The Laramee Filter: pseudorandom thoughts, subsequently put on the Internet.
Tom Laramee
Date Published:
May 10th, 2024
Word Count:
3,135 (20:00 read time)
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The Medical Field Is Finally Getting Serious about Helping Adolescents with Gender Dysphoria

And while I expect very little (or nothing) to change in the United States in the short term, it's never too late to begin the discussion.

I was listening to KUOW the other day, their On Point program, and for a moment I thought (a) I was dreaming and (b) it was Christmas.

The topic of conversation was Gender Dysphoria in Adolescents (and the implications for their medical care), and I couldn't believe what I was hearing. The guests said stuff like:

I was absolutely incredulous. Involve the parents in their adolescents medical care?!? Make the best medical decisions for our adolescents instead of worrying about the social-political implications??! There are serious mental health issues that are being largely ignored here?!? Do comprehensive assessments of our adolescents who say they're experiencing gender dysphoria?!?

It was all so rational. I thought perhaps it was too good to be true. I had to listen to the entire episode, and so that's exactly what I did.

This is a Topic I've Written About Before

My first post was written in October of 2022 and was titled What's Happening To the Gender Identities of Our Adolescent Girls?. In re-reading this post, I'm sticking by it. This topic is still wickedly toxic. It has put parents (and families) into a simply impossible (and cruel) position, and the vast majority of the cohort known as "ROGD" or more appropriately "gender distressed, cisgender children" is still at risk in the ways I pointed out in that article.

My main interest was/is that I believe we're actually doing great harm to this generation of adolescent, [biologically] female, girls who are presenting as transgender for the 1st time in their teens. As a result, my interest has been strictly medical, politics be damned.

Only now, other people are starting to notice (Alternate link to that article) If you'd like a relatively succinct summary of the issues at hand, that's a good one.

Here's another recent article by Leor Sapir from the Manhattan Institute[1]. I've highlighted some wonderful excerpts in the footnotes. The article is definitely worth reading in it's entirety.

And change is happening as a result. Following the publishing of the Cass Review, Scotland joined Finland, Sweden, Norway & Denmark (who had conducted their own reviews prior to the Cass report and reached the same conclusion), has paused hormone treatments for adolescents under 18[2]. Wales did the same.

I still think this topic is toxic, and I suspect I'll be accused of being transphobic (similar to nearly every other person who has tried to discuss this topic in any nuanced way whatsoever), but at least now I'll have a lot of company.

A Summary of the Cass Review

I'll admit right away that I don't think I can produce a suitable summary of this podcast: it's just too good, and it's fairly dense, and so I think if you care about this subject, I highly recommend listening to the the entire thing.

In the footnotes, there are two important links. Number one is the full interview with Dr Cass[3], and the other is the link to the Cass Review itself[4]. Both are provided for those who are diligent enough to want to read/hear from the source, with no interpretation.

Below, I'll try to identify ~ten distinct topics and then cite relevant excerpts about each topic (anyplace you see emphasis, it's mine).

On proper treatment protocols:
[The study] found that the evidence base for medicalized treatment of adolescent gender distress was quote: "Inadequate and poor".
For most gender-distressed young people, a medical pathway will not be the best way to manage their distress.
Many often suffer from concurrent mental health issues or autism.
And disappointingly, the team did not find improvements in mental health. In fact, some young people got worse, some made no changes.
So we've not taken a position that any form of care is best, but what we have said is that it is important that all young people get access to evidence-based, non-medical interventions that address the full range of their difficulties.
So this group of young people, if they are depressed, if they're anxious, if they need an autism diagnosis, all of those things should be put in place.
That is honestly the reason I have been vocal. Because I do care about the well-being of trans children. Tremendously, that's what my career is focused on, but I also care about the well-being of gender distressed, cisgender children. And to only focus on one group and not both, I think is harmful.
But actually, there are many different ways in which we can manage distress and anxiety in a 15-year-old that don't involve puberty blockers. And yet we've somehow stopped short of trying those, just because puberty blockers have become so widely believed to be effective.
On the risk of suicide in transgender adolescents:
And as the report says, "It is well established that children and young people with gender dysphoria are at increased risk of suicide." But then the report adds this, "But suicide risk appears to be comparable to other young people with a similar range of mental health challenges." So first of all, what's the evidence for that?
CASS: So how do we know if this is down to the gender-related distress? Or is it because they also have an eating disorder, or they're depressed or a whole raft of other issues? And because a majority of these young people have all of these issues, then what you need to do is compare to what the population rates are of suicidality in young people who have all of those other issues, but are not gender questioning.
And that's where you find that the rates are fairly comparable. So we can't say that it is the gender questioning or the gender incongruence that's giving you additional suicide risk. And so the second part is, does the gender-affirming treatment pathway reduce that suicidality? But such data as we have shows that we can't detect a difference in the suicide rates before and after treatment.
On doctors and psychologists being afraid of questioning the current medical care model:
I think we need to re empower professionals to not be afraid. And they could see somebody who would really see them as a whole person, then I think they would get a much better deal.
The politically infused public discourse is getting this wrong and it's impacting the way that doctors care for their patients. Physicians must be able to practice medicine that is informed by their medical education, training, experience, and available evidence freely and without threat of punishment.
There's so much backlash. (Backlash from where?). With the internet and social media, there are people who have very passionate feelings and are very scared and traumatized, who may get angry at some of the things that either Laura or I are saying, and feel that we're not advocating enough for their communities. And I understand that, but I also think it's really problematic. Because we need to have good debate and we should be listening to one another, at least for people who have the best interests of youth in mind. I would just add that it is terrifying. There's no other way to put it from my perspective to engage in these conversations publicly.
On the need for adolescent girls to establish mental health treatment 1st:
Young people are in a state of mental health crisis, and we can't pretend like that's not a piece of what's going on for a lot of the gender-distressed kids coming in these days.
That has changed drastically in the last 15 years or so, where the mental health issues occur for young people prior to there ever being any gender distress. And it's so critical to do comprehensive assessments that are very individualized. I think to your question, these days, if that isn't being done, then I do worry that there are young people being treated medically who shouldn't be.
Yeah, I don't think we can mandate that all children who socially transition have mental health treatment in our country, because we don't have a national health service.There's tremendous problems with access to mental health care for all youth.
The Cass Review recommends exercising caution and having full parental buy in, and mental health services available for young people who seek to socially transition in any way.
But for others who are distraught and experiencing significant mental health issues and trying to understand why they feel so different and so miserable, then in some of these cases, it just doesn't. Because it doesn't fix the underlying mental health issues.
On involving parents in the treatment of their adolescents:
I will tell you that what I have seen over and over in my clinical practice is how withholding information from parents is really very rarely in the child's best interest. Because 99% of the time, these young people have significant mental health issues and so by not sharing the gender distress with parents, it also often means not sharing the rest of the mental health picture.
And it ends up tearing families apart. Parents feel that they've been left out of the loop. Many times, the parents are very supportive of their child's gender questioning, but simply want to be involved in their care. And so I do agree with Dr. Cass. And what she speaks about in the report regarding the adolescence, that it really needs to involve the parents.
On the need for assessments (and how these don't even exist):
EDWARDS-LEEPER: In addition to putting more resources into research, from my perspective, the focus these days really needs to be on the mental health needs first, as the Cass Report points out. And that means that the majority of providers within these clinics need to be mental health providers and need to be offering the kind of thorough assessment. And then, ongoing support for the young people.
TISHELMAN: One final point I would say is we're talking about assessments, but we really don't have research on what assessments are effective. Right now, we don't have a research basis for making those decisions, but at least we could bring together a diversity of sophisticated clinicians who do believe that transgender youth exist, to come up with some guidelines about what we mean by assessment.
CHAKRABARTI: That is so remarkable. We don't even know yet what the best assessments are, let alone we don't have an evidence base to know what the best treatments are.
On how politics has caused great harm to everyone involved:
And I worry about how politics has infused this field in a way that I think can be detrimental to all youth.
And I'm not entirely sure how we got to this place, but so many seem to be in sort of an echo chamber, where they will not even entertain these conversations or these considerations, and so somehow that has led the field, at least in the United States, somehow we've just spiraled into an inability to critically think, and I do think the political scene is a huge part of that problem.
On the profoundly negative effects on the families involved:
I can't tell you how much empathy I have for these parents that are going through this. To be caught up in this political and polarized field right now is ripping families apart and just causing so much distress for the young person, but for the parents and for the families as a whole. So what I recommend, that they ask the potential provider if they've read the Cass Review.
In support of the data that there's been a huge increase in girls seeking treatment:
This comes as the number of young people seeking clinical help for gender distress continues to grow. And unlike a decade or two ago, most of these people are adolescent natal girls.
And that population has changed in recent years .. to predominantly birth registered girls presenting in the teenage years.
On what might have changed that explains the exponential rise in the number of the adolescent girls seeking treatment for gender dysphoria:
In fact, you have a chart here that shows that around 2013, 2014, every year, essentially, the numbers spike up higher and it's more, many more adolescent girls. What do you think, or what did the review seem to find in terms of what may be driving that rapid rise?
So we looked at what we understand about the biology, but obviously, biology hasn't changed suddenly in the last 10 years. So then we tried to look at what has changed? And one is the overall mental health of teenage girls in particular.
These Quotes Are Also Incredible To Me

These next couple of quotes are from this op/ed (which I've already cited in the 1st footnote but is too good to be completely relegated to the footnotes)[5]. The author (Leor Sapir) has clearly been paying attention. The entire article is very much worth reading.

A couple of sections really resonate with me because here in WA State, the legislature has [rightfully] banned conversion therapy. This is very good. But where things have gone wrong is that "trying to understand the reasons for say, body dysmorphia" has been pulled under the conversion therapy umbrella (and is similarly banned). That part is very broken (as it forbids the possibility of diagnosis). Here's the relevant quote:

In a political climate such as ours, in which mere exploration of the reasons for rejecting one’s body can be labeled “conversion therapy,” differential diagnosis becomes impossible.

It's like poetry.

Another section that succinctly sums up what's been happening at a macro level:

What is likely happening is that an ongoing youth mental health crisis whose origins predate and have little to do with gender is being misdiagnosed and mistreated with harmful and experimental drugs.

A quick nod to the idea of what was called Rapid Onset Gender Dysphoria (one of the many rational, discussable ideas that was simply incredulous to many in the trans-rights community):

Most adolescents referred to pediatric gender clinics are teen girls who have no history of dysphoria in childhood but who do have other mental health challenges that predate their distress with their bodies.

And finally, touching on what wasn't mentioned in the Cass Report article (that upwards of 2/3rd of adolescent girls who show signs of gender distress have a history of mental challenges like depression, abuse, or neurodiversity, which is a critical part of the story):

Puberty is difficult for all teens, and it is not a disease. Puberty blockers offer teens in distress — especially girls with history of sexual abuse, autistic kids and gay kids — false hope by casting puberty as optional.

My hope is that we can begin to set aside the socio-political nonsense surrounding this issue and get back to basics, which is to provide the right level of support for this cohort, so kids get an accurate diagnosis, relevant support, and yeah, we should probably explore an actual diagnosis as step number one[6].

[1] So much is amazing about this op/ed. A handful of quotes:

"In a political climate such as ours, in which mere exploration of the reasons for rejecting one’s body can be labeled “conversion therapy,” differential diagnosis becomes impossible."
"What is likely happening is that an ongoing youth mental health crisis whose origins predate and have little to do with gender is being misdiagnosed and mistreated with harmful and experimental drugs."
"The doctors who’ve advised them say that puberty blockers are known to improve mental health — that they are even life-saving — and that they are fully reversible and just give kids “time to think.” None of this is true."
"The assumption about reversibility, never tested and highly questionable form the start, proved to be the ethical foundation for the entire Dutch experiment, and it quickly crumbled."
"Puberty blockers may give children time to think but they simultaneously rob them of their developing capacity to do so."
"Most adolescents referred to pediatric gender clinics are teen girls who have no history of dysphoria in childhood but who do have other mental health challenges that predate their distress with their bodies."
"Puberty is difficult for all teens, and it is not a disease. Puberty blockers offer teens in distress — especially girls with history of sexual abuse, autistic kids and gay kids — false hope by casting puberty as optional."

[2] Given the toxicity of this subject in the US, I don't anticipate any changes to the gender-affirming zeitgeist any time soon, but at least now parents can be informed about the forces that are truly in play w/r/t this generation of adolescent girls, which will allow them to make informed and rational medical decisions.
[3] The full interview with Dr. Cass: The evidence was disappointingly poor.
[4] The full report from Dr. Cass: Independent review of gender identity services for children and young people.
[5] Which, let's face it: nobody reads the footnotes anyways.
[6] I only say that because it's the first step for [literally] every other medical condition and/or mental health condition. It doesn't make me a genius to point this one out.