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Monkeypox virus found in asymptomatic people
The findings, published in Annals of Internal Medicine, follow a similar, non–peer-reviewed report from Belgium. Researchers in both studies tested swabs for monkeypox in men who have sex with men. These swabs had been collected for routine STI screening.
It’s unclear whether asymptomatic individuals who test positive for monkeypox can spread the virus, the French team wrote. But if so, public health strategies to vaccinate those with known exposure “may not be sufficient to contain spread.”
In an editorial accompanying their paper, Stuart Isaacs, MD, associate professor at the University of Pennsylvania, Philadelphia, said it “raises the question of whether asymptomatic or subclinical infections are contributing to the current worldwide outbreak.”
Historically, transmission of monkeypox and its close relative, smallpox, was thought to be greatest when a rash was present, Dr. Isaacs wrote. “Long chains of human-to-human transmission were rare” with monkeypox.
That’s changed with the current outbreak, which was first detected in May. On Aug. 17, the World Health Organization reported more than 35,000 cases in 92 countries, with 12 deaths.
Research methods
For the French study, researchers conducted polymerase chain reaction tests on 200 anorectal swabs from asymptomatic individuals that had been collected from June 5 to July 11 in order to screen for gonorrhea and chlamydia. Of those, 13 (6.5%) were positive for monkeypox.
During the study period, STI testing had been suspended in individuals with monkeypox symptoms because of safety concerns, the researchers reported.
The research team contacted the 13 monkeypox-positive patients and advised them to limit sexual activity for 21 days following their test and notify recent sexual partners. None reported having developed symptoms, but two subsequently returned to the clinic with symptoms – one had an anal rash and the other a sore throat.
In the Belgian report, posted publicly on June 21 as a preprint, 3 of 224 anal samples collected for STI screening in May tested positive for monkeypox. All three of the men who tested positive said they did not have any symptoms in the weeks before and after the sample was taken.
At follow-up testing, 21-37 days after the initial samples were taken, all patients who had previously tested positive were negative. This was “likely as a consequence of spontaneous clearance of the infection,” the authors of that paper wrote.
Clinical implications of findings are uncertain
Monica Gandhi, MD, MPH, a professor of medicine at the University of California, San Francisco, said in an interview that the clinical implications of the findings are uncertain because it’s not known how much viral transmission results from asymptomatic individuals.
Nevertheless, Dr. Gandhi said that “vaccinating all gay men for monkeypox who will accept the vaccine is prudent,” compared with a less aggressive strategy of only vaccinating those with known exposure, which is called ring vaccination. That way, “we can be assured to provide immunity to large swaths of the at-risk population.”
Dr. Gandhi said that movement toward mass vaccination of gay men is occurring in the United States, Canada, Europe, and Australia, despite limited vaccine supply.
She added that, although monkeypox has been concentrated in communities of men who have sex with men, “anyone with multiple sexual partners should be vaccinated given the data.”
However, a WHO official recently cautioned that reports of breakthrough infections in individuals who were vaccinated against monkeypox constitute a reminder that “vaccine is not a silver bullet.”
Non-vaccine interventions are also needed
Other experts stressed the need for nonvaccine interventions.
In his editorial, Dr. Isaacs said an “expanded” ring vaccination strategy in communities of high risk is likely needed, but ultimately the outbreak will only be controlled if vaccination is accompanied by other measures such as identifying and isolating cases, making treatment available, and educating individuals about how to reduce their risk.
Aileen Marty, MD, a professor of infectious diseases at Florida International University, Miami, said in an interview that the new evidence makes it “incredibly important” to inform people that they might be infected by a sex partner even if that person does not have telltale lesions.
Dr. Marty said she has been advising men who have sex with men to “reduce or eliminate situations in which they find themselves with multiple anonymous individuals.”
Although most individuals recover from monkeypox, the disease can lead to hospitalization, disfigurement, blindness, and even death, Dr. Marty noted, adding that monkeypox is “absolutely a disease to avoid.”
Authors of the French study reported financial relationships with Gilead Sciences, Viiv Healthcare, MSD, AstraZeneca, Theratechnologies, Janssen Pharmaceuticals, Pfizer, GlaxoSmithKline, and bioMérieux. Dr. Isaacs reported grants from the Department of Veterans Affairs and the National Institutes of Health and royalties from UpToDate. Dr. Gandhi and Dr. Marty reported no relevant financial interests.
The findings, published in Annals of Internal Medicine, follow a similar, non–peer-reviewed report from Belgium. Researchers in both studies tested swabs for monkeypox in men who have sex with men. These swabs had been collected for routine STI screening.
It’s unclear whether asymptomatic individuals who test positive for monkeypox can spread the virus, the French team wrote. But if so, public health strategies to vaccinate those with known exposure “may not be sufficient to contain spread.”
In an editorial accompanying their paper, Stuart Isaacs, MD, associate professor at the University of Pennsylvania, Philadelphia, said it “raises the question of whether asymptomatic or subclinical infections are contributing to the current worldwide outbreak.”
Historically, transmission of monkeypox and its close relative, smallpox, was thought to be greatest when a rash was present, Dr. Isaacs wrote. “Long chains of human-to-human transmission were rare” with monkeypox.
That’s changed with the current outbreak, which was first detected in May. On Aug. 17, the World Health Organization reported more than 35,000 cases in 92 countries, with 12 deaths.
Research methods
For the French study, researchers conducted polymerase chain reaction tests on 200 anorectal swabs from asymptomatic individuals that had been collected from June 5 to July 11 in order to screen for gonorrhea and chlamydia. Of those, 13 (6.5%) were positive for monkeypox.
During the study period, STI testing had been suspended in individuals with monkeypox symptoms because of safety concerns, the researchers reported.
The research team contacted the 13 monkeypox-positive patients and advised them to limit sexual activity for 21 days following their test and notify recent sexual partners. None reported having developed symptoms, but two subsequently returned to the clinic with symptoms – one had an anal rash and the other a sore throat.
In the Belgian report, posted publicly on June 21 as a preprint, 3 of 224 anal samples collected for STI screening in May tested positive for monkeypox. All three of the men who tested positive said they did not have any symptoms in the weeks before and after the sample was taken.
At follow-up testing, 21-37 days after the initial samples were taken, all patients who had previously tested positive were negative. This was “likely as a consequence of spontaneous clearance of the infection,” the authors of that paper wrote.
Clinical implications of findings are uncertain
Monica Gandhi, MD, MPH, a professor of medicine at the University of California, San Francisco, said in an interview that the clinical implications of the findings are uncertain because it’s not known how much viral transmission results from asymptomatic individuals.
Nevertheless, Dr. Gandhi said that “vaccinating all gay men for monkeypox who will accept the vaccine is prudent,” compared with a less aggressive strategy of only vaccinating those with known exposure, which is called ring vaccination. That way, “we can be assured to provide immunity to large swaths of the at-risk population.”
Dr. Gandhi said that movement toward mass vaccination of gay men is occurring in the United States, Canada, Europe, and Australia, despite limited vaccine supply.
She added that, although monkeypox has been concentrated in communities of men who have sex with men, “anyone with multiple sexual partners should be vaccinated given the data.”
However, a WHO official recently cautioned that reports of breakthrough infections in individuals who were vaccinated against monkeypox constitute a reminder that “vaccine is not a silver bullet.”
Non-vaccine interventions are also needed
Other experts stressed the need for nonvaccine interventions.
In his editorial, Dr. Isaacs said an “expanded” ring vaccination strategy in communities of high risk is likely needed, but ultimately the outbreak will only be controlled if vaccination is accompanied by other measures such as identifying and isolating cases, making treatment available, and educating individuals about how to reduce their risk.
Aileen Marty, MD, a professor of infectious diseases at Florida International University, Miami, said in an interview that the new evidence makes it “incredibly important” to inform people that they might be infected by a sex partner even if that person does not have telltale lesions.
Dr. Marty said she has been advising men who have sex with men to “reduce or eliminate situations in which they find themselves with multiple anonymous individuals.”
Although most individuals recover from monkeypox, the disease can lead to hospitalization, disfigurement, blindness, and even death, Dr. Marty noted, adding that monkeypox is “absolutely a disease to avoid.”
Authors of the French study reported financial relationships with Gilead Sciences, Viiv Healthcare, MSD, AstraZeneca, Theratechnologies, Janssen Pharmaceuticals, Pfizer, GlaxoSmithKline, and bioMérieux. Dr. Isaacs reported grants from the Department of Veterans Affairs and the National Institutes of Health and royalties from UpToDate. Dr. Gandhi and Dr. Marty reported no relevant financial interests.
The findings, published in Annals of Internal Medicine, follow a similar, non–peer-reviewed report from Belgium. Researchers in both studies tested swabs for monkeypox in men who have sex with men. These swabs had been collected for routine STI screening.
It’s unclear whether asymptomatic individuals who test positive for monkeypox can spread the virus, the French team wrote. But if so, public health strategies to vaccinate those with known exposure “may not be sufficient to contain spread.”
In an editorial accompanying their paper, Stuart Isaacs, MD, associate professor at the University of Pennsylvania, Philadelphia, said it “raises the question of whether asymptomatic or subclinical infections are contributing to the current worldwide outbreak.”
Historically, transmission of monkeypox and its close relative, smallpox, was thought to be greatest when a rash was present, Dr. Isaacs wrote. “Long chains of human-to-human transmission were rare” with monkeypox.
That’s changed with the current outbreak, which was first detected in May. On Aug. 17, the World Health Organization reported more than 35,000 cases in 92 countries, with 12 deaths.
Research methods
For the French study, researchers conducted polymerase chain reaction tests on 200 anorectal swabs from asymptomatic individuals that had been collected from June 5 to July 11 in order to screen for gonorrhea and chlamydia. Of those, 13 (6.5%) were positive for monkeypox.
During the study period, STI testing had been suspended in individuals with monkeypox symptoms because of safety concerns, the researchers reported.
The research team contacted the 13 monkeypox-positive patients and advised them to limit sexual activity for 21 days following their test and notify recent sexual partners. None reported having developed symptoms, but two subsequently returned to the clinic with symptoms – one had an anal rash and the other a sore throat.
In the Belgian report, posted publicly on June 21 as a preprint, 3 of 224 anal samples collected for STI screening in May tested positive for monkeypox. All three of the men who tested positive said they did not have any symptoms in the weeks before and after the sample was taken.
At follow-up testing, 21-37 days after the initial samples were taken, all patients who had previously tested positive were negative. This was “likely as a consequence of spontaneous clearance of the infection,” the authors of that paper wrote.
Clinical implications of findings are uncertain
Monica Gandhi, MD, MPH, a professor of medicine at the University of California, San Francisco, said in an interview that the clinical implications of the findings are uncertain because it’s not known how much viral transmission results from asymptomatic individuals.
Nevertheless, Dr. Gandhi said that “vaccinating all gay men for monkeypox who will accept the vaccine is prudent,” compared with a less aggressive strategy of only vaccinating those with known exposure, which is called ring vaccination. That way, “we can be assured to provide immunity to large swaths of the at-risk population.”
Dr. Gandhi said that movement toward mass vaccination of gay men is occurring in the United States, Canada, Europe, and Australia, despite limited vaccine supply.
She added that, although monkeypox has been concentrated in communities of men who have sex with men, “anyone with multiple sexual partners should be vaccinated given the data.”
However, a WHO official recently cautioned that reports of breakthrough infections in individuals who were vaccinated against monkeypox constitute a reminder that “vaccine is not a silver bullet.”
Non-vaccine interventions are also needed
Other experts stressed the need for nonvaccine interventions.
In his editorial, Dr. Isaacs said an “expanded” ring vaccination strategy in communities of high risk is likely needed, but ultimately the outbreak will only be controlled if vaccination is accompanied by other measures such as identifying and isolating cases, making treatment available, and educating individuals about how to reduce their risk.
Aileen Marty, MD, a professor of infectious diseases at Florida International University, Miami, said in an interview that the new evidence makes it “incredibly important” to inform people that they might be infected by a sex partner even if that person does not have telltale lesions.
Dr. Marty said she has been advising men who have sex with men to “reduce or eliminate situations in which they find themselves with multiple anonymous individuals.”
Although most individuals recover from monkeypox, the disease can lead to hospitalization, disfigurement, blindness, and even death, Dr. Marty noted, adding that monkeypox is “absolutely a disease to avoid.”
Authors of the French study reported financial relationships with Gilead Sciences, Viiv Healthcare, MSD, AstraZeneca, Theratechnologies, Janssen Pharmaceuticals, Pfizer, GlaxoSmithKline, and bioMérieux. Dr. Isaacs reported grants from the Department of Veterans Affairs and the National Institutes of Health and royalties from UpToDate. Dr. Gandhi and Dr. Marty reported no relevant financial interests.
FROM ANNALS OF INTERNAL MEDICINE
California wants to snip costs for vasectomies and condoms
SACRAMENTO – California is trying to ease the pain of vasectomies by making them free for millions of residents.
Federal law and state law require most health insurers to cover prescription contraceptives at no cost to the patient. But those provisions apply to only 18 Food and Drug Administration–approved birth control options for women, so anyone with testicles is out of luck.
California lawmakers are now considering a bill that would expand that requirement to male sterilization and non-prescription birth control, including condoms and contraceptive sponges. If the Contraceptive Equity Act of 2022 passes, commercial insurance plans regulated by the state won’t be allowed to impose out-of-pocket costs, like copays, coinsurance, and deductibles, on those modes of birth control.
“It’s pretty groundbreaking in that way – it’s a whole new framework to think about contraception as something that is relevant for people of all genders,” said Liz McCaman Taylor, a senior attorney with the National Health Law Program, a group that advocates for the health rights of low-income people.
A vasectomy is an outpatient surgical procedure in which the patient’s supply of sperm is cut off from his semen by sealing or snipping the tubes that transport sperm from the testes to the penis. Most men need to recover on the couch with an ice pack for a day or 2, and a test a few months later determines whether the procedure worked.
Because vasectomies are elective procedures and usually not urgent, price can be a deciding factor.
For Nathan Songne, cost was the most stressful part of the procedure. For several years, the 31-year-old had known he didn’t want to have kids biologically. Better to adopt a 4-year-old and skip the diaper stage, he thought. He was adopted by his stepfather as a child and knew he didn’t need to be genetically related to his children to love them.
“My only concern was that I had no idea how much it was going to cost me because nobody told me,” said Mr. Songne, who lives in Mission Viejo, in Orange County. If the procedure cost $1,000, as he expected, he wouldn’t be able to afford it.
Mr. Songne’s insurance, which he gets through his work assembling guitars, covered 70% of the Aug. 8 procedure, leaving him with a bill of just under $200. “Cost did affect my decision, but because it was only $200, it made me feel a lot more relieved about continuing on with the vasectomy.”
There are two hot times of year in the vasectomy business, according to Mary Samplaski, MD, an associate professor of urology at the University of Southern California, Los Angeles. First, she sees an uptick during the March Madness college basketball tournament, when men choose to recover on the couch watching hoops.
The end of the year is also busy, she said, because many patients have finally met their annual insurance deductible and can afford the procedure.
Patients discuss out-of-pocket costs in about 20% of her vasectomy consultations. “It’s obviously a nerve-wracking procedure,” Dr. Samplaski said. “And on top of that, if your copay is high, there’s even less reason to want to do it.”
In April, Jacob Elert comparison-shopped for a vasectomy near his home in Sacramento because his health plan doesn’t cover the procedure. He had hoped to schedule one with his regular urologist, but that would have come with a $1,500 price tag.
Instead, he found a chain of vasectomy clinics where he could get the procedure for $850. Three months later, a test confirmed the vasectomy was a success.
Mr. Elert has no regrets, but had price not been a factor, he would have preferred to go to his regular urologist. “That’s the doctor I trust,” Mr. Elert said. “But it was just way too expensive.”
In November, California voters will decide whether to lock rights to abortion and contraception into the state constitution. But Proposition 1 doesn’t address issues such as cost and coverage, said Amy Moy, a spokesperson for Essential Access Health, a group that runs California’s Title X family planning program.
“The constitutional amendment is kind of the long-term protection, and we are still working to reduce barriers for Californians on the short-term and day-to-day level regardless of their gender,” she said.
SB 523 has sailed through preliminary votes in the state legislature, which faces an end-of-August deadline to act on bills. If the measure passes, it would take effect in 2024, and California would join a handful of states that require plans they regulate to completely cover vasectomies or nonprescription birth control.
The California Association of Health Plans is still evaluating the measure, which may be amended in the final days of the legislative session. But the association generally opposes bills that require additional insurance benefits because they could lead to higher premiums, spokesperson Mary Ellen Grant said.
SB 523 applies to more than 14 million Californians who work for the state, have a student health plan through a university, or have state-regulated commercial health plans. They would become eligible to receive free over-the-counter birth control – such as emergency contraception, condoms, spermicide, and contraceptive sponges – in addition to vasectomies. The bill would not apply to the millions of Californians whose health insurance plans are regulated by the federal government.
The specifics of how the benefit would work, including the frequency and amount of birth control that insurers must cover and whether patients would have to pay upfront and be reimbursed later, would be hammered out after the measure is adopted. Ms. McCaman Taylor said allowing people to simply present their insurance card at a pharmacy counter and walk away with the birth control they need would be preferable.
“We kind of learned from the national experiment with COVID over-the-counter tests that reimbursement wasn’t the best model,” she said. “If people can’t afford to pay out of pocket for it, they’re just not going to get it.”
The California Health Benefits Review Program, which analyzes legislation, projected that roughly 14,200 people with state-regulated commercial insurance would get vasectomies in California in 2022. Eliminating cost sharing would increase the number of vasectomies by 252 in the law’s first year, the program estimated.
It’s a small increase. But that, plus a jump in the use of other contraceptives covered by the bill, particularly condoms, could add up to a big reduction in unintended pregnancies. Roughly 12,300 unplanned pregnancies might be averted each year if the mandate takes effect, a reduction of more than 11%, according to the analysis.
This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
SACRAMENTO – California is trying to ease the pain of vasectomies by making them free for millions of residents.
Federal law and state law require most health insurers to cover prescription contraceptives at no cost to the patient. But those provisions apply to only 18 Food and Drug Administration–approved birth control options for women, so anyone with testicles is out of luck.
California lawmakers are now considering a bill that would expand that requirement to male sterilization and non-prescription birth control, including condoms and contraceptive sponges. If the Contraceptive Equity Act of 2022 passes, commercial insurance plans regulated by the state won’t be allowed to impose out-of-pocket costs, like copays, coinsurance, and deductibles, on those modes of birth control.
“It’s pretty groundbreaking in that way – it’s a whole new framework to think about contraception as something that is relevant for people of all genders,” said Liz McCaman Taylor, a senior attorney with the National Health Law Program, a group that advocates for the health rights of low-income people.
A vasectomy is an outpatient surgical procedure in which the patient’s supply of sperm is cut off from his semen by sealing or snipping the tubes that transport sperm from the testes to the penis. Most men need to recover on the couch with an ice pack for a day or 2, and a test a few months later determines whether the procedure worked.
Because vasectomies are elective procedures and usually not urgent, price can be a deciding factor.
For Nathan Songne, cost was the most stressful part of the procedure. For several years, the 31-year-old had known he didn’t want to have kids biologically. Better to adopt a 4-year-old and skip the diaper stage, he thought. He was adopted by his stepfather as a child and knew he didn’t need to be genetically related to his children to love them.
“My only concern was that I had no idea how much it was going to cost me because nobody told me,” said Mr. Songne, who lives in Mission Viejo, in Orange County. If the procedure cost $1,000, as he expected, he wouldn’t be able to afford it.
Mr. Songne’s insurance, which he gets through his work assembling guitars, covered 70% of the Aug. 8 procedure, leaving him with a bill of just under $200. “Cost did affect my decision, but because it was only $200, it made me feel a lot more relieved about continuing on with the vasectomy.”
There are two hot times of year in the vasectomy business, according to Mary Samplaski, MD, an associate professor of urology at the University of Southern California, Los Angeles. First, she sees an uptick during the March Madness college basketball tournament, when men choose to recover on the couch watching hoops.
The end of the year is also busy, she said, because many patients have finally met their annual insurance deductible and can afford the procedure.
Patients discuss out-of-pocket costs in about 20% of her vasectomy consultations. “It’s obviously a nerve-wracking procedure,” Dr. Samplaski said. “And on top of that, if your copay is high, there’s even less reason to want to do it.”
In April, Jacob Elert comparison-shopped for a vasectomy near his home in Sacramento because his health plan doesn’t cover the procedure. He had hoped to schedule one with his regular urologist, but that would have come with a $1,500 price tag.
Instead, he found a chain of vasectomy clinics where he could get the procedure for $850. Three months later, a test confirmed the vasectomy was a success.
Mr. Elert has no regrets, but had price not been a factor, he would have preferred to go to his regular urologist. “That’s the doctor I trust,” Mr. Elert said. “But it was just way too expensive.”
In November, California voters will decide whether to lock rights to abortion and contraception into the state constitution. But Proposition 1 doesn’t address issues such as cost and coverage, said Amy Moy, a spokesperson for Essential Access Health, a group that runs California’s Title X family planning program.
“The constitutional amendment is kind of the long-term protection, and we are still working to reduce barriers for Californians on the short-term and day-to-day level regardless of their gender,” she said.
SB 523 has sailed through preliminary votes in the state legislature, which faces an end-of-August deadline to act on bills. If the measure passes, it would take effect in 2024, and California would join a handful of states that require plans they regulate to completely cover vasectomies or nonprescription birth control.
The California Association of Health Plans is still evaluating the measure, which may be amended in the final days of the legislative session. But the association generally opposes bills that require additional insurance benefits because they could lead to higher premiums, spokesperson Mary Ellen Grant said.
SB 523 applies to more than 14 million Californians who work for the state, have a student health plan through a university, or have state-regulated commercial health plans. They would become eligible to receive free over-the-counter birth control – such as emergency contraception, condoms, spermicide, and contraceptive sponges – in addition to vasectomies. The bill would not apply to the millions of Californians whose health insurance plans are regulated by the federal government.
The specifics of how the benefit would work, including the frequency and amount of birth control that insurers must cover and whether patients would have to pay upfront and be reimbursed later, would be hammered out after the measure is adopted. Ms. McCaman Taylor said allowing people to simply present their insurance card at a pharmacy counter and walk away with the birth control they need would be preferable.
“We kind of learned from the national experiment with COVID over-the-counter tests that reimbursement wasn’t the best model,” she said. “If people can’t afford to pay out of pocket for it, they’re just not going to get it.”
The California Health Benefits Review Program, which analyzes legislation, projected that roughly 14,200 people with state-regulated commercial insurance would get vasectomies in California in 2022. Eliminating cost sharing would increase the number of vasectomies by 252 in the law’s first year, the program estimated.
It’s a small increase. But that, plus a jump in the use of other contraceptives covered by the bill, particularly condoms, could add up to a big reduction in unintended pregnancies. Roughly 12,300 unplanned pregnancies might be averted each year if the mandate takes effect, a reduction of more than 11%, according to the analysis.
This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
SACRAMENTO – California is trying to ease the pain of vasectomies by making them free for millions of residents.
Federal law and state law require most health insurers to cover prescription contraceptives at no cost to the patient. But those provisions apply to only 18 Food and Drug Administration–approved birth control options for women, so anyone with testicles is out of luck.
California lawmakers are now considering a bill that would expand that requirement to male sterilization and non-prescription birth control, including condoms and contraceptive sponges. If the Contraceptive Equity Act of 2022 passes, commercial insurance plans regulated by the state won’t be allowed to impose out-of-pocket costs, like copays, coinsurance, and deductibles, on those modes of birth control.
“It’s pretty groundbreaking in that way – it’s a whole new framework to think about contraception as something that is relevant for people of all genders,” said Liz McCaman Taylor, a senior attorney with the National Health Law Program, a group that advocates for the health rights of low-income people.
A vasectomy is an outpatient surgical procedure in which the patient’s supply of sperm is cut off from his semen by sealing or snipping the tubes that transport sperm from the testes to the penis. Most men need to recover on the couch with an ice pack for a day or 2, and a test a few months later determines whether the procedure worked.
Because vasectomies are elective procedures and usually not urgent, price can be a deciding factor.
For Nathan Songne, cost was the most stressful part of the procedure. For several years, the 31-year-old had known he didn’t want to have kids biologically. Better to adopt a 4-year-old and skip the diaper stage, he thought. He was adopted by his stepfather as a child and knew he didn’t need to be genetically related to his children to love them.
“My only concern was that I had no idea how much it was going to cost me because nobody told me,” said Mr. Songne, who lives in Mission Viejo, in Orange County. If the procedure cost $1,000, as he expected, he wouldn’t be able to afford it.
Mr. Songne’s insurance, which he gets through his work assembling guitars, covered 70% of the Aug. 8 procedure, leaving him with a bill of just under $200. “Cost did affect my decision, but because it was only $200, it made me feel a lot more relieved about continuing on with the vasectomy.”
There are two hot times of year in the vasectomy business, according to Mary Samplaski, MD, an associate professor of urology at the University of Southern California, Los Angeles. First, she sees an uptick during the March Madness college basketball tournament, when men choose to recover on the couch watching hoops.
The end of the year is also busy, she said, because many patients have finally met their annual insurance deductible and can afford the procedure.
Patients discuss out-of-pocket costs in about 20% of her vasectomy consultations. “It’s obviously a nerve-wracking procedure,” Dr. Samplaski said. “And on top of that, if your copay is high, there’s even less reason to want to do it.”
In April, Jacob Elert comparison-shopped for a vasectomy near his home in Sacramento because his health plan doesn’t cover the procedure. He had hoped to schedule one with his regular urologist, but that would have come with a $1,500 price tag.
Instead, he found a chain of vasectomy clinics where he could get the procedure for $850. Three months later, a test confirmed the vasectomy was a success.
Mr. Elert has no regrets, but had price not been a factor, he would have preferred to go to his regular urologist. “That’s the doctor I trust,” Mr. Elert said. “But it was just way too expensive.”
In November, California voters will decide whether to lock rights to abortion and contraception into the state constitution. But Proposition 1 doesn’t address issues such as cost and coverage, said Amy Moy, a spokesperson for Essential Access Health, a group that runs California’s Title X family planning program.
“The constitutional amendment is kind of the long-term protection, and we are still working to reduce barriers for Californians on the short-term and day-to-day level regardless of their gender,” she said.
SB 523 has sailed through preliminary votes in the state legislature, which faces an end-of-August deadline to act on bills. If the measure passes, it would take effect in 2024, and California would join a handful of states that require plans they regulate to completely cover vasectomies or nonprescription birth control.
The California Association of Health Plans is still evaluating the measure, which may be amended in the final days of the legislative session. But the association generally opposes bills that require additional insurance benefits because they could lead to higher premiums, spokesperson Mary Ellen Grant said.
SB 523 applies to more than 14 million Californians who work for the state, have a student health plan through a university, or have state-regulated commercial health plans. They would become eligible to receive free over-the-counter birth control – such as emergency contraception, condoms, spermicide, and contraceptive sponges – in addition to vasectomies. The bill would not apply to the millions of Californians whose health insurance plans are regulated by the federal government.
The specifics of how the benefit would work, including the frequency and amount of birth control that insurers must cover and whether patients would have to pay upfront and be reimbursed later, would be hammered out after the measure is adopted. Ms. McCaman Taylor said allowing people to simply present their insurance card at a pharmacy counter and walk away with the birth control they need would be preferable.
“We kind of learned from the national experiment with COVID over-the-counter tests that reimbursement wasn’t the best model,” she said. “If people can’t afford to pay out of pocket for it, they’re just not going to get it.”
The California Health Benefits Review Program, which analyzes legislation, projected that roughly 14,200 people with state-regulated commercial insurance would get vasectomies in California in 2022. Eliminating cost sharing would increase the number of vasectomies by 252 in the law’s first year, the program estimated.
It’s a small increase. But that, plus a jump in the use of other contraceptives covered by the bill, particularly condoms, could add up to a big reduction in unintended pregnancies. Roughly 12,300 unplanned pregnancies might be averted each year if the mandate takes effect, a reduction of more than 11%, according to the analysis.
This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Annual PSA screening important for Black men
, new data suggest.
The data come from a review of 45,834 veterans (aged 55-69 years) who had been diagnosed with prostate cancer. About one-third of these men self-identified as non-Hispanic Black, and the rest were White.
During the study period (2004-2017), 2,465 men (5.4%) died of the disease.
The review found that annual prostate-specific antigen (PSA) screening significantly reduced the risk of dying from prostate cancer among Black men but not White men.
The study was published online in JAMA Oncology.
“These results may be biologically plausible because a shorter screening interval may be valuable for detecting aggressive disease, which is more common in Black men,” say investigators, led by University of California, San Diego, radiation oncology resident Michael Sherer, MD.
“Given that Black men are younger at diagnosis and have worse prostate cancer survival compared with White men,” more intensive screening recommendations “may benefit Black patients,” they write.
The study “conclusions are reasonable,” said Christopher Wallis, MD, PhD, a urologic oncologist at Mount Sinai Hospital in Toronto, when asked for comment.
Annual screening may well have “a greater potential to benefit” Black men, he said. “While we would ideally see randomized data supporting this, those data are unlikely to ever be forthcoming. Thus, this study provides a strong rationale to support the recommendations from many guideline panels (including those from the American Urological Association) that Black men, in the context of shared decision-making, may benefit more from PSA-based prostate cancer screening than the population at large,” he added.
Overall, the findings could help inform screening discussions with Black men, the investigators comments. In its most recent guidance, the U.S. Preventive Services Task Force recommends shared decision-making regarding PSA screening for men aged 55-69 years.
Similar screening frequency
For their study, the team reviewed Veterans Health Administration data to assess PSA screening patterns – which they categorized as no screening, less than annual screening, or annual screening – in the 5 years leading up to diagnosis.
They then correlated screening behaviors with the subsequent risk of dying from prostate cancer.
Overall, the reduction in risk of prostate cancer–specific mortality (PCSM) associated with screening was similar among Black men (subdistribution hazard ratio, 0.56; P = .001) and White men (sHR, 0.58; P = .001).
However, on multivariable regression, annual screening, in comparison with some screening, was associated with a significant reduction in the risk of dying from prostate cancer only among Black men (sHR, 0.65; P = .02), not among White men (sHR, 0.91; P = .35).
The cumulative incidence of PCSM among Black men was 4.7% with annual screening but 7.3% with only some screening.
Among White men, the cumulative incidence of PCSM with annual screening was 5.9% vs. 6.9% with less than annual screening.
Screening frequency was similar between Black men and White men. Black men were younger on average (61.8 vs. 63.1 years) and had slightly higher PSA levels at diagnosis but were not more likely to have regional or metastatic disease.
No funding was reported for this study. The investigators have disclosed no relevant financial relationships. Dr. Wallis has received personal fees from Janssen Canada.
A version of this article first appeared on Medscape.com.
, new data suggest.
The data come from a review of 45,834 veterans (aged 55-69 years) who had been diagnosed with prostate cancer. About one-third of these men self-identified as non-Hispanic Black, and the rest were White.
During the study period (2004-2017), 2,465 men (5.4%) died of the disease.
The review found that annual prostate-specific antigen (PSA) screening significantly reduced the risk of dying from prostate cancer among Black men but not White men.
The study was published online in JAMA Oncology.
“These results may be biologically plausible because a shorter screening interval may be valuable for detecting aggressive disease, which is more common in Black men,” say investigators, led by University of California, San Diego, radiation oncology resident Michael Sherer, MD.
“Given that Black men are younger at diagnosis and have worse prostate cancer survival compared with White men,” more intensive screening recommendations “may benefit Black patients,” they write.
The study “conclusions are reasonable,” said Christopher Wallis, MD, PhD, a urologic oncologist at Mount Sinai Hospital in Toronto, when asked for comment.
Annual screening may well have “a greater potential to benefit” Black men, he said. “While we would ideally see randomized data supporting this, those data are unlikely to ever be forthcoming. Thus, this study provides a strong rationale to support the recommendations from many guideline panels (including those from the American Urological Association) that Black men, in the context of shared decision-making, may benefit more from PSA-based prostate cancer screening than the population at large,” he added.
Overall, the findings could help inform screening discussions with Black men, the investigators comments. In its most recent guidance, the U.S. Preventive Services Task Force recommends shared decision-making regarding PSA screening for men aged 55-69 years.
Similar screening frequency
For their study, the team reviewed Veterans Health Administration data to assess PSA screening patterns – which they categorized as no screening, less than annual screening, or annual screening – in the 5 years leading up to diagnosis.
They then correlated screening behaviors with the subsequent risk of dying from prostate cancer.
Overall, the reduction in risk of prostate cancer–specific mortality (PCSM) associated with screening was similar among Black men (subdistribution hazard ratio, 0.56; P = .001) and White men (sHR, 0.58; P = .001).
However, on multivariable regression, annual screening, in comparison with some screening, was associated with a significant reduction in the risk of dying from prostate cancer only among Black men (sHR, 0.65; P = .02), not among White men (sHR, 0.91; P = .35).
The cumulative incidence of PCSM among Black men was 4.7% with annual screening but 7.3% with only some screening.
Among White men, the cumulative incidence of PCSM with annual screening was 5.9% vs. 6.9% with less than annual screening.
Screening frequency was similar between Black men and White men. Black men were younger on average (61.8 vs. 63.1 years) and had slightly higher PSA levels at diagnosis but were not more likely to have regional or metastatic disease.
No funding was reported for this study. The investigators have disclosed no relevant financial relationships. Dr. Wallis has received personal fees from Janssen Canada.
A version of this article first appeared on Medscape.com.
, new data suggest.
The data come from a review of 45,834 veterans (aged 55-69 years) who had been diagnosed with prostate cancer. About one-third of these men self-identified as non-Hispanic Black, and the rest were White.
During the study period (2004-2017), 2,465 men (5.4%) died of the disease.
The review found that annual prostate-specific antigen (PSA) screening significantly reduced the risk of dying from prostate cancer among Black men but not White men.
The study was published online in JAMA Oncology.
“These results may be biologically plausible because a shorter screening interval may be valuable for detecting aggressive disease, which is more common in Black men,” say investigators, led by University of California, San Diego, radiation oncology resident Michael Sherer, MD.
“Given that Black men are younger at diagnosis and have worse prostate cancer survival compared with White men,” more intensive screening recommendations “may benefit Black patients,” they write.
The study “conclusions are reasonable,” said Christopher Wallis, MD, PhD, a urologic oncologist at Mount Sinai Hospital in Toronto, when asked for comment.
Annual screening may well have “a greater potential to benefit” Black men, he said. “While we would ideally see randomized data supporting this, those data are unlikely to ever be forthcoming. Thus, this study provides a strong rationale to support the recommendations from many guideline panels (including those from the American Urological Association) that Black men, in the context of shared decision-making, may benefit more from PSA-based prostate cancer screening than the population at large,” he added.
Overall, the findings could help inform screening discussions with Black men, the investigators comments. In its most recent guidance, the U.S. Preventive Services Task Force recommends shared decision-making regarding PSA screening for men aged 55-69 years.
Similar screening frequency
For their study, the team reviewed Veterans Health Administration data to assess PSA screening patterns – which they categorized as no screening, less than annual screening, or annual screening – in the 5 years leading up to diagnosis.
They then correlated screening behaviors with the subsequent risk of dying from prostate cancer.
Overall, the reduction in risk of prostate cancer–specific mortality (PCSM) associated with screening was similar among Black men (subdistribution hazard ratio, 0.56; P = .001) and White men (sHR, 0.58; P = .001).
However, on multivariable regression, annual screening, in comparison with some screening, was associated with a significant reduction in the risk of dying from prostate cancer only among Black men (sHR, 0.65; P = .02), not among White men (sHR, 0.91; P = .35).
The cumulative incidence of PCSM among Black men was 4.7% with annual screening but 7.3% with only some screening.
Among White men, the cumulative incidence of PCSM with annual screening was 5.9% vs. 6.9% with less than annual screening.
Screening frequency was similar between Black men and White men. Black men were younger on average (61.8 vs. 63.1 years) and had slightly higher PSA levels at diagnosis but were not more likely to have regional or metastatic disease.
No funding was reported for this study. The investigators have disclosed no relevant financial relationships. Dr. Wallis has received personal fees from Janssen Canada.
A version of this article first appeared on Medscape.com.
FROM JAMA ONCOLOGY
Patients who engage in risky ‘chemsex’ benefit from appropriate treatment
Chemsex combines sex, drugs, and smartphones, and physicians know very little about it. Dedicated consultations were instituted in the fall of 2019 at the Infectious Diseases Department at the Saint-Louis Hospital in Paris. It’s estimated that 1,000 persons who were patients there practice chemsex.
Alexandre Aslan, MD, is one of the department’s physicians; he is also a sexologist and psychotherapist-psychoanalyst. At the ALBATROS International Congress of Addiction, which took place in the French capital in June, he presented the results of a study of patients who engage in chemsex and who regularly attend those consultations. Through this research, light is being shed on the phenomenon.
This news organization invited Dr. Aslan to discuss the issues connected with this practice.
Question: What exactly is chemsex, also known as party ‘n’ play (PnP)?
Dr. Aslan: Hearing the word “chemsex,” one would automatically think that it is what it sounds like it is: having sex while on drugs. That’s not really what it is. According to the definition that’s been published in the scientific literature, chemsex is a practice seen among men who have sex with men, where they take some very specific substances during sexual activity to sustain, enhance, or intensify the sexual experience, but also to “manage” issues related to intimacy, performance, and concerns about sexually transmitted infections (STIs). The substances are most commonly a cocktail of three drugs: GHB [gamma-hydroxybutyrate], cathinones, and crystal meth. In chemsex, smartphones play a central role as well, through the use of social networking and dating applications – those location-based apps that allow users to instantly find partners.
Question: In what ways does meeting through apps influence the sexual relationship and the use of substances?
Dr. Aslan: Because the plan to meet up for sex is being made through these kinds of apps, the promise to have sex is often implied – and this is before the individuals even meet up in real life. Let me explain. It’s not an encounter or a person that’s going to trigger sexual desire. Instead, it’s something within – the sexual “urge” inside of the individual – that’s going to drive them toward sexual activity. Now, finding yourself promising to have sex with someone – someone you don’t know, haven’t spoken to, and haven’t actually met – in an environment where it’s possible that you’ll meet several people and where the moments in which the sexual acts take place are predominantly characterized by pornography-related performance scripts: This can push you to take substances so you can “let go” and get to the point where you’re able to adapt to the requirements of the situation. Seeking to perform well and to not be overly inhibited, these individuals have found that this drug cocktail proves to be quite explosive, imparting a very strong capacity for experiencing excitement and even bringing about new sexual practices.
Question: Can you speak a bit about drug-enhanced sex?
Dr. Aslan: We sexologists consider it to be a very particular type of sex. People who engage in it feel that the sex is very intense, with unbelievable experiences, and that they have a deeper connection with their partner. In fact, it’s a type of sex where taking these substances does away with the very principles of sexual physiology – in other words, desire followed by excitement, plateau, orgasm, and resolution. Little by little, one’s sexual partner is no longer going to exist in the sex session, and the benefit is a succession of partners whose sole purpose is to keep the fire of excitement burning, an excitement that’s also reinforced by the substances taken. It’s “sex” under the influence rather than a sexual encounter linked to desire.
Question: What impact does it have on health?
Dr. Aslan: This practice brings with it numerous complications, such as STIs, but also physical injuries, as these sessions can last for 24 to more than 48 hours. There are also psychological complications, because these drugs can bring about depression, paranoia, self-harm, and even episodes of decompensation. And then, it should be noted that later on, the spotlight gets pulled away from the sex – the pretext from the very beginning – and shifts toward the taking of drugs: The individuals will no longer be able to separate the sexual encounter from the taking of drugs. Then, in a few years, there’s no longer the sexual encounter, only the taking of drugs. In the United States, between 2021 and 2022, there was a decrease in the number of deaths caused by heroin and prescription opioids. On the other hand, since 2020, the overdoses that have exploded in number are those related to fentanyl, nonprescription opioids, and stimulants – cocaine and methamphetamine, which can come back into the practices particularly through the seemingly “playful” arena of sex.
Question: How is it that things have gone from being a practice that’s under control to full-on drug addiction?
Dr. Aslan: You still have people who manage to keep things under control. But the kinds of drugs that are taken are highly addictive and compel the individual to take even more. It’s one big circle: The exciting sexual relationship itself, to which you add substances that cause even more dopamine to be released, and a smartphone screen with excitatory pornographic images on it all the time. In all the patients we see, we notice a trajectory that looks like the trajectory of every drug. When they’re at the beginning – in other words, the first year – after a first experience that they consider to be explosive, they may not return to the scene right away, and then they do return to it. They realize that it’s perhaps not as marvelous as the first time, but they’re going to give it another try. During this novelty phase, a strategy is pursued whereby they adapt and make adjustments in an attempt to feel again what they felt the first time. At the end of a year or two, they become disillusioned and they refocus on all activities having to do with drug use. Our hospital department conducted a survey where we asked detailed questions to over 100 individuals. It showed that people noticed the negative consequences that chemsex had on their work (60%), on their private lives and sex lives (55%), and on their relationships with friends and family (63%). This means that people are well aware of the negative effects that this practice has in very important areas of their lives. But even if they notice all of that, even if they resolve to have a certain number of sexual relations without drugs involved, these substances are so powerful in releasing a rush of dopamine that that very fact can sweep away any capacity the individual may have had to make a decision and stick to it, and they’re going to feel practically “compelled” to use. This is what’s called a craving.
Question: How do you identify patients who engage in chemsex among the patients in your infectious diseases department?
Dr. Aslan: As a rule, all patients admitted to our department are asked a series of questions. Do you use drugs to engage in sexual relations? Which drug do you prefer? How do you take it? Do you have a good time? Do you find that it’s good for you? Are you okay with how much you’re using? We also ask patients to tell us when they last had drug-free sex. It’s a very important question, because if we can identify someone who has had 10 or so partners a month but hasn’t had drug-free sex for over a month, we’ll try to steer the conversation to where they’ll come to think that it might not be such a bad idea to talk about it.
Question: Should a physician be asking younger patients whether they’re engaging in chemsex?
Dr. Aslan: Yes, but the physician has to be very careful. We often have a tendency to believe that we’re capable of speaking with our patients about relevant matters related to sex. We see ourselves as that kind of person, not to mention we’re open-minded. Now, as in all fields of medicine, we have to educate ourselves about how best to approach patients – in this case, about their sexual health. Because sometimes, despite our best intentions, we can do harm. The idea that we have of our own sexual behavior does not necessarily help provide counsel regarding another person’s sexual behavior, particularly when there are differences between the two. If you’re interested in the issue, you need to be trained on all the answers that could come up. There are training courses online. There’s a module on sexual health and chemsex at a site designed to give private practice physicians guidance about PrEP. It’s at least a place to start. This way, physicians will know what questions they can ask and when they should reach out to a specialist, such as a sexologist with training in these specific issues.
Question: What is the treatment based on?
Dr. Aslan: The traditional approach taken by addiction medicine physicians may not be comprehensive enough. Likewise, a sexologist’s approach alone can only go so far. It’s impossible to get by thinking that a single discipline can hold the solution, all the answers. So, it’s a multidisciplinary sexual health treatment. There should be a psychiatrist or addiction medicine physician who knows the drugs and is capable of navigating through this landscape of psychiatric comorbidities (such as psychoses and ADHD).
There also has to be a sexologist for the treatment of any sexual dysfunctions there may be. At Saint-Louis Hospital, 60% of patients who engage in chemsex said that engaging in the practice was related to a sexual problem that they noted – but never went to see a doctor about – before the first time they used. Be that as it may, it’s still the case that if these patients had been able to see a sexologist – who would have treated the problem – the drug may perhaps not have taken hold.
There also has to be a practitioner who can focus on risk reduction. In other words, someone capable of helping the patient get to the desired level of use where the craving, the need for instant gratification, can be kept in check.
In practice, one can sometimes, in addition to all of that, turn to medical treatments to manage the craving or medical comorbidities, an approach based on sexology to provide care for the sexual dysfunction or even to help the person learn how to evoke sexual or erotic fantasies without drugs, and an approach based on addiction medicine or psychotherapy, as some of our patients experienced sexual abuse in childhood. In the end, chemsex is just the outer layer – a problem that only seems to pertain to sex but that, in reality, covers up a wide range of issues. And not only sexual issues or issues that are related to drugs like chemsex is.
Question: What are the outcomes of this multidisciplinary treatment?
Dr. Aslan: Before we finish, I must point out and just state that the patients, when they’re cared for and when they’re provided with the appropriate treatment, change their practices. Some of our patients, even those with more advanced cases in terms of frequency, how often they’re injecting drugs – every 30 minutes over the course of 24 or 48 hours, with complications such as thrombosis, sepsis, and abscesses – they’ve completely stopped after several months of treatment. They now lead lives that, as they’ve told us, work better for them. So, those of us in the health care industry, we have to get organized and set things up in a way that will allow us to focus our efforts on treating these patients.
A version of this article first appeared on Medscape.com. This article was translated from the Medscape French edition.
Chemsex combines sex, drugs, and smartphones, and physicians know very little about it. Dedicated consultations were instituted in the fall of 2019 at the Infectious Diseases Department at the Saint-Louis Hospital in Paris. It’s estimated that 1,000 persons who were patients there practice chemsex.
Alexandre Aslan, MD, is one of the department’s physicians; he is also a sexologist and psychotherapist-psychoanalyst. At the ALBATROS International Congress of Addiction, which took place in the French capital in June, he presented the results of a study of patients who engage in chemsex and who regularly attend those consultations. Through this research, light is being shed on the phenomenon.
This news organization invited Dr. Aslan to discuss the issues connected with this practice.
Question: What exactly is chemsex, also known as party ‘n’ play (PnP)?
Dr. Aslan: Hearing the word “chemsex,” one would automatically think that it is what it sounds like it is: having sex while on drugs. That’s not really what it is. According to the definition that’s been published in the scientific literature, chemsex is a practice seen among men who have sex with men, where they take some very specific substances during sexual activity to sustain, enhance, or intensify the sexual experience, but also to “manage” issues related to intimacy, performance, and concerns about sexually transmitted infections (STIs). The substances are most commonly a cocktail of three drugs: GHB [gamma-hydroxybutyrate], cathinones, and crystal meth. In chemsex, smartphones play a central role as well, through the use of social networking and dating applications – those location-based apps that allow users to instantly find partners.
Question: In what ways does meeting through apps influence the sexual relationship and the use of substances?
Dr. Aslan: Because the plan to meet up for sex is being made through these kinds of apps, the promise to have sex is often implied – and this is before the individuals even meet up in real life. Let me explain. It’s not an encounter or a person that’s going to trigger sexual desire. Instead, it’s something within – the sexual “urge” inside of the individual – that’s going to drive them toward sexual activity. Now, finding yourself promising to have sex with someone – someone you don’t know, haven’t spoken to, and haven’t actually met – in an environment where it’s possible that you’ll meet several people and where the moments in which the sexual acts take place are predominantly characterized by pornography-related performance scripts: This can push you to take substances so you can “let go” and get to the point where you’re able to adapt to the requirements of the situation. Seeking to perform well and to not be overly inhibited, these individuals have found that this drug cocktail proves to be quite explosive, imparting a very strong capacity for experiencing excitement and even bringing about new sexual practices.
Question: Can you speak a bit about drug-enhanced sex?
Dr. Aslan: We sexologists consider it to be a very particular type of sex. People who engage in it feel that the sex is very intense, with unbelievable experiences, and that they have a deeper connection with their partner. In fact, it’s a type of sex where taking these substances does away with the very principles of sexual physiology – in other words, desire followed by excitement, plateau, orgasm, and resolution. Little by little, one’s sexual partner is no longer going to exist in the sex session, and the benefit is a succession of partners whose sole purpose is to keep the fire of excitement burning, an excitement that’s also reinforced by the substances taken. It’s “sex” under the influence rather than a sexual encounter linked to desire.
Question: What impact does it have on health?
Dr. Aslan: This practice brings with it numerous complications, such as STIs, but also physical injuries, as these sessions can last for 24 to more than 48 hours. There are also psychological complications, because these drugs can bring about depression, paranoia, self-harm, and even episodes of decompensation. And then, it should be noted that later on, the spotlight gets pulled away from the sex – the pretext from the very beginning – and shifts toward the taking of drugs: The individuals will no longer be able to separate the sexual encounter from the taking of drugs. Then, in a few years, there’s no longer the sexual encounter, only the taking of drugs. In the United States, between 2021 and 2022, there was a decrease in the number of deaths caused by heroin and prescription opioids. On the other hand, since 2020, the overdoses that have exploded in number are those related to fentanyl, nonprescription opioids, and stimulants – cocaine and methamphetamine, which can come back into the practices particularly through the seemingly “playful” arena of sex.
Question: How is it that things have gone from being a practice that’s under control to full-on drug addiction?
Dr. Aslan: You still have people who manage to keep things under control. But the kinds of drugs that are taken are highly addictive and compel the individual to take even more. It’s one big circle: The exciting sexual relationship itself, to which you add substances that cause even more dopamine to be released, and a smartphone screen with excitatory pornographic images on it all the time. In all the patients we see, we notice a trajectory that looks like the trajectory of every drug. When they’re at the beginning – in other words, the first year – after a first experience that they consider to be explosive, they may not return to the scene right away, and then they do return to it. They realize that it’s perhaps not as marvelous as the first time, but they’re going to give it another try. During this novelty phase, a strategy is pursued whereby they adapt and make adjustments in an attempt to feel again what they felt the first time. At the end of a year or two, they become disillusioned and they refocus on all activities having to do with drug use. Our hospital department conducted a survey where we asked detailed questions to over 100 individuals. It showed that people noticed the negative consequences that chemsex had on their work (60%), on their private lives and sex lives (55%), and on their relationships with friends and family (63%). This means that people are well aware of the negative effects that this practice has in very important areas of their lives. But even if they notice all of that, even if they resolve to have a certain number of sexual relations without drugs involved, these substances are so powerful in releasing a rush of dopamine that that very fact can sweep away any capacity the individual may have had to make a decision and stick to it, and they’re going to feel practically “compelled” to use. This is what’s called a craving.
Question: How do you identify patients who engage in chemsex among the patients in your infectious diseases department?
Dr. Aslan: As a rule, all patients admitted to our department are asked a series of questions. Do you use drugs to engage in sexual relations? Which drug do you prefer? How do you take it? Do you have a good time? Do you find that it’s good for you? Are you okay with how much you’re using? We also ask patients to tell us when they last had drug-free sex. It’s a very important question, because if we can identify someone who has had 10 or so partners a month but hasn’t had drug-free sex for over a month, we’ll try to steer the conversation to where they’ll come to think that it might not be such a bad idea to talk about it.
Question: Should a physician be asking younger patients whether they’re engaging in chemsex?
Dr. Aslan: Yes, but the physician has to be very careful. We often have a tendency to believe that we’re capable of speaking with our patients about relevant matters related to sex. We see ourselves as that kind of person, not to mention we’re open-minded. Now, as in all fields of medicine, we have to educate ourselves about how best to approach patients – in this case, about their sexual health. Because sometimes, despite our best intentions, we can do harm. The idea that we have of our own sexual behavior does not necessarily help provide counsel regarding another person’s sexual behavior, particularly when there are differences between the two. If you’re interested in the issue, you need to be trained on all the answers that could come up. There are training courses online. There’s a module on sexual health and chemsex at a site designed to give private practice physicians guidance about PrEP. It’s at least a place to start. This way, physicians will know what questions they can ask and when they should reach out to a specialist, such as a sexologist with training in these specific issues.
Question: What is the treatment based on?
Dr. Aslan: The traditional approach taken by addiction medicine physicians may not be comprehensive enough. Likewise, a sexologist’s approach alone can only go so far. It’s impossible to get by thinking that a single discipline can hold the solution, all the answers. So, it’s a multidisciplinary sexual health treatment. There should be a psychiatrist or addiction medicine physician who knows the drugs and is capable of navigating through this landscape of psychiatric comorbidities (such as psychoses and ADHD).
There also has to be a sexologist for the treatment of any sexual dysfunctions there may be. At Saint-Louis Hospital, 60% of patients who engage in chemsex said that engaging in the practice was related to a sexual problem that they noted – but never went to see a doctor about – before the first time they used. Be that as it may, it’s still the case that if these patients had been able to see a sexologist – who would have treated the problem – the drug may perhaps not have taken hold.
There also has to be a practitioner who can focus on risk reduction. In other words, someone capable of helping the patient get to the desired level of use where the craving, the need for instant gratification, can be kept in check.
In practice, one can sometimes, in addition to all of that, turn to medical treatments to manage the craving or medical comorbidities, an approach based on sexology to provide care for the sexual dysfunction or even to help the person learn how to evoke sexual or erotic fantasies without drugs, and an approach based on addiction medicine or psychotherapy, as some of our patients experienced sexual abuse in childhood. In the end, chemsex is just the outer layer – a problem that only seems to pertain to sex but that, in reality, covers up a wide range of issues. And not only sexual issues or issues that are related to drugs like chemsex is.
Question: What are the outcomes of this multidisciplinary treatment?
Dr. Aslan: Before we finish, I must point out and just state that the patients, when they’re cared for and when they’re provided with the appropriate treatment, change their practices. Some of our patients, even those with more advanced cases in terms of frequency, how often they’re injecting drugs – every 30 minutes over the course of 24 or 48 hours, with complications such as thrombosis, sepsis, and abscesses – they’ve completely stopped after several months of treatment. They now lead lives that, as they’ve told us, work better for them. So, those of us in the health care industry, we have to get organized and set things up in a way that will allow us to focus our efforts on treating these patients.
A version of this article first appeared on Medscape.com. This article was translated from the Medscape French edition.
Chemsex combines sex, drugs, and smartphones, and physicians know very little about it. Dedicated consultations were instituted in the fall of 2019 at the Infectious Diseases Department at the Saint-Louis Hospital in Paris. It’s estimated that 1,000 persons who were patients there practice chemsex.
Alexandre Aslan, MD, is one of the department’s physicians; he is also a sexologist and psychotherapist-psychoanalyst. At the ALBATROS International Congress of Addiction, which took place in the French capital in June, he presented the results of a study of patients who engage in chemsex and who regularly attend those consultations. Through this research, light is being shed on the phenomenon.
This news organization invited Dr. Aslan to discuss the issues connected with this practice.
Question: What exactly is chemsex, also known as party ‘n’ play (PnP)?
Dr. Aslan: Hearing the word “chemsex,” one would automatically think that it is what it sounds like it is: having sex while on drugs. That’s not really what it is. According to the definition that’s been published in the scientific literature, chemsex is a practice seen among men who have sex with men, where they take some very specific substances during sexual activity to sustain, enhance, or intensify the sexual experience, but also to “manage” issues related to intimacy, performance, and concerns about sexually transmitted infections (STIs). The substances are most commonly a cocktail of three drugs: GHB [gamma-hydroxybutyrate], cathinones, and crystal meth. In chemsex, smartphones play a central role as well, through the use of social networking and dating applications – those location-based apps that allow users to instantly find partners.
Question: In what ways does meeting through apps influence the sexual relationship and the use of substances?
Dr. Aslan: Because the plan to meet up for sex is being made through these kinds of apps, the promise to have sex is often implied – and this is before the individuals even meet up in real life. Let me explain. It’s not an encounter or a person that’s going to trigger sexual desire. Instead, it’s something within – the sexual “urge” inside of the individual – that’s going to drive them toward sexual activity. Now, finding yourself promising to have sex with someone – someone you don’t know, haven’t spoken to, and haven’t actually met – in an environment where it’s possible that you’ll meet several people and where the moments in which the sexual acts take place are predominantly characterized by pornography-related performance scripts: This can push you to take substances so you can “let go” and get to the point where you’re able to adapt to the requirements of the situation. Seeking to perform well and to not be overly inhibited, these individuals have found that this drug cocktail proves to be quite explosive, imparting a very strong capacity for experiencing excitement and even bringing about new sexual practices.
Question: Can you speak a bit about drug-enhanced sex?
Dr. Aslan: We sexologists consider it to be a very particular type of sex. People who engage in it feel that the sex is very intense, with unbelievable experiences, and that they have a deeper connection with their partner. In fact, it’s a type of sex where taking these substances does away with the very principles of sexual physiology – in other words, desire followed by excitement, plateau, orgasm, and resolution. Little by little, one’s sexual partner is no longer going to exist in the sex session, and the benefit is a succession of partners whose sole purpose is to keep the fire of excitement burning, an excitement that’s also reinforced by the substances taken. It’s “sex” under the influence rather than a sexual encounter linked to desire.
Question: What impact does it have on health?
Dr. Aslan: This practice brings with it numerous complications, such as STIs, but also physical injuries, as these sessions can last for 24 to more than 48 hours. There are also psychological complications, because these drugs can bring about depression, paranoia, self-harm, and even episodes of decompensation. And then, it should be noted that later on, the spotlight gets pulled away from the sex – the pretext from the very beginning – and shifts toward the taking of drugs: The individuals will no longer be able to separate the sexual encounter from the taking of drugs. Then, in a few years, there’s no longer the sexual encounter, only the taking of drugs. In the United States, between 2021 and 2022, there was a decrease in the number of deaths caused by heroin and prescription opioids. On the other hand, since 2020, the overdoses that have exploded in number are those related to fentanyl, nonprescription opioids, and stimulants – cocaine and methamphetamine, which can come back into the practices particularly through the seemingly “playful” arena of sex.
Question: How is it that things have gone from being a practice that’s under control to full-on drug addiction?
Dr. Aslan: You still have people who manage to keep things under control. But the kinds of drugs that are taken are highly addictive and compel the individual to take even more. It’s one big circle: The exciting sexual relationship itself, to which you add substances that cause even more dopamine to be released, and a smartphone screen with excitatory pornographic images on it all the time. In all the patients we see, we notice a trajectory that looks like the trajectory of every drug. When they’re at the beginning – in other words, the first year – after a first experience that they consider to be explosive, they may not return to the scene right away, and then they do return to it. They realize that it’s perhaps not as marvelous as the first time, but they’re going to give it another try. During this novelty phase, a strategy is pursued whereby they adapt and make adjustments in an attempt to feel again what they felt the first time. At the end of a year or two, they become disillusioned and they refocus on all activities having to do with drug use. Our hospital department conducted a survey where we asked detailed questions to over 100 individuals. It showed that people noticed the negative consequences that chemsex had on their work (60%), on their private lives and sex lives (55%), and on their relationships with friends and family (63%). This means that people are well aware of the negative effects that this practice has in very important areas of their lives. But even if they notice all of that, even if they resolve to have a certain number of sexual relations without drugs involved, these substances are so powerful in releasing a rush of dopamine that that very fact can sweep away any capacity the individual may have had to make a decision and stick to it, and they’re going to feel practically “compelled” to use. This is what’s called a craving.
Question: How do you identify patients who engage in chemsex among the patients in your infectious diseases department?
Dr. Aslan: As a rule, all patients admitted to our department are asked a series of questions. Do you use drugs to engage in sexual relations? Which drug do you prefer? How do you take it? Do you have a good time? Do you find that it’s good for you? Are you okay with how much you’re using? We also ask patients to tell us when they last had drug-free sex. It’s a very important question, because if we can identify someone who has had 10 or so partners a month but hasn’t had drug-free sex for over a month, we’ll try to steer the conversation to where they’ll come to think that it might not be such a bad idea to talk about it.
Question: Should a physician be asking younger patients whether they’re engaging in chemsex?
Dr. Aslan: Yes, but the physician has to be very careful. We often have a tendency to believe that we’re capable of speaking with our patients about relevant matters related to sex. We see ourselves as that kind of person, not to mention we’re open-minded. Now, as in all fields of medicine, we have to educate ourselves about how best to approach patients – in this case, about their sexual health. Because sometimes, despite our best intentions, we can do harm. The idea that we have of our own sexual behavior does not necessarily help provide counsel regarding another person’s sexual behavior, particularly when there are differences between the two. If you’re interested in the issue, you need to be trained on all the answers that could come up. There are training courses online. There’s a module on sexual health and chemsex at a site designed to give private practice physicians guidance about PrEP. It’s at least a place to start. This way, physicians will know what questions they can ask and when they should reach out to a specialist, such as a sexologist with training in these specific issues.
Question: What is the treatment based on?
Dr. Aslan: The traditional approach taken by addiction medicine physicians may not be comprehensive enough. Likewise, a sexologist’s approach alone can only go so far. It’s impossible to get by thinking that a single discipline can hold the solution, all the answers. So, it’s a multidisciplinary sexual health treatment. There should be a psychiatrist or addiction medicine physician who knows the drugs and is capable of navigating through this landscape of psychiatric comorbidities (such as psychoses and ADHD).
There also has to be a sexologist for the treatment of any sexual dysfunctions there may be. At Saint-Louis Hospital, 60% of patients who engage in chemsex said that engaging in the practice was related to a sexual problem that they noted – but never went to see a doctor about – before the first time they used. Be that as it may, it’s still the case that if these patients had been able to see a sexologist – who would have treated the problem – the drug may perhaps not have taken hold.
There also has to be a practitioner who can focus on risk reduction. In other words, someone capable of helping the patient get to the desired level of use where the craving, the need for instant gratification, can be kept in check.
In practice, one can sometimes, in addition to all of that, turn to medical treatments to manage the craving or medical comorbidities, an approach based on sexology to provide care for the sexual dysfunction or even to help the person learn how to evoke sexual or erotic fantasies without drugs, and an approach based on addiction medicine or psychotherapy, as some of our patients experienced sexual abuse in childhood. In the end, chemsex is just the outer layer – a problem that only seems to pertain to sex but that, in reality, covers up a wide range of issues. And not only sexual issues or issues that are related to drugs like chemsex is.
Question: What are the outcomes of this multidisciplinary treatment?
Dr. Aslan: Before we finish, I must point out and just state that the patients, when they’re cared for and when they’re provided with the appropriate treatment, change their practices. Some of our patients, even those with more advanced cases in terms of frequency, how often they’re injecting drugs – every 30 minutes over the course of 24 or 48 hours, with complications such as thrombosis, sepsis, and abscesses – they’ve completely stopped after several months of treatment. They now lead lives that, as they’ve told us, work better for them. So, those of us in the health care industry, we have to get organized and set things up in a way that will allow us to focus our efforts on treating these patients.
A version of this article first appeared on Medscape.com. This article was translated from the Medscape French edition.
‘Misleading’ focus on urinary symptoms preventing early prostate cancer diagnoses
Researchers from the University of Cambridge said there was “no evidence of a causal link between prostate cancer and either prostate size or troublesome male urinary symptoms” and called for early prostate cancer to be rebranded “as primarily an asymptomatic disease” to encourage more men to get tested earlier when the condition is more treatable.
The authors of the ‘Opinion’ article, published in the journal BMC Medicine, argued that persistence by health bodies in flagging prostate cancer as a symptomatic disease – frequently presenting with slow urinary flow, frequency, and nocturia – worked against efforts to reduce mortality rates, which had remained largely unaltered in the UK and many other countries over the past decade and largely driven by late detection.
Public advice by the NHS, for instance, acknowledges that prostate cancer may be symptomless for many years but lists ‘an increased need to pee,’ ‘straining while you pee,’ and ‘a feeling that your bladder has not fully emptied’ as the top three signs that should not be ignored.
Messaging gives men ‘a false sense of security’
No wonder, the authors argued, that lower urinary tract symptoms and prostate cancer risk had become “causally associated,” as reflected in a 2003 survey finding that 86% of the public thought that prostate cancer was accompanied by symptoms, while only 1% were aware that it could be asymptomatic.
Lead study author Vincent Gnanapragasam, PhD, professor of urology at the University of Cambridge and an honorary consultant urologist at Addenbrooke’s Hospital, maintained: “We urgently need to recognize that the information currently given to the public risks giving men a false sense of security if they don’t have any urinary symptoms. We need to emphasize that prostate cancer can be a silent or asymptomatic disease, particularly in its curable stages. Waiting out for urinary symptoms may mean missing opportunities to catch the disease when it’s treatable.”
Although prostate enlargement can cause the lower urinary tract problems mentioned in public health messaging, the researchers said this is rarely due to malignant prostate tumors, quoting some research suggesting that “mean prostate volume was lower in men found to have prostate cancer compared to those with benign biopsies.” The Prostate testing for cancer and Treatment (ProtecT) trial in the UK concluded there was “no association or a negative association with more severe symptoms and prostate cancer,” they said.
Screening program
The researchers said they were not advocating introducing an immediate screening program, and they acknowledged that updating advice to focus on the often symptomless nature of the disease could lead to an influx of men requesting a PSA test from their GPs. But concerns this could result in overinvestigation and overtreatment “which previously deterred greater promotion of PSA testing in men with no symptoms” had been lessened by today’s “image-based diagnostics and risk-adapted management strategies,” they said.
The authors hoped for an eventual “intelligent tiered screening program” for prostate cancer to be introduced. In the meantime, Dr. Gnanapragasam said, “We’re calling on organizations such as the NHS, as well as patient charities and the media, to review the current public messaging.”
Amy Rylance, head of improving care at Prostate Cancer UK said: “This study reinforces the fact that men shouldn’t wait for symptoms before they act. Early prostate cancer is often symptomless, which is why we urge men to be aware of their risk instead. This is particularly important for men over 50, Black men, and men with a family history of prostate cancer.
“We know that most people assume that they would have symptoms if they had prostate cancer, and that not having straightforward signs to look out for can cause anxiety or confusion. That’s why our risk checker is designed to help men understand their risk factors and what action they can take, regardless of symptoms.”
A version of this article first appeared on Medscape.co.uk.
Researchers from the University of Cambridge said there was “no evidence of a causal link between prostate cancer and either prostate size or troublesome male urinary symptoms” and called for early prostate cancer to be rebranded “as primarily an asymptomatic disease” to encourage more men to get tested earlier when the condition is more treatable.
The authors of the ‘Opinion’ article, published in the journal BMC Medicine, argued that persistence by health bodies in flagging prostate cancer as a symptomatic disease – frequently presenting with slow urinary flow, frequency, and nocturia – worked against efforts to reduce mortality rates, which had remained largely unaltered in the UK and many other countries over the past decade and largely driven by late detection.
Public advice by the NHS, for instance, acknowledges that prostate cancer may be symptomless for many years but lists ‘an increased need to pee,’ ‘straining while you pee,’ and ‘a feeling that your bladder has not fully emptied’ as the top three signs that should not be ignored.
Messaging gives men ‘a false sense of security’
No wonder, the authors argued, that lower urinary tract symptoms and prostate cancer risk had become “causally associated,” as reflected in a 2003 survey finding that 86% of the public thought that prostate cancer was accompanied by symptoms, while only 1% were aware that it could be asymptomatic.
Lead study author Vincent Gnanapragasam, PhD, professor of urology at the University of Cambridge and an honorary consultant urologist at Addenbrooke’s Hospital, maintained: “We urgently need to recognize that the information currently given to the public risks giving men a false sense of security if they don’t have any urinary symptoms. We need to emphasize that prostate cancer can be a silent or asymptomatic disease, particularly in its curable stages. Waiting out for urinary symptoms may mean missing opportunities to catch the disease when it’s treatable.”
Although prostate enlargement can cause the lower urinary tract problems mentioned in public health messaging, the researchers said this is rarely due to malignant prostate tumors, quoting some research suggesting that “mean prostate volume was lower in men found to have prostate cancer compared to those with benign biopsies.” The Prostate testing for cancer and Treatment (ProtecT) trial in the UK concluded there was “no association or a negative association with more severe symptoms and prostate cancer,” they said.
Screening program
The researchers said they were not advocating introducing an immediate screening program, and they acknowledged that updating advice to focus on the often symptomless nature of the disease could lead to an influx of men requesting a PSA test from their GPs. But concerns this could result in overinvestigation and overtreatment “which previously deterred greater promotion of PSA testing in men with no symptoms” had been lessened by today’s “image-based diagnostics and risk-adapted management strategies,” they said.
The authors hoped for an eventual “intelligent tiered screening program” for prostate cancer to be introduced. In the meantime, Dr. Gnanapragasam said, “We’re calling on organizations such as the NHS, as well as patient charities and the media, to review the current public messaging.”
Amy Rylance, head of improving care at Prostate Cancer UK said: “This study reinforces the fact that men shouldn’t wait for symptoms before they act. Early prostate cancer is often symptomless, which is why we urge men to be aware of their risk instead. This is particularly important for men over 50, Black men, and men with a family history of prostate cancer.
“We know that most people assume that they would have symptoms if they had prostate cancer, and that not having straightforward signs to look out for can cause anxiety or confusion. That’s why our risk checker is designed to help men understand their risk factors and what action they can take, regardless of symptoms.”
A version of this article first appeared on Medscape.co.uk.
Researchers from the University of Cambridge said there was “no evidence of a causal link between prostate cancer and either prostate size or troublesome male urinary symptoms” and called for early prostate cancer to be rebranded “as primarily an asymptomatic disease” to encourage more men to get tested earlier when the condition is more treatable.
The authors of the ‘Opinion’ article, published in the journal BMC Medicine, argued that persistence by health bodies in flagging prostate cancer as a symptomatic disease – frequently presenting with slow urinary flow, frequency, and nocturia – worked against efforts to reduce mortality rates, which had remained largely unaltered in the UK and many other countries over the past decade and largely driven by late detection.
Public advice by the NHS, for instance, acknowledges that prostate cancer may be symptomless for many years but lists ‘an increased need to pee,’ ‘straining while you pee,’ and ‘a feeling that your bladder has not fully emptied’ as the top three signs that should not be ignored.
Messaging gives men ‘a false sense of security’
No wonder, the authors argued, that lower urinary tract symptoms and prostate cancer risk had become “causally associated,” as reflected in a 2003 survey finding that 86% of the public thought that prostate cancer was accompanied by symptoms, while only 1% were aware that it could be asymptomatic.
Lead study author Vincent Gnanapragasam, PhD, professor of urology at the University of Cambridge and an honorary consultant urologist at Addenbrooke’s Hospital, maintained: “We urgently need to recognize that the information currently given to the public risks giving men a false sense of security if they don’t have any urinary symptoms. We need to emphasize that prostate cancer can be a silent or asymptomatic disease, particularly in its curable stages. Waiting out for urinary symptoms may mean missing opportunities to catch the disease when it’s treatable.”
Although prostate enlargement can cause the lower urinary tract problems mentioned in public health messaging, the researchers said this is rarely due to malignant prostate tumors, quoting some research suggesting that “mean prostate volume was lower in men found to have prostate cancer compared to those with benign biopsies.” The Prostate testing for cancer and Treatment (ProtecT) trial in the UK concluded there was “no association or a negative association with more severe symptoms and prostate cancer,” they said.
Screening program
The researchers said they were not advocating introducing an immediate screening program, and they acknowledged that updating advice to focus on the often symptomless nature of the disease could lead to an influx of men requesting a PSA test from their GPs. But concerns this could result in overinvestigation and overtreatment “which previously deterred greater promotion of PSA testing in men with no symptoms” had been lessened by today’s “image-based diagnostics and risk-adapted management strategies,” they said.
The authors hoped for an eventual “intelligent tiered screening program” for prostate cancer to be introduced. In the meantime, Dr. Gnanapragasam said, “We’re calling on organizations such as the NHS, as well as patient charities and the media, to review the current public messaging.”
Amy Rylance, head of improving care at Prostate Cancer UK said: “This study reinforces the fact that men shouldn’t wait for symptoms before they act. Early prostate cancer is often symptomless, which is why we urge men to be aware of their risk instead. This is particularly important for men over 50, Black men, and men with a family history of prostate cancer.
“We know that most people assume that they would have symptoms if they had prostate cancer, and that not having straightforward signs to look out for can cause anxiety or confusion. That’s why our risk checker is designed to help men understand their risk factors and what action they can take, regardless of symptoms.”
A version of this article first appeared on Medscape.co.uk.
52-year-old man • erectile dysfunction • insomnia • migraine headaches • disclosure of infidelity
THE CASE
A 52-year-old man requested medicine to help him with erectile dysfunction. After obtaining a medical history and performing a physical exam, the family physician (FP) asked for more details about the patient’s situation. He reported that his wife, who had recently seen the same FP for counseling related to her frustrations with her husband, was uninterested in sex. He then added that he was having an affair with a 32-year-old female co-worker and wanted to improve his sexual function.
He admitted to feeling guilty about this situation and was conflicted about whether to end the affair. He also stated that since the affair, his insomnia had worsened, he was drinking more alcohol, and he was having migraine headaches. As the FP for both patients, and with the knowledge that the wife was worried about possible infidelity, the physician felt some level of conflict about the situation. The following is a discussion of the issues that this patient encounter raised.
DISCUSSION
Issues related to infidelity are common to both men and women. They are also common in same-sex relationships; in general, however, lesbian couples have fewer outside partners, whereas gay men are more likely to seek variety by having multiple partners.1
It is widely understood that successfully committed couples spend quality time together, emphasize each other’s strengths, show respect, accept influence, and nurture their friendship. However, many couples experience infidelity at some time in the course of their marriage. It is difficult to put an exact estimate on rates of infidelity due to problems with research methodology, inaccurate reporting, and a lack of agreement on a definition for infidelity.2 General categories of infidelity include emotional only, sexual only, and combined sexual and emotional infidelity.3,4 In terms of sexual infidelity, one study found that 25% of married men and 15% of married women admitted to having had extramarital sex at least once during their relationship.5 However, other studies suggest that women are closing the “sexual infidelity” gap and engaging in sexual affairs at a similar rate to men.6 There are websites that, in fact, have made it easier for married individuals to engage in affairs.
Reasons for infidelity. Men and women often have different motives in engaging in infidelity. In general, men’s motivations are more often related to sexual dissatisfaction and women’s to emotional dissatisfaction.7,8 However, infidelity may not always be the result of marital unhappiness.
Some studies suggest that the presence of opportunity may override the positive aspects of a relationship.9 Opportunity is heightened in the work environment, as reflected by the finding that 50% of infidelity occurs in the office.10 Research suggests that all relationships may be vulnerable to infidelity if the right opportunities present themselves.11
In general, health care providers are encouraged to use caution in generalizing about infidelity, as the subject is extremely complex, nuanced, and difficult to measure with exactitude.12
Continue to: The impact of infidelity
The impact of infidelity on couples varies due to factors such as the pre-morbid health of the marriage,13 the depth of involvement with the affair partner,14 and pre-existing attitudes about infidelity.13
Infidelity is a common cause of divorce in America. However, in a sample, Schneider et al15 found that despite initial threats to leave the marriage after infidelity, less than one-quarter of partners divorced. Other studies have found that disclosure of the infidelity and a commitment to work on the marriage may be an essential component of healing.16
Emotionally focused couples therapy, with its emphasis on attachment and bonding, may hold promise for helping couples successfully work through the trauma brought on by extramarital relationships.17 Psychologist and infidelity researcher Shirley Glass found that of the two-thirds of couples who chose to stay together after an affair, 80% of them reported a better marriage after treatment.11
Initial steps to take, and questions to ask
Both male and female patients need to feel comfortable surfacing sexual concerns with their clinicians. In this case, the concerns of the husband are interwoven with broader marital issues, which are the source of emotional and psychosomatic distress. His decision regarding his affair carried with it potentially life-altering consequences for his wife, 3 children, and affair partner and her family. It also raised ethical issues for the FP, who was providing care to both the husband and the wife. Appropriate care requires that a physician in this situation
- demonstrate a nonjudgmental approach
- clarify personal ethics in response to patient behaviors
- maintain confidentiality
- apply an ethical framework to resolve value dilemmas
- avoid actions that would be harmful to patients.
Interviewing can help to elicit information that may be clarifying not only to the physician but also to the patient. When interviewing a patient such as the one in this case, it would be wise to ask:
- How long has the affair been going on?
- Why is the patient engaging in the affair?
- Is abuse (emotional or physical) a factor in the marriage?
- Does the patient still have feelings for their spouse? Does the patient want to work on the marriage?
- Has the patient talked to a friend or therapist about the situation?
- Would the patient be willing to talk to a therapist?
Continue to: Ethical and legal considerations
Ethical and legal considerations
Some therapists espouse the view that being “neutral” in the presence of an affair is as much a value judgment as taking one side or the other. In the presence of emotional or physical abuse, it might indeed be best to support a marital separation. However, in other situations when there are young children involved and the patient is undecided about what to do, the FP can discuss the pros and cons of working on a marriage that suffers from more treatable types of disrepair (ie, stress, disconnection, repetitive arguments).
Provision of care. If the patient is unwilling to end the affair, the physician needs to decide whether they feel ethically at ease with prescribing sexually enhancing performance medication, given that the patient’s wife is also a patient. A physician in this situation might feel that they are betraying the wife by providing such medications to the husband. In such cases, it might be appropriate to refer the husband to a colleague.
In all cases of infidelity, however, it is wise to discuss safe-sex practices in order to limit the risk of transmitting a sexually transmitted infection (STI) to the spouse (or affair partner) and offer testing for STIs.
Confidentiality. Despite feelings the physician might have about betraying the wife’s trust by providing the performance-enhancing medicine to the husband, there is very little justification for revealing the affair to the wife. In general, confidentiality can only be broken if there is a high level of imminent danger associated with nondisclosure. The physician needs to realize the serious legal implications of breaking confidentiality in this situation, as such disclosure may prompt the initiation of divorce proceedings.
Real-world recommendations
Check your own biases. Infidelity can trigger a whole host of emotional reactions in physicians based on their own personal and professional history. It is important to be aware of such emotions and if sufficiently triggered, discuss the case with a colleague.
Continue to: Encourage bibliotherapy and marriage therapy
Encourage bibliotherapy and marriage therapy. The conversation might go something like this:
“I would recommend you do some reading about infidelity. If you are interested in working on your marriage, you might want to consider a couples counselor who can help you. Research shows that while such counseling can help couples work through infidelity, disclosure needs to occur as part of that process. Research also indicates that about two-thirds of marriages stay together after the revelation of an affair and that such couples can experience healing if they commit to a therapeutic process. If you are unsure how you want to proceed, it might be helpful for you to explore your situation with an individual therapist. What would you like to do next?”
There are also written resources that the patient might find helpful; see “3 bibliotherapy resources for infidelity” for recommendations.
SIDEBAR
3 bibliotherapy resources for infidelity
Not ‘Just Friends’: Protect Your Relationship from Infidelity and Heal the Trauma of Betrayal (Shirley Glass)
After the Affair: Healing the Pain and Rebuilding Trust When a Partner Has Betrayed You (Janice Abrams-Spring)
How Can I Forgive You: The Courage to Forgive, the Freedom Not To (Janice Abrams-Spring)
Referral to an individual or marriage counselor is warranted if the patient wants to work through the issues alone or with their partner. Disclosure of infidelity may not always be necessary for successful reconciliation if the affair has ended. A marriage therapist to whom you refer needs to be competent in working with infidelity.
Our patient. At the completion of the initial consultation—and after a discussion focused on the issues described, including encouragement to seek counseling—the FP acceded to the patient’s request for sexual performance-enhancing medication.
Continue to: The patient returned a few months...
The patient returned a few months later. His wife had found texts between him and his affair partner and told the patient that they had to enter into couples therapy or she was going to file for divorce. The patient told his physician that he had ended the extramarital relationship and was working on his marriage with a qualified marriage therapist; however, he felt lingering feelings of loss, discomfort in the workplace, and confusion about his choices. The physician was supportive and encouraged him to share these feelings, if possible, with an individual therapist or to find a friend who could listen while being supportive of his marriage. The physician also offered his services as a sounding board.
A year later, the patient had found another job and was still working on his marriage.
THE TAKEAWAY
This case underscores the importance of some basic health care tenets. It reminds us that maintaining patient confidentiality is paramount, and that nonjudgmental interviewing can help us to help our patients navigate challenging situations. The particulars of this case also highlight the importance of referring patients out for individual or marriage counseling and making a referral to a colleague when a situation makes us feel as if we are betraying a patient’s trust.
CORRESPONDENCE
David C. Slawson, MD, 2001 Vail Avenue, Suite 400B, Mercy Medical Plaza, Charlotte, NC 28207; [email protected]
1. Blumstein P, Schwartz P. American Couples: Money, Work, Sex. William Morrow; 1983.
2. Blow A, Hartnett K. Infidelity in committed relationships I: a methodological review. J Marital Fam Ther. 2005;31:183-216. doi: 10.1111/j.1752-0606.2005.tb01555.x
3. Glass S, Wright TL. Sex differences in type of extramarital involvement and marital dissatisfaction. Sex Roles. 1985;12:1101-1120.
4. Thompson AP. Emotional and sexual components of extramarital relations. J Marriage Fam. 1984;46:35-42. doi: 10.2307/351861
5. Laumann EO, Gagnon JH, Michael RT, et al. The Social Organization of Sexuality: Sexual Practices in the United States. University of Chicago Press; 1994.
6. Oliver MB, Hyde JS. Gender differences in sexuality: a meta-analysis. Psychol Bull. 1993;114:29-51. doi: 10.1037/0033-2909.114.1.29
7. Glass SP, Wright TL. Justifications for extramarital relationships: the association between attitudes, behaviors, and gender. J Sex Res. 1992;29:361-387. doi: 10.1080/00224499209551654
8. Spanier GB, Margolis RL. Marital separation and extramarital sexual behavior. J Sex Res. 1983;19:23-48.
9. Atkins DC, Baucom DH, Jacobson NS. Understanding infidelity: correlates in a national random sample. J Fam Psychol. 2001;15:735-749. doi: 10.1037//0893-3200.15.4.735
10. Treas J, Giesen D. Sexual infidelity among married and cohabitating Americans. J Marriage Fam. 2000;62:48-60. doi: 10.1111/j.1741-3737.2000.00048.x
11. Glass SP. Not ‘Just Friends’: Protect Your Relationship From Infidelity and Heal the Trauma of Betrayal. Free Press; 2002.
12. Blow A, Hartnet K. Infidelity in committed relationships II: a substantive review. J Marital Fam Ther. 2005;31:2. doi: 10.1111/j.1752-0606.2005.tb01556.x
13. Buunk B. Conditions that promote breakups as a consequence of extradyadic involvements. J Soc Clin Psychol. 1987;5:271-284. doi: 10.1521/jscp.1987.5.3.271
14. Charn IW, Parnass S. The impact of extramarital relationships on the continuation of marriages. J Sex Marital Therapy. 1995;21:100-115. doi: 10.1080/00926239508404389
15. Schneider JP, Irons RR, Corley MD. Disclosure of extramarital sexual activities by sexually exploitative professionals and other persons with addictive or compulsive sexual disorders. J Sex Edu Therapy. 1999;24:277-287. doi: 10.1080/01614576.1999.11074316
16. Atkins DC, Eldridge KA, Baucom DH, et al. Infidelity and behavioral couple therapy: optimism in the face of betrayal. J Consult Clin Psychol. 2005;73:144-150. doi: 10.1037/0022-006X.73.1.144
17. Johnson SM, Makinen J, Millikin J. Attachment injuries in couple relationships: a new perspective on impasses in emotionally focused marital therapy. J Marital Fam Therapy. 2001;27:145-155. doi: 10.1111/j.1752-0606.2001.tb01152.x
THE CASE
A 52-year-old man requested medicine to help him with erectile dysfunction. After obtaining a medical history and performing a physical exam, the family physician (FP) asked for more details about the patient’s situation. He reported that his wife, who had recently seen the same FP for counseling related to her frustrations with her husband, was uninterested in sex. He then added that he was having an affair with a 32-year-old female co-worker and wanted to improve his sexual function.
He admitted to feeling guilty about this situation and was conflicted about whether to end the affair. He also stated that since the affair, his insomnia had worsened, he was drinking more alcohol, and he was having migraine headaches. As the FP for both patients, and with the knowledge that the wife was worried about possible infidelity, the physician felt some level of conflict about the situation. The following is a discussion of the issues that this patient encounter raised.
DISCUSSION
Issues related to infidelity are common to both men and women. They are also common in same-sex relationships; in general, however, lesbian couples have fewer outside partners, whereas gay men are more likely to seek variety by having multiple partners.1
It is widely understood that successfully committed couples spend quality time together, emphasize each other’s strengths, show respect, accept influence, and nurture their friendship. However, many couples experience infidelity at some time in the course of their marriage. It is difficult to put an exact estimate on rates of infidelity due to problems with research methodology, inaccurate reporting, and a lack of agreement on a definition for infidelity.2 General categories of infidelity include emotional only, sexual only, and combined sexual and emotional infidelity.3,4 In terms of sexual infidelity, one study found that 25% of married men and 15% of married women admitted to having had extramarital sex at least once during their relationship.5 However, other studies suggest that women are closing the “sexual infidelity” gap and engaging in sexual affairs at a similar rate to men.6 There are websites that, in fact, have made it easier for married individuals to engage in affairs.
Reasons for infidelity. Men and women often have different motives in engaging in infidelity. In general, men’s motivations are more often related to sexual dissatisfaction and women’s to emotional dissatisfaction.7,8 However, infidelity may not always be the result of marital unhappiness.
Some studies suggest that the presence of opportunity may override the positive aspects of a relationship.9 Opportunity is heightened in the work environment, as reflected by the finding that 50% of infidelity occurs in the office.10 Research suggests that all relationships may be vulnerable to infidelity if the right opportunities present themselves.11
In general, health care providers are encouraged to use caution in generalizing about infidelity, as the subject is extremely complex, nuanced, and difficult to measure with exactitude.12
Continue to: The impact of infidelity
The impact of infidelity on couples varies due to factors such as the pre-morbid health of the marriage,13 the depth of involvement with the affair partner,14 and pre-existing attitudes about infidelity.13
Infidelity is a common cause of divorce in America. However, in a sample, Schneider et al15 found that despite initial threats to leave the marriage after infidelity, less than one-quarter of partners divorced. Other studies have found that disclosure of the infidelity and a commitment to work on the marriage may be an essential component of healing.16
Emotionally focused couples therapy, with its emphasis on attachment and bonding, may hold promise for helping couples successfully work through the trauma brought on by extramarital relationships.17 Psychologist and infidelity researcher Shirley Glass found that of the two-thirds of couples who chose to stay together after an affair, 80% of them reported a better marriage after treatment.11
Initial steps to take, and questions to ask
Both male and female patients need to feel comfortable surfacing sexual concerns with their clinicians. In this case, the concerns of the husband are interwoven with broader marital issues, which are the source of emotional and psychosomatic distress. His decision regarding his affair carried with it potentially life-altering consequences for his wife, 3 children, and affair partner and her family. It also raised ethical issues for the FP, who was providing care to both the husband and the wife. Appropriate care requires that a physician in this situation
- demonstrate a nonjudgmental approach
- clarify personal ethics in response to patient behaviors
- maintain confidentiality
- apply an ethical framework to resolve value dilemmas
- avoid actions that would be harmful to patients.
Interviewing can help to elicit information that may be clarifying not only to the physician but also to the patient. When interviewing a patient such as the one in this case, it would be wise to ask:
- How long has the affair been going on?
- Why is the patient engaging in the affair?
- Is abuse (emotional or physical) a factor in the marriage?
- Does the patient still have feelings for their spouse? Does the patient want to work on the marriage?
- Has the patient talked to a friend or therapist about the situation?
- Would the patient be willing to talk to a therapist?
Continue to: Ethical and legal considerations
Ethical and legal considerations
Some therapists espouse the view that being “neutral” in the presence of an affair is as much a value judgment as taking one side or the other. In the presence of emotional or physical abuse, it might indeed be best to support a marital separation. However, in other situations when there are young children involved and the patient is undecided about what to do, the FP can discuss the pros and cons of working on a marriage that suffers from more treatable types of disrepair (ie, stress, disconnection, repetitive arguments).
Provision of care. If the patient is unwilling to end the affair, the physician needs to decide whether they feel ethically at ease with prescribing sexually enhancing performance medication, given that the patient’s wife is also a patient. A physician in this situation might feel that they are betraying the wife by providing such medications to the husband. In such cases, it might be appropriate to refer the husband to a colleague.
In all cases of infidelity, however, it is wise to discuss safe-sex practices in order to limit the risk of transmitting a sexually transmitted infection (STI) to the spouse (or affair partner) and offer testing for STIs.
Confidentiality. Despite feelings the physician might have about betraying the wife’s trust by providing the performance-enhancing medicine to the husband, there is very little justification for revealing the affair to the wife. In general, confidentiality can only be broken if there is a high level of imminent danger associated with nondisclosure. The physician needs to realize the serious legal implications of breaking confidentiality in this situation, as such disclosure may prompt the initiation of divorce proceedings.
Real-world recommendations
Check your own biases. Infidelity can trigger a whole host of emotional reactions in physicians based on their own personal and professional history. It is important to be aware of such emotions and if sufficiently triggered, discuss the case with a colleague.
Continue to: Encourage bibliotherapy and marriage therapy
Encourage bibliotherapy and marriage therapy. The conversation might go something like this:
“I would recommend you do some reading about infidelity. If you are interested in working on your marriage, you might want to consider a couples counselor who can help you. Research shows that while such counseling can help couples work through infidelity, disclosure needs to occur as part of that process. Research also indicates that about two-thirds of marriages stay together after the revelation of an affair and that such couples can experience healing if they commit to a therapeutic process. If you are unsure how you want to proceed, it might be helpful for you to explore your situation with an individual therapist. What would you like to do next?”
There are also written resources that the patient might find helpful; see “3 bibliotherapy resources for infidelity” for recommendations.
SIDEBAR
3 bibliotherapy resources for infidelity
Not ‘Just Friends’: Protect Your Relationship from Infidelity and Heal the Trauma of Betrayal (Shirley Glass)
After the Affair: Healing the Pain and Rebuilding Trust When a Partner Has Betrayed You (Janice Abrams-Spring)
How Can I Forgive You: The Courage to Forgive, the Freedom Not To (Janice Abrams-Spring)
Referral to an individual or marriage counselor is warranted if the patient wants to work through the issues alone or with their partner. Disclosure of infidelity may not always be necessary for successful reconciliation if the affair has ended. A marriage therapist to whom you refer needs to be competent in working with infidelity.
Our patient. At the completion of the initial consultation—and after a discussion focused on the issues described, including encouragement to seek counseling—the FP acceded to the patient’s request for sexual performance-enhancing medication.
Continue to: The patient returned a few months...
The patient returned a few months later. His wife had found texts between him and his affair partner and told the patient that they had to enter into couples therapy or she was going to file for divorce. The patient told his physician that he had ended the extramarital relationship and was working on his marriage with a qualified marriage therapist; however, he felt lingering feelings of loss, discomfort in the workplace, and confusion about his choices. The physician was supportive and encouraged him to share these feelings, if possible, with an individual therapist or to find a friend who could listen while being supportive of his marriage. The physician also offered his services as a sounding board.
A year later, the patient had found another job and was still working on his marriage.
THE TAKEAWAY
This case underscores the importance of some basic health care tenets. It reminds us that maintaining patient confidentiality is paramount, and that nonjudgmental interviewing can help us to help our patients navigate challenging situations. The particulars of this case also highlight the importance of referring patients out for individual or marriage counseling and making a referral to a colleague when a situation makes us feel as if we are betraying a patient’s trust.
CORRESPONDENCE
David C. Slawson, MD, 2001 Vail Avenue, Suite 400B, Mercy Medical Plaza, Charlotte, NC 28207; [email protected]
THE CASE
A 52-year-old man requested medicine to help him with erectile dysfunction. After obtaining a medical history and performing a physical exam, the family physician (FP) asked for more details about the patient’s situation. He reported that his wife, who had recently seen the same FP for counseling related to her frustrations with her husband, was uninterested in sex. He then added that he was having an affair with a 32-year-old female co-worker and wanted to improve his sexual function.
He admitted to feeling guilty about this situation and was conflicted about whether to end the affair. He also stated that since the affair, his insomnia had worsened, he was drinking more alcohol, and he was having migraine headaches. As the FP for both patients, and with the knowledge that the wife was worried about possible infidelity, the physician felt some level of conflict about the situation. The following is a discussion of the issues that this patient encounter raised.
DISCUSSION
Issues related to infidelity are common to both men and women. They are also common in same-sex relationships; in general, however, lesbian couples have fewer outside partners, whereas gay men are more likely to seek variety by having multiple partners.1
It is widely understood that successfully committed couples spend quality time together, emphasize each other’s strengths, show respect, accept influence, and nurture their friendship. However, many couples experience infidelity at some time in the course of their marriage. It is difficult to put an exact estimate on rates of infidelity due to problems with research methodology, inaccurate reporting, and a lack of agreement on a definition for infidelity.2 General categories of infidelity include emotional only, sexual only, and combined sexual and emotional infidelity.3,4 In terms of sexual infidelity, one study found that 25% of married men and 15% of married women admitted to having had extramarital sex at least once during their relationship.5 However, other studies suggest that women are closing the “sexual infidelity” gap and engaging in sexual affairs at a similar rate to men.6 There are websites that, in fact, have made it easier for married individuals to engage in affairs.
Reasons for infidelity. Men and women often have different motives in engaging in infidelity. In general, men’s motivations are more often related to sexual dissatisfaction and women’s to emotional dissatisfaction.7,8 However, infidelity may not always be the result of marital unhappiness.
Some studies suggest that the presence of opportunity may override the positive aspects of a relationship.9 Opportunity is heightened in the work environment, as reflected by the finding that 50% of infidelity occurs in the office.10 Research suggests that all relationships may be vulnerable to infidelity if the right opportunities present themselves.11
In general, health care providers are encouraged to use caution in generalizing about infidelity, as the subject is extremely complex, nuanced, and difficult to measure with exactitude.12
Continue to: The impact of infidelity
The impact of infidelity on couples varies due to factors such as the pre-morbid health of the marriage,13 the depth of involvement with the affair partner,14 and pre-existing attitudes about infidelity.13
Infidelity is a common cause of divorce in America. However, in a sample, Schneider et al15 found that despite initial threats to leave the marriage after infidelity, less than one-quarter of partners divorced. Other studies have found that disclosure of the infidelity and a commitment to work on the marriage may be an essential component of healing.16
Emotionally focused couples therapy, with its emphasis on attachment and bonding, may hold promise for helping couples successfully work through the trauma brought on by extramarital relationships.17 Psychologist and infidelity researcher Shirley Glass found that of the two-thirds of couples who chose to stay together after an affair, 80% of them reported a better marriage after treatment.11
Initial steps to take, and questions to ask
Both male and female patients need to feel comfortable surfacing sexual concerns with their clinicians. In this case, the concerns of the husband are interwoven with broader marital issues, which are the source of emotional and psychosomatic distress. His decision regarding his affair carried with it potentially life-altering consequences for his wife, 3 children, and affair partner and her family. It also raised ethical issues for the FP, who was providing care to both the husband and the wife. Appropriate care requires that a physician in this situation
- demonstrate a nonjudgmental approach
- clarify personal ethics in response to patient behaviors
- maintain confidentiality
- apply an ethical framework to resolve value dilemmas
- avoid actions that would be harmful to patients.
Interviewing can help to elicit information that may be clarifying not only to the physician but also to the patient. When interviewing a patient such as the one in this case, it would be wise to ask:
- How long has the affair been going on?
- Why is the patient engaging in the affair?
- Is abuse (emotional or physical) a factor in the marriage?
- Does the patient still have feelings for their spouse? Does the patient want to work on the marriage?
- Has the patient talked to a friend or therapist about the situation?
- Would the patient be willing to talk to a therapist?
Continue to: Ethical and legal considerations
Ethical and legal considerations
Some therapists espouse the view that being “neutral” in the presence of an affair is as much a value judgment as taking one side or the other. In the presence of emotional or physical abuse, it might indeed be best to support a marital separation. However, in other situations when there are young children involved and the patient is undecided about what to do, the FP can discuss the pros and cons of working on a marriage that suffers from more treatable types of disrepair (ie, stress, disconnection, repetitive arguments).
Provision of care. If the patient is unwilling to end the affair, the physician needs to decide whether they feel ethically at ease with prescribing sexually enhancing performance medication, given that the patient’s wife is also a patient. A physician in this situation might feel that they are betraying the wife by providing such medications to the husband. In such cases, it might be appropriate to refer the husband to a colleague.
In all cases of infidelity, however, it is wise to discuss safe-sex practices in order to limit the risk of transmitting a sexually transmitted infection (STI) to the spouse (or affair partner) and offer testing for STIs.
Confidentiality. Despite feelings the physician might have about betraying the wife’s trust by providing the performance-enhancing medicine to the husband, there is very little justification for revealing the affair to the wife. In general, confidentiality can only be broken if there is a high level of imminent danger associated with nondisclosure. The physician needs to realize the serious legal implications of breaking confidentiality in this situation, as such disclosure may prompt the initiation of divorce proceedings.
Real-world recommendations
Check your own biases. Infidelity can trigger a whole host of emotional reactions in physicians based on their own personal and professional history. It is important to be aware of such emotions and if sufficiently triggered, discuss the case with a colleague.
Continue to: Encourage bibliotherapy and marriage therapy
Encourage bibliotherapy and marriage therapy. The conversation might go something like this:
“I would recommend you do some reading about infidelity. If you are interested in working on your marriage, you might want to consider a couples counselor who can help you. Research shows that while such counseling can help couples work through infidelity, disclosure needs to occur as part of that process. Research also indicates that about two-thirds of marriages stay together after the revelation of an affair and that such couples can experience healing if they commit to a therapeutic process. If you are unsure how you want to proceed, it might be helpful for you to explore your situation with an individual therapist. What would you like to do next?”
There are also written resources that the patient might find helpful; see “3 bibliotherapy resources for infidelity” for recommendations.
SIDEBAR
3 bibliotherapy resources for infidelity
Not ‘Just Friends’: Protect Your Relationship from Infidelity and Heal the Trauma of Betrayal (Shirley Glass)
After the Affair: Healing the Pain and Rebuilding Trust When a Partner Has Betrayed You (Janice Abrams-Spring)
How Can I Forgive You: The Courage to Forgive, the Freedom Not To (Janice Abrams-Spring)
Referral to an individual or marriage counselor is warranted if the patient wants to work through the issues alone or with their partner. Disclosure of infidelity may not always be necessary for successful reconciliation if the affair has ended. A marriage therapist to whom you refer needs to be competent in working with infidelity.
Our patient. At the completion of the initial consultation—and after a discussion focused on the issues described, including encouragement to seek counseling—the FP acceded to the patient’s request for sexual performance-enhancing medication.
Continue to: The patient returned a few months...
The patient returned a few months later. His wife had found texts between him and his affair partner and told the patient that they had to enter into couples therapy or she was going to file for divorce. The patient told his physician that he had ended the extramarital relationship and was working on his marriage with a qualified marriage therapist; however, he felt lingering feelings of loss, discomfort in the workplace, and confusion about his choices. The physician was supportive and encouraged him to share these feelings, if possible, with an individual therapist or to find a friend who could listen while being supportive of his marriage. The physician also offered his services as a sounding board.
A year later, the patient had found another job and was still working on his marriage.
THE TAKEAWAY
This case underscores the importance of some basic health care tenets. It reminds us that maintaining patient confidentiality is paramount, and that nonjudgmental interviewing can help us to help our patients navigate challenging situations. The particulars of this case also highlight the importance of referring patients out for individual or marriage counseling and making a referral to a colleague when a situation makes us feel as if we are betraying a patient’s trust.
CORRESPONDENCE
David C. Slawson, MD, 2001 Vail Avenue, Suite 400B, Mercy Medical Plaza, Charlotte, NC 28207; [email protected]
1. Blumstein P, Schwartz P. American Couples: Money, Work, Sex. William Morrow; 1983.
2. Blow A, Hartnett K. Infidelity in committed relationships I: a methodological review. J Marital Fam Ther. 2005;31:183-216. doi: 10.1111/j.1752-0606.2005.tb01555.x
3. Glass S, Wright TL. Sex differences in type of extramarital involvement and marital dissatisfaction. Sex Roles. 1985;12:1101-1120.
4. Thompson AP. Emotional and sexual components of extramarital relations. J Marriage Fam. 1984;46:35-42. doi: 10.2307/351861
5. Laumann EO, Gagnon JH, Michael RT, et al. The Social Organization of Sexuality: Sexual Practices in the United States. University of Chicago Press; 1994.
6. Oliver MB, Hyde JS. Gender differences in sexuality: a meta-analysis. Psychol Bull. 1993;114:29-51. doi: 10.1037/0033-2909.114.1.29
7. Glass SP, Wright TL. Justifications for extramarital relationships: the association between attitudes, behaviors, and gender. J Sex Res. 1992;29:361-387. doi: 10.1080/00224499209551654
8. Spanier GB, Margolis RL. Marital separation and extramarital sexual behavior. J Sex Res. 1983;19:23-48.
9. Atkins DC, Baucom DH, Jacobson NS. Understanding infidelity: correlates in a national random sample. J Fam Psychol. 2001;15:735-749. doi: 10.1037//0893-3200.15.4.735
10. Treas J, Giesen D. Sexual infidelity among married and cohabitating Americans. J Marriage Fam. 2000;62:48-60. doi: 10.1111/j.1741-3737.2000.00048.x
11. Glass SP. Not ‘Just Friends’: Protect Your Relationship From Infidelity and Heal the Trauma of Betrayal. Free Press; 2002.
12. Blow A, Hartnet K. Infidelity in committed relationships II: a substantive review. J Marital Fam Ther. 2005;31:2. doi: 10.1111/j.1752-0606.2005.tb01556.x
13. Buunk B. Conditions that promote breakups as a consequence of extradyadic involvements. J Soc Clin Psychol. 1987;5:271-284. doi: 10.1521/jscp.1987.5.3.271
14. Charn IW, Parnass S. The impact of extramarital relationships on the continuation of marriages. J Sex Marital Therapy. 1995;21:100-115. doi: 10.1080/00926239508404389
15. Schneider JP, Irons RR, Corley MD. Disclosure of extramarital sexual activities by sexually exploitative professionals and other persons with addictive or compulsive sexual disorders. J Sex Edu Therapy. 1999;24:277-287. doi: 10.1080/01614576.1999.11074316
16. Atkins DC, Eldridge KA, Baucom DH, et al. Infidelity and behavioral couple therapy: optimism in the face of betrayal. J Consult Clin Psychol. 2005;73:144-150. doi: 10.1037/0022-006X.73.1.144
17. Johnson SM, Makinen J, Millikin J. Attachment injuries in couple relationships: a new perspective on impasses in emotionally focused marital therapy. J Marital Fam Therapy. 2001;27:145-155. doi: 10.1111/j.1752-0606.2001.tb01152.x
1. Blumstein P, Schwartz P. American Couples: Money, Work, Sex. William Morrow; 1983.
2. Blow A, Hartnett K. Infidelity in committed relationships I: a methodological review. J Marital Fam Ther. 2005;31:183-216. doi: 10.1111/j.1752-0606.2005.tb01555.x
3. Glass S, Wright TL. Sex differences in type of extramarital involvement and marital dissatisfaction. Sex Roles. 1985;12:1101-1120.
4. Thompson AP. Emotional and sexual components of extramarital relations. J Marriage Fam. 1984;46:35-42. doi: 10.2307/351861
5. Laumann EO, Gagnon JH, Michael RT, et al. The Social Organization of Sexuality: Sexual Practices in the United States. University of Chicago Press; 1994.
6. Oliver MB, Hyde JS. Gender differences in sexuality: a meta-analysis. Psychol Bull. 1993;114:29-51. doi: 10.1037/0033-2909.114.1.29
7. Glass SP, Wright TL. Justifications for extramarital relationships: the association between attitudes, behaviors, and gender. J Sex Res. 1992;29:361-387. doi: 10.1080/00224499209551654
8. Spanier GB, Margolis RL. Marital separation and extramarital sexual behavior. J Sex Res. 1983;19:23-48.
9. Atkins DC, Baucom DH, Jacobson NS. Understanding infidelity: correlates in a national random sample. J Fam Psychol. 2001;15:735-749. doi: 10.1037//0893-3200.15.4.735
10. Treas J, Giesen D. Sexual infidelity among married and cohabitating Americans. J Marriage Fam. 2000;62:48-60. doi: 10.1111/j.1741-3737.2000.00048.x
11. Glass SP. Not ‘Just Friends’: Protect Your Relationship From Infidelity and Heal the Trauma of Betrayal. Free Press; 2002.
12. Blow A, Hartnet K. Infidelity in committed relationships II: a substantive review. J Marital Fam Ther. 2005;31:2. doi: 10.1111/j.1752-0606.2005.tb01556.x
13. Buunk B. Conditions that promote breakups as a consequence of extradyadic involvements. J Soc Clin Psychol. 1987;5:271-284. doi: 10.1521/jscp.1987.5.3.271
14. Charn IW, Parnass S. The impact of extramarital relationships on the continuation of marriages. J Sex Marital Therapy. 1995;21:100-115. doi: 10.1080/00926239508404389
15. Schneider JP, Irons RR, Corley MD. Disclosure of extramarital sexual activities by sexually exploitative professionals and other persons with addictive or compulsive sexual disorders. J Sex Edu Therapy. 1999;24:277-287. doi: 10.1080/01614576.1999.11074316
16. Atkins DC, Eldridge KA, Baucom DH, et al. Infidelity and behavioral couple therapy: optimism in the face of betrayal. J Consult Clin Psychol. 2005;73:144-150. doi: 10.1037/0022-006X.73.1.144
17. Johnson SM, Makinen J, Millikin J. Attachment injuries in couple relationships: a new perspective on impasses in emotionally focused marital therapy. J Marital Fam Therapy. 2001;27:145-155. doi: 10.1111/j.1752-0606.2001.tb01152.x
Two genetic intestinal diseases linked
Two genes that have been linked separately to rare intestinal diseases appear to share a functional relationship. The genes have independently been linked to osteo-oto-hepato-enteric (O2HE) syndrome and microvillus inclusion disease (MVID), which are characterized by congenital diarrhea and, in some patients, intrahepatic cholestasis.
It appears that one gene, UNC45A, is directly responsible for the proper function of the protein encoded by the other gene, called MYO5B, according to investigators, who published their findings in Cellular and Molecular Gastroenterology and Hepatology. UNC45A is a chaperone protein that helps proteins fold properly. It has been linked to O2HE patients experiencing congenital diarrhea and intrahepatic cholestasis. The mutation has been identified in four patients from three different families with O2HE, which can also present with sensorineural hearing loss and bone fragility. Cellular analyses have shown that the mutation leads to reduction in protein expression by 70%-90%.
Intestinal symptoms similar to those in O2HE have also been described in diseases caused by mutations in genes that encode the myosin motor proteins that are involved in cellular protein trafficking. This group of disorders includes MVID. The researchers hypothesized that the UNC45A mutation in O2HE might lead to similar symptoms as MVID and others through the altered protein’s failure to assist in the folding of myosin proteins, although to date only the myosin IIa protein has been shown to be a target of UNC45A.
To investigate the possibility, they examined in more detail the relationship between UNC45A and intestinal symptoms. There are various known mutations in myosin proteins. Some have been linked to deafness, but these do not appear to contribute to intestinal symptoms since patients with myelin-related inherited deafness don’t typically have diarrhea. Bone fragility, also sometimes caused by myosin mutations, also appears to be unrelated to intestinal symptoms.
Previous experiments in yeast suggest that the related gene UNC45 may serve as a chaperone for type V myosin: Loss of a yeast version of UNC45 caused a type V myosin called MYO4P to be mislocalized in yeast. In zebrafish, reduction in intestinal levels of the UNC45A gene or the fish’s version of MYO5B interfered with development of intestinal folds.
The researchers used CRISPR-Cas9 gene editing and site-directed mutagenesis in intestinal epithelial and liver cell lines to investigate the relationships between UNC45A and MYO5B mutants. UNC45A depletion or introduction of the UNC45A mutation found in patients led to lower MYO5B expression. Within epithelial cells, loss of UNC45A led to changes in MYO5B–linked processes that are known to play a role in MVID pathogenesis. These included alteration of microvilli development and interference with the location of rat sarcoma–associated binding protein (RAB) 11A–positive recycling endosomes. When normal UNC45A was reintroduced to these cells, MYO5B expression returned. Reintroduction of either UNC45A or MYO5B repaired the alterations to recycling endosome position and microvilli development.
Loss of UNC45A did not appear to affect transcription of the MYO5B gen, which suggests a suggesting a functional interaction between the two at a protein level.
UNC45A has been shown to destabilize microtubules. Exposure of a kidney epithelial cell line to the microtubule-stabilizing drug taxol also led to displacement of RAB11A-positve recycling endosomes, though the specific changes were different than what is seen in MYO5B mutants. The researchers were unable to validate the findings in tissue derived from O2HE patients because of insufficient material, but they maintain that the cell lines used have proven to be highly predictive for the cellular characteristics of MVID.
Overall, the study suggests that reductions in MYO5B and subsequent changes to the cellular processes that depend on it may underlie the intestinal symptoms in O2HE.
The researchers noted that O2HE patients have different phenotypes. Of the four patients they studied, three had severe chronic diarrhea and required parenteral nutrition. One patient later had the diarrhea resolve and her sister did not have diarrhea at all. This heterogeneity in severity and duration of clinical symptoms may be driven by differences in the molecular effects of patient-specific mutations. The two siblings had mutations in a different region of the UNC45A gene than the other two participants.
“Taken together, this study revealed a functional relationship between UNC45A and MYO5B protein expression, thereby connecting two rare congenital diseases with overlapping intestinal symptoms at the molecular level,” the authors wrote.
The authors reported that they had no conflicts of interest.
This article was updated 7/13/22.
Congenital diarrheas and enteropathies (CoDEs) are rare monogenic disorders caused by genes important for intestinal epithelial function. The increasing availability of exome sequencing in clinical practice has accelerated the discovery of new genes associated with these disorders over the past few years. Several CoDE disorders revolve around defects in trafficking of vesicles in epithelial cells. One of these is microvillus inclusion disease which is caused by loss-of-function variants in the gene MYO5B, which encodes an important epithelial motor protein. This study by Li and colleagues reveals that a recently discovered novel CoDE gene and protein, UNC45A, is functionally linked to MYO5B and that loss of UNC45A in cells causes a very similar cellular phenotype to MYO5B-deficient cells.
Jay Thiagarajah, MD, PhD, attending in the division of gastroenterology, hepatology and nutrition and codirector of the congenital enteropathy program at Boston Children’s Hospital, as well as assistant professor in pediatrics at Harvard Medical School, also in Boston. Dr. Thiagarajah stated he had no relevant conflicts to disclose.
Congenital diarrheas and enteropathies (CoDEs) are rare monogenic disorders caused by genes important for intestinal epithelial function. The increasing availability of exome sequencing in clinical practice has accelerated the discovery of new genes associated with these disorders over the past few years. Several CoDE disorders revolve around defects in trafficking of vesicles in epithelial cells. One of these is microvillus inclusion disease which is caused by loss-of-function variants in the gene MYO5B, which encodes an important epithelial motor protein. This study by Li and colleagues reveals that a recently discovered novel CoDE gene and protein, UNC45A, is functionally linked to MYO5B and that loss of UNC45A in cells causes a very similar cellular phenotype to MYO5B-deficient cells.
Jay Thiagarajah, MD, PhD, attending in the division of gastroenterology, hepatology and nutrition and codirector of the congenital enteropathy program at Boston Children’s Hospital, as well as assistant professor in pediatrics at Harvard Medical School, also in Boston. Dr. Thiagarajah stated he had no relevant conflicts to disclose.
Congenital diarrheas and enteropathies (CoDEs) are rare monogenic disorders caused by genes important for intestinal epithelial function. The increasing availability of exome sequencing in clinical practice has accelerated the discovery of new genes associated with these disorders over the past few years. Several CoDE disorders revolve around defects in trafficking of vesicles in epithelial cells. One of these is microvillus inclusion disease which is caused by loss-of-function variants in the gene MYO5B, which encodes an important epithelial motor protein. This study by Li and colleagues reveals that a recently discovered novel CoDE gene and protein, UNC45A, is functionally linked to MYO5B and that loss of UNC45A in cells causes a very similar cellular phenotype to MYO5B-deficient cells.
Jay Thiagarajah, MD, PhD, attending in the division of gastroenterology, hepatology and nutrition and codirector of the congenital enteropathy program at Boston Children’s Hospital, as well as assistant professor in pediatrics at Harvard Medical School, also in Boston. Dr. Thiagarajah stated he had no relevant conflicts to disclose.
Two genes that have been linked separately to rare intestinal diseases appear to share a functional relationship. The genes have independently been linked to osteo-oto-hepato-enteric (O2HE) syndrome and microvillus inclusion disease (MVID), which are characterized by congenital diarrhea and, in some patients, intrahepatic cholestasis.
It appears that one gene, UNC45A, is directly responsible for the proper function of the protein encoded by the other gene, called MYO5B, according to investigators, who published their findings in Cellular and Molecular Gastroenterology and Hepatology. UNC45A is a chaperone protein that helps proteins fold properly. It has been linked to O2HE patients experiencing congenital diarrhea and intrahepatic cholestasis. The mutation has been identified in four patients from three different families with O2HE, which can also present with sensorineural hearing loss and bone fragility. Cellular analyses have shown that the mutation leads to reduction in protein expression by 70%-90%.
Intestinal symptoms similar to those in O2HE have also been described in diseases caused by mutations in genes that encode the myosin motor proteins that are involved in cellular protein trafficking. This group of disorders includes MVID. The researchers hypothesized that the UNC45A mutation in O2HE might lead to similar symptoms as MVID and others through the altered protein’s failure to assist in the folding of myosin proteins, although to date only the myosin IIa protein has been shown to be a target of UNC45A.
To investigate the possibility, they examined in more detail the relationship between UNC45A and intestinal symptoms. There are various known mutations in myosin proteins. Some have been linked to deafness, but these do not appear to contribute to intestinal symptoms since patients with myelin-related inherited deafness don’t typically have diarrhea. Bone fragility, also sometimes caused by myosin mutations, also appears to be unrelated to intestinal symptoms.
Previous experiments in yeast suggest that the related gene UNC45 may serve as a chaperone for type V myosin: Loss of a yeast version of UNC45 caused a type V myosin called MYO4P to be mislocalized in yeast. In zebrafish, reduction in intestinal levels of the UNC45A gene or the fish’s version of MYO5B interfered with development of intestinal folds.
The researchers used CRISPR-Cas9 gene editing and site-directed mutagenesis in intestinal epithelial and liver cell lines to investigate the relationships between UNC45A and MYO5B mutants. UNC45A depletion or introduction of the UNC45A mutation found in patients led to lower MYO5B expression. Within epithelial cells, loss of UNC45A led to changes in MYO5B–linked processes that are known to play a role in MVID pathogenesis. These included alteration of microvilli development and interference with the location of rat sarcoma–associated binding protein (RAB) 11A–positive recycling endosomes. When normal UNC45A was reintroduced to these cells, MYO5B expression returned. Reintroduction of either UNC45A or MYO5B repaired the alterations to recycling endosome position and microvilli development.
Loss of UNC45A did not appear to affect transcription of the MYO5B gen, which suggests a suggesting a functional interaction between the two at a protein level.
UNC45A has been shown to destabilize microtubules. Exposure of a kidney epithelial cell line to the microtubule-stabilizing drug taxol also led to displacement of RAB11A-positve recycling endosomes, though the specific changes were different than what is seen in MYO5B mutants. The researchers were unable to validate the findings in tissue derived from O2HE patients because of insufficient material, but they maintain that the cell lines used have proven to be highly predictive for the cellular characteristics of MVID.
Overall, the study suggests that reductions in MYO5B and subsequent changes to the cellular processes that depend on it may underlie the intestinal symptoms in O2HE.
The researchers noted that O2HE patients have different phenotypes. Of the four patients they studied, three had severe chronic diarrhea and required parenteral nutrition. One patient later had the diarrhea resolve and her sister did not have diarrhea at all. This heterogeneity in severity and duration of clinical symptoms may be driven by differences in the molecular effects of patient-specific mutations. The two siblings had mutations in a different region of the UNC45A gene than the other two participants.
“Taken together, this study revealed a functional relationship between UNC45A and MYO5B protein expression, thereby connecting two rare congenital diseases with overlapping intestinal symptoms at the molecular level,” the authors wrote.
The authors reported that they had no conflicts of interest.
This article was updated 7/13/22.
Two genes that have been linked separately to rare intestinal diseases appear to share a functional relationship. The genes have independently been linked to osteo-oto-hepato-enteric (O2HE) syndrome and microvillus inclusion disease (MVID), which are characterized by congenital diarrhea and, in some patients, intrahepatic cholestasis.
It appears that one gene, UNC45A, is directly responsible for the proper function of the protein encoded by the other gene, called MYO5B, according to investigators, who published their findings in Cellular and Molecular Gastroenterology and Hepatology. UNC45A is a chaperone protein that helps proteins fold properly. It has been linked to O2HE patients experiencing congenital diarrhea and intrahepatic cholestasis. The mutation has been identified in four patients from three different families with O2HE, which can also present with sensorineural hearing loss and bone fragility. Cellular analyses have shown that the mutation leads to reduction in protein expression by 70%-90%.
Intestinal symptoms similar to those in O2HE have also been described in diseases caused by mutations in genes that encode the myosin motor proteins that are involved in cellular protein trafficking. This group of disorders includes MVID. The researchers hypothesized that the UNC45A mutation in O2HE might lead to similar symptoms as MVID and others through the altered protein’s failure to assist in the folding of myosin proteins, although to date only the myosin IIa protein has been shown to be a target of UNC45A.
To investigate the possibility, they examined in more detail the relationship between UNC45A and intestinal symptoms. There are various known mutations in myosin proteins. Some have been linked to deafness, but these do not appear to contribute to intestinal symptoms since patients with myelin-related inherited deafness don’t typically have diarrhea. Bone fragility, also sometimes caused by myosin mutations, also appears to be unrelated to intestinal symptoms.
Previous experiments in yeast suggest that the related gene UNC45 may serve as a chaperone for type V myosin: Loss of a yeast version of UNC45 caused a type V myosin called MYO4P to be mislocalized in yeast. In zebrafish, reduction in intestinal levels of the UNC45A gene or the fish’s version of MYO5B interfered with development of intestinal folds.
The researchers used CRISPR-Cas9 gene editing and site-directed mutagenesis in intestinal epithelial and liver cell lines to investigate the relationships between UNC45A and MYO5B mutants. UNC45A depletion or introduction of the UNC45A mutation found in patients led to lower MYO5B expression. Within epithelial cells, loss of UNC45A led to changes in MYO5B–linked processes that are known to play a role in MVID pathogenesis. These included alteration of microvilli development and interference with the location of rat sarcoma–associated binding protein (RAB) 11A–positive recycling endosomes. When normal UNC45A was reintroduced to these cells, MYO5B expression returned. Reintroduction of either UNC45A or MYO5B repaired the alterations to recycling endosome position and microvilli development.
Loss of UNC45A did not appear to affect transcription of the MYO5B gen, which suggests a suggesting a functional interaction between the two at a protein level.
UNC45A has been shown to destabilize microtubules. Exposure of a kidney epithelial cell line to the microtubule-stabilizing drug taxol also led to displacement of RAB11A-positve recycling endosomes, though the specific changes were different than what is seen in MYO5B mutants. The researchers were unable to validate the findings in tissue derived from O2HE patients because of insufficient material, but they maintain that the cell lines used have proven to be highly predictive for the cellular characteristics of MVID.
Overall, the study suggests that reductions in MYO5B and subsequent changes to the cellular processes that depend on it may underlie the intestinal symptoms in O2HE.
The researchers noted that O2HE patients have different phenotypes. Of the four patients they studied, three had severe chronic diarrhea and required parenteral nutrition. One patient later had the diarrhea resolve and her sister did not have diarrhea at all. This heterogeneity in severity and duration of clinical symptoms may be driven by differences in the molecular effects of patient-specific mutations. The two siblings had mutations in a different region of the UNC45A gene than the other two participants.
“Taken together, this study revealed a functional relationship between UNC45A and MYO5B protein expression, thereby connecting two rare congenital diseases with overlapping intestinal symptoms at the molecular level,” the authors wrote.
The authors reported that they had no conflicts of interest.
This article was updated 7/13/22.
FROM CELLULAR AND MOLECULAR GASTROENTEROLOGY AND HEPATOLOGY
Vasectomy requests increase after Roe ruling
Urologists told The Washington Post that more men are seeking the procedure to prevent pregnancies and avoid abortion-related concerns.
“It was very, very noticeable [June 24], and then the number that came in over the weekend was huge, and the number that is still coming in far exceeds what we have experienced in the past,” Doug Stein, MD, a Florida urologist known as the “Vasectomy King” for his advocacy of the procedure, told the newspaper.
Before June 24, Dr. Stein received four or five vasectomy requests per day. But since then, that number has increased to 12 to 18 requests per day.
“Many of the guys are saying that they have been thinking about a vasectomy for a while, and the Roe v. Wade decision was just that final factor that tipped them over the edge and made them submit the online registration,” he said.
Urologists in California, Iowa, and New York also told the Post that they’ve seen a massive increase in the number of vasectomy consultations, as well as an increase in website traffic on their pages that offer information about vasectomies.
About 2 decades ago, Americans said the main reason they relied on a vasectomy as a form of birth control was that they or their partners had all the children they wanted. In the past decade, other reasons became more common, such as medical issues and problems with other types of birth control, the newspaper reported.
In anticipation of Roe v. Wade being overturned and anti-abortion legislation taking effect in states, advocates for vasectomies have encouraged people to get the procedure.
Dr. Stein said his practice is now booked through the end of August with vasectomy appointments, so he’s opening more days in his schedule to accommodate patients who submitted recent requests. He and his associate, John Curington, MD, said men under age 30 without children are requesting the procedure in greater numbers than before, with some citing the concurring opinion by Justice Clarence Thomas, which said the Supreme Court should reconsider other landmark cases that protect rights under the 14th Amendment, such as access to contraceptives.
“I’d say at least 60 or 70% are mentioning the Supreme Court decision,” Dr. Curington said, according to the Post. “And a few of them have such sophistication as young men that they actually are thinking about Justice Thomas and his opinion that contraception may fall next. And that’s shocking. That’s something that doesn’t enter into our conversations ever, until this week.”
A version of this article first appeared on WebMD.com.
Urologists told The Washington Post that more men are seeking the procedure to prevent pregnancies and avoid abortion-related concerns.
“It was very, very noticeable [June 24], and then the number that came in over the weekend was huge, and the number that is still coming in far exceeds what we have experienced in the past,” Doug Stein, MD, a Florida urologist known as the “Vasectomy King” for his advocacy of the procedure, told the newspaper.
Before June 24, Dr. Stein received four or five vasectomy requests per day. But since then, that number has increased to 12 to 18 requests per day.
“Many of the guys are saying that they have been thinking about a vasectomy for a while, and the Roe v. Wade decision was just that final factor that tipped them over the edge and made them submit the online registration,” he said.
Urologists in California, Iowa, and New York also told the Post that they’ve seen a massive increase in the number of vasectomy consultations, as well as an increase in website traffic on their pages that offer information about vasectomies.
About 2 decades ago, Americans said the main reason they relied on a vasectomy as a form of birth control was that they or their partners had all the children they wanted. In the past decade, other reasons became more common, such as medical issues and problems with other types of birth control, the newspaper reported.
In anticipation of Roe v. Wade being overturned and anti-abortion legislation taking effect in states, advocates for vasectomies have encouraged people to get the procedure.
Dr. Stein said his practice is now booked through the end of August with vasectomy appointments, so he’s opening more days in his schedule to accommodate patients who submitted recent requests. He and his associate, John Curington, MD, said men under age 30 without children are requesting the procedure in greater numbers than before, with some citing the concurring opinion by Justice Clarence Thomas, which said the Supreme Court should reconsider other landmark cases that protect rights under the 14th Amendment, such as access to contraceptives.
“I’d say at least 60 or 70% are mentioning the Supreme Court decision,” Dr. Curington said, according to the Post. “And a few of them have such sophistication as young men that they actually are thinking about Justice Thomas and his opinion that contraception may fall next. And that’s shocking. That’s something that doesn’t enter into our conversations ever, until this week.”
A version of this article first appeared on WebMD.com.
Urologists told The Washington Post that more men are seeking the procedure to prevent pregnancies and avoid abortion-related concerns.
“It was very, very noticeable [June 24], and then the number that came in over the weekend was huge, and the number that is still coming in far exceeds what we have experienced in the past,” Doug Stein, MD, a Florida urologist known as the “Vasectomy King” for his advocacy of the procedure, told the newspaper.
Before June 24, Dr. Stein received four or five vasectomy requests per day. But since then, that number has increased to 12 to 18 requests per day.
“Many of the guys are saying that they have been thinking about a vasectomy for a while, and the Roe v. Wade decision was just that final factor that tipped them over the edge and made them submit the online registration,” he said.
Urologists in California, Iowa, and New York also told the Post that they’ve seen a massive increase in the number of vasectomy consultations, as well as an increase in website traffic on their pages that offer information about vasectomies.
About 2 decades ago, Americans said the main reason they relied on a vasectomy as a form of birth control was that they or their partners had all the children they wanted. In the past decade, other reasons became more common, such as medical issues and problems with other types of birth control, the newspaper reported.
In anticipation of Roe v. Wade being overturned and anti-abortion legislation taking effect in states, advocates for vasectomies have encouraged people to get the procedure.
Dr. Stein said his practice is now booked through the end of August with vasectomy appointments, so he’s opening more days in his schedule to accommodate patients who submitted recent requests. He and his associate, John Curington, MD, said men under age 30 without children are requesting the procedure in greater numbers than before, with some citing the concurring opinion by Justice Clarence Thomas, which said the Supreme Court should reconsider other landmark cases that protect rights under the 14th Amendment, such as access to contraceptives.
“I’d say at least 60 or 70% are mentioning the Supreme Court decision,” Dr. Curington said, according to the Post. “And a few of them have such sophistication as young men that they actually are thinking about Justice Thomas and his opinion that contraception may fall next. And that’s shocking. That’s something that doesn’t enter into our conversations ever, until this week.”
A version of this article first appeared on WebMD.com.
Nurse who won’t give Viagra to White conservative men resigns
the day after her now-viral post.
The discriminatory tweet with political overtones comes just days after the U.S. Supreme Court handed down its decision to overturn Roe v. Wade, which permitted abortions.
Libs of TikTok, which featured the tweet, identified the nurse practitioner as Shawna Harris. More than a dozen visitors to WebMD’s healthcare directory, which indicates Ms. Harris specialized in family medicine, gave her a 1-star (out of 5 stars) review after the posting. Among the comments left on the site:
“By threatening patients that hold views she is against, she has broken the bond of trust between patient and doctor.” Still another visitor voiced: “If you are White and conservative I’d be careful going here because she tweeted she withholds medication based on race and political affiliation. That’s scary.”
Meanwhile, the health system where she worked, Sarah Bush Lincoln in Sullivan, Ill., in a since-deleted bio listed Ms. Harris’ rating as 4.8 out of 5 stars. The bio stated she was a certified family nurse practitioner and was board certified by the American Academy of Nurse Practitioners.
Sarah Bush Lincoln posted the APRN’s apology and resignation on Twitter. “I am deeply sorry for my posts on social media,” she wrote, according to the health system’s tweet. “I allowed my personal feelings to spill out. Those hateful words are not aligned with how I have provided care to my patients.”
Jerry Esker, the health system’s president and CEO, also stated in the post: “Our mission is to provide exceptional care to all. That means we provide care to everyone regardless of race, religion, gender, sexual orientation, disability, income, national origin, cultural personal values, beliefs, and preferences.”
Mr. Esker added that he wanted to talk with the APRN before taking any action and that “everyone is entitled to due process,” according to the health system post.
Sarah Bush Lincoln is a 145-bed, not-for-profit, regional hospital in east central Illinois, according to its website.
A version of this article first appeared on Medscape.com.
the day after her now-viral post.
The discriminatory tweet with political overtones comes just days after the U.S. Supreme Court handed down its decision to overturn Roe v. Wade, which permitted abortions.
Libs of TikTok, which featured the tweet, identified the nurse practitioner as Shawna Harris. More than a dozen visitors to WebMD’s healthcare directory, which indicates Ms. Harris specialized in family medicine, gave her a 1-star (out of 5 stars) review after the posting. Among the comments left on the site:
“By threatening patients that hold views she is against, she has broken the bond of trust between patient and doctor.” Still another visitor voiced: “If you are White and conservative I’d be careful going here because she tweeted she withholds medication based on race and political affiliation. That’s scary.”
Meanwhile, the health system where she worked, Sarah Bush Lincoln in Sullivan, Ill., in a since-deleted bio listed Ms. Harris’ rating as 4.8 out of 5 stars. The bio stated she was a certified family nurse practitioner and was board certified by the American Academy of Nurse Practitioners.
Sarah Bush Lincoln posted the APRN’s apology and resignation on Twitter. “I am deeply sorry for my posts on social media,” she wrote, according to the health system’s tweet. “I allowed my personal feelings to spill out. Those hateful words are not aligned with how I have provided care to my patients.”
Jerry Esker, the health system’s president and CEO, also stated in the post: “Our mission is to provide exceptional care to all. That means we provide care to everyone regardless of race, religion, gender, sexual orientation, disability, income, national origin, cultural personal values, beliefs, and preferences.”
Mr. Esker added that he wanted to talk with the APRN before taking any action and that “everyone is entitled to due process,” according to the health system post.
Sarah Bush Lincoln is a 145-bed, not-for-profit, regional hospital in east central Illinois, according to its website.
A version of this article first appeared on Medscape.com.
the day after her now-viral post.
The discriminatory tweet with political overtones comes just days after the U.S. Supreme Court handed down its decision to overturn Roe v. Wade, which permitted abortions.
Libs of TikTok, which featured the tweet, identified the nurse practitioner as Shawna Harris. More than a dozen visitors to WebMD’s healthcare directory, which indicates Ms. Harris specialized in family medicine, gave her a 1-star (out of 5 stars) review after the posting. Among the comments left on the site:
“By threatening patients that hold views she is against, she has broken the bond of trust between patient and doctor.” Still another visitor voiced: “If you are White and conservative I’d be careful going here because she tweeted she withholds medication based on race and political affiliation. That’s scary.”
Meanwhile, the health system where she worked, Sarah Bush Lincoln in Sullivan, Ill., in a since-deleted bio listed Ms. Harris’ rating as 4.8 out of 5 stars. The bio stated she was a certified family nurse practitioner and was board certified by the American Academy of Nurse Practitioners.
Sarah Bush Lincoln posted the APRN’s apology and resignation on Twitter. “I am deeply sorry for my posts on social media,” she wrote, according to the health system’s tweet. “I allowed my personal feelings to spill out. Those hateful words are not aligned with how I have provided care to my patients.”
Jerry Esker, the health system’s president and CEO, also stated in the post: “Our mission is to provide exceptional care to all. That means we provide care to everyone regardless of race, religion, gender, sexual orientation, disability, income, national origin, cultural personal values, beliefs, and preferences.”
Mr. Esker added that he wanted to talk with the APRN before taking any action and that “everyone is entitled to due process,” according to the health system post.
Sarah Bush Lincoln is a 145-bed, not-for-profit, regional hospital in east central Illinois, according to its website.
A version of this article first appeared on Medscape.com.
Alabama cites Roe decision in call to ban transgender health care
Alabama urged a federal court on June 28 to drop its block on the state’s ban on gender-affirming care for transgender youth, citing the Supreme Court’s recent decision to overturn Roe v. Wade.
Alabama Attorney General Steve Marshall said the high court ruled that abortion isn’t protected under the 14th Amendment because it’s not “deeply rooted” in the nation’s history, which he noted could be said about access to gender-affirming care as well, according to Axios.
“No one – adult or child – has a right to transitioning treatments that is deeply rooted in our Nation’s history and tradition,” he wrote in a court document.
“The State can thus regulate or prohibit those interventions for children, even if an adult wants the drugs for his child,” he wrote.
In May, a federal judge blocked part of Alabama’s Senate Bill 184, which makes it a felony for someone to “engage in or cause” certain types of medical care for transgender youths. The law, which was put in place in April, allows for criminal prosecution against doctors, parents, guardians, and anyone else who provides care to a minor. The penalties could result in up to 10 years in prison and up to $15,000 in fines.
At that time, U.S. District Judge Liles Burke issued an injunction to stop Alabama from enforcing the law and allow challenges, including one filed by the Department of Justice. Mr. Burke said the state provided “no credible evidence to show that transitioning medications are ‘experimental.’ ”
“While Defendants offer some evidence that transitioning medications pose certain risks, the uncontradicted record evidence is that at least twenty-two major medical associations in the United States endorse transitioning medications as well-established, evidence-based treatments for gender dysphoria in minors,” he wrote in the ruling.
Medical organizations such as the American Academy of Pediatrics, American Psychological Association, and American Medical Association have urged governors to oppose legislation this year that would restrict gender-affirming medical care, saying that such laws could have negative effects on the mental health of transgender youths.
But on June 28, Mr. Marshall focused on the Constitution and what he believes the recent overturn of Roe implies.
“Just as the parental relationship does not unlock a Due Process right allowing parents to obtain medical marijuana or abortions for their children, neither does it unlock a right to transitioning treatments,” he wrote.
“The Constitution reserves to the State – not courts or medical interest groups – the authority to determine that these sterilizing interventions are too dangerous for minors,” he said.
Since the Supreme Court overturned Roe, people have expressed concerns that lawsuits could now target several rights that are protected under the 14th Amendment, including same-sex relationships, marriage equality, and access to contraceptives.
Justice Clarence Thomas, who wrote a concurring opinion to the majority decision, said the Supreme Court, “in future cases” should reconsider “substantive due process precedents” under previous landmark cases such as Griswold v. Connecticut, Lawrence v. Texas, and Obergefell v. Hodges.
At the same time, Justice Brett Kavanaugh, who also wrote a concurring opinion, said the decision to overturn Roe was only focused on abortion, saying it “does not mean the overruling of those precedents, and does not threaten or cast doubt on those precedents.”
A version of this article first appeared on WebMD.com.
Alabama urged a federal court on June 28 to drop its block on the state’s ban on gender-affirming care for transgender youth, citing the Supreme Court’s recent decision to overturn Roe v. Wade.
Alabama Attorney General Steve Marshall said the high court ruled that abortion isn’t protected under the 14th Amendment because it’s not “deeply rooted” in the nation’s history, which he noted could be said about access to gender-affirming care as well, according to Axios.
“No one – adult or child – has a right to transitioning treatments that is deeply rooted in our Nation’s history and tradition,” he wrote in a court document.
“The State can thus regulate or prohibit those interventions for children, even if an adult wants the drugs for his child,” he wrote.
In May, a federal judge blocked part of Alabama’s Senate Bill 184, which makes it a felony for someone to “engage in or cause” certain types of medical care for transgender youths. The law, which was put in place in April, allows for criminal prosecution against doctors, parents, guardians, and anyone else who provides care to a minor. The penalties could result in up to 10 years in prison and up to $15,000 in fines.
At that time, U.S. District Judge Liles Burke issued an injunction to stop Alabama from enforcing the law and allow challenges, including one filed by the Department of Justice. Mr. Burke said the state provided “no credible evidence to show that transitioning medications are ‘experimental.’ ”
“While Defendants offer some evidence that transitioning medications pose certain risks, the uncontradicted record evidence is that at least twenty-two major medical associations in the United States endorse transitioning medications as well-established, evidence-based treatments for gender dysphoria in minors,” he wrote in the ruling.
Medical organizations such as the American Academy of Pediatrics, American Psychological Association, and American Medical Association have urged governors to oppose legislation this year that would restrict gender-affirming medical care, saying that such laws could have negative effects on the mental health of transgender youths.
But on June 28, Mr. Marshall focused on the Constitution and what he believes the recent overturn of Roe implies.
“Just as the parental relationship does not unlock a Due Process right allowing parents to obtain medical marijuana or abortions for their children, neither does it unlock a right to transitioning treatments,” he wrote.
“The Constitution reserves to the State – not courts or medical interest groups – the authority to determine that these sterilizing interventions are too dangerous for minors,” he said.
Since the Supreme Court overturned Roe, people have expressed concerns that lawsuits could now target several rights that are protected under the 14th Amendment, including same-sex relationships, marriage equality, and access to contraceptives.
Justice Clarence Thomas, who wrote a concurring opinion to the majority decision, said the Supreme Court, “in future cases” should reconsider “substantive due process precedents” under previous landmark cases such as Griswold v. Connecticut, Lawrence v. Texas, and Obergefell v. Hodges.
At the same time, Justice Brett Kavanaugh, who also wrote a concurring opinion, said the decision to overturn Roe was only focused on abortion, saying it “does not mean the overruling of those precedents, and does not threaten or cast doubt on those precedents.”
A version of this article first appeared on WebMD.com.
Alabama urged a federal court on June 28 to drop its block on the state’s ban on gender-affirming care for transgender youth, citing the Supreme Court’s recent decision to overturn Roe v. Wade.
Alabama Attorney General Steve Marshall said the high court ruled that abortion isn’t protected under the 14th Amendment because it’s not “deeply rooted” in the nation’s history, which he noted could be said about access to gender-affirming care as well, according to Axios.
“No one – adult or child – has a right to transitioning treatments that is deeply rooted in our Nation’s history and tradition,” he wrote in a court document.
“The State can thus regulate or prohibit those interventions for children, even if an adult wants the drugs for his child,” he wrote.
In May, a federal judge blocked part of Alabama’s Senate Bill 184, which makes it a felony for someone to “engage in or cause” certain types of medical care for transgender youths. The law, which was put in place in April, allows for criminal prosecution against doctors, parents, guardians, and anyone else who provides care to a minor. The penalties could result in up to 10 years in prison and up to $15,000 in fines.
At that time, U.S. District Judge Liles Burke issued an injunction to stop Alabama from enforcing the law and allow challenges, including one filed by the Department of Justice. Mr. Burke said the state provided “no credible evidence to show that transitioning medications are ‘experimental.’ ”
“While Defendants offer some evidence that transitioning medications pose certain risks, the uncontradicted record evidence is that at least twenty-two major medical associations in the United States endorse transitioning medications as well-established, evidence-based treatments for gender dysphoria in minors,” he wrote in the ruling.
Medical organizations such as the American Academy of Pediatrics, American Psychological Association, and American Medical Association have urged governors to oppose legislation this year that would restrict gender-affirming medical care, saying that such laws could have negative effects on the mental health of transgender youths.
But on June 28, Mr. Marshall focused on the Constitution and what he believes the recent overturn of Roe implies.
“Just as the parental relationship does not unlock a Due Process right allowing parents to obtain medical marijuana or abortions for their children, neither does it unlock a right to transitioning treatments,” he wrote.
“The Constitution reserves to the State – not courts or medical interest groups – the authority to determine that these sterilizing interventions are too dangerous for minors,” he said.
Since the Supreme Court overturned Roe, people have expressed concerns that lawsuits could now target several rights that are protected under the 14th Amendment, including same-sex relationships, marriage equality, and access to contraceptives.
Justice Clarence Thomas, who wrote a concurring opinion to the majority decision, said the Supreme Court, “in future cases” should reconsider “substantive due process precedents” under previous landmark cases such as Griswold v. Connecticut, Lawrence v. Texas, and Obergefell v. Hodges.
At the same time, Justice Brett Kavanaugh, who also wrote a concurring opinion, said the decision to overturn Roe was only focused on abortion, saying it “does not mean the overruling of those precedents, and does not threaten or cast doubt on those precedents.”
A version of this article first appeared on WebMD.com.