It’s just such an extreme, radical step to take. It’s bleeding obvious to me that the best and kindest way to handle gender dysphoria — for anyone, but especially kids — is to help them <become> comfortable in their body without resorting to cutting off major pieces of it.
That certainly is an obvious thing to think of. What technique would you recommend for helping kids with gender dysphoria become comfortable in their bodies, and how much evidence is there that it works?
Watchful waiting (the “treatment” before affirmation was all the rage). About 90% of kids grew out of it and, usually, going through puberty was the cure. That’s the point at which kids were happy to be male or female ( and in many cases realized “hey I don’t wish I was a boy/girl, I’m just lesbian/gay.”)
Because they are now middle-agers —and there are so many of them (easily googlable) — who talk about how grateful they are not to be young today, because they would have been transed, medically harmed, and their sexual function destroyed. Instead, they are happy, intact adults living life — which is more than can be said for, say, Jazz Jennings (for whom I have enormous sympathy). If anyone’s experience serves as a cautionary tale of everything that goes wrong by transing children, it’s poor Jazz’s.
Also, yes, a few middle-agers are transitioning today, but it’s nothing like the huge (hopefully soon playing out and waning) phenomenon we see in teens.
But whether you believe anyone grows out of their gender-related beliefs or not, here’s a more fundamental issue:
The 21st century Western notion of “being trans” is simply a cultural creation. It’s something we quite literally made up. We also made up the (harmful) “treatments” for it. If you’re interested in this topic I invite you to read https://bprice.substack.com/p/trans-is-something-we-made-up
Interesting. Do those other made-up cultural phenomena you mentioned there, like windigo and susto, also have observable biological markers and correlations with prenatal hormone exposure? Or is that unique to the made-up cultural phenomenon known as "being trans"?
I see you didn’t fully read the article then, so it’s impossible to engage fruitfully: what is underlying windigo? A real thing, anxiety. What is underlying “being trans” (as well as other cultures’ extremely varied expressions of similar phenomena?)? Gender nonconformity, a real thing, which may indeed across cultures and across times and places have underlying biological causes, be related to hormones etc.
What is unique and made up is not gender nonconformity (there are always, say, some extremely feminine men in each culture). What is made up is our wrong body narrative and set of “treatments” and beliefs which other cultures (including cultures with better outcomes for their GNC people) do not share.
Homosexuality has biomarkers; gender dysphoria not so much. And yes, windigo would have indistinguishable biomarkers from generalized anxiety (e.g. elevated cortisol)
Yes. Basically she’s doing what people did before mindless (and profitable) “affirmation and transition.” She does therapy with these kids to see what is at the root of their body-loathing. She’s amazing. I admire her enormously for doing this at a time when that’s considered by many to be “transphobic.”
Ironically she’s doing more to help gender-questioning kids than all the “gender clinics” put together.
“she wouldn’t force kids into a mental health exam before giving them insulin, so why would she make that a prerequisite for youth gender medicine?”
This is obnoxious from a supposed medical professional. The answer is obvious: because gender dysphoria is a mental illness, and type 1 diabetes isn’t.
Now before somebody runs off to Twitter cancel me, I understand why there are lots of social reasons why the average person would be uncomfortable with calling gender (or “chest”) dysphoria mental illness in casual conversation, and I don’t make a habit of running around calling trans people “mentally ill”. And I’m totally open to the idea that in at least some cases, the best treatment for gender dysphoria might be surgical transition.
But the reality is that by any definition that is remotely consistent, gender dysphoria is, medically speaking, a mental illness. And any medical professional needs to be cognizant of that and be willing to turn the best efforts of modern mental health care on the subject. To not do so is negligence.
“Trust the experts” only applies if the experts are willing to behave like experts, and that includes things like “doing the scientific method, not pantomiming it for activism”.
“This is obnoxious from a supposed medical professional. The answer is obvious: because gender dysphoria is a mental illness, and type 1 diabetes isn’t.”
The duplicity these people employ is beyond insane.
Part of the problem here is the complete breakdown in the ability of large part of the media (including our host; sorry, Jesse!) and medical profession to make the 100% accurate observation that being transgendered is a reality-denying psychiatric condition and proceed accordingly. That shouldn't even be controversial; it's *literally* what a declaration of believing you were "born in the wrong body" is! What someone needs to do is analyze the history of how the media and medical profession became so completely disarmed from dealing with this particular reality-denying psychiatric condition as compared to, say, paranoid schizophrenia, as it seems to have been the thin edge of the wedge on a lot of other issues these days.
Yeah if you don't want to call it a mental illness it's at least mental health related. I wouldn't necessarily call the moderate anxiety I occasionally take some benzos for a mental illness either, but it's certainly a mental health related issue. Same thing with ADD maybe it's not really a clear mental *illness* the way schizophrenia is but it's certainly related to mental health.
I experience more anxiety than the average person in certain situations and there's a extremely effective solution for that in benzos as long as you're capable of only taking them occasionally. My psychiatrist agrees that as long as a patient can take a medication responsibly it's not necessary that they be suffering life destroying consequences to be treated for it. Some other psychiatrists see it differently and will only write benzos in cases of extreme acute panic attacks or Generalized Anxiety Disorder so bad you're not leaving the house. Of course these same docs have zero issue throwing SSRIs at every single person who walks through the door so it's not really principled about meeting the conditions of the mental illness it's just being stingy with benzos, which I agree they should be careful with, but if you write someone a script for 10 Ativan and they don't ask for a refill until 4 months later I think it's pretty safe so say they're not abusing the meds.
Yeah, that comment is really frustrating. If you don't give some one insulin who is diabetic they will get sick and die. But you wouldn't just give insulin to someone who walked in off the street without a prescription and said 'I think I'm diabetic, give me insulin', because giving insulin to a non-diabetic will hurt them. You wouldn't give ritalin to someone without actually figuring out if they suffer from ADD and you wouldn't give anti-depressants to someone unless you determined they were depressed etc. and needed them.
There's this bizarre desire see hormones/surgery as life saving care and yet also somehow not a medical decision at all. I notice we don't even say 'sex-change' any more.
My instinct is to agree. Are there other cases where a slang/informal term for a major medical procedure has been taken on by doctors/researchers as their preferred term? It seems rare, at the very least, to me.
However I don't fault Jesse for using the term "top surgery" since he's trying hard not to appear biased against the trans community. I can see not wanting to die on a hill that's just about terminology (even if that terminology is dangerous).
"Are there other cases where a slang/informal term for a major medical procedure has been taken on by doctors/researchers as their preferred term? It seems rare, at the very least, to me."
Yes, it's very common among plastic surgeons to use terms like "face lift" and "tummy tuck" when speaking to the public.
Cosmetic surgery does seem like a special category though. And part of the problem with gender "affirming" surgery seems to be that it is sold by activists as having no more downside than a (successful) cosmetic procedure.
There's also getting your tubes tied, which is elective, but not cosmetic. I've heard of vasectomies being called The Snip, but only in really informal settings.
There's also a kind of in-group faux-hipness to "top surgery," I think; saying "top surgery" implies that you're so immersed in the scene that you don't need to explain "top of what?" I find it grating for that reason as well.
Does it help differentiate "done for breast cancer reasons" from "done for dysphoria reasons"?
If someone says they got a double mastectomy I would infer there was a non-dysphoria issue.
If they say "top surgery" I assume a dysphoria issue.
Regardless of whether you think these surgeries are justified for dysphoria, that seems like an at least somewhat useful distinction/connotation. (edit: fixed pluralization of surgery)
I don't know... rhinoplasty is rhinoplasty, whether it's done for aesthetic or physiological (breathing) reasons.
But even allowing for the use of different terms, "top surgery" is still a deliberately unclear euphemism chosen precisely because it hides what it does. So if you want a different term, drop the Latin and call it "breast removal" or the like. But not "top surgery" (and "bottom surgery is even worse), which sounds like how you'd explain it to a toddler.
I guess "Top surgery" though _also_ lets you combine both breast augmentation (for trans females) and breast removal (for trans males)
"Bottom surgery" then covers both vaginoplasty and phalloplasty.
I agree that the terms are partly chosen to sound less invasive/serious, but they do _also_ differentiate/categorize in a useful way.
And aren't even 'mastectomy' and 'rhinoplasty' chosen for how they sound?
'Rhinoplasty' sounds much more serious than 'nose job' so it doesn't sound like a vanity project.
'Mastectomy' I think sounds (or sounded - once everyone knows what it means the euphemism treadmill has done its work and they sound the same) less bad than 'breast removal'.
Yeah that’s what I was thinking. Rightly or wrongly, that’s the same connotation I get, even though I technically know that both are essentially the same thing (plus or minus the cosmetic adjustments one may make depending on whether you want the result to look like a male chest or a female chest with tiny boobs)
Well there is that angle; gaslighting the mentally infirm into willfully participating in their own sterilization. The Nazis would have found that brilliant.
It is truly bizarre to see how willing the medical establishment has been to double- and triple-down on the idea that no one needs to worry about any of this because gender-affirming care is literally NEVER administered based on a misdiagnosis. Sure, the Rachel Levines and Jack Turbans of the world will admit (if pushed), giving teen girls double mastectomies as a treatment for anxiety and depression might not make sense if their anxiety and depression are coming from causes other than gender dysphoria. But don't worry! Clinicians are able, with 100% accuracy, to ALWAYS accurately detect when anxiety and depression are caused by true, persistent, gender dysphoria. And no clinic in these United States has ever, or will ever, perform a double mastectomy on this population without one of those perfectly accurate diagnoses (but don't you dare suggest mastectomies should be limited to those who've received significant counseling and diagnosis, you filthy gatekeeper).
It's just nuts. I'd wager that every person on this board has, personally, been the recipient of at least one medical diagnosis that, in retrospect, proved obviously incorrect. Medical diagnoses are really hard! The idea that we don't need to worry about mistakes in gender-affirming care because NO MISTAKES WILL EVER BE MADE is insane.
Oh, don't worry. Dr. Olson-Kennedy famously pointed out that if a patient changes their mind, they can always get reconstructive surgery. So what's the big deal?
And just like that, the clinic can get paid twice. Once to lop off the patients' natural breasts and then again to sew on new fake ones a few years later.
That comment by Olson-Kennedy is really unbelievable, isn't it? I don't know whether it's more stupid, more ignorant, or more condescendingly arrogant.
Anybody who has ever been involved in mental health care, or is close to someone who has, should absolutely understand that the idea of getting a diagnosis and a treatment right on the first try with any consistency is laughably naive (my now-wife was diagnosed with like 3 different things before they settled on bipolar disorder and has been on at least half a dozen different treatments, not counting dosage changes, before they settled on something that consistently worked).
The thing is they're also dealing with motivated patients. It's like screening adults for ADD you're gonna get a fair amount of ppl who specifically want to be Dx w/ Adult ADHD so that they can be prescribed Adderall . The smart ones will go online and quickly get a good overview of what they should say and how they should respond to questions in the ADD assessment they're asked to fill out. With these childhood GD cases you've got basically the same thing. A group of highly motivated patients seeking a specific thing who have been told or read online exactly how they should respond to these assessments. So even just checking all the boxes and doing all the assessments isn't really enough.
The psychiatrist really needs to interview the patient in detail to get a more honest view of the patient. Ideally they'd have a neutral non activist therapist talk to them for several sessions. It's much easier to con a quick assessment form than it is to keep up an act for hours of therapy.
If they want any hope of getting something approaching the honest truth they need to evaluate these kids over many sessions and using many different assessments that the patient likely hasn't taken the equivalent of a study prep course for.
It's also critical for doing differential diagnosis. Even without some highly motivated patients who've been coached on how to answer questions there's still a chance someone could score high on GD but the underlying cause be another mental health issue. When it comes to young kids they should be screening for basically everything else and trying out treatments for those discovered conditions before pulling the trigger on permanently life altering medical interventions.
I think this is a very good point. I generally agree with the point that much of psychiatry is less well justified than the rest of medicine. That's one reason I am so skeptical of surgical treatments for mental/emotional complaints such as gender dysphoria.
However, if you're trying to win over the psychiatric establishment and turn them away from particularly bad behavior, it makes sense to be strategic, and make a distinction between better and worse methods of diagnosis and treatment, and better and worse research. I think that's what Jesse is trying to do.
we <all> would have scored highly on it at 14. I remember sleeping on my stomach at age 11 to try to flatten my chest. I couldn’t have put it into words then, but I knew the trouble that boobs would bring me.
And when I was 14 I would have scored highly on it for being upset that I still barely filled out an A cup. Would anyone suggest that a late to mature adolescent girl should get implants to assuage her dysphoria? After all, you can just get them removed later if you want! Invasive medical procedures for everyone!!!
My girl wore a 32c cup at 14 and wasn’t finished growing! She hated it and hated the attention as well, but never in a million years would I have said “sure honey, let’s get you a double mastectomy.”
Yeah she really had a time of it, especially with her brothers’ friends. Got to the point we had to stop sleepovers for the boys for a while but all survived.
Best of all, she experienced the singular joy of nursing her babies. Had she been denied that by virtue of her parents capitulating to her adolescent self she’s have had good cause to hate us.
And it’s probably not limited to girls. I don’t particularly care now but my disproportionately large man boobs were a major source of physical anxiety for me at that age.
As a woman with a naturally large bust, I second this. Girls with large busts are subject to a lot of really shitty behaviors and expected to just deal with it. The answer we get from adults is often along the lines of "you need to dress in a way that makes them less obvious", in other words, "it's your fault". It gets a bit better once you're an adult, but you also encounter people who wave it off because supposedly a large bust is valued in society.
It seems deeply misogynistic to treat this as a problem of girls and women with large busts rather than as a problem with (mostly) men treating girls and women based on their appearance.
It's not misogynistic, it's practical? You can easily tell your daughter what to do to minimize the issue on her side of things; it's literally impossible to tell all males everywhere your daughter might go to behave themselves. That's not to say that society *shouldn't* still communicate to men and boys that such behavior is unacceptable, but that's a multi-year project -- it's not going to do anything to prevent some random guy from shouting, "Looking good, chesty" at your daughter as she walks down the street tomorrow.
Unquestionably she had to learn to dismiss unsolicited attention and her clothing choices are still deliberate.
The boys’ friends on the other hand were far too invasive until we spoke to them, one going so far as to enter her room early one morning. For a few not even the conversation worked.
It was a situation of young male hormones run rampant in the midst of a young woman and we understood, which is why we had to put a stop to the boys’ friends staying overnight for a while. As I said, everyone survived.
All that to say these issues are a common part of adolescence, not a symptom of mental illness requiring mastectomies.
Can we get into a deep dive into the bombshell Reuters dropped, that the drug companies making puberty blockers are actively refusing to pursue FDA approval for use in trans youth?
Makes sense to me in a twisted, late capitalism way. Usually, FDA approval is sought because without it, doctors are reluctant to prescribe the drug, which limits sales. But since so many "affirming" doctors are willing to prescribe Lupron et al off-label, the manufacturers really have no financial incentive to roll the dice on an FDA-controlled risk/benefit study; their revenue numbers are doing just fine as-is.
My main question is: where does the malpractice buck stop? Is it the individual doctors who wrote the prescriptions, the clinics where they operated out of, or like Purdue pharmacy with Oxy, could detransitioners potentially sue the drug manufacturers themselves?
Same principle would seem to apply in both scenarios; plenty of kids willing to volunteer for puberty blockers, so just give some of them placebos.
If giving untested drugs to kids was a FDA dealbreaker, it would be impossible to bootstrap ANY pediatric drugs through the approval process. "Can't give it to kids because it's untested; can't test it because that would require giving it to kids" would be an insurmountable obstacle if it was that cut and dry.
I'd be a little concerned about letting people sue the manufacturers, maybe if they were pushing the off-label use on doctors.
I had some persistent nerve pain in my foot and was prescribed a short-term course of an... antidepressant?(that or something similar) that was apparently known to have reasonably valid off-label uses for my neuropathy.
Had something gone wrong, I'd be inclined to blame the doctor, but not the manufacturer, under the thinking that the doctor was the one who was responsible for suggesting the treatment. (Had something gone wrong I may/may not have been _correct_ in blaming the doctor, just how I might have felt)
Edit, oops forgot this point
Also... if off-label uses are in fact good, but manufacturers can be sued, then that really cracks down on them _across the board_ - all uses.
I'm thinking that refusing to pursue approval when they already know the drug is being pervasively used off-label might qualify as implicitly encouraging the off-label nature of the prescriptions.
I don't think that route could (or should) work. Unless the company is in fact actively (if subtly) endorsing the off-label use (for instance, by distributing articles that promote such use).
I’m thinking that if someone attempted to sue the manufacturer, the manufacturer’s defense could be zillions of articles and “studies” purportedly showing that the drugs were life saving interventions with almost no negative side effects.
Basically, Look, the doctors on the ground and all the major American medical associations swore this was great. How could we know they were all wrong to the point of criminality?
Fair—but wasn’t it revealed that they had suppressed research and/or actively campaigned to get the drugs into widespread circulation?
Seems like in this case, the Dutch did a little trial off-label 15 years ago and then other doctors independently and without nudging from pharmaceutical companies followed suit.
I don't know about suppressing research, but Purdue actively marketed Oxy as "addiction-proof" to doctors. If Lupron makers are actively marketing the drug as "safe and reversible", then that's a similar situation.
Both are ultimately cases of 'too good to be true' medicine. Chronic pain is a legitimate moral conundrum for doctors, because the most effective drugs to treat it come with serious addiction risks. When a newly-hyped miracle drug comes along promising doctors the best of both worlds (make their patients pain go away without turning them into junkies in the process), of course lots of doctors jumped on the bandwagon (the kickback compensation also helped grease the wheels).
With trans/potentially trans minors, the longer the doctors wait to facilitate transition, the tougher time the patients will have 'passing', because they'll have gone through their natal puberty which is pretty much a one-way trip. But the sooner the transition is facilitated, the greater the risk of patients regretting what they thought they wanted but turned out to be 'irreversible damage'.
So between newly hyped "safe and effective" puberty blockers promising a "pause button" on natal puberty, and "studies" showing that early transitions neeeeeeever backfire, doctors are being told things about youth gender medicine that are quite literally too good be true.
In the case of Oxy, the manufacturers were ultimately held accountable for their "too good to be true" marketing campaign. In the case of Lupron, the only difference might be that if the drug companies can show that Tumblr/TikTok activists are doing all the marketing on a pro-bono basis, then the manufacturers hands might be cleaner than those of Purdue.
Just stepping away from the context and looking at the methodology here, it’s infuriating that they try to apply statistical (sorry, data science) techniques which only really make sense with continuous data, to bullshit measures which are flags or at best discrete values. That bollocks CDM could be improved, from a certain point of view, by using a single question “do you have breasts?” And taking the values zero and one. This would give 100% improvement after surgery with a completely sound statistical basis, but telling us nothing of any use.
I could understand this if the audience for the articles was the general public this is published in a scientific journal. Are those people really so statistically illiterate that they just let this go without a hint of worry?
I'd love to see an experiment where science reporters are given equally strong/weak data sets but on different topics. One set of data could be like the data in this article "proving" that top surgery for teens is helfpul. The other could be equally strong/weak data "proving" that a 6-month course of therapy in lieu of puberty blockers is helpful. What headlines would they write based on each of these data sets?
That CDM survey is too much. If it gets validated, then I REALLY will lose all faith in the medical establishment. (1) As Jesse and other commenters have pointed out, many would score high no matter what, and it's designed to get lower scores following mastectomy, no matter how one's feeling about it. (2) The questions are leading and will get higher scores due to the power of suggestion. Even an adolescent who isn't particularly self-conscious in a bikini will think: Oh, maybe I should be? (3) An adolescent or young woman coming in convinced they need to medically "transition" will know exactly how to answer the questions to get what they want. Granted, that is a danger with a lot of these types of self-scored subjective surveys, but it's particularly egregious in this case.
I'm scoring about a 12-14 as a busty woman who's perfectly happy with her breasts. Some of them seem like good questions, but stuff like "I have to buy certain clothes because of my chest" (I do, because there's a bunch of cuts that don't fit right because my breasts are large) are going to flag innocuous things.
Your observation brings up another problem: the phrase "because of my chest." What does that mean? Because I have female breasts, period? Because I don't like the (or I worry that others don't like... or DO like) the particular size or shape of my breasts? Etc.
I also like this one: "I worry that people are looking at my chest." Pretty close to universal concern, there.
The scoring for the statements doesn't even make sense! In most cases, larger numbers seem to indicate that the respondent does not like their chest. But the very first one is "I like looking at my chest in the mirror," which surely a person with chest dysphoria would put at a 0, no? The rest of them are okay scoring-wise, until you get to the additional ones, which are a mess.
I made a comment a day or two ago about the same thing regarding the first statement. Jesse Singal pointed out that the people scoring the survey should know to reverse the scoring for that one. Regardless, it's a mess.
"It's convenient to think of yourself as being on the right side of history. Your critics become dinosaurs in their own time, incapable of understanding. You may be incapable of understanding, too, but at least you have faith. At least you have given yourself over to the cause.
The further you go—the more patients you cut up, the more critics you silence—the harder it is to see your destination clearly. But it must be beautiful and just because you've sacrificed for it and identified yourself with it and you are a Good Person.
The entire conference spoke to this Good Person. You are a good person because you are overcoming your biases. You are a good person because you oppose the bad people (even if you don't understand them and we won't talk about them because that would be like letting them win)."
"The endpoint of this education in 'allyship' is a person who cannot question what she supports because she cannot see it, because she lacks the language to formulate the question, because she lacks the confidence of her own perceptions, because she has 'problematized' away any ground she might stand on or any principle she might insist on. She looks on real horrors with starry eyes because she must.
Of course the bad feelings don't really go away. The horror doesn't go away. But you lose touch with its true sources. You project it on the only people against whom you're allowed—encouraged—to vent bad feelings: the people trying to warn you you’re causing harm.
The more horror you must sublimate, the more horrible your detractors must become, even if the worst thing they say is simply: look. Look at what you’re doing."
Sounds an awful lot like what just happened this week with the AMA asking the DOJ to pursue domestic terrorism charges against the "look at what they're doing" brigade of Chris Rufo, LoTT, etc.
All of this feels like it should ultimately lead to some Alec Guiness-in-The Bridge on the River Kwai, "What have I done?" moment, but I highly doubt that will happen to any degree given what went on with the state-run eugenics programs of the early 20th Century.
I have arrived at the point I no longer trust anyone who can’t bust out a Vizio flow doc and explain each step in their thinking as well as how they handle exceptions.
Please come out publicly with this information! With "receipts" if possible (and if possible to do without violating privacy.) There's a pernicious lie going around that this does not happen. The more solid, specific evidence of what's going on, the better.
Every time I read one of these pieces of yours, Jesse, I get almost paralyzed by disbelief.
I’m so glad you’re doing this work—and I’m so happy to contribute every month so that you can—but it is just *bananas* that each and every study is so flawed it basically never should’ve passed review let alone get touted in MSM articles as proving “lifesaving care”!
The correlation between chest dysphoria and anxiety/depression seems like it wouldn't necessarily be relevant to this study even if it was strong. The correlation is at a single point in time, they haven't presented any evidence that decreasing one effects the other. Also those r values are pitiful. Even assuming the relationship WAS causal those r values implied that 'chest dysphoria' explains 1-4% of the anxiety/depression differences. A double mastectomy is a pretty radical intervention for that kind of response...
Yes, these are all good points that I eschewed so as to not get too deep into the weeds. But "X and Y are correlated" of course does not imply that if you change X, Y will move with it. That comes up in my book at least once or twice.
So what happens when some troubled individuals decide they'd be happier without thumbs? Or toes? Or vision in both eyes? Will a cottage medical industry in elective amputation spring up? Will universities put out skewed studies affirming the benefits self-mutilation? Will schools declare that information on students considering radical destructive surgery be concealed from parents?
This is madness.
There's an old short story by Ray Bradbury titled "The Watchful Poker Chip of H Matisse" about this very thing...a man who incrementally cuts off pieces of himself and replaces them with inanimate objects to make himself more "interesting." It was written as satire. And we are rapidly getting there.
"Based on the subjects' reports we found that BIID has an onset in early childhood. The main rationale given for their desire for body modification is to feel complete or to feel satisfied inside. Somatic and severe psychiatric co-morbidity is unusual, but depressive symptoms and mood disorders can be present, possibly secondary to the enormous distress BIID puts upon a person. Amputation and paralyzation variant do not differ in any clinical variable. Surgery is found helpful in all subjects who underwent amputation and those subjects score significantly lower on a disability scale than BIID subjects without body modification."
"Amputation of the healthy body part appears to result in remission of BIID and an impressive improvement of quality of life. Knowledge of and respect for the desires of BIID individuals are the first steps in providing care and may decrease the huge burden they experience."
That conclusion is a pretty generous reading, I would say.
A study of 54 individuals, based on a questionnaire, through email, composed primarily of "Caucasian" men.. The 7 who had "completed" amputations reported reduced BIID (well, yeah), but there were also reports of medication and therapy being helpful. One woman, with schizophrenia, was included in the study, but four individuals were eliminated because their primary motivation was sexual.
I really enjoy your articles (and your book) that go beyond headlines to look deeper into research papers and analyze whether the papers actually prove what the press releases or articles say they prove.
It’s just such an extreme, radical step to take. It’s bleeding obvious to me that the best and kindest way to handle gender dysphoria — for anyone, but especially kids — is to help them <become> comfortable in their body without resorting to cutting off major pieces of it.
If only common sense were common. . ..
That certainly is an obvious thing to think of. What technique would you recommend for helping kids with gender dysphoria become comfortable in their bodies, and how much evidence is there that it works?
Watchful waiting (the “treatment” before affirmation was all the rage). About 90% of kids grew out of it and, usually, going through puberty was the cure. That’s the point at which kids were happy to be male or female ( and in many cases realized “hey I don’t wish I was a boy/girl, I’m just lesbian/gay.”)
Considering that many people transition in their 30s, 40s, or later, how can we be sure that those kids *actually* grew out of it?
Because they are now middle-agers —and there are so many of them (easily googlable) — who talk about how grateful they are not to be young today, because they would have been transed, medically harmed, and their sexual function destroyed. Instead, they are happy, intact adults living life — which is more than can be said for, say, Jazz Jennings (for whom I have enormous sympathy). If anyone’s experience serves as a cautionary tale of everything that goes wrong by transing children, it’s poor Jazz’s.
Also, yes, a few middle-agers are transitioning today, but it’s nothing like the huge (hopefully soon playing out and waning) phenomenon we see in teens.
But whether you believe anyone grows out of their gender-related beliefs or not, here’s a more fundamental issue:
The 21st century Western notion of “being trans” is simply a cultural creation. It’s something we quite literally made up. We also made up the (harmful) “treatments” for it. If you’re interested in this topic I invite you to read https://bprice.substack.com/p/trans-is-something-we-made-up
Interesting. Do those other made-up cultural phenomena you mentioned there, like windigo and susto, also have observable biological markers and correlations with prenatal hormone exposure? Or is that unique to the made-up cultural phenomenon known as "being trans"?
I see you didn’t fully read the article then, so it’s impossible to engage fruitfully: what is underlying windigo? A real thing, anxiety. What is underlying “being trans” (as well as other cultures’ extremely varied expressions of similar phenomena?)? Gender nonconformity, a real thing, which may indeed across cultures and across times and places have underlying biological causes, be related to hormones etc.
What is unique and made up is not gender nonconformity (there are always, say, some extremely feminine men in each culture). What is made up is our wrong body narrative and set of “treatments” and beliefs which other cultures (including cultures with better outcomes for their GNC people) do not share.
Homosexuality has biomarkers; gender dysphoria not so much. And yes, windigo would have indistinguishable biomarkers from generalized anxiety (e.g. elevated cortisol)
My impression is that those are a different population, but you raise a good point.
Go over to the Gender: A Wider Lens podcast for much more about this. Sasha Ayad (one of the podcasters) does Gender Exploratory Therapy.
Yes. Basically she’s doing what people did before mindless (and profitable) “affirmation and transition.” She does therapy with these kids to see what is at the root of their body-loathing. She’s amazing. I admire her enormously for doing this at a time when that’s considered by many to be “transphobic.”
Ironically she’s doing more to help gender-questioning kids than all the “gender clinics” put together.
“she wouldn’t force kids into a mental health exam before giving them insulin, so why would she make that a prerequisite for youth gender medicine?”
This is obnoxious from a supposed medical professional. The answer is obvious: because gender dysphoria is a mental illness, and type 1 diabetes isn’t.
Now before somebody runs off to Twitter cancel me, I understand why there are lots of social reasons why the average person would be uncomfortable with calling gender (or “chest”) dysphoria mental illness in casual conversation, and I don’t make a habit of running around calling trans people “mentally ill”. And I’m totally open to the idea that in at least some cases, the best treatment for gender dysphoria might be surgical transition.
But the reality is that by any definition that is remotely consistent, gender dysphoria is, medically speaking, a mental illness. And any medical professional needs to be cognizant of that and be willing to turn the best efforts of modern mental health care on the subject. To not do so is negligence.
“Trust the experts” only applies if the experts are willing to behave like experts, and that includes things like “doing the scientific method, not pantomiming it for activism”.
Heck, you can go even more agnostic and just say “because there’s no blood test for chest dysphoria.”
“This is obnoxious from a supposed medical professional. The answer is obvious: because gender dysphoria is a mental illness, and type 1 diabetes isn’t.”
The duplicity these people employ is beyond insane.
Part of the problem here is the complete breakdown in the ability of large part of the media (including our host; sorry, Jesse!) and medical profession to make the 100% accurate observation that being transgendered is a reality-denying psychiatric condition and proceed accordingly. That shouldn't even be controversial; it's *literally* what a declaration of believing you were "born in the wrong body" is! What someone needs to do is analyze the history of how the media and medical profession became so completely disarmed from dealing with this particular reality-denying psychiatric condition as compared to, say, paranoid schizophrenia, as it seems to have been the thin edge of the wedge on a lot of other issues these days.
Yeah if you don't want to call it a mental illness it's at least mental health related. I wouldn't necessarily call the moderate anxiety I occasionally take some benzos for a mental illness either, but it's certainly a mental health related issue. Same thing with ADD maybe it's not really a clear mental *illness* the way schizophrenia is but it's certainly related to mental health.
I experience more anxiety than the average person in certain situations and there's a extremely effective solution for that in benzos as long as you're capable of only taking them occasionally. My psychiatrist agrees that as long as a patient can take a medication responsibly it's not necessary that they be suffering life destroying consequences to be treated for it. Some other psychiatrists see it differently and will only write benzos in cases of extreme acute panic attacks or Generalized Anxiety Disorder so bad you're not leaving the house. Of course these same docs have zero issue throwing SSRIs at every single person who walks through the door so it's not really principled about meeting the conditions of the mental illness it's just being stingy with benzos, which I agree they should be careful with, but if you write someone a script for 10 Ativan and they don't ask for a refill until 4 months later I think it's pretty safe so say they're not abusing the meds.
Yeah, that comment is really frustrating. If you don't give some one insulin who is diabetic they will get sick and die. But you wouldn't just give insulin to someone who walked in off the street without a prescription and said 'I think I'm diabetic, give me insulin', because giving insulin to a non-diabetic will hurt them. You wouldn't give ritalin to someone without actually figuring out if they suffer from ADD and you wouldn't give anti-depressants to someone unless you determined they were depressed etc. and needed them.
There's this bizarre desire see hormones/surgery as life saving care and yet also somehow not a medical decision at all. I notice we don't even say 'sex-change' any more.
Why has “top surgery” replaced “double mastectomy”? Purely for its euphemistic quality? If so, why are we going along with this?
I never say "top surgery"! Euphemisms have no place in medical care.
My instinct is to agree. Are there other cases where a slang/informal term for a major medical procedure has been taken on by doctors/researchers as their preferred term? It seems rare, at the very least, to me.
However I don't fault Jesse for using the term "top surgery" since he's trying hard not to appear biased against the trans community. I can see not wanting to die on a hill that's just about terminology (even if that terminology is dangerous).
"Are there other cases where a slang/informal term for a major medical procedure has been taken on by doctors/researchers as their preferred term? It seems rare, at the very least, to me."
Yes, it's very common among plastic surgeons to use terms like "face lift" and "tummy tuck" when speaking to the public.
Ah, thanks for those examples.
Cosmetic surgery does seem like a special category though. And part of the problem with gender "affirming" surgery seems to be that it is sold by activists as having no more downside than a (successful) cosmetic procedure.
There's also getting your tubes tied, which is elective, but not cosmetic. I've heard of vasectomies being called The Snip, but only in really informal settings.
There's also a kind of in-group faux-hipness to "top surgery," I think; saying "top surgery" implies that you're so immersed in the scene that you don't need to explain "top of what?" I find it grating for that reason as well.
Yes...and that makes it sound more acceptable.
Does it help differentiate "done for breast cancer reasons" from "done for dysphoria reasons"?
If someone says they got a double mastectomy I would infer there was a non-dysphoria issue.
If they say "top surgery" I assume a dysphoria issue.
Regardless of whether you think these surgeries are justified for dysphoria, that seems like an at least somewhat useful distinction/connotation. (edit: fixed pluralization of surgery)
I don't know... rhinoplasty is rhinoplasty, whether it's done for aesthetic or physiological (breathing) reasons.
But even allowing for the use of different terms, "top surgery" is still a deliberately unclear euphemism chosen precisely because it hides what it does. So if you want a different term, drop the Latin and call it "breast removal" or the like. But not "top surgery" (and "bottom surgery is even worse), which sounds like how you'd explain it to a toddler.
I guess "Top surgery" though _also_ lets you combine both breast augmentation (for trans females) and breast removal (for trans males)
"Bottom surgery" then covers both vaginoplasty and phalloplasty.
I agree that the terms are partly chosen to sound less invasive/serious, but they do _also_ differentiate/categorize in a useful way.
And aren't even 'mastectomy' and 'rhinoplasty' chosen for how they sound?
'Rhinoplasty' sounds much more serious than 'nose job' so it doesn't sound like a vanity project.
'Mastectomy' I think sounds (or sounded - once everyone knows what it means the euphemism treadmill has done its work and they sound the same) less bad than 'breast removal'.
Correction: mastectomy is based on Greek, not Latin.
Yeah that’s what I was thinking. Rightly or wrongly, that’s the same connotation I get, even though I technically know that both are essentially the same thing (plus or minus the cosmetic adjustments one may make depending on whether you want the result to look like a male chest or a female chest with tiny boobs)
“Top surgery” is covered by insurance.
"Mutilation" is a bit of a loaded term though. A nose job generally isn't called "facial mutilation".
Well there is that angle; gaslighting the mentally infirm into willfully participating in their own sterilization. The Nazis would have found that brilliant.
It is truly bizarre to see how willing the medical establishment has been to double- and triple-down on the idea that no one needs to worry about any of this because gender-affirming care is literally NEVER administered based on a misdiagnosis. Sure, the Rachel Levines and Jack Turbans of the world will admit (if pushed), giving teen girls double mastectomies as a treatment for anxiety and depression might not make sense if their anxiety and depression are coming from causes other than gender dysphoria. But don't worry! Clinicians are able, with 100% accuracy, to ALWAYS accurately detect when anxiety and depression are caused by true, persistent, gender dysphoria. And no clinic in these United States has ever, or will ever, perform a double mastectomy on this population without one of those perfectly accurate diagnoses (but don't you dare suggest mastectomies should be limited to those who've received significant counseling and diagnosis, you filthy gatekeeper).
It's just nuts. I'd wager that every person on this board has, personally, been the recipient of at least one medical diagnosis that, in retrospect, proved obviously incorrect. Medical diagnoses are really hard! The idea that we don't need to worry about mistakes in gender-affirming care because NO MISTAKES WILL EVER BE MADE is insane.
Add to all of that the fact that the "diagnosis" is officially up to the child, and that suggesting alternative explanations is supposedly unethical.
Oh, don't worry. Dr. Olson-Kennedy famously pointed out that if a patient changes their mind, they can always get reconstructive surgery. So what's the big deal?
And just like that, the clinic can get paid twice. Once to lop off the patients' natural breasts and then again to sew on new fake ones a few years later.
Which will also need to replaced every ten years. KA CHING
That comment by Olson-Kennedy is really unbelievable, isn't it? I don't know whether it's more stupid, more ignorant, or more condescendingly arrogant.
Dr. Olson-Kennedy must have read 'Sneetches' and thought Sylvester McMonkey McBean was really on to something.
Anybody who has ever been involved in mental health care, or is close to someone who has, should absolutely understand that the idea of getting a diagnosis and a treatment right on the first try with any consistency is laughably naive (my now-wife was diagnosed with like 3 different things before they settled on bipolar disorder and has been on at least half a dozen different treatments, not counting dosage changes, before they settled on something that consistently worked).
As a Biological Psychologist, I agree with you completely.
The thing is they're also dealing with motivated patients. It's like screening adults for ADD you're gonna get a fair amount of ppl who specifically want to be Dx w/ Adult ADHD so that they can be prescribed Adderall . The smart ones will go online and quickly get a good overview of what they should say and how they should respond to questions in the ADD assessment they're asked to fill out. With these childhood GD cases you've got basically the same thing. A group of highly motivated patients seeking a specific thing who have been told or read online exactly how they should respond to these assessments. So even just checking all the boxes and doing all the assessments isn't really enough.
The psychiatrist really needs to interview the patient in detail to get a more honest view of the patient. Ideally they'd have a neutral non activist therapist talk to them for several sessions. It's much easier to con a quick assessment form than it is to keep up an act for hours of therapy.
If they want any hope of getting something approaching the honest truth they need to evaluate these kids over many sessions and using many different assessments that the patient likely hasn't taken the equivalent of a study prep course for.
It's also critical for doing differential diagnosis. Even without some highly motivated patients who've been coached on how to answer questions there's still a chance someone could score high on GD but the underlying cause be another mental health issue. When it comes to young kids they should be screening for basically everything else and trying out treatments for those discovered conditions before pulling the trigger on permanently life altering medical interventions.
I think this is a very good point. I generally agree with the point that much of psychiatry is less well justified than the rest of medicine. That's one reason I am so skeptical of surgical treatments for mental/emotional complaints such as gender dysphoria.
However, if you're trying to win over the psychiatric establishment and turn them away from particularly bad behavior, it makes sense to be strategic, and make a distinction between better and worse methods of diagnosis and treatment, and better and worse research. I think that's what Jesse is trying to do.
My daughter would’ve scored very high on that absurd chest survey at age 14 and it had absolutely nothing to do with any dysphoria or trans nonsense.
It had everything to do with drawing boys’ attention and getting through normal adolescence with a disproportionately large bust size.
What a freaking insane world. No wonder other countries are showing this lunacy to their populations and asking, “do you want this done to your kids?”
we <all> would have scored highly on it at 14. I remember sleeping on my stomach at age 11 to try to flatten my chest. I couldn’t have put it into words then, but I knew the trouble that boobs would bring me.
And when I was 14 I would have scored highly on it for being upset that I still barely filled out an A cup. Would anyone suggest that a late to mature adolescent girl should get implants to assuage her dysphoria? After all, you can just get them removed later if you want! Invasive medical procedures for everyone!!!
My girl wore a 32c cup at 14 and wasn’t finished growing! She hated it and hated the attention as well, but never in a million years would I have said “sure honey, let’s get you a double mastectomy.”
oh, poor girl. by no means was I even close to that size, but I was simply horrified when my mom made me start wearing a training bra.
Yeah she really had a time of it, especially with her brothers’ friends. Got to the point we had to stop sleepovers for the boys for a while but all survived.
Best of all, she experienced the singular joy of nursing her babies. Had she been denied that by virtue of her parents capitulating to her adolescent self she’s have had good cause to hate us.
And it’s probably not limited to girls. I don’t particularly care now but my disproportionately large man boobs were a major source of physical anxiety for me at that age.
Hereditary gyno does indeed limit what you can wear
Well, bigger impact on what you can be comfortable NOT wearing, but yeah.
The wrong kind of shirt can draw attention to it far more than going shirtless would, is my experience.
Also true
As a woman with a naturally large bust, I second this. Girls with large busts are subject to a lot of really shitty behaviors and expected to just deal with it. The answer we get from adults is often along the lines of "you need to dress in a way that makes them less obvious", in other words, "it's your fault". It gets a bit better once you're an adult, but you also encounter people who wave it off because supposedly a large bust is valued in society.
It seems deeply misogynistic to treat this as a problem of girls and women with large busts rather than as a problem with (mostly) men treating girls and women based on their appearance.
We had more than one uncomfortable conversation with our sons’ friends about that very thing.
It's not misogynistic, it's practical? You can easily tell your daughter what to do to minimize the issue on her side of things; it's literally impossible to tell all males everywhere your daughter might go to behave themselves. That's not to say that society *shouldn't* still communicate to men and boys that such behavior is unacceptable, but that's a multi-year project -- it's not going to do anything to prevent some random guy from shouting, "Looking good, chesty" at your daughter as she walks down the street tomorrow.
Unquestionably she had to learn to dismiss unsolicited attention and her clothing choices are still deliberate.
The boys’ friends on the other hand were far too invasive until we spoke to them, one going so far as to enter her room early one morning. For a few not even the conversation worked.
It was a situation of young male hormones run rampant in the midst of a young woman and we understood, which is why we had to put a stop to the boys’ friends staying overnight for a while. As I said, everyone survived.
All that to say these issues are a common part of adolescence, not a symptom of mental illness requiring mastectomies.
Can we get into a deep dive into the bombshell Reuters dropped, that the drug companies making puberty blockers are actively refusing to pursue FDA approval for use in trans youth?
https://www.dailywire.com/news/puberty-blocking-drug-companies-refuse-to-conduct-safety-trials
Makes sense to me in a twisted, late capitalism way. Usually, FDA approval is sought because without it, doctors are reluctant to prescribe the drug, which limits sales. But since so many "affirming" doctors are willing to prescribe Lupron et al off-label, the manufacturers really have no financial incentive to roll the dice on an FDA-controlled risk/benefit study; their revenue numbers are doing just fine as-is.
My main question is: where does the malpractice buck stop? Is it the individual doctors who wrote the prescriptions, the clinics where they operated out of, or like Purdue pharmacy with Oxy, could detransitioners potentially sue the drug manufacturers themselves?
How do you create a clinical trial for puberty blockers (experimenting on children by definition) that makes it past an ethics review board?
Seeing as kids are already being given the drugs anyway, set up a control group and monitor for years.
That's fine as a scientific study, but it's not how FDA approvals work.
Same principle would seem to apply in both scenarios; plenty of kids willing to volunteer for puberty blockers, so just give some of them placebos.
If giving untested drugs to kids was a FDA dealbreaker, it would be impossible to bootstrap ANY pediatric drugs through the approval process. "Can't give it to kids because it's untested; can't test it because that would require giving it to kids" would be an insurmountable obstacle if it was that cut and dry.
I'd be a little concerned about letting people sue the manufacturers, maybe if they were pushing the off-label use on doctors.
I had some persistent nerve pain in my foot and was prescribed a short-term course of an... antidepressant?(that or something similar) that was apparently known to have reasonably valid off-label uses for my neuropathy.
Had something gone wrong, I'd be inclined to blame the doctor, but not the manufacturer, under the thinking that the doctor was the one who was responsible for suggesting the treatment. (Had something gone wrong I may/may not have been _correct_ in blaming the doctor, just how I might have felt)
Edit, oops forgot this point
Also... if off-label uses are in fact good, but manufacturers can be sued, then that really cracks down on them _across the board_ - all uses.
I'm thinking that refusing to pursue approval when they already know the drug is being pervasively used off-label might qualify as implicitly encouraging the off-label nature of the prescriptions.
I don't think that route could (or should) work. Unless the company is in fact actively (if subtly) endorsing the off-label use (for instance, by distributing articles that promote such use).
Informative discussion of some of the issues here: https://www.nejm.org/doi/full/10.1056/NEJMp0802107
It would be interesting to know if the drug companies are doing any marketing, especially indirectly through sponsored social media content.
I’m thinking that if someone attempted to sue the manufacturer, the manufacturer’s defense could be zillions of articles and “studies” purportedly showing that the drugs were life saving interventions with almost no negative side effects.
Basically, Look, the doctors on the ground and all the major American medical associations swore this was great. How could we know they were all wrong to the point of criminality?
And yet Purdue got sued into the ground over the opioid crisis, so the precedent exists.
Fair—but wasn’t it revealed that they had suppressed research and/or actively campaigned to get the drugs into widespread circulation?
Seems like in this case, the Dutch did a little trial off-label 15 years ago and then other doctors independently and without nudging from pharmaceutical companies followed suit.
I don't know about suppressing research, but Purdue actively marketed Oxy as "addiction-proof" to doctors. If Lupron makers are actively marketing the drug as "safe and reversible", then that's a similar situation.
Both are ultimately cases of 'too good to be true' medicine. Chronic pain is a legitimate moral conundrum for doctors, because the most effective drugs to treat it come with serious addiction risks. When a newly-hyped miracle drug comes along promising doctors the best of both worlds (make their patients pain go away without turning them into junkies in the process), of course lots of doctors jumped on the bandwagon (the kickback compensation also helped grease the wheels).
With trans/potentially trans minors, the longer the doctors wait to facilitate transition, the tougher time the patients will have 'passing', because they'll have gone through their natal puberty which is pretty much a one-way trip. But the sooner the transition is facilitated, the greater the risk of patients regretting what they thought they wanted but turned out to be 'irreversible damage'.
So between newly hyped "safe and effective" puberty blockers promising a "pause button" on natal puberty, and "studies" showing that early transitions neeeeeeever backfire, doctors are being told things about youth gender medicine that are quite literally too good be true.
In the case of Oxy, the manufacturers were ultimately held accountable for their "too good to be true" marketing campaign. In the case of Lupron, the only difference might be that if the drug companies can show that Tumblr/TikTok activists are doing all the marketing on a pro-bono basis, then the manufacturers hands might be cleaner than those of Purdue.
Just stepping away from the context and looking at the methodology here, it’s infuriating that they try to apply statistical (sorry, data science) techniques which only really make sense with continuous data, to bullshit measures which are flags or at best discrete values. That bollocks CDM could be improved, from a certain point of view, by using a single question “do you have breasts?” And taking the values zero and one. This would give 100% improvement after surgery with a completely sound statistical basis, but telling us nothing of any use.
I could understand this if the audience for the articles was the general public this is published in a scientific journal. Are those people really so statistically illiterate that they just let this go without a hint of worry?
gonna need a BARpod deep dive or a novel-length Singal-minded article on the new Jon Stewart episode on pediatric gender affirming care https://twitter.com/theproblem/status/1578052464334589952
Can't we all just ignore Jon Stewart after his critical race theory struggle session with Andrew Sullivan?
But sadly other people don't ignore Jon Stewart.
I mean, his show's ratings would suggest otherwise
I think the technical term is "Tolstoy-length"
I'd love to see an experiment where science reporters are given equally strong/weak data sets but on different topics. One set of data could be like the data in this article "proving" that top surgery for teens is helfpul. The other could be equally strong/weak data "proving" that a 6-month course of therapy in lieu of puberty blockers is helpful. What headlines would they write based on each of these data sets?
Excellent idea. This would be a fantastic study or journalistic project for someone to pursue.
That CDM survey is too much. If it gets validated, then I REALLY will lose all faith in the medical establishment. (1) As Jesse and other commenters have pointed out, many would score high no matter what, and it's designed to get lower scores following mastectomy, no matter how one's feeling about it. (2) The questions are leading and will get higher scores due to the power of suggestion. Even an adolescent who isn't particularly self-conscious in a bikini will think: Oh, maybe I should be? (3) An adolescent or young woman coming in convinced they need to medically "transition" will know exactly how to answer the questions to get what they want. Granted, that is a danger with a lot of these types of self-scored subjective surveys, but it's particularly egregious in this case.
I'm scoring about a 12-14 as a busty woman who's perfectly happy with her breasts. Some of them seem like good questions, but stuff like "I have to buy certain clothes because of my chest" (I do, because there's a bunch of cuts that don't fit right because my breasts are large) are going to flag innocuous things.
no button-down shirts, ever.
Your observation brings up another problem: the phrase "because of my chest." What does that mean? Because I have female breasts, period? Because I don't like the (or I worry that others don't like... or DO like) the particular size or shape of my breasts? Etc.
I also like this one: "I worry that people are looking at my chest." Pretty close to universal concern, there.
Wearing a bra at all could be considered 'I have to buy certain clothes because of my chest', even if it's a regular off the shelf oen.
The scoring for the statements doesn't even make sense! In most cases, larger numbers seem to indicate that the respondent does not like their chest. But the very first one is "I like looking at my chest in the mirror," which surely a person with chest dysphoria would put at a 0, no? The rest of them are okay scoring-wise, until you get to the additional ones, which are a mess.
I made a comment a day or two ago about the same thing regarding the first statement. Jesse Singal pointed out that the people scoring the survey should know to reverse the scoring for that one. Regardless, it's a mess.
I work for a hospital system and we give minors mastectomies every month. I’ve seen two 14 year olds get them.
I’ve been informed that this never happens.
Wanting to feel like the good guy in a movie is a hell of a drug. Just lets you skip over all the parts that make reality messy and warrant caution.
Eliza Mondegreen writes about this in her piece on attending the recent WPATH conference. https://elizamondegreen.substack.com/p/so-i-went-to-wpath
"It's convenient to think of yourself as being on the right side of history. Your critics become dinosaurs in their own time, incapable of understanding. You may be incapable of understanding, too, but at least you have faith. At least you have given yourself over to the cause.
The further you go—the more patients you cut up, the more critics you silence—the harder it is to see your destination clearly. But it must be beautiful and just because you've sacrificed for it and identified yourself with it and you are a Good Person.
The entire conference spoke to this Good Person. You are a good person because you are overcoming your biases. You are a good person because you oppose the bad people (even if you don't understand them and we won't talk about them because that would be like letting them win)."
"The endpoint of this education in 'allyship' is a person who cannot question what she supports because she cannot see it, because she lacks the language to formulate the question, because she lacks the confidence of her own perceptions, because she has 'problematized' away any ground she might stand on or any principle she might insist on. She looks on real horrors with starry eyes because she must.
Of course the bad feelings don't really go away. The horror doesn't go away. But you lose touch with its true sources. You project it on the only people against whom you're allowed—encouraged—to vent bad feelings: the people trying to warn you you’re causing harm.
The more horror you must sublimate, the more horrible your detractors must become, even if the worst thing they say is simply: look. Look at what you’re doing."
Sounds an awful lot like what just happened this week with the AMA asking the DOJ to pursue domestic terrorism charges against the "look at what they're doing" brigade of Chris Rufo, LoTT, etc.
All of this feels like it should ultimately lead to some Alec Guiness-in-The Bridge on the River Kwai, "What have I done?" moment, but I highly doubt that will happen to any degree given what went on with the state-run eugenics programs of the early 20th Century.
Ayup.
I have arrived at the point I no longer trust anyone who can’t bust out a Vizio flow doc and explain each step in their thinking as well as how they handle exceptions.
Please come out publicly with this information! With "receipts" if possible (and if possible to do without violating privacy.) There's a pernicious lie going around that this does not happen. The more solid, specific evidence of what's going on, the better.
But also when it does happen it's a good thing because it's a "life-saving intervention".......that never happens.
Every time I read one of these pieces of yours, Jesse, I get almost paralyzed by disbelief.
I’m so glad you’re doing this work—and I’m so happy to contribute every month so that you can—but it is just *bananas* that each and every study is so flawed it basically never should’ve passed review let alone get touted in MSM articles as proving “lifesaving care”!
The correlation between chest dysphoria and anxiety/depression seems like it wouldn't necessarily be relevant to this study even if it was strong. The correlation is at a single point in time, they haven't presented any evidence that decreasing one effects the other. Also those r values are pitiful. Even assuming the relationship WAS causal those r values implied that 'chest dysphoria' explains 1-4% of the anxiety/depression differences. A double mastectomy is a pretty radical intervention for that kind of response...
Also 13!?
Yes, these are all good points that I eschewed so as to not get too deep into the weeds. But "X and Y are correlated" of course does not imply that if you change X, Y will move with it. That comes up in my book at least once or twice.
This is a very good point.
So what happens when some troubled individuals decide they'd be happier without thumbs? Or toes? Or vision in both eyes? Will a cottage medical industry in elective amputation spring up? Will universities put out skewed studies affirming the benefits self-mutilation? Will schools declare that information on students considering radical destructive surgery be concealed from parents?
This is madness.
There's an old short story by Ray Bradbury titled "The Watchful Poker Chip of H Matisse" about this very thing...a man who incrementally cuts off pieces of himself and replaces them with inanimate objects to make himself more "interesting." It was written as satire. And we are rapidly getting there.
Good question! Here's what happens:
"Based on the subjects' reports we found that BIID has an onset in early childhood. The main rationale given for their desire for body modification is to feel complete or to feel satisfied inside. Somatic and severe psychiatric co-morbidity is unusual, but depressive symptoms and mood disorders can be present, possibly secondary to the enormous distress BIID puts upon a person. Amputation and paralyzation variant do not differ in any clinical variable. Surgery is found helpful in all subjects who underwent amputation and those subjects score significantly lower on a disability scale than BIID subjects without body modification."
"Amputation of the healthy body part appears to result in remission of BIID and an impressive improvement of quality of life. Knowledge of and respect for the desires of BIID individuals are the first steps in providing care and may decrease the huge burden they experience."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3326051/
That conclusion is a pretty generous reading, I would say.
A study of 54 individuals, based on a questionnaire, through email, composed primarily of "Caucasian" men.. The 7 who had "completed" amputations reported reduced BIID (well, yeah), but there were also reports of medication and therapy being helpful. One woman, with schizophrenia, was included in the study, but four individuals were eliminated because their primary motivation was sexual.
I’m envisioning Tigris from the Hunger Games.
We are already there. This article is over twenty years old.
https://www.theatlantic.com/magazine/archive/2000/12/a-new-way-to-be-mad/304671/
I really enjoy your articles (and your book) that go beyond headlines to look deeper into research papers and analyze whether the papers actually prove what the press releases or articles say they prove.
Stuart also has a great Substack if anyone is interested: https://stuartritchie.substack.com