#N.H.S.

[probablyasocialecologist]

While maintaining that “for some, the best outcome will be transition,” it nevertheless effectively recommended that the N.H.S. abandon the guidelines embraced by major mainstream medical associations and restrict the use of medications that have been offered for decades to adolescents across the globe with vanishingly few negative side effects or regrets. The reason, the report says, is that these treatments are insufficiently supported by reliable, long-term evidence. Then, remarkably, the report recommends treatments — psychological treatment and medications for depression and anxiety — that have even less proof behind them in helping children (or adults) with gender dysphoria, though they may help with other mental health issues, and many children with dysphoria already get these treatments. And for all its insistence of evidence, the report is peppered with mere speculation about the potential causes of gender dysphoria: pornography and the phenomenon of social contagion are invoked, with zero credible evidence to support them. It is a strange document. Social conservatives welcomed the report. But it has also been heralded in some liberal quarters in Britain, where even the Labour Party has supported its conclusions, and around the world as a model of open-minded rationalism, of well-intentioned — progressive, even — unbiased scientific inquiry attempting to provide information in young people’s best interests. This, they declare, is what following the science and the evidence looks like. But is it? In an effort to evaluate the Cass report’s findings and recommendations, I spent the months since it was released poring over the document, researching the history of transgender medicine and interviewing experts in gender-affirming care as well as epidemiologists and research scientists about the role of scientific evidence in determining care standards. What I have come to realize is that this report, for all its claims of impartiality, is fundamentally a subjective, political document.

[...]

A great deal of the media coverage of gender-affirming care in the West has painted a picture of huge numbers of children, some of them suffering from profound mental illness, rushed into medical transition, practically force-fed puberty blockers and hormones, then fast-tracked to surgery once they turned 18, based on unproven treatment and perhaps bogus science. But the report itself not only fails to show any evidence of significant regret among patients or other forms of harm; its own data also contradicts the notion of rushed transition. Of the more than 3,300 medical records examined as part of the review, about a quarter of children and adolescents were referred to an endocrinologist, which suggests a significant screening process. Indeed, on average, patients had more than a half dozen consultations before being referred. If anything, the evidence suggests a lack of care bordering on neglect, which is not surprising considering that millions of people are on waiting lists for treatment of all kinds by Britain’s crumbling health system. One of the most common pieces of feedback was that young people lingered on waiting lists, sometimes for years. A number of participants in focus groups convened for the purpose of the report said they felt that they had to “prove” to clinicians that they were transgender.

[...]

At one point the report posits that because a child has never had the experience of growing up in their assigned sex, they would have no way to know whether they might regret transition. “They may have had a different outcome without medical intervention and would not have needed to take lifelong hormones,” the report says, referring to children assigned female at birth. It is hard to know what to make of a statement like that. A person gets only one life; waiting to see how it works out isn’t really an option. To a queer woman like me, this is an ominous echo of something many of us have heard many times in our lives: Maybe you just haven’t met the right man yet. The wish — whether expressed by a parent, a teacher, a therapist or a suitor — is a wish for a child not to be queer. It is hard to find a satisfying explanation for these kinds of conjectures and conclusions in the report other than this one: Many people find transgender people at best unsettling and possibly deluded or mentally ill, or at worst immoral and unnatural. They appear to believe it would be better not to be trans. As much as Cass’s report insists that all lives — trans lives, cis lives, nonbinary lives — have equal value, taken in full it seems to have a clear, paramount goal: making living life in the sex you are assigned at birth as attractive and likely as possible. Whether Cass wants to acknowledge it or not, that is a value judgment: It is better to learn to live with your assigned sex than try to change it. If this is what Cass personally believes is right, fair enough. It can charitably be called a cultural, political or religious belief. But it is not a medical or scientific judgment.

13 Aug 2024 | Link

[itsawritblr]

The Courage to Follow the Evidence on Transgender Care.

(WOW, the New York Times -- which a couple years ago had an ad about a qu**r girl who wished for a world in which J.K. Rowling wasn't the author of Harry Potter -- has published yet another opinion piece about trans, this one about the Cass Review. Personally, I think he's too lenient, but at least he's bringing attention to the review to Americans. )

(For those who can't read the NYT page, here's the text.)

Opinion, David Brooks, April 18, 2024.

Hilary Cass is the kind of hero the world needs today. She has entered one of the most toxic debates in our culture: how the medical community should respond to the growing numbers of young people who seek gender transition through medical treatments, including puberty blockers and hormone therapies. This month, after more than three years of research, Cass, a pediatrician, produced a report, commissioned by the National Health Service in England, that is remarkable for its empathy for people on all sides of this issue, for its humility in the face of complex social trends we don’t understand and for its intellectual integrity as we try to figure out which treatments actually work to serve those patients who are in distress. With incredible courage, she shows that careful scholarship can cut through debates that have been marked by vituperation and intimidation and possibly reset them on more rational grounds.

Cass, a past president of Britain’s Royal College of Pediatrics and Child Health, is clear about the mission of her report: “This review is not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves or rolling back on people’s rights to health care. It is about what the health care approach should be, and how best to help the growing number of children and young people who are looking for support from the N.H.S. in relation to their gender identity.”

This issue begins with a mystery. For reasons that are not clear, the number of adolescents who have sought to medically change their sex has been skyrocketing in recent years, though the overall number remains very small. For reasons that are also not clear, adolescents who were assigned female at birth are driving this trend, whereas before the late 2000s, it was mostly adolescents who were assigned male at birth who sought these treatments.

Doctors and researchers have proposed various theories to try to explain these trends. One is that greater social acceptance of trans people has enabled people to seek these therapies. Another is that teenagers are being influenced by the popularity of searching and experimenting around identity. A third is that the rise of teen mental health issues may be contributing to gender dysphoria. In her report, Cass is skeptical of broad generalizations in the absence of clear evidence; these are individual children and adolescents who take their own routes to who they are.

Some activists and medical practitioners on the left have come to see the surge in requests for medical transitioning as a piece of the new civil rights issue of our time — offering recognition to people of all gender identities. Transition through medical interventions was embraced by providers in the United States and Europe after a pair of small Dutch studies showed that such treatment improved patients’ well-being. But a 2022 Reuters investigation found that some American clinics were quite aggressive with treatment: None of the 18 U.S. clinics that Reuters looked at performed long assessments on their patients, and some prescribed puberty blockers on the first visit.

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Unfortunately, some researchers who questioned the Dutch approach were viciously attacked. This year, Sallie Baxendale, a professor of clinical neuropsychology at the University College London, published a review of studies looking at the impact of puberty blockers on brain development and concluded that “critical questions” about the therapy remain unanswered. She was immediately attacked. She recently told The Guardian, “I’ve been accused of being an anti-trans activist, and that now comes up on Google and is never going to go away.”

As Cass writes in her report, “The toxicity of the debate is exceptional.” She continues, “There are few other areas of health care where professionals are so afraid to openly discuss their views, where people are vilified on social media and where name-calling echoes the worst bullying behavior.”

Cass focused on Britain, but her description of the intellectual and political climate is just as applicable to the U.S., where brutality on the left has been matched by brutality on the right, with crude legislation that doesn’t acknowledge the well-being of the young people in question. In 24 states Republicans have passed laws banning these therapies, sometimes threatening doctors with prison time if they prescribe the treatment they think is best for their patients.

The battle lines on this issue are an extreme case, but they are not unfamiliar. On issue after issue, zealous minorities bully and intimidate the reasonable majority. Often, those who see nuance decide it’s best to just keep their heads down. The rage-filled minority rules.

Cass showed enormous courage in walking into this maelstrom. She did it in the face of practitioners who refused to cooperate and thus denied her information that could have helped inform her report. As an editorial in The BMJ puts it, “Despite encouragement from N.H.S. England,” the ���necessary cooperation” was not forthcoming. “Professionals withholding data from a national inquiry seems hard to imagine, but it is what happened.”

Cass’s report does not contain even a hint of rancor, just a generous open-mindedness and empathy for all involved. Time and again in her report, she returns to the young people and the parents directly involved, on all sides of the issue. She clearly spent a lot of time meeting with them. She writes, “One of the great pleasures of the review has been getting to meet and talk to so many interesting people.”

The report’s greatest strength is its epistemic humility. Cass is continually asking, “What do we really know?” She is carefully examining the various studies — which are high quality, which are not. She is down in the academic weeds.

She notes that the quality of the research in this field is poor. The current treatments are “built on shaky foundations,” she writes in The BMJ. Practitioners have raced ahead with therapies when we don’t know what the effects will be. As Cass tells The BMJ, “I can’t think of another area of pediatric care where we give young people a potentially irreversible treatment and have no idea what happens to them in adulthood.”

She writes in her report, “The option to provide masculinizing/feminizing hormones from age 16 is available, but the review would recommend extreme caution.” She does not issue a blanket, one-size-fits-all recommendation, but her core conclusion is this: “For most young people, a medical pathway will not be the best way to manage their gender-related distress.” She realizes that this conclusion will not please many of the young people she has come to know, but this is where the evidence has taken her.

You can agree or disagree with this or that part of the report, and maybe the evidence will look different in 10 years, but I ask you to examine the integrity with which Cass did her work in such a treacherous environment.

In 1877 a British philosopher and mathematician named William Kingdon Clifford published an essay called “The Ethics of Belief.” In it he argued that if a shipowner ignored evidence that his craft had problems and sent the ship to sea having convinced himself it was safe, then of course we would blame him if the ship went down and all aboard were lost. To have a belief is to bear responsibility, and one thus has a moral responsibility to dig arduously into the evidence, avoid ideological thinking and take into account self-serving biases. “It is wrong always, everywhere, and for anyone, to believe anything upon insufficient evidence,” Clifford wrote. A belief, he continued, is a public possession. If too many people believe things without evidence, “the danger to society is not merely that it should believe wrong things, though that is great enough; but that it should become credulous, and lose the habit of testing things and inquiring into them; for then it must sink back into savagery.”

Since the Trump years, this habit of not consulting the evidence has become the underlying crisis in so many realms. People segregate into intellectually cohesive teams, which are always dumber than intellectually diverse teams. Issues are settled by intimidation, not evidence. Our natural human tendency is to be too confident in our knowledge, too quick to ignore contrary evidence. But these days it has become acceptable to luxuriate in those epistemic shortcomings, not to struggle against them. See, for example, the modern Republican Party.

Recently it’s been encouraging to see cases in which the evidence has won out. Many universities have acknowledged that the SAT is a better predictor of college success than high school grades and have reinstated it. Some corporations have come to understand that while diversity, equity and inclusion are essential goals, the current programs often empirically fail to serve those goals and need to be reformed. I’m hoping that Hilary Cass is modeling a kind of behavior that will be replicated across academia, in the other professions and across the body politic more generally and thus save us from spiraling into an epistemological doom loop.

[medinainternational]

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[businesspr]

How Palantir Became a Front-Runner for the UK’s Multimillion-Dollar NHS Contract

Palantir, the analytics company chaired by Peter Thiel, has courted N.H.S. England with pandemic help and assertive lobbying. Its big reward may be yet to come. source https://www.nytimes.com/2023/09/29/world/europe/uk-nhs-palantir.html

[immaculatasknight]

Learn to love your executioner

[newstfionline]

Friday, September 13, 2024

Harris and Trump Bet on Their Own Sharply Contrasting Views of America (NYT) Donald J. Trump’s America is a grim place, a nation awash in marauding immigrants stealing American jobs and eating American cats and dogs, a country devastated economically, humiliated internationally and perched on the cliff’s edge of an apocalyptic World War III. Kamala Harris’s America is a weary but hopeful place, a nation fed up with the chaos of the Trump years and sick of all the drama and divisiveness, a country embarrassed by a crooked stuck-in-the-past former president facing prison time and eager for a new generation of leadership. These two visions of America on display during the first and possibly only presidential debate between Ms. Harris and Mr. Trump on Tuesday night encapsulated the gambles that each candidate is taking in this hotly contested campaign. Mr. Trump is betting on anger and Ms. Harris on exhaustion. Mr. Trump is trying to repackage and resell his “American carnage” theme eight years later, while Ms. Harris is appealing to those ready to leave that in the past. The question is who has a better read on the American psyche eight weeks before the final ballots are cast.

Cuba’s Broken Economy (El Espectador/Colombia) Cuba is on a downward spiral and appears to be headed for economic collapse. Cubans lack essential items such as food and medicine, especially milk and bread, while the prices of other products, such as gasoline and electricity, have increased by dizzying percentages of up to 500%. The island nation imports 80% of the food it consumes. In 1958, a year before the communist takeover, it was not only self-sufficient in beef, milk, tropical fruits, coffee, tobacco, fish and seafood, pork, chicken, vegetables and eggs, but it also exported surplus produce. Yet today, according to press reports, the magnitude of the crisis is such that Havana has contacted the UN World Food Program (WFP) for the first time in its history to request help. Since 1959 Cuba has systematically suffocated the private sector, renouncing innovation, competitiveness and excellence in the process. There have been consequences.

More than half of Brazil is racked by drought (Washington Post) In the north of Brazil, dried rivers have left communities accessible only by boat landlocked. In the central west, fires are razing what were once wetlands. And in the densely populated southeast, smoke from tens of thousands of blazes is choking cities. Brazil is in the grip of its worst drought on record, Brazil’s Center for Natural Disaster Monitoring and Alerts said this month, a drought that has parched at least 59 percent of Latin America’s largest country and dried out more than 1,400 cities. Along the Rio Madeira in Amazonas state, locals are trekking miles on the hot sands of the dried riverbed in search of water. In the Pantanal, the world’s largest tropical wetland, fires have scorched an estimated 20,000 square kilometers (7,720 square miles). The vast Cerrado region is in the grip of the worst drought in at least 700 years, according to researchers at the University of São Paulo. And the air in São Paulo state has grown so heavy with forest fire smoke that authorities have urged people to avoid physical activity outside.

England’s Health Service Is in Deep Trouble, Report Finds (NYT) England’s National Health Service, one of the country’s most revered institutions, is in “critical” condition, according to a government-commissioned report that cited long waits for treatment, crumbling hospitals, mental health patients in “vermin-infested cells” and far fewer M.R.I. scanners than in comparable countries. The hard-hitting review, published late on Wednesday, was commissioned by Britain’s new prime minister, Keir Starmer, after he won the general election. The dire state of the N.H.S. was a key reason many people voted for his Labour Party in July, according to polls. But the report underscores the scale of the challenge the government faces to revive a health care system that is in a spiral of decline after years of underinvestment and administrative meddling and is still suffering the aftershocks of the pandemic.

Lawmakers review plan to raise retirement age in fast-greying China (Reuters) China’s top legislative body this week assessed an official plan to delay the country’s retirement age, among the world’s lowest, taking a key step towards changing decades-old labour laws and easing economic pressures stemming from a shrinking workforce. The ruling Communist Party said in July that China would gradually raise the country’s retirement age. The retirement age is now 60 for men, about six years below that in most developed economies, while for women in white-collar work it is 55, and 50 for women who work in factories. Having people work for longer would abate some pressure on pension budgets with many Chinese provinces already reeling from large deficits. It would also delay pension payouts and require older workers to stay at their jobs longer, which may not be welcomed by all of them. Reform is urgent with life expectancy in China rising to 78 years as of 2021 from about 44 years in 1960, and projected to exceed 80 years by 2050. At the same time, the working population needed to support the elderly is shrinking.

Pope marvels at Singapore’s skyscrapers and asks that the lowest migrant workers not be forgotten (AP) Pope Francis on Thursday praised Singapore’s economic strength as a testament to human ingenuity but urged the city-state to look after the weakest, too, especially foreign workers, as he opened the final leg of his tour through some of Asia’s poorest countries in one of the world’s richest. In a common appeal from history’s first Latin American pope, Francis called especially for dignified pay and conditions for migrant workers, who have helped build Singapore into one of the world’s most advanced financial powerhouses. “These workers contribute a great deal to society and should be guaranteed a fair wage,” Francis said. Singapore has long touted as a success story its transformation from a colonial port lacking natural resources into a financial and trade power in just a few decades since independence from Malaysia in 1965. The former British colony enjoys one of the highest living standards in the world, and is known for its safety and low crime rate. But it is also one of the most expensive cities to live in and its competitive work environment makes for a stressful, overworked people.

Israeli Commandos Carried Out Raid on Secret Weapons Site in Syria (NYT) Israel carried out a commando raid in Syria on Sunday that obliterated a Hezbollah missile production facility near the Lebanese border, killing a number of people at the site, according to American and other Western officials. The operation included a daring raid by Israeli special forces, who rappelled down from helicopters and apparently seized materials from the missile facility, the officials said. Ground forces were used in the attack because of its complexity and to recover information from the secret weapons site, the officials said, adding that there were no Israeli casualties. The officials said the raid included airstrikes on the sprawling site, the Scientific Studies and Research Center, which is near Masyaf, in the country’s northwest. Syria’s state news agency, SANA, reported on Monday that 18 people were killed and dozens more injured.

New video, witnesses challenge Israel’s account of U.S. activist’s killing (Washington Post) Aysenur Eygi, a 26-year-old Turkish American, was fatally shot in the head on Friday in the village of Beita, near Nablus, following brief clashes after Friday prayers. The Israel Defense Forces said Tuesday it was “very likely” she had been hit “unintentionally” by one of its soldiers. “The incident took place during a violent riot,” the statement said, and the fire was aimed at “the key instigator.” But a Washington Post investigation has found that Eygi was shot more than a half-hour after the height of confrontations in Beita, and some 20 minutes after protesters had moved down the main road—more than 200 yards away from Israeli forces. Last month, another American citizen, Daniel Santiago, a 32-year-old teacher from New Jersey, was shot in the thigh by Israeli forces in the same olive grove where Eygi was killed. The IDF said Santiago was “accidentally injured” when soldiers “fired live rounds in the air” to disperse protesters.

2,000-Pound Bombs Likely Used in Mawasi Strike (NYT) Large craters and a bomb fragment from an Israeli airstrike on a camp for displaced people early Tuesday provide strong evidence that Israel used 2,000-pound bombs, according to three weapons experts. The United States has previously warned Israel that the powerful munitions can cause excessive civilian casualties in the densely populated Gaza Strip, and suspended exporting U.S.-made 2,000-pound bombs to Israel earlier this year. Israel said it had carried out “precise strikes” aimed at Hamas militants, but has so far declined to say what sort of bombs were used. At least 19 people were killed in the blasts and more than 60 others injured, Gazan authorities said, a toll that appeared likely to rise. Video filmed after the attack and verified by The New York Times showed two enormous blast craters measuring close to 50 feet wide.

South Africa’s traveling ‘health train’ (AP) Thethiwe Mahlangu woke early on a chilly morning and walked through her busy South African township, where minibuses hooted to pick up commuters and smoke from sidewalk breakfast stalls hung in the air. Her eyes had been troubling her. But instead of going to her nearby health clinic, Mahlangu was headed to the train station for an unusual form of care. A passenger train known as Phelophepa—or “good, clean, health” in the Sesotho language—had been transformed into a mobile health facility. It circulates throughout South Africa for much of the year, providing medical attention to the sick, young and old who often struggle to receive the care they need at crowded local clinics. For the past 30 years—ever since South Africa’s break with the former racist system of apartheid—the train has carried doctors, nurses and optometrists on an annual journey that touches even the most rural villages, delivering primary healthcare to about 375,000 people a year.

Cholera Deaths Soar Worldwide Despite Being Easily Preventable (NYT) The cholera outbreaks spreading across the globe are becoming more deadly. Deaths from the diarrheal disease soared last year, far outpacing the increase in cases, according to a new analysis by the World Health Organization. Cholera is easy to prevent and costs just pennies to treat, but huge outbreaks have swamped even well-prepared health systems in countries that had not confronted the disease in years. The number of cholera deaths reported globally last year increased by 71 percent from deaths in 2022, while the number of reported cases rose 13 percent. Much of the increase was driven by conflict and climate change, the W.H.O. report said. “For death rates to be rising so much faster even than cases are increasing, this is totally unacceptable,” said Philippe Barboza, who leads the cholera team in the health emergencies program of the W.H.O. “It reflects the world’s lack of interest in a disease that has plagued humans for thousands of years, afflicting the poorest people who cannot find clean water to drink,” he said. “How can we accept that in 2024 that people are dying because they don’t have access to a simple bag of oral rehydration salts that cost 50 cents?”

“A hug? Why not!” (Worldcrunch) A video of King Charles sharing a hug with the New Zealand women's rugby union team at Buckingham palace has gone viral on social media. The British sovereign was hosting the Black Ferns—set to play against England's Red Roses on Saturday—at the palace when winger Ayesha Leti-I'iga asked him to share a hug with the team. “Why not?,” he answered before getting a group hug.

[paulinedorchester]

When I wrote here about the N.H.S.'s image versus what seems to be the reality, this is the sort of thing that I was thinking of:

Meanwhile, it's still Hanukkah:

And here's something very gratifying (admittedly, the phrase "Italian opera singing" covers a lot of ground, not to mention a multitude of sins):

[thenewsart]

Britons Love the N.H.S. Some Will Also Pay to Avoid It.

For David Haselgrove, it was a battle each day to get out of bed, then another struggle to put on his socks. Stairs were often impossible, and the pain made him tetchy and difficult to live with. But when he sought medical help for his arthritis, Mr. Haselgrove was told the wait for a specialist consultation was more than two years. It might be another two years before surgery. “If I wasn’t the…

[antonio-velardo]

Antonio Velardo shares: How Britain Put One of the World’s Best Health Care Systems on Life Support by Adam Westbrook

By Adam Westbrook The N.H.S. is one of Britain’s proudest achievements, and it’s unraveling. Published: December 7, 2023 at 05:01AM from NYT Opinion https://ift.tt/n9y2uAa via IFTTT

[hackernewsrobot]

Palantir has courted N.H.S. England with pandemic help and assertive lobbying

https://www.nytimes.com/2023/09/29/world/europe/uk-nhs-palantir.html

[religion-is-a-mental-illness]

By: Azeen Ghorayshi

Published: May 13, 2024

After 30 years as one of England’s top pediatricians, Dr. Hilary Cass was hoping to begin her retirement by learning to play the saxophone.

Instead, she took on a project that would throw her into an international fire: reviewing England’s treatment guidelines for the rapidly rising number of children with gender distress, known as dysphoria.

At the time, in 2020, England’s sole youth gender clinic was in disarray. The waiting list had swelled, leaving many young patients waiting years for an appointment. Staff members who said they felt pressure to approve children for puberty-blocking drugs had filed whistle-blower complaints that had spilled into public view. And a former patient had sued the clinic, claiming that she had transitioned as a teenager “after a series of superficial conversations with social workers.”

The National Health Service asked Dr. Cass, who had never treated children with gender dysphoria but had served as the president of the Royal College of Pediatrics and Child Health, to independently evaluate how the agency should proceed.

Over the next four years, Dr. Cass commissioned systematic reviews of scientific studies on youth gender treatments and international guidelines of care. She also met with young patients and their families, transgender adults, people who had detransitioned, advocacy groups and clinicians.

Her final report, published last month, concluded that the evidence supporting the use of puberty-blocking drugs and other hormonal medications in adolescents was “remarkably weak.” On her recommendation, the N.H.S. will no longer prescribe puberty blockers outside of clinical trials. Dr. Cass also recommended that testosterone and estrogen, which allow young people to develop the physical characteristics of the opposite sex, be prescribed with “extreme caution.”

Dr. Cass’s findings are in line with several European countries that have limited the treatments after scientific reviews. But in America, where nearly two dozen states have banned the care outright, medical groups have endorsed the treatments as evidence-based and necessary.

The American Academy of Pediatrics declined to comment on Dr. Cass’s specific findings, and condemned the state bans. “Politicians have inserted themselves into the exam room, which is dangerous for both physicians and for families,” Dr. Ben Hoffman, the organization’s president, said.

The Endocrine Society told The New York Times that Dr. Cass’s review “does not contain any new research” that would contradict its guidelines. The federal health department did not respond to requests for comment.

Dr. Cass spoke to The Times about her report and the response from the United States. This conversation has been edited and condensed for clarity.

What are your top takeaways from the report?

The most important concern for me is just how poor the evidence base is in this area. Some people have questioned, “Did we set a higher bar for this group of young people?” We absolutely didn’t. The real problem is that the evidence is very weak compared to many other areas of pediatric practice.

The second big takeaway for me is that we have to stop just seeing these young people through the lens of their gender and see them as whole people, and address the much broader range of challenges that they have, sometimes with their mental health, sometimes with undiagnosed neurodiversity. It’s really about helping them to thrive, not just saying “How do we address the gender?” in isolation.

You found that the quality of evidence in this space is “remarkably weak.” Can you explain what that means?

The assessment of studies looks at things like, do they follow up for long enough? Do they lose a lot of patients during the follow-up period? Do they have good comparison groups? All of those assessments are really objective. The reason the studies are weak is because they failed on one or more of those areas.

The most common criticism directed at your review is that it was in some way rigged because of the lack of randomized controlled trials, which compare two treatments or a treatment and a placebo, in this field. That, from the get-go, you knew you would find that there was low-quality evidence.

People were worried that we threw out anything that wasn’t a randomized controlled trial, which is the gold standard for study design. We didn’t, actually.

There weren’t any randomized controlled trials, but we still included about 58 percent of the studies that were identified, the ones that were high quality or moderate quality. The kinds of studies that aren’t R.C.T.s can give us some really good information, but they have to be well-conducted. The weakness was many were very poorly conducted.

There’s something I would like to say about the perception that this was rigged, as you say. We were really clear that this review was not about defining what trans means, negating anybody’s experiences or rolling back health care.

There are young people who absolutely benefit from a medical pathway, and we need to make sure that those young people have access — under a research protocol, because we need to improve the research — but not assume that that’s the right pathway for everyone.

[ The Tavistock Gender Identity Development Service in London, which until recently was the National Health Service’s sole youth gender clinic in England. ]

Another criticism is that this field is being held to a higher standard than others, or being exceptionalized in some way. There are other areas of medicine, particularly in pediatrics, where doctors practice without high-quality evidence.

The University of York, which is kind of the home of systematic reviews, one of the key organizations that does them in this country, found that evidence in this field was strikingly lower than other areas — even in pediatrics.

I can’t think of any other situation where we give life-altering treatments and don’t have enough understanding about what’s happening to those young people in adulthood. I’ve spoken to young adults who are clearly thriving — a medical pathway has been the right thing for them. I’ve also spoken to young adults where it was the wrong decision, where they have regret, where they’ve detransitioned. The critical issue is trying to work out how we can best predict who’s going to thrive and who’s not going to do well.

In your report, you are also concerned about the rapid increase in numbers of teens who have sought out gender care over the last 10 years, most of whom were female at birth. I often hear two different explanations. On the one hand, there’s a positive story about social acceptance: that there have always been this many trans people, and kids today just feel freer to express who they are. The other story is a more fearful one: that this is a ‘contagion’ driven in large part by social media. How do you think about it?

There’s always two views because it’s never a simple answer. And probably elements of both of those things apply.

It doesn’t really make sense to have such a dramatic increase in numbers that has been exponential. This has happened in a really narrow time frame across the world. Social acceptance just doesn’t happen that way, so dramatically. So that doesn’t make sense as the full answer.

But equally, those who say this is just social contagion are also not taking account of how complex and nuanced this is.

Young people growing up now have a much more flexible view about gender — they’re not locked into gender stereotypes in the way my generation was. And that flexibility and fluidity are potentially beneficial because they break down barriers, combat misogyny, and so on. It only becomes a challenge if we’re medicalizing it, giving an irreversible treatment, for what might be just a normal range of gender expression.

What has the response to your report been like in Britain?

Both of our main parties have been supportive of the report, which has been great.

We have had a longstanding relationship with support and advocacy groups in the U.K. That’s not to say that they necessarily agree with all that we say. There’s much that they are less happy about. But we have had an open dialogue with them and have tried to address their questions throughout.

I think there is an appreciation that we are not about closing down health care for children. But there is fearfulness — about health care being shut down, and also about the report being weaponized to suggest that trans people don’t exist. And that’s really disappointing to me that that happens, because that’s absolutely not what we’re saying.

I’ve reached out to major medical groups in the United States about your findings. The American Academy of Pediatrics declined to comment on your report, citing its own research review that is underway. It said that its guidance, which it reaffirmed last year, was “grounded in evidence and science.”

The Endocrine Society said “we stand firm in our support of gender-affirming care,” which is “needed and often lifesaving.”

I think for a lot of people, this is kind of dizzying. We have medical groups in the United States and Britain looking at the same facts, the same scientific literature, and coming to very different conclusions. What do you make of those responses?

When I was president of the Royal College of Pediatrics and Child Health, we did some great work with the A.A.P. They are an organization that I have enormous respect for. But I respectfully disagree with them on holding on to a position that is now demonstrated to be out of date by multiple systematic reviews.

It wouldn’t be too much of a problem if people were saying “This is clinical consensus and we’re not sure.” But what some organizations are doing is doubling down on saying the evidence is good. And I think that’s where you’re misleading the public. You need to be honest about the strength of the evidence and say what you’re going to do to improve it.

I suspect that the A.A.P., which is an organization that does massive good for children worldwide, and I see as a fairly left-leaning organization, is fearful of making any moves that might jeopardize trans health care right now. And I wonder whether, if they weren’t feeling under such political duress, they would be able to be more nuanced, to say that multiple truths exist in this space — that there are children who are going to need medical treatment, and that there are other children who are going to resolve their distress in different ways.

Have you heard from the A.A.P. since your report was published?

They haven’t contacted us directly — no.

Have you heard from any other U.S. health bodies, like the Department of Health and Human Services, for example?

No.

Have you heard from any U.S. lawmakers?

No. Not at all.

Pediatricians in the United States are in an incredibly tough position because of the political situation here. It affects what doctors feel comfortable saying publicly. Your report is now part of that evidence that they may fear will be weaponized. What would you say to American pediatricians about how to move forward?

Do what you’ve been trained to do. So that means that you approach any one of these young people as you would any other adolescent, taking a proper history, doing a proper assessment and maintaining a curiosity about what’s driving their distress. It may be about diagnosing autism, it may be about treating depression, it might be about treating an eating disorder.

What really worries me is that people just think: This is somebody who is trans, and the medical pathway is the right thing for them. They get put on a medical pathway, and then the problems that they think were going to be solved just don’t go away. And it’s because there’s this overshadowing of all the other problems.

So, yes, you can put someone on a medical pathway, but if at the end of it they can’t get out of their bedroom, they don’t have relationships, they’re not in school or ultimately in work, you haven’t done the right thing by them. So it really is about treating them as a whole person, taking a holistic approach, managing all of those things and not assuming they’ve all come about as a result of the gender distress.

I think some people get frustrated about the conclusion being, well, what these kids need is more holistic care and mental health support, when that system doesn’t exist. What do you say to that?

We’re failing these kids and we’re failing other kids in terms of the amount of mental health support we have available. That is a huge problem — not just for gender-questioning young people. And I think that’s partly a reflection of the fact that the system’s been caught out by a growth of demand that is completely outstripping the ability to provide it.

We don’t have a nationalized health care system here in the United States. We have a sprawling and fragmented system. Some people have reached the conclusion that, because of the realities of the American health care system, the only way forward is through political bans. What do you make of that argument?

Medicine should never be politically driven. It should be driven by evidence and ethics and shared decision-making with patients and listening to patients’ voices. Once it becomes politicized, then that’s seriously concerning, as you know well from the abortion situation in the United States.

So, what can I say, except that I’m glad that the U.K. system doesn’t work in the same way.

-

When asked after this interview about Dr. Cass’s comments, Dr. Hoffman, the A.A.P.’s president, said that the group had carefully reviewed her report and “added it to the evidence base undergoing a systematic review.” He also said that “Any suggestion the American Academy of Pediatrics is misleading families is false.”

--

[dertaglichedan]

A National Treasure, Tarnished: Can Britain Fix Its Health Service?

Fifteen hours after she was taken out of an ambulance at Queen’s Hospital with chest pains and pneumonia, Marian Patten was still in the emergency room, waiting for a bed in a ward. Mrs. Patten, 78, was luckier than others who arrived at this teeming hospital, east of London: She had not yet been wheeled into a hallway.

For months, doctors at Queen’s have been forced to treat people in a corridor because of a lack of space. As the ambulances kept pulling up outside, the doctor supervising the E.R., Darryl Wood, said it was only a matter of time before nurses would begin diverting patients into the overflow space again.

“We’re in that mode every day now because the N.H.S. doesn’t have the capacity to deal with all the patients,” Dr. Wood said.

Despite her ordeal, Mrs. Patten was sympathetic. Decades ago, she said, the National Health Service saved her husband’s life when he had a heart attack. “It’s got to cope with a lot more people,” she said. “You can’t be grumpy about it.”

Her stoicism captures the reverence that Britons have for their cradle-to-grave health system, but also their rueful sense that it is broken.

As it turns 75 this month, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history: flooded by aging, enfeebled patients; starved of investment in equipment and facilities; and understaffed by doctors and nurses, many of whom are so burned out that they are either joining strikes or leaving for jobs abroad.

Interviews over three months with doctors, nurses, patients, hospital administrators, and medical analysts depict a system so profoundly troubled that some experts warn that the health service is at risk of collapse.

“Doctors and nurses face an endless stream of patients filling beds,” said Matthew Trainer, the chief executive of the N.H.S. trust that runs Queen’s and another nearby hospital, the King George. “For the clinical staff, that removes a sense of hope — that sense that what you’re doing matters.”

More than 7.4 million people in England are waiting for medical procedures, everything from hip replacements to cancer surgery. That is up from 4.1 million before the coronavirus pandemic began in 2020.

Mortality data, exacerbated by long wait times, paints a bleak picture. In 2022, the number of excess deaths rose to one of the highest levels in the last 50 years, and those numbers have kept rising, even as the pandemic has ebbed.

In the first quarter of 2023, more than half of excess deaths — that is, deaths above the five-year average mortality rate, before the pandemic — were caused by something other than Covid-19. Cardiovascular-related fatalities, which can be linked to delays in treatment, were up particularly sharply, according to Stuart McDonald, an expert on mortality data at LCP, a London-based pension and investment advisory firm.

Proliferating labor unrest only adds to the crisis, throwing hospitals that were already barely coping into near paralysis. While Mrs. Patten waited for a bed at Queen’s, doctors were picketing outside, protesting starting wages that are comparable to those earned by baristas working at Pret-a-Manger, a sandwich chain in the hospital’s lobby.

FULL STORY

[businesspr]

Junior Doctors at N.H.S. Begin 6-Day Strike

The young doctors’ walkout is planned for six days — their longest action yet — and could result in numerous canceled medical visits and surgical procedures. source https://www.nytimes.com/2024/01/03/world/europe/national-health-service-doctors-strike.html

[immaculatasknight]

The captive mind

[fuojbe-beowgi]

"You Don’t Have to Be a Doctor to Know How Much Trouble the N.H.S. Is In" by Allyson Pollock and Peter Roderick via NYT Opinion https://www.nytimes.com/2023/03/17/opinion/nhs-britain-privatization.html?partner=IFTTT