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Notes -
Are puberty blockers chemical castration?
A follow-up to the discussion with @netstack
This was originally a deep-chain reply, but after a few spergy, reddit-tier replies on my end, and @netstack's saintly curiosity, the conversation resulted in a decent-quality argument, that I'd like to get more eyes on and see I missed any obvious objections.
I did some extra digging as well. The wiki for Lupron links to the paper "Reforming (purportedly) Non-Punitive Responses to Sexual Offending", and while it's about triptorelin instead of Lupron, it's another GnRH. In any case a systematic review of the use of GnRH on sexual offenders (sci-hub) should hopefully settle the matter.
As a side note this paper makes me think the difference between GnRH's and DMPA's is that the former have (or promised to have) fewer side effects, not that they work on a fundamentally different principle (and while we're on the subject, let me just say I'm rather bemused at all the handwringing in all these papers about the side effects of these drugs on convicted sex offenders, when I compare them to the dismissal of any such concerns around giving the same drugs to children).
No, it just completely went over my head, lol.
This is a fun one. From what I understand chemical castration is meant to be reversible. This is what the wiki for chemical castration says right on the top, and I saw, but failed to bookmark, a paper that made that claim about DMPA's specifically, but that seems to be the general consensus on chemical castration:
So if irreversibility is a necessary condition for classifying something as chemical castration... than it seems that chemical castration does not meet the standard.
Now, I'm somewhat sympathetic to the "non-central" argument, you can argue that something that's reversible doesn't quite have that quality of having one's balls cut off that you'd expect from a term like "castration". It is also true you're going to have a hard time finding sources about the reversibility of puberty blockers, since dr. Cass' team looked, and all they can say is:
But when gender care providers themselves tell me that "puberty blockers are reversible (asterisk)", the asterisk being you can't stay on them too long, or that if you start them too early you're never going to have an orgasm, when celebrity cases like Jazz Jennings say they don't regret going on blockers, but the downside was "there wasn't enough tissue to work with when it came to the surgery" (and also don't know what an orgasm is), when the industry comes up with procedures like sigmoid vaginoplasties or zero depth vaginoplasties to either hack around or throw up their hands about the issue, can we say that there are good reasons to suspect some of the changes may be irreversible? What is even supposed to be the mechanism for reversibility? For a fully developed adult it's just a question of restoring testosterone levels and sperm counts, but for a child that never went through puberty we're basically hoping their body will catch up with development as if nothing ever happened.
Yeah, I know that as far as evidence goes, this doesn't rise to the standard of a proper well-designed study, but like I said in the other comment, the gender industry isn't particularly transparent about results they don't like. I understand wanting to remain agnostic on the reversibility question, but if you grant that these concerns are reasonable, it seems like puberty blockers are an at least as, and may possibly turn out to be more of, a central example of chemical castration, than chemical castration itself.
I think more people could understand the depths of this debate better by steelmanning the pro puberty blocker/pro HRT side a little and seeing that allowing people to go though puberty normally is also not reversible. And a lot of transgender adults (and teens off the very basis that they are seeking out hormones) openly express that they wish they didn't have to go through their natural puberty.
So from their perspective what bans can end up doing is that instead of the person getting to decide which irreversible thing they go through based off their own desires, it's the government choosing for them.
There is no simple choice here, someone will be upset by permanent changes. A teenager who makes a mistake and gets on hormones without consideration, or a teenager who is forced to go without care and ends up as a sad trans adult who just wishes they had the autonomy given to make choices about their own body when they were younger.
And blockers came up as the compromise solution and promoting them as the free space where everything can be reversed seems just like wishful thinking from everyone. Because if it's true then it's a very easy solution that won't cause any harm.
The part many on the left are missing is that puberty itself is a large part of the mechanic by which teens become heteronormal. When I was around 12, I felt disgusted by teens, sexuality in general and was a somewhat odd kid to begin with. At that time there already was lots of talk about nonstandard sexualities and I strongly identified with asexuals. I also thought that I was very far from the average male, among other things refusing any kind of violence (I distinctly remember refusing to even watch shows/movies or play games portraying violence), an intellectual above all kinds of base instincts. Typical arrogant nerd stuff. Especially early puberty then felt like shit, very moody & scared of what happens with me. Then sometime in late puberty all of that went out of the window, suddenly I was a temperamentally fairly stereotypical guy. And even in retrospect, I had been to some degree in denial even when younger. In elementary school I was often beating up other kids for various reasons. I just learned that I was going nowhere with that attitude, so I had to force myself out of it and pretended that it never happened. Which combined with my otherwise bookish personality naturally led to the described intellectual self-image.
Conditionals are obviously hard to prove, but I could easily see my pre-puberty self taking puberty blockers to not become a disgusting, violent, sexual men. Especially with the argument that oh, it's reversible anyway, so just try it out. It would have been a grave mistake, but I wouldn't have known, and in particular it's easy then to then just stay the course and tell yourself you took the right option.
My wife is very similar in the other direction; She always was a tomboy who felt more comfortable with boys, then puberty hit and she changed. She also could see herself mistakenly choosing to take puberty blockers in her youth. And now our daughter is just the same, so we make sure to always tell her that her mom had the same struggles. Imagining her mistakenly getting talked into puberty blockers is horrifying, and worse, very plausible.
So overall while I have quite some sympathy, going through puberty seems like the less-bad option even for the majority of those who feel somewhat uncomfortable with their sex.
I'm going to play Devil's Doctor here:
You underwent a drastic change in your personality as a consequence of a hormonal surge that was out of your control. That's 'normal'. It's puberty.
Yet the person you became isn't the same person as the one before. I mean, puberty hit me hard, but I never felt as if my values or goals changed because of it (beyond being even more eager for the company of the fairer sex).
This seems to me to be analogous to a person who, for their entire life, had sworn off addictive substances, but ended up on benzos or opioids for Medical Reason and found themselves hooked, and are now unwilling to try and become sober.
Why should we so strongly privilege puberty because it's "natural"? Many things are natural, such as 50% infant mortality rates, dying of a heart attack at 50 or getting prostate cancer by 80.
Nature, a blind and indifferent force, cares nothing for our individual well-being or our carefully constructed notions of self. To equate "natural" with "good" or "desirable" is a fundamental error, a logical fallacy we often fall prey to.
In the UK, the laws around consent for minors are relatively simple. Past the age of 16, they're assumed to be competent to consent to or decline medical procedures until proven otherwise. Below that age, there's no strict cut-off, if they can prove to their clinician that they are able to weigh the risks and benefits, they are able to consent or withhold it, and even override parental demands.
Someone who wishes to be the opposite sex is someone I pity. Medical science as it currently stands can't provide them more a hollow facsimile of that transition, it's Singularity-complete based off my knowledge of biology. Even so, the desire is one I consider as valid as any.
If they understand that:
A)Puberty blockers have risks and might not be truly reversible if they change their mind.
B) It won't solve all their problems, it won't physically make them indistinguishable from their desired sex.
Then I see no reason to declare that they're making a mistake. By the values they hold, it's the right decision. If they're forced to pass through puberty, they might desist, or they might spend their life wracked with regret that they didn't pull the trigger (hopefully not literally). You can pass far easier before testosterone wracks your body. It's a helluva drug/hormone.
A lot of life-changing decisions can be ones that change the person making them irrevocably, and into a person who would affirm them in retrospect. But I would yell at someone who suggested that couples who are iffy about childbirth be forced to have a child in the hopes that'll change their mind, or fix their marriage or some other well-intentioned goal. Or if we suddenly were to say that everyone should be made to try alcohol and cigarettes because the kind of people who try them tend to stick to it.
We're forced to deal with a messy world that doesn't always readily cough up pathways to our desires when we ask. I'm all for overcoming biology, and I think that people who understand what they're getting into are entitled to ask for even imperfect solutions.
Want to be more muscular? Try tren, if you know what you're in for. Want to lose weight? Take ozempic, while keeping an eye on your eyesight and pancreas. Want to be the other sex? This is the closest we can get you today.
It's because it's both natural and we have a long track record of that path working.
It's a very difficult problem to come up with an alternative pathway that leads to physically and mentally healthy humans at our current level of tech. Unconstrained thinking is probably not a good idea when it comes to complex biological and psychological changes.
It becomes even more absurd to even attempt this in the name of people with disordered relations to their own body, when puberty itself may help resolve that disordered relationship.
Maybe people's intuitions that living their values will make them happy are just wrong. Maybe this is especially true for a group that is prone to a bunch of other mental disorders.
...
We can't exactly take it for granted that mentally ill people are holding values that will actually make them happy , or that they have a reasonable understanding of the risk they're taking on (especially when faced with dubious information from medical practitioners)or have reasonable expectations for these treatments.
Or hell, that their stated euphoria and relief will be lasting.
Society is entitled to say no. My doctor won't give me SARMs for some reason.
Discussions like this make you feel the void left by any natural law or common understanding of virtue.
I did stress that I'm playing Devil's
AdvocateDoctor. I don't want puberty blockers, if I had the misfortune of having a child who desired them, I would do almost anything in my power to dissuade them. I'm not in the business of prescribing them either, I'm not a psychiatrist for kids and teenagers. In fact, the UK is cracking down on even the relatively few (compared to the US) "legitimate" gender transitioning clinics.That being said: Natural law is bullshit. There is no coherent collection of principles that the term usefully refers to. Most adherents ignore the literal meaning and embrace a gazillion unprincipled exceptions. The closest it has to a working definition is status-quo bias.
Even teleological definitions have absurd conclusions. Is the meaning of life to maximize entropy? It is, if the outcome of a process defines its purpose.
Even mild exposure to different cultures and their associated values will tell you that beyond a small core (often contentious itself) there's no "common understanding of virtue".
Even simple sounding ideas, like "don't murder, or steal from your neighbors" will have people arguing ad-nauseum what counts murder or stealing or even a neighbor.
If I pity people who want to be the opposite of the sex they were at birth, then I pity people who genuinely believe in natural law or "objective" morality even more.
One of them is a matter of personal values. The other is basing your moral foundations on wishful thinking.
I'm a moral relativist and a moral chauvinist. I know my values are just as valid (or not) as anyone else's. I also happen to think they're better, with the implicit understanding that to use such a comparative term necessarily needs an observer by whose light it is better or worse (me). Anyone who has convinced themselves that there's objective grounding to their morality, well, I don't want to have what they're smoking.
Quite a few gynecologists and many endocrinologists would be out of a job if the outcome of human hormones acting as they would always had the desired outcome.
I don't contest that the overwhelming majority of people are neutral or slightly positive towards puberty, assuming they even cared to reflect on it.
I would be the last person to disagree about the limits of modern science, engineering and medicine. I also think we should be improving our tech (and we are).
On the other hand, constraining thinking to only that which is known to be possible is... a choice.
You might have gotten away with it a thousand years back, when the lives you and your grandpa lived were nigh interchangeable. That's not the case today, we're living in a scifi novel with reality's rather lax attitude towards plausibility.
And it might not. The rate of desistance with puberty is not 100%. A non-zero number of people will find themselves still wanting to transition, and face even greater hardship for even less change.
I'm for reflecting on whether or not that risk is worth taking, from the perspective of someone who has to:
They need to add up the benefits and risks themselves.
I do not hold happiness as the only terminal value, nor do most people. If they disagree, then they're welcome to start a fent habit.
Whether doing something will make a person happier, either in the short-term, in the long term, or just on average, is far from the only consideration when making a choice.
There are plenty of people who are just depressed, so we wouldn't be out of a job.
Mental illnesses are not made equal.
Someone who had an overwhelming desire to fly and tried to do so might have been better off in an insane asylum if they were born in the 1700s.
Today, they might be a hang-glider hobbyist, a pilot, an astronaut.
Did the people who jumped off cliffs or the Eiffel Tower with inadequate parachutes or mechanical contraptions count as mentally ill or suicidal? Not by most definitions I've heard of. They would still have been "better off" if society had caged them, or at least lived longer. Yet today, we soar.
Your argument argues, just as strongly, for doing our level best to present reliable information to patients. You could also force doctors to present information that better represented reality, on the pain of liability. You could have people be grilled by a different doctor or some other Authoritative Individual who had to be convinced that the patient understood the risks and benefits. This is already common practice in psychiatry, at least where I work. Things like detention under the Mental Health Act or forced treatment require multiple people uninvolved with the original case to sign off. This isn't trivially gamed either, I've seen the headaches my bosses get went they're trying to put these in place without unimpeachable evidence.
Death, be it ours, or that of the universe, doesn't mean temporary endeavors are worthless. At least not to me.
Even in the short term, the hedonic treadmill goes brrr. I'd love to win the lottery, even if a year later my happiness would have regressed to near baseline levels.
You should try a different doctor. Some are more flexible. If I had a patient who understood the risks and benefits, and I wasn't violating laws (because I wish to keep my license, my own moral proclivities aside), then I'd prescribe them.
There are many things that would nice if they were real. You know, a benevolent Creator, objective morality, a pill that changes your gender with no consequences.
Sometimes, you're shit out of luck. Sometimes you can make something just as good. Sometimes you pick the lesser evil out of available options while working on making better ones.
If you have a god-shaped hole, in a universe that doesn't have a god, make one yourself from applying linear algebra to {the majority of text Mankind has written}. If you can't become the opposite sex today, maybe settle for the terrible ersatź substitute.
All I say is maybe.
I know. You just run into places in these discussions where you're clearly in need of a common touchstone, even if we can't get back.
True. But, practically, internal dissension seems more relevant than the inability to get the entire human race to agree. Nobody in America is overly bothered by the fact that Saudis have a different moral code.
Although the balance has shifted with how connected we are.
This is the majority of philosophers btw. I personally don't take a strong stance on metaethics (another way to put it is that I'm too lazy to read enough to formulate one and always puts it off) but that always gives me pause here. What many people find very unintuitive is the consensus position.
It doesn't disprove the "narrow is the path and few find it" argument if even otherwise healthy people have issues that require correction imo. Seems like it does the opposite.
The standard for any treatment (or social convention for that matter) has never been that it's 100% successful.
I actually think that's part of the problem: society is constantly being overturned in the name of smaller and smaller minorities until we hit one where the tradeoffs for doing so are actually serious and visible.
The situation before the general pullback, where public cachet was redistributed to a small number of people who would likely be even smaller given healthy puberty, combined with credulous diagnosing and taboos against "conversion therapy" seems totally backwards.
I meant it in the broader sense. I suppose what the Greeks would call eudaimonia and now philosophers translate as "human flourishing", to avoid exactly these problems.
And I suppose that's a coherent personal position. However, society clearly has certain standards for medical treatment.
Yes, it would be better if everyone was given accurate information on blockers. But that's not the only medical ethic. It seems like we have some pretty high standards for things like amputations which is precisely why exuberant claims were made about the necessity of transition to save a child's life. Even my opponents have implicitly yielded the point: the goal is not short-term gender euphoria in exchange for things we know tend to give people meaning like the ability to experience sexual pleasure and have children or not suffer side-effects from cross-sex hormones.
It's to literally save lives and improve human flourishing. It is not like your own personal decision to spend $3 on a lottery ticket (which costs you almost nothing and doesn't require any medical professional to be complicit).
Maybe that's what I see myself as doing, but for society.
The arguments against a lot of TRA claims and medical practices to help them are usually on pragmatic grounds.
I've done my best to explore what drives philosophers to endorse objective morality, and found all their arguments lacking. It would help if the people who believed in objective morality could agree with each other on what it looked like, but alas.
I belong to the most oppressed minority of all,
gamers, individuals. It doesn't get any smaller than that.I also strongly value personal liberty. It's far from my only consideration, but it is a powerful one. The same arguments, namely paternalism, thinking that you can't allow such far-fetched thinking, would also restrict me.
I'm willing to support people in their quest for personal liberty, even if I think they're misguided, for the same reason that you want the right to free speech to cover heinous kinds as well. Nobody needs to have speech that's popular and favored protected by law.
Society isn't actually a monolithic entity (I'm not claiming that you're saying this, you appear to appreciate nuance). It's made of individuals, and some of them, like medical professionals or regulators, have disproportionate influence.
As the former, if not the latter, I consider it my duty to explain my views. At the absolute very least, I'm painfully self-consistent, and many of my opponents (the average philosopher, for example) aren't. There's plenty of vagueness and moral gray in that field, let alone when it becomes political.
It is certainly not consistent. As @RovScam helpfully illustrates in his own comment, it is trivial to consider an isomorphic example where almost nobody would consider it their business to interfere if the patient, their parents and the treating physicians were all on board.
Modus ponens, modus tollens. I've addressed the specific example of elective limb amputation before. To summarize, if the person was otherwise sane (or at least had capacity), couldn't be dissuaded despite plenty of effort, found a surgeon willing to help, and could afford it, then I see that as entirely fine. I wouldn't like to pay for it with my taxes, there are better things to waste them on.
Young teens make many life changing decisions with uncertain payoffs. Opting for a less conventional field of scholarship might be one.
"We know that leaving school at 11 and then tilling the fields leads to a satisfying and happy life, why bother with the stress and expense of uni".
If someone is busy sacrificing their ability to party with friends in high school in exchange for grinding for med school, what of it? They'd definitely be getting more sexual pleasure in the short term, and likely have more kids if they didn't have to finish residency.
The issue is that the people you're trying to look out for vehemently disagree on what counts as human flourishing. They certainly don't appreciate your attempts to dictate what they should choose, even if you good intentions.
If money is the biggest factor, then I have little objection to saying such procedures shouldn't be paid for by the public, any more than breast implants or a boob job typically are. I say typically for a reason, because someone who had a mastectomy for cancer might qualify.
The core of this is that meme:
"I consent." Says a distressed young child. "I consent." Says their worried but loving parents, and some doctor making sure they're ticking the consent boxes. "I don't-" Says someone whose consent seems entirely unnecessary to me, at least when they're not paying for this.
As a matter of such longstanding custom or clear law that it can easily be said to be "society's" position.
If we lived in a libertarian world where people were expected to take on all of the costs of a procedure and balance the risks themselves I think your personal take would be coherent for society to adopt.
In practice, neither of those things may be the case. Society collectively pays for a bunch of services and we insist on rigorous epistemic and ethical standards even when people might willingly take the risk. Even the people arguing for the specific case we're discussing pay deference to that expectation.
I think this status quo has a lot to recommend it but, even if I could be convinced it should change, I'd like to know why this topic (given how I feel about the object-level issue) should motivate that change.
tl;dr: They can have it when I have the same easy access to steroids.
The consequences of majoring in programming right now with AI is unclear. The consequences of lopping of your limb are.
We seem to think that matters, which is why one involves far more ethical requirements.
I'm not sure they actually do though?
The argument for gender affirming care has always been that it will reduce things like suicide rates and suicide ideation and the comorbidities associated with trans identification and thus it functions as medicine, as it's commonly understood. The controversy is about whether gender affirming care achieves some broad definition of human flourishing but the general goal it should be achieving if it is effective medicine (and a brief, heroin-like moment of bliss doesn't count) doesn't seem to be controversial.
The whole emotional blackmail line of "dead son or live daughter" has this assumption built in.
If it turns out that the evidence isn't good for this then their case falls apart by its own standards.
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