Lies, Damn Lies, and Harriet Hall

I thought I’d start my posts on Harriet Hall’s mess by starting at the extreme: are there any assertions that flatly contradict reality? There shouldn’t be too many, after all, as Hall has a background in medicine and skeptical investigation. She should have spotted them.

[CONTENT WARNING: Transphobia]

Who’s Speaking?

When I started skimming over her review of Abigail Shrier’s book, though, I ran into a problem.

There are many social media sites and online forums that facilitate the discovery of a trans identity. Trans influencer gurus commonly offer advice like this […]

Those who transition rarely adopt the stereotypical habits of men (like buying a weight set) and only 3% have had a phalloplasty (to create an artificial penis) and only 13% say they want one. A common response is “I don’t know exactly that I want to be a guy. I just know I don’t want to be a girl.”

Is that Hall talking, or is she summarize arguments Shrier has made? It’s hard to separate Shrier’s views from Hall’s, as there’s no citations I can use to disambiguate the two and the latter’s review seems to be a lazy copy-paste-massage job. Compare that last paragraph Hall wrote to three consecutive ones in Shreir’s book:

They make little effort to adopt the stereotypical habits of men: They rarely buy a weight set, watch football, or ogle girls. If they cover themselves with tattoos, they prefer feminine ones—flowers or cartoon animals, the kind that mark them as something besides stereotypically male; they want to be seen as “queer,” definitely not as “cis men.” […]

Only 12 percent of natal females who identify as transgender have undergone or even desire phalloplasty.

They have no plans to obtain the male appendage that most people would consider a defining feature of manhood. As Sasha Ayad put it to me, “A common response that I get from female clients is something along these lines: ‘I don’t know exactly that I want to be a guy. I just know I don’t want to be a girl.’ ”

I spotted that laziness last time I looked at Hall’s work, but this time around it provides her a shield: maybe she’s on autopilot, and just blindly parroting what Shrier has to say? On the other hand, Hall is a grown-ass woman: she wrote this article and signed her name on the bottom, taking at least partial responsibility for the assertions made within. I’ve decided to credit both equally, unless the text clarifies who is speaking, but I want to signpost this ambiguity.

No Scientific Literature

Let’s jump straight into a whopper.

Prior to 2012, there was no scientific literature on girls age 11–21 ever having developed gender dysphoria at all.

This one is pretty easy to check. Open up Google Scholar, search for “adolescent gender dysphoria,” then revise the search window so that it ends at 2011.

Participants. A total of 44 adolescents (19 males, 25 females) referred consecutively to the Gender Identity Service, Child, Youth, and Family Program (CYFP) at the Centre for Addiction and Mental Health (CAMH) between February 2005 and February 2008 participated as probands. All of the probands were given a DSM–IV– TR (American Psychiatric Association, 2000) diagnosis of GID by the attending clinician. Demographic information was collected as part of the clinical assessment.

Devita Singh, Joseph J. Deogracias, Laurel L. Johnson, Susan J. Bradley, Sarah J. Kibblewhite, Allison Owen-Anderson, Michele Peterson-Badali, Heino F. L. Meyer-Bahlburg & Kenneth J. Zucker (2010) The Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults: Further Validity Evidence, The Journal of Sex Research, 47:1, 49-58, DOI: 10.1080/00224490902898728

Note that this is a follow-up on a questionnaire first developed in 2007 that’s aimed in part at diagnosing gender dysphoria in adolescents. In other words, diagnosing gender dysphoria in adolescents was a common enough occurrence that some researchers decided to standardize it in 2007.

In 1994, the DSM-IV committee replaced the diagnosis of Transsexualism with Gender Identity Disorder. Depending on their age, those with a strong and persistent cross-gender identification and a persistent discomfort with their sex or a sense of inappropriateness in the gender role of that sex were to be diagnosed as Gender Identity Disorder of Childhood (302.6), Adolescence, or Adulthood (302.85). For persons who did not meet these criteria, Gender Identity Disorder Not Otherwise Specified (GIDNOS)(302.6) was to be used.

Meyer III, Walter, et al. “The Harry Benjamin International Gender Dysphoria Association’s standards of care for gender identity disorders, sixth version.” Journal of Psychology & Human Sexuality 13.1 (2002): 1-30.

This paper describes the evaluation and subsequent treatment of a biologic female who presented at age 15 requesting gender reassignment. Multimodality treatment, which continues at the time of writing, has included psychotherapeutic, educational, psychophar-macologic, and endocrinologic interventions. The literature on transsexualism is reviewed, with particular emphasis on the evaluation and treatment of the adolescent girl, and current etiologic theories are discussed.

Dulcan, Mina K., and Peter Allen Lee. “Transsexualism in the adolescent girl.” Journal of the American Academy of Child Psychiatry 23.3 (1984): 354-361.

Twenty-seven adolescent gender identity patients (10 girls and 17 boys) who presented with transsexual wishes for sex reassignment surgery were the subjects of investigation. The average age of the patients was 16.80 years for the girls (range 13-18) and 16.53 for the boys (range 12-19). A psychiatric, psychological, and social profile of the patients is provided, and follow-up of the patients over a period of 5 years is reported.

Lothstein, Leslie M. “The adolescent gender dysphoric patient: An approach to treatment and management.” Journal of pediatric psychology 5.1 (1980): 93-109.

The rationale for investigating gender identity disturbances in children and young adolescents stems from three sources. The first, and probably most widely cited of the three, has come from retrospective accounts of adult patients with disturbances in gender identity or sexual orientation (6), and from non-psychiatric populations of adult homosexuals (4,33,42). […] A second reason for focusing upon the earliest occurrence of this behaviour has been stimulated by the general interest within psychiatry in prospective, as opposed to retrospective, studies. The thrust of a prospective research strategy is rooted in the notion that the development of a particular psychiatric syndrome will be more fully understood (and hopefully, treated) if one is able to observe it in its germinal forms as well as noting the factors contributing to its growth.

Bradley, S. J., et al. “Gender Identity Problems of Children and Adolescents the Establishment of a Special Clinic.” Canadian Psychiatric Association Journal 23.3 (1978): 175-184.

Most of that scientific literature is trash and outdated, but Shrier/Hall didn’t claim anything about quality.

How did these two get so ass-backwards? Here’s my theory: the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders was released in 2013, and it was the first one to use the term “gender dysphoria.” If you assert gender dysphoria is best thought of as a mental disorder, and if you assert the only valid mental disorders are those present in the DSM, then technically speaking the diagnosis of “gender dysphoria” didn’t exist until 2013. The hundreds of research papers present before then don’t count, because even though they often used the words “gender dysphoria” those words lacked the technical meaning they picked up in 2013. You can roll that back a year by declaring it to be a typo or pointing to a draft of the DSM.

If that is the reasoning, it’s comically infantile. Arguing gender dysphoria was never present in children before 2012 is akin to arguing the universe wasn’t expanding before 1912 or that the Earth didn’t have plate tectonics before the 1960’s. Science is descriptive, not prescriptive, and is carried out by fallible human beings with their own biases and ignorance. The existence of something is not contingent on whether someone in a lab coat noted it exists, in fact by definition the thing must have existed before a lab coat came near. This reasoning is only compelling to infants that have not developed object permanence.

California’s Curriculum

There’s a section of the review that talks about California.

Gender stereotypes are taught in kindergarten. Children are taught that they might have a girl brain in a boy body or vice versa; never mind that that is biologically nonsensical. […] The achievements of gender-nonconforming women are downplayed because they don’t count as true women.

This, too, is easy to check. Like most public-facing government policy, the guidance for teaching health in California primary schools is online. Let’s have a peek at Chapter 3, the one covering kindergartners to Grade 3, with a little emphasis added by me:

Students also learn about individual differences, including gender, from a very early age. Gender socialization begins before children start school—students may believe that different norms are associated with people of particular genders by the time they enter kindergarten. While this understanding may be limited, students can still begin to challenge gender stereotypes in a way that is age appropriate. While students may not fully understand the concepts of gender expression and identity, some children in kindergarten and even younger have identified as transgender or understand they have a gender identity that is different from their sex assigned at birth. The goal is not to cause confusion about the gender of the child but to develop an awareness that other expressions exist. This may present itself in different ways including dress, activity preferences, experimenting with dramatic play, and feeling uncomfortable self-identifying with their sex assigned at birth. However, gender non-conformity does not necessarily indicate that an individual is transgender, and all forms of gender expression should be respected.

Shrier and Hall have this completely backwards too! The curriculum straight-up asks teachers to challenge gender stereotypes. Note as well that it actually endorses a major TERF talking point, that gender non-conformity is not the same as being transgender. TERFs however use that to dismiss transgender people via hyper-skepticism; here, instead, it’s used to support both non-conformity and transgender children. Hence why it is worthy of scorn instead of praise.

It’s theoretically possible the California curriculum could work to remove gender stereotypes and emphasize non-conformity as an option, while simultaneously or in later grades downplaying gender-nonconforming women. In practice, though, the odds of that happening are so slim that it’s not worth my time to verify.

The American Psychological Association

The American Psychological Association guidelines go much further than respecting and supporting trans identities; they mandate that therapists adopt gender ideology themselves. Therapists must accept and affirm the patient’s self-diagnosis. Shrier likens this to telling an anorexic teen “If you think you are fat, then you are. Let’s talk about liposuction and weight-loss programs.”

Aha, we have an authorship clue! More importantly, though, it isn’t much effort to check this claim. Let’s bring up the latest guidelines from the APA, and look at the section on “Gender Affirming Practices.” The emphasis on “WHEREAS” is in the original, but the rest was added by me.

WHEREAS affirming therapeutic practices and guidelines recommend that the therapist should remain objective and nonjudgmental to the outcome, focusing on empowering the client to be active in exploring, discovering, and understanding their own identity (American Counseling Association, 2009; APA, 2012; 2015; American Psychiatric Association, 2018; Byne et al., 2012; Edwards-Leeper et al., 2016)

Yet again, Shrier has this completely backwards. The therapist’s role is to guide the patient. If that patient thinks they are transgender, the therapist can help them find ways to test that hypothesis; if the patient decides they are not, the therapist must accept that rather than sticking with the original diagnosis. This is like criticizing physicists for their tendency to “accept and affirm” the output of a particle accelerator. Empiric evidence carries substantial weight and should never be dismissed without reason, but that doesn’t mean alternative explanations should be completely ignored.

Also, the reference to anorexia is not only a cheap shot, it is disanalogyous. There is a strong scientific consensus that providing liposuction and weight-loss instruction to anorexics will degrade their quality of life. Conversely, there is a strong scientific consensus that providing appropriate medical treatment to a transgender person that requests it will enhance their quality of life. That APA guideline drops some citations:

WHEREAS transgender and gender nonbinary people whose gender has been affirmed report increased quality of life (Ainsworth & Spiegel, 2010; APA, 2015; Gerhardstein & Anderson, 2010; Kraemer et al., 2008; Newfield et al., 2006);

WHEREAS individuals who have experienced gender-affirming psychological and medical practices report improved psychological functioning, quality of life, treatment retention and engagement, and reductions in psychological distress, gender dysphoria, and maladaptive coping mechanisms (Austin & Craig, 2015; de Vries et al., 2014; Haas et al., 2011; Sevelius, 2013; White Hughto & Reisner, 2016);

Should we pull up one of these studies? Sure, why not, maybe one of the largest and most professional medical organizations in the world is lying to us.

The efficacy of hormone therapy in relieving psychiatric distress related to gender dysphoria has largely been inferred through clinical practice and low quality evidence. In 2008, the first systematic review exploring the relationship between hormone therapy and the mental health of transgender individuals was conducted. Published in 2010, the review found that hormone therapy in individuals with gender identity disorder (the DSM-IV diagnostic name for gender dysphoria) likely improves gender dysphoria, psychological function, comorbidities (e.g., depression,anxiety, and suicidality), sexual functioning, and overall quality of life. However, the quality of the empirical evidence was very low. All of the reviewed studies pertaining to psychological functioning were nonrandomized and largely cross-sectional designs. Moreover, the majority of the studies evaluated hormone therapy in concert with sex reassignment surgery and so an evaluation of the specific relationship between hormone therapy and the psychological functioning of transgender individuals independent of surgical interventions was not possible. Since 2008, several higher quality studies exploring the relationship between hormone therapy and psychological functioning in transgender individuals have been published, thus an updated systematic evaluation of the research literature is warranted.

White Hughto, Jaclyn M., and Sari L. Reisner. “A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals.” Transgender health 1.1 (2016): 21-31.

Read enough of these papers, and you’ll notice a theme: early research was tarnished by assumptions about transgender people. Researchers often assumed that you were only a “valid” transgender person if you wanted sex-change surgery. In reality, many if not most transgender people are satisfied with changing only their secondary sex characteristics, like facial hair and body fat location. This makes sense, as all of us primarily sex people by these secondary characteristics; merely changing those goes a long way to relieving any dysphoria, and for mild dysphoria it may be enough. When we’re instead asked to sex ourselves via our primary characteristics, riots tend to ensue and human rights watchdogs raise a red card.

This review focuses on three studies that made fewer assumptions, containing a total of 247 transgender people. What effect did hormone therapy, and hormone therapy alone, have on them? I’ll just focus on two of those effects:

Participants in both studies had depression scores in the normal range at baseline as indicated by the SCL-90-R Italian version depression sub-scale, Zung Depression Scale, and SCL-90 Dutch depression subscale. Nonetheless, the SCL-90-R Italian version and SCL-90 Dutch version each showed statistically significant reductions in depression post-hormone therapy across the two studies … One study also assessed depression scores using the Zung Depression Scale and saw a similar statistically significant reduction at 12-month follow-up […]

The SCL-90 anxiety subscales showed higher than normal anxiety for participants in both studies at base-line (…). At follow-up, both studies saw a statistically significant reduction in anxiety with scores in the normal range at 3–6-month follow-up (…) and 12-month follow-up (…), as well as significant standardized mean change scores (…). … One study also showed a reduction in anxiety using a different continuous measure (Zung Anxiety) from above the normal range at baseline (…) to within the normal range at 12-month follow-up (…) and this change was highly significant (…).

I’m greatly amused that even though transgender people started off no more depressed than the general public before hormone therapy, they nonetheless managed to become less depressed thanks to that therapy!

I’ll be quoting and citing a lot of studies here, for reasons you’ll learn, but I do want to detour a bit to point out something important. A consequence of science being descriptive instead of prescriptive is that it’s perpetually behind the curve. The first hormone treatments for menopause began in the 1940’s, and yet it wasn’t until the 1990’s that solid clinical trials were preformed. Clinicians figured the treatment would work, carefully administered it to patients that wanted to try it, monitored them for side effects, and well before the science had caught up reported positive outcomes. There’s nothing unethical about any of that. So why would we withhold similar treatment from transgender people, even if no scientific study has provided evidence that it provides a net benefit?

I mean, how do you think these studies were carried out? They waited for evidence that hormone therapy was beneficial for transgender people to appear in the scientific record, then decided to test if hormone therapy was beneficial? Of course not! Transgender people asked to try therapies that could plausibly benefit them, found they worked well, and researchers followed up on this. It is science’s job to describe why they worked, rather than act as a prescriptive gate-keeper. Bear that in mind when I get citation happy.

Suicide Prevention

Speaking of citation spam, here’s Shrier and Hall again:

Suicide is common, but there is evidence that factors other than gender dysphoria may be causing the suicidal ideation, and there is evidence that affirmation does not ameliorate mental health problems. In one study of adult transsexuals, there was a rise in suicidality after sex reassignment surgery.

The American Psychological Association already showed affirmative care does ameliorate mental health issues, but it’d be worth getting a eleventh, twelfth, thirteenth, fourteenth, fifteenth, sixteenth, and seventeenth opinion just to be extra cautious. Emphasis in the original:

TGNB children who have socially transitioned demonstrate comparable levels of self-worth and depression as non-TGNB children. This has been demonstrated in research that asks parents to report on their child’s mental health (Olson et al., 2016) as well as asking the youth themselves (Durwood et al., 2017). Although TGNB youth who have socially transitioned report slightly higher levels of anxiety compared to non-TGNB peers (Durwood, et al., 2016; Olson et al., 2016) the fact that self-worth and depression outcomes are equal is powerful due to the significantly worse mental health outcomes experienced by non-supported TGNB youth.

Further, research has specifically shown lower suicidal ideation and suicidal behavior when a TGNB youth’s chosen name is consistently used. The more contexts that it is used (home, school, work, and friends), the stronger the effects (Russell et al., 2018). Usage of chosen name resulted in a 29% decrease in suicidal ideation and a 56% decrease in suicidal behavior for each additional context in which it was used. […]

Pubertal suppression is associated with decreased behavioral and emotional problems as well as decreased depressive symptoms (de Vries et a., 2011). Prior to pubertal suppression, 44% of youth experienced clinically significant behavioral problems; however, after an average of two years of pubertal suppression only 22% experienced them. And 30% experienced clinically significant emotional problems prior to pubertal suppression compared to 11% after two years of care. Pubertal suppression has also been shown to significantly improve overall psychological functioning after only six months of care (Costa et al., 2015). Additionally, transgender individuals who desired and received pubertal suppression as adolescents have significantly lower lifetime suicidal ideation compared to those who desired but did not receive it (Turban et al., 2020).

Thanks, Trevor Project! Or is it “The Trevor Project?” Titles with “the” in them can be tricky.

Anyway, did you notice there’s no overlap between the studies they cite and the ones the APA cited? Nor does the study promoted in this MSNBC news item, titled “Sex-reassignment surgery yields long-term mental health benefits, study finds,” show up in either source. As a Canadian I’m obligated to hit my CanCon quota,  so let’s also bring in an older study from Ontario for my nineteenth opinion. Emphasis mine:

Suicide risk was not evenly distributed, [….] While consideration of suicide did not differ significantly by level of social support, those with high levels of social support were significantly less likely to attempt suicide than those with little support (2% versus 16%). Strong parental support for one’s gender identity or expression was associated with significantly lower past-year prevalences of both suicidal consideration and attempts. Those experiencing high levels of transphobia were more likely to consider suicide than those experiencing low levels. Interestingly, there was no suggestion that suicidality (either consideration or attempts) differed between those who had experienced trans-related workplace discrimination and those who had not. Transphobic violence, in contrast, showed strong associations. […] Finally, medical transition status was significantly associated with suicidality. Past-year serious consideration of suicide was highest among those who were planning a medical transition (55% considered suicide in this group), significantly higher than among those who had completed a transition, and among those who were not planning to or did not need to transition. Those planning or in process of medically transitioning sex also had very high prevalences of past-year attempts (27% and 18%, respectively), each significantly higher than prevalences of attempts in the other two groups: 1% among those who completed medical transition and 3% among those not planning a transition or for whom the concept did not apply.

Against all that, Shrier and Hall can only come up with one study that says transitioning increases suicide risk. They never provide a citation or link to it, but dollars to donuts it’s this study:

How can I be so confident? Because a decade ago it set off a firestorm of transphobia and became one of the most widely-quoted studies on transgender health. It’s been brought up so many times in TERF circles that Shiv started calling it “that fucking Swedish study.” But what did said study actually say? Let’s ask the lead author.

The aim of trans medical interventions is to bring a trans person’s body more in line with their gender identity, resulting in the measurable diminishment of their gender dysphoria. However trans people as a group also experience significant social oppression in the form of bullying, abuse, rape and hate crimes. Medical transition alone won’t resolve the effects of crushing social oppression: social anxiety, depression and posttraumatic stress.

What we’ve found is that treatment models which ignore the effect of cultural oppression and outright hate aren’t enough. We need to understand that our treatment models must be responsive to not only gender dysphoria, but the effects of anti-trans hate as well. That’s what improved care means. […]

People who misuse the study always omit the fact that the study clearly states that it is not an evaluation of gender dysphoria treatment. If we look at the literature, we find that several recent studies conclude that WPATH Standards of Care compliant treatment decrease gender dysphoria and improves mental health.

That’s it. That’s the best evidence Hall and Shrier can bring to show that gender affirming treatment is harmful, and it shows the exact opposite of what they claim! In contrast, I’ve produced over twenty studies that either show or suggest gender-affirmative care reduces mental health issues and/or reduces suicidal ideation, after only a few minutes on Google.

Dr. Kenneth Zucker

If you paid keen attention earlier, you may have noticed one name popped up repeatedly in my citations. Dr. Kenneth Zucker helped found the clinic mentioned in an earlier article, spent a good thirty years working with transgender patients, and was an early pioneer of the field. Or, as Shrier and Hall describe him,

Dr. Kenneth Zucker is a case in point. A highly respected expert on gender dysphoria, he refused to reduce the source of distress to one problem; he insisted on looking at the whole kid. In a series of 100 boys he treated who had not been socially transitioned by parents, a whopping 88% outgrew their dysphoria. He was accused of practicing conversion therapy, was fired, and his reputation was ruined.

If you stop and think about it, though, being a pioneer is a red flag. Charles Darwin left a lasting mark on biology when he developed an iron-clad foundation for evolution, but On the Origin of Species never actually explained the origin of species. He lacked the knowledge to explain inheritance, a rather critical part of speciation. Sigmund Freud was a pioneer of psychoanalysis and a major influence on psychology, but the story of Emma Eckstein hints at the flaws in his thinking. “Scientific pioneer got things wrong” is a dog-bites-person story, because the first few people in a field were working from ignorance and thus likely to be biased by their preexisting beliefs. While many if not most adapt as new information comes it, It should be no surprise if a few instead dig in their heels and resist following the evidence.

In Zucker’s case, when he started it was common for researchers to believe that gender dysphoria was a fetish or illness to be “cured.” Nowadays we call such things “conversion therapy” and try to pass laws against its practice.

Conversion therapy or reparative therapy is any treatment, including individual talk therapy, behavioural or aversion therapy, group therapy treatments, medical or drug-induced treatments, which attempt to change someone’s sexual orientation, gender identity or gender expression. Simply put, it is abuse.

While no authority has directly accused Zucker of practicing conversion therapy, his clinical practice sounded an awful lot like it.

The former chief psychologist of the gender identity program at one of Canada’s largest mental health facilities was catapulted into headlines in 2015 when a complaint prompted a review of his now-closed clinic by the Centre for Addiction and Mental Health (CAMH) in Toronto.

The review occurred at the same time as a law was passed in the Ontario legislature banning so-called conversion therapy for minors, a discredited practice that falsely claims to change someone’s gender or sexual identity. The center’s report stopped shy of characterizing Dr. Kenneth Zucker’s practice as conversion therapy, but it did conclude his methods were “out of step” with the latest research findings and that they warranted sweeping reforms. Zucker’s clinic, which was housed inside CAMH but operated largely independently, closed later that year; the decision was met with support from nearly 1,400 stakeholders, including clinicians and researchers in the field of transgender health. […]

When reached for comment, Zucker reiterated that he denies practicing conversion therapy. However, he also acknowledged previously describing a possible objective of his own practice as including working to “reduce their child’s desire to be of the other gender” if that’s what the parents want. (The American Academy of Pediatrics describes gender identity conversion therapy as methods that “are used to prevent children and adolescents from identifying as transgender or to dissuade them from exhibiting gender-diverse expressions.”)

Read on, and you’ll note several instances where Zucker states a medical expert or panel says X, only to have that expert or a representative says they don’t say X. He’s stubbornly clinging to old and harmful ideas, contrary to where the research has led those who followed. Shrier and Hall are half-right: Zucker has indeed been accused of practicing conversion therapy, that likely led to the closing of his clinic, and it’s probably trashed his reputation in the field he helped start.

Shiv’s written about Zucker’s approach to medical care twice, though, with the second quoting from the experts that reviewed Zucker’s clinic. Three bullet points from the summary are worth quoting in full:

  • Research knowledge and clinical guidelines have evolved, particularly in the last five years, and society’s understanding and acceptance of the diversity of gender expression and identity have changed. There appears to be a mismatch between literature research findings (including those from GIC itself), and clinical practice and approach.
  • Clinic assessments are long and, at times, appear to be clinically inappropriate for the child’s age. Questions were raised by the reviewers about the information shared regarding participation in research as documentation suggested that consent obtained may not have been fully informed.
  • Feedback from families indicated that the clinic supported families very differently. Some families reported that services or referrals were not offered to them despite requests while other families reported receiving exceptional supports for long periods of time. In some instances, the reviewers expressed concern regarding the possible over-involvement of parents in a child’s treatment planning.

I would call performing “clinically inappropriate” assessments of children, possibly neglecting consent, and “over-involvement of parents” to be the exact opposite of “looking at the whole kid.” That is the lie in Hall’s review of Shrier’s book. As for the “88% outgrew it” thing, I defer to Shiv and eight other people who’ve slashed that old falsehood to ribbons. I see Dr. Sarah has talked about it as well.

Before I move on, though, I’d like to point out one of the promotional blurbs written for Shrier’s book.

“In Irreversible Damage, Abigail Shrier provides a thought-provoking examination of a new clinical phenomenon mainly affecting adolescent females—what some have termed rapid-onset gender dysphoria—that has, at lightning speed, swept across North America and parts of Western Europe and Scandinavia. In so doing, Shrier does not shy away from the politics that pervade the field of gender dysphoria. It is a book that will be of great interest to parents, the general public, and mental health clinicians.”— KENNETH J. ZUCKER, PH.D., adolescent and child psychologist and chair of the DSM-5 Work Group on Sexual and Gender Identity Disorders

Shrier’s book white-washes Zucker’s reputation, and Zucker returns the favour by using his credentials to boost Shrier’s book. You’ve got to admire how brazen this scam is. Also, it’s a bad sign that Zucker is endorsing an over-hyped and long-debunked transphobic talking point. More evidence he’s become an irrelevant crank.

Dr. Ray Blanchard

Speaking of which:

Dr. Ray Blanchard questions whether adolescent girls who suddenly identify as trans even have gender dysphoria. He believes they are a mixture of those who will be transgender no matter what, those who will outgrow their dysphoria and live as gay adults, and those who have borderline personality disorders and have identified a kind of faux gender dysphoria as the locus of their unhappiness. Rigorous empirical study is needed to guide diagnosis, understanding, and treatment; but in the current political environment good science has become almost impossible.

In reality, Blanchard’s theories have already been studied in depth (if you’re getting sick of citation spam, I won’t object if you watch the Contrapoints video instead).

In subsequent years, several independent research groups have tested autogynephilia theory, and their results further disprove its taxonomical and aetiological claims. For starters, every single follow-up study has shown that, while the correlations that Blanchard and other researchers prior to him described generally hold true (i.e. that FEFs are more common in ‘non-classical’ trans women than ‘classical’ ones), counter to Blanchard’s theory there are always substantial numbers of ‘classical’ trans women who report experiencing FEFs and ‘non-classical’ trans women who report never experiencing them (Nuttbrock etal., 2011a; Smith etal., 2005; Veale etal., 2008). These studies also challenge several additional claims necessary for autogynephilia theory to be substantiated, such as the idea that FEFs compete with sexual attraction toward other people, that asexual trans women are predominantly ‘autogynephilic’ and that bisexual trans women are merely ‘pseudobisexuals’ (Nuttbrock etal., 2011a; Veale etal., 2008). […]

The possibility that factors other than sexual orientation may be responsible for FEFs is further supported by Nuttbrock etal. (2011a, 2011b), who found that FEFs varied considerably among trans women depending upon age and race (with the highest levels observed in older and white subjects), and that these outcomes were mediated by a history of dressing femininely in private. This finding strongly supports alternative theories that have posited that FEFs arise from, or are exacerbated by, social factors such as secretive crossdressing and/or having to hide or repress female/feminine inclinations (Serano, 2007, 2016; Veale etal., 2010) …

As previously mentioned, Blanchard never used any cisgender controls in his studies, presumably because he assumed that FEFs were unique to trans female/feminine-spectrum people. Two research groups have since administered autogynephilia scales (similar or nearly identical to Blanchard’s) to cisgender women. Moser (2009) found that 93% of his cisgender female subjects had experienced FEFs in some capacity, with 28% experiencing them frequently. Veale etal. (2008) also found that cisgender women frequently report FEFs, with 52% experiencing them at levels comparable to Blanchard’s ‘autogynephilic’ group (see also Moser, 2010). When roughly 65% of cisgender women respond affirmatively to questions like ‘I have been erotically aroused by contemplating myself in the nude’, or ‘I have been erotically aroused by contemplating myself wearing lingerie, underwear, or foundation garments’ (Moser, 2009), it seems both illogical and needlessly stigmatising to single out trans women as supposedly being ‘autogynephiles’ for having similar erotic experiences (unless, of course, the label is primarily intended to pathologise trans women’s sexualities even when they are female-typical).

Serano J. Autogynephilia: A scientific review, feminist analysis, and alternative ‘embodiment fantasies’ model. The Sociological Review. 2020;68(4):763-778. doi:10.1177/0038026120934690

Good science has been performed, and it largely refutes Blanchard’s theories. The most damning nail in the coffin comes from transgender people themselves. Science is descriptive, so the most direct way to test a sociological theory like Blanchard’s is simply to ask transgender people how well it describes them. Here are some of their responses; they had no idea what other transgender people were saying, and each paragraph is a different speaker.

It holds up this idea that there are only two types of transsexuals, and that they have to fit in either category. Well first off, being a very active member in the trans community, I can say this isn’t so. There is such a huge spectrum of gender and/or
sexual variants in the trans community.

It is society trying to put transsexual people in a box. Some like me are a mix.

Transitioning is a horribly painful thing. I’ve lost friends, good friends, family, have been thrown on the street by my family. Why would someone go through that for a sexual thrill?

Practically, I wonder how much brainwashing Blanchard’s subjects underwent, because none of the transsexuals I have known recognize their experience in his theory.

My reasons for being an MTF are as far from that as one could imagine, and so too for those I trust and respect most.

I also feel that this classification ignores me: I never had a history of dressing as female before my transition.

I only admitted to myself I am transsexual at the age of 45 after a life of marriage and children, I was not feminine in appearance or action. So it seems to fit my case well.

When I first heard about the theory I did find it quite disturbing and didn’t think one would do that, until I met one that fits perfectly in Blanchard’s picture of autogynephilia and although I think that it’s wrong to transition just because of sexual arousal, if it makes this one person happy and helps him/her leading his/her life than who am I to judge?

I believe that people that identify as cross-dressers are more in the group of autogynephilia I am not a cross-dresser I am transsexual.

Sounds to be an unsupported method used by conservatives to make transsexuals look like sexual deviants.

Veale, Jaimie F., David E. Clarke, and Terri C. Lomax. “Male-to-female transsexuals’ impressions of Blanchard’s autogynephilia theory.” International Journal of Transgenderism 13.3 (2012): 131-139.

If I told you that a theory could only explain 16% of the evidence, at most, would you think of it as a good theory? I certainly wouldn’t. Yet that’s the percentage of transgender women who thought Blanchard’s theory had any validity. Note that “any validity” includes “I can think of one other person who might fit this,” so the fraction of transgender women it describes well is much smaller than 16%. Also bear in mind that Blanchard’s theory completely ignores transgender men. I haven’t seen solid numbers, but one study estimates trans men are about a third of all transgender people. That’s a lot of people to leave out of your theory.

If we had no alternative theories, that lousy rate might be acceptable. But the “wrong body” and “mismatched body parts” theories are either endorsed by a majority of transgender people or match what they describe without invoking a sex binary. At minimum, Blanchard’s theories should be shelved next to the luminiferous aether and plumb-pudding model.

We can easily state something stronger. Blanchard’s theories divide transgender women into two categories: autogynophiles who derive sexual pleasure from being viewed as women, and effeminate gay “men” who respond to anti-femme peer pressure by transitioning. Recasting gender identity in terms of sexual attraction carries an implicit assumption that all transgender women are horny deviants in need of a “cure.” There’s a good argument this is slander trying to pass as science, so a better shelf might be the one holding craniometry and hysteria.

Another fun fact: guess who else endorsed Shrier’s book?

“Thoroughly researched and beautifully written.”RAY BLANCHARD, PH.D., head of Clinical Sexology Services at the Centre for Addiction and Mental Health from 1995–2010

It’s telling that Shrier’s bio of Zucker and Blanchard drops no hint of their close professional connections. This makes it look like the two independently came to their views, when in reality both sat on the same journal editorial boards and acted as peer reviewers for one another. Blanchard even mentored Zucker and worked at the same clinic.

Where’s the Science?

Let’s switch to a passage where authorship is clear.

This book will undoubtedly be criticized just as Lisa Littman’s study was. Yes, it’s full of anecdotes and horror stories, and we know the plural of anecdote is not data, but Shrier looked diligently for good scientific studies and didn’t find much.

Scroll back up. How many studies have I spammed at you? Didn’t I open this post by doing a fifteen second Google Scholar search, which netted hundreds of studies? We can quibble over the quality of those studies, certainly, but we’ve reached a point where even conservative organizations like the APA and the American Academy of Pediatrics think there is sufficient evidence to write guidelines for care. Another data point on depth: the World Professional Association for Transgender Health, the largest and most respected organization studying the health of transgender people, was founded 42 years ago. They hit the ground running.

This is the 7th version of the Standards of Care since the original 1979 document. The first six versions were published in 1979, 1980, 1981, 1990, 1998, and 2001. Version 7 of the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People will be available in several additional places for wide distribution and ease of access.

When I do a simple Google Scholar search for “WPATH,” Google Scholar claims to find six thousand citations. There’s a lot of irrelevant clutter, such as lauditory profiles of the founders, but that basic search digs up recommendations for version 8 of their Standards of Care, debates over what those standards should be, and a lot more. Nor are they the only game in town.

These guidelines expand on the original UCSF Primary Care Protocol for Transgender Care, which since its launch in 2011 has served thousands of providers and policymakers across the U.S. and around the world; the page on hormone administration alone received more than 5000 visitors in the month of November, 2015. These Guidelines complement the existing World Professional Association for Transgender Health Standards of Care and the Endocrine Society Guidelines in that they are specifically designed for implementation in every day evidence-based primary care, including settings with limited resources.

The overall structure and list of topics for inclusion were developed in consultation with the CoE’s Medical Advisory Board (MAB), a diverse group of expert clinicians from a variety of academic and community based settings. Also contributing to the overall design and structure was a review of the range of consultation requests received by the CoE since the 2011 launch of the original Protocol. The guidelines were then written using an authorship – peer review approach. Primary authors from both within and outside the MAB were invited for individual topics, after which a peer review and modified consensus process was used to arrive at the final guidelines presented here. The diverse authorship allows the development of a broadly applicable document, rather than one that solely reflects the practice at a single academic medical center, such as UCSF.

Flip through the two-hundred page document, and you’ll not only find a citation list after every chapter, you’ll see they used a coding system to rate the quality of evidence. Hell, as I’m writing this mainstream scientific journals like the Lancet will devote entire series to the health of transgender people, and the New England Journal of Medicine will publish articles that call gender-affirming care an “essential treatment.”

If Shrier can’t find much good science on this subject, she never looked for it in the first place.

Dereliction of Duty

You may have noticed that when authorship isn’t ambiguous, it’s usually Shrier making the claims. There are exceptions where Hall makes claims, most notably this one:

I think the affirmative care model is a mistake and a dereliction of duty and should stop.

I’m reminded of creationists who earn degrees to boost their credibility. Most of the time, this degree has nothing to do with biology because it is almost impossible to expose yourself to the relevant science and remain a creationist. Harriet Hall, in contrast, was a family physician. Her current bread and butter is debunking pseudo-science, which involves doing quite a bit of research on a topic. Even an expert has their limits, of course; I can forgive her not double-checking Shrier’s assertions about California’s curriculum, or going along with the whitewash of Dr. Kenneth Zucker.

I cannot forgive her for again distorting the science and promoting misinformation in her own area of expertise. You saw me produce over twenty studies which support the affirmative care model, with respect to mental health. You saw me link to multiple policy documents produced by relevant medical regulatory bodies that, on the basis of those studies, recommend affirmative care. Hall cannot claim ignorance over these and continue to burnish her medical credentials, any more than a creationist with a biology degree can spout misinformation about biology.

Hall has not only become the pseudo-scientists she tries to debunk, she’s become that rare breed who could credibly claim to be an expert on the matter. These are the most dangerous, and there should be harsher consequences for her promotion of lies and medical misinformation than having an article yanked with a vague disclaimer about why.