Category: medicine and health

WPATH and the U.S. government try to interfere with research on gender care

June 30, 2024 • 10:30 am

Below are three articles, the first one in The Economist, the second in the NYT, and the latest from Colin Wright’s Substack site, showing that both the U.S. government and WPATH (World Professional Association for Transgender Health: the most influential organization dealing with doctors and therapists who provide care for gender dysphoric and trans people) have been pressuring scientists to get rid of minimum age limits for “affirmative care”. (WPATH, by the way, though purporting to be a “World Professional Association”, is influential only in North America, having almost no bearing on transgender care in other countries.)

As you know, “affirmative care” is that form of care for gender-dysphoric adolescents that guides and pressures them to become trans people, affirming (rather than exploring) their feelings that they’re in the wrong bodies. Beyond cursory “rah rah” therapy, the program then gives adolescents puberty blockers that supposedly pause their development to give them time to decide, and then urges hormonal treatment and—sometimes—top or bottom surgery.  It’s the “affirmative” part—the idea that the child’s views and desires must be catered to—that bothers many of us.  Involved in this are three issues:

1.)  Are adolescents to be trusted with making decisions about medical care that can affect their lives in a major way, decisions that involve taking hormones and having surgery that can sterilize them and (in the case of bottom surgery) lead to severe complications?  Shouldn’t there be a minimum age limit for making such decisions?  According to the NYT article below, the Biden administration had issued draft guidelines, but these were never enacted. (To my mind, these guidelines seem way too young. 17 for genital surgeries and 14 for hormone treatments?)

The draft guidelines, released in late 2021, recommended lowering the age minimums to 14 for hormonal treatments, 15 for mastectomies, 16 for breast augmentation or facial surgeries, and 17 for genital surgeries or hysterectomies.

Now, it appears, many people want NO age minimums, and that includes the U.S. government.

2.)  The long-term effects of puberty blockers on adolescents are not known very well. In some European countries the use of such blockers as regular therapy is banned, and blockers are employed only in clinical trials.

3.)  The bulk of cases of gender dysphoria resolve themselves on their own, without dysphoric people needing hormones or surgery before puberty, and many on hormone therapy stop that therapy, which may not (as gender advocates say) be completely irreversible. Many of these children resolve as homosexuals, which involves neither medicine nor surgery.  As Pamela Paul of the NYT noted, with links:

Studies show that around eight in 10 cases of childhood gender dysphoria resolve themselves by puberty and 30 percent of people on hormone therapy discontinue its use within four years, though the effects, including infertility, are often irreversible.

Europeans are taking a more watchful approach to these questions, but somehow in the U.S. many gender activists want no minimum age limit for affirmative care (including the use of blockers when kids are quite young), only perfunctory therapy for gender-dysphoric adolescents (perhaps only a single session), and make decisive (and erroneous) pronouncements that puberty blockers are not only perfectly safe, having no long-term effects, but are also completely reversible.

This first report, from the Economist (click to read) shows that WPATH tried to impede the work of scientists and researchers working on reviews of transgender issues, reviews meant to inform WPATH’s own guidelines for transitioning. In other words, WPATH wanted researchers to come up with only those results that the organization wanted, results that buttressed affirmative therapy.

Both this article and the NYT article resulted from discovery documents and emails released in a court case challenging Alabama’s ban on transgender medical care for minors.

Here are some experts showing how WPATH resisted systematic analysis of relevant data. (WPATH adamantly denied the results of the NHS’s Cass Review in England, which put considerable brakes on affirmative care in the UK).

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

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

There was then a negotiation stipulating that WPATH didn’t have to approve the data, but could offer review and feedback to the researchers without “meddling” in publication:

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

But only one review was ever published, about the effects of hormone therapy on transgender people, and, six years later, there are no more articles published, despite the fact that the EPC group has enough data for SIX more reviews.  Something fishy is going on, but what it is we don’t know. (Bolding below is mine.)

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

Since WPATH is all out for affirmative care, and demonizes those who call for caution (e.g., the Cass Review), the bit in bold above looks like arrant interference by WPATH with the scientific process.  One could lump WPATH’s behavior in this case along with attempts by other ideologues to make reality comport with ideology—what I call the “reverse appeal to nature”, or “What we consider good and moral must be seen in nature.”

But what seems even worse, at least to American liberals, is that officials in the Biden Administration, including the trans woman who is the assistant secretary for Health and Human Services, have tried to get WPATH to drop all its guidelines for age minimums.  And the pressure worked! WPATH has no more age guidelines.

Click below to read the NYT piece, or find it archived here


Some excerpts (I’ve added a link to Levine):

Health officials in the Biden administration pressed an international group of medical experts to remove age limits for adolescent surgeries from guidelines for care of transgender minors, according to newly unsealed court documents.

Age minimums, officials feared, could fuel growing political opposition to such treatments. [JAC: That apparently means that age limits indicate that there are issues involved with decisions to undergo such treatments. But this is not a political issue!]

Email excerpts from members of the World Professional Association for Transgender Health recount how staff for Adm. Rachel Levine, assistant secretary for health at the Department of Health and Human Services and herself a transgender woman, urged them to drop the proposed limits from the group’s guidelines and apparently succeeded.

Now WPATH, an organization to which many American doctors and therapists adhere, has no age guidelines at all.  If an eight-year-old girl says she feels like she’s in a boy’s body, then affirmative care could begin immediately, and hormones administered soon thereafter. And surgery at any age!

Now I’m not sure about the ethics of a trans woman in the government —or any person, be they cis or trans—pressuring a professional organization to drop age limits for “adolescent surgeries”, but it doesn’t sound kosher.  No bureaucrat should be applying any pressure. for this is an issue best left to doctors and medical ethicists. Yet the pressure from Levine and her office was constant:

The email excerpts released this week shed light on possible reasons for those guideline changes, and highlight Admiral Levine’s role as a top point person on transgender issues in the Biden administration. The excerpts are legal filings in a federal lawsuit challenging Alabama’s ban on gender-affirming care.

One excerpt from an unnamed member of the WPATH guideline development group recalled a conversation with Sarah Boateng, then serving as Admiral Levine’s chief of staff: “She is confident, based on the rhetoric she is hearing in D.C., and from what we have already seen, that these specific listings of ages, under 18, will result in devastating legislation for trans care. She wonders if the specific ages can be taken out.”

Another email stated that Admiral Levine “was very concerned that having ages (mainly for surgery) will affect access to care for trans youth and maybe adults, too. Apparently the situation in the U.S.A. is terrible and she and the Biden administration worried that having ages in the document will make matters worse. She asked us to remove them.”

There are a lot more emails that I haven’t read, but here’s one more bit showing that even within WPATH there was dissent about removing age limits:

In other emails released this week, some WPATH members voiced their disagreement with the proposed changes. “If our concern is with legislation (which I don’t think it should be — we should be basing this on science and expert consensus if we’re being ethical) wouldn’t including the ages be helpful?” one member wrote. “I need someone to explain to me how taking out the ages will help in the fight against the conservative anti-trans agenda.”

The international expert group ultimately removed the age minimums in its eighth edition of the standards of care, released in September 2022. The guidelines reflected the first update in a decade and were the first version of the standards to include a dedicated chapter on medical treatment of transgender adolescents.

The fact is that we know very little about the long-term effects of various medical interventions on the health and mental well-being of gender-dysphoric adolescents. And with WPATH and the government trying to impose their own dictates on what the results should be, gender care in America looks dire.  Like any other branch of medicine and therapy, it should be informed by science, not ideology, and ideologues should not be dictating how the scientific results should turn out. Yet WPATH continues to make statements without evidence, preferring anecdotes:

The final WPATH guidelines state that distress about breast development in particular has been associated in transgender teenagers with higher rates of depression, anxiety and distress.

“While the long-term effects of gender-affirming treatments initiated in adolescence are not fully known, the potential negative health consequences of delaying treatment should also be considered,” the guidelines state.

“Gender-affirming surgery is valued highly by those who need these services — lifesaving in many cases,” Dr. Bowers said.

I’m pretty sure the “lifesaving part”, as epitomized in the advice given parents of gender-dysphoric children, “Do you want a live son or a dead daughter?”  Gender dysphoria is often accompanied by depression and other mental issues, and there’s no evidence I know of that gender-dysphoria alone causes suicide in the absence of affirmative care.

UPDATE: I’d missed this article from Reality’s Last Stand, but it’s highly relevant. Click below to read it:

 

An excerpt, noting that apparently the NYT had even more damning emails but didn’t publish them (bolding below is the author’s):

Last night, I had drinks with a friend I hadn’t seen in a long time, determined not to talk about The Issue. But a few minutes before I arrived, I found out that The New York Times had decided not to publish a part of a story about the World Professional Association for Transgender Health—an advocacy group that creates “standards of care” for trans medicine, which American medical groups avow to adhere to (they don’t) and claim are evidence-based (they aren’t).

That part of the story would have discussed recently unsealed WPATH documents, subpoenaed by the state of Alabama, as part of a lawsuit, Boe v. Marshall. Alabama parents, medical providers, and a Birmingham pastor named Paul Eknes-Tucker sued the state because of its ban on “gender-affirming care” for minors—and the criminalization of those who practice it.

. . .The emails show that Hopkins did conduct a systematic review, and that—like all the other SRs—it found diddly squat in terms of evidence supporting the efficacy of hormones and surgeries. But WPATH prevented Johns Hopkins from publishing these reviews because they didn’t come to WPATH’s preferred conclusions. WPATH hid this very important information from the entire world, then published standards of care saying an evidence review was impossible. And a government agency knew this!

We are talking about kids and the most invasive possible interventions here. We are talking about venerable academic institutions and government agencies and censorship and secrets.

. . . Turns out, there’s a whole heckuva lot more of these damning emails. The New York Times had access to them but chose not to cover them. A source told me this is because no one from Johns Hopkins would comment on the record. The documents will be available via the LGBT Courage Coalition tomorrow (I will add a link and start a thread when it’s up), but I had a chance to preview them. If you have not yet had what GIDS whistleblower Anna Hutchinson called her “holy fuck!” moment, now’s the time.

After discussing the concessions the Johns Hopkins researchers made to WPATH, apparently deep-sixing six review papers, author Davis says this:

Can you believe the John Hopkins folks agreed to this? This is not science. WPATH is not credible. And this is why we in America are the outliers: we’re not basing guidelines on systematic reviews, or reality. We’re basing them on an activist group’s political agenda, and even the HHS knows there’s no good evidence. In fact, AHRQ was asked to review guidelines for treating gender dysphoric youth back in 2020, because, the request said:

There is a lack of current evidence-based guidance for care of children and adolescents who identify as transgender, particularly regarding the benefits and harms of pubertal suppression, medical affirmation with hormone therapy, and surgical affirmation. While these are some existing guidelines and standards of care,2, 5-6 most are derived from expert opinion or have not been updated recently so a comprehensive evidence review is currently not available.

What did AHRQ decide, after communicating with the Hopkins researchers?

The EPC Program will not develop a new systematic review because we found protocols for two systematic reviews that addresses portions of the nomination, and an insufficient number of primary studies exist to address the remainder of the nomination.

Basically, they said someone was already doing it, and there wasn’t enough evidence to sort through. But the someone already doing it had already agreed to put science aside and only discuss benefits, not harms.

In future years the suppression of scientific research on gender medicine in America will be seen as a scandal. And besides unforeseen damage to people’s lives, we can expect a spate of lawsuits.

Both WPATH and the Biden Administration bear the blame for the latest series of missteps.  In its efforts to placate the progressive Left (something I didn’t predict when Biden was elected), the Biden Administration has badly mishandled issues of sex and gender.

h/t: Rosemary

Readers’ wildlife photos

June 24, 2024 • 8:15 am

I am still running low on photos, though I have a handful of contributions, and would greatly appreciate any readers sending in their good photos. Thanks!

Today we have a text-and-photo natural history and medical lesson from Athayde Tonhasca Júnior; his narrative is indented and you can enlarge the photos by clicking on them.

Suspicions and proofs

From a hundred rabbits you can’t make a horse, a hundred suspicions don’t make a proof (Fyodor Dostoyevsky)

Few people contributed more with entries to medical dictionaries than renowned German physician, anatomist and pathologist Friedrich Gustav Jacob Henle (1809-1885): Henle’s fissure, Henle’s layer, Henle’s ligament and Henle’s tubules are some of the several terms named after him. But there’s more from the good doctor: in a 1840 paper quirkily titled Von den Miasmen und Contagien (On Miasmas and Contagions), Henle championed the theory that microscopic organisms caused diseases, which was questioned by his peers. Later, Henle proposed the necessary steps to prove the theory, such as detecting the suspected agent in every case of the disease and establishing its absence in healthy people. These ideas were refined by Henle’s most famous student, Robert Koch (1843-1910), a future Nobel laureate, and are known today as the Henle-Koch postulates – although often, and unfairly, called just Koch postulates. These guidelines hold that the suspected microorganism must be present in every host affected by the disease but absent in healthy organisms; the microorganism must be isolated from a contaminated host and grown in a culture; the cultured microorganism should cause the disease when inoculated into a healthy organism; and the microorganism must be isolated again from the inoculated organism and identified as being identical to the original agent.

Dr Henle helped debunk the belief that diseases were caused by miasma, or bad air. Image in the public domain, Wikimedia Commons.

The original Henle-Koch postulates are no longer universally applicable because we learned quite a lot since they were formulated: for example, many pathogenic organisms are regularly found in healthy hosts, and the rules are not valid for viruses, which had not yet been discovered. Nonetheless, the postulates gave a rigorous scientific foundation to the emerging field of medical microbiology. By establishing a reliable causal relationship between microorganisms and infectious diseases, doctors could explore options for prevention and treatment.

Drs Friedrich Henle and Robert Koch were entitled to be proud of their work, but they probably would have been surprised to learn that their postulates are also relevant in the field of pollination ecology.

Pollination is the fundamental mechanism of plant reproduction. Since plants can’t go out on a date, they need an agent to transfer pollen for them. For nearly 90% of all wild flowering plants, this work is done by animals, mainly insects. And considering that more than 75% of the world’s most important crops benefit in some degree from animal pollination, identifying pollinating agents is enormously important for the economy and humanity’s well-being.

The apparently obvious way of recognizing pollinators is by checking out which creatures visit flowers. However, it has long been known that an insect or any other animal landing on a flower does not necessarily contribute to its pollination. Some visitors are nectar thieves: they take the flower’s nectar without touching stigmas or anthers. Others are nectar robbers: they get it through holes in the flower made by themselves or by previous visitors. Visitors in search of pollen may also contribute zilch to pollination if they eat pollen on the spot and take away few or no pollen grains. Sometimes they are too good at gathering it, carrying the entire loot back to their nests, leaving nothing for plant reproduction. In some cases, these pollination cheats can constitute the bulk of flower visitations. To complicate matters, visitors can be cheats and pollinators at the same time, or under different circumstances.

The sixteen-spot ladybird (Tytthaspis sedecimpunctata) is a keen flower visitor but an abysmal pollinator because it gobbles down pollen to its heart’s content © Gilles San Martin, Wikimedia Commons.

Pollination will happen only when pollen grains from the anthers (male parts of the plant) make their way to a stigma (female part). Evidence for this crucial event can be obtained by a sequence of conditions analogous to the Henle-Koch postulates. It must be demonstrated that pollen is transferred from anthers to the vector (the suspected pollinator), transported by the vector, and  deposited on a receptive stigma by the vector (Cox & Knox, 1988).

The process of cross-pollination © Ali Niaz, Wikimedia Commons.

These steps seem straightforward, but they are in fact not easy to prove. King et al. (2013) had a go at it with observations from two Scottish sites and a deciduous forest in Costa Rica. They kept an eye on recently opened flowers from 13 species, waiting for the first visitor to alight on a bloom. Once that happened, the stigma from that flower was taken to a laboratory, where pollen grains were recovered, identified and counted. By carrying out repeated observations, the authors obtained estimates of single-visit deposition (SVD), which measures a visitor’s ability to take pollen from a given plant and deposit it in another plant where it can lead to fertilization. By estimating SVD values of the main flower visitors, the authors discovered that about 40% of them were not effective pollinators.

In southeast England, bramble (Rubus fruticosus agg.) flowers are frequently visited during daytime by flies, bumble bees (Bombus spp.) and the European honey bee (Apis mellifera). But an analyses of SVD revealed that most pollination is done at night by moths (Anderson et al., 2023). In a similar vein, Ballantyne et al. (2015) evaluated potential pollinators of heather (Erica tetralix, E. cinerea and Calluna vulgaris) and gorse (Ulex europaeus and U. minor) in Hyde Heath, England. By combining the frequency of flower visitation with SVD values, it was possible to establish who was pollinating what. Hoverflies were frequent visitors, but they deposited few pollen grains. The European honey bee, another regular visitor, was an efficient pollinator of common heather (C. vulgaris), but not as good as bumble bees for the other plants. In fact, SVD data for 76 plants from 30 families in Kenya, Israel and UK have confirmed the frequently reported observation that the European honey bee, despite often being the most abundant flower visitor, is a less effective pollinator than are solitary bees and bumble bees (Willmer et al., 2017).

Networks illustrating a combination of frequency of flower visitation and mean SVD for the main pollinators of heather and gorse. 1: Bombus terrestris/lucorum; 2: B. pascuorum; 3: B. lapidarius; 4: B. jonellus; 5: B. hortorum; 6: A. mellifera; 7: Halictidae; 8: other solitary bees © Ballantyne et al., 2015.

If you suspect that estimating SVD is hard work, you are right. There are alternatives, such as percentage of flowers that develop into fruit, fruit weight, fruit production, and so on. But these methods are equally laborious and not as precise as SVD. A great number of studies have used visitors’ features such as their abundance, hairiness and size, their pollen load, the number of stigmas touched, and the frequency and duration of flower visits. These are indicators of visitors’ potential, but not proof of effectiveness. For example, pollen attached to a visitor’s body may be lost on the way, or end up on incompatible or unreceptive stigmas. We need evidence of pollen deposition that may lead to fertilisation.

A marmalade fly (Episyrphus balteatus) on a grey-haired rockrose (Cistus creticus) flower. Pollination in action? Possibly, but the presence of pollen grains alone does not guarantee it © Aka, Wikimedia Commons.

Conservation organisations, academics, the press and social media have reiterated—often exaggeratedly—the imperiled state of pollination services. These concerns heighten the importance of safeguarding pollinators’ abundance and welfare, and the quality and extent of their habitats. Pollinators are in the spotlight, which opens opportunities for public involvement, new projects, funding – and to bandwagon jumping. A range of flower visitors have been claimed to be pollinators based solely on the fact that they are flower visitors. Even a tree frog was recently reported in the press as a new member of the pollinators club because one specimen was observed with pollen attached to its back. Could it be a pollinator? Possibly, but not likely:  a frog or any animal may accidentally fertilise a flower, but that does not make them reliable, consistent pollinating vectors. Like any other scientific endeavour, progress in our understanding of pollination ecology and processes requires data resulting from hard work. Just listing creatures that fancy a pretty flower won’t do.

Flower-loving Pepé Le Pew is not likely to contribute to pollination © Prayitno, Wikimedia Commons.

Readers’ wildlife photos

May 29, 2024 • 8:15 am

Today the wildlife is H. sapiens medicalensis: portraits of medical workers taken by reader Christopher Moss in the hospital where he works as a doctor.  To show how intrepid he is, he took one of these when he himself was hospitalized for a bone marrow transplant. (Normally he’s a doctor there.)

Christopher’s captions are indented, and you can enlarge the photos by clicking on them.

These are all portraits taken on film, with a variety of cameras. Many are taken on a weekend morning after rounds at the hospital, when I used to torment the nurses and fellow docs by taking a camera into the hospital. I see there are notices all over the place now declaring photography forbidden except with permission of the micro-managing administrators, so there can be no more such photos.

Emily. Pentax 645N, 75mm/f2.8, Tri-X @400, HC-110, Nikon 9000 scan:

Holly. Nikon F6, 85mm/f1.4, Ilford XP2 @200, Rodinal 1:100 semi-stand:

Treva. Rolleiflex 2.8GX, Rolleinar 1, HP5+ @400, TMax Dev, Imacon 848 scan:

Terry-Lynn. Rolleiflex 2.8GX, HP5+, TMax developer, Imacon 848 scan:

Khaled. Nikon F6, Nikkor 85mm/f1.4, XP2 @ ISO200, Rodinal stand, Imacon 848 scan:

Dan. Nikon F6, Nikkor 85mm/f1.4, XP2 @ ISO200, Rodinal stand, Imacon 848 scan:

Elaine and Chelsie. Nikon F6, Nikkor 85mm/f1.4 AFD, TMax 400 at 400ISO, TMax developer, Imacon 848 scan

Brenda. Leica M7, Summarit 75, TMax400, Rodinal stand, Imacon 848 scan.

Lockdown lunacy. I was not allowed to shave because of a bleeding tendency! Nikon F6, 50/1.4, XP2 @200, HC-110, Nikon 9000 scan:
Post-BMT and hairless! Nikon F6, XP2 Super, Diafine, Nikon 9000 scan.

Thomas. Hasselblad 503cx, Sonnar 250mm/f5.5, TMax 100, Diafine, Nikon 9000 scan:

Hasselblad selfie. Hasselblad 500c/m, Distagon 50/4, XP2 Super pushed to 3200, HC-110, Hasselblad X1 scan.

Guest post: The new Cass Review

April 18, 2024 • 9:15 am

The final version of the Cass Review (formally the “Independent Review of Gender Identity Services for Children and Young People”) was issued on April 10. Here’s a brief summary by the CBC, noting that doctors and others have griped about it:

A long-anticipated — and contentious — national review of gender-affirming care for youth in England was released last week, resulting in headlines across the U.K. saying that gender medicine is “built on shaky foundations.”

The Cass Review, chaired by pediatrician Hilary Cass, was commissioned by England’s National Health Service (NHS) in 2020.

Even before the final report was published, the review has led to significant changes for youth gender medicine in England, where the debate over transgender care has become increasingly heated, with complaints of both long waiting lists and medical treatments being too readily available to youth.

Last month, the Cass Review findings led to a ban on the prescription of puberty-suppressing hormones except for youth enrolled in clinical research.

That’s a move away from the standard of care supported by many international medical bodies, including the Canadian Pediatric Society (CPS), the American Academy of Pediatrics and World Professional Association for Transgender Health. Though several European countries including Sweden have also restricted access to puberty blockers and other medical treatments for youth.

The report cites a systematic review of evidence, commissioned as part of the Cass Review, which found “a lack of high-quality research” that puberty blockers can help young people with gender dysphoria.

While experts in the field say more studies should be done, Canadian doctors who spoke to CBC News disagree with the finding that there isn’t enough evidence puberty blockers can help.

I had no time to read the long report, and didn’t think that just regurgitating a summary for the readers was sufficient. But reader Jez told me he was going through it, and I asked him if he wouldn’t mind writing his take for this site. He kindly agreed, and so, without further ado. . . .

First, though, Jez notes

“The Cass Review’s final report (and its other publications) are available here.

 

THE CASS REVIEW: A READER’S TAKE

by Jez Grove

Since around 2014, the number of children and young people presenting at gender clinics in the Western world has surged and the patient profile has switched dramatically from predominantly pre-pubertal males to teenage females. Both changes are unexplained. The treatment offered to these patients has also significantly shifted: a psychosocial and psychotherapeutic approach has given way to many being offered medical treatment with puberty blockers (gonadotropin-releasing hormone analogues, GnRH) and cross-sex hormones.

In September 2020, Dr Hilary Cass, a retired consultant paediatrician and former President of the Royal College of Paediatrics and Child Health, was appointed to undertake a full review into how NHS England* “should most appropriately assess, diagnose and care for children and young people who present with gender incongruence and gender identity issues [and] to make recommendations on how to improve services […] and ensure that the best model/s for safe and effective services are commissioned”. [Cass Review Final Report, henceforeth “CRFR”, Appendix 1: Terms of Reference]

The Cass Review’s Interim Report (2022) highlighted that a lack of evidence on the medium- and long-term outcomes of the treatments that children and young people were receiving was limiting the advice that the Review could give. In response, it commissioned an independent research programme to provide “the best available collation of published evidence, as well as qualitative and quantitative research to fill knowledge gaps” and set up a Clinical Expert Group to help it interpret the findings. [CRFR, p. 25]

The Interim Review also warned that social transitioning (changing, name, appearance and pronouns, etc.):

. . . .“may not be thought of as an intervention or treatment, because it is not something that happens within health services. However, it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning. There are different views on the benefits versus the harms of early social transition. Whatever position one takes, it is important to acknowledge that it is not a neutral act, and better information is needed about outcomes”. [Cass Review Interim Report, henceforth”CRIR”; pp 62-63]

The findings of the Interim Report led to the closure of the Gender Identity Development Service (GIDS) last month.

Last week, the Cass Review published its Final Report. Dr Cass begins it with an apparent effort to placate her critics; her opening sentences read:

“This Review is not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves, or rolling back on people’s rights to healthcare. It is about what the healthcare approach should be, and how best to help the growing number of children and young people who are looking for support from the NHS in relation to their gender identity”. [CRFR, Foreword from the Chair, p. 12]

However, she is not blind to the problems that have developed in this area of healthcare:

“It often takes many years before strongly positive research findings are incorporated into practice. There are many reasons for this. One is that doctors can be cautious in implementing new findings, particularly when their own clinical experience is telling them the current approach they have used over many years is the right one for their patients. Quite the reverse happened in the field of gender care for children. Based on a single Dutch study, which suggested that puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence, the practice spread at pace to other countries. This was closely followed by a greater readiness to start masculinising/feminising hormones in mid-teens, and the extension of this approach to a wider group of adolescents who would not have met the inclusion criteria for the original Dutch study. Some practitioners abandoned normal clinical approaches to holistic assessment, which has meant that this group of young people have been exceptionalised compared to other young people with similarly complex presentations. They deserve very much better”. [CRFR, Foreword from the Chair, pp. 13-14]

The problems with the evidence base that sparked the Review persist, with Cass writing that the independent research programme she had commissioned

. . . .“has shown that there continues to be a lack of high-quality evidence in this area and disappointingly […], attempts to improve the evidence base have been thwarted by a lack of cooperation from the adult gender services.  The Review has therefore had to base its recommendations on the currently available evidence, supplemented by its own extensive programme of engagement”. [CRFR, p. 20]

The failure of the UK’s adult gender services to cooperate is perhaps the most shocking revelation in the report. As Cass notes,

“When clinicians talk to patients about what interventions may be best for them, they usually refer to the longer-term benefits and risks of different options, based on outcome data from other people who have been through a similar care pathway. This information is not currently available for interventions in children and young people with gender incongruence or gender dysphoria, so young people and their families have to make decisions without an adequate picture of the potential impacts and outcomes”. [CRFR, p. 33]

A quantitative data linkage study was intended to

. . . “use existing data held by the NHS, including data from GIDS, hospital wards, outpatient clinics, emergency departments and NHS adult GDCs, to track the journeys of all young people (approximately 9,000) referred to the GIDS service through the system to provide a population-level evidence base of the different pathways people take and the outcomes. This type of research is usual practice in the NHS when looking to improve health services and care received.  However, this has not been the case for gender-questioning children and young people and the hope was that this data linkage would go some way to redress this imbalance”. [Cass Review Final Report, p. 190]

Despite its “not particularly unusual” methodology, it took more than a year for the study to receive ethics approval from the Health Research Authority (HRA); Cass considers the “robust scrutiny and consideration [to be] entirely appropriate given the sensitivity of the subject matter”. [Ibid.] The independent research team “undertook stakeholder engagement and developed the patient notifications and communications resources to explain the research and provide information about how to opt-out of the study should an individual choose to do so. […] In January 2024, the Review received a letter from NHS England stating that, despite efforts to encourage the participation of the NHS gender clinics, the necessary co-operation had not been forthcoming”. [Ibid.] Appendix 4 of the Review sets out the details and history of the “thwarted” study.

The proposed linkage study had been complicated by the fact that, uniquely, GIDS patients are issued new National Health Service (NHS) numbers when registering their new gender identity. Cass notes:

“From a research perspective, the issuing of new NHS numbers makes it more difficult to identify the long-term outcomes for a patient population for whom the evidence base is weak”. [CRFR, p. 229]

The UK government had to bring forward a special legislative instrument to facilitate linking the patients’ new and old NHS records; NHS England had vowed to pursue the thwarted research before the special instrument’s powers expire in 2027.

There are other serious unintended consequences of allowing young patients to change their NHS numbers. Cass writes,

“Safeguarding professionals have described a range of situations where this has put children/young people at risk. These include young people attending hospital after self-harm not being identifiable as a child already on a child protection order; records of previous trauma and/or physical ill health being lost; people who do not have parental responsibility changing a child’s name and gender; children being re-registered as the opposite gender in infancy; children on the child protection register being untraceable after moving to a new area”. [CRFR, p. 229]

While Cass has been unable to use a stronger evidence base, she has provided a valuable service in bringing together an independent and thorough assessment of the existing research in areas related to the assessment, diagnosis, and treatment of gender-confused children and young people and suggested a way forward.

The Review gives:

  • An overview of the patient profile, including mental health and neurodiversity, adverse childhood experiences, theories about the rise in referrals and the change in case mix, and the weak evidence with regard to suicidality.
  • An important appraisal and synthesis of the available international guidelines. Cass notes,

“For many of the guidelines it was difficult to detect what evidence had been reviewed and how this informed development of the recommendations. For example, most of the guidelines described insufficient evidence about the risks and benefits of medical treatment in adolescents, particularly in relation to long-term outcomes. Despite this, many then went on to cite this same evidence to recommend medical treatments.

Alternatively, they referred to other guidelines that recommend medical treatments as their basis for making the same recommendations. Early versions of two international guidelines, the Endocrine Society 2009 and World Professional Association for Transgender Healthcare (WPATH) 7 guidelines influenced nearly all the other guidelines. These two guidelines are also closely interlinked, with WPATH adopting Endocrine Society recommendations, and acting as a co-sponsor and providing input to drafts of the Endocrine Society guideline. WPATH 8 cited many of the other national and regional guidelines to support some of its recommendations, despite these guidelines having been considerably influenced by WPATH 7. The links between the various guidelines are demonstrated in the graphics in the guideline appraisal paper (Hewitt et al., Guidelines 1: Appraisal).

The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.” [Cass Review Final Report, p. 130]

  • An overview of the existing clinical approach and clinical management and recommendations to improve them.
  • Recommendations for a new service model for NHS England, including follow-through services for 17-25 years-olds to ensure continuity at “a potentially vulnerable stage in their journey” and “allow clinical and research follow-up data to be collected”. [CRFR, p. 225] She also stresses the needs for detransitioners to be supported and warns of the dangers of private healthcare providers outside the NHS not following its policies.
  • Finally, she cautions that, while innovation in healthcare is important, there must be a “proportionate level of monitoring, oversight, and regulation that does not stifle progress, but prevents creep of unproven approaches into clinical practice. Innovation must draw from and contribute to the evidence base”. [Cass Review Final Report, p. 231]

To critics who say the Cass Review tells us nothing new, surely the onus is on them to justify continuing to provide children and young people with “gender-affirming care”, care for which we already knew there is no reliable evidence on the medium-and long-term outcomes.

______________________

* Health is devolved in the UK; Scotland, Wales, and Northern Ireland (and indeed all other  healthcare services) are free to ignore the Cass Review’s findings, but may be unwise to do so.

Dawkins and Sokal on the dumb ideological ploy maintaining that human sex is “assigned at birth”

April 9, 2024 • 12:30 pm

What a pair! The renowned biologist and the hoax-exposer/mathematician, teamed up to attack the medical profession’s new and woke tendency to deny the existence of biological sex as a reality. (Yes, all animals have exactly two sexes, which are not made up by society.) This eloquent op-ed is in the Boston Globe, and you can click below to read it for free, or find it archived here (h/t Mark, Barry).

It’s the “sex assigned at birth” meme, which any fool knows was made up to pretend that biological sex doesn’t really exist in nature, but is merely a “social construct”. This is the same risible meme taken apart by Alex Byrne and Carole Hooven in a recent NYT op-ed. As Alan and Richard note below, the distortion of reality was made for ideological reasons—by gender activists who want to see biological sex as a spectrum, and that is based on the the insupportable view that if you distort biology, transgender or transsexual people will not be “erased”. But, as I’ve said ad infinitum, you don’t need to distort biology to justify treating such people with civility and respect, and to confer on them the same moral value as everyone else has.

The excerpt from the above speaks for itself, but has a lot of useful links to show how well the termites have dined.

The American Medical Association says that the word “sex” — as in male or female — is problematic and outdated; we should all now use the “more precise” phrase “sex assigned at birth.” The American Psychological Association concurs: Terms like “birth sex” and “natal sex” are “disparaging” and misleadingly “imply that sex is an immutable characteristic.” The American Academy of Pediatrics is on board too: “sex,” it declares, is “an assignment that is made at birth.” And now the Centers for Disease Control and Prevention urge us to say “assigned male/female at birth” or “designated male/female at birth” instead of “biologically male/female” or “genetically male/female.”

After discussing the biological definition of sex, which, as you know well by now involves differences in developmental systems that produce gametes of different size and mobility, Sokal and Dawkins give a sharp rap on the knuckles of the medical establishment. I’ve put the last two paragraphs in bold; the penultimate one shows the trend and motivation, while the last one shows the damage.

Much is speciously made of the fact that a very few humans are born with chromosomal patterns other than XX and XY. The most common, Klinefelter syndrome with XXY chromosomes, occurs in about 0.1 percent of live births; these individuals are anatomically male, though often infertile. Some extremely rare conditions, such as de la Chapelle syndrome (0.003 percent) and Swyer syndrome (0.0005 percent), arguably fall outside the standard male/female classification. Even so, the sexual divide is an exceedingly clear binary, as binary as any distinction you can find in biology.

So where does this leave the medical associations’ claims about “sex assigned at birth”?

A baby’s name is assigned at birth; no one doubts that. But a baby’s sex is not “assigned”; it is determined at conception and is then observed at birth, first by examination of the external genital organs and then, in cases of doubt, by chromosomal analysis. Of course, any observation can be erroneous, and in rare cases the sex reported on the birth certificate is inaccurate and needs to be subsequently corrected. But the fallibility of observation does not change the fact that what is being observed — a person’s sex — is an objective biological reality, just like their blood group or fingerprint pattern, not something that is “assigned.” The medical associations’ pronouncements are social constructionism gone amok.

. . .For decades, feminists have protested against the neglect of sex as a variable in medical diagnosis and treatment, and the tacit assumption that women’s bodies react similarly to men’s bodies. Two years ago, the prestigious medical journal The Lancet finally acknowledged this criticism, but the editors apparently could not bring themselves to use the word “women.” Instead the journal’s cover proclaimed: “Historically, the anatomy and physiology of bodies with vaginas have been neglected.” But now even this double-edged concession may be lost, as the denial of biological sex threatens to undermine the training of future doctors.

The medical establishment’s newfound reluctance to speak honestly about biological reality most likely stems from a laudable desire to defend the human rights of transgender people. But while the goal is praiseworthy, the chosen method is misguided. Protecting transgender people from discrimination and harassment does not require pretending that sex is merely “assigned.”

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It is never justified to distort the facts in the service of a social or political cause, no matter how just. If the cause is truly just, then it can be defended in full acceptance of the facts about the real world.

And when an organization that proclaims itself scientific distorts the scientific facts in the service of a social cause, it undermines not only its own credibility but that of science generally. How can the public be expected to trust the medical establishment’s declarations on other controversial issues, such as vaccines — issues on which the medical consensus is indeed correct — when it has so visibly and blatantly misstated the facts about something so simple as sex?

 

Read also Byrne and Hooven; click below (or read it archived here):

Finally, the infamous Lancet cover:

Bret Weinstein denies that AIDS is caused by HIV

March 11, 2024 • 9:30 am

A high-up worker in the pharma industry sent me a video from last month  showing biologist Bret Weinstein apparently denying to Joe Rogan that AIDS is cause by infection with the human immunodeficiency virus (HIV). (That claim starts about three minutes in, but watch the whole video below.)

Apparently Weinstein subscribes to Rogan’s “competing hypothesis” that AIDS is simply group of symptoms caused not by a virus, but by taking “party drugs” (3:53). Weinstein finds that explanation “surprisingly compelling.”  He also suggests darkly that Nobel laureate Kary Mullis—also an HIV denialist—died “strangely” (there were conspiracy theories about Mullis’s death).  Then the video stops, but you can hear the whole 3½-hour episode here.

The first several minutes of the video below, which you’ll have to scroll back to see, show Weinstein expressing doubt that a virus also causes Covid-19.

You may remember that Weinstein and his partner, biologist Heather Heying, touted the antiparasitic drug ivermectin as a treatment and preventive for the “syndrome” known as Covid-19, even though there was no evidence that the drug was effective (see also here).  In other words, Weinstein seems fond of heterodox and discredited causes of and treatments for diseases: he’s a medical conspiracy theorist.

The pharma guy who wrote me said this:

I don’t mean to obsess about BW, but after the Evergreen debacle and getting a modicum of credibility, he went crazy about COVID and the efficacy of ivermectin so much so that Sam Harris ripped him for conspiratorial thinking and now they’re enemies.  I was livid because people like him were giving horrible medical advice to the public as a biologist-who-claims-to-be-an-authority and may have really harmed people who were listening to his claptrap.  3 weeks ago, he was on Joe Rogan’s show (which I don’t watch but saw a link) wherein he’s now giving airtime to the ‘AIDS is not caused by HIV’ conspiracy theory.

As a member of Pharma industry who watched colleagues like myself craft thousands of molecules to become specific drugs tailored to fit and inhibit the active sites of HIV protease, reverse transcriptase, integrase, and to antagonize HIV binding to the chemokine receptor CCR5 that the virus uses to enter T-cells, I know for a fact that these drugs prevent AIDS by stopping HIV viral replication and entry.  All were approved in Phase 3 with data and are used in various combinations to make drugs like the Quad pill that have suppressed HIV to undetectable levels, allowing HIV-infected individuals to lead pretty normal lives.  Ergo, AIDS IS caused by HIV!  QED.

There were then some words not suitable for a family-friendly site, but among them were the claims that Weinstein is “a conspicuous troll who is hurting people.”

VICE News has a summary of Weinstein’s appearance on Rogan and on their shared and bogus theory of AIDS. An excerpt:

Weinstein’s “evidence,” he made clear, is partially drawn from reading about this theory as outlined by Robert F. Kennedy in his book The Real Anthony Fauci, published in 2021. (One review of the book noted that Kennedy managed to misrepresent numerous scientific studies he cites, which does not make a strong case for its scientific rigor; nor does the fact that it was written by Robert F. Kennedy.)

“I came to understand later, after I looked at what Luke Montagnier had said and I read Bobby Kennedy’s book on Fauci, was that actually the argument against HIV being causal was a lot higher quality than I had understood, right?” Weinstein told Rogan. “That it being a real virus, a fellow traveler of a disease that was chemically triggered, that is at least a highly plausible hypothesis. And with Anthony Fauci playing his role, that was inconvenient for what he was trying to accomplish.”

. . .The conversation generated substantial outcry from scientists and public health researchers on Twitter; David Gorski, an oncologist who frequently writes about the anti-vaccine world and pseudoscience, identified the conversation as an example of “crank magnetism,” writing, “Once you go down the rabbit hole of pseudoscience, quackery, and conspiracy theories in one area (e.g., #COVID19), it is nearly inevitable that you will embrace fractal wrongness in the form of multiple kinds of pseudoscience (e.g., antivax, AIDS denial, etc.).”

And this is, of course, indisputably part of a larger pattern. Rogan and Weinstein regularly repeat discredited scientific ideas, mainly around their promotion of ivermectin as a treatment for COVID and Rogan’s constant promotion of anti-vaccine ideas. The AIDS conversation makes clear that COVID denialists are branching out, using their forms of pseudo-inquiry to draw other bad ideas back into the public discussion.

And from Wikipedia:

Appearing on a Joe Rogan podcast in February 2024, Weinstein erroneously stated that some people with AIDS were not infected with HIV and that he found the idea that AIDS was caused by a gay lifestyle, rather than the HIV virus, “surprisingly compelling”. The American Foundation for AIDS Research reacted to the podcast, saying “It is disappointing to see platforms being used to spout old, baseless theories about HIV. … The fact is that the human immunodeficiency virus (HIV), untreated, causes AIDS. … Mr. Rogan and Mr. Weinstein do their listeners a disservice in disseminating false information …”.

As for Weinstein’s implication that Karry Mullis’s death may have involved his “maverick” view that HIV didn’t cause AIDs (shades of Karen Silkwood!), Michael Shermer responded on February 16 with a tweet:

I’m especially distressed by this kind of quackery, which in the end can cost lives, by a man who started out in my own field, evolutionary biology.  Now, having left Evergreen State far behind him, Weinstein appears to be trying to make a name for himself by being medically heterodox. It’s fine to question untested theories, but the evidence is now very, very strong that HIV causes AIDs and that Covid-19 is caused by a coronavirus.

People often say that “pseudoscience” isn’t that harmful. After all, what’s the danger in reading the astrology column or tarot cards? But that’s just the thin edge of the wedge that opens up medical pseudoscience like that given above. And that can kill people.

Pro-Palestinian protesters heckle president of the AMA speaking at our medical school

March 3, 2024 • 9:30 am

The University of Chicago doesn’t like to publicize protests about the Middle East war, as they make the school look bad. And the University is even more secretive about punishing protestors—like these—who violate the University “Protest and Demonstration Policy” by shouting down speakers (also see the President’s statement here). I have been unable to find out, in several cases, whether local punishments have been applied to disruptive students.  This is kept a secret for reasons best known to the University.

These violations of University policy, involving disruptions of other people’s speech, are not protected by the University’s free expression policy, which hews very close to the First Amendment of the Constitution. But despite their illegality, they continue. And they invariably involve pro-Palestinian demonstrators, some of whom have vowed not to respect the protest and demonstration policy.

So far the University has either failed to punish violators, or has given them only a slap on the wrist, like writing an essay on “my demonstration experience.” It’s not rocket science to figure out that if demonstrators violate University regulations but aren’t punished seriously, and there’s no record of a violation on their transcript, then the illegal protests will continue.  A regulation that’s not enforced is a regulation without teeth.

Below is are two short videos from Instagram showing a protest at the Medical School that occurred last month.  The speaker (or “attempted speaker”) is Jesse Menachem Ehrenfeld, the new President of the prestigious American Medical Association (AMA).  He is accomplished, Jewish, and gay.

The last two traits caused the protest that occurred when he was invited to speak to his alma mater, for he got his MD here. Despite his being a liberal and an honored physician, and despite his attempt to present a “Grand Rounds” talk on LGBTQ+ equity in medicine to the the Alpha Omega Alpha medical honor society, the students still harassed him.

You can see the “issues” by listening to the angry and loud protests below (note that the cowardly speakers donned masks to hide their identities).  Ehrenfeld is accused of Israeli “pinkwashing” (the crazy claim that Israel only pretends to support LGBTQ+ rights to distract people from the country’s supposed crimes); accused of the AMA not having formally called for a ceasefire in Israel; and accused of being complicit in the deaths of Palestinian civilians because of Israel’s supposed war crimes.

As the Instagram post says below, “Security escorted protestors out of the lecture hall.” That’s a step in the right direction, since the University has failed to do even that during other protests.  But are these protestors medical or other students at the University? If so, then they must be punished. If they’re not from the University community, then they’re likely guilty of trespassing and can be banned from campus. Whatever the University does about this, it must involve more than simply removing disruptive protestors from the venue, as that’s not really a deterrent, much less a punishment.

These protests invariably involve only pro-Palestinian students, simply because the pro-Israeli ones aren’t into this kind of disruption. And this has led pro-Palestinian demonstrators to ask why  they’re being singled out by the University.  But that’s a dumb question with an easy answer: “Because they’re the only group that holds these types of angry and disruptive protests with respect to the war.”

I wonder whether after Israel is victorious, as I think it will be, these protests will continue.  I think they will, because the anger will only be intensified.

Here’s another post sponsored by the Students for Justice in Palestine, a registered student organization. Some of the video overlaps with that above, but they also have the temerity to tell Ehrenfeld what his ethical responsibility is:

On 2/20, Healthcare workers and medical students led disruptions and a banner drop during American Medical Association President Jesse Ehrenfeld’s talk at UChicago Medicine. AMA stop the hypocrisy, you have an ethical obligation to stand against genocide. You have an ethical obligation to stand with life, in solidarity with Palestine. Ehrenfeld, history is watching! Med Students say: Ceasefire Now!
Repost from @hcw4palichi

The students apparently disagree with the restriction that there is a time and place for free expression—times and places where it doesn’t disrupt University activity.  This video also shows security asking students to leave, but they persist in a “silent protest,” holding up a banner in the classroom. I am not sure if that’s a violation of University regulations, but it should be, because it is disruptive, particularly when there are many signs held by many students. I would say, “no signs in the lecture hall.”