Original post: Replication Attempt - Bisexuality And Long COVID

Table of Contents

1. Summary Of Best Comments And Overall Updates
2. Comments Proposing Explanations Based On Response Patterns
3. Comments Proposing Explanations Based On Biology
4. Comments By Jim Coyne
5. Comments Expressing Concerns About The Dangers Of Calling Things Psychosomatic
6. Other Comments

1. Summary Of Best Comments And Overall Updates

Many people commented that bisexuality is a vague concept with unclear boundaries, and Long COVID is also a vague concept with unclear boundaries. Maybe some people are more willing to self-identify as belonging to a vague concept with unclear boundaries, and so they would be more likely to respond that they had bisexuality and Long COVID. For example, if you have a few stray thoughts about the same sex sometimes, are you bisexual? If you might have felt very slightly more fatigued after getting coronavirus, do you have Long COVID? Maybe the same people who say yes to the first question will say yes to the second.

There were a few different versions of this idea - see Comments Proposing Explanations Based On Response Factors for more. I respond to them in more depth there. My short response is that this is plausible, but I lean against it for a few reasons:

• If this were true, the bisexuality effect would be stronger for milder cases of Long COVID, since mild cases are the ones where people are on the border between identifying it or not. But the effect was equally strong for mild and severe cases.

• I checked to see if people who identified with other vague categories had more Long COVID. This was mostly true for left-leaning or weird categories, and mostly false for right-leaning or normal categories. For example, Christians and Republicans had no more Long COVID than people who said no religion or no political party, but polyamorous people and rationalists did. The strongest effect was for ambidextrous people, but ambidextrous people also have more mental illness.

• I checked to see if people who self-identified as having mental illnesses had more Long COVID than people who doctors diagnosed with them. But the opposite was true, suggesting it’s the mental illness that correlates rather than the tendency to self-identify with things.

Another common concern was whether bisexuality might be associated with biological differences, such that it could correlate with organic/immunological Long COVID rather than psychosomatic Long COVID. Many people gave examples of bisexuals having larger or smaller brain regions, but 1) I’m skeptical of these kinds of neuroimaging studies, and 2) brain regions still seem like the sort of thing that cause functional neurological conditions and not immunological ones.

Nobody in the comments got this far, but I was eventually able to find a study showing that bisexuals had more cancer, asthma, and heart disease than straight (or gay) people. One popular explanation is that bisexuals have more mental health issues → smoke and drink more → have more disease. This study breaking down cancer by type finds excess smoking-related cancers and equal amounts of most others. Other sources suggest bisexuals are more likely to be overweight, although the effect is small. So one possibility is that smoking, obesity, or some other risk factor like this either makes people more likely to get COVID, or more likely to get Long COVID conditional on that.

My survey didn’t show that bisexuals reported getting COVID more than straights. Bisexual women were on average one BMI point heavier, which doesn’t seem like much. And this is just anecdotal because I didn’t have it on the survey, but very few ACX readers seem to smoke.

So: bisexuals get many different well-established health conditions more often than straight people. Usually there’s a reasonable explanation, and it’s harder to think of the reasonable explanation for Long COVID, but I’m reluctant to dismiss this as a line of thinking entirely. So I think it’s plausible the increased Long COVID comes from generally worse health, which might be due to smoking or obesity or something else. I think this was the biggest update I made since writing the first post.

2. Comments Proposing Explanations Based On Response Patterns

Peter Gerdes asks:

I'm wondering if it's explained by something like how likely you are to hear symptoms and think "that's something that describes me" rather than just kinda going with the default answer unless you are forced into picking the other.

I mean, suppose you've occasionally had sexual or sexualish thoughts about someone of the same gender (Iess sure if there is a standard answer effect if homosexual). One sort of person might not think much of that unless they feel them quite strongly while another might report they are bisexual. The same kind of attitude plausibly affects how you answer long COVID questions.

This is a good point, but if it were true, I would expect to see it in other questions asking whether you self-identified as something that lots of people might be on the edge of.

There was no such effect among Democrats, Republicans, Christians, or vegetarians. I would expect someone who goes to church occasionally and thinks God might exist to have the same dilemma about whether to identify as Christian as someone with a few homosexual thoughts would have about whether to identify as bisexual. But we don’t see the same effect there.

Also, I asked about psych conditions in two ways: do you think you have it, and were you ever diagnosed by an MD? There ought to be a strong self-identification effect for the first, but a smaller one for the second. But there was more of an association with Long COVID for the second. For example, 3.7% of people with self-diagnosed ADHD had Long COVID, compared to 4.4% of people with MD-diagnosed ADHD.

There were a few exceptions - polyamorous people, rationalists, and (to a much lesser degree) effective altruists all had higher Long COVID too. But these groups also have higher rates of bisexuality and mental illness; I think they are just weird.

Chris Phoenix writes:

Did you correlate with political orientation? I'd expect that in the US, people willing to acknowledge they're bisexual are probably much more likely to be liberal than conservative/Republican/etc.; and that liberals/Democrats/etc. are probably, on average, more willing to acknowledge that they've had covid / that covid can be dangerous / etc.

Limiting the analysis to left-of-center women only didn’t significantly change the results. Also, gays are probably just as left-as-center as bisexuals and the result was much weaker there. There was a significant association between politics and risk of Long COVID, but it was only about half as strong as sexuality.

Toggle writes:

Feels like you’re neglecting a possible arrow of causality in the other direction!

Imagine that there’s a relatively common personality trait, which expresses itself as a strong antipathy to stand out from one’s neighbors or be classified as a minority or exception; these people really really want to be ‘normal’, at least up to some threshold. Then, it seems obvious to me that they’d resist identifying as *either* bisexual *or* long-Covid.

This is not to exclude the other extreme- people with a very *low* threshold to identify as being part of a minority group or otherwise outside the typical human experience for their culture. Those people, in turn, would be more likely to identify as both bisexual *and* long-covidy, on the basis of minor expressions of either.

“People have a gradient for how willing they are to accept a self-identity far from their cultural center of gravity” seems like a pretty intuitive claim to me by observation. The only question is what fraction of our population tends towards Alternative hypothesis: monosexuality is a culture-bound mental illness, and long COVID is more prevalent than people think.

Suppose most people are 'actually' bisexual, but for cultural reasons they tend to believe they are either hetero- or homosexual. If that were the case, then the people who identify as bisexual will tend to be more introspectively perceptive, more willing to defy accepted truths, etc.

If those people are saying they experience long COVID at a greater rate, it may be because that rate is closer to the true rate, and monosexual people are under-reporting because they are less likely to be aware they have long COVID symptoms (e.g. less likely to notice their brain fog), or more likely to explain their symptoms in more socially normal/acceptable ways (e.g. allergies).either extreme; if they happen to be evenly balanced, it makes for a weird situation where overdiagnosing bisexuals exactly cancel out underdiagnosing people on the other side.

This isn’t exactly the same as Peter’s comment. Peter’s comment was about likelihood of choosing any identity (which is rebutted by the data on Christians, Republicans, etc). This one is about choosing a “weird” identity.

As we saw above, certain weird-identity havers like polyamorous people and rationalists did have more Long COVID, but I attributed that to being part of the same cluster of genuinely weird people as bisexuals.

In order to distinguish these hypotheses, we’d have to find a group of people who were weird along a different axes, maybe one that made them less likely to land in the liberal/poly/bisexual group instead of more so.

Separately in both men and women, weird-but-not-woke political groups (libertarians, Marxists, alt-right, neoreactionary) were less likely than the average person to report Long COVID, and less likely than mainstream conservatives. I find libertarians and Marxists, who I would expect to be less interested in the right-wing project of minimizing COVID than conservatives, sort of interesting. But I won’t claim to have fully debunked this concern.

Chris Buck (author of Why Viruses Must Die) writes:

A simpler explanation might be that bisexual people are more likely to be virtuous followers of what I call the 15th Commandment: Thou shall not self-deceive. In other words, the actual rate of long Covid could be identical across all sexual orientations but bisexuals are somewhat more likely to correctly perceive it and acknowledge it.

Mike phrases this more aggressively:

Alternative hypothesis: monosexuality is a culture-bound mental illness, and long COVID is more prevalent than people think.

Suppose most people are 'actually' bisexual, but for cultural reasons they tend to believe they are either hetero- or homosexual. If that were the case, then the people who identify as bisexual will tend to be more introspectively perceptive, more willing to defy accepted truths, etc.

If those people are saying they experience long COVID at a greater rate, it may be because that rate is closer to the true rate, and monosexual people are under-reporting because they are less likely to be aware they have long COVID symptoms (e.g. less likely to notice their brain fog), or more likely to explain their symptoms in more socially normal/acceptable ways (e.g. allergies).

I think this is a good point, but I think it bleeds into my idea of “psychosomatic illness”.

Or, rather, there’s a weak version of this, where straights and bis have equal amounts of fatigue, but only the bis notice this: “Huh, I’ve been more tired than usual lately”. This could be some of the effect.

But I think the strong version of this is that straights have some fatigue, ignore it, and it goes away, whereas bisexuals have some fatigue and focus on it in a way that makes it worse and turns it into a trapped prior. This is how I think of chronic pain and several other psychosomatic illnesses.

If this were true, you might expect bisexual people to (on average) report weaker cases of Long COVID than heterosexuals, since strong cases would be noticeable. Sample size was too low to really have a strong sense of this, but for the record, bisexual average was 2.7/5 and straight average 3.0/5, with total sample size 22 (11 straights, 11 bis).

3. Comments Proposing Explanations Based On Biology

Evan Þ (author of Papyrus Rampant) writes:

Here's a potential alternate interpretation of the data that occurred to me: Perhaps bisexual people are more likely to have more sex, which means they're more likely to contract STD's, which means that on average they are immunologically different to some degree and might legitimately get different physiological consequences from COVID. I don't actually believe this - I think your theory is at least as likely - but I'd be very interested in any analysis that tries to look into this.

Some commenters responded that (on average) gays have more sexual partners than bisexuals (at least in men; in women they’re about the same), but didn’t show the same elevated Long COVID effect. Also, if sexual contact caused immune problems down the line, this would be a big deal and we would already know.

Theophylline writes:

My immediate thought upon reading this was that, contrary to Scott's expectation, I would bet that bisexuals are quite likely to be immunologically different. Specifically, both the immune system and sexuality are potentially influenced by or correlated with levels of testosterone and estrogen.

For example, high estrogen makes people prone to more severe manifestations of all sorts of illnesses associated with an overactive immune system because estrogen causes histamine release. Testosterone, on the other hand, tends to act as a mast-cell stabilizer and suppresses the immune system. In line with this theory, homosexual men often have higher testosterone than straight men according to a few studies, which could explain their unusually low long covid rate (I remembered the association off the top of my head, but here's a small study I just found with a brief search showing "significantly higher" testosterone in homosexual men: https://ajp.psychiatryonline.org/doi/10.1176/ajp.131.1.82 )

Unfortunately for my theory, I haven't been able to find any studies on the average hormone profiles of bisexual men, and at least based on this this meta-analysis: https://link.springer.com/article/10.1007/s10508-020-01717-8 bisexual women have at best slightly higher testosterone than average, though the abstract itself says that most studies on the topic have been "small, biased, and heterogenous" and that little confidence should be placed in their findings.

LadyJane writes:

A lot of the bisexual people I know, particularly bisexual women, seem to have chronic pain and/or autoimmune disorders of some sort. (A few weeks back I noted a similar pattern among trans people I know.) Cisgender homosexuals, on the other hand, seem to be just as healthy as cisgender heterosexuals. Possibly even more so, since both gay men and lesbians tend to be more athletic and physically fit than the average straight person - which might explain why homosexuals tend to have even lower rates of Long COVID than heterosexuals. I've long thought that gender dysphoria in trans people might be tied to more general "body mapping" issues that would strongly correlate to various health problems; the same could be true, to a lesser degree, of bisexual people.

It's possible that both trans-ness and bisexuality are the result of a sort of anatomical and neuro-hormonal "chimerism" that isn't present in either fully straight or fully gay cis people. I don't mean they're the result of literal genetic chimerism (which is far rarer than bisexuality or gender dysphoria), but rather, that they're caused by some sort of mismatch involving the body's neurological and hormonal transmitters and receptors. Most likely, this "mix-up" would occur during early fetal development, with downstream effects on things like muscle growth and immunological functionality.

I find something like this plausible; I wouldn’t describe it as “chimerism” so much as there are lots of cases where it’s fine to be A, fine to be B, but bad to be somewhere in the middle, the body needs some way to settle on either A or B, and maybe there’s some general process that it can be better or worse at.

Related: I just checked and, although left- and right- handed people have similar amounts of Long COVID, ambidextrous people have 2-3x as much, maybe an even stronger amount than bisexuals. This could also fit the response bias hypotheses above.

Michelle Taylor writes:

Neurodiversity also correlates to a bunch of other physical disorders like EDS and digestive system problems, likely because of underlying pervasive development disorders - I'm not sure why that makes it 'more likely to be psychosomatic' rather than 'body that went slightly wrong in development is more susceptible to cumulative damage'.

It's fairly clear by now from autopsy evidence that covid does a load of subtle damage most people just don't notice because it doesn't stop them functioning, but if you're already on the edge of not functioning (or just more adept at noticing small changes) it is more likely to tip you over.

Thanks for bringing this up. I’ve written about my thoughts on the EDS correlation here. I do think of the digestive system problems as probably more about the nervous system (“gut brain axis”) than the digestive system itself, but I don’t know enough to be sure.

I agree this challenges and blurs the concept of “psychosomatic”; if you have digestive issues because you’re stressed and this changes the way your brain tells your gut to contract, and then your gut doesn’t contract the right amount, is that psychosomatic or not? I agree that if Long COVID is partly “psychosomatic” it might well be according to this expanded definition.

4. Comments By Jim Coyne

Coyne, who blogs at Coyne of the Realm, is a psychologist and hero of the replication crisis, so I take his comments seriously (also, I appreciate his kindness and restraint compared to the last time he got into an argument about fatigue-related conditions)

His critical article is here. It’s long so I’ll try to summarize and respond to his main points as best I can.

Is my sample size too small?:

My experience is that most of the time readers do not actually check numbers in tables and instead rely on what authors say about them. Scott actually refers to the numbers in the table in his text. I could readily see that even if he had a superb survey to produce numbers, these would not be very interesting. Here’s why the numbers should be dismissed by anyone serious about relying on evidence. The numbers in key cells are too small. To understand that, we need to appreciate that numbers are not exact but are estimates and have confidence intervals indicating how precision there is to them. Scott does not provide these confidence intervals, although he gives in his text the results of analyses he claims show their statistical significance, and these analyses should have allowed hand calculation of confidence intervals.

This does not matter because we can simply eyeball the numbers and see something is wrong. Scott tells us elsewhere he had 7,341 people complete his survey. That number is huge, but we do not even have to know that to see he is dealing with very small differences. Woman who say that they are bisexual rather than some other sexual orientation may not necessarily be different in other women. It is strange that there are only 38 avowed homosexual women in Scott’s study and only one said they had long COVID. Of 254 women who endorse bisexuality, only 18 said that they had long COVID. Of 514 women who endorse heterosexuality, 17 say they had long COVID. Don’t even bother with the Other category. These numbers are so small, we cannot take them too seriously. We definitely cannot say that we are confident that these numbers would be significant with a larger sample. We must say that there is nothing to say.

I’m not sure what Coyne means here.

There’s no rule saying you can’t detect an effect with a sample size of 254. It depends on the size of the effect you’re trying to detect. If you think groups look different, you do a significance test to see whether the difference you found is significant given the sample size. I did a chi squared test and it was 0.016 for the analysis Coyne is talking about. That’s well below traditional standards of significance. If there’s some other sense in which my sample was too small, I’m interested in hearing what test Coyne thinks would detect it.

I don’t know why he thinks it’s suspicious that there are only 38 homosexual women. 11% of respondents were women (this is a tech-heavy blog whose readership skews male, and this gender balance has been consistent on all past surveys), and 4% of those women were homosexual. That’s pretty close to known population averages.

I have trouble believing such a strong association exists between bisexuality and reports of long Covid. I wonder if Pirate Wires really captured a lurking powerful finding that no one else noticed in the CDC data or if they merely cherrypicked a finding that disappears with proper control of confounds.

I won’t explain “confound” here, but I will give some examples. A few decades ago, researchers discovered that drinking coffee in America was associated with dying from lung cancer, whereas tea was the apparent culprit in the United Kingdom and Ireland. Eventually, the researchers noticed that people were likely to smoke when drinking coffee or tea. No effect of hot drinks was found for nonsmokers. Then there is the excess of Lisa Minelli vinyl in their record collections allegedly found to distinguish early victims of HIV/AIDS…Could a swift record burning have saved lives?

Yes, all cross-sectional data is vulnerable to confounding. Given that we can’t randomly assign people to be bisexual or not, we are forced to try to read the cross-sectional tea leaves. I tried adjusting for various confounders in my data (the one I showed was gender). If someone else wants to try adjusting for others, they can access the public survey data here.

Still, I think the proper thing to do here is to acknowledge that the association exists and start a discussion on what potential confounders might be involved. If this does turn out to be because of confounders - maybe bisexuals drink more coffee, and coffee causes Long COVID - that would be fascinating! Would you rather nobody ever report the bisexual thing, and then we never learn that coffee caused Long COVID?

I hope I made it clear that the finding in the data was that bisexuals had more Long COVID, and that psychosomatization was my personal non-data-based guess as to why.

Scott, you got yourself in serious trouble making up questions and playing survey research scientist. Survey research is an art and craft done with an increasingly sophisticated methodology. If you thought you needed to do a survey, you should have used off-the-shelf instruments with validated cutpoints, as well as the standard questions used to assess gender and sexual preference. To analyze your data, you should have hired graduate students who know something about causal inference from noncausal survey observational data […]

Your survey is much too long and your sample will be biased by lots of people giving up without leaving you their data or they will follow your advice and only answer the questions they chose.  The instructions accompanying the questionnaire suggest that this is OK. You would have been better to have communicated that completing this survey is serious business and they should do the best they can to answer every question.

This second point is factually not true. Comparing two similar questions from the beginning and end of the survey - Political Spectrum near the beginning, and Trust The Media near the end - the first got 7291 results, and the second got 7229 results, and I think most of the difference was because the second question was more complex.

But even if there had been a large drop-off, I think it would be unlikely that the people who dropped out would have a different degree to which bisexuality correlates with Long COVID than the general population. Or that this degree would be so dramatic that it would cause twice as many bisexuals as straight people to have Long COVID on my survey even though in the general population it’s the same. Or that by coincidence it would exactly mirror the result in the CDC survey.

One can always tell people to be more rigorous, and this is true at any level of rigor. But one can also defend the level of rigor one uses as appropriate for the task, and I think that’s true here.

Your questions that are intended to assess mental disorder are odd and they likely provide uninterpretable and misleading data. It is never a good idea to use data from screening question data rather than a structured interview in which the researcher can explain what is meant by questions and probe respondents’ responses to see if they understood what was being asked. This is a big deal. Even with well-validated questions and cutoff points, most endorsements of mental disorder will be false positives and so you will substantially overestimate the prevalence of disorder and distort its correlates.

They are apparently not uninterpretable since you can replicate most real findings about mental disorders with them.

For example, the best nationwide analyses find that women have more depression than men; my survey also finds this. Too easy? It’s well-known ADHD people are more likely to have substance abuse issues; my survey finds people with ADHD are 4x as likely to report this. Still too easy? The most careful experiments find that schizophrenics are less likely to be able to see the Hollow Mask Illusion: my survey also finds this.

In general, when a finding is real, I’ve been able to replicate it. This is because there’s a very high correlation between whether you answer “yes” to the question “are you bisexual?” and whether a long complicated survey instrument would determine you were bisexual. And so on for many other variables of interest. See also the correlation between the PHQ-1 and longer depression tests.

I would be happy to make a bet with Coyne about whether some randomly chosen effect in the literature also shows up in my survey. I don’t think I’ve tested whether or not my survey accurately reports that schizophrenics are more likely to be depressed, or that women are more likely to be liberal. Would you like to bet on whether these show up in the data?

I appreciate that there are some situations where it’s important to have structured diagnostic interviews for rigorously-defined constructs, but these are more often when trying to determine the size of an effect, or when to take some specific action in an individual case, rather to establish broad correlations like I’m trying here. See here for more about my thoughts on this.

The wording of multiple-choice response options is too creative to work. You are left not knowing why respondents endorsed particular mental disorders. They might endorse major depression because they have been in treatment for years or only because they consulted a primary care physician and were required to complete a depression screening questionnaire. As is all too common that physician told the respondent they were depressed but the physician accepted a false-positive without conducting the necessary follow up interview.

Again, the necessary level of rigor depends on what you’re trying to do with a question.

Consider for example the question “are you a smoker?” Lots of great research has been done with this question! For example, people who answer this question “yes” get more lung cancer than people who answer it “no”. This is enough to suggest (without proving causation) a smoking / lung-cancer connection. If self-identified smokers and self-identified nonsmokers got exactly the same amount of lung cancer, that would be strong evidence against a connection.

This is true even though it’s a terrible question - it doesn’t establish how much you smoke, how often, whether you smoked as a teenager but not anymore but you still consider yourself “a smoker”, etc. You wouldn’t want to draw conclusions about the number of smokers in the US or the exact size of a smoking / lung cancer link from this. But you can absolutely say “smoking is correlated with lung cancer, more research needed to determine the size of this effect and what causes it”. That’s because, overall, the “smoker” group will smoke more than the “nonsmoker” group, and whatever effects smoking has will be higher in that group.

Because asking someone “are you bisexual?” correlates very well with whatever other bisexuality-related construct you want to invent, my survey is able to replicate known findings about bisexuality, like that women are more likely to identify as bisexual, bisexuals have (on average) more sexual partners, etc. This survey would not be appropriate for other purposes, like determining the exact rate of bisexuality by some standard other than self-identification.

I would not take your questions too seriously whether respondents have had COVID. It is not surprising that you report that you “got much lower rates of Long COVID than the CDC, more like 3% than 20%.” Do you think your readers should believe you or CDC or neither? 

It is bizarre and wrongheaded to insist that there should be one “real” Long COVID number and anyone who doesn’t get it is messing up. There are no universally-used case criteria for Long COVID. Different studies’ numbers change constantly based on how strict their criteria are, how they ask the question, how long after the COVID case they’re asking, what sample they’re asking, etc, etc, etc. So for example, Logue et al found 33% of patients had Long COVID symptoms by their definition; the British Office of National Statistics said 14%, Sudre et al said 2%, and the CDC said 20%. None of these people are lying or incompetent, it’s just that there’s no single “correct” definition of Long COVID or correct population to ask about it.

I said on my post that this was not an attempt to establish a prevalence of Long COVID (which would be meaningless - see here for me writing about other people’s attempts to do so and then explaining why they’re meaningless). It’s an attempt to get a cutoff at a certain random point into two groups, one of which has more Long COVID than the other. If one group contains more bisexuals, that’s a potentially meaningful result.

Overall, Scott asks so many leading questions in his survey and offers so many different multiple choice options that should greatly confuse participants and anyone who seeks to re-analyze the data he gathered. The biggest question is why he chose to cherry pick an alleged association between bisexuality and long COVID out of all the associations he could possibly tease out.

The ACX survey is a platform for me and others to investigate questions of interest to us. I’ve used it for lots of things - see for example this attempt to replicate the finding that you can perform wisdom of crowds with yourself. I tested the bisexuality hypothesis because it was on Pirate Wires and I wanted to see if the same hypothesis held in a second data source. It did. I think something being a conceptual replication attempt frees it from accusations of cherry-picking.

But let me step back into this discussion and offer my expertise about the meaning of “psychosomatic” in science and in pseudoscientific attacks on patients with misunderstood physical health conditions. In science, “psychosomatic” has often been attached to physical health conditions before their diagnosis and biology are properly understood. In uncorrected popular prejudice, the term “psychosomatic” has often been used to deny patients appropriate medical treatment for a medical problem.

Please see the section immediately below for a more thorough response to this concern.

5. Comments Expressing Concerns About The Dangers Of Calling Things Psychosomatic

After bringing up some of the alternative explanations discussed above, Michelle Taylor wrote:

I am somewhat biased on this because I believe the world is currently making a dreadful mistake ignoring long covid which will become increasingly apparent as people with it age and can no longer ignore the minor symptoms, and things which are psychosomatic tend to be ignored or dismissed by society as something you can somehow just stop experiencing

I want to emphasize that I’m not claiming that Long COVID is only psychosomatic (let alone that it’s “fake”).

Almost all organic conditions have a psychosomatic shadow. Consider eg heart attacks. These are as organic as they come. But about a third of cases where people come into the emergency room with sudden-onset sharp chest pain are having a psychosomatic issue, usually a panic attack.

You’ll find the same thing across almost any condition. Seizures? Probably about 25% of them are psychosomatic. Headaches? These can be caused by a host of organic issues (brain cancer, meningitis, dehydration, etc) but also by stress. Leg paralysis? Can be caused by leg injuries or conversion disorder. Blindness? Psychosomatic blindness has fallen out of style these days, but used to be quite popular - the British commander in the Revolutionary War had it. Having insects crawling all over your body? Can be caused by insects crawling all over your body, or by delusional parasitosis.

If there were no organic cases of Long COVID, it would make COVID one of the only coronaviruses in its family not to have a postviral syndrome. But if there were no psychosomatic cases of Long COVID, it would make Long COVID maybe the only condition in history with zero psychosomatic shadow. So when responsible people have this discussion, they’re not asking “are any cases real?” or “are any cases psychosomatic?”. They’re asking what percent are in which category. People really want to root for “Team It’s All Psychosomatic, If You Say It’s Organic You’re Gullible” or “Team It’s All Organic, If You Say It’s Psychosomatic You’re A Monster”, but that’s not how any of this works.

I had previously written about why I thought the vast majority of cases were organic with only a very small psychosomatic shadow. So I would feel dishonest if I didn’t also write about it when I made an update towards thinking the size of the psychosomatic shadow was larger. If people are jerks about it, I’ll try to correct them; if they keep being jerks, I’ll ban them.

Siebe Rozendal writes:

The science behind psychosomatic medicine is often extremely poor, using bad definitions and wrong tests. The field is driven by highly dogmatic people with uncomfortably close ties to the insurance industry (if it's psychological, there's somehow no need to pay social security)

Here's a good blog on the topic:

https://mecfsskeptic.com/history-of-psychosomatic-medicine/

Most conditions classified as "(potentially) psychosomatic", such as fibromyalgia, irritable bowel syndrome, and ME/CFS have plenty of evidence of a biomedical origin that the psychosomatic crowd conveniently ignores.

The consequence of labeling diseases as psychosomatic are lack of treatment, harmful treatment, lack of research funding, and lack of social security. You might want to be a little more careful throwing that term around.

Again, stop rooting for “Team Every Disease Is Always Psychosomatic” or “Team Every Disease Is Always Organic”!

I can’t tell if Siebe is trying to deny the existence of psychosomatic illness entirely or what, but that is not really a going hypothesis. I don’t know of a single doctor or scientist who would agree with that. I mentioned above a study suggesting that a third of ER visits for chest pain were psychosomatic. A third! That’s millions per year!

I think people tend to confuse the debate “does psychosomatic illness exist?”, which isn’t a real question because everyone agrees it does, with “is illness X entirely psychosomatic, such that it has no organic cases?” As Siebe points out, there are many times people had that debate and doctors discovered a firm biological basis for the illness. As Siebe doesn’t point out, there are other times people had that debate and the illness did turn out to be entirely psychosomatic - Morgellon’s, electromagnetic hypersensitivity, candida hypersensitivity, etc. You can’t just go “Here’s a time Team Organic won, therefore Team Organic is always right, wooo!” There are no teams!

I’m very sure Long COVID is often an organic illness with a biological basis. I’m not claiming it’s in the same class as Morgellons. Having acknowledged that, like all conditions with a biological basis, there will also be lots of psychosomatic cases, just as with heart attacks and everything else.

Does this make it irresponsible/trollish to mention that some cases might be psychosomatic, in the sense that it gives aid and comfort to some (hypothetical?) person saying it’s all psychosomatic? I think the worst-case scenario is that, since Long COVID is in the news, extremely sympathetic, and has maximally vague symptoms, its psychosomatic shadow could be much bigger than normal, big enough to be worth thinking about (not that I have any good ideas what to do once we’re thinking about it). There’s no amount of “did you hear about this one time someone labeled a case ‘psychosomatic’ and it was bad and offensive?” that will change my mind about this.

6. Other Comments

JDK writes:

Didn't a pretty well done Norwegian study show that there wasn't even link between "long Covid" and actually having contracted Covid among adolescents?

There was an apparent link though between loneliness and long Covid.

So in any cohort that seems to correlate with higher LC prevalence perhaps one should investigate whether loneliness also correlates. (Maybe also look at severity of symptoms from whatever viral infection and poor physical activity per Norwegian study. One might hypothesize that a non lonely gym attending group would have less "long Covid" than a lonely sedentary cohort.)

Is SA's essay really about "replication" at all?

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2802893

vinayprasadmdmph.substack.com/p/bombshell-new-study-on-long-covid

I’m pretty skeptical of this. As mentioned above, I think it’s very unlikely Long COVID is 100% psychosomatic. But even 100% psychosomatic conditions obey their own supposed rules; people who had had COVID would be more likely to psych themselves into thinking they had Long COVID than people who didn’t. So the total lack of correlation is surprising on any theory.

Here’s a claim that COVID antibodies are a pretty bad test for whether someone’s really had COVID. I don’t know how that interacts with whatever statistics are being used in that study, but its results are surprising enough either way that something seems off.

Shasha writes:

I am very curious what people here make of long COVID biomarker findings. Multiple groups have found multiple sets of blood biomarkers, some with very good predictive value; see Table 2 in this review article https://www.thelancet.com/journals/ebiom/article/PIIS2352-3964(23)00117-2/fulltext.

This is a meta-analysis which discusses 239 potential biomarkers for Long COVID. I don’t think conditions usually have 239 biomarkers, but I’m not going to read the 23 studies they drew from to figure out which are good vs. bad. When I’ve looked into depression biomarkers, it’s been very hard to distinguish them from general bad health markers, and Long COVID would be especially hard since you would have to distinguish them from previously-had-severe-COVID markers. But I expect that once all this work is done there will be some good biomarkers that will survive various tests.

James writes:

Would be really interesting to get these results further broken down by Kinsey scale. The suggestions of bisexuality being dependent on cultural suggestibility or tendency towards self-identification with labels seem to make much more sense lower on the Kinsey scale. At 1 or 2, sure most men will say they're straight and the ones that say they're bi would be more likely to identify with other controversial labels. By the time you reach 3 or 4 on the Kinsey scale though, it's not really something you can still be uncertain about, so at that point people are either identifying as bi or intentionally staying closeted (meaning no disrespect to those making that choice, I did the same for a long time).

I agree and I’ll try to include a Kinsey scale on the next survey if I remember.