Law doesn't improve care for mentally ill (New Haven Register, 4/23/2013)

Law doesn't improve care for mentally ill
by Arjune Rama, MD

Like my fellow Connecticut residents still shaken by the Newtown shootings, I was excited and relieved when Connecticut Senate Bill 1160 (“An Act Concerning Gun Violence Prevention and Children’s Safety”) passed April 3.

The law establishes a dangerous weapons offenders registry and requires a universal background check for all gun purchases. Those wishing to purchase long guns will need an eligibility certificate that requires fingerprints, a firearms safety training course and a national criminal background check.

No firearm may be loaded with greater than 10 bullets except in a person’s home or at a shooting range.

However, as a mental health care provider, I am infuriated by one section in particular:

“Sec. 10. (NEW) (Effective October 1, 2013) Whenever a person is voluntarily admitted to a hospital … for care and treatment of a psychiatric disability … the hospital shall forthwith notify the Commissioner of Mental Health and Addiction Services of such admission and provide identifying information including, but not limited to, name, address, sex, date of birth and the date of admission. The commissioner shall maintain such identifying information on all such admissions.”

In other words, starting this fall, if someone comes to our emergency department asking to be admitted to the hospital for mental health care, our service is obligated to report his or her name, address, sex, date of birth and the date of admission to the state government.

I have to make my patients aware that they are welcome to treatment, but will also become a part of a growing database, even if their illness is completely unrelated to guns or violence. While this may not seem particularly problematic, consider the delicate scenarios in which people are voluntarily admitted to a psychiatric unit.

These are octogenarians for whom the death of a spouse has driven them to the brink of suicide. These are college students with new-onset schizophrenia trying to understand why their roommates have placed tracking devices in their brains. These are people freshly laid-off figuring out how to handle their frustration. These people are entrusting us with their most private pain.

Prior to reading the legislation, I thought that perhaps we were entering a period wherein mental health care would receive higher priority. I thought that we as a society finally realized that mental illness is a cage in which our patients find themselves. Instead, I am realizing that the Connecticut law serves to strengthen the bars of that cage, expand the cage itself and put tracking tags on everyone in it.

While this legislation has some groundbreaking provisions that will undoubtedly save lives, I hope that our lawmakers realize the potential outcomes for some of our most desperate citizens. Those looking for solace to prevent possibly killing themselves may think twice to present to the emergency room to avoid being documented on a government list.

For the same reason, those with bubbling anger may similarly choose to take matters into their own hands rather than to responsibly seek help.

In sum, the mental health provisions in this law do not improve care for the mentally ill. Rather, these provisions improve the containment and tracking of the mentally ill. By attempting to contain and track rather than treat and prevent, we may inadvertently lose more lives as a result.

The Liberal Arts: Stealing from Peter to Pay Paul (Hum Magazine, April 2013)

by Arjune Rama, MD


“You know, we don’t need a lot more anthropologists in the state. It’s a great degree if people want to get it, but we don’t need them here. I want to spend our dollars giving people science, technology, engineering, math degrees. That’s what our kids need to focus all their time and attention on. Those type of degrees. So when they get out of school, they can get a job.”
 -Florida Governor Rick Scott 
(The Marc Bernier Show, 10/11/2011) 

Since late 2012 to present, Mr. Scott, pursuant to his statement above, has been pushing the Florida legislature to consider freezing state university tuitions for three years in “strategic areas” based upon supply and demand in Florida’s job market. Effectively, this means that the tuition burden for those obtaining degrees in science, technology, engineering and mathematics (STEM) would remain stable while the tuition for those choosing liberal arts degrees (such as anthropology) would climb to fill the financial gap. In other words, under his proposal, a liberal arts degree would be more expensive than a STEM degree.

Despite having pursued a STEM degree myself, I am perplexed by this logic. I knew that by going into medicine I would be well compensated; shouldn’t I have paid more than my liberal arts colleagues and not the other way around? As a psychiatrist-in-training I am confused in other ways: how am I to understand the underpinnings of behavior without the work of anthropologists? How am I to appreciate the depths of human misery without the work of those who have devoted their lives to literature, the stage, and the screen?

I can imagine Mr. Scott’s reply, “I’m not saying the arts aren’t important. But we only need a dozen musicians to fill our iPods, a few artists to deck our walls and a handful of actors to grace our stages. So why are we investing in so many?” The reason is this: art, like science, is not based on a one-to-one ratio. Investing in one artist or scientist does not translate into a piece of work that “legitimizes” the funding. Artists and scientists alike all stand on the shoulders of those who came before. The Beatles did not create Sgt. Pepper’s Lonely Hearts Club Band by themselves. John Lennon and Paul McCartney were informal students of American blues and rock luminaries upon whose work they built their own masterpieces. Similarly, Albert Einstein’s photoelectric law was not a singular creation but rather a work deeply influenced by Max Planck’s quantum theory developed years earlier.

According to Dale Brill, who chairs this task force on academic funding, when it comes to liberal arts majors, “There will always be a need for [liberal arts graduates]. But you better really want to do it, because you may have to pay more” (Sun Sentinel, 10/12/2012). Given the similar nature of artistic and scientific progression, such a proposed funding structure reeks of hypocrisy. If there will “always” be a need for liberal arts graduates, then why are we disincentivizing their education? The answer lies between the lines of Mr. Brill’s policy: while we need the liberal arts they are inherently less valuable than the sciences.

Bizarrely, despite his overt support of producing STEM students, Mr. Scott fails to address what actually happens to STEM majors while in college. According to a study released in October 2011 by the Center on Education and the Workforce at Georgetown University, 60% of STEM students end up leaving the major prior to graduation. This figure begs the question: if these careers are so lucrative and necessary, why are students switching? Elaine Seymour’s and Nancy Hewitt’s Talking About Leaving: Why Undergraduates Leave the Sciences (Westview Press, 1997) established that poor teaching was found to be the most significant factor. The Wisconsin Center for Education Research is currently working on a study entitled Collaborative Research: Talking about Leaving Revisited: Exploring the Contribution of Teaching in Undergraduate Persistence in the Sciences in order to further address the issue. The Wisconsin group posits that a mere 10% reduction in the transfer rate of STEM students would produce three-fourths of the one million STEM graduates that President Obama announced last year as a goal over the course of this decade.

I do not believe that Mr. Scott has a grudge against the liberal arts. I think he, in good faith, is searching for a solution to the problem of our lack of STEM graduates to fill the increase in STEM jobs. He is looking to bolster Florida’s economy and incentivize the pursuit of a college education in an era when tuition has spiraled out of control. However, his approach is at best merely shortsighted and at worst completely unnecessary. While using financial resource allocation to incentivize STEM majors may create more STEM students in the short-run, research suggests that these students may not even graduate with these majors and therefore fail to fill STEM jobs in the long-run. The solution to this problem lies in a reallocation of funding which reaps rewards on a much longer timescale but with a far less headline-capturing strategy: revamping the ways that we educate those students already motivated to pursue STEM majors so that we can bring them to graduation and subsequently into STEM careers. Unfortunately, investments in improvements in teaching style frequently requires a large investment up front with long-term rewards only reaped long after the lawmakers who championed them are out of office.

The Rape of "India's Daughter" by India's Sons (Hum Magazine, March 2013)

by Arjune Rama, MD

“Mother, I want to live.” Unable to speak, 23-year-old Jyoti Singh Pandey wrote these words on a piece of paper in an intensive care unit at Safdarjung Hospital in New Delhi while being treated for injuries resulting from being gang-raped and beaten on a bus. Only 5% of her colon remained in her body when she was brought into the trauma center on December 16th, 2012. She died on December 29th from her multiple blunt injuries and massive gastrointestinal infections.

As a physician I pride myself on being able to tolerate ghastly images. I did not vomit or faint when I saw my first cadaver or bloodied trauma victim. However, just reading the details of Ms. Pandey’s experience nauseates me. In trying to wrap my mind around what happened to her I find myself at a loss. I am reminded of when astronomers explain how much farther Saturn is from Earth than Mars. Both distances are on the order of millions of miles. Though Mars is much closer to Earth, on such a scale my mind is unable to realistically differentiate the distances. Similarly, Ms. Pandey’s experience is many orders of magnitude greater than the darkest experiences of my life and thereby nearly impossible to fully appreciate.

She has been dubbed “India’s Daughter.” As such I like to think that she is collectively Our Daughter. In order to honor the memory of Our Daughter, we need to effect change. Although I am heartened by the demonstrations and hope her story will help lead to a reduction in the incidence of sexual assault in India, I do not want the details of her lived experience to be lost in the sociopolitical shuffle. The words “gang-rape” and “beating” do not capture the hell this woman experienced. To ensure that our enthusiasm for change does not waver with governmental distractions and changes in the news cycle, we need to put ourselves into her shoes on that horrible night and tattoo her experience into our memories. Let’s not allow safe journalistic language to obfuscate the depths of devastation this woman endured.

In service of harnessing our collective vitriol, I would like to engage you, dear reader, in a thought experiment. Since her suffering was on a nearly inconceivable level, we need to psychologically layer the multiple transgressions she experienced upon ourselves to fully appreciate it. For example, I begin by imagining my clothes being removed forcibly on a city bus. If the transgression stopped there I would go home sobbing and eternally humiliated. I would likely never ride a bus again. Then I add another layer: in addition to being forcibly stripped, someone touches my genitals. This is beyond humiliation; I have been physically violated. Then I add a multiplier: violation by not one person but by five. Already I am approaching a level of terror of which I struggle to conceive. Up to this point, legally speaking, I have been “molested.”

Then I move into a plane of terror that thoroughly exceeds my ability to fully appreciate. I imagine that those men take turns penetrating me. Without condoms. For nearly an hour. Thoughts about deadly infectious diseases like hepatitis or AIDS fly through my mind. Next someone is beating my head with a luggage rod. In my semi-conscious state I realize that someone has pushed that same rod into my anus, past my rectum, stopping at my transverse colon (roughly 2 feet into my body). Then an incomprehensible sensation occurs wherein the rod is removed, pulling my colon out with it, pulsing and bleeding onto the bus floor whereupon millions of bacteria leap onto my entrails. I haven’t been merely exposed. I haven’t been merely violated. I have literally been turned inside out. On a city bus.

This is exactly what happened to Our Daughter.

Lets not distance ourselves from the perpetrators no matter how comforting such separation might feel in this moment. As Ms. Pandey has been called “India’s Daughter,” let’s remember that her assailants are also “India’s Sons.” This moniker is neither a point of pride nor an insult. If we are to truly appreciate the magnitude of this issue we have to recognize that our sons have a problem. Sadly, instead of addressing the problem with our sons, some Indian state governments have foisted greater limitations on our daughters. In some states, women are further limited in how they dress or how late they may stay out at night as a result of Ms. Pandey’s rape and subsequent death. Such statutes only serve to reinforce a patriarchal system in which the sexuality of women is considered a liability and thereby covered over in order to curtail male sexual violence.

Instead of more rules that simply sweep sex under the rug, we need to pull the rug off completely to show our sons what sex is and what sex is not. Sex is about love. Sex is about passion. While sex is powerful, it is not to be used as power over another person. Least of all, sex is not a weapon. When our daughters show their skin, they are not inviting harassment or assault. They are allowing themselves to feel pride in their own bodies. Our sons must recognize that the mothers, sisters, and grandmothers they love so dearly were once the young women currently being catcalled, molested and raped.

If our goal is to raise men as opposed to overgrown boys, we must show our sons that manhood does not occur when the clock strikes midnight on their eighteenth birthday. A boy becomes a man slowly over time, through demonstrations of respect and restraint. A man is secure in his masculinity such that he does not need to molest or rape a woman to feel sexually vital. Furthermore, a man does not need to participate in gangs or think with a mob-mentality; he thinks and acts for himself. So secure is he in his sense of right and wrong that he is willing to intervene in a mob, even if it causes him to lose face. If there was a single man in that group of boys that took Our Daughter’s life, the event would have been over before it began. If these expectations of our sons seem daunting lets remember the details of the evening Our Daughter spent on that bus. Let’s put ourselves into her horrifying position. Let’s remember that in the aftermath of her experience she voiced one basic wish: she wanted to live. We owe Our Daughters so much more.

Treating the "mind" versus the "brain" in substance dependence (Hum Magazine, February 2013)

by Arjune Rama, MD

Note: The patient below has been completely de-identified in order to protect his/her health information.

“You don’t have any idea what you’re dealing with, do you?” asked Mr. Johnson a mere two minutes into my interview. The scene is the Crisis Intervention Unit. The time is 3:00am. I have a feeling my breath is terrible. The hospital pizza I engulfed earlier in the evening has decided to stage a churning acidic protest in my guts. However, far worse than my half-closed eyes, my halitosis or my gastrointestinal distress is the fact that he’s absolutely right. Mr. Johnson is here because he has come to the realization that living sober is about as awful as living as an alcoholic. As a result, he has decided life is simply not worth living.

As a practitioner, patients caught in this double-bind are among the most frustrating to treat. They are living proof that substance dependence treatment can be quite shortsighted. The logic is charmingly simple and irritatingly simplistic: if you’re drinking too much, then you should probably stop. Once you stop, all will be better.

To properly understand the failure of this logic, we need to distinguish the brain from the mind. Although our medications and therapies are effective in removing alcohol from the brain, we are less successful filling the empty space left in the mind. Mr. Johnson’s alcohol use started as a coping strategy and slowly evolved into a way of navigating the world: a drink to take the edge off at a dinner party; a libation or five to take the edge off of a bad day at the office; a quick stop at the corner bar after work to steel himself against a troubled marriage and a wayward teen. Alcohol played prominently in the way his mind functioned for years.

After “treatment,” suddenly there was no sedative to bring out the best “Mr. Johnson” when he attended a dinner party. Frustration from days at the office lingered long into the evening. Problems at home, at one time nicely obscured by liquor, were now seen in sharp relief.

When Mr. Johnson accurately noted that I couldn’t appreciate his situation, I was reminded of my personal development thus far. Like most physicians, I am a person suited to delayed gratification, long-term goal-setting, and possessed of a persistence to achieve these goals. This isn’t to say that I’m superior to him. Rather, for reasons as arbitrary as genetics and birthright, the decision centers of my brain do not have to compete with the influence of a substance such that my mind can look at the ups and downs of life with balance. As a result, I have little to no tangible life experience with which to help his mind function without the aid of a substance.

So after staring blankly for a few seconds (which seemed like minutes) at Mr. Johnson, I dispensed momentarily with my medical training regarding suicide risk assessment or attempting to present treatment options to achieve sobriety. Instead I sat on the edge of his bed and said, “You’re right. I don’t know what I’m dealing with. This sounds absolutely awful, though… tell me what its like.” Given the constrictions of a busy crisis unit, I still had to complete my evaluation, disposition decision, and documentation within an hour. Eventually he was voluntarily admitted to the hospital out of concern for serious potential harm to self.

I have no delusions that my brief talk filled the void in his mind left by the removal of alcohol. However, during our discussion it occurred to me how patients like Mr. Johnson are constantly marginalized in the hospital setting. Through medical school and into residency I have heard the phrase, “he’s just going to go out and drink after discharge anyways…” more times than I can count in reference to the disposition of patients like Mr. Johnson. Its true, the relapse rate for patients who are newly sober is staggeringly high. So what are we as practitioners to do?

We need to listen. And I mean, really listen. We need to be taught by our substance-dependent patients because, more than likely, we have zero background with which to help them. Listening in this way may be very uncomfortable as it requires us to step away from the familiar books and diagrams that put us in the revered position of “Doctor” and step towards the unfamiliar thought processes of those who have put their lives in our hands. We cannot hear our patients if we try to remain on this imaginary pedestal: our ears are simply too far away to catch anything helpful.

As a result I strongly encourage my medical students to read actual descriptions of real patients’ experiences with addiction and better yet, listen to one or more of their patients who is willing to describe their personal addiction stories. I believe that the more and varied stories we read and hear, the better equipped we are to understand the cold vacuum left behind when alcohol is removed from the equation. As we accumulate a greater war chest of patient experiences, we can better apply our skills as physicians to fill a space once occupied with alcohol-lubricated decision-making with smooth yet sober coping strategies. In this way, we can help change their minds.

Why (Most) Diet and Exercise Regimens Fail (Hum Magazine, January 2013)

By Arjune Rama, MD

Every January, Americans nationwide start the year off with a new diet and exercise regimen. I am confident that almost all of these will fail. I am loath to bet against the underdog, as I have found myself in that very position multiple times in my life,  but with this one I can’t help myself. This approach to change is simply fundamentally flawed because it does not acknowledge that being overweight is an addiction. Like so many other addictions, being overweight is merely the tip of the iceberg below which myriad other addictions reside. Not only are we addicted to the transient hyperglycemia/caffeine high from our high-sugar cereals and coffees, we are addicted to the speed with which our cars take us to our parking spots as this allows us to sleep in just a bit longer. We are addicted to the convenience of the elevator that whisks us to our comfortable desk where we will work our sedentary jobs that keep us at a comfortable heart rate. We are addicted to the productivity we feel as we motionlessly work while eating our lunches at these desks and eventually reverse the entire trip home all the while jonesing for the largest meal of the day, the calories from which will transform directly into fat as we slip into sleep. Then the cycle begins again.

With all of these micro-addictions, it makes sense that wholesale change is Herculean at best and Sisyphean at worst. I don’t blame people for failing; the entire enterprise is destined for failure. I don’t mean to say that change is impossible but I think the only way to approach the kind of change most people seem to want (lower BMI, definition of skeletal musculature, higher exercise tolerance, lower daytime fatigue, improved mood, etc.) is to assess every change you are considering instituting as something you will do for the rest of your life. For example, ask yourself, “Will I wake up every day for the rest of my life and run thirty minutes before work?” or “Is it realistic for me to never eat sugar again?” The answer is most likely no.

Nothing frustrates me more than to see new diet programs advertised on television. These programs propose a precisely opposite approach to what has been proven to help people overcome addiction. We don’t need more options. We need better ways to utilize the ones we already have. I think we should approach our addiction to food and our sedentary lifestyles via the Alcoholics Anonymous model for change. Alcoholics Anonymous has been demonstrated to work in the long term. In the market of ways to curb alcoholism this program has the largest body of evidence for success.

In AA, successful members of the program acknowledge first that they are powerless to alcohol. I love the seriousness of that word: powerless. I have never heard a dieter say that they are powerless to food. But its true. The truly amazing part of AA is despite the rigor with which they have achieved their long-lasting effects, even the most stalwart participants have relapsed twenty and thirty years after sobriety. This is how devastating addiction really is. I also love that alcoholics consider themselves alcoholics for life as a way to internalize the disease and remain constantly vigilant. To approach such a difficult change with any less intensity is like trying to fight a lion with an overcooked noodle. You might as well put an apple in your maw and lie down on a plate.

So what the hell are we supposed to do? I have an idea. If being overweight is a multifaceted addiction, why not approach each part individually as opposed to some kind of all encompassing diet/exercise regimen. I would employ a multistep method akin to AA. The first step could simply be taking the stairs to your office every single day for a few months. That’s it. Eat anything you want day-in and day-out but you no longer use elevators. You don’t even remember what that box with sliding doors and buttons does. I know that sounds incredibly slow on the scale of weight loss progress but I guarantee you many would fail. I don’t say that to be harsh; the odds are stacked against people as its not easy to even find the stairs in many buildings. Also, you’re busy. You are expected to be somewhere quickly all the time. I think if you can do that for a couple months you’re ready for the park-your-car-far-away-from-the-office-and-walking routine. That’s not easy either. You’re going to need a good parka because you will be the only one who parks in the last space and walks through a torrential storm while coworkers silently consider the state of your mental health. Now, here comes the real challenge. Now you have to take the stairs every day AND walk from the furthest parking lot spot. And remember: this is for the rest of your life. Let’s do just that for another few months. Notice that we have not even touched the issue of diet. No gym memberships purchased. No spandex worn. Indeed no money has changed hands and yet you have done an incredible amount of change: you now leap up stairs to meetings, powerwalk in the parking lot daily, and have replaced that once savory morning sleep time by going to sleep earlier. Forever.

Of course, it stands to reason that at some point in the future when a large number of obesity promoting habits have been stably changed that you could start using the elevator or the closer parking spot. However, at that point you’ll likely be making up for those easy yet inconvenient tasks with replacements that are far more rigorous and in a much more compressed time frame such that you might miss the days of a simple walk up the stairs.

Eventually, if one is successful at stacking these tasks I imagine one could tack on a diet change here or there. But just like the stairs and parking lot scenario, this would have to be relatively small and repeated for a rather long time before larger changes are instituted. If all of this seems exhausting, then you’re accurately appreciating how incredibly difficult it is to treat an addiction. You need to physically change your brain on a neuron-to-neuron basis. Considering there are billions of neurons in the cerebral cortex alone, this is no simple task.

I think the problem with most people’s wish to diet is our underlying desire is not to actually change the way we look but rather to be someone else entirely. We see a picture on a magazine cover or in a film and secretly covet not only the way that person looks but the glamour of their very existence. Being ourselves with an improved physique is nice but far from glamorous. Consider that rarest-of-rare person who is hard-headed enough to start January 1st running thirty minutes daily, consistently eating low-fat, low-carbohydrate, high-protein foods, sleeping eight hours nightly, and drinking copious amounts of water and actually keep it up for, say, six months. The pounds will no doubt come off but that person is the same person with the same hang-ups that made him overweight in the first place. Relapse is almost inevitable. The problem is that no real neuronal change has been effected as this blitzkrieg of reform was enacted out of the excitement of turning over a new leaf rather than a reasoned decision to completely change one’s life forever. The discipline that comes out of slow and steady piecemeal segmental modification represents actual character change for which I can’t think of any substitution. That level of discipline likely feels superior to any level of glamour and probably leads to a greater likelihood of overcoming the addiction in the long-term. If this seems overwhelming and impossible, consider what they say in AA: you have to take it one day at a time.

Let's put gender on a continuum (Hum Magazine, December 2012)

By Arjune Rama, MD

I don’t understand the fervor of gender identification and the subsequent lifelong segregation we impose upon children. Gender is a mantle placed on fetuses in utero by way of the pink coloring of a genetically female infant’s room to the blue balloons hanging from a mailbox in anticipation of a genetically male infant. So what if it’s a boy? So what if it’s a girl? Why are these facts so important?

As a scrawny boy in elementary school I envied girls mainly because their games usually didn’t require physical prowess. Mostly, their games appeared to revolve around fantasy, e.g., MASH MASH is an acronym for Mansion Apartment Shack House. This paper-and-pencil game is based somewhat on a combination of chance and arbitrary questions (the specifics of which I now forget). Regardless, by the end of the game one’s future abode was determined. Perhaps my jealousy was misplaced as I later learned that such games had a dark subtext of catty abuse. At the time, however, I would loved to have taken part, avoided being terrible at kickball, and had the chance to actually speak to people. Boys, in my opinion, didn’t do enough talking. They were all action, sweat and violence with the occasional merciless taunting.

I think my frustration with hard-and-fast “boy” and “girl” activities stems from growing up in a home in which strict gender identification was not pushed. I don’t mean to suggest that I was not raised as a male but rather that my parents allowed me to play as I liked. I gravitated towards “boy” games, no doubt secondary to the influence of television and school, but I don’t recall my father or mother saying, “that’s a girl’s game” and steering me away. Just as importantly, sexual preference was never pushed. I have always dated girls but I wonder what would have happened if I brought a boy home. We never ran into that situation but I think my parents would be accepting of my choices as they always have.

So what am I like now? I think that I embody a lot of what people consider feminine attributes. I speak with a feminine lilt unless I’m around a bunch of men who don’t know me well and then I feel compelled to give off a more “masculine” air. I’m averse to violence. I don’t like watching or playing sports. I like things that are delicate and small. I am a good listener and I love stories. My perception of romance, from what I learned in school and on TV, was restricted to the tall-dark-and-handsome-take-charge attitude expected of boys and the damsel-in-distress-waiting-to-be-swept-away attitude expected of girls. The type of romance that actually appeals to me is the intertwining of two people who share elements of both of these types; some days I want to be the one who sweeps away and sometimes I want to be the one who is swept.

I chose to address this topic because I think that if we all took a moment to examine the proportions of masculinity and femininity within us then perhaps certain groups, particularly people who are transgendered, might seem more like points on the same continuum of strictly “boys” and strictly “girls” rather than aberrations that don’t have a place in society. Transgender is a term under intense dispute and as I don’t purport to be an expert on sexuality I hope people more knowledgeable than I will make some comments on the subject. My basic understanding of the term transgender is that it is an umbrella word for those who fundamentally disagree with the gender dictated to them by virtue of being born genotypically male or female (XY or XX) or phenotypically male or female (possessing a penis or a vagina).

I feel we are making a mistake to so fervently place our children into one category or another. Perhaps we do this to side-step the life stressors currently experienced by those who consider themselves transgendered. While I think we can teach our kids to be more tolerant than that, I can’t condemn anyone who wants to protect their children from the pain related to crises of identity.

Perhaps the best way we can instill comfort with regards to gender identification for our children is to start them early with the idea that perhaps gender is an issue of proportion rather than two slots. Maybe in every man there is a proportion of femininity and vice versa. We could describe it like eye color. Some people have blue eyes, some have blue-green eyes, some have green eyes, etc. Of note, I purposely do not address sexuality (homosexuality, heterosexuality, pansexuality, etc.) because as I understand it, sexual preference operates independently of the gender with which someone identifies.

In college I took a class on gender and sexuality in which we read about the Incans placing transsexual people in positions of reverence. Anthropologists hypothesize that the reason behind this placement was that if one person could cross boundaries of sexual identity with ease then perhaps he/she had an uncommon insight into the human condition from which others could learn. I am fascinated by this situation for two reasons, 1) gender identification is hardly a new issue and 2) perhaps American society has it all wrong; maybe we are marginalizing the very people who carry unusual insight into personhood.

I realize I am hardly the first person to propose a proportional view of gender or gender as being on a continuum. My point is that if we elect to accept these hypotheses, we have a lot to gain with respect to the treatment of people who are transgendered. They may seem less different than those who fit into the strictly “boy” and “girl” categories thereby receiving the treatment and respect they deserve. As a result, I think American society would collectively take a large step forward in terms of tolerance and understanding.

Shaken Baby Syndrome (Hum Magazine, November 2012)

By Arjune Rama, MD

I have never shaken a baby. I will never shake a baby. Until we had our own child I considered people who have caused Shaken Baby Syndrome to be some of the lowest examples our species has to offer. I used to think to myself, “What kind of animal could shake a baby so hard that she bleeds into her brain?” However, I am starting to understand why people do it. Although I neither accept nor endorse it, I recognize that the situation is more complicated than I once thought.

Considering that babies scream despite having been fed, changed, walked around, bounced, hugged, and kissed, I am amazed by how rarely parents talk about just how furious our babies can make us. I think about it frequently, especially in the context of the horrific level of global child poverty. I marvel at our daughter’s fortune to have been born into a family that desperately loves her and wants to provide her with everything. I hear myself angrily thinking, “How dare she treat us this way? Does she know how lucky she is?”

Those angry feelings sharpen to a point when her cry suddenly cuts through the quiet of our all-too-short nights. The English translation of that cry is, “Tomorrow your twelve-hour work day will be a groggy-eyed waking nightmare.” As the cry shifts into a throaty scream, in my half-awake/half-asleep state I feel a slowly growing animus bloom inside me. While I try to intellectualize away the possibility of hurting her, hardwired human feelings like desperation, hopelessness, and anger are frighteningly difficult to keep at bay. Nothing breeds desperation like hopelessness. And nothing fuels anger like desperation.

Perhaps surprisingly, I believe that this anger is directed much less at our baby than at myself. In these 4.00 a.m. confrontations I experience feelings of aggression in direct proportion to my perception of personal failure at the most important job of my life. In those moments I feel like my love is not enough or that if I were stronger or smarter, she would not be crying. As a physician training in psychiatry I thought that I would be better equipped to successfully navigate the emotional waters of childrearing. I could not have been more wrong. Although I am trained to manage my emotions in the context of a doctor-patient relationship, the degree of parental closeness I have with my daughter renders me unable to use my background in any meaningful way. In these tense situations, she is like a boxer who constantly clutches her opponent so tightly during a bout that both fighters are immobilized.

Shaking a baby is child abuse, criminal, and unacceptable under any circumstances. However, I believe that the anger from which it stems is not so inaccessible to even the most loving parent. I realize that we live in a climate of childrearing wherein whole sections of bookstores are dedicated to the craft and hours of armchair wisdom are seemingly available from every family member, friend, and grocery store clerk. While I do not intend to add to that forest of writing or earfuls of anecdotes, I would like to propose a single simple bit of advice that I use before I step into my daughter’s room in the middle of the night during a maddening crying jag. I remind myself that I come first. I love myself first. I realize that these statements are anathema in a world that screams, “Your child comes first!” However, if I can’t love myself despite my well-intentioned attempts to satisfy her frequently insatiable level of need, then I can’t really love her either. It’s like being on an airplane. In the event of an emergency landing, we are asked to secure our own masks before assisting others. If I tried to secure her mask first, I might not last long enough to do much of anything on her behalf anyway.