“Standing O” For Birth Control

Sometimes, when I was taking care of patients at a community clinic – whether in Oklahoma or Kansas or Massachusetts or even California – I would get students or assistants of some sort.  Nurses, nursing students, a physician assistant, physician assistant students, students from nearby colleges who are training to be medical assistants, or sometimes some kind of doctor extender I’d never heard of or didn’t understand would be assigned to me or rotate from a pool of available helpers.

Of course, I would always like them to actually get some knowledge from me. Sometimes that was the toughest thing for me to do. They needed to both pay attention and have a few functioning neurons. Although I usually figured out a way to quiz them a bit, they usually seemed, if I ended up running into them days or weeks later, to remember me as the one who was fun and told stories and paid attention to them.

Sometimes, they do remember certain things I would consider “rituals.”  One of my best known rituals is “The standing O” – Literally rising from my desk, applauding and shouting “BRAVO!” if someone did something I considered exceptional.  You know, like a standing ovation for an actor or musician.

I believe that so many people make bad, even incredibly horrible decisions, regarding their health and medical lives, that when they make good decisions, they should be recognized.  The drug addict who quit before getting pregnant so the child would be well usually gets one.  The schizophrenic who twice stopped drugs and got so sick he had to go to the hospital but who the third time I saw him finally decided medicines were worth taking, so he did not have to go to the hospital got one, too.

My personnel has pointed out to me that one of the things that I always give my “standing O” for is when someone decides to use contraception – and not only women.  Once, and only once, I remember I gave it to a man who told me that he had gotten himself a vasectomy. I nearly retracted it when I found out the real reason he claimed to have done it was not to limit giving his (vaguely suboptimal, or perhaps just drug addled) genome to the next generation.  I thought he was a walking bouquet of sexually transmitted diseases and told him to take care of himself.

Unfortunately, all too often I wonder about my colleagues, especially the marginally supervised and admittedly highly overworked trainees who seem to be treating the poor.

I force women patients to discuss contraception.  I have never been complained about on this one, although I occasionally get someone who does not want to discuss it, which is fine with me.  In such a case I just tell them that because some of the meds that I prescribe might not be very good for an embryo or fetus, as part of my obligation to discuss “advantages and risks” I need to at least offer such a discussion.

Sometimes women mention religion and sometimes they just shrug their shoulders and I let this go. Obviously I do not agree with this approach, but I do know enough about when to throw my own thoughts out the window and just keep practicing medicine.

So once we have a diagnosis, and at least a little bit of an idea about medication, I ask, “Is there any chance you could be pregnant?” Sometimes I get answers like “No,” or even “Hell, no” and then I say, “I just want to make sure you understand the risks of taking this medicine while pregnant.  I think that is part of my job, so I have to ask you, ‘how do you know you are not pregnant?'”

I have learned, the hard way, to be a little suspicious of abstinence. Without making political judgments, I can only say that we do our children no service when we withhold “the birds and the bees” from them and try to keep them as naive as possible until wedding bells ring.  Biology is stronger than theology in we puny humans.

Social impairments (schizophrenia and related illness, even retardation) can give way to subjugation.  Sexual risks are not exactly calculated and pregnancy prevention is hardly ever a consideration.  This population is at a high risk for sexual exploitation and rape.

I would not know anything unless I asked.  I feel it is my duty. “I can’t find a boyfriend” — think this one over when you have a chance.  Boys will be boys, and they won’t always be friends.

I have serious reasons for my concerns.  There is a risk of defects among people with a genetically transmitted mental illness or those who are on prescription medicines for same. Likewise, a risk of not carrying a child to term.

As far as I am concerned, I need a release to talk with the patient’s obstetrician or gynecologist and we are usually talking about a high risk pregnancy.  In all the instances with which I have been involved, (thank the powers that be, whatever you believe they are), either the child is lost in the first trimester, mercifully, or we bring through a normal birth with extra monitoring and a few extra ultrasounds.

Luckily there are plenty of people maintaining databases on this that are accessible to physicians and even materials for patients.  This is one of the reasons I won’t practice without the internet online in my office as I face the patient.  I want instant information at my fingertips to help this person whom I may not ever see again.

Another great excuse is, “I will not sleep with a man, I am a lesbian,” which is easy to manage if that is all they say.  But occasionally it goes all the way to, “I will sleep only with women, who are lots better, and if you are free I love women who look nice and have lots of degrees.” Such women usually give me a bad time when I show my wedding ring and reference my deliriously happy marriage with a heterosexual male. Retorts to that range from “Too bad” to “A serious blow against our side.”

But those women who inform me that they know they are not pregnant because they are actually, consciously, using a form of contraception are the ones who get a standing ovation.  Sometimes other people on my team who are present take pleasure in joining in.  The patients love it – they feel loved and validated for one of the few times in their lives.

Far and away the most common form of contraception practiced by the socioeconomically challenged woman is tubal ligation. However, this is usually after the fact.  Or after MANY facts.

Most common answer here is “I had enough kids.  I had to do something.”  Usually from a woman who has had six or seven, and who tells me her doctor offered it at the time of her last delivery.

But having one’s tubes tied is major surgery.  Besides all of the risks inherent, there is – of course – the cost.  Figured against the cost of any more human lives and the possibility of the complications if the mother is a drug or alcohol addict, in an abusive relationship, or just plain poor, it’s probably worth the risk.  But who can make such a decision?  It has to be the mother.

It is usually surgery, for these folks, even now that there are newer procedures where they can close the tubes by inserting something.  The statistics vary, but it is possible to get an ectopic pregnancy, not to mention STDs (Sexually Transmitted Diseases). None of the poor women who seem to get this after five or six or seven kids seem to be talking about taking paramours.  Some of them do talk about getting a little sleep.

Wikipedia cites statistics that say the rates in the population went down in June, probably because women have more options. Not the poor.  This seems to remain their most popular form of birth control.

Any woman who has done anything to take charge of her own reproductive life will continue to get a standing “O.’ For poor and disenfranchised women, their ovations may be a bit longer and louder.