Tom Salinsky

As many readers will know, Stephen Fry got himself into trouble recently when an interview was published in which he is quoted as making various observations about the natures of male and female, gay and straight sexuality. The interview is not currently available online, but if you wish to read extracts from it, then try The Guardian’s coverage for less than total hysteria.

The outcry over this has driven Fry off Twitter (again) and everyone is now weighing in with their own opinion. As ever, this debate boils down to the following trite observation – men and women, taken as groups, differ in some respects but not in others. Thus, those looking for a fight can make lengthy lists of the differences and rubbish those who emphasise the similarities, or can play down the differences and give endless examples of similarities instead.

But I don’t believe Fry’s personal musings should be cause for alarm or criticism. They were offered in no way as the last word on the subject, despite his possibly rather conclusive tone, and notwithstanding his subsequent claims to have been misquoted. And they seem on their face to be perfectly fair enough. It is a readily observable fact that gay men find anonymous sexual encounters easy to come by with no need to for money to change hands. That, further, while the world is crawling with prostitutes and rent-boys, the number of straight male escorts is vanishingly small (although there’s no shortage of straight men who would volunteer to earn a living in this way). That Playgirl magazine, launched at the height of the women’s lib movement and marketed to straight women is in fact read largely by gay men. Why should not a gay man venture some speculations as to the nature and cause of these obvious differences? Especially one whose non-professional opinion is eagerly sought on a very wide range of other topics – literary, musical, technological, cultural, sartorial, zoological – almost no subject is out-of-bounds where Stephen Fry is concerned, except for female sexuality apparently.

But it doesn’t take the brain of Stephen Fry to detect the obvious difference between the sexes which emerges after even the most cursory examination of the evidence, and which no list of thoughtful similarities will do anything to dispel. Men and women certainly do tend to process the world of sex and sexuality differently. In this post, I will attempt to give an explanation of why this is so, drawn from several different pieces of research, documentaries, pop science books and lectures I have consumed over the years. Regrettably, I find myself unable to footnote any of this very extensively, but if anyone really wants to take me on, then let’s head to the comments and/or the library. Most of this is logic, observation and common sense anyway. Let’s start from first principles.

Preparatory notion 1. Men and women are different and similar and diverse

For much of the rest of this blog post, I am going to be talking about men and women as groups, types or Platonic Ideals. But it’s perhaps necessary to acknowledge that a human man and a human woman will no doubt have far more in common than a human (of either sex) and a chimp. Or indeed, a dolphin, a racoon, a banana or a bicycle. It’s not that these similarities between humans don’t exist, they simply aren’t my topic for today.

And both groups are also terribly diverse. It’s certainly possible to identify women whose behaviour sounds much more like the prototypical male I am describing, or vice-versa. I’m not suggesting that each group is entirely homogenous, and that any particular man or woman you happen to meet (or be) is guaranteed to perfectly exemplify whatever behaviour I am claiming for that group. I am claiming, however, that certain behaviours are much more typically found in men than women, or the other way round, and I don’t want the presence of outliers to distract us from the interesting conclusions we can draw about the great majority, somewhere in the middle of the bell-curve. Once again, it’s not that these outliers don’t exist or aren’t interesting – it’s just that they aren’t whom I wish to write about today.

Preparatory notion 2. The mind evolved

The field of evolutionary psychology is excitingly controversial, although those who oppose the very idea of it, often seem to be to be attacking a straw man (as in this debate between Stevens Pinker and Rose). No serious researcher is taking the field to the absurd excesses described by those who seek to denigrate this approach, and like any scientist, evolutionary psychologists are free to speculate, while being careful to separate such speculation from evidenced conclusions.

But the basic idea that the mind evolved can hardly be denied. Tiny kittens play-fight to discover how to defend themselves and catch prey, but this play-fighting is instinctive, not taught to them. Birds hatch with all the required muscle co-ordination for flight and don’t require the blank slate of their brains to be written on by an extensive programme of schooling. Human infants learn to talk even when exposed to primitive and incomplete versions of what will become their native language, as in the deaf children of hearing parents who effortlessly turn the clumsy signs of the adults closest to them into the full linguistic richness of British Sign Language (or whichever).

Although humans are blessed with an extra capacity for general reasoning and abstract thought, compared to other animals, nevertheless much of what we do remains instinctive, unconscious and shaped by billions of years of evolution, rather than a few thousand years of culture. Thus we crave foods rich in salt, fat and sugar because moderate quantities of these things are essential to our survival, and they were not always easy to come by in the African savannah. If we failed to prioritise acquiring them, or passed up opportunities to consume them, we tended to be outcompeted by those that did. These being instinctive actions, shaped and promoted (though not actually controlled moment-to-moment) by our genetic makeup, a proclivity for aggressive consumption of salt, fat and sugar became the norm in the population.

Today, when foods high in salt, fat and sugar are readily available (at least in some parts of the world), this adaptation is no longer such a benefit, but evolution shapes us only slowly. We’ve needed salt to survive for hundreds of millions of years, but McDonalds has been in business for only a few decades.

Humans evolved around a million years ago. Hominids around 15 million years ago. Primates around 75 million years ago. Mammals about 250 million years ago. Tetrapods around 400 million years ago. Vertebrates 500 million years ago.

Sex evolved about a billion years ago.

So we’ve been boy and girl for almost as long as we’ve been anything at all. It’s not inconceivable that evolution might have shaped male and female brains differently, given a billion years in which to work. But we’ll come back to men and women once we’ve considered another more general point. We are now ready to begin asking some serious questions about sex and sexuality.

Question 1. How do we choose our mates?

Evolution isn’t only about survival of the fittest (which itself doesn’t survival of the strongest, or healthiest – “fit” in this sense means suitable or most fitting to the environment). Not just natural selection, the weeding out of the least fit, but sexual selection plays an important part. The price for sex (no we’re not still talking about rent boys and hookers) is that by reproducing sexually, I only get to pass on half of my genes. So I need to be pretty careful that my super-duper genes aren’t being dragged down by your inferior ones. Thus we get careful choosing of mates, display behaviour and phenomena like peacock’s tails. A peacock doesn’t need an elaborate tail for its own survival – quite the reverse, they are cumbersome and cost energy to maintain. But a peacock who can sustain this preposterous plumage must be, in general, a superior specimen, blessed with a robust constitution, excellent health and fitness and bags of stamina, at least some of which may be genetic in origin. Thus a discerning peahen who prefers to mate with the larger-tailed gentleman will find more of her genes in the next generation, whereas those who seek out the tiny-tailed may discover that the next generation is bereft of her genetic bounty since her offspring suffered from the same lazy attitude, heart condition or inherited disease as their dad.

Note that none of this is mentally considered by the peahen. It is simply a fact that because peahens who prefer to mate with big-tailed males have a greater genetic influence on the next generation, so  necessarily, the next generation contains a higher percentage of peahens who get turned on by big tails.

Quite obviously, even as sophisticated adult humans, with all our language and culture and technology, we also have mate preferences that we didn’t decide for ourselves, but simply woke up with aged about 10. And while it (once again) isn’t true that there is a single monolithic standard of beauty or attractiveness, patterns do emerge and so Marilyn Monroe is generally feted for her beauty whereas Bella Emberg received such compliments less frequently.

But even if we ignore the problem of establishing a global standard for attractiveness, we can still accept that people tend to rate people they meet in terms of how attractive they are – and we need not limit ourselves to physical beauty. A potential mate may strike you as attractive because of their power, charm, vulnerability, sense of humour, kindness, personal wealth, liking for adventure, exotic accent or any one of a number of other reasons. But, if forced to, you could give any person of the appropriate sex whom you happened to meet a rating on an imagined desirability scale. So if you should want a global measure, you can think of this as the average across all potential mates.

Sexual selection tells us that in the game of mating, those whose combined desirability scores are the highest are going to be those who most influence the next generation’s gene pool, and so evolutionary theory tells us that behaviour which tends to lead to this outcome will be selected-for and so come to dominate. That leads us to…

Thought experiment 1. The ice rink

You are one of twenty players (sexes are not relevant for the purposes of this game) who will shortly be let loose on an ice rink. It doesn’t have to be an ice rink, but freedom of movement is key. Each of you wears a number on your back, allowing you to be ranked in order from 1 to 20. Numbers have been assigned randomly and secretly, so – although you can see clearly what number somebody else wearing, you cannot see and do not know your own designation.

The game is to find someone who will agree to leave the ice-rink with you, holding your hand, and the aim is for each pair to attempt to maximise their combined score. So a 9 who leaves the rink holding hands with a 5 will score 14, but will be beaten by an 8 who leaves the rink holding hands with a 11. You can change your mind as often as you wish and the time limit is fairly generous so no-one is making any snap decisions.

The game begins. What is your strategy? The obvious (and correct) strategy is to immediately start looking for number 20. Regardless of what number is on your own back, nothing will give you a higher score than leaving with number 20 in tow. Pretty soon number 20 is spotted and quickly has a great many potential partners. There’s a 1:20 chance in fact that this will be you. So let’s assume it is – you are busily looking out for number 20 when you gradually realise that everyone else has come looking for you. You are number 20! Who are you now looking for? Well, the best score you can possibly get will now be 39, provided you can find number 19. So number 19 now becomes the only person whose hand you are willing to hold. 19 eagerly agrees to hold your hand, and you both happily leave the ice rink having won the game. But the game isn’t over yet.

Once 19 and 20 are paired off, all attention naturally switches to number 18, who is now the best prize available. Number 18 will now only accept the advances of number 17, and so on. By starting with the rule “maximise your combined score” we end up with everybody pairing up with the closest number to them.

Answer to question 1. People choose as their mate the most attractive person who will accept them.

Again, “attractive” is assumed to have a multiplicity of meanings, but this complexity doesn’t change the fact that we find some people more “attractive” than others – even if we couldn’t give a very satisfactory definition of “attractive” even when asked. And because we both seek and select, we reject people if we think we can do better, but set our sights as high as we dare. In life, unlike in the ice rink game, we get a sense of our own level of attractiveness (even if, or especially if, this changes over our lifetime) and so don’t bother approaching those way out of our league because the risk of rejection is suicidally great. When we encounter pairs who appear to buck this trend, they tend to be figures who attract startled comment. “What does she see in him?” and so on. This is precisely because they are outliers and not the norm.

Preparatory notion 3. Game theory can help us understand human psychology

Evolution finds solutions that “work”, where “work” in this sense can be taken to mean “increases the representation of those genes in the gene pool of the next generation”. Evolution in this sense is circular. Natural selection means survival of the fittest. What does “fittest” mean? Those who tend to survive. But if a subtly different shape of fin, a different trade-off in heart construction, or a thicker, shaggier coat creates a survival advantage, then over generations, a population of organisms will shift in that direction. Evolution tests countless tiny variations on the currently best designs and – especially if the environment changes – discards the ones which don’t help and retains the ones that do. It isn’t guaranteed to find perfectly optimal solutions, and if the environment changes very rapidly then evolution may not be swift enough, but when it works, this is how it works.

In just the same way, when it comes to sexual selection, evolution can generate variations on brain construction which give rise to different psychologies which give rise to different strategies. Those strategies which tend to maximise inclusive fitness – in other words those which don’t only aid survival for this individual organism but which contribute to their ability to genetically dominate future generations – will be selected for. But note that even homo sapiens is not granted a psychological makeup which is explicitly and consciously focused on inclusive fitness maximising. If it were the case that, for example, men were consciously focused on maximising their genetic representation in the next generation, that most men would be ferociously keen to donate to as many sperm banks as possible as often as possible – but this is not a solution which evolution could plausibly find. We would expect men to enjoy orgasm however, and this they generally do.

Of course, sex and reproduction is only worthwhile if you live long enough and so other forces come in to play. Some male mammals (although no females as far as I know) will eat their own young if food is scarce. The calculation (not performed consciously of course) is that if I eat my kids today, I can father lots more offspring when there’s enough food to go around. But if I don’t, I’ll die now leaving only this litter, who will probably die themselves. Layered on top of all of these evolved, primal, psychological forces are more recent, subtler drivers such as the need for acceptance, social status and so on, not to mention a whole other wealth of cultural, societal and fashionable forces which also act upon us, and all of that is without even mentioning all of the personal preferences which make us unique.

But game theory – the mathematical study of what tactics are most likely to lead to success given certain rules to play by – can certainly be employed to allow us to discover how evolution might have shaped this part of our mind. We can then look at human societies and behavioural norms and come to some conclusions about how many of these primal needs are preserved, and how many are muffled or eradicated altogether.

And here we must – for the first time – start considering men and women differently, instead of considering evolution, psychology, mate-selection and sex-differences simply as phenomena.

Question 2. What is a man’s best mate-selection strategy for maximising inclusive fitness?

Since the mind evolved, and since the mind evolved under this kind of selection pressure, we can be fairly sure that most men will be seeking a mate who is the most attractive person who will accept him. But maximising inclusive fitness doesn’t only mean finding a life partner. The potential cost of sex to a man is very little. He will never have to bear the child through pregnancy and the time which elapses between conception and birth may very well mean that he is no longer conveniently at hand to raise the child, or possibly no longer identifiable as the genetic father. But like a gambler with an unlimited bankroll, there is no reason for him not to keep rolling the dice again and again and again. Given the choice between having sex with number 18 and having sex with number 11, regardless of what number is on his own back, he would prefer number 18. But he’ll cheerfully have sex with number 11 if no-one else is around.

For men, promiscuity makes sense. Why would you not have sex whenever possible, provided you are still eating enough and providing a decent enough shelter to ensure that you will still be fit and healthy enough to have more sex tomorrow? There is no cost and from an evolutionary point of view, it’s an easy (and fun!) way to out-compete less eager rivals.

Not only that, but it’s also easy to see why men would prefer to have lots of sex with lots of different partners, rather than settling down with just one straight away and raising a family. All that time spent looking after your first child is time you could be spending anonymously fathering dozens more.

Question 3. What is a woman’s best mate-selection strategy for maximising inclusive fitness?

For women, however, the picture is vastly different. There is a tremendous potential cost for a woman in having sex with a man. This cost is twofold. Firstly, if she becomes pregnant, she will have six-nine months of discomfort, followed by many years of expending energy in childcare (this is a potential cost for a man too, as mentioned, but an all-but guaranteed cost for a woman).  The second cost is more subtle. Gestating this baby is a missed opportunity to gestate the baby of another man. Thus, because she wants her genes to be given the best possible advantage in the next generation, she will strongly prefer to have babies only with the most attractive men available.

Now, this is all very well if you are number 20. You simply wait for number 19 to come along, refuse to have sex with him until you have some way of forcing him to stick around and share the burden of childcare with you and give birth to a series of prodigious wonder-children.

But what about the rest of the population? You might imagine that the ice-rink experiment teaches us that number 12s just have to settle for living with and raising children with number 11 or number 13, but a better strategy exists for the female of the species. The possible lack of certainty about paternity here works in the woman’s favour. The very best strategy for all but the most desirable female is to find the most attractive male who will accept her, and then get him to help bring up the child which she gives birth to after having had sex with a much more attractive man.

Question 4. What evidence do we see of this in the modern human world?

This trio of observations – men and women each seek the most attractive person who will accept them, men favour promiscuity over a stable relationship, women need both a helpmate and a genetic mate but they don’t have to be one-and-the-same – unlocks a tremendous amount of human sexual activity, even though almost nobody actually gives totally free reign to these desires. From these observations we should expect to see – and do see…

• Men are more likely to have multiple sexual partners, and will resist being “tied down” when still young and studly.
• Women will be much more choosy about with whom they have sex and will be looking for life partners from a much younger age
• Men will be very concerned about paternity and feel extremely threatened if it is suggested that the baby they are cradling might have been fathered by another man, unbeknownst to them.
• Both sexes will be concerned about the possible consequences of infidelity on the part of their partner, but each will be concerned about different outcomes. Men fear cuckoldry. Women fear abandonment. As Steven Pinker puts it, women who discover that their man is cheating think “he’s having sex with her – oh god, what if he’s in love with her!?” whereas men who discover that their woman is cheating think “she’s in love with him – oh god, what if she’s having sex with him!?”
• Men, who are briefly deciding where to deposit their sperm before moving on to the next conquest, will tend to make the decision about on whom to bestow their genetic gift on the basis of factors which can be assessed quickly – chiefly physical appearance. Women, who are deciding at their leisure with whom to attempt to form a pairbond, will tend to weigh up a wider variety of factors before they commit to a sexual liason, including (but not limited to) trustworthiness, resourcefulness, kindess and so on as well as physical beauty.
• And – as Stephen Fry noted – we should expect to see, and do see that gay men, genetically predisposed towards promiscuity but not having to play the mating game with women, will tend to be very promiscuous (despite the fact that no offspring will ever result from this behaviour).

Objecting that these behaviours are cultural rather than genetic misses the point three times. Firstly, it is surely not a coincidence that the biases we would expect to see thanks to evolution exactly coincide with our current cultural biases. Secondly, it entirely skips over the question of where these cultural biases come from.

Maybe because of these two (and I’ll come to the third in a moment) some who took offense at what Fry had to say simply deny that the behaviours listed above are remotely commonplace. Now, I’m not offering any particular evidence that they are, but they resonate profoundly with how men and women are depicted, talked about and represented. Offering a handful of outliers – as discussed earlier – does nothing to provide evidence that these very, very familiar behaviours are, on the contrary, vanishingly rare. It only offers evidence that they are not the totality of human behaviour. Fine. Nobody ever said they were.

And nobody ever said they were desirable either, which is the third way in which taking offense at Stephen Fry’s remarks misses the point. Simply because these behaviours are commonplace doesn’t mean that we should be happy with them, blithely accept them and even if we don’t like them, shrug our shoulders and say “there’s nothing we can do – it’s genetic.” Genetic tendencies are not implacable predestinations. They are powerful forces, but other forces certainly exist, and as thinking creatures with the capacity for abstract thought, rationality and selflessness, we can ask ourselves what kind of society we would like to live in and do what we can to bring that about.

And so, in many Western societies, attitudes – especially straight male attitudes towards women – are profoundly shifting away from what might be expected given these primal, evolutionary forces; but the shift is not, and I doubt ever will be, so complete as to eradicate any meaningful difference between the sexes. If you doubt that these evolutionary forces still act on our unconscious desires and behaviours, then consider this elegant study (sorry, no citation).

Researchers interviewed, took photographs of and took blood tests from a number of young women in nightclubs. From the interviews, they determined whether the women were single or in a stable relationship. From the photographs, they measured how much bare skin they were exposing as a percentage. And from the blood tests, they determined where they were in their menstrual cycle. The results were a strong correlation between fertility and skin exposure. The more likely they were to conceive tonight, the more flesh was on display. Their relationship status was almost irrelevant.

In all likelihood, not one of these women is making a calculated, rational decision to expose more skin tonight for this reason, and women being choosy in the way they are and for the reasons they are – both discussed above – even those dressed most provocatively may have failed to find anyone worthy to go home with, but this study does show I think at least one way in which our evolutionary legacy continues to influence our behaviour, whether we know it or not.

In a later post, I’ll explain why science can prove that there’s no such thing as bisexuality and why women genuinely don’t know what they want. If that doesn’t get you cross, then nothing will.

3D is back in our cinemas and it’s big business. Cinemas can charge more for 3D movies, 3D movies earn more revenue and – along with monster screens – are another key differentiator for cinema, in this frighteningly modern age of Blu-ray, iTunes and Bittorrent (whatever that is).

Of course, 3D is nothing new, and I don’t want to use this space to reproduce Wikipedia entries about its history, nor whine about it being used badly or inappropriately, nor even do I want to assess its place as another colour for moving picture artists to add to their palette. I want to talk about something more fundamental – what is it?

The briefest of history lessons, just to explain why 3D is suddenly back in our cinemas, and to add a little context. 3D in this sense essentially means delivering two subtly different images to each eye. This can be done in various ways, with the most popular in the twentieth century being the red/blue anaglyph method. This sends a red-tinted image to one eye and a blue-tinted image to the other eye thanks to cardboard glasses. The method is cheap to implement but entails obvious compromise of colour within the images. LCD shutter glasses which blocked all light reaching each eye alternately were briefly experimented with but you can’t give out expensive items of electronic equipment free with breakfast cereal and they need both power and careful synchronisation with the projected image. Neither is ideal, which is why 3D was so niche for so long.

The reason for the current swathe of 3D movie is that two new technologies have caught up with an existing one. The glasses you get given at your local Vue or Odeon today are polarised, which effectively means that half the light enters one eye and the other half enters the other eye. No colour distortion, but a dimmer image, and you can’t just blast twice the light through 35mm film to make up for the shortfall, since twice the light means twice the heat and you’ll melt the celluloid. However, the advent of digital (filmless) projectors combined with hugely reflective metal screens means that polarisation can be deployed without the images being reduced to a murky gloom. Reflective screens + polarised glasses + digital projection systems = $$$ it seems.

And more is to come – 3D TV is on its way, with several lenticular (you know, like those corrugated postcards which seemed to move if you tilted them) systems which send a different image to each eye, provided you sit in just the right position and keep your head still.

But what exactly is the benefit of all of this?

Well, it isn’t 3D except in the very trivial sense that the images you are watching now have an apparent third dimension of depth to add to their existing dimensions of height and width. No, it’s stereoscopy or stereo imagery which is no more like actually being there than a stereo recording is actually like being at a concert.

Let’s start by considering how our brains interpret the three-dimensionality of the world at the moment. Information about how near or far things are comes from three sources.

• Perspective. Things which are further away are smaller in our field of vision (Dougal) and parallel lines which recede from us appear to converge.
• Parallax. Things which are nearer to us appear to cross our field of vision more quickly, whereas things which are further away cross our field of vision more slowly. This works even with stationary objects if you move your head. Try it now and notice that your monitor or laptop screen moves through your field of vision much more than the wall behind it.
• Stereoscopy or stereopsis. The left eye sees a different version of the image than the right eye. The brain automatically combines both images into a single version of reality, giving each element of the image a “depth value”.

Of these three, perspective is present in any photograph of the world, and is obviously a part of any movie, 3D or not. The second, parallax, in the first sense is equally present in any live-action movie and, was a key reason for Walt Disney to create his multiplane camera in the 1930s. However, in the second sense, it is absent from all movies, 3D or not. You can’t move your head and see a different image as you could if you were witnessing the events live. The 3D stereoscopy is an illusion, one which is shattered if you try and interact with the image in even the most trivial way. We are not Luke Skywalker, able to walk around the projection of Princess Leia and see her from whatever angle we please. At least with your “RealD” glasses you can move your head without the image actually falling apart, unlike those lenticular TVs I mentioned earlier (disclaimer: this technology will obviously improve over time and I haven’t sat in front of one myself yet, so I know not whereof I speak – but that’s the prerogative of a blogger, is it not?).

Undoubtedly, 3D stereoscopy can enhance some movies. It can also ruin others (for some insights into what’s going right and wrong see this fascinating series of article by David Bayon on the PCPro blog). But it would please me if there were more realistic descriptions readily available for what is going on. Traditional “2D” cinema creates an illusion of depth through perspective and parallax. People with good vision in only one eye don’t live in flatland and if you close one eye, your ability to – for example – catch a ball will only be very slightly impaired. Stereoscopic movies enhance the depth illusion but do not complete it, and very odd effects can be created when an object which appears to be jutting out towards the viewer, then moves off the edge of the screen.

Stereoscopic movies are probably here to stay and the technology now exists to retrofit stereo into movies shot with a single camera, so we’ll be seeing more of them, not less. But they aren’t now, nor will they ever be as three dimensional as the room you’re sitting in right now. For that, you’ll have to go to theatre.

Part three is here.

TOM

Muddy waters? Not at all!

You say that you don’t see complementary/placebo medicine as competing with scientific medicine. However, not all placebo practitioners see it that way. Many peddlers of placebo cures directly attack what they sometimes term “allopathic” medicine as causing harm, arranged to make money for “big pharma” or who-knows-what other ills. Here’s a quick sampling of web pages and opinions which it took me about two minutes to find.

“Antibiotics kill bad as well as healthy bacteria. This results in weakening of immune system. Homeopathic medicines strengthen the immune system by building resistance to sickness. They do not disturb or hamper digestive system.”
http://www.otherhealth.com/research-scientific-validity-homeopathy/9877-modern-medicine-allopathy-homeopathy.html

“Allopathy’s strength lies in intervention. When you need a shot of penicillin, you need a shot of penicillin. When your body needs insulin, no therapy other than insulin injections will do. If surgery is required, then surgery is the solution. Allopathy’s weakness lies in the simple fact that removing the symptoms of a disease does not necessarily remove the cause of the disease. Its greatest weakness is that many of its cures are killing people. One reason many people have left conventional medicine for healthier alternatives is that death is not an acceptable side effect.”
http://www.mnwelldir.org/docs/therapies/what_is.htm

“[The World Health Organisation] wants to remain ignorant about AIDS, because it is under the control of the big Multinational Companies manufacturing the so–called HIV–detection kits and the highly toxic drugs like AZT, which products they must sell by any means to make the big bucks.”
http://www.wonder-cures.com/art8.htm

Now, it’s easy for you and me to dismiss these as the ravings of cranks, and indeed you then say “you think most people are aware that they [evidence-based and alternative medicine] are different in conception”. Presumably you think this is important. If people are aware that antibiotics are a sensible (although not a guaranteed) treatment for pneumonia but that homeopathic remedies are unsuitable, then they will steer clear of them – despite the fact that they are readily available.

How does it help this vital distinction between evidence-based and placebo medicine to be maintained if placebo medicine shares shelf-space with evidence-based cures in Boots? If NHS doctors provide imaginary treatments on request? If evidence-based medicine is offered side-by-side with placebo medicine, as birthing pools are provided side-by-side with epidurals in maternity wards? How can the lines not be blurred in patients’ minds? And do you not share my concern about the possibility of harm once these lines are successfully blurred? This is where the muddy waters really are, I believe.

Yes, there is no market for herbs on broken legs, but there is a big market for homeopathy which is no more magical, but which presents a more credible face to the western world. Homeopathic pills look like medicines (which partly accounts for their effectiveness, although studies show that saline injections – a more impressive intervention – can be even more effective in pain relief for example) and so they appeal to a moderately medically-literate audience. But that appeal depends on blurring the distinction which you identified. And it works – the market for homeopathy in the UK is estimated at £30m annually (£4m on the NHS). For complementary medicine as a whole it is £1.6bn. That’s a lot of money to spend on magic.

I agree, that if it were the case that all promoters of homeopathic medicine (and other placebo interventions) were eager to direct their patients towards evidence-based interventions for more serious or urgent situations (regardless of the inevitable cognitive dissonance that this requires), then they would do considerably less harm. But your personal experience of this kind of co-operation happening in China or on the NHS doesn’t change the fact that it is not the norm. When researchers visit high street homeopathic vendors, they are prescribed useless sugar pills as a malaria prophylaxis and told not to bother with evidence-based immunisation. When patients visit websites for information about homeopathy, they may read information which presents evidence-based medicine as a cure which is worse than the disease. When practitioners of placebo medicine are criticised in the press, they often attempt to silence their critics by legal means, as happened recently to Simon Singh, heedless of the fact that open scientific debate is essential for determining best options for patient care.

The upshot of all of these behaviours could be and is that patients die who might well have lived had they not been fed this misinformation. The further consequence is that it becomes easier for evidence-free attacks on mainstream medicine, such as the anti-vaccination campaign, to take hold in the public consciousness. This seems to me like far too high a price to pay for the temporary alleviation of chronic pain in some patients, or the illusion of relief from self-limiting conditions for others.

We know that pneumonia kills, but that it can be effectively treated by antibiotics. We know that a lot of people are unaware of the fact that homeopathy is a useless treatment for pneumonia, because homeopathic treatments are readily available, and if no-one thought they would be effective, market forces would ensure that – like herbs for broken legs – they would be nowhere to be found. People who believe that homeopathic remedies will treat their pneumonia will likely die. Homeopaths have a strong vested interest in maintaining this belief. Homeopathic pills in Boots and the presence of an institution such as the Royal London Homeopathic Hospital are very effective in helping to maintain this belief.

Your initial question to me was “why are you so cross about this?” My question to you is “why aren’t you?”

JOHN

The reason I am not cross about it is that I don’t think there is any evidence that a significant number of people are being harmed by choosing to go to alternative practitioners. Do you know of any?  Its true that these advertisements appear to be very misleading, but I think people have enough sense to know  that they need to be in hospital with severe chest or abdominal pain and that they need a surgeon for a broken leg.

They go to the alternative practitioners only when they have discovered that they have the kind of symptoms which are painful or distressing but not due to any disorders that conventional medicine can help except by support and the doctor’s continuing interest  and concern. Sadly,  that may be more forthcoming from a homeopath.

And, as I have said there is something about these  miracle cures that has a very strong appeal to human nature. I’m not sure that one can or should legislate against it unless you can show that harm has resulted on a significant scale. What is significant? Well, there is undoubtedly a considerable morbidity and mortality arising from the side effects of drugs and the mistakes that happen in the conventional medicine system.   Is the harm caused by inappropriate use of alternative medicine on the same scale?

Part two is here

TOM

I’ll keep this as brief as I can.

Parts of your reply misrepresent my position slightly. I’d like to clear up any misconceptions.

I don’t equate evidence with certainty. Absolutely, we can be less sure than we would ideally like that a given intervention will be effective in a given case, but we always have an evidence base on which to make such judgments – even if the best we can say is “this is a wildly experimental treatment which stands as good a chance of curing your cancer as it does of killing you on the spot, but we’ve run out of other things to try – what do you say?” If this is a lottery, it’s one where we can often buy an awful lot of tickets.

Thus, I continue to insist that everything is split into two categories. A physician can recommend a treatment because there is evidence to suggest that it will be effective or can ignore the evidence which shows that a treatment is no better than placebo and prescribe it anyway. A physician can honestly tell a patient that the evidence is inconclusive, or dishonestly claim results which are not supported by data of any kind.

The other slippery issue is that of false claims. You approve of the wording on the Homeopathic Hospital’s website regarding Iscador, but I’m not sure you are looking at this website the way a patient might. Here’s a page from a website all about Iscador.

Here we read that “one of the primary functions of Iscador^® is that it stimulates parts of the immune system that can slow the growth of cancer cells”. This, as we know, is rubbish. On the same website, there is a link to a single study, published in a Complementary Medicine Journal which purports to show a significant benefit to cancer sufferers using this preparation. However, as we have already seen, a review of all the available literature shows that overall there is no good evidence that Iscador has this effect. This is the usual pattern. Evidence-based (or science-based) medicine which reviews all the available evidence, and people with a pill to sell (herbal or pharmaceutical) who pick only the studies they like and ignore the rest.

Now consider the effect on a patient who may have seen these other claims made for Iscador’s magical cancer-healing powers, coming across Iscador on a National Health Service website. It isn’t the details of the mode of action that stick in the mind – it’s the key message MISTLETOE CURES CANCER. And this message is reinforced, not contradicted, by the product’s availability through an apparently prestigious and trustworthy source. So while the NHS might stop short of actually saying “mistletoe cures cancer”, it ends up delivering that message just the same.

It is at least partly for this reason that the Ten23 campaign is targeting Boots. When homeopathic preparations are seen side-by-side on the shelf with active pharmaceuticals in the country’s largest and most-trusted pharmacy, it is almost inevitable that patients will get the wrong impression (this is reinforced by dire warnings on the sides of the bottles). So, it becomes impossible to clearly send a message that homeopathy will not cure your cancer, is not a suitable defence against malaria, will not cure your child of eczema and so on, and the result is that people believe the hype, and sometimes that belief turns out to be deadly.

My feeling is that placebo cures possibly do have a role in treating chronic conditions such as back pain, may even have a role in treating minor self-limiting conditions although this is more likely to be simply a waste of everyone’s time,* but are a danger as soon as they are let near anything remotely life-threatening. With a powerful lobby that can’t bring itself to say “for god’s sake get proper medicine if you feel really poorly,” the only answer is to try and destroy the credibility of these interventions as much as possible, or stand by as greedy corporations and misguided practitioners continue heedless of the harm they cause.

So it isn’t that homeopathy on the NHS is itself prescribed in a cavalier or life-threatening way, rather that this activity is an enabler, enhancing the credibility of others with fewer ethics or less regard for evidence, and also fuelling the fires of hysterical media coverage of things like Andrew Wakefield’s infamous MMR paper. Is public demand for medicalised quick-fixes a good enough reason to accept this corrosion of public standards of evidence? I don’t think it is.

You asked the excellent question – can you have medicine without quackery? I don’t know if you can. But I do know that mainstream medicine has no business flattering the quacks.

One final question for you. Many churches pray for people with life-threatening illnesses and many people feel happy that people are praying for them. What if this were offered as a service on the NHS? Is government-sponsored prayer also something you would endorse?

* Caveat – when I have a sniffle, I’m perfectly well aware that no matter what I do it will probably last 3-4 days, but I prefer Lemsip to a homebrewed hot lemon drink because the fact that Lemsip tastes a bit medicine-y makes me feel better. The placebo effect is also present with pharmaceutical interventions of course.

JOHN

I don’t see complementary medicine (or if you prefer ‘placebo medicine’) as competing with scientific medicine. I think most people are aware that they are different in conception and that for some major illnesses or accidents only science will deliver. Very few people put herbs on broken legs these days. There would be no demand for it on the NHS.

Whether there would be a demand for prayers for healing on the NHS I don’t know but it might catch on and save a lot of money currently spent on visits to A and E.

When I was in China last year, I was interested to see that some of the hospitals and clinics we visited  had Western scientific medicine  and TCM ( traditional Chinese Medicine) departments running side by side. The patients chose which one to go to, but if the doctor they went to initially thought they had got it wrong they were cross-referred to the other wing.  So the two approaches can co-operate.

That’s all I  have to offer for now. I hope I have muddied the waters a bit so you can get to work clearing them again.

Part one is here…

TOM

Let’s start by enlarging the list of things we both agree on.

I agree that placebo pills cause no direct harm whereas absolutely any active chemical introduced into the body has at least the potential for harm, even those which have long been associated with health and well-being; there is, for example, some evidence that routinely taking vitamin supplements when not indicated may have negative health outcomes.

I also agree that homeopathy and other alternative modalities make some people feel better but regret that the only way to safeguard the efficacy of the intervention is to mislead patients as to what is going on. It is important that the patient believes that the pill, needle, shamanic ritual or whatever will be efficacious. When prescribing even (or especially) a very risky treatment like radiotherapy, a physician can explain the potential costs and benefits, based on a large body of evidence, in order that the patient can make an informed choice. Prescribing placebo treatments as if they are effective removes that informed choice, but telling the patient “this won’t work” is a self-fulfilling prophecy, so homeopaths – whether or not they are themselves deluded – are deceiving their patients.

Of course, if patients want it and are made to feel better, why should we worry about removing informed choice? I do have an answer to this question, but I don’t want to get ahead of myself. Let me finish responding to your points first.

You write that you think that homeopathy is an appropriate use of public funds to treat chronic conditions for which no effective evidence-based treatment exists, and it may be that the London Homeopathic Hospital does restrict itself to interventions in those cases. It may also be that all of the Homeopaths working there are medically qualified (I wasn’t aware of this – do you have a reference?).

But it is not true, despite the name, that within the tranquil environment of the LHH, homeopathy is the only evidence-free service available. A quick look at their website reveals that they are also happy to provide Reiki, Acupuncture, Reflexology and Iscador – a new one on me – which we learn is “a preparation of mistletoe, which enhances immune system responses.” Bearing in mind that this is on a page titled Complementary Cancer Care Programme, doesn’t this worry you at all? Do you really want your patients believing that mistletoe will cure their cancer? Who benefits from sustaining this belief, except those who have “Iscador” to sell?

Only one passage in your very thoughtful email stood out as something I would really take issue with – this one: “Every form of medical practice has its own philosophy, including evidence based medicine, which, by the way is not always as reproducible in an ordinary community setting as it is under strict experimental conditions.  Even EBM in most cases only offers a probability of a cure or improvement: a significant proportion of those treated will not benefit at all. Some will be harmed.” Let me begin with your last point. Yes, every active treatment has a risk, but as I’ve said EBM enables patients and physicians to make informed choices. It is possible to do great harm with the best intentions, which is way we must hold evidence in such high regard. Are you familiar with the on-going libel case which the British Chiropractic Association recently brought against the journalist Simon Singh? This case illustrates one of my chief reasons to want to see homeopathy and other sham treatments no longer flattered by government support.

You warn me that lab trials are not always replicated in the real world. But my definition of “evidence” is not so narrow as to only include clinical trials (although I still regard a large, prospective, double-blind, randomised trial as the gold standard for determining whether and to what extent a given intervention will be effective). We can certainly obtain data from retrospective analyses, and from seeing what actually happens in the real world. Sometimes these results are surprising, but EBM means we can’t ignore results which sound wrong to us or which go against long-cherished notions.

For example, the United States Preventative Services Task Force recently altered its recommendations regarding breast cancer screening. In their report was the rather surprising and controversial finding that self-examination appears to have no effect whatsoever on breast cancer death rates, but that it can create a lot of unnecessary fear and alarm. The emphasis (at least in the States) is now on breast awareness – has anything in your breasts changed recently? – rather than teaching women to perform rigorous and regular self-examinations. Many people object to this advice on the basis that they have a belief that breast self-exams are important, or that they have a story about someone who found a lump during such an exam, and whose life may have been saved thanks to the operation which swiftly followed. This doesn’t alter the evidence which is that such exams make no difference to health outcomes, and we take lives in our hands if we allow our preconceptions and biases to defeat the evidence.

Where we really part company is when you describe different forms of medical practice as having their own philosophies. It sounds to me as if you are claiming that each of these philosophies is equally good, and the only real difference is in the philosophical starting point, EBM being no better and no worse than homeopathy. While that might be a useful diplomatic position to take, I simply can’t accept it, any more than I would accept Apartheid (or any one of a number of other atrocities) as a mere difference in political philosophy.

While it is true that there is a bewildering array of supposedly therapeutic modalities available, they all slot cleanly into one of two categories – based on evidence or not based on evidence. Anything not based on evidence is based to some extent on subjectivity and personal choice. A practitioner who accepts Reiki but rejects Iridology has no objective basis for making this choice. They simply prefer Reiki and allow confirmation bias to do the rest.

When the system is working (and god knows it doesn’t always) evidence-based medicine prevents even the most enthusiastic champion of a particular intervention from being able to claim that it works when it doesn’t. We know that Dimebon is ineffective for treating Alzheimer’s and so it will not be prescribed. We know that mistletoe will not cure cancer, but at the Royal London Homeopathic Hospital, they will apparently provide it to anyone who asks, and at the taxpayer’s expense.

This means that proponents of non-evidence based modalities have no choice but to duck the issue, or misleadingly cherry-pick from the data in order to create a false picture – which is exactly what the select committee experienced when it asked notable homeopaths to give evidence. Who benefits from this corruption of the scientific method? Isn’t this exactly the “denying the validity of science itself” which you hoped wouldn’t happen? Why does homeopathy get a pass? Because it does no harm? I’m not so sure that’s true.

You began by saying that you wanted to include in our discussion the whole context of treatment, and here again I agree enthusiastically. So, while we both know that a sugar pill in itself is guaranteed harmless, we also know that we are talking about a complicated cultural phenomenon which is not limited to a person taking a pill, and therefore nor is homeopathy’s reach confined to people suffering from chronic back pain. Nor is it always the case that homeopaths advise people who need conventional treatment to go and get it. In 2006, a survey performed by Sense about Science which was followed up by Newsnight found that every high street homeopath visited by a researcher about to travel to a malaria-infested country was given useless homeopathic quinine and none were told to visit a GP or a travel clinic or even to buy a mosquito net.

How are “responsible” homeopaths supposed to respond to this? The Royal Homeopathic Hospital did its best to smack down this irresponsible behaviour, but what are they really saying? “We all know the sugar pills don’t really work, so don’t for goodness sake go giving them to someone who actually needs medicine.” What would the True Believers make of that!? By beginning from a position which isn’t supported by evidence, “responsible” homeopaths are now in an impossible bind. They either have to defend the magic to the hilt, or admit that it’s all a load of imaginative nonsense. Not surprisingly, they hem and haw and waffle and evade, they dissemble in front of parliamentary select committees, and essentially they let the harm continue, such as in the horrifying case of the Australian couple who attempted to treat their baby daughter’s eczema with homeopathy until eventually she died after months of excruciating pain (they are now in prison).

So even if we are happy to divide quackery into good (prescribed by responsible physicians in tandem with evidence-based treatments where appropriate) and bad (prescribed willy-nilly by people with little or no medical training, and cheerfully offered as a substitute for evidence-based treatments, or non-medicalised interventions) – the question must still be asked can you have one without the other? This line of argument will eventually bring us back to vaccines, but I feel I should stop here, having written quite a lot already, and get another response from you.

JOHN

Can we aim for something a little more concise? I don’t have time for a discussion in this depth!

I am very pleased that you are taking such an interest in medicine and medical ethics. I note that you are a very much a postitivist in your approach and have no time for post-modernist ideas of different beliefs having equal validity! Well I don’t know that I have in extreme cases where it is clear that science has the best solution (e.g. antibiotic for pneumonia or angioplasty for blocked artery).

However, there are many grey areas where all is not as certain as one would like. As I have already mentioned, the much venerated ‘gold standard’ trial doesn’t simply distinguish effective from ineffective interventions. When the effect is really clear you dont need a trial. What we usually get is a statistical result showing that the probability of an effect is greater than could be due to chance alone. This means that some patients will do well but others won’t. The NNT (number needed to treat) may be 4 or 5 for a good drug or 10 or more for many others. So we can’t promise our patients that even a gold standard treatment will do them any good (or no harm). It’s a game of roulette. No one can tell what will happen to any individual.

It is unfortunately not the case that everything slots neatly into two categories, evidence-based or not. Evidence can be strong or weak. Evidence is continually being modified or even contradicted. It doesn’t apply to all individuals. So I tell my patients who ask me if complementary treatments are any good, that some patients find them helpful but others don’t. Same difference.

I agree that it would be dishonest to say that ‘a sugar pill’ will have a biochemical effect. But you can say that, some practioners believe that the way this pill was made can make a difference to the ability of some people to cope with an illness that conventional medicine has not been able to help very much.

I agree, of course, that no one should make false claims about these remedies. The information for cancer patients from the Homeopathic Hospital seems to me to make it very clear that these treatments are to help you cope with the illness and its definitive treatment rather than to act alone. I dont know about the eczema girl who died, it is often difficult to tell from these accounts exactly what happened. But no responsible doctor would have advised the parents to ignore conventional medicine. I don’t think this would happen at the Homeopathic Hospital. I went on a visit to the place and met the medical director Dr Sara Eames who was very clear about this. She also told us that all the medical staff have medical qualifications.

Can you have good quackery without bad? Can you have medicine without quackery? I don’t think you can have medicine based on evidence alone. There isn’t enough evidence for one thing. And people are often have health beliefs that are so firm that no amount of statistical information will influence them. The placebo effect, if you want to call it that will often make something happen. If you prefer you can call it the effects of thoughts and feelings being processed by different brain areas resulting in changes in pain perception, sensation, reduced muscular stiffness, improved mood and reduced anxiety etc. etc.

Enough for now!

I recently invited my father to an exchange of views about homeopathy – me from the point of view of an ethusiastic skeptic, eagerly slashing down falsehood and flummery wherever I find it; he from the point of view of a physician with decades of experience actually helping people to get better. Here is the first of our exchanges…

TOM

As I understand it, you think that NHS should continue to provide homeopathic remedies under some circumstance, and you are surprised at the strength of my feeling that they should not. Through this exchange of emails, I hope to better understand your position (since you speak from experience of treating patients, which I can’t) and to get you to better understand mine.

I imagine there is quite a lot of common ground between us, so before we get to the fun of the debate, here are some statements I think we can both agree with.

–          Homeopathy doesn’t work. Reviewing the evidence base as a whole reveals that homeopathy works no better than placebo. While a number of studies do exist which apparently show a more significant effect, these are always smaller studies often with methodological flaws. The better the study, the smaller the effect. This finding is confirmed by the Cochrane Collaboration and the recent Select Committee report.

–          Homeopathy couldn’t possibly work. The notions that “like cures like” and that “dilution increases potency” are pre-scientific magical thinking. Many homeopathic remedies are so diluted that it is literally true that not a single molecule of the original substance can possibly remain. How the water used for the dilution “remembers” the substance (and none of the other substances it had previously been in contact with) is a mystery which homeopaths avoid tackling.

–          Evidence-based medicine is, in general, a good thing. Especially within a cash-strapped NHS, treatments should be provided to patients on the basis of the best evidence available, not on a patient’s demand, nor a physician’s whim, nor in order prop up a discredited theory.

Assuming that we agree on these three points, it seems that you wish to make an exception to the evidence-based rule for homeopathy. Is that right? If so, here are the questions that next spring to mind.

1. Under what circumstances do you think it is appropriate for the NHS to provide homeopathic remedies? What are the possible negative consequences of doing this under these circumstances (if any)?
2. Do you feel the same way about chiropractic, reflexology, acupuncture, iridology, reiki (to name a few)? Are some of these interventions more worthwhile than others in your opinion? Are they all equally beneficial placebos or are some more worthy of public funding than others?
3. Are you concerned about the drop-off in vaccinations which has taken place in the UK and the USA recently? Do you see any connection between this and people’s fondness for alternative medicine?

JOHN

I think the first thing I’d like to say is that when considering the possible beneficial or harmful effects of any form of  treatment, I like to include not just the intrinsic chemical power of the substance prescribed, but the whole context of treatment.

The so-called placebo effect also includes the  treatment environment, the way the doctor approaches the patient, her kindness and consideration,  her ability to listen and to accept people’s distress. The faith of both doctor and patient in the theory, the method, the procedures, and in the personal relationship are all important too.  Every form of medical practice has its own philosophy, incuding evidence based medicine, which, by the way is not always as reproducible in an an ordinary community setting as it is under strict experimental conditions.  Even EBM  in most cases only offers a probability of a cure or improvement: a significant proprtion of those treated will not benefit at all. Some will be harmed.

You and I don’t believe that homeopathic remedies can have any chemical effect as such. But this is not chemotherapy. These patients are not being treated with agents that can kill cancer cells or eliminate antibodies. The patients who attend homeopathic practitioners and the homeopathic hospitals are suffering from chronic diseases for which conventional chemical medicine or surgery can do no more. The treatment is not and should not be a substitute for ‘proper’ medicine.  At the London Homeopathic hospital, where all the clinical staff are medically qualified, they examine people in the usual way and advise anyone who needs conventional treatment to go and get it.  The homeopathic treatment process  (including the empty tablets) has the effect of making patients feel better and feel cared for. It gives them some hope. The placebo effect can be incredibly powerful and can certainly  relieve pain and other symptoms such as nausea, giddiness, anorexia etc.

Are the remedies expensive?  No, compared with modern drugs, often unscrupulously promoted by pharmaceutical companies and overprescribed by doctors, they are cheap. Unlike most conventional drugs there is no risk of  serious adverse effects. The London Homeopathic Hospital has just had a fairly expensive refit. It looks beautiful, calm, tranquil and peaceful. It would be a pleasure to go there for treatment.  OK they don’t cure any cancers or kill any bacteria. But a large part of medical practice is about helping people to cope with  chronic illnesses that can’t (yet) be cured or with distressing symptoms that are not even understood.

There has always been a need for some sort of magic and mystery in medicine, going back to the ancient shamans. This has not gone away, despite the acievements of scientific medicine. If some patients are helped to feel better by what we see as pseudoscience, why should we be outraged? It doesn’t mean that we are denying the validity of science itself.

I think the money is well spent!   And, by the way, I have no  personal interest to declare.

Finally in answer to your last three points:

1) I have argued above that the remedies should be seen in the context of the treatment as a whole and the kind of ill-health for which homeopathic treatment is suited.

2) I think a similar case can be made for the other complementary therapies but I dont think any of these are publicly funded at present. I think some treatment ‘stories’  will  help some patients  but not others and there is no reason why those whom conventional medicine still cannot help adequately should not explore them. It’s important, if you have a chronic illness, to have a plan, to keep trying.

3) I think the drop-off in immunisations has been largely due to Dr Wakefield, a thoroughly conventional medical researcher who got carried away and did a lot of harm. I don’t think homeopathy has anything to do with refusing vaccines of proven effectiveness.