Why domestic violence needs to be a “guy” issue

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Although I have never been the victim of physical/sexual/verbal abuse, I see the consequences of these actions in many of my patients. I try to listen, not judge and provide resources for women who are either in an abusive relationship or suffering mental/physical repercussions of a previous relationship. But more than a few times I have thought, “Why doesn’t this woman just leave?”.

Over the past few weeks, two seemingly disparate articles have made me rethink this statement. The Star Tribune newspaper published an investigative article on sex trafficking, highlighting the customers of prostitution rather than the female victims. Efforts have succeeded in many states to prosecute the pimps and sex customers and not the female victims, as the majority of these young women are the victims of violence and feel enslaved and unable to leave. They often start as teenage runaways trying to escape an abusive home life, only to find themselves picked up by an older male who seems to provide safety and love. It doesn’t take long until these young women are enslaved in a different way – to drugs, sex work and physical violence from their pimps. Leaving is not an option as they have no family to go home to, no friends who can help and they carry the societal shame of what they have done. With this in mind, new initiatives have begun to educate and prosecute the male customers of the sex trade. If demand can be decreased, there will not be a need for supply.

The second article appeared on the blog  of a former neighbor and friend. This independent, opinionated, musically and athletically talented young woman had been the victim of domestic violence dealt by her boyfriend. Her story was horrifying as she came close to death a few times while also being  psychologically abused and estranged from her close and loving family.  Why didn’t she leave?  Why did she continue to make excuses for someone who left bruises on her body? But what if we changed the “blame” game? What if we asked, similar to the prostitution story above, why is the abuser abusive? What led him to believe that he has the right to choke and punch someone that he loves? Where has he learned the words that can systematically wear down a person’s self-esteem?  Why isn’t his family recognizing the bruises, put down words and unhealthy control he exerts?

The majority of our current resources around domestic violence are geared to protecting women once they leave an abusive relationship; providing a safe place to stay, legal services and job training. This is important but will never effectively change the behavior that led to the situation. We need research to find out what exists in our society that allows men to believe that this is acceptable behavior. Only when we understand that this is a “guy” issue and not a female victim issue, will we be able to effect change.

 

My Day of Confusion at Work as an Ob/Gyn

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During the delivery of a baby last week, the parents informed me that they had decided not to know the sex of the baby prior to delivery. I joked that I would need to watch a You Tube video prior to the momentous event so that I would be reminded of how to correctly identify the “parts” as either boy or girl. Luckily, I got it correct under pressure of both the delivery and the gender identification and disaster was averted. But it did allow me to reflect on how important this subject has become for the newest generation of parents.

When I first started in practice 25 years ago, routine ultrasound at 20 weeks gestation was not standard practice. The quality of ultrasound was far inferior to current imaging and even when looking for gender, you could be mistaken or not obtain a clear picture. Although not evidence based, routine ultrasound at 20 weeks gestation is now the norm and anticipated from the time of the first OB appointment. The purpose of the scan is to rule out major structural abnormalities but expectant moms see it as “finding out the sex of the baby”. Relatives and siblings are invited to view the unveiling and crowd into the small, darkened room for the 45 minute procedure.

Reveal events have now become the mid-pregnancy social occasion. The sex of the child is concealed in some way and the expectant parents “reveal” boy or girl status to invited guests. A competition seems to have started for favorite You Tube video/creativity with these events. Subsequently, our office has been swept up into the planning process for the Reveal. Following are just a few of the duties that our Ultrasound Techs have been asked to perform.
1. Call the Bakery and note boy or girl for the couple so that a cake can be baked with either a blue or pink interior frosting, revealed when the cake is cut.
2. Stuff the appropriate color golf balls into a box so that when the balls are hit they emit either a blue or pink cloud of dust.
3. Stuff a pinata with either blue or pink candy.
4. Write the sex of the baby on a piece of paper and fold in such a way that prying eyes can’t deduce the writing. That paper is then given to a favored family member to see, while everyone else stays in the dark until the day of arrival.

Studies have shown that parents bond better with their newborn when they are aware of the sex of the baby prior to delivery. It would also make sense that they would have a name for the baby at delivery, but this seldom seems to be the case. With the current generation of parents, planning how events will unfold during the delivery as well as in the first days post-partum is a priority so it only follows that knowing the sex of the baby would be part of the plan. It is only when they have parented for a few weeks or months, that they come to realize that this wonderful journey is full of detours and bends in the road and not a straight path.

Here’s hoping that I will get the sex correct the next time I am under pressure to perform. I have the You Tube video bookmarked for quick reference.

Who is responsible for the Health Care Mess?

CRO_health_affordableCareAct_05-14[1]I as a physician am. You are. The President and Congress are. Pharmaceutical companies are. Or, as President Trump was heard to say, “Health Care is a lot more complicated than I thought”. As someone who has been in the midst of health care for 30+ years and who has also seen better health care for fewer dollars in other parts of the world, I would like to share my thoughts as to how we can talk common sense and come up with a better solution than either ObamaCare or TrumpCare.

We first have to discuss whether health care is a human right or a privilege. As the richest country in the world and one with the largest economy, I would argue from a moral standpoint that access to basic health care is a right. Luke 12:48 was quoted to me by a judge when our family appeared in court to formally adopt our Korean daughter. “From everyone who has been given much, much will be demanded; and from the one who has been entrusted with much, much more will be asked.” The judge understood that our family was blessed with talents, wealth and knowledge and asked that we use these instruments in the community for a greater good. The same should be held true for America – we benefit from living in a country with numerous natural resources, a democratic government and public school system. Using great minds in our country, we should be able to implement a basic health care system that is available to all of our citizens. If we have a finite amount of money to spend in the budget, where should health care fall in the priority list? Currently 55% of the US budget is spent on the military and only 6% on healthcare for all US citizens. Are we ok with spending money to defend our country beyond US soil while back home our own citizens die or become sick due to preventable illness?

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Now that you are well into the quagmire of the ethics of Health Care, lets turn to the players in the system. The current system of paying hospitals and physicians is backwards. Spending my time in the office doing procedures is much more lucrative than counseling patients on improved lifestyle and performing preventative care. I can deliver a baby by cesarean in 30 minutes during daylight hours and be paid almost twice as much as compared to managing a women in labor for 24 hours, spending all night in the hospital and getting up for a 4 am vaginal delivery. Treating a woman with heavy menses with either birth control pills or a Mirena IUD only generates an office visit charge vs. performing a hysterectomy that takes an hour and increases my payment 10x.   The ACA made an attempt to fix this by implementing quality care standards (such as lowering the cesarean rate) that if met, increased your paycheck from the government. Unfortunately, the cost of implementing and reporting those standards was often more costly than the payback. Physicians are human just like every other American – some of us will strive to provide the most cost-effective care for our patients while others will look out for only their bottom line.

US senators are currently tying themselves in knots trying to come up with a Health Care plan that satisfies both conservatives (any government health care is too much) vs. moderates (expand benefits to the needs of their specific state). I find it ironic that conservative states such as Ohio and West Virginia want more federal money for the  opioid epidemic that has devastated their health care budget but yet these are some of the same states where the citizens and government officials are working to defund  Planned Parenthood. Having seen the astronomical costs both emotionally and economically when babies are born to drug addicted mothers, common sense would be to provide free or reduced cost birth control in those impoverished areas where opioid addition has taken hold. Each government representative is doing what is best for their state and citizens and not one of them has been willing to stand up and declare what is best for the country as a whole. If they really cared about America they would put aside political divides and approach this as adults, not toddlers trying to protect their pile of toys. Our President, as a former Democrat and now a Republican, should be working to bring these opposing sides together and Make American Great by being the champion of a health care policy for all Americans.

The price of prescription medications in this country are higher than anywhere in the world. And yet the pharmaceutical companies that develop and manufacture these same drugs are based in the US and use taxpayer dollars to fund the research and development of drugs. Drugs are sold to other developed nations for 30-40% less than what our own citizens are charged. These same countries have a universal health care system that negotiates drug prices with the manufactures, something the US lacks. The US lacks an impartial regulatory board that not only regulates the prices of drugs but also puts restrictions on the use of new and expensive medications. Regulation also needs to be instituted in regards to advertising of drugs, both to patients and to health care providers. When I started in practice 25 years ago, my clinic had a policy that drug reps weren’t allowed into physician offices to meet with us. We were also discouraged from receiving freebies such as dinner. At the time, I thought it was a bit overboard. Now I realize that this practice shaped my ability to fact check dubious claims made by well dressed pharm reps who were treating me to an expensive dinner. How is the average consumer able to decide between a generic inexpensive drug that has no public advertising and a drug that appears in a full-page color spread and is purported to drastically alter their life for the better?

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And finally the American people are to blame for the health care mess. We want to have our pick of the candy store (health care) without regard to price or outcome and we don’t want to be held accountable for our personal decisions that drive up the cost of the candy store. 35% of Americans are overweight and 10% are morbidly obese, contributing to the skyrocketing incidence of hypertension, diabetes, joint and low back pain, heart disease, sleep apnea and endometrial cancer. But we continue to sit on the couch and eat unhealthy diets, all while complaining about the price of medications to control our illnesses. I discussed this very subject with a mid 50 woman this week. She smokes 1/2 a pack of cigarettes a day and is taking 4 medications related to the health effects of her smoking. We discussed  priorities regarding her health and how she spends her money in addition to options to improve her overall health. She has knee pain and doesn’t feel that she can walk or exercise. She is worried about the health effects of pesticides on food, so limits herself to one fruit or vegetable a day. The perceived level of stress in her life limits her ability to quit smoking. She enjoys the sun so spends summer weekends laying outside and visits tanning booths in the winter. After twenty minutes of this, I gave up trying to motivate her. And I was paid the same amount for a preventative care visit whether I had started this discussion or not.

Yes, it is much more complicated than anyone imagined. But not impossible. We don’t need to recreate the wheel, as many first world countries, such as Australia and Canada, have health care systems that not only work but also cost much less and have better outcomes. I think whether you call yourself conservative or liberal, we can agree that a health care system that costs less with better outcomes is a winner for all Americans.

 

 

 

 

#Menstravaganza

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For those of you who have been following this blog over the past few years, you know that I am passionate about all things related to women’s health care. Considering that my job as an Ob/Gyn physician is intimately interwoven with this topic, it is only to be expected that my children are exposed to my opinions during conversations at home. They also hear about my experiences in Haiti and are often recruited to assist with the construction of reusable menstrual pad kits that are distributed to young Haitian girls to encourage them to remain in school after they start menstruation.

May 28th (5-28) is Menstrual Hygiene Day and is dedicated to creating awareness around an often taboo subject. The 5-28 has significance in that most women bleed for 5 days every 28 days. Although Western civilization has made great strides in the past few decades around menstrual health education, the stigma and embarrassment for young girls persists. My daughters and I were finishing a restaurant meal when we noticed that the girl leaving the table next to us had a large blood stain on the back of her dress. We looked at each other with horror while having a hurried discussion about whether it was less embarrassing to run after her and inform her of the stain vs. letting her find out herself. The decision was made as we heard the door of the restaurant close behind her and our chance was lost. Would we have wasted time in discussion if the bleeding had stained her clothes from a large cut on her leg? The blood is the same but the source so much different.

When my daughter informed me that she was combining both of the above experiences into one argumentative essay for her final AP Composition Essay, I had to smile and then pity the male teacher who was to be subjected to her strident opinions. This same teacher (late 30’s) admitted that he has never purchased feminine hygiene products for his wife and had no advice for sources of information to help support her argument that luxury taxes should be abolished on tampons and pads. Because of the work of humanitarian organizations such as WASH in developing world countries and women’s health advocates in this country, resources for information were plentiful.  I have included the first part of her essay below.

Luxurious Taxes

Toothpaste, sunscreen, chapstick, shampoo, condoms, viagra. All daily items, all exempt from taxes. Daily essential items that are categorized as a necessity and aren’t taxed. Items thought to be a luxury, however are taxed. Flowers, cell phones, nail polish, TVs, computers, and jewelry. They add pleasure to your life. Those items are bought by choice and personal interest. What defines whether an object is declared a necessity or a want? Does the gender of a buyer for an object affect the tax, non-tax ruling? Tampons are taxed, but females need them to tend to their monthly periods. Taxes should be removed on tampons in every state. They are looked upon too lightly and assumed to be more of a extravagance and less of need. They are the “pink tax”.

My mom is an OBGYN and she sees female patients on a daily basis that revolve around period defects. Patients are suffering from heavy streaming periods and other dysfunctions that are uncomforting. They have to change tampons more frequently than an average person. Changing tampons every hour is inconvenient and costly.  My mom works with women to try and assist them in feeling more comfortable with the unnatural feeling periods and other dysfunctions of being female and save them time and money from buying so many tampons. However seeing a doctor about menstrual issues becomes even more costly when trying to fix your awkward period malfunctions. Women are feeling embarrassed and uncomfortable.

Tampons. They are declared a luxurious item in thirty-eight states of the United States. On holidays, taxes are removed on some everyday items, however, tampons and pads are still taxed on those special occasions. Tampons are still looked upon as a non-essential item, as if they are used by choice. As if women choose to go out and buy a $7 box of wonderful cotton plugs. As if women choose to have periods every month for an average of thirty-six years of their life. As if women choose to spend close to $2,000 on such a “luxurious” item as a small cylindrical object made of cotton. As if women are being spoiled with an item to protect their blood from leaking out. What a treat.

Tampons aren’t flowers. People wouldn’t buy a box of tampons for their friend’s birthday. Tampons are a common piece of feminine hygiene that keep blood from spilling out uncontrollably and make periods a little less worse. Periods are a naturally occurring part of a female’s life that they can’t prevent, not to mention the berserk side effects of mood swings, cramps and cravings. Tampons and pads have to be used to prevent blood from pouring out and leaking everywhere, time after time after time.  Every second you feel uncomfortable blood shedding; every minute you’re hesitant of leaking; every hour you’re contemplating if you need to change tampons; every day you’re in fear of the current of your flow; every week you wonder when it will be done. Periods aren’t a choice. Tampons aren’t a choice. They are a need. Tampons are calculated to be needed for 456 periods, 38 years, and 2,280 days (2015, Kane) of a female’s life. Tampons are a female necessity.  

Although her grade for the entire essay was high, the one critique by her teacher is evidence that we still have some work to do in this country when it comes to education around menstrual health. He penned ” too graphic”.

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The work that needs to be done in developing world countries is even greater.  There is a growing awareness that less stigma around menstruation results in better lives for both boys and girls. Girls that stay in school beyond the age of menstruation because they have access to a private bathroom as well as menstrual pads, also have fewer children and are better able to secure a job to support their family because they have obtained a higher level of education. My involvement with the sewing center at Helping Haiti Work has reinforced what I have seen researched. The need for menstrual protection supplies in schools is recognized, but the thirst from teachers and students for education is even greater. Our Haitian seamstresses have been provided with women’s health training and given charts and pelvic models to use in their educational sessions. For $16 a day they will assist in the distribution of the reusable menstrual pad kits and provide 3-4 hours of education to teachers and students.

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My hope is that a future granddaughter will pen a similar essay to the one above for her ancient history class and use our current experiences as the beginning of the end when it concerns the menstruation taboo.

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What Moms really want/need for Mother’s Day

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Dear Baby Daddy,

This letter applies to anyone who has fathered a child, whether they be husband, boyfriend or estranged partner. If you aren’t aware, this Sunday is Mother’s Day. You should be honoring not only the woman who gave you life but also the woman who gave life to your children. And this honor thing should not be for just one day. It should be every day.

Being in the baby business for the past 25 years, I have been present at the start of hundreds of families. This is the moment that parenting starts and some guys do it better than others. Let me give you a few clues as to what is expected of you.

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  1. Remember when this all started 9 months ago? You were there for the blessed event of conception and if you didn’t want to be a father, you should have voiced that opinion with the use of a condom. FYI – they are inexpensive, freely available and can be kept in your wallet for just such an occasion. History tells us about one immaculate conception and your partner hasn’t made history by being the second. This child is your responsibility for the remainder of your life, so stick around. And that means at the birth as well as the birthday parties. Responsibilities come in the form of monetary payments as well as emotional/physical support.
  2. Start practicing your involvement by coming to a few obstetric appointments. Hearing the heartbeat of the baby is a pretty cool trick that we doctors perform each visit. You can ask questions your partner may have forgotten. You CAN’T play video games on your phone during the entire visit – that makes you look like a child rather than a potential father.
  3. Set a good example at home with your diet and exercise habits. Eating a meal of McDonald’s on the couch while watching tv all evening doesn’t help your partner make nutritious food choices that will help her baby grow. Go for a walk and then help to cook a meal. You might even have a conversation about baby names that wouldn’t have happened in front of the tv. And if your partner is trying to give up smoking or drugs for the welfare of your child you are not allowed to offer her a cigarette, smoke in front of her or invite friends over for a night of illegal substance use.
  4. Support your partners decision to breast feed. Her breasts are not your property and will soon belong to your unborn child. Get over it!
  5. Pony up the money for a birthing class. When patients tell me they can’t afford the $80 fee, I wonder how they will afford to care for a child over the next 2 decades. I realize that you don’t need a birthing class in order to have a baby, but it makes the experience much less anxiety producing for both the mom and the doctor. Nobody would consider driving a car before taking driving lessons, but everyone thinks they are an “expert” at the birthing process because they watched someone else give birth.
  6. Your partner is in labor and you are with her at the hospital. These pointers will help you in how you are treated by the nurses and doctors. Your wife is our patient – not you. You will be required to get your own food and drink. If your partner is awake, you should be also. Sleeping on the couch in the room while your partner is trying to birth your child isn’t acceptable. Since the doctor and the nurse have been up all night helping to care for your partner, you have no excuse. And realize there will be a few sleep deprived nights ahead, so this is good practice.
  7. Labor hurts. Let me say this again; Labor hurts. Just because you and your partner decided that a natural childbirth without pain meds was a good idea last month doesn’t mean she can’t change her mind when she realizes that the horror stories she has heard are true and more. It’s her body and her decision – its your job to be supportive of her decision. Would you consider having your appendix removed without anesthesia to make it a more “natural” process? I didn’t think so.
  8. The baby has arrived and you are home. Now the hard work begins. Your partner has just pushed a volleyball out her vagina and she may be a bit sore. She is also experiencing 2 boulders sitting on her chest that leak copious amounts of milk at inopportune times. Your job is to take over the household responsibilities for at least a week. No sports on tv, no guy time, no video game marathons.
  9. For those men who are not living with the mother of their child, don’t feel that the above rules aren’t applicable to you. You are still on the hook for financial support and you should make sure that your visits aren’t disruptive but that you are helpful. Hold your child and become acquainted while mom takes a nap. Purchase a package of diapers as a gift. Offer to wash the dishes in the sink. See #1 – this is your child and your responsibility. Your parents (paternal grandparents of child) also should be holding you responsible. And if you think all this parenting work is too difficult – buy a lifelong supply of condoms.
  10.  You and your partner have made the mutual decision to stop producing more babies. She has birthed a few children as well as managed the birth control options to this point. Now it’s your turn. A vasectomy takes 10 minutes – that is the length of time for 2 contractions in a 12 hour labor – and is much less painful than one contraction. If your partner went thru childbirth without pain meds, you might want to consider a vasectomy without pain meds to make it more “natural”.  And finally, don’t forget the flowers this weekend.

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Fake News in Medicine – or how to get your medical degree from the internet

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A 22 year woman, pregnant for the first time, informed me at her obstetrics appointment this week that she had done “all of her research on the internet” and didn’t want any vaccines for herself or her infant because she is concerned about preservatives. I had a difficult time not asking her what preservative laden food she had eaten the day before. Another patient declined the tetanus/pertussis vaccine that is recommended at 7 months of pregnancy to provide passive immunity against whooping cough to an infant before they become fully vaccinated. This has become recommended due to periodic outbreaks of whooping cough among unvaccinated children. Her reason for declining the vaccine? “My friend told me it is a bad idea”. I spent an extra five minutes explaining why the vaccine is recommended, why contracting whooping cough as a young child can be serious and potentially deadly and that the vaccine has been proven safe in pregnancy. She continued to decline and on her way out the door informed the staff that Dr Jaeger told her that her baby might die.

In the past week in Minnesota there has been an outbreak of measles – 11 children have been affected, 10 of them were not immunized and many required hospitalization. Measles is one of the most contagious of human diseases and it is expected that more cases will be identified. Fortunately, it is very unlikely that any of these cases will be fatal as the children are otherwise healthy and were identified early in the course of the infection. All of these cases occurred in the Somali community, an immigrant population that can be distrustful of western medicine. They are a cohort that is seen as an easy target by the anti-vaccine movement, which spreads its false information via social networks and word of mouth. Studies have documented that Somali parents are more likely to believe that the MMR (measles, mumps, rubella) vaccine causes autism and are more likely to refuse the vaccine than non-Somali parents.

Fake news is defined as false information or propaganda published under the guise of being authentic news. History is replete with medical snake oil remedies to cure disease. But with the widespread acceptance of the internet as a source of information – true or not – the increase in fake medical news has skyrocketed. In an attempt to research what is best for their children, parents can be susceptible to the spread of this false information. Additionally, the anti-vaccine movement is being emboldened by the current Trump administration who has appointed Robert F Kennedy Jr to a task force that purports to investigate the safety of vaccines. Mr Kennedy holds no medical degree, has done no actual research and his intent is to push forward the anti-vaccine agenda with pseudoscience that is difficult for the average American to understand. But when he has the backing of the President of the US, he is given more credibility than he deserves.

Ironically, the anti-vaccine mindset is only possible because medical research and vaccines have almost totally eradicated communicable diseases from the developed world. My patient who declined the pertussis vaccine during pregnancy has never seen a child die of whopping cough, which occurred in 1 out of 5 children in the 1920’s.  As recently as 1980, 2.8 million deaths worldwide were attributed to measles. Global measles deaths have decreased by 79% since widespread immunizations have been implemented. Do we really want to be reminded of what it feels like when you lose a child to a preventable illness?

 

 

The cost of being a woman

 

Two headlines caught my attention this week. One focused on the luxury tax for tampons that is part of the law in 46 of the 50 states. The other headline was buried in all of the news about the Republican sponsored Health Care Act.  Tom Price, head of HHS, would like to see the co-pay for contraception reinstated. As part of the ACA, contraception is free under the majority of health care plans. Both of these costs are charged to women. On a monthly basis this may not seem too costly. But let’s look at the average sum that a woman would need to pay over her lifetime for both tampons and contraception.

Tampons: an average woman uses 30 tampons for each menstruation. A box of 36 tampons costs $7 at Target. That amounts to 360 tampons per year or $70. When multiplied x 35 years that costs a woman $2450.

Contraception: Prior to the ACA, an average co-pay per month for birth control pills was $30. If a woman were to start pills at age 20 and continue to age 45 it would cost $9000 for contraception.  The average family size is 2 children, so you could subtract $1000 for the time it takes to become pregnant and the pregnancy itself. I would argue that there are other costs during that time that offset the $1000 (maternity clothes, nursing bras etc…) but those are probably considered “luxury items” by society standards.

$10,450 is the total cost of tampons and contraception for a woman during her lifetime. But some of our lawmakers want to extend this burden even further, questioning why men should have to help pay for maternity care as part of health insurance. Despite the backing of Ivanka Trump, I doubt that the current legislature will approve any bill that provides for paid maternity leave. Women caregivers are the norm for elderly parents who need assistance and many choose to decrease their paid work commitments to provide this care.

At what point will our society honestly discuss the financial inequalities that exist between men and women?  Male partners should share the finances of contraception – much cheaper than the cost of supporting  a child to age 18.  Women should not be the only members of society that are burdened with the cost of maternity care.  Removing the luxury tax on tampons is a no-brainer as I have never heard any woman describe her period with the work luxury.  And I have heard many words used to describe periods! Paid maternity leave is present in  every  country in the world other than the US and Papua New Guinea. If we want to make this country great, maybe we should start with the women.