Saturday, July 21, 2007

Crackdown on Juvenile Sex Offenders

Sexual offender registeries, once primarily for adult sexual offenders, are increasingly aimed at teenagers:

Since 1994, federal legislation has required many sex offenders to register with the police, which can aid sex-crime investigations. But Megan’s Law, which went into effect in 1996, mandates that law enforcement also notify the public about certain convicted offenders in their communities. One of the ways states do this is through publicly accessible Web sites. At least 25 states now apply Megan’s Law, also known as a community-notification law, to juveniles, according to a recent survey by Brenda V. Smith, a law professor and the director of the National Institute of Corrections Project on Addressing Prison Rape at American University’s Washington College of Law. That means on many state sex-offender Web sites, you can find juveniles’ photos, names and addresses, and in some cases their birth dates and maps to their homes, alongside those of pedophiles and adult rapists.

However, juvenile sex offenders are different from adult sex offenders:

Adult models, he notes, don’t account for adolescent development and how family and environment affect children’s behavior. Also, research over the past decade has shown that juveniles who commit sex offenses are in several ways very different from adult sex offenders. As one expert put it, “Kids are not short adults.”

while most juveniles who have committed sex offenses are boys around 13 or 14, in other ways they are not a homogeneous population. Though a small percentage — no one knows how many — will become adult rapists or pedophiles, the vast majority, 90 percent or more, will not, Chaffin says. Most have not committed violent assaults or abused multiple children repeatedly. Usually they have had sexual contact — from fondling to oral sex to intercourse — with a child who is at least two years younger than they are. Also, many of the juveniles have been sexually abused themselves, and as a consequence, they act out sexually, typically for a transitory period.

Some, whether they have been abused or not, are what therapists call “na├»ve experimenters” — overly impulsive or immature adolescents who are unable to approach girls or boys their own age; instead, they engage in inappropriate sexual acts with younger children. Others are generally delinquent juveniles for whom sexual abuse is just one of the ways they break laws, and according to studies, they are much more likely to commit a property crime than they are to commit a second sex offense. They are from working-class, middle-class and upper-middle-class homes, from intact families as well as very broken ones. There are also a number of children — how many is unclear — who are adjudicated for what some therapists would say is “playing doctor” or normative “sexual experimentation.” These are broadly considered to include sexual acts that are spontaneous, intermittent and “consensual” (legally, children under 16 usually cannot consent to sex) between youths within a couple of years age. Similarly, there are the so-called Romeo and Juliet cases, like the highly publicized one in Georgia involving Genarlow Wilson, who is serving an 11-year prison sentence for having consensual oral sex with a 15-year-old girl at a party when he was 17. There have also been court cases of 12- and 13-year-old boys who grabbed girls’ breasts or buttocks in school hallways and were adjudicated as “sex offenders.”

According to the Diagnostic and Statistical Manual of Mental Disorders, a diagnosis of pedophilia requires a person to be at least 16 years old and with “recurrent, intense, sexually arousing fantasies” over a period of six months or longer, that he acts upon with a child who is at least five years younger. Many sex-abuse therapists, however, say they’d be wary of diagnosing pedophilia in even a 16- or a 17-year-old. At 16, a teenager’s history of sexual interest is relatively short, notes David Prescott, a therapist and the president-elect of the Association for the Treatment of Sexual Abusers, and it is still subject to change, compared with the history of a 40-year-old who is sexually attracted to young children.

Some of the juvenile sex offenders are being discovered by neigbors and classmates:

Kids Google one another’s names; curious neighbors type in their ZIP codes on sex-offender Web sites. And the problems begin.

Last year, an eighth grader at a Delaware middle school arrived one morning to find kids in the hallway pointing at him and snickering. At first, the boy, Johnnie, who asked me protect his privacy by identifying him by a friend’s nickname for him, was confused. He thought it might be because of his new haircut. Then one kid called him a rapist. Another jeered, “Hey, aren’t you a sex offender?” One teenage boy threatened to beat him up.

Friday, July 20, 2007

Drug Interactions can cause Pregnancy

The Cortlandt Forum describes an interesting malpractice case in which a drug-drug interaction between Tegretol and a birth control pill led to pregnancy:

The 32-year-old woman suffered from bipolar disorder and depression, which she claimed were exacerbated by a divorce and the difficulties of her young son, who had developmental problems. Dr. T referred her to a psychiatric clinic under the care of Dr. P. The psychiatrist started her on bupropion (Wellbutrin) for depression and the anticonvulsant carbamazepine (Tegretol) for her bipolar disorder.

After her discharge from the clinic, the patient continued to see Dr. T. She told him she was “in a relationship” and was taking norethindrone and ethinyl estradiol (Norinyl 1/35) for contraception. Several months later, she announced that she was pregnant despite the oral contraceptive (OC) and had been advised there was a chance of birth defects because she was taking carbamazepine during the first trimester.

The woman decided to have an abortion. During counseling at an abortion clinic, she was told that carbamazepine could interfere with the contraceptive effectiveness of norethindrone and ethinyl estradiol. A plaintiff’s expert later explained that carbamazepine could induce liver enzymes that metabolize estrogen, further reducing the efficacy of the hormone, which is already at a low dose in Norinyl 1/35.

The case proceeded through the depositions and other discovery, then settled for $135,000 a month before trial.

Tegretol (carbamazepine) is a notorious hepatic enzyme inducer. It induces cytochrome P450 3A4, leading to reduced serum levels of birth control pills. Another medication that can do this, although to a lesser extent, is Provigil (modafinil). I warn all my female patients taking Provigil that it can reduce the effectiveness of birth control pills.

Saturday, July 14, 2007

The Quantum State of Cheney

Normally I try to avoid non-medical political commentary on this blog, but I found this Tom Tomorrow cartoon too clever to skip (try clicking on the cartoon or click here if it is too small to read). Although Tomorrow's politics are the opposite of mine, this is one of the best political cartoons I have seen and therefore I'm going to feature it today.

I find the field of quantum mechanics to be fascinating, though my my limited mathematical background only permits a superficial understanding.

If one subscribes to the Many Worlds interpretation of quantum mechanics, one could imagine billions of parallel universes, a few in which Cheney is all executive or all legislative, but most containing a Cheney who is a mixture of executive/legislative. There would also be some in which Cheney is neither, and Gore or Kerry is President- a scary thought.

Thursday, July 05, 2007

Practicing Pelvic exams

A commenter asks:

I've been in practice for 30 years,and teach medical students.I went to med school in Vt and FP residency in Mn. I never heard of practicing pelvic exams in woman under anesthesia. Was this the standard practice in any medical school or an urban myth?

Practicing pelvic exams in women under general anesthesia was not done when I was a medical student (93-97) or resident. Can any older docs confirm if this was ever done??

Learning Pelvic Exams

A commenter on Kevin MD asked:

Is it still true today that anesthesized female patients in the OR provide the opportunity for med students to practice pelvic/rectal exams in secret? Secret from the patient who has no idea this is happening to her? Supposedly the vague consent form the patient signs before the operation is the legal cover teaching hospitals and doctors hide behind to justify this clandestine procedure.I wonder if the surgeon would resent the patient should he or she be asked that the practice not be done. Or might the request not even be honored. The idea of medical students lining up to probe and examine the vagina of an unsuspecting unconscious patient for their own benefit, in my opinion, is nothing short of medical rape.

Medical students are no longer allowed to practice pelvic exams on anesthesized female patients.

Most medical students learn the basics of a pelvic exam from "standardized patients."
Below is a link about standardized patients:

However medical students still need to practice to get good, and many leave medical school without the ability to do an adequate pelvic exam. Some learn how to do it during OB/GYN rotations, but in many cases the patients on OB/GYN services don't want students to examine them. Therefore many doctors don't become proficient at pelvic exams until residency, if it all.

Tuesday, July 03, 2007

The Problems with HIPAA

The 1996 Health Insurance Portability and Accountability Act (HIPAA) has led to family members and caretakers being unable to access needed information about a patient:

Government studies released in the last few months show the frustration is widespread, an unintended consequence of the 1996 law.
Hipaa was designed to allow Americans to take their health insurance coverage with them when they changed jobs, with provisions to keep medical information confidential. But new studies have found that some health care providers apply Hipaa regulations overzealously, leaving family members, caretakers, public health and law enforcement authorities stymied in their efforts to get information.

The law is unclear, and in most cases the safest thing to do is not share information:

Some reports blame the language of the law itself, which says health care providers may share information with others unless the patient objects, but does not require them to do so. Thus, disclosures are voluntary and health care providers are left with broad discretion.

Teaching staff to protect records is easier than teaching them to share them, said Robert N. Swidler, general counsel for Northeast Health, a nonprofit network in Troy, N.Y., that includes several hospitals.
“Over time, the staff has become a little more flexible and humane,” Mr. Swidler said. “But nurses aren’t lawyers. This is a hyper-technical law and it tells them they may disclose but doesn’t say they have to.”

Of the 27,778 privacy complaints filed since 2003, the only cases investigated, she said, were complaints filed by patients who were denied access to their own information, the one unambiguous violation of the law.

So as long as you give patients access to their own information, there is no penalty for being secretive with most others, leading to situations like this:

Birthday parties in nursing homes in New York and Arizona have been canceled for fear that revealing a resident’s date of birth could be a violation.

Patients were assigned code names in doctor’s waiting rooms — say, “Zebra” for a child in Newton, Mass., or “Elvis” for an adult in Kansas City, Mo. — so they could be summoned without identification.

Nurses in an emergency room at St. Elizabeth Health Center in Youngstown, Ohio, refused to telephone parents of ailing students themselves, insisting a friend do it, for fear of passing out confidential information, the hospital’s patient advocate said.

State health departments throughout the country have been slowed in their efforts to create immunization registries for children, according to Dr. James J. Gibson, the director of disease control in South Carolina, because information from doctors no longer flows freely.