It seems unfortunate to me that, in respectable company, people can't ALSO propose treatments that may make the mind more in line with the body -- rather than only considering cutting up the body to be more like the mind.
For example, it seems plausible that a young male who wants to become a female might have the mismatch resolved with more testosterone and other hormones -- which could lead to feeling right in a male body. Hormones, as is well known, impact thought processes and brain development as well as bodies.
There's a sense in society that one's current mind is precisely "you", and everything must be done in service of it -- but we know that drugs can change minds and it's still a version of "you". And potentially a version that's long-term happier in one's body. This seems doubly applicable in cases where people are still developing.
Until we have technology that actually allows people to become fertile members of the opposite sex, the above seems like a more elegant solution to mismatch, more in line with nature and evolution. How often would it actually work? Not sure, but a sane society would be studying it.
Are you sure no one hasn’t studied that already and found it doesn’t work?
I think yours is basically a common reaction to the idea of being trans, certainly it was roughly mine before I actually knew any people I knew were trans. In my case I think it was definitely partly rooted in squick about the idea of transition, plus some sexual orientation baggage.
Why is matching what some idea you have of nature and evolution a goal worth having? Your brain is a biological computer, all your desires have physical causes. I think the necessary perquisite to being able to recruit participants for your study is for them to be able to trust that you’re not just trying to get rid of them because you find their existence upsetting.
I see nature/evolution as an “occam’s razor” or “chesterton’s fence”, which should be defaulted to in the absence of strong evidence to the contrary.
I won’t claim I don’t have any biases. What we really need is a clinical study randomly assigning people to one of these two treatment groups, so that people who prefer science over biases can look to that.
If there have been semi-decent studies on this, I’m not aware of any. If others are aware, I hope they’ll share.
I will leave aside the question of whether the framing in which being trans is a medical problem is helpful for the sake of argument, though I think I am on the "not helpful" side of that.
I'll also assume that you're arguing for randomized controlled trials of current consensus treatments for trans people, rather than some not yet existent way of changing trans people's preference for what gender they are perceived as.
A randomised controlled trial is a way of solving specific problems in medical research, namely medical researchers are biased towards thinking their pet intervention helped, and the placebo effect where giving people treatments with no plausible non-psychological mechanism for improving a condition actually does improve people's condition, or at least their perception of their condition.
Given that the problem we are trying to solve is essentially people finding perceiving themselves painful, if current treatments work via the placebo effect that should have zero impact on our decisions on how to treat trans people.
Given current moral/political opinions among potential study participants recruiting a fair control group is likely to be impossible. In the case the participants are already convinced that the treatment works, as is probably the case for the majority of trans people already, you are effectively adding a negative treatment of persuading people to forgo medical treatment they really want to your control group, in which case the experiment will be biased in favour of finding a positive result anyway. In the case where you somehow recruit a control group who won't be upset by the fact they aren't receiving treatment they won't be representative of the group you're trying to treat so your experiment won't be properly controlled anyway and you might as well just do an uncontrolled trial.
I last went looking at the medical research around surgeries around 2019, and didn't think much of the studies available then, though I have no particular expertise in evaluating medical research, and in hindsight was working with a clear bias towards wanting evidence that surgery was a bad option. Since then I have seen reporting around study that found positive results for whatever treatment it was looking at, but I haven't looked deeply into it.
I will also point out that many trans people feel like medical treatments for them are subject to isolated demands for rigour. We allow patients to evaluate the risks and choose to undergo surgeries that only work some of the time, and leave some percentage of patients regretting them all the time for non-controversial things.
What I'm suggesting, and I agree that it's not easy to do in the present cultural moment, is to have say 100 teens with gender dysphoria, who are *unsure* of what the best path is, which I believes includes lots of people.
50 would be randomly selected to be treated by doctors who are skeptical of surgery, and believe in making sure hormone levels etc are healthy to match the *birth gender* and potentially bring the mind in line with the body.
50 would be treated by the school of thought currently in vogue in the US, which is very pro-surgery etc.
Then follow up on outcomes -- life success, self-reported happiness, suicide, etc. Doesn't matter how much was placebo or not. All that matters is randomization and outcome, because outcome is what we care about.
Finally, absolutely people should always have the right to get surgery, regardless of the outcome of the trial. I am talking about trying to figure out what the medical establishment should recommend to people.
So before being prescribed hormones people usually need to be examined by an endocrinologist, I don’t know what they’d do if they found someone’s hormone levels already outside the normal range before they started treatment, but if trans people have weird hormone levels to begin with and no one has noticed that sounds like a failure of the medical community.
I think your proposed experiment is based on the misconceptions that doctors are the ones pushing for physical transition and that they have some other treatment that they aren’t providing for ideological reasons which I understand they don’t.
Giving people who are unsure about their gender surgery and hormones is probably unethical even if it turns out to be effective but I don’t think that’s what you mean. I understand that puberty blockers are used in some cases, the claim that they are used for teens who are unsure about themselves rather than who are sure but doctors don’t think it counts is one I would have to be convinced of.
Basically I think a RCT between puberty blockers and no treatment for people who are genuinely unsure could be ethical depending on some other factors.
Similarly for people who are sure a RCT between puberty blockers and starting HRT immediately could be ethical.
I also think your proposed measurements of success are missing the point somewhat. These treatments aim to produce subjective improvements, so trying to measure their success objectively is inherently difficult and somewhat beside the point. Probably the right measure is to compare whatever problems people report before and after treatment, for example “do you still avoid showering because you find looking at yourself naked painful?”. Suggesting people should be suicidal before we let them do things to improve their lives does not sound like a great choice to me. Obviously this makes it hard to compare outcomes between your control and your treatment group.
Re objective — those still seem the most important endpoints to me. Does it matter if we fixed the showering issue if it added new ones that lead to bad life outcomes? So I think objective by far the most important, but for sure, study subjective too.
This is the biggest elephant in the room - by far. If someone's brain is telling them to cut off their arm, we treat their brain rather than cutting off the arm. But if someone's brain is telling them to cut off their genitalia, we just go along with it? This... doesn't make much sense to me.
Well, that may be b/c (AFAIK) trans is quite a lot more than "cut off their genitalia". For one, it's also usually "turn my genitals into different genitals" rather than "have no genitals". For another, vocal aesthetic - trans folks usually put in a lot of effort in "voice training" to change the sound of their voices.
Like, I'm phrasing this in a pedantic way, but if you're finding yourself confused (about anything), the answer is that you either don't know something, or know a wrong thing. People want to do this thing. If you're confused by that, what might you not know about their wanting, or what might you know that's incorrect about their wanting?
I was being polite and open to discourse, not looking to start yet another Internet fight. Lets try to be empathetic to both each other and the transgender community :-) The question is: what is the problem we're trying to solve?
a) Making individual people happy
b) Making people happy in ways approved by society
I think we can agree that a) is our goal here, as "approved by society" was quite traumatizing as recently as 20 years ago, right?
But if its about the happiness of individual humans, why are treatments of their brain considered to be taboo? If there's a magic pill that makes you comfortable in your current body without needing any surgery or vocal training, why would that be a bad thing? If the side effects of this pill are smaller than the side effects of surgery, it should be an excellent solution for many trans folks.
Once again - I fully support the right of all humans to be happy and don't care if someone gets surgery or does anything they want to their own body. But I think its unfair to tell people that they don't get the right to treat their brain if they want and all they get is the option to change their bodies instead.
In this case attempt to modify trans people’s brains rather than their bodies is taboo because there is a long history of harmful and often non-consensual attempts to do just that.
Is there an aspect of your identity that is inconvenient in this society? If there was a magic pill that changed that aspect of your identity would you take it? If so why don’t you go around advocating for research into making that pill and let trans people advocate for the one you’re suggesting if they want to.
Why does history of society matter here at all? Isn’t the goal to make people *happy* rather than resolve some sort of historical injustices? I’m advocating for giving people a *choice* between swallowing a pill and taking all the complicated steps Aella talks about in her post.
And yes - there are tons of problematic brain behaviors that would be great to fix with a pill but for which no proper research is done for societal reasons. I.e. the exploration treatment of PTSD with drugs like MDMA is progressing extremely slowly because of the taboo on recreational drugs.
I’m explaining why there is a taboo, and why I think your moral intuitions are unhelpful in this particular case.
I think if you want to experiment with using MDMA to change consenting people’s gender identity, and the people in question aren’t consenting because of a coercive social environment, and you’re not torturing them or something, that would be perfectly ethical, though because of the history I explained you might find recruiting study participants difficult.
Basically I think the difference is one of agency. The taboo on recreational drugs primarily removes drug users agency, though there might be sufficient coercive shit in the medical establishment that there are occasionally people whose agency is protected by the taboo. The taboo on conversation therapy protects people’s agency, though it might slow down the or stop the development of an effective conversion therapy, if such a thing is possible and such a therapy doesn’t fall out of general improvements in our understanding of the brain and its relationship to the body.
As an aside which you may well not need convincing of: a good reason for a total ban on conversion therapy, as opposed to say just banning all the specific ineffective and often evil things people try, is that people are inventive and if you don’t ban the whole idea people who are offended by trans people expressing their existence will think up some new devilry to get around your ban.
That's an interesting take, and I'm glad you talked about it. Do you know of any science done in that direction? (There might be studies of other uses of testosterone, like for body building, that would include relevant data?)
Otherwise, AFAICT we (I think all human cultures?) have a pretty strong revulsion against "things that alter the mind" in a way that we *don't* have a revulsion to "things that alter the body"; dipping into religion, the soul is a much bigger deal than the body.
The traditional "modify the gender to match the sex" (= "stop being a sissy", "act more ladylike") and the modern "modify the sex to match the gender" (hormones and surgery) both seem wrong to me. Can't we just accept people (including ourselves) for who they are? Some males are "feminine", some females are "masculine", and that's just a normal variation. There isn't a need to change one thing to "match" the other.
That was mostly my initial reaction to the idea, however I’ve come around.
Firstly for at least some (I would guess large) proportion pf trans people there seems to be something beyond discomfort with socially enforced gender roles going on, for example they often report great improvements in mental health soon after starting HRT, before any physical changes have time to occur.
Secondly getting society to stop enforcing gender roles is hard, and recognising non-binary genders are a way to make incremental progress towards not making people modify their gender to match their sex. David MacIver writes more about this here, for example: https://www.drmaciver.com/2019/09/gendering/
Finally of course the idea that “we” are somehow making trans people physically transition is likely to really piss off trans people because getting access to it is typically a fairly onerous process that they have to actively fight for, rather than something they feel they are being forced to do.
SHBG reduces the rate at which testosterone crosses the blood-brain barrier (and generally reduces the bioavailability of testosterone). Levels of SHBG can be increased abnormally by various diet/lifestyle factors. Rising transgenderism could be due to rising prevalence of endocrine disruptors and diet/lifestyle that has an endocrine disrupting effect. Dollar for dollar society probably gets more bang for the buck doing research into how to prevent abnormal fetal development than in doing fancy surgeries on individuals. But this might be taken like the deaf people who are offended by the idea that someone might want to cure deafness. It's a whole tribal identity built around an illness.
I'd survey mothers of trans kids to see what they ate and did while they were pregnant. Did they have above average exposure to plastics, pesticides, etc. If anyone ever did this they might find some very cheap interventions that reduce the risk by half. But it'd probably never get funded by woke government agencies because prevention requires admitting it's preferable to not be trans. There's almost no prevention research yet due to politics. Compare this: https://www.psychologytoday.com/us/blog/science-and-philosophy/202008/controversy-surrounding-the-drive-cure-deafness Wherein deaf people agitate against curing deafness due to an ideological commitment to denying deafness is a problem.
"I don’t know - I’m working on a survey right now and hope to have a spot of evidence here soon."
If you're doing a survey on autogynephilia in trans women, I would recommend talking with me. I did a detailed survey on autogynephilia in trans women as part of the ACX reader research survey, and I've got some interesting results that potentially have implications for how to best investigate it, but it has taken a long time to process the data, so I haven't published the results yet. If you want to talk then I can give you a preview of some of my relevant findings.
Oof. Sitting with this one and how it relates to what I pick from my very, very liberal bubble about cis-het-masculinity. Definitely open to talking about it if anyone wants to engage haha.
Interesting points.
It seems unfortunate to me that, in respectable company, people can't ALSO propose treatments that may make the mind more in line with the body -- rather than only considering cutting up the body to be more like the mind.
For example, it seems plausible that a young male who wants to become a female might have the mismatch resolved with more testosterone and other hormones -- which could lead to feeling right in a male body. Hormones, as is well known, impact thought processes and brain development as well as bodies.
There's a sense in society that one's current mind is precisely "you", and everything must be done in service of it -- but we know that drugs can change minds and it's still a version of "you". And potentially a version that's long-term happier in one's body. This seems doubly applicable in cases where people are still developing.
Until we have technology that actually allows people to become fertile members of the opposite sex, the above seems like a more elegant solution to mismatch, more in line with nature and evolution. How often would it actually work? Not sure, but a sane society would be studying it.
Are you sure no one hasn’t studied that already and found it doesn’t work?
I think yours is basically a common reaction to the idea of being trans, certainly it was roughly mine before I actually knew any people I knew were trans. In my case I think it was definitely partly rooted in squick about the idea of transition, plus some sexual orientation baggage.
Why is matching what some idea you have of nature and evolution a goal worth having? Your brain is a biological computer, all your desires have physical causes. I think the necessary perquisite to being able to recruit participants for your study is for them to be able to trust that you’re not just trying to get rid of them because you find their existence upsetting.
I see nature/evolution as an “occam’s razor” or “chesterton’s fence”, which should be defaulted to in the absence of strong evidence to the contrary.
I won’t claim I don’t have any biases. What we really need is a clinical study randomly assigning people to one of these two treatment groups, so that people who prefer science over biases can look to that.
If there have been semi-decent studies on this, I’m not aware of any. If others are aware, I hope they’ll share.
I will leave aside the question of whether the framing in which being trans is a medical problem is helpful for the sake of argument, though I think I am on the "not helpful" side of that.
I'll also assume that you're arguing for randomized controlled trials of current consensus treatments for trans people, rather than some not yet existent way of changing trans people's preference for what gender they are perceived as.
A randomised controlled trial is a way of solving specific problems in medical research, namely medical researchers are biased towards thinking their pet intervention helped, and the placebo effect where giving people treatments with no plausible non-psychological mechanism for improving a condition actually does improve people's condition, or at least their perception of their condition.
Given that the problem we are trying to solve is essentially people finding perceiving themselves painful, if current treatments work via the placebo effect that should have zero impact on our decisions on how to treat trans people.
Given current moral/political opinions among potential study participants recruiting a fair control group is likely to be impossible. In the case the participants are already convinced that the treatment works, as is probably the case for the majority of trans people already, you are effectively adding a negative treatment of persuading people to forgo medical treatment they really want to your control group, in which case the experiment will be biased in favour of finding a positive result anyway. In the case where you somehow recruit a control group who won't be upset by the fact they aren't receiving treatment they won't be representative of the group you're trying to treat so your experiment won't be properly controlled anyway and you might as well just do an uncontrolled trial.
I last went looking at the medical research around surgeries around 2019, and didn't think much of the studies available then, though I have no particular expertise in evaluating medical research, and in hindsight was working with a clear bias towards wanting evidence that surgery was a bad option. Since then I have seen reporting around study that found positive results for whatever treatment it was looking at, but I haven't looked deeply into it.
I will also point out that many trans people feel like medical treatments for them are subject to isolated demands for rigour. We allow patients to evaluate the risks and choose to undergo surgeries that only work some of the time, and leave some percentage of patients regretting them all the time for non-controversial things.
What I'm suggesting, and I agree that it's not easy to do in the present cultural moment, is to have say 100 teens with gender dysphoria, who are *unsure* of what the best path is, which I believes includes lots of people.
50 would be randomly selected to be treated by doctors who are skeptical of surgery, and believe in making sure hormone levels etc are healthy to match the *birth gender* and potentially bring the mind in line with the body.
50 would be treated by the school of thought currently in vogue in the US, which is very pro-surgery etc.
Then follow up on outcomes -- life success, self-reported happiness, suicide, etc. Doesn't matter how much was placebo or not. All that matters is randomization and outcome, because outcome is what we care about.
Finally, absolutely people should always have the right to get surgery, regardless of the outcome of the trial. I am talking about trying to figure out what the medical establishment should recommend to people.
So before being prescribed hormones people usually need to be examined by an endocrinologist, I don’t know what they’d do if they found someone’s hormone levels already outside the normal range before they started treatment, but if trans people have weird hormone levels to begin with and no one has noticed that sounds like a failure of the medical community.
I think your proposed experiment is based on the misconceptions that doctors are the ones pushing for physical transition and that they have some other treatment that they aren’t providing for ideological reasons which I understand they don’t.
Giving people who are unsure about their gender surgery and hormones is probably unethical even if it turns out to be effective but I don’t think that’s what you mean. I understand that puberty blockers are used in some cases, the claim that they are used for teens who are unsure about themselves rather than who are sure but doctors don’t think it counts is one I would have to be convinced of.
Basically I think a RCT between puberty blockers and no treatment for people who are genuinely unsure could be ethical depending on some other factors.
Similarly for people who are sure a RCT between puberty blockers and starting HRT immediately could be ethical.
I also think your proposed measurements of success are missing the point somewhat. These treatments aim to produce subjective improvements, so trying to measure their success objectively is inherently difficult and somewhat beside the point. Probably the right measure is to compare whatever problems people report before and after treatment, for example “do you still avoid showering because you find looking at yourself naked painful?”. Suggesting people should be suicidal before we let them do things to improve their lives does not sound like a great choice to me. Obviously this makes it hard to compare outcomes between your control and your treatment group.
Again, it’s not treatment vs no treatment, it’s two kinds of treatment, as I described.
Re “sure”, it’s not sure clear what that means with teens, who can’t meaningfully consent to some things because they have a lot of growing and learning left. I base that on detrans stories: https://bariweiss.substack.com/p/the-testosterone-hangover?r=3ppaf&s=r&utm_campaign=post&utm_medium=web&utm_source=direct
Re objective — those still seem the most important endpoints to me. Does it matter if we fixed the showering issue if it added new ones that lead to bad life outcomes? So I think objective by far the most important, but for sure, study subjective too.
This is the biggest elephant in the room - by far. If someone's brain is telling them to cut off their arm, we treat their brain rather than cutting off the arm. But if someone's brain is telling them to cut off their genitalia, we just go along with it? This... doesn't make much sense to me.
Well, that may be b/c (AFAIK) trans is quite a lot more than "cut off their genitalia". For one, it's also usually "turn my genitals into different genitals" rather than "have no genitals". For another, vocal aesthetic - trans folks usually put in a lot of effort in "voice training" to change the sound of their voices.
Like, I'm phrasing this in a pedantic way, but if you're finding yourself confused (about anything), the answer is that you either don't know something, or know a wrong thing. People want to do this thing. If you're confused by that, what might you not know about their wanting, or what might you know that's incorrect about their wanting?
I was being polite and open to discourse, not looking to start yet another Internet fight. Lets try to be empathetic to both each other and the transgender community :-) The question is: what is the problem we're trying to solve?
a) Making individual people happy
b) Making people happy in ways approved by society
I think we can agree that a) is our goal here, as "approved by society" was quite traumatizing as recently as 20 years ago, right?
But if its about the happiness of individual humans, why are treatments of their brain considered to be taboo? If there's a magic pill that makes you comfortable in your current body without needing any surgery or vocal training, why would that be a bad thing? If the side effects of this pill are smaller than the side effects of surgery, it should be an excellent solution for many trans folks.
Once again - I fully support the right of all humans to be happy and don't care if someone gets surgery or does anything they want to their own body. But I think its unfair to tell people that they don't get the right to treat their brain if they want and all they get is the option to change their bodies instead.
In this case attempt to modify trans people’s brains rather than their bodies is taboo because there is a long history of harmful and often non-consensual attempts to do just that.
Is there an aspect of your identity that is inconvenient in this society? If there was a magic pill that changed that aspect of your identity would you take it? If so why don’t you go around advocating for research into making that pill and let trans people advocate for the one you’re suggesting if they want to.
Why does history of society matter here at all? Isn’t the goal to make people *happy* rather than resolve some sort of historical injustices? I’m advocating for giving people a *choice* between swallowing a pill and taking all the complicated steps Aella talks about in her post.
And yes - there are tons of problematic brain behaviors that would be great to fix with a pill but for which no proper research is done for societal reasons. I.e. the exploration treatment of PTSD with drugs like MDMA is progressing extremely slowly because of the taboo on recreational drugs.
I’m explaining why there is a taboo, and why I think your moral intuitions are unhelpful in this particular case.
I think if you want to experiment with using MDMA to change consenting people’s gender identity, and the people in question aren’t consenting because of a coercive social environment, and you’re not torturing them or something, that would be perfectly ethical, though because of the history I explained you might find recruiting study participants difficult.
Basically I think the difference is one of agency. The taboo on recreational drugs primarily removes drug users agency, though there might be sufficient coercive shit in the medical establishment that there are occasionally people whose agency is protected by the taboo. The taboo on conversation therapy protects people’s agency, though it might slow down the or stop the development of an effective conversion therapy, if such a thing is possible and such a therapy doesn’t fall out of general improvements in our understanding of the brain and its relationship to the body.
As an aside which you may well not need convincing of: a good reason for a total ban on conversion therapy, as opposed to say just banning all the specific ineffective and often evil things people try, is that people are inventive and if you don’t ban the whole idea people who are offended by trans people expressing their existence will think up some new devilry to get around your ban.
Agreed
That's an interesting take, and I'm glad you talked about it. Do you know of any science done in that direction? (There might be studies of other uses of testosterone, like for body building, that would include relevant data?)
Otherwise, AFAICT we (I think all human cultures?) have a pretty strong revulsion against "things that alter the mind" in a way that we *don't* have a revulsion to "things that alter the body"; dipping into religion, the soul is a much bigger deal than the body.
The traditional "modify the gender to match the sex" (= "stop being a sissy", "act more ladylike") and the modern "modify the sex to match the gender" (hormones and surgery) both seem wrong to me. Can't we just accept people (including ourselves) for who they are? Some males are "feminine", some females are "masculine", and that's just a normal variation. There isn't a need to change one thing to "match" the other.
That was mostly my initial reaction to the idea, however I’ve come around.
Firstly for at least some (I would guess large) proportion pf trans people there seems to be something beyond discomfort with socially enforced gender roles going on, for example they often report great improvements in mental health soon after starting HRT, before any physical changes have time to occur.
Secondly getting society to stop enforcing gender roles is hard, and recognising non-binary genders are a way to make incremental progress towards not making people modify their gender to match their sex. David MacIver writes more about this here, for example: https://www.drmaciver.com/2019/09/gendering/
Finally of course the idea that “we” are somehow making trans people physically transition is likely to really piss off trans people because getting access to it is typically a fairly onerous process that they have to actively fight for, rather than something they feel they are being forced to do.
Not forced to do, but pressured by those societal gender roles.
SHBG reduces the rate at which testosterone crosses the blood-brain barrier (and generally reduces the bioavailability of testosterone). Levels of SHBG can be increased abnormally by various diet/lifestyle factors. Rising transgenderism could be due to rising prevalence of endocrine disruptors and diet/lifestyle that has an endocrine disrupting effect. Dollar for dollar society probably gets more bang for the buck doing research into how to prevent abnormal fetal development than in doing fancy surgeries on individuals. But this might be taken like the deaf people who are offended by the idea that someone might want to cure deafness. It's a whole tribal identity built around an illness.
I'd survey mothers of trans kids to see what they ate and did while they were pregnant. Did they have above average exposure to plastics, pesticides, etc. If anyone ever did this they might find some very cheap interventions that reduce the risk by half. But it'd probably never get funded by woke government agencies because prevention requires admitting it's preferable to not be trans. There's almost no prevention research yet due to politics. Compare this: https://www.psychologytoday.com/us/blog/science-and-philosophy/202008/controversy-surrounding-the-drive-cure-deafness Wherein deaf people agitate against curing deafness due to an ideological commitment to denying deafness is a problem.
> preferable to not be trans
To quote one trans friend: "I would never wish this on anyone."
AFAIK a trans man doesn't want to be trans; they want to be a man.
"I don’t know - I’m working on a survey right now and hope to have a spot of evidence here soon."
If you're doing a survey on autogynephilia in trans women, I would recommend talking with me. I did a detailed survey on autogynephilia in trans women as part of the ACX reader research survey, and I've got some interesting results that potentially have implications for how to best investigate it, but it has taken a long time to process the data, so I haven't published the results yet. If you want to talk then I can give you a preview of some of my relevant findings.
This was a very clear statement of more or less what I think about transness.
> Cruel narratives
Oof. Sitting with this one and how it relates to what I pick from my very, very liberal bubble about cis-het-masculinity. Definitely open to talking about it if anyone wants to engage haha.