Irreversible Reputational Damage
The unquestioning treatment of paediatric transition by Science Based Medicine
When I was a new parent in the early 2000s, controversy around the MMR vaccine was a live issue as a result of Andrew Wakefield’s 1998 study in The Lancet showing a link to autism. Fears around safety had led to a drop in vaccination, and measles and mumps were both on the rise. Brian Deer’s Sunday Times investigation showed financial conflicts of interest, but it would not be until several years later that Wakefield’s paper would be withdrawn and Wakefield himself struck off for falsification.
I had always liked to believe myself to be studiously diligent and rational when it comes to decision making, like many men smugly believing myself to be more capable than most of making cold and detached assessments based solely on the evidence. I had no time for anti-vaxxers, or religious fundamentalists, or climate change deniers.
Faced with the prospect of giving the MMR vaccine to my own child, I was terrified.
I found myself forced to make a decision, weighing up the risks of vaccination that I knew, coldly, rationally, statistically, was the right thing to do - but was also unable to separate from the anecdotes, headlines and testimonials that it would cause irreversible damage. Absorbing through constant media exposure the fear that by trying to do the right thing, I might do the wrong thing.
It is impossible to truly detach yourself from the culture you live in, so even though I spent huge amounts of time reading and researching and reassuring myself that it was the best thing, I never completely rid myself of that fear.
It was like being trapped in an inescapable loop through some twisted version of Asimov’s first law - I must not harm my child, nor through inaction allow my child to be harmed.
Trying to get my head around this was when I really appreciated how much science you simply have to take on trust, as a layperson. Even if you read papers, you are relying on the data described being real. Relying on the gatekeeping of publication and peer review to provide that necessary barrier to fraud or nonsense, trusting that the process itself is not corrupt. Relying on others to reproduce the results and publish their findings, not simply ignoring weak or contrary indications.
Unless you do everything yourself from the ground up, you’re taking it on faith on some level - and even then, you’re building on science and knowledge that has come before. At some point, no matter what, you have to draw a line and decide who you believe. Sometimes this doesn’t come down to who convinces you they are right, but someone else convincing you that they are wrong.
During this time, while trying to navigate a sea of misinformation, and academic papers I was ill-equipped to understand, I frequently read a blog called Respectful Insolence. This was the home of the pseudonymous Orac, scourge of antivaxxers and quacks. Amidst the atheists and climate scientists doing battle with their own flavours of online denial and unreason, here was a medical doctor rationally and forensically dismantling medical misinformation and bias. Even if I could never be sure of safety, if I could explain why the critics’ arguments were fallacious or unsustainable or cherry-picked then it went some way to lessening the fear.
Lacking the ability or resources to demonstrate that something was true, and forced to take scientific consensus on trust, I could reassure myself that I was more likely than not to be doing the right thing as long as I could satisfy myself that the opposing arguments were weak. But the idea that I was making a purely rational and dispassionate decision was nonsense. I was grasping for the things that made sense to me, and I can well understand how the strong emotions - the raw desire to protect - could have pushed me in completely the opposite direction.
I did read Respectful Insolence and other similar blogs for a few more years, but eventually life moved on and for many years I stopped getting involved in pointless online arguments. Here is one post from a couple of years later that I do remember reading though - all about the unethical experimental treatment of autistic children with Lupron - or as Orac put it, chemical castration. Grim stuff, and he was rightly scathing.
"Once again, if you’re going to propose doing something as radical as shutting down steroid hormone synthesis in children, you’d better have damned good evidence to justify it, and the Geiers don’t. "
In a curious coincidence, rereading this now I note that it mentions in passing Simon Baron-Cohen’s hypothesising that autism was the result of an “extreme male brain”.
I first started to become aware that things were not right in the world of sex and gender around 2016, when I came across Jordan Peterson’s claims about hierarchies and sex roles. He seemed to posit quite conservative ideas about gender roles and innate preference that I disagreed with, and - like any egotistical man with access to a keyboard - I was keen to tell anyone who would listen what I thought. I read the research he often referred to - including Baron-Cohen’s - about sex preferences, toy studies, primate studies, implications for women in STEM etc. I formulated my own opinions based on this, believing some of this to be weak or misrepresented, or selective and an incomplete picture. However, it was while making arguments against some of what was being said that I found myself more often than not being attacked on forums and social media and reddit by people who I had thought were on my “side”.
More and more, I encountered people for whom the idea that there was such a thing as a male or female “essence” to be foundational to the idea that there was a physical, immutable basis for being transgender. That is: somebody “transgender” was someone for whom there existed an innate tendency towards gendered interests, behaviour and expression associated with those typical for the opposite sex. This was, to me, an absurd and sexist claim - for it required there to be a “sex-appropriate” tendency towards broad stereotypically gendered behaviour and expression (wearing makeup, dresses, taking up less physical space, being quieter and more deferential etc) rather than these being learned cultural manifestations of sexism. The more I laughed at how absurd and offensive these claims were, and pointed out wildly inconsistent language and contradictions, the more I realised that some time in the prior decade, virtually the entire online “skeptical” community had been replaced by pod people.
I stopped laughing when I realised this extended to the majority of the political and media class, HR departments, institutions, social media platforms and so on - all taken over by absurd, regressive and incoherent ideas.
This conflict has become ever more intense over the last few years, with one of the major pop culture flashpoints occurring in mid-2020, when JK Rowling posted her now famous essay on the conflict between women’s rights and present-day transactivism/sex-denial.
I mention this because in the replies to one of her tweets around that time, I saw this:
Here we have a classic sexist put down, with the name “Karen” used to dismiss a woman as hysterical, stupid, ill-informed. “Karen”, used in this way, means simply “shut up, bitch”.
But it was only reading the surrounding responses that I discovered with disappointment that the David Gorski casually using sexist terms to denigrate a woman’s opinion was the blogger I had previously known as Orac a decade and a half prior.
In May, Science Based Medicine - of which David Gorski is managing editor - published, and then retracted, Harriet Hall’s review of Abigail Shrier’s “Irreversible Damage”, which centers on the rise in adolescent girls adopting a cross-sex identification, and the possibility that this is driven by societal factors and social contagion.
Given Gorski’s dismissal of Rowling it was unsurprising that he - along with founder and executive editor Steven Novella - had decided that Shrier’s book was bad and wrong, and that it required dismantling, rather than reviewing, so they followed up the retraction with with a further four pieces “debunking” Shrier’s book instead - one written by themselves, the others by guest contributors Rose Lovell and AJ Eckart.
These responses have been so partisan and error-filled that many have been shocked to see Science Based Medicine cover itself in shame in this way.
I have come to the conclusion that a point-by-point rebuttal is, well, pointless. These have been done over and over, to no avail, for example:
I believe such efforts - while cathartic and necessary for those on the sidelines - will only dig Gorski and Novella in deeper. Witnessing this unfolding drama and the ever more aggressive responses to these corrections, it is as if the authors have become mired in a psychological trap, a self-referential reality tunnel where information that does not fit is either filtered out or treated as hostile, and that very hostility used to reinforce existing beliefs. All nitpicking is deemed bad faith, a cover for some other agenda, bigotry, whatever. A point rebutted is irrelevant, because the whole picture must be believed to remain true. The believer can simply divert their attention to unrebutted points and “forget” the weakness that has been exposed. It is impossible to present arguments to undermine the belief.
So, I’m not going to bother detailing all the ways in which I think they are questionable or flat-out wrong. Rather, I’m going to look at one part of a single sentence only, and try to illustrate how it is a result of assumptions, wishful thinking, well-meaning activist beliefs and unquestioning acceptance of shoddy terminology instead of anything like the rigour and skepticism that was once professed by the authors.
To rebut the claim that there is any sort of shift in the ratio of girls to boys identifying as transgender, and to dismiss that this should be something people should concern themselves with given the susceptibility of this demographic to social contagion, they write:
“ [...] the shifting of the gender ratio could mean that there was likely a backlog of AFAB demand for services.”
Firstly, I believe that the clumsy use of both “could” and “likely” may represent psychological leakage. They offer a statement here with precisely zero evidence in support, and on some level they know this, so begin with “could”. However, they also know that their aim is to debunk Shrier’s narrative. An unevidenced guess holds little weight except to present as a potential alternative, but that is insufficient. So while they know they are speculating wildly, they also “know” that Shrier must be wrong. Within the same sentence they upgrade their alternative hypothesis to “likely”, with no justification, seemingly other than they want it to hold more weight than Shrier’s.
Secondly, the idea that there has been a backlog demand for female-to-male transition is in part based on an assumed universality of what it is to be transgender - that is, that male-to-female transitioners represent the same phenomenon as female-to-male transitioners, and so should be present in equal proportions in the population if they were the result of normally-distributed biological factors, which is an exercise in begging the question. In reality, reasons for transitioning are diverse and root cause too often unexamined. For example:
Some transitioners (and detransitioners) are clear about having done so since they were homosexual in a non-accepting society.
Some male transitioners are frank about their sexual motivation for doing so.
Some female detransitioners are describe their desire having been based on *escaping* sexualisation or trauma.
These are all perspectives that make complete sense in a male-dominated society that punishes gender nonconformity and sexualises/objectifies women and girls. But to avoid entertaining this possibility, the authors present the unevidenced assertion that this is “likely” a trend towards parity, a correction to the true norm that was always there, based on a hypothesis of an evenly distributed common factor.
Any suggestion as to it being the result of societally-influenced motivations undermines the whole idea that nonconforming children must be “fixed”. If for some reason there aren’t equal numbers of male and female transitioners, this would raise the question: why is there a difference? With no material basis for a sex-differential, that leaves only cultural factors - and if we are looking at a culturally-influenced phenomenon then it would be monstrous to sterilise unhappy children to make them “fit” societal expectations. Nobody wants to be a monster, so we witness this wild grasp for an alternative.
So they selectively and optimistically interpret the evidence to claim that there is a close to 1:1 F/M ratio (there isn’t, it is actually more than 2:1), invent a reason, without evidence, and then declare it “likely” because anything else undermines the whole basis of paediatric cross-sex affirmation and transition.
Thirdly, the use of the term AFAB (or Assigned Female At Birth). This raises many questions, such as:
How does this terminology relate to the appalling practice of surgical “assignment” of sex to infants with ambiguous genitalia as a result of DSDs?
Who performs this sex assignment and how?
Does a baby who has not been assigned a sex have no sex?
In other species, does this assignment take place, or are all other species sexless?
If a baby is born prematurely, do they have the same sex as if they are born at full term?
How does such terminology relate to the tens of millions of female babies terminated in sex-selective abortions resulting from pre-natal scans?
If sex was not assigned at birth, would that put an end to FGM?
If we are talking about the assignment of “sex”, why do we use the word “transgender”?
If sex was not assigned at birth, would that therefore mean nobody would be transgender?
Is sex actually independent of the process of “assignment”?
By “assignment” do you really mean “observation”?
Why specify “at birth”, unless you believe that sex can literally be changed in later life?
If sex is observed, not assigned, is the same both before and after birth, and cannot literally change in later life, why say “assigned female at birth” instead of simply “female”?
Questions like this have no real end, and where you stop - what you choose to just accept - is a matter of judgement, of what you find convincing. These are the sorts of simple questions that a skeptical person would use to interrogate a belief for logical consistency and utility. My experience however is that the words sex and gender are used interchangeably, and switched around whenever necessary to ridicule simple questions to different audiences, in different contexts. Rather than subject such things to scrutiny we see supposed skeptics expressing hostility towards anyone who raises questions, and going along with “in-group” terminology.
I want to digress into one more point.
In an original Harriet Hall piece, with reference to the idea that putting a child on puberty blockers “essentially guarantees infertility”, Rose Lovell responded in the comments:
“Yes, it does. That's why discussing it is part of the informed consent process.”
However, I find it telling that in Rose Lovell’s response article, this flippant dismissal is omitted.
I think an admission that the only barrier to the sterilisation of children is a child’s informed consent, in an area with this much uncertainty, is a scandal all on its own, and that there was no rush to put this claim out there more visibly makes it clear that, again on some level, they know this.
Referring back to my criticism of The Lancet’s flawed editorial on trans youth, which derided the idea that puberty blockers can cause infertility and loss of sexual function as “false” and stoking fears, I think that this is at odds with Lovell’s statement. The Orac of old would pick up on such contradictions, while nowadays Gorski is more interested in dismissing and smearing critics.
When it comes to paediatric transition, I have great sympathy with parents who are honestly trying to do what is best in this mess of conflicting information. I do not envy anyone forced to make a binary choice on behalf of a loved one between intervention and non-intervention, when both options are portrayed as abusive and harmful depending on who you believe. As with the MMR scandal, the information landscape is poisoned, but nowadays things are far more toxic. The route based on faith and magical thinking will get you lauded and praised, while the one filled with questions and uncertainty will get you cancelled. Hollywood is tripping over itself to tell approving stories of one, and if you find them hard to swallow, well you’re probably an agent of the far right. The polarisation - thanks in no small part to the US political landscape and cultural hegemony - is off the scale.
Gorski has decided which of those paths he is going to champion, but I no longer find his arguments convincing, and his unwillingness to examine contrary information in good faith or honestly present the unknowns makes me wonder: how does dogmatism and motivated reasoning take over like this? What is it about this particular subject that takes people down a path of unreason? Why do they become so completely incurious - indeed, openly hostile - to other viewpoints?
Postmodernism gets a lot of flack, but I think it is valuable to bear in mind this idea that our perception of the universe is only true or false based on certain perspectives. Our mental models are always limited, and all models are wrong - but some are useful. The value lies in not being precious about models for their own sake, in knowing when to switch between them, understanding their limits, and honestly evaluating the alternatives.
Somehow though, a large number of influential people have come to the conclusion that their model is not only true, but also the only one that is not outright bigotry. They have associated a moral dimension to their perspective and it has left them unable to consider anything else.
At the moment that is the only explanation I have. Their model has “kindness” built in, so they cannot allow themselves to consider anything else, because to do so is de-facto “unkind”. Trying to persuade them otherwise is unkind. Pointing out what they have got wrong is unkind. Questioning is unkind. Forcing children to go through puberty is unkind. Leaving children with functioning sexual organs and reproductive systems longer than is absolutely necessary is unkind. Anything but acceptance of the one true path is unkind.
I think on some level they know that this is another medical scandal unfolding, no different from every other time young lesbians have been institutionalised, lobotomised, sterilised. Perhaps that is why there is such an aggressive need for everybody to go along with it - because if all the world is complicit, they don’t have to feel personal responsibility for when the bubble eventually bursts.