Thank you for this. I read the entire Yale report a couple of months ago. As a trained researcher (Ph.D. Vanderbilt, Clinical Psychology; Professor of Psychology for 30 years), I was appalled.
A major theme I read was that we should accept low-quality research because there isn't high-quality research.
Be interested to see if Jesse has the same impression. Can't wait for part 2.
Of one thing we can be sure, and it’s that trans activists and their allies will fight hammer and tongs to block the production of high quality evidence and, if such evidence should ever emerge, they will fight tirelessly to discredit it and the researchers.
HI...perhaps you can answer this for me......For research to be "high-quality", Must you have randomized tests of patients? I have been trying to understand the difference between low-quality and high quality research.
I ask because trans activist Erin Reed wrote the following:
"Sapir and other far-right news outlets claimed that the ASPS had “broken consensus with other major medical organizations on transgender care” by stating that evidence surrounding gender-affirming surgeries for transgender youth is “low quality.” This term, used in a technical context, refers to the lack of blinded clinical trials or other intensive forms of study that may not be feasible, rather than the colloquial meaning of "poor quality." "
So first of all, you can be better than low quality with either moderate or high quality evidence.
You do not need a clinical trial to be blinded to get high or moderate quality evidence. Blinded is nice but of course you aren't going to do that for these interventions which have observable physical effects. So asking for blinded would not make sense. That is a straw man that keeps being brought up. They keep saying these studies, which are not being called for, can't be done. Ok, do the studies that can be done! Or, I know, show us the outcomes for all the things Chen et al 2023 said it would measure, how about that? How about for longer than 2 years?
It is true that tandomized controlled helps, as people might change over time absent intervention. So picking people randomly for medical intervention vs say psychological support would be more informative then letting people pick which of the two they get and then following them, as their choices for treatment might depend on things which are relevant for how they do with a given intervention.
Relevant also for controlled studies--for gender dysphoria no one knows the "natural history" for adolescents, i.e. whether they will most likely outgrow it (and what that depends upon in the person). For childhood onset they most likely outgrow it without social or medical transition, or used to...
So you don't know what will happen if you intervene, or if you don't. The evidence is inadequate.
"Relevant also for controlled studies--for gender dysphoria no one knows the "natural history" for adolescents, i.e. whether they will most likely outgrow it (and what that depends upon in the person). For childhood onset they most likely outgrow it without social or medical transition, or used to..."
I thought it was the reverse for who would outgrow it - that childhood onset was more likely to persist and adolescent onset was more likely to be transient.
Maybe it's - "childhood onset that persists to adolescence" vs "adolescent onset"
Actually, A.D., you are correct on every score in what you are saying. I was trained in the early 70s that there is a group of individuals, mostly boys who knew from day one that they were girls. Nobody reasonable doubts that. Most did not outgrow it. And they were psychologically healthy.
But that's not the case any longer. Most cases are adolescent onset, girls, and kids with multiple psychiatric problems.
So, your last sentence fits with the research and with my training 50 years ago.
Hey thanks for the sources. I only had time to read one of them, and are heading out for the day.
Which one of the sources did you get your data about 80% from. I want to be sure to read that one first. I'll get to all of them later in the day or tomorrow. Thanks again.
Some of those studies I might be inclined to be skeptical of as either being too recent (if there's been a social push to question might that push numbers higher) or too far back (if there was a lot of stigma with being trans, might that push things too far the other way)
(And another one is about "effeminate behavior" not "dysphoria".)
At least based on the dates there, this one:
Wallien, M. S. C., & Cohen-Kettenis, P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413–1423.
Lists:
trans-21/54
cis-33/54
(It does not further break down gay/lesbian)
That's got a higher percentage, but still < 50%
I have not read that paper, it stood out to me both as a good year(late enough for gay rights early enough before the recent rise), the highest percentage, and definitely (based on the title) about dysphoria.
If I am understanding your question correctly, let me try to give my views on this.
The Gold standard is double blind completely randomized studies. Those are probably impossible in this area. But that does not mean that studies that are, essentially, correlational (which many many in the area are) simply get elevated to being high quality, and conclusive statements are made about their correlational findings. No. That's inappropriate in social science.
We also don't know how many followup, correlational studies from these clinics are NOT reported because they don't support the views of the clinic.
I have also seen studies that seem, very clearly, to rely on "p-hacking" to get their results. In other words, they vary the internal structure of their study to get significant results. This kind of thing results in totally erroneous statistical conclusions. Those are low quality.
There are other markers of low quality in this area. Often, in the studies I have read, there is no indication of whether all of the youth who had, for example, transitioned from the particular clinic were followed. How representative are the samples studied of the people who were treated at a particular clinic. When that is the case, how do you "mark" those who drop out? Is there a bias or lack of bias in the people who are followed?
Most of the studies seem to be from gender clinics (I'm sure there are exceptions). Cass, for example, had no investment in the findings of her review.
I remember that in the "Dutch Protocol", the seminal study of gender care, the beginning N was 70 and the ending N was 55.
So it lost a bit over 20% of participants but I don't think the study can say why. (Actually, 1 of the 55 persons died from an infection from vaginoplasty since I believe they had been on puberty blockers and had a micro-penis so insufficient flesh to work with so rectal tissue was used, I believe.)
I think the 1 who died was one of the 15 lost between going from 70 to 55. They checked the 55 1 year after surgery and that poor kid passed away soon after surgery, so...."lost to follow-up".
Thanks for all this detail Jesse. Meanwhile, here is drama I covered about Cass Review and its detractors:
Cass Review Author Denounces As 'Baseless' And 'Cynical' Dissidents' Claim That She Touted Abigail Shrier's Scathing Polemic On Trans Kids
Two dissidents opposed to Britain's designs for reforming its care of gender-distressed kids claimed this week that Dr. Hilary Cass once "recommended strongly" Irreversible Damage by Abigail Shrier.
It's interesting how often putting how you would *like* to be seen (as having integrity in this case) really signals the opposite. And so, the Democratic People's Republic of Korea is neither democratic, nor a people's republic.
My first question (as a retired lawyer) is why this report was issued under the auspices of the Law School rather than the Yale Medical School. That fact alone imbues the report with a patina of politization and makes it suspect from the jump.
I think this type of institute is actually to provide public argumentation for or against certain positions. Lawyers are quite well positioned to provide reasonable sounding arguments, especially when it doesn't have to be 2 way.
I think the point is an important one that there is more than a financial conflict of interest when providers of youth gender medicine weigh in as experts on the topic, but I think that this sentence from Jesse's article under sells it: "I want to be clear that the argument here is a bit more nuanced than a straightforward financial conflict of interest. It’s also that if you’re a clinician delivering this care, you’re probably doing so because you think it works."
If you have been prescribing puberty blockers, cross-sex hormones, and mastectomies to minors, and such practices turn out to be unsupported by evidence, that means you have been doing terrible things to kids. It would be a truth that would be very difficult to countenance.
This feedback was a breath of fresh air, and decisively hit the nail on the head. I do wonder what the reckoning will be once this incredibly painful and harmful moment of gender insanity passes.
When does behavior cross from "spreading misinformation" to being "lies?" I'm really tired of seeing people lie and when they are called out on their lies, those who stand up to them using safe words like "spreading misinformation." call a lie a lie. The word misinformation is being used too much.
Agreed—misinformation allows people who are often knowingly misleading people (i.e., lying) to use word salads to slither out when they’re called in it.
Signal is always delicate in his wording, in the way Jane Austen used the word “delicate” as a term of praise—sensitively diplomatic and charitable about disagreements. So he critiques the Cass CEG for not revealing the names of their contributing experts. I suspect, though, that no one would have wanted to be part of the CEG without anonymity. The ideologues have made it downright dangerous, professionally and personally, to go on record objecting to “gender affirmative care.” Anyone participating in Cass’s work knew from the start what the Jack Turbans and Meredithe McNamaras were going to do. Anonymity was essential for honest work.
Great article. One thing caught my eye near the very end, though: "I asked ChatGPT to graph the real dataset..."
(a) Why? If you already had the data in the sheet, it's trivial to just select it and hit Insert > Chart.
(b) I would recommend leaving this kind of detail out in the future. It's no more relevant to the end product than which editor or spell checker you use while writing, and it gives critics a ready-made point to latch on to try to shrug off the rest of the article as 'just an AI hallucination'.
Actually, it does make me genuinely question the validity of the graph. ChatGPT should not be used at all to make this kind of graph, except maybe to write code to render it. At no point should you put actual data directly through gpt
Well, you can create a chart from the spreadsheet data as I described above, and it does match up with the one pictured in the article. It just seems like a bizarre use case for something that you can do natively in Google Sheets in three clicks – using ChatGPT probably took *more* effort.
Came here to say exactly this. Well said, and thanks! As a numbers guy whose job was supposed to have been taken by robots already I can say that even the best LLMs are completely unreliable about basic things pretty often. Reading "I asked ChatGPT," in an article is even more suspicious to me than seeing a Wikipedia citation.
"Invalid professional viewpoint" is a remarkable series of words.
I haven't seen that in the engineering/physics space. I'm not going to strut about "well this is because we can actually quantify/prove our XYZ", but you gotta wonder.
"It is genuinely surprising that any of the co-authors would agree to put their names on a document like this."
I can only conclude that they assumed no one would actually read it, just quote it approvingly in headlines and tweets. Explains their approach in "responding" to the Cass report (apparently without having read it) - "No one actually *reads* these papers, do they? Let's just roll with what we saw about it in the tweets and headlines." It seems to come down to clout-chasing, depressingly.
I prefer the Hanlon's Razor approach. When people read opposing arguments against a position that they hold dear, their reading comprehension often goes out the window as they look for some nugget to attack. This can happen with otherwise very astute people.
Brilliant stuff Jesse, this is the gold I subscribe for! I have realised that I am now vastly better informed about the state of transgender medicine in the UK and USA than in my own country (Australia). My suspicion is that we're somewhere between the pre-Cass UK and US approaches.
"The paper’s lead author, Meredithe McNamara, is an adolescent physician at Yale Medical School"
Is "adolescent physician" the way this is usually phrased? It reads like we've got a Doogie Howser M.D. situation. Pediatrician focusing on adolescents seems too wordy, though.
I also highly recommend Reed for that sort of "enjoyment"
I was just reading one of her first blog posts about Cass Report and aside from the usual blatant misrepresentation, one thing leapt out to me: she's weirdly honest and explicit with respect to the wacky principles and messed conceptions of evidence that guide her evaluation. She thinks that systematic reviews should be judged by whether they conform with the statements from professional/lobbying orgs instead of the other way around. She writes:
"It is important to note that the Cass Review contains very little new data and evidence. Any statements it makes are based on the same level of evidence that every major medical organization in the United States, along with some of the largest mental health societies in the world and professional associations of transgender health, have determined to support transgender care. If its claims differ from those institutions, it’s because reviewers made choices to view the evidence around transgender care negatively."
Usually when confronted w/ systematic reviews critical of affirmative care, TRAs deflect and accuse you of transphobia. I suspect they know that deferring to orgs who haven't shown their work over SRs that do show their work isn't defensible and might be embarrassed to be caught explicitly doing that. But Reed has no shame. She's close to proposing a new evidence pyramid that puts unsubstantiated claims from lobbying groups at the top.
“In this report, we cite studies that are peer-reviewed, up to date, conducted by respected investigators, and published in high-impact journals that are widely read. This represents the highest-quality evidence available to physicians making treatment decisions in this context.”
In other words, they appear to want one to use use eminence (the bottom of the evidence pyramid)....not systematic reviews (the top). The are saying to pay attention to **who** is saying it, not what they are saying. (Hence the extreme focus on ad hominem attacks as well, in this approach.)
The latter, systematic reviews, would involve actually looking at the studies and trying to take out biases and stuff like that....can't have that! It is a particularly interesting view if it is said by someone at a high status institution....could be read as "don't look at the evidence, just listen to me"...if one were cynical...
Adolescent medicine is a specialty just like internal medicine or endocrinology. Typically using this descriptor means the person completed an adolescent medicine fellowship as part of their training.
They do. After much study I’ve concluded that one of the main divisions is belief in gender ideology. (And that’s a whole other rabbit hole.) My guess is that these Yale people have drunk the kool-aid on this non-falsifiable belief system, and to the extent they know they’re lying, they pat themselves on the back for telling noble lies. They have a unique truth to spread, just like evangelicals, Maoists, and QAnon shite-posters. I don’t know when it subsides. There’s too much private foundation and lobbying money operating outside of the democratic process. It’s in every school, public and private, cloaked under ‘anti-bullying’. (Who could argue with that? Just try…) It will end, eventually, but it will burn a lot of people and institutions before it is done. Bright side: Jesse will sell a lot of books?
My doctors’ health care organizations now record my “sex assigned at birth” and my gender identity. I’ve challenged them on this by taking the position the information is incorrect. My sex was determined biologically at conception and observed at birth. I have no gender identity. I do not identify as a man; I am a man.
They show no interest in having a discussion that could lead to the outcome I seek.
When the ideology has penetrated this deeply, how can it be defeated?
What concerns me most is the inability of McNamara et al. to understand the concept of holistic and comprehensive care that Cass emphasizes throughout her review. It seems that they really do not understand these concepts because medicine for them - and possibly in the United States in general - is all about treating the immediate symptom. "You are suffering from pain? There, it's gone now. You think that this has resulted in internal bleeding? That is not what you were here for. For that, you have to meet some other specialist." Cass understands that medicine is an inexact discipline where much is unknown (she starts the Review with a wonderful quote by Atul Gawande to emphasize this very point). In an interview with the BBC, a few days after the publication of the Cass Review, she mentioned: “I certainly wouldn't want to embark on a treatment where somebody couldn't tell me with any accuracy what percentage chance there was of it being successful, and what the possibilities were of harms or side effects." The systematic reviews (as well as the individual studies that McNamara and friends tout) show some weak evidence of short-term benefits at best. Often, we don't even get that. And that these minuscule benefits happen to be psychosocial is extremely relevant, because strong placebo responses in psychiatry have been noted for many decades now (Weimer et al., 2015). Even in double-blind clinical trials of treatments for pain or psychiatric disorders, the responses to placebo are often similar to the responses to active treatment (Colloca and Barsky, 2020). Such findings raise the possibility that these interventions might actually be causing harm. Next, we have no idea from these studies - whether individually or collectively - who exactly might benefit from them (there is no way to state, for example, that patients who show certain outcomes in an ECG test or tolerate a certain class of drugs and do not have a history of diabetes will probably be the best candidates for the interventions). And because these treatments have been repurposed for gender-affirming purposes in the last "8-10 years" (as per McNamara et al., p.16), we have very limited idea about the possible complications. Even with the pain medication oxycodone hydrochloride (known as OxyContin and approved by the FDA) at the heart of the opioid crisis and responsible for thousands of deaths ever year, it took many years before the extent of the harm became apparent to the general public – and that is for a drug that was prescribed to large swathes of the population. For drugs that are prescribed to smaller segments of the population, it can take much longer before their safety risks are established. Risks usually manifest many years after the intervention becomes routinely available. Serious adverse effects are rare and often go undetected during early evaluation (if they appeared in early experience, they would likely cause the developer to abandon the project) of the treatment in animals or volunteers. They may not appear in formal clinical trials, which are powered to detect a predicted treatment effect – and not rarer events that may be much smaller than the treatment effect. Detecting them require active post-marketing surveillance of many more patients than were enrolled in trials or the passive accumulation of case series or individual case reports. Since these observations are uncontrolled, it requires considerable knowledge of the background incidence of these effects in untreated people to determine if the occurrence in treated patients is greater than expected. None of the infrastructure to track such observations is remotely in place. And yet these people - with enormous conflicts of interest - are continuing to recommend these treatments on children and young adults. And these interventions happen to be off-label and on *minors* – whose bodies and brains are at their most vulnerable to any intervention – with lifelong consequences. What part of this basic narrative do these people not understand?
Here's something that caught my eye, from McNamara, et al.:
--Further, 32% of respondents strongly agreed or agreed with the statement “There is no such thing as a trans child.” Denying the existence of transgender people of any age is an invalid professional viewpoint.--
The implication seems to be that the only way to have an informed opinion on the topic is if you already share the views of McNamara, et al. That's like me saying "If these polls weeded out all of the pro-Trump respondents--he's just an iillegitimate candidate, after all--Harris would be leading by 100 points!"
Excellent piece, while it would be easy to drip with contempt it’s remarkably focused on the facts of the matter, and I appreciate the very dry sense of humor about peeples [sic] who can’t spell.
What’s really fascinating is that the framing of this “debate” is so powerful that there are fixed points that recur in discussion which are literally impossible to eliminate and will never resolve which I saw clearly spelled out.
It’s like stomach ulcers.
For all decades leading up to the early 80’s stomach ulcers were considered a physiological manifestation of stress - “stress ulcers”. Treatment focused on how to manage, reduce or eliminate stress. Then in the early 80’s Australian doctors Barry Marshall and Robin Warren discovered that most peptic ulcers were actually caused by the bacterium Helicobacter pylori.
You could think of it as the “ulcers cause stress” and not “stress causes ulcers” change.
Imagine with a pediatrician starting with a remarkable position that by a common variation on the definition of trans - a person’s body doesn’t match their perception of their sex - all children (100%) are trans by definition. The condition of anxiety, unhappiness, disquiet that accompanies their trans/formation from a sexless child into sexualized adults is so common as to be unremarkable. New lumps, hair, (acne and fat) along with angst and moodiness are the default condition of puberty. What happens then when you reframe the debate:
Are there any children who do not have a range of anxieties and unhappinesses when they transition into adults? Can you ever find a child with zero dysphoria at the onset of puberty?
What then do you study? Why is Cass therefore entirely unremarkable? What interest do we afford charlatans who cannot see what is in front of their eyes? Why is the concept that 95% (I will say 100%) of such unhappiness conditions evaporate after full trans/ition to adulthood unremarkable? Adulthood is not all unicorns and rainbows. I suspect a large number of people are “dysphoric” as adults and will always be because for the most part, childhood is Eden, carefree and sexless. That’s the remaining 5% of children who do not have “adulthood blockers”.
Until we stop taking about the fiction of gender, this will circle the drain forever
I had no body dysphoria at the onset of my male puberty in 1967. And while most people say they detested middle school, I was very happy in what was then called junior high. I was also gay, but I always knew I would deal with it at the appropriate time, and I did. ( I do hate society for having robbed me of the sex and romance that my straight peers took for granted during their teens. )
I was relatively happy in Jr High, and High School. At puberty I grew into looking like a linebacker with massive hairy legs for marching with a marimba, and now everyone's friend for carrying booze and joints in crevices of the massive marimba for the other band members, as well as racy books to read while bored with the field machinations was entertaining in the fall and winter, and abandoning Honor Society and other storied institutions on field trips to have underage sex with older men in sleazy joints was a strange poetic justice in the spring. Ahh, sweet gay youth!
Compared to adulthood? Children don't work, don't take care of beings totally dependent on them, and don't face death in the face, generally. That's the fantasy eden of pre-adulthood
I have to say that it’s a simple fact the concept of childhood is not defined by trauma in any world culture, it is defined by innocence. The concept of childhood trauma is so staggeringly overblown it’s on par with trans violence. I’ve seen studies that 25% 50% up to 75% or more children have experienced “trauma”. It’s a bullshit call for sympathy for organizations which serve traumatized children. I had a rank alcoholic father an a bipolar mother, was bullied in school, yet strangely I found childhood not defined by incidents, but by wonder, nature, friends, music, teachers I loved and family who looked after me.
Yes; there are children abused Id be silly to say that it wasn’t true. But not 75% of children are traumatized, not 50%, not 25%. Being frightened, getting in a fight, a natural disaster, serious illness - these are events which don’t define childhood for the vast majority of children. Going through a single event is not a traumatic childhood. It’s a normal childhood. It’s forgotten as an exception.
Except for annoying helicopter parents and overexposure to Internetworking, children today - worldwide - have the most amazing chance of an idyllic childhood in the history of mankind. Illness, poverty, war, famine - simply don’t exist anywhere near the scale of when even wartime childnood in London, bombs dropping during the Blitz, children still found life magic.
That depends on the childhood in question. When discussing severely dysphoric children—regardless of one's opinion on the appropriate diagnosis and treatment—their experience is hardly idyllic. I agree with your main point that, in general, puberty is often more traumatic than childhood and can even be more challenging than adulthood. Much of this is attributable to the lack of experience in managing such challenges to our identity.
Here's the key issue: while adults face more responsibilities, complexities, burdens, opportunities, and potential for things to go wrong, they also possess more resources, experience, independence, and relationships to help them navigate life. In contrast, children encounter fewer sources of trauma but have significantly less opportunity and capability to exercise agency.
Well I feel peculiar reading this because I see "except for exceptions". There are children who have more traumatic than average. Any general statement is true "except for exceptions". I stand by my statement.
I think my opinion is probably skewed because of 12 years as a social worker in Oakland and then 2+ decades teaching public school. There are quite young children who are sexually exploited, forced to witness domestic violence, neglected by drug- and alcohol-addled adults…
We don’t have Dickens-like workhouses for six-year olds in this country, and minors are no longer subject to capital punishment, but the conditions of childhood can still be pretty nightmarish. And it feels sometimes like our institutions are half-hearted in their safeguarding efforts.
It's peculiar but the existence of such children is sad in part precisely because we expect childhood to be a trouble-free eden; the contract between expectation and what happens to some is jarring and troublesome.
Re your opening statement, yes, this sort of research is incredibly time and energy intensive and few do it for that reason, but it's hugely needed. I don't have anyone to gift a subscription to but is there a way to just kick in a few bucks to you as a thank you?
Send me an email with how much worth of gift subs you want to donate, and then I'll tweet that the first X people who respond get one? No pressure but that might be one way to do it -- I'd prefer that over just taking money.
Thank you for this. I read the entire Yale report a couple of months ago. As a trained researcher (Ph.D. Vanderbilt, Clinical Psychology; Professor of Psychology for 30 years), I was appalled.
A major theme I read was that we should accept low-quality research because there isn't high-quality research.
Be interested to see if Jesse has the same impression. Can't wait for part 2.
Of one thing we can be sure, and it’s that trans activists and their allies will fight hammer and tongs to block the production of high quality evidence and, if such evidence should ever emerge, they will fight tirelessly to discredit it and the researchers.
HI...perhaps you can answer this for me......For research to be "high-quality", Must you have randomized tests of patients? I have been trying to understand the difference between low-quality and high quality research.
I ask because trans activist Erin Reed wrote the following:
"Sapir and other far-right news outlets claimed that the ASPS had “broken consensus with other major medical organizations on transgender care” by stating that evidence surrounding gender-affirming surgeries for transgender youth is “low quality.” This term, used in a technical context, refers to the lack of blinded clinical trials or other intensive forms of study that may not be feasible, rather than the colloquial meaning of "poor quality." "
https://www.erininthemorning.com/p/fact-check-asps-did-not-break-consensus
This is a red herring.
There are 4 levels of grade and you can move between them based upon how the study is done (e.g. indirectness, or strong dose-response effect). There is a handy chart here: https://www.jclinepi.com/article/S0895-4356(10)00332-X/fulltext table 3.
So first of all, you can be better than low quality with either moderate or high quality evidence.
You do not need a clinical trial to be blinded to get high or moderate quality evidence. Blinded is nice but of course you aren't going to do that for these interventions which have observable physical effects. So asking for blinded would not make sense. That is a straw man that keeps being brought up. They keep saying these studies, which are not being called for, can't be done. Ok, do the studies that can be done! Or, I know, show us the outcomes for all the things Chen et al 2023 said it would measure, how about that? How about for longer than 2 years?
It is true that tandomized controlled helps, as people might change over time absent intervention. So picking people randomly for medical intervention vs say psychological support would be more informative then letting people pick which of the two they get and then following them, as their choices for treatment might depend on things which are relevant for how they do with a given intervention.
Relevant also for controlled studies--for gender dysphoria no one knows the "natural history" for adolescents, i.e. whether they will most likely outgrow it (and what that depends upon in the person). For childhood onset they most likely outgrow it without social or medical transition, or used to...
So you don't know what will happen if you intervene, or if you don't. The evidence is inadequate.
Thank you...
"Relevant also for controlled studies--for gender dysphoria no one knows the "natural history" for adolescents, i.e. whether they will most likely outgrow it (and what that depends upon in the person). For childhood onset they most likely outgrow it without social or medical transition, or used to..."
I thought it was the reverse for who would outgrow it - that childhood onset was more likely to persist and adolescent onset was more likely to be transient.
Maybe it's - "childhood onset that persists to adolescence" vs "adolescent onset"
Actually, A.D., you are correct on every score in what you are saying. I was trained in the early 70s that there is a group of individuals, mostly boys who knew from day one that they were girls. Nobody reasonable doubts that. Most did not outgrow it. And they were psychologically healthy.
But that's not the case any longer. Most cases are adolescent onset, girls, and kids with multiple psychiatric problems.
So, your last sentence fits with the research and with my training 50 years ago.
Seems that about 80% of even those children "who knew from day one" that they were the opposite sex actually *do* outgrow it. http://www.sexologytoday.org/2016/01/do-trans-kids-stay-trans-when-they-grow_99.html
Sissy boys and tomboy girls grow up again and again to be gay men and lesbians. I know, I am one of them.
This is why to me "gender affirming care" is the gay/lesbian conversion therapy from hell.
BTW, I explain all this to other gay men and they get angry and accuse of transphobia, etc. Just totally clueless and don't want to know either.
Hey thanks for the sources. I only had time to read one of them, and are heading out for the day.
Which one of the sources did you get your data about 80% from. I want to be sure to read that one first. I'll get to all of them later in the day or tomorrow. Thanks again.
Interesting.
Some of those studies I might be inclined to be skeptical of as either being too recent (if there's been a social push to question might that push numbers higher) or too far back (if there was a lot of stigma with being trans, might that push things too far the other way)
(And another one is about "effeminate behavior" not "dysphoria".)
At least based on the dates there, this one:
Wallien, M. S. C., & Cohen-Kettenis, P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413–1423.
Lists:
trans-21/54
cis-33/54
(It does not further break down gay/lesbian)
That's got a higher percentage, but still < 50%
I have not read that paper, it stood out to me both as a good year(late enough for gay rights early enough before the recent rise), the highest percentage, and definitely (based on the title) about dysphoria.
If I am understanding your question correctly, let me try to give my views on this.
The Gold standard is double blind completely randomized studies. Those are probably impossible in this area. But that does not mean that studies that are, essentially, correlational (which many many in the area are) simply get elevated to being high quality, and conclusive statements are made about their correlational findings. No. That's inappropriate in social science.
We also don't know how many followup, correlational studies from these clinics are NOT reported because they don't support the views of the clinic.
I have also seen studies that seem, very clearly, to rely on "p-hacking" to get their results. In other words, they vary the internal structure of their study to get significant results. This kind of thing results in totally erroneous statistical conclusions. Those are low quality.
There are other markers of low quality in this area. Often, in the studies I have read, there is no indication of whether all of the youth who had, for example, transitioned from the particular clinic were followed. How representative are the samples studied of the people who were treated at a particular clinic. When that is the case, how do you "mark" those who drop out? Is there a bias or lack of bias in the people who are followed?
Most of the studies seem to be from gender clinics (I'm sure there are exceptions). Cass, for example, had no investment in the findings of her review.
Thank you for your response.
I remember that in the "Dutch Protocol", the seminal study of gender care, the beginning N was 70 and the ending N was 55.
So it lost a bit over 20% of participants but I don't think the study can say why. (Actually, 1 of the 55 persons died from an infection from vaginoplasty since I believe they had been on puberty blockers and had a micro-penis so insufficient flesh to work with so rectal tissue was used, I believe.)
In a retrospective study that included the cohort of the original Dutch Protocol kids, about 20% discontinued identifying as the opposite gender too.
https://doi.org/10.1093/jsxmed/qdad062.088
Thanks for this study. I just read it, with interest.
You might want to read Abbruzzese et al, The Myth of reliable research in pediatric gender medicine... (2023).
There is also a paper by Biggs on the history of the Dutch protocol which talks about the younger kids a lot, too.
I think the 1 who died was one of the 15 lost between going from 70 to 55. They checked the 55 1 year after surgery and that poor kid passed away soon after surgery, so...."lost to follow-up".
I had read about the 70 down to 55 issue, but didn't know about the rest. Thanks!
Thanks for all this detail Jesse. Meanwhile, here is drama I covered about Cass Review and its detractors:
Cass Review Author Denounces As 'Baseless' And 'Cynical' Dissidents' Claim That She Touted Abigail Shrier's Scathing Polemic On Trans Kids
Two dissidents opposed to Britain's designs for reforming its care of gender-distressed kids claimed this week that Dr. Hilary Cass once "recommended strongly" Irreversible Damage by Abigail Shrier.
https://benryan.substack.com/p/cass-review-author-denounces-as-baseless
Thank you both! It's unbelievable that this "Integrity Project" essay is being taken seriously. People are not paying attention.
It's interesting how often putting how you would *like* to be seen (as having integrity in this case) really signals the opposite. And so, the Democratic People's Republic of Korea is neither democratic, nor a people's republic.
Hey Ben, have you read through Gideon Myers Katz's (GidMK on Twitter) multi-part series reviewing and critiquing the Cass Review?
do you have a link? thanks.
https://open.substack.com/pub/gidmk/p/the-cass-review-into-gender-identity?r=kctx4&utm_medium=ios
Above is Part 1
My first question (as a retired lawyer) is why this report was issued under the auspices of the Law School rather than the Yale Medical School. That fact alone imbues the report with a patina of politization and makes it suspect from the jump.
Yes this was referred to again and again in the comments of the Lydia Polgreen Times piece. I'd be interested to know as well.
I think this type of institute is actually to provide public argumentation for or against certain positions. Lawyers are quite well positioned to provide reasonable sounding arguments, especially when it doesn't have to be 2 way.
My guess (and this is just a guess) is it might have something to do with the reports theoretical impacts on policy.
I think the point is an important one that there is more than a financial conflict of interest when providers of youth gender medicine weigh in as experts on the topic, but I think that this sentence from Jesse's article under sells it: "I want to be clear that the argument here is a bit more nuanced than a straightforward financial conflict of interest. It’s also that if you’re a clinician delivering this care, you’re probably doing so because you think it works."
If you have been prescribing puberty blockers, cross-sex hormones, and mastectomies to minors, and such practices turn out to be unsupported by evidence, that means you have been doing terrible things to kids. It would be a truth that would be very difficult to countenance.
This feedback was a breath of fresh air, and decisively hit the nail on the head. I do wonder what the reckoning will be once this incredibly painful and harmful moment of gender insanity passes.
When does behavior cross from "spreading misinformation" to being "lies?" I'm really tired of seeing people lie and when they are called out on their lies, those who stand up to them using safe words like "spreading misinformation." call a lie a lie. The word misinformation is being used too much.
Agreed—misinformation allows people who are often knowingly misleading people (i.e., lying) to use word salads to slither out when they’re called in it.
Signal is always delicate in his wording, in the way Jane Austen used the word “delicate” as a term of praise—sensitively diplomatic and charitable about disagreements. So he critiques the Cass CEG for not revealing the names of their contributing experts. I suspect, though, that no one would have wanted to be part of the CEG without anonymity. The ideologues have made it downright dangerous, professionally and personally, to go on record objecting to “gender affirmative care.” Anyone participating in Cass’s work knew from the start what the Jack Turbans and Meredithe McNamaras were going to do. Anonymity was essential for honest work.
Some other NHS reports do not list their authors either, also, I believe.
Great article. One thing caught my eye near the very end, though: "I asked ChatGPT to graph the real dataset..."
(a) Why? If you already had the data in the sheet, it's trivial to just select it and hit Insert > Chart.
(b) I would recommend leaving this kind of detail out in the future. It's no more relevant to the end product than which editor or spell checker you use while writing, and it gives critics a ready-made point to latch on to try to shrug off the rest of the article as 'just an AI hallucination'.
Actually, it does make me genuinely question the validity of the graph. ChatGPT should not be used at all to make this kind of graph, except maybe to write code to render it. At no point should you put actual data directly through gpt
Well, you can create a chart from the spreadsheet data as I described above, and it does match up with the one pictured in the article. It just seems like a bizarre use case for something that you can do natively in Google Sheets in three clicks – using ChatGPT probably took *more* effort.
Right. Just want to confirm that’s actually been double checked.
Came here to say exactly this. Well said, and thanks! As a numbers guy whose job was supposed to have been taken by robots already I can say that even the best LLMs are completely unreliable about basic things pretty often. Reading "I asked ChatGPT," in an article is even more suspicious to me than seeing a Wikipedia citation.
You're correct I remember it felt odd reading it.
Maybe it was his way of saying, I´ve got a podcast, a Substack, and a book to write. I´m sooooooo tired, and I want you to know.
"Invalid professional viewpoint" is a remarkable series of words.
I haven't seen that in the engineering/physics space. I'm not going to strut about "well this is because we can actually quantify/prove our XYZ", but you gotta wonder.
I'm not sure what about this leads you to believe that things cannot be quantified in medical research.
"It is genuinely surprising that any of the co-authors would agree to put their names on a document like this."
I can only conclude that they assumed no one would actually read it, just quote it approvingly in headlines and tweets. Explains their approach in "responding" to the Cass report (apparently without having read it) - "No one actually *reads* these papers, do they? Let's just roll with what we saw about it in the tweets and headlines." It seems to come down to clout-chasing, depressingly.
I prefer the Hanlon's Razor approach. When people read opposing arguments against a position that they hold dear, their reading comprehension often goes out the window as they look for some nugget to attack. This can happen with otherwise very astute people.
Brilliant stuff Jesse, this is the gold I subscribe for! I have realised that I am now vastly better informed about the state of transgender medicine in the UK and USA than in my own country (Australia). My suspicion is that we're somewhere between the pre-Cass UK and US approaches.
"The paper’s lead author, Meredithe McNamara, is an adolescent physician at Yale Medical School"
Is "adolescent physician" the way this is usually phrased? It reads like we've got a Doogie Howser M.D. situation. Pediatrician focusing on adolescents seems too wordy, though.
Lmao no I'll fix it
You mean this Meredeth McNamara? Start at second 50:
https://www.youtube.com/watch?v=7hyXQWmf2r0&t=55s
oh this is so ironic..."the standards of care"...
the ones based upon suppressing the systematic review outcomes, those standards of care!
https://www.economist.com/united-states/2024/06/27/research-into-trans-medicine-has-been-manipulated
Do you know who Erin Reed is? I think you would enjoy reading the substack that Reed puts out on gender/genderism/trans.
I'm saying you will "enjoy" it because Reed is very popular with activists and is a Niagara of disinformation and distortions.....
I also highly recommend Reed for that sort of "enjoyment"
I was just reading one of her first blog posts about Cass Report and aside from the usual blatant misrepresentation, one thing leapt out to me: she's weirdly honest and explicit with respect to the wacky principles and messed conceptions of evidence that guide her evaluation. She thinks that systematic reviews should be judged by whether they conform with the statements from professional/lobbying orgs instead of the other way around. She writes:
"It is important to note that the Cass Review contains very little new data and evidence. Any statements it makes are based on the same level of evidence that every major medical organization in the United States, along with some of the largest mental health societies in the world and professional associations of transgender health, have determined to support transgender care. If its claims differ from those institutions, it’s because reviewers made choices to view the evidence around transgender care negatively."
Usually when confronted w/ systematic reviews critical of affirmative care, TRAs deflect and accuse you of transphobia. I suspect they know that deferring to orgs who haven't shown their work over SRs that do show their work isn't defensible and might be embarrassed to be caught explicitly doing that. But Reed has no shame. She's close to proposing a new evidence pyramid that puts unsubstantiated claims from lobbying groups at the top.
You are correct....I believe activists, possibly including Reed, want to invert evidence pyramids. And they have been explicit about it.
From another report by the Yale group:
“In this report, we cite studies that are peer-reviewed, up to date, conducted by respected investigators, and published in high-impact journals that are widely read. This represents the highest-quality evidence available to physicians making treatment decisions in this context.”
https://medicine.yale.edu/lgbtqi/clinicalcare/gender-affirming-care/report%20on%20the%20science%20of%20gender-affirming%20care%20final%20april%2028%202022_442952_55174_v1.pdf
In other words, they appear to want one to use use eminence (the bottom of the evidence pyramid)....not systematic reviews (the top). The are saying to pay attention to **who** is saying it, not what they are saying. (Hence the extreme focus on ad hominem attacks as well, in this approach.)
The latter, systematic reviews, would involve actually looking at the studies and trying to take out biases and stuff like that....can't have that! It is a particularly interesting view if it is said by someone at a high status institution....could be read as "don't look at the evidence, just listen to me"...if one were cynical...
I prefer Ben Ryan's critique of Reed.... :)
Those future exhibits in civil litigation against the liars, charlatans and extremists who foisted gender ideology on the world, right?
Adolescent medicine is a specialty just like internal medicine or endocrinology. Typically using this descriptor means the person completed an adolescent medicine fellowship as part of their training.
This topic is incredibly difficult to read and discuss since I feel like the opposing sides live in different realities
They do. After much study I’ve concluded that one of the main divisions is belief in gender ideology. (And that’s a whole other rabbit hole.) My guess is that these Yale people have drunk the kool-aid on this non-falsifiable belief system, and to the extent they know they’re lying, they pat themselves on the back for telling noble lies. They have a unique truth to spread, just like evangelicals, Maoists, and QAnon shite-posters. I don’t know when it subsides. There’s too much private foundation and lobbying money operating outside of the democratic process. It’s in every school, public and private, cloaked under ‘anti-bullying’. (Who could argue with that? Just try…) It will end, eventually, but it will burn a lot of people and institutions before it is done. Bright side: Jesse will sell a lot of books?
I’m not sure gender ideology will end.
My doctors’ health care organizations now record my “sex assigned at birth” and my gender identity. I’ve challenged them on this by taking the position the information is incorrect. My sex was determined biologically at conception and observed at birth. I have no gender identity. I do not identify as a man; I am a man.
They show no interest in having a discussion that could lead to the outcome I seek.
When the ideology has penetrated this deeply, how can it be defeated?
What concerns me most is the inability of McNamara et al. to understand the concept of holistic and comprehensive care that Cass emphasizes throughout her review. It seems that they really do not understand these concepts because medicine for them - and possibly in the United States in general - is all about treating the immediate symptom. "You are suffering from pain? There, it's gone now. You think that this has resulted in internal bleeding? That is not what you were here for. For that, you have to meet some other specialist." Cass understands that medicine is an inexact discipline where much is unknown (she starts the Review with a wonderful quote by Atul Gawande to emphasize this very point). In an interview with the BBC, a few days after the publication of the Cass Review, she mentioned: “I certainly wouldn't want to embark on a treatment where somebody couldn't tell me with any accuracy what percentage chance there was of it being successful, and what the possibilities were of harms or side effects." The systematic reviews (as well as the individual studies that McNamara and friends tout) show some weak evidence of short-term benefits at best. Often, we don't even get that. And that these minuscule benefits happen to be psychosocial is extremely relevant, because strong placebo responses in psychiatry have been noted for many decades now (Weimer et al., 2015). Even in double-blind clinical trials of treatments for pain or psychiatric disorders, the responses to placebo are often similar to the responses to active treatment (Colloca and Barsky, 2020). Such findings raise the possibility that these interventions might actually be causing harm. Next, we have no idea from these studies - whether individually or collectively - who exactly might benefit from them (there is no way to state, for example, that patients who show certain outcomes in an ECG test or tolerate a certain class of drugs and do not have a history of diabetes will probably be the best candidates for the interventions). And because these treatments have been repurposed for gender-affirming purposes in the last "8-10 years" (as per McNamara et al., p.16), we have very limited idea about the possible complications. Even with the pain medication oxycodone hydrochloride (known as OxyContin and approved by the FDA) at the heart of the opioid crisis and responsible for thousands of deaths ever year, it took many years before the extent of the harm became apparent to the general public – and that is for a drug that was prescribed to large swathes of the population. For drugs that are prescribed to smaller segments of the population, it can take much longer before their safety risks are established. Risks usually manifest many years after the intervention becomes routinely available. Serious adverse effects are rare and often go undetected during early evaluation (if they appeared in early experience, they would likely cause the developer to abandon the project) of the treatment in animals or volunteers. They may not appear in formal clinical trials, which are powered to detect a predicted treatment effect – and not rarer events that may be much smaller than the treatment effect. Detecting them require active post-marketing surveillance of many more patients than were enrolled in trials or the passive accumulation of case series or individual case reports. Since these observations are uncontrolled, it requires considerable knowledge of the background incidence of these effects in untreated people to determine if the occurrence in treated patients is greater than expected. None of the infrastructure to track such observations is remotely in place. And yet these people - with enormous conflicts of interest - are continuing to recommend these treatments on children and young adults. And these interventions happen to be off-label and on *minors* – whose bodies and brains are at their most vulnerable to any intervention – with lifelong consequences. What part of this basic narrative do these people not understand?
Excellent question.
I'll echo others--this is great.
Here's something that caught my eye, from McNamara, et al.:
--Further, 32% of respondents strongly agreed or agreed with the statement “There is no such thing as a trans child.” Denying the existence of transgender people of any age is an invalid professional viewpoint.--
The implication seems to be that the only way to have an informed opinion on the topic is if you already share the views of McNamara, et al. That's like me saying "If these polls weeded out all of the pro-Trump respondents--he's just an iillegitimate candidate, after all--Harris would be leading by 100 points!"
Excellent piece, while it would be easy to drip with contempt it’s remarkably focused on the facts of the matter, and I appreciate the very dry sense of humor about peeples [sic] who can’t spell.
What’s really fascinating is that the framing of this “debate” is so powerful that there are fixed points that recur in discussion which are literally impossible to eliminate and will never resolve which I saw clearly spelled out.
It’s like stomach ulcers.
For all decades leading up to the early 80’s stomach ulcers were considered a physiological manifestation of stress - “stress ulcers”. Treatment focused on how to manage, reduce or eliminate stress. Then in the early 80’s Australian doctors Barry Marshall and Robin Warren discovered that most peptic ulcers were actually caused by the bacterium Helicobacter pylori.
You could think of it as the “ulcers cause stress” and not “stress causes ulcers” change.
Imagine with a pediatrician starting with a remarkable position that by a common variation on the definition of trans - a person’s body doesn’t match their perception of their sex - all children (100%) are trans by definition. The condition of anxiety, unhappiness, disquiet that accompanies their trans/formation from a sexless child into sexualized adults is so common as to be unremarkable. New lumps, hair, (acne and fat) along with angst and moodiness are the default condition of puberty. What happens then when you reframe the debate:
Are there any children who do not have a range of anxieties and unhappinesses when they transition into adults? Can you ever find a child with zero dysphoria at the onset of puberty?
What then do you study? Why is Cass therefore entirely unremarkable? What interest do we afford charlatans who cannot see what is in front of their eyes? Why is the concept that 95% (I will say 100%) of such unhappiness conditions evaporate after full trans/ition to adulthood unremarkable? Adulthood is not all unicorns and rainbows. I suspect a large number of people are “dysphoric” as adults and will always be because for the most part, childhood is Eden, carefree and sexless. That’s the remaining 5% of children who do not have “adulthood blockers”.
Until we stop taking about the fiction of gender, this will circle the drain forever
I had no body dysphoria at the onset of my male puberty in 1967. And while most people say they detested middle school, I was very happy in what was then called junior high. I was also gay, but I always knew I would deal with it at the appropriate time, and I did. ( I do hate society for having robbed me of the sex and romance that my straight peers took for granted during their teens. )
I was relatively happy in Jr High, and High School. At puberty I grew into looking like a linebacker with massive hairy legs for marching with a marimba, and now everyone's friend for carrying booze and joints in crevices of the massive marimba for the other band members, as well as racy books to read while bored with the field machinations was entertaining in the fall and winter, and abandoning Honor Society and other storied institutions on field trips to have underage sex with older men in sleazy joints was a strange poetic justice in the spring. Ahh, sweet gay youth!
You were with me until you claimed that childhood is a carefree Eden. That’s a fantasy, not reality.
Compared to adulthood? Children don't work, don't take care of beings totally dependent on them, and don't face death in the face, generally. That's the fantasy eden of pre-adulthood
I have to say that it’s a simple fact the concept of childhood is not defined by trauma in any world culture, it is defined by innocence. The concept of childhood trauma is so staggeringly overblown it’s on par with trans violence. I’ve seen studies that 25% 50% up to 75% or more children have experienced “trauma”. It’s a bullshit call for sympathy for organizations which serve traumatized children. I had a rank alcoholic father an a bipolar mother, was bullied in school, yet strangely I found childhood not defined by incidents, but by wonder, nature, friends, music, teachers I loved and family who looked after me.
Yes; there are children abused Id be silly to say that it wasn’t true. But not 75% of children are traumatized, not 50%, not 25%. Being frightened, getting in a fight, a natural disaster, serious illness - these are events which don’t define childhood for the vast majority of children. Going through a single event is not a traumatic childhood. It’s a normal childhood. It’s forgotten as an exception.
Except for annoying helicopter parents and overexposure to Internetworking, children today - worldwide - have the most amazing chance of an idyllic childhood in the history of mankind. Illness, poverty, war, famine - simply don’t exist anywhere near the scale of when even wartime childnood in London, bombs dropping during the Blitz, children still found life magic.
It really depends on the specific adults controlling the child’s environment.
There are always, but childhood is generally a state of innocense, wouldn't you say? I can hardly call childhood a state of existential anxiety
That depends on the childhood in question. When discussing severely dysphoric children—regardless of one's opinion on the appropriate diagnosis and treatment—their experience is hardly idyllic. I agree with your main point that, in general, puberty is often more traumatic than childhood and can even be more challenging than adulthood. Much of this is attributable to the lack of experience in managing such challenges to our identity.
Here's the key issue: while adults face more responsibilities, complexities, burdens, opportunities, and potential for things to go wrong, they also possess more resources, experience, independence, and relationships to help them navigate life. In contrast, children encounter fewer sources of trauma but have significantly less opportunity and capability to exercise agency.
Well I feel peculiar reading this because I see "except for exceptions". There are children who have more traumatic than average. Any general statement is true "except for exceptions". I stand by my statement.
I think my opinion is probably skewed because of 12 years as a social worker in Oakland and then 2+ decades teaching public school. There are quite young children who are sexually exploited, forced to witness domestic violence, neglected by drug- and alcohol-addled adults…
We don’t have Dickens-like workhouses for six-year olds in this country, and minors are no longer subject to capital punishment, but the conditions of childhood can still be pretty nightmarish. And it feels sometimes like our institutions are half-hearted in their safeguarding efforts.
It's peculiar but the existence of such children is sad in part precisely because we expect childhood to be a trouble-free eden; the contract between expectation and what happens to some is jarring and troublesome.
Re your opening statement, yes, this sort of research is incredibly time and energy intensive and few do it for that reason, but it's hugely needed. I don't have anyone to gift a subscription to but is there a way to just kick in a few bucks to you as a thank you?
Send me an email with how much worth of gift subs you want to donate, and then I'll tweet that the first X people who respond get one? No pressure but that might be one way to do it -- I'd prefer that over just taking money.