Tag: scientific literature

A Teen Gender-Care Debate Is Spreading Across Europe

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As Republicans across the U.S. intensify their efforts to legislate against transgender rights, they are finding aid and comfort in an unlikely place: Western Europe, where governments and medical authorities in at least five countries that once led the way on gender-affirming treatments for children and adolescents are now reversing course, arguing that the science undergirding these treatments is unproven, and their benefits unclear.

The about-face by these countries concerns the so-called Dutch protocol, which has for at least a decade been viewed by many clinicians as the gold-standard approach to care for children and teenagers with gender dysphoria. Kids on the protocol are given medical and mental-health assessments; some go on to take medicines that block their natural puberty and, when they’re older, receive cross-sex hormones and eventually surgery. But in Finland, Sweden, France, Norway, and the U.K., scientists and public-health officials are warning that, for some young people, these interventions may do more harm than good.

European health authorities are not reversing themselves on broader issues of trans rights, particularly for adults. But this turn against the Dutch protocol has inflamed activists and politicians in the United States. Republicans who have worked to ban its recommended treatments claim that the shifts in Europe prove they’re right. Their opponents argue that any doubts at all about the protocol, raised in any country whatsoever, are simply out of step with settled science: They point to broad endorsements by the American Medical Association, the American Psychiatric Association, and the American Academy of Pediatrics, among other groups; and they assert that when it comes to the lifesaving nature of gender-affirming care, “doctors agree.”

But doctors do not agree, particularly in Europe, where no treatments have been banned but a genuine debate is unfurling in this field. In Finland, for example, new treatment guidelines put out in 2020 advised against the use of puberty-blocking drugs and other medical interventions as a first line of care for teens with adolescent-onset dysphoria. Sweden’s National Board of Health and Welfare followed suit in 2022, announcing that such treatments should be given only under exceptional circumstances or in a research context. Shortly after that, the National Academy of Medicine in France recommended la plus grande réserve in the use of puberty blockers. Just last month, a national investigatory board in Norway expressed concerns about the treatment. And the U.K.’s only national gender clinic for children, the Tavistock, has been ordered to close its doors after a government-commissioned report found, among other problems, that its Dutch-protocol-based approach to treatment lacked sufficient evidence.

These changes in Europe have so far been fairly localized: Health authorities in many countries on the continent—among them Austria, Denmark, Germany, Italy, and Spain—have neither subjected the Dutch approach to formal scrutiny nor advised against its use. Yet questions about the protocol seem to be spreading. At the end of March, for example, a Belgian TV report described a 42-fold increase in patients at a leading gender clinic in Ghent and raised questions about the right approach to care. Doubts about the protocol have even come to the country that invented it, at the Center of Expertise on Gender Dysphoria in Amsterdam. “Until I began noticing the developments in other EU countries and started reading the scientific literature myself, I too thought that the Dutch gender care was very careful and evidence-based,” Jilles Smids, a postdoctoral researcher in medical ethics at Erasmus University in the Netherlands, told me via email. “But now I don’t think that any more.”

Kirsten Visser, a Netherlands-based advocate and consultant for parents of trans teens, says her own son, Sietse, started receiving “definitely lifesaving” care at the Amsterdam center in 2012, at the age of 11. Around the time that Sietse showed up at the clinic, the Dutch protocol was becoming established internationally, largely through the work of a child and adolescent psychiatrist there named Annelou de Vries.

After completing a Ph.D. on gender dysphoria in Dutch adolescents, de Vries published two seminal papers with the clinical psychologist Peggy Cohen-Kettenis and other colleagues, in 2011 and 2014. The former looked at the psychological effects of puberty suppression on 70 young people over a period of two years, on average; the latter tracked outcomes for 55 of those people who had gone on to receive gender-reassignment surgery, over an average of six years. Taken together, the studies found that the teens showed fewer symptoms of depression after having their puberty suppressed, as well as a decrease in behavioral and emotional problems; and that the ones who went on to take gender-affirming hormones and have surgery grew into “well-functioning young adults.” De Vries’s expertise has since been widely recognized within the field: She served as a co-lead on the revision of the adolescent section of care guidelines recently published by the World Professional Association for Transgender Health, and is now president-elect of the European equivalent, EPATH.

But in the years after her two studies were released, research done in other European countries led to concerns about their relevance. In 2015, for example, Finnish researchers described a phenomenon that “called for clinical attention,” as they put it: More children were reporting gender dysphoria, and a greater proportion of them had been assigned female at birth. The fact that three-quarters of those Finnish teens had been diagnosed with separate and severe psychiatric conditions appeared to be at odds with the data from the Netherlands, the paper argued. The Dutch studies had found that just one-third of adolescents with gender dysphoria experienced other psychiatric issues, suggesting they were in far better mental health.

In Sweden, too, clinicians grew alarmed by the sudden increase in the number of teenagers seeking gender care. Mikael Landén, a professor of psychiatry at the University of Gothenburg, told me that this population has increased 17-fold since 2010. One explanation for that change—that more open-minded attitudes around gender have emboldened kids to seek the help they need—just doesn’t ring true to him. He’d studied those views in his early work, he said, and found that, on the whole, Swedish attitudes toward transgender people have been very positive for a long time.

When the government asked Landén and a group of other scientists to write an evidence-based review of hormone-based treatments for young people, their verdict, after two years of study, was expressed definitively: The original research findings from de Vries were outdated, and do not necessarily apply to the group of teens who have been coming forward in more recent years. The Dutch protocol had been “a valuable contribution,” he told me, and “it was reasonable to start using it” in Sweden. But times had changed, and so had the research literature. In 2021, for instance, a team based at the U.K.’s Tavistock clinic published research showing no detectable improvements in the mental health of youngsters who had been put on puberty blockers and followed for up to three years.

Read: The war on trans kids is totally unconstitutional

De Vries acknowledged some concerns about the research when we spoke in February. “Our early outcomes studies were really from another time and comprised small samples,” she told me, and they looked only at trans youth who had experienced gender dysphoria from childhood. She granted that there is some research to suggest that kids who don’t arrive at the clinic until they’re older are worse off, psychologically, than their younger peers; but she also said her team has run studies including 16-year-olds, and that their findings were “not worrisome.” She agrees that other researchers have not replicated the long-term follow-up research on kids who went through the Dutch protocol, but she pointed out that the short-term benefits of such treatment have indeed been seen in other studies. Research conducted in the U.S., and published earlier this year, found that a group of 315 trans and nonbinary youth were on average less depressed and anxious, and better-functioning, after two years of hormonal treatment.

In the meantime, de Vries and her colleagues have urged clinicians in other countries to do more of their own investigation, in part because the youngsters who receive care at gender clinics in the Netherlands seem to be in comparatively good mental health from the get-go. It’s not yet clear, she told me, that studies of this group will be applicable to youth in other countries. “Every doctor or psychologist who is involved in transgender care should feel the obligation to do a good pre- and post-test,” one of de Vries’s co-authors on the 2011 and 2014 studies said to a Dutch newspaper in 2021. “The rest of the world is blindly adopting our research.”

De Vries is now working on a research project, funded by an $864,000 grant, that will try to answer newly forming doubts about the Dutch protocol. Her proposal for the grant, filed in 2021, described its subject as a “once so welcomed but now sharp[ly] criticized approach.”

That such criticisms are becoming mainstream even in her own country is itself a startling development. After all, the Netherlands has long been at the vanguard of progressive health-care practices. When the Dutch approach to transgender care for adults first started taking shape during the 1970s (many years before the protocol for kids would be established), the country’s politics were dominated by a steadfast opposition to taboos. James Kennedy, an American-born professor of modern Dutch history at Utrecht University, has described this as the country’s “compassionate culture”: In a radical departure from its traditional Christian conservatism, long-standing policies were being spurned; and even touchy subjects such as death and sex were made the subject of broad public-policy debates. Sex work, for example, was widely tolerated, then legalized in 2000. Similarly, the Royal Dutch Medical Association offered formal guidelines for the practice of euthanasia in the 1980s, and a corresponding national law—one of the world’s first—codified the rules in 2002.

Against this backdrop of openness, in which doctors were seen as authoritative figures who were well equipped to decide what was best for their patients, one of the first dedicated clinics for transgender people was established in Amsterdam in 1972. It offered an array of services—blood tests, hormone therapy, and surgeries—to trans adults. According to a recent book by the historian Alex Bakker, Dutch surgeons, some of them inspired by their Christian beliefs, developed techniques that would reduce patients’ psychological suffering. “Helping those in need trumped ‘taboos’ about the sanctity of life or fixed gender roles,” Kennedy told me. The Dutch protocol for treating gender dysphoria in children, as established in the 1990s, reflected a further extension of this philosophy, aiming to smooth adult transitions by intervening early.

Read: Take detransitioners seriously

Nevertheless, in December, a journalist named Jan Kuitenbrouwer and a sociologist named Peter Vasterman published an opinion piece in a leading daily newspaper, NRC, that took aim at the Dutch protocol and its “shaky” scientific foundations, and alluded to the international scrutiny of the past few years. “It is remarkable that the media in our neighboring countries report extensively on this reconsideration,” the article said, “but the Dutch hardly ever do.” Like critics elsewhere, Kuitenbrouwer and Vasterman pointed to the rising numbers of children seeking care, from 60 to 1,600 in the Netherlands across a dozen years, and the unaccounted rise in those assigned female at birth; and they suggested that this new generation of people seeking treatment is not analogous to those included in the studies conducted by de Vries a decade ago. De Vries and some colleagues countered that their more recent research addresses this concern. “Scientific evaluation has always been an integral part of this challenging model of care, where young people make early decisions about medical interventions with lifelong implications,” they wrote in the same newspaper.

Also in December, a clinical psychologist at Radboud University’s gender clinic in Nijmegen named Chris Verhaak told a different Dutch outlet that puberty blockers affect children’s bones, and maybe also their brain development. “It is not nothing,” she said. Verhaak is currently running a government-funded study to understand the source and nature of the increase in the number of patients. (Results are due to be presented to the Dutch House of Representatives this year.) In another interview that month, she said that for up to half of cases, the gains in suppressing puberty are not clear. “I worry about that,” she told the newsweekly De Groene Amsterdammer. “Especially because we also experience enormous pressure to provide these puberty inhibitors as quickly as possible.”

Verhaak’s comments in particular sparked dismay among trans groups, which saw them as promoting destructive narratives about social contagion. Verhaak and her direct collaborators say that they are no longer speaking to the media until their study is released, but Hedi Claahsen, a professor and principal clinician on the Radboud center’s gender team, told me that practitioners are cautious and follow national guidelines. When I asked if her center’s approach differed from the one used in Amsterdam, she told me, “No clinic is exactly the same.” Individual providers, who are working at different institutions, may end up providing care that reflects “a different vision.”

Another, more significant round of criticism arrived at the end of February, when another widely read Dutch newspaper, de Volkskrant, published a 5,000-word article under a headline reading: “The treatment of transgender youth in the Netherlands was praised. Now the criticism of ‘the Dutch approach’ is growing.” The authors spoke with Iris, a 22-year-old woman who spent five years on testosterone and had a double mastectomy that she now regrets; they pointed to a new population of kids assigned female at birth seeking care only in their teens; and they noted reservations about the protocol in Finland and Sweden. “Is the ‘Dutch approach’ still the way to go?” the story asked.

The article prompted debate on Twitter, where Michiel Verkoulen, a health economist working with the government of the Netherlands to address the long-standing problem of ever-expanding waiting lists and their impact on young people’s mental health, accused the Dutch protocol’s critics of ignoring what he described as the elephant in the room. “What to do with the people for whom transgender care is critical?” he asked. “You can put every research aside, keep asking for more, and argue that diagnostics and treatments should be stricter … But the question remains: What then?”

“In the Netherlands there are more and more people saying that gender diversity is woke and it’s nonsense and it’s bullshit,” Visser, the consultant for parents of trans teens, told me. Sam van den Berg, a spokesperson for an Utrecht-based trans-rights organization called Transvisie, argued that this debate does not need to happen. The quality of care for children with gender dysphoria is better in the Netherlands than almost anywhere else, she said. “We don’t feel it’s necessary to change anything.” Indeed, doctors in the Netherlands are still free to provide gender-affirming care as they see fit. The same is true of their colleagues in Finland, Sweden, France, Norway, and the U.K., where new official guidelines and recommendations are not binding. No legal prohibitions have been put in place in Europe, as they have been in more than a dozen U.S. states, where physicians risk losing their medical license or facing criminal sanctions for prescribing certain forms of gender-affirming care.

But the trend toward more conservative application of the Dutch protocol is likely to have real effects in European countries, in terms of which kids get treatment, and of what kind. Louise Frisén, an associate professor at Karolinska Institute and a pediatric psychiatrist at the child and adolescent mental-health clinic in Stockholm, Sweden, told me she worries that under her country’s new guidelines, many of her teenage patients will find it harder to access medical care. The benefits of treatment are clear, she said, and she further claimed that the policy change has caused anguish for some patients who are panicking at the looming prospect of puberty.

As for de Vries, when I spoke with her a few weeks before the article in de Volkskrant was published, she agreed that clinicians should be cautious, but not to the point where treatment becomes inaccessible. Outcomes for those with later-onset dysphoria do need to be investigated further, she acknowledged, but “if we are going to wait ’til the highest-standard medical evidence provides us the answers, we will have to stop altogether.” In that sense, Europe’s brewing disagreement over treatment could turn into paralysis. “That’s what worries me,” she said. “You will always have to work with uncertainties in this field.”

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Frieda Klotz

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April 28, 2023
Was the COVID Toilet Panic Overblown?

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In the dark early days of the pandemic, when we knew almost nothing and feared almost everything, there was a moment when people became very, very worried about toilets. More specifically, they were worried about the possibility that the cloud of particles toilets spew into the air when flushed—known in the scientific literature as “toilet plume”—might be a significant vector of COVID transmission. Because the coronavirus can be found in human excrement, “flushing the toilet may fling coronavirus aerosols all over,” The New York Times warned in June 2020. Every so often in the years since, the occasional PSA from a scientist or public-health expert has renewed the scatological panic.

In retrospect, so much of what we thought we knew in those early days was wrong. Lysoling our groceries turned out to not be helpful. Masking turned out to be very helpful. Hand-washing, though still important, was not all it was cracked up to be, and herd immunity, in the end, was a mirage. As the country shifts into post-pandemic life and takes stock of the past three years, it’s worth asking: What really was the deal with toilet plume?

The short answer is that our fears have not been substantiated, but they weren’t entirely overblown either. Scientists have been studying toilet plume for decades. They’ve found that plumes vary in magnitude depending on the type of toilet and flush mechanism. Flush energy plays a role too: The greater it is, the larger the plume. Closing the lid (if the toilet has one) helps a great deal, though even that cannot completely eliminate toilet plume—particles can still escape through the gap between the seat and the lid.

Whatever the specifics, the main conclusion from years of research preceding the pandemic has been consistent and disgusting: “Flush toilets produce substantial quantities of toilet plume aerosol capable of entraining microorganisms at least as large as bacteria … These bioaerosols may remain viable in the air for extended periods and travel with air currents,” scientists at the CDC and the University of Oklahoma College of Public Health wrote in a 2013 review paper titled “Lifting the Lid on Toilet Plume Aerosol.” In other words, when you flush a toilet, an unsettling amount of the contents go up rather than down.

Knowing this is one thing; seeing it is another. Traditionally, scientists have measured toilet plume with either a particle counter or, in at least one case, “a computational model of an idealized toilet.” But in a new study published last month, researchers at the University of Colorado at Boulder took things a step further, using bright-green lasers to render visible what usually, blessedly, is not. John Crimaldi, an engineering professor and a co-author of the study, who has spent 25 years using lasers to illuminate invisible phenomena, told me that he and his colleagues went into the experiment fully expecting to see something. Even so, they were “completely caught off guard” by the results. The plume was bigger, faster, and more energetic than they’d anticipated—“like an eruption,” Crimaldi said, or, as he and his colleagues put it in their paper, a “strong chaotic jet.”

Within eight seconds, the resulting cloud of aerosols shoots nearly five feet above the toilet bowl—that is, more than six feet above the ground. That is: straight into your face. After the initial burst, the plume continues to rise until it hits the ceiling, and then it wafts outward. It meets a wall and runs along it. Before long, it fills the room. Once that happens, it hangs around for a while. “You can sort of extrapolate in your own mind to walking into a public restroom in an airport that has 20 toilet stalls, all of them flushing every couple minutes,” Crimaldi said. Not a pleasant thought.

The question, then, is not so much whether toilet plume happens—like it or not, it clearly does—as whether it presents a legitimate transmission risk of COVID or anything else. This part is not so clear. The 2013 review paper identified studies of the original SARS virus as “among the most compelling indicators of the potential for toilet plume to cause airborne disease transmission.” (The authors also noted, in a dry aside, that although SARS was “not presently a common disease, it has demonstrated its potential for explosive spread and high mortality.”) The one such study the authors discuss explicitly is a report on the 2003 outbreak in Hong Kong’s Amoy Gardens apartment complex. That study, though, is far from conclusive, Mark Sobsey, an environmental microbiologist at the University of North Carolina at Chapel Hill, told me. The researchers didn’t rule out other modes of transmission, nor did they attempt to culture live virus from the fecal matter—a far more reliable indicator of infectiousness than mere detection.

Beyond that, Sobsey said, there is little evidence that toilet plumes spread SARS or COVID-19. In his own review, published in December 2021, Sobsey found “no documented evidence” of viral transmission via fecal matter. This, at least, seems to track with the three years of pandemic experience we’ve all now endured. Although we can’t easily prove that bathrooms don’t play a significant role in spreading COVID-19, we haven’t seen any glaring indications that they do. And anyway, the coronavirus has found plenty of other awful ways to spread.

Just because toilet plume doesn’t seem to be a vector of COVID transmission, though, doesn’t mean you can forget about it. Gastrointestinal viruses such as norovirus, Sobsey told me, present a more serious risk of transmission via toilet plume, because they are known to spread via fecal matter. The only real solutions are structural. Improved ventilation would keep aerosolized waste from building up in the air, and germicidal lighting, though the technology is still being developed, could potentially disinfect what remains. Neither, however, would stop the plume in the first place. To do that, you would need to change the toilet itself: In order to create a smoother and thus better-contained flush, you could change the geometry of the bowl, the way the water enters and exits, or any number of other variables. Toilet manufacturers could also, you know, stop producing lidless toilets.

But none of that will save you the next time you find yourself staring into a toilet’s blank maw. Crimaldi suggests wearing a mask in public bathrooms to protect against not just the plume created when you flush but also the plumes left by the person who used the bathroom before you, the person who used it before them, and so on. You don’t need to have any great affection for masking as a public-health intervention to consider donning one for a few minutes to avoid literally breathing in shit. Sobsey offered another bit of unconventional bathroom-hygiene advice, which he acknowledged can only do so much to protect you: If you find yourself in a public restroom with a lidless toilet, he said, consider washing your hands before you flush. Then “hold your breath, flush the toilet, and leave.”

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Jacob Stern

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January 26, 2023
Are Gas Stoves Doomed?

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Somehow, in a few short days, gas stoves have gone from a thing that some people cook with to, depending on your politics, either a child-poisoning death machine or a treasured piece of national patrimony. Suddenly, everyone has an opinion. Gas stoves! Who could have predicted it?

The roots of the present controversy can be traced back to late December, when scientists published a paper arguing that gas stoves are to blame for nearly 13 percent of childhood asthma cases in the U.S. This finding was striking but not really new: The scientific literature establishing the dangers of gas stoves—and the connection to childhood asthma in particular—goes back decades. Then, on Monday, the fracas got well and truly under way, when Richard Trumka Jr., a member of the Consumer Product Safety Commission, said in an interview with Bloomberg News that the commission would consider a full prohibition on gas stoves. “This is a hidden hazard,” he said. “Any option is on the table. Products that can’t be made safe can be banned.”

Just like that, gas stoves became the newest front in America’s ever expanding culture wars. Politicians proceeded to completely lose their minds. Florida Governor Ron DeSantis tweeted a cartoon of two autographed—yes autographed—gas stoves. Representative Jim Jordan of Ohio declared simply: “God. Guns. Gas stoves.” Naturally, Tucker Carlson got involved. “I would counsel mass disobedience in the face of tyranny in this case,” he told a guest on his Fox News show.

No matter that Democrats are more likely to have gas stoves than Republicans, and in fact the only states in which a majority of households use gas stoves—California, Nevada, Illinois, New York, New Jersey—are states that went blue in 2020. Why let a few pesky facts spoil a perfectly good opportunity to own the libs? The Biden administration, for its part, clarified yesterday that it has no intention of banning gas stoves. In the long run, though, this may prove to have been more a stay of execution than a pardon.

Beyond the knee-jerk partisanship, the science of gas stoves is not entirely straightforward. Emily Oster, an economist at Brown University, suggested in her newsletter that the underlying data establishing the connection between gas-stove use and childhood asthma may not be as clear-cut as the new study makes it out to be. And because those data are merely correlational, we can’t draw any straightforward causal conclusions. This doesn’t mean gas stoves are safe, Oster told me, but it complicates the picture. Switching from gas to electric right this minute probably isn’t necessary, she said, but she would make the change if she happened to be redesigning her kitchen.

Whatever the shortcomings of the available data, it’s clear that gas stoves are worse for the climate and fill our homes with pollutants we’re better off not inhaling. Brady Seals, a manager at the Rocky Mountain Institute and a lead author of the new paper, told me that even assuming the maximum amount of uncertainty, her work still suggests that more than 6 percent of childhood asthma cases in the U.S. are associated with gas stoves.

Regardless of the exact science, gas stoves might be in trouble anyway. Statistically, they’re not all that deeply entrenched to begin with: Only about 40 percent of American households have one. Plus, induction stoves—a hyper-efficient option that generates heat using electromagnetism—are on the rise. “We’re not asking people to go back to janky coils,” said Leah Stokes, a political scientist at UC Santa Barbara who has provided testimony on the subject of gas stoves before the U.S. Senate, and who is currently in the process of installing an induction stove in her home.

Rachelle Boucher, a chef who has worked in restaurants, in appliance showrooms, and as a private cook for such celebrity clients as George Lucas and Metallica, swears by induction. She started using it about 15 years ago and has since become a full-time evangelist. (In the past, Boucher has done promotions for electric-stove companies, though she doesn’t anymore.) Induction, she told me, tops gas in just about every way. For one thing, “the speed is remarkable.” An induction stovetop can boil a pot of water in just two minutes, twice as quickly as a gas burner. For another, it allows for far greater precision. When you adjust the heat, the change is nearly instantaneous. “Once you use that speed,” Boucher said, “it’s weird to go back and have everything be so much harder to control.” Induction stoves also emit virtually no excess heat, reducing air-conditioning costs and making it harder to burn yourself. And they’re also easier to clean.

Induction stoves do have minor drawbacks. Because they are flat and use electromagnetism, they aren’t compatible with all cookware, meaning that if you make the switch, you may also have to buy yourself a new wok or kettle. Flambéing and charring will also take a little longer, Boucher told me, but few home cooks are deploying those techniques on a regular basis. In recent years, induction has received the endorsement of some of the world’s top chefs, who have tended to be ardent gas-stove users. Eric Ripert, whose restaurant Le Bernardin has three Michelin stars, switched his home kitchens from gas to induction. “After two days, I was in love,” he told The New York Times last year. At his San Francisco restaurant, Claude Le Tohic, a James Beard Award–winning chef, has made the switch to induction. The celebrity chef and food writer Alison Roman is also a convert: “I have an induction stove by choice AMA,” she tweeted yesterday.

If it’s good enough for them, it’s probably good enough for us. At the moment, induction stoves are more expensive than the alternatives, although their efficiency and the fact that they don’t heat up the kitchen help offset the disparity. So, too, do the rebates included in last year’s Inflation Reduction Act, which should kick in later this year and can amount to as much as $840. The price has been falling in recent years, and as it continues to come down, Stokes told me, she expects induction to overtake gas. A 2022 Consumer Reports survey found that while 3 percent of Americans have induction stoves, nearly 70 might consider going induction the next time they buy new appliances. “I think the same thing’s going to happen for induction stoves” as happened with electric vehicles, Stokes told me. In the end, culture-war considerations will lose out to questions of cost and quality. The better product will win the day, plain and simple.

Still, gas stoves’ foray into the culture wars likely means that at least some Republicans will probably scorn electric stoves now in the same way they have masks over the past few years. And this whole episode does have a distinctly post-pandemic feel to it: the concern about the air we’re breathing, the discussion of what precautions we ought to take, the panic and outrage in response. The new gas-stove controversy feels as though it has been jammed into a partisan framework established—or at least refined—during the pandemic. “I don’t know if this discourse that we’re seeing now could have happened five years ago,” Brady Seals told me. Whatever happens to gas stoves, the public-health culture wars don’t seem to be going anywhere.

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Jacob Stern

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January 13, 2023