Some Orthodoxies Are Cracking
Good News for those who advocate for informed choices
This is a repost (with editing for space) of a piece last month from Megan McArdle. She wrote about Gender orthodoxy, but I thought that she made several good points which apply to a wide variety of societal issues — e.g., COVID-19, Climate Change, etc.
What she didn’t mention is that something they all have in common is a glaring absence of Critical Thinking from organizations and individuals that we would ordinarily expect to be competent and objective. Instead they are virtue signaling by adhering to political correctness — the hell with Science!
The reason that they have the audacity to knowingly misrepresent Science is based on their belief that the public is scientifically illiterate, plus few citizens are Critical Thinkers (thanks to K-12). That’s why we have to fix those…
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In his groundbreaking book, “Private Truths, Public Lies,” political scientist Timur Kuran attacks a vexing question: How can official orthodoxies persist for so long even when few people believe them?
I read that book hungrily during the “Great Awokening,” trying to understand why so many institutions quickly abandoned their liberal commitments for radical social justice politics — and reread it as the Trump administration sought to impose its own brand of public truth on issues such as free speech. That proved to be excellent preparation for what happened recently.
A jury on Jan. 30 awarded $2 million in damages to a woman who sued her psychologist and plastic surgeon for their role in a “gender-affirming” mastectomy she got when she was 16. This verdict does not necessarily implicate all such surgeries. Erica Anderson, a former president of the U.S. Professional Association for Transgender Health, testified for the plaintiff, whose psychologist she said was “wholly unqualified, failed to observe standards of care and simply blew it.” But the verdict puts practitioners on notice that there are risks to mindlessly affirming.
On Tuesday, the American Society of Plastic Surgeons issued a position paper recommending waiting until age 19 to perform transition surgeries, saying “there is insufficient evidence demonstrating a favorable risk-benefit ratio for the pathway of gender-related endocrine and surgical interventions in children and adolescents.”
Though ASPS policy has been evolving toward caution for some time, this seems to raise questions, not just about surgery for minors but hormone treatments. Shortly after the guidance came out, the American Medical Association released a statement taking a more cautious stance than its previous recommendations, saying “surgical interventions in minors should be generally deferred to adulthood.”
These might seem like small shifts. But as Kuran notes, when public orthodoxy differs widely from private opinion, orthodoxies are prone to a “preference cascade” where public opinion snowballs. Medical association support has been one of the strongest arguments offered by proponents of pediatric medical transition. Now that support seems to be weakening, opening up space for more doubt.
Public orthodoxies that diverge from private opinion may be surprisingly stable, but they can also prove remarkably unstable, because they depend on private thoughts to stay private, giving doubters the illusion that they are lone deviants rather than members of a silent majority. Each skeptical voice makes it more likely that further doubts will be raised, triggering a rapid shift to a new equilibrium.
If you’ve wondered how communism collapsed, that’s how. And if you’ve wondered why communist regimes are so oppressive, that’s also your answer. When you are the custodian of a fragile orthodoxy, you cannot afford to allow a hint of dissent.
If you have followed the gender wars, you understand the parallel I’m drawing, but for those who haven’t, let me make it explicit.
Starting around 2015, an orthodoxy on transgender issues crystallized, seemingly out of nowhere. Transgender women were women, full stop, and it was transphobic to suggest that some spaces — such as locker rooms, prisons or sports — should be reserved for biological females.
The prevailing view was that gender-dysphoric kids “knew who they were,” and denying them medical interventions to realize their true selves risked driving them to suicide. Boilerplate assertions that pediatric medical transition was “evidence-based,” “medically necessary” and even “lifesaving” began appearing everywhere, includingjournalistic style guides.
It is now clear that the evidence for these assertions was weak, and it’s not clear why so many medical associations offered such strong endorsements with so little to back them up. But once issued, they all reinforced each other — questions about one could be quelled by pointing to all the others, and who has any right to question our most eminent medical professionals?
Well, anyone has the right, but that orthodoxy was vigorously protected by freelance thought police who answered even the mildest query with accusations of transphobia. Those accusations could have real costs, like your job or your friends. By the time I went to the Ivy League swimming championships in 2022 to cover the controversy over a trans swimmer, people I talked to evinced a wariness that seemed more appropriate to a Cold War spy novel than to citizens of a free republic.
This manufactured consensus looked invincible, until it wasn’t. A few years ago, it was risky in many professional circles to even hint at doubt. But slowly, journalists began raising more and more concerns. Now, a whopping malpractice verdict and the shifting stance of the medical societies make it increasingly risky for doctors not to question these interventions.
With more of these suits in the offing, malpractice insurers will ask that same question. If they don’t like the answers, that may ultimately mean the end not just of surgeries for minors, but of hormones and puberty blockers, even in states where they are legal. If that happens, opponents of those interventions will no doubt cheer…
… Juries and judges are now handling these questions because so many institutions failed to do their job. And many people will pay a price for that, most of all the ones whose bodies will never be the same.
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As part of the journey on gender ideology as a social construct instead of just gender as a biological given, we should go back a bit further. In the 80's and 90's, it became vogue, legal, and accepted for women to take jobs from men who were more qualified. Because we were woefully unprepared to have a rational discussion about the absolute differences between males and females, we let the powers that be convince us that women should be able to lawfully and rightly take jobs that had previously been held by men. Those jobs had been previously held by men because the male is generally stronger, faster, more focused, and able to move big items with less stress than a female. We bought it hook, line, and sinker. Thus the EEOC and Affirmative Action machine was able to take over everything. I am aware that these ideologies include more than just gender, but let's limit this discussion to women and men in the workplace.
There are jobs that men are more generally suited to and some jobs women simply cannot do without some accommodation being made. Any military, first responder, construction, or other job that requires physical superiority (there, I said it!) should be filled by males. But we, in our infinite social engineering wisdom decided that not only could we not discuss the obvious differences in the male and female abilities in jobs requiring speed and strength, we could never, ever keep women out of these jobs because...but that is where the logic fell apart. There is not a because except for personal preference, the demand for the recognition of dreams (I've always wanted to be a fireman, etc.), and the inability to foresee consequences.
We have done a great disservice to our girls over the last six decades by telling them (without shame) that they can do anything they want to do. False. They can hold jobs they cannot do, but only through legal force and making the males around them pick up their slack. The job still must be done and it falls to the more skilled and capable in any group to get it done. Take a female police officer that cannot, and I mean cannot, chase down and subdue a suspect. If there are males around, and they are always called in for just this purpose, the female is relieved of the requirement to do her job because the men showed up and had to do it.
Take our military combat units. We send men into war to kill people and break things. However, again in our infinite social engineering wisdom, we decided that women should not be kept out of combat because it would affect her promotions as they are rightly based on combat experience. How much in just pure dollars has it taken us to care for the medical needs of the females we put into the military and whose bodies were simply not up to the lesser physical readiness standards than males? How much in just pure dollars have we spent in setting up the facilities for women in male-dominated outposts and camps because the girls simply had to go play soldier? Now for the big question: Is the military better for having put women in combat? Are those women better off? Are the men who lost promotions to women of lesser ability and performance better off? I say no on all fronts.
Decades ago, we did not have the ability to sort out gender issues and it resulted in our allowing millions of females to take jobs from their more-qualified male peers. Once we start allowing ideology to squash truth and open discussion, our trajectory takes us to bad places. Fifty years to now and we have a transgender ideology that still does not acknowledge the absolute differences between males and females, and that one cannot be the other. It is all part of the same inability to acknowledge simple, yet absolute truths. The inability to even discuss controversial topics tells one just how much they fear truth.
The article frames the collapse of pediatric gender medicine primarily as a “preference cascade” problem — an orthodoxy sustained by social pressure, institutional conformity, and fear of dissent until enough cracks appeared to make skepticism publicly safe again. That’s part of the story. But it badly underestimates the most important stabilizing force in the system:
follow the money.
The surgeries are enormously expensive. The hormones and blockers often continue indefinitely. The counseling, monitoring, revisions, fertility interventions, and complications can extend for years. In economic terms, this is not a one-time treatment model. It is recurring revenue.
And once these procedures receive moral endorsement from elite institutions — “lifesaving,” “medically necessary,” “affirming care” — the political pressure to publicly finance them becomes intense. Insurance companies are pushed to cover them. Medicaid is pushed to cover them. State systems are pushed to cover them. Employers are pressured to include them. The public spigot opens.
At that point, the incentives become self-reinforcing.
Hospitals build departments around the practice. Medical schools create training pathways. Pharmaceutical companies benefit from long-term hormone dependency. Activist organizations gain fundraising leverage. Professional associations acquire ideological and reputational investment in the model. Entire institutional ecosystems become financially and politically committed to its continuation.
That is why the “consensus” became so aggressively defended.
The article treats the phenomenon mostly as a psychological and sociological event — people afraid to dissent from elite opinion. But elite opinion itself often follows institutional incentives. Once a treatment pathway becomes financially embedded inside major medical systems, dissent threatens not merely reputations but revenue streams, grant structures, legal exposure, staffing, and institutional prestige.
In that sense, the system behaves less like a scientific enterprise and more like a protected market.
And protected markets are notoriously resistant to self-correction.
That helps explain why weak evidence could coexist with such extraordinary certainty. Normally, medicine proceeds cautiously when long-term evidence is sparse, especially for irreversible interventions on minors. But here caution was often replaced with moral absolutism. Skepticism itself became evidence of bad character. That is usually a warning sign that something other than science is stabilizing the consensus.
The article correctly notes that once malpractice verdicts appear and medical associations begin retreating, the entire structure can unwind quickly. But again, the real pressure point may not be ideological at all.
It may be actuarial.
The moment insurers begin viewing these procedures as high-liability medicine rather than protected medicine, the economics change dramatically. Hospitals suddenly face litigation risk. Carriers reassess exposure. Public systems reconsider reimbursement. The same institutions that once moved in lockstep toward expansion can begin moving in lockstep toward retreat.
And that is the uncomfortable possibility hanging over this debate: if the medical consensus crumbles, what follows is not merely cultural embarrassment. It is potentially a financial calamity for institutions that expanded aggressively into a treatment model now facing mounting legal, scientific, and public scrutiny.
The article sees a preference cascade. Fair enough.
But preference cascades alone do not sustain billion-dollar medical ecosystems.
Money does.