Female Sexuality–Do we have a problem?

I would like to open this forum to questions/comments about sexual function and how doctors, society, etc may or may not be appropriately pathologizing female sexual function, sexual desire, or sexuality in general. It is my opinion that “Female Hypoactive Sexual Desire Disorder” does not exist. Our culture sends us so many messages about how everyone everywhere wants sex all the time and if you don’t want sex all the time there is something wrong with you. This is not the case and different people have different levels of sexual desire, and there is a wide variety of “normal.” What do you think?*

Framing Disease: The example of female hypoactive sexual desire disorder“ by A. Jutel

*As always, please be respectful and withhold vulgar language or I will be unable to post your comment/question. Thank you.

First, Do No Harm

Primum non nocere means just that: first, do no harm. As an OB/Gyn who sees women daily regarding reproductive health issues, this part of the Hippocratic Oath echoes in my mind regularly. An absence of action — doing nothing or withholding treatment — can also do harm. In the past few years, a variety of legislation has placed restrictions on access to reproductive health care. This legislation has been passed under pretenses of guarding and better informing patients. However, I currently live in Utah and see first-hand the impact these laws have on women and their families. This legislation establishes barriers to safe health care procedures such as medical and surgical abortions for no sound or scientifically informed reasons. Restrictive legislation in health care has a net result of harming patients.

Health care providers are sometimes the sole advocates for patients and should speak out against laws that limit access to safe, evidence-based health care. We have seen such laws being passed in Texas, North Carolina, Ohio, and several other states. Some examples of these harmful policies are:

  1. The Mandated Use of Ultrasound
  2. Bans on the Use of Telemedicine
  3. Regulation of Outpatient Clinics as Ambulatory Surgical Centers
  4. Mandated Waiting Periods and Gestational Age Limit Bans
  5. Requirements for Admitting Privileges to Local Hospitals
  6. Parental Notification Mandates

1. The Mandated Use of Ultrasound

Legislators have decided that they know better than doctors when and how ultrasounds should be used in abortion care. Some laws require a woman to receive written information regarding her right to see the ultrasound, some obligate her to see the ultrasound, and some not only force her to see the image but also obligate the physician to describe the image to her in detail. Research shows that ultrasound mandates don’t change a woman’s mind, because a woman has usually thought long and hard about her decision to terminate her pregnancy. I am currently required by law to ask my patients if they would like to see the ultrasound. In my own experience, many say yes; however, none of my patients have changed their minds after seeing the image. The mandate only serves to increase health care costs by subjecting women to unnecessary tests in these instances. There are many versions of these laws, depending on the state in which the physician practices. How and when a doctor performs an ultrasound prior to an abortion depends on these laws, not what is medically relevant to provide the best health care to the patient.

Ultrasounds are used by women’s health professionals for valid medical reasons, including ruling out ectopic pregnancies and determining how far along a pregnancy is. This test is performed prior to the abortion, but there is no medical reason for it to be performed on the same day as the abortion. Ultrasounds should not be used for political or other purposes that fall outside of a standard of medical necessity.

We routinely show the patient an ultrasound image if she asks or if she agrees to view images for educational purposes. Laws that require women to view or hear her ultrasound against her will violate her rights and presume that she is uneducated about what pregnancy means. In no other area of medicine are doctors required to show patients images of their bodies or organs.

2. Bans on the Use of Telemedicine

Many areas of the country have few or no physicians, and health care resources are scarce. In these areas, the ability to counsel patients using modern technology such as video conference calls can actually mean the difference between receiving health care and not. Restrictions on the use of telemedicine means a woman may not have the opportunity to speak to a doctor regarding her pregnancy options: continuing the pregnancy and becoming a parent, continuing the pregnancy to ultimately place the child up for adoption, or terminating the pregnancy. Women deserve to be informed of all of their options in a timely manner, especially when a pregnancy is in question, and this may be safely done via phone or web interface. I see women who have traveled upwards of 500 miles to have an abortion, which is not easy for most women when you consider travel expenses, child care, and time off work. Similar to mandated waiting periods, having women make more than one trip when a tele-consult would suffice is a considerable burden in many areas of the country. It does nothing to promote patient safety or quality of care.

Physicians often counsel patients — their own patients and patients of other physicians if on-call — over the phone regarding symptoms, medications, and therapy options. Doctors also deliver the babies of their colleagues’ patients as a standard practice, despite childbirth being 14 times riskier than a first trimester abortion. Abortion care is no different than other health care in this way. Legislative requirements for same-provider counseling or in-person counseling don’t advance patient safety or quality of care and only create roadblocks to getting needed care.

In some innovative telemedicine programs, nurses dispense medical abortion medication after an initial, earlier visit with a physician to establish the pregnancy and discuss options. There is no safety reason why women should not be able to receive these medications in a separate office from a nurse after tele-approval by a physician.

3. Regulation of Outpatient Clinics as Ambulatory Surgical Centers

A variety of states have imposed requirements that outpatient clinics conform to the same or similar regulations as an operating room in a hospital. These requirements can include anything from having wider doorways to having equipment in the room for general anesthesia (even though it is not used). These laws force the conversion of a perfectly safe outpatient clinic into a surgical suite that has features above and beyond the needs of the procedures being performed. Imagine going to have a hair cut but instead receiving a hair transplantation procedure. Better? Sure. Necessary? Absolutely not. In many areas of the country, such as mine, requiring abortion clinics that are already up to code and medical standards to meet additional ambulatory surgical center standards will leave those clinics destitute, resulting in women with fewer options for safe care (including many procedures unrelated to abortion care, such as cancer screenings).

Abortion is a procedure that is generally safely done in an outpatient setting. Its potential complication risks are no different than many other outpatient medical procedures performed in a provider’s office. State laws should not require abortion care to be performed in settings that meet ambulatory surgical center standards as other medical procedures with similar risk-profiles do not face the same requirements. None of the practices in which these other medical procedures are performed (colonoscopy, for example) are required to adhere to more complex surgical center standards.

Hysteroscopy and many assisted reproductive technology procedures such as taking a look inside the uterine cavity with a camera are performed in outpatient clinics that are not surgical centers. The procedures use instruments inside the uterus with the same risks of perforation, hemorrhage, and infection as an abortion procedure. Truth be told, the surgical management of a miscarriage is exactly the same as a first trimester surgical abortion. Exactly the same. I am permitted to perform a dilation and curettage in my clinic as long as it is in the context of a miscarriage, however this is not so in the case of the termination of an otherwise normal pregnancy. The only difference is a discrimination against the pregnant person’s fertility desires.

4. Waiting Periods and Gestational Age Limit Bans

Despite federal law upholding legal access to an abortion procedure up to 24 weeks of gestation (except in cases of incest/rape or lethal fetal anomalies where no gestational age limit applies) many states are passing their own laws that reduce the gestational age limit for legal abortion procedures. Depending on the state in which she lives, a woman may have an abortion only before 20 or 22 weeks, effectively reducing the time she has to make her life-altering decision. A variety of states have also imposed waiting periods: the length of time between receiving informed consent for an abortion and the time of receiving the actual procedure which may range anywhere from 24 to 72 hours. These may seem like conflicting concepts, and that’s because they are. One law intends to require a more expedited decision process so as not to exceed the reduced gestational age limit, while the other requires a woman to wait longer under the guise of allowing her to make a more thoughtful decision. I take care of many women whose pregnancies have been diagnosed with horrible diseases and conditions incompatible with life, and these women must endure the knowledge of their very desired baby’s diagnosis. Often these traumatic diagnoses are made after 20 weeks. She may have the diagnosis near (or past) that state’s gestational age limit, which would require her to go to another state to terminate or to carry a pregnancy full-term, undergoing the risks of pregnancy and childbirth, only to watch her newborn suffer and die. Pregnancy, like other conditions such as cancer or heart disease, is time-sensitive and requires expedited treatment, not arbitrary delays imposed by the state.

My state, like many others, requires a waiting period before a woman can have an abortion. These laws are especially intrusive for women seeking pregnancy terminations. They presume women haven’t considered their pregnancy options carefully and need “extra time” to be sure. If this is the case, much more dangerous procedures such as organ transplants, brain surgery, plastic surgery, etc. should also require waiting periods. Additionally, these unnecessary regulations and their exceptions are often confusing and may result in requiring a victim of rape or incest to suffer longer because she is waiting for the procedure to be allowed. Being forced to delay the provision of abortion care can also increase the cost and risk of the procedure and thus further delay it, sometimes pushing the pregnancy into the next trimester and bumping up against gestational age bans.

5. Requirements for Admitting Privileges to Local Hospitals

A recent defeat in Texas upheld unconstitutional legislation that requires abortion providers to have admitting privileges to a hospital located within 30 miles of their clinic. To understand why this is problematic, it is necessary to understand that, in order to practice medicine at a given hospital, a physician must have admitting privileges to that hospital. This allows the patients a doctor takes care of to be admitted to and cared for as an inpatient of that hospital. Admitting privileges, however, are not required to practice medicine at an outpatient clinic as an outpatient clinic — by its definition — does not have the capacity to provide inpatient care. Many other states have placed similar regulations on abortion providers, resulting in shortages of legal abortion providers when hospitals decide not to or, in many cases, are disallowed from granting “those” physicians with admitting privileges. There is no medical justification for this policy and it is a danger to women’s ability to access care.

Once again, in no other specialty are physicians required to have admitting privileges to a hospital in order to perform outpatient procedures. For decades, abortions have been provided safely in an outpatient setting and, if complications arose, the physician would call for an ambulance to take the patient to the hospital. Patients taken to a hospital emergency room are treated whether their provider has admitting privileges or not. With these laws, hospitals wind up under tremendous pressure to deny privileges to abortion providers. In the case of Mississippi, the last clinic may close because the only abortion provider in the state is being denied admitting privileges, leaving women in that state with no in-state provider. Recent legislative efforts in Texas would close several rural clinics in already under-served areas, leaving many women hundreds of miles from care.

6. Parental Notification Mandates

A variety of states require minors to inform their parents (or legal guardians) of their decision to have an abortion. This is a discriminatory practice when dealing with abortion care. Only when a teenager seeks an abortion do these laws dictate that the teen must notify their parents about their pregnancy and decision to terminate said pregnancy before an abortion may be performed. In contrast, no law requires parental notification of a teen’s sexual activity, pregnancy planning, positive pregnancy test, or the decision to carry a pregnancy to term and have a baby. It is only if the teen desires to terminate a pregnancy that some states feel it is necessary for the parents to be involved under the guise of “protecting” the minor. If a minor can be trusted to engage in sexual activity as well as make the decision to become a parent or carry a pregnancy to term to place a baby up for adoption, doesn’t it seem that the minor should also be trusted to make the decision not to become a parent or to undergo the risks that pregnancy and childbirth incur?

Adolescents under the age of 18 are considered minors, but most are capable of making decisions regarding their sexual health. In a Position Statement published in the Journal of Adolescent Health by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Adolescent Medicine their collective stance is clearly stated:

Federal and state laws should support physicians and other health care professionals and their role in providing confidential health care to their adolescent patients.

Each state has its own set of laws regarding parental notification for things such as contraception, sexually transmitted infection screening and treatment, prenatal care, adoption, etc., but parental notification requirements can be problematic, prohibitive of care, and at times unsafe. Some teenagers do not have contact with their legal guardians, some are victims of abuse, and some may be estranged or geographically far from their parents. These realities may delay or prevent access to healthcare for such an important and time-sensitive health condition as pregnancy. The sooner a pregnant person can access care, the better the health outcomes.

SPECIAL THANKS TO THE GUTTMACHER INSTITUTE FOR PROVIDING FACTUAL DATA REGARDING NATIONAL AND INTERNATIONAL REPRODUCTIVE HEALTH