Tuesday, December 4, 2012

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

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.

Tuesday, October 9, 2012

Bullying: What are we doing right? What are we doing wrong? (Hum Magazine, October 2012)

Once all of us sixth-graders piled into the gym the rules were simple: find the nametag of your eighth-grade “big brother/big sister” for the year. As one would imagine, it was sheer pandemonium. “Who would I get?” “Who did you get?” We scurried across the squeaky floor searching for our nametags with the name of our corresponding eighth-grader who would steward us through the choppy waters of early junior high. Simultaneously, our “big siblings” were on the lookout for the nametags of their mentees to whom they would impart their fourteen years of wisdom. Within minutes I saw hugs and pats on the back. I saw broad smiles and bright faces.

And then it happened.

After he pulled me by the shoulder, whipped me around and literally punched my nametag onto my chest, I thought I would vomit. The next few months were hell. Unbeknownst to the school administration, this was not a mentorship; this was a pairing of the nastiest bully with the feeblest kid. I started to take the far stairs to get to science class. Even then I couldn’t hide. I was constantly paranoid. Empty hallways felt like long, dark alleys. My routes to class became so circuitous that I started arriving chronically late. Even then he would find me. My “big brother” cannily chose to punch me in the arm so my bruises would not reveal the abuse. I would take my tardy slip without a word and then settle into my desk still shaking. He told me he had come by my house and knew which window faced into my bedroom. I’d never been so terrified in my whole life. I was too scared to tell my parents. I was too embarrassed to tell my friends. I felt paralyzed.

That was 1992. Exactly twenty-years ago. However, back then, when I went home from school I felt safe. I didn’t have a cell phone to receive harassing text messages. As these were the days before Facebook, I didn’t have any nasty posts waiting for me. In this era of incredible connectivity among young people there is seemingly no respite from such harassment. This all-encompassing psychic pounding of vulnerable young people has accompanied a frightening uptick in suicides in the context of bullying. During the last school year, “John,” a 7-year-old student in Miami, Fla. was bullied and sexually assaulted by an older classmate to the point that he attempted suicide once by deliberately standing in traffic with his eyes closed and another time by sticking a metal hanger into an electrical socket. Rachel Ehmke, a 13-year-old seventh grader in Mantorville, Minn., died April 29, 2012 after hanging herself at her home after receiving merciless texts and reading school graffiti calling her a “slut.” Perhaps most famously, on the evening of September 22, 2011, Rutgers University student Tyler Clementi posted from his cell phone on Facebook, “Jumping off the gw bridge sorry” after which he jumped to his death from the George Washington Bridge. Clementi’s death followed soon after his roommate secretly recorded and streamed online video of Clementi being intimate with a male partner in his dorm room. Seemingly no age group is spared. These are our elementary school students. These are our high school students. These are our college students. As a parent of a toddler, I find myself asking, “What would I do for my daughter in this situation?” Even worse, since I cannot predict how bullying will evolve, I feel woefully unprepared to protect her. I feel paralyzed in a similar way to when I was bullied myself.

Perhaps the most surprising element of this worsening and evolving trend is that the advice we as adults give our children does not seem to be working. Stan Davis, LCSW and Charlisse Nixon, PhD conducted the Youth Voice Project, a research project surveying 13,000 students’ perceptions in grades 5-12, from 31 schools in 12 states of strategy effectiveness to reduce bullying in schools (http://www.youthvoiceproject.com/). Sadly, some of the most commonly recommended strategies by adults (i.e., telling the person to stop, telling the person how I feel, walking away, and pretending it doesn’t bother me) produced markedly worsening of bullying. Furthermore, worsening of bullying was reported when school staff gave reprimands rather than strategies, i.e. saying if they had acted differently they would not have been mistreated, telling them to solve the problem themselves, or silencing youth by telling them not to tattle.

So if our traditional ways of advising our children are ineffective, what seems to work? Davis and Nixon’s research suggests that telling an adult at home, telling a friend, and telling an adult at school seem to make things better more often than make them worse. Overall it seems that the age-old recommendation to  “take matters into your own hands” is not only ineffective but frequently contributes to worsening the issue rather than improving it. Instead, approaching the issue by making others aware (peers and adults) seems to have an appreciable effect in reducing abuse.

Even though there weren’t such well-developed studies when I was in the sixth-grade, I coincidentally ended up doing one of the recommendations from the Youth Voice Project. After a few months, I simply could not tolerate the physical and psychological toll. I gingerly walked into my Principal’s office and tried to explain the situation calmly and rationally but couldn’t help but to burst into tears mid-sentence. I didn’t know how devastated I really was until I saw her reaction to my runny face. I frequently think about her consolation and how she completely understood the fear and misery of daily bullying. I’m not sure exactly what happened but I was never harassed again by this particular boy. To that particular Principal (you know who you are) thank you so much. As we start this new school year, I am reminded that in a world where bullying has become more vicious, pervasive, and lethal, we as mental health providers need to further examine this difficult subject and our students need more educators like my Principal.

Saturday, September 1, 2012

Oak Creek Massacre: Trying to Understand Hate Crime (Hum Magazine, September 2012)

The Federal Bureau of Investigation defines hate crime (also known as bias crime) as “a criminal offense committed against a person, property, or society that is motivated, in whole or in part, by the offender’s bias against a race, religion, disability, sexual orientation, or ethnicity/national origin.” While we will never know the motivation behind Wade Michael Page’s rampage at a gurdwara in Oak Creek, Wisc. last month, through his affiliation with white supremacist organizations and claims by his friends that he talked about an impending “racial holy war” it stands to reason that his offense was motivated by hate.

As a mental health provider I am curious about what motivates people to commit such atrocities. I find the word “hate” to be too generalizing to precisely identify the motivations for these crimes. Fortunately, some social justice literature has been generated on this topic to help parse this word out. In a 2002 study, McDevitt et al. suggested that hate crime offenders can be grouped by four motivations: thrill seekers (66%), offenders who view themselves as defending their turf (25%), those responding to a real or perceived hate crime (8%) and a small group of offenders whose life’s mission is to rid the world of groups they consider evil or inferior (1%). Their investigation using data from the Boston Police Department suggests that the most common type of hate crime was one where an attack was committed for the thrill or excitement experienced by the offender. According to McDevitt et al., “In 91 percent of these thrill-motivated cases, the perpetrators reported having left their own neighborhood to search for a victim in a gay bar, a temple in another part of town, or a minority neighborhood. The target was chosen because the offender perceived that the victim was in some way significantly different from the offender.”

The issue of “difference” plays prominently in the Wisconsin murders. If Page had attacked worshipers at a mosque, a link to the events of September 11th, 2001 might have been more comprehensible, although no less tolerable. Instead, he elected to attack non-Muslim Indian-Americans on a seemingly random day. This appears to be less likely an act of retribution against a certain group but rather against people who simply fit an perceived image of terrorism. While it may be appealing to explain the motivation for these crimes as a case of mistaken identity, in a recent piece for The Washington Post, Valarie Kaur and Simran Jeet Singh lucidly explain the pitfalls of such a hypothesis: “The notion of ‘mistaken identity’ is not just wrong, it’s dangerous. In the initial aftermath of 9/11, Sikhs told the media, ‘Sikhs are not Muslims.’ Our community quickly realized its mistake, and made a commitment to express solidarity with Muslims. Although we are distinct religious communities, we have shared in the experience of hate violence, religious bigotry, and racial profiling.”

While the issue of difference motivating Page frightens me very much, I find myself even more afraid of the “thrill-seeking” element of hate crimes as noted in the research by McDevitt et al. While psychiatric interventions would have likely been employed with Mr. Page had he survived, I see this as a second-best solution by virtue of it being after the event. Fundamentally, we as Americans must confront the fact that so many find a “thrill” in violence against a nameless, shapeless “other.” As a clinician I feel at a loss as to what effective measures can be taken. Certainly issues of bias begin early in life suggesting the value of an education that emphasizes tolerance. Also, a heavier emphasis on psychiatric evaluation in routine medical care could help to identify and help those at risk for such thrill-seeking violent behavior. Further research in this area, particularly in light of recent events, is merited. Until a clearer management strategy is developed, the best we can do is to support those who have been psychologically traumatized by these incidents and mourn those who we have lost.


Kaur, V. and Singh, S.J. (2012, August 10). Two Sikh Americans: Let’s retire ‘mistaken identity.’ The Washington Post. Retrieved from http://www.washingtonpost.com/blogs/guest-voices/post/two-sikh-american-activists-lets-retire-mistaken-identity/2012/08/10/776ab9d8-e329-11e1-a25e-15067bb31849_blog.html

McDevitt, J., Levin, J., and Bennett, S. (2002). "Hate Crime Offenders: An Expanded Typology (abstract)." Journal of Social Issues 58(2): 303–317, NCJ 204396. Retrieved from http://www.nij.gov/topics/crime/hate-crime/motivation.htm

Sunday, July 29, 2012

The unconscious way SLC citizens keep the peace (The Salt Lake Tribune, 6/30/2012)

The unconscious way SLC citizens keep the peace

After working for two years in Salt Lake City following years of living in New York and Boston, I left Utah last month for work back on the East Coast. A few months ago I wrote about my transition from New York City to Salt Lake City in “Why in the world would you move to SLC?” (Opinion, Feb. 12).

In that article I wrote about how my overall experience in Salt Lake was positive, particularly with respect to the friendliness of the people. Now that I have returned to familiar territory, I am struck by the differences between geographic areas but also the effect my time in Salt Lake has had on what I value in a city.

One unfortunate incident in my new city sent my mind reeling back to my life in Salt Lake. Three days after moving to New Haven, Conn., my wallet was stolen. After signing up for my library card I accidentally left my wallet in plain site while browsing the stacks.

While this error could have led to theft in just about any community, a very disappointing difference played prominently in this case. 

According to the officer with whom I filed my police report, a library patron reported seeing a wallet to the circulation desk employees. To my surprise, they proceeded to do nothing, and the wallet was subsequently stolen. While I do not hold anyone responsible for my carelessness, I couldn’t help but think, “You know, in Salt Lake, the librarian would have just picked it up and held it behind the desk.” 

Maybe I’m giving the citizenry of Salt Lake too much credit, but my gut says otherwise.

I use this example not to highlight urban crime but rather to contrast the sense of community or lack thereof certain cities evoke. While living in New York City I learned to love the independent every-man-for-himself vibe. However, the communal feel of Salt Lake charmed me and shifted my perspective on what I value in city life.

In my theft case, certainly all of the requisite municipal services were well-executed, including the swift arrival and professionalism of the New Haven police, even considering the relatively low-level nature of the crime. Despite the appropriate police response, I will never forget how I felt as I left the library. 

Once all the paperwork was done, I walked out into the street with only my new library card and two books, past hurried sidewalkers who avoided eye contact, didn’t smile or say hello. At that moment, the financial loss and bureaucratic headache of replacing my identification and credit cards felt immaterial. Instead, I couldn’t shake the great city paradox of feeling completely alone in a crowd.

When I think about my situation I recall the writing of urban theorist Jane Jacobs: “The public peace — the sidewalk and street peace — of cities is not kept primarily by the police, necessary as the police are. It is kept primarily by an intricate, almost unconscious, network of voluntary controls and standards among the people themselves, and enforced by the people themselves.” 

I believe Salt Lake is a city wherein such an unconscious standard prevails. A police presence would not be the impetus for a Salt Lake librarian to use common sense and pick up an accidentally misplaced wallet. Rather, picking up a wallet is a choice to preserve the public peace that does not require a sidearm, badge or uniform. 

For all the advantages and resources of my new home, I will miss those simple acts of kindness that serve to bind the Salt Lake community. 

Arjune Rama completed his psychiatry internship at University of Utah School of Medicine. He will continue his psychiatry training at Yale in July.

© 2012 The Salt Lake Tribune

Wednesday, May 16, 2012

Commentary: Childhood insult was an odd reminder of American heritage (The Detroit News, 5/16/2012)

May 16, 2012

Commentary: Childhood insult was an odd reminder of American heritage


"Go back to your own country!" shouted a neighbor from her porch. I heard this as I was taking a shortcut through her yard from the neighborhood soccer field to my house during the summer between seventh- and eighth-grade.

While one might expect my first response to be stomach-burning anger, my first feelings were of pure surprise. I thought to myself, "But ... this is my country ..." It wasn't until I did a faceplant into my bed that I burst into tears. I felt confused. I felt ashamed. I began to ask myself, "Do I not belong?"

I was born in Detroit and graduated from the same neighborhood school where I went to kindergarten. I don't have an Indian accent. I don't say this as a point of pride; it's just a fact. The country to which my neighbor referred is a place I have visited twice — once as a baby and once when I was 11 years old. In my opinion, I was as Michigan as they get. As a child I would forget that I didn't look like every other Grosse Pointe teenager. Human eyes face outward.

A little background on my family. My mom and dad were born in Chennai, India. My father came to Detroit to receive training as a general surgeon and then sub-specialized in vascular surgery at St. John Hospital, where he has been treating patients for over 30 years. My mother earned her MBA from Wayne State at night while managing our household.

Despite her hectic schedule she made time to tutor me in chemistry, which is fitting because she also used to teach chemistry at a local college. Since graduating, she has worked in banking in Metro Detroit for nearly 15 years. So while my parents were born and raised in India, they have spent the greater part of their lives in Michigan. Their roots are Indian but their hearts, minds and citizenship are red-white-and-blue.

I'm an American citizen with Indian heritage. I'm married to an American citizen with European heritage. We have a child who is an American citizen with Indian and European heritage; she's a living, breathing symbol of the American "melting pot." I've never felt more like an American than I do now.

To the woman who yelled, I'd like to say this: Thank you for reminding me that we're such a young country that we don't always know a true American when we see one.

As an aside, if you need some minimally invasive vascular surgery by an American who was trained in your neighborhood, lived in your area longer than you, and loves his country, I know a guy. Maybe we can provide some banking assistance from an American who studied locally and understands the economics of the area like the back of her hand.

Either way, let us know if we can help you out — it's the American way.

Arjune Rama was raised in Grosse Pointe Shores. He will begin his psychiatry residency at Yale University School of Medicine this July.

Saturday, April 7, 2012

Seizure management as seen through Ken Kesey's "One Flew Over the Cuckoo's Nest"

Here is my first attempt with the web-based presentation platform prezi.com to weave medically relevant fiction with clinically applicable information. My goal is that you can read the text with with some sidebars that are interesting and informative such that the clinical material is more memorable. The presentation is best viewed by scrolling over the lower right corner of the bottom bar and clicking "Fullscreen." Also, you can zoom in and out as you please by scrolling your cursor over the left-hand part of the page where you'll find "+" and "-" signs.

Thursday, April 5, 2012

Common errors on psychiatry rounds as seen through Sylvia Plath's "The Bell Jar"

click for larger view

The above excerpt copied into my notebook is from Sylvia Plath's The Bell Jar (1971) with my annotations.

Plath presents her protagonist Esther Greenwood's initial evaluation by the rounding team. She describes the unsettling feeling of suddenly being addressed by a "troop of young boys and girls" with an older gentleman, presumably the attending physician. I've circled Esther's statements to her treatment team in blue

In sum we see the following problems:

1) No introduction to the patient by the treatment team delineating the names or various training levels of the crowd (medical student? intern? resident? attending?).
2) Practitioners forcing a cheerful smile as if patients can't suss out real from fake.
3) The need to appear pensive when evaluating psychiatric patients (the 'Hmm...').
4) The desperation of medical students/residents to appear correct in the eyes of their superiors fostered by the current style of clinical medical education (a trainee going so far as to correct a patient regarding her own sleep habits).
5) Neither the students nor the attending address any of the four issues she raises regarding feeling lousy, being unable to sleep, feeling unable to read, and experiencing a lack of appetite.
5) No discussion of the plan with the patient who is swiftly turfed to another provider.

Overall, I think this passage serves as a simple resource to teach third-year medical students some common errors found on psychiatry rounds as seen through the eyes of a patient.

Saturday, February 11, 2012

NYC to SLC (The Salt Lake Tribune, 2/11/2012)


“So, are you converting to Mormonism?”

“Are you going to get another wife or two?”

These are some of the questions I was asked when I told my friends that my wife and I were moving from New York City to Salt Lake City for work. At first I laughed them off, but after hearing the same questions over and over, I asked myself, “What’s with all the Mormon-bashing? When did that suddenly become OK?”

I imagine that if I were moving to San Francisco, no one would ask me if I was coming out of the closet. If I were moving to Detroit, no one would dare ask if I was going to buy a gun to carry to work. And yet, when it comes to the LDS Church, its open season for jokes that border on ignorance and often cross into outright bigotry.

The most surprising aspect of these barbs is that they often came from people who belong to minorities that have been stereotyped and marginalized into oblivion: Muslims, homosexuals, among others. Often the people who made these comments are some of the most tolerant and accepting people I know in almost every other respect.

And what has been my “Mormon experience” in Utah? I hardly notice it at all.

I think people have knocked on our door once or twice. No one has suggested that I take on more wives. In fact, the mainstream LDS Church denounced that practice long ago. When I’ve visited the Salt Lake Temple grounds I have been approached a couple of times with offers of more information about Mormonism. But when I declined, the young women handing out pamphlets respectfully allowed me to go about my business. In fact, if I went to the very center of any religion and didn’t get solicited, I’d be halfway disappointed.

Allow me to explain our particular situation and thereby qualify some of my statements. We live in a fourplex occupied exclusively by graduate students or hospital employees near the University of Utah, so we likely get less exposure to religious proselytizing than most. I am sure our location contributes at least in part to our not noticing the Mormon influence about which we were constantly warned. That being said, here are the four major differences I have noticed in Salt Lake City which are a function of it being the center of The Church of Jesus Christ of Latter-day Saints:

1. Beer on draft at a restaurant/bar must have an alcohol content of 3.2 percent or less by weight. Bottled beers are unrestricted in alcohol content.

2. All beer purchased at convenience stores like 7-11 must meet the 3.2 percent rule.

3. All liquor or beer with an alcohol content greater than 3.2 percent must be purchased at state-run liquor stores.

4. These are the nicest, most polite people I have ever met.

As you can see, three of the four differences are related to alcohol.

There also is a quality that is undeniably welcome, especially to an interracial couple from out of state. My wife is Caucasian and I am an Indian-American. When we walk down the street pushing a stroller carrying our half-Indian, half-Caucasian daughter, well-intentioned people approach and speak in high-pitched baby gibberish, just like in any other city.

While I don’t mean to sound like I work for visitsaltlake.com, I can honestly say that I have never lived in a more pleasant and simultaneously more misunderstood city than this one.

Arjune Rama and his wife moved to Salt Lake City from New York City in 2010. He just completed a psychiatry internship at the University of Utah.

© 2012 The Salt Lake Tribune

Tuesday, January 17, 2012

#7 - "i won't back down" (tom petty cover) by Arjune

this is one of the most important songs to me. the original tom petty version gives me strength when i'm at my lowest of lows. i just got through a really tough situation so this is dedicated to my beautiful and patient wife, angelic daughter and the rest of my incredibly patient family who sacrificed so much to help me be successful. I can't say thank you enough. Thank you thank you thank you!!!