22. Families of Slain Sue Aurora Theater

May 11, 2016

In the news today is a story about a civil suit brought by the families of the killed and wounded against Century 16 theaters, claiming that the theater should have provided more security.

The theater responds that James Holmes was a madman, an ‘evil genius’, who was hell-bent upon destruction, that his arrival was unpredictable and that he was unstoppable.

Two important clues mitigates against that theory.  1) Holmes was wearing body armor and was heavily armed.  2) And when he was confronted at his vehicle by police, he surrendered immediately and without resistance.   From these facts, as a former forensic psychiatrist, I infer that he was very concerned about getting hurt.  Just guessing,  I’d say that like most people who act like bullies, he was himself a cowardly person.  My speculation is that there is a good chance he would have folded immediately if taken under fire.  And of course he might or would have stopped shooting if wounded or killed.

In 2012 the population of Colorado was 5,192,000.  At that time the number of concealed weapons permits existing in the state was 139,560, meaning that as many as 2.7% of Colorado’s citizens habitually go armed.  In a theater reported to have contained 400  patrons, statistically speaking, there would have been, on average, 10.68 armed patrons, had the management of the theater not reduced that number to zero by posting “No Guns” signage prohibiting law-abiding citizens from entering the theater armed.

With everyone in the theater crouching to flee, except the shooter who remained upright, it would have been likely that some of the armed patrons could immediately have returned fire, either hitting the shooter or causing him to stop shooting and flee.  This is not at all unlikely, and in fact is exactly what has happened in some previous active-shooting situations.  One that comes to mind is a shooting in a southern church where the shooter was immediately shot and killed by a young woman congregant who was armed.

In the Gabby Gifford shooting, an armed Safeway patron had emerged from the store and, having heard the shooting and screaming, was standing concealed, having drawn a bead on a man with a gun standing in the parking lot.  The man with the gun was not aiming it at anyone, and turned out to be someone who had taken the gun from the shooter.  The armed patron very wisely had waited until the situation became clear before opening fire, and in the end, holstered his weapon without shooting.

Century 16, as its management argues, may not reasonably have been expected to provide armed protection to its patrons, but in this case, if earlier news reports were right about the sign banning firearms, and its “no guns” policy,  it may have consciously and intentionally adopted a policy that prevented patrons from protecting themselves.  It will be interesting to see whether the courts consider that argument.

There is one further speculative argument.  It has been argued hypothetically that a rampage shooter might intentionally select a “No Guns” area, in which case that policy actually exposes patrons to a slightly nigher risk of harm even when it doesn’t actually  happen.


21. Department of Justice v. North Carolina — Human Biological Waste Facilities, Showers and Sex

North Carolina:  Persons may only use bathrooms, locker rooms and showers that are designated for the sex that appears on their birth certificates.

U.S. Department of Justice:  In any publicly-funded facilities, and in the facilities of companies employing more than 10,000 people, persons may use bathrooms, locker rooms and showers designated for the sex they regard themselves to be.

May 9, 2016

Let’s cut the crap.

I’ve listened to so much imprecise, inaccurate and uninformed opinion and description of the elements of this issue in the past couple of days that I feel the need to clear the air.

First of all, this is a question that it was once, as long ago as the mid 1990’s, my responsibility to resolve.  Second, I attended a recent talk at the local Humanist Society given by a dainty little person with a high voice and short hair who insisted he was a man who had once been a woman, but without providing any anatomical details by which the audience could make an independent judgment.  She asked to be called “he”, and frankly I’m not sure how I want to handle that.  By all of the cues upon which I have come to rely during my four score and one years, the speaker seemed to me to be a woman.  So I naturally thought of her as “she”, and that is how I will describe her for now.

Next, I find that our language regarding these matters is so thoroughly euphemistic that it threatens to derail a clear view of the issues.  So for the sake of this essay I am going to jettison words like bathroom, toilet, rest room, powder room, washroom and water closet, most of which describe activities that we do not do in the shitter or the pissoir. For the sake of avoiding jarring or distracting anglo-saxon terms, however, I will employ ‘defecate’ and ‘urinate’ because they are at least direct in meaning, though softer to the ear because they come from the Latin terminology and therefore sound more clinical than vulgate.

As I understand it, the federal Department of Justice (DOJ) rulings regarding the new law in North Carolina actually effect not only places where persons of all ages might defecate or urinate, but also locker rooms where they might change for work or for school athletics. The DOJ rules will also apply in workplace, school and health-club group shower facilities.  The issue has arisen because for the past few years political activists among those people who self-identify as Lesbian, Gay, Bisexual and Transgender (often known as the LGBT community) have been agitating to be allowed to use the facilities assigned to the sexual identity with which they feel most comfortable.  And to be complete in our avoidance of euphemisms, let us agree that, despite mythology, homosexual women are not all from the island of Lesbos, and not all homosexual men are caricatures of effeminacy, fey or “gay”.

By the way the term “gender” itself has within recent decades, become a euphemism for sex.   Not long ago gender used to refer only to things masculine, feminine or neuter: i.e., social, cultural or linguistic differences.  Biological maleness and femaleness was called, sex.  Now, in the interest of delicacy, and to avoid saying ‘sex’ out loud, some people have taken to referring to male and female ‘gender’.  (derisive snort)  

In terms of the somewhat militant invasion of facilities for the disposal of human biological waste, that started little more than two decades ago, when women began barging into men’s facilities at sports stadia.  Women’s facilities, given that women generally urinate sitting down and require more booths, were in deplorably short supply and the lines in front of Women’s Rooms were many times as long as those in front of Men’s Rooms.  While unproven, it always seemed to me from accounts at the time, that these invasions were led by women who were somewhat more assertive, aggressive even, and perhaps not as intimidated, nor even impressed, by the thought or sight of male genitalia.  But that’s just an educated guess.  In the Bay Area it was the assertive Berkeley Woman who strode past the urinals to claim a booth for herself, and bully for her!

So in her talk, the LGBT speaker who thinks of herself as a man focused upon the problem of finding a place to defecate or urinate, and basically said it was unfair and hurtful that other users of the facility questioned, by look, behavior or word, her right to be there.  This, she said, was distressingly insensitive and should never be done by a thoughtful person.

During the question period at the Humanist talk, I raised the issue of the expectation of privacy that men or women might have, which heretofore has included the assumption that others using facilities for these particular bodily functions would be of the same sex. I mentioned that the seeking of privacy for urinating or defecating seems to be a common tendency among many mammals, possibly because of the vulnerability to predation that these functions may produce.  I suggested that the instinctive need for privacy might come from a very ancient (limbic) part of the brain and might represent a very strong interest, deserving of respectful accommodation.   To which others suggested that even if real, such an emotional need might easily be overridden by (cortical) reason — that there is no longer such a danger in the modern epoch.  The fear is atavistic, they implied, serves no function, and needs to be relinquished.

It wasn’t until a week or two later that an adventitious rebuttal to that argument appeared in the form of a documentary about India that I will describe in a few moments.

Back in the mid-’90s, as I said, I was faced with these same issues in a real-life case that, for me,  illustrated the complexity of the relevant factors.  As a company medical director I was asked to decide when a male mechanic undergoing sex change could begin to use the women’s locker room and shower.  The thing is, male to female sexual reassignment begins with several months of female hormone treatments resulting in the development of female breasts.  This progresses along perhaps with psychological counseling, and beginning of wearing women’s clothes, perhaps the use of makeup, depilation and so on, but before the patient undergoes surgery to remove the penis and testicles and to create a surgical simulation of a vagina.  In this  particular case the mechanic had breasts, had grown his hair long, had lost his facial, chest, axillary, arm and leg hair, but still had a penis.  So with whom could he share locker and shower space without anyone experiencing the stress of feeling undressed in the presence of strangers of the opposite sex?  With neither sex, actually.

My recommendation at the time was that the man could change from street to work clothes with his female co-workers, but could not undress or reveal the part of him that was still male.  To change those particular undergarments he would have to find a private space within the women’s locker room or not change them at work.  Generally speaking, my thought was that individuals in transition should not expose parts of themselves that identified them as being of the opposite sex than others using a sexually segregated facility.  The compromise worked out well enough in that particular case.

In the North Carolina controversy most of the concern of the public and the legislature seems to be for the comfort and safety of women and girls.  The U.S. Department of Justice is seeking to impose rules that will effect public, school and business facilities for urinating, defecating, showering and changing, and there seems to be a fear that, using the DOJ rules as a pretext, males will seek to enter places designated for girls and women.  

Opponents of the North Carolina law and supporters of the federal action, as well as many journalists in their interviews of the litigants, scoff at any hypothetical danger, and aver that such a fear is irrational, atavistic and bogus, since there have been no such cases ever reported in North Carolina.  Supporters of the state law have had to agree sheepishly that it is true that there have not.

But is our deeply emotional urge for privacy when defecating and urinating, and to a greater or lesser extent during any time we are naked and undefended, as useless a vestige as the vermiform appendix?  Is the human race far beyond any actual need for privacy during these moments?  

Well, first of all I think that even an emotional need is a true need and deserves to be respected, especially when it is this deep and powerful.  But more to the point, I saw a full-length documentary only a month ago about a serious, present-day problem that grows steadily more dangerous in parts of India.  As it happens, there are not only no public facilities for defecating and urinating in those regions, but there are also no such facilities in most private homes either.   Everyone simply has to find a place out of doors to defecate, urinate, or wash.  Moreover, there are no places, public or private, where women may apply or discard blood absorbing products during menstruation.  The report said that it is the common practice was for women to wait until they returned to their homes, and then, at night and under cover of darkness, to steal outside to some nearby field or hillside to relieve themselves.  And this has resulted in a large and ever increasing number of rapes and murders of women and girls, apparently while they are seeking a place to empty their bowels or bladder in the privacy of darkness.

In view of this contemporary phenomenon, one might draw the inference that it is because we have well-lighted sex-segregated facilities that are easily accessible to women, sanitary and private, that there are few or no cases of molestation or assault to which we can point as an indication of the need to maintain sexually segregated facilities.  The irony being that we can’t prove the need for sexual segregation where we urinate, defecate, change or shower, because we have sexual segregation where we urinate, defecate, change and shower.   Given the state of our nation’s plumbing — the ceramic and plastic kind — we might not ever experience anything like the risk level Indian women encounter, but the Indian phenomenon does reveal that there are a significant number of predatory men around even in these modern times, and that they probably should not be given completely voluntary access, solely on their own say-so, to facilities intended for women and girls.

In an age when “gender reassignment”, though still quite rare, has, since Christine Jorgensen, become slightly more common, the North Carolina solution, to have individuals use the facilities with the same label as the sex indicated on their birth certificates, does not seem fair or reasonable.  But it also seems patently naive and foolish merely to accept whatever gender an individual self-selects.  Since the number of sex reassignments is still manageably small, it might be practical to require that sex other than birth sex be certified judicially, with appropriate input from medical experts.


20. E-cigarettes, Shortage of Addiction Counselors and Increased Suicide — Related?

May 8, 2016

In one of the weekly reviews of the news to which I subscribe, I ran across three news items between which I saw some tie-ins.  Others, I thought, might have seen the three items as unconnected.

The three items were the following:

1) The British Royal College of Physicians, like our AMA, recommends the use of e-cigarettes as a “harm reduction” strategy.

2) The Wall Street Journal for 4/28/16, (p. A-3), in an article by Arian Campo-Flores, reported that there is an increased demand for qualified addiction counselors because of a [Ed: doctor-driven] boom in prescription opiate addiction, coupled with an Obamacare requirement that addiction disorders be covered by private insurers and Medicaid.  Campo-Flores says there is, however,  a scarcity of addiction counselors due to a history of low pay and rapid burn-out in the field.

3) Suicides hit a 30-year high in the U.S., according to a recent release from the National Center for Health Statistics.

My first reaction when seeing these three items is that in my experience it seems they may be causally interrelated.

Sometime around the early 1990’s, there emerged a new specialty in medicine, designed to deal with “chronic pain”.  At the same time a division was developing among addictionologists.  Most doctors sought to help addicts to abstain from their drugs, by a combination of long-term cognitive therapies, like the 12-step programs, and the brief initial use of medications designed to ease the impact of withdrawal symptoms over a short period of detoxification.  A growing number of others, who seemed to have given up on actually treating addiction, were satisfied to deal with addiction by prescribing similar addicting substances that were less risky than the original drugs of choice.  The best examples of this “harm-reduction” approach were the methadone clinics that provided a free oral drug (developed by the Germans during WW II when they were cut off from access to regions of the world growing poppies, the source of opium and morphine).   The theory was,  while methadone was just as addicting as heroin, it was longer acting, and, could be administered orally, once a day, in a clinic.  Since several intravenous fixes of heroin a day were no longer required to feed the addiction, at least the risks of needle-sharing;  HIV, hepatitis C, etc., could be avoided.  Because the drug was provided free, the need for criminal activity to pay for drugs was also reduced.

The “risk-reduction” approach grew popular with public entities like city and county governments, partly, it seemed to me, because, requiring only minimally trained personnel, it was cheaper and easier to administer than to offer treatment with a goal of eliminating the addiction itself.

This shift in public health policy coincided roughly with the Chinese experiment of providing basic, low-level healthcare to its underserved population by sending “barefoot doctors”, with two years of medical training, out into the countryside.  Here in the U.S. the experiment took the form of allowing supervised practice by former military paramedics, and by nurses with an additional two years of training as nurse-practitioners.  I don’t mean to question the wisdom of the U.S. programs.  As a matter of fact I was asked to be the first private practice physician in Northern California to act as a preceptor for a member of UC Davis’ first graduating class of nurse practitioners.  And later, as the director of a busy occupational clinic at United Airlines, my staff included two other physicians and three nurse practitioners.  With immediate supervision and physician support, a medical team including nurse practitioners both was safe and efficient.  I mention the inclination of the times, to reduce costs by using lesser-trained individuals and changing their title from “doctor” to “primary care practitioners”, because it supported the idea of treating the huge problem of addiction with “harm reduction strategies” rather than actual treatment.

Meanwhile doctors had continued to create opioid addicts by treating the acute, short-lived pain from occupational injuries and surgical procedures with too-lengthy out-patient prescriptions of highly addicting oral pain-killers like Percodan (ocycodone), over which they exhibited far too little control and supervision.  One compounding error often committed to this day is that many doctors prescribe Percodan in the common medicinal dose of “once ever four hours, round-the-clock”, when the effects of Percodan last six hours, and when the recommended dose should actually be:…once every six hours, only as needed for severe pain.

Conservative physicians were in the habit of using addicting opioids only for very short-term problems, prescribing only a few pills at a time with no automatic refills, thereby keeping close tabs on the use of the medication.   Opoids can addict a patient for life after only a very few days of use.

As a private family physician during this period, and later company doctor treating 2,000 employee injuries a month, I began to see increasing numbers of patients asking for Percodan and other opioid medication refills, who had been given the drugs for months by other doctors!  The older guideline was that long-term use of addicting pain killers should be limited to patients with an illness expected to end in death within, say, a year or two.

The doctors who ran chronic pain clinics, often dealing with such controversial entities as “fibromyalgia”, began to exert pressure upon the medical community and the state licensing boards, to train all physicians to recognize and treat chronic pain with opioids, (or to refer patients to the chronic pain clinics).  Physicians who took the more conventional conservative approach and used non-addicting medications and physical modalities to relieve pain were threatened with reprimand and discipline for “under-treatment” of patients in need if they failed to treat complaints of chronic pain with “adequate” doses and durations of prescriptions.  Special courses were mandated by state medical boards for “reeducation” in the treatment of chronic pain.

Thus, chronic-pain and harm-reduction addiction clinics gradually carved out a comfortable economic niche for themselves in the medical market.

Now, after a couple of decades of treating addictions with “harm-reducing” prescriptions of the same or with other very similar addicting substances, we are seeing a huge wave of addictions to prescription pain-killers, along with an accompanying  wave of overdose deaths.   Duh!

From my later career as a general, addiction and forensic psychiatrist, I am aware that alcoholism and addiction are drivers of the suicide rate.  Opiates and alcohol are depressant drugs.  Suicide is most prevalent among the victims of major depression and those with the characterologic depression associated with personality disorders.  Some of the people most susceptible to addictions and substance abuse are those with personality disorders.

Viewed from the other side, addicts often exhibit the personality traits of people with personality disorders, especially those  in what is called Cluster B:  Borderline, Narcissistic, Antisocial, and less obviously, Histrionic Personality Disorder.  Addicts often lie to get their drug of choice, have little regard for those whose lives they impact adversely, engage in relationships based upon rage, are controlling and manipulative. Their denial looks a lot like grandiosity.  Their treatment of the other people in their lives is described as expressing a “lack of empathy”.  But on the other hand, disregarding the feelings of others is not easily distinguished from treating others as if you were angry at them.  This kind of rage-based relationship to others is an explicit feature of some of the the Cluster B disorders, and one might generalize that it features to some degree in all the personality disorders.

In Karl Menninger’s famous and classic treatise on depression, the book called, Man Against Himself”, he describes depression as anger that, when deprived of its important external targets, reflects back upon the self.  Suicide, he says, is acting out that anger against oneself (and others), and serves both as an expression of the anger, and simultaneously as punishment for any guilt one may feel because of one’s unwarranted anger towards others.   Persistence of those dysfunctions over a lifetime is probably the reason why unresolved personality disorders are associated with a suicide rate as high as that of major depressive disorder.

It is probably not a coincidence that the 12 steps of AA can be an effective antidote to many of these dysfunctional personality traits.  Ironically, when one chooses, “harm reduction” as the dominant official response to addiction, a strategy that looks suspiciously like enabling behavior, the addiction is simply not addressed, and neither are the personality traits that may well, if they fester long enough, lead to suicide.  Thus, in this way, choosing what some call, “harm reduction” strategies to deal with addictions may, over time, tend to drive the suicide rate up.

The same flawed logic that lies behind “harm-reduction” forms of “treatment” of opiate addiction, is what some use to justify using nicotine patches and e-cigarettes for the treatment nicotine addiction.  Nicotine is more quickly and firmly addicting than heroin.  As few as four cigarettes can initiate an addiction that lasts for several decades.  While the tars, like heroin needles, carry their own additional risk, nicotine itself is still the largest known risk factor for the arterial damage that underlies heart attacks and stroke.

In a world where addictions can actually be overcome and recovery achieved, maintaining addictions with the addicting substances themselves, or similar ones, is a problem masquerading as a cure.  Utilizing 28-day inpatient programs, mandatory 12-step attendance and long-term monthly monitoring by FAA-appointed airline-physician Medical Monitors, the Human Intervention and Motivation Study (HIMS), conducted conjointly by the FAA, the Airline Pilots Association (ALPA) and several major airline medical departments, demonstrated a long-term recovery rate for alcoholic pilots of above 95%.  The airlines applied similar programs to its other employees with a comparable long-term success rate.  And the HIMS program became the model for intervention and treatment for physicians impaired by substance abuse.

One side issue mentioned in the suicide article: along with the number of suicides, the overall number of suicides by gun has increased in the past several years.  However, while gun ownership has increased steeply during the period studied, the percentage of suicides by gun, for both men and for women, has decreased, once again mitigating against the prevalence of guns as a cause of the violence of suicide.