More on Abigail Shrier, Harriet Hall, Science-Based Medicine, Jesse Singal, and transitioning

July 3, 2021 • 11:00 am

Yesterday I reported on the site Science-Based Medicine’s defense of their “deplatforming” a book review written by one of their own editors, Dr. Harriet Hall. Hall had written a favorable review of Abigail Shrier’s book Irreversible Damage, itself about the dangers of transsexual adolescents undertaking medical treatment prematurely or without proper guidance. Hall approved the book, but the editors, including Steven Novella and David Gorski (N&G), summarily removed her review (it was reposted by Michael Shermer and Skeptic magagzine). N&G asserted said it was not removed because the review was ideologically impure or that there was a social-media pushback, but simply because Hall’s review was full of inaccurate statements and bad science.

I put up N&G’s response, and since I hadn’t yet read Shrier’s book (I am beginning it now), I simply reported that two well known skeptical scientists and doctors had objected to Hall’s review and to Shrier’s contentions. I still think that N&G should NOT have removed Hall’s review, but left it up with their own response. That, after all, is what free speech is about. But I’m not yet (and may never be) acquainted sufficiently with the data to pass judgement on these dueling views. But I will note further exchanges in this disparity of opinions.

One of these, pointed out by a reader, was a series of tweets by Jesse Singal, who writes for The Atlantic as well as New York Magazine and other outlets, and has some expertise in scientific and sociological studies of transgender transitioning (see here and here). He’s also written an article below in the July Spectator about how the media distorts what little good data exists about the psychological outcomes of transitioning. (The data appear to be far scantier than one would think from the vociferous claims of transgender advocates.)

First, though, Singal fired a fusillade of 16 tweets in response to N&G’s attack on Hall and Shrier, and I’ll reproduce these here. As always, judge for yourself, and dig further if you’re unclear or intrigued. I’ll reproduce them all as they’re a quick read, and they should be perused along with Singal’s Spectator piece at the bottom.

The Spectator piece mentioned in the next tweet is linked to and discussed at the bottom of this post.

Gorski’s tweet at Rowling above is clearly out of line here, and in fact is gratuitously nasty.

One gets the impression from these tweets, many of which are summarized in detail in Singal’s article below (click on screenshot), that N&G were firing from the hip, making unsubstantiated claims about the literature that verge on distortion. The problem with all of this is that everyone is so polarized on the issue, whether rightly so because of the data or because of ideological bias, that it’s hard to know whom to trust. However, Singal’s article below does show that he’s read many of the original studies questioning the supposed “safety” of puberty blockers and the claimed suicide-reducing effect of transitioning. Both claims are “problematic,” i.e., we really don’t have good data. Read and judge for yourself. I’ll give a few quotes from Singal:

Singal’s piece makes several points. First, although some U.S. gender clinics adhere to what we’d see as proper care for gender-dysphoric children and adolescents, many do not, and few seem to come close to the standards used in European countries.

Second, many of the studies cited by the media to show that transition is safe—beginning with the administration of puberty-blocking hormones, are flawed, and, in fact, we have no good information about the safety of these blocking hormones. Further, studies cited to show that transitioning reduces the risk of suicidality in transgender children are flawed to the point that we have no idea whether this is true. The patterns we see could have other explanations, like clinics not taking on children with serious mental problems.

Third, the mainstream media, which by and large adheres to the ideology of unreserved advocates for transitioning, generally refuses to report any of the incomplete data, false assertions, or problematic claims. That, says Singal, is because the media has an ideological bias on this issue, something I don’t doubt.

I’ll give a few quotes from Singal’s article, and. though it’s long (if your attention span is short), it’s well worth a read.

First, on the disparity of European versus American treatments:

In 2007, the Dutch Protocol, as it is known, was brought to the States, initially to Boston Children’s Hospital. These days, blockers and hormones are available in many more American youth clinics, though access varies considerably by geography.

There are some crucial distinctions between the Dutch approach and how some US youth-gender clinicians currently practice. For example, because, as the Dutch clinicians Annelou de Vries and Peggy Cohen-Kettenis wrote in a 2012 article describing their protocol, ‘most gender dysphoric children will not remain gender dysphoric through adolescence’ (a finding that has emerged at multiple clinics), the Dutch clinic has historically discouraged childhood social transition, while also discouraging parents from shaming children for gender-nonconforming behavior. Clinicians there promote the practice of ‘watchful waiting’ until the onset of puberty, at which point, if the GD persists, it is taken as a useful indicator that blockers might be the right choice.

Further reflecting the clinic’s cautious approach, youth with significant mental health problems or a lack of family support (or both) have not been eligible for physical transition. So when we look at the Dutch-protocol data, we’re looking at a subset of kids and teens who were carefully assessed, over a long period of time, to ensure they had clinically significant gender dysphoria and that other mental health problems could be ruled out as the primary drivers of their distress. They all had good family support when they began transitioning.

. . . The lack of outcome data for gender-dysphoric youth who physically transition is one reason there has been a steady drip of news, mostly out of Europe, reflecting growing unease about these treatments. The UK has seen a complicated, slow-boiling controversy at the National Health Service’s sole provider for youth transition services, the Gender Identity Development Service at the Tavistock Clinic in London. Staffers there raised concerns about the quality of care; some argued children were being fast-tracked toward blockers and hormones in part as a result of activist pressure. Complaints from a young detransitioner who insists that she was not properly assessed, and who had a double mastectomy she regrets, culminated in a High Court ruling declaring that under-16s are unlikely to be able to consent meaningfully to blockers or hormones, making it much harder for this group to access treatment. An appeal is underway; in the meantime a convoluted process will still allow some young people to access these services with parental permission.

This spring Sweden banned youth medical transition outright at a number of gender clinics, including one at the famed Karolinska Institute, except in approved research studies. And in June last year the body that recommends on treatment methods in the Finnish public healthcare system published guidelines that emphasized the need for thorough assessment prior to the administration of blockers or hormones — stating that blockers may only be given ‘on a case-by-case basis after careful consideration and appropriate diagnostic examinations’.

These steps seem to reflect a growing realization that the holes in the research on youth medical transition are too big to ignore. Three major reviews of the literature conducted by government agencies in Finland, Sweden and the UK found an alarming lack of data supporting early treatments.

On how the media distorts the data:

Journalistically, the proper response to this issue is to give the details in all their complexity — not to leap to some extreme in which we pretend, for the sake of our political agenda, that there are zero legitimate questions about youth transition. Unfortunately, though, that’s what just about every major American media outlet has been doing. To be fair, this trend started well before the GOP state laws were introduced, but it is getting worse. The threat posed by these laws is often deployed as an excuse to not ask too many questions about extremely unsettled areas of medical research centered on very vulnerable populations.

I mean, what are you, anyway? One of those transphobic Trump supporters? This attitude underpins how these transition stories are framed and what news gets ignored entirely. Apart from the occasional fleeting reference neither CNN nor the New York Times nor the Washington Post nor Vox, all of which have offered near-blanket coverage of the proposed bans on youth medical transition, covered the NICE evidence review [the NHS’s National Institute for Health and Care Excellence] or any of the Tavistock controversy or the Karolinska decision. These outlets routinely repeat activist claims which should be given serious scrutiny and which sometimes defy basic, generally agreed-upon facts. ‘There is no consensus criteria for assigning sex at birth,’ explained CNN in a news article published in March, though editors there later struck that bizarre statement.

Mainstream coverage of this issue is a buffet of sanctimonious overclaiming. It says authoritatively that kids in the US can’t go on blockers or hormones prior to lengthy, in-depth assessment (false). That no one under 18 is getting surgery (false). That the worldwide rise in referrals to youth GD clinics is almost entirely the result of reduced stigmatization (no one knows). That GD [gender dysphoria], or the perception that one has GD, can’t spread through adolescent social networks (almost certainly false on the basis of anecdotal evidence and any familiarity with developmental psychology). That it’s a ‘myth’ that significant number of kids who believe themselves to be trans will later feel differently (false, according to all the existing data). That only a tiny percentage of people detransition (we have no data at all on this in the context of youth gender care in the States).

The last paragraph sums up in a nutshell what we don’t know but what is asserted to be true by liberal media.  I won’t go further except to say that Singal, who is no opponent of guided and informed transitioning, emphasizes our ignorance:

Most reporters don’t have much experience covering this issue.  When they take it up, they reach out early on to an activist organization, which in turn recommends media-friendly ‘experts’ who happen to be on the vanguard of this issue; i.e., seeking to break down the final vestiges of the ‘gatekeeping’ of trans youth. They will earnestly confide in the journalist that among real experts (like themselves), there are no legitimate concerns with the safety of medical treatment of very young trans youth. People who feel differently are transphobes. Simple.

This is a comfortable storyline, but it’s just not true. We desperately need better data on trans youth healthcare. But we don’t have it yet — in many ways, everyone is flying blind, especially families of kids with later-onset GD. Parents deserve every scrap of information that can help them understand not just the potentially profound benefits but also the risks and unknowns of blockers and hormones. American journalists, from an understandable but misguided desire to position themselves on the right side of an emotionally taxing and fraught issue, are hindering their ability to get it.

I’m well familiar with the ideological bias of liberal American journalists, and am prepared to believe that, since they’re not scientists, they want to be on the side of the angels. But this debate will continue, and it will continue until we have sufficient data to settle the medical issues. We appear to be a long way from that.

Is the autism pandemic real?: a new book

August 23, 2015 • 9:30 am

What’s clear in the U.S. is that diagnoses of autism have increased tenfold over the last three decades; what’s unclear is why. Possible answers are many, including (of course) vaccination, which has been exculpated; a better ability of doctors and psychologists to diagnose autism, a change in the criteria for diagnosis (the DSM, for instance, expanded the criteria for “autism spectrum disorder”), unknown environmental causes like chemicals in the water or pesticides, and so on.

Steve Silberman’s new book, NeuroTribes: The Legacy of Autism and the Future of Neurodiversity, argues that the “epidemic” is due simply to changes in the diagnostic criteria (note: I haven’t read it, but am going on today’s New York Times review by Jennifer Senior).  He excoriates the anti-vaxers who blame autism on shots, or on the mercury in those shots, and extensively recounts the history of autism, beginning with Hans Asperger‘s work in Vienna.

Senior finds faults in the book, including an overly-short treatment of the vaccination controversy and a tendency to give too much backstory on patients, but in the end gives the book a strong endorsement:

But carry on nonetheless. “NeuroTribes” is beautifully told, humanizing, important. It has earned its enthusiastic foreword from Oliver Sacks; it has found its place on the shelf next to “Far From the Tree,” Andrew Solomon’s landmark appreciation of neurological differences. At its heart is a plea for the world to make accommodations for those with autism, not the other way around, and for researchers and the public alike to focus on getting them the services they need. They are, to use Temple Grandin’s words, “different, not less.” Better yet, indispensable: inseparably tied to innovation, showing us there are other ways to think and work and live.

The most moving chapter, one that had me fitfully weeping throughout, is the penultimate one, which chronicles that miraculous moment 20 or so years ago when autistic adults finally began to find their own tribe after lifetimes of mis­diagnoses and alienation. Silberman tells the simple story of an autistic woman named Donna Williams who had just written a memoir, visiting two compatriots she had never met. “Seeing the thrill that Williams got from the lights playing off a Coke can,” Silberman writes of one, “he later sent her a belt covered in red sequins from Kmart as a gift.”

It’s an apt metaphor for our culture’s evolving attitude toward autism: If the light bounces off something a little differently, it can be seen in a whole new way.

The first paragraph above is a bit confusing to me.  The “neurodiversity” movement sees the variation in behavior and thinking as part of a normal spectrum, which may well be true for autism, but not for something like schizophrenia. And yes, of course people who are described as being “mildly autistic” or “have a touch of Asperger’s” are often those who are brilliant achievers in some area, and don’t seem to need “special treatment” at all. But there’s nothing controversial in what Silberman is saying here. Some of those on the “neurodiversity spectrum” do need help, for, regardless of whether and how people regard them as ill, they can’t function in society without special attention.

So who has ever doubted that “the world should make accommodations for those with autism”? For severe forms, at least, we don’t ask them to squeeze, without help, into the Procrustean bed of society.

The last two paragraphs are also uncontroversial; we should of course treat these people as humans with human dignity, and avoid stigmatizing them as “odd” or “sick” as far as we can. What I wonder, though is whether the extreme forms of autism, even if they’re the end of a spectrum, are to be celebrated as “diversity” rather than treated as an illness. Some, like Kay Redfield Jameson in her book Touched With Fire, argue that mental illness (she suffers from bipolar disorder) has salutary side effects, giving many cases of artists, writers, and scholars whose achievements, she claims, were promoted by their illness.

But the celebration of “neurodiversity” claim can go too far. As I wrote in a previous post on the neurodiversity movement,

I agree that there may be a spectrum for many mental conditions like depression, autism, and even bipolar disorder, and that the spectrum may even be continuous rather than a bimodal one having peaks at “normal” and “disordered”. After all, neurological conditions likely reflect a nexus of genetic causes—with cognitive and behavioral differences based on many genes—as well as environmental influences. Nevertheless, the important question is this: what do we do about those who suffer from things like bipolar disorder or autism? And I say “suffer from” deliberately, for doctors clearly see most such individuals as suffering because of their conditions. By accepting the condition as “normal”, or writing it off as simply one segment of a spectrum, neurodiversity advocates implicitly—and sometimes explicitly—deny that these conditions should be be cured.

I find that odd and even reprehensible. In the desire to see everyone as “normal”—as part of the rainbow of human diversity—this movement totally rejects the idea that some people are actually suffering and could benefit from treatment. Why else are there drugs for bipolar disorder, and why do parents desperately seek help—both medical and psychological—for children with autism?

The neurodiversity issue seems to me an extension of “identity politics”—which I’ll take here as the view that everyone is special and unique, and deserves to have their desires, abilities, and personality not only accepted, but celebrated. It’s the same mentality that has decided that, in school contests, everyone should get a prize so that nobody will be disappointed, or feel stigmatized or inferior. In the neurodiversity movement, not only should one not stigmatize “mental illnesses” (something I absolutely agree with, for these conditions are, like all disorders, determined by genes and environment), but we should accept them to the point that we shouldn’t even try to cure them.

But ask those who suffer, or who live with the sufferer, whether we should seek cures. Since conditions like autism, bipolar disorder, or schizophrenia must surely reflect neurological issues, they can in principle be cured or controlled. Bipolar disorder, for instance, can now be largely controlled with drugs, and believe me, those who have this issue want those drugs, despite their often unpleasant side effects. And which parent with an autistic child wouldn’t want that child to be helped or cured through some kind of intervention? The “facilitated communication” scam, in which people claimed to help autistic children “speak” by guiding their hands on a keyboard (the facilitators proved to be the ones doing the communicating), shows how desperate parents are to help such children.

In its desire to celebrate mental diversity, the neurodiversity movement in fact promotes suffering. Making sure that all children get prizes is one thing, and not terribly harmful, but denying children or adults cures for mental disorders is a different matter. That’s both thoughtless and horribly selfish, placing a misguided liberal ideology above the well being of the afflicted.

Or, as my doctor, Alex Lickerman, told me when I asked him about this movement, “The issue is not how far from normal you have to be to be considered as having a ‘disease’. The issue is how much of the way you are ‘built’ is causing you to suffer—and what do we do about it. . . The neurodiversity movement is utter nonsense. Ask those who have these problems whether or not, if a cure was offered, they would accept it.”

If we’re going to celebrate neurodiversity, then why not celebrate “health diversity”, and say that those who suffer from various illnesses should be held up as part of a continuous spectrum of wellness? Yes, of course nobody with chronic conditions and illnesses should be stigmatized or mistreated, but we should think twice before we argue for withholding cures, as many “neurodiversity” advocates do.

Now Silberman may not hold the “celebrate all differences” view of autism, and I hope he doesn’t. What interests me about the issue is the dramatic rise in cases of autism, and what we should do when it causes suffering. What interests me less is celebrating severe suffering as simply one tail of a distribution.

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