As a Biological Psychologist and research scientist, I agree with your (detailed) analysis. However, in some sense it's beside the point (with which, I think, you probably agree). People see what they want to see in data, especially data that deal with fuzzy psychological concepts, or which can be spun to support an ideological agenda.
However, probably the most important issue, from my perspective, is the fact that you cannot simply manipulate anatomy and physiology to change a person into something they would like to be (or you would like them to be). Biology doesn't work like that. Further, we have known the deleterious effects of cross sex hormones and blockers for over half a century (ever since the drugs were first synthesized). It amazes me that people are now "debating" their effects. Except in the rarest of instances will traumatic hormonal manipulation help someone who is suffering from a psychological or psychosocial condition. I discussed some of that in "There is "Biological Evidence for Gender Identity..." but it’s not what you think."
Interestingly, much of the back-and-forth about "gender identity," its associated issues and their putative amelioration is driven by misconceptions about biological causation, biological malleability, and fundamental misunderstandings of neuroscience on both sides of the debate. In some ways, it's become like the debate over abortion:, misconceived by people on both sides of the issue, and subject to a perpetual attempt to win the argument by presenting progressively larger bodies of "facts".... with no one making a fair and honest assessment of their "opponents" point of view.
To be clear, I agree with your analysis. I'm just not sure if it's going to make much of a difference until people decide to more carefully — and objectively — consider the fundamental biological and psychological aspects of this issue. Everything is biology, after all.
I only ever seem to comment or tweet you when I want to disagree so first of all I have to state what great work you do and how much I appreciate it.
But with every write up like this that I read, I less understand your position on supporting hormones for *some* children as a better solution than, say, leeches.
Have you written about the positive research or the persuasive arguments that have led to this position? About which are the cases you can definitively make such a prescription for? If not, would you? Please.
Regarding the redundant scale items (I'm a social psychology PhD) - There are different approaches to making scales. Sometimes what you want *is* to ask the same exact thing in slightly different words.
Every response has some error associated with it. By asking the same question multiple times and averaging together, you average away the error.
For instance, a commonly used measure of "extraversion" asks people whether they are "hard to get to know" and, separately, whether they "keep others at distance." By averaging these very similar items (and others) together you get a more accurate score.
[Very technical addendum: These items are specifically for the "negative keyed" sided of the "enthusiasm" aspect of extraversion. Other "aspects" will ask somewhat different questions -- but they, too, will do so in very similar ways within themselves. So the full measure of extraversion with all its "aspects" includes both clearly different items and items that resemble each other. For instance, the "assertiveness" aspect asks whether you "take charge," which is different from the "enthusiasm" items however you slice it.]
Thanks for looking at this. In my own view, these studys are likely to have high participation bias. Why are the participants involved in the study? why do they want this care? have the participants and their families been told that most kids grow out of gender dysphoria without social transition and gender meds? have they been lied to regarding dysphoric youth suicide rates as is so common? have the participants and their familys been told about the long term downsides of gender meds? or that their child may have issues that arent related to gender at all, as many detransitioners report in retrospect. my apologies if this was covered. i assume the participants and their families are full believers of many of the common inaccurate gender biz catch phrases regarding this care. considering the celebratory and non critical ideation of gender care in many communities, participant feelings about this care is likely to be influenced by many factors other than the care itself.
also, i dont understand why a control group cant be used. in a previous study i read that a control group cant be used becuase not using these meds would put the control participants at risk. given these results it would seem they wouldnt be at any risk at all
The article doesn't fully address two big problems with the study:
1) The authors assume that avoiding medicalization would have led to worse outcomes. This assumption is particularly inappropriate given evidence that the majority of children who don't medicalize do desist; they come to accept their bodies. (In other words, the implications of there being no control group need to be articulated more clearly.)
2) The 2 year timeline is ridiculously short. There can be euphoria after taking action one fervently believes will help, especially as schools and peers lavish praise on a child for their "bold" "courageous" "authentic" living. As time goes on, as the problems underlying rejecting one's bodies remain unsolved, as the medical consequences of messing with one's previously-healthy body become more evident, and as a child matures....bad feelings can mount. There is evidence of depression and regret, and also suicide, happening after more time has passed. (See the big Swedish study, for example.)
I would also like to state for the record that the concept of a child having been born in the wrong body is as mystical and anti-science as it gets. And that it is an outrage that doctors mislead children into believing they can become the other sex...that the hormonal and surgical measures imposed on their previously healthy bodies will in any way enable them to have the body and experiences of someone of the opposite sex. Analyzing the obviously biased studies of the Gender faithful as if this were any other medical treatment evaluation, is a cop-out. How did it come to be that people fear they will be seen as unreasonable if they point out that the whole basis of any of this is madness?
"Gender affirmation" medicine is premised on everyone agreeing to the anti-science redefining of vital words like woman and man, rendering those words absolutely meaningless. Going along with that doesn't just subject kids to a medical scandal of horrific proportions. It also fuels other unacceptable consequences in our world: men in women's prison cells, lesbians chastised for insisting on same sex relationships, females and males alike losing the right to sex-based privacy, women losing female-only sports, the reification of vile sexist stereotypes, and more. I, for one, do NOT agree to that redefinition or to the forfeiture of rights that goes with it. Most people don't. Any discussion of pediatric "gender affirmation" medicine must acknowledge the definitional sleight-of-hand upon which it is based.
"I am opposed to the sorts of policies Trump is proposing — . . . to codify into federal policy a ban on even adults changing their legal sex."
Jesse, I color my hair, stay out of the sun, and follow a strict diet and exercise regimen that enables me to pass for a woman ten or more years younger than my chronological age of 70. My "authentic self" is not that of an old crone cashing her Social Security check, but that of a woman enjoying late middle age.
Should I insist that Medicare pays for my next facelift? Should I be able to change the birth date on my driver's license and birth certificate?
>A tiny bit of political throat-clearing before we start: If you write critically about youth gender medicine, you will hear from a lot of people who are aghast that you could do so given the threats trans people in the United States (adults and children alike) face.
I find this attitude absolutely infuriating. Yes, noting that the evidence base isn't great might leave medical interventions vulnerable to fearmongering, lies and hysteric reactionary responses by bad faith actors. But you know what also leads to that? Attempts to suppress any criticism at all on patently absurd claims of 'harm' to trans people.
I'm in Australia and there's an upcoming vote on constitutional change to create an indigenous 'Voice' to the parliament - effectively an advisory body comprised of indigenous people, to raise issues with the government, guaranteed to exist into the future.
Because it's a constitutional change the actual wording is vague as to the composition of the entity, how it operates, etc etc., and people understandably are asking for detail. However, the government is ducking these questions, instead asking citizens to vote on the principle, and to trust that the parliament will set out the specific details later. Unsurprisingly, this doesn't wash with everybody, but the response has been to either imply that voters asking questions are doing so in bad faith, or ignorance (some activists have told questioning voters to read a 300 page report on the Voice that the government hasn't even endorsed as the model it wants), or that detail isn't something that is needed on a constitutional question.
The vote might succeed on principle alone, but I find it disturbing how many advocates of change reflexively believe that any questions being asked to derail the 'right thing to do'. Some people might be acting in bad faith, and there's a risk that the debate could be bogged down in insignificant minutiae, but even so, it shouldn't be that difficult to give the public a TL;DR and respond effectively to misconceptions. Frankly, the unwillingness to engage on anything but the 'principle' smacks of laziness and arrogance, and could sink the entire campaign.
"Take items like “My outward appearance represented my gender identity” and “My physical appearance adequately expressed my gender identity.” For one thing, these items are so similar that I’m surprised they’re both on the scale — they seem truly redundant..."
Jesse, I'm surprised that you're surprised. Clearly you haven't been subjected to a lot of psychological questionnaires, which are rife with this kind of redundancy. Often these sets of questions are preceded by a statement like "Many of the questions may appear similar, but please answer them all." The two you cite don't appear as similar as some I've seen. There are subtle differences between "outward appearance" and "physical appearance" and not-so-subtle differences between "expressed" and "represented," not to mention that sneaky adverb "adequately."
There are good reasons to doubt the importance of this scale, but the redundancy is par for the course in psychological testing. I just did some quick searching to try to find out what the purpose of it might be, and I found a couple of sources that mention redundant questions as a way to weed out people who aren't paying attention or who aren't taking the questionnaire seriously (or robots perhaps). It seems unlikely that this was the case here though.
Thanks for taking the enormous amount of time to evaluate this “study.” It is discouraging that this will be used to justify pushing kids into gender transition. Don’t give up on this issue. We need same people to keep pushing back.
If we want to actually know whether these hormone treatments work, someone is going to need to bite the bullet and run a randomized trial. Randomize the participants to usual mental health treatment or usual mental health treatment with hormones. It's probably going to be controversial because there will be researchers who insist that it's unethical to randomize kids when we "already know" that the hormones work. Except that we don't have enough information to know if they work and medicine is littered with treatments that we were certain we knew worked but were abandoned when high quality evidence showed that they were either useless or caused more harm than good. There's a serious ethical problem with refusing to do high quality studies on a treatment that doesn't have good evidence one way or another.
Your post is wonderful, and nuanced, and the comments are germane. If I were a NEJM reviewer I'd have easily rejected the Chen et al article (and I'm pretty chickenshit).
It would have been enough for /me/ with a point you barely touched on -- the numbers of those in each category of the Beck's scale are in /all/ cases substantially lower after 24 months than at the inception of the study. The researchers are not following a consistent cohort! It's as though they have no clue that there are ways of handling cohort loss. What would the breakdowns be if we followed the group who completed the inventory in all cases? What is the breakdown of cases -- and what are the changes -- among the approximately one-third who are missing at the end?
It's magical thinking to conclude /anything/ based on such numbers. Yet the NEJM -- one of our flagship journals -- let it get past peer review, blustery conclusions and all.
One commenter said you're winning, Jesse. But you're not. We're not. One powerful institution after another falls. Enough.
The severe depression scores should be amended to include the suicides, which would make the before/after percent with severe depression almost the same.
Thank you, as always, for all this work. I sincerely hope that someone, somewhere is currently engaged in an extensive study of this, including controls with placebos, gender dysphoric kids who do not go the hormone route, and a comparison of mental health with kids that do not have gender dysphoria. I hope in 2-5 years we have the results of such a study that is rigorous, unbiased and has the interests of all children at heart.
OK, how come I paid for this Substack and I still have to pay for _Blocked and Reported_? Jesse Singal is worse than a Satanist, he is a Sam Smithonist.
As a Biological Psychologist and research scientist, I agree with your (detailed) analysis. However, in some sense it's beside the point (with which, I think, you probably agree). People see what they want to see in data, especially data that deal with fuzzy psychological concepts, or which can be spun to support an ideological agenda.
However, probably the most important issue, from my perspective, is the fact that you cannot simply manipulate anatomy and physiology to change a person into something they would like to be (or you would like them to be). Biology doesn't work like that. Further, we have known the deleterious effects of cross sex hormones and blockers for over half a century (ever since the drugs were first synthesized). It amazes me that people are now "debating" their effects. Except in the rarest of instances will traumatic hormonal manipulation help someone who is suffering from a psychological or psychosocial condition. I discussed some of that in "There is "Biological Evidence for Gender Identity..." but it’s not what you think."
Https://everythingisbiology.substack.com/p/there-is-biological-evidence-for
Interestingly, much of the back-and-forth about "gender identity," its associated issues and their putative amelioration is driven by misconceptions about biological causation, biological malleability, and fundamental misunderstandings of neuroscience on both sides of the debate. In some ways, it's become like the debate over abortion:, misconceived by people on both sides of the issue, and subject to a perpetual attempt to win the argument by presenting progressively larger bodies of "facts".... with no one making a fair and honest assessment of their "opponents" point of view.
To be clear, I agree with your analysis. I'm just not sure if it's going to make much of a difference until people decide to more carefully — and objectively — consider the fundamental biological and psychological aspects of this issue. Everything is biology, after all.
Thanks for a great read, Frederick
Hi Jesse,
I only ever seem to comment or tweet you when I want to disagree so first of all I have to state what great work you do and how much I appreciate it.
But with every write up like this that I read, I less understand your position on supporting hormones for *some* children as a better solution than, say, leeches.
Have you written about the positive research or the persuasive arguments that have led to this position? About which are the cases you can definitively make such a prescription for? If not, would you? Please.
Thanks again
Regarding the redundant scale items (I'm a social psychology PhD) - There are different approaches to making scales. Sometimes what you want *is* to ask the same exact thing in slightly different words.
Every response has some error associated with it. By asking the same question multiple times and averaging together, you average away the error.
For instance, a commonly used measure of "extraversion" asks people whether they are "hard to get to know" and, separately, whether they "keep others at distance." By averaging these very similar items (and others) together you get a more accurate score.
[Very technical addendum: These items are specifically for the "negative keyed" sided of the "enthusiasm" aspect of extraversion. Other "aspects" will ask somewhat different questions -- but they, too, will do so in very similar ways within themselves. So the full measure of extraversion with all its "aspects" includes both clearly different items and items that resemble each other. For instance, the "assertiveness" aspect asks whether you "take charge," which is different from the "enthusiasm" items however you slice it.]
Thanks for looking at this. In my own view, these studys are likely to have high participation bias. Why are the participants involved in the study? why do they want this care? have the participants and their families been told that most kids grow out of gender dysphoria without social transition and gender meds? have they been lied to regarding dysphoric youth suicide rates as is so common? have the participants and their familys been told about the long term downsides of gender meds? or that their child may have issues that arent related to gender at all, as many detransitioners report in retrospect. my apologies if this was covered. i assume the participants and their families are full believers of many of the common inaccurate gender biz catch phrases regarding this care. considering the celebratory and non critical ideation of gender care in many communities, participant feelings about this care is likely to be influenced by many factors other than the care itself.
also, i dont understand why a control group cant be used. in a previous study i read that a control group cant be used becuase not using these meds would put the control participants at risk. given these results it would seem they wouldnt be at any risk at all
The article doesn't fully address two big problems with the study:
1) The authors assume that avoiding medicalization would have led to worse outcomes. This assumption is particularly inappropriate given evidence that the majority of children who don't medicalize do desist; they come to accept their bodies. (In other words, the implications of there being no control group need to be articulated more clearly.)
2) The 2 year timeline is ridiculously short. There can be euphoria after taking action one fervently believes will help, especially as schools and peers lavish praise on a child for their "bold" "courageous" "authentic" living. As time goes on, as the problems underlying rejecting one's bodies remain unsolved, as the medical consequences of messing with one's previously-healthy body become more evident, and as a child matures....bad feelings can mount. There is evidence of depression and regret, and also suicide, happening after more time has passed. (See the big Swedish study, for example.)
I would also like to state for the record that the concept of a child having been born in the wrong body is as mystical and anti-science as it gets. And that it is an outrage that doctors mislead children into believing they can become the other sex...that the hormonal and surgical measures imposed on their previously healthy bodies will in any way enable them to have the body and experiences of someone of the opposite sex. Analyzing the obviously biased studies of the Gender faithful as if this were any other medical treatment evaluation, is a cop-out. How did it come to be that people fear they will be seen as unreasonable if they point out that the whole basis of any of this is madness?
"Gender affirmation" medicine is premised on everyone agreeing to the anti-science redefining of vital words like woman and man, rendering those words absolutely meaningless. Going along with that doesn't just subject kids to a medical scandal of horrific proportions. It also fuels other unacceptable consequences in our world: men in women's prison cells, lesbians chastised for insisting on same sex relationships, females and males alike losing the right to sex-based privacy, women losing female-only sports, the reification of vile sexist stereotypes, and more. I, for one, do NOT agree to that redefinition or to the forfeiture of rights that goes with it. Most people don't. Any discussion of pediatric "gender affirmation" medicine must acknowledge the definitional sleight-of-hand upon which it is based.
"I am opposed to the sorts of policies Trump is proposing — . . . to codify into federal policy a ban on even adults changing their legal sex."
Jesse, I color my hair, stay out of the sun, and follow a strict diet and exercise regimen that enables me to pass for a woman ten or more years younger than my chronological age of 70. My "authentic self" is not that of an old crone cashing her Social Security check, but that of a woman enjoying late middle age.
Should I insist that Medicare pays for my next facelift? Should I be able to change the birth date on my driver's license and birth certificate?
If you don't think so? Why not?
>A tiny bit of political throat-clearing before we start: If you write critically about youth gender medicine, you will hear from a lot of people who are aghast that you could do so given the threats trans people in the United States (adults and children alike) face.
I find this attitude absolutely infuriating. Yes, noting that the evidence base isn't great might leave medical interventions vulnerable to fearmongering, lies and hysteric reactionary responses by bad faith actors. But you know what also leads to that? Attempts to suppress any criticism at all on patently absurd claims of 'harm' to trans people.
I'm in Australia and there's an upcoming vote on constitutional change to create an indigenous 'Voice' to the parliament - effectively an advisory body comprised of indigenous people, to raise issues with the government, guaranteed to exist into the future.
Because it's a constitutional change the actual wording is vague as to the composition of the entity, how it operates, etc etc., and people understandably are asking for detail. However, the government is ducking these questions, instead asking citizens to vote on the principle, and to trust that the parliament will set out the specific details later. Unsurprisingly, this doesn't wash with everybody, but the response has been to either imply that voters asking questions are doing so in bad faith, or ignorance (some activists have told questioning voters to read a 300 page report on the Voice that the government hasn't even endorsed as the model it wants), or that detail isn't something that is needed on a constitutional question.
The vote might succeed on principle alone, but I find it disturbing how many advocates of change reflexively believe that any questions being asked to derail the 'right thing to do'. Some people might be acting in bad faith, and there's a risk that the debate could be bogged down in insignificant minutiae, but even so, it shouldn't be that difficult to give the public a TL;DR and respond effectively to misconceptions. Frankly, the unwillingness to engage on anything but the 'principle' smacks of laziness and arrogance, and could sink the entire campaign.
"Take items like “My outward appearance represented my gender identity” and “My physical appearance adequately expressed my gender identity.” For one thing, these items are so similar that I’m surprised they’re both on the scale — they seem truly redundant..."
Jesse, I'm surprised that you're surprised. Clearly you haven't been subjected to a lot of psychological questionnaires, which are rife with this kind of redundancy. Often these sets of questions are preceded by a statement like "Many of the questions may appear similar, but please answer them all." The two you cite don't appear as similar as some I've seen. There are subtle differences between "outward appearance" and "physical appearance" and not-so-subtle differences between "expressed" and "represented," not to mention that sneaky adverb "adequately."
There are good reasons to doubt the importance of this scale, but the redundancy is par for the course in psychological testing. I just did some quick searching to try to find out what the purpose of it might be, and I found a couple of sources that mention redundant questions as a way to weed out people who aren't paying attention or who aren't taking the questionnaire seriously (or robots perhaps). It seems unlikely that this was the case here though.
Thanks for taking the enormous amount of time to evaluate this “study.” It is discouraging that this will be used to justify pushing kids into gender transition. Don’t give up on this issue. We need same people to keep pushing back.
If we want to actually know whether these hormone treatments work, someone is going to need to bite the bullet and run a randomized trial. Randomize the participants to usual mental health treatment or usual mental health treatment with hormones. It's probably going to be controversial because there will be researchers who insist that it's unethical to randomize kids when we "already know" that the hormones work. Except that we don't have enough information to know if they work and medicine is littered with treatments that we were certain we knew worked but were abandoned when high quality evidence showed that they were either useless or caused more harm than good. There's a serious ethical problem with refusing to do high quality studies on a treatment that doesn't have good evidence one way or another.
Your post is wonderful, and nuanced, and the comments are germane. If I were a NEJM reviewer I'd have easily rejected the Chen et al article (and I'm pretty chickenshit).
It would have been enough for /me/ with a point you barely touched on -- the numbers of those in each category of the Beck's scale are in /all/ cases substantially lower after 24 months than at the inception of the study. The researchers are not following a consistent cohort! It's as though they have no clue that there are ways of handling cohort loss. What would the breakdowns be if we followed the group who completed the inventory in all cases? What is the breakdown of cases -- and what are the changes -- among the approximately one-third who are missing at the end?
It's magical thinking to conclude /anything/ based on such numbers. Yet the NEJM -- one of our flagship journals -- let it get past peer review, blustery conclusions and all.
One commenter said you're winning, Jesse. But you're not. We're not. One powerful institution after another falls. Enough.
The severe depression scores should be amended to include the suicides, which would make the before/after percent with severe depression almost the same.
Thank you, as always, for all this work. I sincerely hope that someone, somewhere is currently engaged in an extensive study of this, including controls with placebos, gender dysphoric kids who do not go the hormone route, and a comparison of mental health with kids that do not have gender dysphoria. I hope in 2-5 years we have the results of such a study that is rigorous, unbiased and has the interests of all children at heart.
I was way off in my estimate on how often you would reference Testosterone; I didn't realize how widespread the issues with this study were.
I wish more of your expert references were willing to be on the record, but I don't blame them for wanting to keep their names out of this debate.
I hope they release all of their data for further review. I'm sure it would be illuminating.
OK, how come I paid for this Substack and I still have to pay for _Blocked and Reported_? Jesse Singal is worse than a Satanist, he is a Sam Smithonist.