Tuesday, May 17, 2016

How I wish my students would read science: a case study on Gender Ideology

I have wondered about the issue of Gender Dysphoria, and when several of my friends and acquaintances posted links to a position statement by the American College of Pediatricians, I was interested. Even as a public LGBTQ ally, I continue to be sceptical of positions that fail to recognize the predominant biological sex binary. I was encouraged as I began reading the ACP position that it distinguished between the clinical definitions of sex and gender, since we often don't understand this distinction because of less specific definitions of the words in common speech. Here I'm going to model stream of consciousness how I read a scientific argument like that made by the ACP, and the kind of thinking I try to model for my Biochemistry students as we work through scientific arguments. We usually don't pick such ideologically controversial topics, but there is still plenty of ambiguity in Biochemistry.

Initial Impressions

The American College of Pediatricians webpage looked like a valid organization of health care professionals. (I believe it is, even with what I later discovered about the group).

The first point highlighted the predominant sexual binary and its import for continuation of the species. Both facts that concord with my prejudices and understanding. While we don't need every individual to reproduce for survival, we need most individuals to reproduce. But the ACP paper failed to even acknowledge that sex is determined by many more genetic factors than those found on the X and Y chromosome, and they identified all variation from the binary as a disorder. This very black and white oversimplification made me uncomfortable.

At point 2 they recognize the sociological and psychological contributions to gender. Gender is significantly defined by culture and psychology (some have argued completely, but I suspect this doesn't reflect a typically more ambiguous reality). That gender is significantly culturally defined also agreed with my understanding and biases. But once again their statement is black and white, not recognizing any genetic or epigenetic component to gender identity. This increased my discomfort.

The first sentences on point 3 made me uncomfortable--implying a very strong separation between mind and body, psychological and physical problems, that I'm not sure is justified scientifically. In the remainder of the point they identify gender dysphoria as a recognized psychological problem by citing the DSM-V, a diagnostic manual which tends to contain the broad consensus standards by which American psychologists work. This inclined me to believe that gender dysphoria is a problem, and increased their credibility in my emotions.

With point 4 they state something that seems self-evident to me, and a reason I think puberty delaying drugs should be approached with _extreme_ caution. They said that puberty is not a disorder, and delaying it is a disorder. While I still was uncomfortable about the lack of nuance (delaying puberty is sometimes a smaller problem than the alternative), it further inclined me to believe them.

At point 5 I thought, if only 98% of gender dysphoric boys and 88% of gender dysphoric girls resolve their gender dysphoria after puberty, we really shouldn't give them puberty delaying drugs that come with real health risks (points 6-8). But the words "as many as" gave me pause once again. Why are they saying "as many as"? If there is a number, you should look into it. If there isn't a number, you should be dubious of the claims.

Then points 6-8 seemed to be continuing a rhetorical trend that made me uncomfortable. 6 implies that all children who delay puberty will choose to undergo sex changes. It took me a minute to think about it, but while delaying puberty is partly for the purpose of making later sex change less difficult, it is explicitly for the child to have more time to mature and make a very difficult, life-altering decision. Yes, the child is still too young to make a fully mature decision, but at least the child is an older teen rather than a young teen or preteen. And it isn't the puberty delaying drugs with the health risks, as at least one of my friends understood after reading the ACP statement. It's the cross-sex drugs. If this is a scientific statement, they should be justifying these claims with numbers, or make it clear that they are speculating and give justifications for their extrapolations. What is their evidence that children who delay puberty invariably choose sex-change and its associated risks instead of resolving their gender dysphoria and undergoing late, but otherwise normal, puberty? They don't provide links for this, so it looks a lot like a slippery slope argument, and further reason for concern.

Point 7 then compares suicide rates among cross-sex adults over an unspecified period of time with what will happen to children who undergo the same procedure much earlier and after delaying puberty. It is reason for concern, but it is apples and pears (related, but not the same). They do provide a reference to the peer reviewed article, which is good, but they don't even provide a link. And the journal it is published in is in the Public Library of Science. That means it is free online. Why, in such an important statement, would you not take the minute required to provide your readers with a link to the original research? This made me look at the other references more closely. While the references are sound, none of them provide clickable links, despite many of them being freely available online. This is disturbing in an organization that claims professionalism.

But I had only done some of this analysis by the first read through. I had noticed numerous red flags, but all the things that accorded with some of my prejudices, and the proper science-speak on other points, made me inclined to believe the the ACP conclusion in point 8 that using drugs to delay puberty is probably harmful. I wasn't comfortable with calling it abuse--especially since I was aware of a study that found that children who delayed puberty were just as happy in their 20s as their peers who did not, so I had memories that gave pause to claims of abuse. But I though, we probably shouldn't be delaying puberty for most cases of gender dysphoria if it only helps such a small percentage of the already small percentage of children with gender dysphoria.

Looking Further

I still had to relieve my concerns with the red flags. I made myself look further. The comments of another interested party on Facebook helped, but it turns out it isn't hard to discover something about the ACP by a simple Wikipedia search:


This group consists of 60-200 members--except that's an estimate because they don't publish how many members they have, just the credentials of a few. That's compared to the American Association of Pediatrics 64,000 members. So it comprises at most 0.1-0.3% of American pediatricians. So this statement is officially supported by only a very small percentage of pediatricians.

I read the follow up clarifications on points 3 and 5. Instead of 2 and 12% of male and female children that don't resolve gender dysphoria, it may be 30 and 50% that don't resolve after puberty. Most likely it's somewhere in between, maybe 1 in 6 males and 1 in 4 females. Where are the recommendations of the ACP for those children? Are those children simply broken and not valuable? The ACP position is clearly that they are broken.

I then went to the "about" page and read it. The ACP makes it clear that they are starting from an ideological position: "We expect societal forces to support the two-parent, father-mother family unit and provide for children role models of ethical character and responsible behavior."

Scientific Merit

At this point, I would hope it is clear to any of my students that the ACP position statement is of dubious scientific quality. Before concluding that my beliefs are scientifically justified, I should be going to other sources. The Wikipedia article suggested a likely one, so I looked it up. Here it is, Just the Facts about Sexual Orientation and Youth from the American Psychological Association. Just having skimmed a few parts, it's a much more useful read--broadly informative, more nuanced, and less dogmatic in its claims. Clearly more focused on caring for the child rather than asserting an absolute societal norm.

So while I don't think I disagree with any of the facts presented in the ACP position paper, and I agree with the recognition of gender dysphoria as a problem, I am back to believing that the best way to address the problem is to give parents and health care providers tools and choices. They are working directly with the children, so give them best tools available and the right to do their best to help their children as they see fit. Do you imagine the parents care more about a sexual agenda than about their own children? Maybe a few, but I doubt many. I'm sure they will sometimes make mistakes, and that cultural norms sometimes hurt children, but we've been ideologically hurting 2-30% and 12-50% of these children for generations without any possible help for them. I'm glad that doctors are trying to help this small population, and hopeful that over time they will figure out the best ways to do it based on empirical observation more than on ideology.

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