It’s a simple rule of thumb. The efficacy of a diagnostic test is determined largely by the base rate of the phenomena under study. If pedophilia is rare, for example, it’s going to be hard to detect.

Presume that pedophiles comprise 5% of the male population. If one then asserts that pedophilia is baseless, that statement is 95% accurate. Only 5% of the population is misdiagnosed. Psychological tests for pedophilia, despite comforting illusions to the contrary, never approach that level of precision.

Pedophiles are also extremely secretive; they’re devious too, eliminating confidence in self-reports. The bigger concern however is the appalling costs of diagnostic errors. In custody battles, for instance, men who are not pedophiles (false positives) can lose their kids, whereas men who are pedophiles (false negatives) can gain them. Imprudent evaluators and expert witnesses, who then arm themselves with makeshift psychological tests for pedophilia and unabashedly insert themselves into protracted litigation, make mockery of diagnostic decision-making. That such tests, and the testimony surrounding them, have gained admissibility as scientific evidence in the courtroom is regrettable in the extreme.

 

It was a sympathetic and deeply moving portrayal; repetitive movements, striking gestures, cascading emotions; altogether seemingly unstoppable. My wife and I were transfixed. Alexx Shilling’s solo dance was breathtaking, and Victoria Marks’ choreography was flawless. In a world hooked on psychobabble, Tourette Floret is a thoroughly refreshing example of how psychological phenomena can be effectively depicted without words.

 

Doctors have heart attacks, get cancers, and feel depressed. They get sexually transmitted infections (STIs) too. His or her tattoos, genital piercings, and pubic hair prunings are no doubt suspect, but more likely it is something else entirely. Being too high, too drunk, or too impassioned to play safely are the more probable culprits. STIs can happen to anyone. It’s an ironic realism of medicine. Nailing down behavioral risk is certainly important, but not to the exclusion of making safe sex fun. Even doctors are more likely to reach for pleasure enhancing safe sex accessories when the going gets hot.

 

Sporting a do is better than a don’t, because the do, apparently, reduces the risk of sexually transmitted infections (STIs). Using a nationally representative probability sample, doctors at UCSF discovered that extreme grooming of pubic hair may create epidermal microtears that serve as conduits for STIs, or alternatively, extreme groomers have higher incidences of STIs because they engage in more adventurous sex. Curious findings no doubt but in either case the research relied upon a notoriously capricious methodology, the one-shot self- report questionnaire. As noted in the previous post (The Metaphoric Center of Sex) one of the three truisms of sex is that people lie like hell about it. Perhaps folks who are willing to admit extreme grooming are more willing to admit STIs too, which in itself would account for the covariation. The real issue however is not so much the risks of pubic pruning, but the bankruptcy of safe sex. Condoms suck. Putting time and money into developing pleasurable alternatives to condoms safeguards sex for everyone. Lest we forget, we’re all denizens in a tangled world of desire.

Several years ago I attended the 40^th birthday party for Robin Finck, the guitarist of Nine Inch Nails. Ten of us were crammed into a small booth in a nondescript restaurant in Sherman Oaks, California. The guy sitting next to me asked: What do you do? Not wanting to play the academic card I said I’m the lead singer and lyricist of the Americana Desolation Punk Rock band Crying 4 Kafka. I write songs like Give Sodomy A Chance. When he stopped laughing he said I’ve written an opera about oral sex. We shook hands and exchanged addresses. His name is Thomas Ades. The Wall Street Journal describes him as one of the most important composers working today. His opera, Powder Her Face, has been performed in the Royal Opera House (London) and the Brooklyn Academy of Music.

Sex is an unending soliloquy, certainly for a Gogolesque academic with decades of study. Envisioning the nexus that dominates the metaphoric center of sex I ultimately inferred that it was reducible to three facts: women get pregnant but men don’t; sex has the capacity for extreme pleasure; and people lie like hell about sex. During a two-day conference at Stanford Law School I happened to mention, as a parenthetical aside, my three-fact epiphany. Michael McConnell, the Stanford Law Professor who organized the conference, suggested that I add one more fact to the list. There’s no such thing as the reasonable person either.

 

In 2010, Science Magazine did a series of articles on the new Diagnostic and Statistical Manual, the DSM V. Many of the researchers involved in this revision, it was noted, had financial ties to pharmaceutical companies. Other questions were raised as well. Was there enough scientific evidence, for example, to support the diagnoses? More fundamental however was the concern with diagnosis itself. Instead of steadily accumulating and then discarding ephemeral classifications, one article suggested that psychology and psychiatry pay closer attention to the people they treat, and the symptoms that trouble them, than agonizing over a moribund deck of disorders.

 

I saw an Ouija board at a vintage store, Artifact, on Division Street in Portland Oregon. The board looked guileless and abandoned. Then I found myself thinking about the composer John Cage and the poet James Merrill. Merrill wrote Changing Light at Sandover in homage to an Ouija board; Cage composed Music of Changes sparked by the I Ching. Both strategies seemed jejune to me. I never resonated with Merrill’s poems, they aren’t especially visceral, and though I admired Cage for many reasons, the I Ching, no less than the Ouija Board, seemed like artifice to me. I prefer messy representations drawn from the frieze of memories and associations, coupled with the serendipity of human consciousness.

Once upon a time, psychologists spun intricate webs of theory, concocted of equal parts fact and fiction. Now, bubbling with exultations, a new era has arisen, whereby evidence-based rules supreme. Progress no doubt, but a bit disingenuous too, certainly for a discipline that steadfastly refuses to publish null results. Perhaps, instead, it would be more accurate to say that the true clarion call of the new centurions of psychological research is something on the order of carefully manicured evidence, though admittedly it doesn’t have quite the same punch as its evidenced-based counterpart. If marketing of psychological research is the objective, evidence-based is surely the way to go. If accuracy were the goal, more humility would do the profession well.