Cont: Trans women are not women (IX)

[mumblethrax]

Seems like the null hypothesis and the Hippocratic Oath prevail, then: No puberty blockers for prepubescent children suspected of having gender dysphoria.

I'm not sure what you think the null hypothesis is, and the Hippocratic oath isn't a thing.

 

[mumblethrax]

Indeed (re: the highlighted). The pdf that mumblethrax linked to also noted that the drugs have been used as puberty blockers for ~30 years. This sounds like a long time, but that means the kids it was used on are only in their mid 40s. You'd like a broad health assessment of those initial cohorts, at the very least.

When it comes to the question of whether or not puberty blockers stunt growth, can we safely assume that people in their 40s have stopped growing?

 

[Ziggurat]

I'm not sure what you think the null hypothesis is

In this instance, the null hypothesis would be that puberty blockers don't help children with gender dysphoria.

and the Hippocratic oath isn't a thing.

The concept of doing no harm very much is, which was the obvious point.

 

[d4m10n]

In this instance, the null hypothesis would be that puberty blockers don't help children with gender dysphoria.

I don't think "help children with gender dysphoria" can be reduced to a single hypothesis test, since there are several questions which need to be answered.

Do puberty blockers help alleviate dysphoria in the short term, compared to similarly situated control subjects without the treatment?

Do puberty blockers help alleviate dysphoria in the long term, when compared against CSH undertaken after puberty instead of before?

What are the long-term health effects of blockers for patients who skip the process of endogenous puberty?

If I've learned anything from the Cass Review so far, it's that the evidence base isn't remotely in place to answer these questions yet.

 

[Emily's Cat]

Incredibly dishonest. Here's the chain of that conversation for you again:



As you can see, you claimed that their use as puberty blockers was off-label, and that they were approved only for use in treating cancer. I claimed that they were approved as puberty blockers (and not for "their use for gender dysphoria").


I haven't done that at all. You don't seem to be able to keep the conversation straight.

The approved primary indication is for cancer - that's what it "says on the tin". There is an approved secondary indication for precocious puberty.

They are NOT approved for use as puberty blockers in normal adolescents who do not have precocious puberty!

Seriously, if you have to get down into teensy semantic quibbles and bait-and-switching of terms, you should reconsider your argument.

 

[Emily's Cat]

Indeed (re: the highlighted). The pdf that mumblethrax linked to also noted that the drugs have been used as puberty blockers for ~30 years. This sounds like a long time, but that means the kids it was used on are only in their mid 40s. You'd like a broad health assessment of those initial cohorts, at the very least.

As an analogy, I used to point that (when teaching advanced classes) that we still don't whether people conceived IVF will have normal lifespans (the first being born in 1978), but we know they often exhibit epigenetic alterations

It's also conflating use to halt an inappropriate precocious puberty and use to interrupt a perfectly normal puberty.

FFS, it's nearly as bad as claiming that sumatriptan has been used to treat 'headaches' for 20 years and using that to support it being used for tension headaches. It's blatant motte and bailey, reliant on conflating the medical condition of precocious puberty with transgender.

 

[theprestige]

I'm not sure what you think the null hypothesis is, and the Hippocratic oath isn't a thing.

I'm confident you understand both my meaning and my point.

 

[Elaedith]

Since we are on this issue, I remember there was some interesting information in Benjamin Boyce's interview with endocrinologist Dr Will Malone in 2019. Like all of Boyce's interviews it's very long. The part I found most interesting was the description of how the affirmation-only approach with promotion of medical transition was simply declared by fiat to be the only acceptable approach by organisations like the endocrine society, AAP and APA, despite lack of data and with suppression of debate. This bit starts around 28.40.

Another interesting issue explained in the interview is that the affirmation-only psychotheraputic approach used in the US is not consistent with the Dutch protocol (where the medical approach with puberty blockers originated). Although the Dutch protocol did use medical transition, it was accompanied by a neutral rather than affirmative theraputic approach to avoid consolidating cross-sex identity where it would otherwise have resolved. This is explained around 20.00.

The interview also covered what we have been discussing surrounding puberty blockers in the earlier part. Everything Malone said about this is consistent with the Cass review.

 

[mumblethrax]

In this instance, the null hypothesis would be that puberty blockers don't help children with gender dysphoria.

That strikes me as too vague to be useful. You'll probably want to look for a specific effect.

The concept of doing no harm very much is, which was the obvious point.

I mean, it's a concept, sure. It's unclear how it has any practical value here.

If I've learned anything from the Cass Review so far, it's that the evidence base isn't remotely in place to answer these questions yet.

That seems to be pretty close to the state of things. Weak evidence for a benefit, weak evidence for adverse effects.

The approved primary indication is for cancer - that's what it "says on the tin". There is an approved secondary indication for precocious puberty.

If there's an approved secondary indication, then it also says that on the tin. That's what approval is. It means (among other things) that they can advertise it for that purpose. Which they do.

They are NOT approved for use as puberty blockers in normal adolescents who do not have precocious puberty!

I didn't claim they were.

Seriously, if you have to get down into teensy semantic quibbles and bait-and-switching of terms, you should reconsider your argument.

Again, this is incredibly dishonest. You denied that they were approved for use as puberty blockers at all. Now you want to weasel your way out of that and somehow that's my fault. You might be fooling somebody, but it isn't me.

It's also conflating use to halt an inappropriate precocious puberty and use to interrupt a perfectly normal puberty.

At no point did this occur.

FFS, it's nearly as bad as claiming that sumatriptan has been used to treat 'headaches' for 20 years and using that to support it being used for tension headaches. It's blatant motte and bailey, reliant on conflating the medical condition of precocious puberty with transgender.

This is just foolish. The claim is about safety, rather than efficacy, so it would be more like saying that aspirin has been used safely for years and so it's probably safe for prevention of pre-eclampsia, too. And "blatant motte-and-bailey"? It's not even a motte.

 

[Ziggurat]

I mean, it's a concept, sure. It's unclear how it has any practical value here.

If you don’t understand how the concept of not making things worse applies here, I really don’t know what to say to you.

 

[mumblethrax]

If you don’t understand how the concept of not making things worse applies here, I really don’t know what to say to you.

I don't see how not making things worse is preferable to not letting things get worse, which is why I don't particularly think "do no harm" is a useful principle in modern medical ethics. Or any kind of ethics, really.

 

[Ziggurat]

I don't see how not making things worse is preferable to not letting things get worse, which is why I don't particularly think "do no harm" is a useful principle in modern medical ethics. Or any kind of ethics, really.

First, because if you make things worse, that doesn’t preclude them continuing to get worse on their own as well. Second, because you might be wrong about them getting worse on their own. Third, if you can’t make things better, then maybe you don’t even understand the problem.

 

[mumblethrax]

First, because if you make things worse, that doesn’t preclude them continuing to get worse on their own as well.

It also does not preclude them getting better due to "making things worse", so this is not a reason to prefer "do no harm" to "allow no harm".

Second, because you might be wrong about them getting worse on their own.

You also might be right about them getting worse on their own, so this is not a reason to prefer "do no harm" to "allow no harm".

Third, if you can’t make things better, then maybe you don’t even understand the problem.

And this does not even address the question. If you can't make things better, there's no reason for intervention at all.

 

[Ziggurat]

If you can't make things better, there's no reason for intervention at all.

No ****. That's exactly the point of "first, do no harm".

 

[mumblethrax]

No ****. That's exactly the point of "first, do no harm".

If the only situation where "first, do no harm" gives you any ethical guidance is the one where no physician who doesn't have to wear a football helmet indoors needs ethical guidance, then it's entirely useless.

 

[Darat]

No ****. That's exactly the point of "first, do no harm".

It's a bit of a sidebar but the "do no harm" is not really used in modern medical ethics - you are looking at "non-maleficence". A quick think explains why the "do no harm" is not used in considering medical ethics, for example even a blood test causes undeniable harm to a patient (an injury) using "do no harm" as a rule would bring modern medicine to a standstill.

Your wider point is of course still correct, "puberty blockers" have been used unethically by some medical practitioners when treating pre-pubescent children given the lack of research.

This is one of those tricky areas in medical ethics when the only valid research possible is going to involve real people undergoing treatment with these drugs. Personally I don't think we know enough yet about how to treat trans children outside of physical medicine to start research on delaying or supressing puberty via chemical or physical means.

 

[Rolfe]

One huge problem identified at the Tavistock was the lack of record-keeping and follow-up. At an earlier stage these treatments were justified on the grounds of research, but there was no control group and no proper protocol. No systematic data-gathering operation was mounted, and no systematic protocol of follow-up examinations. Instead, at some point the treatments were simply held to be a success and they carried right on.

So research opportunities that might have answered a lot of questions were lost. Nobody was looking at desistance or detransition rates or even regret. There was a huge attrition rate among the original participants, and nobody tried to follow these patients up to find out why. It was simply assumed that the patients who continued to attend were typical of the entire cohort. However, many detransitioners who have come forward have said that they didn't go near their original provider once they realised the whole thing was a horrific mistake, for various reasons.

The attitude even among medical professionals seems to have been, we know this is the best way to treat paediatric gender dysphoria and that's what we're going to do. Anyone who treats a child in a different way (as would be necessary for a control group on the watchful waiting pathway) is a child abuser, and anyone who questions our actions is a bigoted transphobe.

 

[mumblethrax]

It's a bit of a sidebar but the "do no harm" is not really used in modern medical ethics - you are looking at "non-maleficence". A quick think explains why the "do no harm" is not used in considering medical ethics, for example even a blood test causes undeniable harm to a patient (an injury) using "do no harm" as a rule would bring modern medicine to a standstill.

And in particular, there is no compelling reason to prioritize non-maleficence over its counterpart, beneficence. A much better general gloss would be something like "provide treatment that you have reason to believe is likely to produce benefits that outweigh its risks, while respecting the autonomy of your patient. And if you live in a civilized country, something about distributive justice".

 

[shuttlt]

One huge problem identified at the Tavistock was the lack of record-keeping and follow-up. At an earlier stage these treatments were justified on the grounds of research, but there was no control group and no proper protocol. No systematic data-gathering operation was mounted, and no systematic protocol of follow-up examinations. Instead, at some point the treatments were simply held to be a success and they carried right on.

So research opportunities that might have answered a lot of questions were lost. Nobody was looking at desistance or detransition rates or even regret. There was a huge attrition rate among the original participants, and nobody tried to follow these patients up to find out why. It was simply assumed that the patients who continued to attend were typical of the entire cohort. However, many detransitioners who have come forward have said that they didn't go near their original provider once they realised the whole thing was a horrific mistake, for various reasons.

The attitude even among medical professionals seems to have been, we know this is the best way to treat paediatric gender dysphoria and that's what we're going to do. Anyone who treats a child in a different way (as would be necessary for a control group on the watchful waiting pathway) is a child abuser, and anyone who questions our actions is a bigoted transphobe.

I used to have some connection to psychotherapists at the Tavistock who came into psychotherapy in the 70s. They were heavily connected to the Oxford New Left and Cultural Studies. I remember in the 90s having conversations with a couple of them about the challenge of testing psychoanalytic theories. Effectively the majority view was remarkably similar to the kind of opinions expressed by homeopaths and chiropractors on this forum... the treatments were so personalised and dependent on the relationship between therapist and patient, that they couldn't be tested. My impression is that much of what the Tavistock is built on is actively opposed to the idea of evidence based medicine. Many of the same people were connected to similar debates on the New Left about the privileging of theory.

 

[theprestige]

It also does not preclude them getting better due to "making things worse", so this is not a reason to prefer "do no harm" to "allow no harm".

You don't have an argument that it makes things better, though.

And this does not even address the question. If you can't make things better, there's no reason for intervention at all.

I knew my confidence was not misplaced.