Month: November 2024

Categories
Funding Medicine Policy Reading

The Word “Mental” in Project 2025. (v)

The fifth instance of the word “mental” in Project 2025 is on page 518 in the section about the Health Resources and Services Administration (HRSA):

Withdraw Ryan White guidance allowing funds to pay for cross-sex transition support. HRSA should withdraw all guidance encouraging Ryan White HIV/AIDS Program service providers to provide controversial “gender transition” procedures or “gender-affirming care,” which cause irreversible physical and mental harm to those who receive them.

You can learn more about Ryan White, the person, here. (Learning both about him and how HIV is transmitted while in elementary school was revelatory for me. I learned how a disease can unfairly confer stigma onto people, even kids! More importantly, I learned that I could do something to reduce the stigma, like shake the hand of someone with HIV without fear.)

The Ryan White HIV/AIDS Program (RWHAP):

helps low-income people with HIV. We help them receive: 

  • Medical care  
  • Medications  
  • Essential support services to help them stay in care

More than 50% of people with diagnosed HIV – about a half million people – receive services through the RWHAP each year. 

We also help diagnose, treat, prevent, and respond to end the HIV epidemic in the U.S.

Notice how specific the target population is! The RWHAP provides more details as it relates to the Project 2025 recommendation:

Of the more than 561,000 people served by the RWHAP in 2020, 2.1 percent, approximately 11,600 were transgender. 

Thus, the Project 2025 recommendation is specifically aimed at these 11,600 people.

Are “gender transition” procedures or “gender-affirming care” controversial? Yes. Note that “controversial” does not mean “dangerous”. Pineapple on pizza is controversial. People have opinions.

Do “gender transition” procedures or “gender-affirming care” cause “irreversible… mental harm to those who receive them”?

Let’s see what the research says. The data to answer this question isn’t as robust as what is available for abortion. Because the study designs have weaknesses in them (e.g., not enough people enrolled; did not follow people over time; etc.), much of the research is classified as “low quality”. This is a fair evaluation.

Based on available data, the current consensus is that gender transition surgeries do not cause “irreversible… mental harm”. They rather seem to reduce distress, smoking, and suicidal ideation.

Only 15% of people who had gender transition surgeries about forty years ago responded to a survey. They reported high satisfaction, less negative moods, and reduced mental health issues. (What about the remaining 85%?)

If regret is considered “mental harm”, it also appears that the rate of regret following gender transition surgeries is less than 1%. This is far lower than regret following other surgeries that have nothing to do with gender transition (around 14%). (Again, there are challenges with this data: How does one accurately measure regret? When there is no agreement about which tool to use, or no tool yet exists, it’s hard to know if you’re measuring what you want to measure.)

Hormone treatment, which has been studied more than gender transition surgeries, also does not seem to cause “irreversible… mental harm”. It seems associated with increased quality of life, decreased depression, and decreased anxiety for most transgender people. How does this happen? One pathway seems to be through reducing gender dysphoria, body dissatisfaction, and uneasiness.

It looks like there isn’t enough data to state with confidence that either intervention — surgery or hormones — reduces death by suicide. (Suicide is a relatively rare event. However, transgender people are far more likely to think about suicide compared to cisgender people, gay or straight.)

We return again to an important caveat about scientific research: It looks at populations of people, not individuals. Are there people who underwent “gender transition” procedures or “gender-affirming care” and suffered “irreversible… mental harm”? There is probably at least one person who would say yes.

However, from what data is available, it looks like most people who undergo gender transition surgeries and hormone treatment do not experience mental harm and, in most cases, experience improvements in their mental health.

The phrasing “irreversible physical and mental harm to those who receive them”, troubles me, too. This makes it sound like people who undergo these interventions have no agency, that they have no say in what happens to them. People choose to take hormones or undergo surgery. There are gatekeepers to these interventions.

The strenuous objection that some have to the mere idea of “gender-affirming care” also puzzles me. People have preferences about their identities and they like receiving care that affirms these identities. For example:

  • If someone prefers to communicate in a language other than English, providing health care to them in their preferred language is affirming.
  • If someone prefers to work with a health care professional from a similar cultural background (and I’m not referring only to race or ethnicity — I’m including regional culture, age, communication styles, etc.), accommodating that preference is affirming and helps people feel more seen. (It’s often gratifying for the health care professional, too).
  • Heck, calling someone by their preferred name is affirming care. And while this can include pronouns, I’m actually thinking of all the Williams in the world who would prefer to be called Bill, the John Smiths who, upon greeting them as “Mr. Smith”, shoot back, “Mr. Smith is my dad! Call me John!”, and the people who prefer to be called by a nickname.

Going back to the original text, though:

First, RWHAP only pays for outpatient services. This means RWHAP funds could never be used for gender transition surgeries.

Second, Project 2025 authors may have included more recommendations elsewhere about prohibiting “gender transition” procedures or “gender-affirming care” for any resident of the US. (I can only tolerate reading this enormous document in small doses.) People who are eligible for RWHAP are, by definition, poor. Will the authors also oppose these interventions for rich people? (Does Project 2025 oppose the idea of transgender people only if public dollars are spent for their care? Or do they entirely oppose the idea of transgender people, even if they are millionaires or a billionaire?)

Third, we all, including the authors of Project 2025, must continually check our biases. All of us are prone to believe that “I make correct assessments“, when our assessments can be phenomenally wrong. Until there is more and better data, the assertion that “‘gender transition’ procedures or ‘gender-affirming care’… cause irreversible physical and mental harm to those who receive them” is false.

Categories
Medicine Policy Public health psychiatry

The Word “Mental” in Project 2025. (iv)

(I am skipping over the third instance of the word “mental” in Project 2025 for now. There are two reasons for this: First, the quote is “mental or psychological issues”, which is part of a long list of categories of information. Second, the relevant paragraph describes the Family Educational Rights and Privacy Act (FERPA) and Protection of Pupil Rights Amendment (PPRA). I am not familiar enough with either regulation. To understand what the author is trying to say, I will need to read more. If you know more about this and are willing to explain it to me, feel free to let me know.)

The fourth instance of the word “mental” is on page 461 under the section of National Institutes of Health:

Finally, HHS [Department of Health and Human Services] should create and promote a research agenda that supports prolife [sic] policies and explores the harms, both mental and physical, that abortion has wrought on women and girls.

The construction of this sentence is curious. A generous interpretation is that the author has limited experience with research and is unfamiliar with the order of operations. Another possibility is that the author is intentionally dressing up an opinion in the lab coat and safety goggles of unbiased science.

Scientific research begins with questions. Studies seek to answer these questions. Once there are good enough answers, officials can then craft policies that are informed by these answers. We all understand that more questions will come up, which leads to more studies, which leads to more answers, some of which will challenge what we once knew. We learn and adapt accordingly.

The more logical framing of this short paragraph would be:

  • Does abortion cause mental and physical harms for women and girls? (That question can be answered through research.)
  • If the answer is yes, then develop pro-life, anti-abortion policies.

The thing is, research already exists that answers the question, “Does abortion cause mental and physical harms for women and girls?”

Please meet the Turnaway Study:

The Turnaway Study is [Advancing New Standards in Reproductive Health]’s prospective longitudinal study examining the effects of unwanted pregnancy on women’s lives. The major aim of the study is to describe the mental health, physical health, and socioeconomic consequences of receiving an abortion compared to carrying an unwanted pregnancy to term.

Note that the Turnaway Study actually asks two questions:

  1. Does abortion for an unwanted pregnancy cause mental and physical harms for women and girls?
  2. Does carrying an unwanted pregnancy to term cause mental and physical harms for women and girls?

(Another note: The Turnaway Study included females ages 15 and older, so does not include all girls who could get pregnant.)

The authors of Project 2025 do not include the second question in their call for research. Is it that they do not care? Or that the answers would not change their minds?

The Turnaway Study is clear in its results:

The main finding of The Turnaway Study is that receiving an abortion does not harm the health and wellbeing of women, but in fact, being denied an abortion results in worse financial, health and family outcomes.

When specifically examining mental harms, the Turnaway Study found “women who have an abortion are not more likely than those denied the procedure to have depression, anxiety, or suicidal ideation.” There was also no evidence that women were more likely to use more tobacco, alcohol, or drugs after an abortion.

Now, let’s be clear: The results of the Turnaway Study do NOT show that women who have an abortion never experience symptoms of anxiety, depression, PTSD, or suicidal ideation. (I assume this is what the Project 2025 authors mean when they write “mental harms”.) The study shows that the rates of these conditions are about the same whether women with unwanted pregnancies receive abortions or not.

That’s the thing with research. Scientific studies examine groups of people, not individuals. While most women who have an abortion (or not) won’t experience anxiety or depression, a small percentage will. If you’re one of the women who does, that sucks. But just because one woman has an unwanted psychological outcome doesn’t mean that all women will. Multiple factors, including chance, contribute to the risk.

The Royal We make choices all the time that involve significant risk, though we assume that we will be fine because the odds are in our favor. Let’s use the following question to test our assumptions of safety: Are you more likely to die while being in a moving car, or from accidentally falling down?

The numbers are close, but you’re more likely to die from unintentionally falling (14/100K) than from being in a moving car (13.4/100K)! You’re also far more likely to die while in a car or from falling down than from a homicide (7.5/100K).

However, despite this data, no one has suggested a policy platform on the federal level to prevent falls. (Similarly, no one is advocating the outlawing of cars.)

If the authors of Project 2025 were open to editorial feedback, I would suggest that they omit words to punctuate their point:

Finally, HHS [Department of Health and Human Services] should create and promote an agenda that supports prolife policies.

There’s no point in doing research if the results won’t change what you do. Just say what you mean.

Categories
Policy Public health psychiatry Reading

The Word “Mental” in Project 2025. (ii)

The second instance of the word “mental” in Project 2025 is on page 6, just a few paragraphs after its first appearance in the foreword:

This resolve [“Every threat to family stability must be confronted”] should color each of our policies. Consider our approach to Big Tech. The worst of these companies prey on children, like drug dealers, to get them addicted to their mobile apps. Many Silicon Valley executives famously don’t let their own kids have smart phones. They nevertheless make billions of dollars addicting other people’s children to theirs. TikTok, Instagram, Facebook, Twitter, and other social media platforms are specifically designed to create the digital dependencies that fuel mental illness and anxiety, to fray children’s bonds with their parents and siblings. Federal policy cannot allow this industrial-scale child abuse to continue.

This 100-word paragraph features inflammatory language sure to capture a caring parent’s eye: drug dealers! addicting! child abuse! Let’s take a closer look:

Are social media companies preying on children like drug dealers? I don’t know the intentions of leadership at social media companies, but there is evidence that these companies make mega amounts of money from the attention of youth. One paper revealed that, in 2022, “advertising revenue from youth users ages 0–17 years [was] nearly $11 billion”.

Billion with a B! Let’s name names. According to the same paper:

The greatest advertising revenue profits derived children [sic] ages 0–12 years old was from YouTube ($959.1 million), followed by Instagram ($801.1 million) and Facebook ($137.2 million). Among youth ages 13–17 years old, the greatest estimated advertising revenue was generated on Instagram ($4 billion), TikTok ($2 billion), and YouTube ($1.2 billion).

(It’s true: Only old people use Facebook.)

How do these numbers compare to other businesses?

EntityRevenue (one year)
Los Angeles Dodgers$549 million
Taylor Swift$1.04 billion
Cannabis tax revenue$3 billion

Instagram made more money than Taylor Swift!

Is it true that “many Silicon Valley executives famously don’t let their own kids have smart phones”? It looks like the answer is yes, or at least they restrict their kids’ access to media.

Do social media platforms “create the digital dependencies that fuel mental illness and anxiety”? In short, the answer is yes, but not for every child and adolescent.

The excellent Surgeon General Vivek Murthy issued an advisory about the effects of social media on youth mental health:

Usage of social media can become harmful depending on the amount of time children spend on the platforms, the type of content they consume or are otherwise exposed to, and the degree to which it disrupts activities that are essential for health like sleep and physical activity. Importantly, different children are affected by social media in different ways, including based on cultural, historical, and socio-economic factors.

The American Academy of Pediatrics (AAP) has a Center of Excellence on Social Media and Youth Mental Health that includes a policy statement on the risks and benefits of social media use and how media can affect the development of young minds.

The American Psychological Association has shared information about relationships between the amount of time youth spend on social media and mental health outcomes (more time spent associated with worse outcomes), why young brains are especially vulnerable to social media, and called out social media companies to improve the safety of their products.

Does social media fray children’s bonds with their parents and siblings? The framing of their argument suggests that the fraying of bonds is entirely the fault of children using social media. Kids don’t have the money to buy phones and computers themselves. Humans learn through observing.

AAP correctly states:

Parents’ background television use distracts from parent–child interactions and child play. Heavy parent use of mobile devices is associated with fewer verbal and nonverbal interactions between parents and children and may be associated with more parent-child conflict. Because parent media use is a strong predictor of child media habits, reducing parental media use and enhancing parent–child interactions may be an important area of behavior change.

This research paper about problematic media use in early childhood points out that “parent’s PMU [problematic media use] remained the strongest correlate of concurrent child PMU” and “parental warmth and responsiveness might be protective of the development of PMU among young children”.

In sum, the authors of Project 2025 have some legitimate and evidence-based concerns about the adverse effects of social media on kids.

So why do the authors of Project 2025, who have voiced support of the incoming President, seem to have no issue with his own social media platform (Truth Social)?

And why, after vilifying Silicon Valley executives, is there no outcry about Elon Musk, now an owner of a (financially failing) social media company, having a position in the federal government? (Also, is it efficient to have two leaders of the Department of Government Efficiency?)

And if the authors of Project 2025 want to change federal policy to prevent “industrial-scale child abuse”, then surely they want to prevent deaths of children. For [the] third straight year, firearms killed more children and teens, ages 1 to 17, than any other cause including car crashes and cancer. There are solutions to prevent guns from killing kids. Strange that there are absolutely no firearm policies in Project 2025!

Categories
Policy Reading

The Word “Mental” in Project 2025. (i)

The word “mental” appears 16 times in “Mandate for Leadership: The Conservative Promise”, better known as Project 2025.

It first appears in the foreword on page 4, under the first promise to “restore the family as the centerpiece of American life and protect our children”:

Today, the American family is in crisis. Forty percent of all children are born to unmarried mothers, including more than 70 percent of black children. There is no government program that can replace the hole in a child’s soul cut out by the absence of a father. Fatherlessness is one of the principal sources of American poverty, crime, mental illness, teen suicide, substance abuse, rejection of the church, and high school dropouts. So many of the problems government programs are designed to solve—but can’t—are ultimately problems created by the crisis of marriage and the family. The world has never seen a thriving, healthy, free, and prosperous society where most children grow up without their married parents. If current trends continue, we are heading toward social implosion.

Let’s take a closer look at this with a critical eye:

Yes, according to the CDC, in 2022, about 40% of all children in the US were born to unmarried women. Let’s be charitable and assume that the author made a rounding error: Just under 70% of these “nonmarital births” occurred in Black women. For what reason did he highlight the percentage for Black women? The percentage for American Indian and Alaska Native women was about 68%. The second lowest percentage was among White women, which was just over 27%.

It is beyond the scope of my expertise to remark if fatherlessness is “one of the principal sources of American poverty, crime… rejection of the church, and high school dropouts”, but I can comment on “mental illness, teen suicide, [and] substance abuse”.

(A quick skim of data, though, shows that “Christian women in the U.S. are more religious than their male counterparts” and “women are more likely than men to say they attend worship services regularly”. From this data it seems that fathers are more likely to reject the church.)

This paper from 2013, The Causal Effects of Father Absence from the Annual Review of Sociology, tries to correct for flaws of past studies that tried to discern what happens to kids when their fathers are absent. From their work the authors conclude there is:

  • strong evidence that father absence negatively affects children’s social-emotional development, particularly by increasing externalizing behavior (where “externalizing behavior” means aggressive and attention-seeking behavior, in contrast to “internalizing behavior”, which manifests as anxiety and depression)
  • strong evidence that father absence increases adolescents’ risky behavior, such as smoking or early childbearing
  • [some suggestion] that the psychological harms of father absence experienced during childhood persist throughout the life course

Again, let’s be generous towards the author and assume that he equated “externalizing behavior”, “internalizing behavior”, and “risky behavior” to “mental illness[es]”. (Behaviors alone do not always constitute mental illnesses.) Yes, research supports the idea that an absent father results in behavioral problems in children. However, fatherlessness itself may not be a “principal source”. I could not find robust studies that examined any relationship between motherlessness and mental illness. (Single mothers are far more common than single fathers. Motherless children may exhibit these same worrisome behaviors.)

I am not able to find data that directly links absent fathers to teen suicides in the US. (There is a paper that describes “parental absence predicts suicide ideation through emotional disorders” in China, though this doesn’t focus solely on absent fathers. A paper from the US in 1998 concludes that “dramatic increase in youth suicide during the past three decades seems unlikely to be attributable to the increase in divorce rates”.) If there is an indirect linkage, it is likely mediated by other factors that led to the absence of the father.

While it is true that no governmental program can “replace the hole in a child’s soul cut by the absence of a father”, it is not only the absence of a father that cuts holes in children’s souls. No program, whether offered by the government or a church, can replace a missing father, mother, or other parental figure. Programs are not people. So let’s talk about actual people.

Over two-thirds of children live with married parents. The nonmarital birthrate continues to decrease over time. Divorce rates are also decreasing. In light of these facts, that “fatherlessness” is actually decreasing, what “crisis of marriage and the family” and pending “social implosion” is the author talking about?

The authors of Project 2025 do not seem to recognize what the authors of “The Causal Effects of Father Absence” declare: “family disruption is not a random event and because the characteristics that cause father absence are likely to affect child well-being through other pathways.” (emphasis mine)

If they are concerned about “poverty, crime, mental illness, teen suicide, substance abuse, rejection of the church, and high school dropouts”, there are more fruitful ways to address these problems:

Reduce the likelihood that children experience adverse childhood events. People with fewer adverse childhood events are less likely to develop mental illnesses, like depression, and less likely to attempt or die by suicide. (Fathers can be sources of adverse childhood events. There is research that shows that youth with “harsher fathers” engaged in more offending behaviors and used more substances than youth with “absent fathers”. Sometimes, unfortunately, fatherlessness is the better option.)

Promote health equity. Improving physical environments where people live, work, and play improves mental health and well-being, as does access to education. People want to work and learn in healthful spaces. Reducing income equality also improves physical and mental health. People want enough money to live in safety and comfort. Ensure that people have easy access to health care when they need it, but, even better, create a healthy nation where people won’t need to routinely see a doctor.

Promote social connections to reduce loneliness. People who are socially isolated are more likely to develop physical illnesses, such as heart disease and diabetes, as well as mental illnesses, such as anxiety and depression.

Note that these interventions require looking beyond the immediate family, and certainly beyond the presence or absence of a father. We live in communities. Because we all live in an interdependent networks, if the community is experiencing crisis, it will impact families. So why does Project 2025 instead put so much focus on the father?