Medical revision: You probably don’t need to drink 8 cups of water per day (and you can eat more cheese)

January 3, 2023 • 9:15 am

Now I’m not a doctor (I just play one in academia), so I’m not going to tell you to stop drinking so much water. After all, some people need to. But the upshot of this new article from The Washington Post (click on screenshot below) is that most people don’t have to act like camels, swigging and guzzling from their fancy water bottles that they tote everywhere. They even guzzle in public!  If you drink only when you’re thirsty, most people will be fine. Read on:

I have to say that, as a curmudgeon who been this way for decades, I always feel a bit snarky when I see full-grown adults toting water bottles everywhere with them, and swigging at random. Surely much of this comes from the medical “wisdom” that you need to drink 8 cups of water (roughly 64 ounces, or half a gallon) per day. And, of course, there’s water available everywhere in America, so you don’t need your own personal bottle.

I see much of this as an infantile behavior: adults needing, like infants, to suck on a bottle full of liquid. It’s just like adult cats “kneading” as a leftover behavior from their kittenhood. (Of course, I do carry a water bottle if I’m out for the day in a foreign land (many places don’t share the American habit of having water fountains widely available), or in places where the local water isn’t safe to drink (e.g., India).

But otherwise, I just don’t like drinking water. It has no flavor, and I drink it only when I’m thirsty. Usually that’s in the morning before coffee, and then with dinner (along with wine). I seem to do fine on about 20 ounces per day, and have never been dehydrated. Even worse: the medically-inspired advice to drink lots of water has even boosted the most useless industry ever: bottled water, which is no better than tap water and has the byproduct of producing plastic refuse:

Now I know what some readers will say.  “I LIKE drinking water!” If so, more power to you, but I take that statement with the same grain of salt I do when someone tells me “I LIKE eating broccoli” or “I don’t eat desserts because I don’t like sweets.”  But this news, from last month’s Washington Post, heartened me. No longer do I—or you—have to feel like if you’re not sucking on the adult version of a baby bottle, you’re doing something wrong.

Here’s the news, and look at where that medical dictum comes from! (My bolding):

We’ve all heard the age-old advice to drink eight cups of water a day. But if you fall short, don’t worry: That advice is probably wrong anyway.

That’s according to new research, published in the journal Science, which found that for most healthy adults, drinking eight cups of water a day is completely unnecessary. The advice is misguided in part because it doesn’t take into account all the water that we get from our food and from other beverages like coffee and tea. The research found that our water needs vary from one person to next and depend on factors like your age, sex, size, physical activity levels and the climate that you live in.

The authors of the study say that for healthy adults, there is no real benefit to drinking eight cups of water a day. Nor is it dangerous: Your body will just excrete the extra water you consume in your urine.

“If you drink eight cups of water a day, you’ll be fine — you’re just going to be spending a lot more time in the bathroom,” said Herman Pontzer, a professor of evolutionary anthropology and global health at Duke University and a co-author of the study.

The advice to drink eight cups of water a day stems from a 1945 recommendation from the Food and Nutrition Board of the National Research Council, which encouraged adults to consume about 64 ounces of water daily. The recommendation referred to a person’s total daily intake of water, including from all their foods and beverages, but it was widely misinterpreted to mean that people should drink eight 8-ounce glasses of water every day.

Some experts have argued that the widely held belief was not rooted in science. One study of 883 elderly adults for example found that there was no evidence of dehydration among the 227 people in the study who routinely drank less than six glasses of water daily.

“Until we have more evidence-based documentation that fluid intake of eight glasses per day improves some aspect of an elderly person’s health,” the researchers concluded, “encouraging a fluid intake above a level that is comfortable for the individual seems to serve little useful purpose.”

Nevertheless, the advice is so widely ingrained that many companies use it to market products. You can buy 64-ounce water bottles designed to motivate you to drink the equivalent of eight cups of water daily, and water-bottle sensors that will track your water intake and remind you to “hydrate” every 30 to 40 minutes.

SENSORS THAT REMIND YOU TO HYDRATE EVERY 30-40 MINUTES! WHAT A WORLD!

“We have guidelines telling people how much water to drink,” said Pontzer, who wrote a book on metabolism called “Burn.” “But the reality is that people have been kind of making it up.”

Indeed. I am comfortable with two or three medium sizes glasses a day, on top of wine, coffee, and other beverages. I estimate that I drink about 24 ounces of pure water per day—less than half the recommendation.

I wonder if any reader will be heartened by this, or will most people get defensive and say they like water (what’s to like? it’s flavorless), or that there’s nothing to lose by swilling the stuff (yes there is: hours in the bathroom). Many of my male friends (women won’t share this information) tell me that they get up several times per night to urinate.  I never have to do that, and I’m fine.

Here’s what the article recommends (my bolding again):

So how much water should you drink? The answer is simple: Drink when you’re thirsty. Prioritize water, and try to avoid sugary drinks, which can cause metabolic problems. Coffee and tea are fine as well.

Get that? (I bet you were going to inform me that coffee is a diuretic.) It seems that, all along, I’ve been doing what’s recommended. The final advice:

While the caffeine they contain can increase urination, they will still be hydrating so long as you consume less than 400 milligrams of caffeine, Rosinger said. Keep in mind that you get water from your food as well. Some water-rich foods are fruits, vegetables, beans, yogurt, brown rice, and soups.

“If you’re paying attention to your body and drinking when you feel like you need to, then you should be fine,” Pontzer said.

And here’s the Science paper, which reports that a lot of normal water intake (up to 50%) comes from food, and 85% from food and other liquids, including coffee and juice). Water generated by your metabolism constitutes about 10% of your daily water usage. Drink 8 glasses per day? Fuggedaboutit!

I have more good news too, also from the Post. Click to read:

An excerpt:

. . .when people talk about their fondness for cheese, it’s often in a guilty way, as in, “Cheese is my weakness.”

“Cheese is packed with nutrients like protein, calcium and phosphorus, and can serve a healthy purpose in the diet,” says Lisa Young, an adjunct professor of nutrition at New York University­. Research shows that even full-fat cheese ­won’t necessarily make you gain weight or give you a heart attack. It seems that cheese doesn’t raise or reduce your risk for chronic diseases, such as heart disease and Type 2 diabetes, and some studies show it might even be protective.

Don’t sue me if you stop drinking water, chow down on cheese, and then get sick. I am just the messenger here!

National Health Service ends “gender-affirming care,” replaces with “holistic and appropriate” care

October 25, 2022 • 9:45 am

The NHS has come to its senses and issued a whole new set of protocols for treating gender dysphoric youth. Previously, the Tavistock Clinic in London was the go-to place for these children, whose numbers have risen rapidly in the past few years, especially for females (graph below from here):

But there were complaints from patients, and a commissioned report on the Clinic by Dr. Hilary Cass damned the form of care practiced at Tavistock: “affirmative care,” which in practice meant affirming a child’s wishes about changing sex, which led to buttressing their wishes by giving puberty blockers to prepubescent youth, and ultimately adding hormone therapy and referring children for surgery to remove breasts and remodel genitals (the NHS never covered gender-transition surgery).

The problem was that many youth with gender dysphoria have mental problems or are simply distressed about their sexuality, and that lots of these difficulties resolve themselves without changing gender—often by becoming gay, which involves no drugs or surgery.

It was this rush to judgment and treatment, combined with a spate of pending lawsuits by former patients, that led to Tavistock’s downfall. Its functions will not only be farmed out to other centers, but the whole notion of “affirmative care” is being abandoned in favor of what I see as more sensible approach, which the article below calls “a holistic view of identity development in children and adolescents. Preliminary assessment will include “nonaffirmative” but supportive therapists, and there will be no “rush to hormones”;  puberty blockers (whose long-term effects are still largely unknown)  and hormones like testosterone administered only in clinical trials. The whole National Health Service protocol has been revised, and those who evade it by, say, ordering their own hormones, will not be further supported by the NHS.

These changes, following protocols already implemented in Sweden and Finland, are described in the article below from the Society for Evidence Based Gender Medicine (click to read):

 

Here’s what the article says about why the Tavistock protocols were abandoned.

The reasons for the restructuring of gender services for minors in England are 4-fold. They include (1) a significant and sharp rise in referrals; (2) poorly-understood marked changes in the types of patients referred; (3) scarce and inconclusive evidence to support clinical decision-making, and (4) operational failures of the single gender clinic model, as evidenced by long wait times for initial assessment, and overall concern with the clinical approach.

And a bit about the new program:

The new NHS guidance recognizes social transition as a form of psychosocial intervention and not a neutral act, as it may have significant effects on psychological functioning. The NHS strongly discourages social transition in children, and clarifies that social transition in adolescents should only be pursued in order to alleviate or prevent clinically-significant distress or significant impairment in social functioning, and following an explicit informed consent process. . . 

The new NHS guidelines represent a repudiation of the past decade’s approach to management of gender dysphoric minors.  The “gender-affirming” approach, endorsed by WPATH and characterized by the conceptualization of gender-dysphoric minors as “transgender children” has been replaced with a holistic view of identity development in children and adolescents. In addition, there is a new recognition that many gender-dysphoric adolescents suffer from mental illness and neurocognitive difficulties, which make it hard to predict the course of their gender identity development.

“Social transition” comprises the acts of medical professionals facing children with gender with gender dysphoria and helping them change gender with puberty blockers and hormones.

There are ten highlights (i.e., changes from the Tavistock protocols) in the NHS’s new system. They’re described in the article, and I’ll put them below with one or two aspects of each intervention (there are more in the article). All extracts from the article are indented; my own comments are flush left.

1. Eliminates the “gender clinic” model of care and does away with “affirmation”

  • “Affirmation” has been largely eliminated from the language and the approach. What remains is the guidance to ensure that “assessments should be respectful of the experience of the child or young person and be developmentally informed.”

  • Medical transition services will only be available through a centralized specialty Service, established for higher-risk cases. However, not all referred cases to the Service will be accepted, and not all accepted cases will be cleared for medical transition.

2. Classifies social gender transition as an active intervention eligible for informed consent

  • The NHS is strongly discouraging social gender transition in prepubertal children.

They outline the criteria needed to address gender transition, which include “persistent and consistent gender dysphoria” and “a clear and full understanding of the implications of social transition.”

3. Establishes psychotherapy and psychoeducation as the first and primary line of treatment

  • All gender dysphoric youth will first be treated with developmentally-informed psychotherapy and psychoeducation by their local treatment teams.

This is one of the main ways the Tavistock model failed: it didn’t use therapists who would assess the patient objectively rather than push them into changing genders.

4. Sharply curbs medical interventions and confines puberty blockers to research-only settings

  • The NHS guidance states that the risks of puberty blockers are unknown and that they can only be administered in formal research settings. The eligibility for research settings is yet to be articulated.

  • The NHS guidance leaves open that similar limitations will be imposed on cross-sex hormones due to uncertainty surrounding their use, but makes no immediate statements about restriction in cross-sex hormones use outside of formal research protocols.

This is an important change because the long-term effects of puberty blockers, especially used in combination with hormones like estrogen or testosterone, are not known.

5. Establishes new research protocols

  • All children and young people being considered for hormone treatment will be prospectively enrolled into a research study.

  • The goal of the research study to learn more about the effects of hormonal interventions, and to make a major international contribution of the evidence based in this area of medicine.

These studies will be continued into adulthood, as they should be. It’s important to know whether there are delayed injurious effects of hormones, as well as psychological “desisting”, or regret for changing gender.

6. Reinstates the importance of “biological sex”

  • The NHS guidance defines “gender incongruence” as a misalignment between the individual’s experience of their gender identity and their biological sex.

This change and the others implicitly assume that there is such a thing as biological sex and that it’s not a social construct. They don’t say there are only two biological sexes, but I think that’s assumed.

7. Reaffirms the preeminence of the DSM-5 diagnosis of “gender dysphoria” for treatment decisions

  • The NHS guidance differentiates between the ICD-11 diagnosis of “gender incongruence,” which is not necessarily associated with distress, and the DSM-5 diagnosis of “gender dysphoria,” which is characterized by significant distress and/or functional impairments related to “gender incongruence.”

The DSM-5 is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition—the latest set of criteria used to diagnose mental illness. The addition of distress is important because without distress the panoply of treatments outlined for gender dysphoria aren’t used.

This is one of the most important changes, advocating a variety of expertise brought to bear on gender dysphoria, none of it dedicated to affirming the patient’s wishes:

8. Clarifies the meaning of “multidisciplinary teams” as consisting of a wide range of clinicians with relevant expertise, rather than only “gender dysphoria” specialists

  • The NHS guidance clarifies that a true multidisciplinary team is comprised not only of “gender dysphoria specialists,” but also of experts in pediatrics, autism, neurodisability and mental health, to enable holistic support and appropriate care for gender dysphoric youth.

  • Such multidisciplinary teams will be the hallmark of the new Service, into which challenging and risky cases may be referred. In addition to specific expertise in gender identity development and incongruence, the clinical leadership teams of the newly-established Service will include strong, “consultant level” expertise in a wide range of relevant areas:

    • neurodevelopmental disorders such as autistic spectrum conditions

    • mental health disorders including depressive conditions, anxiety and trauma

    • endocrine conditions including disorders of sexual development pharmacology in the context of gender dysphoria

    • risky behaviors such as deliberate self-harm and substance use

    • complex family contexts including adoptions and guardianships

9. Establishes primary outcome measures of “distress” and “social functioning”

  • The rationale for medical interventions for gender-dysphoric minors has been a moving target, ranging from resolution of gender dysphoria to treatment satisfaction.  The NHS has articulated two main outcome measures of treatment: clinically significant distress and social functioning.

These criteria are used for specifying treatment for other illnesses like depression.

10. Asserts that those who choose to bypass the newly-established protocol will not be supported by the NHS

  • Families and youth planning to obtain hormones directly from online or another external non-NHS source will be strongly advised about the risks.

The NHS will not support further treatment of those who obtain and take hormones outside of the NHS’s protocols.

Can anybody argue that these are not more sensible protocols than the ones used previously? Since most gender dysphoric children turn out to be either cis or gay if not given hormones and surgery, shouldn’t one take these kinds of precautions before injecting or cutting such people?

The premise, of course, is that many children who are dysphoric don’t need “affirmation” (especially if there’s social pressure to change their gender), but compassionate therapy to see how serious their problem is and how strongly they wish to change identity. If you can’t vote until you’re 18, why should you be able to start changing your hormones and body parts before then?  18 is just a subjective age, of course, but the protocol is based on not immediately accepting the views of children—or their parents, who can pressure kids destined to be gay into seeing themselves as transsexuals—that they’re in the wrong body. You don’t just affirm that right off the bat, but ascertain it with intensive therapy.

Of course there will be many objections to these protocols by trans activists who are of the “affirmative care” stripe, but I think that in twenty years we’ll look back on the present as a time when many children were harmed by improper medical and psychological care. That’s the basis of the more than 1,000 lawsuits likely to be filed against Tavistock.

Minnesota medical students take ideological oath including, among other things, to “honor all indigenous ways of healing”

October 14, 2022 • 9:30 am

In the last several decades, the “white coat ceremony” has become a tradition at medical schools, with the entering students receiving their doctor’s coats and then reciting the Hippocratic Oath. There are many variants of this ancient oath, and often students write their own version to supplement the traditional one.  As you can imagine, some of these go beyond the doctor’s pledge, adding pledges of social justice, ideological belief, and so on. I’ve seen several versions of these white coat oaths; the FIRE article below mentions them at HarvardColumbiaWashUPitt Med, and the Icahn School of Medicine. But perhaps the one most distressing to scientists and advocates of science-based medicine is this one, recited at the University of Minnesota’s white coat ceremony on August 19.

According to the Foundation for Individual Rights and Expression (FIRE), the speaker is Robert Englander, Associate Dean for Undergraduate Education for the Medical School, who leads the students in what is both a pledge and a prayer. (Curiously, Englander’s university bio has disappeared from its website.)

Now this oath wasn’t written by the administration itself, but, according to FIRE and the agenda of the ceremony, by a committee of fifteen incoming medical students on the “Oath Writing Committee.”  These students may, of course, not represent the beliefs of their class as a whole; in fact, it’s likely that, as usual, it’s the activists who seek the loudest megaphone. Click on screenshot below to see the article, and I’ve put the video of the recitation below that.

Here’s the two-minute video of the oath:

Here’s the oath’s text reproduced from FIRE’s letter sent yesterday to the medical school deam (I’ve bolded the sentence that bothers me the most.)

With gratitude, we, the students of the University of Minnesota Twin Cities Medical School Class of 2026, stand here today among our friends, families, peer, mentors, and communities who have supported us in reaching this milestone. Our institution is located on Dakota land. Today, many Indigenous people from throughout the state, including Dakota and Ojibwe (ooj-jib-way), call the Twin Cities home; we also recognize this acknowledgment is not enough.

We commit to uprooting the legacy and perpetuation of structural violence deeply embedded within the healthcare system. We recognize inequities built by past and present traumas rooted in white supremacy, colonialism, the gender binary, ableism, and all forms of oppression. As we enter this profession with opportunity for growth, we commit to promoting a culture of anti-racism, listening, and amplifying voices for positive change. We pledge to honor all Indigenous ways of healing that have been historically marginalized by Western medicine. Knowing that health is intimately connected to our environment, we commit to healing our planet and communities.

 We vow to embrace our role as community members and strive to embody cultural humility. We promise to continue restoring trust in the medical system and fulfilling our responsibilities as educators and advocates. We commit to collaborating with social, political, and additional systems to advance health equity. We will learn from the scientific innovations made before us and pledge to advance and share this knowledge with peers and neighbors. We recognize the importance of being in community with and advocating for those we serve.

There are the usual arguable claims, which should not be professed or vowed by the students or foisted on them by the dean and fifteen vocal students. The claims include these:

  1. The implication that the original owners of the school’s land was the Dakota people. (Note that the oath says that acknowledgement is “not enough,” but what else will they do for the Dakota people? Will they give the land back, or compensate the original owners? There is no vow to do either.)
  2. Inequities in medicine are not just rooted in past forms of oppression, but are ongoing, and reflect white supremacy as well as other forms of bigotry.
  3. There is “structural violence deeply embedded in the healthcare system”.  What, exactly, do they mean by “structural violence”?
  4. There is a “gender binary” that causes further traumas. I think they’re referring to the “sex binary”, which is real. Few people assert that there is a “gender” binary when “gender” is construed as a person’s sociosexual role.
  5. The students will “honor all Indigenous ways of healing that have been historically marginalized by Western medicine.”  ALL OF THEM?  There are a million of them if you count all forms of indigenous healing overtaken by Western medicine. Yes, a few of these treatments may be efficacious, but almost none have been subject to scientific testing using the gold standard of double-blind treatment.  “Honoring” a form of pre-scientific healing simply because it’s was practiced by indigenous people is ludicrous. Certainly you shouldn’t disparage the people themselves who use such healing, as the treatments were developed outside of science, but you shouldn’t honor all the ways of healing themselves. Most of them don’t accomplish anything; what kind of “honor” does that deserve?
  6. The rest of the oath is boilerplate social-justice jargon, and there’s nothing wrong with that, but this is an ideological/political pledge, not a medical-school pledge. As FIRE notes in its article, this is a form of compelled speech that many of the students might not agree with, but are nevertheless force to give fealty to.

Now many of you can say—and this is likely true—that the social-justice aspects of this pledge are meaningless, and the students don’t have to live up to them.  Nor do the students have to consider shamanism, chanting, herbs, and so on as worthy of “honor.”  (These, by the way, were not historically “marginalized” by Western medicine, but were replaced by scientifically-based treatments because those treatments work.)

If, as the students also pledged, they will “restore trust in the medical system,” they can begin by refusing to honor traditional treatments that don’t work. It is no dishonor to indigenous people to reject methods they developed in the absence of science. I suspect it is the “progressiveness” of this oath that has led to widespread ridicule against it and perhaps to the disappearance of Robert Englander’s bio.

Now on to FIRE, which has legal objections to this oath. Their main objection is that this is not only compelled speech—making students swear to something that they disagree with and is not a requirement of the profession—but also that, in the future, students could be punished for failing to adhere to what they’ve sworn. This is not a fanciful scenario:

From the FIRE article:

FIRE respects students’ rights to express their views. But because only a small committee of all new students penned the statement, some of the other several-hundred students may have been compelled to express that handful of classmates’ opinions as their own. (It’s unclear whether any students dissented and, if so, whether they could opt out.)

We’re also concerned that these subjectively squishy commitments could become de facto professionalism requirements, and that students could be punished for failing to uphold them. For example, what must a medical student do to adequately practice “anti-racism”? And whatever that may be, if she does not (as UMMS understands that term), could she be dismissed for violating her oath? What if she refuses to take the oath in the first place?

FIRE has certainly seen administrators of professional programs in medicinedentistrylaw — even mortuary science — who deployed ambiguous “professionalism” standards to punish students for otherwise protected speech.

. . .More than 10% of the campus-related cases in which FIRE intervenes now concern requirements that students and faculty demonstrate their DEI commitments or contributions, or personally make land acknowledgements.

Again, while universities, students, and faculty are free to encourage or promote DEI-type values, forcing others to say they believe in these concepts is not only contrary to many universities’ legal obligations — but violates their moral obligations, too.

Consider: Even students or faculty who broadly agree with a university’s stance on DEI may believe, for example, that land acknowledgements are merely performative. Or a faculty member who studies race and gender may have highly nuanced views on DEI not reflected by the university’s stance. Students, likewise, may disagree with other aspects of a given DEI pledge.

Medical students possibly being made to read verbatim from ideological pledges if they wish to become physicians would be a new low.

I’d add that surely a lot of the students forced to say that they’ll honor all indigenous methods of healing “historically marginalized by Western medicine” certainly don’t believe that, but are nevertheless forces to vow it.  How many of those reciting students accept the curative powers of, say, shamanic rituals?

Here is the summary of the objections in the letter written by Zachary Greenberg, FIRE’s Senior Program Officer for Campus Rights Advocacy, went to Jakub Tolar, the Dean of the Medical School, as well as to the school’s President and General Counsel:

While UMMS may encourage students to adopt these views, the First Amendment bars the university from requiring them to do so. The First Amendment protects not only the right to speak, but the right to refrain from speaking. Requiring new students to “vow” or “commit” to contested political viewpoints violates students’ clear expressive rights, is inconsistent with the role of the university as a bastion of free inquiry, and cannot be enforced at a public institution.

UMMS can require students to adhere to established medical standards, but this authority cannot be abused to demand allegiance to prescribed ideological views—even ones that some students do indeed hold. Specifically, UMMS may not compel students to recite a land acknowledgment, commit to “uprooting the legacy and perpetuation of structural violence deeply embedded within the healthcare system,” or “promote[e] a culture of anti-racism.” Nor may it force students to express a commitment to “embody cultural humility,” or “advance health equity.” Even if written by a group of students, UMMS may not subsequently require all students adhere to these views.

Because students may reasonably perceive recitation of this oath as mandatory, FIRE calls on UMMS to make clear that students may refuse to say it without penalty, and that students will not have to affirm any political viewpoints as a condition of their continued education at the school.

We request receipt of a response to this letter no later than the close of business on October 20, 2022.

My prediction? UMMS will not reply. Will there then be a lawsuit? I don’t think so—unless they find medical students injured by professing what they don’t believe, and what medical student would be plaintiff to such a suit?  But I do think that in future years the school will refrain from such over-the-top vows.

Should you get that bivalent booster shot?

October 4, 2022 • 12:00 pm

My primary-care physician, Dr. Alex Lickerman, discusses the question everyone’s asking: should you get that bivalent booster? (For most people it would be their third booster and the fifth Covid shot). You can access Alex’s post by clicking on the screenshot below. (Be sure to look at the graphs and read it all.)

Alex always looks at the science before he decides what’s to recommend, and by that I mean the primary literature. When I first asked him about whether to get a booster, he said he didn’t know because the data hadn’t been published, and all the existing studies were on antibody levels in mice. Now he looks at more data. I’ll give his conclusion below but do have a look at his post.

My own decision was to get the booster simply because I’m traveling tomorrow, but, as always, consult your own doctor or decide from the data themselves. People tend to get covid on airplanes these days (a friend who just returned from Boston said only 5% of the passengers on her Southwest flight wore masks), and Alex said that it couldn’t hurt me to get one before traveling—but it might not help me much, either.

CONCLUSION: Should you get the bivalent booster? In the absence of human trial data, we might think about this question as follows: We can be reasonably certain that the bivalent booster will produce a level of neutralizing antibodies that diminishes the risk of infection from COVID. We don’t know how long that protection will last, but a fair guess would be from 3 to 6 months. If there is some reason you feel the need to reduce your risk over the next 3 to 6 months, say, for travel, getting the bivalent booster would seem reasonable. On the other hand, if in addition to being vaccinated, you’ve had COVID recently (meaning you’ve been infected with an Omicron variant), likely the same level of protection accrues, obviating the need for the bivalent booster. If your main concern is dying from COVID and you’ve already received the primary series and one or two boosters, your risk is so low that getting another shot would seem superfluous. If you are at high risk for dying from COVID, while there is no data to suggest the bivalent booster might further reduce your risk beyond levels afforded by the primary series and one or two boosters, there is also likely little risk of getting it. In the absence of data to guide us, this would then be a personal decision.

Often Alex answers questions in the comments, so if you have any, put them below. I’ll tell him that he might look at the comments.

Is this a valid exception to protected free speech?

September 4, 2022 • 11:20 am

Here’s a case where one might want to suppress speech in apparent violation of the First Amendment. But after due pondering, I don’t think it’s a good idea. But I waver, as you’ll see, and even though I come down against the bill, as it may be a bad precedent, I am not sure of my stand.

This has to do with a new California law (not yet signed by Gavin Newsom) that punishes physicians who contradict conventional wisdom about Covid-19, with some of that wisdom specified by law. It applies to words, not to actions.

I found this bill through note and links sent by reader Gary, who said this:

I’ve seen very little discussion of California Assembly Bill 2098.  The intention of the bill is good, as are many attacks on free speech, but I, and perhaps you, feel that curbing free speech is generally not the best solution.  Under AB-2098, passed in the California Assembly and Senate, but not yet signed by the governor, physicians and surgeons would face disciplinary action if they voiced an opinion contrary to certain facts about COVID-19 and the associated vaccines as determined by the legislature.  The disciplinary action could include revoking their license to practice.  I despise misinformation and disinformation, but the solution in my opinion, is not punishing those who disagree with the scientific consensus.   The solution is the spread of solid information, not the attempted squelching of misinformation.
I think that this bill is going to the governor’s desk with very little discussion or notice.  He has three weeks to sign the bill, but hasn’t made his position public.   If you think it’s important, you may want to include it in your website.
I’ve put the meat of the bill below. It calls for licensing boards, which are arms of the government, to take action against doctors who “disseminate misinformation or disinformation related to COVID-19, including false or misleading information regarding the nature and risks of the virus, its prevention and treatment; and the development, safety, and effectiveness of COVID-19 vaccines.” In other words, this involves the government suppressing speech, an apparent violation of the First Amendment. But does it fall under the few court-allowed forms of speech that are NOT protected by that Amendment?
The seven points leading to this Diktat are below. These are pretty well established, but they are not absolute facts, as no scientific assertion is beyond questioning. For example, the statement in (c) about the safety and efficacy of COVID-19 vaccines is the best guess we have, but do we know the long-term effects of the vaccines? No, as they’ve been around for only two years. And remember that our knowledge about this disease and about the vaccines, changes almost week by week. Yes, it’s an attempt to protect the health of the public by squelching speech, just as “hate speech” laws are attempts to protect the feelings of the people.

But have a look at the text of the bill from the link above:

LEGISLATIVE COUNSEL’S DIGEST

AB 2098, Low. Physicians and surgeons: unprofessional conduct.

Existing law provides for the licensure and regulation of physicians and surgeons by the Medical Board of California and the Osteopathic Medical Board of California. Existing law requires the applicable board to take action against any licensed physician and surgeon who is charged with unprofessional conduct, as provided.

This bill would designate the dissemination of misinformation or disinformation related to the SARS-CoV-2 coronavirus, or “COVID-19,” as unprofessional conduct. The bill would also make findings and declarations in this regard.

THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

SECTION 1.

The Legislature finds and declares all of the following:

(a) The global spread of the SARS-CoV-2 coronavirus, or COVID-19, has claimed the lives of over 6,000,000 people worldwide, including nearly 90,000 Californians.

(b) Data from the federal Centers for Disease Control and Prevention (CDC) shows that unvaccinated individuals are at a risk of dying from COVID-19 that is 11 times greater than those who are fully vaccinated.

(c) The safety and efficacy of COVID-19 vaccines have been confirmed through evaluation by the federal Food and Drug Administration (FDA) and the vaccines continue to undergo intensive safety monitoring by the CDC.

(d) The spread of misinformation and disinformation about COVID-19 vaccines has weakened public confidence and placed lives at serious risk.

(e) Major news outlets have reported that some of the most dangerous propagators of inaccurate information regarding the COVID-19 vaccines are licensed health care professionals.

(f) The Federation of State Medical Boards has released a statement warning that physicians who engage in the dissemination of COVID-19 vaccine misinformation or disinformation risk losing their medical license, and that physicians have a duty to provide their patients with accurate, science-based information.

(g) In House Resolution No. 74 of the 2021–22 Regular Session, the California State Assembly declared health misinformation to be a public health crisis, and urged the State of California to commit to appropriately combating health misinformation and curbing the spread of falsehoods that threaten the health and safety of Californians.

I’ve put in bold below the two definitions that make me waver about opposing this bill.

SEC. 2.

Section 2270 is added to the Business and Professions Code, to read:

(a) It shall constitute unprofessional conduct for a physician and surgeon to disseminate misinformation or disinformation related to COVID-19, including false or misleading information regarding the nature and risks of the virus, its prevention and treatment; and the development, safety, and effectiveness of COVID-19 vaccines.

(b) For purposes of this section, the following definitions shall apply:

(1) “Board” means the Medical Board of California or the Osteopathic Medical Board of California, as applicable.

(2) “Disinformation” means misinformation that the licensee deliberately disseminated with malicious intent or an intent to mislead.

(3) “Disseminate” means the conveyance of information from the licensee to a patient under the licensee’s care in the form of treatment or advice.

(4) “Misinformation” means false information that is contradicted by contemporary scientific consensus contrary to the standard of care.

(5) “Physician and surgeon” means a person licensed by the Medical Board of California or the Osteopathic Medical Board of California under Chapter 5 (commencing with Section 2000).

This is what I wrote back to Gary:

I’ll have a look, but remember that the scientific consensus changes rapidly, and who is the legislature to determine what the correct “facts” are? And will they then punish doctors for giving out information about diet, etc. that contradicts the legislature? There’s no end to this, and I’m a bit wary of legislating what information is “absolute truth that cannot be contradicted”.

And I stand by my claim that the government should not be in the business of what doctors say about COVID-19, even if it goes against a world of conventional wisdom. This is freedom of speech, even if emitted by a doctor. Or are they allowed only to pronounce on items not related to medicine, or parrot the latest consensus?

It’s a different matter, however, if a doctor acts in a reckless way, violating professional standards like injecting patients with some Trumpian nostrum to cure COVID-19. In that case it is action, not talk, that causes harm, and boards should have the write to examine a doctor’s conduct and, if necessary, punish them or take away their licenses. Likewise, hospitals should be able to fire them. False advertising, too, is illegal, so a doctor is liable to sanction if he or she advertises cures that are known or demonstrated to be bogus. But advertising is not the same as a doctor simply making a pronouncement. Advertising is luring in patients under false pretenses.

Now I am sort of on the fence about this one, for “disseminating information to patients that you know is false, and doing so with malicious intent”, is indeed malpractice. But that’s already covered by the law.  How can you prove that a doctor is doing this with “malicious intent or an intent to mislead”?

This is the same distinction that we see between saying hurtful and “harmful” words like “gas the Jews” or “Jews are acquisitive and in a conspiracy to dominate the world”, which is harmful but legal speech, and causing actual physical harm by hitting someone or inciting predictable and immediate violence against them. The one difference is that patients tend to take their doctor’s advice. But sometimes doctors give bad advice, which is why we urge second opinions on serious matters. A doctor may give bad advice, like “you’d be better off having three stents put in now,” but to me that’s not illegal unless the doctor means it maliciously. The doctor must intend to do harm, and carry that out by treating the patient. And intention is what is nearly impossible to prove in this bill.

To me this bill seems good on the face of it, but creates a precedent where the legislature decides what medical facts are acceptable, and what opinions cannot be uttered. Just remember how advice on diet (and smoking) has changed just in my lifetime.  Let’s leave this to the consensus of doctors and their professional organizations, and let it apply only to actions, not to words.

I’m sure some readers will disagree with me, and that’s fine. Have your say below. As I said, I’m of two minds about this bill.

The New Zealand government subsidizes spiritually based “traditional” healing, with no evidence that it works

September 2, 2022 • 9:30 am

I have nothing in general against “traditional medicine” so long as it’s efficacious.  But that’s the rub, for, as the old Q&A goes: “What do you call traditional medicine that works? Medicine.” Thus, if something is being touted, especially by the government, as a useful form of medicine, it should have been scientifically tested to ensure that it does what it does.

Many of our modern drugs do indeed come from plants, but not all of those were used in traditional or “indigenous” medicine: some were found simply by surveying plants by medical scientists looking for useful effects. And of course without testing—with the gold standard being double-blind testing—you can’t tell whether a plant-based drug is better than a placebo.

This lack of testing appears to be characteristic of Rongoā Māori (“RM”), the traditional healing used by Māori in New Zealand, as reported by the article from the University of Auckland shown first below. And that lack of hard evidence for efficacy, while it shouldn’t lead to the banning of Rongoā Māori, shouldn’t lead to its declaration as being equal to modern medicine, nor should it lead to the government’s funding of untested remedies. But it’s already too late.

Since this is New Zealand, testing of Māori claims isn’t needed: tradition and anecdotal health claims are enough. Indeed, criticism of such claims is seen as racist.

And so, as the article below reports, the Kiwi government is funding a $100,000 program to “support injury recovery through Rongoā Māori. The program is funded through the “ACC” (Accident Compensation Corporation), a government body established in the 1970s to oversee the provision of support, treatment and rehabilitation for people involved in accidents. What we have, then, is government support for traditional medicine used to heal accidents.

But this is only the camel’s nose, for as the article below implies, this is just the first step in insinuating traditional healing into regular medical practice guaranteed to all Kiwis by their government.

In fact, in several ways Rongoā Māori is similar to Mātauranga Māori, traditiional “ways of knowing” that I’ve written about at length.  Both systems contain a mixture of theology, spirituality, and practical knowledge, both are imbued with fact claims that can’t be tested, and both are touted by their practitioners as deserving equal treatment with modern science.

It is the “equal treatment” that worries me, as neither MM or RM are coequal with science. Parts of MM can be considered empirical truths—”practical knowledge” like how to grow plants or catch eels—but I have no idea whether RM is efficacious in healing, at least beyond having a placebo effect. Finally, both MM and RM involve the ubiquitous valorization of the ways of indigenous people. Traditional customs should of course be taught as aspects of anthropology and sociology, important parts of New Zealand’s history, but shouldn’t be valorized to the point where they’re considered coequal to science or medicine.

What is involved in Rongoā Māori? The two articles below (click on screenshots), as well as the short video, give you an idea.

 

A shorter explanation of RM is here.

Here are the major components of RM, considered “holistic healing” with a big dollop of spirituality. This list comes from the two articles above and a few others.

a.) Traditional plant remedies.  The second article above gives a list of which plants are used and for what ailments. They must be used in a proper way—not just in their preparation, but ensuring that they’re gathered in traditional ways. Here’s what the second article says

The use of plant remedies does not require regulatory approval as long as they do not contain a scheduled medicine. However, as some pharmaceuticals are derived from plants, it is possible that Rongoā may contain active ingredients. As long as these pharmaceuticals are not purposely added to a remedy no restrictions apply to the use of such plants. Note that some plants, for example St Johns wort, can interact with conventional medicines.

  •  Appropriate tikanga (customs and rites) must be observed during the collection, preparation and storage of Rongoā.
  • Plant material must be correctly identified, gathered from non-polluted areas and prepared safely and hygienically.
  • Plants are usually crushed or dried and mixed with water or ethyl alcohol.
  • Plant remedies should only be prescribed and dispensed by Tohunga [traditional healers] to individual patients. Tohunga will advise on appropriate use.
  • Plant remedies should not be labelled with therapeutic claims. Labels should contain the ingredient(s), instructions for use, date of preparation, expiry date and who the remedy is prescribed for.

But if they cannot make therapeutic claims, why is the government paying for them? The important question is whether all or any of the drugs are useful in healing the ailments they’re prescribed for. Before you say “they must be, as they’re based on tradition,” be aware that a lot of spiritually-based traditional medicines tested in the U.S. have been shown to be bunk.

I have found no mention of testing for any of these plants. While some of the traditional herbal medicines may be efficacious, I see no sign that they’ve been tested or compared to modern pharmaceuticals that must be and have been tested.

b.) Massage. Massage can be useful in temporary relief, and even chiropractic can be useful for back problems, but the idea of adjusting the body because it’s diseased or out of whack, as evidenced in the articles and the video above, is dubious (I’d say “bunk,” but I’m being kind here.) Look at the video and watch them adjusting the feet of a man with a lower back problem. This is called romiromi, or “body alignment”.

c.) Lunar calendar relationality (maramatka). I don’t know how this is implemented, but it’s a big red flag.

d.) Meditation.  Your mileage may very, but I haven’t been prescribed meditation for any accidents I’ve had.

e.) Spirituality. This site at Health Navigator New Zealand explains that the spiritual side of RM is its most important aspect. A quote:

The most fundamental part of rongoā Māori is the traditional spiritual teachings, which can be seen as the basis of all traditional medicine. For Māori, rongoā is a part of the Māori culture from Tāne (God of the forest) who retrieved the three baskets of knowledge from Io (God) with the knowledge and teachings to guide us in this world.

As Māori, we believe we are part of the children of Tāne, along with the creatures of the forest such as the birds, trees and plants and, therefore, we have a strong connection to rongoā rākau. To learn rongoā, people have to become apart of the world of Tāne. They become connected and immersed in the forest, learning about a relationship far beyond the physical elements of the trees and plants. To utilise Te Oo Mai Reia, the healer must become immersed in ancient spiritual teachings while becoming a vessel to achieve the healing through Io alongside the use of physical touch to create balance and shift energies.

This is a form of shamanism.

Now this is all well and good, and if people want to use RM for diseases or healing from accidents, that’s their prerogative. I wouldn’t, but that’s my choice. But what I dislike is the insistence of these articles and practitioners that RM is just as good as modern medicine and should be offered coequally by the government. Here are two quotes from the University of Auckland article:

Located in Dance Studies in the Faculty of Creative Arts and industries, Ngākau Oho will provide a personalised recovery programme for 20 ACC clients and their whānau. In the process, the programme aims to reclaim and normalise rongoā Māori as a viable and everyday healthcare practice.

Recent efforts to address Māori health inequities across the health sector have focused on increasing the number of Māori health professionals and Māori access to culturally relevant rehabilitation services, says Dr Reihana.

Why is this in a dance studio? But wait—there’s more, and this is the worrisome part (my emphasis):

The programme will provide ACC with evidence-based insight on how rongoā Māori would be embedded within established healthcare services.

“We believe the approach we develop will be an innovation that can be used within the health system, and importantly, by Māori health practitioners, providers and whānau, helping ensure that rongoā Māori practices can be a real and easily accessed option for Māori in wellbeing and recovery,” says Dr Reihana.

This implies that RM will indeed become part of the government-funded healthcare system of New Zealand.  But what is the “evidence-based insight” that is forthcoming, since there is no mention of controls?

Finally, Donna Kerridge, the RM practitioner shown in the video above, says this:

“I think the Western health and healing system is awesome; it’s not better, it’s not worse.”

This is the insistence on absolute equality that is ubiquitous in both MM and RM, and it’s just wrong. If you have diabetes, do you want traditional herbal medicine or insulin? If you have an infection, do you want plants or antibiotics? Now many Māori do avail themselves of modern medicine instead of or alongside RM, and those people are the savvy ones. But it seems risible to say that RM is exactly as good as modern medicine. It can’t be, because its “testing” is based on anecdotes instead of scientific studies with controls.

I want to add one bit about “alternative medicine” in the U.S. In 1991, the government established the National Center for Complementary and Integrative Health as part of the National Institutes of Health. Its goal was to scientifically study “alternative medicine”, using the kind of controls that all science-based medicine uses.  As Wikipedia notes:

NCCAM’s mission statement declared that it is “dedicated to exploring complementary and alternative healing practices in the context of rigorous science; training complementary and alternative medicine researchers; and disseminating authoritative information to the public and professionals.” As NCCIH, the mission statement is “to define, through rigorous scientific investigation, the usefulness and safety of complementary and alternative medicine interventions and their roles in improving health and health care.”

Since the NCCAM’s founding, over two billion dollars have been spent testing stuff like coffee enemas, intercessory prayer, magnet therapy, and so on. Not one “alternative treatment has worked. You’ll be amused at the examples given in the article about the treatments tested and their outcomes. A screenshot is below (click to enlarge). NOT ONE WORKED! And for the others, no results were ever reported, which means that they didn’t work, either.

Two quotes from the article:

In 2012, the Journal of the American Medical Association (JAMA) published a criticism that NCCAM had funded study after study, but had “failed to prove that complementary or alternative therapies are anything more than placebos.” The JAMA criticism pointed to large wasting of research money on testing scientifically implausible treatments, citing “NCCAM officials spending $374,000 to find that inhaling lemon and lavender scents does not promote wound healing; $750,000 to find that prayer does not cure AIDS or hasten recovery from breast-reconstruction surgery; $390,000 to find that ancient Indian remedies do not control type 2 diabetes; $700,000 to find that magnets do not treat arthritis, carpal tunnel syndrome, or migraine headaches; and $406,000 to find that coffee enemas do not cure pancreatic cancer.”  It was pointed out that the public generally ignored negative results from testing, that people continue to “believe what they want to believe, arguing that it does not matter what the data show: They know what works for them.” Continued increasing use of CAM products was also blamed on the lack of FDA ability to regulate alternative products, where negative studies do not result in FDA warnings or FDA-mandated changes on labeling, whereby few consumers are aware that many claims of many supplements were found not to be supported.

I’ll take my coffee in the other end, thank you.

And here’s a skeptical take (there are other criticisms given of NCCAM by doctors and scientists):

A 2012 study published in the Skeptical Inquirer examined the grants and awards funded by NCCIH from 2000 to 2011, which totaled $1.3 billion. The study found no discoveries in complementary and alternative medicine that would justify the existence of this center. The authors argued that after 20 years and an expenditure of $2 billion, the failure of NCCIH was evidenced by the lack of publications and the failure to report clinical trials in peer-reviewed medical journals. They recommended that NCCIH be defunded or abolished and the concept of funding alternative medicine be discontinued.

That money hasn’t been completely wasted, for it’s debunked therapies that people insisted would work. And those therapies won’t be approved by the FDA or used by rational doctors. Still, therapies are usually tested clinically when there’s some preliminary evidence that it might work. The tests above were simply based on “folk claims.”

 

All I’m asking is that Rongoā Māori be tested the same way as the NCCAM tested its putative remedies. If RM treatments aren’t (and they surely aren’t), Kiwi taxpayers should be protesting loudly about wasting their money on subsidizing spiritually-based medicine 

American Academy of Pediatrics pulls back on “affirmative care” while a Seattle hospital pushes it, offering surgery and puberty blockers to adolescents

August 23, 2022 • 11:45 am

Enlightened medical opinion seems to be coming around to the view that for adolescents who want to change gender, i.e. become transsexual, the use of puberty blockers is not necessarily a good way to go. The blockers, which are supposed to stop puberty in its tracks (in a completely reversible way) are given to allow young people a pause to ponder their options. But they are increasingly seen as untested and possibly unsafe. European countries like Sweden, France, and Finland have either limited the use of puberty blockers to “exceptional cases” or clinical trials, or have prohibited their use entirely.

This is all part of a pushback against “affirmative care”: the idea that if a child decides they want to become transsexual, they must be completely supported, with psychotherapy not examining their decision or encouraging throughtful assessment, with parents urged to accept their child’s wishes, and with the medical establishment dispensing whatever hormone therapy or surgery the child wishes.

The problem with this is not that support shouldn’t be given. It’s that children or teenagers who are too young are being pushed by doctors, parents, and peers to make decisions about issues that may involve irreversible medical interventions. European countries vary in the age at which sex reassignment surgery is legal, usually ranging from 15 to 18. For transgender hormone therapy, ages in Europe range from a minimum of 14 up to 18, with most countries having minimums of 16 to 18.

That kind of therapy causes irreversible changes in the body, while genital surgery renders one sterile and often incapable of orgasm. I have no strong views on age limits except that they should be after puberty and not lower than 16. Your mileage may vary.

And I’ve just discovered, through an article in the City Journal, that the American Academy of Pediatrics, which used to be all for “affirmative care”, seems to have suddenly started reevaluating its position. The article notes this:

Moira Szilagyi, president of the AAP, has written that “gender-affirming care . . . doesn’t push medical treatments or surgery; for the vast majority of children, it recommends the opposite.”

This is a welcome development, and marks a reversal of the AAP’s previous policy. That policy was announced in a 2018 Pediatrics article, whose lead author was Jason Rafferty; it argued that “watchful waiting” is akin to “conversion therapy” and should be avoided. “Watchful waiting” refers to an approach that emphasizes psychotherapy as a measure of first (and hopefully last) resort to help minors in distress feel comfortable in their bodies. Its premise, confirmed by 11 studies, is that the vast majority of children with gender dysphoria will desist by adolescence and feel comfortable enough in their bodies not to require medical transition. The Dutch researchers who developed pediatric transition explicitly warned against early transition. Yet transgender activists in the United States have criticized this model, insisting that because transgender identity (i.e., body rejection) is a normal and healthy aspect of human existence, mental health professionals should never steer patients toward a “cisgender” outcome.

If Szilagyi believes that medicalization is the wrong way to go “for the vast majority of children” with gender dysphoria, then this constitutes a de-facto repudiation of the Rafferty statement and the AAP’s previous policy.

Here’s an extract from AAP President Szilagyi’s piece, an an op-ed in the Wall Street Journal called “Academy of Pediatrics Responds on Trans Treatment for Kids: To ‘affirm’ a child or teen means destigmatizing gender variance and promoting the child’s self-worth.”

Regarding Julia Mason and Leor Sapir’s op-ed “The American Academy of Pediatrics’ Dubious Transgender Science” (Aug. 18): In its recommendations for caring for transgender and gender-diverse young people, the AAP advises pediatricians to offer developmentally appropriate care that is oriented toward understanding and appreciating the youth’s gender experience. This care is nonjudgmental, includes families and allows questions and concerns to be raised in a supportive environment. This is what it means to “affirm” a child or teen; it means destigmatizing gender variance and promoting a child’s self-worth. Gender-affirming care can be lifesaving. It doesn’t push medical treatments or surgery; for the vast majority of children, it recommends the opposite.

This isn’t the story that is being told by anti-transgender activists. No European country has categorically banned gender-affirming care when medically appropriate. Contrary to what Dr. Mason and Mr. Sapir claim, the U.K. isn’t moving away from gender-affirming care. It is moving toward a more regional, multidisciplinary approach, similar to what is practiced in the U.S.

This does seem to be a change of policy. “Affirmation” no longer means “go full steam ahead for the gender change” but, properly, to “promote a child’s self-worth.” Further, affirmative care no longer means “pushing medical treatments or surgery; for the vast majority of children it recommends the opposite.”

I’d say that this is a move towards enlightenment, even if it was promoted by what European countries are doing. It’s not clear, though, that this will become the AAP’s official policy.

Nevertheless, some places, like Seattle Children’s Hospital, continue to offer surgery, puberty blockers, and hormones to children as young as nine. Granted, you need parental permission for this treatment, and you can’t get bottom surgery until you’re over 18, but dispensing blockers, drugs, and cutting off the breasts of females younger than 16 is not something I’m a fan of.

This story comes from KOMO news in Seattle, a station and website affiliated with ABC, and you can check its assertions by going to the Seattle Children’s Hospital website on gender care (link below). Click to read:

This is from KOMO:

The gender clinic at Seattle Children’s Hospital (SCH) provides children as young as 9 years old with “gender-affirming medical care,” like puberty blockers, and children in their “mid-teens” with non-genital transition procedures known as “top” surgeries.

We accept new patients ages 9 to 16,” the SCH gender clinic website states. “Patients ages 17 and older and patients who have not yet started puberty will be directed to community resources.”

The website notes that the clinic “primarily provides gender-affirming medical care (such as puberty blockers  and gender-affirming hormones)” to patients. Children must receive parental consent for any “gender-affirming” treatment.

“Brief mental health support” is also available, according to the site, but the clinic suggests that “if you are looking for gender-affirming mental health services only, or for ongoing mental health support,” there are better resources that focus solely on that.

Patients must be 18 years or older to receive gender transition surgeries involving genitals, such as vaginoplasties and phalloplasties, according to another page on SCH’s gender clinic website.

Sure enough, the website link given above says this:

We accept new patients ages 9 to 16. Patients ages 17 and older and patients who have not yet started puberty will be directed to community resources. Our clinic primarily provides gender-affirming medical care (such as puberty blockers and gender-affirming hormones). Brief mental health support focused on family decision making and mental health documentation prior to initiating gender-affirming care is also available. If you are looking for gender-affirming mental health services only, or for ongoing mental health support, here are some community resources.

Puberty blockers, with their attendant medical unknowns, are offered to children who have started puberty but haven’t completed it, and those in their “mid-teens” can get surgeries like double mastectomies, breast augmentation, thyroid cartilage surgery, and “facial gender-affirming surgery.” I can’t find the age at which hormone therapy is given, but I presume it’s either after puberty has begun or in one’s mid-teens.

But there are some claims that seem dubious, like these given at the Hosptial’s pdf on puberty blockers:

No, puberty blockers are not permanent. If you decide to stop puberty blockers without starting cross sex hormones, your body will start going through the puberty of your sex at birth. You can stop the puberty blockers at any time, but we will work with you on how to do that.

We can safely and legally recommend puberty blockers for you based on our medical experience and judgement and your specific health needs. The Endocrine Society and the World Professional Association for Transgender Health support puberty blockers. The Food and Drug Administration (FDA) approves puberty blockers for children who start puberty at a very young age, but has not approved puberty blockers for transgender children.

But at the same place they say this:

The long-term safety of puberty-blocking medicines is not completely understood. There may be long-term risks that we do not know about yet.

Indeed, this is in line with Britain’s new NHS guidelines to not give hormonal treatment, including puberty blockers, to adolescents under 16. Further, Sweden’s Karolinska institute says this:

  • In light of the above, and based on the precautionary principle, which should always be applied, it is hereby decided that hormonal treatments (i.e., puberty blocking and cross-sex hormones, see above) will not be initiated in gender dysphoric patients under the age of 16.
  • For patients between ages 16 and 18, it is hereby decided that treatment may only occur within the clinical trial settings approved by the EPM (Ethical Review Agency/Swedish Institutional Review Board). The patient must receive comprehensive information about potential risks of the treatment, and a careful assessment of the patient’s maturity level must be conducted to determine if the patient is capable of taking an informed stance on, and consenting to, the treatment.

The U.S. is often touted as having the world’s best medical care. But when it distorts the dangers of hormonal treatment, or rushes children and adolescents onto an escalator towards transsexuality without proper therapy and information, it’s a travesty.

h/t: Williams

Foreign accent syndrome: a bizarre form of speech disorder

August 7, 2022 • 1:15 pm

Foreign accent syndrome (FAS) is a very rare speech disorder—fewer than 100 cases have been seen in the last century—first described in 1907. In this edition of “60 Minutes Australia,” several such people are highlighted, centering on two Aussies who both developed an inescapable “Irish” accent, one after a migraine and the following a tonsillectomy. (You can find other examples on YouTube, like this one.) The highlight is on Angie Yen, and at 5:47 you can hear a recording of her Aussie accent before the change.

FAS is sometimes temporary and can be treated, though not necessarily cured, with speech therapy. And it’s not exactly the same as a genuine national accent, as a native Irish person might be able to tell with Angie.  Wikipedia says this:

To the untrained ear, those with the syndrome sound as though they speak their native languages with a foreign accent; for example, an American native speaker of English might sound as though they spoke with a south-eastern English accent, or a native English speaker from Britain might speak with a New York American accent. However, researchers at Oxford University have found that certain specific parts of the brain were injured in some foreign accent syndrome cases, indicating that particular parts of the brain control various linguistic functions, and damage could result in altered pitch and/or mispronounced syllables, causing speech patterns to be distorted in a non-specific manner. Contrary to popular belief that individuals with FAS exhibit their accent without any effort, these individuals feel as if they have a speech disorder. More recently, there is mounting evidence that the cerebellum, which controls motor function, may be crucially involved in some cases of foreign accent syndrome, reinforcing the notion that speech pattern alteration is mechanical, and thus non-specific.

I was surprised at the emotionality and tears that accompany the meeting of two Aussie women at 10:56, both having FAS of the Irish variety (the condition is significantly more common in women than men). This shows the psychological burden of suddenly losing your own accent.  Both seem desperate to resume their old way of speaking.

Towards the end, Angie has an MRI brain scan, revealing both over- and underactive parts of the language center. (Angie again bursts into tears from both relief at the assurance that she’s not faking it—something she was accused of—and inquisitiveness about how she got this way.) The other Aussie woman, Kate, also has disordered activity, though not as severe, perhaps because she’s had the condition longer and is trying to compensate for it.

At the end, with hope that the condition can be mitigated with therapy, the two women share a Guinness (!) with the interviewer. Neither of them can stomach the brew.

The death of the Tavistock clinic, recounted by one of the whistleblowers

August 5, 2022 • 12:00 pm

Sue Evans was a nurse therapist working at the Tavistock Clinic in London, dealing largely with issues of gender dysphoria in young people. In this piece from Bari Weiss’s Substack (again, subscribe if you read regularly), Evans describes how in the early 2000s the clinic became a place of fulminating “affirmative therapy”, changing its normal procedure of talk therapy to the willy-nilly dispensing of puberty blockers and hormones—all without any thoughtful examination of what was happening. If there was any “social contagion”, it was among the sheeplike employees at Tavistock who jumped aboard a woke juggernaut at the expense the patients’ well being.

Click to read. Because this has already been covered widely, I’m mentioning it for those who haven’t yet read what happened at Tavistock. You are probably aware that after an independent report on the clinic, the NHS has now ordered its closure, with its functions farmed out to several geographically distributed sub-clinics, and with a lesser concentration on “affirmative therapy” and less recommending of drugs to facilitate transsexual changes.

It wasn’t that long after Evans had been working at Tavistock—which I didn’t realize was a clinic specializing largely in talk therapy—before the idea of giving puberty blockers and hormones to gender dysphoric patients swept through the clinic, much to Evans’s dismay, since there was hardly any expertise there in using drugs for gender transitioning.

And then social contagion, stemming from advocacy groups, intensified the pressure to use drugs.

Evans:

The external influence of the advocacy groups increased. Instead of being a clinical, research-focused service where we were learning and developing ideas, it felt like it was a fait accompli that we had to go along with what Mermaids [an advocacy group] and patients wanted—even if we, the mental-health-care professionals, had legitimate questions about the appropriateness of the treatments that patients and patient advocates were demanding.

For example, a weird paradox arose at a conference on transgender health care hosted by Tavistock around 2005: the opening speaker declared that we were no longer supposed to think of gender dysphoria as a mental illness. But we were a mental-health team working at a mental-health facility. What were we supposed to be doing if not treating patients with psychological conditions?

Remember, this was all before the internet took hold of an entire generation of teenagers. There were no online groups dedicated to gender affirmation and coaching kids on what to say to their providers to secure cross-sex hormones. We mostly saw younger boys who believed themselves to be girls from an early age and a few teenagers who felt like they were trapped in the wrong bodies. So, although I felt aware of the gathering force of thinking around the area of gender dysphoria and transgender identity, it was hard to foresee the slow-motion avalanche that would hit over the next two decades.

Yet even what I saw in those years worried me deeply and working on the Gender Identity Development Service started to affect my personal well-being. I would come home with a headache on the days that I worked in the unit, and my heart would beat quickly when I went in the next morning. It felt like every time I raised a concern about us rushing prematurely to prescribe drugs that would have permanent effects on our patients, I’d be met with an eye roll and the unstated “Oh, here she goes again,” or “Can’t she just fit in?”

A concerned Evans went to the clinical director of Tavistock and raised these issues, and this led to an investigation of the clinic—in 2006.  Evans didn’t see the results of that investigation until 2019, but it was damning. Sadly, the conclusions were also buried:

It was only in 2019 that I saw the full report when Hannah Barnes, a BBC journalist, obtained it via a Freedom of Information request. It confirmed all the disturbing things I had reported: Our data was poor; it wasn’t being stored properly; and there were not sufficient follow-ups with patients once they left the service—meaning we didn’t know how our patients were faring unless they voluntarily wrote to us.

As we have now learned from more recent whistleblowers, the recommendations in the report were buried, and when any criticism or difficult questions arose in the press, the Tavistock management would repeat the same mantra about how they were “a world-class service.” It’s important to acknowledge that there might have been some staff still struggling to deliver thoughtful, measured care, but the noise around our standards was growing louder.

In the face of an unchanged work milieu, Evans quit her work on gender-dysphoric patients. That’s when an explosion of referrals hit the clinic—mostly biological female adolescents who wanted to transition to the male gender. Later, when one of them—who had been rushed through puberty at 16, went on testosterone at 17, and had a double mastectomy—participated in a lawsuit against the clinic, Evans signed on as a co-claimant. They won, with the ruling that minors under 16 could not give informed consent for puberty blockers (these nearly always lead to hormone injections and full transition). But they lost the appeal.

Then, in September 2021, the government commissioned another report on Tavistock, and this one disbanded the facility, farming out its mission to other clinics and deemphasizing the default use of drugs to transition as well as urging more emphasis on objective but empathic talk therapy as a first line of treatment. This result we all know.

Evans had a rough time of it, but ends on a high note:

I didn’t seek any of this. It has been a pretty stressful few years. When I get a letter from patients or parents from around the world, and they tell me, “Well done, thank you for speaking up, you didn’t give up,” I sometimes get a lump in my throat. It’s been hard to be suspected of being prejudiced when all I wanted was safer clinical practice, more scrutiny and evidence collecting, and improved data storage.

Because what I am is a nurse. And my job as a nurse is to treat all my patients with respect and an open mind. I try to think about who they are as people, and to relate to their experience and empathize with them. I also believe we need to keep an open and curious clinical mind when something is occurring in society that seems novel or not yet fully understood. It should never be that doctors and nurses are unable to question diagnoses and prescriptions.

If my actions all those years ago have made a contribution, then I am proud. I made the right decision to raise my hand to ask another unwanted question.

There will come a time, I think, when this rush to transition, with its attendant use of “affirmative therapy”, puberty blockers, and hormone treatment, will be seen as a crazy era in medicine and therapy. Of course there are people for whom this kind of transitioning is the right thing to do, but what we often see now is madness, with affirmative therapy being pushed not because we have evidence that it’s the best thing to do for gender dysphoria—we don’t  have that evidence—but because it’s ideologically “proper.” If someone suggests that they feel as if they might belong in a marginalized group, the philosophy now seems to be to get them in that group as soon as possible, ignoring other outcomes of dysphoria, like homosexuality.

60 Minutes Australia segment on Elizabeth Holmes and the downfall of Theranos

July 31, 2022 • 1:45 pm

Elizabeth Holmes, the founder of Theranos, was convicted of defrauding investors and will be sentenced in October. Her partner in fraud, Sunny Balwani, was also convicted of fraud, but defrauding patients as well as investors. He’ll be sentenced in November. I predict both will get jail time, though far less than the maximum (20 years for each of them).

In this new piece from 60 Minutes Australia, the scandal of the fake blood machine is reprised, but the centerpiece is two whistle-blowers who came forward to report that the Theranos machine, called “Edison”, supposedly able to diagnose 200 diseases from a tiny amount of blood, didn’t work. Both, Tyler Schultz and Erica Cheung, were scientists given access to the inner sanctum of Theranos. Both quickly discovered that Edison didn’t work and the startup was a big hoax. Eventually, worried about patient safety, both began talking to John Carreyrou, a Wall Street Journal reporter who broke the story on Holmes and Theranos and wrote the definitive book on the scam, Bad Blood. (Well worth a read!) Cheung also testified in court against Holmes and Balwani.

Schultz is involved in another way: his grandfather, ex-diplomat and businessman George Schultz, was both a patron of Holmes and an investor in Theranos. Because of Tyler’s whistleblowing, his relationship with his grandfather was damaged.

What’s new about this is that we get to hear from the whistleblowers themselves, who talked not only to Carreyrou, but to federal regulators and the prosecution. They’re admirable people whose lives were put on hold for a long time (and of course who put themselves out of business) because they valued the truth. They address several questions that have arisen in this saga, including Holmes’s defense that her fraudulent actions resulted from her being manipulated and dominated by Balwani. (Schultz and Cheung both reject that claim.)

If you’ve been following this saga, this is a nice 19-minute video that fleshes it out.