Puberty blockers: Can a drug trial solve one of medicine's most controversial debates?

I didn't spot the whip 🫣

It's a photo of a bloke in fetish gear with a whip.

Nobody's laughing.

That's a supermarket assistant. It's a bit low to stick their photo on here and laugh at it. People should be free to dress how they like and call themselves what they like. Let's stick to protecting our children, and ourselves, and our spaces.

What is 'gender incongruence'?

Is it something to do with a dislike of your body? You imply this with this statement: body dysphoria, the subjective personal experience of feeling at odds with a body that is developing/has developed a particular way

But then you talk about 'external' sources - the distress that comes from being subject to social dynamics that deny a person's own sense of self.
Do you expect everyone else to see you as you want to be seen? Because this is completely unreasonable. None of us has the power or the right to be seen as we want to be seen by everyone else.

But what has this got to do with body dysmorphia anyway?

Is your 'gender incongruence' a wish to have a different body? Or is it about wanting to behave in a non-gender-stereotypical way. Because many of us do that without changing our bodies.

You think you are being punished for transgressing against social expectations applied to everyone based on the sex they were assigned at birth.

Have you any idea what it's like to be a woman who doesn't comply with those sort of expectations? Of course you don't.

this is being done deliberately to punish us for transgressing against social expectations applied to everyone based on the sex they were assigned at birth.

I would think it more likely that those who are rude about a trans identity are doing so not because such an identity 'transgresses' social expectations applied to everyone based on sex but because trans identities enforce and rely on those expectations.
There are plenty of women who are sick to death of the idiotic presentational and behavioural norms that have confined them forever, and who are glad to see male people adopting them, because the adoption of these norms by people of both sexes helps to sever the association between being a woman and appearing a certain way.

It is, then, insulting when some of the male people who present in this way assert that it is because they are women.

It is also pretty offensive to equate "grudgingly humouring" with a microagression. Asking someone to deny the evidence of their senses is asking A LOT. If people go as far as grudgingly humouring the request, they have already gone further than it is reasonable to expect. Is it a microaggression to be a bad actor - or is the real microagression the requirement placed on other people to join in a pretence that is deeply offensive to them?

Very good piece, as usual, from VS. I can't agree with the 'ultras' who criticise Cass for basically not saying, it's all a load of bollocks. That would have probably left the Review dead in the water. Just seemed pragmatism to me.

Excellent article by Victoria Smith in Unherd

https://unherd.com/newsroom/nhs-puberty-blocker-trials-are-unethical/

the comments are worth a read too.

How do you sort the wheat from the chaff? The true-trans from the sprogs who will grow out of it? Even the ones who have all the blockers and all the hormones and all the surgeries who never voiced regret, how do you rewind time and do it over to discover that their lives would have worked out fine anyway, with none of it?

For as long as you believe that "misgendering" is motivated by nastiness, you will struggle with it for that reason. It might be worth considering that most of the time, people use pronouns automatically, subconsciously, to refer to you. Those pronouns may be based solely on habit, or on perception of you as a man, with no intention to mock or to be cruel. But if you think the worst of someone, you will always believe they have it in for you.

It is not transphobic to instinctively recognise someone's sex, and it is not transphobic to refer to someone with pronouns based on that sex. Many people, me included, do not much care what "gender" someone sees themselves as being or what image someone tries to present to the world. They may find some presentations distasteful - I don't tend to like the results of cosmetic surgery, or for that matter heavy makeup. Again, failing to keep that distaste completely hidden may be a little rude, but it is not healthy to frame it as hostility.

No-one has any obligation to see you as you see yourself, or as you would like to see yourself.

The aim of the treatment is to address gender incongruence.

Gender incongruence harms people in multiple ways.

Some of these harms emerge 'internally' - body dysphoria, the subjective personal experience of feeling at odds with a body that is developing/has developed a particular way. The treatment can address this by slowing or stopping these changes - some of which are irreversible - from progressing further. Successful treatment allows a person to effectively 'jump the rails' and progress along a developmental path that no longer causes this incongruence.

Some of these harms have 'external' sources - the distress that comes from being subject to social dynamics that deny a person's own sense of self.

We are acutely aware of when people are grudgingly humouring us. Those microaggressions are very obvious - we are supposed to know - that's the point after all.

We are subject to increased hostility if identified as trans people; this hostility alone causes distress. It is distressing to be misgendered, especially when it is clear that this is being done deliberately to punish us for transgressing against social expectations applied to everyone based on the sex they were assigned at birth.

You could put one of us in a rocket and fire us off into space, never to be perceived by another human being again. It would not stop us from experiencing sex dysphoria.

if the aim of treatment isn’t really the treatment (how the patient sees their own body) but how other people respond to it, then this ‘treatment’ is as much social as medical. This is more problematic, because nobody can guarantee the patients the sort of social reception they will get

This is what 'passing' is all about. It's not about the person having the treatment seeing their body differently, it's about attempting to convince others that they are the opposite sex.

I think the first question which needs to be answered regarding this 'treatment' is what, exactly, is it supposed to achieve?

Is it supposed to help the patient to accept their body? If so, why are physical treatments being used instead of helping the patient to accept their body as it is?

If it's really to try to dupe other people into believing that that person is the opposite sex, how can this be in any way ethical?

Still felt there was a tiny amount of deference to the idea that "trans" is a tangible, biological medical issue instead of a mental health problem, and no explanation as to how or why treatment pathways had suddenly shifted from psychological care to drug treatment. If I were someone reading this article with no knowledge of all the furore I would wonder what had prompted this fundamental change.

This is consistent with the Cass Report, which sees gender identity as a fact rather than belief i.e. that it's true that we all have one. However, it cautions against seeing it as the first answer to a child's distress.

As I don't believe we all have a gender identity myself, this doesn't sit right with me at all. It's equivalent to NHS led exorcisms to remove evil entities that are "causing" distress with a side helping of permanent body modification (both within the endocrine system and with body parts, once the child is old enough for surgery and believes that this next step in the affirmation journey is what they need).

However, the Cass recommended approach does mean that the vast, vast majority of children would not end up on a medical pathway at such a young age and there's a good chance that a truly neutral therapeutic approach will resolve their dysphoria.

What's more no child would go on this pathway at all until the puberty blocker trial is complete. Which itself need to meet ethics approval.

So it's all still pointing at the same place, just without denying the existence of gender identity as a "thing".

Thank you @BonfireLady for great points. I read the InDepth article this morning and was (a bit) heartened by the factual narrative of the article (and that it was actually published by BBC). Very well written. Again, feel this article being allowed is yet another teeny, tiny step back from the previous stance of pretending there was nothing to see except bigots and shrill women.

Still felt there was a tiny amount of deference to the idea that "trans" is a tangible, biological medical issue instead of a mental health problem, and no explanation as to how or why treatment pathways had suddenly shifted from psychological care to drug treatment. If I were someone reading this article with no knowledge of all the furore I would wonder what had prompted this fundamental change.

So children will be harmed in the name of research, rather than access adult data. For God’s sake Wes Streeting, sort this out!

Is there an ethical issue with doing such a study on children? I think there is - as laid out in the article and by pp. There is a further issue though, even if there were no ethical problems, about how society treats transitioned people.

If single sex sports services and spaces are assumed to be opened up to trans people, then that conversation should be being had in a very public way right now (and should have been had before any of this started). That would mean that, eg, boys who transition understand that that doesn’t necessarily give then access to women’s single-sex provision and vice versa. That really needs to be a proper part of and investigation, because unlike most medical intervention, the impacts are not just felt by the individual.

Edited to add, if the aim of treatment isn’t really the treatment (how the patient sees their own body) but how other people respond to it, then this ‘treatment’ is as much social as medical. This is more problematic, because nobody can guarantee the patients the sort of social reception they will get

Yes, the ‘improvements in mental health’ justification was tagged on later after the Dutch study. But primarily PBs were used to prevent males from developing testosterone-enabled male physical features and thus, theoretically, it was supposed to make it easier for them to pass as women and make them less unhappy as adults.

To clarify what I meant - even someone who has some understanding of the issues uses biased language, presumably subconsciously. Benefits are assumed to exist; harms are somewhat dismissed as "potential", i.e. they may not even exist. Certainly from my parental perspective, benefits are very nebulous and harms seem clear and unavoidable. Harms are absolutely staring us in the face when it comes to surgery, and hard to deny with the disruption of endocrine balance with cross sex hormones. Then there are puberty blockers, disrupting the natural maturation processes.

How it can be a good thing to deny a child puberty during the appropriate age range is completely beyond me. Life can be tough, puberty can be tough, but it's part of the human condition, and avoiding tough experiences that everyone can expect to experience is not a healthy way to navigate life.

GDPR is potentially being deliberately misused in this scenario as a blocking tactic.

The Cass Review was brought about by whistleblowing at the Tavistock and concerns about serious ethical and medical misconduct.

The Cass Review has ultimately upheld these concerns and identified areas where serious harm may be being done to children.

GDPR contains the ability to have an exception. I believe there's a few that might apply in this situation.

If there was a situation where serious harm was suspected, then it would fall under a public interest issue on the grounds of health / harm to children.

You CAN make exceptions when the national or public interest is greater than the interests of the individual. Such a case could be in the area of serious harm to children.

I do note the following though re child abuse.

However I do think there is a clause that prevents this if it's felt that information might not be in the best interests of an individual whom that data was about.

So perversely I think that if someone had been abused by having had unnecessary surgery, if it was felt that it wasn't in their individual benefit to release that information or question whether they had been experimented on because the psychological impact on them as an individual would be catastrophic, then you might be able to legally withhold it and then therefore conceal a huge scandal in doing so.

I somewhat suspect if someone had the balls to take it to court, a judge would however probably rule in the public interest because of an ongoing concern.

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Excellent idea, thank you.

It'll make a change from complaining.

is it right to perform this particular trial on children and young people at all?

Let me think about this for a second.

Hmmm. No.

NOW remind me, who is it who is pushing for this most and remind you of their sex and also remind you of the sex of those children most likely to be caught up in this.

Is it the same sex?

Hmmm.

I suppose what I am trying to say is that we don't know enough about gender dysphoria or the best way to manage it to be thinking about a medical pathway for kids. We don't even know if the medical pathway is the right treatment for adults with this condition. We would need a strong body of evidence that medical transition has better long term outcomes for gender dysphoria than alternatives ( such as talking therapies or no intervention). We would need long term studies over a range of health outcomes of those who medically transitioned and those who did not ( of both sexes).
And we would need to know how to ascertain which pre-pubertal kids desisted after puberty and which continued to have gender incongruence.

Puberty blockers are the start of the medical transition pathway. All of above has to be established before looking at puberty blocker trials as puberty blockers only make sense if we already know medical transition is only effective treatment for feelings of gender incongruence, and we know how to accurately diagnose which kids will have settled incongruence for life.

That down-turned mouth reminded me of Donald Trump.

I didn't know the bbc had let Cohen go too.

It’s fantastic to see Cohen writing again for the BBC. Her work with Hannah Barnes has had and continues to have lasting global impact. The Cass Review was brought to the US Supreme Court last week. The road to this began with their Newsnight investigations.

Why the BBC let them go baffles belief.

Good thread pulling together her other work

x.com/journalismseen/status/1866031321241256285?s=46&t=A2fpFNgDRyXF2d6ye97wEA