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Therapeutic Jurisprudence

Tue, 01 Dec 2020 00:00:00 -0500

After the 1973 decision Roe v. Wade , a crisis of meaning emerged in opinions of the United States Supreme Court dealing with reproduction and sex. The law became less intelligible as questions of truth and justice were understood and resolved from differing perspectives. The recent decision Bostock v. Clayton County typifies this crisis in both its reasoning and its judgment. In Bostock as in other cases since Roe , psychological and psychiatric concepts mingle with legal ones. An examination of the interplay of these elements can illuminate the problem and may suggest ways to move beyond it.

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Surgical Sex

Mon, 01 Nov 2004 00:00:00 -0500

When the practice of sex-change surgery first emerged back in the early 1970s, I would often remind its advocating psychiatrists that with other patients, alcoholics in particular, they would quote the Serenity Prayer, “God, give me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” Where did they get the idea that our sexual identity (“gender” was the term they preferred) as men or women was in the category of things that could be changed?

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The Making of a Killer

Sat, 01 Nov 2003 00:00:00 -0500

Harvard and the Unabomber: The Education of an American Terrorist.
by Alston Chase
W.W. Norton. 432 pp. $26.95

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Handbook of Religion and Health

Thu, 01 Nov 2001 00:00:00 -0500

The tradition of the scientific handbook as a concise, accessible source of validated information emerged in the late nineteenth century when the factual burden of scientific and medical subjects began to overwhelm students. The Handbook of Religion and Health draws on that tradition and raises the presumption that useful information linking religion to health has grown to a degree calling for summation and evaluation.

The book is thorough, encompassing in the term “health” both mental and physical well-being, and in the term “religion” all that can be construed as an aspect of spirituality, both traditional, organized creeds and nontraditional, individualistic practices. It reviews the American periodical literature of the twentieth century for any scientific correlation”either positive or negative”between religion and health.

The book consists of eight parts that cover issues relating health to religion. A section briefly summarizing the history of religion, science, and medicine is followed by one discussing the debate as to religion’s possible effects on health. These sections are then followed by three more that review contemporary research on mental health, physical disorders, and the use of health services in relation to religion. The book closes with three sections on recommendations for practice, future research, and references.

Among the references to contemporary scientific literature the authors note common failures of research design and provide “grades” to direct the interested reader towards published works that provide the best evidence linking health to religion. This book thus offers an up-to-date”through 2000”review of the periodical literature on this topic. The Handbook concludes with a chapter on needs and priorities for further research.

The authors report the consistent but not overpowering evidence that modest health benefits follow from religious commitment. While they are careful in their claims and note the need for more studies to confirm and extend these modest findings, the sheer bulk of the book (712 double-columned pages) leads one to expect somewhat more.

The authors, professors of psychiatry, psychology, and medicine at Duke and Southern Methodist University, readily admit that little rigorous scientific research has been done to demonstrate the effects of religious practice on health. Indeed, most of the beneficial findings they report are anecdotal or serendipitous. But even these discoveries are so modest that they hardly warrant further elaboration in methodical studies.

Above all, the authors wish to refute the suggestion that religious convictions may injure one’s physical or mental health, a claim that has been made since Nietzsche referred to the religious European as “a herd animal . . . sickly and mediocre.” The Handbook documents the views of several celebrated psychologists, including Sigmund Freud, who have seen religion as a kind of mental illness and thus harmful by definition. Most often it has been described as a form of obsessive compulsion or morbid anxiety. Anyone with knowledge of psychiatry and familiar with either obsessive compulsive disorder or morbid anxiety has to marvel at the glibness and lack of intellectual rigor that such claims displayed.

The authors of the Handbook diligently review these reports and rightly conclude that the evidence for the negative claims is scant and that the claims usually reflect the investigators’ preconceptions and closed-mindedness. Actual injuries from religious conviction”aside from the deleterious consequences of avoiding essential medical treatment among followers of Christian Science and similar groups”are extremely rare. These negative claims and isolated reports, like most of the purported positive correlations, have not been demonstrated by hypothesis-generated research but by anecdotes needing more empirical confirmation.

Epidemiological research can easily refute the claim that religion produces ill health, but strong positive evidence is needed to conclude that religious practice directly causes good health. We might all agree that religious beliefs can lead a person to avoid excesses of wine, women, and song, and therefore exposure to many pathogens. But this is far from proving that good health”for example, the correlations reported in the Handbook between tiny reductions of diastolic blood pressure and religious practice”is a direct result of attending Sunday worship.

And yet, the authors are highly ambitious. They are riding a wave of interest in exploring how physical conditions, such as vulnerability to infection and persistence of chronic immunologic illness, may be tied to emotional states and environmental stressors. The disciplines of psycho-neuroendocrinology and psycho-immunology have emerged from those studies. The authors of the Handbook attempt to press this research further, into the domain of religious life and observance. They claim that they have evidence to propose a “new way of practicing medicine that considers the body, mind, and spirit ” (emphasis added). Indeed the book’s Foreword promises a “new paradigm” for which this text will serve as a “definitive sourcebook.” These grand claims and promises are, alas, not met and thus are clearly overstated given that the authors find such meager evidence of health benefits of religion in the more than 1,200 studies and 400 research reviews they examine. Even the most sympathetic reader of this book will be let down in the wake of these introductory claims.

Even more disappointing is the authors’ posture towards religion itself. The Handbook simply does not take into account why people seek out a religion and what kind of effects religions and their advocates hope to promote in human life. After adolescence, when one might pray for clearer skin and curlier hair, most religious people do not expect their lives will be longer or freer of physical vicissitudes because they meditate on the teachings of the prophets or follow the way of the cross. Authentic religious piety rests on an apprehension of life’s meaning and seeks a path to a less selfish, more generative maturity tied to that apprehension. Health, like wealth, may accompany religious devotion, but neither can be its aim. Not to put too fine a point on it: one doesn’t go to church for the same reasons one goes to the gym.

The most disagreeable aspect of the book is its scientism and medical materialism. The authors write in the desiccated tone of the social scientist who divorces his thought from the human encounter with the transcendent”which is, of course, an encoun ter on which their entire project depends. Nowhere in this tome does one find a statement of (let alone any enthusiastic support for) the authentic place of religion in our being”where it fits, what it claims, and what it adds. It is as though the authors believe that religion can best be accommodated within our materialist and consumerist culture by hinting that, like Vitamin C, it may protect us from the common cold.

Paul R. McHugh is Psychiatrist-in-Chief at Johns Hopkins Hospital.

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The Sexual Century

Wed, 01 Nov 2000 00:00:00 -0500

In The Sexual Century , Ethel Spector Person, a New York psychoanalyst associated with Columbia University, presents a collection of her essays on sexual development and pathology written over the last twenty“five years. Here one finds Dr. Person’s reflections on such topics as cross“dressing, transsexualism, homosexuality, sexual fantasies, and the psychological differences between men and women.

Dr. Person employs all the standard, and now scientifically dubious, Freudian explanatory devices in her arguments, including castration anxiety, the oedipal complex, even penis envy. That, along with the typical Olympian style that Freudians are prone to employ even”or especially”when they are saying nothing different from what others have said before them, deprives this book of much sustaining interest. To make sex boring is difficult, but as many others have noted the Freudians, after a century of practice, have mastered the trick.

Two impressions occurred to me in reading these pages that reflect on the evolution and standing of Freudian thought and practice at the turn of the century. The first is that Dr. Person’s study provides further evidence of the retreat of psychoanalysis from its initial and provocative claims to be the “basic science of human nature.” The second is to notice again the remarkable”but all too human”tendency to claim credit but to avoid blame for actions one has championed. Dr. Person claims credit for her discipline in liberating us from repressive sexual moralism, but takes no responsibility for the deadly consequences of sexual “liberation” that we face today.

This book is devoted to the discussion of sex and its deviations and makes no attempt to employ psychoanalytic views to illuminate other aspects of human psychological constitution or social behavior. Freud and his followers made larger claims for their ideas. They asserted that our libidinous attitudes, drives, and conflicts explained everything”our fears and failures, of course, but also our false claims to rationality, especially as related to our creations, life choices, commitments, and character. Based on these opinions Freud saw himself as a new Copernicus and a “conquistador” from psychology. He preened himself as an authority in the humanities as well as in the clinic, a scientist whose understanding of sex, and of our tendencies to deny and repress its power, gave him the key to understanding human nature and made him a bearer of the cold light of fact to an ignorant and myth“ridden civilization.

No one”especially no scientist of mental life”believes that anymore. The power of reason”and how that power can be a force for good even as it can be disrupted by disease or deflected by conflicts”is evident to all. Our sexual natures are a part of us, but far from the fundamental part. We are both freer and more complex than classical psychoanalysis ever acknowledged.

Not even in the domain of therapy do psychoanalysts reign unchallenged any longer. Cognitive/be havioral therapy, specialty group therapies, behavior treatments, and psychopharmacology all have evidence“based authority in the treatments of anxiety, depression, alcohol/drug addiction, and psycho social demoralization.

The turn of a psychoanalyst such as Dr. Person towards the rare and esoteric sexual disorders is not an advance into new territory but a surrender of the main concerns of psychiatry to other investigators and clinicians. But even in this clinical cul“de“sac Dr. Person’s conceptual energy is as depleted as her ideas are shopworn.

This is especially disappointing if one seeks answers to practical questions that Dr. Person’s long experience in the sex clinics might deliver. For example, even though their numbers are vanishingly few, a close study of patients with sex“change operations might demonstrate what outcomes constitute a success or failure of this life“threatening operation. Such knowledge would help us decide about its application and utility. Yet Dr. Person apparently does not see this issue as interesting. She describes her experience with these patients by telling psychoanalytically inspired stories about them. But her final opinion”anticipated by any reader accustomed to the fixed rails of Freudian thought”seems at once trivial and untrue: if a patient has long believed that his gender of rearing was in error and really wants this surgical operation, he and/or she best have it. Dr. Person’s distinctions between sex and gender”the one given by nature, the other constructed by culture”are straightforward. But they are the very ideas that lead most of us to recognize that surgical sex“change is nonsense, resting as it does on the preposterous assumption that one’s biologic constitution is as much a malleable artifact as one’s dress.

In three chapters on the correlation between sexual fantasies and sexual experiences, Dr. Person makes her only attempt at an evidence“based opinion. She demonstrates”from questionnaires given to college students”that fantasies and experiences are highly correlated, and concludes from this that the experiences provoke the fantasies. But of course a correlation between observations does not demonstrate causality; the more likely explanation for Dr. Person’s correlative data is that heightened sexual fantasies stimulate the search for sexual experiences. Yet she does not even discuss this possibility.

As one who has watched psychoanalysis evolve in America over the last half of the twentieth century, I find this book a paltry end“product”stuck on sex and making crude errors over cause and correlation. Yet I find it hard to feel pity for Dr. Person: if she is surrendering the broad claims of psychoanalysis and turning essentially to sexology, then she has something else to answer for.

Dr. Person is not alone in claiming that Freudian psychoanalysis was a major force influencing sexual thought and practice in the twentieth century. But the title of her book, The Sexual Century , suggests that Dr. Person believes this influence to be wholly beneficial. She writes, “Sexual liberation has . . . transformed the way [we] regard our bodies and live our sexual lives . . . . These changes in attitudes and behaviors are . . . the product of the ideology of self“fulfillment coupled with medical advances that have made sex safer, less likely to have unwanted consequences.” Even a casual reading of this statement provokes one to wonder how Dr. Person, given that she labors daily in a great American hospital, can ignore the awful results of the liberation she celebrates.

I work in such a place and see it awash with the detritus of sexual liberation. I oversee the treatment of hundreds of patients afflicted with sexually transmitted diseases”many wondering who betrayed them. The HIV virus is a diabolic life form. In the 1970s, when Dr. Person began her writings, no one could have predicted”or even imagined”the bio“characteristics that make it so lethal. But no longer can one offer the excuse of ignorance. The liberationist doctrine certainly helped”along with such other changes in our world as consumerism and ready contraception”to develop the hosts and environments within which the HIV virus flourishes.

The brightest and wealthiest of my HIV“afflicted patients can hold out against its ravages by means of the most complicated of medical/pharmacologic regimens. But most poor patients with HIV are unable to afford or sustain these treatments, and we watch their progressive decline in a fashion one would not wish on anyone”a worsening debilitative weakness, aggressive superimposed infections, dementia, apathy, and death.

In fact, the treatments we presently have (that carry, one should not fail to mention, their own toxic, potentially lethal, side effects) will sooner or later”mostly sooner”fail in their primary purpose as the virus mutates into a resistant form and erupts with new vengeance. I can present many stories about these patients, their impairments, and their fears for the future. Some of them were at one time counterparts of the fantasizing college students Dr. Person studied. But they are now tragic human beings who occasionally will mention to me how they never expected”or were warned about”the medical risks of their sexual behavior. A peculiar kind of blindness is required to work every day in a large American municipal hospital and still laud sexual liberation.

Psychoanalysis was one of the Big Ideas of the twentieth century. This book shows that it may soon join the other leading creeds from that loveless century, Marxism and Eugenics, in the sizable dustbin of history reserved for the doctrines of that time.

Paul R. McHugh, M.D., is the Henry Phipps Professor of Psychiatry and Director and Psychiatrist“in“Chief at the Johns Hopkins Medical Institutions in Baltimore, Maryland.

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Not So Gay Blades

Tue, 01 Feb 2000 00:00:00 -0500

The Age of the Bachelor: Creating an American Subculture
by howard p. chudacoff
princeton university press, 341 pages, $29.95

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