Editor’s note: This is the second guest post discussing Abigail Shrier’s Irreversible Damage: The Transgender Craze Seducing Our Daughters solicited from experts in transgender medical care. In this post, Dr. A.J. Eckert describes the many errors, misrepresentations, and misunderstandings of science in Shrier’s book, doing so in more detail than was done in our recent guest post by Dr. Rose Lovell, who provided an excellent overview of the problems with the book. Dr. Eckert plans a second part to this discussion, which they are currently working on. We look forward to its completion. I also note that there have been errors discovered in this long post. Where errors have been corrected in the text there is a notice, with a note to go to the addendum, which explains the four errors and changes made to correct them, provide more context, and generally strengthen the review, all in order to be transparent. Note that the corrections are made in the temporal order in which the errors were found, which is why the correction numbers are not sequential.

Over the last couple of weeks, Abigail Shrier’s controversial 2020 book Irreversible Damage: The Transgender Craze Seducing Our Daughters has enjoyed a renewed surge of interest and controversy on the Internet. On June 15, Dr. Harriet Hall, retired family physician and longtime contributor to the Science-Based Medicine blog, posted a favorable review of Shrier’s book on SBM.

The physicians behind SBM characterize their blog as one “dedicated to evaluating medical treatments and products of interest to the public in a scientific light and promoting the highest standards and traditions of science in health care”. SBM is widely regarded in its dedication to evidence-based medicine. Hall’s review was pulled from the SBM blog less than two days later for review, having been found not to meet the standards of SBM. Shrier sees this move as bullying, writing that “a book review by a respected physician was bullied out of existence in America,” while Dr. Hall sees it as an “Alex Berenson:

Ms. Shrier, Lisa Littman, whose 2018 study proposed the diagnosis of “rapid onset gender dysphoria” (ROGD), and now apparently Dr. Hall see themselves as victims of a “woke” activist movement trying to censor science. Hall’s review has already been republished on another website, one that is prominent in the circles of the skeptical movement. (Note added 7/18/2021: Last week, Dr. Hall also republished a revised version of her review on her own blog.) In contrast to claims of Shrier having been “silenced,” her book has garnered praise and support, with several sites taking up her cause in the past week alone. Before Dr. Hall’s review, Shrier had previously appeared at a high-profile Senate hearing. She still has a platform as a columnist for the Wall Street Journal and has expressed her views on several podcasts, including Joe Rogan’s massively popular one. Meanwhile, in part due to Shrier’s enthusiastic promotion, Littman’s made-up diagnosis of ROGD has enjoyed a renewed interest, spread widely, and is accepted by many as a real medical diagnosis.

Bad science, however, remains bad science, and personal opinions based in confirmation bias and politicized beliefs are bad science.

Irreversible Damage was published by politically conservative firm Regnery Publishing and claims to shed a light on “biological female teens caught up in this transgender craze.” Shrier, a freelance journalist with a JD from Yale Law School, per her own admission, knew little about gender dysphoria before writing her book. She also admits to having negligible understanding of human anatomy, psychology, and endocrinology. (It shows.)

The book title alone is inflammatory and misleading, and clearly intended to alarm concerned parents, the target demographic for Shrier’s book. Shrier uses emotional language throughout to appeal to the reader. Her book presents a mix of anecdotal reports, opinion pieces, and minimal cited research. The studies she cites are either misinterpreted or cherry-picked to only include those experts she deems reputable, all of whom have a problematic track record in transgender health and research. Her “Select Bibliography”, an annotated version of which is included as an appendix to this post, lists resources that are equally problematic.

Throughout her book, Shrier refers to her subjects as “biological girls,” a term that conflates sex with gender and mischaracterizes Shrier’s subjects. The reason is that a person’s sex refers to the identity assigned by doctors, parents, and medical professionals at birth, most often based on external anatomy (genitals). Sex is often confused or interchanged with gender, which involves a person’s own sense of their behaviors, characteristics, thoughts, and social factors, and is not determined by biological sex. A person’s gender may or may not conform to the male and female binary and may or may not align with their sex assigned at birth.

More accurately, Shrier’s subjects are “AFAB”, or “assigned female at birth“, because no one gets to choose what sex they’re assigned at birth. When discussing transgender and gender non-conforming individuals, this terminology is generally preferred over “biological male/female”, “male/female bodied”, “natal male/female”, and “born male/female”, which are considered defamatory and inaccurate. Moreover, disturbingly, most of the individuals covered in Shrier’s book were not personally interviewed. Their stories are told exclusively by their parents, all of whom use she/her pronouns for their trans children. (Throughout this review, I will be using the term “trans” as an umbrella term for all transgender and gender non-conforming people. I acknowledge that some non-binary and gender non-conforming people do not identify as trans, and am using it solely based on its core definition: from Latin, “trans” means on the opposite side. For identity, “trans” means someone assigned a sex at birth that is different from their gender identity.) Shrier reports conducting nearly 200 interviews, with over 48 families, and admits, “I have relied in part on parent accounts.”

Shrier’s use of she/her pronouns for her subjects, “for the sake of clarity and honesty”, is also problematic. She defends her referring to these subjects using pronouns that do not correctly reflect the gender with which they identify, commonly referred to as “misgendering,” by appealing to the First Amendment, a common strategy employed to attack the rights of LGBTQ people. For example, The Denial-of-Care Rule (now blocked, but at the time, released by the Department of Health and Human Services), allowed health care workers, in essence, to impose their religious beliefs on patients, and to decide who they will and will not treat, targeting both reproductive health care and gender-affirming care.

Throughout her book, Shrier characterizes those who ask that their accurate names and pronouns are respected as demanding, volatile teenagers who “fly into rage” when their request is denied. She scoffs at pronouns in email signatures, referring to them as “gender Ideology”. Pronouns matter not only for trans visibility and understanding; research finds that for youth, their use can mean the difference between a distressing and positive experience. A 2018 study in the Journal of Adolescent Health found that those youth who could use their accurate names and pronouns had 71% fewer symptoms of severe depression, a 34% drop in suicidal thoughts, and a 65% decrease in suicide attempts. Since Shrier’s subjects’ chosen pronouns are not disclosed, I will use they/them pronouns when discussing these individuals. Intentionally misgendering and deadnaming (calling them by their birth name after they have chosen a new name that fits their gender identity) trans people is disrespectful, harmful, and dangerous.

The following is Part One of a discussion of the arguments and claims in Shrier’s book and where they go wrong. There is a lot to review here and, as my patients will tell you, I am not one for brevity. I will focus on the core beliefs forming the bedrock of Shrier’s arguments: gender dysphoria in AFAB teenagers is the newest fad; “gender ideology” (or “transgender ideology” or “trans ideology”) pushes teens into “becoming” trans (see corrections in addendum, specifically Error #2); Rapid Onset Gender Dysphoria is real; the DSM-IV is the superior diagnostic manual because it classified trans identity as a mental illness; 80% of children desist from a trans identity; today’s teens don’t follow the correct rules for being trans and therefore are not trans but definitely are mentally ill.

In Part Two, we will discuss what I refer to a bit tongue-in-cheek as Abigail Shrier’s “Trans Agenda™”: turn all lesbians into trans men, tell teens it’s not cool to be cisgender (having a gender identity that aligns with sex assigned at birth) and heterosexual, love-bomb teens that “come out” so they stay in the trans community, coach teens to say they’re suicidal so they can get on hormones, separate youth from their parents, and deny biology.

We will review the “dangers” of gender affirmation-social, medical, and surgical, discuss Shrier’s underlying thoughts on all trans people, and address Shrier’s solutions to the transgender craze. I will include some historical context and the complicated web of Shrier’s sourced professionals and resources as well, both very important to acknowledge when discussing the healthcare of trans people.

Claim: Gender dysphoria is a new phenomenon in AFAB teenagers

According to Shrier, “before 2012, in fact, there was no scientific literature on girls ages 11-21 ever having developed gender dysphoria at all”. A review of research studies reveals a 1998 research study on puberty delay in trans adolescents, an Introduction to Transmasculine Studies from 2005, 2011 medical guidelines for treatment of transgender youth, and those specific to transmasculine young people, and much more; there is a robust base of scientific literature on AFAB trans youth. One wonders if Shrier knows how to use Google and PubMed, given that these references are not difficult to find.

Shrier reports, “for the first time in medical history, natal girls…constitute the majority” (of the “sudden surge of adolescents claiming to have gender dysphoria”). Her cited source examined sex ratios in children and adolescents referred to the Gender Identity Development Service (GIDS) in the UK. The study found an increased ratio of adolescent referrals. Specifically, 32% were AMAB (assigned male at birth); 68% AFAB, which aligned with results from an Amsterdam clinic. However, a Toronto clinic reported a larger proportion of AMAB referrals. The study found an increased ratio of adolescent referrals. Specifically, 32% were AMAB (assigned male at birth); 68% AFAB, which aligned with results from an Amsterdam clinic and Toronto clinic. The Toronto clinic reported a larger proportion of AMAB referrals in childhood. [Correction made. See addendum for explanation under Error #5.]

The limitations of Shrier’s source are that it draws from anecdotal surveys, small databases, and inconsistent, soft studies, and neglects social/cultural factors, such as the fact that it is often easier for AFAB young people to “come out,” especially since gender-variant behavior in AMAB (assigned male at birth) young people may be more exposing and lead to social stigma. Adolescents not seen at specialized clinics are not represented in gender dysphoria studies, a factor that skews the ratio, therefore, the study can only assume that the data reflects a real change in ratios in the overall trans youth population.

The sex assigned at birth ratio for trans adolescents is much closer to 1:1. This ratio appears to be consistent across nations. Though there has been a recent temporal shift to more AFAB trans adolescents, the ratio remains closer than 2:1 in either direction.

Claim: “Gender ideology”* is influencing AFAB teenagers

Shrier considers the following practices, oriented around school, to be the impetus for teens “becoming” trans: asking students to state their name, sexual orientation, and gender pronouns; joining a Gay-Straight Alliance; making a trans friend; being taught that gender identity is in the brain, sexual attraction in the heart, and sex in the genitals; seeing counselors who may suggest that you are transgender; and teaching youth about gender identity and sexual orientation. These are characterized as a “gender ideology,” an oft-recited phrase that is never really defined. [Correction made. See addendum for explanation under Error #2.]

Shrier alleges that the mere mention of gender identity by an educator influences the identities of children and students. She even argues that education around trans youth as a fix to bullying is egregious. To her, all that is required is “that students display decency, civility and kindness to their classmates”. This is in direct opposition of what the research shows: increased education and visibility of trans identities leads to better understanding and empathy for a population that experiences a disproportionate amount of school harassment. Shrier then goes on to warn that schools with LGBTQ curricula “normalize” being LGBTQ, and this “encourages adolescents to focus relentlessly on their own gender identities and sexual orientations”. The research actually shows that greater LGBTQ representation is associated with increased empathy and decreased anti-trans bias.

According to Shrier, the internet coaches and indoctrinates teenagers in “radical gender ideology” or “extreme gender ideology” (again, whatever that means). [Correction made. See Addendum for explanation under Error #3.] She supports this claim with the following statement provided by a trans youth: “arguably, the internet is half the reason I had the courage to come out”. This statement does not bolster Shrier’s arguments. Research suggests that positive representation and increased visibility are crucial for minority populations; discussion and information about trans people reduces transphobia. Reducing transphobia increases public support for trans rights.

“Never before had gender dysphoria sufferers ‘come out’ as trans based on the encouragement of friends or following self-saturation in social media. Never before had identification as ‘transgender’ preceded the experience of gender dysphoria itself”, Shrier contends. This is only partially true; never before has there been the widespread access to information and education that modern social media provide. Positive representation, as noted above, has helped more LGBTQ people recognize themselves and come out. Trans people have always existed; there’s just more visibility now, and a chance to shift away from the negative characterizations of trans people in the media.

The idea that gender identity is influenced by friends and the media segues us into a discussion of ROGD, or Rapid Onset Gender Dysphoria, a phenomenon Shrier endorses even though it is not a medical entity recognized by any major professional association and has no good evidence to support its existence. This bears repeating: Rapid Onset Gender Dysphoria is a fake diagnosis, just like “adrenal fatigue“, a fake diagnosis favored by naturopaths.

Claim: Rapid Onset Gender Dysphoria is real

ROGD is a diagnosis proposed by Lisa Littman of Brown University, to support the hypothesis of transgender identity as peer contagion. Littman coined the phrase to describe parents’ accounts of their teenage children suddenly manifesting symptoms of gender dysphoria and self-identifying as transgender along with other children in their peer group. Littman speculated that ROGD could be a “social coping mechanism” for other disorders.

Littman’s study was published in 2018 and immediately ran into problems. [Correction made here. See Addendum for explanation under Error #4.] The Brown University press release describing the study was removed days later, with the Brown University Press Office noting:

In light of questions raised about research design and data collection related to Lisa Littman’s study on “rapid-onset gender dysphoria,” Brown determined that removing the article from news distribution is the most responsible course of action.

A second press release noted:

Brown does not shy away from controversial research. The University’s Office of Communications decided to publicize research on Brown’s website on “rapid onset gender dysphoria” recognizing the topic to be a subject of rigorous debate in the field of study.

After the research paper was published in the Journal PLOS ONE, concerns were raised about the paper’s research design and methodology by leading academics in the field. These concerns were serious enough that PLOS ONE announced that it would conduct a post-publication re-review of the article to “seek further expert assessment on the study’s methodology and analyses.”

Given the concerns about research design and methods — not the controversial nature of the subject — the University decided to stop featuring this news story on its news site. However, the research article is still available on the journal’s website and on the author’s Researchers @ Brown page. The University does not know how long the re-review of the paper will take, or what (if any) actions the journal will take.

The university also noted:

  1. This is not about academic freedom.
  2. This is about academic standards.
  3. Academic freedom and inclusion are not mutually exclusive.

Seven months later, Brown University stated:

Seven months after the academic journal PLOS ONE indicated plans to seek further expert assessment on a study focused on “rapid-onset gender dysphoria,” the journal has republished the research with a series of corrections and updates by the study’s author to address concerns raised in the journal’s reassessment.

The revised study by Lisa Littman, assistant professor of the practice of behavioral and social sciences at Brown University, is now retitled “Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.” It includes revisions and updates to multiple sections of the study, including the title, abstract, introduction, materials and methods, discussion and conclusion sections.

PLOS One published the revised study on Tuesday, March 19. In addition to the updated study, the journal included a correction / notice of republication and a separate formal comment from researcher Angelo Brandelli Costa, associate professor of social psychology at the Pontifical Catholic University of Rio Grande do Sul, Brazil.

Shrier described the treatment of Littman’s paper thusly: “…activists stormed the peer-reviewed scientific journal accusing her of anti-trans bigotry”. Littman’s study skewed results by drawing from blogs openly hostile to transgender youth, the same blogs where Littman developed the concept of ROGD in the first place. The study formed its conclusions around the beliefs of parents who already presupposed the existence of ROGD, since Littman only posted her survey on the three blogs that invented and promoted ROGD. Today, the entire research base of ROGD consists of one 2017 poster abstract of an online survey of 164 parents and a 2018 research study with 90-question survey responses from 256 parents.

There are several similarities between Littman and Shrier: neither woman interviewed her trans teen subjects; neither had any previous experience working with transgender youth; both drew their conclusions primarily from reports by parents, who had their own views on their child’s trans identity. Neither understand that “rapid onset” is tough to characterize, because teens often delay coming out in hostile environments. Judging by the attitudes of parents surveyed, I would posit that their children were likely afraid to disclose due to minority stress factors including social stigma, fears of rejection, and very real concerns about violence. If a youth’s coming out as trans seems to be “out of the blue”, it could well be because that youth is afraid to discuss their gender identity with their parents, whom they know to be hostile to a gender identity other than what was assigned at birth. “Rapid” in ROGD describes the parents’ sudden awareness of their child’s gender dysphoria, which, for the child, may be longstanding and consistent. ROGD as an argument is packaged to describe the speed of onset and spread of gender dysphoria among teen friend groups. “Rapid” in this context does not describe the speed of gender dysphoria onset and spread. Logically: a study that only surveys parents about their observations tells us nothing about their child’s internal sense of identity.

Disaffirming approaches to care, such as those advocated by proponents of ROGD, have been shown to lead to high rates of depression, anxiety, substance use, and poor school performance. Depression, anxiety, substance use, and poor school performance primarily manifest in those youth living in unsupportive environments. The only social contagion supported by scientific research is the change in attitude about anti-transgender prejudice. Friend clusters are a good thing for trans youth; supportive friends are directly associated with positive well-being. There is no scientific evidence to support the idea that gender identity is contagious. In fact, the social contagion argument has been used against the LGBTQ community in various forms for decades.

Claim: Real trans people have “traditional dysphoria”

Shrier identifies a “real” transgender person as one for whom “the body feels wrong,” and for whom “the only option is to present as the opposite sex.” She states that “they want to pass.”

The term “passing” is complicated. Being able to “pass” means that a trans man is seen by society as a man and is gendered correctly. “Passing” means avoiding the pain of being misgendered. For many trans people, “passing” means safety. “Passing”, however, also implies playing at a gender. Trans people are already the gender they say they are. “Passing” also reinforces gender stereotypes and enforces a pressure to conform to these stereotypes. “Passing” implies that the ultimate goal for trans people is to be perceived as cisgender. It means molding oneself to fit a cisnormative (the assumption that cisgender is the norm, privileged over any other form of gender identity) society.

Not all trans people want to pass. Nonbinary and gender non-conforming people don’t pass, according to societal standards. As one writer notes, “Social conservatives’ biggest problem with transgender people isn’t that we exist, but that we don’t police the boundaries of our identity strictly enough for their liking.”

Shrier writes that gender dysphoria presents in early childhood, around ages 2-4. This is not accurate; around 2-4 years old, children understand their gender identity. Most trans children experience gender dysphoria around age 7, and, although it manifests in early childhood, gender dysphoria can persist for years before patients take any steps toward gender affirmation.

The Diagnostic and Statistical Manual of Mental Disorders, or DSM, firmly established in the medical world as the source for psychiatric codes and diagnoses, is sourced by Shrier in her definition of “traditional gender dysphoria”, her made-up term that further alienates those who deviate from her standards. Of note, the DSM does not specify age of onset in its diagnostic criteria for gender dysphoria.

It is important to Shrier that we know that gender dysphoria was previously known as Gender Identity Disorder. She uses an outdated version of the DSM manual, DSM-IV, and conflates gender dysphoria with gender identity disorder to define it as characterized by a severe and persistent discomfort in one’s biological sex. Shrier’s criteria for “traditional gender dysphoria” mean a bodily discomfort that must be “excruciating”. Per Shrier, in those cases only, medical transition may be indicated…maybe.

For context, the DSM-IV was published in 1994, with the newest version, the DSM-V, published in 2013. Citing an outdated version of the DSM and an outdated diagnosis ignores the advancements in healthcare and scientific research over a period of nearly 20 years. To quote the American Psychiatric Association, publishers and editors of the DSM (bolding is mine):

With the publication of DSM–5 in 2013, “gender identity disorder” was eliminated and replaced with “gender dysphoria.” This change further focused the diagnosis on the gender identity-related distress that some transgender people experience (and for which they may seek psychiatric, medical, and surgical treatments) rather than on transgender individuals or identities themselves. The presence of gender variance is not the pathology but dysphoria is from the distress caused by the body and mind not aligning and/or societal marginalization of gender-variant people. It needs to be ego-dystonic to qualify as a diagnosis and having a discussion with our patients about the diagnosis prior to charting it is necessary and good care. The DSM–5 articulates explicitly that “gender non-conformity is not in itself a mental disorder.” The 5th edition also includes a separate “gender dysphoria in children” diagnosis and for the first time allows the diagnosis to be given to individuals with disorders of sex development (DSD). DSM–5 also includes the optional “post-transition” specifier to indicate when a particular individual’s gender transition is complete. In this “post-transition” case, the diagnosis of gender dysphoria would no longer apply but the individual may still need ongoing medical care (e.g., hormonal treatment). Nevertheless, discussions continue among advocates and medical professionals about how best to preserve access to gender transition-related health care while also minimizing the degree to which such diagnostic categories stigmatize the very people that physicians are attempting to help.

The APA also includes the following caveats:

The Gender Dysphoria diagnosis functions as a double-edged sword. It provides an avenue for treatment, making medical and surgical options available to TGNC [Transgender and Gender Non-Conforming] people. However, it also has the potential to stigmatize TGNC people by categorizing them as mentally ill. The ultimate goal would be to categorize TGNC treatment under an endocrine/medical diagnosis. In the past, TGNC patients were disproportionally diagnosed with psychotic/mood disorders to explain their gender variance. Because of this, many in the community are understandably skeptical of mental health and psychiatric care.

By citing the DSM-IV, Shrier establishes her reality where being transgender is a pathology to be fixed. This belief undermines science and harms trans people. She makes statements such as the following: “trans influencers typically promote trans as a lifestyle to celebrate, not the result of a malady they hope to cure”. Categorizing trans identity as a mental illness requires that all “real” trans people experience gender dysphoria. A grave result of pathologizing transgender identity is the resulting impact on human rights, which negatively influences every aspect of trans lives.

Research finds that as many as 41.5% of trans people have a mental health diagnosis or substance use disorder. This is widely accepted to be a consequence of minority stress, the chronic stress from societal stigma and discrimination experienced by trans people due to their identity and expression. To reiterate, trans identity in itself is not a mental health disorder. A gender identity is not a mental disorder. Being trans is not an illness to be fixed and eradicated.

J. Michael Bailey, whom Shrier interviews, is a psychologist at Northwestern University, whose controversial 2003 book, The Man Who Would Be Queen (included in Shrier’s bibliography), endorses a pseudoscientific view of trans people developed by psychologist Ray Blanchard, and was noted to be dangerous to the social progress of the trans community. Unsurprisingly, Bailey claims to have been “silenced” by the trans community and supports Shrier’s views, having been quoted thusly in her book: “We have scant evidence that gender identity-a person’s ineffable sense of (their) own gender-is immutable. In fact, we have very good evidence that in many cases it is not.” (Conveniently, he provides no source for this latter claim.) Bailey is a proponent of Littman’s hypothesis of ROGD as well and exhibits disinterest in learning from the community he claims to help, shrugging his shoulders, “I don’t know what the correct language is and I don’t really care.”

In another chapter, Shrier interviews Dr. Paul McHugh, a key figure in the academic pathologization of sex and gender minorities, who refers to gender dysphoria as an “overvalued idea” and “ruling passion.” McHugh is no ally to the LGBTQ community; he shut down his gender clinic at Johns Hopkins in 1979, alleging that he “wasted scientific and technical resources and damaged (our clinic’s) professional credibility by collaborating with madness rather than trying to study, cure, and ultimately prevent it.” McHugh also endorses Blanchard and Bailey’s views, is a proponent of conversion therapy, and continues to oppose “the transgender cause.” In a 2014 Wall Street Journal op-ed, he states:

This intensely felt sense of being transgendered constitutes a mental disorder in two respects. The first is that the idea of sex misalignment is simply mistaken—it does not correspond with physical reality. The second is that it can lead to grim psychological outcomes. The transgendered suffer a disorder of “assumption” like those in other disorders familiar to psychiatrists. With the transgendered, the disordered assumption is that the individual differs from what seems given in nature—namely one’s maleness or femaleness. Other kinds of disordered assumptions are held by those who suffer from anorexia and bulimia nervosa, where the assumption that departs from physical reality is the belief by the dangerously thin that they are overweight.

Shrier also often compares being trans with anorexia. The American Psychiatric Association guidelines of affirming care are, to Shrier, politically correct gender ideology, and akin to affirming an anorexic who thinks she’s fat as correct in her assessment. She compares affirming trans patients to a black girl who wants to be white and is affirmed by doctors that she is, in fact, white. Having established these false equivalencies, Shrier goes on to lament that, for the girl with anorexia and the one who desires to be white, “we would cry out for the therapist not to encourage the girl’s distorted perception”. Additionally, she writes, “we would never want (therapists) to automatically agree with the patient’s self-diagnosis…in fact, it still isn’t the mental health professional’s job with regard to any other psychiatric condition”. These statements belie Shrier’s understanding of being trans as a mental health disorder, despite medical consensus that variations in gender expression represent normal dimensions of human development, and the removal of gender identity disorder from the DSM nearly 20 years ago.

The belief that a diagnosis is clinically required to access gender affirming care, known as transmedicalism, can contribute to stigma and discrimination toward transgender individuals. Gender dysphoria is not a requirement of being trans. To this, Shrier snarks, “those of us plagued with social anxiety are officially on notice: we’re probably “trans”. Dismissive and offensive comments like these belie Shrier’s point: these AFAB teens don’t qualify as “real” trans people. Shrier has firmly established herself in the long line of cisgender people passing judgement on and pathologizing transgender people. Though she admits to limited knowledge about dysphoria prior to writing her book, learning from trans people and about trans identities has never been a criteria to being an expert on trans health; Shrier fits into this narrative just fine. In the case of these AFAB teens, Shrier is clear: in her mind, none of them exhibit “traditional dysphoria,” therefore, they are not actually trans.

Claim: Today’s AFAB teens are definitely not trans

Shrier appeals to traditional sex stereotypes to invalidate her subjects’ gender identities: she characterizes a subject as “a girly girl” who liked to dress up in high heels and frilly dresses in their childhood, another as having the “prospect of becoming a professional ballet dancer”. Shrier extolls the virtues of womanhood while carrying a prejudice against transmasculine youth for exhibiting feminine traits. According to Shrier, to even be considered valid in their identity, trans men must meet a high standard of masculinity.

A good example of trans masculinity, as reported by Shrier, is Brandon Teena, a young man who was targeted and murdered for being trans. Brandon presented as a man and had a girlfriend. He was 21 years old when he died in 1993; his life and death were portrayed in the movie Boys Don’t Cry. Brandon Teena was deadnamed and mischaracterized by the epithets on his gravestone; Shrier is content to do the same, although she does slip up and use his chosen name in one instance. She summarizes Brandon Teena’s life as one spent chasing “a strikingly conservative vision of happiness”.

Though Shrier weaponizes classic gender stereotypes against trans people, in another chapter, she blames schools for introducing kids to gender stereotypes to push a gender ideology. She says, “gender ideologues make sure (she) learns that things like sports and math are for boys. It’s essential that (she) learns gender stereotypes because, without them, “gender identity” makes no sense at all”. Shrier appeals to gender essentialism, also known as biological essentialism or determinism, the idea that men and women have inherent, unique, and natural attributes that qualify them as their separate gender, that these differences are often biological or sexual, and that behaviors, interests or abilities are biologically pre-determined, rather than shaped by society. A gender essentialist ignores the evidence of a sex and gender spectrum and believes that gender and sex are identical, therefore it is impossible to have a sex assigned at birth that does not match gender identity. In this framework, gender affirmation is a submission to essentialist thought: trans people are making their bodies more feminine or masculine, thus promoting the fusion of sex and gender. Gender essentialism theory supports Shrier’s claim that gender identity makes no sense without learning gender stereotypes. Essentialist ideas, now viewed as outdated and inaccurate, ground the male/female binary in biology and may lead to more prejudice against trans people.

Gender essentialism and Shrier’s conclusion about gender identity are based in faulty assumptions. Gender affirmation is different from “becoming the opposite sex”. The former acknowledges that trans people are already men, women, or non-binary people exploring ways to better express their gender identity; the latter implies that trans people are not valid until they alter their bodies, precludes the existence of non-binary people, assumes there is only one way to transition and ignores gender expression (e.g., butch trans women/femme trans men) and genderqueer identities.

A recent first-of-its-kind study examines the origins of essentialist thinking and the differences between cisgender and transgender children’s views of gender essentialism. Findings suggest that all children might develop an essentialist view of gender early in life, even if their own gender experiences are at odds with certain aspects of essentialism. These findings infer that children essentialize categories even when their own identities cross category boundaries. The study also suggests that transgender children might share other children’s intuitions that gender, even their own gender, is inborn and biologically determined. Trans children might believe that what led to their gender identity and expression was some aspect of their biology, even though it did not align with their sex assigned at birth. Trans children might be as essentialist as cis children—they might just ascribe gender identity, rather than sex assigned at birth, as an essentialized attribute.

Shrier sees everyone in terms of a “boy-girl” dichotomy, implying a binary system not supported by science. She writes that “girls are different”, with different inclinations and gifts, and possessed of empathy and deeper emotions. In turn, she encourages AFAB youth to “stop taking sex stereotypes so seriously”. Yet Shrier claims that AFAB trans teens are not valid because they don’t adhere to gender stereotypes. She contradicts herself with the assertion that AFAB trans teens “regard men as the measure of all things” when she states that AFAB trans teens “definitely” do not want to be seen as “cis men”.

Of Youtuber Chase Ross, a trans man interviewed by Shrier who later issued an apology for appearing in the book, Shrier notes: “while he could pass as a small man if he wanted to, he seems to have something else in mind. His earrings, cat tattoos, flop of hair dyed every vivid shade of parrot, and nail polish all slyly nod toward the sex of his birth.” This assertion precludes the existence of gender non-conforming people outside of the binary, and is harmful to anyone, including cisgender people, whose gender expression deviates from traditional sex stereotypes.

Shrier understands AFAB trans people as those who exclusively date and are attracted to women, making note of her AFAB subjects who have “dated boys” as another reason to distrust their trans status. Shrier – and she will elucidate this argument later – believes that trans men are actually just butch lesbians, and her hope, framed as concern for young AFAB teens, is that they will turn back and embrace their intended womanhood. AFAB trans teens are also not valid, because, as Shrier states: “they almost never undergo the phalloplasty necessary to achieve one of the defining features of manhood, (so) it’s hard not to see their male identities as fragile; a quick trip to a urinal, and the jig is up”.

This statement again conflates sex with gender and reinforces a gender binary. Centering the understanding of a real man around genitalia is dismissive of transmasculine people who are not possessed of a penis and harmful to women and non-binary people who have a penis. In 2019, the American Psychiatric Association released new guidelines for psychological practice with boys and men, addressing the psychological harms of traditional masculinity, and defining multiple masculinities inclusive of sexual and gender minorities.

Although Shrier concedes that phalloplasty is complicated, she does not make the connection that this may be one of the reasons that some AFAB trans people do not move forward with the surgery. Other reasons include financial constraints, inadequate insurance coverage, and a relative dearth of surgeons who both perform genital gender affirming surgery and accept insurance. Finding a competent surgeon who is trustworthy, knowledgeable about trans health issues, and accessible cost- and location-wise, is a near-impossible task. Shrier’s final argument against AFAB trans teens is that their parents deny signs of gender dysphoria in childhood. For example, one subject wanted to be a boy at 4-5 years old and cut their own hair; however, according to mom, their “desire to be a boy was neither pronounced, severe, or persistent.” Another mother reports that “her (child) just didn’t seem like a boy trapped in a girl’s body”.

Claim: Gender dysphoria resolves in 70% of children

Shrier writes that gender dysphoria resolves in 70% of children who identify as trans. This statement sees her confusing two separate claims. The 70% statistic comes from Dr. Kenneth Zucker, who stated that a full 70% of the children he saw at his clinic for treatment did not have gender dysphoria in the first place. The “gender dysphoria resolves” statistic is 80%, a number widely bandied by the media, public, and journals to suggest that 80% of transgender children will come to identify as cisgender in adolescence or early adulthood. Though this statistic has been debunked many times and came to be known as the “desistance myth“, the widely acknowledged presumption is that most trans children will desist, a presumption that raises questions around whether we should support the gender identities of trans children.

Between 2008 and 2013, four follow-up studies on trans children were published in peer-reviewed journals. The studies were (separately) conducted at a clinic in Toronto and a clinic in the Netherlands. Though the estimates of desistance drawn from the studies are those widely quoted today, all four studies had serious methodological concerns.

The original studies used the (at the time current) diagnostic criteria of Gender Identity Disorder in the DSM-IV, which were predominately focused on gender expression, meaning that cisgender children, such as AFAB “tomboys” and AMAB boys who liked to play with feminine-coded toys, and other children with gender non-conforming behaviors, were included in the GID category. (Gender expression is how a person publicly expresses or presents their gender. This can include behavior and outward appearance such as dress, hair, make-up, body language and voice. Others perceive a person’s gender through these attributes.) These children never claimed to be transgender, so, rather unsurprisingly, most were not transgender at follow-up. Despite never expressing gender dysphoria or trans identity, these patients were classified as desistors. 40% of the participants in the study did not even meet the then-current DSM IV diagnostic criteria; similarly, these participants, who were never identified as gender dysphoric, became classified as desistors. Research was limited to those children whose parents brought them to the clinic for diagnosis and treatment, believing that their child’s identity was a problem requiring psychiatric treatment. If a young adult followed by the study since childhood was not pursuing medical and/or surgical gender affirmation, the assumption was made that they were desisting. Participants lost to follow up were also classified as desisters. The four clinics had high ratios of participants who did not follow up: 22%, 25%, 30%, and 32%. Lack of re-engagement with the clinic, for whatever reason, was counted as desistance.

All four studies failed to acknowledge: not all trans people medically transition; socioeconomic and/or cultural factors; negative clinic experiences; those who moved, were institutionalized, or died; and finally, the possibility that some people repress their gender identity. The studies used a binary gender framework, ignoring gender non-conforming identities and intersex people. The studies conflated gender identity and sexual orientation, leading to statements such as “the majority of those who desist by or during adolescent grow up to be gay, not transgender”, as if those two options are mutually exclusive.

Underscoring all of this is that the 80% statistic is employed to justify delaying social transition, which signals to trans children that they are not to be trusted and that they are not valued for who they are. The insidious undercurrent of all appeals to not affirming children in their identity is that we must, first and foremost, protect cisgender children from the possibility of “mistakenly” transitioning, even if this means exposing trans children to the stress of living in a gender they do not identify with.

It is important to note that the children in the Dutch clinic were discouraged from social affirmation prior to puberty. Those in the Toronto clinic were treated according to a schema that sought to lower the odds of patients growing up to be transgender and reduce the likelihood of GID persistence.

The latter clinic, CAMH’s Child Youth and Family Gender Identity Clinic, was run by Zucker and Blanchard (yes, the Blanchard discussed earlier). In 2003, Child & Adolescent Psychiatrist Dr. Pickstone-Taylor, advocate against the pathologization of children with Gender Diversity, was quoted in the JAACAP (Journal of the American Academy of Child and Adolescent Psychiatry) saying Zucker practiced “something disturbingly close to reparative therapy for homosexuals”. This concern was raised by other healthcare professionals. In his 1990 research paper “Treatment of gender identity disorders in children“, Zucker himself writes: “A fourth rationale for the treatment of cross-gender identification in children is the prevention of transsexualism in adulthood. There is little controversy in this rationale, given the emotional distress experienced by gender-dysphoric adults and the physically and often socially painful measures required to align an adult’s phenotypic sex with his or her subjective gender identity.” [Correction made in the above paragraph. Explanation in Addendum under Error #1.]

Zucker claims that 80% of children with gender dysphoria will desist; investigators reviewed his patient files and found that 72% of the children treated by Zucker never met the clinical criteria for gender dysphoria, as noted by Zucker himself. This means that 90% of the patients Zucker claimed to “cure” were never transgender in the first place. Unsurprisingly, Shrier includes an interview with Zucker for her book in which she extols his virtues, believing that Zucker was “stunningly successful” in his treatment of dysphoric children because 88% of them outgrew their gender dysphoria. Of course, children can’t outgrow something they never had.

Shrier writes, “until the 2015 controversy that cost him his job, Kenneth Zucker was universally recognized as an international expert on child and adolescent gender dysphoria”. Zucker ascribed to outdated and harmful conversion therapy practices, and following provincial legislation outlawing gender identity change efforts, his clinic was shut down. Shrier characterizes the damaging conversion therapy that Zucker exposed his young patients to as: “he helped children and adolescents with GD grow more comfortable in their bodies”. McHugh sees conversion therapy as “striving to restore natural gender feelings to a transgender minor”, an approach discredited by every major professional medical organization.

Countering this narrative, a cross-sectional study of 27,715 U.S. trans adults found that recalled exposure to gender identity conversion efforts was significantly associated with severe psychological distress in the previous month and lifetime suicide efforts. Those exposed to gender identity conversion efforts before age 10 had a significantly increased risk of lifetime suicide attempts. A 2019 study followed a cohort of children aged 3-12: over 300 trans children, who had socially, but not medically, transitioned; nearly 200 of their cis siblings; and approximately 300 unrelated cis children (the control group). Two-thirds of the children were AFAB. The study found that there is almost no difference between transgender and cisgender kids in knowing their gender identity, in how they identify with or express their gender. The researchers note that this was especially surprising since the transgender children were, prior to social affirmation, treated as a gender other than the one they currently identify as. A prior study echoed these findings.

AFAB trans teens are mentally ill (and not trans)

Citing a Joe Rogan podcast, Shrier states “adolescent girls today are in a lot of pain”. She notes a depression rate in teen girls that is three times higher than that of boys, and a 25% increase in suicide rates between 2009 and 2017. The article cited reports an increase in suicide contemplation by 25%, not suicide rate. These statistics apply to cisgender girls only, and it is disingenuous to pretend that they include trans youth, in whom the rate of suicide attempt is closer to 50%.

If Shrier is extrapolating this suicide statistic to apply to white girls, (her characterization of AFAB trans teens; white, upper-class, with nothing to rebel against), a systematic review and meta-analysis on gender differences in suicidal behavior in adolescents undermines this; multi-racial students were the most likely to consider suicide, followed by American Indian and Alaskan Native, Native Hawaiian and other Pacific Islander students. Overall, cisgender males were still more likely to commit suicide.

Shrier believes that healthcare guidelines for trans people are driven by political correctness, not biology. Though evidence strongly suggests that gender identity, like sexual orientation, is innate, there is support in the scientific literature for a biological basis of gender identity, although using this approach relies on the previously-discussed concept of biological/gender essentialism. Research studies on people with differences in sex development (DSD) notes that those with an XY genotype felt more comfortable when raised as boys, despite being raised as female and undergoing genitoplasty at birth. Data highlights the potential influence of abnormal hormone exposure on the development of trans identity in some individuals (although it is important to note that most trans identity development cannot be explained by atypical sexual differentiation.)

A biological origin of trans identity is also supported by a base of evidence noting atypical sexual differentiation of the brain. The perception of one’s gender identity is linked to the brain and differs from the body phenotype in trans people. The degree of genital masculinization may not reflect that of the brain. Postmortem brain studies have noted trans-specific cerebral phenotypes. Brain phenotypes for trans people seem to exist. There may be evidence for the role of genetic factors and exposures affecting development of trans identity, although no studies to date demonstrate the mechanism.

On one hand, studies supporting a biological cause for trans identity help establish a reality of gender identity based in science. On the other, biological essentialism does not equal acceptance of trans people, as noted earlier. A study of university students exposed to an article with a strong bioessentialist view of gender identity demonstrated increased prejudice toward trans individuals. Biological essentialism also lends support to arguments that trans people are broken and can be fixed, that their behaviors are culturally driven and can be adapted to their sex assigned as birth. This debate directly echoes the one around the gay gene, widely popular and discussed in the 90s and early 2000s. Establishing a biological basis for homosexuality would have potentially lent legitimacy to LGB sexual orientations; however, the discovery of a “gay gene” could lead to the systemic eradication of sexual orientations outside of heterosexuality.

The modern debate is identical aside from substituting gender identity for sexual orientation. Throughout history, anti-LGBTQ groups have claimed that sexual orientation and gender identity is a “choice”. The risks of finding biological underpinnings of both sexual orientation and gender identity are clear. Scientific research has long debunked the assertions that LGBTQ people are deviant, broken, and detrimental to society. The scientific consensus is that trying to change LGBTQ people through “conversion therapy” programs is harmful. LGBTQ identities are deeply complex, normal, and natural variations of human sexuality and gender identity. Maybe science should focus less on the causes of identity and sexuality variation, and more on challenging the discrimination and inequities sexual and gender minorities face on a daily basis. Indeed, it is worth questioning which side is politicized. A press release by the American Medical Association (AMA)—certainly not a “woke” liberal organization!—that supports APA guidelines states that the American Medical Association, American College of Physicians, American Academy of Pediatrics, American Psychiatric Association, Pediatric Endocrine Society, and World Professional Association for Transgender Health, all major medical organizations, “oppose the dangerous intrusion of government into the practice of medicine and the criminalization of health care decision-making”.

Shrier writes an entire chapter on gender-affirming therapists. She opens with a joke: a woman walks into a clinic with her son and tells the therapist that her son thinks he’s a chicken. The therapist asserts that the son is a chicken. The punchline, per Shrier: ‘This is, roughly, the scenario created by “affirmative care.”‘ Going beyond that crass and offensive joke, Shrier continues, claiming that therapists today “must agree…that a male with gender dysphoria who identifies as a woman really is a woman”. Gender identity is innate; a person’s genital assortment only describes sex assigned at birth and does not always inform gender. Shrier counters, “affirmative therapy compels therapists to endorse a falsehood: not that a teenage (youth) feels more comfortable presenting as a boy-but that (he) actually is a boy”.

Shrier understands that all major professional medical organizations endorse gender affirming care. To her, this endorsement means that that the doctor is no longer in the driver’s seat when it comes to medical judgement; instead, the patient is in control. The gender affirming model means that doctors believe their patients who identify as trans. Informed consent is a step toward healing the insidious and damaging history of cisgender doctors setting arbitrary and subjective requirements for transgender patients.

“Get on board with “affirmative therapy”-or lose your job and maybe your license,” Shrier warns.

In Shrier’s words, gender affirming care is “fashionable,” an assertion both damaging and inaccurate. Only 20 states in the United States have laws banning conversion therapy for minors. 4 states partially ban conversion therapy. 23 states and 4 territories have no state law or policy on conversion therapy. This year, legislatures in 20 states proposed banning health care providers from delivering medically necessary gender-affirming care to transgender and gender-diverse minors. In April, Arkansas became the first state to outlaw any gender-affirming medical treatments for trans youth, overriding a veto from the governor.

Trans youth experience significant disparities that are compounded by the endless wave of inflammatory and baseless opinion, masked as concern. As evident in this review, the same names and sources come up again and again, in a toxic feedback loop that does not allow for difference in opinion (or gender identity) or counterarguments. To certain groups, the “trans agenda” is real, and gender-affirming care is dangerous. Reviewing the history of trans healthcare sheds a light on Shrier’s insights, which are not new, just repackaged in rhetoric that appeals to a mass audience.

Part Two will explore these concepts.

Addendum: List of corrections

The author and editor wish to issue four corrections. We offer our thanks to Jesse Singal, who helpfully pointed these errors out. We believe that the post is now stronger for the corrections.

Error #1

The original review read:

In 2003, the American Academy of Child and Adolescent Psychiatry (AACAP) reported that Zucker practiced “something disturbingly close to reparative therapy for homosexuals”.

This was an unintentional mischaracterization, as it implies that the AACAP had released a statement to that effect. We therefore changed the text to be more precise. The text above now reads:

In 2003, Child & Adolescent Psychiatrist Dr. Pickstone-Taylor, advocate against the pathologization of children with Gender Diversity, was quoted in the JAACAP (Journal of the American Academy of Child and Adolescent Psychiatry) saying Zucker practiced “something disturbingly close to reparative therapy for homosexuals”. This concern was raised by other healthcare professionals. In his 1990 research paper “Treatment of gender identity disorders in children“, Zucker himself writes: “A fourth rationale for the treatment of cross-gender identification in children is the prevention of transsexualism in adulthood. There is little controversy in this rationale, given the emotional distress experienced by gender-dysphoric adults and the physically and often socially painful measures required to align an adult’s phenotypic sex with his or her subjective gender identity.”

We apologize for this lack of clarity and are happy to make the situation clear, and to be totally transparent about the correction made.

Error #2

The original version of the post stated that Abigail Shrier frequently used the term “woke gender ideology,” which Dr. Eckert described as an “oft-recited phrase that is never really defined.” It has been pointed out to us that Abigail Shrier never actually used the exact phrase “woke gender ideology” in Irreversible Damage. It was even suggested that attributing that phrase to her was “fabricating” a quote—or even libelous. SBM would, of course, never fabricate a quote, and we are all about correcting errors when they are discovered. So Dr. Eckert and I have corrected this particular error by removing the word “woke” from in front of “gender ideology” in every instance in the post in which the phrase was mistakenly attributed to Shrier.

The correction being made, we do note, however, that it is inarguable that Shrier did frequently use the term “gender ideology” in her book. (It’s just that she didn’t use the word “woke” in front of it, which makes including the word in the quotes attributed to her an unintentional error.) I count its use a total of 16 times, not counting two instances in the endnotes. I also counted one instance of “gender options and ideology,” one instance of “transgender ideology,” and one instance of “trans ideology.” There was also one usage of “monstrous ideology” (in context referring apparently to “gender ideology” or “trans ideology”).

We argue that this particular mistake is likely understandable, because it is not as though Shrier hasn’t shown herself to be willing to use the word “woke” in reference to transgender activists, for example:

Nonetheless, even though in the context of how Shrier uses the phrase we do not see a huge difference between the “woke gender ideology” and “gender ideology,” precision does matter when a writer is using quotation marks and this is an error that shouldn’t have occurred. We regret the error and thank Mr. Singal for allowing us to correct this post to make its wording more precise.

Error #3

Mr. Singal noted one other instance that he characterized as “all-out fabrication”:

Specifically, in the original review, Dr. Eckert wrote, “According to Shrier, the internet coaches and indoctrinates teenagers in ‘radical trans ideology’ (again, whatever that means).”

It is true that Shrier never used the exact phrase “radical trans ideology” in her book. She did, however, use the term “extreme gender ideology” in one instance, and elsewhere, as Mr. Singal’s own search shows, she used the term “radical gender ideology,” although, again, as Mr. Singal points out, she never used the exact phrase “radical trans ideology.” We have therefore changed the original sentence to reflect what Shrier actually wrote. We apologize for not making sure that only exactly the same phrases that Shrier used in her book were in quotes. Failure to do so twice was admittedly sloppy (albeit not “fabrications,” as Mr. Singal accuses Dr. Eckert of). We also point to Mr. Singal’s own search results that he Tweeted out yesterday to show how such Dr. Eckert might have inadvertently made this and the previously discussed error:

Error #4

Littman’s 2018 ROGD study itself was not “pulled”; The Brown University news article on Littman’s study was retracted. The study itself underwent review and was republished with corrections.

The original passage read:

ROGD is a diagnosis proposed by Lisa Littman of Brown University, to support the hypothesis of transgender identity as peer contagion. Littman coined the phrase to describe parents’ accounts of their teenage children suddenly manifesting symptoms of gender dysphoria and self-identifying as transgender along with other children in their peer group. Littman speculated that ROGD could be a “social coping mechanism” for other disorders. Her study was published in 2018 and pulled shortly thereafter, a move described by Shrier as “activists stormed the peer-reviewed scientific journal accusing her of anti-trans bigotry”.

We have altered the passage that described the ROGD study as having been “pulled” to be clear about what happened to Littman’s study:

Littman’s study was published in 2018 and immediately ran into problems. The Brown University press release describing the study was removed days later, with the Brown University Press Office noting:

In light of questions raised about research design and data collection related to Lisa Littman’s study on “rapid-onset gender dysphoria,” Brown determined that removing the article from news distribution is the most responsible course of action.

A second press release noted:

Brown does not shy away from controversial research. The University’s Office of Communications decided to publicize research on Brown’s website on “rapid onset gender dysphoria” recognizing the topic to be a subject of rigorous debate in the field of study.

After the research paper was published in the Journal PLOS ONE, concerns were raised about the paper’s research design and methodology by leading academics in the field. These concerns were serious enough that PLOS ONE announced that it would conduct a post-publication re-review of the article to “seek further expert assessment on the study’s methodology and analyses.”

Given the concerns about research design and methods — not the controversial nature of the subject — the University decided to stop featuring this news story on its news site. However, the research article is still available on the journal’s website and on the author’s Researchers @ Brown page. The University does not know how long the re-review of the paper will take, or what (if any) actions the journal will take.

The university also noted:

  1. This is not about academic freedom.
  2. This is about academic standards.
  3. Academic freedom and inclusion are not mutually exclusive.

Seven months later, Brown University stated:

Seven months after the academic journal PLOS ONE indicated plans to seek further expert assessment on a study focused on “rapid-onset gender dysphoria,” the journal has republished the research with a series of corrections and updates by the study’s author to address concerns raised in the journal’s reassessment.

The revised study by Lisa Littman, assistant professor of the practice of behavioral and social sciences at Brown University, is now retitled “Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.” It includes revisions and updates to multiple sections of the study, including the title, abstract, introduction, materials and methods, discussion and conclusion sections.

PLOS One published the revised study on Tuesday, March 19. In addition to the updated study, the journal included a correction / notice of republication and a separate formal comment from researcher Angelo Brandelli Costa, associate professor of social psychology at the Pontifical Catholic University of Rio Grande do Sul, Brazil.

We agree that describing Littman’s paper as being “pulled” was a sloppy way to say it, given that it was the press release that was removed from the university’s press site and the study itself was never actually retracted. That being said, it is undeniably true that Littman’s paper did undergo a second review, leading to its republication in a substantially revised form. We apologize for this error and appreciate the opportunity to be very clear about what, exactly, happened after the publication of Littman’s ROGD paper. We believe that being clear about what happened to Littman’s paper is important.

Error #5

The study in question notes that Toronto reported a larger proportion of AMAB patients referred in childhood. For adolescents, the general trend of an inversion in sex ratios in favor of AFAB referrals was also reported in Toronto. This is not clear in my review and will be corrected appropriately.

The review should read:

The study found an increased ratio of adolescent referrals. Specifically, 32% were AMAB (assigned male at birth); 68% AFAB, which aligned with results from an Amsterdam clinic and Toronto clinic. The Toronto clinic reported a larger proportion of AMAB referrals in childhood.

Appendix: Abigail Shirier’s “Select Bibliography”

Shrier recommends these books in her “Select Bibliography”:

  • When Harry Became Sally: Responding to the Trangender Moment by Ryan T. Anderson (2018). At the time, Anderson was a research fellow at the conservative Heritage Foundation. The book is largely based in junk science; Anderson posits that Dr. Paul McHugh’s hypothesis that being transgender is a mental illness was correct, endorses Blanchard’s autogynephilia categorization of trans women, and perpetuates the ‘desistance myth’. In Feb 2021, the book was the first to be banned under a new hate speech policy on Amazon.com. According to Anderson and his many supporters, the book has been suppressed by trans activists.
  • The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism, written by psychologist J. Michael Bailey in 2003. Bailey, like Zucker, connects childhood gender dysphoria with male homosexuality later in life. He also endorses and presents Blanchard’s concept of autogynephilia. Based in junk science, but when the book caused controversy, Bailey claimed that the book has been suppressed by trans activists.
  • As Nature Made Him: The Boy Who Was Raised As a Girl, written by Canadian journalist John Colapinto in 2000, and covering the details of the David Reimer case. The inclusion of this book by Shrier is a surprise: it is a clear example of how ones’ gender identity is internal, supported by biology, and cannot be changed by external influences. It documents the case of an intersex individual. Those with differences of sex development, or DSD, undermine any arguments that sex and gender are binary. David underwent a routine circumcision at 8 months old that went so wrong that there was no hope of recovering his penis. His parents elected to have his genitals altered to represent AFAB genitals, and raised him as a girl named Brenda. This failed miserably, and, as a teenager, David reclaimed his male identity. David committed suicide in 2004. David’s surgery was performed by Dr. Money, a physician who believes that a person’s gender identity and sexual orientation are determined by environmental and social factors only.
  • Girl Land, written by American writer, conservative social critic, and former staff writer for The Atlantic, The New Yorker, and The Wall Street Journal Caitlin Flanagan, in 2013. The book is “a rousing reminder to parents to protect their daughters”. Innocent girlhood is being threatened; in this case, by internet porn and social media. Flannagan did not interview any teenage girls; book is based entirely in speculation around white, middle-class teens. To Flanagan, things were better in her day. Shrier echoes these sentiments in her book.
  • Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life, written in 2014 by American psychiatrist Allen Frances, who served as a chair of the American Psychiatric Association task force when the DSM-IV was being developed and revised. Frances is a critical opponent of the current diagnostic manual, the DSM-5. He is most concerned about the increase in diagnosis of psychiatric conditions in children. Though this book is clearly included to support Shrier’s appeal to the DSM-IV as the superior diagnostic manual, Allen Frances recently noted that GID was kept in the DSM-IV to facilitate gender-affirming hormones and surgery, and never made sense as a mental disorder.
  • Strange Contagion: Inside The Surprising Science of Infectious Behaviors and Viral Emotions and What They Tell Us about Ourselves, written by psychologist and journalist Lee Daniel Kravetz in 2017 to investigate eight teen suicides in Palo Alto. He considers whether people can catch infectious ideas and behaviors, and examines how eating disorders, fear, and suicide can be contagious. Of note, Kravetz does not discuss trangender identity, which Shrier adds to his list as another psychic epidemic.
  • The Coddling of the American Mind: How Good Intentions and Bad Ideas are Setting Up a Generation for Failure, written by Foundation for Individual Rights in Education (FIRE) president Greg Lukianoff and social psychologist Jonathan Haidt in 2018 expanding on an essay they wrote for The Atlantic. FIRE is a non-profit group focusing on protecting free speech rights on college campuses in the U.S.; this book explores “political polarization and changing culture” on college campuses. Specifically, these white cisgender male authors do not support trigger warnings or safe spaces, invoking a culture of “safetyism” that does not prepare young people for the real world. Safe spaces originated in gay and lesbian bars in the 1960s to create a place of community and resistance at a time that anti-sodomy laws were still in effect and police raided gay bars on a regular basis. Safe spaces are important for marginalized minority groups to feel supported and respected free of judgement and unsolicited opinions. Haidt and Lukianoff heavily source from Jean Twenge’s iGen (see below) even though its premise is highly disputed. Students are discussed throughout the book, but not interviewed themselves.
  • Try to Remember: Psychiatry’s Clash Over Meaning, Memory, and Mind, written by American psychiatrist, researcher, and key historical figure in the academic pathologization of sex and gender minorities Paul McHugh in 2008. McHugh discusses false memory syndrome and multiple personality disorder, which he was active in debunking throughout the 1990s. McHugh posits that PTSD be a diagnosis frequently made up by therapists, dismisses widely accepted psychoanalytic views without discussing counterarguments, and bases his arguments on a handful of case histories.
  • On the Objective Study of Crowd Behaviour, written by English psychiatrist, medical geneticist, pediatrician, and mathematician Lionel Sharples Penrose in 1952. Describes “crazes”, panics, outbreaks of religious enthusiasm, and political ideas as “catching.” However, Penrose himself points out that objective analyses cannot be made as there is no available numerical data.
  • White Guilt: How Blacks and Whites Together Destroyed the Promise of the Civil Rights Era, written by Black conservative author Shelby Steele in 2006. In the wake of civil rights legislation passing in 1965, Steele claims there has been a shift from white supremacy all the way to white guilt. According to Steele, white people have corrected themselves morally and systemic racism no longer exists. Black people should take responsibility for their crime rates and poor academic performance and not blame a system imposed on them by white people.
  • iGen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy—and Completely Unprepared for Adulthood—And What That Means for the Rest of Us, written by psychologist Jean Twenge in 2017. This book examines a generation of adolescents who grew up during the widespread use of smartphones. Twenge expresses concern over isolation of these teens, and attributes high levels of anxiety and depression to technology. Twenge cherry-picks data and treats correlation as causation. Twenge draws her conclusions and then collects data. Shrier fully endorses Twenge’s moral panic over youth and technology, though to date there has been no scientifically valid evidence to prove a direct link between social media and mental health.
  • Crazy Like Us: The Globalization of the American Psyche, written by American journalist Ethan Watters in 2010. Presents the hypothesis that mental illnesses are affected more than we think by the beliefs and expectations embedded in a culture. Though the book presents thorough research, it equally relies on perspectives and insights, and ascribes cause and effect where it may not exist. Nevertheless, Watter’s arguments for a link between globalization and mental health are compelling and worth reviewing.

Author

  • Dr. AJ Eckert, D.O. (they/them) is Connecticut’s first out nonbinary doctor, Medical Director of Anchor Health’s Gender and Life-Affirming Medicine (GLAM) Program, and Assistant Clinical Professor of Family Medicine at Frank H. Netter MD School of Medicine at Quinnipiac University. Dr. Eckert has been involved in LGBTQ healthcare for over fourteen years with seven years’ experience as a provider of primary and preventative care and gender-affirming services, including hormone treatment and puberty blockers. Dr. Eckert hosts Queering Health with Dr. E, Anchor Health’s bimonthly YouTube and IGTV show, which focuses on demystifying LGBTQ healthcare and promoting the wellness of queer people through open discussions, stories, interviews, and more.

Posted by AJ Eckert

Dr. AJ Eckert, D.O. (they/them) is Connecticut’s first out nonbinary doctor, Medical Director of Anchor Health’s Gender and Life-Affirming Medicine (GLAM) Program, and Assistant Clinical Professor of Family Medicine at Frank H. Netter MD School of Medicine at Quinnipiac University. Dr. Eckert has been involved in LGBTQ healthcare for over fourteen years with seven years’ experience as a provider of primary and preventative care and gender-affirming services, including hormone treatment and puberty blockers. Dr. Eckert hosts Queering Health with Dr. E, Anchor Health’s bimonthly YouTube and IGTV show, which focuses on demystifying LGBTQ healthcare and promoting the wellness of queer people through open discussions, stories, interviews, and more.