The view from the Overton window

The Overton window describes the range of policy ideas currently acceptable to the public. The range moves over time: policies that were unthinkable a decade ago might be under discussion today. For example, marijuana legalization used to be a symbol of membership in the counterculture and dealing pot could result in a jail sentence. Today, adult use is legal in 15 U.S. states. The Marijuana Policy Project is working on legalization in five more states in 2021, and we may see legalization at the Federal level in the next few years.

In similar fashion, views on a disease can change. Chronic fatigue syndrome, typically ignored or viewed with skepticism just 15 years ago, has become the focus of a research program at the National Institutes of Health with the full support of NIH senior leadership. The disease has been renamed to myalgic encephalomyelitis/chronic fatigue syndrome, or ME/CFS.

As formerly unthinkable views become commonplace, social, legal and administrative norms are updated. Language is also adapted, making conversations easier.1

Post-finasteride syndrome lies outside the Overton window today. Here are some of the attitudes that keep the syndrome out of view and out of bounds:

  • Men seeking treatment for hair loss are vain, anxious, depressed and hypochondriacal
  • Men with sexual dysfunction are weak
  • Sexual anatomy and function are not acceptable topics of conversation
  • Sexual dysfunction is probably a psychological condition, not a biomedical condition
  • Young men are uninformed about health and medicine and may be unreliable witnesses to their own experience
  • People reporting adverse psychological experiences may lack a grip on reality and cannot be believed
  • Drugs cannot cause psychological adverse events such as depression, anxiety and suicidal ideation
  • People who post in anonymous online health forums take on fictional “syndromes” invented in these communities (a.k.a. social media illnesses)
  • If an experience or disorder is not recognized by doctors and the medical establishment, it is probably made-up.
  • “Side effects” go away after stopping a drug. It’s impossible for “side effects” to persist after stopping the drug because it has left the body.
  • Unfamiliar or infrequently mentioned conditions are unlikely to be valid.
  • If symptoms cannot be empirically confirmed (e.g. in conventional medical tests), they are probably made-up.

For examples of these attitudes in published literature, see Responding to a literature of doubt.

In many of these attitudes, attention is directed away from the experience being reported, towards characteristics of the person making the report. In the absence of data, listeners draw conclusions from information available to them, subject to their beliefs and biases.

Biases help us cope with the uncertainty of life, but they also create blind spots. A proper investigation of post-finasteride syndrome is blocked by a tangle of mutually reinforcing biases which play out in numerous settings including patient-doctor interactions, social life and the research community.

In order to properly evaluate whether post-finasteride syndrome is valid, these assumptions and biases must be dislodged. We must return to first principles, insisting on the rigorous use of reason and evidence, and recognizing that absence of evidence is not evidence of absence. Then the work can begin: confirming what is known, identifying the unanswered questions and planning research unencumbered by biases.

Note

  1. Since marijuana legalization, the terms medicinal use and adult use have been adopted. In ME/CFS, the term post-exertional malaise distinguishes the condition from ordinary fatigue.