On June 22, I reported here that the site Science-Based Medicine (“SBM”) had removed from its site a book review written by one of its editors, Dr. Harriet Hall. I characterized this removal as an “unfair deplatforming” and suspected that the review, of Abigail Shrier’s book Irreversible Damage (about the dangers of medically treating young children—mostly girls—to affirm their new gender identity as boys), had been removed because of public pushback.

The explanation below for the removal, by SBM founders Steven Novella and David Gorski, takes issue with those reasons for removal, and spends most of its space defending the removal on the grounds that, by making erroneous scientific statements (many based on Shrier’s contentions), Hall’s review had violated the strict scientific/medical standards of the site. (Hall’s review is still available at other sites, like this one.)

I haven’t yet read Shrier’s book, but I did read Hall’s review and this post by Novella and Gorski, and so we’re left with dueling opinions.  I don’t really have a dog in this fight (my main concern about transgender issues involve law and ethics, not medicine), and so I’ll suspend judgment for the nonce, even after I do read Shrier’s book. The issues at hand involve reading many, many scientific papers as well as having some medical expertise; the first I am unwilling to do and the second I don’t have. There will be at least one more installment of this SBM “explanation” involving more arcane medical issues.

I recommend that readers read Shrier’s book for themselves as well as the upcoming series of SBM articles, which take serious issue with Shrier’s claims.

Ultimately, this is an issue that the public and the courts must make, but one that must rest heavily on medical and psychiatric data. Whatever you conclude, I think that the publication of Shrier’s book and of Hall’s review were useful for two reasons. First, some of their claims might be correct; even Novella and Gorski agree with Shrier and Hall that much of the research on treatment for transgender children is anecdotal and needs more rigorous studies. Second, it’s only this type of back-and-forth that will clarify the empirical issues under contention, and (I hope) ultimately lead to their resolution. I note, though, that this hope may be vain given the ideological maelstrom around the topic.

But let’s proceed: click on the screenshot to read.

First, Novella and Gorski argue that Hall’s piece was published without review because she was one of the site’s editors (and remains so), but concerns were raised by themselves and other editors that ultimately led to the retraction:

Two weeks ago, one of our editors published a book review that raised concerns with Dr. Gorski and me, as well as at least one other editor, soon after it published. Reading it, we both feared that this book review had probably strayed beyond evidence or expert opinion and thus required a robust response. This was a review of a book by Abigail Shrier titled Irreversible Damage: The Transgender Craze Seducing Our Daughters. This particular book discussed a complex area of medical practice that also happens to be one embroiled in heated political debate. Because of the context of this topic, we believed it especially critical that SBM be perceived as a politically neutral and reliable source of information about the relevant science. Unfortunately, Dr. Hall’s fellow editors were concerned that the review in question did not achieve this goal.

Our first step was to carefully review the article and then discuss our concerns directly with Dr. Hall to hopefully find a solution. The challenge here was that, while we had enough background knowledge to immediately see there were serious problems with the review, none of us are topic experts. Reviews outside SBM by those with expertise in this area seemed to be making valid scientific criticisms of the opinions and claims in Ms. Shrier’s book, which the review took at face value.

Clearly what we needed was time to do a deeper dive on this complex controversy, to wrap our heads around the published evidence, and to vet the claims and arguments on both sides. This is something we would have preferred to do prior to publication, but we no longer had that luxury. Giving an immediate half-baked analysis would not do SBM readers justice. Ultimately, we decided to hit the “pause” button, to withdraw the review for a time while we consulted outside experts and did our own internal review. Since Dr. Hall indicated she would publish her article on an alternate site (and immediately did), we saw no pressing need to leave the article on SBM while this review was underway.

Novella and Gorski (N&G) are highly respected men, and I have no reason to doubt this explanation, so I won’t argue that pressure for social media had anything to do with the retraction.

And here are the claims that Novella and Gorski make about Shrier and Hall’s (S&H’s) putative errors. The characterization of their criticisms are mine, as well as the comments.

a.) S&H argue that the recent rapid increase in the proportion of adolescents seeking transgender transitioning is due to social contagion. That is, S&H claim that it’s become more acceptable to declare that you’re a transgender person, for which you get a lot of affirmation and support, than to say (if you’re a girl) that you’re a tomboy or a lesbian. 

N&G deny the social contagion hypothesis, and say that the increase (which they deny is higher than fourfold) can be solely attributed to both better diagnoses (like autism or ductal carcinoma), and to the number of children and adolescents reporting to gender clinics. This is possible, but I do not rule out social contagion as a contributing factor, especially when one sees the strength of “affirmation” when you say you’re transgender.

b.) S&H neglect the rigorous “standards of care” for children claiming gender dysphoria. And indeed, the World Professional Association for Transgender Health has a list of standards (reproduced in N&G’s piece) that seem rigorous and reasonable, with the possible caveat that use of hormone blockers to stall puberty may not be “fully reversible”. Otherwise, they seem reasonable, so long as the adolescent (and there must be an age limit for medical intervention) has been fully informed of the benefits and risks of medical transition rather than simply subject to affirmation. Similar standards are, say N&G, promulgated by The Endocrine Society.

I have no issue with the standards, though we have to be mindful of what even N&G say:

Of course, these are standards, and not every practitioner adheres perfectly to the standard of care in any aspect of medicine. But we don’t take outliers and use that to criticize the standard or pretend it is typical or common. Interviews with those involved in transgender care indicate that adherence to rigorous standards as outlined above are the norm.

But the question is really how many practitioners adhere to these standards? Shrier, I believe, argues that there are too many exceptions, and I simply cannot judge, nor can anybody. Given the fact that some transgender children get puberty blockers or hormones on the black market, it would be hard to answer this question.

As for whether puberty blockers are “fully reversible”, as the medical standards insist, I’m not so sure about that. Here’s an except from a recent NYT article on puberty blockers (I haven’t listed all the possible harms described in the article, and note of course that there are the psychological benefits of transitioning):

The impact of puberty blockers on brain development is similarly hazy. The Endocrine Society guidelines point to two studies: A small one published in 2015 showed that the drugs did not seem to impact executive functioning (cognitive processes including self-control and working memory), while a 2017 study of rams treated with GnRH agonists suggested chronic use could harm long-term spatial memory. (Of course, rams are not humans.). . . . .

c.) Gender dysphoria is not a “disorder” like anorexia. N&G argue that, unlike anorexia, gender dysphoria shouldn’t be seen as a psychiatric disorder because the word “disorder” implies that the condition should be cured—and not by allowing gender transitioning. Frankly, I don’t care what you call gender dysphoria, nor do I think that it automatically has to be “cured”, for surely many children do have a deeply ingrained feeling that they are in the wrong body, and many feel better when they do something about it. But using the DSM (the Diagnostic and Statistical Manual of the American Psychiatric Association), which reclassified gender dysphoria from a disorder to “not a disorder” between the DSM IV and DSM V, doesn’t reassure me. The DSM is a pretty subjective and arbitrary way of “diagnosing” mental conditions. I’ve read a fair amount of it and am not speaking from ignorance.

And there are the comorbidities of gender dysphoria: mental illness that often goes along with the condition, both before and after transitioning. These may be correlates and not causations, but it’s worrisome that these conditions often go together. And even if they are merely correlated, one cannot automatically (as many do) argue that gender-dysphoric children must transition because otherwise they’ll kill themselves, or that, after transitioning, a higher rate of suicide among transgender people is evidence that they’ve been harassed to the point of suicide.

d.) Hall’s claims about the proportion of children who “outgrow” gender dysphoria conflates prepubescent children with adolescents. Based on what N&G say, this is a fair criticism. Hall does this conflation, they say, when asserting that some transgender children “outgrow” their desire to have a new gender identity.

e.) S&H, claim N&G, exaggerate the number of adolescents who regret having transitioned.  N&G say the incident of “regret” is 1% or less.

f.) N&G argue that overall, people who transition between sexes are generally happier. They cite several studies showing “a significant improvement in psychological functioning” after a year, as well as a decrease in suicidal ideation and improved quality of life.  I have no quarrel with this, and it’s an important finding.

N&G have a long discussion which goes into other issues, but I think I’ve hit their main issues above. I am trusting that they are fairly representing the literature rather than just citing data that support their claim that transitioning is a good thing that should generally be supported. Because I don’t know the literature, one should leaven this trust by reading Shrier’s book and looking at her own references.

In the end, I have no issue with applying accepted standards of care to adolescents who wish to transition, as well as waiting until they’re of a proper age of consent. I don’t know what that age should be, but it can’t be 2 or 4 years old, and if it’s after puberty, say 16-18, it’s already too late for a nearly full medical transition. The British High Court recently ruled that children under the age of 16 are too young to give informed consent for the use of puberty blockers unless they have parental consent.

In the end, this argument is above my pay grade, though I’ll continue reading about it. In the meantime, the “agreement” between N&G and S&H comes down to this:

Where we agree with Dr. Hall is that the current state of this evidence is far from ideal. Mainly for practical reasons, most of this research is not blinded or controlled. To put this into context, however, most surgical interventions are not studied in blinded trials, and sham surgical interventions are rare. You cannot blind a trans individual to whether or not they received a gender affirming intervention.

But we do agree that given this reality, we need to continue to study and monitor such interventions for both medical and psychological outcomes. This is where an informed medical and ethical discussion should take place, balancing the risks and benefits of interventions given the limitations of the research. There is also a meaningful ethical conversation to be had about the proper age of consent and balancing that with risks vs. benefits of gender-affirming interventions.

In other words, it’s the familiar ending of science papers, “More work needs to be done.” But that’s cold comfort for children who have gender dysphoria now. And it does say that some of Shrier’s contentions are credible and worth investigating.

 

h/t: Jay