In early July, Science-Based Medicine published my guest post responding to a prior review by Dr. Harriet Hall of Abigail Shrier’s book Irreversible Damage: The Transgender Craze Seducing Our Daughters. Journalist Jesse Singal responded to the criticism of Shrier’s book and issues related to the medical treatment of transgender adolescents discussed on SBM and directly called me out about several issues in my summary, entitling his response to my post and Dr Eckert’s additional posts deconstructing all the problems with Shrier’s book Science-Based Medicine’s Coverage Of “Irreversible Damage” Included About 19 Errors, False Claims About Three Sex Researchers, Made-Up Quotes, And Endless Misinformation, which is quite a mouthful. With thanks to the SBM team for the opportunity, I’m going to respond to some of his criticisms today, specifically the ones relevant to my post. Dr. Eckert will respond to the criticisms relevant to their post in part two.

Before I dive in, let me just start by saying that I do thank Mr. Singal for pointing out a handful of minor errors in my post. However, for all his hyperattention to minute details, I think that he missed the forest for the trees. Indeed, in my post, I explicitly stated that I had deliberately written my article as a broad overview, emphasizing that it was not intended to be a detailed line-by-line analysis of Shrier’s book or Dr. Hall’s review (“Instead of writing several long posts worth of refutations, I’ll try to summarize and discuss her core points”). Likewise, my response here today will not be a line-by-line analysis and rebuttal of either Shrier’s book or Singal’s criticisms of my previous article. Writing is, in fact, not my full time job, and I’m donating what time I can afford to SBM for this purpose. As an aside, if you want a chapter-by-chapter, paragraph-by-paragraph detailed deconstruction of nearly everything that is wrong in Shrier’s book, cognitive psychologist Cass Eris has you covered.

Here is the first installment of her video series on Shrier’s book, if you are interested:

Now, let’s move on to addressing my share of Mr. Singal’s claimed “19 errors.”

Some corrections and comments

Quotations vs paraphrases

Singal criticizes my lack of direct quotes (as he puts it, “Lovell throws out a bunch of what appear to be quotes from Shrier’s book”). Paraphrasing Shrier was an intentional decision on my part, and it was clear in context that I was not directly quoting her (at least to anyone other than Singal, given that no one else seemed to have misunderstood). Part of the reason for my choice was that, contrary to the assessments of her book by Dr. Hall and Mr. Singal, Abigail Shrier’s language is heavily biased and uses a lot of transphobic rhetoric. For example, in the author’s note at the beginning of the book (freely available through the samples found on Google and Amazon, for those who might want to check it out for themselves and compare my characterization with Shrier’s own words), Shrier notes, “For the sake of clarity and honesty, I refer to biologically female teens caught up in this transgender craze as ‘she’ and ‘her.'” She does this even when the individuals themselves stated that they use other pronouns (e.g., Joanna). In her book, Shrier even goes so far as to misgender Leelah Alcorn (chapter 3), a young trans woman who killed herself in 2014 at the age of seventeen (link leads to her suicide note – read with care) after parental rejection and conversion therapy. Leelah was posthumously misgendered by those same parents. As a young trans woman (i.e., she was assigned male at birth), she could not have been a victim of the “craze” that Shrier claims is “seducing our daughters” as Shrier’s “daughters” are those who are assigned female at birth. Misgendering her as male makes no sense in the context Shrier provides in the book. As both Dr. Eckert and I have pointed out, using the name/pronouns assigned at birth is damaging to trans people who identify with other pronouns. (Note that some of my citations involve the converse statement – that the use of the preferred name/pronoun relieves psychiatric distress.)

Shrier doesn’t stop there. Elsewhere in her book, she “jokingly” compares trans identity to self-identifying as a chicken (Chapter 6), repeatedly conflates gender identity with sexual expression and experience (e.g., in Chapter One: “Many of the adolescent girls who adopt a transgender identity have never had a single sexual or romantic experience. They have never been kissed by a boy or a girl.”), and insults those with whom she doesn’t agree (e.g., Dr Olson-Kennedy, whom she describes in Chapter 9 as looking “more like a coed caught prepping for finals than the recipient of the National Institutes of Health’s first grant, $5.7 million, to study the outcomes of medical treatment of transgender youth”). Given the potential harm of exposing readers of this blog, some of whom are likely to be trans, to such language and rhetoric, I chose what I considered to be the path of least harm and therefore paraphrased Shrier. Whether Singal believes or accepts it or not, in doing so I was also attempting to put her arguments in the most neutral light that I could manage, stripping away her hyperbole to try to summarize and address her core statements.

Quantity and quality of citations

Singal also has some critiques about details in the citations I provided in my guest post on the medical and scientific aspects of trans care. Here is my response. I chose not to provide every single citation that I could for every single statement that I made for the sake of brevity and readability. I chose to provide examples of studies within the body of literature on the topic. Additionally, I preferentially cited freely available papers in order to avoid paywalls precisely so that readers could read the cited studies in question if they so desired and look up the citations in those studies if they so chose. That sometimes meant citing a smaller or somewhat less rigorous study or commentary. And I’ll note that all studies have weaknesses, even the best and largest randomized controlled trial. The issues which Singal raises with the individual studies do not imply that the totality of my prior post, or that the preponderance of evidence with regard to the medical care of transgender youth, is incorrect.

Singal also argues that my characterization of Shrier’s book as having insufficient citations was inaccurate, asking “Will any reader who sees this description of citations being ‘rare’ come away thinking there are 22 pages of them in the book?” I dispute that. The number of pages of citations does not mean that the citations are adequate, appropriate, or correct*. Indeed, as longtime readers of SBM have seen, this is a favorite tactic of many of the people whose misinformation and pseudoscience we regularly deconstruct (e.g., Joe Mercola): to list a large number of dubious and irrelevant citations adjacent to their claims in order to give the appearance of scientific rigor. More importantly, from my medical perspective, there is a glaring lack of citations for some very bold claims all throughout her book. As an example, let’s look at the section on Lupron in Chapter 9. It’s three pages long with five citations (4-8; 9 and 10 are footnotes). In my opinion, all of the below quoted statements require a citation to support their claims:

  • […] Lupron is the go-to puberty blocker, FDA-approved to halt precocious puberty.
  • What the FDA has not approved is using Lupron to halt normal puberty in anyone […]
  • […] doctors don’t like to interrupt healthy endocrine signaling based on the say-so of minors […]
  • […] gender dysphoria has no observable diagnostic criteria.
  • […] endocrinologists have been administering Lupron “off-label” to gender dysphoric minors in ever-rising numbers for a decade.
  • In that case, infertility is almost guaranteed—and sexual development and potential for orgasm may be foreclosed for good. (Side note: This has a “citation” which, when you look at the citation section, has no citation included as it is in fact a footnote)
  • We wouldn’t consider a drug that stunted your growth in height and weight to be a psychologically neutral intervention […]

It goes on. And on. So no, I emphatically reject Singal’s claim that Shrier includes sufficient citations to back up her claims. Like Joe Mercola (a particularly prolific user of this technique of misinformation), in terms of citations Shrier tries to impress readers with quantity and mostly ignores quality.

Blanchard, Bailey, CAHM, and Zucker

I will concede that Singal was correct on one point when he noted that I had made an error including Ray Blanchard in a parenthetical with Kenneth Zucker when discussing academics who have been removed from their previous places of employment. Mea culpa and the error has been corrected. There is no excuse, but there is an explanation. Kenneth Zucker, Ray Blanchard, and J. Michael Bailey all tend to cluster in the literature, and mentions of them also tend to cluster in Shrier’s book. In any event, Blanchard did resign from HBIGDA (now WPATH) in protest over the controversy surrounding Bailey’s book The Man Who Would Be Queen. Bailey also resigned as Chairman of the Department of Psychology at Northwestern University over allegations of research misconduct. Whether resignation under political fire should be considered different than being fired could be a matter of reasonable debate to some. (Side note: My citations here are chosen for their quotations and use or citations of primary materials.)

Singal also questions whether I disagree with the settlement between Zucker and his former employer, the Centre for Addiction and Mental Health (CAMH). For context, Zucker was a psychologist employed at the CAMH Gender Identity Clinic which was criticized for allegedly practicing conversion therapy on transgender youth. This resulted in an independent review of the Clinic, with a final report published in 2015, the results of which Zucker contested in a lawsuit that resulted in a settlement between Zucker and CAMH. The citation Singal uses regarding the settlement states that the issue found with a report on Zucker’s interactions with patients was around its description of physician-patient interactions, specifically calling out one quote where a family member reported that Zucker had called a patient a “hairy little vermin”. According to this same source, the clinic reaffirmed its decision to close the child and youth gender identity clinic (“CAMH stands by its decision to close the child and youth gender identity clinic”). While the clinic’s exact settlement language is not something I have been easily able to find online, it appears to me that this was more an issue of misattributed quotes instead of an issue of the Clinic saying that Zucker being right in his methodology. Even without that quote, there were enough issues with the Clinic identified in the report (link leads to a page containing this report, for the curious) that I agree with CAMH’s decision to close it down.

The 2015 US Trans Survey

Next, I will address a few specific claims by Singal about my discussion of the US Trans Survey results. As briefly discussed in my previous post, the US Trans Survey is an IRB-approved US-based survey of adult transgender people. The 2015 version, which is the second iteration, was accessibility-oriented, and is the largest and most complete such survey I am aware of. Its results are also available for other researches to explore upon request. The results of the US Trans Survey are widely cited and are publicly available in both English and Spanish.

First, he (and a commenter) questioned my use of the phrase “population-based”. Instead of clarifying his concern himself, he links to a search for “population-based survey” in Google Scholar and then quotes the US Trans Survey’s statement which, in brief, states that because of the methodology involved “[…] it is not appropriate to generalize the findings in this study to all transgender people.” In his article, Singal acts as if this sentence means that the results should never be generalized. What Singal doesn’t realize is that many surveys and studies say something like that about their generalizability, and whether a study can be generalized is a common topic when physicians and scientists discuss studies. As a random example, let’s look at this study published in the New England Journal of Medicine which evaluated and reported on health-care associated infections. In it, the authors state “[…] the 2015 survey included geographically diverse sites, but the results may not be generalizable to all U.S. hospitals.” Does this mean we shouldn’t use the data from this study or from the US Trans Survey? No!

Shockingly, while a sample that is perfectly representative of the population is theoretically possible, it’s exceptionally difficult to do. So there is effectively no perfect study or survey which can be extrapolated out to an entire population. That’s kinda a big reason why we use statistics. But we can’t just sit around twiddling our thumbs until perfect numbers come around while patients suffer, so we use the numbers we have as approximations which we refine with more data.

Additionally, I also had actually responded to concerns about my use of this term in the comments of my original post. In that discussion, I was pretty explicit in admitting that I had chosen the wrong term in discussing the US Trans Survey. I would have told Singal to refer to this discussion in the comments had he addressed me directly about his concerns. But he didn’t. See below for more discussion of his choice of communication method.

Second, Singal implies that the US Trans Survey shouldn’t be treated as reliable. If he deems a study of over twenty-seven thousand transgender people as “unreliable” or “nonrepresentative”, I challenge him to cite a larger or better study instead (side note: the larger the study sample, usually the more reliable the results and more reflective of the larger population). If such a study exists, I am not aware of it. In addition, most reports on the prevalence of gender dysphoria do not come from the US. As I pointed out last time, we know from historical data that the sex ratio for transgender populations is not consistent from country to country so extrapolating across nations is difficult at best. Additionally, many studies rely on patients self-presenting to a clinic or undergoing surgery (such as this study, for example, also not from the US), which is less representative than the US Trans Survey because of the numerous barriers to care which transgender and other minority people experience within each country, region, state, or county. Also, most studies of transgender people are small as medical studies go – maybe a few hundred participants at most (see this study, for example). By necessity, they are also not infrequently so-called “convenience samples.” The most comparable (based on sheer size) survey to the US Trans Survey that I have been able to find is the 2016 Williams Institute report, but that didn’t report a sex ratio. Another issue is that, unlike many countries, the US does not have a national health service from which data can be easily retrieved, and our census does not ask about transgender status. So I use the US Trans Survey because it is currently the best data set we have (within and outside of the US) that includes the largest number of trans people, represents people who don’t have access to medical care or medical studies to participate in, and is incredibly comprehensive for the field. Is any single study perfect? No. But we work with what we have. I would certainly consider a better source if it existed.

Thirdly, Singal states that I am promoting a falsehood that the sex ratio approaches 1:1 of trans women to trans men. Let me refer again to Chapter 4 of the Survey [PDF], page 45, wherein Figure 4.2 shows a gender identity breakdown of 33% trans women, 29% trans men, and 35% nonbinary people (I calculate a ratio of 1.1:1:1.2, rounded). On the same page the authors also share their data for sex assigned at birth. 57% were assigned female at birth, and 43% were assigned male at birth. From that, I calculate a ratio of 1.3:1. No matter which set of ratios one uses, however, that’s a huge shift from the old 3:1 ratio of trans women to trans men. Note, however, that all of the data on this page are rounded to begin with. Being extra precise with rounded numbers would not make the resultant numbers more accurate. In any event, I find that both sets of ratios which I calculated round to approximately 1:1, and I stand behind that for now. If an actual statistician, which Singal is not, finds significant error here I’d certainly be interested in talking with them.

Biological binaries and sexual reductionism

Singal also repeats yet again his view that the concept that human biological sex is binary (“[…] Shrier is making the straightforwardly accurate claim that almost everyone is biologically male or female. This is just true, and until recently it was uncontroversial”). As Dr Eckert and I have both discussed in our guest posts, this view is a reductionist approach that is inaccurate based on existing science. Every trait in biology exists on a spectrum. There is no true black-or-white binary. With regard to human sexual differentiation there exists a spectrum of anatomy, sensitivity of hormone receptors, hormone levels, genetics, and karyotypes. Let’s look at hormone levels as an example. Most hormone levels fall within what’s called a “normal range”. That “normal range” is defined based on testing on “healthy” human participants, and statistically determining the range of values into which 95% of the participant measurements fall. Androgen levels vary widely among cisgender women, even without including those with polycystic ovary syndrome (PCOS); that androgen level variety is common enough that it’s an issue in sex-segregated sports. And never mind the fact that these examples do not address the complexity of our own internal sense of masculinity, femininity, androgyny, or not having a gender. Differences of sexual development are just the obvious tip of the iceberg of this biology. Additionally, breaking humans into two sex categories even as a cultural concept completely ignores the rich diversity and history of gender and sexual minorities throughout the world, which continues despite the effects of colonialism. We know that there is more than one factor that goes into development of the various factors of human biological sex. So why two? What makes two superior to three, as many cultures have done throughout history and today? (Scientific American published a beautiful infographic on the topic of sexual differentiation and differences of sexual development, for the curious.)

On hormones and humans

Unsurprisingly, Singal questions the safety of GnRH agonists for the purposes of affirmative treatment, noting that “there are now enough questions about this that the U.K.’s National Health Service, for instance, changed its language on this issue”. Once again I find it curious how much weight Singal places on the NHS’s statements questioning gender-affirmative treatment while completely ignoring statements from several other prominent medical organizations in support of affirmative therapy and GnRH agonists:

Due to the dynamic nature of puberty development, lack of gender-affirming interventions (i.e. social, psychological, and medical) is not a neutral decision; youth often experience worsening dysphoria and negative impact on mental health as the incongruent and unwanted puberty progresses. Trans-affirming treatment, such as the use of puberty suppression, is associated with the relief of emotional distress, and notable gains in psychosocial and emotional development, in trans and gender diverse youth.
American Psychiatric Association [PDF download] (2020)

BE IT FURTHER RESOLVED that the American Psychological Association and the National Association of School Psychologists support affirmative interventions with transgender and gender diverse children and adolescents that encourage self-exploration and self-acceptance rather than trying to shift gender identity and gender expression in any specific direction.
American Psychological Association (2020)

Pubertal suppression is fully reversible, enabling full pubertal development in the natal gender, after cessation of treatment, if appropriate. The experience of full endogenous puberty is an undesirable condition for the GD/gender-incongruent individual and may seriously interfere with healthy psychological functioning and well-being. Treating GD/gender-incongruent adolescents entering puberty with GnRH analogs has been shown to improve psychological functioning in several domains”
Endocrine Society Guidelines (2017)

Add to these groups the dozens of local, state, and national organizations who are signatories to this letter to the Senate regarding the Equality Act, including the American Academy of Family Physicians where the letter is hosted online, which states “Medical care for transgender youth is evidence-based and has proven effectiveness.” (As a side note, the NHS doesn’t exactly have a good reputation for providing quality transgender care in a timely fashion.) Singal’s singular focus on the NHS statement reeks of cherry picking.

Singal and others seem intentionally blind to the reality “on the ground” of treating transgender youths. Contrary to characterization of this treatment by Singal and other “gender critical” advocates, hormone therapy and puberty blockade are never undertaken lightly. Make no mistake, contrary to Shrier’s apparent belief that Lupron and hormones are doled out like candy to anyone who might get the notion in their head that they might be trans, abundant counseling and informed consent go into the process, even in the gender affirmative model of treatment. For my part, every patient I take care of is well informed about the permanent and transient effects of hormone therapy and Lupron, as are the parents of transgender adolescents, and all are advised to consider gamete storage before starting any therapy. Every patient is offered referral to mental health and support groups and encouraged to take advantage of these resources before and during gender affirming treatment.

Finland and Sweden

Singal also relies heavily on reports from Finland and Sweden on transgender youth, which I find interesting given these countries’ complex histories with respect to transgender rights. Both have a reputation as being trans-friendly. But as recently as 2017 Finland still required transgender people to be sterilized in order to be permitted to transition. Sweden had a similar rule, no longer in place as of 2013. So why does Singal give so much weight to those specific countries, which are not the United States? Remember, Shrier wrote primarily about the United States! Different countries have different cultures, histories, and legal requirements/rights and these have profound effects on the lived transgender experience for both adults and youth.

The medium for the message

Through this whole incident I remain struck by Singal’s choice of medium with which to voice these concerns and questions. Singal proved that he could find my email address when he emailed me and asked for a page number for a claim I made (which I provided). Instead of asking me questions directly or attempting to engage me in dialogue, he chose to blast questions into the ether that is Twitter (which I haven’t used in years), write a long blog post on his normally-paywalled blog, and then continue to obsessively and impatiently tweet demands at the Twitter accounts of Science-Based Medicine and Dr. Gorski for a reply, leading to Dr. Gorski getting annoyed enough to block him. If he had actually bothered to ask, he might have realized that I had already answered some of his questions in the comments of my last post, and that if he would simply be patient there would be a reply to his post. For someone who appears so very concerned about “witch hunts“, Singal seems to be quite dedicated to platforms and methods that encourage them. It’s also worth repeating one more time that Singal isn’t exactly loved for his views on transgender people, his lack of expertise in this subject, and his previous tactics. Perhaps that has something to do with it?

Reflecting back on this whole kerfuffle, I have to wonder how many appointments and counseling sessions Singal has observed. How many times has he sat with a trans youth after a suicide attempt because their parents took away their prescribed hormones? Or seen the profound relief that often comes with acceptance and appropriate medical therapy? Speaking from a personal perspective, I entered the practice of medicine to reduce human suffering. Currently, the preponderance of medical evidence supports affirmation and medical therapy; therefore that is the treatment approach that I use, support, and argue for. If another mode of therapy ever proves superior then I will be happy to alter my practice accordingly and embrace it. Unfortunately thus far, none has. Certainly, conversion/reparative therapy has been tried without success. Indeed, I believe that the non-affirmative model that Shrier champions and the rhetoric that she and Singal spread cause harm to the patients I serve. If you don’t believe me, I will cite one such example from Chapter 11, in which Shrier argues that if “you find your daughter steeping in a tea of gender ideology with all of her peers, do what it takes to lift her out and take her away,” after which she suggests removing your child from college or even moving the entire family elsewhere in order to remove the child from the influences “seducing” them to think they are trans, characterizing this as a successful strategy.

Conclusion: There are better sources

In summary, I am not even remotely convinced by Singal’s counterarguments, and I don’t think the readers here should be either. He is excessively reliant on details to the point of appearing very pedantic and while missing the entire point of the multiple articles on this blog on the topic. Whether such is his intention or not, in my opinion he does an excellent job of concern trolling. Shrier’s book is simply not a good resource. It does not reflect the science, reality, and complexity of transgender medicine. (In my opinion, it doesn’t even try to.) It therefore should not be taken as fact, good science, or even a supportable scientific viewpoint. No number of tweets or blog posts will change that.

If one is in doubt on the preponderance of evidence, I encourage them to use the services of their local library and/or Google Scholar to research the issues for themselves. I recommend starting with the statements from US-based organizations I linked above and their citations. I also recommend the following authors and books with whom I am familiar for general reading:

Editor’s note: Part two of this response to Mr. Singal’s “19 errors,” written by Dr. A. J. Eckert, will be published on Saturday or Sunday.

* Deleted: “…as is true in my copy of the book.” Jesse Singal, being Jesse Singal, is making a big stink about this as something that “must be corrected” as though this were some sort of error in deconstructing his “19 errors” or Shrier’s book that discredits everything. It is not, but it was deleted so as not to be an unnecessary distraction. Singal’s complaint about it does, however, confirm Dr. Lovell’s and the editors’ point about his weaponization of pedantry.

Author

  • Rose Lovell, MD, is a family medicine physician recently graduated from Natividad Family Medicine Residency in Salinas, California. Her experience with transgender medicine started as a premedical student volunteering at a local transgender clinic in 2012, continued through medical school where she did research into the use of sexual orientation and gender identity collection methods, and into residency where she received awards for starting a transgender health program at her residency clinic. She is a member of the World Professional Association for Transgender Health and previously blogged at Open Minded Health, a blog on gender and sexual minority health.

Posted by Rose Lovell

Rose Lovell, MD, is a family medicine physician recently graduated from Natividad Family Medicine Residency in Salinas, California. Her experience with transgender medicine started as a premedical student volunteering at a local transgender clinic in 2012, continued through medical school where she did research into the use of sexual orientation and gender identity collection methods, and into residency where she received awards for starting a transgender health program at her residency clinic. She is a member of the World Professional Association for Transgender Health and previously blogged at Open Minded Health, a blog on gender and sexual minority health.