Wednesday, December 30, 2015

Quiz: What's Catholic Teaching on Family Planning? (Shocker)

This post conforms to the blog rules.Catholic doctrine on contraception (including hormonal and non-hormonal, long- and short-acting) is:
  1. Use of contraceptives by sexually active persons breaks up the unitive and procreative aspects of sex, and is grave matter that may constitute mortal sin.
  2. Contraceptives are a band-aid for women's health issues and should not be used for medical purposes in women who are not sexually active.
  3. Contraceptive use is technically occasionally licit (i.e. not objectively wrong), but is always imprudent.
  4. A and B
  5. A and C
  6. None of the above
The answer, shockingly, is F. Humana Vitae (HV) explained why contraception is objectively sinful because it destroys the good in licit sexual acts. The only licit sexual acts occur within sacramental marriages, and HV only touched on contraception in marriage. When sex occurs outside marriage, there is already an objective evil. It is not clear (i.e. it is not yet part of Catholic teaching) whether contraception augments the evil in these actions (like fornication, adultery, and extramarital sexual abuse) or can mitigate it. Theologians who wish to think with the mind of the Church have gone both ways on this issue. Many, like Germaine Grisez and Janet Smith, have opined that contraception is always wrong. Others, like Fr. Robert Landry, maintain that it is not always objectively illicit, but is usually or often imprudent. For more, here's Jimmy Akin.

True or false: It is good that children not come of non-marital sexual unions.

True. It's occasionally uncomfortable to admit it, but it's actually good when children are not conceived outside of marriage. Children have a right to grow up in a family, raised by a father and a mother, and many or most children born today are born with this right infringed. You're not a eugenicist if you think it's good that children's rights are preserved. Don't believe me? Try the next question.

True or false: It is good that children not be born of non-marital sexual unions.

Careful here. It's good when children aren't conceived. But once conceived, their rights must be protected as much as possible, including their right to life. Post-fertilization effects and abortion rob a child of something even more basic than the right to be raised by mother and father.

Catholic doctrine on primary sterilization (mutilating of a human body by removal or altering of otherwise-healthy organs for the sole purpose of destroying fertility) is:
  1. Sterilization is mutilation of the human body, which is dignified not only by creation in the image of God, but also by the Incarnation.
  2. Temporary sterilization is occasionally appropriate even if the principle of double effect does not apply.
  3. The Catechism only specifies that sterilizations on innocent persons are against the moral law.
  4. A and B
  5. A and C
  6. None of the above.
The answer is A. No temporary sterilization, no sterilization ever unless there is a medical reason for removal of a "diseased organ." C is interesting. The second half of a sentence in CCC 2297 states "directly intended amputations, mutilations, and sterilizations performed on innocent persons are against the moral law." But to take this and run off sterilizing prisoners would ignore the first half of the sentence: "Except when performed for strictly therapeutic medical reasons...." With all this information, let's go see a patient.

Case Study: A 32-year-old African-American G5P2113 (pregnant five times, with two children born at term and one born preterm, with one abortion or miscarriage, we don't know which; currently pregnant) at 26 weeks presents to obstetrical triage at Hospital A with abdominal pain. This is her third visit this pregnancy. She consistently maintains that she receives care at the resident clinic at Hospital B, but has likely never established prenatal care. She is unmarried and does not have custody of her living children. She has multiple psychiatric admissions for bipolar disorder, she is not currently on medications, she is currently homeless, and the resident seeing her suspects she just came from selling herself. She has been kicked out of several maternity homes for disruptive behavior. During today's interview in triage, she appears disheveled and emotionally labile. It is clear from her responses to questions about her medical and social history that she is either intellectually disabled or out of touch with reality. She insists that she is full term and that it's time to induce her labor, although her triage workup reveals no evidence of labor, or other obstetric or gynecologic pathology. Upon the patient's discharge from triage from Hospital A, the attending supervising the resident states, "she needs a strong postpartum plan," meaning that she should receive a LARC or be sterilized so that she won't get pregnant again. Hospital A and Hospital B are Catholic. What is an acceptable postpartum family planning option for this patient?
  1. Natural family planning/fertility awareness
  2. Mirena
  3. Paragard
  4. Nexplanon
  5. Essure
  6. Postpartum filshie clip tubal ligation
  7. Parkland method tubal ligation
  8. Depot haldol and social work consult for another group home placement
A: Wrong. There is so much beauty to NFP, but for a woman who doesn't have money for bus ticket and who isn't medicated and out of touch with reality, it is not enough.

B: Wrong. Mirenas can be placed immediately postpartum but rate of expulsion is relatively high. Plus, mirena is a progestin-containing system and has post-fertilization effects.

C: Wrong. Paragard can also be expelled when placed in the postpartum period, and also has post-fertilization effects.
D: Wrong. Can be placed postpartum, but has post-fertilization effects.

E: Wrong. Cannot be placed postpartum, and is a permanent, primary sterilization.

F: Wrong. Even if it can safely be done postpartum and is as close as you can get to a temporary sterilization (you can pop off the clips and re-anastomose the tubes), it's still a primary sterilization and HV condemns even termporary sterilizations.

G: Wrong. That's a permanent primary sterilization.

H: Really? That's the best we can do for her? I am totally dissatisfied with our options. 

This woman is unmarried and her ability to truly consent to sex is in question. Children have a right to be born to a family, raised by a mother and father, and it is better for her not to have children right now. I can't render her sterile because that is objectively wrong. It may not be objectively wrong for me to render her infertile (although it might be imprudent), but all my options for rendering her infertile (aside from condoms, which she can't control) have postfertilization effects.

Conclusion: I want to think with the mind of the Church. I know Catholic teaching, like every appropriate body of law, does not include dicta for every particular situation. But I know Catholic teaching grasps the truth whenever it speaks on issues of faith and morals. And it works, because it's the truth. 

But right now, there is nothing that works for patients like my case study (and I have seen her for three of those four triage visits). Where is the truth here? Do I need to develop something new?

Tuesday, December 15, 2015

Emergency Contraception

Emergency contraception can be considered licit as a form of self-defense after sexual assault. It deserves a long exposition (which I can't give you while I'm on my month of nights*), but here's quick a rundown.

The Ethical and Religious Directives are more specific here than on ectopic pregnancy. Directive 36 states:
If, after appropriate testing, there is no evidence that conception has already occurred already, [the female victim] may be treated with medications that would prevent ovulation, sperm capacitation, or fertilization. It is not permissible, however, to initiate or recommend treatments that have as their purpose or direct effect the removal, destruction or interference with implantation of a fertilized ovum
What does this mean practically? "Appropriate testing" is often taken to mean the Peoria Protocol.** The Peoria Protocol lays out how to tell with moral certainty that a woman has not ovulated and that the primary effect of EC is anti-ovulatory. It involves serum progesterone (<1.5 is pre-ovulatory, okay to give EC) and urine LH (negative is pre-ovulatory, okay to give EC).***

Unfortunately, even if the Peoria protocol can predict the right timing for emergency contraception, it's not clear we have anything to use.
  1. Hormonal IUDs: insertion of a mirena or skyla as EC relies not only on the anti-ovulatory effects of the levonorgestrel, but also on the intrauterine effects, which act after fertilization. Although it may be argued that application of the Peoria Protocol could allow these effects to be avoided, a systemic hormone (to reach the hypothalamus) is more targeted than an IUD, which would also have to be removed if the patient is later sexually active.

  2. Paragard: this relies on post-fertilization effects (which is why it works up to five days after the act of intercourse), and cannot be licitly used.

  3. Plan B: is levonorgestrel, given in one 1.5mg dose or two 0.75mg doses twelve hours apart. Strangely, we can't seem to figure out whether its main effect is primarily anti-ovulatory or post-fertilization. A 2016 review of plan B, done through a Catholic lens as a summary of lots of work by the same authors, found that plan B almost always works through post-ovulatory mechanisms, even when administered before ovulation.

  4. Ella: ulipristal is a selective progesterone receptor modulator. It is given in one 30 mg dose. It antagonizes progesterone at its receptors on the endometrium, which mean it only has post-fertilization effects. This is the same mechanism of action as mifepristone (RU486, which is given in doses of 600mg for elective abortions). Although package inserts deny that it is abortifacient, this indicates that a 30mg dose is not suspected to have post-implantation effects. For a Catholic who understands life to begin at sperm-egg fusion, ulipristal is extremely likely to lead to loss of embryonic life.
  5. Hormonal pills: these may be licit before ovulation (still need the Peoria protocol), used in a Yuzpe-like regimen, so that there's enough estrogen to actually act as an anti-ovulant. More research needed!
  6. Meloxicam: this COX-2 inhibitor can, at doses of 30 mg/day taken for five days during the late follicular phase and the day of the LH surge, prevent functional ovulation in 90% of women with no effect on LH, progesterone, estradiol levels, or cycle length. There are concerns that NSAIDs disrupt implantation. Jury's still out, but this seems the most defensible option at this time. It relies on a hospital's ability to identify the follicular phase/LH surgr (a.k.a. you need the Peoria protocol).

*I wrote the first draft of this post on a month of nights my intern year. By the time I got back to it to revise it, I was on a month of nights during my second year. Wow.

**A complete moral explanation supporting the Peoria protocol can be found in Slosar JP. Catholic health care and emergency contraception. Healthcare Ethics:2000;8,4. (No link available.)

***Notice I didn't give units. Do not use cutoffs in a blog post to determine management of patients requesting EC. You need a working relationship with your hospital lab and you need to be better acquainted with the Protocol's other reference ranges for progesterone before you can use it.

"Absurd States," Gradualism, and NFP

This post conforms to the blog rules.I'm going to tie two patients together to illustrate a point about the difficulties I'm facing in a post-pill culture. The phrase "absurd state" in the title comes from the phrase used to describe cryopreserved embryos, who need to be maintained in cryopreservation to avoid likely death. It's a state that would never had existed had we not used technology outside of the truth.

I saw a  patient at one in the morning on call a few weekends ago. My diagnosis was round ligament pain, but we spent most of the visit talking about how she was trapped in a cycle of heroin and cocaine use, and she wanted to get clean. She had overdosed twice in the past week, she told me, and she didn't want that for her future. She told me about her plans to get into a suboxone clinic and a maternity home. She impressed me and I told her so.

Exactly twenty-three hours later (I looked at the clock) she was back after being found unresponsive, having overdosed again. She was brought back with narcan and the emergency department sent her to triage to rule out obstetric concerns. In the words of my second-year who was in triage at the time, she was "high as a kite." I was angry at drugs and angry at her for ruining a life that had such potential to turn around. I'd been told that if drug addicts' lips are moving, they're lying. I grew used to that as a fact during my time on the substance abuse service as a third year med student, but it stung to be reminded.

Three overdoses in a week. "She's going to kill herself," I observed softly to my second-year. One of these times, someone's not going to find her, or she's going to make sure she's not findable.

"That poor baby," added my second-year. Both baby and mother were in an absurd state, brought about by drug developments and the breakdown of marriage, families, and mores.

I saw a different patient in clinic a few days later. This one had been addicted to narcotics and benzodiazepines, but had weaned off her narcs by the time I saw her. She complained that she had missed so many prenatal care visits because she'd lost her job and was now living with her two alcoholic parents. I was less impressed with this person from the start, but I sympathized and tried to connect her with social help to get her better situated. Narcotics and benzodiazepines, more than some other drugs, seem to make people childish.

Not a week later, she happened to present to triage in labor, and I saw her with her mother, who looked exactly like mine. I know people can hide alcoholism more than they can hide, say, meth addiction, but I was even less trustful of this patient than before. She was moving her lips when she called her parents alcoholics; was she lying? I saw her postpartum. She was not handling new motherhood well, and I was again unimpressed. I know the postpartum state is uncomfortable (especially when we aren't giving you your xanax), but I felt frustrated by this patient, and I spoke with a little more sternness than I usually do.

"Do you want to be pregnant again?"

"No," she answered. "Unless I meet Mr. Amazing."

I ignored the comment and dug back to the issue. "What are you planning to use to prevent pregnancy?"

"Abstinence," she answered readily.

I had to recover from an instant of shock, because she was completely serious. "Is that what you used before this pregnancy?" I asked, unimpressed in the extreme.

"Yeah," she said, still serious. "It worked really well until one day I just said '**** it.'"

I was pressing my lips together in frustration at this point. "This time," I said, "I want you to think about another way to avoid pregnancy."

"I don't want my tubes tied."

"I don't think you should have your tubes tied," I rejoined. She was under thirty and there was still hope that she'd stop the benzos and go back to a normal life. "But abstinence didn't work last time, so you can't use it again." I gave her a run-down of the available methods of family planning, including NFP. And then came the time in my life I never wanted to come: I advised that someone not use NFP.

"But fertility awareness takes discipline," I said at the end, "and I don't think that's the best choice for you right now." The words were like a knife in my soul, but I went on: "You either need to make big changes in your life so that you can develop that discipline, or you need to use something that will chemically change you so that you can't get pregnant."

Our culture has become dependent on birth control. There are failings in the culture that seem to now need the crutch of birth control to avoid great evils. There are whole swaths of souls in absurd states. Following in the (unfortunately infamous) footsteps of Benedict XVI, I applied the principle of gradualism during that conversation. Was I wrong? I went to confession and the priest was vague; he told me it was grave matter (which I knew), but did not tell me whether I had sinned or not.

It's in these cases where I begin to feel very culture-of-deathish sentiments creeping up in me. Sentiments like "she shouldn't be able to be pregnant any more," or "it would have been better for that child not to have been conceived." But those are lies. A life can be made right and she should keep her fertility. And that life is precious, and should be cared for (by another person, perhaps).

But does gradualism allow us to avoid the objective evil and choose a lesser evil in situations like this? Not because it's good, but as a bridge to what is good? Can I suggest mirena (not as my peers do, as a panacea for all female woes, but) as a rescue until a person's life can grasp the good?

This post doesn't come to a clear conclusion and I'd appreciate comments and suggestions.

Saturday, November 28, 2015

Whether to Consent for Tubal Ligation

The Hiding Place is the story of a Catholic watch maker who sheltered Jews during the Holocaust. She was taken to a concentration camp, where she was put to work on an assembly line. As a watch-maker, she took easily to the assembly of relay switches. Too easily. She recounts how her foreman, a fellow prisoner, reacted:
"Dear watch-lady! Can you not remember for whom you are working? These radios are for their fighter planes!" And reaching across me he would yank a wire from its housing or twist a tiny tube from an assembly. "Now solder them back wrong. And not so fast! You're over the day's quota already and it's not yet noon."
I am a pretty good intern. I can see seven postpartum patients in an hour and a half, consent half of them for circumcision, counsel half of them on family planning options, discharge half of them, write their orders, finish and route their notes appropriately, and present them coherently at morning rounds. I still miss a detail here and there. But overall, I'm pretty good at what I do.

I can even consent for tubal ligation and arrange the paperwork for the two different states in our catchment area. (I have previously opined that it is not morally wrong to consent patients for BTLs.) But should I be this awesome at hooking people up with sterilizations? Should I be making it harder for people to get BTLs and, for that matter, contraceptives?

"Dear intern!" I hear in my head, "Can you not remember for whom those sterilization papers/OCPs/LARCs work? Those break down marriage and the family!" Many thoughts have flown in the past few weeks about whether I should yank some wires. (Note that I am not comparing my attendings and fellow residents to Nazis. I am only opposed to sterilization, not the people who do it.)

Thanks to: and uptodate
On one hand, it is not my legal right or my professional prerogative to interfere with choices made by competent persons. It's not only feminist hate crime, but it could probably be construed as malpractice to interfere with someone's BTL by not completing their paperwork in a timely and correct fashion before their discharge. Anyone suing according to standard of care would simply point to ACOG's Opinion 385 and say "Doctor, this Opinion is standard of care. You were not practicing according to standard of care."

On the other hand, a little slip in the paperwork and someone could be delayed in receiving a BTL just long enough to have a different thought about it. One in five women who choose BTL within a year of their delivery regret it. And permanent primary sterilization is a grave evil even if someone doesn't rethink it. Did Corrie ten Boom care whether she'd be punished for soldering the wires wrong?

In the end, I decided to apply the principles I apply to any other consent: I counsel completely and accurately, I give the patient time (e.g. I tell them to think about it and talk with at least one other family member on postpartum day 1 and/or 2) and I fill out the paperwork if the patient chooses on the last day I see her. I have had patients who say (after I talk with them), "I decided not to, I'll just go with the [other method, usually a LARC]." I'm not happy about the LARC, but I am full of joy that I can throw away their BTL consent and hope that they learn to appreciate their fertility in the time they've afforded themselves.

Some disagree with me about whether BTLs are good for women, and others disagree with any involvement in the process. But I doubt that many would disagree with my approach to postpartum tubal consents: I counsel completely, give the patient time to make their own, informed decision (and speak with the attending after I see them, who usually offers a different opinion). I then witness when they make this decision on a form for the state.

Sunday, November 15, 2015

How to Consent for Tubal Ligation

There are two important things to discuss with patients when consenting for BTL: permanence and regret.

Only 50-56% of women can have a child after a tubal reversal (26% if you're trying to reverse it after age 39). The largest study done on tubal ligation was a prospective, multicenter piece of research done by the CDC, and was called the CREST study. It found that people under the age of 30 are 3.5 to 18 times as likely to request reversal than those over 30 (of those sterilized between 18 and 24, 40.4% requested information on reversal).

Not all insurance pays for the reversal, either. 

The CREST study found that 14 years after BTL, there is a large amount of regret, especially among patients with certain characteristics. Here are the numbers for regret at 14 years:
    • 20.3% of women who were 18-30 years old regretted their sterilization
    • 21.7% of black women
    • 20.4% of unmarried women
    • 17.6% of women who chose BTL within a year of their last child's birth
Regret develops in a linear fashion, meaning that around 5% regret at 3 years, then 10% at 7, then 20% by 14 years. It's difficult to extrapolate 14 years over a lifetime, especially a woman's lifetime, which has a natural time of infertility that can bring on or increase pre-existing regrets.

When women are under the age of 30, black, unmarried, or choosing BTL within a year of delivery, I counsel them that about 1 in 5 women like them regret their decision to get a tubal ligation. I also stress that the real world is not like Friends, and BTLs are permanent. I recommend on pospartum day 1 (or during prenatal care) that they talk about the decision with their loved ones and look into LARCs (and natural methods, of course), which are reversible and can be just as effective.

Friday, October 30, 2015

Two months in review (9-10/2015)

In the past two months, I've been on Labor and Delivery, and on the clinic service. During this time, I clocked my personal best and worst weeks in terms of duty hours. I logged 92 hours on week on L&D (when I worked two weekends on either side of a busy week), and I logged 30 hours on a (very average) clinic week.

I got a lot done during that month of 30 hour work weeks: doctor visits, dental appointments, making curtains, a car wash, moving forward on research projects (18 patients recruited for my survey study, phone calls towards one patent, drawings for a manufacturer on another, and signing on to another device study at my hospital), and moving forward on fun projects (contacted an illustrator on two children's books [was turned down but hey at least I contacted someone], and went live for beta testing on another [sorry I can't link or it'd compromise anonymity]). I also furthered some of the NFP projects, completing fundraising on a video project for NFP-only interviewees (now that's gonna compromise anonymity when the video comes I'll probably have to delete that later), completing a final version of new-evangelization-style NFP handouts for patients in our metroplex (and getting half of the funds for that!), and half-finalizing the manuscript of the pocket-Napro book that myself and another NFP-only resident are working on.

I have learned to do a discharge summary in ten minutes. I have learned to do dishes once every two weeks without inviting every bug in the metroplex. I have started walking to work more (because I hate scraping cars).

I'm still chronically exhausted. A major spiritual battle right now is how to deal with fatigue; it's actually the core battle of my life. At the same time, I am tempted to think I do not pray, sacrifice, or love God enough. But the reality is, that my prayer (outside the starvation rations of just MP, EP, and meditation) is the prayer on the Cross: complete obedience and self abnegation. And my penance is the penance of Christ's ministry: who needs flagellation when all personal time is lost in a 90 hour work week?

P.S. There are two additions that need to be made to OB/GYN Ethics 101: methotrexate for ectopics, and emergency contraception. I'm also working on elevator speeches and details on the post-fertilization effects of IUDs. Thank you for being patient! The next five months will be very, very hard for me and I have posts scheduled through that time, but new material will be slow to come out.

Thursday, October 15, 2015

Racism or Love?

This post conforms to the blog rules.To my surprise, one of the things I'm adjusting to in my new city is the tension of race. Perhaps it's because the population is less diverse (where I came from most recently, the population was about 40% white, 25% black, 25% Hispanic, and 10% Asian, while my new hospital is about 40% white, 60% black). Maybe the events surrounding Ferguson have made racial tension more dramatic everywhere. But I think it's probably because I'm more immersed than ever before (eighty hours a week with a 60% black population), and I've realized that being black in America is not just a color; it's a well-developed and different culture.

I've spent much of the past month thinking, talking, and working through my reaction to this culture. In so doing, I've realized I've held most of the predominant mentalities on the question. Let me take you on the tour.

Mentality 1: Classism
Src: Joe Pappillon
I was raised in the geographic south. My parents are upper middle-class white homeowners and I was raised in a neighborhood of the same demographic. Our neighborhood was across the street from a large swath of low-income apartments which were primarily occupied by black people. In the name of safety, I was raised to see that neighborhood and those people with an unfortunate lens of distrust, pity, and even occasional pitilessness (because "they're doing it to themselves"). The expressions "trashy" and "work ethic" floated around our house when race came up.

Mentality 2: Positive Discrimination

Src: Slate on Fisher v. Texas
As a kid, I played T-ball. There was one black girl on the team and I recall a perfect memory from left field, as it dawned on me that my ancestors were on the cruel side of history, and hers were the victims. I wanted to do something to make it up to her. Childlike, I imagined bringing her an armful of presents, before I realized that she wouldn't understand or really benefit from them. Ever since, I've thought the desire to atone for the past in the complicated present is childish. Then I realized how many black people think it's a great idea. (This only makes sense. I'm sure my T-ball teammate would have loved an armful of presents.) It seems like a good idea for some issues in some communities, and an unnecessary crutch in others.

Mentality 3: Color-blindness
At my upper-class, white all-girl high school, I received a nauseating overload of privilege-awareness, minority-empowerment, and bias-shedding. (My teachers were young and teaching the hip doctrine of cultural acceptance, or they were old and had unresolved guilt from the era of segregation.) In our white, upper-class bubble with little to no involvement with the cultures we were supposed to tolerate and nurture, all this had the opposite of the intended effect: I ached for the day when people would please stop talking about race. Freeman said it, and he's black, so isn't it true? (No: watch how easy it was for me to snap right out of it into something dangerous).

Mentality 4: Overt Racism
Then I started residency and realized how well-developed and different black culture really is. I was repulsed by one particularly bad experience during a clinic month: a childish, obese woman and two badly behaved, screen-dependent toddlers made me extremely angry. I felt like I needed the "control of the classroom" that my teaching friends talk so much about! There had been so many patients who were kind and well-behaved of various races, but an unfortunate run of those who were not, all of a single race. And here I met the most frightening mentality I'd ever had: true racism. I was an inch away from attributing my frustration to the wrong thing (race), an inch away from thinking, "All these people are so juvenile and disgusting."

I caught myself, terrified that such a thought could cross my mind.

Gone was my idea that racism doesn't exist: as long as people will enjoy spending time with people who look like them, we'll have different cultures that cluster around different races. And as long as we have different cultures, we'll have the potential to attribute our frustration with individuals to race. But the problems in that exam room was so deeply rooted that I couldn't go to the idea that I or others could somehow "make up" for the complex series of events (since the 1600s) that led us to today. And I couldn't accept the childhood classism: I saw it for what it was in that exam room, just a soft racism. I went home confused that day.

Mentality 5: Love
A week later, I was working in a community clinic and met a black woman who humbled me. At my age, she had four children under six and was pregnant again. She had just left the father of her children because she'd discovered he'd exposed himself and her to HIV, and that he'd had another wife and fathered three other children while he was fathering hers. But she was firm in her plans to raise her children well. Her two year old was with her and very well-behaved. Sitting across from her, I was impressed at how generous she could be in spite of all that had happened to her. And now I knew what to do with my confusion about race.

Her culture, I thought, is broken--it makes for some broken families and selfish, addicted people. So is my culture. Why can't I be mature enough to look at each person as they are without a) dissociating them from their color and culture but also without b) attributing all the negatives attached to that culture to them? Why can't I be prudent enough to combat objectively problematic elements of black culture while also calming down about others?

A classist will whisper "That woman's probably a welfare mom." Positive discriminators say, "We need to pour more funds into the programs that assist STD prevention." The color-blind protest, "I don't see how marital turmoil is relevant to the question of race," and a racist would say something not worth printing. None of those contain the full truth. The right answer is the simplest: love each person without ignoring the problems and the beauty in them and their world.

I'll end with an observation about the beauty of black culture. I'd never heard or seen an ice cream truck until I moved out of my white neighborhood and into the inner city. The first time I heard the truck go by, I was so shocked that I stood up and went to a window. Why hadn't I seen one before? There was more isolation and fewer children where I grew up. (We were one of four families on the whole street, the other three of which had six children combined). We never played with our neighbors and our extended family are all out of state. Last year, among the low-income apartments that I used to distrust, I saw parents (yes, mothers with fathers!) walking children in strollers and whole extended families partying on patios.

It still takes me effort to avoid falling into classism and color-blindness. It's worth the work, though: not only is it the right thing to do, but it's much more satisfying and fruitful to love.

St. Agnes. Credit: Mike Boening

Sunday, September 13, 2015

How to Counsel on Family Planning

Ask whether they want to be pregnant (in a clinic or postpartum setting) in the next few years. Based on the respose, talk about the three types of family planning methods: long-acting, short-acting, and natural. Long-acting includes nexplanon (3 years), mirena (5 years), pargard (10 years), and depo (3 months). Short-acting includes the pill, the patch, and the nuvaring.

You have to explain natural a little more, because Sex Ed and Bedsider haven't already. I explain FABMs like this: "There are fertility awareness methods that researchers have found to be effective. Our bodies are smart: we can only get pregnant a few days a month, and our bodies give us signs about which days these are. You can learn to pick up on these signs and know every day whether you can get pregnant that day, or whether you can't. And based on that, you use that day for intercourse or not. Some women find it really empowering."

If they express interest in FABMs, I always add: "It's neat because you'll be able to use it all your life. But to get that confident with your own feritlity, you do meet with a teacher. Maybe decades ago women knew this, but our mothers haven't taught us! Do you have the time and transportation to meet with a teacher? Usually it's every two weeks, then every month, and it takes about six or eight months to feel really confident." (Some are online if the answer is no.)

The Good
The Bad
Cost (cash)
Some with Fe, folic acid
Effectiveness based on pt (applies to all short acting and FABMs)
24+ h
estrogen warnings (never in daily smoker > 35 yo, h/o DVT/PE/CVA/MI, SLE with APA, migraine w aura + FNDs)
POPs (progestin-only pills)
Safe in lactation (applies to all progestin-only)
Intermenstrual bleeding, spotting
24 h

Ortho evra (patch)
Simpler than pills
Doesn’t work well >90kg, double risk VTE compared w/ OCPs
7 d
Lactation, estrogen warnings
Simpler than pills
Vaginal discharge
7 d
Lactation, estrogen warnings
Depo provera
Amenorrhea in 55% at 1 yr, 68% by 2. Decreases crises in SCD
Irregular bleeding, wt gain 3lb/yr, reversible bone loss
3 mo
possible pregnancy, local cellulitis
No GU tract procedure. Palpable by patient
Unpredictable bleeding that doesn’t Δ w/ time. 10% rule for 1) irreg bleeding, 2) wt gain, and 3) acne
3 yr
possible pregnancy, local cellulitis
0.2% for yr 1
0.7% by yr 5
Amenorrhea in 20% and oligo in 60% at 1 yr
Irregular bleeding first 3-6 months
5 yr/ 3yr
IUD contraindications (<6wks postpartum, uterus sounds >8cm, possible pregnancy, untreated GU infxn incl PID in past 3 mo) plus brca, anticoagulant use, liver dz/tumor
No hormones
Increased bleeding with natural cycle
10 yr
IUD contraindications plus Wilson’s
Translates into GYN managmt, distance teaching
Very involved charting and follow-up
Language barrier, h/o noncompliance

Needs follow-up
Language barrier, h/o noncompliance

Objective, online teaching available

Monitor $200
Strips $35/30 (need 10+/mo)
Language barrier, h/o noncompliance, not good with devices

Thermom $10
Couples only
Most difficult rules
Language barrier, h/o noncompliance

I always put something in her hand if she wants to try a natural method. That's the way the prescriptions and devices work: there's always a pill pack, a crisp, robust brochure, or a prescription at the end of conversations for contraceptives. When I refer a patient to an NFP teacher, I hand her a nifty little packet (I made a bunch of these) with the person's business card and a page detailing her new method of family planning and singing its praises.

Prices for FABMS vary by location and teacher. I called around to get prices for each of the teachers I refer to (MM, CrMS, and BOM in my new metroplex) so that I can tell the patient what to expect.

Sources: the chart is reprinted from FACTS with the author's permission. Her sources:
Cost estimates: 1 and 2.
Mirena data: PI.
Depo data: PI.
Nexplanon data: PI. (No pregnancy rate, so I used the norplant datum from the paragard PI, which matched the CDC data linked below.)
Nuvaring data: PI.
Patch data: PI
Paraguard PI is here, but there aren't any numbers on increased bleeding.
Effectiveness: CDC (6% for depo)
The big chart you might see everywhere is from Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Stewart F, Cates W, Stewart GK, Kowel D, Guest F. Contraceptive Technology: Seventeenth Revised Edition. New York, NY: Irvington Publishers; 1998.
FABM review here.

Saturday, August 29, 2015

Two months in review (7-8/2015)

In the past two months, I've been on night float and on the ultrasound service. I've worked an average of 68 hours per week and used 1-2 servings of caffeine per 24 hour period. I've delivered 35 babies, done 5 C-sections (as primary surgeon), and done about 160 ultrasounds of various types.

I'm learning how to admit patients to triage, evaluate them, "dispo" them (send them home or keep them), answer dozens of types of nurse and patient phone calls, and "update the board" (keep abreast of what every patient is doing in labor and delivery). I'm also working on ways to wash laundry only every other week, recycle in my small borough, cook only once a week, make a bed while getting out of it, and shower in the time it takes to sing a Credo. I've replaced a car battery, hung blackout curtains, and bought several loads of furniture. And most importantly, I'm trying to make space in all this work for the liturgy of the hours, meditation, the rosary, confession, and Mass. I've made a lot of mistakes, but I'm being patient with myself as I try to do better. It's been a challenge.

I enjoy the work, especially when the deliveries are beautiful or I get things right. I'm at a good hospital with excellent and friendly nurses and my upper levels and chiefs are paying it forward, being kind to me so that I can be kind to the students and the next generation of residents in the future.

Things to learn in the future are how to not miss morning meditation, how to write discharge summaries in ten minutes, how to round on a dozen people in an hour and a half, and how to do dishes only once a week without starting an impromptu microbiology lab. I am also working on having local NFP resources printed for handing to patients in clinic (which is happening in the next two months) and having my elevator speeches together for when I am doing nothing but seeing postpartum and clinic patients. Any prayers would be appreciated!

Friday, August 14, 2015

Consecrated Virginity FAQ

On June 20, 2015, I became a consecrated virgin living in the world, according to canon 604 of canon law (the body of legal principles governing the Catholic Church). This vocation is ancient and new, and it's viewed positively by traditional Catholics. There is already an excellent FAQ on consecrated virginity in general, but because of previous posts and the very worldly nature of my schedule, I wrote this post.

What do you do?
As of this writing I'm an intern in obstetrics and gynecology, so I work fifty- to eighty-hour weeks at a hospital in labor and delivery, the emergency room, the operating room, and the women's health clinic. I also pursue research in fertility. But what I do is less important than what I am: a bride of Christ. I will live a life of prayer and penance and remain without marrying a human person (and without physical children) in this life.

You're a consecrated virgin and you spend seventy hours a week with pregnant people and researching fertility?
Yes. God has a sense of humor. (But there's also a long precedent of consecrated women caring for women, mothers, and children, so I'm not that strange.)

So! You're childfree?
I suppose it depends on how you define "childfree." If you mean "without children," then yes. I have made a permanent, irrevocable commitment to preserve my physical virginity, so I will never voluntarily have sex and thus won't have children. (Not only will I not bear my own children, but I cannot act as a surrogate or adoptive mother, since these actions don't dignify children according to their right to be raised by their father and mother. Accepting the moral teachings of the Church is part of being a Catholic, which is a prerequisite to consecration.)

But I thought "without children" was the meaning of the word "childless." I am not an expert, but I thought "childfree" meant at least two things besides "without children." I thought it implied 1) sexual activity and 2) a belief that children aren't desired. Even though childfree men and women often sincerely acknowledge that they love children (and some choose to be childfree to care for children of others), they have decided that for them, or for now, or forever, children are not desireable as a fruit of their sexuality.

Although I'm a sexual being and still live my sexuality, I don't have a "sex life," so I can't make the decision to be childfree (as I understand the word). Of course, if "childfree" only means "without children," I am childfree. (So's the pope, and he has plenty to say about the decision not to have children.)

So, you pretty much just had a wedding ceremony by yourself?
No. Human persons are meant to give themselves completely to the infinite Love that is God. Whether they do this through another human or directly (by God's grace!), they must make a total sacrifice of self so that nothing is left. To "marry oneself" is impossible--one can't give everything away and also be receiving it. The woman in the story I linked to was having a wonderful epiphany about the independence of her strength and happiness from the lives of other persons, but she wasn't marrying herself.

So no, I'm not marrying myself. Am I marrying anyone at all? Yes. "Virgo est qui Deus nubit," St. Ambrose said, "the virgin is she whom God has married."

Oprah covered the final vows of several Dominican sisters and pointed out that their vows are a marriage. However, she said that "the groom is present only in spirit." I remember watching that episode and laughing a little sadly. God the Son is more present and more real than any human person, even far away from the blessed sacrament.

God is not some imaginary thing we think off to. He stands under and continuously creates everything. It's because He has you in mind that you're existing right now. So no, I'm not marrying a vague spiritual idea. I'm marrying He who Is, who is more terrifyingly real than any thing.

Is this because you want to be a priest? Would you be a priest if you could?
No and no. I want to be the saint that Christ has in mind when He loves me. That saint is feminine, and has quite a lot on her plate without trying to be an alter Christus as God shapes only men to be. I love my call. I think it's probably the most fantastic one He's ever created!

I don't think the second question makes sense. It's like "what animal would you be?" It might tell a little about me, but it's bound to misrepresent me if it's taken absolutely. Just as I can't (and don't want to) become an eagle, I can't become a priest, since God gave us a fatherly priesthood. But just as I could (and might) say at a dinner-party "I'd like to be an eagle" because I would love to fly, I can say (like St. Therese) that I would love to be a priest because I want to resemble Him in every way I can imagine.

In reality, I have that flight of priestly glory in my consecrated virginity. Each of us has it in our calls to sainthood--we just have to take it, and bowl between the rails.

Did you choose this for more freedom from obedience? Habits?
No. Consecrated life developed from the second half of the first millennium to the end of the second. The developments were beautiful and helpful for the Church and the world of that time. And, like every development that the Holy Spirit rolls out, there is something perennially helpful about it. It is good that some wear "distinctive dress." It is good to have a structured community. But it is not necessary. Otherwise, how would so many early virgin martyrs and anchoresses have become holy?

In North America, most Catholics in the new evangelization associate orthodox consecrated life with full habits, thriving communities, and a return to the rigors of the evangelical counsels. All these things are fantastic and support orthodox religious life! However, living the counsels to the fullest, as Raniero Cantalamessa and Thomas Dubay point out, does not have to involve obedience to men, or a set degree of exterior poverty.

This was a hard pill for me to swallow, because I was wary of "consecrated women" who didn't wear habits, live in convents, have a rigorous rule of life and schedule, and exhibit the forms of obedience and poverty. Slowly, I began to recognize that I this state in life entailed complete submission to the counsels, although in a way I did not understand.

Is this something for ex-nuns?
I know consecrated virgins who left convents. In one case I know of, this was because there was not enough contemplative prayer after the novitiate in the order she joined. Consecrated virginity is not something for people who don't want to love our Lord.

Are consecrated virgins basically nuns?
Consecrated virgins have been called brides of Christ since the years of the early Church. This title that has also been accorded to nuns and religious sisters for centuries as well. But in important ways, we are not like nuns. Important aspects to the religious life include the charism of a founder, community life, and distinctive dress. Consecrated virginity does not have these elements of consecrated life, which developed later in Church history to adorn religious life.

So, you're a layperson (or in a lay movement, or you're a lay consecrated woman)?
The words "lay" and "layperson" have changed in the past century. "Lay" used to refer to anyone who was not in orders (anyone besides priests, deacons, and bishops). It then came to mean anyone who was not in consecrated life or in orders. In either sense, a consecrated virgin is as lay as a cloistered Carmelite.

Is consecrated virginity the same as making private vows?
No. Vows are made by a human soul to God; God consecrates a consecrated virgin. Because consecration is an act of God, it is permanent and irrevocable.

I do make a threefold propositum during the consecration, which beautifully lines up with the three counsels. However, I am not made a bride of Christ by my propositum. I am passively swept up as God deigns to consecrate me at the hands of His bishop.

Why isn't this a sacrament?
There are seven sacrosanct signs producing grace (signum sacrosanctum efficax gratiae). These are primary channels of grace God gave to save us, that will not change until the end of time. At the end of time, their purpose will be complete, and there will be no more baptisms, no more marriages, no more ordinations, and no more Masses. Sacramental realities will give place to non-sacramental realities.

Consecrated virginity is a non-sacramental reality. It belongs to the world to come, which is why it seems like a lack-of-something (e.g. like being childfree) here on earth.

What do consecrated virgins wear?
They wear modest clothing that suits their time, place, and work. They might dress a little more modestly than a faithful Catholic woman in their age group. Practically speaking, I wear scrubs in the hospital, conservative professional clothing under my white coat in clinics, and long skirts and modest shirts to Mass. Some consecrated women do not wear pants so that they can witness more completely to God's love in the gift of femininity. I wear pants because otherwise, I'd put up unnecessary barriers to friendships and evangelization.

Do you have a rule of life? An horarium? Superiors?
I do have a rule of life. My spiritual director approved it before my consecration. I do have an horarium, although prudent direction helps me adjust it as rotations change. I do not have superiors, although I treat my bishop as a loving father, for whom I would do anything that wouldn't jeopardize my moral or fiscal stability.

How do you live the evangelical counsels if you don't make vows?
This deserves a post all on its own! The counsels are meant to change our hearts to Christ's and make us thirst for God the Father. I live poverty by leading a radically simple life; this was rather easy as a medical student (living on loans) and is still easy as a resident (living to pay back loans). There is no money spent that is not spent for Christ and with Him in mind.

I live chastity by working to increase the purity of my intentions, so that I can be chaste in body and mind as I become single-hearted like Christ, wanting only whatever the Father wants. For instance, I often want to ask my upper-level residents for feedback because I want praise. That thirst for confirmation is better quenched by Him, so I choose chastity when I purify my intention and only ask for feedback when I want it.

I live obedience by constantly looking for the will of God. Paying attention to the circumstances and holy desires I find in the present moment, I look for ways to advance God's mission to save souls. For example, perhaps I choose to listen carefully to a patient's slow explanation of what is going on, even though I have so many more to see. Perhaps I accept my ignorance during my training as a way to be with Him during his humbling human childhood.