Outcomes of Sex Reassignment Surgery

My recent consideration of the book Galileo's Middle Finger and my previous interview with Helen Boyd have prompted me to think again about the science of sex and gender. As I have mentioned many times before, there isn't a lot of hard, reliable science out there.

You might consider that science isn't the best tool with which to view transgenderism. To me, that's a little like saying that counting isn't the best tool with which to view how much money you have.

Opposed: Prof Paul McHugh

Since the study of transgenderism is such a huge field, let's narrow it down to one, relatively well-delineated question: should genetic males be offered sex reassignment surgery? You might already have an answer to this question, one way or the other, but let's look a bit more closely.

Detransitioning is the process whereby someone post sex reassignment surgery, living as the opposite sex, regrets their decision, and returns to their original sex. We know it happens, and that means that sex reassignment surgery isn't for everyone.

Paul McHugh, an eminent psychiatrist, and University Distinguished Professor of Psychiatry at Johns Hopkins in Baltimore, went so far as to discontinue sex reassignment surgery at Johns Hopkins in 1979, after studying the outcomes. He wrote:

McHugh: We saw the results as demonstrating that just as these men enjoyed cross-dressing as women before the operation so they enjoyed cross-living after it. But they were no better in their psychological integration or any easier to live with. With these facts in hand I concluded that Hopkins was fundamentally cooperating with a mental illness. We psychiatrists, I thought, would do better to concentrate on trying to fix their minds and not their genitalia.

You can read his whole 2004 article here. I can see how some of his terminology could be inflammatory, but he comes across as someone who believes what he is doing is right. Before you dismiss him completely, read the whole article. In particular, his review (in the same article) of the previously-misguided surgical treatment of intersex children is very balanced and enlightened, and I find it very difficult to disagree with any of it.

Benefits and harms

Suppose you have heart disease. Your doctor suggests you take aspirin, because there is good evidence that aspirin prevents heart attacks. You take aspirin, confident that you will not have a heart attack, because you are doing the right thing.

But it isn't as simple as that. Not everyone with heart disease will suffer a heart attack, so not everybody needs to take aspirin. And some people who take aspirin will still suffer a heart attack, meaning that aspirin is incompletely successful at preventing heart attacks.

Balanced; benefits and harms

All we can say is that aspirin reduces the risk of heart attack. The actual reduction of risk per person is unexpectedly low. It's only when this small benefit is multiplied by thousands of people across a population that it becomes demonstrable. Multiplied across tens, or hundreds of thousands, aspirin can be shown to prevent hundreds of heart attacks.

But aspirin isn't harmless. As well as its benefits, aspirin causes harms. Again, per individual, these harms are tiny, but multiplied across a population, aspirin can be shown to cause an increased risk of bleeding events. We tend to think of these as risks, but to me (and others) this is an unhelpful word, as it implies that risks are avoidable, where in this case they are not: they are inevitable. It creates the irony that some people will take aspirin and experience only the harms (even though most people expect only the benefits!).

There is therefore a bargain to be struck, between the benefits and the harms of any treatment. In the case of aspirin, we can see that the benefits strongly outweigh the harms, and therefore it makes rational sense to take aspirin. For some treatments, the balance of benefit versus harm is not so clear-cut.

There are also people who are already at risk of having a bleeding event. Those people have a different balance of harm versus benefit. For some of them, it may still make sense to take aspirin; for others, it may make sense not to.

So aspirin is a simple example (there is an excellent discussion of aspirin in this context here on Alvin Lin's blog). This article is about the benefits and harms of sex reassignment surgery.

More complicated than aspirin

Once again, we are faced with a population: people born male who request sex reassignment surgery. It's clear that, if we provide that for all of our population, some will receive benefits, and some will receive harms. Some will receive a mixture of both benefits and harms.

Confusing: statistics

As ethical, and rational people, what we want to do is to maximise the benefits and minimise the harms. Our best efforts may mean that more people have benefit than harm, or more correctly that the total sum of benefit outweighs the total sum of harm. (But it may be hard to judge between a hundred people feeling better, but one person losing their life: which is the greater sum?) If we decide that the balance favours performing the surgery, that's an argument for offering the surgery. If, however, we decide that that the balance favours not performing the surgery, then that's an argument for not performing it.

This is the argument put forward by Paul McHugh, but he is missing one important point: that even if the balance of harm and benefit favours not performing the surgery, this applies to a population, and not individuals, and there may therefore be individuals for whom the benefit is greater. In other words, even if, on the whole, surgery is more harmful than beneficial, there will still be some individuals for whom surgery would be the right thing.

The corollary of all this is that, even if surgery is shown to be more beneficial than harmful, there will still be some people for whom surgery would not be the right thing; in other words, surgery still wouldn't be for everyone!

I'm sorry if I am making your head spin. What's the answer to this conundrum? Science, and plenty of it.

Counting your blessings: estimating benefits and harms

The first question is this: taken as a population seeking sex reassignment surgery, how does the sum of benefit compare to the sum of harm?

You might think that's easy: just find a load of post-op transsexuals and ask them if they are happier since they transitioned. Most of them will say yes. So there's your answer, surely? But a sceptic like me would say: hang on. You might not be counting everyone. Some people might have detransitioned. Some people might have taken their own lives (this number is non-trivial where gender dysphoria is concerned, as this study reminds us). Some people might be so miserable that they declined to answer the survey. This is sampling bias, just one of the many biases potentially associated with research.

I came across this useful paper here at the Bournemouth and Poole Joint Strategic Needs Assessment (JSNA) page. It seems to cover the whole UK, and it has a lot to recommend it: it's short; it contains excellent information including great statistics, and it seems to have a very good idea about the priorities in the care of transgender people. On the other hand, it doesn't say who its authors are; it gives no date, and no sources for its figures. I would really like to know if this is some sort of annual report, and if so, where it comes from.

What it says (in brief) is that sex-reassignment surgery is becoming a lot commoner in the UK, but that trans people face a lot of difficulties in schools, in the workplace, and in their personal and emotional lives. So does sex reassignment surgery result in a greater quality of life?

It's difficult to estimate quality of life. You can't measure it directly; you can only ask people to report it. As a result, it is very prone to error and bias, and people telling the researchers what they think they want to hear, or telling them what they wish were true.

Thankfully for us, Una over at Transas City has done the homework for us, and presents a magnificent, detailed meta-analysis of 34 studies from the literature, together with a very detailed discussion of the strengths and limitations of each study. To save you going through it, the bottom line is this: transsexual treatment (not just surgery) is usually (but not always) associated with a better quality of life afterward, though some problems (such as social integration, difficulties finding employment, and so on) persist. I can't praise Una's article highly enough; she has really put in a lot of hard work to bring this data together.

Meanwhile, Elizabeth Hungerford over at Sex Matters presents four different studies, which suggest increased risk of mortality (including suicide) in transsexuals, increased criminal behaviour, and a disconnect between the subjective reporting of outcomes (most people reported improvement) and the objective reporting of outcomes (a lot of complications were reported). She writes:

Hungerford: As this brief review of long term studies illustrates, positive patient satisfaction should be separated from objectively measurably negative outcomes in order to fully understand the efficacy and “success” of “sex reassignment” procedures. We must be skeptical and refuse to accept emotionally motivated claims of “necessity” that are not supported by long term evidence. We must subject these studies to rigorous, unflinching analysis.

And I really think she has a point. Sometimes, giving people what they want isn't the same as giving them what they need. What should a good doctor, using the principles of medical ethics to guide them, offer the person who asks for sex reassignment treatment?

So where does that leave us?

Cumbersome: scientific research

The ideal scientific study will never happen. In it, a large cohort of gender-dysphoric individuals will present for treatment. They will be subjected to an intense battery of psychological testing, designed to demonstrate every facet of psychological function, and every hint of psychiatric illness. They will then be randomised into at least two arms (preferably three). In one arm, they get full treatment: hormones, surgery, the works. In the second arm, they get the next best treatment: counselling, cognitive-behavioural therapy, maybe antidepressants. In the third arm, they get no treatment at all, but get observed to see what happens if you have no treatment at all. The three groups get followed up for a long period (e.g. a decade) to see what the outcomes are. We decide, based on the result, what the best possible treatment for gender dysphoria is.

The reason this study will never happen falls into several areas. First, to enrol patients in a study, you need to fully inform them of what might happen. Tell someone seeking sex reassignment surgery that they may be randomised to a group which doesn't receive it, and they will instantly withdraw from your study. Second, you need a large cohort of people to get robust results, and it's very difficult and expensive to conduct large studies on large groups of people. Third, the longitudinal followup required means that many researchers cannot devote the time required. A PhD, for example, would normally require all the research to be done in a few years. But unless we wait for a lot longer, we might only observe a "honeymoon period" where everything seems rosy (or potentially the opposite: a period of turmoil and unhappiness while settling into a new life which is ultimately more satisfying). Finally, as described here, nobody really wants to touch this sort of research any more.

One solution: real informed consent

By what means can we identify people, in advance, who will ultimately benefit from sex reassignment surgery? Or who won't? The answer is: we cannot. Nobody can tell the future. Doctors are no more able to tell the future than anyone else. And there are a lot of surgical procedures where the outcome is far from certain in advance. Coronary artery bypass grafting, for example, improves lives for many thousands, but opening someone's chest with a saw and plumbing their major blood vessels into a pump (in order to carry out the surgery) is risky, difficult, and expensive.

Informed: consent

Nonetheless, there is a solution, and it is the same as for any type of surgery. We fully inform the individual of the very best information we have, and let them make the choice. We make the assumption that the adult acting with capacity is the best judge of their own best interests. Note that Paul McHugh has already made up his mind--doctor knows best--and he is happy to make the decision that he knows better than his patients what is best for them. Having decided that transgenderism is a mental illness, he may possibly be more comfortable with the notion that transgender people lack capacity to judge their own best interests. This sort of medical paternalism is (thankfully) well on the wane.

Informed consent for surgery might look something like this:

Sex reassignment surgery is likely to be painful and leave you subject to several complications, including incontinence, scarring, bleeding, infection, wound breakdown, blood clots, and even your own death, though this is very rare. The surgery will be permanent and cannot be reversed. You may not have full sexual function afterward, and you may never be able to experience orgasm. Afterward, you are likely to feel better in yourself, but your risk of suicide will remain high, and you may still experience difficulty integrating into society. If you still want the surgery, sign here.

In my experience, most surgical consent forms tend to stress the negative. They need to be seen to make it clear to the patient that while everyone hopes the surgery will go well, and tries to bring about a great result, that might not actually happen.

But making people clearly aware that surgery might go wrong, and even if it goes right, it won't solve all their problems, is a big step forward from saying "no, you can't have surgery". People should be given this information early and often during the consent process for sex reassignment surgery, so that they can really weigh the decision.

I haven't had sex reassignment surgery, so I don't know what the consent process is like. Those of you who have, please post your experiences and comments below.

Meanwhile, we can only hope that particles of good science continue to be done, and that meta-analysis of those particles can clarify the picture for everyone.

Galileo's Middle Finger - Part Two

This is the second of my articles discussing the book Galileo's Middle Finger, by Alice Dreger. If you haven't already, it makes sense to start reading at Part One, which discusses intersex individuals.

Dreger: When people ask me how transgender is different from intersex, I usually start by saying that that intersex and transgender people have historically suffered from the opposite problems for the same reason. Whereas intersex people have historically been subjected to sex "normalizing" hormones and surgeries they have not wanted, transgender people have had a hard time getting the sex-change hormones and surgeries they have wanted. Both problems arise from a single cause: a heterosexist medical establishment determined to retain control over who gets to be what sex.

Manly: legs

Here she is, shortly into chapter 2, Rabbit Holes, and characteristically getting right down to the nub of the issue. (For my own, similar take on intersex vs transgender, I refer you to this post, though you might need to scroll down a bit).

Dreger: In the great majority of cases, medical scans won't detect any intersex feature in a transgendered person's body. Nevertheless, many people believe that transgender must be a special form of intersex involving the brain.

This fits with my comment that some transgender individuals look to the existence of intersex individuals to provide justification for their behaviour.

Dreger: Although there is very little science to support it, this has become the most popular explanation of transgender, probably in part because it is the easiest one for uptight heterosexuals to accept. (...) In practice, this story of transgender can function as a kind of get-out-of-male free card for men who seek to become women anatomically. When that card is played, the comforting narrative of "true selves" is preserved.

And there are scientific papers (such as this one) which seek to demonstrate anatomical differences in the brains of trans people. Though mostly their brains are very similar, some studies purport to demonstrate subtle differences in tiny regions of the brain (for example, some regions in MtF transsexuals are less like men and more like women). Most of these studies have small numbers of non-randomised participants, and even if these findings are robust (and I am nowhere near convinced that they are), correlation is not causation.

Science may indeed unlock some of these puzzles in time, but the only thing I am convinced of is that the science is pretty unconvincing so far.

Controversial: Bailey

It's at this point in the narrative that Dreger introduces Professor J. Michael Bailey, the author of the controversial work The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism, published in 2003. Bailey drew on the work of Ray Blanchard, and is therefore supportive of the autogynephilia model, to which I subscribe, as you probably already know. See here for a fuller discussion of this model. In that link, I also discuss how the autogynephilia model makes me feel uncomfortable about myself, because it insists the root of my crossdressing is in sexual desire.

Dreger points out that the French translation of autogynephilia is amour de soi en femme (love of oneself as a woman) which is a much nicer expression.

But where I feel uncomfortable about the autogynephilia model, a lot of people felt a lot worse.

Dreger: Before Bailey, many trans advocates had spent a long time working to desexualize and depathologize their public representations in an effort to reduce stigma, improve access to care, and establish basic human rights for trans people. (...) This is similar to how gay rights advocates have desexualized homosexuality in the quest for marriage rights, portraying themselves in living rooms and kitchens instead of bedrooms, in order to calm fearful heterosexuals.

Indeed, a few retrograde clinicians, like Paul McHugh, a psychiatrist at the Johns Hopkins School of Medicine, still actively use the idea that male-to-female transgender is really about perverted sexuality and mental illness to argue against access to sex-transitional hormones and surgeries.

For Bailey or anyone else to call someone with amour de soi en femme an autogynephile or even a transgender woman-- rather than simply a woman-- is at some level to interfere with her core sexual desire. Such naming also risks questioning her core self-identity in a way that calling the average gay man homosexual simply can't. One really must understand this if one is going to understand why some trans women came after Bailey so hard for naming and describing autogynephilia. When they felt that Bailey was fundamentally threatening their selves and their social identities as women-- well, it's because he was. That's what talking openly about autogynephilia necessarily does.

Lynn Conway by Charles Rogers

It's worth digressing here to make a couple of remarks. Just because a scientific theory makes you uncomfortable, doesn't make it wrong. And just because you insist upon something, doesn't make it right. If you want to convince me, you need to do a lot better than insist. I respond to evidence, not vehemence. This has occasionally caused me to get into uncomfortable debates with other trans people when I dare to question them about their views and beliefs. Sometimes, when they are unable to explain themselves, they resort to some variant of: "Of course, you couldn't possibly understand. You're only a crossdresser, where I am a woman".

But back to the book. Dreger goes on to describe how a prominent transwoman called Lynn Conway, at the University of Michigan, started "what became a war" against Bailey, assisted by Andrea James and Deirdre McLoskey. Together they began to systematically ruin Bailey's reputation. They campaigned to have the book removed from consideration for the 2004 Lambda Literary Award. They cooked up stories about him practising psychology without a licence, doing research without appropriate ethical oversight, and even having sex with one of his research subjects. And Dreger digs deeply and thoroughly into all of this, interviewing as many of the original people involved as possible.

Dreger: As a result of all this, Bailey came across pretty clearly as an abuser, a trans-basher, and a sexual pervert.

After nearly a year of research, I could come to only one conclusion: the whole thing was a sham. Bailey's sworn enemies had used every clever trick in the book-- juxtaposing events in misleading ways, ignoring contrary evidence, working the rhetoric, and using anonymity whenever convenient, to make it look as though virtually every trans woman represented in Bailey's book had felt abused by him and had filed a charge.

But why did Conway, James and McLoskey feel they had to do all those things?

Dreger: "Narcissistic injury," the physician-researcher Anne Lawrence said to me, by way of explanation. "Followed by narcissistic rage." That, she told me, was the only real way to explain what happened to Bailey. The whole thing had been an attempt to kill the messenger bringing a message that Lawrence guessed wounded the accusers' sense of self.

Captivating: the book

By this point, we are barely a third of the way through the book. Several things stand out. First, the book is extremely readable, and the narrative is told in a personal, conversational style. Second, Dreger's scholarship is impeccable: many hundreds of hours of interviews and research have gone into this book (you should see the references), and Dreger seems uncompromising in her search for the truth. Third, it's clear that a great deal of her personal energy has been invested, not just in writing the book, but in sympathising with the people in it, befriending them and becoming part of their lives. Fourth, writing this book has taken considerable courage, and Dreger has herself come under fire, risking her own career and reputation (drawing parallels with Galileo, of course).

Overall, the book is a phenomenal read; gripping as a thriller, scholarly, yet incredibly human. There are so many points in the book where I thought: I can't believe I am actually reading this! I can't recommend it highly enough.

We part company with the book at this point, partly because this blog post is already way too long, and partly because the book leaves the subjects of gender and sex as Dreger finds other (compelling) subjects to sink her hungry scholastic teeth into.

I think the world of gender is changing more rapidly than it ever has before. The emergence of transgender celebrities like Laverne Cox and Caitlyn Jenner has caused mainstream society to become much more aware (and thankfully, accepting) of trans people and trans issues. Nonetheless, I am very uncomfortable about what happened to Bailey: vilified for his views, not because they were wrong, but because they made people uncomfortable. Dreger points out (and I don't know why I didn't think of this before) that as a result of Conway's attack on Bailey, "no one in sex research will touch male-to-female transsexualism with a ten foot pole any more. Which must have been just what Conway meant to do". That explains why there isn't good science: because scientists fear personal retribution if they publish results which are unpopular.

The way to enlightenment is not to silence people, even the ones who disagree with us, but to engage in open, civil, respectful debate; to seek out the best evidence, and incorporate it into the picture, recognising that the picture isn't complete and may yet change as new discoveries come to light.

Dreger's book has inspired me to be a little more upright, a little more outspoken in defence of the truth, a little more questioning of the "facts", than I was previously. And perhaps, therefore, a little more willing to extend my middle finger, just like Galileo.

Galileo's Middle Finger - Part One

My book this week is called Galileo’s Middle Finger, and it was recommended to me by my friend Patricia. You need to read this book, she told me. It took me a while to get around to it, but she was dead right.

Alice Dreger

Galileo’s Middle Finger is written by Alice Dreger, professor of clinical medical humanities and bioethics at the Feinberg School of Medicine in Chicago. I had not come across her work before. Her book is a personal account of her own involvement in a series of medical and ethical issues, over two decades of her life. For readers of this blog in particular, the first three chapters will be of greatest interest. The first discusses intersex people; the second and third transgender people. There is so much to talk about that I am going to split this article into two blog posts.

One of the themes of this blog (one I am always going on about) is that, when it comes to the study of sex and gender, hard scientific knowledge is pretty lacking. In its place is often entrenched dogma, coming from people (scientists themselves and their supporters) who insist on a particular paradigm or point of view; and the equally entrenched opposition of the activists and pressure groups, waving flags and making demands.

If someone comes up with a new idea, it can easily fall foul of one or even both of those groups, not because it is wrong, but because it challenges the way people think, and people (even scientists) can find themselves attacked and vilified, especially in this age of instant social media and viral messages.

Dreger is my kind of scholar: the one who is most interested in the truth above all, "a belief in evidence even when it challenges [her] political goals". In her book she describes how she has been on both sides of these debates; at times siding with the activists, pushing hard against dogma and accepted wisdom. At other times, she has sided with the scientists, defending them against unfair or personal attacks from critics.

Let’s cover some concrete examples. In the first chapter of her book, entitled Funny Looking, Dreger comes right to the point on the very first page.

Dreger: This was my stance: Children born with genitals that look funny but work fine should not be surgically altered just because their genital appearance upsets or worries some adult. Big clitorises shouldn't be shortened, and baby boys with very small penises shouldn't be sex-changed just because their phalluses induce Freudian crises of conscience in their caregivers.

Neither fish nor fowl: intersex

She is talking, of course, about intersex children, that 1 in 1000 or so babies who are born with genitalia which seem to be neither quite boy nor girl. In some (rarer) cases, intersex people can possess both testicular and ovarian tissue in an ovotestis. Cases of intersex people have been cropping up in the medical literature for centuries (I recall coming across them as a student) and are depicted in medical textbooks naked, in black-and-white, with a bar over their face to cover their "anonymity".

Originally, of course, medicine had nothing to offer those people. But over the last few decades, increasingly intersex children have been dealt with surgically. Big clitorises (and I'm sorry for wearing my geek hat long enough to point out that the official plural of clitoris is clitorides) were surgically shortened to look more normal (but often causing scarring and the inability to achieve orgasm). Small penises were sometimes completely amputated, and the child raised as a girl. Unfortunately surgery on children's genitals rarely turns out right.

I stress this was usually done with the very best of intentions by most doctors. I believe (and Dreger does too) that the doctors thought they were doing the right thing by these children. They believed that rigidly enforcing an anatomical binary would spare these children growing up different, and make them fit more comfortably. They believed if they did not provide the surgery, the children would commit suicide in puberty.

Dreger: Modern medicine now sought to reinforce the "optimum gender of rearing" by early management of children born with sex anomalies by means of "sex-normalising" surgeries, hormone treatments, delicate euphemisms, and sometimes lies.

This was also the system that led to a lot of really angry intersex adults who discovered that they had been harmed by the medical care meant to "save" them and who knew that the basic system was still being used on children who would likely grow up as hurt and angry as they were. In the early 1990's, a core group of these people formed the intersex rights movement I eventually joined. Some of these intersex adults had been physically harmed--left with damaged sexual sensation, incontinence or repetitive infections. Many had been psychologically harmed--left with a sense of having been too monstrous for their parents to accept as they came, of being sexually freakish, of being fountains of familial shame. All were left with a burning desire to try to save others from going through what they had.

Things were made worse by the actions of people like Dr. John Money. Money's most famous case was David Reimer, a healthy (non-intersex) boy whose penis was destroyed during a botched circumcision attempt. Money suggested that Reimer be raised as a girl, and he underwent removal of his testicles as a baby, together with hormone treatments intended to feminise him. Unfortunately, none of this worked: Reimer always identified as a boy (despite a rigid "girl" upbringing). Worse, Money continued to publish fraudulent reports (in what became known as the "John/Joan" case) that Reimer was doing well as a girl, and his reputation and prestige meant that other doctors followed his example of treatment. Money was a charlatan whose harms extended far beyond this one patient.

How do you measure up?

Together with intersex friend Bo Laurent, Alice Dreger formalised the Intersex Society of North America into a non-profit, tax-exempt organisation. Its purpose was to provide solidarity for intersex people, to realise they are not alone; to campaign to the medical profession for better, more understanding treatment of intersex individuals; and for more acceptance from society for intersex individuals.

Dreger: The problem in intersex care wasn't a problem of gender identity per se. The problem was that, in the service of strict gender norms, people were being cut up, lied to, and made to feel profoundly ashamed of themselves. Bo said it as plainly as she could: Intersex is not primarily about gender identity; it is about shame, secrecy and trauma.

Gradually, they began to gain some traction with doctors. One tool they used was the Phall-O-Meter (pictured), a ruler which is designed to measure the size of a newborn baby's genitals. Calibrated in inches, it was a way of showing how ridiculous it is, that one could use a ruler to categorise something as profound, as far-reaching, as a human being's sex. (This example misses out the humorous captions like "Phew! Just squeaks by!" for a barely acceptable penis).

Dreger: When I would ask treating physicians, "What is the goal of pediatric intersex treatment?" I was amazed at how often they could not articulate an answer. ... It would have been much easier if all these doctors had been evil. Instead they were good-- human, scared. They tried hard to write us off as evil, but when they met us, they realized that we were also good-- and human, and scared.

Giving the finger: Galileo

This is my second reason to love the book: that Dreger talks with compassion and a deeply-sensitive humanity. She adds more than a dash of her own personality to the book, so that, instead of reading like a dry academic treatise, it reads like a personal memoir, and is therefore approachable, funny and poignant. Alice, I would love to have dinner with you!

After some years involved in ISNA, Dreger decided to leave. It is here that the next chapter begins, the chapter involving transsexuals. But I wanted to finish this article by pointing out that the intersex community was very fortunate to find an ally in Alice Dreger: passionate, committed, articulate and seemingly fearless.

You might be wondering where the book's title comes from. It comes from the fact that one of Galileo's fingers (his middle one, of course) is preserved in a jar in the Museo Galileo in Florence. The museum insists that the finger is mounted pointing upward to the heavens which Galileo loved so much. But, because Galileo was fearless in speaking out against the Establishment of his time (getting himself in trouble with Pope Urban VIII over his views of celestial mechanics), Dreger impishly points out that an alternative interpretation is that Galileo is still sticking his middle finger up in the air against stubborn orthodoxy and entrenched dogma.

Join me for Part Two.