Category: mental illness

NBC and the NYT appear to be duped by a discredited technique: facilitated communication

April 16, 2026 • 9:30 am

Facilitated communication, or “FC,” is the supposed ability of people who can’t speak and are severely handicapped to “communicate” by having a “helper” guide them in pointing out letters or words.  Wikipedia describes it this way:

Facilitated communication (FC), or supported typing, is a scientifically discredited technique which claims to allow non-verbal people, such as those with autism, to communicate. The technique involves a facilitator guiding the disabled person’s arm or hand in an attempt to help them type on a keyboard or other such device that they are unable to properly use if unfacilitated.

There is widespread agreement within the scientific community and among disability advocacy organizations that FC is a pseudoscience. Research indicates that the facilitator is the source of the messages obtained through FC, rather than the disabled person. The facilitator may believe they are not the source of the messages due to the ideomotor effect, which is the same effect that guides a Ouija board and dowsing rods.  Studies have consistently found that FC is unable to provide the correct response to even simple questions when the facilitator does not know the answers to the questions (e.g., showing the patient but not the facilitator an object).  In addition, in numerous cases disabled persons have been assumed by facilitators to be typing a coherent message while the patient’s eyes were closed or while they were looking away from or showing no particular interest in the letter board.

James Todd called facilitated communication “the single most scientifically discredited intervention in all of developmental disabilities.”

And indeed, I thought FC had been discredited a long time ago. (I posted about it here in 2017 when the idea was used as an excuse for sexual assault.) But no, it’s reemerged with the publication of new bestselling novel, Upward Bound, touted by, among others, the New York Times, which lately has a real penchant for woo. The novel (#305 on the Amazon overall list today) has drawn huge attention because the author, 28 year old Woody Brown, is severely autistic and cannot speak. Yet he got a degree in English from UCLA followed by an MFA degree at Columbia, doing all assignments through a facilitator—his mother Mary.  She herself worked as a “story analyst for Hollywood studios.”

I’ve put a video below showing Brown “writing” by pointing at a letter board held by his mother, who then interprets the pointing. It’s not convincing.

But I’m getting ahead of myself. The novel is below (screenshot goes to publisher).

And yes, the NYT appears to have bought the whole thing, assuming that Woody actually wrote the novel. Read their article by clicking below, or finding the piece archived here).

A couple of excerpts from the NYT:

Woody Brown knew he wanted to be a writer when he was 8 years old. Around that age, he made up stories about his alter ego, Cop Woody, a hero who went around saving people.

The tales stunned his mother, Mary Brown. She’d been reading to him since he was a baby, but never imagined that he could create his own elaborate plots.

As a toddler, Woody was diagnosed with severe autism. Doctors concluded he couldn’t process language, and said it was pointless to explain things to him or talk to him in complex sentences. Whenever Woody spoke, it sounded like shrieks and gibberish.

But Mary came to realize that her son understood more than he appeared to. He would become hysterical if they deviated from their daily routine, but if she explained why they had to stop at Target before getting lunch at McDonalds, he would calmly follow her into the store. At 5, Woody learned to communicate by pointing at letters to spell out words, using a laminated card. He began responding to Mary’s questions, first with single-word answers, and later with short sentences. When he started spelling out his Cop Woody stories, Mary recognized some of the plots, which were lifted from the headlines. Woody had been following the news on the TV and radio.

“That’s how Mom figured out that I was listening to everything,” Woody told me when we met on a recent morning at his parents’ home in Monrovia, Calif., where he lives. To express this, Woody tapped letters on a board with his right index finger, while Mary, who was seated next to him on the couch, followed his finger taps and repeated the words aloud.

When he learned to communicate by spelling, it felt like an escape hatch had opened, Woody explained.

“Miraculous discovery,” he spelled. “I thought I would be caged my whole life, and then the door was open — left ajar, not flung wide, because the majority of people still doubted me.”

. . .While not strictly autobiographical, the stories in “Upward Bound” are shaped by Woody’s experience. He describes the agony of being unable to share his thoughts or control his verbal and physical tics, and the frustration of being underestimated by people who look at him and see an uncomprehending, mentally disabled person.

“I wanted to reach neurotypical readers, the well intentioned people who don’t realize that we are the same inside,” Woody explained. “I have all the thoughts, dreams, longings and intelligence as any neurotypical person. I just present a little differently.”

The author of the piece, Alexandra Alter, visited Woody and his mom, and describes the interview as if Woody himself were answering her questions by pointing at the letterboard. The only reference to the possibility that it’s Mary rather than Woody who is speaking is this:

Some of the communication methods Mukhopadhyay teaches have drawn criticism from language experts who argue that the person holding the board might be influencing or misinterpreting comments from a disabled person. The American Speech-Language-Hearing Association doesn’t recommend the method, and put out a statement in 2019 warning that the resulting words might not reflect the disabled person’s intentions.

There are also skeptics who doubt someone as severely autistic as Woody can form and express sophisticated thoughts, much less write a novel.

Mary said she isn’t surprised some people question Woody’s abilities — it took her years to recognize what he was capable of. But she bristles at critics who say the way they communicate is harmful or manipulative.

“How on earth am I harming him?” she said.

Mary has also faced questions over whether she’s influencing or shaping Woody’s writing, which she insists she isn’t. When Woody is conversing, his finger flies across the board, but when he’s writing, Mary makes him spell out each word slowly. He can also type on a keyboard, but prefers to write with the letter board, because his poor fine motor skills make it hard to hit the right keys, and the time spent fixing typos makes him lose focus.

That’s the only reference in this long, glowing article to the possibility of facilitated communication, and there is no reference to the long, sad history of FC—a history that has made investigators almost universally say that it’s the facilitator and not the disabled person who is doing the “speaking.” (For a free Frontline documentary showing this, go here.)

Now it’s time for you to see Woody communicate. This video comes from NBC’s Today show, and Woody’s novel is breathlessly pronounced “deeply heartfelt and moving” and “authentic” by Jenna Bush Hager (W.’s daughter). Pay attention to the pointing by Woody and interpretation by Mary.  Seriously, I cannot see at all a string of meaningful words.

As one correspondent wrote, “[Woody] is frequently not looking at the board while pointing, AND, when they show what he’s pointing to, it doesn’t correspond at all to actual words. I’m actually blown away that they showed this so clearly.” Indeed!  Didn’t NBC get a bit dubious about this, much less the NYT, whose reporter saw the same thing?  All I can say is that if this is really facilitated communication from Woody, it would be the first real facilitated communication ever documented. But it wasn’t tested, as they did no test on Woody. (They could, example, test his abilities by having Mary interpret things that only Woody knows, or using another facilitator.)  Has Jenna even heard of facilitated communication?

Now I’m not ruling this out as authentic communication, but the demonstration above doesn’t increase my priors. Shame on the NBC for buying this without doubts.

Fortunately, at least two people wonder if Woody’s novel is his own composition or Mary’s. The first is Daniel Engber at the Atlantic, who wrote the critical article below (archived here if it’s paywalled).

Engber watched the NBC clip, and says this:

But if you watch the footage closely, and at one-quarter speed, it doesn’t look like he is spelling anything at all. Brown’s finger can be seen, at several points, in close-up, from a camera just behind his shoulder—and what he taps onto the board seems disconnected from the sentiments that Mary speaks aloud.

Katharine Beals, a linguist affiliated with the University of Pennsylvania who has a son with autism, has studied Brown’s controversial method of communication since the early 2000s, and she has cataloged the ways in which it fails. She told me that she found the clip from NBC to be upsetting. Beals conceded that it can be hard in some cases to say whether such communication is real—but not in this one. “This isn’t subtle,” she said. “You can see that he’s not pointing to the letters.”

On YouTube, where the clip from NBC is posted, viewer comments are aggressive, ranging from ridicule to accusations of fraud. These are snap judgments based on a single, highly edited video; in the end, there is no way to prove or disprove from afar Brown’s capacity to write. But several professional organizations, including the American Speech-Language-Hearing Association, have issued formal warnings against the use of Rapid Prompting, a training method for communication from which Brown’s approach is derived. “There is uncertainty regarding who does the spelling,” ASHA says. And given that the method may mislead, “children and their families can incur serious harm.”

Of course there is a strong desire by Mary, and all facilitated communicators, to believe that they’re merely translating someone else’s thoughts—all the more reason to do appropriate tests and controls.

More from Engber

I emailed Brown, directly and through his publisher, to request an interview and ask if he or his mother would explain the spelling process as it appeared on the Today show. I got an emailed statement back. “I can understand why people are curious—even skeptical—about my method of communication,” it said. The statement continues:

It is mysterious and confounding to see a severely autistic nonspeaker perform acts of scholarship and fiction writing if you don’t presume intelligence in a disabled person. I have been using the same green board since I was in middle school and I find the letters and colors very calming. A keyboard requires specific aim and is unforgiving of error. I have a distinct brain but imperfect aim. This may look chaotic but in this way I keep up a steady rhythm with my finger that helps me stay on track. I am no savant. I came to novel writing like most published authors. I have read many books, attended good colleges, and got my MFA in writing at one of the country’s best programs. The only difference is that I communicate in a different manner.

Clinicians quickly came to understand that the method was susceptible to a very powerful “Ouija-board effect”: A facilitator could unwittingly deliver subtle and subconscious prompts—gentle pressure on a person’s wrist, perhaps—that shaped the outcome of the process. When the typers were subjected to formal “message-passing tests,” in which they would be asked to name an object or a picture that they’d seen while their helper wasn’t in the room, they almost always failed. Even kids who had produced fluid written work seemed incapable, under those conditions, of saying anything at all.

By 1994, the method was broadly disavowed. Yet a core group of true believers continued to promote its use. The New Jersey professor was among them. So was Mary Brown. In 2011, Mary posted on an autism-community website that her son’s use of facilitated communication had “helped him keep up at grade level.” The post has since been taken down, and FC has given way in recent years to its purportedly more reliable offshoots: Rapid Prompting and a similar approach called Spelling to Communicate. Now, instead of holding the speller’s hand, most facilitators hold the letter board instead. At first glance, the risk of influence seems less acute.

But wait, another fan of pseudoscience likes it! Yep, it’s RFK, Jr.:

ASHA has described Rapid Prompting and Spelling to Communicate as bearing “considerable similarity” to FC and thus as “pseudoscience.” But a formal disavowal by experts simply isn’t what it used to be. Health and Human Services Secretary Robert F. Kennedy Jr. has declared himself a fan of these methods: Doubters are delusional, he said in 2021; they remind him of doctors who still deny the harms of childhood vaccines. In January, Kennedy appointed two letter-board users and an expert trainer in Spelling to Communicate to the federal government’s Interagency Autism Coordinating Committee. Meanwhile, an audio series about nonspeaking autistic children who allegedly display their telepathic and clairvoyant powers via letter board has been listed among Apple’s most popular podcasts for more than a year.

Sales of Upward Bound are soaring too. Following the Today show segment, Brown’s book reached Amazon’s top-10 list for books of any kind. This was preceded by a platinum-level rollout that included starred advance reviews, awestruck and largely uncritical features in The New York Times and The Guardian, and testimonials from A-list novelists including Paul Beatty, Roddy Doyle, Rivka Galchen, and Mona Simpson. This is the kind of marketing that any debut literary author would kill to have.

Critics of Rapid Prompting and related methods are aghast. “This really feels like a crescendo,” Beals said. “It’s really, really out of control.”

. . . The problem is, reasonable doubts about the book have been overlooked as well—by Penguin Random House and by the media outlets that have hyped it. (The dewy-eyed feature in the Times does provide, in passing, an attenuated paraphrase of ASHA’s statement about Rapid Prompting.) Then there is the phalanx of established authors who have mentored Brown and endorsed his work. Those who responded to my questions told me that they’d found no reason to suspect that he had not written what they’d read. Rivka Galchen, a staff writer at The New Yorker and an associate professor at Columbia, worked closely with both Brown and his mother across four semesters. Although it had crossed her mind, at first, that his writing might be influenced, the worry vanished over time, based on what she saw. “I’m not a doofus,” she told me. And even if some doubts had lingered, she would have felt both unqualified and disinclined to investigate the question. “Do I have students whose girlfriends write their prose? Do I have students who use AI? I have no idea,” Galchen said. “I feel like I have to take it on faith.”

It’s always unwise to take something on faith, particularly something that has been previously discredited and whose present instantiation can be tested but wasn’t. Although Engber likes the book and recommends it, he’s dubious about authorship.  Likewise, I am not willing to accept Woody Brown as the author.

Neither is Freddie deBoer in the article he recently put up. Its title tells the tale (click to read):

deBoer is even more skeptical than Engber:

Stop me if you’ve heard this one before: The New York Times has again casually endorsed facilitated communication, or FC, a relentlessly-discredited practice that plays on the desperation and credulousness of parents of severely disabled children. As in the past, they’ve done this while barely seeming to understand that they’re doing something controversial at all. The culprit this time is a review of the new novel Upward Bound “by” Woody Brown, a man with severe autism who has been nonverbal his entire life and dictated his book through FC, which is also the means through which he earned a masters degree and other remarkable feats. Brown, like so many others who have been “saved” through FC, was found to have all manner of remarkable intellectual abilities once someone else was “facilitating” his communication.

The review describes Brown “tapping letters on a board” while his mother interprets and voices the words. That is the textbook structure of FC: a disabled person who cannot otherwise communicate produces output while a facilitator mediates, guides, or stabilizes the process. Or so proponents claim. Without the facilitator, the disabled person is mute; with their guidance, they suddenly become remarkably verbally proficient, often learned and verbose. If you’re new to the FC debate, you should trust your skepticism: the fact that the mother has to be present and participating, the fact that Brown cannot manipulate the board without the mother’s involvement, the fact that he has never been subject to rigorous research that involves “message-passing” or “double-blind” tests…. This is the inconvenient, damning reality.

So how did we get here? I guess the Times feels like it’s fine to smuggle in flagrant pseudoscience under the guise of a book review. Hey, it’s just a book review! But I’m afraid that claims of fact that appear in the paper’s pages are the paper’s responsibility, and this review represents a profound journalistic failure. The review treats FC as valid, when in fact FC has been exhaustively discredited for decades. In doing so, it does something worse than merely misinform; it participates in a harmful fiction that exploits vulnerable families and misrepresents disabled individuals. As I’ve said before, this issue is difficult to address in part because the families who fall for FC are so sympathetic. And the FC community goes to great lengths to enable this form of wishful thinking; they’ve created a number of superficially-different approaches to avoid scrutiny and defy the debunkings of the past, including avoiding the term “facilitated communication” itself. They now tend endorse tools like letter boards and techniques like “spelling,” which they claim are fundamentally different. But it’s all still FC, all still a matter of a verbal and cognitively-unimpaired adult “interpreting” the language of a severely disabled person and producing language that they’re consistently and conspicuously incapable of producing on their own.

The Times article never grapples with the evidence. Instead, it substitutes anecdote for science: the mother “realized” her son understood more than expected; the facilitator “saw tension evaporate.” But these are precisely the kinds of subjective impressions that controlled studies were designed to test and, where appropriate, falsify. The best we get from the review’s author, Alexandra Alter, as far as an acknowledgement of FC’s discredited reality lies in these paragraphs:

It goes on, but you get the points: Woody is likely not composing anything himself, the writing is probably due to his mother, the NYT and NBC are uber-credulous, and the buying public, eager to embrace woo and a feel-good story, is making the book a best seller. Oh, and this credulous acceptance of a method discredited for years is harmful to autistic people, to science, and to reason as a whole.’

deBoer spends a lot of space attacking the NYT, as he’s done in the past, but he does give some insight into why the paper is touting FC so hard:

As with so many recent bad publicshing decisions, rehabilitating FC reflects the paper’s increasing dependence on a subscriber-driven business model, where maintaining the sensibilities and emotional investments of its core readership – affluent brownstone liberals who would prefer the pleasant version of reality, thanks – often takes precedence over adversarial truth-telling. In an earlier era, when advertising and broad retail circulation were more central to its finances, the Times had greater latitude to challenge its most dedicated audience. Today, with digital subscribers a) the dominant revenue base and b) heavily drawn from demographics that are highly educated, high income, and progressive-leaning, there’s a clear incentive not to alienate a readership that is drawn to narratives of underdog triumphs and redemptive uplift. Facilitated communication fits neatly into that worldview, offering a reassuring story about disability that flatters the moral intuitions of well-meaning readers while sidestepping the far more difficult reality. The result is a kind of audience capture that encourages credulity precisely where skepticism is most needed. Who wants to read a downer story about genuinely non-verbal, deeply disabled people on their phone while they ride the 4 train uptown to take Kayleigh to her $20,000/year dance lessons?

This may well explain the Times‘s recent touting of religion, whose factual claims could also be seen as pseudoscientific (indeed, Ross Douthat’s evidence for God, presented in the NYT, is based on science).  It does no harm to criticize religion, for the NYT subscribers are likely soft on it. If they’re not believers, they’re “believers in belief”: people who aren’t themselves religious but see faith as an essential social glue essential for “the little people” who hold society together.But Ceiling Cat help you if you promote nonbelief!

h/t: Greg

Addendum by Greg Mayer

The Times just went deeper into the FC morass. The columnist Frank Bruni, who should know better– he’s a professor at Duke, fer chrissakes– just went all in on the dubious book:
Let’s leave readers with a happier thought. I’m reading a novel, “Upward Bound,” written by a young man named Woody Brown who was diagnosed with severe autism as a child and thought to be incapable of sophisticated communication. He still struggles with speech, as our Times colleague Alexandra Alter explained in an excellent recent profile of him. But he’s an effective writer, complaining in “Upward Bound” about caretakers’ tendency to let their autistic charges idle “as if time means nothing to people who have nothing but time.” His book takes readers inside the thoughts of someone like him. And it’s a revelation that forces you to ask: How much do we overlook in people — how many gifts do we fail to nurture — by making overly hasty judgments? Woody’s mom believed in him. Then college and graduate-school professors did. Then editors. Tapping letters on a board to spell out his answers to Alexandra’s questions, he told her: “I thought I would be caged my whole life, and then the door was open.” Now he’s free — and he’s flying.
It’s in his weekly dialogue with Bret Stephens. While Stephens didn’t endorse FC, any sane journalist would have pushed back, so his silence on it in the column is a black mark on him, as well. If you want to see how FC works, watch the Frontline documentary “Prisoners of Silence” (available free here), which thoroughly debunked FC– in 1992! When I taught a course on “Science & Pseudoscience”, I used to show this to the class, because it shows how pseudosciences work, how they are evangelized, how their proponents reject criticism by employing well-known hedges and dodges, and the harm they can do.

Gender-altering surgery raises the incidence of mental illness in those with gender dysphoria

March 3, 2025 • 11:00 am

Here’s a new article in the Journal of Sexual Medicine that investigated the effects of gender-changing surgery on both males and females (over 18) with a diagnosis of gender dysphoria.  The results won’t make gender extremists happy, as in both cases rates of mental distress, including anxiety, and depression, were higher than those having surgery than those not having surgery after two years of monitoring. However, this doesn’t mean that the surgery shouldn’t be done, as the authors note that other studies show that people undergoing surgical treatment are, over the longer term, generally happy with the outcome.  The main lesson of the paper is that people who do undergo such surgeries should be monitored carefully for post-surgical declines in mental health.

Click the headline below to read.

The authors note that there are earlier but much smaller studies that show no decline in mental health after surgery, but these are plagued not only by small sample size, but also by non-representative sampling reliance on self-report, and failure to diagnose other forms of mental illness beyond gender dysphoria before surgery. The present study, while remedying these problems, still has a few issues (see below).

The advantages of this study over earlier ones is that the samples of Lewis et al. are HUGE, based on the TriNetX database of over 113 million patients from 64 American healthcare organizations. Further, the patients were selected only because they had a diagnosis of gender dysphoria and no record of any other form of mental illness (of course, it could have been hidden). Patients were divided into four groups (actually six, but I’m omitting two since they lacked controls): natal males with gender dyphoria who had or didn’t have surgery, and natal females with and without surgery. Here are the four groups, and I’ve added the sample size to show how much data they have:

  • Cohort A: Patients documented as male (which may indicate natal sex or affirmed gender identity), aged ≥18 years, with a prior diagnosis of gender dysphoria, who had undergone gender-affirming surgery.

  • Cohort B: Male patients with the same diagnosis but without surgery. [Cohorts A and B had 2774 patients.]

  • Cohort C: Patients documented as female, aged ≥18 years, with a prior diagnosis of gender dysphoria, who had undergone gender-affirming surgery.

  • Cohort D: Female patients with the same diagnosis but without surgery. [Cohorts C and D each had 3358 patients.]

A and B are the experimental and control groups for men, as are C and D for women.  Further, within each comparison patients were matched for sex, race, and age to provide further controls.  And here are the kinds of surgeries they had:

To be included, all patients had to be 18 years or older with a diagnosis of gender dysphoria, as identified by the ICD-10 code F64. This criterion was chosen based on literature highlighting elevated mental health concerns for transgender and nonbinary patients with gender dysphoria [15, 16]. Gender-affirming surgery cohorts consisted of patients with a documented diagnosis of gender dysphoria who had undergone specific gender-affirming surgical procedures. For transmen, this primarily included mastectomy (chest masculinization surgery, CPT codes 19 303 and 19 304), while for transwomen, this encompassed a range of feminizing procedures such as tracheal shave (CPT code 31899), breast augmentation (CPT code 19325), and vaginoplasty (CPT codes 57 335 and 55 970). These surgeries were identified using clinician-verified CPT codes within the TriNetX database, allowing for precise classification.

Note that there were a lot more “bottom” surgeries for trans-identifying men (as the authors call them, “transwomen”) than for trans-identifying women (“transmen”). Men prefer to change their genitals more often than women, even though, if you know how vaginoplasties are done, you have to be hellbent on getting one. (I don’t know as much about the results of getting a confected penis.)

I’ll be brief with the results: in both comparisons, those patients who had surgery had a significantly higher postsurgical risk of depression, anxiety, suicidal ideation, and substance abuse. But surgery had no effect on body dysmorphia: the obsession with flaws in one’s appearance.  Here are the tables and statistical comparisons of cohorts A vs. B and C vs. D, and the effect of surgery is substantial (results on women are similar though differences are smaller).  Some of the differences are substantial: anxiety in men, for example, was nearly five times higher in those who had surgery than those who did not.

As you see, there are significant differences for everything save body dysmorphia, for which there are no differences at all. The authors conclude that yes, at least over the two-year measurement period (again, mental states were monitored by professionals, and were not due to self report). Given that surgery does seem to improve well being over the long term, as the authors note twice, they conclude that the results provide more caution about taking care of patients who have transitional surgery:

The findings of this study underscore a pressing need for enhanced mental health guidelines tailored to the needs of transgender individuals following gender-affirming surgery. Our analysis reveals a significantly elevated risk of mental health disorders—including depression, anxiety, suicidal ideation, and substance use disorder—post-surgery among individuals with a prior diagnosis of gender dysphoria. Importantly, however, our results indicate no increased risk of body dysmorphic disorder following surgery, suggesting that these individuals generally experience satisfaction with their body image and surgical outcomes. Notably, the heightened risk of mental health issues post-surgery was particularly pronounced among individuals undergoing feminizing transition compared to masculinizing transition, emphasizing the necessity for gender-sensitive approaches even after gender-affirming procedures.

Possible problems. There are two main limitations of the study noted by the authors. First, individuals electing surgery may have higher levels of distress to begin with than those who didn’t, so the elevated rate of mental disorders in the surgery group could be artifactual in that way. Second, patients who have had surgery may be wealthier or otherwise have more access to healthcare than those who didn’t, and so higher rates of mental distress could result simply from a difference in detectability.

Now I don’t know the literature on long-term effects of surgery on well-being, so I’ll accept the authors’ statement that they are positive, even though patients with greater well being could, I suppose, still suffer more depression and anxiety. But those who are looking to say that there should be no surgery for those with gender dysphoria will not find support for that in this paper. What they will find is the conclusion that gender-altering surgery comes with mental health risks, and those must be taken into account. It’s always better, when dealing with such stuff. to have more rather than less information so one can inform those contemplating surgery.

Is it unethical to allow doctor-assisted suicide for mental illness?

May 30, 2024 • 11:30 am

I may have mentioned this case before, but it’s one that’s guaranteed to cause arguments, for it involves the Netherlands’ policy of allowing doctor-assisted suicide of patients with incurable and debilitating mental illness. The description is at the Free Press, and you can read about Zoraya ter Beck by clicking on the screenshot below:

The U.S, has no such policy, although the following states and countries have medical aid in dying for physical illnesses (see the Wikipedia article for notes and qualifications):

Physician-assisted suicide is legal in some countries, under certain circumstances, including Austria, Belgium, Canada, Luxembourg, the Netherlands, New Zealand, Portugal, Spain, Switzerland, parts of the United States (California, Colorado, Hawaii, Maine,Montana, New Jersey, New Mexico, Oregon, Vermont, Washington and Washington DC) and Australia (New South Wales, Queensland, South Australia,Tasmania, Victoria and Western Australia). The Constitutional Courts of Colombia, Germany and Italylegalized assisted suicide, but their governments have not legislated or regulated the practice yet.

I haven’t looked carefully at all these places to see if they allow physician-assisted suicide for the mentally ill, but as far as I know the Netherlands is unique in this respect. Canada was supposed to allow it, but has put it on hold.

Opposition to general euthanasia is often based on religion (“God will take you when it’s time”), and opposition to euthanasia for mental illness is based on the supposition that the illness may be temporary, so that people might recover and be glad they didn’t choose doctor-assisted suicide.

In my view, not only should people with any intractable illness that causes great pain should be allowed to die legally, and I don’t exempt mental illness. In fact, severe depression or bipolar disorder can be the equivalent of cancer: although mental illness might not kill you by itself, it can make life not worth living, so that death would seem to be an ethical choice for both the patient and the state. Further, at least in the Netherlands there are sufficient protections in place to ensure that a person who has a good chance of recovering will not be euthanized, and that the illness must be intractable as judged from previous medical interventions.

But I digress: click to read (it’s archived here):

The details:

Even as a child, Zoraya ter Beek had a persistent wish to die. Growing up in the quaint Dutch town of Oldenzaal, she never felt as if she fit in. At the age of 21, she was diagnosed with autism; a year later, she started wearing a “Do Not Resuscitate” tag around her neck. Last Wednesday, her wish was finally granted: after a three-year wait, Zoraya ended her life through physician-assisted suicide. She had just turned 29.

. . . .Zoraya received little or no support from her family. When she turned 18, she moved out of her childhood home to live with her boyfriend, Stein. He was ten years older than her, and her parents didn’t approve of the age difference. When I first contacted her, Zoraya had been estranged from her mother and three older sisters for six years. Her father died last year from cancer.

As a young adult, Zoraya felt unable to study, or embark on a career. She told me Stein, who is an IT programmer, was worried about how she felt, and encouraged her to get therapy. Over the course of a decade, she tried everything to relieve the symptoms of her mental illness—including, at last, 33 rounds of electroconvulsive therapy, where electric currents jolt the brain.

Zoraya’s last treatment was in August 2020, after which she says her psychiatrist told her: “There’s nothing more we can do for you. It’s never going to get any better.”

“After we heard that, we all kind of knew what that meant,” Zoraya told me, referring not only to herself but her boyfriend, her friends, and her doctors. “I was always very clear: if it doesn’t get better, I can’t do this.”

I ask you: who would insist that this young woman, in deep pain from mental illness that could not be cured or even helped, stay alive? And why?

And so Zoraya went ahead:

Earlier this month, she told The Guardian: “People think that when you’re mentally ill, you can’t think straight, which is insulting.”

“In the Netherlands,” she added, “we’ve had this law for more than 20 years. There are really strict rules, and it’s really safe.”

Zoraya had great faith in not only the law but also the medical profession.

“Doctors want to help people feel better,” she told me. “Doctors don’t become doctors to kill people, even if that’s what you’re wishing for.”

Nevertheless, Zoraya had a plan B—or, as she called it, an “escape plan”—in case her application didn’t get final approval. It was a suicide kit, which she told me she’d obtained from Exit International, an NGO that advocates for the legalization of voluntary euthanasia.

In the end, she didn’t need it. Zoraya had hoped to be euthanized on her birthday, May 2. But there had been some last-minute bureaucratic delays. Nevertheless, her assisted suicide was approved a couple of weeks ago.

Another argument against assisted suicide for the mentally ill is that it could lead to a “slippery slope,” in which people who aren’t that ill, or pretend that they’re suffering, use it as an exit when they could be cured. But although the number of cases of euthanasia for mental illness is increasing, I know the Netherlands’ criteria are sufficiently strict to halt any slope. The increasing numbers reflects, I think, the public’s increasing acceptance of euthanasia as a humane way to end a miserable life, as well as increasing dissemination of information:

The fact is an increasing number of people suffering from mental illness in the Netherlands are choosing to end their lives. Zoraya is right that the assisted dying law has been around for years, but even as recently as 2010, there were only two recorded cases of medically assisted suicide that involved psychiatric suffering. Last year, there were 138.

But Zoraya is all on board with the regulations as they are, and agrees that they should be strict. And so, with the help of a doctor, she ended her life:

Zoraya told me she didn’t want a funeral, because she didn’t think her friends would want to say goodbye. But she did want her boyfriend to be with her at the end. When I spoke to her, she described how she wanted to die:

I will take my place on the couch. [The doctor] will once again ask if I am sure, and she will start up the procedure and wish me a good journey. Or, in my case, a nice nap, because I hate it if people say, “Safe journey.” I’m not going anywhere.

On Wednesday, a friend of hers posted an announcement on X: “Zoraya passed away today at 1:25 p.m. Or as she saw it herself: she went to sleep.”

Few details of her death have been reported—except that her boyfriend was at her side.

It’s sad to envision this, but we are not at the point where conditions like Zoraya’s can be treated. But again, who can gainsay that she did what was best for her? Who could be so churlish as to say she must stay alive.

The answer: the faithful.

If you want to see religious jobs who argue that prayer and recognize the value of suffering should have kept her alive, read this article in the Catholic Herald: “Zoraya ter Beek deserved doctors who cherished her life as precious.”  A quote from that:

As Catholics, we have a powerful message to tell that there is value to be found in suffering: when we step into church, we are met with the sight of Christ crucified, and are reminded of the agony he bore because he loved us. In fact, it’s because Christ experienced being human that we can be sure that he understands and cares for us in our suffering. Still, most of us are not lawmakers. We’re not campaigners or politicians. Trying to justify our Catholic beliefs to the world can seem overwhelming – almost pointless, when our faith is so often denigrated.

As Catholics, we must continue to remind ourselves of the power of prayer; not exclusively praying for a change of heart of those in positions of power who may choose to legalise assisted dying, though that is of course important, but rather praying in order to cultivate closeness to God in our own lives. We must rely on God first, and only then can we show others that we can help them bear their pain. We must confide in the one who bore the greatest pain for us, and petition, in prayer, to be given the strength to imitate his goodness and his compassion in our own lives. Finally, we must never lose hope, even in cases where a person appears determined to die. We must pray for them to the very end, for by God’s grace, no soul is ever truly beyond saving.

This is the maliciousness of religion: keep the suffering going, for superstition tells us that God will make it all right in the end.  It’s horrible.

Here she is in a video made by The Free Press:

Can therapists diagnose Trump as mentally ill, and warn people about his potential to promote violence, without examining him?

June 13, 2023 • 9:00 am

I’ve written twice about this subject:  the controversies involving Yale clinical and forensic psychiatrist Bandy X. Lee (no longer at Yale). Lee has been accused of violating the Goldwater rule, which involves giving professional psychiatric opinions about public figures you haven’t examined—in this case Donald Trump. The article below from Mother Jones magazine describes her travails around “diagnosing” Trump and warning of his potential to incite violence. As I wrote in November of 2020:

I agree that Donald Trump is mentally ill, but I’m not a professional, and thus am not bound by the strictures of professional associations to avoid diagnosing someone you haven’t personally examined. And those strictures exist most prominently in the American Psychiatric Association’s (APA’s) “Goldwater rule“, created after a number of psychiatrists pronounced Barry Goldwater unfit for office in 1964. Here’s the rule from the APA’s “Principles of Medical Ethics,” and this rule is still in force:

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

There doesn’t seem to be a penalty for psychiatrists who flout this rule, however, as psychiatrists who have diagnosed Trump as ill, or even lobbied Congress to proceed with the Trump Dump, have suffered no penalties.

In general I tend to agree with the Goldwater Rule, even if it’s nonbinding and the APA levies no penalties for flouting it (other people, as you’ll see, can punish violators). Yes, I think Trump is mentally ill, afflicted with narcissistic personality disorder, but I still think, as I did three years ago, that giving a professional diagnosis, whether you be a doctor or a psychiatrist (who are doctors), is pretty close to slander, and has far more potentially deleterious consequences than a statement by average Joes like me. “Professional” statements can be used for impeachment, removal from office, and so on. That said, I don’t see a problem with professionals warning the public about the dangers of someone based on their past behavior, without giving them a professional diagnosis. That’s what Lee claims to have done, and she was fired for it.

But in the past, Lee, who never examined Trump, appears to have come pretty close to diagnosing him. In a debate in Salon, Lee not only pronounced Trump to be mentally ill, but then went on to say the Goldwater Rule is itself harmful. Wikipedia notes this:

Lee then stated in an interview with Salon in May 2017 that Trump suffers from mental health issues that amount to a “state of emergency” and that “our survival as a species may be at stake.” She also discussed her political views, linking what she sees as increasing inequality in the United States to a deterioration in collective mental health.

And she discusses the 2020 debate with Biden.

[Salon]: Trump spent most of the debate heckling and interrupting, mixed with some blatant lying. How would you assess his debate performance?

[Lee]: The huge error was in allowing the debate to happen in the first place. “How was his debate performance?” is the wrong question to start. A debate presupposes mental health. We cannot pretend to have one when management of psychological impairment is what is warranted. The majority of the country may be horrified at what he is doing, but we continue to help the disorder in every way possible by treating his behavior as normal. It applies first to the politicians, then to the media and then to pundits who do not come out and honestly say: “This is beyond anything I have seen and beyond what I can understand — can we consult with experts?” And experts, for a psychological matter, would be mental health experts. Perhaps even specialists of personality disorders or sociopathy would be necessary, given the severity.

To me that comes close to giving a professional opinion, but it’s not 100% clear cut. She does say that he has a mental health disorder, and to me that’s a professional opinion. (After all, one psychiatrist said that “he may just be a jerk.”)  There is, of course, a continuum between jerks and the mentally ill, and where to draw the line is unclear.

Bandy went on to organize a conference of mental-health professionals in April, 2017, that resulted in a collection of essays by various therapists,  The Dangerous Case of Donald Trump, a book that became a bestseller. (Note: I haven’t read it.)

Mother Jones reports on the fallout, and on Bandy’s firing from Yale (click on screenshot):

Bandy certainly has the expertise to warn people about potential violence, and that’s what she continued to say about Trump after her book came out: the man has the behavior that tends to lead to violence among his followers, something instantiated in January of 2021.  She has studied criminal gangs and their leaders, and sees their behavior mirrored in Trump’s. She also notes that these leaders lose their influence when they are put in jail. (Bandy also argues that since 1900, violence tends to spike whenever there’s a Republican President.)

At any rate, Bandy continued her warnings about Trump’s likelihood to inspire violence, which of course came true. And she continued to be criticized by the APA.  She appears to have been skirting the Goldwater rule, saying that she didn’t violate it, yet also asserting that the rule doesn’t really apply when there’s another rule that overrides it. This is from her Wikipedia bio:

Lee says that when meeting with lawmakers, she was adhering to the American Psychiatric Association’s guideline, which precedes the Goldwater rule, and which urges psychiatrists “to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government.” In an interview she also said, “whenever the Goldwater rule is mentioned, we should also refer to the Declaration of Geneva, established by the World Medical Association 25 years earlier, which mandates physicians to speak up if there are humanitarian reasons to do so. This Declaration was created in response to the experience of Nazism.”

And from the Mother Jones article:

According to Lee, Trump’s extreme dangerousness puts him in a completely different category from previous Republican presidents, who merely endorsed a set of harsh economic policies that are associated with increased violence. In contrast to past presidents with likely personality disorders, she believes, Trump has a psychological profile that is common among violent offenders. “There is typically a developmental arrest caused by early trauma or abandonment,” Lee says. “As adults, they still act like children in the playground; convinced that might makes right, they often can’t stop bullying others. “Trump’s mother, Lee points out, became chronically ill when he turned two, and his father was cruel and emotionally unavailable, repeatedly urging his son to be “a killer.”

. . . Despite the scolding directed her way by influential psychiatrists, Lee contends that she has never broken the Goldwater Rule, which, as she wrote in 2017, “is the norm of ordinary practice I happen to agree with.” In The Dangerous Case of Donald Trump, she and her co-authors challenged Trump’s fitness to serve based on his behavior rather than on a diagnosis per se. “The issue that we are raising is not whether Trump is mentally ill,” Gilligan writes in his chapter. “It is whether he is dangerous.” As proof of the psychological peril at hand, the authors point to Trump’s angry tirades and verbal abuse of subordinates, his admiration of authoritarian leaders, conspiratorial fantasies, aversion to facts, and attraction to violence.

You can see the conflict here. In the first paragraph, Lee implies that Trump has a personality disorder, and has a psychological profile—connected with childhood abandonment—that leads to bullying and promoting violence.  That sounds very much like a claim derived from professional psychiatric experience. Yet in the second paragraph she says she’s never broken the Goldwater Rule: she was just warning people about Trump’s propensities given his behavior.  But this is a distinction without a difference: that warning comes from professional experience. (Of course, people like us could also make such prognostications without penalty, but a prediction derived from professional experience comes awfully close to violating the Goldwater rule.)

Well, does it matter? Lee turned out to be right, of course, and Trump was impeached (unsuccessfully) as Democratic members of Congress, like Nancy Pelosi, called him “unhinged.” And then there was January 6, and other calls from Trump for his supporters to beat up people.

In the meantime, Lee was fired from teaching at Yale after 17 years following a Twitter kerfuffle with Alan Dershowitz (she said Dershowitz “had taken on ‘Trump’s symptoms by contagion'”, which again skirts the Goldwater rule). Dershowitz complained to Yale about this “violation,” and Yale dumped Lee.  She’s now suing the University and, as she’s become un-hireable in universities, got a degree from Yale Divinity School. She’s now a visiting professor at Union Theological Seminary, where she’ll start a violence prevention institute.

So, if Lee turned out to be right, did she still violate the Goldwater rule? This is a close call, but on balance, and based on the fact that her opinions and warning were derived from her professional expertise, I’d say “yes”.

But two questions remain. First, is the Goldwater rule a good one? I’d say “yes,” given the dangers of chilling public discourse by giving quasi-professional medical opinions. It’s for the same reason that administrators of the University of Chicago don’t make pronouncements on public issues, even when speaking for themselves. It’s because even in private speech, their words carry an imprimatur of authority, and that could chill speech in the University. In some cases violations of the Goldwater rule are clear; if Bandy had diagnosed Trump from afar with narcissistic personality disorder, she would be in violation of the APA’s rule—even though she wasn’t a member of the APA.

But there are no professional sanctions that come with violating the rule.

This leads to the third question: should Bandy have been fired by Yale, even if her predictions about Trump were right? Here I say “no.”  She was fired because Dershowitz complained to Yale about her violations of the Goldwater rule. But even if she violated it, Yale didn’t have an obligation to let Bandy go. And given that she claims, with some justification, that she warned about Trump based on his behavior, not a clinical diagnosis, I don’t think she should have been dumped. After all, Yale derailed the career of an accompanlished psychiatrist. Note how Wikipedia begins her bio:

Bandy Xenobia Lee is an American psychiatrist whose scholarly work includes the writing of a comprehensive textbook on violence.  She is a specialist in public health approaches to violence prevention who consulted with the World Health Organization and initiated reforms at New York’s Rikers Island Correctional Facility.  She helped draft the United Nations chapter on “Violence Against Children,”  leads a project group for the World Health Organization’s Violence Prevention Alliance, and has contributed to prison reform in the United States and around the world.  She taught at Yale School of Medicine and Yale Law School from 2003 through 2020.

That is positive accomplishment, which to me argues against her firing.

And had she been wrong about Trump’s incitement of violence, I still don’t think she should have been fired.  And, as I said, there is some justification for what she did even if she did break the Goldwater rule. After all, she didn’t give a formal diagnosis just to criticize the man: she did it to warn people about what he was capable of doing. (Remember, psychiatrists are allowed to break rules about professional confidence if they think their patients are likely to commit crimes of violence.)

As I said, I haven’t read all of Lee’s writings. But based on what I have read, and on the description in Mother Jones,  which of course does lean way Left, I think Lee was acting according to both her training and her conscience.  Although her warnings didn’t have any effect in impeaching Trump or preventing the insurrection he promoted, she didn’t deserve to have her career forced off the rails by Yale.

Bandy Lee (from her Twitter account)

h/t: Fred

What’s happening to psychology?

June 16, 2022 • 11:45 am

One would expect that psychology, like all other academic and health-related professions, would be going woke, though I haven’t heard much about this area beyond the “affirmative care” controversy with respect to transgender people.

But this article below, whose title implies that wokeness is invading psychology, also implies that the influence of “politics” on psychology is pervasive, and is having unhealthy results on patients.  It’s from the journal Psychreg, which describes itself this way:

Founded in 2014, Psychreg is a free, award-winning digital publication dedicated to keeping everyone informed about psychology, mental health, and wellness. The publication, as well as the open-access Psychreg Journal of Psycholgy, are published by Psychreg Ltd, a media company based in London, United Kingdom.

Click to read:

I’m going to summarize the thesis in one sentence: psychology has adopted a “politicially correct” narrative, which is that nearly all mental illness or mental disturbance, including schizophrenia, can be traced back to “trauma and attachment narratives”: i.e.,  the sufferer must have experienced trauma and a loss of attachment some time in their lives.

Now this seems overly simplistic for several reasons. For one thing, it implicitly blames parents or friends for someone’s mental illness, which is not only hurtful when incorrect but can derail therapy. And, as Marshall says “Clearly people can develop psychosis with no trauma or threat in their lives.” He points out that the heritability of schizophrenia is about 80%, which doesn’t rule out environmental causes as contributors to the condition, but also implies that their role is relatively minor.

What I wonder is if this “trauma and attachment” narrative is somehow conditioned by psychologists becoming woke. We all know how loosely the term “traumatized” is thrown about, even used to one’s reaction at hearing “hate speech”. It is one of the three dicta of Lukianoff and Haidt that are said to explain the fragility of today’s youth:

 1) The Untruth of Fragility: aka “What doesn’t kill you makes you weaker,”

2) The Untruth of Emotional Reasoning: aka “always trust your feelings,” and

3) The Untruth of Us vs. Them: aka “life is a battle between good people and evil people.”

If you are fragile, you can make sense of your illness as a result of trauma. And if you have a Manichean view of the world, as in #3, you can pin your problems on other people: a breaking of attachment.

Now I’m not trying to denigrate the mentally ill here, for Ceiling Cat only knows how many conditions can be unbearably painful. Rather, I’m trying to understand why the “attachment/trauma” explanation is, according to Marshall, taking over psychology. Just a few quotes:

As a clinical and forensic psychologist, I’ve always been interested in the causes – not correlates – of mental health, because associations, masquerading as causal mechanisms, bedevil psychology. Our profession is at a crossroads between science-based causal reasoning and knowledge versus politically biased narratives, where scientific evidence is irrelevant – and trauma is all that matters.

This part implies that it’s affecting diagnoses:

. . .Clinical culture is creaking under the weight of a blank slate trauma assumption. Even when it comes to the adversity to trauma pipeline, the position is unclear.  In outpatient psychiatric clinics in New York, a review of newly admitted patients found 82% with at least one adverse childhood experience (ACE), 68% with two, and a staggering 42% with four or more ACEs; these are correlational studies, telling us nothing about what causes what.

And a bit more:

My experience, and that of others, particularly of child mental health service, is constant reference to trauma and attachment which in turn can leave the impression that this is all that matters.  Imagine any other field of study or science that paints a two-dimensional picture of causal mechanisms in human well-being, ignoring decades of science on other factors? Physics without gravity; biology without natural selection. The over-focus on adversity then attachment/trauma, while well-intended, can lead to two-dimensional contaminated mindware, over-applied to every person’s emotional struggles.

. . . . Critical psychiatry approaches can highlight the presumed damaging effects of diagnosis. The problem is that deprived people are desperately seeking diagnoses for themselves, their children, and relatives in their droves. When a person can label pain and distressing emotions, this can alter positively such experiences and is relieving. An excellent diagnostic process should be collaborative and include a causal formulation. A diagnostic process should describe and classify problems, not the person.  An ideal diagnostic assessment can view issues on a spectrum and blur the line between normative and pain. What’s the alternative? Well-being descriptions based on poverty, attachment and trauma for profoundly psychotic or seriously depressed people?  The risk is that clinicians who overapply trauma/attachment models could explain autism, fetal alcohol spectrum, ADHD, and a raft of neurodevelopmental disorders from this blank slate standpoint.

Now the article isn’t written very well, but I did want to call your attention to what may be a misguided form of ideology creeping into psychology and psychiatry. Do weigh in if you have any experiences about the stuff above. And note that “diagnoses” are often tentative, sketchy, or weird in psychology, as evidenced by the continual changes of the DSM “diagnoses” in successive editions.

h/t: Ginger K.

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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