Interesting. But I feel the need to call out a bit of a black and white fallacy here when Matt mentions there are two explanations for the gap between Sweden and the US. There, are, in fact many more than that.
A broad heading encompassing a ton would be “Sweden is wrong for one or many of a whole host of potentially reasons while the US approach is correct”.
I’m not saying that is definitely the case. But there are certainly more than the two explanations framed in the piece.
I don't doubt that part of the growth in puberty blockers & gender reassignment surgery is profit seeking, but I doubt 100% of it is. It's hard to put a % on it, but my hunch is more of it is ideological crusading. It used to be that culture war stuff was red hot on the right, but a bit of a yawner in the center & the left (outside of activists). The backlash against Trump changed that. Now any decent person not on the right is socially obligated to be a passionate culture warrior & desent is not tolerable. My guess is that this phenomenon springs more from that than from profit motives. Is there any evidence that doctors in the gender affirming care space are raking it in (relatively)?
Assuming you can afford American health care, then your best strategy is to make sure you don't consume too much. Just like food, children's toys, and so many other markets.
Such a great balance b/t innovation and access, after acknowledging the tradeoff. The prestige of American medicine is insane, in good and bad way. Immigrants (like my parents) want their children to be doctors in America so desperately b/c they understand the rich rewards, economically and socially, of the profession. Personally i think we shld break up AMA cartel and allow more doctors, domestic and foreign
People googling "get Adderall fast" is a sign of UNDERprescription - it's a sign that it's not as available as buyers want. If people were googling "how to get milk fast", would you say that we're consuming too much milk, or not enough?
Overtreatment is plausible in situations where the patient doesn't know what they want and are just going with the doctor's recommendation. But there are many situations where the patient knows exactly what they want and doctors are just gatekeepers standing in the way. It's not overprescription for some doctors to give patients what they're asking for.
Isn’t there a third explanation here, something more like: 3. Because lots of healthcare is provided more slowly in Sweden and there is no economic incentive to change this?
For example, I think that wait time for most medical specialists are higher in Sweden. (This report suggest you’re twice as likely to have to wait a month or more to see a specialist there than you are in the US: https://www.oecd.org/health/waiting-times-for-health-services-242e3c8c-en.htm.) Is that because the Swedish medical establishment has made a deliberate assessment that longer waiting times are better? Or is it more likely that they lack a mechanism whereby demand generates supply and so everything just goes more slowly?
Perhaps this is just a more positive way of framing your option 2. Yes, the U.S. is more inclined to a “more, more, more” (and “faster, faster faster”) approach, but that doesn’t necessarily imply that this is harmful. If the U.S. also provides hip replacements more quickly than Sweden, for example, that wouldn’t make me wonder if we need to slow down those surgeries.
Or consider this admittedly stretched analogy: Wait times at my local DMV are an order of magnitude longer than at my local Starbucks. Is that because the DMV has sensibly decided that patience is a virtue? No, they just have no incentive to be fast, whereas Starbucks does. Is Starbucks too fast, causing me to drink too much coffee? Maybe, but the DMV is for sure too slow.
Similarly, if it turned out Sweden or the Netherlands were moving too slowly, what would be the mechanism to correct that? Given the structure of their healthcare system, wouldn’t you expect both that they would provide this care more slowly and that they would be slow to change their guidance?
I don't think it is a matter of "moving more slowly" because of resource constrictions. The Dutch actually have a different model of care, I believe it is referred to as "watchful waiting", because they think that kids will play around with identity until they hit puberty and it is only when they are into puberty and sexuality emerges that you can start making diagnoses. They're also a lot more into screening for co-morbidities and so on. It also isn't just the Swedes or Dutch, the Finns have taken a similar approach, and the UK appears to be backing off "gender affirming" care also after initially going all in on it (probably because they get a lot of US influence). The French have also made sceptical noises. So it is not just one European healthcare system.
Great article! There is another aspect to our overuse/overprescriptive opioid debacle. In the late 80's, when I was in medical school, physicians were credibly accused of under treating real pain. There were horrific stories in the press about cancer patients dying in agony because of our hesitance in using opiods. There was even testimony demanded by and presented to Congress to this effect. The pain score was invented and touted as the "5th vital sign" to be documented on every patient. We've all seen the 1-10 pain scale by now. As usual, this pendulum swing was quickly monetized and here we are.
Since there are trans adults who are clearly happier off for it (e.g. Buck Angel, etc), it seems to stand to reason that if you could address their issues earlier they could arrive at a good place earlier in life. However predicting whether a kid will grow up to be an adult who wants to transition or not seems like a devilishly tricky thing. At least worth taking a lot of caution over, so the apparent emerging northern European Dutch/swedish/finnish/british approach of slow-and-steady just seems more sensible to me. The fact that there frequently appears to be a disconnect between what voluble activists say and what the actual degree of certainty is involved also gives me extreme pause.
I think the evident failure/cowardice of major media to report even-handedly on the subject has been one of the reasons i have really come to distrust them more broadly.
This perspective fails to consider that going through puberty is itself a clarifying experience and helps confirm to gender questioning youth whether they truly would be happier if they transitioned.
Halting puberty and asking the same kid whose growth—physical, emotional, mental, and sexual—is halted to then make a mature decision about permanent changes and identity is just…not sure how people square that.
Here's an example: While skiing this last winter, my daughter fell and hit her head, blacked out for a few seconds and had short memory loss.
Took her to the ER at the base of the mountain. Filled out paperwork. Got called back quickly and talked to a nurse who said they didn't have the facilities to do anything except sit and watch her. They suggested we go to the bigger ER 30 minutes away.
We were not at that ER for more than 5 minutes and all that happened was filling out the usual paperwork and having a nurse tell us to go somewhere else. They never even took my daughter's vitals.
Low and behold a few weeks later I get a bill from them for $30 which is the amount of that visit that our insurance didn't cover. They charged $1,100 for that visit in which they did nothing, our insurance paid all but $30. I reported it as insurance fraud, and it's still pending.
Meanwhile at the bigger ER we went to they took vitals, x-rayed my daughters hand, and had her sit there for 2 hours to make sure she didn't develop concussion symptoms. They offered an MRI if I wanted, but thought it wasn't necessary. I agreed and declined.
The bill for that was almost $8,000 and our copay after insurance was $140. Of that, only $500 was for the x-ray. Crazy effing system.
Interesting - I wasn't expected from the headline that teen trans care would be a major part of this, but I think the argument makes sense.
Just on a personal anecdotal note, my probably biased perspective is that my VA doctor - who doesn't have market incentives - is generally more conservative in their approach to health recommendations than are some of the specialists I've gone to that have offices in strip malls. And I think this post goes a long way in explaining why.
The financial incentives are definitely different. The commercial medical office has a business to run while my VA doctor is salaried or on contract. But it's also very likely the case that the type of doctor who wants to be salaried or on contract for the VA is probably a different kind of doctor that one who wants to own their own medical practice. So I think the personality and goals of doctors also matter a great deal here.
As far as trans kids go, I'm very much on the side of how Sweden does it. And the reason for that is that dramatic early interventions can result in children becoming both sterile and never being able to have an orgasm for the rest of their lives. Those are significant downsides and are also downsides that pre-pubescents cannot really understand the impact of. Significant and permanent side effects that the patient can't really understand should, I think, promote a more conservative approach.
Interesting. But I feel the need to call out a bit of a black and white fallacy here when Matt mentions there are two explanations for the gap between Sweden and the US. There, are, in fact many more than that.
A broad heading encompassing a ton would be “Sweden is wrong for one or many of a whole host of potentially reasons while the US approach is correct”.
I’m not saying that is definitely the case. But there are certainly more than the two explanations framed in the piece.
If you're going to link to your tweet and say "read my mentions here" to demonstrate a point, maybe don't keep deleting all your old tweets?
I don't doubt that part of the growth in puberty blockers & gender reassignment surgery is profit seeking, but I doubt 100% of it is. It's hard to put a % on it, but my hunch is more of it is ideological crusading. It used to be that culture war stuff was red hot on the right, but a bit of a yawner in the center & the left (outside of activists). The backlash against Trump changed that. Now any decent person not on the right is socially obligated to be a passionate culture warrior & desent is not tolerable. My guess is that this phenomenon springs more from that than from profit motives. Is there any evidence that doctors in the gender affirming care space are raking it in (relatively)?
For some context on why and how “ObamaCare” was attempting to address issues like this, please see this piece I wrote several years ago: https://jonthinks.substack.com/p/why-obamacare-should-not-be-repealed-and-or-replaced-275d627ed094?r=mrvx1&s=r&utm_campaign=post&utm_medium=web
Well done. Thank you, Matt.
I like my Substacks like I like my Chili "nuclear strength heat".
Assuming you can afford American health care, then your best strategy is to make sure you don't consume too much. Just like food, children's toys, and so many other markets.
Such a great balance b/t innovation and access, after acknowledging the tradeoff. The prestige of American medicine is insane, in good and bad way. Immigrants (like my parents) want their children to be doctors in America so desperately b/c they understand the rich rewards, economically and socially, of the profession. Personally i think we shld break up AMA cartel and allow more doctors, domestic and foreign
People googling "get Adderall fast" is a sign of UNDERprescription - it's a sign that it's not as available as buyers want. If people were googling "how to get milk fast", would you say that we're consuming too much milk, or not enough?
Overtreatment is plausible in situations where the patient doesn't know what they want and are just going with the doctor's recommendation. But there are many situations where the patient knows exactly what they want and doctors are just gatekeepers standing in the way. It's not overprescription for some doctors to give patients what they're asking for.
> People googling "get Adderall fast" is a sign of UNDERprescription
People googling this are not trying to get Adderall for its therapeutic purposes.
C Sections have a lot of advantages for patients compared to natural birth, so I don't think that part of the article makes a great point.
Thank you. This really needed to be said by someone with an audience.
Isn’t there a third explanation here, something more like: 3. Because lots of healthcare is provided more slowly in Sweden and there is no economic incentive to change this?
For example, I think that wait time for most medical specialists are higher in Sweden. (This report suggest you’re twice as likely to have to wait a month or more to see a specialist there than you are in the US: https://www.oecd.org/health/waiting-times-for-health-services-242e3c8c-en.htm.) Is that because the Swedish medical establishment has made a deliberate assessment that longer waiting times are better? Or is it more likely that they lack a mechanism whereby demand generates supply and so everything just goes more slowly?
Perhaps this is just a more positive way of framing your option 2. Yes, the U.S. is more inclined to a “more, more, more” (and “faster, faster faster”) approach, but that doesn’t necessarily imply that this is harmful. If the U.S. also provides hip replacements more quickly than Sweden, for example, that wouldn’t make me wonder if we need to slow down those surgeries.
Or consider this admittedly stretched analogy: Wait times at my local DMV are an order of magnitude longer than at my local Starbucks. Is that because the DMV has sensibly decided that patience is a virtue? No, they just have no incentive to be fast, whereas Starbucks does. Is Starbucks too fast, causing me to drink too much coffee? Maybe, but the DMV is for sure too slow.
Similarly, if it turned out Sweden or the Netherlands were moving too slowly, what would be the mechanism to correct that? Given the structure of their healthcare system, wouldn’t you expect both that they would provide this care more slowly and that they would be slow to change their guidance?
I don't think it is a matter of "moving more slowly" because of resource constrictions. The Dutch actually have a different model of care, I believe it is referred to as "watchful waiting", because they think that kids will play around with identity until they hit puberty and it is only when they are into puberty and sexuality emerges that you can start making diagnoses. They're also a lot more into screening for co-morbidities and so on. It also isn't just the Swedes or Dutch, the Finns have taken a similar approach, and the UK appears to be backing off "gender affirming" care also after initially going all in on it (probably because they get a lot of US influence). The French have also made sceptical noises. So it is not just one European healthcare system.
Great article! There is another aspect to our overuse/overprescriptive opioid debacle. In the late 80's, when I was in medical school, physicians were credibly accused of under treating real pain. There were horrific stories in the press about cancer patients dying in agony because of our hesitance in using opiods. There was even testimony demanded by and presented to Congress to this effect. The pain score was invented and touted as the "5th vital sign" to be documented on every patient. We've all seen the 1-10 pain scale by now. As usual, this pendulum swing was quickly monetized and here we are.
Since there are trans adults who are clearly happier off for it (e.g. Buck Angel, etc), it seems to stand to reason that if you could address their issues earlier they could arrive at a good place earlier in life. However predicting whether a kid will grow up to be an adult who wants to transition or not seems like a devilishly tricky thing. At least worth taking a lot of caution over, so the apparent emerging northern European Dutch/swedish/finnish/british approach of slow-and-steady just seems more sensible to me. The fact that there frequently appears to be a disconnect between what voluble activists say and what the actual degree of certainty is involved also gives me extreme pause.
I think the evident failure/cowardice of major media to report even-handedly on the subject has been one of the reasons i have really come to distrust them more broadly.
This perspective fails to consider that going through puberty is itself a clarifying experience and helps confirm to gender questioning youth whether they truly would be happier if they transitioned.
Halting puberty and asking the same kid whose growth—physical, emotional, mental, and sexual—is halted to then make a mature decision about permanent changes and identity is just…not sure how people square that.
Another thing is FFS and insurance payments.
Here's an example: While skiing this last winter, my daughter fell and hit her head, blacked out for a few seconds and had short memory loss.
Took her to the ER at the base of the mountain. Filled out paperwork. Got called back quickly and talked to a nurse who said they didn't have the facilities to do anything except sit and watch her. They suggested we go to the bigger ER 30 minutes away.
We were not at that ER for more than 5 minutes and all that happened was filling out the usual paperwork and having a nurse tell us to go somewhere else. They never even took my daughter's vitals.
Low and behold a few weeks later I get a bill from them for $30 which is the amount of that visit that our insurance didn't cover. They charged $1,100 for that visit in which they did nothing, our insurance paid all but $30. I reported it as insurance fraud, and it's still pending.
Meanwhile at the bigger ER we went to they took vitals, x-rayed my daughters hand, and had her sit there for 2 hours to make sure she didn't develop concussion symptoms. They offered an MRI if I wanted, but thought it wasn't necessary. I agreed and declined.
The bill for that was almost $8,000 and our copay after insurance was $140. Of that, only $500 was for the x-ray. Crazy effing system.
Interesting - I wasn't expected from the headline that teen trans care would be a major part of this, but I think the argument makes sense.
Just on a personal anecdotal note, my probably biased perspective is that my VA doctor - who doesn't have market incentives - is generally more conservative in their approach to health recommendations than are some of the specialists I've gone to that have offices in strip malls. And I think this post goes a long way in explaining why.
The financial incentives are definitely different. The commercial medical office has a business to run while my VA doctor is salaried or on contract. But it's also very likely the case that the type of doctor who wants to be salaried or on contract for the VA is probably a different kind of doctor that one who wants to own their own medical practice. So I think the personality and goals of doctors also matter a great deal here.
As far as trans kids go, I'm very much on the side of how Sweden does it. And the reason for that is that dramatic early interventions can result in children becoming both sterile and never being able to have an orgasm for the rest of their lives. Those are significant downsides and are also downsides that pre-pubescents cannot really understand the impact of. Significant and permanent side effects that the patient can't really understand should, I think, promote a more conservative approach.