It's an additional reason why I stand against attacks on trans people's rights - because for the past four years it's been an anti-trans talking point to attack the agency and rights of autistic people in a way that could threaten our ability to give consent when folk are - I was going to say under 18- but I'd now have to say under 25, given the noises Cass has made about brain development. Indeed in some trans hostile US states trans autistic people of all ages have had their rights attacked - and ADHDers too
I also think the overall context needs always to be held in mind.
This is a moral panic which was stoked and funded originally by the religious right (but with elements of the British left helping to launder it) It took off about 2016 and produced a huge spike in negative news items which became sustained over the space of about eight years to demonise trans people as predators and dangers to children. That's now bearing fruit at a high level and we're seeing some quite alarming institutional capture of previously very professional bodies which a few years ago wouldn't have done this stuff.
There's an element of backlash to it - but it's really backlash to recent progress by gay people and women as well. It's just that the people who want to roll that back hope to start with targeting trans people and to work from there.
Think for a moment of the other current UK moral panics against immigrants and disabled people. Right wing governments work by splitting their opposition - hoping to use hate campaigns to override people's class interests and to get them to vote for them. So they try to persuade people that instead of voting for parties that would help them on stuff like health, housing, education etc, they should be morally revolted by them because they help migrants, people on benefits and trans people who the Right demonise as criminals, scroungers, free loaders and warning for worse slurs
rapists perverts and dangers to children
Our current Labour Party deals with this wedge issue by joining the Tories on the Right wing side of the wedge. Trans people are caught in this as a target alongside disabled people and immigrants. As a woman I advocate for my rights and I saw the backlash to Me Too. That's what happens when you ask not to be ill-treated by the powerful. Powerful people who like the status quo try to stop that and roll it back.
This is really the same game that was played over gay rights and section 28 to take the rights of a minority who are not yet fully socially accepted and to use that as a wedge issue to get social conservatives on the left to rally to the right.
But despite the Cass Review, the anti-trans campaigners haven't been able to stand their demonology up - British GIDS were actually cautious on referrals to endocrinology for puberty blockers. The data showed this and Cass's report had to admit that. Meanwhile detransitioning is remarkably rare - about 1% - and also as we discussed earlier - a very complicated issue as people counted as detransitioners are usually still trans but desisting with certain treatments for varied reasons.
We need to remember what this is and why it's so important to stand by trans people right now. A lot of our left wing parties are running scared of the moral panic and are willing to work with the Right over it.
As the parent of a genderqueer disabled autistic person, I can assure you that this is not the case. Although being autistic does make it even harder than usual to access appropriate care.
Sounds like Cass doesn't know much about autism either. 🤬
"Tougher rules on the teaching of gender identity"
"Schools will be told not to teach lessons on gender identity... at all. And if it arises - if children ask about it - to make clear to students that these are 'contested questions.'"
It’s also bound up with their idea to ban sex education entirely for the under nine’s. So that will make the sexual abuse of children under that age considerably harder to detect.
It’s also bound up with their idea to ban sex education entirely for the under nine’s. So that will make the sexual abuse of children under that age considerably harder to detect.
Yep.
It's the same evil with Trans kids, disabled people, asylum seekers, and probably others I can't think of right now. Tory government by tabloid headline: always take the political points and fuck the consequences for the innocent people on the receiving end.
Mary Whitehouse and Victoria Gillick ride again. And its done using the attack on trans people to legitimate it. When I think of the damage done by those who helped disguise this stuff as 'feminism' I could weep.
In other news American medical organisations have spoken out about the Cass Review
The Endocrine Society and the president of the American Academy of Pediatrics both commented
Here's a snippet but you can see the full thing in the article I linked
STATEMENT FROM ENDOCRINE SOCIETY:
We stand firm in our support of gender-affirming care. Transgender and gender-diverse people deserve access to needed and often life-saving medical care.
NHS England's recent report, the Cass Review, does not contain any new research that would contradict the recommendations made in our Clinical Practice Guideline on gender-affirming care.
The guideline, which cites more than 260 research studies, recommends a very conservative approach to care, with no medical intervention prior to puberty. Estimates indicate only a fraction of transgender and gender-diverse adolescents opt to take puberty-delaying medications, which have been used to treat early puberty in youth for four decades.
The guideline recommends beginning treatment with puberty-delaying medications that are generally reversible.
As adolescents grow older and can provide informed consent, then hormone therapy can be considered.
Our guideline suggests waiting until an individual has turned 18 or reached the age of majority in their country to undergo gender-affirming genital surgery.
Medical evidence, not politics, should inform treatment decisions.
The response from American Academy of Pediatrics President, Dr. Ben Hoffman when asked to comment was telling. It's more general
“The AAP’s gender-affirming care policy, like all our standing guidance, is grounded in evidence and science. Pediatricians understand the complexities of gender-affirming care and they know how to counsel families. The goal is not a certain treatment or timeline, but instead to listen to the patient and create a safe environment to address their needs.
“What we’re seeing more and more is that the politically infused public discourse is getting this wrong — and it’s impacting the way that doctors care for their patients. Physicians must be able to practice medicine that is informed by their medical education, training, experience, and the available evidence, freely and without the threat of punishment. Instead, state legislatures have passed bills to ban and restrict gender-affirming care, which means that right now, for far too many families, their zip code determines their ability to seek the health care they need. Politicians have inserted themselves into the exam room, and this is dangerous for both physicians and for families.”
Mary Whitehouse and Victoria Gillick ride again. And its done using the attack on trans people to legitimate it. When I think of the damage done by those who helped disguise this stuff as 'feminism' I could weep.
In other news American medical organisations have spoken out about the Cass Review
The Endocrine Society and the president of the American Academy of Pediatrics both commented
Here's a snippet but you can see the full thing in the article I linked
STATEMENT FROM ENDOCRINE SOCIETY:
We stand firm in our support of gender-affirming care. Transgender and gender-diverse people deserve access to needed and often life-saving medical care.
NHS England's recent report, the Cass Review, does not contain any new research that would contradict the recommendations made in our Clinical Practice Guideline on gender-affirming care.
The guideline, which cites more than 260 research studies, recommends a very conservative approach to care, with no medical intervention prior to puberty. Estimates indicate only a fraction of transgender and gender-diverse adolescents opt to take puberty-delaying medications, which have been used to treat early puberty in youth for four decades.
The guideline recommends beginning treatment with puberty-delaying medications that are generally reversible.
As adolescents grow older and can provide informed consent, then hormone therapy can be considered.
Our guideline suggests waiting until an individual has turned 18 or reached the age of majority in their country to undergo gender-affirming genital surgery.
Medical evidence, not politics, should inform treatment decisions.
The response from American Academy of Pediatrics President, Dr. Ben Hoffman when asked to comment was telling. It's more general
“The AAP’s gender-affirming care policy, like all our standing guidance, is grounded in evidence and science. Pediatricians understand the complexities of gender-affirming care and they know how to counsel families. The goal is not a certain treatment or timeline, but instead to listen to the patient and create a safe environment to address their needs.
“What we’re seeing more and more is that the politically infused public discourse is getting this wrong — and it’s impacting the way that doctors care for their patients. Physicians must be able to practice medicine that is informed by their medical education, training, experience, and the available evidence, freely and without the threat of punishment. Instead, state legislatures have passed bills to ban and restrict gender-affirming care, which means that right now, for far too many families, their zip code determines their ability to seek the health care they need. Politicians have inserted themselves into the exam room, and this is dangerous for both physicians and for families.”
Peer review in science isn't perfect (it's a human endeavour afterall), but it's very effective. Since the Cass report puts so much store in the quality of science, Cass and her colleagues will no doubt welcome the review of their work by experts in the field they reported on. Though, since those reviews are coming in consistently as "not significant enough to warrant consideration of changing current practices" they may have preferred something more positive to suggest that all their work actually means anything to the experts in the field.
Wes Streeting the new health secretary is pro Cass and his being gay and Christian doesn't make endangering trans people and joining attacks on them any better.
Starmer is also bad on this - he wrote a statement for Attitude magazine but his subsequent backing down on trans people's rights caused the owner of the magazine to feel that as a gay man he had to make a statement addressing Starmer's anti-trans positions
And Attitude is clear: LGBTQ+ rights include trans rights, trans rights are human rights and human rights are not political. Or at least shouldn’t be. It’s politicians that make human rights political, and when they do so in search of popularity, support and/or power you have but one chance to hold them to account
(The linked article contains some discussion of someone we can't discuss here for legal reasons - so discussion of it would have to leave out the famous author in question)
By the way, here is the latest on how poorly the Cass Review is faring when it is examined by academics
Wes Streeting the new health secretary is pro Cass and his being gay and Christian doesn't make endangering trans people and joining attacks on them any better.
In the case of Streeting, it was fairly clear that he waited to see which way the wind blew before jumping in with both feet.
Not just a bigot, but an opportunistic one.
Being Christian is incidental, between him and God, and anyway this is the left hand kingdom, not the right hand one.
Wes Streeting the new health secretary is pro Cass and his being gay and Christian doesn't make endangering trans people and joining attacks on them any better.
In the case of Streeting, it was fairly clear that he waited to see which way the wind blew before jumping in with both feet.
Not just a bigot, but an opportunistic one.
Being Christian is incidental, between him and God, and anyway this is the left hand kingdom, not the right hand one.
I had the opportunity to see Cass speak about her report, it was interesting. Some of what she was saying makes sense - e.g. children identifying as trans pre-puberty need help fast as things like the puberty blockers are going to be a lot less help mid-way through puberty. But also she seemed somewhat naive as to how aspects of what she said could be used and her how her recommendations for wholistic assessment intersect with the phenomenon of CAMH waiting lists.
Is there any kind of academic analysis of both sides of this thing which isn't driven by politics? And can someone post a link to it? Because I literally don't know what's being said and by who and how academically reliable any of them are.
Cass states parts of the report were mis-represented in the press (which is certainly true of some parts, suggesting a 0-25 service is not the same as saying over 18s should be treated as lacking capacity for example). Others have felt that the meta-analyses wrongly excluded some studies on quality grounds - this is a major area of contention.
Basically Cass stated there is a lack of evidence about various treatments being offered, and that pilot treatment protocols originally duplicated from clinics abroad, were expanded and became part of routine clinical practice without being properly evaluated. Also people were having to wait qfar far too long for treatment. She also noted a major change in referral patterns since 2005 (I think) which is not full explained and therefore weren’t addressed in earlier studies.
So Cass recommended various treatments should be subject to more research (e.g. pre-scribing puberty blockers, so children being prescribed them should be followed up to understand outcomes) and that provision of care should be widened in order to reduce wait times. This doesn’t allow for the government shutting down the one children’s clinic without having set up and staffed the planned network of clinics, so in fact access to care maybe reduced.
Also, felt that kids in distress were being referred for gender issues, and then local services did not see and assess their distress in the meanwhile - ie a diagnostic overshadowing problem. If the child had gender distress services were acting as if that explained all issues they might be presenting with. This does not really recognise the extremely high thresholds for care in CAMH currently - potentially introduced extra delay.
My impression at the talk was that Cass herself felt any kind of medical transition carries some level of physical risk / disadvantage but accepted this would be worth it for people with a trans identity. However, she felt that if intervention happened at a point of which a young person was still uncertain, it might set them on a trajectory they might not otherwise have followed. She backed this up from anecdotes from some trans adults she had talked to, specifically I think one person who told her that whilst they lived successful as a tranwoman and had no intention of detransitioning but felt that perhaps she had just been a slightly feminine presenting gay boy.
The problem here is absence of evidence is not evidence - so it is not clear that doing less is less dangerous than doing more.
One thing she said I found interesting, was that children trying to transition in stealth both had more urgency for puberty blockers because they feared discovery but also this attempt at stealth meant they weren’t able to try out different forms of gender expression. Whilst I think she has a point here, I think it is naive to the issues around bullying for gender non-conforming children. I have a friend whose biologically male child identifies as non-binary and occassonally attended school in a skirt etc but has not stopped because it was socially so difficult (I don’t know if they were actually bullied.)
Wes Streeting the new health secretary is pro Cass and his being gay and Christian doesn't make endangering trans people and joining attacks on them any better.
In the case of Streeting, it was fairly clear that he waited to see which way the wind blew before jumping in with both feet.
Not just a bigot, but an opportunistic one.
Being Christian is incidental, between him and God, and anyway this is the left hand kingdom, not the right hand one.
What is the left hand kingdom?
I was thinking maybe it meant that Streeting is going to Hell(metaphorically anyway), but that would seem to clash with the previously implied idea that no one besides God and Streeting know if he is a Christian.
Cass states parts of the report were mis-represented in the press (which is certainly true of some parts, suggesting a 0-25 service is not the same as saying over 18s should be treated as lacking capacity for example). Others have felt that the meta-analyses wrongly excluded some studies on quality grounds - this is a major area of contention.
Basically Cass stated there is a lack of evidence about various treatments being offered, and that pilot treatment protocols originally duplicated from clinics abroad, were expanded and became part of routine clinical practice without being properly evaluated. Also people were having to wait qfar far too long for treatment. She also noted a major change in referral patterns since 2005 (I think) which is not full explained and therefore weren’t addressed in earlier studies.
So Cass recommended various treatments should be subject to more research (e.g. pre-scribing puberty blockers, so children being prescribed them should be followed up to understand outcomes) and that provision of care should be widened in order to reduce wait times. This doesn’t allow for the government shutting down the one children’s clinic without having set up and staffed the planned network of clinics, so in fact access to care maybe reduced.
Also, felt that kids in distress were being referred for gender issues, and then local services did not see and assess their distress in the meanwhile - ie a diagnostic overshadowing problem. If the child had gender distress services were acting as if that explained all issues they might be presenting with. This does not really recognise the extremely high thresholds for care in CAMH currently - potentially introduced extra delay.
My impression at the talk was that Cass herself felt any kind of medical transition carries some level of physical risk / disadvantage but accepted this would be worth it for people with a trans identity. However, she felt that if intervention happened at a point of which a young person was still uncertain, it might set them on a trajectory they might not otherwise have followed. She backed this up from anecdotes from some trans adults she had talked to, specifically I think one person who told her that whilst they lived successful as a tranwoman and had no intention of detransitioning but felt that perhaps she had just been a slightly feminine presenting gay boy.
The problem here is absence of evidence is not evidence - so it is not clear that doing less is less dangerous than doing more.
One thing she said I found interesting, was that children trying to transition in stealth both had more urgency for puberty blockers because they feared discovery but also this attempt at stealth meant they weren’t able to try out different forms of gender expression. Whilst I think she has a point here, I think it is naive to the issues around bullying for gender non-conforming children. I have a friend whose biologically male child identifies as non-binary and occassonally attended school in a skirt etc but has not stopped because it was socially so difficult (I don’t know if they were actually bullied.)
Unless I’m missing something really huge, from this description, the report itself actually sounds kind of reasonable, suggesting caution while people try to figure this stuff out.
@ChastMastr The biggest danger I see in it is that trans children will be dying while the adults try to figure out whether said kids are trans enough
Are medical treatments the only option to prevent suicide for underage trans children?
For some, yes. And this has been the key criticism of Cass - she treats withholding treatment as a neutral act with no consequences and hence defaults to a precautionary principle of not treating.
EDIT: and, it should be clear, puberty blockers were already pretty rare - I think the figure I saw was 5 prescriptions in Scotland to treat trans kids. They were never being handed out willy nilly or as a first step.
Are medical treatments the only option to prevent suicide for underage trans children?
That's one of those really dangerous questions. I don't think you mean it to be but it frames the discussion in a certain way. I.e. we don't want to give drugs to underage children, there must be other ways of keeping them safe...
I want to reframe it and I think you'll see why.
Identity is tricky for everyone. Puberty is tricky for everyone. Now, imagine yourself as a 12 year old who is in the wrong body. Try to imagine how painful puberty can be going through these bodily changes in the wrong body.
Puberty blockers have been widely used in the context of precocious puberty. Therefore we have medication that arrests puberty. It reverses nothing, it does not preclude puberty occurring, as puberty progresses, once the medication is stopped. Now, all medication comes with risks and side effects, I will come back to that in a moment. but to me given the above, this is the most logical treatment and likely to be the most effective.
I just want to pause here and point out that I am a middle aged cis, heterosexual male. All I have written above is based on my lived experience, both personal and professional. If anything I have said is not appropriate or fair then I want to be corrected by someone who knows. However, I wrote it because this is my empathy to this situation. I think so much of the criticisms come from a failure of imagination - of anti-trans people being unwilling to listen to people who have lived this and put themselves in their shoes. I say that because to me, it's really obvious that a trans person going through (the wrong) puberty is obviously going to be at a high risk of self harm, including suicide.
So, to the Cass Report. Firstly, it's my fault that this debate got bumped up here as I was reflecting, on the election thread, on things that Wes Streeting has said as he becomes Health Secretary. I also noted, as an aside, because I know people here would be interested that in a long interview, he talked about his experience of being both gay and a Christian and being not always welcome in church.
In all honesty, I had not thought when I wrote that about the Cass report and what he had said. I was thinking of some shipmates who would be interested - and in my defence, I was right and I was asked for details to find the interview. However, I am sorry that I forgot about what he had said about Cass and how that is an important part of the discussion as well. I will write about Streeting in a subsequent post but here I want to talk about Cass.
I will first state the same caveat I have said before. I am a specialist Paediatric Surgeon and a researcher. As such, I believe I bring some expertise to this conversation but it is not my area. Cass is a very experienced paediatrician who was appointed to carry out a study on the care of children presenting with gender dysphoria and report to the government on the evidence base and provide guidance for what treatment should be. I have serious issues with the report and think it very dangerous, but I have to acknowledge who Cass is and how they got to where they are.
Firstly though, let me explain my professional experience. As a paediatric surgeon, this is not an area in which I generally practice. The specialists will be paediatric endocrinologists and mental health teams. However, I have three relevant points of contact here. One is slightly oblique.
The oblique one is that paediatric surgeons look after children born with Disorders of Sex Differentiation (DSD). I therefore claim some relevant specialist knowledge of DSD even though I do very little of it as it is not part of my sub-specialist interest but I work closely with colleagues who do and I will occasionally come across this in my neonatal or paediatric practice. I mention DSD not because it's directly relevant but because we work with the endocrinologists and other teams to care for these children and there are some parallels with caring for trans kids and because my knowledge here is important for rebutting the bigots who try to say that trans does not exist because of biology. That's the oblique one.
More importantly, trans kids exist. Therefore they have other medical and surgical problems and I meet them in my regular practice. There is one child that has made a big impression on me. A couple of years ago I saw a twelve year old who came to ED with abdominal pain. There are lots of parts to this but mostly the decision is appendicitis or not. However, there are also important other diagnoses to consider. Some of these apply to both sexes and some of sex-specific. The child I met was a twelve year old boy. Having taking the history and examined his abdomen, I was happy it was not appendicitis but a testicular torsion can present as abdominal pain and therefore examination of external genitalia is an essential part of the examination in boys. However, it was at this point that the mother told me that he was biological female. It had not been evident in anyway up to this point, due to pubertal stage and the fact that for very good reasons we only undress children as much as we need to for examination. You can expose just the abdomen for adequate examination. It was very interesting talking to him and his mother. He very clearly knew himself to be male, used a different name from his birth name, and his mother was fully accepting. I had no doubt about where he was with himself and where he was coming from. The colleague who referred him had neglected to give me this background information... Anyway, any teenage girl presenting with abdominal pain must have a pregnancy test as it could be an ectopic pregnancy. This is the only time in my professional career that I have performed a pregnancy test on a boy.
So that's an example of my direct professional experience.
The third perspective is that as a practising surgeon and researcher, I am used to evaluating the evidence base and making decisions about treatment options based on the data that exists for literally hundreds of clinical scenarios.
I have said all of this before, but it bears repeating I think. In short, I have huge issues with the Cass Report. Accepting, that it lies slightly outwith my expertise and therefore a degree of caution is warranted on my part. However, I think I can justify my criticism.
Cass used the University of York's Centre for Reviews and Dissemination to perform a series of systematic reviews. They are an excellent, world-leading unit on medical evidence. This is a very good thing. What they found was a paucity of high-quality evidence for the use of puberty blockers. That is true. Where I differ from Cass, is that they appeared to be surprised by this fact. In paediatric practice there is insufficient evidence in lots of areas. This is partly due to how difficult it is to do the studies and partly because we - as a speciality - are playing catch up. In some ways, building a better evidence base in paediatric surgery is my life mission.... but anyway.
Cont/
Therefore, the conclusion was that puberty blockers should not be routinely given until we have better evidence. This, to me, is completely wrong. Firstly, whilst we do not have the clear evidence of long-term outcomes in this patient group, we do have long-term data from using puberty blockers for precocious puberty. This is well-established endocrinology practice for several decades. That is not as good as having the evidence for their use in gender dysphoria but it is still relevant data. Moreover, we have lots of data on the risks of not treating.
The bigots who want to use Trans people in their culture wars seem to believe that if we stop diagnosing and treating these adolescents, they will disappear. Cass seems to have fallen into the same trap. It is not as though a child who's a bit unhappy can present to their GP and get given live-altering medication. These drugs are only prescribed by quaternary specialists and it is only one part of the treatment, psychological support is also vital. It is definitely true that Cass has given the bigots ammunition and that is a major problem - and it fits with the title of this thread. It has also ham-strung clinical decision-making. Each patient and their family should be allowed to have the discussion with their clinician and weigh up the risks and benefits. There are concerns about the long-term effects of puberty blockers. That is reasonable but these concerns should not preclude people from receiving treatment if, on-balance, they and their clinical team believe the risks of not treating are greater. All medical practice is about a balance of risks.
I'll write about Mr Streeting specifically later as this post is already two posts and far too long.
As an aside, I've been reading back my previous comments. Unfortunately, my predictive text changed 'precocious puberty' to 'precious puberty' I hope no one was confused.
Anyway, The Secretary of State for Health, Mr Streeting. I stand by what I said on the Purg thread about being cautiously optimistic about his tenure. Time will tell.
I understand where @Louise is coming from. Streeting could do better here. I still feel some sympathy though as politically and morally, he needs to tread a careful path if he wishes to speak out against an expert report. Conversely, he should definitely listen to expert criticisms. In time, I think Cass will be largely discredited but the SoS for Health is not qualified to do so.
I am willing here to give Wes the benefit of the doubt for now. It should be noted, however that it is easy for me to do so and maybe I am completely wrong. That is because I have no skin in this game. It costs me nothing.
However, I don't think identity and puberty are 'tricky for everyone '.
Re puberty blockers; I presume one of the main reasons for their use in trans young people is that it makes gender affirming treatment, ie surgery in particular, more straightforward and successful in terms of outcome for the person?
However, I don't think identity and puberty are 'tricky for everyone '.
Re puberty blockers; I presume one of the main reasons for their use in trans young people is that it makes gender affirming treatment, ie surgery in particular, more straightforward and successful in terms of outcome for the person?
I think that would be the preferred use for many trans people. Right now it's more "this trans boy is going to really struggle to deal with growing breasts he doesn't want and deal with monthly reminders that his body isn't the way he feels it should be" and trying to mitigate the distress.
However, under the existing system people were getting puberty blockers sometime after puberty started, which could be said to be the worst of both worlds - side-effects with minimal benefits in terms of being able to pass.
However, I don't think identity and puberty are 'tricky for everyone '.
Re puberty blockers; I presume one of the main reasons for their use in trans young people is that it makes gender affirming treatment, ie surgery in particular, more straightforward and successful in terms of outcome for the person?
Thank you.
There's a variable level of 'trickiness.' I was thinking about our sense of self and the normal challenges of puberty and adolescence. Mostly because that's how I found my way in to this topic. I am hoping to provide an avenue of empathy.
Ouch that's a horrible phraselogical construction. Hey ho.
Therefore, the conclusion was that puberty blockers should not be routinely given until we have better evidence. This, to me, is completely wrong. Firstly, whilst we do not have the clear evidence of long-term outcomes in this patient group, we do have long-term data from using puberty blockers for precocious puberty. This is well-established endocrinology practice for several decades. That is not as good as having the evidence for their use in gender dysphoria but it is still relevant data. Moreover, we have lots of data on the risks of not treating.
The bigots who want to use Trans people in their culture wars seem to believe that if we stop diagnosing and treating these adolescents, they will disappear. Cass seems to have fallen into the same trap. It is not as though a child who's a bit unhappy can present to their GP and get given live-altering medication. These drugs are only prescribed by quaternary specialists and it is only one part of the treatment, psychological support is also vital. It is definitely true that Cass has given the bigots ammunition and that is a major problem - and it fits with the title of this thread. It has also ham-strung clinical decision-making. Each patient and their family should be allowed to have the discussion with their clinician and weigh up the risks and benefits. There are concerns about the long-term effects of puberty blockers. That is reasonable but these concerns should not preclude people from receiving treatment if, on-balance, they and their clinical team believe the risks of not treating are greater. All medical practice is about a balance of risks.
I'll write about Mr Streeting specifically later as this post is already two posts and far too long.
AFZ
Thank you! This all makes sense to me. If puberty blockers have been shown to be as safe as this sounds (with the caveats you mention), then I think that makes a huge difference.
It's a point of interest that one of the new Junior Ministers in the UK health department (i.e. one of Wes Streeting's deputies) has a trans child. Stephen Kinnock
It's a point of interest that one of the new Junior Ministers in the UK health department (i.e. one of Wes Streeting's deputies) has a trans child. Stephen Kinnock
Although AFAIK they are in their 20s, so out of the scope of this legislation.
There's more Labour-related transphobia today. I won't link to it because it involves some one who is a legal risk to talk about but the other party was Rachel Reeves the Chancellor. They're riddled with bigotry at the top and Streeting will have blood on his hands if he goes ahead with this. They really seem to be as bad as the Tories on this.
The new minister for health Karin Smith follows anti-trans hate groups (check out who she follows on Twitter) and enthusiastically backs the Cass Review, so there's another one.
The new minister for health Karin Smith follows anti-trans hate groups (check out who she follows on Twitter) and enthusiastically backs the Cass Review, so there's another one.
Though the Cass review has not called for a permanent ban on puberty blockers - so they are over-reaching by some distance when saying they are doing this on the basis of her recommendations.
Also, the Cass review called for significant improvements in mental health support for young people, and other similar measures that would improve services for all young people as well as trans people. If people who are using the Cass report to call for anti-trans measures but aren't also calling for these improvements have simply weaponised the report to push their ideological position.
One of the things that really gets to me is that I have loved ones who are non binary and I witness the joy and confidence it gives them to express their gender. I've helped with finding and shopping for things that work for them and been happy to see how great they feel and how good they look. Absolutely nothing about it harms me - having happy flourishing people around me makes me happy too.
But then I know they can't be themselves or dress as themselves outside the house, they have to go back in the closet because these absolute fuckers and our callous and witless media have drawn a target on their backs for every thug and bully in the UK. It affects both non-cis and cis people because it whips up violent bullies to police gender. And worse, they've done it claiming to 'protect women'. Well I want protected from them and their crankery and persecution masquerading as feminism.
People like Starmer and Streeting and Reeves and Rayner had a chance to start changing this but instead, despite their huge majority, they've doubled down on the vicious prejudice that preceded them. They've made their first victims young people as it's easy to ignore and write off their voices but they've also catered to leaders of the Gender Critical hate movement in ways that show they're fine with it and won't challenge the bullies and persecutors.
Comments
https://19thnews.org/2023/05/trans-laws-autistic-youth-mental-health/
I also think the overall context needs always to be held in mind.
This is a moral panic which was stoked and funded originally by the religious right (but with elements of the British left helping to launder it) It took off about 2016 and produced a huge spike in negative news items which became sustained over the space of about eight years to demonise trans people as predators and dangers to children. That's now bearing fruit at a high level and we're seeing some quite alarming institutional capture of previously very professional bodies which a few years ago wouldn't have done this stuff.
There's an element of backlash to it - but it's really backlash to recent progress by gay people and women as well. It's just that the people who want to roll that back hope to start with targeting trans people and to work from there.
Think for a moment of the other current UK moral panics against immigrants and disabled people. Right wing governments work by splitting their opposition - hoping to use hate campaigns to override people's class interests and to get them to vote for them. So they try to persuade people that instead of voting for parties that would help them on stuff like health, housing, education etc, they should be morally revolted by them because they help migrants, people on benefits and trans people who the Right demonise as criminals, scroungers, free loaders and warning for worse slurs
Our current Labour Party deals with this wedge issue by joining the Tories on the Right wing side of the wedge. Trans people are caught in this as a target alongside disabled people and immigrants. As a woman I advocate for my rights and I saw the backlash to Me Too. That's what happens when you ask not to be ill-treated by the powerful. Powerful people who like the status quo try to stop that and roll it back.
This is really the same game that was played over gay rights and section 28 to take the rights of a minority who are not yet fully socially accepted and to use that as a wedge issue to get social conservatives on the left to rally to the right.
But despite the Cass Review, the anti-trans campaigners haven't been able to stand their demonology up - British GIDS were actually cautious on referrals to endocrinology for puberty blockers. The data showed this and Cass's report had to admit that. Meanwhile detransitioning is remarkably rare - about 1% - and also as we discussed earlier - a very complicated issue as people counted as detransitioners are usually still trans but desisting with certain treatments for varied reasons.
We need to remember what this is and why it's so important to stand by trans people right now. A lot of our left wing parties are running scared of the moral panic and are willing to work with the Right over it.
Sounds like Cass doesn't know much about autism either. 🤬
Today's plan:
"Tougher rules on the teaching of gender identity"
"Schools will be told not to teach lessons on gender identity... at all. And if it arises - if children ask about it - to make clear to students that these are 'contested questions.'"
[BBC Radio 4 Today program]
I mean, seriously?
AFZ
Yep.
It's the same evil with Trans kids, disabled people, asylum seekers, and probably others I can't think of right now. Tory government by tabloid headline: always take the political points and fuck the consequences for the innocent people on the receiving end.
You need a long spoon to sup with the devil, but I think it would kill the idea at birth.
No sex education before the age of 9. Dear God. Hasn't anyone told them that pornography isn't kept under the counter at the newsagents any more?
https://twitter.com/SteveChalke/status/1790624052832239737?t=CvzCszuk1Clp_Gi_jVe1oA&s=19
Some of the comments there are absolutely toxic.
Of course. I hadn't read them.
Populism is all they have. Expect more of this shit between now and election day.
It's a tried and tested approach to promoting bigotry. Claim to be protecting children.
In other news American medical organisations have spoken out about the Cass Review
https://www.erininthemorning.com/p/endocrine-society-and-american-academy
The Endocrine Society and the president of the American Academy of Pediatrics both commented
Here's a snippet but you can see the full thing in the article I linked
The response from American Academy of Pediatrics President, Dr. Ben Hoffman when asked to comment was telling. It's more general
Thanks Louise.
Excellent statements, both.
https://www.thepinknews.com/2024/04/11/wes-streeting-labour-trans-women/
Starmer is also bad on this - he wrote a statement for Attitude magazine but his subsequent backing down on trans people's rights caused the owner of the magazine to feel that as a gay man he had to make a statement addressing Starmer's anti-trans positions
https://www.attitude.co.uk/news/keir-starmer-attitude-letter-469078/
(The linked article contains some discussion of someone we can't discuss here for legal reasons - so discussion of it would have to leave out the famous author in question)
By the way, here is the latest on how poorly the Cass Review is faring when it is examined by academics
https://law.yale.edu/yls-today/news/report-addresses-key-issues-legal-battles-over-gender-affirming-health-care?s=09
Oh and one of Sunak's last acts was to give Hilary Cass a peerage.
I hope things will get better for trans people but with Starmer and Streeting in charge I sadly can't be confident about that.
In the case of Streeting, it was fairly clear that he waited to see which way the wind blew before jumping in with both feet.
Not just a bigot, but an opportunistic one.
Being Christian is incidental, between him and God, and anyway this is the left hand kingdom, not the right hand one.
What is the left hand kingdom?
(Academic meta-analyses where commissioned from various universities to support it.)
By the Cass people or by others? And has Cass responded to that?
Basically Cass stated there is a lack of evidence about various treatments being offered, and that pilot treatment protocols originally duplicated from clinics abroad, were expanded and became part of routine clinical practice without being properly evaluated. Also people were having to wait qfar far too long for treatment. She also noted a major change in referral patterns since 2005 (I think) which is not full explained and therefore weren’t addressed in earlier studies.
So Cass recommended various treatments should be subject to more research (e.g. pre-scribing puberty blockers, so children being prescribed them should be followed up to understand outcomes) and that provision of care should be widened in order to reduce wait times. This doesn’t allow for the government shutting down the one children’s clinic without having set up and staffed the planned network of clinics, so in fact access to care maybe reduced.
Also, felt that kids in distress were being referred for gender issues, and then local services did not see and assess their distress in the meanwhile - ie a diagnostic overshadowing problem. If the child had gender distress services were acting as if that explained all issues they might be presenting with. This does not really recognise the extremely high thresholds for care in CAMH currently - potentially introduced extra delay.
My impression at the talk was that Cass herself felt any kind of medical transition carries some level of physical risk / disadvantage but accepted this would be worth it for people with a trans identity. However, she felt that if intervention happened at a point of which a young person was still uncertain, it might set them on a trajectory they might not otherwise have followed. She backed this up from anecdotes from some trans adults she had talked to, specifically I think one person who told her that whilst they lived successful as a tranwoman and had no intention of detransitioning but felt that perhaps she had just been a slightly feminine presenting gay boy.
The problem here is absence of evidence is not evidence - so it is not clear that doing less is less dangerous than doing more.
One thing she said I found interesting, was that children trying to transition in stealth both had more urgency for puberty blockers because they feared discovery but also this attempt at stealth meant they weren’t able to try out different forms of gender expression. Whilst I think she has a point here, I think it is naive to the issues around bullying for gender non-conforming children. I have a friend whose biologically male child identifies as non-binary and occassonally attended school in a skirt etc but has not stopped because it was socially so difficult (I don’t know if they were actually bullied.)
I think I missed this post…?
I was thinking maybe it meant that Streeting is going to Hell(metaphorically anyway), but that would seem to clash with the previously implied idea that no one besides God and Streeting know if he is a Christian.
Unless I’m missing something really huge, from this description, the report itself actually sounds kind of reasonable, suggesting caution while people try to figure this stuff out.
Are medical treatments the only option to prevent suicide for underage trans children?
For some, yes. And this has been the key criticism of Cass - she treats withholding treatment as a neutral act with no consequences and hence defaults to a precautionary principle of not treating.
EDIT: and, it should be clear, puberty blockers were already pretty rare - I think the figure I saw was 5 prescriptions in Scotland to treat trans kids. They were never being handed out willy nilly or as a first step.
That's one of those really dangerous questions. I don't think you mean it to be but it frames the discussion in a certain way. I.e. we don't want to give drugs to underage children, there must be other ways of keeping them safe...
I want to reframe it and I think you'll see why.
Identity is tricky for everyone. Puberty is tricky for everyone. Now, imagine yourself as a 12 year old who is in the wrong body. Try to imagine how painful puberty can be going through these bodily changes in the wrong body.
Puberty blockers have been widely used in the context of precocious puberty. Therefore we have medication that arrests puberty. It reverses nothing, it does not preclude puberty occurring, as puberty progresses, once the medication is stopped. Now, all medication comes with risks and side effects, I will come back to that in a moment. but to me given the above, this is the most logical treatment and likely to be the most effective.
I just want to pause here and point out that I am a middle aged cis, heterosexual male. All I have written above is based on my lived experience, both personal and professional. If anything I have said is not appropriate or fair then I want to be corrected by someone who knows. However, I wrote it because this is my empathy to this situation. I think so much of the criticisms come from a failure of imagination - of anti-trans people being unwilling to listen to people who have lived this and put themselves in their shoes. I say that because to me, it's really obvious that a trans person going through (the wrong) puberty is obviously going to be at a high risk of self harm, including suicide.
So, to the Cass Report. Firstly, it's my fault that this debate got bumped up here as I was reflecting, on the election thread, on things that Wes Streeting has said as he becomes Health Secretary. I also noted, as an aside, because I know people here would be interested that in a long interview, he talked about his experience of being both gay and a Christian and being not always welcome in church.
In all honesty, I had not thought when I wrote that about the Cass report and what he had said. I was thinking of some shipmates who would be interested - and in my defence, I was right and I was asked for details to find the interview. However, I am sorry that I forgot about what he had said about Cass and how that is an important part of the discussion as well. I will write about Streeting in a subsequent post but here I want to talk about Cass.
I will first state the same caveat I have said before. I am a specialist Paediatric Surgeon and a researcher. As such, I believe I bring some expertise to this conversation but it is not my area. Cass is a very experienced paediatrician who was appointed to carry out a study on the care of children presenting with gender dysphoria and report to the government on the evidence base and provide guidance for what treatment should be. I have serious issues with the report and think it very dangerous, but I have to acknowledge who Cass is and how they got to where they are.
Firstly though, let me explain my professional experience. As a paediatric surgeon, this is not an area in which I generally practice. The specialists will be paediatric endocrinologists and mental health teams. However, I have three relevant points of contact here. One is slightly oblique.
The oblique one is that paediatric surgeons look after children born with Disorders of Sex Differentiation (DSD). I therefore claim some relevant specialist knowledge of DSD even though I do very little of it as it is not part of my sub-specialist interest but I work closely with colleagues who do and I will occasionally come across this in my neonatal or paediatric practice. I mention DSD not because it's directly relevant but because we work with the endocrinologists and other teams to care for these children and there are some parallels with caring for trans kids and because my knowledge here is important for rebutting the bigots who try to say that trans does not exist because of biology. That's the oblique one.
More importantly, trans kids exist. Therefore they have other medical and surgical problems and I meet them in my regular practice. There is one child that has made a big impression on me. A couple of years ago I saw a twelve year old who came to ED with abdominal pain. There are lots of parts to this but mostly the decision is appendicitis or not. However, there are also important other diagnoses to consider. Some of these apply to both sexes and some of sex-specific. The child I met was a twelve year old boy. Having taking the history and examined his abdomen, I was happy it was not appendicitis but a testicular torsion can present as abdominal pain and therefore examination of external genitalia is an essential part of the examination in boys. However, it was at this point that the mother told me that he was biological female. It had not been evident in anyway up to this point, due to pubertal stage and the fact that for very good reasons we only undress children as much as we need to for examination. You can expose just the abdomen for adequate examination. It was very interesting talking to him and his mother. He very clearly knew himself to be male, used a different name from his birth name, and his mother was fully accepting. I had no doubt about where he was with himself and where he was coming from. The colleague who referred him had neglected to give me this background information... Anyway, any teenage girl presenting with abdominal pain must have a pregnancy test as it could be an ectopic pregnancy. This is the only time in my professional career that I have performed a pregnancy test on a boy.
So that's an example of my direct professional experience.
The third perspective is that as a practising surgeon and researcher, I am used to evaluating the evidence base and making decisions about treatment options based on the data that exists for literally hundreds of clinical scenarios.
I have said all of this before, but it bears repeating I think. In short, I have huge issues with the Cass Report. Accepting, that it lies slightly outwith my expertise and therefore a degree of caution is warranted on my part. However, I think I can justify my criticism.
Cass used the University of York's Centre for Reviews and Dissemination to perform a series of systematic reviews. They are an excellent, world-leading unit on medical evidence. This is a very good thing. What they found was a paucity of high-quality evidence for the use of puberty blockers. That is true. Where I differ from Cass, is that they appeared to be surprised by this fact. In paediatric practice there is insufficient evidence in lots of areas. This is partly due to how difficult it is to do the studies and partly because we - as a speciality - are playing catch up. In some ways, building a better evidence base in paediatric surgery is my life mission.... but anyway.
Cont/
Therefore, the conclusion was that puberty blockers should not be routinely given until we have better evidence. This, to me, is completely wrong. Firstly, whilst we do not have the clear evidence of long-term outcomes in this patient group, we do have long-term data from using puberty blockers for precocious puberty. This is well-established endocrinology practice for several decades. That is not as good as having the evidence for their use in gender dysphoria but it is still relevant data. Moreover, we have lots of data on the risks of not treating.
The bigots who want to use Trans people in their culture wars seem to believe that if we stop diagnosing and treating these adolescents, they will disappear. Cass seems to have fallen into the same trap. It is not as though a child who's a bit unhappy can present to their GP and get given live-altering medication. These drugs are only prescribed by quaternary specialists and it is only one part of the treatment, psychological support is also vital. It is definitely true that Cass has given the bigots ammunition and that is a major problem - and it fits with the title of this thread. It has also ham-strung clinical decision-making. Each patient and their family should be allowed to have the discussion with their clinician and weigh up the risks and benefits. There are concerns about the long-term effects of puberty blockers. That is reasonable but these concerns should not preclude people from receiving treatment if, on-balance, they and their clinical team believe the risks of not treating are greater. All medical practice is about a balance of risks.
I'll write about Mr Streeting specifically later as this post is already two posts and far too long.
AFZ
Anyway, The Secretary of State for Health, Mr Streeting. I stand by what I said on the Purg thread about being cautiously optimistic about his tenure. Time will tell.
On the subject of the Cass Report, this is from The Guardian, a couple of months ago: https://www.theguardian.com/society/2024/apr/12/cass-review-watershed-moment-nhs-gender-services-wes-streeting-young-trans-people
I understand where @Louise is coming from. Streeting could do better here. I still feel some sympathy though as politically and morally, he needs to tread a careful path if he wishes to speak out against an expert report. Conversely, he should definitely listen to expert criticisms. In time, I think Cass will be largely discredited but the SoS for Health is not qualified to do so.
I am willing here to give Wes the benefit of the doubt for now. It should be noted, however that it is easy for me to do so and maybe I am completely wrong. That is because I have no skin in this game. It costs me nothing.
AFZ
However, I don't think identity and puberty are 'tricky for everyone '.
Re puberty blockers; I presume one of the main reasons for their use in trans young people is that it makes gender affirming treatment, ie surgery in particular, more straightforward and successful in terms of outcome for the person?
I think that would be the preferred use for many trans people. Right now it's more "this trans boy is going to really struggle to deal with growing breasts he doesn't want and deal with monthly reminders that his body isn't the way he feels it should be" and trying to mitigate the distress.
Whatever its intent, this is how it's being weaponised.
Thank you.
There's a variable level of 'trickiness.' I was thinking about our sense of self and the normal challenges of puberty and adolescence. Mostly because that's how I found my way in to this topic. I am hoping to provide an avenue of empathy.
Ouch that's a horrible phraselogical construction. Hey ho.
Thank you! This all makes sense to me. If puberty blockers have been shown to be as safe as this sounds (with the caveats you mention), then I think that makes a huge difference.
https://x.com/JolyonMaugham/status/1811670898740490413
https://x.com/JolyonMaugham/status/1811682692653564128
Although AFAIK they are in their 20s, so out of the scope of this legislation.
It doesn't bode well does it?
But then I know they can't be themselves or dress as themselves outside the house, they have to go back in the closet because these absolute fuckers and our callous and witless media have drawn a target on their backs for every thug and bully in the UK. It affects both non-cis and cis people because it whips up violent bullies to police gender. And worse, they've done it claiming to 'protect women'. Well I want protected from them and their crankery and persecution masquerading as feminism.
People like Starmer and Streeting and Reeves and Rayner had a chance to start changing this but instead, despite their huge majority, they've doubled down on the vicious prejudice that preceded them. They've made their first victims young people as it's easy to ignore and write off their voices but they've also catered to leaders of the Gender Critical hate movement in ways that show they're fine with it and won't challenge the bullies and persecutors.
It's a disgrace and I fear for what will happen.