Tavistock. Part Two: Clinical Dilemmas

Talk by Polly Carmichael.

Part Two on the tension between different approaches for dealing with “Gender Dysphoria”.   Hopefully part one provided some background for any neophytes. Tavistock Clinic: Part One.

Dr Carmichaels speech is : here  The summary is taken from a transcription provided by Mumsnet volunteers; for which I am very grateful.

The  talk took place in the following context:

  • 4500% rise in the number of referrals, to the Tavistock, over a decade.
  • Rise in females (reversing sex ratio in less than a decade)
  • Tavistock pilot to place younger children on puberty blockers.

This change in protocol followed work done by Dutch Gender Identity Services.  As you will see, from my earlier blog, the Tavistock were under some pressure to revise their treatment protocols to allow earlier medical interventions.

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The evidence from introducing puberty blockers, at an earlier age, has resulted in children invariably progressing to cross sex hormones and entrenched on a medical pathway.  The pro-medicalisation Lobby argue this is because they are 100% accurate in identifying those children who would persist.  The alternative perspective is that the act of blocking puberty somehow locks in the Gender Incongruence. If this is correct we are medicalising those who would have desisted and, historically, many of those would simply be gay. I cover this here The Woke Gay Conversion Therapy?

There are many people working in this field who have raised this as a concern: 9AAEBE78-2449-4E00-B2BE-9351E9599D90

We don’t know whether these children would have desisted and reconciled to biological sex.  The pro-interventionists have another  perspective. They argue this is evidence the screening is working and it may be unfair to the children not put on this clinical pathway! This is also the argument used against setting up a control group. From the perspective of the Tavistock it would be unethical to leave a cohort untreated if they meet the diagnostic criteria for intractable Gender Dysphoria.  I do wonder if anyone has thought to include parents, who oppose medical intervention, to see what the long term outcome is for our children?

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Another startling admission is that we simply don’t know what the long term implications are on developing brains. 👇This is a clear admission this is an experimental treatment.  Have politicians,and parents,  been persuaded to take this risk because activists claim our children are at a high risk of suicide?  Have activists managed this by leveraging questionable data on likely suicide? (I blogged about this here Suicide in the Trans Community)

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This paragraph is important because there are still documents out there calling this intervention a “pause”.  Indeed here is Polly herself from the CBBC children’s programme “Becoming Leo”. 36D86977-4F65-4CD8-AF4C-2A7E48DF5E3F

Many people working in this field have postulated that going through a natural puberty  resolves gender incongruence in the majority of cases. Dr Carmichael is clearly aware of this research and emphasises that the treatment, at Tanner Stage 2, means that these children will at least have had a partial puberty.

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She concedes the paucity of long term data on outcomes. She also anticipates concerns  about competing mental health diagnoses.  In this way the “Gender Dysphoria”, it is implied, has to be treated to resolve these other difficulties. This neatly avoids any suggestion mental health issues underpin the “Gender Dysphoria”, or desire to find a label/treatment.

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The framing of this discussion is entirely reliant on whether you believe in an “innate gender”.  If you do believe a child can be born in the wrong body it  necessitates treatment.  If you believe gender is a social construct then societal sex stereotypes are the problem.  These seem to be irreconcilable belief systems.  Worth having a look at how Mermaid’s diagnostic criteria works.  Would anyone not meet the diagnosis threshold given this criteria?

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Dr Carmichael , below, frankly admits that the evidence has yet to catch up with practice. She further acknowledges there is no consensus and there is concern about the long term health impact. The only way this treatment can even approach an ethical justification is if you are confident that:

a) Gender Identity is innate

b) The Tavistock have a reliable system for targeting irreversible treatments only on children who would, in any case, have persisted. 

c) You believe data that suggests there is a suicide epidemic in trans-identified youth. {This makes intervention a life saver & justifies pharmaceutical interventions}.

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So what has effected this change?  Political Interest and Lobbying.  Let us not forget the role of the Women & Equalities Committee. Since it morphed, from a  Women’s committee, it has been successfully colonised. In its original incarnation it focussed on women’s issues.  As predicted, women’s concerns have been pushed to one side with a wider focus on “Equalities”.

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The quote below👇 touches on the real change in the landscape surrounding “Transgender” children. Dr Carmichael acknowledges that some children are being socially transitioned at pre-school age. This is also a reference to the growing condemnation of “watchful waiting” , now badged as a practice akin to #GayConversionTherapy.  The memorandum of understanding (MOU) she references commits to a ban on therapeutic work to resolve Gender Incongruence.  BACP (British Association for Counselling and Psychotherapy) & the BPS (British Psychological Society) have signed up to a ban on Gender Identity “conversion”.  The Royal College of GPs has also signed this MOU.

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The fact most desisters  are predicted to be gay  seems to have escaped their notice. Counselling, to reconcile to biological sex,  is now officially condemned by these, erstwhile, esteemed professional bodies.  As of May 2020 there are is a  further move to outlaw any therapy to address “Gender Dysphoria” by, once again, conflating it with Gay Conversion Therapy. See here Gender Identity Conversion Therapy

There’s a huge amount to unpack here. 👇

401C86F5-0FAD-422C-B5C1-170B87F2D93DDr Carmichael is not happy  the Tavistock  are being accused of not being sufficiently affirmative.  She does appear to be trying to raise awareness of the changing nature of the child referrals.  Her interpretation of the parents, mentioned above. does not accord with my own perspective.  Socially transitioning a three year old and then attempting to report a young child for the Hate Crime of misgendering another child!  Is  this the behaviour of parents who are simply being protective! If I was relaying this story, verbally, my incredulity would be at such a high pitch only dogs would be able to hear me!

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In the section below there are a lot of erms as Dr Carmichael hesitates over the admission the treatment compromises fertility . She is anxious about this, but not for the reasons you might expect. She is concerned about  young people who defer medicalisation to try to salvage their reproductive health. The reason for this is they may not “pass” ,if they delay long enough to have a chance at parenthood.  This is not an uncommon viewpoint. One practitioner in this field praises the children who are kind enough to see themselves as future child adopters.

Sacrificing fertility is quite a significant thing to ask children to consent to and yet her concern is one of “presentation”.  Polly is aware this is indicative of that great sin of “binary thinking”. {Its almost as if she knows, on some level, there are only two sexes!}  No doubt Polly would consider me a “biological essentialist” but, like many women (and men),  I was in my thirties before I desired children. I would not have made a mature  decision, to place my fertility at risk, at age 12.

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And that last sentence! Actually wondering how the Tavistock can support children to feel comfortable enough to live with their bodies!   Klaxon Klaxon Klaxon!! This is what parents would like to know!  Shouldn’t the first line of treatment be body-positive?  In less than a decade we seem to have normalised  a bodily dis-associative disorder and completely over-turned decades of work, especially for the female body.

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Another thing that is hard to keep up with is the removal of any reference to mental health issues. The diagnostic criteria for Gender Dysphoria has now officially been re-classified to remove suggestions it is a Mental Health issue.  I sense Dr Carmichael really wants  to find a way to talk about co-morbidities here. However  activists have successfully  rebadged Gender Dysphoria as a naturally occurring variation and references to mental health are removed from the official diagnostic manual.

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How many of these children/teens placed on an irreversible pathway may have benefited from some good therapeutic exploration of their motivations?  Therapeutic Interventions to resolve Gender Dysphoria

This is a good summary of what the impact of this Conversion versus Affirmation model does to practitioners in this field.  I diverge on many points with Dr Carmichael but she is right that we are favouring medical solutions to resolve psychological issues. The lack of psychological support has also been raised by Tavistock staff who have now left and are whistleblowing.

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To balance the pressure for medical intervention we need a diversity of voices. These should include detransitioners,  It should include parents of children struggling with this “condition”.  It should include people who understand the concept of an iatrogenic “illness”.  It should include people who have expressed concern about what we are doing to young people. We need a countervailing voice to Lobby groups like Mermaids, Stonewall and Gendered Intelligence.

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The above is not a bad summary.

  • We need more empirical data, less opinion.
  • We need to look at contextual factors. (School teaching on Gender Identity, for one)
  • I disagree about taking a lead from young people.  Detransitioners have taught us that.

We need to urgently take measures to make certain we are not  medicalising children who could have lived a life without hormone dependency and surgical interventions.

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The problem with this service is that it seems to be driven by people who see this as a social justice cause, They are excited at disruptive thinking, eroding or destroying social norms.  I will leave you with this quote from Bernadette Wren, who also works at the Tavistock. This is from the Transgender Equality Inquiry in 2015.  I sense that Dr Wren should have been more careful. Sometimes a social revolution doesn’t take the form you, naively, imagine it will:

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Therapeutic Interventions to resolve Gender Dysphoria

This article shows how a good therapist can identify underlying issues and attempt to resolve Gender Dysphoria without medicalised responses to bodily discomfort.  The therapist is fluent in Gender Identity speak  but does have the courage to honestly interrogate what “Gender” means to the clients they see. It is important to  note that any therapist may, or perhaps will, feel compelled to speak in approved language to get published. Additionally our young people have imbibed the new lexicon so the therapist may need to speak in the approved language, to establish a dialogue with Gender Dysphoric youth.

The article: Psychoanalyst on Transitory Trans Identity   Author Alessandra Lemmas

Psychoanalysis pays attention to unconscious motivations in the formation of “identity”.  This is in marked contrast to Gender Identity proponents of a medicalised response. Lemmas talks of the need for  “a posture of implicit scepticism”  when dealing with claimed identities. This is in marked contrast to Gender Identity medical practitioners who prioritise a subjective sense of self and demand only “belief”.   This is an excerpt from a response to an article in the British Medical Journal about how to treat Gender Dysphoria. The response is from Dr Helen Webberly, currently suspended from the General Medical Council,  who is not alone in her stance: Helen Webberly . 

7497F32A-55A9-4C68-BBF4-F5ABE45B1E43The belief that people can, literally, be born in the wrong body underpins the lack of a therapeutic approach to young people presenting with Gender Identity Issues. Merely to suggest that this may be an incorrect, self-diagnosis, generates outrage that  we are denying the “lived experience” of the transgender community. Yet we know, as Lemmas, and many others, point out most desist, reconcile to biological sex and many are simply gay. 👇

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The author subscribes/pays lip service to the idea that sex is assigned at birth, rather than merely observed, as it is in 99% + cases.  She subshumes both Lesbians and Gay men underneath the “transgender” umbrella. The statistics on post-operative satisfaction accept the narrative from within the Gender Identity community with no acknowledgment of the methodological flaws with the phenomenon of “loss to follow up”. {This is where a patient loses contact with the Gender Identity Service they are using. Detransitioners say they don’t return to the services which, they feel, actively harmed them, so this cohort disappear from the “follow up”}

The three case studies, in this article, cover many of the issues raised by parents dealing with our gender Dysphoric offspring.  All claimed a transgender identity with no prior history  sound puberty. We are told about the huge spike in referrals to the UK’s main Gender Identity Clinics and a wider social context emphasising choice and very much of a piece with the atomising of the individual in neoliberal, capitalist, societies.

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The first case is illustrative of the complicity of transgender identity.  More on “Anita” below. 👇. As you can see Anita claims multiple identities encompassing male, gay & female as well as “drag queen”.  Already taking cross sex hormones but with no intention to progress to more surgical changes.

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The dialogue seems to settle on the idea that gender identity can be fluid and an exploratory phase. Nevertheless Anita is already medicalising, We leave this case here, though I will just add that I have never seen a satisfactory explanation of what “living as a woman” means. It seems to depend on circular reasoning /a retreat to sex stereotypes.
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Janes case is more complex and, arguably, requires a more robust interrogation since Jane seems to fully intend a full transition to “live as a man”.   The sessions are challenging and, on more than one occasion, the analyst reports the anger triggered by the exploration of underlying issues. What emerges is a young girl whose parents have traditional gender roles in the household. Janes perception is that her mother is a “hostess” with little power, standing in the household.  On being pressed much of Janes “Identity” seems built about rejecting all the signs associated with being a “girl” such as make-up and long hair.  Here are some of Jane’s thoughts on what being a girl means to her:

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Tellingly., Jane reveals that they did not feel they measured up to the expected level of attractiveness as a girl.  Even more revealing is an expression of same sex attraction. Not as a lesbian but as a male attracted to females. Another common theme in detransitioners is the yearning for passing privilege as a male and how this, in retrospect, seemed to become more unattainable as they sought to identify as male.

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Jane is also adopted and vehemently rejects any idea this relates to their gender identity issues, However it later emerges that the birth mother was from a culture which prized male children, in preference to girls.  This prompts some self reflection and the realisation / admission that maybe this was bound up with the idea that her mother may have kept a male child.

248B3FDC-75C6-4E19-963F-3C15E42131C3Janes situation resolved itself without medical intervention. She is in a same sex relationship and has found a way to identify as a strong woman in her on line world after previously observing that she felt “insubstantial” and, significantly, failed to garner the same respect when she was coded female.

The third case study is Alex, who is a female who identified as male at 16. Alex was not interested in being dissuaded from hormones and surgery, as is common with our Gender Dysphoric youth. Alex’s parents affirmed the new identity and accepted their daughter as a son. Alex, however,still wished to access therapy, but still underwent a double mastectomy at age 19.  Post surgery Alex was, initially “happy” but then became depressed and suicidal and revisited the sexual abuse that they had endured at age 10, and realised the link between the abuse and the desire to remove their breasts . A54C4CEA-6ED9-4124-9D69-F442DC35785ETellingly, the parents were not aware of the sexual abuse and it did made me reflect on their role as affirming parents and, if they had been aware of this history, would it have made them exercise more caution?  I do NOT say this to judge those parents.  Any one of us could have genuinely advocated for this stance in the belief, pushed relentlessly by our media and advocated by public bodies, that this is the right thing to do.

I am conflicted about the “woke” language. By espousing the idea that someone can born “in the wrong body” {which is the belief system underpinning  transgender ideology} the danger is our Gender Confused children are getting mixed messages.  On the one hand the implication is that they may be hard-wired with a conflict between sexed bodies and an opposite sex brain.  At the same time it is clear that some of these cases are complicated by sexual orientation, history of sexual abuse and family dynamics.  There remains no diagnostic test that can separate the influence of “neuroplasticity” from the notion of an opposite sex brain.  In an ideal world we would start from the clear premise that there is no solid evidence that there is a biological basis for this incongruence between sexed bodies and a “gender identity”.   That does NOT mean that Gender Dysphoria does not exist or that it cannot, in a minority of extreme cases, be extremely debilitating and, for adults, may lead to an inescapable desire for medical intervention.

Irrespective of these misgivings this is a good article and those of us dealing with Gender Dysphoric teens know how hard it is to navigate this terrain.  Some solid therapeutic work seems to have built up sufficient trust to garner some solid insights from these young people.  Of course I wish that self-awareness pre-dated significant surgery but for parents struggling with this, especially,  I do recommend this piece.

 

Puberty Blockers: Part Two

Endocrine Society and the case for Puberty Blockers.

For my second post I will look at an article which, on balance,  advocates for an affirmative approach for children/teenagers with Gender Dysphoria. Endocrine News

Historically the treatment, for children, was to watch and wait.  The medical consensus indicated that the majority resolve gender identity issues, following puberty. In the light of this research  the treatment protocol was to defer medical intervention.   An overview of some of the research, advocating for this approach,  is contained in this article:  Critique of the American Association of Paediatrics.

Over the last decade, however, the sector has moved to an affirmative model of care which holds that discordance between biological sex and gender identity is a biologically based phenomenon. The condition of Gender Dysphoria is no longer regarded as a psychological phenomenon. We are told  one can be “born in the wrong body”  and the phrase “assigned fe/male at birth” is in widespread use, even by medical practitioners. This ideological shift  underpins a revision  to how we treat children presenting with issues of Gender Identity. Medical intervention, according to this theory, is merely confirming a biological fact. This necessitates aligning the physical body to an, assumed, opposite sex brain.

Despite the overall thrust in favour of early intervention the article does  raise some interesting ethical dilemmas and  makes some, albeit limited, reference to opposing clinical views.   The language used, however, talks of “biological gender” rather than “biological sex” which serves to reinforce belief in the biological underpinning for the condition. 👇

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Notice also the sleight of hand that presents puberty blockers as a “delay” and a device to “buy time”.   {Later on in the piece it seems  clear that we are not simply delaying or pausing puberty, watch the language shift}2F2853F7-D2AC-44F6-9DD6-0B5A6B7626BBNorman Spack was the person involved in the high profile, early transition, of the child of, Mermaids founder Susie Green.  The last sentence is indicative of the number clinicians feeling wary, or ill-equipped to practice in this field.  The effect of this reluctance, arguably, leaves the discipline dominated by those with a particular zeal to work in this area. Are those clinicians more likely to adhere to biological theories of its aetiology? Are the treatments advocated then more likely to  follow an affirmative pathway? Most practitioners I encounter, who work in this field, do seem to subscribe to a “born in the wrong body” narrative which, I would contest,  deeply influences their approach to practice. Do we have enough variety of approaches in the  Gender Identity specialists, working with Gender Dysphoric children /teens?

So what vidence is there for the  claims of a biological origin for “transgenderism” ? There is research showing a much higher incidence of transsexuals in identical twins than in fraternal twins. 👇 The figure of 40% has been critiqued, but do we even need to cast doubt on this figure? Wouldn’t we expect it to be at least closer to 100% if the cause is biological & not cultural/ environmental? 

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The research relies on the, hugely contested, notion of female brain versus male brain. The article below raises some questions about the nature of the research, the lack of  consistent outcomes and limited understanding of the effects of cross-sex hormones on the brain, or the impact of neuroplasticity. I think it is a fair conclusion to say the jury is still out  but here is one study: The Transgender Brain . 

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Clearly there are divergent views but irrespective of those espousing the idea of conflicting “brain sex” the fact remains  we do not have a diagnostic tool to “prove”  anyone, presenting with Gender Dysphoria, has a biological condition. In the absence of definitive, diagnostic criteria are we confident that early intervention is the best course of action?   Especially in the context of historically high rates of desistance from a trans-identity? Ken Zucker has worked in this field for decades and is also quoted in the article.

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Not only are we looking at an average of 80% desistance rates there is also a high correlation between those that desist but many will mature  into gay males or lesbians. Are we being cautious enough?  The level of  desistance rates  is often disputed but it has been a consistent finding that the majority desisted even if you reject the figure of 80%. There are legitimate criticisms of the data on persistence /desistance. Loss to follow up is one.  Patients who cease to engage with service providers may be desisters or, as is argued, they may have moved to other providers.  De-transitioners are pretty consistent in saying they would not return to the very professionals who were complicit in their medicalisation/surgery so this has to form at least part of the “loss to follow-up” population. I have covered some of these critiques in part one.  Here a pro-affirmation practitioner raises caution about a too swift diagnosis even though, as they make clear, they are proponent of a “hard-wired” transgender identity. 

7DDABD2C-893C-453D-B03D-AC0E65A36B63726A78C5-CE14-4D4D-AE2A-940D9AD6B80EIt is clear, to me, this is a contentious area and furthermore that there is no consensus on a biological basis for Gender Dysphoria. However, if as I contend, the “hard-wired” belief is  widely accepted by the sector  it will have an impact on clinical approaches. It follows that identifying this population early is believed to  allow swift intervention to ameliorate present, or anticipated, distress.  It appears to be a widely, and fervently, held,  view, that it is necessary to block puberty and administer cross sex hormones at ever younger ages. A more recently advanced justification, in this paper, is that blocking puberty reduces the need for later surgery and, makes it easy for the Transgender child to conform to norms for their target sex.

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The move to earlier medicalisation, for gender dysphoric children is a) conditional on a belief it is biologically based b) that we can identify this population with a degree of accuracy. I reiterate: we currently do not have a reliable, medical method of testing any biological markers for innate gender /sex incongruence.   In the UK we can start puberty blocking at age 12.  Spack advocates for age 10-12 for girls and 12-14 for boys.  This prevents development along expected lines so the idea is that we halt masculinisation in boys and feminising effects in females.  We halt female breast development and promote greater height and, do the opposite to males. Yet the very phrase “puberty-blockers” gives an impression of a targeted intervention when we actually don’t know what other impact these drugs  have.

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Notice above that we are not talking about a “delay” or a “pause” we are now talking about “prevent pubertal progression”.  That is a change of language that matters.  If we are right we are preventing something that is undesirable. If we are wrong…..

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The article continues and references the , by now well documented, change in the sex ratios in those presenting with Gender Dysphoria.  This shift cannot be explained by an underlying biological basis unless argued, as it is, that we are now more accepting of Transgender communities which enables more girls to come out. As many of us  have highlighted there does seem to be a dearth of middle-aged women suddenly discovering their authentic selves.   I have not seen any research which questions why there are so many older males and an almost complete absence of late transitioning in the female sex.   I am also not sure that Butch lesbians would concur that there is widespread acceptance of “masculine” women as is argued below.

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What we are talking about below is removal of the testes or ovaries, womb, inversion of the penis and creation of a facsimile or neo-vagina. The proponents of this tend to use medical or euphemistic language to soften what they are actually undertaking.  Hence we have the prevalence of “top surgery” crowd funders which do not use the terminology of “double mastectomy”.

50F3102B-9A92-472C-9A99-6F7AEAE78937 Spack’s own policy is that patients must have the support of “both custodial parents”.  That phrase jumped out because we are starting to see cases of parental disagreement and the non-custodial parent is omitted from this statement. He also states that there must be a referral letter that confirms there is no other co-morbidities.  I know from my own reading that this is not the case with many of the cases I have followed.  I have seen diagnosis of Border Line Personality Disorder and Schizophrenia described as “coincidental” to the Gender Dysphoria.  This is often accompanied with a demand to respect the bodily autonomy of those with mental health conditions. Here is a letter sent by Dr James Barret to the London Review of books which confirms that mental health conditions, of a most serious nature, are not a barrier to treatment:

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Norman Spack , on the other hand, states that severe psychopathology must be ruled out before commencing treatment:

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Below we are told that there is no “litmus test before Tanner 2 puberty”.  Also it is also revealed that those who go onto puberty blockers don’t desist.  I have seen Dutch research that confirm a 100%, of those on puberty blockers,  don’t reconcile to their biological sex, and do go onto cross-sex hormones.  Here is that  Dutch Study

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GnRH analogues appear to be pretty fast acting.  What this means for these adolescents is that they are left in a “prepubertal” state and out of step with their cohort.  Again we are told they are “reversible” but of course all of that is a moot point if, as the Dutch study illustrates, most don’t desist once they have embarked on medical intervention.

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Here is a clear statement that the price that will be paid is “infertility”.   I have lost count of the number of people who have , not always politely, accused me of lying about this and here we have it confirmed.  Of course it is difficult to have a conversation with a 12 year old about infertility and for them to understand what they are giving up.  Ironically there was , quite rightly, outrage from the Trans Community, at those countries that made sterilisation a pre-condition for their treatment.  Yet on this type of sterilisation transactivists have been resolutely silent. (Though there are adult transsexuals who have expressed concern about youth medicalisation).

4696C6A3-58C1-484B-9004-BF36531D9D607AC75242-C3DE-4BEE-91CB-9ADE1C9943E5Here is a risk benefit analysis which again promotes the benefits of earlier intervention.  Yes. Cancer is a risk.  Yet we can simply surgically remove the at risk organs.  And of course appropriately sized breasts has to be a priority!

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It is true that puberty blockers have been used for precocious puberty for decades. This research mainly covers girls who are more prone to early onset puberty or, perhaps, more likely to be medicalised. Even whilst claiming the safety of puberty blockers for this group of patients it is admitted that we are still not clear if the same applies to “transgender” patients.

1BD724F1-4676-401E-AC29-EBEDB23F9836Furthermore it is also not quite true that there are no dissenting voices about the safety of the treatment.  Adverse outcomes: Puberty Blockers.  

Also note that this patient group have a diagnosed condition.  We do not have a diagnostic tool for the transgender patient group.  Furthermore , there is a dearth of males in the first cohort so limited research on this group.

The article concludes with this statement.  I am not reassured. Not at all.

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