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Sometimes things just come together in the most marvelous way. Taking a break from my ongoing (and perpetual) study of what I do to justify my existence (and pay the rent), I discover that there’s NEWS – now bear with me, as these items seem distinctly unrelated…at first. But I won’t leave you wondering about the connection –

Coffee linked to lower risk of death – “A study finds that older adults who drink java are less likely to die than those who don’t. Subjects who averaged four or five cups per day fared best, though it’s not clear why.” A bet: the study says its not the caffeine, as those on decaf do as well as those on the livelier stuff, so, say I, it’s clearly the polyphenols in the coffee. There, wasn’t that easy?

Italian university switches to English – “…one of Italy’s leading universities – the Politecnico di Milano – is going to switch to the English language. The university has announced that from 2014 most of its degree courses – including all its graduate courses – will be taught and assessed entirely in English rather than Italian.” Well, sure. English is already the international language of science, and of business. They want their classes to address the world as it is and as it is becoming, and for their students to be ready to live and work in that world.

Whites Account for Under Half of Births in U.S. – “After years of speculation, estimates and projections, the Census Bureau has made it official: White births are no longer a majority in the United States.” I guess that means that salsa really isn’t a fad. I’m so grateful.

So…”they” are taking over our language, and “they” are taking over our country, and soon we’ll all look like what we drink – if we want to live long and prosper in this fine new world.

Maybe now (well, eventually…) we’ll all have some peace.

The main thing I worry about is whether or not there will enough coffee for all us. As greed-and-ignorance-propelled climate change causes warmer and warmer temperatures in the higher elevations where good coffee is grown, there will be less of it. We could fight about this, but when we all look the same, who will we fight? Maybe those who can afford the coffee because they haven’t been paying those who grow, harvest, transport, and market it what their labor is really worth.

Ah, but there’s a solution for that, isn’t there…

(And we’ll also need to do some clever plant breeding to build a more adaptive coffee tree. Hmm…if we can do that to the coffee tree, might we also build a more adaptive culture, so we don’t have to continue “…consuming resources at a pace that is 52 percent faster than what the Earth can renew“? Let’s get the coffee thing fixed first. We’re going to need all we can grow – to deal with that other thing, not to mention all the denial that’s keeping us from dealing with ANY of it!)

[NOTE: This post is a work-in-progress, posted here to make it available at the earliest opportunity to a number of interested individuals. I will soon be adding more content, sources, and references. Meanwhile, the core of my argument is decently laid out, and will be, I should hope, informative. ~t.c.]

For years I have watched the psychiatric community’s increasing interest in bipolar disorder[1] (BD). Once a mysterious,  troubling, and untreatable phenomenon, it has become the ideal psychiatric illness: it’s apparently organic in origin, it responds, often well, to a variety of medications, and appropriate diagnosis and treatment often leads to highly significant restoration of functionality for afflicted individuals.

This affliction, major in its impact on an individual’s ability to live and work successfully and with the appearance of normalcy, shows us just how powerful and useful modern psychiatry has become.

During approximately the same time, one of the most perplexing and disruptive of the personality disorders[2] has also been receiving increasing attention, although not from psychiatry, which has had little to offer it: borderline personality disorder[3] (BPD). In 1993, clinical psychologist Marsha Linehan published documentation of her research validated treatment program for BPD. A first, it has since been joined by other validated approaches.

There is, however, a back-story to all this – several of them, in fact. I will focus on two: the transformation of psychiatry into a role with diminished significance in the mental illness treatment community, and one probable consequence of this: the very real problem of misdiagnosis of both bipolar disorder and borderline personality disorder.

Back-story #1: Psychiatry, once dominant in mental illness treatment, becomes second-fiddle

It is a little hard to believe, in our time, that in the recent past the application of psychology to problems of mental illness was all but non-existent. If one had a “mental illness”, and there was not an obvious and treatable organic cause, one got psychotherapy (if it could be afforded) from a psychiatrist. But there were three problems with this services delivery model, all contributing to the demotion of psychiatry as the primary source of research and treatment services in mental health:

Problem 1: Psychiatrists were (and still are) necessarily expensive. The training of a psychiatrist was and is long, arduous, and expensive: after attaining an MD or equivalent, one did a multi-year residence in psychiatry, which itself involved training in two only casually related fields: psycho-pharmacology and psychotherapy. When finished, there were training expenses to be recouped, and ostensibly valuable services to be offered, at a price which would be expected to reflect their supposed value.

Problem 2: Psychiatric psychotherapy was not grounded in science… In the 1940s, 50s, and 60s, psycho-pharmacology didn’t amount to much, which more or less eliminated one of the hurdles would-be psychiatrists had to cross. Psychotherapy itself was dominated by the psychoanalytic, psychodynamic, Jungian, and other largely European and Freudian-derivative theoretical orientations, which were all busy distinguishing themselves as bastions of theory, not science. Psychiatry of this time presents the curious picture of individuals who have received some of the best scientific training available anywhere embracing a body of learning rooted almost solely in anecdote and experience with clinical populations who representativeness of the larger population of individuals needing professional attention was unknown and of no apparent interest. Psychiatry was functioning more like religion, or philosophy, than anything resembling an empirical science.

Problem 3: …Consequently, psychiatry got modest results, at best, and with only a few disorders. However, this problem was about to addressed by a different breed of service provider. Experimental psychologists, working in the fields of learning and cognition, were busy distinguishing themselves as bastions of science, with the result that well-grounded systems-models of brain function were developed which could be fruitfully applied to multiple species, including the human one. Applications of these models began to get results where before there had been little – with prison populations, addicts, conduct-disordered adolescents, back-ward chronically mentally ill individuals, and even the ordinary “worried-well”.

This was all accomplished with new, previously unseen levels of efficiency in delivery of treatment services, and without the burden of the opaque, obfuscated psycho-analytic, -dynamic, or -whatever theory, which was still being thrust at psychiatric residents in the medical schools and hospitals as the supposed best thinking that was available in the field.

To put it as clearly as possible: in outpatient settings, and at times in inpatient ones as well, psychologists were clearly getting better results than classical psychiatry, more quickly, and at a service-delivery-hourly-cost significantly below that necessarily charged by psychiatrists. Psychiatry was in trouble, and there was no obvious solution to the threat posed by emergent clinical applications of research validated models of mental function emerging from experimental and cognitive psychology.

A national response: modern clinical psychology is born. These results psychologists were getting got noticed. After World War II ended, it was apparent to the US Government that thousands of returned servicemen and women needed help that couldn’t be provided either by physicians (because their dis-ease was not fundamentally organic), or psychiatrists (because there weren’t enough of them, and they weren’t basically affordable anyway). Clinical psychology DID exist, but the cohort of professionals was breathtakingly small.

So, the US Government did what governments do best: it initiated a system-wide response to a system-wide need, called a conference of psychology department chairmen (as they were, then), in Boulder, Colorado, in 1949, and basically told them that funds would be made available to them for the development of clinical psychology programs in their institutions. Modern clinical psychology was born, as a social institution, in the space of a few days. The solution to the post-WWII mental health services scarcity problem, if not instantly created, was nevertheless launched.

It takes a few years to train a service provider in clinical psychology, but they do not need to have a PhD to be as effective as a one, and even with one they are out the door and working far sooner than any psychiatrist could be. In addition, they are far more price-accessible to most people in need. Finally, due to the superiority of their training (being science-based, not theory-based), they are often more effective with more problems.

Clinical psychology has always been based on experimental psychology, and has never been the property of psychiatry. Because psychiatry never brought into its psychotherapy practices the scientific methods of general allopathic medicine, the psychotherapy it offered was surpassed by therapy which was based on scientific research – that of the experimental psychology community. Whether they wanted to or not, psychiatrists now played second fiddle to clinical psychology in the mental health professional community.

Backstory #2: The resurrection of psychiatry, as physician to the mentally ill, paves the way to diagnostic myopia and misdirection

Fortunately for psychiatry, there were two saving trends on the rise in the sixties: the ascendancy of biochemical biology and modern neuroscience[12], and  the emergence of truly effective psychotropic medications. These trends completely revived the notion of an effective organic approach to mental illness, an approach which Freud and his associates and students had abandoned simply because they had so very little to work with.

When new drugs made it possible to push the chronically mentally ill out of hospitals and into the community, the need for effective medical management of this population was created. Now, both psychiatrists and the drug companies, as well as politicians seeking to minimize tax dollars sunk into management of the chronically mentally ill, had a shared  interest in seeing psychiatry flourish. Chronic mental illness was largely seen as deriving from organic causes (even though the research supporting this was skimpy at best, in most cases), and thus accessible to medical management – if the drugs could be found. Soon, many of them were, and “big pharma” made sure the psychiatric community knew about them.

It has subsequently become clear that the big pharmaceutical companies have become masters of capturing the attention the professional psychiatric community. They provide the most accessible information about psychotropic medications (the Physicians’ Desk Reference), and are “..the source for most clinical research” funding in psychiatry[4]. As psychiatry had come too often to dance to the tune of big pharma, there have been problems[10]:

  • The childhood bipolar disorder research and diagnosis scandal[5];
  • Suppression of unfavorable drug research results[6];
  • Obfuscation of authorship of pharmaceutical research reports[11];
  • Complicity with price gouging by the pharmaceutical industry[7];
  • Continuing controversy about the freedom of the leaders of the psychiatric community to do their own thinking[8].

It goes without saying that all of these issues were and are vigorously disputed[9], with big pharma often leading the way.

What cannot go without saying is this: in spite of problems associated with the transformation of modern psychiatry into what it is today:

  1. The level of expertise in the profession, relative to management and treatment of organically based mental illness is at an all-time high. What modern psychiatry does best is not done better, or even as well, by any other profession.
  2. The treatment efficacy of the profession, relative to organic disorders, while still not what is desired by all of us, is also at an all-time high, and at its best is simply exceptional. Today, psychiatry can change and  save lives in ways never before seen. We should all be grateful for this.

A consequence of the fall and rise of modern psychiatry: misdiagnosis of bipolar disorder and borderline personality disorder

This much, at least, BD and BPD have in common: both are under-diagnosed, in some circumstances, and over-diagnosed in others. This may seem odd, but there is substantial evidence of this, and there are multiple factors contributing to the problem[13].

[Note: I must stop here, today, but will return at my earliest opportunity to complete this. See my last footnote for some of the sources I’ll be using.]

NOTES

1. For reliable and well-written professional summaries of the bipolar disorder diagnosis, please see Bipolar Disorders and Bipolar Affective Disorder.

2. For reliable and well-written professional summaries of personality disorders as a class of problem, please see Personality Disorders (at the Merck Manual website), Personality Disorders (at the Medscape website), and  (at the NIMH website).

3. For reliable and well-written professional summaries of borderline personality disorder, please see Borderline personality (at the Merck Manual website), and Borderline Personality Disorder (at the Medscape website), and Borderline Personality Disorder (at the NIMH website).

4. See NIMH RDoC vs DSM, paragraph three.

5. The center of the controversy has been Harvard psychiatrist Joseph Biederman, how has been extremely active both in promoting the concept of childhood bipolar disorder and its diagnosis, and in receiving vast amounts of money from the pharmaceutical industry. In an effort to be fair, let me just say that this raises questions about self-promotion, intellectual independence, and trust, which do not benefit psychiatry, Harvard, or Dr. Bierderman.

6. A book could be (and several have been) written on this subject, the incidents are so numerous. Here’s one especially disturbing incident, involving apparent suppression of research indicating that certain types of antidepressants are not safe for children. Additional coverage of this problem is available in Drug Companies & Doctors: A Story of Corruption.

7. Again, where do I start? Well, here one interesting place – a lengthy, carefully sourced article by Marcia Angell is a Senior Lecturer in Social Medicine at Harvard Medical School and former Editor in Chief of The New England Journal of Medicine: The Truth About the Drug Companies. Here’s an interesting response to her article.

8. See Conflicts of Interest Plague the Next International Manual of Mental Disorders, Experts Argue.

9. Here’s one noteworthy exchange, between Marcia Angell (see note 7, above) and several individuals of note.

10. …and that’s an understatement. See Drug Companies & Doctors: A Story of Corruption for much more on this.

11. See Authorship Rules for Medical Journals Flouted by Pharma Industry, Experts Say, and Ghostwriting Revisited: New Perspectives but Few Solutions in Sight.

12. The decade from 1990 to 1999 was declared by President George H. W. Bush to be the “Decade of the Brain”. This was both a call for increased effort in, and focus on, neuroscience research, and a recognition of the immense promise of the field, given its current status. For more on this, see Project on Decade of the Brain.

13. Partial list of sources to be used:

Instead of some light summer reading, I offer you some heavy spring reading – it can’t really wait until summer.

The coming new edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (expected to be published in Spring of 2013, as the DSM-5) promises to be yet another major step forward, though not necessarily because of any dramatic reorganization in the diagnostic categories having to do with trauma and dissociation. What’s new (as I understand it) is (a) public access to the development process, due to first-time-ever use of the Internet, coupled with overt solicitation of public comment, and (b) the plan to have an online, updated edition of the DSM, which is why it’s being termed “DSM-5” and not “DSM-V”, so that there can be a “DSM-5.1”, etc. I strongly suspect that we’ll have to subscribe to keep current (or maybe access will come with purchase of the hard-copy version).

The final of three comment periods has opened – see Last Chance for Public Feedback on DSM-5 (this will give you an overview of the current status of the DSM-5 revision effort) and DSM-5 Draft Criteria Open for Final Public Comment – May 2nd through June 15th, 2012 (on the DSM-5 homepage).

Commenting is easy (but you will have to register with the DSM-5 website). However, be aware that many, if not all, of the work groups associated with various diagnostic categories have elicited research and recommendation papers from leading authorities on the relevant diagnoses, and familiarity with these papers (all that I’ve seen are available online) is a likely prerequisite for crafting of a valuable comment.

Their location is not highly visible at the DSM-5 website. Select an individual disorder, then the “rationale” tab on its page, and you’ll probably see the link. I offer two such links below. These review papers are well worth your attention, if you haven’t already seen them.

Finally, for a couple of  additional perspectives of central interest, consider looking at:

Enjoy!

Here it is short and sweet: If you eat fast food to any significant extent (you know who you are!), your risk of becoming depressed in the future increases (if you aren’t already depressed). If depression is a problem in your life, you should seriously consider reviewing your diet, eliminating any fast food you find and increasing your consumption of whole and fresh foods.

This is the major finding of yet another study on the relationship between diet and mood (depression in particular) – and here is a summary of the study, written for medial professionals: Junk Food Linked to Depression.

Here are the key points I see in this summary:

  • Using a “…prospective cohort design [which] affords the potential for investigating cause-effect relationships,” researchers followed a group of almost 9000 people over time, to look at the relationship between depression and consumption of “fast food” – quick take-out food, and commercial bakery items. At the beginning of the study, none “…of the participants had been diagnosed with depression or had taken antidepressants before the start of the study.”
  • ” Fast food consumption was defined as total consumption of hamburgers, pizza, and hot dogs/sausages. Commercial baked goods consumption was defined as total consumption of croissants, doughnuts, and muffins.”
  • A positive dose-response effect was found: The more food of this sort consumed, the greater the risk of becoming depressed in the future.
  • Consistent consumption of these foods produced an almost 40% increase in the chance of becoming depressed in the future.
  • “…the researchers note that even small quantities of fast food were linked to a significantly higher risk for depression.”
And from the article, here are some excellent summary statements:
  • “…the intake of this type of food should be controlled because of its implications on both health (obesity, cardiovascular disease) and mental well-being.”
  • “Limiting trans fatty acids content in several foods, avoiding the consumption of fast food and bakery, and increasing the consumption of other products such as vegetables, legumes, and fruits should be a primary goal for clinicians and public health makers…”
  • “…it is prudent for clinicians to assess and address the dietary as well as exercise habits of their patients, in addition to pharmacological and other established treatments.”

These findings are congruent with a number of previously published studies which document similar or related causal effects between diet and mood:

Trans-Fats Linked to Increased Depression Risk [2011.01.28] – “Consumption of trans-unsaturated fatty acids (TFAs or trans-fats) has been linked to a significantly increased risk for depression. On the other hand, olive oil, monounsaturated fatty acids (MUFAs), and polyunsaturated fatty acids (PUFAs) appear to have a protective effect and lower depression risk…”

More Evidence Confirms Diet’s Link to Mental Health [2011.10.14] – “…new studies from Australian investigators show that diet quality can have a significant effect on mental health outcomes and may potentially have a role in preventing and treating such common illnesses as depression and anxiety.” “…better diet quality was associated with better mental health in adolescents cross-sectionally and over time.” “…these findings suggest it may be possible to prevent teenage depression by ensuring adolescent diets are sufficiently nutritious, and improving diet quality may help treat depressive symptoms in this population.”

Clear Link Between Mood and Food [2012.03.20] – “New research shows there is a strong link between higher levels of nutrient intake and better mental health, thereby adding to the growing body of evidence demonstrating the critical role of diet in mood disorders.” A broad range of nutrients were monitored in the reviewed small-sample study of a clinical population (i.e., all individuals were adults living in the community and had been diagnosed with mood disorders), and consumption of all nutrients correlated positively with scores on the Global Assessment of Functioning scale very commonly used in psychiatric assessment.

Improvements in one’s diet are appropriately considered a significant preventive or treatment response with mood disorders – especially depression. Overall cost is likely to be less than that for other modes of response, and such action is ideal for self-management of mood. I do this myself (along with purposeful strenuous exercise – also validated by research as a highly appropriate response to risk or presence of mood disorders), as I want my mental function to be optimal at all times. I strongly urge others to consider doing it as well. It’s a smart move.

Life is now. Memories necessarily reference the not-now. Fantasies do so as well, and can refer to past, present, or future.

It strikes me that the great challenge of our lives is –

1. To learn to stay connected to our sensory present (our senses being our only way of having direct contact with our physical environment, including the real people in it, etc.). Part of this sensory present is the internal communications we receive about ourselves, both via proprioception (see here and here) by means of the internal dialogs natural to higher order function in our brains (e.g., “I want another brownie, but I don’t want any more calories, so…no thanks.”). Some of these dialogs involve activation of memories with which we are not yet finished, a problem for us, often.

2. To stay particularly in touch with our affective (feeling) response to anything to which we persistently attend, as this reveals our true values.

3. To see that our actions, when we choose to act, are congruent with these feelings.

Living well with these challenges creates, I think, true integrity – integration of the self in the fullest sense of the word.

“Living well” is a moving target, as we all live in the midst of a dynamic world, a rushing river of change. We must repeatedly check to see that we’re headed down the right road, and not toward some ditch. And what’s the matter with ditches? Well, that’s where pond scum lives! We may aspire to higher outcomes than that.

And so it is that every day has its work for us, and for this we do well to offer our gratitude in response.

All of us struggle with our sense of reality. Sometimes we cannot quite “see” what’s really happening. Other times we don’t question what we see so much as our ability to respond well to it.

In any case, a little thought clearly leads to the fact that our sense of our reality – encompassing both ourselves and what is around us – is something distinct from the reality itself. Unfortunately, it’s just not always easy to get a good sense of what’s really happening.

Consider for a moment, if this line of thought is a little murky for you, that all of science is simply an effort to address this problem – to get a better sense in our minds of what’s really happening “out there”. Science is hard work, which leads me to conclude that the problem it addresses is often not easily resolved.

I find that my own personal sense of reality and myself is subject to many distortions. Rarely do these mental errors help me live better, feel better, or like myself more, in the long run. In fact, such mental errors can often lead to short-term disaster!

In a recent email to a client, I addressed this issue, asking what they needed to remember about themselves and their situation in order to limit such mental distortions as much as possible.  I then offered the following ideas which I personally have found it very useful to remember.

  • I care about the people in my life, and this is good for me and them.
  • I can interact with them in ways that add value to their lives and mine.
  • Direct control of my feelings is not possible (because feelings are an automatic brain response), but indirect control, through attending my physical health, my thoughts, and where I choose to direct my attention, is actually easy, and usually has a powerful effect.
  • There are many aspects of my present situation which are evidence of great good fortune in my life. I am foolish to allow my attention to dwell too long on misfortunes which come my way, unless it is to learn something useful to carry forward in my life.
  • Investing a small amount of time in experiencing and expressing gratitude for what I have can lead to immediate substantial gains in the quality of my state of mind.
  • Progress in any area of my life is almost always possible, if I’m willing to accept the fact of my having limited power and knowledge. It can be difficult to be a mere human being, with all the limitations inherent in this status, but acceptance of my limitations can free me to work at reducing them, through patient, focused effort.
  • Good mental health is strikingly like good physical health: it usually doesn’t just happen, but rather results from intelligent, directed, repeated efforts. Children usually see and react; adults see, then plan, then act. They get better results. It’s better to be an adult.

To get these statements, I just asked myself what is true about my situation in life, and what I need to remember, given these descriptive truths, in order to function well. The set of “reminders” above are the result. They are not a final set, to be sure, but I note that just reading them improves my state of mind.

So…the question NOW is simply…what do YOU need to remember, about yourself and your life, to function well? I’ll predict that time spent with this question will be rewarding for you. I’d be interested to know what you discover…

I’ve just fielded a question on the Talk page of the Wikipedia article on PTSD. It’s a good question (a couple, actually), and my answer might be useful to repeat here. The visitor asks why the article says this:

“Children may develop PTSD symptoms by experiencing bullying or sexually traumatic events like age-inappropriate sexual experiences.”

The concern is the reference to “age-inappropriate sexual experiences” rather than “rape”.  “Why does it say that instead of simply rape?  The Webster dictionary defines rape is having sex with who is below a certain age [http://www.merriam-webster.com/dictionary/rape%5B3%5D].  And what does age-inappropriate mean?  Would it be less dramatic if the person was their own age, instead of significantly older?”

My response (edited very modestly, for this venue):

I don’t have time to provide you with the reference citations which I’d like to offer, in responding to your questions, but  will respond using the knowledge I’ve acquired from many trustworthy sources in over 30 years of work in clinical and research psychotherapy, involving adults, adolescents, and children, many of whom had experienced what we call age-inappropriate sexual activity, often with negative consequences. I hope you’ll forgive my not backing up what I say with proper sourcing.

First, your questions are excellent ones. Please understand that casual language is often sloppy, and this won’t help us here. What the law, or the dictionary, defines as rape may well be different in important ways from a medical or psychological definition. The dictionary you cite appears to be giving a pseudo-legal definition. There is no “right” definition. Linguists write definitions (and dictionaries which contain them) on the basis of how people USE words. Philosophers and other thinkers are free, of course, to ”stipulate” definitions, as well. In formal, thoughtful writing, we usually stipulate definitions so that they help us with our thinking. They become tools, used to accomplish goals. That’s why legal people see “rape” differently than, say, anthropologists, or therapists. And note that even in groups of professionals in the same field, definitions can differ significantly.

So, let me begin by saying simply that from my perspective rape is always inappropriate (!), and is AGE-inappropriate when it involves a sexually immature individual. Note that physiological sexual maturity bares only a loose relationship to legal sexual maturity, and for good reasons (which I won’t take up here). If only some rape is ”age-appropriate”, as opposed to simply ”inappropriate”, it is also true that not all age-inappropriate sexual behavior is rape – which I think should be obvious, upon a little reflection. Inappropriate touching, for example, isn’t necessarily rape.

Age-inappropriate sexual experiences, in psychology/psychotherapy are those generally seen as those which involve an individual doing something sexual which is clearly not usual or expected for their age. This can be tricky to distinguish, however. Clearly, many, if not all, infants and children explore their sexual organs, and each others’, as well. This is normal, and generally harmless. At what point is something age-inappropriate occurring? There is no clear dividing line. It not dissimilar to the problem of distinguishing pornographic literature from erotic literature. I can offer no easy solutions to these problems.

That said, the key concept here is that sexual experiences involving children/adolescents who are not sexually mature ”can” have immediate and/or delayed long-term negative consequences. This is clearly cause for concern. It is very important to note that not only are not all sexual experiences children have inappropriate, not all of them cause any problem at all. Event consequences are driven by the degree of involvement, the nature of the act, whether or not there was coercion, how the child felt about it at the time, the reaction of adults who came to learn of the event, and so on. Many factors influence the consequences of a sexual experience involving a child.

We should never simply stipulate that something MUST be a problem (although this is commonly done in courtrooms). Rather, when we let the individual involved tell us of their experience and what it means to them, then we can know the real psychological consequences.

Well-meaning people can create a problem where none existed, with a child. Some individuals come through quite serious experiences with very little if any damage. Others are greatly hurt by what appear to be modest experiences. And, regardless of the consequences, those of us who come to learn of a given experience may have good cause for concern. It would be nice if we could view all this in simple terms, but I don’t think that would be accurate, useful, or intelligent.

Among the problematic consequences of age-inappropriate sexual behavior which we deal with in clinical psychotherapy are these:

* Lose of a child’s sense of safety: Loss of control over what’s done with your body is at the least unpleasant, and at worst traumatic. It may be difficult to feel safe in the world for some time after such an event.
* Loss of trust of key individuals in a child’s life: A sexually inappropriate relative becomes an untrustworthy relative. Children need families they can trust. A sexual abuse incident is one way to lose a functional relationship with a sibling, or a parent, or a grandparent. This can have long term consequences.
* Outright psychological trauma: When there substantial levels of fear involved, and the child is unable to resolve these feelings. enduring trauma may result. This is how once acquires PTSD.
* Premature sexualization of the child: This is the problem non-professionals usually forget or ignore or have no awareness of. Children introduced to sexual experiences before they are ready or desirous of them, may come to think that sex is a part of emotional intimacy. This may lead them to be sexual with other children, or other adults, in unwanted and unacceptable ways, and in ways that can damage others as well. I once knew a very pretty, charming 10 year old girl who had been removed from a succession of foster homes because she couldn’t keep her hands where they belonged. She had been “prematurely sexualized”. She thought what she was doing was OK, and her behavior led to repeated social rejection. This sort of thing is far more common than most people realize, and definitely one of the reasons why we’re concerned about age-inappropriate sexual behavior. It can lead to an child’s experiencing themselves as unacceptable to others in general, which can lead to depression, self-medication with various psychotropic substances, and other long-term damaging consequences.
* Disturbance to individuals associated with the child: Even when inappropriate sexual experiences are not a problem for a child, they can be for others. I dealt with a 9 year old boy once whose parents were quite upset because his female babysitter (age 13 – and not a relative) had climbed into bed with him late at night. They couldn’t imagine that he wasn’t somehow injured by this experience – clearly (one would think!) age-inappropriate sexual behavior. It turned out that he was only annoyed. He couldn’t make sense of what she was doing, and got up, went downstairs, and slept on the family sofa. Problem solved. All I had to do was calm down the parents, so they wouldn’t continue to disturb their son.

This is not intended to be a complete list, but I do believe it addresses most major issues.

Relative to a hypothetical age-inappropriate sexual experience, you ask “Would it be less dramatic if the person was their own age, instead of  significantly older?” It could well be, although “drama” is not the issue, as I’m sure you realize. The problem with older individuals is their misbehavior can lead to a needless and inappropriate distrust of all older people. Also, older individuals are likely to initiate more mature (and thus age-inappropriate) activities with younger individuals. At the same time one must note that in most cultures it is deemed appropriate for young, sexually mature hetersexuals to pair off such that the male is older than the female – one major research effort determined that the age difference deemed ideal by many cultures was about 3.5 years (with the male being older).

I will conclude my remarks by saying that I’m concerned about the tendency in some families, communities, and schools, to pathologize the normal. Two six year old girls simulating intercourse, because they are curious and cannot make sense of why adults would do this, do not really need a semi-hysterical, or punitive, or any other negative reaction from adults. I could cite other cases, many of them not so easy to think about…and that’s my point. A thoughtful examination of an event is a far wiser response than is a knee-jerk negative reaction of any kind. I prefer to act from knowledge rather than pre-drawn conclusions based on some principle rather than good data. It think that we don’t yet have all the knowledge about age-inappropriate sexual experiences that we’d like to have. The situation is clearly better than it has been in the past, without doubt, but we’re not finished out work, so to speak.

I hope my responses are useful to you. Thanks for your great questions!