Over the last few years, thereās been an explosion of awareness about the condition known as gender dysphoria ā a sense of deep, painful discomfort with oneās biological sex, the gender associated with it, or both. Gender dysphoria can cause devastating anguish when the person suffering from it lacks access to treatment. As I put it in an Atlantic article from a couple of years ago, it has been described by some people who have it as āa weight, a buzzing, an unavoidable source of rumination and worryā.
For some people with gender dysphoria, simply changing their hair, clothes, and other aspects of their appearance to present in a more stereotypically male or femaleĀ or androgynous manner is enough to bring relief; for others, only hormones, surgery or both will suffice. But the only treatment for severe, persistent gender dysphoria for which thereās any real evidence is transition.
While the LGBT community has ever-shifting labels that mean different things at different times, itās safe to say that most people who identify as transgender have or had gender dysphoria, and transitioned in part as an attempt to alleviate it.
Despite the significant gains made by the trans rights movement in recent years, the scientific underpinnings of gender dysphoriaĀ and its treatment are still almost completely unknown. Even the available evidence for the efficacy of hormones is only, according to a 2010 systematic review, āvery low quality.ā As the British Journal of Medicine pointed out on its website in 2019, drawing on two more recent systematic reviews of youth GD treatment, āThere are significant problems with how the evidence for Gender-affirming cross-sex hormone has been collected and analysed that prevents definitive conclusions to be drawn.ā
Furthermore, there are also some increasingly-heated culture wars going on in this area that hinge a great deal on certain scientific questions no one knows the answer to: How concerned should we be about what appears to be a growing number of ādetransitionersā ā that is, people who transition their gender and then transition back? How common is detransition in the U.S. or the U.K.? How often do kids with GD experience ādesistance,ā or their GD simply abating in time?Ā
(Desistance is itself an immensely controversial and complicated discussion, and some people wrongly claim it is quite rare ā I went deep into the weeds here and here if youāre curious about what the literature on it does and doesnāt say.)
Given all this uncertainty, and given the stakes for people trying to better understand their own struggles with GD, it seems like a particularly important time for the scientific study of this subject to operate in a transparent, careful manner.Ā
Instead, it is becoming more and more difficult for researchers to study this subject without accidentally stepping on certain political landmines ā landmines that are understandable given some of the dark history associated with the scientific establishmentās treatment of gender nonconforming people, but which really are hindering scientific progress.
And an incident that unfolded this spring at a neuroscience journal shows just how bad things are getting. It suggested that only a very particular, very narrow storyline is allowed ā and if you deviate from it, you risk professional and reputational damage. In the long run, this sort of science-by-petition, in which activists who can make a loud enough racket can get research retracted that wouldnāt be retracted otherwise, is exceptionally harmful.
Back in December, the journal eNeuro published a paper entitled āA New Theory of Gender Dysphoria Incorporating the Distress, Social Behavioral, and Body-Ownership Networks.ā The paper was tagged as āTheory/New Concepts,ā and it indeed challenged a common understanding of gender dysphoria.
That understanding holds that, to oversimplify somewhat, gender dysphoria arises from having the body of a male but the brain of a female (or vice-versa). While far from dispositive, some past studies have suggested that transgender individuals with gender dysphoria have brains more like the sex they identify with than their natal sex.Ā (Some of these studies were performed posthumously on trans people who had been on hormones, raising the possibility that the hormones caused the observed brain differences.)
Not so fast, argued the author of the eNeuro article. Stephen Gliske, a researcher who trained as a physicist but who gained sufficient expertise in neuroscience to be hired as a research assistant professor in the University of Michigan Medical Schoolās department of neurology, posited a new theory questioning “the relevance of cerebral sexual dimorphism in regard to gender dysphoriaā.
Instead, he argued that āin individuals with gender dysphoria, the aspects of chronic distress, gender atypical behavior, and incongruence between perception of gender identity and external primary sex characteristics are all directly related to functional differences in associated brain networks.ā
Almost immediately, Gliskeās paper was denounced by a group of researchers and activists who accused it of peddling dangerous ideas about trans people. Unfortunately, eNeuro did not respond with agility. Over a disastrous, opaque, flawed process that took months to unfold, the journal first demanded Gliske choose between cutting one section of the paper and having it retracted. After he agreed to the cut, the journal put an edited version online. Then, when academics again complained, this time launching a Change.org petition, the journal launched yet another round of reviews and eventually retracted the paper.
Before explaining the way things spiraled out of hand, itās important to acknowledge thatĀ the initial critique of Gliskeās paper had some merit to it.Ā The first version contained a section entitled āImplications for clinical practiceā. In it, Gliske argued that āThe use of gender reassignment as a therapy is sometimes motivated on the assumption that the distress is due to the individuals having a brain sex different than their gender assigned at birth and that the desire to change genders is based on a correct sense of true gender.ā
If, as Gliske’s own theory suggested, this is false, it could call into question such treatments, he argued. āOur new theory furthers the discussion regarding biologically-based treatments independent of gender identity affirmation that might address distress and body ownership in individuals with gender dysphoria.ā That is, ātreatments based on our new theory could instead involve targeting the distress and/or body ownership networks, perhaps specifically seeking to restore a sense of ownership over body parts perceived as incongruous.ā
Anyone even faintly aware of the politics surrounding trans rights will understand why this was an ill-advised passage. While the present state of the evidence that transition works isĀ not as sturdy as it could be,Ā and some people with gender dysphoria are actively hoping for other options,Ā it is still the case that transition is the only real game in town at the moment, and that access to it feels like a life-and-death matter for many trans people. Moreover, thereāsĀ also a dark history of attempts to biologically alter LGBT people to āfixā them.Ā
Itās not unreasonable, then, that a trans person, or someone who simply cares about them, might be alarmed reading a paper thatĀ raises, without much context, the possibility of ābiologically-based treatments independent of gender identity affirmation that might address distress and body ownership in individuals with gender dysphoriaā.
On 7 December, with the article up on eNeuroās website in a near-final, post-peer-review form, the journalās editor-in-chief, Christophe Bernard, a French neuroscientist, emailed Gliske. After laying out some of the concerns raised about the paper, Bernard wrote, āWe therefore ask you to remove the Implications for Clinical Practice section, as well as any other reference to clinical implications throughout the article, abstract, and Significance Statement, before final publication. These changes will be noted to journal readers with a formal published notice. ā¦ If you decline to make these changes, the Editorial Board will move to retract your article on the grounds that the clinical implications are not supported by the available data.ā
Whether or not this critique was well-grounded (and, again, I believe it was, although the bit about the āavailable dataā didnāt make much sense given that Gliske was positing a new theory) this is an unusual situation. It isnāt common for the author of a paper that has already gone through the peer-review process to be told he or she has to delete one particular section or choose to have the entire paper retracted. But what came next was even stranger.
Some of the activists criticizing the paper were not mollified by the revisions made to it. Instead, a group of them led byĀ Troy A. Roepke of Rutgers University,Ā launched a Change.org petition demanding not only retraction of the paper, but revisions to eNeuroās editorial process which would ensure that āat least one reviewer should come from the community directly impacted by these types of papers to ensure that language and intent are not dangerous, deleterious, or damningā.
The petition distorts and misrepresents the contents of the paper in basic ways. After claiming, without any evidence, that āthe clear intent of the paper was to do harm to the transgender community, one of the most vulnerable communities across the globeā (bolding in the original), it argues that there is a ābasic assumption that transgender people are a deleterious deviation with a disordered network of brain regions which pervades the entire manuscriptā.Ā
But the paper isnāt about, and makes no moral claims of any sort, about transgender people ā itās about the neurological origins of gender dysphoria. It doesnāt take a particularly sophisticated grounding in philosophy to understand that whether GD is the result of one brain theory versus another doesnāt, on its own, prove anything about the moral status or worth of people with gender dysphoria.
The most vicious homophobic bigots, after all, are just as enthusiastic about gay-bashing whether the theory is that homosexuality is genetic (in which case the responsible genes need to be wiped out), or the result of corrupt cultural influences (in which the responsible influences need to be wiped out). This is just a wild moral leap on the part of the petitioners, and itās surprising that the journal would pay any mind to such a confused and inflammatory petition.
But not only did the journal heed this groupās input, it let Roepke and eight coauthors pen a response that was published on the eNeuro website alongside the original article. That response is just as strange as the petition,Ā exhibiting a lack of familiarity with the evidence base for treating gender dysphoria, and with the specific arguments of Gliskeās paper. For example,Ā the authors accuse Gliske of making claims which conflict with existing empirical observations about gender-affirming intervention, ignoring the fact that he quite specifically states that treatment can alleviate distress āĀ and they themselves cite a paper pointing out the weakness of the evidence base for hormones.
It would have been strange enough for the eNeuro editors to give so much oxygen to Roepkeās bad-faith petition and response. But itās what happened next where this story tips over from āstrangeā into ābizarre’ ā for now Gliske received an email from eNeuro informing him that, actually, the paper was being retracted.Ā
The editors’ reasoning is explained in a ‘synthesis statement’Ā which, again, contains many odd claims that donāt quite line up with the paper that was actually published. It often reads as though the editors simply threw as many complaints at the wall as they could ā many of them picayune and easily debunked by reading the paper or the editorial comments sent to Gliske during the editing process ā in an attempt to make the paper seem extremely sloppy.
At one point, for example, the authors note that Gliske used the word transsexual, and that this, along with some other terms in the paper, are āno longer adequate terms to be used andĀ should be adjusted for a more respectful languageā. But in the body of the paper itself there is a single use of this term: āI also use the term ātransgenderā throughout this manuscript, though I recognize that some references instead use the word transsexual to refer to the same concept.ā So his only use of this term is to explain that he is not going to use it, and to explain why it appears in the citations (transsexual is simply the older term for ābeing trans,ā and is seen by some trans people as outdated or offensive, while others embrace it).
Similarly, the synthesis statement asks: ā[W]hat exactly is the author trying to say in the paragraph noting that trans people have been found to have elevated presence of autistic traits within relation to their theory?ā
But in an exchange still visible on the eNeuro site (archive), a reviewer recommended that Gliske add a mention of autism to the section on common gender-dysphoria comorbidities ā not a surprise given the well-established link between the two conditions. Again, this is simply strange: in a public statement, the journalās editors criticised the author of a paper for making an editorial decision the journal itself asked him to make.
But all these odd and nitpicky complaints could be seen as moot, because the reviewers give away the game in a sentence that clearly reveals their gripe is political, not scientific:ā[T]he author appears disrespectful to the community because he/she does not seem to believe that a transgender personās statement of belonging to one or the other gender is taken at face value and believed to be true.āĀ
This is worth exploring. The authors of the synthesis statement donāt bother explaining what ābelonging to one or the other genderā could possibly mean in a neuroscience context. Gliskeās paper has no bearing on the question of whether a trans person is āreallyā a woman or a man (or neither in the case of a nonbinary person), because of course no theory of gender dysphoria could, on its own, settle such a philosophical and sociological issue.
His paper, again, is simply an attempt to posit a new theory about gender dysphoria. The only neuroscience-related explanation of this phrase which could apply here is something like āGliske does not seem to believe that a transgender man/woman has a male/female brainā. But that, of course, is exactly the theory he is arguing against! If this is actually what his critics intended to mean, they are claiming that it āappears disrespectfulā to posit that the brainsex theory of gender dysphoria is false.
This would be news to many gender dysphoric people. There is, of course, a vast diversity of opinion about what causes gender dysphoria among those who have or had the condition. There are desisters, who appear to outgrow the condition over time, usually in their younger years ā they, of course, do not think that they were ātrapped in the wrong body,ā because their GD didnāt turn out to be permanent.
Detransitioners, meanwhile, donāt tend to believe in the brainsex theory either. While some destransition because they lack the money or support to continue living as their felt gender, others realize they simply werenāt really trans. A subset of detransitioners continue to have gender dysphoria, but do not believe the solution is to transition, because it didnāt work for them ā in fact, when some detransitioners in this category tried to hold panels at a trans health conference,Ā one on detransitioning and one on alternate treatments for GD, those panels were abruptly cancelled due to the outcry of activists
Many happily transitioned people, too, believe that whatever GD is, itās more complicated than having one ātypeā of body and the other ātypeā of brain, or the closely related idea of having an innate and immutable ‘gender identity’: Trans writers ranging from Andrea Long Chu to Natalie Reed to Natalie Wynn (aka Contrapoints) to various ‘gender-critical’ trans women have all critiqued these ideas, which they tend to view as oversimplifications which donāt capture the full texture of the trans experience.
It makes no sense, then, to view theories of gender dysphoria as being off-limits if they tell a different story than brainsex-mismatch. To do so is to ignore the views of many, if not most, people with gender dysphoria. Itās also completely unscientific: When you donāt know much about what causes a phenomenon, you canāt draw strict boundaries about what sorts of explanations will be deemed worth exploring versus rejected out of hand.
This episode bears certain noteworthy similarities to what happened to Lisa Littman, the M.D. who in 2018 published a PLOS Onepaper on ārapid onset gender dysphoria,ā or the very young and mostly unexplored theory that in some cases young people (usually teenage girls) might develop gender dysphoria and/or a transgender identity quite suddenly as a result of peer influence or social media. (For what itās worth, in my own reporting I have certainly come across kids who fit that bill,Ā but Iām careful not to posit this as a definite explanation in any particular case because so little is known about ROGD and it could be harmful for parents to jump to this conclusion regarding a newly āoutā child.)
Like Gliske, Littman was proposing a new theory that was viewed as threatening by some activists (they believe that the concept of ROGD is a means of āinvalidatingā the claims of trans youth). Like Gliske, she dealt with a wave of criticism within andĀ beyond the academy that often seemed geared at producing a high quantity of claims about her research rather than high-quality ones.
And like Gliske, she had to deal with institutions caving in to activists, and with a bruising post-peer-review re-review clearly designed to appease those activists: Brown University retracted the press release announcing the study and issued a bizarre āapologyā without noting anything in the paper that had been wrong, and PLOS One issued a ācorrectionā consisting of many cosmetic updates and then acknowledged to me that there had been no errors in the paper. (I had never heard of a paper being ācorrectedā when there werenāt any errors.)Ā
Littman subsequently published a paper showing that just about every critique issued at her paper in an attempt to invalidate it could also be applied to papers on trans youth that had garnered no complaints from activists, probably because those papers didnāt make any politically threatening claims.
āThere is a clear double standard,ā she told me in an email. āResearch articles that do not adhere to the gender-identity affirming narrative are called out as unacceptable, even when their methods are consistent with those cited to support the use of the gender-identity affirming model of care. It appears as if groups are engaging in motivated reasoning ā āI donāt want this research to be true, so I will aggressively question every single attribute of the work, even if I’m comfortable with those same attributes in research articles that support my view.ā Unfortunately, many people are misusing the terms ābiased,ā āmethodologically flawed,ā and ādebunkedā when they really mean āchallenges my assumptions,ā ācomes to a different conclusion than me,ā and āhas known limitations.āā
Littman, to her credit, hasnāt been deterred ā sheās continuing to research this subject, and recently solicited the accounts of individuals who have desisted or detransitioned.
Maybe Stephen Gliskeās paper was completely off-base. Maybe itās on the right track. Maybe itās somewhere in between. Now that itās been retracted, though, a message has been sent, loud and clear: Donāt try to look into this theory. That chilling effect is far more dangerous than any individual retraction or faux ācorrectionā. In the long run, it will cut off entire avenues of research that could help lead us to better understand a very important and vexing subject.
Think about what the gender dysphoria research scene must look like at the moment to genuinely inquisitive, compassionate, brilliant 25-year-old neuroscientists, psychologists and psychiatrists-in-training? What possible reason would they have to want to attack this fascinating subject with any of the vigor and intellect theyād apply to other, less controversial subjects? All the incentives point in the opposite direction: Run far from here.
Itās heartbreaking to think of all the knowledge that will be lost as a result ā and all the people who will suffer more than they needed to because of the way scientific inquiry was wrongly crimped.
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