How should I treat someone with body dysmorphia who believes they are 130 kg when they're closer to 50? Should I agree with them and affirm them as fat as they believe they are? Or should I - if it's my place - implore them to go to talking therapy and refuse to be drawn into their self-hating fantasy?

1) Someone’s body dysmorphia is not - generally - affirmed or denied by ordinary everyday passing social interactions. In polite society, you simply don’t comment on someone’s body composition. Gender is an entirely different matter as it is a constant differentiator in day to day life. Also, in my experience, body dysmorphia has nothing to do with other people’s affirmations. We’ve all seen examples of people getting repeated surgeries to change their appearance because they simply cannot see what everyone else is seeing when they look in the mirror.

2) I think in determining “how to handle it” from the perspective of psychotherapy, we should consider what treatment is considered effective. Psychotherapy is simply not effective at changing someone’s gender identity or ameliorating gender dysphoria. The established treatment for gender dysphoria is to align the person’s gender identity and gender expression.

To me, this makes sense when applied to your own life. Therapy might be able to help me realize that my perception of the size of my nose is not accurate, but therapy is not going to be effective at changing my gender identity. Do you feel that your gender identity could be changed using Cognitive Behavioural Therapy?

3) Refer back to the questions that I think should be asked if you find it too difficult to accommodate pronouns:

>What do you expect someone who is gender dysphoric to do? What do you believe the appropriate course of action is for someone in that situation? What would you expect or appreciate if you were a person in that situation?

Your description of getting surgeries based on a distorted view of what they see in the mirror sounds exactly like gender dysphoria to me.

I have a big nose like you and even having had romantic partners compliment me on it hasn't stopped me feeling bad about it, but I agree it's definitely more trivial than believing you ought to be the other sex, somehow. They usually say "it's handsome" rather than try to convince me it's a normal size, which is perhaps a more merciful lie!

I don't know about CBT, but I know that people can be convinced by others that they should be the other sex: it happens all the time on youtube, tiktok, tumblr and across the web. That's how this became so wide spread in the first place.

So I absolutely believe people can be helped to accept the truth of themselves and their real body and not require hormonal or surgical interventions. Here I'm mostly talking about insecure young people - the very different cohort of older men where there's a sexual element involved might be boned (pardon the pun!) but that's all the more reason not to have the rest of society change laws and social mores to facilitate it.

If I was gender dysphoric (unable to accept the truth and be comfortable in my own body) AND believing in gender identity then I'm sure I would expect people to affirm my delusion and I'd viscerally dislike those that didn't. If I was later cured, I'd hope I'd appreciate those who stuck to their guns and didn't lie to me. Maybe it's impossible to fully accept yourself (like our big noses) and one just has to live with it and cope with it as healthily as they can. I would consider getting my nose carved down to size (regardless of how big it really is) a failure for everyone involved.

In terms of "people being convinced by others", I think this is a relatively recent phenomenon. I think it's possible to be simultaneously concerned about social contagion and social influences, especially among young people who don't have a fully developed understanding of themselves, hasty treatments without due diligence on behalf of medical providers, commercial incentives in the medical community, etc, etc... while also acknowledging that some people simply do suffer from legitimate, intractable gender dysphoria.

There is no evidence that I can find that reparative therapy is effective. A teenager being lured into something on social media for social clout is simply not the same thing as a person who genuinely, intractably believes that they were born in the wrong body.

> If I was gender dysphoric (unable to accept the truth and be comfortable in my own body)

One thing I find interesting about this framing ("unable to accept the truth", "affirm my delusion") is that it seems to ignore any kind of biological/chemical occurrences in the body and brain that could explain gender dysphoria and instead casts it purely in a judgemental "these trans people are just nuts" light, which seems odd given that this is a topic on which we clearly don't have all the answers.

Just because we cannot see the physical manifestation of suffering or understand someone's experience when put through the lens of our own experience does not mean that their suffering does not exist or is irrational or delusional. Many chronic pain sufferers understand this.

One thing I can't understand is the assertion that simply respecting another person, usually by doing nothing other than accommodating some alternative pronoun use is such an incredible burden so as to cause apparent extreme mental anguish among the people being asked for this accommodation.

If I have an acquaintance who is transgender, using their preferred pronouns that match their outward appearance and identity is:

1) Not difficult - what is more difficult and socially strange is referring to a person who is trying to present as a woman a "man" or a person who is trying to present as a man a "woman".

2) Not a self-delusion - or any kind of determination at all, really - about their biological sex. I have encountered non-transgender people in my life who are androgynous. You either make a mistake with their pronouns, or ask. There is no way of knowing what their biological makeup is, and I don't experience any kind of internal consternation over it. You take what they say at face value and move on.

3) Is simply offering a modicum of respect.

So much of all of this is tied up in the fact that a lot of people, for whatever reason, just really want to be mean. It seems their default is to be sneering, judgemental, and offer behavior that is more indicative of the worst instincts of high school students rather than well-adjusted adults.

I said 'gender identity' not 'gender'.

Up until the early 1900s, the word "gender" did not apply to people. It applied to words. The word "libro" has a masculine gender, but obviously the object itself has no gender or sex. Rarely, "gender" was a synonym for sex, but this was generally considered to be informal or a mistake. As Henry Watson Fowler, a teacher of English usage, wrote in 1926:

> "Gender...is a grammatical term only. To talk of persons...of the masculine or feminine gender, meaning of the male or female sex, is either a jocularity (permissible or not according to context) or a blunder."

Then in middle-1900s academics began defining gender in various new ways. Money used it as a word to describe the way a person presents their sex. Other academics invented the term "gender role" to describe the things a culture associates with men and women. These academics did not believe that "gender" was some innate characteristic of a person's mind. In fact, many of them were arguing there was no difference between men and women in the head, and "gender" roles were social constructions. Even here, though, the concept of gender applied to things, not to people (eg the gender of pink clothes is feminine).

At the same, time the word "sex" began to more commonly be used to refer to coitus, and so normal, non-academics started using gender more commonly as a synonym for biological sex to avoid using the word "sex."

Then in the last thirty years, the term "gender identity" has arisen to describe one's own internal sense of being a boy/man or woman/girl in one's own mind (see the genderbread person), and furthermore the claim is that this is immutable and if there is a conflict between your "gender identity" and biology or how society sees you, it is your biology and/or society that should change. It is only in the last thirty years that people are considered to have something called "gender" that is different than biological sex.

Interestingly this new sense of "gender" almost seems to be a mutant child of the two, completely separate previous definitions of the word gender (gender as biological sex, a property of a person, man or woman and gender as ones presentation and expression more masculine or feminine).

I do not believe that "gender identity" is a meaningful concept. It is an anti-concept, it mashes together unlike things and makes it harder to think and reason about the underlying phenomena. I do not believe that someone has a fixed gender identity that can be distinguished from their biological sex. I do not believe believe that "gender" (as opposed to biological sex) is a property of a person.

"I am a woman, but I don't always like to act or dress as a stereotypical woman, my self-expression is fluid" is a banal and unobjectionable statement.

"I don't like to act or dress as a stereotypical woman, therefore I am not a woman, my gender identity is genderqueer/non-binary" does not make any sense. It is making a mishmash of concepts.

If you believe the modern idea of "gender identity" is real and valuable then you need to properly define it, explain why it is useful, and what is your evidence that it really exists.

See, this is where you guys get it twisted. This is not a matter of playing along, it's not a game. It's a matter of social practicality. Example:

If you meet a new person who clearly appears to be a woman, do you use female pronouns with that person? What if that person is biologically male and has transitioned, and you simply don't know that? Presumably you don't do genital inspections on every new person you meet to ensure that you are not "playing along with childish games", right?

1) should institutions that have female only spaces or events be allowed to exclude pre-op transwomen? Post-op? For example, the women's only nude spa in Seattle that got in trouble for excluding a transwoman -- https://www.courthousenews.com/after-banning-trans-women-was...

2) If a coworker of mine who I know to be a biological male (he has sired children, etc.) socially transitions (no surgery), should I be forced to call him "she" and say that he is a woman? What if he makes almost zero effort to pass as a woman? What if he medically transitions?

3) Should I be able to make an argument on social media (Reddit etc.) such as "Men cannot get pregant" or "trans women are not real women" without getting banned for hateful conduct?

All three of these things are really happening, and are the real issues getting me freaked out (also, that and transitioning kids who very obviously are not "girls in a boys body")

I'm not sure how such a thing is strictly enforceable. Even in states that have banned trans people from using the bathroom that they prefer, it seems to operate mostly on the honor system.

> If a coworker of mine who I know to be a biological male (he has sired children, etc.) socially transitions (no surgery), should I be forced to call him "she"

What does "forced" mean? The reality is that if you cannot make this basic accommodation that most people consider to be a matter of social etiquette in 2025, other people may not perceive you in a positive way and that can have unintended consequences.

You mentioned in another reply that you feel its important to respect cultural norms and expectations when it comes to things like what you are expected to wear. Well, basic respect of pronouns and not antagonizing transgender people are increasingly a 'cultural norm'.

> Should I be able to make an argument on social media (Reddit etc.) such as "Men cannot get pregant" or "trans women are not real women" without getting banned for hateful conduct?

People seem to make comments like this on reddit without getting banned now? A search of reddit for that term brings up many results.

There seems to be a resurgence and re-normalization of plain LGBTQ+ hate and antagonization these days. Twitter/X is full of people thrilled that "gay" and "retarded" are acceptable adjectives for them to use again.

So, in January 2025 I am not really buying any arguments about "I'm not allowed to even discuss basic issues around gender" because those discussions are absolutely happening and the rules seem less restrictive than they have in a long time.

Exhibit A: Mark Zuckerberg's latest announcement that you are allowed to post vile garbage about LGBTQ people without restriction.

Can you find a randomized controlled study where the "affirmative" approach of aligning gender expression with identity has been compared to a "reparative" approach of aligning identity with biology? I have read a lot of studies on this and what you are saying simply is not backed by the evidence. Whenever I read a study that has been referenced on NPR or such, I read the details and the details do not support what the people citing the study say it supports.

In all other cases, if someone's mental conception of themselves was not aligned with the biological reality of their self, we would say the default is that the person should try to adjust their mental conception. A treatment that involved all of society changing, or even more extreme -- actual removal of body parts -- would need to pass a very high burden of experimental evidence. From what I have read, that burden of proof has not ever been close to being met. There are no studies that say that aligning gender expression works better than helping the person cope with or get over their dysphoria. If I have missed such a study, I would like to read it.

Do you feel that your gender identity could be changed using Cognitive Behavioural Therapy?

I do not have a gender identity and I do not have a gender. I a sex and I have an identity as a sexed being. I have a brain that has developed under the influence of testosterone, I have the knowledge of having a penis, I have the knowledge that society sees me as a male and penis-haver and all that entails. I have the knowledge that if I used a woman's locker room and exposed my penis, women would freak out, and so I do not do that. Etc. etc. I wear the clothes that I do because that is what society expects of me. There are all sorts of clothes and outfits from other cultures that I prefer aesthetically but I don't wear because they do not align with the norms of my current culture.

It's actually really difficult for me to understand how a person's fundamental well-being is intrinsically and immalleably tied to names and clothing.

Of all the possible forms of clothing humans have worn in the last ten-thousand years, only a tiny sliver of those clothing are socially acceptable for me to wear. And yet we all deal with that.

If someone were to intentionally call me the wrong name, while everyone else gets called the name they have asked to be called, that would bother me, but only because that is a power move that singles me out. If I were to, say, join a fraternity, where everyone had to have a name assigned to them, that would not bother me, and I would be fine being called that name while hanging out in the fraternity.

If someone were to call me a "woman" I would be upset because it is the reality of my biology that I am a man. Furthermore, saying you are a "woman" is usually saying, "You lack the positive qualities we usually associate with being a man -- you are weak, you are cowardly, you are whiny, etc."

I understand your perspective - in a different world without ethical qualms or risk of harm we could conduct those studies and maybe have better, more conclusive answers. What I am suggesting is that we have the data and research that we have. While you have chosen to draw a line at requiring randomized controlled trials to convince you that a certain outcome is the right one, there is an abundance of research and clinical data that does exist endorsing affirmation of gender identity, and we can explore some of it, if you like.

> In all other cases, if someone's mental conception of themselves was not aligned with the biological reality of their self, we would say the default is that the person should try to adjust their mental conception.

Can you elaborate on what you mean by "other cases" that are directly comparable with gender dysphoria, and can you find some studies that support the effectiveness of this approach? Gender dysphoria seems pretty unique from a clinical perspective despite a common thread it may have with other conditions.

> I do not have a gender identity and I do not have a gender. I a sex and I have an identity as a sexed being.

I think it's great that you are very clear on your role in society when it comes to what side of the biological sex binary you are on. It's a luxury to not have to be concerned with it, but not everyone has that luxury.

> It's actually really difficult for me to understand how a person's fundamental well-being is intrinsically and immalleably tied to names and clothing.

What you are saying here is that "this is my experience and I do not understand why everyone else does not have the same experience". Do you not see a problem with that? You can have your opinion and that's fine. Other people do not have to share your opinion or approach the world in the same way.

You appear to start from your biology and work backwards, as if the mind does not exist. Others would suggest that you and your biology do not even exist without the conscious mind making them real. Thus, the power of the conscious mind is actually more critical to this whole equation than whatever your biology is.

Stop thinking about your own experience for 5 minutes and think about the experiences of other people and where they might be coming from based on their own perception, experience and biological realities - including the biology of what goes on in the brain!

Where the current public discourse on these issues goes off the rails is that we conclude that, because these concerns around improper incentives and improper treatment exists, or because there are some issues around social influence of children on social media, that "gender dysphoria" broadly is either not real or not a legitimate problem that people deal with.

> If someone was too short, or too tall, or thought they were black (even though they were unambiguously white)

If someone was 5'8" and underwent leg-lengthening therapy to become 6'1", would we not call that person "tall", or would we jump through strange mental hoops to justify antagonizing them based on their genetic makeup?

> Until a mind reading machine exists

Again, the problem here is that you are concluding that unless you can rationalize and validate someone else's thought process or mental condition through the lens of your own experience, then their experience is irrelevant to you, not real, and that they are worthy of mockery and derision instead of respect and consideration.

We don't need a mind reading machine to understand what gender dysphoria is, because gender dysphoric people tell us what they are thinking and feeling, not to mention they tend to know what will reduce their feelings of dysphoria.

It's not this simple. For one, lots of people are all kinds of confused. There are people who think they are dysphoric, transition, then realize they totally messed up. There are people who say, "I went through a period when I was a kid where I was a tom-boy or told my parents I was the other sex -- thank goodness this kind of ideology wasn't around then because I could have been trannsed. I'm perfectly happy in my biological sex right now." If you read a lot of stories they aren't necessarily "dysphoric" they just think it will benefit them someway to transition, in the same way a weightlifter who goes on steroids is not "dysphoric" about his body, he just might think he is happier to be muscled up.

And we also have people who later admit that they lied about the nature gender identity in order to get sex change drugs and trans people who admit there is substantial political pressure to make their personal testimonials about gender identity conform to a certain script: https://nymag.com/intelligencer/article/trans-rights-biologi... https://www.nplusonemag.com/issue-30/essays/on-liking-women/

Because we do not actually have the technology to turn a man into a female (or vice versa), I think the most honest and best course is to tell that person, "Sorry, you are not a woman, and the surgery you are asking for will not actually get you want you want. Cross-dressing and wearing lipstick does not make you a woman. But if you learn to accept who you are, you can live a happy life." To be convinced that this common sense approach is not the best approach, I would need very strong evidence -- at minimum multiple randomized controlled trials by honest researchers.

Some people start businesses, it doesn't go well, they then realized they messed up and totally regret it. Does this mean that all entrepreneurship should be banned?

The logical failure in your argument is that you are saying that because there are problems with current approaches to transgender care, that gender dysphoria is not real and does not need to be taken seriously or treated or accommodated.

> I think the most honest and best course is to tell that person, "Sorry, you are not a woman, and the surgery you are asking for will not actually get you want you want. Cross-dressing and wearing lipstick does not make you a woman. But if you learn to accept who you are, you can live a happy life."

There is zero evidence that your "common sense approach" works at all, and there is zero evidence that reparative or conversion therapy works at all for those with legitimate gender dysphoria.

Clinical psychologists Kenneth Zucker's work in getting the majority of his patients over their dysphoria is "evidence" that reparative therapy works -- https://www.thecut.com/2016/02/fight-over-trans-kids-got-a-r...

Every random comment on Reddit that "I suffered from dysphoria and then started lifting and doing masculine things and got completely over it" is evidence that reparative therapy works.

It's not gold standard evidence, it's not proof-beyond-a-reasonable doubt, but it is evidence. But the "evidence" for "affirmation" and "medical transition" do not meet this gold standard either.

With medicine, the burden of proof is on the person doing the intervention. "First do no harm." Social transition and medical transition are both MAJOR interventions, the burden of proof is on the proponents. "You have to give people this drug, no we have never done a controlled clinical trial on it, but you have no evidence that NOT giving them the treatment works." What? You need to do a RCT before promoting a new treatment as the standard of care. "Affirmation" has never proved itself in an RCT so "Sorry, you are a man" should be the default.

You are conflating social trends among young people to identify as gender non-confirming for social clout, with adults who have intractable gender dysphoria. It is disingenuous to point to children who were likely not genuinely gender dysphoric to begin with, claim that they were 'cured' and conclude that this solution is then viable for all people with gender dysphoria. There is an incredible amount of nuance to the situation that you are simply ignoring.

One of two things is true:

1) You genuinely do not understand the 'separation of concerns' when it comes to these issues surround gender, biological sex and gender dysphoria, current social trends, and sensational political headlines.

2) You are being intentionally misleading.

I'm going to assume you are arguing in good faith and that #1 is true. In that case, I recommend you take a step back and try to recalibrate your understanding of the issue. I don't know the best way to accomplish that - maybe do some research and read some stories of transgender people published prior to 2015 before it became the political fight du jour.

>Every random comment on Reddit that "I suffered from dysphoria and then started lifting and doing masculine things and got completely over it" is evidence that reparative therapy works.

You've gone from demanding randomized controlled trials to referring to random comments from anonymous users on Reddit about how lifting weights cures gender dysphoria?

I think it's safe to say that the conversation has gone off the rails, although maybe that happened a few replies ago.

It's not just me who is conflating them, the official medical establishment doesn't treat children much differently these days. Zucker was canceled, "watchful waiting" or "reparative therapy" is officially condemned by the APA. "Intractable gender dysphoria" is not something that can be reliably or objectively diagnosed a priori. A relative of mine who has transitioned their son, partly based on medical advice, partly on the advice of adult trans friends, seems to repeating arguments about it being a fixed property and affirmative care being the only approach. Now, I personally do not think this boy has dysphoria at all, he sees a perfectly normal boy to me, he just liked Elsa and princess dresses as a kid because Elsa is a super-stimuli character. But that's not what the medical people say.

You can't separate the kids and adults issue because the most powerful activists who are making policy and getting people canceled are not making a proper distinction themselves.

You can't separate the kids and adults issue because there was a direct road from redefining the words "man" and "woman" to the medical "experts" like Diane Ehrensaft, cited by NPR and NY Times telling parents to not tell their four-year-old things like: "you have a penis, you can never grow up to be a woman or get pregnant, you will grow up to be a man, you are a boy."

It's not the sensationalist headlines that is making me freak about this, it's seeing my own relatives sending a little boy down the path where "continuity of care" ( https://www.youtube.com/watch?v=v0V0PXrezHM ) will lead to having his penis cut off like Jazz Jennings -- https://malcolmrichardclark.substack.com/p/the-truth-about-j... https://x.com/SJWilliams123/status/1654534161015635973

I don't know the best way to accomplish that - maybe do some research and read some stories of transgender people published prior to 2015 before it became the political fight du jour.

I have, but you need to re-calibrate your understand for the recent situation. The people who transitioning now are not exhibiting the same types of life stories as those who did thirty years ago. It seems like a different phenomena, and I am much more concerned with the phenomena now, when if afflicts so many people, including parents I know who are transitioning their kids, than I am about the phenomena 30 years ago.

You've gone from demanding randomized controlled trials to referring to random comments from anonymous users on Reddit about how lifting weights cures gender dysphoria?

Yes, once you have anecdotal evidence of something working on a n=1 approach, the thing to do is expand it to an n=many RCT. That hasn't been done. It should have been done. Also, comments on niche subreddits inhabited by relatively normal people are some of the best anecdotal evidence you can find. Anecdotes from friend groups are limited in their own way. Popular memoirs and newspaper stories are both highly selected and filtered by publishers for preferred narratives, and the person writing them understands that a lot is at stake and they have to be careful about how they narrate their story. Random commenters on niche forums have much less incentive to lie (this doesn't apply to big forums where people will lie to get rise out of people, and the comments that reach visibility are selected).

(By male hormone I'm assuming you mean testosterone, and by female hormone I assume you mean oestrogen.) i in fact If being "more male" came from having more testosterone (and vice versa), then logically when children go through puberty and develop into adults, they would become "more" male or "more" female.

As adults become elderly and naturally produce less sex-associated hormones, they would become "less" male or female.

(Fetuses do not all begin in the womb as female, that's a common misunderstanding. We start off physically undifferentiated, and develop along a genetically predetermined pathway as we grow. Some animals use temperature or other environmental triggers to pick, humans use genes.)

Would that mean a male bodybuilder who injects testosterone is more male than a man that doesn't? His phenotype may become visibly more masculine, but that doesn't change his sex at all. Same for a female bodybuilder that injects testosterone - she may develop stereotypically male physical characteristics like large muscles and a deeper voice, but her sex is unaffected.

The causality is the other way: being male - or - female results in a physiology (adult testicles/ovaries) that produces sex associated hormones in larger or lesser degrees depending on the person (and in some cases very low amounts or not at all).

This makes sense if sex is a binary (with rare differences of sex development - detailed here https://www.theparadoxinstitute.com/read/sex-development-cha... ) that results in different levels of sex hormones in the body and resulting phenotype. So yes, everyone is male or female.

(I'm not referring to gender here - I'm talking only about sex)

If there's a spectrum then some men could be biologically "more male" than others and vice versa for women. I've not seen any evidence of this myself, but I'm happy to be proven wrong!