The image here is the front of the Great Seal of the United States – but it has been doctored. The word Unum is replaced by Mediocris which is not Latin for Mediocrity although it might as well be – it’s Latin for Average.
Earlier posts have dealt with Artificial Intelligence (AI) issues – The Miracle of Artificial Intelligence – and although it may not look like it is dealing with AI, In Secula Seculorum picks up on what is for me a key point – Generative AI (Large Language Models) and RCTs (Randomized Controlled Trials) are averaging machines that risk bringing mediocrity out of the wealth that all of us (e pluribus) as individuals have to offer.
A few weeks ago a colleague calling himself (jokingly) Mr Evidence Based Medicine (EBM) emailed a vignette about his interactions with two bright impressive Gen-Zs – which echoed my interaction in Miracles of AI with several very impressive and likable Gen-Zs that left me, like him, scratching my head.
His exchanges with Gen Z centred on Transgender issues, mine on RSV vaccines. This post is not about Transgender issues – the Trans element is secondary to the AI dynamic. There will be a further post, linked to this one, next week, involving exchanges centred on Electro-convulsive Therapy (ECT) where again ECT is secondary to the dynamic AI has introduced into our efforts to reach a consensus.
EBM and Chat GPT
Mr Evidence-Based-Medicine talking about Trans issues with two intelligent, university going Gen Z women who fact-check me in real time on Google and Chat GPT with the evidence and their own experience contradicting what I was saying.
“What is all this about trans people raping women in women’s toilets? All our trans friends are respectful. You could not tell they were trans. This is just a slur. Our friends are gentle folk. Where are your data?”
I move on to “puberty blockers”. Hormones are bad – they have been stopped.
“Why? They are natural to the body. Why have they stopped them? Didn’t medical professionals prescribe them before?”
I say the suicide risk in adolescents with dysphoria has been exaggerated.
They tell me the Chat GPT studies show
- A large US survey found that for high school students, about 26% of transgender or questioning students attempted suicide in the past year, compared with about 5% of cisgender male students. CDC+1
- A review of many studies concluded that transgender youth “report more than four times greater rates of suicide attempts compared with their cisgender peers.” PMC+2PMC+2
- One study of 120,617 adolescents (ages 11-19) found the lifetime suicide attempt rate for transgender female-to-male adolescents (i.e., assigned female at birth, identify as male) was 50.8%, followed by 41.8% for adolescents identifying as “not exclusively male or female,” 29.9% for male-to-female, 27.9% for those questioning, 17.6% for cisgender females and 9.8% for cisgender males. PMC
- Research of clinic-referred transgender adolescents (i.e., those seen in a specialised gender identity clinic) in one large dataset estimated an annual suicide-death rate of about 13 per 100,000 over 11 years, which is ~5.5 times that of comparable cisgender adolescents. SpringerLink
- Importantly: while the risk is elevated, context matters. Studies highlight that many of the elevated risks are associated with social, environmental and minority stress factors (e.g., discrimination, lack of support, victimisation) rather than the identity per se.
I say regret and detransitioning are under-estimated.
Chat GPT reports the research on detransition rates as follows:
- A large U.S. survey (the 2015 U.S. Transgender Survey) found that of 17,151 respondents who had undergone gender affirmation, 2,242 (or about 13.1%) reported having at some point “detransitioned” (that is, lived again as their sex assigned at birth, at least for a while). SpringerLink+3fenwayhealth.org+3PMC+3
- However, among those, a majority said their “detransition” was temporary, and often driven by external pressures (e.g., family, society) rather than a change of identity per se. PMC+2PMC+2
- In youth (children/adolescents) who socially transitioned, a study found that 7.3% of youth had retransitioned (i.e., changed gender presentation back or changed identity) by an average of ~5 years after initial social transition. Pediatrics
- Among those who have undergone irreversible surgical procedures (e.g., genital surgery), the rates of regret/detransition appear to be very low (often under 1-2%) in the studies that exist. SpringerLink+2GenderGP+2
- A recent systematic review (to May 2024) looked at “point-prevalence proportion of detransition events” in persons who started puberty blockers or gender-affirming hormones and found the study quality is variable and the estimates vary widely
Reflections
Mr. EBM went on to say in the email not to the Gen Zs:
It’s difficult to say I think we should stop all this. I just come across as an old person who doesn’t understand. Gen Z wanted data to challenge their ideas and I couldn’t produce it.
The evidence accessible to the public shows HIGH suicide rates, LOW detransition rates, and low regret.
As far as Gen Z are concerned, the evidence is in. Is there a way to advance the field? Or do we sit it out? Is there a Gen Z group that can be supported in a public media campaign?
The problem from a “do no harm” perspective was supply of drugs and services. The supply of hormones that interfere with normal adolescent maturation has been stopped – a supply side intervention. We are continuing to tackle this from the supply side to ensure no drugs and services available.
However, we are not working on the demand side and this problem arose as a result of demand.
There doesn’t seem to be anything coordinated being done on the demand side, No Gen Z on Tik-Tok or Instagram influencing views. Surely this is where we need to go with reviews, with communication strategies?
Stepping Back
Mr EBM called himself that. I need to stress in terms of what comes next, several decades ago EBM meant taking what we knew from clinical trials and when what was Evident in or with the patient in front of us, which combined should dialectically lead to a new synthesis.
This is not what EBM means for Pharma. The embodiment of company trials in Guidelines has subverted the possibility of a dialectic. Mr EBM does not work in industry.
Some of us on the RxISK side of things dealing with Young Women increasingly turning to SSRIs – see Authenticity Inc – have also wondered about the demand side he points to. We seem to have semi-concluded there is not a lot we can do to compete with paid influencers and Chat GPT, but still wonder if there is a way forward – a way to cross the divide to Gen Tik-Tox.
Johanna Ryan outlines the chaos that is the current demand side in a just posted RxISK post – Authenticity Inc.; Telehealth and Influencers.
In Mediocrity We Trust?
At present A.I. and perhaps most of the internet are fundamentally unscientific – Wikipedia may be an exception.
Context gets stripped away. Our voice and our doctor’s voice are stripped away. Our doctors are increasingly becoming Follow The Science Badge wearing Puppets – See Health Care and Science in Real Life.
A.I. and RCTs are a tool that we can access, just as nuclear energy, guns, and medicines are tools. Any Magic, or Miracles, that can be brought out of their use lies in us and our use of these tools – not in the tools.
To adapt a phrase from Mahatma Gandhi:
How can those who think they possess absolute truth be fraternal scientific?
What lies in books or scientific journals or can be extracted from RCTs or Chat GPT may be useful, but the scientific process and the progress that stems from that process hinges in its entirety on achieving consensus on observables – on what is happening in Real Life – not in following something.
We risk having the Miracle of A.I. turn each of us into an Artificial I – someone who thinks we have arrived and are solid because we have a clear point of view derived from our own research (asking Chat GPT a question).
Rather than having a vibrant body (community is the in word on the web) emerge from the talents of each of us, we risk imprisonment in a Digital Cage. We risk having AI turn the very best Wine into Water.
The image below is the flip side of the Great Seal. The words imply that God’s Providence (the Eye) favors our (American) efforts to create a New World Order. In Secula Seculorum sounds semi-sacred especially when chanted. The Seculorum here is the same as Seclorum in the Seal, and celebrates the Catholic Church’s, carrying out God’s will of course, to create a new World Order.
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