New paper argues that “gender-affirming care” for adolescents should not be measured by whether it’s “effective”

[UtopiaPlanitia]

Thread on TwiX from journalist Leor Sapir:

https://x.com/LeorSapir/status/1872632988531372290

"A new paper argues that “gender-affirming care” for adolescents should not be measured by whether it’s “effective” at reducing psychiatric distress and improving life functioning. Authors (inc. A. de Vries) gesture toward an “autonomy” focused model.

To be clear, this line of thinking has animated the “affirming” model for a while now. The authors are now saying it explicitly. Clinical/psychosocial outcomes don’t really matter, apparently. This isn’t medicine."

https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-024-01143-8

I’ve been mulling over this all morning.

Placing what the authors have said in the context of the wider NHS this is really an own goal. The UK is not the US and the NHS runs on the basic principle of Utilitarianism- doing the greatest amount of good for the greatest number of people. The whole premise of accessibility to treatments is based on cost effectiveness, which from a health economics point of view it should be. That’s how NICE operates.

If (as the authors claim) offering so called “Gender Affirming Treatment is not based on positive outcomes but on what transgender/gender distressed kids want then the whole thing falls apart.

Let’s pretend for a minute that these treatments do absolutely no harm at all but are given without evidence of benefit either (on want not need) and that even genuine life saving or morbidity reducing care is not rationed ( Cancer diagnosis and treatment, ADHD waiting lists anyone?) Why should the NHS offer it? We have nationalised, publicly funded healthcare which is rationed and based on clinical need. There are lots of people who want the NHS to offer them a treatment but as an entity it doesn’t because it’s not medically necessary. If it’s not life saving (remember those suicide stats and ‘better a live daughter than a dead son?’) or proven of clinical benefit why should the NHS fund those treatments anymore than they fund cosmetic plastic surgery or laser removal for tattoos? Why should this be any different?

On current NHS principles it shouldn’t. And again, if it’s about want rather than medically necessary why do kids need access to it? We don’t let them have any other cosmetic procedures or even tattoos until they’re 18 so how is this different?

Once again this whole ideology shows itself to be a compete shitshow based on false premises. It’s not about lifesaving care for desperately ill and unhappy children.
It’s about legitimising access to hormones and surgeries some adult males have reasons for wanting. On which I will say no more to avoid the deletion.
/Rant over.

Rant away @Faffertea. Two great posts 👏

This very grim article showcases how divorced these medics are from society's basic principles of safeguarding children. We know that transactivists are dependent on transitioning children for their own purposes but to see qualified doctors being so divorced from the principles of keeping children safe, is utterly depressing.

The more I read of this paper (I’m having to read it in stages) the more it feels to me as though it’s an argument to keep medically transing children no matter what flaws and dangers are pointed out by current and future research.

There are three main groups of people this ‘argument’ benefits: the adult men who wish to live as women for fetish purposes, the doctors who are/have been carrying out medical transition of patients, and the ideologues - the people who have made being queer and trans their entire existence.

The first group needs society to believe that childhood gender dysphoria is the same condition as theirs in order to have society believe their behaviour is not sexual in nature.

The second group needs society to believe that childhood gender dysphoria exists in a certain way that can only be successfully treated with surgical and hormonal interventions because that is what they have been doing to children and they do not consider themselves monsters for doing so and do not want society to consider them monsters for doing so. (There might also be a profit motive for some doctors).

The third group needs society to believe that (childhood) gender dysphoria is a reason why they are a special category of people for whom normal rules don’t apply and to whom undue weight should be given to what they say. It looks like for some of these people that it’s sunk cost fallacy and for others it’s the social power currently afforded to them by their status. I also wonder if, for some adults it’s the misery loves company approach: in other words, ‘I need others to keep making the same decision I did in order for me to not question, and to be happy in, this extreme decision I made’.

This is musing. I'm a very low level clinical researcher as part of my day job but in no way an expert.

The theoretical principles of gender identity stop research being done on pragmatic benefit. If low dose testosterone is, for example, an effective mood stabiliser and antidepressant with a particular effect for eg adolescent girls with autism, that would be worth knowing. But if you can't even say that the people you want to recruit for your study are adolescent girls, and if the ethics committee will throw out your study unless you exclude girls who aren't questioning their gender, you're not going to be able to find out anything that applies more generally than in 'trans boys' and the effect you achieve is going to be misunderstood on first principles.

Not, you understand, that I am keen on dosing girls with testosterone. But if it's going to happen, it should be studied as the dosing of girls with testosterone for mental health, not the 'replacement' of 'low testosterone' in 'trans boys'.

A few more quotes from the Chu article:

'Like many of my trans friends, I’ve watched my dysphoria balloon since I began transition.'

'I was not suicidal before hormones. Now I often am.'

'I also believe that surgery’s only prerequisite should be a simple demonstration of want.'

'There are no good outcomes in transition.'

So. This boils down to Action for Trans Health's insistence that trans people should have any surgery they want, because they want it.

https://www.tumblr.com/edinburghath/163521055802/trans-health-manifesto

'We demand hormones & blockers are made available over-the-counter and by free prescription upon request.* *We need free, universal access to safe hormones & blockers at any age, the opportunity to decide our own doses, and universally accessible information on the safety & efficacy of different regimens.'

'We demand the right to multiple surgeries, including reversal of previous surgeries if desired, so that we do not have to fear regret. We demand the free & timely provision of genital surgeries, additive & reductive chest surgeries, hysterectomies and orchiectomies, tracheal & vocal surgeries, facial surgeries, lipoplasty, contouring & microdermabrasion, surgical hair removal & transplantation, and any other possible procedure to meet our needs as we express them.'

I'd say it's insane, which it is, but the troubling thing is that anyone has actually bought this narrative, that the NHS - the NHS! - has performed mastectomies on teenage girls based on precisely this reasoning. They've sterilised children!

I mean, ffs. How do we ever get over this?

Wasn't it the 2023 Denver Colorado WPATH Symposium where attendees bemoaned that none of the outcome measures were positive and asked if someone could invent another measure that would be positive? This paper looks as if they couldn't find one so "outcome measures are oppressive" is their next best thing. It just gets weaker all the time.

(Sorry I don't have chapter and verse on that WPATH meeting, but I think someone who attended talked about it on the Gender a Wider Lens podcast?)

And it is high time someone published a paper "using tinfoil hat negativity as a theoretical lens". Science needs the tinfoil hat perspective.

Well, I've been surprised by how some people who seem like reasonable and intelligent adults are pushing for children to be given puberty blockers. Including several elected MPs.

How can they still be pushing for this? I know they are, but how?! Would they take the same stance if the treatment in question was for something else; migraines, or epilepsy, for example. Does anyone remember that spoof drug 'Cake', I think it was on Brass Eye, and various public figures were encouraged to denounce it despite it being completely fictional, and made themselves look rather stupid in the process. It feels like we are in an episode of Brass Eye, or perhaps we need a new episode to catch out these elected idiots who can't see past the end of their own egos.

@AmaryllisNightAndDay I think Eliza Mondegreen went to WPATH as well as Genspect, so it may have been her report.

Thankyou @Crouton19 - yes that's right, it was Eliza Mondegreen. It was EPATH in Ireland rather than WPATH in Denver. And - I might have guessed! - there's a Mumsnet discussion about it with generous quotes https://www.mumsnet.com/talk/womens_rights/4799382-dont-stop-believin-three-days-at-the-european-professional-association-for-transgender-health

"a prominent Dutch researcher mused: “What should we use as an outcome measure? Mental health needs? What if you ask the kids: are you happy with the treatment and they say, ‘yes, we are happy’?”"

You are right. And the trouble is, when you start talking about "girls with autism" (even gender questioning girls) instead of "trans boys" it becomes obvious to consider they might have vaginal intercourse (willingly or otherwise) and then you'd really have to worry about the physical dangers of vaginal atrophy. I don't know what physical effects low doses of testosterone have - maybe not vaginal atrophy? - but anyway it's plain speaking that shows up dodgy assumptions. Best avoided.

Yes, it does have a Brass Eye feel to it. I assume they've accepted the narratives, swallowed them whole, with the logic fails and all.

People have criticised the Cass Report, therefore people who believe TWAW think that makes it de facto unreliable - never stopping to wonder who has criticised it, based on what reasoning, and why.

I understand that the pro-trans view is that anything that affirms a person's identity (including surgery) is a measurable outcome. Therefore there's no need to ask whether they're happy or not.

Crazy, but that does seem to be the logic.

JKR has tweeted about it:

https://nitter.poast.org/jk_rowling/status/1873048335193653387#m

It took me a little while to read the whole paper. I experienced it as a set of jaw-dropping WTAF moments, where it contradicted itself on some occasions and on others it simply stated the quiet bits out loud, leaving them hanging in the air.

For all the words that it used, it couldn't explain why medically assisted transition was apparently a good idea, nor why it was even needed - its purpose being simultaneously to "cure" dysphoria, while resulting in feeling better (as long as "feeling better" is redefined), while also not requiring gender dysphoria as a prerequisite anyway, while also saying that outcomes were better when it was gender dysphoria that was being addressed.

Ultimately, the takeaway for me was that the authors had skin in the game, so needed the outcome to be simple: medically assisted transition is a good idea. It tied itself in multiple knots to deliver this message. In this bit they open with one of the quiet bits out loud (that their collective view has a bias) and then describe how each of them is linked to it all:

A central aspect of reflexive thematic analysis is acknowledging that researchers’ positions influence the research process, inviting researchers to critically reflect on their subjectivity and positionality. We, the authors, comprise a mix of junior (EO and SS) and senior researchers (KG, DD, and AV). The first two authors (EO and SS) are PhD candidates with a background in Gender Studies and Sociology. KG is a trained ethicist and psychiatry resident with clinical and research experience in GAMT. DD is an academic researcher trained in social and medical psychology whose work primarily focuses on members of marginalized groups. AV is a child psychiatrist and senior researcher with extensive clinical and research experience on adolescent transgender care and served as a co-author on the SOC8 Adolescents chapter. All authors are currently affiliated with the Center of Expertise on Gender Dysphoria (CEGD) in Amsterdam, the Netherlands.

In other words, some of us make money from this (and/or wrote the original guidelines from which many others make money), some of us have done this to ourselves and some of us are junior researchers (who want to keep our jobs and grants, so won't rock the boat). So we've written a paper to justify it all as "effective", as long as the word effective isn't scrutinised too much.

PPs have commented on Elizabeth Mondegreen's observations from EPATH. I was also thinking about this as I was reading it. It's all about "embodiment goals".. where distressed young people (including children) are put in a position where they think they are getting holistic medical care... but when you peel back the layers, there is no oversight at all and they are making irreversible decisions about their own bodies without understanding what any of this means for their future mental and physical health.

'served as a co-author on the SOC8 Adolescents chapter.'

Ah. I see.

D'oh. I meant Eliza Mondegreen.

@UtopiaPlanitia I'd add to your three groups the transhumanist contingent. Some of whom have been bankrolling trans activism since at least the 90s.
They believe in fully libertarian healthcare: a pharmacy should be just like a supermarket, with all medications available to all comers, no scripts required. And all surgeries are equal.
One of the (many) things that baffle me about the trans rights movement are the social justice oriented friends who are completely taken in by this version of healthcare "justice". It's access on the basis of $$ nothing more nothing less. Rich men can get as many boobs as they like inserted. Poor women can't get lifesaving heart surgeries.
I feel quite sick after reading the sections of the Chu article @ArabellaScott quoted and want to do something useful to counteract what feels right now like a death cult.
Maybe I shoud check out the fundraising thread. Wish I could manifest Kali or something.

In fairness, even sections of the second wave included ideas about healthcare that are, well, unwise, and lead to a great deal of suffering in the name of autonomy.
The death of Kathy Acker one of the saddest stories - https://en.wikipedia.org/wiki/Kathy_Acker#Later_life_and_death
Expanding this to include children, though, that's certainly a whole new layer of evil.

This is about the size of it. It doesn’t matter to de Vries if patients are healthier or happier after ‘treatment’. All that matters is what they look like.

There are quite a few connections here with the rise in appetite (in some circles) for decolonising healthcare, where claims are made that outside of the western world there are other, equally valid ways of understanding health (spiritual healers, shamans, rituals etc.).

Where you find 'decolonising' arguments, you also tend to find claims that participatory research is the only valid type of research. Here, the subjects of the research decide what to research, how it should be researched and what constitutes good outcomes. As with many things, there are things to be learned from participatory research. Historically, researchers have focussed on the elements of conditions/disorders that interest them, as opposed to the aspects that most concern patients (menopause and endometriosis are 2 examples). However, addressing this weakness doesn't require the scientific method to be disregarded.

Previous threads discussing the ethical approval process for the upcoming puberty blockers trial have touched on what outcomes will be measured.

In the PB trial, the primary endpoints (the main outcomes that the trial is designed to measure) are likely to be changes in levels of distress/symptom severity, changes in functionality - such as school attendance, self care, socialising etc. The secondary endpoints (additional outcomes) are likely to include wider quality of life indicators, unwanted side effects, adherence levels to the treatment protocol and drop out rates.
There will also be exploratory endpoints (outcomes that are not the primary focus but can offer information for future research) which may well include differences within sub groups and follow on uptake rates in cross sex hormones and surgery.

The Cass Report highlighted the need for gender medicine to be brought in line with other areas of medicine, and this recommendation extended beyond paediatric medicine. This, and taking power and control from the Tavi, plus so many eyes now on the field, the de Vries school of thought has less reach than ever in the UK.

In the US, campaigners have ben working on a clever strategy with the medical insurance companies. They have been trying to make it compulsory for any coverage of costs for puberty blockers, cross sex hormones and surgery to automatically entitle costs relating to future treatment needed for complications arising from side effects and de-transition costs, should claimants later wish to de-transition. The insurance companies have made it clear that if they are forced to do this, they will withdraw cover for the gender medicine - which is very telling about their confidence in their safety and efficacy!

Excellent point regarding transhumanists.

William Gibson’s Neuromancer was meant to be a warning not an instruction manual 😏

They believe in fully libertarian healthcare: a pharmacy should be just like a supermarket, with all medications available to all comers, no scripts required. And all surgeries are equal.

Indeed, @TheCourseOfTheRiverChanged and yet many of these champions will also proclaim themselves to be anti-capitalist, eat the rich etc. Where do they think the money for these treatment goes, because surgeries are not performed by off-grid muesli-knitting hippies 🤔 . How many boobs (on or off) = 1 Malibu beach house?