This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.
Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.
We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:
-
Shaming.
-
Attempting to 'build consensus' or enforce ideological conformity.
-
Making sweeping generalizations to vilify a group you dislike.
-
Recruiting for a cause.
-
Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.
In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:
-
Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.
-
Be as precise and charitable as you can. Don't paraphrase unflatteringly.
-
Don't imply that someone said something they did not say, even if you think it follows from what they said.
-
Write like everyone is reading and you want them to be included in the discussion.
On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.
Jump in the discussion.
No email address required.
Notes -
The CASS report predominantly based its conclusions on the lack of high-quality research, a point it reiterates often, not on high-quality affirmative evidence against treatment. There is some such evidence - for instance see this Reddit comment I wrote about puberty blockers and the indications that they both lock children onto the transgender pathway and permanently damage brain development - but like all evidence on the issue it isn't very good. In the absence of evidence that a treatment is safe and effective, the burden is traditionally on those advocating for the treatment to prove that it is. However, even aside from new studies actually providing information, "gender-affirming care" now has both established practice and a political ideology behind it, so abolishing it in any sort of permanent and widespread way seems likely to require more evidence. Without new evidence you might see some governments abolish or discourage it specifically for children, but others will continue to feed a fraction of every new generation into the trans pipeline and even places that get rid of it could easily flip back in a generation. The medical consensus turning against it would be a much more effective and stable solution, and something like a high-quality randomized control trial showing gender transition failing to outperform the control group would be a big step in that direction.
If anything "lack of high-quality research" understates the case. There is not a single randomized control study of gender transition, in either children or adults. It's incredibly easy for non-RCTs to give false results even if you do a reasonably good job, and most don't do even that. Read through something like Scott's Alcoholics Anonymous post or his ivermectin post and imagine how much worse it would be if only the non-RCT subset of the studies he looks at were available. That's why fields like nutrition, where long-term randomized control trials are impractical, are so terrible despite far more quantity and quality of research than a small field like gender dysphoria.
As an example, here's an excerpt from the Cass Report I've looked into previously:
Here is the meta-study being cited, the classification into high/moderate/low quality was not done by the Cass Report but by the meta-study. Note that many of the studies only looked at physical outcomes like "is puberty suppressed". At the time trans activists complained about the CASS report excluding a lot of studies, but among other things that includes studies that only investigated whether puberty blockers stop puberty and made no attempt to investigate whether stopping puberty provided any psychological benefit. This is the single supposed "high-quality" study. It isn't a randomized control study, it compares patients who have been given puberty blockers to ones who just started the assessment process. (It also compares to a "cisgender comparison group", such comparisons tend to be even more worthless.) Among other potential problems, this means the results are very plausibly just regression to the mean or benefits from the other mental-health care provided. If you think the parents of children with worse self-reported "internalizing, suicidality, and peer relations" are more likely to seek treatment than the parents of children who are currently doing fine, which the study itself shows, then improvement over time is the expected result even if you don't do anything. Plus they did do other things, it specifically mentions "the care provided in the present study also involved the offering of appropriate mental health care". It also mentions that the "control" group has an average age of 14.5 years and the treatment group 16.8 years. And that's the only "high-quality" study the meta-study could find on puberty blockers, here are the reasons given for why it considered the other studies to be even worse.
You're overstating the importance of randomized controlled trials (RCTs) in medical research.
As a famous parody of your point, this 2003 study found that no RCTs had been done of parachute use when jumping out of airplanes and concluded that there is insufficient evidence to conclude that parachutes are effective. As a follow up, this 2018 study did implement a RCT for parachute use when jumping from airplanes and concluded that parachutes do not in fact prevent injury. (Participants jumped from an airplane on the ground.)
Less facetiously, we have no RCTs demonstrating that HIV causes AIDs, but we can still be pretty confident about the link between the virus and the disease. Recognizing this relationship has led to a lot of good medical progress both for the populationis affected by AIDs and those not affected by AIDs (by for example keeping HIV out of blood transfusions to prevent the spread of AIDs).
I happen to also be skeptical of the benefits of transition. But your explanation of the science is not good here and at best leading you to the "right belief for the wrong reason".
I don't think that this is going to happen. The progress can be slow at times but following evidence-based practice is not a partisan thing, it is just a way forward. Takes a lot of work, hard work assessing evidence, figuring it all out, learning who can you trust since no one person is able to do fully etc.
It is said that currently about 50% of medical practices are not strictly evidence based. It takes time to re-evaluate everything, do high quality studies and so on. Many doctors have their own biases and can be very resistant to change. Maybe it will never be that their recommendations are 100% or even 99% based on good evidence. But I expect that it will become better with time as it is much better than it was 50 or 100 years ago. Maybe there will be some temporary setbacks in some places. That is also expected and in a way it is also good as it will provide a control group :)
More options
Context Copy link
I harp on RCTs because most of the time I read non-RCTs (in fields like healthcare and sociology with complicated and frequently opaque mechanisms) they end up utterly failing to adequately compensate for their disadvantages. Though of course this is a biased sample, I'm generally not reading studies on obvious and non-controversial subjects. It's always stuff like "we controlled for X" where X is whatever arbitrary handful of factors the authors thought of (leaving whatever residue is left as the "effect", or conversely erasing the effect with Everest controls), or "we matched with a non-random pseudo control group" (like the puberty blockers study I discussed) where we're supposed to trust how well matched they really are and there's often obvious differences between the groups. It is with good reason that in applications like clinical trials where RCTs are possible, they are considered the "gold standard" and are often required for approval by organizations like the FDA.
It's bad enough that I think anyone trying to argue the contrary needs to very specifically justify why the non-RCTs in the case in question actually work, not vaguely gesture at the fact that sometimes we can gather adequate evidence without RCTs. Otherwise I think it is very easy for people, including medical professionals, to assume that (for instance) just because 50 studies on puberty blockers have been conducted and they have become established clinical practice we now know whether they are better or worse than nothing. Sorry, 5-HTTLPR and depression had 450 studies and turned out to be completely fake, you need the very highest quality of studies to know whether the thing you're talking about is even real. There are of course plenty of ways to mess up RCTs too, the replication crisis is filled with them, but my impression whenever I see RCTs on a subject compared with non-RCTs (as in Scott's posts I linked in the prior post) is of a huge and often unbridgeable difference in baseline reliability. Sometimes conducting RCTs really is impossible (and in those cases I expect our understanding of the issue to be much worse) but if they're possible then conducting a high-quality RCT is going to be my go-to recommendation for both understanding the issue and creating evidence compelling enough that it can potentially convince others.
What do HIV and parachutes have in common? A much clearer mechanism of action. With gender dysphoria what we instead have is the murky waters of people creating narratives about their own subjective experiences based on whatever memes their culture has lying around, something people are terrible at doing accurately. Such introspection provides a wide range of insights: miracle supplements or faith-healing producing amazing boosts in well-being, subconscious reasons for your problems accessible through dream-analysis, neurasthensia, suppressed memories, etc. So yes, I'm sure you can make the case for HIV without a RCT, but that case would have to focus specifically on evidence particular to that case, my default without such evidence is to be skeptical of non-RCTs and look for the many ways they can go wrong.
By the way, based on you posting this in reply to someone else I think you mistook his posts for mine.
More options
Context Copy link
I am far too used to people using the parachute idea as justification to not do RCTs in places where an RCT would clearly be best practice. Most recently, involving COVID restrictions, which are assumed to work because "physics" or whatever but never get tested. We don't apply such flimsy reasoning elsewhere. Designer drugs have to go through trials despite being physics telling you they should work because they interact with the target molecule in models. If you can do an RCT, and choose not to, you better have a good reason to do so, and parachutes isn't a good enough reason.
Early parachute designs were actually tested. Nobody took the claims of their inventors at face value, they wanted evidence that they work, so their inventors tested them either personally or with objects/animals. That's why we don't need additional RCTs for the concept of parachutes, even though you could do one using animals. If they were invented for the first time tomorrow, you'd probably want to do something like an RCT:
Take 20 crash test dummies.
Randomly assign 10 to use the parachute, and 10 to not.
Simulate identical falls for all 20.
Hand the dummies to a blinded team of engineers who assess damage
Compare the results statistically to see if the safety intervention reduced injuries
I think it depends. To me, in anything science, RCT is the gold standard. There are workarounds that can be used when doing RCT is unethical due to the danger to the control group or in some cases the data is impossible to gather. In those cases other methods can work, though I generally take them to be low value and require a lot more of them done under lots of conditions before I accept the results.
More options
Context Copy link
More options
Context Copy link
The 2018 study did, as a matter of experimental design, include jumps from a plane in midflight. But the convenience sample of people willing to participate in an RCT of parachutes just happened to consist 100% of people asked while the plane was on the ground.
More options
Context Copy link
So does this mean Ivermectin was actually great, and all the critics were Ivermectinophobes? Or do we, in fact, have some ways to judge the quality of studies, and know for a fact that the absence of certain design features tends to mean a study's finding will tend to be overturned, if done properly?
We will never know either way. One side is claiming ivermectin cures cancer and homosexuality and the other is claiming it has a high risk of causing death. Neither is willing to tell the truth.
More options
Context Copy link
Medicine is hard, and answers to important medical questions can't fit in the length of a tweet. I have a phd in machine learning, so I'm confident I could form an opinion on your questions if I tried really hard and read a bunch of papers and thought about the problem for a week. But I don't care to do that, and so at some point I have to trust other people's judgements.
Part of the parachute study's point is that RCTs are not enough! And you are placing too much faith in RCTs! It's very easy to design a RCT that "looks good from the outside" but has a fatal flaw that makes it not applicable to the real world. In the parachute example, the fatal flaw is that the plane was grounded the whole time. Downthread, people are pointing out a bunch of fatal flaws in hypothetical RCTs for gender transition that would undermine any possible conclusion.
No matter what the methods are of an experiment, you can't get around having to sit down carefully and examine all of the assumptions.
Well, we might run into a problem here, because I don't care much for credentials, but I respect a sincerely held belief. If you don't really want to put your name on the argument for puberty blockers, just poke holes in the arguments against them (but never, ever, for them), I don't know how far we're gonna get, but let's give it a go.
Right, but are you going to tell me that the absence of randomization in controls is going to make the exact same study better? Like, I get that RCT might not be the be-all end-all, or that in some context might not be practically achievable, but you can't beat down any and all skepticism with "the science is settled, chud" type arguments (which is exactly what was happening in the case of transgender care for many years, even if you weren't doing it personally), and retreat to "ho hum, it's so nuanced" when people point out the poor quality of your studies.
I keep linking to that old blogpost about prescribing Lupron to autists, because I never got a good answer for it. Somehow it was clear as day that it's quack medicine back in 2006, and only hardcore libertarians ever dreamt of arguing that maybe we should let people try it if they want, but now doctors are prescribing the same drug to the children of often unwilling parents, with absolutely no evidence (by their own admission), and we're supposed to just roll with it?
I'm happy to, and I believe that if you do that, the entire edifice falls apart. Not just puberty blockers, but the entire concept of "gender dysphoria" as a diagnosis.
All I'm trying to say is that your original post overemphasized the importance of RCTs in medicine. I'm not trying to make any claim about gender dysphoria or its treatment.
You are absolutely correct! But parachutes have been proven to work in practice, while everything about gender affirming surgery is left to the future, a la "they would killed themselves otherwise".
If Junior says he's Napoleon, he is clearly in need of help. But if he says he's Napoleonette, he's stunning and brave. Can he/she/they buy a pack of cigarettes?
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
Great post and actually reverses my opinion. You've Singal-pilled me. I don't understand how any of those studies can be taken seriously by anyone else, but I guess it is important we get anything at all to satiate the people pushing this before axing it. Though I will point out that there are still plenty of communists, even though the communist experiment has failed several times over now.
I guess I'm Singal-pilled in that I see the utility in continuing experiments. I don't actually care if they're government funded or not. Certainly, if I was cutting research, research into something I despise would be one of the first things I cut. But, more nuanced than what I thought, I guess.
Because it's not about the science (or even The Science). We've danced this dance before with Intelligent Design. It's about "we have these pre-existing conclusions on the question, now we're just digging around for 'facts' to support it and squash our opposition".
A large part of transphobia/the trans backlash/TERF or what you want to call the reactions of ordinary people is that the question has moved very quickly from "some people suffer from dysphoria and feel absolutely convinced they are born in the wrong body, should we not help them?" and the answer to that being fought over "is this a mental illness or not, meaning should we try to treat them so they stop thinking this or should we give them drugs and surgery?", which is a whole controversy on its own, to "well what is sex and gender anyway? gender roles are socially determined, gender is a binary, now sex itself is a binary, there is no such thing as 'male' or 'female', 'man' or 'woman', let's smash cisheretonormativity, you are a woman if you feel that you are a woman" which is a much wider and deeper question and does involve undermining and overthrowing long-held traditional notions of 'this is a man' and 'this is a woman' as part of the broader revolution of attitudes around sexuality.
And then you throw six year old children into the mix of that witches' brew.
Or hey, Trust The Experts, if a two year old pulls the barrettes out of their hair, it is a very strong sign they are trans!
Ordinary people may be brought around to accept "adult person is now convinced he is she and wants to change their body to suit" with the approval of "here are serious and grave medical professionals who sign off on 'yes George is indeed Georgina'", but making it "here is Susie who hasn't changed one scrap of her appearance or behaviour except now she is claiming to be nonbinary 'they/them' and will fly off the handle into an absolute hysterical shrieking fit of rage if some poor passerby calls them 'she'" and "sure this may look like a guy, sound like a guy, and have raped two women violently as a guy, but now you must believe with all your heart and all your mind and all your soul that she is a real woman and should be put into a women's prison" is a step too far.
Except if you object to "yes but this is a guy, surely? isn't it dangerous to put a rapist in with women, you know?" then you are a wicked and violent transphobe who wants to ensure troubled trans kids commit suicide. Look at The Science! Trust The Science! and here those studies are pulled out to support the case.
Is it any wonder people eventually go "That makes me a transphobe? Okay, I'm a transphobe!" and the real suffering dysphoria people get thrown out with the bathwater?
We had a candidate for the Supreme Court dodging "what is a woman? well how can I possibly know, I'm not a biologist" and though I completely understand why she did it, as it was a 'gotcha' question, the fact remains: a woman can't dare to give an opinion on what is a woman. Had it been "what does it mean to be black (or Black, even)?" would she, as a black woman, have clammed up the same way? Would she be open to accusations of racism had she given an opinion on what it is to be black? See the difference there?
More options
Context Copy link
More options
Context Copy link
Three (rather hypocritical) cheers for actually going and looking at the evidence.
More options
Context Copy link
More options
Context Copy link