Steven Novella and David Gorski defend their removal of Harriet Hall’s book review (the book: Irreversible Damage by Abigail Shrier)

July 2, 2021 • 9:15 am

On June 22, I reported here that the site Science-Based Medicine (“SBM”) had removed from its site a book review written by one of its editors, Dr. Harriet Hall. I characterized this removal as an “unfair deplatforming” and suspected that the review, of Abigail Shrier’s book Irreversible Damage (about the dangers of medically treating young children—mostly girls—to affirm their new gender identity as boys), had been removed because of public pushback.

The explanation below for the removal, by SBM founders Steven Novella and David Gorski, takes issue with those reasons for removal, and spends most of its space defending the removal on the grounds that, by making erroneous scientific statements (many based on Shrier’s contentions), Hall’s review had violated the strict scientific/medical standards of the site. (Hall’s review is still available at other sites, like this one.)

I haven’t yet read Shrier’s book, but I did read Hall’s review and this post by Novella and Gorski, and so we’re left with dueling opinions.  I don’t really have a dog in this fight (my main concern about transgender issues involve law and ethics, not medicine), and so I’ll suspend judgment for the nonce, even after I do read Shrier’s book. The issues at hand involve reading many, many scientific papers as well as having some medical expertise; the first I am unwilling to do and the second I don’t have. There will be at least one more installment of this SBM “explanation” involving more arcane medical issues.

I recommend that readers read Shrier’s book for themselves as well as the upcoming series of SBM articles, which take serious issue with Shrier’s claims.

Ultimately, this is an issue that the public and the courts must make, but one that must rest heavily on medical and psychiatric data. Whatever you conclude, I think that the publication of Shrier’s book and of Hall’s review were useful for two reasons. First, some of their claims might be correct; even Novella and Gorski agree with Shrier and Hall that much of the research on treatment for transgender children is anecdotal and needs more rigorous studies. Second, it’s only this type of back-and-forth that will clarify the empirical issues under contention, and (I hope) ultimately lead to their resolution. I note, though, that this hope may be vain given the ideological maelstrom around the topic.

But let’s proceed: click on the screenshot to read.

First, Novella and Gorski argue that Hall’s piece was published without review because she was one of the site’s editors (and remains so), but concerns were raised by themselves and other editors that ultimately led to the retraction:

Two weeks ago, one of our editors published a book review that raised concerns with Dr. Gorski and me, as well as at least one other editor, soon after it published. Reading it, we both feared that this book review had probably strayed beyond evidence or expert opinion and thus required a robust response. This was a review of a book by Abigail Shrier titled Irreversible Damage: The Transgender Craze Seducing Our Daughters. This particular book discussed a complex area of medical practice that also happens to be one embroiled in heated political debate. Because of the context of this topic, we believed it especially critical that SBM be perceived as a politically neutral and reliable source of information about the relevant science. Unfortunately, Dr. Hall’s fellow editors were concerned that the review in question did not achieve this goal.

Our first step was to carefully review the article and then discuss our concerns directly with Dr. Hall to hopefully find a solution. The challenge here was that, while we had enough background knowledge to immediately see there were serious problems with the review, none of us are topic experts. Reviews outside SBM by those with expertise in this area seemed to be making valid scientific criticisms of the opinions and claims in Ms. Shrier’s book, which the review took at face value.

Clearly what we needed was time to do a deeper dive on this complex controversy, to wrap our heads around the published evidence, and to vet the claims and arguments on both sides. This is something we would have preferred to do prior to publication, but we no longer had that luxury. Giving an immediate half-baked analysis would not do SBM readers justice. Ultimately, we decided to hit the “pause” button, to withdraw the review for a time while we consulted outside experts and did our own internal review. Since Dr. Hall indicated she would publish her article on an alternate site (and immediately did), we saw no pressing need to leave the article on SBM while this review was underway.

Novella and Gorski (N&G) are highly respected men, and I have no reason to doubt this explanation, so I won’t argue that pressure for social media had anything to do with the retraction.

And here are the claims that Novella and Gorski make about Shrier and Hall’s (S&H’s) putative errors. The characterization of their criticisms are mine, as well as the comments.

a.) S&H argue that the recent rapid increase in the proportion of adolescents seeking transgender transitioning is due to social contagion. That is, S&H claim that it’s become more acceptable to declare that you’re a transgender person, for which you get a lot of affirmation and support, than to say (if you’re a girl) that you’re a tomboy or a lesbian. 

N&G deny the social contagion hypothesis, and say that the increase (which they deny is higher than fourfold) can be solely attributed to both better diagnoses (like autism or ductal carcinoma), and to the number of children and adolescents reporting to gender clinics. This is possible, but I do not rule out social contagion as a contributing factor, especially when one sees the strength of “affirmation” when you say you’re transgender.

b.) S&H neglect the rigorous “standards of care” for children claiming gender dysphoria. And indeed, the World Professional Association for Transgender Health has a list of standards (reproduced in N&G’s piece) that seem rigorous and reasonable, with the possible caveat that use of hormone blockers to stall puberty may not be “fully reversible”. Otherwise, they seem reasonable, so long as the adolescent (and there must be an age limit for medical intervention) has been fully informed of the benefits and risks of medical transition rather than simply subject to affirmation. Similar standards are, say N&G, promulgated by The Endocrine Society.

I have no issue with the standards, though we have to be mindful of what even N&G say:

Of course, these are standards, and not every practitioner adheres perfectly to the standard of care in any aspect of medicine. But we don’t take outliers and use that to criticize the standard or pretend it is typical or common. Interviews with those involved in transgender care indicate that adherence to rigorous standards as outlined above are the norm.

But the question is really how many practitioners adhere to these standards? Shrier, I believe, argues that there are too many exceptions, and I simply cannot judge, nor can anybody. Given the fact that some transgender children get puberty blockers or hormones on the black market, it would be hard to answer this question.

As for whether puberty blockers are “fully reversible”, as the medical standards insist, I’m not so sure about that. Here’s an except from a recent NYT article on puberty blockers (I haven’t listed all the possible harms described in the article, and note of course that there are the psychological benefits of transitioning):

What are the risks?

Puberty blockers are largely considered safe for short-term use in transgender adolescents, with known side effects including hot flashes, fatigue and mood swings. But doctors do not yet know how the drugs could affect factors like bone mineral density, brain development and fertility in transgender patients.

The Endocrine Society recommends lab work be done regularly to measure height and weight, bone health and hormone and vitamin levels while adolescents are taking puberty blockers.

A handful of studies have underscored low bone mineral density as a potential issue, though a 2020 study posited that low bone mineral density may instead be a pre-existing condition in transgender youth. Treatment with gender-affirming hormones may theoretically reverse this effect, according to Endocrine Society guidelines. . .

The impact of puberty blockers on brain development is similarly hazy. The Endocrine Society guidelines point to two studies: A small one published in 2015 showed that the drugs did not seem to impact executive functioning (cognitive processes including self-control and working memory), while a 2017 study of rams treated with GnRH agonists suggested chronic use could harm long-term spatial memory. (Of course, rams are not humans.). . . . .

c.) Gender dysphoria is not a “disorder” like anorexia. N&G argue that, unlike anorexia, gender dysphoria shouldn’t be seen as a psychiatric disorder because the word “disorder” implies that the condition should be cured—and not by allowing gender transitioning. Frankly, I don’t care what you call gender dysphoria, nor do I think that it automatically has to be “cured”, for surely many children do have a deeply ingrained feeling that they are in the wrong body, and many feel better when they do something about it. But using the DSM (the Diagnostic and Statistical Manual of the American Psychiatric Association), which reclassified gender dysphoria from a disorder to “not a disorder” between the DSM IV and DSM V, doesn’t reassure me. The DSM is a pretty subjective and arbitrary way of “diagnosing” mental conditions. I’ve read a fair amount of it and am not speaking from ignorance.

And there are the comorbidities of gender dysphoria: mental illness that often goes along with the condition, both before and after transitioning. These may be correlates and not causations, but it’s worrisome that these conditions often go together. And even if they are merely correlated, one cannot automatically (as many do) argue that gender-dysphoric children must transition because otherwise they’ll kill themselves, or that, after transitioning, a higher rate of suicide among transgender people is evidence that they’ve been harassed to the point of suicide.

d.) Hall’s claims about the proportion of children who “outgrow” gender dysphoria conflates prepubescent children with adolescents. Based on what N&G say, this is a fair criticism. Hall does this conflation, they say, when asserting that some transgender children “outgrow” their desire to have a new gender identity.

e.) S&H, claim N&G, exaggerate the number of adolescents who regret having transitioned.  N&G say the incident of “regret” is 1% or less.

f.) N&G argue that overall, people who transition between sexes are generally happier. They cite several studies showing “a significant improvement in psychological functioning” after a year, as well as a decrease in suicidal ideation and improved quality of life.  I have no quarrel with this, and it’s an important finding.

N&G have a long discussion which goes into other issues, but I think I’ve hit their main issues above. I am trusting that they are fairly representing the literature rather than just citing data that support their claim that transitioning is a good thing that should generally be supported. Because I don’t know the literature, one should leaven this trust by reading Shrier’s book and looking at her own references.

In the end, I have no issue with applying accepted standards of care to adolescents who wish to transition, as well as waiting until they’re of a proper age of consent. I don’t know what that age should be, but it can’t be 2 or 4 years old, and if it’s after puberty, say 16-18, it’s already too late for a nearly full medical transition. The British High Court recently ruled that children under the age of 16 are too young to give informed consent for the use of puberty blockers unless they have parental consent.

In the end, this argument is above my pay grade, though I’ll continue reading about it. In the meantime, the “agreement” between N&G and S&H comes down to this:

Where we agree with Dr. Hall is that the current state of this evidence is far from ideal. Mainly for practical reasons, most of this research is not blinded or controlled. To put this into context, however, most surgical interventions are not studied in blinded trials, and sham surgical interventions are rare. You cannot blind a trans individual to whether or not they received a gender affirming intervention.

But we do agree that given this reality, we need to continue to study and monitor such interventions for both medical and psychological outcomes. This is where an informed medical and ethical discussion should take place, balancing the risks and benefits of interventions given the limitations of the research. There is also a meaningful ethical conversation to be had about the proper age of consent and balancing that with risks vs. benefits of gender-affirming interventions.

In other words, it’s the familiar ending of science papers, “More work needs to be done.” But that’s cold comfort for children who have gender dysphoria now. And it does say that some of Shrier’s contentions are credible and worth investigating.

 

h/t: Jay

29 thoughts on “Steven Novella and David Gorski defend their removal of Harriet Hall’s book review (the book: Irreversible Damage by Abigail Shrier)

  1. I have read Shrier’s book and recommend others do. It is rigorous and her social contagion hypothesis is quite convincing.

  2. Gorski and Novella have the full support of PZ Meyers and his “horde”, except for the fact they haven’t punished Harriet Hall enough. It’s your typical “burn the witch” nonsense over at that hate site.

    I was amused to see this: “Novella and Gorski (N&G) are highly respected men”. Really? Gorski certainty isn’t. Novella is way less respected than he used to be, but not quite on the lower rung that Gorski currently is at, but could easily end up there. Gorski completely abandoned rational thinking and skepticism a while ago. Even Ophelia Benson has noted this.

  3. If they want to “be perceived as a politically neutral and reliable source of information about the relevant science” they should have left up Dr. Hall’s review and posted theirs in response. The best response to (perceived) bad speech is good speech, not censorship.

    1. Yep. Arguments against the author’s contentions /= argument to remove a review.

      Imagine some Hall supporter coming along and getting WordPress to retract this post of Jerry’s, citing as their reason that the N&G positions he summarizes are incorrect. That makes zero sense; the N&G positions may very well be incorrect, but that’s not a reason to ban an article discussing them.

    1. Also, re:

      S&H, claim N&G, exaggerate the number of adolescents who regret having transitioned. N&G say the incident of “regret” is 1% or less.

      If you read the study that N&G link to for the 1% claim, it is not about adolescents taking puberty blockers, it is about *adults* undergoing surgery. (The “mean age” of the subjects undergoing surgery in each study is listed in Table 2; often these mean ages are in the 30s, 40s and 50s; fairly obviously, people transitioning at that age are likely to have a rather settled mindset.) Also, most of these studies are from well in the past, and so are not about the rather recent rapidly rising rates of adolescents identifying as trans.

      1. That’s kinda ironic given they take Shrier to task for conflating (younger) children with adolescents.

        A grain of salt on both their houses, I say.

  4. Having taken a while to find a footing in this domain – the larger picture includes so-called “endocrine disruptors” or “environmental estrogens” – which, as I suggest, are touchy stand-in phrases for genuine outstanding questions about chemicals used in plastic products, to name one large player. Of course, once one starts to think about this, then even the casual drive down the street becomes a great way to inhale a number of combustion products – not just carbon monoxide, but products from inefficient combustion from a number of fuel types, including the oil that coats the inside of the cylinder that – presumably – slowly burns off.

    The number of things to consider are enormous.

    While a number of these chemicals get California proposition 65 warnings, or not, the outstanding question is about what *consistent* low-level exposure does to a *developing* human being. That is where my comment links to the topic of *developing* children, and their struggle or confusion with an important factor of how they feel about themselves in terms of their sex.

    Leonard Sax, MD has simply written (I recall from memory – apologies if it is inaccurate) – in his book Why Gender Matters, or perhaps Girls On The Edge – to not use plastic – always use food/drink stainless steel or glass – for beverages, for starters.

  5. I agree with you about the DSM being “Problematic” if you’ll pardon the expression. It’s gone through 3 revisions just since I first started my studies. It’s an attempt to codify, quite roughly, disorders in that most complex object in the known universe, namely the human nervous system, about which we’re barely beginning to learn the function and dysfunction. It can’t help being far from perfect. They do the best they can, of course, and constantly update and improve it, and MANY people, at least in psychiatry, must go with their clinical judgment in the waaaay more than fifty shades of gray areas. But, of course, that’s inescapably anecdotal and subject to bias, so it’s not an ideal solution either.

    I think it’s frankly reckless for anyone to claim that puberty blockers are “fully reversible” until that is proven beyond any reasonable doubt. The burden of that proof is definitely on those making that claim, since puberty is a vastly complex process that has effects on essentially every aspect of the developing body. Poking that hornet’s nest without very good reasons would make me quite nervous.

    The consent issue really is tricky…our frontal lobes don’t even finish maturing until we’re in our mid-twenties, but gender dysphoria affects people far younger, and as you correctly point out, by the time they reach even legal age of consent, puberty has moved them past comparatively easy changes. And truly informed consent is probably always a pipe dream or at least a euphemism.
    It’s a very difficult situation for the people stuck in it, and none of the answers are straightforward. Obviously, much research needs to be done into the nature and causation of gender dysphoria, and whether or not it is something that SHOULD be prevented even if it CAN be prevented…the latter being a political and ethical issue as much as a medical/scientific issue.

  6. Gorski lost my respect years ago when he threw another female doctor under the bus (I can’t remember her name) because he was trying to ingratiate himself to the Skepchicks of all people.

  7. I’ve seen more than a few cogent rebuttals of the SBM post. One point I’d like to bring up involves the Keira Bell case in England. A teenage girl who had been absolutely certain she was ‘really a boy’ was encouraged by the official Gender Identity Development Service to take puberty blockers and surgical steps to transition. She regretted it in her 20’s, transitioned back as far as she could, and sued. The case came down to whether or not a teenager could consent.

    I followed the course case a bit and it reminded me of the Intelligent Design case in Dover. Those who offered only dramatic rhetoric and extraordinary assertions were not allowed to testify: it focused on the science. And the judges discovered that the scientific evidence for safety and efficiency was of such poor quality or quantity that their ruling said in part that a teenager could not consent to puberty blockers/ hormones because it was impossible to give them enough valid information to have an informed consent.

      1. I assume you’re talking about rebuttals to the SBM post? Coel has already posted the link to Jesse Singal. The other ‘cogent rebuttals’ which directly address the June 30 article are, I’m afraid, anonymous ones on various feminist sites, though usually filled with links to more credible sources which refute specific points. It might be a bit early for more formal articles, but I expect them. These are not new criticisms.

  8. Lets’ be honest, the review was removed because of bad ideology not bad science. In science, civil debate is treasured. N&G are not acting scientifically and the site should be renamed Ideological Based Medicine.

  9. I don’t know about Gorski, but the one thing that bothers a bit about Dr. Novella is that he NEVER admits that he was wrong. I once heard him say on his podcast that black bears are totally harmless. I pointed out that black bears do on occasion kill people. Well, he said, of course it is a wild animal and you have to be careful. Never did admit that what he said was indeed factually incorrect. It is a small thing I know, but for all of the talk of science and skepticism an admission that he misspoke might have been nice.

    1. I had a similar experience with Dr. Gorski. I commented that I did not think he was correct in his assertion that the “Central Dogma” of biology was DNA makes RNA makes Protein.
      I provided the correct quote regarding coding information not being recoverable from a processed protein, provided a link to Dr. Cricks original paper, and gave the page number.
      He responded with a Wikipedia link (that also declared him wrong further down) and declared his version as being so prominent that it is now all that matters.
      They deal with a bunch of cranks to be fair but do seem to have lost any sense of humility.

      1. I’m glad you said this! I updated my knowlege!

        “A second version of the central dogma is popular but incorrect. This is the simplistic DNA → RNA → protein pathway published by James Watson in the first edition of The Molecular Biology of the Gene (1965). Watson’s version differs from Crick’s because Watson describes a two-step (DNA → RNA and RNA → protein) process as the central dogma.[7] While the dogma, as originally stated by Crick, remains valid today,[6] Watson’s version does not.[2]”

        “Source” : https://en.m.wikipedia.org/wiki/Central_dogma_of_molecular_biology

        Indeed, not having recently reviewed precisely what “the central dogma” is – partly because it seemed to me sort of mundane – I had the same off-the-cuff impression of DNA->RNA->protein.

        But Crick’s writing is clear and elegant, showing how the main object is *information*. THAT is REALLY interesting. DNA->RNA->protein is not (really).

      2. Oh hell, here’s Crick :

        “The Central Dogma. This states that once “information” has passed into protein it cannot get out again. In more detail, the transfer of information from nucleic acid to nucleic acid, or from nucleic acid to protein may be possible, but transfer from protein to protein, or from protein to nucleic acid is impossible. Information means here the precise determination of sequence, either of bases in the nucleic acid or of amino acid residues in the protein.”

        … beautiful, precise writing.

      3. I provided the correct quote regarding coding information not being recoverable from a processed protein

        How are people getting this wrong? OK, mentally functional adult humans of IQ greater than (mean_IQ)-(1*SD_IQ) and possessed of the information that 64 possible DNA codon tuples encode about 20 amino acids.
        After taking out a handful of START and STOP tuples, you’ve an average of three possible tuples per amino acid. You can’t go back to the original sequence – for a two-amino acid protein, you have 6 possible sequences that can generate it (on average) ; for a molecule of insulin (51 amino acids) it’s about 7*10^23 possible sequences that could generate the same protein.
        That’s a convenient coincidence – you could generate a mole of insulin-producing sequences, and still not have much better than evens chance of generating the human wild-type sequence.

      4. This is one of Larry Moran’s issues. I cannot get too excited about this. I think the battle is lost; most college biology textbooks use the historically incorrect version, which is not wrong, only incomplete.

        Maybe the problem is the rather fancy term “dogma” and any attribution to Crick. If rephrased as “the central concept in molecular biology is that protein is coded by mRNA which is copied from DNA” this would be a reasonable simplification. All textbooks inevitably simplify reality, otherwise they would be unreadable.

  10. I’ve read Dr Harriet for years – she is top notch, leagues above her co-editors. Further, I agree with Abagail Shrier. A good discussion of this a recent interview with Dr. Jordan Peterson is very helpful (whatever you feel about Dr. Peterson and his odious religiosity he has first class analytic mind)
    https://www.youtube.com/watch?v=fSKQfATa-1I

    (I”ve ordered her book – I’ve only seen her on about 4 podcasts)

    By framing this issue as a civil rights one many activists have cowed the scientific community here I think (no expert here).

    D.A.
    NYC

  11. I gave up on reading Gorski when he began to believe himself infallible (not a rare development in surgeons). I have, however, read Irreversible Damage and would strongly recommend it to all with open minds. And reading it came with consequences for me, too. My wife, whom I have known for 45 years, and who is a child psychiatrist who deals with the occasional gender confused patient picked it up and read it. She was apoplectic about how unfair Shrier was, how awful the parents of these kids were (the main sin being that if you try to do ‘everything’ to help your child you are being over-protective), and of course, by implication, how awful I must have become to buy, read and recommend the book. It has since disappeared, apparently taken to her clinic so the teams of therapists can read and it and know their enemy. I doubt I shall get it back, or if I do it will be covered in spittle and red pencil commentary with sections expurgated. Oh, well, I tried.

  12. Ultimately, this is an issue that the public and the courts must make, but one that must rest heavily on medical and psychiatric data.

    That is not a recipe for a good outcome. Could we perhaps throw a little bit of sex in there, to make for a really messy outcome, which people will be trying to disentangle the various harms from for several generations to come.

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