New Study on Puberty Blockers, Cross-Sex Hormones and Youth Suicide and a Response to Turban and Singal

June 20, 2022

Last week the Heritage Foundation released my new study on the effect of state policies easing access to puberty blockers and cross-sex hormones on youth suicide rates. The study generated a large amount of attention from policymakers, the traditional media, and on Twitter. Given that the topic is a highly emotional and politicized one and given the low quality of discourse on Twitter, much of the social media response was inaccurate and ad hominem. Fortunately, Twitter is not the real world and the serious response of a number of policymakers with steps they are taking to address the risks posed by these drugs makes responding to Twitter critics pointless.

The reactions of two prominent commentators, Jack Turban and Jesse Singal, however, warrant a response, not for the merit of their criticisms but because they have enough influence outside of Twitter that their mistaken criticisms might undercut the positive policy responses my study has facilitated. Turban is a professor at Stanford Medical School and is the author of two of the three studies claiming that puberty blockers and hormones are protective against suicide and therefore must be made widely and readily availably. Singal is a journalist who has engaged in extensive criticism of Turban’s work and is therefore someone that skeptics of these medical interventions might look to for guidance on what to think about my new study.

Other than dismissive and ad hominem comments, Turban’s main objection to my research is that minors are not supposed to be getting access to these drugs without parental consent so that looking at variation in state policies regarding the ability of minors to access health care without parental consent would be irrelevant. He writes, “One thing to note is that @TheEndoSociety and @wpath guidelines require parental consent to access gender-affirming hormones. This entire report is based on the incorrect assumption that minors can easily access hormones without parental consent.” He adds, “Since trans youth account for about 1.9% of teens, only a fraction of those desire hormones, only a few percent of those are able to access them, and of those even fewer would access without parental consent, the logical jump made by the Heritage people doesn’t make sense.”

I never claim that “minors can easily access hormones without parental consent.” My study is based on the natural policy experiment that results from some states having one fewer barrier to minors getting these drugs by having a provision in law that allows minors to access healthcare without parental consent, at least under some circumstances. It just has to be easier for minors to get these drugs, not that they can do so “easily.”

But Turban seems to suggest on Twitter that this virtually never happens. Where would I get the idea that minors can access these drugs without parental consent? It comes from Turban’s own research. In his 2022 study on the effects of cross-sex hormones on suicidal ideation, he analyzes the results of a survey given to a convenience sample of adults who identify as transgender. In Table 1, he reports that 3.7% of those who say that they received cross-sex hormones between the ages of 14 and 17 are still not “out” to their families as transgender. These respondents must have obtained those drugs without parental consent since their parents do not even know that they identify as transgender. In addition, we see in that same table that only 79.4% of those adults who got hormones between the ages of 14 and 17 say that their families are supportive. We might reasonably assume that unsupportive families would not have given consent to their teenage children getting hormones, especially if they continue to be unsupportive several years later when those children are now adults. Yet somehow, nearly a fifth of those who got the drugs as teenagers did so despite the lack of support from their families.

If we accept Turban’s claim that 1.9% of teenagers identify as transgender, that translates into 1,900 out of every 100,000 teenagers. My finding is that easing access by reducing the parental consent barrier increases youth suicide rates by 1.6 per 100,000 young people. For my result to be plausible, it would only have to be the case that .08% of teenagers who identify as transgender would have to seek these drugs, find that it is easier to access them when states have minor consent provisions, and then kill themselves to result in an additional 1.6 suicides per 100,000 young people. And this assumes that the entirety of the increase in suicides occurs among individuals who identify as transgender and get the drugs, even though we know that there is a contagion effect with suicide so that the 1.6 increase would include young people who did not get the drugs but were influenced by the deaths of others.

The bottom line is that the magnitude of my study’s estimated increase in suicide risk associated with these drugs is entirely plausible given Turban’s own numbers about the frequency with which minors are accessing these drugs without parental consent.

Other than name-calling with words like “misleading,” “crude,” and “shodd[y],” Singal has two seemingly substantive objections to offer. First, he claims “this isn’t even about blocker and hormones — it’s about which states have lower ages of medical consent. Then he says ‘Well, around the time blockers became available, the suicide rates go up.’ This is an exceptionally crude approach.” Second, he embraces a criticism expressed by Elsie Birnbaum that it is ridiculous to describe states like Texas and Utah as having “easier” access to these drugs, adding: “This is a good catch and should immediately cause anyone with any knowledge of this subject to deeply question the study.”

With both of these criticisms, Singal appears to think that the proper way to study the effects of puberty blockers and cross-sex hormones would be to compare the suicide rates in places based on the number of prescriptions being dispensed, the number of clinics offering these treatments, or their state reputation as being more or less permissive on transgender issues. While I understand why it is tempting to think that these direct comparisons would be better, if our goal is obtaining an unbiased, even if imprecise, estimate of causal effects, it is far better to focus on state minor access provisions. Because modern research designs for isolating causal effects are not necessarily intuitive, let me try to offer a brief explanation for readers (and Singal) who are not trained researchers.

The gold-standard research design for isolating causal effects is a randomized controlled trial (RCT), in which a lottery would assign some people to get the drugs and others not to get the drugs. Researchers would then compare the outcomes for the two groups over time. Any significant differences in their outcomes would have to be caused by the drugs and not by some preexisting difference between the treatment and control groups, since the two groups would be identical, on average, at the start of the experiment. Unfortunately, the effects of puberty blockers and cross-sex hormones in treating what is called gender dysphoria has never been studied with an RCT. Turban, the Biden administration, and others claiming with confidence that these drugs save lives should support an RCT to prove what they say, but they do not, and we are left without the kind of rigorous evidence that is normally required for initial approval of drugs by the FDA.

Short of an RCT, there are a number of research designs that have been developed that attempt to imperfectly approximate the causal rigor of a true experiment. They do so by looking for ways in which exposure to treatment is “exogenous.” That is, they look for why some people get the drugs while others do not for reasons that are unrelated to factors that might separately influence the outcomes. A lottery is perfectly exogenous because chance determines who gets the treatment and chance has nothing to do with causing outcomes. If the reasons that some people get the treatment while others are in the control are related to the outcomes, however, then we have an “endogeneity” problem and the results are biased.

It is easy to illustrate this endogeneity problem in Turban’s research on this issue. Turban examines a survey of adults who identify as transgender and compares those who sought and got these drugs to those who sought but did not get the drugs in terms of their more recent thoughts about suicide. One of the reasons some people who sought these drugs would be unable to get them would be if they were not considered psychologically stable, since being psychologically stable at the time is supposed to be a criteria for prescribing the drugs. Rather than being random and unrelated to later outcomes, the reason that some people end up in Turban’s treatment or control groups is caused by their psychological condition when they sought treatment, which would be related to the suicide outcomes being measured — or endogenous. It is obviously biased and unhelpful to compare treatment and control groups that begin with different average psychological health in terms of their later psychological outcomes.

The same endogeneity problem applies to how Singal seems to think this issue should be examined. We know that there is significant comorbidity between gender dysphoria and other challenges that young people have, including depression, anxiety, and autism spectrum disorder. To the extent that demand for puberty blockers and cross-sex hormones is related to people having other psychological challenges, comparing places based on the number of prescriptions or clinics would be endogenous and misleading. It would be biased by the likelihood that places with more of these drugs being dispensed would also be places with a higher prevalence of other psychological challenges, which would be related to suicide rates in those places independent of whether the drugs helped, hurt, or made no difference. Similarly, comparing states based on whether they had reputations for being permissive or “blue” states would be endogenous and misleading. It would be comparing treatment and control groups that differed at the start in ways that are related to suicide outcomes.

To find something closer to the true causal effect, we would need exogenous sources of variation in the treatment other than a lottery. My study takes advantage of plausibly exogenous variation in exposure to treatment with respect to WHERE there is a lower barrier to accessing treatment, WHEN that treatment is available, and WHO is affected by the treatment. States adopted policies about the ability of minors to access healthcare without parental consent for reasons that had nothing to do with, and generally long preceded, the transgender issue. On the margin, parental consent is one additional barrier to minors getting puberty blockers and cross-sex hormones.

Singal believes that it is a defect of my study that this variation in minor consent policies is not “about blocker and hormones,” but he fails to understand this is a virtue of the research design. Because minor consent provisions are a barrier to accessing puberty blockers and cross-sex hormones that is not “about” this issue, variation in the existence of this barrier is exogenous and helps isolate causal effects. It’s true that minor access provisions are not the most important or direct barrier to access, but they help generate unbiased effects. To the extent that these provision are entirely unrelated to the issue, they would be random noise and would bias effects toward zero but would not bias the direction of the results.

In addition to exogenous variation regarding where these drugs could be accessed with or without an extra barrier, we have exogenous variation in when the drugs became available. This is why it is important that we observe that there is no difference in youth suicide rates between states with or without minor access provisions before the drugs are introduced but there is after.

Lastly, we have exogenous variation in who would be affected. If states with a minor access provision began to differ systematically with respect to suicide only after 2010, we should observe this pattern also among a slightly older population that would not be affected by minor consent provisions. The fact that there is no effect for a slightly older population is also important.

Obviously, it would be far better to have an RCT if we wanted to isolate the causal effects of puberty blockers and cross-sex hormones on youth suicide. But absent an RCT, my study uses quasi-experimental research design features that generate credibly causal effects. It’s imperfect, but it is a huge improvement over the obviously endogenous research design that Turban and Green use and much better than the direct but endogenous approaches that Singal criticizes my study for lacking.

Channeling all of his Twitter erudition and a penchant for research nihilism, Singal asserts that my study is no different in its defects from prior ones: “The dude makes perfectly fair comparisons of some of the past work on this subject, most notably Jack Turban’s, and then he reaches into basically the same bag of tricks. It’s SUCH a bad article.” While I like being compared to The Dude, claiming that my study is comparable to those by Turban and Green is just incorrect.

Twitter is a dangerous place for young people with gender dysphoria, but it is also a dangerous place to discuss the merits of different studies. If Turban or Singal were willing, I’d be happy to get together in a public forum to discuss these issues at greater length. An audience would benefit far more from such a discussion than Twitter name-calling and drive-by research critiques.


I’ll respond to one more substantive objection that Jesse Singal echoes and that was raised initially by Dave Hewitt, an English substacker. Hewitt claims that my results are sensitive to outlier states, such as Alaska or Wyoming, that have above-average youth suicide rates. He attempts to illustrate this concern by switching whether AK and WY are classified as having a minor access provision or not. He then produces a graph that shows the unadjusted difference in suicide rates between states based on the existence of a minor access provision shrinks to zero if both AK and WY are switched in how they are classified.

Importantly, Hewitt only shows us the unadjusted difference, not the final results adjusting for baseline differences in state suicide rates, as displayed in Chart 3 and Appendix Tables 2-5 in the study. States differ in their average suicide rate across the entire time period studied, including the years before puberty blockers and cross-sex hormones were introduced as a therapy for gender dysphoria around 2010. Hewitt is aware of this fact when he notes, “The suicide rate of this age group in Alaska is far higher than any other state… Wyoming has the highest overall suicide rate in the country across all age groups.”

Because there are time-invariant factors that might make some states have higher or lower youth suicide rates, my analysis controls for each state’s suicide rate at baseline. And to the extent that there are time-variant but age-invariant factors that affect the change in suicide rates over time, I control for the annual suicide rate in each state in each year for a slightly older population that should be unaffected by a minor access provision.

Yes, Alaska and Wyoming have high suicide rates and switching states with high rates from the treatment to the control group would alter the unadjusted difference between those groups of states. But this is irrelevant to the question of whether states experience a change in youth suicide rates when cross-sex treatments become available based on having one fewer exogenous barrier to minors accessing those treatments — especially when we control for time-invariant and age-invariant factors that make the rate higher in some states than in others.

Switching states from one category to the other is also the wrong way to test whether the results are sensitive to one or two states. The proper way to test for sensitivity would be to run the regression with all of the controls and to drop individual states from the analysis to see if the result still holds. If any single state is driving the result, then dropping it from the analysis should substantively change the result.

I’ve done this and Hewitt’s (and Singal’s) concerns about sensitivity to outlier cases are unfounded. If I drop Alaska from the analysis presented in Appendix Table 2, the result remains unchanged. If I drop Wyoming, the result remains unchanged. If I drop Alaska and Wyoming at the same time, the result remains unchanged. In fact, I’ve dropped each of the 50 states and DC one by one and the results remain statistically significant and virtually identical in magnitude across all 51 robustness checks.

I’m working on revising this “working paper” and submitting to a peer-reviewed journal and will comply with the replication data set policies of that journal. In the meantime, Hewitt, Singal, or anyone else interested in replicating my analysis and trying other robustness checks can easily do so by downloading and analyzing the data. The study lists the handful of data sources and provides links. The full model specifications are also provided in the appendix tables.

Pass the Popcorn: Sympathy for, Well, Not Exactly the Devil, But…

May 21, 2022

(Guest post by Greg Forster)

I went to see The Northman and I came out thinking: “Yes, that was definitely a Robert Eggers movie.”

I liked it! But I didn’t think I had very much to say about it – a Robert Eggers movie in general doesn’t take place at the level of consciousness and is intentionally difficult to surface at that level – so I didn’t blog about it. I was tempted just to post: “This is a great Robert Eggers movie, but it is a Robert Eggers movie. So if you go and you don’t like it, you have no complaint coming.”

But I just walked out of Alex Garland’s Men, and now I think I have something to blog about both these movies.

One aspect of The Northman – only one aspect, this is a Robert Eggers movie after all – is its attempt, bold almost to the point of foolhardiness, to bring the viewer inside the mentality of genuinely pagan religious belief. I say “genuinely” pagan because it’s quite rare to see pagan religion depicted in anything like an authentic manner. Half the problem is that since the rise of the advanced religions, which have permanently changed our way of understanding truth and goodness, it’s almost impossible to subjectively realize a pagan worldview – and the various attempts to revive paganism, which range from the sinister to the ridiculous, almost never make the effort, because the attempts are (consciously or unconsciously) motivated by political passions. The politics are always in the driver’s seat.

One thing I really appreciated about The Northman is that I think – as far as any of us can really know – Eggers has really given us a glimpse (no more than that) of a genuinely pagan perspective. That’s quite an artistic achievement.

The difficulty with it is that the world of real paganism is constituted by things that are, well, pathetically silly to anyone who has the advantage of having lived in the world of advanced religion (even if you yourself don’t believe) and have therefore learned to do things like differentiate truth from myth or associate justice and beauty.

So not everyone is going to be prepared to follow where Eggers wants to take you.

And I do think Eggers, with masterful skill, has given us a few hints – in ways that are subtle enough not to become a distraction that takes us out of the world of the story – that he knows perfectly well that these things really are silly – or horrible – for those of us who have been better taught.

But I also think one point of The Northman is to show us that, for people who had no better options available, to kill your enemies and go on killing them until they kill you in order to win glory in Valhalla, while it involved a sacrifice of human decency that was painful to oneself as well as to others, was not necessarily worse than the cold, calculating pursuit of mercenary self-interest that human life bereft of all religion inevitably becomes.

Men has moved me to blog about this aspect of The Northman, because Men is a movie about the intractability of evil – but one that slowly, by a very shocking series of twists and turns, brings us to the point where we can have sympathy even for people who do terrible things, without accepting or excusing their evil. Precisely because evil is intractable, because evil is a web all of us are born already caught in, as we inherit our wounded souls from the wounded souls of those who came before, and inflict wounds on others because we are wounded.

In other words, while Men is not actually about religion and does not even broach the question of whether there is a way out of the web of evil or what that might be, it is a movie about evil that is clearly biblical in formation. (For crying out loud, the trailer shows the main character eating a frigging apple that gets called “forbidden fruit.” How much more obvious do they have to make it?)

Exactly as the Bible says, sex is not the cause of evil, but dysfunctional sexuality is the most obvious and most monstrous (in the original sense of the term) effect of evil. Men fear they are not loved, and feel how ruinous it is to be unloved. So, wrongly and inexcusably but in a psychological sense inevitably, they approach women in a variety of ways in postures of demand. The hurting of women that results ranges from the trivial to the catastrophic. Women know this all too well. So, wrongly and inexcusably but in a psychological sense inevitably, they approach men in a variety of ways in postures of preemptive blame. This prompts men to fear they are unloved, and so on forever, each generation passing on its wounded souls to the next.

At least, among those who have found no way out of the web.

The emphasis, in Men, is on the culpability of men – unsurprisingly, not only in light of the title but in light of Garland’s previous work. The entire cycle is portrayed, though. And in the end, as our heroine is dramatically confronted with the intractable nature of evil, with the fact that even her tormentor was born within a web of woundedness, she comes to – not to forgive, no, and certainly not to excuse. But, I think, at least to pity, before she does what is necessary and then turns away.

Oklahoma’s Genius Idea: Hold School Board Elections on [Checks Notes] Election Day

April 21, 2022

(Guest post by Greg Forster)

OCPA carries my latest, on a bill in Oklahoma that would enact the truly extraordinary reform of holding school board elections on Election Day. The edu-special-interests hate the idea, because of course public schools are “the cornerstone of democracy” but not, like, the kind of democracy where schmucks like you and me get a vote:

It goes without saying that they consistently oppose, in the name of democracy, everything that might make education actually accountable to the people it’s supposed to serve. Whether it’s transparency about what is being taught or school choice policies or legal protection for parental rights, actual democracy is always somehow anti-democratic. Education schools have even invented elaborate political theories to justify defining “democracy” as their unaccountable rule over us.

One of the cornerstones of this strange kind of democracy is holding school board elections at extremely unusual times—generally in the spring. Surprising as this is to ordinary people who are blessedly unfamiliar with the techniques of political rent-seeking, it’s actually quite rare for school board elections to be held on Election Day. This ensures that only the most highly motivated voters participate – the special interests who profit by governing the system for their own advantage. So school boards, who are the front-line party responsible for negotiating terms with school employees, mostly represent the interests of the employees, not the public who pays for the system and is supposed to be served by it.

Let me know what you think!

And the Higgy Goes to… Abraham Flexner

April 18, 2022

It was a very light year for Higgy nominations. I suspect that this is not because we have a shortage of (un)worthy nominees. Perhaps instead our team of regular nominators is just a bit worn out by all of the Higginess (to coin a new term) that surrounds us. But we must soldier on.

Greg submitted Steven Novella and David Gorski for consideration. These two academic doctors run a web site that claims to promote science in medicine. Unfortunately, under intense pressure from bullies, they abandoned that mission to erase and repudiate a positive review of Abigail Shrier’s book on the excesses of the transgender craze among young people, Irreversible Damage, that had been published on their web site. These actions by Novella and Gorski were cowardly and intellectually dishonest, making them (un)worthy nominees for The Higgy.

But they are not this year’s recipients for a few reasons. First, there are two of them and the Higgy can only go to one person. if we go down that slippery slope pretty soon we’ll be giving The Higgy to The Guardians, The Silence Breakers, Ebola fighters, The Protester, The Good Samaritans, The American soldier, The Whistleblowers, or even me — each of whom was selected by the parody (?) (check this) magazine, Time, as Person of the Year. Wow, nearly half of the persons chosen by Time in the last two decades weren’t persons at all. In any event, we have to maintain standards and limit the William Higinbotham Inhumanitarian of the Year Award to an individual inhumanitarian.

In addition, while Novella and Gorski’s behavior was deplorable, giving inhumanitarian awards to every academic who displayed cowardice and intellectual dishonesty would be like handing out speeding tickets at the Indianapolis 500. Besides, those who really deserve condemnation in that saga are the bullies who torment people for saying eminently sensible things about the excesses of the transgender craze among young people and the academic institutions and organizations that should be protecting scholars against such abuse.

Joe Nathan also offered Secretary of Education Miguel Cardona as a nominee for The Higgy. Cardona is also a very (un)worthy nominee given his efforts to adopt regulations to strangle charter schools. But U.S. cabinet members destroying liberty by fiat falls more in the category of Big Scary Dictator Disorder (BSDD) than the Petty Little Dictator Disorder (PLDD) The Higgy is meant to recognize.

The recipient of this year’s William Higinbotham Inhumanitarian of the Year Award is Abraham Flexner. Flexner’s promotion of the false notion of an expert as someone with a credential is a perfect example of PLDD. He imagined that he could reshape the world for good with his controlling plans, but his righteous good intentions blinded him to the damage that would be done by paving the way for the certification of professions and occupations of almost every sort. This marks the first time that my nominee for The Higgy has been selected.

Abraham Flexner joins past winners, Alison CollinsMark DiRoccoKosoko JacksonJohn Wiley BryantPlatoChris ChristieJonathan Gruber, Paul G. Kirk, and the inaugural winner, Pascal Monnet.

Pass the Popcorn: Learning to Fight Like You

April 16, 2022

(Guest post by Greg Forster)

“It is strategic and necessary.”

Q: Is the movie Everything Everywhere All at Once as good as everyone says it is?

A: Yes. Yes it is.

Q: But now that you’ve told me it’s that good, won’t I inevitably be disappointed, because my expectations will be too high?

A: Nope. At least, not if you see it on the big screen, the way movies were meant to be seen.

Q: It’s that good?

A: It’s that good.

Q: Does it earn its R rating?

A: Yes. Yes it does.

Q: What is this movie about? What is its message?

A: This is an experience that will really be much better if you don’t insist on understanding it and evaluating it before you have it.

Q: But I am required to see it on the big screen, the way movies were meant to be seen?

A: Yes. There will be no dispensations.

Q: Why?

A: This is how I fight.

Higgy Deadline Extended

April 15, 2022

The announcement of winner (loser) of the William Higinbotham Inhumanitarian of the Year Award has been delayed until Monday, April 18. The Higgy and taxes are due at the same time and both are being extended due to the observance of Holy Week and Passover holidays.

Get your nominations and filings in so that you don’t have to pay a penalty!

For the Higgy: Abraham Flexner

April 15, 2022

The word “expert” shares the same root as the word “experience.” Both are derived from the Latin past participle for “try” — having tried. This origin reflects the long held understanding of what makes someone an expert. It is having done something for a long time so as to have attained mastery of the skill and wisdom from the experience.

Our current understanding of what makes someone an expert is having received a credential that certifies expertise. Someone is an expert in public health because they have a degree from a prestigious institution and hold a high office with responsibility over public health. There is no need for them to have had a long record of experience or demonstrate any wisdom. In fact, they can be relatively young and demonstrably foolish, but they have the credential and position and are therefore expert. If the gross malpractice of our public health response to the pandemic revealed anything, it is how destructive our modern notion of expertise has become.

The false and harmful substitution of credential and position for experience and wisdom in defining expertise has spread to almost every occupation. Teachers are deemed expert because they are certified, not because they have learned from practicing their trade and demonstrated effectiveness. Academics are thought to be experts in their areas because they have written on the topic and are faculty in that field, not because they have done relevant things and shown themselves to be wise. The confusion of credentialing for expertise has spread occupational licensing as a barrier to a whole host of careers, from braiding hair to making floral arrangements.

Abraham Flexner played a major role in creating this modern understanding of what makes someone an expert. Flexner earned a BA in classics from Johns Hopkins University at age 19 after only two years of study. He also briefly studied psychology at Harvard and University of Berlin without earning a graduate degree from either institution. He then returned to his native Louisville and opened a private prep school to promote his ideas about education. As Wikipedia describes it, “‘Mr. Flexner’s School’ did not give out traditional grades, used no standard curriculum, refused to impose examinations on students, and kept no academic record of students. Instead, it promoted small learning groups, individual development, and a more hands-on approach to education.”

In 1908 he wrote a book critiquing higher education for its use of lectures and outdated pedagogical techniques. This book impressed the Carnegie Foundation, which commissioned Flexner to investigate medical education and and make recommendations for how best to prepare doctors. The resulting Flexner Report is heralded for having reshaped and remarkably improved the training of doctors. That may be true (although there have been some serious, negative side-effects), but Flexner’s model for training doctors also negatively shaped how we train almost every profession and the associated notions of expertise.

When Flexner wrote his report, doctors were largely trained by a combination of apprenticeship and lectures. Prospective doctors were not required to have attended college. They were not expected to have studied basic sciences. They simply paid existing doctors to shadow them and/or enroll in one of the 155 medical schools, most of which were unaffiliated with a university and owned by doctors who gave lectures.

While condemning almost all of the existing institutions, Flexner praised Johns Hopkins, his alma mater. The correct approach according to Flexner was to require students to have attended college prior to medical education, have medical schools there were attached to universities and licensed by the state, and to emphasize hands-on learning, including laboratory-based science instruction.

These practices, which were quickly and widely adopted, may have been sensible but they may have been unnecessary to mandate and came at a significant cost. Raising the bar for entry into medical school by requiring that students first attend college and raising the expense of medical education by replacing cost-efficient lectures with laboratory science instruction drove almost all of the institutions training black doctors out of business. The quality of medicine may have improved overall but the sudden disappearance of newly trained black doctors and the difficulty of black patients to access white doctors had a negative effect on healthcare in the black community. In addition, state licensing of medical schools with the intentional goal of limiting the supply of newly trained doctors dramatically increased the costs of healthcare.

But the worst part of Flexner’s model for training doctors is that every profession insisted that they should adopt the same approach even if there were no improvements in quality to compensate for the discriminatory and financial costs of raising the barriers to entry through credentialing. The argument was that if you want to have high quality professionals you have to adopt Flexner’s approach. Now teachers, dental hygienists, optometrists, pharmacists, accountants, lawyers, and every other profession needed to be trained like doctors. In all cases, apprenticeship models where people could acquire experience in a professional, master its skills, and demonstrate wisdom were replaced with systems of credentialing.

Credentialing may be warranted in certain circumstances, but the burden of proof for requiring credentials should be on the profession wishing to raise barriers to entry given the discriminatory and financial costs that necessarily follow. We are also weakened in resisting these unwarranted calls for increased credentialing because we have broadly accepted Flexner’s modern understanding of expertise.

It is particularly ironic that Flexner was the champion of this modern notion of expertise as credentialing given how he lacked both the credential and experience as a doctor. Flexner reshaped medical education without ever having studied or practiced medicine. His claim to expertise, such as it was, was in pedagogy, having run a prep school. Lacking experience and wisdom from the practice of medicine, Flexner asserted a false expertise in medical education that made it easier for him to be foolish about the negative side-effects of his recommendations.

For having advanced this false notion of expertise, Flexner significantly worsened the human condition and is (un)worthy of consideration for The William Higinbotham Inhumanitarian of the Year Award.

For the Higgy: Steven Novella and David Gorski

April 12, 2022

(Guest post by Greg Forster)

The crucial role of science is to provide logically and empirically rigorous tests, in cases where such testing is possible and methodologically appropriate, of our beliefs about the world we live in. We need these tests because for the most part, our beliefs are shaped by social forces that are not strongly (or at all) influenced by the question of what is actually true. As Jonathan Haidt has evocatively put it, reason rides belief not like a human rides a horse but like a human rides an elephant – for the most part, the elephant goes where it wants. The ability of one isolated individual to control their elephant is very limited, and so we are mostly at the mercy of social systems that seek to manipulate and exploit our beliefs for their own interests. Social systems that instead force us to hold one another accountable for being true and responsible in our beliefs are the only effective countermeasure – and science, which is at bottom a social system defined by mutual adherence to an agreed-upon set of methodological principles, is one of the most valuable of these systems.

Unfortunately, as the tragic example of William Higinbotham himself proves so pungently, scientists themselves are only human – elephant riders, subject to all the pressures of manipulation, exploitation and conformity. And the very success of science in providing reliable tests of belief has made the capture of “science” as a label socially valuable. Everyone wants to be able to claim that their policy is “evidence based,” so suborning the scientists has become one of the most important paths to political power.

Thus we have seen the rise of new institutions, created by scientists for the purpose of resisting these pressures.

And, inevitably, the subversion of these new institutions by the pressures they were created to resist.

Steven Novella and David Gorski run a website called Science Based Medicine. There are only three names on the SBM masthead: Novella (founder and executive editor), Gorski (managing editor) and Harriet Hall, who has the title “editor.” Stick a pin in that fact, we’ll come back to it.

As the About page of SBM puts it: “Online information about alternative medicine is overwhelmingly credulous and uncritical, and even mainstream media and some medical schools have bought into the hype and failed to ask the hard questions. We provide a much needed ‘alternative’ perspective – the scientific perspective.”

Novella and Gorski regularly draw a distinction between “evidence based” and “science based” medicine. “Evidence based” means you can point to some kind of superficially plausible piece of evidence supporting your view. This is the cheap and corrupt standard by which science is subverted. “Science based” means all available evidence that meets scientific standards is taken into account, with awareness that each individual piece of evidence is subject to ambiguity and uncertainty.

They blame “online information,” “mainstream media” and “some medical schools” for bowing to hype and pressure from merely evidence-based approaches, making a science-based approach impossible in those venues.

But when they themselves came under similar pressure, they folded. Faster than . . .

They made the mistake of publishing a review of Abigail Shrier’s book Irreversible Damage, which calls out the many claims in transgender medicine that are evidence-based without being science-based. In such a brand-new area of study, how can we know much of anything yet?

Unsurprisingly given the mission of SBM, the review was positive. And it was not by some fly-by-night outside contributor, but by Hall, editor of SBM and the only other name on the masthead besides Novella and Gorski. In fact, independent journalist Jesse Singal, who was instrumental in bringing the subsequent SBM shenanigans to light, went to Hall’s SBM archive page and counted 700 articles she had contributed to the site before this review.

Why do I have to post Singal’s count of how many articles Hall contributed? Because I can’t count them myself. The SBM archive pages for Hall and Novella are mysteriously not available to the public any more. (Gorski’s works fine, which may have to do with the fact that he is listed as the person who manages the author information pages.)

You know what else you can’t read at SBM any more? Hall’s book review. But you can read it at Skeptic magazine, which has reprinted it.

SBM’s archives are managed by Memory Hole Services, Inc.

Now, as you read the account below of of Novella and Gorski’s actions, to grasp their true Higgyworthiness you have to set aside not only your opinions on transgenderism and more specifically the merits of Shrier’s book, but even the merits of Hall’s review.

Assume in Novella and Gorski’s favor – in the teeth of all indications to the contrary – that transgenderism is great, that Shrier’s book is awful, and that Hall’s review is likewise awful.

Now, even on that set of assumptions, try to read this series of events without laughing:

  1. Novella and Gorski pull down Hall’s review and post a statement explaining that the review did not meet SBM’s editorial standards, but not explaining how or why it did not meet their editorial standards; the statement blusters angrily, across several paragraphs, about “false accusations” that the review was removed for political reasons, but without specifying any other reason the review was removed.
  2. This having mysteriously failed to alleviate anyone’s doubts, Novella and Gorski write and publish a lengthy article in which they repeat a series of false and anti-scientific activist talking points about gender science. Singal has the lengthy tale of the tape, but to take a few examples, they falsely claim that the DSM-IV treated all people who self-identify as another gender as mentally ill; they claim there is overwhelming evidence that the officially endorsed but nonbinding professional standards of youth transgender treatment are widely adhered to, while citing no such evidence and ignoring clear and convincing evidence to the contrary; and they apply extremely high methodological standards to studies whose findings they don’t like while ignoring even more serious methodological problems in studies whose findings they do like.
  3. SBM then publishes two articles by transgender activists that are equally full of false and anti-science activist talking points, including an impressive number of provable factual lies about the contents of Shrier’s book – even some made-up quotations that aren’t in the book! – as well as false statements about the underlying studies and news stories. One of the authors, in the course of attempting to discredit a set of studies, actually misrepresents the studies in a way that makes them look better than they are, presumably out of ignorance. Singal again has the lengthy tale of the tape.
  4. As Singal and others point out these errors, SBM corrects some and lets others stand.
  5. After having officially issued corrections of made-up quotations and other lies from the author of the second follow-up article, SBM proceeds to publish an additional article by that author – in case any shred of SBM’s credibility remained undemolished.

The walls of enforced silence around unscientific but “evidence-based” claims related to transgenderism seem now to be collapsing, partly because of this and this.

The effort to stop people from asking questions about science is, on the face of it, futile and Higgyworthy.

Which of course means such efforts are now going to be redoubled. Singal is still on the case; the headline on his latest article about this topic: “Researchers Found Puberty Blockers And Hormones Didn’t Improve Trans Kids’ Mental Health At Their Clinic. Then They Published A Study Claiming The Opposite.”

However, few people beclown themselves as obviously as Novella and Gorski. They are truly worthy of The Higgy.

Let Parents Take the Lead on Pre-K

April 5, 2022

(Guest post by Greg Forster)

OCPA carries my latest, which compares the government push to get more and more kids into pre-K with the recent (additional) dismal research findings on pre-K’s effects:

The study followed students through sixth grade and found negative outcomes lasting all the way through the study period. Students who attended pre-K had lower test scores than those who did not. A negative pre-K effect was also found for disciplinary infractions, attendance, and receipt of special education services.

Nor is this the first study to question the benefits of pre-K, at least for most students. A few years ago I published an OCPA report going over the issues in pre-K, including the results of decades of empirical research on its effects.

But the finding that pre-K is neutral or negative on the whole doesn’t mean pre-K is bad for every child; it just means the negative effect on some children outweighs the positive effect on others. Instead of trying to get all kids or no kids into pre-K, we might try getting the right kids in:

In fact, I serve on the board of a private school that offers a pre-K program. We don’t do that because we enjoy hurting kids. We do it because in the community where we serve, there are kids who will benefit from this program. It doesn’t matter how many other kids there are who wouldn’t benefit from it, as long as there are at least enough who would benefit to justify offering a pre-K classroom.

But we aren’t using the power of the state to shove families into pre-K indiscriminately. We know our community, and we work with parents to identify the students who would benefit from our program. No child walks into our doors unless both our staff and the parents agree that the child will benefit from being there—and nobody is applying political pressure to that decision.

Parents should be empowered with school choice, and then the state should back off and let them decide.

Let me know what you think!

The Higgy Isn’t Technically Late, But I May Still Win It – Nominate Me or Some Other Fool!

April 3, 2022

(Guest post by Greg Forster)

Your humble Higgy correspondent apologizes for the tardiness of the opening bell for this year’s William Higinbotham Inhumanitarian of the Year Award. He was at a conference. He apologizes for the crime of prioritizing anything above JPGB.

You’d think he’d take this responsibility more seriously, given the weighty impact of The Higgy on world events. Last year’s winner, hobbled by the public humiliation of Higgy dishonor, has already been defenestrated from her position by a San Francisco electorate that was just too rabidly right-wing, too hidebound in Philistinish conservatism, to appreciate the fine performance art of her PLDD governance. (Among the troglodyte Frisco reactionaries organizing the recall election effort that removed her was Gaybraham Lincoln.)

We’re not technically late, because April 1 was still the last business day. But you’re free to nominate your humble correspondent for The Higgy anyway!

Yes, with the arrival of April Fool’s Day, it’s time once again for the William Higinbotham Inhumanitarian of the Year Award – “The Higgy.” Each year, we (dis)honor the most (un)worthy candidate from your nominations of people afflicted with PLDD (not BSDD, note the difference).

Past “winners” of The Higgy include Alison Collins, Mark DiRocco, Kosoko Jackson, John Wiley Bryant, Plato, Chris Christie, Jonathan Gruber, Paul G. Kirk and the incomparably petty inaugural winner, Pascal Monnet. The award is named for history’s greatest monster, William Higinbotham; as a special way of (dis)honoring Higinbotham, we have not even given him The Higgy.

Get your nominations in by April 15, Tax Day – definitely a day to discountenance petty little dictators!

To inspire you to greatness in discerning pettiness, we carry on immemorial Higgy tradition and reproduce below the text of Jay’s original post launching The Higgy. Good hunting!


As someone who was recognized in 2006 as Time Magazine’s Man of the Year, I know a lot about the importance of awards highlighting people of significant accomplishment. Here on JPGB we have the Al Copeland Humanitarian Award, but I’ve noticed that “The Al” only recognizes people of positive accomplishment.  As Time Magazine has understood in naming Adolf Hitler, Joseph Stalin, and Ayatullah Khomeini as Persons of the Year, accomplishments can be negative as well as positive.

(Then again, Time has also recognized some amazing individuals as Person of the Year, including Endangered Earth, The Computer, Twenty-Five and Under, and The Peacemakers, so I’m not sure we should be paying so much attention to what a soon-to-be-defunct magazine does.  But that’s a topic for another day when we want to talk about how schools are more likely to be named after manatees than George Washington.)

Where were we?  Oh yes.  It is important to recognize negative as well as positive accomplishment.  So I introduce “The Higgy,” an award named after William Higinbotham, as the mirror award to our well-established “Al.”

Just as Al Copeland was not without serious flaws as a person, William Higinbotham was not without his virtues.  Higinbotham did, after all  develop the first video game.  But Higinbotham dismissed the importance of that accomplishment and instead chose to be an arrogant jerk by claiming that his true accomplishment was in helping found the Federation of American Scientists and working for the nonproliferation of nuclear weapons.  I highly doubt that the Federation or Higinbotham did a single thing that actually advanced nonproliferation, but they sure were smug about it…

I suspect that Al Copeland, by contrast, understood that he was a royal jerk.  And he also understood that developing a chain of spicy chicken restaurants really does improve the human condition.  Higinbotham’s failing was in mistaking self-righteous proclamations for actually making people’s lives better in a way that video games really do improve the human condition.

So, “The Higgy” will not identify the worst person in the world, just as “The Al” does not recognize the best.  Instead, “The Higgy” will highlight individuals whose arrogant delusions of shaping the world to meet their own will outweigh the positive qualities they possess.

We will invite nominations for “The Higgy” in late March and will announce the winner, appropriately enough, on April 15. Thanks to Greg for his suggestions in developing “The Higgy.”

%d bloggers like this: