I'd be interested to hear your thinking on what problems the account I've given runs into (different from merely the plausibility of alternative models), such that it might fail to account for some aspect of the phenomena. That might also serve to focus the discussion - what aspects of the phenomena do we see which stand out as requiring certain types of explanation? — Isaac

I'm gonna bracket away any of the legal recognition stuff for this post. Despite it being important. I'll focus on what I understand to be the medical takes. A lot of these are references taken from Philosophy Tube's recent video on the topic, which is localised to NHS England. I'm not authoritative, and I can neither say whether the sources are authoritative or representative of ideologies etc.

If I understand the current medical metagame on what counts as a trans person in the UK, it's typified by the following (classes of) live events:
( 1 ) Person has gender atypical behaviour+identification for their associated natal sex young age. This can include the assigned gender role just "feeling wrong", the body feeling off and so on (gender incongruence)
( 2 ) ??? - this is experimentation with gender expression, learning how to perform your gender, internalising social norms, and trauma.
( 3 ) ??? - somehow ( 2 ) leads to mental illness.
( 4 ) Clinically significant distress associated with the experiences in ( 1 ) and ( 2 ) make the person diagnosable with gender dysphoria.
( 5 ) They count as trans because of the diagnosis.

That seem about right? The socially defining trait for being trans is the conjunction of gender incongruence and clinically significant distress yielding a diagnosis of gender dysphoria.

I think the more progressive account keeps the gender incongruence, but drops the clinically significant distress. That transforms it from necessarily a pathology to often associated with a pathology.

One way this manifests in treatment access is that allocation of gender therapy/gender reassignment is done to alleviate distress (as you'd expect any medical treatment), so that aligns the administration of treatment (in the public mind) with alleviating gender dysphoria - the clinically significant distress. Rather than aligning treatment to remove gender incongruence for aesthetic/personal/life affirming reasons (like cosmetics or restorative surgery). There's a difference in how treatment behaves in those as well I think?

The bar for obtaining hormone therapy and surgical interventions for adults at the minute is still fairly high, the treatment pathway goes through nonsurgical and non-medicational therapies and assessments first (see flowcharts here). In that regard a diagnosis of gender dysphoria is almost a necessary condition for receipt of gender affirmation therapy. It is nowhere near a sufficient one. The process of obtaining gender affirmation therapy/interventions is very long even after gender dysphoria is diagnosed AFAIK.

In contrast, changing it so that gender incongruence plays the role of that necessary condition, you can depathologise trans identities more while maintaining similar screening processes and what treatments are (in principle) available). The bar may be lowered for gender affirmation by removing the emphasis on clinically significant distress being tied to the gender incongruence. I think this is the thrust of the following passage in the Trans Health Manifesto of the Edinburgh branch of Action for Trans Healthcare.

TRANS HEALTH MANIFESTO

Trans health is bodily autonomy. We will express our needs, and they will be met. We will change our bodies however we want. We will have universally accessible and freely available hormones & blockers, surgical procedures, and any other relevant treatments and therapies. We will end the medical gatekeeping of our bodies. We will have full, historical accountability for the abuses perpetuated against us in the name of 'healthcare'. We will see reparations for these crimes, and the crimes committed against others in our names.

We are not too ill, too disabled, too anxious, too depressed, too psychotic, too Mad, too foreign, too young, too old, too fat, too thin, too poor, or too queer to make decisions about our bodies and our futures. We are all self-medicating. Our agency will be recognised. We each labour far harder for the health of ourselves and those around us than any doctor ever has, and we will continue build supportive communities on principles of mutual aid.

We deny the separation of bodies, minds, and selves - a violence against any part of us is a violence against all of us. We believe that the epidemic of chronic conditions in our communities is a consequence of the war of attrition waged against us over centuries. We do not exist in isolation, and it is essential to our healthcare that we are all healing together, healing each other, and healing our world.

(They are strongly left wing).

And here's a supporting quote to contrast the role gender dysphoria plays in current treatment availability:

Appendix B: Referral for surgical intervention
Referrals for a surgical intervention must be made by a Lead Clinician from a
specialist Gender Dysphoria Clinic that is commissioned by NHS England, with
necessary accompanying clinical opinions as described in this service specification.
A decision about an individual’s suitability for surgical interventions to alleviate
gender dysphoria requires careful assessment and support from a specialist multidisciplinary team, taking into account medical, psychological, emotional and social
issues in combination. As such, and given the potential range of complexities that
may be experienced by individuals on the NHS pathway of care and the potential
treatments, referrals to the specialist surgical team will not be accepted from other
providers or health professionals.
Before a referral for surgery is made, the Lead Clinician in the Gender Dysphoria
Clinic will have met with the individual to review current treatment interventions, and
to assess the individual’s needs and readiness for the surgical intervention, both as
described in the criteria below and as an assessment of the individual’s physical
health generally. The processes of shared decision making and of obtaining consent
(as described earlier in this document) will provide the patient with necessary
information, and will allow the individual sufficient time to ask questions, and to
reflect on the advice of the Lead Clinician to enable an informed decision on the
treatment options, risks and benefits. — Service specification: Gender Identity Services for Adults (Surgical Interventions)

So the thing which I think is inaccurate, and even dangerous for health outcomes of trans people, is the insistence on clinically significant distress as part of the determination of (the diagnosis which) gives access (start of access...) to gender affirmation therapy. It simultaneously pathologises and confounds the identity with its comorbidities, saying "too much", but also too little constitutively of the origin of gender incongruence, saying "too little".

Though, how the gender affirmation healthcare system functions is... more orthogonal... to this more fundamental shift I've portrayed. The whole thing could be made a lot better for trans people with the current definition and treatment pathways (can grab you more citations if needed).

So - to your question. Is it judgement neutral? I doubt it. I don't know anyone's capable of that, but here I'm small-c conservative. If we're to accept that clinicians are pressured into conformity (and assuming they can be persuaded out of it eventually) then I'd far rather they conform to existing societal pressures (which at the least are well known, if not all that healthy) than conform to what essentially can be indistinguishable from the latest fad. We have an obligation to do no harm, and I don't think that's met by rushing into treatments with low quality evidence when the evidence of the harm being mitigated is only of similarly low quality. — Isaac

Maybe this intersects with the obliqueness of the issues - while the determinative aspects of trans identity influence the healthcare pathways, the current administration of the system can be discussed more independently of it. There's much more discussion of these operational aspects in the video I linked.

I think essentially the conversation here cannot really progress without addressing the issue of negative pressure and positive ideology in the medical service provision. As I cited earlier, the evidence for both efficacy and safety of all medical interventions is sketchy at best, as is evidence of the harms suffered without those interventions.

Obviously, in such an environment, campaign groups are not going to just throw their hands up and say "oh well, we can't resolve this yet, more research need", they're going to cherry-pick the best sounding results from the weak collection and stick them front-and-centre. This goes for both side, clearly. So I don't see much room for progress on medical grounds alone. the most comprehensive meta-analysis I've managed to find (NICE and the review of GIDS in the UK) concluded the evidence was weak. As far as I'm concerned, that shifts the discussion to that about sensible default positions, not correct medical approach, which, in my view, simply cannot be established using the quality of evidence we currently have.

I think there are still issues of philosophical interest, but if any argument hinges on the medical question of efficacy, it needs to do so from a position that the question is, as yet, unresolved. It cannot do so from a position that the medical treatments are safe and efficacious, and the processes best practice. Not only is this questionable on epistemological grounds, but the premise of any 'campaign' is that current practice is flawed. Such a premise must have, as a fundamental axiom, the notion that existing knowledge and practices can be flawed. It cannot then use, as a basis for it's argument, the unquestioned accuracy of any current knowledge and practice.

I agree that the pathologising of the issue is the problem, but where I think I struggle is with what happens once that's been removed. If we no loner require the 'clinical distress', then the harm being resolved by the medical intervention is not clinical any more, it becomes, if not societal, then... ecological? We'd be claiming that there exists, naturally, a cohort of humans who identify as some other sexual phenotype than the one they were born as, but without this being a medical issue (not a defect), nor a societal one (we haven't fucked up and made a whole cohort of people unable to fit in). Just a naturally occurring feature of a population that some of them desperately (but not clinically desperate) need a different body (but not just any different body, they don't need a tail or broader shoulders, or a third arm, they need the body of the other sex).

On its face I find this implausible, but to dig a little deeper for some more flesh on those bones...

1. Why sex? Why not skin colour, hair type, height? If this phenomenon naturally occurs and isn't socially constructed, then is it just coincidence that it hinges on the most socially relevant phenotypical traits and not the socially irrelevant ones?

2. Where's the precedent? Tribes famously have long-accepted cross-gender roles. Some consider there to be a third gender, some simply accept that some women do men's things and vice versa. Suicide rates in tribes are famously low (with some not even having a word for the act). So where are the distraught Nádleehi, for example?

3. Why would this particular form of dissatisfaction deserve attention? We have famously limited resources (NHS on it's knees etc), if we remove the clinical need, then what differentiates this form of bodily dissatisfaction from any other? On what grounds do we deny steroids to the unhappily puny? On what grounds would we deny hair straighteners to those dissatisfied with their afros? I don't want this to be taken as a slippery slope argument, more a question of where (if) we'd draw a line.

4. How do we frame such a state of affairs without invoking a 'female/male brain'? At best there's what appears to me to be a very thin line to tread here. We want to say that it's the sex of the body that matters (not just any bodily dissatisfaction will do). We want to fix that using endocrinological interventions (about as close to the brain as you can get without actual lobotomy). But we want to stop short of saying that the brain is sexualised in any way. Do you think that needle can be threaded? How are we to explain how GnRH therapy works to bring about the chosen identity, but at the same time not say that such an identity is created by natural gonadotrophin? I struggle to see how we can leave open to those who have naturally occurring gonadotrophins of one functional sort, any identity they choose, but at the same time say with confidence that artificial GnRH therapy brings about a certain identity with efficacy?

There's many other questions, but I'll leave it there for now. The issue is a large and varied one.

What you call ‘compelling evidence’ is reductionist methodology: colour reduced to monotone, and shades of grey reduced to black or white. We make these judgements most accurately based on the perspective for each interaction, NOT based on some popular or politically-determined binary classification of characteristics. The way I see it, denial of colour or shade variation is harmful - as is asserting that black and white are not socially constructed and cannot be opted in and out of. — Possibility

Can you actually give real world examples of what you are referring because otherwise I have not got anything to respond to.

However social constructionism is a theory and a contested theory at that, you are simply claiming without evidence that certain traits are social constructed but if you apply that to everything consistently nothing is real (It is an anti realist stance).

Who decides what is constructed and what isn't and on what grounds? There are reasons to expect, as with other living things, sexually dichotomous behaviour. What of my behaviour is responding to a social construct?

It also reads like an allegation and an allegation that peoples behaviours are not sincere. That might apply to certain people and certain behaviours but it is a strong allegation to make in general.

And if you dismantle one view of things you inevitably replace it with something else equally dogmatic like social constructionism.

Also your position reads like social engineering, that you want to engineer diversity but that is usually the most shallow and insincere form of diversity.

Like a couple of men who have posted lots of pictures of themselves in skirts on the web claiming they are "dismantling toxic masculinity." As if wearing a skirt has some kind of magical gender powers and when I can show them loads of examples of men in dresses behaving toxically on line.

There are reasons to expect, as with other living things, sexually dichotomous behaviour. — Andrew4Handel

Do you think a profoundly effeminate gay male or ‘butch duke’ fits neatly onto a dichotomous scale , or are you are arguing for a scale that expresses a masculine-feminine continuum?

Do you think a profoundly effeminate gay male or ‘butch duke’ fits neatly onto a dichotomous scale , or are you are arguing for a scale that expresses a masculine-feminine continuum? — Joshs

It's not a scale it is a dichotomy.

Everyone is a unique individual with a profound personal inner life.

Are you referring to a scale of stereotypes? A scale of disorders of development? A genetic scale.

What is the difference between a "profoundly effeminate gay male" and any other gay male or any other male?
Is it that they work different jobs? The tone of their voice? Hairstyle? lack of conformity?
I don't get this "Profoundly effeminate comment"

A gay man of any shade is nothing like a woman and a woman is not just a flamboyant high pitched gay male. Men being attracted to other men is a different experience than woman being attracted to men and the sex is different.
In my opinion...

But we are here because a male impregnated a female and that is essential for the survival of our species and a fundamental. We need to know whether someone is the opposite sex to reproduce.

It's not a scale it is a dichotomy.

Everyone is a unique individual with a profound personal inner life.

Are you referring to a scale of stereotypes? A scale of disorders of development? A genetic scale. — Andrew4Handel

Arent you arguing that there is such a thing as masculine and feminine behavior , and that these are based in biology, which is what allows dog owners to distinguish between male and female dogs based on their behavior?

If you believe this, then dont you accept the possibility of intermediate forms of biologically-formed gender ( like hermaphroditism is an intermediate form of genetic sexual identity)? If biology can produce intermediate sexes , why shouldn’t it be able to produce intermediate genders?

Arent you arguing that there is such a thing as masculine and feminine behavior — Joshs

Yes but that they only occur in the sex being described. Any behaviour exhibited by men is male behaviour.
Behaviour permed by both sexes could be described as neutral or unisex, including like eating, sleeping, fidgeting etc.

I don't know much about dogs but I assumed there sex would have to be discovered based on genitalia.

If you believe this, then dont you accept the possibility of intermediate forms of biologically-formed gender — Joshs

Intersex conditions I know tend to occur in either males or females. For example Klinefelter syndrome only occurs in males. Turner Syndrome only occurs in Females. Androgen insensitivity syndrome occurs in males.

But regardless I don't see that as part of a spectrum because they can often lead to infertility.

A spectrum to me would be where more than a combination of an egg and sperm or male and female could produce a new human.

A spectrum of gender to me is meaningless because everyone is different and we exhibit a huge range of behaviours which don't belong to either sex or any named gender identity. It actually dilutes human diversity to creating stereotypes and unnecessary flags.

However social constructionism is a theory and a contested theory at that, you are simply claiming without evidence that certain traits are social constructed but if you apply that to everything consistently nothing is real (It is an anti realist stance). — Andrew4Handel

Reality consists of relation. Nothing could be ‘real’ in itself, in isolation from any and all interaction - there’s no way to be certain, and it’s frankly a pointless line of inquiry. There is understanding, perception/prediction and observation/measurement of reality, with varying degrees of accuracy.

Intersex conditions I know tend to occur in either males or females. For example Klinefelter syndrome only occurs in males. Turner Syndrome only occurs in Females. Androgen insensitivity syndrome occurs in males. — Andrew4Handel

These ‘syndromes’ and other conditions you mention are named as ‘disorder’ in relation to an assumed dichotomy. They’re exceptions to the rules we impose on reality by virtue of a perceived structure that excludes them rather than understanding. We observe genetic incidents of XXY and XO, for instance, as ‘real’, yet to some extent invalid, human conditions. Something to be fixed because fertility is perceived as a norm.

You seem to be saying that gender dysphoria, having no observable/measurable evidence, should be dismissed as ‘not real’ according to these rules we impose on reality, rather than something to be fixed.

What I’m saying is that discrepancies between one’s perception and these normative rules creates human conditions that are still ‘real’ at this level of perception/prediction, and that it is their perceived invalidity and NOT their lack of evidence that excludes them, rather than challenging us to understand the broader reality from which these conditions arise. I’m saying that surgery as a solution misses the point - manufacturing observable ‘evidence’ of upholding the rules perpetuates ignorance, isolation and exclusion. As successful as it may be for some, it’s cheating the system in pursuit of social validity. So when it fails to achieve that goal, the regret is understandably devastating. But that’s NOT compelling evidence that they should have simply followed the rules as they stand, and assumed their biological sex as gender identity. Rather, I find it evidence that these rules reflect an inaccurate relational structure of perception/prediction between what we observe/measure and what we understand.

When we perceive as much value in one’s personal gender identity as in the normative rules for gender that we impose on reality, it becomes clear that there is more to understanding the complex relational structure between X and Y chromosomes, observable/measurable sex characteristics and hormones, desire, behaviour and gender identity than these rules imply. Yes, there are observable sex characteristics that are more or less indicative of biological sex, but they’re not nearly as accurate as you would hope. This imprecision, like geocentric system calculations, suggests that our existing perception/prediction structures are… well, wrong.

I’m suggesting that we put aside the rules as they currently exist, and instead seek to develop more accurate structures of perception/prediction between what we observe/measure and what we’re only recently beginning to understand about the broader reality from which all these diverse human conditions arise. Listen to and observe young people when they struggle to learn and accept the rules in relation to experience. Binary, dichotomy, spectrum - these aren’t going to cut it, to be honest. I get the sense that we’re looking at a multi-dimensional value structure, more like a qualitative wavefunction. Perhaps we’re even going to have to dispense with some of our quantitative shortcuts or assumptions and interact more honestly, one human to another...

But we are here because a male impregnated a female and that is essential for the survival of our species and a fundamental. We need to know whether someone is the opposite sex to reproduce. — Andrew4Handel

We may need to ‘know’ whether someone is the opposite sex to reproduce, but do we really need to reproduce? All of us? Fundamentally? If there’s enough babies being born for the species to ‘survive’, then why is this binary identity a fundamental necessity for everyone? Surely we don’t need to ‘know’ this every time we interact?

I get the sense this may be a personal issue for you. Prediction error and mistaken assumptions are a primary source of pain, humiliation and loss in human experience.

I agree that the pathologising of the issue is the problem, but where I think I struggle is with what happens once that's been removed. If we no loner require the 'clinical distress', then the harm being resolved by the medical intervention is not clinical any more, it becomes, if not societal, then... ecological? We'd be claiming that there exists, naturally, a cohort of humans who identify as some other sexual phenotype than the one they were born as, but without this being a medical issue (not a defect), nor a societal one (we haven't fucked up and made a whole cohort of people unable to fit in). Just a naturally occurring feature of a population that some of them desperately (but not clinically desperate) need a different body (but not just any different body, they don't need a tail or broader shoulders, or a third arm, they need the body of the other sex). — Isaac

I think there's three different concepts bleeding together here.

The first is trans identity. I think broadly construed that applies to people who've transitioned surgically, people who live as the opposite gender otherwise, and I'd guess people like the Nádleehi. To me this is a binary concept - someone has trans identity or they don't. People are cis or trans. People are two-spirit or not. There could be a discussion regarding a-gender, genderfluid people there, but let's not go there for now unless you think it's necessary. I don't think they fit on the binary, but I don't think they're necessarily trans either.

The second is gender dysphoria. This is clinically significant distress caused by having a gender identity different from the assigned gender of a body. As far as I'm aware the current metagame for defining trans identity (operationally) treats gender dysphoria as determinative of being trans. You are trans if you've got gender dysphoria.

The third is gender as a social construct. This is as it says on the tin (up to an account of social construction lol). What gender means for the two-spirit, I imagine, is different from what gender means for a trans person in the UK.

So, onto a critical account using these distinctions.

If you specify gender as a concept within a mechanism of social construction, you evaluate trans identity within that mechanism of social construction. If you have the UK gender construct in mind, you end up with (some) trans people wanting to go from one side of the construct to the other in the account of trans identity. Then it appears perplexing that something which seems natural (bodily variation) seems to coincide with something granted as socially constructed (gender identity).

On the flip side, the presence of people of trans identity seems close to a cultural universal. There are people who are gender incongruous regardless of the gender concept, and there will be people who identify with what is rendered incongruous (like identifying as a woman while having male natal sex). Then there is how that gender incongruity is expressed through social constructions.

So with respect to:

2. Where's the precedent? Tribes famously have long-accepted cross-gender roles. Some consider there to be a third gender, some simply accept that some women do men's things and vice versa. Suicide rates in tribes are famously low (with some not even having a word for the act). So where are the distraught Nádleehi, for example?

The precedent being that gender roles are known to vary across societies. If system of gender norms contains a positive and supportive role for a Nádleehi, I imagine they would have less "clinically significant distress" for them in that context. In a traumatic context, more clinically significant distress. I tried looking for an experiment of someone who's family environment/upbringing was Nádleehi for some time, and then they were immersed in a scenario with westernised/(Christian etc etc) gender norms.

It is an anecdote supported with a newspaper article, but it is better than nothing:

I have read of instances in the past where, when a Nadleehi was born into a family, a celebration involving other families would be held, as having a Nadleehi child was considered to be a great event. Then, in modern times, I see LGBTQ2S Diné and Nadleehi people today who were kicked out of their families, bullied viciously, or in the case of Fred C. Martinez, murdered.

I would not learn any of this until I went to college and started researching Nadleehi and other tribes that had Two Spirit people. When I first read about Fred C. Martinez and what happened to her, I wept. She was accepted by the matriarchs and women in her family as Nadleehi, yet would be bullied at school and sent home by officials for “wearing feminine clothing.”

Her life would come to a tragic end when she went to a party and left with Shaun Murphy. Her body would be found a week later and it was never charged as a hate crime. — The Struggle to be Nádleehi

with supplementary information about the murder of Fred Martinez here.

"Cortez is a good community, but it has been my experience after living here 20 years that there are definite conflicts between Indians and whites," says Mark Larson, who represents Cortez in the state house of representatives. "We had [an incident in which] high school youth beat a Ute Indian to death in the park several years ago. And we had another incident where a couple of youths beat another Indian to near death."

But none of that history kept Martinez--a proud Navajo--in the closet. Friends always assumed that he might be gay, and his mother says she knew for three or four years that he was nadleehi. But it wasn't until summer 2000, right before his freshman year at Montezuma-Cortez High School, that the 6-foot-tall, 200-pound Martinez started to let his dark hair down and live in a manner that felt natural to him.

"He just started wearing makeup. He liked girl stuff," Mitchell says. "He felt good and he felt happy for being that way. And he said to his brothers and me, 'If you don't like the way I am, go ahead and tell me right now.' But nobody said anything."

Not at home, anyway. Friends, however, say Martinez was a frequent target of verbal harassment at school, and Mitchell says her son was sent home by school officials for painting his nails, plucking his eyebrows, and wearing makeup. "He would say to me, 'People don't like me for the way I am,'" she says. "And I would just tell him, 'Sonny, you just have to be yourself.'"

Dee Goodrich knows how difficult it must have been for Martinez to be himself. Goodrich, who is 26, is both Navajo and nadleehi. He grew up in Cortez and, until a couple of years ago, dressed almost exclusively as a woman.

"My sister was real traditional in her ways and was real active in the powwow circuit. I wanted to be just like her," says Goodrich, who performed as a female in powwow "jingle dances" and still designs stunning powwow costumes for his niece and others.

"Nadleehi is an old word for people who are blessed with the gift of being both a man and a woman at the same time. It's a sacred word," he says. "I always wanted to be like that. I always felt more feminine than I did masculine."

However, not all of Goodrich's classmates were privy to the same Native American teachings. And when Goodrich started to call himself Deanna, pluck his eyebrows, and powder his face, he was treated as anything but sacred. "No matter how many times I thought I was going to go to school and have a good day, I got harassed," he says; "faggot" was the slur most often tossed his way. "I felt secure the way that I was, so I didn't understand why people had to say what they said. For some reason some people just really wanted to knock me down." — Getting along in Cortez...

I think this establishes that Martinez was gender incongruous, had a supportive environment at home (was good there), was recognised as Nadheeli there, but when exposed more strongly to violent gender norms, they were bullied and then murdered. The lack of clinically significant distress, plus the desire to express in a gender incongruous manner I think demonstrates that trans identity isn't reducible to gender dysphoria.

It might be worthwhile thinking about how "clinically significant distress" could be caused in this context. If we've got someone who grew up without clinically significant distress associated with their gender identity for some time, then (plausibly) you're bullied and attacked for that identity, it will traumatise you, and has a high chance of causing clinically significant distress. The proximal cause of the trauma seems to be having a tendency towards gender incongruous expression and people treating you like shit for not abiding to norms which forbid that expression. Compound event of what looks like an innate tendency with a social construction.

Where are the distraught Nádleehi? Wherever their identity and norms grate on each other. A construal of gender incongruence that reaches before gendered expression in social norms needs support from a bodily capacity which engenders (pun intended) bodies to gender incongruous behaviour.

4. How do we frame such a state of affairs without invoking a 'female/male brain'? At best there's what appears to me to be a very thin line to tread here. We want to say that it's the sex of the body that matters (not just any bodily dissatisfaction will do). We want to fix that using endocrinological interventions (about as close to the brain as you can get without actual lobotomy). But we want to stop short of saying that the brain is sexualised in any way. Do you think that needle can be threaded? How are we to explain how GnRH therapy works to bring about the chosen identity, but at the same time not say that such an identity is created by natural gonadotrophin? I struggle to see how we can leave open to those who have naturally occurring gonadotrophins of one functional sort, any identity they choose, but at the same time say with confidence that artificial GnRH therapy brings about a certain identity with efficacy?

My intuition for how to thread it is to look for more interaction effects, I suspect (with some support) that these interactions render it impossible to reduce causation to a single bodily mechanism, or even bodies as a whole. In its simplest form, the manifestation of gender incongruence seems bodily and social, and is effected by gene expression - which itself is environmentally mediated.

So, I suspect it can be threaded. With the construal that having a trans identity is biologically predisposed, but that gender expression is socially constructed, administering hormones would change the biology but also the interaction effect. To put it another way. body properties are gendered, gendering works through societal expectation, if you change the body to better fit the societal expectation of the body, you'd be making a social and bodily intervention at the same time.

1. Why sex? Why not skin colour, hair type, height? If this phenomenon naturally occurs and isn't socially constructed, then is it just coincidence that it hinges on the most socially relevant phenotypical traits and not the socially irrelevant ones?

If this is a question about NHS resource allocation, I'll address it later. I don't think it's a coincidence, but I don't think that the desire for something socially constructed (to gender express in a certain way) renders the desire not naturally occurring. Like if you've got a sweet tooth, cookies or cake may suffice. If you've never seen a cake, you'd only crave a cookie.

3. Why would this particular form of dissatisfaction deserve attention? We have famously limited resources (NHS on it's knees etc), if we remove the clinical need, then what differentiates this form of bodily dissatisfaction from any other? On what grounds do we deny steroids to the unhappily puny? On what grounds would we deny hair straighteners to those dissatisfied with their afros? I don't want this to be taken as a slippery slope argument, more a question of where (if) we'd draw a line.

Maybe we've not removed the clinical need - that would be true if trans people didn't have clinically significant distress. What I've tried to show is that gender dysphoria isn't determinative of trans identity. Someone who is not distressed by their body wouldn't necessarily get the surgery, or have resources allocated to it based on clinical need.

In terms of the others, I believe you can change your body's impact on your gender expression only with surgery+hormone+gender expression treatment. You need help and drugs for that. And it's something that needs medical intervention to change in some cases.

There's a sub issue here about distinguishing NHS time for treatment (a resource question) and whether it's permissible to treat some body issues with surgical/drug interventions in a moral sense.

The challenge to anyone who wants to reject my thesis is to come up with an answer to this question that is not based on relations with society. — unenlightened

I think I largely stated my position on this to @Isaac here. The tl;dr in our context that "based in the social" and "based in the body" are sufficiently mingled up that construing gender identity as "based in the social" does a disservice to gender identity being a social relation between bodies, afforded by those bodies' developmental mechanisms.

When that character interacts with the education system, quiet passivity becomes laziness, unsteady hands become carelessness, forgetting names and faces is inattention and rude, and so on. I become moralised, and these things become 'wrong' with me rather than mere facts about me.

Otherwise than through they eyes of convention, how could there be anything wrong, uncomfortable, conflictual with being a man with a vagina, or a woman with a penis? One's physicality can only possibly be in conflict with an image of an ideal, which necessarily must come from others. — unenlightened

But we might even agree in general. Am I right in thinking you see the genesis of identity as some kind social trauma, whereas character is something innate?

Am I right in thinking you see the genesis of identity as some kind social trauma, whereas character is something innate? — fdrake

Yes. I'm saying that Any combination of male/female/no-sex brain and body, along with any combination of hormone regime that naturally occurs is bound, short of physical pain resulting, to be accepted as 'just the way I am' unless there is an induced conflict between that and 'the way I ought to be'.

In short the only possible source of conflicted identity is social. I mean who d'you even think you are, fdrake? That's just a duck! :razz:

The first is trans identity. I think broadly construed that applies to people who've transitioned surgically, people who live as the opposite gender otherwise, and I'd guess people like the Nádleehi. To me this is a binary concept - someone has trans identity or they don't. People are cis or trans. — fdrake

Unlike your definition of gender dysphoria, this definition still seems too vague to work with. It's seems no more than saying people who are trans, are trans. What is it to be trans? Is it wanting to act like another gender to the one assigned to you at birth, or is it wanting a different sexual phenotype to the one you have? Or is it both?

If the former, then gender dysphoria must be construed as a solution, not a motive - it's something the mind has 'come up with' to pin it's hopes on. Like (in your sugar craving example) saying that the lack of cookie is the problem. It's not - the lack of sugar is the problem, the cookie was a solution, the lack of which now seems traumatic, but if offered a cake, the trauma of cookie-less-ness would go away.

If the latter, then why sexual characteristics? Why not arm length, or head size, or hair colour?

If both, then why would they be connected at all if gender is a social construct. If we want to say there's no such thing as a female brain, then the association between female body parts and female gender roles is nothing but coincidence (biologically), we'd expect a pathological desire for female body parts and a natural desire to play a woman's gender role to be completely unrelated.

Societal attitudes to gender roles seems to be essential (to come back to this later).

The proximal cause of the trauma seems to be having a tendency towards gender incongruous expression and people treating you like shit for not abiding to norms which forbid that expression. Compound event of what looks like an innate tendency with a social construction. — fdrake

I think this is a good broad assessment. So with regards to treatment -

How would you feel about skin-whitening being offered to black kids in neighbourhoods suffering from systemic racism in the police?

How would you feel about chemical castration of homosexuals in Islamic regimes?

If both of those make you feel a little icky, then what's the difference between them and gender re-assignment for people suffering the sort of trauma Fred Martinez experienced?

We mustn't lose sight here of the pro-trans movement's agenda. The campaign slogan is not "we must reluctantly use sex-change surgery, until society finally accepts us for who we are (which we're working on)", nor is it "the medical barriers ensuring sex-changes are only considered in cases where the level of trauma is sever enough to justify the risk - let's keep things just as they are". Organisations like Mermaids and Stonewall are campaigning for easier access to sex-change drugs, and more encouragement of trans children to seek out that option.

having a trans identity is biologically predisposed, but that gender expression is socially constructed, administering hormones would change the biology but also the interaction effect. To put it another way. body properties are gendered, gendering works through societal expectation, if you change the body to better fit the societal expectation of the body, you'd be making a social and bodily intervention at the same time. — fdrake

I think that works as far as avoiding the 'female brain' problem, but it lands us straight back into the idea that medication is only needed to better meet societal expectations. Again, would skin-whitening for black kids in racists communities be a good solution, something to promote? If not, then why sex changes for trans kids in gender-strict communities?

gender dysphoria isn't determinative of trans identity. — fdrake

Yes, I think we agree there, that's where I'd end up too. I can see a situation where there could be sufficient biological tendencies (through behaviours like imprinting) to explain universal gender preferences without resorting to notions like a 'female brain'.

There's a sub issue here about distinguishing NHS time for treatment (a resource question) and whether it's permissible to treat some body issues with surgical/drug interventions in a moral sense. — fdrake

Yes, that's the direction I was going in. There's all sorts of clashes between one's body and society's acceptance of it, between one's body and one's own desires for it. Why privilege sexual characteristics?

Unlike your definition of gender dysphoria, this definition still seems too vague to work with. It's seems no more than saying people who are trans, are trans. What is it to be trans? Is it wanting to act like another gender to the one assigned to you at birth, or is it wanting a different sexual phenotype to the one you have? Or is it both? — Isaac

Apologies, I'd previously construed trans identity as gender incongruence. Rather than trans identity as gender dysphoria. There's an argument there that Diné gender norms couldn't produce gender incongruity in Nádleehi because Nádleehi are an "axis" on the space of gender. But I've made the assumption that such identities aren't orthogonal/independent from the other gender constructs, they're desires to express otherwise, to claim a different place on the same axis, or a mixed state of its values.

What is it to be trans? Is it wanting to act like another gender to the one assigned to you at birth, or is it wanting a different sexual phenotype to the one you have? Or is it both? — Isaac

I imagine it's both? I think gender incongruence is worldwide, right (cultural universal + biological predisposition ?) But how gender incongruence manifests is localised to a system of gender norms.

If the latter, then why sexual characteristics? Why not arm length, or head size, or hair colour? — Isaac

Why not for what purpose?

I think that works as far as avoiding the 'female brain' problem, but it lands us straight back into the idea that medication is only needed to better meet societal expectations. Again, would skin-whitening for black kids in racists communities be a good solution, something to promote? If not, then why sex changes for trans kids in gender-strict communities? — Isaac

The best distinction I can come up with is that one - skin whitening - shames the body that it's applied to, and one is either an expression of that body's nature or is caused by a shamed incongruity between body and norm. I think the first is prejudicial violence "these people need to be white!" whereas the second is expressive change "We need to be otherwise!".

You could maybe rejoinder that someone could want to change their skin colour for precisely the same reasons. In that case, I think it's either a bullet bite scenario (which I don't like) or I should parry with a distinction. If we use @unenlightened's social pressure/identity+shame dynamic as a proxy, the skin bleaching is explainable entirely by shaming social norms, my response to him was that trans identity is isn't explainable by shame, only trauma is.

The question about gender reassignment I think comes after the question about whether someone is trans, and the ethical norms are different. Oppression vs expression, shame being imposed from without vs undoing shame from within. I'd prefer not to think about it in terms of shame, because as you've highlighted people from more supportive social backgrounds (I imagine) have less chance of being traumatised about their gender incongruence.

I would be interested in finding out whether trans people without trauma express the desire to transition with a different frequency than those with it!

If both of those make you feel a little icky, then what's the difference between them and gender re-assignment for people suffering the sort of trauma Fred Martinez experienced? — Isaac

There's a volitional aspect to it. I think we can grant that societal pressures are in play without throwing informed consent and expression of will out the window. If this syllogism was valid:

( 1 ) Decision X is influenced by norm Y.
( 2 ) Norm Y is coercive.
( 3 ) Decision X was done with highly restricted agency.

We'd either be biting the bullet that most decisions were done with restricted (so the force of your distinctions is undermined, all agency is restricted what's the big deal), or alternatively we could quibble about what a sufficient degree of restriction and coercion is for the decision to count as being done from a position of highly restricted agency.

We'd be going back to a previous discussion about informed consent there though. Resolving it would require us to map out how volition, expression and autonomy work in the presence of norms, and a theory of how norms coerce. I don't think we're resolving that here, and I don't know where I'd start.

Yes, I think we agree there, that's where I'd end up too. I can see a situation where there could be sufficient biological tendencies (through behaviours like imprinting) to explain universal gender preferences without resorting to notions like a 'female brain'. — Isaac

I'm glad that we see eye to eye on that.

Yes, that's the direction I was going in. There's all sorts of clashes between one's body and society's acceptance of it, between one's body and one's own desires for it. Why privilege sexual characteristics? — Isaac

Maybe an inverse argument works here. Perhaps we privilege sexual characteristics precisely because of the desires and social status of people with gender incongruity and gender dysphoria, so we're making that decision "after the fact", rather than through an a-priori comparison.

Societally, I don't know why sexual characteristics are privileged. I could imagine a horrific world where skin bleaching is NHS prescribed rather than something you buy at Boots (though both are horrid). I suppose the distinction for me is that I intuit that someone can choose to undergo transition for expressive reasons, and it meaningfully effects change.

Inversely, do you think there's something about white-skin identity which would be expressed by skin bleaching? That wrings as wrong in my head as your examples did. I'm not even sure there is a specific white-skin identity, just a "not-dark skinned" one. Putting it pretentiously, I'm under the impression that there's something affirmative in gender transition, but only something negating in the skin bleaching one. "Make me not this!" (skin bleaching) vs "Make me not this AND make me this" (transition).

Do you get the same impression?

The best distinction I can come up with is that one - skin whitening - shames the body that it's applied to, and one is either an expression of that body's nature or is caused by a shamed incongruity between body and norm. I think the first is prejudicial violence "these people need to be white!" whereas the second is expressive change "We need to be otherwise!".

You could maybe rejoinder that someone could want to change their skin colour for precisely the same reasons. In that case, I think it's either a bullet bite scenario (which I don't like) or I should parry with a distinction. If we use unenlightened's social pressure/identity+shame dynamic as a proxy, the skin bleaching is explainable entirely by shaming social norms, my response to him was that trans identity is isn't explainable by shame, only trauma is.

The question about gender reassignment I think comes after the question about whether someone is trans, and the ethical norms are different. Oppression vs expression, shame being imposed from without vs undoing shame from within. I'd prefer not to think about it in terms of shame, because as you've highlighted people from more supportive social backgrounds (I imagine) have less chance of being traumatised about their gender incongruence. — fdrake

So, using your definitions from above, would it be an unfair paraphrasing to say that you see the difference between sex-changes and skin-whitening as being that in the former the participants don't mind, but in the latter they do mind (but feel they have to)?

You seem to want to stop short of saying that a normal (non-pathological, supportive society) expression of trans identity would involve any traumatic need to change sex. There might, however, be an idle preference for doing so, but the trauma is societal in cause.

With black kids in a non-racist neighbourhood, there would equally be no non-pathological need to change skin colour, but the difference is that none would even have an idle preference for doing so, such that when society offers it as a 'solution' to it's own racism, no one would take it otherwise.

If that phrasing is close to right, then I think I can agree with it in principle (whether it's true is a far more difficult thing to determine, but I agree it could be). The problem with that account is two-fold:

1) It kinda makes it sound like society is OK to push harsh bio-chemical interventions on it's minorities (rather than simply tolerate them) on the grounds that they "don't mind". I can't get to feeling good about that, even though I've no strict moral objection. I can get to a reluctant "Oh well, I suppose if they don't mind then I've no reason to stop them", but it's not something I'm going to waive flags over, I'm not going out on the street to cheer on the fact that society's found a way to get out of it's obligation to tolerate differences by using drugs.

I come back to the fact that the pro-trans activists are not pushing a reluctant stop-gap awaiting a better solution. They're pushing this as the end goal.

2) If the free and un-coerced consent of the trans community to this stop-gap 'solution' is the only thing separating it from the unconscionable skin-whitening 'solution' to racism, then it is vitally important that the community is unaffected by any form of social coercion. It is vitally important that the discussion around gender and sex takes place in an environment where people are free to express their views and encounter a range of opinions on the matter so that they can make up their own minds.

Do we have such an environment, do you think? Are trans activists generally working toward, or in opposition to, such an environment?

Putting it pretentiously, I'm under the impression that there's something affirmative in gender transition, but only something negating in the skin bleaching one. "Make me not this!" (skin bleaching) vs "Make me not this AND make me this" (transition).

Do you get the same impression? — fdrake

Not really, no. I think that 'identity' like any other concept is socially constructed, a post hoc story we 'pick off the shelf' to explain the various biochemical goings on in our heads which are (absent of any story) just a lot of electrical signals and chemistry. I don't believe people are born with stories already programmed, I don't see how they could be. I think we learn, through our culture and environment, to make different types of sense out of the interocepted data we get from the internal receptors in our brains.

As such someone who is black wanting to be white and someone who is male wanting to be female are both societal stories offered to explain a whole host of (probably completely incongruous) neurological goings on. One person might, then, identify as trans for a whole bunch of completely different neurological reasons to another. Same for identifying as 'white'. It's just a story, offered by society and it matches up with set of interocepted neurological goings on in need of an explanation, in need of some sense made of them.

Obviously, we all share similar neural goings on, so some stories are going to be very popular if they make sense of those shared processes, but it's also true that some stories are going to very popular if they're presented to the exclusion of all others and with huge social pressure to conform. This makes it very difficult to tell whether it's the quality of the story (good at explaining the interocepted data) or the PR of the story (advertised itself well) that accounts for its popularity.

As such, I don't see any reason why we couldn't find ourselves in a future where 'being white' was presented as a thing some people are, given a lot of good PR and thereby become just as popular a story as the trans identity is today.

Note, none of this denigrates the stories (life is quite impossible without them), nor is it an attempt to de-legitimise trans identities (calling it 'just a story' is not meant as demeaning - everything is 'just a story'). It's a warning that because everything is 'just a story' society has to be very careful about the way in which it presents its smorgasbord of available stories, especially if some stories lead to serious consequences (trauma or drugs).

1) It kinda makes it sound like society is OK to push harsh bio-chemical interventions on it's minorities (rather than simply tolerate them) on the grounds that they "don't mind". I can't get to feeling good about that, even though I've no strict moral objection. I can get to a reluctant "Oh well, I suppose if they don't mind then I've no reason to stop them", but it's not something I'm going to waive flags over, I'm not going out on the street to cheer on the fact that society's found a way to get out of it's obligation to tolerate differences by using drugs. — Isaac

I can understand the concern with that. There's two things I want to highlight. The first is that it's worthwhile recalling the distinction between how the treatment is administered and whether it's worthwhile to do. That is relevant because perhaps Mermaids aims of depathologizing trans identity and making treatment more accessible perhaps could be attained by making the current system better administered, the people who administer treatment more informed, and educating GP gatekeepers to treatments (this includes voice coaching and other non-invasive interventions etc). There was an NHS report to this effect (can cite if required) - a lot can be gained by making the current treatment work better without a fundamental reimagining of how trans identity is seen by doctors. Though the latter, I strongly believe, would aid the former. And of course the former would aid the latter.

The second thing I'd want to raise is a kind of case study. If we assume that the only reason for gender affirmation interventions is, essentially, peer pressure to shame their recipients, that would collapse the distinction between gender affirmation and "conversion therapy". The latter is universally traumatogenic, the former has a less than 1% rate of regret. It may be difficult to establish long term improvements in condition caused by the assignment, but exactly the same would hold for the kind of non-invasive treatments which are stipulated to be worthwhile in this context. Like therapy, you'll know how the short term effects swamp the long term ones - the further out in time you go from the intervention the less the observed impact on health outcomes. On that basis, should we scrap all mental health interventions because there's insufficient evidence it works long term?

And if we're working on a basis of "do no harm and this might work" - like therapy - why wouldn't greater access to medical aid for trans people (including reassignment surgery) be entailed by the same humanitarian premises which suggest that increased access to mental health services is necessary?

I'd guess you do see a distinction between conversion therapy and gender reassignment? If you don't we probably need to examine that area of the dialogue before we can proceed.

I think we have made some progress though, it seems we agree that there is a way to thread the needle between gender as a social construct with biological enablers vs male/female brains, I think we also agree that this hasn't been definitively established. Do we also agree the theory "social constructions alone determine gender incongruity" isn't established, and is likely to be too reductive

perhaps Mermaids aims of depathologizing trans identity and making treatment more accessible perhaps could be attained by making the current system better administered, the people who administer treatment more informed, and educating GP gatekeepers to treatments (this includes voice coaching and other non-invasive interventions etc). — fdrake

Yes, I think that's definitely true (the changes being needed). I have strong doubts this is what Mermaids are actually doing though, based on their other activities (for example their attempt to de-legitimize LGB charities), but the question of what trans activists are actually trying to do might properly be secondary to any question about the nature of the trans phenomena. One thing I think we can adamantly agree on is that trans identity is a real thing, so there's something there to account for outside of any campaign group's activities around it.

There was an NHS report to this effect (can cite if required) — fdrake

I believe I've read it. This one?

a lot can be gained by making the current treatment work better without a fundamental reimagining of how trans identity is seen by doctors. — fdrake

Yes, I think this is a strong way forward. In fact it might even strengthen the barriers against medical intervention for some if the principles already in place were applied properly. We saw, at Tavistock the effects of too lax an approach.

If we assume that the only reason for gender affirmation interventions is, essentially, peer pressure to shame their recipients, that would collapse the distinction between gender affirmation and "conversion therapy". The latter is universally traumatogenic, the former has a less than 1% rate of regret. — fdrake

Yes. In some ways that's one of the issues I see. If we say that some aspect of the person needs to be adjusted to match the other, then why not the brain? It's relatively plastic, responsive to pharmaceutical intervention... Why not make trans people happy with the body they have by adjusting their brains rather than make their current brain chemistry happier by adjusting their bodies. Is there a reason, other than efficacy, why one is icky and the other not? The reason I don't think the relative efficacy of the treatments gives us the whole picture is that even research into "conversion therapy" seems wrong. It's not that it currently doesn't work, it's that we don't even want it to.

For me, both therapy approaches seem wrong because we shouldn't be tinkering with bodies or brains as if they were custom cars which can have parts swapped our with little effect on the whole. Not without very strong cause. We simply don't know enough to do that.

For the current trans movement, it seems tinkering with the brain to make it better fit both society's expectations and somatic biology is taboo, but tinkering with the body, for exactly the same reasons (replace somatic biology for psychological biology) is not only OK, but revolutionary. Something to be cheered on with great enthusiasm. I honestly have absolutely no insight at the moment into why.

So, going back to efficacy, is there a reason why sex change works and therapy (not limited here to conversion therapy alone) doesn't? I can think of a few, but only speculative. To be clear, I'm talking here about all therapeutic solutions, not just "conversion therapy".

1) if one wants a new car, but can't afford it, the situation can be dealt with one of two ways; one can either be given the money, or one can undertake to change one's relationship with material possessions. The former is more likely to work because it's easier. Its simply something about our psyches that we believe in the power of material changes more than we do in the plasticity of the brain. Arachnophobes will commonly think removal of all spiders is more likely to make them feel better that CBT. But they're wrong. The material change is only likely to shift the anxiety elsewhere whereas CBT for phobias can be very effective. People are frequently incorrect about the likelihood of an approach working and this can lead to failures in those approaches which require long term commitment.

2) I don't think the social peer effects can be ruled out. The placebo effect of having a cure for which everyone congratulates you ("how brave!") rather than berates you (the stigma of mental health treatment remains undented) is enormous when considering that the end points are all expressed in mental terms (how 'satisfied' you are, how many 'regrets'...as if such end points were not themselves social!)

3) I know I've mentioned it before and you've diligently (and probably, sensibly) avoided it but I can't ignore the fact that the sex change option is supported by one of the largest industries in the world with the largest lobbying power by far. We can't pretend that isn't going to have an impact anywhere in this. Therapy is cheap and creates only employment. Drugs are expensive and generate huge profits for very powerful industries with a proven history of pushing profitable solutions over efficacious ones.

I think we have made some progress though, — fdrake

Agreed. It's good to talk without the usual knee-jerk tribalism these topics so often descend into. As I've said, I've had colleagues affected by this. There are establishments, academic and otherwise, where this very conversation would at least be flagged, if not muffled entirely.

Do we also agree the theory "social constructions alone determine gender incongruity" isn't established, and is likely to be too reductive — fdrake

Forgot to answer this. Yes. I think that social constructions are 'selected' to make sense of biological interocepted data. That biological data is likely to be non-homogenised, and so groups of people will likely reach for the same narrative for similar reasons. Given the disconnect though, I think it unlikely there'd ever be a one-to-one correspondence, just a loose, fuzzy correlation.

To me this is a binary concept - someone has trans identity or they don't. People are cis or trans. — fdrake

I think people want to be special in whatever way is available to them, or they don't.
Some people primarily want to avoid trouble, and some don't.
I think this whole gender/sex issue is just one of the expressions of this.

Life is hard enough as it is, why make it more difficult for oneself?

based on their other activities (for example their attempt to de-legitimize LGB charities) — Isaac

Is this the LGB Alliance you're talking about? Any other examples?

I believe I've read it. This one? — Isaac

Yes.

For me, both therapy approaches seem wrong because we shouldn't be tinkering with bodies or brains as if they were custom cars which can have parts swapped our with little effect on the whole. Not without very strong cause. We simply don't know enough to do that. — Isaac

I need to ask why though. I can see the premise:

( 1 ) We don't know enough about the risks involved.

And the conclusion:

( 2 ) We ought not modify bodies.

But it's not a very strong argument by itself. Too many qualifying phrases, and the overall pattern of inference isn't justified either. So you'd need to demonstrate why ( 1 ) implies ( 2 ) and flesh out these qualifying words:

For me, both therapy approaches seem wrong because we shouldn't be tinkering with bodies or brains as if they were custom cars which can have parts swapped our with little effect on the whole. Not without very strong cause. We simplydon't know enough to do that. — Isaac

Underlined and bold are underlined modifiers to currently unarticulated premises, which are bolded. There's also the issue of going from a factual statement:
"..seem wrong.."
implied by "..because we shouldn't.."+(analogy)+(causal statement)+(qualifier to causal statement) ).

If you can't see what bits are which in the above quote to my paraphrase of the argument, I can throw more words at it. We may need to have a similar discussion about how you were using natural and constructed in relation to when we ought to apply treatment earlier.

I do find what you're saying plausible though, I figured it was time I started asking you hard questions as well.

2) I don't think the social peer effects can be ruled out. The placebo effect of having a cure for which everyone congratulates you ("how brave!") rather than berates you (the stigma of mental health treatment remains undented) is enormous when considering that the end points are all expressed in mental terms (how 'satisfied' you are, how many 'regrets'...as if such end points were not themselves social!) — Isaac

I agree peer effects can't be ruled out, but I don't think it's been demonstrated that the intervention is a placebo, or whether that matters for administering treatment. Answering the above exercise would help with that, I think.

3) I know I've mentioned it before and you've diligently (and probably, sensibly) avoided it but I can't ignore the fact that the sex change option is supported by one of the largest industries in the world with the largest lobbying power by far. We can't pretend that isn't going to have an impact anywhere in this. Therapy is cheap and creates only employment. Drugs are expensive and generate huge profits for very powerful industries with a proven history of pushing profitable solutions over efficacious ones. — Isaac

Yes. It is a reason to be suspicious, but it's of weak relationship to any norms of administrative treatment in this context. It would need to be more concrete and evinced. Without those things and exhaustive contextual efforts, I doubt this train of argument would be a decisive factor either way given the uncertainties we've agreed surround other issues and this issue's relationship to the broader picture. I believe we can't practically tell if such weak evidence (in that Bayesian sense) would be decisive in this state of evidence, therefore it would not be decisive in our discussion. That is why I've ignored the point.

Agreed. It's good to talk without the usual knee-jerk tribalism these topics so often descend into. As I've said, I've had colleagues affected by this. There are establishments, academic and otherwise, where this very conversation would at least be flagged, if not muffled entirely. — Isaac

Yes. I believe there aren't many spaces in which this discussion could be had. I am grateful for it.

Is this the LGB Alliance you're talking about? Any other examples? — fdrake

Examples of court cases? No, I think that's the one all this has pretty much coalesced into. but I'm talking about the wider debate, the attempt to demonise people like Kathleen Stock, the harassment of feminist journalists like Julie Bindell, Suzanne Moore, Hadley Freeman... But also the giving of medical advice to children contrary to NHS guidelines. It's not a good look.

I figured it was time I started asking you hard questions as well. — fdrake

OK. I'll have a go.

For me, both therapy approaches seem wrong because we shouldn't be tinkering with bodies or brains as if they were custom cars which can have parts swapped our with little effect on the whole. Not without very strong cause. We simply don't know enough to do that.[hopefully replaced the bolding correctly, it doesn't transfer in quotes] — Isaac

I'll start by saying that this is really intended to be an argument about sensible priors in the absence of good evidence. so there's obviously two parts to question 1) is there really an absence of good evidence, and 2) given (1), have I made a case for avoiding medication being a sensible prior.

To tackle (1). I've not yet heard any update to Dr Cass's meta study for the NHS. It may be that I'm out of the loop, but at this stage, the best data I have on evidence is that it is "weak". That goes for 'puberty blockers', gender re-assignment surgery, and gonadotropin therapies. So I consider (1) to be a given, but I may be persuaded otherwise in the light of new evidence.

So to (2), a much harder case to make. Is leaving things alone the best policy if you've only weak evidence an intervention will help? I have to admit that this comes from a gut feeling. I'm going to justify it, but I'm going to be open about the fact that the justification is post hoc. I wouldn't have to give it a moment's thought to feel it's wrong to give medication to someone because it might help them. I suppose an obvious life-or-death situation would change my mind, but it would have to be clear, not just more guesswork on weak evidence.

So, to actually attempt a post hoc justification. I think the first argument is one of a sensible baseline for therapy (of any sort). If we don't accept a 'state of nature' as a baseline, then we have no grounds to distinguish pathology from merely bad design. Is my appendix a pathology? Should women's cervical openings be a little wider for easier childbirth? Do I have the optimum number of fingers? It's essential in medicine to be able to identify a pathology. That's done by assuming that whatever flaws it may have, there exists an archetype which acts as a default model of physiological function, and that archetype is based, not on a sci-fi 'blue-sky-thinking' ideal. It's based on a 'state of nature'.

The second argument is one of responsibility (not going to invoke the bloody trolley scenario but...). We are generally held to be more responsible for that which we actively do than for that which we reasonably fail to prevent. I'm responsible if I detonate the bomb, but I'm not responsible for not interfering with its detonation (unless doing so would be really easy - hence 'reasonable'). As such, doctors and other clinicians ought pay closer attention to the potential side effects of the drugs they administer than to the potential outcomes of a failure to administer. Side effects are weighted more heavily. In the case of weak evidence for both, weak evidence of side effects trumps weak evidence for negative outcomes from a failure to intervene.

So. Having done that (?). Can I return the challenge?

You say...

it's of weak relationship to any norms of administrative treatment in this context. It would need to be more concrete and evinced. — fdrake

I've taken a similar approach with the highlighting of qualifiers. What measures the strength of such a relationship and in saying it needs to be 'more' concrete, you're implying some target level of concreteness that's not yet been reached? What is this target level? The pharmaceutical companies have been legally (in some cases criminally) convicted of fraud. I'm struggling to see what greater level of evidence would be required that they engage in fraud. I can see a point about not assuming every drug is promoted fraudulently, simply because some are, but I can't see how one would support a proposition that multiple convictions for fraudulent activity do not weigh at all into an argument about whether some current activity might not be entirely on the level.

Of course, I wouldn't advocate a position that no medication can now be trusted, that would be absurd, but I do think it has to constantly weigh in the balance now. We're just unfortunately in an economic system where that's a constant factor. If one is weighing risks, one has to include in that calculation the risk of fraud.

I've taken a similar approach with the highlighting of qualifiers. What measures the strength of such a relationship and in saying it needs to be 'more' concrete, you're implying some target level of concreteness that's not yet been reached? What is this target level? The pharmaceutical companies have been legally (in some cases criminally) convicted of fraud. I'm struggling to see what greater level of evidence would be required that they engage in fraud. I can see a point about not assuming every drug is promoted fraudulently, simply because some are, but I can't see how one would support a proposition that multiple convictions for fraudulent activity do not weigh at all into an argument about whether some current activity might not be entirely on the level. — Isaac

I can be quite specific about what I'd need to be convinced that concerns about pharmaceutical companies' influence were relevant.

hat measures the strength of such a relationship and in saying it needs to be 'more' concrete, you're implying some target level of concreteness that's not yet been reached?

Yes. It's clearly true that there are vested interests in prescribing drugs to make profit, even when they're not needed. It's not clear how this interfaces with trans treatment. As far as I know, even non-surgical interventions are relatively difficult to obtain - if they were handed out like candy there would be much fewer complaints about the process being obstructive. I believe that's also evinced by the NHS report. Though there's no guarantee that every healthcare system has similarly strict/harsh/draconian/badly administered barriers. I think that's a mark against the factual claim that there's been an effective pressure by drug companies to popularise transition treatment and hormone therapies - they're still seen as insufficiently available or badly administered by trans rights groups.

I suppose there is an angle there where pharmaceutical companies are making policy decisions for trans rights groups, or some entryist angle, but I wouldn't believe that without hard evidence in context.

Hard evidence in context is what I meant by concreteness. Give me documentation about exactly how one pharmaceutical company has influenced one major service provider and I'll be more convinced this line is relevant.

but I can't see how one would support a proposition that multiple convictions for fraudulent activity do not weigh at all into an argument about whether some current activity might not be entirely on the level. — Isaac

I do think they weigh in, just weakly. They weigh on one issue in our discussion specifically - healthcare provision. If you focus on that, there's no evidence been provided about how these fraudulent patterns have effected gender affirmative treatment. Then there's also no evidence, so far, that whatever effect is postulated has sufficient impact on the issue as a whole to support any particular point in it. So it's relevant, and if pharmaceutical companies lobbying (or other corruption) were demonstrated to be a major driver on the adoption of trans healthcare measures, that those adoptions were nevertheless wrong also hasn't been demonstrated.

Those two sources of uncertainty make me not want to discuss it further, as I believe it would derail our discussion. Though if you wrote an essaypost with evidence and extremely detailed links to at least one issue in gender affirmative treatment, I'd be more inclined to go down that route. Ball's in your court.

Though do take note if you decide to write it of how many connections you need to document to the issues we're discussing. Closing that gap would take us far afield.

Will respond to your other points later.

But also the giving of medical advice to children contrary to NHS guidelines. It's not a good look. — Isaac

I can agree it's not a good look, I'm left with a similar feeling that the significance of it not being a good look hasn't been articulated. I'm left with a sense that you believe these misadministration are a direct result of how trans rights organisations comport themselves? If so, why do you think that's the case? I'm imagining the premise that there's something sinister about the comportment of trans rights orgs is required to get your objection going, enough to treat that conduct as direct cause for inappropriate medical guidance being given to trans people.

I don't necessarily agree with the suppositions required to get this line of inquiry going, nevertheless I am interested in how you're tying it all together.

The rest of that paragraph I think requires a different tack.

Examples of court cases? No, I think that's the one all this has pretty much coalesced into. but I'm talking about the wider debate, the attempt to demonise people like Kathleen Stock, the harassment of feminist journalists like Julie Bindell, Suzanne Moore, Hadley Freeman... But also the giving of medical advice to children contrary to NHS guidelines. It's not a good look. — Isaac

I believe you are construing that how these people were treated was at best unreasonable and at worst wrong. I think there's a convincing case that the conduct is reasonable, despite the harms. But I would also need to know why you believe this state of affairs isn't a good look to engage properly with your
opinions.

To tackle (1). I've not yet heard any update to Dr Cass's meta study for the NHS. It may be that I'm out of the loop, but at this stage, the best data I have on evidence is that it is "weak". That goes for 'puberty blockers', gender re-assignment surgery, and gonadotropin therapies. So I consider (1) to be a given, but I may be persuaded otherwise in the light of new evidence. — Isaac

Is this being evaluated in terms of long term alleviation of mental health symptoms associated with gender incongruence? Would appreciate the paper link. Regardless, there is always going to be an issue painting with too broad a brush - many therapies don't have well demonstrated long term health outcomes, especially for mental health issues, nevertheless they are administered and justified in terms of their risk/reward ratio. I believe a consistent case could be made for cancelling/deprioritising resource allocation to these treatments, but to me it seems suspicious why a broad point like insufficient evidence of improving long term health outcomes is being leveraged in the context of trans healthcare rather than for the broad swathe of treatment it would apply to. Why appeal in this context and not others?

In that regard there's also a concreteness problem, documented evidence or a strong argument that such a broad thing ought apply more in this case than others, and why. I think we'd need an argument that also takes into account the very low regret rate of transition surgery - which is much less than other highly promoted, even deemed necessary, surgeries which manifestly alleviate some source of harm (lined earlier, can relink if required).

I think you're presenting evidence very strongly here, which I appreciate. What I'm not following well is the philosophical side of your position. How you're linking your points, how the concepts you're employing relate to evidence, justifying how you infer one thing from another.

So to (2), a much harder case to make. Is leaving things alone the best policy if you've only weak evidence an intervention will help? I have to admit that this comes from a gut feeling. I'm going to justify it, but I'm going to be open about the fact that the justification is post hoc. I wouldn't have to give it a moment's thought to feel it's wrong to give medication to someone because it might help them. I suppose an obvious life-or-death situation would change my mind, but it would have to be clear, not just more guesswork on weak evidence. — Isaac

I agree there, it's hard to argue for that, nevertheless it's a commonplace occurrence for healthcare providers to make that gamble. Medication for mental illness is a particularly strong example, but the same also goes for other health conditions. EG: I've had a rash on my body since just after covid, it's spread to lots of places. I've never been sent to a dermatologist, nevertheless I've been prescribed treatment courses for allergies, eczema, and fungal infections with no tests to see what is what. I am not trying to claim this is right (I would prefer the test), I'm trying to say it's commonplace. In that regard, it seems this is another place where the means of your criticism applies generically to healthcare services, rather than to gender affirmation specifically.

Of course, I wouldn't advocate a position that no medication can now be trusted, that would be absurd, but I do think it has to constantly weigh in the balance now. We're just unfortunately in an economic system where that's a constant factor. If one is weighing risks, one has to include in that calculation the risk of fraud. — Isaac

Like here, you seem aware that the points you're making apply in lots of cases, to the extent where you noted that the point is general enough to apply to all treatments, nevertheless there isn't much of an argument taking this intuition and contextualising why it is sufficiently prescient to gender affirmation treatments to "flip" some issue one way vs the other. Also about what "the issue" is.

IMO, this isn't necessarily a problem, it's just that concrete instances and arguments are required to render these perspectives relevant to the case (evidentially), on precisely what the case is (conceptually), and what we ought to do about it (normatively).

I also thank you for the post-hoc admission, I've noticed the same in myself. I have a lot of beliefs I've
picked up from the media I read/watch in this area, and I appreciate the opportunity to examine them.

So, to actually attempt a post hoc justification. I think the first argument is one of a sensible baseline for therapy (of any sort). If we don't accept a 'state of nature' as a baseline, then we have no grounds to distinguish pathology from merely bad design. Is my appendix a pathology? Should women's cervical openings be a little wider for easier childbirth? Do I have the optimum number of fingers? It's essential in medicine to be able to identify a pathology. That's done by assuming that whatever flaws it may have, there exists an archetype which acts as a default model of physiological function, and that archetype is based, not on a sci-fi 'blue-sky-thinking' ideal. It's based on a 'state of nature'.[/quote

I think this is a decent start. Though I don't think it plays well with the simultaneous intuition that gender is socially constructed. A "state of nature" in context, seems to me, would consist of the current state of play of gender norms and an individual's place within them. The archetypes there would be the gender roles of men and women, which are the default mode. The default mode of functioning would be expected conduct and appearance of men and women.

I don't find what I just wrote particularly persuasive, what I want it to do is draw out how badly those two concepts play with each other.
— Isaac

The second argument is one of responsibility (not going to invoke the bloody trolley scenario but...). We are generally held to be more responsible for that which we actively do than for that which we reasonably fail to prevent. I'm responsible if I detonate the bomb, but I'm not responsible for not interfering with its detonation (unless doing so would be really easy - hence 'reasonable'). As such, doctors and other clinicians ought pay closer attention to the potential side effects of the drugs they administer than to the potential outcomes of a failure to administer. Side effects are weighted more heavily. In the case of weak evidence for both, weak evidence of side effects trumps weak evidence for negative outcomes from a failure to intervene. — Isaac

I think that's one system of norms which applies to the issue, which could be persuasive. The other regards informed consent, the ongoing horribleness of inhabiting what you feel is the wrong gendered body for you, and how intervention does indeed remove a constant source of social trauma for those who'd opt for it.

I believe this should be evaluated in the context of prescription without testing in general. What do you think distinguishes the seemingly benign example of administering anti-fungals for a non-fungal rash with no test from the less benign example of administering gender affirmative interventions after other mental health screening has been done?

Trying to render your perspective in an argument:

( 1 ) We are judged more harshly for that which we do than that which we don't.
( 2 ) Mitigating circumstances for doing something change the harshness of judgement about it.
( 3 ) Mitigating circumstances for not doing something change the harshness of judgement about it.
( 4 ) There are mitigating circumstances for not medically intervening in trans people's lives (in unspecified circumstances X for unspecified reasons Y) when it would really do more harm than good.
( 5 ) There are no mitigating circumstances for medically intervening in trans people's lives (with the same qualifier) when it would really do more harm than good.
( 6 ) Therefore we would be judged more harshly for medically intervening in trans peoples' lives (in unspecified circumstances X for unspecified reasons Y).

Mine is something like:

( 1 ) If a person desires treatment X, and we would not be judged harshly for administering it, then X can be administered without harsh judgment.
( 2 ) If administering X to a person is desired by the person and seen as sufficiently justified by a qualified set of clinicians, then administering X to the person would not be judged harshly.
( 3 ) X is judged by the person and some qualified clinician to be sufficiently justified in that case.
( 4 ) The person desires X.
( 5 ) We would not be judged harshly for administering X to the person.

I think both arguments are valid, we're largely talking about the concept "and we would not be judged harshly for administering it". I treat ( 2 ) as sufficient to establish the treatment wouldn't come with harsh judgement, I think you're arguing that there isn't a way for (some class of treatments) to be sufficiently justified by a qualified set of clinicians in this instance?

Also, this is just a literature request: I am interested in "potential side effects of failing to administer" too, do you have any literature on this? As for potential side effects of administering - my intuition is that judging negative effects of therapy would be similar to judging negative effects of voice coaching, counselling etc as part of gender affirmation. Surgery and hormone therapy maybe come with different risk assessments (I think this is reflected in the NHS's current treatment pathways).

As far as I know, even non-surgical interventions are relatively difficult to obtain - if they were handed out like candy there would be much fewer complaints about the process being obstructive. I believe that's also evinced by the NHS report. — fdrake

That's true, to a point. But as I said. The Mermaids campaign slogan is not "things are fine just as they are, but let's not let them get worse". If there are currently sufficient barriers to treatment (and if treatment is something which oughtn't be 'handed out like candy') then things are fine as they are, the campaign objective of Mermaids are wrong.

Though there's no guarantee that every healthcare system has similarly strict/harsh/draconian/badly administered barriers. I think that's a mark against the factual claim that there's been an effective pressure by drug companies to popularise transition treatment and hormone therapies - they're still seen as insufficiently available or badly administered by trans rights groups. — fdrake

I agree we'd have to conclude that any pressure has not been effective. I don't think it necessarily leads to a conclusion that it isn't present, nor that it isn't a danger which needs to be weighed. If I know Bob is generally a liar, I take whatever he says with a pinch of salt, I verify his claims with others before believing them. That done, I might make good decisions based on my advisors. It would be a mistake then to look at my quality decision-making ans say "looks like Bob wasn't so bad after all". Clinical guidelines needs to be aware of social pressures, lobbying pressures and the weakness of evidential bases. That they already are is not an indication that those pressures do not need attending to. Again, the Mermaids campaign slogan is not "things are fine just as they are, but let's not let them get worse".

I suppose there is an angle there where pharmaceutical companies are making policy decisions for trans rights groups, or some entryist angle, but I wouldn't believe that without hard evidence in context.

Hard evidence in context is what I meant by concreteness. Give me documentation about exactly how one pharmaceutical company has influenced one major service provider and I'll be more convinced this line is relevant. — fdrake

I'm not sure exactly what level of evidence you'd want. A repeating theme throughout my opinion here is going to be - why would I give them the benefit of the doubt here? I don't owe these corporations anything and they've done nothing to earn any trust. If a convicted murderer is found with a gun in the car, it's of more significance than if I were found with a gun in my car (I hunt).

I'm wary of going down another rabbit hole. I've been bitten once. There is a chain of funding connections between billionaire with heavy investments in pharmaceuticals and funding for trans rights groups (including a lot of University-based centres, particularly in the US), but there's no smoking gun, there's no document which says Joe Bloggs funded 'Drugs for Trans' and now he's a Lupron-billionaire. I don't see why there would be. Our economy is literally designed to protect people who want to influence events in favour of their investments. If you don't believe that, then I don't see any way we can proceed.

So yes, there is a string of evidence (I'm not the sort of person to simply arrive at conclusions without such), but no, none of it is concrete in the sense you're' looking for, so I'm reluctant to spend the time it would take to accumulate it all into a long post if it's not going to progress the discussion in any interesting direction. I don't think it should be needed for the points I'm making...

Here's a good article on the reach of the pharmaceuticals https://www.bmj.com/content/330/7496/855 in the BMJ. If you're of the view that corporations with this amount of reach, who could earn around up to £1million in profit from each transitioning young person, are nonetheless simply restraining themselves on this occasion out of good will, then again, I think we've hit a dead end. Our understandings of how the modern economy works are just too incompatible.

If powerful corporation have a) the power, and b) the incentive to bring about situation X, then situation X comes about. I'm going to suspect those corporations of having had a hand in it. To not would imply they have both will and means, but nonetheless restrained themselves, but then just got lucky anyway. I find that unnecessarily implausible. As I said, I don't owe these companies anything, I've no reason to withhold judgement until I have court-worthy documentary proof.

And I think people generally hold this view too, just not with pharmaceuticals (for reasons outside of the scope of this thread). How much evidence have we all demanded to consider the Shell-funded reports on climate change suspicious? How much documentary proof did we all require to mentally convict Trump of the various wrong-doings for which he's still not been criminally convicted? What paper-trail do we all demand to suspect Russia of a second, third, fourth war crime given it's first? The merest hint of a scandal is enough to render any politician's speeches nothing but empty rhetoric.

For some reason articles like that in the BMJ, a string of criminal and civil convictions for fraud, the partial responsibility for over 100,000 deaths in the ongoing opioid crisis... never seem enough to raise suspicions about pharmaceutical promotions above tin-foil hat wearing conspiracy.

But it may be a clash of incompatible world-views. Happy to drop it if so, I've been there before to no gain.

I'm left with a sense that you believe these misadministration are a direct result of how trans rights organisations comport themselves? If so, why do you think that's the case? — fdrake

It's generally been the report of the clinicians involved There was a swathe of resignations form Tavistock before it was closed and most cited an environment where speaking out was considered 'transphobic' in some way. With Stock, Moore, Birchill etc, that's exactly the environment these campaign groups are creating. The same is true in academia, I hear the same from colleagues. Now, either it's coincidence that this environment spread to clinicians (where it is more dangerous than just unpleasant), or it's a result of the campaign to create such an environment.

I would also need to know why you believe this state of affairs isn't a good look to engage properly with your opinions. — fdrake

I think that's answered best by something I've already said. I don't believe there's a 'right' way for people to interpret their biology. I don't think the chemical and electrical signals in our brain actually mean anything absent of a narrative of which there is no one right fit. That makes it important for there to be a community with enough freely available narratives for people to be able to find ones which make sense of their particular experiences. The harder, more complex a society is, the more narratives it's going to need. Also (highly speculative), the further we get from a 'natural' lifestyle, I suspect the more 'out of sync' some of our brain activities will get and the more complex narratives will be required to make sense of them. A society which seeks to close down options as 'unacceptable' is in danger of causing harm. That goes for people like Fred Martinez not finding a narrative he could use in the modern culture he found himself in, but it goes equally for the young lesbian who doesn't want to be told that her feelings of sexual attraction to same sex phenotypes is 'abusive' because she 'ought' to be attracted to anyone calling themselves a woman.

If we can't make a society in which a few incompatible narratives can be allowed to exist alongside one another without resorting to court or institutional bullying then we've lost hope.

Is this being evaluated in terms of long term alleviation of mental health symptoms associated with gender incongruence? Would appreciate the paper link. — fdrake

Dr Cass's Interim Report https://cass.independent-review.uk/wp-content/uploads/2022/03/Cass-Review-Interim-Report-Final-Web-Accessible.pdf

The CQC report on Tavistock https://api.cqc.org.uk/public/v1/reports/7ecf93b7-2b14-45ea-a317-53b6f4804c24?20210120085141

The gonaotrophin evidence report https://www.evidence.nhs.uk/document?id=2334888&returnUrl=search%3Ffrom%3D2020-01-01%26q%3Dgender%2Bdysphoria%26sp%3Don%26to%3D2021-03-31

I believe a consistent case could be made for cancelling/deprioritising resource allocation to these treatments, but to me it seems suspicious why a broad point like insufficient evidence of improving long term health outcomes is being leveraged in the context of trans healthcare rather than for the broad swathe of treatment it would apply to. Why appeal in this context and not others? — fdrake

I don't think it should be limited to this case at all. I'm in favour of a broad reach here, but the reasons for focussing on trans issues are, as Dr Cass highlights, that the numbers are increasing exponentially. There's no precedent for that. We have therapies which are ineffective (or weakly evidenced) for all sorts of mental health problems, and many are growing, but linearly. The numbers of children seeking treatment for gender-related issues has increased beyond anything we've ever seen outside of epidemics. The need for proper protocols for treatment is therefore very urgent and the need to stem any wrong-turns is heightened.

I think we'd need an argument that also takes into account the very low regret rate of transition surgery - which is much less than other highly promoted, even deemed necessary, surgeries which manifestly alleviate some source of harm (lined earlier, can relink if required). — fdrake

The argument (for me) is the one I gave above. If we have a material solution vs a mental solution, the material solution will be favoured (regardless of long term outcomes). It's easier and we have a psychological bias in favour of believing external causes more than we believe internal ones. Also, the end points are insufficiently robust at measuring personal gains, they still ask about 'satisfaction' or 'regret' which are both socially mediated. Clinical interventions ought not be measured on the basis of the degree to which society finds the end goals attractive.

it seems this is another place where the means of your criticism applies generically to healthcare services, rather than to gender affirmation specifically. — fdrake

Again, I refer back the the alarming rate of increase in children seeking treatment for gender-realted issues. It is unlike any health issue outside of epidemics, that we've ever experienced.

What do you think distinguishes the seemingly benign example of administering anti-fungals for a non-fungal rash with no test from the less benign example of administering gender affirmative interventions after other mental health screening has been done? — fdrake

In essence, nothing. I disagree that the prescription of anti-fungals for a non-fungal rash is benign. We're facing, in the next few years, an anti-biotic resistant c.diff and s.aureus problem in hospitals which is rapidly overtaking all other causes of hospital-related death. That crisis was brought about by northing else but the over-prescription of anti-biotics. Medical interventions are not isolated. Our biochemistry is not like the custom car whose parts can be swapped out. We ourselves are a very finely tuned ecosystem of chemicals and biota, and socially we form an even greater such system.

That said, I'd refer to what I've said before about the rates. There's not been a recent 100-fold increase in the numbers of children seeking rash treatments, so the not-so-benign prescription of dubious anti-fungals is not so pressing an issue.

Also, this is just a literature request: I am interested in "potential side effects of failing to administer" too, do you have any literature on this? — fdrake

Nothing springs to mind, but It's my wife who is most active in this field, I get most of this from her. I'll ask.

@unenlightened

Yes. I'm saying that Any combination of male/female/no-sex brain and body, along with any combination of hormone regime that naturally occurs is bound, short of physical pain resulting, to be accepted as 'just the way I am' unless there is an induced conflict between that and 'the way I ought to be'.

In short the only possible source of conflicted identity is social. I mean who d'you even think you are, fdrake? That's just a duck! :razz: — unenlightened

Shitposting:

One of my high school friends used to troll internet forums and voice hang outs as "The French Pirate". They invited me, it sounded fun. It was fun. I wanted to be "The French Privateer", so Francis Drake. There was also a character called "X-Drake" in a manga I was reading at the time. Hence the name.

And it just kinda stuck. I'm quite grateful I didn't choose the name "schlongpusher69". I imagine that would've stuck too.

Substantive:

Angle 1

You've raised some good points about social conflicts being internalised as identities, especially about shame. I'll raise you the same challenge I did with Isaac, how does that cash out in this context?

A1 ) Surgical transition is permissible in some contexts, y/n?
A2 ) Hormone treatment is permissible in some contexts, y/n?
A3 ) Gender affirmation schooling (voice therapy) is permissible in some contexts, y/n?
A4 ) Therapy for gender dysphoria is permissible in some contexts, y/n?
A5 ) Counselling for trauma which has caused all this shame is permissible in some contexts, y/n?

In addition to the answers, I would like a description of why that seems right to you.

Angle 2

If I've read you correctly, I believe the what marked (whatever identities are in play) here as artificial for you was that they seemed to come bundled with shame, rooted in social conflict. This was contrasted to someone's "character", which describes who they are without the social baptisms of shame, trauma and other "holes". I have some questions about that:

B1 ) If identities are socially constructed, what stops shame from being an essential part of one?
B2 ) What general consequences does this "artificiality" of shame have for people who have it?
B3 ) Why can't people's characters be inherently shameful? We can be quiet or good at mathematics, but not shameful, why?
B4 ) Why is it appropriate to treat "character" as a state of nature, prior to social identity, whenever we observe someone their character's expression becomes identified? As much as socialisation builds character, it builds identity - that these two develop in tandem undermines treating one as a state of nature and the other as social artifice.

@Isaac

But it may be a clash of incompatible world-views. Happy to drop it if so, I've been there before to no gain. — Isaac

Yeah there's no point us pursuing the pharmaceutical industry's corruption in this context. It's a reason to be suspicious of all drugs which are prescribed without assessment. Among other reasons. Smoking gun absent, I don't see much point. This is just a context thing, would be happy to pursue it in other contexts - like you invoking it for the Pfizer/AstraZeneca vaccine trials seemed very justified to me. The difference here is just the degree to which the specifics are left to speculation.

That's true, to a point. But as I said. The Mermaids campaign slogan is not "things are fine just as they are, but let's not let them get worse". If there are currently sufficient barriers to treatment (and if treatment is something which oughtn't be 'handed out like candy') then things are fine as they are, the campaign objective of Mermaids are wrong. — Isaac

What do you take as the campaign objectives of Mermaids? I don't have a good sense of a unified ideology for them, over and above making things easier for trans people.

The argument (for me) is the one I gave above. If we have a material solution vs a mental solution, the material solution will be favoured (regardless of long term outcomes). It's easier and we have a psychological bias in favour of believing external causes more than we believe internal ones. Also, the end points are insufficiently robust at measuring personal gains, they still ask about 'satisfaction' or 'regret' which are both socially mediated. Clinical interventions ought not be measured on the basis of the degree to which society finds the end goals attractive. — Isaac

Solution is a bit of an overstatement, one of the premises of this discussion was that long term therapy is ineffective in preventing relapses - so we're not contrasting long term solutions to an issue, we're contrasting based on limited evidence in order to minimise present and ongoing suffering. This will be heuristic, ideologically motivated, institutionally suspect, involve various lobbying groups. Such as the decision made this week from the English government blocking Scotland's passed reforms on gender recognition - this wasn't done using longitudinal studies either.

I get the impression that, because your position applies to lots of medical interventions, the best consistent response for you is to bite the bullet that recognises the inconsistent and flawed treatment in society, mandate "it ought to be the case that more medical interventions should be strongly based on data from controlled studies", and claim in absence of such data, no intervention should be taken. Whenever benefits+uncertainty = costs + uncertainty, do nothing.

That crisis was brought about by northing else but the over-prescription of anti-biotics. Medical interventions are not isolated. Our biochemistry is not like the custom car whose parts can be swapped out. We ourselves are a very finely tuned ecosystem of chemicals and biota, and socially we form an even greater such system. — Isaac

I think this would have more bite if it wasn't already granted that gender affirmation treatment is both a social and a bodily intervention.

If we can't make a society in which a few incompatible narratives can be allowed to exist alongside one another without resorting to court or institutional bullying then we've lost hope. — Isaac

I agree. What is especially frustrating is that Mermaids and trans rights groups are not problematising the discussion by themselves, the arguments you're giving really are used by people "out in the wild" as means of stymying the improvements of trans rights. In our context, we can discuss them with more leeway. Out in the wild, they're often treated as weapons, so it's no surprise that such moves are seen as attacks.

That makes it important for there to be a community with enough freely available narratives for people to be able to find ones which make sense of their particular experiences. — Isaac

This would be nice. As supporting argument for an argument I think it's not a good one, though. Firstly it's an "ought" statement, "it's important", secondly it's currently false for transgender issues. I believe you are suggesting that nonmedical interventions are more appropriate, because the reason medical interventions are being pursued for trans people is ultimately because society's fucking awful for minorities. This is also similar to @unenlightened's point I think, though from a different angle.

Like I asked @unenlightened, how do you think trans people ought to be treated?

the reasons for focussing on trans issues are, as Dr Cass highlights, that the numbers are increasing exponentially. There's no precedent for that. — Isaac

Is there any model aside from the social that can explain this increase?

A1 ) Surgical transition is permissible in some contexts, y/n?
A2 ) Hormone treatment is permissible in some contexts, y/n?
A3 ) Gender affirmation schooling (voice therapy) is permissible in some contexts, y/n?
A4 ) Therapy for gender dysphoria is permissible in some contexts, y/n?
A5 ) Counselling for trauma which has caused all this shame is permissible in some contexts, y/n? — fdrake

This all feels to me rather like the question of abortion. Given social pressures, economic and normative, on women who become pregnant, that we are not going to treat or try to change, should, abortion be legal? A reluctant yes, but removing the stigma and properly funding childcare and motherhood would be a better solution in almost every case.

To be honest, I don't have the expertise to answer, but it is clear to me that there is a need or desire to transition only to the extent that what one is, is, or is felt to be, "wrong". And that means it is a social artefact. And what is permissible is an artefact of the same society. So I suppose that what society says is wrong with an individual, it needs to facilitate them changing. But I don't have to like it.

B1 ) If identities are socially constructed, what stops shame from being an essential part of one?
B2 ) What general consequences does this "artificiality" of shame have for people who have it?
B3 ) Why can't people's characters be inherently shameful? We can be quiet or good at mathematics, but not shameful, why?
B4 ) Why is it appropriate to treat "character" as a state of nature, prior to social identity, whenever we observe someone their character's expression becomes identified? As much as socialisation builds character, it builds identity - that these two develop in tandem undermines treating one as a state of nature and the other as social artifice. — fdrake

B1. Shame is ubiquitous, but what stops it from being essential is that it can only arise from comparison.
B2. This is a huge question, that I could make a whole thread on. From shame one hides oneself and tries to be what one is not, leading to anxiety of being exposed as a fraud, and from being hidden comes the sense of isolation and loneliness. Think of anorexia for an example of how social pressure creates lethal misery through body-shaming.
B3. I don't understand the difference from B1.
B4. I distinguish character and identity by crude definition thus: character is what one is, and identity is the image one has of what one is. Both develop and change due to biology, socialisation, and other environmental influences. (No one becomes a pianist or comes to see themself as a pianist without a piano in the environment.) Does this make more clear how shame operates at the level of self-image, and not at the level of actual self? How it operates though is to divide the individual into inner and outer, and all the other conflicts within psyche. Hence, in this case 'I am outwardly male and inwardly female' or vice versa. So the division between state of nature and social artifice is indeed part of the same division in psyche, and of course the individual cannot actually be divided, so some aspect must dominate and some aspect must be suppressed. Or some aspect acted out, and some aspect hidden away. and because we feel this division, we look for and cherish the imagined unity of 'authenticity', the great prize of therapy.

Speaking of anorexia, another body dysphoria, would we advocate liposuction as a treatment?

To be honest, I don't have the expertise to answer — unenlightened

I also don't have the expertise to answer. Regardless, I have an opinion and feelings on the matter, and I want it all battle tested.

This all feels to me rather like the question of abortion. Given social pressures, economic and normative, on women who become pregnant, that we are not going to treat or try to change, should, abortion be legal? A reluctant yes, but removing the stigma and properly funding childcare and motherhood would be a better solution in almost every case.

To be honest, I don't have the expertise to answer, but it is clear to me that there is a need or desire to transition only to the extent that what one is, is, or is felt to be, "wrong". And that means it is a social artefact. And what is permissible is an artefact of the same society. So I suppose that what society says is wrong with an individual, it needs to facilitate them changing. But I don't have to like it. — unenlightened

That makes sense to me. I can sympathise with reluctant support somewhat. Do you think it's in no one's "character" to transition? Further, is gender part of someone's character (vs sex)? Like... is it in my character to have male gender identity?

B1. Shame is ubiquitous, but what stops it from being essential is that it can only arise from comparison. — unenlightened

I see! This is what I'm getting at. You seem to be construing character as a collection of unary properties of a person ("I am good at mathematics"), and identity as a collection of comparison relations which obtain of he people ("I need to be stronger" or "I need to present (more like X)"). Usually there's a good distinction to be had between those unary properties - like "is red"- vs relational properties - like "is redder than" - but I think that's quite hard to draw a firm line on here.

The reason being is that personal characteristics also seem socially constructed to a large degree, like you being good at mathematics. Does that mean you were demonstrated to be better than your peers through exams/implicit assessments of competence/demonstrations through completing exercises? I'm sure you see in each of those cases, there is a social relation underlying the ascription of the property "is good at mathematics" to yourself, even if the property itself is unary. The stated examples are also comparisons - "good at mathematics (relative to this exam performance record)", "good at mathematics (relative to aggregate peer approval)", "good at mathematics (as ensured by passing these exercises)". Why do you get to be "good at mathematics" in your character? I'm not doubting that you *are* good at it btw, I'm asking how you make sense of it given the above.

So the division between state of nature and social artifice is indeed part of the same division in psyche, and of course the individual cannot actually be divided, so some aspect must dominate and some aspect must be suppressed. Or some aspect acted out, and some aspect hidden away. and because we feel this division, we look for and cherish the imagined unity of 'authenticity', the great prize of therapy. — unenlightened

I'm still struggling to understand your view and how it relates to the topic. I think I'm getting there though. Are there norms in the "state of nature"? What's the state of nature made of? If humans are essentially undivided why do we see the proliferation of identities in contravention of that fact?

B2. This is a huge question, that I could make a whole thread on. From shame one hides oneself and tries to be what one is not, leading to anxiety of being exposed as a fraud, and from being hidden comes the sense of isolation and loneliness. Think of anorexia for an example of how social pressure creates lethal misery through body-shaming. — unenlightened

I can see the case for anorexia and shame. I think applying the same to trans people is... problematic... though. When you say "From shame one hides oneself and tries to be what one is not" - in the context of a trans person, are you saying that an M2F trans person "really is" a man but feels the need to become a woman?

That makes sense to me. I can sympathise with reluctant support somewhat. Do you think it's in no one's "character" to transition? Further, is gender part of someone's character (vs sex)? Like... is it in my character to have male gender identity? — fdrake

@unenlightened I'm not symphatising with reluctant support as your proposed "solutions" don't solve being unwanted pregnant for 9 months and then going through the hell that's labour. It's not about the unborn kids or fetuses, it's about the rights to your own body. And it's not as if abortion is anything new. It was entirely without moral consideration before the church but good to see Christian values are firmly rooted in your mind through cultural conductivity.