Hacker News Reader

Comment by ed25519FUUU | Hacker News Reader

> “Estrogen is not a treatment for ODD. I can’t be more emphatic about that,” McGough said. “You won’t find a reference anywhere that supports the use of estrogen for ODD.”

Well certainly the doctor got this theory from someplace. They believed this young man would be better behaved if he had less testosterone and more estrogen, and went ahead with a treatment against scientific evidence (and ethics quite frankly).

So where did the doctor get this theory? Let's ask ourselves that question, and follow up with this question: what other theories are medical and science professionals getting that aren't science based?

View on HN

Probably many, but that's not really the problem. We want people to be developing and appropriately testing theories. What we don't want is:

* Treating people against their will outside of specific extreme circumstances which this was not one of

* Coercing vulnerable populations into treatment

* Concealing treatment plans from guardians

* Treating in a manner that is not in line with evidence based practice

* Treating in a manner that is not designed to advance the patient's well-being but is instead designed to pacify the patient for another person's convenience

* Running what amount to illegal clinical trials that have not been validated for medical and ethical soundness, safety, and legitimacy by a medical oversight board

* Insurance fraud (I don't know how payments work in correctional facilities, but generally speaking there is zero probability this treatment plan would result in reimbursement from an insurer. I would naively assume they lied about what they were doing for reimbursement)

As a healthcare practitioner, behavior like this makes me sick. The legal system should open up on this guy with all they've got.

There is no "theory". This is a sickening attempt at using a farcical medical diagnosis to ruin the entire life of a prisoner, even worse, a youth prisoner. History is littered with examples of lobotomies and chemical pacifiers being used to control "oppositional defiant" prisoners.

A doctor with medical credentials would know far better than anyone else, the foundational and fundamental damage done to someone with induced gender dysphoria, the practical effect of giving an ordinary man estrogen. This is psychopathic behaviour that has become all too routine in our national prison complex.

Your unspoken assumption is that "treatment" was a primary goal at all. Here, I would consider if "treatment" is instead the weapon of choice used in service of the actual goal: to brutalize one person so severely that it causes others to sit silently in fear, rather than stand up and speak out.

"This boy was super aggressive towards me, a doctor! so I must punish him for that transgression against me, a doctor! and ensure that I make an example of him! I have just the thing, I'll humiliate him by making him into a girl! I'll lose my license, but it's worth it because I'll be remembered forever as the boogeyman in every juvey in the country!"

> and went ahead with a treatment against scientific evidence

Despite a lack of scientific evidence not against. Don't think this has been tested and disproved in a scientific manner. And for ethical reasons probably won't be.

A relationship between male hormones and aggressive behavior while sometimes questioned is generally well supported. Yes that's not ODD but one can easily see the train of thought here.

What the doctor did is obviously very unethical and wrong (if the story is true)

But it certainly doesn't seem like a random out-of-nowhere idea to me.

Seems equally likely to me that the doctor was unethically treating based off own untested hunches as it is that it was a purely sadistic action.

> A relationship between male hormones and aggressive behavior while sometimes questioned is generally well supported.

That a relationship exist is well supported. The cause and effect, as per more modern research, however is one that more recent (ie > last 30 years) has found to be quite different than previous assumptions.

Throw in a random number of test subjects in a room, observe aggressiveness, and then measure testosterone and you get a clear pattern. Now change the test by first measuring the testosterone and then observe aggressiveness, and the data is all over the place.

The part that more modern research is questioning is not that the relationship does not exist, but rather in what direction the arrow points. Can behavior effect hormone secretion? More and more data seem to support that very theory.

Aggressive dogs get their balls cut off and it seems to work. Would there be a reason to assume that it doesn't work in humans in a similar way?

Yes, because they tried that in the past on violent criminals back in the less ethical days. They also tried cutting out the Amygdala and nearby parts of the brain.

The result was not great for either. The more aggressive an individual were the smaller the effect is. Testosterone also get secreted by other areas of the body so you also need to add suppressive drugs for that. Biggest effect was measured by chemically removing testosterone for women as they have the smallest amount to begin with. Going from above average testosterone in men to below average gave no results. Castrating the most violent criminal, usually against their will, has some studies showing minor results while others no results.

There is something called the challenge hypothesis. The theory is that testosterone acts as a modulating effect for managing social status. When an individual suddenly gain status the body reacts by secreting testosterone. Testosterone in turn regulate how much energy an individual will spend on behavior to retain that status. For animals that gain and maintain status by exclusively aggression, this then correlate nicely with testosterone. Reducing a male dogs testosterone would reduce the amount of effort they will spend to defend their status against other male dogs, and since dogs are very territorial, there is ample of opportunities where such behavior occurs. However for very aggressive dogs the effect will be much smaller, so its not a solution in those cases and the solution instead tend to be euthanasia.

Social status for humans is massively more complex, and the relation to violent crime even more so.

That high testosterone levels are a poor predictor of aggressiveness but almost universally present in violent criminals doesn't tell us much.

That behavior affects hormones, again, is interesting but doesn't tell us much.

What we're really discussing here is whether significantly cutting off testosterone would reduce aggressive behavior over time. That the relationship between testosterone levels and aggression isn't perfect is a nuisance.

For example reducing testosterone would reduce bodily strength significantly. Would that reduce aggression? Perhaps. Reducing testosterone is sometimes shown to increase empathy. Could empathy help reduce aggression? Perhaps. You could then argue that it's "not testosterone" and one should refrain from physical exercise and attend psychological empathy training to get the same effect. Logically it's a valid argument but practically speaking it misses the point.

The data we have from chemical castration of sex offenders is very solid. There are people criticizing it saying that something else is at play[0]. But nonetheless it's very effective in practice.

The data from animal experiments is strong too. There's definitely a profound change in behavior. Again, it's sometimes called into question over some oddly specific behaviors but it seems rather uninteresting to me.

In your later comment you mention some experiments from a long time ago on violent criminals but I have a hard time finding anything that isn't about sex offenders or animals. So I'd appreciate a link.

As far as theoretical arguments against it go, I'd say the strongest is that high levels are simply a proxy for some irreversible virilization that happened earlier in life. Which would much better explain why both criminal male and females are relatively high T.

[0] say that people who accept the treatment are naturally predisposed to have lower recidivism

If you want to do the work I can recommend a book called The Trouble With Testosterone that takes a meta perspective on the different research on the topic. It is a fun evening/day going through it cited studies.

> The data we have from chemical castration of sex offenders is very solid

The data show same result for female chemical castration of sex offenders. Usually the study goes something like this: a self selected set of child sex offenders volunteer for chemical castration, and later they report a diminished desire for sex. The problem with linking this to aggression is on several layers. It self selected for individuals that want to reduce their desire for sex. It is self reported. And it is about diminished desire for sex.

Will reducing bodily strength cause a reduction in aggressiveness? If we leave the topic of sex offenders and look at aggressiveness as a whole, bodily strength might very well effect social status and thus fit the challenge hypothesis. Crippling a high social status individual and they will likely spend less energy on defending their status, through the result is going to vary depending on the culture.

The empathy studies are interesting (the book above list a few of those). According to one such study, giving men increased testosterone does not decrease their ability to read emotion in an eye test, but giving it to women does reduce their ability. Again this show a repeating pattern of those studies where within normal range, high or low testosterone levels can not predict behavior. You need to give people testosterone so that they are outside human levels to get any significant effect, and then the result is often minor unless taken to a very extreme level.

> As far as theoretical arguments against it go, I'd say the strongest is that high levels are simply a proxy for some irreversible virilization that happened earlier in life. Which would much better explain why both criminal male and females are relatively high T.

What is your source for that? Criminals have higer rate of violence, and if violence causes testosterone secretion, then the higher level can be explain by the increase violence. male-male competition in prison is also likely a bit more intense than outside which would also explain a higher level of testosterone.

> The data show same result for female chemical castration of sex offenders

As expected. Why would it not work in females? You'll be easily getting these levels to a very "unnatural" level below the low end for both males and females.

The studies aren't just on self reported feelings. You're looking at reductions in recidivism exceeding 50%. Yes some studies show a much smaller reduction, but AFAIK every study does show some improvement. Sure as I noted myself it could be self-selection as some argue, but nonetheless there isn't a study out there outright disproving it. There are a few countries where it's mandatory but not sure if there's any data from these.

When you've got studies showing efficacy, to disprove them you'd want something of higher rigor. Say a proper RCT. If one says self selection taints the result then you want a study that controls for that.

Again I'm absolutely not opposed to the notion that there's some cultural/societal feedback loop involved. I'm just arguing that administering strong blockers MAY help with many issues relating to aggressiveness. And that these arguments on just how linear or predictable the relationship is are interesting but not that relevant to disproving the practical efficacy of such a treatment.

I fully agree that one shouldn't demonize the hormone itself and anyone who has high levels. That's what that line of research tells me as far as I'm concerned.

> What is your source for that?

Regardless of what causes violence we have a huge undeniable discrepancy between males and females. If we go with the explanation that violent behavior bumps T up that goes nowhere in explaining the enormous sex difference. Don't remember the exact ratio off top of my head by it's definitely somewhere around 1 to 10 so not buying a purely societal explanation. And if you look at the extremes, say serial killers or very brutal forms of murder it grows even wider apart.

So it would seem logical to me that in these violent high T females either the T does matter or it doesn't but is an indication of virilization earlier in life.

As to the claim that testosterone levels would be a proxy for earlier virilization - for example digit ratios are believed to be an indicator of virilization in utero and studies do show that they correlate with adulthood T levels[0]. Pretty sure there are studies relating it to criminality too.

Personally my hunch is that it's a bit of both. Say if we put everyone on these drugs I'd imagine overall violent crime would drop but males would still be vastly outnumber females.

[0] https://europepmc.org/article/med/21592297

Just because castration can have an effect on recidivism for some forms of sex offenders (and please point towards a source because it does make the discussion more worth having), it does not mean it have an effect on say axe murderers.

Gun control may also have an effect on recidivism for gang related violence involving military weapons, but is unlikely to effect child sex rapists. Not everyone that work for once set of criminals work for an other set of criminals, nor are recidivism and aggressiveness the same thing.

And there are studies where violent criminals of the non-sex offending nature were given testosterone reducing drugs. It did not work.

> Regardless of what causes violence we have a huge undeniable discrepancy between males and females

That kind of research are plenty in gender research. Men are X more likely to be math professors, having a job, and a number of other gender stereotypical aspect. There is a lot of culture involved and it very hard to separate culture from biology.

But even considering what we know about biology, aggression and crime are not the same and female on female aggression tend to be different than male on male aggression. Culturally we tend to ignore the former and focus on the later.

And finally, there is some evidence that in many cultures male aggression get rewarded with social status, and in the challenge hypothesis, that would link aggression with testosterone through culture. Game theory experiment has demonstrated that testosterone can influence players to be more or less aggressive in an economic game depending on the design of the rules. If aggression is rewarded with maintaining status then injecting players with testosterone increase aggression. If the game is changed and it is cooperation that is rewarded, players with raised testosterone play more cooperative. All cited in that above book.

Quoting from Heim & Hursch (1979): "Of 102 sex offenders, only three castrates (2.9%) relapsed into sex offenses. However, in only 41 cases was the period of observation long (5-10 years). Therefore, there was a maximum of 7% recidivism during this observation period. The recidivism incidence before castration was as follows: Of 102 subjects, 59 (58%) had relapsed."

2.9%/7% vs 58% (this one is on surgical on chemical)

Fedoroff, J.P., Wisner-Carlson, R., Dean, S., & Berlin, F.S. (1992): "All patients received equivalent amounts of group psychotherapy. Of these, 17/46 (37%) relapsed. The rate of relapse among subjects receiving treatment with medroxy-progesterone acetate (MPA) was 4 out of 27 subjects (15%) whereas the rate of relapse among subjects not receiving MPA was 13/19 (68%) "[1]

15% vs 68%

And since you bring up math professors, there's actually a study showing a single dose of testosterone improved spatial cognition in females [2].

Again I'm not opposed to cultural angles. I don't doubt that culture makes small innate differences look much bigger. But that's more philosophical/anthropological, it doesn't tell us much on whether a drug would or wouldn't work at scale. We could go on and deconstruct every psychiatric drug this way.

[0] https://doi.org/10.1007/BF01541244 [1] https://doi.org/10.1300/J076v18n03_10 [2] https://www.sciencedirect.com/science/article/pii/S016643281...

Yes, surgical and chemical castration undoubtedly reduce sexual interest, sexual performance, and have likely a impact on sex offenders. Removing estrogen and testosterone seems to have an effect on sex offenders recidivism, although it does not work on everyone.

This does not mean estrogen causes aggression. It mean estrogen is as a sex hormone, and sex hormones are connected to behavior which is relevant for recidivism.

> I don't doubt that culture makes small innate differences look much bigger. But that's more philosophical/anthropological, it doesn't tell us much on whether a drug would or wouldn't work at scale.

Understanding biology is needed in order to understand whether a drug would or wouldn't work at scale. Take Oxytocin as an example. A great hormone that makes mothers bond with their child. It has shown to improve prosocial, operate like an anti-depressant, improves trust, make people more generous, and even improve wound healing. It have been considered for use in everything from medicine to vitamin supplements.

More modern research however find that there is a problem. It improves prosocial behavior for the in-group but it also create anti-social behavior towards the out-group. It increases trust with the in-group, and causes fear with the out-group. It make women increase parental behavior and at the same time increase racist behavior, and it makes perfect sense. It a hormone that is connected to the goal of sexual reproduction. It increase behavior that benefit offspring during the first years and it strengthen the bond between mother and the child nearest blood-relatives so that the child has the best likelihood to survive. It also protect the child against non-related individuals who is an increase risk of being a threat.

Understanding what a hormone actually do is critical to understand its medical effect.

(deleting because of not funny unwise comment)

If you post like this here again we will ban you. Adding a nationalistic flamewar to what is already a gender flamewar is either arson or criminal negligence.

https://news.ycombinator.com/newsguidelines.html

I am sorry about that. It haven't been thought in a 'nationalistic flamewar' sense or anything like that, text didnt really carry it. So again, sorry.

Appreciated.

It certainly worked, no? https://news.ycombinator.com/item?id=23864426

That's a rather strange definition of "worked".

Not to defend the doctor, but common sense? Sex hormones obviously have a huge effect on behavior, and anyone who has interacted with both men and women can see these effects. I'll refer you to the following study to answer your question about "non-science based theories and treatments": https://www.bmj.com/content/363/bmj.k5094

Not that I think "oppositional defiant disorder" is even a sound classification to begin with, but the lawyer's assertion that estrogen is not an accepted or common treatment for males with ODD is spot on. This was done solely with the intent to harm, by offending a deep and fundamental aspect of the person in question.

However “Common sense” is often wrong. That is why you can’t treat people based on whatever hunch you have. Also you would hope that common sense and basic medial ethics would make you avoid violating the Nuremberg code.

Reply on news.ycombinator.com