Category: health

The Lancet extols Indigenous Traditional Knowledge

April 25, 2024 • 11:15 am

The British medical journal The Lancet has become infamous for being woke (its editor is beyond redemption), and is most infamous for the cover below.  As I once said, its wokeness makes it the British version of Scientific American, though it deals with original research and is entirely (or supposed to be entirely) medical in nature.

The journal has just become a bit more infamous by publishing a glowing paean to “Indigenous Peoples and their knowledges” (is “knowledge” suppose to be plural here?), seemingly making the knowledge of indigenous people coequal to the knowledge produced by modern science. In other words, it’s adopting what seems to be the national policy of science education in New Zealand.

Click to read; it’s free (the pdf is here). The authors are from Uganda, Canada, Tanzania, New Zealand (of course), the U.S., and Canada:

The main message, besides the boilerplate about oppression, is that indigenous people have knowledge that is essential in helping us solve not only the problem of global warming, but also “health discourse.”

Now you know that’s not really true. While indigenous people may have some observations bearing on the effects of both human health and especially global warming, it’s up to both national politics and international science to address global warming. (I don’t have much confidence they’ll remedy the problem.) And it’s up to modern medicine to deal with health issues. We’re way beyond the days of herbal cures and chanting. To say that indigenous “knowledges” is not only important, but “the optimal way forward” (see below) is to indulge in hyperbolic and performative rhetoric.

But let me give a few quotes.

Indigenous Dene Elder Francois Paulette from northern Canada talked about climate change at the 2015 Parliament of the World Regions and warned “Your way of life is killing my way of life.”
He ended his speech with the words: “Rise! It’s time to stand up for our future.”More than 8 years after this speech, an estimated 68% of the Northwest Territories, Canada, which includes the Dene Peoples territory, was evacuated due to 238 wildfires. Communities lost their homes and hunting and food-foraging areas and were exposed to poor air quality for months on end. Elder Francois’ words still ring true today for many Indigenous Peoples around the globe. We are still far away from the world understanding the impacts of climate change on Indigenous communities and the need to move towards efficient and comprehensive action for planetary health.

 

Indigenous Peoples have experienced historical and ongoing colonialism, ecocide, epistemicide, racism, and severe marginalisation and are disproportionately affected by poverty and reduced life expectancy.Yet despite these challenges they continue to protect and steward about 80% of all the remaining biodiversity on Earth. For Indigenous Peoples, every day is Earth Day, with the basis of their lives underpinned by a healthy relationship with the planet and extensive Indigenous Traditional Knowledges (ITK) developed over millennia. However, Indigenous leadership within planetary health practice to shape research, policy, and practice is still challenged by a multitude of factors.

It’s simply not true that indigenous people steward 80% of the Earth’s biodiversity. First of all, the reference seems to be talking only about Australia. Second, the reference appears to show that 80% of the Earth’s biodiversity occurs in areas occupied by indigenous people. There’s no evidence I can find that the locals are “stewarding” that biodiversity beyond the statement, “This highlights how indigenous communities have mastered how to live alongside nature in a way that other communities have not.” It seems that living in areas with biodiversity is equivalent to “stewarding” that biodiversity. But we know that’s not true. In many cases indigenous people have destroyed biodiversity, like the extensive burning of natural forest by the Māori or the burning of prairie by Native Americans not to preserve it, but to get food, as well as their mass slaughter of bison by driving them o0ver the cliffs. That killed far more animals than they can use. What kind of “stewarding” is that?

ITK is also extolled for its “practical knowledge”; and indeed, that’s where it excels: understanding the place and rhythm of where food grows, how to catch that food, how to make stuff that one needs to live (knives, baskets, and so on). But ITK is not equivalent to modern science in many ways that are important: ITK is not generally driven by hypothesis testing, double-blind congrolled experiments, statistics, an atmosphere of doubt, and so on. While ITK is a bag of practical observations, modern science is a bag of tools for finding out stuff.

The article also has the obligatory denigration of “western” science, too, and a denial that indigenous “ways of knowing,” contain more than empirical fact. But in fact ITK, like New Zealand’s Mātauranga Māori, comprises far more than practical knowledge, including religion, mythology, traditional stories, superstition, morality, and guidlines for living. My bolding below:

ITK is increasingly informing climate and biodiversity solutions.  Although this is positive for Indigenous recognition, Indigenous Peoples who hold this knowledge are not usually directly involved in leading such efforts due to structural marginalisation. Implementation movements need to ensure that Indigenous Peoples and their rights are platformed first and foremost within any discussion around ITK. Additionally, ITK is often deemed myth or legend, or faces erasure within western-based institutions, despite it being replete with practical understandings of ecology, meteorology, and the relationship to the environmental rhythms gained over generations of observation and experimentation. Scientific disciplines, including within the medical and health sciences fields, therefore continue to largely marginalise ITK and there are expectations that it should conform to a western standard of evidence as the sole grading rubric of validity—a demonstration of the continuing effects of colonisation.

Well, yes, we need to bring as many voices as possible within science, but by “voices,” I don’t mean “ethnic groups”. I mean we should cast the net as wide as possible looking for scientific talent, and if we find a bit of practical indigenous knowledge to help move science forward, well, so much the better. But in the end, the statement in bold gives away the authors’ desire to “decolonize” modern science: “western standards of evidence” are apparently not the only standards of evidence for judging knowledge. But if they aren’t, what other standards should we use?  Tradition, superstition, and so on? Modern science is simply a toolkit of methods used to ascertain what is true. And there are no other ways to find out what’s “valid” beyond that. (I’m using “science” as “science construed broadly” here, as, for example, what a mechanic does to find out where the problem is in a car.) If the authors think there are ways of knowing beyond this, let them tell us. As it is, you won’t find a single example in this article besides the unsubstantiated claim that indigenous people “steward” 80% of the world’s biodiversity.

It’s hard for me to go on, as this article suffers from the diagnostic problem of all such sacralizations of indigenous knowledge: a lack of examples of how indigenous knowledge has contributed to modern knowledge. A few anecdotes will not suffice. After all, the National Science Foundation has just allocated $29 million to establish a “Center for Braiding Indigenous Knowledges and Science (CBIKS)”, and there had better be substantial payoff to justify that kind of dosh.

The article goes on, but the ideas are familiar: because indigenous people were oppressed and treated badly (often true!), their “knowledges” should be seen as almost sacred, but certainly very valuable, and coequal to “western” science. But if you look at the advances that modern science has made in just 150 years in physics, chemistry, biology, and so on, none of them would even be possible with indigenous knowledge. Yet that knowledge is to be considered highly important, and, without it, say the authors, science is blinkered:

Without meaningful engagement and data representation, Indigenous initiatives are sidelined or neglected. Indigenous Peoples and their knowledges should not just be “considered” within climate change and health discourse and practice, which is typically the case now, but platformed as the optimal way forward.

Platformed as the optimal way forward? What does that mean? Why can’t ITK just be “considered”?  Finally, we hear once again the notion that ITK is one of two essential eyes in science’s way of finding knowledge (I believe this metaphor comes from Canada’s First People):

 Researchers, practitioners, and policy makers need “to see from one eye with the strengths of Indigenous ways of knowing, and to see from the other eye with the strengths of western ways of knowing, and to use both of these eyes together” for the survival of our planet. We need to understand that Ko au te awa, ko te awa ko au (I am the river, and the river is me).

You see how both eyes are considered necessary and coequal to move science forward? I don’t think that’s the case.  Indigenous ways of knowing can, as I’ve said, add practical knowledge to what modern science has found, but it’s by no means a coequal “eye.” And I don’t understand why I have to adopt the mantra that the river is me to study hydrology. After all, I never learned much about genetics from thinking “I am the fruit fly, and the fruit fly is me.”

I’ll regard indigenous knowledge as more important when its promoters start giving us examples—real examples, not anecdotes about catching eels—of how it has made, or can make, important contributions to empirical knowledge.  We shall see what the NSF’s $29 million produces.

Guest post: The new Cass Review

April 18, 2024 • 9:15 am

The final version of the Cass Review (formally the “Independent Review of Gender Identity Services for Children and Young People”) was issued on April 10. Here’s a brief summary by the CBC, noting that doctors and others have griped about it:

A long-anticipated — and contentious — national review of gender-affirming care for youth in England was released last week, resulting in headlines across the U.K. saying that gender medicine is “built on shaky foundations.”

The Cass Review, chaired by pediatrician Hilary Cass, was commissioned by England’s National Health Service (NHS) in 2020.

Even before the final report was published, the review has led to significant changes for youth gender medicine in England, where the debate over transgender care has become increasingly heated, with complaints of both long waiting lists and medical treatments being too readily available to youth.

Last month, the Cass Review findings led to a ban on the prescription of puberty-suppressing hormones except for youth enrolled in clinical research.

That’s a move away from the standard of care supported by many international medical bodies, including the Canadian Pediatric Society (CPS), the American Academy of Pediatrics and World Professional Association for Transgender Health. Though several European countries including Sweden have also restricted access to puberty blockers and other medical treatments for youth.

The report cites a systematic review of evidence, commissioned as part of the Cass Review, which found “a lack of high-quality research” that puberty blockers can help young people with gender dysphoria.

While experts in the field say more studies should be done, Canadian doctors who spoke to CBC News disagree with the finding that there isn’t enough evidence puberty blockers can help.

I had no time to read the long report, and didn’t think that just regurgitating a summary for the readers was sufficient. But reader Jez told me he was going through it, and I asked him if he wouldn’t mind writing his take for this site. He kindly agreed, and so, without further ado. . . .

First, though, Jez notes

“The Cass Review’s final report (and its other publications) are available here.

 

THE CASS REVIEW: A READER’S TAKE

by Jez Grove

Since around 2014, the number of children and young people presenting at gender clinics in the Western world has surged and the patient profile has switched dramatically from predominantly pre-pubertal males to teenage females. Both changes are unexplained. The treatment offered to these patients has also significantly shifted: a psychosocial and psychotherapeutic approach has given way to many being offered medical treatment with puberty blockers (gonadotropin-releasing hormone analogues, GnRH) and cross-sex hormones.

In September 2020, Dr Hilary Cass, a retired consultant paediatrician and former President of the Royal College of Paediatrics and Child Health, was appointed to undertake a full review into how NHS England* “should most appropriately assess, diagnose and care for children and young people who present with gender incongruence and gender identity issues [and] to make recommendations on how to improve services […] and ensure that the best model/s for safe and effective services are commissioned”. [Cass Review Final Report, henceforeth “CRFR”, Appendix 1: Terms of Reference]

The Cass Review’s Interim Report (2022) highlighted that a lack of evidence on the medium- and long-term outcomes of the treatments that children and young people were receiving was limiting the advice that the Review could give. In response, it commissioned an independent research programme to provide “the best available collation of published evidence, as well as qualitative and quantitative research to fill knowledge gaps” and set up a Clinical Expert Group to help it interpret the findings. [CRFR, p. 25]

The Interim Review also warned that social transitioning (changing, name, appearance and pronouns, etc.):

. . . .“may not be thought of as an intervention or treatment, because it is not something that happens within health services. However, it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning. There are different views on the benefits versus the harms of early social transition. Whatever position one takes, it is important to acknowledge that it is not a neutral act, and better information is needed about outcomes”. [Cass Review Interim Report, henceforth”CRIR”; pp 62-63]

The findings of the Interim Report led to the closure of the Gender Identity Development Service (GIDS) last month.

Last week, the Cass Review published its Final Report. Dr Cass begins it with an apparent effort to placate her critics; her opening sentences read:

“This Review is not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves, or rolling back on people’s rights to healthcare. It is about what the healthcare approach should be, and how best to help the growing number of children and young people who are looking for support from the NHS in relation to their gender identity”. [CRFR, Foreword from the Chair, p. 12]

However, she is not blind to the problems that have developed in this area of healthcare:

“It often takes many years before strongly positive research findings are incorporated into practice. There are many reasons for this. One is that doctors can be cautious in implementing new findings, particularly when their own clinical experience is telling them the current approach they have used over many years is the right one for their patients. Quite the reverse happened in the field of gender care for children. Based on a single Dutch study, which suggested that puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence, the practice spread at pace to other countries. This was closely followed by a greater readiness to start masculinising/feminising hormones in mid-teens, and the extension of this approach to a wider group of adolescents who would not have met the inclusion criteria for the original Dutch study. Some practitioners abandoned normal clinical approaches to holistic assessment, which has meant that this group of young people have been exceptionalised compared to other young people with similarly complex presentations. They deserve very much better”. [CRFR, Foreword from the Chair, pp. 13-14]

The problems with the evidence base that sparked the Review persist, with Cass writing that the independent research programme she had commissioned

. . . .“has shown that there continues to be a lack of high-quality evidence in this area and disappointingly […], attempts to improve the evidence base have been thwarted by a lack of cooperation from the adult gender services.  The Review has therefore had to base its recommendations on the currently available evidence, supplemented by its own extensive programme of engagement”. [CRFR, p. 20]

The failure of the UK’s adult gender services to cooperate is perhaps the most shocking revelation in the report. As Cass notes,

“When clinicians talk to patients about what interventions may be best for them, they usually refer to the longer-term benefits and risks of different options, based on outcome data from other people who have been through a similar care pathway. This information is not currently available for interventions in children and young people with gender incongruence or gender dysphoria, so young people and their families have to make decisions without an adequate picture of the potential impacts and outcomes”. [CRFR, p. 33]

A quantitative data linkage study was intended to

. . . “use existing data held by the NHS, including data from GIDS, hospital wards, outpatient clinics, emergency departments and NHS adult GDCs, to track the journeys of all young people (approximately 9,000) referred to the GIDS service through the system to provide a population-level evidence base of the different pathways people take and the outcomes. This type of research is usual practice in the NHS when looking to improve health services and care received.  However, this has not been the case for gender-questioning children and young people and the hope was that this data linkage would go some way to redress this imbalance”. [Cass Review Final Report, p. 190]

Despite its “not particularly unusual” methodology, it took more than a year for the study to receive ethics approval from the Health Research Authority (HRA); Cass considers the “robust scrutiny and consideration [to be] entirely appropriate given the sensitivity of the subject matter”. [Ibid.] The independent research team “undertook stakeholder engagement and developed the patient notifications and communications resources to explain the research and provide information about how to opt-out of the study should an individual choose to do so. […] In January 2024, the Review received a letter from NHS England stating that, despite efforts to encourage the participation of the NHS gender clinics, the necessary co-operation had not been forthcoming”. [Ibid.] Appendix 4 of the Review sets out the details and history of the “thwarted” study.

The proposed linkage study had been complicated by the fact that, uniquely, GIDS patients are issued new National Health Service (NHS) numbers when registering their new gender identity. Cass notes:

“From a research perspective, the issuing of new NHS numbers makes it more difficult to identify the long-term outcomes for a patient population for whom the evidence base is weak”. [CRFR, p. 229]

The UK government had to bring forward a special legislative instrument to facilitate linking the patients’ new and old NHS records; NHS England had vowed to pursue the thwarted research before the special instrument’s powers expire in 2027.

There are other serious unintended consequences of allowing young patients to change their NHS numbers. Cass writes,

“Safeguarding professionals have described a range of situations where this has put children/young people at risk. These include young people attending hospital after self-harm not being identifiable as a child already on a child protection order; records of previous trauma and/or physical ill health being lost; people who do not have parental responsibility changing a child’s name and gender; children being re-registered as the opposite gender in infancy; children on the child protection register being untraceable after moving to a new area”. [CRFR, p. 229]

While Cass has been unable to use a stronger evidence base, she has provided a valuable service in bringing together an independent and thorough assessment of the existing research in areas related to the assessment, diagnosis, and treatment of gender-confused children and young people and suggested a way forward.

The Review gives:

  • An overview of the patient profile, including mental health and neurodiversity, adverse childhood experiences, theories about the rise in referrals and the change in case mix, and the weak evidence with regard to suicidality.
  • An important appraisal and synthesis of the available international guidelines. Cass notes,

“For many of the guidelines it was difficult to detect what evidence had been reviewed and how this informed development of the recommendations. For example, most of the guidelines described insufficient evidence about the risks and benefits of medical treatment in adolescents, particularly in relation to long-term outcomes. Despite this, many then went on to cite this same evidence to recommend medical treatments.

Alternatively, they referred to other guidelines that recommend medical treatments as their basis for making the same recommendations. Early versions of two international guidelines, the Endocrine Society 2009 and World Professional Association for Transgender Healthcare (WPATH) 7 guidelines influenced nearly all the other guidelines. These two guidelines are also closely interlinked, with WPATH adopting Endocrine Society recommendations, and acting as a co-sponsor and providing input to drafts of the Endocrine Society guideline. WPATH 8 cited many of the other national and regional guidelines to support some of its recommendations, despite these guidelines having been considerably influenced by WPATH 7. The links between the various guidelines are demonstrated in the graphics in the guideline appraisal paper (Hewitt et al., Guidelines 1: Appraisal).

The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.” [Cass Review Final Report, p. 130]

  • An overview of the existing clinical approach and clinical management and recommendations to improve them.
  • Recommendations for a new service model for NHS England, including follow-through services for 17-25 years-olds to ensure continuity at “a potentially vulnerable stage in their journey” and “allow clinical and research follow-up data to be collected”. [CRFR, p. 225] She also stresses the needs for detransitioners to be supported and warns of the dangers of private healthcare providers outside the NHS not following its policies.
  • Finally, she cautions that, while innovation in healthcare is important, there must be a “proportionate level of monitoring, oversight, and regulation that does not stifle progress, but prevents creep of unproven approaches into clinical practice. Innovation must draw from and contribute to the evidence base”. [Cass Review Final Report, p. 231]

To critics who say the Cass Review tells us nothing new, surely the onus is on them to justify continuing to provide children and young people with “gender-affirming care”, care for which we already knew there is no reliable evidence on the medium-and long-term outcomes.

______________________

* Health is devolved in the UK; Scotland, Wales, and Northern Ireland (and indeed all other  healthcare services) are free to ignore the Cass Review’s findings, but may be unwise to do so.

Is assisted dying moral for patients with severe, deblilitating, and incurable mental illness?

April 14, 2024 • 10:00 am

UPDATE: I forgot one argument of which readers reminded me: the “slippery slope argument.”  To wit:

5. Assisted suicide laws could lead to a “slippery slope” condition whereby shady doctors allow people to be medically euthanized for curable conditions, or even to allow relatives to kill their grandmothers.  Yes, this is a danger, though one that can be ameliorated with sufficient stringent vetting laws.  The “kill your grandmother” argument can be prevented completely, and certifying certain doctors and shrinks for their objectivity in vetting would be another good step. But when weighed against the suffering eliminated by assisted dying laws, I think the slippery-slope argument, while surely worth considering, is outweighed.

________________________

Assisted suicide for people who have severe and incurable mental illness has always seemed a no-brainer to me, but I’m surprised at the number of people who push back when I bring this up.  But, if the procedure is implemented properly, the objections to it don’t seem tenable, and in the end seem to resemble arguments against abortion.  That is, the pusher-backers say that people in tough spots shouldn’t have control over their bodies, that the procedure might spread if it’s allowed, and, underneath the objections of many, we find religious feelings—in this case feelings like “God will take you when He’s ready, not when you’re ready.”

Yet it seems to me undeniable that some cases of mental illness, like the main one documented in the Free Press article below, are so severe that they resemble terminal illnesses—illnesses for which enlightened people would favor assisted suicide (I might use the term “euthanasia”) in this post.  If you’re terminally depressed, in horrible mental pain all the time, constantly thinking about suicide, and have tried every possible remedy without any success, then why aren’t you in a position similar to that of a cancer patient who, having tried all remedies, now faces a finite term of horrible pain ending certain death? (I presume you’re aware that even in states not permitting assisted suicide, doctors often mercifully end the lives of such patients by giving them an overdose of morphine.)

The difference with mental illness is that death is not certain and the pain will last a lifetime. Sure, maybe researchers will come up with a cure for an intractable mental illness, but that also holds for terminal physical illnesses. People with bad prognoses often hope that a cure will be discovered before they die.

Now for the state to effect euthanasia, there must of course be restrictions.  Beyond that, anybody has, in my view, the right to kill themselves by other means, like hanging, shooting, or jumping in front of a train. That kind of suicide is illegal, though I think the illegality is nuts. But for the government to help you die, it’s not proper to provide anybody with the means of euthanasia. There are many reasons, but I won’t enumerate them.

Naturally, in places where euthanasia is officially legal (see the map below), there are such restrictions for the physically ill:

Physician-assisted suicide is legal in some countries, under certain circumstances, including Austria, Belgium, Canada, Germany, Luxembourg, the Netherlands, New Zealand, Portugal, Spain, Switzerland, parts of the United States and all six states of Australia. The constitutional courts of Colombia, Germany and Italy legalized assisted suicide, but their governments have not legislated or regulated the practice yet.

In most of those states or countries, to qualify for legal assistance, individuals who seek a physician-assisted suicide must meet certain criteria, including: they are of sound mind, voluntarily and repeatedly expressing their wish to die, and taking the specified, lethal dose by their own hand. The laws vary in scope from place to place. In the United States, PAS [physician-assisted suicide] is limited to those who have a prognosis of six months or less to live. In other countries such as Germany, Canada, Switzerland, Spain, Italy, Austria, Belgium and the Netherlands, a terminal diagnosis is not a requirement and voluntary euthanasia is additionally allowed.

Below is a map of where assisted suicide is legal throughout the world, and there aren’t many places. The states in the U.S. where it’s legal include Maine, Hawaii, Washington D.C., Washington State, Colorado, New Mexico, New Jersey, Vermont, and Oregon. But in no state is assisted suicide permitted for those with mental illness. For physical illnesses or other conditions that are likely to kill you in a few months, here are the general criteria in the U.S.:

  • an adult as defined by the state
  • a resident of the state where the law is in effect
  • capable of using the prescribed medications without assistance
  • able to make your own healthcare decisions and communicate them
  • living with a terminal illness that is expected to cause death within 6 months as verified by qualified healthcare professionals

Places where assisted dying is legal (see the key for variations):

Vgonzalez630, CC BY-SA 4.0, via Wikimedia Commons

Places that permit euthanasia for those with mental illnesses include only the Netherlands, Belgium, Luxembourg, Switzerland, and—perhaps after 2027—Canada. I haven’t looked up the criteria for state assistance for euthanasia for the mentally ill in all four countries, but here are the criteria for the Netherlands given in the Free Press article below by writer Rupa Subramanya.

Dutch law requires those seeking assisted suicide to show they are in great pain, have no alternative, and are acting of their own volition. They also must get sign-off from at least two doctors, including a psychiatrist. The process can take a few years, culminating with a doctor giving the patient a fatal medication or, if done by oneself, a cup filled with poison to drink. When it’s over, a government panel reviews the case to ensure everything was above board.

Click below to read the article. The woman pictured, Zoraya ter Beek, suffered her whole short life from depression, autism, and borderline personality disorder, and said she was in constant pain. Nothing helped, and eventually the doctors and shrinks said there was nothing more that they could do for her. Tired of living, she applied for and qualified for assisted suicide. She is still alive but scheduled to die in May. (That isn’t final, of course, for I’ve read of such patients who change their minds at the last minute, willing to go on but heartened by the fact that at any time they could choose to die.) Her boyfriend loves her, but agrees with her decision.

Here are some of the objections to assisted suicide for mental illness, and my responses (all text is mine).

1.) The patient could get better but, by taking their life, are depriving themselves of a livable and perhaps enjoyable future. Yes, but that’s true of even physical illnesses. Besides, the prognosis must be confirmed by several doctors and examined post facto by the state.  And I would ask those who make this argument, “Who are you to tell someone that they must go on living when they’re in intractable pain?”  For those of us who have been severely depressed, it’s hard to convey to others that this kind of severe and prolonged mental pain is fully capable of making you wish to die.

2.) It’s up to God to determine when you die, not you.  As an atheist, or even as a rationalist, I find this argument bogus. Here it’s similar to the religious argument against abortion, assisted suicide for physical illnesses, or, as Peter Singer discusses, euthanasia for newborn babies who have a condition that will cause them to suffer and, ultimately, kill them with certainty in a short time. Besides, are you going to base medical decisions on assuming that there’s a god for which we have no good empirical evidence? Isn’t medical treatment supposed to be based on empirical criteria?  Do you tell a dying atheist that you can’t increase the morphine drip because God doesn’t want that?

Here’s a quote from the article:

All this pointed to a “dystopian view of the future,” said Theo Boer, the healthcare ethics professor.

“Whether or not you’re religious, killing yourself, taking your own life, saying that I’m done with life before life is done with me, I think that reflects a poverty of spirit,” Boer told me.

. . . . Theo Boer, the bioethicist, acknowledged that none of the suicides in the Bible is condemned, but he added that they are not lionized or commemorated either.

“Suicide in the Bible belongs in the realm of the tragic, and the tragic should not be condemned—nor should it be regulated or celebrated,” he said.

This palaver, including the phrases “Life is done with me” and “poverty of spirit” seems to reflect religious belief, but it’s already clear from opposition to euthanasia in many places (especially the U.S.) that we shouldn’t cut short what is up to God to determine. But if God is omnipotent, wouldn’t He be behind a mentally ill person’s decision to have assisted euthanasia?

3.) It’s contagious.  There are several statistics given in the article about assisted dying increasing over time. Most are for physical conditions, with only one for mental illness (my bolding)

In 2001, the Netherlands became the first country in the world to make euthanasia legal. Since then, the number of people who increasingly choose to die is startling.

In 2022, the most recent year for which there is data, Dutch officials recorded 8,720 cases of euthanasia, a 13.7 percent increase from 2021, when there were 7,666 cases. To put this in perspective, there were a total of 170,100 deaths in the Netherlands in 2022—meaning euthanasia cases comprised more than 5 percent.

“This upward trend, in both the absolute and relative numbers, has been visible for a number of years,” the country’s Regional Euthanasia Review Committee’s 2022 Annual Report states. What’s more, the number of euthanized people between the ages of 18 and 40 jumped from 77 in 2021 to 86 in 2022. And the number of people with psychiatric disorders who choose euthanasia is rising: In 2011, there were just 13 cases; in 2013, there were 42; and by 2021, there were 115. 

This trend is not limited to the Netherlands. From 2018 to 2021, countries where euthanasia or assisted suicide is most popular saw sizable increases in the number of people signing up to die: In the United States, where ten states and the District of Columbia have physician-assisted suicide, there was a 53 percent jump; in Canada, 125 percent.

But why wouldn’t you expect the numbers to rise as people become aware that they have this alternative? It’s not written about very often, so you have to see articles like this to find out about it.  But even so, this is a question of ethics, not of statistics.  If the regulations are sufficiently rational and stringent that they prohibit spur-of-the-moment suicides or mental conditions for which every possible cure hasn’t been tried, why should we care about the increase? And wouldn’t you want the ability to die a peaceful and painless death if you had a condition that could be terminated in a peaceful way, at a time and place of your choosing, and when you are surrounded by loved ones? (This is, as I’ve learned, the way it usually occurs.)

4.) It hurts those who are left behind.  I’ve heard this argument used often against those who discuss self-inflicted suicide. “If you kill yourself, think of all the people who will miss you and be in pain.” But this seems eminently selfish to me.  Everybody who dies before their friends, relatives, and loved ones (and that means all of us) faces that as a certainty.  If someone’s in intractable physical pain and dying of cancer, would you tell them to hang on for your sake? Of course not! The same holds for incurable mental illnesses. It’s selfish and boorish to ask someone to stay alive for the sake of your—or other people’s—feelings.

For #5, see the update at top. 

For some people, suicide is simply a no-go zone, which is why suicide hotlines exist to talk those who wish to die out of that wish. But that’s different, for someone who calls a hotline has a good chance that they’re simply emitting a cry for help, and want to be talked out of it. (However, some do kill themselves.) That’s why I think those hotlines are great things. But assisted dying with stringent criteria needed to qualify, and the use of drugs that assure a painless death, are not equivalent to a suicide hotline.

I’m sure that ethical philosophers have discussed this issue before, and feel free to cite articles below if you know of them (I don’t).  These are of course tentative ideas that I’ve thought about for a long time (note: I’m NOT a candidate!), and were given shape by the article above, but I’m willing to listen to other points of view. If you have them, or if you agree with what I’ve said, weigh in below. But do read the Free Press piece.

The New England Journal of Medicine apologizes for not recognizing the attack on Jews in Nazi Germany

April 5, 2024 • 9:55 am

Well, here we are ninety years after the Nazis began persecuting Jews in Germany, and I guess the prestigious New England Journal of Medicine (NEJM) is feeling guilty for having completely ignored that persecution until the war was nearly over (1944). No matter that none of the editors of the journal back then are still active, much less alive: they still feel that a long apology is in order.

I guess I don’t mind their late mea culpa (it’s five pages long), and I’m not even sure a medical journal should take political stands, but in this case the Nazis affected the practice of medicine in Germany. For one thing, they fired more than 3,000 Jewish doctors, and, of course, later sent them to the camps. And the Nazi doctors were, of course, often complicit in medical outrages, like the euthanasia of the mentally ill and the gruesome and torturous experiments on inmates in concentration camps.  One could, I suppose, make a Kalven-like case that the Nazis were indeed hurting the practice of medicine (though in a different country), and so their crimes fall under the ambit of NEJM.

And so the NEJM editors, recognizing that other journals, like the Journal of the American Medical Association and Science, did call out Nazi atrocities, are trying to catch up. Unfortunately, they coopt the language of DEI to explain the journal’s ignoring of Nazi atrocities.

Here’s how the journal begins its admission of ignorance, willful or otherwise. I’ve put links to key articles they reference that are on the Internet rather than their footnotes:

Hitler was first specifically mentioned in the Journal in 1935, in an article by Michael M. Davis, a noted American health expert and reformer, and his collaborator Gertrud Kroeger, a leading German nurse. Yet between this article and 1944, when Nazi war crimes were first explicitly acknowledged in an editorial, the Journal remained all but silent regarding the deeply antisemitic and racist motives of Nazi science and medicine and the threat to the “ideals” of civilization. . . .

Articles on Germany or Nazis in the 1930s and 1940s are overwhelmingly about the compulsory and oversubscribed sickness insurance system, “socialized medicine,” and “quackery,” not the persecution and mass extermination of Jews. In fact, when it did address Nazi “medical” practices, the Journal enthusiastically praised German forced sterilization and the restrictive alcohol policies of the Hitler Youth.

Finally, the Nazi Reckoning after 14 years:

But when the Allied powers liberated the concentration camps, it became clear, as the so-called Doctors’ Trial (1946–1947) categorically demonstrated, that the medical profession in Germany embraced Nazism’s antisemitic and eugenic ideology8 and was deeply complicit in the implementation of mass extermination. The crimes of the Nazi state could no longer be ignored. The first Journal article explicitly damning Nazi medical atrocities is a 1949 article by Leo Alexander, a Viennese-born American neuropsychiatrist, who gathered evidence for the trial of the Nazi doctors at Nuremberg.More articles would be published from the 1960s onward, as scholars started documenting the atrocities committed by medical doctors, and especially after the Declaration of Helsinki of 1964, which established a number of ethical principles regarding human experimentation.12

The journal admits that it was an “outlier” in this respect, but then goes into excruciating and tedious detail into the one article it wrote in 1935 by Davis and Kroeger—an analysis of German “socialized medicine”. Click on screenshot below to get the pdf. Be warned, it’s a snoozer, even though it approves of socialized medicine.  I’m not sure why NEJM even mention this article save that it was attacked two weeks after publication in a letter to the editor, whose author, Joseph Muller, claimed that the Davis and Kroeger piece was propagandistic and “unworthy to appear in our periodical”.

The criticism:

Davis and Kroeger’s article did not go unchallenged. In a letter to the editor published 2 weeks later, Joseph Muller, a dermatologist and an active member of the Massachusetts Medical Society (which owned and still owns the Journal), complained about the Journal using Davis and Kroeger’s article “as a propaganda organ for half cooked world improvers.”21 The article, he claimed, was “neither medical nor scientific, but contains plenty of propaganda and is therefore unworthy to appear in our periodical. It is remarkable by omission of facts rather than by its statements.” Moreover, he wrote, the omission “that more than three thousand medical men were deprived of their means of supporting themselves should open the eyes of the American medical profession to one great danger of State Medicine.” Though Muller showed sympathy for the Jewish doctors, however, the real crux of his critique was not Nazi genocidal atrocities but — remarkably — the danger that socialized medicine could hold sway over the profession, a long-held concern among American physicians about “state medicine.”

As we see below, first author Davis answered Mueller’s criticism in a very brief response that basically swept away Nazi atrocities (Kroeger didn’t answer; the journal said she was a Nazi sympathizer). Its heart is this:

The deplorable repressive policy of the Hitler government in respect to Jewish physicians had no bearing on the main point which the article was intended to bring out, namely, that the organized medical profession of Germany has, by the actions described in the article, been placed in a more responsible position than ever before with respect to the medical services under German health insurance.

In other words, “who cares about the Jews, we were talking about medical insurance”.

Well, what we have is medical history, and of course it wasn’t just doctors who ignored what the Nazi regime is doing. Many people had no idea about the camps, though ignorance of the persecution of the Jews should have been evident to any thinking person.  But the apologia could have occupied but a single page, saying just what I said above.  Sadly, the piece goes on and on, and finally drags in DEI-like elements in trying to explain the exchange of letters above as well as the journal’s failure to cover the medical atrocities of the Nazi regime (bolding is mine):

Davis’s brief response to Muller’s attack is important in that it reveals what have come to be understood as critical elements of structural racism: unconscious bias, denial, and compartmentalization. In his rejoinder, Davis tried to bring some clarification to his omission by denying the relevance to his argument of discrimination against and persecution of Jews.  , , For Davis, the expansion of medical power was thus more important than the fact that this gain in power came at the expense of thousands of Jewish physicians. Moreover, it did not matter to Davis that the doctor whom he described as the “guardian of the health interest” of the German people had to be “Aryan” to be able to practice.1 As we now know, however, this reliance on the benevolent and altruistic physician to act in accordance with the Hippocratic Oath was insufficient to prevent the atrocities committed by physicians in the Nazi death camps.

And later, there’s this, called “moral blindness”:

And beyond Davis, how do we account for the virtual silence of the Journal about these issues over the ensuing decade? Part of the answer lies in denial, compartmentalization, and rationalization, all of which depend on structural and institutional racism — deep historical, often unrecognized, bias and discrimination that serve the status quo.

Well, we don’t know whether Davis’s (or the NEJM’s biases) were unconscious, and is it really news that many Americans didn’t like Jews in the 1930s and 1940s? Those were the years of the popular antisemitic radio broadcasts of Father Coughlin, and of the equally popular antisemitism of Charles Lindbergh, American Hero. And yes, there was structural and institutional racism, most familiar to academics as the “Jewish quotas” in many universities instituted in the 1920s, and lasting for at least three decades.

This history is well known and well documented, save for the possibility of “unconscious” bias, a dubious concept that remains controversial. Regardless, I find it somewhat bizarre that the NEJM feels the need to apologize so many years afterwards, when during WWII it was simply following the American Zeitgeist that preferred to ignore the plight of European Jews. And equally bizarre is that it coopts the language of DEI to implicate structural and institutional racism, which of course was simply the racism put in place by Hitler and many Germans after they whipped up sentiments against the Jews. Is anything accomplished by using modern concepts that are arguable (“structural racism” and “unconscious bias” as a cause of inequities) rather than what’s really at issue here: the fact that not many people cared about the Jews during WWII?  I’m just glad they didn’t mention “the inequities affecting Jewish doctors due to structural racism and unconscious bias.”

Bill Maher’s latest monologue

March 30, 2024 • 1:15 pm

Bill Maher’s latest monologue, “Stuck on stupid,” takes out after what he sees as overreactions to the covid pandemic (including closing schools and denying flatly that the virus came from a Wuhan lab),  I remember disinfecting groceries with alcohol and staying a long distance away from people, and, seriously I don’t think that Maher is correct to say that those behaviors were simply stupid. After all, remember that people were dying of a virus that we didn’t understand, and a lot of people hadn’t yet been vaccinated.

So I think here Maher is being snarky with the wisdom of hindsight. He even seems to diss vaccinations!

And yes, we have learned some stuff: how to make RNA vaccines, that those vaccines work, and that, right now, we don’t really need to have our sixth booster unless we’re immunocompromised.

This ain’t one of Maher’s better efforts. I didn’t follow his opinions at the beginning of the pandemic, but I know some reader did, so please weigh in below.

Bret Weinstein denies that AIDS is caused by HIV

March 11, 2024 • 9:30 am

A high-up worker in the pharma industry sent me a video from last month  showing biologist Bret Weinstein apparently denying to Joe Rogan that AIDS is cause by infection with the human immunodeficiency virus (HIV). (That claim starts about three minutes in, but watch the whole video below.)

Apparently Weinstein subscribes to Rogan’s “competing hypothesis” that AIDS is simply group of symptoms caused not by a virus, but by taking “party drugs” (3:53). Weinstein finds that explanation “surprisingly compelling.”  He also suggests darkly that Nobel laureate Kary Mullis—also an HIV denialist—died “strangely” (there were conspiracy theories about Mullis’s death).  Then the video stops, but you can hear the whole 3½-hour episode here.

The first several minutes of the video below, which you’ll have to scroll back to see, show Weinstein expressing doubt that a virus also causes Covid-19.

You may remember that Weinstein and his partner, biologist Heather Heying, touted the antiparasitic drug ivermectin as a treatment and preventive for the “syndrome” known as Covid-19, even though there was no evidence that the drug was effective (see also here).  In other words, Weinstein seems fond of heterodox and discredited causes of and treatments for diseases: he’s a medical conspiracy theorist.

The pharma guy who wrote me said this:

I don’t mean to obsess about BW, but after the Evergreen debacle and getting a modicum of credibility, he went crazy about COVID and the efficacy of ivermectin so much so that Sam Harris ripped him for conspiratorial thinking and now they’re enemies.  I was livid because people like him were giving horrible medical advice to the public as a biologist-who-claims-to-be-an-authority and may have really harmed people who were listening to his claptrap.  3 weeks ago, he was on Joe Rogan’s show (which I don’t watch but saw a link) wherein he’s now giving airtime to the ‘AIDS is not caused by HIV’ conspiracy theory.

As a member of Pharma industry who watched colleagues like myself craft thousands of molecules to become specific drugs tailored to fit and inhibit the active sites of HIV protease, reverse transcriptase, integrase, and to antagonize HIV binding to the chemokine receptor CCR5 that the virus uses to enter T-cells, I know for a fact that these drugs prevent AIDS by stopping HIV viral replication and entry.  All were approved in Phase 3 with data and are used in various combinations to make drugs like the Quad pill that have suppressed HIV to undetectable levels, allowing HIV-infected individuals to lead pretty normal lives.  Ergo, AIDS IS caused by HIV!  QED.

There were then some words not suitable for a family-friendly site, but among them were the claims that Weinstein is “a conspicuous troll who is hurting people.”

VICE News has a summary of Weinstein’s appearance on Rogan and on their shared and bogus theory of AIDS. An excerpt:

Weinstein’s “evidence,” he made clear, is partially drawn from reading about this theory as outlined by Robert F. Kennedy in his book The Real Anthony Fauci, published in 2021. (One review of the book noted that Kennedy managed to misrepresent numerous scientific studies he cites, which does not make a strong case for its scientific rigor; nor does the fact that it was written by Robert F. Kennedy.)

“I came to understand later, after I looked at what Luke Montagnier had said and I read Bobby Kennedy’s book on Fauci, was that actually the argument against HIV being causal was a lot higher quality than I had understood, right?” Weinstein told Rogan. “That it being a real virus, a fellow traveler of a disease that was chemically triggered, that is at least a highly plausible hypothesis. And with Anthony Fauci playing his role, that was inconvenient for what he was trying to accomplish.”

. . .The conversation generated substantial outcry from scientists and public health researchers on Twitter; David Gorski, an oncologist who frequently writes about the anti-vaccine world and pseudoscience, identified the conversation as an example of “crank magnetism,” writing, “Once you go down the rabbit hole of pseudoscience, quackery, and conspiracy theories in one area (e.g., #COVID19), it is nearly inevitable that you will embrace fractal wrongness in the form of multiple kinds of pseudoscience (e.g., antivax, AIDS denial, etc.).”

And this is, of course, indisputably part of a larger pattern. Rogan and Weinstein regularly repeat discredited scientific ideas, mainly around their promotion of ivermectin as a treatment for COVID and Rogan’s constant promotion of anti-vaccine ideas. The AIDS conversation makes clear that COVID denialists are branching out, using their forms of pseudo-inquiry to draw other bad ideas back into the public discussion.

And from Wikipedia:

Appearing on a Joe Rogan podcast in February 2024, Weinstein erroneously stated that some people with AIDS were not infected with HIV and that he found the idea that AIDS was caused by a gay lifestyle, rather than the HIV virus, “surprisingly compelling”. The American Foundation for AIDS Research reacted to the podcast, saying “It is disappointing to see platforms being used to spout old, baseless theories about HIV. … The fact is that the human immunodeficiency virus (HIV), untreated, causes AIDS. … Mr. Rogan and Mr. Weinstein do their listeners a disservice in disseminating false information …”.

As for Weinstein’s implication that Karry Mullis’s death may have involved his “maverick” view that HIV didn’t cause AIDs (shades of Karen Silkwood!), Michael Shermer responded on February 16 with a tweet:

I’m especially distressed by this kind of quackery, which in the end can cost lives, by a man who started out in my own field, evolutionary biology.  Now, having left Evergreen State far behind him, Weinstein appears to be trying to make a name for himself by being medically heterodox. It’s fine to question untested theories, but the evidence is now very, very strong that HIV causes AIDs and that Covid-19 is caused by a coronavirus.

People often say that “pseudoscience” isn’t that harmful. After all, what’s the danger in reading the astrology column or tarot cards? But that’s just the thin edge of the wedge that opens up medical pseudoscience like that given above. And that can kill people.

Israeli hospital saves Gazan child using a stem-cell transplant

February 29, 2024 • 11:00 am

It’s not widely known that Israeli hospitals will treat any Palestinian who’s sick or injured, given that a few conditions are met. First, the patient must not be a terrorist, though children of terrorists will be and have been treated so long as they’re accompanied by a relative (mother or grandparent) who is not suspected of terrorism.

Further, the patient must have a condition that is not treatable in a Palestinian hospital.  Finally, the patient must have permission from the Palestinian Authority (PA) to go to an Israeli hospital (the PA is supposed to cover the expenses but often doesn’t), and, if the patient is from Gaza, permission from the Gazan authorities.  Since the PA sometimes doesn’t pay up, often the treatment winds up being free, which means it’s paid for by Israel.

This has been going on forever, and yet it’s rarely publicized.  If Israel is an “apartheid state”—even with respect to Palestinians—this treatment wouldn’t be dispensed. It is, pure and simple, a case of humanitarianism and altruism.  And remember, this is not a one-off: it happens all the time.  It involves the Israelis helping people regarded as their antagonists, but they do it anyway, for they value life.  Remember that when you hear that the IDF is deliberately killing civilians for the sake of taking life.

How many people are treated in this way? The American Journal of Public Health answers this in a 2018 article:

Undoubtedly, the short- and long-term suffering of an ill Palestinian delayed at a checkpoint is always unfortunate, and occasionally even tragic. [JAC: delays for sick people passing through checkpoints into Israel sometimes occur to allow ambulances and the like to be checked for terrorists, bombs, or weapons, which have been found in ambulances and other vehicles.] However, despite ongoing terror threats, and even during unrest and wars, many Palestinians do pass daily into Israel for medical care. Israeli hospitals have long provided Palestinians with extensive medical services. For example, during the research period (in 2005 alone), approximately 123,000 Palestinians were treated at just one institution, Hadassah Hospital in Jerusalem, which included 15000 admissions as well as 32,000 visits to the emergency department.

In general, special entry permits are issued in humanitarian cases for ill people, their chaperones, and for Palestinian medical teams. For example, more recently, in 2016, 93,890 such authorizations were issued for patients (plus 100,722 for accompanying family) to be treated at hospitals throughout Israel. At the two West Jerusalem Hadassah hospitals alone, 15,743 patients, comprising more than one third of the total, came through checkpoints and were cared for there. Another 16% (6,577 patients) crossed into Israel and were treated in hospitals in East Jerusalem.

During the same year, 9,832 Palestinian children with birth defects and chronic diseases were treated in Israeli hospitals. During the first half of 2017, 46,132 such permits have been issued and a further 2,163 authorized Palestinian medical personnel to work or be trained in Israel or East Jerusalem (written personal communication, October 4, 2017, Ido D. Dechtman and Yuval Ran, Medical Corps, Tel Aviv, Israel Defense Forces). Another noteworthy example of Israeli compassion for the suffering of her Arab neighbors is the treatment of more than 4,000 victims of the Syrian Civil War in civilian hospitals at Israeli government expense.

Do people realize this? If they do, do they even care, or do they manage to write it off as some kind of “sickwashing”?  I find it a heartening example of humans at their finest.

So here’s the story of one Gazan child whose life was saved by a complex procedure in an Israeli hospital. This is a report from the Elder of Ziyon site.

Click to read; I’ve reproduced the whole short post below:

There’s an intro from the EoZ, and then the details from the Sheba Medical Center (further indented). Bolding comes from the EoZ’s post:

I received this from Sheba Medical Center:

Among Sheba’s values are “peace through health” – treating all patients from the region and Middle East and seeing healthcare as a path to peaceful coexistence.

At the outbreak of the war there were sixty-one Palestinian patients being treated at Sheba and housed on the campus with sixty-eight family members.

Sheba has continued to receive Palestinian patients from the West Bank throughout the war, as well as providing food, shelter and any needed treatments to the forty families from Gaza that were being treated at Sheba and cannot return at this point.

One story in particular is stunning.

W—–, who has asked that her identity and photo be obscured, came to Sheba from Gaza, with a toddler son S—- who has a serious and fatal immune system deficiency disorder. What was needed was a stem cell transplant, but he had no bone marrow match with his younger brother or other family members.

Sheba staff told W—- and her husband that if she had another baby, there was a possibility that child could be a match and a donor. They decided to try. She became pregnant and a test revealed that the fetus would indeed be a match for her sick son. So, Sheba put them up on the campus and treated her for the duration of her pregnancy and delivery.

The baby boy, G——, was born on Oct. 17.

While Sheba was receiving a flood of those injured and traumatized by the war, and with 200 doctors and nurses mobilized into the army, they proceeded with taking extraordinary steps to save the life of one Palestinian child.

The newborn’s cord blood was sufficient for the needed stem cell transplant. The procedure has been performed and the now-four-year-old son is expected to regain full health and live a normal life. When it is possible to do so, his family will return to Gaza with him and his new baby brother.

Hamas fired machine guns into cribs and then raped the mothers of the babies before murdering them, and Sheba is going to great lengths to save the life of a single toddler from Gaza.

You unfortunately will not read this story anywhere else. But our values will continue to define us, and we will continue to hold them high.

They are right – this story will not be published in the media. Stories of Israeli Jews being a light unto nations are not very popular right now for those who want to push the opposite message.

There is nothing inconsistent between this story from Sheba and what the IDF is doing in Gaza.  In both cases they are doing everything they can to save lives – both Israeli and Arab.

I wanted to reproduce this in the hopes of showing the humanitarian of Israelis, which in cases like this I consider both tear-inducing and reassuring. But it also shows what humans of any nationality are capable of if they can set aside fear and hatred of The Other.

New tendentious and possibly dangerous APA book on “gender-affirming care”

February 19, 2024 • 12:30 pm

From the Washington Monthly we hear of a brand-new book published by the prestigious American Psychiatric Association (APA), a book dealing with (and all gung ho for) “gender-affirming” care. You know what that is: it’s the care that goes to a child with gender dysphoria, taking him or her directly to a therapist or doctor who affirms the child’s feelings of being born in the “wrong” body, then to prescribing puberty blockers and other hormones, and, then if the patient wants it, to excision of body parts: operations on genitalia and removal of breasts, along with hormone treatment that eliminates a patient’s ability to have an orgasm.

Click below see the book on Amazon. It’s $58 and, as you see below it, the 18 ratings on Amazon so far aren’t very laudatory. But according to Amazon it came out only on January 7, and the gender activists haven’t yet weighed in. But they will after they read psychiatrist Sally Satel‘s critical take.

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Why such poor reviews? Perhaps, as Sally notes in her description of the book in Washington Monthly, because it’s written by gender-affirming advocates and is woefully short on warnings about possible dangers of this kind of medical and psychiatric care. Nor does it appear to offer any alternative care that doesn’t wind up with hormone therapy.

Click to read:

Although the book is published by the APA, it doesn’t constitute “official APA guidance.” But here’s psychiatrist Sally Satel’s take (excerpts indented, bolding is mine):

Last fall, the APA’s publishing arm issued a textbook called Gender-Affirming Psychiatric Care. Described in accompanying promotional material as an “indispensable” resource, the book is written for mental health and primary care clinicians. The publisher, American Psychiatric Association Publishing, APPI, hails it as “the first textbook in the field to provide an affirming, intersectional, and evidence-informed approach to caring for transgender, non-binary, and/or gender-expansive (TNG) people.”

The “affirming, intersectional” textbook is not official APA guidance. Still, APA Publishing describes it as “rigorous” and “an expert view from fields that include psychiatry, psychology, social work, nursing, pharmacy, public health, law, business, community activism, and more. And because each of the 26 chapters features at least one TNG author, wisdom gleaned from lived experience bolsters the professional perspective provided throughout the book.” One would hope that “lived experience” might enhance the scholarship, but that is not the case here.

Affirming care for children with gender dysphoria, a condition that, according to the APA, refers to individuals who suffer from “a marked incongruence between one’s experienced/expressed gender and assigned gender [at birth],” is a major subject of the book. Unfortunately, though billed as a compendium of “best practices,” Gender-Affirming Psychiatric Care, instead of providing even-handed analyses of the controversies within a still-evolving topic of great clinical and social importance regarding the science of treating gender dysphoric youth, the volume approaches it as a settled matter when it is not.

The textbook’s treatment philosophy is that if a child or teen desires transitional steps, then the physicians should proceed, taking the patient’s request on its face. According to the authors, “Clinicians should … always allow patients autonomy in their care.” The authors further advocate for puberty blockers (chemicals that suppress the natural hormonal development and the appearance of secondary sexual traits) and then cross-sex hormones (estrogen or testosterone) to produce the physical characteristics aligned with the patient’s gender identity.

When it comes to gender-affirming surgery (which, for natal girls, can entail the removal of breasts, uterus, and ovaries, as well as penile construction; and for natal boys, involves the genital removal and the creation of a vaginal canal), patients first require a psychiatric evaluation before surgical consultation. In this evaluation, the authors say that “the [mental health] clinician should never place barriers to surgery, only identify those that exist and assist with overcoming them.” (Emphasis added.) While the final decision to operate ultimately lies with the surgeon, who is tasked with obtaining informed consent from the patient and guardian, a psychiatric greenlight is also necessary. Surely, there are times when a yellow or red light is appropriate. It’s telling that a book of 420 pages only mentions guardians once and in the context of saying that guardians and parents (who get five mentions) should not be part of decisions concerning their transitioning kids’ medical data. Parents are referenced only in the context of being unsupportive to their children’s desire to transition.

Satel has other beef. The book doesn’t cover the fate of youths who aren’t given this kind of care, many of whom become gay or no longer gender-dysphoric without affirmative treatments; the book doesn’t cover those who de-transition or reverse the process when it’s going on before medical treatment (“desisters”); the book doesn’t describe alternative treatments in which therapists don’t automatically buy into the patient’s wishes and narratives; and, most important, and, most important, the book doesn’t warn of the potential dangers of some of the medical treatments—dangers recognized by other Western countries.

First is the need for more objective care:

As a practicing psychiatrist, I would expect this volume to probe how to conduct productive interviews with all patients, especially children and young teens, who consider themselves candidates for a gender-affirming approach. After all, this is a book from the American Psychiatric Association’s publishing arm. As such, it should advise clinicians to examine, over many sessions, patients’ experiences and developmental struggles (such as emerging sexuality and identity formation), to learn about their home lives and social worlds, as well as to treat them for the frequent co-occurring issues, such as depression, anxiety, and posttraumatic stress disorder, which sometimes manifest as gender dysphoria in youth.

This would seem to be at the heart of any responsible psychiatric assessment of whether chemical intervention (which can be irreversible) and procedures as life-altering as “confirmation surgery” should be recommended. However, oddly, such foundational steps are ignored.

Here’s Satel on the lack of discussion of the dangers of affirmative therapy (again, we’re talking about young people who may not be mature enough to make such important decisions). To me, this almost verges on academic malpractice:

Finally, a reader gets no sense that gender-affirming care is the subject of vigorous international scientific debate. Remarkably, the textbook does not mention that in 2020, the United Kingdom’s National Health Service commissioned a comprehensive review of puberty blockers and cross-sex hormones and concluded that “the available evidence was not deemed strong enough to form the basis of a policy position” on their use.  Similarly, in 2022, Sweden’s National Board of Health and Welfare suspended hormone therapy for minors except in very rare cases and limited mastectomies to research settings. Likewise, the Norwegian Healthcare Investigation Board now defines all medical and surgical interventions for youth as “experimental treatment,” and the French National Academy of Medicine advises caution in pediatric gender transition.

Regardless of the authors’ personal views, a textbook that is advertised as “rigorous—and timely” as well as “informative” should, at the very least, acknowledge, and ideally explore, the tension between the European and American approaches and elucidate the concerns raised by European medical authorities.

Why the lacunae? As Satel notes, every chapter has at least one likely gender-activist author (“TNG”), and this has resulted in the sorry situation where the APA gives its imprimatur to treatment that might be dangerous or, at best, ineffective. Do note, however, that Satel also opposes state-imposed bans or limits on treatment for adults.

Gender activism is one thing, but when it comes with the imprimatur of the APA and without mention of either alternative therapies nor warnings about the dangers of medical care that have been recognized by other countries, that activism is irresponsible.

The worst thing one can say about this book is that it’s probably going to be highly recommended by ACLU lawyer Chase Strangio.