#clinical reported outcomes

[dermatology-cro]

[transcriptioncity]

What is Linguistic Validation?

What is Linguistic Validation? Ensuring Accurate and Culturally Relevant Communication Linguistic validation services are part of an intensive process that ensures translated content retains its original meaning and cultural nuances. This method involves more than just translation; it scrutinises accuracy, cultural relevance, and appropriateness. Experts compare the translated text with the…

[jeeva-trials]

Human-Centric eClinical Trial Platform | Jeeva Trials

The Jeeva eClinical Cloud was developed by researchers with empathy who listen and learn to help clinical researchers, hospital sites, academic medical centers, CROs, and biopharmaceutical sponsors accelerate patient enrollment by 3x faster.

[fight-nights-at-freddys]

MASTER POST OF PROSHIP RESOURCES!!! <3<3

this is just for links (bc i just have No Way of formatting this properly), so for more in-depth stuffs and credits, head to the google doc, or the carrd !! :3c

Fiction ≠ Reality

Violent media -

Does Media Violence Predict Societal Violence? It Depends on What You Look at and When

Video Game Violence Use Among “Vulnerable” Populations: The Impact of Violent Games on Delinquency and Bullying Among Children with Clinically Elevated Depression or Attention Deficit Symptoms

Extreme metal music and anger processing

On the Morality of Immoral Fiction: Reading Newgate Novels, 1830–1848

How gamers manage aggression: Situating skills in collaborative computer games

Examining desensitization using facial electromyography:Violent videogames, gender, and affective responding

'Bad' video game behavior increases players' moral sensitivity

Fiction and Morality: Investigating the Associations Between Reading Exposure, Empathy, Morality, and Moral Judgment

Comfortably Numb or Just Yet Another Movie? Media Violence Exposure Does Not Reduce Viewer Empathy for Victims of Real Violence Among Primarily Hispanic Viewers

Fantasy Crime: The Criminalisation of Fantasy Material Under Australia's Child Abuse Material Legislation

Being able to distinguish fiction from reality -

Effects of context on judgments concerning the reality status of novel entities

Children’s Causal Learning from Fiction: Assessing the Proximity Between Real and Fictional Worlds

Reality/Fiction Distinction and Fiction/Fiction Distinction during Sentence Comprehension

Reality = Relevance? Insights from Spontaneous Modulations of the Brain’s Default Network when Telling Apart Reality from Fiction

How does the brain tell the real from imagined?

Meeting George Bush versus Meeting Cinderella: The Neural Response When Telling Apart What is Real from What is Fictional in the Context of Our Reality

loli/shota/kodocon -

If I like lolicon, does it mean I’m a pedophile? A therapist’s view

Virtual Child Pornography, Human Trafficking and Japanese Law: Pop Culture, Harm and Legal Restrains

Lolicon: The Reality of ‘Virtual Child Pornography’ in Japan

Report: cartoon paedophilia harmless

‘The Lolicon Guy:’ Some Observations on Researching Unpopular Topics in Japan

Robot Ghosts And Wired Dreams Japanese Science Fiction From Origins To Anime [pg 227-228]

Australia's "child abuse material' legislation, internet regulation and the juridification of the imaginationjuridification of the imagination [pg 14-15]

Multiple Orientations as Animating Misdelivery: Theoretical Considerations on Sexuality Attracted to Nijigen (Two-Dimensional) Objects

Positive Impact on Mental Health

Art therapy -

The effectiveness of art therapy for anxiety in adults: A systematic review of randomised and non-randomised controlled trials

Efficacy of Art Therapy in Individuals With Personality Disorders Cluster B/C: A Randomized Controlled Trial

Effectiveness of Art Therapy With Adult Clients in 2018 - What Progress Has Been Made?

Benefits of Art Therapy in People Diagnosed With Personality Disorders: A Quantitative Survey

The Effectiveness of Art Therapy in the Treatment of Traumatized Adults: A Systematic Review on Art Therapy and Trauma

The clinical effectiveness and current practice of art therapy for trauma

Writing therapy -

Optimizing the perceived benefits and health outcomes of writing about traumatic life events

Expressive writing and post-traumatic stress disorder: Effects on trauma symptoms, mood states, and cortisol reactivity

Focused expressive writing as self-help for stress and trauma

Putting Stress into Words: The Impact of Writing on Physiological, Absentee, and Self-Reported Emotional Well-Being Measures

The writing cure: How expressive writing promotes health and emotional well-being

Effects of Writing About Traumatic Experiences: The Necessity for Narrative Structuring

Scriptotherapy: The effects of writing about traumatic events

Emotional and physical benefits of expressive writing

Emotional and Cognitive Processing in Sexual Assault Survivors' Narratives

Finding happiness in negative emotions: An experimental test of a novel expressive writing paradigm

An everyday activity as treatment for depression: The benefits of expressive writing for people diagnosed with major depressive disorder

Writing about emotional experiences as a therapeutic process

Effects of expressive writing on sexual dysfunction, depression, and PTSD in women with a history of childhood sexual abuse: Results from a randomized clinical trial

Written Emotional Disclosure: Testing Whether Social Disclosure Matters

Written emotional disclosure: A controlled study of the benefits of expressive writing homework in outpatient psychotherapy

Misc -

Emotional disclosure about traumas and its relation to health: Effects of previous disclosure and trauma severity

Treating complex trauma in adolescents: A phase-based integrative approach for play therapists

Emotional expression and physical health: Revising traumatic memories or fostering self-regulation?

Disclosure of Sexual Victimization: The Effects of Pennebaker's Emotional Disclosure Paradigm on Physical and Psychological Distress

Kink/Porn/Fantasies

Sexual fantasies -

A Critical Microethnographic Examination of Power Exchange, Role Idenity and Agency with Black BDSM Practitioners

Women's Rape Fantasies: An Empirical Evaluation of the Major Explanations

History, culture and practice of puppy play

What Exactly Is an Unusual Sexual Fantasy?

The Psychology of Kink: a Survey Study into the Relationships of Trauma and Attachment Style with BDSM Interests

Punishing Sexual Fantasy

Women's Erotic Rape Fantasies

Sexual Fantasy and Adult Attunement: Differentiating Preying from Playing

What Is So Appealing About Being Spanked, Flogged, Dominated, or Restrained? Answers from Practitioners of Sexual Masochism/Submission

Dark Fantasies, Part 1 - With Dr. Ian Kerner

Why Do Women Have Rape Fantasies

The 7 Most Common Sexual Fantasies and What to Do About Them

Sexual Fantasies

Pornography -

The Effects of Exposure to Virtual Child Pornography on Viewer Cognitions and Attitudes Toward Deviant Sexual Behavior

American Identities and Consumption of Japanese Homoerotica

The differentiation between consumers of hentai pornography and human pornography

Pornography Use and Holistic Sexual Functioning: A Systematic Review of Recent Research

Claiming Public Health Crisis to Regulate Sexual Outlets: A Critique of the State of Utah's Declaration on Pornography

Pornography and Sexual Dysfunction: Is There Any Relationship?

Reading and Living Yaoi: Male-Male Fantasy Narratives as Women's Sexual Subculture in Japan

Women's Consumption of Pornograpy: Pleasure, Contestation, and Empowerment

Pornography and Sexual Violence

The Sunny Side of Smut

Other -

Fantasy Sexual Material Use by People with Attractions to Children

Fictosexuality, Fictoromance, and Fictophilia: A Qualitative Study of Love and Desire for Fictional Characters

Exploring the Ownership of Child-Like Sex Dolls

Are Sex and Pornograpy Addiction Valid Disorders? Adding a Leisure Science Perspecive to the Sexological Critique

Littles: Affects and Aesthetics in Sexual Age-Play

An Exploratory Study of a New Kink Activity: "Pup Play"

Jaws Effect

The Jaws Effect: How movie narratives are used to influence policy responses to shark bites in Western Australia

The Shark Attacks That Were the Inspiration for Jaws

The Great White Hope (written by Peter Benchley, writer of Jaws)

The Jaws Myth [not a study BUT is an interesting read and provides some links to articles and studies]

Slenderman Stabbings

Out Came the Girls: Adolescent Girlhood, the Occult, and the Slender Man Phenomenon

Jury in Slender Man case finds Anissa Weier was mentally ill, will not go to prison

2nd teen in 'Slender Man' stabbing case to remain in institutional care for 40 years

Negative effects of online harassment

How stressful is online victimization? Effects of victim's personality and properties of the incident

Prevalence, Psychological Impact, and Coping of Cyberbully Victims Among College Students

Offline Consequences of Online Victimization

The Relative Importance of Online Victimization in Understanding Depression, Delinquency, and Substance Use

Internet trolling and everyday sadism: Parallel effects on pain perception and moral judgement

The MAD Model of Moral Contagion: The Role of Motivation, Attention, and Design in the Spread of Moralized Content Online

Morally Motivated Networked Harassment as Normative Reinforcement

When Online Harassment is Perceived as Justified

Violence on Reddit Support Forums Unique to r/NoFap

"It Makes Me, A Minor, Uncomfortable" Media and Morality in Anti-Shippers' Policing of Online Fandom

[charmedreincarnation]

Let me share you some examples of people outside of a spiritual realm using the law of consciousness. Reading about placebo opened my eyes to realize whether I believe it or not, use it or not, it is always operating.

1. During wartime, particularly in World War II, when medical supplies were limited, the use of a saline solution as a placebo became prevalent. One notable figure associated with this practice is Henry Beecher, a medic during the war. When morphine, a powerful painkiller, was scarce, Beecher resorted to injecting injured soldiers with a saline solution (a mixture of salt and water) as a substitute.The fascinating observation was that many soldiers responded positively to the saline placebo, reporting a reduction in pain. Beecher’s experience led him to further investigate what is now known as the placebo effect. He discovered that even inert substances like saline could elicit a therapeutic response in individuals, highlighting the power of belief and the mind’s influence on healing. Using saline as a placebo during wartime was a practical solution to address the scarcity of medical resources. It allowed healthcare providers to provide some form of treatment while conserving limited supplies for critical cases. The phenomenon observed in these wartime placebo administrations contributed to our understanding of the placebo effect and its role in medical practices.

2. And then there was another placebo test done with surgeries demonstrated the power of the placebo effect in the context of surgical interventions for knee pain.

The study, often referred to as the “fake leg surgery” study, focused on patients with osteoarthritis in the knee. Participants were randomly assigned to either receive real arthroscopic surgery or undergo a sham procedure where no actual surgical intervention took place. The sham surgery involved making small incisions and mimicking the actions and sounds associated with the actual procedure.The surprising finding was that both groups, those who underwent real surgery and those who had the sham surgery, reported similar improvements in their knee pain and functionality. This suggested that the positive outcomes experienced by the participants were not necessarily due to the physical intervention but rather to psychological factors such as the placebo effect.

3. The most fascinating one was this one: The study aimed to explore the role of mindset in reversing some aspects of aging.

In this experiment, Langer and her team created a simulated environment reminiscent of the 1950s to immerse a group of elderly participants. The participants were instructed to act as though they were 20 years younger and encouraged to engage in activities that required physical and mental activity. It aimed to create an atmosphere where the participants felt as if they were stepping back in time.The results of the experiment were described as astonishing. Participants reportedly experienced improvements in various areas, including physical health, cognition, and overall well-being. The study suggested that by changing one’s mindset and engaging in an environment that challenges typical aging stereotypes, individuals may experience positive effects on various aspects of their lives.

4. The Man Who Overdosed on Placebo" is a story about a 26-year-old man, often referred to as "Mr. A," who was part of a clinical trial for an antidepressant drug. In a desperate state of mind, he attempted suicide by ingesting 29 capsules of what he believed to be the experimental drug. This act was triggered by his depression, which had worsened after a breakup with his girlfriend.

However, unbeknownst to him, the pills he had taken were not the actual antidepressant, but rather placebos - essentially inert substances, often sugar pills, used in clinical trials as a control group. Despite this, Mr. A's vitals showed alarming signs similar to those of a drug overdose, reflecting the power of belief over the physical body, a phenomenon known as the "nocebo effect."

The nocebo effect is essentially the evil twin of the placebo effect. While the placebo effect can lead to improvements in health due to positive expectations, the nocebo effect can cause negative symptoms or even exacerbate existing ones due to negative expectations. In this case, Mr. A exhibited symptoms of an overdose solely because he believed he had taken an overdose.

5. Sam Londe, is one of the best but sad classic example of the nocebo effect, as detailed in Dr. Joe Dispenza's book "You Are the Placebo."

Sam Londe was diagnosed with esophageal cancer, a condition known for its grim prognosis. His doctors informed him that he didn't have much time left to live. Accepting this diagnosis, Londe quickly became bedridden and his health deteriorated rapidly, following the trajectory his doctors had predicted.However, upon his death, an autopsy revealed a surprising fact: there was not enough cancer in his body to have caused his death. The small tumor in his esophagus was not large enough or in a position to interfere with his swallowing or breathing. Essentially, Londe didn't die from cancer; he died from believing he was dying of cancer.

This case demonstrates the power of the mind over the body, both positively (the placebo effect) and negatively (the nocebo effect). In this case, Londe's negative beliefs about his prognosis led to physical symptoms and ultimately his death.

I've seen dozens of examples where of stuff like this particularly in the realms of hexing and witchcraft. Honestly, the same could probably be said about subliminals. But it doesn't matter much.Why? Because they work. It's all about observation and choice. You could say it’s the mind but the mind operates on logic. This goes beyond the mind and to your true being, what observes the mind observing the pain in the first place.

Actually I was talking to someone who had been struggling with shifting for a while about this and it really resonated with her which is why I decided to share it. She took a water bottle, labeled it shifting juice and just assumed that when she finishes the bottle she has “full access to shifting powers” is that how it works. Nope. Did she shift after two years of struggling. Yep. It doesn’t matter what story you create yourself whether you want to use logic or not whatever you assume and persist in and know as a fact will harden into truth and therefore reality.I just wanted to share this story bc I find it absolutely hilarious how we sometimes take it so seriously yet it can be so easy. I know placebo is just an assumption. It’s like when you tell children you checked under their bed for the monsters and drafted them and they assume so so they can sleep soundly at night. Call it whatever you want assumption, placebo, it’s all just words and each community calls it something different but at the end of the day it works wether you know the truth behind it or not.

[targaryenrealnessdarling]

Nova Genesis

Part Two

Summary: disgruntled with the decision to return to Earth, who knows what the prisoners aboard will do to cling to their false freedom. And who will get mixed up with it | Word Count: 5.5k~ | Warnings: smut, p in v sex, dubcon, choking, degradation, blood, murder, threatening behaviour

She blinked hard, having stared at the blue, intrusive light of her computer screen for what seemed like hours now. Pressing the heels of her palms against her lids provided some relief to the thudding in her temples, but not nearly enough. This place was suffocating. And she briefly wondered how on Earth the prisoners had lasted as long as they had without going completely insane. She closed her laptop in a huff, her report written, a script planned out in her head for what she would tell Dr Dibs. She steeled herself, preparing for any reaction, her shoes plodding on the linoleum floor, every step echoing her growing apprehension, but she knew this conversation with her was inevitable. The dim lights in the corridor flickered as she reached the door. She paused for a moment, collecting her thoughts before entering.

Inside, Dibs was hunched over a tray of instruments, methodically wiping each one with a clinical precision that made her skin crawl. The doctor didn’t look up, her voice calm, almost detached.

“You’re here to tell me it’s over, aren’t you?”

Even the tone she used seemed unemotional, a stark contrast to the mess she had been when they had first arrived and broke into their systems, destroying samples. She held her breath, “Yes. The investigation is wrapping up. We’ve gathered enough evidence to ensure this project is shut down. The prisoners will be returned to Earth.”

Dr Dibs shook her head, placing a gleaming scalpel on her table before moving to the next. “And you think that’s a good idea? Bringing them back?”

“Doesn’t matter what I think.”

Dibs finally looked up, her eyes dark with something unreadable. “No, I suppose it doesn’t,” she mused, before her lips turned into a small, cynical smile.  “They’ll tear each other apart before you even reach the atmosphere.”

Her stomach churned with unease at her words, though she tried not to show it on her face that the doctor had managed to make her uncomfortable. There was, of course, a whispering of rebellion amongst those who didn’t want to go back, she knew that. But naively perhaps, thought it would go no further than a few choice words. 

“An announcement will be made shortly. I suggest you prepare yourself for the outcome.”

“Prepare myself?” she echoed, her voice dripping with irony. “It’s you and your team who should be preparing. Once you announce their return to Earth, you’ll be the only thing standing between them and their worst nightmares.”

The prisoners were gathered in the central area of the ship, their eyes flickering with a mix of curiosity and suspicion as she stood before them, report in hand, flanked by guards. The air was thick with tension, the kind that makes every breath feel weighted. Each gaze was filled with distrust, hatred almost, all except one, half-lidded with amusement. She took a deep breath, projecting as much authority as she could muster. 

“After thorough consideration and investigation from our colleagues, it has been decided that this mission will be terminated, and all of you will be returned to Earth.”

A murmur spread through the crowd, a mix of surprise, disbelief, and anger. Monte stepped forward, his face a mask of barely contained fury.

“I’m not going back to Earth, not like this. You’re sending us back to rot in a cage, to be paraded around like freaks. We’re not going back. Not all of us.”

“This isn’t up for debate. The decision has been made,” she repeated, her voice firm though her heart pounded against her ribs.

Monte's fists clenched at his sides, his knuckles turning white as the tension in the room thickened. His fury, barely held in check, finally broke through, spilling over like a dammed river and before anyone could react, he lunged forward, knocking over the nearest table with a force that sent equipment clattering to the floor. Other prisoners, emboldened by his defiance, began to move as well, their voices rising in a chaotic blend of anger and desperation. Chairs were overturned, shouts echoed off the metallic walls, and the guards tensed, readying themselves for violence.

“You’re sentencing us to worse than death!” Monte roared, his voice booming above the growing chaos. “You’re no better than the people who sent us up here in the first place!”

No. She thought. I’m a lawyer, I’m helping them. Surely.

She could not think why they would be so desperate to stay. So eager to die up here where nobody could find them, or even know where they were. But seeing the sheer determination in some of their looks, she briefly understood.

These people want to disappear.

Her hand hovered near her comms device, but she knew calling for more backup would escalate the situation further. But the guards, finally springing into action, moved to subdue Monte as he approached, and the other prisoners stepped in, creating a human barrier. The room descended into utter chaos as shoves turned into punches, and the violence spread like wildfire.

Across the room, Ettore leaned casually against the wall, a smirk playing at the corners of his lips as he watched the chaos unfold. His eyes locked onto hers from across the room, and for a brief moment, amidst the turmoil, their gazes held. There was something predatory in his expression, a dark amusement at her situation, as if he was enjoying the spectacle of her losing control.

“You think you can control us?” Monte snarled, his body wedged between two guards. “You think you can just send us back to that hellhole?”

With her heart hammering in her chest, she couldn’t shake the feeling that this was just the beginning. She tore her eyes away from Monte’s seething form, only to find Ettore still watching her, his expression unreadable. She turned sharply on her heel, retreating to the relative safety of her team, her mind spinning. In the midst of the chaos, one thought lingered in her mind. Ettore’s smirk, his gaze that seemed to pierce through it all, as if he was waiting for her to slip.

Waiting for the vulnerability he was sure was going to rear its head.

Mink sidled up to Ettore, her expression serious as she glanced around to make sure no one was listening. Her voice was low, almost a whisper, filled with concern. “Monte’s losing it. You can see that, right?”

Ettore didn’t respond immediately, his eyes still following the path she had taken as she retreated with her team. The smirk from earlier lingered faintly on his lips, but there was something darker beneath it. He turned to Mink, his voice detached. “Monte’s been on edge since day one. Today just gave him the excuse he’s been waiting for.”

“He’s desperate. Desperate people do stupid things. What happens when she figures out what’s really going on here? If this blows up, they’ll throw us all under the bus.” 

"Whether it’s Monte that takes us out or Earth, doesn’t really matter in the end, does it?"

Her jaw tightened, frustration flickering across her face. “And what about you? What’s your angle in all this? Are you just going to sit back and watch him burn everything down?”

His gaze darkened as he thought about her, like the snuff of a candle, his blue eyes went near-black. There was something about the way she held herself, the way she looked at him, that intrigued him more than he wanted to admit. She had a confidence, a belief in her own righteousness that he found almost laughable. Yet, underneath it all, he could sense the tension, the fear she tried so hard to mask. He’d seen that look before, on other women, other people, just before they broke.

"Maybe I’ll just sit back and watch," Ettore finally answered. "Or maybe I’ll give her a little push, see how far she can really go before she snaps."

The door pressed shut behind her as she pushed into her quarters for the evening, still dressed even at such a late hour. She carried the day’s stress with the tension in her shoulders. If she focuses hard enough, she can still grip the panic she felt earlier that day when the prisoners had all turned on her and her staff. She kicked off her shoes, the tension in her shoulders momentarily easing as she stretched out her feet. The dim lights overhead cast a warm, soft glow over the small, sterile space. A brief respite.

As she was about to take a breath and unwind, everything went dark. The ship's systems cut out abruptly, plunging the room into an oppressive, suffocating silence. She froze, her heart leaping into her throat as she was enveloped in complete darkness. No emergency lights. No familiar hum of the ship's engines. Just an endless, empty, nothingness.

She couldn’t see her hand in front of her face, the blackness so absolute it felt as if the walls were closing in around her. Panic began to creep in, but she forced herself to stay calm. The air felt heavy, thick with an unnatural stillness that made her skin prickle.

“Stay calm,” she whispered to herself, reaching out for something, anything, to ground her. But her fingers met only empty space. She knew the layout of her quarters, could navigate it with her eyes closed, but the utter darkness was disorienting. She felt her way along the wall, her fingertips brushing against the cold metal, her breath quickening with each step.

The thought that this wasn’t an accident slithered into her mind. Could this be sabotage? A prelude to something worse? The faces of the prisoners flashed in her mind. Monte’s fury. Ettore’s unsettling calm, and a chill ran down her spine.

Her breath hitched as she considered the possibilities. The ship wasn’t supposed to fail like this. Not without warning. Not without backup systems kicking in. She reached for the small comms device, fumbling in the darkness, but the screen remained dead.

She was alone, blind, and utterly vulnerable.

Heart pounding in her chest, her hand gripped the door frame of her quarters as she cautiously stepped out into the pitch-black corridor. The darkness was suffocating, every sound amplified, her senses on high alert. She moved quietly, trying to navigate the ship's labyrinth passageways by memory.

The path she was taking should have led her to the guards’ station, but the disorienting blackness made it impossible to be sure. She fought down the rising panic, forcing herself to focus. She couldn’t afford to get lost. Not with people she knew loathed her, possibly lurking about in the adjoined ship.

After what felt like an eternity, she finally stumbled upon the entrance to the guards’ station. Relief washed over her as she pushed open the door, expecting to find safety within. Her foot slipped, and the metallic scent of something deep filled her nose, sharp and acrid. It was only when her foot caught on something soft and unmoving that she stifled a gasp, her hand flying to her mouth to keep from making a sound.

She took a step back, nearly tripping over her own feet in her haste to put distance between herself and the grisly reality. Her mind raced, trying to process the horror of it all. How had this happened? Who could have done this?

With trembling hands, she eased herself to the floor, her hand patting over the body of one of the guards until she found her target. The gun felt too large in her hand as she picked it up. The cold weight of the weapon in her grasp was both alien and strangely comforting. She wasn’t trained for this, but she wasn’t about to be caught unarmed.

“WHERE ARE YOU, YOU BITCH?!”

She froze, her breath catching in her throat. The voice was close, too close. And oh so familiar. Her heart thundered in her chest as she gripped the gun tighter, backing up against the wall, her pulse racing. Fear threatened to consume her, but she forced herself to stay calm, to think.

Monte was out there, hunting her.

She could recognize that voice anywhere, the fury behind it unmistakable. He’d gone into her room and discovered she wasn’t there, and now he was hunting her down with a vengeance. Thank God she’d kicked off her shoes. The thought flashed through her mind as she pressed herself against the cold metal wall, her breathing shallow, trying to remain as silent as possible. Without the squeak of her trainers on the floor, she had a chance, however slim, of slipping away unnoticed.

The darkness was both her enemy and her ally. It masked her movements, but it also made every step fraught with the risk of revealing her position. She had no idea where Monte was now, only that he was close, and that his rage was palpable, even through the thick walls of the ship.

Monte’s voice echoed again, closer this time, filled with venom. “WHERE ARE YOU!”

The darkness was suffocating as she crossed into the prison ship, the stale air thick with tension. She prayed Monte wouldn’t think to look for her here. The ship's unfamiliar layout was like a labyrinth of potential traps. Every step felt like it could be her last, each sound amplified in the oppressive silence.

She stumbled into the rec room, her heart pounding against her ribs. She backed up slowly, her senses heightened, straining to catch any sound of Monte’s approach.

And then she heard it, the sound of deliberate footsteps. Monte was getting closer. She couldn’t see him yet, but she knew he was near, racing down the hall towards the rec room, the door luckily closing softly shut to note she had not been near. But all the same, the fear lingered.

Backing up, she collided with something solid. Her first instinct was to scream, but before she could make a sound, a strong hand clamped over her mouth, muffling the cry. She was shoved against the cold metal wall, her back pressed firmly against it as a tall figure loomed over her. Her heart raced, terror surging through her.

“Shh,” he whispered, his breath warm against her cheek.

Ettore.

They stayed like that for what felt like an eternity, the air thick with a tension that was both terrifying and oddly charged. She didn’t dare move, her breath shallow and trembling against his hand. He leaned in closer, his lips almost brushing her ear as he whispered. 

“Stay quiet, and maybe we’ll both make it out of this.”

She nodded slightly, in no position to argue or protest. His voice was a low, dangerous murmur, but there was something almost protective in the way he held her, his body shielding hers from the imminent threat. It was a strange, twisted sense of security, and despite the circumstances, she found herself clinging to it.

Monte stormed into the room, his heavy footsteps echoing through the pitch-black space. The door slammed against the wall, the sound reverberating through the silence. Her entire body tensed, a wave of raw terror gripping her as she pressed herself against the wall, wishing she could melt into it and disappear.

She had never been more scared in her life. The darkness was all-consuming, robbing her of her senses. She couldn’t see Monte, couldn’t gauge his distance or his intentions. All she knew was that he was close, far too close. 

Ettore’s hand remained firmly over her mouth, his grip steady but not harsh. She could feel the rough texture of his palm against her lips, could almost feel the thudding of his own heart against hers, and she fought to keep her breathing steady, her panic threatening to break through. For the first time, she was thankful for the darkness, for the inability to be seen, but it didn’t stop the tears from welling up in her eyes, blurring what little she could make out in the blackness.

Monte’s voice boomed through the room, a raw, violent shout that made her flinch involuntarily. “Where the fuck are you, you bitch? You think you can hide from me?”

Her tears spilled over, silently sliding down her cheeks, and Ettore’s hand, still covering her mouth, felt the wetness. She didn’t know if it was fear, hopelessness, or the sheer weight of the situation crashing down on her, but she couldn’t stop the silent flow.

She tried desperately to make out Ettore’s face, to find some anchor in the overwhelming darkness, but it was impossible. He was just a shadow, a vague outline she could barely discern, his presence more felt than seen.

Monte’s footsteps grew closer, his breathing heavy and erratic as he stalked through the room, searching for her. She could feel Ettore’s grip tighten slightly, a silent reassurance or perhaps a warning to stay silent. Her heart pounded so hard she thought it might give them away.

The sound of Monte’s boots scuffing against the floorboards seemed deafening in the darkness. The tension was unbearable, a taut line ready to snap at any moment. Monte cursed under his breath and turned away, his footsteps retreating as he left the room. The door slammed shut behind him, and the oppressive silence that followed was almost worse than his presence. She didn’t dare move, not even to breathe, until she was sure he was gone.

“Jesus…” she whispered in relief when Ettore’s palm dropped from her lips. She expected him to move away, for them to find some way of escape.

But his hand, once firm over her mouth, slowly slid down to her neck, his fingers curling around the sensitive skin, holding her in place. The touch was no longer just about silence, it was possessive, controlling. She could feel his breath against her ear, slow and deliberate, as the tension between them morphed into something darker, more dangerous.

Her heart raced for a different reason now, a confusing mix of fear and something else, something she didn’t want to acknowledge. His other hand moved with a deliberate slowness, tracing the line of her waist before cupping her womanhood through her jeans. She gasped softly, the sound barely escaping her lips, but it was enough to let him know that she was fully aware of his intentions.

In the darkness, with Monte gone, the only thing she could see was his outline, and the only thing she could feel was the slow, purposeful movement of his hands. He held her firmly against the wall, his grip on her neck tightening just enough to remind her who was in control.

His hand applied just enough pressure to make her pulse quicken. "You're shaking," he noted, his tone almost mocking. "Is it fear, or something else?"

She could tell from his tone, he was loving this. Amused by her fear and helplessness. He enjoyed far too much the feeling of having someone’s life and control in his hand. 

"Tell me, are you scared of what I might do? Or are you more afraid of how much you might want it?"

Her breath hitched, the question slicing through her like a knife. After a moment that felt like an eternity, she finally found her voice, though it was barely more than a whisper. “I'm not scared and I don't want you-”

The lie hung heavy in the air between them, and Ettore chuckled darkly, his free hand sliding down her body. He didn't believe her for a second, and she could tell.

His fingers deftly found the button of her jeans, and with a single, practiced motion, he popped it open. “So if I touch you here,” he whispered, his hand sliding beneath, “you won’t be wet?”

All it took was his fingers to dip beneath her underwear, sliding between her folds to collect her arousal on his fingertips, for her to freeze, the realisation dawning darkly that his presence in the darkness, his grip on her, and his words, were all having the effect she wanted least to happen.

She bit her lip, trying to suppress the involuntary reaction that coursed through her as he drifted north to circle her clit with ease.

“You’re not the woman I thought you’d be,” he continued, his tone mocking. “Say you're a professional? You're a fucking liar.”

Once again, she tried to make out his face. Trying to imagine his expression. She was convinced he could somehow see hers as he pushed forward, stretching her hot walls around his fingers to harshly fuck her with his fingers, as if testing the dangerous waters.

Her hand clamped on his wrist. She wanted him to stop. She wanted him to carry on. The darkness was doing her indecision no favours whatsoever, blurring her common sense.

He bruised his body against hers, pinning her even more firmly to the wall. The sound of her moisture clicking against his skin both erotic and a terrifying reminder of how her control had waned.

“Tell me to stop,” he challenged, his voice low, a whisper that curled around her like smoke. “But you won’t, will you?”

Her voice came a shaky whisper, an attempt to grapple back that sense of self she felt was swiftly slipping. But her tone betrayed the conflict raging inside her. “You…don't know me-” she strained to say, wincing as she felt the rough pads of his fingers brush the front of her walls.

She felt his breath, amused against her face. Ettore’s response was a low, mocking chuckle. “Maybe not,” he murmured, his lips brushing against her ear, “but I know enough.”

Her whine was low as his fingers left her, but her heart stuttered in place when he rolled her jeans over her hips, taking her underwear with it. His knee harshly nudged her legs apart so she couldn't close them, before moving his sweatpants down just enough, his breath hot against her neck, where his palm still pressed.

Fuck. Fuck. Fuck.

He knew enough about her to know that at this moment, she wouldn't stop him. Perhaps, couldn't. If she even tried. She choked air out her lungs when his chest pressed against hers, one hand pulling her leg over his hip to angle her up.

And the sharp pang of panic when she felt the blunt head of his cock press into her. She felt herself starting to say ‘no’, but all words died on her lips as she felt him stretch her open on his length, disappearing inside her with barely a sound of his own.

It was sharp and biting, the pain initially. If it could have been called foreplay, none of it had really been for her in any case, so she felt every inch of him. And she winced, eyes pressing shut when his pace was immediately brutal, snapping against her hips with commanding intensity.

All she could do was press her fingernails into his arm, try and share some pain with him in some twisted way. That's the only sound he made, was a low groan, his grip around her throat tightening to feel the rapid thrum of her pulse.

She hated it. Hated giving him this…sick sense of control over her. Knowing that he would be much too proud and one track minded to stop until he'd come, she thought, get it over with.

She clenched around him, hard. Wanting him to lose it himself and just finish what he started. And when she felt his breath catch, she smirked in victory, until his hand raised to her face, pushing her head harshly back, her jaw anchored in his grip.

“No you don't, you fucking bitch,” he breathed, low and dangerous in a way that made her heart freeze. “Think you can rush me?”

The smirk that had momentarily crossed her lips vanished as she realised how deeply she had miscalculated. Ettore wasn’t going to simply take what he wanted and be done. He was going to make her feel every second of it, make her pay for that brief moment of defiance.

“You’re going to come on my dick, and when you do, you’ll sound pathetic. Just like you are.”

It was fucking annoying, was all she thought, that when he renewed his pace to borderline erratic, the pain ebbed into sharp pleasure. The hand that held her leg around his waist drifted inwards, clumsily circled her clit, too quickly and firmly to feel entirely pleasurable, but just enough combined with his relentless assault to send her spiralling.

Her breath hitched, and she felt the tears prick at the corners of her eyes, more from frustration and rage than anything else. He could feel it too, how close she was to breaking, how her body betrayed her resolve. Ettore revelled in it, every small tremble, every shaky breath, feeding his twisted need to dominate.

He pressed her sensitive bundle of nerves like he hated her, and it was enough to send a full body shudder from the top of her spine right through her core. He only let out a breath of smug relief feeling her walls clamp him in, tending uncontrollably around him.

The room was silent except for the harsh breaths they both struggled to catch. The darkness around her seemed to close in, the only light left in the room the fading stars behind her vision. As the reality of what had just happened began to set in, she felt Ettore’s body still against hers, the warmth of him inside her chasing away the numbness that had momentarily overtaken her.

For a moment, neither of them moved. Then, with a surge of disgust and anger, she pushed against his chest, forcing him away from her. Her hands trembled as she scrambled to right her clothes, feeling hot in her chest with shame. Ettore staggered back, and she could practically feel his smug grin in the darkness. He adjusted himself with a deliberate slowness, clearly savouring the moment. His breathing was still laboured, but there was an unmistakable air of satisfaction surrounding him.

“No use fighting it,” he murmured, amusement seeping into every word.

She scoffed, her hands fumbling with the buttons of her jeans. “Dick,” she muttered under her breath, the word laced with a mix of anger and frustration.

Ettore’s smirk only deepened, his eyes glinting with satisfaction. “Call me what you want. You know I’m the only one who can get you through this. You need me. Whether you like it or not.”

The emergency lights flickered on, casting a dim, flickering glow over the room. The sudden illumination was a relief, pulling her back from the suffocating grip of darkness. She could finally see again, the oppressive void around her receding. The sight of Ettore standing there, so smug and composed, sent a wave of shame crashing over her. Disgust curled in her stomach, twisting alongside a sick sense of arousal she couldn’t fully suppress.

But like a cold slap to the face, she knew Monte was still out there, stalking the ship, hunting her down. And now, with the lights on, it would be easier for him to find her. |It was a jolt, reigniting the fear she had momentarily pushed aside amidst the dull haze of thrumming pleasure. 

Ettore seemed to sense her shift in focus, his smirk fading into something more serious. "He’s not far," he said, his voice low and measured. “Stick with me. I know a quick way back.”

She didn’t respond, her mind racing. The thought of Monte finding her now, after everything, sent a fresh wave of terror through her. As much as she despised the idea, as much as she loathed Ettore for what he'd done, he was her best chance at survival. But how could she, with everything she knew and everything she had just experienced, possibly trust him?

Was the onus on her? For allowing him to do what he did? For the way she had let him touch her, for the strange, conflicted sensations she had felt?

Before she could dwell on it further, Ettore yanked her forcefully, snapping her back to the present. They had to move quickly. The urgency in his grip was impossible to ignore, and in the rush, she realised too late that she had forgotten to feel for her gun.

They hurried through the narrow corridors, the cold metal walls echoing with the distant sounds of chaos. When they finally reached the entrance to her team’s ship, he pulled her inside with a final, rough tug. Panting, she glanced around the familiar interior of the vessel, trying to steady herself. Ettore didn’t waste a moment.

“Do you have the authority to access the emergency autopilot system?” he asked, his voice sharp, cutting through the haze of fear and confusion.

She hesitated for just a second. “Yes, but what about everyone else? We can’t just leave them.”

“There’s no time,” he shot back, his eyes locking onto hers with an intensity that made her stomach drop. “Monte’s not going to stop until he finds you, and when he does, you’re dead. We need to get off this ship now.”

Her hands shook as she moved toward the control panel, the reality of the situation weighing heavily on her. She could feel Ettore’s gaze on her, urging her to move faster, to make the choice she knew she had to make. The ship’s systems roared to life, as did the alarms, signalling their imminent departure from the prison ship. For a brief, harrowing moment, she could hear Monte’s voice echoing through the corridor, filled with rage, mingling with the desperate shouts of others. But then the door hissed shut, sealing them off from the chaos outside.

Ettore was already behind her, his presence looming, suffocating in the small space. “Control Room. Now,” he ordered, his tone leaving no room for argument. Panic surged through her, her mind racing as she obeyed, her steps hurried and frantic. She couldn’t think straight, couldn’t process the fact that a dangerous criminal was now alone with her on her ship. Panic pushed her forward instead. Primal and urgent.

Once there, her mind scrambled for any option, any way to get the ones who wanted to return to Earth safely off the prison ship. “We can’t just leave them behind,” she stammered, turning, desperation clear in her voice. “There are others who want to return-”

Her blood ran cold as she whipped back at him, he stood tall, almost proud, holding a gun to her face. A brief, fleeting thought roared through her mind that she doubted it was loaded, but she dare not entertain it right now. Not when fear gripped her ribs. 

Her own gun. She knew the second she went to feel for it. 

He’d stolen it during her moment of weakness.

Ettore smirked, his expression infuriatingly smug. “No hard feelings,” he said, his voice dripping with mockery.

Her heart raced with a potent mix of anger and terror. This wasn’t how it was supposed to go. She had come here with the intention of doing good, of offering these people a chance at redemption or at least a fair trial. And now, what had she done? She’d left behind an entire ship of prisoners, all so she could be trapped here, alone, with him.

She stared at Ettore, her mind swirling with a thousand conflicting emotions. The anger bubbling up inside her was nearly as strong as the fear. How had it come to this? How had she let herself be so easily manipulated, so trapped?

“Here’s how this is going to work,” he said, his tone all business now, as if he were discussing a simple transaction. “You’re going to take me back to Earth, and when we get there, you’re going to make sure I live a nice, cushy life. No more cells, no more guards, just freedom. I’m sure a smart woman like you can figure out how to make that happen.”

She opened her mouth to protest, to argue, but the cold, unyielding barrel of the gun in his hand kept her silent.

“And in return,” he continued, his eyes darkening with a twisted sort of pleasure, “we’ll have some fun on the way back. You’ll make sure of that too, won’t you?” 

Anger and fear warred within her, but the sharp edge of reality kept her from saying anything that might push him further. She felt utterly trapped, forced into a role she never imagined she’d play. The man in front of her was dangerous, and there was no telling what he would do if she refused.

Ettore’s smirk softened, just a little, as if he could sense her internal struggle. “You’re smart. You know what the right choice is.” 

She wanted to scream, to cry out in frustration and fear. A dark, violent urge flared within her, the impulse to bash him over the head, to kill him and be done with it. But here, alone in the vastness of space, without the guards or anyone else to enforce order, who would hear her? Truly hear her? Her fury would echo into the void, and she would still be utterly and entirely, alone.

His voice was a soft, poisonous whisper. “So, what’s it going to be, little lawyer?”

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[religion-is-a-mental-illness]

By: Andy L.

Published: Apr 14, 2024

It has now been just little under a week since the publication of the long anticipated NHS independent review of gender identity services for children and young people, the Cass Review.

The review recommends sweeping changes to child services in the NHS, not least the abandonment of what is known as the “affirmation model” and the associated use of puberty blockers and, later, cross-sex hormones. The evidence base could not support the use of such drastic treatments, and this approach was failing to address the complexities of health problems in such children.

Many trans advocacy groups appear to be cautiously welcoming these recommendations. However, there are many who are not and have quickly tried to condemn the review. Within almost hours, “press releases“, tweets and commentaries tried to rubbish the report and included statements that were simply not true. An angry letter from many “academics”, including Andrew Wakefield, has been published. These myths have been subsequently spreading like wildfire.

Here I wish to tackle some of those myths and misrepresentations.

-

Myth 1: 98% of all studies in this area were ignored

Fact

A comprehensive search was performed for all studies addressing the clinical questions under investigation, and over 100 were discovered. All these studies were evaluated for their quality and risk of bias. Only 2% of the studies met the criteria for the highest quality rating, but all high and medium quality (50%+) studies were further analysed to synthesise overall conclusions.

Explanation

The Cass Review aimed to base its recommendations on the comprehensive body of evidence available. While individual studies may demonstrate positive outcomes for the use of puberty blockers and cross-sex hormones in children, the quality of these studies may vary. Therefore, the review sought to assess not only the findings of each study but also the reliability of those findings.

Studies exhibit variability in quality. Quality impacts the reliability of any conclusions that can be drawn. Some may have small sample sizes, while others may involve cohorts that differ from the target patient population. For instance, if a study primarily involves men in their 30s, their experiences may differ significantly from those of teenage girls, who constitute the a primary patient group of interest. Numerous factors can contribute to poor study quality.

Bias is also a big factor. Many people view claims of a biased study as meaning the researchers had ideological or predetermined goals and so might misrepresent their work. That may be true. But that is not what bias means when we evaluate medical trials.

In this case we are interested in statistical bias. This is where the numbers can mislead us in some way. For example, if your study started with lots of patients but many dropped out then statistical bias may creep in as your drop-outs might be the ones with the worst experiences. Your study patients are not on average like all the possible patients.

If then we want to look at a lot papers to find out if a treatment works, we want to be sure that we pay much more attention to those papers that look like they may have less risk of bias or quality issues. The poor quality papers may have positive results that are due to poor study design or execution and not because the treatment works.

The Cass Review team commissioned researchers at York University to search for all relevant papers on childhood use of puberty blockers and cross-sex hormones for treating “gender dysphoria”. The researchers then graded each paper by established methods to determine quality, and then disregarded all low quality papers to help ensure they did not mislead.

The Review states,

The systematic review on interventions to suppress puberty (Taylor et al: Puberty suppression) provides an update to the NICE review (2020a). It identified 50 studies looking at different aspects of gender-related, psychosocial, physiological and cognitive outcomes of puberty suppression. Quality was assessed on a standardised scale. There was one high quality study, 25 moderate quality studies and 24 low quality studies. The low quality studies were excluded from the synthesis of results.

As can be seen, the conclusions that were based on the synthesis of studies only rejected 24 out of 50 studies – less than half. The myth has arisen that the synthesis only included the one high quality study. That is simply untrue.

There were two such literature reviews: the other was for cross-sex hormones. This study found 19 out of 53 studies were low quality and so were not used in synthesis. Only one study was classed as high quality – the rest medium quality and so were used in the analysis.

12 cohort, 9 cross-sectional and 32 pre–post studies were included (n=53). One cohort study was high-quality. Other studies were moderate (n=33) and low-quality (n=19). Synthesis of high and moderate-quality studies showed consistent evidence demonstrating induction of puberty, although with varying feminising/masculinising effects. There was limited evidence regarding gender dysphoria, body satisfaction, psychosocial and cognitive outcomes, and fertility.

Again, it is myth that 98% of studies were discarded. The truth is that over a hundred studies were read and appraised. About half of them were graded to be of too poor quality to reliably include in a synthesis of all the evidence. if you include low quality evidence, your over-all conclusions can be at risk from results that are very unreliable. As they say – GIGO – Garbage In Garbage Out.

Nonetheless, despite analysing the higher quality studies, there was no clear evidence that emerged that puberty blockers and cross-sex hormones were safe and effective. The BMJ editorial summed this up perfectly,

One emerging criticism of the Cass review is that it set the methodological bar too high for research to be included in its analysis and discarded too many studies on the basis of quality. In fact, the reality is different: studies in gender medicine fall woefully short in terms of methodological rigour; the methodological bar for gender medicine studies was set too low, generating research findings that are therefore hard to interpret. The methodological quality of research matters because a drug efficacy study in humans with an inappropriate or no control group is a potential breach of research ethics. Offering treatments without an adequate understanding of benefits and harms is unethical. All of this matters even more when the treatments are not trivial; puberty blockers and hormone therapies are major, life altering interventions. Yet this inconclusive and unacceptable evidence base was used to inform influential clinical guidelines, such as those of the World Professional Association for Transgender Health (WPATH), which themselves were cascaded into the development of subsequent guidelines internationally.

-

Myth 2: Cass recommended no Trans Healthcare for Under 25s

Fact

The Cass Review does not contain any recommendation or suggestion advocating for the withholding of transgender healthcare until the age of 25, nor does it propose a prohibition on individuals transitioning.

Explanation

This myth appears to be a misreading of one of the recommendations.

The Cass Review expressed concerns regarding the necessity for children to transition to adult service provision at the age of 18, a critical phase in their development and potential treatment. Children were deemed particularly vulnerable during this period, facing potential discontinuity of care as they transitioned to other clinics and care providers. Furthermore, the transition made follow-up of patients more challenging.

Cass then says,

Taking account of all the above issues, a follow-through service continuing up to age 25 would remove the need for transition at this vulnerable time and benefit both this younger population and the adult population. This will have the added benefit in the longer-term of also increasing the capacity of adult provision across the country as more gender services are established.

Cass want to set up continuity of service provision by ensure they remain within the same clinical setting and with the same care providers until they are 25. This says nothing about withdrawing any form of treatment that may be appropriate in the adult care pathway. Cass is explicit in saying her report is making no recommendations as to what that care should look like for over 18s.

It looks the myth has arisen from a bizarre misreading of the phrase “remove the need for transition”. Activists appear to think this means that there should be no “gender transition” whereas it is obvious this is referring to “care transition”.

-

Myth 3: Cass is demanding only Double Blind Randomised Controlled Trials be used as evidence in “Trans Healthcare”

Fact

While it is acknowledged that conducting double-blind randomized controlled trials (DBRCT) for puberty blockers in children would present significant ethical and practical challenges, the Cass Review does not advocate solely for the use of DBRCT trials in making treatment recommendations, nor does it mandate that future trials adhere strictly to such protocols. Rather, the review extensively discusses the necessity for appropriate trial designs that are both ethical and practical, emphasizing the importance of maintaining high methodological quality.

Explanation

Cass goes into great detail explaining the nature of clinical evidence and how that can vary in quality depending on the trial design and how it is implemented and analysed. She sets out why Double Blind Randomised Controlled Trials are the ‘gold standard’ as they minimise the risks of confounding factors misleading you and helping to understand cause and effect, for example. (See Explanatory Box 1 in the Report).

Doctors rely on evidence to guide treatment decisions, which can be discussed with patients to facilitate informed choices considering the known benefits and risks of proposed treatments.

Evidence can range from a doctor’s personal experience to more formal sources. For instance, a doctor may draw on their own extensive experience treating patients, known as ‘Expert Opinion.’ While valuable, this method isn’t foolproof, as historical inaccuracies in medical beliefs have shown.

Consulting other doctors’ experiences, especially if documented in published case reports, can offer additional insight. However, these reports have limitations, such as their inability to establish causality between treatment and outcome. For example, if a patient with a bad back improves after swimming, it’s uncertain whether swimming directly caused the improvement or if the back would have healed naturally.

Further up the hierarchy of clinical evidence are papers that examine cohorts of patients, typically involving multiple case studies with statistical analysis. While offering better evidence, they still have potential biases and limitations.

This illustrates the ‘pyramid of clinical evidence,’ which categorises different types of evidence based on their quality and reliability in informing treatment decisions

The above diagram is published in the Cass Review as part of Explanatory Box 1.

We can see from the report and papers that Cass did not insist that only randomised controlled trials were used to assess the evidence. The York team that conducted the analyses chose a method to asses the quality of studies called the Newcastle Ottawa Scale. This is a method best suited for non RCT trials. Cass has selected an assessment method best suited for the nature of the available evidence rather than taken a dogmatic approach on the need for DBRCTs. The results of this method were discussed about countering Myth 1.

Explainer on the Newcastle Ottawa Scale

The Newcastle-Ottawa Scale (NOS) is a tool designed to assess the quality of non-randomized studies, particularly observational studies such as cohort and case-control studies. It provides a structured method for evaluating the risk of bias in these types of studies and has become widely used in systematic reviews and meta-analyses.

The NOS consists of a set of criteria grouped into three main categories: selection of study groups, comparability of groups, and ascertainment of either the exposure or outcome of interest. Each category contains several items, and each item is scored based on predefined criteria. The total score indicates the overall quality of the study, with higher scores indicating lower risk of bias.

This scale is best applied when conducting systematic reviews or meta-analyses that include non-randomized studies. By using the NOS, researchers can objectively assess the quality of each study included in their review, allowing them to weigh the evidence appropriately and draw more reliable conclusions.

One of the strengths of the NOS is its flexibility and simplicity. It provides a standardized framework for evaluating study quality, yet it can be adapted to different study designs and research questions. Additionally, the NOS emphasizes key methodological aspects that are crucial for reducing bias in observational studies, such as appropriate selection of study participants and controlling for confounding factors.

Another advantage of the NOS is its widespread use and acceptance in the research community. Many systematic reviews and meta-analyses rely on the NOS to assess the quality of included studies, making it easier for researchers to compare and interpret findings across different studies.

As for future studies, Cass makes no demand only DBRCTs are conducted. What is highlighted is at the very least that service providers build a research capacity to fill in the evidence gaps.

The national infrastructure should be put in place to manage data collection and audit and this should be used to drive continuous quality improvement and research in an active learning environment.

-

Myth 4: There were less than 10 detransitioners out of 3499 patients in the Cass study.

Fact

Cass was unable to determine the detransition rate. Although the GIDS audit study recorded fewer than 10 detransitioners, clinics declined to provide information to the review that would have enabled linking a child’s treatment to their adult outcome. The low recorded rates must be due in part to insufficient data availability.

Explanation

Cass says, “The percentage of people treated with hormones who subsequently detransition remains unknown due to the lack of long-term follow-up studies, although there is suggestion that numbers are increasing.”

The reported number are going to be low for a number of reasons, as Cass describes:

Estimates of the percentage of individuals who embark on a medical pathway and subsequently have regrets or detransition are hard to determine from GDC clinic data alone. There are several reasons for this:

Damningly, Cass describes the attempt by the review to establish “data linkage’ between records at the childhood gender clinics and adult services to look at longer term detransition and the clinics refused to cooperate with the Independent Review. The report notes the “…attempts to improve the evidence base have been thwarted by a lack of cooperation from the adult gender services”.

We know from other analyses of the data on detransitioning that the quality of data is exceptionally poor and the actual rates of detransition and regret are unknown. This is especially worrying when older data, such as reported in WPATH 7, suggest natural rates of decrease in dysphoria without treatment are very high.

Gender dysphoria during childhood does not inevitably continue into adulthood. Rather, in follow-up studies of prepubertal children (mainly boys) who were referred to clinics for assessment of gender dysphoria, the dysphoria persisted into adulthood for only 6–23% of children.

This suggests that active affirmative treatment may be locking in a trans identity into the majority of children who would otherwise desist with trans ideation and live unmedicated lives.

I shall add more myths as they become spread.

==

It's not so much "myths and misconceptions" as deliberate misinformation. Genderists are scrambling to prop up their faith-based beliefs the same way homeopaths do. Both are fraudulent.

[fatliberation]

I totally understand and can empathize with fat activists when it comes to medical fatphobia. But I do think its important to provide nuance to this topic.

A lot of doctors mention weight loss, particularly for elective surgeries, because it makes the recovery process easier (Particularly with keeping sutures in place) and anesthetic safer.

I feel like its still important to mention those things when advocating for fat folks. Safety is important.

What you're talking about is actually a different topic altogether - the previous ask was not about preparing for surgery, it was about dieting being the only treatment option for anon's chronic pain, which was exacerbating their ed symptoms. Diets have been proven over and over again to be unsustainable (and are the leading predictor of eating disorders). So yeah, I felt that it was an inappropriate prescription informed more by bias than actual data.

(And side note: This study on chronic pain and obesity concluded that weight change was not associated with changes of pain intensity.)

If you want to discuss the risk factor for surgery, sure, I think that's an important thing to know - however, most fat people already know this and are informed by their doctors and surgeons of what the risks are beforehand, so I'm not really concerned about people being uninformed about it.

I'm a fat liberation activist, and what I'm concerned about is bias. I'm concerned that there are so many BMI cutoffs in essential surgeries for fat patients, when weight loss is hardly feasible, that creates a barrier to care that disproportionately affects marginalized people with intersecting identities.

It's also important to know that we have very little data around the outcomes of surgery for fat folks that isn't bariatric weight loss surgery.

A new systematic review by researchers in Sydney, Australia, published in the journal Clinical Obesity, suggests that weight loss diets before elective surgery are ineffective in reducing postoperative complications.

CADTH Health Technology Review Body Mass Index as a Measure of Obesity and Cut-Off for Surgical Eligibility made a similar conclusion:

Most studies either found discrepancies between BMI and other measurements or concluded that there was insufficient evidence to support BMI cut-offs for surgical eligibility. The sources explicitly reporting ethical issues related to the use of BMI as a measure of obesity or cut-off for surgical eligibility described concerns around stigma, bias (particularly for racialized peoples), and the potential to create or exacerbate disparities in health care access.

Nicholas Giori MD, PhD Professor of Orthopedic Surgery at Stanford University, a respected leader in TKA and THA shared his thoughts in Elective Surgery in Adult Patients with Excess Weight: Can Preoperative Dietary Interventions Improve Surgical Outcomes? A Systematic Review:

“Obesity is not reversible for most patients. Outpatient weight reduction programs average only 8% body weight loss [1, 10, 29]. Eight percent of patients denied surgery for high BMI eventually reach the BMI cutoff and have total joint arthroplasty [28]. Without a reliable pathway for weight loss, we shouldn’t categorically withhold an operation that improves pain and function for patients in all BMI classes [3, 14, 16] to avoid a risk that is comparable to other risks we routinely accept.

It is not clear that weight reduction prior to surgery reduces risk. Most studies on this topic involve dramatic weight loss from bariatric surgery and have had mixed results [13, 19, 21, 22, 24, 27]. Moderate non-surgical weight loss has thus-far not been shown to affect risk [12]. Though hard BMI cutoffs are well-intended, currently-used BMI cutoffs nearly have the effect of arbitrarily rationing care without medical justification. This is because BMI does not strongly predict complications. It is troubling that the effects are actually not arbitrary, but disproportionately affect minorities, women and patients in low socioeconomic classes. I believe that the decision to proceed with surgery should be based on traditional shared-decision making between the patient and surgeon. Different patients and different surgeons have different tolerances to risk and reward. Giving patients and surgeons freedom to determine the balance that is right for them is, in my opinion, the right way to proceed.”

I agree with Dr. Giori on this. And I absolutely do not judge anyone who chooses to lose weight prior to a surgery. It's upsetting that it is the only option right now for things like safe anesthesia. Unfortunately, patients with a history of disordered eating (which is a significant percentage of fat people!) are left out of the conversation. There is certainly risk involved in either option and it sucks. I am always open to nuanced discussion, and the one thing I remain firm in is that weight loss is not the answer long-term. We should be looking for other solutions in treating fat patients and studying how to make surgery safer. A lot of this could be solved with more comprehensive training and new medical developments instead of continuously trying to make fat people less fat.

[covid-safer-hotties]

Listing archived on our website

Summary Background Patient-reported outcomes and cross-sectional evidence show an association between COVID-19 and persistent cognitive problems. The causal basis, longevity and domain specificity of this association is unclear due to population variability in baseline cognitive abilities, vulnerabilities, virus variants, vaccination status and treatment.

Methods Thirty-four young, healthy, seronegative volunteers were inoculated with Wildtype SARS-CoV-2 under prospectively controlled conditions. Volunteers completed daily physiological measurements and computerised cognitive tasks during quarantine and follow-up at 30, 90, 180, 270, and 360 days. Linear modelling examined differences between ‘infected’ and ‘inoculated but uninfected’ individuals. The main cognitive endpoint was the baseline corrected global cognitive composite score across the battery of tasks administered to the volunteers. Exploratory cognitive endpoints included baseline corrected scores from individual tasks. The study was registered on ClinicalTrials.gov with the identifier NCT04865237 and took place between March 2021 and July 2022.

Findings Eighteen volunteers developed infection by qPCR criteria of sustained viral load, one without symptoms and the remainder with mild illness. Infected volunteers showed statistically lower baseline-corrected global composite cognitive scores than uninfected volunteers, both acutely and during follow up (mean difference over all time points = −0.8631, 95% CI = −1.3613, −0.3766) with significant main effect of group in repeated measures ANOVA (F (1,34) = 7.58, p = 0.009). Sensitivity analysis replicated this cross-group difference after controlling for community upper respiratory tract infection, task-learning, remdesivir treatment, baseline reference and model structure. Memory and executive function tasks showed the largest between-group differences. No volunteers reported persistent subjective cognitive symptoms.

Interpretation These results support larger cross sectional findings indicating that mild Wildtype SARS-CoV-2 infection can be followed by small changes in cognition and memory that persist for at least a year. The mechanistic basis and clinical implications of these small changes remain unclear.

[probablyasocialecologist]

The Cass Report is fatally flawed in its methodology, and as a result, its recommendations are harmful. Speaking on behalf of TransActual, Keyne Walker said: “It undermines the legal competence of both children and adults to access medical treatment and dismisses almost all existing clinical evidence on trans people’s healthcare by applying impossible evidence standards which, if applied to other medicines would invalidate more than three quarters of the existing treatments used in paediatric care which, like puberty blockers, are currently being prescribed off-label.” The report’s primary conclusions rest on excluding 98% of the relevant evidence on the safety and efficacy of puberty blockers and hormones for lack of blinding and controls. What this means is that they require studies in which some patients are given the treatment, and others are unknowingly given placebos. This is not only a clear breach of medical ethics and monstrous suggestion, but also impossible due to the obviousness of the impacts of puberty blockers and hormones.  The report also strays far beyond its scope and competence in recommending a review of adult services and in suggesting that young people ought to stay under the care of children and young people’s services until the age of 25. The latter is based on highly questionable understandings of brain development which have been repeatedly debunked as an oversimplification of the constant changes in human neurology over the course of our lives.  This recommendation, especially in a context of an already broken system of care for both adults and children, has the potential to have a significant negative impact on the lives and wellbeing of trans people in the UK.  Underpinning this report is the idea that being trans is an undesirable outcome rather than a natural facet of human diversity. This is clear not only from the recommendations but also from the exclusion of trans researchers from the design of the review process and the links individual members of the research team have to anti-trans groups, which the Cass team were warned about. Download the full briefing

[transmutationisms]

do you feel like SSRIs are mostly pseudoscience? I'm not sure if I should be open to trying them or avoid them at all costs since I'm not sure if they even work or if they will mess me up permanently

a preliminary note that i don't find the category 'pseudoscience' to be useful & would classify SSRI research more as 'methodologically shoddy science' or 'ideologically slanted' or 'part of a centuries-long effort on the part of psychiatrists to secure themselves professional prestige by claiming neurobiological etiologies where none are shown to exist' &c &c. imo the notion of 'pseudoscience' is itself pretty positivistic, ahistorical, and ideologically noxious (particularly apparent in any analysis of epistemological imperialism).

that aside: you raise two major issues with SSRIs, namely whether they work and whether they will cause you harm.

efficacy of SSRIs is contested. a 2010 meta-analysis found that in patients with mild or moderate depressive symptoms, the efficacy of SSRIs "may be minimal or nonexistent", whilst "for patients with very severe depression, the benefit of medications over placebo is substantial". a 2008 meta-analysis found a similar distinction between mildly vs severely depressed patients, but noted that even in the latter population, drug–placebo differences were "relatively small" and argued that the differences between drug and placebo in severely depressed patients "seems to result from a poorer response to placebo amongst more depressed patients" rather than from a greater efficacy of SSRIs. a 2012 meta-analysis found some SSRIs consistently effective over placebo treatments, but several authors disclosed major relationships with pharmaceutical companies. a 2017 meta-analysis concluded that "SSRIs might have statistically significant effects on depressive symptoms, but all trials were at high risk of bias and the clinical significance seems questionable" (emphasis added) and that "potential small beneficial effects seem to be outweighed by harmful effects".

when evaluating any of this evidence, it is crucial to keep in mind that studies on antidepressant trials are selectively published—that is, they are less likely to be published if they show negative results!

A total of 37 studies viewed by the FDA as having positive results were published; 1 study viewed as positive was not published. Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive.

meta-analyses are not immune to this issue, either. in addition to the problem that a meta-analysis of a bunch of bad studies cannot magically 'cancel out' the effects of poor study design, the authors of meta-analyses can and do also have financial interests and ties to pharmaceutical companies, and this affects their results just as it does the results of the studies they are studying. according to a 2016 analysis of antidepressant meta-analyses,

Fifty-four meta-analyses (29%) had authors who were employees of the assessed drug manufacturer, and 147 (79%) had some industry link (sponsorship or authors who were industry employees and/or had conflicts of interest). Only 58 meta-analyses (31%) had negative statements in the concluding statement of the abstract. Meta-analyses including an author who were employees of the manufacturer of the assessed drug were 22-fold less likely to have negative statements about the drug than other meta-analyses [1/54 (2%) vs. 57/131 (44%); P < 0.001]. [...] There is a massive production of meta-analyses of antidepressants for depression authored by or linked to the industry, and they almost never report any caveats about antidepressants in their abstracts. Our findings add a note of caution for meta-analyses with ties to the manufacturers of the assessed products.

so, do SSRIs work? they are certainly psychoactive substances, which is to say, they do something. whether that something reduces depressive symptoms is simply not known at this point, though it is always worth keeping in mind that the 'chemical imbalance' narrative of SSRIs (the idea that they work by 'curing' a 'serotonin deficiency' in the brain) has always been a profitable myth. look, any medical treatment throughout history has been vouched for by SOME patients who report that it helped them—no matter how wacky it sounds or how little evidence there was to support it. this can be for a lot of reasons: placebo effect, the remedy accidentally treating a different problem than it was intended for, the symptoms coincidentally resolving on their own. sometimes the human body is just weird and unpredictable. sometimes remedies work. i'm sorry i can't give you a more definitive answer about whether SSRIs would help you.

as to potential risks: these are significant. SSRIs can precipitate suicidal ideation, a risk that has been consistently downplayed by pharmaceutical companies and studies. SSRIs are also known to contribute to sexual dysfunction and dissatisfaction, again a risk that is minimised and downplayed in much of the literature and in physician communication with patients. further (known) side effects range through emotional blunting, glaucoma, QT interval prolongation, abnormal bleeding & interaction with anti-coagulents, platelet dysfunction, decreases in bone mineral density leading to increased risk of osteopenia and osteoporosis, jaw clenching / TMJ pain, risk of serotonin syndrome when used in conjunction with other serotonergic substances, dizziness, insomnia, headaches, the list goes on.

i don't mean to sound alarmist; all drugs have side effects, some of the ones above occur rarely, and you may very well decide the risk is acceptable to you to take on. i would, though, always encourage you to do thorough research into potential side effects before starting any drug, including an SSRI. more on SSRI side effects in david healy's books 'pharmageddon', 'let them eat prozac', 'the antidepressant era', and 'the creation of psychopharmacology'; 'pillaged' by ronald w maris; and 'the myth of the chemical cure' by joanna moncrieff.

in addition to the above, SSRIs are known to come with a risk of 'discontinuation syndrome'—that is, chemical withdrawal when stopping the drug. this, too, is often downplayed by physicians; many still deny that it can even happen. some patients don't experience it at all, though i can tell you purely anecdotally that SSRI withdrawal was so miserable for me i simply gave up on quitting for over a year, despite the fact that at that point i was already thoroughly experienced with chemical withdrawals from other, 'harder' drugs. again, i am not telling you not to go on SSRIs if you decide these risks are worth it to you! i simply think this is a decision that should always be made with full knowledge (indeed, this is a core, though routinely violated, principle of medical 'informed consent').

ultimately this is not a decision anyone should make for you; it's your body and mind that are at stake here. as always i think that anyone considering any kind of medical treatment should have full knowledge about it and should be making all decisions freely and autonomously. i am genuinely not pushing any agenda 'for' or 'against' SSRIs, only against prescription of them that is done carelessly, coercively, or without fully informing patients of what risks they're taking on and what benefits they can hope to see.

[littlegreenwyvy]

You have covid

"I'm sure it's just a flu"

Flu:

Covid:

"I tested negative for covid"

"It's not so bad cuz hardly anybody dies of covid anymore anyway"

(Note, this ^ study's scope was for the 'core' of the pandemic (I.e. the first 2-3 years), but still has implications today)

"I'm young and healthy so I don't have to worry"

Take covid seriously, or else

Sources:

[floral-ashes]

With the Alberta government announcing a ban on gender-affirming care until 16 years old, let’s take a minute to correct some misinformation using peer-reviewed publications. A thread.🧵

“High quality evidence doesn’t support gender-affirming care.”

‘High quality evidence’ is a technical term that essentially just means ’no randomized controlled trials.’ RCTs are not scientifically feasible for trans youth care and would be unethical (link).

The evidence-base for gender-affirming care is quite robust and is at least as good at the evidence base for comparable interventions like abortion and birth control. For an overview of available studies, albeit already few years outdated, see page 144 onwards (link).

“Over 80% of kids grow out of being trans.”

That’s just not true. The claim is based on old, poor-quality studies that included tons of kids who never claimed to be trans (link).

But even if we took the percentage at face value, it would be irrelevant since it’s based on pre-pubertal data and virtually all the so-called ‘desistance’ occurred before puberty, when gender-affirming care becomes available (link).

More recent, better studies suggest that only around 2.5% have ‘grown out of it’ after 5 years (link).

“Kids falsely believe that they are trans because of social contagion.”

There is no evidence for that claim. It’s based on the reports of transphobic parents who were surprised that their kid came out ‘out of the blue’ and happened to have trans friends, as trans kids tend to do. For a careful explanation of why the claim is completely unsupported by evidence, see this (link).

Studies of trans youth that used clinical data to look into the claim have also failed to find any evidence of epidemic or large-scale social contagion (link).

“We need a years-long diagnostic process to make sure kids are ‘truly’ trans before they transition.”

There is no evidence that gender assessments fare any better than self-report at predicting future outcomes, as we explain in our recent review (link).

“Gender-exploratory therapy can help identify the trauma that made these kids gender dysphoric.”

Gender-exploratory therapy is extremely difficult to distinguish from classic conversion therapy, which also starts from the premise that ‘trauma’ makes people LGBTQ2S+ (link).

Since conversion therapy is known to be harmful, we have reasons to believe that gender-exploratory therapy would be as well.

Self-directed exploration is good. Forced exploration rooted in suspicion towards trans identities isn’t. If you’re starting from the belief that trans identities are inherently suspicious, you’re not doing therapy, you’re doing transphobia.

Any more myths about gender-affirming care you’d like me to bust, Tumblr?

[itsawritblr]

Breaking Down Cass Review Myths and Misconceptions: What You Need to Know.

An answer when some tranny or handmaiden disputes the review. (long post with lots of facts!)

Via The Quakometer:

It has now been just little under a week since the publication of the long anticipated NHS independent review of gender identity services for children and young people, the Cass Review.

The review recommends sweeping changes to child services in the NHS, not least the abandonment of what is known as the “affirmation model” and the associated use of puberty blockers and, later, cross-sex hormones. The evidence base could not support the use of such drastic treatments, and this approach was failing to address the complexities of health problems in such children.

Many trans advocacy groups appear to be cautiously welcoming these recommendations. However, there are many who are not and have quickly tried to condemn the review. Within almost hours, “press releases“, tweets and commentaries tried to rubbish the report and included statements that were simply not true. An angry letter from many “academics”, including Andrew Wakefield, has been published. These myths have been subsequently spreading like wildfire.

Here I wish to tackle some of those myths and misrepresentations.

Myth 1: 98% of all studies in this area were ignored.

Fact

A comprehensive search was performed for all studies addressing the clinical questions under investigation, and over 100 were discovered. All these studies were evaluated for their quality and risk of bias. Only 2% of the studies met the criteria for the highest quality rating, but all high and medium quality (50%+) studies were further analysed to synthesise overall conclusions.

Explanation.

The Cass Review aimed to base its recommendations on the comprehensive body of evidence available. While individual studies may demonstrate positive outcomes for the use of puberty blockers and cross-sex hormones in children, the quality of these studies may vary. Therefore, the review sought to assess not only the findings of each study but also the reliability of those findings.

Studies exhibit variability in quality. Quality impacts the reliability of any conclusions that can be drawn. Some may have small sample sizes, while others may involve cohorts that differ from the target patient population. For instance, if a study primarily involves men in their 30s, their experiences may differ significantly from those of teenage girls, who constitute the a primary patient group of interest. Numerous factors can contribute to poor study quality.

Bias is also a big factor. Many people view claims of a biased study as meaning the researchers had ideological or predetermined goals and so might misrepresent their work. That may be true. But that is not what bias means when we evaluate medical trials.

In this case we are interested in statistical bias. This is where the numbers can mislead us in some way. For example, if your study started with lots of patients but many dropped out then statistical bias may creep in as your drop-outs might be the ones with the worst experiences. Your study patients are not on average like all the possible patients.

If then we want to look at a lot papers to find out if a treatment works, we want to be sure that we pay much more attention to those papers that look like they may have less risk of bias or quality issues. The poor quality papers may have positive results that are due to poor study design or execution and not because the treatment works.

The Cass Review team commissioned researchers at York University to search for all relevant papers on childhood use of puberty blockers and cross-sex hormones for treating “gender dysphoria”. The researchers then graded each paper by established methods to determine quality, and then disregarded all low quality papers to help ensure they did not mislead.

The Review states,

As can be seen, the conclusions that were based on the synthesis of studies only rejected 24 out of 50 studies – less than half. The myth has arisen that the synthesis only included the one high quality study. That is simply untrue.

There were two such literature reviews: the other was for cross-sex hormones. This study found 19 out of 53 studies were low quality and so were not used in synthesis. Only one study was classed as high quality – the rest medium quality and so were used in the analysis.

Again, it is myth that 98% of studies were discarded. The truth is that over a hundred studies were read and appraised. About half of them were graded to be of too poor quality to reliably include in a synthesis of all the evidence. if you include low quality evidence, your over-all conclusions can be at risk from results that are very unreliable. As they say – GIGO – Garbage In Garbage Out.

Nonetheless, despite analysing the higher quality studies, there was no clear evidence that emerged that puberty blockers and cross-sex hormones were safe and effective. The BMJ editorial summed this up perfectly,

Myth 2: Cass recommended no Trans Healthcare for Under 25s.

Fact

The Cass Review does not contain any recommendation or suggestion advocating for the withholding of transgender healthcare until the age of 25, nor does it propose a prohibition on individuals transitioning.

Explanation

This myth appears to be a misreading of one of the recommendations.

The Cass Review expressed concerns regarding the necessity for children to transition to adult service provision at the age of 18, a critical phase in their development and potential treatment. Children were deemed particularly vulnerable during this period, facing potential discontinuity of care as they transitioned to other clinics and care providers. Furthermore, the transition made follow-up of patients more challenging.

Cass then says,

Cass want to set up continuity of service provision by ensure they remain within the same clinical setting and with the same care providers until they are 25. This says nothing about withdrawing any form of treatment that may be appropriate in the adult care pathway. Cass is explicit in saying her report is making no recommendations as to what that care should look like for over 18s.

It looks the myth has arisen from a bizarre misreading of the phrase “remove the need for transition”. Activists appear to think this means that there should be no “gender transition” whereas it is obvious this is referring to “care transition”.

Myth 3: Cass is demanding only Double Blind Randomised Controlled Trials be used as evidence in “Trans Healthcare”.

Fact

While it is acknowledged that conducting double-blind randomized controlled trials (DBRCT) for puberty blockers in children would present significant ethical and practical challenges, the Cass Review does not advocate solely for the use of DBRCT trials in making treatment recommendations, nor does it mandate that future trials adhere strictly to such protocols. Rather, the review extensively discusses the necessity for appropriate trial designs that are both ethical and practical, emphasizing the importance of maintaining high methodological quality.

Explanation

Cass goes into great detail explaining the nature of clinical evidence and how that can vary in quality depending on the trial design and how it is implemented and analysed. She sets out why Double Blind Randomised Controlled Trials are the ‘gold standard’ as they minimise the risks of confounding factors misleading you and helping to understand cause and effect, for example. (See Explanatory Box 1 in the Report).

Doctors rely on evidence to guide treatment decisions, which can be discussed with patients to facilitate informed choices considering the known benefits and risks of proposed treatments.

Evidence can range from a doctor’s personal experience to more formal sources. For instance, a doctor may draw on their own extensive experience treating patients, known as ‘Expert Opinion.’ While valuable, this method isn’t foolproof, as historical inaccuracies in medical beliefs have shown.

Consulting other doctors’ experiences, especially if documented in published case reports, can offer additional insight. However, these reports have limitations, such as their inability to establish causality between treatment and outcome. For example, if a patient with a bad back improves after swimming, it’s uncertain whether swimming directly caused the improvement or if the back would have healed naturally.

Further up the hierarchy of clinical evidence are papers that examine cohorts of patients, typically involving multiple case studies with statistical analysis. While offering better evidence, they still have potential biases and limitations.

This illustrates the ‘pyramid of clinical evidence,’ which categorises different types of evidence based on their quality and reliability in informing treatment decisions

The above diagram is published in the Cass Review as part of Explanatory Box 1.

We can see from the report and papers that Cass did not insist that only randomised controlled trials were used to assess the evidence. The York team that conducted the analyses chose a method to asses the quality of studies called the Newcastle Ottawa Scale. This is a method best suited for non RCT trials. Cass has selected an assessment method best suited for the nature of the available evidence rather than taken a dogmatic approach on the need for DBRCTs. The results of this method were discussed about countering Myth 1. Explainer on the Newcastle Ottawa Scale

As for future studies, Cass makes no demand only DBRCTs are conducted. What is highlighted is at the very least that service providers build a research capacity to fill in the evidence gaps.

Myth 4: There were less than 10 detransitioners out of 3499 patients in the Cass study.

Fact

Cass was unable to determine the detransition rate. Although the GIDS audit study recorded fewer than 10 detransitioners, clinics declined to provide information to the review that would have enabled linking a child’s treatment to their adult outcome. The low recorded rates must be due in part to insufficient data availability.

Explanation

Cass says, “The percentage of people treated with hormones who subsequently detransition remains unknown due to the lack of long-term follow-up studies, although there is suggestion that numbers are increasing.”

The reported number are going to be low for a number of reasons, as Cass describes:

Damningly, Cass describes the attempt by the review to establish “data linkage’ between records at the childhood gender clinics and adult services to look at longer term detransition and the clinics refused to cooperate with the Independent Review. The report notes the “…attempts to improve the evidence base have been thwarted by a lack of cooperation from the adult gender services”.

We know from other analyses of the data on detransitioning that the quality of data is exceptionally poor and the actual rates of detransition and regret are unknown. This is especially worrying when older data, such as reported in WPATH 7, suggest natural rates of decrease in dysphoria without treatment are very high.

This suggests that active affirmative treatment may be locking in a trans identity into the majority of children who would otherwise desist with trans ideation and live unmedicated lives.

I shall add more myths as they become spread.

[redavexat]

In case you missed any of the text, all of it is written here:

Medical transition works

80% of individuals reported significant improvement in dysphoria

78% of individuals reported significant improvements in psychological symptoms

72% of individuals reported significant improvement in sexual function

positive results across the board, even in 15- year follow ups

Source for all above: https://pubmed.ncbi.nlm.nih.gov/19473181/

"Wellbeing was similar to or better than same-age young adults from the general population" source for the above:

Quality of life increases dramatically with 'gender affirming treatment

source for the above: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6224813/

Long term follow-ups: https://www.jsm.jsexmed.org/article/S1743-6095(15)32422-X/fulltext

The above link shows as unsafe when you open it, it'll give you a message before sending you to the page. I'm not familiar enough with how websites work to confirm whether proceeding past that point is safe, click past the pop-up message at your own risk. I did, and the article IS there.

social transition works

"Shown to correlate with improved psychological functioning"

Source for above: https://www.sciencedirect.com/science/article/abs/pii/S1054139X1630146X

levels of depression and anxiety which closesly match levels reported by cisgender children

Source for above: https://www.jaacap.org/article/S0890-8567%2816%2931941-4/fulltext

puberty blockers are safe and reversible

Hormone blockers are the only treatment used on adolescents that are completely reversible.

Source for above: https://assets2.hrc.org/files/documents/SupportingCaringforTransChildren.pdf

"Current evidence Does not support an adverse impact of gender- affirming hormone therapy on cognitive performance"

"Our results suggest that there are no detrimental effects of GNRHA on EF"

source for above: https://www.sciencedirect.com/science/article/pii/S0306453020301402?via%3Dihub

"Relieves stress for trans adolescents"

"is reversible"

Source for above: https://academic.oup.com/jcem/article/102/11/3869/4157558

"Poorer psychological well-being before treatment"

Source for above: https://www.sciencedirect.com/science/article/abs/pii/S1054139X20300276

"Behavioural and emotional problems and depressive symptoms decreased"

source for above: https://sciencedirect.com/science/article/abs/pii/S1743609515336171

Hormone blockers are not new: "Since the mid 1990s..." and "The Royal college of psychiatrists, in 1998..."

source for above: https://www.tandfonline.com/doi/full/10.1080/26895269.2020.1747768

Many more studies: This screen of the video is far too small and compressed for me to read most of these links. If anyone knows of a higher quality version, thatd be great.

Puberty blockers aren't harmful to bone density: https://www.eurekalert.org/news-releases/842073

Puberty blockers don't cause osteoporosis or sterility: https://academic.oup.com/jcem/article/84/12/4583/2864749 Transphobia is real [personal side note, this comment isn't in the video: Does this really need a source to begin with?]: https://fra.europa.eu/sites/default/files/eu-lgbt-survey-results-at-a-glance_en.pdf

46% felt discriminated against or harrassed within the past year for being trans

29% felt discriminated against when it came to looking for employment

70% hid being trans during schooling before becoming 18 years old

55% had an incident of violence within the past year in part or whole because of them being trans

The ~40-50% Suicide rate is fake It's the attempt rate: https://transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf

The suicide rate is undocument and doesn't exist.

Discrimination is harmful

The attempt rate rises for people who: Lost a job due to bias (55%) were harrassed/ Bullied in school (51%) Had low household income were the victim of physical assault (61%) were the victim of sexual assault (64%)

Same source as above for attempt rate

Other factors include: gender-based victimisation discrimination bullying violence being rejected by the family, friends, and community harrassmentby intimate partner, family members, police and public discrimination and ill treatment at health-care system

source for above: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5178031/

[Another illegible "Many more studies" screen]

Social/ familial support helps:

[Top link doesn't work]

[next is too illegible]

It can decrease the likelihood of a suicide attempt 57% -> 4%

Chosen name/ pronoun use does the same:

https://www.jahonline.org/article/S1054-139X(18)30085-5/abstract 71% drop in severe depression 34% drop suicidal ideation 65% drop in suicide attempts

Gender and sex aren't the same These institutions and organisations would like to disagree with you: American Psychological association American medical association American psychoanalytic association Human rights campaign american academy of pediatrics american college of osteopathic pediatricians royal college of psychiatrists United Nations United Kingdom's National Health Service (NHS) American academy of child and adolescent psychiatry American academy of dermatology American academy of family physicians American academy of Nursing American academy of physician assistants American college health association American college of nurse-midwives American college of obstetricians and gynecologists American college of Physicians American counselling association American heart association American medical association American medical student association American nurses association American osteopathic association American psychiatric assocation American Psychological association American public health association American society of plastic surgeons Endocrine society GLMA National association of nurse practitioners in women's health national assocation of social workers National commission on correctional health care pediatric endocrine society society for adolescent health and medicine world medical association world professional association for transgender health world health organisation (WHO) Stanford medical American pediatrician association National institutes of health Canadian institute of health research scientific american

[cashandprizes]

The Boring CBT Final for the Fun CBT King - By Lexi Moon aka CashAndPrizes

Okay! People asked and I fought tumblr to deliver!

Hi, I'm CashAndPrizes also known as Lexi Moon, and I am a doctoral student studying clinical psychology. I wrote about Redacted (specifically Lasko) for my final for Cognitive Behavioral Therapies. Here's the paper.

Shout out to my beloved friends in the WhoreHome and W.A.R. for keeping me going through this paper. I love you dearly.

Words of warning:

I am a clinician in training. I am still being supervised. I have not been graded on this final yet. (I'll update when I get it!) And I am definitely not an expert. Take everything here with a grain of salt.

I am not a licensed therapist but even if I was I am not your therapist. I'm play acting as Lasko's therapist for a class. Take everything here with a grain of salt. If you read any of this and think "It's a bit loud in here" do not assume this is absolutely you. If you have the means, please try finding your own mental health professionals and if you don't, please do a lot of research on these subjects. Don't use this as a diagnosis please, I'm just a guy.

I filled in a lot of Lasko's backstory based on my experiences with patients and my beloved Lasko kinnies who were instrumental to the writing of this paper. (I won't tag you and call you out, but you know who you are an I love you.) Your headcanons might be different - that's cool. I'm not claiming canon over most of this - but I did use the transcripts and timeline very heavily.

If you don't like the idea of pansexual, transgender, Indo-Caribbean/Trinidadian child of immigrants Lasko - pookie this might not be for you. If that sounds like your jam though - come on in, the water's fine.

Without further ado. Ladies and Gentlemen, this is Mambo Number Five. Here's Lasky. I can, in fact, fix him.

Case Summary

This case conceptualization addresses the hypothetical course of treatment for Lasko Moore, a character in a modern-fantasy audio narrative. Lasko Moore presented to treatment as a 30-year-old pansexual and transgender Indo-Caribbean man working as an administrator and adjunct professor at Dahlia Academy for Magical Novices for persistent anxiety symptoms. Upon intake, Lasko reported experiencing near constant racing thoughts that he was unable to “turn off”, panic attacks, and increased anxiety about social interactions at his work. He described spending a significant amount of mental energy preparing for and reviewing social interactions with colleagues such that he often avoids his colleagues in an effort to minimize his anxiety. Lasko reported that the anticipation around coworker interactions (meetings, socials, etc.) becomes quickly overwhelming as he becomes preoccupied with what he will say and do in an effort to try and minimize his tendency to become hyperverbal and overshare information as well as stuttering. He described this process as starting with embarrassment over previous interactions which leads to critical thoughts like “I shouldn’t be so anxious” which leads to rehearsal of potential outcomes of interactions. However, in the moment of social interactions he becomes so anxious as there “aren’t any objectives [or] any specific roles” to the conversations that he “word vomits” and becomes tangential and overshares until he runs out of breath and stops himself from talking due to his own critical thoughts and begins to isolate himself. 

Lasko was initially diagnosed with Panic Disorder (F41.0) and Generalized Anxiety Disorder (F41.1) to capture his persistent anxious state with occasional intense bouts of extreme anxiety and panic. An initial long-term goal was collaboratively set as improving his coping strategies and tolerance of anxious affect to better network and create relationships. As this was Lasko’s first time utilizing mental health services, treatment began with inhibitory learning in combination with Acceptance and Commitment Therapy in order to facilitate willingness to experience interoceptive cues and extinguish avoidance due to fear of negative consequences. This was able to reduce his panic attacks as he felt more able to tolerate overwhelming anxious affect. Despite his clear engagement with treatment through attendance, homework, and skills practice, Lasko continued to struggle with critical thoughts and avoidance of coworkers which he identified as a major barrier to his continued professional development and potential non-academic relationships. Through collaborative exploration, a persistent early maladaptive schema relating to his critical thoughts emerged and treatment shifted to a goal of starting dialogue between schema modes to facilitate the use of coping strategies to build interpersonal effectiveness. Lasko was born as the human-born child of Trinidadian immigrants who moved the southern California in the early 1990s due to political unrest. From an early age Lasko faced high academic expectations from his parents who desired upward mobility for their child and a “piece of the American Dream.” His mother was emotionally labile to the point of explosive outbursts where his father was more passive and spent significant energy working and caring for his wife. This experience started Lasko’s early maladaptive schema regarding rigid standards with no support, which only became worse when Lasko’s elemental powers began developing at thirteen and his parents expected perfect control (and perfect suppression) of his powers with no training and a highly critical environment. This led to Lasko isolating himself at home as much as possible to hide his lack of control but left him with an environment that created a positive feedback loop where his lack of control led to increased yelling and criticism which led to worsening outbursts of his powers. This culminated in a final traumatic event when Lasko was seventeen and lost control of his powers, leading to his mother “calling [him] everything she could think of […] she was so loud and I just wanted her to stop” to the point that Lasko accidentally sucked all of the air out of the room and almost suffocated his mother. Though Lasko was able to find support with the Department of Uniform Magical Practices and become emancipated from his parents, these experiences developed a maladaptive pattern of hypercritical thinking about himself, especially in the context of social relationships.

Research

Avelino Cardoso et al. (2023) pose potential ways to modify and apply Schema Therapy to sexual and gender minorities. This work focuses on understanding how of harmful implicit and explicit messages about gender and sexuality contribute to early maladaptive schemas based on consideration of the minority stress model, and how Schema Therapy interventions can be applied to sexual and gender minorities. One area of particular relevance from this article is the conceptualization of an inner critic mode that specifically represents stereotypes and prejudice that are naturalized by society. When applying these principles to the case of Lasko, the environment of his childhood can be understood as an essential aspect of the treatment. Though Lasko did not present to treatment looking to discuss the impact of his pansexuality and transgender identity, potentially because of the clinician’s own advertised identities, the impacts of systemic oppression against sexual and gender minorities can be woven into treatment for his hypercritical early maladaptive schema. Based on the suggestions of Avelino Cardoso et al. (2023), it may be worth examining his secondary schemas around shame and social isolation as also being shaped by his experience as a gender and sexual minority and how that may contribute to his predominant hypercritical schema. 

A major concern for this section of the paper is the lack of research modifying second and third wave cognitive behavioral therapies for sexual and gender minorities. Results for Acceptance and Commitment Therapy with LGBTQ+ individuals only revealed one article about group therapy and a study proposal; results for Schema Therapy with LGBTQ+ individuals only provided Avelino Cardoso et al.’s (2023) theoretical essay. There does not appear to be much research and what research exists is extremely limited with no randomized control trials. This makes it clear that evaluating the efficacy of treatment for sexual and gender minorities is not a priority, which leads to a major critique of Avelino Cardoso et al.’s work. Though the article is useful for considering how to address systemic change in the room, it seems to attribute lived experiences of sexual and gender minorities to a schema rather than ongoing threats in a world where hate crimes and discrimination against LGBTQ+ individuals is on the rise. The abandonment and violence that these individuals may face is not imagined and it can be seen in the lack of interest in research.

ADDRESSING Model

When considering the case of Lasko, it is important to remember that psychology does not develop in the vacuum of individual experiences – psychology develops based on the global environment, which includes the social, political, economic, and cultural contexts as well as individual context. Utilizing Hays (2022) ADDRESSING Model, the impact of Lasko’s intersecting identities can be understood to have a major impact on his current symptom presentation and the development of early maladaptive schemas and schema modes. Lasko was born to first generation immigrants from Trinidad with strong Indo-Caribbean and Catholic roots – and he was assigned female sex at birth. Using a systems-focused lens, Lasko’s current symptoms can also be understood within the larger context of living in a world where several aspects of his identity are under intense scrutiny and political debate. As a child of immigrants and as someone Indo-Caribbean, Lasko likely faced explicit and implicit messages about his intellectual capabilities, his body, and his work ethic. While Lasko directly experienced his mother as extremely critical and never satisfied with his performance, it is just as likely that he received messages as a child about needing to work harder than many of his same aged peers for equal amounts of recognition based on his racial, ethnic, and sex assigned at birth. There is also the element of the disconnect between his sex assigned at birth and his gender presentation, and the messages he received about being transgender from his Catholic, Trinidadian immigrant parents as well as the American culture – which were likely discouraging at best and hostile at worst. 

Keeping all of this in mind, Lasko’s hypercritical, social isolated, and emotional deprived schemas can be understood as also being a direct result of the intersection of his identities – and this does not even cover the added layer of being an empowered human-born. In a variety of ways, Lasko has had very different experiences than his peers by virtue of being a transgender, pansexual, child of unempowered human immigrants. When Lasko describes feeling different from the people around him growing up and when he entered the empowered world, this is a real experience based on the multiple identity intersections – it is not hard to believe that he did not have many friends or family members between the late 1990s and late 2000s that had similar experiences to him. This left him with the acute sense that he was fundamentally different and needed to work much harder than those around him, and also that to get validation he needed to sacrifice his needs (or identities) for those of others.

Methodology

The initial treatment approach for Lasko was a combination of Acceptance and Commitment Therapy and inhibitory learning with interoceptive and in vivo exposure, which was successful in decreasing his panic symptoms but not generalized anxiety symptoms. Lasko reported that he experienced sudden panic attacks that seemed random and included symptoms such as accelerated heart rate, tightness in his chest, hyperventilation, feeling that he would lose control, sweaty palms, and loss of control over his magic. At the time of treatment, he reported that he had been having at least one panic attack every other month since he was a teenager and that they would occur more frequently when he was in periods of intense stress. After exploration, Lasko was able to determine that he often had panic attacks related when he spends time ruminating in anticipation of social interactions. Lasko explained that during panic attacks he tends to seek quiet, dark places to hide and “ride out” the panic attack and that he has thoughts like “I’m going to mess this up” or “I can’t do this.” 

Treatment started with Acceptance and Commitment Therapy and inhibitory learning as an evidence-based approach for treating panic attacks and generalized anxiety to address his symptoms and reduce further panic attacks as well as his anxious thought patterns (Barlow, 2021; Ruiz et al, 2020). Acceptance and Commitment Therapy (ACT) is a therapeutic practice that focuses on improving psychological flexibility and understanding the function of behavioral patterns (Gordon & Borushok, 2017). Much of early treatment with Lasko consisted of psychoeducation around the therapeutic process, behavioral therapy, and mindfulness. He took easily to ACT and benefited from understanding how avoiding social interactions was negatively reinforced by decreasing his anxiety while keeping him from creating connection. Inhibitory learning through multiple types of exposure (in-vivo and interoceptive) was able to make him more comfortable with feeling panicked, effectively reducing his panic attacks (Ramnero & Törneke, 2008). However, his baseline anxious affect and negative thoughts did not ease despite the use of ACT, so treatment shifted towards understanding the function of his persistent negative thoughts through Schema Therapy.

Lasko’s symptom presentation after several sessions of ACT and inhibitory learning was a persistent anxious affect and worry (especially around social situations) that felt uncontrollable and critical ruminative thoughts. As it seemed treatment had plateaued, the content of sessions moved towards a deeper understanding of his critical thoughts based on an indication of deeply held early maladaptive schemas. Barlow defines early maladaptive schemas as persistent behavioral, cognitive, and relational themes developed in early childhood that are reinforced throughout lifetime and that cause significant disruption and dysfunction (2021). Schemas are often viewed as truths about the self and others and are difficult to challenge because of the deep affective component and lifetime of reinforcement (Barlow, 2021). Movement towards schema work started with psychoeducation which involved discussing how schemas are reinforced through modeling (in this case by his mother’s critical comments about his performance) and how people can often act in ways that reconfirm schemas into adulthood. Lasko then completed the Young Schema Questionnaire - Revised and received high scores on schemas related to emotional deprivation, social isolation, and unrelenting standards (Rijkeboer, 2015). During the debriefing and explanation of the results, Lasko reported that when he was completing the questionnaire he felt “really seen” in a way that was uncomfortable but also validating to his experiences in childhood and as a queer person of color living in America.

The topic of sessions then moved towards further psychoeducation about the process of schema work, including delving into his schemas and determining schema modes with the goal of improving his understanding of schemas and working towards healthier integration of modes and coping strategies (Barlow, 2021). Lasko was committed to treatment but apprehensive about “what would come up,” speaking to his concerns about dredging up uncomfortable memories and feelings. In response, he was encouraged to revisit his understanding of ACT and his core values as a reminder of why he wanted to continue treatment and work through feelings of discomfort and grief. The next session started proper schema work, starting with Lasko explaining his understanding of schemas and how they were currently impacting him. He aptly summarized that his childhood experience of feeling intense pressure to do well academically and conform to socially and religiously defined gender roles left him feeling isolated from his peers and that he always needed to work harder and do more, while also feeling as though he had no support or anyone who truly understood him – this led to the development of schemas related to emotional unrelenting standards, social isolation, and emotional deprivation. 

The first step of schema work was to identify schema modes as recommended by Barlow (2021). Lasko completed the Young Schema Mode Inventory (YSMI) as homework (along with his regular thought and feeling records) and scored highly in the following modes: vulnerable child, compliant surrenderer, detached self-soother, punitive parent, and demanding parent (Lobbestael, 2015). With this in mind, the next session started with reviewing his thought and emotion records as a baseline for identifying schema modes. Lasko was able to sort different thoughts and feelings into categories that broadly resembled the categories for child modes, coping modes, and parent modes, but he struggled to come up with names for them. He eventually decided on “Young Lasko” to describe his vulnerable child mode, “The Doormat” to describe his compliant surrenderer mode, and “The Critic” to describe his punitive and demanding parent modes with suggestions from the therapist based on his results on the YSMI. Lasko was overwhelmed with sadness and fear during this session, describing how hard it was to name and admit these schemas out loud and how scared and vulnerable he felt. He reported a heavy weight on his chest and how badly he wanted to hide from the therapist and his own internal experience, and his wavering control over his powers was evident by the rustling of papers in the room. The second half of the session was dedicated to using ACT and mindfulness techniques to sit with the almost intolerable affect without judgement. The session closed with a discussion of how he could focus on his value of self-care after the session and he decided that he had plans to meet with his friend group the next day and try to talk with them about his feelings as a form of self-care and confirming his acceptance in his friend group. 

The following session he reported that his conversation with his friend group had gone “really well, better than [he] expected” and the session started by discussing how this did not conform to his expectations as a way to integrate the initial phase of inhibitory learning into the present. The conversation then moved to re-introducing the names for his schema modes and utilizing a combination of mindfulness skills and reaffirmation of his core values to give a voice to those modes and their needs by recommendation of Barlow (2021). Lasko explored that “Little Lasko” felt “awful, awful all the time” and was a sad little boy trapped in a girl’s body who “[held] onto all the bad stuff” including feelings of being completely isolated from others and deep sadness. Lasko further explored that “The Doormat” was a representation of how he had worked so hard in school and at home to make everyone else happy and that by avoiding his own needs and wants (for self-expression, acceptance, nurturance, joy, etc.) he thought he would get his needs met. At this point in treatment, discussing “The Critic” was still too affectively laden so discussion started with the first two with the goal of working up to “The Critic.” Based on guidelines from Barlow (2021), the next few sessions focused on identifying the ways these schemas had developed within his childhood and how they had once been adaptive and essential for his survival. Lasko’s homework between these sessions was to read handouts given by the therapist about schema modes and the ways they are internalized throughout childhood. Lasko was also willing to try journaling once a week from the perspective of either “Little Lasko” or “The Doormat” to better understand how integral they had been to his survival. 

Session Description

This transcript describes the first part of the schema work, where Lasko began to identify and label schemas with prompting from the therapist. Rather than just using the terms from the YSMI, Lasko was encouraged to create his own meaning to better represent his own understanding of the schema modes based on evidence-based methods from Barlow (2021). The goal of this session was to help Lasko observe the schema modes based on his thought and feeling record from the previous week and start thinking of the modes as parts of him that were observable separate from himself.

Therapist: You’ve summed up schemas and how they work, and I don’t even have anything else to add. Lasko: I really, um, want to make sure you know I’m serious about this. I want to get better, I want to be better. Therapist: It feels like it’s really important for you to feel like I know how hard you’re working right now. Lasko: Yeah, well… Yeah, I don’t want you to think I’m not doing the work. Therapist: It’s interesting because you’re the one paying for sessions, you know? While I’m glad that we are working together towards your goals, what you get out of this is really up to you. Can we talk more about how you want to make sure I know you’re working hard? I think that’s really tied to this whole schema thing I’m trying to sell you on. Lasko: I’m already sold on it!  Therapist: [Hm] Lasko: … That’s… that’s what you mean, isn’t it? Therapist: [Affirmative hm] Lasko: Fuck – sorry – shit! I um… I feel like I need to prove to you that I’m listening and trying really hard. Therapist: What will happen if I think you aren’t trying? Lasko: Well, you won’t take me seriously – at all. You’ll think I’m wasting your time and that I should – I need to be doing more and taking it seriously. Therapist: And how would I be feeling with you? Lasko: Angry, because I’m wasting your time – but I’m not, or I don’t want to. I don’t want to waste your time, you have so many other patients you could be seeing and if I’m not doing what I should be doing then I’m just- I’m taking up space someone else could be using and they probably need it more than me. I mean, I’m fine you know, I’m anxious but I can survive, right? There’re people out there who need your time more than me and I’m wasting it – or I would be. I’m not – I don’t think I’m wasting your time right now except I keep rambling. Therapist: There’s a through-line in there that I want to pull. You feel like you need to do what I expect you to do, right? Lasko: Yeah, I mean you’re the therapist. You’re the expert with – all the experience and degrees. So yeah, I should be doing what you expect. Therapist: It sounds like there’s some part of you that feels like you need to be doing what I say you should do, even if you don’t want to or have something else to say – like your “rambling” – and that if you don’t, you’re wasting my time. Does that feel right?

Lasko: I want to do this, I do. But um, yeah. That feels right. Therapist: And you do what I say you should do because if you don’t…? Lasko: Well I’m wasting your time. And then you’ll – I mean you probably won’t, you’re a really nice person and you’re so helpful but I just… I have this thought that you’ll get mad at me. Therapist: I would be mad at you. What would I do if I was mad at you? Lasko: You would um… Well I know you wouldn’t, because you just – you’re not like that but like my mom would start screaming at me. She would just… she would just yell and tell me that I was wasting their money because I wasn’t doing well enough at the school they paid for me to go to you know? Or I messed up the nice clothes they paid for. Or I just – anything like that really, I was wasting money and time and I was a waste of space and… Fuck – sorry – wait, um. This is hard to talk about and I don’t want to cry. Therapist: This is really hard, I’m really putting you through it already today, aren’t I? Lasko: [Affirmative hm] Therapist: I want to take what you just said and kind of summarize, kind of explain, is that okay? So, it sounds like you have these thoughts that you aren’t trying hard enough – or at least that I don’t think you’re trying hard enough, right? And these thoughts serve to make sure that you show me how hard you’re working so that I believe you, because if I don’t, I might think you’re wasting my time and become angry and yell at you.  Lasko: That’s a really succinct way to put it, but yeah. Therapist: So what I think is happening here, is that there’s a part of you that is so terrified that I will become angry and yell at you and make you feel just awful about yourself. And to deal with that, there’s another part of you that works really hard to try and anticipate and meet my needs so I won’t become angry with you. And then there’s also this third part of you, this part that is so critical and reminds you of how scary I could become if I got angry with you and kind of beats me to the punch by being mean first. And all three of these parts were working together in those last few minutes. Lasko: Wow… yeah, that um… you hit the nail right on the head. That feels right. It’s not – um, it’s not really great for me, though. Therapist: What I’d like to do is start by giving a voice to these parts of you, just letting them speak. Do you think we could do that? Lasko: That… That sounds really awful. But, yeah we can… we can do that. Therapist: And here I am, asking you to do these terrible things you don’t want to do and you’re doing them with me anyway.  Lasko: That’s the um.. that part of me that tries to meet your needs, right? That’s what you said? Therapist: I think so. I really want to hear more from that part of you.

At this point in the transcript, the therapist was using a combination of techniques to try and get closer to the schemas that were indicated in Lasko’s dialogue. There was a mix of rephrasing/restating what Lasko had said with the dual purpose of making sure the therapist understood and phrasing things in a way that would lead to more dialogue about schemas. The therapist in this section also started outlining the core schema modes operating at the moment in broad terms to gauge Lasko’s ability to tolerate and explore them further with the intention of eventually moving towards labeling schema modes. In this section, it is becoming clear that Lasko’s persistent anxiety about the therapy (proving he is engaged enough) is a result of active schema modes that attempt to anticipate and meet the therapist’s needs to prevent criticism and anger on the part of the therapist. This insight from the conversation can be broadened to potentially explain the utility of Lasko’s critical thoughts and anxiety around social interactions – he spends so much time preparing and planning for these interactions to try and anticipate and meet the needs of others to prevent criticism and anger from his peers, the mere idea of which causes deep feelings of fear and sadness, by criticizing himself first.

Therapist: I think so. I really want to hear more from that part of you. Lasko: I mean – geez, what should I say? Therapist: Maybe we could start with what that feels like…? Lasko: It feels like I’m always guessing, trying to figure it out. I feel like I have to do everything right, try harder, do more…I feel like I always need to be doing more, doing it better. Therapist: What emotions does this part of you have? Lasko: Um, I don’t – I don’t know.  Therapist: Do you think I should bring out your old friend the feelings wheel? Lasko: Yeah that might – might help. You know how much I love the wheel. Yeah – um, I guess I feel… inadequate? Maybe… Therapist: Can I suggest something that I’m sensing in you? Lasko: Please, you’re way better at this than me. Therapist: I’m wondering if this part of you feels desperate. Lasko: Yes, desperate. Therapist: Desperate… it feels like there’s more to that. Desperate for what, do you think? Lasko: Desperate… desperate to please – desperate to get it right. Therapist: Wow… desperate to please feels really powerful. I see you rubbing your chest right now, what are you feeling? Lasko: It’s like… my chest feels tight – a little like when I have panic attacks. Therapist: That connection feels really important. What do you make of that? Lasko: I feel – I’ve felt desperate when I’ve had panic attacks before. Like desperate for air, which is just – it’s funny as an air elemental you know, well not funny-funny, but it’s just – anyway, it’s like desperate for air but it’s also like I’m desperate for… I don’t know how to phrase it…? For it to stop, yeah, but also like I… I want to do things right when I talk to people but I always fuck it up – sorry – wait, don’t apologize Lasko. Sorry, I – sorry – fuck. I just- I want to have better interactions with people! I want things to go better and to communicate better so people like me and – I don’t know. Therapist: So people like you… do you think that’s what this part of you wants? Lasko: Yes – so badly… So badly it hurts. Therapist: It hurts in your chest, right there? Lasko: Yeah… it’s tight and heavy and then I start crying because I’m just – I’m a mess. Therapist: You’re feeling so much right now, and you’re doing it because I said we should. Lasko: Well… yeah, it’s um – it sucks but you know better than me. Therapist: That seems to be a thought you have a lot, we’ve talked about it before on your thought and emotion records – and I think it’s really tied to this part of you. Lasko: I mean… maybe, yeah. Therapist: What do you think you could name this part? How do you think we could refer to it? Lasko: Like a name? What kind of name…? Therapist: It’s really up to you, I think it’ll be more helpful to use whatever you think is the best way to describe it rather than my clinical-ese jargon.  Lasko: I don’t… I don’t really know. I’m not good at this kind of thing. Can’t you – you can just name it, right? Therapist: I could, but I feel like if I name it we’re staying in this pattern where you just acquiesce to my demands. Lasko: Which is like – the whole point of this, yeah. Therapist: Exactly. What feels hard about thinking of a name? Lasko: I don’t – I don’t want to pick some stupid name that I have to use, and you’ll think “wow that was a really stupid name choice, I should have picked it.” Therapist: [Hm] Lasko: Yeah, you don’t have to say anything, I hear it. Also, I just… naming it feels so real, you know? Then it’s a real thing. Therapist: And there’s something about it being “a real thing” then? Lasko: Then I’d… I’d have to talk about – acknowledging all of it – that feels really awful. I feel like I can’t breathe right now. Therapist: I can feel the air becoming thin too. Why don’t we take a few moments and just notice how you’re feeling and breathe through it?

This section of the transcript starts to explore and move towards labeling the schema mode of the Compliant Surrenderer. This mode attempts to anticipate and meet the needs of his hypercritical Punitive and Demanding Parent mode to protect his Vulnerable Child mode, which becomes clear in the transcript as he verbalizes that this part of himself is desperate to do well (whatever that may look like) so that others will like him. Just sitting with this part of himself causes Lasko almost intolerable feelings of desperation and panic, likely due to his fear of his Punitive and Demanding Parent mode as well as a fear of criticism and rejection from the therapist.

Closing Thoughts

I really enjoyed this case and this paper. While I didn't choose a current patient, I feel that I got a lot out of this assignment. It was really interesting to think formally about a character and work through a treatment plan and focus on a specific element of treatment. I managed to pick a case where I got to implement schema therapy, which is one of the forms of CBT that I find most interesting in addition to ACT. Despite this being a fictional character, I have certainly had previous patients who have similar struggles – and I also felt that I was able to use the media (and my previous experience to fill in gaps) to make the most of this assignment for my learning.

As I was working on this case, it occurred to me that though I felt like I was able to portray this character as accurately as possible I felt like so much was missing or unaccounted for. Because I was working from a CBT rather than psychodynamic lens, I felt like there were clear points where I would have ideally worked more relationally to address resistance or spoken more about the therapeutic relationship. There are always a million different things you could pick out of a patient’s response to respond to, and it was challenging to focus more on the schemas rather than talk about the relationship. I also felt like because of the limits of this paper, I did not have enough space to talk in the methodology or transcript session about how I felt his identities played a part in the development of his schemas. In this example, it was very clear to me that Lasko’s experiences of his parents were only part of the equation as development does not exist in a vacuum – there is a reality that his identity as a pansexual, transgender, Indo-Caribbean, second-generation immigrant and his experiences of xenophobia, racism, heterosexism, and transphobia would have also impacted his feelings of isolation/difference from others and internalized pressure to present and perform well. I also think that this would have been something I discussed in subsequent sessions as I believe this is another function of his schemas – to protect and prepare himself from his experiences of a hostile, sometimes violent world.

References

Avelino Cardoso, B. L., Paim, K., Figueiredo Catelan, R., & Liebross, E. H. (2023). Minority stress and the inner critic/oppressive sociocultural schema mode among sexual and gender minorities. Current Psychology, 42(23), 19991–19999. https://doi.org/10.1007/s12144-022-03086-y 

Barlow, D. H. (2021). Clinical handbook of psychological disorders: a step-by-step treatment manual. Sixth edition. New York, The Guilford Press.

Hays, P. A. (2022). Addressing Cultural Complexities in Counseling and Clinical Practice: An Intersectional Approach. Fourth edition. Washington DC: American Psychological Association.

Lobbestael, J. (2015). Validation of the Schema Mode Inventory. In M. van Vreeswijk, J. Broersen, & M. Nadort (Eds.), The Wiley‐Blackwell Handbook of Schema Therapy: Theory, Research, and Practice (pp. 541–552). Wiley-Blackwell. 

Ramnero, J., & Törneke, N. (2008). ABCs of human behavior: Behavioral principles for the practicing clinician. Oakland, CA: New Harbinger & Reno, NV: Context Press.

Rijkeboer, Marleen (2015). Validation of the Young Schema Questionnaire. In M. van Vreeswijk, J. Broersen, & M. Nadort (Eds.), The Wiley‐Blackwell Handbook of Schema Therapy: Theory, Research, and Practice (pp. 531-540). Wiley-Blackwell. 

Ruiz, F. J., Luciano, C., Flórez, C. L., Suárez-Falcón, J. C., & Cardona-Betancourt, V. (2020). A multiple-baseline evaluation of acceptance and commitment therapy focused on repetitive negative thinking for comorbid generalized anxiety disorder and depression. Frontiers in Psychology, 11. https://doi.org/10.3389/fpsyg.2020.00356 

Home. (n.d.). Redacted Audio. Retrieved May 5, 2024, from https://redacted-audio.com/

Appendix

Character and Media Primer

Redacted Audio is an urban-fantasy audio narrative on YouTube that centers around the fictional city of Dahlia in southern California and its inhabitants (“Home”, n.d.). In this urban-fantasy world, people are separated into four categories: unempowered humans; empowered humans, which can be further broken down into elementals and energetics (people with control over the four elements, gravity, sound waves, magnetics, psychokinesis, telepathy, seers, or a jack of all trades) and shifters (e.g.: werewolves); vampires, who are turned unempowered or empowered humans that feed on blood to survive, have superhuman speed and senses, and cannot go out in the sun; and demons, beings of pure magic that are not necessarily evil or good. The character I have chosen is an empowered human who was born to unempowered human parents – a human-born – which is a rare kind of person who often faces discrimination and barriers to learning how to control their magic. Lasko is an administrator and adjunct faculty member at the Dahlia Academy of Magical Novices, which is essentially magical community college where students (of any age) can learn mastery over either their specialty or all aspects of empowered human magic. The Dahlia Academy of Magical Novices operates as a school under the larger Department of Uniform Magical Practices, which oversees magical practices, ethics, and maintains the covert status of magic. Lasko specifically has natural control over the element of air, giving him an increased lung capacity and control over air (making wind currents, taking air out of the room, making tornados, etc. – think air benders in Avatar: The Last Airbender if you are familiar), but chose to complete his full certification at The Dahlia Academy of Magical Novices to have a better understanding of all types of magic. He teaches an introductory class on magic for incoming students as a way to provide a less discriminatory experience for other human born students.

ACT Hexaflex

YSQ-R Table

YSMI Table

That's all, folks!