Cass!
I’ll soon have more to say about the long-anticipated Cass Review’s final report, “Independent review of gender identity services for children and young people,” which was officially released last night. In the meantime, here’s just a tiny bit of what I highlighted while I was going through it yesterday.
The question being asked is not “are you really trans?” but “how should we help you?”
This Review is not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves, or rolling back on people’s rights to healthcare. It is about what the healthcare approach should be, and how best to help the growing number of children and young people who are looking for support from the NHS in relation to their gender identity.
People disagree, but some people are afraid to share their thoughts because: politics!
Clinicians who have spent many years working in gender clinics have drawn very different conclusions from their clinical experience about the best way to support young people with gender-related distress.
There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.
Polarisation and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse, and in the long run will also hamper the research that is essential to finding the best way of supporting them to thrive.
The research? It’s crap!
This is an area of remarkably weak evidence, and yet results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint. The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.
Based on a single Dutch study, which suggested that puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence, the practice spread at pace to other countries.
Some practitioners abandoned normal clinical approaches to holistic assessment…
The first step for the NHS is to expand capacity, offer wider interventions, upskill the broader workforce, take an individualised, personal approach to care, and put in place the mechanisms to collect the data needed for quality improvement and research.
Spread it out, slow it down, think it through.
Whilst some young people may feel an urgency to transition, young adults looking back at their younger selves would often advise slowing down.
For some, the best outcome will be transition, whereas others may resolve their distress in other ways. Some may transition and then de/retransition and/or experience regret. The NHS needs to care for all those seeking support.
The ability of the child or young person to lawfully consent to this proposed treatment is only one issue. There are two other issues to be addressed; the judgement that the clinician makes as to whether a treatment is indicated for a patient, and the information they provide to them about the potential benefits, risks and alternatives.
ROGD: We won’t name it, but we’ll describe it.
From 2014 referral rates to GIDS began to increase at an exponential rate, with the majority of referrals being birth-registered females presenting in early teenage years
Today’s population is different from that for which clinical practice was developed with a higher proportion of birth-registered females presenting in adolescence. They are a heterogenous group with wide-ranging co- occurring conditions, often including complex needs…
We have to talk about sexuality! Gender and sexuality are not wholly separate!
In the original Dutch study, 89% of the 70 patients were same-sex attracted to their birth-registered sex, with most of the others being bisexual. Only one patient was heterosexual.
“…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.”
More soon!
Thank you, Lisa. May it be widely reported, and make a real difference, here. Azeen Ghoryashi includes this quote from Dr Cass, and a link to Cass' interview with the BMJ:
“Children and young people have just been really poorly served,” Dr. Cass said in an interview with the editor of The British Medical Journal, released Tuesday. She added, “I can’t think of another area of pediatric care where we give young people potentially irreversible treatments and have no idea what happens to them in adulthood.”
Thanks Lisa, for this conversation I wondered about the this sentence "This is an area of remarkably weak evidence, and yet results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint." I have seen many times where the TRAs misrepresent studies that do not show positive outcomes, but how often is it the other side? Gender medicine critics who look at studies showing positive outcomes but misrepresent those?
In that same vein, what should the standard be to allow use of puberty blockers or cross-sex hormones? I see the Endocrine Society warning about plastics interfering in natural hormonal processes on one hand, but then advocate for medications that intentionally interfere with those processes on the other. Is it even possible for those interventions to have a positive effect outside of something on the mental side of care? Personally I think the bar would need to be WAY higher to justify those interventions, even in adults.