remember, successful transplant does not necessarily imply successful function. I have to admit that it is a procedure I will watch with much interest, but from the corner of the room. If all goes well, it will surely be a boon for those women who have lost their uteri through surgery or disease, or even in the genetic lottery that occasionally intervenes so tragically in some lives. Until now, I suppose, adoption would have been the only option, but I understand the wish to gestate one’s own baby with one’s own eggs and in one’s own body.

Maybe, someday, uterine transplants will be viewed much like heart transplants… and yet they are not. Let us not forget that unlike hearts or kidneys, unlike lungs or livers that are transplanted only in extremis and when all other less drastic options have failed, with uterine transplants, survival of the recipient without the organ is not at stake; survival of the baby in utero is, however. And it’s not just survival, we’re aiming for either… It’s the healthy survival of an initially normal fetus that has developed and grown in an abnormal environment. Heaven only knows, enough can go wrong in a normal uterus -even with the best of care- let alone one stitched in place and clothed in chemical soup.

Perhaps I’m viewing this as an elder who has seen many promising ideas go badly wrong -think, for example of thalidomide and the developmental anomalies it produced in fetuses. Or DES for threatened miscarriages that resulted, among other things, in clear cell carcinoma of the vagina. So my advice is one of caution. Just because we can do it, doesn’t mandate that it must be done… Should be done. Ideas come and go -that’s what they’re for after all; it’s how we make progress. Improve things… But in this case, the results may influence -even malign- future generations; the results may be future generations. Let’s get it right -we’re not just dealing with kidneys here.

The Night of the Undead -Condom, that is… (female condom, I mean)

They’re back! Well, sort of… My somewhat sketchy memories of them -professional, you understand- are that they resembled the plastic bags you get at a supermarket… not female condoms (FC1s). They didn’t look at all like condoms! In fact, I still remember the jokes about needing Walmart greeters on entry and theft alarms on exit -this from the women themselves. No one seemed particularly enamoured of the concept: they were apparently made of polyurethane and quite apart from the distracting noise they made during use, they were ungainly not to mention unsightly. To use one at all required unprecedented devotion to the product and a fair amount of lead time…

Ahh, but they’re back; this time with fresh clothes: the new and apparently improved FC2 is made of non-rustling synthetic latex (as reported in the BBC News magazine : http://www.bbc.co.uk/news/magazine-25348410 ). I mean, the concept is a good one: empower the person who would suffer most from a pregnancy -the woman. And the article cites other advantages of the device as well: ‘They can be inserted hours before sex, meaning that there is no distraction at the crucial moment, and they don’t need to be removed immediately afterwards. For women, there is better protection from sexually transmitted infections, since the vulva is partially covered by an outer ring that keeps the device in place.’ All well and good; hard to argue with that… I guess.

Perhaps I am being overly critical, but I begin to sense a car salesman approach to a more professional selection in an article recently published in Lancet Global Health about three new models of the female condom: ‘The Cupid is available in India, South Africa and Brazil. It is vanilla scented and comes in pink or natural colours. It is currently the only model besides the FC2 to have been qualified by the World Health Organization (WHO) for public-sector purchase. A smaller version aimed at the Asian market is in trial.’ I suppose anything you can do to spruce up a classic is worthwhile if it makes it more desirable…

Innovation is what drives industry and no doubt adding variations to something I hadn’t even thought about for years, will appeal to a new and younger audience. A different audience. Several models -or at least their names- tweaked my interest. One, called the Air Condom -apparently available in Columbia- has a little pocket of air somewhere in it to make it easier to insert. And then there’s the Panty Condom (gotta love the name) that ‘is packaged with a special pair of knickers’ to keep it in place. Wow. That’s gotta appeal, eh?

But is merely sprucing up an old idea enough? I can’t help but wonder why the female condom never achieved much success in the first place. Is making a re-usable product -as some have suggested for poor countries- the answer? Or even an answer? I mean, would you hang it on the line to dry..? There must be something vaguely anathema about it -something subtle, perhaps embarrassing: something unsettling in the background. Or maybe it comes from the male partner and his unwillingness to countenance it. Who knows..? It might be as simple and intuitive as the idea that it’s better to Saran-wrap the outside of a stick than the inside of a glass. Anybody’s guess, I suppose.

And yet, whether the female condom ever takes off (no pun intended) I think that all is fair in family planning. Anything that adds a little spice to it, or makes people realize they have options is good. There’s an article in the Huffington Post with an interesting variation on this theme: ‘To Promote Family Planning, Let’s Have More Controversy’ ( http://www.huffingtonpost.com/christopher-purdy/to-promote-family-planning_b_4174943.html ) In other words, if people are talking about it -whether positively or critically- they’re thinking about it. Discussing it …and publically! Even condemnation provokes worthwhile response.

A good example of this is another mention in the Huffington Post of the Gates Foundation awarding grants for ‘Condoms of the Future’: http://www.huffingtonpost.com/2013/11/20/gates-foundation-condom_n_4312699.html Make male condoms interesting; make them exciting; make them up front and used above all. So if men aren’t happy with female condoms, make them happy with the testosterone version. Let men think they’re the ones leading the fashion parade. Let them think they’re in control… As long as family planning is out there and -dare I say- sexy in the community at large, everybody wins. Maybe even a souped up multicoloured twenty-first century retro model like the female condom. Personally, I’d change the name…

Teenage Sexuality

It seems like every time I turn around nowadays, I learn something new about what my colleagues are doing -or not… A recent article published online in JAMA Pediatrics, Dec. 30/13 (abstract: http://archpedi.jamanetwork.com/article.aspx?articleid=1791584 ) suggests that we in the medical profession are not doing enough to disseminate information about sexual health -especially to teenagers. The study was from the USA (North Carolina), and so might not be universally applicable, but it got me thinking.

I suspect the problem is not confined to the study area reported; it is all too probable -if not understandable- in most countries, but Canada is the one with which I have the most experience, so let me begin with it. Teenagers in any country, are a difficult group: they are usually healthy and often unaccustomed to visiting a doctor except with a specific complaint to be resolved. The age difference between a teen and her doctor, or nurse, is usually significant and often an impediment to easy and trustful communication. And sometimes her world-view and experience clouds the risk and her own consequence-assessment of her behaviour -especially if others are engaging in it. Many have yet to learn from their mistakes…

Another not insignificant factor -at least in this country- is the frequent accompaniment into the doctor’s office of the teen by her mother. A totally understandable and laudable practice, at least a priori.  Sometimes it is to give the young girl confidence on her first visit, or to make sure that she asks the right questions and of course receives the correct answers. But it does make it difficult to delve more than superficially into the sexual history, contraceptive needs, and more particularly, issues surrounding normal, healthy sexual functioning: such things as pain, lubrication, orgasm or even partner expectations. There are a lot of questions that are both embarrassing and difficult for her to raise, let alone answer, with a parent present. A mother can be a two-edged sword…

And I suppose that one of the cardinal rules of medicine –Listen first, talk later– is also turned on its head with teen sexuality: teens seldom ask about it, in my experience. They’ll ask about contraception (sometimes) or sexually transmitted diseases -and more specifically whether or not I think they have one- but almost never about other sexually related concerns unless I ask them. Whether it’s because I am a male and generationally distant, or because they are too embarrassed to raise the subject -especially when the answers so obviously lie just a mouse-click away- I’m not sure. But I can say that when I do raise the subject, after a short, suspicious period of feigned indifference, most seem relieved.

As a male gynaecologist dealing with often nervous, and bashful teenage girls, the problem is usually finding a way to work into the subject of sexual health without alarming or further embarrassing the patient -the younger ones in particular. Indeed, wherever possible I try to have them seen by my female associates instead, recognizing that they may feel more comfortable dealing with another woman. No doubt this could be seen as an abdication of my responsibility to a patient in need of care, but in many cases it’s a more sensitive approach, and one that may ultimately prove more valuable and helpful to the teen at a particularly impressionable -not to mention vulnerable- stage of her life.

But in reality, and given the exigencies and problems inherent in finding available specialists, I realize that sometimes we -the patient and I- must attempt to transcend both the gender and the generational gap as best we can. And so, with regard to inquiries about sexual health, I try to fall back on experience and advice from my more seasoned colleagues. It’s usually inappropriate to inquire without a reason -it smacks too much of prurient curiosity even from a health professional. But sometimes it can be a careful addendum to questions about contraception. Or perhaps during the queries about some other problem for which they have sought help -pain, for example. I am often asked to see a young patient discovered to have an ovarian cyst (a not uncommon, but often painful result of irregular or absent ovulation in younger teenagers -benign, but nonetheless frightening). The discussion lends itself to asking if she gets pain with such things as exercise, bowel movements… or intercourse -a natural progression of embarrassing yet understandably relevant questions that allows further pursuit of the topic. A rather different approach is to embed the sexual questions in the lengthy and detailed initial history that allows the girl to see that you are being thorough -not intrusive. It is unabashed subterfuge, I admit, but in many such circumstances, the end does justify those means. Or is it just me?

So I can understand why it may seem that the sexual health inquiry appears to be absent or minimal -in the study at mentioned at the beginning, at any rate.  One must first achieve rapport -a relationship deemed to be both trustworthy and private- and this takes time; it seldom occurs on the first visit, and almost never with the mother present. It is a long-term goal and cannot be hurried. Even those admittedly tentative answers to the thorough and hopefully sensitive consultation history may need to be reconsidered -re-approached as it were- once she has come to know and trust you.

I think all of us in the position of health care advisers wrestle with these challenges and recognize that our goal in promoting teen sexual health should be to interfere less and to educate more; to facilitate her ability to make informed choices; to help her to recognize and avoid risks; and perhaps most important of all, to be sensitive to her growing independence and to let her understand that we celebrate it. Criticism will only turn her away. 

But we are all learning; communication between age groups and genders is often riven with inadvertent blunders and unplanned insensitivity. Words -questions- can be met with sullen withdrawal or sudden suspicion and mistrust. Anger. Rejection. Embarrassed silence… It was Oscar Wilde who said: Experience is the name every one gives to their mistakes. And yet we must never forget that experience teaches -even across generations. Rapport is not often given freely, it must be won, and its path frequently winds through a dark, mysterious forest of little mistakes.