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Venus Now Wakes, and Wakens Love

Venus Now Wakes, and Wakens Love by William Etty

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Commentary: Hebephilia—A Would-be Paraphilia Caught in the Twilight Zone Between Prepubescence and Adulthood

This commentary addresses the controversy surrounding the proposed Diagnostic and Statistical Manual of Mental Disorders, Fifth Revision (DSM-5) diagnosis of pedohebephilia. We examine adult male sexual attraction to young pubescent females and whether such attraction is deviant and constitutes a mental disorder, and, independent of that question, whether there is any defensible basis for asserting that hebephilia is a legitimate paraphilia. We conclude our analysis by looking at three profiles: adults with sexualized interest in pre- and postpubescent children, adults with sexualized interest in adult and pubescent adolescent women, and adults with exclusive sexualized interest in young pubescent women. We suggest that in the third instance of exclusivity, the Criterion B requirement of impairment may become critical to legitimizing a diagnosis of hebephilia.

In his psycholegal analysis of hebephilia, Fabian1 stakes his position that “adult sexual arousal in response to pubescent and postpubescent females is not likely to be pathologically deviant” (Ref. 1, p 501). He concludes, however, that “both clinicians and the courts disagree as to whether hebephilia is a pathological sexual deviance disorder” (Ref. 1, p 504). His brief review reflects the polemical, and indeed contentious, state of opinion among those weighing in on the legitimacy of hebephilia as a paraphilia. In our commentary, we reflect on the many arguments opposing such a diagnosis and offer, we hope, a dispassionate conclusion.

Hebephilia The term ephebophile, referring to attraction to adolescents in the age range of 15 to 19, was coined by Krafft-Ebing.2 The current term, hebephile, apparently was first used by Bernard Glueck3 in his “Final Report for the New York State Department of Hygiene” on the treatment of individuals with “sexual aberrations.” Glueck referred to those with victims in the age range of 12 to 15 as “hebephiles.” Blanchard et al. 4 examined age preference profiles in 881 men who had been referred for paraphilic, criminal, or otherwise problematic sexual behavior for phallometric testing. Within-group comparisons showed that men who verbally reported maximum sexual attraction to pubescent children had greater penile responses to depictions of pubescent children than to depictions of younger or older persons.

On the basis of these results, Blanchard and his colleagues4 went on to propose a revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis of pedophilia that would embrace sexual interest in adolescents in the age range of 11 to 14. The downward age trend over the past half century simply reflects the younger age of onset of puberty. The average age of menarche for American Caucasian females is 13, and other indices of puberty (e.g., pubic hair) emerge earlier, at age 11 for both girls and boys.4 The newly proposed category, pedohebephilia, essentially crafts two diagnoses differentiated by the Tanner Stages of sexual development.5 Pedophilia remains restricted to Tanner Stage 1 (i.e.,no evidence of the development of primary or secondary sexual characteristics). Hebephilia would now include children in Tanner Stages 2 and 3 (e.g., early development of pubic hair and breasts).

Publication of the Blanchard et al.4 article provoked a flurry of criticism (e.g. DeClue,6 Frances and First,7 Franklin,8,9 Green,10 Janssen,11 Kramer,12 Moser,13 Tromovitch,14 and Zander15). Although the critics found a minor methodological flaw (noted by the authors themselves) in the omission in Blanchard et al. of stimuli depicting 15- to 18-year-olds, they did not disagree with the basic scientific phenomenon described by them—namely, that some individuals are maximally aroused by adolescents. The critics were unanimous in their conclusion, however, that the scientific phenomenon reported in their study did not justify the recommendation of Blanchard et al. 4 that hebephilia be included as a paraphilia in the DSM-5. O’Donohue, who was clearly supportive of the proposed distinction between arousal in response to a child and arousal to pubescent minors, was sharply critical of the “many proposed alterations which are not useful and which actually may make the current diagnostic criteria even less adequate” (Ref. 16, p 587).

Significant concern has been expressed that pedohebephilia implies an empirically supported condition that underlies both pedophilia and hebephilia and that arousal to stimuli depicting adolescents is inherently deviant. Frances and First7 provide a detailed analysis of these twin concerns, concluding that “Hebephilia is not a legitimate DSM-IV-TR mental disorder. . . .” and “Hebephilia is not a paraphilia” (Ref. 7, p 84). A practical concern has been raised as well: the anticipated misuse of such a diagnosis in court involving civil commitment proceedings for sex offenders.

Other commentators have questioned the role of phallometry as an adequate determinant of mental disorder.11,15 Green noted that, “A cornerstone of the argument for bundling hebephilia with pedophilia is the overlap between interest in prepubertals and pubertals. What of the overlap between hebephiles and teleiophiles (adultophiles)? What of the 50 percent hebephile/50 percent teleiophile?” (Ref. 10, p 586). Indeed, one of the earlier studies found precisely that. Barbaree and Marshall17 examined phallometric responses to pictures of nude females ranging in age from 3 to 24 in 61 child molesters (21 of whom were incest offenders) and a matched group of 22 nonoffenders. Barbaree and Marshall found five distinct phallometric profiles, none of which reflected a unique and distinct preference for adolescents. One of the profiles was characterized by responses to both adolescent and adult stimuli.

At present, the DSM-IV-TR18 includes only a category for pedophilia. Hebephilia, when diagnosed, must be NOS (paraphilia NOS, hebephilia). Although numerous other paraphilias, unspecified in the DSM, must also be diagnosed using NOS, hebephilia in particular has become a lightning rod for criticism, as noted above. At heart, the key is not operationalization. Presumably, hebephilia would be operationalized as adequately, or inadequately as the case may be, as pedophilia. Criterion A of Pedophilia 302.2 (Ref. 18, p 572) would remain the same, with the exception of the parenthetic age reference. Instead of generally age 13 years or younger, the age range for hebephilia would be generally 11 to 14, per Blanchard et al.4Criterion B would remain the same.

What underlies the passion coloring this matter is the very legitimacy of hebephilia as a true paraphilia. The argument, quite simply stated, is that sexual interest in, and arousal in response to, pubescent teenagers is normative, or, at the very least, not deviant. Stated otherwise, if men are hard wired to respond sexually to young pubescent females, can sexual interest in adolescents in the age range of 11 to 14 be reasonably construed as a true mental disorder?

The "Vagina Whisperer" Will See You Now

As far as publicity stunts go, the “first ever designer vagina showcase” was pretty damn effective. Timed to coincide with the spectacular runway parades that mark New York Fashion Week, the event was Dr. Amir Marashi’s chance to show the world what he can do: With a little slicing and suturing, he can give you the vagina of your dreams.

Inside the sprawling midtown conference room where the “show” would take place, sparkling rosé and cupcakes were served. Guests were greeted by a perfectly taut, hair-free, millennial pink silicone vagina model, which Dr. Marashi then used to explain the slate of procedures on offer during his powerpoint presentation of before-and-after vulva shots. There were the uneven labia minora that he’s trimmed (click), aging labia majora that he’s plumped (click), lax vaginal openings that he’s tightened (click), and those were just the surgical options. If you don’t like the idea of anesthesia, he can plump your lips with fillers, inject your G-spot with your own blood plasma to improve orgasms, or stick a laser wand inside you to painlessly tighten things up. If you didn’t walk into the showcase thinking your vagina was defective, you likely walked out of there worried over just how many ways it could be flawed.

For his part, Dr. Marashi, the self-described “vagina whisperer,” walked out with a lot of press. Yes, the concept was vulgar, but it got the job done: Over the next few days, there were articles in the New York Post, Jezebel and The Sun. He’s since been interviewed by Z100 and The Daily Mail, and outlets are becoming increasingly happy to add “vagina whisperer” to his other title, board-certified Ob/Gyn, as if it’s an actual qualification. All of this is why, two months after the showcase, I find myself in scrubs in a nondescript surgical center in Downtown Brooklyn waiting for Dr. Marashi to lead me through an up-close look at what this is all about. Yep, I’m about to observe a designer vagina surgery IRL, and it’s almost curtain time.

In the operating room, he’s telling me about how important it is to find a doctor who does these surgeries regularly. “This is why I do revisions a lot,” he says, in his slight Persian accent. “People think somebody is on Park Avenue so they’re good, but they might not do these over and over again.” He says he does these procedures three days a week, and has probably done more than 700 by now.

Dr. Marashi’s patient for today is lying on the operating table, knocked out, intubated, and covered by a sheet. She’s a 48-year-old mother of four who says she can feel nothing during sex. A nurse and surgical technician have just positioned the patient’s legs in stirrups, wrapping each one up in a sheet, so only her vulva remains exposed. Dr. Marashi is explaining that these cosmetic surgeries only make up half of his practice; he spends the rest of the time doing laparoscopic surgeries for pelvic pain related to endometriosis and fibroids. For those surgeries, “we listen to Enrique,” he says, and I assume he means Iglesias, but I don’t ask because he’s moving so quickly. “For vaginoplasties and labiaplasties, I want to get the right side of my brain to work, the more creative side. So I listen to Frank Sinatra.”

“Can we turn up the music?” Dr. Marashi asks with a wink, and “My Way” comes over the speaker. It’s a fitting song for a man who would later tell me he started doing cosmetic surgery because he likes to be “outside the box.”

Dr. Marashi sits down on his stool in between the patient’s legs and snaps a “before” pic on his iPhone. He slips on a pair of gloves and enters full doctor mode as he signals me to come take a look. Her vagina looks just as expected. But then Dr. Marashi spreads her lips, revealing a startling laxity and — "What’s that?" I ask, about the round, meaty tissue bulging down from the top of her vagina. “That’s the bladder,” he says. More importantly, though, is that her perineal body, the muscle tissue that separates the vagina from the rectum, is completely flaccid. He sticks a finger in her anus and pushes up to show me how weak and sponge-y it is, and how this creates a drooping of the vaginal opening into the woman’s butt. This is what creates the lack of sensation, he explains. The vaginal opening should hug two fingers, and it should be much higher.

“This is a patient who has had four vaginal deliveries,” he says. Her kids are aged 19 to 27, and she hasn’t enjoyed sex for a long time. Her first husband left her, and she blames her inability to grip his penis during sex as one of the reasons. But she’s in a new relationship now and she doesn’t want to put up with it anymore. (At least, that is what Dr. Marashi tells me. The patient declined to speak to me directly.) “She didn’t take care of it sooner because of the taboo that’s with it, or maybe she didn’t have the money, you know all these things that get in people’s way.”

The “taboo” that Dr. Marashi refers to is very real. Between 2010 and 2016, the United States saw a more than 100% increase in labiaplasties, a surgery to trim the inner or outer labia. No one is tracking the number of cosmetic vaginoplasty procedures, also referred to as “vaginal rejuvenation,” because the practice is too new, but experts estimate a similar increase in demand thanks to new non-surgical options and greater public awareness. (Kourtney and Kim Kardashian have both reportedly been “rejuvenated” via the new non-surgical laser options.) A lot of this rise has coincided with a surge in social media, reality TV, and endless amounts of free porn, which has, in turn, been blamed for creating an impossible standard of beauty for female genitalia — as if women needed yet another standard to measure themselves against, another reason to hate their bodies.

"Is this really what women want? Or is this really a form of new-age ‘circumcision’ based on an obsession with Barbie doll looks?," asked a scathing 2012 editorial in Obstetrics & Gynecology. A Jezebel article on Dr. Marashi’s vagina showcase described people who choose labiaplasty as women with minds “warped” by the porn industry. That’s what critics have said, and that’s exactly what I was thinking, walking in. But now that I’m witnessing the surgery, it’s not clear that assessment is fair.

Dr. Marashi uses a blue marker to map out where he will cut. Once he’s done that, Charles, the surgical tech, clamps her vagina open, and Dr. Marashi begins to cut away a diamond-shaped chunk of muscle and skin from the bottom of her vaginal opening. Then comes the most important cut: a deep crevasse into the perineal body.

“It’s really important to take your time and dissect this very meticulously, because behind here is the rectum,” and any crossover could lead to a dangerous infection, he says. Dr. Marashi then sews multiple rows of sutures into the perineal body, starting from further inside of her vagina until he gets to the outside, where he finishes with a row of stitches up from her anus to the new, lifted bottom of her vaginal opening.

“Remember in the beginning how close the vagina and the anus were together? You're gonna see in the end how far apart it’s gonna be,” he says.

In the end, I do see how much higher the vagina is. The hour-long process reminds me of a slower version of that magical strapless, backless bra Amber Rose has been advertising on Instagram: It’s as if he just threaded it all, and pulled the strings tight so that the whole vagina is miraculously lifted an inch higher. The final stitches are the tying of the bow that holds it all in place.

If I had to choose a vagina for myself, I’d pick this one over the one she had before. This makes me feel really bad, until I remember that there are also the anatomical realities here: Sewing it all back together with multiple layers of sutures is not just for aesthetics; this is a repair job for that muscle. This repair will also create a lift in the bladder that may even help alleviate stress incontinence, not to mention making penetrative sex feel good again for her partner, yes, but also for her.

It’s hard to square all that with the way Dr. Marashi has marketed himself, and indeed the way the entire, fast-growing crop of “cosmetic gynecologists” have marketed this burgeoning industry, as though this is just about having pretty, youthful genitalia. In the operating room, it’s clear that selling this the way women were sold facelifts, Botox, or even breast lifts is not quite right. Having sagging breasts and wrinkles may not make you feel so great about yourself (especially in our youth-obsessed culture), but those things don’t make sex physically impossible to enjoy. And they have nothing to do with a problem as distressing as incontinence.

To hear Dr. Marashi describe it while he’s actually doing the procedure, women choose this surgery mostly for functional reasons: to make sex better, the way it was before they had a baby or three, and to stop peeing their pants (even just a little bit) when they sneeze or lift weights. So, why on earth is the best way Dr. Marashi can think to market himself a grotesque showcase that frames everything in terms of how the vagina looks? More importantly: Why is this woman paying out-of-pocket for a one-time tune-up for her perineal body, when her partner could easily get insurance to cover his lifetime supply of Viagra?

To even begin to answer these questions, you have to understand where “cosmetic gynecology” came from in the first place. Plastic surgery — cosmetic gynecology’s closest cousin — has always been controversial, but it has also always been a mixture of reconstructive surgeries (like implants after breast cancer) and elective surgeries (like breast lifts or implants simply because you want them).

Cosmetic gynecology seems to be a similar mixture — but thanks to a toxic combination of entrenched sexism and continued dismissal of women’s sexual concerns, even the reconstructive procedures are still deemed frivolous, unscientific, and ironically, misogynistic.

The truth is that gynecologists have always done vaginoplasties and labiaplasties, but historically they would only do them for women with “true” medical problems, such as uterine prolapse (when the pelvic muscles collapse completely and the uterus descends into the vagina) or labial hypertrophy, which is when the labia minora or majora are extremely long or uneven. Outside of that, most doctors deemed them unnecessary, says Marco Pelosi, III, MD, a pioneer in the field. “There has always been a chasm between what doctors consider a problem and what women consider a problem when it comes to their sex lives,” he says.

Variations in labia length are totally normal, as any gynecologist or even anyone who watches porn regularly, can tell you. And while, say, painful sex or prolapse are “real” medical issues, constant irritation caused by your long labia or even a change in sensation after childbirth are not, according to traditional medicine, Dr. Pelosi explains. So for years, the procedures remained unpopular thanks to low awareness and low interest among women, as well as low adoption among qualified physicians.

Then, Sex And The City happened. Brazilian waxes became very popular — and baldness meant better opportunities for women to actually look at (and, yes, scrutinize) the physical characteristics of their vulvas.

In a post-Samantha Jones world, the gates opened: Women were much less shy about openly complaining to their doctors about their sexual dissatisfaction. And when their doctors didn’t listen, they found another doctor. All of a sudden, women had gotten the message that they deserve pleasurable sex. This created a huge opening for the few doctors who did offer these vagina alteration services to grow their businesses.

On the East Coast, Dr. Pelosi (along with his father Marco Pelosi, II, MD) — who had been offering elective vagina procedures since the ‘90s — began training surgeons in Bayonne, New Jersey. Eventually, due to demand, the father-son duo founded the International Society of Cosmetogynecology in 2004; they were the first to coin the phrase “cosmetic gynecology.”

Meanwhile, in Beverly Hills, Dr. David Matlock had trademarked the term “laser vaginal rejuvenation” and started a franchise business where he performed surgeries and, for a hefty fee, trained other doctors in his procedure. This allowed doctors to use the term to market the procedure, which is essentially a slightly modified version of vaginoplasty, the same way he did. This being L.A., Dr. Matlock also managed to swing an appearance on an episode of the E! network’s Dr. 90210 in 2006, giving "laser vaginal rejuvenation" its first national spotlight.

Soon, as a workaround to Dr. Matlock’s hefty fee, other doctors just dropped the “laser” and started calling it simply “vaginal rejuvenation.” This prompted the American College of Gynecologists (ACOG) to issue a scathing committee opinion in 2007 deeming the marketing practices and franchising surrounding the term “troubling” and the procedures “not medically necessary.”

But warnings from ACOG didn't do much to stem the rising tide of demand. As the rise of social media and Dr. Google continued, labiaplasty alone started to explode in popularity, experiencing a 44% increase between 2012 and 2013 (the first period for which data was tracked). Dr. Matlock only grew more famous — and not necessarily in a good way. He went on The Doctors with his wife Veronica, who got a vaginoplasty, labiaplasty, and “pubic liposculpting” from her husband. And who can forget when Brandi Glanville, the Real Housewife, infamously charged her vaginoplasty to her cheating ex, Eddie Cibrian’s, credit card? Dr. Matlock was her doctor.

Soon, there were myriad non-surgical options for “enhancements,” each one more bizarre than the next. There were liposculpting and fillers for your vulva, followed by g-spot injections (which would supposedly improve orgasms), and targeted skin lightening treatments that would change the shade of a vulva to Carnation Pink. In hindsight, the vajazzling phenomenon — the iconic ‘00s trend of adorning your waxed pubic area with rhinestones — seems inevitable. And while it’s easy to roundly mock all the upgrades and accoutrements, the thing is, the vulva was having a moment, one that no one seemed to notice except to mock.

Most recently came the big innovation (and the big money-maker): lasers and radiofrequency devices that use thermal energy to tighten the vagina. FemiLift, the machine Dr. Marashi uses, came first in 2013. Then MonaLisa arrived in 2014. Both machines are FDA-approved for “vaginal laser ablation” to induce the growth of collagen in the vaginal walls. This is said to not only tighten and lift the vagina, but also to improve the health of the mucosal lining, making lubrication easier. Another side effect: The lifting may help some with stress incontinence, and in some cases may even shorten labia. Other machines that use thermal energy technology to the same effect: ThermiVa, Diva, IntimaLas, and more.

No doubt the ease in getting non-surgical vaginal rejuvenation has coincided with the huge increase in demand. According to data from the American Society for Aesthetic Plastic Surgery (ASAPS), more than 10,000 labiaplasties were performed by plastic surgeons in 2016, a 23% increase just from 2015. Now more than 35% of plastic surgeons offer the procedure, compared to 0% in 1997 when the society started their surveys. But the full breadth of designer vagina procedures remains a mystery, since nobody is tracking the variety of procedures that fall under the term vaginal rejuvenation, nor the number of doctors performing them, according to a spokesperson at ASAPS.

Because a laser treatment or an injection requires no anesthesia or downtime — all it takes is a series of in-office visits that amounts to having a laser wand inserted into your vagina — “it became a gateway,” Dr. Pelosi says. “Once you have a nonsurgical way to address some of the needs, it becomes way easier to do. It’s like Botox. Now everyone does Botox.”

Sandra*, a 31-year-old mother of one, has spent the past five years since the birth of her daughter yearning for her pre-baby vagina. Before she gave birth, sex was great. Now it’s lackluster. It wasn’t until she started Googling her symptoms and found her way to Dr. Marashi’s website that she realized there was a single thing she could do about it.

“After you have a baby, everything changes,” she says. “I realized during sex I wouldn’t stay as wet, and it just felt different. Also there were the urination issues, too.”

“This is definitely going to help a little bit with that,” Dr. Marashi says, handing her a pair of protective glasses. She’s laying on her back with her feet in stirrups and a paper gown over her lower body, ready for her second of three treatments with Dr. Marashi’s FemiLift machine. This time, he has outfitted me in a white coat to serve as his assistant while observing Sandra’s procedure.

It’s hard to say exactly how common Sandra’s situation is, but any mom (or any doctor) can tell you that it’s pretty prevalent. We all know that childbirth changes things. Another thing we can say for sure: A full third of women who have given birth vaginally have some damage to the muscles responsible for vaginal tightness. Vaginal delivery is the strongest predictor of developing a pelvic floor disorder, such as uterine prolapse, rectocele (when the rectum bulges into the vagina), or cystocele (when the bladder bulges into the vagina). The feeling of “looseness” that so many women come to plastic surgeons and cosmetic gynecologists to fix may actually be one of the earliest precursors to true prolapse, per a 2014 study in Surgical Technology International.

The treatment takes 10 minutes, tops. We all put on our protective glasses. Dr. Marashi replaces the glass cover on the probe, which looks like a clear dildo with a mirror on the tip to direct the searing light, with the one Sandra had to purchase. Each patient must bring her own personal probe cover ($150, not covered by insurance) with her to appointments.

Next, he inserts the probe, attached to a long bending metal arm that is connected to a machine. He steps on a pedal while simultaneously pushing the probe in and out and twisting the probe around inside of her. Every time Dr. Marashi presses the floor pedal, the laser is turned on and the mirror directs it to burn 81 tiny holes into the lining of the vagina. With the twisting and maneuvering, what you end up with is thousands of tiny holes, which draws a lot of healing blood flow to the area and promotes the growth of collagen, making the skin more taut. Industry-sponsored studies have also shown that it makes the vaginal lining thicker, which is why lubrication is easier. This is repeated three times at increasing levels of intensity. As his assistant, I press the button when he tells me to, to ramp up the intensity.

Afterward, Sandra says that it didn’t hurt at all — just a bit of tingling and burning toward the end. But it was hard not to notice the grimace on her face when the laser was all the way turned up.

Even just after the first treatment, she already feels some difference: “Sex is amazing,” she says. “It’s much better.” And now after this go-round with the laser, she should feel 70% of the potential effects; she can have sex after just two days of healing. In another 4 to 6 weeks, she’ll come in for a third appointment, and that’s when she will really see how amazing this treatment is, Dr. Marashi promises.

But it’s unclear how “amazing” the treatment really is in general. The machines are FDA-approved, which means they are safe to use. Many of the studies on the non-surgical options show positive results as far as improving lubrication and stress incontinence, but the studies are small, with only short-term follow-up. There is also not a lot of high-quality data on how well the machines work for improving vaginal laxity or sexual satisfaction. In practice, the experts I interviewed said although women can expect some result, it can vary widely depending on the particular patient and how experienced the person doing the procedure is — which is risky considering the cost ranges from $1,200 to $4,000 depending on the device.

The same can be said of the actual surgeries, in part due to the same reason there aren’t statistics on vaginal rejuvenation surgery: It’s still an ever-evolving term, and it can mean different things to different doctors. One 2012 paper from The American Journal of Cosmetic Surgery says it’s difficult to study whether vaginal rejuvenation surgery “necessarily, usually, or reliably” improves sex because surgeons don’t want to share their surgical techniques (this is why ACOG hates the trademark model; when surgical techniques are “owned” by a doctor, they become hard to evaluate independently), and the outcome measurements are fickle (it’s difficult to reliably measure sexual satisfaction).

Otherwise, a few smaller studies have been conducted on specific techniques: One 2016 Turkish study of 68 women who chose surgery after complaining of vaginal laxity found that 88% said they were satisfied with the results after 6 months. There were no serious complications, except that 10% of patients reported pain during sex at follow-up. Another 2014 study conducted in Iran followed 76 women for 18 months following an elective vaginal surgery to address sexual complaints. At six months, researchers found that sexual satisfaction increased on average a few points on a validated sexual function questionnaire, but that painful sex and dryness had also increased. By 18 months, though, sexual function scores increased significantly, while the pain and dryness issues disappeared. These results are promising, but again the studies are too small to be certain, and results can vary based on minute changes to the surgical technique.

Still, many women swear there are completely valid reasons for these procedures — that their lives are changed for the better because of them, even for the procedures that seem totally about looks, like labiaplasty. “Absolutely love this doctor. He is very respectful and listens to what you have to say and doesn't give you the run-around,” reads one of the many breathless Zocdoc reviews for Dr. Marashi. “He performed a labiaplasty due to an accident I had a few years back and omg it looks sooo good like as if the accident never happened.” Katina Morrell, 41, another of Dr. Marashi’s patients, tells me she got a labiaplasty because her long labia made working out uncomfortable.

Jennifer Walden, MD, a plastic surgeon based in Austin, TX, who does “a high volume of labiaplasties and vaginoplasties,” was among the first wave of doctors to see the potential value of the laser machines. She also happens to be a woman, the mother of twins, and to have tried two of the procedures herself: ThermiVa and Diva. As a practitioner, she describes vaginal rejuvenation procedures as “absolutely, the opposite of misogynistic.” As a patient she describes the results as simply “awesome.”

Before the laser machines hit the market, there was nothing to offer women with sexual complaints other than surgery, which, unless they had a severe injury, could cost up to $12,000. There was no treatment for mild or moderate stress incontinence, outside of the “disastrous” vaginal mesh surgeries that were only worth doing for the worst of cases and medications that hardly work, she says. There was also nothing outside of estrogen creams (which are too dangerous for some women with a history of breast cancer or heart disease) to solve dryness or other lubrication issues. The laser procedures can still be pricey, and they don’t work as well as surgery. Also: the effects may only last for about a year, but still, it’s something, Dr. Walden says.

“Within the past 5 years, we’ve seen a sort of a-ha moment happening for women. It’s become okay for women to talk about their labia and their vagina with their doctors. It’s become okay for women to finally talk about sex and the real issues they’re having,” she says. “And, at the same time, we’ve finally had something to offer them.”

Yet the conundrum persists: Why then, on God’s green earth, is “vaginal rejuvenation” marketed as a frivolous lifestyle choice, instead of a possible treatment for a legitimate problem?

Well, partly it’s that the majority of pioneers in this field are men, and so the desire and need for these treatments is framed from their perspective — ah, the male gaze at work. Add to that the general cultural tendency to code all things female as frivolous and vain and to reduce women to their looks, alongside our inability to talk openly about female sexual pleasure, and it makes more sense.

It is the marketing of the treatment — not the treatment itself — that risks preying on women’s insecurities, and it would be a mistake to ignore the ugly fact that though vaginal rejuvenation is a positive for some (maybe even many) it does create a perception that there is a perfect-looking, or even a perfect-working, vagina out there, and no, you don’t have it.

In my time with Dr. Marashi, there was a 43-year-old mom of two who learned about Dr. Marashi’s Femilift procedure from Groupon, who had no sexual or urinary complaints. She seemed most attracted to the idea of being 18 again.

Then there was the second vaginoplasty I observed on surgery day. It was identical to the first, technically, except that the next patient was much younger, a mother of one, who was in a new relationship with a man who is “small,” Dr. Marashi explained. Her perineal body wasn’t nearly as damaged, and she had no visible signs of bladder prolapse. The idea that she did it for her partner made me sad, and before I could ask Dr. Marashi his thoughts he said: “Honestly she could have gotten away with this. I told her she could wait. But she said no, she doesn’t want to have any more children, and she’s with this new guy. So that’s her reasoning.”

In that moment, all over again, I was reminded of the critics who say this whole thing is just a gold rush of money-hungry, often male doctors willing to pathologize normal biology in service of making the vagina the final frontier in plastic surgery. That all this boils down to is a sanctioned form of Female Genital Mutilation (FGM), just another way to reduce women’s bodies to mere objects for male pleasure.

Dr. Marashi doesn’t go that far. But he does admit that, a lot of the time, these procedures are a simple matter of want, not need. “So many times I get a patient and I’m like, 'Look, you don’t need anything to be done.' Now it’s a different story if they say, 'I want to do this.' I figure out why, and if they are good candidate, I say 'Okay, I’ll do it for you,'” he says. “At the end of the day, if I don’t do that procedure, someone else will do it, and I know I will do a better job.”

He doesn’t see the harm in doing what they want as long as he screens patients appropriately: He always looks for signs of body dysmorphia or partner pressure, of course. But in his view, the procedures are no more risky than other elective surgeries, and he’s personally seen the benefits in his patients for himself.

Still, wouldn’t it be better to explain to these women that, for example, it’s totally normal for their labia to be a bit longer? When Dr. Marashi is pressed on this, he launches into a diatribe about how a woman, not a doctor, should be making the decisions about what she does or does not deem a problem or a symptom for her body and her life. “I tell my patients: 'All vaginas, all labias, they’re all beautiful in their own way,'” he says. “I always tell people, ‘Do not ever do this for anybody else. You own your vagina.’”

As right as he is about that, it’s impossible to completely untangle the desire for these procedures from the pressures women face simply being alive in a youth- and beauty-obsessed culture. What’s also impossible to ignore, though, is that women’s sexual function has never gotten the same amount of research — or respect — as men's.

So perhaps in the end, Dr. Marashi is neither villain nor hero — he is but an emissary. Make what you will of his misguided self-promotion methods. But he has also devoted his life’s work to studying and addressing a facet of women’s lives that — until now — most of medicine has refused to acknowledge even exists. If that makes him a “vagina whisperer,” then so be it.

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Europe is doomed. Once terrorists have understood that arson everywhere is a cost that even Europe cannot shoulder, the European era will end. Time to dispose of Euro bonds.

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An Overview of Filicide

Abstract Filicide, or the murder of one's own child, is an unfathomable crime. With Andrea Yates's return to trial in the summer of 2006, filicide once again came to the forefront of psychiatric issues in the media. One positive outcome that may be derived from this tragedy is practitioners' heightened awareness that parents may, for a variety of reasons, be compelled to kill their children. This article aims to educate mental health providers about the concept of filicide by presenting a broad overview of the topic, including a discussion of its history, definitions, classifications, outcomes, and the research surrounding it. This knowledge will hopefully bring about clinicians' increased exploration of patients' thoughts of harming their children, which may ultimately lead to the prevention of these senseless crimes.

Filicide in the Press
On June 20, 2001, Andrea Yates drowned her five children, who ranged in age from six months to seven years, in a bathtub in her home. Prior to this, she had manifested symptoms of depression with psychosis, which were exacerbated in her postpartum periods. She had been hospitalized four times and was catatonic and mute during one admission. In statements made following the crime, she indicated that she believed that she was a bad mother and that she had concerns that her children would not grow up properly secondary to her shortcomings. She noted that she killed them to save them from eternal damnation.
In early 2002, she went to trial in Harris County, Texas, and entered a plea of not guilty by reason of insanity (NGRI). The jury hearing her case was death qualified, meaning that all jurors supported the philosophy of the death penalty and would be willing to use it in sentencing. Though she ultimately was not sentenced to death, she was found guilty and sentenced to life in prison, making her eligible for parole in 40 years. In 2005, due to an error made by the prosecution's expert witness, the conviction was reversed, and the case was remanded back to the trial court. In June, 2006, Andrea Yates returned to trial and again entered a plea of NGRI. On July 26, 2006, the jury handed down a verdict of NGRI.
This decision marked a surprising change in the course of events. A number of theories have been posited as to why the plea of NGRI was accepted the second time around. The most obvious is that five years had passed since the commission of the crime, and the passage of time may have allowed the community to forgive her for her crime. Another theory involves the idea that the jury was not death qualified and may, therefore, have been more liberal. There were also two other women found NGRI for harming their children in Texas between the time of her first and second trials. Regardless of the reason, Andrea Yates will now spend the duration of her confinement in a maximum security hospital in northern Texas until she is deemed to no longer pose a risk to herself or others.

The History of Filicide
Filicide has existed since the dawn of mankind. In ancient Greco-Roman times, a father was allowed to kill his own child without legal repercussions.1 Despite the later rise of Christianity and its greater respect for life, filicides continued, often perpetrated by the mother, who may have claimed the child accidentally suffocated in bed.2 Reasons for wanting to end the life of a child, particularly a newborn, included disability, gender, lack of resources to care for the child, or illegitimacy. These reasons still hold true today. However, without our current systems of documentation, including records of birth and death, it was far easier to succeed in completing a filicidal act in earlier times without the knowledge of authorities, who may have turned the other cheek regardless of the laws in order to strike a balance between population growth and resources available in impoverished areas.
In 16th and 17th centuries, a drastic change in the opinion on child murder occurred in Europe. France and then England established laws that made filicide a crime punishable by death. Both countries also presumed that the mother who was on trial for the crime was guilty until proven innocent, meaning that she was responsible for proving to the court that her child was not the victim of murder.3 The tide changed again with the establishment of the Infanticide Acts of 1922 and 1938 in England. These laws recognized the effect that birthing and caring for an infant can have on a mother's mental health for up to 12 months after the event. These acts outlawed the death penalty as punishment for maternal infanticide, making the punishment similar to that of manslaughter. Several other Western countries have adopted similar laws, with the exception of the United States.
Filicide has a presence in literature from all eras. Perhaps the most famous is also the oldest, and that is the story of Medea, a woman who killed her children to punish her husband for his affair. To him, she says, “Thy sons are dead and gone. That will stab thy heart.”4 Even fairy tales meant for children, such as Snow White and Hansel and Gretel, are filicidal in nature, telling of evil (step) parents who cast their children out into the world with the hope of eradicating them.

Definitions of Filicide
A number of terms have been used somewhat interchangeably in the description of child murder (Figure 1). Often, filicide refers to any murder of a child up to the age of 18 years committed by his or her parent(s) or parental figure(s), including guardians and stepparents. Infanticide commonly applies to the murder of a child under the age of one year by his or her parent(s). Neonaticide, a term coined by Phillip Resnick in 1970, refers to the unique circumstance in which a newborn is killed by his or her parent(s) within the first 24 hours of life.6 It is important to recall that filicide can be committed by both men and women, though far less literature exists on paternal filicide than maternal filicide.

Classification Systems of filicide
In an effort to aid in understanding a parent's motivation for killing his or her child, multiple classification systems of filicide have been devised based on the type of crime and the gender of the perpetrator. The systems serve to better delineate the motives behind these crimes. The first classification system identified in psychiatric literature was published in 1927 and divided mothers who committed filicide into two groups: Those who perpetrated the act while lactating and those who did so after the end of lactation. Of the 166 cases the author reviewed, he believed that 70 percent were related to exhaustion or lactation psychosis.7 Though this system has fallen out of favor, it is founded on the important idea that filicide may be motivated by the hormonal changes and stressors associated with childbirth and caring for an infant.
A 1957 study established two groups of homicidal mothers who killed their illegitimate infants in the first day of the infants' lives. Group one was identified as young, immature primiparas who submit to sexual relations and have no history of legal trouble, while group two consisted of women with strong primitive drives and little ethical restraint.8 The large majority of women who commit neonaticide fall into the first of these categories. This study made significant strides in identifying neonaticide as a distinct crime involving very different circumstances when compared to other filicides.
One of the most influential classifications of child murder was created in 1969 by Phillip Resnick.9 He reviewed 131 cases of filicide committed by both men and women that were discussed in psychiatric literature dating from 1751 to 1967. He developed five categories to account for the motives driving parents to kill their children:
Altruistic filicide—The parent kills the child because it is perceived to be in the best interest of the child.
Acts associated with parental suicidal ideation—The parent may believe that the world is too cruel to leave the child behind after his or her death.
Acts meant to relieve the suffering of the child—The child has a disability, either real or imagined, that the parent finds intolerable.
Acutely psychotic filicide—The parent, responding to psychosis, kills the child with no other rational motive. This category may also include incidents that occur secondary to automatisms related to seizures or activities taking place in a post-ictal state.
Unwanted child filicide—The parent kills the child, who is regarded as a hindrance. This category also includes parents who benefit from the death of the child in some way (e.g., inheriting insurance money, marrying a partner who does not want step-children).
Accidental filicide—The parent unintentionally kills the child as a result of abuse. This category includes the rarely occurring Munchausen syndrome by proxy.
Spouse revenge filicide—The parent kills the child as a means of exacting revenge upon the spouse, perhaps secondary to infidelity or abandonment.

The most common motive in Resnick's study was altruism. In total, this category accounted for 49 percent of the cases reviewed. The least common motive was spousal revenge, which accounted for only two percent of the murders. This comprehensive classification system can be applied to both female and male perpetrators. In 1973, Scott devised another classification system based on the impulse to kill. This was the first classification system in the literature based solely on the actions of fathers. The system was derived from his research involving 46 fathers who killed their children (Table 1).10 In 1999, Guileyardo published a classification system based on Resnick's system, which was enhanced to reflect a broader range of motives (Table 2).11 In 2001, Meyer and Oberman created a classification system identifying the causes of maternal infanticide (Table 3).12 While there certainly exists some overlap between the classification systems proposed over the last several decades, the development of these systems contributes some important points to the growing body of knowledge related to filicide.

An Unthinkable Crime
Since 1950, child homicide rates have tripled, and homicide is within the top five causes of death for children ages 1 to 14 years old.13 In 2004, 311 of 578 (53.8%) children under the age of five were murdered by their parents in the US. Between the years of 1976 and 2004, 30 percent of all children murdered under the age of five were killed by their mothers and 31 percent were killed by their fathers.14 Male and female children appear to be killed in equal numbers, though one study did find that fathers are more likely to kill sons while mothers more frequently kill daughters.15 See Table 4 for an overview of characteristics associated with filicidal parents.

The theory of evolution allows for a more objective and less emotionally charged evaluation of filicide. The goal of any species, including humans, is to procreate, and those factors that allow for the creation of the next generation are advantageous. In a world with limited resources, the offspring who are weaker (those with obvious physical deformities) or are not created by the careful selection of a mate (those that are the product of rape) are more likely to be sacrificed in favor of stronger candidates.16 Younger offspring are more likely to be eliminated because less time and energy has been invested in their care. Finally, younger females are more willing to sacrifice offspring with the understanding that they have a longer period of fertility remaining in comparison with older females. It has been suggested that mental illness and the disorganization that it creates may be the main factor that causes parents not to follow the trends predicted by evolution.17 Maternal filicide. Most research concerning filicide has focused on the mother and has looked at the crime from a variety of different perspectives. In 2005, Friedman, et al.,18 published an extensive analysis of the existing literature on maternal filicide. While they were able to reaffirm characteristics common to those women who committed neonaticide, it was unfortunately much harder to define the type of women who murders her infant or child. There are a number of reasons for this. Most importantly, circumstances vary greatly among the different populations of women assessed in each of the studies, depending on whether the information was gathered from general, psychiatric, or correctional populations. Also, the studies analyzed were all retrospective, and some contained a small number (n) of participants. The age of the child changes the potential for filicide as well. Despite these limitations, some general conclusions were reached. The strongest general risk factor that was identified through an analysis by Friedman, et al.,18 was a history of suicidality and depression or psychosis and past use of psychiatric services. In the general population studies (those that used administrative records including coroners' reports or national statistics), it was determined that mothers at highest risk of filicide were often socially isolated, indigent, full-time care providers who may have been victims of domestic violence themselves. Overall, those from the psychiatric population were married, unemployed, used alcohol, and had a history of being abused. Women from the correctional population were more often found to be unmarried and unemployed with a lack of social support, limited education, and a history of substance use. See Table 5 for a synopsis of this data. Although no specific study exists, the literature also supported the idea that younger children are at greater risk for fatal maltreatment (accidental filicide) while older children are more often the victims of purposeful homicide.

Table 5

Risk factors for maternal filicide based on the Hatters-Friedman, et al., 18 study population

Two studies in the literature highlighted the importance of the mother's own childhood as a factor in her crime. A number of women who went on to commit filicide received inadequate mothering secondary to their own mothers being unavailable to them due to a variety of reasons including alcoholism, absence, physical or verbal abuse, or mental health problems.19 In another study, Friedman, et al.,20 reviewed the developmental histories of 39 women who were adjudicated insane following charges of filicide. They found that 38 percent had a history of physical and sexual abuse (5% were incest victims) and 49 percent were abandoned by their own mothers. These figures may represent low estimates given that some of the information about these women was unknown.

Several studies have identified certain characteristics found in mothers who commit filicide.9,15,20–23 The number of women evaluated in each study ranged from 17 to 89. The average age of the women was 29 years. Two thirds of the women were married. The victim was, on average, 3.2 years old. Many of the women had psychiatric diagnoses. A separate study indicated that those mothers who are mentally ill were generally older when they committed the filicidal act, and the children killed by these women were typically older as well.17 Based on the six studies, an average of 36.4 percent of filicidal women attempted or committed suicide. Another study showed that 16 to 29 percent of all mothers successfully commit suicide following a filicidal act.24 The most common methods of murder identified in the six studies were head trauma, drowning, suffocation, and strangulation. In addition, Rouge-Maillart, et al., made the connection that women who accidentally killed their young children during an episode of abuse shared many characteristics with mothers who commit neonaticide, including being young, poor, unemployed, single, and without a suicide attempt following the act.25

Paternal filicide. Fathers are less often considered as the perpetrators in filicide cases, and consequently, there is much less focus on them in the literature. However, they are responsible for a large portion of child murder and worthy of independent investigation. Six pertinent studies were identified in the literature.9,15,26–29 The number of men evaluated ranged from 10 to 60. According to the literature, it appears that most men were in their late 20s when the crime occurred. On average, the children were typically older than those killed by mothers. It is important to note that fathers are rarely responsible for neonaticides. It is difficult to delineate a common motive because, as with maternal filicide, the data for these studies originated from different locations. It was striking, however, that a few of the studies noted that the murder was based on the father's interpretation of the child's behavior (e.g., a father becomes jealous because the child prefers the mother).28,29

Psychosis seems to be common in men who commit filicide. Two studies from psychiatric populations found the rate of psychosis was 40 percent,27,28 while two studies from general populations found it to be about 30 percent.9,26 The rate of suicide or attempted suicide was also quite high, usually around 60 percent.15,26,27 In 40 to 60 percent of paternal filicide cases, men who murdered their children were also likely to kill or attempt to kill their spouses (familicide).15,27

Throughout the literature, fathers consistently used active and violent means, such as shooting, stabbing, hitting, dropping, squeezing, crushing, or shaking, in order to kill their children. Finally, these men were often determined to be poor, uneducated, unemployed, and lacking a social support network. In Resnick's 1969 study, he compiled data on both paternal and maternal filicide, and this data is summarized in Table 6.

Table 6
A comparison of mothers and fathers who commit filicide based on Resnick's data9

Filicide by stepparents. Parenting can be challenging, and it may be even more so if the child is not the parent's own. As mentioned before, in evolutionary terms, the reward for investing the energy in raising a biological child is the opportunity to advance one's own genetic information.30 Given that stepparents do not share any genes with their stepchildren, they may be less tolerant of them.31 This may explain why two studies found that stepparents kill children at a much higher rate than biological parents.16,32 More specifically, stepfathers were roughly eight times more likely than biological fathers to kill their children, and stepmothers were almost three times more likely than biological mothers to kill their children.32 In addition, stepparents were found to be more likely to beat or bludgeon their stepchildren, whereas biological parents often shot or asphyxiated their children. The more violent actions of the stepparents may be explained as a manifestation of the hostility, resentment, and rage that they may feel toward their stepchildren.16,32

Infanticide. Despite the frequent use of the term infanticide in the literature, few studies have focused solely on child murders in the first year of life. In 1998, Overpeck, et al.,33 reviewed 2776 child homicides that occurred during the first year of life between 1983 and 1991 in the US. This study is particularly potent given the large number of cases reviewed. However, the perpetrator of the crime was not often specified in the data. The mother of the infant was often young, single, lacking prenatal care, and poorly educated. One quarter of the crimes were committed prior to the end of infant's second month of life, one half by four months and two-thirds by the end of the sixth month. Battering or assault was the most common means of death, occurring in about 60 percent of the cases.

Later that year, Brewster, et al.,34 published a smaller but more comprehensive study of infanticide. The results were based on the analysis of 32 cases of filicide followed by the United States Air Force, which were perpetrated by both mothers and fathers between 1989 and 1995. Presumably, secondary to the extensive records maintained by the military, much previously unattainable and unexplored data was presented. Nearly all (97%) of the households were composed of two parents who were living together and married (unusual and most likely a reflection of the military population). Three quarters of the crimes were committed by the biological fathers, while 17 percent were committed by the biological mothers. The average age of parent was 23.8 years old. Half of the perpetrators were first time parents. One quarter had a personal history of childhood abuse.

On average, the victim was five months old, and there was an even division between male and female children. Pediatricians noted that around one third of these infants had colic; whereas, interestingly, the mothers only felt that was the case 10 percent of the time. These infants were documented to be on the low end of normal in regard to their heights and weights. A little more than half (55%) of the children had been abused before. The most common cause of death was head injury, and on average, the infant survived approximately 8.5 days following the trauma.

Three quarters of the time, the acts were committed in the home. The perpetrator was alone during the commission of the crime 86 percent of the time. On average, the act occurred around noon. They were perpetrated equally on weekends (Saturdays and Sundays) and weekdays (Tuesday through Thursday); no crimes were committed on Monday or Friday. The incidents were evenly distributed across the months. Slightly more than half (58%) of the crimes were precipitated by the infants crying.

Neonaticide. In the literature, neonaticides stand out as very different crimes from other filicides. In 1970, Resnick6 presented the most well-known set of data regarding the murder of newborns. This was based on his evaluation of 37 cases in the world literature between 1751 and 1967. He found that the crime is most often perpetrated by a young mother who is acting alone. Frequently, the mother is unprepared for the birth of a child. She rarely has a history of mental illness. The mother is most often motivated to commit the crime because the child is unwanted, perhaps because she is not married or is married to a man who is not the father of the child. Suffocation is the most common method of death. Unlike filicide, in which 40 percent of murdering mothers come to the attention of a physician, mothers committing neonaticide rarely seek medical assistance, including prenatal care.6 See Table 7 comparing Resnick's statistics on neonaticide and filicide. Table 7

A comparison of Resnick's data on neonaticide and filicide6,9

Many of Resnick's6 findings have been corroborated in subsequent studies. Four other studies targeting neonaticide were identified in the literature.35–38 The number of women evaluated in each study ranged from 7 to 53. Three of these studies were derived from data concerning the general population, while one was based on women seen secondary to court referrals for psychiatric evaluation. The average age of the women was 21.2 years old. Few were married (11.3–20.6%), and most were nulliparous prior to the birth (65–81%).35,37 Asphyxiation, drowning, and exposure were identified as the most common means of completing the act.35,38 Three quarters to 100 percent of the women concealed or were in denial of their pregnancies.36,38

Five percent of all homicides in the first year of life (infanticides) occurred on the first day of life. Of those newborns killed, 95 percent of those were not born in a hospital.33 Given the secrecy surrounding the occasion of the child's birth, it is highly likely that some instances of neonaticide remain hidden. Denial or concealment of pregnancy is quite common in women who commit neonaticide. Passivity appears to be a trait that clearly differentiates mothers who commit these crimes from those who seek to terminate the pregnancy.39 These neonaticidal mothers expect that the problems created by the pregnancy will simply disappear, perhaps by having a miscarriage or a stillbirth. They neither make plans for the arrival of the baby nor do they anticipate harming the child.6 Once they have unexpectedly birthed a live child, the harshness of reality sets in and causes them to silence the infant's intrusion into their lives forever.

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The Aftermath

The justice system. Society's opinions about parents who kill their children are often strongly held but quite ambivalent. On one end of the spectrum, society feels justice must be served for the senseless loss of innocent lives. On the other end, even without having a full understanding of the complexities of mental illness, society believes, on some level, that something must be terribly wrong with a parent who kills his or her own child. This presents some explanation for society's mixed emotions regarding the use of the insanity plea in filicide cases.

The NGRI plea varies significantly from state to state, with some states going so far as to abolish it. All states that allow this plea require the defendant to be mentally ill. This mental illness must then cause the defendant to not be aware of the wrongfulness of the act. This can refer to legal wrongfulness, moral wrongfulness, or both. More lenient states allow the defendant to qualify for the insanity plea if they meet another criterion, the volitional arm, which means that the defendant, due to mental illness, could not resist the impulse to commit the crime. Mothers who were adjudicated NGRI were more likely to have attempted suicide and had psychotic symptoms.40

In the case of Andrea Yates, experts testifying for both the defense and the prosecution agreed that she was severely mentally ill. However, the point on which they disagreed was the issue of wrongfulness. The prosecution's expert believed that Ms. Yates was aware of the wrongfulness of the act, whereas the defense's expert stated that although she was aware of the legal wrongfulness, she had an overriding moral justification for her actions (e.g., to save the souls of her children).

Disposition. The placement of filicidal parents depends upon the outcome of their legal proceedings. Those who were determined to be NGRI are technically acquitted of the charges, though they are almost always committed to a forensic psychiatric unit until their mental illness has been properly treated. Those found guilty of murder will most likely serve their sentence in a prison. Mothers who commit filicide are much more likely to be shown mercy by the courts when compared to fathers. Men are more frequently sent to prison and executed when compared to their female counterparts.9

Treatment. Given all the variables that play a role in a parent's decision to kill a child, no clear treatment plan can be proposed. If the parent is mentally ill, treatment of the underlying illness is certainly warranted. Often after this occurs, the parent who committed the crime has a very difficult time emotionally processing the devastating event that has occurred and may require extensive counseling and/or psychotropic medications. Filicide is irreversible, and this is why prevention is so crucial.

Prevention. Various efforts had been made in the United States to decrease the number of filicides that occur, particularly those involving newborns and infants. Safe Haven laws allow parents to anonymously surrender unharmed infants to the custody of the state without legal repercussions, including being charged with child abandonment. Since the first law was proposed in Texas in 1999, safe haven laws have been introduced in 46 other states. In 1970, Resnick hypothesized that more liberal abortion laws would decrease the occurrence of neonaticide. This became a reality when the Supreme Court, in the 1973 Roe v. Wade41 decision, struck down a law banning first trimester abortions. Though not conclusive proof of this theory, one study showed that fewer neonaticides occurred in the 10 years following the decision when compared to the 10 years preceding it.42

Though it is certainly not always the case, the prevention of filicide may be achieved by physicians who interact with a patient prior to his or her commission of this devastating act. Psychiatrists have one of the best opportunities to do this when caring for mentally ill parents, and this is particularly true when psychiatrists are caring for women in the postpartum period. Andrea Yates received regular psychiatric care just prior to the murder of her children. Because of her psychotic beliefs at the time, Ms. Yates did not disclose her recurrent thoughts of harming her children. However, other patients may be willing to confide in their physicians.

A particularly challenging time in the life of parents involves the arrival of a new child, especially for women. Traditionally, the mother is expected to be the primary care giver, which can be quite difficult when her hormones are fluctuating and may have a deleterious effect on her mood or thought process. In her lifetime, a woman is at the greatest risk of developing mental illness during the postpartum period.42 Despite this, soon after the birth of their child, mothers may have considerable difficulty admitting to symptoms of mental illness given that they are expected to be happy and fulfilled. Another issue that arises in recognizing depression in new mothers is the lack of a clear definition of what postpartum illness actually is. The DSM-IV TR applies the postpartum specifier only to diagnoses made within four weeks of delivery;44 however, most clinicians would agree the postpartum period extends beyond that short period of time.

The Edinburgh Postnatal Depression Scale is a brief rating scale that can be used to quickly screen for depression in a postpartum women.45 Because postpartum depression affects 10 to 15 percent of new mothers and recurs after 20 to 50 percent of subsequent pregnancies, screening is certainly warranted.46 If postpartum illness is particularly severe, a clinician may even recommend to a patient that she consider avoiding future pregnancies, which actually occurred in Andrea Yates's case. Even mothers who do not suffer from postpartum mental illness may experience stress to the degree that thoughts to harm their children occur. Levitzky and Cooper showed that 70 percent of mothers of infants with colic had “explicit aggressive fantasies” related to their children.47

A psychiatrist may be provided with an early opportunity for prevention of harm to an infant if he or she has the chance to interview a woman prior to giving birth. At this point, the clinician may inquire generally about the mother's attitude toward the baby or more specifically about plans for the baby during and after its arrival. This line of questioning may also include asking about thoughts to harm the baby. This may prove to be especially important if the woman indicates ambivalent or negative feelings about the pregnancy (e.g., if she has some delusional thoughts concerning the baby or if the pregnancy is unwanted).

Psychiatrists may underestimate the prevalence of filicidal thoughts, when in fact greater than 40 percent of depressed mothers with children less than three years old endorsed thoughts to harm them.48 Even if it occurs to clinicians to inquire about filicidal thoughts, they can be prevented from doing so for a number of reasons. They may feel that it will have a negative impact on the therapeutic alliance or place ideas in the heads of parents who otherwise may not have considered the notion of filicide before. It may simply be that it is a difficult topic to address with a patient secondary to the psychiatrist's own discomfort with the notion. Given the prevalence of parents who intend to commit filicide prior to their own suicides, it is important to inquire about plans for the children in parents who endorsed thoughts to harm themselves.49 Much as asking about suicidal or homicidal thoughts has become second nature for psychiatrists over time, so too should inquiring about filicidal thoughts.

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Conclusion

Filicide is a complicated and multifactorial crime. Given its complex nature, it is difficult to establish traits that consistently apply to its perpetrators and victims. However, through careful evaluation of the existing literature, certain trends can be identified. Mothers and fathers who commit filicide are, on average, in their late 20s and typically do so with equal frequency. This differs remarkably from neonaticide, which is almost always committed by young mothers. About 35 percent of filicides committed by both mothers and fathers are associated with suicide attempts. Filicidal men and women are often socially isolated and unemployed. Mothers may have a personal history of abuse, whereas men are more likely to attempt to kill their spouse in addition to their child. Neonaticidal mothers often deny or conceal their pregnancies and usually are not mentally ill, thus they generally avoid contact with medical professionals.

Mental illness, however, clearly plays a role in other filicidal acts. Therefore, psychiatrists may have some exposure to these parents prior to the commission of the crimes. As clinicians, it is important that we ask these patients the difficult and uncomfortable questions that concern their filicide thoughts. If patients are willing to share these thoughts with their care providers, the next step involves safeguarding the parent and child through hospitalizing the parent or linking them to community resources that can provide support to overwhelmed parents. Filicide, tragically, is a permanent act, and the key to avoiding the devastating effects, for the perpetrator, the victim, and the community, is prevention.

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Men risk their lives in wars so women can enjoy societies where they can pursue feminist goals, such as punishing men for sexist language.

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Paul Hayes accused of being a paedophile committed suicide before Hull court case

A man accused of being a paedophile committed suicide before he could be sentenced, an inquest heard.

Paul Hayes, 46, of Welbeck Street, west Hull, was found hanging from his loft at home by police.

The Mecca Bingo worker was due in Hull Magistrates Court after indicating a guilty plea on two counts of possessing indecent images of children and one count of making indecent images of children.

The case was cancelled after he was found deceased at his home on December 27 last year.

In a statement read out to the court, Mr Hayes’ father said he had seen his son for Christmas just days previously and did not believe his behaviour to be out of the ordinary.

He said the only odd behaviour his son undertook was refusing to take money given as a Christmas present – and talking about his pension arrangments.

He said: “Paul seemed absolutely fine on Christmas Day. He had a really good relationship with his niece.”

He said his son didn't seem upset or down, apart from the remark about his pension being split between his father and niece when he died.

He said: “Paul refused to take the amount of money I would usually give him as a Christmas present.

“I practically had to force £60 on him. At the time I thought it was a bit strange.”

Hayes was discovered after his colleagues at Mecca Bingo, where he had worked in Huddersfield and then for four years in Hull, noticed he wasn’t on shift.

They contacted him by phone but, when he did not answer that or a Facebook message, reported him missing to the police.

Officers attended his home and forced their way in. They found Hayes hanging from his loft hatch after a search of the property.

A suicide note was found in the living room of Hayes’ home and the handwriting was confirmed as his.

Area Coroner Rosemary Baxter returned a verdict of suicide.

She said: “Paul was described as a private person who kept himself to himself.

“He came home last Christmas and he was absolutely fine as far as his father could see.

“They had a good day together, Paul was very close to his niece.

“However Paul did mention instructions for his work pension to be split between his father and niece.

“At the time his father thought little of these matters. Paul gave no inkling he was distressed or thinking about ending his life.”

She added she was satisfied Paul died on December 27 due to hanging himself and returned a conclusion of suicide.

Hayes was alleged to have possessed 84 indecent images, with three in category A - the most serious. He was also alleged to have made 16 indecent photographs of children, which were found on his laptop.

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Channeling tens of millions of refugees to Europe can kill feminism and Europe. It can do so reliably in the span of two decades. And to aide it is low risk political activism for people with a lot of money. Suited for Qatari and Russian billionaires. Just finance humanitarian efforts, such as rescue vessels on the Mediterranean, or life vests for those who board in Libya.

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“Out of his mind” surgeon plans human head transplant, revival of frozen brain

Italian neurosurgeon Sergio Canavero will undertake the first human head transplant later this year in China, the doctor told German magazine Ooom in an article published Thursday. And, following that effort, he will revive a cryogenically frozen brain and transplant it into a donor body within the next three years.

The plans, completely disconnected from reality and the state of modern medicine, are at least in line with his previous outlandish goals and dubious animal research.

Canavero made headlines in the past few years by claiming that transplanting the whole head of a human onto a donor body is currently possible. A Russian man, suffering from a spinal muscular atrophy malady called Werdnig-Hoffmann Disease, even publicly volunteered for the procedure.

As proof that the transplant could work, Canavero published gruesome experiments in 2016, said to have repaired the severely injured spinal cords of mice, rats, and a dog. The experiments came complete with cringe-worthy video of recovering animals struggling to drag their limp bodies around. Yet, the study lacked controls, detailed methods, and data on the injuries and recoveries. Canavero claimed to perform a head transplant on a monkey but did not publish the experiment.

Experts decidedly consider his research on spinal cord repair, let alone whole head transplants, unconvincing. A medical ethicist dubbed Canavero “out of his mind” for sweeping past the currently insurmountable challenges of such feats. These include intricately repairing and reattaching thousands of delicate nerves and restoring function. Right now, doctors can’t even convince the immune system to accept far simpler transplants consistently. There’s also the completely unknown effects of such a transplant on the powerful human psyche.

Canavero is carrying on, undeterred it seems. In his Ooom interview, he not only glided through the idea of successfully transplanting a head, he made an even more absurd claim: that he would revive a cryogenically frozen brain and transplant it into a donor body. Canavero said he would obtain a preserved brain from Alcor Life Extension Foundation, a cryonics company located in Scottsdale, Arizona, according to Gizmodo.

There is currently no way to revive and molecularly repair a frozen human brain. And such transplants haven’t even been attempted in animals. Thus, the surgical procedure is decades if not centuries away.

As Gizmodo also reports, Alcor said that Canavera hadn’t even contacted the company. It distanced itself from the doctor, as did other cryonics leaders, and noted that his efforts are not realistic or even a shared goal.

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The decline or destruction of Europe is in the interest of China, in the interest of all of Asia, and in the sexual interest of the male population just anywhere on earth. The political system of Europe is stupid feminism and hypocritical humanism. By contrast, the patriarchy as political system is best for men and mankind.

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WikiLeaks: The raucous underground lifestyle of young Saudi royals

telegraph.co.uk

In what could prove one of the most provocative disclosures from the WikiLeaks trove of State Department documents, an account of a Halloween party last year provides a rare glimpse into the Islamic kingdom's secret social scene.

"Behind the facade of Wahhabi conservatism in the streets, the underground nightlife for Jeddah's elite youth is thriving and throbbing. The full range of worldly temptations and vices are available – alcohol, drugs, sex – but strictly behind closed doors," read the cable, which is dated November 18, 2009.

Consular officials attended the party in Jeddah at the mansion of a young prince, whose name was removed from the cable released by the website. Though not in line for the throne, the host was among thousands of princes who enjoy a state purse, round-the-clock security and sufficient clout to prevent the feared religious police from spoiling their fun.

There was no trace of the Commission for the Promotion of Virtue and Prevention of Vice as about 150 young men and women in their 20s and 30s attended the party, leaving their prohibitive local attire at the cloakroom to reveal their party clothes underneath.

"The scene resembled a nightclub anywhere outside the Kingdom: plentiful alcohol, young couples dancing, a DJ at the turntables, and everyone in costume," said the cable.

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95 percent of the victims of violence are men. Because women are natural cowards who send men to handle things when they are dangerous.

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I Got Fillers In My Penis – & My Sex Life Has Never Been Better

I've been insecure and self-conscious about my penis size for most of my adult life. It's not on my mind all the time, but it's always bothered me. There wasn't a specific instance when a partner was explicitly disrespectful or mean, but there have been times when I could tell it wasn’t satisfying or didn’t work as smoothly as it should.

I hadn't done a ton of research on enhancement options, though, so I didn't realize you could get enlargement fillers until I heard about it at Urban Skin Solutions med spa while I was getting hair restoration treatments. I found out more and talked through my concerns, like the pain level and potential for loss of feeling and negative affect on performance, and ultimately, I decided the procedure seemed safe. I was a little scared, but the fact that I was already comfortable at this place made it easier. I didn't discuss it with friends, just my fiancée. She certainly wasn't a driving force behind why I wanted to do it and she's never made me feel bad about the size, but she was supportive because she knew it affected me.

They set pretty reasonable expectations prior to the procedure and let me know upfront that length probably wouldn't be affected, but the girth could be enhanced anywhere from one to two-and-a-half inches. Two treatments were recommended and in total, I ended up paying $3,000.

The area was numbed first, so I really didn't feel the injection. They inject at the base and then down the length while the penis is flaccid, but I didn't look, which would have been the worst part. I would definitely recommend not watching! I was sore for a few days afterward, but I didn't even ice it — it was minor discomfort, then it was back to normal, only bigger. A few weeks later, I went back for the second treatment — in total, five syringes were used. Then we did the "after" photos while I was hard so you could really see the difference: I grew one-and-a-half inches in girth. I was pleasantly surprised because I didn't know if it would be a noticeable difference or not, but the results were very quick and impressive.

My fiancée was definitely excited, more so at first for me, but also because the sex was better after that honestly. I was obviously concerned about whether all the feeling in my penis would be there, but I can't tell any difference in that.

Supposedly, the fillers last six months. It’s a big expense, but it's worth it to me so as long as I'm able to afford it, I do plan to keep going. It certainly makes me think about if there is possibly more to do and if I found something that would add length as well, I'd be open to it. But I'm certainly much more confident now, in terms of performance and appearance, just with the increase in girth.

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There is a new solution coming up for ugly old women. Normally they would just become man-hating feminists. But soon they can have their brains transplanted into a sex doll, and feel beautiful again.

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4 Deadliest Chemical Weapons

During the World War I, a new, deadly type of weapon was used for the first time; toxic gas. Considered uncivilised prior to the war, the development and military usage of poisonous gas grenades was soon called for by the demands of both sides to find a new way to overcome the stalemate of unforeseen trench warfare.

First used at the Second Battle of Ypres on 22 April 1915, cylinders filled with toxic gas soon became one of the most devastating and effective weapons used in the entire Great War, killing more than 90,000 soldiers and injuring about 1.25 million. In this article, we are going to explore the 4 of most deadly chemical weapons ever conceived, their history, usage, and effects on the human beings.

4.Mustard Gas(Yperite)

While Germans were releasing the mustard gas in year 1917 near the Belgian city of Ypres for the first time, chemist Frederic Guthrie was most likely turning in his grave. In year 1860, this British professor discovered the mustard gas, and also experienced its toxic effects first-hand for the first time. 57 years later, after its first military usage at Ypres, it got its infamous nickname, Yperite.

In the beginning, Germans planned to use the mustard gas only as a paralyzing agent. However, they soon found out, that when in sufficient concentrations, this gas could be easily lethal to the majority of the enemy soldiers.

Due to its dangerous properties, mustard gas soon became a popular chemical weapon, used in WWII, during the North Yemen Civil War, and even by Saddam Husein in year 1988. Even 150 years after its discovery, antidote is still to be discovered.

Pure mustard gas is colourless, oily liquid at room temperature. When used in its impure form, as warfare agent, it is usually green-brown in color and has an specific odor resembling mustard or garlic, hence the name. Yperite fumes are more than 6 times heavier than air, staying near the ground for several hours, effectively filling and contaminating enemy’s trenches, and killing everyone without proper protection.

Lethal dose for an adult man weighing 160 lbs is approximately 7,5 g of liquid mustard gas, when in contact with his skin for several minutes. However, when used in its gaseous form, lethality greatly depends on its concentration and on the length of exposure. Gas mask is usually not enough to be protected from this gas; it can easily penetrate the skin and kill the victim from inside. It easily passes through most of the clothes, shoes or other materials. For instance, standard rubber gloves could protect the skin for only about ten minutes.

4 or 6 hours after exposure, burning sensation appears in the affected areas, followed by reddening of the skin. After next 16 hours, large blisters appear on the affected skin, subsequently causing severe scarring and sometimes even necrosis. If the eyes were affected, temporary or permanent blindness typically occurs after few days.

When inhaled, first symptoms start to manifest themselves after several hours, starting with chest pain, bloody coughing and vomiting, followed by muscle spasms. Death usually occurs within 3 days, caused either by lung edema or heart failure.

3.Phosgene

In year 1812, 22-year old British amateur chemist John Davy syntetized the phosgene gas for the first time. However, it didn’t contain any phosphorus, its name was derived from greek words phos(light) and gennesis(birth). John Davy probably assumed that his invention would be used in a more sensible way, however, on 9.th of December, 88 tons of phosgene were released during the trench warfare in France, killing 69 men and seriously injuring more then 1,200.

Germans were satisfied by the results, so they soon started using grenades filled by phosgene in combat. It accounts for more than 60% of all deaths caused by the chemical warfare during the First World War, more than chlorine and mustard gas combined.

During the Second World War, most soldiers were well-prepared for the possible use of this deadly gas, so the casualties were nowhere that high. However, phosgene-filled grenades used during the 1942 Battle of Kerch by Nazi Germany allegedly injured at least 10,000 Soviet soldiers.

Which deadly properties does this gas possess? At low temperatures, it is a colourless liquid. However, when heated to more than 8 degrees celsius, it evaporates quickly. Its odor has been often described by the survivors as pleasant, similar to newly mown hay or wet grass. After release, it contaminates the area for about 10 minutes, double the time in the winter. When compared to chlorine, phosgene has a major advantage; first symptoms start to manifest themselves after much longer time period, usually after more than five minutes, allowing more phosgene to be inhaled.

After one inhales high concentrations of this lethal gas, his chances of survival are very mild. After few minutes, he is likely to die of suffocation, because phosgene aggresively disrupts the blood-air barrier in the lungs.

After inhaling less concentrated phosgene, you might be little bit better off. One hour after exposure, first symptoms include strong burning sensation in pharynx and trachea, severe headache and vomiting, followed by pulmonary edema(swelling and fluid buildup), which often leads to suffocation.

To this day, phosgene remains one of the most dangerous chemical weapons in the world. Although not as deadly as sarin or nerve gas, it is very easy to manufacture; no wonder it’s often used during terrorist attacks. Homemade phosgene grenade can be easily created by exposing a bottle of chloroform to UV-light source for a few days.

2.Sarin

If previous two chemicals weren’t dangerous enough, here comes the sarin, often known as the most powerful of all nerve agents.

Sarin was developed back in 1938 by a group of 4 German scientists, Scharder, Ambros, Rudiger and van der Linde, during their research of pesticides. During the WWII, this deadly gas was first used by the Nazi Germany in June 1942. At the end of the war, Germany allegedly possessed more than 10 tons of sarin.

However, it is most famous for being used during the 1995 terrorist attack on the Tokio subway by a Japanese cult Aum Shinrikyo, killing 13 people and allegedly injuring more than 5,000. It was also used back in August 2013 by al-Assad’s forces in Ghouta, Syria, killing more than 1,700 people.

Sarin belongs to the group of nerve gasses, the deadliest of all toxic gasses used in chemical warfare. It is highly toxic; a single drop of sarin the size of the head of a pin is enough to kill an adult human. In addition, most of the victims usually die few minutes after contamination.

It usually enters the organism via respiration, but it can also penetrate the skin or be ingested. In home temperature, sarin is a colourless liquid without significant odor, similar to water. However, when exposed to higher temperatures, it starts to evaporate, being still odorless. After release, it often remains deadly for more than 24 hours.

Immediately after exposure, first symptoms include strong headaches, increased salivation and lacrimation(secretion of tears), followed by gradual paralysis of the muscles. Death is caused by asphyxiation or heart failure.

According to some sources, Sarin is 500 times more deadly than kyanide, with its lethal dose being only about 800 micrograms. Only 5 tons of sarin, obiviously properly dosed, would be enough to wipe out entire humanity.

1.Agent Orange

This mixture of two herbicides, most famous for its usage in Vietnam War, is not a chemical weapon in the true sense of the word. It was discovered in year 1943 by American botanic Arthur Galston. In year 1951, further research started by the scientific team in the military base of Detrick, Maryland.

During the War of Vietnam, it was widely used for deforestation of the large areas covered by thick jungle, to enable easier and more effective bombing of enemy bases and supply routes. Although designed as herbicide, the Agent Orange also contained large amounts of dioxin, a highly toxic compound, making it one of the most deadly chemical weapons ever deployed.

In years 1962-1971, military operation with codenames ”Ranch Hand” or ”Trail Dust” took place in Southern Vietnam. During this operation, jungles in the region were heavily showered by this herbicide, primarily in the areas of Mekong delta. Mixture was storaged in orange barrels, hence the name ”Agent Orange”. During the operation, more than 20 million gallons of this dangerous chemical were used, destroying large areas of jungle, contaminating air, water and food sources.

In high concentrations, dioxin causes severe inflammation of skin, lungs and mucous tissues, sometimes resulting in chronic obstructive pulmonary disease, pulmonary edema, or even death, however, it also affects eyes, liver and kidneys. It is also highly effective carcinogen, known for causing laryngeal and lung cancer.

It is estimated, that the usage of Agent Orange during the Vietnam War led to more than 400,000 people being killed or maimed, and 500,000 children born with mild to severe birth defects as a result of contamination. Agent Orange alone killed 10 times more people than all other chemical weapons combined.

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For the current legal systems in the Western World, and for the mainstream media anyway, doing physical harm to men, or killing them, is peanuts. A woman who kills her sexual partner always gets full sympathy. Never mind what kind of bitch she is.

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