#World Professional Association for Transgender Health

[religion-is-a-mental-illness]

By: Jesse Singal

Published: Jun 27, 2024

In April Hilary Cass, a British paediatrician, published her review of gender-identity services for children and young people, commissioned by NHS England. It cast doubt on the evidence base for youth gender medicine. This prompted the World Professional Association for Transgender Health (WPATH), the leading professional organisation for the doctors and practitioners who provide services to trans people, to release a blistering rejoinder. WPATH said that its own guidelines were sturdier, in part because they were “based on far more systematic reviews”.

Systematic reviews should evaluate the evidence for a given medical question in a careful, rigorous manner. Such efforts are particularly important at the moment, given the feverish state of the American debate on youth gender medicine, which is soon to culminate in a Supreme Court case challenging a ban in Tennessee. The case turns, in part, on questions of evidence and expert authority.

Court documents recently released as part of the discovery process in a case involving youth gender medicine in Alabama reveal that WPATH's claim was built on shaky foundations. The documents show that the organisation’s leaders interfered with the production of systematic reviews that it had commissioned from the Johns Hopkins University Evidence-Based Practice Centre (EPC) in 2018.

From early on in the contract negotiations, WPATH expressed a desire to control the results of the Hopkins team’s work. In December 2017, for example, Donna Kelly, an executive director at PATH, told Karen Robinson, the EPC's director, that the WPATH board felt the EPC researchers “cannot publish their findings independently”. A couple of weeks later, Ms Kelly emphasised that, “the [WPATH] board wants it to be clear that the data cannot be used without WPATH approval”.

Ms Robinson saw this as an attempt to exert undue influence over what was supposed to be an independent process. John Ioannidis of Stanford University, who co-authored guidelines for systematic reviews, says that if sponsors interfere or are allowed to veto results, this can lead to either biased summaries or suppression of unfavourable evidence. Ms Robinson sought to avoid such an outcome. “In general, my understanding is that the university will not sign off on a contract that allows a sponsor to stop an academic publication,” she wrote to Ms Kelly.

Months later, with the issue still apparently unresolved, Ms Robinson adopted a sterner tone. She noted in an email in March 2018 that, “Hopkins as an academic institution, and I as a faculty member therein, will not sign something that limits academic freedom in this manner,” nor “language that goes against current standards in systematic reviews and in guideline development”.

Not to reason XY

Eventually WPATH relented, and in May 2018 Ms Robinson signed a contract granting WPATH power to review and offer feedback on her team’s work, but not to meddle in any substantive way. After WPATH leaders saw two manuscripts submitted for review in July 2020, however, the parties’ disagreements flared up again. In August the WPATH executive committee wrote to Ms Robinson that WPATH had “many concerns” about these papers, and that it was implementing a new policy in which WPATH would have authority to influence the EPC team’s output—including the power to nip papers in the bud on the basis of their conclusions.

Ms Robinson protested that the new policy did not reflect the contract she had signed and violated basic principles of unfettered scientific inquiry she had emphasised repeatedly in her dealings with WPATH. The Hopkins team published only one paper after WPATH implemented its new policy: a 2021 meta-analysis on the effects of hormone therapy on transgender people. Among the recently released court documents is a WPATH checklist confirming that an individual from WPATH was involved “in the design, drafting of the article and final approval of [that] article”. (The article itself explicitly claims the opposite.) Now, more than six years after signing the agreement, the EPC team does not appear to have published anything else, despite having provided WPATH with the material for six systematic reviews, according to the documents.

No one at WPATH or Johns Hopkins has responded to multiple inquiries, so there are still gaps in this timeline. But an email in October 2020 from WPATH figures, including its incoming president at the time, Walter Bouman, to the working group on guidelines, made clear what sort of science WPATH did (and did not) want published. Research must be “thoroughly scrutinised and reviewed to ensure that publication does not negatively affect the provision of transgender health care in the broadest sense,” it stated. Mr Bouman and one other coauthor of that email have been named to a World Health Organisation advisory board tasked with developing best practices for transgender medicine.

Another document recently unsealed shows that Rachel Levine, a transwoman who is assistant secretary for health, succeeded in pressing WPATH to remove minimum ages for the treatment of children from its 2022 standards of care. Dr Levine’s office has not commented. Questions remain unanswered, but none of this helps WPATH’s claim to be an organisation that bases its recommendations on science. 

[ Via: https://archive.today/wJCI7 ]

--

==

So, there are 6 completed reviews sitting somewhere, that WPATH knows shows undesirable (to them) results. And they know it. And despite - or perhaps, because of - that, they wrote the insane SOC8 anyway. And then, at the behest of Rachel Levine, went back and took out the age limits, making it even more insane.

This isn't how science works, it's how a cult works.

When John Templeton Foundation commissioned a study on the efficacy of intercessory prayer, a study which unsurprisingly found that it's completely ineffective, it was forced to publish the negative results.

So, even the religious are more ethical than gender ideologues when it comes to science. This is outright scientific corruption.

[coochiequeens]

A man who got where he is, careerwise and having a family by transitioning later in life, wants to take that way from minors.

Image: WASHINGTON, DC - OCTOBER 21: (L-R) Jesse M. Ehrenfeld, MD, MPH, President of the American Medical Association; Admiral Rachel L. Levine, MD, the 17th Assistant Secretary for Health (ASH) for the U.S. Department of Health and Human Services; and Charlotte Clymer, writer, transgender activist, and military veteran speak on stage during Learning With Love: The 2023 PFLAG National Convention, four days of educating, lobbying, networking, and leading with love, taking place October 19-22, 2023 in Washington, DC. (Photo by Paul Morigi/Getty Images for PFLAG National)

A head-on collision between science and politics

By JESSE SINGAL JUN 25, 2024

When the World Professional Association for Transgender Health’s Standards of Care Version 8 was released in September 2022, a very strange thing happened: WPATH removed references to minimum age requirements for various medical interventions, describing the change as a “correction” in a notice that now reads, weirdly: “This correction notice has been removed as it referred to a previous version of the article, which was published in error.” Whatever happened, exactly, it’s clear that until late in the game the document did have age minimums until, suddenly, it did not.

The SoC 8 was supposed to have been created via something called the Delphi process. As the document itself explains: “Consensus on the final recommendations was attained using the Delphi process that included all members of the guidelines committee and required that recommendation statements were approved by at least 75% of members.” Suffice it to say that making a sudden, major change so late in the game calls into question whether that process was fully adhered to.

Thanks to a rather remarkable document just unsealed as part of Boe v. Marshall, one of the many American lawsuits over youth gender medicine, we now have a potential explanation for why the age guidelines were removed: direct pressure from assistant secretary for health of the Department of Health and Human Services Admiral Rachel Levine (who is a trans woman herself) and the American Academy of Pediatrics.

The document is titled “Appendix A To Supplemental Expert Report Of James Cantor, Ph.D. In it Cantor, a Canadian sex researcher, critic of youth gender medicine, and frequent expert witness on behalf of those attempting to ban or or restrict it (including in this case), claims that “Assistant Secretary for Health Dr. Rachel Levine strongly pressured WPATH leadership to rush the development and issuance of SOC-8, in order to assist with Administration political strategy.”

He backs this claim up with the following internal communications from WPATH members involved with the creation of the SoC 8 (here and elsewhere in the document, the names of the people who wrote the words in question are redacted):

I have just spoken to Admiral Levine today, who—as always is extremelysupportive of the SOC 8, but also very eager for its release—so to ensureintegration in the US health policies of the Biden government. So, let’s crack onwith the job!!! 

I am meeting with Rachel Levine and her team next week, as the US Department of Health is very keen to bring the trans health agenda forward.

The failure of WPATH to be ready with SOC 8 is proving a barrier to optimal policy progress and she [Dr. Levine] was eager to learn when SOC 8 might be published. 

[T]his should be taken as a charge from the United States government to do what is required to complete the project immediately. 

More worryingly, Cantor charges that “Assistant Secretary Levine also attempted to and did influence the substantive content of SOC-8, based on political goals rather than science. Specifically, Assistant Secretary Levine, though [sic] a staff member, pressured WPATH to remove recommended minimum ages for medical transition treatments from SOC-8.”

Here, too, he has evidence from anonymized emails written by those involved in the SoC 8:

Sarah Boateng, who is Adm. Levine’s chief of staff [said the] biggest concern is the section below in the Adolescent Chapter that lists specific minimum ages for treatment, she is confident, based on the rhetoric she is hearing in DC, and from what we have already seen, that these specific listings of ages, under 18, will result in devastating legislation for trans care. She wonders if the specific ages can be taken out and perhaps an adjunct document could be created that is published or distributed in a way that is less visible than the SOC8, is the way to go. 

The issue of ages and treatment has been quite controversial (mainly for surgery) and it has come up again. We sent the document to Admiral Levine. . . She like [sic] the SOC-8 very much but she was very concerned that having ages (mainly for surgery) will affect access to health care for trans youth and maybe adults too. Apparently the situation in the USA is terrible and she and the Biden administration worried that having ages in the document will make matters worse. She asked us to remove them. We have the WPATH executive committee in this meeting and we explained to her that we could not just remove them at this stage. 

[W]e heard your [Dr. Levine’s] comments regarding the minimal age criteria for transgender healthcare adolescents; the potential negative outcome of these minimal ages as recommendations in the US [. . . ] Consequently, we have changes to the SOC 8 in this respect. Given that the recommendations for minimal ages for the various gender affirming medical and surgical intervention are consensus-based, we could not remove them from the document. Therefore, we have made changes as to how the minimal ages are presented in the documents. [Note: “your” may well refer to an aide of Levine’s rather than the Secretary herself, though it’s unclear.] 

Cantor also includes emails from SoC 8 contributors expressing surprise at the sudden change, including this one making. . . well, the same point everyone else made after news of the late-stage “correction” broke:

I don’t see how we can simply remove something that important from the document—without going through a Delphi—at this final stage of the game [. . . ] I realize that those in favor of the bans are going to go right to the age criteria and ignore the fact that we actually strengthened the strictness of the criteria to help clinicians better discern appropriate surgical candidates from those who are inappropriate [. . . ] It’s all about messaging and marketing. 

I��m actually crashing on a different but related freelance story at the moment. Check out Leor Sapir’s Twitter timeline for more details about this and another just-unsealed document. Next week, when I’ve caught my breath, I’ll write a little bit more about this as well as yet another damning claim Cantor makes, that the American Academy of Pediatrics “issued an ultimatum to WPATH: Should WPATH not delete the age minimums, AAP would not only withhold endorsement of SOC-8, but would publicly oppose the document.” 

But I wanted to at least get this short piece up, because the Levine angle is important and alarming. It demonstrates an indisputable conflict between how WPATH has portrayed the SoC 8 — as a document steeped in evidence and careful deliberation on the part of experts — and how the guidelines were actually formulated.

[itsawritblr]

Publication of the leaked WPATH files.

Via Environmental Progress.

The written WPATH Files come from WPATH’s member discussion forum, which runs on software provided by DocMatter. Ninety seconds of the 82-minute video was made public last year. We are making the full video available for the first time. One or more people gave me the WPATH Files, and my colleagues and I attempted to summarize them as a series of articles. We quickly realized the topic was too sensitive, complex, and large to be dealt with as a work of journalism, and we moved the project to the research institute I founded seven years ago, Environmental Progress (EP). The Files are authentic. We redacted most names and left only those individuals who are leading gender medicine practitioners to whom we sent “right-of-reply” emails. We know WPATH members discussed our emails internally. No WPATH leader or member has denied that the Files are anything other than what they appear to be. EP is publishing a 70-page report to provide context for the 170 pages of WPATH Files. Mia Hughes is the author of the report. It and accompanying summary materials can be downloaded at the link below. That link also provides a link to the full WPATH video. What follows are simply a few highlights. People with a serious interest in the topic should read the report and all the files."

READ: THE WPATH FILES AND REPORT

[eredhes]

[ID Lino prints of a stylised Przewalski’s horse rearing up, there are two versions of the design, mirrored, except the first one has a dark face, neck, and shoulder stripes. The first image is the first design against a landscape, gradient rainbow background. The second image is both designs double printed with black ink on top of the same design printed with gradient rainbow inks. End ID.]

Personal favourites from the rainbow batch.

50% of the profits for these will be donated to the Good Law Project who are currently challenging the ban in the UK on puberty blockers for trans young people. I started typing out a longer explanation but I will instead link to the statement from the World Professional Association for Transgender Health (WPATH) on the Cass Review (the reason blockers have been banned) here.

I'd also encourage you to donate directly to the Good Law Project here.

eredhes.etsy.com

[feminismisstillahatemovement]

In 2017 I interviewed Bernadette Wren, then head of psychology at the Tavistock Gids clinic, and asked what effect puberty blocking drugs have on the adolescent brain. Looking highly uncomfortable, she replied that the evidence so far was only anecdotal but that the clinic would study its patients “well into their adult lives so that we can see”.

Even back then, before whistleblowers had exposed the rush to medically transition children, it was alarming to hear that heavy-duty GnRH agonists such as triptorelin — used to treat advanced prostate cancer and “chemically castrate” sex offenders — were being prescribed to arrest puberty in hundreds of children as young as 11.

Moreover, they were being used “off-label” before any clinical trials. And the long-term study Wren promised never materialised: Gids (the Gender Identity Development Service) routinely lost touch with patients, and the 44 it did follow reported little long-term mental health improvement.

This shocking chapter in medical history, where the ideological objectives of trans rights campaigners trumped the welfare of disturbed children, is coming to an end worldwide. The decision by NHS England effectively to ban the prescription of puberty blockers comes after the Cass review noted these drugs could “permanently disrupt” brain development, reduce bone density and lock children into a regime of cross-sex hormones requiring life-long patienthood.

NHS England unites with other national health services including those in Finland, France, Sweden and, most notably, the Netherlands — where the “Dutch protocol”, a regime of early blockers then hormones, was devised in 1998 — in pulling back from prescribing them.

Even in the United States, where a toxic combination of extreme activism and medical capitalism has pushed child gender medicine to grotesque extremes, with double mastectomies performed on 14-year-old girls, there is some retrenchment.

Leaks from the World Professional Association for Transgender Health, the body which formulates guidance on “trans healthcare”, reveal doctors perplexed at how they should explain to an 11-year-old child that drugs will render them infertile. Crucially, liberal media such as The New York Times are now reporting grave medical misgivings about child transition, once dismissed as a culture-war issue for the Republican right.

Yet the question remains: how was this ever allowed to happen? For years, puberty blockers were cheerily billed as a mere “pause button”. In 2014, Dr Polly Carmichael, the last head of Gids before the Cass review ordered its closure, went on CBBC in a show called I Am Leo, saying of blockers: “The good thing is, if you stop the injections, it’s like pressing ‘start’ and the body carries on developing as it would if you hadn’t started.”

The BBC permitted her to make this unevidenced claim to an impressionable audience of six to 12-year-olds. Imagine hearing this as a developing girl, freaked out by your new breasts and periods. No wonder Gids referrals subsequently rocketed.

Carmichael failed to mention that she did not know if pressing “restart” on puberty is always medically possible — it is not — and in fact, almost every child Gids put on blockers went on to irreversible cross-sex hormones.

After years in a Peter Pan state while their peers developed, they understandably felt there was no way back and forged on with treatment. Yet if allowed to experience natural puberty, almost 85 per cent of gender dysphoria cases resolve themselves.

Nor did Carmichael tell CBBC kids that the blockers-hormones combination, if taken early enough, not only results in sterility but kills the libido so that a young person will never experience an orgasm.

At the 2020 judicial review brought by a former Tavistock clinician and Keira Bell, the brave young detransitioner rushed onto hormones by Gids, judges expressed astonishment at Gids’s lack of an evidence base.

Reporting on this issue for seven years, I too have been struck by a complete clinical incuriosity. Not only was data not collected, but those who queried treatments or pressed for evidence faced angry condemnation. Perhaps activists knew what research might find because one long-term Finnish study, recently reported in the BMJ, destroyed the myth used to justify blockers: that a child will commit suicide if denied them.

The Finns found that “gender-affirming care” does not make a dysphoric child less suicidal. Rather, such children had the same suicide risk as others with severe psychiatric issues. In other words, changing bodies does not fix troubled minds.

Yet even after NHS England’s announcement, activists refuse to heed the now-overwhelming evidence. In its response, Stonewall persists with the myth that puberty blockers “give a young person extra time to evaluate their next steps”.

Many questions remain unanswered: will private clinics still be permitted to prescribe puberty blockers; and is Scotland’s Sandyford child gender clinic still determined to close its ears to all evidence? Plus, we have few details on how the NHS’s new “holistic” treatment for gender-questioning children will operate when it opens next month.

This repellent experiment — in which girls who like trucks or little boys who dress as princesses, and who invariably grow up to be gay, are corralled inexorably down a road towards life-changing treatments — belongs in the book of medical disgraces. As do the cheerleaders who raised money for Mermaids and those who persecuted whistleblowers or damned journalists asking questions as transphobic.

In 50 years, chemically freezing the puberty of healthy children with troubled minds will be regarded with the same horrified fascination as lobotomies — which, never forget, won the Portuguese neurologist Antonio Egas Moniz the 1949 Nobel prize.

--------------------

{Article source (behind paywall)}

[probablyasocialecologist]

While the Cass Review has been presented by the U.K. media, politicians and some prominent doctors as a triumph of objective inquiry, its most controversial recommendations are based on prejudice rather than evidence. Instead of helping young people, the review has caused enormous harm to children and their families, to democratic discourse and to wider principles of scientific endeavour. There is an urgent need to critically examine the actual context and findings of the report. Since its 2020 inception, the Cass Review’s anti-trans credentials have been clear. It explicitly excluded trans people from key roles in research, analysis and oversight of the project, while sidelining most practitioners with experience in trans health care. The project centered and sympathized with anti-trans voices, including professionals who deny the very existence of trans children. Former U.K. minister for women and equalities Kemi Badenoch, who has a history of hostility toward trans people even though her role was to promote equality within the government, boasted that the Cass Review was only possible because of her active involvement. The methodology underpinning the Cass Review has been extensively criticized by medical experts and academics from a range of disciplines. Criticism has focused especially on the effect of bias on the Cass approach, double standards in the interpretation of data, substandard scientific rigor, methodological flaws and a failure to properly substantiate claims. For example, although the existing literature reports a wide range of important benefits of social transition and no credible evidence of harm, the Cass Review cautions against it. The review also dismisses substantial documented benefits of adolescent medical transition as underevidenced while highlighting risks based on evidence of significantly worse quality. A warning about impaired brain maturation, for instance, cites a single, very short speculative paper that in turn rests on one experimental study with female mice. Meanwhile extensive qualitative data and clinical consensus are almost entirely ignored. These issues help explain why the Cass recommendations differ from previous academic reviews and expert guidance from major medical organisations such as the World Professional Association for Transgender Health (WPATH) and the American Academy of Pediatrics. WPATH’s experts themselves highlight the Cass report’s “selective and inconsistent use of evidence,” with recommendations that “often do not follow from the data presented in the systematic reviews.” Leading specialists in transgender medical care from the U.S. and Australia emphasize that “the Review obscures key findings, misrepresents its own data, and is rife with misapplications of the scientific method.” For instance, the Cass report warns that an “exponential change in referrals” to England’s child and adolescent gender clinic during the 2010s is “very much faster than would be expected.” But this increase has not been exponential, and the maximum 5,000 referrals it notes in 2021 represents a very small proportion of the 44,000 trans adolescents in the U.K. estimated from 2021 census data.

7 August 2024

[catboybiologist]

Ho boy I just got hit with a wave of HRT related asks.

I'll respond to them to the best of my ability, but imma make a copy/paste disclaimer here:

I AM NOT A MEDICAL PROFESSIONAL. I have a very, VERY marginal ability to interpret medical data over the average person due to my bio background, but it's far less than people think- hell I just said something wrong about insurance that someone had to correct.

Unfortunately, however, the nature of trans healthcare being under constant political threat worldwide means that everyone should prepare to diy, and know the basics of how they would pull that off. That's why I'm answering these questions, more info out there is always better. HOWEVER, you would better be served by other sources, like:

Anything I say directly about medical care will be an interpretation or regurgitation of something that is likely in these sources, plus a dash of personal experience. My bio knowledge and interpretation is not going to kick in here, it's gonna be too far deep in the weeds of cellular mechanisms that it's not directly relevant.

[misscammiedawn]

Gender, Dissociation and Clinical Stigma - The Third Person

Before I begin I just want to note that typically Media, Myself and I entries are aimed at depictions of dissociative disorders in popular fiction. Today's entry is a graphic novel memoir by a transgender woman with dissociative identity disorder. As it's both not in the public zeitgeist and good representation by virtue of being lived experience of someone who struggled within the mental healthcare system I want to recommend people buy the book (or check it out of their local library). I fully support the artist and want to prop up something good and beautiful.

With that said, let's begin...

CW: therapy abuse

With all the recent hysteria in the US and UK media over transgender healthcare it can be easy to forget the hurdles we all have to climb to receive care. Though Informed Consent is becoming more of a standard practice these days the DSM-5 Criteria for Gender Dysphoria indicates a 6 month requirement for observation before HRT can be prescribed. Many of us needed to jump the hoops of living 6-12 months "in the gender role that is congruent with their gender identity" before we were allowed to begin our gender journey in earnest.

Of course. This requires a clinician (or two for surgical options) to observe this, monitor it and sign off on it. But therapists are humans and are full of prejudice, bias and their own beliefs. They aren't guaranteed to think it is medically necessary or positive for a person seeking gender affirming care to receive it.

So where does DID fit into this picture?

A study, published in 2015, states clearly that 30% of transgender individuals met the criteria for a dissociative disorder.

Yet even still, The World Professional Association for Transgender Health (WPATH), the gold standard for transgender care included this warning in their Standards of Care up until September 2022.

(source)

Fortunately that passage is no longer included in WPATH guidelines as of the 8th revision released in 2022. I shall say the above passage did grant a scare for us, though, as it was very much the practice when we were going for our surgery.

Standards of Care improve and medical understandings of both gender and dissociative care are becoming kinder towards clients.

Even still. There's always that fear. That months of therapy could be wasted on a clinician who was never going to sign off on HRT and was never going to believe our lived experience as a system.

We wouldn't have gotten nearly half as far as we have gotten without our therapist helping us identify our condition, manage our symptoms and develop cooperation and communication.

It's terrifying to think what life would be like if our symptoms not only went unmanaged, but we were made to feel fake and attention seeking by the very person we paid to take care of us...

-

With that intro in mind, The Third Person by Emma Grove is a memoir told in graphic novel format over 920 pages covering the period of life where she began therapy in hopes of receiving feminizing HRT not realizing she had an undiagnosed case of dissociative identity disorder.

When one opens the book they will see an Author's Note declaring that every word in the book is as accurate as Emma's memory will allow and any edits are to streamline the story, not to tailor anything to match the author's point of view and there is a dedication:

"For Katina - We finally did one together"

The story proper begins in media res Winter 2004, as Emma asks her therapist if he would like to hear about the book she was reading and the therapist responds asking why the client decided to speak with him "as Emma" today. Emma, confused, does not understand the question and is probed about her parts, about Ed and Katina and about her childhood. That last word being enough to cause Emma to freeze up, dissociate and...

This simple intro gives us all the context a reader needs to understand the antagonistic dynamic between Toby, the therapist, and his patient(s). Both client and patient are unable to understand the other and harbor suspicions about the other's intentions.

Without the context we only know Emma had a book, she no longer has a book and she suspects her therapist of being a mean person who is playing tricks on her.

We will get context later.

The first chapter of the book provides an introduction to the author's late teens and early 20s where they explore their gender identity and have their first experiences with their masked dissociative disorder.

The book goes to lengths to show the stress of the author dividing themselves between having to present male in their public life and sneaking out to bars where they can wear make-up, wigs and outfits to present female.

They take on their legal name, Ed, during their public life and when going out to clubs take the name Katina, from the first bar they visited presenting femme. The name Emma comes later when the system is working to transition into living as a woman in all aspects of their shared life.

The book patiently explores the stress of having to divide ones own self for their safety in spaces where they cannot present their truth without threat from an intolerant society. If 30% of transgender people suffer from dissociative disorders then a much higher number of them know the stress of having to compartmentalize themselves into different presentations for different audiences.

For us, we know that pain all too well. Our birth identity remains with us as a member of our own system. Less a ghost of our past and more a remnant of a mask we constructed to perform the version of self required for our safety.

The artwork does a good job of displaying switches and co-consciousness with subtle expression work, the hair style/wigs that each alter favors. For example we have the left displaying co-consciousness and a switch.

As the years go on, Katina finds ways to go out to the club and exist in her comfort and Ed labors hard to ensure that they can live for the times they get to "become" themselves.

Katina is established to be a fierce personality who will get aggressive when people push against her. She loves to dance and sing and party at the club. She is both a free spirit without inhibition and a fierce protector who will keep the system safe.

I recall feeling a deep fondness and connection towards Katina when we first read the book.

Once the narrative has firmly established the history that lead to the system seeking HRT we are brought into the meat of the book. A white void with a sofa and an armchair. The therapist's office where Katina, Emma and Ed speak with Toby.

Toby is a trans man that Katina believes to be an ally who will sign off on their HRT once the prerequisite 3 month waiting period is over. Unfortunately over the course of those months Toby becomes aware of Emma and Katina's switches and is convinced that it would be unethical for him to sign off on HRT when it is possible that there may be another 'guy part' in there who will 'wake up' one day and decide that he did not want to transition.

To his credit, once Toby suspects a dissociative disorder he does offer Emma a referral to a specialist. They do not take it as they just want to be signed off for HRT and have no interest in exploring their situation beyond transitioning. So they stick with Toby, convinced that another transgender individual will support them.

Toby, however, sticks to his guns and refuses to agree until they manage the DID.

In the opening, sampled above, Emma switches out at the mere mention of her childhood. Here we find that Katina will front any time Emma is made to think about her past and she refuses to allow Toby to force her to think about it or discuss it. She goes as far as to demand Toby promise not to push which, again, Toby refuses.

During this conflict both sides have exaggerated gestures of frustration, many exclamation points and underlined words. This is not a healthy dialogue at all. Toby is refusing to find middle ground or guide the therapy towards its intended destination. He denies all Katina's attempts to negotiate around the need to talk about her childhood (something she is convinced at this point has nothing to do with her stated goal of HRT) and continuously pushes that she needs to talk about it, without elaborating as to why.

Toby, untrained in dissociative disorders, is focused on getting her to open up about her childhood trauma. Katina, uninterested in exploring trauma, wants to be signed off for HRT. Neither side is willing to budge.

This isn't therapy. This is an argument.

Recently I wrote a Tumblr post about the "Hair Dryer Incident"

The Hair Dryer Incident is a story about a patient with OCD whose life was being massively disrupted by the fear that they had left their hair dryer plugged in at home and it would burn their house down. The clinician advised them to take the hair dryer to work with them every day so that they could see the hair dryer with them and not have to drive home to ensure it was safely unplugged.

There was debate in medical circles about whether this was "enabling" because it did nothing to treat the illness, only managed the life disrupting symptom of needing to drive home to check that the dryer was not plugged in.

For Toby in this scenario he believes that allowing Emma to transition would be "enabling" the sickness that he perceives, that being dissociative identity disorder. He has brought his own baggage into the office and only views Emma and Katina as parts of Ed. No amount of Emma and Katina self-advocating in his eyes will change his mind because they are not "real" in his view.

Of course, he is not fully sold on Emma's condition being real either. There is a sequence in which Emma is left alone in the room and she, having a fascination with books, checks out Toby's bookshelf. This causes Toby to become suspicious and decide that Emma has been reading the medical textbooks on dissociative disorders in order to fake an illness and trick him.

This is not a healthy therapeutic alliance and Toby is breaking all 3 key pillars of establishing a strong patient/client partnership.

Much of modern therapy techniques are based on the concept of Therapeutic Alliance. The history of which dates back to Sigmund Freud and the concept of transference but was refined and redefined by Carl Rogers in the modern Patient Centered Therapy (sometimes referred to as Rogerian Therapy).

With that in mind let's examine the 3 key elements of successful PCT(*) and how Toby failed.

Lead with a Patient Centered Approach This means to check all baggage at the door. Cultural biases have no room inside the clinic (during the book Toby openly mocks Emma's faith in God) and that the patient's priorities are the ones that should be focused on. Both client and clinician should be on the same page of what treatment is being sought, what goals are and how they will be achieved. Toby and Emma (or Katina and Ed) never establish this agreement during their time together. Katina/Emma/Ed are firm in their desire to transition and Toby is firm on his refusal to allow this until the DID is addressed.

Set clear goals with a treatment plan. A good treatment plan will have dates, targets and regular review and reward honesty for both/all parties involved in the alliance. Toby is telling Emma and Katina that they need to open up about their childhood but does not explain how this will benefit or what their goals are. Simply "it's good to talk about it" with no direction or assurances.

Regularly review satisfaction with the therapeutic process, relationship, and treatment plan. This element states that it is important that the clinician be upfront with any potential misdiagnosis and discuss any skepticism in the process and lead from a position of patient satisfaction. I do not need to highlight how Toby failed to lead from a position of patient satisfaction here.

Clearly Toby has a personal concept of what the correct approach is and is holding Emma/Katina's gender affirming care hostage until they can satisfy his unspoken objectives. Correctly applied PCT should be a discussion of mutual agreement and achievable goals worked over a period of time. Toby is not applying these principals at all. His modality simply seems to be "talk about it." I'll be an ethical writer who discloses their biases and say I despise PCT/Rogerian therapy. It is, however, the leading modality within western therapy and it is well researched. Not to mention it is the modality Toby appears to be utilizing in the book. I firmly disagree with Freud on all things (except the concept of infant experiences have lifelong ramifications. A broken clock is right twice a day) and disagree with Rogers on the idea that the client has all of the answers and needs to get out of their own way. An issue with this is that DID is a covert disorder and it will do everything it can to stay hidden. PCT does not offer an environment where patients will be able to navigate their condition as unless they are aware of their symptoms, how and when they manifest and are open to discussing those facts they will naturally steer away from circumstances that would lead to a diagnosis. Most people, including myself, have to exist in the mental healthcare system for 5-12 years before being correctly diagnosed with DID(*) and will experience a number of incorrect diagnoses before finding appropriate care. For us it was 9 years and 7 diagnoses. So. Toby's directive is that the system needs to get to the root of the condition and neither Katina nor Emma are willing to open up about their childhood. Katina continues sticking to her guns and refuses but Emma, desperate to start her medical transition, agrees to open up and the two form a shaky alliance where week by week the pair go back and forth between alliance and conflict. In time Emma describes her childhood being raised by her grandfather who was physically abusive towards her. All too quickly Katina's fears are justified by Toby's combative approach to patient care. One session Emma demands to know why she cannot work on her DID while she transitions and Toby states firmly that she is "not transsexual" which triggers Emma to dissociate into a black void that no one can reach her within. She wanted to be seen and regarded as a woman and a trans man told her flat out that he cannot and does not see her as such. Going back to the hair dryer incident as a reference for a moment. Ed is a member of the system and does show up for therapy on some days. At a point Katina, fed up with being denied treatment, makes a plan to quit their job and start a new life living as a woman 24/7. Ed creates a safety net to prevent this from ruining their collective life and continues to work in the meanwhile. Ed's role in the system has been ground down to working and working alone. He spends his days keeping so busy that he cannot dwell, a panel having the thought bubble "I can't slow down! If I slow down I have to think!" which is depressingly relatable to how we were in the worst years of repressing our gender identity. If Ed is unhappy living as a closeted man who has to occupy himself 24/7 to stop from caving in on himself, if Emma and Katina are both completely stunted by their inability to transition; is it ethical to allow them to transition and to work on their condition while allowing them the freedom to live openly as their chosen gender and prevent a circumstance that is harming the entire system? Toby seems to think it is enabling.

30% of the transgender individuals in the study above were observed to meet the criteria for a dissociative disorder. Living a life where one must mask has severe detrimental impacts on a person's psychology. This is true not just for transgender individuals but for those with autism (*) and other individuals on the LGBT spectrum (*) where the cognitive dissonance between who a person values themselves to be versus how they must present to the world causes the mind to dissociate further and allow contrary thinking to exist in individual pockets of a person's life as well as creates an alienation of the self. Healing under these circumstances requires accepting and embracing oneself, not creating a further divide.

After Toby "caught" Emma looking at the bookshelf he became convinced that she was faking her condition. That she had been plucking symptoms from a book and performing them for him. That she fit the criteria "too well"

Emma rightfully demands to know why she would complicate her receiving HRT by doing something that prevents her being able to. The pair bicker and Toby cuts off the session abruptly.

in the heat of the moment, assuming that Emma was an attention seeker who does not deserve care, Toby declares "Your grandfather was right to hit you."

Even Emma later admits later that therapy should have ended with Toby right there and then. Hindsight is 20/20, as they say. Alas, a mixture of finances and sunk cost keep Emma returning to the chair week after week.

Being trans and having DID are terrifying. In order to receive care and treatment we must insist to a world that what is happening in our hearts and minds is true in spite of all that the world outside tells us is true. We need to not only reach that conclusion within our own lives but must express that truth loud enough that the people around us see it, regard it and accept it.

As so many things in this world are, it's so hard to earn and so easily burned.

"You're faking it for attention" is such an easy sentence to fling at someone and in a therapeutic setting all things should lead to curiosity. Even if a person were faking, it's not normal and healthy behavior for someone to do that. Toby is displaying a complete lack of curiosity and compassion. He is framing himself as the victim in a potential deception from someone who is paying what little money they can put together to receive his care.

I hate Toby.

As the story continues, Emma and her system begrudgingly continue, flitting back and forth between a healthy and unhealthy dynamic with their therapist that shares a lot of similarities to abuse honeymoons. It is worth noting that as the book is a memior it will inevitably be painted with the author's personal view of past events because, as discussed in the Umineko article on recontextualized memories, a human mind cannot avoid applying present understandings to past experiences when recalling memory. This is seen in the book when we see things that Emma cannot possibly have witnessed, such as Toby's facial expression after she leaves the office.

This is not to throw shade at how Emma depicts her former therapist, as he was quite horrid to all 3 of them and quite obviously did more harm than good during their time together. I just wish to note that skewed perspectives are an inevitability. Even still. They do make some progress in talking about the situations. We come to learn of the system origins and how Katina was a friend to the young and lonely child they used to be and that their abusive childhood was centered around physical abuse from their grandfather. While discussing this Emma notes that she could make Katina go away forever with a single phrase. A few short words that she can never ever say and mean or Katina would go away and never come back... and I think that's where I'll stop with the synopsis. I (specifically me, Dawn) broke down in tears the first time I read the book and I have no will to put myself through that again at this exact moment and I wish for you all to have the catharsis of experiencing it for yourself.

I will say in way of positivity that the story is quick to make its conclusions in the final chapters by displaying therapy done right and the fact that even if parts can no longer be heard or even felt, they will always endure in moments where they can add a little color to the world.

They got to write this book together, after all.

For all the sadness this memoir elicits it speaks an honest and hard truth of the desperation, isolation and confusion that can be found in managing sentiments of identity and gender in a time when there was so little understanding and acceptance, particularly for transgender people.

We are lucky these days to have the internet as it is where we can create community and find our people and in finding our people have a better understanding of who we are and how we can live our truths. Visibility of transgender and plural populations has been increasing in part due to the fact we are able to feel unalone and forge community.

2004 did not have those luxuries and I am saddened that Emma Grove had to live through that stigma and lost so much time to unethical and prejudice care from a clinician.

I do hope that in the future we can continue accepting and encouraging one another and living lives where we are not forced to hide, mask or pretend.

-

For other Media, Myself and I articles, please check out the following:

[evidence-based-activism]

"Research into trans medicine has been manipulated"

The Sources

A recent Economist* article has described how the World Professional Association for Transgender Health (WPATH) has manipulated research into trans medicine. The article is reproduced here in full by the Society for Evidence-Based Gender Medicine (SEGM). The SEGM also discusses the topic in their discussion on how "WPATH Influence Undermines WHO’s Transgender Guidelines"

*For those who care: The Economist is rated as "least biased" and "highly factual" by Media Bias/Fact Check. While it has varied over time, they currently tend to be preferred by a left-leaning audience.

The Situation

Essentially, unsealed court documents have shown WPATH first commissioned research into trans medicine from Johns Hopkins University (for the "development" of their guidelines) and then prevented the researchers from publishing this research. (Among other ethical violations including undue influence over manuscript contents and requiring researchers to (illegitimately) claim independence from WPATH.)

Presumably their suppression and manipulation of the research occurred because the conclusions reached by the researchers did not meet advance their desired opinions.

This is extraordinarily unethical from a scientific, medical, and political perspective. Strong objections from the researchers involved were documented, but ultimately failed to prevent the limitation of academic freedom and maintenance of scientific integrity. Aside from this, their actions have deprived their own community (trans individuals) from potentially vital information about their medical treatments.

So, the next time someone asks for "proof" that the current standards of trans medicine are not evidence based and may, in fact, be harmful: reply with these sources documenting the unscientific, unethical suppression of such proof. (And, while you're at it, remind them that the burden of proof is on intervention, not the lack of intervention.)

Choice Quotes from the Sources

From the reproduced Economist article:

From early on in the contract negotiations, WPATH expressed a desire to control the results of the Hopkins team’s work.

Ms Robinson [the research director] saw this as an attempt to exert undue influence over what was supposed to be an independent process.

But an email in October 2020 from WPATH figures, including its incoming president at the time, ... made clear what sort of science WPATH did (and did not) want published. Research must be “thoroughly scrutinised and reviewed to ensure that publication does not negatively affect the provision of transgender health care in the broadest sense,” it stated.

[The WPATH president has] been named to a World Health Organisation advisory board tasked with developing best practices for transgender medicine

Another document recently unsealed shows that Rachel Levine, a trans woman who is assistant secretary for health, succeeded in pressing wpath to remove minimum ages for the treatment of children from its 2022 standards of care.

From the extended discussion by the SEGM:

The court documents reveal that WPATH leadership was "caught on the wrong foot" when two systematic reviews of evidence regarding endocrine interventions, ... did not provide the kind of support that WPATH was hoping to see. Consequently, WPATH leadership, ... took action to prevent the evidence evaluation team from making public the offending systematic reviews.

The court documents also reveal that WPATH subsequently instituted a new approval policy to ensure that only favorable evidence reviews could be published by researchers engaged in evaluating the evidence: (... WPATH had to approve the conclusions. ... WPATH had ongoing content control over the content of the planned publication. ... WPATH had the final document control.)

The authors were also required to insert into the article a statement that asserted its independence from WPATH, effectively denying that WPATH interference had taken place. [Imagine a drug company exerting this much influence over research into their a drug, and then demanding the researchers lie about this influence.]

[The Baker 2012 review] was the only review to survive WPATH’s approval process, despite "dozens" of reviews being completed by the Johns Hopkins team, as the court documents reveal. [Meaning dozens were suppressed, presumably for unfavorable conclusions.]

The Baker review has an alarming number of irregularities, which bear the marks of WPATH interference, and which deserve a separate spotlight. Here, we will only note that the review's conclusions ... are explicitly contradicted by the actual systematic review findings, which found only "low" and "insufficient" evidence.

The suppressed evidence regarding hormones interventions for all age groups raises questions about what basis WHO is using for its presumption that hormones should be widely available to all adults who seek them [This is of particular concern since several influential members of WPATH - including its president - have been appointed to the WHO board developing clinical guidelines]

[religion-is-a-mental-illness]

By: Gerald Posner

Published: Mar 4, 2024

Newly leaked files from the world’s leading transgender health-care organization reveal it is pushing hormonal and surgical transitions for minors, including stomach-wrenching experimental procedures designed to create sexless bodies that resemble department-store mannequins.

The World Professional Association for Transgender Health documents demonstrate it’s controlled by gender ideologues who push aside concerns about whether children and adolescents can consent to medical treatments that WPATH members privately acknowledge often have devastating and permanent side effects.

Yet the US government, American doctors and prominent organizations nonetheless rely on WPATH guidelines for advice on treating our youth.

The files — jaw-dropping conversations from a WPATH internal messaging board and a video of an Identity Evolution Workshop panel — were provided to journalist Michael Shellenberger, who shared the documents with me.

Shellenberger’s nonprofit Environmental Progress will release a scathing summary report, comparing the WPATH promotion of “the pseudoscientific surgical destruction of healthy genitals in vulnerable people” to the mid-20th-century use of lobotomies, “the pseudoscientific surgical destruction of healthy brains.”

‘Arbitrary’ age limits

The comparison to one of history’s greatest medical scandals is not hyperbole.

It is particularly true, as the files show repeatedly, when it involves WPATH’s radical approach to minors.

When the organization adopted in 2022 its current Standards of Care — relied on by the National Institutes of Health, the World Health Organization and every major American medical and psychiatric association — it scrapped a draft chapter about ethics and removed minimum-age requirements for children starting puberty blockers or undergoing sexual-modification surgeries.

It had previously recommended 16 to start hormones and 17 for surgery.

Not surprisingly, age comes up frequently in the WPATH files, from concerns about whether a developmentally delayed 13-year-old can start on puberty blockers to whether the growth of a 10-year-old girl will be stunted by hormones.

During one conversation, a member asked for advice about a 14-year-old patient, a boy who identified as a girl and had begun transitioning at 4.

The child insisted on a vaginoplasty, a surgery that removes the penis, testicles and scrotum and repositions tissue to create a nonfunctioning pseudo-vagina. It requires a lifetime of dilation. Was he too young at 14?

Marci Bowers, WPATH’s president and a California-based pelvic and gynecologic surgeon who is herself transgender, said she considered any age limit “arbitrary.”

But she would not do it. Why?

“The tissue is too immature, dilation routine too critical.”

In lay terms, that means boys who are too young do not have enough penal tissue for the surgery and the surgeon must harvest intestinal lining to build the faux vagina. Even Bowers admits that can lead to “problematic surgical outcomes.”

She would know since she has performed more than 2,000 vaginoplasties. Her highest-profile patient is 17-year-old Jazz Jennings, the transgender star of reality TV show “I Am Jazz.”

Three corrective surgeries were required to fix problems from the original vaginoplasty.

“She had a very difficult surgical course,” Bowers admitted in a 2022 appearance on the show. “We knew it would be tough — it turned out tougher than any of us imagined.”

Still, Bowers told her colleagues in the internal discussion forum of the best age for an adolescent to undergo surgery: “sometime before the end of high school does make some sense in that they are under the watch of parents in the home they grew up in.”

Christine McGinn, a Pennsylvania plastic surgeon and herself transgender, agreed. McGinn has performed “about 20 vaginoplasties in patients under 18” and thinks the “ideal time in the U.S. is surgery the summer before the last year of high school. I have heard many other surgeons echo this.”

Waiting until teens are older than 18 and in college is problematic, she said: “there are too many stressors in college that limit patients’ ability to dilate.”

Dangers downplayed

WPATH assures patients that surgical and hormonal interventions are tested and safe. It is a different matter in private.

President Bowers, for instance, said publicly in 2022 that puberty blockers are “completely reversible,” although in the internal forum she conceded it is “in its infancy.”

What about children who are infertile for life since they started hormone blockers before they reached puberty?

Bowers told her colleagues the “fertility question has no research.”

At other stages, members talk frankly about the complications for the transition surgery for girls, a phalloplasty in which a nonfunctioning pseudo-penis is fashioned from either forearm or thigh tissue.

It requires a full hysterectomy and surgical removal of the vagina. They also discuss other serious consequences, including pelvic inflammatory disease, vaginal atrophy, abnormal pap tests and incontinence.

A 16-year-old girl who had been on puberty blockers for several years before she was put on testosterone for a year had developed two liver tumors that an oncologist concluded the hormones had caused. Another member described “a young patient on testosterone for 3 years” who had developed “vaginal/pelvic pain/spotting . . . [and] atrophy with the persistent yellow discharge.”

Several colleagues described patients with similar conditions, some with debilitating bowel problems or bleeding and excruciating pain during sex (“feeling like broken glass”).

Vaginal estrogen creams and moisturizers as well as hyaluronic acid suppositories “can be helpful.”

One WPATH member seemed surprised: “The transgender people under my surveillance do not complain about this matter. However, I confess that I have never asked them about it.”

Rise of ‘de-gender’ surgery

The litany of transition surgery’s side effects did not stop WPATH from endorsing far more radical “nullification” surgeries for patients who do not feel either male or female and identify only as nonbinary.

Several dozen so-called “de-gendering” surgeries are designed to create a sexless, smooth cosmetic appearance that is unknown in nature. There is even an experimental “bi-genital” surgery that attempts to construct a second set of genitals.

In 2017, when tabloids reported a 22-year-old man had spent $50,000 to surgically remove his sex organs so he could “transform into a genderless extra-terrestrial,” it seemed a one-off oddity.

But WPATH has enshrined that concept in its Standard of Care — the same document in which the group endorsed for the time first time chemical or surgical castration for patients who identify as eunuchs. (WPATH even linked to the Eunuch Archives, where men anonymously share castration fetishes.)

These science-fiction-like surgeries are not only reserved for adults.

“How do we come up with appropriate standards for non-binary patients?” asked Thomas Satterwhite, a San Francisco-based plastic surgeon who has operated on dozens of patients younger than 18 since 2014. “I’ve found more and more patients recently requesting ‘non-standard’ procedures.”

What are nonstandard procedures? They include “non-binary top surgery,” a mastectomy without nipples. There are brutal procedures for girls that eliminate all or part of the vagina and for boys that amputate the penis, scrotum and testicles.

The goal, as one San Francisco surgical clinic proclaims on its website, “is a smooth, neutral body that is cosmetically free of sexual identification.” On TikTok the trend is called a “flat front.”

‘Too young to understand‘

A particularly intense subject of discussion was whether minors could understand the lifelong consequences of their gender treatments. Minors are presumed by law to be incapable of making an informed decision about having a vasectomy or tubal ligation.

Gender surgeries are an exception, however.

WPATH’s Standard of Care allows all procedures so long as the minor “demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.”

In a May 2022 internal workshop, “Identity Evolution,” WPATH members conceded that was all but impossible.

Daniel Metzger, the British Columbia endocrinologist who cowrote the Canadian Pediatric Society’s position paper on health care for trans minors, said, “I think the thing you have to remember about kids is that we’re often explaining these sorts of things to people who haven’t even had biology in high school yet.”

Metzger noted adolescents are incapable of appreciating the lifelong consequence of infertility. “It’s always a good theory that you talk about fertility preservation with a 14-year-old,” he said, “but I know I’m talking to a blank wall. They’d be like, ‘ew, kids, babies, gross.’ Or, the usual answer is, ‘I’m just going to adopt.’ And then you ask them, ‘Well, what does that involve? Like, how much does it cost?’ ‘Oh, I thought you just like went to the orphanage, and they gave you a baby.’ . . . I think now that I follow a lot of kids into their mid-twenties, I’m always like, ‘Oh, the dog isn’t doing it for you, right?’”

There is extensive research showing adolescent brains are wired to have little control over rash behavior and are not capable of grasping the magnitude of decisions with lifelong consequences. It is why society doesn’t allow teens to get tattoos or buy guns. Car-rental agencies set 25 as the minimum age for renting a car, and Sweden sets the same limit for deciding on sterilization.

Detransitioners ignored, shunned

Although many WPATH members privately doubt that adolescents can give truly informed consent to life-altering procedures, they must affirm whatever children say about their gender.

Unless, the WPATH files disclose, the patient wants to reverse course and become a so-called detransitioner.

WPATH members mostly dismiss those cases as insignificant or overblown by the media and question whether minors who want to revert to their birth sex really understand what they are doing.

It’s a question that would never be asked for minors who declared themselves to be gender dysphoric.

One case involved a 17-year-old boy, just graduated from high school, who had been on testosterone for two years. He was reported to be “very distraught and angry. He reports he feels he was brainwashed and is upset by the permanent changes to his body.”

A self-described “queer therapist” did not believe any young person could be brainwashed. “In my experience, those stories come from people who have an active agenda against the rights of trans people.”

WPATH President Bowers said that “I do see talk of the phenomenon [detransitioners] as distracting from the many challenges we face.”

‘Frankenstein files’

The leaked files put a spotlight on the danger of mixing ideological activism with medicine and science. They should serve as an urgent wakeup call for the medical associations and government agencies that rely on WPATH guidance for transgender health.

The files might even prompt investigations into how those with distorted personal agendas seized control of the organization at the expense of science and patients.

Investigating what has gone wrong at WPATH might prove uncomfortable for some gender progressives in the Biden administration, none more so than Adm. Rachel Levine, the assistant secretary for health. Levine, the first transgender four-star military officer, is a WPATH member and has lavished praise on the organization.

She says it “assesses the full state of the science and provides substantive, rigorously analyzed, peer-reviewed recommendations to the medical community on how best to care for patients who are transgender or gender non-binary. It is free of any agenda other than to ensure that medical decisions are informed by science.”

Either Levine is unaware of the hormonal and surgical experimentation the group promotes or refuses to acknowledge it.

“The Frankenstein files.”

That is how a pediatrician described the leaked documents after I shared them with her.

Unfortunately, this is no horror novel.

It is a medical travesty playing out in real time, and the casualties are our children.

[mybeautifulchristianjourney]

There have been numerous reports over the years that have found that “gender affirming care” is not based in scientific fact and is harmful for those who partake in it — especially children. However, two recent factors have served to significantly increase the urgency of those calling for an end to gender transition procedures.

In May, the World Professional Association for Transgender Health (WPATH) files were leaked, which “revealed that the clinicians who shape how ‘gender medicine’ is regulated and practiced around the world consistently violate medical ethics and informed consent.” Additionally, a groundbreaking...

[mightyflamethrower]

German Study: Vast Majority of People Will Grow Out of Transgenderism Within 5 Years

The current U.S. affirmation model holds that health care professionals should affirm anyone who presents as transgender and start that adult, or child, down a pathway of “gender-affirming care” that may include potentially sterilizing puberty blockers, cross-sex hormone injections, and transgender surgeries to remove healthy breasts and reproductive organs.

But the groundbreaking Cass Review in the U.K. found “remarkably weak evidence” undergirds these criteria. Leaked files from the primary medical group driving gender dysphoria diagnoses, the World Professional Association for Transgender Health, similarly undermined the affirmation model. Bucking the trend among their colleagues, and standing up to professional ostracization, a growing number of medical experts have spoken out against the present consensus. “Transition affirmation is not proven to be safe or effective long term,” said Dr. Andre Van Mol, representing the American College of Pediatricians, the Christian Medical and Dental Associations, and the American Academy of Medical Ethics earlier this week. “It does not reduce suicides. It does not repair mental health issues or trauma. Minors cannot give truly informed consent. Children have developing and immature brains. Their minds change often. They are prone to risk taking, they are vulnerable to peer pressure, and they don’t grasp long term consequences.” And as such, he contended, “Refusing to provide gender transition procedures or so-called gender affirming health care is non-discriminatory and is appropriate both professionally and scientifically.”

File this under: Things the rest of us already knew.

[probablyasocialecologist]

The 388-page report featured 32 recommendations on how transgender care should be conducted within NHS England. It incorrectly claims that there is “no good evidence” supporting transgender care and calls for restrictions on trans care for individuals under the age of 18, although it does not advocate for an outright ban. The report endorses the idea that being transgender may be caused by anxiety, depression, and OCD issues, despite the American Psychological Association, the largest psychological association in the world, rebutting this as lacking evidence. It also claims that transgender individuals can be “influenced” into being trans, a nod to the discredited theory of social contagion and rapid onset gender dysphoria, rejected by over 60 mental health organizations. Lastly, it seemingly endorses restrictions on transgender people under the age of 25, stating that they should not be allowed to progress into adult care clinics. To support these recommendations, the report was released alongside “reviews” of the evidence surrounding transgender care, using these reviews to assert that there is "no good evidence" for gender-affirming care. A closer inspection of the reviews released alongside the Cass report reveals that 101 out of 103 studies on gender-affirming care were dismissed for not being of "sufficiently high quality," based on the Newcastle-Ottawa Scale—a subjective scale criticized for its flaws and potential unreliability due to a high risk of bias. This critique is particularly significant given the contentious political nature of the subject and connections between reviewers, Cass, and anti-trans organizations.

[...]

Immediately after the release of the Cass Review, experts in transgender healthcare from around the world voiced their opposition to its findings. Dr. Portia Predny, Vice President of the Australian Professional Association for Trans Health, criticized the findings and recommendations as “at odds with the current evidence base, expert consensus, and the majority of clinical guidelines worldwide.” Similarly, a statement from the Professional Association for Transgender Health Aotearoa condemned the review, noting, “The Review commissioned several systematic reviews into gender-affirming care by the University of York, but appears to have ignored a significant number of studies demonstrating the benefits of gender-affirming care. In one review, 101 out of 103 studies were dismissed.” It is important to note that gender affirming care saves lives, and there is plenty of evidence to show for it. Numerous studies have demonstrated that gender-affirming care significantly reduces suicidality, with some showing a decrease in suicidality by up to 73%. A review compiled by Cornell University, which compiled over 50 journal articles on the topic, shows the efficacy of transgender care. These findings were echoed recently in an article published by the Journal of Adolescent Health, which found that puberty blockers dramatically lowered depression and anxiety. All of these studies and more have led to The Lancet, a medical journal with international acclaim, to publish a letter stating that gender affirming care is lifesaving preventative care. The largest and most influential medical organizations support trans care. A recent and historic policy resolution passed overwhelmingly by the American Psychological Association, the largest psychological organization in the world, states that gender affirming care is a medical necessity and that being trans is not “caused” by things like autism and PTSD.

[justinspoliticalcorner]

Mira Lazine for Erin In The Morning:

On Monday, a team of nine international experts on transgender care drafted a 39-page response paper to the Cass Review. The paper argues that the Cass Review, including the additional York Reviews, has numerous methodological problems in both how it was conducted and how it interprets its data, and that it has been grossly misused by governmental bodies across the world in justifying bans on gender affirming care, especially for minors. The Cass Review is a review of the literature on puberty blockers’ effects on transgender youth conducted by Dr. Hillary Cass, a researcher who has no prior experience working with transgender youth, and who has consulted with Ron DeSantis appointed Florida medical board members in establishing the Review. In addition to the main document outlining clinical recommendations, it also has several systematic reviews conducted by researchers from the University of York. The Review has been used to justify bans on puberty blockers in England, and has been cited in court cases restricting gender affirming care across the United States.

“The Review repeatedly misuses data and violates its own evidentiary standards by resting many conclusions on speculation. Many of its statements and the conduct of the York [systematic reviews] reveal profound misunderstandings of the evidence base and the clinical issues at hand,” says the paper. “The Review also subverts widely accepted processes for development of clinical recommendations and repeats spurious, debunked claims about transgender identity and gender dysphoria. These errors conflict with well-established norms of clinical research and evidence-based healthcare. Further, these errors raise serious concern about the scientific integrity of critical elements of the report’s process and recommendations.” The article is entitled “An Evidence-Based Critique of ‘The Cass Review’ on Gender-affirming Care for Adolescent Gender Dysphoria,” and is authored by Dr. Meredithe McNamara, Dr. Kellan Baker, Dr. Kara Connelly, Dr. Aron Janssen, Dr. Johanna Olson-Kennedy, Dr. Ken C. Pang, Dr. Ayden Scheim, Dr. Jack Turban, and Dr. Anne Alstott. It was announced both by Turban in a post on Twitter, as well as on the Yale Law School’s website. Both McNamara and Alstott are professors at Yale who co-founded the Integrity Project, a project that aims to provide legal justice to marginalized peoples.

The core of the paper is divided into seven sections that each tackle a different element of the Review. The first section focuses on how the Review actually is compliant with established standards of care recommendations for providing legal protections for gender affirming care. The authors compare it to the World Professional Association for Transgender Health’s (WPATH) eighth rendition for standards of care and the Endocrine Society clinical practice guidelines, finding that recommendations for individualized and evidence based care are consistent across these different documents. The authors state, “the Review does not conclude that gender-affirming medical care for adolescent gender dysphoria should be banned. Thus, it should not be cited in support of bans on medical treatments for gender dysphoria.”

[...] This paper shines a new light on interpretations for the Cass Review, suggesting that it’s based on low quality work and has been falsely interpreted in legal proceedings across the world. The lack of expertise from Cass herself contrasts with the expertise of the authors of the paper, all of whom represent institutions across the world that have decades of research and clinical practice on transgender individuals. Legal decisions made using the Cass Review need to be reevaluated in light of the sweeping critiques found within this paper.

Yale Law School researchers wrote an article debunking the anti-trans Cass Review that has been used to justify bans on gender-affirming care in the UK and USA.

[winnipegwinterpeg]

The Manitoba government is taking steps to improve accessibility to gender-affirming care and also ensure health-care providers are up to date on the latest information.

Health Minister Uzoma Asagwara (they/them) made the announcement on Wednesday, saying the province is working to ensure patients receive care as quickly as possible.

“I’ve often said that love is action and today our government is demonstrating our love for the queer and trans community by taking action to improve gender-affirming health-care in Manitoba,” Asagwara said at a news conference on Wednesday.

“As your minister of health, I want to be very clear about one thing – affirming, supporting and lifting up the gender identity of Manitobans is a part of essential health-care.”

Some of the steps the province is taking to improve wait times for transgender patients include removing the requirement for a patient to obtain two medical referrals to access specialist care, as well as expanding the number of primary-care providers who can refer patients for gender-affirming care.

Manitoba is also creating a working group that will connect communities to services around the province.

“Gender-affirming care allows for folks to be their true selves, have appropriate supports and feel at home in their bodies,” Asagwara said.

“We also know that gender-affirming health-care saves lives.”

The Manitoba government devised these steps in collaboration with Klinic Community Health. These steps are aligned with the World Professional Association for Transgender Health’s latest clinical guidelines.

[evidence-based-activism]

Hi, @peaktransd, you asked a question on this post about "studies about hormones and the placebo effect". I've looked into this and found some relevant information!

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No high quality research on transgender affirming hormone care

The first, important, aspect here is that there is little to no high quality research on the use of hormones for transgender affirming care.

By this point we've all heard of the Cass review [1, emphasis mine] which found:

For puberty blockers: "The review of the evidence looked at nine studies that met the inclusion criteria. A key limitation of all the studies examined was the lack of reliable comparative studies, as well as of clear expected outcomes. All the studies were small uncontrolled observational studies, and all the results were of low certainty. Many did not report statistical significance."

For hormones: "Ten uncontrolled observational studies met the inclusion criteria. Again, the key limitation to identifying the effectiveness and safety of gender-affirming hormones for children and adolescents with gender dysphoria was the lack of reliable comparative studies."

Notably the important point here is that all of the research is uncontrolled observational studies, which do not allow for the examination of the placebo effect. Also, to preempt any objections, the Cass review team has created a website with FAQs [2] to address the mis- and disinformation being spread about the review.

Further, this article [3] argues "that although [gender affirming treatment] for [gender dysphoric] youth lacks a rigorous evidence base, it is undertaken as routine medical treatment in a strongly placebo effect enhancing environment", highlighting why we absolutely need good quality evidence into this topic.

The state of research for adults is similar. There are no comprehensive reviews about adult treatment, and some of this is by design. By this I mean, WPATH (the World Professional Association for Transgender Health) has purposefully suppressed unfavorable evidence.

There's a compounding issue here; in the reviews that do exist they tend to find very little evidence base for supporting hormone use and then make a recommendation in support of hormones anyway. These studies are often used as evidence by proponents who do not read past the abstract of the study.

Some studies on hormones and mood in transgender adults [all emphasis mine]:

This 2016 review [4] indicated: "Hormone therapy interventions to improve the mental health and quality of life in transgender people with gender dysphoria have not been evaluated in controlled trials. Low quality evidence suggests that hormone therapy may lead to improvements in psychological functioning."

This 2016 review [5] claimed a positive conclusion ("gender dysphoria-related mental distress may benefit from hormonal treatment") but proceeds to note that "results mentioned earlier need to be considered in light of certain limitations". These limitations include: single site studies, small sample size, type/dose of hormone restatement usually not reported (and poor consistency when reported), “more than half the studies did not mention/control for psychiatric comorbidity”, and “recruitment/follow-up attrition represented an issue". They also hide this key point: "most importantly, as no study used a blinded randomized controlled trial design, results could have also different explanations because of the study design" in the limitations section. Given the extent of the issue, these limitations should have at least been mentioned in the abstract and the researchers should not have suggested such a definitive conclusion.

This 2018 review [6] indicated that "although the existing body of research supports [gender-affirming hormone therapy] improving mental wellness, many studies used cross-sectional and uncontrolled observational methods relying on self-report." Again, this important caveat was hidden in the conclusion; with the abstract making far bolder claims than supported by evidence.

This 2019 review [7] concluded that "because the certainty of this evidence was very low to low, recommendations for hormone use to improve quality of life, depression and anxiety could not be made."

This 2021 review [8] came to the same conclusion stating "certainty in this conclusion is limited by high risk of bias in study designs, small sample sizes, and confounding with other interventions."

Even for the very few "controlled" studies, they are not randomized control trials. Instead they are before treatment – after treatment comparisons for transgender individuals or cross sectional studies comparing transgender and "cisgender" comparison groups. Notably, neither of these designs allow the researcher to elucidate the origin of observed effects (e.g., is improvement coming from hormone therapy or social affirmation?).

(And as a side note, this Cochrane (the "gold standard" for those unaware) review [9] concluded: "We found insufficient evidence to determine the efficacy or safety of hormonal treatment approaches for transgender women in transition. This lack of studies shows a gap between current clinical practice and clinical research. Robust RCTs and controlled cohort studies are needed".)

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Confounding factors: the effect of hormone therapy on non-transgender individuals

There's a particularly important confounding factor here; we have evidence that hormone therapy is associated with improved mood. As such, improved mood with gender affirming care may simply be the result of this natural physiological effect.

This 2023 systematic review and meta-analysis [10] with "14 eligible randomized controlled trials (RCTs) ... to investigate the effect of exogenous estrogen on depressive mood in women" found "strong evidence that exogenous estrogen exerts its antidepressant effect by stabilizing estrogen levels".

This 2009 systematic review and meta-analysis [11] with "seven studies (N=364) ... that included a placebo-control group in a double-blind design" found "[testosterone] may have an antidepressant effect in depressed [men], especially those with hypogonadism".

This 2014 systematic review and meta-analysis [12] of "sixteen trials with a total of 944 subjects ... showed a significant positive impact of testosterone on mood" and ultimately concluded "Testosterone may be used as a monotherapy in dysthymia and minor depression or as an augmentation therapy in major depression in middle-aged hypogonadal men".

This 2019 systematic review and meta-analysis [13] of "27 randomized placebo-controlled clinical trials involving a total of 1890 men found that testosterone treatment was associated with a significant reduction of depressive symptoms, particularly in participants who received higher-dosage regimens."

Further, the fact that these results were all the strongest in people with lower endogenous hormone levels, lends support to the hypothesis that this effect would be substantial in cross sex supplementation given the naturally low endogenous hormone levels for these individuals. (Please note, however, that this hypothesis has not yet been investigated.)

This isn't a placebo effect, since the randomized controlled trials above indicate that the effect on mood is above and beyond any placebo effect. However, I believe it's a related point.

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Hormones on cognitive function

To address the other point in that post, there really isn't evidence that women would "get smarter" if they take testosterone or men would "get dumber" if they take estrogen. Again, there's no high quality studies on transgender individuals, but there is some adjacent evidence for non-transgender individuals.

There is evidence that the reduction of estrogen levels in older women may be associated with cognitive decline. [14]

This review [15] and this study [16] both link higher endogenous testosterone levels in women (i.e., in women with PCOS) with lower cognitive performance.

That being said, this "randomized, placebo-controlled trial" [17] manipulated the levels of testosterone in women with PCOS and did not record changes in their cognitive function. This may be because the sample size was simply too small (n=29), or there could be a "critical window" in which testosterone effects women's cognitive performance, or any number of other possibilities.

These reviews [18, 19] found low testosterone levels are associated with with cognitive impairment in men although the effects of testosterone substitution are mixed. This appears to support the hypothesis that testosterone suppression may reduce cognitive performance, but in reality "the ability of the body to convert testosterone into estrogen suggests that part of the actions of testosterone could be mediated by estrogen". So, any decrease due to testosterone suppression would likely be offset by estrogen supplementation. In fact this review [20] discusses the evidence for this.

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The stereotype threat

As suggested by @mycodyke, an important factor here is the stereotype threat. This refers to how "behavior can be a consequence of priming effects, ... when a stereotype becomes activated, stereotype-consistent behavior may follow automatically from that activation" [21].

The study she linked [22] goes into this, finding that men performed the same in a cognitive task regardless of priming condition, whereas women performed worse only when primed with female condition. This replicated an earlier study [23] that found "no sex differences were observed" when the task instructions didn't emphasize sex-stereotypes.

Other similar studies:

This study [24] found "sex difference was reliably elicited and eliminated by controlling or manipulating participants’ confidence"

This meta-analysis [25] suggested that "male superiority on spatial ability tasks ... is related to the implementation of time limits".

This study [26] also suggested this, finding that "the magnitude of gender differences was linearly related to the amount of time available for test completion".

All of this indicates that sex differences on this task (and likely in other similar situations) are the result of individual expectations about their performance. This is also commonly brought up for self-fulfilling prophecies; that is, if someone believes they will succeed/fail they are more likely to succeed/fail.

And this has real-world consequences. For example, in this study [27], "in a simulated job interview, [participants] … were confronted with either sexist … or non-sexist … behavior … [and] results indicated that female participants in the sexist condition performed significantly worse on the mathematical test than female participants in the control condition … suggest[ing] an influence of psychological and interpersonal processes on seemingly objective test outcomes."

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Conclusion

I hope this helps! To sum up:

There is little to no high-quality research into the effects, benefits, or harms of hormone therapy for transgender adults or adolescents

There is evidence suggesting that hormone supplementation effects mood in non-transgender adults, indicating an important confounding factor for transgender hormone research

There is no evidence that testosterone makes women smarter or that estrogen makes men dumber; there is, in fact, some limited evidence suggesting the opposite

The belief in the above is likely a result of the stereotype threat; transgender individuals who have started hormone therapy are likely to perform worse/better because they believe they should perform worse/better as a result of ingrained stereotypes

References below the cut:

Cass, H. (2024). Independent review of gender identity services for children and young people.

Final report – FAQs. (n.d.). The Cass Review. https://cass.independent-review.uk/home/publications/final-report/final-report-faqs/

Clayton, A. (2023). Gender-affirming treatment of gender dysphoria in youth: a perfect storm environment for the placebo effect—the implications for research and clinical practice. Archives of Sexual Behavior, 52(2), 483-494.

White Hughto JM, Reisner SL. A Systematic Review of the Effects of Hormone Therapy on Psychological Functioning and Quality of Life in Transgender Individuals. Transgend Health. 2016 Jan;1(1):21-31. doi: 10.1089/trgh.2015.0008. Epub 2016 Jan 13. PMID: 27595141; PMCID: PMC5010234.

Costa, R., & Colizzi, M. (2016). The effect of cross-sex hormonal treatment on gender dysphoria individuals’ mental health: a systematic review. Neuropsychiatric Disease and Treatment, 1953-1966.

Nguyen HB, Chavez AM, Lipner E, Hantsoo L, Kornfield SL, Davies RD, Epperson CN. Gender-Affirming Hormone Use in Transgender Individuals: Impact on Behavioral Health and Cognition. Curr Psychiatry Rep. 2018 Oct 11;20(12):110. doi: 10.1007/s11920-018-0973-0. PMID: 30306351; PMCID: PMC6354936.

Rowniak, S., Bolt, L., & Sharifi, C. (2019). Effect of cross-sex hormones on the quality of life, depression and anxiety of transgender individuals: a quantitative systematic review. JBI Evidence Synthesis, 17(9), 1826-1854.

Baker, K. E., Wilson, L. M., Sharma, R., Dukhanin, V., McArthur, K., & Robinson, K. A. (2021). Hormone therapy, mental health, and quality of life among transgender people: a systematic review. Journal of the Endocrine Society, 5(4), bvab011.

Haupt C, Henke M, Kutschmar A, Hauser B, Baldinger S, Saenz SR, Schreiber G. Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women. Cochrane Database of Systematic Reviews 2020, Issue 11. Art. No.: CD013138. DOI: 10.1002/14651858.CD013138.pub2.

Zhang, J., Yin, J., Song, X., Lai, S., Zhong, S., & Jia, Y. (2023). The effect of exogenous estrogen on depressive mood in women: A systematic review and meta-analysis of randomized controlled trials. Journal of psychiatric research, 162, 21-29.

Zarrouf, F. A., Artz, S., Griffith, J., Sirbu, C., & Kommor, M. (2009). Testosterone and depression: systematic review and meta-analysis. Journal of Psychiatric Practice®, 15(4), 289-305.

Amanatkar, H. R., Chibnall, J. T., Seo, B. W., Manepalli, J. N., & Grossberg, G. T. (2014). Impact of exogenous testosterone on mood: a systematic review and meta-analysis of randomized placebo-controlled trials. Ann Clin Psychiatry, 26(1), 19-32.

Walther, A., Breidenstein, J., & Miller, R. (2019). Association of testosterone treatment with alleviation of depressive symptoms in men: a systematic review and meta-analysis. JAMA psychiatry, 76(1), 31-40.

Sherwin, B. B. (2003). Estrogen and cognitive functioning in women. Endocrine reviews, 24(2), 133-151.

Perović, M., Wugalter, K., & Einstein, G. (2022). Review of the effects of polycystic ovary syndrome on Cognition: Looking beyond the androgen hypothesis. Frontiers in Neuroendocrinology, 67, 101038.

Sukhapure, M., Eggleston, K., Douglas, K., Fenton, A., Frampton, C., & Porter, R. J. (2022). Free testosterone is related to aspects of cognitive function in women with and without polycystic ovary syndrome. Archives of Women's Mental Health, 25(1), 87-94.

Schattmann, L., & Sherwin, B. B. (2007). Effects of the pharmacologic manipulation of testosterone on cognitive functioning in women with polycystic ovary syndrome: a randomized, placebo-controlled treatment study. Hormones and Behavior, 51(5), 579-586.

Mohamad, N. V., Ima-Nirwana, S., & Chin, K. Y. (2018). A review on the effects of testosterone supplementation in hypogonadal men with cognitive impairment. Current drug targets, 19(8), 898-906.

Zhang, Z., Kang, D., & Li, H. (2021). Testosterone and cognitive impairment or dementia in middle-aged or aging males: causation and intervention, a systematic review and meta-analysis. Journal of Geriatric Psychiatry and Neurology, 34(5), 405-417.

Janowsky, J. S. (2006). The role of androgens in cognition and brain aging in men. Neuroscience, 138(3), 1015-1020.

Spencer, S. J., Logel, C., & Davies, P. G. (2016). Stereotype threat. Annual review of psychology, 67(1), 415-437.

Ortner, T.M., Sieverding, M. Where are the Gender Differences? Male Priming Boosts Spatial Skills in Women. Sex Roles 59, 274–281 (2008). https://doi.org/10.1007/s11199-008-9448-9

Sharps, M. J., Price, J. L., & Williams, J. K. (1994). Spatial cognition and gender instructional and stimulus influences on mental image rotation performance. Psychology of Women Quarterly, 18(3), 413-425.

Estes, Z., Felker, S. Confidence Mediates the Sex Difference in Mental Rotation Performance. Arch Sex Behav 41, 557–570 (2012). https://doi.org/10.1007/s10508-011-9875-5

Maeda, Y., Yoon, S.Y. A Meta-Analysis on Gender Differences in Mental Rotation Ability Measured by the Purdue Spatial Visualization Tests: Visualization of Rotations (PSVT:R). Educ Psychol Rev 25, 69–94 (2013). https://doi.org/10.1007/s10648-012-9215-x

Voyer, D. Time limits and gender differences on paper-and-pencil tests of mental rotation: a meta-analysis. Psychon Bull Rev 18, 267–277 (2011). https://doi.org/10.3758/s13423-010-0042-0

Koch, S.C., Konigorski, S. & Sieverding, M. Sexist Behavior Undermines Women’s Performance in a Job Application Situation. Sex Roles 70, 79–87 (2014). https://doi.org/10.1007/s11199-014-0342-3