December Talk

This week I gave a talk as part of the Chaos Computer Club event FireShonks, and it is now online: Chat Control: Mass Screenings, Massive Dangers” (Dec. 27, 2023). It warns that mass screenings for low-prevalence problems are often doomed to backfire according to the implications of probability theory. It builds on numerous recent SubStacks, including:
– this book review of Welch et al’s Overdiagnosed, which focuses on the dangers of medical programs that share this dangerous structure;  
– this effort to situate possible system-level solutions in the context of existing legal regimes, especially the concept of suitability in EU/German law; 
– these Chat Control posts (1, 2, 3, 4);
– these AI Act posts (1, 2, 3); and 
– this essay on reification and the common liberty-security mismappings in relevant debates. 

Happy new year to digital freedom fighters and techno-solutionists all!


Fienberg’s Polygraph Testimony Story

File this as proof that, sometimes, math changes the world… 

I found myself wanting to review the transcript/tapes and post a huge block quote in my SubStack on mass security screenings for low-prevalence problems. But these things get long. So here’s Stephen Fienberg’s polygraph testimony story. It starts around minute 12 of interview tape 1. (Here are tapes 2 and 3, a synthesis of my larger polygraph interview series, and the National Academy of Sciences polygraph report SF co-chaired.) 

It’s a fascinating story. I was on the airplane — in those days I actually used to get upgraded. So I remember I was sitting in first class in the first row, and my cell phone rang. And the voice on the other end said, “Could you hold the line for Mr. McSlarrow?” I didn’t know who Mr. McSlarrow was. And this person gets on the phone and says, “I’m Kyle McSlarrow, I’m the Deputy Secretary of the Department of Energy.” And then I realized I should have known who he was, because he was scheduled to testify at the hearing the next day with me. And he said, “I wanted to alert you to the fact that we’ve changed our minds. And I’m faxing you a copy of my testimony. Where should I send it?” I said, “Well, I’m on the airplane; you can’t send it here. Why don’t you send it to the National Academies, and they’ll make arrangements to give it to me. Can you tell me what it is?” And he told me a little bit, but not a lot of the reversal of this absolute position that they were going to continue to plan to polygraph everyone.

And then next morning I met with the study director from our study, Paul Stern, and he handed me a copy of this fax. And basically what it said was, everything I had planned to testify about was inappropriate. So in about 10 or 15 minutes, we rewrote the script and I prepared somewhat different testimony. And of course McSlarrow went first, and so I got a chance to scribble in the margins and he clearly was doing something beyond the script as well. And his Q&A happened before I ever testified also. So, in some sense, the hearing was over before I got to the table, although there were some interesting questions and answers. It was a fun process. I’ve testified before Congress on a number of occasions before. In some sense, this is the first time I ever thought it really mattered, and where the script went out the window in a quite remarkable way.

I can’t imagine that without pressure to do something to justify their position, there would have been any reason for them to change. I mean, there there’s two different things: There’s the policy that said “We’ll polygraph everyone.”And there was the reality, which is they’ve never done that. And so the April Federal Register statement was really all about implementing the policy that had been in the legislation way back when and — and they didn’t say how they were gonna do that, either. My friends at Los Alamos told me it had never been implemented. And after April it still hadn’t been implemented. So there are complicated dynamics and I’m not privy to all the details. What the Deputy Secretary said was, “I’ve read the report carefully now, and it moved me — in the sense that it moved my position from the one we took in April, to a new one. I found the arguments compelling,” he said, “so now we’re not gonna polygraph everyone. We’re only gonna polygraph half the people.” That’s not quite — it was much more elaborate, but it more or less amounted to about half the people…

[But why, I asked inaudibly, would you see a program doesn’t work and backfires, and do it less, instead of not doing it?]

And the great exchange happened in the question and answer session of McSlarrow, when Senator Bingaman asked him exactly that question. So he laid out the new policy, the new policy being different groups being polygraphed at different rates — high-risk, high-security people would have polygraphs on a regular basis, random polygraphs for some others, an issue we discussed in the report. So this wasn’t totally at odds with the report. And — and a bunch of other things, like the polygraph would not be definitive. And so it wasn’t just the movement of numbers, but direct public recognition that the polygraph was not infallible. Which is the way people thought about it in this context before.

And Senator Bingaman’s question was terrific, because he picked up our report. He asked the deputy secretary to open it to Table S1. To read the numbers. And there was this wonderful exchange. He said, “Do you need me to give you a copy?”And one of our staff members was about to hand him a copy of the report, and he said “Oh no, I don’t need that. It’s imprinted in my mind.” And then Senator Bingaman went on and — and said, “Well, there’s such-and-such numbers in this table. And if I understand the proposals, that would lead to approximately half those numbers being polygraphed every year. So let’s just take those tables and divide the numbers by two.” And then he went through the scenario, and he said, “There’s a lot of false positives in this scenario, and false negatives here, and how do you propose to deal with that, given that the Academy said you shouldn’t do this at all?” And it was an interesting exchange.


May Talks

This month I gave two talks on my two favorite case studies in bad science: lie detection and breastfeeding

The first, “Psychic X-rays: Holy Grail, Cover Story – or the End of Human Rights?” (video; slides) was part of the Border (Dis)placements symposium that took place 13 May at Stroom Den Haag. Psychic x-rays — technologies that claim to see and sometimes change what’s going on inside your mind — are a growing phenomenon. Focusing on the recent case study of EU Horizons 2020-funded “AI lie detector” iBorderCtrl, this talk looked at them through three lenses. As science, they seek the holy grail of a unique sign of internal states like truthfulness. As praxis, they may function as a cover story. Seen through both lenses, they undermine security. Finally, in terms of first principles, they violate cognitive liberty – that sacred internal space where freedom of thought and feeling is inviolate, and the integrity of which is the foundation of all other human rights. Looking at iBorderCtrl through all these lenses shows why we should keep current bans on algorithmic decision-making and profiling, ban mass security screenings for low-prevalence problems, and recognize cognitive liberty as part of human dignity. 

The second, “Exclusive Breastfeeding: Bad Science, Risky Practice, & Failed Policy” (video; slides) was part of the University of Kent, Centre for Parenting Culture Studies’ “Parenting culture and feeding babies” symposium. I Tweeted highlights when I wasn’t presenting. 


False findings in JAMA Psychiatry

Here’s an email I sent JAMA Psychiatry editor Dost Öngür regarding false findings that he recently allowed to be published in his journal. I sent it on March 25, and his March 28 reply is below (ed. 03-29-23). 


Hi Dr. Öngür,

This evening, JAMA Psychiatry turbo-rejected my comment (submitted at 7:45 p.m. rejected at 8:32).

Is this how you do dialogue about ethics when someone informs you that your journal has published false findings?

Thanks and best regards,


“Research Misconduct Generated False Findings Requiring Retraction”

Inaccurate data in scientific papers constitutes research misconduct when “data are altered, omitted, manufactured, or misrepresented in a way that fits a desired outcome” (1). This applies to Zandberg et al’s recent JAMA Psychiatry article “Association Between State-Level Access to Reproductive Care and Suicide Rates Among Women of Reproductive Age in the United States” (December 28, 2022; (2)).

The authors reported enforcement of abortion restriction laws “was associated with higher suicide rates among reproductive-aged women (β = 0.17; 95% CI, 0.03 to 0.32; P = .02).” But eTable 5 shows that, in their analysis, two of three reproductive-age category bins returned insignificant results. The results presented as primary appear to drop the oldest bin and combine the younger two: p-hacking. The authors misrepresented this misleading result as pertaining to all reproductive-age women, and misrepresented their findings as having “remained significant when using… different age categorizations.”

In addition to p-hacking and misrepresentation of results, the authors did not accurately represent their reported findings’ practical significance. Suicide is rare. The expected number of suicides in their N = 1022 subsample of interest was zero. So the real-world implication of their claimed 5.81% suicide rate increase is zero. This illustrates why we probably want to look at counts and not rates when it comes to rare events.

The authors also inflated that claimed rate increase. The correct 95% compatability interval estimate is 1.03-1.0581 (3). The reported finding corresponds to the upper bound.

Abortion is reliably associated with about a 2x statistically and clinically significant suicide risk increase (4). We don’t know if the link is causal or not, but we know it’s substantial. Women deserve to know that. Fabricating results that tell the opposite story, as Zandberg et al did, doesn’t serve them.

Science is not self-correcting (5). But scientists reward authors who report their own honest mistakes (6). So I asked Zandberg to retract based on these concerns, and received no reply (7).


(1) “The Prevalence of Inappropriate Image Duplication in Biomedical Research Publications,” Elisabeth M. Bik, Arturo Casadevall, and Ferric C. Fang, ASM Journals: mBio, Vol. 7, No. 3,

(2) “Association Between State-Level Access to Reproductive Care and Suicide Rates Among Women of Reproductive Age in the United States” Jonathan Zandberg, Rebecca Waller, Elina Visoki, and Ran Barzilay, JAMA Psychiatry, 2023;80(2):127–134. doi:10.1001/jamapsychiatry.2022.4394.

(3) “Science Fiction: Bad abortion-suicide research turns risk upside-down, but will the authors retract?” Vera Wilde, SubStack, March 15, 2023,

(4) “Abortion Myths, Part 1: Dubious science downplays substantial possible risks of abortion,” Vera Wilde, SubStack, Feb. 23, 2023,

(5) “The natural selection of bad science,” Paul E. Smaldino and Richard McElreath, Royal Society of Open Science, Vol. 3. No. 9, September 2016,

(6) “The consequences of retraction: Do scientists forgive and forget?” Alison McCook, June 16, 2015, Retraction Watch,

(7) Author correspondence, March 20, 2023,





Thank you for your message.  We monitor posts on our website to make sure they are collegial and constructive and we concluded that your comments did not meet that criterion.


I see that you have tweeted and also have a blog post about this specific concern. As stated in the journal’s commenting policy, we do not post comments that “duplicate what a commenter has already said in one or more previously published comments.” If you wish to provide an original comment that you have not posted elsewhere and that is without unfair allegations of research misconduct, we may consider it.



Dost Ongur


Antidepressants in Pregnancy Criticism on Mad in America

Excited to announce the publication of a critique of the research literature on antidepressants in pregnancy. Dubious Science: Downplaying the Risks of Antidepressants in Pregnancy,” runs today on Mad in America: Science, Psychiatry and Social Justice. The post explores methodological problems in science that starts out with evidence of substantial possible risks, and launders them through faulty and nontransparent means into purported evidence of no risk.



Revised Newborn Jaundice Guidance Risks Preventable Harm

This is a response to the American Academy of Pediatrics’ August 2022 “Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation,” published by Alex R. Kemper, MD, MPH, MS, FAAP; Thomas B. Newman, MD, MPH, FAAP; Jonathan L. Slaughter, MD, MPH, FAAP; M. Jeffrey Maisels, MB BCh, DSc, FAAP; Jon F. Watchko, MD, FAAP; Stephen M. Downs, MD, MS; Randall W. Grout, MD, MS, FAAP; David G. Bundy, MD, MPH, FAAP; Ann R. Stark, MD, FAAP; Debra L. Bogen, MD, FAAP; Alison Volpe Holmes, MD, MPH, FAAP; Lori B. Feldman-Winter, MD, MPH, FAAP; Vinod K. Bhutani, MD; Steven R. Brown, MD, FAAFP; Gabriela M. Maradiaga Panayotti, MD, FAAP; Kymika Okechukwu, MPA; Peter D. Rappo, MD, FAAP; Terri L. Russell, DNP, APN, NNP-BC in the journal Pediatrics.

New guidance from the American Academy of Pediatricians on managing jaundice in newborns normalizes dangerous complications of accidental starvation from breastfeeding, appears not to consider numerous possible iatrogenic harms from phototherapy, and does not compare the relative benefits and risks of the simplest strategies for treating neonatal jaundice and preventing its progression — namely, supplemental formula feeding before and during phototherapy. 

Starvation is the root cause of modal neonatal jaundice. Underfeeding worsens jaundice of all origins. Jaundice severity, in turn, increases risks including death and permanent brain injury. Preventing and treating starvation jaundice is literally as easy as giving a bottle.

Modern misconceptions about “exclusive breastfeeding” — a modern, Western intervention introduced without safety monitoring —commonly lead to insufficient milk intake in the days before mothers’ milk usually comes in, days or weeks before supply is established, and whenever insufficient milk persists or presents. This is a frequent occurrence and the cause of common, fully preventable harm. Current consensus normalizes signs of complications from resultant starvation including the appearance of pink uric acid crystals, excessive weight loss and crying, and jaundice. There is nothing normal or necessary about starving newborns.

The empirical literature links neonatal jaundice with possible substantial increases in neurodevelopmental harm including autism. It also links phototherapy with such risks. Of many jaundice-autism studies, the new AAP guidance authors cite only Wu et al 2016 — who estimate in line with other such studies that both jaundice-autism and phototherapy-autism effects may be quite substantial. This forms part of a body of evidence troubling the notion that phototherapy protects infants from harm, and suggesting that, rather, phototherapy may be associated with even more preventable harm than jaundice itself. This finding in the phototherapy-autism literature has been widely under-reported due to rampant misuse of statistical significance testing, a mistake denounced by leading methodologists

Before phototherapy, early modern healthcare providers advised breastfeeding moms to switch jaundiced babies to formula. The evidence still supports that treatment. Formula-fed newborns have greater bilirubin clearance than breastfed ones. Phototherapy efficacy hinges on excretion. Insufficient milk intake from breastfeeding likely first contributes to jaundice and its progression, and then compromises phototherapy efficacy. Phototherapy should be used as a second-line treatment after formula-feeding whenever possible, to minimize iatrogenic risks. Complementary formula supplementation should be standard with phototherapy.

Before breastfeeding’s modern resurgence in the mid-1970s, formula-feeding was the norm, and early modern societies lost generations of knowledge about safe breastfeeding. So reformers who brought breastfeeding back didn’t know what they didn’t know: All previous advanced civilizations had a safety infrastructure ensuring infants got enough to eat despite common breastfeeding insufficiencies. Prelacteal feeding traditions, shared nursing practices, and well-organized wetnursing professions were their common features. In most contemporary foraging societies today, newborns are breastfed by another lactating mother in the full 48 hours before their own mothers’ milk usually comes in. Starving newborns in the service of breastfeeding promotion is a well-intentioned but tragic, recent mistake. Treating jaundiced, breastfed babies with phototherapy may compound the permanent harm of this accidental neonatal starvation. It’s also not a humane response to hungry newborns.


Book Chapter in Uncertain Diagnoses Springer Book

Excited to announce the publication of the Springer volume Diagnoses Without Names: Challenges for Medical Care, Research, and Policy, ed. Michael D. Lockshin, Mary K. Crow, and Medha Barbhaiya. The book explores circumstances surrounding uncertain diagnoses, different stakeholder uses of diagnosis, and the importance of challenging prevailing norms to accept uncertainty as part of the diagnostic process.

My chapter, “Shame, Name, Give Up the Game? Three Approaches to Uncertainty,” builds on my experiences as a family member of a then-undiagnosed lupus patient and later as the head of a lupus patient support group chapter, as well as my later dissertation research on a diagnosis decision support tool (among other case studies in AI) that these experiences informed. 


Publication and a Poem

Delighted to announce my new peer-reviewed article on the neonatal jaundice-autism link, published today:Neonatal Jaundice and Autism: Precautionary Principle Invocation Overdue.” (Free full-text here.)

And a fitting poem from E.E. Cummings’ Misanthropic Moods

pity this busy monster, manunkind, 

not. Progress is a comfortable disease:
your victim(death and life safely beyond)

plays with the bigness of his littleness
–electrons deify one razorblade
into a mountainrange; lenses extend

unwish through curving wherewhen til unwash
returns on its unself. 

                                            A world of made
is not a world of born — pity poor flesh

and trees,poor stars and stones, but never this
fine specimen of hypermagical

ultraomnipotence.    We doctors know

a hopeless case if — listen:there’s a hell
of a good universe next door;let’s go


Publications, Postcards, and A Poem

This year I published a peer-reviewed article and got a book chapter accepted in a forthcoming book. The article, “Breastfeeding Insufficiencies: Common and Preventable Harm to Neonates,” is indexed in PubMed and the full-text is available here. The book chapter, “Shame, Name, Give Up the Game? Three Approaches to Uncertainty,” is forthcoming in Diagnoses Without Names: Challenges for Medical Care, Research, and Policy, ed. Michael D. Lockshin, Mary K. Crow, and Medha Barbhaiya, with Springer. 

I also made many more lovely postcards from home, this time with additional assistance. 

Here’s to a happy, healthy 2022. 

“I Heard a Bird Sing”

I heard a bird sing
     In the dark of December
A magical thing
     And sweet to remember. 

“We are nearer to Spring
     Than we were in September.” 
I heard a bird sing
     In the dark of December. 

                                –   Oliver Herford



Postcards from Home

Here are some of the postcard paintings and poems for dear ones that I’ve been making and revisiting lately.

I paint postcards
that are too beautiful and fragile to mail,
and then I mail them.
Something about the kindness of strangers.
Something about watching the ocean take back what it gave.

By Jane Hirshfield

A man tips back his chair, all evening.

Years later, the ladder of small indentations
still marks the floor. Walking across it, then stopping.

Rarely are what is spoken and what is meant the same.

Mostly the mouth says ones thing, the thighs and knees
say another, the floor hears a third.

Yet within us,
objects and longings are not different.
They twist on the stem of the heart, like ripening grapes.

“All Souls’ Day”
By D.H. Lawrence

Be careful, then, and be gentle about death.
For it is hard to die,
it is difficult to go through the door,
even when it opens.

And the poor dead, when they have left
the walled and silvery city
of the now hopeless body
where are they to go, Oh where are they to go?

They linger in the shadow of the earth.
The earth’s long conical shadow is full of souls
that cannot find the way across the sea of change.

Be kind, Oh be kind to your dead
and give them a little encouragement
and help them to build their little ship of death
for the soul has a long, long journey after death
o the sweet home of pure oblivion.
Each needs a little ship, a little ship
and the proper store of meal for the longest journey.
Oh, from out of your heart
provide your dead once more, equip them
like departing mariners, lovingly.

“God’s Grandeur”
By Gerard Manley Hopkins

The world is charged with the grandeur of God.
It will flame out, like shining from shook foil;
It gathers to a greatness, like the ooze of oil
Crushed. Why do men then now not reck his rod?
Generations have trod, have trod, have trod;
And all is seared with trade; bleared, smeared with toil;
And wears man’s smudge and shares man’s smell: the soil
Is bare now, nor can foot feel, being shod.

And for all this, nature is never spent;
There lives the dearest freshness deep down things;
And though the last lights off the black West went
Oh, morning, at the brown brink eastward, springs —
Because the Holy Ghost over the bent
World broods with warm breast and with ah! bright wings.


You would think I’d be better, for how ill I suffer fools.
But to build and to destroy seem to require different tools.


I am trapped inside 
a small mammal
on an open plain

a small gazelle
a wide, grassy plain

“The Shrine Whose Shape I Am”
By Samuel Menashe

The shrine whose shape I am
Has a fringe of fire
Flames skirt my skin

There is no Jerusalem but this
Breathed in flesh by shameless love
Built high upon the tides of blood
I believe the Prophets and Blake
And like David I bless myself
With all my might

I know many hills were holy once
But now in the level lands to live
Zion ground down must become marrow
Thus in my bones I am the King’s son
And through death’s domain I go
Making my own procession

Welcome to my country,
where we never run out of fear
and the danger of other people
is outweighed only by the danger
of being too much alone.
Make yourself at home.

You don’t need to know
everything about light
to be a passenger
on the boat of light.

You don’t need to know
everything about fire
to carry a torch
and pass it on.

Cease this constant weighing of life,
as if you knew what it was made of,
what it was meant for,
and how to measure its worth.


Everything has momentum.
Once you are breathing,
it’s hard to stop.

And once you’ve stopped?
Even harder, then,
to start back up again.

“May Day”
By Sara Teasdale

A delicate fabric of bird song
Floats in the air,
The smell of wet wild earth
Is everywhere.

Red small leaves of the maple
Are clenched like a hand,
Like girls at their first communion
The pear trees stand.

Oh I must pass nothing by
Without loving it much,
The raindrop try with my lips,
The grass with my touch;

For how can I be sure
I shall see again
The world on the first of May
Shining after the rain?


Covid @ Home

We’ve been busy for the past few days on Covid @ Home. It’s in a state where people can look at it now. Would love comments, especially if you know any doctors or nurses who would like to take a look. Translations to some other major languages are next.


Hypothetical Homunculi

There is no record of my first attempts to sketch to paint a homunculus for my dear friend Hanka the reproductive biologist, which is doubly lucky. First because they were hideous, misshapen, golem-like creatures. That’s the whole point, homunculi being strange, distorted miniatures. Think of the Mayan origin story of the first attempted humans—made of mud, so flimsy they dissolved in water. Think lumpy, living bits of clay, with hugely over-long arms or legs, lips or noses, like troll dolls or Gumby, but less friendly.

Front of Sensory Homunculus, Wikimedia Commons.

And second because that was the wrong and lesser idea of a homunculus, aesthetically and conceptually. Hanka kindly took my first sketches in stride and pointed me to Hartsoeker’s superior version, a late 17th century microscope inventor’s envisioning of how perhaps a whole human being was holding his knees already inside a single sperm—a poetic, visual version of Monty Python’s “Every Sperm is Sacred.

Preformation, drawn by N. Hartsoecker 1695, Wikimedia Commons.

I liked Hartsoecker so much, I tried being faithful to him at first…

But while I could get the feel right in the strokes, and execute on color, graphically they were all wrong.

Oils on 40 x 50 cm canvas, sadly.

When wrong, one reads. Carol Rumens had a lovely poetry piece in The Guardian recently that mentioned Bentley and Chakravatrula’s research on cell behavior making

“a good case for the hypothesis that cell activity is ‘a perception-action process.’ In other words, that cells engage in a process ‘analogous to a human moving their eyes or their heads or their bodies to create and interact with variables in optic flow.’ Cells make decisions!”

I took this as a mandate to give a sperm an eye.

Left-to-right: Atomic sperm, surveillance sperm, Hartsoeker sperm, sperm all the way down…

Hanka disapproved. She said the eye was creepy. And also that it would be more accurate to give them noses instead.

But as sperm cannot swim as well with noses, I cut off the nose to right the chase.

Something new and different was needed. Visions of double helices danced in my head. This may have something to do with Hanka’s recommendation of Jeremy Narby’s Cosmic Serpent, an Amazon anthropologist’s rendition of a DNA origin story, and how it jibed with what Shulgin theorized about the origins of life in TiKHAL (along the lines of panspermia and with a delightfully cheeky critique of evolutionary theory as faith), as well as the no less trippy stuff on horizontal gene transfer relayed in David Quammen’s The Tangled Tree. Hartsoeker’s error seems less quaint in light of Darwin’s.

Mirrors were lying around, and the art vortex began pulling them in.

Oils on canvas with mirrors.
Oils on canvas with mirrors and silver flake.
The world’s blackest acrylic paint, Black 3.0, with gold flake and gold sheets, on a set of 10 variously-sized canvasses.

At last, Hanka liked what I made. The hypothetical homunculus had become real art. And that’s the magic of creation.


Tree of Life

Oils on 100 x 120 cm stretched canvas.

Not sure if this is still just a layer… But here is some Gabriela Mistral, trans. Ursula K. Le Guin.

“Hymn to the Tree”
For Don Jose Vasconcelos

Brother tree, who grappled
to the earth with your dark hooks,
yet lift up your bright brow
in an intense thirst for heaven:

give me patience with the dross,
the clay, that nourish me,
yet let the memory not sleep
of the blue land I come from.

Tree, you who let the traveler know
the sweetness of your presence
by your cool, ample shade
and the halo of your fragrance:

let my presence be revealed
in the fields of life,
the mild, warm influence
of a creature blest.

Tree ten times productive,
of rosy apples,
of wood to build with,
of sweet-scented breeze,
of sheltering foliage,

of emollient gums,
and miraculous resins,
full of laden branches
and melodious throats:

make me opulent in giving,
so I can be as fecund as you are,
make my heart and thought
as vast as the world!


A sheet of beaten gold
and on the golden level
two bodies like skeins of gold.

A body of glory listening
and a body of glory speaking
in the field where nothing speaks.

A breath that goes to a breath
and a face that quivers to it
in a field where nothing quivers.

To remember the sad time
when they both had Time
and lived under its yoke,

in the hour of the stroke of gold
when Time’s left on the doorstep
like a dog without an owner…

“Last Tree”
A Oscar Castro

This solitary margin
that has been mine from birth,
that goes from side
to burning side of me,

and runs from my forehead
down to my fevered feet:
this Island of my blood,
this scrap of monarchy,

I bring it in my arms,
I give it back, complete,
to tamarind or cedar,
the last of my trees.

For if in a second life
I don’t get what I was given
and miss the cool
and silence of this haven,

and pass through the world
running, flying, in a dream,
I don’t want doorsteps of houses
for my refuge, but a tree.

I’ll leave it all I had
of ashes and the sky,
and the wordy side of me,
and the silent side,

the loneliness I chose,
the loneliness I got,
and the tithe I paid the glory
of my sweet, tremendous God,

my game of give and take
with clouds and winds,
and my trembling knowledge
of hidden springs.

O my true Gabriel,
so near my trembling arms,
ever before me
with branch and balm!

Maybe it’s already born, and I
haven’t the grace to know it,
or it’s the nameless tree
I carried like a blind child.

Sometimes I feel the descent
of a fresh, soft air
and see rise around me
the round trunk—there—

But maybe my dream’s already
clothed in its leaves,
and I’m dead and don’t know it,
singing under my tree.



I love the idea of cosmetic x. It started with the suggestion of cosmetic psychopharmacology as a lipstick in pill form that you can put on the pig of a despairing brain:

Cosmetic psychopharmacology is not unlike cosmetic surgery. As more women get breast implants, the rest of us feel flat chested. And so it is with more women taking antidepressants and antianxiety medications. Suddenly you’re the odd one out if you aren’t like your friends, taking something to ‘take the edge off’ or give you a little lift to withstand the slings and arrows on your journey.

Dr. Julie Holland, *Moody Bitches: The Truth about the Drugs You’re Taking, the Sleep You’re Missing, the Sex You’re Not Having & What’s Really Making You Crazy* (p. 17).

Of course there’s not only cosmetic psychopharmacology, but also cosmetic psychology—a term I’m surprised it doesn’t seem anyone has yet applied to positive psychology. Positive psychology is the American-dominated field seeking to convince people with shitty quality of life in a failing empire (or two) that making gratitude lists is their salvation. (Some of its major players are known for being embroiled in contentious politics beyond that as well, to say the least.)

And then there’s cosmetic politics, the make-believe choice of legitimate government in a regime that is not.

In 2014, political scientists Martin Gilens and Benjamin Page, in a study published in Perspectives on Politics, empirically established how average U.S. citizens are almost completely ignored by U.S. governmental authorities in terms of public policies. Reviewing U.S. public opinions of policy issues, along with examining 1,779 different enacted public policies between 1981 and 2002, they determined that ‘even when fairly large majorities of Americans favor policy change, they generally do not get it. They conclude, ‘The central point that emerges from our research is that economic elites and organized groups representing business interests have substantial independent impacts on U.S. governmental policy, while mass-based interest groups and average citizens have little or no independent influence.”

When dissent—be it through public opinion polls, protest demonstrations, or otherwise—becomes impotent in changing policy, this is an indicator of living under authoritarian rule.

Bruce E. Levine, *Resisting Illegitimate Authority: A Thinking Person’s Guide to Being an Anti-Authoritarian—Strategies, Tools, and Models,* p. 238

You could call this form of government plutocracy (rule by the wealthy) or kleptocracy (rule by corrupt, self-enriching networks)… And you could call the elections that ostensibly validate it as somehow democratic (in spite of the evidence to the contrary), masturbation (as George Carlin does) or kabuki theater (as American pundits often do). But really the appearance of ritualized consent in the form of electoral process to legitimate fundamentally anti-democratic systems of power is cosmetic politics. It just seems more correct and less innately derogatory than the other terms. It’s not the real exercise of power; it’s the lipstick. You don’t need insults, obscure referents, or Marxist terms like false consciousness, to describe it.

And to say something is cosmetic is not innately an insult. All personification in literature is cosmetic. “I bowed my head, and heard the sea far off / washing its hands”—James Wright, At the Slackening of the Tide. “It was not Night, for all the Bells / Put out their Tongues, for Noon”—Emily Dickinson, “It was not Death, for I stood up.” And still another, all from the same source:

“The yellow fog that rubs its back upon the window-panes,

The yellow smoke that rubs its muzzle on the window-panes,

Licked its tongue into the corners of the evening,

Lingered upon the pools that stand in drains,

Let fall upon its back the soot that falls from chimneys,

Slipped by the terrace, made a sudden leap,

And seeing that it was a soft October night,

Curled once about the house, and fell asleep.”

(T.S. Eliot, The Love Song of J. Alfred Prufrock)

Mary Oliver, *A Poetry Handbook: A Prose Guide to Understanding and Writing Poetry*, p. 103-4.

Something that is cosmetic is on the surface and improves the appearance but not the substance—definitionally. Maybe such a thing does not really exist in people and societies though, because organisms react to stimuli (see all of Stimulus-Organism-Response psychology and physiology, e.g., Porges)… Maybe even purely cosmetic acts tend to have substantive feedback loops, and so not be purely cosmetic at all. Certainly in literature and art, the medium is the message; the surface is part of the substance in a way; and the idea of anything in poetry being “cosmetic” seems odd, like a modernist misunderstanding of why we make useless pretty things.

There is something useful in humanity, self-expression, truth that is also beautiful, the right shade of lipstick with a nice dress. Although I will be the last person to defend cosmetics in the psychopharmacology, psychology, and political contexts, I seem now to have put myself in the position of admitting (at least) that we live with them. We co-exist with those who alter appearances to maintain unhealthy and unfair status quos—and we are even, in some ways, the same. Unless we manage to actually change things.

Of course, this is only what artists and humanists always do. See a bogeyman and relate to him, and try to drag others along, too. The paradox of liberal democratic societies: accidental corporatist empathy edition…


Initial and The Voices

It’s been a while since I painted Rilke

Acrylic on canvas.

By Rainer Maria Rilke
From The Book of Images
Translated by Edward Snow

Let your beauty manifest itself
without talking and calculation.
You are silent. It says for you: I am.
And comes in meaning thousandfold,
comes at long last over everyone.


Gieb deine Schönheit immer hin
ohne Rechnen und Reden.
Du schweigst. Sie sagt für dich: Ich bin.
Und kommt in tausendfachem Sinn,
kommt endlich über jeden.

Gouache, acrylic, pencils, and pens on paper.

“The Voices”
Nine Leaves with a Title Leaf

Title leaf

The rich and the fortunate can well keep quiet,
nobody wants to know what they are.
But the destitute have to show themselves,
have to say: I am blind
or: I am about to become so
or: nothing on earth works out for me
or: I have a sick child
or: right here I am pieced together…

And perhaps even that won’t suffice.

And since otherwise people pass by them
the way they pass things, they have to sing.

And the songs you hear there can be really good.

True, human beings are strange; they’d rather
hear castrati in boys’ choirs.

But God himself comes and stays a long time
whenever these maimed ones bother him.

“Die Stimmen”


Die Reichen und Glücklichen haben gut schweigen,
niemand will wissen was sie sind.
Aber die Dürftigen müssen sich zeigen,
müssen sagen: ich bin blind
oder: ich bin im Begriff es zu werden
oder: es geht mir nicht gut auf Erden
oder: ich habe ein krankes Kind
oder: da bin ich zusammengefügt…

Und vielleicht, daß das gar nicht genügt.

Und weil alle sonst, wie an Dingen,
an ihnen vorbeigehn, müssen sie singen.

Und da hört man noch guten Gesang.

Freilich die Menschen sind seltsam; sie hören
liber Kastraten in Knabenchören.

Aber Gott selber kommt und bleibt lang
wenn ihn dieseBeschnittenen stören.


The Anti-Cogito

Spring painting continues.
“The anti-cogito.” Acrylic, pencils, ink on stretched canvas. Straight lines read “Cogito ergo sum falsus” (repeating), while wavy lines read “Je me sens donc je suis.” A repudiation of Descartes in line with modern decision-making science.
“Cogito ergot [sic] sum falsus.” Gouache and acrylic on paper. Almost in time for bicycle day.
“Cogito, ergo sum falsus.” Acrylics and ink on canvas. Wavy lines at top quote in red from Stephen Porges’s The Pocket Guide to the Polyvagal Theory: “In a critical sense, when it comes to identifying safety from an adaptive survival perspective, the ‘wisdom’ resides in our body and in the structures of our nervous system that function outside the realm of awareness” (p. 43). Way lines in the middle in purple: “In contrast to reptiles, mammals have two vagal circuits: an unmyelinated vagus shared with reptiles and a uniquely mammalian circuit that is myelinated. The two vagal circuits originate in different areas of the brainstem” (p. 62-3).
“Je me sens, donc je suis.” Gouache and mirrors on paper.
“She rides through lavender fields,” gouache and mirrors on paper.
“Lavender fields,” gouache and mirror on paper.

So birth control might cause depression, but could it also cure it?

Depression is a big deal. Over 300 million people are affected globally, it’s THE leading cause of disability globally, and it affects lots women more than men (2x for unipolar depression). Being depressed is bad for your physical health as well as your quality of life, although we still don’t understand a lot about the reasons for the inflammation that characterizes depression and its physical health correlates like heart disease. Sad. Let’s turn depression off.

Pregnancy is also a big deal. It carries a lot of serious health risks and costs, and then at the end of it you have this whole new person to keep alive for quite some time, and they are basically the worst room-mate ever but you can’t legally kick them out. Tough. Let’s prevent pregnancy.

Ok, so we’re turning depression off cos it’s sad and preventing pregnancy (at least until we don’t wanna prevent it anymore) cos it’s intense. You’d think preventing pregnancy might even help turn depression off, since not being able to do the whole baby thing perfectly seems like it could be quite stressful, and no one can do it perfectly. (Plus the not knowing if you’re pregnant can also be quite stressful.) Stress gone, mental health better! Right?

Wrong. Or at least, that’s not what you see in the wonderful world of birth control…

The Paradox of Birth Control and Depression

Birth control should be good for women’s mental health because it relieves stress by reliably preventing pregnancy. Yet studies link birth control (in the form of hormonal contraceptive pills) to depression in some women. These studies are observational and that annoys me. Now here are three useless paragraphs on why I find that so, so very annoying.

Experiment Better, Dammit: An Annoyed Interlude

There is no readily apparent reason why we don’t have better data on this and lots of other things that people experiment with by themselves all the time. It’s just because no one has yet bothered to code, fund, and organize a platform to allow people to set up and run their own experimental studies or participate in other people’s. Then we could turn lots of individual experiments into much more scientifically powerful experimental data. All this good experimenting is going to waste! Stop that. Experiment in a structure with other people, with basic infrastructure for things like open data in place from the start. Please?

Probably the results couldn’t be published in many peer-reviewed journals or presented at conferences. But independent researchers work outside of those constraints all the time. If you want to measure a genocide in a war zone through snowball sampling, or some other risky project no IRB would approve, then your best bet is probably to go do it and then take the results public. We live in a world where, for better and for much, much, worse, people can put whatever they want on the Internet (limited time offer, some restrictions may apply). And you know what? Making citizen-scientists the experimental practitioners and putting the data out there automatically might prevent a lot of fraud (or just bad science) that results from perverse incentives in academia and publishing (not that industry is any better). Most published research findings are false, but a truly open science platform could help change that.

It’s not quite so simple as “the truth will out” (cf fake news). But we could and should have a big open platform where people can just do good science together including experiments on lifestyle, diet, birth control, and these sorts of things. Otherwise we end up with only observational data on these really important issues for everything, and that’s dumb. But the platform solving this problem doesn’t exist and I can’t code it. That’s why we’re faced with this ongoing depression-birth control mystery among others…

The Antibaby Pill Blues

In Germany, they call “the pill,” the anti-baby pill. I love this because it is so German. It says what it means that Americans (indeed most Anglophones) would never come out and say. Are you anti-baby? Fine. Take this pill. It’s an antibaby pill. You know what it does. Done.

In Scandinavia, they do data. The state tends to collect a lot on citizens from birth to death. So their medical databases are awesome. Thus, when you see this Danish observational study linking antibaby pills (or rather, hormonal contraception) and depression, you know these people are serious and this is good data. Not experimental data (twitch, twitch). But good data. And this is basically the finding you see in a lot of studies, but this one is methodologically the strongest of the lot afaik.

But wait, the plot thickens. Not every study on birth control and depression reaches the same conclusions. For instance, an American study found no association between taking the antibaby pill and depression among adolescents. But this study relied on self-reports, unlike the Danish study which used data from registries. So respondents could have lied or, with deference to Harper Lee, been mistaken in their minds. That would be especially true if the effect size at issue were small, and so a small measurement error could make it disappear.

The effect size at issue is small. Some estimates put the rate of depression caused by the antibaby pill at 1%. It also might be relatively difficult to measure this small effect size in a smaller sample. And indeed, the sample size in the American study is under 5,000, versus over a million in the Danish study.

Ok, so there are discrepant findings from observational studies. But overall it seems like the risk of hormonal birth control causing depression is small but real. So in terms of statistical significance, it’s not surprising that smaller studies on subgroups are missing the effect; that’s probably why you see some discrepant findings. But practically, that 1% still matters. Hormonal birth control is really commonly used, and 1% of a million is 10,000. Those 10,000 women’s mental health matters. It matters that a common medication/birth control practice could be contributing in a non-negligible way to one of the world’s biggest public health problems. And this is also just really bad news for women in general, if basically their best birth control option (for a lot of people for a lot of reasons) carries a risk of screwing up their brains, quality of life, and bodies (to the extent that depression is really a total-organism problem featuring chronic low-grade inflammation).

But wait, there is a conspicuous problem here.

It’s the Hormones, Stupid

Depression is a mental health problem that sometimes creates or contributes to mental health crises that sometimes result in psychiatric in-patient admissions. That is a proxy measure of people who are not just depressed but in freefall (and not willing/able to talk their way out of it, or too socially isolated to be plugged into help, or whatever). And there is a big fat under-discussed gender effect on that subgroup of bad outcomes within bad outcomes.

In Ayelet Waldman’s A Really Good Day, she mentions that the majority of female in-patient psych admissions happen during the week prior to menstruation. (And this is the first time I’ve seen this discussed in public, illustrating how her work is so taboo-shattering and important.) Hormones can really, really fuck you up.

This is not only a female problem. We know that boys and men tend to be more violent and experience more violence from other men as well (in the form of things like assault and homicide; clearly the gender numbers change with things like domestic violence and sexual assault). We know that testosterone is a contributing causal factor in these patterns of violence. It also seems to contribute to the much higher successful male suicide rate. I am too lazy to link to all these findings, but by all means look them up yourself using the Force, Luke.

So hormones cause big problems for all of humanity, but… That’s not cool to say. Seriously. Talking about how hormones (especially sex hormones) influence behavior and mental health is still, somehow, largely taboo.

The weirdly obvious problem in the studies I’ve seen so far linking hormonal birth control to depression is that they ignore this cyclical nature of women’s mental health. Studies on birth control and depression need to assess whether women are seeking treatment for depression more outpatient (which makes it look like they have 1% higher depression risk or so on the anti-baby pill)… Rather than having in-patient admissions. Or if there is some other story with respect to the intensity of the problem (in-patient admission or not) versus the persistence. There are a few possible stories.

Cry Me a Quiverful

To be more precise, there are three categories of possible stories here.

  1. Women on hormonal contraception are more depressed than women who are not.
  2. Women on hormonal contraception are not more depressed than women who are not.
  3. Women on hormonal contraception are depressed in a different pattern than women who are not. That pattern may or may not reflect a qualitative difference in depression type or presentation which would make it hard to characterize in a binary way (i.e., antibaby women are or are not more depressed than other women).

If the first is true (antibaby pill depresses a small % of women who take it), we don’t only want to confirm it. We want to know why that is. Here are a few hypotheses.

A. The scientific literature is suggestive that maybe there are differences across the menstrual cycle in how stable, smart, and creative women are. (More on this later and thank you, Frau Doktor Obvious.) So naturally there is probably fluctuation in functioning across various important arenas that keys into fluctuation in hormones. Perhaps hormonal antibaby measures help to level out higher cognitive-emotional highs and lower lows. So women on birth control who are depressed experience a more even (and thus possibly more persistent, depressed) state than their non-hormonally medicated counterparts who would sometimes feel great but at other times feel bad enough that they get admitted to the psych ward. (That would be measurable if you asked women how they were doing while tracking their cycles, which existing fertility tracking apps are capable of doing… except usually women on the pill don’t use those apps, and anyway it’d be better to get experimental than observational data if possible.) Let’s call this the boom and bust hypothesis.

B. Could also be that some women are sensitive to the synthetic hormones used in hormonal birth control in a neuropsych context. They could have a kind of inflammatory, autoimmune, or allergy-related reaction. We know depression is characterized by chronic low-level inflammation, and not much more about that facet of it. But that could be a hint of a mechanism linking birth control and depression. Call this the inflammation hypothesis.

C. Could also be that mimicking pregnancy (which hormonal birth control does in a way) without actual pregnancy makes women sad cos their bodies / brains know they’re not really pregnant. I don’t know how this would work, it’s just an idea. Organisms are not stupid and this hypothesis could also include super-simple mechanisms like the obvious psychological one—some women really want kids but take birth control anyway, and that’s depressing. Call this the missing pregnancy hypothesis.

D. Come to think of it, could be that delaying/preventing pregnancy overall changes the modal state of fertile adult women from pregnant/lactating (majority of the time) and fertile (minority of the time due to pregnancy/lactation), to non-pregnant and non-fertile. That changes a lot of things, not just the stuff the birth control itself directly rejiggers. For instance, it changes lifetime exposure to estrogen, and it looks like that affects Alzheimer’s risk. (Pregnancy appears to be protective against Alzheimer’s— so this story might also jibe with the inflammation hypothesis. Since inflammation is implicated in depression and Alzheimer’s alike, although we don’t begin to know the causal arrows in either case.)

So… How many women’s doctors have told them that the pill increases some cancer risks as well as depression? How many women’s doctors know that decreasing lifetime fertility can adversely impact Alzheimer’s risk? With rare exceptions, these things are just not discussed in general care settings. We have been engaging in a big medical-social experiment without fully informed consent. This is outrageous. Except this happens all the time and it’s called modern medicine.

Most people would probably still make the trade-off between their best birth control method today, and fewer kids in 1, 5, and 10 years. But that’s not a trade-off we’ve explicitly made. The lifetime medical implications for women of having effective birth control may be non-negligible even as the lifetime professional and personal implications for women and society of women having effective birth control are so staggering that we don’t need to do the math to know the score. It’s not fair but it’s true, and no one talks about it. The impact of that silence is that we don’t get more needed research on what in the world is going on here.

Anyway, let’s say previous female generations’ greater cumulative lifetime pregnancy exposure was protective against depression, or inflammatory processes that correlate with and might both cause and be caused by it, or something else that matters here. Call this the my once-starving Romanian great-grandmother was perfectly healthy after having seven kids without ever being offered a condom, but I’m allergic to everything despite having great medical care, hypothesis. Wait, that’s too long. Ok, the cumulative pregnancy exposure hypothesis.

That’s plenty of hypotheses. But those only deal with the depression effect if it’s real. What if it’s not?

What if women on the pill are just more plugged into medical care, and so it looks like they’re more depressed cos they get more depression diagnoses and treatment cos they’re getting more medical care? The healthcare access hypothesis.

What if women on the pill just think they’re more depressed for some reason even though they’re not? Could be a nocebo effect, and this is not without precedent in this context. Lots of women believe that hormonal birth control causes weight gain, when really the passage of time correlates with weight gain (we think). They are just looking for a reason for the weight gain, or a visible effect of the birth control, or both. Could also be women on the pill think they’re more depressed but are actually not, because they’re just thinking about themselves and their mental states more because of some sort of self-selection that underpins the decision to take antibaby measures. Or they just expect bad effects, so they see them (expectancy effects). So this is the something is wrong with me hypothesis… or, perhaps snappier but less politically correct, the hysterical women hypothesis.

I dislike this hypothesis precisely because it keys into stereotypes about hysterical women making up problems. But… There is some support for it in the literature. But that support contradicts other findings in the literature. Hormone levels do so affect cognitive and emotional functioning according to lots of research. (It’s also obviously true.) So it’s really weird to come across papers denying that.

What’s up with this apparent scientific support for the idea that hormonal birth control’s apparent deleterious psychological effects on some women are psychogenic or psychosomatic? And if this question was settled back in 2004 at the latest, then why does research to the contrary persist? The review article in the penultimate link says:

Seven small randomized-controlled trials were found in a review of the literature which studied this hypothesis [i.e., emotional side-effects of hormonal contraceptives come from pharmacologic versus psychological mechanisms] in a direct way. They do not support the origination of these side effects being from the pharmacological properties of hormones. No association was found between hormone levels and emotional functioning in females.

Stephen A. Robinson, Matt Dowell, Dominic Pedulla, and Larry McCauley, “Do the emotional side-effects of hormonal contraceptives come from pharmacologic or psychological mechanisms?” *Medical Hypotheses*, Vol. 63, No. 2, 2004, p. 268-273

Wait… What? What exactly were those studies saying that hormone levels don’t affect women’s emotional functioning? Who funded them? How many subjects did they have? Is there any clue about why their findings apparently contradict a lot of other research out there, while supporting the hysterical women hypothesis that psychological effects of hormonal birth control are all in women’s heads?

Luckily, these questions are easy to answer because when you go from the marvelous free database that is PubMed to the publisher’s website for this article, the relevant PDF is available for purchase from ScienceDirect for $35.95. Because academic publishers are evil and Aaron Swartz is dead. It’s almost like one set of institutions (academic publishing) colludes with another (academia) to hold a grip on information the public has mostly already paid for (with tax money to science and education), because profit is all they care about.

Hey, I know. Maybe women on the antibaby pill are more depressed than women not on it because they spend less time worrying about getting knocked up or finding non-toxic fingerpaints, and more time thinking about the state of the world.

Moving on, what if the depression effect is real but not? What if antibaby women’s depression is just occurring in a different pattern than that of women who aren’t on hormonal birth control? This possibility is almost the same as the very first, the boom and bust hypothesis. It’s just a little more generally formulated, and it recognizes that the hypothesis doesn’t necessarily belong in the “this link is real” hypothesis category. That categorization assumes too much. But for simplification purposes let’s just going to collapse this last possibility into the first and move onto theoretical moorings and empirical possibilities for testing these hypotheses.

Theoretical Support

One could think of additional theoretical support for each of these hypotheses. But that would take way too long for a random blog post. Instead I brainstormed ways to test each hypothesis instead because that’s fun.

It’s also arguably logical here because any information we glean about possible causal mechanisms supporting one theory over another from experiments testing each theory is bonus; any new information about this mystery is valuable. It is so crazy that we have been running this huge social experiment of hormonal birth control for roughly half a century… And don’t have some of these really basic questions answered about how it affects mental health.

Experimental Fantasies

Recap: In the world in which the depression-birth control link is small but real, we need to consider the boom and bust, inflammation, missing pregnancy, and cumulative pregnancy exposure hypotheses. In the world in which it’s not, we need to consider the healthcare and hysterical women hypotheses. There is an in-between world in which the link is qualitative, the real story is about different patterns or manifestations of depression rather than quantitative changes in depression incidence itself. But we are ignoring that world because it kind-of fits into the first world alright for now, under boom and bust.

These are my favorite study ideas for moving this puzzle forward in as compact and comprehensive a fashion as possible. They run from observational to experimental and easier to harder, and ideally one would do it all. But in reality, probably no one will do any of these things.

First, one would want to test inflammation by comparing serum levels of standard inflammation markers like ESR and CRP in hormonal birth control and non-hormonal birth control groups containing depressed and non-depressed women. Ideally this would be experimental data, but in practice you’re getting observational data and it already exists. Someone just needs to look at the Danish registries’ data again, or another Scandinavian state work of data art. It would be really interesting to include in the study some autoimmune response markers if possible, even just the most general ANA. Since inflammatory, allergic, and autoimmune responses share correlates, might exist on a spectrum in some ways, and are all seemingly increasing in modern life, particularly in the realm of autoimmune diseases for women.

(It might also be interesting to see if there are “time capsule” samples one could cross-reference to check changes in these markers over time—like was done to show rising incidence of celiac, to test for changing base rates of inflammatory markers. But that’s less likely to be possible in women’s health research specifically, since women weren’t well-represented in the armed forces 50 years ago—the celiac samples came from the Air Force… And female subjects who can at all possibly get pregnant are still not all that well-represented in medical research studies today. Women’s bodies are considered riskier and so research on women’s health suffers… At least until more women are in charge of it in a way that lets them freely choose to experiment on themselves.)

Another cool thing one could do with good, big observational data like this is look at cumulative pregnancy exposure and related outcomes broadly conceived, like depression diagnosis, suicide (an extreme proxy measure of depression, one might say) and some pre-determined hunk of problems associated with inflammation (qua depression correlate). This would go some way towards testing the inflammation and cumulative pregnancy exposure hypotheses.

The remaining hypotheses seem like they would be best tested through experiments. To see what’s in the realm of possible there, I looked back at this great study on mifepristone (aka the abortion pill). Researchers studied the effects of low-dose mifepristone on the endometrium of 90 women for six months. They found mostly suppressed ovulation and menstruation. No menstruation is a huge health benefit for most women.

They also found no pregnancies. That is a high efficacy rate for birth control, although of course more research would help better assess how effective and under what conditions compared to which alternatives this method really is.

And they found “Because follicular development is maintained, the endometrium is exposed to estrogen for prolonged periods unopposed by progesterone.” I’m not sure what that means, but it sounds like it involves overall less tinkering with natural hormonal balance than any hormonal birth control. That could be good, could be bad, we don’t know yet (afaik).

But we do know a few useful things from this awesome study that has probably not gotten enough play just because people are afraid to try new things and mifepristone/misopristol are associated with (gasp!) abortion. First, there is already a viable alternative to hormonal contraception that appears to be equally effective, non-invasive, temporary, and safe. It’s just not in wide use at all, and it’s not clear why.

Second, six months apparently qualifies as long-term on PubMed (… but not on OkCupid).

And third, it’s now ok to call amenorrhea (the medical condition of not getting your period) a health benefit. This seems like some form of progress. It’s often said that their creators put a dummy week in earlier hormonal birth control pills in order to reassure women they weren’t pregnant by giving them withdrawal bleeding. But now we have easy access to early pregnancy tests, we know regular periods are not necessary for women’s health, and it’s become ok to say in a scientific journal that not getting regular periods would be great, would be a health benefit, without hedging about the valence of this. So that seems cool. Medicine tricks women less, women’s quality of life improves, and one more gender taboo shatters.

Why not build on this mifepristone research by pitting low-dose mifepristone against low-dose progesterone-only hormonal birth control (the best tolerated and least risky for most subgroups of current antibaby pill formulations) in a randomized controlled double-blind trial to see how depression incidence compares across groups? That’s not a meaningless rhetorical question. It’s actually a really important one. Because holy shit, mifepristone has also shown promise in rapidly reversing psychotic depression.

This finding might make sense as an inverse corollary to the antibaby-depression relationship, since most hormonal contraception uses (at least) progesterone, while mifepristone’s mechanisms include progesterone receptor antagonism. So progesterone and mifepristone are sort-of opposites in one of the ways they work on hormones. So it makes sense that if progesterone causes depression in 1% of women, then a chemical that screws with progesterone receptors could similarly decrease depression in some small percentage of women.

The prevalence of depression with psychotic features is also in the neighborhood of 1%. That fits. So we really want to see low-dose mifepristone and low-dose progesterone pitted in an RCT to see if depression, and especially psychotic depression, decrease in the former at about the same rate that they increase in the latter. Because that would potentially solve the puzzle in a mechanistic sense while also solving it in a practical sense. Or at least, it would strongly suggest that women who do poorly on progesterone should try mifepristone instead—and that instead of making their lives worse (more depression) while making them better (antibaby), it might make their lives better (less depression) while making them better (antibaby). Isn’t that what medicine is supposed to do?

I hope I’m wrong about the politics of all this, and this experiment has already been done or is in progress / planning. But I’m afraid we’re not getting this mifepristone v. progesterone RCT. Probably it hasn’t happened yet because people are afraid of new things and “the abortion pill” is controversial. That is stupid and wrong.

You might say well, the design is perfectly feasible, the idea is promising, and so this will probably be executed somewhere abortion is less controversial in the next 10-20 years. But then you would not be looking then at mifepristone’s history of being pulled from the German market for not being profitable. For all the wrong reasons, there is not good current access to and further research on “the abortion pill,” which probably should be better known as “the birth control pill that doesn’t occasionally give you depression or cancer.”

Here is a less feasible mifepristone RCT design: Treatment group gets standard hormonal contraceptive, control group gets no active birth control but takes a dummy pill instead. Plus everyone gets a nice dose of mifepristone/misopristol to induce abortion every month in the event of pregnancy. This would test the missing pregnancy hypothesis that it’s fooling the body/brain/organism into thinking it’s pregnant when it’s not that makes some women depressed on the antibaby pill. Because they would actually be probably pregnant, but aborting every month (or every three months on average), instead of discovering it.

On one hand, if you see no increase in depression in the pregnant and aborted group, but you do see increased depression in the hormonal birth control group, then it looks like support for this hypothesis. On the other hand, this is a terrible idea. Are blindly, temporarily pregnant women really the right control group here? There’s not a better option. But it also seems obvious that the hormonal changes of early pregnancy will be more depressing than the hormonal changes of being on hormonal birth control. So you can’t really test the missing pregnancy hypothesis with this design. Maybe you can’t test it adequately with any design. You also can’t test the cumulative pregnancy exposure theory adequately with this design, cos month 1 of pregnancy repeated represents a different cumulative hormonal exposure than months 1-x repeated. (There might also be a few minor ethical issues in a study that intends to let some women get pregnant and then quietly give them abortions without informing them at any step per se, nbd.) 

A more feasible (but still not terribly feasible) RCT design: women are randomized to be on and off hormonal birth control, with the control group blinded with dummy pills. They do daily (or maybe 3x/weekly is enough) real-time cognitive and emotional check-ins regarding mood and body temperature to test the boom and bust theory. Everyone uses a back-up, non-invasive birth control method like condoms. This seems totally possible with current tech, in terms of having a smart-phone app asking women questions regularly and getting them to answer in real-time, more or less.

This study is still not terribly feasible for two reasons. First, because no one is going to be on birth control and use condoms at the same time, right? Maybe someone would do it for science; but then again, maybe they shouldn’t. The hassle is just so much larger and the potential pay-off so much smaller than in the mifepristone v. progesterone RCT. But… If people would do it, then maybe we would learn whether hormonal birth control really causes depression or just levels out normal mood fluctuations over the cycle. Second, the real reason this study hasn’t happened and is unlikely to happen anytime soon is that no pharmaceutical company seems likely to profit from its results either way. Unless I’m missing something and it’s all been done?

One could similarly envision a study doing real-time cognition/mood checks on women using hormonal birth control and women with no birth control access. That would test the medical care access hypothesis. But it would also be hugely unethical because honestly, if you’re talking to women without birth control access, it should be to help them have better healthcare and not to study how that lack of access affects their mental health.

So what about a volunteer study running “long-term” (six months) that just asks women to let themselves be randomized to different established birth control methods? Hormonal (treatment) or other (control). If you really wanted to standardize it, you could specify low-dose progesterone and copper IUD since those are probably the least risky and most effective options in the best-established hormonal and non-hormonal groupings of options. And of course match the groups on relevant measures like prior depression. On one hand, surely this has been done. On the other hand, there is such a crazy amount of basic research that has not been done in a sound way when it comes to women’s health.

In part this is for nefarious reasons having to do with profit and sexism. But why turn to those explanations when there are also completely innocuous ones staring us in the face? Other people and institutions have been afraid to experiment on pregnant women or women who could become pregnant, for fear of doing harm. That is a good and appropriate fear. As an unintended consequence, however, this pattern harms women when we wind up with less informed choice on important medical/lifestyle issues.

But women are (in some countries and contexts) allowed to experiment on themselves. It’s possible to access both low-dose mifepristone and low-dose progesterone in a lot of places. And it’s possible to participate in a study with other people who can access them, too. So the best study I can think of to address the birth control-depression paradox is unlikely to be run in the usual way anytime soon, but maybe it can happen anyway…

I didn’t mean to come back to this, but now it makes the most sense as a closing. I really hope some badass, somewhere, someday will code an open science platform that helps more people design and participate in more research. (Or does this already exist?) It would be like Reddit for methodologists, or an interactive XKCD for nerds. (Oh wait, that’s XKCD.) There are just too many unanswered questions, and too many smart people out there willing to help answer them… with a little (structured) help from their friends.