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I've got your "Physician outrage" right here!
March 23, 2012 10:57 PM   Subscribe

Where is the physician outrage? Metafilter's own jscalzi played host to an anonymous post by an outraged physician who put forth a five point plan for civil disobedience in the face of legislators demanding that physicians prescribe transvaginal ultrasounds to women who may choose to abort.
posted by ChrisR (81 comments total) 38 users marked this as a favorite

 
I don't actually need a transvaginal ultrasound for any health reasons but if the physician who wrote this knows another physician in Indiana - I would be willing to get the procedure and sign over the image for repeated use throughout the land(s). I'm completely serious.

Jscalzi's blog has been fantastic lately, btw.
posted by fluffy battle kitten at 11:15 PM on March 23, 2012 [8 favorites]


well said.
posted by chapps at 11:26 PM on March 23, 2012


So true. It is astonishingly efficient at flying in the face of everything they teach us about ethics in medical school. It violates all four of the basic principles of medical ethics: Autonomy (well they took away the right to choose against the procedure and still receive the proper care), beneficence (the procedure has no proven medical benefit for the sake of birth control, and in fact will discourage people from receiving care), non-maleficence (well, I'm sure it isn't that demeaning! Just kidding, of course it is.), and justice (the very requirement serves to limit the equitable treatment of women). So I guess what I'm trying to say is: if they feel that medical ethics don't apply to them (or evidence based decision making for that matter), why do they feel so compelled to make medical decisions?
posted by SounderCoo at 12:01 AM on March 24, 2012 [17 favorites]


Dead-on riposte from jscalzi to a comment in the thread. The man uses words efficiently I must say.
posted by George_Spiggott at 12:01 AM on March 24, 2012 [7 favorites]


Not everyone who believes that these laws are barbaric are cheering this post. For example, at Pandagon, Amanda Marcotte had this to say. For those who don't want to read post, her arguments are, basically:

(a) It's not effective civil disobedience if it takes place in secret.

(b) Once it's no longer secret, you'll get shut down, which is a good way to make abortion-related healthcare even harder to get and to make the anti-choicers happy.

Apparently some abortion providers (this physician doesn't claim to be one) left comments saying similar things in Scalzi's post, but I don't feel like reading the comments to find them.
posted by Kutsuwamushi at 12:17 AM on March 24, 2012 [1 favorite]


Just what I was about to say, Kutsuwamushi. Marcotte also points out that doctors can't really trust their patients to keep quiet about their refusal to follow ridiculous laws, because anti-choicers can sometimes be abortion-having hypocrites.
posted by misfish at 12:22 AM on March 24, 2012 [5 favorites]


Yeah - the type of woman who has an abortion for the right reason, unlike those sluts.

It would be a terrific statement, but statements can't give women abortions.

I think what bothers me most about this post is that the author seems to have fallen victim to the just world hypothesis. They seem to believe that because refusing to follow these laws would be completely justified that the result would be positive - or at least not too bad. Either the disobedience wouldn't be discovered or it would cause lawmakers to have some kind of epiphany about women's rights.

There is a slight undercurrent of blame in some of those comments against abortion providers who have a more realistic outlook, and prioritize keeping their practice open. That's really sad.
posted by Kutsuwamushi at 1:06 AM on March 24, 2012 [3 favorites]


The doctor is right and jscalzi is right and everyone who opposes this awful procedure. However I am sad to say that Amanda at Pandagon has a point: loudly anti-choice women have abortions, people from conservative religious communities have abortions. In most cases the way they deal with it afterwards is to suppress the memory, never speak of it, and carry on as before. But in a few cases they loudly regret their decision, tell all about the 'horrors' and get reintegrated into their community. I think Roe of Roe v Wade did this?

Anyway, it certainly happens, and it offers these women a very tempting route through their own personal difficulties. It's very understandable why they should do it, as they are caught in the dreadful double-bind that conservative religion imposes on women.

But given this, non-compliance has to be a risky strategy for abortion providers. I don't know what the answer is. Perhaps to non-comply and treat is as civil disobedience, and accept the repercussions.
posted by communicator at 1:07 AM on March 24, 2012


I just read Marcotte's piece and I'm having trouble figuring out what she's suggesting exactly beyond choosing to provide abortions if you don't already. I thought at first she was suggesting being more public about not performing the procedure. ("Civil disobedience works best if it has a public component, to draw attention to your issues in hopes of changing the law."), but then she says that doctors getting their licenses stripped for not obeying the law is what anti-choicers want.

So is she suggesting becoming an abortion provider and simply going along with the law and performing the transvaginal ultrasounds? ("Yes, a non-consensual procedure is a horrible thing, but if you look at the choices women make, not being able to get a safe, legal abortion is more horrible. ")
posted by ODiV at 1:09 AM on March 24, 2012


Yes, she's suggesting they do the ultrasound, awful as that is, because the alternative is that there will soon be no abortion providers at all in certain states. I reacted strongly against it when I first read it, but now I see her reasons. I don't know.
posted by communicator at 1:13 AM on March 24, 2012 [1 favorite]


Meanwhile, on the other side of the pond...
posted by the cydonian at 1:16 AM on March 24, 2012


Yes, she's suggesting they do the ultrasound, awful as that is, because the alternative is that there will soon be no abortion providers at all in certain states. I reacted strongly against it when I first read it, but now I see her reasons. I don't know.

I believe #4 addresses this concern. Under no circumstances do the procedure against the patient's wishes, falsify the report if you have to. The public nature of civil disobedience is all well and good, but offering safe, legal abortions without raping your patients is the priority here.
posted by kafziel at 1:20 AM on March 24, 2012 [3 favorites]


kafziel, I think you are missing a point here. It is perfectly possible for hypocritical anti-choicers to go and get an abortion, all the while intending to expose their doctor as an evil abortion provider, who didn't bust out the rape wand because s/he is all about denying women the opportunity to truly and properly understand through the magic of ultrasound that they are terrible sluts.

Then, the doctor gets their license revoked, and lots of people lose their access to a safe, legal, and necessary medical procedure. There is no winning here.
posted by misfish at 1:27 AM on March 24, 2012 [3 favorites]


I feel like the patients who didn't get raped probably won, at least a little bit. I'd have to seriously question any argument in favor of physicians raping their patients.

Like I just posted in response to the blog itself, "refusal to perform the procedure is the first priority, and any other concerns - balancing the desire for public protest versus the need for continuing practice - are to be weighed in light of the adamant refusal to rape your patients."
posted by kafziel at 1:32 AM on March 24, 2012 [2 favorites]


Basically, as far as medical advice goes, "take one for the team" is kind of unconscionable. And that's what the pandagon blogger is advocating. Fuck that.
posted by kafziel at 1:33 AM on March 24, 2012


Yep, it's fucked up. It's designed to be fucked up and horrible and really unpleasant for doctor and patient. That's the point.

There's no right answer. There's no win-win except to get horrible laws like this repealed, or prevent them being passed in the first place.
posted by misfish at 1:37 AM on March 24, 2012 [3 favorites]


It's not just women having abortions who you would have to worry about. Medical professionals rarely work in a vacuum. If you work for an organization like Planned Parenthood, you probably don't need to worry about your coworkers being anti-choice. However, if you work in a hospital, that's much less certain. Someone would notice. Falsifying documents is not as easy as it might sound.

Kafziel, I understand why you think that Marcotte's argument is vile. But the alternative that she sees is forced pregnancy and childbirth because there are no more abortion providers. I'm not sure that it's possible to pick which is worse. I know which one that I personally find most terrifying, but that's very subjective.

The fault is on the lawmakers who craft these laws, not the abortion providers who are trying to do their best to serve women in need.
posted by Kutsuwamushi at 1:42 AM on March 24, 2012 [2 favorites]


So true. It is astonishingly efficient at flying in the face of everything they teach us about ethics in medical school. It violates all four of the basic principles of medical ethics: Autonomy (well they took away the right to choose against the procedure and still receive the proper care), beneficence (the procedure has no proven medical benefit for the sake of birth control, and in fact will discourage people from receiving care), non-maleficence (well, I'm sure it isn't that demeaning! Just kidding, of course it is.),
SounderCoo

I completely agree, but what I don't understand is why requiring transvaginal ultrasounds for abortion is rape and repugnant (it is!), but requiring pap tests and/or pelvic exams for birth control isn't subject to the same criticism. I don't think the latter practice, which is commonly required by doctors although not backed by any law, is any different. Pap tests and pelvic exams also have no proven benefit relevant to birth control, patients don't have the right to choose against the procedure and still receive proper care and it fact it discourages proper care, there's no autonomy, and while there may be benefits to pap testing, they don't have anything to do with birth control. Where's the outrage on this?
posted by Violet Hour at 2:01 AM on March 24, 2012 [10 favorites]


Mark my words, this will end like gay bashing did.

With outing.
posted by effugas at 2:03 AM on March 24, 2012


They're really not analogous situations,Violet Hour. The point of the pap isn't to punish the dirty slut for wanting birth control.
posted by craichead at 2:06 AM on March 24, 2012 [5 favorites]


Craichead, you'd be surprised. But the fact remains that using birth control as a reward for what should be voluntary cancer screening is paternalistic and manipulative. Birth control should not be a reward for being a good girl and getting your pap test or STI screen. That's just sick. We don't require cholesterol screenings or eye exams for birth control, and they're about as relevant to it as pap tests.
posted by Violet Hour at 2:10 AM on March 24, 2012 [9 favorites]


You could definitely make that case. But it would be a different case than what we're discussing here, because this isn't about paternalism. It's about assault. And doctors aren't legally required to perform paps, so the civil disobedience issue isn't relevant, either. Maybe you should do a separate FPP?
posted by craichead at 2:24 AM on March 24, 2012 [1 favorite]


Modern definitions of rape tend to treat duress and undue influence as wholly invalidating consent. The fact that the undue influence is exercised by an individual on their own behalf, rather than that of the state doesn't seem very relevant to me. I think Violet Hour is right here. While this does not diminish the horror of legislation that requires doctors to rape, it is a horror in its own right.
posted by howfar at 3:29 AM on March 24, 2012 [1 favorite]


I have been waiting for a chance to ask this of people whom I agree with about the badness of these laws, and whose opinions I respect...

If a transvaginal ultrasound, as a pre-condition of an abortion, is rape, why isn't a pap smear, as a precondition for a birth control prescription?

It's even more invasive and uncomfortable, and the threat of being denied access to birth control seems like duress of the same kind (if not the same degree) as the threat of being denied access to abortion.

I don't think "rape" is a good argument. I think that the best argument against these laws is that their sole purpose and intent is to cause suffering. They are cruel by design, not in terms of the physical experience, but emotionally. We don't need laws like that. The pap smear rules are not meant to shame or punish anyone.
posted by OnceUponATime at 3:53 AM on March 24, 2012 [1 favorite]


Oops -- I apologize for not reading to the end of the thread.
posted by OnceUponATime at 3:55 AM on March 24, 2012


It is perfectly possible for hypocritical anti-choicers to go and get an abortion, all the while intending to expose their doctor as an evil abortion provider, who didn't bust out the rape wand because s/he is all about denying women the opportunity to truly and properly understand through the magic of ultrasound that they are terrible sluts.

So you're saying the majority of women who DON'T want the procedure should be forced to comply anyway because "what if maybe they're lying"?

Who the fuck's side are you on?
posted by EmpressCallipygos at 4:40 AM on March 24, 2012 [1 favorite]


What I don't understand about these laws is that the patient has the right to refuse any and all treatments they do not wish to have. As far as I know, this is effective in all states across the board. So why can't these physician's just emphasize as part of their informed consent process in big bold letters, "YOU HAVE THE RIGHT TO REFUSE ANY AND ALL PROCEDURES AT ANY TIME!"

I mean, these laws do not trump informed consent, and if the patient is properly informed that THEY CAN REFUSE these ultrasounds and they actually refuse them, then the law, while repulsive and a form of institutional rape as far as I'm concerned, is not enforceable.

My reading of the laws is that they are written for the physicians, so if a better job is done in an informed consent process, more patients will refuse. And if physicians beyond abortion providers emphasize the "YOU HAVE THE RIGHT TO REFUSE" treatment part of the informed consent process, it will help patients understand more that they, in face, due have the right to refuse treatments and parts of treatments. And hopefully women needing or wanting abortions start refusing the ultrasounds......

And if I misunderstand the law or various laws as written, I apologize. But what it comes down to, for me, is that women are going to need to be self-advocators for themselves for abortions in states requiring transvaginal ultrasounds in the same ways they need to self-advocate for other issues surrounding reproductive rights --- including those during the childbirth process (such as VBAC vs repeat c-section rights).
posted by zizzle at 4:55 AM on March 24, 2012 [1 favorite]


Meanwhile, over in Tennessee...
posted by Thorzdad at 5:08 AM on March 24, 2012 [1 favorite]


I would hope/imagine that here in Canada our various physicians' colleges and licensing bodies would just put out a statement telling the gov't to go fellate itself. This can put docs in a pinch between the Law and the College, but hey, that's what confidentiality is for.
I would NOT falsify records or pull any 'stunts' -- better to just document reasoned refusal on behalf of the patient.

This whole mess must be friggin' disgusting for sonographers.

Also worth pointing out is that inevitably some of these scans will actually find major fetal anomalies. That is actually what OB ultrasound is used for in a sane society, after all.
posted by biochemicle at 5:37 AM on March 24, 2012 [1 favorite]


So you're saying the majority of women who DON'T want the procedure should be forced to comply anyway because "what if maybe they're lying"?

Who the fuck's side are you on?


No, I'm saying this is fucked up because of law makers, and doctors who provide abortions in America are in a really nasty, fucked up position. As are, obviously, the people who need abortions.

It's not fair and it makes me want to cry.
posted by misfish at 5:40 AM on March 24, 2012


Wait. Women can, actually, get birth control without a pap. Doctors may not encourage that, given the risks of dying from untreated cervical problems, but they don't force you to get one. Ok. Maybe there are doctors out there who won't prescribe unless they get to open the speculum. Sheeeesh. I hope not.

I have never been pregnant, but am having some unexplained health issues that led me to need a dildo wand transvaginal ultrasound appointment this week.

It was invasive, painful, and embarrassing. And nobody would even claim that I'm 'to blame' for needing it, unlike those women who legislators would like to shame for becoming pregnant.

Wouldn't wish it on anyone. Especially not the waiting after. Forcing someone to have this done and then wait around for 24 hours is cruel. All I'm waiting for is the report and I'm a mess.
posted by bilabial at 6:36 AM on March 24, 2012 [4 favorites]


So how hard is it to perform an illegal abortion, these days?
posted by Space Coyote at 6:43 AM on March 24, 2012


For reference, bilabial, I live in a small rural community with two doctors offices in town, one of which is a branch of Mercy (which used to be St Johns). BOTH require me to have a pap before they will prescribe my birth control. I simply do not have an option there.

Granted, I could travel over an hour away to the third largest city in my state, but the two large hospitals/physicians there are also related to large healthcare providers and also require me to get a pap smear before a birth control prescription. In all honesty, I've always just thought that was an absolute for my birth control.
posted by youandiandaflame at 6:45 AM on March 24, 2012 [1 favorite]


....I'm actually wondering why we're equating pap smears with transvaginal ultrasounds in the first place, because:

PAP SMEARS:

often totally painless
screen against cervical cancer

TRANSVAGINAL ULTRASOUND:

often quite painful
posted by EmpressCallipygos at 6:49 AM on March 24, 2012 [1 favorite]


If a transvaginal ultrasound, as a pre-condition of an abortion, is rape, why isn't a pap smear, as a precondition for a birth control prescription?

It's even more invasive and uncomfortable, and the threat of being denied access to birth control seems like duress of the same kind (if not the same degree) as the threat of being denied access to abortion.


One difference between the two is that routine pap smears have been documented to provide some measure of overall health benefit to the women that receive them, while the sole purpose of a required transvaginal ultrasound is to take facts about fetal development and try to "make them personal". If anything, the latter procedure actually increases the potential for harm to the patient's emotional health, putting it in direct contradiction to the principle of "First, Do No Harm".

Ideally, women should be able to make an informed personal decision about the benefits of routine pap smears on their own without the coercive duress of being potentially denied birth control, but at least that coercion comes from the medical profession's belief that it'll ultimately help the health of the women under their care. This may or may not excuse the "requirement". The transvaginal ultrasound issue has no such excuse.
posted by radwolf76 at 6:50 AM on March 24, 2012 [2 favorites]


Meanwhile, over in Tennessee...

What the... Why in the world would anyone want this information public, aside from malicious intent? How on earth could something like this even be proposed? Does Tennessee not have patient confidentiality laws? How could this even work under HIPAA, basically just disclosing All The Informations to everyone?

Ugh. Sigh. I agree with the original post, at least, especially the first point. Reinforce again and again that patients have the right to refuse, or just document "Patient refused ____." Falsifying documents does put you at serious risk of (at least) losing your license, but I guess I'm in the camp that thinks even that is better than performing unethical, coerced procedures intended only to be cruel and with no medical benefit.
posted by byanyothername at 6:54 AM on March 24, 2012 [1 favorite]


So how hard is it to perform an illegal abortion, these days?
posted by Space Coyote at 9:43 on March 24


It's no harder than it ever was. However it leads to the result of people like me having memories of my mother (an ER nurse in a major city) coming home and breaking down in tears, more than once, because a preteen or teenage girl bled out in the ER due to those (in her words, and she was a practicing Christian) "fucking butchers".

If you came of age after Roe v Wade, you may not have an idea of the horrors that were visited on women before that time.
posted by pjern at 6:59 AM on March 24, 2012 [8 favorites]


If the point is civil disobedience, yes the doctor should do it and try to get the law overturned on the grounds that it violates medical ethics etc. If the point is for the doctor to not rape his or her patients with the dildocam, the author has a point--with the attendant risks mentioned by Marcotte. "Not wanting to rape your patients" and "wanting to commit an act of civil disobedience" aren't the same thing, though, and they shouldn't be conflated.
posted by immlass at 7:28 AM on March 24, 2012 [1 favorite]


I am in pediatrics, and this particular procedure is not remotely routine for my client population (though it would be if I were in a practice that provided gynecological services to adolescent women), but I also cut my educational an clinical teeth on the ethics of autonomy, beneficence, non-malificence, and justice. This is what I am doing:

*Making myself visible to lawmakers. I have been writing letters, going to my state board meetings and putting this discussion on the agenda, and making sure I am alerted when healthcare related issues are being heard in committee or on the floor so that I can reiterate my presence. We have this idea that lawmakers writing bills/laws/agendas/platforms perform due diligence as far as scope of practice requirements that define provider licenses, clinical guidelines, or current practices. They do not. They speculate and make it up as readily as strangers on the internet when it comes to healthcare-based questions. Often, just this visibility will arrest the direction of a committee because a provider will point out that what they are suggesting is patently incorrect or violates a licensing board. But if no one is there, looking over their shoulders, they will proceed.

*Spending incredible amounts of time (relatively. But 60 seconds is sometimes 4x more than normal) with ANY and ALL informed consent. In my world, this means for things as "benign" as an Rx for an antibiotic. I also explain that I am spending this time because there is so much debate about patient autonomy and informed consent right now, and that this is good practice for other, more advanced and riskier interventions. I reiterate that as the patient, they ARE autonomous and have a voice in their own care.

*Talk about the issues openly, where any one can find me (professional discussion boards, twitter, professional events, with colleagues). As I am also in the interviewing process for permanent placement, and I out myself there as a patient advocate and my feelings about informed consent, patient (and women's rights), and my unwillingness to comply with any law that removes patient autonomy, weakens informed consent, or overly burdens it (it AZ, lawmakers used the state supreme court to overly burden informed consent, requiring that IC be given by multiple practitioners in such a way that they knew would close down Planned Parenthoods). So far, the reception to this has been awesome.

*I stay unafraid of the primary threat, which is "losing my license." If I lost it protecting a patient from a law that was in direct opposition to accepted clinical guidelines, professional policy statements, my professional board, or accepted clinical algorithms, then my education is still useful in research while I fight such a decision. Obviously, as one person, I should not make any kind of unilateral decision based on what I, personally, think, but how I practice and the safest way to practice is VERY clearly given by collective agency--by accepting my license, I accept the adopted clinical practices of my professional board. This does include accurate charting, applying clinical guidelines to interventions, the four ethical tenants, etc. It may not include procedures handed down by agenda-laden lawmakers.

This isn't perfect and it doesn't address everything, and it seems like everyday there is something that I haven't thought of that is pointed out to me by a patient, by a colleague, by action from lawmakers, by ethical discussion in the field. But I mainly remind myself that I am a tool of my SCIENCE not of political goals of any kind, and I am in SERVICE to my patient, not to the interests of a lawmaker or religion. And I do feel that this kind of attitude, one I believe the vast majority of providers share, will serve best the greatest number of patients regardless of their political and religious beliefs. Further, serving the equal-class citizenship of women serves best ALL patients. All of them.

But let me say, too, that this is hard and it's a constant balance of time against failure. Sometimes I can only manage to click-send a form email to lawmakers. Sometimes I feel like I am running through a script of informed consent moreso than thinking through it. Sometimes a colleague or patient says something that I feel I should have slowed down with, addressed more. But it's these kinds of uncertainties born of the pace of healthcare (as well as power imbalances) that lawmakers are taking advantage of. The more they see we don't take time with our patients and believe that our education trumps the patient's ability to know what they believe is best for themselves, the easier it is for lawmakers to seed that kind of landscape with weeds that choke out anything that has even a small chance of improving health or saving a life.
posted by rumposinc at 7:28 AM on March 24, 2012 [37 favorites]


....I'm actually wondering why we're equating pap smears with transvaginal ultrasounds in the first place

Because any insertion of an object into a woman's vagina without proper consent is a sexual assault by penetration. I don't think anyone is attempting to minimize the significance of this legislation, so I'm not sure why you appear to be attempting to minimize the significance of the same sexual assaults occurring in a different context. We can be outraged about both, I promise.

at least that coercion comes from the medical profession's belief that it'll ultimately help the health of the women under their care

But wouldn't this justify withholding any form of medical care from any currently or previously sexually active woman who refused to have a cervical smear test? The idea that it is acceptable for doctors to refuse care in the notional interests of a patient seems pretty evil to me.
posted by howfar at 7:39 AM on March 24, 2012 [4 favorites]


Because any insertion of an object into a woman's vagina without proper consent is a sexual assault by penetration. I don't think anyone is attempting to minimize the significance of this legislation, so I'm not sure why you appear to be attempting to minimize the significance of the same sexual assaults occurring in a different context. We can be outraged about both, I promise.

To my experience, I was unaware of any consequences arising from refusing a Pap Smear, however. I've only just now seen in this thread that there are even clinics that require you to get a Pap Smear before getting birth control.
posted by EmpressCallipygos at 7:57 AM on March 24, 2012


Hmm. I agree with howfar and Violet Hour in that I think that the analog between required transvaginal ultrasounds and pap smears is strong, and if one is rape, then so is the other. I think I disagree in that I think neither one is, and we should stop throwing the word around so loosely. I agree with the argument against the law stated by radwolf76 (which I think is the same argument I gave) but I think it is completely orthogonal to the "state mandated rape" argument, which I don't think is credible, given the invasiveness of many other medical procedures performed under various kinds of duress.
posted by OnceUponATime at 8:53 AM on March 24, 2012


OnceUponATime I think I'd like to hear some examples of the type of duress you think is comparable. Informed consent is generally regarded as a keystone of medical ethics, suspended generally only when the patient cannot consent and needs immediate treatment in order to protect their health. Perhaps it is more eroded than I believe, but it would be helpful if you could explain where.
posted by howfar at 9:04 AM on March 24, 2012


Why this plan will not work based on the history of abortion in this country, from When Abortion Was A Crime by Leslie Regan.
Finally, after hunting through the city, this couple had successfully located a physician, a nurse, and a room in which the young unmarried woman could safely and secretly have an abortion—her reputation preserved. They were pleased. Both were reporters for the Chicago Times . She was not the desperate unmarried woman she seemed, and he was neither her brother nor lover. Rather, the pair played these roles as part of their investigation of the abortion business in Chicago. They reported their discoveries in a month-long series of "revelations." The story began on December 12, 1888, and stayed on the front page every day through Christmas. In the method of the New Journalism forged in the 1880s, these investigative journalists had gone undercover and underground, into the "social cesspool," to expose the underworld and elite hypocrisy and, thus, inspire social reform.
The 1888 Times exposé is the earliest known in-depth study of illegal abortion. The investigation showed abortion to be commercially available in the nation's second largest city despite the criminal abortion law. The reporters retold their conversations with the hundreds of practitioners whom they had approached. They made the private practice of abortion public.
It's sad, but civil disobedience would probably not help the doctors or the women in those states if it were done in private, and to publically announce it would lead to death threats and bombings no doubt.
posted by winna at 10:02 AM on March 24, 2012


I'm going to give trivial examples, so please don't think that I'm equating any of these with a mandatory transvaginal ultrasound, but ... Vaccines are required by law (as they should be, in my opinion!) for public school attendees. Blood tests are required in some states before a marriage certificate can be issued. And, of course, doctors won't prescribe antibiotics for strep without a strep test, among other diagnostic procedures which are required to get access to other medical care. (I know the ultrasounds are not diagnostic in this case!)

We require people to submit to needles in their skin and swabs down their throats (and, in the case of pap smears, speculums in their vaginas, which is why it is the closest analogy) for a variety of medical and non-medical reasons. Informed consent is required for all of these, but there is still a kind of duress, since we deny people access to public school/marriage/other medical care if they do *not* consent.

The mandatory ultrasound laws are bad laws, but I want to be careful that the arguments we make against it don't end up being the same kind of arguments conservatives use against adding Gardasil to the required vaccine schedule.
posted by OnceUponATime at 10:10 AM on March 24, 2012


The difference is that vaccines, strep tests, and pap smears all have benefits that we have decided are really super-important. We need vaccines to keep people from getting diseases. We need strep tests to prevent drug-resistant bacteria. Women need pap smears so we can catch cancer before it's too late. (Although I agree they shouldn't be a condition for birth control... I mentioned in a thread a few weeks ago that this is a big problem for me personally).

The transvaginal ultra-sound being performed because of a state mandate, outside of the doctor's medical opinion, it has no benefit except to make women not want to get abortions. It's supposed to make them think "Oh god, there's a tiny baby inside me! I don't want to kill that tiny baby after all!" Even though at this stage there is no tiny baby for them to see, so it's actually really pointless. It's pure psychological manipulation to discourage them from receiving a legal medical procedure. You might as well decide they need to get water-boarded first to understand what it's like to die. It's just pointless and cruel.
posted by bleep at 10:18 AM on March 24, 2012 [5 favorites]


You need a strep test before prescribing antibiotics because the results of the strep test tell you which antibiotics to use. That's a bit different. Requiring pap tests for birth control is more like requiring a cholesterol test before prescribing antibiotics for strep. In fact, it wouldn't surprise me at all if physicians required a pap test before treating women for strep, or at least used the appointment to hassle women about it.
posted by Violet Hour at 10:33 AM on March 24, 2012 [1 favorite]


For the record, the health clinic at University of Illinois at Urbana-Champaign when I was in college there just two years ago required a yearly pap to get your BCP pills. When I studied abroad, they wouldn't let me fill my prescription for the time I'd be abroad because it intersected with my required pap. They wouldn't let me schedule an earlier pap either because they said you only get one covered per calendar year. My school insurance didn't cover me going to anywhere else either and the local Planned Parenthood couldn't get me an appointment on such short notice.

It was really fucked up and I ended up flying to Spain (which is thankfully a great place to visit) where BCP pills can be bought question-free. It cost less than me paying out-of-pocket at a private doctor to give me the prescription in the US. And there were tapas. I wish I had been more of a firehead then though and had agitated to expose UIUC's stupid policies. It's all about controlling women so you can protect them from their naughty behavior.

I had another recent pap experience that was so awful that I can't talk about it here because I've filed a formal complaint against the doctor, who definitely used the pap as a way to harass me about being sexually active.
posted by melissam at 10:37 AM on March 24, 2012 [3 favorites]


Blood tests are required in some states before a marriage certificate can be issued

I'm in the UK, and am not aware of this. What is the justification for the policy? It seems like something of an intrusion upon privity of contract to me.

diagnostic procedures which are required to get access to other medical care


I don't actually think that this is a reasonable comparison. Neither the ultrasounds nor the smear tests are diagnostic in relation to the treatment they are set as barriers too. If someone seeks medical treatment, their free and informed consent is presumably to all aspects of the treatment, including diagnostic ones, as it is not possible to prescribe the correct treatment without the correct diagnostic procedures.

Vaccines are required by law (as they should be, in my opinion!) for public school attendees

This is a more interesting comparison with the smear test, but I'm still not sure that it is that good a fit. The usual justification for compulsory vaccination (which does not currently exist where I am) is herd immunity. One is forced to submit to vaccination in order to prevent you from harming others by being a carrier. This is controversial, but at least it falls within the normal realm of legal coercion. The difference between the two cases (smear & vaccination) seems to me like the difference between being arrested for being drunk at home and being arrested for driving drunk. It is much harder to justify the former coercion than the latter.

A truly comparable requirement would be to be tested for and vaccinated against HPV rather than a requirement to submit to a cervical smear.

The difference is that vaccines, strep tests, and pap smears all have benefits that we have decided are really super-important

As the smear tests are the point of contention at the moment, I'd like to ask if you think that they should be made compulsory for all women, rather than just some women seeking birth control from some doctors?
posted by howfar at 10:48 AM on March 24, 2012



As the smear tests are the point of contention at the moment, I'd like to ask if you think that they should be made compulsory for all women, rather than just some women seeking birth control from some doctors?


Actually the pap smears are a derail, and I said in my comment that I don't believe they should be compulsory for anyone and even that it was personally a big problem for me. But the difference is that they have a medical purpose, which is testing for cancer (it's just that the patriarchy doesn't believe I can be trusted to get them often enough on my own). The purpose of a pap smear isn't to make me feel bad about getting birth control pills.
posted by bleep at 10:52 AM on March 24, 2012


Okay maybe I didn't say that, but that was what I meant. It's ridiculous to make them required.
posted by bleep at 10:55 AM on March 24, 2012


The purpose of a pap smear isn't to make me feel bad about getting birth control pills.

Perhaps. I'm not sure it matters. I personally don't think that having a motive that is not actively malign is sufficient justification for sexual assault. If someone were to touch me intimately without my consent (and I think we agree that the undue influence here undermines consent) the fact that they were doing it because they wanted to help me do something I had chosen not to do would not seem like a sufficient justification.
posted by howfar at 11:02 AM on March 24, 2012


I'm not advocating for compulsory pap smears and it's not okay that they're required but they do have a medical purpose which is to check for cancer. Transvaginal ultra-sounds as a mandatory prerequisite for abortion do not have a medical purpose. That's the difference between the two issues. It's all pretty horrible that women have to go through this shit just due to the misfortune of being born a woman and people try to act like sexism is dead.
posted by bleep at 11:21 AM on March 24, 2012


You know, I'm reminded of a few years ago, when some pharmacists refused to fill birth control prescriptions for women because they objected on "moral or religious" grounds. And some states actually extended protection to them to pull this kind of shit if they wanted to.

How is this any different? Couldn't doctors in the states that allow protection to pharmacists who let their fucked up view on women get in the way of doing their job properly claim precedent? The difference would be that the pharmacists would be actively denying a woman basic medical care, while the doctors would be protecting women from unnecessary medical intrusion but that wouldn't matter to the neanderthals that would no doubt try to claim the case of the pharmacists and the case of the doctors somehow aren't equivalent (and I mean equivalent on the grounds that they claim - religious and moral ground - because when we look at the true motivation behind each action they sure as hell aren't equivalent).

BUT, once we allow pharmacists, and by extension, doctors to refuse to things based on moral grounds, where do we stop it? Can I refuse to do my job based on moral grounds because I feel a customer was rude to me and morally I don't think rudeness is acceptable? What is even the point of having laws then? WHY the FUCK are we letting religion and "morality" (which we know can be used to justify any crazy shit that any person wants to believe) dictate government?
posted by triggerfinger at 11:41 AM on March 24, 2012 [2 favorites]


fluffy battle kitten: I would be willing to get the procedure and sign over the image for repeated use throughout the land(s).

Move over Creative Commons, here comes Pubic Domain!
posted by dr_dank at 11:58 AM on March 24, 2012


See Virginia Postrel on making Birth Control OTC
posted by stratastar at 12:04 PM on March 24, 2012


Where is the physician outrage? Well, compassion for (female) patients in the ob-gyn medical community is often lacking. No surprises there. I'm pleased to see that some doctors are mad about the new "laws" (these bills give "law" a bad name).

Second, mandatory procedures = more billing, as long as your patients don't stop coming to your office for the desired procedure (here, abortion) altogether. A TV ultrasound can be done by a tech right in the office, doesn't require sedation, and takes 5-10 minutes max (I've had one, thankfully with my consent and for medical reasons). Talk about markup. Again, I see that some doctors would rather be ethical than reap the guaranteed billing and that is great.

My fave comment in the linked blog:

I don’t need to comment. The post says it all. My grandfather was a doctor before medicine was owned by insurance and pharmaceutical companies, I and suspect he’s rotored his way to the core of the earth by now.
posted by Currer Belfry at 12:11 PM on March 24, 2012 [1 favorite]


There's actually another way in which Pap smears aren't quite equitable to transvaginal ultrasounds, at least for the purposes of this discussion; I can accept that "vaginal penetration with anything without your consent is rape". Hell, even a speculum requires vaginal penetration.

However: the other way in which these two cases aren't equitable is this:

CASE A:

I want birth control. I go to a clinic that requires me to have a pap smear before I can get a prescription for Yasmin or other hormonal contraceptive, or before I have an IUD. I do not want a pap smear, and I refuse; the clinic therefore refuses me my contraceptive. There is no other clinic in my area.

CASE B:

I want an abortion. I go to a clinic that require me to have a transvaginal ultrasound before I can get a abortion. I do not want a transvaginal ultrasound, and I refuse; the clinic therefore refuses to perform the abortion. There is no other clinic in my area.


The difference is in the OUTCOME of both of these cases, to wit:

OUTCOME A:

I do still have a few other alternatives to hormonal contraception, such as condoms and the contraceptive sponge. So even though I don't have the contraceptive method I want, I do still have something. I buy a few packs of Trojan and a couple of boxes of the Today sponge, use both, and it's at least a solution.

OUTCOME B:

I'm....pretty much up shit creek.
posted by EmpressCallipygos at 12:12 PM on March 24, 2012 [3 favorites]


Plus there's new pap smear guidelines that do away with annual checks so the requirement prior to prescription of BCP has even less to stand on.
posted by zorrine at 12:30 PM on March 24, 2012


Blood tests are required in some states before a marriage certificate can be issued

I'm in the UK, and am not aware of this. What is the justification for the policy?


There are only two states in the US that require blood tests before marriage (actually, one requires and one suggests):

- Montana suggests a blood test from the female to test for rubella immunity, but the woman has the right to waive the test. The reason for the test is because infants born with rubella usually do not survive.

- Mississippi requires a blood test from the man and woman, to test for syphilis. This used to be a common requirement in many states, as part of FDR's campaign to fight the spread of venereal disease -- syphilis was becoming an epidemic, and at that time there was no known cure. Similar to rubella, an infant born with syphilis rarely survives. In the past few decades, all other states removed this requirement.

Outside the US, there are other places that test before marriage. France tests for rubella and requires a medical exam, Mexico tests for HIV, Turkey requires a medical exam, Tunisia tests for various diseases. Usually the law is part of a greater initiative to fight infectious disease, especially diseases that infants cannot survive if they are born with it.
posted by Houstonian at 1:10 PM on March 24, 2012


TRANSVAGINAL ULTRASOUND:

often quite painful


Really? I've had literally dozens of them in the course of fertility treatment and never had even minor discomfort. This is not in any way to say that it's OK to mandate them and I'm sure there are some people for whom any procedure hurts but to say "often" does not seem to me to be accurate.

Re: pap smears. There is a legitimate reason to mandate them in relation to birth control which is that the virus that causes cervical cancer is sexually transmitted. Therefore, people who are sexually active and using hormonal birth control without condoms are at higher risk. That doesn't mean that they should be done as frequently as they are (the guidelines have just changed) but it isn't a good analogy for this reason. It's not about punishment, it's about cancer screening, period.
posted by Maias at 4:20 PM on March 24, 2012


Really? I've had literally dozens of them in the course of fertility treatment and never had even minor discomfort. This is not in any way to say that it's OK to mandate them and I'm sure there are some people for whom any procedure hurts but to say "often" does not seem to me to be accurate.

Erm, that's actually one of the biggest points that the dissenters are bringing up - that it is not only invasive, but can be very uncomfortable and sometimes painful. I've heard it in a number of different news accounts on the matter.
posted by EmpressCallipygos at 7:55 PM on March 24, 2012


Re: pap smears. There is a legitimate reason to mandate them in relation to birth control which is that the virus that causes cervical cancer is sexually transmitted. Therefore, people who are sexually active and using hormonal birth control without condoms are at higher risk. That doesn't mean that they should be done as frequently as they are (the guidelines have just changed) but it isn't a good analogy for this reason. It's not about punishment, it's about cancer screening, period.

This. This this this.

Hi. I had cervical cancer last fall. Just before I turned 38.

I had managed to unintentionally go about three years without a pap, thanks to my gyn moving, a few badly-timed family emergencies, and life just interfering with scheduling. But eh, I've been in a mutually-monogamous relationship (yes I'm very very sure) for 10 years, and had no reason to think I was at high risk when I got around to getting a gyn checkup.

Well. The entire last quarter of the year totally fucking sucked and colposcopy and conization were pretty unpleasant, but I was damn lucky, because if this cancer had progressed a few more millimeters I'd be missing my uterus right now.

This is preventative health care at work, people. The thing that we wish physicians would do more of, not less.
posted by desuetude at 9:09 PM on March 24, 2012


This is preventative health care at work, people. The thing that we wish physicians would do more of, not less.

Why not mandate mole screenings when you buy sunscreen then? My mother almost died of skin cancer and if you are buying sun screen you probably intend to be out in the sun. There are all kinds of cancer screenings that are good to get, however they should be a woman's choice and not a condition for her to make reproductive choices. Pap smears should be cheap and easy to get...for people who want to get them.

The whole debate reminds me that for many women in the US, getting reproductive care is not easy. Planned Parenthoods are frequently overbooked and sometimes not nearby. The whole state of reproductive care in this country is abominable.
posted by melissam at 9:44 PM on March 24, 2012 [3 favorites]


I would suspect that there are risks to the use of hormonal contraceptives when you have cervical cancer. It's not unreasonable to want to make sure that what you prescribe is not contraindicated by an undisclosed medical condition.
posted by kafziel at 9:56 PM on March 24, 2012


I would suspect that there are risks to the use of hormonal contraceptives when you have cervical cancer. It's not unreasonable to want to make sure that what you prescribe is not contraindicated by an undisclosed medical condition.

Sun is quite bad for people who have melanoma too. As for this, there is very preliminary evidence they increase the risk of cervical cancer in HPV-positive women some studies, but I can't find anything on them making it worse if you have it. EIther way, I've never heard of a doctor refusing to give BCP to an HPV-positive woman.
posted by melissam at 10:02 PM on March 24, 2012


I would suspect that there are risks to the use of hormonal contraceptives when you have cervical cancer. It's not unreasonable to want to make sure that what you prescribe is not contraindicated by an undisclosed medical condition.

Nope. Hormonal contraceptives are not contraindicated if you have an abnormal pap test or even full-blown cervical cancer. People walk out the door with a pill prescription as long as they've submitted: it's not like they wait for the results of the pap test to come back before prescribing (which they would have to if there were an actual medical relationship between paps and birth control). They don't take your pills away if your pap test comes back abnormal. The only medical test needed to prescribe the pill is a blood pressure check.
posted by Violet Hour at 10:10 PM on March 24, 2012


This is preventative health care at work, people. The thing that we wish physicians would do more of, not less.

Not at the expense of bodily autonomy, we don't.
posted by Violet Hour at 10:42 PM on March 24, 2012


It's great to see someone ask "Why isn't mandatory pap smear before being prescribed BC rape?" on this thread, because I think that policy is a good example of how this shit becomes normalized. The people who are negatively impacted by it are kind of invisible.

I've never tried hormonal birth control because of the pap smear requirement, despite having had health problems that may have been alleviated by it. It's an option I never got to explore because I refused to submit to an unnecessary, uncomfortable, and unrelated procedure.

There are probably women out there who have had terrible experiences getting a pap smear in order to get BC, or who don't get BC because they can't or won't do the pap smear. But we think it's normal so we don't really get outraged on their behalf.
posted by Kutsuwamushi at 11:09 PM on March 24, 2012 [1 favorite]


There are probably women out there who have had terrible experiences getting a pap smear in order to get BC, or who don't get BC because they can't or won't do the pap smear. But we think it's normal so we don't really get outraged on their behalf.

That's why, if you'll note earlier, I pointed out another, more crucial, reason why comparing Pap smears before BC and transvaginal ultrasounds before an abortion is not equitable.
posted by EmpressCallipygos at 6:15 AM on March 25, 2012


Anyway, to inject a bit of levity:

A grass-roots protest project, which calls itself "The Snatchel Project," is enlisting knitters and crocheters to craft a uterus, vulva, or other such item and send it to a male congress member with a note to the effect that "now that you have one, you can leave mine alone".
posted by EmpressCallipygos at 6:23 AM on March 25, 2012 [2 favorites]


That's why, if you'll note earlier, I pointed out another, more crucial, reason why comparing Pap smears before BC and transvaginal ultrasounds before an abortion is not equitable.

But, as Violet Hour points out, it is still a compromise of bodily autonomy, isn't it? Not to mention that there are all kinds of reasons why women seek hormonal contraception, including those that have nothing to do with sex. We should also take into account the women who are unable to use a barrier method because of the control exerted by their partner but may be able to use a hormonal method in secret.

I just don't understand why anybody who believes women should have control over their own reproduction, health and bodies would want to regard some artificial restrictions as more acceptable that others. The fact that something has a health benefit does not, in a liberal society, mean that we have the right to impose it upon anyone. Cervical cancer is not a transmissible disease (although HPV is, but then so are lots of other things that are not tested for), so this is not a public health issue, but rather a matter of a personal health intervention being forced upon an individual in exchange for a treatment they may badly need.

Preventative medicine is a wonderful thing, but so is the liberty to reject it if one chooses.
posted by howfar at 7:34 AM on March 25, 2012 [2 favorites]


EmpressCallipygos

Wait, so now it's ok to rape people if it's for their own good? Come on.

Also, you're argument about the outcome of refusing is a bit flawed, since barrier methods have a higher failure rate than hormonal ones:


OUTCOME A:

I do still have a few other alternatives to hormonal contraception, such as condoms and the contraceptive sponge. So even though I don't have the contraceptive method I want, I do still have something. I buy a few packs of Trojan and a couple of boxes of the Today sponge, use both, and it's at least a solution.
But then the condom broke or my partner wouldn't use them, and I ended up getting pregnant and seeking an abortion.
posted by Violet Hour at 8:01 AM on March 25, 2012


But, as Violet Hour points out, it is still a compromise of bodily autonomy, isn't it?

I didn't say it wasn't. I didn't say it was an ideal. My fear was simply that the discussion about "is or isn't a pap smear rape or not" was distracting us all from the matter of "while we're all arguing about Pap smears being rape, there are women who are being denied ABORTIONS, and that strikes me as rather a more pressing matter."

Wait, so now it's ok to rape people if it's for their own good? Come on.

How in the hell are you getting that out of what I said? I mean, I even SAID that "I can even accept the argument that an unwanted pap smear is rape," so how are you getting that my position is "it's okay to rape people"?

Also, you're argument about the outcome of refusing is a bit flawed, since barrier methods have a higher failure rate than hormonal ones.

And that is why I mentioned the use of TWO barrier methods in my explanation. And hormonal methods do still have a small failure rate themselves.

And the whole point of my analogy was to illustrate that "the person refusing a particular medical procedure and being denied an abortion already has a 100% rate of pregnancy, and is thus in a more pressing situation than the person who isn't pregnant yet, so can we get back to talking about the bigger fire, please?"
posted by EmpressCallipygos at 10:05 AM on March 25, 2012


And because I know that someone is going to try to twist my words YET AGAIN:

1. No, I also do not think it is right that someone should be forced to go through a Pap Smear in order to obtain contraception, if that is their choice.

2. Yes, I think access to contraception is an extremely important issue.

3. Yes, I think it is important to talk about that to, and to work for that too.

4. All I mean by "can we get back to talking about the more pressing matter" is, can we get back to talking about transvaginal unltrasounds In this particular FPP, since it's what it's about in the first place. I invite anyone to do a FPP about limiting access to contraception based on forced Pap Smears, as it's something I didn't know about.
posted by EmpressCallipygos at 10:08 AM on March 25, 2012


I agree that this has become a derail, I just don't think that the way to end the derail was to suggest that one issue was less important than the other, which you did appear to do at certain points. There are plenty of very important things that aren't the subject at hand, after all.

I'm sorry if you feel people have twisted your words, I'm fairly sure that was no-one's intention, it certainly wasn't mine.
posted by howfar at 10:42 AM on March 25, 2012


"not as important as" was a poor word choice on my part, my apologies. I meant more "related, but different enough that I think it's a significant derail."
posted by EmpressCallipygos at 12:45 PM on March 25, 2012


Why not mandate mole screenings when you buy sunscreen then? My mother almost died of skin cancer and if you are buying sun screen you probably intend to be out in the sun. There are all kinds of cancer screenings that are good to get, however they should be a woman's choice and not a condition for her to make reproductive choices.

But, you don't buy sunscreen from a physician. Meanwhile, it's kind of hard to make reproductive choices without a uterus.

I don't actually think that there's a terrifically compelling reason to require prescriptions for ongoing use of BC pills at all. But we do, and all prescription drugs generally require at least a yearly check-up of some sort with a physician, during which you're assessed beyond the bare minimum directly related to the prescription. This is a good thing, the doctor treating you as a person, not just as a singular medical issue.

I mean, c'mon, my allergist checks my height at every visit, which I promise you, has nothing to do with my sinuses. (And she will call in scrips over the phone w/out requiring visit, but only if I've seen her within a year.)
posted by desuetude at 8:49 PM on March 25, 2012


all prescription drugs generally require at least a yearly check-up of some sort with a physician

I don't know where you're getting this info, but it's not true. My psychiatrist has never required this to prescribe anything to me, and I haven't had an annual check up in several years.
posted by krinklyfig at 4:01 AM on March 26, 2012


It is interesting to me that there are quite a few people in this thread who appear to regard bodily autonomy as a right that may be suspended when it is for an individual's "own good". I'm sure that the supporters of compulsory transvaginal ultrasounds believe that they are for the good of those subjected to them.

I'm not trying to draw an equivalence, there are some very unpleasant motivations that apply to the promoters of such ultrasounds that do not apply in any way to people making "own good" arguments here. However, I also think it's worth bearing in mind the very slippery slope one steps upon when defending depriving someone of a liberty in order to improve their life.
posted by howfar at 8:06 AM on March 26, 2012


> I don't know where you're getting this info, but it's not true. My psychiatrist has never required this to prescribe anything to me, and I haven't had an annual check up in several years.

Your psychiatrist is a physician. He does want to see/evaluate you in person at least once per year, right? That's what I meant by a check-up with the prescribing physician, I didn't mean a full physical exam by your GP.
posted by desuetude at 7:58 PM on March 27, 2012


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