The Courage to Follow the Evidence on Transgender Care

[maestrob]

April 18, 2024

By David Brooks

Opinion Columnist

Hilary Cass is the kind of hero the world needs today. She has entered one of the most toxic debates in our culture: how the medical community should respond to the growing numbers of young people who seek gender transition through medical treatments, including puberty blockers and hormone therapies. This month, after more than three years of research, Cass, a pediatrician, produced a report, commissioned by the National Health Service in England, that is remarkable for its empathy for people on all sides of this issue, for its humility in the face of complex social trends we don’t understand and for its intellectual integrity as we try to figure out which treatments actually work to serve those patients who are in distress. With incredible courage, she shows that careful scholarship can cut through debates that have been marked by vituperation and intimidation and possibly reset them on more rational grounds.

Cass, a past president of Britain’s Royal College of Pediatrics and Child Health, is clear about the mission of her report: “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 health care. It is about what the health care approach should be, and how best to help the growing number of children and young people who are looking for support from the N.H.S. in relation to their gender identity.”

This issue begins with a mystery. For reasons that are not clear, the number of adolescents who have sought to medically change their sex has been skyrocketing in recent years, though the overall number remains very small. For reasons that are also not clear, adolescents who were assigned female at birth are driving this trend, whereas before the late 2000s, it was mostly adolescents who were assigned male at birth who sought these treatments.

Doctors and researchers have proposed various theories to try to explain these trends. One is that greater social acceptance of trans people has enabled people to seek these therapies. Another is that teenagers are being influenced by the popularity of searching and experimenting around identity. A third is that the rise of teen mental health issues may be contributing to gender dysphoria. In her report, Cass is skeptical of broad generalizations in the absence of clear evidence; these are individual children and adolescents who take their own routes to who they are.

Some activists and medical practitioners on the left have come to see the surge in requests for medical transitioning as a piece of the new civil rights issue of our time — offering recognition to people of all gender identities. Transition through medical interventions was embraced by providers in the United States and Europe after a pair of small Dutch studies showed that such treatment improved patients’ well-being. But a 2022 Reuters investigation found that some American clinics were quite aggressive with treatment: None of the 18 U.S. clinics that Reuters looked at performed long assessments on their patients, and some prescribed puberty blockers on the first visit.


Unfortunately, some researchers who questioned the Dutch approach were viciously attacked. This year, Sallie Baxendale, a professor of clinical neuropsychology at the University College London, published a review of studies looking at the impact of puberty blockers on brain development and concluded that “critical questions” about the therapy remain unanswered. She was immediately attacked. She recently told The Guardian, “I’ve been accused of being an anti-trans activist, and that now comes up on Google and is never going to go away.”
As Cass writes in her report, “The toxicity of the debate is exceptional.” She continues, “There are few other areas of health care 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 behavior.”

Cass focused on Britain, but her description of the intellectual and political climate is just as applicable to the U.S., where brutality on the left has been matched by brutality on the right, with crude legislation that doesn’t acknowledge the well-being of the young people in question. In 24 states Republicans have passed laws banning these therapies, sometimes threatening doctors with prison time if they prescribe the treatment they think is best for their patients.

The battle lines on this issue are an extreme case, but they are not unfamiliar. On issue after issue, zealous minorities bully and intimidate the reasonable majority. Often, those who see nuance decide it’s best to just keep their heads down. The rage-filled minority rules.

Cass showed enormous courage in walking into this maelstrom. She did it in the face of practitioners who refused to cooperate and thus denied her information that could have helped inform her report. As an editorial in The BMJ puts it, “Despite encouragement from N.H.S. England,” the “necessary cooperation” was not forthcoming. “Professionals withholding data from a national inquiry seems hard to imagine, but it is what happened.”

Cass’s report does not contain even a hint of rancor, just a generous open-mindedness and empathy for all involved. Time and again in her report, she returns to the young people and the parents directly involved, on all sides of the issue. She clearly spent a lot of time meeting with them. She writes, “One of the great pleasures of the review has been getting to meet and talk to so many interesting people.”

The report’s greatest strength is its epistemic humility. Cass is continually asking, “What do we really know?” She is carefully examining the various studies — which are high quality, which are not. She is down in the academic weeds.

She notes that the quality of the research in this field is poor. The current treatments are “built on shaky foundations,” she writes in The BMJ. Practitioners have raced ahead with therapies when we don’t know what the effects will be. As Cass tells The BMJ, “I can’t think of another area of pediatric care where we give young people a potentially irreversible treatment and have no idea what happens to them in adulthood.”

She writes in her report, “The option to provide masculinizing/feminizing hormones from age 16 is available, but the review would recommend extreme caution.” She does not issue a blanket, one-size-fits-all recommendation, but her core conclusion is this: “For most young people, a medical pathway will not be the best way to manage their gender-related distress.” She realizes that this conclusion will not please many of the young people she has come to know, but this is where the evidence has taken her.

You can agree or disagree with this or that part of the report, and maybe the evidence will look different in 10 years, but I ask you to examine the integrity with which Cass did her work in such a treacherous environment.

In 1877 a British philosopher and mathematician named William Kingdon Clifford published an essay called “The Ethics of Belief.” In it he argued that if a shipowner ignored evidence that his craft had problems and sent the ship to sea having convinced himself it was safe, then of course we would blame him if the ship went down and all aboard were lost. To have a belief is to bear responsibility, and one thus has a moral responsibility to dig arduously into the evidence, avoid ideological thinking and take into account self-serving biases. “It is wrong always, everywhere, and for anyone, to believe anything upon insufficient evidence,” Clifford wrote. A belief, he continued, is a public possession. If too many people believe things without evidence, “the danger to society is not merely that it should believe wrong things, though that is great enough; but that it should become credulous, and lose the habit of testing things and inquiring into them; for then it must sink back into savagery.”

Since the Trump years, this habit of not consulting the evidence has become the underlying crisis in so many realms. People segregate into intellectually cohesive teams, which are always dumber than intellectually diverse teams. Issues are settled by intimidation, not evidence. Our natural human tendency is to be too confident in our knowledge, too quick to ignore contrary evidence. But these days it has become acceptable to luxuriate in those epistemic shortcomings, not to struggle against them. See, for example, the modern Republican Party.

Recently it’s been encouraging to see cases in which the evidence has won out. Many universities have acknowledged that the SAT is a better predictor of college success than high school grades and have reinstated it. Some corporations have come to understand that while diversity, equity and inclusion are essential goals, the current programs often empirically fail to serve those goals and need to be reformed. I’m hoping that Hilary Cass is modeling a kind of behavior that will be replicated across academia, in the other professions and across the body politic more generally and thus save us from spiraling into an epistemological doom loop.

https://www.nytimes.com/2024/04/18/opin ... eport.html

[Belle]

I prefer the messaging of Dr. James Lindsay who speaks about the growing rate of cults in the USA and around the world. Trans is yet another of these cults and people join/support/sympathize with them because they 'want to be nice'. Dr. Lindsay says if you've bought into the trans issues and supported or had your child surgically mutilated you're flying the flag of that cult on your front veranda!! I know these cultists; some of them are in our wider family. They're into the cults of climate, gender, identity, trans, BLM and any number of damaging and divisive groups - all of which are forged on the victim/oppressor anvil - and which are rushing the western world into the showers.

In Australia recently, with the Higgins/Lehrmann fiasco, we've seen cult members of #metoo rushed into those showers and many careers have been ruined. Of course, they've damaged others outside the cult too - but people are seeing it all for what it was. Now some of the lefty media outlets which support the cults and which weaponize them - have turned against one of its major protagonists, journalist Lisa Wilkinson, who has been disinvited onto her former TV show!!

There is but one salve; the Left usually eats itself.

Dr. Lindsay has said, very tellingly, that when people have fallen behind on the economic metrics they're far more susceptible to these cults. We see that play out here on The Pub at CMG. I totally agree and I also agree that it's part of the new phenomenon he describes; the road to "Neo Liberal Communism". That latter ideology thrives in an environment of instability and one of the best ways of achieving that instability is to pit YOU against US. Victim against oppressor.

Once the USA was formidable and had a shared project. Now it is not only susceptible to cults but actually being torn apart by them. The NY Times is a major figure in promoting many of those cults and this is why it is discredited.

To quote David Brooks: For reasons that are not clear, the number of adolescents who have sought to medically change their sex has been skyrocketing in recent years, though the overall number remains very small. For reasons that are also not clear, adolescents who were assigned female at birth are driving this trend, whereas before the late 2000s, it was mostly adolescents who were assigned male at birth who sought these treatments. That's because they belong to a cult, Mr. Brooks, and you've obviously not discerned that fact at all because you are immersed into the cults system yourself, so celebrated by the NYT. Mr. Brooks, have you drawn the dots yet on how cult systems have empowered Trump voters during the last years? No, I didn't think so as this would provide a singular threat to the ideological 'business model'. And it would mean you'd regard people labelled 'deplorable' as having any currency or worthwhile right to dissent at all!!

We've had a 'cult' in the western world for over 2 millennia and it was based on real love, empathy and care: Christianity. It is being systematically unravelled because of the threat it poses to the recently-emerging cults and a new pernicious ideology of victimhood 'status'.

(And I do not expect 'Joe' to create 'discomfort' by answering this posting of mine. The correct word is "triggered", isn't it?)

[Holden Fourth]

As you know I work with children and at the moment we have two students 'transitioning' between genders. One of the students I know well and she/he (please excuse the maybe inappropriate pronouns) has had a determination to make this transition from quite a young age. In this case I can see that it's probably a true and proper course to benefit that child who is now a mid teenager.

However, what has also become apparent, is that there is a lot of pressure from a number of groups (not necessarily medical) on children to go through this process and we've been exposed to a couple of particularly nasty cases here in Australia. Many of these children are not necessarily suitable for gender transition but once the process is started, reversing it becomes almost impossible. I can provide you with case studies if you wish verification but it's not really necessary

The concept raises a number of questions for me. The main one is: "At what age is a child (up to the age of 18?) able to make a fully informed decision about transitioning genders?" From one point of view, yes they should wait until they can make the decision themselves but conversely will delaying the process have deleterious effects? As Cass points out, we don't really know at this time.

The report’s greatest strength is its epistemic humility. Cass is continually asking, “What do we really know?” She is carefully examining the various studies — which are high quality, which are not. She is down in the academic weeds.

And we should really take the following on board (pun not intended). I read so much stated by people on various forums that is pure unadulterated shite with hardly a scrap of pertinent evidence. These same people would castigate me because prefer a 'data based' approach to gathering evidence and eventually (sometimes not of course) forming an opinion.

In 1877 a British philosopher and mathematician named William Kingdon Clifford published an essay called “The Ethics of Belief.” In it he argued that if a shipowner ignored evidence that his craft had problems and sent the ship to sea having convinced himself it was safe, then of course we would blame him if the ship went down and all aboard were lost. To have a belief is to bear responsibility, and one thus has a moral responsibility to dig arduously into the evidence, avoid ideological thinking and take into account self-serving biases. “It is wrong always, everywhere, and for anyone, to believe anything upon insufficient evidence,” Clifford wrote. A belief, he continued, is a public possession. If too many people believe things without evidence, “the danger to society is not merely that it should believe wrong things, though that is great enough; but that it should become credulous, and lose the habit of testing things and inquiring into them; for then it must sink back into savagery.”

[Belle]

That final quote from Clifford about belief is very compelling, EXCEPT that Christians BELIEVE without a scintilla of 'evidence'. That has worked for over 2000 years, more or less, but it does also throw into relief reasons WHY people have willingly suspended disbelief over the centuries. The entire paradigm of religious belief is fraught, complex and enigmatic. And Clifford's comment about sinking back into savagery is very prescient.

Maybe because the religion of Christianity has a welfare aspect to it and a metaphysical side - as reflected in art, music, literature and theology itself - this is partially explicable.

As for trans; you're at the coalface being still at school and you can see the over-reach of the cult. All we're saying, as non-cultists - is that children should be left alone and what they do as adults is entirely up to themselves. Jordan Peterson has said that studies show that most people who view themselves as trans-sexuals actually are homosexuals. Actually, Dr. Peterson goes further and suggests that perhaps adults shouldn't be left to decide what surgeries they inflict upon themselves as this only gives a financial incentive to unscrupulous doctors!

It is no co-incidence to me or my family that the progressive relatives have bought into the new cults and that in one family there are TWO non-binaries. When we heard this we all said, "well, who would have thought?"

You know the cult capture is complete when a world leader cannot tell you what a woman is.

[Holden Fourth]

You know the cult capture is complete when a world leader cannot tell you what a woman is.

But they should be able to tell us what a female is - there is a scientific and medical definition.

[Belle]

'The science is settled'.

Of course there are transgender human beings; conservatives just don't want CHILDREN mutilated. Or given the right to determine whether they should be castrated before 21 years of age. And, as with Covid, we cannot trust or be guaranteed the medical profession will behave with integrity. And there's a cult, as I've said, where parents listen with earnestness about their childrens' wants and desires and fall over themselves to cater to their the slightest whims. Band-wagoners. When I was teaching the first thing I realized was that children wanted to know who the adults were. The fetishization of the child and the sanctification of somebody like Greta Thunberg by the progressive Left is just embarrassing to all of us - and confusing for children. Rearrangement of the English pronoun system to accommodate this tiny, tiny cohort is something you just simply couldn't make up!! In Canada it's illegal not to use 'their preferred pronouns'. Only in decadent societies does this garbage fly. Maslow's "Hierarchy of Needs" springs to mind.

Dr. Lindsay said the only thing which will stop children being surgically re-assigned is huge law suits from them as they grow up and have regrets. He has also argued that if you believe children should be 'free' in their education and follow their own desires you find that when they become adults they cannot handle a place like university and need 'safe spaces' to cope. Katharine Birbalsingh demonstrates with her own 'free school' (see her discussion with Dr. Boghossian) that discipline and routine enable her students to perform spectacularly well and their 'liberation' comes from achievement and security. We do a great disservice in pandering to children.

I wonder if they have trans issues in Palestine and how they deal with this, or have dealt with this??!!