We must fight back against all this 'nuance' and 'reporting' and "protecting vulnerable populations from quackery," lest the bigots win
|Jun 4||Public post|| 16||1|
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Last week the New York Times published an article by Amy Sohn about chest-binding, the practice of natal female people, mostly trans men and nonbinary individuals, wearing a tight garment to flatten their breasts, making them look less female. Sohn’s article focuses specifically on teens who are doing this. “Some transgender teens say they buy binders so that they can ‘pass’ as male or to diminish feelings of discomfort with the body known as body dysphoria,” she writes.
Many, many people say they get relief from gender dysphoria by binding — that’s why it’s such a common practice. But Sohn explains that we don’t know much about the health effects of binding:
Participants [in this study] reported a statistically significant improvement in mood after binding. They also reported decreased gender dysphoria, anxiety and depression. As for physical effects, 97.2 percent of the group that bound reported at least one negative physical symptom, such as back pain, overheating, chest pain and shortness of breath. Other symptoms included numbness, bad posture and lightheadedness.
Sohn clearly notes that there is a good reason people bind: It helps them feel better. No one could possibly read this article and come away believing Sohn doesn’t communicate that there are benefits to binding to weigh alongside its potential physical side effects, or that she bears animosity toward trans people.
Just kidding! It’s 2019, after all. Here’s BuzzFeed’s LGBT editor, Shannon Keating, in a tweet that helped spark what would become a bit of a Twitter pileon centered on Sohn’s piece (GNC means “gender nonconforming):
I don’t think this is an accurate summary of the Times piece at all. It isn’t true that Sohn’s “entire story” highlights the downsides — it explains clearly and accurately why there are benefits to binding. In addition to the above language, Sohn quotes a 17-year-old who notes the physical toll of binding but who also says, “In all honesty, I couldn’t have cared less about the damage being created, just that my chest was flat.” It’s a perfectly reasonable subject to examine from a critical, science-minded perspective, simply because so little is known about it and because of the shockingly high prevalence of physical harm in the study Sohn cites. And even that study, which did find impressive self-reported psychological effects of binding — “On average, respondents’ rating of their mood before and after binding significantly increased from a 2.1 to a 3.8 on a 5-point scale,” and reported (qualitative) reductions in suicidality — is far from dispositive on the question of binding’s benefits relative to its downsides, since its non-random sampling method may have pulled in a disproportionate number of happily transitioned trans people relative to the broader population of people who have bound at one time or another. This is why research is important and we need more of it. You can’t take one-off anecdotal accounts as gospel, even if it’s clear that binding offers absolutely life-changing relief to some of the people who do it.
Anyway, it’s Keating’s claim that 4thWaveNow is an “anti-trans hate group” that really gives away the game here. (This will be a bit of a digression, but I promise I’ll pull everything together shortly.) The full 4thWave controversy is complicated: The short version is that the site’s founder, Denise, has a daughter, Chiara, who announced at 17 that she was trans and wanted to go on hormones, seemingly (from Denise’s point of view) out of nowhere. Now in her early twenties, she no longer identifies as trans and believes that she was instead “struggling to deal with trauma, internalized homophobia, and social isolation” — a story similar to the ones I heard when I interviewed desisters and detransitioners for my article in The Atlantic about the controversy over youth gender dysphoria and its treatment last year. (There’s also evidence that trauma can cause or exacerbate dysphoria in gender clinicians’ own writings on this subject, and it has come up in my interviews with them.)
Chiara’s path, of teenagers determining they are trans as a result of other stuff going on in their lives rather than a deep-seated, permanent alienation from their natal sex and its associated gender, definitely happens sometimes. I’ve talked to people it’s happened to — they haven’t been hard to find, and their stories are credible. This probably accounts for some of the massive, mostly-natal-female, uptick in referrals to youth gender clinics that clinicians are seeing just about everywhere, though another part of the chunk is simply people becoming more aware of what it means to be transgender and realizing there are services available to relieve their or their kids’ distress. No one knows what the breakdown is, even if plenty of people claim to confidently proclaim the answer.
More broadly, all the available evidence suggests that dysphoria sometimes abates on its own without transition, particularly in young people — a phenomenon called desistance. I don’t know how many times I’ve written a version of this sentence, but: Some activists and journalists have attacked the extant desistance research from every conceivable angle, claiming desistance is quite rare, but their arguments are severely overstated. In March, when I was working on these posts on this controversy, I corresponded with Thomas Steensma, a pioneering clinician at the “Dutch Clinic” in Amsterdam, which is arguably the most famous gender identity clinic in the world — Steensma and his colleagues have published some of the best and more comprehensive outcome data on gender-dysphoric youth, including the studies trans advocates use to argue, correctly, that youth transition with puberty blockers followed by hormones appears to profoundly help some kids with gender dysphoria. Steensma estimated to me that about 60% of the young people who pass through his clinic and who meet the clinical criteria for GD at one point eventually desist. Because of cultural and contextual and clinical differences, it’s really important not to apply that estimate to other settings, and as I’ve stated repeatedly, the frequently trotted-out desistance estimate of 80% is likely too high. The point is that however frequent this occurrence is, it isn’t rare. There is no evidence anywhere to support the claim that desistance is rare, not without kidnapping the statistics we do have, hurling them into a windowless van, flying them to a CIA black site in some lawless nation, and torturing them mercilessly.
In light of this data and their own stories, Denise and the other contributors to 4thWaveNow express skepticism about what they see as a rush toward physical transition for gender dysphoric young people who might, given some time and space to explore, find that they don’t feel that way in the long run. There are things that go up on the site I disagree with — I do think it is sometimes too skeptical of physical transition for young people and sometimes uses overheated language, and have other qualms that might be worth getting into at a later date but which aren’t the point here. However, the site also highlights gaps in the research other people haven’t, and tells stories mainstream outlets, particularly progressive ones, are mostly refusing to tell.
This post, showing via Facebook-group screenshots that some of the top experts in the world have no idea whether kids who go on puberty blockers followed by hormones will ever be able to have something approaching full sexual function, is just one example: It’s an uncomfortable subject, to be sure — as those in the Facebook thread point out, explaining why it’s been hard to do research on the question — but also exactly the sort of question any potential consumer of any medical procedure deserves an answer to. Now, if the answer is “No, they won’t ever have anything approaching full sexual function,” that doesn’t mean kids with severe dysphoria shouldn’t go on blockers — it just means that this is information people should use to weigh an important medical decision, and which they don’t presently have access to. No sane person would claim that if someone points out that a given antidepressant can cause impotence, the person pointing that out is “anti-depressed-people.” Caring about a patient population means asking exactly these questions, not sweeping them under the rug: In fact, the Facebook post 4thWave sums up was sparked by the supportive father of a trans 15-year-old seeking to start estrogen asking that very question about sexual function.
Everyone keeps forgetting that there’s a huge amount of uncertainty when it comes to this stuff. As the journal Pediatrics put it last year: “Low-quality evidence suggests that hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact are generally lacking. Future research to address these knowledge gaps and improve understanding of the long-term effects of these treatments is required.” (I’m lumping together puberty blockers and hormones here a bit, but the uncertainty issues pertain to both.)
So no, 4thWaveNow is not a “hate site.” It makes even less sense to call it one now that Denise’s daughter Chiara, who didn’t originally know her mom was running the site — meaning there was, at least hypothetically, some chance Denise was misrepresenting her experience — has now come forward and started talking about it in her own words, such as in this interview and in her work with the Pique Resilience Project. The stories of mom and daughter line up.
The uncertainty 4thWave focuses on is of course pertinent to the binding discussion as well, so it makes perfect sense that someone writing about binding would seek a quote from the group. Because so many natal female people with gender dysphoria bind, the clinic-referral trends strongly suggest that many, many kids have begun binding in recent years. How many? Who are they? What caused them to make that decision? How many of them have clinically diagnosable GD? How many of them will continue to experience dysphoria over the years? Have any of them had a single conversation about their gender issues with a qualified, compassionate clinician? Where are they getting their online information about safe binding and gender dysphoria?
The answers to these questions, in order:
-We don’t know.
-We don’t know.
-We don’t know.
-We don’t know.
-We don’t know.
-We don’t know.
-We don’t know.
I understand why Shannon Keating and others are threatened by this sort of thing — by focusing on the unknowns and risks of puberty blockers or hormones or binders or anything else that some trans people find absolutely lifesaving. Acknowledging desistance and detransition and the fuzziness of the data does, in fact, bring with it risks. There’s a risk parents will try to prevent kids with genuinely severe GD — GD that will not go away in time — from transitioning out of a misguided belief that they will desist.
All I can do on that front is repeat myself again:
It’s vitally important, whenever discussing this subject, to caution parents against confidently predicting their kids’ long-term trajectories on the basis of zoomed-out desistance statistics. The fact is that for a given kid, there’s no way to know for sure. There are kids with severe GD who desist. There are kids with little or no GD who develop it after puberty, big-time, who transition, and who live happily ever after as trans adults. If you are confident your 5-year-old with GD will desist, you’re doing it wrong. If you are confident your 5-year-old with GD won’t desist, and that blockers and hormones are definitely in her future, you are also doing it wrong. Parents should allow themselves and their kids to inhabit an uncertain, exploratory space for a while as young ones figure out who they are — that’s a point that has been hammered home to me by some of the leading authorities on this subject.
But once you put all this stuff in full context, it’s becoming horrifying the extent to which many mainstream outlets and journalists are, for the most part, abdicating any responsibility to guide readers through this stuff in a reasonable, evidence-based way, and in many cases seeking to lash out at and smear those seeking to do so. Because of how the internet works and the rush to impugn anyone who asks questions about this particular subject, it’s now a Known Fact in many quarters that the New York Times published a horribly transphobic article.
Naturally, Jezebel chimed in: “At the New York Times, ‘Objectivity’ Means Quoting One Trans Teen and One Anti-Trans Group.” Except the article quoted plenty of other people, too! And, again, 4thWave isn’t an anti-trans group in any meaningful sense of the word! I have to cop to some bias here — Jezebel summed up my 13,000-word Atlantic article with a rant by Harron Walker headlined “What’s Jesse Singal’s Fucking Deal?,” mangling an absolutely key detail in the process (I emailed them to ask them to correct it multiple times but haven’t heard back) — but it’s still frustrating to watch the outrage machine chug into gear, making sure people understand how evil and transphobic it is to, you know, do journalism:
The Times’ reliance on non-trans doctors, researchers, parents, and even specifically anti-trans advocacy groups, says more about who the Times is comfortable speaking with rather than anything about binding. The result is fear-mongering article that further damages a group that faces alarming rates of suicide and violence, another essential factoid left out of the piece. This piece, and others like it, masquerade as insight to cis people, but in fact are a vehicle for anti-trans myths and fears.
The argument, here and elsewhere, is that because the Times, in a health article, relied more on experts and (to the limited extent it was available) data rather than personal testimony, and because it interviewed people who think we should proceed cautiously when it comes to teenagers and a practice that injures 97% of participants, the paper committed a journalistic wrong. How do you even respond to that? It’s just an entirely different galaxy of journalistic norms.
Now, there are things I would have done differently had I written Sohn’s article. I do agree with one criticism, stemming from this paragraph:
But some worry that parental efforts to affirm a young person’s identity by supporting binding may contribute to self-hate. Jane Wheeler, a co-founder of an organization called Rethink Identity Medicine Ethics, which examines standards of care for gender-variant children and youth, said binding “feeds into a normalization of body hatred, that some forms of body hatred are O.K.”
As a number of people, including Keating, pointed out online, Rethink Identity Medicine Ethics seems to have zero online footprint. I wouldn’t have quoted someone from such a ghostly group. But it’s by no means a crazy quote — body hatred is, of course, an actual thing that teenagers, particularly female ones, experience. It’s very much the case that parents need to find some balance here, that ‘affirmation’ can, as some experts have explained, be a complicated matter. You can ‘affirm’ your child and his or her distress without saying, “Yup, you’re definitely going to feel this way forever so we should definitely have you start binding and then get you top surgery in a few years.” I think (hope???) everyone knows this? How can this be controversial?
Things are so, so, so, so, so, so, so bad when it comes to mainstream journalism and youth gender dysphoria at the moment. I don’t really have a word for it. It isn’t just Jezebel calling for most of the usual rules of common sense and sound science reporting to get tossed out the window. Many outlets are taking that general stance, because it’s not worth the bother to treat this as a normal health/science beat: Anyone who does will get branded an evil transphobe, as the Times learned over the weekend. So what happens, in practice, is that mainstream outlets (left-of-center ones, at least) stay mostly quiet on the more complicated facets of this conversation, or their coverage is dictated by editors and reporters with the loudest and most radical views, who are convinced that the only reason anyone could have any questions about any of this is rank bigotry and ignorance.
The craziest part really is watching the rules of responsible science journalism getting rewritten in real-time, but only for this one issue. For this one issue, anecdotes are more valuable than data (unless the data tell a straightforward pro-medical-transition story). For this one issue, 15-year-olds are qualified to make their own serious medical decisions and if their parents have questions about the long-term consequences, it’s the parents who are the ones being irresponsible. For this one issue, teenagers’ feelings couldn’t possibly have anything to do with the social and cultural milieu in which they are immersed — anything they feel is a deep-seated reflection of who they essentially are and always will be, because teenagers are known for their stability, of course. For this one issue, the most serious medical treatments available should be the first step to address psychological distress, not the second or third, after a spell of psychological counseling and assessment.
I think it’s unlikely the New York Times will be running another balanced article on any aspect of the youth gender-dysphoria debate anytime soon. It’s in violation of the new rules, after all.