It Would Be So Easy For Liberal Outlets To Do A Better Job Covering Gender Dysphoria

Also: There was a football game Sunday night, if memory serves

(“I signed up for that Jesse Singal guy’s newsletter and the first one that hits my inbox, there’s an image that appears to be… a photo he took of a TV with Tom Brady on it? So I unsubscribed immediately — and called the cops.”)

That was quite a game. Ugly and tense and too much defense, and I would imagine most of the nation disliked the outcome even more than the slog of watching it unfold. I have a tortured relationship with my NFL fandom, which arrived with Drew Bledsoe in 1993 and which, like Tom Brady, is well past its prime years and probably won’t be around for more than a few more seasons. But Sunday night was still magical: It’s just amazing to watch something like this, a rare treat as a sports fan. It doesn’t make sense that this team has had the run it has had. And I’ll leave it at that before I alienate all of you.

Admin Stuff

Here’s my best correction ever. Usually I wouldn’t highlight a minor error like this one, but in my last newsletter I wrote that “acts of casual incompetent are an important and ever-growing part of my brand.” On Twitter, someone asked me if this was intended as a wry joke. Oh my sweet, sweet, trusting readers.

Keep sending me the names of social-science researchers doing interesting work. I have a couple promising leads already, but I’d love to find some more early(ish)-career social scientists asking interesting questions who I could feature in this newsletter. No promises that I’ll go with any given suggestion, of course, but I’m sure there are a lot of academics out there whose work deserves a wider and/or more general audience.

Sometimes You Downvote the Bear, and Sometimes the Bear, Well, He Downvotes You

In the wake of my segment last week about Brian Earp’s theory of social-media outrage, a couple readers reached out to me to point to Reddit as a website able to avoid at least some forms of social-media sociopathy with a simple mechanism other sites use, too: upvotes and downvotes. When I post something on Reddit, people upvote it if they like it and downvote it if they don’t. The site’s default view puts the most highly upvoted posts at the top, and drops downvoted posts down well out of view of the casual peruser — severely downvoted posts require an extra click to even read, the algorithm’s way of affixing a HERE THERE BE DRAGONS warning to them.

Because Reddit has a few really bad communities that have fomented radicalism and, well, general dickery, I think it has a bad reputation in the eyes of many online observers. But I find this view to be a bit blinkered: As bad as some of Reddit’s communities (or subreddits) can be, overall, the tone of conversation on the site is pretty good. For the most part it’s a platform where people have actual discussions without ritually decapitating one another all the time. And surely, as Earp would predict, the fact that Reddit, unlike Twitter, has a built-in mechanism that unambiguously and economically signals disapproval — the downvote — is part of the reason why.

There are other reasons, of course. The lack of a tight character limit means a lot of the pathological social incentives and temptations that have set in on Twitter aren’t as potent on Reddit, rendering the comparison a bit apples-to-oranges. But still: It’s clear that upvoting and downvoting works, in a certain fundamental way, as a means of delivering feedback in online social settings, and there are important lessons to be drawn from this fact.

It Would Be So Easy for Liberal Outlets To Do a Better Job Covering Gender Dysphoria (Slate Edition)

There are some major issues with how liberal publications cover gender dysphoria at the moment. On Medium, I’ve run down some of them when they’ve been relevant to my own work, but the general problem is much bigger and broader than what I’ve written about to date, and is an increasing source of worry to me. People really, really need accurate information on this subject, and if liberal publications supposedly dedicated to sound science won’t provide it, who will? (Suffice it to say conservative publications also cover this subject poorly, in their own ways, but I am less confident in my ability to nudge them to do better because of the political chasm between them and myself.)

If I wanted to, I could dedicate the next two weeks of this newsletter simply to explaining the major problems with recent columns and articles about gender dysphoria that have run in big-name liberal outlets. Alas, I’d like this newsletter to maintain some semblance of balance, subject-matter-wise — there are people being jerks on Twitter who require my attention as well, after all. So for now, I’ll open up this subject’s coverage on Singal-Minded with some thoughts on a single, frustrating article that ran in Slate a few weeks ago: “The Dysphoria Paradox,” written by Devon Price. Part of the reason the article is frustrating is that with just a few tweaks and the insertion of a currently-missing paragraph or two, it could have provided readers with accurate, useful information. Instead, it misleads.

(Disclosure: Price’s piece originally included a reference and link to my Atlantic article on youth gender dysphoria that severely misrepresented its content. Slate, to its credit, quickly removed that link and posted a forthright correction acknowledging this misrepresentation after I emailed editors there. But by the time I even got to that reference, I was developing major qualms about the piece, and my critique of it has nothing to do with that particular error and correction.)

It’s going to take a bit of background to explain the problems with the Slate article. The best evidence we have suggests that, for properly diagnosed people with gender dysphoria, hormones and surgery offer important and sometimes lifesaving relief. There’s an emerging scientific consensus on this, even if there’s an absence of high-quality studies, and even if the studies that have been published generally come from settings with fairly intense diagnostic processes, which might limit their generalizability as so-called “gatekeeping” goes out of style (that’s why the properly diagnosed qualifier is key).

But some people who identify as trans and who go on hormones and/or get surgery subsequently transition back to the gender associated with their natal sex. A subset do so because they run out of money for the ongoing medical care they need, or find the world is too transphobic to continue living in as a trans person, or for other reason — but others detransition simply because they come to the realization that they aren’t really trans.

This last category of detransitioners, whose members I focused on for part of my Atlantic article, and who have formed an online community calling for more careful assessment and diagnostic processes for transgender and gender nonconforming people (particularly young ones), is a source of white-hot controversy, in part because so little is known about how prevalent detransition is. Some trans activists insist it’s so rare that detransitioners are only brought up for bigoted reasons, as a means of sneakily advocating for unnecessary roadblocks for trans people who need medical care or undermining the very validity of trans identities (think of the “ex-gay” movement’s attempts to caution people against the “homosexual lifestyle”).

Detransitioners themselves, on the other hand, often insist there are more of them than most people realize, and highlight the fact that there is approximately zero published research that can answer this question in a present-day American context. As I wrote in my Atlantic piece, the most commonly cited detransition figure — 2.2% — “comes from a study, conducted in Sweden, that examined only those people who had undergone sex-reassignment surgery and legally changed their gender, then applied to change their gender back—a standard that, [the detransitioner Carey Callahan] pointed out, would have excluded her and most of the detransitioners she knows.” For this and other reasons, including Sweden’s very different cultural context and health-care system, this figure can’t really be used to state anything confident about 21st-century detransition in the U.S. We just don’t know, at least not yet.

One thing that detransitioners commonly report is a sort of whack-a-mole gender dysphoria in which, after they address some aspect of their dysphoria with a medical or cosmetic intervention, their dysphoria either comes back after the initial glow of the procedure or treatment in question wears off, or pops up in a different place on their body: You get a double mastectomy and no longer feel dysphoric about your chest, for example, but find you are newly and intensely worried about your hips, which remain pretty “womanly” and which you worry will cause people to clock you as female. (I think detransitioners have a cleverer name for this phenomenon than ‘whack-a-mole dysphoria,’ but I’m blanking on it so I’ll go with this one.) To some detransitioners, this whack-a-mole dysphoria served as a warning sign that medical interventions weren’t providing the relief they hoped for — that maybe physically transitioning wasn’t, in fact, the right solution to the complicated problems they were grappling with.

Callahan had a lot to say about this subject when I interviewed her:

I met Carey in Columbus in March. She told me that her decision to detransition grew out of her experience working at a trans clinic in San Francisco in 2014 and 2015. “People had said often to me that when you transition, your gender dysphoria gets worse before it gets better,” she told me. “But I saw and knew so many people who were cutting themselves, starving themselves, never leaving their apartments. That made me doubt the narrative that if you make it all the way to medical transition, then it’s probably going to work out well for you.”

Carey said she met people who appeared to be grappling with severe trauma and mental illness, but were fixated on their next transition milestone, convinced that was the moment when they would get better. “I knew a lot of people committed to that narrative who didn’t seem to be doing well,” she recalled. Carey’s time at the clinic made her realize that testosterone hadn’t made her feel better in a sustained way either. She detransitioned, moved to Ohio, and is now calling for a more careful approach to treating gender dysphoria than what many detransitioners say they experienced themselves.

On the other hand, there are happily transitioned trans people who report having experienced something similar. We simply don’t know much about this phenomenon, why it happens, and what it means. But all this — both the existence of whack-a-mole dysphoria and how little-understood it is — is important information for anyone considering transitioning to have. The message here is not “If you experience whack-a-mole dysphoria, you should stop transitioning,” but rather something like, “Some detransitioners say they experienced whack-a-mole dysphoria, and, in retrospect, view it as having been a warning sign about having been on the wrong medical path. This doesn’t mean transition is wrong for you, but it’s simply something to be aware of.”

One setting in which a patient might, or might not, have this sort of thing explained to them is at an informed-consent clinic. Informed consent, in trans health contexts, is an important innovation which grant trans adults access to hormones and surgery if they say they want them, eliminating the possibility of a medical professional standing in the way, gatekeeping. But informed is a vital part of this idea — according to the relevant professional guidelines, such as the World Professional Association for Transgender Health’s Standards of Care (SOC), clinicians are supposed to inform patients, in a comprehensive way, of all the known benefits and potential risks and unknowns of whatever treatment they are hoping to gain access to. But according to Callahan and some other detransitioners, all too often clinicians forget the informed part: “As patients, us gender-dysphorics are flying blind in a lot of ways- no one is studying alternative methods of managing gender dysphoria, no one is studying our outcomes when we receive informed consent care, and no one is even studying whether clinics fulfill the tasks the SOC says they are supposed to,” she wrote in an important short blog post published Sunday. I’ve spoken with experienced clinicians who have expressed similar concerns — it is undeniably the case that in some trans healthcare setting people are getting subpar care because clinicians don’t sufficiently inform them about the treatments they are seeking.

Anecdotes are generally frowned upon in scientific contexts, for understandable reasons, but in any area with as thin a research base and as profound a lack of high-quality evidence as trans healthcare, a dash of it can be vital: No competent, informed, compassionate clinician would fail to tell a new patient that there is zero or near-zero data on American detransition rates, and that while the number might not be high, anecdotally, some patients detransition, and a subset of them report that whack-a-mole dysphoria was, in hindsight, a warning sign.

A similar logic should extend to good-faith journalism on this subject, and that, at long last, sums up my gripe with Devon Price’s Slate article: It steamrolls ahead with the assumption that whack-a-mole dysphoria is simply a normal bump in the road toward becoming a happily transitioned trans person, because for Price themself, it was (Price uses they/them pronouns). Price’s story is important, of course, and they are correct to point out that “the expectation of immediate joy” is an unrealistic way to look at transition, and that “much of public writing and thought about trans issues posits that transition should be unilaterally positive in order to be worthwhile,” which is an unsophisticated understanding of dysphoria and transition. But there are other stories too, and as is all too common in this subgenre of journalism, Slate and Price ignore them entirely.

That’s a problem when discussing a subject where there’s effectively no scientific evidence. It’s like if I held up Carey Callahan’s stories about what she saw at that clinic and concluded that anyone who experiences whack-a-mole dysphoria shouldn’t transition. That would be an unfair, overstretched reading of the available evidence — but so is Price’s story, which simply tosses aside the common-sense notion that for some people, whack-a-mole dysphoria might be an important warning sign that not all is going well with their transition.

Price’s story does what liberal journalism on gender dysphoria often does these days: It stakes out one side on an issue shrouded in genuine uncertainty, and accuses anyone on the other side, or in the middle, of being transphobic. Price writes that the unrealistic expectation of immediate relief from dysphoria “feeds into a lot of dangerous misconceptions—including the popular trans-critical myth of ‘rapid-onset gender dysphoria,’” which you can read about in a more balanced article than the one Price links to here. Setting aside the fact that to call ROGD a flat-out ‘myth’ is to run far ahead of the available evidence, at least according to a close reading of WPATH’s nuanced statement on the subject, the connection between ROGD and the article’s main argument is only loosely explained, and doesn’t really apply to medical interventions — and, therefore, to whack-a-mole dysphoria. (To overexplain: Early in the article, Price is clearly talking about a version of whack-a-mole dysphoria they themself have experienced while transitioning physically, but then they pivot to a similar but not really equivalent phenomenon involving kids suddenly getting more dysphoric after realizing they are trans.)

Whack-a-mole dysphoria and ROGD are, in fact, two distinct subjects, and one can easily talk about or debate one without mentioning the other. But by linking the two, Price contrives a false connection between one interpretation of the former and an immensely controversial subject in the trans community. This has the effect of rendering the opinion that whack-a-mole dysphoria might sometimes be a warning sign as, if not transphobic, at least transphobia-adjacent (because something something ROGD). But they really are totally separate concepts, and in fact, plenty of detransitioners have histories of dysphoria that look perfectly “traditional” and which don’t involve anything in the same ballpark as ROGD.

This rhetorical maneuvering allows Price to brush aside even the possibility that whack-a-mole dysphoria should be seen as a warning sign, just because it wasn’t for Price themself. This isn’t an appropriately measured treatment of this subject. It is absolutely true that a subset of trans people are happy they transitioned, but experienced setbacks along the way. But we also know that for at least some people, whack-a-mole dysphoria does augur trouble ahead, and might be a legitimate reason to at least slow things down and ask a few questions.

It’s irresponsible to simply ignore this possibility entirely, especially given how little we know about, well, any of this stuff. What percentage of people detransition? We don’t know. What percentage of people getting treatment for gender dysphoria develop whack-a-mole symptoms? We don’t know. What percentage of whack-a-mole dysphoria sufferers detransition? We don’t know. What percentage of happily transitioned people went through a period of whack-a-mole dysphoria? We don’t know.

We don’t know, we don’t know, we don’t know, we don’t know.

This is the problem with both Price’s article and a great deal of liberal writing on gender dysphoria: The we don’t knows, which are in fact legion, are either ignored or shoveled into a ramshackle shed labeled Transphobic Garbage where, the fallacious thinking goes, they won’t hurt anyone. There is, in this article and so many others, no attempt to grapple with the sheer uncertainty surrounding these subjects, no attempt to treat gender dysphoria with the same care and nuance with which outlets treat a whole host of other scientific subjects. Even on nichey subfacets of the broader gender-dysphoria discussion where there is almost no scientific evidence whatsoever, like whack-a-mole dysphoria, writers confidently proclaim the right answer — the only acceptable answer.

Imagine someone who experiences whack-a-mole dysphoria, and who then comes across this Slate article: Phew, they might think. I was worried that maybe this was something I should bring up with my doctor, but the idea that whack-a-mole dysphoria signals a real problem is clearly just a transphobic myth. But we don’t know this! You really can’t assume that any individual’s experience will line up with Price’s. A worsening of dysphoria symptoms while treatment is going on is absolutely something that a transitioning person should bring up with whichever clinicians they have access to, because in some cases it really might be a warning sign, even if it’s just a warning sign they were never given accurate, realistic information about what to expect from hormones and should receive some, or their dosage is off, or whatever else.

To publish a story like this, in which important testimonies are simply ignored — the term ‘detransition’ doesn’t come up — and in which a pat answer is provided to a question about which we don’t actually have anything approaching substantive data, isn’t good journalism. Unfortunately, this style of morally swashbuckling liberal coverage of gender dysphoria, characterized by a marked surfeit of certitude and deficit of evidence, is becoming all too common. In the long run, that is going to do harm, because when complicated things are presented as simple, people get hurt.

Some relatively minor tweaks would have rendered this a good, useful, balanced story. Price should have just toned down some of the article’s too-strong claims, acknowledged detransitioners exist and sometimes report whack-a-mole dysphoria, pointed out that no one can make strong, certain statements about what this phenomenon means because it’s such a little-understood subject, and nodded to the fact that one person’s experience is just that. None of this would have had any bearing on the article’s most interesting, important argument: People shouldn’t assume that transition is always a straight line of steady improvement, because sometimes, it isn’t.

That’s all it would have taken. In many other journalistic contexts, editors would ask for this basic level of due diligence, even in an opinion column. But I’m finding, more and more often, that editors at liberal outlets refuse to fully do their jobs on this subject. A real timorousness has set in when it comes to coverage of gender dysphoria, and it’s incredibly dispiriting to watch.

Questions? Comments? Threats involving the transphobia-shed? I’m at, or on Twitter at @jessesingal.