Category: Policy

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Policy Systems

The Word “Mental” in Project 2025. (ix + x + xi)

The ninth, tenth, and eleventh instances of the word “mental” in Project 2025 are on page 875 in the section about the Federal Trade Commission:

Protecting Children Online. The FTC has long protected children in a variety of different contexts. Internet platforms profit from obtaining information from children without parents’ knowledge or consent—and social media’s effect on the well-being of American children is well-documented. Around 2012, American teens experienced a dramatic decline in wellness. Depression, self-harm, suicide attempts, and suicide all increased sharply among U.S. adolescents between 2011 and 2019, with similar trends worldwide. The increase occurred at the same time that social media use moved from rare to ubiquitous among teens, making social media a prime suspect for the sudden rise in mental health issues among teens. In addition, excessive social media use is strongly linked to mental health issues among individuals. Several studies strongly support the notion that social media use is a cause, not just a correlation, of subjective well-being and poor mental health.

This harkens back to the second time the word “mental” appears in the text, where the authors accuse Big Tech of engineering social media for industrial-scale child abuse. The punchline is, yes, the authors of Project 2025 have legitimate and evidence-based concerns about the adverse effects of social media on kids. I appreciate that this section here at least includes people of all ages (i.e., parents) in asserting that “excessive social media use is strongly linked to mental health issues among individuals”.

After this brief foray into children’s mental health, the text veers back towards its point: Trade and contracts.

Targeting children to create potentially harmful contracts or making parents responsible for such contractual relationships is an unfair trade practice.

… leading to this recommendation:

The FTC should examine platforms’ advertising and contract-making with children as a deceptive or unfair trade practice, perhaps requiring written parental consent.

While a perspective of interdependency views everything as being related to everything else, bringing up the mental health of children within the context of the Federal Trade Commission is curious. As we will see in the next instance of the word “mental” in this document (we’re nearing the end — “mental” only shows up 16 times), there’s ambivalence in this chapter about the role of the FTC. Children’s mental health is used chiefly as a potential subject of regulation. Who is better poised to regulate social media and its effects on children? The government? Or parents? Surprisingly, this seems open to debate in this section. (This entire chapter on the FTC uses notably less inflammatory language, too.)

It is clear, just from reviewing the appearance of the word “mental” in this text, that the authors of Project 2025 have opinions about who should have the power and authority to regulate other people. It is apparent who they believe should (cis male, heterosexual fathers) and who should not (women, children, and everyone else). Because Project 2025 makes multiple references to the authority of Judeo-Christian faith, which worships the Father (dude), the Son (dude), and the Holy Ghost (do spirits have genders?), this is presumably why.

Instead of struggling with how to reconcile the agency that all humans can and could have at this current time and place, the authors of Project 2025 have elected an “all or nothing” approach. This is also reflected in the black-or-white, provocative language used in many portions of this enormous document.

Categories
Medicine Policy Systems

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

The eighth instance of the word “mental” in Project 2025 is on page 648 in the section about the Veterans Health Administration:

Examine the surpluses or deficits in mental health professionals throughout the enterprise, recognizing that the department needs a blend of social workers, therapists, psychologists, and psychiatrists with a focus on attracting high-quality talent.

This chapter advocates for “Veteran-centric” care and wants military veterans to have easier access to high quality services. This recommendation is part of a list that calls for bolstering health care personnel to reduce wait times for veterans. This is completely reasonable.

(There are some highly biased comments in this section, such as “the Left’s pernicious trend of abusing the role of government to further its own agenda”, even though the preceding sentence is literally “rescind all departmental clinical policy directives that are contrary to principles of conservative governance”, as if “conservative governance” isn’t an agenda???)

I do wonder how the arbiters will know what numbers of mental health professionals are a “surplus” versus a “deficit”. Most (all?) health systems struggle with a “scarcity” or “substantial shortages” of behavioral health professionals. Perhaps the authors of Project 2025 are aware that mental health professionals, such as psychiatrists, are far more likely to be registered Democrats. The VA directives they want rescinded are ”abortion services and gender reassignment surgery”, so perhaps the “surplus” of mental health professionals are the pernicious Lefties who support those services.

Like most other physicians who trained in the US, I spent time in residency and fellowship working in VA hospitals. (As a medical student I did not train at a VA, but was instead sent to an Air Force base for part of my pediatrics rotation!) We were in the midst of the Iraq War. The VA patients under my care at that time were around my age. (How did fate send us on such different paths, only to intersect in the hospital?) The psychological wounds of these young men from fighting in the war were still gaping. I also saw Vietnam War- and World War II-era patients whose memories were deteriorating, their bodies not yet as infirm as their minds.

Apart from one unfortunate experience, I found my work experiences at the VA meaningful. I know it sounds corny, but it truly is a privilege to provide care to people who have served in the military. (We’ll put aside for now the vexing reality that trainees spend so much time learning their health care profession on patients who don’t have much money in publicly-funded institutions. Never did I nor a colleague treat an Admiral, Commander, or other high-ranking, presumably not poor, officer.) While not routine, I continue to encounter veterans now who are homeless and have significant psychiatric conditions. My primary goal in those instances is to get them connected to the local VA if possible, since the VA, for all of its bureaucratic problems, often offers many more resources than other public programs.

When I consider the provision of mental health services at the VA, I can’t help but think that the best way that we can protect the mental health of veterans is to limit their exposure to war. We can’t prevent all bad things from happening, but war is an especially bad thing. It messes people up. I’m not even talking about formal psychiatric disorders. War induces heartache. I think about the various veterans I’ve worked with as colleagues (some as health care professionals, most not), and what stands out to me is how much loss they carry. They’re “fine”: They are married, they have kids, they have fun hobbies, they do satisfactory to exemplary work at their jobs, some have even achieved high status in their professions.

And then I see artifacts from a comrade who died, sense their guardedness, hear their reluctance to speak about their time in service.

There are things that civilians may never understand. Here I agree that veterans deserve high quality health care. The issue is that the authors of Project 2025 apparently believe that some people do not deserve certain kinds of health care, high quality or not.

Categories
Homelessness Policy Public health psychiatry

The Word “Mental” in Project 2025. (vi + vii)

The sixth instance of the word “mental” is on page 509 in the section about “First-Day and First-Year Administrative Reforms” for The Department of Housing and Urban Development (emphasis mine):

The Office of the Secretary should execute regulatory and subregulatory guidance actions, across HUD programs and applicable to all relevant stakeholders, that would restrict program eligibility when admission would threaten the protection of the life and health of individuals and fail to encourage upward mobility and economic advancement through household self-sufficiency. Where admissible in regulatory action, HUD should implement reforms reducing the implicit anti-marriage bias in housing assistance programs, strengthen work and work-readiness requirements, implement maximum term limits for residents in PBRA and TBRA programs, and end Housing First policies so that the department prioritizes mental health and substance abuse issues before jumping to permanent interventions in homelessness. Notwithstanding administrative reforms, Congress should enact legislation that protects life and eliminates provisions in federal housing and welfare benefits policies that discourage work, marriage, and meaningful paths to upward economic mobility.

The seventh instance of the work “mental” is on page 516 as a footnote to the paragraph above (emphasis again mine):

The U.S. Interagency Council on Homelessness (USICH) was established in the 1990s, and numerous Administrations have devoted enormous resources to the Housing First model, experimenting with various ways to provide federally financed rapid rehousing and permanent housing opportunities. Housing First is a far-left idea premised on the belief that homelessness is primarily circumstantial rather than behavioral. The Housing First answer to homelessness is to give someone a house instead of attempting to understand the underlying causes of homelessness. Federal intervention centered on Housing First has failed to acknowledge that resolving the issue of homelessness is often a matter of resolving mental health and substance abuse challenges. Instead of the permanent supportive housing proffered by Housing First, a conservative Administration should shift to transitional housing with a focus on addressing the underlying issues that cause homelessness in the first place.

    Long-time readers will recognize that this falls right into my professional bailiwick…

    (cracks knuckles)

    … but I won’t spend too much time on the data because there are excellent summaries elsewhere. For example, the Office of Policy Development and Research published Housing First: A Review of the Evidence. There they describe the stance the federal government took in the 1990s, summarized as “treatment first”:

    housing was available only to individuals experiencing homelessness who were willing to work for it.

    This is exactly what the authors of Project 2025 want. If they know this history, they know that this “treatment first” model did not reduce homelessness, but an alternate model called “housing first” did, and for various populations:

    Overwhelming evidence from several rigorous studies indicates that Housing First programs increase housing stability and decrease rates of homelessness. The best available evidence indicates that Housing First programs successfully house families and individuals with intersecting vulnerabilities, such as veterans, individuals experiencing substance use or mental health issues, survivors of domestic violence, and individuals with chronic medical conditions such as HIV/AIDS. 

    While the authors of Project 2025 argue that “mental health and substance abuse challenges” are the “underlying issues that cause homelessness in the first place”, they again are ignoring data that illuminates the actual underlying issue (emphasis again mine):

    Much of the research looks at the variation in homelessness among geographies and finds that housing costs explain far more of the difference in rates of homelessness than variables such as substance use disorder, mental health, weather, the strength of the social safety net, poverty, or economic conditions.

    Is it true that there are some people who are homeless because of their “mental health and substance abuse challenges”? Yes. However, their common denominator is not having enough money. There are people with “mental health and substance abuse challenges” who are not homeless and that’s because they have enough money, or someone else has enough money, to pay their rent. (Think of the depressed ladies who buy cases of wine from Costco and return to their suburban homes to drink 20 bottles of wine a week….)

    So that’s the data. But, as a psychiatrist who works with people who are or were homeless, let me share some some “n of 1” perspectives about the work.

    Importantly, most people who are homeless don’t need the services of a psychiatrist. Could they use mental health support? Sure: When you don’t know where you’re going to sleep tonight, anxiety is a natural reaction. If you find a place to sleep, but there isn’t a door you can lock (or a door, period), you probably won’t sleep well. Without routine access to a bathroom or running water, you can’t keep yourself as clean as you would like, so you start feeling self-conscious about it. It’s hard to perform well at work if you aren’t sleeping well, you don’t feel your best, and you don’t have a place to call home. You know what solves these psychological problems better and faster than a psychiatrist? Housing.

    A psychiatrist can help people with significant psychiatric conditions (like schizophrenia) who are homeless. Among the reasons some people have shared with me about why they will not move indoors:

    • The aliens will assassinate me if I move inside.
    • I want an apartment, but God tells me that I don’t deserve to be indoors.
    • If I move in, they will turn on the parametric speakers to make me insane.

    Most of these people don’t have jobs because their symptoms get in the way of their ability to show up on time, work with customers, etc. Because many of them have had terrible experiences with the traditional health care system, some are reluctant to talk with me. But, with the essential help of my non-medical colleagues, many will. Some people, with time and relationship-building, will agree to try medication to treat their symptoms. (Yes, this really happens.)

    When you don’t have a stable place to live with a door to lock and easy access to cabinets and calendars, it’s hard to take medication as prescribed. Pills get lost. Other people might pilfer them. Someone might run off with your bag. Plus, if medications make you sleepy, you might only take them when you know you can sleep safely. You know what makes it easier to take medication on a regular basis and manage side effects like sedation? Housing.

    Maybe you’ve heard about long-acting injectable medications. Instead of having to take a pill every day, you can get a shot once a month. This sounds like an elegant solution, right? Some people are cool with shots, but a lot of people aren’t. (Would you want to get a shot every month instead of taking pills?) But let’s say our hypothetical patient who doesn’t have a place to live is willing to get a shot every month. (This really happens, too, but not as often.) The challenge here is finding the person every month to administer the shot. Maybe they will come to a clinic or other meeting spot, but their symptoms can make tracking time (and appointments) a challenge. I can go out and try to find them, but if they move around (because of their symptoms, privacy, safety, etc.), there is no guarantee that I will. You know what helps people receive their medications like monthly shots on a routine schedule? Housing.

    But let’s go to an extreme. Let’s say that I’m working with someone who is homeless whose psychiatric symptoms are severe and dangerous. Maybe they have stopped eating because they are certain that they don’t have internal organs. Or how about this: A man is chasing children with a lead pipe because he believes that the kids are government agents trying to kill him. Here I exercise my coercive power: I go through the steps to hospitalize both people against their wills for psychiatric reasons.

    So now they’re not on the streets, they are in a hospital somewhere. Time passes, treatment works, and they no longer need to be in the hospital. So where are they supposed to go upon discharge? They didn’t have a place to live before the hospitalization. In this Project 2025 universe, they don’t deserve housing because they’re not working, so back out onto the streets they go. And the cycle begins all over again.

    Let me also tell you that most people under my care want to work. Because people who are homeless live in the same culture as those of us who have housing, we are all indoctrinated in the idea that there is value in work, and your value as a person involves work. The jobs they often want are often completely reasonable. The person who thinks the aliens will assassinate her? She wants to work as a bookkeeper again. The person who fears the parametric speakers? He’s open to working in the print shop. The person who hears God telling him that he can’t move indoors? He’d like to be a barber. But when you don’t have an address to put on your job application, or you don’t have the money to apply for classes or a business license, how can you make your employment dreams a reality?

    If the goal is to reduce the number of people who are homeless, then accept the research data and make housing more affordable for all. If the goal is to reduce the number of psychiatrically ill people who are homeless, then ensure that they have stable places to live so they can meaningfully participate in treatment.

    But if the goal is to coerce people, with the threat of homelessness as the cudgel, to live according to the values of the Project 2025 authors, then just be up front about it. Just make sure you follow that line of reasoning to its logical conclusion: Put it in writing that you believe some people deserve to be homeless — and thus deserve to die.

    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.