- Email: [email protected]
Reality versus virtual reality: which articles, which data
Editorial
Reality versus virtual reality: which articles, which data Arnold Robbins
Arnold Robbins, MD, FAPA Associate Professor of Clinical Psychiatry, Boston University Medical School, Distinguished Life Fellow of the American Psychiatric Association, Founding Chair of the Massachusetts Medical Society’s Committee on Men’s Health, President of the Massachusetts Chapter of the Men’s Health Network E-mail: [email protected]
Online 3 December 2007
390
We live in a strange age. Despite the unprecedented availability of information at our fingertips, the propensity of human beings to form conclusions based on imagination, ‘mob’ propaganda, and sheer fantasy has distressingly continued unchanged over the centuries [1], reminding us all too vividly of our tribal beginnings and shortcomings. Not infrequently these days, the make-believe ideas we engender are accompanied by ‘data’ and we are all wearied by the recognition that pretty much any position that an individual or group takes can be supported by ‘data’. One of my wise colleagues in psychiatry once put it this way: ‘Data is not evidence. Data is evidence when combined with wisdom, thoughtfulness and common sense’. In the behavioral sciences (itself a misnomer!), this is especially a problem because we lack specific parameters and indicators in the laboratory to judge a phenomenon and must resort to questionnaires, interviews, and nuance, all of which are deeply biased by current social mores and the social setting (set) in which these phenomena take place. So many times we have seen medicine, and especially psychiatry, follow the wrong Gods unquestioningly, leading us into blind alleys from which it takes years to extricate ourselves. All of which provides a particular dilemma for peer reviewers and journal editors. Which articles go beyond simply a point of view, and are substantiated by wisdom and depth, and which are merely an outgrowth of a current social trend? And which articles are motivated by the current social trend to KNOW that men are inherently defective in some manner and the task is simply to delineate that, and that women do not share these defects.
Vol. 4, No. 4, pp. 390–392, December 2007
An article in point that exhibits much of our dilemma is that in this month’s jmhg by Rutz & Rihmer on suicidality in men [2]. The premise is stated as follows: ‘If we look at today’s high male suicide rates as the outmost evident proof for MEN BEING MENTALLY ILL (caps are mine)’ then certain conclusions can be drawn. Sounds good on the surface, until we look a little deeper. The incidence of suicide in men is not easily ascertained and defined, but is generally considered to be in the neighborhood of 17.8 per 100,000 population [3]. The authors use this figure (not 170 deaths per 100,000 or 1700 deaths per 100,000 but 17.8!) to claim that this shows how depressed men as a whole really are, and from that how to help men with their helplessness!! This figure is contrasted with the lower incidence of suicide in women despite there being many times more attempts in women than in men (which the authors assiduously avoid calling ‘risk-taking behavior’ because it does not appear to fit the particular thesis they are advancing). Data on suicidal behavior in men after marital separation from two small western countries are given as examples of the increased vulnerability of all men to stress, rather than raising the question of societal problems and mores within those two countries [2]. Furthermore, the authors, in their zeal to prove their point, ignore completely the fact that, in most Western countries, when a man loses his wife through divorce he also loses his children and his financial integrity due to the draconian policies against fathers practiced by our courts and judges. And so too the authors must know that suicide is frequently not related to depression at all, but is an option for those seeking release from chronic, painful and incurable disease. Sig-
ß 2007 WPMH GmbH. Published by Elsevier Ireland Ltd.
Editorial mund Freud himself is an example. Much is made in the article about men turning to alcohol to deal with depression, and because of their ‘alexithymia’ not experiencing the feeling of depression at all. Those in the substance abuse field know how difficult it is to diagnose substance abuse in women because until recently women were able to keep their substance abuse hidden due to self and societally imposed dictates. It is very likely that substance abuse rates in women are at least the same as those of men, and perhaps greater. And in the US, at least, men turn to self-help groups such as Alcoholics Anonymous in far greater numbers than do women, and turn to these sources for help far earlier in the course of their disease [4]. As for alexithymia, we all know of the great poems and works of fiction written by men describing sorrow in exquisite detail and with great sensitivity. While as far as acting out behaviors are concerned, which the authors feel are frequently favored male choices to deal with stress, how do we comprehend that in the US in 2005 alone 80,000 women were estimated to drink or use drugs during their entire pregnancy, despite knowing of the horrible consequences to their offspring [5]. This figure is almost certainly low due to problems in case finding. And what are we to make of statistics published by the Harvard Medical School in Boston that in the years from 1971 to 2000 the average man increased his daily caloric intake by 168 calories, while the average woman increased hers by a whopping 335 calories a day, this despite obesity being one of the great health risks in the US [6]. Another attribute laid on men by these authors is that of acting out violence in their relationships. In the May 2007 edition of the American Journal of Public Health, Whitaker et al. studied the frequency of violence in intimate partners and concluded: almost 24% of all relationships had some violence and half were reciprocally violent. In nonreciprocally violent relationships, women were the perpetrators in more than 70% of the cases. Reciprocity was associated with more frequent violence among women, but not men [7]. These findings ‘surprised’ Whitaker and his colleagues, allegedly. Regarding hidden depression, Rutz & Rihmer simply conclude that since men suicide successfully more often than do women they must be as depressed, and the differences in incidence are credited to men’s
hidden depression. But they do not even consider that the reported incidence of depression in women may be much lower than the actual prevalence, and that the reality may be that a certain subset of women ask frequently and repeatedly for help, while the majority of others do not, and instead attempt to hide their depression. This is certainly borne out in my own clinical practice where many women appear to suffer for years with depression adamantly refusing help until their husbands threaten to, or actually do, leave them. Nor do the authors discuss the disaster of attention deficit hyperactivity disorder (ADHD) affecting males, which if untreated (and it usually is untreated due to the lack of obtaining medical attention by the parents of these children) is highly associated with affective instability and substance abuse. In the US, child abuse and neglect is epidemic and violence against children is everywhere apparent. Again according to US government statistics, mothers are involved in this violence far more frequently than fathers in the region of 70% to 30%, respectively [8,9]. Does not acting out violence against children count as violence? Rutz & Rihmer also point out the supposed reluctance of men to seek help medically. In the US, the health care system has historically been a maternal and child system, and, more recently, one that is more directed to women and less to children and men (recent statistics reveal that studies of breast cancer in women received from 2–7 times the funding, depending on what is included, than those for prostate cancer, and far less is spent on cancer in children [10]). In 1960, Maternal and Child Health clinics were spread throughout the state of Massachusetts where many psychiatric and medical services were available to women and not a single clinic in the state system was staffed to do outreach or see men (N. Holstein, pers. comm). Frequently access for men is limited by the working hours of physicians (generally 10 to 4), and by the fact that, until very recently, insurance for lower income groups was limited to women with young children, while men were not eligible to have this vital and excellent insurance, called Medicaid. Clinics at the workplace are rare. And women use medical help far earlier in their lives in relation to reproductive issues while men rarely have symptoms of ill health until well into their 40s, if then. Outreach in Public
Vol. 4, No. 4, pp. 390–392, December 2007
391
Editorial Health Clinics for men in the state of Massachusetts, for example, is almost nonexistent, and, as a result, men feel these clinics to be inhospitable and avoid them (N. Holstein, pers. comm.). Women are further brought into contact with the health profession through having to vaccinate their children by law, as well as for receiving prenatal care to protect them and their offspring. Before such laws were enacted mandating these preventative measures there was widespread avoidance on the part of many women of these procedures, thereby creating the need to mandate these measures, with the result of indoctrinating women to preventative health care. No such mandate exists for men, with the sole exception perhaps of the frequent incidence of hypertension in young African–American men, which has caused some public health notice with resultant increased participation [11]. And, finally, to mention Rutz & Rihmer’s poetic claim that we are all in the same boat. Although men and women bear certain similarities, we are certainly not in the same boat. It may very well be the case that men’s lives are more difficult in Western society. Men by necessity work far longer hours in the workplace than do most women, and their work is often more menial and harsh and demanding with no recourse to opt out and rely on social forms of relief. Men have, for years, and until
recently shouldered heavy burdens of sheer survival for themselves and their families and communities. There are many countries in the world where this is still true. And we don’t know much about, and the authors don’t discuss, or even nod to, those broad evolutionary trends in men and women, further shaped by the societies they create, which are very different in the phenotypes for each sex. Our pets do most of the same things that other family members do, but that does not put them in the same boat as we humans because of biosocial systems that determine the final outcomes and mandates of their and our behaviours. Men are not, after all, women, nor women men. It is embarrassing to have to say this at our state of knowledge, but it needs to be said. When we observe our animal friends and neighbors we recognize the deep biosocial differences between the sexes. Only slowly and belatedly is this being done in any reasonable manner with humans. What men appear to need most in today’s life is an end to trashing and bashing, equal justice and rights toward their children, and true attempts at societal and scientific enlightenment into what we are and why we are the way we are. In the meanwhile we must be careful that our researches and opinions reflect reality and not the ‘virtual’ reality so prevalent today.
References [1] Wilson EO. On Human Nature. Cambridge, MA: Harvard University Press; 1988. [2] Rutz W, Rihmer Z. Suicidality in men – practical issues, challenges, solutions. jmhg 2007;4(4):393–401. [3] World Health Organization. Figures and Facts about Suicide. Geneva: WHO; 1999. [4] Grant JE, Potenza MN, editors. Textbook of Men’s Mental Health. Washington, DC: American Psychiatric Association; 2006. [5] U.S. Department of Health and Human Services: Administration for Children & Families. Child Welfare Outcomes, 2001: Annual Report. Safety, Permanency, Wellbeing. Washington, DC: U.S. Government Printing Office. Available at: http://www.acf. hhs.gov/programs/cb/pubs/cwo01/index. htm#toc.
392
[6] Anon. Healthy Eating for a Healthy Heart: A Special Health Report from Harvard Medical Scool. Cambridge, MA: Harvard Medical School, 2007. Available at: http://www. health.harvard.edu/special_health_reports/ healthy-heart-diet.htm. [7] Whitaker DJ, Haileyesus T, Swahn M, Saltzman LS. Differences in frequency of violence and reported injury between relationships with reciprocal and nonreciprocal intimate partner violence. Am J Public Health 2007;97:941–7. [8] U.S. Department of Health and Human Services: Administration for Children & Families. Child Maltreatment 2002. Washington, DC: U.S. Government Printing Office, 2004. Available at: http://www.acf.hhs.gov/programs/ cb/pubs/cm02/index.htm.
Vol. 4, No. 4, pp. 390–392, December 2007
[9] U.S. Department of Health and Human Services: Administration for Children & Families. The Third National Incidence Study of Child Abuse and Neglect (NIS-3). Washington, DC: Child Welfare Information Gateway. Available at: http://www.childwelfare.gov/ systemwide/statistics/nis.cfm#n3. [10] U.S.Department of Health and Human Services. National Cancer Institute 2006 Fact Book. Rockville, MD: US Department of Health and Human Services, National Institutes of Health; Available at: http://obf. cancer.gov/financial/attachments/06Factbk. pdf. [11] Peters RM, Benkert R, Dinardo E, Templin T. Assessing quality of care for African Americans with hypertension. J Healthc Qual 2007;29:10–20.
Reality versus virtual reality: which articles, which data Arnold Robbins
Arnold Robbins, MD, FAPA Associate Professor of Clinical Psychiatry, Boston University Medical School, Distinguished Life Fellow of the American Psychiatric Association, Founding Chair of the Massachusetts Medical Society’s Committee on Men’s Health, President of the Massachusetts Chapter of the Men’s Health Network E-mail: [email protected]
Online 3 December 2007
390
We live in a strange age. Despite the unprecedented availability of information at our fingertips, the propensity of human beings to form conclusions based on imagination, ‘mob’ propaganda, and sheer fantasy has distressingly continued unchanged over the centuries [1], reminding us all too vividly of our tribal beginnings and shortcomings. Not infrequently these days, the make-believe ideas we engender are accompanied by ‘data’ and we are all wearied by the recognition that pretty much any position that an individual or group takes can be supported by ‘data’. One of my wise colleagues in psychiatry once put it this way: ‘Data is not evidence. Data is evidence when combined with wisdom, thoughtfulness and common sense’. In the behavioral sciences (itself a misnomer!), this is especially a problem because we lack specific parameters and indicators in the laboratory to judge a phenomenon and must resort to questionnaires, interviews, and nuance, all of which are deeply biased by current social mores and the social setting (set) in which these phenomena take place. So many times we have seen medicine, and especially psychiatry, follow the wrong Gods unquestioningly, leading us into blind alleys from which it takes years to extricate ourselves. All of which provides a particular dilemma for peer reviewers and journal editors. Which articles go beyond simply a point of view, and are substantiated by wisdom and depth, and which are merely an outgrowth of a current social trend? And which articles are motivated by the current social trend to KNOW that men are inherently defective in some manner and the task is simply to delineate that, and that women do not share these defects.
Vol. 4, No. 4, pp. 390–392, December 2007
An article in point that exhibits much of our dilemma is that in this month’s jmhg by Rutz & Rihmer on suicidality in men [2]. The premise is stated as follows: ‘If we look at today’s high male suicide rates as the outmost evident proof for MEN BEING MENTALLY ILL (caps are mine)’ then certain conclusions can be drawn. Sounds good on the surface, until we look a little deeper. The incidence of suicide in men is not easily ascertained and defined, but is generally considered to be in the neighborhood of 17.8 per 100,000 population [3]. The authors use this figure (not 170 deaths per 100,000 or 1700 deaths per 100,000 but 17.8!) to claim that this shows how depressed men as a whole really are, and from that how to help men with their helplessness!! This figure is contrasted with the lower incidence of suicide in women despite there being many times more attempts in women than in men (which the authors assiduously avoid calling ‘risk-taking behavior’ because it does not appear to fit the particular thesis they are advancing). Data on suicidal behavior in men after marital separation from two small western countries are given as examples of the increased vulnerability of all men to stress, rather than raising the question of societal problems and mores within those two countries [2]. Furthermore, the authors, in their zeal to prove their point, ignore completely the fact that, in most Western countries, when a man loses his wife through divorce he also loses his children and his financial integrity due to the draconian policies against fathers practiced by our courts and judges. And so too the authors must know that suicide is frequently not related to depression at all, but is an option for those seeking release from chronic, painful and incurable disease. Sig-
ß 2007 WPMH GmbH. Published by Elsevier Ireland Ltd.
Editorial mund Freud himself is an example. Much is made in the article about men turning to alcohol to deal with depression, and because of their ‘alexithymia’ not experiencing the feeling of depression at all. Those in the substance abuse field know how difficult it is to diagnose substance abuse in women because until recently women were able to keep their substance abuse hidden due to self and societally imposed dictates. It is very likely that substance abuse rates in women are at least the same as those of men, and perhaps greater. And in the US, at least, men turn to self-help groups such as Alcoholics Anonymous in far greater numbers than do women, and turn to these sources for help far earlier in the course of their disease [4]. As for alexithymia, we all know of the great poems and works of fiction written by men describing sorrow in exquisite detail and with great sensitivity. While as far as acting out behaviors are concerned, which the authors feel are frequently favored male choices to deal with stress, how do we comprehend that in the US in 2005 alone 80,000 women were estimated to drink or use drugs during their entire pregnancy, despite knowing of the horrible consequences to their offspring [5]. This figure is almost certainly low due to problems in case finding. And what are we to make of statistics published by the Harvard Medical School in Boston that in the years from 1971 to 2000 the average man increased his daily caloric intake by 168 calories, while the average woman increased hers by a whopping 335 calories a day, this despite obesity being one of the great health risks in the US [6]. Another attribute laid on men by these authors is that of acting out violence in their relationships. In the May 2007 edition of the American Journal of Public Health, Whitaker et al. studied the frequency of violence in intimate partners and concluded: almost 24% of all relationships had some violence and half were reciprocally violent. In nonreciprocally violent relationships, women were the perpetrators in more than 70% of the cases. Reciprocity was associated with more frequent violence among women, but not men [7]. These findings ‘surprised’ Whitaker and his colleagues, allegedly. Regarding hidden depression, Rutz & Rihmer simply conclude that since men suicide successfully more often than do women they must be as depressed, and the differences in incidence are credited to men’s
hidden depression. But they do not even consider that the reported incidence of depression in women may be much lower than the actual prevalence, and that the reality may be that a certain subset of women ask frequently and repeatedly for help, while the majority of others do not, and instead attempt to hide their depression. This is certainly borne out in my own clinical practice where many women appear to suffer for years with depression adamantly refusing help until their husbands threaten to, or actually do, leave them. Nor do the authors discuss the disaster of attention deficit hyperactivity disorder (ADHD) affecting males, which if untreated (and it usually is untreated due to the lack of obtaining medical attention by the parents of these children) is highly associated with affective instability and substance abuse. In the US, child abuse and neglect is epidemic and violence against children is everywhere apparent. Again according to US government statistics, mothers are involved in this violence far more frequently than fathers in the region of 70% to 30%, respectively [8,9]. Does not acting out violence against children count as violence? Rutz & Rihmer also point out the supposed reluctance of men to seek help medically. In the US, the health care system has historically been a maternal and child system, and, more recently, one that is more directed to women and less to children and men (recent statistics reveal that studies of breast cancer in women received from 2–7 times the funding, depending on what is included, than those for prostate cancer, and far less is spent on cancer in children [10]). In 1960, Maternal and Child Health clinics were spread throughout the state of Massachusetts where many psychiatric and medical services were available to women and not a single clinic in the state system was staffed to do outreach or see men (N. Holstein, pers. comm). Frequently access for men is limited by the working hours of physicians (generally 10 to 4), and by the fact that, until very recently, insurance for lower income groups was limited to women with young children, while men were not eligible to have this vital and excellent insurance, called Medicaid. Clinics at the workplace are rare. And women use medical help far earlier in their lives in relation to reproductive issues while men rarely have symptoms of ill health until well into their 40s, if then. Outreach in Public
Vol. 4, No. 4, pp. 390–392, December 2007
391
Editorial Health Clinics for men in the state of Massachusetts, for example, is almost nonexistent, and, as a result, men feel these clinics to be inhospitable and avoid them (N. Holstein, pers. comm.). Women are further brought into contact with the health profession through having to vaccinate their children by law, as well as for receiving prenatal care to protect them and their offspring. Before such laws were enacted mandating these preventative measures there was widespread avoidance on the part of many women of these procedures, thereby creating the need to mandate these measures, with the result of indoctrinating women to preventative health care. No such mandate exists for men, with the sole exception perhaps of the frequent incidence of hypertension in young African–American men, which has caused some public health notice with resultant increased participation [11]. And, finally, to mention Rutz & Rihmer’s poetic claim that we are all in the same boat. Although men and women bear certain similarities, we are certainly not in the same boat. It may very well be the case that men’s lives are more difficult in Western society. Men by necessity work far longer hours in the workplace than do most women, and their work is often more menial and harsh and demanding with no recourse to opt out and rely on social forms of relief. Men have, for years, and until
recently shouldered heavy burdens of sheer survival for themselves and their families and communities. There are many countries in the world where this is still true. And we don’t know much about, and the authors don’t discuss, or even nod to, those broad evolutionary trends in men and women, further shaped by the societies they create, which are very different in the phenotypes for each sex. Our pets do most of the same things that other family members do, but that does not put them in the same boat as we humans because of biosocial systems that determine the final outcomes and mandates of their and our behaviours. Men are not, after all, women, nor women men. It is embarrassing to have to say this at our state of knowledge, but it needs to be said. When we observe our animal friends and neighbors we recognize the deep biosocial differences between the sexes. Only slowly and belatedly is this being done in any reasonable manner with humans. What men appear to need most in today’s life is an end to trashing and bashing, equal justice and rights toward their children, and true attempts at societal and scientific enlightenment into what we are and why we are the way we are. In the meanwhile we must be careful that our researches and opinions reflect reality and not the ‘virtual’ reality so prevalent today.
References [1] Wilson EO. On Human Nature. Cambridge, MA: Harvard University Press; 1988. [2] Rutz W, Rihmer Z. Suicidality in men – practical issues, challenges, solutions. jmhg 2007;4(4):393–401. [3] World Health Organization. Figures and Facts about Suicide. Geneva: WHO; 1999. [4] Grant JE, Potenza MN, editors. Textbook of Men’s Mental Health. Washington, DC: American Psychiatric Association; 2006. [5] U.S. Department of Health and Human Services: Administration for Children & Families. Child Welfare Outcomes, 2001: Annual Report. Safety, Permanency, Wellbeing. Washington, DC: U.S. Government Printing Office. Available at: http://www.acf. hhs.gov/programs/cb/pubs/cwo01/index. htm#toc.
392
[6] Anon. Healthy Eating for a Healthy Heart: A Special Health Report from Harvard Medical Scool. Cambridge, MA: Harvard Medical School, 2007. Available at: http://www. health.harvard.edu/special_health_reports/ healthy-heart-diet.htm. [7] Whitaker DJ, Haileyesus T, Swahn M, Saltzman LS. Differences in frequency of violence and reported injury between relationships with reciprocal and nonreciprocal intimate partner violence. Am J Public Health 2007;97:941–7. [8] U.S. Department of Health and Human Services: Administration for Children & Families. Child Maltreatment 2002. Washington, DC: U.S. Government Printing Office, 2004. Available at: http://www.acf.hhs.gov/programs/ cb/pubs/cm02/index.htm.
Vol. 4, No. 4, pp. 390–392, December 2007
[9] U.S. Department of Health and Human Services: Administration for Children & Families. The Third National Incidence Study of Child Abuse and Neglect (NIS-3). Washington, DC: Child Welfare Information Gateway. Available at: http://www.childwelfare.gov/ systemwide/statistics/nis.cfm#n3. [10] U.S.Department of Health and Human Services. National Cancer Institute 2006 Fact Book. Rockville, MD: US Department of Health and Human Services, National Institutes of Health; Available at: http://obf. cancer.gov/financial/attachments/06Factbk. pdf. [11] Peters RM, Benkert R, Dinardo E, Templin T. Assessing quality of care for African Americans with hypertension. J Healthc Qual 2007;29:10–20.