North Carolina and LGBT

North Carolina's governor signed a law barring local jurisdictions from passing laws which allow  trans sexual people who have penises and testicles from using public bathrooms designated for women.

If you find this bizarre or confusing, join the club.

This fight, from the ACLU perspective is about discrimination against a reviled group which only wants respect.  It is for some, similar to the old "Whites Only" or "Colored" bathrooms. 

But it's not that simple and it's not clear what the real issues are. 

I have tried, unsuccessfully to explore the complexities of this before, which span biology, law, ethics and culture.

That "LGBT" includes trans sexuals is an alliance of emotion and/or sympathy, but while  lesbians, male "gays" and a bisexuals have so much in common as to be almost indistinguishable on many levels, the trans sexual is a horse of a very different color.

Most of us would agree that homosexuality is not a "choice" but an innate biological state, something a person cannot and often would not want to change about himself or herself. There are some authorities, like Paul McHugh who might argue that sexual attraction and identification may be more fluid and malleable over the course of a person's life and there may be many influences on all this, but few people with experience in this realm would call it a "choice" or believe "deconditioning" or psychotherapy would work or should be recommended.

Trans sexuals might be described as people who feel the gender they've been handed (assigned) in life is wrong for them. The common expression is, "I'm a female trapped in a male body" or "I'm a male trapped in a female body."

Some make a distinction between "trans sexual" and "transgender"  by saying the trans sexual is a person who feels the wrong sex has been assigned whereas the trans gender may not feel this way.  But these are distinctions which are often blurred and there is much confusion about who belongs to which group. If you are a lumper rather than a splitter, this  group is heterogeneous: Some may be "pseudo hermaphrodites"  i.e. people whose external genitalia (clitoris, vulva, penis, scrotum) do not match what is inside or do not match the chromosomal sex in their cells--46 XY for males, 46 XX for females.)  Some of these pseudo hermaphrodites have biochemical enzyme deficiencies which result in "masculinization" of external genitalia and some have receptor dysfunction which means testosterone simply bounces off their cells and this results in feminine external genitalia (i.e. clitoris, vagina, vulva.) 

In the case of the biochemically disordered pseudohermaphrodites, there is sometimes a transition from female to male external genitalia at puberty, and the individual "grows" a penis and musculature develops. With some conditions (e.g. congenital adrenal hyperplasia) infants thought to be males will resolve to a female phenotype, often with biochemical and surgical therapy.  

All these different types of conditions may be subsumed under the rubric "trans sexual," although some would make distinctions between trans gender people (who may or may not feel they have been assigned the wrong sex) and trans sexuals (who always feel themselves to be the wrong gender). Got that?

But many, if not most trans sexuals have no biochemical enzyme deficiencies or receptor dysfunction. Why they have "gender dysphoria" is not understood, for the most part. They are simply males who think they would be happy as females or vice versa.

Not all male to female transgender have their penises and testicles removed. They may simply get estrogen therapy, but their anatomy remains unchanged.

Now consider when such a person decides to use a public bathroom.

In this country, we have segregated the sexes. This is not true all over the world.
In this country we have laws against public nudity and against men displaying their penises to women, whether or not they do so in a sexual way. Why we have these laws is more difficult to understand, but it has to do with cultural norms, and we might want to change these.

But to paper over the truths about all this and simply claim the North Carolina legislature was acting out of hate, intolerance of LGBT is wrong.  There may be resistance to the "T" part of LGBT but not to the homosexuals. Nobody is saying gay women should not be allowed into women's bathrooms.

The LGBT community has welcomed in trans sexuals. This is understandable because both homosexuals and trans sexuals/ transgenders have faced adversity and even hate based on their own sexual preferences. But it is a perilous linkage when faced with bathroom privileges possibly dorm assignments or trans genders in the military.

We ought to think these things through and not simply start screaming.

Transexual, Gay, Lesbian: Apples and Oranges?

This is a blog I have been warned against writing, but, at the risk of offending many of my best friends, I will offer it up, in the spirit of open inquiry and stating emphatically at the outset, I have only questions, not answers.

Some personal history: in medical school I was fascinated by issues which would now be called, "gender identity."  As fate would have it I found myself in a medical school where the departments of endocrinology and pediatric endocrinology and pediatrics were essentially laboratories of biochemistry.  The first report of five alpha reductase deficiency (5AR)was made by a fellow in endocrinology there, Julianne Imperato McGuinley. (This was what the book Middlesex was about.) 

First there are people some call "trans genders" who may not feel they've been assigned the wrong sex,  which some distinguish from "trans sexuals," who always have the feeling they have be assigned the wrong sex.

 People with 5 AR are born with "ambiguous genitalia" i.e, when the mother asks, "Boy or girl?" the doctor is staring at the genitalia and he's not sure. The clitoris is large and might be a small penis and the testicles are not dangling in a scrotum but there might be lumps in the inguinal canals (groin) or in the abdomen which might be testicles. The urethra opens at the base of the clitoris/penis. So, the matter of sexual assignment is in doubt. In the Domican Republic, where this trait is common, whole villages named their kids the Spanish equivalent of "Pat" or "Robin" or "Terry"--gender neutral names, because they knew some of the little girls would sprout penises at age twelve.

The medical school had a Metabolic Research Unit (MRU) which received patients with 5RU and also got patients with 17 hydroxyprogesterone dehydrogenase deficiency (17OHPD), an enzyme which catalyzes the production of testosterone, and these patients are born with amibiguous or female genitalia, because they are first wave of testosterone which occurs in the "first puberty" in utero was diminished.  Many of these people, with 46 XY chromosomes go through infancy and childhood feeling not like girls, chasing after their friends shooting toy guns, and acting like "tomboys."  When puberty arrives, as is the case for the 5AR patients, a tidal wave of testosterone basically floods past the bottleneck and exposes these folks to enough testosterone to masculinize their genitalia and their skin and hair and muscles. 

Both 5RU and 17 OHPD patients are "pseudohermaphrodites," i.e., their outward appearance (their "phenotype") do not match their chromosomes or their glandular tissues, i.e. they have intra adominal testes but not in a scrotum. On the outside, they look like girls; but on the inside they have testes.

Another group of  pseudohermaphrodites were patients born with ambiguous genitalia who had Congenital Adrenal Hyperplasia, a condition in which various enzymes along the pathway to cortisol production were deficient and so finding the road to cortisol blocked the metabolities on that assembly line, that roadway to cortisol detoured to roadways to male hormone production.  A ittle girl with 46 XX gets born with an enlarged clitoris and swollen labia, fused like a scrotum, and the question was whether she is a boy or a girl.  Maria New, the great pediatric endocrinologist, used the laboratory of Ralph Peterson and together they figured out what was going on and were able to treat these patients and say these were girls whose  ambiguous genitalia would regress once they were treated with cortisol. Sometimes surgery was necessary, but for the most part, these girls were successfully identified, treated and wound up leading normal lives as females.


In some cases of these infants, there were difficult decisions to be made regarding "gender assignment." Would a boy whose penis would never become much larger than a big clitoris ever be able to function as a male? Should "he" be assigned to the female gender and surgery be done to fashion a vagina? 

The MRU also got  people with testicular feminization, brought in for study. T fem patients have male chromosomes, 46 XY, but they have very unambiguous genitalia, on the outside: a clitoris, a vagina and nothing that looks like testicles. As they grow, they are frequently very pretty women, with no body hair, no pubic hair and luxurious scalp hair. But their vaginas end "blindly," and they have no cervix, no uterus and the gonads found in their pelvis are, under the microscope, typical testes. These people are "resistant" to testosterone, i.e. the receptors on their cells which make hair cells grow beard or pubic hair do not function; testosterone simply bounces off their cells.  In utero, if there is no testosterone effect, the body develops along female lines, for reasons not entirely clear. These are pseudohermaphrodites of a different sort.  It's not that they cannot make testosterone--their levels are often quite high--but unlike the 5RU or 17OHD patients, they cannot respond to these levels. This is a disorder of receptor function. These folks do not have "gender dysphoria" and have no doubt they are female and function as females, identify as femaies and feel female no matter what their chromosomes or gonads may be.

The same medical school had as chief of it's Westchester Division of Psychiatry, a very talented man named Paul McHugh, who had done important work in clarifying what is and is not schizophrenia. Turns out, as McHugh demonstrated, the sine qua non of that diagnosis is hearing voices--auditory hallucinations. With that, whatever serious disorder you may have, it's not schizophrenia.  That observation has held up over time and now that genetic studies are starting to unravel schizophrenia, it's still in place.

So, it is in light of that experience, of seeing people who had some confusion about exactly what sex they are, I have faced the problem of "trans sexuals."

For that early, formative part of my career, I thought of all these patients with these biochemical "abnormalities," or "differences" as people with pathology, with a problem to be solved by the powers of medical science.  This idea developed in no small part because these were "patients" presenting themselves, usually with their parents for a "solution" to their "problems" which could be defined in terms of enzymes, biochemistry and later genetics. 

But now I am seeing people arrive in my office asking me to provide them with testosterone (if they are 46 XX and feel they are men in a woman's body) or estrogen (if they are 46 XY and feel they are women trapped in a man's body.)  Some ask for support through "reconstructive" surgery, i.e., the removal of their testes and fashioning of a vagina. 

And I do not know what to think.

I'm not even sure what the risks of raising the blood levels of  a  genetic woman to male levels. I'm got some idea what the risks of raising a genetic man's estrogen levels to a female range, but there are more unknowns there than knowns. 

I have little doubt that homosexuality is not a disease, not a pathology.  I do not doubt that most homosexuals are "born that way."  

But even there, there is room for nuance.  Paul McHugh wrote an amicus brief for the Supreme Court in which he noted studies which suggest just how plastic and fluid sexual preference can be over the lifetime of, most particularly, women. While he stopped short of calling homosexuality a choice, McHugh suggested that all human beings go through phases of variable attractions to their own and the opposite sex and many things beyond genetics or immutable biology influence sexual preference at different times over a lifespan. 

 Unfortunately, he was writing to oppose gay marriage. The legal basis for the argument was everyone agrees that under the 5th and 14th amendments, you cannot discriminate against a class of people who are born a certain way, say Black,  and can do nothing to change that. But if people are not born gay, fixed gay, destined to be gay, then there is no "class" of biologically fixed gay people who can be considered an offended group by a law which forbids gay marriage.

It is a curious argument, in the sense that McHugh may be arguing gays are really no different from people who consider themselves exclusively heterosexual, so while we should not revile them for swinging just a little wider in one of life's arcs, neither do they qualify for special protection, since they aren't that different. 

 Fortunately, McHugh's argument did not carry the day, but it did taint the notion of his scientific objectivity when it comes to transgenders. On the other hand, while he did not claim homosexuality is a mental illness, he does say people who have "gender dysphoria" i.e. who seek help to change their sexuality, who have no definable biochemical reason for sexual confusion,  are profoundly mentally ill.

McHugh became the chief of psychiatry at Johns Hopkins and after taking on that role Hopkins stopped all transgender sexual surgery.  The reasons given had to do with follow up studies on the patients who had undergone transgender surgery. They had, in the Hopkins group,  and in multiple other studies,  a suicide rate of something like 20-30 times control groups.  This suggested a rather extreme form of "buyer's remorse." In the Hopkins experience almost one out of three people who underwent transgender surgery committed suicide.  It also suggests McHugh might be correct to assert these patients do not have, primarily "gender dysphoria" but a far more serious underlying pathology which resides in close proximity to depression.

So, I have to ask whether we are mixing apples and oranges to include homosexuals with transgenders with pseuohermaphrodites or people with definable biochemical abnormalities in the same group.  

I wonder whether the Lesbian, Gay, Transgender alliance is one based in politics or simply in the common experience of being attacked because of your sexuality.

 But is the sexual conflict of the transgender  or trans sexual person really comparable to that of the homosexual or, for that matter, the pseudohermaphrodite? 

One might argue that it's the experience of discrimination which matters, not the genetics.  A mix race child is likely to be considered simply Black by racists to seek to deny her the use of a "whites only" bathroom. In that sense, it doesn't matter if she is different, genetically from others in her class, when that class is defined by the way she is treated by others.  Surely, under the Third Reich, German, French and Polish Jews, half Jews, Roma and homosexuals all found themselves in the same cattle cars, no matter what their differences.

Next week I'll go to the Endocrine Society meetings where there will be sessions on these issues. 

I'm hoping to attend with an open mind.  
Confused, but hopefully open.

The Strange Nucleotides of Music

One regret:   I never heard my grandmother sing in her choir. 
My mother's parents  lived on a fourth floor walk up and if you leaned out of their kitchen window you could not quite touch the elevated subway which rumbled by. They did not have the money or time for sports.  They went to work and returned home.  My grandfather, to my knowledge never threw a ball his entire life; his one sport, after he retired on his union pension, was to walk to the park and sit on the benches and argue politics with his cronies. 
For my grandmother, it was her choir.

I heard about it, but I never heard her sing.

She was, rumor had it, very distantly related to Benny Goodman.  Who knows if that is true. She smiled and shrugged when I asked her about it.  "A cousin," she said. "A distant cousin, if that." 

That was a factoid which surfaced when my firstborn son started playing the theme from "Romeo and Juliet" on his keyboard, age five.  Where did that come from? I am not remotely musically talented, cannot carry a tune and failed at all attempts to learn the clarinet. His mother's side had some musical people.  His maternal grandfather was the sort who could listen to a song and then pick it out on the piano. And his mother sings in a choir. So there are likely some musical genes from at least one side, but I always liked the story about Benny Goodman.

As he grew up, he picked up the saxophone and was good at it, played in the high school jazz band, and other instruments got added along the way, guitar, and finally piano.  He was always very modest about his own musical talents. 

"When I first got to NYU," he said, "I thought I was God's gift to jazz tenor sax.  But, after about six weeks, hanging out with the real music students, and at the Greenwich Village clubs, I realized if I worked really, really hard for four years, I might just edge up into mediocrity."

Of course, that's part of his glass half empty personality. Watching his younger brother win wrestling tournaments at age 10, he said, "Right now, he is better at something than I will ever be at anything, my whole life."

Turned out, he was wrong about that.

One of the great satisfactions of life is acquiring mastery of something, of anything. It always requires attention to detail the untrained cannot appreciate, and it requires, above all, persistence.  But for some things, it also requires something that likely resides in the nucleotides of our DNA.  Whatever that is, he's got it.

His younger brother, the wrestler, grew up to be a surgeon, which in our family was not a huge surprise.  Both parents are in medicine and dinner table conversations have always been about patients and diseases and medical things, which left the musician in silence. Of course, he absorbed quite a lot of medicine just from hearing about it all the time, but it's not as if he could add much; he could only ask the occasional question. 

Which left him with the sense, despite his parents' best efforts to deny it, that what he did in life, music, did not count for much. 

Of course, nothing could be further from the truth.  Listening to some performance or song any of us might try to express what that music does to us, how and why it was so wonderful, but he can, in a few sentences dissect exactly how that effect had been achieved, the process, the details that made it work. 

Now, he teaches me piano by Skype. I proved to be pretty hopeless at performance, just could not get rhythm and notes lined up. So he's teaching me composition, which necessitates some basic music theory.  It turns out, each key has chords and each set of chords follows certain rules and if you follow the rules, the music sounds right, but if you violate them it just reeks. There are numbers and things which explain it and which make perfect sense to him.  Something about going from the fifth to the first to end a song and make it sound finished.  Stuff like that.

The fact is, I do what I do for a living because, given the modest level of my own intelligence and my paltry mathematical skills, it was the best I could do.  His mother had other talents, but eventually she also found that the money was better in nursing and midwifery than in journalism, and the emotional rewards were better. His brother was one of those people who just had to go into surgery, and if he had not found surgery, he might have wound up in jail, or selling insurance.  We all just kind of drifted where the tides pulled us and we benefit society modestly; at least we do no great harm, pollute no rivers, deplete no resources, drive nobody into poverty, move nobody out of their homes, demean nobody,  make nobody feel worthless. 

The musical son, on the other hand, works in that world which actually enriches the soul.   

A friend in Hampton has a son who graduated from Winnacunnet High, then college, and then, inexplicably, went off to China, where he learned Chinese and enrolled in a Chinese university graduate program and it's anyone's guess what he'll do with that. For fans of "House of Cards" we can imagine he'll become the next Raymond Tusk, advising Presidents on China, or he'll anchor some American corporation in China. When this Hampton mother talks about her son, she has that dazzled look some parents have which says, in a look, "I have no idea where this creature came from."  He's done something few of us could have imagined doing,  something few of us would be able to do.  He's flown off with E.T. . He's had a close encounter of the Third Kind. He's simply left us all behind, on Starship Enterprise. Chinese is a tonal language, which makes it very tough for an English speaker,  and the written language is just as daunting. Going to China is going forth boldly where others would never dare.

We have the same feeling about the musician. Yes, there were some dabblers in the family, but nobody who went from dabbling to mastery in music.  It's not that we all went off into medicine because we thought it was more important than music--none of us had that thing we call "the talent" to go the music route. So we settled in to do something anyone with half a brain and tenacity can do.  For music, you need something more than determination.

Some days, on my commute, a song will come on the radio and I'm transported by intracranial time travel to another time and place entirely.   "Angie" by the Stones:  I'm catapulted back to a moment, a scene on the neurology ward, when that song came across the hall from the nurses' station and I'm totally back there, mind time travelling, out of the blue. Lots of songs can do that. They are as potent as smells, firing off neurons bubbling up buried treasures.  It's a wonder I don't drive off the road. 

Which is why, though we'll never convince him of this, what he is doing is in some ways more valuable  than what the rest of his family has done.  We kept people going, restore some people to better health, but he is doing stuff that will bind into  brains of people he'll never know, and become part life where joy resides.

And who says joy isn't important?

The Importance of Dogs

Not Tugboat. A facsimile

I did not want my current dog.  I only ever owned one dog in my life, a Shepard/ Lab mix,( mostly Shepard except for his Lab ears,) prior to this current dog, a yellow Lab, Tugboat.  
 When that first  dog, Bugs, got suddenly ill and could not stand up, it was the day we we driving up to New Hampshire to start our new life, and we had to detour to the vet to have him killed. 

A bad experience. 
The vet said, "Bugs has always trusted you to do the right thing for him. You have to do it now."
I had never hurt that dog, never so much as hit him. He wasn't a very demonstrative dog, but I think he trusted me. 
So I watched while they overdosed him with some opiate and he stopped breathing.

Never again, I vowed.
"Sure," my wife said, , "Right. " And a year later we had the new dog.

That would be the actual dog

He gets me up every morning at 4:30 AM (5:30 Daylight Savings Time) and demands his routine: outside to pee, poop (which I have to bag, such fun),  inside to eat and after I do my treadmill,  he wants his 20 minute walk. Then he's set until I get home.  

My wife and I  travel more now, and every time we do, we have to get the dog a place in a dog hotel.  One of these is the Taj Mahal of dog hotels and has a twenty yard swimming pool, which, as a Lab, he particularly appreciates. 

Weekend mornings,  we go to the beach. Plaice Cove beach does not exist at high tide but at low tide it is wide open and he gets to chase a rubber ball which can be flung thirty yards with the spear chucker thing.  The day is planned around the tides.  Whatever errands I have for Saturday or Sunday, they have to be done  between  high and half tide. Low tide is for the dog.

The dog rules my schedule and my life. 

On the other hand, he is a very friendly dog and I have met many people on the beach,  as I ran up to tear him away from beach walkers. 

If I had only known, when I was young and riding the testosterone wave, how many women one meets with a dog, I would have owned dogs then. 

But now, not so much.

Bugs, the first dog, saw a beach only once in his life, but he did run along the river and the Cabin John Creek (his favorite outing) and he tangled with the local fauna, which included muskrats and deer.  There were lots of beavers, but beavers are very tough on dogs and I had to get him back on leash, whenever there were beavers around.

The Shepard was an intimidating dog, and I did not meet many women with him, but I did meet a lot of muskrats, which are almost as good. 

Muskrat

Muskrats, it turns out, will stand their ground against even a big, eighty pound Shepard, and they are very spunky and inspiring.  Bugs threw one up in the air, and it did two back flips before landing on its hind feet and it raised its paws and its chin and looked at the two of us, "You want a piece of me? Well, here I am." I dragged the dog away, who was only too happy to be dragged away. 

I don't know why I'm talking about dogs today.

Downy Woodpecker, Resident of Hampton, NH

Oh, wait. I remember. We saw a Downy Woodpecker on our morning walk; that's why. I would never have seen this wonderful bird if I had not been out at sunrise dragged along by Tugboat, who  ignored him, too busy sniffing the almost Spring, half melted ground. 

The woodpecker flew right by my face, and landed on a branch and looked around and then flew off. 

But he made my morning and I owe Tugboat that.

Little Sisters of the Poor Go Supreme

Who can resist the Little Sisters of the Poor?

I mean, the name alone!  

And they do such nice things, like providing homes for destitute women, where they sing and dance and think lovely thoughts.

But, as is so often true for religious institutions which do work in the secular world, whether it's running hospitals or universities or homes for poor women, nuns cannot do all the work, the cleaning of the rooms, the hauling of garbage, the surgery, the radiology the emergency room nursing. So even the nuns and the priests need help and they have to hire non Catholics and when they become employers in America the nuns incur certain social responsibilities, like paying for health insurance. 

And that's where the nuns found themselves in conflict with the government. Under the Affordable Care Act, the nuns had to provide health insurance which covers contraception, but if they don't approve of contraception, they have to inform the government of that objection so the government can provide it.  The Little Sisters has to file a form which says they do not want to pay for contraception.

The government is not asking the Little Sisters to provide the names and addresses of the employees affected by their refusal; the government just wants the declaration of objection, as I understand it.  The government will say, "Okay, if your employer won't provide this, we will." 

But what the Little Sisters said was, "No, we don't want you to provide contraception coverage to our employees, even our Protestant or Jewish employees, because we consider contraception a sin, an evil and we will not be party to that."

That the employees may disagree about this, that the government disagrees about this does not matter. The Little Sisters refuse to be tainted by even thinking about what their female employees may be doing in their off time. 

Their case is now before the Supreme Court: If you want to work for us, you have to accept we will not allow the government to pay for your contraception.

It's not enough that any pamphlets about contraceptive coverage has to be put in a separate envelop and mailed separately to employees. 

It's not enough that the position of the Little Sisters about contraception can be posted and explained and advocated by the Little Sisters to all those non believers among their employees. Employees must not be allowed to avail themselves of the government's program to pay for their contraception.

So the religious beliefs of the Little Sisters are going to be imposed upon their employees by the act of forbidding the government from identifying them.

We are not going to allow those naughty government people to lead you down the path toward perdition.

Where do you begin with this argument, as a matter of law or as a matter of policy?

You have a religious order which has decided to step beyond religious rites to operate in the world of social need, but it decides in doing so, it will use this action to impose it's views on non Catholics. 

Without Justice Scalia to find some virtue in this argument, this is a case I would not bet the Little Sisters will win.

But, here is the really amazing thing about this case: It comes on the heels of the scandals concerning priests and sexuality.  

It comes at a time when most Catholics practice contraception and reject the Church's argument against contraception. 

It is a stand against contraception, which, if experience is any teacher, means the practical consequences could be more abortions. 

Does anyone, other than the Little Sisters,  still believe contraception is a sin because God wants sex to be for procreation only?

It all reminds me of the time I sent a patient to Georgetown University hospital for a semen sample. The patient happened to be Catholic and he and his Catholic wife were having trouble conceiving, so I had to know whether he made sperm. 

I get a call from an embarrassed director of the laboratory: "Uh, Doctor, you do know we cannot do a semen analysis."

"No, I did not know. Why not?"
"Because to provide a semen sample the patient has to masturbate, a cardinal sin."
"But this is to help him get his wife pregnant. To make more little Catholics!"
"Sorry, Doctor. Those are the rules. This is a Catholic hospital."

Actually, I had forgotten that. Georgetown is a Jesuit institution and they keep the Catholic part pretty muted, beyond the obligate photo of the Pope next to the elevator in the main lobby.

At what point does the Catholic Church realize its position toward sex leads regularly to absurdity and real harm?

If this were just the Baptist owners of a fast food restaurant, you could say, well, those people are Bible thumpers and beyond the reach of reason. But the Catholics got Jesuits. We might have expected something more subtle and better thought out from this group.

Really, in this day and age. 

A Plan for Responding to the Next Terrorist Attack

By now I think any of us can write all the stories for the news broadcasts for  the inevitable next terrorist attack:

1/ "Bombs explode at ...[fill in the blank: airport, shopping mall, train station, subway, bus, soccer game]... and emergency response is swift and heroic and it is not immediately clear who is behind the attack, but ISIS takes credit."

Got that?  
Be sure to include the five second video, someone captured on his smart phone at the time of the attack, showing smoke and people running, and show this in endless loops,  as if we are seeing  "breaking news" every five minutes.

2/ Police are deployed to airport, shopping malls etc, in the best  classic closing-the barn-door-after-the-horse-has-escaped manner. 
3/ Terrorism experts are interviewed about what this all means and they say what this means is we have suffered another terrorist attack and there may be more but we cannot say exactly when or where.
4/ Public officials issue statements calling the attacks cowardly and reassuring the public this isn't the fault of public officials.
5/ Donald Trump says, "I told you so."
6/ Some officials remind us we need to engage Muslims to help root out and identify potential disaffected young Muslims who may be radicalized.

The facts are these:
1/  Why They Do The Things They Do

In much of Europe, France, Belgium, England, Germany, Muslims account for only 7.5% of the population but comprise 65% of the prison population, which means young Muslim men (and sometimes women) are unemployed, bored, disaffected and attracted to any bad boy who raises a flag and pays attention to them. 
Up to 14% of  Muslims in Europe say they are attracted to the message of radical Islam. But about 7% of non Muslim youth--the hard core "losers"--also say they are attracted, suggesting that there is a bad boy culture inhabited by people  who simply want  to disrupt a society they think keeps them down.

2/ Predicting the Next Attack: Good Luck With That

ISIS likely does not plan San Bernadino or even Brussels from some central nerve center, but just acts as a cheerleader for individual malcontents who want to strap on a suicide vest, or go hijack an airplane and none of that takes much in the way of money transfers or central office organization. 

 A bunch of disaffected young men who have been spurned by blonde women in the Western cities where they live  can now  go out and blow something up in revenge. No blondes in this life, but plenty of virgins awaiting in the next.

Sexual frustration, envy, economic despair may play a role in some of these bombers and shooters, but when they  have no central command and control you have about as much chance of intervening in the next attack as you have in preventing the next mugging or convenience store hold up,  because these events are just too random and unconnected. At least with banks and convenience stores you can have security cameras. 

This is no war we are fighting. We are fighting individual deviants who are connected only by their desperation and inclination toward violence, as are many street thugs, who get their kicks through violence.

3/ Do We Have a War of Cultures?

If only 7.5% of young Muslims sympathize with ISIS and the idea of killing people randomly in the name of Allah, that is still maybe a million people. And it's hard to keep track of that many people, even if we knew who they were.

4/ Our Relation to the Muslim World:

In some parts of the world we have Muslims who are supposedly joining us in fighting the Taliban, ISIS or Al Qaeda who are themselves pretty hideous, like the Afghan police who chained young boys to beds in their police barracks so they could rape them at night for fun and pleasure.  Allies like this just make your skin crawl and at some point we have to ask ourselves if they are worth it.

Throughout larger portions of the Middle East, women are treated like possessions, regarded as the source of shameful lust and kept covered and imprisoned at home and although people in these cultures may not hate us or even think much about us, we have a hard time respecting them and they sense that, and we will never be friends. 

But we have substantial numbers of Muslims living in this country, in Detroit, New York, Boston who are fully integrated, who share our values about treating women well, who are doctors and lawyers and professors and contribute substantially to our nation.  We have no reason to alienate these people and every reason to embrace and celebrate them.

5/ Get Used to It: The Inevitable

We will continue to have bombings and shootings like Paris, and San Bernadino and Brussels for years to come, but none of them threaten the existence of our Republic.  This is not like the London Blitz or Panzer divisions sweeping across the fields carrying a force which can subjugate us, occupy us and haul people off to concentration camps.  Terrorists disrupt but they do not destroy free societies. 

We are all a little disoriented: We can understand a shoot out in a bank. We can even understand a street mugging turning into murder. We can wrap our minds around a gang rape in a park. These are deviant behaviors we have come to terms with. 

We are still trying to get accustomed to suicidal young people who want to take out as many people as they can,  because they feel oppressed and they want to go out in a blinding flash of "glory."  

But, next time,  let's just shrug and say, "Oh, THAT again," and stop interviewing experts and putting breathless news anchors on TV  with all their wide eyed solemnity, asking questions of government officials about what all this means, and about what could have been done to prevent it.

We know what it means by now.
We know nothing can be done to prevent the next one.
We just have to shake it off and move on,  and be glad it wasn't us this time.

Women and Power

Maggie Smith before Aunt Violet: Miss Jean Brodie

With Hillary Clinton's candidacy for President much as been written about whether she is actually making history or would be if she is elected.  And much has been said about her posing a threat to males. The words "emasculating" and "castrating" keep floating up from the loam.

Actually, I do not buy the idea that women who function in positions of power are a threat to the male ego. This may be because some of the best teachers I had in medical training were women. They were in a position of power over me but they infused me with new power by teaching me how to do things, an arterial stick, a mental status assessment. They left me more powerful, not less.

The Countess Markievicz

Power has been said to be an aphrodisiac, and Henry Kissinger is often the prime example. Henry, the ultimate nerd, a Dr. Strangelove look alike, dated beautiful women and nobody could understand why women accepted his invitations and the answer was always, "Well, power is an aphrodisiac." I cannot speak for these women, but the man was, is, and always has been a wimp and a phony, which is the worse sort of wimp.

What makes a woman powerful, in my eyes at least, is not the office or job title, but her personal qualities. Women like Aunt Violet of Downton Abbey, who can cut anyone down to size with a single line, a single apt observation. Those are the women who wield real power. 

Kathleen Lynn 1874-1955

Women who can see past the glitter, the uniform, the money to the essence of a man are the most dangerous and most interesting women. And the best women of all are those who may by birth or marriage or personal attainment have reached a level of comfort and security, but who remain sympathetic to and dedicated to those who have been left behind: women of a liberal persuasion who cut down to size the posers and the cruel and the men indifferent to the suffering of their fellow men.

Today's New York Times carries a discussion of women who were potent forces in the Irish Easter Uprising in the early 20 th century (circa 1917). The Irish, over the years have produced a disproportionate number of women who refused to be cowed.

The hung over day after St. Patrick's day is a good time to remember what Ireland really gave the world, and it goes way beyond Guinness, James Joyce and the Kennedys.