Hear No Moms, See No Moms, Treat No Moms

How power shapes psychedelic science

My last post, on conflicts of interest and the need for more feminist philosophy of science in research methods, promised an example of how power shapes science in the psychedelic renaissance. This is a good exercise for me as a methodologist looking for what my own perspective might otherwise make me miss. Because my assessment of the evidence on psychotropics versus psychedelics has long been that pharmaceutical companies appear to be doing a lot of harm with bad science for profit, while psychedelics appear to be far more effective (and cheaper) treatments than anything else for a number of serious problems. The effect sizes are just so much bigger, the interests so differently stacked. So for me to criticize the psychedelics literature is a tougher test in listening for bias than if I were to look only at science that I already tend to suspect has its heart (and its estimates) in the wrong place.

Since re-joining Twitter last fall to connect more with people about my breastfeeding research, I’ve heard a lot of criticisms of so-called normal or natural childbirth education and practice, birth horror stories, prenatal and postpartum mental health woes, and, of course, breastfeeding shame spirals, formula shortage rants, and public health messaging that constantly lies to moms desperate to do what’s “best” for their babies. And I’m struck that these moms are left out of the psychedelic renaissance, even though they should have been the first group helped by it. When mama ain’t happy, ain’t nobody happy. 

At first glance, it seems pretty obvious why no one invited moms to the party. Psychedelics are taboo. Mommies doing drugs is taboo. (Next thing you know, they’ll be drinking and smoking.) Besides, pregnant and breastfeeding women are the clitoris of human subjects research; people kinda know it’s there, but far too often avoid it, lest things get messy. 

But moms have problems. Prenatal mental health problems — depression, anxiety, PTSD, substance abuse. Labor pain, anxiety, and traumatic stress. Postpartum mental health problems. Psychedelics may be substantially safer and more effective than standard care for them all. And replacing standard care with safer and more effective alternatives might in some cases also prevent substantial harm to kids, as in the context of possible doubling of autism risk in children whose moms took SSRIs (the most common type of antidepressants) in pregnancy. 

One of the reasons psychedelics are probably safer for moms (and, maybe, thus babies) than psychotropics is that they’re often highly effective after one or two doses. This is a big exposure difference with daily psychotropic medication. 

Another is that the problems psychedelics treat are themselves potentially risky, and psychedelics just look ridiculously more effective than psychotropics. For example, in a recent phase 3 trial on MDMA-assisted therapy for severe PTSD, Mitchell et al found that 33% of patients experienced remission in the treatment versus 5% in the control group, and 67% no longer met the diagnostic criteria in the treatment versus 32% in the control group. So mostly it helped people a lot. Compare that with common pharmaceutical treatments for PTSD, which don’t help about half of patients, and trauma-focused therapies, which have high dropout rates because they hurt like hell and still don’t work for many people. MDMA blows standard care for PTSD out of the water, and also happens to feel nice instead of horrific (ban it!).

We’re talking about really common problems. PTSD incidence in high-risk groups of pregnant women and new moms is more than one in six. Around one in seven reproductive-age American women takes antidepressants. Figures like these miss women in pain who are self-medicating with other substances.

The much smaller exposure time to few-shot psychedelic as opposed to daily psychotropic drugs, plus far greater efficacy, also means that it would be relatively easy and safe for breastfeeding moms to “pump and dump” (throw away) contaminated breastmilk following psychedelic drug treatment. This might literally save lives. Postpartum depression expert Karen Kleiman had a pregnant woman with a history of postpartum depression, Dawn, come to a talk she gave, get a session to be sure she was doing everything right to prevent recurrence, and ultimately shoot herself in the head because she couldn’t bear to either take more meds or stop breastfeeding. (Karen discusses this rare but tragic story in Suzanne Barston’s excellent breastfeeding book Bottled Up.)

There are so many reasons this should never happen. For one, there’s insufficient evidence to say breastfeeding matters that much, for any reason, at all. But it’s also true that you don’t have to choose between treating your depression and safely breastfeeding your baby — because psychedelics could probably help you do both (just pump and dump when you treat). 

As common as prenatal and postnatal mental health problems are, birth is the big opportunity to potentially improve a lot of women’s lives with psychedelics. All moms give birth. You can’t beat a 100% base rate. 

Granted, a lot of women wouldn’t be interested in this intervention. I’m one of them. My son’s fairy-tale home birth stands out as a peak experience, a designation often given to psychedelic experiences. Drug-free, plenty of good help but no doctors or machines that go bing, and the hilarious surprise of a perfect little boy where we were promised a girl, it was the best day of my life. I would be the last person in line to expose my baby to any substance or intervention I didn’t medically have to, and there’s a high bar for “have to.”  

But a lot of women weren’t so lucky, understand risks differently, or have different preferences. New research forthcoming by medical anthropologist (and Twitter friend) Liz Sutton suggests that being denied pain medication in labor, a common occurrence, may be psychologically harmful. Medicine and society should help more women experience a good birth. 

There’s a golden opportunity in labor, when many women request pain medication, to offer them a drug that is both analgesic (like MDMA, LSD, or ketamine) and that might help prevent trauma and postpartum mental health problems. In 2014, researchers in Saudi Arabia ran a trial on ketamine for labor pain that no one in the West has touched with replication or citation. It was a success at reducing pain, although the informed consent could’ve been better (many women were unpleasantly surprised by side effects, cos they were tripping). 

Women who have C-sections aren’t left out of this story: ketamine is a perfectly good anesthetic for major surgery. A 2021 study out of Iran suggests that using ketamine in C-sections might prevent postpartum depression, just like one would suspect it might. (In many trials, ketamine looks like the closest thing to penicillin psychiatry has ever seen, curing suicidality more or less instantly. The discrepancies seems to be about whether there’s temporary euphoria or lasting protection, and lasting how long — except for that time a corrupt pharmaceutical company tinkered with the molecule to make it patentable, made it less trippy in the process, found that it didn’t work anymore, got FDA approval anyway, and sold it to vets at a huge mark-up.)

But MDMA makes the most sense in terms of supporting birth physiology. It releases oxytocin. This would probably promote labor progression and strengthen uterine contractions — bringing a whole new meaning to “ecstatic birth.” 

The point here is not to argue for or against including moms in the psychedelic renaissance. It’s that power shapes science, and we need to see this happening more clearly in order to do better science — if we believe science is about discovering truth and helping people live better lives. Inclusion of some groups, like traumatized vets, in the psychedelic renaissance — and exclusion of others, like traumatized moms, serves powerful social networks’ interests. Most obviously, states have an interest in reducing the costs of war. The U.S. and Israel have been world leaders in researching MDMA for PTSD; war machines make a lot of troubled souls. 

There’s no bad intent required here. Only structure. Powerful social networks put women and children’s well-being last (particularly certain women and children), as a function of putting other interests first; and even apparently counter-cultural scientists reproduce that (de)valuation in their apparently neutral, humanitarian science. The structure always wins.