Is there a difference with regard to how long the medication is taken?
'Safe' seems a bit like a loaded term, things can be considered relatively safe (albeit with known side-effects) in one circumstance but less safe (more risky?) in another.
For example oral contraceptives might be considered to be safe but maybe not so much if taken continually for many years.
That evidence does not of course confirm the efficacy of using PBs with trans children. That can be debated. But safety is another matter. Why should a drug proven to be safe in delaying puberty with precocious puberty cases by unsafe with trans cases?
One complication is that medical ethics standards might make it hard or impossible to test whether puberty blockers are helpful for trans kids.
I can't find it again, but I read an article about why it was so hard to prove that face masks were useful against covid. (Here's a kind of similar article though.) Scientists couldn't ethically do randomized controlled trials of masks, because it was already well established that face masks keep out viruses, so it would be against medical ethics to make an unmasked control group expose themselves to covid.
So all the antimaskers yelling on Facebook about how masks aren't scientifically proven were shouting for a type of proof that scientists couldn't ethically/legally give them. One scientist (in the article I can't find again) was quoted as saying it's like claiming that parachutes aren't scientifically proven to work, because ethically you can't push a control group out of an airplane without parachutes.
Doing "proper" scientific experiments on underage subjects is already pretty ethically complicated, from the little I know. It might be especially hard to get a study done on gender treatment, since it's already well known that gender affirmation is incredibly successful in trans adults. It might not be possible to "prove" it using modern research standards.
Is there a difference with regard to how long the medication is taken?
'Safe' seems a bit like a loaded term, things can be considered relatively safe (albeit with known side-effects) in one circumstance but less safe (more risky?) in another.
For example oral contraceptives might be considered to be safe but maybe not so much if taken continually for many years.
Fair enough. Safe enough to be used with children suffering from precocious puberty. That seems to be a statement representing considered medical opinion. So perhaps consider this question. What might there be in the bodies of trans children which would make the medication less safe for them, given that the medical aim, of delaying puberty, is the same?
So far as longevity of use is concerned, I am sure there must be evidence in the treatment of precocious puberty, about how long the treatment continues. That would provide some kind of practical baseline. A point which underlines the possible lack of wisdom in the Cass report in not considering such evidence of safety.
Re precocious puberty and transgender, issues of safety and efficacy. It’s on the borderline between being a Styx issue and the Epiphies thread issue. I’m happy to discuss that in the Epiphanies thread.
On this thread, I’ll confine myself to summarising this way. Safety is one factor, efficacy another. The PB drugs work safely in delaying puberty with precocious puberty cases. There is evidence of that. What that evidence says about efficacy with trans children may be debated.
If I may open the discussion here.
One of the criticisms of the Cass report has been that it ignored or discounted the evidence of safe use of puberty blockers in cases of puberty blockers. The argument appears to be that it’s not relevant, since precocious puberty is one thing, trans is another.
My dispute with that viewpoint is that it glosses over the difference between drug safety and drug efficacy. PB drugs have been used safely for over thirty years in precocious puberty cases. The medical effect is to delay the onset of puberty since it be beneficial to the health of children experiencing precocious puberty. PBs are successful in producing that delay. Hence their continuing use for that purpose.
That evidence does not of course confirm the efficacy of using PBs with trans children. That can be debated. But safety is another matter. Why should a drug proven to be safe in delaying puberty with precocious puberty cases by unsafe with trans cases?
This is a good point.
I will just mention in passing my medical credentials, although I am not a specialist in the area or an expert really.
However, as stated, the use of hormone therapy that delays pubertal development in precious puberty is well established and safe.
Therefore, most of the people who claim to be concerned about puberty blockers as a risk in young people with gender dysphoria are mostly talking bollocks. There is work to do around this whole area because the data is limited but it is rational to expect the direct biological risks of the medication to be very low. It is demonstrable that the risk to mental health of not treating these young people is significant. Hence we are where so much of medical practice in children is (including mine): The evidence base is insufficient but we make the best judgement we can based on the evidence we have.
The problem is that the debate has been hijacked for political reasons making a rational assessment impossible.
Let me take you on a small detour to illustrate my point. I work with kids with Hirschsprung disease. HD is a rare congenital condition where the nerve supply to the colon does not develop properly. It always involves the bottom bit of the bowel for a variable length. Rarely it involves the whole colon. Surgically we remove the affected part of the bowel and join it back together. Most of our patients have good function after surgery.
A small number will have unmanageable issues with bowel function and we get to a point around the age of 6 or 7 where we decide that having a permanent stoma gives them a much higher quality of life. It's a minority but these patients have a sudden improvement in their quality of life. But it's a big step and many people really do not want a stoma.
That is not remotely controversial because there is no politics interfering here but can you imagine for a moment if there was a law that said we were not allowed to perform a stoma for these kids until they are 18? Imagine committing them to whole childhood of faecal incontinence because someone decided that stomas are so disfiguring that they should not be allowed.
Now, I am not arguing here for medical paternalism. I am not arguing that doctors are always right and I am not arguing that there should not be statutory and common law oversight of the medical profession.
What I am saying is that we need to have the debate properly about what is appropriate and Right-Wing Arseholes hijacking the debate as fuel for their culture war is obscene.
As the thread title implies there is a sense in which the powers that be are using Trans kids for their political game. Much like the way immigrants are used as a political football that I regularly rant about, there are real human beings at the end of this who are harmed. Which makes this kind of politics simply evil.
Anyway, to return to the point here, the idea that puberty blockers are not safe is a stretch. I am interested in genuine experts who have concerns based on evidence. I have only really heard them from people who clearly believe that trans kids will simply stop existing if we stop treating them. The real experts will talk about the limitations of the data but to me the concern seems to be a truly faux one born of politics and not science. And that is deeply disingenuous. The scientific questions I would ask about puberty blockers used in this context would be: Is there a safety issue using them at a later age? (They'd be used at a younger age for precious puberty). Is there a safety issue if they end up being used for longer? What are the overall physiological and psychological effects in the long term? These are all legitimate questions but again the reality is that if we wait to answer them fully before we allow treatment then we are allowing a well-recognised harm to occur. Moreover as has been noted, it's very difficult to develop any useful data if they are not used.
Anyway, just my thoughts. Get the politics out of this. The regulatory authorities are quite capable of examining the evidence. Right Wing arseholes cannot even spell "evidence" and do not care who they harm in the process of fighting their culture war as they have nothing else.
It strikes me that there are some similarities here with the effect of drugs on pregnant women (probably the same deal for pregnant trans men and non-binary folk but x100). You can't ethically conduct trials on pregnant women in most cases, so there are a lot of medications where the only evidence we have is observational, where the women and her doctor agreed that the risks of coming off the medication outweigh the possibility of harm to the foetus. We had to have this sort of discussion when Mrs Feet (who has been long term on an SNRI) was pregnant with Little Miss Feet, and the evidence was limited, so we ultimately had to trust the lack of any contraindications for the particular drug she was on. If some gobshite had tried to say that Mrs Feet's treatment was "experimental" because of this lack of unethical experiments and said she should be banned from taking that medication that would probably have been enough to tempt me to commit a defenestration.
Perhaps I'm being cynical? I have no quarrel with the Cass finding that the Tavistock Clinic had been swamped,by the massive increase in demand. So the affirmative action standard had become unaffordable and the triage system for handling children unsustainable.
I've no doubt that there was no political will to provide significant extra money for the service.
If that analysis is even half correct, then Cass was operating under severe political constraint to provide an affordable solution. That would go some way to explaining the report recommendations. Including the less than accurate and overcautious assessment of the safety and efficacy of PBs. The recommendations bought time for implementation and therefore saved on at least short term resource costs.
Speculative I know but it goes some way to explaining the report. It looks very thorough and professionally presented. But appearances can be deceptive.
A particular dilemma for everyone involved is that there is no risk free option,
This is very much a central point, and it is important to emphasize that "do nothing" is very far from risk free, and as such, "do nothing and wait" is not the conservative, cautious approach that some of its proponents would paint it.
As other posters have noted, the large majority of adult trans people are strongly in support of puberty blockers, supporting kids through social transition, and so on. That is important.
There are also adults who regret their transition, or have reverted to their prior gender, and consider their transition an error. These people exist as well - they're not making it up, either - but they are a minority. That doesn't mean that they aren't important - they are people, and just as important as any other people - but that doesn't make "I made a choice I regret, so nobody else should be able to make that choice" a good argument.
It does suggest as a fruitful area of study "let's get better at understanding who the people who are likely to regret transition are, so we can provide better advice".
Detransition is a subject which has been used in some very discreditable ways by anti-trans campaigners and it's been the subject of some very prejudiced journalism in big name non-right wing publications where you wouldn't expect to find such bad journalism but sadly you do.
Evan Urquhart is a trans journalist who specialises in reporting on trans related issues. He wrote this article in Slate but it helps show that this issue requires caution and nuance and expanding how we think about gender
It starts with some debunking of a well - known piece of anti-trans journalism in a big name magazine but the more interesting stuff comes later in the piece
The thing is, in my years of work covering trans issues, I have never come across a story that continued to fit the pattern of a cis person who made a mistake after I’ve read all the smaller, less viral interviews the detransitioned person ever gave.
There are detransitioned people whose stories have been presented that way by reporters, but the stories that go viral turn out to have cleaned up the untidy bits where the detransitioned person explains they believe they experienced gender dysphoria the same way other trans people do, and decided to detransition due to their newfound moral or ideological beliefs. This group includes... all or almost all the detransitioned people whose stories have become popular in the mainstream.
He goes on to look at how some studies of detransition seem not to get how non binaryness factors in, counting as regret or detransition people who went on to identify as nonbinary because a binary transition wasn't right for them, these people
felt no regret over the medical steps they’d taken, even though their understanding of their gender may have changed...To me, this suggests that the mainstream understanding of detransition needs to evolve from simple parables about the dangers of transness as a social contagion to more acceptance of nonbinary identities and more awareness of the multitude of paths through gender an individual life can take.
Urquhart points out that most things that would aid detransitioners aid trans people eg. better medical treatment, research, more acceptance of gender nonconformity, better acceptance of nonbinary transitions and an end to the current moral panic, but what doesn't work and doesn't help detransitioners either is using them to attack trans people and to limit their rights and access to medical treatment.
He goes on:
Disappointment or regret over medical procedures happens, but we consider it an individual matter, not a widespread social concern. However, gender transition is different, because transphobia is a vicious and destructive force, and detransitioners are hurt by it as well. That’s why, in recent years, trans people have become more welcoming towards our nonbinary siblings, including those who felt pressured by societal transphobia to pursue a binary transition at first...
so as Urquhart says one of the best ways to help detransitioners is to stop the moral panic and also to become more accepting of 'nonbinary people who do not medically transition, or whose medical goals do not include a cis-normative appearance.'
The pressure to “normalise” human diversity does lead to some pretty nasty behaviour. My daughter and I have discussed this a lot. She thinks a fear of the different is probably a meme.
As best as I can tell, this is not the "unpleasant propaganda" that @Evangeline paints it, but a claim that puberty blockers in biologically male adolescents might cause permanent fertility damage, and so aren't as reversible as some claim.
If that is true (and the authors don't seem to have a large enough dataset to robustly make that claim, but they have enough to raise the question), then it means the statement "puberty blockers are reversible" is false.
It doesn't mean that puberty blockers might not be an appropriate treatment for a child who says that they are trans. It's an attempt to measure some effects of these drugs.
The preprint of the study is interesting, they note the very high incidence of suicidal ideation in their (small) sample. So obviously, you’d want to set the risk of infertility against the risk of self harm or suicide in calculating cost benefit. It’s somewhat difficult to work out from the article the generalisability. They say this about their sample:
we have collected living testicular specimens for clinical and research applications from 92 individuals. Of these, 5 withdrew from the study, leaving 87 patients for further analysis. Among these, 55 (63 %) were oncology patients, 11 (12 %) had hereditary diseases, and 16 (18 %) were diagnosed with gender dysphoria (GD). All 16 GD patients identified as transgender female. The average age at the time of gender transition and fertility preservation (FP) surgery is 8.1 (age range = 2—15; std deviation = 4.6) and 12.5-years old (age range = 10—16; std deviation = 1.8), respectively. The average age of PB initiation is 12.1-years old (age range = 10—16.4; std deviation = 1.83). Remarkably, 100 % of GD patients were under PB treatment including 9 patients (56 %) at the time of FP surgery, highlighting the widespread nature of PB intervention in this demographic (Table 1).
Then if I have understood correctly they go on to develop a predictive model based on a single cell study of one 14 year old. (I may have that summary wrong, it’s a bit difficult to follow). What is fairly clear, is that they haven’t got samples from people who were on puberty blockers, and then came off them for a period of time. They are looking at cellular changes in the testes, and predicting that these are not reversible. They don’t look at any other physiological or psychological effects of treatment.
Evangeline,
The choice of openly transphobic sources when more neutral sources are available and the sarcastic tone plus no evidence at all that you are interested in what trans people themselves have to say or discussing things respectfully with trans people are breaking the guidelines for this board.
Please read the guidelines and the rules for the entire forum and understand that anti-trans campaigning breaks the rules.
What is fairly clear, is that they haven’t got samples from people who were on puberty blockers, and then came off them for a period of time. They are looking at cellular changes in the testes, and predicting that these are not reversible. They don’t look at any other physiological or psychological effects of treatment.
Which is pretty normal for a research paper. This paper is not an attempt to develop policy on the "correct" treatment of children who identify as trans girls - it's basically an observation that says "we looked at cell samples that patients submitted for fertility preservation, and we found these features in the samples from patients on puberty blockers". It's one piece of data, which is interesting, and certainly raises questions about how reversible puberty blockers are.
That's a useful thing to know, but that doesn't necessarily mean that it affects anything. Other data says that the vast majority (98% in one Dutch study) of children who begin hormone treatment for gender dysphoria continue with hormone treatment and transition. Which says that the "reversibility" question is somewhat moot, given that very few of the patients who begin this treatment choose to reverse it.
Anti-trans campaigners have a habit of latching on to these small bits of data and running with it, as though it is somehow obvious that the male fertility of a trans girl has to be the most important thing in the world, presumably because penis.
What is fairly clear, is that they haven’t got samples from people who were on puberty blockers, and then came off them for a period of time. They are looking at cellular changes in the testes, and predicting that these are not reversible. They don’t look at any other physiological or psychological effects of treatment.
Which is pretty normal for a research paper. This paper is not an attempt to develop policy on the "correct" treatment of children who identify as trans girls - it's basically an observation that says "we looked at cell samples that patients submitted for fertility preservation, and we found these features in the samples from patients on puberty blockers". It's one piece of data, which is interesting, and certainly raises questions about how reversible puberty blockers are.
That's a useful thing to know, but that doesn't necessarily mean that it affects anything. Other data says that the vast majority (98% in one Dutch study) of children who begin hormone treatment for gender dysphoria continue with hormone treatment and transition. Which says that the "reversibility" question is somewhat moot, given that very few of the patients who begin this treatment choose to reverse it.
Anti-trans campaigners have a habit of latching on to these small bits of data and running with it, as though it is somehow obvious that the male fertility of a trans girl has to be the most important thing in the world, presumably because penis.
Given that most anti-trans campaigners are also anti-abortion it's not a surprise that they consider reproductive organs the only/most important part of the anatomy. The only surprise is them applying it to traditionally male anatomy rather than just traditionally female.
The preprint of the study is interesting, they note the very high incidence of suicidal ideation in their (small) sample. So obviously, you’d want to set the risk of infertility against the risk of self harm or suicide in calculating cost benefit. It’s somewhat difficult to work out from the article the generalisability. They say this about their sample:
So, having done a bit of digging, there's a lot of issues with the pre-print, so many I'd suspect it's unlikely to see the peer-reviewed light of day anywhere soon. There's a lot of naive treatment of the data (e.g. they claim to see widespread use of PBs when... that was pretty much baked into the design, and 16 isn't a big sample, esp. when it's a skewed subset); there's problems with the stats reporting all over the place.
This also happens with ABA. The studies are tiny and observational. The "risks" that conclusions have been predetermined and the data manipulated seems high.
I've not read this study but I'm not putting any weight on conclusions from studies which had small sample sizes. In fact I would argue that the best thing one can do with studies with eye-catching claims that rely on small sample sizes is to ignore them entirely.
Pretty brutal framing in the British news today with the publishing of the Cass review. Not at all surprised if trans people feel incredibly down today
The comments touch on all the usual transphobic talking points - claiming trans kids are "confused", and using neurodivergence and mental health issues as an excuse not to support transition, blaming "influencers" for people being trans, and privileging the experiences of a tiny number of detransitioners over the vast majority of trans people. It's hard to avoid the conclusion that the government appointed someone to lead the enquiry who would give the answers they wanted.
I haven’t read the whole thing yet, it’s 400 pages long - but it seems one of the issues they identify is that young people being referred to gids, are not getting assessments and mental health support for other issues for which they should also have support. That comes down to NHS funding and CAMH thresholds and waiting lists again.
I haven’t read the whole thing yet, it’s 400 pages long - but it seems one of the issues they identify is that young people being referred to gids, are not getting assessments and mental health support for other issues for which they should also have support. That comes down to NHS funding and CAMH thresholds and waiting lists again.
Mrs LB said the same thing. And you're scarcely going to want to wait to get through massive paediatric CAMHS queues before referring to GIDS. Especially if treatment by GIDS is actually what is needed to address the MH issues.
.The Cass Review, a government-commissioned study on UK transgender healthcare, has been rightly condemned as a thinly-veiled act of bigotry wrapped in the guise of “concern.”
From its inception, this review embodied exclusion and bias. The deliberate omission of any trans voices in the process, the blatant disregard for globally accepted medical evidence, and the appointment of conversion therapy advocates to positions of power – all of these choices were calculated and malicious
Points he makes:
(1) researchers with a long history of activism in the discredited field of 'conversion therapy' (what used to be used on gay people to try to make them straight) were allowed to shape methodology
(2) That meant 'a wide body of globally accepted research supporting trans healthcare' got thrown out to suit
(3) Consequences for young trans people are 'terrifying' as access to 'life-saving treatments like puberty blockers and hormone therapy' will be denied them, or delayed and delayed and delayed... same thing.
(4) anti-trans groups who want to stop trans people existing are celebrating
(5) The Labour Party completely betrayed trans people by embracing this
(6) The media have uncritically amplified this while generally excluding trans voices
(7) It includes stuff like claims that historically 'trans people were predominantly trans women, and that we are biologically pre-disposed to gendered toys'
He concludes that
" Beneath the veneer of concern, it’s clear what this review is part of: a coordinated effort to legislate trans people out of existence. We must not be silent. The deliberate omission of trans voices, the manipulation of data, the cruelty of denying vital care – all these acts demand our outrage"
It is very much in my mind that this report has been published in a UK election year and concerns a horribly hot button political issue. It may be that the report's findings "we need to take the toxicity out of talking about this" is the only truly important thing that could be said right now. Maybe post election when things aren't politically so tense things may calm down and improve.
Within the Cass Review anti-trans prejudice is not acknowledged as a problem or a threat to trans children. Across several reports the Cass Review centers the concerns of non-affirmative professionals, including those who do not believe in the existence of trans children.
The existence of anti-trans prejudice amongst healthcare professionals is well-documented in existing literature (Brown et al., Citation2018; Stroumsa et al., Citation2019) and Cass Review reports indeed provide clear indication of professional ignorance or prejudice.
However, across Cass Review reports, there is no instance where professional views on trans children are identified as ill-informed or prejudiced or are rejected from inclusion in the review. Instead, the views of ignorant or pathologizing professionals seeking support for non-affirming practice with trans children are presented with sympathy. There is no parallel consideration of the rights or welfare of trans children, nor discussion of an NHS duty of care to protect trans children from being harmed by professionals who reject the validity or existence of trans lives
(Bold mine)
Cass Review commentary positions non-affirmative approaches as “neutral,” contrasting them to affirmative approaches that are framed as “ideological.”...
In the Cass Review, individuals who deny the existence of trans children are retained and valued as professional experts, with all healthcare professional views welcomed, included those grounded in the erasure, rejection, and problematisation of trans children
(Bold mine)
To me this is the thumb in the scales from the beginning - denialist views being treated as 'neutral' and denialists being sympathised with while those they harm get overlooked.
Taking 'toxicity' out of a debate where one side is denying the others existence, in my opinion isn't really possible, because denying and trying to stop people's existence *is* a toxic position from the get go - 'you don't exist, you are deluded about yourself, I want you and people like you to be stopped existing.'
People who deny other people's existence from positions of power over those others and try to enforce this on them *are* in my opinion doing something inherently and dangerously 'toxic'
People targeted in this way for just existing and needing access to medical care aren't in my opinion doing something toxic and are entitled to fight back and fight for their lives without being put on a moral par with their denialist persecutors who are trying to wipe them out or erase them.
What might there be in the bodies of trans children which would make the medication less safe for them, given that the medical aim, of delaying puberty, is the same?
So far as longevity of use is concerned, I am sure there must be evidence in the treatment of precocious puberty, about how long the treatment continues. That would provide some kind of practical baseline. A point which underlines the possible lack of wisdom in the Cass report in not considering such evidence of safety.
They are also older when they start (at an age when their bones and their brains need puberty to develop properly), and there is no point at which they are supposed to return to resume normal puberty.
The two groups aren't comparable.
@Louise Thank you for your post. I don't know much about trans children, but having your very existence denied by people whose opinion can affect your life is horrendous.
Xitter is an absolute horror show right now, and I can only think of all the trans kids looking at years of suppression at the hands of the state. The glee of transphobes is utterly disgusting to behold.
I wasn't impressed by Wes Streeting's reaction. He muttered something about the scandals that had gone on. So don't expect anything from Labour. Basically, the state has given up on trans kids.
I wasn't impressed by Wes Streeting's reaction. He muttered something about the scandals that had gone on. So don't expect anything from Labour. Basically, the state has given up on trans kids.
It's actually worse than that - the state is going to be actively engaged in gaslighting and bullying trans kids.
I was thinking how bizarre that transgender should be pathologized and persecuted by the state, but I remember how gays were also, actually imprisoned. So it's not new.
I wasn't impressed by Wes Streeting's reaction. He muttered something about the scandals that had gone on. So don't expect anything from Labour. Basically, the state has given up on trans kids.
It's actually worse than that - the state is going to be actively engaged in gaslighting and bullying trans kids.
Yes, he went on air with the political editor of the Sun to retract his previous half-hearted noises of support.
And what do people like Streeting know about gender identity? Absolutely sweet fanny adams, like most of the commentators now celebrating.
Indeed.
It is not my area but I know enough to be sceptical of this report. Conversely, Cass is well credentialed. I think the critics of the report are right that the handling of the evidence is poor and thus the conclusions are deeply flawed.
However, I do feel some sympathy for Streeting. He is the (almost certainly) in-coming Secretary of State for Health. What else can he do but say publicly that he accepts the report? Even no statement from him would be a big statement. He cannot politically oppose the report at this stage and arguably as a non-expert he cannot morally do so either. I'm much more interested in how he responds next when appropriate people make representations to him.
They are also older when they start (at an age when their bones and their brains need puberty to develop properly), and there is no point at which they are supposed to return to resume normal puberty.
The two groups aren't comparable.
I just wanted to pick this up since no one else has yet - the above statement is wrong. Puberty blockers are just prescribed as a "pause button" so that the child's family and doctors can keep monitoring them and see if they are a good candidate to go through medical transition as an adult. They aren't permanent and people do go through puberty after they stop taking them.
Here's a link from the American Academy of Pediatrics about it:
It's just that it's a lot easier for a person to transition as an adult if they haven't gone through the "wrong" puberty first. When the child becomes an adult, if it turns out they aren't trans, or they feel okay to live with the body they were assigned at birth, they can just stop the blockers and go through puberty the old-fashioned way.
If they need to transition, they will go through puberty when they start taking the hormones of their preferred gender - this also happens to adults who medically transition without having had blockers as a child, except for them it's a second puberty, which seems awfully unfair!
In the coming days, I’ll be speaking to experts, relevant organisations, and trans people themselves to better understand the report and its implications... Its findings must not be spun by those ideologically opposed to trans healthcare
I can see some expert groups have commented such as PATHA (Professional Association for Transgender Health Aotearoa)
The Professional Association for Transgender Health Aotearoa (PATHA) is disappointed to see the number of harmful recommendations made by the NHS-commissioned Cass Review, released yesterday in England. This review ignores the consensus of major medical bodies around the world and lacks relevance in an Aotearoa context
It'll be interesting to see what other responses there are.
In the coming days, I’ll be speaking to experts, relevant organisations, and trans people themselves to better understand the report and its implications... Its findings must not be spun by those ideologically opposed to trans healthcare
I can see some expert groups have commented such as PATHA (Professional Association for Transgender Health Aotearoa)
The Professional Association for Transgender Health Aotearoa (PATHA) is disappointed to see the number of harmful recommendations made by the NHS-commissioned Cass Review, released yesterday in England. This review ignores the consensus of major medical bodies around the world and lacks relevance in an Aotearoa context
It'll be interesting to see what other responses there are.
He is the (almost certainly) in-coming Secretary of State for Health. What else can he do but say publicly that he accepts the report?
Well, as above, he could avoid going to speak with the political editor of the Sun (and former employee of the G*ido F*wkes blog) to play into some of the worst talking points of the anti-trans lobby: https://twitter.com/jrc1921/status/1778130338906099783
[The reaction to such reports is very much a political choice - one is reminded of the fate of Professor David Nutt's report]
Some shocking stuff in a good piece from journalist Sasha Baker (they/them) writing in Dazed. I hadn't seen research on the extent of abuse (as in ill-treatment) from family members before (linked in their article). It ought to have rung alarm bells for Cass but seemingly hasn't.
The model offers all the harm of conversion therapy, with the convenient excuse that transition may be considered if all other avenues have been exhausted. Cass acknowledges that some young people will need medical intervention, but in presuming that the majority will not, and that it should be avoided at all costs, Cass appears to be endorsing conversion practices on a mass scale
The needs of clinicians... and parents, whose consent must be obtained for a treatment plan to commence, are treated as the most important thing. The needs of the patients themselves, who Cass consistently misgenders, and whose wishes she repeatedly and explicitly rejects in her report, are some way down the list. It appears never to occur to Cass that some transfeminine people have no interest in vaginoplasty, some nonbinary people may want surgery, or hormones, or both, and some trans people prefer physical intervention before social transition, often for their safety.
The fact that over 40 per cent of trans people in the UK experience abuse from family members merits no discussion, despite Cass’ proposed assessment model allowing parents to provide a history of their child’s gender
They conclude that Cass Review amounts to an' all-out assault on the dignity and lives of trans children and young adults'.
Some further points that I don’t think have come up here yet:
The trans journalist Erin Reed, who has a long record of advocative but measured and well-evidenced research has found that Cass visited and consulted the leader of Ron De Santis’ measures to limit trans youth treatments. https://erininthemorning.com/p/cass-met-with-desantis-pick-over
Cass is recommending that trans people up to twenty five should be considered minors
…and furthermore even social transition should not be allowed without clinical intervention
Essentially, if combined which seems to be the intent, this means that trans adults would not be allowed to transition socially without clinical support if the recommendations were followed. She had no remit to examine treatment for adults.
Comments
'Safe' seems a bit like a loaded term, things can be considered relatively safe (albeit with known side-effects) in one circumstance but less safe (more risky?) in another.
For example oral contraceptives might be considered to be safe but maybe not so much if taken continually for many years.
One complication is that medical ethics standards might make it hard or impossible to test whether puberty blockers are helpful for trans kids.
I can't find it again, but I read an article about why it was so hard to prove that face masks were useful against covid. (Here's a kind of similar article though.) Scientists couldn't ethically do randomized controlled trials of masks, because it was already well established that face masks keep out viruses, so it would be against medical ethics to make an unmasked control group expose themselves to covid.
So all the antimaskers yelling on Facebook about how masks aren't scientifically proven were shouting for a type of proof that scientists couldn't ethically/legally give them. One scientist (in the article I can't find again) was quoted as saying it's like claiming that parachutes aren't scientifically proven to work, because ethically you can't push a control group out of an airplane without parachutes.
Doing "proper" scientific experiments on underage subjects is already pretty ethically complicated, from the little I know. It might be especially hard to get a study done on gender treatment, since it's already well known that gender affirmation is incredibly successful in trans adults. It might not be possible to "prove" it using modern research standards.
Fair enough. Safe enough to be used with children suffering from precocious puberty. That seems to be a statement representing considered medical opinion. So perhaps consider this question. What might there be in the bodies of trans children which would make the medication less safe for them, given that the medical aim, of delaying puberty, is the same?
So far as longevity of use is concerned, I am sure there must be evidence in the treatment of precocious puberty, about how long the treatment continues. That would provide some kind of practical baseline. A point which underlines the possible lack of wisdom in the Cass report in not considering such evidence of safety.
This is a good point.
I will just mention in passing my medical credentials, although I am not a specialist in the area or an expert really.
However, as stated, the use of hormone therapy that delays pubertal development in precious puberty is well established and safe.
Therefore, most of the people who claim to be concerned about puberty blockers as a risk in young people with gender dysphoria are mostly talking bollocks. There is work to do around this whole area because the data is limited but it is rational to expect the direct biological risks of the medication to be very low. It is demonstrable that the risk to mental health of not treating these young people is significant. Hence we are where so much of medical practice in children is (including mine): The evidence base is insufficient but we make the best judgement we can based on the evidence we have.
The problem is that the debate has been hijacked for political reasons making a rational assessment impossible.
Let me take you on a small detour to illustrate my point. I work with kids with Hirschsprung disease. HD is a rare congenital condition where the nerve supply to the colon does not develop properly. It always involves the bottom bit of the bowel for a variable length. Rarely it involves the whole colon. Surgically we remove the affected part of the bowel and join it back together. Most of our patients have good function after surgery.
A small number will have unmanageable issues with bowel function and we get to a point around the age of 6 or 7 where we decide that having a permanent stoma gives them a much higher quality of life. It's a minority but these patients have a sudden improvement in their quality of life. But it's a big step and many people really do not want a stoma.
That is not remotely controversial because there is no politics interfering here but can you imagine for a moment if there was a law that said we were not allowed to perform a stoma for these kids until they are 18? Imagine committing them to whole childhood of faecal incontinence because someone decided that stomas are so disfiguring that they should not be allowed.
Now, I am not arguing here for medical paternalism. I am not arguing that doctors are always right and I am not arguing that there should not be statutory and common law oversight of the medical profession.
What I am saying is that we need to have the debate properly about what is appropriate and Right-Wing Arseholes hijacking the debate as fuel for their culture war is obscene.
As the thread title implies there is a sense in which the powers that be are using Trans kids for their political game. Much like the way immigrants are used as a political football that I regularly rant about, there are real human beings at the end of this who are harmed. Which makes this kind of politics simply evil.
Anyway, to return to the point here, the idea that puberty blockers are not safe is a stretch. I am interested in genuine experts who have concerns based on evidence. I have only really heard them from people who clearly believe that trans kids will simply stop existing if we stop treating them. The real experts will talk about the limitations of the data but to me the concern seems to be a truly faux one born of politics and not science. And that is deeply disingenuous. The scientific questions I would ask about puberty blockers used in this context would be: Is there a safety issue using them at a later age? (They'd be used at a younger age for precious puberty). Is there a safety issue if they end up being used for longer? What are the overall physiological and psychological effects in the long term? These are all legitimate questions but again the reality is that if we wait to answer them fully before we allow treatment then we are allowing a well-recognised harm to occur. Moreover as has been noted, it's very difficult to develop any useful data if they are not used.
Anyway, just my thoughts. Get the politics out of this. The regulatory authorities are quite capable of examining the evidence. Right Wing arseholes cannot even spell "evidence" and do not care who they harm in the process of fighting their culture war as they have nothing else.
AFZ
I want to try to get at least some of the politics out of this and see if we can have a rational discussion, at least on this point.
I've no doubt that there was no political will to provide significant extra money for the service.
If that analysis is even half correct, then Cass was operating under severe political constraint to provide an affordable solution. That would go some way to explaining the report recommendations. Including the less than accurate and overcautious assessment of the safety and efficacy of PBs. The recommendations bought time for implementation and therefore saved on at least short term resource costs.
Speculative I know but it goes some way to explaining the report. It looks very thorough and professionally presented. But appearances can be deceptive.
This is very much a central point, and it is important to emphasize that "do nothing" is very far from risk free, and as such, "do nothing and wait" is not the conservative, cautious approach that some of its proponents would paint it.
As other posters have noted, the large majority of adult trans people are strongly in support of puberty blockers, supporting kids through social transition, and so on. That is important.
There are also adults who regret their transition, or have reverted to their prior gender, and consider their transition an error. These people exist as well - they're not making it up, either - but they are a minority. That doesn't mean that they aren't important - they are people, and just as important as any other people - but that doesn't make "I made a choice I regret, so nobody else should be able to make that choice" a good argument.
It does suggest as a fruitful area of study "let's get better at understanding who the people who are likely to regret transition are, so we can provide better advice".
Evan Urquhart is a trans journalist who specialises in reporting on trans related issues. He wrote this article in Slate but it helps show that this issue requires caution and nuance and expanding how we think about gender
The Trans “Detransition” Wars
It’s a real phenomenon. But it’s not the crisis many seem to think
It starts with some debunking of a well - known piece of anti-trans journalism in a big name magazine but the more interesting stuff comes later in the piece
He goes on to look at how some studies of detransition seem not to get how non binaryness factors in, counting as regret or detransition people who went on to identify as nonbinary because a binary transition wasn't right for them, these people
Urquhart points out that most things that would aid detransitioners aid trans people eg. better medical treatment, research, more acceptance of gender nonconformity, better acceptance of nonbinary transitions and an end to the current moral panic, but what doesn't work and doesn't help detransitioners either is using them to attack trans people and to limit their rights and access to medical treatment.
He goes on:
so as Urquhart says one of the best ways to help detransitioners is to stop the moral panic and also to become more accepting of 'nonbinary people who do not medically transition, or whose medical goals do not include a cis-normative appearance.'
Your source works for a right-wing rag run by white supremacists, I wouldn't trust her to tell me if the sky was blue or not.
Do you have a link to the original study?
Here's the preprint. It's not published yet.
https://www.biorxiv.org/content/10.1101/2024.03.23.586441v1.abstract
As best as I can tell, this is not the "unpleasant propaganda" that @Evangeline paints it, but a claim that puberty blockers in biologically male adolescents might cause permanent fertility damage, and so aren't as reversible as some claim.
If that is true (and the authors don't seem to have a large enough dataset to robustly make that claim, but they have enough to raise the question), then it means the statement "puberty blockers are reversible" is false.
It doesn't mean that puberty blockers might not be an appropriate treatment for a child who says that they are trans. It's an attempt to measure some effects of these drugs.
I know right?
I should have said more propaganda from a right-wing
(ETA hidden texted mental health slur, DT, temp hosting - please note this)
Then if I have understood correctly they go on to develop a predictive model based on a single cell study of one 14 year old. (I may have that summary wrong, it’s a bit difficult to follow). What is fairly clear, is that they haven’t got samples from people who were on puberty blockers, and then came off them for a period of time. They are looking at cellular changes in the testes, and predicting that these are not reversible. They don’t look at any other physiological or psychological effects of treatment.
The choice of openly transphobic sources when more neutral sources are available and the sarcastic tone plus no evidence at all that you are interested in what trans people themselves have to say or discussing things respectfully with trans people are breaking the guidelines for this board.
Please read the guidelines and the rules for the entire forum and understand that anti-trans campaigning breaks the rules.
Louise
Epiphanies Host
Which is pretty normal for a research paper. This paper is not an attempt to develop policy on the "correct" treatment of children who identify as trans girls - it's basically an observation that says "we looked at cell samples that patients submitted for fertility preservation, and we found these features in the samples from patients on puberty blockers". It's one piece of data, which is interesting, and certainly raises questions about how reversible puberty blockers are.
That's a useful thing to know, but that doesn't necessarily mean that it affects anything. Other data says that the vast majority (98% in one Dutch study) of children who begin hormone treatment for gender dysphoria continue with hormone treatment and transition. Which says that the "reversibility" question is somewhat moot, given that very few of the patients who begin this treatment choose to reverse it.
Anti-trans campaigners have a habit of latching on to these small bits of data and running with it, as though it is somehow obvious that the male fertility of a trans girl has to be the most important thing in the world, presumably because penis.
Given that most anti-trans campaigners are also anti-abortion it's not a surprise that they consider reproductive organs the only/most important part of the anatomy. The only surprise is them applying it to traditionally male anatomy rather than just traditionally female.
So, having done a bit of digging, there's a lot of issues with the pre-print, so many I'd suspect it's unlikely to see the peer-reviewed light of day anywhere soon. There's a lot of naive treatment of the data (e.g. they claim to see widespread use of PBs when... that was pretty much baked into the design, and 16 isn't a big sample, esp. when it's a skewed subset); there's problems with the stats reporting all over the place.
I've not read this study but I'm not putting any weight on conclusions from studies which had small sample sizes. In fact I would argue that the best thing one can do with studies with eye-catching claims that rely on small sample sizes is to ignore them entirely.
https://www.theguardian.com/society/2024/apr/10/thousands-of-children-unsure-of-gender-identity-let-down-by-nhs-report-finds
The comments touch on all the usual transphobic talking points - claiming trans kids are "confused", and using neurodivergence and mental health issues as an excuse not to support transition, blaming "influencers" for people being trans, and privileging the experiences of a tiny number of detransitioners over the vast majority of trans people. It's hard to avoid the conclusion that the government appointed someone to lead the enquiry who would give the answers they wanted.
Mrs LB said the same thing. And you're scarcely going to want to wait to get through massive paediatric CAMHS queues before referring to GIDS. Especially if treatment by GIDS is actually what is needed to address the MH issues.
From experience, Mr O'B will deal with the issues with due depth and care.
It will be available on catch-up later, I will provide a link.
AFZ
The Cass Review: A government-sanctioned attack on trans lives
Points he makes:
(1) researchers with a long history of activism in the discredited field of 'conversion therapy' (what used to be used on gay people to try to make them straight) were allowed to shape methodology
(2) That meant 'a wide body of globally accepted research supporting trans healthcare' got thrown out to suit
(3) Consequences for young trans people are 'terrifying' as access to 'life-saving treatments like puberty blockers and hormone therapy' will be denied them, or delayed and delayed and delayed... same thing.
(4) anti-trans groups who want to stop trans people existing are celebrating
(5) The Labour Party completely betrayed trans people by embracing this
(6) The media have uncritically amplified this while generally excluding trans voices
(7) It includes stuff like claims that historically 'trans people were predominantly trans women, and that we are biologically pre-disposed to gendered toys'
He concludes that
" Beneath the veneer of concern, it’s clear what this review is part of: a coordinated effort to legislate trans people out of existence. We must not be silent. The deliberate omission of trans voices, the manipulation of data, the cruelty of denying vital care – all these acts demand our outrage"
https://www.globalplayer.com/catchup/lbc/uk/episodes/2zGviCCZB8Q5X2EUmPHtLupaoH/
The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children
This particularly struck me:
(Bold mine)
(Bold mine)
To me this is the thumb in the scales from the beginning - denialist views being treated as 'neutral' and denialists being sympathised with while those they harm get overlooked.
Taking 'toxicity' out of a debate where one side is denying the others existence, in my opinion isn't really possible, because denying and trying to stop people's existence *is* a toxic position from the get go - 'you don't exist, you are deluded about yourself, I want you and people like you to be stopped existing.'
People who deny other people's existence from positions of power over those others and try to enforce this on them *are* in my opinion doing something inherently and dangerously 'toxic'
People targeted in this way for just existing and needing access to medical care aren't in my opinion doing something toxic and are entitled to fight back and fight for their lives without being put on a moral par with their denialist persecutors who are trying to wipe them out or erase them.
At least that's how I see it.
They are also older when they start (at an age when their bones and their brains need puberty to develop properly), and there is no point at which they are supposed to return to resume normal puberty.
The two groups aren't comparable.
(Think I messed up my quotes, sorry.)
Ibthink I’ve fixed them. BroJames, Purgatory Host, acting Epiphanies[/sup{
It's actually worse than that - the state is going to be actively engaged in gaslighting and bullying trans kids.
Yes, he went on air with the political editor of the Sun to retract his previous half-hearted noises of support.
He's an awful and despicable individual.
Indeed.
It is not my area but I know enough to be sceptical of this report. Conversely, Cass is well credentialed. I think the critics of the report are right that the handling of the evidence is poor and thus the conclusions are deeply flawed.
However, I do feel some sympathy for Streeting. He is the (almost certainly) in-coming Secretary of State for Health. What else can he do but say publicly that he accepts the report? Even no statement from him would be a big statement. He cannot politically oppose the report at this stage and arguably as a non-expert he cannot morally do so either. I'm much more interested in how he responds next when appropriate people make representations to him.
I just wanted to pick this up since no one else has yet - the above statement is wrong. Puberty blockers are just prescribed as a "pause button" so that the child's family and doctors can keep monitoring them and see if they are a good candidate to go through medical transition as an adult. They aren't permanent and people do go through puberty after they stop taking them.
Here's a link from the American Academy of Pediatrics about it:
https://www.healthychildren.org/English/ages-stages/gradeschool/puberty/Pages/sex-gender-identity-and-puberty.aspx
It's just that it's a lot easier for a person to transition as an adult if they haven't gone through the "wrong" puberty first. When the child becomes an adult, if it turns out they aren't trans, or they feel okay to live with the body they were assigned at birth, they can just stop the blockers and go through puberty the old-fashioned way.
If they need to transition, they will go through puberty when they start taking the hormones of their preferred gender - this also happens to adults who medically transition without having had blockers as a child, except for them it's a second puberty, which seems awfully unfair!
https://www.thepinknews.com/2024/04/10/cass-report-labour-mp-nadia-whittome/
She's quoted as saying among other things
I can see some expert groups have commented such as PATHA (Professional Association for Transgender Health Aotearoa)
Cass Review out of step with high-quality care provided in Aotearoa
It'll be interesting to see what other responses there are.
Fair point.
Well, as above, he could avoid going to speak with the political editor of the Sun (and former employee of the G*ido F*wkes blog) to play into some of the worst talking points of the anti-trans lobby: https://twitter.com/jrc1921/status/1778130338906099783
[The reaction to such reports is very much a political choice - one is reminded of the fate of Professor David Nutt's report]
The British government is throwing young trans people under the bus
Some key bits
They conclude that Cass Review amounts to an' all-out assault on the dignity and lives of trans children and young adults'.
- The trans journalist Erin Reed, who has a long record of advocative but measured and well-evidenced research has found that Cass visited and consulted the leader of Ron De Santis’ measures to limit trans youth treatments. https://erininthemorning.com/p/cass-met-with-desantis-pick-over
- Cass is recommending that trans people up to twenty five should be considered minors
- …and furthermore even social transition should not be allowed without clinical intervention
Essentially, if combined which seems to be the intent, this means that trans adults would not be allowed to transition socially without clinical support if the recommendations were followed. She had no remit to examine treatment for adults.