Mental Disorders Proliferate in Newly Expanded "Bible" of Diagnoses

 

If you've ever wondered if you've got a bona fide psychological "disorder," the new handbook for mental health providers, the Diagnostic and Statistical Manual of Mental Disorders, Volume 5 has the answer--and it's more likely than ever to be "yes." The list of definitions was first published in 1952 as a spiral pamphlet describing eleven categories of mental disorder. Subsequent volumes (1968, 1973, 1980, 1994) ballooned the number of ailments, and now the 947-page tome boasts nearly 400 maladies. Sounds like the US tax code (73,608 pages).

Like lawmakers who keep writing more laws, and the IRS, that keeps writing tax regulations, psychiatrists just can't stop defining who's sick. Of course, that's what they're all paid to do, and the ones who want to keep their jobs are invested in adding to the density of their fields. A politician gets famous and re-elected for creating landmark legislation. The IRS hires more people as citizens might be violating more rules. But psychiatrists?

Same thing, especially the way health care payments are evolving under Obamacare, set to cover 32 million Americans who never before enjoyed this benefit. As descriptions of disorder include more people, mental health professionals' clientele and reimbursements grow.

A cynical view, maybe, but it's undeniable that a growing number of people now have a diagnosis to pin to their conditions. A review of the new psychiatric tome by Dr. Carol Tavris in the New York Times sheds light on what's going on.

As part of her look at the new "Bible" of mental ailments, she considers Gary Greenberg's bash, The Book of Woe. Greenberg doubts the entire enterprise of labeling clusters of symptoms. The new DSM-5 supposedly used ethical, empirical trials to verify that its categories are discrete, or at minimum that professionals would agree on diagnoses. Greenberg exposes the fallacy in all that, and says the American Psychiatric Association rushed to publication without adequate reliability testing because it desperately needed the money from its sale.

The new DSM tries to describe disorders so prescribers can choose appropriate medications. But even though more people than ever take pills to moderate feelings and behaviors, nobody's ever seen brain markers for specific illnesses, and as Dr. Tavris notes, "no lab tests yet exist for depression, schizophrenia, bipolar or obsessive-compulsive disorder, or, for that matter, any other mental disorders."

But plenty of professionals dismiss the touchy-feely aspect of therapy, and prefer nice, neat medical definitions, just like other illnesses have. The taxpayer-supported National Institute of Mental Health is spending our money basing a new competitor volume to the DSM-5 on exactly that idea, according to director Thomas Insel: "Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion or behavior." That one should be a really fun read.

But there has to be a middle road--don't some disorders have emotional or situational roots, while others are malfunctions of brain circuitry? It's also not an either-or thing--many disorders are combinations of both--and the proportions of physiological versus mental components in a single person's disorder can fluctuate. We just don't know enough about the mind-body connection to get haughty.

But docs are haughty enough to load the Psychiatric Association's manual with so many disorders that any creative or idiosyncratic person can surely find herself somewhere in its pages. Allen Frances, editor of the previous edition of the DSM, knocks the current volume (in his own new book, Saving Normal) for "new diagnoses that would turn everyday anxiety, eccentricity, forgetting and bad eating habits into mental disorders." Dr. Tavris responds that Frances' own DSM-4 "gave us a Disorder of Written Expression, Caffeine-Induced Sleep Disorder and Age-related Cognitive Decline, all of which I suffer on every deadline." Beneficiaries of Obamacare take note: you can be eligible for treatment as a result of normal living.

We need to see both individuals and diagnostic categories as fluid and changeable, especially since psychiatry is such an inexact science, but instead, we wrap our identities around them. But where does that leave the likes of me--a psychologist and not a psychiatrist? This is an issue I haven't seen discussed: that psychiatrists, those med-school-trained prescribers of pills that alter brain chemistry, wrote the book for the rest of us therapists, the ones whose best and only weapon is talk.

I see therapy as educating clients about patterns that keep them in nonconstructive habits, and suggesting personalized alternatives that allow them to reach their goals. Great for problems where the client can control his feelings or the situation, but what of the person whose anxiety comes unpredictably, or whose overwhelming compulsions have no logical basis?

I'm with the NIMH in seeing that brain chemical-altering medications can greatly improve not only serious disorders like schizophrenia, but many of the "neuroses" that we previously ascribed to volition. There's probably no way to know what part of behavior is physiologically/neurologically/hormonally caused and not really under a person's control, versus what part is psychological and attitudinal. Increasingly, researchers are finding that the physiological plays a dominant role in disorders.

Even if medication is likely to work, prescribing is an art, not a science, often a hit-or-miss dance where symptoms recede and return. The same medication may alleviate symptoms for one person and exacerbate them in another, even when both seem to have the same problem. Or the dosage or manufacturer may be the critical variable, and in any case, hitting the medication sweet spot with minimal side effects and maximized benefits is a personalized journey of trial-and-error.

That leaves the question of the usefulness of the DSM-5. With so many political, social and financial ramifications, collecting symptoms into diagnoses is fraught with peril.

To offer a controversial example: Plenty of people (gays included) continue to suffer from being homosexual or belief that it's deviant, even though it was deleted as a disorder two Manual editions ago. The justification for the cut would be that the diagnosis itself created suffering, and that once homosexuality is fully accepted, gays can be at ease with their orientations. But if that's the case, then expanding the number and scope of disorders, as the new Manual does, increases our nation's woe.

But somebody's gotta put names to what's ailing the populace. I have a friend whose 25-year-old daughter lives with Asperger's Syndrome. When the girl was growing up, before her problem was identified, the mom faced a frustrating and heart-wrenching task finding the right school for her. The girl "bounced off the walls," acted inappropriately, and couldn't follow through on anything. Once she was diagnosed with Asperger's Syndrome, the family could finally make sense of her symptoms and stopped blaming themselves. This allowed them to better shape their expectations of her, and more confidently approach sources of help.

So slotting symptoms into diagnoses offers both benefits and drawbacks. Sometimes, though, individuals slide through the slots onto a conveyor belt to certain standard treatments--when the patients would be better off as a unique sum of their particular assets and issues. As we learn more about the mind, what we discover is that its workings are more complex than we thought, not less. Its foibles become less likely to fit into defined parameters, and become more defiant of labeling--just as we're locking down those very labels in authoritative "bibles."

Mental health professions should heed Dr. Tavris' suggestion for responding to the revered tome: "If people treated the DSM the way most treat the other Bible--nod their heads to it, say they believe in it, and continue sinning--we might be all right."

Dismiss your Anger and Accept Your Mistakes--Two Useful Themes

I'm a huge fan of professor, writer and psychologist Carol Tavris. She's got two themes that help navigate life, every day. One of them aids when you're faced with difficult people and frustrating situations, and the other explains the way President Obama and his crew gets away with so many huge imbroglios.

On the personal level, here's a tip for when you get mad, from Dr. Tavris' first book (Anger, the Misunderstood Emotion): Anger builds on itself.

When I first started out in private practice, I accepted the idea that expressing one's anger was therapeutic. Get it all out there; let it fly. In graduate school, I learned that padded bats, bobo dolls, (those bounce-back sand-weighted inflatable figures), and pillows all helped clients cope with frustration, anger and stress. Primal Scream therapy was a famous modality (not a Scottish rock band), a way to tap deeply-seated rage from childhood. Past lives regression to repair soul damage from pre-birth experiences led to many hypnosis-enabled outbursts.

"We're mad as hell, and won't take this anymore!" righteously shrieked "Network's" character Howard Beale, the perfect icon for sensibilities of the era.

Then Carol Tavris actually looked at what researchers knew about anger. Oops: all those strategies for releasing rage actually backfire. Once you're angry, if you dwell on it, you just get angrier. If you and your spouse "share" your ire, it turns to fire rather than reconciliation. Each party increases the stakes and feeds off the other's intensity as fights escalate. My clients found this useful; they learned to redirect their anger or calm down.

Now we turn to another theme from Dr. Tavris that relates to recent headlines concerning Pres. Obama.

It's capsulized in the perfect title of her third book (2008, with Elliot Aronson), Mistakes Were Made (But Not By Me). The subtitle really isn't needed, but it's "Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts."  Everyone knows why we justify ourselves but just look at the news to see how cleverly the administration uses this technique to protect the POTUS from blame.
Some examples: The IRS targets only conservative groups for invasive scrutiny when they apply for nonprofit status; agency head Lois Lerner proclaims she did nothing wrong and then takes the Fifth Amendment. "Mistakes were made, but not by ME!" (Now left-leaning reporters are scurrying to show that non-conservative groups faced equally intense investigation.)

Requests for defense of the Benghazi, Libya consulate last September were ignored and four people die, covered up by UN Ambassador Susan Rice hitting Sunday Morning news shows swearing the attack was fueled by upset over a YouTube video. The President and Hillary Clinton shrug about their 24-hour "war-room" eye into the action there. "Mistakes were made, but not by ME!" Interestingly, Susan Rice, who appeared to be "thrown under the bus" a couple weeks ago when trotted out to quell outrage about Benghazi, is now rewarded by a promotion to advisor to the president on foreign affairs, and will ostensibly wield more power than before, "at the elbow of the president."


Dr. Carol Tavris

Editors' and reporters' phone records at the Associated Press were secretly collected by the Justice Department last month, in a frightening demonstration of government intrusion on press freedoms. US Attorney General Eric Holder claims no knowledge, passing the buck to his deputy, Eric Cole. In a perfect "Mistakes were made, but not by me!" statement, he said on May 15 he'd "recused himself" from involvement. How convenient.

The "mistakes were made, but not by me" response works. A couple weeks ago it looked like the president had, as Ricky Ricardo famously intoned about Lucy, "a whole lotta 'splainin' to do!" And now, all three stories are fading. Nothing of substance will result from these shocking revelations, and certainly nobody's recanting denials, claiming responsibility--or admitting hiding the facts. Instead, "...not by me!" keeps echoing as more information comes out and the administration mops up. Yes, it's an effective way to distance, using that passive, third-person voice. Keep that in mind when you need an effective diversion from the truth.

Hoarders Confess on the Radio: Just another Compulsion?

Spent an hour today chatting on-air with my husband about a new designation in the Diagnostic and Statistical Manual of Mental Disorders, volume 5: Hoarding Disorder.

It was always recognized as a problem, but was listed previously as a type of obsessive-compulsive disorder. This go-round, HD (not "high-definition") merited its own, separate listing. New research has found genetic markers and brain responses that set it apart from the rest of the OCD category, and it often wasn't successfully treated with meds that worked fairly well with other compulsions.

I'm fascinated with the whole idea of compulsions--what causes people to do things that are self-destructive, often as they realize they're harming themselves doing them?

Why do people gobble down boxes of crackers or huge bags of chips when they're not hungry, hating themselves with every bite? Why do people pull out (and sometimes eat!) their hair, a disorder called trichotillomania, or cut themselves uncontrollably, usually termed "self-harm"? What pulls well-to-do people to repeatedly steal stuff they don't want from stores (kleptomania)? And what propels commonly-cited fears of contamination like repetitive hand-washing? Are urges like "sex addiction" related compulsions?

Today on the Michael Medved Show, a caller named Kathy admitted she hoarded garbage. You could hear sadness in her voice--not revulsion or panic or embarrassment--just a near-tears sadness. She holds down a day-job, lives alone in a house, and said she couldn't stand to be there by herself for long enough to remove it. She stayed on the line while the staff found her a local source for help.

But Kathy wasn't the only caller who said she had no one to whom she could turn. Hoarders are often cut off by disgusted relatives, and rather than cultivating friendships tend to withdraw into their fortresses of trash and "treasures." In preparing for the show, I read a Scientific American article describing hoarders who collect their bodily refuse, like fingernails or urine. Animals are another commonly-hoarded item; a woman named Irene Vandyke had 67 dead cats in a freezer, and 100 live ones in crates.

Another caller to the show said he'd been part of a church volunteer crew who spent 8 hours one Saturday cleaning just the outside of a house declared uninhabitable by health authorities. When that happened, the owners just camped (and hoarded) in their backyard, using a fire pit for cooking and warmth.

Researchers have come up with some answers about these disorders, but they're far from definitive. Medications that work for some people just don't for others. Most people with these compulsions wish they could quit, yet even with psychotherapy, may continue. Some, like hoarders, might not even recognize they have a problem, and only when forced to confront it react with anger or anxiety.

I'm convinced that everyone yearns to feel relaxed and "normal" and that despite psychological overlays and triggers, ongoing compulsions are at root physiological. Which brings hope that with continued research, we'll be able to eventually conquer them. Hoarding has been shown in several studies to have a genetic component, with markers seen on various chromosomes, including Chromosomes 14 and 22Q11. It's considered a recessive trait, unlike Obsessive-Compulsive Disorder, which is dominant.

We sound so sure about such pronouncements, but I'm skeptical when, at this point, we claim understanding. We're in the earliest stages of figuring out what goes on in the brain, much less how that activity coordinates with genes and chemicals throughout the body to cause reactions. Some compulsions are actually healthy, and, under the term "instinct" are the means we, and other species, survive.

Brain and body chemicals tell us when we're hungry and sated--have they gone awry for the obese? Are "fight or flight" responses to danger related at all to the chemicals that tell some people to check the stove twenty times to be sure it's off? Or maybe to "scrupulosity," where one is consumed with fears of sinning? I would suspect variants of similar mechanisms at work across all of these, though we don't really know the chemicals or DNA switches or brain activity or combination that's malfunctioning.

In any case, compulsions are unlikely to be someone's "fault." They're imposed on the patient, like cancer is, against his will.  Certainly self-discipline, intervention and learned strategies (such as those in Cognitive-Behavioral therapy) can mitigate biology-based urges (unlike with diseases like cancer that aren't behavioral). But that still leaves so very little in answer to the question, "What drives these people to...?"

[Coming soon: a post in this space in praise of psychologist Carol Tavris and her dubious view of the new DSM-V--and why psychiatrists shouldn't write psychologists' "Bible."]

This time, God Intervenes and Obama Fails

God sent two disasters. Three reasons  explain why one re-elected the president, and the other didn't help him at all.

I've written how amazed I was last September when TV buzzed with damning news about the Obama administration handling of the terrorist attack on the American consulate in Benghazi, Libya. As election day approached, it looked like the president would fall to his own spin-masters, who tried to blame a planned al Qaeda attack on a crowd upset about a YouTube video. Families of soldiers lost at Benghazi were expressing their hurt and outrage all over Fox News, and the story not only proved Obama's "We've got al Qaeda on the run!" a lie, but increasingly showed his incompetence in foreign affairs.

Then Hurricane Sandy struck, and on election day Obama was triumphant, a hero promising aid and appearing sympathetic. Fourteen percent of exit-polled voters said his reaction to the storm "was the most important factor" in their decision on presidential candidate, and three-quarters of those went for Obama.

Though the Libya story went dormant, it didn't die, and as the plot thickened with additional scandals about IRS political targeting and seizing of Associated Press phone records, God sent the Oklahoma tornado.

Heart-wrenching stories about trapped school-children shielded from falling debris by the sheltering bodies of their praying teachers have gripped the nation, and certainly left me teary. Today articles in the New York Times about the bravery and devastation in the path of the tornado were followed by a piece on Obama's reaction. He immediately pledged to give Oklahoma "everything that it needs right away," an offer of largess some congressmen, including Oklahoma's senator Tom Coburn, think should be tempered by an assessment of fiscal reality.

The Times story began with a few paragraphs on the president's televised address about the disaster, spiced with discussion of budget considerations, then hastened to say, "The disaster served to distract attention at least for a day from controversies that the White House would prefer not to talk about, particularly the handling of last year's attack on a diplomatic post in Benghazi, Libya, the targeting of conservative groups by the Internal Revenue Service, and the seizure of phone records of journalists reporting on national security."

The press isn't speeding to change the subject this time. Last time, with Sandy, the shift from failures of the administration to admit terrorism, much less prevent it, to the impact of the storm brought Obama's victory over Mitt Romney. This time, coverage of the president's reaction to disaster is received with skepticism.

Why the difference? Three main reasons, in bold below.

One is the bias of the press--for Obama and their own ratings. In the days prior to the election, media, most editorially in support of Obama's re-election, had little desire to focus on a scandal taking place far away, in a dangerous part of the world few viewers or readers could picture. Fox News was all over the story, but when Sandy hit, even the "fair and balanced" network dropped their coverage completely, knowing people most wanted reassurance about the disaster on their doorsteps.

The population-dense location of Hurricane Sandy's devastation, as opposed to the somewhat remote woes in Moore, Oklahoma also contributes to Obama's less-than-heroic reception. The New York area, center-of-the-world when it comes to media outlets, felt the brunt of the hurricane with thousands of reporters, bloggers and Instagrammers to document it.  Millions of people were affected, and 110 lost their lives. By comparison, 24 perished in the Oklahoma tornado, and far, far fewer people than with Sandy have been affected.

The tornado visuals are shocking. But now they've been presented, and today's front page carries only the obligatory below-the-fold follow-up. The one-day distraction is over.

Perhaps the most salient reason that Pres. Obama isn't redeemed by his tornado response, as he was with Sandy, is that the two new scandals are too offensive to everyone, press included.  Everyone's afraid of the power of the IRS to accuse and to ruin reputations, even if the results of its intrusion and digging show nothing wrong. Look at the defensive mopping-up that Apple had to do when blamed for moving funds offshore--legally--to avoid taxes. Liberals--pardon me, Progressives must have been flummoxed by that news, since their hatred for big corporations and tax-avoidance schemes was offset by their fondness for their iPads, iPhones and Macs. Everyone loves Apple and poor deceased Steve Jobs. Even PC users keep their music in their iTunes folders. And everyone fears the phrase "IRS audit."

So it gets personal when you learn that the IRS is being used by the government to target political foes. Sometimes the other side's in power, and you could be the next foe to go. No one wants to allow the IRS to become the invasive means for politicians to punish.

And the secret seizure of Associated Press communications doesn't sit well with the public, either.  Consumers want reporters to go out and cover the news, unhindered by government interference. News gatherers resent the accusation that they put the country in danger, the rationale offered by Attorney General Eric Holder for taking phone records of 20 AP reporters and editors.  There's something sacred about the First Amendment, and journalists are rightfully protective of their abilities to seek out the truth.

This time, not even an Act of God can distract sufficiently to save the president from scrutiny. If only the electorate had this kind of media follow-through in September, we might not be mired in the triple-whammy scandals that are now earning even more attention than the pathos of a twister's destruction.

Enraged that Obama's Spinners Snagged him the Presidency--with God's help

With all this outrage about Hillary Clinton and the cast of characters involved in the spin of the September terrorist attack on the American embassy in Benghazi, many, like me, recall the original event with "where were you then" importance.

I happened to be visiting a friend in Honolulu, significant because she has a TV that's often tuned to Fox News, while our household is TV-free. I recall being riveted to the screen as info about the attack unfolded, and Fox reporters spent mounting hours unraveling the spin put on the tragic and lethal events by White House operatives, including, illogically, our ambassador to the U.N., Susan Rice.

The event was gaining traction. Questions about the veracity of initial explanations were explored. It was looking more and more like the kind of horrific lie that could leave a culpable president the loser to his Republican opponent. Hillary was backed into a corner. Photos of the Embassy devastation made it clear that this was a well-planned bombing, not some street protest over a months-old item on YouTube, that just happened to coincide with September 11. And it was coming out that the White House, with its real-time attendants in the 'war room' observing and discussing everything as it occurred, chose to thwart rescue so as to minimize the attack as an act of aggression, if not war.

The airwaves were heating up. Parents of dead personnel were interviewed over and over. News reports pointed to White House deception; for highest-level Dems President Obama's re-election was the primary goal, and the safety of US personnel secondary. This story was changing the course of history.

Then, news about Benghazi stopped completely. Fox turned its attention away from the panels, interviews, statements of lack of confidence by Republicans, and denials from the White House. And President Obama was re-elected.

Now we've got Gregory Hicks, Mark Thompson and Eric Nordstrom and a growing list of other evidence--emails and statements at the time--to confirm the truth of the deadly event. But it's too late to re-do those first weeks, and, most crucially, the election.

What happened? Hurricane Sandy. God sent Barack Obama a hurricane. Its devastation and uncertainty not only shut down all inquiry about Benghazi, but gave the president his chance to shine. Exit polls after his re-election showed that 14% casting ballots named the president's reaction to Hurricane Sandy as the most important determinant of their presidential choice. Of this decisive 14%, three-quarters voted for Barack Obama. Without Hurricane Sandy, Mitt Romney would have won.

Now we've got retrospective outrage, all over the place. This weekend, Peggy Noonan had an excellent, scathing column in the Wall Street Journal, shredding White House defensiveness. We're seeing where the highest-level spin doctors excised any reference to terrorism and especially al Qaeda, lest it conflict with Obama's repeated campaign line, "We've got al Qaeda on the run!" Conquering al Qaeda was supposedly a great achievement of his first term, proof of his worthiness for re-election. That al Queda wasn't "on the run," but killing Americans and we refused to stop it, wouldn't help Obama's integrity or perceived competence.

photo shown repeatedly, from inside Libya embassy after the bombing

It's all out there now. We're still stuck with Obama. Still stuck with huge national debt and the ridiculousness of the Stimulus Package handing out the people's cash in an environment where unemployment has basically held steady. And now we're seeing how the urgency of politics trumped national security. The additional news about the IRS targeting groups with conservative titles adds to the distressing picture that the goal, from many angles, was to keep Obama in the presidency, even at the cost of ethics and lives.

That still leaves me perplexed about God's motive in sending Hurricane Sandy, but I've got enough faith to hope that over time, we'll understand the bigger picture, and benefit appropriately. Until then, I keep remembering those October days glued to the big-screen TV of my friend in Honolulu, and wondering how all the shocking news will play out this time.

Stimulus vs. Sequestration... and Bad Tattoos

The news is filled with stories that elicit reactions, and as I'm catching up on the paper I have plenty, each worthy of contemplating but not so complex it requires an entire post. Here are just two...

A Seattle Times story, "Scientists Feeling Sequester Pinch" (May 1) describes researchers' visit to Sen. Patty Murray to lament the tightening of federal funds for their projects. For example, an oncologist at the Fred Hutchinson Cancer research center (who had "spun off" two private companies of his own from his work) complained that with his federal grant halved, "one of his senior staffers left to take an industry job," and several students' positions may not be subsidized.

Leave aside that these workers are moving from government to private sector employ, which is fine with me. The issue that perplexes is "how does the sequester mesh with all the federal stimulus money that Pres. Obama distributed into the economy?"  Didn't the feds assign $787 billion to rebound from the big recession?  And now they've just raised the amount of Stimulus funds to $840 billion! Noted: the American Recovery and Reinvestment Act of 2009 was to make up for the 2008 across-the-board economic recession, and the Sequester was to carve a budget for this year. But it's all from the same source, headed out to generally the same or similar recipients.

Did you think the Stimulus was done, its funds distributed to worthy shovel-ready projects? Then you must've missed the huge explosion of publicity when an extra fifty-three billion dollars got tacked on just last year. Don't you feel the new economic verve?

Well, you probably wouldn't, since according to Recovery.gov, the administrative body created to ensure transparency in Stimulus disbursal, just $252 billion of the $840 billion allocated has actually been spent ($2 billion won't ever be spent, because a few projects missed deadlines for use). Even so, billions have gone out there for health research. Please explain: What's keeping that infusion of funding from offsetting sequestration?



Tattoo gives new meaning to 'eyes on the back of my head.'

Over the past few days I've had several reminders of another conundrum of life: tattoos. 1) A piece in the NY Times yesterday by a Baby Boomer who regrets the droopy green unicorn on her likely-droopy right buttock. 2) Driving through the Rainier Valley section of Seattle, I saw many newly-opened, brightly-painted tattoo parlors, whose names coincidentally included the word "Lucky." 3) A news story revealed that a New York realty firm offered a 15% pay raise to staffers tattooing the company logo anywhere on their bodies (40 of 800 employees obliged). 4) And the Northwest has sunbathed in luxuriously warm temperatures this week, exposing the ubiquitous ink that usually resides beneath sweatshirts and flannel.

Rarely do I meet a tattooed person who, if it were free, instant and painless, wouldn't wash off at least some of the needle-scars they paid for. Googling "tattoo removal, Seattle," I'm amused to find my own dermatologist on the lucrative laser bandwagon, and further entertained reading Yelp notations like "it's not really their fault that this ugly green tattoo is taking so damn long to disappear!" and "tattoo removal is almost the worst pain in the world."

People on their way to get tattoos don't read Yelp recommendations for removal clinics, I'll grant you. But they should: "I thought I'd have to pay an arm and a leg to get this tattoo off my neck." What good is a clean neck when you're missing an arm and a leg?

A Los Angeles Yelper helpfully told a cash-strapped peer she could save money by having a new design inked on top of the old. Which is a much better idea than the failed results she reports: "My sister still has a shadow of the words 'PIMP' in Old English on the back of her neck." A woman with "PIMP" in Old English on her neck? What was she thinking?

Louise Rafkin, who wrote the NY Times piece, remembers the youthful exuberance that led to her tattoo but recognizes the truth: "So now I'm middle-aged with a misshapen cartoon animal on my rear." Louise, you're not the only one. Take a look at some of the worst-tattoo sites and you're in for a giggle. In fact the TLC TV network did a two-part special on "America's Worst Tattoos," featuring the brilliantly-hued tattoo artist Megan Massacre.

Megan Massacre at work

She's in the process of lasering off a large arm tattoo, inked by an old boyfriend who "did a really awful job." Professionally, she also covers up others' lousy art with larger drawings, an effort she calls "polishing a turd." In fact, she turned a little owl near the toes of a Rachael Ray Show audience-member into a large, rust and teal-colored feather sweeping up the woman's ankle. So feminine.

At 27, Ms. Massacre's learned some rules, like facing tattoos toward the center of the body, fitting their sizes to the target extremities, and avoiding children's portraits: "They can come out looking demonic or like an alien or like an old person," she told the New York Daily News. "I saw somebody who had a tattoo of a baby and it looked just like Richard Simmons.”


Not quite Richard Simmons, but not a baby, either...

"Not having a tattoo in Seattle is like living in Los Angeles without sunglasses," opines a directory on the Seattleite website, and it's definitely true. "I love this place because Spyder is a genius," gushed a patron of Apocalypse Tattoo. "The ferret skeleton tattoo he did for me is incredibly detailed..." Ferret skeleton?

Sometimes it's tough for me to focus on the faces of baristas and sales clerks who are heavily tattooed. I respect them as individuals but worry that by so distractingly inking their skin they've made their lives more difficult. I'd rather notice their communication than their "sleeves" and the glint of silver in their tongues, or the hole-enlarging rings they've inserted in their floppy lobes. I know there's a story for every drawing and puncture, and I'm dying to ask, but wouldn't deign to intrude.

Is this a youth-versus-age thing? Not sure, but as these human art displays get older, they'll watch their tats morph into distorted shapes, or regret permanently scarring themselves. The one thing we know is that change is constant, and when people develop, evolve, grow and droop, they'll see their early choices differently. All this synthesizes down to: Don't get tattoos; spare yourself, even if having them now seems the most meaningful commitment you can make.

Male and Female: Different despite denials

I'm a bit agog right now, after reading an article in the April 21 New York Times' Sunday Review called "The Tangle of the Sexes." In it two researchers report their analysis of 13 psychological studies done by others--where they conclude that men and women don't form two different categories.

Their assertion that males and females should be judged on the same continua, as individuals, is certainly laudable; nobody wants old-time prejudice that would box women into restrictive careers or make assumptions about feelings.

But just because men and women share an emotional and even an interest spectrum doesn't mean they're not discrete in major ways. In fact, the genders differ in such basic, fundamental aspects as to render early Gloria Steinem feminism yawningly passe.

How could these researchers bash the "Men are from Mars, Women are from Venus" logic that sold John Gray millions of books (which they explicitly do in their study, in February's "Journal of Personality and Social Psychology")? How can they deny that so many physical and brain differences shape behavior?

Beats me. In fact, the two researchers, Bobbi Carothers, who completed the analysis for her doctoral thesis, now senior data analyst at Washington University in St. Louis, and Harry Reis, a psychology professor at the University of Rochester, admit that indeed the genders do exhibit some unbridgeable differences. Their penultimate paragraph in The Times describes their confirming their findings by checking typical, vastly disparate results: "Just to be safe, we repeated our analysis on several dimensions where we did expect categorical differences: physical size, athletic ability and sex-stereotyped hobbies like playing video games and scrapbooking. On these we did find evidence for categories based on sex."

Indeed. I chuckled when I looked over their journal article. The studies they chose to analyze were mainly the typical university studies using college students as subjects. I remember earning my degree at UCLA; it was required that we "volunteer" for several studies every year. How do you tease out the self-selection involved in data on those who not only made it to research-oriented universities but offer themselves up as subjects?

But, you might answer if you happened to take the time to read the journal article, Carothers and Reis just tried a new statistical approach on data that originally showed the sexes as psychologically polar. They found a way to say men and women aren't so different after all.

Beyond the fact they ignore using homogeneous populations, their study, which is

covered as a big deal, comes to a "duh" conclusion: Even though men score differently from women in most traditionally-recognized gender markers, there are plenty of men and women who respond in one or more psychological and social ways more like the other gender. The wife who takes charge of finances, the husband who enjoys childcare may be mighty feminine or masculine in the majority of their other interests and behaviors.

I reflect that showing men and women as interchangeable is essential to the ongoing effort to legalize same-sex marriage. The crux of the issue is whether men and women are uniquely joined, a "marriage of opposites," as I often call it, when they wed, or whether the institution has morphed into simply a declaration of commitment that any two people can make. If it's something special--bringing together two categories, male and female, that are compatible yet essentially different, it's worth preserving as it has always been. By shifting the definition to the joining of two-of-any-kind, America is bereft of any relationship that recognizes the reality of these basic differences.

And inherent differences between the genders are indeed reality. Ann Moir and David Jessel were the first to shock readers in 1989 with their description of brain research, Brain Sex: The Real Difference Between Men and Women. That was followed in 1997 with Deborah Blum's Sex on the Brain: The Biological Differences Between Men and Women. As the field of neuropsychology lept forward, Melissa Hines chronicled it in Brain Gender (2004), and a new stir erupted when neuropsychiatrist Louann Brizendine published The Female Brain (2006). Those are just the books I happen to have on my shelf; I'm sure you can buy many others that confirm the inescapable truth that men and women are hardwired differently, and that these differences profoundly affect attitudes, communication styles and behavior.

Of course men and women aren't all clump-able into two isolated camps, different on every measure. Of course plenty of men embrace stereotypically female interests, and ditto in reverse for women. But what's the gain in denying the plethora--the overwhelming landslide--of data that illuminate chasms that, by being recognized, allow for greater understanding and harmony?  You can reorganize studies to your heart's content to show that individuals are just that, but despite society's eagerness to say homosexuality is the same as heterosexuality, and men and women are interchangeable, certain essential differences cannot be erased, and gender is discernible in every cell of each human on the planet.