Dr. Cass’ report is massive in that it is giving an opening to people skeptical of youth gender medicine an opportunity to start speaking up without fear of reprisal. For that, I am extremely grateful. You are right that she does say that children may be better off taking these drugs before 18. As a Democrat voter who finds himself somehow associated with the so-called Far Right on this issue, I can both be so grateful to Dr. Cass and at the same time recognize the absurdity of her suggestion that anyone would be *medically* better off taking drugs to comply with their own gnostic concept of being born in the wrong body. It is absolutely possible that cosmetic procedures could make someone happier (implants, Botox are great examples), but that is not germane to whether there is any medical basis for a child to alter their body surgically or medically. We allow adults to make these decisions, because they are entirely empowered to do what they want to their body, but it is not now, has never been, and never will be *medically* essential to “transition” someone from their natural body to an imitation of the physical and social characteristics of the opposite sex. This is obvious to anyone who thinks about it critically, and it is extremely uncomfortable to admit, because this is the thinking of The Bad Guys. No one should be hurt, discriminated against, etc! Let’s be clear about that! But it’s also utterly horrifying that we are imposing this undefinable gnosis on the country.
This is basically where I’m ending up on this as well - kind of an Andrew Sullivan-esque position where I’m unconvinced that “gender identity” is a real thing whatsoever, and I’m particularly concerned that young gay kids are getting shunted unnecessarily into this pathway of lifetime medicalization via unproven hormone treatments rather than being allowed to work out their experiences naturally.
What follows from that? If someone is badly burned, say, plastic surgery might be required for them to have anything resembling a normal life: friends, a job, romantic relationships. Should doctors not recommend it, or insurance not cover it, because it's not "medically necessary" for bare survival?
Any effects on one’s confidence and self-esteem (as well as how one is treated by others) are subjective, not objective. Injuries that one person might not mind, or might even take pride in, might be personally debilitating to someone else. In the latter case a doctor can’t say “well, I think you look great” or “some chicks dig scars”—the effect on the patient is real even if it’s subjective.
If you want to equate elective plastic surgery with reconstructive surgery for serious burns, that’s your prerogative. It’s unserious, extremely unconvincing and not worth engaging with though.
Well, I took you to be equating sex reassignment surgery with elective plastic surgery. Did I understand you right? If so, do you think that’s a serious comparison?
I actually think this is a very helpful line of thinking. For starters, how would you define someone who was burned? Regardless of whether action is taken on those burns, how would you define someone who was burned and who would then be in a position to consider surgery?
Ken Burns’s “Swagitude” is going up on my bookshelf, right next to Carl Sagan’s “What’s Your Sign, Baby? Unlocking the Power of Astrology to Get the Best out of Life,” Foreword by Bill Nye the Science Guy.
A little too glib. If you read the report, Dr Cass is essentially describing what would be a good approach to learn whether there are any benefits to medically treating children. Cass does point out that there is no clear evidence of any benefits today. And the report does state that no one should be treated while there are other comorbidities, which is definitely *not* how GD treatment is done today -- Planned Parenthood, for example, doesn't require any psychological evaluation before prescribing cross sex hormones for anyone over 18 (and apparently 16 with parental consent).
From what I've read, something like 85% of gender dysphoric children desist after going through puberty (based on Reuters reporting and Wikipedia). But if instead of going through puberty, they're put on blockers, 98% will continue on to cross-sex hormones.
Now, if you put a pre-pubescent child on blockers and then cross sex hormones, they will almost certainly be unable to have orgasms, and they'll almost certainly be sterile. Which brings up another issue that isn't addressed in the Cass report. How do you get informed consent from 10-12 year old child for a lifetime of hormone treatments with unknown long term effects, sterility and sexual disfunction?
It is certainly possible that on balance, there are some children that might benefit from medically transitioning before age 18, but the report gives no evidence of that, nor that there are any procedures for determining whether a particular given child will benefit. On the other hand, the downsides of early transition are clear and have been observed repeatedly.
In short, Cass points out that medical procedures with very significant downsides have been given to children without any evidence of long term benefits. That's simply not endorsing how GD is treated today, in the UK or especially in the US.
What are your thoughts on treatments like HRT for post-pubescent children (aprox. ages 15-17)? The risks seem to plateau and the extremely low rates of desistance by that point indicate to me the end of puberty should be more of the dividing line than adulthood.
A good question. I assume you mean cross-sex hormones, not HRT (hormone replacement therapy) as there are no hormones being "replaced."
However, I don't have the stats that I'd need to begin to guess at an answer, such as the percent of trans 15 year old who would desist on their own. Given how onerous the medical transition process is, I'd still think that avoiding medical transition should be the default goal.
I will say that I'd still be concerned about the difficulty of getting informed consent from someone that young.
I know this is only adjacent to the thrust of your argument, but it is important to call out that even if she is saying that both things can exist, it's important to understand which case exists more often. In other words, is it 50/50 or does one situation pop up more frequently than the other? For instance, if research shows that it's most often the case that children who are struggling with their gender will resolve that conflict without requiring irreversible surgical intervention or hormones, shouldn't that be the path that is the default? Similar to other issues regarding kids, prudence is usually the recommended course. I would think that should be the case here as well. So yes, both things can be true, but one of them should drive policy. Just because some people can drink and drive just fine, it doesn't mean that there should be no laws against it.
I think there's a bit of a leap of logic, in that you seem to be implying that the Cass report is a package deal: if you agree with the findings, you're obliged to also agree with Cass's policy recommendations.
But this is not remotely the case. Consider an analogy: you're the CEO of a company, and you commission the head of IT to compose a report on the company's cybersecurity vulnerabilities and a list of recommendations on how to address them. The head of IT comes back with a report which finds that the company is most vulnerable to a cyberattack through its payment processing facility. The report also recommends that this vulnerability by alleviated by installing Software A on the server controlling payment processing. You read the report and agree that the payment processing server presents the greatest risk of a successful cyberattack, but (having a background in computer science yourself) think that installing Software B on the server would be a better solution to the problem.
You aren't disagreeing with the FINDINGS of the report; you're disagreeing with its RECOMMENDATIONS. Some people have read the Cass report and disagreed with both its findings and its conclusions (e.g. Erin Reed). Some people have read the Cass report and agreed with both its findings and conclusion (e.g. you). Some people have read the Cass report and agreed with its findings, but disagreed with its conclusions. I don't think the latter response is necessarily wholly ridiculous: when reading a medical report which says "the evidence base for these treatments is extremely poor with a distinct lack of long-term followup with the patients to whom these treatments were administered; many clinics refused to share their data, which leaves us in the dark", it's understandable that some people's reaction is "wow, this is a medical scandal in the making, we should hit pause on this pending better quality research". That reaction is understandable even if it directly contradicts the conclusions of the person who wrote the medical report.
You seem to think it's obvious that, even if gender-affirming care may have been administered to too many minors, the number of minors who should be receiving these treatments is greater than zero. I don't know what the correct number is, and I would also be surprised if it was zero. But history is littered with examples of medical treatments (even extremely common medical treatments, the first port of call in any GP's playbooks) for which we eventually determined that the correct number of patients to be administered these treatments was zero. (e.g. The correct number of pregnant mothers who should be administered thalidomide is zero - not a hundred, not ten, zero.) If, as a society, we eventually determined that the correct number of children who should be receiving gender-affirming care was zero, that would not be remotely without precedent when looking at the history of evidence-based medicine. This is a bit like the golden mean fallacy (as you've gestured towards in the header image): when one side is saying "LOTS of kids should transition!" and the other side is saying "NO kids should transition!" - that does not remotely imply that the correct answer is "SOME kids should transition!" If we followed that reasoning to its logical conclusion, then SOME pregnant mothers would still be taking thalidomide and our world would be vastly poorer for it.
This is well put. By her own report, Dr. Cass has NO EVIDENCE for her OPINION that there are children who would benefit from medically "transitioning". And there is absolutely no known protocol for determining WHICH are the children who would so benefit, assuming they exist.
Which is why she recommends that this only be done in the context of CLINICAL RESEARCH, and NOT be made available to the general population of children experiencing gender dsyphoria.
The "science" behind the gender affirmation fad is shockingly bad. One or two poorly defined, data-cherry-picked, non-random studies from Europe form the shakey foundation. The fact that medical associations in north America continue to support the experimental treatment of vulnerable young people unconscionable.
Really wonderful breakdown of the reception of Cass’s report.
I keep an open mind that some kids might be well served by childhood transition, but the paucity of data on this leaves me wary, given the stakes.
It’s been interesting to see the way some transgender adults have changed their positions over the last several years (thinking of Corinna Cohn, Buck Angel, and the Aarons), and I wonder whether even in the best of cases, transition isn’t a bandaid for a wound better healed in other ways.
You put into words exactly my thoughts. Also, even *if* these treatments were somehow medically necessary, they have no way of knowing which kids *need* them.
Another topic that, unless you're fully one side or the other depending on who you're talking to, will generate an instant knee jerk reaction and name calling. I'm pretty tired of this all or nothing attitude.
“I would absolutely stunned if they’re not both true” !?!? Where’s the fucking verb in this sentence? You’re clearly a filthy, non-native-English-speaking immigrant who snuck in here to steal subscription newsletter jobs from upstanding white Americans and rape a few disabled girls and puppies on the weekends. You’d never catch Hitler writing verbless scrivel like this.
Dr. Cass’ report is massive in that it is giving an opening to people skeptical of youth gender medicine an opportunity to start speaking up without fear of reprisal. For that, I am extremely grateful. You are right that she does say that children may be better off taking these drugs before 18. As a Democrat voter who finds himself somehow associated with the so-called Far Right on this issue, I can both be so grateful to Dr. Cass and at the same time recognize the absurdity of her suggestion that anyone would be *medically* better off taking drugs to comply with their own gnostic concept of being born in the wrong body. It is absolutely possible that cosmetic procedures could make someone happier (implants, Botox are great examples), but that is not germane to whether there is any medical basis for a child to alter their body surgically or medically. We allow adults to make these decisions, because they are entirely empowered to do what they want to their body, but it is not now, has never been, and never will be *medically* essential to “transition” someone from their natural body to an imitation of the physical and social characteristics of the opposite sex. This is obvious to anyone who thinks about it critically, and it is extremely uncomfortable to admit, because this is the thinking of The Bad Guys. No one should be hurt, discriminated against, etc! Let’s be clear about that! But it’s also utterly horrifying that we are imposing this undefinable gnosis on the country.
This is basically where I’m ending up on this as well - kind of an Andrew Sullivan-esque position where I’m unconvinced that “gender identity” is a real thing whatsoever, and I’m particularly concerned that young gay kids are getting shunted unnecessarily into this pathway of lifetime medicalization via unproven hormone treatments rather than being allowed to work out their experiences naturally.
Plastic surgery could make me happier with my appearance, it could ease some anxieties, but that doesn’t make it medically necessary.
What follows from that? If someone is badly burned, say, plastic surgery might be required for them to have anything resembling a normal life: friends, a job, romantic relationships. Should doctors not recommend it, or insurance not cover it, because it's not "medically necessary" for bare survival?
Feelings of gender dysphoria are not the same as the objective reality of a burn victim.
"Feelings" are not the same as "objective reality". Very wise, grandmaster.
Let me try my own koan. "Perception is not the same as knowledge."
Any effects on one’s confidence and self-esteem (as well as how one is treated by others) are subjective, not objective. Injuries that one person might not mind, or might even take pride in, might be personally debilitating to someone else. In the latter case a doctor can’t say “well, I think you look great” or “some chicks dig scars”—the effect on the patient is real even if it’s subjective.
If you want to equate elective plastic surgery with reconstructive surgery for serious burns, that’s your prerogative. It’s unserious, extremely unconvincing and not worth engaging with though.
Well, I took you to be equating sex reassignment surgery with elective plastic surgery. Did I understand you right? If so, do you think that’s a serious comparison?
I actually think this is a very helpful line of thinking. For starters, how would you define someone who was burned? Regardless of whether action is taken on those burns, how would you define someone who was burned and who would then be in a position to consider surgery?
*Democratic voter
Ken Burns’s “Swagitude” is going up on my bookshelf, right next to Carl Sagan’s “What’s Your Sign, Baby? Unlocking the Power of Astrology to Get the Best out of Life,” Foreword by Bill Nye the Science Guy.
A little too glib. If you read the report, Dr Cass is essentially describing what would be a good approach to learn whether there are any benefits to medically treating children. Cass does point out that there is no clear evidence of any benefits today. And the report does state that no one should be treated while there are other comorbidities, which is definitely *not* how GD treatment is done today -- Planned Parenthood, for example, doesn't require any psychological evaluation before prescribing cross sex hormones for anyone over 18 (and apparently 16 with parental consent).
From what I've read, something like 85% of gender dysphoric children desist after going through puberty (based on Reuters reporting and Wikipedia). But if instead of going through puberty, they're put on blockers, 98% will continue on to cross-sex hormones.
Now, if you put a pre-pubescent child on blockers and then cross sex hormones, they will almost certainly be unable to have orgasms, and they'll almost certainly be sterile. Which brings up another issue that isn't addressed in the Cass report. How do you get informed consent from 10-12 year old child for a lifetime of hormone treatments with unknown long term effects, sterility and sexual disfunction?
It is certainly possible that on balance, there are some children that might benefit from medically transitioning before age 18, but the report gives no evidence of that, nor that there are any procedures for determining whether a particular given child will benefit. On the other hand, the downsides of early transition are clear and have been observed repeatedly.
In short, Cass points out that medical procedures with very significant downsides have been given to children without any evidence of long term benefits. That's simply not endorsing how GD is treated today, in the UK or especially in the US.
What are your thoughts on treatments like HRT for post-pubescent children (aprox. ages 15-17)? The risks seem to plateau and the extremely low rates of desistance by that point indicate to me the end of puberty should be more of the dividing line than adulthood.
A good question. I assume you mean cross-sex hormones, not HRT (hormone replacement therapy) as there are no hormones being "replaced."
However, I don't have the stats that I'd need to begin to guess at an answer, such as the percent of trans 15 year old who would desist on their own. Given how onerous the medical transition process is, I'd still think that avoiding medical transition should be the default goal.
I will say that I'd still be concerned about the difficulty of getting informed consent from someone that young.
If you accept that a trans woman is a woman and vice versa, it is HRT in a way
I know this is only adjacent to the thrust of your argument, but it is important to call out that even if she is saying that both things can exist, it's important to understand which case exists more often. In other words, is it 50/50 or does one situation pop up more frequently than the other? For instance, if research shows that it's most often the case that children who are struggling with their gender will resolve that conflict without requiring irreversible surgical intervention or hormones, shouldn't that be the path that is the default? Similar to other issues regarding kids, prudence is usually the recommended course. I would think that should be the case here as well. So yes, both things can be true, but one of them should drive policy. Just because some people can drink and drive just fine, it doesn't mean that there should be no laws against it.
I think there's a bit of a leap of logic, in that you seem to be implying that the Cass report is a package deal: if you agree with the findings, you're obliged to also agree with Cass's policy recommendations.
But this is not remotely the case. Consider an analogy: you're the CEO of a company, and you commission the head of IT to compose a report on the company's cybersecurity vulnerabilities and a list of recommendations on how to address them. The head of IT comes back with a report which finds that the company is most vulnerable to a cyberattack through its payment processing facility. The report also recommends that this vulnerability by alleviated by installing Software A on the server controlling payment processing. You read the report and agree that the payment processing server presents the greatest risk of a successful cyberattack, but (having a background in computer science yourself) think that installing Software B on the server would be a better solution to the problem.
You aren't disagreeing with the FINDINGS of the report; you're disagreeing with its RECOMMENDATIONS. Some people have read the Cass report and disagreed with both its findings and its conclusions (e.g. Erin Reed). Some people have read the Cass report and agreed with both its findings and conclusion (e.g. you). Some people have read the Cass report and agreed with its findings, but disagreed with its conclusions. I don't think the latter response is necessarily wholly ridiculous: when reading a medical report which says "the evidence base for these treatments is extremely poor with a distinct lack of long-term followup with the patients to whom these treatments were administered; many clinics refused to share their data, which leaves us in the dark", it's understandable that some people's reaction is "wow, this is a medical scandal in the making, we should hit pause on this pending better quality research". That reaction is understandable even if it directly contradicts the conclusions of the person who wrote the medical report.
You seem to think it's obvious that, even if gender-affirming care may have been administered to too many minors, the number of minors who should be receiving these treatments is greater than zero. I don't know what the correct number is, and I would also be surprised if it was zero. But history is littered with examples of medical treatments (even extremely common medical treatments, the first port of call in any GP's playbooks) for which we eventually determined that the correct number of patients to be administered these treatments was zero. (e.g. The correct number of pregnant mothers who should be administered thalidomide is zero - not a hundred, not ten, zero.) If, as a society, we eventually determined that the correct number of children who should be receiving gender-affirming care was zero, that would not be remotely without precedent when looking at the history of evidence-based medicine. This is a bit like the golden mean fallacy (as you've gestured towards in the header image): when one side is saying "LOTS of kids should transition!" and the other side is saying "NO kids should transition!" - that does not remotely imply that the correct answer is "SOME kids should transition!" If we followed that reasoning to its logical conclusion, then SOME pregnant mothers would still be taking thalidomide and our world would be vastly poorer for it.
This is well put. By her own report, Dr. Cass has NO EVIDENCE for her OPINION that there are children who would benefit from medically "transitioning". And there is absolutely no known protocol for determining WHICH are the children who would so benefit, assuming they exist.
Which is why she recommends that this only be done in the context of CLINICAL RESEARCH, and NOT be made available to the general population of children experiencing gender dsyphoria.
Yeah, but big difference between thalidomide and gender-affirming care
Nowhere did I argue that thalidomide and gender-affirming care are the same.
The "science" behind the gender affirmation fad is shockingly bad. One or two poorly defined, data-cherry-picked, non-random studies from Europe form the shakey foundation. The fact that medical associations in north America continue to support the experimental treatment of vulnerable young people unconscionable.
Is that swag book out yet?
Asking for a friend.....
😉
It is, and it makes a great Father's Day gift!
It does, but I for one await Jeff Maurer's "The Untold Story of the Pazzi Conspiracy."
If you’re already a father, do you really need it?
If you’re a father going through a midlife crisis, then yes.
Really wonderful breakdown of the reception of Cass’s report.
I keep an open mind that some kids might be well served by childhood transition, but the paucity of data on this leaves me wary, given the stakes.
It’s been interesting to see the way some transgender adults have changed their positions over the last several years (thinking of Corinna Cohn, Buck Angel, and the Aarons), and I wonder whether even in the best of cases, transition isn’t a bandaid for a wound better healed in other ways.
You put into words exactly my thoughts. Also, even *if* these treatments were somehow medically necessary, they have no way of knowing which kids *need* them.
Another topic that, unless you're fully one side or the other depending on who you're talking to, will generate an instant knee jerk reaction and name calling. I'm pretty tired of this all or nothing attitude.
“I would absolutely stunned if they’re not both true” !?!? Where’s the fucking verb in this sentence? You’re clearly a filthy, non-native-English-speaking immigrant who snuck in here to steal subscription newsletter jobs from upstanding white Americans and rape a few disabled girls and puppies on the weekends. You’d never catch Hitler writing verbless scrivel like this.
Wait until you see the argument about Genspect.
The biggest surprise here is that noted author and historian Shelby Foote had so much game.
One of your best written and most sensible pieces I've read. Props.