This is what the Cass Review says on the idea of social contagion / influence (my bold):
38. Research suggests gender expression is likely determined by a variable mix of factors such as biological predisposition, early childhood experiences, sexuality and expectations of puberty. For some, mental health difficulties are hard to disentangle. The impact of a variety of contemporary societal influences and stressors (including online experience) remains unclear. Peer influence is also very powerful during adolescence as are different generational perspectives.
39. Pragmatically the above explanations for the observed changes in the population are all likely to be true to a greater or lesser extent, but for any individual a different mix of factors will apply.
40. This is a heterogenous group, with broad ranging presentations often including complex needs that extend beyond gender-related distress and this needs to be reflected in the services offered to them by the NHS.
41. Too often this cohort are considered a homogenous group for whom there is a single driving cause and an optimum treatment approach, but this is an over-simplification of the situation. Being gender-questioning or having a trans identity means different things to different people. Among those being referred to children and young people’s gender services, some may benefit from medical intervention and some may not. The clinical approach must reflect this.
AND
47. The World Professional Association of Transgender Healthcare (WPATH) has been highly influential in directing international practice, although its guidelines were found by the University of York appraisal process to lack developmental rigour.
48. Early versions of two international guidelines - the Endocrine Society 2009 and WPATH 7 - influenced nearly all the other guidelines, except for the recent Nordic guidelines.
49. Given the lack of evidence-based guidelines, it is imperative that staff working within NHS gender services are cognisant of the limitations in relation to the evidence base and fully understand the knowns and the unknowns.
Let me repeat, one of the two most influential templates for healthcare lacks developmental rigour and yet the NHS wanted to do a study based on its premise without first exploring issues around influence coming from poorly evidenced sources and sources with no evidence at all.
78. Therefore, sex of rearing seems to have some influence on eventual gender outcome, and it is possible that social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence
We KNOW that parenting is leading to different outcomes in gender incongruence and yet we want to medicalise knowing this.
1.41 Support and advocacy groups advised that to hear from the young people at the heart of the Review, opportunities needed to be created where they felt safe, could be supported before, during and after their contribution, and would be engaged around topics on which they have a genuine ability to inform and influence decisions.
There is no questioning about the nature and agenda of support and advocacy groups themselves. There is no talk of the role of parents and where they could voice concerns safely and be taken seriously. Surely if we are talking about EIGHT year old and under 14 year olds generally this is kinda essential before you start talking about sodding blockers.
A failure to consider the cause, potential influences and contributory factors can lead to people taking polarised positions. Nuanced discussion is needed about how best to understand and respond to the children and young people at the centre of the debate
Hmm well yes Hilary. What was that about weaponisation again???
6.6 Academics have identified three important ways in which sex differences are expressed (Babu & Shah, 2021):
• gender role behaviours (these are behaviours such as toy preferences, play, physicality)
• gender identity (an innate sense of belonging and self-identification of one’s gender as male, female or an alternative gender)
• and later, sexual orientation (the sex of the individuals to whom one is sexually attracted).
6.7 It is thought that all three of these can be influenced by biological and social factors, and this is an evolving area of research.
But its more important to priortise and fund a trial into puberty blockers apparently. Like FUCK ME.
The ‘social brain’ 6.40 The ‘social brain’ is the network of brain regions that are involved in understanding other people’s intentions, desires and beliefs. The slowly maturing prefrontal cortex is a key part of this network, so there are considerable changes in these abilities through teens to adulthood.
6.41 Through adolescence, peers have an increasing influence and parents a lessening influence. Adolescents’ evaluation of their social and personal worth is strongly influenced by what their peers think about them. Studies have shown adolescents to be hypersensitive to social isolation, so much so that going along with peers in order to avoid social risk, even if it means taking health and legal risks, might be seen as the rational choice because it reduces the possibility of social exclusion (Blakemore, 2018).
It pretty much says teens will do stupid shit and risk their health in order to maintain social acceptance. Cass seems to have forgotten this.
7.1 A generation is a group of people who share similar birth years, life experiences and cultural influences. Every generation encounters new experiences, advances, technologies, challenges and stressors that have a profound effect on their behaviours, attitudes and beliefs.
7.2 It may appear somewhat simplistic to divide people by birth year, but this is a helpful way of understanding how perspectives, as well as health and illness, can be shaped by major world events (most recently the Covid-19 pandemic), as well as social and economic conditions.
7.3 Generation Z is the generation in which the numbers seeking support from the NHS around their gender identity have increased, so it is important to have some understanding of their experiences and influences.
7.4 They are defined as those who were born between 1995 and 2009 and are characterised by their digital nativism (proficiency in using technology and social media) and unique characteristics such as being entrepreneurial, socially conscious, pragmatic and diverse (Jayatissa, 2023).
7.5 In terms of broader context, Generation Z and Generation Alpha (those born since 2010) have grown up through a global recession, concerns about climate change, and most recently the Covid-19 pandemic. Global connectivity has meant that as well the advantages of international peer networks, they are much more exposed to worries about global threats
7.6 Generation Z and some younger Millennials (Generation Y) generally have different beliefs about the fluidity and mutability of gender than older generations. Attitudes have changed at speed, such that within a 6-month period between early 2020 and late 2020/early 2021 Generation Z adults surveyed in the USA became the first generation in which the majority responded negatively to the statement “there are only two genders, male and female” (Twenge, 2023).
7.7 There are also generational differences in the numbers of young adults reporting that their experienced gender does not align with their birth-registered sex. Based on US Census data, in 2021-2022, 5.6% of Generation Z adults identified as transgender or non-binary, compared to 2.4% of Millennials and 1.5% of Generation X.
But yes, social contagion is controversial and exists within a bubble that isn't somehow extremely relevant. It literally says that we should be listening to ideas of belief but somehow we should accept the controversy of social contagion and not ask some bloody big questions especially when this doesn't match with actual reality. This reality gap is a key point in terms of whether any medicalisation is liable to be ultimately effective!!!!
8.23 For children and young people with gender incongruence, ‘innate’ or biological factors may play a part in some individuals, in ways that are not yet understood, and in others psychosocial factors, including life experiences, societal and cultural influences, may be more important. Since biological factors have not changed in the last 10 years it is necessary to look at other possible reasons for the increase in referrals and the disproportionate representation of birth-registered females.
Psychosocial factors
8.24 Various explanations have been advanced for the increase in predominantly birth-registered females presenting to gender services in early adolescence often with complex presentations, and/or additional mental health problems and/or neurodiversity:
Societal acceptance: The proposition is that greater acceptance of transgender identities has allowed young people to come out more easily and the increased numbers now reflects the true prevalence of gender incongruence within society.
• Changes in concepts of gender and sexuality: These might include a change in expressions of sexuality versus gender and a wider spectrum of expression (for example, non-binary and other gender identities that are more common presentations in birth-registered females).
• Manifestation of broader mental health challenges: For example, in the same way that distress can manifest through eating disorders or depression, it could also show itself through gender-related distress.
• Peer and socio-cultural influence: For example, the influence of media and changing generational perceptions. This is potentially the most contested explanation, with the term ‘social contagion’ causing particular distress to some in the trans community.
• Availability of puberty blockers: The change in the trajectory of the referral curve across many countries coincided with the implementation of the Dutch approach, starting first in the Netherlands and then similarly adopted in other countries.
8.25 Simplistic explanations of either kind (“all trans people are born that way” or “it’s all social contagion”) do not consider the wide range of factors that can lead young people to present with gender-related distress and undervalues their experiences.
Note there is no thought given to social contagion being a problem to those who have loved ones they think are the victims of safeguarding and they feel need safeguarding - its like there is still a vacuum of recognising its a hugely contested area but despite this the report shows bias.
Despite the point that there is a danger of social contagion it then automatically dismisses it as a simplistic factor that should somehow be ignored too.
8.37 In reality, for any individual young person, there will be different socio-cultural influences that impact on their understanding of both their gender and sexual identity, and this is an area that warrants better exploration and understanding.
BUT BLOCKERS AND SOCIAL CONTAGION IS CONTROVERSIAL AND UPSETS TRANS IDENTIFYING PEOPLE!!! ARRRGGHHH (actually angry at this point quoting Cass's own report)
8.42 The association is likely to be complex and bidirectional - that is, in some individuals, preceding mental ill health (such as anxiety, depression, OCD, eating disorders), may result in uncertainty around gender identity and therefore contribute to a presentation of gender related distress. In such circumstances, treating the mental health disorder and strengthening an individual’s sense of self may help to address some issues relating to gender identity. For other individuals, gender-related distress may be the primary concern and living with this distress may be the cause of subsequent mental ill health. Alternatively, both sets of conditions may be associated with and influenced by other factors, including experiences of neurodiversity and trauma.
Remember folks, we are weaponising.
Peer and socio-cultural influences
8.45 Sources of information for young people are predominantly online and peer-to-peer, and this applies to multiple aspects of their lives.
8.46 The generational changes in understanding and beliefs about the mutability of gender form the basis for many young people’s understanding of their own experiences and the experiences of those around them.
8.47 It is the norm that all experiences of health and illness are understood through the norms and beliefs of an individual’s trusted social group. Thus, it is more likely that bodily discomfort, mental distress or perceived differences from peers may be interpreted through this cultural lens.
8.48 More specifically, gender-questioning young people and their parents have spoken to the Review about online information that describes normal adolescent discomfort as a possible sign of being trans and that particular influencers have had a substantial impact on their child’s beliefs and understanding of their gender.
8.49 The Review’s focus groups with gender diverse young people found that “Young people struggle to find trusted sources of information, favouring lived experience social media accounts over mainstream news outlets”.
BuT cONtRoVeRsY. bUT wEAponISation. We MuST dO TrIAl InTO bloCKerS FiRST.
Availability of puberty blockers
8.50 The dramatic increase in presentations to NHS gender clinics from 2014, as well as in several other countries, coincided with puberty blockers being made available off protocol and to a wider group of young people. The only country with an earlier acceleration in referrals is the Netherlands, where the Dutch protocol was developed.
8.51 It is not possible to attribute causality in either direction to this association, but it remains a possibility that a lower threshold for medicalisation has had an influence on the number of young people seeking this intervention.
FUCK ME. JUST SERIOUSLY. IT ACTUALLY SAYS THIS. Less safeguarding and disregard for ethics might be driving medicalisation. You mean the Tavistock was a fucking car crash?!
8.55 In later childhood and into early puberty, online experience may have an effect on sense of self and expectations of puberty and of gender. As discussed in relation to adolescent development, this is a time where the drive to f it in with peers is particularly strong. Young people who are already feeling ‘different’ may have that sense exacerbated if they do not fit in with the demonstrations of masculinity and femininity they are exposed to socially and/or online.
8.56 Peer influence during this stage of life is very powerful. As well as the influence of social media, the Review has heard accounts of female students forming intense friendships with other gender-questioning or transgender students at school, and then identifying as trans themselves.
8.57 It is the norm for people to view their experiences of life events, health and illness through their own cultural lens and personal beliefs. Cultural norms in younger people might impact how they interpret their personal, sexual and gender identity
We should medicalise because of social change? REALLY?
Safeguarding
10.43 As with all health care provision, when working with children and young people safeguarding must be a consideration. There are complex ways in which safeguarding issues may be present. Clinicians working with children and young people experiencing gender dysphoria have highlighted that safeguarding issues can be overshadowed or confused when there is focus on gender or in situations where there are high levels of gender-related distress.
10.44 Sources of risk in this group include:
• transphobic bullying in school and in other settings
• breakdown in relationships with families
• online grooming or harm
• cultural or religious pressure.
10.45 The Review has heard about a small number of cases where the child’s gender identity was consciously or unconsciously influenced by the parent. It is very important that the child/young person’s voice is heard and that perceptions of gender identity represent the child/young person’s sense of self.
10.46 The Review has also heard a series of accounts of children and young people at safeguarding risk being lost to follow-up and/or of young people presenting to the emergency department with a safeguarding history that staff were unaware of because of changes of name and NHS number
EIGHT TO THIRTEEN YEAR OLDS OFTEN WITH COMPLEX NEEDS FOLKS. We should heard their voices and rule out influence from parents. Nothing about healthcare professionals, social workers, teachers and other adults in a child's life maybe having an influence though. KINDA important if we are talking about kids with unfettered internet access don't you think?!
12.36 The information above demonstrates that there is no clear evidence that social transition in childhood has positive or negative mental health outcomes. There is relatively weak evidence for any effect in adolescence. However, sex of rearing seems to have some influence on eventual gender outcome, and it is possible that social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence. For this reason, a more cautious approach needs to be taken for children than for adolescents:
Children:
• Parents should be encouraged to seek clinical help and advice in deciding how to support a child with gender incongruence and should be prioritised on the waiting list for early consultation on this issue.
• Clinical involvement in the decision-making process should include advising on the risks and benefits of social transition as a planned intervention, referencing best available evidence. This is not a role that can be taken by staff without appropriate clinical training.
HELLO TEACHERS.
• It is important to ensure that the voice of the child is heard in any decision making and that parents are not unconsciously influencing the child’s gender expression.
• For those going down a social transition pathway, maintaining flexibility and keeping options open by helping the child to understand their body as well as their feelings is likely to be advantageous. Partial rather than full transition may be a way of ensuring flexibility, particularly given the MPRG report which highlighted that being in stealth from early childhood may add to the stress of impending puberty and the sense of urgency to enter a medical [seems to be text missing]
Adolescents:
• For adolescents, exploration is a normal process, and rigid binary gender stereotypes can be unhelpful. Many adolescents will go through a period of gender non-conformity in terms of hairstyle, make-up, clothing and behaviours. They also have greater agency in how they present themselves and their decision-making.
• For those considering full social transition, the current long waiting lists make it unlikely that a formal clinical assessment will be available in a timely manner. However, it is important to try and ensure that those already actively involved in their welfare (parents/carers, any involved clinical staff such as their GP, school staff or counsellors) provide support in decision making and plans to ensure that the young person is protected from bullying and has a trusted source of support. For both children and adolescents:
• Outcomes for children and adolescents are best if they are in a supportive relationship with their family. For this reason parents should be actively involved in decision making unless there are strong grounds to believe that this may put the child or young person at risk.
• Help may be needed if a child/young person wishes to reverse their decision on transitioning, which can be a difficult step to take
12.37 The clinician should help families to recognise normal developmental variation in gender role behaviour and expression. Avoiding premature decisions and considering partial rather than full transitioning can be a way of ensuring flexibility and keeping options open until the developmental trajectory becomes clearer
Yes it actually says this.
13.3 For those who are considering a medical transition, there is a strong sense among service users that this should be facilitated by the NHS, but a recognition that there is a need for better information on which to base decisions/consent.
13.4 Young people and young adults participating in the Review’s focus groups highlighted a lack of reliable and accurate information about medical transition. In particular, the need to be informed of any known and unknown risks and potential side effects of hormone interventions when making informed decisions about care and treatment. Some participants felt there needed to be more information for people wanting to come off the medical pathway.
These are the same young people who are heavily reliant on social media rather than traditional sources for their information remember. God forbid the generation of their parents with a good understanding of some of these issues might be having some issues with whats happening with their kids and how its all about prioritising beliefs from a younger generation as society has changed.
WeApoNISinG.