“Some ideas are so stupid that only intellectuals believe them.”

Orwell was right about that one, too ^

The thing is, it’s just not possible for anyone to have an informed opinion on everything. And that’s OK. One problem with gender is that so many people have read a listicle on Everyday Feminism and think they know what they’re talking about. Or they import their entire gay-rights software package and plug in trans rights as if there’s no difference between the two. Or they crowdsource their judgment (“read the room!”).

These kinds of shortcuts lead people to predictably wacky places.

But whatever shortcuts Scott Alexander of SlateStarCodex took somehow led him off in a very strange direction in his recent ‘take’ on puberty blockers:

I’m not a child/adolescent psychiatrist and I don’t prescribe hormones, so I’m not an expert in this topic and this should be considered my amateur opinion only (although my impression is that the APA, AMA, and various other guideline-setting organizations agree with me). But I think these are overall good, for a few reasons:

• The effects of birth-sex puberty are irreversible and will make it much harder to transition in the future. The effects of puberty-blockers are mostly reversible, and preserve the option to either transition or return to birth-sex in the future. Like all drugs there are potential side effects, some of which are irreversible, but in the case of puberty blockers these seem mild and comparable to other psychiatric interventions. I think the precautionary principle supports having confused children who don’t know what they want do the reversible rather than the irreversible thing.

• The biggest studies suggest that about 98% of children who take puberty blockers do later go on to transition (nothing in real life is 98%, so I assume something is wrong with this study, but things do seem to lean towards a vast majority continuing). An optimistic interpretation is that the screening process is very good and they’re only given to people who really want them; a pessimistic interpretation is that they push children further onto the transgender path. I don’t think whatever “pushing” doctors can do is enough to produce these kinds of numbers - compare the success rate of doctors/parents trying to push kids away from transgender! - so I lean towards the optimistic interpretation. That makes it even clearer that we should do the reversible thing (which helps 98% of people and reversibly harms 2% of people) and not the irreversible thing (which helps 2% of people and irreversibly harms 98% of people).

• As a pseudo-libertarian, in difficult decisions I prefer the option which preserves individual choice. It becomes more complicated when there are children involved. But it becomes less complicated again when the child spontaneously requests something, their parents agree, their doctors agree, and all medical guideline-making organizations agree. So now the calculus becomes “deny people the right to make decisions about their own bodies in a way which irreversibly harms 98% of them and helps 2%” vs. “allow people to make decisions about their own bodies in a way which helps 98% of them and reversibly harms 2%”.

• I do think it’s suspicious and bad that everyone is suddenly becoming transgender, and I support efforts to figure out why and stop it at the root, in some way which will prevent so many kids from wanting to be transgender. But it seems cruel to fail to figure that out, let lots of kids become horribly depressed about their gender, and deny them access to treatment. By all means, figure out that smoking causes cancer, but if you haven’t figured that out and cancer rates are still high, don’t restrict access to chemo. I realize these goals are sort of in competition, in the sense that allowing people to transition raises the visibility of transgender which might contribute to transgender being more common, but faced with the extremely-well-established finding that denying care directly hurts transgender people, vs. the very conjectural hope that maybe it would, in the distant future, decrease the rate of gender dysphoria, I once again go with clear evidence over vague conjecture, and letting people control their own bodies vs. not doing that.

If she means some childhood intervention stronger than this, I probably oppose it, although I’d have to look at each thing individually to be sure.

But none of this is especially relevant to the current debate, since my paragraph deliberately didn’t single out either side as worse than the other. It just said lots of people seemed too addicted to arguing about this.

Let’s say the skeptics are completely right. About 1500 kids get puberty blockers each year in the US, but probably some cases are unrecorded, and probably the numbers will increase over time, so let’s say 5,000 kids. We’ll assume it’s inappropriate for half of these kids, and they end up sterile and mentally ill without having been helped in any way.

This is going to sound insensitive, but as far as “bad US medical policies” go, 2,500 children having their lives low-key ruined is nothing. I can think of a dozen US medical policies that are much worse than that! I wrote here about how bad IRB policies probably kill about 50,000 people per year! The failure to allow human challenge trials for COVID vaccines probably killed about 10,000 people; the decision to delay the vaccine an extra few weeks to influence the 2020 election probably killed about 1,000. Inappropriate prescribing of antipsychotics causes 1800 deaths in the UK each year (the US number is probably closer to 10,000). Laws about organ donation incentives are “responsible for millions of needless deaths”. Even if you only care about children, there was the whole FDA fish oil story. Even if you only care about sterilization, Paul Ehrlich is still around! I’ve tried so hard to raise awareness of some of these issues, and although I’m deeply grateful for the five people who take them seriously, it’s a massively uphill battle.

But as soon as anyone brings up gender, the awareness raises itself. Millions of people who have never thought about IRBs spend a substantial portion of their lives having strong opinions on gender. At least one presidential candidate is centering his entire campaign around gender. Richard Hanania, whose many flaws have never included a lack of self-awareness, freely admits that I Hate Pronouns More Than Genocide. The rest of the world may hold that philosophy only implicitly, but they hold it nevertheless.

So yes, I think this is because arguing about gender is addictive. I say this as someone whose many flaws also do not include lack of self-awareness, and who’s spent years fighting the addiction and mostly winning.

Deep in the comments section, someone raises an uncomfortable question: “If the use of puberty blockers are more beneficial than harmful, why did Norway, Finland, Sweden, and the UK rethink their use?”

But—never fear—Alexander’s got this covered, too—not in the sense that’s actually looked into but in the sense that he’s decided in advance that it can’t possibly matter:

I haven't looked into this, but my prior is that it's because Europeans are hopeless communist nanny-staters who ban anything cool on general instinct. Cf. melatonin, GPT-4.

This is truly wild stuff.

Alexander thinks something “suspicious and bad” is afoot with “everyone […] suddenly becoming transgender” (indicating he believes that at least many of the people coming out as trans are not “innately” trans) and he supports “efforts to figure out why and stop it at the root” (so he recognizes that coming out as trans is not only not a positive thing, it’s not even neutral—he clearly thinks that it’s better that people don’t come to think of themselves as trans in the first place). But, given that we haven’t turned off the tap yet, it would be—*checks notes*—bad to not allow children who have come to identify as trans at a time where something “suspicious and bad” is influencing people to identify as trans to transition. Make it make sense.

The first problem is that Alexander has no idea what he’s talking about and is utterly contemptuous of what he doesn’t know. He has no idea about the literature on desistance. He takes claims of “reversibility” at face value. He’s astoundingly incurious about the potential unintended consequences of blocking a vital stage in human physical, sexual, social, cognitive, and emotional development.

Alexander lays out the optimistic and pessimistic explanations for the relationship between puberty blockers and persistence: maybe doctors are just amazing at assessing which patients will benefit and which won’t, but maybe the drugs prevent kids from outgrowing gender dysphoria and transgender identification. He even acknowledges that the 98% figure is impossible (“I assume something is wrong with the study”) but then proceeds merrily as though the doctors must be right and therefore 98% of children must be helped (so who cares about the 2%!).

Then he goes much, much further and suggests nobody should really care about any of this, because—even if the skeptics are right and half of kids who undergo this intervention “end up sterile and mentally ill without having been helped in any way”—“this is going to sound insensitive, but as far as ‘bad US medical policies’ go, 2,500 children having their lives low-key ruined is nothing.”

So everybody coming out as trans is bad and suspicious and maybe a lot of kids will have their lives “low-key ruined,” but what’s the big deal? Why do you care so much? Are you some kind of gender weirdo?

The real problem, if you ask Alexander, is that this debate seizes hold of people and turns their lives upside-down, that people who care too much about kids being left “sterile and mentally ill without being helped in any way” end up just as addled as the opioid addicts Alexander treats.

Better to be like Alexander: boldly and flippantly ignorant, utterly indifferent to the stakes.