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Archive for the ‘Health Care’ Category

There is a recently published article on Scientific American, “Are Men the Weaker Sex?” This article has been getting a good deal of attention in my Facebook feed. From the article:

Contrary to cultural assumptions that boys are stronger and sturdier, basic biological weaknesses are built into the male of our species. These frailties leave them more vulnerable than girls to life’s hazards, including environmental pollutants such as insecticides, lead and plasticizers (Source)

I agree with many of the things in this article, but I find it a little hard to read. It seems to be doing something similar to what Emily Martin identifies in “The Egg and the Sperm: How Science Created a Romance Based on Stereotypical Gender Roles.”

The article is full of normative comparisons of non-normative developmental events. For example, it says that the male foetal development is “more complicated” and that

In our species, the female is the default gender, the basic simpler model: Humans start out in the womb with female features (that’s why males have nipples).

Fair enough that ‘female’ is default, but does that necessarily imply “simpler?” Sure males have nipples as a result of vestigial similarities, but also (according to Elisabeth Lloyd) women have clitorises and orgasms as a developmental vestige of male reproductive function.

The article states:

The simpler female reproductive system has to turn into the more complex male reproductive tract, developing tissues such as the testis and prostate.

But is that empirically true that the male reproductive tract is “more complex”? Each seems to have their own unique complexities.

The whole thing kind of strikes me as a bit creepy. Can’t we acknowledge differences without trying to rank them as “more complex, “more advanced,” “simpler,” or “more basic?”

In fact, women and men evolve at the exact same rate. That is what sexual recombination is all about. One is not more simple or more basic and the other more complex or more advanced. This seems all kinds of distorted.

I am emphatically not saying that we should not look at particular vulnerabilities that men might face. I think we should. In addition, we should also look at particular vulnerabilities that women might face. I just don’t see why in doing so we have to rank these differences.

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For valentine’s day, I thought I would post something about preventing spousal violence.

Earlier this year, a Justice Canada federal study was released, which details the incidents and costs of spousal violence. There are some interesting findings from the study. For one thing, the study estimates that the costs of spousal violence are very high: an estimated 7.4 billion per year in Canada (and this is said to be a deliberately conservative estimate). The costs include things like legal bills, emergency room visits, lost wages due to time off from injuries, the costs of personal safety measures such as paying for call display to identify stalking spouses, and possible moving expenses to escape the spouse.

Here is the findings on the incidence of spousal violence as reported by The Toronto Star:

Drawing on a Canada-wide police database, researchers found almost 50,000 cases of spousal violence reported to police that year, more than 80 per cent of them involving female victims. The cases included 65 homicides, 49 of them women. (Source: Beeby)

Here is the break-down of the costs associated with spousal violence by gender:

Altogether, total costs were conservatively estimated at $4.8 billion for female victims and $2.6 billion for male victims. (Source: Beeby)

I think that is interesting. Note that according to the study, 80% of the victims of spousal violence are women and 20% are men, but violence committed against men accounts for 35% of the costs associated with spousal violence. The Star article does not describe why the costs are higher for men than for women. If I had to guess I would say that the higher costs are likely associated with the wage gap, since men earn more than women on average, their time away from work would be more expensive. But that is just a guess. Perhaps the issue is that men have more disposable income on average than women do, and so men spend more on their own protection than women do. Beeby mentions that the study found that 80% of the costs of violence are born by the victim themselves (the remainder is born by public services and employers). I am not sure what else might account for the difference.

So this study shows that shelters save money. But they also save lives. It is interesting to note, however, that shelters tend to save men’s lives more than women’s lives:

Let us look at the statistics and see who is murdering whom. Going back to the 1970s we learn that the domestic homicide rates in the U.S. were about the same for men and for women, around 1,000 such killings per year.

Coming to today, the latest figures available from the Bureau of Justice Statistics provide a comparison of intimate homicide rates for 2005 compared with 1976. Here is the official breakdown for 2005: 329 males and 1,181 females were killed in that year by their intimate partners. Clearly men are much more likely to kill their partners than women are to kill theirs. We know from other research that same-sex homicide is predominantly male, a fact of some significance in the statistical breakdown because some of the male intimate homicide victims are not killed by women at all but by their male partners.

Returning to the discrepancy between the decline in the rates of female-on-male domestic homicide and the male-on-female rates, Statistics Canada (1998, 2005, 2010), and other Canadian sources reveal the same trend has occurred in Canada since the years that the women’s movement took shape. For the year 2009, for example, three times as many Canadian women were killed by spouses and ex-spouses as were men.

So what is the explanation for this striking decline in women killing their partners? Researchers including myself attribute the decline to the fact that women who often killed out of fear for their lives now had an alternative avenue of escape thanks to the availability of women’s hot lines and domestic violence services, including shelters. (Keep in mind that women who kill their partners are generally battered women, whereas men who kill are often striking out due to a break-up or threatened break-up.)

“Exposure reduction theory” is the term coined by Wells and DeLeon-Granados in a 2004 article to explain this phenomenon of the significant decline in male homicides by their partners. This theory holds that if a woman can escape from a dangerous battering situation, she will do so, and that if she resorts to using lethal partner violence, it is most likely a protective mechanism. In any case, it is a paradox, rarely realized that the proliferation of domestic violence prevention for which women and victims’ advocates have fought so hard is saving the lives of battering men more than of battered women. Many of the female victims who obtain help from domestic violence services are eventually stalked and killed. (Source: van Wormer)

Shelters provide women a way of escaping violent relationships, and this is more likely to save their male partner’s life than to save the woman’s own life. Clearly, we still need to be doing more for women, but what exactly? Would men’s shelters help reduce homicide of female partners? Van Wormer’s article is not as clear on that. She does suggest that stresses like job loss might increase the rate at which men kill their partners:

So we can conclude that socio-economic status is clearly a correlate of the male-on-female killings. In contrast, the economic factor is less striking in the female-on-male intimate homicide rates. We should also consider the fact that the recent rise in the numbers of murder-suicides and whole family slaughters is correlated with the high unemployment rates for men. (Source: van Wormer)

So shelters clearly help, and if job loss is correlated with spousal homicides by men, shelters should continue to be funded during times of recession. It is great that shelters save men’s lives, but we still have work to do thinking about how we can reduce the rate of women who die at the hands of their intimate partners.

Link Round-Up

Dean Beeby “Spousal violence costs Canadians billions, study findsThe Toronto Star. December 24, 2012.

Katherine van Wormer “Women’s Shelters and Domestic Violence Services Save the Lives of Men,” Psychology Today. December 11, 2010.

Katherine van Wormer “Reducing the Risk of Domestic Homicide” Social Work Today. Vol. 9 No. 1 P. 18. January/February 2009.

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I often see these commercials for the Cancer Treatment Centers of America, and I find them misleading and unethical. I can’t seem to embed the video, but it can be found at this link. Most of their commercials are all about giving the patient “hope” where there was no hope before. But each commercial also carries a disclaimer: “No case is typical. You should not expect these results.” So the CTCA are suggesting that you should have hope and that they will offer you hope when other MDs fail to do so, but that you should also no have hope that it will work for you (although here “hope” is replaced with “expect”).

You need more than a second opinion. You need a second chance.

You need more than a second opinion. You need a second chance.

1. Legal Reasons for Disclaimers in Medical Advertisements

The reason for the disclaimer results from a lawsuit in the 1990s:

Cancer Treatment Centers of America was the subject of a Federal Trade Commission (FTC) complaint in 1993. The FTC alleged that CTCA made false claims regarding the success rates of certain cancer treatments in their promotional materials. This claim was settled in March 1996, requiring CTCA to discontinue use of any unsubstantiated claims in their advertising. CTCA is also required to have proven, scientific evidence for all statements regarding the safety, success rates, endorsements, and benefits of their cancer treatments. CTCA was also required to follow various steps in order to report compliance to the FTC per the settlement.

Cancer centers and hospitals in general (including Cancer Treatment Centers of America) have been the subjects of some controversy over their advertising. Many doctors and other observers have noted that many cancer organizations’ advertising are sparsely regulated and, therefore, often contain unsupported and misleading claims as to the efficacy of their cancer treatments.

In 2001, the FDA issued CTCA a Warning Letter concerning three clinical trials that were conducted in violation of FDA requirements. (From Wikipedia)

I understand that there are legal reasons for the disclaimer. Nevertheless, I find it creates an odd message overall. It also illustrates some of the problems with advertising in medicine.

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Yesterday in the USA, Federal Judge Roger Vinson ruled that the individual mandate was unconstitutional (the whole opinion is here), and so ruled the entire health care law is void:

Because the individual mandate is unconstitutional and not severable, the entire Act must be declared void. This has been a difficult decision to reach, and I am aware that it will have indeterminable implications. At a time when there is virtually unanimous agreement that health care reform is needed in this country, it is hard to invalidate and strike down a statute titled “The Patient Protection and Affordable Care Act.” (pg. 76)

One thing raised in the ruling is whether the individual mandate is unprecedented:

Congressional Budget Office Memorandum, The Budgetary Treatment of an Individual Mandate to Buy Health Insurance, August 1994 (“A mandate requiring all individuals to purchase health insurance would be an unprecedented form of federal action.”) (“CBO Analysis”). Never before has Congress required that everyone buy a product from a private company (essentially for life) just for being alive and residing in the United States. (pg. 38)

Judge Roger Vinson rightly notes that the mere fact that a law is unprecedented does not necessarily mean that it is unconstitutional, but, he writes,  a lack of previous similar legislation might nevertheless count against the presumption that a law is constitutional:

As I explained in my earlier order, the fact that legislation is unprecedented does not by itself render it unconstitutional. To the contrary, all federal legislation carries with it a “presumption of constitutionality.” Morrison, supra, 529 U.S. at607. However, the presumption is arguably weakened, and an “absence of power” might reasonably be inferred where — as here — “earlier Congresses avoided use of this highly attractive power.” Printz v. United States, 521 U.S. 898, 905, 908,117 S. Ct. 2365, 138 L. Ed. 2d 914 (1997); id. at 907-08 (“the utter lack of statutes imposing obligations [like the one at issue in that case] (notwithstanding the attractiveness of that course to Congress), suggests an assumed absence of such power”) (emphasis in original); id. at 918 (“almost two centuries of apparent congressional avoidance of the practice [at issue] tends to negate the existence of the congressional power asserted here”).

The mere fact that the defendants have tried to analogize the individual mandate to things like jury service, participation in the census, eminent domain proceedings, forced exchange of gold bullion for paper currency under the Gold Clause Cases, and required service in a “posse” under the Judiciary Act of 1789 (all of which are obviously distinguishable) only underscores and highlights its unprecedented nature.  (pg. 39)

Does that mean that if there were a previous law that imposed similar obligations, then the presumption that the law is constitutional would be strengthened?

Because Rick Ungar uncovered a precedent from 1798 “An Act for the Relief of Sick and Disabled Seamen.” Ungar writes:

In July of 1798, Congress passed – and President John Adams signed – “An Act for the Relief of Sick and Disabled Seamen.” The law authorized the creation of a government operated marine hospital service and mandated that privately employed sailors be required to purchase health care insurance.

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Mombies Comic

A comic humorously depicting pregnant women as zombies; by Jen Sorensen

Often when people think about issues of autonomy (the right to make decisions for one’s self) for pregnant women, they think about access to abortion. Other than having the decision to keep or terminate a pregnancy constrained by lack of abortion access, there are other ways that pregnant women lose decision-making rights.

In most of the USA people are allowed to make “living wills” or issue “advance directives” in order to indicate what medical treatment they would like to receive (or not receive) under particular circumstances. The point of the advance directives is to allow people to retain decision-making rights (that is, autonomy) even in the event that they are unconscious when they encounter the medical system. These “advance directives” can be very specific, or they can be very general, such as simply appointing someone to make decisions on one’s behalf in the event that one is unconscious or otherwise incompetent to make one’s own decisions.

Well, most people are allowed that right. But in 35 states pregnant women are not allowed that right. A partial list of these states can be found here. In these states if a woman is pregnant her living will is no longer considered valid and her advance directives for how she would like to receive (or refuse) care are ignored. If she has named someone to make decisions on her behalf, this too is ignored. Instead the doctors are required to make decisions about her treatment in the “best interests of the fetus.”

This is just one more example of how women’s autonomy is precarious. It is only respected if women are not pregnant, but if a woman becomes pregnant her rights to autonomy seem to become limited. Doctors will actually administer pregnancy tests to women (of childbearing age) before honouring (or ignoring, depending on the results) their living wills.

What Could be Done?

I have been trying to think of ways that a pregnant woman could retain the right to have her advance directives followed. One idea I had was that perhaps women should include a “no pregnancy test” clause in their advance directives. Alternatively, women could also include detailed instructions about which treatments they would accept or refuse if they were pregnant and unconscious or otherwise incompetent. This might not mean that the directive would be honoured, but I think it might provide the basis for legal action if the directive were ignored.

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I recently found the article, “Who Decides?” by Scott Lemieux via a post on Figleaf’s blog (I left a comment there and this post is a modified version of that comment).

Lemieux muses about abortion access in Canada:

In Canada, late-term abortions are not legally restricted, and Canada also doesn’t have the other kinds of restrictions found in many American states and doesn’t exclude abortion from guarantees of health care. As far as I can tell, there’s no evidence that Canadian women get late-term abortions at significantly higher rates (and historically overall abortion rates in Canada have actually been lower). Essentially, absent evidence to the contrary, I think the presumption in favor of a woman’s decision-making capacity is justified, and further restrictions are likely to do more harm than good.

I find Lemieux’s musings on what abortion and abortion access might be like in Canada to be highly misleading. Canada does not have the kind of easy access to abortion that Lemieux implies.

Lemieux is right when he says that there are no laws restricting abortion in Canada. But that does not mean there are no restrictions. Most abortions in Canada are done in hospitals (rather than clinics) and hospitals are left to make their own policy regarding abortion. Most hospitals do have policies that restrict late-term abortion access. Hospitals used to set a cut-off of 21 weeks (with exceptions made for mother’s health or foetal health), but recently with advances in prenatal testing (especially prenatal genetic testing) many hospitals have increased this limit to 24 weeks (again with health-based exceptions). In these cases hospital policy does not seem to reflect a commitment to women’s decision-making (after the early period of the pregnancy), instead the policies reflect changes in medical technologies and the dates at which reliable test results become available. Some clinics also place limits on when they will perform abortions.

Second, even though abortions are legal, no hospital or doctor is required to perform them. So Canada also has issues with access when women cannot find a doctor in their area willing to perform an abortion. In some cases this effectively means there is no access. One province (PEI) has no abortion providers at all; and a second (New Brunswick) has virtually no abortion providers. Canada is also a large country with a small population so even in the provinces that do have abortion providers, women in the northern or rural areas of those provinces might not be able to access abortions.

Third, while it is true that abortions are covered under most provincial insurance plans (so they are a part of our guaranteed health coverage, as Lemieux states), abortion is one of the few services that are excluded from reciprocal billing (PDF).  Part of the guarantees made in the Canadian Health Act is that insurance coverage is portable from province to province. This means that if I live in Ontario, I am covered by the Ontario Health Insurance Plan (OHIP), but if I go on vacation to BC and have an accident I can still use my insurance in the BC hospitals. One of the few exceptions to this promise is abortion coverage. Most provincial insurance plans will cover abortion within that province, but will not cover abortions if you travel to another province. Obviously this can cause significant access problems for women in PEI and New Brunswick who cannot find access in their own province. It also limits access to abortion for college and university aged women who go to school outside of their home province. Most students remain covered under their home province, and if they find they need an abortion while in another province they will have to pay out of pocket.

Canada might not have any laws restricting abortion access, but this does not mean that access to abortion in Canada is unrestricted.

I include some links for further reading after the fold.

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About ten years ago I was at a meeting and we were discussing what the policy on female genital cutting (FGC, female genital mutilation (FGM), or female circumcision) should be in the hospitals of the Canadian city where I was living at the time. The woman who was giving the presentation about the facts of FGC said at one point in the presentation that there was “no benefit” to FGC that could be weighted against its harms. Now, I do not support FGC in any way, but I was also quite bothered by this statement because it is one that renders the women who engage in FGC unintelligible and irrational, which makes discussing FGC with women impossible. I have been thinking about this issue again because I recently saw this video about the increasing requests for labiaplasty in Australia (The video is NSFW):

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