Noteworthy News Articles on Mental Health Topics, May 30-31, 2005

CHICAGO -- They call her ''Ana.'' She is a role model to some, a goddess to others -- the subject of drawings, prayers and even a creed. She tells them what to eat and mocks them when they don't lose weight. And yet, while she is a very real presence in the lives of many of her followers, she exists only in their minds. Ana is short for anorexia, and -- to the alarm of experts -- many who suffer from the potentially fatal eating disorder are part of an underground movement that promotes self-starvation and, in some cases, has an almost cult-like appeal.
      Followers include young women and teens who wear red Ana bracelets and offer one another encouraging words of ''thinspiration'' on Web pages and blogs. They share tips for shedding pounds and faithfully report their ''cw'' and ''gw'' -- current weight and goal weight, which often falls into the double digits. They also post pictures of celebrity role models, including teen stars Lindsay Lohan and Mary-Kate Olsen, who last year set aside the acting career and merchandising empire she shares with her twin sister to seek help for her own eating disorder. ''Put on your Ana bracelet and raise your skinny fist in solidarity!'' one ''pro-Ana'' blogger wrote shortly after Olsen entered treatment.
     The movement has flourished on the Web and eating disorder experts say that, despite attempts to limit Ana's online presence, it has now grown to include followers -- many of them young -- in many parts of the world. No one knows just how many of the estimated 8 million to 11 million Americans afflicted with eating disorders have been influenced by the pro-Ana movement. But experts fear its reach is fairly wide. A preliminary survey of teens who've been diagnosed with eating disorders at the Lucile Packard Children's Hospital at Stanford University, for instance, found that 40 percent had visited Web sites that promote eating disorders. ''The more they feel like we -- 'the others' -- are trying to shut them down, the more united they stand,'' says Alison Tarlow, a licensed psychologist and supervisor of clinical training at the Renfrew Center in Coconut Creek, Fla., a residential facility that focuses on eating disorders.
     Experts say the Ana movement also plays on the tendency people with eating disorders have toward ''all or nothing thinking.'' ''When they do something, they tend to pursue it to the fullest extent. In that respect, Ana may almost become a religion for them,'' says Carmen Mikhail, director of the eating disorders clinic at Texas Children's Hospital in Houston. She and others point to the ''Ana creed,'' a litany of beliefs about control and starvation, that appears on many Web sites and blogs. At least one site encourages followers to make a vow to Ana and sign it in blood.
     People with eating disorders who've been involved in the movement confirm its cult-like feel. ''People pray to Ana to make them skinny,'' says Sara, a 17-year-old in Columbus, Ohio, who was an avid organizer of Ana followers until she recently entered treatment for her eating disorder. She spoke on the condition that her last name not be used. Among other things, Sara was the self-proclaimed president of Beta Sigma Kappa, dubbed the official Ana sorority and ''the most talked about, nearly illegal group'' on a popular blog hosting service that Sara still uses to communicate with friends. She also had an online Ana ''boot camp'' and told girls what they could and couldn't eat. ''I guess I was attention-starved,'' she now says of her motivation. ''I really liked being the girl that everyone looked up to and the one they saw as their 'thinspiration.' ''But then I realized I was helping girls kill themselves.''
     For others, Ana is a person -- a voice that directs their every move when it comes to food and exercise. ''She's someone who's perfect. It's different for everyone -- but for me, she's someone who looks totally opposite to the way I do,'' says Kasey Brixius, a 19-year-old college student from Hot Springs, S.D. To Brixius -- athletic with brown hair and brown eyes -- Ana is a wispy, blue-eyed blonde. ''I know I could never be that,'' she says, ''but she keeps telling me that if I work hard enough, I CAN be that.''
     Dr. Mae Sokol often treats young patients in her Omaha, Neb., practice who personify their eating disorder beyond just Ana. To them, bulimia is ''Mia.'' And an eating disorder often becomes ''Ed.'' ''A lot of times they're lonely and they don't have a lot of friends. So Ana or Mia become their friend. Or Ed becomes their boyfriend,'' says Sokol, who is director of the eating disorders program run by Children's Hospital and Creighton University.
     In the end, treatment can include writing ''goodbye'' letters to Ana, Mia and Ed in order to gain control over them. But it often takes a long time to get to that point -- and experts agree that, until someone with an eating disorder wants to help themselves, treatment often fails. Tarlow, at the Renfrew Center, says it's also easy for patients to fall back into the online world of Ana after they leave treatment. ''Unfortunately,'' she says, ''with all people who are in recovery, it's so much about who you surround yourself with.''
     Some patients, including Brixius, the 19-year-old South Dakotan, have had trouble finding counselors who truly understand their struggle with Ana. ''I'd tell them about Ana and how she's a real person to me. And they'd just look at me like I'm nuts,'' Brixius says of the counselors she's seen at college and in her hometown. ''They wouldn't address her ever again, so it got very frustrating. ''Half the time I'm, like, 'You know what? I give up.''' Other days, she's more hopeful. ''I gotta snap out of this eventually if I want to have kids and get a job. One day, I'll get to that point,'' she says, pausing. ''But I'll always obsess about food.''
     On the Net:
National Association of Anorexia Nervosa and Associated Disorders: http://www.anad.org
National Eating Disorders Association: http://www.edap.org/

When the drug industry came under fire last summer for failing to disclose poor results from studies of antidepressants, major drug makers promised to provide more information about their research on new medicines. But nearly a year later, crucial facts about many clinical trials remain hidden, scientists independent of the companies say.
      Within the drug industry, companies are sharply divided about how much information to reveal, both about new studies and completed studies for drugs already being sold. The split is unusual in the industry, where companies generally take similar stands on regulatory issues. Eli Lilly and some other companies have posted hundreds of trial results on the Web and pledged to disclose all results for all drugs they sell. But other drug makers, including Pfizer, release less information and are reluctant to add more, citing competitive pressures.
     As a result, doctors and patients lack critical information about important drugs, academic researchers say, and the companies can hide negative trial results by refusing to publish studies, or by cherry-picking and highlighting the most favorable data from studies they do publish. "There are a lot of public statements from drug companies saying that they support the registration of clinical trials or the dissemination of trial results, but the devil is in the details," said Dr. Deborah Zarin, director of clinicaltrials.gov, a Web site financed by the National Institutes of Health that tracks many studies/ Journal editors and academic scientists have pressed big drug makers to release more information about their studies for years. But the calls for more disclosure grew stronger after reports last year that several companies had failed to publish studies that showed their antidepressants worked no better than placebos.
     In August, GlaxoSmithKline agreed to pay $2.5 million to settle a suit by Eliot Spitzer, the New York attorney general, alleging that Glaxo had hidden results from trials showing that its antidepressant Paxil might increase suicidal thoughts in children and teenagers. At a House hearing in September, Republican and Democratic lawmakers excoriated executives from several top companies, including Pfizer and Wyeth, for hiding study results. In response, many companies promised to do better. At the same time, Merck and Pfizer have been criticized for failing to disclose until this year clinical trial results that indicated that cox-2 painkillers like Vioxx might be dangerous to the heart.
     Drug makers test their medicines in thousands of trials each year, and federal laws require the disclosure of all trials and trial results to the F.D.A. While too complex for many patients to understand, the trial results are useful to doctors and academic scientists, who use them to compare drugs and look for clues to possible side effects. But companies are not required to disclose trial results to scientists or the public. Some scientists and lawmakers say new rules are needed, and a bill that would require the companies to provide more data was introduced in the Senate in February. So far no hearings have been scheduled on the legislation. The bill's prospects are uncertain, said a co-sponsor, Senator Christopher J. Dodd, Democrat of Connecticut.
     The drug makers have been criticized both for failing to provide advance notice of clinical trials before they begin and for refusing to publish completed trial results for medicines that are already being sold. The two issues are related, because companies cannot easily hide the results of trials that have been disclosed in advance, said Dr. Alan Breier, chief medical officer of Lilly, the company that has gone furthest in disclosing results. "You're registering a trial -- at some point, the results have got to show up," Dr. Breier said. He added that disclosing trial results was important both to give doctors and patients as much information as possible and to improve the industry's reputation, which has been damaged by several recent withdrawals of high-profile drugs. "Fundamentally, what we're doing is in the interest of patients, and I think that that is the winning model, for academia, for industry and for the future," he said.
     In September, Pharmaceutical Research and Manufacturers of America, an industry lobbying group known as PhRMA, said it would create a site for companies to post the results of completed trials. Then, under pressure from the editors of medical journals, the major drug companies in January agreed to expand the number of trials registered on clinicaltrials.gov, the N.I.H. site, which was originally created so patients with life-threatening diseases could find out about clinical trials. But Merck, Pfizer and GlaxoSmithKline, three of the six largest drug companies, have met the letter but not the spirit of that agreement, Dr. Zarin said. The three companies have filed only vague descriptions of many studies, often failing even to name the drugs under investigation, Dr. Zarin said. For example, Merck describes one trial as a "one-year study of an investigational drug in obese patients."
     Drug names are crucial, because the clinicaltrials.gov registry is designed in part to prevent companies from conducting several trials of a drug, then publicizing the trials with positive results while hiding the negative ones. If the descriptions do not include drug names, it is hard to tell how many times a drug has been studied. "If you're a systematic reviewer trying to understand all the results for a particular drug, you might never know," Dr. Zarin said. "You don't know whether you're seeing the one positive result and not the four negative results - you don't have context."
     Pfizer, Merck and GlaxoSmithKline say that they disclose their largest trials, which determine whether a drug will be approved. Though they would not discuss their policies in detail, executives and press representatives at the companies said generally that disclosing too much information about early-stage trials might reveal business or scientific secrets. Rick Koenig, a spokesman for Glaxo, said the company understood the concerns about disclosure and planned to add more information to clinicaltrials.gov. He declined to be more specific, saying Glaxo and other companies were discussing the issue with regulators and medical journal editors. In contrast, Lilly has registered all but its smallest trials at clinicaltrials.gov. Dr. Breier of Lilly said the company believed that it could protect its intellectual property and still increase the amount of information it released. Lilly has also posted the results of many completed studies to clinicalstudyresults.org, the Web site created last September by PhRMA. That site now contains some information on nearly 80 drugs that are already on the market. Both Lilly and Glaxo have posted detailed summaries of hundreds of studies. Pfizer, on the other hand, has posted only a few, and Merck has posted none.
     All the companies were meeting the group's guidelines for the site, said Dr. Alan Goldhammer, associate vice president for regulatory affairs at PhRMA. The lobbying group requires only that its members post a notice that a trial has been completed and a link to a published study or a summary of an unpublished study, he said. Studies completed before October 2002 are exempt from the requirements, and PhRMA has not set penalties for companies that do not comply. "We're seeing pretty regular posting on a weekly basis, and as best we can assess right now, things are on track for meeting the goal we and our members set for ourselves," Dr. Goldhammer said.
     The continued gaps in disclosure have caused some lawmakers to call for new federal laws. The bill introduced in February by Mr. Dodd and Senator Charles E. Grassley, Republican of Iowa, would convert clinicaltrials.gov into a national registry for both new trials and results and impose civil penalties of up to $10,000 a day for companies that hide trial data. But Mr. Dodd said that the chances the bill would pass in this Congress were even at best. "I haven't had that pat on the back saying, 'This is a great idea, let's get going on this as fast as we can,' " Mr. Dodd said.
     Dr. David Fassler, a psychiatry professor at the University of Vermont and a longtime proponent of more disclosure, said that trial reporting had improved in the last two years. But he said that a central federally run site, as opposed to the current mix of government and industry efforts, was the only long-term solution.

New love can look for all the world like mental illness, a blend of mania, dementia and obsession that cuts people off from friends and family and prompts out-of-character behavior -- compulsive phone calling, serenades, yelling from rooftops -- that could almost be mistaken for psychosis. Now for the first time, neuroscientists have produced brain scan images of this fevered activity, before it settles into the wine and roses phase of romance or the joint holiday card routines of long-term commitment.
      In an analysis of the images appearing today in The Journal of Neurophysiology, researchers in New York and New Jersey argue that romantic love is a biological urge distinct from sexual arousal. It is closer in its neural profile to drives like hunger, thirst or drug craving, the researchers assert, than to emotional states like excitement or affection. As a relationship deepens, the brain scans suggest, the neural activity associated with romantic love alters slightly, and in some cases primes areas deep in the primitive brain that are involved in long-term attachment.
     The research helps explain why love produces such disparate emotions, from euphoria to anger to anxiety, and why it seems to become even more intense when it is withdrawn. In a separate, continuing experiment, the researchers are analyzing brain images from people who have been rejected by their lovers. "When you're in the throes of this romantic love it's overwhelming, you're out of control, you're irrational, you're going to the gym at 6 a.m. every day -- why? Because she's there," said Dr. Helen Fisher, an anthropologist at Rutgers University and the co-author of the analysis. "And when rejected, some people contemplate stalking, homicide, suicide. This drive for romantic love can be stronger than the will to live."
     Brain imaging technology cannot read people's minds, experts caution, and a phenomenon as many sided and socially influenced as love transcends simple computer graphics, like those produced by the technique used in the study, called functional M.R.I. Still, said Dr. Hans Breiter, director of the Motivation and Emotion Neuroscience Collaboration at Massachusetts General Hospital, "I distrust about 95 percent of the M.R.I. literature and I would give this study an 'A'; it really moves the ball in terms of understanding infatuation love." He added: "The findings fit nicely with a large, growing body of literature describing a generalized reward and aversion system in the brain, and put this intellectual construct of love directly onto the same axis as homeostatic rewards such as food, warmth, craving for drugs."
     In the study, Dr. Fisher, Dr. Lucy Brown of Albert Einstein College of Medicine in the Bronx and Dr. Arthur Aron, a psychologist at the State University of New York at Stony Brook, led a team that analyzed about 2,500 brain images from 17 college students who were in the first weeks or months of new love. The students looked at a picture of their beloved while an M.R.I. machine scanned their brains. The researchers then compared the images with others taken while the students looked at picture of an acquaintance. Functional M.R.I. technology detects increases or decreases of blood flow in the brain, which reflect changes in neural activity.
     In the study, a computer-generated map of particularly active areas showed hot spots deep in the brain, below conscious awareness, in areas called the caudate nucleus and the ventral tegmental area, which communicate with each other as part of a circuit. These areas are dense with cells that produce or receive a brain chemical called dopamine, which circulates actively when people desire or anticipate a reward. In studies of gamblers, cocaine users and even people playing computer games for small amounts of money, these dopamine sites become extremely active as people score or win, neuroscientists say.
     Yet falling in love is among the most irrational of human behaviors, not merely a matter of satisfying a simple pleasure, or winning a reward. And the researchers found that one particular spot in the M.R.I. images, in the caudate nucleus, was especially active in people who scored highly on a questionnaire measuring passionate love. This distinction, between finding someone attractive and desiring him or her, between liking and wanting, "is all happening in an area of the mammalian brain that takes care of most basic functions, like eating, drinking, eye movements, all at an unconscious level, and I don't think anyone expected this part of the brain to be so specialized," Dr. Brown said. The intoxication of new love mellows with time, of course, and the brain scan findings reflect some evidence of this change, Dr. Fisher said.
     In an earlier functional M.R.I. study of romance, published in 2000, researchers at University College London monitored brain activity in young men and women who had been in relationships for about two years. The brain images, also taken while participants looked at photos of their beloved, showed activation in many of the same areas found in the new study -- but significantly less so, in the region correlated with passionate love, she said.
     In the new study, the researchers also saw individual differences in their group of smitten lovers, based on how long the participants had been in the relationships. Compared with the students who were in the first weeks of a new love, those who had been paired off for a year or more showed significantly more activity in an area of the brain linked to long-term commitment.
     Last summer, scientists at Emory University in Atlanta reported that injecting a ratlike animal called a vole with a single gene turned promiscuous males into stay-at-home dads -- by activating precisely the same area of the brain where researchers in the new study found increased activity over time. "This is very suggestive of attachment processes taking place," Dr. Brown said. "You can almost imagine a time where instead of going to Match.com you could have a test to find out whether you're an attachment type or not." One reason new love is so heart-stopping is the possibility, the ever-present fear, that the feeling may not be entirely requited, that the dream could suddenly end.
     In a follow-up experiment, Dr. Fisher, Dr. Aron and Dr. Brown have carried out brain scans on 17 other young men and women who recently were dumped by their lovers. As in the new love study, the researchers compared two sets of images, one taken when the participants were looking at a photo of a friend, the other when looking at a picture of their ex. Although they are still sorting through the images, the investigators have noticed one preliminary finding: increased activation in an area of the brain related to the region associated with passionate love. "It seems to suggest what the psychological literature, poetry and people have long noticed: that being dumped actually does heighten romantic love, a phenomenon I call frustration-attraction," Dr. Fisher said in an e-mail message.
     One volunteer in the study was Suzanna Katz, 22, of New York, who suffered through a breakup with her boyfriend three years ago. Ms. Katz said she became hyperactive to distract herself after the split, but said she also had moments of almost physical withdrawal, as if weaning herself from a drug. "It had little to do with him, but more with the fact that there was something there, inside myself, a hope, a knowledge that there's someone out there for you, and that you're capable of feeling this way, and suddenly I felt like that was being lost," she said in an interview.
     And no wonder. In a series of studies, researchers have found that, among other processes, new love involves psychologically internalizing a lover, absorbing elements of the other person's opinions, hobbies, expressions, character, as well as sharing one's own. "The expansion of the self happens very rapidly, it's one of the most exhilarating experiences there is, and short of threatening our survival it is one thing that most motivates us," said Dr. Aron, of SUNY, a co-author of the study. To lose all that, all at once, while still in love, plays havoc with the emotional, cognitive and deeper reward-driven areas of the brain. But the heightened activity in these areas inevitably settles down. And the circuits in the brain related to passion remain intact, the researchers say - intact and capable in time of flaring to life with someone new.

When Gregory phoned to ask whether I would offer him and his wife marriage counseling, I told him that wasn't my specialty. At the time, I didn't treat couples. "I'd be happy to refer you," I said. "We've tried other counselors," Gregory told me. "Friends of mine tell me you have an unusual ... " he said, his voice trailing off. "You get through to them." He paused. "Our 20th anniversary is supposed to be in three months. We're not going to make it. There's just no passion left."
      My practice was unusual. I had found that traditional psychotherapy -- the 50-minute hour once a week -- often left people struggling with distressing symptoms for years. So I had begun treating men and women for three to six months, seeing them as often as five times a week in nontraditional settings like restaurants, their homes and offices. I had encouraged them to phone me with important thoughts and feelings any time of the day or night, for a minute or an hour.
     Bending professional boundaries in these ways is highly controversial. It calls upon the therapist to be extra cautious never to lose sight of the fact that he is always talking with a patient, never a friend. Indeed, I had seen how transference and countertransference -- powerful emotions transplanted into the doctor-patient relationship from other dramas in my patients' lives or my own -- sharply increased when I left the confines of my office.
     In individual therapy, I had worked very hard to harness those raw emotions in service to tracing the roots of depression, anxiety and even psychosis. But I worried whether the additional emotional tides inherent in interacting with a couple would prove too difficult to navigate.
     Something about Gregory - maybe the sadness in his voice or his coming 20th anniversary - made me want to take the risk. "If we did work together," I told him, "it wouldn't be talking an hour here or there. I don't think that saves marriages." "We would try anything," he said. "This is our last stop before court."
     Gregory called his wife, Elaine, and we decided to meet three days later. The issues were clear. Gregory was a powerful, conservative man who completely controlled his family's finances and saw his wife as a vulnerable woman who needed his protection. He did not share his feelings with her. He did not ask her advice. Elaine was intensely beautiful but painfully shy. She had never made an airline reservation on her own. She had no credit card. She had stopped working, had raised the couple's children full time and now felt imprisoned in her marriage. I saw little tenderness or excitement in the way Gregory and Elaine related to each other. They did not touch. There were no knowing glances. No playfulness. Like a number of marriages that last more than five years, the energy had gone out of theirs.
     A day later, I gave them a plan that embraced three of my core beliefs about marriages (including, by the way, my own, which has lasted more than 10 years):
1. Everything in the world loses its charge if left too close, for too long, to anything of opposite charge (atoms, magnets - and couples). The fact that couples often floss their teeth together and share the same laundry basket makes it a lot harder (if not impossible) to worship each other enough to have good sex.
2. People generally marry or end up living with those who speak to their core weaknesses, not their core strengths. Staying together happily relies on taking risks to radically change each partner's role in the relationship.
3. Because each person needs to make sweeping individual changes, talking to husbands and wives together is often a waste of time. It can even make things worse by getting them angrier at each other and feeling more hopeless.
     Treating a couple as individuals also seemed like a way to reproduce the relatively unstructured work I had already done without introducing a new and unpredictable dynamic.  The plan I offered Gregory and Elaine was, therefore, for them to separate for 100 days, to help rekindle the romantic energy that had brought them together. Each would try to look "new" to the other by exercising, dieting and buying new clothes. And during those 100 days, I would meet with each of them 30 times and talk with them by phone as much as needed to find out how their core weaknesses as individuals were eroding their potential as a couple, and encourage them to make the changes necessary to revitalize their marriage.
     They agreed. Luckily, they were in a financial position to pay thousands of dollars for so many hours of treatment. But since working with them, I have treated patients of much lesser means, seeing them less frequently. I learned Gregory was the product of controlling, intrusive parents; his "superior" position in the marriage was actually his way of keeping Elaine from getting close enough to overwhelm him. Elaine's "shyness" and lack of sexual confidence was a byproduct of growing up with hypercritical and cruel parents, who drastically eroded her self-esteem.
     I had the two of them start "dating" again, but this time Elaine picked the restaurants and weekend getaways and made all the reservations, with a new credit card in her name. Only she could initiate sex, according to fantasies I had slowly encouraged her to describe. Gregory embraced the process, transferring some of his money into his wife's name to give her more freedom, realizing that Elaine was not his mother or father and that he could share with her his most closely held dreams and fears (as he had with me). "We each made our own changes," Elaine told me a year later, "but we're happier together than ever -- maybe truly in love for the first time. So, tell me, why did we pick each other, to begin with?" I responded: "Because even though you're separate people, you knew you could help heal one another. Maybe that's the only true love there really is."

Just Like Bodies, Psyches Can Drown in Disasters
M. Laurie Leitch, New York Times- 5/31/2005

I sit with her as she tells how her son had gone to market that fateful day and, therefore, survived. I am there to work with the traumatic stress symptoms of survivors like Pairao. However, my first connection to her is as a mother, and I feel a surge of gratitude that my own children are alive and safe back home.
      In the first days of disaster relief work, I wondered how I could possibly make a difference when the magnitude of loss, destruction and trauma was so huge. There is skepticism and hot debate among some experts as to the suitability of Western-based approaches to disaster mental health. I share this skepticism, and I arrived with my own questions about whether there is a place for mental health services in the immediate aftermath of a natural disaster. My experience with survivors like Pairao convinced me that we need a new science of disaster relief -- one that gives immediate aid not just to the body or to the mind but to the two together, as inseparable parts of the whole survivor.
     The month I spent working in the Phang Nga Province of Thailand convinced me that we should have arrived sooner. Thai Red Cross personnel, nurses, doctors and Buddhist monks told us how frustrated they were at how little they knew about the symptoms and treatment of trauma. Our nine-member trauma team's work was done under the auspices of the Princess' Mobile Medical Unit, affording an access and a legitimacy we would not otherwise have had. We worked in medical tents, refugee camps, Buddhist temples and schools, providing treatment and training.
     The lack of information about traumatic stress meant that medication was often prescribed in lieu of other treatments. Children and adults had been given major medications for symptoms like night terrors, headaches, weakness in limbs and stomachaches, all symptoms of traumatic stress, which can often be successfully treated without medication, particularly with early intervention. In one case, a woman received an antidepressant for sleep problems and then attempted suicide.
     Mental health approaches that rely on "talking it out" would not have been culturally appropriate, nor are they suited to disasters. However, early interventions that ease traumatic stress while restoring the body's resiliency are needed. The term most often used for integrative treatments that link the mind and the body is "holistic," a term too broad to be useful and one that often generates suspicion.
     A disaster's reach extends far beyond its immediate victims. We know from long-term studies of post-traumatic stress that the emotional aftermath can last far beyond a decade. Even in non-Western countries where mental health services exist, they tend to be used only in cases of the most extreme mental illnesses, usually in combination with medication and hospitalization. During our time in Thailand, we found few Thai relief workers who knew about traumatic stress. Yet traumatic stress knows no boundaries, political or cultural, and can lead to long-term emotional disability, work-related problems, family strain and dissolution, substance abuse and an array of physical syndromes.  I could see the effects of trauma as I listened to a man describe with despair his rages at his 5-year-old granddaughter. I worked with a panicky 25-year-old in the medical tent who reeked of alcohol. I heard the distress of a fisherman and village leader who was afraid to go back to the sea.
     There is a growing body of scientific evidence that what we consider physical symptoms and what we consider psychological symptoms are intertwined. The work of Dr. Jon Kabat-Zinn, an emeritus professor of medicine at the University of Massachusetts, on the effects of stress on the immune system, has helped bring attention to the need for a new approach that rejects the false dichotomy of mind and body. This has important implications for work with disaster survivors.
     Any traumatic event generates a cascade of physiological and emotional responses. Dr. Gaithri Fernando, a clinical psychologist born in Sri Lanka, writing in a newsletter of the International Society for Traumatic Stress Studies, cautions that Sri Lankans have never experienced this type of adversity before and that the magnitude of the disaster may "overtax the resilience" that often characterizes these people. This can also be said for other countries devastated by the tsunami.
     A new science of disaster relief must include treatments that go beyond the current models pitting one set of needs against another. Instead, new models must link the mind and body, recognizing that the resilience of one affects and depends on the resilience of the other. Pairao and hundreds of thousands of survivors -- of this and future disasters -- are depending on it.

Dr. William G. Reiner, a faculty member at the University of Oklahoma and Johns Hopkins, says he is just a "dull guy leading a dull life." That seems unlikely. A 57-year-old psychiatrist and urologist, Dr. Reiner is a leading specialist in the treatment of children with the intersexual condition, boys and girls born with ambiguous genitaliA. "I like working with these children," he said on a break in a meeting in Washington, where he had made a presentation before the American Association for the Advancement of Science. "They've had atypical life experiences, and they tend to be extraordinarily sensitive and vulnerable. They see an aspect of what it means to be alive in a different way from the rest of us."
Q. How did you begin with your unusual specialty?
A. In the early 1980's, I was a urologist in central California, and this remarkable 14-year-old "girl" came to my office. "I'm a boy, not a girl," this child declared.
      The child had an intersex condition. At birth, he didn't have a penis, but rather something that appeared more like an enlarged clitoris. He had a partial testicle on one side. Internally, he was half female, and he looked more female than male. Indeed, since infancy, his parents had raised him female. Since puberty, however, that one testicle had begun producing enough male hormones to masculinize him. To all he now insisted, "You've got it wrong: I'm a boy!" And this child wanted me to help convince his parents he was male. Moreover, he wanted me to help him get surgery so that his phallic structure looked more like a penis. I was able to do both.
     That was the beginning for me. Over years, I saw dozens of children with anomalies of their genitaliA. Eventually, I retrained in psychiatry so that I could help them with the nonsurgical aspects of what they encountered. These children moved me. When you hear someone declare with such clarity that they know themselves far better than the experts, it is life changing.
Q. Aren't these intersex conditions rather rare?
A. There are probably around 1,000 intersex babies born every year in the United States. The numbers can add up. The term actually refers to six different conditions where children are born with ambiguous sexual structures. The majority are the result of something going wrong early in a pregnancy, where the fetus is exposed to an inappropriate amount of hormones in the uterus.
     You can get genetic girls who look from the outside like males because they were exposed to male hormones at a critical stage of fetal development. Conversely, you can get genetic males looking like females because they didn't get enough male hormones in utero. There are a whole group of more mixed external manifestations of gender that also occur.
     Until the 1950's, when an intersex child was born, they were let be. But starting in the 1950's, the general approach was to make the child into one sex or another. If it was a partially masculinized female, there was a surgical attempt to turn her into a "normal" female. Structures were created so that she could have intercourse later. If the child was a genetic male, the question was, Will the adult penis be large enough for sexual intercourse? The vast majority of the children with severe inadequacy of the penis were converted to "female" surgically and then raised as girls.
Q. So the prescription for the intersex boys was castrate them and put them into a dress?
A. The problem was, In a large number of children, as with my first intersex patient, it never took. Gender has far more to do with other important structures than external genitals.
Q. How do you know what constitutes gender identity?
A. As part of a research study, I've personally seen and assessed 400 children with major anomalies of the genitals. Of those, approximately 100 might be called "intersex." Our findings have been many and complex. The most important is that about 60 percent of the genetic male children raised as female have retransitioned into males. We also found that of this group there were some genetically male children, who despite genital anomalies were raised as males, and they continued to declare themselves as male.
Q. What conclusions can you draw about the eventual sexual identity of an intersex child?
A. That you can castrate a male at birth, create a female genital structure, raise the child as a girl, and in a majority of the cases, they'll still recognize themselves as male. Now many of the children I've seen are still young. I don't know what will happen as they get older. The larger point is that it's been a monstrous failure, this idea that you can convert a child's sex by making over the child's genitals in the sex you've chosen. This began in the 1950's, when surgeons who felt helpless when they encountered intersex children thought they were helping them with sexual reassignment. The psychologists were saying, "You can make a boy or a girl or anything you want." It wasn't true. The children often knew it.
Q. The idea of sexual reassignment surgery started at Johns Hopkins, where you are a part-time faculty member. Has there been a change in attitude among the staff members there?
A. It's my understanding that the originators of that standard of care may still support that idea and are still on staff. But I've also spoken with the Johns Hopkins Institutions' pediatric urologists, and my sense is they'd be very leery of sex assigning a genetic male to female.
Q. Can children grow up mentally healthy if they have ambiguous genitalia?
A. I think that these sexual assignments often create more problems than they solve. The children grow up with unhealthy secrets. What the kids tell me is that while they didn't know they were males, they always knew something was wrong because they were "too different" from all the other girls. In my psychiatric practice, I've had families where the parents asked me to be with them when they told their children, "You were actually born a boy." That turned out to be a critical moment because every child converted to being a boy within hours, except for two. With those two, they refused to ever discuss their sexual identity again. Still, none of them stayed female.
Q. Because of all this new research, is the accepted standard of care of intersex children changing?
A. There's no one standard now. Five years ago, a genetic male child born without a penis or a severely inadequate one almost universally would have been assigned female at birth. Today, about two-thirds of the pediatric urologists say they wouldn't go that route, which means that one-third still might. That says that we're not sure of the right way, yet. It's an irony to me that surgeons have gotten the worst criticism from intersex adults for these practices. Certainly psychologists and endocrinologists were also involved. From what I've seen, it's the surgeons that have made the biggest changes the fastest. I think part of the reason for that is that surgeons do things to their patients physically and are, therefore, very sensitive to doing the right thing.
Q. What conclusions do you draw from your study?
A. That sexual identity is individual, unique and intuitive and that the only person who really knows what it is is the person themselves. If we as physicians or scientists want to know about a person's sexual identity, we have to ask them.

Insomnia affects up to twice as many women as men, and Taiwanese researchers have identified socioeconomic status as a factor in determining which women are affected. A study published this month in The Journal of Epidemiology and Community Health suggests that women of higher income with more education have lower rates of sleeplessness than those who are less fortunate. The study is based on a representative sample of 40,000 residents of Taiwan 15 or older who were interviewed about their sleep habits. Over all, the study showed that students and regular exercisers were the best sleepers, and that insomnia was associated with older age, divorce or separation, low income, joblessness, smoking and failure to graduate from high school.
      Not surprisingly, the number of children in a household was associated with sleeplessness. Women and men with children were affected equally. Unemployment and divorce, on the other hand, caused insomnia in women at much greater rates than in men. While women with higher educational attainment had less insomnia, education appeared to have the opposite effect on men. The more education men had, the more likely they were to suffer insomnia. "I think most of the results can be generalized to other countries," said Dr. Ying-Yeh Chen, the lead author on the study and a research fellow at the Harvard School of Public Health. "Gender inequality is a pervasive phenomenon." But the authors conclude that socioeconomic status, while it is important, does not by itself explain why women lie awake more than men, and that the sex difference in insomnia may be largely caused by inherent biological factors.

PITTSBURGH -- In the months after David Golebiewski's 19-year-old daughter was killed in a car crash, grief consumed his life. He couldn't go to the restaurant where his daughter had worked, and he spent five hours a day in Internet chat rooms with other parents who lost children. Doctors say Golebiewski was suffering from ''complicated grief'' -- a condition some hope will soon be recognized by the American Psychiatric Association. They say the condition is more severe than grief and different from depression, and affects as many as 1 million people a year.
      Dr. Katherine Shear, a psychiatry professor at the University of Pittsburgh School of Medicine, said that with complicated grief, the usual feelings of disbelief, loss and anguish do not go away, and eventually affect every part of a person's life. Left untreated, doctors say, complicated grief can lead to depression, suicide, drug and alcohol abuse, even heart disease.
     Dr. Holly Prigerson, director of the Dana-Farber Cancer Institute's Center for Psycho-Oncology and Palliative Care Research and an associate professor of psychiatry at Harvard Medical School, said the term ''complicated grief'' has been used for about 10 years. ''Unlike a lot of disorders following bereavement, including depression, it tends to persist for years and become a chronic distressed state -- a sort of frame of mind,'' Prigerson said. Researchers estimate that 10 percent to 15 percent of the surviving relatives of people who die naturally experience complicated grief, Prigerson said. She said people who lose someone they were emotionally dependent on are at greatest risk. She is working to get the disorder recognized in the American Psychiatric Association's next edition of the Diagnostic and Statistical Manual of Mental Disorders. The next DSM-V will be published in 2012.
     Dr. Michael First, a Columbia University psychiatry professor and member of a committee that will decide what goes into the DSM, said the panel will consider whether complicated grief merits its own designation. ''From what I've seen so far, it's certainly not an off-the-wall suggestion,'' First said. He said doctors see patients all the time, especially the elderly, who never get over the death of a loved one.
     Dr. Richard Glass, a psychiatry professor at the University of Chicago and deputy editor of the Journal of the American Medical Association, said studies have shown that people suffering from complicated grief do not meet the criteria for depression or post-traumatic stress, although some of the symptoms overlap. ''The evidence so far indicates that there really is something different here,'' Glass said.
     The most recent study, published Tuesday in JAMA by Shear and her colleagues at the University of Pittsburgh, examined different ways to treat complicated grief. Researchers found that 51 percent of patients treated with a therapy developed just for the symptoms of complicated grief showed improvement. So did 28 percent of complicated grief sufferers who underwent a treatment commonly used for depression.
     Golebiewski, 56, of North Fayette, was given the therapy for complicated grief as part of the study. It included being tape-recorded while he talked about his daughter's life and death, then listening to those recordings. He said after listening to the tapes repeatedly, he developed ways of dealing with those feelings. ''I was able to visualize her again in life and as happy as she was and the cheerful person that she was,'' he said. ''I was able to see her there in that context.''
     On the Net:
http://www.upmc.edu
http://jama.ama-assn.org

Crystal Meth & H.I.V.: Ever Higher Risks
Michael Specter, The New Yorker-5/23/2005

San Francisco's Magnet center is hard to miss. It occupies a storefront directly across the street from Badlands, a city landmark of its kind, at Eighteenth and Castro Streets, perhaps the gayest address in the world. Magnet is a drop-in clinic for a community that has been besieged by health problems for nearly a quarter of a century since the men of the Castro began to die of the plague.
     Even today, with a million Americans infected with H.I.V. and half a million others already dead, many of the clinics and counselling facilities that focus on the health of gay men remain dreary places, largely hidden from view. Magnet is neither of those things. Its bright setting, modern furniture, and polished wood floors make it look far more like an art gallery than like a doctor's office. One needn't be sick to go there, nor is it necessary to make an appointment. Drop in any time, to be tested for syphilis, chlamydia, gonorrhea, or H.I.V. It also functions as what its director, Steven Gibson, calls a "hotel lobby for the people of the Castro, a place to talk, to worry, to smile, to cry," or, as Magnet's Web site puts it, to "cruse (online or real time)."
     Last month, on one of the first genuinely warm nights of spring, the center held a small gathering called Tina's Cafe. The sidewalks of the Castro were filled with men. So were the bars and coffee shops; the Men's Room, the Midnight Sun, and even the "gay" Starbucks, on Eighteenth Street, were all bustling by 8 P M., and a small crowd had begun drifting into Magnet. A new exhibition had been installed--a series of sexually suggestive pictures taken from the Internet. The visitors stared at the walls in awkward silence for a while, then took seats at tables covered with lollipops and M&M's. There was a bar with wine and soda in the back, where a d.j. was setting up his equipment. Soon, a tall man in a short dress appeared. His name was Michael Siever, and he wore a brunet wig, high-heeled pumps, and magenta stockings. "Welcome to Tina's Cafe," Siever told the crowd. "I am really glad you are here. We are going to talk about what's real tonight. About paranoia and violence and anger and fear. About reality." A couple of dozen heads nodded in unison. "We are going to talk about what is happening to our world." Siever has the soothing voice of a psychotherapist, which he is. He is also the director of the Stonewall Project, a highly regarded counselling program. "Tonight, above all, we are here to talk about Tina."
     Tina is crystal methamphetamine, a chemical stimulant that affects the central nervous system. It is hardly a new drug, and it has many other names: biker's coffee, crank, speed. It has also been called redneck cocaine, because it is available on the street, in bars, and on the Internet for less than the price of a good bottle of wine. Methamphetamine is a mood elevator, and is known to induce bursts of euphoria, increase alertness, and reduce fatigue. In slightly less concentrated forms, the drug has been used by truckers trying to drive through the night, by laborers struggling to finish an extra shift, and by many people seeking simply to lose weight. Crystal first gained popularity in the gay community of San Francisco in the nineteen-nineties, where it became the preferred fuel for allnight parties and a necessity for sexual marathons. Its reputation quickly spread. Crystal methamphetamine is highly addictive, but its allure is not hard to understand; the drug removes inhibitions, bolsters confidence, supercharges the libido, and heightens the intensity of sex. "The difference between sex with crystal and sex without it is like the difference between Technicolor and black-andwhite," one man told me at Tinas Cafe. "Once you have sex with crystal, it's hard to imagine having it any other way." The first thing people on methamphetamine lose is their common sense; suddenly, anything goes, including unprotected anal sex with many different partners in a single night--which is among the most efficient ways to spread H.I.V. and other sexually transmitted diseases. In recent surveys, more than ten per cent of gay men in San Francisco and Los Angeles report having used the drug in the past six months; in New York, the figure is even higher.
     After years of living in constant fear of AIDS, many gay men have chosen to resume sexual practices that are almost guaranteed to make them sick. In New York City, the rate of syphilis has increased by more than four hundred per cent in the past five years. Gay men account for virtually the entire rise. Between 1998 and 2000, fifteen per cent of the syphilis cases in Chicago could be attributed to gay men. Since 2001, that number has grown to sixty per cent. Look at the statistics closely and you will almost certainly find the drug. In one recent study, twenty-five percent of those men who reported methamphetamine use in the previous month were infected with H.I.V. The drug appears to double the risk of infection (because it erases inhibitions but also, it seems, because of physiological changes that make the virus easier to transmit), and the risk climbs the more one uses it. Over the past several years, nearly every indicator of risky sexual activity has risen in the gay community. Perhaps for the first time since the beginning of the AIDS epidemic, the number of men who say they use condoms regularly is below fifty per cent, after many years of decline, the number of new H.I.V. diagnoses among H.I.V. gay men increased every year between 2000 and 2003, while remaining stable in the rest of the population.
     In San Francisco, I spoke with several men about the thrills and the dangers of crystal methamphetamine. Their stories, often eerily similar, tend not to end happily. "I used to have the house and the Mercedes and the big job," a lawyer named Larry told me at Tina's Cafe. "Then I fell into crystal. Oh, my God, it was great. I felt young and powerful and wonderful. And the sex. I was having the type of sex I could have only fantasized about before." He sat for a moment and sipped from a can of Diet Coke. "Crystal destroyed my life," he said. "I sold everything I could put my hands on. What I didn't sell, I lost: my house, my career. The more I used it, the more I needed it. At one point, I broke into my own house to try and steal furniture. Crystal tells your brain to go back and get more, more, more. The logical side of your mind is saying, `I can't keep doing this,' but you are still on your way to the dealer's house." Larry has been off methamphetamine for three years, but he says the struggle begins anew every day. "Crystal motivates everything. The sex. The desire. Everything." He shook his head. "I wish I had never heard of it, but I can't say it wasn't great."
      Twenty million people have died of AIDS, most of them in Africa, where the epidemic grows more devastating every year, as it does in places like China, Russia, and India. Ten thousand people die each day--seven every minute--and seventeen thousand more become infected. In America, however, the sense of crisis has passed. After increasing rapidly throughout the nineteen-eighties, the number of new cases peaked in 1993, and within two years so did the number of deaths. In 1996, when effective H.I.V. therapy became widely adopted, the incidence of AIDS began to all dramatically. Few diseases without a cure have evolved as rapidly. In 1985, AIDS was considered so horrifying that Ryan White, a sweet-tempered boy from Indiana, wasn't even permitted to attend his seventh grade class for fear that he could infect his schoolmates. Gay men were routinely turned away by terrified staffs at hospitals, and film crews even refused to work on stories that involved AIDS patients. These days, however, H.I.V. is often compared to diabetes--a chronic but largely manageable disease.
     Yet AIDS has not disappeared in America; there are more than forty thousand new H.I.V. infections each year. (The numbers have remained remarkably high especially among black gay men, minority women, and drug addicts who share needles. What's new is the rise in infections in the gay communities in such cities as San Francisco and New York,) Nonetheless, AIDS has receded as a threat in the public consciousness, and as a cause for philanthropy or for political discourse. That is almost as true in the gay community as it is anywhere else. After all, many people have seen friends or lovers rise from what seemed like certain deathbeds once they received
the proper medications. Those medicines transformed gay life, and, naturally, the new physical realities were accompanied by a tremendous change in attitudes about what H.I.V meant. By the late nineties, there were thousands of men living with H.I.V who were vigorous, healthy, and eager to reclaim the type of life they thought they had lost. As they began to gain weight and feel better, many returned to the kinetic night life that had virtually disappeared at the height of the epidemic, including allnight "circuit parties," which often include serial sexual encounters.
     With bars in places like Chelsea and the Castro filling with healthy men, and the continual migration of new people in search of a more open life, some men began to wonder, What's so bad about H.I.V.? It's a treatable disease. Pharmaceutical companies ran ads depicting H.I.V.-positive men as rugged and virile. At first, such advertisements seemed necessary, to insure that people realized that the new treatments could help them return to a normal life. But some ads went far beyond that. Impossibly active men were shown climbing mountains or racing sailboats, and though the ads may have been unrealistic, they played into the growing medicalization of America. Pharmaceuticals have become a basic part of the lives of millions of people in the United States, who routinely take pills for depression, cholesterol, and blood pressure, to help pay attention in class, to sleep, and to cure sexual dysfunction. The fact that tens of thousands of people were undertaking a battery of anti-H.I.V medications didn't seem unusual.
     "It's hard to maintain your vigilance for twenty-five years," Michael Siever told me one day at the Stonewall offices. "What was my life once? You used to walk down the street and see death everywhere you looked. People with lesions on their faces, people on crutches and in wheelchairs, if they could even go outside. I went to memorial services every weekend. Always. This was a community of ghosts. And that is not true anymore. There is this cocktail, and it was like magic. Before that, AIDS was always in your face; you could never put it out of your mind, but after enough years you just want to forget. And now you can go somewhere and in the heat of sex--and I am not even talking about the drug part, just in the heat of sex--it's much easier to forget. I used to have a button that said, `If It Moves, Fondle It ' People miss those days and wish they were part of them, and the drug helps you get back to the place where all your concerns go out the window."
     Crystal methamphetamine became popular among people in the gay community just at the moment when the drug cocktails for H.I.V were starting to work, and when the Internet had begun to shape the way people interacted socially. "I was seeing a patient at one of the S.T.D. clinics one day," Jeffrey Klausner, who is the director of the Sexually Transmitted Diseases Prevention and Control Services of the San Francisco Department of Public Health, told me. "It was in the spring of '99, and we were starting to see a small increase in the number of syphilis cases in gay men: ten in 1998, and by the next spring there were already another ten. I asked this one guy how many sexual partners he had had in the past two months, which is something we always ask. And he said fourteen. And then I asked him how many he had had in the past year. And he said fourteen.
"That was a little odd," Klausner continued. "I said, `Well, what happened two months ago? The man replied, `I got online.'"
     Klausner is a tweedy sort of doctor, he dresses in khakis, blue blazer, and buttondown shirt, and unabashedly conveys the image of a man who is by no means cool. "I didn't have a clue what he meant," he said. "Nothing. So he explained it. Well, I am a fifty-year-old, overweight, H.I.V.positive man. I am balding I'm not that attractive. But I can go online any time of the day and I can get a sexual hookup. I can go to this site on AOL and I can say I want to meet somebody now for sex. And that's all there is to it' " Recounting this story six years later, Klausner still looked mystified. "I asked him to explain. And he told me, `I go online and put out my stats--if I am a top or a bottom, what I like to do. I am a top, I am H.I.V.-positive. So I will say, "Does anyone want to be topped by an H.I.V.positive guy?" ' " Klausner continued to recall the conversation: "'I'll get five responses in half an hour. And then I will speak to them on the phone. If I like their voice, I will invite them over and look through my window. If I like what I see, then I will be home, and if not I can pretend I am gone. It's been great. I don't have to talk to anybody to do it. I don't have to go out of the house. I can get it like this,' he said, and snapped his fingers."
     After hearing the story, Klausner asked his public-health investigators to include questions about that kind of activity in their routine interviews. Seven out of the next nine people they saw had met their most recent sexual partner online. "It turned out that crystal methamphetamine and the Internet were the perfect complements for high-risk sex," Klausner said. "Crystal washes away your inhibitions. Makes you feel good and want sex. And the Internet is there to respond to your whims. It's fast, it's easy, and it's always available."
     Klausner and others embarked on studies that concentrated on the use of the Internet, on attitudes about AIDS, and on the role of methamphetamine in gay life. The results were hard to misinterpret: the Internet has turned out to be a higher-risk environment than any bar or bathhouse--men who meet online are more likely to use the drug, more likely to be infected with H.I.V., and less likely to use condoms.
     Methamphetamine can be consumed in any number of ways: you can drink it, snort it, inject it, swallow it in a pill, take what is known as a "booty bump"--insert the drug like a suppository--or "hot-rail" it (a process in which you heat a glass bowl, put the powder in the glass, and inhale the vapors, which go straight to your lungs). "Methamphetamine has a nine-to-twelve-hour halflife, which means that weekend warriors can start on Thursday and only dose five times to make it to Sunday evening," Steven Shoptaw, a psychologist with the U.C.L.A. Integrated Substance Abuse Programs, told me.
     Shoptaw and his colleague Cathy Reback, a principal investigator at Friends Research Institute, who also works for the Van Ness Recovery House, in Los Angeles, have carried out some of the most comprehensive research on the effect of the drug on gay men. "You are going to be active," Shoptaw says. "Feeling sexy. The libido will be pushed and, with the advent of Viagra and other, similar drugs, you no longer have to worry about `crystal dick' "--which had seemed like the one obvious drawback to the sexual experience that methamphetamine provides. Crystal methamphetamine constricts the blood vessels, which makes sustained erections difficult. Viagra reverses that effect. "So now you can go from Thursday to Sunday and have outrageous amounts of sex," Shoptaw said. "It's cheap-you can get a hit for twenty bucks that lasts a day. It is the perfect drug." Shoptaw added, "The issue about how a drug interacts with a culture also matters, because, if having that kind of sex is important, then this drug fits with the culture in a way that cocaine and alcohol don't."
     The physical changes caused by methamphetamine are profound. The drug instantly increases the amount of at least three neurotransmitters in the brain: dopamine, serotonin, and norepinephrine. Those chemicals are released naturally by the body when we feel good, but crystal unlocks a constant flood of the substances, particularly dopamine. In contrast to cocaine, which is almost completely metabolized in the body, methamphetamine lasts much longer. As with all drugs, the bigger the rush the harder the crash. After long use, the effects diminish in intensity, and depression is common. Abusers forget to drink water, and can become dangerously dehydrated. The chemicals used to make the drug are so toxic that for those who smoke it there is the danger that their teeth can crumble and fall out. Severe anorexia and malnutrition are also risks. Methamphetamine can cause heart failure and stroke. All users, not just addicts, suffer some longterm damage to the brain; memory loss and paranoia are common. "In other places with other people, H.I.V is a different issue," Shoptaw told me. "But with gay men it is about the drugs. It's simply about methamphetamine. The data on that are so clear."
     In Shoptaw's office at U.C.L.A., he and Reback showed me a slide that said almost everything one needed to know about the relationship between H.I.V and methamphetamine use: it summarized a survey of how likely certain gay men were to be infected with H.I.V. If the men in the study said that they had used methamphetamine in the past six months, there was a low but significant chance that they would be infected. For men who used it once in a while, the figure was twenty-five per cent. When the researchers interviewed chronic users, the number climbed to forty per cent. Sixty per cent of users in outpatient treatment programs were infected, and for users in residential care the number is nearly ninety per cent. "You know that slogan from the Clinton campaign?" Reback said. "We have paraphrased it many times: `It's the drug, stupid.' When you are talking about H.I.V infection among gay men, it's the drug."
      I walked over to the Starbucks on Eighteenth Street with my laptop one afternoon and went online. There are dozens of sites devoted specifically to uniting men for the purposes of immediate, anonymous, and, often, drug-induced sex. The Web site Craig's List has unintentionally become a sexual superstore for men and women, straight or gay, there is m4m4sex.com and also manhunt.org, the current favorite in San Francisco. (There is hunkhunter.com and bigmuscle.com, among many, many others.) The sites were numbingly similar, and the advertisements on them couldn't be more explicit. Statistics are usually invoked, and pictures of body parts provided (or sought) as proof. It almost makes the seventies, when throngs of men congregated in bathhouses and on the piers of the Village, seem innocent. Despite laws and regulations instituted at the height of the AIDS epidemic, sex clubs continue to exist in many cities; there is, for instance, the West Side Club, housed in an unexceptional-looking building in Chelsea, where men--both H.I.V - negative and H.I.V-positive--can have anonymous and, if they want, unprotected sex. Another club in New York admits only men with certain physical attributes; others demand that all clothing be checked at the entrance (except, apparently, boots). In San Francisco, clubs are legal, but most sexual encounters are not supposed to be permitted. They are, of course; why else go to a sex club? At least there you can put a box of condoms on the counter and some posters on the walls. Education and interventions are not easily transferred to cyberspace. "The Internet sucks you in," Tom Orr told me in San Francisco. Orr, a thirty-four-year-old native of Seattle, rewrites show tunes in a salacious, funny way (much like "Forbidden Broadway"), from a gay perspective. "On the Internet, you can be whoever you want to be. Smoke some crystal, get online, and there is nothing you won't or cannot do." He is trying to quit the drug. For the most part, he has been successful, he said, but there have been occasional lapses. At Tina's Cafe, for example, where he performed some of his songs, he mentioned a serious "Christmas binge." He said, "It's a constant temptation. It's everywhere in this town. Anyplace you swing your purse."
     I went to the personals section of Craig's List and clicked on the link for "men seeking men." Then I typed the letters "PNP" into the search bar at the top of the page. ("PNP" stands for "party and play." It's the not very secret code that means you want sex and drugs.) "We call it ordering in," Orr had told me earlier. In less than a second, there were seven hundred and seventy-one entries on my list. (This was just for that day in the San Francisco Bay Area. For comparison's sake, I carried out the same search on the New York City version of the Web site and saw two hundred and twenty-one postings.) The first San Francisco listing said, "Preppy white bottom guy, coming to Castro wants to get fucked." There followed an extremely detailed list of the man's various attributes ("38, 5'8", 150, medium complexion, well built, 8 x 6 cut") and his desires (needs PNP). Another post said, "U.L.L.4 O. PP," which stands for "Up Late Looking for Other Partying People." Another said, "I'm a hot, down-to-earth, VERSATILE black male and I'm looking for an erotic adventure. Not interested in predictable 'orifice by numbers' encounter, and tired of scripted narratives/verbal roles." He went on to say that he was "PNP friendly' and "Poz" (H.I.V.-positive), and that he was hoping for something hot and unexpected. Immediately.
     "I don''t want to romanticize something that was often very hard and even dangerous," Jeff Whitty told me when I met him the following week in New York. Whitty wrote the Tony Award winning musical "Avenue Q," and he has talked a lot about the dangers of crystal methamphetamine. "But I long for the days when people would actually cruise each other. I can't remember what I was reading--I think it was Gore Vidal's memoir, and he paints these pictures of being gay after the war, when you would follow someone for fifty blocks. It was a weird, funny ritual, but in a way it was actually more open. At least you could look at somebody, see how the person moved, interact. But that is now gone. Now we have the Internet when you want to hook up. You can get sex within minutes. Anonymous. No names. No commitments. No connections. Is that what we are really looking for?"
     One of methamphetamine's most dangerous effects is the weakening of inhibitions gay men might have about unprotected anal intercourse; people are suddenly happy to be receptive partners-- "bottoms." The argument is often made that heterosexuals engage in risky sex, too, and that, in any case, most gay men don't. But it takes only a small group to fuel an infectious epidemic. "I don't think I can say what kind of life most gay men want," Whitty said. "But if they are doing this on the Internet, with methamphetamine, and they are infected with H.I.V, then they are going to infect other people. I don't care what kind of sex anyone has. That's up to them. But we have a problem. And we need to start dealing with it a little more responsibly if we don't all want to die. How many times does that message need to be sent?"
     On February 11th, the New York City Department of Health announced that a gay man who had repeatedly engaged in unprotected sex with many partners while using crystal methamphetamine was diagnosed with a remarkably aggressive strain of H.I.V.--a "supervirus"--that was resistant to essentially all normal medications. The diagnosis was made late last year, and within four months the man had progressed to AIDS--a process that can take a decade or more. The announcement, which caused a furor in the gay communities of New York and other cities, was a frightening reminder of the precarious lives of the millions who are infected with H.I.V. But it was little more than that. There is so far no evidence to suggest that this single case represents a greater threat; the announcement seemed to have much more to do with publicity, awareness, and fear at a time when public-health officials say that complacency in the gay community has become common. The man, whose name has been withheld, is in his midforties. He had been using crystal methamphetamine about once a month for five years but recently had started using it at least every week. Excessive use of crystal methamphetamine not only lowers your inhibitions but compromises the immune system, which is essential for any defense against H.I.V. Viral resistance is hardly new, nor is it a phenomenon restricted to H.I.V. Also, people who use H.I.V medications need to take them at regular intervals. A weekend drug binge, when reality is banished, and even water is rarely consumed, seems unlikely to encourage such a regimen.
     Still, it was the man's age that surprised me. I could understand that people who had not been alive to see men dying by the thousand in San Francisco, New York, and other cities might have to learn to exercise caution. But the average age of newly infected gay men in New York and San Francisco is nearly forty. The real problem lay not with naive youngsters but with those who had been aware of this epidemic virtually their entire adult lives. "You want to kill yourself?" Larry Kramer writes in his new book, "The Tragedy of Today's Gays." "Go kill yourself. I'm sorry. It takes hard work to behave like an adult. It takes discipline.... Grow up. Behave responsibly. Fight for your rights. Take care of yourself and each other." Kramer has been offering such advice for decades. How, in 2005, can people ignore it? What could motivate a person who has lived through the worst of the epidemic to cast off the safe-sex practices that have protected him for years?
     "For a lot of people, this is like coming out of a really tough war," Daniel Carlson told me. Carlson is a thirty-five-year-old former marketing executive who two years ago started H.I.V Forum, in New York, because he was concerned that gay men simply weren't confronting the central problems facing their community. "They want to deal with it all by running away," he said. "There is tremendous pain and there has been for years. The prevention message has been lost completely. It used to be simple: AIDS equals death. Now the world is murkier than that. Fatigue is genuine. But also gay culture is focussed on youth, and once you hit forty you are no longer that cute kid on the block, the pretty kid. You are not married. You don't have a partner, and you are trying to assess what you want out of life. There are many who are confused and unhappy, and you mate that with cultural norms that have moved away from safety and you have a pretty explosive situation."
     There is also evidence to suggest that the resurgence of H.I.V is a result of problems that go beyond the midlife crises of gay men who did not expect to be alive today. It is never easy to fashion a message that can change the behavior of a community--let alone a dispirited and often despised minority "We knew from the first days of the epidemic that knowledge was necessary but not sufficient," Ron Stall, a professor of epidemiology at the University of Pittsburgh, told me. Stall recently left the Centers for Disease Control, where he ran the Prevention Research Branch at the National Center for H.I.V., S.T.D., and T.B. Prevention. "If you want to demonize the gay man about his sexual behavior, then you might as well walk up to somebody who is smoking a cigarette and ask him if he knows it is dangerous, or ask somebody who is driving without a seatbelt. This is a basic phenomenon we see among humans--taking a risk because it is convenient in the short term, even if in the long term it is something none of us would do. After all, it's not just one cigarette that causes emphysema; it's making a poor choice for thirty years.
     "The epidemic of crystal methamphetamine is real and it's serious," Stall continued. "But I suggest that everyone just stand back and ask, How is it that AIDS and substance abuse have been twin epidemics that have interacted and made each other worse? That question has bothered me from the beginning." For his research, Stall has drawn on data collected from the Urban Men's Health Study, one of the largest surveys taken of a gay population. He looked at mental health issues such as depression, partner violence, and substance abuse. He also examined the extent to which the men in this study of nearly three thousand people reported having been sexually abused as children. "I was surprised to see the extent to which one epidemic was associated with the other," he said. "Depression, partner violence, substance abuse." He controlled the sample for race, class, level of education, and H.I.V status. Then he and his colleagues cross-referenced the data from all of the categories and found that each category was associated with all the others. That means that there are at least four significant epidemics going on in gay communities in the United States, and that they are interacting and making one another worse. Stall refers to this phenomenon as "syndemics"--a syndrome of interacting epidemics. The higher the number of the epidemics that any particular man experienced, the more likely he was to have risky sex, and to test positive for H.I.V.
     "This suggests that substance abuse is a thread in a larger tapestry" Stall told me. "And one shouldn't forget that crystal methamphetamine also acts at first as an antidepressant. People talk about `Will and Grace' and how accepting America is now of homosexuality. That is simply not true. America has come a country mile, I agree. Still, in the state I just left"--Georgia, where the C.D.C. has its headquarters--"almost four out of every five adults recently voted to deny gay men and lesbians the right to even have a civil marriage. We have an awful lot more work to do."
     So, of course, does the gay community, which many people feel has badly distorted the fundamental message of prevention, by subordinating it to the idea that there is nothing wrong with being H.I.V.-positive. I went to see a Bay Area psychologist named Walt Odets one morning in his sunny, well-tended house, on a quiet street not far from the Berkeley campus. For many years, his clients have been mainly gay men. He is fifty-eight but looks far younger. Odets is an uninfected gay man who readily admits that for him the pain of the epidemic has not dissipated. "I still hold an intuitive horror about the whole thing," he told me. "Sometimes I think of myself as a trauma victim. I had a partner who died in '92, and it is still a horror to me. But I can see that it depends on circumstances. Many people don't really care."
     Odets believes that the gay community split in 1985, the moment a reliable H.I.V test was available. "Before that day, everyone was in it together," he said. "Nobody knew who had it and everyone acknowledged that it was a horror. And then, in April of 1985, we started protecting people who had H.I.V. And we did that by normalizing infection--and we have done that all along. It has completely compromised prevention work, to the extent that when the AIDS Health Project, in San Francisco, put up a banner outside its facility that said `Stay Healthy, Stay Negative' the gay public was incensed. Men wrote in and said, `I have H.I.V and I am perfectly healthy. How dare you imply that I am not?' " While it has always been important to protect and support H.I.V.-infected men in the gay community, Odets argues that it has become difficult to teach men who test negative how essential it is for them to remain uninfected. "This is not about making positive men feel good about themselves," Odets said. "It's about protecting H.I.V.-negative men." He told me that he had even conducted workshops where it was nearly impossible to shift the primary prevention message from supporting positive men to remaining uninfected. "There is just way too much guilt. Too much discomfort because what you are saying to a positive man is `I don't want to be like you."'
     Daniel Carlson agrees. "There is some level of guilt about not living with the disease," he said. "About staying negative. People will say, `Oh, look at you going around and glorifying your negative status.' I don't go around and say, `Hey, I tested negative today, joy to the world.' And, believe me, when people test positive they do talk about it and they get support. People like me--we keep our mouths shut."
     A few weeks ago, I spent an evening stuffing condoms and lubricant pouches into packets at the headquarters of Gay Men's Health Crisis, in New York. The organization, founded by Kramer and several friends in his Village apartment in 1982, has evolved considerably since then. It was formerly run by, and for, white men, but its president now is Ana Oliveira, who has spent much of her working life in the South Bronx. You are just as likely to see a Hispanic man or a black woman in the elevator as a white man from Chelsea or the Village. The condom-wrapping group meets periodically to prepare packets (two condoms, two pouches of lubricant) to hand out at discos or gay clubs or in communities like Fire Island--any place gay men might gather to have sex. The annual Black Party was held at Roseland in March, and a team from G.M.H.C. was there with a supply of condoms. The Black Party is one of many on the gay circuit where thousands of men meet to dance, to drink, and, sometimes, to engage in anonymous sex. The parties often last past dawn. A friend of mine who was there this year said that it was almost impossible to find a condom, or information about H.I.V., but that crystal methamphetamine was for sale everywhere and sexual activities ranged from "unbelievable to outrageous."
     At G.M.H.C., six men sat at a tenfoot-long table in a conference room, sipping sodas and putting condoms into packages. They talked about the epidemic as they worked. Each had spent time in the past two years trying to persuade people to practice safe sex. It's not an easy task, but there are some signs of progress. "A year ago in the Barracuda"--a Chelsea club--"we couldn't even hand out condoms," Norman Candelario, a staff member at G.M.H.C., said. "It's better now. Not great. But better. Now we are asking why are people using crystaL And the answers are always body image, stigma, age. It's really self-esteem. A lot of these men are just lonely and depressed."
Murmurs of agreement circled the room. "So we go right at that," Timothy Kokott, one of the volunteers, said. "We talk to people about the problems, and I tell them it is absolutely O.K to guard your negative status. This is our community, and we have seen too many people die in it. But we are not going to give up. And many of us never did give up. Yes, the crystal problem is real, and it's true that people don't protect themselves. We are going to have to change that." He stared silently at the back of his hands for a moment. "And we will. I absolutely believe we will."