Brexit and the waning days of the United Kingdom

[Gups]

Was Josq speaking of "gender care" as a general concept when he said it's crap, or about gender care as currently implemented in the UK? Or are those two things basically the same and there's no such thing as "decent gender care" vs "crap gender care"?

Note: I don't even know what is encompassed in the term "gender care", so if either of you would care to expand on the term I'd appreciate it

So there's maybe three sides to this debate.

First of all of course there is the "trans doesn't exist - biology determines everything" side, which views gender care in itself as an abomination.  I'm sure you understand this side, so no need to discuss.

Beyond that though (and remember this is all talking about kids) there's the "watchful waiting" side of gender care - the idea that if a kid expresses gender dysphoria you should explore if there are other diagnosis going on, and above all just wait to see if the dysphoria subsides before starting on irrevocable treatments.

The third side is the "if a kid says they're trans, believe them" side.  Which trying to be as fair as possible, puts a lot of emphasis on the personal autonomy of kids, with a side of if a kid goes through the "wrong puberty" that can be incredibly distressing for someone with gender dysphoria and might cause suicide.

So anyways - a lot of the debate about "gender care" is whether you should follow the second or the third approach.

The conclusion of the Cass Report was basically to say that we have very little good evidence of which approach leads to the better outcomes in terms of mental health and happiness - that very little follow up has been done on kids who receive "gender care" no matter how defined.

I think that's a reasonable summary except that Cass very much comes down in favour of the second approach and as a result is being smeared by people like Owen Jones and Billy Bragg who are in favour of the third - on the basis that she ignored certain studies which favoured their view. This criticism was based on a screenshot by a trans activist of what they said was a literature review undertaken by the Cass team, but actually related to an entirely different study. In other words, deliberate misinformation but nevertheless relied on. 

As to follow up on kids who receive gender affirming "care", it's not so much that there was little follow up, it's that we don't know whether there was or not because the Tavistock and other clinics (with one exception) who prescribed puberty blockers refused to provide any information or data.

[Gups]

Some more detail here

https://www.realityslaststand.com/p/fact-checking-critics-of-the-cass

[Sheilbh]

As background, I thought the Guardian explainer on the Cass Review was good:

What are the key findings of the NHS gender identity review?
Report by Dr Hilary Cass finds young people being let down by lack of research and evidence on medical interventions
Denis Campbell and Sally Weale
Wed 10 Apr 2024 00.01 BST
Last modified on Wed 10 Apr 2024 09.37 BST

A review into the NHS's gender identity services has found that children and young people have been let down by a lack of research and evidence on medical interventions in a debate that has become exceptionally toxic.

Dr Hilary Cass said her report was not about defining "what it means to be trans" or "undermining the validity of trans identities", but about "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". Here are the review's key findings.

The evidence

"This is an area of remarkably weak evidence," Cass writes in the foreword to her 398-page report.

Despite that, she adds: "Results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint. The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress."

When Cass began her inquiry in 2020, the evidence base, especially about puberty blockers and masculinising and feminising cross-sex hormones was "weak". That was exacerbated by the existence of "a lot of misinformation, easily accessible online, with opposing sides of the debate pointing to research to justify a position, regardless of the quality of the studies."

Cass commissioned the University of York to undertake systematic reviews of the evidence on key issues, such as puberty blockers. It found that "there continues to be a lack of high-quality evidence in this area". York academics, as part of their research, tried to document the outcomes seen among the 9,000 young people who the Tavistock and Portman NHS trust's gender identity development service (Gids) treated between 2009-2020. However, it was "thwarted by a lack of cooperation from [six of England's seven NHS] adult gender services".

The new NHS services for these young people must routinely collect evidence of what treatments work, and learn from them to improve clinical practice, the report states.

The debate

Cass acknowledges that the discussion around how to care for such young people is polarised, both among health professionals and in wider society. For example, some clinicians believe that most people who present to gender services "will go on to have a long-term trans identity and should be supported to access a medical pathway at an early stage".

"Others feel that we are medicalising children and young people whose multiple other difficulties are manifesting through gender confusion and gender-related distress. The toxicity of the debate is exceptional," the report says.

Cass has been criticised for talking both to groups who support gender affirmation – the medical approach – and also those who believe greater caution is needed. Some experienced doctors who have offered different viewpoints have been "dismissed and invalidated", she says.

"There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media and where name-calling echoes the worst bullying behaviour. This must stop."

The toxicity of debate has made some clinicians fearful of working with these young people.

The Tavistock and Portman NHS Trust

When its Gids service was set up in 1989, it saw fewer than 10 children a year, mainly birth-registered males who had not reached puberty. Most received therapy and only a few hormones from the age of 16.

But in 2011 the UK began trialling the use of puberty blockers, as a result of the emergence of "the Dutch protocol", which involved using them from early puberty. However, a study undertaken in 2015-16, although not published until 2020, shows "a lack of any positive measurable outcomes".

"Despite this, from 2014 puberty blockers moved from a research-only protocol to being available in routine clinical practice." This "adoption of a treatment with uncertain benefits without further scrutiny" helped increase the demand among patients for them, the report finds.

An NHS England review in 2019, which examined the evidence on medical intervention and found evidence of its effectiveness to be "weak", led to Cass being asked to undertake her review.

Changing patient profile

Referral rates to Gids have rocketed since 2014, but there has also been a shift in the profile of those using services. For centuries transgender people have been predominantly trans females who present in adulthood. Now the vast majority are teenagers who were registered as female at birth.

An audit of discharge notes of Gids patients between 1 April 2018 and 31 December 2022 showed the youngest patient was three, the oldest 18, and 73% were birth-registered females, according to the review, which tries to discover why things have changed so dramatically.

One area it explores is the deterioration in mental health among young people, and the links with social media, which have brought pressures to bear on them that no previous generation has experienced.

"The increase in presentations to gender clinics has to some degree paralleled this deterioration in child and adolescent mental health," the review says. "Mental health problems have risen in both boys and girls, but have been most striking in girls and young women."

Youngsters who present with gender identity issues to services may also have depression, anxiety, body dysmorphia, tics and eating disorders, as well as autism spectrum disorder (ASD) and/or attention deficit hyperactivity disorder (ADHD). Referrals to Gids are also associated with higher than average rates of adverse childhood experiences, the review says.

"There is no single explanation for the increase in prevalence of gender incongruence or the change in case-mix of those being referred to gender services," the review says, concluding instead that gender incongruence is a result of "a complex interplay between biological, psychological and social factors".

Transitioning

Young people's sense of their identity is not always fixed and can evolve over time, Cass says.

"Whilst some young people may feel an urgency to transition, young adults looking back at their younger selves would often advise slowing down," the report says.

"For some, the best outcome will be transition, whereas others may resolve their distress in other ways. Some may transition and then de/retransition and/or experience regret. The NHS needs to care for all those seeking support."

Social transitioning

Social transitioning is the process by which individuals make social changes in order to live as a different gender, such as changing name, pronouns, hair or clothing, and it is something that schools in England have been grappling with in recent years.

According to the Cass review, many children and young people attending Gids have already changed their names by deed-poll and attend school in their chosen gender by the time they are seen.

The review says research on the impact of social transition is generally of a poor quality and the findings are contradictory. Some studies suggest that allowing a child to socially transition may improve mental health and social and educational participation.

Others say a child who is allowed to socially transition is more likely to have an altered trajectory, leading to medical intervention, which will have life-long implications, when they might otherwise have desisted.

"Given the weakness of the research in this area there remain many unknowns about the impact of social transition," the review concludes. "In particular, it is unclear whether it alters the trajectory of gender development, and what short- and longer-term impact this may have on mental health."

The review recommends that parents should be involved in decision making, unless there are strong grounds to believe this may put a child at risk, and where children are pre-puberty, families should be seen as early as possible by a clinician with relevant experience. It also suggests avoiding premature decisions and considering partial rather than full transitioning as a way of keeping options open.

Future care

The report says that in the future any young person seeking NHS help with gender-related distress should be screened to see if they have any neurodevelopmental conditions, such as autism spectrum disorder, and also given a mental health assessment.

NHS England has already in effect banned the use of puberty blockers because of limited evidence that they work. Cass found that there is "no evidence that puberty blockers buy time to think", which their advocates have claimed. There is also "concern that they may change the trajectory of psychosexual and gender identity development" as well as pose long-term risks to users' bone health, the review says.

There is also a lack of evidence to prove that masculinising and feminising hormones improve a young person's body satisfaction and psychosocial health, and there is concern over the impact on fertility, growth and bone health. There is also no evidence they reduce the risk of suicide in children, as their proponents have claimed.

Lastly, the evidence base showing whether psychosocial interventions – therapy – work for those who do not undergo hormone treatment is "as weak" as for puberty blockers and cross-sex hormones.

All this means that there is "a major gap in our knowledge about how best to support and help the growing population of young people with gender-related distress in the context of complex presentations".

Although worth noting that this is taking place in the context of a very stretched NHS. Last I read there's something like 7.5 million treatments on waiting lists in the NHS right now, that's particularly acute for mental health services. I think the ideas set out here are good - but there's lots of very good ideas and demands on NHS resources, which are limited:

Review of gender services has major implications for mental health services
Tobi Thomas Health and inequalities correspondent
Cass report calls for move away from mainly medical treatment as part of dramatic shift in approach to gender dysphoria
Wed 10 Apr 2024 00.01 BST
Last modified on Wed 10 Apr 2024 06.00 BST

A long-awaited review by consultant paediatrician Hilary Cass into the NHS's gender services for children calls for a dramatic shift in the type of treatment offered to children and young people with gender dysphoria.

The report proposes that instead of being offered mainly medical treatment, young people referred to NHS gender services should "receive a holistic assessment of their needs to inform an individualised care plan", meaning that questions of gender identity should be treated alongside other possible mental health concerns.

It found that a medical pathway, such as puberty blockers, would not necessarily be the best option for children with gender dysphoria, and should not be provided "without also addressing wider mental health and/or psychosocially challenging problems". The review suggests this "should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment".

The idea of a holistic assessment has so far been welcomed by medical experts, such as Dr Lade Smith, the president of the Royal College of Psychiatrists, who said: "Children who are gender questioning also commonly experience mental illness. It is extremely important that every child who is gender questioning has timely access to services that are holistic and respond to their individual needs."

But the proposals will have major implications for wider children's mental health services, which are already overstretched.

The waiting lists for gender-affirming care on the NHS are incredibly long. As of August 2022, there were 26,234 adults waiting for a first appointment with an adult gender dysphoria clinic, of whom 23,561 had been waiting more than 18 weeks. The number of children on the waiting list was approximately 7,600, of whom about 6,100 had been waiting more than 18 weeks.

In October, a coroner concluded that long waiting lists and barriers that prevent transgender people accessing gender-affirming care in the UK contributed to a decline in the mental health of Alice Litman, a young trans woman who killed herself in 2022.

The Cass report acknowledges that long waiting lists are a barrier to the NHS's ability to provide effective gender-affirming care. It states: "It is only when they have been on very long waiting lists, and sidelined from usual care in local services, that they are forced to do their own research and may come to a single medical answer to their problems."

However, general mental health services for young people are no better.

More than a quarter of a million (270,300) children and young people in England are still waiting for mental health support after being referred to children and young people's mental health services in 2022-23, according to the children's commissioner.

Between July and September of last year, children and young people who had an appointment for suspected autism had waited on average nine months (295 days) after their initial referral. This is despite the National Institute for Health and Care Excellence recommending that people with suspected autism should be diagnosed within three months of a referral.

Cass's report said long waiting lists for gender services were in part due to an "unprecedented" increase in demand in recent years, which created "an unsustainable service model". "Prior to 2009, Gids (the gender identity development service) did not attract significant attention. At that time, the service saw fewer than 50 children a year, with even fewer receiving medical treatment," the report states.

Since the closure of the Gids clinic at the Tavistock and Portman NHS foundation trust in London in 2023, NHS England pledged to open eight regional clinics delivering a "different model of care". The report has welcomed this, saying the regional centres "should allow care and risk to be actively managed ... reducing waiting times for specialist care". But since only one of these regional centres has opened, waiting lists will remain high for the foreseeable future.

More on the specific care recommendations:
https://www.theguardian.com/society/2024/apr/10/gender-medicine-built-on-shaky-foundations-cass-review-finds

But online I think this has all been positioned as basically the same as American states literally criminalising trans healthcare, which I think is wrong.

[Gups]

It's not a question of opinion, it just is wrong and anyone saying otherwise is either lying or has believed lies without bothering to go anywhere near the report.

[Josquius]

I'm not getting the Cass Report.
Gender care, especially for kids, is crap.
This was well known before, though the proof for it is useful.
But the transphobic culture war zealots are celebrating as if it proves everything they say right?- care being shit doesn't mean improve care it means...don't have care?

Umm, no.

Gender care for kids is not 'well known to be crap'.  Lots of the activist types keep trying to argue that it is "settled science", when in fact the science is anything but.

Yes, culture warriors on both sides are trying to argue the Cass Report - the "left" arguing that the Cass report unjustly invalidated a bunch of studies that would've proved their point (the Report says they were of low value), while the "right" tries to argue that it should equal a ban on youth gender care (the Report just says we need more and better data).

Not my experience of trans rights activist types at all.
They're endlessly going on about how rubbish the current situation is.
The huge waiting lists at every turn, having to open up about really personal stuff and validate their existence to people to get anywhere, having to outright lie about being stereotypically of their target gender as any hint of behaviour more stereotypical of the birth gender will get them booted...

Not to say their criticisms are all well founded and valid. There's good reason why sex change operations aren't just handed out on demand. Just listing the sorts of things they say here as to say they think the current system is good is just untrue.

[Sheilbh]

Scottish Greens have also said they'll support the no confidence motion in Yousaf's government. So unless he can find some extra MSPs to back him, that'll be it given that he's only got a minority.

It's not happened before, but the process (in the Scotland Act) is that if the government loses a vote of confidence the First Minister has to offer his resignation. There's then 28 days in which to fill the role of First Minister (i.e. for a majority to be formed). If they can't fill the role then there's an extaordinary general election.

[Gups]

Wonder if the SNP might split

[Sheilbh]

Wonder if the SNP might split

Yeah I was thinking that - Harvie's making an explicit pitch that it's time for SNP members and MSPs to consider whether they're in the party that can deliver "progressive" independence or if their values should take them elsewhere. Especially as they're saying the SNP are now appeasing "the most reactionary forces in the country". But also I've been really struck at just how personal and strong the Greens' attacks on the SNP have been today - I think they maybe have an opportunity to become the "left" independence party.

At the same time you've got Salmond's Alba lurking (I still think Salmond is too toxic but maybe not).

Also very funny how angry the Greens are that Yousaf announced this before the Greens' emergency conference to vote on whether to end the coalition - which seems a bit daft but...

[Tamas]

Situation is so desperate developers are willing to build flats above and around listed ruins but that idea is of course also rejectex: https://www.theguardian.com/uk-news/2024/apr/25/ludicrous-plan-to-build-skyscraper-over-georgian-building-in-birmingham-rejected

[Sheilbh]

Incidentally someone else did the maths. The SNP have 63 MSPs, the opposition who are voting no confidence (Greens, Lib Dems, Tories and Labour) have 64.

To get to 64, Yousaf needs the vote of Ash Regan who he beat in the leadership (she largely ran on a gender critical and more aggressively pro-independence platform). Shortly after the leadership election she left the SNP and joined Alex Salmond's Alba party (and is their only MSP) - Yousaf remarked that it was "no great loss".

She has apparently sent him a detailed letter of her conditions for support. Alex Salmond was on the radio earlier saying he'd recommend Yousaf accepts those terms or "he'll be known as 'Humza the Brief'." So Yousaf may end up voluntarily stepping down (which wouldn't prompt an election still the same 28 days to find a majority).

Although I'm not clear what happens in the Scottish Parliament for a tied vote. I don't know how the Presiding Officer is required to vote I think in the Commons the Speaker will vote to defeat a no confidence motion (I think the Speaker will always vote for more debate, more time and for the status quo - as it is not their role to create a majority where one does not exist).