Reprimanded for using non-inclusive language

[whopper]

This use of language is encountering 2 extremes that are putting most of us in the middle of a BS hissy fit. Those that are being overly sensitive and those that are trying to intentionally be insensitive.

Just the other day my wife, a mental health professional, encountered another who refuses to use the term "Black and White Thinking" and is replacing it with "Blue and Orange Thinking" because the former term has "racial overtones."

Pseudoseizure as a term, years ago, was changed to Non-Epileptic Seizures (NES). The new term is BS. Why? 1) There was no seizure so why are we calling it a seizure when it's not a seizure? 2) It turns out there are correlations with real epilepsy and the so-called "Non-epileptic seizures" that aren't seizures. People with epilepsy have NES in higher frequency showing some type of correlation so to say they're "non-epileptic" is misleading. 3) There are plenty of physiological phenomenon that are seizures that are non-epileptic such as alcohol withdrawal seizures but now we got this misleading and inaccurate term that causes even further confusion to add to the confusion.

So, and remember I was in academia when this new term happened. Why the change? "Cause some people find pseudoseizures offensive." I asked who? Where was the data? I saw no presented data whatsoever. I saw no patients or even physicians other than those who wanted the name change making claims the term was offensive, and the ones making the claims had no data showing such. Most patients don't even know what this term is. I even got a response of "when you tell them they're not having a seizure, the patient gets offended so this way we can tell them they had a seizure even though they didn't have a seizure."

So okay fine, let's be cautious. Let's change the term (which I still thought was going overboard) but to change it to a term that's misleading, confusing, and other phenomenon also fit what that title is? Why don't we call cars, "horse drawn carriages 2.0," despite that they're not horse-drawn anymore.

A little while ago the term LatinX was introduced by unspecified academics. Some were saying we had to use that term or we were sexist or whatever "ist" you can think of. Despite this the overwhelming majority of people who speak Spanish find the term useless, their own language masculinized or feminized every noun and who "owns" the Spanish language and culture to a degree where they have the right to say people of this culture must now be called by such when the people in that culture don't even feel that way?

And on that order, if the thinking of non-binary isn't introduced into conversations where M or F is asked, and this is sexist, isn't Spanish as a language then sexist? They have a masculine and feminine for every noun.

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[comp1]

You have to put Psychogenic (P) in front of the Non-Epileptic Seizures (NES) acronym. It helps everyone out.

 

[SubzDoc]

You have to put Psychogenic (P) in front of the Non-Epileptic Seizures (NES) acronym. It helps everyone out.

Correct, it is PNES and not NES. I try to sound the entire acronym out as a single word, "P-NES."

 

[splik]

Pseudoseizure as a term, years ago, was changed to Non-Epileptic Seizures (NES). The new term is BS. Why? 1) There was no seizure so why are we calling it a seizure when it's not a seizure? 2) It turns out there are correlations with real epilepsy and the so-called "Non-epileptic seizures" that aren't seizures. People with epilepsy have NES in higher frequency showing some type of correlation so to say they're "non-epileptic" is misleading. 3) There are plenty of physiological phenomenon that are seizures that are non-epileptic such as alcohol withdrawal seizures but now we got this misleading and inaccurate term that causes even further confusion to add to the confusion.

So, and remember I was in academia when this new term happened. Why the change? "Cause some people find pseudoseizures offensive." I asked who? Where was the data? I saw no presented data whatsoever. I saw no patients or even physicians other than those who wanted the name change making claims the term was offensive, and the ones making the claims had no data showing such. Most patients don't even know what this term is. I even got a response of "when you tell them they're not having a seizure, the patient gets offended so this way we can tell them they had a seizure even though they didn't have a seizure."

Terminology evolves over time. The term NES/PNES is now outdated and the official term is now functional seizure. Before pseudoseizure, they were called hysterical seizures. Language matters. Patients did not like the term pseudoseizure. Curt LaFrance (one of the main functional seizure researchers) likes to get on his soapbox about the term "pseudoseizure" claiming "pseudo means fake" and thus is inappropriate. Well "pseudo" does not, in fact, mean "fake" in the medical context, it means "resembling" or "having the appearance of." However, in the US at least, many patients and family members do associate "pseudo" with fake or spurious. This means a lot of patients and family members took away that they are malingering and thus it loses specificity in its communication and leads to mistrust and breakdown in the doctor-patient relationship. One of the challenges to treatment is getting patients to buy into diagnosis. If the terminology increases shame and stigma then the diagnosis will be rejected. Patients have told me even seeing the word "psychogenic" creates a significant aversion from them such that they may not do the reading I recommend.

We no longer use terms like idiocy, möron, imbecile, mongòloid, crêtin, lunatic, all of which were official psychiatric terms. Manic-depressive insanity became bipolar disorder. Even retàrd has been expunged from the psychiatric nomenclature as of 10 years ago. This reflects both the changing meaning and abuse of these terms and a quest for terminology that is more useful and precise. Language changes over time. While purists may decry this as decay, languages decay when they are no longer able to describe and reflect the culture around it.

but yes, "blue and orange thinking" sounds ridiculous, and I do worry that LatinX is an example of lexical imperialism given than the gender neutral version of latino is technically "latino." But language also develops through widespread adoption. Words and terminology that are not seen as useful are discarded and forgotten or else not widely use. Those words and phrases that come into common parlance do so in part because enough people see utility to them.

 

[whopper]

The term NES/PNES is now outdated and the official term is now functional seizure

So then, how will the field accommodate those of us who are "offended" by the term "Functional Seizure" cause, and I'm not being sarcastic, I don't think it's appropriate to call a phenomenon a seizure when in fact a seizure did not occur?

Hey I'm offended. (Now I'm being sarcastic-you have to accommodate me being offended or else you're else you're an anti-whopperist. I'm seeking payment for pain and suffering). Seriously me being offended is on this very slight level. I am serious when I say there is an BS factor going on here when we call something a term when in fact that issue is not going on in a medical field with serious real world implications. We should not be calling something a seizure if it is not a seizure. To say that a patient could be misled on their health issue is one of the most basic, but valid, and germaine arguments. I should not be saying a patient had a "functional myocardial infarction" if they had panic attack. I should not be telling they have "functional blindness" if they have Conversion Disorder. How much more simple, logical, and fair can that be? Quoting 1984, "freedom is the freedom to say 1+1=2." I am serious when as a field we should not condone the coining of terms that are misleading and inaccurate.

Of course a patient who had a "functional seizure" shouldn't immediately be thrown into the malingering category but this is seriously going overboard and wrong when you call something it isn't. Like I said before. Want to change the term? Fine by me but don't change it into something it's not.

Does that mean someone who had a seizure didn't have a "functional seizure?" After all they had a seizure and it fits the definition of "functional" Again room for being misled and confused. So then maybe we should change the name to "fake functional seizure" but then oh no someone will be offended but let's ignore the people who are offended for the valid reasons I mentioned above.

And on that order who is the Wizard of Oz who approves a name change?

I do worry that LatinX is an example of lexical imperialism given than the gender neutral version of latino is technically "latino."

Per the people who coined the term LatinX not good enough, but as I mentioned, who owns the language? So then if no one truly owns the language what right does anyone have to say a term must be included or you're ignorant despite that the overwhelming majority who speak the language find the term useless? No one owns the Spanish Language. If language is part of the culture, it really only has legs to stand on if the majority of the culture that speaks it accepts it as a term first. Not anonymous academics who will not take accountability and demand introduction of the term.

 

[comp1]

Functional is such a weird term... I guess the antonym is "organic?" Also a weird term. Is the idea that it helps the patient function in some way, ie distracts from some sort of trauma? If it actually impairs function, then shouldn't it be a dysfunctional seizure? I'm not as caught up in the use of the term seizure. Not every seizure is epileptic, psychogenic or not. I really like the term PNES a lot, sad that it's falling out of favor. If seizure really bothers a provider, they can always substitute spell for seizure in the acronym, but then you really go back to the hysterical old days.

 

[splik]

Functional is such a weird term... I guess the antonym is "organic?" Also a weird term. Is the idea that it helps the patient function in some way, ie distracts from some sort of trauma? If it actually impairs function, then shouldn't it be a dysfunctional seizure? I'm not as caught up in the use of the term seizure. Not every seizure is epileptic, psychogenic or not. I really like the term PNES a lot, sad that it's falling out of favor.

The idea of functional disorders is that they are due to disturbances in the functioning of the body rather than the structure. It's an imperfect term (since technically electrical seizures are also frequently functional in nature if you think about it) but it is currently the most accepted term for these conditions that were previously regarded as hysterical. Functional Neurological Disorder is the preferred term by patients and neurologists. We talk about functional weakness, functional tremor, functional gait disorders, functional tics so it was a natural extension to use the term functional seizure. We also talk about other functional somatic syndromes and symptoms, notable functional GI disorders. I have had patients comment that PNES was an unfortunate acronym as it sounded like a part of the male anatomy. Actually, one patient's husband told me he couldn't stop giggling every time he read it.

 

[G Sheb]

“Psychogenic” is actually the most accurate term. There’s nothing stigmatizing about it unless one considers psychological phenomena shameful or bad.

“Functional” is utterly laughable. Everything is “functional”.

Language changes yes but not always for the better. It’s a reflection of the power dynamics at play. In the past, doctors were the experts and perhaps had more power than they should have.
Now consumerism dominates in health care.

Ironic thing is that probably the most offensive thing among all of these terms is “seizure” itself. Likely rooted in theology and not with the best connotations.

 

[docksan]

“Psychogenic” is actually the most accurate term. There’s nothing stigmatizing about it unless one considers psychological phenomena shameful or bad.

“Functional” is utterly laughable. Everything is “functional”.

Language changes yes but not always for the better. It’s a reflection of the power dynamics at play. In the past, doctors were the experts and perhaps had more power than they should have.
Now consumerism dominates in health care.

Ironic thing is that probably the most offensive thing among all of these terms is “seizure” itself. Likely rooted in theology and not with the best connotations.

I don't think psychogenic is really helpful though, because it allows other providers to minimize a patient's symptoms. Functional is more accurate because the person continues to function despite apparent neurological symptoms. A functional seizure makes sense in that respect.

 

[G Sheb]

I don't think psychogenic is really helpful though, because it allows other providers to minimize a patient's symptoms. Functional is more accurate because the person continues to function despite apparent neurological symptoms. A functional seizure makes sense in that respect.

That’s not what “functional” means.
Functional here refers to the fact that the clinical phenomenon originated from the “function” of the body rather than a particular structural change you can identify. It’s entirely meaningless and doesn’t tell you at all what is happening. It’s really a coded word to avoid “psychological”.

If providers dismiss the symptoms because they are called “psychogenic”, it’s because of their own stigma towards mental illness. It’s like fighting the stigma of the illness by stigmatizing mental illness even more. What an elegant solution!

Psychogenic is the most accurate and neutral term actually. But it doesn’t sell. So we ditch it.

 

[docksan]

Alright you fight the system.

 

[Stagg737]

I'm actually surprised that people were taken aback by the 'right wing' comment.
There are at least 5/6 posters (a clear majority) who were either dismissive or expressed exasperation/discontent with the remarks the educators make. They also got a ton of likes as well. Many of them also admit implicitly or explicity admit their struggles with the cultural changes. The thing is, I'm not basing this on this thread only. And I felt it was important to throw that in so that the OP doesn't get an impression that this is the standard, and the school is out of line. I'm kind of surprised no one has said the W word yet.
I'd consider your post one of them as well, even though it was balanced in other ways.

But to answer your question, sure it's not the end of the world if the physician says this, the patient objects and they are 'corrected' and they apologize.
But the whole point of education is to get better at communication skills, make patients feel comfortable and welcome and point out potential biases that can hamper care.
I think your analysis is sort of missing the impact on a non-binary person.
Here's an analogy. Not a perfect one but along similar lines:
"How do you identify racially?"
"I don't really identify with any race"
"Were your parents black or white?"
Again, not the best one. But the point is that if you are talking to someone who identifies as non-binary, and you follow up with a question if their partner is a "man or a woman", that actually sound very invalidating for their identity. In some ways it was dismissed/ignored, which is why this might ring a few bells of 'unconscious bias'.

Is it the end of the world? Does the OP deserve to be burned on the stake? Will the patient crumble when hearing this? Most likely no. But that's the point of education, so the students get better at communication skills, make patients more comfortable because, really, they are the vulnerable ones.

I see your point, and I agree that the goal is education, which OP seems to fortunately be truly interested in. I also agree that their f/up question was weird and would have pointed it out if I was supervising as well. It wasn't necessary and could have definitely been more sensitive. Saying the question itself was harmful is probably incorrect though, and there are better ways the educators could have conveyed that lesson like using it as an example for unconscious bias instead of a generalization of language's effect in a brief encounter.

Regarding the 5/6 posters you referenced, I think it's a little presumptive to associate several of those statements with being "right wing" instead of with general ignorance. I've met plenty of people who consider themselves (and who many would consider) progressive who are clueless when it comes to some social subjects like gender language. It is probably more likely that those with less knowledge would be more conservative, but other than one obvious post most of them seem to be made more out of ignorance/lack of experience with that community than any political leanings.

 

[G Sheb]

Alright you fight the system.

Look patient centered care has been for the most part a big improvement. But trading scientific and accurate medical terminology with something that apparently even psychiatrists can’t understand what it means is not one of them.
Btw functional is a throwback to the 19yh century.

 

[docksan]

Functional refers to both the fact that a patient, with regard to the brain, retains normal capacity outside of the specific psychological triggers, as well as the fact that there appears to be a functional impairment of processes despite no alteration in structure.

Using basic logic, you could call literally every diagnosis "psychogenic", like depression, anxiety, or stress.

I'm not disagreeing with the idea that there should be a more specific term, but sometimes I will use "dissociative" when describing the symptoms rather than psychogenic as I've had patients tell me quite plainly their doctors tell them the symptoms are "all in their head" only for me to later find a pretty good medical explanation for it.

So for me, at least, using a term that almost literally means "all in your head" to a patient is probably not the wisest thing to do. If there is confusion, perhaps there needs to be a shift on that end versus being frustrated that an outdated term no longer has relevance.

 

[VA Hopeful Dr]

Btw functional is a throwback to the 19yh century.

I mean, maybe? But its still used frequently and in ways (in my area at least) that we all understand and agree on.

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[G Sheb]

Functional refers to both the fact that a patient, with regard to the brain, retains normal capacity outside of the specific psychological triggers, as well as the fact that there appears to be a functional impairment of processes despite no alteration in structure.

Ok. You can make up your own meaning if it makes you feel better.

 

[docksan]

Ok. You can make up your own meaning if it makes you feel better.

You might call that psychogenic.

 

[Osminog]

“Psychogenic” is actually the most accurate term. There’s nothing stigmatizing about it unless one considers psychological phenomena shameful or bad.

“Functional” is utterly laughable. Everything is “functional”.

Language changes yes but not always for the better. It’s a reflection of the power dynamics at play. In the past, doctors were the experts and perhaps had more power than they should have.
Now consumerism dominates in health care.

Ironic thing is that probably the most offensive thing among all of these terms is “seizure” itself. Likely rooted in theology and not with the best connotations.

"Psychogenic" is a term that is rooted in a dualistic conception of illness—that some disorders are physical (e.g., neurological), while others are rooted solely in psychological distress. Psychiatry is gradually moving away from this outdated model. The mind is a product of the physical brain, which is in a constant state of molding and rewiring in response to the physical environment and various electrochemical feedback loops.

When discussing the semantics of diagnostic categories, one also has to consider patients' perceptions and folk psychologies. When you tell a patient that his seizure-like episodes are "psychogenic" or "psychological," it's often going to be interpreted as "It's all in your head" and "You're faking it." It's extremely difficult for a layperson to understand the conceptual distinction between what we know of as malingering/factitious disorder (which carry massive stigmas) and "psychogenic" disorders with involuntary components.

I agree that "functional neurological disorder" is a misnomer and creates confusion; all neurological disorders impair function. Personally, I like the term "non-epileptic seizure-like episodes." The language is relatively neutral but also makes it clear that we're not talking about epilepsy or seizures.

 

[clausewitz2]

"Psychogenic" is a term that is rooted in a dualistic conception of illness—that some disorders are physical (e.g., neurological), while others are rooted solely in psychological distress. Psychiatry is gradually moving away from this outdated model. The mind is a product of the physical brain, which is in a constant state of molding and rewiring in response to the physical environment and various electrochemical feedback loops.

When discussing the semantics of diagnostic categories, one also has to consider patients' perceptions and folk psychologies. When you tell a patient that his seizure-like episodes are "psychogenic" or "psychological," it's often going to be interpreted as "It's all in your head" and "You're faking it." It's extremely difficult for a layperson to understand the conceptual distinction between what we know of as malingering/factitious disorder (which carry massive stigmas) and "psychogenic" disorders with involuntary components.

I agree that "functional neurological disorder" is a misnomer and creates confusion; all neurological disorders impair function. Personally, I like the term "non-epileptic seizure-like episodes." The language is relatively neutral but also makes it clear that we're not talking about epilepsy or seizures.

Functionalism is very much a going concern in philosophy of mind and I would argue one of the major strands underpinning modern cognitive neuroscience. Grossly simplifying, it's the idea that we can discuss mental states and processes in ways specified by their function independent of the details of their physical instantiation. This is perfectly consistent with a strictly monist idea of the mind-body problem; we can say mental states result strictly from physical processes and not at all contradict the idea that mental states and processes do not map one-to-one to a specific neural state. This is agnostic as to whether mental processes can in principle be reduced without residue to some set of neural processes. It does mean that if you have a problem that you can characterize in terms of mental processes or behavior without any ability to map it onto any one or several physical lesions or abnormalities, functional is actually a perfectly respectable way to describe it from a philosophy of mind perspective.

Note under this definition most of what we treat is functional, and indeed, primary psychoses used to be referred to typically as functional psychoses.

It would be interesting though to see a framework of the metaphysics of psychopathology that went all Churchland and simply denied the reality or relevance of mental states, from the starting point that saying that "I want a cookie" is exactly the same sort of statement as "my laptop wants to connect to my printer", i.e. as a kind of loose shorthand.

 

[G Sheb]

Now we're getting somewhere.

"Psychogenic" is a term that is rooted in a dualistic conception of illness—that some disorders are physical (e.g., neurological), while others are rooted solely in psychological distress. Psychiatry is gradually moving away from this outdated model. The mind is a product of the physical brain, which is in a constant state of molding and rewiring in response to the physical environment and various electrochemical feedback loops.

[/QUOTE]

Psychogenic simply means 'originating from the mind'. It's actually entirely accurate in its formulation.
Do we really want to ditch concepts of psyche and mind in our formulation of mental health?

You are right, that there is an implicit dualistic assumption behind terms such as "mind", "psyche", "psychogenic".
But I'd argue this dualism is unavoidable.
Even if you believe that the mind is somehow a product of the brain, the reality is that there is a subjective mental experience, one whose relationship with our objective formulation of the brain has not and will likely never been solved after centuries of science (and philosophy).
This is important clinically because a large part of our work is rooted in humanism, our ability to connect to one's subjective mental experience (through our own), and this where healing happens. So even when you are calling these disorders 'functional', you will end up as a PSYCHiatrist dealing with subjective mental experience to bring healing. Sure, there will always be a place for the physical in our field, and this is what makes it special.


What we're doing here is replacing one admittedly problematic dualistic concept with a much worse one, that is frankly outdated and utterly laughable. The structure/function dualistic formulation falls on its face even after the slightest thought. And if you think this dualism doesn't exist, then 'functional' is not really telling you anything of worth. Everything is functional, yet how are these disorders different? It's precisely because there is something.. psychological going on.

There is an unfortunate push to erase the psyche from psychiatry. Which is why we're seeing some departments call themselves "behavioral health". You might ask why this is happening now. This dualistic problem is not new. The fact that "psyche" has survived this long tells you something. What is changing is that we are moving more and more to a system where "the patient (consumer) is always right". As usual, follow the $$$. Sounds unappealing/offensive to our patients, we'll change it, even if it makes no sense.

When discussing the semantics of diagnostic categories, one also has to consider patients' perceptions and folk psychologies. When you tell a patient that his seizure-like episodes are "psychogenic" or "psychological," it's often going to be interpreted as "It's all in your head" and "You're faking it." It's extremely difficult for a layperson to understand the conceptual distinction between what we know of as malingering/factitious disorder (which carry massive stigmas) and "psychogenic" disorders with involuntary components.

[/QUOTE]

I would really push against. this. Our job is to educate. All it takes is a few minutes of education to let the patients know that this is not voluntary or predicated, that there are probably things in their mental health that they are unaware of that is causing this.
But why would neurologists do all this effort? Just change the word so they don't leave you for someone else.
You could argue that this 'resistance' to psychological forces is clinically important and actually an opportunity to make progress. It's probably related to why they have their symptoms in the first place.

 

[Osminog]

Functionalism is very much a going concern in philosophy of mind and I would argue one of the major strands underpinning modern cognitive neuroscience. Grossly simplifying, it's the idea that we can discuss mental states and processes in ways specified by their function independent of the details of their physical instantiation. This is perfectly consistent with a strictly monist idea of the mind-body problem; we can say mental states result strictly from physical processes and not at all contradict the idea that mental states and processes do not map one-to-one to a specific neural state. This is agnostic as to whether mental processes can in principle be reduced without residue to some set of neural processes. It does mean that if you have a problem that you can characterize in terms of mental processes or behavior without any ability to map it onto any one or several physical lesions or abnormalities, functional is actually a perfectly respectable way to describe it from a philosophy of mind perspective.

As you point out, the model within the philosophy of mind known as functionalism is agnostic to whether mental processes can be reduced to underlying organic causes. If this were the sense in which "functional" is used in the term "functional neurological disorders," then why would the term not apply to stroke- and TBI-induced cognitive impairments, Alzheimer's disease, and post-ictal states? I think the philosophical definition you're describing doesn't capture the distinction that the diagnostic category makes.

Psychogenic simply means 'originating from the mind'. It's actually entirely accurate in its formulation.
Do we really want to ditch concepts of psyche and mind in our formulation of mental health?

You are right, that there is an implicit dualistic assumption behind terms such as "mind", "psyche", "psychogenic".
But I'd argue this dualism is unavoidable.
Even if you believe that the mind is somehow a product of the brain, the reality is that there is a subjective mental experience, one whose relationship with our objective formulation of the brain has not and will likely never been solved after centuries of science (and philosophy).
This is important clinically because a large part of our work is rooted in humanism, our ability to connect to one's subjective mental experience (through our own), and this where healing happens. So even when you are calling these disorders 'functional', you will end up as a PSYCHiatrist dealing with subjective mental experience to bring healing. Sure, there will always be a place for the physical in our field, and this is what makes it special.

What we're doing here is replacing one admittedly problematic dualistic concept with a much worse one, that is frankly outdated and utterly laughable. The structure/function dualistic formulation falls on its face even after the slightest thought. And if you think this dualism doesn't exist, then 'functional' is not really telling you anything of worth. Everything is functional, yet how are these disorders different? It's precisely because there is something.. psychological going on.

There is an unfortunate push to erase the psyche from psychiatry. Which is why we're seeing some departments call themselves "behavioral health". You might ask why this is happening now. This dualistic problem is not new. The fact that "psyche" has survived this long tells you something. What is changing is that we are moving more and more to a system where "the patient (consumer) is always right". As usual, follow the $$$. Sounds unappealing/offensive to our patients, we'll change it, even if it makes no sense.

It sounds like you're concerned about biological reductionism and concomitant deterioration of humanistic care within psychiatry. This is a very reasonable concern. Some mental health clinicians are inclined to talk to patients strictly in terms of "chemical imbalances" and brain anatomy. This sort of framing externalizes the patient's problems of living and reduces their sense of agency; a depression diagnosis becomes a brain defect rather than a personal struggle.

I certainly don't think the psyche should be eliminated from psychiatric practice, but I also don't think that we need dualism to preserve it. We just have to be cognizant of the fact that psychology and neuroscience are just different levels of analysis for the same entity, and we need to recognize which level of analysis is most appropriate in given clinical situations. An analogy: You can look at a moose under a microscope, or you can look at a moose as a whole animal. If you're interested in the functioning of the moose's cells, then you'll use a microscope. If you're interested in the moose's mating habits, then you'll follow the moose as it prances through the forest. In either case, you're observing the same moose; you're just using different tools for observation based on what you're looking to accomplish. If you're considering psychopharmacological pathways, then you figuratively look through the microscope. If you want to learn about how the patient relates to others and perceives himself, then you take a humanistic approach. No dualism needed.

I would really push against. this. Our job is to educate. All it takes is a few minutes of education to let the patients know that this is not voluntary or predicated, that there are probably things in their mental health that they are unaware of that is causing this.
But why would neurologists do all this effort? Just change the word so they don't leave you for someone else.
You could argue that this 'resistance' to psychological forces is clinically important and actually an opportunity to make progress. It's probably related to why they have their symptoms in the first place.

It's a balance, right? You have to educate, but you also don't want to evoke shame and stigmatize patients. It's very hard to explain to patients and their family members that some complex behavior is "psychological" but still isn't entirely voluntary; you open a lot of room for misunderstanding and conflict: "Samantha, the doctor says your seizures are fake and that they're all in your head. Please cut it out. There's nothing physically wrong with you."

 

[G Sheb]

As you point out, the model within the philosophy of mind known as functionalism is agnostic to whether mental processes can be reduced to underlying organic causes. If this were the sense in which "functional" is used in the term "functional neurological disorders," then why would the term not apply to stroke- and TBI-induced cognitive impairments, Alzheimer's disease, and post-ictal states? I think the philosophical definition you're describing doesn't capture the distinction that the diagnostic category makes.


It sounds like you're concerned about biological reductionism and concomitant deterioration of humanistic care within psychiatry. This is a very reasonable concern. Some mental health clinicians are inclined to talk to patients strictly in terms of "chemical imbalances" and brain anatomy. This sort of framing externalizes the patient's problems of living and reduces their sense of agency; a depression diagnosis becomes a brain defect rather than a personal struggle.

I certainly don't think the psyche should be eliminated from psychiatric practice, but I also don't think that we need dualism to preserve it. We just have to be cognizant of the fact that psychology and neuroscience are just different levels of analysis for the same entity, and we need to recognize which level of analysis is most appropriate in given clinical situations. An analogy: You can look at a moose under a microscope, or you can look at a moose as a whole animal. If you're interested in the functioning of the moose's cells, then you'll use a microscope. If you're interested in the moose's mating habits, then you'll follow the moose as it prances through the forest. In either case, you're observing the same moose; you're just using different tools for observation based on what you're looking to accomplish. If you're considering psychopharmacological pathways, then you figuratively look through the microscope. If you want to learn about how the patient relates to others and perceives himself, then you take a humanistic approach. No dualism needed.


It's a balance, right? You have to educate, but you also don't want to evoke shame and stigmatize patients. It's very hard to explain to patients and their family members that some complex behavior is "psychological" but still isn't entirely voluntary; you open a lot of room for misunderstanding and conflict: "Samantha, the doctor says your seizures are fake and that they're all in your head. Please cut it out. There's nothing physically wrong with you."

I don't agree.
What you're describing is not a humanistic approach, but a descriptive behavioral one, just at a macrolevel.
What I am talking about is empathy and connectedness.
You can say for example "x likes to spend time with his 3 friends and ditch his parent" OR you can empathize and understand with what this means.
This will inevitably draw on your subjective experience of the world and theirs. Without this, there's no treatment.
Try as you might you will inevitably end up with dualism, because that's just part of what makes us human.
And so psychiatry inevitably has to involve both. When we're talking about mental illness, we're talking how the brain is working AND our subjective state.

No one is anywhere near figuring out how a bunch of neurons firing could end up with mental, subjective experience. In fact, there's an apparent inherent contradiction in trying to do this and it might never be 'solved'.
Even if chatGPT ends up with developing its own subjective state, it's still a 'subjective state' and it's dualist by nature.
It's incredible how some in our field are arrogant enough to think they can move beyond this when they can't have a remotely scientific diagnostic system or figure out which antipsychotic to prescribe.

It's a balance, right? You have to educate, but you also don't want to evoke shame and stigmatize patients. It's very hard to explain to patients and their family members that some complex behavior is "psychological" but still isn't entirely voluntary; you open a lot of room for misunderstanding and conflict: "Samantha, the doctor says your seizures are fake and that they're all in your head. Please cut it out. There's nothing physically wrong with you."

It's difficult sure. I'm sure it doesn't go smoothly a lot of the time.
But as said above, avoiding the topic and running away from the 'psychological' label actually stigmatizes mental illness even more.
Putting it another way, this is really a sanitized (and meaningless) term that neurologists came up with to avoid difficult discussions. And we latched it on.

 

[whopper]

So if Pseudoseizures are inappropriate and offensive.....

Why then is the term Pseudodementia not inappropriate and offensive?

IMHO what really happened is when providers suspected a PNES or Functional Seizure of Pseudoseizure (now I don't know what to effing call it cause of all of this BS), is the doctor probably laid the malingering accusation inappropriately. Seriously, hardly any layman even knows what this phenomenon is. So if a doctor told a patient they had a pseudoseizure, I'd bet my life's savings the patient wouldn't immediately get offended and exclaim, "so you're saying I had a fake seizure, how dare you!!!"

More likely the patient would ask what that is, and if the doctor was worth their salt say, something the effect of "it's something that looks like a seizure but wasn't a seizure but could've been caused by other significant phenomenon we can't ignore," but instead said something to the effect of "were you faking this?" Or pointed the finger and said they were malingering without investigating the issue further.

As mentioned, changing the term IMHO is going overboard. IMHO it really was about bad providers and changing the name won't make these bad providers any better but if you're going to change the term change it to something correct. Don't change it into something that's objectively BS.

Hey, I didn't say it. People are saying use of the term "PSEUDO" is somehow offensive. Why then don't you see people complaining about pseudodementia.

So what? We're going to call if now Functional Dementia? The person doesn't even having dementia to begin with, but we're going to call it something that it isn't. Yeah that makes sense.....NOT.

And for all the people saying we have to be more sensitive who's going to hold my hand? I'm bugged by this. I demand compensation.


Oh by the way we need to use the term PNES more and more! P-NES!! Yes! How big was that P-NES!? How small was that P-NES?

 

[splik]

So if Pseudoseizures are inappropriate and offensive.....

Why then is the term Pseudodementia not inappropriate and offensive?

pseudodementia has fallen out of favor because it is unspecific though people still use it. For those patients with subjective cognitive complaints inconsistent with objective history or exam, the current term is functional cognitive disorder. It's a bit more specific and there are proposed diagnostic criteria. That said, many patients who fell in the "pseudodementia" category do not have FCD and would be better dx with depression, anxiety, bipolar, PTSD etc

 

[clausewitz2]

As you point out, the model within the philosophy of mind known as functionalism is agnostic to whether mental processes can be reduced to underlying organic causes. If this were the sense in which "functional" is used in the term "functional neurological disorders," then why would the term not apply to stroke- and TBI-induced cognitive impairments, Alzheimer's disease, and post-ictal states? I think the philosophical definition you're describing doesn't capture the distinction that the diagnostic category makes.

The term would not apply to those things because all of those things require evidence of a specific kind of physical lesion or pathological process independent of the mental states and phenomenology in order to be diagnosed definitively. Even if your cognitive profile looks identical to the profile one would expect from someone who had a lesion in, say, their left superior temporal gyrus, if imaging and our best testing does not reveal any evidence of a lesion and there is no history of stroke or TBI, they do not have the same condition that someone who has such a lesion would be diagnosed with.

Meanwhile, someone without an identifiable pathological process/lesion/substance consumption who has all the emotional/mental symptoms of MDD for the appropriate duration of time will always have MDD. If we discover tomorrow that some MDD is driven by a particular abnormality in functional connectivity, provided that this does not apply to everyone with MDD, they will continue to have MDD. Realistically if we had Marvin the robot from Hitchhiker's Guide to the Galaxy had MDD (okay, maybe PDD) too despite being made of metal. It is defined largely in terms of the function of the mental states and processes involved and the hardware doesn't matter.

 

[G Sheb]

You don't have to have a lesion to be diagnosed with epilepsy.
If 'functional' refers to anything besides any kind of physical, material evidence of pathology, then that's dualism that is even worse than the mind/body dualism.
Or you could just call it "emergent property".
"its a problem with the emergent properties of your brain signal that could give rise to your mind". Hey, we avoid "psychological". lol.

My solution is to call it SINO (seizure in name only).

 

[clausewitz2]

You don't have to have a lesion to be diagnosed with epilepsy.
If 'functional' refers to anything besides any kind of physical, material evidence of pathology, then that's dualism that is even worse than the mind/body dualism.

No, you have to have evidence of a specific kind of psychopathological process. If you never have electrographic evidence of some kind of a seizure, you definitely are not getting diagnosed with epilepsy (except provisionally). If you have all the semiology and never show appropriate electrographic changes...well, that's really a pseudoseizure, now isn't it? The hardware matters. You need to have neurons electrically misfiring in a certain way.

 

[G Sheb]

No, you have to have evidence of a specific kind of psychopathological process. If you never have electrographic evidence of some kind of a seizure, you definitely are not getting diagnosed with epilepsy (except provisionally). If you have all the semiology and never show appropriate electrographic changes...well, that's really a pseudoseizure, now isn't it? The hardware matters. You need to have neurons electrically misfiring in a certain way.

Right.
You're defining 'functional' as equivalent to not having any evidence of identifiable pathological process.
You're falling in a kind of dualism right back again, and frankly a worse version. Congrats.

 

[clausewitz2]

Right.
You're defining 'functional' as equivalent to not having any evidence of identifiable pathological process.
You're falling in a kind of dualism right back again, and frankly a worse version. Congrats.

I am having trouble believing you read my previous post explaining what functionalism means in a philosophy of mind context. This is perfectly compatible with monism, it just requires that psychological processes not be reducible without residue to a unique set of physical processes. It doesn't mean they don't ultimately have physical causes. You were arguing this in some of your above posts so I am trying to understand the objection.

 

[docksan]

I'm going to back out of this one, it's giving me psychogenic stress and functional headaches.

 

[comp1]

I'm not sure if a fully developed understanding of gnostic philosophy should really be a requirement to explain to a patient why Keppra is the wrong med for them. It's important to examine why each of these many successive terms to describe particular behavior is eventually determined to be offensive or somehow demeaning. Is this related to our own or others' internalized belief that psychosomatic illnesses are less than those that originate in other manners? Is it the patient's or our preference that they instead have something like demonstrable epilepsy? Wouldn't it be better to address that belief pattern than constantly changing the language to essentially mean the same thing?

 

[G Sheb]

I am having trouble believing you read my previous post explaining what functionalism means in a philosophy of mind context. This is perfectly compatible with monism, it just requires that psychological processes not be reducible without residue to a unique set of physical processes. It doesn't mean they don't ultimately have physical causes. You were arguing this in some of your above posts so I am trying to understand the objection.

You're right. Having followed some of the debate in published papers (which is not settled), I don't think the choice had much to do with philosophy of mind.
If all you're saying is that the 'psychological' phenomena are due to functional alterations in how neural circuits operate without having to identify a particular one to one map with a certain disruption in the circuit, then to me this is not different at all from saying that this is an issue with the mind.

 

[clausewitz2]

You're right. Having followed some of the debate in published papers, I don't think the choice had much to do with philosophy of mind.
If all you're saying is that the 'psychological' phenomena are due to functional alterations in how neural circuits operate without having to identify a particular one to one map with a certain disruption in the circuit, then to me this is not different at all from saying that this is an issue with the mind.. hence 'psychogenic'. We should acknowledge that we are dealing with the 'mind' here, the actual person, and not some other coded software/hardware crap. At the end of the day, the 'software' is.... the patient.

I think the term 'functional' may be more suitable for some other movement disorders, but it's frankly ridiculous for seizures as there's almost always a fairly involved psychological process going on. And these patients are sometimes not 'funcitonal' at all. We shouldn't run away from 'psychogenic' because people dislike to talk about their mental states.

Oh, I agree with you about psychogenic in principle. Pragmatically I think it is sufficiently loaded that it might make a lot of conversations harder than it needs to be. That's entirely a difference in tactics. You are fighting the good fight for sure.

 

[smalltownpsych]

I think this has veered a bit off topic from inclusive language. As far as the OP goes, I described the interaction to a patient of mine who is just beginning hormone treatment for gender affirming care. (Not sure if I like that term, but not in the mood to dissect that today.). Anyway, he didn’t find it offensive as much as thinking the resident was pretty clueless. As they put it, when someone tells you they are non-binary and use non gendered pronouns, it’s just stupid and ignorant to ask if their partner is a man or woman. In my mind, this is just one example of learning how to ask questions neutrally and it is an essential skill for a good psychiatric interviewer to have. How we ask questions and which questions we ask and which ones we follow up on all direct the conversation and we need to have a heightened awareness of that or we will miss key points or just end up pissing off an unstable and potentially violent patient. I’m glad I have that skill pretty well down which is one reason why in 20 years working with volatile patients, I’ve never been attacked.

 

[whopper]

In some places, and this is not an exaggeration, some are advocating for people to start memorizing over 50 gender pronouns and if this is too much for you to start using an app to catalog everyone you meet.

Yes the above is an extreme, but an extreme that does exist. So then the question is where is the line? Where is the line where we're not being inclusive enough?

I'm not trying to bash people who want more than he or she, but where is the line? At 4:45 on the video below "over 31 pronouns in New York City." I'm not trying to be sarcastic. I bet you that any of the people claiming "insensitivity" will themselves not have 31 pronouns memorized. Are they being insensitive? I think most of them will find that ridiculous.

To emphasize I'm being serious, one could retort to the finger pointer, "oh yeah? Recite to me 50 gender pronouns! So common smart-ass you're the one being insensitive cause you can't name over 50!" Now that's being sarcastic, polemic and escalating the anger. Simply asking the question and understanding where do we stand on this shifting issue is practical, valid and apparently now REQUIRED if people are going to start finger-pointing at you for being "insensitive" in a pejorative manner.

So please, someone, tell me where the line is. Is 31 alright and 50 not? Is 3 alright but 31 not? Tell me before you finger point in a manner that could have real professional consequences and cite your reasoning and be prepared to defend your reasoning.

 

[Osminog]

In some places, and this is not an exaggeration, some are advocating for people to start memorizing over 50 gender pronouns and if this is too much for you to start using an app to catalog everyone you meet.

Yes the above is an extreme, but an extreme that does exist. So then the question is where is the line? Where is the line where we're not being inclusive enough?

In my opinion, the line is crossed when inclusivity interferes with ease of communication. The line is also crossed when it becomes clear that an individual is using the pronoun situation in order to exert power over others, or to fulfill a desire to be misunderstood and in conflict with others.

In general, I think the pronoun debate is kind of overblown. When you're directly talking to somebody, you're generally going to only be speaking in the first or second person; "I" and "you" are pronouns that are thankfully immune (so far) from the latest trends in linguistic prescriptivism. Also, if somebody prefers to go by contrived, difficult-to-remember pronouns (e.g., "xe/xem/xyr/xyrs/xemself"), you can just repeatedly use their first name (or "the patient") when referring to them in the third person; it sounds very unnatural, but at least it's inclusive and you wouldn't have to install a pronoun memorization app.

 

[whopper]

he line is also crossed when it becomes clear that an individual is using the pronoun situation in order to exert power over others, or to fulfill a desire to be misunderstood and in conflict with others.

This is why I thought "Psychogenic Non-Epileptic Seizures" fit into that thinking. 11-syllable word, it's not a seizure, it is related to epilepsy, WTF? In hospitals you sometimes can't be bogged down with 11-syllables especially in an emergency hence CT scan, or ER, or CBC terms. Oh I forgot P-NES! Yes yes yes P-NES!

In general, I think the pronoun debate is kind of overblown. When you're directly talking to somebody, you're generally going to only be speaking in the first or second person; "I" and "you" are pronouns that are thankfully immune (so far) from the latest trends in linguistic prescriptivism. Also, if somebody prefers to go by contrived, difficult-to-remember pronouns (e.g., "xe/xem/xyr/xyrs/xemself"), you can just repeatedly use their first name (or "the patient") when referring to them in the third person; it sounds very unnatural, but at least it's inclusive and you wouldn't have to install a pronoun memorization app.

Agree. I do want people to be called the gender they want to be called but there is no hard line and with no common understanding comes a lot of judgmental and unfair finger pointing.

IMHO this parallels the now mostly-dead argument that was popular a few years back of having to put in a third bathroom or you were somehow whatever-phobic.

 

[Fluidity of Movement]

Separately, gender dysphoria is only a diagnosis to allow transgendered individuals access to medical services. No one, beyond the old guard that believe homosexuality is also a mental illness, is using that disorder in any other way. There is a rich historic record of transgendered people throughout time, this is not something new and not a big deal. Now that we can effectively help transgendered folk transition we do see more people identifying as such, but who freaking cares. Are there some people who identify as trans likely as a trauma response to seperate from the person they were when traumatized? I think absolutely there are, but that is for the psychologists at the gender clinic to discuss or an OPP, not for a likely cisgendered heterosexual male to be picking beef with on an inpatient psychiatric unit.

I agree with you, but have some thoughts. Using a lot of quotation marks since internet language and word use can be so tricky.

I think gender dysphoria isn't quite in the same category as homosexuality once was. Trans people don't usually identify as trans, they identify as male / female, this is indicative of a "something" that happened somewhere and now they are in the wrong body likely requiring medical treatment. Homosexuality has never had a legitimate "something" other than society's view of them.

I know the language is hard and putting things under "mental disorder" has so many negative connotations and inaccuracies, but I think that this is a diagnosable issue and since the usual "treatment" for it is transitioning, it's important to make sure that the person is actually trans / has "gender dysphoria" since certain medical interventions are irreversible / can cause harm (depending on the level of transitioning the person desires).

Maybe I'm splitting hairs but I'm trying to better learn myself as I continue to support my trans friends and learn more about people on my training journey.


P.S., isn't "transgendered" faux pas ?

 

[Merovinge]

I agree with you, but have some thoughts. Using a lot of quotation marks since internet language and word use can be so tricky.

I think gender dysphoria isn't quite in the same category as homosexuality once was. Trans people don't usually identify as trans, they identify as male / female, this is indicative of a "something" that happened somewhere and now they are in the wrong body likely requiring medical treatment. Homosexuality has never had a legitimate "something" other than society's view of them.

I know the language is hard and putting things under "mental disorder" has so many negative connotations and inaccuracies, but I think that this is a diagnosable issue and since the usual "treatment" for it is transitioning, it's important to make sure that the person is actually trans / has "gender dysphoria" since certain medical interventions are irreversible / can cause harm (depending on the level of transitioning the person desires).

Maybe I'm splitting hairs but I'm trying to better learn myself as I continue to support my trans friends and learn more about people on my training journey.


P.S., isn't "transgendered" faux pas ?

I certainly agree that someone who requires medical intervention is different than someone who does not, but I would argue that medical intervention is endocrinologic/surgical in nature and not psychiatric. Does that mean that someone should have through psychologic assessment and a lengthy process before irreversible steps are taken? Absolutely. But so should best practice bariatric surgery and I don't see many people looking to add obesity to the DSM 6 (and let's be honest, there are probably a similar amount of psychologic factors leading to obesity). Frankly this should be the case for a lot of cosmetic surgery as well.

I agree the language and evolution of this is complicated, particularly when trying to empower one of the absolutely most disenfranchised sections of society. I am all about learning whatever I can do to make such people's lives easier, just like I feel about people who suffer from schizophrenia. If I have to be inconvenienced with relearning to use some different pronouns, well golly jee that's a sacrifice I am willing to make while I wait patiently for my Nobel Peace Prize.

 

[whopper]

A major problem here, and I found myself shockingly agree with crowds I typically disagree with is the following.

Transitional interventions such as hormonal treatments and surgeries are not in a stage of research where this is well understood. Take depression for example. We've known it's existed before written history, spent billions on studying it, and have plenty of studies with thousands of people on it and yet despite this we still have a lot to learn.

Gender identity studies in interventional treatments are often on the order of "we enlisted 15 subjects." Further these treatments are dealing with either surgery which is permanent or hormonal which if done on someone still growing can have very bad repercussions we don't yet understand.

It's not good medicine to do a surgery on someone where the studies you're relying upon aren't extensive, have small groups of subjects, and even the existing data show high amounts of bad outcomes.

Now all this said I want people to feel dignity, feel they're being treated with respect and if they feel they are of a sexual identity that doesn't match their phenotypic sex to be called by their identity (but ahem over 50 genders to memorize? Where's the line!?!?!).

I fear transitional surgery has a lot more that needs to be refined and defined before such an intervention would take place. I'm also fearing this could be the equivalent of lobotomies that were done even in office up to the 80s by people calling themselves physicians.

 

[smalltownpsych]

In my experience, the patients that are looking to get offended by being misgendered are generally going to target this against people who they think are being judgmental of them and especially parents or others in authority. To me, this aspect of looking for confrontation is more of a normal adolescent developmental dynamic of pushing back against others defining them and the gender part is just where that fight makes the most sense for them. Since I really good at channeling my cats detachment, I don’t get sucked into these types of enactments very often because, like a cat, I just stare at them neutrally or with a mix of mild disdain and humor.

 

[Merovinge]

A major problem here, and I found myself shockingly agree with crowds I typically disagree with is the following.

Transitional interventions such as hormonal treatments and surgeries are not in a stage of research where this is well understood. Take depression for example. We've known it's existed before written history, spent billions on studying it, and have plenty of studies with thousands of people on it and yet despite this we still have a lot to learn.

Gender identity studies in interventional treatments are often on the order of "we enlisted 15 subjects." Further these treatments are dealing with either surgery which is permanent or hormonal which if done on someone still growing can have very bad repercussions we don't yet understand.

It's not good medicine to do a surgery on someone where the studies you're relying upon aren't extensive, have small groups of subjects, and even the existing data show high amounts of bad outcomes.

Now all this said I want people to feel dignity, feel they're being treated with respect and if they feel they are of a sexual identity that doesn't match their phenotypic sex to be called by their identity (but ahem over 50 genders to memorize? Where's the line!?!?!).

I fear transitional surgery has a lot more that needs to be refined and defined before such an intervention would take place. I'm also fearing this could be the equivalent of lobotomies that were done even in office up to the 80s by people calling themselves physicians.

I'll just say that is not the state of the data that I have previously been presented or discussed. I don't specialize in gender issues but have worked with both surgeons and psychiatrists that do and thus far the data has clearly pointed to less SI, less depression and improved overall mental health following medical or surgical transition (the numbers of patients are much higher than 15, they are well into the hundreds now).

I agree that more longitudinal data needs to be collected but this is nothing like lobotomies as there IS data suggesting that withholding treatment is causing harm.

This is a lot like CAP in general. We often lack the adolescent specific data to know about long-term effects with newer treatments and have to run the risks versus benefits. To be very clear there is real risk in not treating adolescent depression, anxiety, SUD, ED, etc, just like there is real risk in not treating transgendered individuals (take one look at their life expectancy or suicide rate).

 

[Shikima]

Or just skip 3rd person pronouns and stick with specific questions involving the word 'You".

How are you doing today? What is bothering you today? How are your medications working?

Keep the exam focused. You are welcome to listen to long embellished stories if you have the time.

Wrap it all up saying - Let us keep working on this together.

 

[whopper]

Maybe the introduction of a completely neutral pronoun. Like I said I'm all for people being treated with dignity but I'm not going to memorize over 50 pronouns. Just make 1 to shut everyone up.

 

[Fluidity of Movement]

I certainly agree that someone who requires medical intervention is different than someone who does not, but I would argue that medical intervention is endocrinologic/surgical in nature and not psychiatric. Does that mean that someone should have through psychologic assessment and a lengthy process before irreversible steps are taken? Absolutely. But so should best practice bariatric surgery and I don't see many people looking to add obesity to the DSM 6 (and let's be honest, there are probably a similar amount of psychologic factors leading to obesity). Frankly this should be the case for a lot of cosmetic surgery as well.

I agree the language and evolution of this is complicated, particularly when trying to empower one of the absolutely most disenfranchised sections of society. I am all about learning whatever I can do to make such people's lives easier, just like I feel about people who suffer from schizophrenia. If I have to be inconvenienced with relearning to use some different pronouns, well golly jee that's a sacrifice I am willing to make while I wait patiently for my Nobel Peace Prize.

This is all very interesting, and the ICD lists 'gender incongruence' under reproductive / sexual health not mental.

But this does beg the question, we have the whole Q part of the alphabet gang, are psychologists and psychiatrists not some of the best ones capable of helping people to determine if they are gay, trans, etc, otherwise?

Many youngsters and teenagers go through this and need support, so uncovering and helping people "figure out" where they are and what they need seems like it is under the medical model.

I know this could be applied to pretty much anything in life, but trans folk have an exceptional amount of waters to navigate and figure out and arriving to the point where it does just become an endocrine / surgical issue seems like we are taking half of the struggle away / denying that it can be as much of a need for psychiatry.

Just my thoughts and I am still a student and learning.

 

[whopper]

I agree that more longitudinal data needs to be collected but this is nothing like lobotomies as there IS data suggesting that withholding treatment is causing harm.

Don't completely disagree. There are some studies that used very high numbers but I see you do get my point.

This is a very controversial subject that unfortunately has become a wedge issue for both the L and R dragging us into the political BS attached with politics.

Some valid questions I've seen from people very much against transitional treatment-Can a 15 year old truly consent to a surgery that will cause genital mutilation? Can a 15 year old consent to hormonal treatment especially if the data is seriously lacking as to possibly permanent repercussions from such treatment? Where does parental permission come in if the patient is under 18?

All of these are valid questions. I don't have answers to them.

IMHO some of the dramatic leap in frequency of transgenderism is not only social media as the answer that most people seem to believe (despite a lack of evidence backing this up, but....and this is only my speculation...THIS IS POSSIBLY A BYPRODUCT OF INCREASED MICROPLASTICS IN THE ENVIRONMENT.

Hear me out. Microplastics have been found to be found in food, water, in several sources in recent years. In recent years the numbers of people who identify as trans has skyrocketed. Microplastic, if found in a body, has been found to bind to sex hormone receptors having measurable negative impact on various markers of reproductive health but we don't know WTF it does to things like gender identity. Given that we now live in a world where we will, whether we like it or not, now imbibe microplastics that will get into our body, WTF is this doing to our body?

Further it just goes to show you the absurdity of the two dimensional politics we have. The R is against transgenderism, the L-open arms. So what if the rise is related to microplastics? Shouldn't then the R drop their lack of concern for the environment and the prior laughs at those concerned about plastic waste? Shouldn't then the L be concerned that this is a result of an exogenous pollutant affecting development and not something that is "beautiful?"

A review of the endocrine disrupting effects of micro and nano plastic and their associated chemicals in mammals

Over the years, the vaste expansion of plastic manufacturing has dramatically increased the environmental impact of microplastics [MPs] and nanoplastics [NPs], making them a threat to marine and terrestrial biota because they contain endocrine disrupting ...

www.ncbi.nlm.nih.gov

 

[Fluidity of Movement]

Hear me out. Microplastics have been found to be found in food, water, in several sources in recent years. In recent years the numbers of people who identify as trans has skyrocketed. Microplastic, if found in a body, has been found to bind to sex hormone receptors having measurable negative impact on various markers of reproductive health but we don't know WTF it does to things like gender identity. Given that we now live in a world where we will, whether we like it or not, now imbibe microplastics that will get into our body, WTF is this doing to our body?

I remember reading about this ten years ago in bio 2. "Plastic babies."

I would still hedge my bets on social acceptance and education though. Everyone was right handed until 100 years ago [ish]. We are in the midst of multiple paradigm shifts all happening at once, and this fluid / shifting / however we want to label it view of gender and sex very well may be our next mainstream social evolution, not just at the fringes.

 

[Merovinge]

I remember reading about this ten years ago in bio 2. "Plastic babies."

I would still hedge my bets on social acceptance and education though. Everyone was right handed until 100 years ago [ish]. We are in the midst of multiple paradigm shifts all happening at once, and this fluid / shifting / however we want to label it view of gender and sex very well may be our next mainstream social evolution, not just at the fringes.

The data behind R/L handedness is absolutely fascinating, love the reference here.

 

[Fluidity of Movement]

The data behind R/L handedness is absolutely fascinating, love the reference here.

Yes, in that everyone was afraid to admit they were left handed or were too afraid to explore the possibility, and now its something like 10-15% of the population.

 

[whopper]

I would still hedge my bets on social acceptance and education though. Everyone was right handed until 100 years ago [ish]. We are in the midst of multiple paradigm shifts all happening at once, and this fluid / shifting / however we want to label it view of gender and sex very well may be our next mainstream social evolution, not just at the fringes.

Very much agree with this analogy.