I Guess I Must Have Once, Huh Doc?
birth control, STIs, and immaculate(ish) conception
When I first started teaching The Sociology of Sexuality a million years ago—a.k.a. 2014—one of my goals was to help students understand that sex is political. Yes, the actual act of sex takes place between two people at a time (or maybe a few people), but our health and relationships are heavily influenced by society which is heavily influenced by politics.
Those students had grown up in a time where people in all states had some access to abortion, the HPV vaccine was between controversies, no one (other than me) was talking about Comstock laws, same-sex marriage laws were being passed by states weekly, abstinence-only-until-marriage programs had been proven to fail, and ACA had made birth control free. They’d also grown up in a time where relationships of all types were portrayed on television (that Ellen’s onscreen kiss had caused so much controversy always shocked them), and many of their peers felt comfortable coming out in high school.
It was not perfect by any stretch, and advocates across the country knew how fragile access to sex education, abortion, and contraception were. But it didn’t surprise me when it took a while to get some students to acknowledge just how much public rules and debates impact our most private relationships.
I doubt I’d have to that issue with today’s students. They’ve grown up in the Trump Era and during the global pandemic when it’s been clear that everything is politics and politics affects everything.
But not today. My 14-year-old accused me of making olives political and told me to stop. She’s right. I’m tired of politics. I don’t want to talk about Trump or RFK, Jr. or Dr. Oz or the plans to cut the Department of Education and gut CDC’s HIV-prevention programs. I don’t want to talk about the fetal personhood bill in Florida or the midwife in Texas who was arrested on abortion charges. I don’t even want to talk about the former North Dakota Republican legislator with an anti-LGBTQ voting record who was convicted of decades of abuse against teenage boys (it’s always the ones you most expect). I kind of want to talk about the war plans on Signal scandal because at least amateur hour can be amusing while it scares the s**t out of all of us. But not today.
Today we’re going back to basics and talking about birth control, STIs, and immaculate(ish) conception.
The Good Things Hormonal Contraception Can Do
for Your Ovaries
A new study out of Australia confirms existing research that shows hormonal contraception can prevent ovarian cancer. This is particularly important because there are no screening tests for ovarian cancer which means it is often caught in later stages, making it more deadly.
The study published International Journal of Gynaecological Cancer included data from over 2.2 million women ages 37 to 72. The researchers looked at thousands of characteristics related to health such as medication use, diet and lifestyle, pregnancy, and hormonal factors. They followed their study subjects for almost 13 years.
During the study period, 1,441 of the women developed ovarian cancer. Researchers analyzed their health characteristics and compared them to their peers who did not get ovarian cancer. They found that women who had ever taken the pill had a 26% lower risk of ovarian cancer. Women who used the pill at a later age saw even more benefit. The research found that those who took oral contraceptives after the age of 45 were 43% less likely to develop ovarian cancer.
While this study can’t tell us why these women have a lower risk of ovarian cancer, researchers believe that it’s tied to how many times you ovulate during your reproductive years. Fewer lifetime ovulations seem to be linked to less ovarian cancer. Remember, the primary method of action for hormonal methods—whether it’s the pill, patch, or ring—is to prevent ovulation. This theory also explains why women who had given birth to two or more children had a 39% lower risk of ovarian cancer compared to women who did not have any children. Each full-term pregnancy you have represents at least nine months without ovulating.
If I were being political, I might mention that hormonal methods of birth control are being attacked by the right and left as being bad for women and that this research reminds us of their added benefits. But not today.
The Good Things Hormonal Birth Control Can Do
for Your Knees
The impact of not ovulating on your ovaries seems like a pretty straight line, but what if I told you that not ovulating could also help prevent ACL tears? I promise I’m not a washed-up actor hosting an infomercial or trying to sell you a set of shiny knives (or a shiny set of knees?).
The ACL connects your thigh bone to your shin bone. It provides stability when you move sideways and makes sure that the shin bone can’t come too far forward. ACL tears are pretty common with an estimated 100,000—200,000 incidents each year in this country. This injury can be very painful and damage other structures in the knee. ACL tears cannot heal on their own; you can live with a minor tear, but more severe tears require surgery.
What’s really interesting is that until age 15 or 16, the number of ACL tears for males and females is similar, but then there’s a spike for females.
The reason might be a hormone called relaxin (which was clearly named after its function was identified). During pregnancy relaxin is produced by the placenta to help the loosen and relax your muscles, joints, and ligaments in preparation for pushing a whole new person out of a rather small hole. Relaxin is part of why pregnant women are a little clumsier than usual and their walk is not unlike that of a penguin.
While relaxin is most associated with pregnancy, it is also produced by the ovaries and released during the post-ovulation half of the menstrual cycle. By suppressing ovulation, the birth control pill keeps relaxin levels low all month.
Researchers at Cedar Sinai’s Center for Research in Women’s Health and Sex Differences (CREWHS) conducted a study with 72 high-level collegiate athletes, 32 of whom used hormonal birth control. Researchers collected blood to measure hormone levels, and tested looseness of the athletes’ ligaments by taking them through a series of physical activities. They specifically tested sideways joint movement which increases the risk of ACL injury.
They found that the athletes who were not taking the pill had different hip and knee movement during the second half of their menstrual cycle when relaxin levels are higher. This didn’t happen to the women on birth control who were able to land a jump with their hips straighter and more parallel.
They also found that the women who had lower relaxin levels because of the pill had fewer ankle sprains, ankle strains, meniscal tears, and knee hyperextensions during the study.
I remember trying to skip around the block with my then four-year-old right after her sister was born. My hips just wouldn’t do it. I blamed relaxin. Others meanly blamed my overall lack of athletic ability. I feel like this study vindicates me. [Ed. Note: Didn’t you injure yourself walking into an unexpected couch yesterday?]
These findings suggest that hormonal birth control can be protective against injury for female athletes. Of course, the authors note that most research on athletes is done on men, so there is a lot we still don’t know.
If I were being political, I might say that investing in more research like this would protect women athletes more than executive orders attacking the transgender community. But not today.
Simple Keys to Combatting STIs: Test More
We spent this weekend binge watching The Pitt which provides a portrayal of both how awful and fabulous emergency departments can be. (The show features Noah Wiley but knows better than to call it an ER.) The packed waiting room scenes instantly raise my blood pressure, but then our heroes save lives, feed people, sit with families who just lost a loved one, and hook patients up with much-needed social services.
A new study suggests emergency departments should also be providing universal screening for syphilis and HIV. The results, presented at the Conference on Retroviruses and Opportunistic Infections, found that opt-out screenings for all patients caught numerous cases of both infections that would have gone undetected under other screening protocols.
In 2019, the University of Chicago Medical Center implemented an opt-out universal screening system for both syphilis and HIV. All patients under 65 who had not been screened in the previous year were tested for both infections unless they declined. More than 37,000 patients were screened during the first two years of this program. In that time, 624 patients tested positive for syphilis, there were 83 new HIV diagnoses, and the ED saw 21 acute cases of HIV.
Opt-out screening casts a much wider net than other strategies such as screening only members of a certain population or screening only people who show up with certain symptoms. It also eliminates some of the stigma that can be associated with the mere suggestion of an STI test. “We test everyone who comes in for syphilis” sounds very different than “We think you need a syphilis test.”
The new study shows—not surprisingly—that when you test more people, you find more syphilis and HIV. For example, if the ED had only screened patients who came in for gonorrhea and chlamydia tests, it would have caught just 23.6% of syphilis cases and 34.1% of HIV diagnoses. If the ED had only screened women of reproductive age, it would have caught just 22.8% of syphilis cases and 14.5% of new HIV diagnoses. If the ED had only screened people coming in with issues related to opioid or other substance use, it would have caught just 18.3% of syphilis cases and 7.2% of new HIV diagnoses.
Syphilis is curable if caught early but can cause long-term health consequences when not treated. (If I were being political today, I might talk about the long-held theory that Trump’s inability to form a sentence is a symptom of tertiary syphilis. But not today.) Syphilis can be especially dangerous during pregnancy. Congenital syphilis can cause miscarriage, stillbirths, prematurity, and low birth weight. Babies born with syphilis can have deformed bones, severe anemia, blindness, deafness, or other neurological issues. Congenital syphilis has been on the rise for the last few years.
Similarly, while there is no cure for HIV, early diagnoses and treatment can ensure a person stays healthy longer and is key to preventing transmission to others. It is also the key to preventing transmission during pregnancy. (If I were being political, I might mention that in his first term Trump invested in HIV prevention while this time around he’s threatening to demolish it. But not today.)
As any viewer of The Pitt knows, EDs see patients who might not otherwise see any health care provider. As any reader of this study knows, ED visits are often a missed opportunities to expand STI testing. Switching to a universal opt-out system could change that.
Simple Keys to Combatting STIs: Treat More
A new study on bacterial vaginosis (BV) prompted headlines declaring that this common infection was actually an STI. That’s not exactly what the study said, and it might cause more confusion about this already misunderstood infection.
The vadge biome (as I’ve never called it before and promise never to call it again) is a delicate balance between many types of bacteria. We don’t like to reduce things—even bacteria—to good and bad these days, but some of the bacteria are helpful and others not so much. BV happens when this balance gets out of whack and the less helpful guys run amok.
Many people with BV don’t have symptoms, but those who do might experience an unusual vaginal discharge, vaginal itching, or burning when they pee. Some say that vaginas with BV smell “fishy.”
BV is not an STI because it’s caused by bacteria that are native to the vagina. That said, it’s more common in people who are sexually active, most common when you have a new partner or multiple partners, and almost never happens in people who’ve never had sex. For a lot of women, BV infections recur frequently.
For the new study published in the New England Journal of Medicine, researchers recruited monogamous male-female couples in which the woman was diagnosed with BV. The couples were divided into two groups. One group got the current standard of care which is to just treat the woman with antibiotics. In the other group, both partners got antibiotics, and the man was given a cream to use on his penis.
The couples were monitored going forward and the results were very telling. When both partners were treated, BV recurred in just 35% of the women. In the group where only the women were treated, BV recurred in 63% of the women. This difference was so noticeable that the study was stopped and all partners were treated.
The study certainly shows that couples can pass the bacteria that cause BV back-and-forth. That doesn’t make it an STI because this back-and-forth can happen without either partner going in search of extra-marital bacteria. Still, the research does help us understand the connection between BV and sex (hint: it’s the penis) and tells us what we can do about it (also treat the person with said penis).
Did A Girl Really Get Pregnant Without Intercourse in the 1980s?
There’s a story in my family from my grandfather’s residency training. I think it happened when he was first training to be a doctor during WWII (the Army fast-tracked him through med school), but it may have happened 20+ years later when he was re-training to be a psychiatrist.
Apparently, a teenage patient came into the ED with terrible stomach pains. She insisted that she had never had sex but soon gave birth to a full-term infant. When my grandfather went to talk to her the next day, he reiterated the questions about whether she’d had sex. This time she replied, “Well, I guess I must have once, huh doc?”
According to Live Science—one of my favorite sources for crazy case studies (see I’m Allergic to Your Nuts)—there’s at least one case where the answer to “did you have sex?” is more complicated than that.
In 1988, a 15-year-old in the Southern African country Lesotho got pregnant without ever having had penis-in-vagina sex. Unlike Jane the Virgin, this was not a case of wrongful insemination, nor did it happen in a laboratory. It’s a story that involves a rare genetic condition, a jealous ex-boyfriend, a blow job, and a knife.
The girl arrived at the hospital in severe abdominal pain. It was quickly determined that she was in labor. Like my grandfather’s patient she insisted she’d never had vaginal sex. Unlike his patient, there was proof that she was right. The doctors who examined her saw that she had no vaginal opening. She had inner and outer labia, but there was just an indentation between the labia minors where you’d expect to find the opening to the vagina. She could not have had vaginal sex.
Further examination—after she gave birth to a healthy baby by C-section—revealed that her vagina measured only 0.8 inches. Vaginas are typically between 2 and 4 inches long but can expand to twice that length during arousal.
The medical team determined that she had distal vaginal atresia, a rare disorder of sexual development in which a fetus that is otherwise female does not form a vagina. It is estimated to affect 1 in 4,000 to 1 in 10,000 newborn females. Many people don’t know they have this condition until after puberty when they don’t get their period.
While I don’t have any stats on this, I feel confident in saying that few of these girls/young women get pregnant naturally, or at least not until after they’ve had surgery to create a longer vagina. So how did it happen back in 1988?
The young woman had actually been to the ED before. Exactly 278 days before (also known as nine months). She’d been attacked with knife by an ex-boyfriend who caught her giving head to another guy. The knife wounds penetrated her upper abdomen. She was treated and released.
The theory of how she got pregnant goes like this: She swallows semen, and instead of going into the stomach (where it would have been killed by acid), it leaked into her abdomen through the holes made by the knife. From there it found its way into the fallopian tubes which are actually not attached to the ovaries but just hanging out nearby.
It's a lot to swallow (pun obviously intended) and feels hard to believe. This one bizarre case is not enough to make me edit the web pages that I wrote last week about how one does and does not get pregnant. I stand by my statement that the only kind of sex that poses a risk of pregnancy is penis-in-vagina. I also remain adamant that a little bit of jizz on the inner thigh isn’t gonna knock anyone up.
This story took place long ago and far away, and the science behind this explanation feels squishy at best, but the most pressing question in my mind is not biological in nature. It’s behavioral.
He finished?!!!?!!??
I mean, there you are mid-blow job. I get it, it feels really good. But then a random guy shows up, and you see that he has a knife. And then the guy with the knife actually gets close enough to start stabbing the girl. On the off chance that you don’t lose your erection instantly, you don’t immediately pull out, put your dick away, and jump to her defense? You come in her mouth first?
By some calculations, that makes you a bigger a**hole than the guy with the knife.