SIO460: Actual Experts Debunk the Cass Review

Transcript

This transcript was generated automatically and may contain errors — the audio is the record.

0:00:11 Thomas: Hello and welcome to Serious Inquiries Only. This is episode 460 and this is a very important one. I'm so glad to be able to present this to you today. Might have heard of something called the CAS report or the CAS review. If you have, you've likely heard of it because someone is claiming that it blew the whole lid off of transgender ideology and the way we We provide medical care to children who might be trans. Treated as like this whistleblower -esque thing out of the UK that just and for all debunked all this gendery nonsense. You're a listener of this show, you probably wouldn't be surprised to find out that then obviously none of that's true. And all -star producer Lydia Smith has assembled not one, not two, but three experts to talk about this. Are three of the authors of what I would call the cast review review, but it's actually called an evidence -based critique of the cast's review on gender affirming care for dysphoria. And so what we're going to hear is actual doctors with actual experience and actual knowledge talk about the reality going on here. It's quite disturbing to learn about how apparently easy it is to produce a nonsense report that has a massive effect on the informational ecosystem.

0:01:33 Thomas: Time was limited. I didn't want to waste any time doing introductions. I figured I'd do that here. So the first first person you'll here is Dr. Meredith McNamara, who among other thing, is Assistant Professor of pediatrics at Yale School Medicine. You will hear from Dr. Kellen baker. Kellen Baker is the executive director of Whitman Walker Institute. From To the website, they leverage cutting -edge research, policy, and education to advance health equity nationwide, particularly for LGBTQI plus people and people living with HIV. And finally the third voice you hear of of our guests, uh, Dr. Ken Pang, who is a consultant pediatrician and biomedical researcher, he is the Senior Principal Research Fellow at the Murdoch Children's Research Institute. So those are our experts, our were so kind to give us this much of their time. And Dr. Meredith McNamara will explain more about the overall project and how this came to be. So don't we go ahead and take a break, which you can avoid at patreon .com slash series pod. Huge thank you to the patrons who make the show happened. With that said, after this break, we'll get on over to our experts and about, well, how much the cast review sucked, in my words, not theirs. Might be theirs, but no, it's mine. Am joined by more experts than I've ever had and you all for coming on. And big a thanks to my wife, Lydia, for wrangling this herd of experts. Going to talk about the CAS report and know, I've read a lot about it. I'm somewhat uh I just wanted to check before we got going just do the the quick you check of like if somebody just googled cast report and they heard about it what would they see and it's a bunch of transphobic nonsense from the new york times and and outlets so it's it's not good so I'm glad we have you all here uh I will have already introduced everybody so let's jump right in um would you mind taking us through the the exposition.

0:03:16 Thomas: But for the average person who maybe hasn't quite of this, but maybe has heard the WordCast report, but know doesn't what's going on. Catch everybody up.

0:03:16 Meredithe: Hi. Well, thank you for teeing me up there. And oddly, the world seems fascinated with the bodies and identities of young people who do not identify as the sex that they were assigned at birth. And CAS review is the latest document to weigh in on this controversial issue, but with a lot of credibility. So the CAS review is a 388 -page report. It took about four years to fully assemble. Was put forth by the United Kingdom's National Health Service. It is, to say the least, a very odd document because it says a lot of things that experts in this field would agree with. It It says a a lot of things that experts in this field would not agree with. Ultimately, it's very clear that this document doesn't do much to serve transgender youth and their families. And yet, it is perceived as kind like the new Bible on this care. Our author group represents a wide range of expertise in research and clinical care in pediatrics, adolescent health, gender affirming care, epidemiology, and policy. And we produced a report that documents some of the issues that I gave you a Cliff Notes version of right here?

0:04:49 Thomas: Yeah. From that description, I wonder if maybe it sounds kind of not a big deal. Like when you put it that way, it sounds Oh, someone did a report on what, and this is specific to the UK and I, it, here's a review of like the current state of care in the UK. Is that what ostensibly they were trying to do?

0:05:06 Meredithe: Know, it's really, think I what's kind of interesting is that it's not clear what the of the cast team was from the outset. Not clearly defined. And so if you don't really know what goal was, then it's hard to say whether or not it actually achieved its goal. Um, what, what I would say is that on the surface, this document looks like it has a lot of credibility because it comes with the seal of approval from the UK's national health service. Seems like it was meant to describe health services for trans youth in the UK who face, unbelievable wait times for access to care and are suffering while they're waiting years for care. But the, the product actually ended up trying characterize the state of the research, standard practices across the world. The kind of transgender youth as told by these youth themselves, and it didn't do any of that well at all.

0:06:05 Thomas: Question on that, if going back to my regular Googling this check now, admittedly, my algorithm might be screwed. I don't think it is. I think these are all the results coming up. Like I see from a month ago, New York Times opinion, Pamela Paul, why is the U.S. still pretending we know gender affirming care works? And it's saying it's been three months since the cast review and, you somehow the U.S. is still in denial. What the cast review or cast report? What is that allegedly based on? I mean, what kind of claims are they making based on this report that that there's no good evidence, quote, for the long term outcomes of interventions to manage gender related distress? You did they use for this? And if can talk about any more of the claims, just so people know kind of what that initial report was before we move on to the review. You

0:06:48 Kellan: Think the interesting question that arises for me when I hear that is why is the New York Times still pretending that its opinion columnists have any expertise in care for transgender youth? That's really what this has turned into. And in so many ways, we see what happened with the cast report there are systematic reviews that are associated with the report and there are a number of reasons why those those systematic reviews violate practice and when you think then about the conversation in the u .s in particular as well as in the uk where a lot of the media sort of political I'm just going to call it a circus the identities and the lives of transgender youth has really turned in this very ugly very very negative direction where the cast report is being cited to deny access to care when in fact the report even despite all the shortcomings one of the things that I think it's important to know about the report is that it does not support bans on care the cast review the cast record was commissioned as meredith has stated by the uk's national health service in order to address the problem of young people waiting far too long for access to high high quality culturally and clinically appropriate care and that is a problem that when you're thinking about how different countries are responding to the cash report and trying to use it as a foundation or an excuse to ban care it's actually running those bans are running completely counter to the entire purpose that the report was commissioned for I

0:08:10 Thomas: Would think

0:08:11 Kellan: .e to understand why there are these you know why are there such long delays this isn't serving people well we need to fix this and also again to its conclusions which are that it takes a systematic review focus on the evidence and I think we should talk more about where the systematic reviews came from how they were done and how they Were incorporated into the final report but at the end of the day the report itself does not support banning care it supports young people trans young people having appropriate appropriate access to a full spectrum of medical interventions that are appropriate for treating gender dysphoria, supporting their health and well -being, making sure that they have access to the care that they need. So to use the report to justify a ban is counter both to its origins and to its conclusions. Exactly.

0:08:59 Thomas: Would think that like if the report said hey people aren't getting the cancer treatment they need fast enough they're having to wait way too long I don't really think you'd be like well we gotta get rid of cancer treatment that seems like the way to go what are we doing it now is this a case people might be wondering again a case of then a report like was hijacked, like was whoever Cass is, were they trying to do like a reasonable thing and then it got taken out of context or no?

0:09:12 Kellan: I

0:09:23 Meredithe: Don't think anyone can pretend to understand the intentions of this author group, because we don't even know who they are. OF the big problems that have with cast review and my colleagues throughout this care is that we don't know who actually wrote it. So there is one physician who has become the figurehead behind this, but there are likely many authors who contributed, and we cannot vet their credentials for conflicts of interest or for even their relevant expertise.

0:09:56 Thomas: I know academics. They don't want their name on a paper that they published. They would never want credit for something they did. That seems a little out of the ordinary, or is it me? Well,

0:10:04 Kellan: Ever, ever. I mean, and that just just underscores how unusual this is that we have this report that is supposed to be an authoritative summation of an entire area of care that is complex I mean there's a lot of different moving pieces you have to make sure you have a coordinated integrated team that's working to make sure young people get the care that they need it's so unusual for the people who are involved in this report to not want their identities not want their names shared what do they have to hide and then those folks who aren't hiding the folks who are in different levels of power in what is now the outgoing of the past conservative government in the uk and even some of the people who are coming in with the new labor government there have been quite a few uh guess exposés I hate to use that That kind of salacious sounding word, but a number of reports of how many key people were placed within the infrastructure of the government entities overseeing this report precisely to get an outcome that would justify banning care. There's quite a few indications that there were a lot of fingers, I mean, I can go so far as to say a number or fists on the scales. Weighing things against the provision of timely, age -appropriate, individualized, evidence -based care for trans young people. Then we have no further information, though, about who at the end of the day actually put those political sentiments into the pseudoscientific language that is used throughout the cash report

0:11:39 Ken: Look, I yeah, with sentiments from Kellan and from Meredith. I think that one of the challenges that, the you report, it seems like it's tried to, know, you take the middle ground and, you talk sometimes about this middle ground fallacy where, you know, a belief that the truth lies somewhere in the middle if you've got different opinions. And I think I that really is a fallacy um a lot of cases you like vaccinations and you know you have people on one hand who don't believe in vaccinations at all on the other hand you've got you science really tells you the benefits of vaccinations if you were to take the middle ground approach there then you should say well you know the truth lies somewhere in the middle and we know that's not the case and I feel like this report's tried to take the different opinions and tried to sort of take the middle ground and I feel that that's that's where it's you of stuck in a lot of ways.

0:12:20 Thomas: Jeez. Yeah. I mean, you take half a vaccine. That's the middle ground. Middle ground is always right. You take half the dose and then you've split the difference between the two positions. Sort of like how we should do half of something about climate change. I do really worry because this is an issue that I really worry. I can only speak for kind of the left that I observe because it's a progressive podcast. But I really worry that there are people a lot of people on of kind of the mainstream left who are being taken in by what, from my experience in interviewing experts like you folks, is just like lies. Like, it just seems to be not correct information, information, and they're being taken into it. So, I'm really both, I mean, obviously dismayed to see that, but I'm glad to see the effort that you all are making. You want to maybe talk about how you went into this? I don't really know, especially does one even start doing something like you all did?

0:13:04 Meredithe: A great question. So speak a little bit about that because our report is housed underneath the umbrella of this policy initiative that I co -founded with the law school here at Yale. And we call ourselves the Integrity Project because we believe that scientific integrity belongs in health policy. Have noticed a disturbing trend where adolescents and are kind likely victims of disinformation in health policy because they just can't really be effective lobbyists for their own self -interest. And that social issues associated with progress and good things tend to stir up people in power and galvanize them to turn those joyful elements of social progress into a political zeitgeist. In And order to get people to accept draconian bans on health care, whether it is reproductive health care or gender affirming health care for transgender youth or adolescent confidentiality, you have to make up a lot of lies about what's actually happening because you have have to scare people. You have to get them on board. The Integrity Project works with academics, experts who do not have conflicts of interest, who do not have a personal vested interest one way or the other or an ideological bent, but we simply understand reality, the research at hand, the experiences of our patients, the deep nuances of clinical research. And because we have that perspective, we also know how it can be misrepresented. Project has produced four multidisciplinary rapid response white papers. Happen to pertain to gender -affirming care, and that's because it really seems to be ground zero for disinformation in health policy. See. Of our papers was also pertinent to the Braidwood versus Becerra decision preventative care mandates. And that is a whole different topic, but I just

0:15:00 Meredithe: Bring it up to...

0:15:00 Thomas: Is that Emtala or was that that one? Oh, okay. Sorry. What is that one. Yeah, sorry. Which stripping of our rights was this? You'll have to remind me.

0:15:09 Kellan: United

0:15:02 Meredithe: Too many, too many. Right. I know, poor Ken, having to listen to us talk about this. I'm so sorry that that this has to darken

0:15:15 Kellan: States going off the rails I think

0:15:17 Meredithe: Your morning and your beautiful Australian morning. The Braidwood versus Becerra case was one in which, self you -identified Christian business owners decided that they no longer wanted to pay for a medication that prevents HIV infection called PrEP and that they didn't feel like they should have to pay for it because they object to sex outside of marriage, intravenous drug use, and same -sex sexual behavior. Having a religious objection meant that they could go off after all preventative care mandates within the Affordable Care Act. That position is based on a lot of false information about human behavior and people's need and desire to prevent HIV infection. And, you know, like, spoiler alert, it's not just uh with same -sex attraction who are at risk for or desire prevention of HIV um there's a lot well

0:16:07 Thomas: Even if it were, this is what I always have to say.

0:16:11 Meredithe: Correct even if it were absolutely um really seek to do though is to identify where the truth is being distorted and where scientific evidence needs an advocate. And thankfully, there are a lot of brilliant people out there in the world who are on the front lines of doing good research and providing evidence -based care, bringing their voices together and their expertise to produce rapid response reports that are intelligible by policymakers, the media, the lay public is really our mission. And the CAST report was right for that for one very important reason, which was that it was getting cited all over .S. policy debates. Being cited in filings in the Supreme Court. I do not want to think about what would happen to transgender youth the world over should this care become banned in a final way in the United States? I

0:17:05 Thomas: So much to say from that, but maybe it's topic for another time, but I'd love to know how that set up that kind of concept you talked about, how that avoids the centrism fallacy by trying to find people who, you know, don't have an ideology. I don't know what it means to have an ideology about matters of health. I mean, I'm I know what effectively means and practically means. I don'T know what IT means in a way that would make it make sense to try to not have an ideology about, you access or what, you KNOW what I mean? Like in a medical sense. How have to investigate that now, but it'S just what occurred to me. Is

0:17:32 Meredithe: Answer would be, let's look at the research together. Let me talk about my patients. Let Ken talk about his patients. Let Kellen talk about the hundreds of studies on his CV that he has co -authored, many of which he has led. And, you let's see where ideology falls. Think I we're really just talking about people's lives and the truth here, people's rights to a healthy and joyful life and the research that backs up what allows them to do that.

0:18:02 Kellan: Another thing that that brings to mind for me is just how sad it is in the current environment meredith has referenced disinformation we're in this social media hyper politicized environment where the truth is viewed as an ideology we're following the research following the facts is viewed as expressing ideology. I mean, a virus like COVID doesn't care. A health condition doesn't care what your political views on it are. It exists. People exist regardless of what your critical views on the matter are. So it's a sad state of affairs when anyone who acknowledges that transgender people exist, that gender dysphoria is a real condition, that transgender people often need health care that is delivered by licensed, caring, and compassionate providers like ken and meredith but acknowledgement and that understanding is viewed as ideological it's not ideology it's facts and

0:18:54 Thomas: Exactly what I was getting at, especially because it often, sometimes that some in people have well -Meaning attempts to help. Often it's looked at as, okay, this is only, you know, like, let's say it's a race issue for a different, just a hypothetical. OK, this race issue, we can't listen to these ideological people of color. But if white people come and say the thing, then that's not ideological. And it must be a really frustrating challenge to for people to kind of not be listened to often until they're legitimized by like, you know, other not marginalized voices. Does that make sense?

0:19:23 Kellan: I mean that's one of the reasons why the integrity project report that we all worked on cites our qualifications over and over and over because there is such a dismissal of both lived experience of transgender people people and of the clinicians who care for them and the researchers who do this work the cast team is proud reportedly of not having anyone involved who actually treats transgender people because that was claimed to be a bias and as we note in the report in no other area of medicine is having clinicians and patient voices of the people who are actually affected and the people people actually providing and seeking the care in no other field of medicine is that deep knowledge and expertise viewed as bias. And so we're in this situation where Dr. Cass was literally picked to head this review because she has never treated a transgender patient. She has no experience, and she has said this herself, she has no experienced with transgender health. In no other field in medicine is ignorance like that held up as any kind of badge of honor. Even even let alone admitted to yet in this case in transgender health care it suddenly becomes something to be proud of because of this implication that if you are someone who knows the transgender people exist you provide this care you do research in this care but somehow that gives you a political perspective on this issue it doesn't it gives us a perspective on what we think should be happening with regard to young people or transgender people of any age being able to get care but it is not bias what is bias is shutting their eyes and ears to the truth to the reality of the experiences of transgender young people their families their health care providers and saying that that somehow makes you qualified to judge anything about their situations and

0:19:32 Thomas: Sense? Wow. Wow. That's mind -blowing. I mean, real live doctors like you folks, I know it works the opposite. Like you don't, no doctor in one specialty is like, well, let me just take a look at this and don't listen to the person in that specialty. I'm going to just quickly talk over them.

0:21:20 Ken: To do maybe is to pick up on something that Karen was just saying is that I think you can see the consequences of having you who have led the report who don't have any you expertise or experience in this And one part of the report that I think where this is really very eminent is in the context of how they approach the use of puberty suppression. And that's probably, I guess, one of the areas that has attracted the sort of most interest and controversy in the contexto of the review. So what I mean by that is in terms of puurity blockers, I, we it the in clinic and we can sort of see the benefits. And those have certainly been backed up by the research. So what's interesting is the CAST review commissioned a series of systematic reviews, and one of those systematic reviews looked at the effects of puberty blockers on a range of things. And when they were specifically focused on the mental health impacts of puurity blockers, they identified one study that they regarded as high quality. So there were other studies that were sort of medium quality or low quality, and they threw out the low quality ones and they really kind considered the medium and the high quality studies. And so they put all these sort of studies and they sort of ended up, you this conclusion that, oh, we don't have good enough evidence to recommend the use of pubic blockers. And as a result, we're suggesting that pubic blocks should only be available in England in the context of a research trial and we can get into some of the problems of that. But I think one of puberty blockers, the primary objective of puurity blockers is to stop unwanted, irreversible physical changes of puberties because a lot of the young people that we see in clinics, that's a really distressing thought for them to have to go through puberty and experience these irreversibly unwanted physical changes. So that might be someone assigned female birth, Earth, it might be breast development, for example. For someone, say a male, Earth, it may be a of their voice, the development of Adam's apple, the development facial hair, et cetera. So we know puberty blockers, and are incredibly effective at stopping those unwanted changes. The systematic reviews agree with this, are thing is that when you work clinically, you understand that there's some nuances around how puberty lockers are used. And certainly from my perspective, puberty walkers are most effective when they're used from early to middle puberty when physical changes that I've just mentioned. However, there's also situations, for example, in England for many years, it's been mandated that if you wanted to access other parts of gender -friendly care, such as estrogen and testosterone under the age of 18, you had to have 12 months of puberty blockers beforehand. And that was irregardless of where you're at in terms of puberties. You could have finished puberty a few years ago, you could be 17, you still

0:23:46 Thomas: What?

0:23:46 Ken: Have to have this mandatory 12 months of puberty blockers and me that kind of it doesn't make any sense those irreversible changes that I just spoke about never happened puberty blockers aren't going to reverse them but you have to go on to puberty blocers regardless and when you do research and you lump everyone together regardless of you know when they started puberty or when they start the puberty blocks I should say you kind of expect the fact that you're going to dilute out the benefits when you when you deal with that but If you don't work in the area and you don' t look for those nuances, then you don t appreciate that you re going to, as I said, dilute the benefits when you try and pull all the research together.

0:24:22 Thomas: Wow. That is my that was really the rule. Because, like, I'm say pretty sure I could have figured that one out. Hey, Hey, do we give the puberty blockers to the people that have already had puberty? No, that seems pointless. Wow.

0:24:32 Ken: That was the rule. In England, for many years, that was the NHS guidance. So it was mandatory to have puberty blockers for a 12 -month period. The idea was that it would give you, I time to think about other types of treatments. But you already finished puberty, it essentially rendered you menopausal. You took away all your sex hormones for 12 months. And we know, you you think about menopause, there's significant effects of, taking you away people's sex hormones. End up with those hot flashes. They can have mood changes. Their energy levels are changed. So I Know, if You have an appreciation for the medicine and you can and understand who's likely to benefit and who's not, then you can focus your attention to the studies that are probably going to tell you most about the population. What was interesting is there was a recent study out of Harvard where they only looked at young people who had had puberty blockers in early to middle puberty, so that group who we expect to benefit from puberty blocks. And then they saw significant improvements in mental health across the board. And think until we start to stratify our research in such a way that we look at those who are likely to benefit versus those who aren't, you know, we're going to get these mixed messages.

0:25:33 Thomas: Wow. That is mind -blowing. Seems bad faith to me. I don't understand that. Almost cherry -picked. So,

0:25:38 Ken: Would agree, I mean, what's also, you now, in bad faith is that, kno, for you the kidney doctors, they identified one study that they said was high quality, the rest they considered was medium quality, but they said, oh, you know, overall there were some that showed some effects and some that didn't, so we don't know. If they just considered the one high -quality study that they didn't identify, that that showed lots of benefits to mental health. But it seemed like maybe we wanted, you now, that wasn't on so it seemed to be disregarded.

0:26:02 Thomas: It's a very gerrymandered report.

0:26:04 Kellan: It was a Very specific approach that they took so it's important to look at the evidence so they commissioned these systematic reviews they purported to look at the evidence and then they focused in only on the elements of well first of all they expected things from different types of medications that aren't supposed to be the results of those medications so puberty delaying medications for example are not supposed to improve mental health on their own though they in clinical practice as ken has noted often do they're supposed to pause puberty they're They're supposed to give people time to make sure that they can work with their doctors, their parents, their families to make the right decision. The CAST report looked at that and said, well, that's not important enough. Going to apply my own assessment of what I think the outcomes of these medications should be. Then I'm gonna discard an entire element of this field of study because it doesn't tell me what I feel. Doesn't say what I would want to know or it doesn'T tell me what I THINK is important. And again, these are people doing these reviews and writing this report who have no experience or expertise, self -admitted no experience or expertise in transgender health. And then you get to this body of evidence, the larger body of evidence that really does show that gender -affirming care or care for transgender people, however you want to define it or describe it, really has a lot of benefits. And it's very clearly documented throughout the literature. And the cast review throws all of those benefits out. The review almost literally never talks about any benefits of this care nor does it talk about the dangers the consequences of not providing care because to the point about where is the middle ground you know what is the mental ground between justice and injustice there is no middle ground where what is middle ground between doing what needs to be done and standing there and refusing to offer help and that's what's happening for a lot of young people they're not getting the care that they need and that isn't neutral. Harmful. It is harmful to withhold care, it's harmful to deny care, and the CAST report refuses to acknowledge these two really, really important elements of this care. That the evidence base clearly shows a benefit from gender affirming care for transgender people, and two, that doing nothing is not neutral. It is in fact harmful to the health and well -being of transgender young people oh

0:28:13 Thomas: Is infuriating. How do you guys not be mad all day? I would have a hard time.

0:28:18 Meredithe: Think we are actually. Yeah. Thank you you for, well,

0:28:20 Kellan: We are we all exercise a lot we all like you know gotta get the angst out somehow

0:28:23 Thomas: Good. You know what? Good. That's a relief. I'm so glad you sound put together. I was like, I'm like white knuckling over here, like so mad on behalf of one the, of the most vulnerable, you I could imagine, especially when you talk about youth, let alone just transgender folks of any age. It's just lies. Like it just, sorry, you don't have to agree to that or talk about motive, but I will. That's lies. Guys.

0:28:45 Meredithe: Know, I think not to just kind of like turn into a rage spiral here. Um, I wanted to do justice to the issue at hand. Um, you know, denial of transgender people, um, attempts to restrict their rights, their their social inclusion, dignity, their access to healthcare is a tale as old as time. And we were always going to have to contend with this bizarre, you landscape. And here it is. And I think the thing that I derive a of -being from is the purpose that comes from being able to do this type of work. Know, I consider myself very fortunate to have advanced training in clinical research and advanced training in adolescent healthcare and an incredibly busy clinic where I get to have long conversations with trans youth and their parents and where I get to consider how I can best serve them. So if I have an opportunity to collaborate with people people all over the world who are absolutely brilliant, who are leading the way in this research and in this compassionate care. If I get to join with them to do something to serve my patients in a different way than what I do when I'm sitting in clinic, I feel pretty good about that. I it's really nice to be on the right side of history here because one way or another, we are going to come to the truth. And I I am very excited to be able to have something like this in writing that patient's parents find this stuff. They send it to me. They sent thank you notes. They said, thank you. Notes to our coauthors. It's, it's really cool. We, we, you know, we don't do it for that, but I just want to leave your audience with, with a sense of optimism and and I am sure that there are many gender diverse people who listen to your show and um want them to know that they have allies cool

0:28:48 Thomas: Please do. That's incredible. That, so that's moving. It is

0:30:40 Meredithe: Good

0:30:40 Thomas: Not. I mean, and normally I'm not that optimistic about like the truth will out just because of how the last eight years have gone over here. But like when it comes to science, I mean you the, in the end, the like truth will Out. If you do the science, right? You actually do it, it will, you can the change the science just by doing a bad job right like oh

0:30:56 Meredithe: No I fully agree I fully agree I will say um know the cast review did make it it a little easy for us to point out its flaws in many ways. I kind of like a laundry list of things I run through in my head at times and I think, did they really do that? They surely did. So one of them is just the wondering aloud, is it perhaps pornography consumption that is leading to high rates of young people seeking gender services?

0:31:21 Meredithe: That's very strange. Is one. The excluding of the vast majority of evidence that really accurately describes the effects of this care, but then to claim that there isn't any evidence, that's very strange. Inclusion of people who doubt the existence of transgender young people in focus groups, I've never seen a set of guidelines include non values and preferences in on care, let alone people who aren't even clinicians. You know, they included office workers in their focus groups, which is really weird.

0:31:21 Thomas: Boy what sorry you're gonna have to slow that one so there's focus groups to just be like hey in general like how cool are you with this whole trans thing and it's like not patients wow it's not so it's people who like work at what like a clinic or something that that yeah

0:32:02 Meredithe: I would say that's fair. Yep. Yep. Yes. People who are employed in various clinical services in the UK, that's the best that I can tell. Important to note that there are really solid guidelines on how to produce recommendations on clinical care. They come from the Institute of Medicine, which is now the National Academy of Medicine. The World Health Organization weighs in on this because not not anybody can just, you a bunch of stuff on paper and say, this is how care should be provided.

0:32:37 Thomas: So normally it's the first step isn't check the twitter replies that's not the first step of care of recommendations.

0:32:42 Meredithe: I would say no. Yeah, I would just, I haven't read that.

0:32:44 Thomas: It must be the second step then.

0:32:48 Meredithe: Of the things that is emphasized in the importance of producing clinical recommendations is you have to consider patients' values and preferences. The World Health Organization and the National Academy of Medicine do not encourage guideline producing bodies to consider the values and preferences of random people.

0:33:06 Thomas: Yeah. Know, when you do an x -ray, they should, you know, you should also x -lay a random guy too, just to be like, all right, how's his bones? Are my God.

0:33:13 Meredithe: You can ask, you guard in the waiting room if perhaps...

0:33:18 Kellan: Can you can just do an onion thing right area man doubts existence of transgender people thinks these clinical guidelines put together by experts are probably not very good like thank you sir and moving on but that's kind of what the cast report did it asked a whole bunch of people who have no equity no understanding of what's going on with this care and essentially made it a referendum on do trans people exist yes or no thumbs up or down and when we talk about the truth while out transgender people exist transgender people have been around for a long time the guidelines that oversee care for transgender people had been around for decades transgender people that body of evidence those expert guidelines aren't going anywhere so there can be political attempts to silence trans voices to silence expert voices and pretend like asking area man on the street what he thinks about whether trans people exist and should have access to care you can pretend that but at the end of the day it's just a fiction because the truth will out the truth is that trans people are here have always been here need access to health care and fortunately have clinicians like ken like meredith like colleagues across the world who are guided by the evidence guided by expert clinical guidelines this care and making it possible for trans people to live happy healthy lives and by the way I should know because I am one and I transitioned in russia 20 years ago and the fact that it is harder now in half of the u .s states plus the uk for transpeople to get access to the care that they need than it was for me 20 years a go in moscow indicates to me that there is a serious problem serious problem yes

0:34:51 Kellan: Some of us get the care that we need and some of us go on to thrive I mean you know my mother would appreciate you know hey mom I did it I got a PhD I have a real grown up job you know some trans people are really fortunate to have access to the care we need the support that we needed to become the people that we were always meant to be and then too many young people especially now don't have that adoption don't have access to that care because of some fiction that people are spreading for political purposes to deny the realities of trans lives and that's cruel it's cruel and it's the antithesis of what we should be doing as medicine as science as people involved in the healing professions as people are involved in generating the science and knowledge that continues to move us and our world forward. We're

0:35:39 Thomas: Said. In case we're all not mad enough, do want to read. They did find, I think, a medical expert for New York Times opinion here. Let me read the first paragraph. Hillary 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 like That's David Brooks, by the way. And that's recent. That's not like where, right when it came out, not that it matters, but like, come on, what are they doing over there?

0:36:11 Kellan: Hiding behind some propped up fictive experts, and I'm using air quotes here for experts, to enact a totally political agenda. Is a political agenda afoot in the UK and the US that gains political power, gains political momentum from bullying trans kids and banning best practice evidence -based care provided by compassionate licensed clinicians it's all about politics this is not about kids this is not about protecting the kids and again I'm using air quotes here what is happening right now with the cast report the bans in the uk the bams in the us is nothing more than politicians and people in power bullying trans young people and making it impossible for them to live their lives and just be who they are, come on being a young person is hard enough we've all been teenagers, we've all been there, it's hard enough without having people in power down at you from their elevated platforms and saying we don't see you don' t care who you are we don´t care what kind of healthcare you need or what your family has said or what you´re healthcare provider has prescribed we don ´t care, we only care about our political agenda and sorry, you´r just a pawn And

0:37:18 Thomas: Horrific. Absolutely horrific.

0:37:20 Meredithe: This report has been released, you marches on policy shifts, and I we need to look forward. The British Medical Association is kind of analogous to the American Medical Association. Is a large authoritative body of, a professional organization that about 20,000 clinicians in the United Kingdom are affiliated with. And they have issued a statement that is urging caution about implementing CASA's recommendations and that they would like to conduct their own review view of of, its contents. A very important and a statement. And in the months to come, the United States Supreme Court will hear the case on Tennessee's ban on gender affirming care.

0:38:07 Thomas: Medical experts those distinguished doctors of medicine so

0:38:11 Meredithe: You know, I think it's, I don't think anyone can predict what's going to happen. In a weird time in which courts are having to opine on medical evidence because the cases being brought before them are incredibly disinformed. And you have plaintiff's attorneys and defendant's attorneys duking it out over clinical research studies. Experts in this care are trying to do is to set the record straight with the truth. I that the cast review will feature prominently in the deliberations on this care and in the oral arguments. And I also know that everything that we need to know to decide whether or not care this should continue to be offered? We already know. One is saying that the science is over, that no more research should happen, because our patients deserve optimized models of care. They deserve more timely delivery of care, they deserve to know everything that can possibly be discovered about the medical treatments that are available to them, and they deserve for those treatments to get better over time. Years ago, we weren't offering GLP ones to people with, uh, diabetes and, and now we are, and it's saving lives. So I excited about ongoing scientific innovation in this field. And what a lot of people don't realize is that there's really robust, solid projects going on that are are funded to continue to optimize this care. Is sleeping the field of gender -affirming care. Nobody You know, has dusted their hands off and said, I guess we did it. I that we just have to kind of keep our on the prize, keep serving our patients, keep speaking out, keep just what we already know about this care and hold our patients close.

0:39:59 Kellan: I think with regard to the Supreme Court, there's actually quite a few factors already in play that support the court coming to the right conclusion. The first is its own precedent. Supreme Court in the U.S. has already held that discrimination against transgender people because they are transgender is sex discrimination that is prohibited under federal law. Is the issue at play here. These bans are denying access to care for transgender people. Not banning that care for cisgender people. There is no clearer expression of sex discrimination than that. The Supreme Court, being guided by its own precedent in the 2020 Bostock case, I think will find that these bans discriminate on the basis of sex by targeting transgender people for denials of care that are still made available, services that are so made available to non -transgender people. People and the another thing that is going on with with regard to the Supreme Court, is every lower court that has considered the evidence, every lower Court in the U.S. that has actually looked at the evidence base, looked at the science, has found that these bans on best practice care for transgender young people are illegal, are not based in medical science, are not based, in fact, and those laws have been overturned. So now we are seeing this question roll up to the Supreme Court. But again, every time a court has actually looked in detail at the evidence, they have found that these bans are impermissible because they're not based in science or medicine. So I think with regard to the U.S. Supreme Court in this case, sex discrimination has already been found by this court to include protections for transgender people, and every court that has considered the evidence has acknowledged the strength of that value of evidence and the importance of this care for transgender young people and for transgender People of any age. So I think there's a lot of reason for optimism around the future, and I think it's just critical that we continue to tell transgender young people, their families, their communities more broadly, that we're there for them, that the voices of transgender young people, even if they were excluded from the cast report, if they're shouted down on the opinion pages of the New York Times, the voices of transgender young people matter and history will hear them I

0:42:17 Meredithe: Analysis on the cast interview was was very in depth but it wasn't exhaustive and um is very hard to to bring large audiences into the weeds on very and niche topics, of which I would say this is one. That we produced covers six different areas. Started with our analysis on the ways in which the The contents of the CAST review, in many ways, align with the contents of clinical practice guidelines that are used to care for youth. CAST Review says outright, this care is appropriate for certain transgender youth. My experience backs that up. Sure Ken can speak to this, but, you also sure that his might back that up, that the research backs this up. You know, the number of trans youth who desire and seek and obtain gender -affirming medical care is extremely small. The next point that we delve into is how the review's own data contradicts its points. It presents volumes of referral data that show that not only are very few of the estimated population of trans youth in the UK receiving referrals to care, but far fewer are receiving contact with gender -confident clinical services, and then even fewer are perceiving medications. This supposed number about, you know, exponential skyrocketing rises in numbers of trans youth, we're not seeing it. Are seeing more young people being referred for care. An increase in referrals is never considered a bad thing, right? These are young people having with their providers and their families and then receiving an option to consider additional help. No problem with that. Other thing about the reviews data is that it makes a lot of, claims you about skyrocketing numbers of care steadily since 2012, when in fact, the first observed plateau in their referrals predated COVID. So predated a global public health emergency that would have ground a lot lot of services to a halt. Just simply not true. Also present a very sharp rise in referrals, but then they include a little footnote from 2020 onwards that says it's highly likely that most of these referrals are double counted or that we're including multiple instances of the same single referral on this graph?

0:44:41 Thomas: What? Why?

0:44:43 Meredithe: I don't know. I don't know. That's a good question, right? Thing that the review provided information on is just how many being seen in the gender identity services had supposedly stopped receiving receiving gender -affirming medical care, elected to for whatever reason, and then are termed quote -unquote detransitioners. And detransiton is a very complex topic. It has a lot of meanings to different people. It's not something that has a formal definition. While one might read the review and think that this detransitions phenomenon is quite common, this is really concerning. A lot of people are receiving irreversible medical treatments, and then they wish they hadn't. Review identified 10 people out of over 3,000 who stopped receiving gender affirming medical treatments. 10. if you would compare that to data on regret for various types of knee surgery, spine surgery in adolescents, for instance, knee surgery in older patients, the regret rates are high. They're 30 to 50%. So we're seeing satisfaction rates in this care that are really high comparable to other types of medical care, but we're review's own data back that up, but it's kind of swept under the rug. So we provide analysis on on that. Also provide a lot of analysis on the strange relationship that the cast reviews team seem to have had with those who conducted the systematic reviews of the literature. Communicated when they probably shouldn't have, they didn't communicate when they probably should have. It doesn't seem like the cast review team actually asked any research questions of the systematic review team. The people actually conducting evidence reviews, reviews. They didn't say, you know, we're interested in these outcomes. They just kind of left it to the researchers. That's the best that we can tell. That's unusual, not conventional, strange, because the people writing the guidelines should really determine Know, what outcomes are of interest. So we didn't see that happen. Also saw that the authors of the systematic reviews themselves at times made recommendations on care, which is really outlandish. Can tell you about this because he's, you an author group on a systematic review for the actual guidelines on care produced by WPATH. And systematic review authors, those who simply search the evidence, are not supposed to decide on care. They're not supposed to issue recommendations. Yet that's what happened here. So that's kind of a rundown of the structure of our report.

0:47:16 Ken: A couple of the points you raised really speak to what Kellen said earlier which is about the politicisation trans youth and how in some ways they're used as political pawns for example helpful for the narrative And if you're saying, well, there's this exponential rise, there's an epidemic in terms of young people presenting to specialist gender services. And so it that narrative and foster to worry in the society that there's something that's happening that is out of control. And the fact that the data didn't support that was and they seem to gloss over it and run with the narrative that seems like it was almost preordained. Similarly, when you talk about their findings in terms of what they call detransition and say it's an incredibly low rate of less than 10 patients out of more than 3,000, again, that seemed to be inconvenient and they got buried in an appendix. And even though I think detransiton is something that I assume is kind of at the forefront of the minds of the people writing this report and thinking about recommendations that that seems to be a significant concern and again it's very odd that their own data that speaks to that didn't get at highlighted all so that's really all that I wanted to add. I mean the only other thing that I for me worth highlighting is that in terms of the recommendations that come out of one of the more egregious ones is that puberty blockers should only be delivered or made available in a research setting and I think you know that's problematic for a number of reasons and you know one for example you know I think it's coercive if the only way you can get access to puberty walkers in England moving forwards is through a randomized controlled trial but we

0:48:54 Ken: Know or the national and international guidelines on clinical research indicate that you can't coerce people into research, but that seems pretty coercive to me. If your only way of getting it is to enter a research trial where you potentially get the treatment, potentially don't, going to be, I think, very problematic and it'll be interesting to see what ethics committees in England think about that. I think there's practical issues as well about making it only available via a research trail that design is randomised because if you get randomised to know people you walk with, you're going to know pretty quickly that you're not on them and I imagine dropout's going to be a huge issue.

0:49:30 Thomas: Just really shoddy work. I'd like to know whose response. Oh, wait, they didn't put their name on it except Cass. Okay, never mind. I can't really write them to find out. Yeah, you so much for all the debunking and for taking us through all that. It is so frustrating to see this. And it's also so frustrating, again, because I know there's so many people, probably people listening who might have like, you know, vaguely on the left, friends and family members who have fallen for this line that this is a a totally new thing that we're just throwing you puberty know blockers at kids as fast as we can we're spraying you all the kids with them just all just everywhere and it's it's just not true and this care to your point is um new but nothing drives me more nuts was it happening with covet too then a segment of our population deciding that because they never seen something it didn't exist prior to that and just deciding well these doctors they must just be winging it then, I guess, because I only found out about this today. It is infuriating. And it's not good medicine. I'm going to venture an opinion, a medical opinion. That's not Good Medicine. I am just going to. So, but anyway.

0:50:29 Kellan: Good medicine not good science and not good policy

0:50:31 Thomas: Yeah. It's so horrifying. But again, I hope my listeners will get the word out aboutthis because this report did a ton of damage. Oh, I usually ask, Anywhere Where you want to send my audience, usually you it's like people's social media, but whatever you want to send people to, I always allow people to do some shout outs, some plugs. And if has anything, please let me know.

0:50:50 Ken: The only part I would say is to send people to the integrity report and to the law school to have a read.

0:50:56 Thomas: Excellent. That'll be in the show notes for sure.

0:50:58 Kellan: 38 pages so yourself a quiet spot have a nice cup of tea and get ready to have your mind blown about all the ways that the cast report misrepresents misinforms politics, and harms the very young people that it claims to protect. It's a shocker, folks. Thanks,

0:51:14 Meredithe: Yeah. We had some new visitors to the Yale Integrity Project website. One little thing I just wanted to say because I wanted to um in one kind of like sentiment from someone in our author group so one point as we were kind of metabolizing the the contents of the cast review one of um co -authors said something quite profound um said you know it's just it bothers me so much much that the cast review is so fixated on the possibility that someone who isn't trans would get gender affirming care, but there is no reciprocal consideration for somebody who is transgender not getting that care. To me, that really shined a light on the biggest problem with it and why it can't be taken seriously as a set of true unbiased guidelines on care because it really missed the boat on that.

0:52:08 Thomas: Absolutely yeah it's it's the kind of thing that I think only makes sense with the unstated premise that trans people aren't real I think that's the only way that makes sense like if you're just gonna say well one person might get treatment that doesn't need it and you don't care about the people who do need treatment who aren't getting it I think think that means you don't believe they're real or they're actually trans or whatever that's just me yeah very

0:52:29 Meredithe: That's not just you, but I'm glad you see it.

0:52:32 Thomas: Frustrating um right. Well, I thank I thank you all so much. I thank you enough. Great work you're doing. And I am definitely going to, I'll include everything in the notes and check out the integrity project because that seems incredibly useful and necessary right now. So thank you so much

0:52:46 Kellan: You. We appreciate it.