In a scene from the movie "Kinsey," opening in theaters on Friday, government agents seize a box of study materials being shipped by Dr. Alfred C. Kinsey, the pioneering sex researcher, and impound the contents as obscene. The scene portrays a time in American history, the 1940's and 1950's, when marital relations were rarely discussed and frank reporting about sex was greeted with a collective anxiety verging on horror. In 1948, when Dr. Kinsey published "Sexual Behavior in the Human Male," he was called a pervert, a menace and even a Communist.
      Much has changed in the years since then. But scientists say one thing has remained constant: Americans' ambivalence about the scientific study of sexuality. Decades after the sexual revolution, sex researchers in the United States still operate in a kind of scientific underground, fearing suppression or public censure. In a culture awash in sex talk and advice in magazines and movies and on daytime TV, the researchers present their findings in coded language, knowing that at any time they, like Dr. Kinsey, could be held up as a public threat.
      Social scientists say that for all its diverse tastes and freedoms, the nation that invented Viagra and "Sex and the City" is still queasy about exploring sexual desire and arousal, even when this knowledge is central to protecting the public's health. In July 2003, for instance, Congress threatened to shut down several highly regarded sex studies, including one of emotion and arousal, and another of massage parlor workers. And last summer health officials refused to finance a widely anticipated proposal backed by three large universities to support and train students interested in studying sexuality. As a result of this continued hostility, researchers say they still know precious little about fundamental questions, including how sexual desire affects judgment, how young people develop a sexual identity, why so many people take sexual risks, how personality and mood affect sexual health and how the explosion of sexual material on the Internet and trysts arranged online affect behavior.
      Perhaps the strongest protests have arisen in response to efforts to treat -- or even to study -- deviant sexual behavior like pedophilia, opposition that has grown only fiercer in the wake of the scandals in the Roman Catholic Church. "I have been in this field for 30 years, and the level of fear and intimidation is higher now than I can ever remember," said Dr. Gilbert Herdt, a researcher at San Francisco State University who runs the National Sexuality Resource Center, a clearinghouse for sexual information. "With the recent election, there's concern that there will be even more intrusion of ideology into science." He added, "But then, this country has always had a troubled relationship with sex research."
      Much of the suspicion is rooted in religious belief. Many devout believers see any effort to catalog sexual behavior as akin to publishing a field guide to carnal sin, an invitation to deviancy. "We know the formula for sexual health, which is sex within a monogamous lifelong relationship," said the Rev. Peter Sprigg, director of marriage and family studies for the Family Research Council, a conservative lobbying group based in Washington. "Studying permutations of it, we think, is an effort, like Kinsey's, to change the sexual mores of the society so that what most people consider deviant behaviors look more normal."
      Although religious conservatives have always objected on principle to sex research, several things have changed since Dr. Kinsey's time, said Dr. John Gagnon, an emeritus professor of sociology at the State University of New York at Stony Brook and the author of "An Interpretation of Desire." "Back then, white small-town Protestants' morality was American morality, and it spoke with one voice," he said. "Now they no longer solely define the conversation; there are competing secular voices talking about sexual health, about pleasure, feminism, the gay movement and so on." In response, Dr. Gagnon said, the critics of sex research have become more organized and politically connected. Mr. Sprigg agreed that conservative groups like Focus on the Family and the Family Research Council have coordinated their critiques of sex research to bring more public scrutiny to the projects. Late last year, the Traditional Values Coalition, an organization of 43,000 churches, publicly objected to some $100 million worth of government-backed research, much of it on sexual behavior, and compiled a roster of more than 150 researchers who had done sex studies. That roster has circulated widely among both critics and scientists, who call it a "hit list."
      "We've all learned to play the euphemism game, where we use code words to disguise the studies," to avoid showing up on such a list, said Dr. Thomas Coates, a sex researcher at the University of California, Los Angeles. Women who work in massage parlors are "high-risk women," and one recent survey of sexual behavior was titled "Social Aspects of Fertility-Related Behavior." In 2003, a small federal grant for a study called "Mechanisms Influencing Sexual Risk Taking" put Kinsey's institute itself, now called the Kinsey Institute for Research in Sex, Gender and Reproduction, back in the fray. The research addresses a question that public health officials say is critical: Why do some people knowingly take sexual risks that could be avoided with simple precautions, like wearing a condom?
      "All of the public health messages teaching people safe sex are designed on the presumption that people behave rationally," said Dr. Erick Janssen, a psychologist at the institute, on the Indiana University campus, and the principal investigator on the study. "But many of them don't, and so the message isn't helping them. In order to understand how best to design these messages we need to understand how they are thinking."
      In Dr. Janssen's continuing investigation, adults enter a small screening room at the institute, where they sit alone and watch film clips on a computer monitor. In one experiment, the participants see a short segment from the movie "Silence of the Lambs," meant to elicit anxiety. They then watch a few minutes of a pornographic video. By measuring arousal, with genital, heart and muscle sensors, Dr. Janssen expects to learn more about how waves of emotion affect arousal, and which states prompt the most reckless sexual behavior. The findings, he and other researchers say, will help scientists understand not only who is likely to risk his health or marriage by taking sexual risks, but when and why. "Then we can begin to intervene more effectively," he said.
      Congress, however, intervened first. In July 2003, Representative Patrick J. Toomey, Republican of Pennsylvania, introduced an amendment to withdraw financing from Dr. Janssen's study and several others. The proposal fell short on the House floor by two votes, but not before the studies were criticized in The Washington Times and ridiculed on conservative blogs and talk shows.. Mr. Sprigg said: "Using government dollars to pay for people to watch porn? I wonder how many Americans would be comfortable with that."
      Another reason many Americans are uncomfortable with sex research is that surveys and genital sensors cannot capture what for many people is a deeply emotional experience. In striving to be neutral, Dr. Kinsey, who trained as a zoologist, described and cataloged human sexual behaviors in the same way he might have with lizards or the gall wasps he studied before turning to men and women. Yet sex for humans is far more complex. It can feel like the cement that binds a romantic relationship, or like a lonely embrace, a listless act. It may enliven a friendship, unsettle a marriage or cause a timid nature to glow with confidence. "Studying sex through physiology, as if it were just another behavior ignores what's going on in people's minds, their own fantasies, their conflicted wishes," said Dr. Leon Hoffman, co-director of the Pacella Parent Child Center in New York. "Using measuring devices, sensors, reduces it to just a physical act, when most of what's going on is mental and not always conscious."
      Nor is sex always an act between equals. Some sexual acts -- harassment and molestation, for example -- beg for judgment, not scientific neutrality, especially when a difference in power or age is involved. That is why almost any discussion of sexuality in minors has been politically radioactive, experts say. In a public condemnation that stunned many sex researchers, Congress in 1999 voted unanimously to denounce a research article in an arcane journal that concluded that some victims of childhood sexual abuse suffered little long-term emotional damage. The article was not an original experiment but reviewed previous surveys. The American Psychological Association, which had published the paper, decided to have an independent panel "re-review" it -- a decision that outraged some of the group's own members and led some scientists to resign from the organization. Although many experts say the paper was scientifically sound, few have dared even propose a study of sexuality involving minors since then, scientists said.
      Pedophilia in particular is off-limits. Psychiatrists and psychologists have studied and tried to treat people imprisoned for sexual crimes, with limited success. But it is not clear whether these convicted felons are representative of all people who have sexual fantasies involving children. People do not choose to become pedophiles, experts say, but usually discover as adults that they are afflicted with unusual desires, and many long resist the urge to act on them. Researchers know that boys who are sexually abused themselves may be at increased risk of developing pedophilia later on, but they still know little about how these urges develop, or in whom. "The intensity of the emotion on this issue is so high that it is heresy to express any concern about a person with pedophilia," much less study treatment, said Dr. Fred Berlin, founder of the Johns Hopkins University sexual disorders clinic. He added, "Since the Catholic Church scandal, I don't know anyone who has even had the nerve to suggest that some in the church are ill and need help." A concern for privacy, which some trace to the small-town morality of Kinsey's time, also has contributed to the wariness many Americans feel when asked to reveal sexual preferences they know may be perceived as quirky or strange.
      Kinsey's original sex surveys revealed the diversity in Americans' sexual behavior: many heterosexual men reported having homosexual experiences. A teenage rock guitarist down the street might stick to conventional monogamy, while her neighbor, an accountant, might prefer role-playing games with multiple partners. Often people themselves are not entirely aware of what most arouses them sexually, studies suggest. In one recent experiment, psychologists found that women could be as aroused by images of homosexual sex as by films of heterosexual sex. This is a provocative finding and may offer important clues to improve sexual health, but it is often not something the woman next door wants to talk about with a researcher, even anonymously. Sexual taste is a wild card, in short, and one that many people would prefer be kept face down. "A lot of high level people in government and politics are very sensitive to the kind of sexual surveys we do, not so much for religious reasons, but because they just say, 'Look, I would never answer those questions,' " said Dr. Edward Laumann, a sociologist at the University of Chicago.
      In 1994, Dr. Laumann and a team of researchers published "The Social Organization of Sexuality," a comprehensive survey of Americans' sexual behavior, which won praise from people on each side of the sex research debate for its integrity, and updated Dr. Kinsey's original work. They found that about 75 percent of the people they surveyed did agree to answer detailed questions about sex, but many did so only after being convinced that their answers were absolutely anonymous and critical to science. It was only last-minute financing from private foundations that allowed the study to be completed at all, Dr. Laumann said, after the government reversed a decision to support the survey.
      Scientists who have spent their lives studying sexual behavior say that the political climate tends to be cyclical, with periods of cold hostility followed by thaws that are often driven by bursts of public concern, like increased worry about sex among young people in the 1960's and teenage pregnancy in the 1970's. "When the AIDS epidemic hit in the 1980's," said Dr. Anke A. Ehrhardt, a Columbia University professor and director of the H.I.V. Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute, "the government had to do research because sexual behavior is at the core of the problem." Since then, the climate for doing sex research may have become even more hostile, she and other researchers said, particularly outside the context of H.I.V. Dr. Laumann, for example, finally managed to find financing for a recent study of sexual behavior and the risk of sexually transmitted disease that should help public health officials contain the spread of chlamydia, a common infection. Where did he conduct the study? In China.



So You're a Loser
Jennifer Huget, Washington Post- 11/9/2004

It wasn't supposed to be this way. Everybody knew you were supposed to be the one relishing that victory lap, high-fiving your teammates, hanging your nameplate on the door of the corner suite, tossing back a few in celebration. Instead, your team's been drubbed and you're left on the bench, stone-faced, chin in hands, nursing thoughts less charitable than when your date tossed a drink in your face. It's bad enough that you lost, but on top of that you had to fall to those people, a bunch of jerks who don't have half your team's wit or talent. And now you're going to have to watch them strut for way too long before you get another crack at sending them back to the minors where they belong.
      Maybe it's just us, but somehow lots of people in town seem to be feeling that way. Let's face it, losing stinks -- whether it's on the field, on the job, on the road to love or at the ballot box. And losing to a hated rival -- Yankees vs. Red Sox, Apple vs. Microsoft, Redskins vs. Cowboys, Tony Soprano vs. Johnny Sac -- multiplies the pain. But experts who regularly counsel competitive athletes, job candidates and others struggling to get ahead in the world say there are ways to ease defeat's sting and not let yourself sink into a prolonged funk. Losers can use their bitter experience to grow stronger -- and give themselves a leg up in the next big contest.
      Tell that to Cindy Curtis of Reston. Curtis, who campaigned in her community for Sen. John Kerry, had one word last week for how she felt: "Awful." "I'm in mourning," Curtis said. "I really am quiet, angry, introverted. I feel very defeated. . . . I won't turn on the TV or read the paper for a while; it's just too much. You've got to be able to swallow something and digest it, and then take the next step."
      According to psychologists, Curtis is on the right track. Whether you're a defeated presidential candidate, a voter who got outvoted or an unsuccessful bidder for a job, a lover or a title, you've got to first process the pain before you can put your loss behind you. "Grief is cathartic," said Joseph Mancusi, president of the Center for Organizational Excellence, a consulting firm in Sterling that helps businesses handle teamwork, leadership, stress management and other issues. "You need to feel down and get it out of your system."
      That done, advise experts, it's time to move on. Easy for them to say. Paul Baard, a motivational psychologist at the Fordham University School of Business in New York, admitted this takes a lot of self-discipline, especially in the immediate aftermath. "You need to ask yourself, 'How quickly can I recover and get on with life and make the best of it?' It's an opportunity to work on your psychological health," said Baard. "You can't keep playing the game after the last inning. You have to take 'no' for an answer."

Equipment Check
Some of us, say psychologists, are better equipped than others to turn loss to our advantage. One of the characteristics of successful losers, so to speak, is the ability to compartmentalize, said Colleen Hacker, professor of physical education at Pacific Lutheran University in Tacoma, Wash., and consulting psychologist to the U.S. Women's National Soccer Team and other elite athletes. The trick, she said, is to "keep [the loss] confined to the appropriate space and time" and to "separate what happened to you from who you are as a human."
      Hacker also cites hardiness, a "personality trait that helps people buffer against adverse events, and resilience, the ability to successfully adapt and maintain a relatively stable and healthy ability to function, physically and psychologically, even in the face of loss, stress, difficulty or trauma." The athletes with whom Hacker works already usually possess hardiness and the ability to compartmentalize. That's part of how they rose to the top of their fields, she said. The non-elite rest of us, alas, have to work hard to cultivate those qualities.
      Hacker, who once delivered a speech to the National Institutes of Health called "Failure as Fertilizer," challenges her defeated clients to use loss to build their skills. "What action steps can you take in the future based on lessons learned from this adverse event?" she asks. Jerry Isaac of Suitland, who was hoping for a change in the White House, has asked himself that very question. "It makes me rethink what I need to be doing for the next four years, what I need to do to help people look at issues through a different prism," he said. "I was not an active participant in this campaign. Maybe these results will make me more active in the future."

Productive Failure
You know the old saw: What doesn't kill us makes us stronger. In psychology-speak that phenomenon is known as "productive failure." Mancusi says the key to productive failure is optimism. "An optimist says, 'We're not dead, we lost an election' and goes on to look for positive things still to do." This approach is far healthier, Mancusi said, than withdrawing, feeling victimized or taking the loss personally.
      "Joe Gibbs is an optimistic coach," Mancusi said of the Redskins' newly returned leader. "He doesn't permit gloom and doom. He looks for people who respond to adversity with a renewed sense of challenge. He can say, 'I've been through this before; we're going to get through this.' "
      Unfortunately, Mancusi said, it's hard for pessimists to convert to optimism, especially in the face of a nasty loss. But, like Hacker, he said losers can improve their game by building resilience. Mancusi's suggestions:
• Ask yourself: "Where have I been before? Haven't I survived?"
• Identify and realistically assess your own strengths.
• Ask yourself: What could I change so I don't go on defining myself as a loser?
• Focus on the challenge ahead, not the mess behind. Keep your eye on the next hole, not the one you just played.
• Rehearse -- don't just list -- the changes you want to make.
• Construct an optimistic world in which you can draw on a number of these things you've worked on when something bad happens again.
      "If you're going to count Babe Ruth's strikeouts," Mancusi said, "you'll never see the home run in the person. And you won't be able to hit the ball when it's coming at you at 95 miles per hour."

Say It Like You Mean It
Curtis, who says she works "in a Republican environment," found it hard to pull herself out of bed and into the office the day after the election. Once she got there, she said, the silence was deafening. "Nobody's gloating," she said. "They're just not talking."
      Time was when no one would have thought anything unusual about that, when it was considered impolite to discuss politics (or sex or religion) in public. Back then, said etiquette expert Peggy Post of the Emily Post Institute, "you really didn't talk about politics. These days it's part of our culture." Given that, Post said, exchanges between victors and the vanquished should follow a few basic rules: Show respect, kindness, consideration. "Hopefully a lot of people learned when they were kids to be a good winner and a good loser," Post said.
      Last week's post-election speeches set good examples for the nation's winners and losers, and demonstrated that the candidates had learned those elementary lessons: Each acknowledged the opponent's strengths and goodwill. Kerry gracefully conceded and offered his congratulations; President Bush refrained from crowing and rubbing salt in Democratic wounds. (In California, Gov. Arnold Schwarzenegger deviated from the model. Asked if he would consider budget-balancing proposals from Democrats, he replied, "Why would I listen to losers?")
      Isaac said he and a Bush-supporting colleague have followed the more generally approved model. The colleague, he said, "praised [Kerry's] concession speech. Even though I think [the colleague] made the wrong decision, I respect the fact that he did make a decision based on his own beliefs -- and he got out and voted. Our discussion wasn't about what happened, but what can happen in the future."
      Not every encounter will be so congenial. If you find you're at a loss for words, consider this tip from Post: "It is gracious to fall back on principles of etiquette," she said. "To say 'congratulations' is good -- if you can do that." As for the winners, Post admonishes, "Don't gloat. That's not constructive."

Michigan Senate Passes Mental Health Reform Legislation
Associated Press, 11/10/2004

LANSING, Mich.-- A mentally ill person who's been hospitalized, jailed or has a violent history could be ordered to receive outpatient treatment if they refuse to comply with their prescribed treatment under legislation approved Wednesday by the state Senate. The measures, which now go to the House, also would let a person designate a patient advocate to make mental health treatment decisions for him or her in the future -- much like what already is done for physical health decisions. The Senate voted 36-0 to pass the 13-bill package. Democratic Sens. Dennis Olshove of Warren and Buzz Thomas of Detroit were absent and didn't vote.
      Part of the package is known as Kevin's Law, named for Kevin Heisinger, a University of Michigan graduate student who was killed by a mentally ill man in a Kalamazoo bus station in August 2000. The attacker was a diagnosed schizophrenic with a history of problems who didn't comply with mental health treatment.
      Sen. Tom George, a Republican from Texas Township in Kalamazoo County, said the legislation would provide an alternative to hospitalization for individuals with a severe mental illness but still give them the help they need. He said too many of the mentally ill end up homeless or incarcerated. The bill would protect the public, George said, by letting family members and others intervene to get mentally ill people treatment before they hurt themselves or others. It would allow any person at least 18 years old to file a petition saying that a person meets the criteria for assisted outpatient treatment. A community mental health program would be required to provide the treatment -- picked up by the program or Medicaid.
      Mark Reinstein, president of the Mental Health Association in Michigan, said Kevin's Law essentially gives courts and mentally ill people more options. Instead of ordering someone to receive treatment in a hospital or other facility, a judge could choose outpatient treatment. Another part of the package involves patient advocates -- those who work on behalf of patients receiving treatment. Reinstein said extending patient advocacy to the mental health field would follow a trend of giving patients more choice early on. "At some point in time when people are functioning well they think about what could happen if they become highly dysfunctional," he said. "They could record their wishes now ... to prepare for the future." The outpatient treatment bills are Senate Bills 683-86; the patient advocate bills are SBs 1464-72.
      On the Net:
Michigan Legislature: http://www.michiganlegislature.org
Mental Health Association in Michigan: http://www.mha-mi.org

Medical Board Takes Radio Psychiatrist's License
Associated Press, 11/11/2004

PORTLAND, Maine -- A prominent Portland psychiatrist is losing his medical license after a state board determined he engaged in "unprofessional and incompetent" conduct during his treatment of a patient in the past decade. The Board of Licensure in Medicine found that Dr. Carl D. Metzger compromised the doctor-patient relationship, scheduled and charged for unauthorized appointments, and encouraged inappropriate dependencies. The complaint filed in April 2002 involves treatment of a single family over a decade, said Randal Manning, the board's executive director. The case did not involve children, drugs or inappropriate involvement with a patient.
      Metzger is a parenting consultant with a practice in Portland's Old Port. He is the author of "The Secret to Happy Children and Grandchildren" and the "Good Parenting Guide" and was the host of a radio talk show for 10 years. Specific allegations have not been disclosed, but Metzger said he plans to appeal the board's ruling.
      Metzger, who characterized the issue as a matter of psychological and philosophical differences, questioned how his behavior could have warranted a "Draconian" response after months of waiting for the board to rule. "The board basically kept it on the shelf until the hearing," Metzger said. "That made me baffled and shocked, that something would then warrant me being punished in the most extreme form." The appointments were worth about $100,000, but Metzger said he accommodated the family for other sessions worth well over $400,000 over 13 years.
      Manning said the hearing was ordered in October 2003. The investigation, Metzger's change of lawyers, requests for delays and scheduling problems pushed the hearing to this week, he said.

When Smoking Becomes a Disorder
Linda Marsa, Los Angeles Times- 11/12/2004

Smoking is the leading cause of preventable death in the United States. Yet despite overwhelming evidence that smoking can kill, more than 2 of 10 Americans continue to light up. A new study may provide insights as to why.
      Almost 70% of smokers suffer from some type of psychiatric or mental disorder, including nicotine dependence, the study found. That dependence is considered more severe than a simple habit and is defined as a chronic addiction to nicotine, comparable to other substance abuse disorders. Such disorders make quitting smoking even more difficult than would ordinarily be expected.
      Researchers at the National Institute of Alcohol Abuse and Alcoholism in Bethesda, Md., analyzed the 2001-02 National Epidemiologic Survey on Alcohol and Related Conditions and subsequent interviews with 43,093 people with psychiatric disorders. The study revealed that nicotine-dependent people make up only 12.8% of the overall population but consume 57.5% of all cigarettes smoked in the United States. Similarly, nicotine-dependent people who also have psychiatric disorders comprise 7.1% of the population yet smoke 34.2% of all cigarettes. "These are huge numbers," said Bridget F. Grant, the lead author of the study and an epidemiologist at the institute.
      Grant defined nicotine dependence as a mental disorder in which compulsive use is often chronic and continues even though people have serious medical conditions that are caused or exacerbated by smoking. "These are people who've tried to quit a million times and can't, and also have severe withdrawal symptoms — nausea, vomiting, anxiety — when they try to stop," she said.
      If smoking cessation programs are to be successful, Grant said, they also must target the underlying mental disorders, such as nicotine dependence. "These people need more than just a patch to quit," she added. The study appeared in the November issue of the Archives of General Psychiatry.

Doctors Often Miss Teen Substance Abuse
Valerie Reitman, Los Angeles Times- 11/12/2004

Severe alcohol and drug abuse by teenagers may be easily missed during routine and urgent-care medical visits, particularly in girls. In a study published in the November issue of Pediatrics, researchers highlighted not only how often clinicians fail to notice the chronic problem in routine examinations, but also how seldom they seem to ask teens structured questions to determine how frequently they take drugs or alcohol.
      In 2002, examinations of 500 urban adolescents, ages 14 to 18, at Children's Hospital Boston failed to detect use or recurrent abuse in about 40% of the more than 100 teens who were later determined to have serious problems. In the 60% of cases in which clinicians correctly identified some use of alcohol or other drugs, they vastly underestimated the severity: Only 10% of recurrent "abusers" were correctly identified while "dependence" was missed in all 36 cases later diagnosed. Yet, when the teenagers were asked specific questions about drug-and-alcohol related behavior in separate interviews after their exams, they were likely to talk about their use of alcohol or drugs. "While a structured screening tool won't necessarily make the adolescent reveal the problem, it hopefully would give the provider a structured way to ask about it," said lead author Dr. Celeste Wilson, a pediatrician and researcher at Children's Hospital Boston.
      Adolescent substance abuse is a chronic problem that contributes to automobile accidents, unwanted pregnancies, sexually transmitted diseases, suicide and crime, and can also be a symptom of underlying mental problems such as depression. Some studies indicate that the majority of adolescents have tried alcohol or another drug by the time they reach 12th grade. Some studies estimate that about 1.4 million teens regularly abuse illicit drugs. As a result, the American Medical Assn. recommends that health care providers screen all adolescents for substance abuse during routine physical exams.
      The authors of the study recommended that medical staff routinely ask teenagers five questions, which they developed into a mnemonic, CRAFFT:
C: Have you ever ridden in a car driven by you or someone else who was using alcohol or drugs?
R: Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
A: Do you ever use alcohol or drugs while you are alone?
F: Do you ever forget things you did while using drugs or alcohol?
F: Do your family or friends ever advise you to cut down on your drinking or drug use?
T: Have you gotten into trouble while you were using alcohol or drugs?
      Funded by the Robert Wood Johnson Foundation, the study involved more than 100 physicians, residents, medical students and nurse practitioners who completed a form giving their clinical impressions about each teen's degree of substance use (none, minimal, problem use, abuse, dependence) after a physical exam with the patient. (The residents were not told the purpose of the evaluation.)
      Of the more than 100 teens who were later identified to have "problem use," the providers correctly identified just 18. Of the 86 most serious abusers (who fell into the "abuse" or "dependence" categories), providers underestimated their problem, categorizing the teens as having no use (24%); minimal use (50%); problem use (15%); abuse (10.5%) and dependence (0%). The problems were more likely to be identified in boys, perhaps because boys are more likely to abuse substances than girls and so clinicians may be more likely to suspect them to be substance abusers, while inaccurately giving the girls the benefit of the doubt.
      Tests that detect the presence of drugs or alcohol in the blood or urine were not used, said Wilson, and she doesn't recommend them for routine screening because they can be misleading. A negative test doesn't necessarily mean that there isn't a problem, just that the substance wasn't used in the last several hours, she said. "It's much more important to understand and communicate what's going on and to get at the root of the problem," Wilson said.




'The Truth About the Drug Companies' and 'Powerful Medicines': The Drug Lords
Stephen Hall, New York Times Book Review- 11/14/2004

During the past year, when I was driving my children to school, I'd hear the same advertisement on the radio again and again. You've probably heard it too: as somber music played in the background, a young man, his voice cracking, explains how he developed a rare and deadly form of cancer. He wonders if he will ever play baseball with his son, and then relates how, thanks to a company called Novartis and its new cancer treatment (never mentioned, but a drug called Gleevec), he's been given a new lease on life.
      What is most fascinating about this ad is that it should seem necessary. As Marcia Angell points out in ''The Truth About the Drug Companies: How They Deceive Us and What to Do About It'': ''Truly good drugs don't have to be promoted. A genuinely important new drug, such as Gleevec, sells itself.'' So why advertise a cancer drug that cures a fatal leukemia and has no competition? The answer, of course, is that Novartis is not advertising Gleevec, but the company itself -- and the virtues of the drug industry as a whole. Why? Because, as Angell notes, a ''perfect storm'' of indignation -- on the part of consumers, regulators+and even doctors -- may be developing around the pharmaceutical business.
      In just one week this summer, the news included reports that Schering-Plough pleaded guilty to cheating Medicaid; the city of New York sued leading pharmaceutical companies, including Amgen, Bayer, Bristol-Myers Squibb, Eli Lilly, Johnson & Johnson and Merck, for inflating costs and defrauding taxpayers; Janssen Pharmaceutica Products admitted it had withheld from the public information about potentially fatal side effects in a schizophrenia drug it markets; and Wyeth settled yet another in the multibillion dollars' worth of lawsuits against it by people who suffered permanent injury from use of the fen-phen weight-loss drugs. All this against a broad public perception of price-gouging, lack of innovation and bombastic self-congratulation. And that brings me back to the Novartis ad.
      An alternative history for Gleevec is recounted in both Angell's methodical multicount indictment of the drug industry and Jerry Avorn's entertaining jeremiad, ''Powerful Medicines: The Benefits, Risks and Costs of Prescription Drugs.'' In this less heroic version, several decades of dogged research by academic scientists -- much of it paid for by American taxpayers through the National Institutes of Health -- had teased out the molecular details of chronic myelogenous leukemia, a rare and fatal hematological cancer. Researchers at Novartis (then Ciba-Geigy) created several compounds that in theory might throw a monkey wrench into the process by which blood cells become cancerous. But these potential miracle drugs sat on the shelf untested, until Brian Druker, a researcher at the Oregon Health and Science University, asked for the compounds and became the first to discern their anticancer properties in the lab dish. Even that wasn't enough. As Avorn tells it, ''Novartis had so little interest in committing resources to the drug's development that cancer researchers had to resort to the bizarre tactic of sending a petition to the company's C.E.O., signed by scientists in the Leukemia and Lymphoma Society of America, imploring him to make more drug available for clinical studies.''
      Novartis has overcome its lack of enthusiasm -- it now charges $27,000 for a year's supply of Gleevec. But those heart-warming ads, now the centerpiece of the Novartis corporate identity, say more than intended about how today's pharmaceutical industry takes credit where little is due. As both Angell and Avorn lay out in painstaking, often enraging, detail, a self-serving mythology -- promulgated on a scale possible only in a business with annual worldwide revenues of $400 billion -- has enveloped the pharmaceutical industry. Angell and Avorn cut through the haze, arguing persuasively that Americans are paying an enormous amount of money for some very mediocre medicines.
      The rising voices of disillusionment have the credentials to back up their scorn. Two of the season's most stinging anti-drug-industry analyses come from former editors in chief of The New England Journal of Medicine. Marcia Angell is one. Jerome P. Kassirer is the other; the title of his book, ''On the Take: How America's Complicity With Big Business Can Endanger Your Health'' (Oxford University, $26), says it all. Jerry Avorn, a professor at Harvard Medical School, helps decide what drugs are used in Boston's Brigham and Women's Hospital. And John Abramson was a doctor in family practice until, as he recounts in ''Overdosed America: The Broken Promise of American Medicine'' (HarperCollins, $24.95), he began to detect what might politely be called statistical legerdemain in articles promoting new drugs in the aforementioned New England Journal.
      These books are not simply diatribes against high prices and lagging development of new medicines. More disturbingly, the authors contend that the drug industry has polluted the scientific basis of modern medicine with rigged market-driven clinical studies that inflate the effectiveness of new, high-priced drugs while concealing their risks to patient safety. Angell's occasionally strident language, laced with terms like ''bribes and kickbacks'' and ''faux research'' seems hyperbolic -- until you consider that one week's worth of headlines.
      The reasons for the transformation of the industry's image from life-saving pioneer to robber baron are many. But at root is a profound shift in the hierarchy of influence and decision making within the companies themselves over the last two decades, as the traditional emphasis on research and development has given way to marketing. The change is everywhere apparent: in the background of many company executives, in the annual balance sheets (in 2001, Angell estimates industrywide marketing budgets at $54 billion, almost double research-and-development outlays, which the industry lobby puts at $30 billion), in the army of 88,000 salesmen (or detailers), trained to bird-dog doctors and persuade them to prescribe their company's drugs. Though much drug industry research remains outstanding, the system rewards what Avorn calls ''trivial pseudo-innovation''; shifting the emphasis from research to marketing was, he says, ''just responding rationally to the legal, regulatory and economic pressures of a marketplace that had become perverse.''
      Angell, who gives a vivid historical context, dates the ''watershed year'' to 1980, on the cusp of a era in which it became ''not only reputable to be wealthy, but something close to virtuous.'' The Bayh-Dole Act of 1980 basically turned academic labs into farm teams for industry research, allowing publicly funded researchers in academic institutions (where much of the real enterprise and innovation occur) to patent their discoveries and license them to the private sector; the law has created a thicket of licensing and royalty relationships, wink-and-nod consultancies and conflicts of interest. As Angell tellingly relates, the authors of one New England Journal article collectively owned up to so many financial conflicts that they had to be listed separately on a Web site. The headline on the editorial she wrote about the episode was ''Is Academic Medicine for Sale?'' One cynical reader replied: ''No. The current owner is very happy with it.''
      Then there was was the Hatch-Waxman Act of 1984, which did what it was ostensibly designed to do, make it easier for generic drug makers to put cheaper medicines on the market -- but at enormous cost to the consumer. In Angell's view, Hatch-Waxman was a Trojan horse bill; its loopholes meant that pharmaceutical companies could, with patent infringement suits costing, say, a mere $5 million, extend government-granted monopolies on popular drugs like Prilosec and Claritin, in some cases for more than four years, yielding them billions of dollars in additional revenue.
      It gets worse. Laws passed in the 1990's gave drug companies extraordinary financial influence over their primary regulator, the Food and Drug Administration, through so-called user's fees to expedite reviews of new drugs. And both Angell and Avorn quote Senator Bill Frist's devastatingly candid remark revealing that one respected candidate for the agency's top job in 2002 apparently lost industry support because ''there was a great deal of concern that he put too much emphasis on safety.''
      As for the recent Medicare reform bill, with its prescription drug benefit, Angell considers the measure a huge windfall for industry, because it explicitly forbids Medicare to bargain on prices. Indeed, Angell foresees a grim day of reckoning, and calls for its immediate repeal.
Pharmaceutical Research and Manufacturers of America, the industry's lobbying group, has tirelessly argued that high drug prices are needed to support the high-risk endeavor of drug discovery and development. Yes, the business is risky. But Angell gives us good reason to dispute the much-quoted figure of $802 million as the average cost for developing a new drug, and the assertions of innovative research and development. She cites studies showing that between 1998 and 2002, 415 new drugs received F.D.A. approval; only 133 were ''new molecular entities,'' or genuinely novel compounds, and of those, only 58 -- or 14 percent of all new drugs for the five-year period -- were considered likely by the F.D.A. to be ''a significant improvement'' over existing products.
      Avorn covers much the same ground, but comes at it by statistical analysis of drug effectiveness and safety. As a ''pharmacoepidemiologist,'' he studies large patient databases to determine how often certain medications are used and how well they work. His watchword is ''evidence-based medicine'' -- the use of randomized controlled clinical trials, in which participants are randomly assigned to receive, for example, a drug being tested or a dummy pill, or of large-scale epidemiological studies to determine with statistical rigor exactly which drugs are safest, most effective and, increasingly, most cost-effective. He laments that ''we have begun to allow the marketplace to usurp the place of evidence in determining which treatments are effective.'' The marketplace has also been very good about playing down side effects: Avorn's accounts of the systematic ''obfuscation of risk'' for two drugs ultimately withdrawn from the market, the diet drug Redux and the diabetes drug Rezulin, are stomach-turning in their detailing of corporate indifference.
      What to do? Angell's most urgent recommendation (among many) is to establish an independent mechanism within the National Institutes of Health, for testing prescription drugs against each other without involving the industry. Avorn, in arguing for more evidence-based medicine, lays out several nonprofit and for-profit scenarios for precisely that kind of independent, data-driven drug assessment. (My own view is that there will be a McDonald's on Mars before drug companies relinquish head-to-head clinical testing of their products -- precisely because high-quality data is a poison pill to most of their marketing.)
      In 1906, Upton Sinclair documented abuses in the meat-packing industry; his book, ''The Jungle,'' catalyzed outrage and helped lead to the Food and Drug Act of 1906, which set the first national food and drug regulatory processes. I doubt either of these books will have a similar impact. Public policy these days is mostly driven by events, not books. My guess is that it will take the pharmaceutical equivalent of a plane crash -- perhaps a devastating new influenza epidemic, a disease for which, as this flu season's experience makes painfully clear, fewer and fewer companies bother to make vaccines; or a hugely successful life-saving cancer drug whose high cost would make the economic wall between the haves (who get to live) and the have-nots (who don't) politically unsustainable. That unpleasant day of reckoning is almost upon us. These fine books go a long way in explaining how our medicine, once so vaunted, has become so bitter. The authors of one scientific article had so many conflicts, they needed a Web site to list them.

Oh, Fine, You're Right. I'm Passive-Aggressive.
Benedict Carey, New York Times- 11/16/2004

The marriage seemed to come loose at the seams, one stitch at a time, often during the evening hour between work and dinner. She would be preparing the meal, while he kept her company in the sun room next to kitchen, usually reading the paper. At times the two would provoke each other, as couples do -- about money, about holiday plans -- but those exchanges often flared out quickly when he would say, simply, "O.K., you're right," and turn back to the news. b"Looking back, instead of getting angry, I was doing this as a dismissive way of shutting down the conversation," said Peter G. Hill, 48, a doctor in Massachusetts who has recently separated from his wife. Even reading the paper at that hour was his way of adamantly relaxing, in defiance of whatever it was she thought he should be doing. "It takes two to break up, but I have been accused of being passive-aggressive, and there it is," he said.
      Everyone knows what it looks like. The friend who perpetually arrives late. The co-worker who neglects to return e-mail messages. The very words: "Nothing. I'm just thinking." Yet while "passive-aggressive" has become a workhorse phrase in marriage counseling and an all-purpose label for almost any difficult character, it is a controversial concept in psychiatry.
      After some debate, the American Psychiatric Association dropped the behavior pattern from the list of personality disorders in its most recent diagnostic manual - the DSM IV - as too narrow to be a full-blown diagnosis, and not well enough supported by scientific evidence to meet increasingly rigorous standards of definition. The decision is likely to have more effect on teaching guidelines and research than on treatment and insurance coverage.
      But psychologists and psychiatrists with long experience treating this kind of behavior say it is hard to study precisely because it is so covert, common and widely variable. These experts make a distinction between passive-aggressive behavior, which most people display at times, and passive-aggressive personality, which is ingrained and habitual. In milder forms it can come across as a maddening blend of evasiveness and contrition, agreeableness and impudence, and in severe cases is often masked by more obvious mental illness, like depression.
      Yet whether pathological or not, they say, the pattern is often traceable to a distinct childhood experience. New research suggests that in many cases it stems from a positive, socially protective instinct -- to keep peace at home, avoid costly mistakes at work, even preserve some self-respect. "Some of the people being demeaned as passive-aggressive are in fact being extremely careful not to commit mistakes, a strategy that has been successful for them," if not entirely conscious, said Dr. E. Tory Higgins, director of the Motivation Science Center at Columbia University. They become difficult, he said, "when their cautious instincts are overwhelmed by demands that they perceive as unreasonable." The classic description of the behavior captures a stubborn malcontent, someone who passively resists fulfilling routine tasks, complains of being misunderstood and underappreciated, unreasonably scorns authority and voices exaggerated complaints of personal misfortune.
      But the phrase itself has its roots in the military. Near the end of World War II, a colonel in the United States War Department used it to describe an "immature" behavior among enlisted men, many of them at the end of long tours: "a neurotic type reaction to routine military stress, manifested by helplessness, or inadequate responses, passiveness, obstructionism or aggressive outbursts." This kind of insolence, among adults protecting themselves from what they saw as unreasonable, arbitrary authority, was in part an adaptive behavior, psychologist say, an effort to preserve some independence amid extreme pressure to conform.
      A similar family dynamic accounts for early development of the behavior, some researchers argue. Dr. Lorna Benjamin, co-director of a clinic at the University of Utah's Neuropsychiatric Institute in Salt Lake City, said people with strong passive tendencies often grew up in loving but demanding families, which gave them responsibilities they perceived to be unmanageable. First-born children are prime candidates, she said: when younger siblings are born, the oldest may suddenly be expected to take on far more extra work than he or she can handle, and over time begin to resent parents' demands without daring to defy them. This hostile cooperation is at the core of passive-aggression, she and other researchers say, and in later in life it is habitually directed at any authority figure, whether a boss, a teacher or a spouse making demands. These passive-aggressive people, Dr. Benjamin said, "are full of unacknowledged contradiction, of angry kindness, compliant defiance, covert assertiveness."
      This history hardly excuses the multitude of hedging, foot-dragging mopes that populate everyday life, but it can help explain some of their exploits. One Los Angeles woman, who asked not to be identified (and swore she was not being passive-aggressive), described a former co-worker who intentionally made assignments late to employees when she didn't approve of a project. At the end of some days, she wrote, this archetypal passive-aggressive used to hide under her desk to avoid saying goodnight to people.
      Sometimes, however, mild passive-aggressive behavior can be an effective means to avoid potentially costly confrontations. In such cases the cooperation is more significant than the underlying resentment or hostility. "A joke can be the most skillful passive-aggressive act there is,'' said Dr. Scott Wetzler, a clinical psychologist at Montefiore Medical Center in the Bronx and the author of "Living With the Passive-Aggressive Man." "They recognize a coming confrontation, and have found a clever way to release the tension."
      It is just this instinctive ability to pre-empt and defuse that, paradoxically, may lead to more problematic passive-aggressive behavior. Dr. Higgins of Columbia has described a personal quality he calls prevention pride, a kind of native caution in the face of new challenges, an effort to avoid all errors. He assesses whether a person is high or low in this style by asking a battery of questions, like how often they broke their parents rules, how often they take risks, how often they have been in trouble by not being careful enough. The style is adaptive, he said, in that it allows people with a certain temperament to avoid failure and embarrassment.
      In one recent experiment, Dr. Higgins and Dr. Ozlem Ayduk, an assistant professor of psychology at the University of California at Berkeley, tested how these especially cautious people reacted to conflict in relationships. The researchers had 56 couples who had been together at least two months keep detailed diaries, answering questions about conflicts, thoughts about the relationship, moods and their partners' behavior. After three weeks, the researchers compared the diaries and found that people who had a highly cautious personal style and were especially sensitive to rejection were significantly more likely than the others to respond to conflicts by going silent, withdrawing their affection and acting cold. "The people in this study were not the type who would ever say, 'I hate you' to the person's face because they are so careful not to do something that puts them out there," and directly offend their partner, Dr. Ayduk said.
      The evidence that this sensitivity can be appealing, at least for a while, is recorded in millions of relationships that have lasted for years. A 45-year-old college instructor in Hawaii recently broke off a long relationship with a man she said was a "wonderful, devoted listener, an extremely sensitive person." But in time, she said, it was apparent that he was also passive-aggressive. On one occasion, she said, he gave away her seat on an airplane while she was finding a storage compartment for her luggage, saying he thought she had taken another seat. On others, he would arrive home early from work and finish off meals they normally shared, without explanation. And when he was in one of his moods, the listening ceased; she may as well not have been in the room. "The challenging thing was, you never know what you did wrong," she said. "That's the difficulty, all these scenarios, I could not point to what I did. I never knew."
      The person who has become hostile may not know exactly why, either. In some cases, psychologists say, people unable to recognize or express their annoyance often don't feel entitled to it; they instinctually let the "little things" pass without taking the time to find out why they are so angry about them. Unsure of themselves, they take care not to offend a spouse, a co-worker or friend. The anger remains.
      When the behavior pattern is deeply ingrained and compulsive, it is neither adaptive nor merely bewildering, but can be dangerous, some experts say. At her clinic in Salt Lake City, Dr. Benjamin treats many people with multiple diagnoses, from attention deficit disorder to obsessive-compulsive disorder to intractable depression, many of them with other problems, like substance abuse or multiple suicide attempts. "And I would say that in close to half of them this passive-aggressive behavior is running the whole show," she said.
      When and if they do get therapy, psychiatrists say, people with strong passive-aggressive instincts are usually determined to fail: the therapist becomes the scorned authority figure. The patients will take their medications and then report with relish that they don't work. The patients will follow advice and then complain that it is senseless, useless. "They are not doing this on purpose; it's part of a deep-seated ambivalence about getting better," a determination to expose the authority as incompetent, said Dr. Marjorie Klein, a psychiatrist at the University of Wisconsin.
      It is left to the individual therapist's skill to deflect or disarm this determination and get patients to at least experiment with an alternate strategy to engage their lives. In one, called cognitive behavior therapy, they learn to monitor their thoughts, moment by moment, to recognize when they are angry, and to challenge unexamined assumptions about confrontation. For example, some people assume that confronting their boss about a raise will be a catastrophe, said Dr. Wetzler of Montefiore, but it often simply is not the case, especially if they have prepared themselves by learning the market value of their skills at other companies.
      Yet Dr. Benjamin said that often the childhood roots of the behavior must be faced and felt, and that means revisiting the parental relationship and learning that it does not have to set the pattern for all relationships with authority. "The main challenge is to help them shift from winning by losing to winning by winning," she said, "to see that it is they who benefit most when they win, not their therapist, their spouse or their boss."
      Just living with the behavior in someone else can be as tough as treating it. To manage garden variety passive-aggressive behavior, psychiatrists often advise a kind of protective engagement: don't attack the person; that only reinforces your position as an authority making demands. Take into account the probable cause of the person's unexpressed anger and acknowledge it, if possible, when being stonewalled during a discussion. And be sure to be on guard against likely retaliation. "If he agrees to go over to your relatives' place for Thanksgiving, but you know he's upset about it, make sure you have alternate transportation to get over there," Dr. Wetzler said. "He may take the car and not manage to get home in time to make it."