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PaperclipPerfector  24d ago (text post)   24432 thread views

Culture War Roundup for the week of April 8, 2024

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When discussing pharmaceutical and surgical interventions in the treatment of gender dysphoria, the gender-critical among us often draw parallels with bodily integrity identity disorder. This is a rare psychiatric disorder in which a person experiences profound distress because of the presence of one or more of their limbs, and requests to have these limbs amputated to alleviate said distress (or tries to amputate them themselves). Colloquially, one might say that people with this condition are able-bodied but identify as disabled.

Given that no one thinks that surgical amputation is the correct treatment for this psychiatric disorder, we gender-criticals argued, it follows that surgical intervention is the wrong approach for people with gender dysphoria. If it's wrong to amputate a mentally ill's person's arm just because they say it's causing them distress, how can it be right to do the same for a penis or breast?

Sadly, one man’s modus ponens is another man’s modus tollens, the medical establishment has noted the parallels, and it is coming to a rather different conclusion:

Sensational news from late last week, that doctors amputated two fingers for a 20-year-old patient to alleviate the young man’s mental distress over being able-bodied, contained a buried clue: “He related his condition to gender dysphoria.”

... A 2018 ethics analysis in a Cambridge University Press publication concludes that there is “no logical difference between the conceptual status of BIID and transsexualism”. It goes on to say that, “given that individuals with transsexualism are offered gender reassignment surgery it seems to us that individuals with BIID ought at least to be considered for treatment, including elective amputation in some cases.”

... But what would it mean to accept the amputee identity at scale, the way we have accepted trans rights as a universal humanitarian movement? Drawing exact parallels, we would likely see a total saturation of amputee culture, from amputee story hour to centring amputee voices in DEI training, and doctors warning parents of the very real suicide risks for amputee-identifying children whose parents refuse to accept them as surgically modified cripples or invalids. Advocates would talk of being “assigned able-bodied at birth” to persuade activist teachers and medical associations to adopt the absolutist position that any attempt to talk kids out of amputee surgery amounts to “conversion therapy”.

The journalist Mia Hughes recently asked readers to imagine a society in which amputee advocates enjoyed the same cultural and political victories as trans advocates.

“Imagine there were a sudden 4000% increase in teens identifying as amputees, but we were all forbidden from being concerned. Instead we were supposed to celebrate it,” she posted on X. “Imagine schools teaching children as young as kindergarten that some people have amputee identities, that they get to choose how many limbs they have. Posters promoting body mutilation adorned the walls of many classrooms.”

Nothing specific to add to this* beyond despair. The Anglophone medical establishment appears to be fully ideologically captured. It doesn't matter if the Tavistock is shuttered and there's a rash of lawsuits directed at youth gender clinics in the US: if you're a medic who's internalised (or been made to internalise) the gender ideology worldview, the implications of that worldview and the role of the medical establishment it affirms have far-reaching implications in medical domains unrelated to gender medicine itself. At this point I honestly can't rule out psychiatrists prescribing anorexics appetite suppressants to aid them in achieving their "bodily attainment goals".

*Other than why the fuck are Canadian doctors so keen to help their fellow citizens maim or destroy their bodies??!!

From the article UnHerd cites:

“He hides his fingers, keeps them flexed, leading to impaired dexterity, localized pain, irritability and anger,” Dr. Nadia Nadeau, of the department of psychiatry at Université Laval wrote in the journal Clinical Case Reports. He grew more determined to find a way to get rid of fingers he considered “intrusive, foreign, unwanted.”

“He had contemplated asking a friend to watch over him and be prepared to call emergency services in case his attempt led to a need for resuscitation,” Nadeau wrote.

After undergoing elective amputation, the nightmares and emotional distress immediately stopped, Nadeau said. The post-op pain resolved within a week, there was no “phantom pain” at one month follow-up and, without the two missing fingers, “he was able to pursue the life he envisioned as a complete human being without those two fingers bothering him.”

It’s not the first time amputation has been used as a treatment for BID. In the late 1990s, a surgeon in Scotland amputated one leg above the knee each in two men who’d felt a “desperate” need to be amputees, and who had been turned away by other doctors.

Despite the scandal that erupted, “At the end of the day I have no doubt that what I was doing was the correct thing for those patients,” the surgeon, Dr. Robert Smith, told a press conference.

The fact that there were only two fingers involved in the Quebec case, as opposed to a complete limb, made the decision to proceed easier for the medical team, Nadeau said.

If this now-amputee were me, I'd try to just get over it. Stop taking any action to either sate or resist the discomfort, meditate real hard, just feel it and let it burn out. I think it'd work for me.

But it's a mistake to not understand the other side's perspective. You have a guy who's constantly distressed, whose daily life is significantly impaired, who's begging for help, where many pharmaceutical and therapeutic interventions have failed, and a simple operation will fix his problem permanently. It makes a certain amount of sense, right? This guy's had this problem since he was a child, and it is a doctors' job to fix it, and nothing else is working.

It reminds me of

https://slatestarcodex.com/2014/11/21/the-categories-were-made-for-man-not-man-for-the-categories/

The Hair Dryer Incident was probably the biggest dispute I’ve seen in the mental hospital where I work. Most of the time all the psychiatrists get along and have pretty much the same opinion about important things, but people were at each other’s throats about the Hair Dryer Incident.

Basically, this one obsessive compulsive woman would drive to work every morning and worry she had left the hair dryer on and it was going to burn down her house. So she’d drive back home to check that the hair dryer was off, then drive back to work, then worry that maybe she hadn’t really checked well enough, then drive back, and so on ten or twenty times a day.

It’s a pretty typical case of obsessive-compulsive disorder, but it was really interfering with her life. She worked some high-powered job – I think a lawyer – and she was constantly late to everything because of this driving back and forth, to the point where her career was in a downspin and she thought she would have to quit and go on disability. She wasn’t able to go out with friends, she wasn’t even able to go to restaurants because she would keep fretting she left the hair dryer on at home and have to rush back. She’d seen countless psychiatrists, psychologists, and counselors, she’d done all sorts of therapy, she’d taken every medication in the book, and none of them had helped.

So she came to my hospital and was seen by a colleague of mine, who told her “Hey, have you thought about just bringing the hair dryer with you?”

And it worked.

She would be driving to work in the morning, and she’d start worrying she’d left the hair dryer on and it was going to burn down her house, and so she’d look at the seat next to her, and there would be the hair dryer, right there. And she only had the one hair dryer, which was now accounted for. So she would let out a sigh of relief and keep driving to work.

And approximately half the psychiatrists at my hospital thought this was absolutely scandalous, and This Is Not How One Treats Obsessive Compulsive Disorder, and what if it got out to the broader psychiatric community that instead of giving all of these high-tech medications and sophisticated therapies we were just telling people to put their hair dryers on the front seat of their car?

But I think the guy deserved a medal. Here’s someone who was totally untreatable by the normal methods, with a debilitating condition, and a drop-dead simple intervention that nobody else had thought of gave her her life back. If one day I open up my own psychiatric practice, I am half-seriously considering using a picture of a hair dryer as the logo, just to let everyone know where I stand on this issue.

Amputating a few fingers is somewhat more invasive than putting a hairdryer in your car. But it's the same principle, right?

That's from the categories are made for man, which Zack's spent a lot of time disagreeing with because, yes, it was about trans people and how to treat them. I didn't even remember that was why Scott told that story until I looked it up again today.

And, it's a good analogy, because this is what it feels like for a medical professional dealing with trans patients. You have adults who beg for hormone treatments, claim to be and appear to be in severe distress due to lacking them, and do indeed appear to improve after taking them. This is what it should look like! There are issues with kids, issues with surgery, but none of those undermine the obvious case for accepting trans people and treating them with hormones - it seems to make them happier and better. Again, yeah, edge cases, but the trans people I know are not perpetually depressed psychological wrecks like you'd expect from rw twitter memes, they're generally normal and happy.

Claiming otherwise requires some sophisticated reasoning, like one that claims happiness or sexual satisfaction are of little value themselves, and only matter when done for in line with a greater purpose - in this case, marriage and having children. And since trans individuals imitate the appearance of sexuality without the fertility backing it, it's bad. I agree with something like that.

Nothing specific to add to this* beyond despair. The Anglophone medical establishment appears to be fully ideologically captured

If A is evidence for B, B should be evidence for A, yes? "One man’s modus ponens is another man’s modus tollens?" If we took this case being a novel case of unnecessary amputation as evidence that trans ideology has thoroughly captured the medical system, or something like that, and then we observe that this isn't novel - I think we should doubt the reasoning that led to the claim of ideological capture.

edit: here is the paper about the case.

Claiming otherwise requires some sophisticated reasoning,

I actually don't think it really needs reasoning that's all that sophisticated. Transforming a hand with five fingers to a hand with three fingers and two stumps is something well within the bounds of current medical technology, and the risks of an unexpectedly negative outcome are substantially lower. In contrast, actual gender transition is so far beyond current medical technology that we're not even close to getting there. I think this is the big problem with the analogy, because the consequences here are extremely relevant. Yudkowsky had an article that I really liked on the subject, actually - https://www.lesswrong.com/posts/QZs4vkC7cbyjL9XA9/changing-emotions

I specifically mean claiming that existing adults who believe themselves to trans women, do so for multiple years, and most centrally are MtFs who genuinely feel terrible about not being women, shouldn't start taking hormones and socially transition. Within this argument the claim isn't that they're Becoming-Woman, the claim is that trying to mime the social roles and appearances of women and starting hormones appears to make them happier, more content, etc

It is incredibly weird to try to imagine though how so many people who are not, in fact, mentally women, could come to the conclusion that they are mentally women and start mimicking that social role and genuinely enjoy it. And as far as I can tell that is true! It really speaks to how complex and contingent human values and desires are, and how many potential configurations of human beliefs and societies there are.

Within this argument the claim isn't that they're Becoming-Woman, the claim is that trying to mime the social roles and appearances of women and starting hormones appears to make them happier, more content, etc

I think most of the friction over transness (and gayness, which is typically only one step removed from transness anyway) is that doing that also tends to be an excuse to express all the attributes of that gender and not just the positive/productive ones.

Public perception is that, being born as the gender that doesn't express those traits as much would cause an ex-gendered individual to know better than to do them/have more innate resistance to them. Of course, that's ignoring that ex-women/lesbians get more leeway on this than ex-men/gays do for sociobiological reasons, so toxic feminine traits in men are going to be noticed and resented more than toxic masculine traits in women will be (if they even happen at the same base rate).

For example, there's a meme around 4chan that boys make the best girls (and... there's probably something to that), but that's ignoring all the times that boys make the worst girls. At an object level, this mainly comes in the form of catty bullshit and other gender-role-specific ways to be a bully, which is why it's easy [for otherwise-normal men] to form a strongly negative association with other men who have developed/are developing the gay lisp (to name one example).

Of course, that reaction also prompts toxic [same adopted gender] to rally around the flag and defend their right to that toxicity, and since the balance of power in western society currently favors women the "it's ma'am" shit gets a pass. Places where the genders are a bit less at war with each other (for whatever reason) tend to produce more media that portrays crossdressing/cross-sex activity in at least a neutral light, which is why that stuff more often comes out of Asia.

one of reasons I wish Russia win over Ukraine (if closely aligned with EU&US they will get this too, eventually)

Being a Russian satellite is not very good for you unless your warlord's name is Kadyrov and you share his religious whims. That alone should outweigh concerns about miniscule numbers of dubious surgeries.

I am not worrying about Ukraine here, I'm hoping loss in Ukraine would show the West they're doing something bad. I poorly phrased this.

Well, I'm hoping loss in Ukraine will show Russia it's doing something bad.

Uh, I thought Kadyrov was pretty bad for the average Chechen?

I suppose so, although I imagine living in a region which receives those massive handouts from the federal budget is better than, everything else remaining the same, not having those handouts.

which Zack's spent a lot of time disagreeing with

As someone who expended a lot of words taking a public figure to task over his perceived hypocrisy/cognitive dissonance on the trans issue, it will not surprise you that I found this post very absorbing. It's so weird how this specific issue seems to break so many people's brains, even (especially?) people who built their reputations on being no-nonsense straight-shooters who don't care whose toes they step on in pursuit of Truth. As soon as the word "gender" is mentioned, they look at their feet and start mumbling about "why do you care anyway it doesn't affect you".

Zack hypothesises that the overrepresentation of trans women in the rat-adjacent sphere is Rationalism's shield against accusations of being insufficiently progressive - if they were to start saying things that run the risk of driving trans women away, the accusations would be substantially harder to defend against. I must admit this sounds grimly plausible to me, but it doesn't explain why Freddie deBoer has the same reaction to this issue.

Claiming otherwise requires some sophisticated reasoning, like one that claims happiness or sexual satisfaction are of little value themselves, and only matter when done for in line with a greater purpose - in this case, marriage and having children. And since trans individuals imitate the appearance of sexuality without the fertility backing it, it's bad. I agree with something like that.

I think the cleaner reasoning is that the disease appears to be memeborne and validating the meme is part of its transmission. If the finger amputation thing catches on and 5% or more people start getting their fingers cut off then there is a real cost. The hidden cost in the treatment, especially the social aspects of the treatment, is that you're spreading the infectious meme. If people only develop the illness internally then sure, a case can be made for treating it it individually. But it's rather like approaching the flu as if it were a nontransmissible issue caused by an unfortunate accident at birth and encouraging people to hug and kiss people with the flu to show that we're all sorry for them.

I don't think this is perfect. There are a significant number of people who seem to have developed something like transness, whatever you want to call it (and maybe there are different things that cluster), people who describe themselves getting off to the idea of being a woman and wanting to wear female clothes and only then learning about being trans and really wanting to be that. Here's an example, and this isn't strong cherrypicking, I linked Zack's blog in this thread.

On 6 August 2006 (I was eighteen years old), while browsing Wikipedia (likely the 31 July revision of what is now the "Blanchard's transsexualism typology" article?), I came across the word autogynephilia for the first time, and immediately recognized that this was the word; this was the word for my thing.

I didn't know it was supposed to be controversial, and was actually surprised that it had been coined in the context of a theory of transsexualism; I had never had any reason to come up with any ludicrous rationalizations that I was somehow literally a girl in some unspecified metaphysical sense.

I wrote in my notebook:

THERE'S A WORD FOR IT. There's a word for it. I don't know whether to be happy that there's an adjective for what I have, or sad that other men have it, & that it's not mine, & only mine. Bless Wikipedia for showing me [...] But still, after all emotions have fitted themselves away, there is the word. "Autogynephilia." So simple; I know all the foreign roots; I should have thought of it. "Autogynephilic." That's what I am.

notebook: THERE'S A WORD FOR IT ...

And:

Scarcity is a metaphysical fact, so why am I hurt when my word (which I didn't invent & only discovered a few hours ago) has so many connotations attached to it that I don't like? The dictionary definition is perfect for me, but all the exposition after that has to do with transsexualism, which annoys me, although thinking of it now, I suppose it would seem to be a logical extension to some. I'm autogynephilic without being gender-dysphoric—or am I? If transitioning cheap & fast & painless & perfect—wouldn't I at least be tempted? What I can't stand is transsexuals who want to express the man/woman they "truly are inside"—because I don't think there's any such thing. It has to be about sex—because gender shouldn't exist.

A lot more people have this experience with 'being trans' than 'autogynephilia', and I've read the same thing about 'being trans'. I don't think this is compatible with an exclusively memetic diagnosis, even though I do think most currently trans individuals would desist and forget about everything related to it eventually if they were in a universe with no other (depending on your POV) TruTrans people / people believing in the meme. And I think as a result your ethical grounding has to actually be able to claim 'no, these people who didn't get it memetically shouldn't transition either' if you want to claim that the concept as a whole should go.

Amputating a few fingers is somewhat more invasive than putting a hairdryer in your car. But it's the same principle, right?

I don't see how placing a hairdryer in your car violates Primum non nocere.

It amazes me to think that I once found Scott's argument in "the categories were made for man" persuasive. Rationalists are all about defining words in ways which "cleave reality at the joints", and yet Scott apparently thinks that "anyone who claims membership in this category" is a better definition of "woman" than "adult human female".

do indeed appear to improve after taking them

Well, some and some. From my understanding, having read Jesse Singal's deep dives into this issue, the evidence base is a lot more mixed than trans activists would have us believe.

If A is evidence for B, B should be evidence for A, yes? "One man’s modus ponens is another man’s modus tollens?" If we took this case being a novel case of unnecessary amputation as evidence that trans ideology has thoroughly captured the medical system, or something like that, and then we observe that this isn't novel - I think we should doubt the reasoning that led to the claim of ideological capture.

If you have examples of cases of bodily integrity disorder being treated with amputation prior to the modern trans activist movement, I would love to see them. Or perhaps I should say - what gives me pause is not that amputations for sufferers of bodily integrity disorder are being carried out, but that they're being carried out using precisely the same reasoning that "gender-affirming care" providers use to justify removing breasts and penises.

I don't see how placing a hairdryer in your car violates Primum non nocere.

Doctor's will cut you open and remove a perfectly healthy kidney from you. You can live with one kidney, but it can give you health complications and issues for life.

Now the justification is to save someone elses life through organ transplantation. But the donor is harmed. So as long as there is a relevant greater justification we do remove healthy parts of the body even aside from Trans or BIID issues.

Which isn't to say we should do that, just that First, do no harm does already have exceptions, even outside of culture war flashpoints.

Funnily enough:

One of the earliest described cases of BID was termed apotemnophilia by Money in 1977

Yes, that John Money!

I don't see how placing a hairdryer in your car violates Primum non nocere.

They did try, first, doing no harm - "attempts at “non-invasive” relief, including cognitive behavioural therapy, Prozac-like antidepressants and exposure therapy".

Well, some and some. From my understanding, having read Jesse Singal's deep dives into this issue, the evidence base is a lot more mixed than trans activists would have us believe.

My recollection of the deep dives is mostly that the scientific evidence isn't strong either way, but both from my recollection of those studies and from anecdotes, most adults who go on hormones are happy about that, and even most adults who eventually stop taking hormones are happy about the fact they took hormones. There's clearly a large core group MtFs who are very committed to being trans and seem to (not necessarily counterfactually, just before and after) be happier as a result.

If you have examples of cases of bodily integrity disorder being treated with amputation prior to the modern trans activist movement, I would love to see them

I mean, the leg amputated in the 1990s I quoted above. I'm not claiming it has no relationship to trans activism, just that "The Anglophone medical establishment appears to be fully ideologically captured" isn't a justified conclusion from this particular amputation and a single paper connecting BID to transgender people.

most adults who go on hormones are happy about that,

Going on hormones and then believing that hormones are bad for you seems like it would be unlikely because of the sunk cost fallacy.

I agree that's a reasonable factor but it doesn't seem like a significant one. I'd be more amenable to an argument of the form "people can adapt to anything, and it's just not bad enough to override the confused desires that led them there", but they do not at all seem to be in the state of "would regret it but see as sunk cost", that feels very different.

I mean, the leg amputated in the 1990s I quoted above.

Sorry, I missed that.

I'm not claiming it has no relationship to trans activism, just that "The Anglophone medical establishment appears to be fully ideologically captured" isn't a justified conclusion from this particular amputation and a single paper connecting BID to transgender people.

Fair point.

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