Just to echo what Milan said — everyone be on your best behavior and try to achieve maximum calm and respectfulness in your choices of language and manner of addressing others.
Sounds good to me. I have a question and since nothing I post appears as a comment unless it is posted as a reply I will do that here. Many people want to end the war on drugs. That may be a noble ambition that affects far more lives then gender issues. So if one decriminalizes drugs and deprives the court system of the power to compel treatment what happens? Considering that even the best treatment programs have very high recidivism rates and won't be compellable by anyone aren't we going to need pharmaceutical companies and people like the Sacklers to produce pharmaceutical grade recreational drugs. If we don't and allow the criminal element to sell adulterated drugs with lethal amounts of fentanyl or car-fentanyl how many will die? I wonder what their brand name for pharmaceutical grade meth will be?
Just dropping in early to remind everyone to play nice in the comments. I know this is a contentious issue but I would like to avoid a repeat of the Florida LGBTQ article’s comments.
I would argue something similar is happening with the DEI industry. The University of Michigan has 163 diversity officials. Now repeat this (though at a lower rate) at every University, every Government office, every major company. Their career incentives ensure they will always find some terrible injustice, some structural edifice that needs to be fixed, some new form of discrimination to fight.
I'm convinced the attention and prevalence of the Transgender issue is driven by a general reduction in overt racism and the acceptance of equal rights for Gay & Lesbians. The activists and DEI careerists will always find a new reason to exist.
I think the version of this hypothesis that makes more sense is that LGBT rights groups raised enormous amounts of money to fund what they were expecting would be a long, brutal war for marriage equality. Instead they won extremely quickly and Republicans haven’t made any real effort to roll it back. So the advocacy machine rushed in to explore a new frontier and politicians who want to be on the right side of the issue followed them, but without a ton of thought as to where any of this is really going.
Any theory of American politics that hinges on the enormous lobbying and opinion-shaping power of HRC and GLAAD is deep in “citation needed” territory. Raising medium sided amounts of money in order to throw themselves gala events and completely fail at ever flipping a single unfriendly vote for any of their extremely hedged legislative goals has been their M.O. for decades: I’m highly dubious that they went from getting their clocks cleaned on the regular on SSM at the state legislative level to somehow dragging a medication-first approach to trans youth care out of the American medical establishment.
In my experience, the push for trans rights bubbled up organically from sites like Tumblr and YouTube rather than any advocacy groups. I've learned a lot more about trans stuff from video essayists like Contrapoints and PhilosophyTube than I have from GLAAD.
You may be right on the limited influence of the particular advocacy groups and their funding levels, but I more interpreted Matt’s comment to be about the cultural momentum around fighting for LGBT rights. People were (are) still primed for a long fight.
It’s an important distinction that this was actually a grass roots push by trans people who saw and opening and who were basing their goals on their own childhood experiences. Convincing the Human Rights Campaign to trim their sails and adopt a more incremental goal is easy: that’s HRC’s entire mission statement. (“We trim our sails before you even ask!”) Arguing a bunch of people with strong feelings about how their own childhoods went out of their conclusions is… harder. (If you doubt, watch the Twitter storm that’s gonna descend on our host in about 12 hours if not already.)
I donated to GLAAD a couple of years ago (long story) and they still send me mail that says, with no caveats, that ‘LGBT people are under attack more than ever’ (paraphrasing) because they (get to) consider conversations like this an “attack” on the Ts
I think it has more to do with a point that Matt has made about progressive groups being incredibly focused on being good allies. Which meant that a subject that heretofore mild publicity got an enormous boost from most groups rallying around it. Which had the side affect of causing it to become a major political battleground issue.
I think the gay rights movement conquered like hell.
My question is when did the T become paramount. I recall saying LGBT, but it was mostly gay rights. The T was a small part of it. I mean it was there but sports issues or gender affirming care for kids were not issues. The T was basically respect people who are different and make sure they are protected in jobs and basic civil rights.
Was it 2019? or was it the explosion of youth identifying as trans? Was it the general idiocy and paralysis that overtook Democratic and center-left thought after George Floyd that advocacy groups saw their chance to push max. demands?
One reason might be that as a G, I'm not sure what rights I'm really missing any more. I can serve openly in the military(not that I personally care to), I'm married, I've got kids. I can't donate blood but while that bothers me a bit I think that's CDC-type overcaution not homophobia.
So assuming you want to support LGBT people, it's Transgender folks who still lack the most protection.
Do you follow Andrew Sullivan? He had a fairly lengthy piece on his Substack recently about how transgenderism (as an ideology) complicates traditional "LGB-ism."
The UK has a pretty deep strain of anti-trans thought running through it. If you're interested in the other side, I'd recommend this three-part series looking into how bad the BBC reporting on "lesbians being pressured into sex" has been:
I think that in today’s progressive spaces, whoever is seen as the most oppressed is given the most attention, and marginalization is seen as a form of oppression; taken together, these make transgender people the highest priority for many.
The 2016 NC Bathroom Bill. GOP realized that they could use it as a new wedge issue to replace gay marriage. Progressives, bolstered by their success in opposing the 2016 Bathroom Bill, thought that they could use the same tactic of "cancelling" anyone who disagreed about trans rights that they had used near the end with Gay Marriage and worked in opposing the 2016 NC Bathroom Bill (and imo got out over their skis on it). Trans rights has been a major battle ground for both sides ever since.
It is a little ironic that during the early days of the gay marriage fights, one argument right-wingers would make was to list a parade of horribles of what gay marriage would lead to next (with widespread transgenderism sometimes being included in that list alongside disturbing stuff like bestiality and incest). And the liberal response was "oh come on none of those things will ever happen."
I don't remember transgenderism being a focus there. It doesn't actually involve any extension of marriage rights, which is what the actual scare tactics summoned up (bigamy/polyandry went along with incest, bestiality, child marriage, and various SciFi scenarios). The other item on the list was the end of marriage itself.
I'm not sold on the idea that the transgender rights issue picked up because marriage equality was resolved so quickly, leaving money in the bank for new causes. I do think it was among the trends waiting in line whenever the intense focus on marriage equality ended and made room for further expansions of concern for groups perceived as marginalized.
"I don't remember transgenderism being a focus there. It doesn't actually involve any extension of marriage rights"
I agree with everything else you wrote, but it does overlap a *bit* with marriage rights, since without marriage equality, who someone can marry (or whether a pre-existing marriage is still valid) depends on whether the state they are in recognizes their gender transition.
Well, to my knowledge, nobody has married their toaster yet, and I remember multiple warnings about that.
The prediction I thought was most likely is that it would prompt straight people to enter fake marriages to get the tax benefits, but that hasn’t happened at all.
But long term, sure, if you push for a societal change, you don’t know where it will end up much later, and you shouldn’t worry about it. I’m sure anyone who favored banning DH Lawrence would look at today’s society and feel completely vindicated. We have in fact loosened our sexual morays in ways they would find horrifying. I just don’t care.
If we were able to glimpse how people live in another sixty years, then barring some major disaster than transforms us into The Road, we’d probably be horrified too. And those future people shouldn’t worry about our opinion either.
"Every generation is, and must be, competent to all the purposes which its occasions require. It is the living, and not the dead, that are to be accommodated. When man ceases to be, his power and his wants cease with him; and having no longer any participation in the concerns of this world, he has no longer any authority in directing who shall be its governors, or how its government shall be organised, or how administered." —Thomas Paine
I think you overlook that trans rights activists have long criticised those mainstream groups for being too focused on LGB issues. So there was almost a defensive move to stop new groups forming that cannibalised their strength. But it does mean the advocacy groups haven't really thought it through either
I'm just a random gay person, not an LGBTQIA+ activist, but I'd list a couple real policy priorities:
- Enforcement of Bostock. As is the case for civil rights protections based on race and gender, I would assume many employers, landlords etc across the country are routinely in violation of it.
- Access to social transition. Many states and institutions still make the process of changing your legal/official name onerous.
- Access to medical transition. Apart from the question of how many of the people prescribed puberty blockers or cross-sex hormones are "really" trans or whether that's a sensical question to ask, it seems clear some people who would really benefit from medical or surgical transition still have trouble accessing it because of the high cost of health care.
- Data collection, including on things like crime victimization, health outcomes, asylum claims, and incarceration, that accurately and consistently reflects people's sexual orientation and gender identity. (I'm not sure how many activists would even support this, but it's a policy issue and I think there's a real case for it.)
- A cure for HIV, and making sure everyone has access to it, or to the latest and best HIV treatments.
- Preventing doctors from surgically intervening on intersex newborns. I'm not sure what the scale of the problem is today or whether government solutions are ideal, but it's certainly the case that some intersex kids have been incorrectly assigned to a gender they ended up not identifying with and operated on as such, to their later deep distress.
- In terms of the school system's relationship to parents: this is a subject of huge controversy, but I really think it is important that teachers and school administrators recognize that violently homophobic or transphobic parents really exist, and consider what they disclose to parents through the lens of that being a possibility.
- There's also the question of what comprehensive, LGBT-inclusive sex education looks like; I wrote out something long on the subject and then deleted it, but suffice it to say what we have now is insufficient.
- Call me crazy, but I'd like to get Hobby Lobby overturned - I guess if you're a literal [bigoted] church you could still fire people for being gay, but a privately held corporation with religious values is not a church and their religious values shouldn't get to trump other employment law.
"Data collection, including on things like crime victimization, health outcomes, asylum claims, and incarceration, that accurately and consistently reflects people's sexual orientation and gender identity."
The problem is that this "ask" is 180 degrees to the demand for self-ID, "gender fluidity," etc. If you want accurate stats, there has to actually be a bureaucratic process for recording gender, sexual orientation, etc. and any changes thereto.
I think #6 reveals the blind spots that a lot of commenters have on LGBT issues in this comment section.
My guess is that LGBT people like us know what it's like to be a kid in the closet and afraid of how your family may react to learning the truth about who we are, so (to me at least) it is better that LGBT kids should be able to confide in trusted adult figures without worrying about that information getting back to their parents. The alternative is that the fear of being outed would lead them to refuse to talk to the most significant adults in their lives outside of family, which means that problems the child is facing (mental health issues, abusive relationships, etc) could become more severe due to the secrecy.
My guess is that people who take issue with that are identifying more with the parents than with the kids, and expect that they should know the details of their child's lives. I don't get that, I think that kids should be entitled to a certain amount of privacy even before they turn 18. My friends growing up felt very real violations of trust and privacy when their parents would go behind their backs and read their diaries and then leverage that information to punish them. Expecting teachers to betray their student's trust like that is tantamount to diary-reading to me. If a teacher has to betray a child's trust to their parents, it should be for something genuinely risky for their health, like abuse or suicidal ideation.
My parents, while not initially very supportive, were never going to kick me out of the house or anything (and I never worried that they would) and it _still_ would have been nice to talk to a sympathetic adult perhaps about some of this with an expectation of privacy.
But I also see this as a parent, and those can be important for parents to know too.
I'm not sure teachers are best for that either? Maybe we should be able to fund school counselors who can provide that expectation of privacy the way a regular counselor/therapist does? They can be properly trained etc.
“…teachers and school administrators recognize that violently homophobic or transphobic parents really exist, and consider what they disclose to parents through the lens of that being a possibility”
Infringing on a parent’s right to raise her child should not be subject to a mere “possibility” or to a teacher’s whim. Florida’s Parental Rights in Education law, for example, holds school personnel to a “reasonably prudent person” standard, constrained by school district policy.
“…their religious values shouldn't get to trump other employment law”
Why not? Religious practice is specifically protected under the law.
Great comment -- I really appreciate your response.
My thinking:
1. Not sure the optimal policy prescription for helping enforcement of Bostock -- but I bet most would be supportive of this
2. Agree 100%. Government bureaucracy, especially w.r.t. social transition is a pox that should be eradicated.
3. Definitely would be supportive of more data collection, but I'd be surprised if this was really animating a lot of the activism here
4. Yes a cure for HIV would be great. But like, that's hard to achieve via policy.
5. This is a really interesting one I haven't thought much about. I'm almost certain this data doesn't exist but I'd love to see how many intersex infants are assigned a gender and then later develop dysphoria vs those who were essentially "assigned correctly" and go on to live non-dysphoric lives.
6. This is a really difficult topic because I think most people think that schools really should protect kids if their parents are deeply homophobic or transphobic while also believing that parents should be informed as much as possible. How do you write a law to address this?
7. Yeah I'd agree this is worthwhile.
8. I thought Hobby Lobby was a fight about birth control (I honestly don't remember -- though I definitely think even religious companies should offer health insurance that includes birth control)
Generally agree but as Allan says, #6 (teachers and informing parents) is fraught with peril in finding the edge cases.
And while I think Hobby Lobby is wrong not to support the contraception, and I'm not religious myself, I'm very nervous about that one.
I would say that outside of 6 and 8, you're generally just asking people to be more tolerant, and the laws to support that. 8 is potentially infringing on someone else's rights and whether you think that should be considered a right or not, they obviously do and that makes it a much trickier fight.
It’s one thing for private advocacy groups to spend money on whatever they want to pursue. It’s another for public institutions (public colleges, governments, schools, etc) to turn DEI into a public make work program for political advocates.
Having gone through training, it seems as if the DEI pros are trying a kind of conversion therapy. Much in the same way religious conservatives thought they could train the gay away (dumb) these DEI people think they are going to train the conservative away (also dumb). It just pisses people off. It’s a power move.
I think this kind of happened in both directions. The GOP saw the writing on the wall that Gay Marriage had become a wedge issue for Democrats, and was now damaging to their brand. As a result, they had to find another issue to take its place and landed on Trans rights. This backfired at first, with the 2016 North Carolina bathroom bill, but the GOP has since figured out that, where as much of the country is pretty much OK with transgendered adults, youth transition and sports still make for good wedge issues.
I think both sides play off each other. Progressives moved a lot faster than most of the country was ready for on trans issues, and I think this helped the GOP find these new wedge issues.
I also think that the success of gay marriage, also made a lot of progressives think that they they could turn opposing trans rights into a "cancellable" offense (as happened with opposition to Gay marriage). This actually worked to a large degree with the NC bathroom bill. However, I think that this strategy only works when you actually have majority support or more for an issue (or at least most people think you do), and we aren't actually there for trans rights issues. Moreover, I think the failure to make youth transition a cancellable issue outside of progressive spheres (notably academia and journalism) has encouraged conservatives to challenge how cancellable other views are.
It seems that progressive's have already lost the ability to successfully use this tactic for bathroom bill and the GOP is now starting to push back on gay rights (see, e.g. the "Don't Say Gay" bill).
I don’t see how the “Don’t Say Gay Bill” affects go rights. So if you can’t provide instruction on sexual preference or identity to K-3rd graders this negatively impacts gay rights? I would think this bill would be like outlawing people running 40 mph on a trail i.e. meaningless. It concerns me that so many feel restrained by the bill. What is it they want to instruct to these young kids? We can support trans kids without centering them in every school policy discussion.
It is less that it directly impacts gay rights (although you can get into whether setting up a situation where a teacher can get sued for mentioning their same-sex spouse or mentioning that a kid has same-sex parents infringes on gay rights), but I think its a shot across the bow at what had become a relative consensus that it's fine to be gay.
“although you can get into whether setting up a situation where a teacher can get sued for mentioning their same-sex spouse or mentioning that a kid has same-sex parents infringes on gay rights”
I don’t see how the bill sets someone up to be sued for mentioning their same sex spouse. I’ve heard this case made but not the foundation for why it’s plausible.
This is getting tangential to my original point but, the bill says:
"3. Classroom instruction by school personnel or third parties on sexual orientation or gender identity may not occur in kindergarten through grade 3 or in a manner that is not age appropriate or developmentally appropriate for students in accordance with state standards."
It doesn't define what constitutes "classroom instruction" or, for that matter, what is "age appropriate or developmentally appropriate" for students over grade 3. I could easily see someone claiming that a teacher who discusses their being gay or a student's parents being gay is engaging in "classroom instruction" in violation of this law, and they wouldn't necessarily be wrong.
FWIW, it looks like the lawsuit would be against the school district, not the individual teacher, and the school board is given 7 (maybe 30?) days to try to "resolve[] the concern" before the parent can sue.
It’s really bad because instruction isn’t really defined. If they meant a lesson plan and a learning goal and an assessment then I’d be pretty indifferent to it. Kids are coming into the classroom trans and with gay families and you want to be able to tell people how to treat others respectfully so that they’re not bullying and not let the rumors run wild, not to argue about whether that girl really has two moms etc.
Here are some definitions for instruction. Suddenly we all forget a rather simple word like instruction? If people want to argue that we should be teaching K-3rd graders about sexual preferences or the nuances of gender identity then make that case, but let’s stop acting like we don’t know what words mean. Are we all Bill Clinton now?
: instruction; plural noun: instructions
1. direction or order.
"he issued instructions to the sheriff"
2.detailed information telling how something should be done, operated, or assembled.
We really don’t know what it means. There’s a ton of small bore interactions that implicitly carry messages about gender and sexuality laced throughout every part of a school day. A lot of teacher prep programs say that everything in a teacher’s presentation is instruction.
I mean I’d never get in trouble for this but that I use he, him pronouns and Mr. is instruction on gender identity under Bostock’s reasoning.
I think this shows that, aside from the money involved, zealousness in being seen (by oneself or others) to be doing "good" feeds much of the moral hazard and propensity for overtreatment
The version of both this hypothesis and this article (the OP) that I'd want to read is how the entrepreneurial non-profit sector finds causes to advocate for, resulting in "over-treatment".
With respect, that’s not at all similar. The growth of DEI is surely a net-drain of university resources, not a source of income. DEI is simply a particularly monstrous example of the tendency of bureaucracy to self-perpetuate (at the *expense* of profits, efficiency, and whatever their institution’s original goals happens to be), a seemingly universal and quite distinct phenomenon from the specifically American issue of profit-driven healthcare, where over medication *serves* its purposes.
Its growth is at a rate that far outpaces any possibility of simply responding to demand. It is rather creating artificial institutional demand by changing internal institutional regulations and practices.
Not the specific number, but I've certainly seen brochures from my own alma matters that promote having different "affinity groups" and student organizations for every conceivable identity permutation you can think of. (I'll add that, in the case of my undergrad, there are fewer than 10,000 students for the school, including all the graduate and professional education programs, so I really struggle to understand how many people could even be using some of these services or how many additional students they could possibly attract.)
A big part of the DEI complex seems to be that corporations and institutions are basically funding the programs to hedge against lawsuits, right? If they get sued for workplace discrimination or harassment they can point to their DEI arrangement and say "while we feel bad for what happened to employee X that was an isolated incident and not reflective of our workplace culture, as you can see we take discrimination and harassment seriously and we have our DEI people on the case..."
maybe, but has the legal environment changed fundamentally in the past 2 years? because DEI departments appeared seemingly out of nowhere and ballooned into truly gigantic size. I suspect it has far more to do with a cultural phenomenon tapping into some structural-economic trends.
Is a response to protect against lawsuits - or is it mostly something they are doing to show that they are doing something? Especially, since its something they can do that often has little overall impact on their day to day business. My conclusion is that it started off as the former, but I'm guessing that given the surge over the last couple of years, its probably more the latter now.
Hedge against suits to some degree. But also it's the easiest way to look like you're spending money to address a problem without addressing a problem.
Culture is really hard to change whether it be societal, corporate, team, or any group.
I accidentally deleted several paragraphs speculating that perhaps the monastic lifestyle had much broader appeal than it did accessibility back when, and that social media is now feeding that impulse with added serotonin for acting like poverty and misery are a virtue.
Glad to know someone else is thinking along those lines.
No idea how to do this, but I wonder whether better civics education would make more students interested in actual governance, including how to actually achieve policy change (outside of university administration).
In 2020, among U.Va. undergrads alone, there were more than 1,100 Black students. I can't point to a specific fact to say you're wrong, but I will observe that given those numbers, the 10:1 ratio you cite does not seem especially plausible to me. (I realize that's the point -- "Look how disproportionate staffing is!" -- but the notion still beggars belief.)
U. Michigan has 1900 black graduate and undergraduate students. While I'm open to seeing a citation proving the 163 figure John cites above incorrect, I've never known him to make crap up, so if that holds, the ratio at U. Mich. is 11.8:1.
For "minority" students of any group except international students, the ratio is roughly 55:1. Including Hispanic students who often identify as white.
Are we really suggesting that we need as many DEI administrators per capita as we do freshman seminar lecturers to generate an acceptable student experience for minority students?
Almost all of this administrative bloat began as a make-work program for over-credentialled humanities grads; it's now become self-perpetuating.
The *only* way forward is to sack, en masse, the various assistant deans and provosts in charge of "student life", "diversity", etc. and every single person below them. To be eligible for a cent of federal research funding, subsidy money, or grant money, universities should be required to adhere to the ratio of teachers to administrative staff that they held in 1977.
Fundamentally, then, I stand corrected: There are many more DEI administrators at U.Va. than I imagined.
In fairness, if you include graduate schools (as the article does) and tally all nonwhite students, undergrad & graduate, I calculate about 75 minority students per administrator. But 94 positions still feels like a lot, especially relative to other student services.
It was an interesting approach to frame this within the overall practice of American medicine. It is basically the inverse of how people usually frame it within the overall framework of identity.
Thank you Matt, for clearly laying out what has been bothering me about the whole transition debate. I had a career in international development and then went to medical school in 2001, right in the middle of the Vioxx/EPO/oxy pushes. I was fascinated by the obvious existence of a political economy of medical knowledge that was completely ignored in medical education at the time. I’ve been working in Comparative Effectiveness Research ever since. I believe everyone should be allowed to decide who they are without harassment, but there was something about the aggressive push for early surgery and powerful drug that bothered me. Now I realize I reminds me of the lecturers telling us we would be bad doctors if we didn’t use EPO to push our patients HB up to 15 or hesitates to increase the dose of Oxy at a patient request. Any intervention powerful enough to help has power to harm. Haven’t we learned by now!
Usually when I hear this kind of opinion I think, "who are the doctors that are aggressively pushing surgery for trans kids? Is this a real thing or just a scare tactic?" Comparison with Europe really reveals the truth doesn't it?
Interesting angle and I largely agree with the sentiment that it might be a good thing if US gender-affirming care guidelines were a bit more cautious until more data comes out. However, I'm not sure that the higher "entrepreneurial spirit" of American physicians applies in this case for a pretty simple reason. The majority of teen/young-adult clinics providing gender affirming care are run out academic pediatric institutions (i.e., clinicians within adolescent medicine divisions within Pediatric Departments existing within university medical schools). And while it would be an exaggeration to say that there is no pressure to meet certain billing thresholds, the financial incentives for pediatricians practicing in these contexts are MUCH lower than physicians practicing in private practice (or even surgeons/interventionalists practicing within academic institutions). I'll use myself as an example. I am a pediatrician and clinical researcher at one of the largest children's hospital in the US (albeit in a completely separate field from adolescent medicine). I am paid a salary (side gripe, which is about half of my internist colleagues). I DO have minimum RVU targets that I'm expected to meet each year, which is fairly easy based on normal patient volume. Theoretically, there are potential RVU targets which if I hit, I would receive a relatively modest bonus. HOwever, in our current fee-for-service nightmare, those targets are so high that a pediatrician providing routine "medical" (counseling, med management...meaning nothing procedural) care has little chance of meeting them. This dynamic applies to the vast majority of adolescent physicians providing gender-affirming care . Furthermore, in academic contexts, these physicians receive no payments, additional RVUs, and/or kickbacks for trans youth undergoing reassignment surgeries (the surgeons and anesthesiologists do) - which are the procedures that would generate larger fees.
So what is the main driver in my opinion? Culture and ideology. I worry that many adolescent clinicians and pediatric endocrinologists are now so worried about being labelled as anti-trans (which would be career ending within those specialties) that raising any critiques/concerns of practice habits and trans-related research is not worth the risk. As a result, the clinicians, researchers, and policy advocates at the forefront of this field are operating within a "feedback-free" environment rife with confirmation bias.
Your explanation does not account for similar behavior among academic physicians with regard to overdiagnosis and overtreatment of other conditions. There is a great bias toward "doing something" and assembling factoids to appear that you are offering something that is special and "state of the art"
Yeah, I agree this plays a role as well. Especially in this context where patients and families often come into clinic expecting some form of treatment that "moves things forward." Talking through options, weighing pros/cons, and suggesting pt/family take time to consider is seen as a let down, especially when you have the specific tool they think is the answer.
It is true that academic centers have more activists because that's where they can pursue those specialized interests. We probably should be cautious about generalizing conflicts and culture within academic centers (like academia in general) to the private practice/community setting. "I don't offer that service. Go find an academic facility or someone trained in it," is pretty common.
I've spent most of my career in academic medicine but also some time in other settings (religious, secular private, county facility) and it's a VERY different world that doesn't follow the academic winds too closely.
And, yes, it's very strange how pediatric physicians are often reimbursed less than their adult counterparts. Never heard it justified beyond "that's how it is," which isn't remotely satisfying. (My wife does the pediatric version of what I do and actually makes more, but the hospital functionally skims off my collections to do so. Which is totally reasonable since she did more training, but it is harder to keep people like me from bolting to private practice.)
Primary care doctor here. Great article. Agree with most of it. Some thoughts:
1) Supplements are a huge problem and one not primarily driven by the general medical community (at least not in my experience). A lot of these are "prescribed" by naturopaths or when people decide to do their own research on-line. Why do people trust facebook for their medical advice? I tell people that just b/c something is "natural" doesn't make it harmless.
2) Agree that the market-driven side of medical practice in the US is a problem causing over-treatment. My husband works at Kaiser where docs are paid a salary. There's no incentive to over-do procedures other than fear of lawsuits and patients' demands (which I do think are true motivators.) It would be interesting if someone did a study looking at rates of cardiac caths, c-sections, elective procedures at Kaiser vs in private practice to see the difference.
3) I think the medical community in the US is doing a of damage with the rapid green-lighting of trans treatment/meds/surgeries for adolescents and children. Good luck with this article -- you're gonna get a lot of hate for it.
As a physician myself, I have no idea how to really advise patients with supplements. Some stuff has data, of course, but so much is just a black box.
Amazing how walling oneself from the system, as Kaiser has, can make such a difference. And can also allow research in care delivery.
I'm pretty sure the pendulum will swing backwards on this issue, like every issue. There's expansion, overshoot, then a new steady state. As such, I think guidelines will and should continue to emphasize reversible therapies for younger patients and irreversible affirming ones for older patients. I'm not in the field but the current guidelines seem pretty reasonable and in line with other medical interventions.
Basically, nothing irreversible until age 16, then full independence for surgery at age 18. The one thing they left very open was breast surgery, which depends on individual breast development (I've taken care of adolescents who needed reduction due to back pain. It also doesn't affect future reproductive ability if the person changes their mind and can be "reversed" surgically, though there's obviously morbidity involved).
I think there's a lot of rhetoric of people attacking and defending principles by misrepresenting policy or guidelines. Much of that is because implementation isn't exact or has second order effects. But in this case, I'd expect most physicians involved here will err on the conservative side. Remember, guidelines also "bind" those on the extremely permissive side (even though they probably helped write them, being academic specialists).
“I’m pretty sure the pendulum will swing backwards on this issue like every issue.” I can’t be so blasé about this. While the pendulum is currently on this trajectory, how many lives will be ruined or destroyed? No, the medical community is not erring on the conservative side on this issue. Any tepid debate or questioning is considered virulently anti-trans. I dread the articles we’ll all read in the Atlantic in 15-20 years about how the medical community completely capitulated to loud, forceful pressure rather than maintain its previous rigid standards.
I guess I just got busy. I’m here, read almost daily, just don’t usually have time to comment or read all of other people’s comments. Thanks for noticing. I’ll try to check in more frequently.
Most of my fellow Democratic committee people talk on issues like this of "being on the right side of history." I always thought, "How can you be so sure?"
I think they have a simplistic model of tying everything together (i.e. abolition of slavery, women's right to vote, and Civil Rights) with "gender affirming care" for youth.
This "positive" attitude has led to disasterous results over the last two years with Defund the Police, embracing DEI industrial complex hucksters, and now this.
Time to get out of the "right side of history" and look at issues on merits.
I do think there is something to the idea of a historical trend toward widening the circle of concern. I feel pretty confident that if anything resembling liberal societies exist 100 years in the future they will be more cosmopolitan than today’s societies in terms of their view of the interests of foreign-born people and in terms of their view of the interests of animals.
But what I don’t think this kind of analysis can get you is to what is actually the right answer in terms of what policies do in fact serve which interests.
I don't deny the great things liberalism and social democracy have done over the past 200 years.
But I really feel over the past 2 years a sort of laziness replaced empiricism.
We all want to help "marginalized" people, and want police brutality to stop.
But I saw a very lazy take on this issue by people which has led to not only bad political outcomes, but bad real life outcomes as violence rates skyrocket in places like Philadelphia in part because of a "Ferguson Effect" encouraged by people who were so sure they "were on the right side of history."
“Lazy” is the perfect term for a lot of the activism around police reform. For all the talk about “doing the hard work” most of that so called hard work was listening to people who said things activists already agreed with and shouting at people in government. The real hard work of balancing the priorities of civil liberties and law enforcement or actual reform policies just got waved off. Those problems are difficult to solve. Ut they really do need to be solved.
The weird thing is that this sort of intellectually lazy stuff tended to come from people who thought of themselves as smart.
The problem with this analysis is that not just violence, but all kinds of bad behavior (i.e. speeding, kids fighting in schools, etc.) rapidly escalated not just in Philly, but everywhere. I definitely agree that the police pulling back on doing their jobs in response to protest is a problem, but I don't think it can explain much about outcomes in, for example, the Delaware County suburbs around Philly, where they don't have Philly PD and don't have the liberal Philly DA but do have a escalation in crime.
(For an example of hilarious analysis, check out this article--https://delawarevalleyjournal.com/is-phillys-tide-of-violent-crime-washing-into-the-suburbs/--from last summer. The headline is, "Is Philly crime spilling into DelCo?!?" And the numbers are, "Philly crime is up a whopping 33%!!! Also, uh, DelCo is up 127%. But Philly is a terrifying dystopian hellscape where woke Libs invite people to murder you!)
That’s interesting. As a historian, I am increasingly coming to the conclusion that “the judgment of History” (and its toned-down cousin “the right side of history”) are merely a subconscious, secularized versions of god. In other words, a rather irrational belief in some form of transcendent, objective, ultimate, Justice or Truth that will prevail in the implicit end times, or at the very least a metaphysical belief in a necessary March towards Progress (the teleological fallacy). It’s nice rhetorically but I think most professional historians long discarded such notions. How can you defend it?
I've invested a lot of my money in stocks because, no doubt, of my irrational belief in some form of transcendent, objective tendency for equity values to increase over time.
Now it's true that past performance doesn't predict future success, but it's a much better guide to that future than randomly flipping a coin.
I don't believe in a "March towards Progress" (which sounds ideological or even religious as you suggest) but, along with Pinker, I believe there is a strong tendency toward progress based on empirical experience.
First, in your case there is, I am sorry to say, a well-defined end-point, your own life-time. Making projections for the next say 50 years is quite different from an ill-defined (or rather undefinable?) “History” or “Future.”
Second, making long-term projection about a specific economic measure in a given economic system for this set time period is quite different from a projection from something as loose as values. Even the very question of whether moral/social progress has been achieved between two given points in the past is debatable whereas SNP 500 is a clear cut number (sure there are other indexes but ultimately equity is quantifiable in a way values are not which makes the heuristics infinitely simpler).
Just observe the progress? For example, it used to be that only property-owning men could participate in politics (or an even more select group), but now it’s common for everyone to have the right to vote. For example, slavery used to be common but is now illegal ~everywhere.
Sure, there is a trend of democratization in the last 200 years, though I would suggest qualifying your assertions a bit ("now it's common for everyone to have the right to vote" - "everyone" in the *shriniking* minority of democratic countries you mean to say). However, my point is that there is zero guarantee that the trend will continue indefinitely. In fact, if you look harder you can see thaat the trend was by no means simple or clear cut, but had many reverses. The Nazis could have won in WWII, the Cold War may have ended up differently etc. At the very least you would need to make an argument to claim that that the victories of the free world in these conflicts was inevitable or that a loss wouldn't have mattered in the long run. Similarly, democracy is famously backsliding in the world for the past 15 years. Any confidence that this is a mere aberration and not the beginning of a new long-term trend would once more require some argumentation.
I do not think you need to make a metaphysical claim that 'progress' is necessary in order to make an empirically well-supported claim that liberalism tends toward broader, more cosmopolitan, more compassionate modes of organizing society.
If liberalism persists and prospers for 100 years, it will no doubt be a more compassionate, more open, more cosmopolitan society and it will no doubt look upon our era with some disdain for our moral failings.
If liberalism fails, then that won't happen. It's not a metaphysical claim, it's a social science claim.
I think if our present society with its current set of social and political configurations still existed in 2122, it would count as "liberalism". So it is possible to envision a form of liberalism that does *not* unfold in the manner I describe. Thus, I struggle to understand why it would be a circular argument to claim that, instead, liberal societies which continue to persist will continue to find new ways to "morally innovate" rather than remain relatively morally static. I believe that "moral innovation" is a crucial component of liberalism's self-justification narrative, i.e., it is crucial for people living today to see themselves as enlightened and compassionate and all-around morally superior to their ancestors of a century past.
1. You're basically saying that if society keeps being both liberal and becoming more cosmopolitan etc. then it will remain liberal and become more cosmopolitan etc. ("moral innovation") that's a tautology. You're not actually making a claim unless you're willing to make a claim on the likelihood of this actually coming to pass.
2. People who talk about the judgement of future generations seem to implicitly subscribe to the notion of inevitable moral progress. However history shows that it's perfectly possible that certain future generations would be morally inferior in every respect, and that, moreover, "future generations" are not a monolith (ditto for "judgment of history" - as if there is a single end vantage point from which to judge. absolute nonsense).
I think you are right but I genuinely wonder if that will be because they will have a better scientific understanding than us or because they will be further removed from lived human experiences. For instance, how a person views Lions will be different depending on whether you live in a city and just watch them on TV or whether you live near them and have to worry that one could eat you while you are walking to school. I'm not entirely confident that the person watching on TV is the one with a higher understanding.
"I do think there is something to the idea of a historical trend toward widening the circle of concern." - One of the best things about increasing the average person's wealth and security is that it makes it easier to look beyond themselves to others.
On the other hand, historical judgment is a weird thing - and I suspect that people in a hundred years will claim that whichever side they are on happens to be the right side of history. I do wonder how people will view abortion - will people will be horrified that anyone ever required a women continue a pregnancy if she didn't want too (like we view historically very common slavery today) - or will they be horrified that anyone ever thought it was okay to kill their child (like we view historically common infanticide today).
It’s odd to me that we don’t focus *more* on China. We speak constantly of the ill effects of slavery that are still present in our society while the people who made my phone lobby against bills that are designed to prevent them from generating a profit thanks to slave and child labor.
Why isn’t this a bigger deal? I think (frankly I hope) that this is the thing that our grandchildren will find disgusting about us.
Agreed. And people who think that progressives who want to use scientific knowledge to make the world a better place are always on the “right side of history” should read up on the eugenics movement.
He didn't just bury the lede. The first half of the essay gives solid support for the second half, which I suspect is why (so far?) nobody is rage-tweeting about it.
"she saw C-section rates go dramatically up at 4 and 5 p.m. — around the time when doctors tend to want to go home."
This is a little misleading. The doctors go home and are replaced by new doctors coming on shift. It's not that they *need* to wrap things up to leave, it's that they don't want to hand off a patient to someone else if they can finish the work themselves because every hand off leads to worse care. My own daughter was born by C-section at the end of a shift. It was clear she was going to need a C-section to get out because she wasn't moving and was having mild distress. Probably they could have waited another hour or so if the shift change wasn't a factor. Indeed, during the middle of a shift they make non-urgent surgeries wait while urgent surgeries take place. The end of the shift is a time to wrap up the non-urgent surgeries that are still outstanding while the new crew picks up the other work.
Agree, sometimes it's trying to not leave extra work for another person. And sometimes a new person comes on and disagrees with the 1st person's management.
Excellent post! I did not see that twist coming, I admit, though in truth it’s not a twist at all. This is the best kind of piece: not merely sharp opinion or suggestions on policy but one which provides a real kind of clarity helping us better understand contemporary phenomena, and -potentially- cool some heads, but perhaps I’m too optimistic…
As a breast cancer survivor who hangs out on Breast Cancer.org's (BCO) message board, I'd say that doctors are often just responding to pushy American consumers who think that they ought to get the best treatment or else they'll switch doctors. The BCO board has American, Canadian, Australian, and British members, and the Americans are the most demanding. They push for second, third, fourth opinions and wonder why they aren't getting the hot, new (and often expensive) treatment. An example: Perjeta, a targeted therapy. Perjeta was approved for early stage HER2+ cancer about eight years ago. Many American patients could get it, but Canadian patients could not. The Canadian patients were resigned to their situation, but the Americans would push their doctors to get it, even when their lumps were smaller than the recommended size (2 cm.)
I'd say the same thing probably happens with the parents of trans kids. They know that gender affirming care is out there, and they think that their kids should have access to the latest and the greatest. If one doctor tries to slow things down and encourages their child to take their time, their parents could always switch providers to the one who will give them what they want. So, doctors give their patients what they -- and their parents -- think they want.
Pretty similar to my take. A few wealthy, influential, demanding people can have a huge influence on their own care as well as the system. It's hard to say that anyone is being greedy or acting irresponsibly or irrationally, but these micro issues do create macro issues.
I'm surprised it's apparently not controversial that ADHD medications are overprescribed! I think Americans actually consume drastically *less* health care than we should. There are people in my social circles who avoid seeking out clearly-needed healthcare for financial reasons or individual neuroses. There's stuff we don't have good treatments for, but I suspect there are millions of Americans going through untreated chronic pain. My experience – as a high-SES, college-educated, insured, US citizen, native-English-speaker white gender-conforming cis dude! – is that you have to all but beg doctors to take your pain seriously, and absolutely no one is going to track you down to make sure you get healthcare. If you move to another city and decide it's easier to live with the pain than deal with the healthcare system to start seeing a new doctor, no one will come find you. It's very rare to have anyone in the healthcare system help you work through whatever anxieties you have about medical treatment either.
So it's not obvious to me that "health care is not actually the primary factor in population-level health" – making health care a commodity you consume changes *everything* about how people relate to it. It means refusing to see a doctor becomes, on some level, thrift. It reduces trust in doctors, raises the stakes of every appointment, creates tiered classes of patients. I understand intellectually overtreatment is happening somewhere, but I suspect it's mostly in the last six months of people's lives. It has not been my experience or that of people I know at all. I think undertreatment is part of the same problem as overtreatment – doctors have no incentive to try harder to fix difficult problems, and no incentive to try to relate to the patient, and overtreatment *later* can be caused by undertreatment in the near term – but no one should come away from this article thinking "everyone needs fewer medical tests".
Yes, thank you! I was diagnosed ADD as a teenager decades ago and suffered from it my entire life. I was wondering if anyone else caught and was annoyed by those statements and scrolling down to find this comment.
The same arguments have been made for decades. When I was first diagnosed it was a much less commonly diagnosed or treated condition. It was so uncommon that my otherwise well-informed and well-educated parents had only heard of it in passing; when their son was diagnosed with it, they had to learn about it essentially from scratch.
Even then, it was extremely common to claim that a huge proportion of the kids diagnosed didn't actually suffer from it, and the teenagers receiving treatment for it did not really need it. The percentage of those cohorts being diagnosed and treated has skyrocketed since then, but the belief and arguments remain the same.
Meanwhile, that folk wisdom creates enormous stress and hassles for my life. Getting my medication, when and as needed, is a huge pain in the ass because of extremely strict prescribing rules, driven in part by the anti-meth frenzy, but also in part because of skepticism by regulatory authorities that the prescriptions are legitimate.
I've suffered from ADD my whole life and am almost certainly cursed to continue to do so for however long I have left. I've also suffered my whole life from the overly restrictive and punitive rules regulating how I can be treated for my condition, in part because the beliefs fueling them are equally eternal. These beliefs are largely wrong and anyway are bad and create bad conditions for folks who really need the help of these medications, like me, so we should stop spreading them, or at least stop repeating them endlessly without context or framing.
I wasn't diagnosed until I was an adult, but this is a way better version of this sentiment than I would have written. It's a certain ironic punishment that people who have a bad working memory and trouble managing routines need to maintain a rigid schedule of contacting doctors to get medications refilled.
Just to echo what Milan said — everyone be on your best behavior and try to achieve maximum calm and respectfulness in your choices of language and manner of addressing others.
Sounds good to me. I have a question and since nothing I post appears as a comment unless it is posted as a reply I will do that here. Many people want to end the war on drugs. That may be a noble ambition that affects far more lives then gender issues. So if one decriminalizes drugs and deprives the court system of the power to compel treatment what happens? Considering that even the best treatment programs have very high recidivism rates and won't be compellable by anyone aren't we going to need pharmaceutical companies and people like the Sacklers to produce pharmaceutical grade recreational drugs. If we don't and allow the criminal element to sell adulterated drugs with lethal amounts of fentanyl or car-fentanyl how many will die? I wonder what their brand name for pharmaceutical grade meth will be?
Pharmaceutical meth goes by the brand name Desoxyn. If meth didn't have the cultural stigma, it might be more widely perscribed, as pointed out here: https://astralcodexten.substack.com/p/know-your-amphetamines?s=r
Bravo on including an honest-to-god end of second act twist in an opinion column
He did a great job of making the first half slow and boring.
Love this kind of Matt column!
Just snuck it right in there. You thought this was about universal healthcare reform? BAM! Gotcha!
Just dropping in early to remind everyone to play nice in the comments. I know this is a contentious issue but I would like to avoid a repeat of the Florida LGBTQ article’s comments.
Aw man, you skip a few days of articles and you miss all the good comment-thread drama! I'll have to go back and check that out.
I would argue something similar is happening with the DEI industry. The University of Michigan has 163 diversity officials. Now repeat this (though at a lower rate) at every University, every Government office, every major company. Their career incentives ensure they will always find some terrible injustice, some structural edifice that needs to be fixed, some new form of discrimination to fight.
I'm convinced the attention and prevalence of the Transgender issue is driven by a general reduction in overt racism and the acceptance of equal rights for Gay & Lesbians. The activists and DEI careerists will always find a new reason to exist.
I think the version of this hypothesis that makes more sense is that LGBT rights groups raised enormous amounts of money to fund what they were expecting would be a long, brutal war for marriage equality. Instead they won extremely quickly and Republicans haven’t made any real effort to roll it back. So the advocacy machine rushed in to explore a new frontier and politicians who want to be on the right side of the issue followed them, but without a ton of thought as to where any of this is really going.
Any theory of American politics that hinges on the enormous lobbying and opinion-shaping power of HRC and GLAAD is deep in “citation needed” territory. Raising medium sided amounts of money in order to throw themselves gala events and completely fail at ever flipping a single unfriendly vote for any of their extremely hedged legislative goals has been their M.O. for decades: I’m highly dubious that they went from getting their clocks cleaned on the regular on SSM at the state legislative level to somehow dragging a medication-first approach to trans youth care out of the American medical establishment.
Agreed.
In my experience, the push for trans rights bubbled up organically from sites like Tumblr and YouTube rather than any advocacy groups. I've learned a lot more about trans stuff from video essayists like Contrapoints and PhilosophyTube than I have from GLAAD.
You may be right on the limited influence of the particular advocacy groups and their funding levels, but I more interpreted Matt’s comment to be about the cultural momentum around fighting for LGBT rights. People were (are) still primed for a long fight.
It’s an important distinction that this was actually a grass roots push by trans people who saw and opening and who were basing their goals on their own childhood experiences. Convincing the Human Rights Campaign to trim their sails and adopt a more incremental goal is easy: that’s HRC’s entire mission statement. (“We trim our sails before you even ask!”) Arguing a bunch of people with strong feelings about how their own childhoods went out of their conclusions is… harder. (If you doubt, watch the Twitter storm that’s gonna descend on our host in about 12 hours if not already.)
See, e.g., the need in certain quarters to insist that Trump was the worst president ever on LGBTQ rights....
I donated to GLAAD a couple of years ago (long story) and they still send me mail that says, with no caveats, that ‘LGBT people are under attack more than ever’ (paraphrasing) because they (get to) consider conversations like this an “attack” on the Ts
I think it has more to do with a point that Matt has made about progressive groups being incredibly focused on being good allies. Which meant that a subject that heretofore mild publicity got an enormous boost from most groups rallying around it. Which had the side affect of causing it to become a major political battleground issue.
I agree — seems a stretch.
I think the gay rights movement conquered like hell.
My question is when did the T become paramount. I recall saying LGBT, but it was mostly gay rights. The T was a small part of it. I mean it was there but sports issues or gender affirming care for kids were not issues. The T was basically respect people who are different and make sure they are protected in jobs and basic civil rights.
Was it 2019? or was it the explosion of youth identifying as trans? Was it the general idiocy and paralysis that overtook Democratic and center-left thought after George Floyd that advocacy groups saw their chance to push max. demands?
One reason might be that as a G, I'm not sure what rights I'm really missing any more. I can serve openly in the military(not that I personally care to), I'm married, I've got kids. I can't donate blood but while that bothers me a bit I think that's CDC-type overcaution not homophobia.
So assuming you want to support LGBT people, it's Transgender folks who still lack the most protection.
But isn't there an inner conflict with some of this?
I see it online between lesbians and transwomen who call them "Terfs," etc.
The BBC has documented some real ugly stuff of lesbians being pressured into sex.
I think supporting trans rights would be supporting Bostock.
I am all for social transitioning.
But does my adopting the Nordic view of medical transitions on kids make me "Anti-trans" or a "trans-phobe" or anti LGBT?
Do you follow Andrew Sullivan? He had a fairly lengthy piece on his Substack recently about how transgenderism (as an ideology) complicates traditional "LGB-ism."
I do read him sometimes. I don't disagree with him on this, but he tends to be obsessive about things.
The UK has a pretty deep strain of anti-trans thought running through it. If you're interested in the other side, I'd recommend this three-part series looking into how bad the BBC reporting on "lesbians being pressured into sex" has been:
https://www.youtube.com/watch?v=b4buJMMiwcg
https://www.youtube.com/watch?v=qfjTG6SVjmQ
https://www.youtube.com/watch?v=fRn1UZ4fhdE
I will check it out.
However, I do see it in American social media.
The violent rhetoric aimed at women is something else.
I think that in today’s progressive spaces, whoever is seen as the most oppressed is given the most attention, and marginalization is seen as a form of oppression; taken together, these make transgender people the highest priority for many.
The 2016 NC Bathroom Bill. GOP realized that they could use it as a new wedge issue to replace gay marriage. Progressives, bolstered by their success in opposing the 2016 Bathroom Bill, thought that they could use the same tactic of "cancelling" anyone who disagreed about trans rights that they had used near the end with Gay Marriage and worked in opposing the 2016 NC Bathroom Bill (and imo got out over their skis on it). Trans rights has been a major battle ground for both sides ever since.
It is a little ironic that during the early days of the gay marriage fights, one argument right-wingers would make was to list a parade of horribles of what gay marriage would lead to next (with widespread transgenderism sometimes being included in that list alongside disturbing stuff like bestiality and incest). And the liberal response was "oh come on none of those things will ever happen."
I don't remember transgenderism being a focus there. It doesn't actually involve any extension of marriage rights, which is what the actual scare tactics summoned up (bigamy/polyandry went along with incest, bestiality, child marriage, and various SciFi scenarios). The other item on the list was the end of marriage itself.
I'm not sold on the idea that the transgender rights issue picked up because marriage equality was resolved so quickly, leaving money in the bank for new causes. I do think it was among the trends waiting in line whenever the intense focus on marriage equality ended and made room for further expansions of concern for groups perceived as marginalized.
"I don't remember transgenderism being a focus there. It doesn't actually involve any extension of marriage rights"
I agree with everything else you wrote, but it does overlap a *bit* with marriage rights, since without marriage equality, who someone can marry (or whether a pre-existing marriage is still valid) depends on whether the state they are in recognizes their gender transition.
Well, to my knowledge, nobody has married their toaster yet, and I remember multiple warnings about that.
The prediction I thought was most likely is that it would prompt straight people to enter fake marriages to get the tax benefits, but that hasn’t happened at all.
But long term, sure, if you push for a societal change, you don’t know where it will end up much later, and you shouldn’t worry about it. I’m sure anyone who favored banning DH Lawrence would look at today’s society and feel completely vindicated. We have in fact loosened our sexual morays in ways they would find horrifying. I just don’t care.
If we were able to glimpse how people live in another sixty years, then barring some major disaster than transforms us into The Road, we’d probably be horrified too. And those future people shouldn’t worry about our opinion either.
"Every generation is, and must be, competent to all the purposes which its occasions require. It is the living, and not the dead, that are to be accommodated. When man ceases to be, his power and his wants cease with him; and having no longer any participation in the concerns of this world, he has no longer any authority in directing who shall be its governors, or how its government shall be organised, or how administered." —Thomas Paine
"We have in fact loosened our sexual morays in ways they would find horrifying"
And what about our sexual whales?
(I think you meant mores)
Exactly what I’d expect a Sex Whale from Tokyo to say!
NSFW except for marine biologists
If you go back and look at what secessionists were saying in 1860-61 they also spoke about a lot of things that would come to pass.
Indeed, and the anti-slavery side would often deny those claims!
I think you overlook that trans rights activists have long criticised those mainstream groups for being too focused on LGB issues. So there was almost a defensive move to stop new groups forming that cannibalised their strength. But it does mean the advocacy groups haven't really thought it through either
I'd love to hear a steelman of the policy ask for LGBTQIA+ activists today. From my vantage, it seems post-Bostock, the victory was largely won.
I'm just a random gay person, not an LGBTQIA+ activist, but I'd list a couple real policy priorities:
- Enforcement of Bostock. As is the case for civil rights protections based on race and gender, I would assume many employers, landlords etc across the country are routinely in violation of it.
- Access to social transition. Many states and institutions still make the process of changing your legal/official name onerous.
- Access to medical transition. Apart from the question of how many of the people prescribed puberty blockers or cross-sex hormones are "really" trans or whether that's a sensical question to ask, it seems clear some people who would really benefit from medical or surgical transition still have trouble accessing it because of the high cost of health care.
- Data collection, including on things like crime victimization, health outcomes, asylum claims, and incarceration, that accurately and consistently reflects people's sexual orientation and gender identity. (I'm not sure how many activists would even support this, but it's a policy issue and I think there's a real case for it.)
- A cure for HIV, and making sure everyone has access to it, or to the latest and best HIV treatments.
- Preventing doctors from surgically intervening on intersex newborns. I'm not sure what the scale of the problem is today or whether government solutions are ideal, but it's certainly the case that some intersex kids have been incorrectly assigned to a gender they ended up not identifying with and operated on as such, to their later deep distress.
- In terms of the school system's relationship to parents: this is a subject of huge controversy, but I really think it is important that teachers and school administrators recognize that violently homophobic or transphobic parents really exist, and consider what they disclose to parents through the lens of that being a possibility.
- There's also the question of what comprehensive, LGBT-inclusive sex education looks like; I wrote out something long on the subject and then deleted it, but suffice it to say what we have now is insufficient.
- Call me crazy, but I'd like to get Hobby Lobby overturned - I guess if you're a literal [bigoted] church you could still fire people for being gay, but a privately held corporation with religious values is not a church and their religious values shouldn't get to trump other employment law.
"Data collection, including on things like crime victimization, health outcomes, asylum claims, and incarceration, that accurately and consistently reflects people's sexual orientation and gender identity."
The problem is that this "ask" is 180 degrees to the demand for self-ID, "gender fluidity," etc. If you want accurate stats, there has to actually be a bureaucratic process for recording gender, sexual orientation, etc. and any changes thereto.
I think #6 reveals the blind spots that a lot of commenters have on LGBT issues in this comment section.
My guess is that LGBT people like us know what it's like to be a kid in the closet and afraid of how your family may react to learning the truth about who we are, so (to me at least) it is better that LGBT kids should be able to confide in trusted adult figures without worrying about that information getting back to their parents. The alternative is that the fear of being outed would lead them to refuse to talk to the most significant adults in their lives outside of family, which means that problems the child is facing (mental health issues, abusive relationships, etc) could become more severe due to the secrecy.
My guess is that people who take issue with that are identifying more with the parents than with the kids, and expect that they should know the details of their child's lives. I don't get that, I think that kids should be entitled to a certain amount of privacy even before they turn 18. My friends growing up felt very real violations of trust and privacy when their parents would go behind their backs and read their diaries and then leverage that information to punish them. Expecting teachers to betray their student's trust like that is tantamount to diary-reading to me. If a teacher has to betray a child's trust to their parents, it should be for something genuinely risky for their health, like abuse or suicidal ideation.
My parents, while not initially very supportive, were never going to kick me out of the house or anything (and I never worried that they would) and it _still_ would have been nice to talk to a sympathetic adult perhaps about some of this with an expectation of privacy.
But I also see this as a parent, and those can be important for parents to know too.
I'm not sure teachers are best for that either? Maybe we should be able to fund school counselors who can provide that expectation of privacy the way a regular counselor/therapist does? They can be properly trained etc.
“…teachers and school administrators recognize that violently homophobic or transphobic parents really exist, and consider what they disclose to parents through the lens of that being a possibility”
Infringing on a parent’s right to raise her child should not be subject to a mere “possibility” or to a teacher’s whim. Florida’s Parental Rights in Education law, for example, holds school personnel to a “reasonably prudent person” standard, constrained by school district policy.
“…their religious values shouldn't get to trump other employment law”
Why not? Religious practice is specifically protected under the law.
Great comment -- I really appreciate your response.
My thinking:
1. Not sure the optimal policy prescription for helping enforcement of Bostock -- but I bet most would be supportive of this
2. Agree 100%. Government bureaucracy, especially w.r.t. social transition is a pox that should be eradicated.
3. Definitely would be supportive of more data collection, but I'd be surprised if this was really animating a lot of the activism here
4. Yes a cure for HIV would be great. But like, that's hard to achieve via policy.
5. This is a really interesting one I haven't thought much about. I'm almost certain this data doesn't exist but I'd love to see how many intersex infants are assigned a gender and then later develop dysphoria vs those who were essentially "assigned correctly" and go on to live non-dysphoric lives.
6. This is a really difficult topic because I think most people think that schools really should protect kids if their parents are deeply homophobic or transphobic while also believing that parents should be informed as much as possible. How do you write a law to address this?
7. Yeah I'd agree this is worthwhile.
8. I thought Hobby Lobby was a fight about birth control (I honestly don't remember -- though I definitely think even religious companies should offer health insurance that includes birth control)
Generally agree but as Allan says, #6 (teachers and informing parents) is fraught with peril in finding the edge cases.
And while I think Hobby Lobby is wrong not to support the contraception, and I'm not religious myself, I'm very nervous about that one.
I would say that outside of 6 and 8, you're generally just asking people to be more tolerant, and the laws to support that. 8 is potentially infringing on someone else's rights and whether you think that should be considered a right or not, they obviously do and that makes it a much trickier fight.
It’s one thing for private advocacy groups to spend money on whatever they want to pursue. It’s another for public institutions (public colleges, governments, schools, etc) to turn DEI into a public make work program for political advocates.
Having gone through training, it seems as if the DEI pros are trying a kind of conversion therapy. Much in the same way religious conservatives thought they could train the gay away (dumb) these DEI people think they are going to train the conservative away (also dumb). It just pisses people off. It’s a power move.
I think this kind of happened in both directions. The GOP saw the writing on the wall that Gay Marriage had become a wedge issue for Democrats, and was now damaging to their brand. As a result, they had to find another issue to take its place and landed on Trans rights. This backfired at first, with the 2016 North Carolina bathroom bill, but the GOP has since figured out that, where as much of the country is pretty much OK with transgendered adults, youth transition and sports still make for good wedge issues.
I think both sides play off each other. Progressives moved a lot faster than most of the country was ready for on trans issues, and I think this helped the GOP find these new wedge issues.
I also think that the success of gay marriage, also made a lot of progressives think that they they could turn opposing trans rights into a "cancellable" offense (as happened with opposition to Gay marriage). This actually worked to a large degree with the NC bathroom bill. However, I think that this strategy only works when you actually have majority support or more for an issue (or at least most people think you do), and we aren't actually there for trans rights issues. Moreover, I think the failure to make youth transition a cancellable issue outside of progressive spheres (notably academia and journalism) has encouraged conservatives to challenge how cancellable other views are.
It seems that progressive's have already lost the ability to successfully use this tactic for bathroom bill and the GOP is now starting to push back on gay rights (see, e.g. the "Don't Say Gay" bill).
I don’t see how the “Don’t Say Gay Bill” affects go rights. So if you can’t provide instruction on sexual preference or identity to K-3rd graders this negatively impacts gay rights? I would think this bill would be like outlawing people running 40 mph on a trail i.e. meaningless. It concerns me that so many feel restrained by the bill. What is it they want to instruct to these young kids? We can support trans kids without centering them in every school policy discussion.
It is less that it directly impacts gay rights (although you can get into whether setting up a situation where a teacher can get sued for mentioning their same-sex spouse or mentioning that a kid has same-sex parents infringes on gay rights), but I think its a shot across the bow at what had become a relative consensus that it's fine to be gay.
“although you can get into whether setting up a situation where a teacher can get sued for mentioning their same-sex spouse or mentioning that a kid has same-sex parents infringes on gay rights”
No one has set up such a situation.
The law passed under two months ago.
I don’t see how the bill sets someone up to be sued for mentioning their same sex spouse. I’ve heard this case made but not the foundation for why it’s plausible.
This is getting tangential to my original point but, the bill says:
"3. Classroom instruction by school personnel or third parties on sexual orientation or gender identity may not occur in kindergarten through grade 3 or in a manner that is not age appropriate or developmentally appropriate for students in accordance with state standards."
It doesn't define what constitutes "classroom instruction" or, for that matter, what is "age appropriate or developmentally appropriate" for students over grade 3. I could easily see someone claiming that a teacher who discusses their being gay or a student's parents being gay is engaging in "classroom instruction" in violation of this law, and they wouldn't necessarily be wrong.
FWIW, it looks like the lawsuit would be against the school district, not the individual teacher, and the school board is given 7 (maybe 30?) days to try to "resolve[] the concern" before the parent can sue.
It’s really bad because instruction isn’t really defined. If they meant a lesson plan and a learning goal and an assessment then I’d be pretty indifferent to it. Kids are coming into the classroom trans and with gay families and you want to be able to tell people how to treat others respectfully so that they’re not bullying and not let the rumors run wild, not to argue about whether that girl really has two moms etc.
Here are some definitions for instruction. Suddenly we all forget a rather simple word like instruction? If people want to argue that we should be teaching K-3rd graders about sexual preferences or the nuances of gender identity then make that case, but let’s stop acting like we don’t know what words mean. Are we all Bill Clinton now?
: instruction; plural noun: instructions
1. direction or order.
"he issued instructions to the sheriff"
2.detailed information telling how something should be done, operated, or assembled.
3. teaching; education.
"the school offers personalized instruction
We really don’t know what it means. There’s a ton of small bore interactions that implicitly carry messages about gender and sexuality laced throughout every part of a school day. A lot of teacher prep programs say that everything in a teacher’s presentation is instruction.
I mean I’d never get in trouble for this but that I use he, him pronouns and Mr. is instruction on gender identity under Bostock’s reasoning.
I think this shows that, aside from the money involved, zealousness in being seen (by oneself or others) to be doing "good" feeds much of the moral hazard and propensity for overtreatment
The version of both this hypothesis and this article (the OP) that I'd want to read is how the entrepreneurial non-profit sector finds causes to advocate for, resulting in "over-treatment".
With respect, that’s not at all similar. The growth of DEI is surely a net-drain of university resources, not a source of income. DEI is simply a particularly monstrous example of the tendency of bureaucracy to self-perpetuate (at the *expense* of profits, efficiency, and whatever their institution’s original goals happens to be), a seemingly universal and quite distinct phenomenon from the specifically American issue of profit-driven healthcare, where over medication *serves* its purposes.
I'm curious to see how much demand there is for DEI administration from current and prospective students. It has to be non-zero, right?
Its growth is at a rate that far outpaces any possibility of simply responding to demand. It is rather creating artificial institutional demand by changing internal institutional regulations and practices.
oh I don't disagree. But if every other university has a DEI administration and your university doesn't, then that may send an unattractive signal.
Sure, having *a* DEI department becomes standard, but 163 of them? Is that truly a sales pitch? Does that appear on any brochure ?
Not the specific number, but I've certainly seen brochures from my own alma matters that promote having different "affinity groups" and student organizations for every conceivable identity permutation you can think of. (I'll add that, in the case of my undergrad, there are fewer than 10,000 students for the school, including all the graduate and professional education programs, so I really struggle to understand how many people could even be using some of these services or how many additional students they could possibly attract.)
A big part of the DEI complex seems to be that corporations and institutions are basically funding the programs to hedge against lawsuits, right? If they get sued for workplace discrimination or harassment they can point to their DEI arrangement and say "while we feel bad for what happened to employee X that was an isolated incident and not reflective of our workplace culture, as you can see we take discrimination and harassment seriously and we have our DEI people on the case..."
Sure, but the Iron Law of Bureaucracy applies here as well.
maybe, but has the legal environment changed fundamentally in the past 2 years? because DEI departments appeared seemingly out of nowhere and ballooned into truly gigantic size. I suspect it has far more to do with a cultural phenomenon tapping into some structural-economic trends.
Is a response to protect against lawsuits - or is it mostly something they are doing to show that they are doing something? Especially, since its something they can do that often has little overall impact on their day to day business. My conclusion is that it started off as the former, but I'm guessing that given the surge over the last couple of years, its probably more the latter now.
Hedge against suits to some degree. But also it's the easiest way to look like you're spending money to address a problem without addressing a problem.
Culture is really hard to change whether it be societal, corporate, team, or any group.
You'd think that consigning yourself to a lifetime of either poverty, misery, or both would do the trick.
Yes, but *why*?
As a long-time player of the Morganites in Sid Meier's "Alpha Centauri," tell me about it!
I accidentally deleted several paragraphs speculating that perhaps the monastic lifestyle had much broader appeal than it did accessibility back when, and that social media is now feeding that impulse with added serotonin for acting like poverty and misery are a virtue.
Glad to know someone else is thinking along those lines.
No idea how to do this, but I wonder whether better civics education would make more students interested in actual governance, including how to actually achieve policy change (outside of university administration).
In 2020, among U.Va. undergrads alone, there were more than 1,100 Black students. I can't point to a specific fact to say you're wrong, but I will observe that given those numbers, the 10:1 ratio you cite does not seem especially plausible to me. (I realize that's the point -- "Look how disproportionate staffing is!" -- but the notion still beggars belief.)
U. Michigan has 1900 black graduate and undergraduate students. While I'm open to seeing a citation proving the 163 figure John cites above incorrect, I've never known him to make crap up, so if that holds, the ratio at U. Mich. is 11.8:1.
For "minority" students of any group except international students, the ratio is roughly 55:1. Including Hispanic students who often identify as white.
Are we really suggesting that we need as many DEI administrators per capita as we do freshman seminar lecturers to generate an acceptable student experience for minority students?
Almost all of this administrative bloat began as a make-work program for over-credentialled humanities grads; it's now become self-perpetuating.
The *only* way forward is to sack, en masse, the various assistant deans and provosts in charge of "student life", "diversity", etc. and every single person below them. To be eligible for a cent of federal research funding, subsidy money, or grant money, universities should be required to adhere to the ratio of teachers to administrative staff that they held in 1977.
My source: https://www.heritage.org/education/report/diversity-university-dei-bloat-the-academy
Table 1 shows the UM figure. It also shows Virginia with 94 DEI staff.
Are these full time DEI admins, or are they people who wear many hats and DEI is one of them?
I've been wondering for a while: what do full-time DEI people do on a daily or weekly basis? How are their results measured?
Fundamentally, then, I stand corrected: There are many more DEI administrators at U.Va. than I imagined.
In fairness, if you include graduate schools (as the article does) and tally all nonwhite students, undergrad & graduate, I calculate about 75 minority students per administrator. But 94 positions still feels like a lot, especially relative to other student services.
It was an interesting approach to frame this within the overall practice of American medicine. It is basically the inverse of how people usually frame it within the overall framework of identity.
Good read.
Thank you Matt, for clearly laying out what has been bothering me about the whole transition debate. I had a career in international development and then went to medical school in 2001, right in the middle of the Vioxx/EPO/oxy pushes. I was fascinated by the obvious existence of a political economy of medical knowledge that was completely ignored in medical education at the time. I’ve been working in Comparative Effectiveness Research ever since. I believe everyone should be allowed to decide who they are without harassment, but there was something about the aggressive push for early surgery and powerful drug that bothered me. Now I realize I reminds me of the lecturers telling us we would be bad doctors if we didn’t use EPO to push our patients HB up to 15 or hesitates to increase the dose of Oxy at a patient request. Any intervention powerful enough to help has power to harm. Haven’t we learned by now!
Usually when I hear this kind of opinion I think, "who are the doctors that are aggressively pushing surgery for trans kids? Is this a real thing or just a scare tactic?" Comparison with Europe really reveals the truth doesn't it?
Interesting angle and I largely agree with the sentiment that it might be a good thing if US gender-affirming care guidelines were a bit more cautious until more data comes out. However, I'm not sure that the higher "entrepreneurial spirit" of American physicians applies in this case for a pretty simple reason. The majority of teen/young-adult clinics providing gender affirming care are run out academic pediatric institutions (i.e., clinicians within adolescent medicine divisions within Pediatric Departments existing within university medical schools). And while it would be an exaggeration to say that there is no pressure to meet certain billing thresholds, the financial incentives for pediatricians practicing in these contexts are MUCH lower than physicians practicing in private practice (or even surgeons/interventionalists practicing within academic institutions). I'll use myself as an example. I am a pediatrician and clinical researcher at one of the largest children's hospital in the US (albeit in a completely separate field from adolescent medicine). I am paid a salary (side gripe, which is about half of my internist colleagues). I DO have minimum RVU targets that I'm expected to meet each year, which is fairly easy based on normal patient volume. Theoretically, there are potential RVU targets which if I hit, I would receive a relatively modest bonus. HOwever, in our current fee-for-service nightmare, those targets are so high that a pediatrician providing routine "medical" (counseling, med management...meaning nothing procedural) care has little chance of meeting them. This dynamic applies to the vast majority of adolescent physicians providing gender-affirming care . Furthermore, in academic contexts, these physicians receive no payments, additional RVUs, and/or kickbacks for trans youth undergoing reassignment surgeries (the surgeons and anesthesiologists do) - which are the procedures that would generate larger fees.
So what is the main driver in my opinion? Culture and ideology. I worry that many adolescent clinicians and pediatric endocrinologists are now so worried about being labelled as anti-trans (which would be career ending within those specialties) that raising any critiques/concerns of practice habits and trans-related research is not worth the risk. As a result, the clinicians, researchers, and policy advocates at the forefront of this field are operating within a "feedback-free" environment rife with confirmation bias.
Your explanation does not account for similar behavior among academic physicians with regard to overdiagnosis and overtreatment of other conditions. There is a great bias toward "doing something" and assembling factoids to appear that you are offering something that is special and "state of the art"
Yeah, I agree this plays a role as well. Especially in this context where patients and families often come into clinic expecting some form of treatment that "moves things forward." Talking through options, weighing pros/cons, and suggesting pt/family take time to consider is seen as a let down, especially when you have the specific tool they think is the answer.
It is true that academic centers have more activists because that's where they can pursue those specialized interests. We probably should be cautious about generalizing conflicts and culture within academic centers (like academia in general) to the private practice/community setting. "I don't offer that service. Go find an academic facility or someone trained in it," is pretty common.
I've spent most of my career in academic medicine but also some time in other settings (religious, secular private, county facility) and it's a VERY different world that doesn't follow the academic winds too closely.
And, yes, it's very strange how pediatric physicians are often reimbursed less than their adult counterparts. Never heard it justified beyond "that's how it is," which isn't remotely satisfying. (My wife does the pediatric version of what I do and actually makes more, but the hospital functionally skims off my collections to do so. Which is totally reasonable since she did more training, but it is harder to keep people like me from bolting to private practice.)
Primary care doctor here. Great article. Agree with most of it. Some thoughts:
1) Supplements are a huge problem and one not primarily driven by the general medical community (at least not in my experience). A lot of these are "prescribed" by naturopaths or when people decide to do their own research on-line. Why do people trust facebook for their medical advice? I tell people that just b/c something is "natural" doesn't make it harmless.
2) Agree that the market-driven side of medical practice in the US is a problem causing over-treatment. My husband works at Kaiser where docs are paid a salary. There's no incentive to over-do procedures other than fear of lawsuits and patients' demands (which I do think are true motivators.) It would be interesting if someone did a study looking at rates of cardiac caths, c-sections, elective procedures at Kaiser vs in private practice to see the difference.
3) I think the medical community in the US is doing a of damage with the rapid green-lighting of trans treatment/meds/surgeries for adolescents and children. Good luck with this article -- you're gonna get a lot of hate for it.
As a physician myself, I have no idea how to really advise patients with supplements. Some stuff has data, of course, but so much is just a black box.
Amazing how walling oneself from the system, as Kaiser has, can make such a difference. And can also allow research in care delivery.
I'm pretty sure the pendulum will swing backwards on this issue, like every issue. There's expansion, overshoot, then a new steady state. As such, I think guidelines will and should continue to emphasize reversible therapies for younger patients and irreversible affirming ones for older patients. I'm not in the field but the current guidelines seem pretty reasonable and in line with other medical interventions.
Basically, nothing irreversible until age 16, then full independence for surgery at age 18. The one thing they left very open was breast surgery, which depends on individual breast development (I've taken care of adolescents who needed reduction due to back pain. It also doesn't affect future reproductive ability if the person changes their mind and can be "reversed" surgically, though there's obviously morbidity involved).
https://www.endocrine.org/clinical-practice-guidelines/gender-dysphoria-gender-incongruence
I think there's a lot of rhetoric of people attacking and defending principles by misrepresenting policy or guidelines. Much of that is because implementation isn't exact or has second order effects. But in this case, I'd expect most physicians involved here will err on the conservative side. Remember, guidelines also "bind" those on the extremely permissive side (even though they probably helped write them, being academic specialists).
“I’m pretty sure the pendulum will swing backwards on this issue like every issue.” I can’t be so blasé about this. While the pendulum is currently on this trajectory, how many lives will be ruined or destroyed? No, the medical community is not erring on the conservative side on this issue. Any tepid debate or questioning is considered virulently anti-trans. I dread the articles we’ll all read in the Atlantic in 15-20 years about how the medical community completely capitulated to loud, forceful pressure rather than maintain its previous rigid standards.
I guess I just got busy. I’m here, read almost daily, just don’t usually have time to comment or read all of other people’s comments. Thanks for noticing. I’ll try to check in more frequently.
Most of my fellow Democratic committee people talk on issues like this of "being on the right side of history." I always thought, "How can you be so sure?"
I think they have a simplistic model of tying everything together (i.e. abolition of slavery, women's right to vote, and Civil Rights) with "gender affirming care" for youth.
This "positive" attitude has led to disasterous results over the last two years with Defund the Police, embracing DEI industrial complex hucksters, and now this.
Time to get out of the "right side of history" and look at issues on merits.
I do think there is something to the idea of a historical trend toward widening the circle of concern. I feel pretty confident that if anything resembling liberal societies exist 100 years in the future they will be more cosmopolitan than today’s societies in terms of their view of the interests of foreign-born people and in terms of their view of the interests of animals.
But what I don’t think this kind of analysis can get you is to what is actually the right answer in terms of what policies do in fact serve which interests.
I don't deny the great things liberalism and social democracy have done over the past 200 years.
But I really feel over the past 2 years a sort of laziness replaced empiricism.
We all want to help "marginalized" people, and want police brutality to stop.
But I saw a very lazy take on this issue by people which has led to not only bad political outcomes, but bad real life outcomes as violence rates skyrocket in places like Philadelphia in part because of a "Ferguson Effect" encouraged by people who were so sure they "were on the right side of history."
“Lazy” is the perfect term for a lot of the activism around police reform. For all the talk about “doing the hard work” most of that so called hard work was listening to people who said things activists already agreed with and shouting at people in government. The real hard work of balancing the priorities of civil liberties and law enforcement or actual reform policies just got waved off. Those problems are difficult to solve. Ut they really do need to be solved.
The weird thing is that this sort of intellectually lazy stuff tended to come from people who thought of themselves as smart.
If I never hear the word "marginalized" again it will be too soon.
I hate hearing it about themselves from fabulously wealthy white women who "suffer under the patriarchy" as they jetset around the world.
They are "marginalized." Yet a poor white guy with black lung in West Virginia is their "oppressor."
The problem with this analysis is that not just violence, but all kinds of bad behavior (i.e. speeding, kids fighting in schools, etc.) rapidly escalated not just in Philly, but everywhere. I definitely agree that the police pulling back on doing their jobs in response to protest is a problem, but I don't think it can explain much about outcomes in, for example, the Delaware County suburbs around Philly, where they don't have Philly PD and don't have the liberal Philly DA but do have a escalation in crime.
(For an example of hilarious analysis, check out this article--https://delawarevalleyjournal.com/is-phillys-tide-of-violent-crime-washing-into-the-suburbs/--from last summer. The headline is, "Is Philly crime spilling into DelCo?!?" And the numbers are, "Philly crime is up a whopping 33%!!! Also, uh, DelCo is up 127%. But Philly is a terrifying dystopian hellscape where woke Libs invite people to murder you!)
Surely being up 127 percent is much easier when you base of murders and crime is so low.
And yes the point was there was a nationwide Ferguson effect.
But it also happened in places where the police aren’t relevant, like air rage.
That’s interesting. As a historian, I am increasingly coming to the conclusion that “the judgment of History” (and its toned-down cousin “the right side of history”) are merely a subconscious, secularized versions of god. In other words, a rather irrational belief in some form of transcendent, objective, ultimate, Justice or Truth that will prevail in the implicit end times, or at the very least a metaphysical belief in a necessary March towards Progress (the teleological fallacy). It’s nice rhetorically but I think most professional historians long discarded such notions. How can you defend it?
I've invested a lot of my money in stocks because, no doubt, of my irrational belief in some form of transcendent, objective tendency for equity values to increase over time.
Now it's true that past performance doesn't predict future success, but it's a much better guide to that future than randomly flipping a coin.
I don't believe in a "March towards Progress" (which sounds ideological or even religious as you suggest) but, along with Pinker, I believe there is a strong tendency toward progress based on empirical experience.
Your analogy fails on several levels.
First, in your case there is, I am sorry to say, a well-defined end-point, your own life-time. Making projections for the next say 50 years is quite different from an ill-defined (or rather undefinable?) “History” or “Future.”
Second, making long-term projection about a specific economic measure in a given economic system for this set time period is quite different from a projection from something as loose as values. Even the very question of whether moral/social progress has been achieved between two given points in the past is debatable whereas SNP 500 is a clear cut number (sure there are other indexes but ultimately equity is quantifiable in a way values are not which makes the heuristics infinitely simpler).
Just observe the progress? For example, it used to be that only property-owning men could participate in politics (or an even more select group), but now it’s common for everyone to have the right to vote. For example, slavery used to be common but is now illegal ~everywhere.
What makes you say there isn’t a trend here?
Sure, there is a trend of democratization in the last 200 years, though I would suggest qualifying your assertions a bit ("now it's common for everyone to have the right to vote" - "everyone" in the *shriniking* minority of democratic countries you mean to say). However, my point is that there is zero guarantee that the trend will continue indefinitely. In fact, if you look harder you can see thaat the trend was by no means simple or clear cut, but had many reverses. The Nazis could have won in WWII, the Cold War may have ended up differently etc. At the very least you would need to make an argument to claim that that the victories of the free world in these conflicts was inevitable or that a loss wouldn't have mattered in the long run. Similarly, democracy is famously backsliding in the world for the past 15 years. Any confidence that this is a mere aberration and not the beginning of a new long-term trend would once more require some argumentation.
I do not think you need to make a metaphysical claim that 'progress' is necessary in order to make an empirically well-supported claim that liberalism tends toward broader, more cosmopolitan, more compassionate modes of organizing society.
If liberalism persists and prospers for 100 years, it will no doubt be a more compassionate, more open, more cosmopolitan society and it will no doubt look upon our era with some disdain for our moral failings.
If liberalism fails, then that won't happen. It's not a metaphysical claim, it's a social science claim.
I would rather suggest that it’s not a tea claim at all but rather a circular argument.
Would you care to elaborate?
I think if our present society with its current set of social and political configurations still existed in 2122, it would count as "liberalism". So it is possible to envision a form of liberalism that does *not* unfold in the manner I describe. Thus, I struggle to understand why it would be a circular argument to claim that, instead, liberal societies which continue to persist will continue to find new ways to "morally innovate" rather than remain relatively morally static. I believe that "moral innovation" is a crucial component of liberalism's self-justification narrative, i.e., it is crucial for people living today to see themselves as enlightened and compassionate and all-around morally superior to their ancestors of a century past.
1. You're basically saying that if society keeps being both liberal and becoming more cosmopolitan etc. then it will remain liberal and become more cosmopolitan etc. ("moral innovation") that's a tautology. You're not actually making a claim unless you're willing to make a claim on the likelihood of this actually coming to pass.
2. People who talk about the judgement of future generations seem to implicitly subscribe to the notion of inevitable moral progress. However history shows that it's perfectly possible that certain future generations would be morally inferior in every respect, and that, moreover, "future generations" are not a monolith (ditto for "judgment of history" - as if there is a single end vantage point from which to judge. absolute nonsense).
This is basically the thesis of a recent book by the pop historian Tom Holland (and is also in the general thrust of a lot of Nietzschean philosophy)
To me the most succinct but effective conservative critique of liberalism is: “good intentions do not equal good results.”
I think you are right but I genuinely wonder if that will be because they will have a better scientific understanding than us or because they will be further removed from lived human experiences. For instance, how a person views Lions will be different depending on whether you live in a city and just watch them on TV or whether you live near them and have to worry that one could eat you while you are walking to school. I'm not entirely confident that the person watching on TV is the one with a higher understanding.
"I do think there is something to the idea of a historical trend toward widening the circle of concern." - One of the best things about increasing the average person's wealth and security is that it makes it easier to look beyond themselves to others.
On the other hand, historical judgment is a weird thing - and I suspect that people in a hundred years will claim that whichever side they are on happens to be the right side of history. I do wonder how people will view abortion - will people will be horrified that anyone ever required a women continue a pregnancy if she didn't want too (like we view historically very common slavery today) - or will they be horrified that anyone ever thought it was okay to kill their child (like we view historically common infanticide today).
It’s odd to me that we don’t focus *more* on China. We speak constantly of the ill effects of slavery that are still present in our society while the people who made my phone lobby against bills that are designed to prevent them from generating a profit thanks to slave and child labor.
Why isn’t this a bigger deal? I think (frankly I hope) that this is the thing that our grandchildren will find disgusting about us.
Agreed. And people who think that progressives who want to use scientific knowledge to make the world a better place are always on the “right side of history” should read up on the eugenics movement.
I actually don't think this will be that controversial of a piece because the argument is laid out too well.
He didn't just bury the lede. The first half of the essay gives solid support for the second half, which I suspect is why (so far?) nobody is rage-tweeting about it.
"she saw C-section rates go dramatically up at 4 and 5 p.m. — around the time when doctors tend to want to go home."
This is a little misleading. The doctors go home and are replaced by new doctors coming on shift. It's not that they *need* to wrap things up to leave, it's that they don't want to hand off a patient to someone else if they can finish the work themselves because every hand off leads to worse care. My own daughter was born by C-section at the end of a shift. It was clear she was going to need a C-section to get out because she wasn't moving and was having mild distress. Probably they could have waited another hour or so if the shift change wasn't a factor. Indeed, during the middle of a shift they make non-urgent surgeries wait while urgent surgeries take place. The end of the shift is a time to wrap up the non-urgent surgeries that are still outstanding while the new crew picks up the other work.
Agree, sometimes it's trying to not leave extra work for another person. And sometimes a new person comes on and disagrees with the 1st person's management.
Talk about burying the lede; did The Boring Company help you with that?
Excellent post! I did not see that twist coming, I admit, though in truth it’s not a twist at all. This is the best kind of piece: not merely sharp opinion or suggestions on policy but one which provides a real kind of clarity helping us better understand contemporary phenomena, and -potentially- cool some heads, but perhaps I’m too optimistic…
Was it your screenwriter dad who taught you to write a third-act twist that leads to people wanting to kill the screenwriter?
Cause, wow. M. Night got nothing on this.
Check out FROM HELL
Or don’t. Finally you’ve said something that would entirely justify Twitter coming at you with torches and pitchforks. For shame.
As a breast cancer survivor who hangs out on Breast Cancer.org's (BCO) message board, I'd say that doctors are often just responding to pushy American consumers who think that they ought to get the best treatment or else they'll switch doctors. The BCO board has American, Canadian, Australian, and British members, and the Americans are the most demanding. They push for second, third, fourth opinions and wonder why they aren't getting the hot, new (and often expensive) treatment. An example: Perjeta, a targeted therapy. Perjeta was approved for early stage HER2+ cancer about eight years ago. Many American patients could get it, but Canadian patients could not. The Canadian patients were resigned to their situation, but the Americans would push their doctors to get it, even when their lumps were smaller than the recommended size (2 cm.)
I'd say the same thing probably happens with the parents of trans kids. They know that gender affirming care is out there, and they think that their kids should have access to the latest and the greatest. If one doctor tries to slow things down and encourages their child to take their time, their parents could always switch providers to the one who will give them what they want. So, doctors give their patients what they -- and their parents -- think they want.
Pretty similar to my take. A few wealthy, influential, demanding people can have a huge influence on their own care as well as the system. It's hard to say that anyone is being greedy or acting irresponsibly or irrationally, but these micro issues do create macro issues.
I'm surprised it's apparently not controversial that ADHD medications are overprescribed! I think Americans actually consume drastically *less* health care than we should. There are people in my social circles who avoid seeking out clearly-needed healthcare for financial reasons or individual neuroses. There's stuff we don't have good treatments for, but I suspect there are millions of Americans going through untreated chronic pain. My experience – as a high-SES, college-educated, insured, US citizen, native-English-speaker white gender-conforming cis dude! – is that you have to all but beg doctors to take your pain seriously, and absolutely no one is going to track you down to make sure you get healthcare. If you move to another city and decide it's easier to live with the pain than deal with the healthcare system to start seeing a new doctor, no one will come find you. It's very rare to have anyone in the healthcare system help you work through whatever anxieties you have about medical treatment either.
So it's not obvious to me that "health care is not actually the primary factor in population-level health" – making health care a commodity you consume changes *everything* about how people relate to it. It means refusing to see a doctor becomes, on some level, thrift. It reduces trust in doctors, raises the stakes of every appointment, creates tiered classes of patients. I understand intellectually overtreatment is happening somewhere, but I suspect it's mostly in the last six months of people's lives. It has not been my experience or that of people I know at all. I think undertreatment is part of the same problem as overtreatment – doctors have no incentive to try harder to fix difficult problems, and no incentive to try to relate to the patient, and overtreatment *later* can be caused by undertreatment in the near term – but no one should come away from this article thinking "everyone needs fewer medical tests".
Yes, thank you! I was diagnosed ADD as a teenager decades ago and suffered from it my entire life. I was wondering if anyone else caught and was annoyed by those statements and scrolling down to find this comment.
The same arguments have been made for decades. When I was first diagnosed it was a much less commonly diagnosed or treated condition. It was so uncommon that my otherwise well-informed and well-educated parents had only heard of it in passing; when their son was diagnosed with it, they had to learn about it essentially from scratch.
Even then, it was extremely common to claim that a huge proportion of the kids diagnosed didn't actually suffer from it, and the teenagers receiving treatment for it did not really need it. The percentage of those cohorts being diagnosed and treated has skyrocketed since then, but the belief and arguments remain the same.
Meanwhile, that folk wisdom creates enormous stress and hassles for my life. Getting my medication, when and as needed, is a huge pain in the ass because of extremely strict prescribing rules, driven in part by the anti-meth frenzy, but also in part because of skepticism by regulatory authorities that the prescriptions are legitimate.
I've suffered from ADD my whole life and am almost certainly cursed to continue to do so for however long I have left. I've also suffered my whole life from the overly restrictive and punitive rules regulating how I can be treated for my condition, in part because the beliefs fueling them are equally eternal. These beliefs are largely wrong and anyway are bad and create bad conditions for folks who really need the help of these medications, like me, so we should stop spreading them, or at least stop repeating them endlessly without context or framing.
I wasn't diagnosed until I was an adult, but this is a way better version of this sentiment than I would have written. It's a certain ironic punishment that people who have a bad working memory and trouble managing routines need to maintain a rigid schedule of contacting doctors to get medications refilled.
Yes, exactly - well said