If you prefer to listen rather than read, this blog is available as a podcast here. Or if you want to listen to just this post:
For those who read my last post, you know what’s coming, a review of Irreversible Damage: The Transgender Craze Seducing Our Daughters by Abigail Shrier. I debated whether I should follow my standard review format, and after much back and forth, I decided to not only follow it, but add a section, so let’s start there:
Briefly, what is this book about?
Shrier is arguing that there has been a huge increase in the number of female teens identifying as transgender, and that this increase is not a result of long standing gender dysphoria, but rather the typical confusion and discomfort associated with puberty combined with a culture that celebrates transgender individuals. That in essence going through puberty is tough and being trans allows them to put that out of their mind while also being cool. Or in words of one of the teenagers she interviewed:
I don’t know exactly that I want to be a guy. I just know I don’t want to be a girl.
Who should read this book?
At the top of my list would be those people who instinctively recoil from Shrier’s argument, And who feel that all, or at least the vast majority of female teens who come out as trans are doing so for good and healthy reasons. BUT who are intellectually rigorous enough to want to be able to steelman the arguments of those on the other side. In saying this, I’m not saying that this book represents a perfectly crafted treatise, free from shortcomings, the book has many. But at the moment it’s the only book length treatment of the argument I’m aware of, and if you want to craft an understanding of the strongest argument being made, this is a critical piece of that. Also I think whatever imperfections it does have are magnified by how contentious the issue is. In my opinion, its mix of data and anecdotes is well ahead of the average Malcom Gladwell book, but he’s saying things people mostly want to hear. The same can not be said for this book, which because of how contentious it is, get’s held to a much higher standard, with any flaws serving as an excuse for dismissing the entire book. I would urge you not to do that, but to approach the materially charitably. Someone, rather than spewing out 280 character “hot takes” on Twitter, has gone to the trouble of putting together 264 pages of material in support of their point. Isn’t that what we all say we want these days?
Beyond that, I would actually say that everyone should read this book. And yes the people I talked about in the last paragraph are included in the set of everyone, but I don’t know that just saying “everyone” would have been an effective persuasion technique for the aforementioned group. But for those who aren’t in that previous group, who may be wondering, “Why should I read it?” My argument would be that anytime a consensus starts hardening around a simple narrative, that it’s the duty of everyone in a healthy society to make sure that this narrative isn’t too simple, that important complexities and second order effects are not being overlooked and above all that the consensus itself is not mistaken. Because as I have pointed out it’s always worse when everyone makes a mistake than when only a few people make a mistake. And this seems like a situation where the consensus is wrong, and a large mistake is being abetted by this incorrect understanding. And the more people we have thinking about the problem the more likely we are to catch and arrest the mistake, if one is in fact being made.
That, of course, is the key question, who in all of this is making a mistake? Is Shrier making a mistake? Or are doctors, transgender influencers, psychiatrists, the teenage girls claiming to be trans, and the culture at large making a mistake? Stated that way, Occam’s Razor would suggest that Shrier is making the mistake. But clearly, the fact that I’m devoting a whole post to the issue, would suggest that I don’t think that’s the case. Why is that? What makes me think that all of those groups might be making a mistake? What is it that suggests to me that Shrier might be right and all of those other people might be wrong?
Let’s start with Shrier. First, it’s important to note that her focus is very narrow. I think that many people, myself included, thought that the book would be a general indictment of all people identifying as transgender, but instead Shrier goes out of her way to make it clear that there are people who genuinely suffer from gender dysphoria, and for those people it’s possible that surgical transition might be the right choice. Her focus is not on those people, but rather the book seeks only to examine teenage and college age girls who identify as transgender, and whether they may be under the influence of a peer contagion effect, i.e. the obvious fact that teenage behavior can be influenced by the attitude of their peers. And Shrier’s not even arguing that all girls who “come out” as transgender are suffering from this peer contagion effect, only that many of them probably are, and that if we can identify that segment, we can end up with a better outcomes overall both for those girls and for society as a whole.
(Side note: In this post when I’m speaking of teenagers or teenage girls, I’m also including people in their early 20’s, but it seems cumbersome to have to write out “teenage and college age individuals” every time. Also while the phenomena Shrier is describing continues into the early 20’s it start’s much younger, and if policies, procedures and attitudes need to change that would probably be the place for it to happen.)
Beyond the narrowness of her focus, the other thing Shrier brings to the table is her own set of groups. The labels for the groups on her side of the issue are a little more convoluted, and they lack expert credentialing, but it’s an important list nonetheless. It includes the parents of transgender teens, detransitioners, and even some well known trasgender activists. And yes, also in that mix are some doctors, psychiatrists and a significant, though at this point, not dominant part of the culture.
Beyond all of this, having read the book, I think she has science and data on her side. For some people the idea that doctors and psychiatrists are driven by fads is obvious, to say nothing of how fad-driven the culture at large is. For others the burden is on those questioning the “experts”. I’m unlikely to sway the people in this latter category in the course of a single blog post, let alone in the course of a few paragraphs, but perhaps an example might help.
In one of my previous posts (a few years back at this point) I talked about the opioid epidemic. I had just read the book Dreamland by Sam Quinones (still highly recommended by the way), and the misuse of science in service of prescribing opioids documented by that book was insane. From that previous post:
[T]he misuse of science, hinged on placing far too much weight on a one paragraph letter published in the New England Journal of Medicine in 1980 which claimed that opiates only ended up causing addiction in 1% of people. Getting past the fact that the author never intended it to be used in the way it was, to base decades of pain management on one paragraph is staggeringly irresponsible. Even more irresponsible, when the pharmaceutical companies got around to trying to confirm the result they found that it didn’t hold up (to no one’s surprise) and they ended up burying and twisting the results they did get. The number of people that died of accidental overdoses directly or indirectly from this misuse of science is easily six figures, possibly seven, particularly since people are still dying. Of course in addition to the misuse of science there was the over reliance on science. I assume that on some level the pharmaceutical companies knew that they were not being scientific, but countless doctors, who were either naive or blinded by the gifts provided by the pharmaceutical company chose to at least pretend that they were doing what they were doing because science backed them up.
From this there would seem to be no question that doctors can screw up in a fashion which is both enormous and coordinated. As far as psychiatrists and therapists, it would appear safe to lump them into this same category of “medical professionals”, particularly given that the litany of their mistakes is just as long if not longer than the doctor’s. From our original list of people opposed to Shrier’s interpretation we still have to address the teenage girls claiming to be trans, transgender influencers, and the culture at large. We’ll come back to those claiming to be trans in a moment. Transgender influencers are probably the least objective actors in all of this, and anyone looking for evidence from that quarter is going to have a very hard separating the facts from the bias. Which leaves only the culture at large, and while their record of failure might be more forgivable than that of the doctors (who are expected to know better) it’s probably more extensive. Also isn’t this what we’re here to discuss? Whether current culture might be wrong on this topic?
It’s entirely possible that you’re still skeptical that all those people could be wrong, if so, let’s try approaching it from a different direction. The one thing we do have a pretty good handle on is the enormous increase of people identifying as trans and seeking treatment. Some statistics from the book to chew on:
- Previous to the last five years the accepted statistic for the prevalence of gender dysphoria was 0.01 percent.
- The prevalence of those identifying as transgender has increased by over 1,000 percent.
- In Britain the increase is 4,000 percent.
- 2% of highschool students now identify as trans.
- Between 2016 and 2017 gender surgeries for natal females quadrupled.
- As of 2018 there had been a 4,400% rise over the previous decade in teenage girls seeking gender treatment.
- “Before 2012, in fact, there was no scientific literature on girls ages eleven to twenty-one ever having developed gender dysphoria at all.”
Taken together, even if you don’t agree with every point, or the conclusions Shrier draws from this data, the fact that there has been a significant increase in the number of people identifying as transgender and that this increase has been particularly notable among teenage and college age girls is hard to deny. (Nor do I think that many people do.) Something has changed dramatically over the last few years, and it’s worth identifying what that something is. I myself took a stab at this a couple of years ago in a two part post (1, 2) and at the time I came up with seven possible explanations, if you’re curious what they were I would direct you to those earlier posts. (Shrier’s explanation is a combination of my 5th and 7th explanations.) My point this time around is more narrow: If you don’t accept Shrier’s explanation for the increase what explanation are you willing to offer in its stead? And does this explanation fit the available data better?
Here we return to considering the evidence provided by all of the girls who identify as transgender. One of the chief arguments against the idea that it’s some sort of crazy fad is that no one would go to all the trouble of binding their breasts, or taking hormones, to say nothing of actual surgery, if they weren’t serious. On its face, this argument seems reasonable, but on the other hand it’s important to remember that these are teenagers we’re talking about. A group not known for being exceptionally far-sighted or clear-thinking. A group who has no problem modifying their bodies with tattoos or piercings, which from a long term perspective seems very similar to binding, and at first glance binding probably appears less permanent.
As far as hormones, there seems to be every reason to suspect that teens view them similarly to other drugs they might consider ingesting, with if anything a bias to view them as less harmful than average because they are perceived to be both natural and corrective. Given that teenagers frequently make irresponsible decisions about drugs which are perceived as being neither of those things, anyone who argues that we can count on them to make responsible, well-informed decisions about trans specific drugs like puberty-blockers and hormones has got to be joking.
When we finally extend this into the category of actual surgery, one would hope that there would be lots of safeguards in place before doing something so potentially life altering, but there are certainly many examples of people who had surgery and later regretted it, including the case of Keira Bell which was recently adjudicated in Britain. We’ll discuss Bell more later, but if we accept the “between 2016 and 2017 gender surgeries for natal females quadrupled” statistic mentioned above, unless we can come up with a better explanation for the increase than the one offered by Shrier it seems like we’re forced to assume that upwards of 75% of surgeries were conducted as part of this trend rather than being conducted on people with actual dysphoria. And that assumes that the 2016 numbers represent a floor, if the trend was already in motion at this point then it may be more than 75%. Finally is there anyone out there that thinks the number of surgeries has gone down since 2017? I wouldn’t bet on it.
You might be willing to grant my general point that teens are dumb, but still not be convinced that they would be dumb in precisely this way, which is certainly a reasonable objection. Out of all the ways for them to misbehave how does it come to pass that they choose this one? At first glance it seems uniquely harmful and misguided, but as it turns out, for reasons still very much in debate, teenage girls seem particularly susceptible to engaging in harmful trends. In modern times we’ve seen significant problems with anorexia nervosa, bulimia, and cutting. Go just a little ways back in time and there was a huge fuss around repressed memories, particularly in conjunction with satanic ritual abuse and as far back as the late 1800’s we see this same group suffering from an epidemic of neurasthenia (essentially fainting and weakness). While we don’t have the space for a deep examination of the similarities between all of these conditions and Shrier’s hypothesis, it does seem clear that it’s not unheard of for a large number of teenage girls to engage in irrational and damaging behavior, that there is a precedent.
As I mentioned the debate is still raging on many of these issues, but we do have some pretty good theories for how a trend like this manages to spread. First, the term we’ve already encountered, the idea of peer contagion. If the massive increase was due just culture becoming more tolerant, if peers had nothing to do with it, we would expect the distribution of transgender teens to be fairly random and uniform. Instead we find, according to the book, that the prevalence of transgender identification within groups of friends is more than 70x the rate you would expect.
Also, while the idea that teenage behavior can be influenced by the attitude of their peers is almost the definition of teenage behavior, the modern world has introduced at least a few other things which contribute to and exacerbate the problem. The first, and most obvious is social media. Shrier provides the statistic that 65% of adolescent girls who decide they’re trans do so after a period of prolonged social media immersion. I understand that this is definitely a statistic which is subject to interpretation, for example what qualifies as “prolonged” and “immersion”? But it’s easy to see many different ways in which social media might contribute, first it makes the contagion part of the peer contagion effect worse. Social media does a great job of connecting people who feel different and marginalized. Everyone can easily imagine how this might be a force for good, but it’s clearly also something which can cause a lot of harm, by seeming to pathologize and amplify uncertainty that might otherwise be just a phase. Stepping into this highly connected environment are transgender influencers, who Shrier spends a lot of time discussing. These individuals have all the incentives in the world to make transitioning seem like a wonderful experience that solved all of their problems.
Finally social media allows people to compare themselves with the whole world, amplifying the peer part of the peer contagion phenomena. Currently, if a teenage girl is wondering if she’s “girly” enough, she can compare herself to the top 0.01% of all the girls in the world through the medium of things like Instagram. A situation where it is vastly easier to make comparisons and decide that you don’t measure up.
Related to this, but at the extremes, there is also the ubiquity of pornography to contend with. Shrier theorizes, and I think it’s a theory deserving consideration, that most pornography has the effect of making sexual activity as a hetrosexual female seem pretty unappealing. Not only is there an enormous amount of porn focused on various forms of humiliation, I also imagine there’s a perception that intimate moments are very likely to be recorded, leading to the very real fear that they will be added to the ranks of women being humiliated. Also a greater and greater majority of teenagers have no experience with sex outside of pornography. This quote from the book is too good not to include:
Many of the adolescent girls who adopt a transgender identity have never had a single sexual or romantic experience. They have never been kissed by a boy or a girl. What they lack in life experience, they make up for with a sex-studded vocabulary and avant-garde gender theory.
Finally, the general point I keep returning to over and over in this space, 100 years ago this issue, to the extent that it existed, was entirely different. Most of the things which are now central to people’s perception of what it means to transition hadn’t even been developed. There was no testosterone, no puberty blockers, and definitely no surgeries. If a significant and growing number of people now feel that they need these things which 100 years ago didn’t even exist, it would seem to say a lot more about the current age than some deep biological truth.
If at this point you are at least willing to entertain the idea that Shrier might be right, that some teenage girls are going to decide that they’re transgender for reasons other than actual gender dysphoria, and consequently any transition is going to end up being a mistake, and that the less these girls transition the better. If you’re willing to consider all of this what do you do now?
Certainly one of your first impulses would be to attempt to identify those individuals who won’t benefit from transition, who are using transition to avoid their problems rather than solve them. In these cases you wouldn’t “affirm” their new gender, or call them by different pronouns. You would take steps to keep them from binding, and definitely do everything in your power to prevent them from taking any drugs which might cause, as the title of the book suggests, irreversible damage.
If you could be sure that you had accurately identified them then such steps would hopefully be uncontroversial. (I’m not sure that this would be the case, but one could hope). No most of the controversy comes over that first step. Even if we are convinced that there are people in this group, how do we identify them? From what was discussed above, and in other places in the book it sounds like there are a few attributes that set this segment apart:
- The transgender identification seems to come out of nowhere.
- It follows a period of intense social media consumption.
- It is closely associated with not fitting in, discomfort with the changes brought on by puberty, or outright depression.
- Friends or other peers of the teen have also recently announced that they’re transgender.
Those markers all seem pretty suspicious by themselves, but if all of them manifested together, it’s hard to imagine that we wouldn’t want to exercise caution. The problem is how do we accurately gauge which of these things might be true in any given case? Particularly if we’ve already decided that the teens themselves are confused and motivated to conceal things? For me the best resource would be the parents, and as a parent myself I am entirely aware of all the things I don’t know about my kids, but most of the things mentioned above should be reasonably obvious to any parent actually paying attention, particularly the first one. And herein lies one of the biggest problems with how things currently work. Even if teachers, therapists and doctors were inclined to push back, which they’re apparently not, parents still appear to be the last to get consulted on how to handle their child’s issues.
Irreversible Damage is as much a book about the parents of these teens as it is the teens themselves, and given that many (though not all) of these teens were unwilling to talk to Shrier she spends a lot of space on interviews with the parents. And while this does leave her open to charges of bias, there does seem to be a pretty consistent pattern:
Teen decides they’re transgender. They start going by a new name and new pronouns at school. This is not communicated to the parents. Parents eventually find out. None of the parents Shrier included (perhaps for obvious reasons) are hardcore conservatives who kick their kid out of the house, they’re generally the kind of people who vote Democrat and volunteer for Planned Parenthood. The parents are unsure how to react, but decide that they should call in outside help in the form a therapist or psychologist. They expect that this person will “get to the bottom of it” but instead they immediately start affirming the new gender identity and discussing drugs like puberty blockers or testosterone. Again without really involving the parent. Beyond all of this, Shrier points out that much of transgender advocacy has an anti-bullying element to it, following from this parents are oftentimes identified as the biggest bully of all. Which is to say, you’re taking the best resource for identifying that segment that might not benefit from transition and, at best sidelining them, and at worse demonizing them.
Now, as I mentioned this description of things probably has some baises: from the sources, the author and my own attempts to abbreviate it for impact and space, but Shrier did base much of this on responses to a survey of 256 parents of transgender teens, conducted by Dr. Lisa Littman, of Brown University. Here are some of the results:
- Over 80% female
- Mean age 16.4
- Most lived at home
- Vast majority had ZERO of the DSM-5 indicators of childhood gender dysphoria (six is necessary to qualify)
- 1/3 had no indications of gender dysphoria even immediately beforehand
- Majority had a diagnosed psychiatric condition, almost half were engaged in self-harm
- 41% had expressed a non-hetrosexual sexual orientation before identifying as trans
- 47.4% had been formally assessed as gifted
- 70% belonged to a peer group where at least one friend was trans, in some the majority of friends were trans
- 60% said it brought a popularity boost
- 90% of parents were white
- 70% of parents had bachelor’s or higher
- 85% of parents supported same sex marriage
- 64% of parents were labeled transphobic for asking the child to take more time to figure it out, etc.
- Less than 13% believed that their child’s mental health had improved 47% said that it had worsened.
Littman conducted this survey as part of an attempt to quantify what she’s taken to labeling Rapid-onset Gender Dysphoria (ROGD, and I’m realizing I should have introduced that term much earlier in the post, but it’s too late now). Littman is one of the many researchers interviewed by Shrier, and her story might be a whole post on it’s own, but whatever else you may say the book is not composed of data-free rants from the fringe, people have done some actual legwork here. Nor does the main recommendation of greater parental involvement in decisions of this magnitude seem like too much to ask.
Still even were this to happen it’s clear that debate would continue to rage over how best to tackle the problem. And many people would continue to insist that even if a person has only started identifying as transgender because of peer contagion, that there isn’t any harm in expecting people to switch to a new name and a new set of pronouns. This argument might have some merit, but many people go on to make this same argument about puberty blockers. Similarly arguing that there’s very little downside; that it’s just a way of hitting a pause button while the teenager in question makes up their mind. But here we get to another one of the book’s significant assertions: puberty blockers are not a way of buying time in order to make a decision, they are a decision. Shrier asserts that nearly 100% of teens who are put on puberty blockers go on to transition further. Now compare this to the old methodology which did not affirm the new gender or use any drugs. The methodology used on people who suffered dysphoria from a very young age, those cases which don’t appear to be ROGD, i.e. which didn’t come as a surprise to the child’s parents. Under this methodology 70% of people grew out of their dysphoria, which was not only longer lasting, but arguably more deeply entrenched!
While reading this book I discussed it’s conclusions with several of my friends. Most were open to the idea that Shrier (and Littman and the rest) might have identified a real problem, but they questioned its impact, in particular they felt that the number of teens who engaged in transitional steps beyond just a change of names and pronouns, and perhaps binding was relatively small. And to be clear I too very much wish there was more data on how common these things actually are, but let’s go through each step of transition and see what can be said about it.
Change in pronouns: The friends who I talked to were willing to accept the argument that puberty blockers are probably bad, but see changing names and pronouns as just common politeness, with no chance of doing any lasting harm. Similar to giving the kid a nickname. Well according to Shrier even just doing a “social transition” can be remarkably sticky. I, for one, think this makes sense, what kid is going to want to publicly back down and admit that they were wrong? Even if it wasn’t a matter of great cultural controversy, which teen voluntarily chooses to look foolish about even small things? And this is a great big thing! Plus it’s a well documented psychological phenomenon that once you make a decision various biases kick in to confirm and strengthen it. Accordingly, I think even this step requires serious consideration. Certainly it shouldn’t be taken on a whim.
Binding: This is another place where I really wish there was better data. I got the impression from the book that most teenage girls who decide to identify as transgender go on to bind their breasts. Perhaps this impression is based on the further impression that teens view it as being relatively harmless. But impressions all the way down is not the way to construct a compelling argument. In any case regardless of its prevalence, it’s not harmless, and can cause: “Fractured or bruised ribs, punctured or collapsed lungs, shortness of breath, back pain, and deformation of breast tissue.” Though again I don’t have any data on how often these complications occur.
Puberty Blockers: I’ve already mentioned Shrier’s worry with respect to puberty blockers, that they’re not working in the way people expect. Here side effects (other than the gigantic one of stopping normal development) are not very well documented, but appear to include loss of bone density, and interference with brain development which may affect intelligence. But here, at least, I did manage to find somewhat better data on how many of the teens in question end up taking them. An article in The Economist claims that half of all children referred to a gender-identity clinic ended up starting puberty blockers, and that such referrals have increased 30-fold over the last decade.
Testosterone: Again good data on how many trans people are taking testosterone is hard to come by, but it’s yet another drug where there are clearly some pretty serious side effects. “Heightened rates of diabetes, stroke, blood clots, cancer, and… heart disease.” Because of the side effects to reproduction many women end up having “prophylactic hysterectomies”. And lest people think they can try it for awhile, and then change their mind, even a couple of months can produce permanent changes to facial hair, voice and genitals.
Surgery: It seems both obvious that this is the rarest step taken by those who are transitioning, particularly phalloplasty or “bottom surgery”, but also that this is where the potential for causing “irreversible damage” is the greatest. Particularly since, as demand has increased it has outstripped the supply of skilled surgeons, leading to even worse outcomes. And certainly there are stories of people who have gone this far, and decided that it was all a horrible mistake. For example Keira Bell, who we’ll get to in a minute.
Doing nothing: I left this for last because after everything that was just mentioned including the 70% of people who grow out of dysphoria under this course of action. It may seem inconceivable that this isn’t the recommended course of action for all teenagers claiming to suffer from gender dysphoria. But there’s one big reason why it’s not. Everyone, but particularly the parents, are terrified that their teenager will commit suicide if they don’t allow them to start transitioning or take puberty blockers. Here Shrier makes perhaps the most important claim of all:
There are no good long-term studies indicating that either gender dysphoria or suicidality diminishes after medical transition.
Lest you think that this claim is unforgivably tainted by Shrier’s biases, in the review of the book which appeared in The Economist, they said the same thing: the research does not back up the claim that failing to affirm increases the risk of suicide. I understand The Economist is not completely free from biases either, but it’s as close as you’re likely to get in this day and age.
In fact, for those who don’t feel like reading the entirety of Irreversible Damage the two Economist articles I already mentioned represent a pretty good summary. In particular their article on the Keira Bell case has some startling quotes, and since it’s already far too late to keep this post from being gigantic and further as a way of reducing the potential bias of relying on a single book, I figured I might as well include some of them:
In 2018 Andrea Davidson’s 12-year-old daughter, Meghan, announced she was “definitely a boy”. Ms Davidson says her child was never a tomboy but the family doctor congratulated her and asked what pronouns she had chosen, before writing a referral to the British Columbia Children’s Hospital (BCCH). “We thought we were going to see a psychologist, but it was a nurse and a social worker,” says Ms Davidson (both her and her daughter’s names have been changed). “Within ten minutes they had offered our child Lupron”—a puberty-blocking drug.
…other transitioners come to see such procedures as a mistake. Claire (not her real name), now a 19-year-old student in Florida, started on testosterone aged 14 because of a loathing for her body. (She was also deeply depressed.) “I felt it was the only option, especially with the insistence that having dysphoria meant you are irrevocably trans and thus you will probably kill yourself if you don’t transition.” Obtaining hormones was easy, she says. “They pretty much gold-stamped me through.” Then, aged 17, her dysphoria disappeared. “I felt extremely lost. I had never heard of this happening.” She came off testosterone, embraced her identity as a lesbian, and is furious. “It is the medical industry and the general social attitude towards dysphoric people that failed me.”
The court concluded that blockers almost always lead on to hormones…
In America intervention was boosted by the Affordable Care Act of 2010, which banned health insurers from discriminating on the basis of sexual orientation and gender identity. In effect, they were thus obliged to cover hormones for people who say they are trans just as they provide contraceptive hormones for women.
In 2018 the American Association of Pediatrics (AAP) said that all medical evidence supports the “affirmative” approach. But according to a detailed rebuttal by James Cantor, a Canadian sexual-behaviour scientist, none of the 11 academic studies of the subject reaches that conclusion.
I could go on, but I think it’s past time to wrap this up. I will include one final thing, some predictions:
- The number of angry detransitioners will continue to grow, and they’ll be in the news more.
- We’ll see more court cases similar to the Keira Bell one, and courts will start imposing age restrictions for various treatments.
- Possibly as early as 2021 the doctors, in an attempt to keep the courts from over-reaching will start changing their standards
- 20 years from now, and possibly a lot sooner, this phenomenon will be viewed as a cautionary tale of putting ideology before data.
- And beyond that this whole thing will be viewed by transgender activists as having ultimately harmed the cause.
I need some feedback here. This went on for a lot longer than most of my posts, was that good or bad? Should I add the “what this book was about” section to all of my reviews? I’m making a few tweaks in 2021 (details to come) and your feedback will help me with that.
Feel free to email me at We Are Not Saved (all one word) at gmail.
So a lot to unpack here and as one of the other people who read the book, I want to consolidate as much as possible so we don’t have thousands upon thousands of words.
The book is not evil nor horrible, given the lack of popular books on this subject it’s valid to be considered. Yet I notice a few issues that I think are pretty serious.
“30 fold” “4,400%” There’s a lot of figures like this which set off a red flag indicating someone is working with tiny bases. The LDS Church is dominant in Utah, but it is quite likely the fastest growing religion in Utah percentage wise is probably something like Bob’s Church of UFO Worship.
“accepted statistic for the prevalence of gender dysphoria was 0.01 percent.”…” increased by over 1,000 percent.” OK but that makes it 0.1%. Where did 0.01% ever come from to begin with?
Scope: So in going through this book I tried to get at some real numbers. One was ‘top surgery’ and the best I can get at is 14,000 mastectomies done in the US for transgender purposes. That is 14,000 in total. At any given time there’s 21.3M teen girls in the US and that 14,000 figure is a total. So say 7,000 are done to teen girls, we aren’t talking about a mass movement here or even a niche fad.
It would be nice to get numbers on ‘puberty blockers’ and testerone scripts but this type of data is very difficult to find for the non-specialist…esp. since the drugs are used for non-transgender purposes in women. But using a varient on the 80-20 rule, let’s say that there’s 5 girls who do sustained T use to every one getting top surgery. That would get you to 0.1% of females.
This implies either the numbers are smaller than they seem OR there are filters already acting that limit the ‘irreversible damage’ aspect going on here. For ‘bottom surgery’ this filter seems to be that the operation is pretty horrible & even in the best case requires a lot of luck. But mastectomies are bread and butter for surgeons (100K+ a year, mostly for cancer) and could easily be ‘sold’ to patients by the medical industry in bulk.
Pauses between the lines: I was struck that she mentions an interview with the therapist who ‘wrote the textbook’ on affirmative care and she included almost nothing of what the woman said, she did let it slip that the key opinion leader said something like “we are playing a waiting game here”, which actually sounds a lot like what the book is advocating….take it slow, be cautious with irreversible decisions etc.
Coherency: One way to read a story like “she seemed normal, then she got real withdrawn and started consuming huge amounts of social media, then she announced she was trans” is social contagion. Another way is the normalcy was deceptive. Something wasn’t right, she went looking and there’s a lot of things you could fall into on social media but for some reason this seemed right.
One issue I notice is that many of the profiles she has in her book are of people who became trans in high school or college and then have continued years later to their parents chagrin. A fad theory has to confront the fact that most people get really into things in HS or early College that they then drop. While I agree going with an identity for a while creates some sunk costs making it harder to just give it up one day, we actually do this quite a lot growing up.
There’s a lot in this book that is journalistically click baitish. Click bait or tabloid journalism isn’t necessarily false, but it does suffer from a lack of proper context.
When we were emailing about things I seem to recall that the 14,000 number had a lot of caveats. And I’m sure that the figures Shrier quotes also have lots of caveats. Do you have a link to those numbers? I’d like to look at where they’re from. All of which is to say why are your numbers the “real” numbers while Shrier’s or for that matter The Economist’s aren’t? They claim 50% of teens who were referred for dysphoria ended up on puberty blockers, and the court found after looking at all the evidence, that 97% of people who were put on blockers ended up moving on to testosterone, which dovetails into the whole “waiting game” assertion, as in puberty blockers are not a tool of postponement, they basically lock people in.
As far as whether people should or should have grown out of it if it were actually a fad, this part is completely anecdotal but my Dad has a rule of thumb that people don’t really settle into the person they’re going to be long term until like 26-27, and Shrier herself mentions someone detransitioning at 25 and ascribes it the fact that the prefrontal cortex is finally developed. All of which is to say, if the trend is only about 5 years old, and the average age is 16.4 the middle of the curve is still well short of the point where you would expect large numbers of detransitioning, which is part of why I provided the predictions.
I agree that there’s some click-baity stuff in the book, but these days it would be surprising if there weren’t.
Here’s where I got the 14,000 figure.
https://journals.lww.com/prsgo/fulltext/2019/06000/mastectomy_in_transgender_and_cisgender_patients_.7.aspx did a study of mastectomies in transgender patients. To do it they looked at a database of plastic surgeries and found only 4,170 mastectomies in either male or transmale patients between 2005-2017. That’s a huge time frame and I don’t know if the database is a list of almost all such surgeries or a tiny piece. Assume tiny piece. Only 14% of those were transmasculine. The rest were cancer, cancer risk reduction, and gynecomastia (essentially ‘man boobs’ being removed).
Brigham & Woman’s Medical center says 100K mastectomies are done every year. If 14% of those are women seeking gender reassignment…..there’s 14,000 per year. I’m assuming 100K mastectomies includes ones done on males.
Going thru this again I feel like I vastly overestimated. 14% of mastectomies done on self-identified male patients are for trans-reasons. Out of 100K mastectomies, I think a lot less than 14% are being done on male identified patients. So if it’s like 5% are done on male patients, then only 14% is transmale patients.
In realit I think the number is much, much, less. Even at 14K per year, though, that seems very small compared to 20M+ girls.
“They claim 50% of teens who were referred for dysphoria ended up on puberty blockers, and the court found after looking at all the evidence, that 97% of people who were put on blockers ended up moving on to testosterone, which dovetails into the whole “waiting game” assertion, as in puberty blockers are not a tool of postponement, they basically lock people in.”
“All of which is to say why are your numbers the “real” numbers while Shrier’s or for that matter The Economist’s aren’t?”
Because I told you exactly where I got my numbers :). Notice the passage above returns to percentages. But how many are being referred? How long between referral and blockers? Isn’t testosterone, per her book, being used first before puberty blockers and in fact is almost pseudo-recreationally used? Why does the Economist claim blockers come before testosterone? Is it because the number of very young cases is actually very small?
This might be a call for a new word I learned, Shepardizing, from Tim Ferris’s recent interview with Martine Rothblatt https://tim.blog/2020/12/16/martine-rothblatt/ I suspect at the end Shrier’s source and The Economist’s source will be the same….not surprising from a book review.
” if the trend is only about 5 years old, and the average age is 16.4 the middle of the curve is still well short of the point where you would expect large numbers of detransitioning, which is part of why I provided the predictions.”
A testable prediction but there’s a problem here. This is being driven by ancedotes rather than numbers. I suspect a bit like the Proud Boys, the online presence exagerrates the actual real life numbers quite a bit. I could easily see this prediction failing but a handful of detransitioners becoming big on social media may make it seem like it happened.
As usual I don’t have the kind of time I wish I had, so I’ll try to condense things into a series of bullets.
-I will take a look at the paper, but you yourself say you’re not sure of the sample.
-If it’s only up through 2017, it really seems like misses the period where things really started to “heat up”.
Also lost me in a couple of areas:
-I didn’t follow where you end up thinking 14,000 is an overestimate, aren’t you saying one study says 14% of mastectomies are for gender reassignment, and another source says 100k per year?
-I don’t know where you’re getting the idea that testosterone comes before puberty blockers, I never came across anything that suggested that, and if you think I said it, I must have written something which was unclear.
Moving on to things I think I understood.
-As far as Shrier’s references, I took very careful notes on where each statistic appeared and so if there’s a specific number you want the source for I should be able to find it, if you want to dig into the paper.
-Let’s take your 14k number (which is perhaps high) but now imagine that it wasn’t doctors doing mastectomies, but that instead it was a religion. Would you still think that it was no big deal? And would the attitudes of the people having it done to them matter in your estimation? If Scientology were lopping off thousands of breasts a year, would your attitude be the same?
But in all of this I think focusing on surgeries is a distraction. Shrier’s key argument is:
-We can wait and do nothing, this has a 70% “success” rate.
-Or we can do something, one of those something’s is puberty blockers which are prescribed a lot (perhaps as high as 50% of the time) particularly to young people because those are the one’s where puberty still can be stopped.
-But puberty blockers don’t work as claimed, they don’t allow people to wait, they lock in a transition decision for 97% of people.
-Therefore doing nothing is better than puberty blockers.
-UNLESS doing nothing results in suicide, but data confirms that it doesn’t.
So which part of that chain are you questioning?
So here’s the issue with 14%
If they put in ‘mastectomies’ in a database of surgeries and found 20% were being done on men (or transmen) and that broke 14% women going trans and 6% men for other reasons….then yea we could say 14% of mastectomies are being done on women transitioning and that’s 14,000 per year. Which is a lot, but compared to 20M+ young girls is not. I had initially read it that way but it appears I was mistaken.
They put in a query along the lines of “show me surgeries of mastectomies on male identified patients”. They only got 4,170. Of that only 14% was for transpuposes (591). That’s not a huge sample size when you consider they were looking over a dozen years.
Suppose after 2017 there was 600 per year happening. That would be more happening every year than the previous dozen years combined, pretty amazing growth but even that is not really a blip. What’s more likely, not only amazing growth but super amazing growth on top of super amazing growth in just 3 years or there was growth in the actual number of cases but visibility went up quite a bit with social media?
As I said in the other comment, to be rigerous 591 surgeries over 12 years doesn’t even amount to 50 a year. 14,000 was a bad estimate on my part, but it’s bad in the direction of being absurdly high.
“-I don’t know where you’re getting the idea that testosterone comes before puberty blockers”
I believe there was quite a bit in the book about getting testosterone, esp. for college women as well as patients swapping stories on what to say to get the scripts etc. I guess if you had a young teen girl you would do puberty blockers first but testosterone seems by are the more frequent drug you’ll find trans identifying women on.
“And would the attitudes of the people having it done to them matter in your estimation? If Scientology were lopping off thousands of breasts a year, would your attitude be the same?”
I would be deeply skeptical of any religion doing medical procedures this drastic…but then we are talking about 14,000 women out of 20M+. Or we might be talking about as little as 50 out of 20M+. Out of millions of people how many should have their breasts lopped off? I don’t know but is the answer zero? If you’re not willing to say that then the ‘right’ answer could easily be thousands when you start dealing with huge populations. I’m really starting to think the number isn’t even thousands but at best hundreds every year.
I’m pretty comfortable saying the answer for the right number of things for Scientology to lop off each year should be exactly zero. Even if Scientology gets 3 billion members, a rate of zero percent still yields zero.
-We can wait and do nothing, this has a 70% “success” rate.
-Or we can do something, one of those something’s is puberty blockers which are prescribed a lot (perhaps as high as 50% of the time) particularly to young people because those are the one’s where puberty still can be stopped.
What I’m not sure about is maybe this is what we are already doing. For all we know waiting is being done and 70% drop out, only the remaining 30% get referred out. Of those 30%, half again do not get puberty blockers so you’re down to 15% of patients who showed up on day 1 saying they may be trans actually getting puberty blockers.
But that’s 15% of pre-pubescant girls who say they are trans. How many of those do therapists see versus older girls for whome puberty is already well underway? We don’t know but the numerous examples she gives about binders indicates for many of these girls puberty has already started some time ago.
By making a very journalistic centered argument she hasn’t really contructed a big picture here…..the ‘funnel’ as they say in clinical trials. I don’t think she is doing this on purpose, but that lack of a macro picture is really something that’s needed here.
“-But puberty blockers don’t work as claimed, they don’t allow people to wait, they lock in a transition decision for 97% of people.”
But they don’t lock in upon a single dose. They lock in upon continued use, so it is somewhat remarkable if:
1. By the author’s own admission, some portion don’t get referred to clinics.
2. 50% that do, do not get puberty blockers.
3. So of the 50% that do get them, almost everyone stays on them long enough to be irreversable.
Might the ‘lock in’ be happening because of those who make it that far, they are really committed hence 97% don’t change their mind? The author makes much of peer groups and social attention making it harder to change gears, but at the same time a lot of teens do change gears all the time. I think here cause and effect get mixed up too easily. A person joins a peer group that pushes them to do something. One way to read that is peer pressure made them do that thing. Another way to read it is they sought out a peer group that would hold them to doing that thing. We tend to read free will into this based on whether we think it’s a good or bad thing giving our kid credit for good things and blaming bad friends ‘influencing’ them for the bad things.
Upping the ante a bit.
If they looked from 2005-2017 and found only 4,170 male/transmale mastectomies and there were 1.2M mastectomies done during that time period (100K per year) that would mean only 0.3% of mastectomies are being done on male/transmales and only 14% of that would be transmale based surgery. That would be only 50 such surgeries per year and we haven’t even gotten to what age the patients are!
I think taking it there is a bit unfair, though, since I don’t know what portion of surgeries the database represents. Since they were looking to study outcomes, one would think they would try to get the biggest database of patients they could.
Could there be only 50 such operations per year? Well maybe, over the last ten years that would give you 500 people that had the operation, more than enough of a pool to give you a dozen, two dozen or three dozen Youtube stars.
I wonder, how much of an effect on breast size does the hormonal treatments have? Perhaps for slender, youngish girls the masectomy is felt unnecessary after the effects of testosterone?
So you don’t think I give the medical community a blank check of infinite trust:
“[T]he misuse of science, hinged on placing far too much weight on a one paragraph letter published in the New England Journal of Medicine in 1980 which claimed that opiates only ended up causing addiction in 1% of people”
Freud: The Making of an Illusion by Frederick Crews is a book I finished not to long ago. Freud had a friend who was a brillant surgeon, but one day he nicked his thumb. It got infected, a portion of it had to be amputated but he was left in agonizing pain. He started using heroin/opium (it was a medicine back then) but got addicted.
Freud read a ‘medical journal’ from the US about a new compound called cocaine, how it did wonders for all sorts of thngs and could be used to help people get off heroin. He tried it with his friend (as well as consuming good amounts himself) and made a bit of a ruckus in Europe writing about how he had cured opioid addiction with cocaine. His friend ended up a monster with two addictions at once (and cocaine is far worse it seems). Freud ended up regretting his early fame as other doctors started observing they couldn’t get the good results he claimed. The ‘medical journal’ he read from the US was written by the pharma company and was more of an advertisement and an outdated one at that. Docs in the US had already realized cocaine didn’t work to break heroin addiction.
The only reason this didn’t spark a cocaine epidemic in Europe was because doctors didn’t take Freud seriously and didn’t jump on his claims.
Strange how the same things keep coming round again and again in different dress.
“if peers had nothing to do with it, we would expect the distribution of transgender teens to be fairly random and uniform. Instead we find, according to the book, that the prevalence of transgender identification within groups of friends is more than 70x the rate you would expect.”
Assuming people make friends uniformly at random? Isn’t the obvious objection to this that people tend to make friends with like-minded people, which in the case of transgender identifying people is other transgender identifying people? Even if you first observed groups of friends, and then observed many of those people going trans one after another, that would still fail to establish any causality because it would be very credible that signs of atypical gender identity are visible prior to medical diagnosis or even that trans identity is correlated with other unobserved variables which impact the probability of making friends.
That’s a fair point, but at best that just means that peer contagion can’t explain the increase, but the increase would still be there. Also couldn’t we compare it to other traits that seem innate and see what the arc there looks like? Do gay individuals generally recognize and identify as gay before they end up with a lot of gay friends or after? In my limited personal experience they identify as gay and they end up in gay social circles.
I tend to agree but that wouldn’t rule out ‘gaydar’ or being inclined to find other friends and social networks that have more gays than usual even before they come out as gay. it also doesn’t preclude the possibility of both. The girl who is a transgender seeks out friends who seem to share some traits that can’t be articulated. Some of them are also transgender but others might simply follow through with a peer contagion that becomes very dramatic in high school or college but doesn’t stick.
You asked for feedback at the end; excellent review.
One question that occurs to me, talking about the Littman survey, you say
“Majority had a diagnosed psychiatric condition, almost half were engaged in self-harm”
Do you think that other psychiatric conditions are much more likely to be grounded in actual physiology or is this kind of automatic affirmation that we see with trans identification present throughout the mental health profession?
Thanks for the kind words. I’m not sure I 100% understand your question. I think the default affirmation tactic for trans identification mean’s it’s treated very differently from other conditions, but I’m not sure I know what you mean by saying psychiatric conditions are grounded in “actual physiology”.
It sounds like the mind-body problem. Are psychiatric conditions grounded in physiology like malformed brain structures or chemical imbalances or are they coming from choices that we may be making…perhaps with the suggestion of the therapist or elsewhere.
I think we are at the point with the brain that’s a bit like trying to read a book by maybe having 3/4 of the table of contents and a very fine scale that can weigh each chapter but as for what the book says we’re just guessing. It gets worse since humans will respond to attempts to study them, for example the patients who wanted testerstone so knew exactly how to answer the questions the therapists asked to get it.
This interpretation of the increasing number of people identifying as transgender is plausible, though I don’t know enough about the subject to determine how frequent it is. You may find relevant this counterargument to the claims being made about rapid-onset gender dysphoria, which argues that while rapid-onset gender dysphoria or something like it does exist, it is much less common than Shrier & al. think, and that they are misinterpreting the relevant studies (although the author objects to the term “rapid-onset gender dysphoria” because it is not actual gender dysphoria but rather some other condition that the sufferer mistakes for gender dysphoria).
Some of the potential problems here discussed may arise from the conflation of different types of transgenderness rather than from non-transgender people thinking they’re transgender. “Gender dysphoria” can refer to physical dysphoria, i.e. the desire to have a body of the opposite sex, and social dysphoria, i.e. the desire to be categorized as the opposite gender by people around you (one person who experiences it describes it thus: “I recognize that I have … every … [anatomical] trait that typically leads one to classify others in the category “woman”, but the concept of being classified as a woman makes me want to sob.”), which is what ‘gender identity’ usually refers to, but physical and social dysphoria do not always occur together. Moreover, some people with social dysphoria do not have a constant gender identity opposite to their birth sex but rather have a fluctuating gender identity (‘genderfluid’) or want to not be identified as any gender (‘agender’) or in some other way have a gender identity more complicated than wanting to be identified as a single gender all the time (‘genderqueer’). Thus, the label “transgender” includes a group of different conditions that may have different effects and benefit from different actions (e.g. someone without physical dysphoria won’t necessarily benefit from physically transitioning). However, many people who are accepting but not especially knowledgeable about transgenderness — the sort of people who, as you said, would be “unsure how to react, but decide that they should call in outside help”, and also some of the transgender-identifying children — think of transgenderness uniformly according to a medical model, whereby all transgender people have a constant and immutable gender identity which produces both physical and social dysphoria and for which surgical transition is a necessary treatment, and assume that any people who exhibit signs of transgenderness (adopting new pronouns, crossdressing, &c.) must fit into this model. They may therefore presume that because they or someone they know has social dysphoria or wants to go by different pronouns, that person must be physically dysphoric and benefit from hormones and surgery, or that someone who doesn’t want to medically transition must not be transgender in any sense. (Not being transgender myself, I had to read about this; my main source is Austin Johnson (2017), “Normative accountability: How the medical model influences transgender identities and experiences”, Sociology Compass, available here.) If the fact that transgenderness is a label that includes a range of conditions rather than a monotonic category were better known and accepted, people who are genderqueer or who only have social dysphoria might be less likely to expect that medical transition would help them or that other people would only accept their gender identity if they transitioned medically.
Also, when you talk about “girls” or “female” people identifying as transgender, it’s not always immediately clear whether you mean that the people in question are congenitally anatomically female or that they identify as female; the latter is the usual convention in discourse about transgenderness, but the context generally indicates the former, and the ambiguity makes this post less clear than it could be.
[Your links worked so I ended up getting rid of the other comment, though the third link doesn’t resolve.]
I read the Thing of Things links, and I have no problems admitting that this is a phenomenon that I don’t understand very well, if at all. But at a bare minimum are some things that seem to be true:
1- The number of people identifying as transgender is skyrocketing. Even if this doesn’t represent a problem I would still very much like to know why that is.
2- There seems to be a one-size fit’s all approach to treatment: complete affirmation. If the situation is super complicated as you say with various mixes of social and physical dysphoria, then this sounds like the exact opposite of what we should be doing.
3- Some people are making decisions with permanent consequences which they later end up regretting. If we could determine who those people are in advance and help them in ways that they didn’t end up later regretting that would be a good thing.
In all of these cases we need more knowledge, and I feel like Shrier’s book adds to the amount of knowledge we have on the subject rather than decreases it, and as such it’s worth reading and discussing.
Just hitting my points again. The skyrocking and permanent consquences claims here seem very shaky. “Top surgery”, for example, may not even exceed 50 operations per year in the US. Totally possible some of those operations are people having permanent consequences which they later regret but the fact that the author hits hard on very high percentages while rarely giving the actual numbers is a sign the hype is being hyped.
#2 makes an interesting objection. One could say diabetics are quite diverse but the treatment is ‘one-size fits all’…namely ‘control blood sugar’. For a doctor, though, that single treament philosophy will result in a diverse array of treatments (some patients get insulin, some drugs, some diet and exercise nagging, others combinations).
“Affirmative therapy” will result in a lot of different treatments just from the inherit diveristy of the population. I could imagine an alternative, say, “challenge affirmation” consisting of challenging the patient’s assertions gently to see if they stick to them or change. But if all of us know so little about this field can we really say for sure our ideas are right?