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…]

Harriet Hall Is No Skeptic

Whoops! When I wasn’t looking, Harriet Hall had a peek at what her critics have been saying and created a revised version of her review of Shrier’s book. The last thing I’d like to do is spread misinformation about Hall’s views, so I spent some time going line by line through both her original review and the revised one, to see what changed.

[CONTENT WARNING: Transphobia, skeptics being capital-S Skeptics]

[Read more…]

A Transgender Athlete Reader

Remember this old thing?

Rationality Rules was so confident nobody would take him to task, his “improved” video contains the same arguments as his “flawed” one. And honestly, he was right; I’ve seen this scenario play out often enough within this community to know that we try to bury our skeletons, that we treat our minorities like shit, that we “skeptics” are just as prone to being blind followers as the religious/woo crowds we critique. And just like all those other times, I cope by writing words until I get sick of the topic. Sometimes, that takes a while.

In hindsight, “a while” turned out to be seven months and about seventeen blog posts. Why on Earth would I spend so much time and effort focused on one vlogger? I don’t think I ever explained why in those posts, so let’s fix that: the atheist/skeptic movement has a problem with transphobia. From watching my peers insinuate Ann Coulter was a man, to my participation in l’affair Benson, I gradually went from “something feels off about this” to “wow, some of my peers are transphobes.”

As I picked apart the arguments made by transphobes, I started to see patterns. Much like with religious and alt-Right extremists, there’s a lot of recycling going on. Constantly, apologists are forced to search for new coats of paint to cover up old bigoted arguments. I spotted a shift from bathroom rhetoric to sports rhetoric in early 2019 and figured that approach would have a decent lifespan. So when Rationality Rules stuck to his transphobic guns, I took it as my opportunity to defuse sports-related transphobic arguments in general. If I did a good enough job, most of these posts would still be applicable when the next big-name atheist or skeptic tried to invoke sports.

My last post was a test of that. It was a draft I’d been nursing for months back in 2019, but after a fair bit of research and some drastic revisions I’d gotten Rationality Rules out of my system via other posts. So I set it aside as a test. If I truly was right about this shift to sports among transphobes, it was only a matter of time until someone else in the skeptic/atheist community would make a similar argument and some minor edits would make it relevant again. The upshot is that a handful of my readers were puzzled by this post about Rationality Rules, while the vast majority of you instead saw this post about Shermer and Shrier.

The two arguments aren’t quite the same. Rationality Rules emphasizes that “male puberty” is his dividing line; transgender women who start hormone therapy early enough can compete as women, according to him, and he relies on that to argue he’s not transphobic at all. Shermer is nowhere near as sophisticated, arguing for a new transgender-specific sporting category instead. Shrier takes the same stance as Rationality Rules, but she doesn’t push back on Shermer’s opinions.

But not only are the differences small, I doubt many people had “women are inherently inferior to men in domain X” on their transphobe bingo card. And yet, the same assertion was made at two very different times by three very different people. I consider this test a roaring success.

One consequence is that most of my prior posts on Rationality Rules’ arguments against transgender athletes still hold quite a bit of value, and are worth boosting. First, though, I should share the three relevant posts that got me interested in sports-related apologia:

Trans Athletes, the Existence of Gender Identity, … / … and Ophelia Benson: The first post proposed two high-level arguments in favour of allowing transgender athletes to compete as the gender they identify with. The second is mostly about calling out Benson for blatant misgendering, but I also debunk some irrational arguments made against transgender athletes.

I Think I Get It: My research for the prior two posts led me to flag sport inclusion as the next big thing in transphobic rhetoric. The paragraph claiming “they think of them as the worst of men” was written with Benson in mind, but was eerily predictive of Shermer.

And finally, the relevant Rationality Rules posts:

EssenceOfThought on Trans Athletes: This is mostly focused on EssenceOfThought‘s critique of Rationality Rules, but I slip in some extras relating to hemoglobin and testosterone.

Rationality Rules is an Oblivious Transphobe: My first crack at covering the primary factors of athletic performance (spoiler alert: nobody knows what they are) and the variation present. I also debunk some myths about transgender health care, refute some attempts to shift the burden of proof or argue evidence need not be provided.

Texas Sharpshooter: My second crack at athletic performance and its variance, this time with better analysis.

Rationality Rules is “A Transphobic Hack“: This is mostly commentary specific to Rationality Rules, but I do link to another EssenceOfThought video.

Special Pleading: My second crack at the human rights argument, correcting a mistake I made in another post.

Rationality Rules is a “Lying” Transphobe: I signal boost Rhetoric&Discourse‘s video on transgender athletes.

“Rationality Rules STILL Doesn’t Understand Sports”: A signal boost of Xevaris‘ video on transgender athletes.

Lies of Omission: Why the principle of “fair play” demands that transgender athletes be allowed to compete as their affirmed gender.

Begging the Question: How the term “male puberty” is transphobic.

Rationality Rules Is Delusional: Rob Clark directs me to a study that deflates the muscle fibre argument.

Cherry Picking: If transgender women possess an obvious performance benefit, you’d expect professional and amateur sporting bodies to reach a consensus on that benefit existing and to write their policies accordingly. Instead, they’re all over the place.

Separate and Unequal: I signal boost ‘s comic on transgender athletes.

Rationality Rules DESTROYS Women’s Sport!!1!: I take a deep dive into a dataset on hormone levels in professional athletes, to see what would happen if we segregated sports by testosterone level. The title gives away the conclusion, alas.

That takes care of most of Shermer and Shrier’s arguments relating to transgender athletes, and the remainder should be pretty easy. I find it rather sad that neither are as skilled at transphobic arguments as Rationality Rules was. Is the atheist/skeptic community getting worse on this subject?

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.

4.5 Questions for Alberta Health

One of the ways I’m coping with this pandemic is studying it. Over the span of months I built up a list of questions specific to the situation in Alberta, so I figured I’d fire them off to the PR contact listed in one of the Alberta Government’s press releases.

That was a week ago. I haven’t even received an automated reply. I think it’s time to escalate this to the public sphere, as it might give those who can bend the government’s ear some idea of what they’re reluctant to answer. [Read more…]

It’s Payback Time

I’m back! Yay! Sorry about all that, but my workload was just ridiculous. Things should be a lot more slack for the next few months, so it’s time I got back blogging. This also means I can finally put into action something I’ve been sitting on for months.

Richard Carrier has been a sore spot for me. He was one of the reasons I got interested in Bayesian statistics, and for a while there I thought he was a cool progressive. Alas, when it was revealed he was instead a vindictive creepy asshole, it shook me a bit. I promised myself I’d help out somehow, but I’d already done the obsessive analysis thing and in hindsight I’m not convinced it did more good than harm. I was at a loss for what I could do, beyond sharing links to the fundraiser.

Now, I think I know. The lawsuits may be long over, thanks to Carrier coincidentally dropping them at roughly the same time he came under threat of a counter-suit, but the legal bill are still there and not going away anytime soon. Worse, with the removal of the threat people are starting to forget about those debts. There have been only five donations this month, and four in April. It’s time to bring a little attention back that way.

One nasty side-effect of Carrier’s lawsuits is that Bayesian statistics has become a punchline in the atheist/skeptic community. The reasoning is understandable, if flawed: Carrier is a crank, he promotes Bayesian statistics, ergo Bayesian statistics must be the tool of crackpots. This has been surreal for me to witness, as Bayes has become a critical tool in my kit over the last three years. I suppose I could survive without it, if I had to, but every alternative I’m aware of is worse. I’m not the only one in this camp, either.

Following the emergence of a novel coronavirus (SARS-CoV-2) and its spread outside of China, Europe is now experiencing large epidemics. In response, many European countries have implemented unprecedented non-pharmaceutical interventions including case isolation, the closure of schools and universities, banning of mass gatherings and/or public events, and most recently, widescale social distancing including local and national lockdowns. In this report, we use a semi-mechanistic Bayesian hierarchical model to attempt to infer the impact of these interventions across 11 European countries.

Flaxman, Seth, Swapnil Mishra, Axel Gandy, H Juliette T Unwin, Helen Coupland, Thomas A Mellan, Tresnia Berah, et al. “Estimating the Number of Infections and the Impact of Non- Pharmaceutical Interventions on COVID-19 in 11 European Countries,” 2020, 35.

In estimating time intervals between symptom onset and outcome, it was necessary to account for the fact that, during a growing epidemic, a higher proportion of the cases will have been infected recently (…). Therefore, we re-parameterised a gamma model to account for exponential growth using a growth rate of 0·14 per day, obtained from the early case onset data (…). Using Bayesian methods, we fitted gamma distributions to the data on time from onset to death and onset to recovery, conditional on having observed the final outcome.

Verity, Robert, Lucy C. Okell, Ilaria Dorigatti, Peter Winskill, Charles Whittaker, Natsuko Imai, Gina Cuomo-Dannenburg, et al. “Estimates of the Severity of Coronavirus Disease 2019: A Model-Based Analysis.” The Lancet Infectious Diseases 0, no. 0 (March 30, 2020). https://doi.org/10.1016/S1473-3099(20)30243-7.

… we used Bayesian methods to infer parameter estimates and obtain credible intervals.

Linton, Natalie M., Tetsuro Kobayashi, Yichi Yang, Katsuma Hayashi, Andrei R. Akhmetzhanov, Sung-mok Jung, Baoyin Yuan, Ryo Kinoshita, and Hiroshi Nishiura. “Incubation Period and Other Epidemiological Characteristics of 2019 Novel Coronavirus Infections with Right Truncation: A Statistical Analysis of Publicly Available Case Data.” Journal of Clinical Medicine 9, no. 2 (February 2020): 538. https://doi.org/10.3390/jcm9020538.

A significant chunk of our understanding of COVID-19 depends on Bayesian statistics. I’ll go further and argue that you cannot fully understand this pandemic without it. And yet thanks to Richard Carrier, the atheist/skeptic community is primed to dismiss Bayesian statistics.

So let’s catch two stones with one bird. If enough people donate to this fundraiser, I’ll start blogging a course on Bayesian statistics. I think I’ve got a novel angle on the subject, one that’s easier to slip into than my 201-level stuff and yet more rigorous. If y’all really start tossing in the funds, I’ll make it a video series. Yes yes, there’s a pandemic and potential global depression going on, but that just means I’ll work for cheap! I’ll release the milestones and course outline over the next few days, but there’s no harm in an early start.

Help me help the people Richard Carrier hurt. I’ll try to make it worth your while.