Hot Topics: Reproductive Medicine

Blog Posts (88)

December 9, 2016

Don’t feel comfortable asking others if they are having regularly scheduled unprotected vaginal penile penetrative intercourse? Then don’t ask


One of the first questions a newly married straight couple often gets from well-meaning friends and family is “when are you going to start trying?” For those of you who are wondering what this question is getting at, it is asking them if they are going to start to try to get pregnant. It is interesting to analyze the language used here. People typically talk about “trying” without ever specifying what they are in fact trying to do. Part of the reason for this may be because people assume the meaning is obvious from the context, such as “they’ve been trying for six months but haven’t gotten pregnant yet.” Another reason probably has to do with our societal discomfort talking about sex.

We use general and vague terms to imply that we are talking about sex, but often don’t feel comfortable out right discussing it. For example, the birth control pill is generally just referred to as “the pill.” There is still shame and stigma surrounding sex, particularly for women and sexual minorities, so it may be easier and safer for a woman to talk about being on “the pill,” even though everyone knows what she is referring to, than to overtly announce that she is using contraception.

Even though we as a society may not feel comfortable explicitly discussing sex, we still feel that it is our business. From a legal perspective, look at how carefully reproductive medicine is regulated. For instance, certain reproductive procedures (e.g. abortion and sterilization) can require waiting mandatory periods – something that is not common in other areas of nonelective medicine. In the social realm, family, friends, and even strangers feel they have the right to comment on a pregnant woman’s behavior, such as by telling her what she should and should not eat or drink.

Returning to the topic of “trying,” family, friends, and again even strangers often have no qualms about asking women about whether they are trying to conceive. This is especially the case for straight women who are recently married and women who are perceived as being near or at the end of their “biological clock.”

Asking women whether they are “trying” is problematic on many levels. First, it assumes that all women want to become pregnant with genetically related children. While this may be true for many women, it is not true for all women. There is already enough social pressure on women in our pronatalist society to have biological children so people should avoid adding to this pressure. Second, asking people if they are “trying” is just a euphemism for asking them if they are having regularly scheduled unprotected vaginal penile penetrative intercourse, which is usually not considered an appropriate topic, especially among strangers. It is typically seen as impolite to discuss sex under certain circumstances or with certain people and discussing reproductive sex (that is, sex for which one of the purposes is reproduction) should not be treated differently.

To summarize, if you don’t feel comfortable asking others if they are having regularly scheduled unprotected vaginal penile penetrative intercourse, then don’t ask them if they are “trying” to conceive.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

December 8, 2016

Don’t feel comfortable asking others if they are having regularly scheduled unprotected vaginal penile penetrative intercourse? Then don’t ask them if they are “trying” to conceive

 

One of the first questions a newly married straight couple often gets from well-meaning friends and family is “when are you going to start trying?” For those of you who are wondering what this question is getting at, it is asking them if they are going to start to try to get pregnant. It is interesting to analyze the language used here. People typically talk about “trying” without ever specifying what they are in fact trying to do. Part of the reason for this may be because people assume the meaning is obvious from the context, such as “they’ve been trying for six months but haven’t gotten pregnant yet.” Another reason probably has to do with our societal discomfort talking about sex.


We use general and vague terms to imply that we are talking about sex, but often don’t feel comfortable out right discussing it. For example, the birth control pill is generally just referred to as “the pill.” There is still shame and stigma surrounding sex, particularly for women and sexual minorities, so it may be easier and safer for a woman to talk about being on “the pill,” even though everyone knows what she is referring to, than to overtly announce that she is using contraception.


Even though we as a society may not feel comfortable explicitly discussing sex, we still feel that it is our business. From a legal perspective, look at how carefully reproductive medicine is regulated. For instance, certain reproductive procedures (e.g. abortion and sterilization) can require waiting mandatory periods – something that is not common in other areas of nonelective medicine. In the social realm, family, friends, and even strangers feel they have the right to comment on a pregnant woman’s behavior, such as by telling her what she should and should not eat or drink.


Returning to the topic of “trying,” family, friends, and again even strangers often have no qualms about asking women about whether they are trying to conceive. This is especially the case for straight women who are recently married and women who are perceived as being near or at the end of their “biological clock.”


Asking women whether they are “trying” is problematic on many levels. First, it assumes that all women want to become pregnant with genetically related children. While this may be true for many women, it is not true for all women. There is already enough social pressure on women in our pronatalist society to have biological children so people should avoid adding to this pressure. Second, asking people if they are “trying” is just a euphemism for asking them if they are having regularly scheduled unprotected vaginal penile penetrative intercourse, which is usually not considered an appropriate topic, especially among strangers. It is typically seen as impolite to discuss sex under certain circumstances or with certain people and discussing reproductive sex (that is, sex for which one of the purposes is reproduction) should not be treated differently.


To summarize, if you don’t feel comfortable asking others if they are having regularly scheduled unprotected vaginal penile penetrative intercourse, then don’t ask them if they are “trying” to conceive.

 

 

 The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.


November 9, 2016

Bioethics faces a rocky but navigable road

by Arthur Caplan, Ph.D.

Academic bioethics has never been popular with Republicans.  Libertarians dislike academic bioethics because it seems too elitist and anti-free market. …

November 9, 2016

President Trump & A Republican Congress: What Might It Mean?

by Craig Klugman, Ph.D.

In a 2000 episode of The Simpsons, a flash forward shows Lisa being elected the first heterosexual female U.S.…

November 3, 2016

Why we should recognize social infertility: the exclusion of lesbian and gay couples and single individuals from definitions of infertility

The diagnosis of infertility is an anomaly among medical conditions because it requires two people, whereas almost all other medical conditions require just one person. For instance, if I break my leg, my diagnosis and treatment does not include or depend upon anyone else within my web of relationships. In contrast, when physicians are assessing a patient for infertility, they inquire about the person’s presumed heterosexual partner. This is because the majority of medical definitions of infertility rely upon heterosexual activity as a prerequisite to determine if an individual is infertile. For example, the World Health Organization (WHO) defines infertility as “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.” 

One significant problem with this definition is that it cannot account for lesbian and gay couples and single heterosexual individuals. Lesbian and gay cisgender couples are not having sexual intercourse (i.e. vaginal penile sex), so they are automatically excluded from definitions of infertility. Single heterosexual individuals may be having intercourse, but it may not be “regular,” which we can presume to mean on a consistent basis, and they may not be having unprotected intercourse.  

Yet, lesbian and gay couples and single individuals, regardless of their sexual orientation, are all infertile in a sense because they are not able to sexually reproduce via intercourse. Some in the bioethics literature have used the term “social infertility” to refer to individuals who are unable to reproduce due to factors associated with their partner. This can include individuals in same-sex couples who are not able to engage in intercourse and individuals who do not have a partner and thus are not able to engage in intercourse. 

In recognizing social infertility, the WHO recently changed their definition of infertility to include lesbian and gay couples and single individuals. Unfortunately, insurance companies in the United States do not tend to recognize social infertility. For example, a lesbian couple in New Jersey is suing their insurance company because it will not cover infertility treatment for them. Between the two women, they have had six miscarriages, which shows they are not just socially infertile, but there are also physiological components to their infertility. However, their insurance company is stating that they have not demonstrated that they are infertile because they have not been having heterosexual intercourse. 

The idea of requiring lesbian and gay individuals to prove their infertility by engaging in vaginal penile intercourse is ridiculous, especially given that modern medicine has various ways of assessing an individual’s fertility (e.g. hormonal tests, ovarian reserve, sperm motility, etc.). We need a broader definition of infertility that does not depend upon an individual’s relationship, or lack thereof, with others. The new WHO definition is a step in the right direction to recognize social infertility as well as the fact that lesbian and gay couples and single individuals can experience physiological infertility on top of social infertility.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.
October 20, 2016

The Ethics of Crisis Pregnancy Centers

"Pregnant? Scared? Need Help?" read signs along major thoroughfares in the southern United States. Many Americans have seen signs like these, often simultaneously advertising free pregnancy and sexually transmitted infection (STI) testing. Unless experiencing a unplanned pregnancy, most people pass by these signs without a second thought. However, for some of our most vulnerable patients, the establishments posting these advertisements - known as crisis pregnancy centers - represent a significant ethical difficulty in reproductive healthcare. Although these organizations are almost exclusively run by community volunteers, they represent themselves as healthcare workers by wearing lab coats and scrubs, providing lab testing and ultrasounds, and setting up offices that look like medical clinics. This would be problematic in itself from a legal perspective but the political and religious perspectives of these organizations provides serious ethical questions as well. Far from unbiased, crisis pregnancy centers (CPCs) are usually religiously affiliated organizations with a hard right agenda of preventing abortion at any cost. Medical evidence and scientific fact are not considered in this equation so clients of CPCs are often told that abortion causes breast cancer, infertility, psychiatric disorders (such as the entirely fictitious post-abortion syndrome), and even, in one case, kidney failure and subsequent dialysis. Furthermore, results of testing done at CPCs are frequently fabricated or ignored - clients are given falsely negative pregnancy test results or incorrect dating ultrasounds to prevent those considering an abortion from pursuing other care. CPC clients are usually unaware that these organizations do not employ trained medical providers or that they have a political agenda. However, the intent is clearly to strongly imply to CPC clients that they are being given information by medical personnel. As such, it seems fair to evaluate CPCs using principles of medical ethics, such as the four basic principles of beneficence, nonmaleficence, autonomy, and justice.

There is no question that the principle of autonomy is violated at these centers egregiously - purposefully providing misleading or false information takes away a person's ability to make informed decisions. However, the other three principles come into play with CPCs as well. Since there are rarely real medical providers at these centers, patients with serious health issues may be given advice that is, at best, suboptimal and, at worst, dangerous, arguably violating the principle of nonmaleficence. When a patient is told they are not pregnant when they are, they will not be able to seek timely prenatal care and are potentially put at risk for complications of pregnancy. When a non-expert performs an ultrasound and provides inaccurate results, fetal abnormalities, ectopic pregnancies, and other concerns go unrecognized. One center in Texas was documented telling a patient with a history of transposition of the great vessels that pregnancy was likely uncomplicated for her and would require “occasional monitoring,” rather than the extensive cardiologic and obstetric care that she would need throughout her pregnancy. These scenarios are not uncommon at CPCs and clearly have the potential to cause harm to patients seen in their offices. The principle of justice should also be considered in the case of CPCs as well – most situate themselves in areas of low socioeconomic status and target low income people as primary clients. These are generally the patients who can least afford access to healthcare and typically have lower levels of education, making them the least able to afford to care for an additional child and most vulnerable to the tactics of CPCs. It is hardly just when vulnerable patients, frequently people of color, are targeted to receive radically different healthcare and information than those with greater financial means, who would be less likely to be looking for low cost services.

Beneficence is the only principle of the four that could be debated depending on one's political and ethical leanings. A more pro-life leaning position might argue that the beneficence attributable to the fetus by potentially preventing an abortion should be considered with the discussion surrounding CPCs. This, of course, is predicated on the assumption that CPCs help to prevent abortions at all, which has yet to be adequately studied, although many CPCs tout the numbers of supposedly prevented abortions on promotional materials. Conversely, a pro-choice argument would be more concerned with the pregnant person, the potential benefits and risks of continuing a pregnancy and abortion, and the beneficence attributable to them. Overall, the patient should be able to determine for themselves what beneficence is for them and whether the patient should be treated as a patient. Regardless of stance, any ethical analysis would involve weighing multiple factors to determine whether or not a particular practice should be considered ethical. Looking at the complete picture surrounding CPCs and considering the violations of nonbeneficence, autonomy, and justice as previously outlined, it is not difficult to conclude that the practices of CPCs are not ethical and should not be endorsed by mainstream medical providers.

Although the ethical violations are clear, the course of action with regard to CPCs is not. These centers tend to fall into a legal gray area, as they are not officially bound by rules regarding medical practitioners and generally fall under non-commercial and/or speech stipulations when it comes to false advertisement litigation. Complicating the issue further is the fact that not every CPC operates this way – some centers follow strict guidelines regarding usage of scientific evidence and disclosure of non-medical personnel status, usually in states that regulate these centers. There is also no question that there is a need for services in populations targeted by CPCs and that, if operated appropriately, they could be a force for good in low income communities. Thus, although it’s difficult to universally condemn the practice, advocacy for regulation of CPCs, especially those who receive state funding, seems key. As medical practitioners, it is important to be aware of the existence of CPCs and their ethical problems. Furthermore, one of the best things we can do for our patients is make sure they do not fall prey to such predatory practices by advocating for laws that plainly identify CPCs as non-medical practices and/or require fact-based counseling, particularly in those centers that receive state and federal funding. Regardless of personal feelings on abortion, honest and ethical practices with patients should be an issue that all medical practitioners can agree with. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

October 20, 2016

The Ethics of Crisis Pregnancy Centers

"Pregnant? Scared? Need Help?" read signs along major thoroughfares in the southern United States. Many Americans have seen signs like these, often simultaneously advertising free pregnancy and sexually transmitted infection (STI) testing. Unless experiencing a unplanned pregnancy, most people pass by these signs without a second thought. However, for some of our most vulnerable patients, the establishments posting these advertisements - known as crisis pregnancy centers - represent a significant ethical difficulty in reproductive healthcare. Although these organizations are almost exclusively run by community volunteers, they represent themselves as healthcare workers by wearing lab coats and scrubs, providing lab testing and ultrasounds, and setting up offices that look like medical clinics. This would be problematic in itself from a legal perspective but the political and religious perspectives of these organizations provides serious ethical questions as well. Far from unbiased, crisis pregnancy centers (CPCs) are usually religiously affiliated organizations with a hard right agenda of preventing abortion at any cost. Medical evidence and scientific fact are not considered in this equation so clients of CPCs are often told that abortion causes breast cancer, infertility, psychiatric disorders (such as the entirely fictitious post-abortion syndrome), and even, in one case, kidney failure and subsequent dialysis. Furthermore, results of testing done at CPCs are frequently fabricated or ignored - clients are given falsely negative pregnancy test results or incorrect dating ultrasounds to prevent those considering an abortion from pursuing other care. CPC clients are usually unaware that these organizations do not employ trained medical providers or that they have a political agenda. However, the intent is clearly to strongly imply to CPC clients that they are being given information by medical personnel. As such, it seems fair to evaluate CPCs using principles of medical ethics, such as the four basic principles of beneficence, nonmaleficence, autonomy, and justice.

There is no question that the principle of autonomy is violated at these centers egregiously - purposefully providing misleading or false information takes away a person's ability to make informed decisions. However, the other three principles come into play with CPCs as well. Since there are rarely real medical providers at these centers, patients with serious health issues may be given advice that is, at best, suboptimal and, at worst, dangerous, arguably violating the principle of nonmaleficence. When a patient is told they are not pregnant when they are, they will not be able to seek timely prenatal care and are potentially put at risk for complications of pregnancy. When a non-expert performs an ultrasound and provides inaccurate results, fetal abnormalities, ectopic pregnancies, and other concerns go unrecognized. One center in Texas was documented telling a patient with a history of transposition of the great vessels that pregnancy was likely uncomplicated for her and would require “occasional monitoring,” rather than the extensive cardiologic and obstetric care that she would need throughout her pregnancy. These scenarios are not uncommon at CPCs and clearly have the potential to cause harm to patients seen in their offices. The principle of justice should also be considered in the case of CPCs as well – most situate themselves in areas of low socioeconomic status and target low income people as primary clients. These are generally the patients who can least afford access to healthcare and typically have lower levels of education, making them the least able to afford to care for an additional child and most vulnerable to the tactics of CPCs. It is hardly just when vulnerable patients, frequently people of color, are targeted to receive radically different healthcare and information than those with greater financial means, who would be less likely to be looking for low cost services.

Beneficence is the only principle of the four that could be debated depending on one's political and ethical leanings. A more pro-life leaning position might argue that the beneficence attributable to the fetus by potentially preventing an abortion should be considered with the discussion surrounding CPCs. This, of course, is predicated on the assumption that CPCs help to prevent abortions at all, which has yet to be adequately studied, although many CPCs tout the numbers of supposedly prevented abortions on promotional materials. Conversely, a pro-choice argument would be more concerned with the pregnant person, the potential benefits and risks of continuing a pregnancy and abortion, and the beneficence attributable to them. Overall, the patient should be able to determine for themselves what beneficence is for them and whether the patient should be treated as a patient. Regardless of stance, any ethical analysis would involve weighing multiple factors to determine whether or not a particular practice should be considered ethical. Looking at the complete picture surrounding CPCs and considering the violations of nonbeneficence, autonomy, and justice as previously outlined, it is not difficult to conclude that the practices of CPCs are not ethical and should not be endorsed by mainstream medical providers.

Although the ethical violations are clear, the course of action with regard to CPCs is not. These centers tend to fall into a legal gray area, as they are not officially bound by rules regarding medical practitioners and generally fall under non-commercial and/or speech stipulations when it comes to false advertisement litigation. Complicating the issue further is the fact that not every CPC operates this way – some centers follow strict guidelines regarding usage of scientific evidence and disclosure of non-medical personnel status, usually in states that regulate these centers. There is also no question that there is a need for services in populations targeted by CPCs and that, if operated appropriately, they could be a force for good in low income communities. Thus, although it’s difficult to universally condemn the practice, advocacy for regulation of CPCs, especially those who receive state funding, seems key. As medical practitioners, it is important to be aware of the existence of CPCs and their ethical problems. Furthermore, one of the best things we can do for our patients is make sure they do not fall prey to such predatory practices by advocating for laws that plainly identify CPCs as non-medical practices and/or require fact-based counseling, particularly in those centers that receive state and federal funding. Regardless of personal feelings on abortion, honest and ethical practices with patients should be an issue that all medical practitioners can agree with. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

October 3, 2016

Stop Pussyfooting Around the Word! Why Amy Schumer and Everyone Else Should Talk about Vulvas!

I recently watched a skit by Amy Schumer where she goes to see her gynecologist. Her gynecologist is professional in every way except that she does not use the medical terms of the vagina and vulva. Instead, she uses the slang term “pussy.” Schumer feels uncomfortable of this and asks her if she would instead use another term. The gynecologist misinterprets this as a request that Schumer does not like this one particular slang term spends the rest of the skit using all sorts of creative slang terminology to refer to women’s vulvas.

This skit not only highlights the discomfort many people have in talking about the female genitalia, but also shows that the words we use to refer to the female genitalia (and the body more broadly) matter. A healthcare professional using slang terms can be awkward and feel unprofessional for the patient. Part way through the skit, Schumer asks her gynecologist to use the medical terms, specifically “vagina.” I applaud Schumer for speaking up in an uncomfortable patient/doctor encounter and requesting words that feel more comfortable for her. 

However, I remain troubled by the fact that the term “vagina” seems the default word medical or non-slang word that most people use for the female genitalia. Indeed, it is commonly used to refer to a woman’s entire vulva and not specifically her vagina. Yet the vagina and the vulva are two different parts of the body. As defined by Merriam-Webster, the vagina is “the passage in a woman's or female animal’s body that leads from the uterus to the outside of the body,” whereas the vulva is “the parts of the female sexual organs that are on the outside of the body.” By referring to female genitalia as just the vagina, other important parts of the vulva are overlooked. This misuse of terms is problematic for at least two reasons.

First, it prioritizes heterosexual intercourse (vaginal penile sex), the type of sex that most straight men prefer and by which most are able to achieve orgasm. By only naming and giving agency to the vagina, we marginalize and even preclude other types of sexual activity. Namely, the clitoris is erased. This is significant because the clitoris is the locus of female sexual pleasure and orgasm. In fact, the vast majority of women require clitoral stimulation in order to achieve orgasm. In using the term “vagina” when in fact we are referring to the vulva, we are minimizing the importance of the clitoris and women’s sexual pleasure. Reducing women’s genitalia to just the vagina – both in the language we use and culturally (e.g. pornography that mainly focuses on vaginal penile sex) – harms women by not acknowledging the most important part for most women’s sexual pleasure: i.e. the clitoris.

Second, using the term “vagina” when one means “vulva” is also problematic because it focuses just on women’s reproductive capacity. In our pronatalistic society, women (at least white, straight, middle-class, able-bodied, Christian women) are valued for their reproductive capacity. The vagina, which notably is also referred to as the birth canal, is the centerpiece for heterosexual reproduction: the vagina is the passage through which the sperm enter the woman’s body and it is the passage through which the baby leaves the woman’s body. By using the word “vagina” to encompass the entire vulva, we are tacitly, and perhaps not so tacitly, showing which part of the female genitalia and which one of women’s abilities (i.e. reproduction) we think is most important.

I look forward to watching more of Amy Schumer’s work, as I appreciate that she directly tackles issues surrounding sexuality and reproduction from a feminist perspective. Perhaps she can use the word “vulva” on one of her upcoming skits, which would help educate people about what the vulva is and would empower others to start using this term as well. But the responsibility is not on her alone; we should all start talking about vulvas!

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

 

September 27, 2016

Thruple Babies: Born of 3 Parents

by Craig Klugman, Ph.D.

If a thruple is a three-person relationship, then would their combined genetic child be a thruby?

A baby boy born in April  is believed to be the first child created from the DNA of three parents: mother, father, and egg donor using the spindle nuclear transfer technique.…

September 14, 2016

Pregnancy, stigma, and moral responsibility in the Zika epidemic

by Kelly McBride Folkers, BS

Pregnancy comes with great moral responsibility from mother to future child. A healthy pregnancy requires that pregnant women abstain from certain behaviors, like eating unpasteurized foods and drinking excessive amounts of alcohol.…