Maintenance Phase - BONUS: Breaking Down The Latest Anti-Trans Victory Lap

Episode Date: July 1, 2024

We went a little easy on the Cass Report in our last main feed episode, so we're back to [Mortal Kombat voice] FINISH HIM!!!This was supposed to be a Patreon bonus episode but we'd rather you support the lovely trans people who helped us with the research and fact-checking of this episode! Julia Serano: https://www.patreon.com/juliaseranoParker Molloy: https://www.readtpa.com/Katelyn Burns: https://www.patreon.com/katelynburnsEvan Urquhart: https://www.assignedmedia.org/supportErin Reed: https://www.erininthemorning.com/Or organizations that work with trans youth in the UK: Gendered Intelligence: https://genderedintelligence.co.uk/Mermaids: https://mermaidsuk.org.uk/Stonewall: https://www.stonewall.org.uk/Thanks to Doctor Dreamchip for our lovely theme song!Support the Show.

Do you have a tagline? No, I was that's part of the reason why earlier I was like, do you have a tagline? Wait, you should do your SAS report one. Do your SAS report one. Why would I do it again? We got to stop keeping our little outtakes because we can't use our like B grade or B list taglines. Hi everybody and welcome to maintenance phase, the podcast that has its notifications turned off on social media

after this week's episode. Oh yeah, we did hear from the anti-trans brain trust as well as the smoothie truthers Thank you for your feedback. So this is like Some somewhere halfway between like a bonus episode and like an episode episode Oh, I feel really bad that like we we sort of shortchanged the cast report in our rapid onset gender dysphoria episode Because we wanted to focus on the way that this specific narrative has taken over all these institutions of the US and the UK. So that's what we focused on in the CAS report. But of course, the CAS report is like 400 pages long. Listening back to that episode, I was like, we went really easy on the CAS report. I think we tried to

get across how it's basically just like a smorgasbord of anti-trans talking points, but it's also just like fairly bad on other things and it includes a lot of other just sort of bullshit and so we wanted to break this out and do like its own little episode. Also, I have COVID and I feel like shit. Bloody. I don't know how detailed this is going to be because I'm very tired and my throat is sore. But we're gonna do our best. We're gonna read a bunch of excerpts. I'm mostly gonna make Aubrey read them because her throat works. Not to brag, but my throat works. So again, I mean, I guess we should preface this by just saying, like, if you're not on, like, fighting about transphobia Twitter, you may not have seen the release of this report. This is yet another one of these, like, smoking gun victory lap things that transphobes have been doing. This is this was the thing that inspired JK Rowling to be like, I will accept an apology from Daniel Radcliffe and Emma Watson, which like they have in no way

offered at any time. I will accept a bottle of McAllen 12.am. We're all just putting shit out there. The reason I wanted to go through this, like, kind of darkly funny pattern in the episode was that this always happens. There's like, this thing comes out, and there's like, this whole victory lap by all the anti-trans brain trust,

and it's like, this smoking gun, we finally proved it. And then there's more scrutiny of the thing that came out, and it's like, this doesn't actually prove it. And like, essentially what's happened with the cast report is it comes out, they do this massive victory lap, the entire UK media just goes ballistic, it's finally proven. And then people are like, wait a minute, in appendix eight, it says only 10 kids detransitioned, right? And they're not actually presenting any evidence. And then since it came out, there's been a lot of more academic dissections of its use of evidence and the way that it's presenting the existing like all that we know about like puberty blockers and hormones and stuff. And so we're now at the place where like now that we have a clearer picture, it's like, oh, yeah, this is pretty clearly I mean, people, people are very reluctant to conclude this.

But it feels very clear to me that this is like a moral panic document that is produced by a government that is in the throes of a moral panic. And also just like, hello, an outsider's perspective. From the US, I will say, listen, our house is not in order on trans stuff. I will start there. And also looking into the UK,

it is absolutely bananas to me how mainstream it is to be like, but trans people aren't who they say they are. I think there's a weird dynamic here where it's like, it's impossible to say like which country is worse because I think our right wing is more extreme than like the Tories. Like the Republicans are much worse than the Tories, I think. But also, we don't have a bipartisan consensus that this form of care is fundamentally illegitimate. And so that is what they have there. But they don't have laws that if you provide gender affirming care, you go to jail. They don't have that. We do.

The issue here is who claims centrism. And in the UK, I mean, like Keir Starmer, who's the leader of the Labour Party, just got on board with like bathroom bans basically. Exactly. So, I mean, we could spend another hour on this, but in the interest of saving my throat, I got to watch it on my fucking tangent. I know that both of us for the first time ever. We don't have time for six hours of the same joke. We have to actually fucking watch it. The clock is ticking of how much I can actually talk.

Wait, did I tell you? I can't remember if I've told you this. Wait, you just said I gotta watch it on my tangents? But it's funny. Alright, give it to me, give it to me, give it to me. I'm enabling you. I'm an enabler. My dad wears hearing aids and every time I walk into his house, the first thing I see is him reaching up to turn down his hearing aids. I wish it were a joke.

It is so not a joke. And I've talked to him about it and he's like, I gotta do it. He's like, here's my little biological sound machine. My daughter. At one point he was like, I don't have a lot of hearing left. I gotta keep what I got. You gotta save it? I'm going to rob you of your hearing? Yeah, he's like, I'm saving this for YouTube. I'm not gonna waste this on my daughter. So hopefully that was worth it. Tangent! Okay, okay, okay, back. I'm done now. It's never happening again. We are going to dive more into the report itself before we do very quickly We're just gonna talk about like the process by which the cast report came about we actually

I just thought of a tangent, but I'm not gonna do it This is gonna be like the Boulevard of broken dreams episode just like so we're really hard I feel like we're gonna end up announcing every time I know I Hate to do this but yeah So the process itself is like kind of a little bit part of this moral panic essentially There had been all these media reports of like all these kids are going to gender clinics and like it's a big fake gender confusion Thing essentially there's all these rumors and eventually the NHS under all this pressure in 2020, was like, okay, we'll commission a review. If you read the original terms of reference for the CAS report, it's

basically supposed to be somebody investigating, like, it's a little fishy why there's so many referrals all of a sudden, why there's this, like, increase in referrals. But that's not really an NHS question. That's more like a societal question, right? Like, why are so many more people identifying as trans, right? And it does throw in, it's like you also need to look at whether or not they're being rushed through procedures. But that is the central question, right? Because as we've discussed, the fact that more people are identifying as trans, unless you're a just straightforward bigot, there's nothing wrong with more people identifying as trans. there's nothing wrong with more people identifying as trans. So to me, the sort of the poison pill was like the entire mandate of this investigation because it's basically being asked to speculate why are so many more people coming into this clinic and that's what a lot of the CAS report spends its time on. This is another one of those moments where I'm like, again, people are just telling on themselves so hard.

It comes up in trans stuff all the time. It also comes up in trans stuff all the time. It also comes up in fat stuff all the time, which is just like, there's gonna be so many of them. Like ergo, there is a big problem. There's just like more of a kind of person. It's like your dad's hearing aid thing. It's like we've already spent our minority points on like gay people.

We can't have a new minority. So to me, one of the main red flags is this kind of terms of reference, but then there's all kinds of other red flags in the process of creating the CAS report. So first of all, the fact that Dr. Hillary Cass has not like she's not a trans physician. This is seen as an asset, the fact that she has no actual subject matter expertise. Oh, she's a real Washington outsider.

Yeah, I mean, this is this is from the CAS review website. It says, given the increasingly evident polarization among clinical professionals, Dr. Cass was asked to chair the group as a senior clinician with no prior involvement or fixed views in this area. So this is again, the sort of resorting to conspiracy where it's like, well, you know, everyone who does this kind of care is like fundamentally illegitimate, right? And they're biased. So we have to go to somebody outside. This is a thing that comes up in politics quite a bit. I know I've yelled about it on the show before, so I'll keep it short. The idea that it is an asset to have someone who has zero experience is not a thing that you would stand for in a surgeon or a pilot.

Yeah, and also, I mean, you know, as a totally abstract principle, the idea of bringing in somebody independent to try to give some sort of impartial adjudication in principle makes sense, I guess. I still think it's a little bit iffy when we're talking about like technical health fields. But then what you would do in that case is you would have a really transparent process, right? We're bringing in this person who doesn't know anything. And so we're going to link them to every single expert. And we're going to have them make sure that they hear the best arguments from everyone, right?

So you sit down with trans health care providers. You sit down with these parents. Sure, fine, right? You hear from everybody. And then you look at which side of this debate has evidence and which side doesn't, right? That would be a fine process, but the problem with the CAS report

is that there's no transparency about the process. The most egregious example of this is that it's not clear how much CAS engaged with the actual clinicians at the clinic at the heart of this investigation. Like there's something really weird about the fact that, you know, we have this audit as appendix eight, which lays out all the numbers, but we have no context for those numbers.

So, like, why did only 25% of kids get care? And this is in keeping with the entire framing of the report as people who do this care are fundamentally biased and illegitimate and not worth engaging with. As we've said, this is a small field and they're not treating that many patients. You could interview every single person who's providing this care in the UK,

it would not be that hard. So that's like the first, like beyond red, like bright red, like magenta flag. And the second issue is the nature of the engagement with actual trans people. So we do know the engagement with actual trans people. So we do know that Hillary Cass met with like pro trans groups like mermaids and there's other NGOs that work with trans youth in the UK. So they have not been completely cut out of the process. Although we have heard from some of the people who were in these quote unquote listening sessions who say that their like pull quotes and their messages were like taken out of context and included in the report or basically that what they said was ignored. Was there a through line with those comments?

Was there a theme of people being like, they didn't include this, and I said this thing. Was there alignment in the this thing? Yeah, so basically, it was a bunch of people who said, you know, I told the cast review positive things about my own transition and positive things about my care, and they took my words and used them as ammunition for this care being given out too easily. So here, I saved one of them.

These are what's known as pull quotes. It's like when you have one of these PDF documents that's kind of nicely laid out, you have these larger font quotes that are sort of highlighted as like one of the core messages. So just imagine you're seeing this like one of the core messages. So just imagine you're seeing this like with no context at all. That is what I am seeing. Oh yeah, good point. I am. Imagine not knowing the name and circumstances of the person who's saying this. There's not only one route or one set way to transition or to be trans. They might want just hormones or just surgery. People are different with different experiences, presentations, and bodies. It's fine for that to be the case.

It's okay to have different plans for your medical transition. Yeah, I mean, sure, I don't know, different people are different. Yeah. So, okay, then I'm going to send you... This is from a very interesting article that comes out afterwards called Critically Appraising the CAS Report, Methodological Flaws and Unsupported Claims. While it seems that this participant is advocating for increased availability of care options for trans people, this quote directly informs the section which suggests, quote, it is important to inform people that

medical transition is not the only option and that choosing not to go down that route does not invalidate their identity. The report then reframes this response as evidence for the need to reduce the number of medical transitions. Again, they're implying that people are being pushed into medical transition, right, as if that's the only option when they've provided no evidence of this being the case. Again, 75% of people who went to this UK gender clinic did not get puberty blockers or hormones. So we already live in a world

where people are not being pushed into this kind of care and are not being told the only way that you'll ever be happy is if we medicalize you. That's not happening. This is so similar. The rhetoric here feels so similar to the rhetoric around crisis pregnancy centers. Yeah, yeah, yeah. Oh, totally.

You've got to go in and hear someone tell you and show you pictures and do all of this stuff to make you feel even worse about an already complicated decision. Also, time shares. Also, time shares. So how they get you to buy time shares. I just want to sit down with you for one hour. She want you to know this is not your only option. It's really an investment. You could have a timeshare.

There is like on one side of this, there's problems with the process of consulting trans people that the way that the quotes are used is just kind of odd in the report. But then there's also we don't know who else was consulted for this. So there's no information about who wrote the CAS report. There's no information about which other groups they sat down with. They do include on the website of like, yes, we sat down with these like pro-trans groups, but I think they're doing that as like a box-ticking exercise to prevent criticism because they know trans people are immediately going to look through this and be like, wait a minute, did they talk to trans people or not? And they can point to this and

be like, look, we did, we did. Even if none of the things that trans people told them are actually in the report substantively. And we know from Erin Reed's reporting that they met with this board in Ron DeSantis' Florida that put together this deranged, quote unquote, evidence briefing that informed the ban on gender-affirming care in Florida,

which they did not announce, right? So we only get that from the fucking weirdos who are sitting on this board are like, oh yeah, I also met with Hillary Cass. That's not normal for a report like this. I really appreciate that you call it Ron DeSantis' Florida. Well yeah, I'm doing it for our UK listeners. Do you think our UK listeners know who Ron fucking DeSantis is? Yes, they absolutely do because of his little shoes. Oh, because of his little shoes.

His little shoes. I just was like, you said it and I was like, oh, it's like Tyler Perry's. Why did I get buried? Tim Burton's A Nightmare Before Christmas. Yeah, yeah, yeah. That's right. Stephen King's apt pupil. I'm trying to look. I only got like 40 minutes of throat left. I'm trying to look. I only got like 40 minutes of throat left.

I'm trying to get as much out as I can. I'm densely backing. I'm just I'm not tangenting. I'm just inserting jokes. So the first section of the cast report is like the context, the context of the United Kingdom. So the main problem with this whole section is that this is basically supposed to be telling the history of gender affirming care for kids, right?

Roughly what we went over in our first rapid onset gender dysphoria episode, like the Dutch clinics, et cetera. But then over and over again, it keeps casting the gender clinic in the UK, the Tavistock Clinic, it keeps casting this clinic as like this rogue clinic. And so here is a longer excerpt from this section. It often takes many years before strongly positive research findings are incorporated into practice. There are many reasons for this. One is that doctors can be cautious

in implementing new findings, particularly when their own clinical experience is telling them the current approach they have used over many years is the right one for their patients. Quite the reverse happened in the field of gender care for children. Based on a single Dutch study which suggested that puberty blockers may improve psychological well-being for a narrowly defined group of children with gender incongruence, the practice spread at pace to other countries.

This was closely followed by a greater readiness to start masculinizing slash feminizing hormones in mid-teens, and the extension of this approach to a wider group of adolescents who would not have met the inclusion criteria for the original Dutch study. Some practitioners abandoned normal clinical approaches to holistic assessment, which has

meant that this group of young people have been exceptionalized compared to other young people with similarly complex presentations. Some practitioners abandoned normal clinical approaches to holistic assessment. Well wait, did they? The whole point of this report should be to figure out whether or not that was the case. And based on the fact that they were seeing people 14 times before giving them puberty blockers or hormones, I think that sounds pretty holistic to me. I don't think they're like playing parcheesy during those 14 appointments. I think they're probably asking kids what is going on in their lives

and inquiring about like other mental health conditions that they have. The idea that these assessments are not rigorous or holistic is completely absurd. But again, they just say this shit. Do we think Parcheesy has a different name in the UK? It's probably something racist. I learned recently that tic-tac-toe is knots and crosses. So that is the first problem with the context section. The second problem with the context section is what we mentioned very briefly in the Wrap It Down to Gender Dysphoria episode, that it doesn't mention the rise of transphobia

in the UK. So this is another excerpt from the Critically Appraising the Cass Report report. The report fails to adequately consider the evidence of significant increases in societal transphobia in recent years. For instance, the number of recorded hate crimes against transgender people reached a record high in 2023, while the British Social Attitudes Survey shows a marked decline in attitudes toward transgender people. 36% of people now describe themselves as prejudiced against transgender people, twice as many as in 2019. Describe themselves as prejudiced.

If we're self-reporting biased, it is safe to assume that this is a dramatic under-report because most of us don't like to see ourselves as biased or prejudiced people. All right, so that's the context section. as biased or prejudiced people. All right, so that's the contact section. Then we have a huge section of the report dedicated to understanding the patient cohort. So this is the whole thing of like, why are the numbers rising?

So this is a very telling excerpt from this, and this is like what it's like to read this entire section of the report. Through adolescence, peers have an increasing influence and parents a lessening influence. Adolescence evaluation of their social and personal worth is strongly influenced by what their peers think about them. Studies have shown adolescence 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. So this is one of those things where it's like, sometimes teenagers will say wacky stuff just to fit in. And you're like, why is this in a report about trans kids? First of all, they do not provide any evidence

that kids think other kids are cooler when they're trans. This is like the linchpin of their entire argument, and they don't even bother trying to prove it. Like, are there schools? Are there social groups? We're like, yeah, having a minority identity makes you like slightly cooler. I guess. Is that the majority of schools in the United Kingdom in 2024? It's really far-fetched, and they're not even bothering to prove it. Secondly, we are not talking about whether kids say that they are trans due to peer pressure. We are talking about whether kids persist in their trans identity for years and then

pursue irreversible medical treatments to confirm that identity. That is so different than just do kids identify as trans. More tangents. It's happening. Tangent. Tangent. I had a friend in high school, we were at like peak peer pressure nonsense. This was like Dare era.

A friend of mine made like a comic strip called peer pressure girl. And every comic strip started with peer pressure girl being pressured to do something that she didn't want to do. And every comic strip ended with peer pressure girl dying from eating rat poison. Nice. That's good. And this this really feels like a peer pressure girl kind of. But where I'm like, yep, we're in panic times. This is something that I feel like reactionary movements do a lot,

is they'll say something kind of in the abstract, if it's true, that they're like, well, do you think teens say things just to fit in? And you're like, well, yeah. No, you'd be a weirdo if you disagreed with that. But then once they get you to agree with that, they're like, well, we proved it. They're saying they're trans to fit in. Sorry, wait, no, no, no, no, no. Nothing further, your honor. Yeah.

We rest our case. You're really getting some mileage out of you rewatching Perry Mason. It's not Perry Mason. It's Law and Order and it's hilarious. And then they have an entire fucking bizarre chapter called Growing Up in the 2000s, where it's talking about these attitude shifts among young people. Where obviously young people are much more likely to believe there's more than two genders than older people, right? And that's something that arose relatively recently. This is also the first section where we start to get a glimpse of

the just sort of like overall kind of weird sloppiness in this document. It makes a lot of claims that don't even have footnotes. So this is an excerpt from another very good article called Biological and Psychosocial Evidence in the CAS Review, a critical commentary. In exploring the factors causing changes in patient profiles, the review asserts that, quote, for many centuries, transgender people have been predominantly trans females. It is unclear what evidence supports this statement. Yeah. Fucking yeah. That's such a weird thing to say in your report with no citation. For centuries

now, most trans people have been trans women. Wait, okay. I just fucking hate it. I just hate it. In.8.14, the review cites Karamanis et al. as a large register-based population study to show that trans identity is mainly determined by environmental factors rather than having a genetic basis. However, this study included only 67 twins and as such is much smaller than the numerous other studies, which did find support for heritability of trans identity.

This is just sort of janky and weird. Like, twin studies are kind of infamously bad and we'll, I want to do a whole episode on it. It's actively bad. I mean, I think the, like, majority of trans people have been trans women thing. Ah, when we were working on trans health care, we had a wild ass fucking moment with the press with Fox News. Actually, let me. I feel like you're more tangentee this episode than usual. I feel like you're doing this on purpose.

Whatever me alone. This is worth it. Let me cook. Do you smell what the Googling is cooking? What? That was terrible. It was really bad. That was terrible. So in 2013, California and Oregon instituted new regulations

requiring private insurance carriers to cover health care for trans people. And it got a bunch of media coverage because we were like a couple of the first states to do that. And fucking Fox News picked it up. And I am sending you. Oh, this is the image that they used to go with the story. Oh, God. Oh, it's Mrs. Doubtfire. Yes. And it's like a scene from that movie where she's like putting out fires on her boobs. Yep. Fuck.

Yes, yes, yes. So we worked with like Media Matters and got a petition up and out and blah, blah, blah, blah, like all of this sort of stuff, but it was like, this is like the level of shit, and that is also, it feels very linked to me to like the majority of shit. And that is also, it feels very linked to me to like the majority of trans people have been trans women. And I'm like, you're just thinking about depictions

designed by and for cis people. It'd be funny if the citation was like, Mrs. Doubtfire, tootsie, some like it hot. Start listing out. Yeah, God. Okay, so getting back to understanding the patient cohort and like why why are more kids showing up at gender clinics? I really couldn't believe what I was reading when I got to this section. So the Children's Commissioners report in 2023 found that

pornography is so widespread and normalized that children cannot quote-unquote opt out. Pornography. The average age when children first see pornography is 13, but 10% have seen it by age 9. The pornography that they are exposed to is frequently violent, depicting coercive, degrading, or pain-inducing acts. Younger exposure had a negative impact on self-esteem. We are going full Andrea Dworkin. This whole section is really fucking weird. And I thought, I thought this was just going to be another thing where they're like, the kids are seeing porn now. And like, I'm also quite concerned with like younger kids stumbling upon porn on the internet with like no context

to understand it. Like, I think this is like a thing that people are anxious about that is like fair enough to be anxious about. But then it explicitly links this to more trans kids. So here's the next couple paragraphs. Several longitudinal studies have found that adolescent pornography consumption is associated with subsequent increased sexual, relational and body dissatisfaction. Research commentators recommend more investigation into consumption of online pornography and gender dysphoria is needed. Some researchers suggest that exploration with gender questioning youth should include consideration of their engagement with pornographic content.

What? First of all, I was going to ask what a research commentator is, but I think that would just be us. Yeah. Given color commentary. Some research Monday morning quarterbackers. Some fucking dickweeds with microphones. So this is basically just like kids are watching porn and kids are trans and so like we should look into it, but at the most basic level, there isn't even a fucking correlation

between kids who were exposed to pornography earlier are more likely to identify as trans. They don't even have a fucking correlation, and a correlation wouldn't prove shit. They don't even have that. It's just like, questions have been raised, and then it has a citation of some researchers suggest that we should look into this,

and it's just some random fucking article of like Yeah, this could be this could be a thing. That's not evidence of anything Yeah, this is like a far right like a Christian right talking point But it's like the porn is turning them trans because the Christian right wants to ban pornography There's no basis for this whatsoever, they're thinking about like whatsoever. They're thinking about like reactivating the fucking Comstock Act. Yeah. They want nothing to do with pornography. So if they can link together transphobia and anti-porn bullshit and they're like weird shit about sex workers,

great. Maybe this is too many examples but like I just can't get over how just openly right-wing of a document this is. Like, it's very openly just aping all of these conservative messages. So here is maybe the worst thing in the entire document. Which like, boy oh boy, that's saying something. Yeah, maybe not. I don't know. It's hard to have a favorite. It's hard to pick faves.

It's hard to have a favorite. I love all my transphobic, excerpt children equally. The role of psychological therapies in supporting children and young people with gender incongruence or distress has been overshadowed by an unhelpfully polarized debate around conversion practices. Terms such as affirmative and exploratory approaches have been weaponized to the extent that it is difficult to find any neutral terminology. This has given the impression that a young person can have either therapeutic interventions or a medical pathway.

The intent of psychological intervention is not to change the person's perception of who they are, but to work with them to explore their concerns and experiences and help alleviate their distress, regardless of whether they pursue a medical pathway or not. It is harmful to equate this approach to conversion therapy, as it may prevent young people from getting the emotional support they deserve. It is harmful to equate this approach to conversion therapy.

Why would you stick up for people who are trying to talk kids out of being trans? Don't compare this to what it's trying to do. It just so it just feels so transparent to me. The problem is parents being called transphobic. The problem is therapy being called conversion therapy. Sorry. Is transphobia a problem? Is conversion therapy a problem?

It also just feels like we are sort of in a moment with trans health care that feels like grids. Yeah, yeah, no kidding. Yeah, yeah, yeah, yeah. Inverts for folks who are unfamiliar. HIV and AIDS used to be referred to as grids, which stood for gay related immune deficiency syndrome. Yep. And the discourse followed because this is where the discourse was at fucking anyway to be like,

well, then the answer is don't be gay. Yeah. Yeah. It feels like we're in a similar place around trans healthcare where it's just like people, there's a incredibly high level of like just sort of ambient discomfort. Right. So anytime there's anything that is an excuse for people to like hit the ejector seat and get out of there and not have to think about it, people will take that, right? Exactly. And this is like, the CAS review is just like one ejector seat button after the next. All right. So now we are getting to the meat of the document. The ostensible purpose of the rest

of the report is assessing the evidence behind gender-affirming care. How much do we know about whether or not this helps kids, right? So essentially the CAS review process commissioned the University of York to carry out seven systematic reviews of existing evidence of various things. The ones that we are going to talk about are social transition, puberty blockers, and hormones. I personally find this a little bit weird because there's already been a ton of systematic reviews done, like the American Academy of Pediatrics did its own review, WPATH did its own review, and like there's not that much research on trans kids. Like one of the things that the sort of the trans skeptical side is correct about is that there isn't a huge body

of research, right? I was reading stuff about social media use and like depression and anxiety among teenagers the other day and there's so many studies that it's like you have to do meta analyses of the meta-analyses. It's like there's like dozens of studies. And so it helps to sort of gather everything together and try to come to some sort of consensus. But for youth transgender care, it is a relatively new field. And because the field was so careful for so long, I mean, some of these clinics

were seeing fewer than 10 kids a year. So we don't have, you know, 40 year longitudinal studies of 10,000 kids because they weren't doing this 40 years ago and they weren't doing studies of 10,000 kids because they weren't doing this 40 years ago, and they weren't doing it on 10,000 kids 40 years ago. So we're just not going to have that kind of data right now. But this is totally normal in medicine, right? That if we're trying to figure out if a treatment works, we don't start by giving it to 10,000

kids, and then we wait 20 years and we see what happened, right? We start basically with anecdotes, then we give it to 100 people and we wait like a year. You kind of zigzag your way toward a conclusion based on like larger and larger pieces of data. And so everything that's been going on in youth transition care is really just like that process happening. It started out with a very small number of kids. The early results were really promising in the Netherlands. And then clinics throughout the rest of the world were like, okay, let's try this. Let's go really slowly. Let's be really careful. This is what the Tavistock Clinic did too. And started gathering data, started seeing

kids. This is just like medicine. Like this is developing a body of medicine, right? There's nothing inherently like suspicious about this. I think the anti-trans movement is trying very hard to make this a debate about like, is gender affirming care for kids perfect? Does it quote-unquote work in every single case? They're trying to make that like the question that we answer, but the real question is, is this care promising enough that we should continue giving it to kids and continue scaling up appropriately? I think another core question is, all right, you'd like more data, that will take decades. What are all of the sort of trans kids and trans people

and their families supposed to do in the meantime? Right, right. Like we've got to be able to walk and chew gum on this stuff a little bit. It's very funny when like trans folks are like, we want large scale randomized controlled trials. It's like, oh, so we should just give it to 10,000 kids right now. Yeah. Because that's what you need to we want large scale randomized controlled trials. It's like, oh, so we should just give it to 10,000 kids right now.

Because that's what you need to have a large scale study. But like, you guys don't want that. The whole approach to me and the sort of tenor of discourse around this stuff just feels like hit the brakes on absolutely everything. Yeah, exactly. And like, there's no real sort of grappling with, yeah, this is like a big community of people

who need resources and need support now. So like, what's your actual theory of change here? What do you think needs to happen? And when you ask that question, the answer you get is, don't call it conversion therapy, but a description of conversion therapy. Again, sort of on its face, this seems like a completely legitimate process,

where for these evidence reviews, what they do is they're trying to stratify the studies according to quality. So this is something that you often see in meta-analyses. It's like you got like, you know, 1500 studies, you got to like put them into tranches and be like, well, these kind of suck. And so we can just like spend less time looking at them. These are medium, these are high. Let's sort of weight the high quality ones a little bit better. This is like a totally

normal process and there's all kinds of objective criteria that are supposed to be content neutral that you can use when you're determining, okay, is this high quality evidence, is this medium quality evidence or low quality, right? The thing that is weird about the approach that is taken for the CAS report is first of all, they constantly conflate the term quality with like the academic definition and the layperson definition So when me and you hear like this is a low quality study, we're like, oh that means it sucks Right? But in academia in the context of these meta-analyses, low quality means it's low certainty.

How much can we conclude from this study? This is the aspartame classification stuff. Exactly, yes. Everybody's like, it definitely gives you cancer, and you're like, no, they reclassified the strength of the evidence. Exactly, and the way that the report, and Cass herself, talk about the evidence is constantly using

the colloquial form. So in the report and in interviews, Cass herself has said that this field is based on remarkably weak evidence. But that's not what the reviews found. The reviews found that most of the studies on this are low certainty. They're promising, but again, because they're relatively small and relatively short, we can't state for certain that they will alleviate gender dysphoria in every single kid. The crucial pieces of context to that classification of low quality evidence is that first of all,

we know from the report that only 97 kids a year are getting hormones, right? Only around 150 are getting puberty blockers. Yeah, yeah, yeah, yeah, yeah. So this is not being like given out like candy on the basis of poor evidence, right? This is a field that's being extremely careful and is continuing to gather data. And the second piece of context is that vast swabs of medical care are given out on the basis of quote low quality evidence all the time.

Again, if you're in the process of figuring out the dimensions by which a treatment works and you know the treatment is safe, right? It's not going to kill you. You do sort of start giving it to more and more people on the basis of the evidence that you have. Most if not all medical treatments are some level of calculated risk, right? Even when you take an Advil, if you're taking ibuprofen, that's like hard on your kidneys. Yes.

And you're deciding I would rather not be in pain than worry about this being like a little bit hard on my kidneys. And different people will have to make different decisions around that thing. We don't think about those as having any amount of risk attached because we're so accustomed to them. But like, this is sort of the name of the game. Can I tell can I can I go on an ibuprofen tangent? Can I do an ibuprofen tangent? So I have been told to take ibuprofen by whack little skeleton because everything hurts all the time. And I did not know this, but apparently using ibuprofen over time, one of the kind of well-known side effects is nosebleeds.

You just like get nosebleeds. So I was on a date at a pho place. Oh no, Michael. And I was like chatting with this dude. And I look down and it's like raining like little drops of like chili oil into my fuh. And I had no idea. And he was like, ah, bleeding. And I just like had to like die for a bunch of napkins at this fuh place.

God damn it. I never saw him again and I never ate there again, even though it was nobody's fault but my own. So the first kind of category of this we're going to talk about is they summarize the data on social transition. So can you describe what social transition is, Aubrey? Yeah, social transition is any of the like sort of like non-medical parts of transition. So it would be for some folks, it'll mean changing your pronouns.

For some folks, it'll mean asking folks to. For some folks, it'll mean asking folks to call you by a different name, all of that kind of stuff. Yes, so here is how the CAS report summarizes it. Oh, I hate it. Wait, I get so much worse than this, all right? Social transition may not be thought of as an intervention or treatment

because it is not something that happens within health services. However, it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning. Which like, again, I would agree, but I would imagine that I would have a different inflection. Yeah. I mean, this is this weird anti-trans talking point that social transition is a medical intervention because it leads to medical interventions.

But social transition is like, I tell my parents that I'm a trans girl and I go to the Target and we get different clothes and I ask people to call me by she, her pronouns. That's not a permanent thing that's something you can reverse in literally minutes. The only you know the only barrier would be potentially getting a haircut would be the hardest thing but they're essentially casting it as like a medical intervention which it just straightforwardly is not. It's also

something that like parents and schools do and as they acknowledge here the NHS would not be involved in any way. You don't get your haircut at the doctor's? I get approval first. I have seven appointments before I get my haircut. That's why you have the fucking beard. You can't get into the doctor's. Okay, so here's the next, wait, let me give you the next two paragraphs.

There are different views on the benefits versus the harms of early social transition. Some consider that it may improve mental health and social and educational participation for children experiencing gender-related distress. Others consider that a child who might have desisted at puberty is more likely to have an altered trajectory culminating in medical intervention, which will have lifelong implications. The lifelong implications, from what we know about adult trans people, are positive, by the way. It's sort of like a little weird. It's like, lifelong implications. Well, all trans people say they're really happy with their care, so I don't know why we're talking about these grave lifelong implications.

Yeah. So these University of York systematic reviews go over the evidence for social transition, as if it's a medical intervention, right? Again, they're trying to stratify all of the research into low quality, moderate quality, or high quality. But after all of this quality analysis, somehow the highest quality study of social transition is a study that interviewed parents, but not trans kids. They also recruited parents from a clinic in Hamburg that does not take an affirming approach. It's like a watchful waiting clinic. It's weird.

It feels like the research equivalent of like voter suppression or something. Yeah, yeah, yeah. I'm like, oh, you created a system in which the most important voices are the ones that are most panicked. If your criteria leads you to this outcome, you have chosen the wrong criteria.

Right, this is, I mean listen, this is everything about like, a gay judge talking about marriage? We do this shit all the time where we act like people who have the most privilege, like people who have the most privilege have their identities sort of centered to the point of erasure,

that their identities don't strike them as identities, right? So they're so used to being at the center that we confuse that with like neutrality. Right. Or objectivity. There's only 11 studies of social transition of trans kids. So very small number of studies. They throw out nine of the studies and they're only left with two. And so this is the conclusion that they reach on the basis of those two.

The systematic review showed no clear evidence that social transition in childhood has any positive or negative mental health outcomes and relatively weak evidence for any effect in adolescence. However, those who had socially transitioned at an earlier age and or prior to being seen in a clinic were more likely to proceed to a medical pathway. So we can't say if it helps or not, but people who socially transition are more likely to

medically transition. It's just... Yeah. Again, that's probably a sign that they're trans, right? We have no evidence that, for example, they're more likely to proceed to a medical pathway and 98% of them detransitioned because they regret it and they were rushed through. No, it's just they proceeded to a medical pathway. There's no evidence that this was a bad outcome or these kids are unhappy at all. It's just that they transitioned.

The other thing about this social transition as a step in medical transition feels like a slip slide into this like ongoing medicalization of trans identities and experiences, right? This feels like further pathologization of transness, right? To be like social transition is actually also medical at a time when so many trans people are like, can you fucking not? Yeah. Can the door we walk through to get here not be a mental health diagnosis? How about that? Right? And this feels like it's like leaning hard in the other direction. They are trying to cast an easily reversible step as

irreversible. Yeah, yeah, yeah, yeah, yeah. The risks of checking it out. I was like, I'm gonna be a girl for a week. Okay, is there any physical harm of that? No, is there any emotional or mental harm of that? Potentially bigotry from other people, but the actual experience of that, there's no risk at all. And yet this document is casting this

as a medical intervention and saying that there's no evidence that it helps on the basis of we threw out nine of the 11 studies that have ever been done on this. I also think there's something to say for not hiding from the fact that within that framework, this is low quality research, right? We have not devoted the resources to this

that we have devoted to other research that people are more accustomed to hearing like cancer research or Alzheimer's research or whatever, right? Yeah. Again, this feels like another weird own goal that's happening here where they're like, the research is low quality. And I'm like, yeah, fuckos, that's because it's not been being

institutionally funded and supported in the ways that it needs to be to like get to the bottom of shit. Another very conspiratorial element of this is that you often hear these this kind of anti-trans brain trust say things like well I just think we should study it as if trans people themselves do not want to study What is the most effective care for trans people? Right as if like the dreaded Transactivists are like stop all the studies and give it to everybody like trans people very much want to know

What is the best pathway for people? What are the best dosages? What are the side effects? This really affects people's lives and they have a way higher stake in this than cis people do. So like if puberty blockers for example affect bone density, that's something trans people are extremely fucking interested in. So there's no reason any, there's no anyone anywhere in this field saying we should stop studying it. Yeah, I would go so far as to say not even that trans people have more of a stake in it than cis people, but trans people have a stake in it. Yeah, yeah.

And people who do not have a stake in it are the people who are sort of making themselves a weird human shield. Exactly. So that was social transition. This has been this has been previously on. So we're not going to talk about puberty blockers or the evidence for puberty blockers. Again, they do the same thing where they look at all of the research that has been conducted. They do this high, moderate and low quality analysis.

There are 50 studies on the effects of puberty blockers. They keep 26 of them, so they end up throwing out around half as low quality. There are not that many studies on the mental health aspects of this. So because puberty blockers have been around for cisgender kids for so long, there's lots of studies on like physiological things. On cisgender kids, there's not as many on the mental health effects of cisgender kids because that's not really like the thing that people are trying to do with cisgender kids They're just like I would just need to delay puberty So for transgender kids

There's only four studies that look at puberty blockers and their effect on mental health and like how how happy kids are with their Bodies like the kinds of things that we are looking at for transgender kids. There's only four studies of this This is from the University of York review and this covers what's called internalizing and externalizing symptoms, which isn't really something that people use colloquially, but internalizing symptoms is like depression, anxiety, and then externalizing symptoms are like aggression and like acting out. Gotcha. It says, three studies assessed internalizing and externalizing symptoms with one reporting

improvements in both, one improvement in internalizing but not externalizing symptoms, and one observed no change in either. A truly mixed bag. It then says, for other psychosocial outcomes, there was either a single study or two studies showing inconsistent results, with studies reporting either a small to moderate significant improvement or no change. I don't know if I'd call that inconsistent because it's either like they're improving or nothing.

I mean on some level that's inconsistent, but it's not like half of them said they got better and half of them said they got worse. It's a really weird way to hide the ball. Yeah, this- To be like, oh, things are either neutral or much better. There's not a lot of studies. I think that's by far the greatest weakness in this field. There just aren't that many studies on like, are kids doing better after they take puberty blockers?

But from what we do know, it appears that like they either do the same or they do better. Any like good faith summary of that would be like, yeah, it's promising enough that we should probably keep giving this to kids, right? We don't have an increase in any of these negative symptoms. I don't know, Mike. I don't trust anything that improves children's mental health. It's also funny with puberty blockers, too, because the evidence on puberty blockers is not as strong as it is on hormones. But some of that is mostly just because puberty blockers don't actually

do anything. There's some studies that are like, kids are just as gender dysphoric after taking puberty blockers as before. And it's like, well yeah, their bodies didn't change. The whole point is that you don't feel comfortable with your body and puberty blockers pause your development but they don't change it. So the review also uses that as kind of an excuse

to be like, oh, well they don't even have that much of an effect. It's like, the point was never that they would have an effect on gender dysphoria. The point was that they would buy you time so that you can really think about whether you want to stay in this identity and then go through with something more irreversible. So it's it's again like holding them to this kind of weird standard. And even by this standard, they are actually showing improvements in mental health markers.

Yeah. The point of puberty blockers is to avoid a wrong gender puberty. Yeah. The point is not to alleviate dysphoria. The point is to avoid making dysphoria worse. So this gets worse when we get to hormones. So hormones are like a bigger deal. It's like a more irreversible intervention. But again, we only have five studies that look at the mental health effects of trans kids taking hormones

Gotcha. There's the University of York makes a table where they break out every single result so they stratify by like depression What did the study say anxiety? What did the study say? And so I am going to send you the list of bullet points since there's only five studies It's quite easy to just read all of the mental health effects that the drugs had. So I'm going to send you a list of this. There's going to be more than five bullets in this list because a lot of the studies measure many different things, but we're only talking about the results of five studies here. Suicidality scores decreased. Increase in well-being. Lower levels of dissatisfaction with body image. Depressive symptoms were lower.

Decreased levels of anxiety. No evidence for difference between groups in suicidality. Prevalence of recent depression, lower. Treated participants less likely to have seriously considered suicide or attempted suicide. Need for treatment for depression decreased at follow-up. Need for treatment for depression decreased at follow up, need for treatment for anxiety decreased, need for treatment for self harm and suicidality decreased, no change in need for treatment for all outcomes,

improvement in gender dysphoria score, decrease in depression, anxiety decreased over time. So listeners at home, are you are you pulling out any themes? Sounds pretty dangerous. We have tons of decreases in anxiety, tons of decreases in suicidality, tons of decreases in depression, and a couple of findings that are like, we didn't really see a big effect. There's like shit we do all the time that does not have effects this uniformly like

neutral to positive. So here is how Dr. Hillary Cass or whoever wrote this report summarizes these findings. As expected, hormone treatment induced puberty in the desired gender. Inconsistent results were found for height slash growth, bone health and cardio metabolic health evidence relating to gender dysphoria, body dissatisfaction, psychosocial and cognitive outcomes was insufficient to draw clear conclusions. Insufficient. That's all they say.

Again, fucking ask a trans person. That's what the studies did and they're fucking ignoring it. Wait, but then then this is, this is the one that fucking killed me. Arbor, here's the next paragraph. Now I'm the one who's flagging, this sucks. There were inconsistencies regarding suicidality and or self-harm with three of four studies reporting an improvement and one no change.

Three studies found kids are less suicidal. One study found nothing. Who could possibly say what effect this has on suicidality? Come the fuck on. So it's like if you had a pill that it was like, oh yeah, three studies that it made you taller. One study said it did nothing. Oh, we can't say anything about whether it makes you taller or shorter.

Yeah, totally. I know someone recently who started antidepressants for the first time and they were like, I don't know if I'm going to keep taking these. I don't feel any different. And I was like, well, do you get feedback from people in your life? And this person was like, Oh, my partner says they've never been more in love with me and my friends are all super happy about it. And I was like, so there's a pill that you can take where you feel no different,

but people in your life love and appreciate you more? That's like my beard. My face itches. But all of my grinder messages end with sir now. You hate it, but it's fucking hot. So we could easily spend like three fucking hours talking about the specific studies and the follow-ups and more of this criteria stuff. But it's like any sort of zoomed out good faith look at the evidence around this issue

finds like yes, methodological issues, none of these studies are perfect, you can nitpick about any single study you want to, but overall we find nearly unanimous benefits to gender affirming care for kids. To the extent that we don't find that, we typically find no change. We don't find harms in any of these studies, right? And I think it would be one thing if we, you know, these studies might find kind of short-term benefits, but then we do find, you know, five years down the line, we find regret rates of, you know, 50, 70 percent. Like, people are falling off of these drugs as they become adults in droves, but we don't see that either. We see study after study after study with regret rates, even with like three year follow ups of less than 5%,

which is not typical of like the medical system. Usually regret rates are much higher than that for various routine procedures. So sorry, on what basis are we saying that there's weak evidence for this care and fucking banning it by law and sending doctors to jail for providing it. I love it that you say we could talk about this for three hours after we have recorded for I'm going to say 12 hours on this topic.

I'm going to limit myself. You're like, look, man, we can go on. I'm not going to spend two entire months of my podcast producing words about this report. So another thing that's missing from this report is any good faith overview of the alternatives to gender-affirming care. One of the things the CAS report refuses to engage with is the fact that kids going through puberty if they already have gender dysphoria is extremely upsetting. And that's also irreversible. And so either way, a kid is going to go through something irreversible. That the option of them not going through anything irreversible is not

on the table. So you basically need to decide you have a binary choice of like, do they go through one puberty or the other? And the all of the data on conversion practices, we're not even going to get into it because it's so fucking dire. The approach that this document proposes and that the NHS, it appears, is now going to be built around is basically giving them therapy. Not necessarily like gender therapy, but like kind of classic, my kid is struggling type of therapy, like things like CBT, right? Or like maybe you put them on antidepressants or maybe you deal with their anxieties. Basically, you're acting as if the trans identity is an output of these other mental illnesses and so you're

treating those mental illnesses directly. So the Cass review also commissioned a University of York systematic review of psychotherapeutic interventions for trans kids. And our friend, the health nerd, Gideon Meyerwitz-Katz, he has been doing this, like, accidental deep dive into the CAS report. He's an epidemiologist. It was supposed to be one article, and then it became a series of three articles, and now it's up to seven. Like so many other people who look into this, you're like, wait a minute, I can't fucking believe what they're doing here. The first thing that he noticed was that they're using a totally different standard of quality than they use in all of the other reviews. The one that they're using in the other reviews is called the Newcastle Ottawa Scale. And then without saying why, they switched to something called the mixed methods appraisal

tool when it comes to therapy interventions. I don't think there's a clear view of which standard is better, but it's really fucking weird to say that, oh, we have these very high standards of quality. We have this objective marker of whether these are high or low quality studies. Then as soon as we get to therapy, as soon as we get to something that doesn't include puberty blockers and hormones, they're like, oh yeah, we're using a different standard. They don't say why. Under the quality rubric that they are using, these are the studies that they have considered high enough quality to be included in the analysis. Gideon lists them out. I'm not going to read all of them out, I'm not gonna read all of them,

but I'm gonna read the first one. One of them is a case study of attachment-based therapy on a single transgender teen. Astonishingly, this was the study considered to be the highest quality of the research that you've ever done. Are you fucking kidding me? A fucking case study.

A literal N of one? I'm gonna flip a fucking table, Mike. But then they also include a study of eight trans teens that looks at whether having a therapist affirm their identity helps them. There's a study of 41 trans teens who take an online mindfulness training. There's a study of two children who downloaded headspace on their parents' phone. And also the one larger study that they include is a study of 201 adolescents that followed them over one year, and it compares trans kids who got therapy to trans kids who got therapy and puberty blockers. And it says, well, the kids who got therapy were doing

better a year later, so therapy works. But Gideon points out the kids who got therapy were doing better a year later, so therapy works. But Gideon points out, the kids who got therapy and puberty blockers were doing even better than that. Sorry, is this a high quality study or not? If we're trusting this study, then we should be giving them therapy and puberty blockers, not just therapy. You're going full internet. Make it make sense.

Not you using the mixed method analysis tool. The math isn't mathing. And so here is an excerpt from Gideon's latest post on this. These findings are, in a word, mixed. Most of these papers are undeniably low quality. And as with the low quality literature for other aspects of health care for trans teens, don't really add much to the literature. In addition, the results were pretty contradictory. While some of these psychological interventions found that trans teens reported better mental

health, some of the studies showed the opposite effect. One trial of traditional psychological care for trans youth found that it might make depression worse. In addition, this review found no data whatsoever looking at interventions aimed at improving gender dysphoria, the entire point of the document. The majority of the studies looked at traditional psychological therapy in a subgroup of transgender children. We already know that CBT is useful for depression.

All this review shows is that traditional psychological therapies may not be effective for transgender teens, which also casts doubt on one of the speculative arguments of the CAS review that bad mental health turns children trans. At best, we could say that psychological interventions could theoretically have benefits for trans teens, but that they seem less effective than medical assistance. In addition, the data is so weak that there's very little you can reasonably say about them at all. The reason I wanted to zoom in on this is that if you're someone who engages with the things that these kind of allegedly I'm not transphobic but transphobic people say is the thuddingly obvious double standards. Right? When it comes to any study

that affirms that puberty blockers and hormones work for kids, they're like, well, you know, the dropout rate was like 7%. And you know, the questionnaire studies, they didn't use the right scale to measure gender dysphoria. And like, they pretend to have these extremely exacting scientific standards about the methodology, right? And they will nitpick you to death. But when it comes to anything that goes against the consensus that gender affirming care works, they're like, oh, yeah, bring in a study with like a 50% dropout rate. Bring in a study that interviews fucking parents about the subjective experience of their kids. Bring in a study where the fucking conclusions of

the study are in the consent form. They don't give a shit. Yeah, and to have someone look at this and be like what the fuck are they doing over there? Yeah, totally totally. It's like so cathartic. This section is called Mike feels validated. Yeah It's like yeah, because I feel like I'm screaming into the void Because it's so hard to get people to engage with this stuff on the merits. Yeah, this is bad work This is shoddy work and it's really obvious how motivated it is and it's really obvious what it is motivated by, right? What they're trying to do is throw out any evidence that shows that this care helps children and they're trying to validate these other approaches that are just not related to the issue at hand.

We're at the point now where, like, it's just time to close this debate. What? Oh no, I downloaded an air horn app. It doesn't sound like an air horn. It's like a foghorn, yeah. It's like not good. Wait, hang on, let me do a different one.

I'll get a different one. Wait, say your closing line again. Until we get some real evidence, it's time to close the debate. What was that? That's a cheering. I can barely even hear that. Yeah, he's right. That's what the people are. I mean, I could have done this.

Oh, no, that's worse. Eventually, I won't even need you, Aubrey. Eventually. Look, you have the app on your phone. That's true. I can just... It does most of what I do. I have some bad news, Aubrey.

I will no longer be needed. Oh, I'm being replaced by AI. Hahaha! Thanks for watching!