COVID-19 Reality

Wow there is soooooo much bogus information about COVID-19 going around right now. Partly this is because the government didn’t say enough soon enough to inform people, partly it is because people don’t want to take the effort to actually look up real information, and mostly because people don’t know how to tell the real from the crap.

Here it is straight.

TL:DR The facts you need to know about COVID-19; How to spot fake news; How to stay sane

Corona virus is a kind of virus (there are many millions of different viruses) that can sometimes affect humans. Other viruses you might be familiar with are influenza, ebola and measles. None of these are the same virus, just like I am a vertebrate, so is a chimpanzee, rat and chicken. We aren’t the same, even though we are in the same category.

Corona virus is zoonotic. That is, it mostly exists in non-human animals and occasionally crosses over to infect humans. The most common form of this is about 20% of the common cold. The common cold is categorised as rhinovirus, which is the group name for many viruses that attack the nose, causing it to “run”. Usually we humans experience a runny nose, a sore throat, some fatigue and fever. Generally we successfully overcome it.

This version is different. It mostly attacks the lungs and heart. Age and gender appear to be less relevant than do you have an existing (whether you know about it or not) lung and heart condition. If so, you have switched from potentially 3 times more deadly than the worst influenza in the last 10 years to potentially 70 times more deadly [link] and [link].

Because this version is so different, we are giving it some special labels. 2019 coronavirus, SARS-2-Cov, SARS-Cov-2, COVID-19, COVID-19 virus etc. For all intents and purposes, they are the same thing (there is a slight difference between the virus itself and the pneumonia/heart conditions caused by it – but let’s keep this at layman’s level, hey?)

Numbers are hard. We humans struggle with them as soon as we reach greater than 1000 of anything. So let us compare COVID-19 to the last big epidemic most people know about – the Spanish Flu. As a matter of destigmatising, it is important to note that this outbreak was named only because Spain was the only country reporting on it. It was first medically detected in the USA. This influenza, while a completely different virus to COVID-19, rocked the world with how deadly it was. It killed about 50 million people world wide (the number varies between 20 million and 100 million because many countries did not keep good statistics). It’s estimated penetration into the community was infecting 1 in 3 people and spread at a rate of about 2.4 infections per infected people. It killed 2.4% of all people who were infected.

COVID-19 has an estimated penetration of 20% to 60% (we don’t really know yet, because it hasn’t finished infecting those who can be infected). This number is important because it gives you an idea of how likely you are to get it if you are in an infected area. This penetration number can be reduced by good hygiene, increased separation from people (social distancing) and isolating those known to be infected. The next number we gave for Spanish Flu was the infections per person. That is, how many people does a not isolated infected person infect? That average is currently being clocked around 2.4 people. In Australia, we are seeing the number increase by 100% every 2 days. That is, if 10 were infected yesterday, then 20 (including that original 10) will be infected tomorrow. If 1000 were infected yesterday, then 2000 will be infected tomorrow. [link]

It is spreading fast.

The next number we used for Spanish Flu was the kill number of 2.4% (estimated because of those bad stats we mentioned earlier). We don’t actually know what the kill number for COVID-19 is as it isn’t over yet (much like the total infectiveness number). However early stats indicate that when the thing is managed well, and the number of people needing hospital is lower than the number of hospital beds available, then the kill rate is 0.9%, which is about 3 times more deadly than the worst seasonal influenza in Australia in the last decade, and not too bad compared to the Spanish Flu estimate. In Australia, where we have kept the number of infected below the number of ICU beds we have, the kill number is really low. But that will change when our infection numbers exceed hospital. We recently saw that in Italy, where a statistic I saw about 7 days ago (approx 16 March 2020) indicated a death rate of 7.7% [link – stats may no longer be relevant]. That is about 3 times worse than the Spanish Flu.

Currently 80% of people infected walk away with no known long lasting effects from COVID-19. The other 1 in 5 infected people aren’t so lucky. The other 20% of people will need hospital assistance. Let us pretend that 5 people go to hospital for care. On average 4 of those will need low intensity support, and walk away with minor lung damage and a stressed heart and should watch that for the next few years. The 5th person will need to go to ICU [Intensive Care Unit] (on average) where they will probably recover and leave the hospital. As the numbers of infected people rise, the number will exceed the ICU beds, and those people will die. That is the difference between Australia now, and Australia when we hit Italy’s level of infection. Somewhere around 5% of the population that are infected, which is likely to be twice the number of the Spanish Flu, will not recover and will not leave the hospital to live their lives.

So what can we do about this?

First of all, follow the medical advice.

  • Hygiene – imagine the world outside your safe zone (usually your house) is covered in wet paint that takes a really long time to dry (up to 48 hours). The only way to keep the paint off you and the things you care about is to avoid touching stuff. Before you eat or touch your face outside your safe zone, wash your hands. When you return to your safe zone, go and have a shower and wash the clothes that you were wearing. Also wipe down any objects you handled while out there, like your phone, wallet and keys. Wipe down the items you brought back. Get used to doing this now.
    • Soap and water is the best method to clean things – soap damages the virus. Use the WHO Standard of Hand Washing. Alcohol that is stronger than 60% harms it too, but not as well as soap. Bleach is the next best. Vinegar, cumin and tumeric are useless.
    • If you have to sneeze or cough, do so into your own elbow or shoulder. The idea is to cut down the spray you eject that covers surfaces.
    • Gloves and masks are minimally effective as most people are not trained to use them properly. Avoid the Dunning-Krugger ignorance effect and think you know how if you have not been formally taught.
  • Social distancing – keep about 1.8 m (6 ft) away from others [link] whenever you are outside of your safe zone. If you don’t touch a person, or get into the region their sneeze/cough can get you, you won’t get infected.
    • People forget that lines are close, schools are close and parties are close. These break social distancing protocols.
    • Sometimes you will have to get closer to people. Minimise these times and go wash afterwards.
    • Rethink going out – if you can avoid leaving your safe zone, do so.
    • Isolating those who have infection – if you know someone, encourage them to keep curfew. If you are in the government, enforce the fines for people who break curfew.

Myths – In an absence of real digestible information and in a spirited effort to make this less serious, people are grasping at quick fixes and misinformation in a delusion that they can get through this faster and unscathed. Stop it. You are putting yourself and others you love at risk.

Quick ways to tell if a thing you hear is fiction

  • “Scientists don’t want you to know” – actually they do want you to know the right information, they don’t want you to think you know misinformation.
  • “How to make your own cure” – no you can’t. If it were that simple, the government would be spending money on that instead of all of these expensive scientific methods.
  • “This natural substance cures/prevents” – not for this, not in humans.
  • “All you have to do is these simple things” that isn’t only listing the primary two methods of Hygiene and Distancing in various ways
  • There is no link to sources

How to not develop an anxiety disorder

  • Slow down your social media and reading all of the scary stuff that is above and beyond what I’ve written here. This is what you should be concerned about, not the other things designed to scare you and make you share stuff. Only share if it is sources and scientific.
  • Have a plan on how to maintain your safe zone. Practice it now while mistakes are not likely to cause contamination so that later when it is more critical you have the system down pat.
  • Stay in contact with your village via the internet (in today’s society, our friends are our village – the people we care about)
  • Reach out to those who are health compromised and offer to get them stuff when you get your own stuff. Leave it at their door to avoid possible contamination. Try to disinfect it first.

And most of all, plan for a long time in this new world, because this isn’t going to blow over soon.

Chronic and Complex Health

There is an interesting point in chronic illness when you have got past the shock, denial, bargaining and anger stage and you have settled on sadness/numbness.

This stage is where the reality of your condition hits you the hardest. The life you had is gone. You can’t do the things you use to do the way you use to do them. You have to factor in this condition for the rest of your days (or for those with just a complex health issue, for a few years).

There are three common phases at this point.

Survival – Doing what you can to get through today, possibly tomorrow. There is no space to really think about next year. It’s just about surviving now.

Existential crisis – A sense of unreality where things stop having meaning, or the meaning of things has shifted. It’s like suddenly discovering that the thing you’ve been calling red all this time is actually green. You’ve woken up from the dream into the wrong world. You look at things that others are getting all anxious about, or slaving their guts out for and realise that it is all fiction. They have no idea what hardship actually means.

Attempted acceptance/planning – In moments where you realise that you’ve kind of got the hang of day to day management considering this thing, you start to wonder what next year is going to look like. You try to make guesses for long term set up and realise that you actually have no idea, because you’ve never experienced this thing before and your guesses now will be invalide next week. Because as your diagnosis sets in, and you’ve been scrabbling to make sense of it all, the situation is changing so rapidly that what was true yesterday is fiction today, and what is true today will be fiction tomorrow – or next week. Planning is a strange concept, but you keep trying.

Of course, you’ll also be flicking around bargaining and anger for a bit too.

For those of you who have experienced chronic illness or complex disease, you’ll recognise these phases.

People being affected by COVID-19 are going through this now. For those people recognising these phases because of COVID-19, you’ve just been given a deep insight into the flailing stage of chronic and complex medical health crises that many people experience.

When all of this settles down to a predictable life, try to remember this for when you come across people experiencing chronic and complex health.

Change

Change is hard, and when unnecessary, it is a waste of resources. There are some very predictable phases that change prompts in humans, which Elizabeth Kübler-Ross describes in the phases of grief. Understanding these phases may help us to understand some of what is happening in the world right now.

Prior to the event that may require you to change, maintaining the status quo is the most efficient way to be. You have a rhythm, a set of expectations and known measures for success. It is within your best interests, as a general rule of thumb, to keep things going this way. An advantage of keeping this status quo, even if it isn’t that good for you, is that it is predictable, and even if we don’t like what we are predicting, predictable is comforting.

—–

Surprise

Generally change events are unexpected. We experience surprise as our predictions for what is supposed to occur fail. Prediction helps us know what to do and when our predictions fail, we need to pause to re-assess. Consider crossing the road. If the traffic behaves as you predict, then you know when it is safe to cross and when it is not. If the traffic starts doing weird things, then you will freeze as you assess how you are going to get across.

Denial

We don’t want the change to be real, or if it is real, bad enough that it requires us to change. Often if we just wait a bit, the anomaly that has caused the change in our prediction will go back to normal and we can continue as we have before. There is an efficiency in denial, where it delays us expending resources on change when that change isn’t necessary as the event was a false alarm, or delays us in over committing resources to a thing that only requires a small modification. We usually don’t notice when denial is effective, because things didn’t become a problem.

Bargaining

If we can do a small thing, pay a small price, make a small deal to get us back to how things use to be, then that is an efficient use of resources. If that doesn’t work, then we will expend more resource on a bigger bargain with someone or something to try to get back to where things use to be. In the cold light of analysis, this expenditure of bargaining resource can be more expensive than making the needed changes, but it feels smarter to do, because we return to the known model – the status quo. When bargaining works, when we can solve the event, then life returns to normal and it was probably the smart way to go. When bargaining works, we often feel like we have overcome a thing and we feel powerful.

Anger

When we realise that bargaining has failed, we try harder. With more aggression. When that fails, we feel powerless. We push harder, or find someone to blame, or something to blame. When we can’t find someone to blame, or blaming others is not in our nature, then we turn the blame to ourselves. When we try harder, or find the person or thing at fault, we can force it to change the thing we can’t do ourselves. When this works, the status quo is resumed. When it fails we run out of options. We despair.

Sadness

Sadness, despair, numbness – these are all ways to describe the reassessment phase as you realise this is real and you can’t stop it. The change has happened. At this point going back is not feasible, but you don’t know what going forward looks like. You are lost.

Acceptance

The change is real and to survive this you must change. An acknowledgement of reality and an assessment of self is common here. Things you use to do that are no longer valid, relevant or effective are discarded and a search for new strategies to go forwards begin. It is important to survive in the moment.

Planning

We have survived, but we haven’t really grown into our new future. Planning looks forward to what the world now looks like with this new reality begin, amidst a frank assessment of how things need to be. Plans are made for that future and changes in the now are implemented to get there.

——

It is important to note that resources can be emotions, action, assets, wealth, friends and so on. IT is also important to note that people don’t just go through these phases linearly – there is a great deal of jumping about between phases, you can visit phases more than once and not everyone goes through every phase.

As I look at the world today, I see a great deal of the first four phases and not much of the last three. Mostly because we just don’t know yet how the world’s changes are actually going to affect us.

It is important to be patient with people who are in denial, who are trying to bargain a way out of this and who express their anger poorly. It is also fair to be patient with people who are sad and between actions. These are all normal. Help people to transition as best you can.

Some people have made it to acceptance and they are making immediate changes to survive the now. We just can’t really do the planning bit as the picture of the world keeps changing every time we look back into it.

People are Bad at Evaluating Future Risk

People are bad at evaluating a risk that is in the future. We seek certainty and struggle with shifting probability or uncertain error margins. This can lead to polarised thinking where we either grossly underestimate a risk, or grossly overestimate a risk.

Most people are fine at understanding relative numbers within two orders of magnitude. That is, we can easily comprehend up to 10 of a thing (first order of magnitude), and frequently up to even 100 of a thing (second order of magnitude), but fail when the number is greater than that.

For example, if I ask you to indicate how much area we need for 200 people you will indicate a certain amount of area. If I had instead asked you to estimate the area we need for 400 people, it would be only marginally larger. If I ask you to estimate one and then the other, you will double the area of the first – but that second area wouldn’t have been the area you picked if I asked you for 400 first. Because the number is greater than 100, we struggle to comprehend it. This is because in nature, when we were roaming around the fields looking for food, the difference between 100 animals and 1000 animals, or a small tree full of berries and a large tree full of berries, was insignificant.

The reverse is also true. When we start looking at 100th or 1,000th.

Our math has got pretty significantly tricky in the last few hundred years. We can do some really fancy stuff. Logarithmic math is really handy for dealing with numbers on vastly different scales of magnitude. However most people don’t really understand what that means. For example, the Voyager probes (1 and 2) had just under 64 kb of memory each. My mobile phone has an extended memory of 64 gb. We recognised that gb is bigger than kb, but by how much? If a byte is an ice cube worth of water, then 64 kb (kilobytes) is half of a bathtub. Now pause and try go figure out what 64 gb (gigabytes) is going to look like.

What do you picture?

The volume of 64 gb (gigabytes) of ice cubes is 2,500 olympic swimming pools, which still defies comprehension except that we get the idea that this is a lot of water. I’m fairly confident that you didn’t think your phone’s storage was that big when compared to the amount used in the Voyager probes.

Still, these are fixed numbers – so even if we can’t really comprehend the scale of it, we can work better with it than a moving number. We struggle when the numbers shift in time. We want a definite thing to plan for and against, ironically so that we can change the definite thing.

We saw this with the millenium bug back before 2000. Our computer scientists warned us that the mechanism of how our computers calculated the date was going to fail. A design flaw that was created for efficiency was not supposed to still be in use by 1995. The problem was that people weren’t upgrading as they should be doing and we really needed them to. What is the worst that could happen? Well, if enough computers fail, then modern civilisation halts. Planes could literally fall out of the air, power stations could stop, water could stop and databases could be irreversibly corrupted (health databases, banks and government registers). Just think about all the things you currently rely on electricity to do. 

“Of course”, said the scientists, “we could just fix it”. The computer scientists estimated the world cost for upgrading the key systems that would ensure that civilisation continues and were ignored for another few years. Which magnified the cost by roughly 100 times. Not percent (which would have just doubled it), but 100 times. It cost up to 1.6 trillion dollars to fix world wide.

Here’s the irony. Because it was fixed, there was no disaster.

People felt justified in calling it a hoax. Even though over 30,000 failures were reported around the world to relevant computing bodies (the systems that weren’t fixed). It was known that not all systems could be fixed due to the long delay in acting, but if enough systems were fixed, the infrastructure would be robust enough to survive a few failing systems.

This is kind of like getting upset that your car didn’t crash like your mechanic warned you about, if you don’t get your brakes repaired. Heeding the warning of your mechanic, you repair your brakes, and then… lo and behold, your car doesn’t crash. Whoa…. spooky.

Climate change is another similar problem. Our world scientists have warned us of a problem. The science is really solid that this is a real problem and that we are going to have dire consequences if we fail to act. That the longer we wait, the worse it is going to get, and the more it will cost to fix.

Much like the millenium bug, people are not taking it seriously because it is hard to comprehend. How bad will it be? Scientists can’t tell you for certain, because it is a moving target. But they all agree it will be bad.

Going back to a previous analogy, if you don’t change the brakes in your car, how bad will it be? Well, you will crash when they fail. But how bad will it be? That depends on the crash. You could just crumple a fender, or you could kill a busload of children, or a range in between.

The denier will say “if you can’t tell me how bad the crash is going to be, I don’t believe you know what you are talking about” and refuse to change their brakes.

Here is the irony though. If we do the world actions needed to stave off climate change, the denier will call it a hoax. If we fail to act, human life on earth might end (worst case bus full of school kids scenario, and kind of hard to come back from), or we might just lose 2/3 of the population. As in 5 billion people. If we do act, we can stave off the worst of that. We are going to lose people, our goal is to try to make that number as small as possible.

Recently there has been a virus outbreak, which has been named COVID-19. Extrapolating from early numbers in Wuhan China indicated that this corona virus had the potential to be really bad. It might also be mild. Extrapolating from a small number set usually has problems.

Consider a random sample of 10 people. 3 of them have blue eyes. Does this mean that the whole population of the world has 30% blue eyes, or that the only blue eyed people in the world were in that sample of 10 people? We just don’t know. So we increase the sample size to 100. It turns out that 20 people in this group have blue eyes. That tells us that there are more than 3 people in the world with blue eyes. We adjust our prediction to 20% of people have blue eyes, but it is still possible that there are only 20 people in the world with blue eyes. Now we look at 1,000 people. 100 of the 1,000 people have blue eyes. What does this mean when we try to extrapolate a trend? Does that mean that only 10% of the world has blue eyes, or that the region that we are sampling from has less than usual, or more?

This is the kind of difficulty that trying to predict how deadly a virus is. As the virus spreads to more people, more accurate predictions of the virus can be made. Yet deadliness is a deceptive term. A virus that is so deadly that it kills its host before it can spread has a 100% deadliness, but poses no real risk to humanity (except for the single host). For a virus to be a risk means it has to be able to spread. This is referred to the reproductive number, or R0 (pronounced “R Naught”). This is a combination of how good the virus is at infecting others and how much people can mitigate that ability. I might normally be the fastest runner at school, but if you break my legs, I’m not going to win the foot race. My ability to win the race has been mitigated. Falling on an object that punctures my lung hundreds of kilometres away from a hospital increases my risk of dying from that wound compared to puncturing my lung in a hospital. The punctured lung is inherently bad, but the risk of death goes up the further away from a hospital I am.

This shifting risk makes it hard for people to grasp risk.

In the case of COVID-19, in the best circumstances, it appears to infect some people asymptomatically. That is, they experience no ill effect and don’t even know they have it. Humans frequently have infections that spread throughout the population without them knowing about it. If COVID-19 only did this, mostly we wouldn’t care.

But it doesn’t.

There are people experiencing serious to deadly outcomes, and potentially 4% of the people infected have died. Or has it. We have not tested every person in the world to get proper numbers, so we can only extrapolate based on the information we have – I refer to the above blue eyed problem.

Factors that change the inherent deadliness of the virus for the individual are related to age, pre-existing conditions, luck, how good the hospital near you is, how overwhelmed the hospital near you is, when you go to seek treatment and so on. There is no fixed number to define this.

Which means that most people don’t comprehend how dangerous the virus actually is.

Another two factors are news coverage and misinformation.

People who report News have their primary goal on profit. Their job is to sell advertisements, which means capturing your attention so you can see those advertisements. Which means hyping everything up. News outlets generally either exaggerate the risk, or complain that the risk has been exaggerated. This leads to a false polarisation of information – it is either really deadly so be afraid, or everyone is lying about how deadly it is, aren’t they silly? Seem familiar? Gone is the myth that news was reported impartially.

Then we have special interest groups who are pushing an agenda above and beyond selling adverts. They are pushing misinformation. Fox media, owned by Rupert Murdoch, shows very strong bias for Murdoch’s interests. Gina Rinehart is a mining billionaire in Australia who pays special interest groups to confuse the public about the risks of mining and fossil fuels. The West Australian Newspaper keeps publishing “opinion pieces” that require no fact checking over “scientific evidence” that does, which strangely enough coincides with the Murdoch agenda and the Rinehard agenda.

A quick way to tell the difference between real news and special interest news is this: If it is a prediction, real news will say “it depends on these factors” with a recommendation to make those factors more favourable; while special interest news will either attack the authority of specialists or give you a definite fixed risk assessment – a confident lie.

We look for something solid to base our next plans on, so we tend to fall for the confident lie rather than taking the time to understand that the outcome is not fixed and we need to understand the factors involved to navigate this threat.

So take that time. If it is a concern for you, take the time to learn about the basic science behind it and ask questions. People who give you confident certainty should be trusted less than people who say “it depends on these factors”. Learn some basic science, learn critical thinking skills, look to international agreement from world scientists – they are usually right, ask “where is this information from, and what is their agenda?”. For example, a strangely named source that refers mostly to itself versus the Australian Government’s CSIRO science department – I’d trust the CSIRO. Educate yourself, but be careful not to fall down a conspiracy theory hole. Most conspiracy theories are wrong.

BPD Part 3 – Borderline Personality Disorder – The Experience

BPD is a complex diagnosis often given to people who present at hospital with suicidal ideation, aggressive behaviour or chaotic social situations; or a combination of all three. People who receive this diagnosis often have poor emotional regulation and tend to see situations in black and white.  This is about might drive the BPD Experience.

In Part 1 [Link] we looked at what BPD isn’t, and some of the many names that BPD is also known by.

In Part 2 [Link] we looked at some of the diagnostic criteria that is used when giving someone a diagnosis, including a list of aspects that I look for when determining if BPD is an appropriate label for someone’s experience.

In Part 3 (this article) we will look at what is probably going on behind the scenes that leads to the experience and behaviours that meet the criteria in Part 2.

In Part 4 (yet to come) we will look at how to tell if something needs to be done about your experience of BPD, and if so, what that might be.

The JDT List

This is a quick refresher on the list that we use when considering BPD as a good descriptor for someone’s experience. For a more full write up, please go and take a look at the bottom third of Part 2.

* A Loss of Self – a chameleon like ability to adapt to the person they are with.

Dysregulated Mood – all moods are at extremes and calm is a foreign concept.

* Perception Distortion – always looking for the threat in the situation, but more in the people they interact with. This includes looking for betrayal, looking for the fight and looking for the threat.

* Black and White Thinking – things are either black, or white, never grey, and certainly not coloured.

* Boundary Confusion – a focus on “how it should be” and low ability to adapt to “this is how it is”. Uncertainty about what is “good enough”, and what “Reasonable” means.

* Chaos – people around them are often thrown into chaos dealing with the persons inner chaos, life and relationship chaos, self harm and or suicide attempts, emotional dysregulation and so on.

Each of these are strong characteristic presentations of a few common underlying thought mechanisms. A thought mechanism is a method by which you solve a problem, which when working properly allows you to function alone, in a group of people and in society in general. When a thought mechanism is not up to the task maladaptive behaviours present, which either harm the individual or those around the individual. 

So what are the underlying mechanisms?

Emotional Dysregulation

Many things look deceptively simple until something goes wrong with it. Let us consider driving your car. When everything works, you get into your car, drive it car and then get to your destination. Now think of everything that could go wrong in that process and you start to realise how complex driving actually is. You could fail to drive properly for a number of reasons, someone else on the road might create an accident, your car might fail in hundreds of different ways, the road itself might have road works, traffic jams or a bushfire covering it. Only once you start to look at what can go wrong with a “simple” process do you realise how complex it is.

When we look at decision making, it is very similar. It seems easy until something goes wrong.

Angry face
Anger is a frequent result of emotional dysregulation which is picked up by health services as a symptom

An important component of decision making is assessing the components of the decision and the outcome of that decision. This relies on how we feel about each of these aspects. For example, if I want to take an object I found on the couch outside, how I feel about the object will change how I tackle the task. Let us say the object is a spider. If I have a phobia about spiders, I will overestimate the danger level of the spider, which may either prompt me to take extreme caution when picking the spider up, or disable my ability to act at all. Even if that spider is made of plastic. A balanced level of feeling will accurately determine that the plastic spider poses no risk, enabling me to pick up the toy and take it outside.

A quick side note here – feeling is what the experience feels like, while an emotion is what you show the world about the feeling you have. Often people use them interchangeably.

The stronger a feeling is that you experience, the more your hind-brain (the limbic system – amygdala, hippocampus, thalamus, hypothalamus, basal ganglia) is warning you of an extreme situation, and thus the less time your brain thinks that you have to solve it. Because of this, people who are erroneously feeling too much about a thing think they have no time to solve it, so everything becomes black and white – safe, or not safe; good, or evil; do, or do not – there is no try. This illusion is created by the sense of immediacy from the extreme emotion, because hind-brain logic tells us that strong emotions must be significant and very now.

Hopefully it is clear how this dysregulation of emotions (feelings) can lead to black and white thinking, and perceptual distortions in assessing a situation. What is less obvious is that if your hind-brain is constantly reporting to you that you are in danger, it can change the way you manage social interactions – you need to be safe, so you alter yourself to be the person that is safe. This contributes to the Loss of Self above. Another aspect that is fed by this dysregulation is Chaos. Because you have no time, you make snap or automatic decisions that will keep you alive in this perceived emergency situation.So far it has worked as you are still alive, but that doesn’t make them good solutions – just good enough solutions. This often leads to very chaotic solutions to situations that seem like emergencies, which in hindsight aren’t.

To take this a bit further, often then chaos is exacerbated by having to now fix the thing that an impulse decision made in perceived danger has mucked up. That fix isn’t well thought out either, as there just simply isn’t time, so that leads to yet another situation that now needs repair. Often when listening to someone with BPD describe the mess they are in, each decision seems understandable in isolation, but often in a series of well meaning but disastrous outcomes, mostly because the person thought things were wrong and needed to be fixed.

Emotion is contagious. It is one of the traits that helped humans survive against stronger predators. When I see something scary, I feel scared and emote that to you. When you see my fear, you are ready for the danger I see but haven’t pointed to. When a person’s emotions are dysregulated, it can prompt those around them to become caught up in the sense of urgency, danger, confusion and chaos. It is important to watch your own feelings and reality check all drivers of strong emotion that you are picking up from the person with BPD, exercising the calm and logic needed to navigate the circumstances. It is important to remember that a person with BPD is not delusional – there is a source to most things being felt and reacted to, however the interpretation is suspect and bares checking.

Social Boundaries

Two out of three people diagnosed with BPD are able to identify with a traumatic past. The vast majority of the traumatic pasts experienced are focused around one or more abusive people. The abusive person may have been accidentally abusive (ignorant of the effect they are having, abusive as a side effect of their own trauma/mental health) or maliciously abusive (people diagnosed with BPD often have a narcissistic person in their lives). The perpetrator of abuse’s reasons for abuse are somewhat irrelevant to the outcome of this section, however it does help when learning how to not be a target to abusive people and how to identify them better in the future. We aren’t going into that here.

The perpetrator of abuse (I’ll just call them the perp) doesn’t want a strong person who will stand up to them, who will call them on their abusiveness, or recognise when the perp is fouling up reality to make their story believable. They need you to be confused, uncertain and vulnerable. As such, these perpetrators will gaslight you, commit moving goal post fallacies, commit emotional and cognitive abuse, trigger strong emotional states and frequently use various charismatic attacks to undermine your sense of reality. This confusion keeps you pliant with their whims.

One out of three people diagnosed with BPD don’t have a significant trauma in their past, thus no single person or series of people who have accidentally or purposefully blurred the social lines of reasonable. In my experience this one in three frequently have stronger rule compliance issues, characterised by a strong sense of completion and confusion when patterns are unfulfilled or people don’t stick to the roles assigned to them to simplify the social equation.

Children are born as tabula rasa – blank slates. They are open to a number of different ways of being human, which allows babies born in various cultures to pick up those cultural norms. If babies couldn’t do this, all humans would either be the same, or chaotically different. A few biological traits underlie this ability to absorb culture, hence why my brother and I are so different – we got different traits from our biology underlying and shaping a similar upbringing.

Text - The Three Unwritten Rules - the three rules are blank.
The unwritten rules of society – it can be very confusing when you are supposed to be following the rules that no one tells you about

As children grow, they first learn the rules of the house they are born into. As they age the child learns the rules of friends places, then rules of school, then rules of bigger schools, then rules of work and so on. Each set of rules is somewhat similar to previous rules, but also significantly different (you can hopefully see here how a perp can mess with this rule acquisition by changing rules arbitrarily – however we are focusing on the lives of people who didn’t have this). A part of growing up is recognising that rules vary from location to location and from group to group. Every time a person is added to a group, the rules subtly shift. Every time a person leaves, the rules subtly shift. We are supposed to automatically pick up that shift and adjust our rule set to manage. People with BPD struggle with this (not the only people to do so).

Signs that this is true for you is that you find one on one easiest. A few people in a group is harder, but ok. Groups of about 6 or more are difficult. You’d rather avoid crowds unless you have a clearly defined role, such as acting, the class clown or the teacher. You can find yourself easily overwhelmed when certain people join the crowd and that overwhelmed takes the form of one of the three following – you shut down, you run away or you become aggressive.

You may recall the bit above about wanting clearly defined roles in a crowd and the bit where you might assign roles to others. These are two tools frequently used to simplify the social calculation – the series of internal processes that we all use to work out what the group is doing, what our part in it is, what we can expect everyone to do, and thus how we stay safe in the group. In BPD this is often defined as the chameleon nature – where the person with BPD will shift their presentation based on how they perceive the group or other person – the-role you take. The flip side is the simplification of other people – the role you assign to them. This is often based on the most dominant personality trait you see in the person. When the person fails to live up to (or down to) the role you have assigned them, it is likely to bewilder you, which can frequently result in panic, anger or disillusionment.

When combined, this feeling of social confusion and danger can someone with BPD to look for clues about social interactions based on the people who are present. Whoever has the strongest personality, or seems the biggest threat, defines the interaction. Their trait defines what the role of the the person with BPD needs to fulfil in order to be safe. If the target person strays too far out of the personality trait, this can leave the person with BPD feeling lost and in danger, which can have strong reactions. The person with BPD can try to guide the target person back to the trait they need them to be, or become angered that the person has failed them, feeling abandoned or betrayed by the person’s failure; frequently redefining the person’s role to an opposite role – Angels become demons as they fall off the impossible pillar they have been awkwardly perched on, or demons become angels when they fail to be bad. Another common pathway for the person with BPD is to lash out in anger – aggression and damage to the environment around them, or self harm and suicide attempts when that aggression is turned inwards.

These traits can also create the look and feel of chaos in the list above.

A quick note about DBT

It is not surprising that the world recognised standard for helping people with BPD is DBT, which mostly focuses on helping people to regulate their emotions, and once a bit more stable, to understand the complexities of social interaction and help create a smoother heuristic (set of malleable rules) for social interaction.

Next time – When something needs to be done about BPD, and what that something can be.

Breaking Bad… Habits – Part 1 – Understanding Your Habit in Four Parts

Humans run on habits. Life is just too complicated to manually do every step of every thing. Instead we learn a habit to take care of that thing, and trigger the habit without thinking. How many of you get to your destination and can’t remember driving there? That was habit taking over. Some of our habits are no longer good, or can be optimised for a better outcome. Yet how do you change a thing that you aren’t aware that you are doing?

Part 1 – Understanding Your Habit in Four Parts

Part 2 – The Five D’s of habit cessation (not yet available)

Part 3 – Replacing habits (not yet available)

We often think of habits as un-thought of actions. Habits can include drug misuse, such as alcohol or meth-amphetamines; or emotional dysregulation such as anxiety leading to running away from social situations.

Understanding the Habit

It is important to understand the habit. We have four components to that:

  • Biochemical – what your brain is doing on a chemical level
  • Cognitive/Emotional – how the habit change how you think, feel and experience the world
  • Social – how the presence or absence of people impact your habit
  • Environment – how the environment you are in impacts your habit

Biochemical

Brain chemistry is complex. When we think certain thoughts, or do certain things, we can affect our own brain chemistry.

Do this exercise – imagine a nice and relaxing place, somewhere that in the past you had an amazingly calming experience. Take some nice and slow breaths and try to feel the sensations of that place, smell the breeze, activate as many senses as you can.

You should now be feeling nice and relaxed.

Do this exercise – imagine a new scene, where that animal or monster you fear is there, or if you have no fear of that, receiving a phone call with bad news about that relative you like. Imagine how that event feels, how helpless you feel and unable to act.

You should now be feeling quite uptight and edgy. Do the first exercise to undo the second.

Through your actions you should have experienced some very interesting feelings. We changed the brain chemistry by imagining two situations. If we added actions to these imaginations, the effect would have been stronger. If we added drugs it may have been stronger still.

We often take actions because of how we are feeling. Either because this feeling requires that action, or because that action stops us from feeling this.

A common aspect of someone whose baseline brain chemistry is messy (up, down and all over the place) is to take a substance that pushes us into a known state of brain chemistry, even if that known state is not very pleasant. It can bring stability. If this is you, I highly recommend you talk to your doctor and get some prescribed medication to help out, and also get a referral to some counselling. You will need a two pronged approach to manage this.

Common neurotransmitter that is an integral part of habits is dopamine. It rewards good outcomes, where good is defined as “I survived”. Unbalanced serotonin (a different neurotransmitter) can cause feelings of anxiety and depression, which can interfere with habit formation. If you feel anxious, or depressed, you don’t want to repeat the thing you just did. If your dopamine reward is less powerful than your serotonin effect, you just don’t want to do the thing. This feels like low motivation, or avoidance because it is too hard.

We can hack the reward centre to improve our habits. Part of this hacking is to balance serotonin and dopamine first if that is a counter to your habit formation (anxiety disorder, depression disorder, mood dysfunction disorders, schizophrenia etc). If you add a thing you safely* enjoy to the task you want to form a habit out of, we associate that good thing with the habit and are more likely to do it.

* safely enjoy – things that don’t have a negative aspect to it. For example, food rewards are great, if you aren’t trying to lose weight or are allergic to that food etc. The safely enjoy is about picking a reward that is good in as many ways as possible, that is now reserved for this habit formation.

Cognitive / Emotional

The cognitive aspect of this is about how we perceive the habit and ourselves. This is looking at our thoughts. For example, I might think that a beer when I get home is my right as a working person, ignoring the literature that points out the harm that is doing to my body and my future. Or I might think that I am a crap person anyway, so there is no point to exercising. The thoughts I have that boost the bad habit need to be faced and corrected, with frequent reminders of the falsehoods attached to those thinking patterns.

There are two forces to every habit. The force that is reinforcing the habit, and the force that is countering the habit. By looking at and examining our thoughts, we want to boost the thoughts that counter the habit we want to change and reinforce the habit we want to replace it with.

The feeling component of this is to examine how the habit makes us feel. I will admit that after I eat ice cream I feel pretty good. What I don’t like is what that ice cream does to my waste line. The obvious part to this is to recognise that icecream is a method I use to increase my “good” feeling.

The more subtle aspects are that I wasn’t feeling good and that is why I ate ice cream, and that ice cream isn’t the only way that I can feel good.

Part 1 – why wasn’t I feeling good? Was it a random fluctuation – which will go if I just wait a bit, was it due to an event – I should look at that event and solve that problem, was it biochemical – do I need to take a medication, etc. Each reason why I was feeling bad and wanted ice cream as my quick fix should be examined and potentially addressed.

Part 2 – what other methods can I use to feel better? Ice Cream is great occasionally, but if it is affecting my waistline, then I need to re-examine the real effectiveness of this. What else can I do that helps me feel better?

Now substitute ice cream for any habit you are doing because it makes you feel differently.

Social

Humans are social animals. We want to fit in. If the people I am with are doing a behavioural pattern, then I am likely to take that behavioural pattern and adopt it into my set of behaviours. A behavioural pattern is a habit.

We can also detest the people we are around and use a behavioural pattern to try to manage that. For example, I would frequently retreat to a dark corner and read to avoid having to socialise with certain family friends. This started to extend to anytime that I was around people I wasn’t immediately comfortable with. This habit affected my social skills, making it harder to manage being around moderate people, whom I should be able to manage. The escape into a book habit was just too easy compared to learn to adapt to moderate people.

The reason to examine the social aspect is that many habits we have are determined by the people we are around or triggered by social situations.

Environmental

This is somewhat similar to the social above, in that environmental factors can affect us in similar ways to social situations. I can see a group of people and not feel the desire for an alcoholic drink. However if we go to play pool at the pub, I find myself ordering a drink. I know many people who point out that when they drink beer, they smoke a cigarette, even though they quit cigarettes years ago – because the two go hand in hand.

A quick shortcut our brains do is to load habits based on environmental factors. Looking at an evolutionary biology aspect – if we are in a jungle setting, we are looking for predators that are camouflaged in the foliage, and that also drop from above. When we are in a savanna setting, we are looking for only predators on the ground. These different environments promote different habit sets. We have brought this into the modern era. So I can not drink when I am at home, but I find it hard to do so at the pub – because the environment is different.

Quick Tip – Not everyone likes you, and that’s OK.

We often run around trying to make sure that everyone likes us. There is a point to doing some of that, but not as much as many people end up doing.

There are a few concepts that are useful to us here that can lead to this error. Each of these has a good point and when taken out of balance leads to bad habits.

1 – we shouldn’t be mean to people, and if we are, we will lose people who have given up putting up with us. This idea pushes us to want to change to be nicer and more wanted. 

However, when taken too far, we fall prone to people who want to take advantage of us.

To check this, changing yourself a bit to fit in is fine, changing a lot is generally bad.

2 – squeaky wheels get oiled, but all wheels need some maintenance oil. When a friend is upset, we quickly want to find out why and help do something about this. When it is because of something you did, or just a random happenstance, AND when a small to moderate thing you can do can help this, then this is a good thing to do. 

However, abusive people use fake squeaking to get more than their fair share of oil, which means we give far too much attention to trying to save these abusive people as friends, instead of putting our efforts into maintaining good friends.

To check this, remember that friends are supposed to be easy to work with and having your life. If you are spending large amounts of energy into trying to keep someone, that can be an indication that something has gone wrong. It might be worth considering letting them go.

3 – we often grow up in small families and start going to a small primary school. This helps us learn how to adapt to managing with people, because we have no real choice about who we are associating with. Learning how to adapt to people and manage incompatible people is a good skill to have.

However, there is a reasonable likelihood that none of these people are the kind of people that are good for you. There are many kinds of people and you need to find the kind that are kind to you. That may be your family and childhood friends/associates, but it also may not be. It is easy to fall into the trap of trying to hold on to people who are bad for us because we had little choice when we were young.

To check this, remember that friends should be low effort to maintain (not zero effort). Look at the people whom you are spending lots of personal energy into maintaining and wonder if you actually like them and if they are actually good for your self esteem… or not. 

Conclusion: Remember, this planet has over 7,500,000,000 people on it. You have a choice. Hang out with and spend energy on the people who do like you, instead of the people who don’t.

Sisyphus spent a great deal of time and energy trying to push that boulder up the hill
[ Friedrich John nach Matthäus Loder Sisyphus ubs G 0825 II ]

Care Fatigue – When you run out of cope

When we are in a crisis, our bodies go into overdrive to be able to put superhuman effort into survival, whether that is running, fighting, or fixing. Our brains go into overdrive along with the rest of our bodies, improving our intellect, empathy, perception and or reflexes. Sometimes our reaction is the opposite – we hide and shut down.

When the crisis is over, we come down from the hyper state and can show reactions such as fatigue, irritability, shaking and avoidance. When a crisis doesn’t abate, we stay in that heightened state. Long term crisis is bad for humans. While short term stress is good to shake things up and prompt us to get out of a slump or groove, long term stress creates unhealthy patterns, makes us more prone to illness. Our mental state can become aggressive, anxious and or depressed.

If we are not alone in the crisis, we can become care fatigued. Care fatigue is where your empathy for the suffering of others becomes overwhelming. Consequences of this are frequently being far more emotional about everything, or becoming numb to everything. We can either want to act and fix everything, or we feel powerless and just want to shut everything out and yell “la la la” until everything has gone away.

If the crisis is big and pervasive, it won’t just go away. We must act. However we can’t always act. We need to care for ourselves and take breaks, have some down time, recover our strength and then go back and push for solutions again. It is fine to turn the screens off for a few days to get some distance, before going back into the quagmire again. It is fine to let someone be wrong because this is not the fight you have the strength for. It is fine to lose your shit at someone who is being offensive occasionally, because you are too tired to be calm in the face of their irrationality. Take a breath, take a break, and then try again.

Anxiety increases when we perceive a problem that is outside of our control. As an example, I am currently witnessing reports of the East side of Australia burning and the North West side flooding. I live in the South West of Australia and can do nothing direct about these things. I am currently witnessing our countries leaders continue to deny 40 years of research on an international scale that says the problems we are experiencing are being directly contributed to by climate change. These and many more things can make me feel very powerless. And indeed, there is little to nothing I can do to directly affect these things. They are so far away and so far beyond my power to affect.

So it is important to look at what I can do. I need to make far away more local. I can and have changed the way I live to ameliorate my own impact on the climate. I can try to educate those around me to ensure that people are woke to the old science of climate change. I can support our local firies and speak to my local politicians to ensure that their future plans are green. I can attend protests and be linked in to XR (extinction rebellion) and other groups that are focused on trying to stop the destructive policies. When I can, I donate to good causes. I paid for a years worth of The Guardian online paper simply because their reporting is accurate and I want to encourage that.

When I take these actions, I feel like I am achieving something at a level that I can affect. Believe me, if I could, I would wade into Parliament and sack the lot of them. But I can’t. So it is important to look at what I can do and go and do it. In the doing, I feel better, and I can see the changes that I have made. I can then encourage others to do the same and if that works, the world will be different.

While one person cannot push back against the world of people, a world of people can push back against the threat to humanity. I can’t make every person act. But I can make me act. And if I can encourage you to join me, then that makes two of us. Now you go prompt someone to stand and act – soon it will be all of us.

Hand squishing a stress ball shaped like a brain
Stress can sometimes feel like someone is squeezing your brain

BPD Part 2 – Borderline Personality Disorder – The Diagnosis in Brief

BPD (Borderline Personality Disorder) is a complex condition that is currently listed as a mental illness. To be given this diagnosis requires meeting certain criteria, which we will examine below.

In Part 1 [Link] we looked at what BPD isn’t, and some of the many names that BPD is also known by.

In Part 2 [this one] we will look at some of the diagnostic criteria that is used when giving someone a diagnosis, including a list of aspects that I look for when determining if BPD is an appropriate label for someone’s experience.

In Part 3 [Link] we will look at what is probably going on behind the scenes that leads to the experience and behaviours that meet the criteria in Part 2.

In Part 4 (yet to come) we will look at how to tell if something needs to be done about your experience of BPD, and if so, what that might be.

There are two primary diagnostic tools that therapists use. The ICD (International Classification of Disease – World Health Organisation) and the DSM (Diagnostic and Statistical Manual of Mental Disorders – Unites States of America).

ICD

The ICD [code F60.3 EUPD] – “Emotionally Unstable Personality Disorder” covers three variants – Aggressive personality (disorder), Emotionally unstable personality disorder (mostly what people think of as BPD) and Explosive personality (disorder). The summary brief reads as

“Personality disorder characterized by a definite tendency to act impulsively and without consideration of the consequences; the mood is unpredictable and capricious. There is a liability to outbursts of emotion and an incapacity to control the behavioural explosions. There is a tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or censored. Two types may be distinguished: the impulsive type, characterized predominantly by emotional instability and lack of impulse control, and the borderline type, characterized in addition by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicide gestures and attempts.”

DSM

The DSM [code 301.83 BPD] – “Borderline Personality Disorder” has a specific entry just for BPD.

“A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) or the following:”

1. Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5)

2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation

3. Identity disturbance: markedly and persistently unstable self-image or sense of self

4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating) (Note: Do not include suicidal or self-mutilating behaviour coverered in Criterion 5)

5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour

6. Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days)

7. Chronic feelings of emptiness

8. Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights)

9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Also check out the Australian BPD Foundation found at https://bpdfoundation.org.au/diagnostic-criteria.php

Reading through those diagnostic criteria seems pretty chaotic and a bit contradictory in places. It can leave you with a very poor impression of people who are diagnosed with BPD. It will also give you very little idea about what it actually looks like.

Joshua Davidson Therapy BPD Checklist

Here is the checklist that I look for. It is not a formal list, but I find it easier to get teh gist of “is BPD a factor in this experience?” than the medical lists above. If I find most of these to be present, then it is time to look closer.

* A Loss of Self – a chameleon like ability to adapt to the person they are with. If more than one person is present, then whomever is deemed the bigger personal threat or has the strongest personality will guide the way the person is. The chamoflague is all about being safe, which can include being submissive, agreeable, overly generous, obstructive or aggressive. Being alone is either a great relief, or incredibly scary, as there is no other person to define oneself with.

* Dysregulated Mood – all moods are at extremes and calm is a foreign concept. Everything is now, everything is extreme, and everything is dramatic. From seeming calm to explosive is rapid, which can also lead to very impulsive actions.

* Perception Distortion – always looking for the threat in the situation, but more in the people they interact with. Always checking for abandonment, betrayal or abuse. People’s actions are checked for malice over charity. Sometimes the reverse of this is true, which leaves the person vulnerable to abusive people as too much charity is given.

* Black and White Thinking – as hinted at in Perception Distortion, actions are filtered via charity or malice with little room in between for “just is”. Things are either black, or white, never grey, and certainly not coloured. A thing that was categorised as “white” will be switched to “black” seemingly rapidly as a certain threshold is tipped.

* Boundary Confusion – either there is a great absence of daily living rules, or a set of rules that are too rigid. A great focus on “how it should be” and low ability to adapt to “this is how it is”. When others break the rule the person has set, it can trigger confusion, anger, anxiety or generally dysfunction. There is no “Goldilocks Zone” in the rules.

* Chaos – people around them are often thrown into chaos dealing with the persons inner chaos, life and relationship chaos, self harm and or suicide attempts, emotional dysregulation and so on. If you look at how the people are acting, realise this is a reflexion of the inner chaos of the person. This is not a trait per se, this is the result of the traits.

Each of these items can be found in a few conditions. For example, a dysregulated mood could be Anxiety Disorder, or Bipolar Affective Disorder. The Boundary Confusion could be Autism Spectrum Disorder. Black and White Thinking could just be a cultural aspect of certain trades, or old concrete thinking.

It is the combination that suggests to me that we should be looking at BPD.

Next time I will go through what drives aspects of my list, which will then help understand what the medical lists are trying to drive at.

Identity

Who we are is complex. It incorporates many aspects of where we grew up, how we identify ourselves, how others identify us, actions we have taken in the past and who we would like to grow into. Identity can be fairly solid, it can shift fluidly, or migrate through a series of stages. I turns out that human biological sex is not binary like we were taught.

Once aspect that is a key component to how we see ourselves and how society sees us is biological sex. I was going to write a big thing about it, but then SciShow on Youtube did it for me.

This episode was written by Carly Britton and covers many aspects that are worth listening to.

In short, human biological sex is not binary, it is a spectrum, and it isn’t necesarrily a single spectrum either.

A binary division is where you attempt to divide a thing into 2 parts. Some handy examples that make sense is dividing numbers into numbers that have enlcosed sections (6,8,9,0) and open sections (1,2,3,4,5,7). However some groupings defy easy binary division based on a simple rule, such as trying to binary divide fruit into sweet and sour. While it is easy to identify some fruits that everyone agrees is sweet and some that are sour, there are a number of fruits that either defy easy identification or fit into yet another category of “it depends”.

Every aspect of what we may think of as “male” or “female” is frequently found in various subsections of human populations, but no single aspect is sufficient to describe all humans. For example if we consider chromosomes, the DNA of our sex expression, we were taught in school the simplified version that males have the XY chromosome expression and females have the XX chromosome expression. While it is possible to create a binary divide of XX is female and all others are male, it becomes very awkward when we have the so called sex chromosome be X, or Y, or XXX, or XYY and so on. Many people who appear female and identify as female have a sex chromosome that is not XX.

An image of various sex chromosomes with additional X's, known as Clienfelter Syndrome. Attribute Wikipedia for the image.
Klinefelter syndrome – the presence of additional X chromosomes
By User:Nami-ja – Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=6094574

Additionally when we add in any other sex identifier to the mix we find that a binary division is impossible. There is not even really a spectrum from “female” to “male”.

Another aspect to consider is the difference between assigned sex and chosen sex. While all the traditional markers for categorising someone as a particular sex, the person may not identify themselves as this sex. This person may chose to make no changes in appearance, cosmetic changes, medical changes and or surgical modification to correct this misalignment. Since the definition of who actually fits into the overly simplistic physical definitions of “male” or “female” are poor, it seems odd to then require that someone who fits the physical criteria is then also required to ignore the very important criteria of “self identification”.

It is also odd to try to fix this by just creating a third category of “neither”. If we look at a simple spectrum such as the rainbow of visible light, it is made of either red, blue or “other”. Applying this third category solution means that orange and violet are considered to be the same, when clearly they are not. And where does watermelon and maroon fit?

Sex identity is complex and involved a number of features such as DNA/chromosomes, gene expression, development, hormones, cosmetic appearance, taste and self identity. To lump all of these aspects into a false binary, or stretch it into a false trinary is hurtful to people who find themselves excluded or poorly labelled for no good reason.

To minimise this hurt, it is important to accept when someone identifies other than your initial evaluation of them and if a person is dressing ambiguously, accept that they may not identify as any simplistic label. It is not offensive to ask someone if they have some prefererd pronouns, and accept if the pronouns someone prefers does not align with your assumptions or comfort.