grendel-khan
i'm sorry, but it's more complicated than that
Housing Poster. Series index here.
User ID: 197
grendel-khan
i'm sorry, but it's more complicated than that
1yr ago
I think it's worth trying to empathize with these people. Consider this previous discussion on some comments by Matthew Cortland, where he vociferously argues against the concept of QALYs, because as a disabled person, QALYs value his life less than that of someone who isn't disabled.
On the one hand, it is devastating to be told that you're not an entire person, even in an accounting sense.
On the other, when you're doing a utilitarianism, either you're going to count disabled people less than non-disabled ones, or you're going to see nothing wrong with deafening someone, or blinding them, and so on.
grendel-khan
i'm sorry, but it's more complicated than that
6mo ago
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.
grendel-khan
i'm sorry, but it's more complicated than that
1yr ago
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.
grendel-khan
i'm sorry, but it's more complicated than that
1yr ago
Thank you so very much! Honestly, it's very motivating to not feel like I'm yelling into a void about this stuff, so the fact that you're here and reading means a lot to me.
grendel-khan
i'm sorry, but it's more complicated than that
1yr ago
Doesn't this prove too much? Attempting to destroy gay or lesbian communities seems bad in the same way; aren't they also "(largely) voluntarily sterile"?
grendel-khan
i'm sorry, but it's more complicated than that
1yr ago
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"?
grendel-khan
i'm sorry, but it's more complicated than that
1yr ago
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.
grendel-khan
i'm sorry, but it's more complicated than that
1yr ago
Hey, I'm really sorry to have not replied here; I've been off themotte for a while.
From what I can tell, investors require parking because they believe that it's required to make the units sellable, so, yes to your first guess. It's an amenity like any other. And while all said they'd require parking in the area in question, many of them said that they wouldn't put in parking if the area was better-served by bike or transit infrastructure.
grendel-khan
i'm sorry, but it's more complicated than that
1yr ago
Thanks! I'm glad folks are interested.
(even if only to keep more Californians in California and not dragging their policies to me)
Now I'm going to be a humorless scold about this; the problems that California has are due to a combination of its policies and its luck. The housing crisis that came to California was a slow burn caused by gradually-applied restrictions on growth which made it so when boom times came, the market couldn't respond. The boom time, in scale and duration, is unique to California, but the policies aren't, which is why Austin is going through the same thing that various California cities do where the rent rises, homelessness surges, and the main response of the city is to obey the very angry citizens and chase homeless people from place to place, trashing their belongings as they go.
The policies are already there. To the extent that California is responsible, it's by displacing people out of the state. Just as in California, the homeless are demonized as outsiders, when they're mostly just people who used to be housed there, but can no longer afford the rent.
grendel-khan
i'm sorry, but it's more complicated than that
1yr ago
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.
grendel-khan
i'm sorry, but it's more complicated than that
1yr ago
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 don't understand; do you think that the existence of people with bad ideas who voted blue means that we shouldn't point out when someone is reasoning badly? Do you think that I'm backing that particular conspiracy theory? (I'm not; I only faintly remember hearing it years ago.) Aren't we supposed to sharpen each other, as iron sharpens iron?
"Someone who you remind me of reasoned badly, so you shouldn't complain about me reasoning badly" is a poor approach.
grendel-khan
i'm sorry, but it's more complicated than that
1yr ago
Are folks here familiar with Scary Pockets? They do a lot of funkified covers, e.g., "Crazy", "I Want It That Way", "Toxic", and many, many others.
I'm not a doctor, and I'm certainly not an expert in communicating with people. But is that how doctors communicate in other circumstances? Does a doctor who notices that you smoke simply provide dry info and leave it at that? From what I can tell, standards around informed consent focus on whether or not information has been provided in a legible way to the patient or caregiver, not on the fastidious maintenance of strict neutrality.
I don't know how this was presented, and neither do you. But it's a stretch to say that it was presented meaningfully differently from how other medical procedures are offered, i.e., it reflects the standard of care in medicine generally. And if your issue is with the standards for informed consent, why tie it to a controversial set of procedures where the public, at least, absolutely does not agree about the risks and benefits?
In short, the dialogue looks like this to me:
It looks like either you're holding gender-nonconforming medical interventions to a uniquely high standard, or you're expressing a general issue you have with medical-ethical standards in an unnecessarily controversial manner.
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