by Jesse Bering
I can feel the self-consciousness slowly consume me as the conversation progresses. Eventually I cannot even retain my train of thought and become tongue-tied. I unravel. I do become overwhelmed at what others might be thinking—I don’t usually assume what they might be thinking with any specificity. That would be too painful an endeavour. But I do give them a generalized voice. I acknowledge to myself that they have seen the acne and most likely think less of me due to its presence.
Another woman, “Laura,” notes:
When I’m talking to people, I always stare them straight in the eye to watch if their pupils wander to other places on my face where I have a zit. And they usually do.
Obviously, acne anxiety isn’t just a female problem. It’s arguably even worse for some males. One sufferer, “Karl,” explains why:
Society doesn’t allow [males] to wear makeup so we have to go out in the world in embarrassment. And if we tell people that we are feeling depressed or are concerned with our looks, we are looked down on as weak and pathetic, especially by other males.
Speaking of thinking about others’ thoughts, I know what you’re thinking: those who’d judge a book by its cover or ostracize a poor, pimpled pal in these ways ought to be scorned in public themselves. I very much agree. But in spite of our sympathy—perhaps empathy—for those suffering from such visible skin disorders, even the most kindhearted among us appear to associate acne sufferers with undesirable characteristics. At least these were the results reported by the psychologist Tracey Grandfield and her colleagues in the Journal of Health Psychology. Using a variation of the Implicit Association Test—an empirical measure used to get at people’s unconscious attitudes and beliefs—the authors found that compared with our ratings of clear-skinned individuals, we’re quick to associate unpleasant concepts (such as “brutal,” “bad,” “ugly,” “angry,” “aggressive,” “vomit,” and “mean”) with acne sufferers. These authors reason that this unfair, unconscious, and visceral reaction to those with serious acne also betrays our evolutionary origins. Research indicates that significant disruptions of the skin surface—showing blood, pus, or flaking skin—elicit greater disgust and contamination fears among observers than “cleaner” disruptions, such as vitiligo and port-wine stains.
For many people, especially those who score high on the personality dimension of social sensitivity, acne is not simply a nuisance; rather, it can seep ruinously into the individual’s core self-concept and lead to severe mental health problems, even rivaling the distress associated with facial disfigurement from burns or accidents. One-third of New Zealand teenagers who described themselves as having “problem acne” had thoughts of suicide, one-quarter displayed clinically significant levels of depression, and one-tenth had high levels of anxiety. As long ago as 1948, the clinicians Marion Sulzberger and Sadie Zaidens concluded that “it is our considered opinion that there is no single disease that causes more psychic trauma, more maladjustments between parents and children, more general insecurity and feelings of inferiority and greater sums of psychic suffering than does acne vulgaris.”
That was more than sixty years ago, and of course the acne-treatment industry has grown enormously since then. (So has the psychiatric subfield of psychodermatology.) Although not always without its own unpleasant side effects, there is an ever-flourishing pharmaceutical garden of ointments, creams, and pills today that the acne sufferers of pus-filled yore could only dream about. Still, not all such treatments are equally available to those with acne, there are considerable individual differences in response to drugs, and a fail-safe “cure” remains elusive. In fact, I suspect that by contrast to previous generations, those who experience moderate to severe acne today find themselves even more depressed than those who came before. Just as overweight people who have tried every diet without success often report feeling powerless over their condition, anyone who has attempted unsuccessfully to rid himself of acne with a wide range of treatment options may feel even more ashamed than ever.
It’s little solace to these poor souls that the condition, like most other human traits, is determined by some combination of genes and environment. How, exactly, our DNA interacts with diet, face-washing habits, exposure to the sun, or any other factor remains little understood. Yet, just as some members of that commiserating breed, the Mexican hairless dog, are more prone to acne than others, so, too, are some of us hairless apes. In balance, acne seems to have less to do with how we live than with the family we were born into. Intriguingly, and for reasons that are still unclear, certain human populations, such as the Kitavan Islanders of Papua New Guinea and the Aché of Paraguay, are spared the blackhead plague. Although their diets and lifestyles are very different from our own, so are their genes.
Yes, less is more in the present case. But few of us are so lucky as to have the silken pelage of a Wookiee or find ourselves born an indigenous Kitavan Islander, and the lifelong zitless are extremely rare. The best-case scenario is that your skin isn’t too much of a workaholic when it comes to sebum production, and so, like everyone else, you’ll get only the occasional breakout here and there. Ideally, in terms of your psychological health, the pimples will be hidden somewhere over there, rather than here on that blinking marquee that is your face, unprotected from the elements.
Whether your acne disappears by your teens or not until your forties, your sebaceous glands will one day, I promise you, run dry as an ancient riverbed. Although you could have easily gotten lost in her glorious wrinkles, for example, I don’t remember a single zit on my eighty-nine-year-old grandmother’s face when that non-ethereal husk of hers was peaceably rehydrated by formaldehyde. So remember, all of you with reddened hides in hiding, those in sore, oozing discontent, acne is a passing cosmetic calamity. There’s no shame in shame, so ask for help if you need it. You aren’t alone in your distress, but save some worrying for those slowly gestating, well-earned wrinkles to come. Above all, be kind to your inner ape that lost its fur in haste.
PART III
Minds in the Gutter
Naughty by Nature: When Brain Damage Makes People Very, Very Randy
If you’re reading this, my guess is that you’re a materialist holding the logical belief that the human brain—with all of its buzzing neural intricacies, its pulpy, electrified arabesque chambers and labyrinthine coves—has been carved out over countless eons by the slow-and-steady hand of natural selection. You will grant, then, that specific brain regions evolved because they generated behaviors that were beneficial to our ancestors. When one part of the brain is compromised—through injury, disease, or some other unfortunate event—the constellation of symptoms that result are often remarkably specific. “The brain is the physical manifestation of the personality and sense of self,” writes the neuroscientist Shelley Batts in Behavioral Sciences and the Law, “and focal damage to brain areas can result in focal changes in behavior and personality while leaving other aspects of the self unchanged.”
Not to get too technical, but if you’re unlucky enough to develop a lesion that interferes with the functioning of your dorsolateral prefrontal cortex—a specialized patch of neural tissue that’s intricately braided into your anterior cingulate cortex—then your working memory, strategy-formation, and planning skills are going to take a major nosedive. Suddenly something as simple as coming up with a list of groceries becomes a major achievement.
Most of us have sympathy aplenty for those patients whose brain disturbances have interfered with their everyday cognitive abilities. We’re perfectly willing to accommodate their intellectual disabilities by helping them create a new mnemonic strategy or giving them a pat on the back or a word of encouragement when they’re trying to remember someone’s name (because, frankly, who hasn’t struggled with these things?). Yet when chunks of gray matter that have evolved to control and inhibit, say, our sexual appetites and other bacchanalian drives experience a similar catastrophic blowout, are we so understanding? What if those impairments lead their victims to dis
play … oh, I don’t know, let’s call them moral disabilities? Cases of libidinal brain systems going haywire have our kindhearted, humanistic materialism rubbing elbows—or butting heads—with our belief in free will and moral culpability.
Although Klüver-Bucy syndrome is relatively rare, it’s one of the most notorious neurological causes of a complete breakdown in one’s ability to control sexual urges. In 1939, the neuroanatomists Heinrich Klüver and Paul Bucy removed the greater portions of both temporal lobes and the rhinencephalon from the brains of rhesus monkeys. Initially, these scientists were interested in studying how mescaline administration produced seizures similar to temporal-lobe fits in epileptic patients and so were attempting to isolate the effects of those drug-addled brain regions. Among a host of other peculiar effects of this rather cruel vivisection, however, the monkeys became incredibly randy, displaying a prominent and indiscriminate desire to copulate. The first documented case of full-blown Klüver-Bucy in humans arrived in 1955, when an epilepsy patient underwent a bilateral temporal lobectomy (a surgical excision of the lobes) and subsequently developed a ravenous sexual appetite, among other things. More often, the syndrome appears in lesser degrees, precipitated by a nasty insult to the medial temporal lobe. It might result from a case of herpes encephalitis or Pick’s disease, or from trauma and oxygen deprivation. Not all such patients experience hypersexuality, mind you, but some do. Other symptoms aren’t terribly appealing either, however; they include hyperorality (a compulsive desire to put things in one’s mouth), apathy, emotional unresponsiveness, and various sensory disorders.
Dramatic case studies illustrating the devastating effects of Klüver-Bucy syndrome abound in the clinical literature, and they raise intriguing philosophical questions for us to consider with respect to the sheer physicality of “free will.” That some patients so stricken are overcome with excessive carnal urges and are not simply using the disorder as a convenient excuse to become freely promiscuous, lewd, and lascivious is perhaps best demonstrated by a 1998 study by the neurologist Sunil Pradhan and his colleagues. In this report, a group of boys between the ages of two and a half and six began to exhibit hypersexualized behaviors after partially recovering from comas induced by herpes encephalitis. One to three months after emerging from the comatose state, “all seven children,” note the authors, “demonstrated abnormal sexual behavior in the form of rhythmic hip movements [sexual thrusting] (two patients), rubbing genitals over the bed (two patients) and excessive manipulation of genitals (all seven patients).” Were these children just helpless, hapless puppets of their ancient, pleasure-driven brains? The authors believe so: “As all patients [were extremely young], with no possibility of environmental learning of sex, these movements most probably represented phylogenetically primitive reflex activities.”
It may be awkward enough telling other parents why your preschooler is humping everything in sight—just try rehashing the foregoing description of Klüver-Bucy syndrome to your friends at the day-care center—but we do tend, as adults, to be mostly forgiving of a child’s improprieties. When this sort of hypersexuality strikes a postpubescent individual whose sexuality is driven by orgasm-propelled desires, things become more interesting—at least, again, in a philosophical sense. Although it would be entirely inaccurate to portray Klüver-Bucy patients as sex-crazed lunatics, they very often display behaviors that would be considered inappropriate by conventional standards. One gentleman in his early seventies, for instance, hugged a female parishioner at his church and repeatedly kissed her. According to the clinical case report, he then asked the shocked woman, “Why don’t we do it again?” Over the ensuing years, his sexual fantasies skyrocketed, and his hyperorality became unmanageable. The report notes that, according to his wife, “he would put any object in his mouth, including dog food, candles, adhesive bandages, and his wedding ring. His appetite seemed insatiable … He died at age 77 years of asphyxiation on several adhesive bandages.”
In a letter to the editor of European Psychiatry, two physicians describe the case of a fourteen-year-old schoolgirl (“Ms. A”) who, prior to developing Klüver-Bucy syndrome after being in an encephalitis-caused coma, “was an intelligent and social girl with a good academic record.” This quiet, well-behaved teenager became somewhat challenging, to say the least, after recovering from her illness. You think you’re raising a difficult teen? Consider what these parents were dealing with:
The patient started … disrobing in front of others, manipulating her genitals, and making sexual advances toward her father. She would lick any object lying on the ground and whenever she got an opportunity, she would rush to the toilet and try to put urine and feces into her mouth [urophagia and coprophagia, respectively].
In another case, an epileptic woman underwent an unsuccessful left-temporal lobectomy to help stop debilitating seizures. Klüver-Bucy symptoms, including hypersexuality, emerged following the surgery. She began masturbating in public and aggressively soliciting her family members and neighbors for sex. After having another seizure, she was brought to the emergency room, where, after half an hour in the waiting area, she began performing fellatio on an elderly cardiac patient. (This may or may not be one of the few examples where one person’s syndrome is another’s lucky day; it’s also unclear if this was a display of hypersexuality or hyperorality, but it’s inevitable, perhaps, that the twain should occasionally meet.)
Other temporal-lobe epileptics have also exhibited hypersexuality in the “postictal” state, which is the period of recovery time following a seizure. The neurologist Vanessa Arnedo and her colleagues presented a case of a thirty-nine-year-old man who began having semi-frequent seizures during the middle of the night. After nocturnal convulsions, he’d sleep for another ten minutes, wake up, and then rape his wife. (In the authors’ more delicate wording, he was described as “becoming sexually aggressive toward his wife by forcing intercourse.”) Importantly, however, “the tremendous remorse and abhorrence for what he had done when he learned of his actions led him to pursue possible surgery mainly to eliminate this postictal behavior.” Other people with similar epileptic profiles also become hypersexualized in the postictal state. To his later horror, one man motioned for his twelve-year-old daughter to join him and his wife in the bedroom following a nighttime seizure.
It is in these last few examples, where Klüver-Bucy syndrome manifests itself in criminal behavior such as rape or child molestation, that our materialistic convictions are really put to the test. In 2003, the neurologists Jeffrey Burns and Russell Swerdlow described how an otherwise well-behaved forty-year-old man developed a case of “new-onset pedophilia” after suffering the appearance of a right-orbitofrontal tumor. The man denied any preexisting interest in children; he did have a predilection for pornography before the tumor, say Burns and Swerdlow, but now he was downloading child porn and making subtle sexual advances to his prepubescent stepdaughter. His hypersexuality applied to full-grown women, too—so much so, in fact, that he couldn’t keep himself from fondling female nurses and staff during a neurological examination. Long story short, when the man’s tumor was removed, his prurient interests and behaviors all but disappeared, and since he was no longer deemed a threat to his stepdaughter, he returned home. But his headaches returned, his tumor regrew, and so did the criminal impulse. A “re-resection” of the tumor was accomplished, the man became a good citizen again, and, as far as we know, that remains true today. In a more recent case copublished by the famed neuroscientist Oliver Sacks, a fifty-one-year-old without any criminal history had part of his right temporal lobe removed to prevent seizures. Following this, he developed telltale signs of Klüver-Bucy, including hypersexuality. His was another case of “new-onset pedophilia,” but, as Sacks laments, in spite of this he was nevertheless sentenced to several years in prison for downloading child porn.
What’s the takeaway message? I’ll let you do the hard work of thinking through the implications for our belief in free will and how it might or might
not apply to Klüver-Bucy syndrome. But another intriguing question emerges, too: If an otherwise “good” person’s brain can be rendered suddenly morally disabled by an invasive tumor or an epileptic short circuit, subsequently causing him or her to do very bad deeds, then isn’t it rather hypocritical to assume that a “bad” person without brain injury—whose brain and neural functioning are organized by the complex interplay between genes and experience (and every single phenomenal aspect of whose mind is therefore physically constrained)—has any more free will than the neuro-clinical case? After all, people have zero control over the particularly idiosyncratic brain they’re born with, and very little control over their early life experiences, which, in turn, can only work with whatever congenital neural substrate is already there.
Perhaps it’s just a matter of timing: the “good” are born with brains that can “go bad,” whereas the “bad” are hog-tied by a prospective morally disabled neural architecture from the very start. And although it may be less common, if a “bad” person behaves in an upstanding manner, could that be the result of fortuitous brain damage or epilepsy, too? Should we not regard such a person highly if he saves a child from a burning building because, like the man gesturing to his twelve-year-old stepdaughter to join him for sex, that isn’t really him?
At issue is not holding healthy people to a “higher standard” or making excuses for criminals, but instead simply recognizing that the degree by which we have control over our actions—any of us—is entirely neurologically based. Free will is physical. And if indeed it’s all brain-based in the end, a position you probably subscribed to at the start of this essay, this also includes the extent, the sophistication, and the parameters by which one can even objectively contemplate free will (such thinking is constrained by brain-based cognitive capacities, after all). The shocking truth is that we’re only as free as our genes are pliable in the slosh of our developmental milieus.