Not surprisingly, the headline about “designer vagina” procedures in a press release this week from BMJ Open, an online publication of the esteemed BMJ (formerly the British Medical Journal) caught my eye — and stopped my coffee cup in midair.

It appears that women are flocking to surgeons for things like “vaginal rejuvenation,” “G-spot amplification,” “revirgination” and “labiaplasty.” According to the BMJ authors, a team from University College Hospital in London, vaginal cosmetic surgery is a growing thing for women who “simply don’t like the way their genitals look.”

Good Lord.

These women are apparently concerned about the visibility of vaginal labia through tight clothing (I must be getting old. Why not just wear looser clothing?). Or, as the BMJ authors put it, they want their labia to look “sleeker” and “more appealing.” The women in question seem to have an “awareness – courtesy of a partner or magazine pictures – of larger than normal labia.” (What kind of partners would say….oh, well.)

There is an actual point, beyond sheer prurient interest, to the authors’ concerns. They are worried, with good reason as I discovered, that Internet ads touting these vaginal cosmetic procedures are of “poor” quality. That is, they often contain inaccurate and misleading information. (Are we surprised?)

So, I put my coffee cup down and did what the authors did: I Googled their search term, female genital cosmetic surgery, and sure enough, up popped endless ads shamelessly appealing to, or dare I say, “creating,” female genital insecurities. For the record, I get that some older women who’ve had multiple babies may have urinary incontinence or other legitimate complications of childbirth – or even plain aging – and might want to have things tightened up a bit. Vaginas, like the rest of our bodies, can get droopy with time.

But young women and girls worried that they don’t look right? First, it was that women’s breasts were too small – or too big. Now, it’s genitals, too? In truth, there’s as much variation in labia length as in many other physical characteristics.

What really gets me about all this is that these made-up genital insecurities make a mockery of the real, and serious, issue of female genital mutilation in developing countries. In our supposedly modern societies, women are persuaded that they don’t “look” right and are choosing surgery they probably don’t need, while girls in Africa are still forced into genital mutilation.

In reality, “Designer vaginoplasty” and “G-spot amplification” are, as the American College of Obstetricians and Gynecologists put it in a 2007 statement, “not medically indicated, and the safety and effectiveness of these procedures have not been documented.”

Which is pretty much what the British researchers concluded.

It doesn’t take a genius to question the wisdom of all this unnecessary female genital cosmetic surgery, but I called one anyway, Dr. Nawal Nour, director of the Ambulatory Obstetrics Practice at Brigham and Women’s Hospital.

Nour won a MacArthur Foundation “genius” award in 2003 for her work on repairing the surgical and emotional damage done to women through female genital mutilation. In fact, she has devoted her entire life to treating the medical complications and legal issues surrounding female genital mutilation and founded the African Women’s Health Center in Boston.

She feels that female genital surgeries, with proper counseling, may make sense if women “have truly physiological complications after childbirth” or when there are other “medical indications to perform some of these surgeries.”

But she is appalled that “more and more girls and women are thinking that they are abnormal,” and that the definition of what is considered “normal” for the length of labia has been getting smaller and smaller.

In the U.S., Nour said, it has been illegal since 1996 for surgeons to knowingly excise, that is, to surgically remove, all or part of the labia in someone under 18. As part of a survey, she called a number of surgeons and asked if they would do it anyway in girls this young. Many said yes, she said, “even though under the law that is considered genital mutilation.”

“Genital mutilation” or “female genital cosmetic surgery.” It’s a fine line, indeed. And tragic, by whatever name you call it.

I have just finished writing a book on chronic pain and, although I didn’t initially plan it this way, I ended up devoting an entire chapter to marijuana because, as I did my research, I found considerable evidence that marijuana is both safe and reasonably effective at relieving pain. In fact, if a person taking opioids (narcotics) for pain relief also smokes marijuana, the dose of opioids needed can often be reduced.

For historical and political reasons, the federal government persists in classifying marijuana as a Schedule I drug, which means it is deemed to have a “high potential for abuse” and no recognized medical usefulness. Both parts of this are false.

Although the government has stymied marijuana research in this country, there has been significant research from other countries on the risks and benefits of inhaled marijuana.

Marijuana used alone is actually remarkably safe, in part because, unlike other drugs, including opioids, it does not cause respiratory depression.

In fact, there are simply no deaths – zero – from marijuana alone, according to the federal Centers for Disease Control and Prevention. This is in stark contrast to deaths from alcohol (80,000 a year), tobacco (443,000 a year), even NSAIDS, non-steroidal anti-inflammatory drugs, which kill an estimated 7,000 to 10,000 American adults every year.

Nor does marijuana seem to be the “gateway” drug that opponents claim it to be. A 1999 report from the Institute of Medicine, part of the National Academy of Sciences, found that marijuana is not the substance that gets teenagers on the road to substance abuse – underage tobacco and alcohol use are.

To be sure, marijuana, like any other drug, is not without risks. Some studies show an increased risk of schizophrenia, especially in young people predisposed to psychosis, though even here the research is mixed. Other studies, including research at McLean Hospital, show cognitive deficits with early adolescent heavy use, though other studies suggest these changes may be reversible once marijuana use stops.

Even the National Institute on Drug Abuse acknowledges that, as one official told me, “marijuana does not kill directly,” though it can contribute in other ways to risky behavior such as traffic accidents, particularly if mixed with alcohol.

Those are serious risks, especially for young people whose brains are still developing. These risks are much less relevant for adults pain patients.

Opponents of medical marijuana often argue that making marijuana legal for medical use is a wedge toward outright legalization. But even if it were legal, marijuana could still be regulated like alcohol and tobacco to discourage under-age use.

Frankly, in an ideal world, I would go a slightly different route: I would classify marijuana as a dietary supplement like Echinacea. This, of course, will never happen. But if marijuana were viewed as a dietary supplement, it would be subject to post-marketing surveillance by the US Food and Drug Administration.

If a given brand were linked with harm, producers could be forced to withdraw that brand from the market. The government enforce accurate labeling so that consumers could be reasonably sure that the marijuana was grown, dried and packaged safely, without molds such as aspergillis, pesticides, formaldehyde or other toxins. Labels could also provide accurate information on the ingredients – for instance, how much psychoactive THC (tetrahydrocannabinol) and non-psychoactive CBD (cannabidiol) each batch contained.

I am certainly not advocating that we become a nation of potheads. But for adults in pain, medical marijuana should clearly be a legal option.

This post originally appeared in WBURs CommonHealth blog.

As the controversy continues to swirl over sex change surgery for convicted murderer Michelle Lynn (formerly Robert) Kosilek (there’s a hearing this month on whether taxpayers should pay for her electrolysis), I got to wondering about some of the questions this case raises.

Certainly, prisoners are entitled to basic health care. But do we really owe her a sex change operation?

Especially if — as some of the evidence I uncovered suggests — it wouldn’t leave her in substantially better mental health than she is in today?

I confess: I’m not sure I would even ask this question if I were sympathetic to her in the slightest. But I’m not. She is a convicted murderer. She is in prison for a reason, and a very good one.

But, that aside, back to my quest for facts: How well does sex reassignment surgery (SRS) work in the first place?

Here’s some data: There was a major study in 2011 by the Karolinksa Institute.

Using data from Swedish registers, they studied 324 people — 191 male-to-females and 133 female-to-males — who had SRS between 1973 and 2003. For each SRS patient, the researchers randomly selected 10 people from the general population who had not had SRS. From this group, two control subjects were matched to each SRS patient — one with the same sex and age as the patient at birth and the other, with the same age and sex as the patient after SRS.

All-cause mortality was three times higher for people who had SRS and deaths by suicide were also higher. People who had the SRS were also at higher risk for hospitalizations for non-gender related psychiatric problems. It’s not totally clear why people who get the surgery get worse. But the authors conclude,

“Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behavior and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism…”

So, in other words, the surgery does get rid of “gender dysphoria,” meaning deep unhappiness with one’s biological sex. But it doesn’t seem to help much with other mental health issues, including suicidality.

If that’s true for Kosilek, I wondered, why should taxpayers foot the bill?

The Karolinksa researchers did caution that for SRS patients their findings didn’t necessarily mean the surgery didn’t help at all: “Things might have been even worse without sex reassignment.”

I wouldn’t be so swayed by this pessimistic study except that it’s methodologically much better than previous research, including an oft-cited 2010 Mayo Clinic study.

Researchers performed a systematic review and meta-analysis of 28 studies of hormone therapy and sex reassignment involving 1093 male-to-females and 801 female-to-males.

The studies were observational and most lacked controls. Overall, in the Mayo review, 80 percent of people who had the sex reassignment reported significant improvement in gender dysphoria, as well as significant improvement in psychological symptoms and quality of life.

But, as the Mayo researchers themselves note, all of these conclusions were based on “very low quality evidence due to the serious methodological limitations of included studies.”

In data-speak: garbage in, garbage out.

Ben Klein, senior attorney for Gay and Lesbian Advocates and Defenders, doesn’t see it that way. “All studies have limitations,” he told me, “but if you look at the overwhelming trend of a significant number of studies, all point to the same conclusion – that sex reassignment surgery is the only effective treatment for gender identity disorder.”

But I’m not buying that — pooling a bunch of bad studies doesn’t yield good data.

It makes more sense to wonder why the surgery doesn’t have better long-term results. One reason, suggests Renee Sorrentino, a Harvard Medical School psychiatrist who runs the Institute for Sexual Wellness in Quincy, is that by the time a person seeks sex change surgery, gender dysphoria has usually been a problem for a long time and is often accompanied by significant traumatic experiences, including bullying. Those deep psychological wounds may not be so easily healed.

That said, I know a transsexual woman, Sara Herwig, who has been helped by the surgery and now feels like a “congruent person.” So I called her.

“The thing to remember about SRS or general reconstructive surgery is that it is not a silver bullet,” she said. “You still have to deal with everything in life that everybody has to deal with. It’s not going to have a big impact on clinical depression or other kinds of mental illnesses.”

Fair enough, but did she believe taxpayers should be on the hook for Kosilek’s surgery?

Herwig has mixed feelings, “My initial reaction is that nobody paid for mine. Health insurance doesn’t cover it. I understand her desire to have the surgery, but … vast numbers of other people I know have had to pay for their own. I do think there need to be reforms in health insurance so such surgeries are covered. But I don’t think the taxpayers should pay for someone to have that kind of surgery.”

In the end, I concluded, neither do I.

And as for this month’s hearing regarding hair removal?

Give me a break. I have a couple of eyebrows I’d like taxpayers to have waxed for me.

(This post was originally published on WBUR’s Cognoscenti blog)

ProPublica reports that The American Pain Foundation has shut down just as two U.S. senators are launching a probe into the heavy financial support it received from painkiller-makers. Syndicated columnist Judy Foreman, author of the upcoming book “A Nation in Pain: Healing Our Biggest Health Problem,” considers the news and its background.

Okay, everybody, deep breath.

The US Senate on Tuesday launched what ProPublica, a generally terrific online investigative news organization, says is a probe into the makers of “narcotic painkillers” and the manufacturers’ ties to groups that advocate sane, responsible use of them. (By the way, “narcotic” is a loaded word; scientists prefer the less stigmatizing “opioid.”)

Let’s hope the Senate runs a genuinely open, fair investigation and that, in the laudable effort to examine the relationship between Big Pharma and advocacy and research groups, it doesn’t abandon pain patients who need the drugs and use them responsibly.

In the meantime, three thoughts. First off, what counts as an “epidemic?”

In a letter reportedly sent to drug makers by Chuck Grassley, an Iowa Republican, and Max Baucus, a Democrat from Montana, the Senate probe is necessary because of an “epidemic” of accidental deaths and addiction due to opioid pain relievers.

Government figures show there were 14,800 overdose deaths in 2008 that involved opioids (far fewer, incidentally, than from alcohol or cigarettes). And many of those 14,800 deaths, the data show, involved other drugs besides opioids. Is that an opioid overdose epidemic?

Secondly, the underlying assumption here is that if Big Pharma pays for advocacy groups or research studies, this automatically means that the advocacy groups or the researchers are tainted. Frankly, it often does. When research or advocacy is supported by Big Pharma money, it should raise red flags. But that’s also the easy, knee-jerk assessment. In truth, it’s often hard to know when the appearance of a conflict of interest is a real conflict.

Thirdly, the underlying problem is that pain researchers and advocacy groups more or less have to turn to Big Pharma for funding because nobody else has the money. The federal government, ideally, should be funding more pain research, but, aside from the fact that the government is broke, it does not hold pain research as a priority. Out of the massive budget for the National Institutes of Health, only 1.3 percent goes for pain research, even though pain is the main reason people go to doctors.

Big Pharma, obviously, is a mixed blessing. For better and for worse, we live in a capitalist system and the companies that make our drugs care mostly about profits. And they’re sometimes unscrupulous. In 2007, Purdue Pharma, the maker of OxyContin, pleaded guilty to federal criminal charges that it misled regulators, physicians and consumers about OxyContin’s addiction risk.

But it’s still a shame, I think, that one of the most valuable pain advocacy groups in the nation, the American Pain Foundation, has collapsed this week, as the Senate investigation gets under way. It posted an announcement on its website saying that it has ceased to exist, effective immediately, because of “irreparable economic circumstances.”

The American Pain Foundation did get 90 percent of its funding from pharmaceutical companies, as page 16 of its 2010 annual report shows. As a journalist trying to sort all this out, I really wish it didn’t. That’s a monstrous red flag.

But who will take up the cause of pain patients if groups like the APF disappear?

It is wonderful that Blue Cross Blue Shield of Massachusetts is concerned about pain reliever abuse and that the company has consulted with some physicians about ways to curb it.

But it is extremely likely that the policy the company is set to put in place July 1, which allows patients to fill a 15– day prescription and one additional 15-day supply, will end up doing more harm than good, becoming yet another barrier for legitimate pain patients who need opioid medications.

There’s no question that a few physicians prescribe too many opioids and a few patients scam their doctors for more. But the far larger problem is under-treatment of the pain of 100 million Americans, some of whom appropriately need opioid medications.

Blue Cross’ new policy, while it may stem from legitimate, benign motivation, could end up making the lives of pain patients more difficult than they already are. Blue Cross is concerned about “doctor-shopping,” that is, patients going from doctor to doctor to get drugs in order to abuse them. But the truth is that many legitimate pain patients go from doctor to doctor not to abuse drugs but to find someone who understands and can treat their pain.

As for the concern that people who fill opioid prescriptions wind up with medicine cabinets full of left-over pills?

That’s absolutely true. In fact, according to federal government figures, that’s where most of the drugs that get diverted to street users come from. But the federal government has a totally inadequate policy for solving this.

The Drug Enforcement Administration designates on day a year (this year it was April 28) as “take-back” day (actually four hours, from 10 a.m. to 2 p.m.) during which people can take their unwanted drugs to disposal sites.

Driving the hysteria about opioid abuse is the fear of addiction. But even with long term use, the risk of addiction is far short of the 100 percent that the public seems to think. The risk of addiction is estimated to be between 4 and 26 percent, and that’s according to a conservative group, the Physicians for Responsible Opioid Prescribing.

There’s another root cause at play here. Basically, though most people haven’t digested it yet, the “war on drugs” has failed.

That’s not my conclusion. It’s the conclusion, issued in June, 2011, of the Global Commission on Drug Policy, a group that included former heads of state, Kofi Annan (the former Secretary-General of the United Nations), Paul Volker (former chairman of the Federal Reserve), George P. Shultz (former US Secretary of State) and others.

“The global war on drugs has failed,” said the group, “with devastating consequences for individuals and societies around the world….Arresting and incarcerating tens of millions of  these people in recent decades has filled prisons and destroyed lives and families without reducing the availability of illicit drugs or the power of criminal organizations.”

Blue Cross’ new policy may end up being benign. But it smacks of the old war on drugs mentality. And if it plays out that way, it could end up hurting pain patients.

Listen to Judy discuss the complexity of painkiller  WBUR, “Radio Boston”

[mejsaudio src=”http://blog.judyforeman.com/wp-content/uploads/2012/04/radioboston_0418_commonhealth-painkillers.mp3″]

As I’m working on my forthcoming book, A Nation in Pain: Healing Our Biggest Health Problem (Oxford, 2013),  I’m also contributing to WBUR’s CommonHealth blog. The following entry first appeared on WBUR’s site.

Today’s New York Times carries a front page article fanning the hysteria – once again – about prescription painkillers.

A prominent number quoted in the article – that, according to the federal Centers for Disease Control and Prevention, 14,800 people died in 2008 in episodes involving these painkillers – is correct. And that’s 14,800 too many. No doubt about it.

But look at what the article failed to say: That, again according to the CDC, half of all those deaths involving prescription painkillers also involved at least one other drug, including benzodiazepines, cocaine and heroin. And that “alcohol is also involved in many overdose deaths.” To blame it all on prescription painkillers – and pain patients and their doctors – is simply not the full truth.

The New York Times story also failed to note that, in contrast to the 14,800 people whose deaths involved prescription painkillers, 443,000 American adults die every year from cigarette smoking. And more than 80,000 die every year from excessive alcohol use. Non-prescription painkillers such as NSAIDS (non-steroidal anti-inflammatory drugs like ibuprofen) aren’t exactly benign, either – they kill an estimated 7,000 to 10,000 American adults a year.

Nor did the article mention the extent of suffering caused in this country by chronic pain.

According to a recent report from the Institute of Medicine, an estimated 100 million Americans live in chronic pain, and that doesn’t count children, people in the military or in institutions such as nursing homes. And – estimates vary – one tenth to one third of them have chronic pain that is severe and disabling. At least some of this latter group do need opioids, probably strong ones, and possibly for the rest of their lives. To put too many barriers in the way of access to opioids is tantamount to what some ethicists call “torture by omission.”

Furthermore, The New York Times articles picks on doctors for overprescribing painkillers. But doctors are not the real problem.

If it’s diversion and abuse that you’re worried about, consider where street abusers actually get their drugs. According to a 2009 government report, 53.3 percent get their drugs free from a friend or relative, 9.9 percent buy them from a friend or relative, 5 percent steal them from a friend or relative. That’s roughly 70 percent who get it from your medicine cabinet and mine. (And yes, 17.6 percent get them from one doctor.)

To be sure, opioids are not perfect painkillers. In fact, by some estimates, they’re only 30 to 40 percent effective. And yes, of course, non-pharmacological treatments are essential (though not always reimbursed) for treating chronic pain, including meditation, exercise, distraction, acupuncture and massage.

Prescription painkiller deaths grab the headlines, and the front page stories. But all too often, the silent suffering of people in chronic pain does not.

Put bluntly, people do not die from marijuana. There are simply no deaths – zero – attributable to marijuana, and that’s according to the government’s own statistics, from the federal Centers for Disease Control and Prevention.[i]

In start contrast, government figures show that 443,000 American adults die every year from cigarette smoking,[ii] and more than 80,000 die annually from excessive alcohol use.[iii]

Even NSAIDS (non-steroidal anti-inflammatory drugs like ibuprofen) are more dangerous than marijuana – they kill an estimated 7,000 to 10,000 American adults a year.[iv]

 

As I’m working on my forthcoming book, A Nation in Pain: Healing Our Biggest Health Problem (Oxford, 2013),  I’m also contributing to WBUR’s CommonHealth blog. The following entry first appeared on WBUR’s site.

At long, long last, the US Senate is paying attention to chronic pain. At a hearing today, they are listening to a handful of pain experts – and patients – who are filling their ears, and hopefully, their hearts, with details about the enormous, unsolved problem of chronic pain in America. What they may not hear – but should – is how woefully uneducated physicians are about chronic pain. There’s a good, and obviously sad, reason why physicians know so little about pain: Medical schools don’t teach it. A major study of 117 medical schools from Johns Hopkins last year showed that out of all those years in medical school, med students get a median of only 9 hours of pain education. Even veterinary students get more. It’s high time Senators, Congressmen, medical school deans and other powers-that-be took this to heart.

As I’m working on my forthcoming book, A Nation in Pain: Healing Our Biggest Health Problem (Oxford, 2013),  I’m also contributing to WBUR’s CommonHealth blog. The following entry first appeared on WBUR’s site.

There’s a dynamite piece in the Jan. 19 New England Journal of Medicine that I would urge anybody in chronic, severe pain to read.

It’s written by Dr. Philip Pizzo and Noreen Clark, who chaired the committee of pain specialists who wrote an important report last June for the Institute of Medicine, an arm of the National Academy of Sciences. Pizzo is dean of the Stanford University School of Medicine and Clark is director of the Center for Managing Chronic Disease at the University of Michigan.

Medical schools barely teach about pain, even though pain is the main reason people go to doctors.

In their New England Journal piece, and in the lengthy Institute of Medicine report itself, Pizzo and Clark argue eloquently that under-treatment of chronic pain is rampant in this country, that we have a “moral imperative” to do better and that many patients in severe pain understandably see their doctors as “poor listeners.” (I can vouch for this personally: The first doctor I saw during an 8-month bout of severe neck pain a few years ago suggested my pain was an emotional problem.)
As Pizzo and Clark say, “the magnitude of pain in the United States is astounding.” More than 116 million Americans live in some degree of chronic pain, and this figure doesn’t even include kids, people in the military or people in nursing homes. The cost is astounding, too: An estimated $560 to $635 billion, more than the costs of cancer, heart disease and diabetes combined.

For me, the most egregious problem is that, as the Institute of Medicine report documents, medical schools barely teach about pain, even though pain is the main reason people go to doctors. A Johns Hopkins survey of 117 medical schools last year showed that doctors learn appallingly little about pain in med school. Other data show that only half of primary care physicians feel even “somewhat prepared” to deal with patients in pain.

As a nationally syndicated health columnist, I have become so concerned about the chronic pain epidemic that I am writing a book on it for Oxford University Press and the International Association for the Study of Pain, an academic group.

As a journalist for almost 40 years now, I have watched with awe and deep respect as people with breast cancer, AIDS and disabilities have cast aside the stigma and isolation and insisted on more respect and better treatment. I think people with chronic pain — and those who love them — should do the same.