Category: medicine and health

National Health Service ends “gender-affirming care,” replaces with “holistic and appropriate” care

October 25, 2022 • 9:45 am

The NHS has come to its senses and issued a whole new set of protocols for treating gender dysphoric youth. Previously, the Tavistock Clinic in London was the go-to place for these children, whose numbers have risen rapidly in the past few years, especially for females (graph below from here):

But there were complaints from patients, and a commissioned report on the Clinic by Dr. Hilary Cass damned the form of care practiced at Tavistock: “affirmative care,” which in practice meant affirming a child’s wishes about changing sex, which led to buttressing their wishes by giving puberty blockers to prepubescent youth, and ultimately adding hormone therapy and referring children for surgery to remove breasts and remodel genitals (the NHS never covered gender-transition surgery).

The problem was that many youth with gender dysphoria have mental problems or are simply distressed about their sexuality, and that lots of these difficulties resolve themselves without changing gender—often by becoming gay, which involves no drugs or surgery.

It was this rush to judgment and treatment, combined with a spate of pending lawsuits by former patients, that led to Tavistock’s downfall. Its functions will not only be farmed out to other centers, but the whole notion of “affirmative care” is being abandoned in favor of what I see as more sensible approach, which the article below calls “a holistic view of identity development in children and adolescents. Preliminary assessment will include “nonaffirmative” but supportive therapists, and there will be no “rush to hormones”;  puberty blockers (whose long-term effects are still largely unknown)  and hormones like testosterone administered only in clinical trials. The whole National Health Service protocol has been revised, and those who evade it by, say, ordering their own hormones, will not be further supported by the NHS.

These changes, following protocols already implemented in Sweden and Finland, are described in the article below from the Society for Evidence Based Gender Medicine (click to read):

 

Here’s what the article says about why the Tavistock protocols were abandoned.

The reasons for the restructuring of gender services for minors in England are 4-fold. They include (1) a significant and sharp rise in referrals; (2) poorly-understood marked changes in the types of patients referred; (3) scarce and inconclusive evidence to support clinical decision-making, and (4) operational failures of the single gender clinic model, as evidenced by long wait times for initial assessment, and overall concern with the clinical approach.

And a bit about the new program:

The new NHS guidance recognizes social transition as a form of psychosocial intervention and not a neutral act, as it may have significant effects on psychological functioning. The NHS strongly discourages social transition in children, and clarifies that social transition in adolescents should only be pursued in order to alleviate or prevent clinically-significant distress or significant impairment in social functioning, and following an explicit informed consent process. . . 

The new NHS guidelines represent a repudiation of the past decade’s approach to management of gender dysphoric minors.  The “gender-affirming” approach, endorsed by WPATH and characterized by the conceptualization of gender-dysphoric minors as “transgender children” has been replaced with a holistic view of identity development in children and adolescents. In addition, there is a new recognition that many gender-dysphoric adolescents suffer from mental illness and neurocognitive difficulties, which make it hard to predict the course of their gender identity development.

“Social transition” comprises the acts of medical professionals facing children with gender with gender dysphoria and helping them change gender with puberty blockers and hormones.

There are ten highlights (i.e., changes from the Tavistock protocols) in the NHS’s new system. They’re described in the article, and I’ll put them below with one or two aspects of each intervention (there are more in the article). All extracts from the article are indented; my own comments are flush left.

1. Eliminates the “gender clinic” model of care and does away with “affirmation”

  • “Affirmation” has been largely eliminated from the language and the approach. What remains is the guidance to ensure that “assessments should be respectful of the experience of the child or young person and be developmentally informed.”

  • Medical transition services will only be available through a centralized specialty Service, established for higher-risk cases. However, not all referred cases to the Service will be accepted, and not all accepted cases will be cleared for medical transition.

2. Classifies social gender transition as an active intervention eligible for informed consent

  • The NHS is strongly discouraging social gender transition in prepubertal children.

They outline the criteria needed to address gender transition, which include “persistent and consistent gender dysphoria” and “a clear and full understanding of the implications of social transition.”

3. Establishes psychotherapy and psychoeducation as the first and primary line of treatment

  • All gender dysphoric youth will first be treated with developmentally-informed psychotherapy and psychoeducation by their local treatment teams.

This is one of the main ways the Tavistock model failed: it didn’t use therapists who would assess the patient objectively rather than push them into changing genders.

4. Sharply curbs medical interventions and confines puberty blockers to research-only settings

  • The NHS guidance states that the risks of puberty blockers are unknown and that they can only be administered in formal research settings. The eligibility for research settings is yet to be articulated.

  • The NHS guidance leaves open that similar limitations will be imposed on cross-sex hormones due to uncertainty surrounding their use, but makes no immediate statements about restriction in cross-sex hormones use outside of formal research protocols.

This is an important change because the long-term effects of puberty blockers, especially used in combination with hormones like estrogen or testosterone, are not known.

5. Establishes new research protocols

  • All children and young people being considered for hormone treatment will be prospectively enrolled into a research study.

  • The goal of the research study to learn more about the effects of hormonal interventions, and to make a major international contribution of the evidence based in this area of medicine.

These studies will be continued into adulthood, as they should be. It’s important to know whether there are delayed injurious effects of hormones, as well as psychological “desisting”, or regret for changing gender.

6. Reinstates the importance of “biological sex”

  • The NHS guidance defines “gender incongruence” as a misalignment between the individual’s experience of their gender identity and their biological sex.

This change and the others implicitly assume that there is such a thing as biological sex and that it’s not a social construct. They don’t say there are only two biological sexes, but I think that’s assumed.

7. Reaffirms the preeminence of the DSM-5 diagnosis of “gender dysphoria” for treatment decisions

  • The NHS guidance differentiates between the ICD-11 diagnosis of “gender incongruence,” which is not necessarily associated with distress, and the DSM-5 diagnosis of “gender dysphoria,” which is characterized by significant distress and/or functional impairments related to “gender incongruence.”

The DSM-5 is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition—the latest set of criteria used to diagnose mental illness. The addition of distress is important because without distress the panoply of treatments outlined for gender dysphoria aren’t used.

This is one of the most important changes, advocating a variety of expertise brought to bear on gender dysphoria, none of it dedicated to affirming the patient’s wishes:

8. Clarifies the meaning of “multidisciplinary teams” as consisting of a wide range of clinicians with relevant expertise, rather than only “gender dysphoria” specialists

  • The NHS guidance clarifies that a true multidisciplinary team is comprised not only of “gender dysphoria specialists,” but also of experts in pediatrics, autism, neurodisability and mental health, to enable holistic support and appropriate care for gender dysphoric youth.

  • Such multidisciplinary teams will be the hallmark of the new Service, into which challenging and risky cases may be referred. In addition to specific expertise in gender identity development and incongruence, the clinical leadership teams of the newly-established Service will include strong, “consultant level” expertise in a wide range of relevant areas:

    • neurodevelopmental disorders such as autistic spectrum conditions

    • mental health disorders including depressive conditions, anxiety and trauma

    • endocrine conditions including disorders of sexual development pharmacology in the context of gender dysphoria

    • risky behaviors such as deliberate self-harm and substance use

    • complex family contexts including adoptions and guardianships

9. Establishes primary outcome measures of “distress” and “social functioning”

  • The rationale for medical interventions for gender-dysphoric minors has been a moving target, ranging from resolution of gender dysphoria to treatment satisfaction.  The NHS has articulated two main outcome measures of treatment: clinically significant distress and social functioning.

These criteria are used for specifying treatment for other illnesses like depression.

10. Asserts that those who choose to bypass the newly-established protocol will not be supported by the NHS

  • Families and youth planning to obtain hormones directly from online or another external non-NHS source will be strongly advised about the risks.

The NHS will not support further treatment of those who obtain and take hormones outside of the NHS’s protocols.

Can anybody argue that these are not more sensible protocols than the ones used previously? Since most gender dysphoric children turn out to be either cis or gay if not given hormones and surgery, shouldn’t one take these kinds of precautions before injecting or cutting such people?

The premise, of course, is that many children who are dysphoric don’t need “affirmation” (especially if there’s social pressure to change their gender), but compassionate therapy to see how serious their problem is and how strongly they wish to change identity. If you can’t vote until you’re 18, why should you be able to start changing your hormones and body parts before then?  18 is just a subjective age, of course, but the protocol is based on not immediately accepting the views of children—or their parents, who can pressure kids destined to be gay into seeing themselves as transsexuals—that they’re in the wrong body. You don’t just affirm that right off the bat, but ascertain it with intensive therapy.

Of course there will be many objections to these protocols by trans activists who are of the “affirmative care” stripe, but I think that in twenty years we’ll look back on the present as a time when many children were harmed by improper medical and psychological care. That’s the basis of the more than 1,000 lawsuits likely to be filed against Tavistock.

Minnesota medical students take ideological oath including, among other things, to “honor all indigenous ways of healing”

October 14, 2022 • 9:30 am

In the last several decades, the “white coat ceremony” has become a tradition at medical schools, with the entering students receiving their doctor’s coats and then reciting the Hippocratic Oath. There are many variants of this ancient oath, and often students write their own version to supplement the traditional one.  As you can imagine, some of these go beyond the doctor’s pledge, adding pledges of social justice, ideological belief, and so on. I’ve seen several versions of these white coat oaths; the FIRE article below mentions them at Harvard, Columbia, WashU, Pitt Med, and the Icahn School of Medicine. But perhaps the one most distressing to scientists and advocates of science-based medicine is this one, recited at the University of Minnesota’s white coat ceremony on August 19.

According to the Foundation for Individual Rights and Expression (FIRE), the speaker is Robert Englander, Associate Dean for Undergraduate Education for the Medical School, who leads the students in what is both a pledge and a prayer. (Curiously, Englander’s university bio has disappeared from its website.)

Now this oath wasn’t written by the administration itself, but, according to FIRE and the agenda of the ceremony, by a committee of fifteen incoming medical students on the “Oath Writing Committee.”  These students may, of course, not represent the beliefs of their class as a whole; in fact, it’s likely that, as usual, it’s the activists who seek the loudest megaphone. Click on screenshot below to see the article, and I’ve put the video of the recitation below that.

Here’s the two-minute video of the oath:

Here’s the oath’s text reproduced from FIRE’s letter sent yesterday to the medical school deam (I’ve bolded the sentence that bothers me the most.)

With gratitude, we, the students of the University of Minnesota Twin Cities Medical School Class of 2026, stand here today among our friends, families, peer, mentors, and communities who have supported us in reaching this milestone. Our institution is located on Dakota land. Today, many Indigenous people from throughout the state, including Dakota and Ojibwe (ooj-jib-way), call the Twin Cities home; we also recognize this acknowledgment is not enough.

We commit to uprooting the legacy and perpetuation of structural violence deeply embedded within the healthcare system. We recognize inequities built by past and present traumas rooted in white supremacy, colonialism, the gender binary, ableism, and all forms of oppression. As we enter this profession with opportunity for growth, we commit to promoting a culture of anti-racism, listening, and amplifying voices for positive change. We pledge to honor all Indigenous ways of healing that have been historically marginalized by Western medicine. Knowing that health is intimately connected to our environment, we commit to healing our planet and communities.

 We vow to embrace our role as community members and strive to embody cultural humility. We promise to continue restoring trust in the medical system and fulfilling our responsibilities as educators and advocates. We commit to collaborating with social, political, and additional systems to advance health equity. We will learn from the scientific innovations made before us and pledge to advance and share this knowledge with peers and neighbors. We recognize the importance of being in community with and advocating for those we serve.

There are the usual arguable claims, which should not be professed or vowed by the students or foisted on them by the dean and fifteen vocal students. The claims include these:

  1. The implication that the original owners of the school’s land was the Dakota people. (Note that the oath says that acknowledgement is “not enough,” but what else will they do for the Dakota people? Will they give the land back, or compensate the original owners? There is no vow to do either.)
  2. Inequities in medicine are not just rooted in past forms of oppression, but are ongoing, and reflect white supremacy as well as other forms of bigotry.
  3. There is “structural violence deeply embedded in the healthcare system”.  What, exactly, do they mean by “structural violence”?
  4. There is a “gender binary” that causes further traumas. I think they’re referring to the “sex binary”, which is real. Few people assert that there is a “gender” binary when “gender” is construed as a person’s sociosexual role.
  5. The students will “honor all Indigenous ways of healing that have been historically marginalized by Western medicine.”  ALL OF THEM?  There are a million of them if you count all forms of indigenous healing overtaken by Western medicine. Yes, a few of these treatments may be efficacious, but almost none have been subject to scientific testing using the gold standard of double-blind treatment.  “Honoring” a form of pre-scientific healing simply because it’s was practiced by indigenous people is ludicrous. Certainly you shouldn’t disparage the people themselves who use such healing, as the treatments were developed outside of science, but you shouldn’t honor all the ways of healing themselves. Most of them don’t accomplish anything; what kind of “honor” does that deserve?
  6. The rest of the oath is boilerplate social-justice jargon, and there’s nothing wrong with that, but this is an ideological/political pledge, not a medical-school pledge. As FIRE notes in its article, this is a form of compelled speech that many of the students might not agree with, but are nevertheless force to give fealty to.

Now many of you can say—and this is likely true—that the social-justice aspects of this pledge are meaningless, and the students don’t have to live up to them.  Nor do the students have to consider shamanism, chanting, herbs, and so on as worthy of “honor.”  (These, by the way, were not historically “marginalized” by Western medicine, but were replaced by scientifically-based treatments because those treatments work.)

If, as the students also pledged, they will “restore trust in the medical system,” they can begin by refusing to honor traditional treatments that don’t work. It is no dishonor to indigenous people to reject methods they developed in the absence of science. I suspect it is the “progressiveness” of this oath that has led to widespread ridicule against it and perhaps to the disappearance of Robert Englander’s bio.

Now on to FIRE, which has legal objections to this oath. Their main objection is that this is not only compelled speech—making students swear to something that they disagree with and is not a requirement of the profession—but also that, in the future, students could be punished for failing to adhere to what they’ve sworn. This is not a fanciful scenario:

From the FIRE article:

FIRE respects students’ rights to express their views. But because only a small committee of all new students penned the statement, some of the other several-hundred students may have been compelled to express that handful of classmates’ opinions as their own. (It’s unclear whether any students dissented and, if so, whether they could opt out.)

We’re also concerned that these subjectively squishy commitments could become de facto professionalism requirements, and that students could be punished for failing to uphold them. For example, what must a medical student do to adequately practice “anti-racism”? And whatever that may be, if she does not (as UMMS understands that term), could she be dismissed for violating her oath? What if she refuses to take the oath in the first place?

FIRE has certainly seen administrators of professional programs in medicine, dentistry, law — even mortuary science — who deployed ambiguous “professionalism” standards to punish students for otherwise protected speech.

. . .More than 10% of the campus-related cases in which FIRE intervenes now concern requirements that students and faculty demonstrate their DEI commitments or contributions, or personally make land acknowledgements.

Again, while universities, students, and faculty are free to encourage or promote DEI-type values, forcing others to say they believe in these concepts is not only contrary to many universities’ legal obligations — but violates their moral obligations, too.

Consider: Even students or faculty who broadly agree with a university’s stance on DEI may believe, for example, that land acknowledgements are merely performative. Or a faculty member who studies race and gender may have highly nuanced views on DEI not reflected by the university’s stance. Students, likewise, may disagree with other aspects of a given DEI pledge.

Medical students possibly being made to read verbatim from ideological pledges if they wish to become physicians would be a new low.

I’d add that surely a lot of the students forced to say that they’ll honor all indigenous methods of healing “historically marginalized by Western medicine” certainly don’t believe that, but are nevertheless forces to vow it.  How many of those reciting students accept the curative powers of, say, shamanic rituals?

Here is the summary of the objections in the letter written by Zachary Greenberg, FIRE’s Senior Program Officer for Campus Rights Advocacy, went to Jakub Tolar, the Dean of the Medical School, as well as to the school’s President and General Counsel:

While UMMS may encourage students to adopt these views, the First Amendment bars the university from requiring them to do so. The First Amendment protects not only the right to speak, but the right to refrain from speaking. Requiring new students to “vow” or “commit” to contested political viewpoints violates students’ clear expressive rights, is inconsistent with the role of the university as a bastion of free inquiry, and cannot be enforced at a public institution.

UMMS can require students to adhere to established medical standards, but this authority cannot be abused to demand allegiance to prescribed ideological views—even ones that some students do indeed hold. Specifically, UMMS may not compel students to recite a land acknowledgment, commit to “uprooting the legacy and perpetuation of structural violence deeply embedded within the healthcare system,” or “promote[e] a culture of anti-racism.” Nor may it force students to express a commitment to “embody cultural humility,” or “advance health equity.” Even if written by a group of students, UMMS may not subsequently require all students adhere to these views.

Because students may reasonably perceive recitation of this oath as mandatory, FIRE calls on UMMS to make clear that students may refuse to say it without penalty, and that students will not have to affirm any political viewpoints as a condition of their continued education at the school.

We request receipt of a response to this letter no later than the close of business on October 20, 2022.

My prediction? UMMS will not reply. Will there then be a lawsuit? I don’t think so—unless they find medical students injured by professing what they don’t believe, and what medical student would be plaintiff to such a suit?  But I do think that in future years the school will refrain from such over-the-top vows.

The biomedical importance of sex (and its binary nature)

September 15, 2022 • 12:00 pm

One might almost think, with widespread denial of a sex binary of men and women—a denial that in most animal groups is both fatuous and ideologically motivated—that there are no average biological differences between men and women. “Blank slaters” tend to outright deny the existence of behavioral or cognitive differences between men and women, often doing so on the erroneous grounds that “some women are in the range of men’s scores and vice versa”. In such cases the concept of averages seems to have slipped their minds.

But as the dogs bark, the caravan moves on. Increasingly recognizing the biological and medical differences between men and women—note the implicit recognition of dividing up the species into two sexes— funding institutes and journals dealing with illness and medicine (as well as  are increasingly recognizing the importance of studying men and women separately (or partitioning the data by sex) in biomedical work. That includes using model organisms such as mice, which may show related sex differences. This is the topic of the new feature in the journal Nature shown below. Click on the screenshot to read (it’s free).

 


First, some indicators that dividing up test subjects by sex can give useful and potentially lifesaving results:

Many of science’s gatekeepers — granting agencies and academic journals — feel the same way. Over the past decade or so, a growing list of funders and publishers, including the US National Institutes of Health (NIH) and the European Union, have been asking researchers to include two sexes in their work with cells and animal models.

Two major catalysts motivated these policies. One was a growing recognition that sex-based differences, often related to hormone profiles or genes on sex chromosomes, can influence responses to drugs and other treatments. The other was the realization that including two sexes can increase the rigour of scientific inquiry, enhance reproducibility and open up questions for scientific pursuit.

When studies do include two sexes, the results can be important for health. For example, sex is known to affect people’s responses to common drugs, including some antibiotics. . .

And here are some important biomedical differences already detected:

. . .Despite the bumpy ride, the federal guidelines that were put into place in the early 1990s have led to some important medical discoveries, perhaps a signal that key revelations could emerge from basic research in a few years.

For instance, there are sex-based differences in the heart’s electrical response to several classes of drug, including antidepressants and antibiotics. As a result, sex-based dose adjustments are now recommended for some drugs.

Steroid hormones such as oestrogens and androgens are thought to be primary actors in many of these differences between men and women. For example, women metabolize propranolol, a blood-pressure drug from a class known as beta blockers, more slowly than men do. Researchers think that sex-related steroid hormones acting on the liver can exert these effects. Other factors could include body size and composition, such as the fat:muscle ratio, which tends to be higher in women.

The cut-offs for risk might also differ between men and women. A 2021 analysis of cardiovascular risk related to systolic blood pressure shows what happens if data for two sexes are pooled rather than analysed appropriately. The authors found that when data were pooled, the range for increased risk was a systolic pressure of 120–129 millimetres of mercury (mmHg). But the sex-specific analyses showed that for women, the risk actually begins to climb when systolic blood pressure tops 110 mmHg. If other studies solidify these findings, the result would be a sea change in risk calculation for cardiovascular disease.

That study, as it happens, “was very much inspired and motivated by an NIH request for applications” about sex differences in health outcomes, says Susan Cheng, a cardiologist at Cedars-Sinai Medical Center in Los Angeles, California, and senior author on the report. Without that call for studies specifically designed to look for sex differences, she says, “we had a lot of ideas, but not a thematic focus”. Their findings that men and women differ in risk cut-offs “was actually a real ‘eureka moment’”, Cheng says. “I was like, ‘how did we not see this before?’.” She attributes the results to the NIH’s challenge. “They made it all happen.”

And good for the NIH!

Now surely you can’t attribute all these differences to “socialization,” as the disparity in hormones is based on genes that are differently activated in men and women. Of course, differences in biology due to any factor, like the Patriarchy, still need to be studied for their biomedical effects. But it’s foolish to attribute everything like the above, including the response of the heart to drugs, to environmental influences.

And, of course, if there are no differences between the sexes with respect to a biological trait or response, we need to know that too! This is true for any groups that a priori may differ biologically, but men and women are the most obvious and least ambiguous grouping.

The article highlights some problems with past research, including an apparent lack of knowledge by investigators about how to use statistics to judge the effects of sex, including the simple dictum of using half men and half women in a generalized test on “the population”.  Below is one chart from the paper partitioning 147 biomedical studies starting in 2019. As you see, more than third of them (55) didn’t even consider sex as a factor to study (and that’s dead easy), more than a third (60) didn’t look for interactions between sex and treatment (essential if you want to know if a treatment works differently in men than in women), and only 32, or about 22%, looked for interactions between treatment and sex (16 of these reported a significant interaction, and 10 a nonsignificant interaction).

Finally, even when sex differences were found, as in the red group that didn’t look for interactions, most studies that found a difference didn’t test that difference statistically. The blue group is the one that used statistical tests, but even in that moiety, 6 tests didn’t report the results and one non-significant result was erroneoously reported as a difference.  I thought biomedical researchers would be more savvy than this.

Now there’s a few gestures in the paper toward the “sex isn’t binary” trope by bringing in gender. For example:

The publishing community is pushing for similar clarity. In 2016, it published the Sex and Gender Equity in Research (SAGER) guidelines, which set out how to report sex-based differences in published research. Individual publishers, including Springer Nature (which publishes Nature), have their own policies encouraging researchers to report results by sex, defined as a cluster of biological traits, and sometimes also gender, which is socially defined.

Since “gender” is a social construct, and progressives say there are a gazillion of them, I don’t see how you can report results by gender unless you lump everyone besides men and women as “other”. (I won’t quibble with “sex defined as a cluster of biological traits”, which is technically incorrect but good enough for the purposes of biomedical research.)

And this is thrown in as well, seemingly out of nowhere:

Defining sex as a crude binary, predicated on the chromosomes present, or on specific anatomy, could be too limiting. Some species, such as the nematode worm Caenorhabditis elegans, have one sex that makes only sperm cells and one that makes both sperm and egg cells. And in a vast assortment of species, sex is determined environmentally rather than chromosomally. And still other species can change sex during their lifetime. Placing cells, tissues or even whole organisms into a pair of categories takes on layers of difficulty in these contexts.

Note the pejorative adjective “crude,” meant, I think, to disparage the binary.  Once again they send in the clownfish, nematodes, and turtles, but these don’t refute the idea of separate sexes. Nematodes can be either males or hermaphrodites, the latter being both male (making sperm) and female (making eggs), some clownfish can change from male to female if the alpha female dies—but there are still two sexes, and temperature-specific sex determination, as occurs in many turtles, still gives you males and females. In that case the two sexes are developmentally channeled via an external stimulus rather than via chromosomes and genes, but there are still men turtles and women turtles. (Why some species do this is still not well understood).

 

The fact remains that these species do not show more than two sexes, that they are in the minority of vertebrates and in an even smaller minority of birds and mammals, and, in the end, humans aren’t clownfish, turtles, or nematodes.

Besides emphasizing the valuable lesson that men and women are biologically different in ways that can be important for medical treatment, this article also shows us that where it really counts, where the rubber meets the road—that is, when lives are at stake—the palaver about the binary of sex being a fiction vanishes.

None of this, of course, is intended to ignore those who have disorders of sex determination or transsexuals who have had hormone therapy or surgery, for those patients may need separate study rather than lumping them into one sex or another. That will be hard to do given the paucity of such people, but everyone deserves the best treatment that science can offer.

Lawsuits impending against Tavistock

September 5, 2022 • 1:15 pm

As I’ve mentioned before, London’s Tavistock Gender Identity Development Service (GIDS) has been dismantled after a report by Dr. Hilary Cass that found serious missteps, weaknesses, and evidentially unsupported treatments of gender dysphoric children. Tavistock’s services will be farmed out to other centrs, with a concurrent de-emphasis on the rush-to-judgement form of “affirmative care” (i.e., believe the child and get doctors and therapists to simply facilitate a hoped-for sex transition), as well as a deemphasis on the use of surgery, hormone therapy, and puberty blockers.

This is in line with what other European nations are doing: pulling back from the no-holds-barred form of affirmative care, raising ages at which adolescents can get drugs or surgery, and using puberty blockers, whose safety has not been demonstrated, only in clinical trials. In those countries, it was the unevidenced medical and psychological care that led to the pullback, while in the UK it’s it’s not only that, but the threat of lawsuits against Tavistock, as I discussed in an earlier post.

The lawsuits, as the notice below indicates, are now a reality. Of the 19,000 young people treated at Tavistock, over 1,000 of them may bring lawsuits against the GIDS via “Pogust Goodhead,” an international litigation firm specializing in group claims.  The piece below allows you to start filing a claim, and I doubt readers here will be doing that, but it also outlines the basis for claims, which is of more interest. Click to read:

I’ll just reproduce the section, “What is the case about?”:

The Tavistock clinic opened in 1989 as the UK’s only dedicated gender identity clinic for children and young people. Prompted by concerns from patients, parents, and clinicians at the clinic, the NHS commissioned an independent review of the GIDS service.

The Cass Review’s interim report in 2022 made a number of recommendations on how the service can be changed and improved. Following the findings of the review, the GIDS Clinic at Tavistock is set to close in Spring 2023 and will be replaced with regional centres.

It is expected that localising services to regional hospitals will result in much needed improvements to standards of care and treatment and reduce lengthy waiting lists.

The report raised a number of concerns, including the lack of a consistent clinical approach to assessing the correct treatment pathway for individuals.

Members of staff at the Tavistock clinic reported pressure to adopt an ‘affirmative and unquestioning approach’ to children and young people reporting feelings of gender dysphoria.

Consequently, there are concerns that some children and young people may have been referred down the path of hormonal treatments, without adequate counselling taking place to understand the background of their feelings of gender dysphoria. The report addresses the issue of ‘diagnostic overshadowing’ meaning that other health conditions may have been overlooked.

As a result, some children and young people have been prescribed hormonal treatments before it was established that this was the appropriate treatment for them.

Service Specifications set by NHS England recommends at least 3-6 appointments at the initial assessment stage, Following this an assessment report and care plan should be produced.
Without a proper assessment process some children may have been misdiagnosed or other health conditions have been missed resulting in delays in being sign posted to the appropriate services.

Studies suggest that a number of children who attended the GIDS clinic later regretted the decision and subsequently wish to de-transition.

If you have concerns about your (or your child’s) clinical experience at GIDS at Tavistock or if you believe you should never have been prescribed hormone treatment in the first place, please get in touch with our lawyers who will be able to help and guide you through the process.

In other words, Tavistock is being accused of a form of medical malpractice: rushing first to judgment and then to treatment.

I don’t know how successful these lawsuits will be, but I doubt that this firm, which has a good record of successful litigation, would instigate such a large-scale lawsuit unless they thought they had a good chance of winning, whether it be in the courts or via settlements.  Let this be a lesson to those Americans and American organizations who are huge advocates of “affirmative care.” As I said, money talks louder than anything in America, and if we’re to assure that gender dysphoric children get thoughtful and empathic treatment, only the threat of lawsuits will do that.  Even ideology must bow before Mammon.

Is this a valid exception to protected free speech?

September 4, 2022 • 11:20 am

Here’s a case where one might want to suppress speech in apparent violation of the First Amendment. But after due pondering, I don’t think it’s a good idea. But I waver, as you’ll see, and even though I come down against the bill, as it may be a bad precedent, I am not sure of my stand.

This has to do with a new California law (not yet signed by Gavin Newsom) that punishes physicians who contradict conventional wisdom about Covid-19, with some of that wisdom specified by law. It applies to words, not to actions.

I found this bill through note and links sent by reader Gary, who said this:

I’ve seen very little discussion of California Assembly Bill 2098.  The intention of the bill is good, as are many attacks on free speech, but I, and perhaps you, feel that curbing free speech is generally not the best solution.  Under AB-2098, passed in the California Assembly and Senate, but not yet signed by the governor, physicians and surgeons would face disciplinary action if they voiced an opinion contrary to certain facts about COVID-19 and the associated vaccines as determined by the legislature.  The disciplinary action could include revoking their license to practice.  I despise misinformation and disinformation, but the solution in my opinion, is not punishing those who disagree with the scientific consensus.   The solution is the spread of solid information, not the attempted squelching of misinformation.
I think that this bill is going to the governor’s desk with very little discussion or notice.  He has three weeks to sign the bill, but hasn’t made his position public.   If you think it’s important, you may want to include it in your website.
I’ve put the meat of the bill below. It calls for licensing boards, which are arms of the government, to take action against doctors who “disseminate misinformation or disinformation related to COVID-19, including false or misleading information regarding the nature and risks of the virus, its prevention and treatment; and the development, safety, and effectiveness of COVID-19 vaccines.” In other words, this involves the government suppressing speech, an apparent violation of the First Amendment. But does it fall under the few court-allowed forms of speech that are NOT protected by that Amendment?
The seven points leading to this Diktat are below. These are pretty well established, but they are not absolute facts, as no scientific assertion is beyond questioning. For example, the statement in (c) about the safety and efficacy of COVID-19 vaccines is the best guess we have, but do we know the long-term effects of the vaccines? No, as they’ve been around for only two years. And remember that our knowledge about this disease and about the vaccines, changes almost week by week. Yes, it’s an attempt to protect the health of the public by squelching speech, just as “hate speech” laws are attempts to protect the feelings of the people.

But have a look at the text of the bill from the link above:

LEGISLATIVE COUNSEL’S DIGEST

AB 2098, Low. Physicians and surgeons: unprofessional conduct.

Existing law provides for the licensure and regulation of physicians and surgeons by the Medical Board of California and the Osteopathic Medical Board of California. Existing law requires the applicable board to take action against any licensed physician and surgeon who is charged with unprofessional conduct, as provided.

This bill would designate the dissemination of misinformation or disinformation related to the SARS-CoV-2 coronavirus, or “COVID-19,” as unprofessional conduct. The bill would also make findings and declarations in this regard.

THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

SECTION 1.

The Legislature finds and declares all of the following:

(a) The global spread of the SARS-CoV-2 coronavirus, or COVID-19, has claimed the lives of over 6,000,000 people worldwide, including nearly 90,000 Californians.

(b) Data from the federal Centers for Disease Control and Prevention (CDC) shows that unvaccinated individuals are at a risk of dying from COVID-19 that is 11 times greater than those who are fully vaccinated.

(c) The safety and efficacy of COVID-19 vaccines have been confirmed through evaluation by the federal Food and Drug Administration (FDA) and the vaccines continue to undergo intensive safety monitoring by the CDC.

(d) The spread of misinformation and disinformation about COVID-19 vaccines has weakened public confidence and placed lives at serious risk.

(e) Major news outlets have reported that some of the most dangerous propagators of inaccurate information regarding the COVID-19 vaccines are licensed health care professionals.

(f) The Federation of State Medical Boards has released a statement warning that physicians who engage in the dissemination of COVID-19 vaccine misinformation or disinformation risk losing their medical license, and that physicians have a duty to provide their patients with accurate, science-based information.

(g) In House Resolution No. 74 of the 2021–22 Regular Session, the California State Assembly declared health misinformation to be a public health crisis, and urged the State of California to commit to appropriately combating health misinformation and curbing the spread of falsehoods that threaten the health and safety of Californians.

I’ve put in bold below the two definitions that make me waver about opposing this bill.

SEC. 2.

Section 2270 is added to the Business and Professions Code, to read:

(a) It shall constitute unprofessional conduct for a physician and surgeon to disseminate misinformation or disinformation related to COVID-19, including false or misleading information regarding the nature and risks of the virus, its prevention and treatment; and the development, safety, and effectiveness of COVID-19 vaccines.

(b) For purposes of this section, the following definitions shall apply:

(1) “Board” means the Medical Board of California or the Osteopathic Medical Board of California, as applicable.

(2) “Disinformation” means misinformation that the licensee deliberately disseminated with malicious intent or an intent to mislead.

(3) “Disseminate” means the conveyance of information from the licensee to a patient under the licensee’s care in the form of treatment or advice.

(4) “Misinformation” means false information that is contradicted by contemporary scientific consensus contrary to the standard of care.

(5) “Physician and surgeon” means a person licensed by the Medical Board of California or the Osteopathic Medical Board of California under Chapter 5 (commencing with Section 2000).

This is what I wrote back to Gary:

I’ll have a look, but remember that the scientific consensus changes rapidly, and who is the legislature to determine what the correct “facts” are? And will they then punish doctors for giving out information about diet, etc. that contradicts the legislature? There’s no end to this, and I’m a bit wary of legislating what information is “absolute truth that cannot be contradicted”.

And I stand by my claim that the government should not be in the business of what doctors say about COVID-19, even if it goes against a world of conventional wisdom. This is freedom of speech, even if emitted by a doctor. Or are they allowed only to pronounce on items not related to medicine, or parrot the latest consensus?

It’s a different matter, however, if a doctor acts in a reckless way, violating professional standards like injecting patients with some Trumpian nostrum to cure COVID-19. In that case it is action, not talk, that causes harm, and boards should have the write to examine a doctor’s conduct and, if necessary, punish them or take away their licenses. Likewise, hospitals should be able to fire them. False advertising, too, is illegal, so a doctor is liable to sanction if he or she advertises cures that are known or demonstrated to be bogus. But advertising is not the same as a doctor simply making a pronouncement. Advertising is luring in patients under false pretenses.

Now I am sort of on the fence about this one, for “disseminating information to patients that you know is false, and doing so with malicious intent”, is indeed malpractice. But that’s already covered by the law.  How can you prove that a doctor is doing this with “malicious intent or an intent to mislead”?

This is the same distinction that we see between saying hurtful and “harmful” words like “gas the Jews” or “Jews are acquisitive and in a conspiracy to dominate the world”, which is harmful but legal speech, and causing actual physical harm by hitting someone or inciting predictable and immediate violence against them. The one difference is that patients tend to take their doctor’s advice. But sometimes doctors give bad advice, which is why we urge second opinions on serious matters. A doctor may give bad advice, like “you’d be better off having three stents put in now,” but to me that’s not illegal unless the doctor means it maliciously. The doctor must intend to do harm, and carry that out by treating the patient. And intention is what is nearly impossible to prove in this bill.

To me this bill seems good on the face of it, but creates a precedent where the legislature decides what medical facts are acceptable, and what opinions cannot be uttered. Just remember how advice on diet (and smoking) has changed just in my lifetime.  Let’s leave this to the consensus of doctors and their professional organizations, and let it apply only to actions, not to words.

I’m sure some readers will disagree with me, and that’s fine. Have your say below. As I said, I’m of two minds about this bill.

American Academy of Pediatrics pulls back on “affirmative care” while a Seattle hospital pushes it, offering surgery and puberty blockers to adolescents

August 23, 2022 • 11:45 am

Enlightened medical opinion seems to be coming around to the view that for adolescents who want to change gender, i.e. become transsexual, the use of puberty blockers is not necessarily a good way to go. The blockers, which are supposed to stop puberty in its tracks (in a completely reversible way) are given to allow young people a pause to ponder their options. But they are increasingly seen as untested and possibly unsafe. European countries like Sweden, France, and Finland have either limited the use of puberty blockers to “exceptional cases” or clinical trials, or have prohibited their use entirely.

This is all part of a pushback against “affirmative care”: the idea that if a child decides they want to become transsexual, they must be completely supported, with psychotherapy not examining their decision or encouraging throughtful assessment, with parents urged to accept their child’s wishes, and with the medical establishment dispensing whatever hormone therapy or surgery the child wishes.

The problem with this is not that support shouldn’t be given. It’s that children or teenagers who are too young are being pushed by doctors, parents, and peers to make decisions about issues that may involve irreversible medical interventions. European countries vary in the age at which sex reassignment surgery is legal, usually ranging from 15 to 18. For transgender hormone therapy, ages in Europe range from a minimum of 14 up to 18, with most countries having minimums of 16 to 18.

That kind of therapy causes irreversible changes in the body, while genital surgery renders one sterile and often incapable of orgasm. I have no strong views on age limits except that they should be after puberty and not lower than 16. Your mileage may vary.

And I’ve just discovered, through an article in the City Journal, that the American Academy of Pediatrics, which used to be all for “affirmative care”, seems to have suddenly started reevaluating its position. The article notes this:

Moira Szilagyi, president of the AAP, has written that “gender-affirming care . . . doesn’t push medical treatments or surgery; for the vast majority of children, it recommends the opposite.”

This is a welcome development, and marks a reversal of the AAP’s previous policy. That policy was announced in a 2018 Pediatrics article, whose lead author was Jason Rafferty; it argued that “watchful waiting” is akin to “conversion therapy” and should be avoided. “Watchful waiting” refers to an approach that emphasizes psychotherapy as a measure of first (and hopefully last) resort to help minors in distress feel comfortable in their bodies. Its premise, confirmed by 11 studies, is that the vast majority of children with gender dysphoria will desist by adolescence and feel comfortable enough in their bodies not to require medical transition. The Dutch researchers who developed pediatric transition explicitly warned against early transition. Yet transgender activists in the United States have criticized this model, insisting that because transgender identity (i.e., body rejection) is a normal and healthy aspect of human existence, mental health professionals should never steer patients toward a “cisgender” outcome.

If Szilagyi believes that medicalization is the wrong way to go “for the vast majority of children” with gender dysphoria, then this constitutes a de-facto repudiation of the Rafferty statement and the AAP’s previous policy.

Here’s an extract from AAP President Szilagyi’s piece, an an op-ed in the Wall Street Journal called “Academy of Pediatrics Responds on Trans Treatment for Kids: To ‘affirm’ a child or teen means destigmatizing gender variance and promoting the child’s self-worth.”

Regarding Julia Mason and Leor Sapir’s op-ed “The American Academy of Pediatrics’ Dubious Transgender Science” (Aug. 18): In its recommendations for caring for transgender and gender-diverse young people, the AAP advises pediatricians to offer developmentally appropriate care that is oriented toward understanding and appreciating the youth’s gender experience. This care is nonjudgmental, includes families and allows questions and concerns to be raised in a supportive environment. This is what it means to “affirm” a child or teen; it means destigmatizing gender variance and promoting a child’s self-worth. Gender-affirming care can be lifesaving. It doesn’t push medical treatments or surgery; for the vast majority of children, it recommends the opposite.

This isn’t the story that is being told by anti-transgender activists. No European country has categorically banned gender-affirming care when medically appropriate. Contrary to what Dr. Mason and Mr. Sapir claim, the U.K. isn’t moving away from gender-affirming care. It is moving toward a more regional, multidisciplinary approach, similar to what is practiced in the U.S.

This does seem to be a change of policy. “Affirmation” no longer means “go full steam ahead for the gender change” but, properly, to “promote a child’s self-worth.” Further, affirmative care no longer means “pushing medical treatments or surgery; for the vast majority of children it recommends the opposite.”

I’d say that this is a move towards enlightenment, even if it was promoted by what European countries are doing. It’s not clear, though, that this will become the AAP’s official policy.

Nevertheless, some places, like Seattle Children’s Hospital, continue to offer surgery, puberty blockers, and hormones to children as young as nine. Granted, you need parental permission for this treatment, and you can’t get bottom surgery until you’re over 18, but dispensing blockers, drugs, and cutting off the breasts of females younger than 16 is not something I’m a fan of.

This story comes from KOMO news in Seattle, a station and website affiliated with ABC, and you can check its assertions by going to the Seattle Children’s Hospital website on gender care (link below). Click to read:

This is from KOMO:

The gender clinic at Seattle Children’s Hospital (SCH) provides children as young as 9 years old with “gender-affirming medical care,” like puberty blockers, and children in their “mid-teens” with non-genital transition procedures known as “top” surgeries.

We accept new patients ages 9 to 16,” the SCH gender clinic website states. “Patients ages 17 and older and patients who have not yet started puberty will be directed to community resources.”

The website notes that the clinic “primarily provides gender-affirming medical care (such as puberty blockers  and gender-affirming hormones)” to patients. Children must receive parental consent for any “gender-affirming” treatment.

“Brief mental health support” is also available, according to the site, but the clinic suggests that “if you are looking for gender-affirming mental health services only, or for ongoing mental health support,” there are better resources that focus solely on that.

Patients must be 18 years or older to receive gender transition surgeries involving genitals, such as vaginoplasties and phalloplasties, according to another page on SCH’s gender clinic website.

Sure enough, the website link given above says this:

We accept new patients ages 9 to 16. Patients ages 17 and older and patients who have not yet started puberty will be directed to community resources. Our clinic primarily provides gender-affirming medical care (such as puberty blockers and gender-affirming hormones). Brief mental health support focused on family decision making and mental health documentation prior to initiating gender-affirming care is also available. If you are looking for gender-affirming mental health services only, or for ongoing mental health support, here are some community resources.

Puberty blockers, with their attendant medical unknowns, are offered to children who have started puberty but haven’t completed it, and those in their “mid-teens” can get surgeries like double mastectomies, breast augmentation, thyroid cartilage surgery, and “facial gender-affirming surgery.” I can’t find the age at which hormone therapy is given, but I presume it’s either after puberty has begun or in one’s mid-teens.

But there are some claims that seem dubious, like these given at the Hosptial’s pdf on puberty blockers:

No, puberty blockers are not permanent. If you decide to stop puberty blockers without starting cross sex hormones, your body will start going through the puberty of your sex at birth. You can stop the puberty blockers at any time, but we will work with you on how to do that.

We can safely and legally recommend puberty blockers for you based on our medical experience and judgement and your specific health needs. The Endocrine Society and the World Professional Association for Transgender Health support puberty blockers. The Food and Drug Administration (FDA) approves puberty blockers for children who start puberty at a very young age, but has not approved puberty blockers for transgender children.

But at the same place they say this:

The long-term safety of puberty-blocking medicines is not completely understood. There may be long-term risks that we do not know about yet.

Indeed, this is in line with Britain’s new NHS guidelines to not give hormonal treatment, including puberty blockers, to adolescents under 16. Further, Sweden’s Karolinska institute says this:

  • In light of the above, and based on the precautionary principle, which should always be applied, it is hereby decided that hormonal treatments (i.e., puberty blocking and cross-sex hormones, see above) will not be initiated in gender dysphoric patients under the age of 16.
  • For patients between ages 16 and 18, it is hereby decided that treatment may only occur within the clinical trial settings approved by the EPM (Ethical Review Agency/Swedish Institutional Review Board). The patient must receive comprehensive information about potential risks of the treatment, and a careful assessment of the patient’s maturity level must be conducted to determine if the patient is capable of taking an informed stance on, and consenting to, the treatment.

The U.S. is often touted as having the world’s best medical care. But when it distorts the dangers of hormonal treatment, or rushes children and adolescents onto an escalator towards transsexuality without proper therapy and information, it’s a travesty.

h/t: Williams

The death of the Tavistock clinic, recounted by one of the whistleblowers

August 5, 2022 • 12:00 pm

Sue Evans was a nurse therapist working at the Tavistock Clinic in London, dealing largely with issues of gender dysphoria in young people. In this piece from Bari Weiss’s Substack (again, subscribe if you read regularly), Evans describes how in the early 2000s the clinic became a place of fulminating “affirmative therapy”, changing its normal procedure of talk therapy to the willy-nilly dispensing of puberty blockers and hormones—all without any thoughtful examination of what was happening. If there was any “social contagion”, it was among the sheeplike employees at Tavistock who jumped aboard a woke juggernaut at the expense the patients’ well being.

Click to read. Because this has already been covered widely, I’m mentioning it for those who haven’t yet read what happened at Tavistock. You are probably aware that after an independent report on the clinic, the NHS has now ordered its closure, with its functions farmed out to several geographically distributed sub-clinics, and with a lesser concentration on “affirmative therapy” and less recommending of drugs to facilitate transsexual changes.

It wasn’t that long after Evans had been working at Tavistock—which I didn’t realize was a clinic specializing largely in talk therapy—before the idea of giving puberty blockers and hormones to gender dysphoric patients swept through the clinic, much to Evans’s dismay, since there was hardly any expertise there in using drugs for gender transitioning.

And then social contagion, stemming from advocacy groups, intensified the pressure to use drugs.

Evans:

The external influence of the advocacy groups increased. Instead of being a clinical, research-focused service where we were learning and developing ideas, it felt like it was a fait accompli that we had to go along with what Mermaids [an advocacy group] and patients wanted—even if we, the mental-health-care professionals, had legitimate questions about the appropriateness of the treatments that patients and patient advocates were demanding.

For example, a weird paradox arose at a conference on transgender health care hosted by Tavistock around 2005: the opening speaker declared that we were no longer supposed to think of gender dysphoria as a mental illness. But we were a mental-health team working at a mental-health facility. What were we supposed to be doing if not treating patients with psychological conditions?

Remember, this was all before the internet took hold of an entire generation of teenagers. There were no online groups dedicated to gender affirmation and coaching kids on what to say to their providers to secure cross-sex hormones. We mostly saw younger boys who believed themselves to be girls from an early age and a few teenagers who felt like they were trapped in the wrong bodies. So, although I felt aware of the gathering force of thinking around the area of gender dysphoria and transgender identity, it was hard to foresee the slow-motion avalanche that would hit over the next two decades.

Yet even what I saw in those years worried me deeply and working on the Gender Identity Development Service started to affect my personal well-being. I would come home with a headache on the days that I worked in the unit, and my heart would beat quickly when I went in the next morning. It felt like every time I raised a concern about us rushing prematurely to prescribe drugs that would have permanent effects on our patients, I’d be met with an eye roll and the unstated “Oh, here she goes again,” or “Can’t she just fit in?”

A concerned Evans went to the clinical director of Tavistock and raised these issues, and this led to an investigation of the clinic—in 2006.  Evans didn’t see the results of that investigation until 2019, but it was damning. Sadly, the conclusions were also buried:

It was only in 2019 that I saw the full report when Hannah Barnes, a BBC journalist, obtained it via a Freedom of Information request. It confirmed all the disturbing things I had reported: Our data was poor; it wasn’t being stored properly; and there were not sufficient follow-ups with patients once they left the service—meaning we didn’t know how our patients were faring unless they voluntarily wrote to us.

As we have now learned from more recent whistleblowers, the recommendations in the report were buried, and when any criticism or difficult questions arose in the press, the Tavistock management would repeat the same mantra about how they were “a world-class service.” It’s important to acknowledge that there might have been some staff still struggling to deliver thoughtful, measured care, but the noise around our standards was growing louder.

In the face of an unchanged work milieu, Evans quit her work on gender-dysphoric patients. That’s when an explosion of referrals hit the clinic—mostly biological female adolescents who wanted to transition to the male gender. Later, when one of them—who had been rushed through puberty at 16, went on testosterone at 17, and had a double mastectomy—participated in a lawsuit against the clinic, Evans signed on as a co-claimant. They won, with the ruling that minors under 16 could not give informed consent for puberty blockers (these nearly always lead to hormone injections and full transition). But they lost the appeal.

Then, in September 2021, the government commissioned another report on Tavistock, and this one disbanded the facility, farming out its mission to other clinics and deemphasizing the default use of drugs to transition as well as urging more emphasis on objective but empathic talk therapy as a first line of treatment. This result we all know.

Evans had a rough time of it, but ends on a high note:

I didn’t seek any of this. It has been a pretty stressful few years. When I get a letter from patients or parents from around the world, and they tell me, “Well done, thank you for speaking up, you didn’t give up,” I sometimes get a lump in my throat. It’s been hard to be suspected of being prejudiced when all I wanted was safer clinical practice, more scrutiny and evidence collecting, and improved data storage.

Because what I am is a nurse. And my job as a nurse is to treat all my patients with respect and an open mind. I try to think about who they are as people, and to relate to their experience and empathize with them. I also believe we need to keep an open and curious clinical mind when something is occurring in society that seems novel or not yet fully understood. It should never be that doctors and nurses are unable to question diagnoses and prescriptions.

If my actions all those years ago have made a contribution, then I am proud. I made the right decision to raise my hand to ask another unwanted question.

There will come a time, I think, when this rush to transition, with its attendant use of “affirmative therapy”, puberty blockers, and hormone treatment, will be seen as a crazy era in medicine and therapy. Of course there are people for whom this kind of transitioning is the right thing to do, but what we often see now is madness, with affirmative therapy being pushed not because we have evidence that it’s the best thing to do for gender dysphoria—we don’t  have that evidence—but because it’s ideologically “proper.” If someone suggests that they feel as if they might belong in a marginalized group, the philosophy now seems to be to get them in that group as soon as possible, ignoring other outcomes of dysphoria, like homosexuality.

Recent pushback on “affirmative care” and hormone blockers

July 31, 2022 • 9:15 am

I’m guessing that some day historians will look back at the mishigass surrounding “affirmative care” and wonder what the deuce was going on in America in the 2020s.

Now let me say at the outset that I have no objection to people with “gender dysphoria” changing their gender using drugs and surgery. But I also think that transitioning should not be allowed until after puberty, and for two reasons. First, we don’t know eough about the safety of “puberty blockers” used to stop the process while adolescents figure out their sexual identity, and second, because children who are too young to make mature judgments should not be allowed to make irreversible decisions about their bodies. Eighteen seems to me to be an appropriate age to begin a medical process of transitioning.

My objection to “affirmative care” is not that we shouldn’t treat young people repectfully when they have with a sincere desire to transition, or fail to support them. But in the U.S., and previously in the UK, the default option was “affirmative care”, with no real psychological probing to dissect the roots of gender dysphoria and see if it was a form of distress that might resolve into a child becoming gay. “Affirmative care”, in its most extreme form, pronounces children who question their sexuality as transsexuals, deems them ready to change sex, and encourages them to go on puberty blockers and then hormone therapy. (There are few adolescents who, once on blockers, decide to stop them and “de-transition.”)

I’m cautious because the huge rise in the number of adolescents who declare themselves transsexual (particularly biological women who want to change gender) could have a number of causes: a relaxation of the stigma against transsexuality, an increase in the genetic propensity to change gender (that’s impossible given the rate of the rise), or—as Abigail Shrier argues in her book Irreversible Damage, a sort of social contagion—a sense among young people that it’s far more cool to be trans than to be gay, and because such people get a lot of props and attention. (Shrier doesn’t claim that transition is always prompted by social contagion.)

Only the first and second hypotheses are supportable, and I think both are at play, but to deny that social contagion hypothesis plays any role in the temporal changes shown below is to deny reality. There are simply too many cases of seeing “detransitioners” (“desisters”) discuss the social pressure they were under, and of others seeing it at play in real life.

Below is an article by writer Lisa Davis you should read (click the screenshot). It’s on Bari Weiss’s site (and I don’t want to hear that Weiss is “alt-right” so that you can ignore it), and explains how several European countries, including the UK, Sweden, France, and Finland, are changing course on affirmative care, replacing it not with a refusal to let people transition, but with a more compassionate and psychologically-oriented inquiry into the roots of gender dysphoria.

The change in Europe comes from a realization of the weakness of the evidence supporting two assertions of trans activists: that puberty blockers are completely harmless and can be completely reversed if someone changes their mind, and that allowing medical transitioning reduces the rate of mental illness and suicide among those with gender dysphoria. We now know that the evidence for the first claim is wrong, and for the second is plagued by methodological weaknesses. We simply need a lot more data, and the Europeans are being cautious while Americans ignore the counterevidence. That’s unwise given the drastic and irreversible nature of many transitions.

Here’s a graph from the article above showing the increase in referrals to the gender-affirming Tavistock clinic, and this is just between 2009 and 2017 (original source here). Both the proportion of and the increase in biological females (compared to males) referred to the clinic for affirmation have increased substantially. If your hypothesis is that the rise reflects purely the de-stigmatizing of transsexuality, this discrepancy between the sexes must be explained. Of course, it also has to be explained if you hold a “social contagion” hypothesis.


 

I completely agree with Andrew Sullivan in his Friday column section called “Yes, the trans madness is real” when he says this:

I recall a few years ago having a heated conversation with some well-meaning trans activists who appeared completely aghast when I voiced some worries about the treatment of kids with gender dysphoria. What if the kid is gay, I asked? How do we know for sure if a pre-pubescent child really is trans and not just experimenting with gender the way many gay kids do? And are these nine-year-old children really mature enough to make life-long decisions that could make them permanently sterile, keep them on drugs for the rest of their lives, or permanently remove their capacity to have an orgasm? How could pre-pubescent kids even know what an orgasm was?

My activist friends were shocked. It seemed to me as if they had never previously been asked these questions. They were all very-well intentioned, and not entirely wrong — in a few extreme cases, there might be a reason to permanently change a child’s sex. But they assured me that no such errors were ever made, that the process was entirely ethical, and that all medical authorities backed it. They insisted that puberty blockers were harmless and fully reversible. The bubble is real.

I think it’s better to give kids with gender dysphoria extensive psychological counseling—NOT affirmative from the outset, i.e., not “affirming” that children who say they’re of another gender must be right—before giving them irreversible medical treatment, treatment that we now know can render people sterile, unable to enjoy sex, and, in the case of puberty blockers, cause other medical damage. Sullivan, who experienced dysphoria himself, says that many adolescents go through a period of confused sexuality, and perhaps would become gay were it not more fashionable to change gender.

Both articles detail some big changes in Europe about how to treat gender dysphoria. I’ll summarize what most of us know already (the first article above gives links):

  • Sweden has revised its guidelines for treating gender dysphoria in adolescents, arguing that gender-affirming treatment may be more harmful than good, and claiming that affirmative treatment “should be offered only in exceptional cases.”
  • Finland, using an evidence-based approach showing that many young people seeking transitioning had severe psychiatric problems, that there were risks to using puberty blockers (see below), both physically in in terms of sexuality, changed its protocol for treating gender dysphoria:

(From Davis’s piece): In Finland, for patients who fit the profile of participants in the Dutch study, after a prolonged period of evaluation, and with a multidisciplinary team including a psychiatrist, psychologist, social worker and nurse, puberty blockers may be started near the onset of puberty, and cross-sex hormones may be possible starting at age 16. Assessments take place at two gender identity clinics; gender surgeries are offered only at one center. Both Finland and Sweden now stress gathering data and extensive follow-up.

My own view is that giving puberty blockers “near the onset of puberty”, or at age 16, is too young.

  • The National Academy of Medicine in France has urged caution in proceeding with drugs and surgery in cases of gender dysphoria since some of it may be due to social contagion. It recommends more extensive psychological counseling of those with gender dysphoria.
  • The Tavistock clinic in London (a notorious place for affirmative therapy) is to be closed, replaced by a number of regional clinics practicing a different brand of care. This is the result of a critical review headed by Dr. Hillary Cass, commissioned to review Tavistock and its practices. Their recommendations, which the government accepted, was to de-centralize the clinics, adopt more “holistic care”, and ratchet back on the use of puberty blockers, which now appear to have possibly severe medical consequences.
  • The medical consequences of puberty-blocking drugs like Lupron, which according to Sullivan have been known for a while, include brain swelling and loss of vision, possible bone damage, and other irreversible effects. In fact, these blockers are used for other conditions, and I understand are always prescribed by doctors treating gender dysphoria “off label”, i.e., they’re not specifically recommended by the FDA for stalling puberty while a child ponders its gender.

This month the FDA added brain swelling to the warning labels of puberty blockers. The sample size is small, and these problems appear only in biological females (the most common sex experiencing gender dysphoria), but an FDA warning is nothing to take lightly. Here’s a tweet about the dichotomy between the American use of blockers willy-nilly in American “affirmative care”, and the warnings on drug labels. Clearly, more research needs to be done (that’s what Sweden and Finland concluded) before blockers are used so readily. But, in contrast to the caution about other new remedies, like Covid-19 vaccines, the standards for usage are very lax in the U.S., and were in the UK as well:

Nevertheless, as both Sullivan and Davis point out, the U.S., urged on by the Biden Administration, is going full steam ahead with affirmative care.

Sullivan:

In the US, however, as many states move in the European direction, the left is pushing harder. California has a bill offering sanctuary for any child seeking a sex change. The Biden administration still insists that “every major medical association agrees: gender-affirming care is life-saving, medically necessary, age-appropriate and a critical tool for health care providers.” The absolute certainty, compared with the second thoughts in Europe, is striking.

Davis, referring to Finland and Sweden’s revised guidelines in comparison to America’s (my emphasis):

Both guidelines starkly contrast with those proffered by the Illinois-based World Professional Association of Transgender Health, an advocacy group made up of activists, academics, lawyers, and healthcare providers, which has set the standard when it comes to transgender care in the United States. WPATH will soon issue new standards that lower recommended ages for blockers, hormones and surgeries. (WPATH did not respond to a request for comment.)

WPATH’s position is in keeping with an array of U.S. medical associations and activist groups across the country that insist gender-affirming care is “life-saving.” Assistant Secretary of Health Rachel Levine, who is herself a transgender woman, recently asserted that there is a medical consensus as to its benefits. Some activists and gender clinicians in the U.S. feel that WPATH doesn’t go far enough, asserting that any child who wants puberty blockers should get them, for instance, or claiming that a teenager who later regrets having her breasts removed can just get new ones.

In Sweden and Finland, this issue has been primarily a question of health and medicine. Here in the U.S. it is a political football.

Why the ignoring of evidence and lack of caution in the U.S. as opposed to Europe? Why are we not following the examples of countries that take an evidence-based approach to medical policy about gender dysphoria? Surely one of the reasons is “wokeness”: the idea that changing gender is to be admired as an act of courage, and that transgender people, or those who wish to become so, should be valorized as members of stigmatized minorities. And, sadly, the Biden administration has bought into the pronouncements of the extreme Left, which include unquestioning approbation for “affirmative care.”

Yes, there’s some stigma about transgender people, and yes, we should help those who, after intensive medical and psychological examination, are deemed to be serious about their gender misindentification rather than confused about their sexuality. And yes, we should treat transgender people in nearly all respects as equals to members of the biological sex they assume.  But what we should not do is, in the interests of seeming virtuous, rush children and adolescents into very serious and irreversible medical procedures without proper vetting.

American hospitals refuse to adhere to new price transparency law

June 8, 2022 • 11:30 am

UPDATE: To underscore the opacity of the present system, its greed, and the way patients are overcharged, read this NYT article from May, “She was told that surgery would cost about $1,300. Then the bill came: $229,000.” Lisa Melody was charged the “chargemaster” price, even though she didn’t agree to that and her insurance company told her otherwise. When she wouldn’t pay that outrageous price for spinal fusion surgery, the hospital in Colorado sued her. A jury found for Melody, and her final bill was only $767. (h/t Enrico)

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In 2020, when I had hernia surgery, I posted the bill that my insurance company received from the University of Chicago Hospitals. It was nearly $64,000!  Europeans and Canadians were properly shocked at these prices, which indicated a big profit for the hospital. Now I didn’t pay nearly that much, as I have a good insurance plan, but the insurance company had to pay it (sometimes employers themselves foot part of the bill); but Americans without insurance would have be billed at that full price.

Shockingly, until last year, there was no way to find out these prices in advance so you could do comparison shopping. As I said in the earlier posts, almost no hospitals publicize the costs of their services or the medications they give you, so you don’t know what the bill is until after you’ve been treated. As I wrote at the time:

Now, can you know these prices in advance so you can comparison shop among hospitals? The answer is NO. While hospitals differ drastically in their costs, it would be nearly impossible to get a figure for the entire operation in advance. Some hospitals, like the Surgery Center of Oklahoma, will quote you a flat price (and for them, my redo surgery [the hernia operation had to be redone] would have been free), and that price, for hernia surgery similar to mine is, I’m told, about $4,500: only 7% of what the bill was above. Nor are these cheaper hospitals worse at what they do: there seems to be little correlation (or even a negative correlation) between the price of a procedure and the quality of the facility and the doctor. (My doctor at the U of C, by the way, was excellent and has a superb record, but more on doctor-shopping later.)

What about the costs above? Are those the sticker costs that then get discounted when billed to the insurance companies (i.e. are they they the so-called “Chargemaster list prices” for each item), or are they the already-discounted costs given to my insurance company?  I have no idea.  It’s as if you went to the grocery store and there were no prices on the food items, and then after a month you get a bill saying, “This is what you have to pay for groceries.

At the post above, Dr. Lickerman answered many readers’ queries (just search for “Lickerman”), which explained more about how dire health care prices were. Of course, other countries have single-payer insurance, but in many cases that results in a parallel series of private insurance because patients don’t want the long wait associated with many national single-payer systems. When I snapped a tendon in my finger in New Zealand, for instance, I could get treated for free, but it would be at least a five-hour wait in the hospital, or I could pay out of my pocket and get reimbursed in the U.S. I chose the latter, and fortunately my insurance company reimburses for medical treatment overseas.

The lack of transparency in pricing did two things: it prevented consumers from comparison shopping to find the cheapest price (especially important if you are paying out of your pocket or have a high deductible), and it generated huge profits for hospitals, which can adjust its “MSRP” prices as well as the discounts from those prices that are given to insurance companies.

This was supposed to be rectified when in 2020 Congress passed The Health Care PRICE Transparency Act, requiring hospitals to disclose the prices of 300 “shoppable” procedures as well as the billing costs for many drugs. It was supposed to take effect on January 1, 2021, and there were fines for violations.

As of today, almost no hospitals are complying, there is almost no transparency, and fines aren’t even being imposed. I heard about this on the NBC Evening News last night, and decided to see what’s going on. What’s going on is that hospitals, greedy for $$, are ignoring the law. And the Biden Administration isn’t doing anything about it. For laws can be enforced by the executive branch of the government.

Hospitals have four tiers of pricing, and all of these prices should be disclosed for each drug and service.  I quote my doctor, Alex Lickerman, here about these tiers:

Charge master price = this is like sticker price on the car. No insurance company expects to pay this. Hospitals create this because they know different insurance companies will be willing to pay different percentages of their charge master price. When insurance companies advertise that they have the biggest “discounts,” what they mean is reductions down off a hospital’s charge master price (which hospitals historically haven’t disclosed). So BCBS might get a 50% discount. Medicaid might get a 95% discount off the charge master price. Medicare might get an 80-85% discount. (I’m making these discounts up).

This is what the uninsured patient pays, and if they don’t pay (they must be treated), they will be dunned and their credit ruined.

The minimum negotiated price = this is the greatest discount, and therefore the lowest price, a hospital gives a third-party insurance payer.

The maximum negotiated price = this is the lowest discount, and therefore highest price, a hospital gives a third-party insurance payer.

Cash price = the price a patient would pay without insurance. Ironically—and horribly—this is often the full charge master price; that is, the price for the service WITHOUT a discount, which is then charged to people to have the least ability to pay it, i.e., the uninsured.

All these prices were suppose to be disclosed by hospitals on the Internet at the beginning of last year, but very few hospitals have obeyed. These sites (here, here, here, here, and here) give the story:

1). There’s a tremendous variation in prices among hospitals that do list them. The New York Times article from last summer is the best source of information:

The data show that the charge for a joint replacement can range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a facility in Monterey Park, Calif. Or within the same area, charges range from $21,000 to $46,000 to treat heart failure in hospitals in Denver, Colo.

Here are some disparate prices from that NYT article, and you can see more examples from the paper. Note that the vertical lines show four times what Medicare pays the hospital (for a colonoscopy) and TEN times what the government pays (for an MRI scan). Almost no insurance company pays anything near as low as what the government pays:

It holds for drugs too, which are often particularly inflated in price. This is for a rabies drug (text from the NYT):

Prices were still secret when Brian Daugherty went to an emergency room near Orlando, Fla., for a rabies shot after a cat bite last summer.

“I tried to get some pricing information, but they made it seem like such a rare thing they couldn’t figure out for me,” he said.

He went to AdventHealth Orlando because it was close to his house. That was an expensive decision: It has the highest price for rabies shots among 24 hospitals that included the service in their newly released data sets.

The price there for an adult dose of the drug that prevents rabies varies from $16,953 to $37,214 — not including the emergency-room fee that typically goes with it.

Mr. Daugherty’s total bill was $18,357. After his insurer’s contribution, he owed $6,351.

2.) Few hospitals are complying with the law. 

“One year after this law making hospitals show prices came into effect, unfortunately, we found that only 14.3% of our country’s. . . hospitals are complying with this law,” PRA founder and CEO Cynthia Fisher said.

The NBC News last night reported only 15% compliance.

Yet hospitals are violating the law left and right, and are not being penalized, even though the penalties are trivial compared to the profits that hospitals rake in. Here’s the law:

The law required hospitals to post prices for all services, including gross charges and discounted cash prices.

In addition, the rule requires the information to be available in two formats, a machine-readable file that contains pricing data for third parties to compare between hospitals and a shoppable service list that displays specific services offered at the facility.

And the fines:

Under the final rule, for hospitals with thirty or fewer beds, the minimum civil monetary penalty will increase to $300 per day. For hospitals with more than thirty beds, the minimum civil monetary penalty will be $10 per bed per day, capped at $5,500 per day. This means the minimum amount for noncompliance with the rule would be $109,500 annually while the maximum amount is $2,007,500 annually. CMS is also requiring that the machine-readable files with pricing information be accessible to automated searches and direct downloads.

In response to a reader’s question after my post about why the bills were so much higher when insurance was involved, Dr. Lickerman said this:

Great question! The answer is, many providers will charge a lower cash pay price because payment is immediate. The bill is higher when insurance is involved because providers create a “chargemaster” which has prices that are like an MSRP when you’re buying a car. It represents a ceiling price–an initial price–in a negotiation that almost no one pays. Providers inflate their chargemaster prices because they know they’ll be forced to negotiate different discounts with insurers. So while private insurers get maybe a 50% discount off chargemaster rates, Medicaid takes maybe a 90% discount (which is why most medical systems consider Medicaid to be “bad” insurance: it reimburses them for a given service at the lowest rate). This is why, paradoxically, if you’re uninsured, you may pay more than even large insurance companies. For reasons that defy logic, medical systems will sometimes quote the uninsured their chargemaster rates–the highest price–rather than a true cash pay rate.

If you’re getting care from a small provider (vs. a large hospital system), you’re much more likely to find a reasonable cash pay rate that ends up being cheaper than going through your insurance (depends on your yearly out-of-pocket max and how far into it you’ve already spent).

Large hospital systems likely raise their chargemaster rates to meet revenue targets. Contrary to what you’d expect, insurers are happy to pay these rates because it enables them to increase premiums, which they want to increase because Obamacare imposed a medical loss ratio of 20% on most insurance plans. That means insurers must spend 80% of their revenues (premiums) on healthcare claims. If you’re limited to only 20% of the pie to make profits, what do you do? Find a way to make the pie bigger so that the absolute dollar amounts you bring in goes up. This is what the insurers have done, and it’s why premiums have gone through the roof since Obamacare was enacted. The unit cost of most medical care has increased mostly with inflation. Healthcare prices set by providers have increased by far more.

Even employers find it hard to determine what they will pay for an insurance plan, as they must hire lawyers and consultants to get around the great wall of secrecy. And sometimes even then it doesn’t work, so they’re buying a plan for their employees whose benefits they don’t know and, since employers must sometimes pay some benefits, they don’t even know how much they would be liable for.

This is greed, pure and simple, and it hurts everyone. Many Americans are impoverished by the cost of healthcare and their inability to do comparison shopping.

There are multiple solutions: Single-payer health, Obamacare for everyone, with government help in paying for private insurance, enforcement of transparency, negotiation of drug prices and so on.

Everyone usually prefers the system they have now, unless they have no insurance. I’m wary of the single-payer system just because it hasn’t worked out well in many places. Here’s what Dr. Lickerman said about it on my earlier post, and at the risk of reader ire in Canada and the UK I’ll present it anyway:

Great question. The idea of having a single payer for all healthcare (the government) definitely has its supporters here in the U.S. But it would likely lead to what we see in Canada (the system outside the U.S. I know best), which is untenable wait times for anything other than emergent care, which is all handled by already-burdened ERs. You won’t go broke getting healthcare in Canada like you can in the U.S., but you won’t have appropriate access to healthcare either. The single payer system there has resulted in a dearth of primary care physicians that’s even worse than in the U.S.

But whatever the solution, it’s not what the U.S. has now, and countries like Canada and the UK do have nearly free single-payer care, which does deal quickly with emergencies.  Here’s what the NYT got when it solicited “explanations” from hospitals in its article last August. Look at these Scrooges!

At the Biggest U.S. Hospitals, Few Prices Are Available

Six months after the new rules took effect, the Times reached out to the highest-revenue hospitals that had posted little or no data about their negotiated rates or cash prices. Here’s what they had to say:

“We will not be providing a statement or comment.”

N.Y.U. Langone has not published its negotiated rates or cash prices.

“Services that do not have a fixed payer-specific rate are shown as variable.”

Stanford Health Care has not published its cash prices. Of more than 300,000 possible combinations of insurance and medical treatment in its data file, it includes prices for 479.

“We do not post standard cash rates, which typically will not reflect the price of care for uninsured patients.”

Cedars-Sinai Medical Center, in Los Angeles, has not published its cash prices. The hospital initially posted a 2.5 GB data file composed almost entirely of more than one million lines that contained no data. After The Times inquired about the large file size, the hospital reduced it to a 1.4 MB file.

“We have listed the fixed rates where possible and, where that is not possible, have listed them as ‘variable.’”
U.C.S.F. Medical Center has not published its cash prices. Of more than eight million possible combinations of insurance and medical treatment in its data file, U.C.S.F. includes negotiated rates for 346. (U.C. Davis, which is part of the same system and has also not published its cash prices, sent an identical statement.)
Penn Medicine is committed to transparency about potential costs.”

The Hospital of the University of Pennsylvania added cash prices to its price transparency file after The Times inquired about why that data was missing.

“The resources we provide ensure that our patients know what kind of assistance is available to them and, ultimately, what a procedure will cost them — not us.”

Montefiore Medical Center, in the Bronx, has not published its negotiated rates or cash prices.

“V.U.M.C. offers a toll-free number which consumers can call if they have questions about what they may be charged for services.”
Vanderbilt University Medical Center, in Nashville, has not published its negotiated rates or cash prices.
“Orlando Health has worked hard over the past several years to deliver helpful pricing information to its patients.”

Orlando Health has not published its negotiated rates or cash prices.

“We are continuing to work on the machine-readable file that includes payer-negotiated rates. … It involves analyzing a daunting number of data points.”

Long Island Jewish Medical Center has not published its negotiated rates or cash prices.

The largest hospitals were chosen based on gross revenue reported to the Centers for Medicare and Medicaid Services in 2018, the most recent year with full data available.

 

If you’re an American, you should be plenty mad about this, be you Democrat or Republican. Everyone needs healthcare, and the fat cats are bilking the government and medical patients, all the while knowingly and insouciantly violating the law.

 

My duck-related injuries

May 24, 2022 • 1:15 pm

There is a lack of news today, so I’ll just add this. I have started developing swimmer’s itch again (“cercarial dermatitis“, caused by flatworm larvae associated with waterforwl). I had it last year, and it was dreadful, with an itchy red rash (and I mean itchy) that lasts several weeks. Scratching is useless; only prescription creams offer temporary relief.

This came, of course, from my double immersion in Botany Pond a week ago to rescue an orphan duckling some peabrain put there. Although I failed to rescue it, a student named Brandon did, and it’s now in rehab. As for me, I thought I’d come off scot-free this time because the water was cold and we don’t have many ducks.

No such luck. The rash, due to an immune reaction from the larvae that drilled into me, is starting, and since I was completely underwater once or twice it’s on my hands, feet, belly, and, well, everywhere. When I called the doc to get some prescription steroid cream, I realized that I may have incurred more duck-related injuries than anyone whose job isn’t to raise ducks.

So far:

1.) Swimmer’s itch, bout 1

2.) Head laceration from running into a tree while chasing drake malefactors

3) Serious ear laceration (11 stitches, some double) from snagging my ear on a tree branch while chasing duck malefactors

4.) Swimmer’s itch, bout 2 (both from attempting to rescue orphan ducklings

5.) Badly banged up knee from falling into the pond several years ago.

Non-medical injury: lost my glasses ($200) while trying to catch a duckling in the main pond. Couldn’t find them in the muddy pond bottom. (BTW, all orphans have been successfully caught and rehabbed.)

I won’t show pictures of the wounds themselves, but I had to tell my doctor that I’m sure he’s never had a patient with so many duck-related complaints. He agreed. But of course I’d do it all over again to save the ducks. I do love me some waterfowl.

Here’s after I was dressed in a turban after my ear injury on May 8, 2020:

And remember, try not to go swimming in ponds where there are ducks. (My swim was of course involuntary.)