In April 2026, a study was published examining the psychiatric outcomes of referrals to youth gender services in Finland. This study looked back at all referrals to youth gender services between 1996 and 2019 and assessed the longer term trajectory of those individuals who received medical treatment, in comparison to matched controls.

What this study found was that not only was there a higher rate of serious psychiatric issues in those who were referred to gender services - which increased markedly in the cohort referred after 2010 - but that those who underwent medical treatment also got significantly worse:

Among adolescents who underwent medical gender reassignment, psychiatric morbidity increased markedly during follow-up—rising from 9.8% to 60.7% in feminising gender reassignment and from 21.6% to 54.5% in masculinising gender reassignment.

While this study cannot determine whether treatment caused the deterioration, this is compelling new evidence pointing towards something that critics of paediatric medical transition have long believed: that the weak evidence base and non-existent follow-up of those undergoing treatment was hiding the fact that the outcomes were shockingly poor.

It is also worth noting that, according to this data, those with high rates of pre-existing psychiatric conditions were routinely denied medical transition, ie. the most severe cases were excluded. In this cohort, referral rates remained roughly the same over time, with only a slight increase. This is in contrast to a common assertion that pre-existing conditions are a symptom of untreated gender dysphoria, that psychiatric gatekeeping is harmful, and that it is paramount to provide medical transition on demand in order to prevent suicide.

That the evidence base for these interventions is weak is by now not really in question since the 2024 Cass Review found serious gaps in the evidence and concluded that puberty blockers should not be given outside of clinical trials. In February this year, Hilary Cass gave an interview to the BBC reiterating the need for the forthcoming clinical trial into the effectiveness of puberty blockers for gender-questioning youth. Cass, who has consistently tried to chart a neutral and evidence-based path through this whole debacle, has stuck to the findings in her report: that the evidence base for these interventions is poor, and we need better evidence before proceeding.

In that light, one of the most scandalous outcomes of the Cass Review - and something that has received shockingly little attention - was the refusal of adult clinics to take part in a data linkage study. This would have provided critical long-term follow-up data on children who had passed through GIDS and moved into a different service in adulthood. That this data exists but has been withheld is shocking and surely we should make the best of what already exists before setting out to collect new information. Such a data linkage study could have been completed well before this latest Finnish study and would have given long-term follow-up data on treatment efficacy that could have been informing policy by now.

That a multi-million pound clinical trial on puberty blockers ever got off the ground while adult clinics stonewalled sharing information that might have obviated the need to even conduct the trial in the first place is, frankly, mindblowing.

Two years on from the Cass Review, the data linkage study is still a matter of contention, with Health Secretary Wes Streeting issuing an update demanding the cooperation of the adult clinics.

Interestingly, this lists the bodies affected, namely the adult clinics and their partners who have so far refused to hand over data. Of interest are the following two organisations:

(4) GTD Healthcare Limited is a company registered in England and Wales (registration number 12293359). It is commissioned by NHS England to provide NHS adult gender services, delivered in partnership with the LGBT foundation through Indigo Gender Services.

(5) LGBT Foundation Ltd is a charity registered (registration number 1070904) and a company registered (registration number 03476576) in England and Wales.

Indigo Gender Service was launched in December 2020, as a partnership between LGBT Foundation and GTD Healthcare. Of Indigo Gender Services’ four directors, one is Paul Martin, CEO of LGBT Foundation, and another is Stephen Whittle, director and interim CEO of Translucent, and many other organisations stretching back over decades of activism.

So, a body set up in tandem with activists with a vested interest in a particular worldview, and run by those self-same activists, has so far refused to cooperate with the reasonable request for patient outcome data. To illustrate some of these positions:

• LGBT Foundation’s written evidence on GRA reform in 2020 was very concerned about the autonomy of under-16s. They argued that children should be able to self-declare their gender at any age without parental consent as long as they are “Gillick competent” - which is about medical competence. The implication of on-demand medical treatment is already assumed at this stage, even if not said directly.

• In June 2021, LGBT Foundation was one of the coalition of lobby groups led by Mermaids and the Good Law Project who attempted to strip LGB Alliance of charitable status for speaking up about the harms of medical transition to LGB youth.

• In January 2024, Manchester City Council produced research in partnership with LGBT Foundation which highlighted a key concern was that “Puberty/hormone blockers are very difficult to access.”

• In March 2025, LGBT Foundation published a report on working with healthcare organisations to deliver “trans affirmative” care.

This is an organisation that is deeply committed to the medicalisation of children, and it is a scandal that they have been allowed in any way to have a say in whether follow-up data can be scrutinised.

Meanwhile, Translucent - another organisation Stephen Whittle leads - spends its time false-consciousness-raising, spreading medical misinformation, smearing its opponents, trying to prevent any outcome other than medical transition for gender-questioning youth, and trashing the Cass Review.

In one particularly shameless display, Translucent criticises the Cass Review for:

Overstating the extent of Detransitioning: Despite reference to engaging with a wide range of stakeholders and examining the data of 3,306 patients, fewer than ten detransitioners were identified.

The problem with this is that this is what the data linkage study would have given actual numbers on. The data linkage study which was in part blocked by an organisation Stephen Whittle leads. So one organisation Whittle is director of is involved in preventing new evidence coming to light, while another organisation Whittle is director of smears Cass in public for not having that data.

The exact people publicly attacking Cass for not having evidence of detransition rates are the ones hiding that evidence in the first place.

If the data was good, organisations like Indigo would surely be champing at the bit to publish it. Meanwhile connected organisations like Translucent spend their time attacking MPs for sharing an analysis of the data we do actually have, ie. the new Finnish study. We seemingly aren’t allowed to see their data, and we aren’t allowed to look at anyone else’s either, if that data is bad.

I’m sure that caring healthcare professionals would like to believe it is possible to conduct an ethical study that can determine whether or not there is a benefit to giving puberty blockers to children. However, the reasons for doing so in the first place are bound up in decades of activism, and it is impossible to get to the root of why you would even give them in the first place without grappling with the worldview that made this treatment possible.

Whether explicitly stated or not, a whole self-supporting belief system is integral to the “affirmative” model of paediatric transition: that gender identity supersedes sex, that it is innate and immutable, that diagnosing it as a medical condition is pathologising and hateful, that children know who they are, that attempts to understand the roots of a desire to be the opposite sex with exploratory therapy is conversion therapy and should be criminalised, that access to puberty blockers is medically necessary and will prevent suicide, that a surge in adolescent girls with serious mental health issues and comorbidities seeking to become the opposite sex is not a cause for concern but a sign of progress. And on and on.

I believe that - in continuing to support the proposed puberty blocker trial - Hilary Cass wants to take a neutral but compassionate stance, and wants to believe everyone is acting in good faith. This is admirable, and I wish that was the world we live in - but I don’t think she really sees how interconnected the on-demand provision of puberty blockers to children is with decades of wider transactivism, and how the same organisations that have stymied the data linkage study are part and parcel with those attempting to prevent any other approach by any means necessary. The production of weak evidence, the suppression of medical research, and the smearing of anybody who actually tries to draw attention to this or robustly address the gaps in our knowledge have gone hand in hand for years.

Whether or not it is possible to actually have an ethical trial of puberty blockers for gender-questioning youth, I think this is something that really shouldn’t have got off the ground while adult clinics were still refusing to release data, especially when there is every reason now to believe that this is ideologically motivated and hiding poor outcomes. It is not a stretch to think that those who have spent years obfuscating and delaying are pinning their hopes on a new study on puberty blockers providing the institutional cover they need to allow them to continue as before.

In this light, pushing for a new clinical trial feels less like genuine scientific enquiry, and more like a bid for retrospective planning consent. Except instead of trying to get away with an eyesore of an extension, they are trying to cover up the extent of the needless sterilisation of same-sex attracted youth.

The paper, led by authors from São Paulo University, covers several different metrics and comparators - upper body strength, lower body, cardiovascular fitness, transwomen compared to men, transmen compared to men, and so on, and crucially across key metrics the authors claim no difference between female performance and male after hormone therapy. In the paper, the authors go so far as to state:

the absence of strength disparities between transgender women and cisgender women found in the current review was consistent and contradicts narratives framing male puberty as conferring irreversible athletic advantages despite GAHT [gender-affirming hormone therapy]

The paper itself does not exist in a political vacuum, and multiple times references bans and policy issues, stating that the findings of this review endorse

nuanced, sport-specific policies rather than blanket bans

This is (predictably) making all the headlines you might expect for its conclusion that there’s no difference in athletic performance between men on cross-sex hormones and women:

• Trans Women in Sport Have No Advantage Over Cis Women, Study Finds

• ‘There’s no reason to ban us from playing’: Analysis debunks notion that transgender women have inherent physical advantages in sports

• Physical fitness of transgender women ‘comparable’ to that of other women

• New Study Once Again Shows Trans Women Have No Physical Advantage Over Cis Athletes

• Review Of 52 Studies Finds No Fitness Advantage For Trans Women Over Cis Women

And so on…

To illustrate the problems with this paper, its conclusions, and the way these are being represented in popular media, I will simply address the single most implausible supposed finding: that there is no difference in upper body strength between female athletes and males after cross-sex hormones and testosterone reduction.

This is the sort of claim that doesn’t even pass the smell test. Upper body strength is one of the largest differentiators between male and female athletic performance - the difference in punching force (for example) is vast.1 On even a cursory inspection of the paper it turns out this whole thing is a mixture of linguistic sleight-of-hand and the mixing of quite different studies into a meaningless result.

This is long and detailed and covers multiple issues but the tl;dr version is: these findings are almost entirely down to one paper by another group of researchers at São Paulo University which compared weak men to national-level female athletes.

Grip Strength

The authors used grip strength as a proxy for upper-body strength. Previous reviews of the difference between male and female grip strength have found huge differences overall:

90% of females produced less force than 95% of males

Almost all men have a stronger grip than almost all women, and this is a finding that correlates linearly with lean muscle mass and hand size - ie, that men are on average larger and have more muscle mass tends to confer a greater grip strength.

In this new review, the authors looked at four papers that measured grip strength in different cohorts of female participants compared to males on different regimens of cross-sex hormones and/or testosterone suppression, over different periods of time, with different levels of physical activity. The result when considering all four papers to produce a combined estimate of the difference in grip strength was:

No significant differences in upper-body strength were observed between transgender women and cisgender women (SMD 0.54, 95% CI −0.95 to 2.02, I² = 75.3%, substantial; GRADE: very low) (figure 2A). These results remained consistent across all categories in the sensitivity analysis (online supplemental table S8a).

Let’s explain what these numbers mean.

• SMD = Standardized Mean Difference. This is the pooled average of the advantage trans-identifying male participants had over female ones, in terms of standard deviations. What this means is that the average finding of these four studies is that, despite hormone therapy, male participants were still 0.54 standard deviations stronger than female ones (or, stronger than about 71% of females, on average).

• CI = Confidence Interval. This is the range of values that we are 95% sure the “true” average lies in. Using the authors’ frequentist statistical framework, if a CI crosses 0 it isn’t statistically significant and thus the null hypothesis (ie that there is no effect) cannot be rejected. In this case, this value is so wide as to render the result pretty well meaningless. So from looking at these four papers we can be 95% sure that the average trans-identifying male is between 0.95 standard deviations weaker than, to 2.02 standard deviations stronger than, the average woman. Or, in other words, the average male after hormone therapy is anywhere from weaker than 83% of women to stronger than 92% of them. For a male, this is a range somewhere between geriatric frailty and peak athleticism, and is therefore meaningless.

• I² = Between-study Heterogeneity. This is a measure of how similar the studies are to each other, and gives a percentage change that any variance between the studies is down to real differences rather than chance. A value of over 75% is classed as substantial heterogeneity, ie there is a high chance that the wide variance is because of differences between the four studies.

In short, they found a moderate upper-body strength advantage, but it was not statistically significant, probably due to a large variance as a result of very different study methodologies, and the overall conclusion was very low certainty.

Basically, they found nothing, or nothing that could be said with any confidence anyway.

Instead of just saying they found nothing, however, they say there is no statistically significant difference. This is one of those classic misleading abuses of scientific phraseology, like creationists dismissing Evolution as “only a theory”.

There is a vast gulf between “we found a moderate difference, but it is not a robust finding statistically and so we can’t really say it is a real difference with any confidence, or whether the real value is drastically higher or lower” and “there is no difference”.

To reiterate, here is the phrasing the authors adopt in their conclusions:

the absence of strength disparities between transgender women and cisgender women found in the current review was consistent and contradicts narratives framing male puberty as conferring irreversible athletic advantages

The authors did not find an “absence of strength disparities” - what they found was that they could not be certain of the moderate-to-large strength disparity to a level of statistical significance.

Bearing in mind that the difference between male and female grip strength is between 2 and 3 standard deviations, a not-statistically-significant range of -0.95 to +2.02 means you cannot rule out that there are basically no differences between males with or without cross-sex hormone therapy and/or testosterone suppression. It would be surprising if such interventions had no effect, but it would be even more surprising if they eliminated it completely. There is a substantial difference, already well-established in the literature, and the point of a systematic review like this should be to establish how much of that well-established difference is eliminated by hormonal interventions.

The authors find they cannot say exactly how big the difference is - but instead of saying “it looks moderate-to-large but we cannot say for certain and further research is needed”, they instead make the overbroad claim that there is an absence of strength disparities, despite the fact that - with confidence intervals you could drive a supertanker through - they also failed to reject the (far more likely and well-supported) hypothesis of a retained male advantage.

Linguistic trickery aside, things get worse when you start drilling down into the actual studies.

The “not statistically significant” difference is derived from a pooled estimate from four papers. Here is Figure 2A from the systematic review, showing how each paper estimated the difference in grip strength between female comparators and trans-identifying males:

A quick glance at that shows that one of these papers is substantially different to the other three. While three found that the male participants were stronger, one found that they were considerably weaker. But there are issues and confounding factors across all four papers, so it is worth looking at them all.

Alvares et al 2022

Firstly, Figure 2A actually contains a typo - the citation “Andrade et al (2022)” should be “Alvares et al (2022)”. Andrade et al is a study on transmen, and not applicable here. This is a trivial issue that will doubtless be corrected at some point.

Alvares et al (2022) was a study 15 trans-identifying males on a variety of long-term hormonal interventions and 13 female comparators by a group of researchers at São Paulo University. The trans-identifying males were described as non-athletes, and they had been on a variety of cross-sex hormones and hormonal suppressants for an average of 14 years. While 13% of these were described as “very active”, this was in comparison to 54% of the female participants. The heights and weights were average in both groups (the females were 13cm shorter and 18kg lighter on average).

The grip strength test took the average of three attempts with the dominant hand, and found 35.3kg in the trans-identifying males vs 29.7kg in the females. This equated to a very large, statistically significant strength advantage among the trans-identifying males of 1.17 (0.36 to 1.98):

Hamilton et al (2024)

Hamilton et al (2024) was a study of 23 trans-identifying males on cross-sex hormones and 21 female comparators. Participants were physically active, and described as “competitive”, which was defined as training three times per week - however all training volume and physical activity levels were self-reported, and as the study itself notes they “may suffer from selection and recall bias”. The average duration of cross-sex hormones was 6 years, so these are again long-term effects. The height and weights of the participants was again reasonably average, with the females 20cm shorter and 13kg lighter on average.

Unlike Alvares et al (2022), the grip strength test took the average of three attempts with both hands, and found 40.7kg in the trans-identifying males vs 34.3kg in the females. This again meant a very large statistically significant difference in grip strength: 1.13 (0.49 - 1.77)

So these first two papers are measuring grip strength slightly differently and among different populations, but despite different absolute values come to a similar differential, which shows a very large male strength advantage is retained despite long-term cross-sex hormones.

Ceolin et al 2024

This is where things start to get a little interesting. The title of Ceolin et al 2024 is “Bone health and body composition in transgender adults before gender-affirming hormonal therapy: data from the COMET study”. This is a protocol for a longitudinal study in Italy where 26 trans-identifying males 26 female controls were selected from a larger cohort and given baseline bodily metrics tests prior to any hormonal interventions. By my reading, the systematic review wrongly seems to treat this as representing one year of hormonal treatment, when it seems to be the pre-hormonal baseline data. In table S4 in the systematic review’s supplemental material, this paper is described as covering cross-sex hormones, but that dose and duration was not recorded. This seems to be misleading - if this really is a baseline, pre-intervention study then the dose was not recorded because there was no dose. This would seem to violate the protocol of the systematic review by directly comparing exposure studies with a non-exposure study.

Additionally, these are non-athletes, and according to the protocol, controls were matched by age and “sex assigned at birth”, but it is ambiguous whether that means that the trans-identified males were matched with female controls or male ones.

This study measured the average of the maximum grip strength of both hands, and found that the male participants recorded 35.46kg, compared to the 30.8kg of the females - a slightly narrower difference than the previous two studies.

The result is that it found that trans-identifying males without hormonal intervention had a medium advantage in handgrip strength over matched female controls, although not quite statistically significant: 0.53 (-0.02 to 1.08):

This is quite a surprising finding. It is expected that males will have higher grip strength than females, and it is plausible that this will decrease after cross-sex hormones. To find only a moderate and not statistically significant difference in two groups of 26 before cross-sex hormones is unexpected. One possible reason is a greater variance in age in the male vs female participants (most of the males seem to be in the 18-33 range, while the females are more like 20-29). The heights are not recorded, but the male participants were below average strength for males in this age group before any hormone treatment, and less than 6kg heaver than the females.

The same Italian team did a followup on this cohort after one year of hormonal intervention, and I cannot explain why this later study was not included in the systematic review.

In that study, by my reading it seems that two of the baseline cohort dropped out, so they include a recalculated baseline for the remainder, and an updated measurement after one year of hormones. The revised baseline grip strength was given as 32.21kg before hormones, and 34.91kg after one year of hormone treatment - so the trans-identifying male cohort actually got stronger after a year on hormones.

This is another surprising result, which could be explained by participants at the younger end of the scale growing up, or unrecorded changes in activity level over the previous year. There are numerous possible confounding factors - but if we calculate the difference between the trans-identifying males and female controls in this later study it seems to result in a statistically significant moderate advantage: 0.59 (0.01 to 1.17).

I admit I am no expert, but I cannot explain why Ceolin et al (2024) has been included despite not covering hormonal interventions, and the later followup has not.

Alvares et al 2025

Now we come to the real outlier. Alvares et al (2025) was a study including 8 trans-identifying males on cross-sex hormones, and 7 females, all of whom were described as “amateur” volleyball players. Here the average period of hormonal intervention was not directly stated, but a minimum of 1 year was part of the inclusion criteria, and the systematic review authors have derived a value of ~7 years from the paper.

Unlike all other studies, this actually found that the trans participants were significantly weaker than the female ones, though this was again not statistically significant: -0.95 (-2.04 to 0.14)

This is an astonishing result - after cross-sex hormones men become massively weaker than women. So how on earth did this happen?

Well, it turns out that this study was not even remotely comparing like with like. While all participants are described as amateur volleyball players, the male and female participants are vastly different.

The female athletes are 5 centimetres taller - averaging around 5’10” - and 7kg heavier than their trans-identifying male counterparts, and train almost 10 hours per week more. These are women in the top 0.5% being compared to men of average height and well below average weight. While these men recorded a grip strength of 34.4kg, the women were far stronger, clocking in at 39.3kg. Indeed, describing all the participants as “amateur” players doesn’t do justice to the fact that - unlike the men who participated at the state and city level - the women in question competed in “second division national level championships”. This is a huge difference in sporting prowess, and - since the first division in Brazil is the elite professional league - is pretty much as high as you can go in volleyball as an amateur.

Another interesting detail from this paper:

Volleyball team organisers (made up of TW) sought out our research centre. They suggested an assessment of the sports capabilities of this population and the possibility of disseminating the research opportunity to other athletes.

That is, this research was directly instigated by trans-identifying males with a vested interest in participating in female sport. There is a perverse incentive for these participants to not try their hardest, knowing that if they demonstrate high grip strength this provides evidence against their inclusion. This introduces massive selection bias - participants who know that underperforming could influence policy in their favour have a significant conflict of interest.

There are techniques for ensuring such tests are engaging in maximum effort, but the paper does not detail whether any such methods were used, and no mention of this possible confounding factor appears in their conclusions, which would seem to be a significant oversight.

In the supplemental material of this latest systematic review, the authors note that there are confounding variables with Alvares et al (2025), and give a different set of values calculated only from the other three studies, which are 0.89 (-0.04; 1.81), 22.7%

So if they exclude just that one paper, they found a strong difference in grip strength (nearly one standard deviation) and with far less differences between the papers to account for errors. These are still not statistically significant, but just barely, and clearly suggests that there is indeed a strength differential - and the heterogeneity of these studies is far better (less than 25% as opposed to over 75% when Alvares et al 2025 is included)

So: the authors have taken studies that compared untrained men with supremely athletic women, self-report activity, under-20s with over-30s, less active men than women, matched controls, hormonal interventions from 0-24 years, grip strength recorded four different ways with no reported verification of maximal effort, and mixed them all together into a single nonsensical result.

In short, they have taken a mess of ingredients and made a beef trifle.

While it is true that a systematic review typically has to deal with some level of differences between studies, the fact that across four studies they achieved a heterogeneity figure of over 75% - and that this was overwhelmingly due to one obvious and implausible outlier study - should have been a big indication that there are simply too many differences to mix these together and produce a palatable result.

Yet that is what has happened - incompatible ingredients served up on a plate, while a chorus of partisan commentators insist that we choke down this tasty dish that’s been placed in front of us. Swallow this with a smile, or you’re a bad person.

I have only looked at grip strength in this systematic review, but it covers multiple other variables, from lean mass, to VO2 max, and over and over again, Alvares et al (2025) is an outlier, destroying the statistical significance of other findings and driving up the heterogeneity:

By my reading:

• Alvares et al (2025) is useless and should not have been included as the cohorts are wildly different

• Ceolin et al (2024) is baseline, pre-intervention numbers and should not have been directly compared to post-intervention studies

• Ceolin et al (2024b) is a one-year followup and it is unclear why it wasn’t included

• Calculating the grip strength differential from Alvares (2022), Hamilton (2024) and Ceolin (2024b) produces a large, highly statistically significant strength advantage for men despite >1 year of cross-sex hormones: 0.91 (0.53 to 1.29)

  

In the fractious ongoing cultural battles over sex and gender, science has become a key battleground, with different factions trumpeting their own pet scientific papers as definitive. In that environment, systematic reviews are supposed to represent the gold standard, providing an objective, neutral assessment of the entire state of the literature.

What has happened here is:

• A team of researchers at São Paulo University conducted research at the request of men with a vested interest in being included in female sports, which compared below-average men with low grip strength to national-level female athletes in the top 1% of female performance.

• Another team of researchers at São Paulo University included this in a systematic review and - instead of dropping it because of the clear methodological issues and confounding factors - combined it with multiple other studies that can’t be directly compared, and produced a result so incoherent as to be meaningless.

• Then, they declared in their conclusion that because they had a meaningless result they had found an “absence of strength disparities”, while arguing their research was evidence against “blanket bans”.

• This was then published by the British Journal of Sports Medicine.

• This was immediately picked up and circulated widely - from news outlets to Wikipedia - as clear evidence that male athletes given cross-sex hormones do not have a performance advantage against female athletes, and thus should not be subject to blanket bans.

The systematic review’s conclusion that there is a lack of strength disparities and that this has implications for sports policy is based on statistically untenable foundations. While I tend to give short shrift to those on the sidelines who cry foul about science that is inconvenient to their political aims, it really does seem that the chain of trust in science has been seriously damaged by activism and groupthink in the area of sex and gender. From paediatric gender medicine to sports science, badly designed studies and papers with obvious issues are being waved through by compliant journals, and shoddy, meaningless results spun as triumphs by political partisans. These generate exactly the expected headlines, which translate into pressure on institutions and political leaders. We need to be able to rely on the scientific method to provide us with a dispassionate and neutral assessment of the evidence which rises above such blatant policy advocacy.

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I originally said here that the punch strength differential is so vast that “there is virtually no overlap”. This is slightly hyperbolic, and based on my memory of this widely reported 2019 paper. However, in fairness, this wasn’t really measuring punch force directly - it was using hand-cranking machines to test upper-body strength. That isn’t to say the difference in punch strength isn’t huge (it is) but when measuring actual punches there is still some overlap in distribution. Below are some illustrative examples of the punch strength differential:

• Loturco et al (2016) compared male and female elite amateur boxers from a range of weight classes (male: flyweight to heavyweight, female: featherweight to light heavyweight). This found a strong punch advantage for men that was only weakly correlated to weight:

• Adamec et al 2020 found an enormous difference with an open-handed strike, but less with a punch:

At their most simple, machine learning recommenders are optimising for some specific goal. The classic and most easily understandable example is monetisation, ie how to get people to spend as much as possible.

For example it is common to target the conversion rate - what percentage of users turn from non-spender to spender - and treat increasing this figure as one primary goal for system optimisation. The approach then is to run experiments, using everything from changes to user interface, to the variety of recommendations presented, to user-specific high-value deals, to the timing and rate at which these are presented to the user, all of which will produce different rates of conversion. When an experiment produces a higher conversion rate, then that is deemed a success and becomes the default, and further experiments are run against that, in a relentless, automated drive to optimise the target metric: converting non-spenders into spenders.

So far, so obvious. Of course different people may respond to different things in different ways and these sorts of optimisations are not one-size fits all. Users are typically segmented and targeted for different experiments and different optimisations - those in one country might respond differently to those in another, men differently to women, over-60s differently to under-30s.

But it is worth stressing that the whole point of this is to produce behavioural change.

This is not a benign approach dedicated to providing the healthiest experience for anyone who happens to use a service, but an aggressively optimised pipeline for creating the behaviour the service demands from the maximum possible number of people. If this comes at a cost of coercion, trickery, and a slow drip of unconscious manipulation in order to extract maximum value, then that is just the logic of the marketplace in action. Businesses that are effective at producing behavioural change will survive and those that do not will die.

Feed-based systems like Twitter and TikTok don’t have to rely on crude demographic data for segmenting their userbase - they build up a sophisticated picture of who you are based on what you have interacted with. And the principal source of revenue is advertising which means that by far the most important metric is attention. The probability of clicking, of sharing, of watching a video beyond a certain number of seconds, how much content you engage with - the more active users a platform has, the more valuable it is to advertisers, and the more engaged users are the more adverts they will see and possibly click on.

So we have created the most effective systems ever for manipulating human behaviour in order to capture as much attention as possible, in ways that are invisible and unknowable to individuals subject to it. Unfortunately, while we largely seem to accept this is on some level pretty bad for society, much of the discourse around the effect of these systems is about pushing individuals to the “left” or the “right”, which represents a gross oversimplification of what is actually happening.

Notions of left and right are far too broad to capture the breadth of our individual political positions. One attempt to improve on this is the political compass, which expands the left/right spectrum with an additional libertarian/authoritarian axis:

So, rather than a simple left/right opposition, more complex political leanings can potentially be conveyed. For example, a left/libertarian would appear here on the political compass:

But even that is a crude simplification, because what the political compass is doing is taking a questionnaire with 62 multiple-choice questions and baking down the answers into some sort of average position on a two-dimensional grid. These are questions such as the following:

A single value on the political compass doesn’t really convey the range of opinions actually held by an individual, it is a simplification. A useful one, to be sure - but another way of thinking about it is that the individual is represented by all their answers to those questions. If each question has an answer 0-3 (from strongly disagree to strongly agree) then another way of representing that person’s political compass position is:

3,0,2,0,0,1,2,3,0,0, (etc…) 

That string of numbers is meaningless at first glance to a human, and would be hard to interpret even if you had a list of questions to hand. But perhaps another way of visualising these answers is in something akin to a chessboard, where the colour of each square denotes the answer:

• black = strongly disagree

• dark grey = disagree

• light grey = agree

• white = strongly agree

In this model, the grid below represents the answers to the political compass that would result in a right/authoritarian viewpoint:

And here is how it would look for a left/libertarian position:

We can tell with a glance at the political compass image that these two are polar opposites politically. It is slightly less obvious by looking at the grid representation of the answers, though when viewed side by side it is possible to see that these are negative images of each other.

Now consider the following slightly different set of answers. This is a position that is still largely the same as the above left/libertarian grid, but with only two different answers, resulting in a position that is slightly more authoritarian:

The only difference is the answers to the following two questions:

These two people have virtually identical left/libertarian politics according to the political compass, with only two points of disagreement. This underlying distinction is invisible to anyone seeing the political compass result, and even that is only marginally different in the first place. Most people would consider these two to have broadly the same politics.

However, these are the two questions, which represent a radically different point of view on matters relating to sexual orientation:

Someone could have answered these questions differently for a wide variety of reasons. Perhaps they think all sexuality is a spectrum and any monosexual desire is inherently limiting, resulting only from cultural mores. Or perhaps they think homosexuality is inherently unnatural. Or they oppose all adoption in principle.

The meaning underlying these choices range from the mistaken to the regressive to the utopian. We cannot truly understand a person’s viewpoint just from this question. Nor can we understand it from a glance at a chessboard abstraction of their answers to multiple political questions, nor an aggregate score on the political compass, nor from binary labels like “left” and “right”. Everything is a simplification, a compression of complicated data into ever smaller and less meaningful abstractions.

Returning to the use of machine learning to drive behavioural change, let’s say for the sake of argument that the below grid represents 64 datapoints a social media platform holds about its users. These - purely to simplify this example - match the questions in the political compass, so in the figure below the two black and white squares correlate to - the difference between the original two left/libertarian individuals (ie, the questions on sexual orientation).

Now imagine a platform is using machine learning to optimise the engagement rate of its users. It wants to turn casual users into obsessives who will click and engage and produce more content, and this platform is unconstrained by what the actual content being engaged with is, the impact this has on the mental health of these individuals, or on society as a whole - it is just blindly optimising for attention by relentlessly exposing users to content to see what works. Through experiments finds that users with strong signals in these two squares (ideally, fully black or white) are highly engaged.

The platform does not know the meaning of these squares. It does not know that it may correlate with homophobia or utopian idealism. It hasn’t even outright asked a question in the way the political compass does - it simply responds to the behavioural data it has accumulated and tries to optimise each user’s feed for maximal engagement.

Now consider the following is an illustration of the noisy datapoints this platform holds about 16 random users. Rather than straightforward black and white, each point is a shade of grey, indicating some level of certainty about this behavioural data:

It just looks like static really. We, as humans looking a this visualisation, can’t tell what they have in common, if anything. And this is to be expected - humans are complex, and we understand that our own individual preferences are unique. Based on the above, could you guess which two are the most similar overall?

It is these two:

Again, it is trivial for computers to perform a comparison such as this near-instantaneously. To the human eye, the grids look like noise, but to the machine, the proximity of two users in this multi-dimensional space is a roadmap for social contagion. If one of those two individuals clicks on a specific inflammatory headline the machine has a high probability that another, similar user will as well. The more information that can be gathered, the stronger the signal amidst these datapoints, the more reliable these predictions will be, and the more effective those predictions will be at increasing engagement.

If we can gather more info, the uncertainty of those views collapses into much clearer positions. By removing the shades of grey over time, collecting more data and producing stronger signals - and thus stronger opinions - much more black and white pictures emerge. For example, in the below example, we can see how gathering more signal eventually finds this one specific matching pattern of behaviour:

But if this pattern is a desirable one that equates to greater engagement, then the logical next step is not simply to detect it, but to create it. How can those initially yellow squares be “nudged” such that anyone that could exhibit this behaviour, does so? If there is a way of doing so, a combination of content and presentation and timing that will unconsciously lead individuals to publicly express views they had not previously considered, then machine learning recommendations will find it.

There is a tradeoff between exploiting what the system already knows about us and exploring possibilities that might gather more data or push us in a new direction. But the relentless, optimising logic of attention as a metric of success fuels the drive to obtain ever more data, to detect stronger signals, to produce more refined suggestions, to generate more attention and more data. And in reality these illustrative squares are a massive simplification of the thousands of dimensions of datapoints gathered about our behaviour on social networks.

It is the collection of ever more data in order to extract signal from noise that is fuelling radicalisation on social media. As these systems try to improve their certainty about our behaviour by gathering more and more of our interactions, so do we too become ever more certain and forthright in the opinions we express through the constant repetition of those actions and the constant feedback of social approval or approbation. Machine learning recommendations provide each of us with an individually tailored on-ramp to whatever extreme views we might one day be capable of holding. These systems have no specific end goal in mind, as long as we keep clicking. We might start with reasonable questions and - through the slow dripfeed of ever more strongly held opinions - find ourselves ten years down the line cheering behaviour that we would once have found abhorrent.

All while flattering ourselves that such radicalisation - such conversion - only happens to other, stupider people.

With advertising as the dominant revenue model for online content, it was inevitable that machine learning recommendations designed to maximise revenue would find ways to devour ever more of our attention. Surfacing points of bland agreement does not produce maximal engagement, so systems drift toward divisive, emotionally triggering material. It is the ruthless logic of the market, and it cannot self-correct, even as it eats away at the fabric of society.

Returning to our original left/libertarian examples with opposing views on gay adoption, they might find in reality that this difference of opinion simply never arises. In their personal lives it might not be discussed - or if it was it could simply be something they agree to disagree on. Whatever the case, they have far more in common than that separates them.

Meanwhile two individuals with radically opposite politics might never find they had a shared viewpoint about gay adoption. Or, even if they did, they might find it is in reality only superficially similar, and held for very different reasons:

Whatever the case, machine learning systems do not see the crude left/right compression of these views, or even the two dimensional left/libertarian vs right/authoritarian labelling - or even the simple grid of political compass answers I’m using in these examples. What they see is a vast, many-dimensional array of datapoints covering content the user has previously interacted with, which can be used to predict what they may interact with in future. Datapoints such as these will inevitably drive social media recommendation engines to surface more content likely to gather interactions from these users. These systems do not care whether this is promoting content that is (in this example) anti-gay adoption, only that they have a high probability of attracting further attention, and feedback, and data, to drive more attention, and feedback, and data.

To each user, interacting with such content is designed to be seductively easy, and consequence free. Social media platforms want to keep you engaged, they want you to act unconsciously, scrolling, clicking, liking - and with the illusion that these are disposable and consequence free actions, as easy as breathing. But with the shift to these opinions being expressed publicly online on a continuous basis, the act of liking or retweeting content becomes - to the outside observer - part of an indelible personal manifesto. Thoughtless statements or casual clicks transformed into strongly held political convictions, date stamped and archived and screenshotted and searchable and permanent.

Having publicly interacted with content that another left/libertarian may find unpalatable, this then works to create a rift between these users. But - crucially - showing this interaction to another left/libertarian will drive further interaction. Again, the systems do not care whether this comes in the form of public shaming, condemnation or outright hostility - they only care that it generates further interaction, and further data.

Social media can rapidly create the illusion of being part of a like-minded “tribe” and then just as rapidly shatter that illusion, by laying bare the faultlines between individuals. Faultlines that, on a one-to-one basis, we are capable of navigating, but are utterly unequipped to deal with when scaled up to the hundreds or thousands and acted out on a public stage with millions able to see and judge our actions.

Once you see someone who you imagine to be part of the same “tribe” expressing wildly different opinions about something important to you, it creates a feeling of dislocation and unease - and social media is on hand to provide the analgesic for that pain. Soothe your discontent by scrolling and agreeing with those who are equally horrified. Or don’t, and find yourself self-censoring for fear of being isolated by the “tribe”.

By surfacing our most divisive opinions to the people most likely to be offended by them, these systems force us into a state of constant anxiety, always at risk of conflict. As the saying goes, “the map is not the territory” - but here, the map (in the form of the behavioural data) is in constant feedback with the territory (our selves). The map and territory shape each other until they become indistinguishable. We eventually become a caricature of ourselves, repeatedly performing the actions that gain us public approval, all while terrified that one wrong datapoint could be surfaced to the very people least equipped to forgive us for it.

We are left living in a state of algorithmic claustrophobia, trapped in a feedback loop where our most divisive, unformed impulses are taken to be the entirety of our selves in public. Only that which can be quantified remains. Our private internal thoughts, all our nuance, disappear as we internalise the logic of the surveillance systems, performing for attention in public only those aspects of us that can be captured and collated as data, until every other part atrophies.

Once you become immersed in these systems, at some point, the greatest fear isn't being watched - it is the fear of no longer being tracked at all. Of not being broadcast and amplified. Of facing non-existence, anonymity and oblivion.

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On the other, everybody relies on Wikipedia, it is a substantial part of AI training sets, it appears top of search results, and occupies a privileged position in the technology ecosystem. It is simultaneously too unreliable for its own use, but “good enough” to provide a single source of truth for the vast majority of questions humanity poses to search engines and AI.

So all that being said, Grokipedia is a terrible idea.

For those that are blissfully ignorant, Grokipedia is Elon Musk’s answer to the bias of the average Wikipedia editor when it comes to contentious political issues, in the form of an AI-generated encyclopedia tuned to produce results more pleasing to Musk’s political sensibilities. Rather than address the issues with Wikipedia and its position in our technopoly, Grokipedia seems to largely plagiarise it while adding a whole new layer of distrust, unreliability, and political polarisation.

In Dirk Gently’s Holistic Detective Agency, author Douglas Adams - in yet another moment of bleakly humorous prescience - came up with the idea of the Electric Monk. This was a labour-saving device whose purpose was to believe things, so that the owner didn’t have to:

As we become ever more rabid consumers of new information, craving constant novelty in our newsfeeds, we are losing the ability to know what to believe - we simply have too many new and conflicting events to spend the time constructing an informed opinion on everything overwhelming our senses. This is the position AI is fighting to occupy in our technological infrastructure, whether in the form of Grokipedia or Google’s AI search results or AI-powered news summaries - ask a question, and get told what to believe. Collapsing the complexity of subjects where there may not be a singular answer into a readily accepted simplistic response delivered with the cold authority of the machine.

This is a huge missed opportunity. Rather than using AI to replace human struggles to discern truth with thought-terminating slop, we could instead try and use AI as a different sort of labour-saving device, to expose the complexity hidden underneath the simplest of statements.

What if, rather than wasting everybody’s time on culture war dick-waving competitions, these vast engineering resources and limitless budgets were poured in to making tools to allow anybody to visualise, connect and judge competing sources of information for ourselves? Sure, Wikipedia is ostensibly transparent, but who can be bothered to trawl through the sources and page history to see how the sausage is actually made and decide whether a particular paragraph is even remotely trustworthy? Who even has the time? What if editors and readers alike were given the ability to verify claims and weight sources and consider uncited sources directly in Wikipedia, providing a layer of accountability on top of the opaque decision-making process?

Wikipedia content is governed by rules - policies about what should be cited, how it should be balanced, what tone to strike and so on - which have been created by community consensus. However, having rules is different to following them, and on Wikipedia the application of policy is also matter of consensus. Humans are fallible, consensus can arrive at poor decisions for all sorts of interpersonal reasons, and as such policy is not always applied consistently.

This is all largely invisible to the casual reader. There is technically an audit trail and talk page discussions, but deciding whether or not the citations justify the text or whether the many arcane policies and guidelines have been correctly applied is not something the vast majority of readers have the time or even the ability to do. No passing user reading a snippet of a Wikipedia article from the top of their search results is going to have much of an idea of how the content on a page has been arrived at and whether it is any way compliant with policy, or the article’s citations.

AI, on the other hand, can do exactly this. Rather than Grokipedia’s focus on telling you a competing version of what is true and synthesising a singular narrative to stack up against Wikipedia, why not analyse the text of a Wikipedia article and its sources, apply Wikipedia’s policies to it, and see to what degree the citations are accurate and the rules have been followed? And why not provide this both as a tool for editors to be able to check their work, and to readers to make more visible the shortcomings of any articles?

I’ve been building a tool that can do this out of my own personal interest. It works by taking an article and breaking it into paragraphs, along with their references, footnotes and any other cited works. It then sends each of these to an AI along with a prompt requiring it to verify the supplied text against the cited references, and asks for the text to be checked against Wikipedia policies and guidance. Does the passage contain any original research? Are medical claims compliant with policy on medically reliable sources? Is everything verifiable and written from a neutral point of view? And so on.

The end result of this is to produce a textual analysis of the paragraph and its policy compliance, along with a numeric score out of 100. The opening section is then separately analysed in conjunction with all of these analyses to verify that the article lede correctly summarises the article itself (per the guidance that the lede follows the body), and finally an overall score for the article as a whole. This is all then combined onto a page containing all of the text and citations of the original article, with a paragraph-by-paragraph score and an analysis of each part that anybody can read.

To illustrate, here is an AI analysis of the Wikipedia article on HMAS Emu, an Australian tugboat. I selected this simply because it recently appeared on the “Did You Know?” section of the Wikipedia homepage, with the note that it “once rescued a cigarette-smoking chimpanzee and his magician owner”.:

This article is short, politically uncontroversial, and reasonably new, and according to a paragraph-by-paragraph AI analysis the text itself is mostly good, with every section scoring highly.

However, while reading the results, I found that the AI analysis did turn up something interesting in this paragraph:

In August 1951, the New Zealand troopship Wahine was carrying 577 New Zealand troops to Korea, when she hit a reef near Masela Island, 250 miles (400 km) north of Darwin.

Running an automated analysis over this text and its citations produced the following assessment:

The passage is largely supported by the cited contemporary newspapers and the Royal Australian Navy Sea Power Centre history, but one factual detail is not supported: the troop count (given as 577) does not match the cited sources, which report 575.

According to this, the article misstates the number of troops on board the TSS Wahine when it ran aground in August 1951. This might seem inconsequential to most, but bear in mind that Wikipedia is entirely dependent on the goodwill of people who care enough about minutae like this, and everything is important to somebody. I’m sure this would be of great importance to the two people who were - or were not -on board at the time.

So - is this true? Well, there are three citations for the claim.

The first is an August 16th 1951 report of the sinking, which says:

The 4,436 ton New Zealand troopship “Wahine,” carrying 575 New Zealand troop replacements for Korea, was 23 miles off the usual channel route when she grounded on a reef near Masela Island early this morning.

The second is a contemporary report of the looting of the vessel, which says:

The Wahine, carrying 575 NZA troops to Korea, ran aground on August 15.

The third is an archive of the maritime record of the Wahine which only says:

1951 August 2 After minor alterations had been effected she departed from Wellington under the command of Captain F. D. Johnson, carrying 577 troops and a crew of 80. Following a call at Cairns, she proceeded to Darwin where she refuelled, leaving there on the 14th of August.

As far as I can tell, the AI assessment is absolutely right - the two contemporary sources say there were 575 troops on board when it ran aground, and the maritime record says only that it was carrying 577 when it departed Wellington two weeks earlier, with a stop off at Cairns in between.

Compare this to the article on the TSS Wahine, which says only that she “left Wellington carrying 577 troops” and is silent on how many were on board when she ran aground.

In my opinion, this is exactly the sort of thing AI can be useful for, namely as a human-directed, labour saving tool applying defined rules to rapidly compare text to sources it has been provided with. Given those three sources, and that text, and Wikipedia’s extensive rules on sourcing, the most we can say is that - according to those sources - there were 577 troops on board when it left Wellington, and 575 on board when it ran aground two weeks later. It is absolutely feasible to have an automated tool flagging up potential errors to editors and readers alike, and in my opinion this is the kind of endeavour that could benefit Wikipedia as a whole if integrated both into the editing process and into the reader’s view of a page.

That being said, the current generation of AI isn’t quite up to doing this entirely automatically. Aside from the problem of the sheer length of some documents or the problems of automating access to paywalled sources or printed books, the main stumbling block is that AI doesn’t know what it doesn’t know. The omission of potentially contradictory references is as significant a problem as misrepresenting the ones that are actually used, so while an AI might score a paragraph highly based on the sources it does cite, when provided with additional ones that have not been cited it can correct and scores low. For now, deciding what has been left out is a matter of human judgement, and any output is highly susceptible to reflecting the biases of whoever asked the question. It is tempting to reshape the prompts and get exactly the results we expect - pages can score high or low depending on the precise wording of the question and the context given, dressed up with the flattering illusion of objectivity we project onto machine-generated text. Checking facts on a low consequence page like HMS Emu is a long way from verifying the neutrality and sourcing on a hot mess battleground such as “Political views of JK Rowling”.

Flawed as it is, I still believe an approach like this is something that would be far more valuable than building a differently-biased spin on top of plagiarised Wikipedia articles, like Grokipedia.

Wikipedia assumes that it on average improves over time, that if the majority of information there is good then any errors will average out, and every technological service that builds upon this assumption compounds it. Tech companies like Google have become so used to operating at scale that it is easy for them to assume an acceptable level of error in search results, and consequently an acceptable level of error in AI-generated responses. Sure, they might not always hit the mark, but on average responses are useful and relevant, as judged by users’ continued attention and usage of the service.

But the average of wrong is not truth.

There is scope here to use AI to make the context surrounding information visible, and all its flaws instantly available for anyone to judge. Instead however, vast amounts of computing power is being given over to further obscuring this, with tech companies endlessly refining their Electric Monks, all deferentially wired up to Wikipedia, all fighting over which brotherhood will be dominant, which monastery will receive humanity’s tithe in return for freeing us from the tiresome burden having to know what to believe.

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Throughout history there have been dark moments where science has been manipulated for political ends, and few are as starkly cautionary as Lysenkoism. This was a period where Soviet science was gripped by an ideologically motivated rejection of Mendelian genetics in favour of a sort of Lamarckism, at the direction of the biologist and agronomist Trofim Lysenko. It was believed, for example, that wheat grown under stressful conditions could pass physically improved resilience onto its direct offspring - that Autumn wheat could be turned into Winter wheat by exposing the seeds to cold. Lysenko decried evolutionary theory as bourgeois doctrine and rejected the notion of a clear definition of species, believing one variety of grain could be transformed into another by exposing it to a different set of environmental factors.

This pseudoscience held sway for decades under the Communist regime, with Lysenko as head of agriculture granted political favour by Stalin, while contrary scientific opinions were dismissed as bourgeois fascism and dissenting scientists arrested and condemned to death. Meanwhile, the attempts to put these ideas into practice did untold damage to Soviet and Maoist agriculture, leading to crop failures on a huge scale and the deaths of millions.

The unhappy legacy of Lysenkoism in contemporary disputes however seems to be as an easy analogy to be exploited for political ends. Lysenkoism provides an example of illegitimate suppression of science that is invoked to compare any disfavoured scientific position to those evolutionary biologists repressed by the Soviets, reputations shredded, papers unpublished, sent to the gulag for daring to speak the truth by an intolerant ideologically-driven regime.

In 2005, journalist George Monbiot compared the Bush administration’s efforts to undermine and stall progress on climate change to “Lysenkoism”, while in 2009 Emeritus Professor Cliff Ollier compared the orthodox mainstream view on climate change to “Lysenkoism”. More recently, the Trump administration’s attitude to vaccination is regularly compared to “Lysenkoism”, while others dismiss social justice activism as “woke Lysenkoism”. These are just a few contrasting examples of many to illustrate that, over the decades that political arguments have raged over the reality of climate change, vaccination, and many other politically contentious topics, comparisons to Lysenkoism have been drawn over and over again by opposing sides.

The problem with using analogies in this way is that they do not truly help us understand which side to believe. Taking an example of a historic injustice and applying it as an analogy to an existing situation can simply feed our own preexisting belief in a contemporary injustice. Arguably for political activists this is the point of the analogy, exploiting past wrongs to win public sympathy and popular support. However, simply being attacked for holding a minority position does not mean that position is correct or that it will ultimately be vindicated. As Carl Sagan said:

It is seductive to lend credence to claims that “the truth” is being suppressed by ideologues, but science rarely deals in such absolutes. Science is - especially at the bleeding edge - messy and couched in uncertainty, in probability, in what we can plausibly say with some degree of confidence given the state of available evidence.

One possible lesson of Lysenkoism is to avoid the black-and-white thinking that led to its dominance and propped it up for so long. To eschew rigid ideas and the arrogance of having access to the whole truth, and to accept some room for uncertainty. But then this is complicated by other, contrary historic situations such as that with Big Tobacco, where doubt and uncertainty were exploited in bad faith to forestall action (as detailed in Merchants of Doubt), tactics that were later employed by the fossil fuel industry to delay action on climate change. We can find ourselves caught between two warring analogies - one where junk science was propped up by ideologues, and one where manufactured doubt was cast on good science to stall progress. When advocates are demanding urgent political action, attempts to inject nuance and complexity are treated with suspicion, and we cannot know for sure which is right without actually assessing for ourselves the quality of the arguments and the evidence on display.

The boring reality is that such situations cannot really be understood without actually assessing whether legitimate science is indeed being attacked or suppressed for political reasons, or whether in actual fact junk science is being rightly ignored by a sensible mainstream. Teasing that out is difficult, slow, complicated, and does not sit well with the slogans and thought-terminating cliches that dominate political discourse.

Perhaps all we can do to chart a path between opposing analogies is to make our best effort to assess that the uncertainty is genuine, and then see how that uncertainty is treated - as part of scientific discourse, or with censure, silencing and smear.

A recent and shameful episode has been the capitulation of McMaster University to a campaign of bullying and invective. After publishing the first three of a planned series of systematic reviews in the field of youth gender medicine - all of which had so far concluded that the evidence was low quality - the authors were subjected to a sustained campaign of bullying with the intention of discrediting their work. As co-author Gordon Guyatt stated in an interview with Jesse Singal:

The young people and my colleague who got us into this in the first place are now so traumatized by the whole scene that they want nothing to do with it. That is, they all pulled their names off. They’re all terrified. They’re all traumatized.

Eventually McMaster published a statement disowning their partners in the research (SEGM) and promising to do better, with some of the authors putting their names to this statement and distancing themselves from the remaining, unpublished reviews which may now never see the light of day. This is disturbing behaviour from such an institution, failing to protect open enquiry, self-censoring to appease partisan critics and hanging the remaining authors out to dry. To see McMaster baited into giving this statement of apology - lending credence to a long-running ideological smear campaign - is pretty disgraceful. As one co-author put it in an interview with Benjamin Ryan:

If I’m a funding body, I would think twice about engaging with McMaster.

Witnessing this sort of thing, it is easy to reach for the parallels to the ideological attacks on evolutionary biologists under Lysenko - not because the silencing is necessarily being enacted in the same way or for the same reasons, but because of the consequences such an obvious chilling effect will have on open inquiry and scientific discourse. Having researchers “terrified” to investigate a subject while institutions bow down to angry mobs and agree to comply with preconceived conclusions can only be a disaster for science.

But summoning the ghost of Lysenko cannot tell us who is right in a given debate, all it can do is act as a stark warning of what happens when the very conditions for uncovering truth are destroyed. This is what science must be ever vigilant towards, and this is what appears to be under threat now, when institutions lack the courage and integrity to protect researchers and their work from campaigns of abuse. Standing up for open, good-faith debate is still the only safeguard we have against repeating our greatest errors.

Last year I wrote a piece about the BMA Council’s decision to publicly critique the Cass Review. In that, I made numerous criticisms of a preprint paper which the BMA relied upon as part of that decision.

The BMA’s “task and finish” report was promised in January but still has not materialised - however, in the meantime, the preprint they cited approvingly has finally been published, and very little of substance has changed there. It has been reformatted and reordered, some of the claims and citations updated, others toned down a little but in essence it is broadly the same, so every criticism I made last year still applies. To summarise here though, the majority of the paper is directed at the methodology used by the York University systematic reviews of the evidence base, and seizing upon trivia to cast doubt on their results.

Since it has now been peer-reviewed though, it is getting a second round of attention - despite offering nothing new - so, rather than reiterate all the flaws I have previously drawn attention to I want to address one of its foundational assumptions in detail.

Before proceeding, it is important to reiterate that the critique is highly concerned with the use of the Newcastle-Ottawa Scale (NOS), claiming it is an inappropriate tool, and that the “adapted” version used by the York team invalidates the results:

The NOS has been criticised and the use of an adapted version negates previous attempts to validate the NOS.

I explained in my earlier piece why this is bunk - the NOS is very widely used, all tools are subject to criticism, replicating results with varied methods is a good thing, and the “adaptations” made to the NOS are completely standard ones that are typically made so that the generic base questions make sense for the review subject.

For now though, suffice to say: this critique challenges not only the specific use of the NOS, but the decision to use the NOS at all. More on this later.

The real starting point of the critique is that, whatever methodology was used, the Cass Review and the York University team proceeded from a faulty perspective.

That is, they approached this by thinking about children and young people in distress, and investigated whether treatments provided to them did actually improve their mental health and wellbeing. This, according to the critique, is the wrong thing to do:

evaluating the efficacy of GAC based on psychosocial well-being alone is misguided

The authors believe this, because to them the purpose of allegedly “life-saving” interventions is not to improve mental wellbeing, but to fulfil cosmetic goals - and it is this fulfilment that will then consequentially improve mental health through realising one’s authentic self:

The primary goal of GAC is to prevent or induce the appearance of certain physical characteristics, and their physiological efficacy is undisputed. Mental health benefits are a logical consequence of living authentically

This is somewhat contradictory, in that mental health improvements are promoted as a “logical consequence” but attempting to evaluate whether this is actually true by checking to see if there are actually any mental health benefits is “misguided”.

But in any case the reasoning here is that what is important is how the child or young person is approached. Providing treatment to alleviate distress is wrong, pathologising and paternalistic and will harm mental wellbeing, while offering children unfettered access to cosmetic alterations to achieve their embodiment goals is right and guaranteed to improve wellbeing:

Given that transgender people have a care need rather than a disease and seek actualisation of their identities as opposed to a cure, this paternalistic lens is inappropriate and pathologising

By this point, the critique is no longer arguing about evidence or from any basis in science, but is making a purely ideological point. It demands that children in distress at their sexed bodies be thought of in a specific way and be given a specific kind of treatment on demand, and any other viewpoint is wrong. Not only that, but any scientific evidence gathered that starts from an alternative point of view is also wrong, and should be disregarded.

So because the Cass Review did not accept up front the ideological perspective of the authors, it is suspect. The authors then cement this viewpoint by drawing an analogy to contraception:

[Gender Affirmative Care] should instead be considered through a similar lens as reproductive healthcare, akin to how healthcare providers and the public think about contraception, HRT, or fertility treatment.

This is quite fundamental to their critique: that Cass should have considered puberty blockers to be as straightforward as taking the contraceptive pill, and by not taking that as the starting point the findings and recommendations are flawed. The argument being made by analogy is that we do not pathologise young people seeking contraception nor do we consider contraception an intervention to improve their mental health, but instead see it as a choice relating to bodily autonomy. So, is that a valid comparison?

There is one citation for this sentence in the paper, and it goes to an earlier paper by one of the co-authors, Florence Ashley, in an ethics journal, making this argument from a rhetorical, ethical and philosophical standpoint. This is not a definitive medical consensus, rather it is the strong opinion of one of the authors.

So let’s look at what that citation actually says.

The earlier paper is titled “Adolescent Medical Transition is Ethical: An Analogy with Reproductive Health” and states its premises up front: transition is about attaining embodiment goals:

In this article, I argue that adolescent medical transition is ethical by analogizing it to abortion and birth control. The interventions are similar insofar as they intervene on healthy physiological states by reason of the person’s fundamental self-conception and desired life, and their effectiveness is defined by their ability to achieve patients’ embodiment goals.

This is claimed to be a legitimate comparison to make because the evidence for mental health benefits for both types of procedure is similar, and there is no scientific evidence suggesting harms of transition:

Since the evidence of mental health benefits is comparable between adolescent medical transition, abortion, and birth control, disallowing transition-related interventions would betray an unacceptable double standard. While great enough risks can override autonomy over fundamental aspects of personal identity, I demonstrate that the available scientific evidence does not corroborate the view that adolescent medical transition is dangerous. Consequently, adolescent medical transition should be recognized as ethical and remain available.

The whole argument rests on the premise that medical transition is already proven to be safe and effective to the same degree as contraception, and thus an analogy can be drawn.

This is a problem then, because the Cass Review went on to find the evidence was incredibly poor. So Ashley’s argument against the Cass Review is that it found the evidence was weak because they didn’t consider it like contraception.

Which is circular and begging the question.

So, how does Ashley arrive at the idea that the evidence is strong? Well, by attacking previous research that found it to be weak by using the exact same circular argument against the two 2020 NICE reviews that predated and precipitated the Cass Review:

The effectiveness of adolescent medical transition was subsequently questioned in evidence reviews of puberty blockers and hormone therapy published by the National Institute for Health and Care Excellence (NICE 2020b; 2020a). The reports were prepared in support of the England-wide review of gender identity services for minors led by Dr. Hilary Cass. Both reviews looked at mental health benefits and concluded that evidence of effectiveness was of very low quality under the GRADE framework for summarizing evidence (Guyatt et al. 2008). As I argue in this paper, understanding effectiveness in terms of psychological benefits mischaracterizes the purpose of adolescent medical transition.

According to Ashley, earlier reviews that found the evidence base to be weak should be disregarded because they want to evaluate effectiveness at alleviating distress rather than straightforwardly facilitate “embodiment goals”.

Additionally, those earlier reviews assessed the evidence using GRADE, which is a tool designed for randomized-controlled trials. However, since most existing literature in this area are nonrandomized, cohort studies, Ashley takes issue with this approach as inappropriately downweighting the available evidence:

The reviews […] employed the GRADE framework for summarizing evidence

[…]

Upholding randomized controlled trials as an evidentiary norm regardless of context underestimates the value of other methodologies.

[…]

Under frameworks tailored to non-randomized studies, such as the Newcastle-Ottawa Quality Assessment Scale, evidence of mental health benefits would likely be assessed as moderate to high

So, here we have Ashley saying that the earlier reviews were too harsh because they used GRADE, and claiming that an evidence review that used NOS would be more forgiving, therefore that the evidence is strong, actually.

We can check this, because Ashley lists several positive papers that would apparently have scored better under NOS:

(van der Miesen et al. 2020; Turban, King, et al. 2020; Carmichael et al. 2021; Moore 2018; Grannis et al. 2021),

And here is how the York University team scored those, using NOS:

• van der Miesen et al. 2020 (puberty blockers) - Rated high

• Carmichael et al. 2021 (puberty blockers) - Rated moderate

• Turban, King, et al. 2020 (puberty blockers) - Rated low (due to lack of followup and that it is based on self-reporting whether participants even underwent treatment)

• Grannis et al. 2021 (hormones) - Rated moderate

• Moore 2018 is a doctoral dissertation, not a published study, so is excluded.

Apart from Turban and Moore (which weren’t anything like as strong as Ashley implied here), as predicted, three of the later papers scored moderate to high under NOS.

It has to be said though that according to a review by The Commission on Human Medicines, the York team bent over backwards to rate these studies generously:

In discussion of the CHM Core Group with Professor Hewitt from the University of York team we were informed that by usual standards the impacts identified as moderate quality evidence would usually be consistent with poor quality evidence, but were placed in this category as the overall quality was so poor they considered a need to provide some differentiation.

In any case, just as Ashley argued in 2022, NOS is an appropriate tool for the job of evaluating nonrandomized studies, and was able to score relevant papers more generously than previous systematic reviews that used GRADE. Despite these efforts though, the actual findings were themselves weak - eg. Carmichael et al found no improvements, van der Miesen et al found small improvements in some areas, none in others, and so on.

Unhappy that despite using the NOS the overall picture in the later studies is still of weak and inadequate evidence, Ashley has now co-authored a paper arguing that they shouldn’t have used NOS after all. Having not got the answer wanted from NOS, they insist another tool would be better:

The ROBINS-I is an example of a more suitable tool

This was addressed in a response to this critique that was published in the BMJ when it appeared in preprint form, which noted that ROBINS-I is less forgiving than NOS:

Our assessment shows that the assessment with the adapted NOS scale probably is more forgiving than the assessment with the ROBINS-I tool. Studies assessed as moderate quality would probably be of critical risk of bias due to its emphasis in confounding in non-randomized studies.

It might be apparent by this point that the authors of the critique are just throwing up any chaff they can think of, and that any approach that doesn’t end up with the desired result is going to be attacked. This is because the fundamental point of contention is not evidentiary, but philosophical.

Florence Ashley’s argument in this earlier paper is that requiring irreversible and experimental medical interventions on distressed children to show some sort of mental health benefit is a “double standard”, because that is not what it is for:

Adolescent medical transition is effective, fulfilling the physiological purpose of bringing the person’s sexual characteristics and gendered self-image into closer alignment. Like abortion and birth control, transition-related interventions do not seek to cure an illness but instead reflect autonomy over fundamental aspects of personal identity. Transition-related interventions are forms of definitional medical care. Proof of mental health benefits is not required of reproductive healthcare, another form of definitional medical care. Asking such proof for adolescent medical transition is an unacceptable double standard.

Ashley concludes that, from this standpoint, researchers should thus stop trying to gather any evidence of mental health benefits:

my argument suggests that studies should move beyond whether transition-related interventions confer mental health benefits and place greater focus on how to best meet individual embodiment goals.

This is not evidence based medicine - it is a philosophical argument to conceptualise medical interventions not as actual healthcare, but as liberal, consumerist choices that cannot be denied. The customer, after all, is always right.

Ashley is of course perfectly entitled to make this argument. The issue here is that what is merely an opinionated rhetorical standpoint is cited in this latest critique as if it were demonstrated to be true. As if it is some settled medical position that the Cass Review is remiss in failing to adopt, rather than an absolutely unhinged call for access to puberty blockers and cross-sex hormones on-demand.

To reiterate, this newly published critique of the Cass Review co-authored by Florence Ashley:

1. Condemns the York University systematic reviews for using the Newcastle-Ottawa Scale to assess the quality of evidence for improved mental health outcomes, because improved mental health isn’t the aim, embodiment goals are.

2. This is based on a citation to Ashley’s own opinion in an essay which insists the evidence for safety and efficacy is good, and therefore youth transition can be considered analogous to contraception.

3. This claim that the evidence for safety and efficacy is good is based on arguing that the 2020 NICE systematic reviews showing the evidence is poor did so because they didn’t use the Newcastle-Ottawa Scale.

It really is another case of the ol’ switcheroo, and frankly this sort of “rhetorical argument presented as fact by citation” is endemic in this field.

Florence Ashley is positing a specific conceptualisation of gender, gender identity and transition - one rooted in consumerism and justified by idealised notions of the self and personal autonomy. From Ashley’s perspective, this overrides the need for evidence - indeed, attempting to collect evidence that doesn’t already accept this perspective is condemned. The evidence must be considered enough already, for this conceptualisation to be true.

The most fundamental argument being made in this critique of the Cass Review is a philosophical one. So it was a fine display of hypocrisy that Ashley recently condemned the involvement of an MIT philosophy professor in a Health and Human Services report into paediatric transition released in the United States, stating on social media:

Yet Ashley’s work is itself a tangled web of philosophical claims held together by self-citations, circular arguments and begged questions that sits right at the heart of the current debate: the ethics and safety and rationale behind paediatric transition. If clinicians can’t even agree why a treatment is being carried out, what it is supposed to do, and what a “good” outcome is supposed to be, how is anyone supposed to evaluate whether it is working?

The Cass Review made the fatal mistake of diligently checking to see if a medical treatment actually had any sort of clinical justification, or led to any improvements whatsoever. As such, every piece of evidence gathered is suspect, because it starts from a perspective of pathology, of treating a condition, of alleviating distress, of minimising harm, of paternalism, of gatekeeping, of thinking doctors know best, of not believing children when they say who they are, of interfering with self-actualisation.

This perspective practically requires a philosopher to unpick it, and it is quite clear that the only evidence the authors will accept is that which agrees with and supports their philosophical starting point: the fulfilment of embodiment goals.

This Wednesday, the UK Supreme Court handed For Women Scotland a resounding win in its case against the Scottish Government, finding unanimously that “Sex” in the UK Equality Act could only mean biological sex, and not sex as modified by a Gender Recognition Certificate. This (in theory) put to rest over a decade of confusion and deliberate misrepresentation over the interaction between the Gender Recognition Act and the Equality Act, and who was covered by sex discrimination measures.

One aspect that has not been given nearly enough focus in the ensuing coverage is the intervention in the case by a group of lesbian campaigners - LGB Alliance, The Lesbian Project and Scottish Lesbians. The submission by The Lesbian Interveners (which is a fantastic band name) focused on the operation of the protected characteristic of “sexual orientation”, which was itself dependent on any interpretation of “sex”. Since the definitions in the Equality Act cover same-sex, opposite-sex and both-sex orientations, establishing exactly how they work affects everyone, gay, straight or bisexual alike. Predictably though, it has fallen to lesbians in particular to defend their sexuality given it was their sexual boundaries under the gravest assault, by men demanding recognition as lesbians.

The judgment gave serious consideration to the arguments put forward in their submission, and found them persuasive, noting:

The second core provision is section 12 of the EA 2010 which defines the protected characteristic of sexual orientation and is framed by reference to orientation towards persons of the same sex, the opposite sex, or either sex. Read fairly, references to sex in this provision can only mean biological sex. People are not sexually oriented towards those in possession of a certificate.

This is an obvious point and one that the interveners have been making, fairly, for years. It is so obvious and straightforward that their opponents have had to generate an awful lot of vitriol to stop anybody being exposed to such a straightforward and obvious point, for fear they might be (rightly) persuaded by it. Nobody’s sexuality is dependent on having the correct paperwork. It is an obvious absurdity that a straight couple might become gay if one pays £5 and fills out an online form.

Disappointingly, lower courts failed to grapple with this basic issue as the case made its way to the Supreme Court. Yet, for the lesbian interveners, this is fundamental because the Equality Act is what protects those who are same-sex oriented from discrimination, and permits things such as gay- or lesbian-only associations to operate. Finally, after all of the interveners facing years of hostility and defamation for standing up for their rights the Supreme Court has quite rightly ruled that the protections for sexual orientation are dependent on actual sex, and not a legal fiction. Nobody’s sexual orientation can be changed by either them or their partner obtaining a government document changing their sex on paper.

All of which is ironic, because the whole rationale for the Gender Recognition Act 2004 was to change both partners’ sexual orientation.

Goodwin

The legal case that ultimately precipitated the Gender Recognition Act was Christine Goodwin vs The United Kingdom, at the European Court of Human Rights. Goodwin successfully argued that a failure to be treated as female by the UK Government violated articles 8 and 12 of the European Convention on Human Rights.

Article 12 is the right to marriage and family life, and because in the UK marriage was strictly between two members of the opposite sex, Goodwin was unable to marry a man:

The applicant in this case lives as a woman, is in a relationship with a man and would only wish to marry a man. She has no possibility of doing so. In the Court's view, she may therefore claim that the very essence of her right to marry has been infringed.

Article 8 is less straightforward, and covers the right to privacy. Since eg. Goodwin’s national insurance number revealed he was in fact male, he was subject to discrimination and harassment in the workplace, and absent decent workplace protections and greater societal acceptance it was ruled that Goodwin should be allowed to keep this information private. Reading the judgment it is clear that this was deemed a violation at least in part due to the UK Government dragging its feet on implementing decent anti-discrimination measures that would have offered greater protections to Goodwin:

a report has been issued in April 2000 by the Interdepartmental Working Group which set out a survey of the current position of transsexuals in inter alia criminal law, family and employment matters and identified various options for reform. Nothing has effectively been done to further these proposals and in July 2001 the Court of Appeal noted that there were no plans to do so (see paragraphs 52-53). It may be observed that the only legislative reform of note, applying certain non-discrimination provisions to transsexuals, flowed from a decision of the European Court of Justice of 30 April 1996 which held that discrimination based on a change of gender was equivalent to discrimination on grounds of sex (see paragraphs 43-45 above). Having regard to the above considerations, the Court finds that the respondent Government can no longer claim that the matter falls within their margin of appreciation

In order to comply with the Convention, the UK Government would need to legislate to address both of these points. A couple of years after this ruling, the Gender Recognition Act was passed, creating the legal fiction that two men could marry if one was, on paper, a woman. Thus the state could go on imagining marriage was a heterosexual institution, all predicated on sexism, homophobia and transphobia.

• Sexism, because it was founded on regressive stereotypes about what “living as a woman” meant and conforming to “the social role of the assigned gender”.

• Homophobia, because the simple idea of just letting men or women marry each other was seemingly unthinkable.

• Transphobia, because rather than focus on anti-discrimination protections for those who transition, instead the state colluded to obfuscate their sex and pretend it hadn’t happened, in the name of privacy.

Rather than permit gay marriage or protect trans people from discrimination or even (gasp) recognise that women are more than just a social role men can adopt, the government of the day chose instead to issue a certificate with the power to declare a gay man to be a straight woman, and then made the information private so nobody could ask about it or, indeed, have to think about it. Sweep it under the carpet and carry on as normal.

It took another 21 years for the Supreme Court to come to the opposite conclusion with respect to the interpretation of the 2010 Equality Act, and state that sexual orientation cannot possibly be changed by the possession of a certificate, because that would be both ridiculous and grossly offensive.

Clarity

So the Supreme Court has given a final ruling that entirely vindicates the many, many campaigners who have been abused and defamed simply for having a correct interpretation of the Equality Act. What has been won has been exactly what For Women Scotland, and LGB Alliance and Sex Matters every other party to this case was seeking: to recognise the Equality Act in its current form, with all its protections intact, interpreted correctly, giving equal protection to women, LGB people, and trans people.

In that light, it is quite revealing that not a single LGBT rights group in the UK welcomed this ruling, which unequivocally defended the rights of LGB people. Stonewall’s response was to describe it as worrying, and express “deep concern at the widespread implications”. But what are those implications, if this judgement is simply clarifying existing law? There are only implications if you have spent the last decade or so being wrong about what the law says - which of course is exactly the problem Stonewall face. Likewise LGBT Consortium, whose joint statement with dozens of signatory organisations expresses deep concern at the “widespread, harmful implications” of the ruling.

Which invites the question - what have they actually campaigning for before now?

If they believe a ruling that protects the rights of LGB people on the basis of sex is “harmful” and “worrying”, on what basis do they believe sexual orientation should be protected in law? Now that we have clarity in law, we should have clarity from those who are expressing outrage at this ruling. If they had such strong views, why did not a single one attempt to intervene in this case to put forward their position on how LGB rights should be interpreted? What it all makes abundantly clear is that whole chunks of civil society are now single-issue campaigners, with a focus solely on advancing some amorphous idea of “trans rights” with either no idea or no concern what that entails or which other rights are thrown under the bus in the process.

In the knee-jerk condemnation of this ruling, these organisations demonstrate that they believe that people who are same-sex oriented should not have protections on that basis. They believe that someone’s sexual orientation can be converted via government paperwork, and that exclusively same-sex attracted men and women should not be allowed to form associations of their own. They believe that an online form and an administrative fee can turn men into lesbians and women into gay men. They should admit that they believe people are sexually attracted to red tape, and campaign for it, honestly and openly, and see just how many of their supporters agree with that.

And all those blindly following their lead in condemning this ruling, desperate to be on the right side of history - the corporate sponsors and trade unions and celebrities and political parties - should finally admit that they are campaigning for the erasure of sexual orientation as a meaningful concept in law, and now they are enraged because a group of lesbians dared to stand up and say no.

In January 2025, the New England Journal of Medicine published an article titled “The Future of Gender-Affirming Care — A Law and Policy Perspective on the Cass Review”. The article is little more than a blatant attack on the integrity of the Cass Review, and sets out the following main points:

• The Cass Review sets an unattainable bar for evidence and violates international standards

• It was secretive and biased

• Its methodology was flawed

While throwing in a few other potshots for good measure, and ending in some absolute gibberish about gender policing.

While only a “perspective” piece, that it was published in the form it is reflects quite badly on the editorial standards of NEJM. That is, the piece isn’t simply bad or contentious, but factually wrong in such a fundamental way that it renders the whole article incoherent.

The term “review” is used interchangeably to mean multiple different things throughout this article, so some basic terminology first:

• Systematic review: a form of academic study that assesses the current state of literature in a field by searching for all published literature on a given subject and assessing the results according to a preregistered criteria, with the aim of producing the best overview of the available evidence.

• Peer review: evaluation of an academic work by experts, a necessary precondition for academic publishing.

• The Cass Review: a four year independent process chaired by Hilary Cass, which examined the NHS care for gender-questioning children and young people and delivered its findings in a final report. As part of that process, the Cass Review commissioned multiple peer-reviewed systematic reviews, which were conducted by the University of York.

Throughout the original piece, the authors shift confusingly between attacking the overall process of the Cass Review itself, the final report of the review, and the peer-reviewed systematic reviews it commissioned. Hopefully the distinctions between these will be clear in what follows.

The Cass Review sets an unattainable standard of evidence

The foundational claim of the NEJM article is the following:

The Review calls for evidentiary standards for GAC [gender-affirming care] that are not applied elsewhere in pediatric medicine. Embracing RCTs [randomized-controlled trials] as the standard, it finds only 2 of 51 puberty-blocker and 1 of 53 hormone studies to be high-quality.

Unfortunately, this is all completely false.

In this instance, they are referencing the York systematic reviews which assessed the evidence base on puberty blockers and hormones:

• The puberty blockers review assessed 50 studies, of which one was high quality - and this was a cross-sectional study, not an RCT.

• The hormones review assessed 53 studies, of which one was high quality - and this was a cohort study, not an RCT.

• Both reviews also considered moderate quality studies (25 and 33 respectively).

In this short quote, the authors get the total number of studies wrong, the number of high quality studies wrong, the standard of evidence wrong, and the requirement for randomized-controlled trials wrong.

This is quite a lot of wrong in a short passage, but without this claim, much of the rest of the article falls apart. The authors insist half a dozen times throughout the article that the Cass Review is holding gender medicine to a “higher standard” than other fields, which is based on this completely false premise - the reviews used an entirely attainable standard (as evidenced by more than half of the papers assessed meeting that moderate/high standard), and there was no requirement for RCTs. This is the sort of very basic fact checking you should expect a piece would be subjected to before being published by NEJM - this isn’t a matter of opinion, it is outright misrepresentation of peer-reviewed research.

This claim of an overly high standard is the basis of other allegations against the Review in the article. For example, the authors claim the Cass Review somehow violates pharmaceutical procurement policy by demanding unattainably high standards:

More generally, the Review’s circumscribed approach to drug approvals is out of step with pharmaceutical law and policy in both the United Kingdom and the United States. […] Former Chancellor Jeremy Hunt’s plans for MHRA to implement the “quickest, simplest regulatory approval in the world for companies seeking rapid market access” conflicts with the evidentiary standards the Cass Review endorses for GAC. Similarly, U.S. law often does not require randomized trials showing a clinical benefit of drugs before approval

But since the Cass Review didn’t specify onerous requirements or demand RCTs, this whole argument is irrelevant.

Still, having falsely decided that the peer-reviewed systematic reviews applied an unattainable standard, the authors go on to speculate this was because the final report of the review was not itself a peer-reviewed scientific publication:

The report’s application of a heightened evidentiary standard probably stems in part from its deviation from standard medical scientific process. Specifically, it lacked peer review

Once more, the authors have shifted target, applying their (wrong) criticism of the York systematic reviews to the final report of the Cass Review. But since their criticism of the peer-reviewed research was incorrect in the first place, none of this follows, and claims of deviation from “standard medical scientific process” is just empty hyperbole.

The authors then claim that - since the final report was not a peer-reviewed publication, it would violate US federal law:

The U.S. Information Quality Act requires peer review for government-published scientific information that “will have or does have a clear and substantial impact on important public policies or private sector decisions.”³ Yet the Cass Review and its principal conclusions that made international headlines were not verified by experts. The Review thus departed from standard practice; indeed, as mentioned above, if the U.S. government issued a report in a similar manner, it would be violating federal law.

The citation here is a federal rule about science commissioned by the US government requiring peer-review. Any federal agency producing its own research internally or communicating scientific data to the public has to be subjected to some level of peer review.

So this is a hypothetical application of a US rule for government-published science - but that’s not what the Cass Review was. It was an independent service review commissioned by NHS England, not a government publication - and the science it commissioned is all peer-reviewed, and published in the British Medical Journal.

The Cass Review was more than a single document, it was a four-year process, chaired by Hilary Cass, and its final report is not “scientific information disseminated by the government”, but rather the conclusions and recommendations of that independent review to NHS England, which summarises the findings of multiple peer-reviewed papers it commissioned as part of that process.

The conclusions were indeed “verified by experts”, because these are the conclusions of the peer-reviewed systematic reviews, and this was fed back to NHS England to inform future service provision. These were then further “verified by experts” because independent medical bodies, including NHS Scotland, further assessed the review’s findings and endorsed them. The idea that you can apply the requirements of US federal bureaucracy to this sort of independent service review and then argue it would “violate federal law” is simply bizarre.

The authors make completely baseless assertions about what “standard practice” is, while conflating multiple aspects of the review, and inventing an inapplicable standard as an excuse to condemn the Cass Review as a whole.

The Cass Review is biased

On top of the fundamental errors and straw man arguments, there is also an unhealthy amount of conspiracism and mudslinging:

observers must speculate about who else participated in the manuscript’s drafting — and whether they held bias against LGBTQ+ people. […] There is evidence of antitransgender bias in invitations to oversee and participate in the report. […] Cass and her colleagues did not attempt to filter out people with antitransgender bias.² Indeed, according to the Review, a third of health professionals whom the authors chose to interview agreed that “there is no such thing as a trans child.”²

To support this the authors cite Cal Horton’s critique of the interim report (which I previously discussed here), but the ultimate source of this claim is the clinical engagement process undertaken as part of the review. I have to wonder if the authors of this piece even checked Horton’s claims, or simply took the description there at face value, and further selectively presented it here as (shock, horror) evidence of bias in the Review.

The Cass Review conducted multiple sessions of stakeholder engagement over the course of its four years. As well as a clinical expert group of NHS Trust nominees, and a panel of 33 specialist gender clinicians, 102 primary and secondary care workers outside of gender services were involved in multiple panel sessions.

Of these, the fourth independent activity involved 66 participants, and the following survey was conducted:

These questions represent different positions on a spectrum of interpretation of “gender distress” and are described in the review document as intentionally worded to prompt discussion among participants:

From this we see that the overwhelming view of clinicians is that gender distress is a symptom, and that it is important to identify and address underlying causes. From a clinical perspective, starting from the point of view that a child who presents with gender distress is, in some fundamental way, a “trans child” forecloses alternative explanations. There are obvious clinical disagreements as to how to interpret and diagnose a child presenting with “gender distress”, but broad agreement on an open-minded and exploratory approach.

The NEJM authors however are of the opinion that holding any view other than theirs is “anti-transgender bias”. What they seek is to exclude other clinical perspectives they disagree with - to “filter out” what they see as bias - based on a single-minded belief that their own position is the only correct one, and they criticise the Cass Review for not doing so. But the whole point of sessions like this is to gauge the true scope of clinical disagreement. Deciding up front what answer you want to get is not science, and this is why it is so important that independent reviews such as this are indeed conducted independently, and not by those with a vested interest in a particular outcome.

And, one more nitpick - this is not “a third of health professionals whom the authors chose to interview”, but rather as this was the outcome of one activity, involving only a subset of professionals interviewed, it is actually 15% of the total.

The Cass Review was methodologically flawed

Despite only being a short perspective piece, the authors pepper the article with a Gish Gallop through some claims from critics of the review, none of which stands up:

Commentators also point out that the Review (and associated studies) misrepresented the data behind its conclusions,¹ had both a high risk of bias according to the Risk of Bias Assessment Tool for Systematic Reviews (ROBIS) and a “substandard level of scientific rigor,”¹ and improperly excluded non-English articles, “gray literature” (non–peer-reviewed articles and documents), and other articles not identified by its simplistic search strategy.¹

Shifting target yet again, the criticism they are referring to in this passage is all directed at the nine peer-reviewed publications by York University commissioned by Cass, rather than the final report. These claims are all derived from a Yale white paper/amicus brief, which itself depends on a preprint paper, both of which I have previously written about. I won’t repeat myself at length here, but suffice to say none of the points made in the above paragraph should be taken at face value. Aside from anything else, rather than being “simplistic”, the York reviews performed the most comprehensive literature search of any systematic review in this area.

But I will point out the hypocrisy that, having complained throughout this article that the Cass Review’s final report wasn’t “peer-reviewed”, what this paragraph actually does is repeat weak, false and misleading arguments from a non-peer-reviewed white paper, which itself cites a non-peer-reviewed preprint paper, to criticise the actually peer-reviewed literature commissioned by the Cass Review.

The effect of citing these claims here is to get weak arguments from sources which are not peer-reviewed and not published in any reputable journal, platformed without serious scrutiny by the NEJM.

Bonus sexism

Having made a poor case against the Cass Review, the authors several times emphasise that they must be on the right side of history by waving vaguely at gender equality and claiming that disagreement must be propping up “gender norms”. This makes little sense, and as presented here really does highlight how gender studies theorising has become a hollow cargo cult of feminism, with the recitation of thought-terminating cliches and shallow buzzwords taking the place of serious insight and analysis. For example:

Moreover, similar calls for higher standards are not applied to cisgender young people receiving gender-affirming care. Cisgender girls sometimes seek hormone therapy for hirsutism;

That the authors interpret girls receiving hormone therapy for hirsutism as “gender-affirming” is highly revealing. It is a concession that girls should be hair-free, as that is indicative of a feminine gender, and thus by removing hair hormonally, this act becomes gender-affirming.

This demonstrates how deeply sexist this worldview and obsession with gender affirmation is, viewing every act through the narrow prism of aspirations towards masculinity or femininity.

Medicine has long been deployed by people seeking to enforce gender norms.

Yes it has, and one such example would be referring to medical treatment for female hirsutism as “gender-affirming”.

Then there is this:

The Review’s departure from the evidentiary and procedural standards of medical law, policy, and practice can be understood best in the context of the history of leveraging medicine to police gender norms. Recent efforts to increase the presence of women in medicine, improve access to reproductive services, and offer GAC seek to break from that history, but the Cass Review represents a return to the past.

Just so we are absolutely clear, this is a perspective piece by two men, criticising a four-year independent review led by a woman, which commissioned a whole series of peer-reviewed systematic reviews, all also written by women, as somehow a setback in “efforts to increase the presence of women in medicine”.

The authors end on a manipulative mashup of the abortion and intersex gambit, both so beloved of those with no real arguments left. Agree with our position, or you must be anti-abortion:

Mainstream medical views have shifted on both abortion access and care of intersex people. But the Cass Review suggests that some actors continue to focus on policing gender in the context of transgender rights. Indeed, U.S. GAC bans exempt intersex surgeries — which suggests that such laws are designed not to protect children, but to enforce the gender binary. The Cass Review’s unacceptable departures from medical law and policy are best understood in a similar way.

Bans on abortion are bad, therefore… the Cass Review must be? The Cass Review commissioning systematic reviews which found an appallingly weak evidence base for medical interventions on children is… enforcing the gender binary, and that’s the same as patriarchal control over female reproduction? It. Does. Not. Make. Sense.

Conclusion

The opening paragraph of this article in NEJM reveals what I believe to be the real concerns of the authors, and what lies at the root of all of the attacks on the Cass Review emanating from the US:

in the United States, the Cass Review has been used to defend new state bans on GAC for young people — including one in Tennessee that currently sits before the U.S. Supreme Court.

The US is so deeply politically divided, even more so now, and whether or not it is ethical and evidence-based to medically intervene in the normal development on vulnerable, mostly gay children is not being decided through the scientific method, but playing out in the courts. A partisan, political divide where how you interpret the evidence decides which political team you must be batting for - and, conversely, which side you support determines what the evidence must be. That the authors manage to tie their position to abortion cements how deeply interconnected these issues are in US political terms, despite having nothing whatsoever in common.

Within these polarised court battles and political posturing, there really is no room to manoeuvre, and no space to concede that the Cass Review may have a point. The Review’s cautious approach to the evidence for paediatric transition offer a stark rebuttal to those arguing in court that this is a robust, safe and evidence-based practice. Unable to produce better evidence, advocates have been left with no alternative than to attempt to undermine the Cass Review. It has to be condemned and discredited, and so we get contributions such as this, published complete with obvious, foundational errors in the NEJM.

There is nothing wrong with the authors having a strong opinion on what they call “gender-affirmative care”. There is nothing wrong with the NEJM publishing that opinion, as part of the cut and thrust of academic disagreement. But that is not what this is - it is a shabby attack on the Cass Review, a recitation of activist talking points in service of a wider political agenda, and one in which the NEJM is an all-too-willing participant. The Cass Review has to be destroyed, for The Greater Good.

In Amusing Ourselves to Death, Neil Postman described how societies are shaped by their communication medium, with technological advances affording new ways to organise society, transmitting information with greater fidelity, more rapidly, over longer distances, or preserving it in ever more accessible forms for future generations.

With the advent of television, not only have we become fixated on news-as-entertainment, but the transmission of information has become bound up with the seductive disinformation of advertising. The commercial realities of broadcasting dictate the content, and not the quality or truth of the information presented. What grabs eyeballs and sells products is what survives in this marketplace. The medium and the message are inseparable, with the kinds of communication possible defined by the medium, which also governs the way that information is perceived, promoting new ways of thinking.

What social media presents to us is a continual stream of new, distracting information, all competing for our attention. I’ve critiqued previously what social media is and how it works, as a mechanism for provoking engagement and meaningless interaction, constantly generating a frothing sea of novelty to be used by the platform to steal ever more attention from its users. What governs the “Success” of this information has nothing to do with its worth as a concept, its quality, its ability to enrich human understanding, but simply how effectively it can grab the attention of our fallible, limited ape brains.

For the unfamiliar, in the Pixar movie “Up”, Doug is a delightfully friendly golden retriever, who is regularly distracted mid-sentence at the possibility of having seen a imaginary squirrel.

Social media is a medium for presenting to every one of its users a continually optimised marketplace of squirrels, a constant stream of distractions, generating actions that can be used to distract other users, generating further distraction, and all of it built on the necessity of new information. It is governed by the same commercial realities as television before it, monetising our attention more directly and precisely than ever before.

The immediacy of this experience is perhaps most representative of how society has become structured around these communication media. Our constant craving for new distractions is reflective of how capitalist logic has become invisibly ingrained in our understanding of the world, with its constant need for growth and expansion. We need new products to replace the old. We need new distractions once the old ones wear off. We need new knowledge, because the old is outdated, fusty, deprecated, supplanted. And that knowledge is tied up, via the unconscious appeal of advertising, with those aspects humans find irresistible: youth and beauty.

We demand novelty, mistaking it for progress. We defer to the next generation as those bringing in the better, cleaner, version 2.0 knowledge that will supplant the old, bug-ridden mistakes of the past.

Perversely, as the amount of information humanity produces has increased and our capacity to store it permanently has become effectively infinite, our communication media has become ever more ephemeral. Knowledge has lost permanence, replaced by news, and comment, and ever more news and comment, until all there is is a mindless repetition of slogans, polarised conflict kept perpetually "fresh" by the roiling sea of instantaneous newsfeeds.

Our context-free, on-demand communication media has created a permanent now. While in 1984, Big Brother controlled the past to control the future, here we are descending into a seductive immanence, a perpetual presentism, with the past denigrated and ignored and recast at every moment to service whatever immediate attention-seeking gratification is required, while the future is always one emotional tantrum, one impotent howl at the injustice of the world away from being brought into being.

It has always been the case that, if your perspective isn't written down and preserved and cited, it doesn't exist. Now, it needs not merely to be recorded, it needs to be repeated, and repeated, and repeated, lest it drop out of sight. We have somehow gone from an oral history, to a written one, full circle to an oral one again, with social media the campfire we tell each other wild tales around, believing them to be true in the moment. Things which go without saying, go unsaid. They don’t make headlines, and they aren’t published or preserved in academic journals. They have to be stated and restated over and over or they don’t appear in our newsfeed, becoming less fresh, less new, less attractive, less true. They corrode over time, not transformed into established wisdom, but old news. Not something to be built on, but something worn out to be replaced.

Our communication systems are built to give us the most up to date information, what’s new, what’s popular, what everyone else believes. The top sponsored search results and nothing else. The first response to a question from an AI trained by looking at this already flawed view of ourselves. Our sophisticated technology allows us simultaneously to record everything, while remembering none of it. As we revert to an oral tradition, perhaps AI will become our Shamens, the keepers of the definitive stories, letting us know what is true today, reshaping a past we have no commercial use for to reinvent our present.

This is an issue that goes far beyond simply social media, or phones, or any other of the convenient scapegoats for the state of society, but is I think now deeply embedded in how we now understand and make sense of the world.

Perhaps we can find a way to communicate ideas regardless of how attractive or commercially viable they are. Communication systems that aren’t built to determine truth by popularity and engagement. An academic discipline dedicated to the speaking of unspoken truths, a repetition of that which doesn’t bear repeating, just to remind us that nothing has changed. A journal of Stating The Bleeding Obvious.

It is hardly controversial to state that readers become emotionally invested in novels and poetry, that viewers are moved to tears by films and television, and our joys and heartbreaks can be reflected back to us by songs. But at the same time, people who don’t play video games tend to look down on them as unserious toys, a vapid activity for children or emotionally stunted adults who need to grow up.

One of the most powerful and affecting experiences I’ve ever with any media, of any sort, I had while playing a video game called Rime, which released in 2017. I cannot describe the impact without spoiling it completely, so if Rime is a game you ever plan to play, please, do yourself a huge favour, and stop reading here. It is short, and not difficult, and it is best to go in absolutely blind. The rest of this piece will ruin the experience for you, so you have been warned.

Superficially, Rime is a puzzle game, with a beautiful visual style influenced by Spanish artists like Joaquín Sorolla. In it, you take on the role of a boy, with a tattered piece of red cloth for a cape, who has been shipwrecked in a mysterious land and is searching for his father. That is how it presents itself at first.

Each of the game’s levels - and there are only five - is marked with a tonal shift, with different mechanics that come into play and force you to learn new approaches and solve new kinds of problems. However, while it seems at first to be a light and simplistic platforming and puzzle game, as it unfolds Rime reveals itself to be an absolute masterclass in design and storytelling.

What only becomes apparent towards the end is that the entire game is an allegory, and each of the five levels represents a stage of grief. The mechanics of each level each in some way a reflection of that stage. The first level, Denial, filled with distractions and pointless achievements, and puzzles that divert you time and again from your true path. The second, Anger, where you are beset at every turn by a giant winged beast who dives on you every time you dare step into the light, and puzzle you solve as you progress fills the sky with more and more turbulent stormclouds. The third, Bargaining, where puzzles require the cooperation of gigantic walking machines, and all the while the architecture of the world seems to shift and confuse and confound progress. The fourth, Depression, where the world turns black and rain-slick, and none of the techniques and mechanics you have learned along the way seem to work, everything seems futile, walking is slow and difficult, and shadows close in and constantly sap the life out of your character.

It is only when you reach the last level, Acceptance, that so much of what has come before really slots into place. You suddenly find yourself no longer the boy, but the father, whose journey through bereavement the entire game up to this point represented. As your character sits in desolation in his child’s empty bedroom, holding on to that small tattered piece of red cloth, you are forced to press a single button to perform the final act that the game demands of you: let go.

I wept when I finished this, and seven years later I still think about it.

Games are a uniquely powerful form of immersive fiction, specifically because they demand active participation. For players willing to invest themselves in the experience, the emotional impact of being directly involved in storytelling like this cannot be underestimated.

While emotionally affecting, the characters in Rime are practically ciphers in and of themselves, placeholders onto which a narrative can be projected. In Rime, the emotional narrative itself is the point, rather than the characters, which helps make the impact universal and personal.

Other games are more cinematic in their experience, with a central character that the player can roleplay, from Aloy to Geralt to Nathan Drake. Here the experience is mediated somewhat by that more sharply-defined character, and while the game itself may be exciting, the player is under no illusion that they are that character. Still, players see aspects of themselves - or how they idealise themselves - in the way they experience these games, in a more directly personal way than fans who idolise characters and actors in Hollywood movies. While we may see an attractive, charismatic star on screen and wish we could be part of their celebrity orbit, that we could be like them, that we could be them, games offer a much more direct relationship. Games place control in the player’s hands, allowing the player to move and manipulate this character, posing them, taking pictures, sharing exciting moments with them over and over.

But the most complex and immersive experiences are those where the actual character in the game is intended to be a representation of ourselves, a customisable avatar, sculpted to suit our own desires. As technology and connectivity have advanced, so too more open-ended and collaborative storytelling has become possible. Where players make themselves anew in the game, and live through whatever experiences the game has to offer as their own stories and adventures. The line between in-world character and our real self outside it blurs and shifts as the possibilities enabled by more computing power advances.

How we relate to these digital avatars varies wildly from situation to situation and from person to person. Is it an extension of myself in the digital game world, an entirely different role I enjoy play-acting within that space, or a mere puppet I have no attachment to whatsoever? Am I making the avatar do my bidding as I watch the results at an emotional remove, perhaps even with disdain or contempt? Do I treat this virtual self with love, and experience its interactions viscerally and personally? Do I create multiple “selves” and treat them differently, just to experience the full variety this game world has to offer?

It reveals a complexity in what we think of as our identities, our ability to simultaneously present a multiplicity of selves, varying by context. What we do in a game world both is and is not “us”, and as the variety and fidelity offered by technological advances have increased, so too has the possibilities of tailoring that digital avatar in ways that transcend our personal limitations. Games can offer a playground to explore alternate selves, alternate possibilities of how to “be”, personalised avatars to which we can form deep attachments - and sometimes that attachment can spill out into the real world.

As people try to make sense of the various ills of the modern world - rising isolation and depression among youth in particular - much attention is rightly given to social media, to adverts, to unrealistic beauty standards, to a plague of handheld devices turning humans away from each other and seeking solace in screens and virtual lives in an epidemic of anxiety and loneliness. So many of us now live our lives embedded in markets and surrounded by media all creating a gnawing sense of inadequacy, while selling back whatever product or service might finally unlock your full potential, to live your best life, to be your best self.

Right now, there is no more seductive and immersive virtual embodiment than gaming.

Dragon Age: The Veilguard is one such recent game which finds itself at the centre of controversy for its shoehorning of contemporary sex and gender issues in the US onto a fantasy world where such things feel out of place. As with most similar games, the game’s character creator offers a huge amount of customisation and tailoring of the in-game avatar.

Body size and shape, hairstyle, scars and tattoos, the possibilities are mind—boggling, and you can sculpt your in-game avatar to your heart’s desire.

However, one notable addition in this latest iteration of the Dragon Age series is a specific option to enable “top surgery” scars.

How we think about this says a lot about how “culture” works, how ideas are normalised and propagated, until they become an unquestioned part of society. “Top surgery” itself is a cutesy euphemism for “radical surgery to remove healthy breast tissue to superficially masculinise female bodies”, and that is without getting into the contested and controversial area of why it is being done in the first place. This would not have been acceptable in any way just a few short years ago.

A toggle for “self-harm scars” would not be acceptable, would it? But if not, why not, and for how long? Maybe today we would recognise that glorification of self-harm will lead to further self-harm in the real world - but where would we be if some prevailing section of Western culture decided that “self-harming” is a stigmatised identity, and as such should be authentically represented in a drive for inclusivity and representation? These rapid shifts to sanitised language and public adulation of the formerly unthinkable demonstrate the malleability of social norms, and it is impossible to say with any certainty what is not acceptable now won’t be celebrated next year.

Is it wrong to find this concerning? Is saying it is grotesque merely a moral panic, the latest in the long line of overreactions to depravity and violence in video games?

These aren’t things that have arisen naturally and unobtrusively from the game world itself, but are a projection of present-day cultural obsessions onto it. For some, the possibility of creating an in-game representation as wish-fulfilment is seductive, and having options such as this have every possibility of becoming fixations that are ultimately harmful - yet the politics behind such choices prevents anyone involved in the process from pointing at or describing that harm.

There is a growing relationship between crafting idealised digital avatars in video games and attempting to fashion an idealised version of ourselves in the real world, as in this 2018 piece in Vice:

During my adolescence, I spent hours of every day in other worlds. I have had many bodies, many names, and many lifetimes. The sorceress I played on Diablo II was just lines of code on a computer […] she has since been reborn again and again in other black mirrors, on other platforms, in other games.

The boy in the mirror is gone, my mother’s stained-glass lily still resting on his chest. And I have become someone much more like that sorceress that I met when I was a child. My hair looks like hers. My body, too. […] I was growing up in a male body, and, while I felt completely in charge online, I had little control over my offline life. Unable to wear what I wanted, to look how I wanted, to be seen by others as I saw myself, I felt detached from myself

The line between fantasy and impossible reality is not merely being blurred here. Rather, such fantasies are treated as proof of their own reality, where playful ideas have become fixations, and the impossible becomes a constant insatiable quest for perfection of an idealised self.

These days the game itself is no longer the game, but merely part of a larger experience, a vast interconnected community. When a specific way of viewing the world is embedded in games and all the connected and supporting platforms all at once - in Twitch’s terms of service, in bans by Reddit admins and Discord mods for stepping out of line, in sanctions on Tiktok or Instagram or Youtube - it becomes a powerful closed system for circulating and enforcing specific ideas about how and who to be. Rather than seeing any cause for concern, modern obsessions around sex and gender are treated universally in this ecosystem as a righteous crusade for liberation and autonomy, and questioning whether stories like the above have any other legitimate interpretation has become unacceptable and unsayable.

We live in an increasingly alienated world, fuelled by a dominant capitalist ethos that fixates on crafting some idealised version of the self as the pinnacle of human liberty. At every turn dangling the possibility of some perfect level of self-realisation, self-actualisation, freedom and liberation, transcending your meagre existence, where the only thing holding you back is your own drive and will to assert dominion, take control of your own life.

In that context, the escapism offered by gaming has moved far beyond some trivial pastime, and is now a multi-billion dollar global industry that makes more money than movies and music combined. Moreover, this industry is in a unique position to influence culture, not only because of the youth of the primary demographics of players, but also the strength of attachment it is possible to feel with in-game avatars. This is especially true for those most vulnerable players, the awkward and isolated, the anxious, the autistic, the depressed and lonely, for whom games offer a lifeline to a form of connection that can seem impossible in the real world.

Humans are malleable, social animals, adaptable, storytellers and story-believers, and we have the ability to swiftly reshape our behaviour - or have that behaviour reshaped - through shifting cultural norms. Games have the power to tell us stories in a way that can immerse us and affect us more deeply than any other media. In ideological hands they can do great harm as a vehicle for spreading and normalising a narrow view of the world as the “true” way. But in the hands of artists, like the creators of Rime, they can open us up to new perspectives and hold a mirror up to the human condition in ways limited only by our imagination.

In May 2024, The Southern Poverty Law Centre (SPLC) added the Society for Evidence Based Gender Medicine (SEGM) and Genspect to its list of hate groups.

Unsealed evidence in the US court case Boe vs Marshall (dealing with access to paediatric transition) earlier this year contained snippets of internal WPATH emails revealing their concern over academic critics like SEGM:

I think we need a more detailed defense that we can use that can respond to academic critics and that can be used in the many court cases that will be coming up. […] we know that some of the studies we have cited in support of our recommendations will be torn about by organizations such as the Society for Evidence Based Gender Medicine.

SPLC are representing the plaintiffs in this case, so at the same time as they are waging a legal campaign which relies on WPATH’s evidence, they are also formally designating groups who WPATH privately fear will tear apart that evidence as “hate groups”. Rather than being impartial and evidence-based designations these labels are little more than reputational attacks as part of an ongoing legal strategy in the highly polarised political landscape in the US.

The more US-based lobbyists can publicly discredit SEGM, the more suspicion can be cast on anyone with any connection to them, any evidence they produce, and now on the findings of the Cass Review. The fact is that the Cass Review’s damning assessment of the evidence for the efficacy and safety of puberty blockers fatally undermines legal cases based on arguing the opposite. The Cass Review is already being cited by their Republican opponents, so in the absence of any actual response grounded in evidence, SPLC’s huge resources are turned to an international smear campaign - one that is exemplified by their CAPTAIN report, which as I’ve previously discussed is built on an echo chamber of activist groupthink and conspiracist logic.

SPLC’s attacks on SEGM serve as a foundation for critical commentary directed against the Cass Review. Since the release of that report - and the later “hate group” designation that it led to - links between SEGM and the Cass Review have been played up in media reports, and by activists like Erin Reed in an effort to undermine public reception of Cass’ findings:

Most recently, members of the newly designated hate group, Society for Evidence-Based Gender Medicine, helped advise the Cass Review in the United Kingdom,

This week, Reed brought further focus on the NHS, complaining that several clinicians connected to the Cass Review will be speaking at the 2024 SEGM conference in Athens. This article has also been reposted by The Lemkin Institute for Genocide Prevention.

Three times in this piece Reed draws attention to SEGM’s “shared funding streams” with the far right:

Notably, SEGM’s funding streams include the same groups that fund the Heritage Foundation, the Alliance Defending Freedom, and the Family Research Council, far-right organizations capitalizing on Christian nationalism.

The source for this is SPLC’s CAPTAIN report, where the basis of this allegation is that in 2020 and 2021 SEGM received donations from four large charitable foundations - American Online Giving Foundation, Fidelity Investments, Vanguard, and the Edward Charles Foundation - which have also either a) received money from bad actors or b) donated money to bad actors:

a large part of SEGM’s funding in 2020 came through a $100,000 donation from the Edward Charles Foundation

…

Analyses of additional financial records from 2021 reveal that SEGM’s total revenue nearly quadrupled from the previous year to nearly $800,000, and that funding appears to have come primarily from donor advised funds. The largest contribution, which came from Fidelity Investments Charitable Gift Fund, totals over $350,000. Notably, Fidelity and Vanguard Charitable Endowment Program (which also donated to SEGM in 2021) have a history of directing money to anti-LGBTQ+ groups, such as the Alliance Defending Freedom and the Family Research Council.

…

[In 2020] In addition to Heritage Foundation, that year, the Charles Koch Institute contributed […] $1.3 million to the Edward Charles Foundation (which funded SEGM that year).

So, taking the Edward Charles Foundation as an example, SPLC cannot outright say something like “SEGM are funded by the Koch Institute” - because there is no evidence of that. All they can say is that in the same tax year as the Edward Charles Foundation received $1.3 million from Koch, the Edward Charles Foundation gave $100k to SEGM. That’s all - and all they do is present these numbers near each other, and thereby strongly imply a financial connection between the Heritage Foundation and SEGM, without actually saying so - which then, in the hands of activists like Reed becomes definitive. There’s nothing here but insinuation - and seemingly false, since according to this Undark report, it was an individual donor who gave money via the Edward Charles Foundation, who simply wishes to remain anonymous:

The donor, a 68-year-old woman from California who asked to remain anonymous because she feared harassment, described herself as a non-religious feminist who had supported Barack Obama and Hillary Clinton.

However, in the case of American Online Giving Foundation, Fidelity Investments and Vanguard the accusation of “shared funding streams” becomes quite staggering hypocrisy. These are huge foundations, collectively worth $21 billion annually, that make thousands and thousands of donations every year, not only to dubious organisations like Alliance Defending Freedom or Family Research Council, but also to SPLC themselves.

• In 2020/21 the Fidelity Investments Charitable Gift Fund gave SEGM $363,500, while also giving SPLC $4,065,459. 

• In 2020/21 Vanguard gave SEGM $22,000 and SPLC 45 times more: $1,084,650

• In 2020/21, The American Online Giving Foundation gave SEGM just $15,201 and SPLC over 130 times more: $1,995,272

And while those much smaller donations to SEGM appear to be one-offs, SPLC have received similar amounts in preceding and subsequent years. Over the past three years, SPLC have received $22 million from these three foundations alone. If receiving grants from these foundations constitutes “shared funding streams” with the far right, as Erin Reed describes it, then the same is true many, many times over of SPLC.

The origin of these claims of "shared funding” go back to the highly conspiracist posts of Health Liberation Now, the activist co-authors of the CAPTAIN report, who cite themselves for these claims in the report itself. Originally they had SEGM in their sights, so I doubt they checked whether their conspiracist logic would apply to SPLC - but in December 2023, when SPLC gave their official stamp to this “research” - and the ensuing “hate group” designation - did they not realise they were implicating themselves?

There’s two possibilities. Either SPLC did not verify this information, in spite of their near-limitless financial resources, in which case why should anybody take anything they say seriously given this level of incompetence? Alternatively, they do know that these allegations of shared funding streams are far more applicable to themselves, in which case this is pure deceit on their part.

There are millions sloshing about in opaque funds, with wealthy US philanthropists funnelling money to pet causes or exploiting tax breaks, and SPLC is one of the fattest pigs at the trough, with three-quarters of a billion dollars in reserve, which they are now using to baselessly smear the reputations of clinicians in the UK in service of an ideological legal agenda in the US.

I think that anyone seeking to understand and address the misinformation and disinformation currently being spread about the Cass Review need to take a long look at the incredibly well-financed activists in the US who have been successfully traducing tiny organisations and blameless individuals, with no serious opposition, for years. As with feminist targets before, these attacks don’t stop at the door of SEGM - they spread, by relentless guilt-by-association, to contaminate absolutely everyone who touches them, or anyone connected to them. Unchecked claims like this are toxic to public discourse, spreading and gaining traction with zero corrective force, creating an unwarranted chilling effect around their targets. Bystanders are quick to believe there is no smoke without fire, and UK clinicians cannot realistically defend their reputations from this sort of partisan dreck from the US. Blandly wondering why the Cass Review has been “largely ignored” in the US misses the point - it is not merely being ignored, it is actively being undermined.

However, while the dissent has been widely covered, what has not really received sufficient attention is the evidence they based this decision on.

In the statement, they make two citations:

• A preprint paper titled “Critically appraising the Cass Review“

• A white paper from the self-styled “Yale Integrity Project” titled “An evidence based critique of the Cass Review”

This is the entire basis on which 21 members of the BMA’s council voted to publicly critique the Cass Review, and bring the entire BMA into disrepute.

Neither of these is a peer-reviewed publication and both are extraordinarily bad in a number of ways, none of which inspires much confidence in the objectivity and reasonableness of those who used them to push this decision onto the BMA.

Both are also a continuation of the process of deeply interconnected source laundering I have already documented here, all produced in service of attacking and discrediting any and all evidence that does not support the so-called “affirmative model”. These are simply the next iteration of an existing echo chamber of interconnected activists all repeating each others’ talking points in a variety of venues, giving the illusion of breadth and independence. That the BMA council has now lent these arguments credence is an embarrassment to the organisation.

An Evidence Based Critique of the Cass Review

The first document offered in evidence is from the Yale Integrity Project. This is a small group set up as part of the Yale School of Law with the express purpose of opposing bans on youth medical transition in the US. It starts from the position that such bans are the result of the spread of “disinformation”, which it seeks to counter. It has given evidence in legal cases in the US in favour of the “gender-affirming” model and published reports attacking the reputation and credibility of clinicians and academics with a different point of view, and downplaying uncertainty.

In 2022, the principal authors (Meredithe McNamara and Anne Allstott, founders of the Yale Integrity Project) released a similar white paper criticising the Society for Evidence-Based Gender Medicine and cherry-picking positive evidence to downplay potential desistance, regret and social contagion among adolescent transitioners, and an unprecedented rise in teenage girls adopting a trans identity.

To give an idea of how all this scholarship is being used, a June 2024 paper was authored by Meredithe McNamara, Anne Allsott and Quinnehtukqut McLamore titled “A thematic analysis of disinformation in gender-affirming healthcare bans in the United States”. This builds on and cites this earlier document, repeating many of these lines, as well as citing six papers authored or co-authored by Florence Ashley, all intended to cast doubt on themes of desistance and social contagion, and to claim the unethicality of attempting to gather better evidence for treatment efficacy. The paper brands claims like the following as disinformation:

• “Many of the children who undergo these procedures have other psychological problems, like attention deficit hyperactivity disorder and autism.”

• “The manifestation of gender dysphoria in adolescents is a relatively new phenomenon. […] Those presenting as adolescents are ‘predominately biologically female.”

• “While you refer to these procedures as ‘sex changes,’ it is important to note that it remains medically impossible to truly change the sex of an individual”

• “systematic reviews from multiple European nations – where similar interventions have been studied – have shocked those nations’ medical professionals and led to greater restrictions on the medical interventions”

And so on. Unfortunately, the Cass Review drives a coach and horses through this, as it substantiates the position that all of the above are completely true, based on the most comprehensive systematic reviews of the peer-reviewed evidence to date. In order to further the project’s stated goals, the Cass Review has to be discredited.

This new Yale Integrity Project document has to be seen in that light. This is not an impartial, non-partisan assessment, but a highly motivated one from a group of activists with a view on helping defend against legal bans on youth medical transition in the US, which so far have been waged with skewed and selective presentation of the evidence and branding contrary positions as “disinformation” and those who point to them “hate groups”.

Other citations of this Yale white paper include:

• Cal Horton’s “The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children” (which I discussed previously, and I'll note again here gave thanks to Quinnehtukqut McLamore for input)

• A paper published in WPATH’s own journal titled “Biological and psychosocial evidence in the Cass Review: a critical commentary” by D. M. Grijseels, which also thanks Quinnehtukqut McLamore for input, and also cites Cal Horton’s paper, above.

As for substantive criticisms of this white paper, there are almost too many to mention. Jesse Singal has produced two long and forensic critiques of this white paper, and is still only halfway through it.

There are too many issues to go into detail here, but one example to illustrate the level of problems. The Yale team make much of the fact that the York systematic reviews employed a “modified” version of the Newcastle-Ottowa Scale (NOS) for evaluating studies:

Furthermore, the York SR team did not implement the NOS as it is presented by its authors. They modified the scale in an arbitrary way that permitted the exclusion of studies from further consideration, for reasons irrelevant to clinical care. For instance, in the York SR on social transition, the modified NOS asked if study samples were “truly representative of the average child or adolescent with gender dysphoria.” There is no such thing as the “average child or adolescent with gender dysphoria” —this is an inexpertly devised and meaningless concept that is neither defined by the authors nor used in clinical research. And yet it was grounds for excluding several important studies from consideration.

However, this is an utterly specious claim. The modification simply clarified the criteria for this specific case, which is absolutely standard when using the NOS (as can be seen in plenty of other instances). So where NOS Q1 says:

• 1) Representativeness of the exposed cohort

  • a) Truly representative (one star)

The York researchers expanded this to define "truly representative" in this instance:

• 1) Representativeness of the paediatric gender dysphoric group Score 1 if:

  • a) truly representative of the average child or adolescent with gender dysphoria / incongruence, e.g., nationally representative community sample, population-based medical database, national gender service, multiple gender services covering different localities

So the Yale team complain both that NOS was "modified", and that "average" is undefined, but the modification the York team made here was a common one and explicitly defines what "average" means in this context. It is just a test that means that the sample was drawn from a broad enough base (national, or geographically distributed) that it is representative of the population as a whole, on average. So studies which don't meet that standard - eg. single clinics, self-selected samples - just had a lower quality score. The authors try to imply this is some sort of novel or arbitrary concept used to wrongly exclude important studies, but these objections are all just sophistry and obfuscation.

The whole document is full of this sort of thing, claims that are so wrong or tendentious that my most charitable assumption is that the members of the BMA council who were swayed by it hadn’t read the Cass Review.

Critically Appraising the Cass Review

The second citation used by the BMA is again not published in a peer-reviewed journal, but a preprint with 21 authors, some of whom will be familiar from my previous piece on source laundering by highly partisan activists. Specifically Florence Ashley (whose dozens of self-referencing academic essays are the source of claims that exploratory therapy is conversion) and - again - Quinnehtukqut McLamore (who has contributed to and co-authored many papers and partisan publications disseminating this same perspective, including the Southern Poverty Law Centre’s CAPTAIN report).

It was also co-authored by D.M. Grijeels, whose own critique of the Cass Review that I highlighted above as being cited by the Yale team is also cited in this preprint, and on top of that the Yale white paper cites this preprint as well. So we actually have three interconnected critiques of the Cass Review by the same handful of activists citing each other.

This preprint is, bluntly, badly written, full of meandering circuitous statements, handwaving and nonsense that makes it very hard to pick out any quotes because very little actually makes any sort of sense in isolation. It also, infuriatingly, refers to the Cass Review as the Cass Report throughout.

The most substantive claim made is that the preprint authors employed the ROBIS (Risk Of Bias In Systematic reviews) tool to assess the “risk of bias” in the York systematic reviews, and determined that they have a “high” risk of bias. ROBIS however is not a straightforwardly objective tool, but one intended to assist experienced systematic reviewers to navigate some subjective assessments in a consistent way, and in that light some of the grading in this preprint is arguably questionable. Comparing some of the scoring to the ROBIS guidance documentation here, it is hard to see how the assessors arrived at some of these conclusions.

For example, The York team searched five standard databases, and there is absolutely no reason to think that is inappropriate, yet were bafflingly marked down for not searching an appropriate range of databases. The preprint authors take major issue with the fact that the search was conducted in English and excluding “grey literature” (ie, white papers, unpublished results, conference papers etc), but there isn’t a compelling reason to do otherwise. Including grey literature or not is not necessarily indicative of bias under ROBIS, and grey literature can be included in a search to assess whether published work exaggerates the effectiveness of a treatment, since poor results in clinical trials sometimes languish unpublished. As for the English language selection, paediatric transition is an overwhelmingly Western phenomenon, and it is, shall we say, unlikely there is a significant piece of published research that isn’t available in English that was excluded from the search, especially since none are presented here. Far too much weight is given to the language restriction when research shows this is rarely a significant source of bias:

To lessen this possible source of bias, efforts are occasionally made to find and include non-English-language literature in systematic reviews. Nonetheless, there is some evidence that, at least in the field of conventional medicine, only incorporating English-language papers does not bias meta-analyses

Multiple reviews are marked down on this scale for not formally assessing methodological quality using appropriate criteria - but the reviews in question did in fact do so, and this all just seems to have been incorrectly scored, because the authors also devote a page to attacking the York team’s use of the Newcastle-Ottawa Scale at all, describing it as not the recommended tool for the job:

the NOS is considered a quality appraisal scale, but within systematic reviews exploring the effectiveness of interventions (which this review claims to be doing) it is recommended that a domain-based risk of bias assessment tool should be used instead of a quality appraisal tool.

This seems to completely mis-cite the Cochrane handbook. The relevant section (Chapter 8) says:

The Collaboration’s recommended tool for assessing risk of bias is neither a scale nor a checklist. It is a domain-based evaluation, in which critical assessments are made separately for different domains, described in Section 8.5

(Cochrane Handbook pp191)

Fine so far - but section 8.5 is for reviewing the very randomised studies the preprint authors claim are unethical and impossible:

Chapter 8 (Section 8.5) describes the ‘Risk of bias’ tool that review authors are expected to use for assessing risk of bias in randomized trials.

(Cochrane Handbook pp417)

For non-randomised and cohort studies of the sort that the York team were reviewing, the Cochrane Handbook says a different tool must be used:

Many instruments for assessing methodological quality of non-randomized studies of interventions have been created, and were reviewed systematically by Deeks et al. (Deeks 2003). In their review they located 182 tools, which they reduced to a shortlist of 14, and identified six as potentially useful for systematic reviews

[…]

The two most useful tools identified in this review are the Downs and Black instrument and the Newcastle-Ottawa Scale

(Cochrane Handbook pp417)

The ROBIS scores seem to be based on criticisms that are completely wrong on their face.

In addition to the overblown “risk of bias” claims are a laundry list of other complaints, none of which are any better when scrutinised. The section titled “Unsupported Claims” contains examples such as the following:

The authors also claimed that ”the switch from birth-registered males to birth-registered females” is ”unlike trans presentations in any prior historical period” (p. 26), without evidence for this change occurring, and without considering studies that contradict this claim.

First, the “evidence for this change occurring” is all in this systematic review, encompassing dozens of papers globally. Here is a series of charts showing the shift in sex ratio from male to female over time:

Second, the citation for “without considering studies that contradict this claim” is this paper, which was considered. It is part of that graph above, right here:

Not only that, but it doesn’t contradict this claim either. What this paper actually did was look at the sex ratio in 2012 and 2015 and find it did not change significantly between those two dates - but by that point the sex ratio had already changed to favour female referrals, by around 2:1, a significant change to ratios in prior decades.

On top of the attempts to poke holes in the methodology, the preprint devotes a good chunk to smearing the Cass Review as part of the “political context”, offering up claims of rising hate crime and attempts to ban youth medical transition in some US states, before concluding:

By making this point, we make no assessment or claim of political bias on the part of the authors of the Cass Report and associated systematic reviews. Rather, we suggest that it is not possible for these authors to separate their research from this social and political context

This is all empty handwaving about completely unrelated things and insinuating some sort of association to the Cass Review before backing innocently away from the pile of steaming bullshit the authors have left at the door of the review.

It attempts to imply this is somehow related to the review because of thematic connections between what the Cass Review found and what it regards as “disinformation” in US legal challenges to paediatric transition:

The specific themes of misrepresentation and disinformation in both Arkansas and other states throughout the U.S. include insinuations that being trans is, in and of itself, evidence of mental illness and can be ”cured” through talk therapy, outdated and misleading claims about the process of gender-affirming care in the U.S., misrepresenting the evidence regarding ”desistance” in transgender youth, and rejection of scientific and medical authority.

But the citation once again brings us full circle, as it is based on the previously mentioned paper on “disinformation” by McNamara, Allsott and McLamore. This is itself all based on the same opinionated essays by Florence Ashley on desistance, ROGD, social contagion and ethicality of paediatric transition as all the other publications - and then re-cited by the authors of these works with the pretence of independence.

There’s a difference between good scholarship that builds upon prior work and this sort of self-referential echo chamber that exists only to amplify its own worldview and rubbish anything that disagrees in the strongest possible terms.

Once again, the same handful of interconnected activists are churning out authoritative-seeming efforts to discredit the Cass Review, building on the earlier chain of laundered sources. None of these are independent works, and the criticisms range from weak to questionable to flat-out wrong. All in service of creating the impression that the Cass Review is “widely criticised” by “scholars”, when in reality it is so much obfuscation by a small number of ideologues. This is all a highly motivated crusade to discredit any medical evidence that does not support their preferred “affirmative model”.

Taking partisan material like this and using it as the sole basis to place the BMA’s reputation on the line by going against the Cass Review is really quite startlingly irresponsible.

I hope one day the BMA leadership comes to its senses and realises how badly they’ve been had.

In Life, The Universe and Everything, the third book in the Hitchhiker’s Guide To The Galaxy series, Douglas Adams conceived of a cloaking device called the “Somebody Else’s Problem Field”:

The Somebody Else's Problem field […] relies on people's natural predisposition not to see anything they don't want to, weren't expecting, or can't explain.

When something is too incomprehensible or bizarre or challenging for the mind to accept, our brains simply edit it out as Somebody Else’s Problem. The conceit being that actually making objects truly invisible is a fantastically difficult and expensive feat, whereas a Somebody Else’s Problem field generator can run indefinitely off a couple of torch batteries. The end result of exploiting our tendency to ignore difficult problems is the same: complete invisibility.

To be clear: it is not simply that you see and ignore the problem, on the assumption someone else will come along and deal with it. Rather, it is that the problem is so big, and so obviously someone else’s to deal with that your unconscious won’t let you even perceive there is a problem to begin with. You can only perceive an object cloaked by a Somebody Else’s Problem field if you catch a glimpse of it out of the corner of your eye, but never if you stare straight at it - the enormity is too much for the mind to handle.

And while Douglas Adams was using science fiction to elegantly poke fun at the human condition, the existence of this sort of effect is an important one to consider when facing a mass of people who seem to be ignoring an obvious problem.

An oft-used parable for such situations is that of The Emperor’s New Clothes, wherein the self-imposed veil of silence about the regal nudist is pierced by one child saying the unsayable. With that act, the spell is broken, and the whole naked edifice comes tumbling down.

But a Somebody Else’s Problem field does not work like that. It does not matter how often you try to bring people’s attention to whatever it is that is cloaked - they won’t see it. Their minds won’t let them see it. You drawing attention to the problem just adds to the problem. If you jump up and down screaming about the problem right in their faces, you become part of the problem, and just as invisible.

It also helps in understanding that this sort of selective blindness isn’t an act of malice or ignorance or self-preservation, but a far deeper and more universal tendency to not pay attention to uncomfortable truths when they’re right in front of us, something everyone has the capacity to be susceptible to. We simply don’t know what we are ourselves blind to.

In cases like this, it is not simply that people know there is a problem, but are afraid to be the first one to point it out - it is that the problem is so huge and complex and difficult that it is unseeable. And in that situation, pointing out in ever more desperate terms just how big the problem is makes it less likely they will see it. Solving this is a much, much harder task than simply laughing at a naked man and congratulating yourself on being the one bold enough to burst that bubble.

For this sort of problem you actually have to find a way to let people catch a glimpse of it, just a fragment, a manageable section out of the corner of their eye. Just enough for them to start to see it, but not so much that they shut down completely. Enough to create a niggle of awareness that something actually is amiss, and no, nobody is dealing with it. No-one has a reassuring hand on the tiller, and the iceberg is hoving into view.

Consider all the times there has been some seemingly seismic event in the sex and gender conflict that had people convinced that now, finally, this would be the one people would be unable to ignore. Men in women’s prisons. Men in women’s rugby. Men in women’s weightlifting. Rowling tweeting. The Cass Review. And on and on.

And the truth is each of these just seemed to make the whole conflict more bafflingly complex, and more invisible. Escalating the abuse and silencing instead of dispelling it. It turns out it isn’t enough to point out the grave injustices, the abuses, the unfairness, the blatant piss-taking. Most people aren’t waiting for the outrageous event that grants them permission to acknowledge the emperor’s nudity - they just won’t see any of this at all, because their unconscious rationalises it away as Somebody Else’s Problem.

The recent release of the Cass Review into healthcare for gender-questioning youth has been welcomed and condemned in equal measure, and the amount of disinformation spread about it by high profile individuals and supposedly reputable organisations is both disappointing and entirely unsurprising. What could have been an opportunity to meet in agreement over the quality of the evidence has instead become an airing of long standing talking points, given fresh life and wider exposure. While some especially egregious gaffes over entirely fictional quantities of evidence excluded have caught the headlines - with Dawn Butler MP ultimately apologising for misinforming parliament and blaming Stonewall for misleading her in turn - there are deeper, more pernicious attacks on the Cass Review that are much harder to unpick.

In recent years, as governments around the world have moved to ban conversion therapy not just of sexual orientation, but also of “gender identity”, some therapists have expressed concern that such moves risk banning the sort of therapy that seeks to understand the roots of an individual’s gender distress. Such concerns have been repeatedly dismissed as groundless - concerns which are once again raised in the Cass Review:

Throughout the Review, clinicians working with this population have expressed concerns about the interpretation of potential legislation on conversion practices and its impact on the practical challenges in providing professional support to gender-questioning young people. This has left some clinical staff fearful of accepting referrals of these children and young people.

Anticipating some of the hostility to the final report, Cass noted in advance the unhelpful and hostile nature of this debate, and the way in which some terms had been “weaponised” for political ends, such as those in the ongoing dispute over appropriate treatment for gender-questioning youth, and the distinctions between “affirmative” and “exploratory” models of care:

The role of psychological therapies in supporting children and young people with gender incongruence or distress has been overshadowed by an unhelpfully polarised debate around conversion practices. Terms such as ‘affirmative’ and ‘exploratory’ approaches have been weaponised to the extent that it is difficult to find any neutral terminology. 

This plea for reasoned debate has not stopped the Cass Review from being condemned for espousing conversion therapy.

Back when the interim report of the Cass Review was released in 2022, WPATH released a statement condemning exploratory therapy as “tantamount to conversion therapy. Now with the final report, WPATH responds again, even more clearly:

The foundation of the Cass report is rooted in the false premise that non-medical alternatives to care will result in less adolescent distress for most adolescents

WPATH considers that anything other than a medical pathway is harmful, and that even trying to suggest other underlying reasons might exist for a child expressing a “trans identity” is not allowed.

WPATH’s affiliated academic journal, The International Journal of Transgender Health, even published a peer-reviewed article laying out all these claims, just prior to the release of the final report, accusing Cass of “cis-supremacy” and “conversion therapy”, that the evidentiary demands are unfeasible, that randomised-controlled trials are unethical, and that “anti-trans professionals” were involved in the process.

These are broad and serious allegations, and they are being repeated over and over by transadvocacy organisations and individuals, believing that there is some weight to these claims. Indeed, if you were to look up Wikipedia for an explanation of what the exploratory approach is, you would be redirected to the page on conversion therapy instead.

In a previous piece, I charted how one tweet was taken out of context and - through a complicated game of telephone - became evidence of a nefarious new form of conversion therapy called “gender critical therapy” in reports to policymakers, despite never actually existing.

In a very similar vein, the phrase “gender exploratory therapy” has become a flashpoint in the debate over conversion therapy, subject to a similar chain of source laundering to give baseless opinion an authoritative gloss. Gossip has been spread as fact, and within activist circles, the notion that exploratory therapy is really conversion is simply a given, circulated and amplified endlessly within echo chambers until we reach the point where the actual basis for the claims is all but forgotten.

Broadly, the chain is as follows:

• 2019: Anastassis Spiliadis’ “Towards a Gender Exploratory Model”

• 2021: Gender: A Wider Lens

• 2022: Health Liberation Now’s “A New Era”

• 2022: Florence Ashley’s “Interrogating Gender Exploratory Therapy”

• 2023: Health Liberation Now’s “SEGM Exposed: Reloaded”

• 2023: Southern Poverty Law Centre’s CAPTAIN report

• 2024: Cal Horton’s “The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children”

Each step along this chain adds its own layer of misinformation and conspiracism, with many more interesting branches along the way, but these are probably the most significant stages. This will hopefully illustrate that the claim is not so simple as something that can be fact-checked and disproved, but is in fact reflective of an entire worldview, a logical consequence of understanding “gender identity” in a particular way, and a perspective that is now supported by a web of interconnected claims that are not easily unpicked.

2019 - Towards a Gender Exploratory Model

In July 2019, Anastassis Spiliadis - a clinician at the Tavistock GIDS - published a paper titled “Towards a Gender Exploratory Model: slowing things down, opening things up and exploring identity development”. In it, he describes a polarisation in therapeutic approaches, between those focused on affirming, validating and facilitating a trans identity in gender questioning youth, and those seeking to prevent one.

Broadly speaking, we can conceptualise competing theoretical approaches in working with young people with GD, as loosely connecting to two different polarities: one that would affirm (often perhaps confirm) a young person’s subjective gender(ed) experience and related hopes (for instance, for medical interventions) in the context of ‘authentic self-knowledge’ (Lopez, Marinkovic, Eimicke, Rosenthal, & Olshan, 2017) or on the basis of their ‘privileged access’ (Wren, 2014); and, on the other hand, one that would posit that offering active therapeutic intervention will effect a change / desistance in the young person’s identification and therefore lead to congruence with their natal sex.

Neither of these is uncontroversial, as approaching therapy with a set outcome in mind (either facilitating or preventing) forecloses other options, and the latter - when coercive or “reparative” methods are employed - is indeed tantamount to the sort of conversion therapy perpetrated against gay people historically.

However the point of Spiliadis’ paper is to chart a third way - an exploratory model that is open, curious and undirected, not seeking impose a particular normative mode of self-expression, but at the same time not shying away from exploring why a young person might wish to be the opposite sex.

He presents a case study of a boy who was adamant he wished to be a girl, but through a process of exploration revealed a same-sex attraction that was suppressed due to homophobic bullying, and that was later reconciled by this undirected and open therapy, to the point of embracing a more fluid identity, encompassing both masculine and gender-neutral pronouns. The boy simply could not understand himself as a boy, in a relationship with another boy, and probing the roots of that enabled alternative understandings of how it was possible to be, without resorting to drastic experimental medical interventions in pursuit of becoming something he could never truly be at all. An affirmative approach would not have explored these roots in such a questioning fashion, and what was otherwise a same-sex oriented boy would likely have been set on a medicalised path in a quest to appear to the world as a heterosexual girl.

This paper reveals the tension between sexual orientation and the medicalisation of gender nonconformity. Taking a gay boy and making him appear “straight” to the world is conversion therapy - but to advocates of the affirmative model, taking a “trans girl” and cruelly denying her medical interventions while insisting on talking therapy to “convince” her she’s simply a gay boy is conversion therapy, denying a fully realised trans identity that a medical pathway would facilitate.

It also reveals the tension within GIDS itself over appropriate therapeutic practice, with some clinicians favouring a slower, exploratory approach, while others held to overly-affirmative practices which have since been criticised in the Cass Review.

2021 - Gender: A Wider Lens

In May 2021, Spiliadis’ paper was discussed on the Gender: A Wider Lens podcast, with Sasha Ayad and Stella O’Malley:

Sasha Ayad says:

This term was first used by a therapist called Anastassis Spiliadis, and he has an excellent paper called “Towards a Gender Exploratory Model: slowing things down, opening things up and exploring identity development”, and he's a colleague of ours and he's written about his gender exploratory model which is brilliant.

And Stella O’Malley responds:

What I am is I'm curious and I'm compassionate and I'm exploratory and trying to find out the person and where they're at, and so if you want to call it gender exploratory, yeah that would suit me better, but I'm just effectively client exploratory you know?

Stella O’Malley went on to found the organisation Genspect a month later, with a live webinar on June 19th:

During this event, other organisations were promoted, including the Society for Evidence-based Gender Medicine (SEGM). At one point, Sasha Ayad mentioned a sentence from the film “Transmission”, by the Centre for Bioethics and Culture:

If you’re the sort of person who is open, curious, resistant to ideological purity and willing to talk to anyone without endorsing any particular viewpoint, it might not be immediately apparent how tweeting about a video like this is going to play out once your ideological opponents seize upon it.

Three of the people featured in this film are or were members of The American College of Paediatricians (ACPeds), which - despite its important-seeming name - is essentially a small conservative and homophobic organisation who split from the much larger American Academy of Paediatrics, specifically over its endorsement of gay adoption in 2002. ACPeds undeniably endorses the sort of “reparative” (conversion) therapy that Spiliadis’ 2019 paper disavows. Indeed, in 2010 it wrote to schools saying that same-sex attraction “can respond well to therapy”, suggesting how to avoid adolescents engaging in “harmful homosexual behaviors”. For anyone following the debate over gender, this 2010 letter contains language that is eerily familiar with regards sexual orientation:

It is not the school’s role to diagnose and attempt to treat any student’s medical condition, and certainly not a school’s role to “affirm” a student’s perceived personal sexual orientation.

Everything that follows has to be seen in this light. Conservative organisations in the US have a long history of advocating outright conversion therapy under reasonable-seeming language. They have treated same-sex attraction and gender nonconformity as the same thing, both deviations from a heterosexual norm, and both to be prevented if possible. Activists are rightly wary of attempts by such organisations to conceal their true motives with sanitised language and front groups.

However there is a difference between being alert to the covert actions of bad faith actors, and baselessly smearing ideological opponents.

Two days after the Genspect webinar, the term “gender exploratory therapy” was picked up on by Mallory Moore of activist group Trans Safety Network, claiming it was simply a new term for conversion therapy:

This tweet was shared by Ky Schevers, of activist group Health Liberation Now:

In August 2021, Schevers went on to tweet about “gender exploratory therapy” as a conversion practice.

In August 2021, Trans Safety Network also went on to publish posts attacking SEGM and Genspect and anyone associated with them, playing up purported affiliations between them and ACPeds.

In September 2021 Schever’s Health Liberation Now co-founder Lee Leveille published an article titled “When Ex-Trans Worlds Collide” citing Moore’s tweets and the Trans Safety Network piece on SEGM, mostly attacking detransitioners, but also outright claiming that “exploratory psychotherapy” is conversion therapy. Leveille warns:

Groups or programs like Inspired Teen Therapy and GDSN, operated by SEGM members, promote what they call “compassionate exploration-based counseling” for teens and young adults built on ROGD frameworks. Florence Ashley cautioned that this was likely to occur, in part because of how politics has merged with trans health in the midst of increased medical support for trans youth. “The new, unsupported theory rapid-onset gender dysphoria is being used to oppose affirmative care for adolescents, and newspapers in the United Kingdom are attacking the national gender clinics for allowing youth to transition, despite their approach falling on the conservative side of trans health. After a steady decline over the past decades, trans reparative therapy may be heading toward a dangerous revival.”

Leveille cites Florence Ashley here to attack the hypothesis of “rapid onset gender dysphoria” (ROGD) originally advanced by Lisa Littman in 2018, and tie it to what Ashley at the time called “reparative therapy”. Both Leveille and Ashley are convinced that ROGD is part of a ploy to attack trans healthcare, and usher in conversion therapy by stealth. Since ROGD posits the idea of peer influence on gender identity it cannot be accepted by advocates of medicalised affirmation, since evidence for social contagion is something that would fatally undermine the straightforwardly affirmative model and mandate a more cautious, exploratory approach. The evidence must be a lie, and the true agenda must be conversion.

This is essentially ground zero for an ensuing web of citations and insular groupthink spreading the claim that bog standard, curious, undirected, exploratory therapy is actually conversion, much of which revolves around the academic musings of Florence Ashley in particular.

By the middle of 2021, this group of activists had already spent well over a year attacking Stella O’Malley as a conversion therapist, targeting the entirely made-up term “gender-critical therapy”, over one repeatedly misrepresented tweet in February 2020. After the Wider Lens podcast, the launch of Genspect and the Gender Exploratory Therapy Association (GETA), all of those prior accusations simply transferred to all possible variations of exploratory therapy, most notably “gender exploratory therapy”.

2022 - A New Era

On June 1st 2022, Lee Leveille published another article on Health Liberation Now titled “A New Era: Key Actors Behind Anti-Trans Conversion Therapy”. This article included a definition of “gender exploratory therapy” which stated that term, and all of its synonyms, are in reality conversion therapy:

“Gender exploratory therapy”: New label for forms of conversion psychotherapy advertised to trans and gender diverse adolescents and young adults, as well as detransitioned individuals. Additional terms interchangeably used by GICE actors are “exploratory therapy,” “exploratory psychotherapy,” or “exploratory talk therapy”, which can be differentiated from affirming models of exploratory therapy via the context of a group or clinician’s beliefs surrounding gender identity and affiliations they hold.

This is, as far as I can make out, the first online resource explicitly making this allegation about the phrase “gender exploratory therapy”, outside of the earlier social media posts by Schevers and Moore, and builds on Leveille’s earlier claim about “exploratory psychotherapy” being conversion therapy.

Leveille claims not only that any therapeutic language which uses “exploratory” in any combination is suspect on its face, but also a key to unlocking whether someone is a conversion therapist is group affiliations. The rest of the article is then devoted to charting such “affiliations” using the loosest possible interpretations, building on the earlier work by both Health Liberation Now and Trans Safety Network.

Much space is devoted to explaining why actual hard-right conversion therapy advocates such as Heritage, ADF and the aforementioned ACPeds are not to be trusted, but when it comes to the actual criticism of organisations like SEGM, the occasional valid points here and there are buried under a mountain of overstatement making it very hard to take in good faith and get to the truth.

For example, it is legitimate to point out that Will Malone of SEGM once co-authored a letter with members of ACPeds, but far more disingenuous to state in “key findings”:

Citations of the work of Kenneth Zucker, Susan Bradley, and Lisa Littman serve as a bridge between “gender exploratory therapy” worlds and established SOGICE actors or advocates.

The logic is that if your work is capable of being cited by someone who is “anti-trans”, to advance an “anti-trans” point, then it must have been created to support that agenda, and therefore whoever produced it - and anyone they associated with - is suspect. Smearing individuals and organisations for such sins as being “cited” by bad actors is an absurd and unreasonable standard.

Really this is an exercise in collating sub-prime evidence for a reputational attack on an entire organisation to tarnish everyone associated with it for all time.

If the aim is to raise awareness of bad actors and nefarious intent, this sort of bad faith accumulation of evidence is wholly counterproductive, as absolutely no-one has time to sift through sorting the wheat from the chaff, and what results is just intense polarisation, where any legitimate claims are brushed off by one side, while baseless claims are taken as gospel by the other.

This is all just throwing everything at the wall and hoping as much sticks as possible, and if there are any legitimate criticisms to be made they are near-impossible to tease out. The point is that the worse SEGM and Genspect can be portrayed, the more anyone who connects to them or anyone connected to them, or cites them, or so much as breathes in their vicinity can be portrayed as spreading “conversion therapy”, no matter what form of words they actually employ.

Posts like “A New Era” are not about teasing apart true claims from false in an effort to genuinely raise the alarm about the very real threat posed by some bad actors on the US right-wing. Rather, this is amassing an arsenal to perform total reputational annihilation against absolutely anyone even remotely, tangentially, six-degrees-of-separation connected to ideological opponent.

Notably, this also makes the completely made-up claim that it is their opponents responsible for a shift in language from a previous focus “gender-critical therapy”:

“gender exploratory therapy,” previously known as “gender critical therapy”,

This conspiracist logic enables Leveille to pretend all previous sources attacking that confected term simply apply to this one too, creating a mountain of “evidence” from nothing whatsoever, and any confusion over changing terminology is just more evidence of how shifty those conversion/gender-critical/exploratory/gender exploratory therapists are.

Importantly, the basis of key claims are several publications authored or co-authored by Florence Ashley. These works are invariably academic opinion essays, cited as authoritative here, and themselves forming a tight network of self-citing publications covering such topics as:

• The Clinical Irrelevance of “Desistance” Research

• Puberty Blockers Are Necessary, but They Don't Prevent Homelessness

• In Favor of Covering Ethically Important Cosmetic Surgeries

• Gatekeeping hormone replacement therapy for transgender patients is dehumanising

• Banning Transgender Conversion Practices: A Legal and Policy Analysis

• A critical commentary on ‘rapid-onset gender dysphoria’

• There is no evidence ROGD Exists

• Why ROGD is bad science

These are all expansions of Ashley’s general view that access to medical transition should be available on a demedicalised, informed consent model. Notions of peer-contagion are myths, detransition and desistance don’t matter, gatekeeping is bad. Fundamentally the perspective is that trans people seeking therapy know they are trans and should be affirmed as such. Puberty blockers must be given to “trans kids” and denial or delay for any reason is “conversion therapy”, and Ashley has built up a few dozen papers on these subjects, which all support the same essential view.

“Trans kids” need to be medicalised, anything in the way of that is conversion, any evidence to the contrary is a lie.

Below is an illustration of Ashley’s self-citations and how they feed into the citations in “A New Era”, as cited by Leveille, along with some of Leveille’s earlier work, combined with the 2021 Trans Safety Network piece on SEGM:

Obviously there are many more citations than these - but these are the ones that, at root, are employed to support the notion that “exploratory therapy” is conversion therapy. And again, there is nothing wrong with self-citation per se, but this does reveal the interconnectedness of all of these beliefs, and how evidence which challenges these views (desistance, regret and detransition, peer contagion) must be attacked and questioned, and anyone who calls attention to them maligned. The claim that ROGD cannot be in any sense a real phenomenon, and the claim that exploration is conversion are inextricably intertwined.

2022 - Interrogating Gender Exploratory Therapy

In September 2022, Florence Ashley published a paper titled “Interrogating Gender Exploratory Therapy”. This is an academic work that explicitly posits that the term “exploratory” is a euphemistic ruse akin to rebadging gay conversion therapy:

Descriptions of reintegrative therapy by people who offer it are reminiscent of how gender-exploratory therapy is described by its proponents.

This paper is - like much of Ashley’s other work - little more than an opinionated essay. As Ashley states:

In this article, I offer questions for clinicians and then offer my personal reflections on gender-exploratory therapy.

However, this work has been cited over and over again by subsequent sources as proof that gender exploratory therapy is conversion therapy. There are no prior academic works that make this explicit claim that I have found, and all subsequent citations can be traced back here, or to one of the precursor works.

What this paper achieves is to take Ashley’s previous focus on reparative therapy and ROGD, combine them with the ideas and language presented by Health Liberation Now, and re-present them with an air of academic authority, refocusing on the new term, “gender exploratory therapy” and all its possible variations.

Ashley’s central point is:

Proponents of gender-exploratory therapy situate their approach as neutral, agenda-free, and more in line with foundational principles of psychotherapy. Yet approaching trans identities and gender dysphoria from a position of suspicion—suspicion that, regardless of indication, they may be attributable to pathological causes and should be explored as such—is incompatible with therapeutic neutrality.

The core of the argument is: that positing a reason why someone might come to think of themselves as “trans” is impermissible. The distinction between “affirmation” and “exploration” rests on the affirmative model exploring only the options for how to express that “transness”, rather than exploring any underlying reasons why they might have come to think of themselves as trans. Positing causal factors - such as autism, peer contagion, or internalised homophobia (as in the case of Spiliadis’ original paper) is forbidden, and to do so erases trans identities, because it implies (or indeed reveals) that they are not some definitive self-truth, but a likely transient stage of confusion and distress.

This is why in a paper supposedly about conversion therapy, Ashley attacks those who have studied ROGD, as well as detransitioners, as “hostile” to the affirmative model, since the existence of individuals for whom social influence was a factor in opting for medical procedures they went on to regret does not sit well with a zero-gatekeeping, informed consent model of transition.

The similarity to the focus of Health Liberation Now’s piece is no accident - the paper cites Health liberation now three times, and gives special thanks to Lee Leveille for reviewing an early draft.

It is perhaps worth pointing out that Florence Ashley is not some marginal figure writing academic texts nobody reads. Until bowing out due to alleged “scheduling conflicts”, Ashley was due to be a key part of the WHO’s working group to set global policy on trans healthcare. Having someone as deeply enmeshed in this sort of partisan, conspiracist activism anywhere near global health policy in this area ought to be a huge concern.

Another person thanked for reviewing this paper is clinician AJ Eckert, who, a month after the publication of Ashley’s paper online, co-authored a post on Science Based Medicine with Quinnehtukqut McLamore titled “Cutting through the Lies and Misinterpretations about the Updated Standards of Care for the Health of Transgender and Gender Diverse People”.

Here, Eckert states that exploratory therapy is conversion because it considers that:

first-line “treatment” for trans youth with gender dysphoria is psychological and seeks to “avoid the risks of social and medical transition“.

Below is an illustration of some of the sourcing for this, removing many of the internal self-citations of Ashley’s work for simplicity (really). The claim about conversion therapy rests on Ashley’s then-freshly-published “Interrogating Gender-Exploratory Therapy”, which cites Leveille, and was reviewed by both Leveille and Eckert, and then published on Science-Based Medicine by Eckert and McLamore.

Eckert takes Ashley’s reworking of Health Liberation Now’s claims and presents them as definitive, and in the process makes it harder to see their origins with Health Liberation Now and Trans Safety Network, as well as Eckert’s involvement in that process. Between them, they have agreed that “gender exploratory therapy” is conversion, and cite each other in turn to support that claim.

To be clear, this relationship between sources is not so much a conspiracy, as a highly motivated interconnected group of activists all sharing the same world view, all saying the same things and reinforcing each others statements - it is just that at each level of citation, the origin is further obscured, and the certainty of the claims increases.

By the time it appears in Science Based Medicine, the fact that this is purely the ideological opinion of a few activists, rather than something that has been empirically found to be true, is hidden behind multiple levels of back and forth citation. This obfuscation is helped along by a writing style that employs a dense accumulation of citations, hyperlinking practically every word - presumably in an attempt to overwhelm any reader with the sheer apparent weight of evidence - little of which stands up to scrutiny.

This is also the point where the Cass Review enters the picture, years before its final publication, in two connected ways.

Firstly, this piece cites an earlier one by Eckert which explicitly attacks the National Institute of Health and Care Excellence (NICE) review of puberty blockers commissioned at the outset of the Cass Review in 2020. Eckert’s earlier article makes multiple false or misleading claims about evidence that was excluded, as well as arguing that randomised controlled trials are unethical, all attack lines that came to be used against the final Cass Review upon publication. Despite being supposedly about the NICE review, the piece devotes half its length to attacking SEGM, who “favorably commented” on the review. Notably, citations for this piece again include the earlier “SEGM Uncovered” article by Trans Safety Network. Again, it is all a dense mess of conspiracist dot joining and tenuous misrepresentation of evidence, and exemplifies how far Science Based Medicine has fallen in recent years, with its total blind spot on trans issues.

Secondly, this also cites another earlier piece by Eckert (“Gender-affirming care is not experimental”) which in turn cites Cal Horton, who also cites Eckert’s earlier work on the NICE review. Horton went on to write the 2024 “academic” critique of the Cass Review, which recycles many of the same points in that article, but more on this later.

Again, trying to take these articles point by point is a task in itself, but to demonstrate the process of exaggerating strengths of claims through extra levels of citation, one example is Eckert’s claim about the reversibility of puberty blockers:

It should be emphasized that the effects of blockers are both temporary and reversible.

This is a strong claim presented with no caveats, and the citation for “reversible” is Cal Horton, who says:

Puberty blockers have a temporary and reversible impact on pausing secondary sex characteristics, with the development of secondary sex characteristics recommencing once puberty blockers are discontinued (Hembree et al., 2017). Puberty blockers also have a temporary and reversible impact on fertility – when puberty blockers are discontinued, endogenous puberty recommences, including the maturation of gametes (Hembree et al., 2017).

This is a slightly more caveated claim (specific to sex characteristics and fertility) than Eckert’s - but the citation for both claims is Hembree et al., 2017, which says something even less definitive:

For those designated male at birth with GD/gender incongruence and who are in early puberty, sperm production and the development of the reproductive tract are insufficient for the cryopreservation of sperm. However, prolonged pubertal suppression using GnRH analogs is reversible and clinicians should inform these individuals that sperm production can be initiated following prolonged gonadotropin suppression. [..] Note that there are no data in this population concerning the time required for sufficient spermatogenesis to collect enough sperm for later fertility. In males treated for precocious puberty, spermarche was reported 0.7 to 3 years after cessation of GnRH analogs. In adult men with gonadotropin deficiency, sperm are noted in seminal fluid by 6 to 12 months of gonadotropin treatment. However, sperm numbers when partners of these patients conceive are far below the “normal range”.

So this is talking about:

• Sperm production in males

• Using those treated for precocious puberty or in adulthood as comparators

• And even then the claims are not without caveats about lack of data

And for girls?

In girls, no studies have reported long-term, adverse effects of pubertal suppression on ovarian function after treatment cessation. Clinicians should inform adolescents that no data are available regarding either time to spontaneous ovulation after cessation of GnRH analogs or the response to ovulation induction following prolonged gonadotropin suppression.

This is very carefully worded, but is questionably using the absence of evidence to imply evidence of absence, and at the same time pushing the lack of data onto the child to make an informed choice about.

So this dubious guidance specifically about fertility based on virtually no data and supposition from other clinical populations becomes cold, hard certainty, through 2 levels of citation. Eckert’s bold claim about complete “reversibility” has nothing to back that up except this chain of obfuscated sources, and citation stacking.

This paucity of evidence of safety and reversibility is exactly why the Cass Review found insufficient basis for those claims - but activists like Eckert and Horton could never accept that is true from the outset, and have to attack those looking for evidence as “anti-trans”. To them, it is clear and obvious and robust, and anyone looking closer and coming to a different conclusion can only be doing so out of hate and bigotry.

Time and again, claims like this become ever more definitive at each layer of citation, none more so than the assertion that exploratory therapy is conversion therapy, which by this point has reached the level of received wisdom.

2023 - SEGM Exposed: Reloaded

In February 2023 Lee Leveille and Quinnehtukqut McLamore co-authored a piece on the Health Liberation Now site that is, frankly, the conspiracist motherlode. It takes everything in “A New Era” and dials it up to eleven - recycling many of the same sources as before and simply adding more certainty and hyperbole along the way.

“SEGM Exposed: Reloaded” hits all the major themes that have arisen so far: exploratory therapy is conversion therapy, anyone even tangentially attached to Genspect or SEGM is a conversion therapist in cahoots with the Christian right-wing, ROGD is debunked pseudoscience, randomised controlled trials are unethical, detransition and regret aren’t problems, and so on.

It attacks Tavistock whistleblowers Sue and Marcus Evans for the standard of care provided by the Tavistock while Marcus Evans was governer:

Incidentally, the types of intrusive psychoanalytic therapies that the NHS actually practiced during Marcus Evans’s governorship have been described by patients and their families as fundamentally degrading, unhelpful, destabilizing, and pathologizing.

The three citations given to support this claim are all opinionated essays and parental reports by Cal Horton again, none of which specifically cover Evans’ tenure, all of which cite Florence Ashley’s claims about ROGD and conversion practices, and all laying out the ideologically-led push for affirmative approaches and total removal of psychotherapeutic gatekeeping which the Cass Review overturned.

It attacks Sue and Marcus Evans as conversion therapists:

the Evanses instead worked to advocate for psychoanalytic conversion therapy in Gender Dysphoria: A Therapeutic Model for Working with Children, Adolescents and Young Adults. […] this book been roundly criticized by transgender activists, including the Polish transgender knowledge base Tranzycja

This links to a report titled “Exploring Till They Bleed” by a Polish transactivist group. That report cites some of the same sources as this piece and many of the precursor works by Florence Ashley, while also thanking Quinnehtukqut McLamore for consulting on the report.

Once more, interdependent sources are cited with every indication that they are separate, when they all rely on the same sources, and the same activists, producing work that is steeped in that same perspective in service of the same political ends. Leaving aside that the vast majority of space is devoted to amassing an orgy of evidence to damn SEGM, the driving force of this whole article is ideological opposition to any psychotherapeutic intervention on gender-questioning children that might lead to them simply growing up to be gay, because the authors and the sources they rely on believe it is conversion therapy.

2023 - CAPTAIN

In December 2023, Southern Poverty Law Centre released its CAPTAIN report, a huge, multi-part series focused on an “anti-LGBTQ+ pseudoscience and disinformation network”.

The core allegation is that a tight-knight group of conservative ideologues are citing each other’s fabricated and tenuous claims to give the appearance of a stronger evidence base than really exists, in order to pass anti-trans legislation in the US.

Ironically, the report was co-authored by Lee Leveille and Quinnehtukqut McLamore, and essentially retreads all of the ground in “A New Era” and “SEGM Exposed: Reloaded”, repeating all of the same tenuous claims, citing themselves as authorities, compiling a vast dossier of fabricated and tenuous claims to give the appearance of a stronger evidence base than really exists.

To illustrate the back and forth laundering:

• Trans Safety Network makes claims about conversion therapy in “SEGM Exposed”, after Moore claims “gender exploratory therapy” is “conversion therapy” on Twitter.

• Which are cited as a definitive claim about “exploratory psychotherapy” by Leveille in “When Ex-Trans World Collide”, combined with Florence Ashley’s opinions on reparative therapy.

• Leveille then expands on these and adds “gender exploratory therapy” in “A New Era”.

• Leveille then has input to Florence Ashley’s “Interrogating Gender-Exploratory Therapy”, which also cites Leveille and Schevers.

• Which is then cited by Trans Safety Network again.

• Both of which are cited in the Tranzycja report McLamore consulted on

• All three of which are in turn cited by both Leveille and McLamore in “SEGM Exposed: Reloaded”

• Which is then ultimately cited again in Leveille and McLamore’s co-authored “CAPTAIN” report, as are many of the intermediary steps.

The basis of the claim that “gender exploratory therapy” is conversion - a claim which runs through the CAPTAIN report - is a chain of back and forth citations between the same four or five people, absolutely none of which is clear in SPLC’s document, and I doubt even clear to the authors themselves by this point - it has just become received wisdom in this tiny echo chamber.

Based on Leveille’s assertion that ordinary therapy can be identified as “conversion” by the network associations of the people espousing it, link after spurious link are thrown at the reader to imply crossover and overlap on the most tenuous of grounds. Science that casts doubt on the certainty of their position is “pseudoscience”, not because it has actually been established to be fake, but because this sort of strong denunciation - repeated dozens and dozens of times across the whole report - is politically useful. Exploratory therapy which was in its origins about avoiding medically harming children who would most likely simply grow up to be gay otherwise, becomes “anti-LGBTQ+”, through the power of demanding that TQ+ and LGB always go together. Actions specifically in service of protecting LGB youth are rhetorically inverted out of political calculus into something anti-LGB because it goes against the demands of a section of TQ+ activism.

Once again, the CAPTAIN report is huge, and trying to go point by point through it is a sisyphean task, and a good portion of it is devoted to discussion of the legal activities of the hard right in the US, where the gender debate seems to be far, far more polarised between two equally deranged extremes than in the UK.

It should be enough to simply warn of the machinations of dubious bad actors pursuing a genuinely regressive agenda, but - in order to advance the cause of unfettered access to transition - this aspect of the report is secondary to the aim of smearing absolutely everyone that a small core of activists dislike, for political ends. Everyone cautioning about regret and detransition and peer contagion and diagnostic overshadowing, or advocating exploratory therapy, must be denounced as a purveyor of pseudoscientific bigotry. If bad actors use your evidence in court, then your evidence is bad, QED.

The indiscriminately conspiracist nature of work like this is, I think, dangerous and self-defeating because there is a core of this report that is highlighting a very real tendency on the right of US politics - ADF, Heritage Foundation, Project 2025 - to exploit the “trans issue” as a wedge. Hammering on “family values” messages, “protecting children” from “LGBTQ+” degeneracy.

As a clear illustration of the polarisation at play, and how SPLC’s framing is counterproductive, one of the responses to the CAPTAIN report came from the The Heritage Foundation’s media outlet, The Daily Signal. This hits most of the main points that to many casual readers would seem reasonable - drawing attention to the unwarranted demonisation of doctors who question the gender-affirming model, and the legitimate concerns about the way that blindly affirming cross-sex identification - especially in children - can mask other issues.

But then about halfway through, you find paragraphs like this:

As ex-gay rights leader Christopher Doyle explains in his book “The War on Psychotherapy,” “One of the strategies that far-left advocacy and gay activist organizations use to smear professional psychotherapists assisting clients distressed by sexual and gender identity conflicts is to intentionally conflate professional therapy with religious practice and/or unlicensed, unregulated counseling. They do this by labeling all efforts—therapeutic, religious, or otherwise—to help clients distressed by sexual and gender identity conflicts [as] ‘conversion therapy.’”

What this paragraph is really referencing is actual sexual-orientation conversion therapy, and promotion of “ex-gay” advocacy, portraying criticism of that as exactly the same disingenuous smear campaign, and blaming the “far-left” and “gay advocates”.

The author of this piece has previously tweeted opinions such as this, praising men who “embraced their masculinity and left the gay lifestyle”:

If you have legitimate concerns about affirmation of cross-sex identity in children being harmful to gay youth, then people who espouse views like this are not your friends. They are not on your side. They are using your reasonableness, your stories, your moderate words as a shield. These are the people who do not want to stop at “trans” and want to carry on getting all mention of “LGB” out of schools, who consider gay men not to be “masculine” enough, and a problem to be fixed.

When SPLC say that some on the US right-wing are using concerns about the affirmative model as cover for conversion therapy they are absolutely right. It is not enough to dismiss SPLC as a bunch of conspiracist loons trying to smear reasonable, decent people with lies when some of it is not lies at all, and it has to be possible to be critical of SPLC’s shoddy work without leaping to the defence of organisations like Heritage. Ultimately, these indiscriminate attacks on reasonable people serves only to polarise and provide cover for bad faith actors. There is a version of this report that could have teased apart the reality of the situation, that could have found the nuance and recognised the political hatchet jobs being perpetrated against some people who are truly acting in good faith.

But SPLC have no interest in writing such a report because it is not in their interest to acknowledge anyone that disagrees with their deranged worldview might have a legitimate point. There is more political mileage to be gained from casting absolutely everyone as in league with the worst, most homophobic elements of the conservative right - and to that end, this report acts to launder of Health Liberation Now’s conspiracism into a higher profile, more “respectable” format, and hide the chain of reasoning behind their “exploratory therapy is conversion therapy” claims. The end result is that this report is now heavily referenced and influential, in a way that Leveille and McLamore’s self-published work could never hope to be, laundered into mainstream acceptability with the “SPLC” branding and stamp of authority.

2024 - Cis-supremacy

Which at last brings us to Cal Horton’s “The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children”.

It is worth noting up front that Quinnehtukqut McLamore is thanked for “helpful feedback”. Additionally:

• An article by Fran Amery is cited (“Protecting children in ‘gender critical’ rhetoric and strategy: Regulating childhood for cisgender outcomes”), which in turn cites Health Liberation Now’s “A New Era” as a source of the claim that “gender exploratory therapy” is conversion therapy. This article is tagged with the keywords “TERF” and “moral panic”, and appeared in a special issue of the Journal of Diversity and Gender Studies titled “Varieties of TERFness”, so clearly no bias on display there (!).

• Eckert’s Science Based Medicine post about the NICE Review is again cited by Horton to cast doubt on the strength of the evidence.

• Horton cites nine pieces of her prior work, all of which have similar levels of dependence on the same sources and hyperbole.

Obviously there are many more citations than these, but crucially, some of the key assertions come down to one of these sources.

Eg. on the specific matter of conversion therapy:

non-affirmative practices are rarely openly labeled as conversion therapy (Ashley, 2022b). Instead conversive practices, or approaches grounded upon the rejection, pathologization or problematisation of gender diversity are commonly veiled under language of “exploratory” therapy (Ashley, 2022c).

The foundation of this claim rests, once again, on Ashley, which means it can all be traced back to an evidence-free tweet about a podcast in 2021 about a paper published in 2019, and everything else is exaggeration, opinion and assertion. This claim that it is “commonly veiled” by this language has no evidence whatsoever to back it up, but chasing the citations to the bottom to discover that is clearly not something any reviewer for The International Journal of Transgender Health has any interest in doing. The entire point is to get into a supposedly peer-reviewed journal article strong claims that the Cass Review advocates conversion therapy and/or is connected to people who do, and thus any language they use to protest this is suspect.

This paper is not a novel contribution, nor is it specifically an attack on the final Cass Review, which was not published until several weeks afterwards. What it is is a synthesis of all of the preceding conspiracist and ideological claims into one academic-seeming text, tying together the multiple strands of argument, and condemning Cass ahead of publication, fashioning something that could be cited time and again to dismiss the Cass Review, whatever its findings turned out to be.

• Exploratory therapy is conversion therapy because it is a cis-supremacist view of the world that treats trans identities as suspect or lesser or undesirable, denying personal autonomy to children who truly know themselves.

• Peer contagion is a cis-supremacist view of the world, that considers trans identities as lesser, a mere fad, a mental health condition, rather than important and honest and true and integral.

• Concern for regret and detransition is a cis-supremacist view of the world, that sacrifices the well-being of the many for the supposed safety of a tiny minority who are really tools of anti-trans forces, and even words like “detransition” are wrong when its all part of a journey of self-discovery.

• Calling for better research and randomised-controlled-trials is a cis-supremacist view of the world, believing that this is “treatment of a disorder” rather than affirming bodily autonomy, placing new, impossible evidentiary bars to life-saving treatment the authors already know works definitely, absolutely, no more evidence needed.

• Anyone advocating any of these points is cis-supremacist, and connected to anti-trans groups, and thus connected to the US Christian right, and look at this mountain of evidence that proves these are all bad people because they use similar words and cite the same research.

The claim that “exploratory therapy” is “conversion therapy” fundamentally is a reflection of a perspective - and if you don’t share that perspective, you must be anti-trans. You can’t talk about one without taking on all the other points because they are all deeply interconnected and self-reinforcing - and these points all arise quite naturally and logically from the same echo chamber of activists, all sharing that worldview.

Coda

There are many more notable branches along this tree of source laundering.

For instance, in May 2023, AJ Eckert and Quinnehtukqut McLamore co-authored another piece for Science Based Medicine, which is little more than a platform for Health Liberation Now’s views on ROGD, detransitioners, and fears of the Christian right. Or the October 2023 article published by the British Psychological Society authored by a group of private gender clinicians arguing that exploratory therapy is conversion, all based on citations of Ashley, Horton and Moore.

Or in December 2023, the paper titled “Recognizing and responding to misleading trans health research”, which seems to exist solely to attack a followup study on adolescent transitioners for daring to mention ROGD. This article, strangely, is written by 9 Australian healthcare professionals - and, once again, Quinnehtukqut McLamore.

And just last week, Scientific American published a favourable interview with Florence Ashley about fighting “anti-trans misinformation”. In it, Ashley cites yet another new paper making the same claims:

Some clinicians have historically sought to minimize the likelihood of someone continuing to identify as trans and/or accessing gender-affirming interventions because of a belief that being trans is inherently undesirable (Ashley, 2022b). However, these approaches are tantamount to conversion practices and are no longer considered ethical (Ashley, 2022b; Coleman et al., 2012; Madrigal-Borloz, 2020).

Of the three citations, one is the 2012 WPATH SOC, which doesn’t support this claim, one is a report by Victor Madrigal-Borloz which doesn’t support this claim, and - once again - the only citation to support this claim is Ashley’s own “Interrogating Gender-Exploratory Therapy”.

This latest paper, once again, cites 12 other publications by Ashley, and despite the lofty title of “narrative review” is in reality a review of Ashley’s own narrative.

More interestingly, in the citations there is news of another forthcoming paper from Ashley, this time co-authored with Leveille and Schevers:

Ashley, F., Parsa, N., kus, t., Leveille, L., Schevers, K., & Rider, G. N. (2023). Gatekeeping gender-affirming care is detrimental to detransitioners [Manuscript submitted for publication].

Over and over the same names seem to crop up making the same attacks and repeating the same talking points. Claims and critiques that seem independent in reality have the same source, and simply repeat and amplify earlier falsehoods with more certainty, obfuscating where it all started and why.

Every single claim that “gender exploratory therapy” is “conversion therapy” ultimately traces back to these small, highly partisan groups of activists, who - as with earlier claims about “gender-critical therapy” - simply made it up. These claims are deeply intertwined with attacks on supposed “anti-trans” clinicians - which allows whole swathes of evidence and recommendations to be condemned - in turn connected to the supposed unethicality of certain kinds of evidence, the irrelevance of detransition and desistance, the “pseudoscience” of ROGD, and the unacceptability of any gatekeeping whatsoever. The claim that exploration is conversion is not an isolated fact that can be disproved, but an inherent component of a self-reinforcing worldview that rejects contrary evidence, since all evidence that does not accord with this worldview is deemed a priori morally suspect.

Academic publishing is now a powerful political tool for taking “grey literature” claims from deeply unreliable and highly partisan activists and lending them the patina of truthiness, a faux-sciencey gloss which allows people in positions of power and authority who would rather not think too deeply about a subject to simply assume that someone else has. Citations don’t say what they are claimed to say, but the exaggerated strength of each claim compounds with every extra cycle through the academic laundromat. This is now being employed to exploit the loaded language of conversion therapy to push for legislation that would mandate a modern form of conversion upon LGB youth under the euphemism of “affirmation”.

Focusing on the terminology of “exploratory therapy” was originally an attempt by those operating in good faith to chart a path through a political minefield, but one that has ultimately failed. Those regressives who genuinely advocate gay conversion therapy have seized on it as cover, and those who are deeply, ideologically invested in paediatric transition have thoroughly poisoned the well, convincing themselves that absolutely any position other than their own reckless demands for unfettered consumer choice is “conversion therapy”. I personally believe that people sounding the alarm in good faith on the harm gender affirmation has done to LGB youth must also endeavour not to be naive to the homophobic agenda of those like ACPeds, but this seems near impossible in a febrile political climate where such distinctions cannot be permitted to be drawn.

The biggest issue though is that the deep conflation of transgender identity with sexual orientation - as evinced by the unthinking propagation of the LGBT(etc) acronym - makes it impossible to tease apart these two subjects and treat them differently. In this environment, any moves to ban “conversion therapy” will inevitably criminalise any approach other than the affirmative model, while any moves to oppose the ban ends up endorsing gay conversion therapy by default.

While the Cass Review was right to draw attention to the danger of conflating exploratory approaches with conversion therapy, such straightforward attempts to respond to this as if it were an isolated claim are ineffective. I believe a far more serious effort is needed to unpick the insular echo chambers that have overtaken this area. We are at the point where political representatives credulously repeat talking points from activist groups that are based on nothing but a hyperbolic series of self-citations, so dense as to be immune to any proper examination. Regardless of what language is used to describe it, anything other than the affirmative model will always be condemned. Cass’ mild attempt to find neutral language is doomed from the outset, because no language is permissible.

For some clinicians this is vindication, years after blowing the whistle on the scandal unfolding at the Tavistock GIDS. For others still deeply committed to the idea of the “trans child”, it is a shocking assault on a stigmatised minority, withdrawing life-saving treatments, akin to outlawing abortion, genocide or other similar hyperbole.

But even those who have welcomed this decision have noted that it does not go far enough, since this policy is not binding upon private practitioners. Of particular note here is GenderGP, a private service offering blockers and hormones essentially on demand, online, with seemingly no meaningful oversight. One of the founders, Michael Webberley, was struck off, and I have previously written about Helen Webberley’s shocking medical tribunal after giving testosterone to a 12 year old girl, which resulted in only a short-lived suspension, reversed on appeal.

In response to this latest news, GenderGP released the following statement addressed to “Mums and Dads, guardians and children, teenagers and families”:

This is a terrifying time

[…]

likely to cause enormous harm and exacerbate the higher rates of suicidality

[…]

Denying essential care to any young person is not acceptable and risks harm.

[…]

GenderGP will not be following the NHS guidance

[…]

continue to fight for that child, do not let policy harm you

And although at least one NHS commissioning body is warning GPs not to accept prescriptions from GenderGP, they are still in a position to continue prescribing blockers to children, catering to a ready supply of parents terrified by media reports and statements such as the above that their nonconforming children will commit suicide if not medically transitioned.

Despite their dubious practices, GenderGP continue to operate, appearing high up in search results on topics related to gender and transition. Success begets success, and advantageous placement in Google rankings is obviously extremely helpful to a commercial, online clinic. And since Google considers Wikipedia to be a highest quality site, GenderGP will be bouyed up - however fractionally - by the links to their site coming from Wikipedia.

Wikipedia articles are supposed to be based on reliable sources, ideally high quality secondary ones with editorial oversight. Self-serving puff-pieces by commercial vendors designed to drive traffic to their services would not seem to fall under that category. Yet as of writing, there are nine such links from Wikipedia to GenderGP’s site, on subjects ranging from Breast Binding to Transgender Inequality, and all have been in place unchallenged for years.

For example, the page on breast binding contains the following:

Duct tape has also been used to bind breasts, but it is dangerous and should be avoided. It is safer to use a binder from a reputable company or a high impact sports bra.^[23]

The citation there is a page on the GenderGP site extolling the benefits of using tape to flatten breasts, complete with prominent buttons to click for those wishing to advance beyond binding:

The link in the Wikipedia article does not support anything in particular as a useful citation - it is merely a spam link to a commercial service, added to pre-existing text.

When considering all of the links to GenderGP, a consistent picture emerges. It turns out that these links were invariably added between 2021 and 2022 by anonymous and throwaway users, whose sole purpose was to add links to GenderGP, sometimes with minimal relevance to the article in question. While some of these were quickly picked up and reverted as spam, most remain to this day.

• In April 2022, this Malta-based IP address added citations to GenderGP on pages on transgender health care, and also conversion therapy.

• Between March and May 2022, the user CreationOfTheNew made a series of edits, adding citations to GenderGP on pages on LGBT youth suicide, hot flashes, and vibrators.

• In December 2021 the user ReadandWeep made a single edit to the page on “Transmisogyny”, linking a self-serving GenderGP article titled “How Fake “Experts” Are Driving the Campaign Against Trans People”, which is still there as of today.

• Between November and December 2021, the user MeadowMellow added a link to GenderGP on four articles, with no other edits made.

• And between 10th and 15th November 2021, this Irish IP address added the link to two pages, on progesterone, and on Real Life Experience (transgender). The page the latter links to is titled “Am I Trans Enough for GenderGP’s Assessment? Yes, You Are!”, extolling the benefits of their no-questions-asked approach:

We are here to help you transition into the body and life you were meant to have. 

[…]

We’ll never act as the gatekeepers of your gender identity. GenderGP won’t ask you for questions, or even do an “am I trans quiz”.

In fact, the final edit from this IP address was made an hour before the creation of the user MeadowMellow.

It is pure speculation, but it is not a huge stretch to suggest that the IP editor added some of this link spam, realised the traceability of their IP address, before creating an account and carrying on behind greater anonymity. There might be good reasons to be suspicious that someone at GenderGP is behind that IP, but nothing beyond circumstantial evidence. Frankly, if commercial services want to spam their links on Wikipedia to boost their search rankings, then the onus is on Wikipedia to have stringent enough procedures to prevent this from happening, or for Google to have sufficient intelligence not to inflate search rankings as a result of backlinks from Wikipedia.

So why has such obvious spam not been noticed or removed at any point in the last few years, and is it simply a matter of not enough editors paying attention to those pages?

In contrast to the aforementioned page on breast binding, the Wikipedia page on the practice of “breast ironing” begins as follows:

Breast ironing, also known as breast flattening, is the pounding and massaging of a pubescent girl's breasts, using hard or heated objects, to try to make them stop developing or disappear. The practice is typically performed by a close female figure to the victim, traditionally fulfilled by a mother, grandmother, aunt, or female guardian who will say she is trying to protect the girl from sexual harassment and rape, to prevent early pregnancy that would tarnish the family name, preventing the spread of sexually transmitted infections such as HIV/AIDS, or to allow the girl to pursue education rather than be forced into early marriage. It is mostly practiced in parts of Cameroon, where boys and men may think that girls whose breasts have begun to grow are ready for sex.

Breast ironing is rightly recognised as violence against women, and acknowledged to have arisen in cultures where the sexualisation and lack of bodily autonomy of women and girls leads to these painful practices, resulting in lifelong deformity. Much easier to punish girls for men’s behaviour, than to even think of changing men’s behaviour. The page itself is flagged as being part of a series on violence against women and girls, and given that it seems unimaginable that a similar form of commercial link spam would have gone unnoticed. There’s no realistic way this page could contain links to clinics offering to carry out these procedures on minors for profit, unnoticed, as this would be widely seen as abhorrent and quickly and removed.

However, even though functionally the practice and outcome is the same as breast binding, editors on Wikipedia treat these two subjects very differently. Breast binding is considered “gender affirmation”, and the widespread view in the West is that such things are not regressive cultural practices, but entirely necessary - even life-saving - in pursuit of authentic self-realisation. Indeed, that trying to prevent such acts is hatred and bigotry. The idea that adolescent girls learning to hate and deform their bodies is in any way a form of violence against women or a result of a culture of sexualisation in exactly the same way as breast ironing is, of course, a forbidden interpretation.

These two pages are directly comparable in terms of subject matter and size, with he only real difference being prevailing cultural narrative. Both breast binding and breast ironing have received similar traffic over the last few years (with breast binding receiving a surge in attention in early 2023).

Yet this GenderGP link was added to the page on breast binding in November 2021, and has remained there ever since.

Nor can it be a matter of edits or editors, since almost six times as many editors have updated that breast binding page in that time frame (58 compared to 10), and the number of editors currently watching these pages for edits is similar (85 for breast ironing, 75 for breast binding) More eyes on the page doesn’t necessarily average out to “more accurate”, but rather “more dogmatic enforcement of prevailing cultural narratives”.

I would suggest that it is mostly because of this bias in interpretation that a clearly spam link to a commercial provider of “gender affirmation” services was allowed to remain in this page in clear breach guidelines for three years and counting. These links remain because, on the whole, Wikipedia editors believe that what GenderGP is offering is good.

Already as the puberty blockers scandal unfolds, questions are being asked as to how this was allowed to happen, and while I’m sure legislation will eventually catch up with private providers, the larger stumbling blocks are cultural ones.

That GenderGP plausibly embedded spam links in multiple Wikipedia articles and fractionally boosted their search rankings as a result is merely a tiny, pedantic part of a large and complicated story that encompasses capitalism, sexism, homophobia, technology and wild-eyed, messianic fervour.

Controversially, the “trans youth” charity Mermaids were signposting parents of vulnerable, confused children to GenderGP, something Mermaids’ former CEO Susie Green admitted, after she had left the charity to join… GenderGP.

To their shame, in an attempt to cast doubt on a 2021 National Institute of Health and Care Excellence review of puberty blockers - which found there was no evidence of the safety or efficacy of the treatments - the increasingly unscientific Science Based Medicine have cited them approvingly:

As the Gender GP writes, “The pain and distress in adolescents who face prejudice and barriers to living in their authentic gender identity cannot be alleviated by a three-monthly injection alone”.

GenderGP has resources casting doubt on regret and detransition, on rapid-onset gender dysphoria, on the ability for children to consent to permanent medicalisation, on suggesting that a child may simply grow up to be a lesbian is a form of “conversion therapy”, and on and on, all of which are echoed or cited by prominent advocates of “gender-affirmative care”. They are not outliers, but are wholly reflective of exactly the care regime that is standard in the US and which has come to be seen as virtuous, medically necessary and lifesaving.

The dominant conceptualisation that “gender identity” is some innate truth that there is a moral imperative to “affirm” has resulted in a tightly interconnected web of self-serving misinformation, linked and interlinked, repeated over and over that this is the right way to view the world and any other way is not only wrong but harmful and bigoted. Private clinicians defying NHS guidance and continuing to facilitate child transition are seen not as recklessly enabling bizarre experimental treatments with completely inadequate evidence and safeguards, but as heroes, bravely standing up to an uncaring state trying to stamp out “trans people”. This cultural narrative is sustained by its own internal logic, blind to any contradictions or nuance, and recognises only its own facts. Entirely normal child development has been simultaneously framed as both something in need of urgent, life-saving medication and something that must not under any circumstances be considered a pathology.

This understanding is what allows so many people to see the exact same practice - the intentional flattening of the healthy breasts of adolescent girls - and believe that one is violence, and the other liberation.

It is the imposition of the practice by external factors that makes it truly unacceptable. Those who are subjected to breast ironing are not truly, freely choosing this for themselves, but forced into it by circumstance, by outside pressure. Indeed, this loss of choice is what makes it so obviously wrong.

By contrast, if breast binding is in service of self-actualisation, of individual choice and transcending material limitations, pursuing an idealised, perfect inner you, then it cannot be bad. The market - dependent on an ideal of liberal, rational individuals, making free choices in their best interests - demands it. And it is the focus on an immutable, individual “identity” projected outward that allows the pretence that no external factors are at play in making that choice.

Questions about where that choice arises - about a sexist, violent, pornographic society that denigrates and objectifies the very bodies these young girls are growing into - are left unasked and rendered unaskable because the veneration of the self is sacrosanct. The act of choice makes it pure, and questioning that choice is unforgivable, a denial of autonomy, of self.

While an extension of the NHS policy on puberty blockers to cover private clinicians such as GenderGP would be welcome, it barely scratches the surface of the huge cultural reckoning we must face as this medical scandal slowly, finally begins to unravel.

In February 2024, Edinburgh University announced the uncontested election of Simon Fanshawe as rector. Fanshawe is one of the original founders of Stonewall, and now a diversity and inclusion consultant, but also quite critical of Stonewall’s direction and approach to issues of sex and gender. Notably, he attended LGB Alliance’s launch event in 2019, and has twice spoken at their annual conference.

Naturally, this meant his appointment was greeted with howls of condemnation, and many tired old attacks on LGB Alliance were wheeled out as a sort of guilt-by-association attack on Fanshawe.

Much of this centred on a long-time misconception that Fanshawe was a founder of LGB Alliance - he wasn’t, as he spent quite a lot of time explaining in the midst of this maelstrom:

Here Simon clearly states it was founded by two lesbians, one of whom (Bev Jackson) replies with more details.

A few days later, the Edinburgh Staff Pride Network released a statement objecting to the appointment, based on:

His close ties to the LGB Alliance (an organisation founded to spread anti-trans propaganda, categorized by the Global Project Against Hate and Extremism as an “anti-transgender” hate group)

This provides two citations to support the idea that LGB Alliance are a terrible organisation who Fanshawe should be condemned for his “close ties” to. Irrespective of the merits of those close ties, or indeed the many hyperbolic misrepresentations and smears contained therein, I want to look at one specific misrepresentation contained in both of these sources, and how it was plagiarised from Wikipedia, which is: who founded LGB Alliance?

Founders

For background, LGB Alliance was founded in 2019 by Kate Harris and Bev Jackson. They tweeted about this at the time, and a more comprehensive account of the founding can be found here.

LGB Alliance was founded at Conway Hall on 22 October 2019 by two lesbians -- Kate Harris and Bev Jackson. Kate is a lifelong feminist and lesbian activist and was a volunteer fundraiser for Stonewall while working as an executive at American Express. Bev was a founding member of the UK Gay Liberation Front and has a long history of activism for progressive causes, including refugee rights. She is a translator and writer.

Should you doubt the veracity of this, they have both given evidence in court as part of the challenge to their charitable status which corroborates all of this.

Bev and Kate met in the spring of 2019.

…

Bev and Kate decided to contact around 70 other LGB people with similar concerns, to hold a meeting and to launch a new organisation. They spent months preparing like underground resistance workers, keeping their meeting secret, because of the hostile climate for their ideas.

After the cancellation of a meeting planned for October 2019 at the LSE about the Gay Liberation Front (of which Bev was a founding member), Kate and Bev planned an alternative meeting for the same date, with a view to launching a new LGB organisation to fill the void they felt Stonewall had left. From Kate Harris’ witness statement in their 2022 tribunal defending their charitable status:

Ms Jackson had been asked to sit on the panel of a GLF anniversary meeting at LSE in October which she references in her witness statement. That meeting was cancelled, but on 18 July 2019 Ms Jackson called me to say that she would be travelling to London in any case and that she thought we should call our own meeting on the date that the meeting had been planned for - 22 October 2019. I said to her “That is the best news I have heard all year!”. This was the day when we both realised that we could finally move forward in setting up a group specifically aimed at fulfilling what became our charitable objects

They spent the intervening months sounding out potential allies, inviting people in strict secrecy, one of whom was Simon Fanshawe, who spoke on the day. Of those attendees, some immediately joined:

Kate and Bev – and the rapidly-assembled little team including Allison Bailey and Malcolm Clark -- also received a barrage of abuse – before a single public statement had been made.

I don’t believe there is any serious dispute that Kate and Bev instigated the meeting and invited the attendees, and whether or not people joined them immediately or came on board soon after, or were later appointed directors doesn’t really change the wide recognition of all involved that Kate Harris and Bev Jackson are the two co-founders.

However, the sources relied upon by Edinburgh Staff Pride Network say something different:

The group was founded by Bev Jackson, Kate Harris, Allison Bailey, Malcolm Clark and Ann Sinnott

So where does this come from?

Wikipedia Synthesis

If you Google LGB Alliance, you see a nice, helpful, authoritative-looking information box populated from Wikipedia, which displays this different set of founders:

Wikipedia is supposed to be an encyclopaedia assembled from what reliable sources say. There are rules against original research and synthesis, which mean that you aren’t supposed to combine multiple sources to make novel claims that no one source makes on its own. Those rules seem to have been disregarded in 2021 when a handful of editors started piecing together a list of names from passing references and adding them together to decide who LGB Alliance’s founders really are. After much back and forth and source juggling, Ann Sinnott was added in August 2021 based on a Pink News story about her resignation, and Allison Bailey and Malcolm Clark were added in September 2021 from similar isolated mentions. Taking multiple independent passing references like this and concatenating the names together is not how sourcing is supposed to work on Wikipedia. This specific list of founders as it now appears (Bev Jackson, Kate Harris, Allison Bailey, Malcolm Clark, and Ann Sinnott) appears nowhere else prior to its invention by these few editors on Wikipedia.

To illustrate how dubious this is, retaining one of those names - Malcolm Clark - was justified with a January 2020 Pink News story describing him as a “founder”, and attacking and misrepresenting one of his Facebook comments. In response to the piece, Malcolm said the following:

In fact, some months later, he reiterated the point in a back and forth with Ryan Butcher, then Pink News’ head of news.

Note that Ryan Butcher here seems to concede the point, yet Pink News have never corrected the record.

It seems not to matter that, according to standard Wikipedia rules on self published sources about an organisation, it is absolutely fine to simply take what their website states as true. It seems not to matter that more reliable sources say that Kate and Bev are the two founders, and that any earlier misreporting can be chalked up to a small, fledgling organisation getting mixed press coverage - again, something Wikipedia’s rules on favouring more recent sources is supposed to correct for. It doesn’t even seem to matter that there is absolutely no dispute about any of this from anyone involved and multiple court documents and journalistic sources verifying exactly what they plainly state on their website. The problem with all these rules about what is a reliable source and what is improper synthesis is that editors decide when and how to apply them, and this is a process that - in niche and highly contentious areas like this - isn’t exactly bulletproof, to put it mildly.

Frankly, it has gone on so long that unless a decent journalistic source outright states that this Wikipedia article is stuffed full of nonsense, I can’t see it ever getting addressed.

Edinburgh Staff Pride Network

Which brings us back to the Edinburgh Staff Pride Network statement, and its two citations, one a Pink News piece, and one a report from the Global Project Against Hate and Extremism (GPAHE), both of which can’t even get the organisation’s founders right.

Wikipedia says, in September 2021:

Bev Jackson, Kate Harris, Allison Bailey, Malcolm Clark, and Ann Sinnott

GPAHE later repeats this, in August 2022:

Bev Jackson, Kate Harris, Allison Bailey, Malcolm Clark, and Ann Sinnott

As does Pink News, in September 2022:

Bev Jackson, Kate Harris, Allison Bailey, Malcolm Clark and Ann Sinnott

The same five names, in the same specific order, and all three incorrect.

The probability of either source independently coming up with that non-alphabetic list of names, in that same order, by pure chance is less than one in a hundred.

Since its fabrication on Wikipedia, that list of “founders” has gone on to appear not only in these two sources, but multiple Pink News articles. The obvious conclusion is that both GPAHE and Pink News have merely copied it from Wikipedia, and in the case of Pink News, they are themselves at least in part the originating source, now regurgitating their own knowing misrepresentations as fact.

This is essentially circular, something editors on Wikipedia should be on the lookout for, but because the information is merely plagiarised (rather than actually cited) and no serious source is likely to write an expose of this GPAHE report and Pink News’ atrocious journalism, there seems no way of correcting this. It is surely only a matter of time before someone cites one of Pink News’ many subsequent articles listing those five founders as “proof” that that’s who the founders are, which will be a particularly intractable case of citogenesis.

It might seem comparatively minor that Pink News is copying this information from Wikipedia, even if it is the roundabout source of these false claims. However, in the case of GPAHE, the plagiarism is far, far worse.

Global Project Against Hate and Extremism

The report which ESPN cites was published by GPAHE in August 2022, on far-right and extremist groups in Ireland. GPAHE give every impression of being a serious organisation monitoring rising hate and extremism across the world, and most of the groups listed are indeed far-right groups. However, the authors saw fit to include LGB Alliance Ireland in that list, a tiny (and now seemingly defunct) Irish group inspired by the launch of LGB Alliance in the UK.

It turns out on close inspection that not only has this report lifted the list of founders from Wikipedia, but in fact, virtually the entire passage was blatantly plagiarised from Wikipedia. Below is a series of sentences collected from the Wikipedia page as it was around the time this report was written, compared to the text of the report itself.

The sentences do not appear in the same order in the Wikipedia page, but apart from minor formatting changes and americanisms which I have excluded from this comparison (commas inside quotation marks, “behavior” instead of “behaviour” etc), virtually all of the GPAHE report is copied verbatim from Wikipedia. Additionally, most of the underlying citations are the same too, with referenced Pink News articles copied from Wikipedia to substantiate the same claims.

The differences are, on the whole, trivial, and this is as clear an example of plagiarism as one could expect to find.

As for the substance, it is worth noting that of the sentences, only the final three actually refer to LGB Alliance Ireland at all. The rest are entirely about LGB Alliance, the UK charity, of which some of those are smears and misrepresentations I have written about previously (for example, John Nicolson’s one-sided account of being piled on organically on social media after repeatedly attacking LGB Alliance and randomly arguing with Jonathan Ross). The GPAHE report not only cites Pink News, but is plagiarised from a Wikipedia article substantially based on Pink News stories. Indeed, most of the negative content on the Wikipedia page and a third of all the citations are from Pink News, who have mounted a sustained attack on LGB Alliance since it was formed. This report is now cited on that page itself, to substantiate an allegation that LGB Alliance Ireland is an extremist organisation. This is not just circular, but a feedback loop, taking the same claims on Wikipedia, and reframing them even more harshly, which then produces more stories exaggerating them further, and on and on in a spiral of hyperbole and condemnation.

GPAHE are an organisation based in Alabama, started up by two former Southern Poverty Law Center veterans. If a US-based organisation with no connection to the UK is classifying a registered UK charity as a “hate group” based on reading a Wikipedia article about them, and copying it almost verbatim into an authoritative looking report, this is not an organisation that anyone should be taking seriously. Yet these are people whose platform enables them to address the UN, and nobody is holding them to account.

Just this week they boasted of their expanded database of hate symbols which is to be used by:

tech companies, governments, law enforcement agencies, militaries, and civil society organizations

Their database lists the acronym “LGB” as a term of anti-trans extremism:

"LGB" is term that is deployed in order to disassociate equal rights for lesbians, gay men and bisexuals from those of trans people by removing the "T" from "LGBT." This version of the acronym was used prior to the 1980s, when the "T" was eventually added. The transnational organization LGB Alliance, headquartered in the UK, uses this acronym to signal their opposition to rights for trans people.

This sort of thing should worry anyone who thinks that LGB is a completely neutral term, if this is what GPAHE and organisations like them are training “law enforcement agencies” to be on the lookout for.

Conclusion

If there were any justice, there should be some sort of correction of the false information Pink News have been perpetuating for years, an admission they have been shamelessly cribbing a list of “founders” from Wikipedia, and most of all a retraction of the shoddy plagiarism in the GPAHE hatchet job. That of course will never happen, because smears like this last forever, are never corrected, and are simply recycled over and over as if no-one has ever challenged them, as this latest attack on Simon Fanshawe demonstrates.

Should someone accused in this fashion reject guilt by association, or is that an admission there is something wrong with the association in the first place? Should you mount a full-throated defence even though it is exhausting and pointless and, by rights, should not even be necessary?

Fanshawe’s situation really shows the impossibility of grappling with these accusations when you’re confronted with them. The protest against his appointment contains so much wrong it is impossible to know where to start. You can write an essay on just a couple of select points, as I have, and still barely scratch the surface of it. And even if you were to go through point by point, explaining at length why every single thing claimed is wrong or a misrepresentation, it will have no effect because this sort of thing will just pop up again.

If Pink News cannot even get something as basic as who founded LGB Alliance right - indeed, showing a flagrant disregard for it - why is anyone taking them seriously?

If GPAHE determine who is or is not a hate group by plagiarising wikipedia, why is anyone taking them seriously, and who is supposed to be holding them accountable?

If Edinburgh Staff Pride Network are relying on this quality of source to inform their opinion, what does that say about their judgement?

Once again, this highlights both the power of Wikipedia to shape social attitudes in these niche areas, and its vulnerability to groupthink, feedback loops and motivated activism, with inadequate oversight, no realistic means of correcting the record and profound real-world consequences.

Where most people would understand conversion therapy to mean abhorrent practices aimed at trying to change someone’s sexual orientation, trans-focused activists have over the past few years directed this label at any therapeutic process that does not straightforwardly affirm an individual’s stated “gender identity”. As I noted in that piece:

The World Professional Association of Transgender Health (WPATH) issued a statement calling “exploratory therapy” tantamount to “conversion”.

This conflict has resulted in the UK Council of Psychotherapy having to release a statement to the contrary:

exploratory therapy must not be conflated with conversion therapy

Ultimately though, if pro-affirmation activists are successful in reframing every approach other than their own preferred model as “conversion therapy”, then any bans will end up making their approach mandatory.

In February 2020, in response to one tweet, a fictitious form of therapy called “gender-critical therapy” was invented by pro-affirmation activists, who decried its alleged practitioners as advocating “conversion therapy”. This term was spread like a moral panic via a handful of weak, partisan media reports, and then laundered into respectability through reports and guides for policymakers, each layer of citation obscuring the fictional, anonymous origins of the phrase.

Use of this invented term was short-lived, and has since been overtaken by the more direct attacks on “exploratory therapy”, but the creation and dissemination of this term is a useful case study in how these fabrications and smear campaigns are spread, and the wider attacks on other language that is taking place.

The rest of this piece is a timeline of the creation and spread of this myth, showing how weak claims - or outright lies - can be very effectively laundered through several layers of citation, taking on the appearance of greater reliability at each level, with the ultimate aim of shaping policy.

February 2020

In February 2020, psychotherapist Stella O’Malley, as part of an exchange with comedy writer Graham Linehan, tweeted the following:

I hate the phrase gender critical but I am making a list! A large number of people contact me seeking help and I don't know enough Irish therapists who can provide compassionate and nuanced therapy.

“Gender-critical” here being a phrase with a complex, muddy history, and meaning in this context simply “a person who understands that sex is real, immutable, and not to be confused with notions of self-declared gender identity”, which describes the vast majority of people on the planet. O’Malley was clearly hoping to collect a list of therapists, who would take an exploratory - rather than an affirmative - approach to psychotherapy with transgender youth.

To which several anonymous Twitter accounts with a transgender flags in their names said things like:

On February 5th, GCN published a piece titled “Graham Linehan calls for list of Irish 'gender critical' therapists for trans children” based on this Twitter furore, quoting the above tweet as follows:

O’Malley’s Tweet has been met with numerous comments calling out the cruel practice of ‘conversion therapy’. One person stated, “Gender critical therapy is conversion therapy. Say it as it is.”

O’Malley never mentioned “gender-critical therapy” and no therapist claimed to offer “gender-critical therapy”. The only source for the claim that “gender-critical therapy” exists and is, in reality, conversion therapy is tweets such as this one.

On February 16th, The Independent published an opinion piece by the male transactivist Gemma Stone titled “Gender critical mental health professionals are trans conversion therapists by another name”. This described the incident as follows:

Prominent trans people on social media spoke out in droves, warning of the dangers of legitimising “gender critical therapy”.

Here in early 2020, what we see is an attempt to associate the phrase “gender-critical” with “conversion therapy” by using the invented term “gender-critical therapy”.

I repeat: no therapist seems to have offered any such thing, and the call in the original tweet was for compassionate, nuanced therapists who would take an exploratory approach.

On February 26th, ILGA World published a report titled “Curbing deception - A world survey of legal restrictions of so-called ‘conversion therapies’ .” This report featured the following entry in the glossary:

5. “Gender critical therapy”

Activists and survivors have pointed out that the term “gender critical therapy” is a term used to refer to a form of “conversion therapy” practiced on trans youth: both notions “rely on the same ideas and want the same end results”.

The ILGA report gives three citations for this, which turn out to be the pieces in GCN, the Independent, and a random blog rant that adds nothing whatsoever, posted anonymously to Medium on 12 February 2020.

Within 22 days of Stella O’Malley not tweeting the phrase “gender critical therapy”, and 11 days of Gemma Stone’s biased opinion piece appearing in The Independent, the urban myth of “gender-critical therapy” had been laundered into a flagship report by one of the largest and most influential trans-rights organisations in the world.

The general public are not the target of such reports - they are aimed squarely at policymakers, and this report was welcomed immediately by the UK’s All Party Parliamentary Group on LGBT issues. In just over three weeks, confected Twitter drama had been sanitised, obfuscated, and presented straight to key influencers in the UK parliament as fact.

June 2020

In June 2020, Teen Vogue published an article by Heron Greenesmith, of the Transgender Law Centre. The thrust of this article was that parents of trans-identifying youth were at the time using an online forum called the “gender critical support board” to post messages such as:

“I need a therapist for my male-identified daughter who won’t just affirm without any questions. We are desperate. Thank you.”

What Greenesmith was specifically critical of was parents apparently making lists of therapists who take an exploratory approach:

Some parents on the Gender Critical Support Board may be seeking what many would view as conversion therapists for their children — licensed mental-health-care workers who, in the parents’ words “won’t just affirm [their gender identity] without any questions.” These parents don’t view “non-affirming therapists” as conversion therapists, but the connections are clear: “gender-critical therapy” is the newest cover of a song that’s been playing for the past 50 years.

As with O’Malley’s tweet, “gender-critical therapy” again is seemingly not something actually on offer from any therapist, but simply Greenesmith’s own description of the kind of therapy that might be offered by therapists who are “gender-critical”. Therapists who are suspected of not being affirming enough are labelled as practitioners of this invented “gender-critical therapy”, again portrayed as a new euphemism for “conversion therapy”, even though no therapist is shown to be using it as such. Note also the weasel words “many would view”, justifying strong unsubstantiated claims of conversion therapy with Trumpian handwaving.

Creating this link between “gender-critical” and “conversion therapy” was the whole point of this article, as signposted by Greenesmith before it was even written, in April 2020.

October 2020

On October 2nd 2020, the phrase appeared in a piece about conversion therapy on Pink News, with reference to a now-defunct Canadian campaign group called “We The Females:

We The Females propose that trans youth should be subjected to “gender-critical therapy”, to deter or prevent them from transitioning.

Note that although it is in quotation marks and has the appearance of a direct quote, it is not, and the author also presents “conversion therapy” in exactly the same way in quotes earlier in the piece. I could find no reference to the phrase in archives of their site or in any of their submitted material to Canadian legislative consultations. This claim appears to be entirely invented and the phrase “gender critical therapy” is not actually attributed to We The Females, but is the author’s personal interpretation.

Five days later, on October 7th 2020, the phrase appeared on a page about conversion therapy on dictionary.com:

As awareness has been raised for the harms associated with conversion therapy, the same discredited practice has once again rebranded, this time using the language of gender-critical therapy

The citation here is the Heron Greenesmith piece in Teen Vogue.

December 2020

The Trevor Project is an influential US-based nonprofit focused on suicide prevention for LGBTQ youth. Starting in 2019 The Trevor Project ran a campaign against conversion therapy. Sometime between November 24th 2020 and December 31st 2020, this page was modified to add:

“Conversion therapy” can come in many forms and is sometimes known by other names, including: “gender critical therapy”

No source is given for this. It doesn’t come from any of the citations for research on conversion therapy they provide, and it doesn’t appear in any of their subsequent publications. The campaign no longer exists on their site. They seem to have simply invented the claim sometime in late 2020 and then forgotten about it.

Given the close associations and even some shared directorships between Transgender Law Centre, The Trevor Project and WPATH, it is unsurprising that they all share the same view of conversion therapy, and when Greenesmith’s Teen Vogue piece came out, she specifically thanked The Trevor Project’s Director of Law & Policy, Casey Pick for the input into the article. The sudden emergence of this specific phrase in a prominent campaign, at that particular time, without any source justifying it, is notable.

Summer 2021

In Summer 2021, an NYC University Law Review piece on the right to sue for gender-affirming care included the text from the Trevor Project campaign site in a footnote, including the unevidenced claim about “gender-critical therapy”.

October 2021

As part of ongoing attempts to legislate against both sexual orientation and gender identity conversion therapy, the Government Equalities Office commissioned research into the extent and nature of conversion therapy in the UK. This research was conducted by Coventry University, and published on October 29th, 2021. This includes the following claim in a footnote:

[…] the grey literature suggests that other forms of conversion therapy may be more specific to transgender people. For instance there have been reports of people sharing lists online of therapists for parents of transgender children seeking non-affirming therapists (Greenesmith, 2020; ILGA, 2020)

This makes the contentious assumption - one refuted by the Cass Review, current NHS service specifications, and the UKCP statement at the top of this article - that a “non-affirming therapist” equates to conversion therapy. The more important thing here though is the two direct citations for this claim are, again, the ILGA report, and Heron Greenesmith’s Teen Vogue piece1.

Although it does not directly repeat the phrase “gender-critical therapy”, it does accept and legitimise the framing that in asking for “compassionate and nuanced therapy”, O’Malley was in some way promoting conversion.

March 2022

The phrase appeared once again in a 2022 UNDP Handbook For Parliamentarians:

Conversion therapy: An umbrella expression to refer to any sustained effort to modify a person’s sexual orientation, gender identity or gender expression. Other terms include: “reparative therapy”, “gay cure”, “ex-gay therapy”, “gender critical therapy” and Sexual orientation, gender identity or gender expression change efforts (SOGIECE) (ILGA).

The citation here is the 2020 ILGA report. So again, this traces back to O’Malley’s tweet, via the original activist misrepresentations in GCN and The Independent, laundered through ILGA, and into a UN handbook created specifically for informing policymakers.

June 2022

The transactivist group Health Liberation Now - who have previously co-authored work with Heron Greenesmith - publish the claim on their website that:

“gender exploratory therapy,” previously known as “gender critical therapy”,

The citation for this claim is once again O’Malley’s deleted tweet, which does not - I repeat - say anything about “gender-critical therapy”.

By this point, no doubt aware that “gender-critical therapy” wasn’t really catching on, activists were claiming that “gender exploratory therapy” was its new name, without acknowledging that they are the only ones that ever used the term.

2023

The phrase appears in a report from a Polish transactivist lobbying group released in 2023, once again derived from ILGA:

Another term mentioned in the ILGA report is gender critical therapy. It relates to “conversion therapy” practiced on transgender youths

[…]

Its main proponents are people associated with SEGM and Genspect organisations,
[…]

The term “gender critical therapy” is generally used by persons who had, at one point, identified with feminism to some degree, such as Stella O’Malley.

No source is given for these claims and there is absolutely no evidence of any of the named individuals or organisations using the phrase “gender-critical therapy”. The claim that Stella O’Malley used the term “gender-critical therapy” goes all the way back - via ILGA - to that 2020 tweet where she explicitly did not say that.

Though they don’t cite them directly, this report does make reference to Health Liberation Now, and repeat many of the same allegations in other areas. Specifically, again they claim a shift in language from practitioners:

Others, like Marcus and Susan Evans, use the term “exploratory therapy”, even though such a term is not mentioned in the ILGA report due to it being fairly new (Spiladis 2019). In recent years, however, the term has become very popular in circles of “conversion therapists”, superseding previously used terms.

Once more, activists alleged that “exploratory therapy” is a new term employed by “conversion therapists”, superseding the previous term “gender-critical therapy”.

Yet no-one outside of these pro-affirmation activists ever seem to have used this term, so claims of it being “superseded” don’t stack up. The excuse given for ILGA not having mentioned “exploratory therapy” before was that it was “fairly new”. This also doesn’t make sense, since the 2019 Spiladis paper cited here precedes the Twitter-based nonsense ILGA actually dumped into their report by a full seven months.

Conclusion

What this all lays bare is that partisan activists seized upon a new term of their own invention (“gender-critical therapy”), talked about it for a couple of years and then moved on to new talking points, while inventing a narrative that it was their opponents who shifted language, to disguise their true, “conversion” aims. In the logic of conspiracists, all new contradictory information actually becomes evidence of just how deep the conspiracy goes, how devious their opponents are in concealing their motives behind “reasonable” language. QAnon standards of evidence and reasoning laundered into respectability, and tenuous hearsay origins obfuscated via handbooks for policymakers.

We have gone from:

• Baseless abuse responding to one deleted tweet, to:

• Partisan coverage in supposedly journalistic outputs with no regard for balance, fact-checking or the consequences of putting out abject drivel, to:

• Biased laundering of these opinion pieces into respectability by ILGA, to:

• Citation in a GEO-sponsored piece of research whose purpose is to inform policy on a hotly contested political issue, and inclusion in a handbook for parliamentarians, produced by the UN Development Programme.

And that’s how Twitter drama and biased pieces in laughably irrelevant publications like Teen Vogue end up shaping global policy.

For the icing on the cake, if you google “gender-critical therapy” you may be fortunate enough to receive something like the following featured snippet:

Why? Because the absolute nonsense in response to one deleted tweet in 2020 has been effectively laundered through so many layers of irresponsible or outright partisan publication with no fact-checking or repercussions, that it can finally be dumped in a Wikipedia page where it may potentially sit forever at the top of search results. Thanks to the toxic editorial dynamics on any page that touches sex and gender, such material cannot be removed without reliable sources that say otherwise - and no-one is going to create those sources, because no-one is watching this steady pollution of information and providing any sort of oversight. There are no functioning checks and balances, and no incentive to create them. Indeed, the only counterpoints are usually equally partisan, unreliable, conspiracist nonsense, coming from the opposite political pole.

Nobody is going to bother writing a serious journalistic piece about how the glossary in a 2020 ILGA report and a 2022 UNDP handbook are based on nothing whatsoever, or about how one misrepresented, deleted tweet seems to be the whole basis of a short-lived moral panic about completely non-existent “gender-critical therapy”.

There is failure at every step of this process.

• Where are the editorial standards at GCN, The Independent, even Teen Vogue? Where is the comeback and oversight for inventing terms out of whole cloth or simply repeating the content of anonymous tweets?

• Where is the oversight and accountability of ILGA taking horribly biased articles and a random anonymous Medium post and laundering them into an authoritative looking “glossary”?

• Where is the oversight and accountability of UNDP adding another layer of indirection by taking ILGA’s report as gospel without checking their sources? Do they even care?

• Where is the oversight and accountability of the Trevor Project simply repeating claims with no evidence or citations, and then deleting it afterwards?

• Where is the oversight and accountability of government-sponsored research legitimising such terrible sources in reports designed to inform policymakers?

• Where is the oversight and accountability of Wikipedia, whose outsize influence and social composition has made it a prime target for spreading partisan political viewpoints?

• Where is the oversight and accountability of Google, who simply serve up the contents of a Wikipedia page as if it was true, with no regard for how any of this information got there, because it is “good enough”?

It is impossible to make sense of political disagreements in the middle of this crisis of misinformation, and every step of the process that is supposed to inform politics is broken, with no checks and balances, and no means of correction. Instead, the very organisations responsible for laundering misinformation into the political sphere with no oversight and no comeback are being placed in charge of gatekeeping what is or is not acceptable opinion.

I’m sure a flash-in-the-pan manufactured controversy gets some consequence-free clicks and views for outlets like The Independent, with no thought for what happens down the line, but these utterly irresponsible and biased publications have resulted in baseless smears against a handful of individuals years down the line being fed directly to policymakers via persuasive and influential reports. These errors don’t correct themselves in aggregate, they accumulate. There is no mechanism by which gossip and exaggeration and urban myths like this can be retracted, no process that withdraws false information from the sum of human knowledge, and even if there were, no-one we can trust to take charge of it.

At the beginning of episode 198 of Blocked and Reported, Katie Herzog discusses recently discovering she has Aphantasia. I recommend listening, because what she describes will be incredibly familiar to anyone who - like I have - come across this term later in life and been absolutely floored by its implications.

Aphantasia is the name given to the state of having no visual internal world, to be “blind” in the mind’s eye. I first came across the term in 2019, in an interview with the legendary Ed Catmull of Pixar, discussing this condition:

The former president of Pixar and Walt Disney Animation Studios says he has a "blind mind's eye".

Most people can close their eyes and conjure up images inside their head such as counting sheep or imagining the face of a loved one.

But Ed Catmull, 74, has the condition aphantasia, in which people cannot visualise mental images at all.

It is now coming up to five years since I discovered this term, which potentially describes my own experience, but also that I still cannot say for certain how widespread it is, how much is a real phenomenon and how much is simply the limitations of language.

What you very quickly discover when trying to explain this to other people is that all of our metaphors for how our brain works - seeing, visualising, picturing, imagining - are visual.

I have taken part in a few online studies, and the types of questions are always the same, as are my answers. Picture a horse or a beach or a meadow or a face or a sunset. Now rate 1-5 how clear the image is.

1. No image at all, I only “know” I am thinking of the object

2. Dim and vague image

3. Moderately realistic and vivid

4. Realistic and reasonably vivid

5. Perfectly realistic, as vivid as real seeing

I am always at the bottom of these scales. Always a 1. Typically around 3% of people answer this, with a further 8% in the “dim” range.

And I am astonished, time and again, when people I have known and loved for years answer anything other than 1 to these tests. To me, the idea it could be anything else is inconceivable. That I could have spent over four decades interacting with friends and relatives every single day of my life and not know that their every waking moment was radically different to mine is quite profoundly upsetting.

So listening to Katie Herzog’s slightly shellshocked discovery in this podcast was highly relatable.

Picture a horse

Are you picturing it? Now describe it.

At this point many people describe its setting, its colouring, its flowing mane, how big it is, what it is doing, how it is standing.

Me, I will make things up as prompted and try to remember the words I have said. A horse you say. What colour? Well, lets go with black and white. Which parts are black and white? Er, I don’t know, maybe some patches on the body? How big? Average horse sized. Where? In a field.

And so on. These are just words. It never occurred to me that to anyone else it was anything other than words. I am assembling facts about a fictional horse. There is no picture, no visualisation, no image. There is only a featureless void, and mental connections being made between abstractions.

When you say picture a beach, I think the word beach. I know what a beach is, I know what its properties are. It is the abstract concept of a beach. I can’t describe the things on it, or what the sand or stones are like, or what colour the sea or sky is or the warm breeze, because all I think is “beach”. If you ask, I could make stuff up, and probably forget quickly enough.

I always assumed that there were people out there who had very strong mental imagery, who could picture and play back the world in three dimensions and technicolour, but I always assumed that anything resembling sort of facility was a vanishingly rare exception. Savants with a photographic memory and suchlike. What I never grasped was that the vast majority of people, when picturing something, do at least see something, somewhat visually, in their heads. Even if not quite the same as seeing with their eyes, there is still something that can be compared more accurately to visualisation than simply repeating the word “horse” in your head. It seems there exists a spectrum between that dazzling facility to picture inside your head, and the blackness inside mine, and the great majority exist in the space between.

And yet I still cannot ever know how much of that difference is genuine, and how much is the limitation of language, of not being able to see inside someone else’s head, or they into mine. Of never being able to truly share your personal experience fully, without the mediation of crude language in between.

I have seen showmen like Derren Brown explaining their superhuman feats of memory as making use of techniques like “loci” and “mind palaces”. That is, to remember seemingly impossible sequences of information, they build rooms in their head and populate the rooms with items, and attach the information to these items.

This never made any sense to me whatsoever. There is no benefit to the mind palace, when the mind palace is just another thing to remember. Without some sort of visual, spatial awareness of these imagined rooms and items, there is nothing for the information to attach to. I always thought I was just doing it wrong, but I now think it is just a metaphor that simply doesn’t work without visualisation of some sort.

This link between the visual and what we remember is why my memory is so hazy, and indeed another aspect of Aphantasia is that of having a generally terrible autobiographical memory. Unless events are part of some narrative I have told and retold, then they are lost - and even then, if I remember the narrative, do I even remember the events? What does this mean for a sense of self, and identity?

Every time Aphantasia comes up in popular media, I see more and more people say they experience the world this way. Perhaps after all we are not the tiny minority it was first thought.

Or maybe, again, this is the barrier of subjective experience and the limitations of language to truly convey our experience outside ourselves.

I cannot ever know the answers, and any difference between what other people experience and my own internal world will remain forever mysterious.

There is a phenomenon I’ve noticed in political discourse many times in recent years, which goes like this:

• An existing term is colonised and its meaning subverted to new political ends

• Previous users of the term are forced to try to come up with a new term to replace the old one

• The new occupants demonise the old, and deny political legitimacy to any new terminology

The best description I can think of for this process is semantic gentrification, in which users of a word’s original meaning are forced out by newcomers who consider themselves morally enlightened in comparison to the older population, who completely change the character of the term in service of their own, narrow interests, and who regard the now-homeless former inhabitants with contempt.

Inherent in this is a sense in which the new meaning is superior to the old, representing a progressive, moral inevitability, and that attempts to reassert old meanings are denied legitimacy as regressive, backwards, and “on the wrong side of history”. Why would you want to hold on to a run down, backwards old semantic neighbourhood, when the shiny new hipster takeover is such a clear improvement?

More than just a straightforward language drift, where a term changes or becomes emptied of meaning over time, this is much more of an explicit takeover. A subversion and destruction of language as a clear exercise of the power of the colonisers, appropriating whatever goodwill exists towards the original semantic structures, while those who are usurped are both ostracised and unable to clearly articulate their position.

And since this process is invariably in service of men’s needs and interests, that really puts the gent in gentrification.

Sex, Gender and Feminism

This process has happened time and again in terms that have been at issue in the sex and gender conflict - words like male, female, man, woman, sex, gender, feminism, all undermined to include their opposites, while legislation and protections using the old meaning are seamlessly transferred to the new.

For example, the female-centric analysis of feminism was colonised and redefined into a gender-centric one promising “equality for everyone”, women’s studies supplanted by gender studies, and so on. Rather than a movement to redress historic inequity for women, and bring women’s needs to the fore, this shift reinforces women’s stereotypical role as primary caregiver, sacrificing their own needs - their own words - to right all of the world’s wrongs.

Of course, in this inverted analysis, the most wrongs are perpetrated against the most “marginalised genders”, and the most marginalised of all are the men who wish to be seen as women, whose concerns have become so central that any women’s issues that exclude them are deemed hateful. The new meaning of feminism - of man, woman, male, female, sex, gender - is “trans-inclusive”, so therefore the only reason to not accept the new meanings is to be “trans-exclusive”. And being exclusionary to marginalised genders sounds like the sort of bad thing that happens in the run-down backwards old meaning of these words, not the shiny new forward-thinking, renovated, artisan-genderfluid-coffee-shop-on-every-corner meaning.

Mounting a resistance has meant starting from scratch, trying to carve out new semantic boundaries where the old ones were, all while being absolutely demonised - invisibly redistricted into bad (right-wing) discursive neighbourhoods.

As this process took shape, the existing users of terms like “feminist” increasingly resisted this process. Some conceded new meanings of “woman” while trying to draw the line at “female”, or used new more precise terms like “gender-critical feminism” to describe what it was they advocated. Others rejected such moves as needless and tautological, since “being critical of gender” is inherent in the meaning of “feminism”. Some have attempted to apply differential labels to the colonisers, such as “genderists”, but lack the cultural power to make this relabelling stick in any meaningful sense. In any case, the problem was that the original words had been taken over and now the new occupants were denying the former inhabitants any language to describe the original meanings.

As time has shown, these attempts to maintain boundaries with new terms or by reclaiming the old ones have faced an enormous struggle, since any language that rejects the gentrified meaning becomes “anti-trans” by definition. No matter what phrasing is used, all alternatives are readily portrayed as a cynical attempt to smuggle “anti-trans” beliefs under reasonable-looking language, to the point where terminology so basic there is nowhere left to go (such as “female” and “biological sex”) are considered “dogwhistles” for hateful bigotry.

For example, when the 2010 Equality Act was written, it would not have occurred to the vast majority of people that “sex” could ever be interpreted as other than referring to a person’s actual, immutable, biological sex. However, the gentrification of sex that has accelerated since then - supplanting it with vague, sovereign conceptions of self-declared “gender identity” - has forced critics to waste time and political impact with cumbersome language and lengthy explanations, just to make statements that ought to be uncontroversial.

In 2023 the Equality and Human Rights Commission (EHRC) suggested clarifying the law to preserve its obvious original intent, but too late. The plain old meaning of “sex” was now anathema to its entitled new squatters, and Stonewall (along with dozens of other organisations) are currently attempting to strip the EHRC of its “A” status for daring to mention boring old “biological sex”:

A recent report by Women’s Rights Network documents how UK Police Forces have adopted a 2021 policy which allows male officers to strip search female detainees, so long as those male officers claim to be female. This absurd policy appears to have been nodded through unchallenged with no serious consultation or visibility, simply because it is seen as “the right thing to do”. However, little about the policy is actually new, but rather formalises what was in many cases already happening. If pressed to ask where all these changes originated, it seems likely those involved would be unable to provide a clear trail of decision making. Across institutions, policies such as this have been brought about by the incremental adoption of “best practices”, all of which take as an underlying assumption that obviously the new and improved understanding of sex is more modern and accepting than the messy old version.

This is unthinkingly accepted by progressive, liberal-minded policymakers, HR departments and uninvolved bystanders alike because of the presumed moral authority of the new semantic occupants, representing as they do “progress”, ushering in an inevitably brighter future. While all of this has taken place, the most vocal advocates have been free to attack any hint of dissent as old-fashioned or conservative, all of which has fostered a climate where zero real scrutiny takes place. Merely trying to describe an alternative position is a doomed, uphill struggle, because it starts from the disadvantaged position of moral inferiority.

Shared understanding cannot be assumed because the entitled new occupants have appropriated the old semantic structures, and supplanted them with their new, fashionable concerns. Every attempt to speak with precision about the pre-gentrification meaning of these words, to talk only about women’s rights and needs, to talk specifically about LGB issues, to make a feminist stand on a newsworthy event or a matter of policy - all becomes a trans issue. The conflict is inescapable, and a huge amount of time is expended trying to restate entirely reasonable feminist points from first principles. All the while the new inhabitants of these well-respected old semantic neighbourhoods have free rein to use their stolen goodwill to reshape society in the way they see fit.

Sensible debate and policy scrutiny around women’s rights has foundered in this environment, which is dismal enough. However, this exhausting process is now well underway in the arena of therapy, in service of the same political ends.

Conversion Therapy

“Conversion therapy” has long been understood as a coercive and often brutal attempt to forcibly change an individual’s sexual orientation, ie to stop a gay person from being gay. Unlike actual therapy, this process has a fixed endpoint in mind - that being heterosexual is the only acceptable outcome - and uses a variety of means, from prayer to coercion to psychological or physical abuse in service of achieving this.

Many would intuitively understand that trying to stop an individual from being gender nonconforming is strongly associated with homophobia. If, for example, you have a small boy who likes wearing dresses and playing with dolls, beating him to make him stop because you’re afraid he’ll grow up gay would seem to be clear and obvious homophobic abuse, and the sort of thing people have in mind with “conversion”. After all, gender is the socially constructed set of roles and norms, and heterosexuality (by way of male dominance and female submission) is perhaps the primary norm that gender invariably enforces. Trying to make a gay person straight is similar to trying to stop a “feminine” boy from “being like a girl” insofar as they are both reflective of rigid social gender norms. Indeed, this sort of pathologisation of stepping out of the strict confines of gender norms is why so many noncompliant young women - many lesbian or bisexual - were institutionalised or lobotomised for “hysteria” throughout the 20th century.

However this previously uncontroversial understanding of an abhorrent practice has been modified in recent years to cover both conversion of sexual orientation and gender identity. And while trying to stop someone from being gender nonconforming would seem to fall under that heading, modern conceptions of “gender identity” radically alter this picture. Specifically, the shift from seeing “gender identity” not as an unconscious internalisation of regressive social norms but instead an authentic expression of some important aspect of individuality. When a boy wears dresses and plays with dolls, rather than accepting this unremarkable behaviour that should not be sanctioned or pathologised, this can now be interpreted as “expressing an innate female gender identity”.

There is an obvious conflict between saying a same-sex attracted girl does not need therapy on the grounds that there is nothing wrong with being a lesbian, and saying a same-sex attracted girl doesn’t need therapy, because they’re “really a straight boy”. This distinction is especially important when the latter perspective takes as a given - even encourages - the possibility of changing the body irreversibly to “match” this conception of internal self.

It is somewhat unclear when and how this redefinition of conversion therapy started, but seems largely taken as read without any call for evidence or any close examination of what it all means. The presumption that LGB and T (or sometimes SOGI, for sexual orientation and gender identity) now always go together has merely created a sort of groupthink that conversion therapy must apply the same to both. These omnipresent acronyms create powerful assumptions and are hard to challenge since any attempt to distinguish the two is portrayed as an attack on both.

Newcomers have moved in on this term and taken over, reshaping it in their own interests, and if you have a problem with this new and improved meaning of conversion therapy, that can only mean you’re trying to justify conversion therapy.

In exactly the same way that straightforward statements of the obvious such as that you can’t literally change sex became unspeakable because of the threat of being labelled “anti-trans”, so challenging the straightforward treatment of gender identity as the same as gay conversion therapy is also “anti-trans”.

So if you, for example, publish a video talking straightforwardly about the complexity of conflating sexual orientation and gender identity under the same umbrella of “conversion therapy”, or if you examine the evidence base for any proposed ban on gender identity conversion therapy in the first place, YouTube will happily slap context on your video correcting your wrongthink.

The term has been gentrified. This is the new, unquestionable, morally superior meaning, enforced by technological intervention to nudge you in the “correct” direction. Sexual Orientation and Gender Identity are the same. LGB with the T, always, and if you have a problem with that you’re on the wrong side of history,

Exploration vs Affirmation

When the UK government proposed a ban on “gender identity conversion therapy”, the British Psychotherapeutic Council rather naively issued a statement that there was:

no real risk of ethical exploratory therapy being misconstrued as an alleged form of “conversion therapy”

All therapy is supposed to be exploratory by definition, and most would regard this as a basic assumption of the process.

In 2022, the Cass Review of the treatment of gender-related issues by the NHS released an interim report, which has led to the winding down of the Tavistock Gender Identity Service (GIDS) and the release of new service specifications by the NHS, stressing the importance of exploratory approaches.

The interim Cass Report describes exploratory therapy as:

Therapeutic approaches that acknowledge the young person’s subjective gender experience, whilst also engaging in an open, curious, non-directive exploration of the meaning of a range of experiences that may connect to gender and broader self-identity.

By contrast, the review described the affirmative approach predominantly used by GIDS as:

A model of gender healthcare that originated in the USA which affirms a young person’s subjective gender experience while remaining open to fluidity and changes over time. This approach is used in some key child and adolescent clinics across the Western world.

The key distinction is that the exploratory approach considers there may be underlying factors leading to an individual’s gender distress - past trauma, unresolved issues with their sexuality - and that if given time to explore these issues, the idea of “being another gender” may actually resolve. Significantly, in the past it has been recognised that the overwhelming majority of young people presenting in this way desist in this manner, with most growing up to be lesbian, gay or bisexual. By this view, exploring underlying causes is vital to avoid “diagnostic overshadowing”, ie the presumption that an individual’s gender distress is self-explanatory, rather than a symptom of other, underlying causes.

However, what the affirmation model takes as its starting point is that a person’s stated gender identity is true, and should be affirmed (not questioned), and the principal exploration is the way in which someone may wish to express their gender, largely focusing on how that may be facilitated (through social or medical transitioning). Rather than examine underlying causes, this approach invariably regards those issues (self-harm, depression, anxiety, even autism) as symptoms of a non-affirmed gender identity.

The response to the Cass Review from advocates of affirmation-only approaches was strong condemnation. The World Professional Association of Trasngender Health (WPATH) issued a statement calling “exploratory therapy” tantamount to “conversion”. They are not alone, and a series of reports and publications in the past couple of years have explicitly called exploratory therapy “conversion therapy” and “pseudoscience”, demonising anyone who suggests gender-questioning youth might in some cases have other unaddressed issues.

By this new understanding, it is considered “conversion” not just to attempt to alter how an individual dresses and behaves, but also to explore whether there is any other reason why an individual is seeking irreversible medical procedures in the first place. Advocates believe it is conversion therapy to consider:

issues such as unprocessed trauma, childhood abuse, internalized homophobia or misogyny, sexual fetishism, and autism as the “real” explanation behind one’s transgender identity, rather than accepting that a child who identifies as trans is sharing a real, deep, and even joyful truth about themselves.

The semantic gentrification of “conversion therapy” has allowed this shift of meaning, all supported by the practically mandatory use of co-associating acronyms like LGBT and SOGI. By taking the false equivalence of sexual orientation and gender identity as a given, and the consequent push for affirmation as the preferred model, more skeptical therapists have found themselves unsure whether basic exploratory therapy will fall foul of plans to criminalise them. Psychological interventions which avoid the risks of social and medical transition are routinely portrayed as conversion, because social and medical transition is now joy.

At the end of December 2023, the World Health Organisation (WHO) announced the composition of its panel which will develop the guidelines on the healthcare for “trans and gender diverse people”. The panel is single-minded in its conception that affirmation is the only permissible route forward, and that “pathologising” gender distress or “gatekeeping” medical transition are conversion practices. At this stage it seems almost certain that WPATH’s affirmation-only approach will be endorsed by WHO, and that any conversion therapy bans which cover gender identity will inevitably criminalise exploratory therapy. Responses to this will be an uphill struggle against not only the policies, but the very meaning of conversion, of identity, of sex and gender.

While doubtless there will be focus on the more visible policy concerns, or apparent institutional takeover by activists, I believe it was all made possible by the longer-term shifts in meaning that have already taken hold. Time and again, important language is being appropriated in service of the narrow self-interest of the language gentry.

Much ink has been spilled over the various problems vexing the Western world: the mental fragility of youth, the absurd obsessions of American liberal politics, the spread of strange ideas on US campuses, the rise of the reactionary (far) right, the increased visibility of narcissists and attention seekers, the amplification of hate and division, and on and on. Invariably the root of each of these supposedly separate problems is placed at individual behaviour. Even when social media or devices are considered factors, again it all too often is blamed on improper or uncontrolled use: weak individuals choosing to use neutral platforms to spread hate and division, or worthless content made by morally bankrupt narcissists, or individuals scrolling incessantly for hours when they could just stop through force of will, or gullibly believing “fake news” or “disinformation” when all that’s needed is some social media training and good honest fact-checkers keeping everyone on the one true path.

Twitter launched in 2006 and, while not being the only social media platform, it is possibly the purest, providing the most dense stream of information with the least direct content. By no means is everyone on Twitter, but for at least 17 years a certain class of people in Western society have been highly active and successful on this platform. Journalists. Politicians. Screenwriters. Third-sector CEOs. Pundits and commentators. Academics. HR department heads. Social activists seeking influence. A strata of hundreds of thousands of highly influential people have spent over a decade and a half connected to a system that seems to foster conformity of language, of belief, of what it is even acceptable to think. People connected via Twitter have been in a position to affect everyone who is not through their connection to legacy media and wider society - through the TV shows they write and direct, the opinion pieces they publish, the departmental policies they enact, the worthy charitable initiatives they fund.

But what actually is “social media”?

From the dictionary result googling for a definition, it means:

“Websites and applications that enable users to create and share content or to participate in social networking”

Which seems broad and all-encompassing and reasonably benign. Again, what about this, from Wikipedia:

“Social media are interactive technologies that facilitate the creation and sharing of content, ideas, interests, and other forms of expression through virtual communities and networks.”

Nothing wrong with any of that, surely. Social media is inherently a participatory form of communication, built around the sharing of ideas through social networks. But this definition is superficial and self-serving, with very little connection to what we call “social media” actually is and what it communicates.

Understanding Media

Canadian communication theorist Marshall McLuhan is perhaps most famous for the phrase “the medium is the message”, which succinctly describes the relationship between the form in which a message is delivered with the way that message is perceived. This means that to understand what messages are actually being conveyed by social media, we need to thoroughly examine the medium itself beyond the rather banal and aspirational descriptions above. In Understanding Media (1964), Marshall McLuhan provided many visionary insights into the world we now live in, anticipating the effect of instantaneous digital communications that are now ubiquitous some 60 years later, so all quotes in the remainder of this piece are from this important book.

As a starting point, let’s pick a popular tweet and examine the information it actually conveys.

McCluhan was clear that in advertising, what we think of as the content was mostly irrelevant, merely there to hypnotise the viewer or reader into unconsciously accepting the underlying advertising message:

Since the advent of pictures, the job of the ad copy is as incidental and latent as the "meaning" of a poem is to a poem, or the words of a song are to a song. Highly literate people cannot cope with the nonverbal art of the pictorial, so they dance impatiently up and down to express a pointless disapproval that renders them futile and gives new power and authority to the ads. The unconscious depth-messages of ads are never attacked by the literate, because of their incapacity to notice or discuss nonverbal forms of arrangement and meaning. They have not the art to argue with pictures. When early in TV broadcasting hidden ads were tried out, the literate were in a great panic until they were dropped. The fact that typography is itself mainly subliminal in effect and that pictures are, as well, is a secret that is safe from the book-oriented community.

By this reading, the Tweet’s content is largely irrelevant - and in this case little more than corporate branded banality with the pretence of counter-culture. It could be anything. Consider how something like this fits into the “virtual communities and networks” description above. Where are those communities and networks represented? What aspect of this is social?

In truth, the most significant parts of a tweet, the components you register subliminally before even consuming the brand-approved content of the tweet itself, are here:

The most important unconscious visual cues are the brand identity that the tweet belongs to, the numeric and visual reactions to the contextless content, and the seductive incentives to participate by signal your own reaction non-textually. A click of a button or a tap of the screen to demonstrate what you think.

McCluhan was very clear about the power of numbers and graphic information:

The statistical aggregation or crowding of numbers yields the current cave-drawings or finger-paintings of the statisticians' charts. In every sense, the amassing of numbers statistically gives man a new influx of primitive intuition and magically subconscious awareness, whether of public taste or feeling: "You feel better satisfied when you use well-known brands."

Making us aware of popularity through numbers and symbology in real-time is the principal information communicated over this media. This is what truly sets social media apart from what has gone before: the fusion of numeric popularity with recommendations based upon success.

We are familiar with the popularity both of an individual tweet, and the account tweeting it, and both of these factors deeply and unconsciously affect our perception of the information it contains.

This screenshot is still an incomplete picture, and considering a single tweet in isolation is like considering a single frame of a TV broadcast to the output of a TV network. A single tweet is not the medium, rather it is countless tweets in combination, shorn of context, and aggregated together into a personalised stream of information, whose very presence in your personal timeline indicates their importance.

It is possible to share original thoughts and ideas on Twitter. It is possible to discover and build a network of like-minded friends in real life. It is possible to engage in meaningful debate across political divides. In theory all of those high ideals about what social media could be are true, but that is not what it is. That isn’t what it is optimised for, that isn’t what is truly being communicated.

In truth, the “social network” part of social media is secondary to the principal communication of this form of media, which is: here is what everyone else is reacting to, and here is how they are reacting.

This is what gives social media its shape, and creates a stream of new content to react to - each of which may already be its own reaction, which demands further reaction, which might generate more reactions in legacy media, which can be re-shared on social media for more reactions, creating new reactions.

What we think of as “social media” is really “reactive media”. The possibility of communicating to people via social connections is secondary to those connections ability to provide impetus to react. The social network/community fantasy is little more than a marketing point.

From a commercial point of view, this sort of reactive media is a pyramid scheme for taking your meaningless reactions to content and using them to encourage other people to react, taking time and attention in pursuit of ad revenue.

When 5-star ratings and automated upsell of related products became ubiquitous on online sales platforms such as Amazon, the consumer manipulation and inherent profit motive was obvious.

It is less straightforward when translated to a tweet with 1 million likes that you are being upsold via the same basic mechanism, but it it precisely the same approach. A continual stream of tweets, each absorbed in a fraction of a second as the user scrolls, unconsciously recognising popularity and incentives to react to it. Instead of a material product for sale, you are invited to participate in displays of allegiance to consumer brands, be they corporate ones or individuals touting their personal brand identities.

This same visual sense is, also, responsible for the habit of seeing all things as continuous and connected. Fragmentation by means of visual stress occurs in that isolation of moment in time, or of aspect in space, that is beyond the power of touch, or hearing, or smell, or movement. By imposing unvisualizable relationships that are the result of instant speed, electric technology dethrones the visual sense and restores us to the dominion of synesthesia, and the close interinvolvement of the other senses.

Because of our inability to truly see the relationships that shaped the information we see, we experience dislocation and dissociation. The network effects at play are out of our control, with our reactions consumed and processed, slicing users into market segments and providing a stream of new targeted content for those groupings, invisible to us. Not only do our groups become polarised, but we no longer get to choose what group we truly belong to or even see its other members - instead, we are allocated to algorithmic buckets of similarity based on our unconscious reactions. Reacting and consuming, and each reaction - or refusal to react - determining what we will be instructed to react to and consume next.

Unconscious Manipulation

McLuhan was scathing of intellectuals’ belief in their own immunity to the unconscious manipulation of advertising:

[T]he literate man, floundering in a milieu of ads, who boasts, "Personally, I pay no attention to ads."

But this imagines the these manipulations are straightforward and obvious, when in truth, the subtle shifts are invisible to the individual, incremental, and detectable only in aggregate:

The effects of technology do not occur at the level of opinions or concepts, but alter sense ratios or patterns of perception steadily and without any resistance.

One thing that stops people truly addressing what reactive media actually communicates is the embedded logic of the market. That is, the idea of the free market as an almost Darwinian force: the combined effect of millions of rational consumers making informed choices, producing over time the most successful outcomes. We apply such concepts to “the marketplace of ideas”, imagining that “good ideas” and “bad ideas” will succeed or fail from similarly aggregate processes, all dependent on the rational engagement of individuals. In the process we applaud ourselves as rational beings, responsible for our own choices, and to accept we are all subject to irrational behaviour in response to systemic influences is to accept that the logic of the marketplace is fundamentally broken. Accepting our whole society is built on a fundamentally broken premise is too bitter a pill to swallow, too large a problem to grasp, so we imagine it fixable with sufficient tinkering around the edges. We shift the blame to others, who are clearly making bad decisions, while putting the onus on ourselves to make good decisions, through strength of will and consumption of the correct information. If we are susceptible to outside influence then that is our own fault for not recognising and protecting ourselves from exposure to bad opinions.

Calling on individuals to moderate their behaviour, or holding them “accountable” for individual statements that collectively add up to a culture of toxicity on such platforms is to flail about believing that we are rational individuals, behaving rationally at all times, engaging rationally on a platform that neutrally conveys our rational thoughts to other rational individuals. If only people would behave themselves dystopia would become utopia through effort of will, and so a failure to do so must represent some sort of individual moral failing.

McCluhan describes rationality not as some additional property we can impose upon sensory experience, but an integral, proportionate part of it:

[R]ationality or consciousness is itself a ratio or proportion among the sensuous components of experience, and is not something added to such sense experience. Subrational beings have no means of achieving such a ratio or proportion in their sense lives but are wired for fixed wave lengths, as it were, having infallibility in their own area of experience. Consciousness, complex and subtle, can be impaired or ended by a mere stepping-up or dimming-down of any one sense intensity, which is the procedure in hypnosis. And the intensification of one sense by a new medium can hypnotize an entire community.

By this understanding, the sensory impact of this new medium - the overload of unconscious, relational, aggregate information - necessarily and essentially impairs our rational faculties. Again, a high degree of irrationality is integral to this medium: the more it demands unthinking reaction, the less rational we are - and reaction is the paramount metric of success, driven by the logic of capitalism.

In fact it seems that so embedded is the grammar of the marketplace in these communication systems that advertising’s need for empty inclusivity - while paradoxically appealing to a never-satisified individualism - has become an integral part of the divisive political battles that rage across them.

Some writers have argued that the Graphic Revolution has shifted our culture away from private ideals to corporate images. That is really to say that the photo and TV seduce us from the literate and private "point of view" to the complex and inclusive world of the group icon. That is certainly what advertising does. Instead of presenting a private argument or vista, it offers a way of life that is for everybody or nobody. It offers this prospect with arguments that concern only irrelevant and trivial matters.

[…]

Instead of the voting bloc, we have the icon, the inclusive image. Instead of a political viewpoint or platform, the inclusive political posture or stance. Instead of the product, the process.

Such platforms can never become a medium that treats us as rational beings or that nurtures and fosters rational engagement, and pleading with individuals to change their behaviour merely hides the systemic effects and places the burden on individuals, while supporting the delusion that our own actions are free from this unconscious influence.

Once we have surrendered our senses and nervous systems to the private manipulation of those who would try to benefit from taking a lease on our eyes and ears and nerves, we don't really have any rights left. Leasing our eyes and ears and nerves to commercial interests is like handing over the common speech to a private corporation

Narcissism

At times it seems as if the modern social media landscape is overrun with narcissists and bullies, as if a groundswell of morally deficient individuals have suddenly been given global reach and visibility. It is easy to simply treat these as an inherently flawed minority, an approach which tends to support pre-existing political biases. When high profile individuals of different political beliefs are dismissed as narcissists or virtue signallers, their politics are by extension seen as inherently, morally flawed as the individuals espousing them.

However, McLuhan renders an interpretation of the story of Narcissus I had not encountered before:

The Greek myth of Narcissus is directly concerned with a fact of human experience, as the word Narcissus indicates. It is from the Greek word narcosis, or numbness. The youth Narcissus mistook his own reflection in the water for another person. This extension of himself by mirror numbed his perceptions until he became the servomechanism of his own extended or repeated image. The nymph Echo tried to win his love with fragments of his own speech, but in vain. He was numb. He had adapted to his extension of himself and had become a closed system.

Now the point of this myth is the fact that men at once become fascinated by any extension of themselves in any material other than themselves.

This is a very different understanding of the origins of narcissism as it applies to these new forms of media. Rather than straightforward and inherent love of the self, it can be seen as an involuntary fascination with the reflection of the self in an online persona. Not simply adoration from some innate moral weakness, but an involuntary response to a technological system that humans are ill-prepared to cope with.

In the physical stress of superstimulation of various kinds, the central nervous system acts to protect itself by a strategy of amputation or isolation of the offending organ, sense, or function.

The overload of being presented with a digital avatar - an instant extension of our central nervous system into the digital realm - who is held up in our stead for public adoration, demonisation or indifference, and the constant demand to curate that online persona to maximise adoration, and minimise ostracisation leads to a numbing and dissociation. We recognise this self that is not the self, but which the world judges as if it were us ourselves, and it creates within us an addictive, narcissistic fascination, as a physiological defence mechanism.

Thus narcissism becomes an inherent aspect of the media itself, and not merely a moral failing of a few who use it poorly. We have not given narcissists a platform, so much as the platform has made us narcissists: unconsciously, reflexively. The platform demands that we consider it as a total extension of self:

Electromagnetic technology requires utter human docility and quiescence of meditation such as befits an organism that now wears its brain outside its skull and its nerves outside its hide. Man must serve his electric technology with the same servo-mechanistic fidelity with which he served his coracle, his canoe, his typography, and all other extensions of his physical organs.

But there is this difference, that previous technologies were partial and fragmentary, and the electric is total and inclusive. An external consensus or conscience is now as necessary as private consciousness.

Maintaining an externally visible persona as an extension of self becomes a necessity, but this digital self-extension presages the mechanisms of modern “cancel culture”:

Sudden social failure or shame is a shock that some may "take to heart" or that may cause muscular disturbance in general, signaling for the person to withdraw from the threatening situation.

The Message

But all these assessments of this new reactive media’s consumption of human behaviour for profit - and what it does to our sense of self - isn’t what it truly is. That is just how it is monetised, not what it communicates.

So returning again, what is the principal information being conveyed, the subliminal impact of typography and pictures, so ruthlessly optimised for grabbing attention, so sensuously organised to encourage seamless, tactile, unthinking reaction?

By providing an instantaneously updated stream of reactions - of what other people are reacting to and how they are reacting - in a form that is unconsciously assimilated, reactive media is a system for enforcing conformity:

In the Asch Conformity experiment, participants were asked to select which line was the same size as the target line in diagrams like the one below:

However, this experiment took place in groups where all but one participants were secretly actors instructed to pick the wrong line. Under social pressure of the rest of the group, the single unknowing participant would reliably succumb to the group beliefs, in defiance of what they could see with their own eyes.

Now imagine that we have built our modern society around communication systems which work by taking hundreds of millions of people and, based on their reaction to situations like these, partition them automatically and invisibly into groups that responded the same way. Systems that identify those who conformed with what they conformed with, and on that basis control what information they should be shown in future. We have created a mechanism for discovering and enforcing completely arbitrary group conformity and inter-group polarisation.

These systems have no real idea what they are enforcing conformity to either, merely algorithmically optimising for the content most likely to garner a reaction from individual users, all to generate more reactions. They create conformity of thought and action by sheer numeric pressure, with no concept of truth or merit. It is the Asch Experiment playing out in real time, across hundreds of millions of people, but where absolutely no-one can say definitively which line is the longest, each cocooned in a silo of social pressure to go along with what everyone else says, at risk of total social isolation for getting the response wrong when there is no definitively right response.

Everyone using these systems is, on some level, affected by this, all the time, because of the Narcissus idea that the digital self is both separate and connected, ever present out there. The stream demands reaction, where lack of reaction is itself a reaction. Not reacting to something you are aware of registers as either defiance or conformity to some other view. React, retweet, reply, share, like, screenshot, dunk, pile-on, scream abuse, deliver a rational take, change the subject, try to ignore - everything is a reaction, or in service of eliciting a reaction, and every reaction is influenced by what other people think. Reaction is the only form of interaction it understands, and failure to react can still be a losing move. Once our “self” is out there, extended into this new digital medium and exposed for all to see, it is subject to unlimited social punishment, at any time, by every other connected human, for absolutely any past action or inaction, and there is no retracting it.

This power of technology to create its own world of demand is not independent of technology being first an extension of our own bodies and senses. When we are deprived of our sense of sight, the other senses take up the role of sight in some degree. But the need to use the senses that are available is as insistent as breathing — a fact that makes sense of the urge to keep radio and TV going more or less continuously. The urge to continuous use is quite independent of the "content" of public programs or of the private sense life, being testimony to the fact that technology is part of our bodies. Electric technology is directly related to our central nervous systems, so it is ridiculous to talk of "what the public wants" played over its own nerves.

This is not something that can be fixed by encouraging people to “behave better”. This is not something that can be fixed by adding “community notes” and “fact checking” and “moderation”. And it is certainly nothing that can be fixed by setting up completely identical services under the control of different corporate overlords expecting them to be any different. With the purchase of Twitter by Elon Musk, a good chunk of “progressive-minded” people have left the platform for other, identical ones, most notably former Twitter CEO Jack Dorsey’s Bluesky. These are little more than clones, communicating the same unconscious conformity and division in exactly the same way, whether that is their intention or not.

The individual tweets, the content, the pretty pictures and funny memes, all sliced and diced to keep your attention - that is not what the medium communicates. That isn’t what this reactive media is. That’s the marketing, the distraction, the hypnosis, the delusion this could ever be a “marketplace of ideas”, the pretence that you are actually doing anything at all of value. What the medium communicates to our unconscious is conformity, dividing people into arbitrary silos based on what behaviours they conform to and inevitably setting them against each other. That is all it can truly communicate. That is at root what this medium is.