Weiner, the Internet and Psyche

As I write this, the pressing question in the news is, "Should Anthony Weiner (congressman from NYC) resign?"  Since I started writing this, Anthony Weiner has resigned.

I dismiss the Republican arguments (all, naturally, recommending that this firebrand congressman resign) as partisan hypocrisy.  That doesn't mean they are wrong, but to take their self-serving recommendations seriously is impossible.  The main source for the accusation of hypocrisy is the continued service of David Vitter, currently a Senator from Louisiana, who was embroiled in a controversy regarding the “DC Madam”, a house of prostitution.  He was never asked to resign, and was subsequently reelected.

The Democrats themselves have been gathering in larger and larger numbers to recommend that Weiner resign.  They presented several arguments, some of which are also voiced by Republicans, including 1) He can not effectively represent his constituents after this embarrassing sexual impropriety, 2) The country is distracted from serious matters by this ongoing national joke, 3) He needs to take time for himself and his family, 4) He has engaged in at least one ethics violation:  Don't engage in behavior that would reflect poorly on the House of representatives or the United States, and 5) he lied to the media, fellow congressmen and congresswomen, and even his wife.

There are, of course, other reasons given, some more artfully articulated than others, but they lack specificity.  Some extrapolate from the other reasons given above:  "If he lied about that then he is vulnerable, or a liar, or hiding something else, etc."

Some said he shouldn't resign.  They argue that he never claimed moral superiority, others have done worse without resigning, he did not violate any laws, and there is no reason to think that this indiscretion will affect his effectiveness as a congressman.  We don't know the extent of congressional bad behavior, but the reasons for his behavior are as understandable as they are reprehensible.

There remains something that was not been given much attention, but is probably the most important thing to consider.  Has Weiner gone nuts (no pun intended)?  He looks and acts sane publicly, his apology seemed sincere and appropriate, he seems to understand that what he did was wrong, and he has vowed not to continue to do it.  So, he's sane, right?

Some say that, as a powerful man, he is predisposed to "risk taking" and may be more likely than most to engage is risky sexual behavior than most people.  I'll grant that, but there are some aspects of this particular indiscretion that scare the pants off of me.  Not literally.

First, when men take risks, they generally do so with an awareness of the consequences and a concerted effort to avoid detection.  Part of the thrill is avoiding getting caught, but Weiner took no precautions.  He did not disguise himself and, in fact, flaunted his identity to the women he had never meet personally.  Another congressman, Chris Lee, resigned in disgrace in a matter hours after he had been outed by a woman with whom he had been corresponding via Craig's List.  One photo of his bare chest was enough to shame him into resigning.  Weiner was certainly aware of that episode, but he was sending photos which were virtually identical in pose, if on occasion more explicit, with no apparent awareness that he too could be exposed and suffer extreme embarrassment and pressure to resign.  Watching a colleague fall next to you while you are engaging in the same behavior without any attempt to disguise yourself is beyond foolish; it's (politically) suicidal.

Second, he engaged in this behavior over a period of years with multiple women, even after marrying his current wife.  Being married does change things.  It is no longer just embarrassing, it is hurtful, and he should have known that.  He lacked the awareness that his behavior would affect his family.

The complete self-absorption, narcissism, lack of awareness and relentless pursuit of this activity in the face of risks that he could not see, but should have, leads me to believe that this is beyond a peccadillo; it's an illness.  He is right to seek "treatment" and, if he does, that would go a long way towards reassuring others that he is not likely to reengage in self-destructive behavior. 

If this is an illness, it would fall into one of several categories.  It might, for example, be a paraphilia.

Paraphilias are ... “characterized by recurrent, intense sexual urges, fantasies or behaviors that involve unusual objects, activities or situations and cause clinically significant distress or impairment in social, occupational or other important areas of functioning. Tends to be chronic and lifelong, although frequency and intensity may vary.  Often not associated with distress.  Clients often claim the problem lies in others’ responses.  This is about justifying and normalizing their behavior to alleviate guilt and embarrassment.  Most deviant people choose to lower their inhibitions by justifying their behavior or engaging in distorted thinking that supports the behavior.”

The term "sexual addiction" is not included in the current version of the diagnostic and statistical manual (DSM-IV), but the topic is under consideration.  Addictive behavior, in sexual terms, would involve “compulsivity (inability to stop), continuation (despite consequences), and obsession (their minds are so preoccupied by these thoughts, other areas of their lives that they could be thinking about are neglected).”

It is not possible now to know if Weiner will have the characteristics that would suggest addiction, but clearly if the behavior continues despite this public shaming he could be considered addicted.  The question is whether he will continue the behavior despite consequences and neglect his work and marriage.

In any event, the behavior he has engaged in is deviant, incredibly risky, and harmful to his family and his occupation.  How likely is it that treatment will be successful?  How long will treatment take?  How likely is it that he will be able to function in his job after treatment?

It is too soon to know the answers to these questions, but my suspicion, based on the nature of the behavior, is that this will not be an easy road for former Congressman Weiner.  He has underestimated the problem from the beginning, and his unrealistic approach has thus far shown, if not a lack of sincerity, at least a failure to appreciate the inevitability of his current dilemma.  I am sure that Congressman Weiner is confident he can put this behind him, live a normal life, stay married, and eventually resume a life of public service in some capacity, but as much as he has underestimated the problem, I think he is overestimating his ability to change his habits.

In order to accept Congressman Weiner as their representative, the constituents will have to extend an extraordinary amount of trust or accept that they have a sexual deviant representing them.  Even assuming they would accept the latter, trust is still necessary, and his actions have already betrayed that trust.

If he should run for reelection, his constituents will decide if they are willing to be disappointed.  I hope that Congressman Weiner can gain some insight into his problems that he has so far failed to demonstrate, but his constituents should be prepared for disappointment.

Regarding the push for resignation addressed towards Weiner and not David Vitter, there is a perceived difference.  Most people understand infidelity, even with prostitutes, as being within the range of normal behavior (although that is not necessarily true).  Even without studying abnormal psychology, the behavior of Weiner clearly falls outside of the normal range of behavior.  Although usually unspoken, there is a fear of an undiagnosed psychiatric disorder; one that may have only now become uncovered, but that may affect every other aspect of his life in ways that cannot be predicted.  When people say, “I’m glad he’s seeking the help he needs”, they are saying that until he has been evaluated and treated by professionals, he should not be allowed to function as a congressman or in any position of responsibility.

My personal assessment is that human interaction via the Internet and social media is so foreign to our psyche that our normal impulses can be warped, and our normal inhibitions can seem unnecessary.  Perspective can be lost, and we have a strong tendency to fool ourselves.  Although unjustified, we may feel safe revealing thoughts, feelings and even images of ourselves that we would not share under any other circumstances because it all seems less real, or anonymous, or private.  It is therefore not at all clear that bizarre behavior via the Internet is reflective of deep psychological disorders.  It may actually be a distortion of our normal, if “antisocial”, nature.  There’s a paradox for you.

There are layers upon layers upon layers of psychological motivation that affect our behavior over the Internet.  The psychology isn’t new perhaps, but the circumstances that affect behavior are new – as new as the Internet as a means of communication.  Maybe it was necessary for Weiner to resign for his own health, but then maybe he is one of us that just went overboard and, given the embarrassment, he might be jarred back into reality.  Or maybe he is so deeply disturbed that he won’t be able to stop.  Even Weiner probably doesn’t know the future at this point. 

I will say that, given our almost universal lack of understanding of his behavior, it was probably necessary for him to resign for the benefit of his fellow congressmen. They might fear that he will begin to act bizarrely in public and moon C-Span, or shout out inappropriately (“You lie!”). 

With time, perspective and counseling, Weiner will understand his behavior and, I think, control it.  He is not the first to find himself embarrassed by the Internet, and I suspect he won’t be the last.  It’s human nature.

Gun Sense and Common Sense

Gun ownership, deaths, injuries and crime set the United States apart from the rest of the world.  Bolstered by the second amendment to the Constitution and a belief that having a gun will provide protection for the household, gun ownership is common. 

I won’t write about how many guns there are or who has them.  I won’t write about the types of guns or how much ammunition they hold.  I’ll just be writing about common sense.

The recent Florida law HB 155 prohibits a pediatrician from asking parents if they have guns in the house.  From the pediatrician’s point of view, it’s a public safety issue on par with safety devices for electric plugs, child safety seats, poison control and a host of other aspects of ordinary life that endanger children.  The NRA backed law sees the issue as one of freedom from being hassled about owning guns.

This law reminded me of something I saw years ago that I will never forget.  It shapes my thoughts and actions to this day.

I met a 13 year old boy in the operating room at Darnall Army Community Hospital during the fall of 1983 when I was on the surgical team on call that day.  We opened him up and found that a bullet had passed from his left side through his body and out the right side transecting the aorta and vena cava (in addition to other serious injuries).  There was too much bleeding, too much damage, and the boy died on the table.

I removed my bloody gloves and gown, got dressed and walked towards my car, but as I passed through the emergency room on the way to the parking lot, there was an elderly man in distress.  His shirt was off and he had electrodes attached to his chest, and he was wailing.  I was told that he was the boy’s grandfather, and he was the one that shot and killed his grandson.

The emergency room doctors told me that they had been hunting deer, and they were wearing camouflage.  The grandfather saw his grandson walking and mistook him for a deer.  I can only imagine the emotions that went through that man’s mind after he fired his rifle.  He was probably joyous at first, terrified when he saw his grandson instead of the deer he expected, and then he probably experienced guilt.

I have no doubt that his guilt was a contributing factor to his chest pain, and I have no idea if he lived or died that day.  I left him there, crying, but I’ll never forget the expression on his face.

Sometimes I see men in the fall wearing camouflage, or men tell me they’re going hunting.  Most are proud to tell me that they are taking their children or their grandchildren hunting with them.  Maybe they might be upset with me for recommending that they wear orange vests, but if they are, I tell them what I experienced, and I hope I never experience again.  Maybe they’ll listen, maybe not.

The Florida law would keep me from even asking if they are going hunting, although their clothing, from boots to hat, scream hunting.

The Florida law isn’t about gun ownership.  It’s a law to protect the sensitive ears of gun owners from stories like mine, and warnings about dangers, and recommendations for safety.  Maybe doctors aren’t qualified to make such recommendations, like keep the guns locked up and the ammunition separate from the guns.  Maybe the gun owning parents already know everything a doctor could possibly tell them about gun safety – and more.  But children still get guns and shoot themselves or others – on purpose or accidentally.  And hunters still wear camouflage without an orange vest in the hopes they can be more effective hunters.

Those, of course, are aberrations, lapses of common sense, bad judgment or neglect and not at all representative of the average American gun owner, but I can see no harm in hearing advice even if the person hearing it needs no warning.  The advice is, after all, only common sense.

A warning is only unnecessary if there is absolutely no risk of danger.  As long as there is risk, common sense should tell us that the voices giving warnings should not be silenced.

Is this such a dangerous concept?  “According to federal statistics, there are guns in approximately half of all U.S. households. Even if no one in your family owns a gun, chances are that someone you know does. Your child could come in contact with a gun at a neighbor's house, when playing with friends, or under other circumstances outside your home.”  This is from the NRA.  It seems they realize the risks of unsecured guns in homes, but hope that nothing happens.  They go on to say that you should teach your child about gun safety, but children aren’t adults; they aren’t as responsible, as knowledgeable, or as mature as adults.  The NRA still does give some good advice.  In this web site (http://www.nrahq.org/safety/eddie/infoparents.asp), they offer information that they would prevent pediatricians from offering. 

Almost everyone could agree that leaving a loaded weapon within reach of a child (depending on how you define child) would be child neglect, or possibly child endangerment, or possibly worse.  We find out about most cases like these after the fact – the cold fact of the injury or death of a child or adult resulting from the “accidental” or even intentional discharge of the weapon by a child.  By law, pediatricians, and indeed all physicians, are obligated to report child neglect and child abuse.  Many cases of child abuse and neglect come to the attention of the pediatrician, sometimes as a result of the questions asked during a visit.  When gun owners successfully stifle the questions, they are in effect saying, “It’s none of your business” if I decide to engage in behavior that is dangerous to my child.

But it is the business of the pediatrician.  It is the business of all of us, but pediatricians are uniquely placed to examine the child (literally) and speak with both child and parents.  The purpose is not nefarious and the result is not intended to be punitive.  The goal is keeping the children alive.

Do parents fear that they will be suspected of neglect?  They shouldn’t unless they gleefully admit to being neglectful.  “I let my kids play with my loaded weapons.  They like the noise the guns make when they shoot ‘em.  Heck, it’s better ‘n fireworks.”  The questions asked are only meant to determine if there is a situation that would put a child in danger.  Parents who are knowledgeable about gun safety are a blessing for pediatricians.  We, doctors, parents and children, are all on the same side.

If a family’s pediatrician seems to be “stepping over the line” and giving unwanted advice, the parents are free to find another pediatrician, or ignore the advice, but to deny that guns are a safety concern worthy of the attention of the pediatrician is ludicrous.  People should not be forced to see physicians (or other health care providers) with whom they disagree, but to silence the doctor in an effort to avoid the issue is, or should be, as illegal as it is willfully ignorant.

I’m sure there are parents who would like to silence doctors on the issue of diet and exercise for children.  Maybe the parents don’t want or need to hear it, and perhaps physicians can avoid offending by avoiding the subject, but that is contrary to the best interests of their patients.  All questions of child safety are uncomfortable for some parents, but the duty of the physician is to the patient, the child, even when it comes to “uncomfortable” issues.  At the very least, the discussion of guns and safety may be redundant.  At most, it is life saving. 

Imagine if the tobacco lobby persuaded a state legislature that pediatricians should not ask parents if they smoke.  Or imagine the automobile industry lobbying to prohibit pediatricians from asking parents if they are using appropriate child car restraints.  I wouldn’t be surprised if the automobile industry would like to avoid having parents think of their children dying in automobile accidents when they purchase a new car.  The list of lobbyists that might like to suppress the speech of pediatricians is almost endless. 

The only reasonable course is to allow pediatricians to do the best job they know to do, and if the patient/parent is unsatisfied, find another.  Laws prohibiting this speech are un-American, unconstitutional, and an intrusion of Big Government that should be an anathema to everyone regardless of political persuasion.