Does it matter if most of us don’t have a separate gender identity?

  • July 13, 2022

I realise that one of my problems in following current debates about same sex spaces, participation in women’s sports and the like is that I don’t know what gender identity means. It is surprisingly hard to get an answer by consulting the sources one might expect to be helpful.

Here for example is the definition of a relevant protected characteristic in the Equality Act 2010 “A person has the protected characteristic of gender reassignment if the person is proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex.” So, if gender reassignment means reassigning the person’s sex then gender and sex mean the same thing, which isn’t how I’d understood it at all.

In an interesting technical paper prepared by statisticians involved with national censuses, the discussion centred on how to keep a long-standing question about sexual identity while allowing people who didn’t like it to opt out and identify instead their gender. At the time of writing ONS was considering a question for the next census, to add to the standard question about sex. In the paper they suggest:

  • What is your sex? Note: a question about gender will follow later if you are aged 16 or over. Male/Female
  • Is your gender the same as the sex you were registered at birth? Yes/No, please write in gender Prefer not to say/
  • Do you consider yourself to be trans? Here trans means your gender is different from the sex you were registered at birth. No/Yes, write in gender/Prefer not to say

This works at a basic level to allow data collection about those who are happy to be described according to their sex at birth and those who aren’t, but it doesn’t help with unpacking current debates about the minority who aren’t, mainly because it allows people to use “gender” to mean whatever they like. However it does signal that sex and gender needn’t mean the same thing.

So…on to two organisations you’d hope had something more substantial to say – The World Health Organisation because of its official status, and the campaigning group Stonewall because if its self-proclaimed status. WHO offers these definitions:

“Gender refers to the characteristics of women, men, girls and boys that are socially constructed.  This includes norms, behaviours and roles associated with being a woman, man, girl or boy, as well as relationships with each other. As a social construct, gender varies from society to society and can change over time.

Gender interacts with but is different from sex, which refers to the different biological and physiological characteristics of females, males and intersex persons, such as chromosomes, hormones and reproductive organs.

Gender and sex are related to but different from gender identity. Gender identity refers to a person’s deeply felt, internal and individual experience of gender, which may or may not correspond to the person’s physiology or designated sex at birth.”

And the glossary offered by the campaigning group Stonewall offers these definitions:

Gender

Often expressed in terms of masculinity and femininity, gender is largely culturally determined and is assumed from the sex assigned at birth.

​Gender identity

A person’s innate sense of their own gender, whether male, female or something else (see non-binary below), which may or may not correspond to the sex assigned at birth.

Both definitions make it clear that sex and gender aren’t the same thing – drawing a fairly conventional distinction between the two. Gender identity is not however awareness of and subscription to one’s gender. The WHO definition implies a psychological characteristic (internal, individual) that is not based just upon reading off one’s social status. The Stonewall definition talks of something innate, implying a built-in feature of mental life and described by the words male/female rather than masculinity/femininity – a nod towards the idea that gender identity might replace sex assigned at birth.

The ”gender” in these definitions of gender identity therefore seems to have a third meaning that is neither a synonym for sex nor a name for a socially constructed role. Something like sex but not defined biologically or gender not defined socially or culturally. Pretty much everything I have looked at online brings me to this position, via circular definitions (your gender identity is how you identify your gender) that use under-specified terms.

I have recently read two books that come to more-or-less the same conclusion – Kathleen Stock’s Material Girls and Helen Joyce’s Trans. I can review them another time but for now I’d simply recommend both – the authors are not disinterested but they are lucid and thoughtful writers and cover a lot of ground in accessible ways. You don’t have to agree with them to be much clearer about what the arguments are.

I was brought up short by one observation in Stock’s book: “It seems clear that, if we want to understand what having a gender identity is like, we shouldn’t ask non-trans people, for many report no particular sense of one.” Frustratingly (and uncharacteristically for Stock) there isn’t a proper reference to support this assertion but it fits my own experience. I’ve got a sex (male) that defines me as a man; I’ve got a gender (conventionally conformist for a white Western European man) that I don’t regard as salient enough to call an identity (my social status is defined by all sorts – social class, education, whiteness, job…) and I can’t think of anything else I could call a gender identity. Stock is dismissive (again uncharacteristically) about this idea that most of the population doesn’t have a gender identity “Maybe, for all we know, there can only ever be misaligned gender identities, relative to sex, and no aligned ones. We shouldn’t let a desire for pleasing symmetry get in the way of actual evidence”.

This strikes me as unsatisfactory. It feels as if it says something about the status of gender identity as an idea if it can’t be defined in a non-circular and specific way. Of course it may be possible to define it better but I can’t find such a definition. And what does it mean about the nature of public debate about these things if it isn’t even acknowledged widely that lots of people have “no clear sense” of a gender identity?

It isn’t obvious that the disputes grounded in (or at least framed by) ideas about gender identity are going to peter out any time soon. Some of the practical decisions (for example about women’s sport) will be made without these ideas ever being adequately formulated. But I do wonder if in the long-run we need to sort them out better, ideally through non-adversarial debate and avoidance of posturing on social media.

ECT in the papers: more melodrama instead of serious reporting about psychiatry

  • July 11, 2022

An article in the Observer 26 June 2022, “Brain damage claims lead to new row over electroshock treatment”, by Science Editor Robin McKie, is typical of its type.

The first version displayed McKie’s dismaying ignorance of the difference between psychology and psychiatry, describing ECT as “one of the most dramatic treatments employed in modern psychology” and suggesting that its greater use in women is likely to indicate a bias on the part of psychologists. Somebody must have pointed out fairly soon after publication that ECT isn’t a treatment employed in modern psychology because it’s a medical treatment administered under the auspices of psychiatrists and isn’t used at all by psychologists. Indeed, psychologists rarely work in the acute inpatient environments where most people with severe or psychotic depression are treated. Certainly the online version was changed within the week.

The article aired Professor John Read’s well-known views on ECT (which he and almost nobody else refers to as electroshock), claiming that the treatment “…is now the focus of a huge row – which erupted last week – …”. I can find no evidence in the professional or mainstream media to support the existence of this “clash”. In fact no evidence of it is provided in the article, which consists only of Read’s views linked to responses from two senior psychiatrists who were presumably invited to comment on them. It just seems to be made up as the excuse for re-hashing an old story.


There is a strong implication that something new has emerged to fuel this so-called row and indeed it is called a “new row” in the article’s headline. I can’t find any evidence that’s true – there is no mention of recent reports about ECT on the home pages of the Royal College of Psychiatrists, the British Psychological Society or the Care Quality Commission. And a search of Google Scholar reveals no new research to back up the claims made by Read. The one relevant link in the article (trailed as a “recent study”) takes us to a 5 year-old piece in the Guardian highlighting the observation that more women than men are given the treatment.

“We know it causes brain damage” says Read despite there being no consensus that’s true, going on to make the bizarre claim that psychiatrists use ECT because they don’t know the difference between psychotic depression and loneliness or bereavement.

McKie seems not to have got around to asking Read a rather obvious question. If we are going to ban ECT completely then what are we going to do instead? Awaiting spontaneous improvement won’t do for somebody who isn’t eating or drinking; psychological therapy isn’t an option for somebody who can’t sustain a conversation; medication can help with delusions and hallucinations but it is not always effective.  I’m guessing he has no idea what sort of depression is actually treated with ECT and didn’t try to find out. Why bother if you can write an article based entirely on recycling what other people say?

The only thing missing was a picture of Jack Nicholson in One Flew Over the Cuckoo’s Nest.

Discussions about the treatment of severe mental illness deserve better journalism than this.

Conversion therapy – there’s still a need for better evidence.

  • May 16, 2022

A notable feature of the debate about conversion therapy is the degree to which it borrows from, implicitly or explicitly, the language of evidence-based practice. There are other criteria of course: the value-based judgement that all attempts to change sexual orientation or gender identity are wrong, or the pragmatic argument about unintended consequences that might come from poorly drafted legislation. Nonetheless it remains reasonable to ask how good the research evidence is, evaluated independently of these other arguments, in providing grounds for proposed legislation to make it illegal.

An immediate problem is posed by the broadness of the definition usually employed. For example recent government documents describe conversion therapy as…“techniques intended to change someone’s sexual orientation or gender identity. These techniques can take many forms and commonly range from pseudo-psychological treatments to spiritual counselling”. What this means is that the form, content or style of any intervention being evaluated is often unclear, or that widely differing interventions are conflated in a single intervention category.

Another barrier to interpreting research findings is the lack of attention given by many commentaries to the question of consent. For example the nature of consent is not reported in the UK survey of experience conversion therapy: the results show that more people were offered than received therapy, but not how many had consented to or even actively requested it. In a US study of the experiences of men who have sex with men, 40% of respondents who had experienced therapy said the decision to initiate therapy had been “mostly” or “completely” theirs. One might expect that unwanted or coerced intervention would be more likely to have negative outcomes, but the necessary analyses don’t seem to have been undertaken.

Apart from this (rather obvious) observation that coerced intervention may be the more harmful, there is another complication that arises. People who request therapy may be seeking help with a range of relationship problems that are conflated with their sexual orientation or gender identity, making it difficult to tease out the effect of the “conversion” element. The recent publication of Patricia Highsmith’s journals and diaries provides an example if a rather atypical one.

Reported outcomes typically describe one of two domains: change in sexual orientation or gender identity rarely occurs; negative effects for example on mood and sense of self-worth are commoner than in those who have not received therapy. The evidence is by no means clear that such negative effects are universal and by comparison, benefits have been rarely sought or reported.

One exception is a study of LGBQ individuals affiliated with the Church of Jesus Christ of Latter-day Saints, 720 of whom provided unstructured comments on their experiences in addition to completing structured assessments. The authors note, of these comments “Many found therapy to be a helpful, even life-saving experience. To be able to talk to a knowledgeable professional about a very private concern was salutary. Others reported improved relationships with family or other close associates. Of particular interest was the large number of individuals who reported decreased levels of depression and anxiety and improved feelings of self-worth…For some participants, psychotherapy was clearly unrewarding. As a general rule, however, experiences of harm or iatrogenic distress were much less frequent than reports of benefit.”

Qualitative studies suggest that benefit accrues from aspects of therapy such as discussions about the meaning of the immutable nature of sexual orientation or gender identity or about how to manage any resultant dissonance that arises in the family or religious groups. One interpretation of how attempts at conversion might contribute is that they can act as a sort of behavioural experiment the results of which will depend upon how they are handled. Sensitive discussion can help, while insensitive, coercive or rejecting responses will not. For example, one study of people who had experience of conversion therapy found that those who had subsequently left the religious community for whatever reason were more negative about the effects of therapy than those who had not. One consequence of the definitional problem (see above) is how difficult it is to find much in the research literature that notes whether conversion therapy came with a certain package of other responses or not.

One piece of evidence I have been unable to dig up is what happens next in countries where legislation has already been passed. Has it led to prosecutions? What is the effect on religious communities? In most of the relevant states evangelical Christian groups predominate and it is hard to find anything about other religions. What happens in the madrasa or orthodox Jewish groups? I think we simply don’t know.

In summary – nobody surely would disagree that imposed or coercive attempts to change somebody’s sexual orientation or gender identity are abusive and should not be allowed. However, the proposed UK legislation initially promised to impose a blanket ban on any form of conversion therapy. Even consented or requested therapy, competently delivered as part of a wider discussion of the issues, would be criminalised.

This takes us away from a popular caricature of conversion to a more complicated picture of a type of talking therapy that might be actively sought, with more mixed motivations and with attempts to use effects of the process as the basis for wider exploration. Should that really be criminalised?  Such an approach might be argued about on the basis of values rather than evidence, but it is difficult to read the research literature and find unequivocal justification for it.

As things stand, the government has backed off (again) and now says it will not legislate on consented therapy involving adults. It is difficult to believe, of this government, that the decision is one of principle – more likely a response to legal advice about difficulties of drafting the law. Only time will tell what the eventual bill contains. Meanwhile some careful planning of prospective research would be a good idea.

  • Steven Meanley, PhD, MPH, Sabina A Haberlen, PhD, Chukwuemeka N Okafor, PhD, MPH, Andre Brown, PhD, MPH, Mark Brennan-Ing, PhD, Deanna Ware, MPH, James E Egan, PhD, MPH, Linda A Teplin, PhD, Robert K Bolan, MD, Mackey R Friedman, PhD, MPH, Michael W Plankey, PhD, Lifetime Exposure to Conversion Therapy and Psychosocial Health Among Midlife and Older Adult Men Who Have Sex With Men, The Gerontologist, Volume 60, Issue 7, October 2020, Pages 1291–1302, https://doi.org/10.1093/geront/gnaa069
  • American Psychological Association, Task Force on Appropriate Therapeutic Responses to Sexual Orientation. (2009). Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Retrieved from http://www. apa.org/pi/lgbc/publications/therapeutic-resp.html 9 May 2022
  • Kate Bradshaw, John P. Dehlin, Katherine A. Crowell, Renee V. Galliher & William S. Bradshaw (2015) Sexual Orientation Change Efforts Through Psychotherapy for LGBQ Individuals Affiliated With the Church of Jesus Christ of Latter-day Saints, Journal of Sex & Marital Therapy, 41:4, 391-412, DOI: 10.1080/0092623X.2014.915907

Putin’s mental state? It’s time we dropped the childish and uninformative mad man view of history

  • March 4, 2022

Former UK foreign secretary David Owen has recently been reported as saying that Putin’s aggressive behaviour on the international stage may be a consequence of taking steroids. The evidence for this assertion is that Vlad’s got fatter in the face in recent times and is being unreasonably aggressive.

Owen has form in the cod diagnosis of politicians – giving us in 2019 the ridiculous condition of Hubris Syndrome – or hubris as we used to call it. My reading of the formulation there (excuse the technical jargon) is that after a few years in power people tend to get up themselves a bit, arrogant and not keen on being contradicted. However, I may be wrong and there’s more to it: a senior neuropsychologist tells us that Hubris Syndrome affects the frontal lobes drenching them in dopamine, and this could be the cause of Putin’s behaviour.

In the same article that reported the Hubris Syndrome idea, a different expert suggests that it’s something to do with the cognitive effects Long Covid. No less absurd as a hypothesis but I suppose it has the advantage of being bang up to date.

If any of this sounds familiar that’s because it is. Not that long ago experts were telling us that President Trump wasn’t just horrible but mentally disordered – most infamously in the multi-contributor volume The Dangerous Case of Donald Trump. And of course the most famous mad man of recent history is Hitler – name-checked 59 times in the Trump book in case we didn’t spot the provenance of the line of thinking. I could keep going but the trail is long – back to Suetonius at least (I’d have to stop there, my ancient history’s a bit thin).

It’s tempting to dismiss all this as ridiculous, which of course it is. It’s raised a momentary laugh when I’ve chatted about it with friends and that’s about what it’s worth. But there are reasons to think we could do with less of it, for the effect it has on the quality of public discourse.

First, pathologizing of political motives as symptoms of mental disorder is really just a variant of psychiatric name-calling, which is a form of insult we could do without. And it infantilizes public discussion about serious matters. Do we really think that the Ukraine invasion is the result of an aggressive impulse by somebody who has temporarily taken leave of his senses? Or that one man can run not just a complex military adventure but a whole country – without the collusion of others in it for the power, money, sex or whatever it is that motivates them?

Malignant despots have something in common, I think, with buffoon politicians like our own prime minister. They are symptoms of the system that allows them to stay where they are, their endurance reflecting not just something about their callous self-interest but also the values of those on whose collusive support they depend.  All of which is kept out of the spotlight by daft pseudo-diagnostic medicalisation, a sort of dark-side version of the Great Man of History story which downplays the systemic and societal and privileges the role of the individual actor.

Picturing Long COVID – time to drop a subtly undermining visual rhetoric.

  • October 13, 2021

Usually I ignore the accompanying pictures when I am reading a newspaper article about health. Just recently however, I have noticed something about the pictures that accompany articles about Long COVID.

Here’s a typical example – a picture of somebody, and it’s nearly always a young woman, reclining on a sofa looking exhausted. Of course we don’t need a photo to help us understand the idea of being exhausted, in the way that we might want an illustration for an article about recent floods or trouble at a street demonstration. So I took to wondering what was going on.

The use of such pictures may represent no more than a desire to break up blocks of text.  But there are a couple of features that drew me to thinking of how similar images have been used to convey something about other conditions.

First, here’s a rather typical image from an article about the 19th Century malady neurasthenia: a woman reclines and does not look, if truth be told, especially discomforted by her experience.

From a different era and with another typical feature (hand on forehead) I didn’t have to look far to find this illustration (left) from an article about premenstrual syndrome.  

And just to counter the idea that these things are entirely gendered here’s a picture (below) with another typical feature – it’s the back of the hand on the forehead – from an article about man flu’.

Perhaps what I’m seeing is no more than a lazy use of stock images but regardless of motive it occurs to me that there’s more to be said. The visual rhetoric hints at connections that the written text may not – between Long COVID and a group of conditions that have over the years shared some degree of being dismissed, of dubious provenance and melodramatic in presentation. And by implication, faintly ridiculous.

I don’t think this representation of illness does any favours to the discussion about the nature of Long COVID – not just to the question of possible underlying pathophysiology but also to the question of whether some cases are psychosomatic (functional) in part or whole.

My solution would be twofold: time to drop the use of the term Long COVID for the trouble it causes by bundling together so many disparate conditions. And when writing about the sequelae of COVID infection it’s time to drop the use of pictures of tired people resting, hand-on-forehead, on the sofa.

Long Covid: the numbers don’t add up, so why do we keep collecting them?

  • October 5, 2021

How common is Long Covid?  Top of the range, with estimates of nearly 40% of people who’ve had Covid still being symptomatic 12 weeks later, come the REACT-2 study and a recently-published analysis from a US database. In the basement come estimates of 0% from a follow up study of children in Melbourne who had recovered from mild or asymptomatic infection, 2.3% at 12 weeks (the Zoe survey), 4% from a study of schoolchildren in Zurich, and 5% for symptoms at 12-16 weeks from a recent ONS survey. And other estimates in between…

Why is there so much variation? There are the usual suspects – results may be influenced by differences in the samples in terms of age, gender, BMI, vaccination status and so on. Many of the symptoms reported are non-specific (such as fatigue, aches and pains, difficulties with concentration) and endorsement is likely to depend upon exactly how they are asked about and whether an attribution to Covid infection is required. Response rates varied greatly – only 13% in a substantial UCL UCL study of young people and 20% in an ONS study of school children. Some attempt to adjust is possible but response bias and confounding can’t be entirely discounted.

Maybe there’s an issue of reporting threshold – the higher estimates coming from counting relatively minor experiences while the lower estimates count only more severe symptoms. Certainly there seems to be an inverse relationship between number of symptoms and prevalence, but severity (intensity, intrusiveness) is harder to gauge from readily available reports. An ONS survey from earlier this year suggested that only about 1 in 10 respondents was limited a lot by their experiences. An intriguing finding from a study of NHS general practice records suggests that GPs are recording very few cases by comparison with those reported from research surveys – in fact about 100th of the numbers, with a quarter of GPs using NHS codes for Long Covid to describe no cases at all in the study period. The headline of the Guardian’s report of the study this article was amended after publication. An earlier version said that GPs in England were “failing to recognise thousands of long Covid cases”. The headline was changed to indicate that the research concluded that “long Covid coding in primary care is low compared with early reports of long Covid prevalence”.” An acknowledgement that at least one possible explanation is that GPs are applying a clinical-severity filter not recognized by researchers.

Another way to ask about the significance of “Long Covid” symptoms is to consider the prevalence of the same sort of symptoms in the general population. For example persistent fatigue is reported by between 10 and 20% of the general population and something like 50% of people with an identified physical disorder. Not many Long Covid studies collect data from comparison groups, but one ONS survey suggested 3.4% of non-Covid respondents had the same symptoms as the Covid+ respondents and the UCL study found a figure of 16%. In both studies the Covid respondents had more symptoms than the non-Covid respondents, but between-study differences raise again the question of why so much variation – no doubt it’s down to sampling, how the questions were asked, and response rates.

So … what is the value, and what is the likely outcome, of collecting not-very-accurate information on underspecified populations of people who have had a Covid infection and who for the most part have non-specific symptoms that are common in the general population? It may be that the result will be a better understanding of the nature of longer-term problems attributable (or attributed) to Covid infection, but it isn’t clear that these surveys are the most efficient way of getting there. And there are potential pitfalls – Long Covid manifestly isn’t a single condition and it is difficult not to see, in the current approach to researching it, the process that Ian Hacking called Making Up People – the bringing into being of a new category of people with what may turn out to be a transient illness (transient as a medical category that is, not for the individual) – in ways that are not beneficial to anybody concerned.

A start would surely be to stop using the term Long Covid. It’s unlikely we’ll convince the media or pressure groups to drop it, but a move in the right direction would be if researchers and clinicians started using more specific terminology to describe exactly what it is they are studying and why.

NICE’s ME/CFS 2021 guideline: a much-needed pause for reflection

  • September 9, 2021

There’s more to the debate than disagreement about research findings: prejudice against psychological diagnoses and treatments is also a factor

NICE’s decision to defer publication of its guidance on ME/CFS is welcome, allowing as it does time for reflection about what is going wrong that prevents consensus on the management of this group of conditions.

Actually, just a read through the draft (consultation) guidance provides some clues. It reads less like a dispassionate review of the evidence and more like a one-sided position statement from the ME Association. There is talk about listening to and believing patients, about energy envelopes, and criticism of trials that use “subjective” outcome measures – like self-reported fatigue and quality of life. What exactly these ideas mean isn’t always made clear. Disbelief isn’t likely to be about somebody being ill (symptomatic with functional impairment) but more about that illness being caused by a yet-to-be-identified physical pathophysiology. The energy envelope is an interesting term that I have not come across in this context (as opposed to engineering or acoustics)  except when used by people who dislike the idea of activity pacing, but its physiological (“objective”) basis is as far as I know undefined. Treatments that “only” change symptoms are described as non-curative but then so are stroke rehabilitation, paracetamol and hip replacement.

What is being played out in these guidelines is a long-standing opposition to (sometimes expressed as hostility, anger or aggression) treatments such as CBT and GET. What is that opposition about? The debate is sometimes framed as being about the status of trials’ evidence but I don’t think that explains the emotional tone. I detect in the background a drive to reject these therapies because they suggest there is a large psychological or motivational element to the illness.

We live in a society in which the idea is not widely accepted that physical illness can have predominantly psychological causes or treatments, and of course the personal experience of physical symptoms is so pressing that psychological ideas can just not seem to work as explanations. Beyond that starting point there is something more going on and I think it is an active prejudice against the idea of psychological (and specifically psychosomatic) diagnosis. There are several reasons for such an aversion. The diagnosis may be misunderstood as meaning that an illness is imagined or even deliberately feigned. No doubt this is also part of the “not believed” complaint. On the other hand it is assumed that if the diagnosis is accurate, the person so diagnosed must be really odd. This idea has its roots, I think, in the history of hysteria and its conflation of the hysterical illness with the hysterical personality. And of course there is a threat inherent in the idea that somebody can be so lacking self-awareness that their body generates an illness in a mysterious way that is outside their control.

Is prejudice too strong a word? I don’t think so: it explains the animus in the reaction to psychological research and practice in the field, which clearly reflects more than disagreement about the interpretation of trial results. And it surfaces even in some of the milder critical responses to NICE’s decision, such as use of the word “relegated” to describe people offered psychological diagnosis or input, with its implications of inferiority and failure.

How can professionals with an interest respond? Of course there is a continuing need to engage with constructive critical appraisal of the research literature, including discussion of the use of so-called PROMs (patient-reported outcome measures) in applied health research. In addition there is a need to explore new ways to discuss attitudes to psychological causes and treatment for functional or psychosomatic illnesses, tackling the idea that these are somehow disreputable or demeaning approaches.

This last question is sensitive because of the anger and resistance it can provoke in some quarters. My own sense is that the result of this sensitivity is some professional foot-shuffling. Too much is made of findings that many functional states are not preceded by severely threatening or traumatic life experiences; psychotherapy is discussed at times as if it is synonymous with CBT which in this context functions largely as an adjunct to rehabilitation rather than as a way of exploring more widely into the psychosocial context of illness development and maintenance; a welcome interest in the physiological mediators of symptom production is unnecessarily and incorrectly accompanied by claims that such research heralds the end of dualism (implication, using a psychological vocabulary is so passé…).

Time will tell, but my own prediction is that for these reasons the impasse will not be resolved merely by a renewed critical appraisal of the literature. Maybe a “form of words” will be found, but a more useful conclusion would be an acceptance that psychological treatments are important because psychological disorders are important – real, potentially serious, treatable and not inferior to physical diseases.

Mental health problems in the COVID-19 pandemic: we need more careful presentation and interpretation of facts and less melodrama.

  • June 24, 2021

Since early on in the COVID pandemic there have been expressions of concern about its impact on mental health and, at least as reported in the mainstream media, those concerns have been couched in frankly melodramatic terms.  In May 2020 the then president of the Royal College of Psychiatrists expressed fears1 that “lockdown is storing up problems which could then lead to a tsunami of referrals.” The (by comparison) rather more muted claim that the pandemic was having a “major impact” on mental health came in the reporting of a questionnaire survey conducted later that summer2. The current president of the Royal College of Psychiatrists, who has echoed his predecessor’s use of the tsunami analogy, attracted headlines towards the end of 2020 by suggesting that the consequences for the nation’s mental health will be the greatest since the second world war3. The doom-laden tone has persisted into this year, with The Prince’s Trust declaring4 that “The pandemic has taken a “devastating toll” on young people’s mental health” and a report from Bradford in West Yorkshire suggesting5 that “The pandemic has had a deep impact on children” who are “a lost tribe in the pandemic”.

There’s a tiresomeness to this sort of coverage, with its implication – familiar to those who regret the stigmatising of mental disorders – that there is something frightening and uncontrollable going on. But melodrama has other more tangible disadvantages.

First is the lost opportunity to conduct, and demonstrate how to conduct, a balanced discussion about the difficulties and uncertainties that attend the interpretation of data. Much of the media coverage consists of anecdotes – the personal interest stories so favoured by journalists – or small-scale interview studies. Data on health service contacts are problematic because of the degree to which disruption caused by the pandemic changes the relation between population prevalence of disorders and attendance rates. So what is, for now, the best evidence probably resides in population surveys.

However, results from self-report symptom questionnaires require more cautious interpretation than they are often given. Self-reported symptoms are mainly markers of distress, and although very high scores can be an indication of mental disorder the likelihood that is so depends upon the context. Two studies that have taken repeat measures suggest that most of the distress created by conditions during lockdown resolves quite quickly 6,7. The major impact headlined in one report2 proved due to a difference between 10% (previously) and 12% (at the time of the survey) in endorsement of a question about thoughts of suicide but did not spell out how often such thoughts are an accompaniment of distress and lead neither to suicide attempts nor to suicide – suicidal thoughts in population surveys are about 1000 times more common than suicides in the same population.

A bias in thinking about attribution arises with this use of language. A few attempts have been made to link Government policy to an increase in mental health problems among the young8, but for the most part no explicit suggestions are made. Instead the resort to analogies with war or natural disaster and talk of unprecedented crisis implicitly leads to foregrounding of the pandemic as the main explanation for mental health problems. To be sure, there are stresses in the current situation but there are also longer-term forces at play9-11. Years of government austerity strategy have done great damage not just to mental health services but to community assets, employment stability and family security – the main resources that constitute resilience for the most vulnerable in society.

Mental health is a vague umbrella term that is used to cover everything from the boredom and frustration that so many of us feel for being unable to see friends or go out socially, to severe mental illness. Not all mental health problems require treatment from the mental health services. Even before the pandemic something like a third of those identified in the Adult Psychiatric Morbidity Survey12 as having depression had not been so diagnosed by a professional. A third of adults referred to the Improving Access to Psychological Therapies (IAPT) service do not attend for the first appointment – voting with their feet 13.

Of course we need better mental health services. We also need to repair the damage done by years of austerity to schools, community resources and the quality of life of the poor and disabled. And the mental health services need to be planning about exactly where their efforts are best placed – blanket statements about mental health do not help with thinking about who needs exactly what sort of assistance, either preventive or therapeutic. These are challenging tasks the public and government support for which isn’t going to be recruited by melodrama rather than reasoned analysis and careful presentation of the facts.

  1. https://www.bbc.co.uk/news/health-52676981 accessed 12 February 2021
  2. https://www.bbc.co.uk/news/health-54616688   accessed 12 February 2021
  3. https://www.theguardian.com/society/2020/dec/27/covid-poses-greatest-threat-to-mental-health-since-second-world-war accessed 12 February 2021
  4. https://www.princes-trust.org.uk/about-the-trust/news-views/tesco-youth-index-2021 Accessed 12 February 2021
  5. https://www.bbc.co.uk/news/health-55864573 Accessed 12 February 2021
  6. Fancourt D, Steptoe A, Bu F. Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England: a longitudinal observational study. The Lancet Psychiatry. 2020 Dec 9.
  7. Shevlin, Mark and Butter, Sarah and McBride, Orla and Murphy, Jamie and Gibson-Miller, Jilly and Hartman, Todd K. and Levita, Liat and Mason, Liam and Martinez, Anton P. and McKay, Ryan and Stocks, Thomas V.A. and Bennett, Kate and Hyland, Philip and Bentall, Richard P., Modelling Changes in Anxiety-Depression and Traumatic Stress During the First Wave of the COVID-19 Pandemic in the UK: Evidence for Population Heterogeneity in Longitudinal Change. Available at SSRN: https://ssrn.com/abstract=3749211 or http://dx.doi.org/10.2139/ssrn.3749211
  8. Townsend, E COVID-19 policies in the UK and consequences for mental health, The Lancet Psychiatry, 2020; 7(2): 1014-1015,
  9. British Medical Association. Cutting away at our children’s futures: austerity and child health. https://www.bma.org.uk/media/2060/cutting-away-at-our-childrens-futures-austerity-child-health-guuk-2016.pdf accessed 12 February 2021
  10. Cummins I. The Impact of Austerity on Mental Health Service Provision: A UK Perspective. Int J Environ Res Public Health. 2018 Jun 1;15(6):1145. doi: 10.3390/ijerph15061145.
  11.  https://blogs.bmj.com/bmj/2020/05/21/young-people-were-reporting-deteriorating-mental-health-even-before-covid-19-struck-we-need-to-take-their-concerns-seriously-going-forward/ accessed 12 February 2021
  12. Adult Psychiatric Morbidity Survey, 2014 https://files.digital.nhs.uk/pdf/t/6/adult_psychiatric_study_ch2_web.pdf accessed 12 February 2021
  13. Improving Access to Psychological Therapies Annual report 2019-20 https://files.digital.nhs.uk/B8/F973E1/psych-ther-2019-20-ann-rep.pdf accessed 12 February 2021

A shorter version if this comment appears in BMJ Opinion

Fake news in academia

  • May 14, 2021

To an impartial reader there was always something odd about Rosenhan’s famous paper “On being sane in insane places”. It didn’t read like a report of high-quality research of the sort you might expect in Science, and the enthusiasm with which it was received (it has been cited >4000 times according to Google Scholar) seemed out of proportion to its form and content as a single author patchily written account of an un-replicated study involving 8 subjects.

Susan Cahalan’s book The Great Pretender goes further along the road of questioning the study, making the case that the whole thing was a fraud. She was unable to find any research records related to the reported results, and when she eventually traced two of the pseudo-patients they confirmed that they had not made the detailed observations reported in the paper and indeed hadn’t been asked to. One of the two was dropped from the final report, perhaps because his experiences were too positive, and yet in the rewritten final paper (now with 8 pseudo-patients) all the other numbers were identical to the earlier draft with 9 pseudo-patients. And most damningly, when the clinical records of Rosenhan’s own admission surfaced they showed that he had lied about what he told the admitting psychiatrist, in fact retailing fairly standard symptoms of schizophrenia.

No doubt the study proved so popular because it suited people to take it at face value. Psychiatry was in a dire state with diagnosis almost meaningless and the abusive nature of inpatient care widely recognized. Calhan quotes Chief Bromden: “It’s the truth even if it didn’t happen”.  Rosenhan had provided a stick with which to beat the system. Calahan reports that even Robert Spitzer knew some of the facts – he had apparently seen the notes of Rosenhan’s admitting psychiatrist but kept quiet because he was keen to force through a more standardised approach to diagnosis. Calahan’s conclusion overall: “The messages were worthy; unfortunately the messenger was not”. Although at the same time as apparently approving of the function of the report in highlighting the need for change in psychiatry, she recognizes the problems with the way the paper was used. It formed part of the rationale for an aggressive deinstitutionalisation which has had catastrophic effects on care of the severely mentally ill in the USA, and it helped feed the growth of the DSM behemoth.

The ambivalence of Calahan’s conclusion is at odds with her book’s unequivocal title, and it started me thinking. If fraudulence and integrity exist in science, how shall we know them? My preliminary take on this is that researchers who misrepresent research fall into four categories, of course with blurry boundaries. It isn’t entirely clear that we know what to do about any of them.

The out-and-our fraudsters. Burt, Wakefield, and now Rosenhan are infamous. They just made stuff up. The list of members of this group is long and will grow. Of course we call out individual studies, but what of the individual academics? Is everything they ever researched to be negated? Lance Armstrong’s Tour de France wins are no longer acknowledged, but every other race he won?

The embellishers.  Perhaps not everything they wrote is made up, but there is no great clarity about which bits were truth and which bits weren’t. To my mind the most under-acknowledged member of this class is Oliver Sacks. He was coy about it, but clear enough: “I mean, perhaps it’s a case that I seized on certain themes, imaginatively intensified, deepened, and generalized them.  But still”.  Or again: “I don’t tell lies, though I may invent the truth”.

And yet Sacks has never, to my knowledge, been called a fraud. Why not? Perhaps because some of the content of his cases would be familiar to many clinicians in the right specialties, and therefore everything he wrote clearly wasn’t made up. Even more so than for the out-and-outers, we can’t be entirely sure how much of the output of people in this group is trustworthy, and therefore what we should do about it.

The spin doctors. Here the behaviour is nothing like making up results; it’s not fraud. Most typically it involves secondary research, reviewing and synthesising the findings of others. This is a difficult skill to get right (see my fourth group) but the efforts of the members in this class are so wilfully wide of the mark, their failure to raise uncertainties or to consider biases so glaring, their findings so predictable from their pre-existing position on the question at hand, that you have to question motives rather than competence. These are academics who should know better. During the pandemic, Heneghan’s approach to COVID transmission is one contemporary example. In my own field I place Kindeman’s outrageous claim that there is no more evidence for the efficacy of ECT than there is for that of homeopathy. Here the answer seems to be attempted rebuttal rather than looking the other way, tempting though that is. Not that it’ll influence the people involved, but perhaps it’ll influence their standing in the academic and wider communities.

The academics who produce flawed evidence is a class that includes pretty much all the rest of us. We try but often get things wrong or present results in a biased way. A personal example. Some years ago, I led a programme part of which involved a case-control study exploring whether life stress might precede the onset of stroke. The answer looked like a tentative Yes and we published in a leading stroke journal. Much later I was approached to consider giving expert evidence in a case involving somebody who had suffered a stroke after a shocking event that was apparently a third party’s fault. My study was being cited. An expert for the defence had produced an eight page critique pointing out the flaws in my study and all I could say to the plaintiff’s team was “fair cop”. The main answer here is rigorous peer review and an academic climate that encourages serious adult debate about uncertainty.

This is a muddy field. Lack of rigour merges into recklessness with the facts and that merges into complete disregard for the facts. There are parallels in the wider public discussion about fake news and online media. A tighter regulatory environment may be one answer but is unlikely to be achievable at scale and with sufficient meticulousness. We need therefore to have a better, that is more critical, approach to engaging with academic and related sources.  Perhaps critical appraisal skills teaching needs to include skills in appraising authors as well as their outputs…

Mental health consequences of the Coronavirus pandemic and its management in the UK: A Hart-sink review

  • April 2, 2021

The coronavirus pandemic has posed some serious challenges for scientists – inherent in the novelty of the infection itself (biology and epidemiology), in the need to explain difficult research to an apprehensive public and in the desire to inform governmental policy without unduly influencing decisions that are in the end political ones. There have been some great successes in rising to the challenge – for example in the development, evaluation and delivery of vaccines supported heavily by NIHR and the NHS and in the fields of infectious disease and genetic epidemiology.

More dismaying has been the way that differences of opinion have been handled. Elements of the press have of course behaved shamefully – what else do we expect – but it has been a real disappointment to see some members of the academic and clinical communities joining in what has been at times more like a childish shouty argument than a serious discussion about a difficult subject.

Against this background, my eye was caught by the release of a document from a group called the Health Advisory and Recovery Team (HART), COVID-19: an overview of the evidence.  The trailers on their website were encouraging-

“HART is a group of highly qualified UK doctors, scientists, economists, psychologists and other academic experts…Our core aim is to find the common ground between the Government and groups that are concerned about COVID-19 restrictions. The ambition is to bring all sides together and to widen the debate in order to formulate an exit strategy that benefits everyone in society…Our research has identified a need for public policy to reflect a broader and more balanced approach across a number of key areas…We must now bridge the gaps in policy areas where there is obvious disagreement. We should try to avoid bias and follow the rapidly emerging evidence to guide us. If we listen and communicate clearly and respectfully with each other we can find the common ground”. 

I restricted my reading to the area I know most about, the consequences of the pandemic and its management for the psychological wellbeing (mental health) of the population. That is to the chapters on COVID policies and harm to children (actually, including young adults), the psychological impact of the Govts communication style and restrictive measures, and the benefits and harms of wearing masks.

On a (very) superficial glance this looks like a scientific review of the evidence; lots of expert-sounding people have authored sections and there are nearly 300 references cited over 55 pages. A more detailed read gives quite a different picture. One notable section (suggesting that wearing a mask is psychologically harmful) isn’t referenced at all.  Newspaper articles are a cited source of evidence and often do no more than recycle anecdotes, and it doesn’t help that there are website links that don’t work.

Where properly conducted research is cited there seems to have been no attempt at systematic identification or reviewing of its findin. Primary research studies are either selectively chosen or selectively reported. Two examples: First, The Prince’s Trust, with a comment on the “devastating impact” of the pandemic, noted that an online survey of theirs found a quarter of young people reporting that they felt unable to cope with what was happening in the pandemic. What was hardly mentioned by the Trust’s press releases (and not at all in the HART report) is that there have been only slight changes in recent years in levels of anxiety (53% in 2018, 55% in 2019, 54% in 2020, 56% in 2021) and depression (38% in 2018 and in 2019, 39% in 2020, 41% in 2021). The same applies to reports of increasing rates of self-harm and thoughts about self-harm: “research shows that suicidal thoughts have increased dramatically” refers to a single study reporting a rise from 8.2% to 9.8%, 12.5% to 14.4% in younger adults.  Bizarrely the original study isn’t referenced, but instead a synopsis of it published in a different journal.

This isn’t to say that reports of not feeling able to cope, or of ending your life, are trivial. But there is considerable uncertainty about their interpretation, which doesn’t get an airing here. For example, it isn’t clear what the link is between mental health and feelings of not being able to cope if the one changes sharply but the other doesn’t. The meaning of “suicidal thoughts” can be difficult to interpret without a lot more detail than a questionnaire can provide, and the link between such thoughts and suicidal acts or suicide itself is not straightforward.  One thing we do know is that a decline in young people’s mental health and increase in self-harm rates is a decade-long phenomenon, associated with social, educational and vocational inequalities and loss of community resources, not something that can be attributed to the pandemic or its management.

The authors describe this report as a rigorously and widely researched document and we have a pretty good idea what rigour in reviewing evidence should look like.  After all, David Sackett and colleagues published Evidence based medicine: what it is and what it isn’t in the BMJ in 1996, the Cochrane Collaboration began its work in 1993, and the Journal of the American Medical Association launched Its series on step-by-step critical appraisal in 1993. Set against such guidance the HART overview doesn’t come anywhere close. The parts I have reviewed are more like personal statements of opinion dressed up as science, with conclusions expressed in over-certain and melodramatic ways – crisis, devastation and catastrophe are part of the vocabulary of journalism, not critical appraisal.

Perhaps all this doesn’t matter too much? The report was written to influence a decision about managing the pandemic in the UK and that decision has now been made.

So as a single incidence it will probably disappear from view, but more generally the bias and tone of pieces like this do need to be challenged. They are bad news for several reasons. Mixing polemics with science just strengthens the arm of critics who want to represent academics as opinion-mongers who dress up their own prejudices in pseudoscience.  It oversimplifies the public policy dilemmas posed by the pandemic, which are more complicated than lockdown-don’t lockdown. But perhaps most importantly it muddies the waters so it is hard to see what the real problems are; anybody sensible thinks that the pandemic is likely to have mental health consequences and we need an adult discussion about what they are and what the inevitable trade-offs are when implementing a response to the risks posed by the virus. At the moment the HART Group really isn’t contributing helpfully to that discussion.

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