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I think that, speaking of that general research, that it's of such low quality that it isn't indicative of a probably false positive effect. And then, I think the disagreement about that is one point of disagreement. And then with respect to research specifically on suicide attempts, I think we just disagree on what the research tends to say in that regard of whether or not suicide attempts to the increase, stay the same, or decrease after transitioning into questions about how to interpret the pattern of who has the highest suicide attempt rate cross-sectionally. So I think that's the kind of stuff we're going to be talking about. That will be my opening statement. Thank you so very much Sean for your opening statement. And with that, April, the floor is yours for your up to ten minute opening statement. Sounds good. Hopefully I can give something that we can bite into you and have a bit of a disagreement on. I think that we should start with the question, which is, should we prescribe or encourage transitioning? And I think that the first thing to recognize with this kind of question is that there is no medical intervention that should be prescribed or encouraged universally. We recognize the benefit of heart bypass surgery, but that doesn't mean that everyone should get heart bypass surgery, or even that everyone with a narrowed coronary artery should get heart bypass surgery. I think that medical transition is like any other medical intervention. It is the responsibility of medical institutions to identify individuals who are likely to benefit from medical transition and to encourage those people to pursue it. So I think that the question that is central to our disagreement tonight is, do people benefit from medical transition? The American Medical Association states that mental health care, hormone therapy and sex reassignment surgery are medically necessary forms of therapeutic treatment for people diagnosed with gender identity disorder. So why do the most prestigious medical institutions in America seem to agree that medical transition can be beneficial? I think we have to dig into the data. There's a few different meta analyses, which are basically collections of all kinds of studies, where they look at various studies, how at risk they are for bias, what their sample size, what potential errors with methodology are. And they try to collect all of them together, synthesize them and come to a general conclusion. So there's one that's very recent. It's a 2021 meta analysis from the Journal of Endocrine Society. And it finds that hormone therapy was associated with increased quality of life, decreased depression and decreased anxiety, including no evidence of increased risk for these things across all studies. There's a 2008 meta analyses, which in one section finds that seven studies in reviews in endocrine and metabolic disorders found that there's no statistically significant difference in mental health related quality of life for transgender people following HRT compared to the general population. The same meta analysis found that the possibility that treatments associated with improvements in mental health being is supported by the findings from a small number of longitudinal studies. So in this debate, we're going to hear about Sean's belief that a lot of these studies are biased. One of the ways you can counteract that bias is by following up with people that's a longitudinal study, or basically continually check in with people. And those both found that HRT and SRS improve quality of life. So I think that one of Sean's big problems is that a lot of the studies that make up these meta analyses are surveys. So basically, you go out to people and you survey them, you ask them how they feel about themselves. And there's a particularly big one with almost 12,000 transgender transgender and non binary youth. And it finds that hormones were associated with lower odds of depression, which was statistically significant to point zero one, as well as finding a significant decrease in past suicide attempts. So I think there are some caveats, these claims, survey data is generally a form of evidence. And I'm willing to bite the bullet on that. However, I think that it's possible to account for this bias and for this weakness. And to just make the claim that although evidence is weak, it is all pointing in one direction. And we can learn something from that. So I think that's kind of like the basic position. And maybe we can get into that more. Thank you so very much, April, for your opening statement. And with that, we're going to get into 45 minutes of open dialogue. The floor is both of yours. Alright, so maybe one product would go with this would be to go through some of the studies that we've already sent each other. With regards to you were talking about some meta analysis and quality of life and whatnot, one of the ones you would sent was this Nobili 2018 meta analysis, we can start there. That's cool with you. Yeah, sounds good. Okay, so there are a few things to say. So people listen to this if you want to follow along or whatever it's called quality of life treatment seeking transgender adults or systematic review and meta analysis. So the BLE 2018 and the claim that it tries to make is that if you look at trans people in general, their quality of life is significantly lower than that of the general population. This is undrue of trans people post transition. And so, you know, one of the things you could make from that is that whatever initially was wrong with the trans people has evidently been remedied by the transition. The first issue is a matter of a very simple statistical literacy. So they report pulling across in this in the abstract pulling across studies show the transgender people report poor mental health quality of life compared to the general population, when the fact size of negative 0.78 standard deviations, they go on. However, meta analysis in a subgroup of studies looking at quality of life and participants who are exclusively post hormone therapy found no difference in mental health quality of life between the groups and the groups being the trans people in the general population. But in fact, I mean, the issue is basically the point estimate here. In the second case is negative 0.42 standard deviation. That is true. The statistical power of this meta analysis was such that that doesn't significantly differ from zero. But the confidence interval for this negative 0.42 goes from negative 1.15 to 0.31, meaning that in fact, the mental health of the general trans people, so not screening for treatment is also within this and the general population, both those means are within this confidence interval. This subgroup doesn't significantly different from either. So that it just seems what's the two things. So there's that, which I think disqualifies the kind of difference they're making and the fact that they said that quote, found no difference because a difference of 0.42 standard deviations wasn't statistically significant. There's an example of a very common, especially in psychology, very common way of misinterpreting the then equating between practical significance and statistical significance. I think that there are deeper problems of this meta analysis that we can get into, but just the abstract alone, just on the like just looking at the data as they present that I don't think their inference is actually even remotely justified. Yeah, I mean, so you're pointing out, this is part of the study, I think that you're pointing out where it makes the claim that there's some evidence to suggest that there's a subgroup. And when you compare it to the general population, it doesn't look like there is a difference in in quality of life. And one of the things that they say is that this isn't statistically significant. So basically, they're saying that like, they're not that confident about those kinds of results. And in general, you will find that like, with a lot of trans studies, there's just like not a very high degree of confidence in them. So there's this another meta analysis, it's the 2021 one. And basically, you can like go down the list on every single study and every single like metric that they're analyzing. So like depression and anxiety and suicidality and whatnot. And in every single one, they'll say something like, well, the quality of the evidence is weak due to like methodological and sample size issues, and so on and the risk of bias. However, what they do find is that even if the if the evidence is weak, it's all pointing in one direction, which is a pretty good sign. And that applies whether or not it's like these big surveys that don't do follow ups that don't have a lot of like controls for biases. But that also applies to studies that are a lot more rigorous, you know, within this field relatively speaking. And so the fact that all of these studies are all pointing in the same direction is a good indicator that there's probably something here. And because there isn't like a lot of evidence of negative effects. So, you know, we don't see like a lot of disasters or problems with transition. It seems like recommending transition to people is a pretty low risk way of maybe improving their mental health. So I think it's kind of like a sweeping statement. I kind of want to stick with with the one paper at a time, unless you want to like abandon this paper. I mean, to reiterate, though, that the central problem with and again, I mean, there are there are serious deep problems in this meta analysis. I'm just talking stuff in terms of the abstract, the central statistical finding is that the difference between post treatment, trans people, and the general population in terms of quality of life is a negative gap of 0.42 standard deviations, whereas in the case of the trans people not filtered for transitioning, that's negative 0.78 standard deviations. But that negative 0.42 standard deviations has a confidence interval of negative 1.15 to 0.31 so that it's statistically significantly differs from neither the general population nor the unfiltered trans population. So that that statistical evidence just, you know, this is, we can say, oh, the studies are biased, etc. And then indeed they are, but this is, you know, setting that aside, just the basic like hypothesis testing here does not actually support the claim that the meta analysis tries to make. So I address this. Yeah, so I mean, what you're pointing at is just that like, it is weak evidence, which I think we're agreeing with, right? That the evidence is like not very strong. What I'm saying is that the evidence so that's not so that that is not what is going on here, right? You're saying that it doesn't have statistical power, right? I'm saying that the difference is not significant between any of the between that middle group and either of the other two. So if we just wanted to take if we wanted to set aside, right, the inferential statistics and just look at the point estimate in that case, right, then the meta analysis would just be wrong in the most flat sense, because they say they found no difference in middle health between quality of life between the two groups. But in fact, there's a gap of point 42 standard deviations that favors the general population suggesting to post trans people still have significantly negative mental health. But again, that's setting aside the inferential statistics, which of course we normally wouldn't do. But we bring in the inferential statistics. And the point is that this gap, I don't know how to say it just does not like the difference is not significant in either direction. So that it's not that it's like weak evidence in favor of them being the same. It's not evidence at all of them even say it is evidence of an improvement, right? Like it is a shift, right? And what you're saying is just that because the confidence interval overlaps with like the general population, and with the pre transition population to, you know, a large enough extent that this is not like a very strong indicator of improvements. That is what you're saying, right? Just to be clear that we're on the same page. So the negative point, seven eight, the first one, that's not pre trans people. That's like trans people as a whole, which actually includes some post transition transition people as a whole, including people who are pre trans. Yes. So the argument that the authors may has to do with the difference between the post transition people and the general population. There's a different argument you can make, which is the difference right between this general trans population and the post treatment ones. But that's going to be I mean, that's complicated for even more reasons, one of which is that they're not the same subset of studies that are way more studies included in the because a lot of the studies just didn't have any data on post transition people. So to compare those two numbers on your literally, that's not like a stable cohort of people. Perhaps we should move to another study. It seems like I feel like you are agreeing with me on this, where like we both understand that the results are not very strong. But like, you do agree that there is like a shift, right? As far as, you know, you can say that's like not significant, right? But it does show a shift in one direction. Well, no, because again, it goes from point, it goes from negative point 78 to negative point 42, which is like a movement towards the general population. So the movement, I mean, in the first I don't think you can, I mean, we can talk there are tons of perspective longitudinal. So we can talk about actual studies that measure the movement, but this isn't how you do that, because it's not a stable cohort of people. And we can also dig into specific studies if you want. But the specific studies find the same thing, like the specific studies, they will tell you the same thing. They will say that this indicates some association between hormone therapy and treatments, and improved quality of life. That's true of the study that you sent me pre debate. And it's true of like, as far as I know, every other, you know, bias study, we can, we can get to other studies for sure. But I guess the other thing I want to say, I don't know if I want to go into this or not, because this is kind of in the weeds. But in terms of this nobili, at all meta analysis, I mean, I'm pretty sure they also just like incorrectly copied a bunch of data. There are several studies I can point to where if you actually compare the data in the original studies to it, reporting this meta analysis, it's pretty obvious they were just being extremely sloppy copy, like the numbers are just wrong. That's the sense which was like deep problems with this specific meta analysis. As I said, that's very in the weeds. I don't know if you want to actually Yeah, that does seem very much in the weeds. I mean, like your position is that like the reviews and endocrine and metabolic disorders as like a journal has like failed to do their peer reviews sufficiently and allowed this study, which just like has incorrect data through the through the process. Oh, yeah, I mean, okay, well, that gets into a whole another issue. I mean peer review meta analysis normally does not check the original data in that way. Moreover, I mean, about half of psychological papers, you know, which go through peer review, have data in it that is wrong, not just in the sense of if you check like against the original sources, it's not even mathematically consistent. So the the peer review system is a little bit slippery though, because like your point about these like problems with psychology, but most of the research regarding trans people is done in like medical endocrinological journals. So it's not in like psychology journals, where you mostly have this issue or even like sociological journals, it's mostly in endocrinology journals, which tend to have a higher standard. So I know, I mean, I don't think that's true at all. There's a I mean, the lowest replication rates that have ever been recorded in fields are all in medical fields. So far as I'm well neuroscience is in the medical field, but cancer research, research on cardiovascular health, those are the and that's where I'll just put this way. Yeah, I strongly disagree with I think that the meta science on the biology and medical science is atrociously bad. Marble even worse than psychology. But in the worst way psychology, the endocrinology field's worse than psychology. Oh yeah, I mean, I think so, although both are quite bad. But but again, like the way to actually test this right would be like I could point you to a study and we could look at the numbers and determine whether or not because it's real simple to see what they do in some cases. But again, we can also table this and just go on to another study. What? Yeah, sure. Let's go to the 2021 minute analysis. Okay, go to the messages. The baker paper. Let me check. Yes. So first thing, I mean, I don't I'm pretty sure this is not meta analysis. It's just a systemic review. I think the meta analysis. I don't see a meta analysis. I think this is just a systematic. Okay, systemic review. Um, it's not really, I mean, you can't really tell from much of this. I mean, all this is going to tell you is that well, some studies find results that are significant. Some results, some studies don't. It's like, yeah, and we're trying to make sense of that literature. But I don't, I mean, to be honest, it's not just that some studies find significant results. So like, lots of studies do find significant results. But even like across all of the studies, they are finding like the same sorts of things, which is either like a neutral or beneficial impact of quality of life, decrease in depression, decrease in anxiety. And that's true, even of like the more rigorous studies. So like one of the things you point out is that there's bias in these studies, which is true. And like this systemic review, it analyzes the bias of a lot of these and actually it like ranks them, right? But what it finds is that even like in the studies that have the lowest bias, they are also finding like this consistent effect, which is true specifically of like the the one that I like pulled out specifically to look at was a good example of this is one of these longitudinal studies, which does a good job of trying to track things and trying to reduce bias. And it also finds like a statistically significant improvement in all of these psychological factors. So I think we so the first thing to say and that's another and I'm happy to go talk about that paper if you want. But in terms of this general question of bias, it's important to say like what we mean by bias. So it might be the case that like there are lots of different things that you might think contribute bias. The bias I'm most concerned about here is publication bias and this systemic review and that matter, I don't like the the really read analysis and most of these meta-analyses that I actually meta-analyses on this quality of life stuff, don't. Your problem is publication bias. So not necessarily methodological bias? Oh, I mean it's both, but I'm talking about this kind of bias is something that like this sort of bias rating system cannot address. And we know that it's quite a profound bias, so that the the if you pre-register studies so as to make us a publication bias does not affect in both psychology and in medical science the probability of the study replicating that in the original publication context we're showing positive significant results is less than half, right? So that this is a very significant bias. This isn't like a small thing and I don't think any of these studies, any of these meta-analyses that are addressed in a serious way, by a serious way, I mean something like an Eggers regression, usually use a funnel plot and a Trim and Fill thing, although that's less good. I mean there are things you can there are ways, there are techniques to actually deal with this sort of stuff and not about this literature I just don't think is interested in doing that for reasons. Yeah I mean your position is I guess correct me if I'm wrong but it sounds like what you're saying is that there's like a publication bias such that the studies that get published are not like reliable in themselves. So like even if it shows that like all of these studies tend to show this effect you think that we should throw out these studies because you believe that there is some factor that prevents accurate data from being reported and in fact results in data that is too biased in favor of trans people or of the of the idea that transgender health care is beneficial. So yeah I mean to be clear this has nothing to do with transgenderism this is just it is a fact of how let's focus on transgender stuff specifically. You know I want to make it clear though that like the fact that the publication bias is a huge bias which makes it so that positive literatures normally don't reflect a real positive is just a general finding in in soft science this is just yeah that's just how it goes and what you look for then are studies that have ways of dealing with or signs that they would survive through this kind of publication bias but the sort of systemic reviews and meta-analysis done in this literature against the norms even in psychology don't seriously attempt to address this at all. So we're just gonna not pay attention to any of these studies. So that would be one reason to discount the whole fuel I mean there are other obvious ones too like for instance we're talking about oh through their depression scores increase after and I want to be clear also because this might seem a little misleading to some people talking right now uh to be listening rather that keep in mind we are just going through the studies like in this one we're just going through one side study so it's not like I don't think there are also studies that show a negative effect but presumably we'll get to those later but I mean one thing we know for sure would improve depression scores would be a sugar pill right so that I mean the placebo effect is real and robust for things like mood disorders so that there's not even it's not even clear that these the observation that they're trying to make which I don't think they've sufficiently evidence but just the observation that the actual mood scores are significantly better in the post treatment condition that would be very easy to explain whether the treatments work or not because they're not dealing with that bias either. Yeah I mean I'll extend an olive branch I guess and point out that the placebo effect is real and it's one factor that might contribute to people feeling better but I would also point out that like the existence of the placebo effect is not an unknown and unaccounted factor in factor in medical literature and it's the reason why we have like the statistical significance levels that we do and so when we find these studies that are like all consistently pointing in one direction and they consistently have like statistically significant results I think that what's that show what is that what that is showing is that there is probably some real effect there that is beyond just placebo especially when like you are doing these like cohort studies where you are following up with people continually and you would expect like more people to be dropping out or to you know not show benefit continued benefit over the long term if it were just placebo okay so I mean the first thing I guess to say about this is I think there's a real confusion then about how we deal with placebo so there are meta analyses showing placebo do have statistically significant effects on mood disorders statistical significance is not how we deal with placebos the way we deal with placebos in medical science generally speaking you're quite right that it's generally dealt with but it's by having active placebo control groups right that is that is the design by which yes it's not yeah I'm aware people use like rcts and double blinds and whatnot right and so the literature specifically addresses this and it specifically says that like we have difficulty getting the rcts past the medical board so we are going to deal with placebo effects we're going to account for the bias in other ways and like one of these ways is to continually follow up with people and to compare cohorts between people who like are you know taking the the transition the treatment in people who aren't and it's not as good as an rct but it is one way of accounting for that kind of bias when you're not able to do an rct and what we find is that like when we implement these sorts of controls we still find significant effects okay so I think so I think we can um and then I'm going to say it doesn't have a deal with placebo but that's going to be so we're going to go in a circle so I'm just going to move on from that because I think people heard our two takes on that specific issue okay you realize it's not just finding significant results it's when you implement these controls and find significant results as well and then I'm not saying that this is like the perfect way to account for placebo or like even the best way necessarily I'm just saying that it is a way and so like these researchers they're not like stupid you're not like going to tell them oh you like there's actually this effect called placebo they're not going to be like surprised by that they're aware of the placebo effect and like that factors into how you analyze the risk of bias in these studies so like when you look at all these studies and you say that like yeah this study is probably like more at risk for placebo having like a confounding factor in this result you can actually like analyze studies based on that and it turns out that even when you look at studies who are like better at accounting for that kind of bias you still find the result of these significant effects well what are these controls that you're talking about the control for placebo effect what's a specific design yeah hold on so in the specific study the one that is published in the journal of clinical endocrinology and metabolism from Oxford academic they say that considering four ethical issues it is not possible to perform a randomized placebo controlled study with no cht control group that's hrt control group we perform a double design study with a cross-sectional comparison between genders for persons with no cht or hrt at baseline and a prospective intervention study on the effects of cht across time so like in lieu of being able to do a proper rct you can implement other methodological controls to help reduce the bias no i mean a perspective longitudinal design that is that is the uh i don't know what you call it that is the preeminent placebo having design that doesn't how does that help get rid of the placebo effect it means the preeminent placebo having design you mean like that's like the maximum way to maximize placebo or it's the one that you most strongly associate with placebo it's the one um in which the placebo effect well i'm thinking in terms of psychiatry and psychiatry it's where it initially got a lot of attention the fact that you know because for people that don't know what a prospective longitudinal study that just means that um like a retrospective longitudinal study longitudinal means over time you do it retrospectively mean you ask people about their past or prospectively you start following them at the beginning of fall you know and follow them throughout and the placebo effect just refers to this fact that due to expectations if you give someone any kind of treatment um as you follow them their mood is going to improve following the treatment even if the treatment doesn't work and we know that because we can give them things that we know don't work and it still happens so the fact that there's a prospective longitudinal design i don't see how that's supposed to eliminate a placebo effect so it's not just that but like the fact that you can look at these people and you can see um like the degree to their to which they're benefiting relative to the group that is having no no treatment i think that that's the key here right is this comparison and you can expect to see like a certain level of benefit if you are just seeing a placebo effect and if you're not seeing a placebo effect or you're seeing something on top of the placebo effect you'd expect to find a larger difference than what you typically see with the cibos so either it's the case that cibos are just like especially strong in this circumstance which you know may be true but like we don't necessarily have evidence to believe that's true or there it does seem to be some underlying extra beneficial effect here so now you're talking i think you hit on one way they could actually address publication bias or not publication by sorry uh placebo effects maybe you point me in the direction i've not seen a paper to do is one thing they could do is um compare let's see if i can get an actual number for example a g of 1.05 um so for instance they could say okay here's a meta analysis uh on like the placebo effect in depression research um according to the brand of meta analysis i'm looking at right now it's a the effect size of g equals 1.05 and then compare and say okay we're just going to subtract that from all the improvements in our interventions in order to address it to get over the fact that yeah we can't do randomized control trial this is a way to kind of get at the placebo effect uh but i've never seen a study actually do that in this literature uh but maybe you have an example that we could look at that as far as a study that is comparing two groups no a study that because what it sounded maybe i'm misinterpreted but but it sounded like you were suggesting was that what they could do is because we know on average how big the placebo effect is in depression trials so even if we don't have a placebo in our specific study what we can do is take that effect and subtract it from the perceived benefit of our study and then see what remains if our if our benefit is significantly greater than the average placebo effect for the outcome we're looking at that's one thing you could do i thought you were suggesting that i was just saying i've not seen a study do that even though i think that would be an interesting way to address i mean so like in this study that i am talking about they are comparing people with no cross hormonal treatment cross sex hormonal treatment to people who do have it and so like they are able to estimate the effect size from that but that is not the same okay i think i just misunderstood you was suggesting something i thought you were suggesting something that you want because that's not what i'm talking about but um okay i think people have heard about the maybe we just go to one of these specific studies and do that okay sure which study do you want to look at specifically um two do you want to do the green one first the green one this is the opposite of the association of gender affirming hormone therapy with depression thoughts of suicide and attempted suicide among transgender and non-binary youth is that the one you mean at all uh i think this is the paper i accidentally yeah oh okay it was one of the ones you said can you send it to me real quick uh yeah and then while they're doing that i just want to send love out there into the intertubes if you would like to get your question or comment read out loud please tag me in chat at amy newman or send in your super chats will which will get you priority red but right back to you too okay i put it in the uh the twitter uh chat yeah i see it so this study um for people who are uh so this so this the first thing to say that i like about this study is that it's looking it has a measure of suicide attempt now the reason why i think that is important this is the kind of literature that i favored looking at is because there's some reason to think that for instance the placebo effect might not impact suicide attempt even though it impacted almost surely impacts asking people how badly it's you know but it might not actually i mean we're particularly interested in getting into the research suggested that might be the case but i'm just gonna say that for the time being that i think suicide attempt is a better outcome for that and a couple other reasons now so this paper is looking at uh some minors i believe was this oh youth age 13 to 24 whatever and it's a big survey there's thousands of trans people and when i were comparing how people are doing in the sample depending on whether or not uh they were in the group that got the wanted hormone therapy and got it or if they were the group of people that wanted hormone therapy did not get it among trans people now there are two things to say i guess so in the first place um i think it is probably true that in that comparison the p it's going to favor the people who got what they wanted but i think a more full consideration of the different groups of trans people and their suicide attempt rates still suggests that there's not a positive effect for these surgeries but i would also say i don't think this particular paper provides very good evidence at all um so if you look at table five of the paper which is the main finding we see that in their overall sample right there is not a significant effect on suicide attempt there is a significant effect this gets to part of what i'm speaking about in terms of the difference between these things there is a significant significant effect on depression self-rated depression um and suicidal ideation but not on actually attempted suicide that effect is not statistically significant now they want to say that okay but if we restrict the sample to ages 13 to 17 there's a significant finding and i mean it's true that it's significant but the p value of significance is 0.04 uh i mean this is funny for many reasons the most obvious reason it's funny is that they corrected for just the two tests they just did it would now not be significant uh but but also and more seriously um we know from uh various large studies of what happens when you try to remove publication bias again and introduce pre-registered replications of studies that uh studies that have p values of like 0.05 to 0.01 um they almost like the probability that they would actually replicate in a publication bias free context is well less than half it's not even close to half um to get close to half you have to get this way lower p values and that's why some people think that there should be like a lower uh significance threshold for what we call quote unquote significant because where the line is actually right now is for arbitrary historical reasons and isn't at the point at which the probability of something being kind of the real deal becomes even half yeah i mean i think that like the evidence for improvements in suicide out is not that strong but i also think it's like telling that in table three of this same paper when you split it up into people who received gender reform affirming hormone therapy and who didn't you do find significant results to 0.001 so like i think that you're pointing out there's like not a very significant result in suicide when you're you know when you're looking at the overall sample or in the ages 13 to 17 but like the actual relevant like factor to this discussion which is like receiving or not receiving ghd is it does seem like there is an effect and that might just be like this study because i have not seen that in other studies frankly so i would like be willing to fight that bullet but i do think that like it is a little bit telling that it does show that effect elsewhere yeah so table i mean there's two things to say so the first place um the point zero zero one statistic refers to the chi-square statistical um comparing three different groups and it's i don't know why they're doing this i the table three is an oddity to me but the three groups um uh oh sorry actually you know what i was reading that wrong but in any case i it's also that it's that's an incorrect read but the more important point is just that this is the difference prior to controlling for the so i'm talking about it's also this difference it's just after controlling for some obvious things you want to control for because one thing you might want to ask is okay if we're comparing people that got the therapy to people who didn't well why didn't they get the therapy is it because for instance they were too poor to get the therapy that's one of the things they try to control for be problematic because it was because they were poor well poverty might have an independent effect has nothing to do with the uh surgery or hormone treatment rather on suicide and so the the effect i was looking at which is the effect that the authors uh point to is the adjusted odds ratio after controlling for some of these more obvious compounding factors yeah and then it's just well the problem with like table five is that it's looking at like overall rates which i think is and and then looking at like the the child's rates for 13 to 17 and i think that like if your point is purely that like the attempted suicide rate and the effect on that from ght he's not that big i think that is consistent with other literature that i've seen that is typically not been able to find a significant effect in this area but i think that like another area where we disagree it is about whether or not we should use suicide attempts as the primary metric for this whereas i think that like even if we can find a significant evidence of other psychological benefits from transition related therapies that that is a good reason to recommend them at least in some cases the goal is like not necessarily always to like the the main metric of success is not necessarily attempted suicide it'd be great if you could also reduce those but it's possible that there's just like there's some cohort that is very likely to engage in attempted suicide and for those people whether or not they receive gender reform affirming hormone therapy they're still going to be likely to do it and then it's possible that for the rest of the people there's going to be a beneficial psychological effect outside of suicide and in that kind of scenario we would expect to see these kinds of results and it would still be beneficial to prescribe HRT in some circumstances so i would think that any significant improvement on general mood is also going to have a real world effect on behavior like suicide attempting well not necessarily especially in like a trans population where the suicidality rate is so astronomically high to begin with yeah not necessarily because it's possible that like the the groups of people that are engaging in attempted suicide behavior are the people who are like you know not receiving the lion's share of the benefit of HRT and you don't necessarily know like which group someone's going to be in when you are evaluating them for prospective candidacy of receiving HRT and if they're like this is just like a hypothetical we don't actually know if this is true but if they're in the group that like is just you know they're going to receive massive psychological suffering regardless of HRT you know they might not benefit but that doesn't mean that like the rest of the people who are benefiting from it shouldn't receive HRT so i think that like the conclusion that is like very specifically isolating one metric which is suicide attempts is a little bit dubious for that reason or i should say like a lot dubious for that reason so i i guess i don't see how that makes sense i mean it's not as if like the suicidality rate right of trans people in general excluding maybe some people who for whatever horrible reason just doomed to commit suicide no matter what happens to them life like suicide out there it's not going to be zero and is their suicide is their propensity to suicide not going to be partly a function of their general psychological well-being i think it i think it probably is but here's like i'm just describing like one scenario in which just if you don't see like one metric decreasing that doesn't necessarily mean that there aren't beneficial effects elsewhere and so like if we can have a medicine like imagine we have like a hypothetical medicine which improves people's quality of life and you know self-perceptions allows them you know to have a lot more confidence for example people who have body dysmorphia disorder right so like they physically use themselves is different from what they are but for like the most extreme cases it doesn't really help them i think that in that kind of circumstance with this hypothetical medicine it would still make sense to prescribe it even if it doesn't help the most extreme cases because there's always a chance that they are not in the most extreme cases and therefore will benefit from it sure so i think maybe i want to reiterate that the reason that i go to suicide attempt data is to try to get around the placebo effect because otherwise we're in this difficult position of the hypothesis the treatment works and the hypothesis the treatment does not work both predict an increase in self-rated mood after the treatment and so that's a that's an epistemically uh black pill the situation to the fact i mean you would say that like a placebo effect would probably have an effect on attempted suicide as well right on no so so that's why i uh like the metric is because i think i must believe this like believe what the placebo has a positive effect on this oh no i don't um yeah i don't think so uh why do you think it's special so and i i can link i mean that's specific uh studies on this um i won't say let me but the the reason is special i mean it's not that special it's just that it's a behavioral and objective measurement is the first thing i should say my general perspective on placebo i think that like the bias you're accounting for is not necessarily placebo but like there is a bias for people to self-report like false things right like a bias to justify past decisions right and i think that the reason to use suicide would be to account for that bias the bias for people might report feeling better than they actually are and so that would be like a good reason to look to more what quote-unquote objective measures like attempted suicide and i think that that is like it's a little bit of an obfuscation because obfuscation because you can provide like actual psychological tests which are pretty like good at teasing out whether or not people truly feel negative about themselves or are just lying about it and even if there is like an effect of people lying about things you know you would still expect that to be seen elsewhere in the data which we don't necessarily see for example like lots of people detransitioning which you don't really see a lot of people detransitioning and so i think that using attempted suicide is like ironically it's kind of the thing that you're accusing these studies of doing which is just like p-hacking their way to find a result that is preferable to them but you are like explicitly looking for the one metric that like might support your position and then ignoring everything else which i think is pretty disingenuous so i think this is this is very backwards so the first place so yeah we need to have a theory and some evidence i think here about what the placebo effect constitutes um so my general view of the placebo effect because it goes on the placebo effect is that because people expect a certain outcome they start it's kind of deluding themselves into thinking the outcome has occurred when it actually has not but then you want to call that a line i don't know but uh they can't do that with respect to certain objective behavioral measurements this is true in other fields like for instance if you look at the placebo effect on insomnia and that lots of placebo effects on self-rated sleep quality not on objective measures of sleep quality in the case of suicide there's a specific reason to think this as well um so there's this uh there's a meta-analysis of uh i didn't think we were gonna i didn't actually think this was gonna be a matter of controversy but there's a meta-analysis on suicide uh research and what it finds is that in general active control groups have suicide interventions i say so we're trying to stop suicide what is the research on that saying well one thing it says is that in active control group situations there is a lesser effect which is what you would expect that means that there's some kind of placebo effect generally speaking with respect to measurements of suicidality um thank you that's all i wanted to like no no no no no no no no no let me finish let me finish the the ending is key okay uh but these interventions already while they did show uh significant effects across general measures of suicidality which includes things like say suicidal ideation the interventions already had no significant effect with respect to suicide attempt so that whatever that placebo effect was seemingly was not happening with respect to an actually attempting suicide which is why and i don't it's not even as brought a suicide it's specifically suicide attempt is what i've and it's not it's not an after it's not an ad hoc like it's because i'm looking for a way to get around the placebo effect this isn't uh this is not a p-allocate version of p-hacking i don't think this is just a principled choice of metric i think well i think that if your goal is to reduce bias i think this is like a stronger way of reducing other kinds of bias than reducing like this the specific placebo effect bias well i think we've said our uh but i mean like even even if we're like about the suicide stuff like the study that you did this to be clear the study that you linked does find like a point zero zero one significance on like less attempted suicide from people who receive g-h-t or h-i-t it's the same thing but yeah well again in the in the multivariate context the p-value was not significant at all for the whole sample and even for the minor sample was significant at p-goals point zero four but more importantly i mean i want to remind people and i because i think this debate is starting to because we're just talking about the sources that you had sent creating somewhat of a misleading situation because i think it's just true even though that study i don't think it's good evidence of it but i think it is just true that the suicide attempt rate is highest among people who wanted this therapy but could not get it what i think is important though i will link again as i linked it center earlier but i'll re-link it as an example and there are multiple studies showing this that even said of comparing people who because i'm going for a minute why i think that compares in this problematic you're talking about people who want a treatment but can't get it well that adds a new feature of suffering to their life namely they think that there is this treatment that they believe in enough to want so they think that's something that's probably going to help them for some reason they unlike other people just can't get it now you might say oh well look sure that's this kind of suffering that there's an problem with this data all data has problems though but we can't get out of it but i think we can get out of it which is by comparing the suicide attempt rate with respect to people who haven't had the the transitioning yet but it's not that they won't be able to get it it's just that they want it someday or they're planning to get it but there's nothing like long run preventing them from getting it and what we see in that case is that the suicide rates are similarly elevated both among people who want to get it but haven't got it yet and people who have already gotten it yeah i've also seen this analysis that you've done here and your your point is that transgender people seeking surgery have higher suicidality than trans people not seeking surgery and it's a little bit like the transgender equivalent of pointing out that patients who are seeking like heart bypass surgery have a higher rate of heart attack than patients not seeking heart bypass surgery which is to say like it's a completely ridiculous point of course people seeking surgery are at higher risk that's why they're seeking surgery but i think that like it's even more absurd that you think that it's unreasonable to compare the groups of people who are wanting but haven't gotten it and wanting and have gotten it you do think it's reasonable to compare people who haven't had it or people who have had it and wanted it to people who just don't want it at all and so i think that like it's just like it's so it's so problematic for that reason but it's also problematic because you've basically you've dismissed like this literature and these publications you've said there's this publication bias so your solution is to do like napkin math where you basically you look at the reported you know the rates of people who are reporting attempted suicide and you just say like well even though this study is not actually coming to the conclusion that you know that there's this effect here I'm just going to like say there's an effect here which I think is like it's just like so out of the bounds of how you should be interpreting these studies and Sean before you answer that I just want to say that we have about four or five minutes of open dialogue before we switch into the Q&A but right back over to you Sean well drag that's no fun um okay so I think you've misunderstood the groups I'm comparing comparing so to take just a specific example I think this is a fairly representative example in the link I sent which people that you can't see it's this surveyed about six thousand American trans people in it and they break down the attempted suicide rate by people who've had all these different kinds of transition related health care so to take the top slash chest breast surgery as an example and so the suicide rates if you if you compare people who do not want it 34 percent attempted rate wanted someday 45 percent have had it 44 percent now what I'm pointing at right now is that those last two numbers in some cases it's a little bit higher in one in some cases a little bit higher in the other overall though those two are the same so I'm not invoking actually comparison between people who just don't want it now the difference between this and it's important to point this out and the paper that we were referencing before there's a difference between the set of people who want it someday and the people who want it but say that they are being prevented from getting it right that they can't get it that research just asking about if you want it someday if you're planning to get it also there's research the words like this that shows the same thing where you get the highest rates are these people who are like prevented from getting the hell the transitioning that they want but my point is that that has that added source of suffering and so the best comparison is between people who have had it and people who just who haven't had it but aren't saying that there's something actually preventing them from getting it the people who want it but haven't had it yes in this I mean again in this way of wording that question yeah I mean like I looked at one of these sources that you linked in your WordPress blog specifically and I don't believe that it actually gave us like the variance for the data that was cited at least not in like the section that I was looking at but it showed like a difference of like 5.1 percent of attempted suicide in the last year versus 8.5 attempted suicide in the last year between people who wanted it but couldn't get it and people who who are able to get it and I think that like you're right to point out there's this like added psychological suffering but like the whole premise is just it's flawed from the beginning because you're doing this like extra you're engaging in this kind of like analysis of the numbers which there isn't actual like literature on like you're just like extrapolating out and doing your own math which I think is like a pretty dishonest way of approaching the problem especially if you're someone who is like supposedly very interested in like the rigorousness of these various studies and with publication bias I think that like if anything you would expect you as an individual to have like a great deal of bias in this area so I think that trusting you to do like your own calculations on this is even worse than looking at a meta-analysis which is why I prefer to actually look at those systematic reviews and meta-analyses of the available literature and those consistently find like a very direct trend in one direction even if the evidence is often through surveys and isn't as good as you maybe want it to be like RCTs there is an effect there and I think it's more reliable than trying to like define these extra these conclusions out of studies that don't explicitly make those conclusions and so whenever you two are both ready to go to the Q&A we are but once again feels like you had one last thing to say so all back to you both of you yeah sure so I just want to reiterate that there are two different questions there are two different ways of sort of assessing these questions that you can ask people you can look at the set of people who want these treatments but say that they've been prevented from getting them and those people are very high suicide rates higher than people who have had the transitions but there's an equaling of the suicide rates between people who have had it and people who merely say that they wanted someday or are planning to get it and that's a different question slightly and I think the difference there eliminates the kind of negative negative bias of the previous question and it sounded to me like you were talking about again comparison slightly different than the actual comparison I'm making also I think we're using the word bias in different ways like I'm worried about publication bias not bias that stops me from doing arithmetic and then April feel free to respond but after that if you would like before we move into the Q&A just tell people what you got going on in the interwebs and then your final thoughts on the subject itself yeah okay so I guess what I would say is that it's really important to rely on these medical institutions and the reason why it's important to rely on them is because when you engage in this kind of like personal analysis of like taking numbers out of a study and then performing your own math on them is it's a really kind of a solipsistic exercise and you expose yourself to all kinds of your own bias that prevents you from making like a very informed decision and like we saw this earlier in our previous debate where like just through personal error which is like fine like the wrong study got linked in your WordPress block which I think is like a good example of exactly this where like it's easy to make mistakes when you're doing your own kind of research and that's why it's important to rely on the system of people checking your work and I think that to the extent that you're concerned about bias in publication that bias and that concern should apply doubly to you and I think that if you are just like an average person that you should not engage in or I think that most people who are like watching this their best bet to determining the truth is actually to look at what is the medical consensus why all of these groups tend to agree and it's not because the evidence is like you know the strongest evidence in the world that's not necessarily the case and a lot of people overstate the ability of transition surgery and healthcare to like reduce suicide or to improve mental health but like the fact of the matter is is that we do see a consistent pattern of beneficial effects and that occurs like you know however you are structuring the methodology of the study whether it's these massive surveys of 12,000 people or whether or not it's like a more you know focused study where you are following up with people and you're providing them a series of rigorous psychological reviews and tests to like tease out whether or not there might be misrepresentation there in either case we're finding the same effect which is an improvement in quality of life depression and anxiety thank you so very much April and with that Sean if you would like to tell us anything you got going on on the interwebs and of course your final thoughts on the subject interwebs why why is anyone calling me Sean last the sort of like a closing statement or whatever I guess I would just say that I think it's probably my fault but for going into the studies that you had sent in such depth I think that a kind of misleading picture was unintentionally painted because again I think that there's a bunch of research on the suicideality that actually just does not that has like the opposite finding and that this is actually the correct way to interpret it but we only kind of began to talk about one of those studies but again I mostly blame on me I don't think that's like a traditional thing or anything oh and I mean this would be like a whole different topic in terms of like trusting doctors or medical researchers and whatnot I mean by perspective on that is there's a huge literature showing generally speaking academics including in biology in the medical field are statistically illiterate people their research articles their peer reviews joke it doesn't find fatal flaws their mathematical insistencies in most of the papers people reading me don't need to be concerned about the same sort of bias because of course I'm not publishing like my my blogs just blog because if I they might say well I want a publication bias because I have citation bias and maybe that's true I'd like to think it's not but maybe it is but of course anyone can just check that by going to Google Scholar and doing their own search for something so I don't I like like the the synopticism is not like it's just totally totally different context so it's the same bias could not even manifest so I don't think the comparison makes sense and I mean like I said they just like they're not a high bar they're actually broadly speaking a joke the medical institution so I mean thank you so very much Sean for your closing statement I do want to remind everyone out there that both of our interlocutors links are in the description below with that if you're enjoying the debate please don't forget to like follow and subscribe and we are moving into the comments keep on sending them to me at Amy Newman but the first super chat five dollars thank you so very much sunflower for what disorders besides gender dysphoria do we condone a patient shopping around for doctors till they get the prescription HRT they want is that directed to both of us I believe that is directed towards you April but I'll read that for what disorders besides gender dysphoria do we condone a patient shopping around for doctors till they get prescription HRT they want I mean you shouldn't do that it's it's good to get like multiple opinions from doctors but like the entire point of having doctors like work with you to figure out what medicine might be beneficial to you is that you are not the person who is a coley in the driver's seat you're actually trusting people to account for maybe you being wrong and not actually being totally informed about what's best for you which is very common because people are not doctors for the most part and therefore have very poor you know poor understanding of the benefit or lack of benefit the medicine is give them it's going to give them so yeah you should you should talk to doctors and you should work with them and you should get second opinions but you shouldn't be shopping around for a specific outcome thank you so very much for the super chat and your response $5 super chat from jupiter darman I want to know why we'd care about what others do in their lives you want a boob job lipo whatever you do it and no one cares why should this be any different let's run go first so there are two reasons why I mean the first place in so far as you are what I would generally call like a good person right you don't want people to do things that are going to increase their own like suffering so if you if you devalue other people's suffering maybe if you're actually neutral towards other people's suffering and then I like you're a psychopath it's part of my response to that but then the second place I think it's very problematic because creating a set of societal norms that encourages transgender people to sort of lean into their identity and congruence I think it's going to create more trans people and therefore make more people who are not in a good place that's it yeah I mean I I sort of agree we're like I don't think that you should if it is true that HRT or surgeries cause significant suffering for trans people then you probably should not encourage people to go down that path right and your goal should be to limit those negative results to the best of your ability so I think that like to an extent it is very problematic that being trans and transitioning has become like a social movement more than just like a very narrow question of medical necessity because I think it's probably going to encourage people to transition who otherwise would not benefit from the transition thank you so much Jupiter and both of our interlocutors and a 776 super chat from Noah's Ark, Kansas no such thing as transitioning it's body mutilation which long-term can only result in the further degeneration of the individual's well-being more of a comment I was going to say any responses if not we're going to keep on moving forward thank you so much Noah's for your super chat support $2 super chat coming in from bubble gum gum marix the perfect girl plays sips estrogen so thanks so much love bubble gum gun all of our supporters out there keep on tagging us at Amy Newman if you want to get read out but we have a $10 super chat from Brandon Hansen April should we take the easy path do what makes us happy in the short term or take the hard path of struggle and growth and taking responsibility for the way we are instead of chasing dopamine yeah so I think you should take the hard path and part of that is like part of how that relates to transgender things is that sometimes people's motivation for pursuing gender affirming healthcare is very much like dopamine focused or like short term focused so sometimes you see this with a lot of surgeries and specific where people you know they just want to feel more beautiful and that psychological effect is something that's temporary and also centers like beauty as a source of meaning in your life which I don't think is very sustainable so like the reason why you're pursuing gender affirming healthcare is very relevant to the amount of benefit that it's going to give you and if it's a sacrifice where you're basically sacrificing you know your long term benefit for this short term hedonism that's not something you should pursue however for the record I don't think that describes all gender affirming surgeries and I think it's very possible that there is a significant cohort of people for whom gender affirming therapies are an important part of their long term social development part of that being like enabling them to engage with people in a very pro-social way which they can't do as long as they're tortured by gender dysphoria etc. Thank you so very much for that super chat and the response and a another super chat from Brandon 10 dollars April are you happy as you are right this moment what else on the trans pathway do you need to feel affirmed at what level does a trans person need to be happy with themselves if you're asking about me personally I would say that a lot of the things that I did to improve my mental health as far as like surgery wise they did improve my mental health however I'm not sure if they were worth it from like a time money energy perspective and so I try to caution people that if you're going to pursue certain like surgical interventions sure they might like improve things but there's a there's a cost to them not just like with money but also like if it's a choice between going to therapy developing like interpersonal relationships developing some sort of like source of meaning in your life or just like ignoring that and trying to chase these like short-term you know visual improvements I think that you're better off developing that like more long-term meaning even if like improving your appearance that's going to help you like frankly that is going to help you know your mental health but there if there's an opportunity cost choose the former rather than the latter and with that that's our super chats we are going to move into our normal questions so keep on sending them in at AB Newman but Delaney and Sean are hormones the real topic doesn't this boil down to respecting pronouns do you want to talk about respecting pronouns real quick I mean I feel like that's kind of a separate issue but we can talk about that it is a separate issue I think it's important because I think it gets to the kind of difference between arguing about transgenderism as like a social phenomenon versus a medical phenomenon and I'm very much more on the side of like it should be like a strictly medical phenomenon and analyzed within that light and I think that like your point would probably be that like people should not be forced to respect pronouns because you know at worst this is kind of like forced line about about your own beliefs but I'll like you say it in your own words and we'll go back and forth yeah I mean respecting people's pronouns is obviously just a way of affirming trans people's internal sense of identity and I'm against that writ large because like I said I think that's I'm not convinced that even with respect to the set of trans people already existing that it would actually help their mental health significantly and I think it would increase the number of people who are trans to begin with within that very poor mental health and so I think it would be a bad thing to do so yeah obviously I don't favor respecting pronouns so maybe on like the more trans positive side right I try to tell people that like your goal should not be to try to control people's language because when you like allow people to just like affect your personal well-being with their language very easily that's just like a recipe for psychological disaster and I see it even where people like you know they get a lot of anxiety or fear or depression about not just what people are saying but what they're actually thinking so if someone is like they'll worry maybe this person's using the pronouns I prefer but they don't actually believe in it I think that when we engage in this kind of like social control we reinforce the trans people that they should be very concerned about what people you know what pronouns they use and I don't think that trans people should concern themselves with that fundamentally so I think that trans people should try to accept that there's going to be people who just like don't support their gender identity and not to make that the metric of personal value in their lives but in a way I mean I agree although I think that would be a little utopian to hope for happening just because what trans people want right like what is to assume is to in some sense be like the cis version of their gender and the thing about the way that trans people tend to think about gender is that it's defined not entirely but quite a lot in relational ways like the definition of what it is to quote be a woman or be a man has in part to do with how you relate to other people and how other people relate to you and so because of that I think a kind of authoritarian disposition is kind of inherent in any kind of transgender movement well I mean look at like cis people right like cis women don't feel the need to assert like force other people to call themselves women and I think that fundamentally the reason for this is because cis women have an internal sense of gender identity which is stable and doesn't like they you know they will present themselves how they want to be and people will decide whether or not they're a woman or not and they believe that they're women and they have like enough people who are reaffirming that identity that like if someone goes up to them and is like you're not a woman they won't care about that because they've they already have this like meaningful self-identity which isn't like dependent on having everyone agree with it and so I think that like the goal for trans people should be to cultivate the same thing where like you should be okay with some people not believing your gender identity and ultimately not make yourself dependent on making sure that every single person agrees with you I think that like that is it's a more reasonable goal because it's more sustainable I don't think it's sustainable to try to force everyone to believe what you believe that will just never happen there will always be people who disagree with you and since you can't change everyone's minds you don't have mind control the more sustainable long-term solution is to make peace with that fact and to develop an internal sense of self-worth that doesn't depend on forcing everyone to agree with you thank you for the responses and then a ten dollar super chat from arcade outpost i-hippocrat did a video about some of these how some of these statistics are generated they pull themselves in a weird fetish forums and academia is quick to canonize it these sacrosanct sourcens sources are often rotten that does get to yeah we talked especially I think about the placebo but they're a list of other issues typically with trans stuff I don't think there's almost nothing approaching well actually that's not true there's but the most part that's how the Scandinavian countries have some very unique data sets there's nothing approaching like an actual random representative sample of anything the duration of a lot of studies is only a couple years which is problematic because the average time it takes for someone to detransition if they're going to is more than that and so they're missing a lot of negative effects there's attrition in the studies which might disproportionately be people that aren't having a good time um the samples are tend to be I mean yeah there's a there's a bunch of different the litany of problems is is massive thank you so very much and then we have a massive double super chat from Noah's Ark Kansas thank you so very much Noah for all of the support but I had my genitals removed inverted and reinserted into my pernium gooch they have a quote I can no longer engage in activities because it's too painful but I still need to stretch it regularly or else my body will close the foreign hole I cannot even satisfy myself because all of the nerve endings have been ruined how can I achieve my gratification slash realization now as a woman at April I mean it sounds like they've had sex reassignment surgery and I don't know if they're they're still transitioning sounds like they still want to be perceived as a woman they want to achieve gratification as a woman I'm not totally sure what that entails gratification I think that like sex reassignment surgery is one of these very difficult things where the technology is just like not very advanced and so whether or not someone benefits from it is like it's going to vary a lot from person to person so I'm not sure if you are if you have the point of your message is that like you haven't benefited from it if you haven't benefited from it I think that you should try to find other things in your life to like cope with the suffering of realizing that you've made a bad decision and I guess that would be my suggestion thank you so very much for that response and all of those super chats who really appreciate the support and question coming in from Delaney is transitioning the correct term when it's just their true self Sean go answer it I mean I would say I mean it's obviously I don't know what you mean by true self well I would use that the way it obviously isn't and it's not this is very obvious trans people have a very pathological sense of like an identity mechanism what we normally mean by who someone really is has to do a cognitive process that begins of a simple observation of what they presently are and for trans people for reasons that are complicated not totally understood their sense of identity somehow disentangles from simple observations of what already is and I would not prefer to that there was like a true self or whatever thank you so very much and moving right along from take time can you ask both guests about their thoughts on the ability for minors to consent to such life changing medical therapy especially given the weak evidence for positive effects as I'll start for a second it looked like James had put down minors transitioning as like the debate question which worried me for a second because I'm not actually prepared to defend that I think that with minors the encouraging them to transition is a lot sketchier I think that for minors you should probably encourage them to wait until they're older and more able to understand the potential benefits downsides and effects of transitioning I would also say that like there are other negative effects of transitioning like social ostracization it's really important to be socially well adapted when you're young and if transition prevents that that's going to have a really negative psychological effect so you know for that reason alone you might want to delay transition but yeah yeah I'd also add that because it is it would an identity disorder obviously I agree that it's not transition but because of that so much to do with the sense of identity and sense of identity tends to be especially fluid in young years that's another reason that the chance of it just kind of spontaneously remission or just going away it's probably going to be a lot higher if you're looking at young people than compared to older people and you see that with detransitioners like age and detransition are very correlated so like if you're younger if you're like very young the detransition rates from like just gender non-conformant behavior so not necessarily medical detransition but like going from being gender non-conforming to being gender-conforming are very very high and as you get older the chance that you are just like going to be you know gender non-conforming and so some part of your brain that aligns itself more towards that kind of behavior is much higher versus versus when you're young that's also true with like earlier in transition so like if you are earlier in transition before you've gotten surgeries your chance of detransition is higher and then after you get surgeries the chance of detransition seems to be lower Thank you to both of our analogators for those questions I think this is more of a joke Delaney says do city girls make a do might have been something from what either of you brought up but Brandon Hansen another part if the person who transitions determines their endpoint then isn't affirming identity just a game of dopamine chasing and wouldn't proper help be accepting yourself plainly Yeah I mean I think that like transition is not just dopamine chasing I think that what you see is that there's like there's a psychological issue in the brain which we don't really have a good way of fixing but by giving people hormones you can reduce some psychological pressure which allows them to be you know very pro-social in their lives in a way that is distinct from just like pure dopamine chasing which is not going to necessarily have that beneficial effect the goal is not just to create dopamine in the brain Thank you Oh no if you were about Yeah let's Sean go Oh yeah I was just gonna say you talked about accepting things as they are and whatnot that I think that's probably my guess is I don't think there's a lot of research on it my speculation is that that'd be a useful thing to try to instill in a lot of people with these sorts of issues it's just not be to not respond in such an upset way to certain desires and identity formations that arise that do not be so attached to them in general but that is not an approach from what I could do as I was looking the other day for some research to try to be kind of there that I would guess would be most useful when I get done it's not done which I think is bizarre the only alternative that I was being able to find really to the sort of standard program is like weird religious therapy of some sort that is not not a not a very standard medical disease chat Thank you both for your responses a five dollar super chat coming in from counselor guy thank you for the support people do not have a sense of gender identity that concept is strictly ideological and western cultural based yeah I mean like I guess what we talk about when we say gender identity it's just like preference for fitting in as a certain gender role and the exact boundaries of that definition of that concept are somewhat nebulous so like I think that's why in literature we talk more about like gender dysphoria to like try to drill down and that's specifically like a set of psychological negative effects that you receive as a result of presenting a certain way or in relation to your for sex characteristics and so we're just like we observe that some portion of the population has these negative psychological effects and the question is what do we do about that and that is really what the discussion is about is like how effective are these treatments for these bad feelings so why do you think it is then that trans people the way they talk about it right isn't in a way of saying hey I really but what I mean by by a woman or a man as a set of gender roles and I really want to manifest those gender roles but rather they say that you know before they've done anything and so that they're perfectly manifest and so the generals of the opposite gender in fact that I already am man or woman in terms of this kind of weird identity language that well seems quite unusual I'm curious why you think it's worded that way I think that there is like we're sort of using like different definitions of woman or like man or gender in this circumstance and the definition of gender that they're using is that gender is just whatever you say you are so like that's what they mean when they're saying that like I'm a woman before they've like manifested gender roles which I mean I think is like philosophically a very weak definition for women like it there's just like no content to it but like that is that is what they're expressing yeah okay so you would say that your perspective on a on gender identity then I thought you were trying to you just think yours is different than most trans people's then well I guess like I'm not very attached to the specific language right so like I think that if I'm included in like the philosophical or social category of like man or woman is not really as important as whether or not I'm able to like manifest those gender roles so like if people call me a man and like that's how they classify me but I'm still allowed to like wear dresses if I want or wear makeup I think that that's like an acceptable an acceptable reality and so like I just don't get hung up that much on specific definitions so if someone were to like say for the purpose of argument we're going to say men are people who have you know testes I think that would be like a legitimate definition and what I really care about is like what rights are attached to that we're not attached to it thank you so very much and another question or a question from alpha uno do gym goers or sports athletes have lower rates of transition I don't do that yeah I've no idea the question is do athletes have lower rates of transition yes indeed I would guess so but that's just a guess thank you for the question though but we're going to keep on moving forward from puamo 3116 I've got a question for Sean what specifically could April show you that you would accept as something that would move your position would you shift it if she could provide it by the end of the question and answers yeah so there are two things I suppose I could shift my position in a fairly clear way so one would be if I if like you know there was a new set of or new to me set of research findings that just contradicted my understanding of the pattern of attempted suicide rates by group if that was true then I would just alter my position and then also and that's possible the second thing I think is is so beyond the the evidential standards of transgender research I can't imagine this happening but if it were true that someone did a long-term perspective longitudinal study using normal meals mood scales but establish measurement and variance across the context and pre-register the study then that would be quite compelling too but I can't imagine that I mean or like a proper RCT that is able to account for the placebo effect yeah although that would be quite yeah and I would like to see them even just try like because a placebo effect especially for sex reassignment surgery real active placebo control group would be hard to do with hormone therapy it might be somewhat easier but they're not even doing sugar pills let alone like there's some there's some medical research where they do like sham surgeries on people and stuff and they're real extreme to try to get the the actual placebo going but again I can't see that ever happening yeah I think you would have to do it with HRT as far as I'm aware these studies don't exist and it's like why most of this discussion has been Sean pointing out that the evidence is weak and then me agreeing and saying that the evidence is weak but it's still showing something and I think that that is like so I get criticized a lot by trans people because I say things like well the evidence for the benefit of HRT is weak and what I'm meaning is that there are like methodological and like sample size issues and confounding variables and etc etc in all of these studies but what like where I'm able to give an olive branch to trans people more broadly is that like well okay yes there are these issues but like it does seem like there is a pattern here and just the best of our knowledge it seems like trans healthcare has an improvement even if like our knowledge is not that great and then I think that what Sean is saying is that like well our evidence is really not that great but then when we look at like a specific metric which I believe to be like more indicative specifically suicide we find even weaker evidence and then he's going to point out well in literature we tend to find false positives and there's a lot of precedence for that so what's the chance that we're just finding the false positive when no benefit exists and he's saying that that's very likely is that right is that pretty much your argument or am I like wrong um yeah the only thing that I would add is that there's I think there's similar possibility perspective of the suicide attempt numbers that there's a null effect and that there's an actual negative well yeah but other than that yeah that was a good summary 1776 super chat coming in from Noah's Arkansis thank you for the continued support my husband was born a woman and I can't even get him to stay in the kitchen our gender roles just to check that can't be cashed I am at loss what does that mean a track that can't be cash if your husband's a woman then presumably they are quite revealing against the gender roles associated with their sex so you know what can you do you marry the what you made thank you so very much again Noah's Ark for the super chat and $5 super chat coming in from counselor guy claiming that someone has a gender identity is assuming that they ascribe to a western post-modernist social constructionist interpretationist of gender I'm going to push back a little against this I think this is coming from people that are probably on my side but I mean there's a sense of which that's true I think which is that like people becoming preoccupied with gender identity happened in a specific philosophic and historic context in the west that is kind of connected with that certainly it rose a lot in connection with kind of deconstructionist and post-modern movements but it is worth saying also the like transsexuals in the west that existed prior to that I think there's some base rate of it just as a mental illness it's always going to be present and then even if people don't emphasize it a lot I mean there's like just this thing called personal identity and we have it with respect to a large set of properties and it's it's not implausible that one of those properties is gender I do think it's kind of weird the degree to which trans people sometimes obsess over that one but thank you for those responses and then another $10 super chat from Brandon Hansen April do you worry about this trend of transness and the rise of far-right groups mimicking the 1930s with the Frankfurt school and the rise of national socialism I mean not really because I think that it will it'll probably stop before it gets too crazy at least I hope it does I think that there's like a certain issue which is that being trans has become very much like a social battleground and definitely not the benefit of trans people which is I think why you get some certain claims about trans people which are just like not helpful and not beneficial and not accurate to like the research so like you have certain rallying cries like you know we need to get these trans kids hormones otherwise the wall commits suicide which I think is just like it's a political bludgeon which the left has picked up but ultimately it's going to hurt trans people because it doesn't seem like we have a lot of evidence for that necessarily and so I think that using this is just like not politically advantageous in the long run and eventually it's going to be revealed and it's going to hurt trans people and I think that it will not be good for us but I don't think that it'll result in like a reordering of society I just don't think it's that big of an issue Thank you so very much and on that we only have a few more questions left in a few more minutes of the Q&A so if you want your burning desire question send it it now and super chats will get you to the front of the line but does April have any thoughts about the WPATH so shape embracing informed consent for trans adults completely de-emphasizing gender dysphoria and stressing trans identity as the bar instead I think it's a position that really comes from this like freedom of choice argument where people will say that like well it's your body and so you ought to be able to do with it what you will as long as you are well informed about the effects rather than the argument that well doctors should prescribe something based on what they think would be like maximally beneficial to you so I think it's kind of like a philosophical difference in values here I think that sometimes people will point to WPATH guidelines as like an unquestionable authority in the field which I think is like a little bit wrong I think that they are they're specifically like an organization with a certain opinion on how transgender healthcare should be done but they're not like the end all be all so I think that like they're a good representation of that specific position but not necessarily a good representation of trans healthcare writ large thank you for that response and then a question from Take Time can you ask April to share their view about what exactly a gender identity is okay so I think that gender identity in the way that people use it typically just means that you want to like take on certain aspects that are associated with a particular sex so I think that and people wouldn't necessarily phrase it in that way but I think that practically that's what people are talking about so when someone tells you that like they're a woman what they mean is that they want to take on aspects that are that women typically take on so like that could be dresses but it could also be like emulating a certain kind of like butch woman aesthetic right those would both be examples of like taking on you know women's aspects and like the reason why I say that is because like a butch woman's aesthetic is distinctly different from a man's aesthetic and so I think that when someone says that they're like a woman what they yeah they're they're basically saying that they want to take on like a certain social role and appearance of someone who is typically a surgeon sex now do you think that's what gender identity means to trans people or to people like do you think that cis people when they say that what the gender is mean that not necessarily so yeah I answered it in the term of like I think this is what progressives think I think that like if you were to ask conservatives or like older people I think that they would just tell you that like gender identity is you know an understanding of your biological reality I think also if you were to go back in the history that's how most people would understand it if you were to just like ask them without explaining the concept but I think that like it varies from culture in the same way that like all words right like the specific sounds that we assigned to concepts will vary between cultures and I think that in the progressive culture the sounds gender identity refer to this like desire to present a certain way whereas I think that within history and within like more traditional culture they refer maybe more to like a biological reality well then do you think because I'm not even sure that's true because and I like I mentioned that I was talking to much progressive people and I said that um you know I present as a male in these various ways but I don't care about it at all suppose I just told them I was completely indifferent I had no sense of wanting one way or the other it just seems to do what's easiest would they say then that because I lack it desire to fulfill a given gender role that I'm not a man I mean I guess maybe they would say that but I think they probably would I mean like I think they'd be like well maybe you're non-binary right I think that like usually you won't hear them like telling you what you are right because I think that there is a lot of social stigma against that and also just because like there's this understanding that you can't actually know what's going on in someone's brain so it's possible that like the way that you represent yourself you know you might come to some self introspection but you change that opinion in the future so I think that's like the reason one of the reasons why they wouldn't like to tell you but I think that like a lot of them would think oh maybe you're non-binary I think that that's yeah I think that is accurate okay so you agree that it's like that's not how they would talk to me which is what I would have to to judge it on but that is what they would be thinking yeah and so like the reason why I kind of distinguish this is because I think that that's how people treat gender identity in practice but I think that there are certain like you know kind of like scripted descriptions where people will give to describe what gender identity is in the same way that like if you were to ask like the average person like what is a woman right not like a progressive ask like you know most people who are non-progressive what is a woman they will give you all sorts of different answers but like what they are essentially all getting at is that like a woman is someone with you know the ability to carry children to get pregnant was like ovum etc and so I think that that's what they might not say it in those words but they would be getting at that and so I think with progressive people they might not say it in the words that I expressed to you but like all of their actions would show that's basically how they're using the term question from and it looks like actually we have one super chat and then the last three questions so a super chat from Noah's Arkansas in what scenario does a kid begin hormone slash surgery treatment without an adult grooming them into that external adult influence not internal feeling no kid thinks to do complex surgery they had his quotes and I think that's kind of wrong at least in my case when I was like 14 years old I like read papers on gender transition and that's like what convinced me that like I wanted to transition and maybe like I'm a unique case of this but like it is certainly possible that people come to the conclusion on their own without any adult ever telling them about it I would assume they're talking about like my kid kids as far as like I don't know like 12 years old okay yeah I mean like they're probably not going to understand what gender transition is and that's why like obviously you shouldn't encourage them to get surgeries because they're not really like they just don't have like the ability to get reasonable input on that thank you a question from turbo April said cis women wouldn't get offended if someone said she wasn't a woman does she think the red pills community's purpose is not to externalize the feeling of what it is to be a man I don't know about the red pill community specifically but I think that like the important relevant metric is that like women have a cis women have a much greater sense of internal gender identity than trans people do trans people are much more reliant on being socially affirmed I think that trans people should be more like cis people in this respect an interesting I think a kind of funny way to think about the means so I mean how to put this one thing that signifies I think a degree of difference between the way in which trans people identify with their I don't really call it identified body in the way that cis people normally do is that like I think it's an over half of cases normally when people like lose a significant part of their body right that they're attached to in the normal way they feel they don't feel like dysphoria about it per se they feel like phantom version of because their brain has been hardwired to identify with and obviously dysphoria I think is a separate thing I think that points to a a difference in what we're calling identity across situations thank you and then the last two questions spicy coming in son what is your educational background to talk about trans issues and why do you care so much about what someone else is doing with their own body what type of evidence do you want I think I've answered the question about the evidence I want the education in the background is relevant is basically just that I claim anyway to have an understanding of how to interpret statistics broadly speaking and if you also think that you have the ability to do that and check what I say and evaluate for yourself if you don't my honest opinion is don't try to form your political opinions like based on social science if you don't even think you're able to read social science for that something else and then why do I care so much about this I mean it's kind of the two reasons it's very I think it is doing damage to society and it is a rising trend so there's that but then honestly the main reason is that I've been making content online for a long time and it's almost all not about trans stuff but people keep asking me to write stuff about trans stuff and I keep even though it's like one percent of the stuff I've written about I keep getting asked to do these rated debates about trans stuff and that's honestly the main reason why I've written the degree that I have about this stuff is just because for whatever reason it's what people want to argue about and we want to thank everyone for arguing about it because we love everyone out there in the modern day debate community because this is our last question I really do want to thank both of our interlocutors for sharing their time with us tonight but alpha uno asks would reinforcing rigid boy and girl gender roles in media decrease gender dysphoria I don't know I think that probably not for trans people and I would say that my guess would be it might it ended a more global transformation towards the way we regard a gender in the past would probably decrease gender dysphoria to some degree it seems like as we've changed our culture the rate at which people are suffering with this condition is also increased obviously that we this would be a whole thing to get into at the end of the debate but some people think that well that's just because people aren't being honest before never admitting it and I think there's a reason instead that's not probably not the case but that'd be a whole other issue thank you all of you out there on the interwebs for sending us your questions and for your support but I want to doubly thank our interlocutors and thank you all for joining us on modern day debate we are a neutral platform welcoming everybody from all walks of life if you enjoy this debate please don't forget to like follow and subscribe it really helps us reach a wider audience and make even more juicy content like tonight's debate on should transitioning be encouraged with our debaters April and Sean here to help us find that answer tonight plus if you like what any of our guests have said tonight both of the links are in the description below plus if you're looking for even more fun the after show at the MDD discord will be off the hook with that I am Amy Newman with modern day debate and we hope you continue having great conversations discussions and debates