Timely and Sensitive Report on Gender Affirming Care. Medicine Needs to Exercise extreme Caution!

# 48 2024 The Rowen Report

Dear Subscriber,

A new report has come out on gender affirming care. Commissioned by England’s National Health Service, Hiliary Cass just released a many hundreds page report on the subject. It was timely, sensitive, in depth, compassionate, and, in my opinion, on point.

USA Today reporter Ingrid Jacques did a good review on the matter, and I will post her report below. And below that, I will add the report from the Guardian and their take on it.

I have repeatedly said that the trans problem is most likely an environmental canary in the coal mine matter where human intoxication of the planet is now causing gender dysphoria in human youth. It was only a matter of time. Amphibians and fish are found to have mixed sexual characteristics in polluted waters at toxin levels far lower than we could measure 30 years ago. This cannot be peer pressure, LBTQ+++, political agendas, etc. It is intoxication. And, we know that our babies born today have over 200 toxic chemicals measurable in their cord blood.

To me, the insanity was rushing to “affirm” care with mutilating surgeries and/or hormone therapy. I personally find this type of intrusion into a confused minor to be abhorrent, especially when we know that most of them will grow out of the confusion as they sexually mature. Below, Jacques tells of a woman who had her breasts removed as part of her gender affirming “care”, only to discover later that she wanted to transition back to her birth sex.

I also don’t believe that sex is assigned at birth. How nonsensical. Sex is determined at the moment of conception by the sperm that enters the egg. Does it carry an X or a Y chromosome. Environmental factors may affect the expression of those chromosomes.

I hope and pray that we will depoliticize a highly charged matter where extremists/activists in the “rainbow” coalition have an agenda to add more soldiers to their armies, wherein they push for “care” to mess with the biological sex of minors well before they can fully understand what they are, or might be, doing to themselves. Sadly, their agenda has infected government. One of the first questions I was asked when in custody was what sex I identified with, and what my pronouns are. What a monstrous change in just 3 years of the current administration. Is this happening in the military as well?

I agree with Hilary Cass. We must use extreme caution on body mutilation whether surgical or hormonal. This also raises a somewhat related point that we should use extreme caution in pushing unevaluated and untested medical treatments, especially on those who ARE already hesitant – like COVID forced genetic jabs, which we are now seeing associated with turbo cancers.

All medical interventions with unnatural substances or cutting carry many, many unknown risks. There is a self serving (in my opinion) organization of “experts” in trans care which became politicized some years back and lost its mission and purpose for a dark agenda. They claim there is “science” behind gender affirming care. How can there be science when 80% of those afflicted realize and fully accept what they are during or after puberty, and they have essentially nothing to show for the good these mutilations do years after the fact with careful follow up.

To Your Excellent Health,

Robert Jay Rowen, MD

'Extreme caution': Cass Review raises red flags on gender-affirming care for trans kids

Maybe the right course of action lies between the extremes. With more children experiencing gender dysphoria than ever before, some humility is demanded among both critics and activists.

Ingrid Jacques

USA TODAY

One of the most contentious battles of our time is over what access transgender young people and their families should have to medical intervention.

A week ago, the U.S. Supreme Court jumped into the fray by allowing Idaho to start enforcing its ban on what has become known by LGBTQ+ proponents as “gender-affirming care” for minors.

The country is nearly split between Republican-led states that have acted to restrict puberty-blocking drugs, hormone treatments and surgeries – and Democratic-led ones that want few if any limits. 

The name-calling on both sides of the issue hasn’t helped. Conservatives wary of intrusive treatments are framed as not caring about transgender kids and making them feel unsafe; liberals are accused of mutilating and indoctrinating children. 

Maybe the right course of action lies somewhere in between these extremes. With more children experiencing gender dysphoria than ever before, some humility is demanded. 

There’s much that we simply don’t know about the long-term implications of giving minors these drugs and surgeries that can permanently change the trajectory of their lives.

That’s one of the findings of the widely anticipated Cass Review, released this month.   

The nearly 400-page report represents a years-long review by Dr. Hilary Cass, a pediatrician, of existing research as well as interviews with young people, families and clinicians. 

The review was commissioned by England’s National Health Service, which has already acted on some of Cass’ interim recommendations. The NHS has said that puberty-blocking drugs will be available only for minors who are in a clinical trial. This follows a trend of other northern European countries hitting pause on such treatments.  

Cass’ report is written in a clear and compassionate manner, and her findings deserve careful consideration in the United States, too.

NCAA rules on trans athletes:These women say transgender rules discriminate against them. So they're suing the NCAA.

Evidence behind youth gender care 'remarkably weak'

Cass’ conclusions point to a need to slow down on drug treatments, and that the evidence supporting related gender care is “remarkably weak.” 

While Cass found that children deserve better, more comprehensive care related to their gender dysphoria, the report cautions strongly against the use of puberty blockers and hormones. 

Some of the key findings from the report: 

•         "There is no simple explanation for the increase in the numbers of predominantly young people and young adults who have a trans or gender diverse identity, but there is broad agreement that it is a result of a complex interplay between biological, psychological and social factors."

•         "The strengths and weaknesses of the evidence base on the care of children and young people are often misrepresented and overstated, both in scientific publications and social debate."

•         "The rationale for early puberty suppression remains unclear, with weak evidence regarding the impact on gender dysphoria, mental or psychosocial health. The effect on cognitive and psychosexual development remains unknown."

•         "The use of ... hormones in those under the age of 18 also presents many unknowns, despite their longstanding use in the adult transgender population." 

•         "Clinicians are unable to determine with any certainty which children and young people will go on to have an enduring trans identity."

•         "For most young people, a medical pathway will not be the best way to manage their gender-related distress." 

Don't experiment on children

These last two findings track with a growing number of young people who are telling their stories of “detransitioning” and who regret that they weren’t offered more comprehensive help before hormones or surgery. 

Some professionals in the medical field are speaking out, too.

Coach stood up for women in sports.Then faced public shaming from her college.

Grace Powell, for instance, had believed she was transgender as a teen and had a double mastectomy and took cross-sex hormones before college. Powell, now in her early 20s, has detransitioned.

She told New York Times’ columnist Pamela Paul: “I wish there had been more open conversations. But I was told there is one cure and one thing to do if this is your problem, and this will help you.”

Others have similar stories. 

When dealing with children, the traditional medical pledge to “do no harm” carries extra weight. Young people and their families deserve the best and most reliable information before making any big decisions.

Cass’ report raises many red flags about how little is known about the long-term consequences of gender-affirming medical treatment in children. She urges “extreme caution” multiple times throughout her review. 

Transgender activists act as if the science on this complicated issue is settled. As Cass shows us, that’s far from the truth. 

Ingrid Jacques is a columnist at USA TODAY. Contact her at ijacques@usatoday.com or on X, formerly Twitter: @Ingrid_Jacques.

https://www.theguardian.com/commentisfree/2024/apr/26/cass-review-gender-identity-services-report

As the dust settles around Hilary Cass’s report – the most extensive and thoroughgoing evidence-based review of treatment for children experiencing gender distress ever undertaken – it is clear her findings support the grave concerns I and many others have raised. Central here was the lack of an evidential base of good quality that could back claims for the effectiveness of young people being prescribed puberty blockers or proceeding on a medical pathway to transition. I and many other clinicians were concerned about the risks of long-term damaging consequences of early medical intervention. Cass has already had to speak out against misinformation being spread about her review, and a Labour MP has admitted she “may have misled” Parliament when referring to it. The review should be defended from misrepresentation.

The policy of “affirmation” – that is, speedily agreeing with a child that they are of the wrong gender – was an inappropriate clinical stance brought about by influential activist groups and some senior gender identity development service (Gids) staff, resulting in a distortion of the clinical domain. Studies indicate that a majority of children in the absence of medical intervention will desist – that is, change their minds.

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The many complex problems that affect these young people were left unaddressed once they were viewed simplistically through the prism of gender. Cass helpfully calls this “diagnostic overshadowing”. Thus children suffered thrice over: through not having all their problems properly addressed; by being put on a pathway for which there is not adequate evidence and for which there is considerable risk of harm; and lastly because children not unreasonably believed that all their problems would disappear once they transitioned. It is, I think, not possible for a child in acute states of torment to be able to think through consequences of a future medical transition. Children struggle to even imagine themselves in an adult sexual body.

Some claim that low numbers of puberty blockers were prescribed. Cass quotes figures showing around 30% of Gids patients in England discharged between April 2018 and 31 December 2022 were referred to the endocrinology service, of whom around 80% were prescribed puberty blockers; the proportion was higher for older children. But these numbers are likely to be an underestimate, as 70% of children were transferred to adult services once they were 17, and their data lost, as very regrettably they were not followed up. This is one of the most serious governance problems of Gids – also specifically addressed by the judges in Keira Bell v Tavistock. Six adult gender clinics refused to cooperate and provide data to Cass. However, having come under considerable pressure, they have now relented.

It is often claimed that puberty blockers were not experimental, as there is a long history of their use. They had been used in precocious puberty (for example where a child, sometimes because of a pituitary abnormality, develops secondary sexual characteristics before the age of eight) and in the treatment of prostate cancer. But they had not been prescribed by Gids to children experiencing gender dysphoria before 2011. The lack of long-term evidence underlies the decision of the NHS to put an end to their routine prescription for children as a treatment for gender dysphoria – that is, for those whose bodies were physically healthy.

The attempts of Gids clinicians to raise concerns about safeguarding and the medical approach were ignored or worse.The then medical director heard concerns but did not act; ditto the Speak up Guardian and the Tavistock and Portman NHS foundation trust management. I was a senior consultant psychiatrist, and it was in my role as staff representative on the trust council of governors that a large number of the Gids clinicians approached me with their grave concerns. This formed the basis of the report submitted to the board in 2018. The trust then conducted a “review” of Gids, based only on interviewing staff. The CEO stated that the review did not identify any “failings in the overall approach taken by the service in responding to the needs of the young people and families who access its support”. I was threatened with disciplinary action. When the child safeguarding lead, Sonia Appleby, raised her concerns before the trust’s review, the trust threatened her with an investigation; and its response, as an employment tribunal later confirmed, damaged her professional reputation and stood in the way of her safeguarding work.

Characterising a child as “being transgender” is harmful as it forecloses the situation and also implies that this is a unitary condition for which there is unitary “treatment”. It is much more helpful to use a description: that the child suffers from distress in relation to gender/sexuality, and this needs to be carefully explored in terms of the narrative of their lives, the presence of other difficulties such as autism, depression, histories of abuse and trauma, and confusion about sexuality. As the Cass report notes, studies suggest that a high proportion of these children are same-sex attracted, and many suffer from homophobia. Concerned gay and lesbian clinicians have said they experienced homophobia in the service, and that staff worked in a “climate of fear”.

It is misleading to suggest that I and others who have raised these concerns are hostile to transgender people – we believe they should be able to live their lives free of discrimination, and we want them to have safe, evidence-based holistic healthcare. What we have opposed is the precipitate placing of children on a potentially damaging medical pathway for which there is considerable evidence of risk of harm. We emphasised the need, before taking such steps, to spend considerable time exploring this complex and multifaceted clinical presentation. Young people and clinicians routinely refer to “top surgery” and “bottom surgery”, terms that serve to seriously underplay these major surgical procedures, ie double mastectomy, removal of pelvic organs and fashioning of constructed penis or vagina. These procedures carry very serious risks such as urinary incontinence, vaginal atrophy, cardiovascular complications and many others we are only beginning to learn about. There is a very serious risk of sexual dysfunction and sterility.

There are no reliable studies (for children or adults) that could support claims of low levels of regret. The studies often quoted (eg Bustos et al 2021) have been criticised for using inadequate and erroneous data. The critical issue here is the fact that children and young people who were put on a medical pathway were not followed up. Studies suggest that the majority of detransitioners, a growing population, who are having to deal with the consequences of having been put on a medical pathway, do not return to the clinics as they are very fearful of the consequences. The fact that there are no dedicated NHS services for detransitioners is symptomatic of the NHS’s lack of concern for this group. Many live very lonely and isolated lives.

What are the key findings of the NHS gender identity review?

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Those who say a child has been “born in the wrong body”, and who have sidelined child safeguarding, bear a very heavy responsibility. Parents have been asked “Do you want a happy little girl or a dead little boy?” Cass notes that rates of suicidality are similar to rates among non-trans identified youth referred to child and adolescent mental health services (CAMHS). Indeed, the NHS lead for suicide prevention, Prof Sir Louis Appleby, has said “invoking suicide in this debate is mistaken and potentially harmful”.

It has been suggested that the Cass report sought to “appease” various interests, with the implication that those who have promoted these potentially damaging treatments have been sidelined. But in reality, it is those of us who have raised these concerns who have been silenced by trans rights activists who have had considerable success in closing down debate, including preventing conferences going ahead. Doctors and scientists have said that they have been deterred from conducting studies in this area by a climate of fear, and faced great personal costs for speaking out, ranging from harassment to professional risks and even, as Cass has experienced, safety concerns in public.

The pendulum is already swinging towards a reassertion of rationality. Cass’s achievement is to give that pendulum a hugely increased momentum. In years to come we will look back at the damage done to children with incredulity and horror.