Tuesday, April 30, 2013

Space for us all on the Spectrum of Abuse

Britain has been rocked  by waves of lurid sex and abuse scandals over the last year. But at the end of the day, after we've given our pointing fingers a good workout, can we do something constructive--prevent it from happening; minimize damage to victims, perpetrators, and society--help people find peace and forgiveness?

I've been wringing my hands over this blog entry for months. I have something to say, but at the same time feel like I'm not entitled to speak. I can't begin to fathom the soul of a monstrous abuser, and the "victimization" I've experienced is nothing compared to the criminal abuse others have endured.
I think what finally moved me to post this blog entry was a line from a citizen petition from "MoveOn" a grassroots political organization in the USA. The petition, drafted by Trina McDonald, a U.S. Navy veteran and rape survivor, says:
According to estimates from the Department of Defense, 19,000 service men and women are sexually assaulted while serving in the United States military every year. But 86% of them never report their assault—too often because seeking justice threatens their safety, their job security, and their future. 
I would expect that many of the unreported assaults fall short of criminal behaviour. And the formally hierarchical structure of the military may intensify cultural pressures and change the weightings that go into the calculus each perpetrator and victim makes, raising the stakes. But I think the numbers reflect a large unspoken truth about our society: People abuse others and subject themselves to abusive relationships universally, constantly, and largely without consideration, healthy reflection, discussion, support, advice, or knowledge of the experience of others that could help put the experience in perspective and help them manage the consequences. The scandals and criminal cases differ only by degree and notoriety from what most of us experience in our lives. We are all entitled to a view and a voice.

If I had one wish for something to come out of my speaking out, it would be to encourage broad, rational thinking about relationships in general--especially the middle ground that most of us encounter. I have found that putting myself on the spectrum has increased my empathy and helped me set aside knee-jerk emotional responses, and avoid bandwagons -- lynch-mob mentalities, political correctness, sexual politics, guilt-tripping, shaming and blaming others. Surely a more empathetic society, a more measured view will help us prevent abuse and come to terms with it when it happens.

 My Framework: Thinking about the times I felt like I'd been exploited, and thinking about some of the milder examples of abusive behavior in the press recently, I concluded there's a graded spectrum of relationships, from exploitative to loving; from relationships governed by "the way of nature" to those governed by "the way of grace"--with lots of all-too familiar ground--space for all of us--in the middle.

Here's the schematic I came up with:

A Spectrum of Relationships 

The Way of
The Way of Grace--->

--The Illegal/NoZone--
--The Stupid Idiot Zones--
--The Grace Zone--
Victim Vulnerability

One party is a child, handicapped, frail, weak, physically or mentally incapacitated
One party is young, immature or naïve adult(s); low self-esteem; on the rebound
Both adults, high self-respect, capable, strong, confident,
Nature of Relationship

Lopsided power—One person submissive, beholden, psychologically or physically dependent on the other
Shifting or misperceived balance of power

Equal, mature; Both parties fully empowered; free to choose and refuse.
Deceptive—One party withholding or lying to manipulate the other’s choice
Both parties withholding, lying, manipulating the other’s choice
Open, honest. Both parties can make informed choices.
Impersonal—One party sees and uses the other as an object; a means to personal gratification
Both parties using each other
Mature, loving. Seeing, caring for the whole person & their long-term wellbeing
Type of Behavior

Abusive—Physical or psychological violation, harm, pain, humiliation, undermining, scarring, depriving of sustainance
Unknowingly or unintentionally harmful treatment of others; misunderstanding
Healthy—gentle, tender, mutually pleasurable, kind, helpful, affirming, uplifting
Downward spiral—Repetitive, ongoing, escalating harm, “grooming”; multiple victims
Changing circumstances convert healthy behavior into an unhealthy interaction
Growth—both parties learn and develop in positive ways from the relationship

This table is a representation of how I'd sort relationships--which inevitably mix elements from all three columns-- at different times, if not usually. Or maybe in some aspects, over some issues, but not others. It's just my personal framework. And possibly it's projection on my part to imagine it reflects anything beyond my own views and values.

Whatever. Under this scheme, the more elements from the red zone, the less healthy the relationship. I would guess victims of red-zone relationships would be more hurt and struggle more to recover. Perpetrators of predominantly red zone relationships more urgently need to have their behavior reversed. They need re-education, therapy, reform. Those are easy things to say.

Harder is admitting that we all err. We all take actions, ranging from completely unintentional to completely intentional and more or less wisely considered, that actively place us on this spectrum, either as perpetrators or as (potential or actual) victims. I don't say this by way of blaming or shaming. I claim this from my own confession. My underlying belief is that we restore ourselves and our relationships through honest self-examination conducted with deep consideration of others. This, followed by reparation of damage, and forgiveness for ourselves and those who've harmed us return us to the present and a more hopeful future.

  Confessions of a Victim

 The embarrassing personal history that is the foundation of my experience  of abuse in relationships would actually begin with a relationship mostly on the "grace" end of the spectrum.

Mike was 30; I was 15. He was a ex-Army paratrooper back from Vietnam, now driving a schoolbus. I rode that bus, getting on at the first stop in the morning and choosing the warmest seat--behind the driver, who had a heater next to his seat. We chatted every day. He was also friends with other kids, but I was his favorite.

At some point I must have given him my phone number. After school got out in June, the family of one of the other kids on the bus route invited him to house-sit while they were on vacation. He phoned and invited me over. The house-sit was at Thornoaks, within walking distance of our home. I told my Mom I was going. She offered to drive me there.

The last thing I wanted was for her to meet Mike. He was African-American. He was a grown-up. She wouldn't have allowed this unsupervised visit. I can't remember what lies I told her to allow me to walk. Probably that I would be back at a certain time. Or maybe that others would be there. Mom was clearly suspicious.

Kids today are much more mature at age 15 than I was back in 1968. For that matter, other 15-year-olds back in 1968 were more mature than I was. I was nervous going over to Thornoaks. Once there I chatted nervously with Mike. I can't remember if I went inside the house. It was a warm, lovely evening. I told Mike I couldn't stay long. He must have seen I was nervous.

Before I left he gave me a 45-rpm record, autographed by the Four Tops (who were friends of his). He kissed me. He said he'd been wanting to do that for a long time. I remember the softness of his lips. I don't remember feeling aroused--just a bit scared. I thanked him for the 45 and we said goodbye. I scooted home. I don't think I saw him again.

I've wondered about him many times in the years since. It would have been so easy for him to have exploited me. I was young and ignorant of the nuances of sexual expectations. We never spoke of faith or beliefs. But he was a good man. Wherever you are, Mike Patterson, bless you.

Fast forward 15-plus years through boyfriends, engagement, marriage at age 22... In this next scene, I'm in my 30s. There were two incidents, both occurring just as or after I'd left academic institutions. On these two occasions, four years apart, my department superiors expressed inappropriate personal affections, shall we say.

"Do you want to close the door?" one had suggested softly from his desk on my last day at the department. A goodbye chat. A kiss. I was attracted to him. I was thrilled. But we were both married. From the safety of my new home in another state I wrote him a gushy schoolgirlish letter, and that was where it ended. I don't think I saw him or heard from him again.

The next encounter with a department superior was more inappropriate. I had evidently learned nothing from the previous encounter. I was curious.  At least I came to my senses quickly, realizing the turn of events was not good--for either of us. But, like one duped by a conman, I was mortified by my own stupidity. I wanted to appear sophisticated, nonchalant, "adult." I was complicit and remained silent. After all, as foolish as I felt afterwards, I had participated of my own free will. Perhaps if I'd said or done something about what happened, it might have changed both our lives for the better. Might I have chosen relationships more wisely in subsequent years? Would he? As it was, until writing this blog entry, I just regretted our relationship privately and never saw him again.

A year later I would astound myself with even greater stupidity: I allowed myself to be "taken" by a foot fetishist. Going home on the Sheridan bus in Chicago after work, it was just getting dark. As I stepped off the bus, a man called after me, saying he noticed that there was gum on my shoe. He offered to remove it.

It never occurred to me that this could be anything but a kind, if bizarre, offer. He bent down, cupped his hand tenderly under the arch of my right foot and poked at the sole of my slip-off shoe. A few seconds later he declared the problem solved. I thanked him and headed toward home.

That wasn't quite the end of it. When I was a few yards away, he chased after me. He said he hadn't gotten it all. Again he slipped his hand under my foot and fiddled with my shoe. He told me that he worked in the shoe store back at the intersection, and if I ever needed shoes, I should come see him!

When I got back to my apartment, I examined my right shoe under a light. There was absolutely no trace of gum; just a bit of what looked like spit. DOH! How could I have been so stupid?

Priests, Lords, and Bishops

My sordid tales fall somewhere in the idiot zone, not unlike the fumblings described in the Guardian news story of allegations against Cardinal Keith O'Brien. The vitriolic critic of gay marriage has now resigned and apologized for not meeting the standards of behavior expected of Roman Catholic priests. I would also place in this middle zone the "inappropriate sexual advances" that Lord Rennard is accused of having made toward several women.

The Guardian news story on Lord Rennard sets his alleged abuse in the context of similar experiences of "Neanderthal behaviour among prominent parliamentarians" -- including chasing women around the office and invitations to come up to hotel rooms:
Channel 4 News last week quoted a former woman Lib Dem parliamentary candidate as saying that Rennard "shoved his hand down the back of my dress" when she posed with him for a photograph. The woman, who asked to remain anonymous, added: "I felt really humiliated, and very undermined and very shameful." 
The article points out the importance of contacts and party loyalty in politics, saying that political careers may add to women's reluctance to report abusive behavior. Similarly, The Guardian's story of one of the Cardinal O'Brien's accusers reflects the forces of authority and power that place his exploitation in the same realm:
"Priest C" was a young priest the cardinal was counselling over personal problems. Priest C's statement claims that O'Brien used night prayers as an excuse for inappropriate contact.... over a period of time...
O'Brien is, says Priest C, very charismatic, and being sought out by the superior who was supposed to be guiding him was both troubling and flattering. Those involved believe the cardinal abused his position. "You have to understand," explains the ex-priest, "the relationship between a bishop and a priest. At your ordination, you take a vow to be obedient to him. He's more than your boss, more than the CEO of your company. He has immense power over you. He can move you, freeze you out, bring you into the fold … he controls every aspect of your life."
Or consider the Roman Catholic priest in Leeds recently found guilty of  sexual asault for "forcefully kissing" and touching the buttocks of a 17-year old girl in church on Easter. Evidently the priest subsequently turned up at the girl's home and professed his sexual attraction to her. In the course of the trial it emerged that the priest had secretly married some years before. (I wouldn't be surprised if there had been common factors in the formation of their relationship.) The priest's wife had testified that he'd told her about the young woman. The story she heard was quite different than the one the jury believed.

After very serious criminal sexual abuse scandals, like the horrific Rochdale and the Savile cases, the UK is changing police practices. The pendulum is swinging back toward seriously listening to victims with allegations of abuse. The U.K.'s Director of Public Prosecutions, Keir Starmer, said in a speech  that the Savile and Rochdale abuse went unchecked because over-cautious police put "too much focus on the victims' credibility and not enough on the suspects." I'm hopeful this change will encourage victims to come forward so that police can stop perpetrators before they can rack up a record like Saville's.

But I don't think this is sufficient. I think society's response needs to be more sophisticated, nuanced, pro-active, deep, and should approach abuse from all angles. This includes recognizing that not all abuse is the same. On my color chart, there might be intensity points for the various factors (different rows in the chart) adding or subtracting from the seriousness of the offence, for example. Differences in intensity should mean differences in the consequences for victims and perpetrators and the processes involved in coming to terms with what has happened.

In the case of the foot-fetishist, for example,  I, the victim, was not enfeebled by age or physical condition -- only by stupidity. There was no lopsided power relationship or a violation of longstanding trust, but the perpetrator was deceptive and did objectify and use me for his own gratification. The interaction didn't actually harm me and it was not ongoing. I can't say what happened to the perpetrator.  It was what it was. I hope I am a bit wiser for the experience.

When there is actual criminal abuse, well into the red zone in all or most of the columns on my chart, communities need to be sure that victims get the care and support they need to minimize psychological damage and come to terms with the trauma of serious abuse. Research is finding better ways to do this.

Care for Victims: For garden-variety inappropriate behavior, I think something different is needed. The orange-yellow-to-green zones on my chart probably aren't in the realm of police concern. But that doesn't mean we should do nothing. What's helped me minimize ongoing pain from idiot-zone interactions is mindfulness and forgiveness -- of others and myself-- based on acceptance of the fact that every human is prone to do stupid things. What's happened is now beyond our control, but what we make of it isn't. Two good quotes come to mind:
“There is nothing either good or bad, but thinking makes it so.”  ~Shakespeare 
"We cannot choose our external circumstances, but we can always choose how to respond to them" ~ Epictetus
I choose to laugh about being had by a foot-fetishist. Because feet don't figure as private parts for me, there was no psychological damage, beyond the sting of feeling stupid. I forgive myself that and learn from it. And the same for my inappropriate interactions with departmental superiors. As the meme on FaceBook said,
"Maturity is knowing you were an idiot in the past; wisdom is knowing you'll be an idiot in the future; and common sense is knowing you should try not to be one now."
I think for victims, making great fuss about these incidents -- beyond acknowledging their inappropriateness  -- may actually deepen rather than heal wounds. In poring over minute details, reliving the experience, explaining the wrong and hurt, you build a case and magnify and prolong both your pain and the cruelty of your abuser. The incident becomes more conspicuous and shameful, disconnecting you, not reconciling you to your world.

Another Facebook quote:
"When you forgive, you release yourself from a painful burden. Forgiveness doesn't mean what happened was OK, and it doesn't mean that person should still be welcome in your life. It just means you have made peace with the pain, and are ready to let it go."
Reversing the Course of Abusers: I think that the priests who made the allegations against Cardinal O'Brien were right to do so. O'Brien may not have been committing criminal acts, but he was in violation of his vows, and after his outspoken criticism of homosexuality, deserved to be called out for his hypocrisy, if nothing else. Likewise the women who have made allegations against Lord Rennard. Society holds politicians and priests to a high standard of behavior. If the allegations are true, these men took advantage of their positions of power to exploit others, and seemed to be unaware of or indifferent to the harm their behavior was causing. I hope that by exposing the abuse to public condemnation, the victims have stopped the perpetrators' exploitative behavior.

I also hope that bringing abuse to public attention won't be at too great a personal cost to the people making the allegations. They are brave, but I worry that the ordeal of public exposure, church tribunals, court cases -- actually may make it harder for the victims recover inner peace.

I worry most about perpetrators who did exploit others but choose to fight the allegations. Does the battle actually make it more difficult for them to see how they were wrong, then attempt to put things right, and come to terms? I know little about it, but have been impressed by examples of facilitated reconciliation.

Prevention: As parents, teachers, and friends of potential victims and perpetrators -- we need to inoculate against abusing and being abused.  Of course we should teach our kids -- even teenagers -- not to go with strangers. That it's not okay for anyone -- even a priest or a relative -- to expose or ask them to expose areas of the body that should be covered by underwear. And if someone says not to tell, you need to tell.

We need to teach our teenagers that relationships should strive for the grace zone. They should be freely chosen, never compelled by differences in inebriation, age, status, self-respect, or physical strength. In a relationship of equals it's less likely that either person will exploit the other. And relationships should be honest, gentle, ennobling, and all about discovering and loving the whole person--not objectifying and using them for sexual gratification or other selfish personal gain.

The mother of a young son put it this way (in the wake of the convictions of Steubenville, Ohio, athletes for gang-raping a young woman):
"A toddler can learn how to use words of kindness.  It’s never too early to teach empathy, compassion, and awareness. ... Give your sons the tools they need to understand that sexuality is a powerful thing, one that they are solely responsible for.  Give them a framework for understanding that sex carries an enormous responsibility—not just to themselves, but to their partners.  Does your son know what rape is?  Does he know what it means?  Does he know that it’s not just creepy smelly guys who hide in alleys who are responsible for rape?  That it’s his peers?  Discuss the ways that a woman can give consent.  Pull the curtains back on the grey areas, and demand that your son learns how to protect himself and his partner."
[Update addition: A brilliant blog by @Soraya L. Chemaly on teaching pre-schoolers respect for others -- behaviors that will serve them (and the world) well for life: http://www.huffingtonpost.com/soraya-chemaly/the-problem-with-boys-will-be-boys_b_3186555.html Quote from this article:
the world would be a different kind of place if children were taught to respect other children's rights from the start. Rights to be, to do, to look certain ways and not others. And that teaching children these things has profound implications for society. Anyone who has studied or worked in the field of domestic violence can tell you that the "overarching attitudinal characteristic" of abusive men is entitlement and the belief that they have rights without responsibility to or respect for others. Similar attitudes feed our steady stream of sexual assault and rape.
For Christians, Jesus showed us what we should aim for: Love others as he loved Mary Magdalen, the possessed, lepers, the woman taken in adultery, and as he described the love of the good Samaritan. But none of us are Jesus. We are going to fall short of this standard. We will be victimized. We will abuse others. That is where self-examination, regret, repentance, vulnerability, apology, forgiveness, and acceptance come into their own. I see these as the best, most sacred, perhaps only ways to move ourselves and our world into the grace zone.

In the air: So maybe this is what it takes to finally get me to publish. This morning I woke up to a BBC radio report on the increasing use of "community resolutions." Reporter Danny Shaw used a freedom-of-information-act request to find out how many police forces in England and Wales are using the informal procedures to resolve cases--rather than issuing cautions or filing charges. Community resolutions might entail the wrongdoer apologizing or repairing damage for example; cautions and charges result in a criminal record.

Evidently 10,160 uses of community resolutions in 2012 involved acts of violence, contravening guidelines from the Association of Chief Police Officers saying they should be used for less serious infractions, including "minor assaults without injury." The number is a jolting rise over 792 uses of community resolution of violence in 2008. A member of the shadow cabinet (i.e. representative of the opposition party) weighs in with her outrage. The general impression conveyed is that police are using community resolutions because, as budgets are slashed, they save much-needed time, money, personel, and paperwork.

But what really got my attention was stashed at the end of the article:

   Acpo's Assistant Chief Constable Garry Shewan said guidelines were in place to help forces decide where the use of community resolutions might be appropriate.
   "But in every case, this decision will be victim-led and above all reflect their views and wishes," he said.
   "At times it may be necessary, and appropriate, to use such informal resolutions to deal with more serious cases.
   "Going through a restorative justice meeting has also been proven to have more impact on an offender than a prison sentence or a court punishment alone, as they see the consequences of their actions and so want to make changes in their future behaviour."
   The Restorative Justice Council - "the national voice for restorative practice" - said it should be "available for all victims of crime who want it, subject to a risk assessment by a trained restorative justice professional".
   "When offered alongside the right sentence for the offender, restorative justice can meet the needs of victims of the most serious crimes," director Lizzie Nelson said.
I realize I may be bringing apples to bear on the oranges of personal relationships, and I am the first to acknowledge I know very little about criminal justice in my adopted homeland. But isn't it possible that victim-led resolution -- with strong support from professionals who can spot the influences and pressures bearing down on victims -- may be the best way out of the orange-zone and on toward the green?

Friday, April 26, 2013

Good News on Aging

The daily news reports from my body largely get worse over the years. So it was a nice change to get some good news on aging from the medical front recently. This might seem a bit random and different than my usual Equipoise postings. But science writing is what I do for a living, and the challenges of aging are another keen interest of mine.

The good news included an epidemiological study which found that it's not just poor childhood nutrition that determines stature and how much people shrink in height during old age: Healthy lifestyle in later life is associated with retaining height. Another study reported on a technique for correcting near-sightedness without surgery or glasses. Completing the hat-trick was a study describing an effective non-surgical way to shrink enlarged prostates, a common curse of aging in men. [Full Lazy Journalist Disclosure: I am rehashing press releases here and have not spent time dissecting the underlying research papers. I think I've included sufficient details so anyone interested in digging in can do so. Hah! Just followed links to other publications' stories on the first story and it looks like they did the same thing...]

Preserving Stature

I'm not sure at what age one reaches maximum height. But evidently we grow up, then we grow down into old age. Wizened. Probably the best-known reason for loss of height is osteoporosis, or thinning of the bones, a condition that takes a particular toll on women after menopause.

But evidently shrinkage is just a natural body change accompanying old age, along with increasing body fat and decreasing bone density. Other conditions can exacerbate height-loss--arthritis and inflammation of the spine, along with osteoporosis, for example.

At a "Consensus Development Conference" on osteoporosis 20 years ago, leading scientists stressed that an important key to avoiding "dowager's hump," bone-thinning, and resulting fractures in  old age was building up extra-solid bones during one's youth. With hormonal changes accompanying menopause, women lose the ability to take up calcium efficiently from their diet. So getting girls to drink that extra glass of milk was crucial to preparing mineral-dense bones able to withstand some losses as calcium is leached away more quickly than it's replaced.

As it turns out, there's more to it than frequent sporting of a Got Milk? moustache in youth. The good news is that you might have some chance of slowing height loss even though you're of a certain age.

The study uncovering the new information on late-life shrinkage was based on a massive survey, "the China Health and Retirement Longitudinal Study," led by Univ. of Southern California economist John Strauss; Yaohui Zhao of the China Center for Economic Research (CCER) at Peking University; and Gonghuan Yang of the Peking Union Medical College. The ongoing survey is following 17,708 adults from age 45 onwards. As reported in the American Economic Journal Applied Economics, the study tracked height and health, but also cognitive function, memory, geographic history, socioeconomic status, education, and blood tests. They'll be collecting these data every two years.

A press release for the study quotes USC economist Geert Ridder, a co-investigator on the study: "Height has been recognized as an acceptable proxy for childhood health conditions, but there are complications there," Ridder says. "Some of adult health might be determined by childhood circumstances, but people shrink differentially, and that shrinkage is also a measure of adult health conditions."

Some of the factors that affected shrinkage included whether a person lived in an urban or rural area (rural people shrank much more); education and literacy (illiterate and less educated men and women shrank more) and "cognitive health:"
Those who had lost more height were also much more likely to perform poorly on standard tests of cognitive health such as short-term memory, ability to perform basic arithmetic and awareness of the date.
Importantly, the data show correlation, not causation, so the study does not show why declining stature is associated with declining short-term memory, for example. It may be that better-educated urban-dwellers have better health care, are better able to maintain both mental and physical health, and doing so prevents loss of height. Or perhaps factors leading to loss of height, such as arthritis following hard agricultural work may follow from early diversion away from school, the cities, and into the fields.

The study says by the time participants entered the study in their mid-40s, overall average height loss for men was 3.3 cm. For women there had been an "average overall height decrease of 3.8 cm." Completing primary school cut this loss by 27% for men and 16% for women.

The baseline CHARLS data is publicly available to researchers at http://charls.ccer.edu.cn. The research is supported by the U.S. National Institute on Aging, the China Natural Science Foundation, the Fogarty International Center of the U.S. National Institutes of Health and the World Bank.

Braces for Aging Eyes

Before finally dispensing with vanity and getting a pair of glasses, several dear friends went through that phase -- holding their newspaper father and father away. When the print grew too tiny to read at arm's length, old-age-denial gave way to reading glasses, bifocals, or vari-focals.

A news release about research at the University of New South Wales, Sydney, offers hope for my friends in avoiding reading glasses. It says they've found a way to correct age-related decline in near vision, or presbyopia. The method involves wearing a corrective contact lens in one eye while you sleep.

The study, reported in "Optometry and Vision Science" built on earlier studies of the corrective-lens technique, called "hyperopic orthokeratology (OK)." During the night, the OK contact lens gently reshapes the cornea, correcting presbyopia by the time you awaken and remove the lens.

The study included 16 middle-aged participants with presbyopia. They wore the rigid plastic lens in one eye each night for a week. The investigators measured participants' vision and the shape of their corneas each morning and evening during the week. From the first day, the procedure corrected close-vision for all participants -- and their close-vision was even better by the end of the week.

The researchers corrected vision in only one eye so that distance-vision would stay the same. When they checked distance-vision, they found no declines in the untreated eye. The overall result was to give participants good monocular vision for both close and distant vision.

To retain the close-vision correction, it was necessary to continue wearing the corrective lens during sleep. When participants stopped wearing the OK lens at the end of the study, their presbyopia returned within a week as the cornea relaxed back into its natural shape.

A news release on the study quotes Anthony Adams, Editor-in-Chief of Optometry and Vision Science: "This study demonstrates that OK is quite viable as a nonsurgical option for monovision that does not require wearing contact lenses during the day, although it does require 'retainer' orthokeratology contact lenses to be worn overnight." Dr Adams adds, "This possibility will certainly appeal to many people, especially since the changes in the corneal curvature of the treated eye are fully reversible."

As for me -- I'll just stick with my glasses, as, no doubt, will people whose aversion to putting things in their eyes exceeds distaste for wearing glasses.

Shrinking An Enlarged Prostate

The third study described a minimally invasive method of shrinking enlarged prostate by reducing blood supply to the gland. The pilot study subjected 14 men to "prostatic artery embolization (PAE)," a procedure that plugs up the arteries feeding the prostate. The study, the first of its kind in the United States, follows larger earlier studies of PAE in Europe.

The UK's National Health Service has a web page describing the procedure (not for the squeamish), and notes the "University Hospital Southampton has been offering a PAE service from April 2012 and is the first UK centre to perform this procedure."

A press release on the U.S. study said, "Nearly all men eventually suffer from an enlarged prostate as they age, and this treatment is almost like turning back the clock and giving them the prostate of their youth," according to Sandeep Bagla, M.D., the study's lead author and an interventional radiologist at Inova Alexandria Hospital in Virginia.

Enlargement of the prostate, or benign prostatic hyperplasia is a common problem besetting men in later years. The press release says more than half of 50-year-old men will have this proliferation of prostate cells, as will more than 80 percent of 80-year-old men. Androgens open the door to the unwelcome excess growth, which can constrict the urethral canal, blocking the flow of urine.

On the bright side--the cell proliferation is not cancerous. The bad news is that constriction of the urethral canal can cause problems, including urinary frequency, urgency, urge incontinence, and having to get up frequently during the night to pee. The hyperplasia can also cause piss problems, including long waits for urination to start; intermittent stopping and starting of flow; having to strain; and dribbling. Left untreated, symptoms may progress, according to Wikipedia, increasing the risk of urinary tract infection, bladder stones, and urine retention -- potentially leading to bladder distension and even kidney failure.

The options for treating enlarged prostate have not been great. The effectiveness of drugs can be so-so, and the drugs in use have various side effects, including decreased libido and ejaculatory or erectile dysfunction. The other option, invasive surgery to remove overgrown tissue, may leave the patient with urine leak, impotence, or other complications.

Although PAE doesn't sound like a picnic, it seems like a better option than more invasive surgery and not a bad choice for men who don't fare well with drugs for benign prostatic hyperplasia. PAE requires only local and regional anaesthetic, and patients may not need an overnight hospital stay for the procedure. Interventional radiologists perform a PAE by inserting a tiny wire and tube through an artery in the leg, then guiding the tube into the arteries of the prostate. A cloud of microscopic particles is fed into the tiny vessels, blocking off blood flow. "By temporarily blocking blood flow through the prostate artery, PAE causes the prostate to shrink, providing a larger passageway for urine," the press release says.

It gives early findings from the U.S. study, which was presented at the 38th Annual Scientific Meeting of the Society of Interventional Radiology in mid-April 13-18:
13 of 14 men (92 percent) who had PAE noticed a significant decrease in symptoms after one month. None of the men suffered any major complications, such as impotence, leaking urine or infection. Most went home the day of treatment.
Bagla is now conducting a larger clinical study of PAE, which will treat 30 men by this fall and then follow the patients for two years to check the long-term consequences of PAE.

Sunday, April 21, 2013

Orthopedics for a Grief Walk

After my husband Koz died, I went to see a very wise and dear psychological counselor. Dr. Bob told me he was shocked and very very sorry. But there was nothing he or psychology could do to help. As the gospel song goes, I would have to walk that lonesome valley by myself.
Michael "Koz" Kozlowski

Now, 13 years later, I understand why he said that, and am wondering if it was actually true.

Inspiring my thoughts is an article in the Journal of the American Medical Association about changes in the upcoming version of the DSM -- Diagnostic and Statistical Manual of Mental Disorders -- aka the Bible of psychiatric diagnosis. Writing in JAMA's Online First publication, Drs. David J. Kupfer, Emily A. Kuhl, and Darrel A. Regier summarize the most significant changes in the new DSM-5, compared to its predecessor, DSM-IV.

This is one of the major changes:
Removal of bereavement exclusion: In DSM-IV, individuals meeting criteria for a major depressive episode were excluded from a diagnosis of major depressive disorder if symptoms occurred within 2 months of the death of a loved one. However, the implication that bereavement ends in only 2 months or that major depression and bereavement cannot co-occur appears false. Depression related to bereavement can share many of the same symptoms as nonbereavement-related depression and can accordingly respond to treatment.
Similarly, major depression can share features with other forms of significant loss or stress, including job loss and natural disasters, and may be in need of intervention. To prevent the denial of diagnosis (and care) of individuals who meet full criteria for a major depressive disorder, even during bereavement or other significant loss, DSM-5 now permits such a diagnosis ...
I find it (painfully) funny that science is just coming around to these insights, and I'm pretty sure that my friends in The Group No One Ever Wants to Join would agree. This would be "Widowed Young," an online support group for people widowed at a young age. I stumbled across WY a few months after Koz died (and actually first "met" my Dear Husband Dave through this group when he joined after his wife, Pat, died.) Many folks from the original WY are still in touch, though the group has now migrated to Facebook (which didn't exist when WY started up).

My exchanges with people in this group, and indirectly with their wider circles of friends, have helped me to see several things about bereavement that I wouldn't have understood by observing only my own grief and that of close relatives (like my Dad).

First, and foremost, there are almost as many ways or styles of grieving as there are people. There's no right or wrong way -- and what helps one person might be emphatically UNhelpful for another. For this reason, it's important to be gentle with and listen to the bereaved -- not to force them into what you think is the "right way to grieve."

Second, there are definitely things that are very broadly UNhelpful that others can say or do in interacting with a bereaved person. And there are a few tricks and observations that our band of widows and widowers came upon that seem to be broadly helpful for dealing with grief -- and at worst innocuous.

In passing, I'll mention three of our group's helpful tricks and observations. I'm not sure which of our members deserves credit for first suggesting these, but I will mention here the ever-wise, eloquent, and helpful "Glo" -- one Gloria Comstock.

1. The Five-Minute Rule: When you think you can't possible stand the agony any longer, impose The 5-Minute Rule, which says you will just try to get through the next five minutes. If you can't handle five minutes, impose the 1-Minute Rule. Repeat as necessary.
2. Take care of yourself: Many people come to bereavement after years focused on caring for others, including the late spouse. The death can mean that even more duties of care fall upon the shoulders of the bereaved. It's pretty common to neglect oneself in these circumstances -- to have forgotten how to care for yourself or to feel that it's somehow not right to do so. But it is right. Have a warm bath -- with nice-smelling bath salts, then go to sleep in a freshly made bed complete with fragrant sheets. Treat yourself to a walk on a beautiful day. Permit yourself some time alone to feel exactly the way you feel. Buy that electric blanket you need to keep warm without your spouse beside you at night. If you have to justify the "luxury" of treating yourself nicely, remember what the airline stewards say in their preflight spiel: Always put on your own oxygen mask before attempting to assist others.
3. It does get better, but not necessarily quickly, consistently, or predictably: Someone in our group brought us the concept of the "Grief 'Gator" -- a vicious beast always lurking out there, ready to pop up unpredictably to chew the ass of the bereaved. He's a fairly constant companion at first, but then usually leaves you -- wanders away for longer and longer periods of time (no doubt in search of fresh meat). An amazing variety of cues can bring the Grief 'Gator scrambling back in an instant: Hearing that song they played at your wedding; a birthday; a major milestone for your child; or, in my case, being told it was impossible to recover the contacts on Koz's broken cell phone. This provoked a total meltdown in the phone company store. There was a long line of other customers who had to witness my tears. I still feel sorry for the poor person who was waiting on me.

Fortunately, at some point you realize the Grief 'Gator has been away for one entire day ... a week .... a month. And when he visits he doesn't chomp as hard, or at least you know you'll get through this latest assault. And of course you can always vent by telling your friends in WY -- they'll understand, and that helps.

Back to the DSM-IV and its successor: The blinding truth that has struck the committee drafting DSM-5 is as compassionate as it is self-serving. Disorders that are approved for treatment by the American Psychiatric Association -- and thus have a DSM code -- are likely to be covered by U.S. insurance providers (to whatever extent your policy happens to include psychiatric problems). Including  bereavement-associated depression as a DSM disorder means that some widows and widowers may be able to get some financial help covering the cost of psychological treatment of depression stemming from bereavement.

Psychiatry-skeptics (and I now live in a country full of them, but that's a whole 'nother story) are probably wondering if this is actually compassionate for the bereaved or just an additional income-stream for psychological service providers. After all--for the past decades the DSM-IV and my brilliant Dr. Bob said the major depression associated with grief was not a treatable disorder. There was nothing they could do to help.

(I should note that it is possible that even back then, Dr. Bob, who knew me well, was only saying my depression would not benefit from extended therapy. He might have found otherwise for someone less resilient or more vulnerable to unremitting depression.)

I expect the change in the DSM, superimposed on individual variation in styles of grief, will bring out the best and worst psychiatry has to offer. I'm sure there will be mental health providers who feel compelled to intervene in and capitalize on garden-variety, "healthy" grieving.  I'm not actually sure what "healthy grieving" means. But I do know that many folks living reasonably happy lives today--but with a major bereavement in their past -- have gotten to where they are without recourse to professional help. I'm sure "medicalizing" major depression associated with grief will mean some providers will throw drugs at a perceived problem when drugs aren't proven to be very helpful, compared to other, slower forms of treatment that insurance doesn't fully cover.

But I am also hopeful that the change in the DSM will encourage serious study of the process of grief. Exactly what is the spectrum of experiences and behaviors that constitute "healthy grief?" I am very sure I have seen in some members of the WY group (and their extended circles of friends and family) thoughts and actions that were not conducive to healing. Heck,  I  had many setbacks and false steps... and I was lucky--sometimes thanks to my friends on WY-- to avoid pitfalls that snared other widows.

Perhaps psychological study can make a science of the sort of collective wisdom we've derived informally on WY as we tried to help one another. Are there any shortcuts through that lonesome valley? Are particular ways of grieving more helpful to certain personality types? Or is it a cultural and generational thing? Do prior major life experiences prime us for more or less healthy grief? What is the time-course of grief and why and how does it vary between people? Are there measures that help at one point during bereavement, but hold a person back later on? Who is most likely to benefit from professional help? What sort of help should this be?

The APA's suggestion that treatment of depression associated with other major losses in life -- losing a job, marriage, or pregnancy, for example -- could inform the understanding of major depression associated with bereavement (and vice-versa) is also worth studying. I'm pretty sure some of my fellow WY-ers who have experienced multiple losses would have some profound insights -- and maybe a few choice words on the subject. (No, losing your pet does NOT feel the same as having your spouse die.)

I see myself standing on some middle ground with respect to psychology -- largely a supporter, but one who believes the science is maturing from its infancy. Forty years ago, as I was trying to come to terms with serious life-threatening illness in a loved one, I went to see a trainee-shrink at the University of Michigan's student health services. She recommended I read Elisabeth Kubler-Ross's book, On Death and Dying. I now see, even from a cursory Wikipedia check, that Kubler-Ross's Five Stages of Grief and the research that gave rise to her famous hypothesis have been roundly criticized.

Thirteen years ago psychology officially had no help for the depressed bereaved. But now? As of this minute, Pubmed lists 12,132 research papers on bereavement and 8,705 on grief. There are even 381 papers on Grief/Bereavement and Mindfulness. I would hope that emerging from somewhere amidst that research is useful knowledge for dealing with all sorts of grief and all sorts of losses.

The emerging science probably already goes beyond DSM-5's conversion with respect to depression following bereavement. One of the growth spurts in psychology springs from the emerging field of "positive psychology" --practices associated a happy, healthy, satisfying life. In contrast, traditional psychiatry, from whence comes the DSM, is rooted in identification and treatment of mental disorders.

Historians of science might identify other "fathers" of positive psychology. But I'd say the forebear of my own leanings toward positive psychology was M. Scott Peck,  who wrote his most famous book, The Road Less Travelled in 1978 -- 9 years after Kubler-Ross's Five Stages. Wikipedia describes Peck's book as "a description of the attributes that make for a fulfilled human being, based largely on his experiences as a psychiatrist and a person."

Because Peck trained as a traditional psychiatrist, and because his work, like Kubler-Ross's, comes from psychiatry's formative years, Peck's methods have the same problems as hers. They are scientifically dubious and rest on hypotheses and models that in large part haven't been tested or proven. But somehow, since I first read The Road Less Travelled -- probably in 1997 or 1998-- Peck's work has rung true for me, unlike Kubler-Ross's, which never did.

Maybe because he's rooted in gloomy old pathology-based psychiatry, Peck is not as uplifting somehow as recent authors of positive psychology. In fact, his book begins with a chapter headed "PROBLEMS AND PAIN" and the Eeyore-ish first line: "Life is difficult." He goes on to say, "What makes life difficult is that the process of confronting and solving problems is a painful one." Among those challenges is confronting grief. Peck continues:
"Yet it is in this whole process of meeting and solving problems that life has its meaning... Problems call forth our courage and our wisdom; indeed they create our courage and our wisdom. It is only because of problems that we grow mentally and spiritually."
I think many of my friends in WY would agree that, if we'd had any choice, we would have preferred NOT to have experienced the death of a spouse--whatever beneficial growth might have resulted. My hope is that a rigorously research-based understanding of "healthy bereavement" will someday help those who grieve obtain what comfort, courage, and wisdom there is to be found in mourning -- as quickly and painlessly as possible.

Wednesday, April 10, 2013

Two Young Adults' Views on Church, Christians & Gays

IS the battle over marriage equality and homosexuality the nail in the coffin of a dying church? In previous blogs I've discussed the decline of the church. Below are links to two different perspectives on attitudes toward gay marriage/homosexuals and reactions of the younger generation to the church.

First: One Young Person's Perspective on the Death of Church and a Complete Guide to Christian Perspectives on Homosexuality
This link-- http://dannikanash.wordpress.com/2013/04/07/an-open-letter-to-the-church-from-my-generation/ --   takes you to An Open Letter to The Church from my Generation. In it a young woman explains how attitudes toward homosexuality on the part of Christians she has encountered are driving her from the church. I found it a powerful testimony.

But the comments that followed were an education. Reactions cover the range of perspectives on the Bible, Christian faith, and homosexuality. Reading some of the comments made me want to turn away, but I slogged through. I reached the end with a better understanding of the mindset of people who view this differently than me; where the points of difference are; where there could be some room for discussion if people would stop shouting at (and start listening to) each other. But it also gave me confirmation and strengthened support for some of my opinions.

For Good Measure (in the interest of Equipoise): Another Young Person's Perspective that Even Evangelical Christians Show Tolerance and Love Sufficient to Embrace a Homosexual:
Being Gay at Jerry Falwell's University: http://www.theatlantic.com/sexes/archive/2013/04/being-gay-at-jerry-falwells-university/274578/
I also found this very powerful. I wonder if reading this (which I did first) actually opened my heart and mind enough to make it through the comments on the other page. While the young author doesn't totally embrace the church, he does find love and acceptance there.

My late husband's nephew, Fr. Matthew Kozlowski, brought my attention to this article. I think it really does shed light on common ground that Christians will reach some day.

I'm still thinking about what I'll say in a review of Rob Bell's new book, What We Talk about When We Talk about God.  But for the moment and the purposes of this post, Bell seems to relegate the whole discussion of homosexuality to the general category of "people God doesn't love." His book would say that would be the null set. In other words, God loves everyone (therefore, homosexuals and any other group you can name are included.)

"I believe God is for every single one of us, regardless of our beliefs or perspectives or actions or failures or mistakes or sins or opinions about whether God exists or not. I believe that God wants us each to flourish and thrive in this world here and now as we become more and more everything we can possibly be. In talking about the forness of God, I want you to see how many of the dominant theological systems of thought that insist God is angry and hateful and just waiting to judge us unless we do or say or perform or believe the right things actually make people miserable and plague them with all kinds of new stresses and anxieties, never more so than when they actually start believing that God is really like that. I want you to see the radical, refreshing, revolutionary forness that is at the heart of Jesus' message about God as it informs and transforms your entire life.
"Then ahead, because when I talk about God, I'm not talking about a divine being who is behind, trying to drag us back to a primitive, barbaric, regressive, prescientific age when we believed Earth was flat and the center of the universe. I believe that God isn't backward-focused -- opposed to reason, liberation and progress -- but instead is pulling us and calling us and drawing all of humanity forward -- as God always has -- into greater and greater peace, love, justice, connection, honesty, compassion and joy"
 My impression is that in his earlier life as a pastor at Mars Hill church, (near Grand Rapids, Michigan) Bell's position on homosexuality was not inconsistent with this, but more non-committal. I recollect that he said something like, "get to know a gay/lesbian person as a close friend or family member. Then formulate your opinion."

The latter approach gets to the heart of what I like about the Atlantic article. When you attach a beloved  face, a beating human heart to that thing--that practice--that group you are rejecting, your whole viewpoint changes. Suddenly you're right there, looking at this one particular neighbor-woman, watching Jesus write something in the sand and then say to you and the assembled group, "let he who is without sin cast the first stone."