Category: medicine

An article in Science takes implicit bias (and its measurement) for granted despite the problems, and suggests interventions that haven’t been shown to work

March 25, 2023 • 11:30 am

Nearly all psychologists have lost their enthusiasm for the idea of implicit bias because of its manifold problems; and the most common test for implicit bias, the IAT (implicit association test) has largely been abandoned by its users. In light of this you’d think the idea and its IAT metric would have dropped out of sight in academics. But that’s not the way it works these days. If an idea like implicit bias fits into the academic Zeitgeist, and we can actually (pretend to) measure how biased people are when they don’t even know it, then it’s full steam ahead with the idea. Ferret out everybody’s bias, because we all have it! And ignore those niggling doubts about the IAT!

This, along with the often problematic notion of “systemic racism”, which persists in all of academia, are two examples of how the authoritarian Left will cling to a concept when it’s been found empirically useless, simply because the idea comports with their ideology.  And this article in Science—one of the world’s two most prestigious science journals—buys straight into the idea of implicit bias and IAT, hardly mentioning that they’re deeply controversial and have not been found to improve race relations. The article also assumes that inequities are due to racism (another dubious conclusion), and that the racism within science is a structural racism, not maniftested by biased individuals but baked into the system. Finally, the article raises the possibility of Big Brother-like monitoring of people to catch the implicit bias that we all know they harbor. (We discussed this suggestion the other day.)

There is no science journal I know of that has not gone in this direction if it’s weighed in at all on that ideology. Science is one and Nature is another.  It’s embarrassing how the two most prestigious journals concerned with understanding nature play so fast and loose with the facts.

Click to read:

The article’s largely about bias in medicine. I’ll give a few quotes showing how embedded the idea of implicit bias is in the article, how little the author and the IAT-users recognize the weaknesses, and describe new methods of measuring implicit bias in light of the IAT’s failure (which they don’t admit). The article is long, but is so similar to others of its ilk that I’ll be brief.

Note the immediate buy-in of the concept of implicit bias below. The article begins with the story of Chastine, a patient with autoimmune disease whose steroids made her gain weight, and then, she claims, doctors would assume that her extra weight was her primary medical condition. (This could, of course, be dispelled by the patient simply telling the doctor this at the outset).:

Stories like Chastine’s are unfortunately common, say researchers who examine how implicit biases—unconscious assumptions based on skin color, gender, sexual preference, or appearance—in health care providers affect patient care. Chastine, who is Black and queer, is now channeling her troubled experience with the medical establishment to aid studies of implicit bias and identify ways to counter it. She is part of a 5-year collaboration between various departments at both the University of Washington (UW) and the University of California, San Diego (UCSD), in which a team is developing a tool to give physicians feedback in real time during patient visits—or shortly after—on what they can do to mitigate their unconscious prejudices.

Here comes the IAW as used by Janice Sabin, a researcher at the University of Washington:

Sabin used the well-known Implicit Association Test (IAT), which determines how strongly an individual associates a trait—such as race or sexual orientation—with a subjective value, such as “good” or “bad.” The quicker you match each concept to a subjective value, the greater the association and the higher your score, which broadly indicates a stronger implicit association between the trait and value.

Sabin found the doctors she tested—a few of them nonwhite—held the unconscious bias that white patients took their medication as prescribed more so than Black patients. It was one of the first studies showing health care providers had unintentional racial prejudices. “It was kind of scary because this was a concept completely foreign to [many] people at the time,” Sabin says.

As I said, the article does mention issues with the IAT, but doesn’t state that its problems (lack of replication, evidence against the unconscious nature of the bias, and the failure of the tests results to lead to effective antiracist programs) are so severe that serious psychologists have abandoned the test:

The IAT remains a standard tool for measuring implicit bias, although some have criticized it because it has to be taken several times to reveal a reliable result, as people’s scores could change every time they take it. Even when people come out neutral on race, most studies will reveal some kind of unconscious prejudice, such as an unrecognized preference of certain sexual orientations or religions.

. . . Scientists have long studied several kinds of interventions that attempt to “erase” implicit bias, but few of them have shown lasting effects. “There is a robust science around implicit bias,” Hardeman says. But, “There is no gold standard for how to intervene right now. It’s imprinted in our brains in ways that make it really hard.”

Simple interventions can dampen biases, as measured by successive IATs, but the changes are usually modest and don’t persist.

. . .Simply asking health care providers to take the IAT without providing context or tools can be counterproductive. A study in 2015 indicated that when medical students are told about their unconscious bias without direction on overcoming it, they tend to get anxious, confused, and nervous interacting with patients who belong to social groups different from their own. That’s why even a quick training on skills to mitigate implicit bias can go a long way, according to Hardeman.

But as the article says (and other articles agree) why measure bias in a way that’s counterproductive if there is no “gold standard about how to intervene” to mitigate bias? Is this all just performative action with no effect on what it hopes to change? And so researchers move on to the Big Brother tests:

That made him [Brian Wood, an infectious disease specialist] eager to take part in UnBIASED’s first experiments, which rely on cameras installed in exam rooms. The cameras in Wood’s Seattle clinic captured interactions between him and his patients, including close-ups of his and their facial features and body language. “I found quite quickly that the patient and I both forgot the cameras were there and just fell into our usual routine and conversation,” he says.

The UnBIASED team then used a type of artificial intelligence (AI) known as machine learning to analyze patterns in the recordings and identify nonverbal cues that could indicate implicit bias. In one of the clips Wood was later shown, he was talking with a patient while leaning forward with his arms crossed on the desk, body language he worries may have made him seem closed and unapproachable. “I reflected on my own as to how that body language might be felt and perceived by the patient,” he says. Wood, who hopes to improve his demeanor, says he welcomed such feedback and is eager for more.

“Reflecting on possible negative moments during a visit was not easy, but felt important and valuable,” Wood says.

The team is now working on translating the experiment’s results into feedback like “digital nudges”—such as an icon that pops onto the computer screen, a wearable device, or other mechanism telling physicians to interrupt patients less or look them in the eye more often. But the UnBIASED team still has challenges interpreting the data in the recordings. For instance, nonverbal signals are nuanced, Hartzler says. “It’s not always as simple as ‘more interruptions means bad.’”

Translation: this method doesn’t seem to work. But nevertheless, the article persists, describing other methods of measuring hidden bias, including clinical simulations of biases and “microaggressions”, constructing training exercises for physicians and nurses, and calling out people on the spot. The problem is that while the article describes a panoply of methods, with at least one “increasing their recognition of bias” in a way that lasted a year (but their own biases or other people’s?), none of the methods seem to have an effect on mitigating bias, conscious or unconscious.  Despite the failure of developing an efficacious program so far, they will persist—forever:

Getting buy-in from whole health care systems could accelerate the process. Recently, California, Michigan, Maryland, Minnesota, and Washington state passed legislation mandating implicit bias training for the medical professionals they license. And since June 2022, Massachusetts physicians are required to take implicit bias training to get a new license or get recertified to practice.

Although researchers see this as a good step, they worry mandated training will become a one-off box-checking exercise. Sustained implicit bias training for physicians should instead be the norm, some emphasize. Hospitals also need to monitor and collect data on health care outcomes for different groups in order to monitor equity, Sabin says. “You have to know where the disparities lie and then begin to work backwards from that.”

It won’t be easy, Hardeman says, noting that, at least in the United States, centuries of white supremacy and other forms of bigotry have resulted in deep-rooted stereotypes and other implicit biases. “Every single person should be thinking about doing this work,” she says. “But if they’re doing it within a system that hasn’t addressed its own biases and racism, then it’s not going to be fully effective.”

Clearly, we’re going to have mandated training for the rest of our lives (much of it involving a form of compelled speech), and all of us who aren’t people of color will be told that we harbor implicit biases and participate in white supremacy, which is now structurally built into medicine.

And yes, of course some people are biased! I can’t help but assume that these people really do mean well instead of just trying to enact an ideology that they know won’t help the situation. But perhaps they should be using methods that work, and if they can’t show they work, they shouldn’t be part of mandated training. It’s not going to make people more “inclusive” to tell them all that they’re ridden with biases they don’t even know about the invisible Klan robes we all wear.

When this kind of palaver invades all of the prestige science journals—in article after article that all say exactly the same thing—you know that we’re in for a long haul.

If you want to measure your own implicit bias for race using Harvard’s IAT, try it here.

h/t: Steve

A “miracle antibiotic” in the offing? New compound works against all multiple-drug-resistant bacterial strains, and also stymies the evolution of bacterial resistance

February 22, 2023 • 10:30 am

A new article from The Lancet reports the synthesis of an antibiotic that not only kills all drug-resistant bacteria that have been tested (in vitro or in vivo in mice), but also seems impervious to being rendered ineffective by the evolution of bacteria. If this works out in humans, it would be a terrific advance in medicine: an antibiotic that can be used on people whose infections aren’t treatable because the bacteria are drug-resistant (this is common in TB, for instance), but also an antibiotic that seems to be impervious to the evolution of bacterial resistance. It’s also easy to synthesize using organic chemistry, and can be easily tweaked in its structure just in case some bacteria eventually do develop resistance.

Click on the screenshot below to read the original article, or download the pdf here.  The researchers hail mostly from UC Santa Barbara, but also come from UC Davis, Singapore, and Australia.

I found the link from reader Jeannie, who sent me a short piece on kottke.org calling attention to the results. That linked to the original paper (above), but added this:

The discovery was serendipitous. The U.S. Army had a pressing need to charge cell phones while in the field — essential for soldier survival. Because bacteria are miniature power plants, compounds were designed by Bazan’s group to harness bacterial energy as a “‘microbial”’ battery. Later the idea arose to re-purpose these compounds as potential antibiotics.

“When asked to determine if the chemical compounds could serve as antibiotics, we thought they would be highly toxic to human cells similar to bleach,” said Mahan, the project lead investigator. “Most were toxic — but one was not — and it could kill every bacterial pathogen we tested.”

Such are the totally unexpected side effects of research, and although this was applied research, it’s also a justification for pure research. Remember: the whole apparatus for sequencing DNA, and then the CRISPR technique, gene editing, and so on, began with the simple observation that some bacteria live in hot springs near the boiling point, and some curious scientists who asked “I wonder how they do it.”

Back to the paper. My take will be short as it’s complicated and, to be sure, parts of it are beyond me. The compound they found was COE2-2hexyl, and below is the structure. It can be synthesized without much difficulty using standard methods of organic chemistry, so you don’t have to get it from massive quantities of fungi or other organisms. Captions are from the paper.

Asyou see, it consists of two aromatic central chains with four long carbon tails, each of which has a nitrogen atom in it:

b and c, COE structural modules are depicted by coloured boxes. The intercalation into phospholipid bilayers is driven by the hydrophobic centre and the terminal ionic functionalities, consisting of the conjugated aromatic core (gold module) and hydrocarbon pendants (blue module), which resemble the fatty acid centre of the bilayer. Additionally, the cationic end groups (red module) and terminal acyl chains (pink module) interact via coulombic and hydrophobic interactions with the membrane surface functionalities; specific example: COE2-2hexyl.

It works, as implied in the caption above, by attacking the cell membranes of bacteria, disrupting essential functions of the membrane. These include the ability of the bacterium to absorb and emit cell contents, to help the bacterium metabolize, and also, critically, to divide. Here’s how COE2-2hexyl looks when it gets into the bacterial membrane and disrupts it. Other similar compounds, called COEs, have the same shape and do the same thing:

COEs share a modular structure that spontaneously integrates into the bacterial membrane

This compound was tested on 17 bacterial isolates taken from people with drug-resistant infections:

You’ll recognize some of these as bacteria that cause gonorrhea, tuberculosis, pneumonia, dysentery (Shigella flexneri) Acinetobacter baumannii, which causes bad infections associated with hospitals, and so on. All of these were isolates taken from humans who had shown antibiotic resistance.  The drugs were tested in vitro, using mouse cell cultures that were infected with bacterial isolates from humans, and also in vivo, in mice that had been infected (there were of course controls that had been mock-treated). (I have to add that I feel sorry for the mice in the control group.)

As the authors note (my emphasis):

Expanded antibacterial activity analyses revealed that COE2-2hexyl exhibited broad antibacterial activity against all 17 clinical bacterial isolates tested (Table 1). Notably, methicillin-resistant S. aureus (MRSA, MT3302) and CRE K. pneumoniae (MT3325) were derived from sepsis patients with refractory bacteremia, whereby the CRE organism was resistant to 20/22 antibiotics determined by clinical VITEK testing (bioMerieux, Inc.) and 19/24 antibiotics determined by broth microdilution.

Note that it worked when nearly all antibiotics had failed. The authors also made two derivatives of this compound, adding one cabon atom to two of the four chains; these two compounds also showed antibacterial activity against 9 drug-resistant bacterial isolates tested.

Of course you’re wondering “well, this is great, but is it safe?”  It was, even in higher doses, and in the doses that killed bacteria. But of course it was safe in mice but may not be in humans. Clinical testing will be in order, and that might take a long time before we see if this and its derivatives are truly “wonder drugs”.

Finally, testing the compound for relatively long periods against bacteria showed that the bacteria did NOT develop immunity to the drug (that’s via natural selection, of course), which is really good news, since few antibiotics have not been overcome by mutations that render bacteria immune to them. (I believe that the Streptococcus bacterium that causes “strep throat” has never evolved resistance to penicillin, nor has the polio virus evolved immunity to polio vaccines, but such cases are rare.) Now, as Orgel’s Second Rule states, “evolution is cleverer than you are,” and eventually, if COE2-2hexyl is used for long enough, bacteria might find a way around it. But right now, things look promising.

Finally why are bacteria unable to evolve resistance to COE2-2hexyl? The clue is in this sentence in the paper:

COE2-2hexyl had specific effects on multiple membrane-associated functions that may act together to disrupt bacterial cell viability and the evolution of drug-resistance through a mechanism of action distinct from most membrane disrupting antimicrobials or detergents which destabilize.

The compound, it seems, disrupts many different functions of the bacterial membrane, and while one disruption might be fixed by one or more mutations in the bacteria, something that screws up your system big time, and in multiple ways, may be impossible to repair, as bacterial mutations that overcome one disruption may make it harder to fix the other disruptions. The more ways a drug can screw up a bug, the less likely it is that the bug can evolve resistance. But remember—bacteria are clever.

I’ll end with the authors’ final paragraph about what’s good about this compound and what needs to be done (mostly efficacy and safety testint in humans). But if this thing works out, it will be a medical advance of almost unparalleled value (bolding is mine):

The ease of molecular design and modular nature of COEs offer many advantages over conventional antimicrobials due to their intermediate molecular size, sufficient aqueous solubility to achieve efficacy, and the absence of complex chemical structures/chiral centers, making synthesis simple, scalable and affordable. The COE refinement workflow potentially accelerates lead-compound optimization by more rapid screening of novel compounds for the iterative directed-design process. It also reduces the time and cost of subsequent biophysical characterization, medicinal chemistry and bioassays, ultimately facilitating the discovery of novel compounds with improved pharmacological properties. Additionally, COEs provide an approach to gain new insights into microbial physiology, including membrane structure/function and mechanism of drug action/resistance, while also generating a suite of tools that enable the modulation of bacterial and mammalian membranes for scientific or manufacturing uses. Notably, further COE safety and efficacy studies will need to be conducted on a larger scale to ensure adequate understanding of the clinical benefits and risks to assure clinical efficacy and toxicity before COEs can be added to the therapeutic armamentarium. Despite these limitations, the modular design of COEs enables the construction of a spectrum of compounds with the potential as a new versatile therapy for the emergence and rapid global spread of pathogens that are resistant to all, or nearly all, existing antimicrobial medicines.

h/t: Jeannie

Should you get that bivalent booster shot?

October 4, 2022 • 12:00 pm

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

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

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

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

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

The biomedical importance of sex (and its binary nature)

September 15, 2022 • 12:00 pm

One might almost think, with widespread denial of a sex binary of men and women—a denial that in most animal groups is both fatuous and ideologically motivated—that there are no average biological differences between men and women. “Blank slaters” tend to outright deny the existence of behavioral or cognitive differences between men and women, often doing so on the erroneous grounds that “some women are in the range of men’s scores and vice versa”. In such cases the concept of averages seems to have slipped their minds.

But as the dogs bark, the caravan moves on. Increasingly recognizing the biological and medical differences between men and women—note the implicit recognition of dividing up the species into two sexes— funding institutes and journals dealing with illness and medicine (as well as  are increasingly recognizing the importance of studying men and women separately (or partitioning the data by sex) in biomedical work. That includes using model organisms such as mice, which may show related sex differences. This is the topic of the new feature in the journal Nature shown below. Click on the screenshot to read (it’s free).

 


First, some indicators that dividing up test subjects by sex can give useful and potentially lifesaving results:

Many of science’s gatekeepers — granting agencies and academic journals — feel the same way. Over the past decade or so, a growing list of funders and publishers, including the US National Institutes of Health (NIH) and the European Union, have been asking researchers to include two sexes in their work with cells and animal models.

Two major catalysts motivated these policies. One was a growing recognition that sex-based differences, often related to hormone profiles or genes on sex chromosomes, can influence responses to drugs and other treatments. The other was the realization that including two sexes can increase the rigour of scientific inquiry, enhance reproducibility and open up questions for scientific pursuit.

When studies do include two sexes, the results can be important for health. For example, sex is known to affect people’s responses to common drugs, including some antibiotics. . .

And here are some important biomedical differences already detected:

. . .Despite the bumpy ride, the federal guidelines that were put into place in the early 1990s have led to some important medical discoveries, perhaps a signal that key revelations could emerge from basic research in a few years.

For instance, there are sex-based differences in the heart’s electrical response to several classes of drug, including antidepressants and antibiotics. As a result, sex-based dose adjustments are now recommended for some drugs.

Steroid hormones such as oestrogens and androgens are thought to be primary actors in many of these differences between men and women. For example, women metabolize propranolol, a blood-pressure drug from a class known as beta blockers, more slowly than men do. Researchers think that sex-related steroid hormones acting on the liver can exert these effects. Other factors could include body size and composition, such as the fat:muscle ratio, which tends to be higher in women.

The cut-offs for risk might also differ between men and women. A 2021 analysis of cardiovascular risk related to systolic blood pressure shows what happens if data for two sexes are pooled rather than analysed appropriately. The authors found that when data were pooled, the range for increased risk was a systolic pressure of 120–129 millimetres of mercury (mmHg). But the sex-specific analyses showed that for women, the risk actually begins to climb when systolic blood pressure tops 110 mmHg. If other studies solidify these findings, the result would be a sea change in risk calculation for cardiovascular disease.

That study, as it happens, “was very much inspired and motivated by an NIH request for applications” about sex differences in health outcomes, says Susan Cheng, a cardiologist at Cedars-Sinai Medical Center in Los Angeles, California, and senior author on the report. Without that call for studies specifically designed to look for sex differences, she says, “we had a lot of ideas, but not a thematic focus”. Their findings that men and women differ in risk cut-offs “was actually a real ‘eureka moment’”, Cheng says. “I was like, ‘how did we not see this before?’.” She attributes the results to the NIH’s challenge. “They made it all happen.”

And good for the NIH!

Now surely you can’t attribute all these differences to “socialization,” as the disparity in hormones is based on genes that are differently activated in men and women. Of course, differences in biology due to any factor, like the Patriarchy, still need to be studied for their biomedical effects. But it’s foolish to attribute everything like the above, including the response of the heart to drugs, to environmental influences.

And, of course, if there are no differences between the sexes with respect to a biological trait or response, we need to know that too! This is true for any groups that a priori may differ biologically, but men and women are the most obvious and least ambiguous grouping.

The article highlights some problems with past research, including an apparent lack of knowledge by investigators about how to use statistics to judge the effects of sex, including the simple dictum of using half men and half women in a generalized test on “the population”.  Below is one chart from the paper partitioning 147 biomedical studies starting in 2019. As you see, more than third of them (55) didn’t even consider sex as a factor to study (and that’s dead easy), more than a third (60) didn’t look for interactions between sex and treatment (essential if you want to know if a treatment works differently in men than in women), and only 32, or about 22%, looked for interactions between treatment and sex (16 of these reported a significant interaction, and 10 a nonsignificant interaction).

Finally, even when sex differences were found, as in the red group that didn’t look for interactions, most studies that found a difference didn’t test that difference statistically. The blue group is the one that used statistical tests, but even in that moiety, 6 tests didn’t report the results and one non-significant result was erroneoously reported as a difference.  I thought biomedical researchers would be more savvy than this.

Now there’s a few gestures in the paper toward the “sex isn’t binary” trope by bringing in gender. For example:

The publishing community is pushing for similar clarity. In 2016, it published the Sex and Gender Equity in Research (SAGER) guidelines, which set out how to report sex-based differences in published research. Individual publishers, including Springer Nature (which publishes Nature), have their own policies encouraging researchers to report results by sex, defined as a cluster of biological traits, and sometimes also gender, which is socially defined.

Since “gender” is a social construct, and progressives say there are a gazillion of them, I don’t see how you can report results by gender unless you lump everyone besides men and women as “other”. (I won’t quibble with “sex defined as a cluster of biological traits”, which is technically incorrect but good enough for the purposes of biomedical research.)

And this is thrown in as well, seemingly out of nowhere:

Defining sex as a crude binary, predicated on the chromosomes present, or on specific anatomy, could be too limiting. Some species, such as the nematode worm Caenorhabditis elegans, have one sex that makes only sperm cells and one that makes both sperm and egg cells. And in a vast assortment of species, sex is determined environmentally rather than chromosomally. And still other species can change sex during their lifetime. Placing cells, tissues or even whole organisms into a pair of categories takes on layers of difficulty in these contexts.

Note the pejorative adjective “crude,” meant, I think, to disparage the binary.  Once again they send in the clownfish, nematodes, and turtles, but these don’t refute the idea of separate sexes. Nematodes can be either males or hermaphrodites, the latter being both male (making sperm) and female (making eggs), some clownfish can change from male to female if the alpha female dies—but there are still two sexes, and temperature-specific sex determination, as occurs in many turtles, still gives you males and females. In that case the two sexes are developmentally channeled via an external stimulus rather than via chromosomes and genes, but there are still men turtles and women turtles. (Why some species do this is still not well understood).

 

The fact remains that these species do not show more than two sexes, that they are in the minority of vertebrates and in an even smaller minority of birds and mammals, and, in the end, humans aren’t clownfish, turtles, or nematodes.

Besides emphasizing the valuable lesson that men and women are biologically different in ways that can be important for medical treatment, this article also shows us that where it really counts, where the rubber meets the road—that is, when lives are at stake—the palaver about the binary of sex being a fiction vanishes.

None of this, of course, is intended to ignore those who have disorders of sex determination or transsexuals who have had hormone therapy or surgery, for those patients may need separate study rather than lumping them into one sex or another. That will be hard to do given the paucity of such people, but everyone deserves the best treatment that science can offer.

Are advocates of “affirmative therapy” pulling back?

September 13, 2022 • 12:45 pm

The other day I got an email from a reader suggesting that perhaps extreme “affirmative-care” activists for transsexuals are backing off of some of their more extreme claims—most notably that some adolescents who demand to transition from one sex to the other might be influenced, perhaps to their detriment, by social pressure.  I have little doubt that this occurs, and that it has influence some young people, for it’s been amply documented. Abigail Shrier’s book Irreversible Damage gives some examples, but that’s not the only source. Some trans people as well as authors have recounted this kind of pressure.

What I don’t know is how many transitions or requested transitions would have occurred without social pressure (which is often intense and always “affirmative”), nor are there much data about transsexuals who bowed to social pressure and then had regrets. (As far as I know, the vast majority of adult transsexuals do not have regrets.

The online impetus to transition is, of course, only part of the “affirmation” of this species of therapy, which involves a rah-rah-go-ahead concatenation of treatment from parents, doctors, and psychiatrists.  These people don’t mean to do harm by giving puberty blockers to children or adolescents; they think they are not only doing good, but are also adhering to what many in the therapeutic community see as the “best practice” for children or adolescents with gender dysphoria. Those standards are promulgated by an organization mentioned below.

Many of these with gender dysphoria”suffer from mental problems, are confused, or might really be gay, which behooves everyone to ratchet back on the instant affirmation. I’ve reported before that European countries are beginning to pull back on affirmative therapy, employing puberty blockers only in clinical trials, and practicing a more objective and watchful therapy whose purpose is to analyze and support rather than to affirm.  The U.S., however, seems to be digging in its heels, holding onto practices that in some cases could be harmful.

Let me emphasize that I don’t object to “affirmation”, but only after rigorous psychological (and medical) investigation shows that transitioning sexes would be the helpful thing to do. What you can’t do is put kids on a treadmill that involves medical intervention merely on the word of the patient and his/her desires alone. The patient much surely be old enough and mature enough to give rational consent.

And while I think there should be age limits for taking hormones (probably 16 or 18, but surely after puberty), I don’t approve of puberty blockers, whose long-term safety (despite the claims below) is not known. On the other hand I also don’t approve of states banning “gender affirming care” unless they specify exactly what they’re banning vis-à-vis psychological therapy and medical practice. Like abortion, such a complex medical issue should not be put in the hands of the state.

But I digress. Here’s the email I got from the reader, who referred me to the NBC article shown below:

Did you know that in the Standards of Care Version 8 released in July this year, the World Professional Association for Transgender Health, or WPATH, they give credence to the possibility of the social contagion hypothesis. Plus, NBC actually covered it. Notice how CHILDREN and trans activists suddenly poo-poo WPATH (previously considered to be the eminent authority on trans health issues). Also, the significance of 4,000+% increase in FTM [female to male] transition is because the majority of transitions prior to around 2015 were MTF. I think it’s important to pay close attention to the Tavistock situation and I’m glad you are.

The Tavistock Gender and Identity Development Service (GIDS) in London practiced hardcore affirmative therapy, often on adolescents, for several decades, treating thousands of young people and helping them transition. But it was closed after a scathing report on poor practice written by an external reviewer, Dr. Hilary Cass. Tavistock is now closed and its activities, made less “affirmative”, are being farmed out to clinics in London and Manchester (see this NYT article for details).

But when you actually read the NBC piece, from June, there’s not much reason to be heartened. Yes, there’s some pulling back from outright rejection of the “social contagion” hypothesis, but otherwise it’s a mess of contradictory claims and anecdotal testimony from patients. Click to read:

But the pulling back doesn’t consist of much,, and even that is drawing criticisms from activists (emphases below are all mine):

The World Professional Association for Transgender Health, or WPATH, a nonprofit professional association devoted to transgender health, will release its Standards of Care Version 8 in July. The last time the standards were updated was in 2012.

The nearly 400-page guidelines, which the association’s president, Walter Bouman, described in an emailed statement as “the most comprehensive set” of guidance ever produced for health care providers who support transgender people, include many significant changes, according to a copy of the guidelines that WPATH shared with NBC News.

The change that is drawing the most criticism is a new chapter dedicated to adolescent care, which was previously part of the chapter on care for children. The chapter presents conflicting statements on support for adolescents: It gives credence to the claim that more young people might be coming out as trans due to “social influence.” It also notes that there’s limited longitudinal research on the effects of gender-affirming care for adolescents, but a growing body of recent studies show it’s beneficial enough that withholding care would be unethical. 

Well, the second sentence seems to be a grudging admission, while the last one I don’t know how to interpret.  What does the growing body of studies say? And surely there can be hardly any data on “gender affirming care” versus “other kinds of care that are more objective and less affirming”! I suspect the data show that gender affirming care is better than no care, which it probably is in terms of self-assessment of patients, but the real question is of the relative efficacy of different kinds of care, some of which may result in out homosexuality rather than gender transition, and for that comparison I would bet shekels to donuts that there are no data.

WPATH is even more grudging about social contagion (my emphasis), devaluing the idea using the words “anecdotal evidence” and “small percentage”.

WPATH’s new chapter on adolescence also states that there has been a “sharp increase in the number of adolescents requesting gender care,” and that anecdotal evidence from a small percentage of people who have changed their minds about being transgender shows that some young people might believe they are trans due to “social influence.” 

But the biggest hedge is to point out that “social contagion” is just one result of social influence:

Regarding criticism of the information in the adolescent chapter about social influence, WPATH said in a statement that, “When discussing social influence, it is important to discuss that it is only one aspect of social development for adolescents, which should also include a discussion of the positive aspects of social connectedness and a feeling of belonging.”

. . . Ducar added that painting transness as a “social contagion” propagates “this myth of ‘grooming’ that the right wing has really been spreading,” even though there’s no data to support it.

(Dallas Ducar is “a psychiatric nurse practitioner and co-founder and CEO of Transhealth Northampton, a trans-led organization that provides health care to trans and gender diverse patients in western Massachusetts.”) But social contagion is not the same thing as “grooming”, and taking the former seriously doesn’t mean you accept the latter. And I don’t know of gender dysphoric youth going online and having their peers tell them that transitioning is a bad idea. It’s nearly always “affirming”, for the advice is often given by those who have transitioned and are seeking post facto affirmation.

According to WPATH, a bunch of peers on the internet telling you to go ahead and have puberty blockers (and telling you where to get them), surgery, and hormone treatment gives you a sense of belonging, which is good. In the abstract, a sense of belonging is good, but probably not when you’re looking for people to tell you to change sex, and how to do it.

There’s more:

Advocates say that language is evidence that WPATH has been influenced by the culture war debate created by some Republicans over the last few years, and it ignores the lived realities of transgender youths themselves.

“We know trans childhood is not a trend,” said Dallas Ducar, a psychiatric nurse practitioner and co-founder and CEO of Transhealth Northampton, a trans-led organization that provides health care to trans and gender diverse patients in western Massachusetts. “We know that gender diversity is part of the human experience. It’s been documented since the Neolithic period and the Bronze Age.”

OF COURSE it’s a trend, whatever its cause. Below are referral rates to Tavistock in just ten years. If you can’t see a trend, you’re blind. As for the Neolithic and Bronze age, well, ten to one we have early historical examples of people of one biological sex saying that they feel like they’re of another, but from these early periods? I’d like to see the  specific claims.

Not only that, but WPATH seems to be making the standards for transitioning more relaxed:

WPATH will make a number of changes to its recommendations for adolescent care in the new chapter. The group will lower the minimum recommended age that providers can prescribe hormone therapy to 14, from 16, if an adolescent has parental consent and meets a list of other criteria, including undergoing a comprehensive evaluation regarding their gender identity.

The association will also lower the minimum recommended age for some surgeries such as chest masculinization and breast augmentation to 15 and 16, respectively, down from 18 in the previous guidelines.

What about PUBERTY? Is that a criterion? And what about puberty blockers? Hormone therapy at fourteen? Is a child capable of making decisions about her whole life at that age? (Parents, many whom have heard that they should be “affirming”, aren’t of much use here.) If WPATH have tightened the criteria for allowing transitioning, that is good, but lowering ages seems to me a precipitous thing to do.

In the end, the article seems to strive for balance by giving both a positive and negative views of “affirmative care”:

Here’s the negative, which isn’t really an attack on affirmative care, but a call for more evidence before it’s practiced:

Allowing adolescents to access treatments worries some advocates who say there isn’t enough research to ensure that the care is safe in the long term.

“The body of evidence to support (hormone replacement therapy) or surgery for anybody, really, but especially for people who are young, it’s extremely flimsy,” said Corinna Cohn, who had gender-affirming surgery when she was 19 and felt afterward that she was “never going to finish becoming myself.”

Cohn, now 47, testified in favor of an Ohio bill in May that would’ve barred gender-affirming medical care for minors and would have also prohibited medical professionals from referring a minor to a different doctor for such care. She said she supported the bill because it would have given people who received transition care as minors the ability to sue their doctors if they regretted the procedure as adults and believed they weren’t mentally sound enough to consent to treatment.

And the response by Ducar:

Ducar said the assertion that there isn’t enough research to support gender-affirming care for adolescents isn’t true.

She said puberty blockers and hormones have been prescribed to cisgender children and cisgender adults for decades, and the scientific research in those populations has shown that the treatments are safe.

“We need to be investing more research money into understanding long-term effects of hormones or blockers or surgery in specific trans populations” — something she said Transhealth Northampton is working on — but “the lack of a robust amount of studies in specific trans populations does not imply that it’s not a valid form of treatment.”

As far as I know, puberty blockers haven’t been used long enough to show that they’re “safe”, and while hormone treatment may be “safe”, it also has side effects like sterility. The side effects of “bottom surgery”, too, are often dire.

As for the last paragraph, let’s see it again:

“We need to be investing more research money into understanding long-term effects of hormones or blockers or surgery in specific trans populations” — something she said Transhealth Northampton is working on — but “the lack of a robust amount of studies in specific trans populations does not imply that it’s not a valid form of treatment.”

If we don’t understand the long-term effects of surgery, hormones, and puberty blockers, then how can they represent a “valid form of treatment”? To me, “valid” means “safe and has been shown to work”.  But maybe WPATH has a different understand of the term.

In the end, the article just shows me that WPATH only reluctantly admits that maybe a few kids have transitioned because of social pressure, but hey, social pressure can be a good thing! And they’re still making quasi-scientific statements that aren’t supported by data.

Until recently I thought that if wokeness was going to recede in America, the first place we’d see it would be in the transsexual controversy, with a greater insistence on proper experimentation and care. After all, wokeness in medicine has the potential to do far more actual harm than wokeness in, say, academia, so the price of getting it wrong is higher.  This is what the Europeans are realizing. But in the U.S., not so much. My bellwether of wokeness has lost its bell.

Uncle Joe doesn’t help:

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

September 2, 2022 • 9:30 am

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

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

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

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

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

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

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

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

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

 

A shorter explanation of RM is here.

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

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

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

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

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

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

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

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

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

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

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

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

This is a form of shamanism.

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

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

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

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

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

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

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

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

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

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

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

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

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

Two quotes from the article:

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

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

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

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

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

 

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

Recent pushback on “affirmative care” and hormone blockers

July 31, 2022 • 9:15 am

I’m guessing that some day historians will look back at the mishigass surrounding “affirmative care” and wonder what the deuce was going on in America in the 2020s.

Now let me say at the outset that I have no objection to people with “gender dysphoria” changing their gender using drugs and surgery. But I also think that transitioning should not be allowed until after puberty, and for two reasons. First, we don’t know eough about the safety of “puberty blockers” used to stop the process while adolescents figure out their sexual identity, and second, because children who are too young to make mature judgments should not be allowed to make irreversible decisions about their bodies. Eighteen seems to me to be an appropriate age to begin a medical process of transitioning.

My objection to “affirmative care” is not that we shouldn’t treat young people repectfully when they have with a sincere desire to transition, or fail to support them. But in the U.S., and previously in the UK, the default option was “affirmative care”, with no real psychological probing to dissect the roots of gender dysphoria and see if it was a form of distress that might resolve into a child becoming gay. “Affirmative care”, in its most extreme form, pronounces children who question their sexuality as transsexuals, deems them ready to change sex, and encourages them to go on puberty blockers and then hormone therapy. (There are few adolescents who, once on blockers, decide to stop them and “de-transition.”)

I’m cautious because the huge rise in the number of adolescents who declare themselves transsexual (particularly biological women who want to change gender) could have a number of causes: a relaxation of the stigma against transsexuality, an increase in the genetic propensity to change gender (that’s impossible given the rate of the rise), or—as Abigail Shrier argues in her book Irreversible Damage, a sort of social contagion—a sense among young people that it’s far more cool to be trans than to be gay, and because such people get a lot of props and attention. (Shrier doesn’t claim that transition is always prompted by social contagion.)

Only the first and second hypotheses are supportable, and I think both are at play, but to deny that social contagion hypothesis plays any role in the temporal changes shown below is to deny reality. There are simply too many cases of seeing “detransitioners” (“desisters”) discuss the social pressure they were under, and of others seeing it at play in real life.

Below is an article by writer Lisa Davis you should read (click the screenshot). It’s on Bari Weiss’s site (and I don’t want to hear that Weiss is “alt-right” so that you can ignore it), and explains how several European countries, including the UK, Sweden, France, and Finland, are changing course on affirmative care, replacing it not with a refusal to let people transition, but with a more compassionate and psychologically-oriented inquiry into the roots of gender dysphoria.

The change in Europe comes from a realization of the weakness of the evidence supporting two assertions of trans activists: that puberty blockers are completely harmless and can be completely reversed if someone changes their mind, and that allowing medical transitioning reduces the rate of mental illness and suicide among those with gender dysphoria. We now know that the evidence for the first claim is wrong, and for the second is plagued by methodological weaknesses. We simply need a lot more data, and the Europeans are being cautious while Americans ignore the counterevidence. That’s unwise given the drastic and irreversible nature of many transitions.

Here’s a graph from the article above showing the increase in referrals to the gender-affirming Tavistock clinic, and this is just between 2009 and 2017 (original source here). Both the proportion of and the increase in biological females (compared to males) referred to the clinic for affirmation have increased substantially. If your hypothesis is that the rise reflects purely the de-stigmatizing of transsexuality, this discrepancy between the sexes must be explained. Of course, it also has to be explained if you hold a “social contagion” hypothesis.


 

I completely agree with Andrew Sullivan in his Friday column section called “Yes, the trans madness is real” when he says this:

I recall a few years ago having a heated conversation with some well-meaning trans activists who appeared completely aghast when I voiced some worries about the treatment of kids with gender dysphoria. What if the kid is gay, I asked? How do we know for sure if a pre-pubescent child really is trans and not just experimenting with gender the way many gay kids do? And are these nine-year-old children really mature enough to make life-long decisions that could make them permanently sterile, keep them on drugs for the rest of their lives, or permanently remove their capacity to have an orgasm? How could pre-pubescent kids even know what an orgasm was?

My activist friends were shocked. It seemed to me as if they had never previously been asked these questions. They were all very-well intentioned, and not entirely wrong — in a few extreme cases, there might be a reason to permanently change a child’s sex. But they assured me that no such errors were ever made, that the process was entirely ethical, and that all medical authorities backed it. They insisted that puberty blockers were harmless and fully reversible. The bubble is real.

I think it’s better to give kids with gender dysphoria extensive psychological counseling—NOT affirmative from the outset, i.e., not “affirming” that children who say they’re of another gender must be right—before giving them irreversible medical treatment, treatment that we now know can render people sterile, unable to enjoy sex, and, in the case of puberty blockers, cause other medical damage. Sullivan, who experienced dysphoria himself, says that many adolescents go through a period of confused sexuality, and perhaps would become gay were it not more fashionable to change gender.

Both articles detail some big changes in Europe about how to treat gender dysphoria. I’ll summarize what most of us know already (the first article above gives links):

  • Sweden has revised its guidelines for treating gender dysphoria in adolescents, arguing that gender-affirming treatment may be more harmful than good, and claiming that affirmative treatment “should be offered only in exceptional cases.”
  • Finland, using an evidence-based approach showing that many young people seeking transitioning had severe psychiatric problems, that there were risks to using puberty blockers (see below), both physically in in terms of sexuality, changed its protocol for treating gender dysphoria:

(From Davis’s piece): In Finland, for patients who fit the profile of participants in the Dutch study, after a prolonged period of evaluation, and with a multidisciplinary team including a psychiatrist, psychologist, social worker and nurse, puberty blockers may be started near the onset of puberty, and cross-sex hormones may be possible starting at age 16. Assessments take place at two gender identity clinics; gender surgeries are offered only at one center. Both Finland and Sweden now stress gathering data and extensive follow-up.

My own view is that giving puberty blockers “near the onset of puberty”, or at age 16, is too young.

  • The National Academy of Medicine in France has urged caution in proceeding with drugs and surgery in cases of gender dysphoria since some of it may be due to social contagion. It recommends more extensive psychological counseling of those with gender dysphoria.
  • The Tavistock clinic in London (a notorious place for affirmative therapy) is to be closed, replaced by a number of regional clinics practicing a different brand of care. This is the result of a critical review headed by Dr. Hillary Cass, commissioned to review Tavistock and its practices. Their recommendations, which the government accepted, was to de-centralize the clinics, adopt more “holistic care”, and ratchet back on the use of puberty blockers, which now appear to have possibly severe medical consequences.
  • The medical consequences of puberty-blocking drugs like Lupron, which according to Sullivan have been known for a while, include brain swelling and loss of vision, possible bone damage, and other irreversible effects. In fact, these blockers are used for other conditions, and I understand are always prescribed by doctors treating gender dysphoria “off label”, i.e., they’re not specifically recommended by the FDA for stalling puberty while a child ponders its gender.

This month the FDA added brain swelling to the warning labels of puberty blockers. The sample size is small, and these problems appear only in biological females (the most common sex experiencing gender dysphoria), but an FDA warning is nothing to take lightly. Here’s a tweet about the dichotomy between the American use of blockers willy-nilly in American “affirmative care”, and the warnings on drug labels. Clearly, more research needs to be done (that’s what Sweden and Finland concluded) before blockers are used so readily. But, in contrast to the caution about other new remedies, like Covid-19 vaccines, the standards for usage are very lax in the U.S., and were in the UK as well:

Nevertheless, as both Sullivan and Davis point out, the U.S., urged on by the Biden Administration, is going full steam ahead with affirmative care.

Sullivan:

In the US, however, as many states move in the European direction, the left is pushing harder. California has a bill offering sanctuary for any child seeking a sex change. The Biden administration still insists that “every major medical association agrees: gender-affirming care is life-saving, medically necessary, age-appropriate and a critical tool for health care providers.” The absolute certainty, compared with the second thoughts in Europe, is striking.

Davis, referring to Finland and Sweden’s revised guidelines in comparison to America’s (my emphasis):

Both guidelines starkly contrast with those proffered by the Illinois-based World Professional Association of Transgender Health, an advocacy group made up of activists, academics, lawyers, and healthcare providers, which has set the standard when it comes to transgender care in the United States. WPATH will soon issue new standards that lower recommended ages for blockers, hormones and surgeries. (WPATH did not respond to a request for comment.)

WPATH’s position is in keeping with an array of U.S. medical associations and activist groups across the country that insist gender-affirming care is “life-saving.” Assistant Secretary of Health Rachel Levine, who is herself a transgender woman, recently asserted that there is a medical consensus as to its benefits. Some activists and gender clinicians in the U.S. feel that WPATH doesn’t go far enough, asserting that any child who wants puberty blockers should get them, for instance, or claiming that a teenager who later regrets having her breasts removed can just get new ones.

In Sweden and Finland, this issue has been primarily a question of health and medicine. Here in the U.S. it is a political football.

Why the ignoring of evidence and lack of caution in the U.S. as opposed to Europe? Why are we not following the examples of countries that take an evidence-based approach to medical policy about gender dysphoria? Surely one of the reasons is “wokeness”: the idea that changing gender is to be admired as an act of courage, and that transgender people, or those who wish to become so, should be valorized as members of stigmatized minorities. And, sadly, the Biden administration has bought into the pronouncements of the extreme Left, which include unquestioning approbation for “affirmative care.”

Yes, there’s some stigma about transgender people, and yes, we should help those who, after intensive medical and psychological examination, are deemed to be serious about their gender misindentification rather than confused about their sexuality. And yes, we should treat transgender people in nearly all respects as equals to members of the biological sex they assume.  But what we should not do is, in the interests of seeming virtuous, rush children and adolescents into very serious and irreversible medical procedures without proper vetting.