Category: medicine and health

The latest from my doc on the pandemic, vaccinations, masks, and Delta

August 9, 2021 • 12:30 pm

My extremely competent and science-oriented physician, Dr. Alex Lickerman, has written post #14 in his continuing series about the coronavirus and the pandemic. It’s free, and you can read it by clicking on the screenshot below.

This one answers a number of questions that many of us have. I’ll give a precis of the answers at the end, but you need to read the whole thing. After all, immunized or not, it’s your health. I think you’ll find the answers reassuring.  And what I like about this post, as with the others, is that the answers are completely driven by data.  When the data are ambiguous or unclear, Alex lets us know.

Alex has volunteered to answer readers’ questions, so feel free to ask them in the comments section below.

Some of the questions asked and answered (or not answered if we don’t have data):

  • Is the Delta variant of cornavirus more contagious than other strains of the virus.
  • Does the Delta variant cause more severe disease than the other variants?
  • How effective are the vaccines against the Delta variant?
  • How much do we need to worry about “breakthrough infections?  Here I’ll quote something Alex notes:

But here’s the bottom line: the absolute risk of becoming infected to which vaccinated people are being exposed in most situations in which they find themselves will be far less than 7.2 to 28.8 percent.

This does explain, however, why breakthrough infections with Delta can and do occur. But what we care about most—and what the vaccines were really designed to mitigate—isn’t the risk of catching COVID-19. It’s the risk of being hospitalized and dying from it (as well as the risk of developing long-COVID). Here, the CDC data tells the real story: as of this writing (at a time when, as mentioned above, the Delta variant is the dominant strain infecting people in the U.S.), of 164 million people fully vaccinated (with a mix of the mRNA vaccines and the J&J vaccine), 5,285 people have been hospitalized for COVID-19 (which yields a risk of being hospitalized from severe COVID-19 if you’re immunized of 0.003 percent), and of those 1,191 died (which yields a risk of dying from COVID-19 if you’re immunized of 0.0007 percent). When you consider the risks most of us take every day without worrying about them at all—for example, over the course of a year, the odds of getting into a car accident are 3.7 percent on average and the odds of dying in a car accident are 0.3 percent, making the annual risk of dying from a car accident 0.01 percent, which is 14 times the risk of an immunized person dying from COVID-19—our inability to think statistically clearly has us afraid of the wrong things. (This goes for the decision to be vaccinated as well: our annual risk of dying from a car accident turns out also to be 14 times the risk of the most common serious adverse reaction to the vaccines—blood clots with the J&J vaccines—which occurs at the same rate as the rate of death from COVID-19 if you’re fully immunized, a rate of 0.0007 percent.)

  • Does immunity conferred by the vaccines wane over time? If so, at what rate?
  • Should we be looking to get “booster” (third) vaccinations?
  • Can fully vaccinated people spread the variant? If so, should vaccinated people mask up?
  • Is traveling safe now?

And I’ll give you a peek at the answers but, as I said, read the whole piece and then fire away with questions. A quote from the article:

CONCLUSION: It’s hard to know how to think about immunization, the Delta variant, and how we should behave in different circumstances to keep ourselves and those around us safe. We’re all seeing the science unfold in real time, revealing just how messy, uncertain, and difficult it is to figure out what’s really true. But, though it takes time, science ultimately gives us answers we can rely on. We can all argue about what policies make the most sense based on what the science shows, but it’s the science we should all use to help us guide our own behavior. And, as of this writing, the science says the following:

  1. The Delta variant is more contagious than other variants.

  2. The Delta variant may be more dangerous than other variants.

  3. The vaccines are likely somewhat less effective in preventing infection with the Delta variant, but still offer an enormous amount of protection. Breakthrough infections are occurring, but they are overwhelmingly mild.

  4. Vaccinated people probably can transmit the infection but almost certainly at a lower rate than unvaccinated people.

  5. The vaccines remain unbelievably effective at preventing hospitalization and death from the Delta variant, so much so that vaccinated people can continue to live as they did before the onset of the pandemic, with the possible exception of wearing masks to prevent asymptomatic spread to vulnerable people in areas of high prevalence of disease.

  6. A third booster shot for non-immunocompromised people doesn’t make sense at this point in the pandemic. Some people who are immunocompromised may want to consider a third shot.

The importance of recognizing natal sex in healthcare

August 7, 2021 • 1:00 pm

The mandatory disclaimer applies here: this post is not about disrespecting transgender or transsexual people, nor about resisting their insistence of what gender or sex they may be. I think I’ve made my position on the humane treatment of such people clear: with a very few exceptions, they should possess all the rights of everyone else.

Rather, I want to evince my surprise that an article like this got published in the respected science magazine Nature, which so far has hewed pretty close to the woke agenda. The piece implies in its title that it’s going to be one of those articles arguing that, medically, transwomen should be treated like natal women (my term for birth sex, with sex defined biologically) and transmen like natal men. But no, the point of the article is not that. Instead, it argues that recognizing the binary nature of sex at birth can make a big difference in people’s healthcare and in preventive measures. In other words, there are times when you have to treat based on birth sex rather than asserted sex or gender. What the article means by “expanding the definition of ‘women’s health'” is to recognize the biological differences between the sexes when they are relevant for medical diagnosis and/or treatment. That is not exactly something amenable to gender activists.

Click to read:

The authors implicitly use the biological definition of sex (women = big gametes or the equipment for making them, men = small gametes or the capacity to make them).

They begin with the problem of fibroid tumors of the uterus, which can occur only in biological women—except for males with developmental disorders like persistent Müllerian duct syndrome.  The authors’ point is that, in medical research, such conditions have been understudied because they affect women—biological (“natal”) women:

More than one-eighth of the world’s population has a condition that can cause pain, heavy bleeding and reduced fertility, all potential consequences of benign tumours called uterine leiomyomas, or fibroids. Fibroids can be debilitating, and are a common reason for surgical removal of the uterus.

Yet fibroids have received relatively little attention from scientists, either in academia or at pharmaceutical companies. The root cause of the condition — and how to reduce its impact on fertility — has been a matter of debate for decades, leaving physicians unsure how best to treat people.

Unfortunately, fibroids are just one of many understudied aspects of health in people assigned female at birth. (This includes cisgender women, transgender men and some non-binary and intersex people; the term ‘women’ in the rest of this editorial refers to cis women.) Clinical and pre-clinical studies alike tend to focus on men: only one-third of people participating in clinical trials relating to cardiovascular disease are women, and an analysis of neuroscience studies published in six journals in 2014 found that 40% of them used only male animals. Two studies and a feature published in Nature on 5 August spotlight the achievements of research into women’s health — and the need for much more.

Asserting that “transgender men are men” won’t help with this issue; you must recognize that the biology behind the syndrome is the biology of women. (Again, I’m happy to call transgender folk whatever gender/sex they wish; we’re talking about treatment here.)

Other issues discussed are diseases like type 2 diabetes, Alzheimer’s and, especially heart disease, which affect men and women differently.

Now it’s clear that if you’re a transgender person you should tell that to your doctor (presumably the doctor can tell, but that hasn’t always been the case). But the point is that even so, you might not be treated exactly as a member of the sex to which you’ve transitioned. There are three other areas where natal sex can make a difference:

Heart attacks, for example, are a leading killer of both women and men, but women don’t always experience the ‘typical’ symptoms usually seen in men. Women are also more prone to blood clots after a heart attack, yet less likely to be prescribed anti-clotting medication by their doctors. Women are 50% more likely than men to receive an initial misdiagnosis after a heart attack, and are less likely to be prescribed medicines to reduce the risk of a second attack, according to the British Heart Foundation.

When it comes to sport, women face a risk of serious long-term injury if we continue to model training and head-injury management on data from men. As our News Feature reports, it’s becoming increasingly clear that women experience and recover from head injuries very differently from men. Research from across many disciplines will be needed if we are to understand why women are almost twice as likely as men to suffer a concussion in sports such as soccer and rugby — and to understand why women take longer to recover from such injuries.

The sports issue here is more about research that’s been neglected in natal women, but that research may lead to differential treatments or preventive measures, as noted below.

And here’s a real argument-igniter:

So far, the evidence is sparse, but preliminary data point to structural differences in the brain. Axons in women’s brains are wired up with thinner microtubules, which rupture more easily; hormonal fluctuations are also thought to contribute. Biomechanics, too, could be playing a part — in rugby, for instance, it seems that women fall differently when tackled, which could raise the risk of concussion. Training regimes designed specifically for women might help to mitigate these injuries.

If these brain differences persist through transition, and evidence shows they seem to, then this will lead to differences in training regimens between biological men and transmen.

At the end, the article reiterates that most studies that have been done, whether on humans or animals, have been done on the male sex. Their conclusion—that studies need to be done on women—implicitly assumes a binary of sex at birth:

But the clear message from those researching the sport is that it is no longer acceptable to use data solely from men in these studies. And when women are included, the data need to be disaggregated by sex and involve a sufficient number of women. A recent study looking at MRI images from elite rugby players did include women (K. A. Zimmerman Brain Commun. 3, fcab133; 2021), but of the 44 elite players only 3 were women.

But the relative dearth of women on grant review panels and scientific advisory boards has meant that few of these decision makers have direct personal experience of women’s health needs or research gaps. This makes it all the more important that funding bodies consult the public when they come to set research priorities.

Since 2016, the US National Institutes of Health has required researchers to carry out pre-clinical studies in both male and female animals, tissues and cells, or to provide an explanation for why it is not appropriate to study both sexes. Now it is up to other funders, researchers and journals to amplify the impact of this change by taking care to report sex-specific data in publications. Funders should also bolster the resources given to support studies of health and disease in women, and track how much money goes to supporting such research across all domains, not merely gynaecological conditions. That which gets measured gets done.

These are important and valuable points, and ones that have been made many times before. Women constitute half the world and deserve to be half the reserach subjects for diseases that affect both sexes.

So when they’re talking about “male and female” animals here, or the “relative dearth of women”, they are talking about biological sex, not the sex to which someone has transitioned. In the second paragraph, for instance, then they’re discussing “decision makers who have direct personal experience of women’s health needs or research gaps”, those will nearly all be biological women.

It’s clear that transsexual people will have their own unique medical issues, and these too need to be studied. All I’m saying here is that Nature published an article in which they assume a sex binary at birth that can affect medical outcomes and treatment down the line (by “binary”, I mean “almost complete bimodality”). This runs counter to the trans-activist narrative that “transwomen are women” and “transmen are men”. So I’m surprised that this article hasn’t yet been attacked.

Perhaps it will, but it still makes several good points, and if you have a clear vision, you’ll see that it’s actually a form of social justice to recognize any differences between biological women and men that obtain at birth, could have medical relevance, and then to ensure that medical issues that differ between the sexes are studied in both biological men and women—not just in samples that are mostly male.  As always, recognizing differences like this implies absolutely nothing about inequality.

And while we’re dealing with the thorny issue of differences in brain structure between men and women, something repeatedly denied by sex and gender activists (again, we have the fallacious assumption that differences should not be studied because they imply ranking), here’s a new thread about the brain that has references (h/t Luana):

There are 15 tweets in this thread on brain differences, and I won’t reproduce them all, as you can access them by clicking on the first one:

. . . .

. . . .

It goes on, and you can read and check the references for yourself. It’s a bit left-bashing, as this Twitter site is wont to be, but just check the data for yourself. Given that natural and sexual selection have been going on in our species for millions of years, while civilization is only about ten thousand years old, it would be surprising if brains did not show differences between the sexes the way that other morphological traits do.

Is being a bit overweight good for you?

July 19, 2021 • 11:45 am

UPDATE: Click on the screenshot to read Flegal’s new essay about what happened to her. Thanks to several readers for sending me the link.

 

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The Sunday edition of the Boston Globe has a free article (click on screenshot below) by Amy Crawford discussing the results of Katherine Flegal and her colleagues on the relationship between weight and health. Flegal was a CDC scientist when she did this work, though she’s now at Stanford. What she and her coworkers did was correlate the relative risk of mortality in five classes of people with different body mass indices (BMIs; which are calculated by one’s weight in kilomgrams divided by the square of your height in meters). The classes are these:

BMI < 18.5, classified as “underweight”
BMI 18.5 to less than 25, classified as “normal weight”
BMI 25-30, classified as “overweight”
BMI 30 to less than 35, classified as “obese”
and BMI over 35, classified (I think) as “morbidly obese”

Flegal et al. also looked at the relationship between weight and mortality in three age classes: 25-59 years, 60-69 years, and 70 years or older. They used mortality data from surveys by the National Center for Health Statistics over three periods of time: 1971-1975, 1976-1980, and 1988-1994, as well as the single year 2000. Since their first paper was published in 2005. there have been more studies and one meta-analysis of all the data (see second screenshot below). Not all the results jibe, but most of them do, at least in showing the most surprising outcome. Read on.

The data, published in the prestigious Journal of the American Medical Association in 2005 (see second screenshot below), showed, with appropriate controls, that while people who were obese or morbidly obese had, as expected, a higher death rate than those of normal weight, as did people who were underweight, people with BMIs of 25-30 (overweight but not obese) had the lowest death rates of all! In other words, you were better off being a tad plump than being “normal”. I had heard this before but hadn’t seen the data.

The Boston Globe article concentrates on the firestorm that the data of Flegal et al. produced, apparently because it went counter to the conventional wisdom that to be the healthiest, you should have the “normal” BMI. The study was apparently sound, and yet a professor of epidemiology and nutrition at Harvard’s School of Public Health took out after the study, calling it “deeply flawed”, and her results were attacked over the years. It was an early example of “cancel culture.”

You can read the Boston Globe article by clicking on the screenshot below:

While it’s true that a few similar studies gave different results, most of them confirmed that a little avoirdupois was good for you, which enraged many people. As the Globe notes (my emphasis):

In 2013, Flegal followed up her 2005 paper with a meta-analysis — a review of published papers — in JAMA. In this research she and her coauthors reviewed 97 studies covering nearly 3 million people. Once again, they found people in the overweight category were least at risk of premature death. And once again, the paper roiled the fields of nutrition and public health, attracting special censure from Willett and his Harvard colleagues.

Willett emailed the CDC director to complain, arguing that the meta-analysis had caused damage and confusion and undermined public confidence in science. “Kathy Flegal just doesn’t get it,’’ he grumbled to a reporter for The Atlantic (“I go by Katherine,’’ Flegal notes). In an interview with National Public Radio, Willett said, “This study is really a pile of rubbish and no one should waste their time reading it.’’

Flegal’s confidence in her data, methods, and findings was never shaken. Still, the attacks took their toll. “There were all kinds of little things—it was like, wow, we’re under siege here!’’ she says. “I lost control of the narrative completely.’’

Flegal retired from the CDC in 2016 and took a part-time role as a consulting professor at Stanford. With more time to reflect on her experience, she finally decided that it was important to share her story. “It’s about getting it off my chest,’’ she says. “But it’s also like, wait a minute, this is not really right! People should know about this.’’

Flegal has now written an essay about her experience of being demonized, but I can’t find it online. I hope a reader can find it for us, and I’ll put it here above the fold. Several people in the article, including Alice Dreger, defend Flegal against the attacks.

Here’s the original study of Flegal et al (click to read, and there’s a free pdf). I’ll show both a graph of the relative risks from the paper, separated by BMI group and age class, and then the numerical data.

First, a plot of the relative risk data, showing that at all age classes it’s higher for people who are underweight, obese, or morbidly obese, set at 1.0 for BMI 18.5 to <25 (“normal”) and slightly lower for BMI 25-30, the “overweight”. The figures in the table below the graph (see below) are more informative.

Figure 1. Relative Risks of Mortality by BMI Category, Survey, and Age

(From paper) BMI indicates body mass index, measured as weight in kilograms divided by the square of height in meters. The reference category with relative risk 1.0 is BMI 18 to <25. Error bars indicate 95% confidence intervals.

And the table of relative risks, “relative” being to people of normal BMI. Notice that the error bars for the overweight often overlap 1, but are consistently lower than 1, suggesting a mortality advantage for being overweight. Note that the relative risk is set at 1 for the “normal class”. Note as well that from BMI 25-30, relative risks are lower, and substantially lower for never-smokers from 25-59 years old.  If you’re between 25-59 and obese, the data also show a reduced relative risk, which is weird, but the rest of the data is as you’d expect.

The authors barely mention the benefits of being “overweight”, mentioning it only twice, and very briefly, and not dwelling on it at all. Did they sense the furor it would cause (my emphasis):

Descriptive data for the 3 survey cohorts are shown in Table 1. The numbers of deaths in the 3 cohorts were 3923, 2133, and 2793, for a total of 8849 deaths. Estimated relative risks are shown in Figure 1 by BMI category, age group, and survey, and relative risks from the combined data set and their SEs are shown in Table 2. Obesity (BMI ≥30) was associated with increased risk, particularly at the younger ages; the relative risks were lower in the oldest group. The relative risk in the overweight category (BMI 25 to <30) was low, often below 1. Relative risks in the underweight category usually exceeded unity (1.00). Relative risks were generally modest, in the range of 1 to 2 in most cases.

They found pretty much the same thing in the data for 2000, with BMIs between 25 and 30 associated with lower relative risks.In general, the authors say that they found less increase in relative risk among the underweight and obese than they expected.

Figure 2. Estimated Numbers of Excess Deaths in 2000 in the United States Relative to the Healthy Reference BMI Category of 18.5 to <25, Shown by Survey and BMI Category

(From paper) BMI indicates body mass index (measured as weight in kilograms divided by the square of height in meters). All estimates are based on the covariate distribution from NHANES 1999-2002, the number of deaths in 2000 from US vital statistics data, and the relative risks estimated from National Health and Nutrition Examination Surveys (NHANES) I, NHANES II, NHANES III, or the combined NHANES I, II, and III data set. Error bars indicate 95% confidence intervals.

Now why, if these data be true, does it seem to be good to have a little excess poundage? Nobody knows, but perhaps “normal” BMI has been improperly defined. It may be the median BMI (I doubt it), but most probably the BMI that doctors think is the healthiest. But it doesn’t seem to be, at least if you consider mortality as the ultimate arbiter of unhealthiness. If I were to hazard a guess, I’d say that in our ancestors, being a bit overweight gave you a selective advantage, as you’d be better able to weather times of famine, and so the evolutionary mortality “setpoint” was set at having a bit more fat than doctors like to see today. But this is just a theory which is mine, and I have no idea whether it’s true.

Below is the meta-analysis by Flegal et al. mentioned above, also published in JAMA, and I haven’t yet read it. I’ll leave that as an exercise for readers (it’s free if you click on the screenshot), who will surely want to discuss this long-known but surprising result. Remember, we don’t know how much confidence we should put in it, as all scientific “facts” are tentative, and later analyses may give different results:

h/t: Tim

Israel can’t catch a break: The rejected vaccine exchange with Palestine

July 16, 2021 • 12:00 pm

There is nothing that Israel can do, however praiseworthy, that isn’t criticized by the Israel- and Jew-haters of the world. What about the free and open gay community in Israel, while at the same time being gay is a criminal offense in Palestine? Well, that’s just “pinkwashing”, something Israel’s accused of doing just to gain the approbation of the world, not because they believe in equal rights for gays.

The latest example of a good deed that Israel tried to do, but was rejected by Palestine, is recounted in the Tablet article below (click on the screenshot). It involves a vaccine exchange with Palestine, which the Palestinians rejected for no good reason. (It reminds me of their repeated rejection of peace overtures.)

This one’s easy to recount. First realize that, according to the Oslo Accords, Israel is not responsible for health care in the Palestinian Territories, including vaccines. Although a lot of people damned Israel for not providing COVID vaccines for Palestine, they didn’t realize that they weren’t supposed to. Palestine is, according to Oslo, responsible for its own healthcare. Nevertheless, when Netanyahu was Prime Minister, vaccine was secretly given to Palestinians, probably the bigwigs in the government.

Now, however, the new Israeli government announced a deal to transfer 1.2 million doses of Pfizer vaccine to Palestine. The vaccines were going to expire at the end of May, the end of June, and the end of August, but were going to be given to Palestine in three batches in return for the Palestinians returning equal amounts of their own Pfizer allotments to Israel in October.  Here’s the announcement from the Israeli Minister of Foreign Affairs.

Palestine agreed to this at first. After all, it’s a win-win situation: Israel has most of its population vaccinated, the vaccines could be used immediately by Palestine while they were still good, and Palestine could replenish the Israeli supply later. Palestine has a low vaccination rate and a high infection rate. They need the vaccine now, not in October.

I suspect this is part of the new Israeli government’s desire to take a softer stance towards Palestine. But, as you might expect, it didn’t work.

After negotiating the deal, Palestine rejected it, and for no good reason. As Tablet explains:

But the deal was short-lived. Mere hours after it was announced, the Palestinian Authority abruptly canceled the entire arrangement. The official reason was that the initial batch of 100,000 vaccines were too close to their expiration dates. The real reason was that they had received extremist backlash on social media over working with Israel.

The conspiratorial notion that Israel deliberately sent unusable vaccines to the Palestinians would later be exposed by events, after both Israelis and South Koreans happily made use of the doses. But it was obviously a lie at the time. The vaccine swap had been in the works for months, and every detail had been carefully vetted by the Palestinian Authority, including the expiration dates. As noted, the entire purpose of the arrangement was to swap soon-to-expire doses for distant doses, so that each population would have vaccines when they most needed them. Naturally, Israel first sent over the doses that expired that month, so that they could be immediately administered. This wasn’t a bait-and-switch, it was the plan. It was a feature—spelled out in the official Israeli statement announcing the deal—not a bug.

The fact that the vaccines were indeed usable comes from the observation that the first rejected batch was used to inoculate Israeli teenagers, while the second batch of 700,000 doses has been traded to South Korea, who is using them now (they also have a high infection rate), and will return the doses when they get their own later. The vaccines were not past their expiration date; they just needed to be used now.

There’s more:

But this arrangement was not explained to the Palestinian population, which allowed extremist and anti-vax elements to turn the public against the supposedly subpar “Israeli vaccines”—a campaign which was no doubt helped by preexisting levels of vaccine hesitancy among Palestinians. Local social media began overflowing with protests against the agreement, and rather than explain how it worked, the Palestinian leadership folded immediately. Of course, had the real issue been the expiration dates of the first batch of vaccines, the obvious solution would have been to renegotiate the deal to exclude them. But that was not the real issue, and so the entire deal was called off.

This reminds me of Abba Eban’s famous quote after the Palestinians had rejected one of the many peace deals they were offered: the Palestinians “never miss an opportunity to miss an opportunity.”

And it’s not just Palestine that’s trying to shift the blame to Israel for this debacle: the Western media and NGOs are helping as well:

But that political failure is unlikely to be rectified anytime soon due to the failures of two other entities that might have pressured the Palestinian Authority to change course: the media and the human rights community.

In June, rather than rebuke the Palestinian Authority for caving to extremists, several prominent NGOs ranging from Human Rights Watch to Physicians for Human Rights went to bat for the vaccine rejection, credulously echoing the false claim that the doses were essentially expired and unusable. These organizations had the contacts and the expertise to understand that this was not the case, but chose not to employ them, instead reflexively putting forward partisan talking points. Had they instead called out the Palestinian Authority for placing politics ahead of public health, its leaders might have altered course.

Here’s a tweet from the director of Human Rights Watch, which hates Israel, blaming that country for the failure:

That’s simply a lie!

Tablet says more:

Meanwhile, the international media did not do much better. Of all people, journalists should reasonably be expected to get to the bottom of whether Israel or the Palestinian Authority was telling the truth about the vaccines. But instead, too many outlets covered the entire affair in “he-said, she-said” terms, as though the truth was unknowable, rather than something that could be determined by careful reporting. The closing of the New York Times dispatch was emblematic of this approach:

Those who accepted Israel’s official position about the donations said the authority’s refusal to accept the vaccines had dented claims that Israel was to blame for the slow vaccination rate among Palestinians. But those who believed the Palestinian position said Israel had acted in bad faith by making the authority an offer that it had no choice but to refuse.

Had the Palestinian Authority originally agreed to accept the vaccines with these expiration dates? Could the doses be administered in time? Or was Israel’s leftist health minister, whose party includes an Arab minister, involved in a sinister scheme to foist unviable vaccines on the Palestinian population? If only there were some journalists around to find out.

There are those, like Human Rights Watch, that hate Israel so much (I wonder why?) that they simply can’t admit that on this one the Palestinians screwed up. Israel tried to do something good for both Palestine and Israel, and would surely save a number of Palestinian lives. When Palestine realized that it would make Israel look good and anger the anti-Israeli-anti-vaxers, they rejected the deal.  Consider that. Both the NGOs and the Palestinians would rather see their people die of COVID than accept the offer from Israel. So now the South Koreans are saved at the expense of Palestinians. (The fate of vaccines expiring in August is not yet known.)

With an attitude like that, it seems useless for Israel to reach out to Palestine to soften the enmity. It now seems as if the Palestinians won’t rest until they occupy Israel and that country disappears. The two-state solution appears to be dead, and is clearly opposed as well by many on the American Left (e.g., the Squad in Congress).

If you’d rather see your own people dead than negotiate a win-win deal with Israel, you are a dysfunctional territory. But we already knew that, for Palestine already uses its civilians as cannon fodder to protect Hamas and its rocket sites from Israeli attacks.

Jesse Singal: Science-Based Medicine has put its foot into it

July 16, 2021 • 9:45 am

The site Science-Based Medicine (SBM), renowned for debunking quackery and insisting on a firm evidential basis for medical treatments, has put its foot into it, and by “it” I mean the controversy about Abigail Shrier’s new book dealing with “rapid onset gender dysphoria”.

It started, as I’ve described before, with a favorable review on the site by physician (and SBM editor) Harriet Hall, assessing Abigail Shrier’s recent book Irreversible Damage: The Transgender Craze Seducing our Daughters. Shrier’s book, which I’ve now read, describes a phenomenon that she and others call “Rapid onset gender dyphoria” (ROGD). This is a phenomenon of recent origin in which young pre-puberty women (almost never boys) suddenly decide that they are really males, and, often with minimal advice and supervision, take hormone blockers to stave off puberty, followed by hormone treatment (and often surgery) to remove breasts and (rarely) construct surgical penises.

Shrier’s thesis was that these transitions are often motivated more by social pressure than innate feelings that one’s body doesn’t match one’s gender, and by transitioning, many of these girls gain affirmation and approbation from their peers, often on socia media. Further, Shrier maintains that these transitions are often poorly supervised and, if the girls weren’t given medical treatment but therapy, most would not transition but develop into adult women. Her book is largely a series of stories, largely because the ROGD is so recent that its origins—and whether medical treatment should be used (as well as the psychological and physiological outcomes)—haven’t been subject to rigorous scientific study. We know very little about how to deal with those who manifest ROGD.

Thus, rather than proving her thesis, which wasn’t Shrier’s intent, she wanted to raise red flags about a phenomenon that could have its origin in social pressure and lead to irreversible harm in adolescents who are often psychologically disturbed. The upshot is that we clearly need more research on this phenomenon before we start giving hormones to girls who, in their teens, decide that they’re actually boys. Hormonal and surgical treatment is, after all, irreversible.

Shrier doesn’t deal with the kind of gender dysphoria that manifests itself in early childhood and continues for a long period, or that is taken care of long after puberty in people like Caitlyn Jenner. She’s concerned with adolescent girls who suddenly declare that they’re boys and take immediate action to fix the situation. Their numbers have increased rapidly, raising the question about the origin of the phenomenon. Shrier’s book is neither shrill nor unempathic: she has deep sympathy for transsexual people who are heavily invested in being a member of their non-natal sex. Rather, she wants to call attention to the phenomenon of ROGD and to question whether surgery and hormones are the right answers for a temporary affliction, exacerbated by the climate of social media and physicians and parents who are told to do “the right thing” (facilitate transition), and who don’t hesitate before “affirming” gender change and supporting medical treatment.

I thought Shrier’s book, while not definitive, was well worth reading, and certainly not worthy of banning, a ban for which ACLU staff lawyer Chase Strangio has argued. It should start a conversations about the phenomenon and inspire the collection of data that don’t yet exist. But of course Shrier has been called a transphobe and has been widely demonized by the transsexual communty. One simply can’t question the Received Wisdom in this area.

Under the leadership of Steve Novella and David Gorski, SBM removed Hall’s review from their site, claiming that its egress was due not to social pressure but to Hall’s review (and Shrier’s book) being full of bad science and poor scientific judgment (you can still read Hall’s review at Skeptic Magazine). Novella and Gorski then posted a defense of the removal (replacing Hall’s review with three articles opposing Shrier’s view), citing several papers that I hadn’t read. Summarizing their defense, I listed six assertions by Gorski and Novella about why Shrier’s claims (and their defense by Hall) were bogus. Unable to evaluate them, as I wasn’t familiar with the literature, I just asked readers to judge for themselves.

Now, however, someone more qualified than myself, and more qualified than Gorski or Novella, has evaluated the data and their own claims. That person is Jesse Singal, who has read all the relevant literature cited by Shrier, Novella, and Gorski, and has published widely in respectable venues about transsexualism.  He concludes that not only should Hall’s review have been allowed to stay on the site, but that Gorski and Novella have behaved badly—indeed, unscientifically—in rushing to damn Shrier’s book and Hall’s review. One can conclude, if Singal be right, that Gorski and Novella are behaving in a woke-ish fashion, mis-citing data as well as accepting results that confirm their views and rejecting those that don’t—for no good reason. In fact, Singal’s indictment of Gorski and Novella’s reading of the literature is pretty damning, implying cherry-picking, confirmation bias, and distortion of the existing data, which is not about ROGD, which Gorski and Novella imply, but dysphoria that starts early in childhood or comes to fruition in adulthood.

Singal’s piece was 40 pages long when I printed it out in 12-point type, so it’s a long read. I’d still recommend it, especially if you’re interested in transgender issues or SBM in general. You can read Singal’s article for free by clicking on the screenshot below, though he would appreciate a donation for his work.

To my own credit, which isn’t substantial, I did pick out some of the same problems as Singal does with the Novella and Gorski piece—for example my asking, despite their claim that medical organizations had very high standards for facilitatating transition, whether those standards were actually used very often (it seems that they’re often flouted). And I questioned whether the change of gender dysphoria from a “disorder” in the DSM-IV to “not a disorder” in the DSM-V was meaningful.  Singal shows that it’s not.

But Singal’s analysis, or rather destruction, of Novella and Gorski’s defense is pretty damning. I urge you to read it for yourself. All I’ll do in this post is highlight, in Singal’s own words, the major problem with their claims. His words are in bold and indented, any comments I have are flush left.

First, Singal’s disclaimer:

I should re-emphasize that I’ve said repeatedly I think banning youth gender medicine is a terribly bad idea. The evidence for those “positive outcomes of early medical interventions” come from research that, as we’ll see, leaves a lot to be desired. But it does suggest that for kids with intense, persistent dysphoria who have been well-evaluated, who have any other mental-health problems under control, and who have have good family support, puberty blockers and hormones are likely to lead to the amelioration of what would have been a great deal of suffering. (I include these conditions because we simply can’t say much about the effectiveness of these treatments under different circumstances.) I do not trust legislators to override doctors’ and psychologists’ decisions in a context like this. But again, the evidence here is thin and low-quality, so at the very least it is imperative that any truly ‘science-based’ outlet communicate this uncertainty to readers. Science-Based Medicine has failed to do so.

Having mental health problems “under control” is key here, for it could have significant bearing on the claim that transitioning by adolescents reduces suicide and suicidal ideation. This is frequent claim for which there appears to be almost no evidence. The correlation could work the other way around: only those adolescents who have had therapy and thus low suicidal ideation are the ones who are allowed to transition.

But let’s proceed to Singal’s beef against Gorski and Novella. Again, if you have the time, I’d urge you to read his piece for yourself. He cites a lot of data, something Gorski and Novella don’t do.

Below I summarize Singal’s paragraph headers; each of which is followed by a substantial explanation in the article.

Problems in “The Science of Transgender Treatment” by Steven Novella and David Gorski

1). Novella and Gorski misinform readers about the difference between the DSM-IV and the DSM-5 entries for “gender identity disorder” and “gender dysphoria,” respectively.

2) Novella and Gorski argue that there is widespread adherence to the standards of care for youth gender medicine without providing any evidence that this is the case, other than referencing ‘countless’ interviews they neither quote from nor link to. They also misrepresent the World Professional Association of Transgender Health’s Standards of Care for the administration of hormones to adolescents.

3) Novella and Gorski badly misunderstand the nature of the desistance debate [JAC: “desistance occurs when adolescents grow out of their transgender identity as they age] and communicate a great deal of misinformation and undue skepticism about the desistance literature to their readers.

4) Novella and Gorski badly misunderstand Hall’s concern about regret.

What they mean is that the data on whether transgender people regret transitioning comes from a different group from the one that Shrier and Hall consider (adolescent girls).

5) Novella and Gorski write off Lisa Littman’s study of rapid onset gender dysphoria as “bad science” without explaining why or engaging with Littman’s own rather credible defense of her work, and they engage in some methodological cherrypicking in order to do so.

6) Novella and Gorski falsely report the result of one study and ignore the fatal weaknesses in another.

These problems involve citing studies of gender-affirming outcomes in adults as if they had anything to say about gender affirming outcomes in adolescents with ROGD.

7) Novella and Gorski conclude their article with a profound exaggeration of the available evidence for youth gender medicine that is completely out of step with what the evidentiary reviews conducted by major medical institutions in multiple countries have found, and make no attempt to explain how they came to such a different, more optimistic conclusion.

So, according to Singal, who gives a lot of the data that contradict Gorski and Novella’s claims, there are problems with their analysis of data, with selective citation, and even with ignoring data they don’t like. Singal makes a compelling case, and he ends with these words:

When it comes to hormones for gender dysphoric youth, it’s pretty remarkable to compare the assessments of Steven Novella and David Gorski with those of NICE.

Novella and Gorski: “[T]here is copious evidence supporting the conclusion that the benefits of gender affirming interventions outweigh the risks.”

NICE [the NHS’s National Institute for Health and Care Excellence]: “Any potential benefits of gender-affirming hormones must be weighed against the largely unknown long-term safety profile of these treatments in children and adolescents with gender dysphoria.”

What evidence are Novella and Gorski drawing upon that NICE missed? They should explain this striking discrepancy. And they should transparently correct their article where corrections are warranted, as well as add numerous points of elaboration and clarification. If they don’t, they will mortgage even more of their site’s long-term credibility than they already have.

This, of course, is not the end of the issue. Neither Gorski nor Novella are shrinking violets, and I’m sure they’ll defend themselves vigorously. But what they can’t do is produce data that don’t exist.

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.

Steven Novella and David Gorski defend their removal of Harriet Hall’s book review (the book: Irreversible Damage by Abigail Shrier)

July 2, 2021 • 9:15 am

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):

What are the risks?

Puberty blockers are largely considered safe for short-term use in transgender adolescents, with known side effects including hot flashes, fatigue and mood swings. But doctors do not yet know how the drugs could affect factors like bone mineral density, brain development and fertility in transgender patients.

The Endocrine Society recommends lab work be done regularly to measure height and weight, bone health and hormone and vitamin levels while adolescents are taking puberty blockers.

A handful of studies have underscored low bone mineral density as a potential issue, though a 2020 study posited that low bone mineral density may instead be a pre-existing condition in transgender youth. Treatment with gender-affirming hormones may theoretically reverse this effect, according to Endocrine Society guidelines. . .

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