The site Science-Based Medicine (SBM), renowned for debunking quackery and insisting on a firm evidential basis for medical treatments, has put its foot into it, and by “it” I mean the controversy about Abigail Shrier’s new book dealing with “rapid onset gender dysphoria”.
It started, as I’ve described before, with a favorable review on the site by physician (and SBM editor) Harriet Hall, assessing Abigail Shrier’s recent book Irreversible Damage: The Transgender Craze Seducing our Daughters. Shrier’s book, which I’ve now read, describes a phenomenon that she and others call “Rapid onset gender dyphoria” (ROGD). This is a phenomenon of recent origin in which young pre-puberty women (almost never boys) suddenly decide that they are really males, and, often with minimal advice and supervision, take hormone blockers to stave off puberty, followed by hormone treatment (and often surgery) to remove breasts and (rarely) construct surgical penises.
Shrier’s thesis was that these transitions are often motivated more by social pressure than innate feelings that one’s body doesn’t match one’s gender, and by transitioning, many of these girls gain affirmation and approbation from their peers, often on socia media. Further, Shrier maintains that these transitions are often poorly supervised and, if the girls weren’t given medical treatment but therapy, most would not transition but develop into adult women. Her book is largely a series of stories, largely because the ROGD is so recent that its origins—and whether medical treatment should be used (as well as the psychological and physiological outcomes)—haven’t been subject to rigorous scientific study. We know very little about how to deal with those who manifest ROGD.
Thus, rather than proving her thesis, which wasn’t Shrier’s intent, she wanted to raise red flags about a phenomenon that could have its origin in social pressure and lead to irreversible harm in adolescents who are often psychologically disturbed. The upshot is that we clearly need more research on this phenomenon before we start giving hormones to girls who, in their teens, decide that they’re actually boys. Hormonal and surgical treatment is, after all, irreversible.
Shrier doesn’t deal with the kind of gender dysphoria that manifests itself in early childhood and continues for a long period, or that is taken care of long after puberty in people like Caitlyn Jenner. She’s concerned with adolescent girls who suddenly declare that they’re boys and take immediate action to fix the situation. Their numbers have increased rapidly, raising the question about the origin of the phenomenon. Shrier’s book is neither shrill nor unempathic: she has deep sympathy for transsexual people who are heavily invested in being a member of their non-natal sex. Rather, she wants to call attention to the phenomenon of ROGD and to question whether surgery and hormones are the right answers for a temporary affliction, exacerbated by the climate of social media and physicians and parents who are told to do “the right thing” (facilitate transition), and who don’t hesitate before “affirming” gender change and supporting medical treatment.
I thought Shrier’s book, while not definitive, was well worth reading, and certainly not worthy of banning, a ban for which ACLU staff lawyer Chase Strangio has argued. It should start a conversations about the phenomenon and inspire the collection of data that don’t yet exist. But of course Shrier has been called a transphobe and has been widely demonized by the transsexual communty. One simply can’t question the Received Wisdom in this area.
Under the leadership of Steve Novella and David Gorski, SBM removed Hall’s review from their site, claiming that its egress was due not to social pressure but to Hall’s review (and Shrier’s book) being full of bad science and poor scientific judgment (you can still read Hall’s review at Skeptic Magazine). Novella and Gorski then posted a defense of the removal (replacing Hall’s review with three articles opposing Shrier’s view), citing several papers that I hadn’t read. Summarizing their defense, I listed six assertions by Gorski and Novella about why Shrier’s claims (and their defense by Hall) were bogus. Unable to evaluate them, as I wasn’t familiar with the literature, I just asked readers to judge for themselves.
Now, however, someone more qualified than myself, and more qualified than Gorski or Novella, has evaluated the data and their own claims. That person is Jesse Singal, who has read all the relevant literature cited by Shrier, Novella, and Gorski, and has published widely in respectable venues about transsexualism. He concludes that not only should Hall’s review have been allowed to stay on the site, but that Gorski and Novella have behaved badly—indeed, unscientifically—in rushing to damn Shrier’s book and Hall’s review. One can conclude, if Singal be right, that Gorski and Novella are behaving in a woke-ish fashion, mis-citing data as well as accepting results that confirm their views and rejecting those that don’t—for no good reason. In fact, Singal’s indictment of Gorski and Novella’s reading of the literature is pretty damning, implying cherry-picking, confirmation bias, and distortion of the existing data, which is not about ROGD, which Gorski and Novella imply, but dysphoria that starts early in childhood or comes to fruition in adulthood.
Singal’s piece was 40 pages long when I printed it out in 12-point type, so it’s a long read. I’d still recommend it, especially if you’re interested in transgender issues or SBM in general. You can read Singal’s article for free by clicking on the screenshot below, though he would appreciate a donation for his work.
To my own credit, which isn’t substantial, I did pick out some of the same problems as Singal does with the Novella and Gorski piece—for example my asking, despite their claim that medical organizations had very high standards for facilitatating transition, whether those standards were actually used very often (it seems that they’re often flouted). And I questioned whether the change of gender dysphoria from a “disorder” in the DSM-IV to “not a disorder” in the DSM-V was meaningful. Singal shows that it’s not.
But Singal’s analysis, or rather destruction, of Novella and Gorski’s defense is pretty damning. I urge you to read it for yourself. All I’ll do in this post is highlight, in Singal’s own words, the major problem with their claims. His words are in bold and indented, any comments I have are flush left.
First, Singal’s disclaimer:
I should re-emphasize that I’ve said repeatedly I think banning youth gender medicine is a terribly bad idea. The evidence for those “positive outcomes of early medical interventions” come from research that, as we’ll see, leaves a lot to be desired. But it does suggest that for kids with intense, persistent dysphoria who have been well-evaluated, who have any other mental-health problems under control, and who have have good family support, puberty blockers and hormones are likely to lead to the amelioration of what would have been a great deal of suffering. (I include these conditions because we simply can’t say much about the effectiveness of these treatments under different circumstances.) I do not trust legislators to override doctors’ and psychologists’ decisions in a context like this. But again, the evidence here is thin and low-quality, so at the very least it is imperative that any truly ‘science-based’ outlet communicate this uncertainty to readers. Science-Based Medicine has failed to do so.
Having mental health problems “under control” is key here, for it could have significant bearing on the claim that transitioning by adolescents reduces suicide and suicidal ideation. This is frequent claim for which there appears to be almost no evidence. The correlation could work the other way around: only those adolescents who have had therapy and thus low suicidal ideation are the ones who are allowed to transition.
But let’s proceed to Singal’s beef against Gorski and Novella. Again, if you have the time, I’d urge you to read his piece for yourself. He cites a lot of data, something Gorski and Novella don’t do.
Below I summarize Singal’s paragraph headers; each of which is followed by a substantial explanation in the article.
Problems in “The Science of Transgender Treatment” by Steven Novella and David Gorski
1). Novella and Gorski misinform readers about the difference between the DSM-IV and the DSM-5 entries for “gender identity disorder” and “gender dysphoria,” respectively.
2) Novella and Gorski argue that there is widespread adherence to the standards of care for youth gender medicine without providing any evidence that this is the case, other than referencing ‘countless’ interviews they neither quote from nor link to. They also misrepresent the World Professional Association of Transgender Health’s Standards of Care for the administration of hormones to adolescents.
3) Novella and Gorski badly misunderstand the nature of the desistance debate [JAC: “desistance occurs when adolescents grow out of their transgender identity as they age] and communicate a great deal of misinformation and undue skepticism about the desistance literature to their readers.
4) Novella and Gorski badly misunderstand Hall’s concern about regret.
What they mean is that the data on whether transgender people regret transitioning comes from a different group from the one that Shrier and Hall consider (adolescent girls).
5) Novella and Gorski write off Lisa Littman’s study of rapid onset gender dysphoria as “bad science” without explaining why or engaging with Littman’s own rather credible defense of her work, and they engage in some methodological cherrypicking in order to do so.
6) Novella and Gorski falsely report the result of one study and ignore the fatal weaknesses in another.
These problems involve citing studies of gender-affirming outcomes in adults as if they had anything to say about gender affirming outcomes in adolescents with ROGD.
7) Novella and Gorski conclude their article with a profound exaggeration of the available evidence for youth gender medicine that is completely out of step with what the evidentiary reviews conducted by major medical institutions in multiple countries have found, and make no attempt to explain how they came to such a different, more optimistic conclusion.
So, according to Singal, who gives a lot of the data that contradict Gorski and Novella’s claims, there are problems with their analysis of data, with selective citation, and even with ignoring data they don’t like. Singal makes a compelling case, and he ends with these words:
When it comes to hormones for gender dysphoric youth, it’s pretty remarkable to compare the assessments of Steven Novella and David Gorski with those of NICE.
Novella and Gorski: “[T]here is copious evidence supporting the conclusion that the benefits of gender affirming interventions outweigh the risks.”
NICE [the NHS’s National Institute for Health and Care Excellence]: “Any potential benefits of gender-affirming hormones must be weighed against the largely unknown long-term safety profile of these treatments in children and adolescents with gender dysphoria.”
What evidence are Novella and Gorski drawing upon that NICE missed? They should explain this striking discrepancy. And they should transparently correct their article where corrections are warranted, as well as add numerous points of elaboration and clarification. If they don’t, they will mortgage even more of their site’s long-term credibility than they already have.
This, of course, is not the end of the issue. Neither Gorski nor Novella are shrinking violets, and I’m sure they’ll defend themselves vigorously. But what they can’t do is produce data that don’t exist.
34 thoughts on “Jesse Singal: Science-Based Medicine has put its foot into it”
Another good book on the topic by a practicing psychologist that changed my mind about psychology :
Why Gender Matters – Leonard Sax, MD PhD
I note that “science” is mentioned as a word that can be used inappropriately (?) in Orwell’s essay Politics and the English Language.
Details for Sax – clinical family psychologist with some decades of practice, Phi Beta Kappa, from MIT.
Would be funnier if written by Leonard Sex. 🙂
Proofread : the author changed my mind – this book is but one that helped.
Overcommenting achievement for the day : UNLOCKED.
I tend to distrust any book which advertises the author’s academic credentials on the cover.
I don’t understand that – I never attributed such significance to such details – especially since a short bio is on the inside cover.
It must depend on the market or audience. Parenting books – now that I think of it – have many such authorship lines. I imagine it is for the same reason popular medical titles have credentials – as there are significant consequences. I think David Sinclair’s book has his creds, because it is explicitly a medical title.
A professor writing for a popular science audience that knows how the system works obviously has a Ph.D. The audience expects it. So I bet Robert Sapolsky’s book lacks creds.
So my listing the author’s credentials – which are unusual – did not strike me as a red flag or a sign to be suspicious of. An MD/PhD is a meaningful degree in the context. And I was compelled by the strength of the writing anyway.
I was intrigued by this criticism, so allow me to show some results of what I found.
Here is an interesting example:
Trick or Treatment : The Undeniable Facts about Alternative Medicine
The Amazon North America entry for this title shows :
“Simon Singh” <– no Ph.D listed
"Edzard Ernst, MD"
Other printings omit the "MD". A quick look at titles on Singh's author page (I have read several, all good), show no Ph.D. – as he studied particle physics at Cambridge.
I do not know the reason for this discrepancy – however, I do not see anything significant behind it. I conjecture that the apparent omission of "Ph.D", while "M.D." or "M.D./Ph.D." is apparently included – even alongside the other – has something to do with the marketing departments or the prior publication record (the popular titles) of the authors themselves. I.e. it is meaningless insofar as it signifies something devious the publisher is doing.
David Sinclair's book Lifespan shows his Ph.D. on it. Sinclair obviously is enjoying a number of things as a consequence of this book and beyond, but what that means for the science he explains in the book is not consequential to me, as it stands on its own.
While I was at it, I looked up titles from the following authors on Amazon in North America and found they do not list any credentials, while they could list "Ph.D." :
I do not know of many medical doctors who write for a general audience, so I did not look them up.
Does this mean that science books from authors listed without credentials when they could list credentials are in a special category relative to books from authors listed without credentials and probably wouldn't do that anyway? Perhaps such as Ed Yong, or Carl Zimmer? I do not see that as an important question.
If Gorski and Novella really support science based medicine, they should reinstate Hall’s article and request permission from Singal to post his on SBM. That would show respect for evidence, reason, and open discussion.
The ACLU is suggesting banning a book? What is this world coming to?! O tempora! O mores!
It wasn’t the ACLU as a whole, but their staff attorney Chase Strangio who is in charge of gender issues for the ACLU. And yes, if you go to the link you can see his tweet to that effect.
I read this as saying Novella and Gorski were in panic mode and feared the backlash more than they wanted to do a clear analysis. Woke is a terrifying, anti-rational, force in society which we should resist.
“I thought Shrier’s book, while not definitive, was well worth reading, and certainly not worthy of banning, as ACLU staff lawyer Chase Strangio argued.”
Jerry, not a typo, but a suggestion: this wording makes it unclear whether the ACLU lawyer wants the ban, or opposes it. The link says he favours it. (feel free to delete this comment)
Yes, he favors banning it. I was unclear and will fix it, thanks.
The episode has left a very sour taste in my mouth regarding Novella. I was an enthusiastic subscriber to The Skeptic’s Guide to the Universe (and even bought their book!) as well as the Neurologica blog. He is discarding the rules of the road that he teaches as a skeptic in this episode, and I no longer feel it worth following him.
I have no understanding on why he agreed to this approach. I have known for a long time that Gorski is willing to accept questionable approaches in affirming transgender identities, so this doesn’t surprise me on his part.
The efforts to suppress Shrier’s book on the part of SBM, and also now among the American Booksellers Association (following an outcry that including it in a set of sample books is VIOLENCE) surely must incur some sort of curiosity in skeptics as to why there is so much effort to suppress books that question the trend of transgender identity (not to mention the ease at which kind people are now willing to shout TERF rather than engage in discussing the issue with the women who raise objections to formalizing gender identity.)
I see a practice in SBM of now using bad science to obfuscate the issue rather than shed light on it and I can say that I am sorely disappointed. I look forward to reading Singal’s article.
The only thing we should (provisionally) trust here are studies by professional researchers, publications in peer reviewed literature, and summaries of those studies by vetted persons (like Jerry). But even at this point I am still on the fence about it.
The problem is that researchers who upset trans activists are harassed and smeared. Read Galileo’s Middle Finger by Alice Dreger. Universities and research institutes are intimidated by them. Brown University apologized for a research paper that found social contagion to be a factor in Rapid Onset Dysphoria.
I have contributed to the discussion of this issue here a number of times previously, as I am the parent of a trans child. Normally, it would be a subject that falls into the broad category of “things that are none of my business”, but it is not a subject that I have the luxury of ignoring.
I know a lot of trans kids, young adults, and parents of those kids. I accept that there are probably people born with disorders that could lead to someone actually having legitimate and unavoidable gender issues. However, I have not encountered any.
What I do see is kids at the onset of puberty, who begin to feel awkward or uncomfortable in their bodies. So far, that is a universal human experience. The difference is that now, those kids are likely to be told that such feelings are the key symptom of gender dysphasia, and transitioning to the opposite sex will solve all their problems.
Once the topic is raised, all the kids will ever receive from counselors or therapists is affirmation, and a referral to yet another professional who will advocate for the next step in the process. Of course, those steps never actually have the promised results, and seem to usually make the problems worse.
Every single trans kid I know who has started the process with hormones has been diagnosed and treated for serious depression.
One of the keys to kids susceptibility to all of this seems to be the normal fascination with the bodies of members of the opposite sex which starts showing up around the same time.
My experience, time and time again, is that trans girls do not want to experience life as a girl, they want to experience life as they imagine it is for girls, which is heavily shaped by their actual sex. It is an idealized image, and not realistically attainable. The same goes for the trans boys.
Typically, they end up dating other kids who were born the opposite sex that they were, whether trans or not.
Beyond those basic observations, it is troubling to me that this is a condition for there is no physical evidence of any disorder, not tests that confirm it. Everyone relies on the feelings and intuitions of the patient, but are willing to “treat” it with serious medical interventions, sometimes even in young kids.
If I went into my doctor’s office and told him I needed a liver transplant, he would not just pencil me onto the transplant list. He would perform tests, find my liver healthy, and refer me to a mental health professional, who would probably not try to give me liver disease affirmation.
This is a dangerous fad, and people who should comply with professional ethics are largely responsible for spreading it. When fear of the trans activist lobby recedes a little, I think we are going to see a great many malpractice lawsuits, at a minimum. Just like the satanic panic that happened years ago, it originates from a small number of therapists, psychiatrists, and physicians. They sow the seeds, affirm and praise the kids, and refer them to a colleague for the next step. They are not acting in the patient’s best interest, and they are very much doing harm. Once the process is started, it is hard to stop. Besides the likelihood of being shunned as an apostate, the hormones already taken have affected their ability to pull back and think clearly.
When SBM and other normally skeptical sources succumb to the political pressure, I feel it is going to get worse before it gets better. Additionally, there is no real evidence that trans hysteria has any actual physical basis.
There is plenty of at least statistical evidence that should cast doubt on the trans phenomenon. It seems to occur in patterns that imply social origins, rather than any physical origin. It spreads among peer groups of unrelated kids attending the same schools, or seeing the same counselor, as one example. Of course, any actual research following up on such things is also a reason for excommunication and shunning. Even the desire to understand the origins of the trend is an offense.
Max, thanks for these insights. I also know a bunch of trans teens (not my own kids but close enough to know well). I was impressed by the series of essays on Quillette by an anonymous journalist who interviewed parents of trans girls. The message from the essays was similar to yours: there is a high prevalence of mental illness among these kids; most of them are on the autism spectrum; they almost universally have little interest in sex, but are intensely focused on an idealized version of the opposite gender; and many of them are probably gay but don’t know it. And the conclusion was similar to yours (and our host’s): we should have compassion and should support medical treatment for the small minority of people who really do experience traumatic gender dysphoria, but we are probably doing awful harm to many other people who are merely experiencing awkward awakenings of their same-sex attraction. Would be interested in your thoughts about that.
The surprising thing to me is that so many of the trans kids I know do not seem to be gay. Boys who think they are girls seem to want to date girls who think they are boys, but obviously are not.
My sister was always gay, but did not realize it until she was a teenager. However, it was obvious to the rest of us long before then. The “boys” my child dates are nothing like that. They always seem to have very feminine features, voices, and mannerisms. Not what one would see as butch, but more pixie-like.
Of course, when I say “kids”, I mean late teens, not literally children, although the start of this was a few years ago, when they were minors legally.
I know some of the parents are religious people, but most in my circle are not. That is mostly irrelevant, except to note that those kids do not seem to be rebelling against anything at home.
It puts the parents in a very hard position. If you push back too hard, you risk alienating the kids. But you don’t want to join those affirming all of it either. I think that would make me complicit.
If my kid thought he was Napoleon, I would not supply him with a regiment of cavalry and a map of Russia.
But more specific to your observation, I don’t think much of it is same sex attraction. I don’t see that a boy who is primarily attracted to boys would idealize the female body to the point of wanting to live it. If anything, it seems to be hyper-heterosexuality.
Drag people tend to be gay, but that is an entirely different community. Trans people tend to be pretty hostile to drag folks.
Again, I have my own experiences, in addition to what I read, and from experiences with other parents and their kids. I have sat in on “affirming” therapy sessions, and feel it is just terribly wrong, at least for kids who do not have any physical disorders or signs from childhood of dysphoria.
I do believe there will come a time when a large number of the surviving kids realize that they have been betrayed, and the lawyers will have a feeding frenzy. A competent and responsible doctor made my mother stop taking an estrogen supplement because of the high risks of cancer, other docs prescribe the same meds to adolescents to treat a disorder with no physical symptoms.
Thanks wow that’s very interesting about attractions among trans boys and trans girls. I agree this seems like a betrayal of many of these kids, with a terrible reckoning to come.
What I wrote was just my own observations among the people I know, but the pattern seems the most common one.
I do agree about the terrible reckoning thing. My kid is relatively fine, doing great in a very difficult program at a good school. Nothing has been done that could not be mostly undone. But the parents of kids who have had terrible surgical interventions are a fairly angry group, and the parents of the kids who resorted to suicide are going to be a force of terrible destruction once justice for harming so many kids starts happening.
On one hand, you have radical woke activists.
On the other hand, the trial lawyers are salivating for the day of reckoning in 10 years.
You can look at the studies (headline “no effect on bone mass”) on body mass for people taking hormone blockers in adolescence, where typically bone mass substantially increases. There is at least a coin flip that these kids are not only growing up to be sterile but they’ll be fracturing hips in parking lots at age 35. What is that going to be worth to a sympathetic jury?
To compare, tattooing a minor or letting a minor get tattooed is a criminal offense in many American states even with parental consent. What is the long term impacts of a bad tat in comparison to an experimental medical procedure that leaves you sterile and at risk for god knows what later in life? Further, aren’t there supposed to be medical ethics restrictions on doing experimental medical procedures with unknown risks on vulnerable populations like prisoners, mentally ill people and children because that is fascism 101?
I am glad that Gorski has finally put his thoughts out there rather than censoring and sniping at others. Now we can actually address the substance of his claims. Maybe one day I can say ‘OK Karen’ to him? We can only dream.
I have watched in real time as Gorski turned from a not-partciularly-interesting or original member of the skeptic community into a fully-fledged ideologue. Thankfully now others are starting to see it.
Unfortunately Dr Novella has decided to go down with the ship as well. It is a shame, but it is his choice to torch his own credibility that he spent 30+ years building up.
Gorski went the *Z *yers route several years ago, and is a horrible, toxic human being. I recall pointing this out a few years ago, and someone on this site doubted me. I suspect they would agree with me now.
Novella, while refraining from the infighting that broke the Atheist/Skeptic movement apart, threw his credibility away years ago, as well. Not only was he happy having Rebecca Watson as a member of the SGU crew (lol) for years, there was that incident when he disinvited Dawkins from a panel/conference because of some SJW/Woke screeching.
I wonder how many people like myself who would otherwise never have read Abigail Shrier’s book, did so just because SBM retracted Harriet Hall’s review of it with so little apparent justification.
I suspect there will be even more who read it because of this recent kerfuffle involving the American Booksellers’ Association.
Jesse Singal is an excellent writer. Here he coins a cat-based metaphor for the selective evaluation of evidence from the same single source depending on whether the evidence supports or refutes one’s preferred interpretations:
“It’s sort of a Schrödinger’s Evidence type of deal: Source X’s credibility exists in a fuzzy superposition of “totally credible” and “entirely untrustworthy” until we find out whether its claim fits comfortably within our politics, at which point its status collapses conveniently into one state or the other.”
Wow! That quote is genius!
Novella and Gorski screwed the pooch royally here. I used to enjoy SBM and I’ve been a big Dr. Harriet fanboy for years.
Abagail S. has been on MANY podcasts lately – she’s very interesting and highlights what I (as very much a non-expert) believe about the issue. The trans activists just MAKE SHIT UP all the time.
There is a moral panic as trans issues have been successfully co-opted and framed as a civil rights issue rather than a medical one. Doctors are cowed: Imagine an anorexic goes to the doc and he is legally obliged to AGREE with them: “Sure, fatty, you ARE huge if you believe it. Let’s get you some liposuction and a stricter diet.” The teen girls usually have other psychiatric problems aside.
Listen to Abby’s podcast or read her (excellent) book.
if you can’t trust the word of a pubescent teenager, what word can you trust? Children typically have their closest friends who are of the same sex. That is, kids tend to have their deepest emotional attachments to a member or members of the same sex. When puberty/hormones blindsides these kids and sexual feelings begin to stir, it is no surprise that some of these sexual fledglings attach these sexual feelings to their closest friends, members of their own sex. And then nature takes its course and things are sorted out. Unless ideological nitwits step in that is. Leave the kids alone during these confusing times and let nature sort it out.
Good read thx for posting