Extensive familiarity with Ray Blanchard (a non-physician) is not a prerequisite for the practice of medicine. And given that my main admittedly sweeping generalization is that there is no medical literature that would support the use of surgical or medical interventions as treatments for gender dysphoria, a conclusion supported by sever…
Extensive familiarity with Ray Blanchard (a non-physician) is not a prerequisite for the practice of medicine. And given that my main admittedly sweeping generalization is that there is no medical literature that would support the use of surgical or medical interventions as treatments for gender dysphoria, a conclusion supported by several recent reviews by experts in the field that I assume you are aware of, I don’t feel that I have an enormous amount of reading to do.
I was actually offered an opportunity to testify at a legislative hearing on a bill banning youth transition. I declined, even after discussing my views in private, because I don't think I have the appropriate amount of professional expertise in the subject to be the person taking the mike in that situation. Among other considerations. However, I have plenty enough standing to smack down this rando substack commenter.
And I think there's some value in it. It's good to articulate one's own arguments, to hear what they sound like (or read what they look like). But I think there's also value in engaging with the pro-trans position, not because it has any factual merit, but precisely because it does not. Trans ideology has gotten into so many institutions despite having a miniscule constituency, no real science behind it, and no claim to moral high ground. The sophistry, the harassment, the intimidation, while it isn't what we might consider good behavior, is very effective. It's good to give some thought to how to counter the arguments, because I suspect part of the success of the ideology is simply that when people here it for the first time they are so baffled they are speechless.
`I have plenty enough standing to smack down this rando substack commenter.'
I believe we're all randos here.
`And I think there's some value in it. It's good to articulate one's own arguments, to hear what they sound like (or read what they look like).'
Agreed. So please provide an argument beyond `there is no evidence to support this modality of care, per my opinion'. You, after all, are arguing that the current standard of care, as recommended by the APA, is incorrect.
I am arguing that the standard of care is not evidence-based, because there is not evidence to support it. If there is evidence, an awful lot of people have missed it, and I've noticed that you haven't made any tangible claim about what the evidence would be if it existed. The absence of any large-scale, randomized, longitudinal clinical trial finding that medical or surgical treatment for gender dysphoria improves outcomes is not an opinion. If it's out there, please let us know.
`you haven't made any tangible claim about what the evidence would be if it existed.'
The APA website I linked to includes citations.
`The absence of any large-scale, randomized, longitudinal clinical trial'
You know very well that this isn't the standard used when dispensing treatment to patients. Even when clinical trials or meta-reviews are available, `evidence' is disputed (e.g., clinical trials of mRNA vaccines). Furthermore, when trials/meta-reviews are conducted the medical establishment persistently uses treatments that are ineffective, countered by the evidence, and scientifically implausible. Acupuncture (reimbursed by insurance) and any other `alternative' or `holistic' treatment, for example.
The APA statement cites a variety of studies that are observational designs. There are no studies there that would be accepted by the FDA as evidence towards adding an indication; I recommend looking up the evidence ladder. They are also (and I'm sure you know that Jessie has covered this ad nauseum) exceptionally poor quality research.
It is of course accurate that physicians do prescribe medications for off-label uses, but this is normally for cases where there is some evidence based justifying it. For example, another medication in the same class may have been approved for an indication. It is of course also accurate that evidence is often disputed (because it's often wrong), which is hardly an argument in favor of moving forward without it.
The comparison to acupuncture or other alternative medicine treatments is actually quite apt. Claiming that someone has a gender identity that is different from their sex is roughly equivalent to claiming that their qi is out of balance or their soul is possessed by demons; both are outside the realm of any basic science research in human physiology.
The funny thing is, I actually have a master's degree in alternative medicine research, so while I'm not the world's leading transgender expert, I have peer reviewed several acupuncture papers and am at least a low-level expert in alternative medicine who is quite familiar with the research and the debates around it.
And there are some "alt med" areas (acupuncture among them) that have a much stronger basis in science than any aspect of transgender medicine. What's been fascinating is watching the anti-quackery community grapple with this; J+K did an episode on David Gorksi, who's physician and a prominent critic of alternative medicine but suddenly went all on on trans ideology. It's bizarre.
I've benefited from acupuncture in the past, and I have an acquaintance who is an acupuncturist and she's been involved in work at a hospital in the Boston area. She's told me (but I didn't retain this info) generally about the research that backs it up.
`And there are some "alt med" areas (acupuncture among them) that have a much stronger basis in science than any aspect of transgender medicine.'
I'm sorry but that's completely ridiculous. Acupuncture has been scientifically implausible for a great many years and has never stood up past exploratory trials, let alone to the standard you raise above (studies randomized, longitudinal, etc).
Obviously, Traditional Chinese Medicine rests on non-scientific concepts, but a variety of research has been done into possible physiological mechanisms relating to the way the needles interact with soft tissues and/or stimulate the nervous system (https://pubmed.ncbi.nlm.nih.gov/29143805/https://pubmed.ncbi.nlm.nih.gov/12467083/https://pubmed.ncbi.nlm.nih.gov/16734514/). The ancients probably didn't think that willow bark was inhibiting their cyclooxenegase enzymes, but they used it and it worked (and became aspirin today). Additionally, a separate treatment modality based on scientific concepts was developed by American physicians within the last century called dry needling, which bears considerable resemblance to some types of acupuncture (https://pubmed.ncbi.nlm.nih.gov/26546163/).
Is acupuncture a panacea? No. Is it probably a lot of placebo? Yes. Are there significant concerns about the quality of the research? Absolutely. But there is a large body of theoretical and clinical evidence for using it for a variety of conditions. There is no comparable evidence for using medical or surgical treatments for gender dysphoria; not one of the studies I cite has any sort of equivalent. I wouldn't say that longitudinal studies are of comparable importance (and where they've been done, acupuncture doesn't show much of a longitudinal effect), because acupuncture needles are not causing irreversible changes in the way that hormonal treatments or surgical interventions do. Acupuncture has a lot more evidence behind it than any aspect of transgender medicine currently does.
I'm just a parent who fell into this issue over the last two years, reading what I can, trying to make sense of it. I enjoy Twitter debates because it does sharpen your arguments. The ones foolish enough to proceed with slogans and "BuT iNtErSeX" are the most tedious. If I need dopamine I'll do it, though. I keep a Notes file w/ things so I don't have to retype things over & over... I'm surprised by friends from college who I thought were smarter than this, that they'd at least engage with the points I've brought up, but no. They shut down. It's most disappointing.
`Extensive familiarity with Ray Blanchard (a non-physician) is not a prerequisite for the practice of medicine.'
Of course it isn't. What's your specialty, though? Because if you're being to asked to treat gender dysphoric people then you should be familiar with the clinical evidence pertaining to treatment options.
`a non-physician'
As a fake doctor myself (PhD), I too appreciate the arrogance that allows me to dismiss the thoughts, opinions, and research of others in areas vaguely related to my expertise. I especially find it rich when computer scientists say anything about computing even though they're completely incapable of actually building a computer like we computer engineers are! Don't get me started on the IT people who ensure our networks run...most of them don't even have a B.S. in a relevant field.
`a conclusion supported by several recent reviews by experts in the field'
I'm not being asked to treat gender dysphoric people (at least not frequently), which is an irrelevant point to whether or not there is any clinical evidence for doing this. Since there is no FDA approved treatment for gender dysphoria, no significant clinical trial on any of the off-label treatments that are being used, if I were asked, I would decline. My current specialty is primary care and public health; I'm moving on to addiction medicine.
There is nothing arrogant about asserting that nonmedical degrees are not relevant to medical practice. Psychologists do not make clinical decisions about whether or not a surgical procedure is indicated. That does not mean that psychology is useless or that psychology degrees are fake. Of course, someone without a college degree at all can easily look form an opinion by doing some research of their own. Everyone's entitled to an opinion.
I'm referring to reviews published by health officials in several countries (most recently Norway) asserting that there is no evidence for medical transition in minors. I assume these people can read, and that there is not some hidden well of evidence that they missed.
`there is no evidence for medical transition in minors'
I don't know about `no evidence' for minors but we were discussing transition as a treatment for gender dysphoria, in general, and not just minors. I cited American *Psychiatric* Association guidelines that recommend transition as a treatment option. You can start your dissenting case by dissecting/refuting the studies they cite.
I'm not saying that transition is necessarily correct for minors but, again, you are the one arguing against the current standard of care for all transgender individuals (regardless of age) so explain to me why I should believe you versus a few decades of study and the recommendations of experts in the field.
`I'm moving on to addiction medicine'
A very noble endeavor; I wish you success.
P.S. Still waiting for the reviews that conclude transition is not an appropriate treatment for gender dysphoria.
"I cited American *Psychiatric* Association guidelines that recommend transition as a treatment option."
The APA, the AAP, and AMA are obviously captured (or just cowards). Look at the Swedish, Finnish, and UK systematic reviews. Putting asterisks around Psychiatric doesn't change anything. And while we're talking psychiatry, please remind of any other conditions that require a psychiatrist where the treatment may include cosmetic procedures? I'll wait.
Also, let's all remember the SoC are put out by self-appointed experts at WPATH, the super geniuses who now include "Eunuch" as a gender identity, and in the SoC8 they cite the Eunuch Archive, which has erotica about small boys getting castrated. So let's not pretend WPATH is the pinnacle of standards, when it's practically a faith-based organization.
`The APA, the AAP, and AMA are obviously captured (or just cowards)'
Or maybe they're just doing the best that they can with the evidence that they have available?
`Putting asterisks around Psychiatric doesn't change anything'
The previous commenter is a medical professional who dismissed the work of non-medical doctors (e.g., psychologists) so I highlighted that actual doctors (psychiatrists) were involved in drafting treatment guidelines.
But they're not. They're refusing calls from their own members (speaking of the American Academy of Pediatrics here, which did questionable things last year at some meeting it had to prevent its members from voting on a proposal to do such a thing) to commission an independent systematic review of the all of the evidence, the way that was done in Sweden, Finland, and the UK.
There's no reason any physician should put more weight on the work of Ray Blanchard, a sexologist, than that of practicing physicians. It wasn't the gotcha you thought it was.
Given that Blanchard's typology is incorporated into the diagnosis of (approximately) gender dysphoria in DSM-IV/V (he participated in the drafting of both), yes, a doctor treating/opining on gender dysphoric persons should be aware of his work and the controversy surrounding it.
I am aware of the APA's position. I have studied more psychiatry and psychology than most physicians and was at the APA's national meeting last year. Even at the best of times, psychiatry is an evidence-poor specialty riddled with controversy. That doesn't mean we shouldn't try to help people, but it does support a general skepticism.
The fact that they rendered an opinion is not in itself problematic; patients exist even when there is not good research on their conditions, so physicians need guidelines even when the evidence is weak. The fact that they reached the conclusions they did is problematic, but is also not inconsistent with other major medical mistakes (or what Vinay Prasad would call medical reversals). The fact that professional organizations have reached conclusions that are not consistent with the best available evidence is an argument in favor of legal bodies forcing physicians to do so, unfortunately.
Extensive familiarity with Ray Blanchard (a non-physician) is not a prerequisite for the practice of medicine. And given that my main admittedly sweeping generalization is that there is no medical literature that would support the use of surgical or medical interventions as treatments for gender dysphoria, a conclusion supported by several recent reviews by experts in the field that I assume you are aware of, I don’t feel that I have an enormous amount of reading to do.
I just wanted to thank you for adding a physician's point of view to things here.
I was actually offered an opportunity to testify at a legislative hearing on a bill banning youth transition. I declined, even after discussing my views in private, because I don't think I have the appropriate amount of professional expertise in the subject to be the person taking the mike in that situation. Among other considerations. However, I have plenty enough standing to smack down this rando substack commenter.
And I think there's some value in it. It's good to articulate one's own arguments, to hear what they sound like (or read what they look like). But I think there's also value in engaging with the pro-trans position, not because it has any factual merit, but precisely because it does not. Trans ideology has gotten into so many institutions despite having a miniscule constituency, no real science behind it, and no claim to moral high ground. The sophistry, the harassment, the intimidation, while it isn't what we might consider good behavior, is very effective. It's good to give some thought to how to counter the arguments, because I suspect part of the success of the ideology is simply that when people here it for the first time they are so baffled they are speechless.
`I have plenty enough standing to smack down this rando substack commenter.'
I believe we're all randos here.
`And I think there's some value in it. It's good to articulate one's own arguments, to hear what they sound like (or read what they look like).'
Agreed. So please provide an argument beyond `there is no evidence to support this modality of care, per my opinion'. You, after all, are arguing that the current standard of care, as recommended by the APA, is incorrect.
https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria
Having met so many engineers who are creationists, I can appreciate the chutzpah it takes to dismiss the work of thousands working over decades.
I am arguing that the standard of care is not evidence-based, because there is not evidence to support it. If there is evidence, an awful lot of people have missed it, and I've noticed that you haven't made any tangible claim about what the evidence would be if it existed. The absence of any large-scale, randomized, longitudinal clinical trial finding that medical or surgical treatment for gender dysphoria improves outcomes is not an opinion. If it's out there, please let us know.
`you haven't made any tangible claim about what the evidence would be if it existed.'
The APA website I linked to includes citations.
`The absence of any large-scale, randomized, longitudinal clinical trial'
You know very well that this isn't the standard used when dispensing treatment to patients. Even when clinical trials or meta-reviews are available, `evidence' is disputed (e.g., clinical trials of mRNA vaccines). Furthermore, when trials/meta-reviews are conducted the medical establishment persistently uses treatments that are ineffective, countered by the evidence, and scientifically implausible. Acupuncture (reimbursed by insurance) and any other `alternative' or `holistic' treatment, for example.
The APA statement cites a variety of studies that are observational designs. There are no studies there that would be accepted by the FDA as evidence towards adding an indication; I recommend looking up the evidence ladder. They are also (and I'm sure you know that Jessie has covered this ad nauseum) exceptionally poor quality research.
It is of course accurate that physicians do prescribe medications for off-label uses, but this is normally for cases where there is some evidence based justifying it. For example, another medication in the same class may have been approved for an indication. It is of course also accurate that evidence is often disputed (because it's often wrong), which is hardly an argument in favor of moving forward without it.
The comparison to acupuncture or other alternative medicine treatments is actually quite apt. Claiming that someone has a gender identity that is different from their sex is roughly equivalent to claiming that their qi is out of balance or their soul is possessed by demons; both are outside the realm of any basic science research in human physiology.
Doctor, shall I pick the mic up off the floor for you?
The funny thing is, I actually have a master's degree in alternative medicine research, so while I'm not the world's leading transgender expert, I have peer reviewed several acupuncture papers and am at least a low-level expert in alternative medicine who is quite familiar with the research and the debates around it.
And there are some "alt med" areas (acupuncture among them) that have a much stronger basis in science than any aspect of transgender medicine. What's been fascinating is watching the anti-quackery community grapple with this; J+K did an episode on David Gorksi, who's physician and a prominent critic of alternative medicine but suddenly went all on on trans ideology. It's bizarre.
I've benefited from acupuncture in the past, and I have an acquaintance who is an acupuncturist and she's been involved in work at a hospital in the Boston area. She's told me (but I didn't retain this info) generally about the research that backs it up.
Gender medicine is its own world, it seems.
`And there are some "alt med" areas (acupuncture among them) that have a much stronger basis in science than any aspect of transgender medicine.'
I'm sorry but that's completely ridiculous. Acupuncture has been scientifically implausible for a great many years and has never stood up past exploratory trials, let alone to the standard you raise above (studies randomized, longitudinal, etc).
There is an extensive scientific literature on acupuncture. Some published in its own niche journals of dubious quality, but some published in mainstream medical journals. (e.g. https://pubmed.ncbi.nlm.nih.gov/29198932/ https://pubmed.ncbi.nlm.nih.gov/26786869/ https://pubmed.ncbi.nlm.nih.gov/29879061/). Research has been conducted using randomized controlled trials of significant scale, with various sham control methods to achieve some degree of blinding.
Obviously, Traditional Chinese Medicine rests on non-scientific concepts, but a variety of research has been done into possible physiological mechanisms relating to the way the needles interact with soft tissues and/or stimulate the nervous system (https://pubmed.ncbi.nlm.nih.gov/29143805/ https://pubmed.ncbi.nlm.nih.gov/12467083/ https://pubmed.ncbi.nlm.nih.gov/16734514/). The ancients probably didn't think that willow bark was inhibiting their cyclooxenegase enzymes, but they used it and it worked (and became aspirin today). Additionally, a separate treatment modality based on scientific concepts was developed by American physicians within the last century called dry needling, which bears considerable resemblance to some types of acupuncture (https://pubmed.ncbi.nlm.nih.gov/26546163/).
Acupuncture is included in the American College of Physicians' clinical practice guideline for low back pain (https://www.acpjournals.org/doi/10.7326/M16-2367), which unlike APA's Transgender Medicine are actually evidence-based, and acupuncture pops up regularly in other guidelines (https://pubmed.ncbi.nlm.nih.gov/29912569/). Acupuncture is covered by Medicare (https://www.medicare.gov/coverage/acupuncture) and most major academic medical centers offer it.
Is acupuncture a panacea? No. Is it probably a lot of placebo? Yes. Are there significant concerns about the quality of the research? Absolutely. But there is a large body of theoretical and clinical evidence for using it for a variety of conditions. There is no comparable evidence for using medical or surgical treatments for gender dysphoria; not one of the studies I cite has any sort of equivalent. I wouldn't say that longitudinal studies are of comparable importance (and where they've been done, acupuncture doesn't show much of a longitudinal effect), because acupuncture needles are not causing irreversible changes in the way that hormonal treatments or surgical interventions do. Acupuncture has a lot more evidence behind it than any aspect of transgender medicine currently does.
You're good at it!
I'm just a parent who fell into this issue over the last two years, reading what I can, trying to make sense of it. I enjoy Twitter debates because it does sharpen your arguments. The ones foolish enough to proceed with slogans and "BuT iNtErSeX" are the most tedious. If I need dopamine I'll do it, though. I keep a Notes file w/ things so I don't have to retype things over & over... I'm surprised by friends from college who I thought were smarter than this, that they'd at least engage with the points I've brought up, but no. They shut down. It's most disappointing.
`Extensive familiarity with Ray Blanchard (a non-physician) is not a prerequisite for the practice of medicine.'
Of course it isn't. What's your specialty, though? Because if you're being to asked to treat gender dysphoric people then you should be familiar with the clinical evidence pertaining to treatment options.
`a non-physician'
As a fake doctor myself (PhD), I too appreciate the arrogance that allows me to dismiss the thoughts, opinions, and research of others in areas vaguely related to my expertise. I especially find it rich when computer scientists say anything about computing even though they're completely incapable of actually building a computer like we computer engineers are! Don't get me started on the IT people who ensure our networks run...most of them don't even have a B.S. in a relevant field.
`a conclusion supported by several recent reviews by experts in the field'
Which reviews are you referring to?
I'm not being asked to treat gender dysphoric people (at least not frequently), which is an irrelevant point to whether or not there is any clinical evidence for doing this. Since there is no FDA approved treatment for gender dysphoria, no significant clinical trial on any of the off-label treatments that are being used, if I were asked, I would decline. My current specialty is primary care and public health; I'm moving on to addiction medicine.
There is nothing arrogant about asserting that nonmedical degrees are not relevant to medical practice. Psychologists do not make clinical decisions about whether or not a surgical procedure is indicated. That does not mean that psychology is useless or that psychology degrees are fake. Of course, someone without a college degree at all can easily look form an opinion by doing some research of their own. Everyone's entitled to an opinion.
I'm referring to reviews published by health officials in several countries (most recently Norway) asserting that there is no evidence for medical transition in minors. I assume these people can read, and that there is not some hidden well of evidence that they missed.
`there is no evidence for medical transition in minors'
I don't know about `no evidence' for minors but we were discussing transition as a treatment for gender dysphoria, in general, and not just minors. I cited American *Psychiatric* Association guidelines that recommend transition as a treatment option. You can start your dissenting case by dissecting/refuting the studies they cite.
I'm not saying that transition is necessarily correct for minors but, again, you are the one arguing against the current standard of care for all transgender individuals (regardless of age) so explain to me why I should believe you versus a few decades of study and the recommendations of experts in the field.
`I'm moving on to addiction medicine'
A very noble endeavor; I wish you success.
P.S. Still waiting for the reviews that conclude transition is not an appropriate treatment for gender dysphoria.
"I cited American *Psychiatric* Association guidelines that recommend transition as a treatment option."
The APA, the AAP, and AMA are obviously captured (or just cowards). Look at the Swedish, Finnish, and UK systematic reviews. Putting asterisks around Psychiatric doesn't change anything. And while we're talking psychiatry, please remind of any other conditions that require a psychiatrist where the treatment may include cosmetic procedures? I'll wait.
Also, let's all remember the SoC are put out by self-appointed experts at WPATH, the super geniuses who now include "Eunuch" as a gender identity, and in the SoC8 they cite the Eunuch Archive, which has erotica about small boys getting castrated. So let's not pretend WPATH is the pinnacle of standards, when it's practically a faith-based organization.
`The APA, the AAP, and AMA are obviously captured (or just cowards)'
Or maybe they're just doing the best that they can with the evidence that they have available?
`Putting asterisks around Psychiatric doesn't change anything'
The previous commenter is a medical professional who dismissed the work of non-medical doctors (e.g., psychologists) so I highlighted that actual doctors (psychiatrists) were involved in drafting treatment guidelines.
But they're not. They're refusing calls from their own members (speaking of the American Academy of Pediatrics here, which did questionable things last year at some meeting it had to prevent its members from voting on a proposal to do such a thing) to commission an independent systematic review of the all of the evidence, the way that was done in Sweden, Finland, and the UK.
There's no reason any physician should put more weight on the work of Ray Blanchard, a sexologist, than that of practicing physicians. It wasn't the gotcha you thought it was.
Given that Blanchard's typology is incorporated into the diagnosis of (approximately) gender dysphoria in DSM-IV/V (he participated in the drafting of both), yes, a doctor treating/opining on gender dysphoric persons should be aware of his work and the controversy surrounding it.
Finland was the first country I recall reaching this conclusion. You're welcome to read what they said.
https://segm.org/Finland_deviates_from_WPATH_prioritizing_psychotherapy_no_surgery_for_minors?s=09
I am aware of the APA's position. I have studied more psychiatry and psychology than most physicians and was at the APA's national meeting last year. Even at the best of times, psychiatry is an evidence-poor specialty riddled with controversy. That doesn't mean we shouldn't try to help people, but it does support a general skepticism.
The fact that they rendered an opinion is not in itself problematic; patients exist even when there is not good research on their conditions, so physicians need guidelines even when the evidence is weak. The fact that they reached the conclusions they did is problematic, but is also not inconsistent with other major medical mistakes (or what Vinay Prasad would call medical reversals). The fact that professional organizations have reached conclusions that are not consistent with the best available evidence is an argument in favor of legal bodies forcing physicians to do so, unfortunately.
PhDs can be so sensitive.
Funny comic (artist credit @TatsuyaIshida9) that's somewhat related: https://twitter.com/gnostiquette/status/1314159604151062529/photo/1
Since calling myself a `fake' doctor wasn't clear enough, I was being self-deprecating.
I know. I said "somewhat related," not "get a load of THAT guy."
`THAT [gal].'