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i'm sorry, but it's more complicated than that

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i'm sorry, but it's more complicated than that

2 followers   follows 0 users   joined 2022 September 04 22:05:51 UTC


Housing Poster. Series index here.


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I pointed to congressional votes.

This doesn't indicate what you think it does. Again, the started reason is that government involvement doesn't help and stated exceptions don't actually work. Which looks to be the case!

I don't think anyone out there with clout is stating that they want women to be able to abort at forty weeks on a whim the same way major organizations on the right say they want rape victims to be forced to carry to term.

Is this some sort of gish gallop of cases that maybe actually happened (almost certainly exaggerated in some area)?

These are the cases that I linked above; did you follow the links? I think I've described them pretty reasonably.

OTOH, we have the case of Kermit Gosnell, who is not even a 1 of 1.

The position here, which makes sense to me, was that if you make abortion hard to access, women will go to less reputable providers, not that Kermit Gosnell was a great guy doing a good job.

Many of the things that abortion activists feel are "onerous" regulations are simply reaction to his practice

These rules, which are somewhat obsolete in the wake of Dobbs since the point was to make abortion less accessible, date to well before Gosnell's crimes were discovered, and they go well beyond what would be required for safety.

It's doubtful that most environmentalists want to help the environment at all.

There are two different things called "environmentalism" I've seen described as 'Green' and 'Gray'.

Green environmentalism is fighting development to save the forest or save the stream or save the neighborhood. It's judging how much harmony you have with the environment by counting the trees you can see from your front porch. It's "we tread lightly on the earth here". It's this tweet showing an aerial picture of Manhattan with the caption, "reminder that the people lecturing you about Earth Day today live here". It's a conviction that we will only be saved by not doing things.

Gray environmentalism is shutting up and multiplying, and is primarily concerned with climate change. It's judging your environmental impact by calculating your carbon footprint. It might be getting an electric car, but it's even more so moving to a city and getting an electric bike instead. It's heat pumps and rooftop solar and nuclear power if we can ever manage to get costs down. It's living near a park instead of having a huge backyard. It's this tweet, dunking on the above by pointing out that Manhattanites have some of the lowest per-capita carbon emissions in the country. It's a conviction that we will only be saved by doing things.

It would be nice if these groups could get along, but they really don't have that much in common.

Deregulation to increase housing development feels like the biggest bang for your buck pro growth policy out there.

This is literally true. See Hsieh and Moretti (2019) and Caplan's addendum; the fact that people can't move to opportunity is a horrible drag on the economy as a whole.

Parking may get more difficult for some but to me that’s a fair trade.

Parking issues are down to economic illiteracy. Parking is scarce because the price is too low (zero almost everywhere), though the cost is distributed elsewhere. We value the time of people seeking parking at zero, so rather than charging enough for parking that there's a space or two free on every block, we mandate ever-larger parking craters in cities. Here's a summary of Donald Shoup's work on parking economics.

I think they just really like abortion and the idea that a woman can change her mind about child rearing at any time.

Okay, but why do you think that? Yglesias is pointing to the stated positions of mainstream conservative interest groups. You're pointing to what, exactly?

This is just a weaponization of womans tears argument.

You're referring to Richard Hanania's idea that women get what they want by pitifully crying so that men will look or feel like monsters by not acceding to their demands?

I understand that you're citing your own lived experience here, but maybe we can do better than that? "Woman's tears" didn't help the 13 year old who's now raising a baby. "Woman's tears" didn't make it so the woman carrying a corpse didn't have to fly halfway across the country and pay twenty-five thousand dollars to save her own life. But the people putting these policies in place were very clear that Shirley these things would not be allowed to happen. Or that Shirley, it would happen to someone else. (If you can stomach reading an advocate's view, here's Jill Filipovic explaining why abortion policy is so hard for precisely that reason.)

The world you're describing, where women can easily just cry to get whatever they want, does not appear to be the world in which we live, certainly not in terms of abortion policy.

Medical care for the indigent and elderly is an extraordinarily popular policy. While I'm curious about why you think it's "destructive", either way, I don't think you need an extra explanation about "women's tears" to explain why very popular policies are hard to dismantle.

As real life continues to contain a lot of stuff, my posting continues to be more occasional, so this is a twofer.

First, Ben Christopher for Calmatters, "Los Angeles’ one weird trick to build affordable housing at no public cost". (Part of an itinerant series on housing, mostly in California. Also at TheSchism.)

"Affordable housing" in California generally means deed-restricted subsidized housing, discussed in depth here. It involves specialized nonprofit developers, a "layer cake" of various granting agencies, a web of everything-bagel requirements from union-only labor to LEED Platinum that really add up.

In December of 2022, the Mayor of LA, Karen Bass, signed Executive Directive 1, which put a sixty-day approval timeline on 100% below-market rate project and skip the discretionary and environmental review processes, but without adding the usual everything-bagel requirements. These projects also get so-called "density bonus" concessions, which allow them to ignore or soften a variety of local restrictions on setbacks, density, height, and so on.

As a result, no public subsidy is needed, and the market just... produces these things.

Though publicly available data on financing is sparse, an early analysis of the program by the pro-housing advocacy group Abundant Housing LA estimated that roughly three-fourths of affordable units proposed through the policy are doing so without any public money.

More details from Benjamin Schrader here and from Luca Gattoni-Celli here. It's especially important because the Bay Area is planning on shoveling enormous amounts of public money at the problem (meme form here), and maybe there's another way.

The key thing here is to Voltron together "ministerial approval and sixty-day timeline" with "unlimited waivers and super density bonus", without sandbagging it somehow. As one of the developers in the article puts it: “To go from acquiring a lot to putting a shovel in the ground in less than a year is kind of unheard of.”

However, nothing good can last; this was accidental, kind of like the time Rhode Island legalized prostitution. David Zahniser for the Los Angeles Times, "Faced with community complaints, Mayor Karen Bass retools her affordable housing strategy".

But ED1 also sparked a backlash from some community groups. Tenant advocates said too many ED1 projects are triggering the demolition of rent-controlled apartments, upending the lives of renters. Homeowner groups complained that ED1 projects have been proposed in historic preservation districts, raising the specter of six-story apartment buildings sprouting up next to stately Victorians and rows of Arts and Crafts bungalows.

The changes would exclude sites with twelve or more rent-controlled properties (regardless of residents' incomes), historic districts, and very high fire hazard severity zones (which might make sense, but you can still build everything else there). Everyone wants to dip their beak.

Pete Rodriguez, Western District vice president of the United Brotherhood of Carpenters and Joiners, said any permanent ED1 ordinance should include provisions that create “more middle-class jobs,” such as requirements for a prevailing wage.

Cindy Chvatal, co-founder of the group United Neighbors, which has pushed back against proposals to rezone lower-density neighborhoods, was far more upbeat. She credited Bass for working with an array of community groups over several months to address concerns about ED1, including the encroachment into historic districts.

(United Neighbors is closely related to Livable California, one of the state's preeminent NIMBY organizations.)

It's unclear how much of an actual effect this will have. Much will depend on whether the policy is expanded or curtailed, going forward.

It’s still far from clear how much of an effect the latest changes will have. Of the more than 200 project applications filed so far, 10 were proposed in historic districts, according to the mayor’s team. Fewer than 10 were proposed on sites with 12 or more rent-controlled apartments, they said.

Also, this week in Berkeley, land of the historic homeless encampment, remember the sacred parking lot, last seen in 2021 where the developer won a ruling?

Ally Markovich for Berkeleyside, "Berkeley will buy Ohlone shellmound site, return it to Indigenous land trust". In March, the city bought the property (mostly with money from one of the indigenous-activist groups) and gave it to the tribe.

The Berkeley City Council unanimously approved an ordinance today authorizing the purchase, making Berkeley among the first in the country to outright return land to Indigenous people. The city will purchase the property with $25.5 million from Sogorea Te’, an Indigenous-led land trust based in Oakland, and $1.5 million from the city’s general fund.

How, might you ask, did the Sogorea Te' get twenty-five million dollars, which seems like a lot for a local band of busybodies?

The money for the purchase comes primarily from the Sogorea Te’ Land Trust. Bolstered by a $20 million contribution from the Kataly Foundation, a family foundation funded by Regan Pritzker of the Hyatt hotel chain and her husband Chris Olin, Sogorea Te’ appears to be the best-funded organization in the nationwide land-back movement, based on tax records reviewed by Berkeleyside.

The city has, in total, spent five and a half million dollars on this.

Berkeley is still on the hook for $4 million for mishandling the application to build housing on the site. In February, an Alameda County Superior Court judge fined Berkeley $2.6 million for violating the Housing Accountability Act when it denied Ruegg & Ellsworth’s application for a housing project on the site. Berkeley was also ordered to pay $1.4 million for attorney fees.

(This may seem like a lot, but Berkeley's annual city budget is over half a billion dollars, or about five thousand dollars per resident.)

The people who now have the land are celebrating.

“We set down a prayer here when we danced just now,” said Gould. “We are using our bodies to put down those prayers because underneath this asphalt our ancestors still hear us and they are calling on us to continue. This is not the end of it. This is the beginning of a new chapter.”

As noted in the 2018 EIR, this is not actually a shellmound or burial ground, but the Ohlone believe that it is, and everyone here is respecting their beliefs. (This is not noted in the article. I've requested a correction.) I remember, but cannot find, some initiative to use "indigenous ways of knowing" or the like in public policy. This is what this looks like in practice.

Sorry, can you be clearer about what you think is "false for the majority"?

I understand that you may not have seen that precise argument... but it's in the quotes upthread. “You can’t get rid of it.” “I guess I thought that, you know, he would not do this, he would not take health insurance away knowing it would affect so many peoples lives." Surely this bad thing can't actually happen.

As it's written:

Once upon a time, I believed that the extinction of humanity was not allowed. And others who call themselves rationalists, may yet have things they trust. They might be called "positive-sum games", or "democracy", or "technology", but they are sacred. The mark of this sacredness is that the trustworthy thing can't lead to anything really bad; or they can't be permanently defaced, at least not without a compensatory silver lining. In that sense they can be trusted, even if a few bad things happen here and there.

There absolutely is disbelief that awful things could actually happen; you see it everywhere. Surely it won't be that bad. Surely people will be reasonable. Surely it will work out for the best.

I think you're being overly narrow in what you think of as The Shirley Exception.

I don't think there's the symmetry you think there is. Institutions on the right are specifically very keen on women in those circumstances carrying to term.

On the left, it's not so much the idea that women in the 40th week can and should and would just change their minds like that, but rather that in situations like, say, this one, having the heavy hand of the government involved will just make things worse. And that narrowly written exceptions don't actually help, given situations like this.

The idea is, if I understand correctly, that the heavy hand of the law will just make things worse, because the Shirley exception is not an actual usable piece of law.

Yes, but the contents also matter, and this is just lazy of you. Who do you think is going to write about this sort of thing? The right?

Yglesias is pointing out that the stated positions of conservative interest groups (e.g., no abortion even in cases of rape our incest) are sometimes really unpopular (per Gallup polls quoted by the FRC), and conservative politicians have become quite good at tiptoeing around this.

DFP did some surveys that discovered that Republicans specifically had some weird ideas about the party's platform; a majority thought they had a healthcare plan that would protect people with pre-existing conditions and opposes the rollback of certain environmental protection rules, nearly half thinks they want to expand Medicaid. These are all wrong. People don't know the party's platform.

The Vox article involved Sarah Kliff interviewing a lot of people who had lost their healthcare under Republican policies, who said things like:

“We all need it,” Oller told me when I asked about the fact that Trump and congressional Republicans had promised Obamacare repeal. “You can’t get rid of it.”


“I guess I thought that, you know, he would not do this, he would not take health insurance away knowing it would affect so many peoples lives,” says Debbie Mills, an Obamacare enrollee who supported Trump. “I mean, what are you to do then if you cannot pay for insurance?”

What part of this do you think is fake or misleading? A significant portion of voters don't know their party's platform, and won't believe it if you tell them because it sounds bad.

Nobody is impressed with the substance of Biden's answers. Nobody even really cares what they were. Obviously, we all already know what Biden's policies are and what his candidacy means. For that matter, nobody cares what the substance of Trump's answers was either.

Maybe the folks here do, because we're all policy wonks ignorant of politics. But I've run into people in the wake of the 2016 election who didn't know what Clinton's position was on opioids, or on Appalachian economic development, or on climate policy, or on Net Neutrality.

This is enough of a problem that if you explain Republican policies in a reasonably objective way to people, they'll frequently think that you're making things up, because of course no one would do something that evil. (Example, example, example.)

The modal voter isn't nearly as well-informed as you seem to think they are. I don't know to what extent the debates would inform them on policy (I've written elsewhere on the potential value of the format), but the starting place isn't where you're describing it.

Thank you for providing context; I really should have included the depth of housing problems at Berkeley (see page 10 and following). About a tenth of students were homeless at some point, though this mostly took the form of couchsurfing. (This matches up with how homelessness works; it's mostly temporary, and people only wind up on the street when they've exhausted their social networks.)

I'd also point out that the University predates the city; the city is there because of the University, which makes claims that the University is ruining the City, in a way, confused.

On another topic, I'm really skeptical about the university's plan to put a homeless shelter right next to a student dorm in the proposed People's Park development.

On the one hand, the homeless people are there in the area around the University already; they're just outdoors. On the other, I absolutely see what you mean. This is a hell of a compromise; more than half of the space will still be a park (an actual park, this time), and there will be more homeless/formerly-homeless people living on the site after the project is complete. It's a testament to just how ideologically committed the left-NIMBYs are that none of these concessions even registered. The maximalist position, I think, would have been an enormous mega-dorm covering the entire footprint of the site, and that's nowhere on the radar.

Perhaps the university is simply planning to build the dorm first and then drop the homeless shelter idea once the dorm is already fait accompli.

I don't think they're insincere, but ironically, the level of protesting has made this outcome considerably more likely. Supportive housing development, like any publicly-funded housing, involves a "layer cake" of various overlapping funding sources and deadlines, a byzantine array of mutually near-contradictory requirements, and so on. (Previously discussed here.) Any disruption or delay can trash the whole process.

In a sense, this is sad, but in another sense, it's probably good for me.

If I had to predict which service was going to become a walled garden, I wouldn't have picked Twitter. Is this enshittification?

Vague swipes at "liberal judges" aside (it's more of a cyclical thing), I think the reason the federal courts wind up legislating from the bench so much is that Congress is so useless.

On the other hand, the California legislature, while sometimes frustrating, actually does things (see here, here, here, here, and here, for example), so you don't in practice see the thing where the courts say "well, Congress could gainsay us if they wanted to", and the court's ruling stands no matter how politically-charged, because Congress generally has enough veto points to prevent it from doing anything controversial.

You can see a worked example of the California process in this very story, where the courts held that "people talking" is an environmental impact, and the legislature passed an urgency measure near-unanimously to gainsay them. (An urgency measure requires a two-thirds majority and takes effect immediately instead of at the beginning of the following year.)

Had this happened in federal court, I assume we'd just be dealing with the ruling and all of its ridiculous consequences.

It rhymes, doesn't it? Hopefully there's no semi-coherent greater meme infrastructure that this all hooks into, but who knows?

Thank you for the heads-up; fixed!

NBC Bay Area, "Protests continue as large walls surround People's Park in Berkeley". (Part of an ongoing series on housing, mostly in California. Also at theschism.)

(Notes on browsing: some of these links are soft-paywalled; prepend archive.today or 12ft.io to circumvent if you run into trouble. Nitter is dead and Twitter doesn't allow logged-out browsing; replace twitter.com with twiiit.com and try repeatedly to see entire threads, but anonymous browsing of Twitter is gradually going away, alas.)

I've covered historic laundromats and sacred parking lots, but what about a historic homeless encampment?

In 1969, some Berkeley locals attempted to make a vacant University-owned lot into a "power to the people" park. The University decided to make it into a soccer field and evicted them a month later. Later that day, at a rally on the Arab-Israeli conflict, the Berkeley student President suggested that the thousands of people there either "take the park" or "go down to the park" (accounts differ), later saying that he'd never intended to precipitate a riot. The crowd grew to about six thousand people and fought police, who killed one student and blinded another.

The park has stayed as it was since then. UC Berkeley has attempted to develop it, first into a soccer field, then in the 1990s into a volleyball court (made unusable by protests), then in the 2010s in an unclear way which involved a protester falling out of a tree they were sleeping in, and most recently starting in 2018, into student housing with a historical monument and permanent supportive housing for currently homeless people.

The status quo involves police being called to the park roughly every six hours on average as of 2018, colorful incidents like a woman force-feeding meth to a two year old, and three people dying there within a six-month span. (There are forty to fifty residents at a given time.) The general vibe from students matches up.

The 2018 plan started having public meetings in 2020; when construction fencing was built in 2021, protesters tore it down; a group calling itself "Defend People's Park" occupied it and posted letters about how an attempt to develop the site is "gentrification", the university could develop "other existing properties", the proposed nonprofit developer for the supportive housing has donors which include "the Home Depot Foundation, a company that profits off construction", and so on.

Legal struggles are related to the 2022 lawsuit to use CEQA to cap enrollment at Berkeley and a lawsuit using CEQA to claim that student noise is an environmental impact. In the summer of 2022, SB 886 exempted student housing (with caveats and tradeoffs) from CEQA, and AB 1307 explicitly exempted unamplified voices from CEQA consideration. The site has been one of about 350 locally-designated "Berkeley Landmarks" (one for every three hundred and forty Berkeleyans) since 1984, but was added to the National Register of Historic Places that summer as well in an effort to dissuade development. (The National Trust sent a letter in support of that student-noise lawsuit.) Amid all this, RCD, the nonprofit developer attached for the supportive housing, left the project, citing delays and uncertainty. The State Supreme Court agreed to hear the case in the summer of 2023, but the case may be moot in light of AB 1307. The university says yes, and "Make UC a Good Neighbor" says no. Search here for S279242 for updates.

And that brings us to this January. On the night of the fourth, police cleared the park in preparation for construction, putting up a wall of shipping containers which they covered in barbed wire the next week to prevent people from climbing them.

Local opponents of the project take the position that "Building housing should not require a militarized police state", which seems to indicate support for a kind of heckler's veto. And, of course, it should be built "somewhere else". (This meme, basically.) Kian Goh, professor of urban planning at UCLA: "So, do places of historical and present political struggle not matter at all to yimbys? Or do they just not matter as much as new housing?".

Construction appears to be proceeding, after more than fifty years of stasis. Noah Smith attempts to steelman the NIMBYs, but I don't find it convincing. I'm sure the people who cheered burning down subsidized housing in Minneapolis saw themselves as heroes, but that doesn't make them any less wrong.

As a postscript, the City Council member representing the district of Berkeley including People's Park is Rigel Robinson, who entered office at 22 as the youngest ever councilmember, and was generally expected to be the next mayor. He abruptly resigned on the ninth, ending what had been a promising political career, likely due to death threats stuck to his front door. The Mayor of Berkeley wrote a supportive opinion piece; a fellow councilmember wrote a similar letter. On the other hand, a sitting councilmember in neighboring Emeryville retweeted "Sure sounds like going YIMBY ruined it for him. Here's to running more real estate vultures out in 2024 🥂". People are polarized about this. It's made the news.

I'm going to nutpick one of the comments from an article on his resignation, as a treat.

The Park People could care less about council members, the next one will be equally clueless about the Park's existence; the Park is beyond municipal dictatorship, it is a world-level political symbol that has now been "awakened" again. The Big Surprise will be the decision by the State Supreme Court to find AB 1307 unconstitutional.

If only people could live inside a world-level political symbol. Current plans for construction at the site are here.

There is a classic industrial accident involving a storage tank.

You may appreciate USCSB's "Hazards of Nitrogen Asphyxiation" video as well.

According to this veto message:

In March, I announced the state's partnership with Civica to create our own line of CalRx biosimilar insulins that will cost no more than $30 per 10ml vial or $55 for five 3ml cartridges. This is a fraction of the current price for most insulins, and CalRx biosimilar insulins will be available to insured and uninsured patients nationwide. With CalRx, we are getting at the underlying cost, which is the true sustainable solution to high-cost pharmaceuticals. With copay caps however, the long-term costs are still passed down to consumers through higher premiums from health plans. As a state, we have led the nation in our efforts and investments to address the true underlying costs of insulin prescription affordability.

Here's the site on CalRx. They plan to start manufacturing next year.

Perhaps I've been unclear. I also dislike vandalism. Not as much as I dislike violent extremism, but I find it distasteful and I don't endorse it. I'm providing some context for why people feel so strongly, but I'm not endorsing vandalism. I hope that clears things up.

"I come back to you now, at the turn of the tide." Or at least, the turn of the legislative season. Some life changes have led to Less Posting, as I've had to focus on more meatspace matters. But the legislative roundup is worth doing. Here's my understanding and my take on the 2022-2023 California legislative season as it relates to housing. (See also Alfred Twu's very detailed writeup (PDF).)

(Part of an ongoing series on housing, mostly in California. Also at /r/theschism.)

This has largely been a successful year. While the YIMBYs didn't get everything they wanted, they got a lot of it, and they are very happy. The major wins:

The major losses:

Note that while the Governor's veto can theoretically be overriden by a two-thirds vote, that hasn't happened since 1980. Also vetoed despite passing the Legislature: SB 58, psychedelics decriminalization (veto message) and SB 403, banning caste discrimination (veto message).

There's some speculation that Governor Newsom is trying to avoid signing anything that would look bad during a Presidential run. Hot take: "Californians suffering so their governor can finish 4th in New Hampshire, they have more in common with Florida than they think".

There is no way to bring a person back on their original development trajectory after they have been affected by blockers.

Well, yes, in a very literal sense, there's no such thing as an action without consequences in the most general sense, but the drugs do not appear to be horribly dangerous in the general sense, which is why they're used for kids who are going through puberty at the wrong time.

For scale, I'd point out that we regularly perform surgery on healthy adolescents, as well as on infants, sometimes in ways that make them very definitely infertile, but despite considerable activism, this hasn't become nearly as much of a major issue, likely because these things are done to make children more gender-conforming, as opposed to less.

The level of concern about potential bone-density impacts, for example, seems disproportionate compared to the way we disregard much more serious issues when no one involved is gender-nonconforming.

Keep in mind that the reports that these reports are untrustworthy, are themselves untrustworthy.

Reed's claims are pretty straightforward: the standards of care that the clinic was supposedly following were flagrantly violated. This should be, in theory, simple to resolve, modulo medical privacy issues. The fact that people who were at the clinic says that their experience doesn't match what she reported seems at least somewhat relevant.

It genuinely worries me that this is the strength of the evidence base on which doctors are heavily implying to parents, "Give your kid this drug or they will kill themselves."

And here, we're back to the beginning. While it matters what the right thing to do is given the pitiful state of the evidence we have (Scott just posted about people dying from an overabundance of caution), I firmly agree that I'd much, much rather know whether the use of puberty blockers in certain instances prevent suicide than not know.

As it stands now, we're either endangering a lot of kids' mental health and very lives, or we're performing nontrivial medical procedures on them that, while not "sterilizing children and making lifelong medical patients of them", aren't actually necessary. I think the evidence leans more toward the former, you think the latter, but the confidence interval is disconcertingly wide.

She may yet prove a liar, but Hannah Barnes, chronicler of the Tavistock's implosion, considers Reed's story basically plausible.

Maybe we're doing Reference Class Tennis here, but the thing this reminds me of is people making outlandish claims about Planned Parenthood, i.e., that they're coercing women into getting abortions so they can sell the parts on the black market, which turn out not to be nearly as spicy as originally reported.

Mainly it looks like you're citing violations of WPATH's standards. You'd think the solution would be to enforce the agreed-on standards, not essentially ban this class treatment altogether. The solution to Kermit Gosnell, for example, wasn't to shut down Planned Parenthood, because performing a service badly doesn't mean that the service shouldn't be provided.

I agree that Tordoff et al.'s work is of lesser quality, and that there simply doesn't exist gold-standard evidence on this issue. I find Turban et al.'s work more convincing.

This is the quality of the evidence base on which doctors are sterilizing children and making lifelong medical patients out of them.

To be clear, we're talking about puberty blockers, which "are falsely claimed to cause infertility and to be irreversible, despite no substantiated evidence".

The WPATH standards, which are on the radical side of global medical opinion (Scandinavian rules, as @arjin_ferman points out, are much more restrictive) emphasize social transition, then possibly puberty blockers, then possibly cross-sex hormones, then possibly surgery. To the extent that it looks like this standard of care isn't being followed, those reports are themselves untrustworthy.

If you're upset about something going on in the world, it behooves you to make sure you're clear on what's actually going on.

Why is it ethical to RCT every other medication before it gets approval?

You're right; I'm not sure what I was thinking. I guess you'd enter adolescents with gender dysphoria into a study, and either give them puberty blockers or a placebo, would be hard to keep secret from the patients. But I'm reminded of AIDS patients desperately trying to beat the blinding system in the AZT trials. ("There were also stories of patients from the 12 centers where the study was conducted pooling their pills, to better the chances that they would get at least some of the drug rather than just placebos.") And a story I can't find right now about a teenager who stole HRT from their mother back in the sixties or seventies.

My concern is less that people are ignoring the evidence we have (as you point out, the best we have is an uncontrolled retrospective study), and more that the people fighting the use of puberty blockers in teenagers have no interest in answering these questions. I see this in the pre-emptive excuse-making; if we did do an RCT and puberty blockers saved lives, maybe the whole thing is still social contagion?

Finally, there being a positive signal in the literature that blockers may reduce suicide risk does not justify scaring the parents into allowing blockers for their kids. Far more confidence is needed to make such statements ethically.

And here we're back to the beginning. If you say, "a massive uncontrolled retrospective study found that kids who present with the symptoms your kid is presenting with were less likely to commit suicide when given this treatment", are you "scaring the parents into allowing blockers for their kids"?

Thanks! I'd previously seen the difference between the Swedish model and WPATH recommendations, and kinda dead-ended there, because I'm not a researcher, just a layman trying to do my homework. (For example, I don't know how you could ethically do an RCT on puberty blockers in children and adolescents.)

I do notice that the NICE report excludes Turban et al. (the strongest evidence I'm aware of that puberty blockers reduce the risk of suicide) with the explanation "Intervention – data for GnRH analogues not reported separately from other interventions". (I don't understand why the criteria were set to exclude nearly every study.) On page 19 and following, it relies entirely on de Vries et al. (2011), which is a prospective study of seventy people, to conclude that "This study provides very low certainty evidence that treatment with GnRH analogues, before starting gender-affirming hormones, may reduce depression." So, in plain terms, it looks promising, but we don't have enough information to have a strong opinion.

It looks like the state of evidence is different now than it was in 2018. These questions are, generally speaking, answerable, and it looks like the best information we have indicates that puberty blockers reduce the risk of suicide in adolescents with gender dysphoria. Perhaps a good use of time would be to develop better diagnostic tools so that dysphoric adolescents who will likely not pursue transition aren't offered puberty blockers, and those who likely will, are.

Okay, that's fair! So, to be clear, this is a question of fact, and if the best estimate we currently have says that puberty blockers are, in particular circumstances, linked to a lower risk of suicide, then you wouldn't have an objection?

they have no evidence that it reduces the risk

I'm aware of Turban et al. (2020) and Tordoff et al. (2022). Note that as of 2018, a literature review concluded that "the psychosocial effects of gender-affirming hormones in transgender youth have not yet been adequately assessed". So at that point, the right thing to tell patients and parents would be different. But it looks like you can reasonably say that puberty blockers are indicated in certain circumstances, and not using them carries an increased risk.