Heard This One Before?

Tell me if you’ve heard of this before: a government responds to the noise around gender-affirming care by setting up an independent review board. This board is tasked with reviewing the evidence, and coming up with guidelines that will inform government policy about the process.

It sure sounds an awful lot like the Cass Review, doesn’t it? The report which has been repeatedly used to deny health care to transgender people, despite withering critiques from the scientific community.

Our concern here is that the Review transgresses medical law, policy, and practice, which puts it at odds with all mainstream U.S. expert guidelines. The report deviates from pharmaceutical regulatory standards in the United Kingdom. And if it had been published in the United States, where it has been invoked frequently, it would have violated federal law because the authors failed to adhere to legal requirements protecting the integrity of the scientific process.

The Review calls for evidentiary standards for GAC that are not applied elsewhere in pediatric medicine. Embracing RCTs as the standard, it finds only 2 of 51 puberty-blocker and 1 of 53 hormone studies to be high-quality. But more than half of medicines used in pediatrics have historically been prescribed off-label on the basis of limited evidence. Physicians have noted that requiring robust evidence for pediatric use of every drug would greatly limit drug treatments for children, who are already considered by researchers to be “pharmaceutical orphans.” Indeed, Cass has herself admitted that RCTs are probably infeasible in the GAC setting; “they’re difficult studies to design because you can’t blind people,” she notes, since patients will see bodily changes when given GAC-related pharmaceuticals.

Daniel G. Aaron and Craig Konnoth, “The Future of Gender-Affirming Care — A Law and Policy Perspective on the Cass Review,” New England Journal of Medicine 392, no. 6 (February 6, 2025): 526–528.

Cass Review commentary positions non-affirmative approaches as “neutral,” contrasting them to affirmative approaches that are framed as “ideological.” There is no recognition of the ideology underpinning approaches that deny the existence or validity of trans children. Cass Review reports do not consider the harms of approaches that deny or reject a trans child’s identity (…). Instead, Cass Review reports provide a sympathetic description of non-affirming professionals, centering the pressure they feel under to adopt an affirmative approach …

A significant indication of cisnormative bias can be seen in the absence of recognition of the existence of trans children across all Cass Review reports. A review expected to define best practices for trans children’s healthcare chooses to entirely avoid the word trans when referring to the children or adolescents who access UK Children’s Gender Services. Whilst including seven references to “transgender adults,” the interim report does not include even one reference to a trans child, adolescent or young person. Trans children are instead reduced to definition as “gender questioning children and young people” (Report 5, p. 11) or “children and young people needing support around their gender” (Report 5, p. 7). This framing conflates trans children, including those who have socially transitioned and are settled and confident in their affirmed identity, with children who are questioning their gender. This conflation erases the existence of trans children.

Cal Horton, “The Cass Review: Cis-Supremacy in the UK’s Approach to Healthcare for Trans Children,” International Journal of Transgender Health (March 14, 2024): 1–25.

When governments start weighing in on health care practice, the results are almost always terrible.

[… pause for dramatic effect …]

[Read more…]

History Says Trans Rights

A key rule I follow when reading academic works: follow the citations, and see if they align with their description in the citing document.

This essay contends that Rykener ought to be understood as a transgender woman because she lived and worked for periods of her life as a woman, and other people in her social milieu accepted her as such. More specifically, I argue that Rykener relied on “gender labor” — the labor others perform to inscribe gender—to place herself within the series “women” (a collective of women not reliant on biologically essentialist definitions for membership). By using the framework of gender labor to argue Rykener is a woman, I provide a new way of reading gendered subjectivity — particularly transgender subjectivity — in the archive. Indeed, the historical document — discovered at the top of a 1395 Plea and Memoranda roll at the London Records Office — gives significant space to the various ways in which Rykener lived as a woman.

Henningsen, Kadin. ““Calling [herself] Eleanor”: Gender Labor and Becoming a Woman in the Rykener Case.” Medieval Feminist Forum: A Journal of Gender and Sexuality. Vol. 55. No. 1. Society for Medieval Feminist Scholarship, 2019.

We tend to equivocate between the present and the past, projecting our own views onto historical people despite a very different lived context. Nonetheless, Henningsen makes a strong case that at least one transgender person existed in 1395, a whopping six centuries ago. This contradicts a not-insignificant number of transphobes who want to claim transgender people are a modern fad or social contagion that never existed in the past.

[Read more…]

Richard Dawkin’s Discontinuous Mind

I mostly agree with Dawkins on this:

Everywhere you look, smooth continua are gratuitously carved into discrete categories. Social scientists count how many people lie below “the poverty line”, as though there really were a boundary, instead of a continuum measured in real income. “Pro-life” and pro-choice advocates fret about the moment in embryology when personhood begins, instead of recognising the reality, which is a smooth ascent from zygotehood. An American might be called “black”, even if seven eighths of his ancestors were white. …

If the editor had challenged me to come up with examples where the discontinuous mind really does get it right, I’d have struggled. Tall vs short, fat vs thin, strong vs weak, fast vs slow, old vs young, drunk vs sober, safe vs unsafe, even guilty vs not guilty: these are the ends of continuous if not always bell-shaped distributions.

Imposing discrete boundaries on something which lacks them is quite dangerous, indeed. It’s also necessary to survive: imagine if I had to stop and consider whether or not a portion of a wall could be opened via the application of force, and where that force should be applied, instead of going “looks like a door with a twist handle, lemmie twist it to escape the fire behind me.” Some level of imposed boundaries are a must, otherwise words cannot exist, but it’s also important to remember these are abstractions imposed for convenience instead of fundamental features of the universe.

As a biologist, the only strongly discontinuous binary I can think of has weirdly become violently controversial. It is sex: male vs female. You can be cancelled, vilified, even physically threatened if you dare to suggest that an adult human must be either man or woman. But it is true; for once, the discontinuous mind is right.

…. Oooo-kay. Dawkins is claiming that biology has a discrete boundary, between the vast majority of the subject that lacks discrete boundaries, and one small portion (sex determination) which has discrete boundaries on a fundamental level. This smells heavily of special pleading. What makes sex determination distinct from the rest of biology? [Read more…]

The Reviews Are In

And they paint a rather different picture of Shrier’s book.

The author’s incantation of the First Amendment does not sufficiently emphasize her red-blooded passion for true democracy, but for the seductive image of a hermetically sealed and patriarchally sound America, one regressively nostalgic for midcentury convention, order, and heroism. Irreversible Damage is Shrier’s own simpering cry to Make America Great Again. And as far as she is concerned, the beneficiaries of free speech’s historic privileges — shabbily enforced where trans voices have been concerned — can only be cisgender. In this dismal and limiting cognitive space where the First Amendment matters — but Shrier’s access to it matters most — the author can write as she pleases: baselessly and brutishly.

Sarah Fonseca. The Constitutional Conflationists: On Abigail Shrier’s “Irreversible Damage” and the Dangerous Absurdity of Anti-Trans Trolls, Los Angeles Review of Books. January 17th, 2021.

This review in particular had the biggest impact on me. I thought that Shrier’s book was primarily evidence-based, for loose definition of evidence. In reality, it sounds like Shrier’s book is best thought of as a “military action” of the “culture war.” Much as with abortion, the goal is to provide a secular mask to religious arguments. What little evidence Shrier brings is really an afterthought, a light window-dressing to distract from the core arguments. In essence there’s two separate layers of arguments going on here, and by focusing on only one I’m giving the impression that I have no rebuttal to the other.

Whether intentional or not, the engine of the “culture war” is a shift from an empiric epistemology, where evidence is weighed to determine the truth, to a form of cultural authoritarianism where the opinions of authority figures are weighed instead. Hall’s 2018 article is a good example of this. She presents the discussion over the healthcare of transgender youth as a he-said, she-said affair. On one side is Dr. Kelly Winters, who has been part of a WPATH advisory panel, presented academic papers on health care, and been awarded for her promotion of the health of transgender people. On the other is Walt Heyer, a preacher who detransitioned and has been an outspoken critic of affirmative care. It makes no sense to put these two on equal footing if we arrive at the truth via evidence and reason. Preachers and media talking-heads carry quite a bit of cultural authority, however, more than an obscure scientist would. Hence why Hall not only places similar weight on the opinions of both, she mentions Walt Heyer by name but not Dr. Kelly Winters; the former carries more weight than the latter, after all.

That review shifted my entire approach to Shrier’s book and Hall’s writing, and I’m glad I read it before going any further on the subject.

As a physician and a researcher who has dedicated my career to taking care of and understanding transgender youth, I recognized the book as bizarre and full of misinformation. I assumed it wouldn’t gain much traction. I was wrong.

I should have realized the internet has dramatically changed the way politically charged misinformation spreads. Online, it often doesn’t matter what’s actually true. The book, full of irresponsible journalistic practices and outright falsehoods, has taken off.

Dr. Jack Turban. “New Book ‘Irreversible Damage’ Is Full of Misinformation“, Psychology Today. December 6th, 2020.

This other review pointed out something rather important. For instance, you’d think that if you’re writing about transgender youth you’d want to talk to transgender youth, right?

Shrier’s book tells the stories of several young people who came out as transgender to their parents. The book claims that these adolescents and young adults were not actually transgender, but actually just confused. The problem is Shrier didn’t actually interview any of these people she wrote about.

The author’s note points out that she only interviewed their parents, who uniformly did not accept their children’s transgender identities. Many of them were estranged from their kids because the children were so hurt by their parents’ rejection. To actually understand the psychology of these young people, one would need to talk to them, not simply rely on stories from parents with whom they do not speak.

To make things worse, the author’s note explains that Shrier changed details in the book to ensure the transgender people she wrote about would not be able to recognize themselves. In doing so, she ensured they could not provide their side of the story or point out any inaccuracies in her reporting.

It’s ROGD all over again! Ask bigoted people for their opinions on subjects they’re bigoted about, and you’ll get bigoted and distorted answers. Summarize those answers in a scientific paper or an in-depth book, and you give false legitimacy to those bigoted beliefs.

Full disclosure: I didn’t stumble on these reviews on my own. Remember how Novella and Gorski of Science-Based Medicine promised a part two on the healthcare of transgender youth? They delivered, by giving Rose Lovell a guest post to discuss the book. She’s a doctor with relevant clinical experience, and she ended her review by pointing readers to the two reviews I shared above. Unsurprisingly, she reaches similar conclusions:

In total, I simply cannot recommend this book to anyone honestly seeking to understand transgender science and medicine. Shrier has written a book in an attempt to prove her specific point, not to explore the nuances of a complex field. While there may be some legitimate concerns (e.g., that of how to support those who choose not to continue to transition or to detransition), the overall narrative in Shrier’s book is so tainted by biased language and misinformation that it throws into question its own legitimacy. I am also very concerned that this book, and others like it, will continue to be used as a primary source in efforts to prevent transgender youth from accessing desperately needed medical care.

Rose Lovell. “Abigail Shrier’s Irreversible Damage: A Wealth of Irreversible Misinformation.” Science-Based Medicine, July 2nd, 2021.

Lovell goes into two arguments of Shrier in depth, then gives a quick gloss over a dozen-ish others. One of those caught my attention:

“Biology is a binary and differences of sex development (DSDs) are vanishingly rare”. False. DSDs are as common as 1 in 5,000 births, and increase to 1 in 200 or 1 in 300 if you include hypospadias and cryptorchidism. Biology is very, very well known to be a spectrum.

Ah, the sex binary. I’ve been on that beat for, what, seven years now? Others agree that sex is not a clear-cut binary.

Consider the multiplicity of features relevant to sex determination: chromosomes, genitalia, gonads, hormone levels, reproductive capacity, and so forth. In order to say that a transsexual after genital reconstruction surgery has under-gone a “sex change,” we must discount other features, including chromosomes, and select genitalia as definitive. But consider a person who has an XY karyotype and is morphologically female due to complete androgen insensitivity syndrome. It’s not clear whether this person is male or female. Indeed, there doesn’t seem to be a factual basis on which to arbitrate the question. But postoperative transsexuality seems exactly analogous. In both cases, there’s no fact of the matter as to what sex or gender the person belongs to.

Bettcher, Talia Mae. “Trapped in the wrong theory: Rethinking trans oppression and resistance.” Signs: Journal of Women in Culture and Society 39.2 (2014): 383-406.

It’s telling that Shrier asserts that sex is binary, even though it isn’t necessary to make her case. It underlines that her true focus is not the health of transgender children, but a cultural rollback to a more patriarchal time. Listen to her in other interviews, and she’ll make arguments about the damaging nature of smart phones and the internet, how LGBT terminology is confusing, and that parents should have primacy over decisions relating to children. Transgender children are being used as a wedge for a grander cultural project, much as opposing abortion is used as a wedge for opposing contraception. This is what the aforementioned engine is pushing.

I’m rambling a bit, though. I found all three reviews quite interesting, and can recommend them if you’d like to read more.

A Good Start

It certainly didn’t seem like that at first blush, though.

Further, we wish to make it clear that Dr. Hall still remains an editor of SBM in good standing. She has worked tirelessly to promote SBM and its principles, contributing over 700 articles to SBM since 2008, all without any compensation or possibility of reward beyond public service. However, at SBM quality matters first, and so we have to remain open to correction when necessary.

Hold on. Harriet Hall has repeatedly shared medical misinformation and lied about the scientific evidence, on a website that claims to promote “the highest standards and traditions of science in health care,” and it hasn’t impacted your view of her at all? Both Steven Novella and David Gorski are not concerned that her flagrant disregard of the science here might spill over to other topics she’s discussed? You’re fine with being used to launder medical misinformation, so long as the actors “remain open to correction?” Yeeesh, I just lost a lot of respect for Science-Based Medicine.

Their response to Hall’s article is also hyper-focused on the scientific literature, with only a few exceptions. That can be quite dangerous, as Allison points out.

Frankly, for a trans person, there’s something surreal and erasing in seeing cis people feuding with cis people over whether we exist. I mean, I am grateful that there are cis people being allies for us … But the fact that people have to come up with logical arguments and “evidence” that our transness is “real,” thus keeping the question alive of whether we do, in fact, exist, keeps giving me the creepy feeling that maybe I’m just a figment of my own imagination. […]

I was just reading HJ Hornbeck’s post about trans athletes, which has all kinds of “scientific,” “objective” evidence that gender dysphoria, gender identity, etc. are real. The problem with going down that path is not only that it concedes the possibility that it could be “disproven,” but also that trans people who don’t fit into the definitions and criteria in those “proofs” are then implicitly left out of the category “real trans.”

When writing about issues at the core of someone’s identity, you need to prioritize humanism over evidence. Hence why I went out of my way to point out the scientific literature is not the final word, that it is not prescriptive. If you doubt me, consider one of the after-effects of ACT UP:

The upshot of all this: “What they were able to revolutionize was really the very way that drugs are identified and tested,” says France. This included scrapping the prevailing practice of testing drugs on a small number of people over a long period of time in favor of testing a huge sample of people over a much shorter period — significantly speeding up the time it took to conduct drug trials.

Similarly, ACT UP insisted that the researchers and pharmaceutical companies that were searching for a cure for AIDS also research treatments for the opportunistic infections that were killing off AIDS patients while they waited for a cure. In the process, says France, “ACT UP created a model for patient advocacy within the research system that never existed before.”

Today it seems natural that people suffering from a disease — whether that’s breast cancer or diabetes — should have a voice in how it is researched and treated. But France says this was decidedly not the norm before ACT UP.

By just reciting the scientific record as if it is a holy book, you roll back the clock to a time when scientists acted as gatekeepers rather than helpers. Instead, start from a patient-centred care perspective where patient rights are placed first. The quality of the science will improve, if anything, and you won’t condescend or impose on the people effected. Novella/Gorski do make some attempts at this, to be fair, but I thought they were easy to miss.

At the same time I was filing away that objection away, though, Novella and Gorski’s follow-up article was really starting to grow on me. It calmly and patiently shoots down a number of arguments made by Shrier and Hall, and the meat of the article doesn’t hold back. They earn their conclusion:

Abigail Shrier’s narrative and, unfortunately, Dr. Hall’s review grossly misrepresent the science and the standard of care, muddying the waters for any meaningful discussion of a science-based approach to transgender care. They mainly rely on anecdotes, outliers, political discussions, and cherry-picked science to make their case, but that case is not valid. […]

At this point there is copious evidence supporting the conclusion that the benefits of gender affirming interventions outweigh the risks; more extensive, high-quality research admittedly is needed. For now, a risk-benefit analysis should be done on an individual basis, as there are many factors to consider. There is enough evidence currently to make a reasonable assessment, and the evidence is also clear that denying gender-affirming care is likely the riskiest option.

I could have used some more citations (shock surprise), but there’s enough there to establish that Novella/Gorski have done their homework. Also, did I mention this is only part one?

Part II of this series will include a far more detailed discussion of the key claims in Abigail Shrier’s book and where she goes wrong by an expert in the care of trans children and adolescents.

Giving a front-line expert a platform to share their insights will do wonders to counter the misinformation. Until that time, we still have a solid takedown of Shrier and Hall’s views on transgender people’s health. Despite my objections, it’s well worth a read.