On what we teach about sex

A few incidents in the last few years of work have made me wonder about the different ways and the different things that parents educate their children about sex. There’s the biological stuff, which is what parents for some reason think is most confronting, but that every single generation in every single country and in fact every sexually-reproducing species since the beginning of animal existence has figured out quite easily. A parent could get away with not ever mentioning to their offspring how babies are made, where they come out of, and the logistics of what sexual intercourse entails, and they’d pick it up anyway. I mean, in most cultures before our grandparents generation such things weren’t discussed by parents with their children – and yet people still had sex and had children, etc. It’s even less of a concern in modern days where there’s television and other media, there’s schools purposely teaching this stuff, and there’s other people (e.g. peers, relatives, health professionals, etc.) who will readily discuss the biology of sex with anyone. So it’s not what we teach children about the physiology of sex that concerns me, but that other stuff we tend to forget about sometimes, the psychosocial aspects of sex in a person’s life.

To go back again to the “olden” days now. Religion used to be a big part in a greater proportion of people’s lives ‘back in the olden days’. That’s a fact, that less people these days than, say, 100 years ago had a religious affiliation, whether that be because they elected to or were expected to by state mandates. In most religions, sex has/had a spiritual connotation and there were rules and consequences described around it. If you had sex before a marriage was confirmed, with someone outside of that marriage agreement, etc. you had “sinned” and would incur a punishment for it. Now, the punishment would be either or both imposed upon you by the church (e.g. been disassociated from the congregation) or by God (e.g. you were lead to believe that God would punish you by disapproval or loss of a post-life privilege, dependant on what the religious creed was). For the non-religious (and of course still applied to the religious) in ‘the olden days’, there was this thing about reputation and social norms.  Of course, social norms and expectations (as does religion) still exist, but modern Western culture places less of an emphasis on it, and more on being your own individual. So our parents and grandparents generation placed greater emphasis on whether others thought or knew that you had been engaging in something as disreputable as having sex with someone you weren’t married to. Sex was a shameful thing. Even for those that were married, it was not a proper thing to discuss or make jokes about or depict in media or entertainment, etc. So, back in the day a parent who educated a child about the psychosocial aspects of sex (the physiology been much too embarrassing to discuss outside of biology classes or by scientists), all you had to do is tell the child not to have sex because they’d either go to hell and die or that the whole town would call them a slut and their life would be miserable.

What are we teaching our children now about sex? Everyone knows about the physiology of sex, even very young children, and parents and their children will share very explicit details about sex. What’s wrong with that? Nothing – except that sex to human beings isn’t just about the biology of it. There’s nothing wrong with having all this knowledge about sex at all! But I’m beginning to believe that we’ve taken too much comfort in only sharing the easy stuff about sex, the stuff every child will eventually figure out even if their parent never tells them about, and have left our children with the hard stuff to figure out on their own.

In my job I’ve met many teenagers having absolutely never considered some of the other consequences of sex, let alone how to deal with them. We teach our children about sex, what it entails, that there’s the possibility of pregnancy and infections, to use condoms to prevent infections, and to use contraception to avoid pregnancy. But where children are missing out on instruction is about romantic relationships, who to have sex with, why or why not to have sex, how is sex related to love, should sex bear any relationship to love at all? These are all questions that increasingly younger people are having to charge through on their own. And I’d like to share with you some examples of questions that I have witnessed some very anxious teenagers try to deal with on their own too:

• How do I tell my parents I’m pregnant? Do they need to know?
• How do I tell my ex-boyfriend that I’m pregnant? Should I tell him?
• Should I tell my parents or my ex-partner/s that I have and STD? How can I tell them?
• Why did I get an STD when I was with a person I loved?
• Should I quit school because the other students won’t stop bullying me about being pregnant in high school?
• Is it ok to be sad about having a miscarriage even though no one else knew I was pregnant?
• What do I do now that I’m pregnant and my parents don’t want me to be and I still haven’t formed a concept on how I feel about abortion?
• How do I tell my girlfriend without hurting her feelings that I think she has a problem ‘down below’ because those warts don’t look normal?
• How can I get an STD when I use a condom all the time except with my regular girlfriend and she isn’t with anyone other than me?
• Is sex always meant to be painful or is it just because I don’t actually want it when it happens?
• Is it normal not to have had sex yet at my age? Does that mean I am lacking something or am sick?

Can a parent or anything in life prepare you to answer those questions? I don’t know. But it certainly would break your heart to have first considered questions like these when they apply directly to you and the situation you find yourself in. I say, good on us for talking to our children openly about sex and the need for safe sex practices and why they’re important, but it’s now time to do the real hard work: prepare our children to think of the consequences if they do find themselves in situations where the safe sex has simply failed. Encourage the young person to think of their own opinions about abortion, about social discrimination against teen parents, about sexually transmitted infections, about the link between love, sex, and relationships, about the effect on career development and parenthood, etc. We don’t need to mandate our kids to the effect of “don’t have sex or you’ll die”, but we could encourage them to ask themselves “could I deal with any of the consequences of sex? If not, then do I need to delay sex for now?” And do this not because the child will go to hell or society will ostracize him, but because he is an independent being worthy of not suffering the negative consequences of sex.

On birthing - part 2

I once met an obstetrician who told me “a healthy baby lives, a sick baby dies”. That was his approach to that time around the birth of a child and also to prenatal care. At the time, I was quite shocked! I thought, then what is the point of medical advances in technology, of medical research, and basically of “medicine” in general? We have studied disease, pathophysiology, human anatomy, microbiology, biotechnology, and devised all sorts of theories and methods to try to keep people alive and healthy. What’s the point of medicine if not that? Well, the obstetrician’s theory was that we may have studied too much, devised too many new things, and medicalised too many things that would (and should, apparently) be just thought of as part of human life: things like childbirth and pregnancy.

I admit that it does concern me when you consider the massive amounts of money spent in neonatal intensive care wards and the number of chronic health problems suffered by those born prematurely. Over the past few decades, the gestational age at with a child could be born safely and with the best chance of survival has drastically lowered. At one point in history, a child born 6 weeks before its due date had little chance of survival. Then someone decided that this should not just be accepted as fact and the chance of survival could be increased by some or another medical intervention. Gradually, newer and newer methods have been devised to support the survival of increasingly more premature (younger) babies. However, the issues has become one not just about supporting a premature baby to survive its first few months of life, but these babies go on to become infants, adolescents, and even adults. The earlier than anticipated a child is born, the greater his chance of dying. The medical efforts needed to keep these babies alive costs a lot of money. Then after ensuring the baby will survive into infanthood, the fact is the younger that child was born, the greater the risk that he will suffer chronic, sometimes lifelong, health problems. The management of chronic health problems of children and adults again costs a fortune. The life of a person who is prematurely-born is, therefore, very draining of resources, economically speaking.

Would it be better if we made health care decisions based solely on economics? Or would it be better if we based them based solely on “nature”, and ‘let nature take its course’ when a woman goes into labour prematurely? Why do we find it so repulsive to accept that “a healthy baby lives, a sick baby dies”? The truth is that the majority of us human beings couldn’t sleep at night if we made decisions like this. If you ask the women who have given birth to premature babies, even extremely premature ones, if the life-saving efforts to keep their children alive into adulthood were worth it (even if that life went on to be marked by chronic illness), do you know what almost all of them would say? They’d say “Yes, of course it was worth it!” And that is because you are talking about a person to whom they have a profoundly close connection, and also because it is a small “innocent” child, apparently deserving of all our best intentions, efforts, love, money, protection, etc. etc. It is also another human being, a person. You could summarise it by saying that we are humane towards other human beings; we are human. That is why we act so many times against logic, against “nature”, against economic viability, and against the greater majority’s good.

For the majority of persons, our instinct is to promote the survival of ourselves and other people; but when it comes to fetuses, there has always been a discussion into whether or when they can be considered a “person”. Now, I’m not about to go into a philosophical, theological, or bioethical discussion about abortion because frankly I think that is a discussion an individual can only have with themselves and come to their own conclusions; I only care to discuss an interesting scenario that was recently raised. Some Australian philosophers made an argument that newborn children are no different to fetuses because they do not understand or yet know what life is, let alone appreciate it. They don’t know what it is to be human, they don’t identify themselves as persons, therefore, they are not persons with the usual “standard” human rights, including a right to be alive. In theory at least, then, you could extend the arguments raised about fetal abortion to “post-natal abortions”, i.e. a newborn child being considered no different to a fetus. If is right or wrong to carry out a procedure to procure the destruction of a fetus with no known congenital defect, so it should be right or wrong to destroy a full-term newly born healthy child... Before I digress, let me just ask if a child has rights? If so, when do those rights come into effect?

Now, I wanted to discuss birthing and not actually “abortion”. Ms. Janet Fraser, whom I spoke about earlier, claims to have incorporated into the coroner’s investigation into her daughter’s death, a stance to defend “women’s rights”. Specifically, she wants acknowledgement of a right of a woman to decide the birthing method of her unborn child, independent from any right owed to the child (or potential child). That’s ok, right? Legally, a cognitively competent person has a right to make decisions over her own body and any intervention to it, medically or otherwise. That legal right overrides the fact of whether an intervention is actually good for you or not. For example, I can refuse to have any surgery being performed upon me, even if that surgery can save my life and without it I will undoubtedly and precipitously die. But not just life-saving surgery, I have a legal right to refuse any medical intervention at all… What about epidural anesthesia at the time of birthing, is it ok to refuse that? What about antenatal care? I mean, pregnancy is not illness, so why should a person be forced to see a medical person, right?.. And what about fetal monitoring? No woman in labour particularly wants to be touched by anyone else. What about wanting to deliver a child traditionally at home and not in a modern hospital, particularly if you are scared of hospitals? And what about assisted delivery, I mean that is rarely to help the woman, is it? What about refusing a caesarian section, that’s a type of surgery so why should a person not have a right to refuse that?...

Why are these questions interesting? Because we accept that a person has a right to make decisions about their own body and their healthcare, but we are also aware that the decisions of this person affect another human being (even if we don’t consider them an independent person yet). Though we are unsure whether this “person” or “potential person” is owed any rights, we have this niggling little feeling that they deserve at least a chance or some consideration in the whole argument. What is the answer? Should a hierarchy be legally set up to nominate whose rights are or whose life is more important at the time of birthing? I don't claim to know what the right answer is, but unfortunately in the world we live in, people tend to be motivated more by laws and potential for punishment (or material reward) than the things that moved us in the past. I guess we can’t expect all people to reason that they will sacrifice something, anything, to ensure the safety and health of their child as a priority to their own personal preferences.

(I will not be donating any of my money to Ms. Fraser’s ‘fight for the rights of all women’, mostly because I appreciate and encourage more people [and not just women] to consider at least in some situations, that other fellow human’s lives are at least as worthy as their lifestyle preferences.)

On birthing - part 1

I recently read a blog post by Janet Fraser where she asked for donations to help fund a legal battle she’s involved in. There is an ongoing coroner’s inquest into the death of her baby so it’s hard to comment on what still has a large number of unknown facts. Briefly, the allegations are that around late 2008, Janet Fraser became pregnant with her third child and decided that her child would be birthed at home without the involvement of any medical or nursing staff. There were apparently no medical antenatal checks during her pregnancy. In March 2009, she went into labour and as she and her partner had planned, they prepared for the birth of their child in their home. At the end of the labour, she delivered a full-term baby that was dead. Resuscitation attempts were made by the child’s father, and then an ambulance was called to take the child to hospital. The baby was not able to be resuscitated. Janet Fraser is not on trial for murder of a child; she is involved in a legal fight to establish her (and, as she claims, all “women’s”) rights to be able to opt to give birth at home, unassisted by medical staff.

Janet Fraser has delivered 3 children, the first of which was born in hospital. In 2003, Ms. Fraser was admitted to hospital for delivery of her first child. The whole interaction of this visit was experienced as a very negative, indeed “traumatic”, experience for her. The physical (aka vaginal) examination was unpleasant, the medical and nursing staff made medical and nursing decisions (apparently for and about her and not in conjunction with her), and her right to a vaginal delivery was denied. A caesarean section was performed for delivery of this child, as deemed medically necessary for either mother and/or child. Ms. Fraser felt that this “medical need” should have been no reason to overlook her right to make health care decisions (i.e. whether to have surgery or not), and a result of this she felt personally violated by the hospital system when the caesarean section was performed on her. This hospital birthing experience came to be interpreted by her as akin to rape. She never wanted to experience this ever again.

For delivery of her second child in 2006, Ms. Fraser wanted to avoid all possibility of having a caesarean section performed upon her (presumably against her will) and so decided to deliver this child at home. She eventually went into labour and this lasted 50 hours. After the birth of the child, she suffered a severe haemorrhage and was taken to hospital. Upon admission to hospital, she reported to hospital staff that she had only being in labour 3 hours so as to avoid potential reporting to policing authorities for child neglect or abuse (from willingly submitting the child to a prolonged labour). I wonder if she herself considered that this whole thing could be called child neglect or abuse had the possibility of prosecution not been raised…

Delivery of her third child in 2009 was attempted in the same way that of the second child was, at home. I guess Ms. Fraser considered that the risk of having another difficult birth after 2 previously difficult births did not warrant the greater medical care that may be offered in hospital. Everyone takes risks in life, right? There is always the chance that mum and/or baby could die during birth, regardless of where it takes place. There was always also the chance that Ms. Fraser could have delivered her third child healthily and so smoothly at her home that none of us would ever have heard of her. She must have weighed up those possibilities, the consequences of their potential outcomes, and then made the decision to deliver her child at home. The outcome was a dead baby; the consequence is that that outcome is final.

On abortion

The rape of the Sabine women, Giambologna

Recently someone asked me to express my views on ‘abortion’, specifically as it relates to my role at work, my personal religious views, and my experience with medical ethics. I found it an interesting little exercise because it made me think about the different roles we play in different social spheres and also the cognitive schemas which we keep constant across these spheres. For example, the religious group to which I belong and whose view I share (or at the very least accept) has a view on abortions that is easily summarised as “it is never indicated”. Now, in my role as a doctor I am at times confronted by people enquiring about termination of pregnancy services. In this scenario you could say that I am paid to educate, to assist, and to aim for the best health outcome for my patient. But I am the same human being doing both roles of Christian and doctor. The other thing to realise is that I represent only myself, not my religion or my profession – and yet to another fellow human, I am both!

I have summarised perfectly my religion’s views on abortion as “it’s never indicated”. Before I summarise my profession’s view on abortion, I must summarise my profession’s role. Doctors have sets of clinical standards and legal standards by which we must exercise our jobs. It is not just about using the best clinical method or doing things legally, it is about using the best clinical method to do legal things that are in the patient’s best interests – as dictated by the patient himself (or a substitute decision maker on his behalf). So my profession’s view of abortion you could say has to do with the performing of legal abortions in a clinically safe manner. Of course, this is given that it is requested by the patient, and is in keeping with the general direction to minimise harm to her or to improve her wellbeing. You could very generally summarise my profession’s views on abortion as “it is indicated when the patient wants it, it is the best thing for her mental and/or physical health, and it is able to be performed in a clinically safe manner”. Now, does everyone in my religion believe exactly the same thing? No! Does everyone in my profession believe the same things as each other? No, of course not. Some of us differ even in antibiotic prescribing!

Personally, I believe whether or not a thing is bad has to be decided by the person to whom the decision directly affects. For example, if my religious belief is that eating a certain food is a sin, then it IS a sin if I personally ate that food. However, if someone else doesn’t believe it is a sin and eats this particular food, then to me that person is not guilty of a sin either in his own view or mine, and I can hold no negative judgement towards that person. The question of MY view on ‘abortion: good or bad?’ for me is redundant. To me what is of relevance is what I do in one or another context. I am both a Christian and a paid medical professional, but I am above all things, a human being. Every human being approaches life with the same basic aim: to do the thing that is best for me and minimize my discomfort (physical and/or mental). No one likes to feel guilty of not doing their job adequately, and no one likes to feel that special type of guilt our religious beliefs can make us feel. Things get even more complicated when you throw in having to act in situations that will directly (and indirectly) affect at least one other human being.

I have reached a position in my life where I don’t want to change anyone’s view to that of my religion, or to change the views of my religious associates to that of my own. I have also been lucky enough to realize that my work is just that: work. So what has all this stuff on religion have to do with my discussion here on abortion? Medically, in my job, it is never my choice to decide on a patient’s medical care if he is competent to make that choice himself, regardless of their or my personal religious or personal views. My job would be to inform accurately and with scientific fact, to ensure that the person has access to adequate psychosocial support, and to aim to protect the patient from mental and psychological harm. None of these tasks have anything at all to do with my own personal religious views on anything.

You can’t discuss abortion, though, without discussing legality. I was asked whether I believed that termination of pregnancy services should be deemed “illegal”. I believe that the main reason that the concept of legality is still introduced into discussions about intentional abortions is that it is contended on some many levels that have little at all to do with either medicine or the law. The way our society deals with such “ethical” or “moral” dilemmas is to pass strict laws or rules to dictate what should be done and where and by whom. For example, a statement could be made that an unborn person has the same human and legal rights to a person who is already born. However as a society a statement like that is not very practical because there are too many things to consider, e.g. at what age or weight is a foetus a ‘person’, what anatomical or biological parts entitle a person to be called a person, etc. So we come up with laws and rules instead, saying for example that a foetus after 24 weeks of gestational age is a person and has this and that other human right but not these other ones yet, etc. This is, you’ll notice, similar in concept to Christian ideology that says “it is never indicated’.

Personally, I believe that health professionals should not be criminally prosecuted for performing abortions that are performed safely and using standard practices when a person has consented to the procedure after being adequately counselled about it. I believe it should also be legal for patients who are intellectually competent to make health care decisions to seek adequate help from health professionals for discussion and possible subsequent performing of an abortion. I also believe that it should remain illegal to perform abortions that are not medically supervised or on people who are not capable of consenting or refusing to the procedure (unless in conjunction with a substitute decision-maker that has the person’s best interests at the forefront). I am glad that termination of pregnancy techniques have been developed in a medical context. For example, it’s better that a doctor with appropriate tools and knowledge perform an abortion than a woman attempt to have one done by someone with no specialized training. To believe that outlawing something which has such a long history of occurring is going to stop it from being done, I think is quite naive.

I do have one problem with our society’s current high rate of abortion, though, and it has nothing (or everything?) to do with either religion or law or ethics. I find it concerning that the high use rate of termination of pregnancy services, and its widespread acceptance, has led to the trivialization of what is essentially (and I think, rightly so) a big decision to be made in a person’s life. It saddens me that some people are coming to think of an abortion as an option for contraception or that it is a common/simple thing like getting a mole removed from the skin. The true and often undiscussed fact is that a lot of women do not understand the psychological impact of their decisions, and the potential for negative psychological sequelae in the years to come. Ideally, no woman should opt for an abortion without having full explanation of the medical or surgical techniques and the potential risks associated. The discussion should include explanations of the changes to be expected in her body, an understanding of the foetus’ current stage of development, an exploration of her own spiritual views, and consideration of her mental and physical health. Now, I am not saying ‘don’t have an abortion because you’ll get depression or other mental problems in the future’. I am simply saying that a patient needs to be given adequate and complete information to help them form their own decisions.