The "Hunger Games" Critique, Sequel Edition

It's not just me: about a year and a half ago the Billy Rubin Blog posted a cranky essay complaining that "The Hunger Games", whatever its cinematic merits, should not have been given a PG-13 rating. (We have since seen the movie during a very, very long flight to Mozambique, and our misgivings remain, unaltered.)

Now comes the sequel, "Catching Fire", and we've not much new to say. We do note, however, that ESPN's "Tuesday Morning Quarterback", Mr. Gregg Easterbook, offered up his own two cents in the midst of NFL Week #12 analysis, with which we entirely agree. It even includes a link to a medical journal!

Movie critics are noting the "Hunger Games" flicks soften the violence of the books. Viewers see Jennifer Lawrence launch arrows, but don't see the children-killing-children bloodbath that makes the books so disturbing. Any faithful cinematic rendering of the "Hunger Games" books would be R-rated, if not NC-17. There goes the shopping-mall tween-girl target audience.

Set aside what it says about contemporary culture that a franchise of bestselling books and box-office hits, about a fascist society that graphically slaughters children, is targeted to affluent shopping-mall girls and their moms. Books for the young-adult market have changed from dreamy happiness (the "Chronicles of Narnia") to horrific brutality ("Hunger Games," the "Golden Compass" trilogy, the thousands of interchangeable vampire books) during the very period in which crime and war have declined, living standards have improved, education has increased and lifespans extended. In "Hunger Games" flicks, Katniss is presented as a positive role model for girls, which seems like saying John Brown is a positive role model for boys. But at least, one might suppose, "Catching Fire" is an instance of Hollywood toning down rather than ramping up violence.

That's not the norm for shopping-mall flicks. This new study from the journal Pediatrics finds that depictions of gun violence are now as common in PG-13 movies as in R-rated fare. PG-13 is the shopping-mall audience: tweens and teens are being deluged with ever-more Hollywood depictions of gun use. Hollywood won't show characters smoking, because viewers might imitate that. But glamorous movie stars gunning down the helpless, Hollywood has no problem there.

--Billy

GYN Update: Good Guys (Gals Mostly, Actually) Win!

Comes news from NYT that the American Board of Obstetrics and Gynecology have reversed their proscription against gynecologists who perform anal pap smears and anoscopies on men. We at the Billy Rubin Blog head into Thanksgiving, to say nothing of Hanukkah, yelping a small huzzah of delight.

It's worth noting that I'm not opposed to medical specialty boards taking hard lines against professional behavior for which there is a general consensus that said behavior is out-of-bounds. (More on specific examples another day, but you could make some assumptions about my views from the single word, "Lyme".) The anoscopies in HPV-positive men, however, did not by any reasonable measure constitute such bad behavior. So we salute the board for its reversal: bravo!

--Billy

OB/GYNs, Male Patients, & Anal Cancer

I am a touch wide-eyed at this news report in NYT detailing the hard line that the American Board of Obstetrics and Gynecology has taken with respect to treating men with anal cancer. The skinny: anal cancer is largely mediated by the same virus that causes most cases of cervical cancer (the human papilloma virus, or HPV). Gynecologists have extensive training in evaluating such cancers, and some GYNs have added men at risk for anal cancer to their patient panels by performing routine screening "anoscopies". The overall number of men cared for by such physicians appears to be very low, but these docs were just mandated by the OB/GYN Board, in no uncertain terms, to drop these patients or risk losing their board certifications. That is, putting it mildly, a pretty heavy sanction.

The logic of the Board is straightforward: OB/GYN is a specialty designed to treat women, period. Two Board members are quoted as emphasizing this, as well as noting that the anoscopy procedure is something that other specialists are capable of learning & performing as a matter of routine. (Side note: I have a colleague in my Infectious Disease division who does a lot of these procedures for our patients--a logical choice given our patient population with many HIV-infected gay men. She has no surgical training, so they have a point.) The article also notes that the Board has concerns about the unscrupulousness of certain OB/GYN doctors who have gone into lucrative business ventures treating men, such as prescribing testosterone treatments, burnishing their credentials with their Board certifications. The Board--understandably, from my perspective--wishes to put a stop to that. That said, I don't think the docs involved in male anoscopies are getting rich by enticing men to have a camera placed in their collective tuchus, so that issue doesn't apply here.

Regardless, the heavy handed no-anoscopies-in-men line is harder for me to comprehend, and though it is true that non-GYNs can perform them, the real issue is whether that's best for patients. "People with various types of medical training can learn the procedure," the article notes, "but experts say that gynecologists are the quickest to master it because of their experience in screening women." There's the rub. One of the docs featured in the article, Elizabeth Stier, is the only professional qualified to perform such procedures. And where does she work? Some Podunk hospital? Um, no: she's at Boston Medical Center, one of the two largest hospitals in New England, staffed by hundreds of doctors. So the loss to these male patients, while small in the grand scheme of things, is nonetheless very real.

--Billy