Reviewing the Cass Review

Hello, everyone. And welcome to our Cast review deep dive episode. If you're hearing this, then I can only assume that you're a glutton for punishment because this is the second half of each of the last two episodes edited together as one big cast focused chunk of work, featuring interviews with doctors Carl Horton, Cora Sargent, Natasha Kennedy, and Rub Walsh. We'll explore some of the connections between the cast team and people who will openly advocate for conversion therapy practices.

We'll also have a look at what the report itself says and how that can and already has caused harm to young Trans. And especially those on the care pathway that the report pretends to care so much about. We hope you find this useful in some way. We'll be providing links to some of the resources that we use to put all of this together, and you can find a link to this in the description of this very hefty episode. So without further ado, take it away, Alex and Ashley, in the past.

We're going to have to issue a content warning. There will be lots of talk of medical treatments and suicide in s. So just to let you know if you don't wish to proceed further. It's time. You knew it was coming. It's the cast report. The C report. We read it, so you don't have to. Mm hmm. We've read it several times, in fact. Too many. As we've spoken of in the last couple of episodes, the report was published on 10 April.

It's stopped referrals to gender identity clinics for all young people, and it's actually accelerated a similar review into adult services as well. So thanks for that, Hillary. The contents have been described not least by me as overreaching, and the methodology has been unethical by several of the experts you're about to hear from. And, of course, as many of you will have seen, there's been an absolute media circus that's followed it. The cast report is split into five specific parts.

Part one talks about the approach and review Turk in the work they undertook. In Part two, the context, which explores the history of services for children and young people with gender dysphoria and highlighting the changing demographic and the rise in referrals over the last few years.

And for Part three, it was understanding the patient cohort and sets out what we have learned about the characteristics of children and young people who are seeking NHS support for gender incongruits and considers what may be driving the rise in referrals and the change in the case mix. That's this episode. Mm hmm. Now, next episode, we're going to be moving on to parts four and five.

Part four is the clinical approach and clinical management, which looks at what we need to do to help children and young people to thrive. Basically, the purpose, expected benefits, and outcomes of clinical interventions in the pathway, including the use of hormones and how to support people who have slightly more complex presentations when they arrive at a gender clinic.

Part five goes over the service model and considers agenda service delivery model, workforce requirements, pathways of care intervie specialist service, further development of the evidence base, and how to embed continuous clinical improvement and research. And this will be our through line when we walk you through this. So now you know what you're going to be stuck listening to for the next God knows how long.

And throughout this, we will be bringing on as many trans academics as we could wrangle onto the podcast. So strap in this is going to be a long ride. Oh, boy. And with that, we jump to Part one. For waver cast review approach to review, and with that we hand over to l Horton. Kyle is a research fellow in Oxford Brooks Center for diversity policy research and practice with a specialism in trans inclusion and applied trans studies.

Cast review relies upon a systematic review of literature on social transition conducted by the University of York in partnership with Tilly Langton. Tilly Langton is a controversial former clinician at Gids the English Children's gender Clinic that has recently been closed down. The Trans safety network has raised concerns about Tilly Langton's connections with gender exploratory therapy and approach that the Trans safety network considered to be conversion therapy.

Having such an individual at the heart of the research team leading the systematic reviews has raised significant concerns. Systematic review conducted by York took a portion of current literature on social transition. Qualitative literature, literature that actually talked to and listen to trans Children or families was disregarded.

My own peer reviewed articles on the experiences with social transition of trans children and families in the UK was not even acknowledged, which may strike you as strange in a review that continually bemoans insufficient evidence. The systematic review summarizes its selected portion of existing literature on social transition in a way that de centers and erases critical research findings.

Reading the York systematic review provides limited insight into what the existing literature actually says about social transition. By contrast, I reviewed all existing literature on social transition in a peer reviewed scoping study published at the start of this year in the leading journal for Trans healthcare, which is worth a read, if you want to see what the current literature actually says about social transition. If you want a longer form explanation of this.

Last episode, al did a brilliant 35 minutes monologue, essentially going into more detail, and you can also find the transcript of that linked in the description of this episode. DCA review brought on someone who actively pushes conversion therapy and chose studies avoiding actually talking to transpeople. With that, we spoke to Lucy from our fantastic consultation team to talk more about the involvement of conversion therapists in CAS review.

So Tilly Wanton's involvement is quite interesting, right? So Tilly is working for York University. Under someone called Joe Taylor, who is running the whole report, Tilly is the only person with experience of the gender dysphoria service or the gender identity service. In the whole research team. There's one other person with experience in, like, young person's care, and that is Laura Fraser. She's go.

She works for King's College London and Children's pallet so it is like, you know, actually a respectable person. But also her involvement wasn't as substantial as Talby. Tb is Tilly's like other name. This can be confusing and make it slightly more difficult to dig up information about her. Sometimes she goes by Tilly, sometimes she goes by Tolbe. I mean, I mean, who are we transfer people to complain about people having reform to I'm not going to reform. D, Drew.

So she was working for York on the research that was commissioned by the cast review that involved various different papers and is called the systematic review of research. And what was done with that was, as your listeners are probably aware, they looked at all of the massive amount of research on young persons care in general, and then threw most of it out. This is something we have seen before with the Nice review. So there is precedent for this.

And you might be like, Well, you know, the thing that people are saying is like, Oh, it's low quality. Research. But they got to set the terms of what they defined as low medium and high quality, and the criteria that they applied was one that excluded and defined most of the research out of being looked at, which is like at best, really bad practice. You would look at that approach, and you'd be like, Well, you know, that seems inadequate and slightly unprofessional, right?

At best more research. And as time is spent on it, you know, we'll see in the next couple of years like actual academics bring that complaint that takes a long time because of the way the academy works. So you might be like, Well, that looks income. And you might level that at the whole research team. Until you look at who did what and you learn that it was only Fraser Langton, who designed the selection process for the research.

So there's only two people on that team that were deciding what approach to take and what research to look at. I would be curious to hear Fraser's thoughts on this as she seems to have no connections to any organizations. It seems to just kind of be just a professional.

So it will be interesting to see what she has to say about her involvement in this process once it hits the fan academically, but anyway, Langton, on the other hand, I used to work for Tavistock, along with many other people, lots of child psychologists were involved in Tavistock. But Langton was part of the cohort of people who left and some of whom whistle blowed on the approaches that Tab was taking. The two names that are going to come up a lot, there are Anna Hutchinson and Anastas Spas.

I'm sorry, if I'm mispronouncing those. And these people are tied together in various ways. Some of which are a matter of public record. So these three individuals, that is Langton, Paris and Hutchinson went to meet with our favorite politician, Kimmy ardenock in 2021 to discuss the conversion therapy bills. So they are engaged consulting politicians on this process. Like, we know that they are like, involved with each other. They also all work together. That's not weird.

Like, that's just how that industry works. But the thing that ties them all together really strongly and the thing that causes us concern is their connection through something called Explore consultation. This was broken I think in 2022 by Malory Moore for Trans safety Network and was really like the thing that put us onto this person's involvement. In bad stuff, right? And the reason for this is because they explore consultation is a group of five people.

S artist Hutchinson, remember them, and Langton, along with someone called Anna Clark and miss Asha Prescott. We're on the sort of list of names involved in delivering some training to some NHS professionals about how to approach people who were not sure about their gender. And if you want to kind of have the full story on this, you should go and check out the trans safety networks article on it, it's very substantial. It's very damning.

But they There are many there are many things wrong with this. We can see examples of them linking to, like, out and out, like, actually transphobic organizations. They link to like mermaids then they also linked to like five other things, all of which are like just transphobic stuff, including like transgender trend and stuff. So like, things that are like, you know, ideological. You can't see me doing like my scare quotes.

And this is the only public connection that Langton has with these people. This organization is not listed anywhere. All we have is like some lecture slides and some like pamphlets and documentation from this event. It kind of seems that once this is speculation. But once Langton got involved with the systematic review, she's obviously got kept her head down. With her involvement in any of these organizations kept her really quiet.

So there's very little else you can find on her apart from her conversation with arnock and her involvement in exploit consultation, which coincided fairly early on in her involvement with the systematic review. I think it was reasonable to say that she should not have been on that systematic review. I would question Joe Taylor's involvement in that because she's the person who's responsible for releasing it. It's her signature at the bottom of the review.

I'd also question, like, York uni in general as to, like, you know, why did you hire this person who, like, has this biased history? Why did they fail to declare their involvement in this organization? There are questions that I would ask of these people. All to say, like, Tilly, not great. There's also other people who are involved in the review. So there's along with the research, there is also like CAS and the people that she spoke to.

So with the CAS review, there are two, like, formally involved bodies. There is the assurance group, which is a list of people and we have that list, and none of them seem particularly weird. They are responsible for just like overseeing the review in a kind of, like, organizational capacity, you know, that. The people whose names have to be on it, so make sure it's not just CAS, but they seem to have been fairly hands off. None of them seem to be specialized in gender care one way or the other.

There is no involvement of trans people. Anywhere in this review. I believe that's because it would be biased. I think there's something in what the trans article about the specifics of that. I can't recall. Mterially we know of no trans people involved in a review. So that's what we know. So the insurance group, you can find the list of them in the cash review, if you want to look it up. The other one is the advisory Pod which are different.

And they are also formally involved in the cash review, and we do not know who is on that list. It's secret for some reason. Some procedural thing. That is apparently normal for reviews like this, but it is also something which should be made public because of how much there is wrong with the review.

We need to know who else is on this because we only know so far one person who's on it because she declared it as a conflict of interest in another piece of research that she published shortly before the cast review came out. And that person is Rita altiala, right? I'm just going to call altiala because I'm sorry. If you're finished, I'm sorry. Sorry to those finish listeners out there. Yeah. Calciala is the only person we know is involved in the advisory board.

And she's like, no good. She's real bad. She's kind of the architect or one of the architects of the finish system that is used in Finland now, which is bad. It's like a gender exploratory approach that's kind of Like your mileage may vary is whether or not you just want to call it conversion therapy. But I think that it is conversion therapy.

I think that there are things which come under the conversion therapy umbrella, which are more extreme, and it's important to keep that in mind when discussing this. But, like, It is an attempt to challenge people's desire to transition rather than, it sounds like you're like, Oh, we just want to explore it. But it's like you are exploring it. That's the point of the whole process. Like, it takes a long time to transition under a gender affirmative approach as well.

Assuming it's applied correctly by teams people who are adequately funded and have enough time. We see the evidence of that transition right Anyway, Yeah. So Kalia, along with that, is involved in the Do harm conference, which is basically a big conference of sort of electronspobic stuff that are like platform detransitioners, bias that conversation. You know, That's like KSG one that happened with big protests outside, wasn't it? Yeah. So you can kind of look up that.

I have sat and watched some of it for my research, and It's interesting. It has a real five. So we believe that altiala introduced C to someone called Oh, I mean it's Hunter. Do I have a last name on my chart? I don't. Sorry about that. Fellows who don't know, there's like a good chart on the wall, just just sell taped up right next to you. It's a really impressive one when you look at the pictures. Yeah. Patrick H. There we go. Found out. Yeah, that's the US guy.

That's the SEGM which is transpobcGroup. It's just like and then you can follow those threads a lot and other people have done work on this to sort of connect those people to, like, more and more explicitly transpobc and religiously right wing organizations that are responsible for transgender care bands in America. There is this kind of, like, very robust network of international conversion therapy advocates or, you know, gender exploratory advocates.

Then there is a more local cohort of people. Some of who might have connections to that. So, for example, at the 2024 conference, Anna Hutchinson, remember her, spoke at the Dino Harm Conference in 2024, Hutchinson was one of the first whistleblowers at Tab stock. And is also the educational lead on the interim service. The NCY P GDS, right? That's a person who probably shouldn't be involved in this, but who is. And it is notable that a lot of the people who are advocating for this.

I'm sure they're not short of work, but they will find a place to be in this new service that they are advocating for the construction of or involved in the architecture of. Does that amount to bias, academic or otherwise? I don't know. Like, is that the motivation? I don't know. It's of note, though. There were also meetings with a Patrick Hunter, who was, according to the Kite trust, the architect of Florida's anti trans SB 254 bill in 2022.

But after being pressed on this, Cass teams said that they were not aware of his wider connections and political affiliations at this time and claimed that he had no influence on the content of the CAS reviews report. And for those who missed Alyssa and Valeria, in the last week's episode, we spoke to Alyssa who walked us through who Patrick Hunter was. Patrick Hunter is a Floridian pediatrician.

He's a member of the Catholic Medical Association, which is a far right advocacy group that's opposed to transgender people and gender affirming care on specifically a religious basis. He's also a leading member of the society for evidence based gender Medicine, people call SagM a lot, which is a horrible little organization, also very publicly anti transgender activists. They have people in their ranks like Stella O'Malley, who is a self admitted conversion therapist from Ireland, right?

Just a terrible place. Uh, and in 2022, he was appointed to the Florida's Board of healthcare to help them write essentially a document that would act as state specific standards of care for treating trans patients, which was named generally accepted professional medical standards determination on the treatment of gender dysphoria. Is that like a Florida version of LicasRview? Yeah, more or less, same general idea is that they tweaked a lot of evidence and outright lied in some places.

We've since discovered from discovery segments of court cases fighting the documents and the bans on healthcare. But as soon as this thing within months of this thing being put out, gender affirming care was completely banned for trans youth in the state of Florida and severely restricted for adult transgender flridians. And he was appointed to that Board of healthcare, to help write that by Florida governor Ron DeSantis, who is, of course, a gigantic stinking bile piece of shit himself.

So, that sounds quite similar to the situation that's happened with Lee Cass review, and no matter, his kind of expertise was sought out for the CAS review if depending on how malicious you think Cass was. So I suppose, could you walk people through what kind of involvement this Patrick had a had on the review? Yeah. So like I said, a lot of things have been uncovered specifically during the discovery process of lawsuits to challenge these various bills.

And one thing we learned is that from e mails from Patrick Hunter's personal e mails that in July and September of 2022, he was put in contact with doctor Cass and forgive me a minor tangent here. He was put in contact with doctor as by a woman named, and I'm going to probably butcher her name. She's from Finland, and it's, I believe, Ritcurtu Calteala. She's the lead psychiatrist at a gender clinic in temp here Finland.

She once called child services on a family for legally seeking gender affirming care for their kid outside of her guidance. That clinic has also been accused by multiple parents of essentially psychologically torturing their kids, asking them a lot of inappropriate questions about their sexual and masturbatory habits, stuff like that. So this is the woman that put Patrick Hunter in contact with Hillary Cass. Cass would have been in contact there as well. Yeah. I actually have the e mail here.

If you'd like me to just read it out in full. It's just a couple of paragraphs. Go on, then. Why not? So this is from Patrick Hunter to doctor Hillary Cass, and he says, doctor Cass, I am interested in learning more about your work in this area. I am a general pediatrician in Florida. I also have a background in bioethics. I have been appointed to the Florida Board of Medicine. The board licenses physicians and can regulate the practice of medicine.

The board is considering adopting rules regarding youth gender transition. I have been studying gender dysphoria and gender medicine since about 20:15 when I first started seeing patients in my clinic. My focus has been on the history and scientific literature, but in the last year, I have also forged relationships with 20 plus patients who have detransitioned. So I don't know. I don't know about the validity of that 20 plus patients who have detransitioned. You guys have read the CAS report.

I think it was something like they studied like almost 4,000 transth and something like 2-10 of them detransition in that entire timeline. And even then some retransitioned as well, I take it. Yeah. No even all of them stuck.

Yeah, well, you know, because we know that a lot of the time people detransition because of social pressure from their family and friends, they're just society or because they have trouble finding work, not because they're not trans, but because life has been made very difficult for them. Exactly. I suppose it's going to sound a bit sus as people my age or bless say. So from that case, he was emailing back and forth with C, I take it, Yeah. So there's two e mails.

The second e mail suggests that they met on September 22 of 2022. I don't know if they met in person or remotely, but I would guess remotely based on some other stuff that they say in their e mails. He provided her with documents and in that e mail that kind of dates when they met what he calls the evidence review from McMaster University and the McMaster report, which is sort of the basis of the whole document banning trans healthcare in Florida.

Yeah, so that seems like quite a e mail chain, right. So I suppose with contacts. Do you feel like he had considerable influence on the CAS review at all? I do. I don't think he had any part in, like, writing it, you know, any of the specifics, but, you know, very explicitly in his e mails, and then an e mail with one of his colleagues, Paul Vasquez, Vasquez makes it really clear.

He says, that the CAS review people are very interested in the Florida evidence review, especially the report from McMaster University. So it's pretty clear that the Finnish psychologist put the two of them in touch and that Cass found his horrible riddled with lies document used to justify the outright ban of gender affirming care for trans youth in Florida, relevant enough to what she was doing that she wanted to look at it. I don't think that it's included in

the citations of the final cast report. I could be wrong. It's an almost 400 page document, a lot of which is just extremely poorly written boring. Yeah. Even the experts on this stuff, I think a lot of them haven't combed over every single page. I can't attest to whether or not those documents appear in the final report, but it's pretty clear that they had a significant effect.

On the road for. And I should also point out I have some notes here about, you know, when the Florida standards of care came out, you know, these were so heinous that they actually prompted the closing of gender clinics at Nicklaus Children's Hospital in Miami and Johns Hopkins all Children's Hospital in St. Petersburg. Florida, not Russia. Speaking. There was a Yale review of the document.

They said, We are alarmed that Florida's healthcare agency has adopted a purportedly scientific report that so blatantly violates the basic tenets of scientific inquiry. So repeated and fundamental are the errors in the June 2 report that it seems clear that the report is not a serious scientific analysis, but rather a document crafted to serve a political agenda. When Cass wanted her eyes all over it.

Yeah. When Hillary Cass had an interview with Vk Trust, when they were pushed on Patrick Hunter, they mentioned that he had a limited influence, if any, on Vica review. What are your thoughts on that? It seems very unlikely to me. I mean, you know, we don't have clear evidence of them interacting more than a couple of times. But, I mean, she very explicitly asked for those documents, and he sent them to her.

And I would say that a lot of the final report maps pretty cleanly to the kind of, very very prohibitive suggestions that they make, you know, about puberty blockers and gender affirming care in general. You know, I mean, most of the cast reports, final recommendations are just don't let trans kids exist, right? Oh, exactly. If I say anymore, I'd be spoiling the second part, I mean.

Yeah. So I think it's pretty likely that Patrick Hunter and his evil, terrible work in Florida had a direct influence on the cast report. So the picture is clear. For those of you following along in your conspiracy boards at home, we see connections drawn between people like an S G member and speaker Rice Certo altiala who introduced Hillary Cass to Patrick Hunter. This is in addition to homegrown gender critical therapists like Tilly Langdon and Anna Hutchinson.

Just to absolutely hammer this point home. All of the trans voices have been completely excluded in favor of gender critical ones. And you can really see what effect it had on a review, especially in how it selected evidence. We spoke to Cal, again, who had list to say about the exclusion of a lot of research. So there's a number of different levels. First of all, there's the research that doesn't even get to the point of being excluded.

So a lot of the qualitative literature, doesn't even get acknowledged, so it's not even excluded. It's literally not noticed. All of my research doesn't get a mention as does a number of other important pieces of qualitative research. All of my research has been with trans children and families.

The majority of whom are or were service users of the English and Scottish Children's gender clinics, a cohort that the cast review should surely be interested in, but that kind of evidence, particularly qualitative evidence hasn't even been included. Hasn't even been acknowledged, which is frustrating in a piece of work where the authors are continually bemoaning a lack of evidence, excluding existing evidence of any type seems either foolish or convenient.

And then the evidence that is there, it's to do with the way the systematic evidence reviews, take decisions on which data and evidence they think is most valuable. Underpinning the final report or a number of they call them systematic literature reviews. And the purpose of those literature reviews is to look at the existing evidence and assess its quality.

And when they say quality, they're looking at things like rigor, whether it's representative of the average experience of the average trans child, well, sorry, the average child distressed about their gender. Because this is a really key point that the cast review doesn't even acknowledge the existence of Trans Children, which is rather shocking in a report that has directly and immediately impacted on Trans Children's healthcare access.

So what they do in the evidence review is they assess the quality of the existing evidence. Across all the systematic reviews, a vast majority of existing evidence is rated as low quality or medium quality, but not high quality. High quality, they're higher medium quality. They're looking for things like randomized control trials or formal trials where there is a control wing.

So, for every child who has x intervention, there is a very similar child who has kind of randomly been given a different intervention. There are huge ethical issues with doing that for interventions such as social transition or, you know, puberty blockers or HRT. The ethics of withholding a treatment that is known to be beneficial is very questionable.

And even what they define as a treatment is something I would I think problematic because they define things like social transition as an intervention as though it is a medicalized decision. Yeah, as if it's come from somewhere external rather than being something that the trans young person has perhaps been pushing for themselves, like it's magically come from outside somehow.

Yeah. And as though it could be imposed kind of irrespective of a child's views as though, you know, Oh, if someone's got this diagnosis, then they are going to be socially transitioned, whether they like it or not. That's just not the way social transition works. It also completely ignores the understanding of how active an intervention, rejecting a trans child is or delaying a social transition.

Something that some of my own researchers focus very specifically on the experiences of families who have delayed a child's social transition, and to do so is a very active intervention in that child's life. And it requires daily and more than daily. Re intervention to continue to reject basically a trans child.

And the idea that social transition is this big dramatic intervention that requires medical evidence to some high degree of rigor, but rejection of a trans child for months or years on end doesn't require any evidence or justification. It's a significant double standard.

And this idea of a double standard cuts across a lot of the cast review approach, the cast review will criticize the evidence base for puberty blockers or HRT, as being insufficiently rigorous, and then go ahead and recommend gender exploratory therapy or close psychological support. You know, things that are sometimes not even defined what they are, but certainly are not underpinned by any kind of evidence base.

And across the whole discussion on evidence, the cast review doesn't take the time to look at the evidence base of the potential harms of what they end up recommending. So there is a growing body of evidence of different types on the harms of conversion therapy, the harms of delayed transition, the harms of forcing trans adolescents through an incongruous puberty.

These harms are documented in the literature and are very known if you know and talk to trans people or trans adolescents or trans children. But the cast review hasn't even looked for that data. They've they've critiqued the evidence base for all affirmative health care and then plucked recommendations out of the blue on what they propose to do instead. So, along these double standards, it held one particular medical protocol in high regard, and it used it to exclude much more evidence.

So we asked al on their thoughts about that decision. Could you walk us through the Dutch model and why they seem to take a shine to that? So the Dutch were some of the early users of puberty blockers. So as far back as 1988, puberty blockers were used. So there's trans older middle aged people who are older than I am, and I'm early 40s. There are people older than me who had puberty blockers at the start of puberty from the Netherlands.

So this is very well established and proven safe and beneficial in the Netherlands. Interestingly, when the Netherlands was at the forefront of gender care for trans youth, the English system where children and young people did not want to adopt the Dutch model, and a lot of advocacy justifying the harms of the earlier English system was needed to get England to even consider adopting the Dutch model. So hearing that people are now singing its praises is interesting.

But then since about 20:15, healthcare providers in a lot of other countries have taken the mantle on and been more progressive and been more trans positive and been more influenced by Actually prioritizing what is in the best interests of trans children and adolescents. And that's particularly clinicians and researchers in places.

It's very much focused on the English speaking world, and I think that's another problem that people haven't even looked beyond the English speaking world because there's a lot of interesting things and progressive things in places like South America.

But in the English speaking world, the more progressive clinical practices have been in places like the United States, Canada, Australia, New Zealand, in all four of those countries, practices are affirmative, and there is a lot of support from the healthcare establishment and from clinicians and from healthcare providers and from trans communities for a gender affirmative health care approach, which is different to the Dutch model,

which is still a bit more pathologizing and a bit more focused on, you know, a lot of kind of assessment and a lot of psychological therapy before any kind of support for affirmative health care interventions.

But all of those approaches from North America and Australia, New Zealand is disregarded in the CAS review because it doesn't fit with their model of really looking for what's gone wrong when a child comes out as trans or an adolescent comes out as trans. And the idea that that individual might have healthcare rights and might be able to access those healthcare rights without massive hurdles and massive intrusive and abusive kind of assessments,

that's kind of outside the realms of possibility for the current people in the cast review and in NHS England who I think can't imagine that kind of a trans positive future. Oh, exactly. I think when it came to dismissing of vose reviews, it did even put out a whole section on just attacking WPF, didn't it as well.

The section where they review healthcare guidance from other countries gives a good indication of the same techniques that you see across the wider review to discredit affirmative healthcare. And someone shared that the systematic review of existing clinical health care guidelines. The original methodology that the CAS review wrote up and committed to following was a methodology that explicitly says, Do not discount guidelines that are rated low quality.

After the fact and in the latter stages of the CAS review, they changed methodology to a different methodology that they adapted specifically so that low quality research methodologies could be ignored. And then the process by which they prioritized rigor of clinical guidelines is very open to personal bias. They had three assessors who gave a score for each health guideline, using a slightly arbitrary system that had been adapted.

And it just so happened that all of the guidelines that have a degree of trans community acceptance and backing, and that all the guidelines that treat trans children with respect were rated as low quality because those guidelines accepted decision making based on the existing evidence. And because the cast review deems the existing evidence to be low quality, they say, you can't make decisions based on that evidence.

Therefore, all the guidelines that make any decisions based on existing evidence are ruled themselves low quality. And then they ended up with the only guidelines from Norway, Sweden and Finland, I think it was rated as high quality. And those guidelines are not considered kind of world class. They're considered guidelines that give as much scope as possible for practices that are intrusive, practices that are pathologizing.

There's been some really shocking examples from some of those countries from young people who've been in within the healthcare system in those countries, you know, some really intrusive and abusive clinical experiences, and the idea that those systems are a model for the UK. It just doesn't stand up to scrutiny. Pretty damning there. It certainly does show the philosophy of the cast review in quite a stark light, and to highlight it even more, this basically sums it up.

Being trans is seen as inherently a bad outcome. It doesn't matter if you're a happy trans teenager or a healthy trans adult. This is a worse outcome than being a SS adult. The cast review uses HRT to justify this eugenesis bigotry. Trans, the cast review argues are more likely than SS people to require ongoing HRT, lifelong medication. Therefore, the cast review argues policies that can limit and reduce the number of trans people are medically speaking morally justified.

It just happens to be in the greater good to reduce the number of trans people. The cast review does not say this explicitly, but it is implicitly there across the cast review recommendations. Puberty blockers and social transition could increase the number of trans adults, and this alone is sufficient to justify restrictions, no matter the harm to trans people of denial of health care of being forced through a puberty that is experienced as deeply harmful and traumatic.

This harm is justified if the overall number of trans people is reduced. No matter the harms of denial of childhood social transition of children growing up rejected and ashamed. This is justified if some children will thereby snap out of it and become ss. One particularly revealing paragraph, the cast review makes clear that evidence drawn from listening to trans people will never be enough.

The cast review writes that even if a trans boy grows into a trans man who is happy and healthy, that cannot be considered a success. His own opinion on his life cannot be counted as evidence. The cast review writes that because such a trans man never had the opportunity to live as a cis woman, he will never know what he's missed out on. Cast review cannot find enough evidence of actual regret to argue that growing up trans is a bad outcome.

So they moved to the territory of imagining a parallel world where all trans people lived as SS. SS lives are inherently more valuable, SS lives are inherently better. Clear rejection of good ethics. It is also clear when the cast review has a clear favoring of double blind tests. In episode one oh three. We spoke to Cra sergeant who had list to say about it.

I feel a little bit like the Charlie Dame with a corkboard by me and a red string across it, because I read the whole cast review over 6 hours. I was just coffee and sore eyes, and then I read all of the systematic reviews that informed it. And then I went to the hormone replacement therapy one, particularly what they call cross sex hormones, but gender affirming hormone treatment.

I will look at that one specifically, and the psychological outcomes from that one specifically because I was a psychologist, and that's what I'm interested in. And it's a good example of something that these systematic reviews have done. It's a little difficult to see what they have done is the first thing. You have to look quite carefully.

It's often in the abstract where they will say only medium and high quality studies were synthesized, which essentially means what they have done is excluded the low quality studies. Now, it's really tricky to talk about low medium and high quality studies in this field, generally, 'cause like you say, blinding is one of the things that they look at to increase the score, which, of course, is very difficult to do when you're talking about either puberty blockers or gender affirming hormones.

I don't know what you do with young people. Just ask them not to look down for two years, I assume. So you can't really blind people to the effect of hormones. But also, you know, the studies are small scale, generally speaking, in this field, and they're looking for large scale studies, which is a bizarre thing to do, in a sense, because it's only a tiny population of people who are trans, right? It's only 0.5% of the population at most.

And of those people, the vast minority of people access hormones in adolescence. There's this huge study in the US by Jack Turban and colleagues in 2022, 21,598 participants. Huge study in the US of trans adults from the ages of 18, all the way to 65 plus. And of those folk of those 21,598 The only found 119 who had received gender affirming hormones in young adolescents and only 362 who had received it in late adolescence.

So this is a tiny field, and the idea that you can find large scale studies in this field, particularly when you're talking about a field that's marginalized and there's not a lot of money, you know, we're not researchers getting huge amounts of money from grants. We're a rag tag bunch of researchers doing our best with what we've got, you know, often. So it's a small community, and it's hard to do large scale studies. They also mark down studies for single site representation.

So if there's only one site that's conducted the research, you know, with one population from one site, then they've marked it down. But, of course, there's often only one clinic in the country conducting these kind of this work, right? Prescribing hormones to puberty blockers or hormones to young people. Usually just the one, like in England, the one, I think, in lots of European countries, the one or maybe a couple.

So the idea that you can mark us down for single site studies when there's only one site available seems a little bit hard. So essentially what they have done, and they've also been concerned about long term follow up. Fundamentally, what they have done is to remove those low quality studies. So, if we look at the psychology outcomes, they've included five studies, and they've removed nine, including that study with 21,000 participants.

They removed it. They just ignored the voices of 21,000 people. And of those nine studies, I read them all and will go into depth of my own podcast in classroom psychology. We will go into depth on them because it's super interesting. But the vast majority of them, some of them have like devson colleagues, long term, six year follow up, I think, Turbin and colleagues is a huge follow up because they're asking adults about their long term distant experiences.

And of those nine, something like seven have really positive effects for psychological outcomes, show strong positive effects. And so what these authors have done, these reviewers have done is to restrict the medium and high quality studies to be the only ones that they've reviewed. And then the cast reviews, like, really focused on the very high quality studies.

But the actual, like, systematic reviews that have been conducted, Unfortunately, that decision to exclude the low quality evidence, which is generally speaking a defensible decision, when you're talking about high quality reviews. But this population is not your average population is a small group of people in a marginalized population, don't get access to this very often. There's only a few sites that give you access.

And by excluding what is in vertic as the low quality studies, they've removed their opportunity to understand the scientific consensus in this field. And the WPA systematic review that they commissioned, the countless systematic reviews across the world. The new guidance that was just released by Germany and other European countries all shows a much more affirmative model, supports a much more affirmative model than Cas has been able to support.

And I think fundamentally that decision to exclude low quality work is a big part of why they've reached a more conservative conclusion. And to my mind, I mean, we conduct and publish systematic reviews rarely as high stakes as this. But in our own systematic reviews, we don't exclude studies because of quality. We always quality as sure.

We must make sure that people understand the strengths and weaknesses of the studies we're reviewing, but we do not exclude studies because to suggest that 21,000 participants in turbines, like the biggest study in the world on Transgendalth care, to consider that is too low quality for your review. It's got to be pretty galling for Turbdon colleagues, I think.

Following the release of the report, in an interview with the Kite Trust, Hillary Cass and her team stated that the double blind studies would be inappropriate. And to cap this off, when we spoke to Rub Walsh about their approach to research, this is important to mention. I keep being astounded by her attitudes to evidence.

When she talks about the use of gender affirming hormones in transgender adults, she specifically references it being pioneered by Magnus Herschfld in the first half of the 20th century. There is no mention of book burnings. There is no mention of the history and politics and context of the lack of evidence that transgender health is suffering from. And I would add to that, if I can find it in my notes, which I can never seem to do.

Although some think that a clinical approach should be based on a social justice model, the NHS works in an evidence based way. So She knows about Magnus Herchfeld Maybe some model has convinced her that Magnus Hechfeld's books were never burned, but the reality is that social injustice is absolutely fundamentally part and parcel of the medical evidence we have.

It's part and parcel of how and why we know more about how to detect a heart attack in a man than a woman in a white person than a black person. Social injustices structure every facet of human society, every social process in human society, and science is far from being not an example of that. It is actually really a prime example of that.

A lot of modern science was profoundly shaped by eugenicists, a lot of the standards of care that she harkens to as normal or usual care as applied to trans people in the mid 20th century. These were conversion practices. These were abuse and they were born of a desire to regulate the types of bodies that are allowed to exist. A book called six conversations we're afraid to have that has not yet come out by Deborah Francis White talks about how people can contain these contradictions.

I really think that in the beginning, she addresses the patients whose She's talking about. Okay. Care she's helping to make inaccessible, let's be frank about it. She seems really sincere in the care that she's expressing. But it is still disingenuous to say to somebody, I know you'll be disappointed that I'm not going to recommend increased access to care.

It's disingenuous to say that she wants to be sure that they're getting the best combination of treatments and that this means putting in place a research program to look at all possible options and to work out which ones give the best results. If what she means by that is a research program you can either participate in or you don't get care or she means a research program, and while we're carrying this out, everything has to stop.

Birth control and abortion are, I think, really important analogies for understanding the sociopolitical dynamics of medical evidence. Birth control as an intervention spread fast and with really very little evidence. The simple reason being that adverse events from pregnancies are so much higher than adverse events from birth control, that it spread through word of mouth that people believed it to be safe. This was not a randomized control trial.

It is not adequate medical evidence upon which N should base guidelines. However, that is why birth control medications spread so quickly and with so little evidence to support them. This is also in the in at at some point in this she talks about the idea that puberty blockers have become much more spread fast and with relatively little evidence.

But unlike birth control, when puberty blockers came on the market, they had already been being used in children, albeit different children with a different indication for decades. I also think that another reason why birth control spread quickly is because there was really a lot of demand for it because it gave people control over the most intimate aspects of their body.

Okay. And there are lots of reasons today, in 2024, there are lots of reasons to be concerned about the long term safety and efficacy of birth control. There's a lot of unanswered questions, people who take birth control to prevent ovulation. There was a lot we don't know about the consequences of that, and there is a lot of reason to think that there could be some really quite serious adverse ones. None of it compares to pregnancy. Suicide is a pretty big adverse event.

One of the studies from the Dutch clinic in adolescence, treatment as usual versus puberty blockers, I think. In any case, they had one patient they mentioned who committed suicide during the course of what was not a very long study. Who had been placed in the no treatment group for a variety of reasons, and they they mentioned the suicide and use it as an explanation for why they were right to classify that person as not suitable for care.

And there is also evidence that if you look at the number of suicide attempts, people who asked for puberty blockers and were denied them in adolescents have a higher rate of suicide attempts than even people who didn't come out until adulthood. So having a sufficiently intense awareness of your let's use gender incongruan for now on your transness. Having that awareness earlier. I mean, I don't I don't necessarily know that it's actually necessarily all about gender, right?

At that point, it could be, well, they've figured out that this is what they want and it's about their body and it's happening and it's out of their control, and there is somebody who has the ability to give them back control who is refusing. And that is traumatic. That is violent. It's common sense. There's also data to support the idea that if children ask for puberty blockers, and you say no, there is a risk of suicide from that. And that's a very serious adverse event.

So again, like birth control, like abortion, the alternative to not providing the treatment comes with significant adverse events, significant risk that outweighs I would argue. Anyway, the risk of providing the treatment. So far, it's relatively rare for people to procure puberty blockers from outside of a regulated medical pathway, but it will get a lot more common now that new prescriptions have been banned. It just will. That's what's always happened.

It's what happened with abortion. It's what's going to happen. And as the CAS report rightly notes, these sources of medications are incredibly unsafe. I mean, while we're doing the analogy, how do we think people would react to a review? I mean, some people would react really well to it, unfortunately.

But a lot of people, most people, normal people would react to review, that had only SS men and specifically SS men who didn't have any experience in obstetrics, deciding about the safety of birth control and abortion. Because if you're a woman or an obstetrician, that makes you biased.

Just to almost to hammer home how much this analogy applies, In 14 55, she suggests that for A fabs who are distressed by menstruation, ignoring all of the other things that are distressing about wrong puberty in that direction, but the birth control is a viable alternative.

And I agree from the point of view of if there's a clinician listening who is now going to try and figure out how best to take care of patients who are getting very distressed about menstruation, birth control is a good alternative given that puberty blockers are now not an option. But if puberty blockers are an option, I don't think that the safety question is any different between the two. Their approach to research was just not great.

Yes. Quite frankly, a lot of a philosophy, which people just kept bringing up in every single one of the interviews, but being trans is a bad outcome was the negative in any kind of approach I had to research. Yeah. It seemed to be the outcome to be avoided, right? So if they put the person through they saw that therapy and they still came out of it as trans, that was a negative outcome. They'd failed as far as they would be concerned.

And in the same interview that openly states its opposition to conversion therapy, its core research philosophy is deeply rooted in the conversion therapy mindset it pretends to reject. Mm hmm. I was really happy that line I made there. Yeah. And also, later on in the website, Holly rood, Hillary Cass said that there was a risk with a conversion therapy ban of a risk of criminalizing clinicians.

Indeed, like So, when she was speaking to MSPs at Holy ood, she apparently had been surprised about the amount of homophobia and transphobia that there is in society. And so people can be kind of a bit scared within that community. She was asked about if we did ban conversion therapy, what would the impact of that be? She said, I'm glad I'm a doctor, not a litigator, because it's a really difficult problem. It's not actually that difficult a problem.

You just keep the roles of conversion therapist and clinician a long way from each other, which is exactly what should be happening. If they're getting close to each other, then you're doing conversion therapy. You're doing clinicianing wrong. I feel. Oh, exactly. Sometimes it feels like she's trying to cover for conversion therapists. Yeah, just that alone. And when you're listening into this pod and the next pod or super CAT, keep the conversion therapy mindset which Cass had in mind.

When listening to points we make. Don't put that down. We'll come back to it later. Okay, so keep those bits in mind when listening in. Rub had mentioned that gender identity clinics refused to hand over dates to GIDs. Attempts to improve the evidence base have been thwarted by a lack of cooperation from the adult gender service. It's not super clear what the motives behind that were.

It's possible that what they really mean is the adult gender service knew that they couldn't get away with illegally handing out people's information without their consent. But alternatively, it could be that they were setting out to I mean, it's not clear what attempt to improve the evidence base they're saying were thwarted by the adult gender services. And so if it's other instances of which I'm aware, then the motives behind that thwarting are actually being fulfilled by this review,

right? You know, I don't know. My maybe the motive is that they want more business, essentially. So by making people wait till adulthood, that makes sure that all the trans people end up in the adult service. Alternatively, perhaps their motive is for more like medical or ethical reasons are opposed to childhood transition, and you want to prevent it by blocking the evidence that would allow us to carry it out. Now, that's obviously requires quite a lot of cognitive distance.

She writes that the length of the waiting list to access gender services has significant implications for this population and NHS service delivery. Implications death. I mean, all the way through this, the language subtly, but it does, it reveals that Cass did kind of choose aside, actually. I honestly don't think she realizes that she did, but she did. So with that, that shows how they did the research. Yep, supposed with the conclusion that they made with

the research leads us to Part two. Yes, indeed. So Part two, as we mentioned earlier on, the explanation given by Cass and the team was context explores the history of services for children and young people with gender dysphoria, highlighting the changing demographic and the rise in referral rate. This basically means this is our spin on history with what gender affirming care for trans people. Starts off with studies from the 1980s, a period of time which cow describes in this quite well.

In the 1970s and 80s, the decriminalization of homosexuality and increased movements for gay rights pushed gender clinics to be less overt in their aims. They no longer explicitly spoke of preventing homosexuality, but the same proto gay risk factors of playing with girls toys or being close to your mother were instead rebranded as gender identity disorder. Being trans was not part of the diagnosis used by gender clinics until after 2013.

Before 2013, gender clinics diagnosed and problematized mainly boys for gender non conformity. The fact that a large majority of the children being studied and probed for gender non conformity in the 1950s to 80s ended up as Cs adults is completely irrelevant to the question of how best to support trans children in 2024. These same studies are relied upon for CAS's key objection to both social transition and puberty blockers.

We want to quote list, part of the CAS review, just because it's probably good to put this quota down. I was wondering if you could save this in your posh English accent. Oh. Sure, y. So several studies from that period suggested that in a minority, approximately 15% of pre pubertal children presenting with gender incongruans, this persisted into adulthood. The majority of these children became same sex attracted cisgender adults.

And this was citing papers from a doctor called Kenneth Zucker back in 1985. I think someone who I'd recommend the audience research, Yes, Kenneth Zucker is a man we recommend you, Google, if you are well, it's not for the faint of heart. Let's put it like that. Anyway, on with the quote, these early studies were criticized on the basis that not all the children had a formal diagnosis of gender incongruans or gender dysphoria.

But a review of the literature, citing a paper by Ristoran Senzmer in 2016, noted that later studies also found persistence rates of ten to 33% in cohorts who had met formal diagnostic criteria at initial assessment. And had a longer follow up periods.

It was thought at that time that if gender dysphoria continued or intensified after puberty, it was likely that the young person would go on to have a. It was thought at that time that if a gender dysphoria continued or intensified after puberty, it was likely that the young person would go on to have a transgender identity into adulthood. Now, this particular part, al very effectively dismantles when they said in our last podcast episode.

The 2016 literature review cited by Cass encompasses studies that aimed to eradicate homosexuality in the 1950s and 60s. Studies aiming to eradicate unmanly behavior in the 1980s through to studies that problematized hobbies, mannerisms and friendships in the 90s and 2000. The majority of children in these studies were not trans. How many were trans we will never know. The study authors did not bother to ask those who they researched. In any case, trans identity was not their primary focus.

This is the foundation upon which the cast review bases their hypothesis that social transition or puberty blockers changes the trajectory, keeping kids as trans who might otherwise be Ss. With Lee Steen's report, which Cal talks about here, they base their studies off of a very specific time period in the 40s and 50s and this extra bit of context pulls together what they were talking about. To answer these questions, we have to understand what the purpose of a gender clinic was last century?

In the 1940s, being gay was criminalized and penalized across the majority of the world? Being gay was a problem. Countries and psychiatrists tried efforts to stop gayus. Literal torture and imprisonment, however, did not stop gay people from existing. The medical and psychiatric establishment recognized that they couldn't stop gay adults from existing. But could they stop gay adults from coming into existence?

Is there something that they could do in the childhoods of these people who grew up to be gay to stop this? The establishment thinking of the 1950s, being gay was obviously and categorically a bad thing. Gay people had difficult and lonely lives. It would be better for everyone if they just stopped being gay. Eradicating gays was clearly a moral good. The primary focus of gender clinics at this time was almost exclusively on preventing men and boys from growing up to be gay.

It went on to talk about the Dutch protocol, which we covered earlier with Cal. After this, it goes into a story of when an affirmative model was used in which it prompted to heavily criticize UK's research methods at the time in its usual hateful pickiness over studies. For those who are only unknown about the situation, we'll walk you through it. So puberty blockers were in use by the Tavistock ImportanGenda Clinic for several years.

And 2004-2007, a nurse named Sue Evans worked there, which will become important later, I promise. As you probably know, blockers are prescribed quite regularly to assist children experiencing precocious puberty, which can kick in when the child is as young as five or six and are considered perfectly safe for use, even if a child has to stay on them for a good few years.

Now, the use of the blockers in trans young people hinged on Gillick Competence, which we've spoken about before, and it's essentially informed consent for under 16. If someone can be said to be Gillick competent, they can meaningfully consent to their own treatment. Enter Bel V Tavistock.

As we reported on at the time in episode number 55, the aforementioned Sue Evans decided in 2019, 12 years after she'd stopped working there, that puberty blockers were an experimental treatment that needed to be stopped, and through the magic of crowd funding, she and a lawyer named Paul Conrath took the case all the way to the high court. Conrath was already well known for his work combating assisted dying and abortion rights here in the UK.

He also defended the couple in Birmingham who didn't want their child to be taught LGBTQ inclusive sex and relationship education, and he also has links with the Alliance defending freedom and other such wholesome organizations. Nice guy, clearly. Now, as for the Belev Tavistock case, along the way, Sue Evans was swapped out in favor of Kira Bell, a detransitioner who comes from a strange parallel universe where people are apparently rushed through NHS gender services.

Bell admitted that she was influenced by gender critical thinkers in her decision to detransition. The accusation of a rushed process was made to and accepted by the high court, who, in December 2020, issued their ruling that under 16 could not meaningfully consent to puberty blockers, and prescriptions for them were stopped. Now, this was thankfully later overturned on appeal. And also, in 2020, cast review was commissioned.

After this bit, Casten proceeded to pat herself on her back and talk about how they were commissioned. One reason brought up on Why Cash reviewers commissioned was the exponential rise in referrals to GIDs in which it showed a graph with a seemingly exponentially growing line.

However, when it was more closely examined by academics, it chose not to mention figures past 2016 because it does flatten off, something that was purposefully admitted to provide a sense of panic to assist people reading the review. And that's what Part two covers. And with that exponential rise, we go to Part three, where it tries to blame young people in the Internet for transpeople existing. So part three, this is in majority a sociologically focused section of case review.

And we've brought an expert on this, Natasha Kennedy, and quite frankly, the entire interview sums this up, so we're just going to play it here. So, Natasha Kennedy, thank you for joining us. So who are not familiar, what is the diagnostic criteria? Just curious. So the previous diagnostic criteria, 1994 to 2013 had desire or insistence to be the other sex as one of the criteria. But that was they could have four out of five.

There were other criteria there, such as preference cross sex roles, preference for playmates, friends of the other sex, preference for cross dressing, those sorts of things. So you could have four out of five of those, so you could theoretically have the other four and not that one. Was the current one, it is required. Take that. That is a requirement. You can't get a diagnosis of gender dysphoria unless you have that. And that is in multiple ways that is really important.

In a sense, it's also going towards self ID, in the end, the only people who knows whether I am trans or whatever is me. Yeah, the same with children. Yeah. So it's actually it's listening to them, listening to what they say.

Yeah. I don't know if this is part of the diagnostic criteria, but persistent, consistent and insistent seems to be the thing of it is if they keep saying it over a reasonably long time period, they're saying the same thing quite consistently, and they don't shut up about it. Basically, they're extremely insistent. Yeah, I don't know if that was part of officially part of it, that's a good one to look for insistence is what they talk.

You said Cass had a preference for the older spec of nuer spec and could have used that sort of the criteria to suit their narrative more? Yeah. I mean, they didn't even mention at least I couldn't see where when I looked didn't mention the new 2013 criteria. They seem to set up a sort of duality between 20th century and early 21st century. So they kind of they made the change.

There was some sort of difference went on around 2000, which actually isn't born out, but they completely ignored the new diagnostic criteria. Mm. What they did talk about under the previous one was that they noticed that there was greater and lesser intensity of gender dysphoria. They got this word intensity. There's nothing in there to judge intensity, but they used it.

And obviously, the children with the more intense gender dysphoria were the ones least likely to desist in the ability of commerce. Now, I think, actually, that intensity argument is Cis and trans, and the intensity is about the desire or insistence to be the other sense. So I think it's kind of tacitly seeping into the older one anyway, and how they couldn't have recognized that in the new diagnostic criteria, I don't know. Yeah, so on the subject of the societal norms,

it seems to push with gender normative C supremacy. We'll go over that. Cast review seem to constantly bring up its society and not biology that causes trans people, according to the Cash review, what are your thoughts on when it brought that up on them review. It's over simplistic. I mean, I think it's society, not biology that causes transphobia. I think we can pretty much agree on that. That includes supremacy, genderism, ssmtivity, all of that.

To do it in either or way like that is way over simplified things being trans is a normal part of being human. And it has been that way since ever. I'm not an archaeologist, but archaeologist has said that, you know, there's evidence going back 9,000 years for trans people. Yeah. 9,000 years ago, you could walk from Northern Europe to England. And you would have had to have walked because They didn't have wheels.

The wheel hadn't been invented, at least not strong enough and light enough to go long distances. So that's how long we've been around. I suspect there are elements of transness in lots of people, but they're not necessarily brought out. But society has some influence. But the influences are minuscule and you cannot control for them. A tiny, tiny thing, can make an enormous amount of difference between people's lives and people's experiences and people's understandings.

So I don't think you can legislate either way. And I suspect there are different reasons anyway, and actually to be perfectly honest, it doesn't matter. We exist. We have always existed. Therefore, it doesn't matter why we exist. And nobody worries about why people exist. Hmm. And actually, people have stopped worrying about whether gay lesbian and by people exist. You know, there's no I mean, yes, you do get people trying to find gay jeans, don't you? But ply think they're a bit weird.

Yeah. I remember that was a thing in the 90s where more than one tide published, once we find the gay gene, we can look for it in fetuses, and then we can perform abortions and just kind of leaving the whole, this will eliminate all gay people unsaid, but that's very definitely what it is. Yeah. I've seen it on a mug and a T shirt about how homosexual acts are observed in thousands of species, but only one has Yeah, homophobia.

And there's a lot of fish and frog and other animal species that change sex? Yes. Within certain environments. So say, Oh, you're unnatural off. Sorry. That was me having a rant more than anything else, 'cause it's just so Facile, the argument that's being made, is it eliminationist. And I think that's where the CAS review and certainly some of the people who've been involved in it. I think that's been their standpoint all along. Genesis in the end. And that is scary.

It is also, I mean, ethically, there is a obviously there's a number of failings in my opinion, in CAS, but one of the worst is what's called epistemological violence. Where you take the data and Your interpretation of that data kind of pushes the worst possible scenario or the worst possible interpretation, particularly for a minority group or a marginalized group. And I think that is one of the things that the cast review is guilty of.

It's epistemologically violent, but it is also there's another one just to get people confused, Epistemic injustice, which testimonial epistemic injustice is one of the ones where basically your opinion, your experience, your point of view is excluded because of who you are. Mm hmm. Mm. I think both of those are big, big, big ethical failings. Yeah. Should we talk about the reports suggestions about different toys and about how that seems to be a completely biological thing? Biological toys.

Mm. I mean, well, I just I remember one GC, couple of GCs. I don't know a few months ago, they were talking about using people's biological name. I mean, I've got to call you. A friend in Sweden, called Mandy. He's a real car enthusiast. He collects American cars like cadillac and stuff like that, and fixes them and repairs them and stuff like that. And he's called Mandy. And there's also a Tibetan Chinese singer who is really, really popular in Japan, sings in Japanese called Allen.

And she's a girl. So biological names. Biological toys just seems like an extension to that. I can remember. Me and my sister used to play with the same toys and my brother sister used to play with the same toys. There was nothing I know about it. Yeah. It's not it's not like those things are decided in utero, you know, to suggest you come out of your parent with a specific preference for dolls houses or Tonka trucks kind of thing.

That's all social that's put onto children who are ruthlessly gendered from the day from the day you're born, the colors that you're allowed to like and wear. And when you get to school, it decides what sports you play. Those digits in my DNA. Yeah. Clearly. Clearly. So there does seem to be some blame in the report suggesting that being trans is actually more predominant in younger generations and making it sound a little bit like a trend. So. What are your thoughts on that?

Without being impolite, I think. I mean, I was a trans child. I knew I was a girl when I was about four or five. But in those days, there was no recognition of it. There was no I didn't even wasn't until I was about 16:17, I think, I I I heard a trans word. So it's just like the left handed graph, isn't it? Because being left handed became more acceptable in the first half of last century. M people I think it's about 11, 12%, people became left handed, didn't they?

Now, that may have also been due to the fact that we had two World Wars and forcing somebody who was left handed to shoot a gun right handed, actually isn't going to help protect your platoon or whatever it is, you know. Yeah. So there may have been a social reason for that acceptance as well. If you look at Japan, Japan has still got about 2% of the population are left handed. That's because there is still a cultural prohibition. People who are left handed talk forced almost to right handed.

I think it's starting to change, but it's not fully there. So it seems to me it's entirely cultural. And like I was talking about Ehduana the priestess in U in what's now Iraq in 4,300 years ago, 43 centuries ago, writing a poem which talked about trans people. We've always been around. It's just that At different times, there have been different cultural prohibitions on trans people. Now, I suspect that that increased with the renaissance.

The Renaissance was when the physical as the basis of culture became more dominant over the psychic or spiritual. I don't know if you've ever been to Venice or Florence. But if you go to Venice. All the houses, all the buildings are Higley piggledy and there's little alleys to go through to go everywhere. It's just grown like that. Yes. Florence, all the buildings are in exact straight line. Ora was where the renaissance happened. The physical became much more important.

And as a sort of tacit underpinning of the culture. And so that made it harder to be to come out as trans. People did, but it was harder. And that has kind of carried on until more recently. And I think quite probably two things. One, the Internet made a difference. Yes. I certainly did for me. Yeah. And also, it wouldn't have made a difference on its own, I don't think.

But because people had started to come out with new vocabulary, like trans, transgender, things like that, because the Internet, especially initially, was very much a text based still is really a text based medium. If you didn't have those words, then it wouldn't have been much use. Those two things coincided and enabled people to come out. So the idea that it's a trend is ridiculous. You know, I can remember a couple of years ago, suddenly everybody was wearing green.

You know, I remember a whole lot of students came into a lecture once and I thought it was St. Patrick's Day. You know. That was about a couple of years maximum, wasn't it? So Trends don't last that long. So break out the Bon jovi because we are halfway there. We're on the second half of our cash review talk, and this time, we only have two parts left of the actual review to talk about, and then a third part, which is going to be us discussing the fallout.

I don't ever want to look at this fucking report ever again. Yeah, I agree, absolutely the same because for the last month and a bit now, it has just been all cash review all the time in what the trans Towers. So hopefully we can just kick this one out the door, put it behind us, and start thinking about something else. Pages of cast plastered on the office walls, you know. Yeah. Yeah, absolutely. And I haven't even engaged with the election stuff yet, because there is about to be an election.

As we record this, it's been announced because I've been too busy thinking, right, I'm just going to stick a massive pin in that and come back to it when I have got the emotional bandwidth to be able to cope with it once we've got this fucking cast review thing done. Oh, exactly. It's once we got to bump out of the way. Mm hm. Somewhat smooth sailing. And indeed, Let's crack on, shall we with Part four.

Part four is clinical approach and clinical management looks at what we need to do to help children and young people to thrive. The purpose, expected benefits, and outcomes of clinical interventions in the pathway, including the use of hormones and how to support complex presentations.

And forly one after that, we're going to be looking at Part five, which is the service model considers the gender service delivery model, workforce requirements, pathways of care into this specialist service, further development of the evidence based on how to embed continuous clinical improvements and research. So let's jump right into part four. Part four, essentially goes over what care Young Trans People will get a lot of this is highlighted in the recommendations.

So we spoke to several people who worked in caring for young transpeople in the NHS, and their insights on this shed some light onto what was recommended. And just to start with, we're already told that Cas lied to Gid staff, assuring them that GDS would not be shut down. It would be changing how some things would be rum. Instead, GDS was closed, and according to those sources, work lied about in the report. Just as background, anonymous sources, which we do not intend to name.

So we will be making some comparisons between Gids and these new services alongside our walk through of the care that's recommended in the report. One recommendation of the review was to prevent GPs from referring trans people to GICs in the first place, but to refer them to CMs first, child and adolescent mental health services. Now, this isn't new news as in a previous consultation from LNHS it covered this, and we made a guide on it, and we'll link that in the description.

So once you finally got referred, you would immediately be affected by the recommendations made by cast. So to start things off, the first recommendation was given the complexity of this population, These service must operate to the same standards as other services seeing young children and young people with complex presentations and or additional risk factors.

There should be a nominated medical practitioner, pediatrician, child psychiatrist who takes over clinical responsibility for patient safety within a service. Now, we are told that in GIDs this wasn't done before, and to put it simply Cs wants a doctor overseeing the care of the young trans person rather than therapists or psychologists.

There was some apprehension over the fact that this person who would take charge of this treatment would not previously have been trained in gender identity and not have experience in working with trans people. So immediately Ls is showing CA is trying to distance itself from GID and further medicalized process.

Following on from this in recommendation two, clinicians should apply the assessment framework developed by Review's clinical expert group to ensure children or young people referred to LNHS services receive a holistic assessment of their needs to perform an individualized care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder and a mental health assessment.

Framework should be kept under review and evolved to reflect emerging evidence, some words on that one. So immediately kind of warning bells. We're starting to ring for a lot of people saying, Well, hang on. Are you suggesting that being trans and being autistic are mutually exclusive, that you can't be an autistic trans person. So that was definitely concerning.

However, as regards the kind of assessment for neuro developmental conditions, and our contacts told us that this was already done, and they had screened for a wide range of factors. Alongside neurodiversity, they mentioned identity, who the person is.

They talked about family, talking about their life story, develop mental information, hopes and wishes for the future, education, academic stuff, interests, their gender jury slash story, slash history, talking about trauma and relationships with body and distress, talking about their mental health, relationships between all of these interrelated things, their peer relationships, talking about gender and sex in general and all of that stuff, and using it to tailor care to the individual,

as Cass did suggest before, yet Cas is framing it as if she invented it first or saying that they didn't do this intensely enough. One part was also quotes to have been saying they should also be aware of the parent slash care or expectation and the impact these may have on the young person's priorities or alternatively, the potential for significant disagreement, slash fragmentation within families, about the nature of the child or young person's distress.

Now, this could be taken as either put anti transparents first or work on family counseling to ensure parents are more accepting or be less evil. But we all know how this depends on the intentions of the clinicians involved. Alongside list and the recommendations, it's essentially recommending more intense screening for neurodevelopmental conditions and using what they would say a differential diagnosis, and Rubes gave us their thoughts on that.

A holistic assessment of their needs to inform individualized care plan sounds great. Should include screening for neurodevelopmental conditions, including autism spectrum disorder and a mental health assessment. On its own, what a good recommendation? Yes, it. It should involve all of that.

What that shouldn't mean, though, is that people whose needs are more complex or more urgent or more intense, which are all overlapping and difficult to distinguish from each other, those people should not be denied care. I mean, it's really I think I do think that there is this and actually, after the first reading of it, I sort of thought that I found that she'd really said this.

And going back, actually, it's really just implicit, this idea that autistic people are really susceptible to social influence. And there's a lot of places where she'll make a point about autistic autistic people are different in some way, usually, quite a deficit oriented way of saying that. And then the next thing she'll say is, you know, teenagers are very susceptible to social influence.

Now, the reason she's saying that is because she can't say autistic kids or at least it may not be the reason, but she can't say autistic kids are very susceptible to social influence because that is exactly the opposite of true. That is false. Autistic people are less susceptible to social influence, and that fact undermines every part of her argument that connects with this overlap.

And so if you would address the question of autistic susceptibility to social influence, her whole analysis would have to change. But, you know, then she would have had to have read You know, anything I'd ever written or answered any of my e mails or somebody like me. In the CAS review, it mentions the tiered approach and essentially reads as a step by step, which we'll quote here. It addresses urgent risk, reduced distress and any associated mental health issues and psychosocial stresses.

So child or young person is able to function and make complex decisions. And I co develops a plan for addressing the gender dysphoria, which may involve a combination of psychological and physical treatment options. Now, that definitely sounds like a deny until desistance approach to us, especially as it said, try reducing distress and any other associated mental health issues and psychosocial stresses, and then the next step is to treat gender dysphoria.

Section 11 also seems to obsess over pushing for talking therapies and obsessing over a one overly over approach where blockers and talking therapies can't be used in conjunction with each other and pushing for an alternative approach. Then as uses a quote from a trans child that they spoke to who said, I think it's helpful for people to know that there's not only one root or one set way to transition or to be trans. They might want just hormones or just surgery.

People are different with different experiences, presentations, and bodies, and it's fine for that to be the case. It's okay to have different plans for your medical transition. But this was as arguing that trans kids want pathways that aren't the usual pathway of hormones, when in reality, following on from the publication, the person who said this quote came out to say that this was taken out of context and was advocating to not remove the pathways that as was seeking out to advocate for.

We'll link that in the description. Following on from that in recommendation free. Standard evidence based psychological and psychopharmological treatment approaches should be used to support the management of the associated distress and co occurring conditions. This should include support for parents, cars, and siblings as appropriate. I had a massive support just after I said the psychopharmological because I know I said that first.

You did. Nailed it. Okay. Now, when Cass is talking about the psychopharmological, according to Oxford dictionary, it means the scientific study of the effects of drugs on the mind and behavior. So, in this case, what different drugs might have on someone's psyche. And that it is recommending to use standard evidence based care to treat the conditions that isn't dysphoria. But this recommendation doesn't mention gender dysphoria yet, just the associated and co occurring ones.

So, we think that this would be doing things like prescribing antidepressants and anti anxiety medication for mental health conditions, which on its face, sounds like, Oh, Yeah, that sounds like that sounds reasonable. But that's essentially saying, No, we don't believe well, not that we don't believe that being trans is a thing, but saying that we can treat being trans with just antidepressants, and if you want anything else, you're being unreasonable.

And we will come back to the way the report does this at the end of the segment. We have been told that Gids already worked with cams on things like this previously? In fact, the method of collaborating with CMS that Cast endorsed is very unclear, mainly in the mechanism in which it goes about its differential diagnosis. How this is done is still a question. Would they discharge and make the child go through CMs before going back to legendaclinics?

Or is it that they will work with CMs but keep them on or will it all be in house? Whichever way it goes, there is a large emphasis on diagnosing for gender incongruent before giving any care, and the only way to do that is via a differential diagnosis. Alongside this, in our interview with doctor Cora Sargent, a lot of sought everything else out first is kind of unhelpful, and Cora brought up the example of body dysmorphia.

When you're trying to put a pediatrician or a psychiatrist at the heart of a sort of holistic set of services for young people, If they aren't well trained and understanding how these issues kind of weave into each other, then it could be that they start to see the idea that, we need to make sure that a person's neurodiversity is treated, you know, in inverted commerce before they can access transition related care, or their mental health is, you know,

treated, or their eating disorders are treated before they can access transition related care without realizing, of course, that you know, young people who are gender diverse experience eating disorders, in part as woven into their gender dysphoria, right? Lots of young people experience eating disorders as a consequence of a society that has unrealistic and unachievable body ideals.

But for the trans community, eating disorders can also be a way to manage a puberty that isn't right for them, right?

We covered this in episoda classroom psychology last week, I think, you know, eating disorders are something that the trans community, young people, it's a part of managing puberty, and the changes associated with puberty when you can't get access to transition related health care, It's also a way to kind of feminize or masculinize our body in some way, like trans guys using like compulsive exercise to masculze their body, especially when they can't get access to medical treatment.

So the challenge here is kind of ironic, right? You've got a service setup that's designed to potentially treat somebody's eating disorder maybe before they can get access to transition related to health care. We really hope that's not the case, but it could easily become the case. And if that happens, then it might be paradoxical, in effect, right?

Because giving young people less access to the transition related health care they need responsively might lead them to use eating disorders, behavior as a way to manage the changes that are otherwise happening against their will with no consent from them, right? They don't consent to the puberty that they're being thrown down. I feel for them. Cora Sergeant there, who is one smart cookie.

Cora has a podcast of her own classroom psychologist, and she has done her own two part deep dive into the cast review, so you should check her out. Was a very interesting point that Cora made. Mm hm. Yeah. Alongside that in recommendation four, it says that when families or career is making decisions about social transition of pre pubertal children, Services should ensure that they could be seen as early as possible by a clinical professional with relevant experience.

And when we spoke to our contacts, they raised the point that Gids has no control whether kids socially transition. They can't just go, that's a dangerous sir Robes had this to say about the discouraging of social transition, and in fact, they wanted to make it a medical. Okay. From the summary, 0.76, systematic review showed no clear evidence that social transition in childhood has any positive or negative mental health outcomes and relatively weak evidence for any effect in adolescence.

However, those who had socially transitioned at an earlier age were more likely to proceed to a medical pathway by which they mean medical transition. Although it is not possible to know from these studies, whether earlier social transition was causative in this outcome.

Lessons from studies of children children with differences in sexual development, which is a sanitized version of disorders of sexual development, better known as intersex conditions, show that a complex interplay between prenatal androgen levels, external genitalia, sex of rearing, and sociocultural environment all play a part in eventual gender identity.

Okay. So yes, that's all fine, but you can't then claim that we don't know whether referring someone's gender identity through social transition is helpful or refusing to do so harmful.

You certainly can't claim as does 69 that the intent of psychosocial intervention is not to change the person's perception of who they are, but to work with them to explore their concerns and experiences and help alleviate their distress, regardless of whether or not the person needs to go for a medical transition. If there's concern, which, however, there was no clear evidence of positive or negative effects, however, they were more likely to proceed to a medical pathway. Is that a however?

Or is that also, by the way, it was probably the people who socially transitioned were the ones who need to socially transition because they were also the ones who medically transitioned, right? Like, there are so many other ways this can be interpreted. But however, suggests that the main way to interpret, This finding is as a problem. There's another bit here. I'm really glad you're editing this because it's going to. Love you, Amber.

For the majority of young people, a medical pathway may not be the best way to achieve well being. That's paraphrasing slightly. For those young people for whom a medical pathway is indicated, it's not enough to provide this without also addressing wider mental health and psychosocial problems, including these. Now, she's doctor. We need evidence for things, right? So where did she get this majority from? Right?

And given that she obviously doesn't have anywhere to get this majority from, Is this claim that a medical pathway is not the best way to achieve well being for that majority. Is that not suggesting that there is some other way to achieve well being? And what might that be? I mean, if it's not conversion therapy, what is it? Then it says again that the intent is not to change someone's perception of themself.

It is harmful to equate this approach to conversion therapy as it may prevent young people from getting the emotional support they deserve. The review also heard that some staff had looked at how standard evidence based treatments, in this case, third wave of CBT could be used to help young people to manage their gender related distress, stressing that this can be achieved without pathologizing or changing a young person's gender identity.

However, this was not developed into a full research study. You can't have it both ways. You can't say, on the one hand, we need evidence that this Before we can do it. On the other, we don't need any evidence that this works before we can do it. And so I don't think you can say that you're not advocating conversion therapy and then say that somebody can treat their gender related distress with CBT instead of transition. That is conversion therapy.

Applying CBT to gender dysphoria, in a way that is not exclusively and explicitly about locating the problem where the problem exists, IE in society and not the individual, and therefore is supportive of your desire to get treatments, which again, we're back to this thing of we've tried to put all these different responsibilities into one person and you can't.

You actually need a kind of separation of powers between the psychological care for the distress that a person is in, be it gender related or not, the assessment that is about trying to make sure that you provide care to people who are going to benefit from it and not to people who are going to be harmed by it and the actual care delivery. These are all things that need to work with a certain amount of independence for each other.

There were a few points rates there, and a lot of it does give the indication of conversion therapy. The whole part about emphasizing CBT or cognitive behavioral therapy is quite damning in itself and using that as if it's an alternative to social transition. Now, when we spoke to our contacts, they, of course, said that involvement of families was already a part of what happened at Gds a lot of it already under under ten pathway and was very keen to emphasize that that was a key part.

They also made sure to mention where it says, clinical professional relevant experience. They immediately said that the new services didn't want Gid clinicians to be part of it anyway, and so they said that particular recommendation would be impossible. We're skipping over recommendation five and going to number six, which said, The evidence base underpinning medical and non medical interventions in this clinical area must be improved.

Following our earlier recommendation to establish a puberty block at trial, which has been taken forward by NHS England, we further recommend a full program of research be established. This should look at the characteristics, interventions, and outcome of every young person presenting to the NHS gender services.

In the recommendation, it also said that puberty blocker trial should be part of a program of research, which also evaluates outcomes of psychosocial interventions and masculiniz slash feminizing hormones. Consent should routinely be sought for all children and young people for enrollment in a research study with follow up into adulthood.

Now, this bit will be covered in the aftermath section, but we wouldn't be surprised in this being the reason the Scottish God stopping prescriptions of puberty blockers after this review was released. According to our sources, Gids already tried to give CAS their research data on psychosocial outcomes with interventions, but it was disregarded as we saw. As we know, GDS definitely isn't the best model, but we shouldn't be deliberating on what the least worst option is regardless.

There is concern in how GDS did handle health care of young trans people. For example, record keeping and a large number of other aspects. Our contact also mentioned that there was a lot that should have been improved and now we're in this position. And with bad record keeping, as now has an excuse to hold back puberty blockers because of this. So it says the research program needs to research puberty blockers and put it behind a research protocol.

But that would mean it wouldn't be a part of standard treatment if the research protocol decides it wants to test it on you. So even if you enroll, you aren't guaranteed care with it. So majority of kids probably won't get blockers or anything and would have to wait to get to the adult clinic, with the recent announcement review into adult care. That seems even less likely now as well.

And when C went on to talk about the lack of research into puberty blockers, she pointed to the effects of puberty blockers on trans kids brains. So let's play the clip. I can remember the phrasing of this one because it was so bizarre. It was something like Other mood effects included a dampening of psychological function. I don't know what that means. I have a PhD in psychology. I study this stuff. I know what I'm talking about. I don't know what that means.

Mood Mood is usually often divided into valence and arousal, Happier feelings and sadder feelings versus alert feelings versus sleepy feelings. Is she saying that it results in people being sleepy? It is associated with a bit more sleepiness is puberty. But more sleep is not the same thing as a maladaptive suppression of psychological arousal.

I mean, also, if she say, if there was a study, I haven't seen one, but maybe there is a study that shows a difference in arousal when people are on puberty blockers. Well, if we're talking about trans people, that's to be expected because their anxiety levels will be lower.

Okay. And of course, she'll say we don't have concrete evidence that their anxiety levels are lower, but that doesn't mean that that isn't a reason to be skeptical that it's like some kind of harmful effect of the medication, either. And on the topic of downsides of puberty blockers, as mentioned about the issues in its effect on bone density. So we also spoke to Rub about this as well. I want to quote this and then I'm going to quote from the study that she's citing.

So Susan 14 43. Multiple studies included in the systematic review of puberty suppression, found that bone density is compromised during puberty suppression and height gain may lag behind that scene in other adolescents. Height gain, I agree with. The systematic review they refer to is the one that they commissioned that was carried out by their specially selected cis people.

And in that systematic review, the specially selected c person wrote Five studies found decreases in bone mineral, apparent density and ZD scores pre post treatment. However, absolute measures generally remain stable or increased or decreased only slightly. Results were similar across birth registered males and females. One study considered timing of treatment and found similar decreases among those starting puberty blockers in early or late puberity.

In the context of bone density, ZED score is where you have standardized your estimate of bone density based on the age and gender of the person in question. And so when you get to puberty, First of all, that's when genders diverge. Second of all, that's when you get a lot of increases in puberty that you don't get before puberty, after birth and before puberty in bone density.

So these Z scores, they're telling you where they are relative to people who aren't on puberty blockers at the same age. So given that puberty triggers an increase in bone density, and we have blocked puberty. Is this a surprise? Do we expect that this is going to be reversed with either the assumption of the endogenous puberty or the provision of an exogenous one? Yeah, that's the right assumption, and it's also borne out by evidence.

There's also evidence to suggest that trans girls in particular have lower bone density before they start puberty blockers than c boys of the same age, for reasons that I think probably have to do with access to participation in sport.

At one point, suggesting and we quote, Studies should evaluate whether simple measures such as stopping periods with the contraceptive pill have the potential to manage immediate distress, as well as more conventional evidence based techniques for managing depression, anxiety, and dysphoria. None of these alternative approaches preclude continuing on a transition pathway, but there may be more effective measures for short term management of distress.

It seems it's saying, use the birth control pill instead of hormones or puberty blockers, and at points also saying that normal antidepressants and anxiety meds would be alternatives, too, as we mentioned a little earlier on, and this is what Rube Walsh had to say about this. At some point in this she talks about the idea that puberty blockers have become much more spread fast and with relatively little evidence.

But unlike birth control, when puberty blockers came on the market, they had already been being used in children, albeit different children with a different indication for decades. I also think that another reason why birth control spread quickly is because there was really a lot of demand for it because it gave people control over the most intimate aspects of their body.

Okay. And there are lots of reasons today, in 2024, there are lots of reasons to be concerned about the long term safety and efficacy of birth control. There's a lot of unanswered questions, people who take birth control to prevent ovulation, there is a lot we don't know about the consequences of that, and there is a lot of reason to think that there could be some really quite serious adverse ones. None of it compares to pregnancy. Suicide a pretty big adverse event.

And when I was preparing this part of my notes, I spent ages trying to dig it up, but I can't remember which one it was, but one of the studies from the Dutch clinic in adolescence, had a kind of it was it was like treatment as usual versus puberty blockers, I think. In any case, they had one patient they mentioned who committed suicide during the course of what was not a very long study, who had been placed in the no treatment group for a variety of reasons.

And they used this they mentioned the suicide and use it as an explanation for why they were right to classify that person as not suitable for care. And, you know, there is also evidence that, you know, if you look at the number of suicide attempts that I mean, it's self report, but if you look at suicide attempts, people who asked for puberty blockers and were denied them in adolescents have a higher rate of suicide attempts than even people who didn't come out until adulthood.

So having a sufficiently intense awareness of your let's use gender incongruent for now or your transness, having that awareness earlier, Clearly, I mean, I don't I don't necessarily know that it's actually necessarily all about gender, right? It at that point, it could be, well, they figured out that this is what they want and it's about their body and it's happening and it's out of their control, and there is somebody who has the ability to give them back control, who is refusing.

And that is traumatic. That is violent. There's also data to support the idea that if children ask for puberty blockers and you don't and you say no, there is a risk of suicide from that. And that's a very serious adverse event. So like birth control, like abortion, The alternative to not providing the treatment comes with significant adverse events, significant risk that outweighs I would argue, anyway. The risk of providing the treatment.

I mean, there's also the fact that so far it's relatively rare for people to procure puberty blockers from outside of a regulated medical pathway, but it will get a lot more common now that new prescriptions have been banned. It just will. That's what's always happened. It's what happened with abortion. It's what's going to happen. And as the cast report rightly notes, these sources of medications are incredibly unsafe.

I really think that I mean, while we're doing the analogy, how do we think people would react to a review. I mean, some people would react really well to it, unfortunately. But a lot of people, most people, normal people would react to a review that had only SS men and specifically SS men who didn't have any experience in obstetrics, deciding about the safety of birth control and abortion? Because if you're a woman or an obsttrician, that makes you biased.

Just to almost to hammer home how much this analogy applies, in 14 55, she suggests that for A fabs who are distressed by menstruation, kind of ignoring all of the other things that are distressing about wrong puberty in that direction, but the birth control is a viable alternative.

And I agree from the point of view of if there's a clinician listening who is now going to try and figure out how best to take care of patients who are getting very distressed about menstruation, birth control is a good alternative given that puberty blockers are now not an option. But if puberty blockers are an option, I don't think that the safety question is any different between the two. Following this, well then go to recommendation seven.

Longstanding gender incongruit should be an essential prerequisite for medical treatment, but it is only one aspect of deciding whether a medical pathway is the right option for an individual. Now, again, this was apparently already done at Gits, but there are now doubts over the use of gender dysphoria as a diagnosis because it's becoming more and more outdated, and of course, Rub had this to say.

Gender dysphoria as a diagnosis doesn't describe some psychological state in which your gender becomes fragile. I mean, we'd have to diagnose an awful lot of s people with gender dysphoria, if that was what it meant.

In fact, what it means is being trans. And part of the reason I have so much to say about the diagnostic definition of gender dysphoria in the DSM is that I'm aware of and tangentially involved in a project to remove gender dysphoria from the DSM on the grounds that the diagnostic entity as it currently exists is well, incoherent for a start. Except the usual way to do that, of course, would be to respond to the evidence base of the original introduction of the diagnostic category.

But since that was done before they had these evidentiary criteria. Instead, we're providing evidence that it is diagnostically sensible not to have this category in a format that's really designed for people putting forward why it makes sense to have a diagnostic category. We can bring it. We can also take it back to the stuff around puberty blockers and evidence there as well, right?

But that often the evidence that's required to change something to change the status quo is disproportionately greater than the evidence that established that status quo, Or even the evidence that there is to maintain that status quo. After this and recommendation eight, NHS England should review a policy of masculilash feminizing hormones. The option to provide mass feminizing hormones from age 16 is available, but the review would recommend extreme caution.

There should be a clinical rationale for providing hormones at this age rather than waiting until an individual reaches 18. It seems that cast review is still fine on people being prescribed hormones, even if they are making the case that someone should wait until they're 18. And for this, the age of 18 really is arbitrary, and it seems to obsess over the constant mentions of brain maturation. And we spoke to Rubes again, who walked us through this.

There's a bit where she says, Moreover, given that the vast majority of young people started on puberty blockers proceed from puberty blockers to masculinizing or feminizing hormones, there is no evidence that puberty blockers by time to think. Some concern that they may change the trajectory of psychosexual and gender identity development. Okay. Unless you can show that this root of taking puberty blockers first, has a higher rate of regret.

And just to be clear, I mean regret with or without re or detransition, then the only way to claim that this changed trajectory is a concern is if being sit is a better outcome. Adolescent development is incredibly delicate. And I mean, people who are ahead of their peers do a lot in terms of pubertal development do a lot worse psychologically in the long term. And that we know. In terms of people who are behind the evidence is less clear.

You know, it's much more equivocal, and I think it probably depends on the individual quite a lot more whether that's a good thing or a bad thing to be surrounded by people who are more developed pubertally than you.

Whatever the case, I do think that when you're in a cultural context where you undergo development synchronously with most of your peers, most of the people who are close in age to you who you spend time with, you're really in synchrony with them because of the way our school system works. I mean, there are other reasons to be worried about it as well, just in terms of we don't really know what happens if you do things for longer than we've done them for before.

So does that does worry me, but then I want to go back to well, why are we using puberty blockers in the first place, right? Because there's this line that you know, there is no evidence that puberty blockers buy time to think. And some concern that they may change the trajectory of psychosexual and gender identity development. So yeah, I actually agree that they are not buying time to think for the patient.

The original context that they were introduced in the Dutch context was that clinicians and parents were not ready to proceed with the usual treatment program of replacing the endogenous puberty with one that was identity con IE, what they used to call cross sex hormones, right?

It was really about the fact that there were children in that service who were putting their clinicians and their parents in the position, well, or who, you know, need to be well, put clinicians and parents in the position. Of really not being a viable option to let them just go through endogenous puberty as had been the normal practice up to that point. Sometimes people were being put on exogenous hormones to induce a puberty.

But a lot of parents understandably were very hesitant about that because it is less reversible than puberty blockers. And so they were put on puberty blockers for about a year to give them and their parents and let's be honest, also their clinicians and to some extent, policymakers to get the ants out of their pants and calm down about it. Like, I I know, it really did come from that kind of harm reduction place and as really a compromise between very insistent patients.

They're variably supportive parents and quite conservative clinicians. We really like Roths. We do to them. We love Rob extremely what do you call it Eloquent speaker. Unlike me, failing to remember the word eloquent. After this, we skip recommendation nine and we go to recommendation ten. All children should be offered fertility counseling and preservation prior to going onto a medical pathway. But this was already done at goods anyway. So moving on to recommendation 25.

We're skipping over a few there we realize, but there are only so many hours a day. And most of it wasn't relevant to part four. Yes. Recommendation 25. Any Chess England should ensure there is provision for people considering de transition, recognizing they may not wish to re engage with the services whose care they were previously under, which again, has been done under Gids anyway. According to ourselves. Yes. So now we move on to 26, not skipping too many men.

The Department of Health and Social Care and NHS England should consider the implications of private health care and any future requests to a NHS for treatment, monitoring, and or involvement in research. This needs to be clearly communicated to patients and private providers. And this is where it has quite a few people worried. When it comes to this and in the CAS review, it is vague about what GICs should do if a child is using a private service.

It doesn't say to discharge them or refuse treatment until they come off of it. The only thing they said was, if an individual were to have taken puberty blockers outside the study, their eligibility may be affected, which is kind of vague and kind of ominous at the same time. However, one recommendation is very targeted, and that would be in recommendation 27.

Okay. The Department of Health and Social Care should work with the general pharmaceutical counsel to define the dispensing responsibilities of pharmacists of private prescriptions and consider other statutory solutions that would prevent inappropriate overseas prescribing. And this would directly be towards people who use gender GP. Those are the specific recommendations in regards for Part four, the rest of the recommendations for Part five, more about provisioning.

So what are your thoughts on that? Well, there's a lot in there, isn't there with all these recommendations. So. What a lot of people bring up is that this you know, the cast review as a whole is not an academic paper. It's not been peer reviewed itself. Fine, it's done some studies which have been incorporated into the data set by the University of York. But as a whole, this piece of work hasn't been peer reviewed.

And what muddy that and what they often used to muddy this is that the opinions made from it are derived from those multiple different studies that have been peer reviewed. But that doesn't make the conclusions that Cass made any more scientific. It's just her and her team's opinion after reading all of these papers. And in a lot of ways, even purposefully misinterpreted them to be different to what the papers actually said. Yes, which we covered a little bit earlier on, didn't we?

And don't forget all of the research that they excluded. Yes, exactly. As Cora said a few times and research methodology, purposefully excluded. Yeah. Well, it wasn't even that they muddled it up. They excluded 90 odd percent of all of the available evidence deciding that it was low quality because it wasn't a randomized control trial or RCT, as a couple of interviewees have referred to it as on that basis, they haven't included it as part of the work in the CS review.

And that's to me, that is such a huge problem. Because as Cora said, if you're using a low quality study, there are ways of correcting for that. The fact that they've chosen to completely exclude that is I feel it tells of an agenda. Exactly, and it's that fruit line that we've brought through the last part, which was the methodology brought was by a Tilly Langton of consultations with Patrick Harper.

So when you look through all the recommendations for queer, you just need to keep an eye out for the exploratory approach that this review seems to go through and then think about the research methodologies as well and the motivations and the philosophy. And you can see how it precipitates the whole of part four. Yeah, absolutely. That through line of trying to make it as obtuse and difficult as possible. And unfortunately, things don't get any better on that subject in Part five, unfortunately.

It's also interesting to mention earlier in one of the recommendations. It's still included in a research protocol about Hormones treatment, which most people would have just considered an absolute blanket ban because it's Tries anyway, Which even if it's behind a research protocol was still a bit strange, but it's still a shit review anyway, but that was just little talked about thing.

I just found a bit like, uh, Once we stop talking about the care that there was, we suppose we've got to look at the logistics of how they want to go about providing this care, which brings us on to Part five. The service model considers the gender service delivery model, workforce requirements, pathways of care into the specialist service, further development of the evidence base, and how to embed continuous clinical improvement and research.

In this section, we'll have a talk about some of a provisioning of care that review advocates for, which seems to make the process even more difficult and obtuse than it already is. The first big fat red flags are that GPs will no longer be able to provide referrals to a gender service, and that gender service is extremely unlikely to provide any meaningful treatment, I blockers and hormones, without being put on whatever research protocol is first.

So we had a chat once again to Rob Welsh about this. As far as I'm concerned, this is crackers. Because where is the caution about subjecting trans kits to the wrong puberty. Such a delicate stage of development, 16 is too old of a limit. PD blockers in trans kids basically exist to avoid having to admit that. We also want to highlight this little gem from Section 94.

Although retrospective research is never as robust as prospective research, it would take a minimum of ten to 15 years to extract the necessary follow up data. So are you saying that's 15 years of your research based model or 15 years of analysis once it's complete, what are you talking about when you say this is going to take ten to 15 years because that's a long fucking time to not get any meaningful gender treatment.

Is certainly an emphasis in some parts where it bases its success on whether they are working on a job or not rather than whether the person's happy. It seems to say it wants to lower the waiting list, but does not define how this is to be done, given how no one would be getting any meaningful treatment now anyway, and how do you plan to reduce waiting list? The treatment you've just made it much harder to access.

It's also preventing GPs from directly referring a child to the gender service, jamming one more wrench into a system so stuffed full of wrenches, you'd think Barn Harcona had taken to eating metological snacks. Did you watch June last night or something? No, I didn't. So I reread it recently, but I think that's part of me saying, Oh, you should watch June Part two, Ashley, because I've not watched it yet. You should it Yeah, Part one was excellent.

So We also need to talk about how this cast review affects regional services. Another element mentioned in Section five, includes something we hear at what the trans and many others considered to be outside the scope of what the cast review was supposed to talk about.

Review advocates that young people who would have or already have aged out of the service while on the waiting lists should be looked after, either by extending the range of regional children and young people services or through linked services. Nice idea in theory, but this was seen as something of an overreach by critics of review. So we spoke to Rub who had this to say about it.

I mean, in common with other people who've made this argument before it just fundamentally misunderstands the literature on adolescent development. Adolescence is from a neo developmental point of view, the beginning of adult like neuroplasticity. At the beginning, it functions differently.

It has different manifestations and effects, but essentially, it's a transition from a child like type of neuroplasticity toward an adult like type of neuroplasticity, along with shifts in your motivations and priorities that make sure that that plasticity is used to equip you to cope in the social world that you actually exist in and not, whichever one it is you might have been dreaming about.

In your child like ideations, there's really a fundamental misunderstanding of what it means to say that adolescence like neurodevelopment continues for as long as we have studied it, which is what the finding actually is. It's not we found that it carries on till 25, it's we found that it doesn't stop, and we looked until they were 25. That's what's really going on here.

I think there probably does come a point where your neuroplasticity starts to look more like aging and less like the continued development. But depending on where you live, it could be anywhere between early 30s and mid to late 60s 70s even. So there are a lot of questions about how exactly the research that they're advocating for is going to be conducted because that's not any information that's been put out there yet. What's this research protocol going to look like?

Who is it going to be through? How well funded is it going to be? How long is it going to take? Because if they're saying that we won't be issuing puberty blockers outside of a clinical trial, it's kind of strong arming people into a political trial, which then means that that's not really informed consent, and that is unethical, surprisingly. Good old coercion method. Yep. It's a classic.

There's also effects on private healthcare, the blocking of people being able to access it or not blocking it. What effect exactly does that have on private health care if you're saying that you're going to stop private health care from being able to prescribe pubT blockers and hormones to those who are not getting it because the clinical trial hasn't been started yet. There's also a particular emphasis on the preventing of overseas are, considerable amount.

And a lot of this, everyone just immediately points to gender GP. But there's also the aspect of, like, what about people who immigrated over to the UK, and what about people still getting health care from their home country? That's going to strongly affect. Quite a few trans people that way, which is horrid to think about, that they would be denied that they might be denied the care they have.

There's been no clarification over how that would work or any indication over their intentions over that. You know, as we've said, there's so much of it that has says, Oh, well, we're going to do this. But it's not explained how it's going to do that, but it's already had a knock on effect. Like the gender service in Scotland, saying, Okay, we're going to stop prescribing puberty blockers, even though the pathway for this research protocol hasn't been explained.

The information has not been released. So anybody who is waiting for puberty blockers as part of the Scottish gender service is now just kind of waiting in limbo as puberty marches on, and that's a really shitty thing to do. That was VCAS report. Ignorance towards evidence, a push for making trans kids lives worse and plan to implement it in Tatas before it was even published.

This is the legacy of Cas report, and now after the publishing O report, the complete and utter failure of a response to it from those in power, those in opposition, and some who campaigned for us, so we're just going to have ali fall out of the report. So even before the report was formally published, its contents were leaked. We got our copy a day early, thanks to this really awesome friend of ours in the media. Hmm, really awesome person.

And immediately, concerns were raised, and other transfolk came out in force to really show their thoughts on it. The main fallout comes a day or so after the report was formally released. And from LG it was a gigantic media circus and transfobs were all over the news. And according to some folks, they received an advanced copy days before any trans outlet got theirs.

And I think we need to point out as well that the review has done a reasonable job of seeming to be respectable and empathic, like how it brings up the potential of some kind of follow on service for 17 to 25 year olds, which sounds kind of like a good idea or the claim that it wants to bring waiting lists down, which is, you know, another good idea. There's just enough ostensibly good stuff in there that a layperson could read it and say, Well, I don't see what the problem is.

It's suggesting this and this and that. Why are you Transits never happy. We're pretty sure that this aspect is why several LGBTQ organizations released quite underwhelming statements about the review within that first couple of days. Wen Stone will release the statement. It said that CAS review can play a vital role in achieving this aim if its recommendations are implemented properly.

Let I urge NHS England and policymakers to read and digest the full report and consider doctor ass plea to remember the children and young people trying to live their lives and the families or carers and clinicians doing their best to support them. All should be treated with compassion and respect. This, unfortunately, was a very cluster statement and was not received well. And while it didn't say, welcome to the full report, it felt like it could be even stronger.

So, following this, the feminist gender equality network put out a more strongly worded letter stating that the cast review contains unsound methodology, unacceptable bias, and unsupported conclusions. As academics and experts in the field, we regard the cast review as potentially harmful to trans children.

And there was much outcry from other trans supportive and trans outlets, including ourselves, of course, who pointed at the connections to conversion therapists that we laid out early on in this big cast review digest. And even following that, on 18 April, it was announced that Scotland's gender identity clinics paused all future prescriptions to puberty blockers, and only those who had previously been prescribed, will receive them.

And this understandably sparked outrage in a trans community, and the following weekend, a protest was staged outside the clinic. Another knock on effect was the news that a review into adult gender services along the same lines as the cast review is being planned as published in the guardian. As we've said for I don't even know how long now. Once they've halted young people's ability to transition, they'll come for the adult next.

We've seen this exact same thing play out in America where people like Patrick Hunter are the ones influencing and even just writing chunks of new anti trans legislation. Now, with all of this, professional bodies were still digesting the report. Chiefly amongst them was WPF and APAF who made own faults known a few weeks later.

In a lengthy statement, it said that WPF and USPAP remained deeply concerned about the facts regarding the CAS reviews process and content, as well as its consequences for provision of care for trans and gender diverse youth. Also said it was concerned about a number of aspects.

The first was the appointment of CAS onto the board and pointed to the fact that the process was without transparent or competitive process, and that Hilary Cass is a pediatrician with hardly any clinical experience or expertise in providing transgender health care for young people. Furthermore, Hilary Cass lacks significant research qualifications or research expertise in transgender health.

They also called the cast review an outlier, ignoring more than three decades of clinical experience in this area, as well as existing evidence showing the benefits of hormonal interventions on the mental health and quality of life of gender diverse young people.

They then went on to say that WPAth and US Path also have serious concerns regarding the ethics of the provision of puberty blocking agents for the young TGD people in the United Kingdom in the context of a research protocol only TGD being transgender diverse people. Two days prior to this statement, the government issued its new RSE guidance. With this sort of ban that they're considering, it has always been cited but always keep citing the CAS review.

And this wasn't the only thing that cited the CAS review as why they wanted to implement a specific ban, and one of them could be considered what some people call the new Section 28. So you've probably heard about this one already. It was unavoidable last week. Side note, Trans News used to be a few pages in. In smaller text, usually about some trans person apparently being the first to do something. Now it's omnipresent and that is so exhausting.

This week's stressful inescapable news is that there is a plan to ban all mention of transpeople during sex and relationship educations at schools. A new Section 28, basically, aimed squarely and specifically at transpeople, which is something that we have been warning about for literally years at this point. I hate being right all the time. I know it's so difficult. At the moment, this is some planned guidance for schools.

On 16 May, the government confirmed that sex education for children younger than nine and any education about transpeople for all pupils will be banned once their legal guidance is updated. This doesn't come to a vote in the Commons or anything. This is an update to guidance, so it is something that they can just do. Not that there will be much opposition in the commons, as it stands at the moment, of course.

Although Nadia Whitom who's the labor MP has openly criticized the plan, saying sex and relationship education is vital for helping to keep children and young people safe and healthy. It is already taught in an age appropriate way by schools.

The Torres claims about what children are learning are designed to fuel hysteria and build support for Section 28 style policies, which is what this latest guidance seems to be harking back to Indeed, because the guidance is a continuation of the government's tired game of Whack a mole in trying to extinguish any and all notion of trans existence. Those in secondary schools will supposedly be taught about the legally protected characteristics of sexual orientation and gender reassignment.

But teaching gender reassignment without first establishing the base of trans identity goes beyond putting the cart before the horses. Instead, it teaches kids about the carts without acknowledging the existence of horses or their necessity in pulling carts. This new guidance preaches safety, but simultaneously denies the education of children about sexual violence until they are in year nine, neglecting to consider children who experience sexual violence at younger ages.

Instead of abuse, children first learn about conception and birth in year five, keeping in line with the heteronormative conservative values tries are keen on upholding. Gov.uk press release of the guidance mentions the cast review, of course, which at time of writing is only six weeks old, explaining the guidance is rushed feel. With no need for parliamentary approval.

This is another cheap win for the government, added to the pile of half baked legislature made amidst the general election induced panic, senselessly cobbled together with tape chewing gum and bigotry. The cast reviews suggested medical restrictions, clearly stirdy feeding frenzy among the lights of Mirian Cakes and Jillian Keegan, providing just enough crumbs of ground to justify imposing similar restrictions in the classroom.

How interesting that the guidance claims to advocate for science all while still adhering to the antiquated and awkward rolling condoms over bananas metaphorizing of human anatomy? If Keegan is so set on accurate education regarding sex organs, she should first consider the repercussions of having children compare their bodies against whatever you find in a fucking fruit book.

In an exclusive what the trans interview, non binary sex educator and soon to be author D Whitnll warns that this will lead to a complete depletion of trans educators. As an ex teacher, what would I have to do, they asked? Would I have to erase my own identity in the classroom? Not explain why I use VM pronouns, why my honorific is MX. Would I be fired for doing so? It makes no sense to me. D worries that this change in guidance endangers trans students who are already out in their schools.

How will the identities be discussed in a classroom? Will they be silenced, raised? When talking about safe sex practices, will anyone provide resources or inclusive for them? Will they have to sit in a classroom with their biological sex and have to experience misgendering the entire lesson. Reassures that they will be fighting every step of a way in the eight week consultation period, fighting four and alongside the trans children the guidance fails to protect.

Though they fear what else this might spell for Trans esia beyond the classroom. Trans Orphan activist Kestrel in another what the Trans interview, likewise forecasts dark days ahead, claiming what little progress has been made in the years following Section 28 being repealed into 2003 will return tenfold traumatizing an entire new generation of trans youth.

The new guidance, according to Kestrel will undoubtedly prove vindicating for educators who still incubate prejudices carried over from the heyday of Section 28 as she pronounces during her interview. We're in a place where Hat is once again on the agenda. So, yes, that's a lot of stuff we just threw at you. But yeah, this is not good. It's not a good look.

The fact that it doesn't have to go through parliament and they can just do this is of some concern, I think, because once it's in, it might be quite difficult to get it out, you know, not without getting someone to have to or several someone to have to completely rewrite the guidance and check out that guidance and replace it with something new.

But then that does mean that you have to come up with something new to replace it and say, well, we're going to check that out and replace it with this. So you need it, essentially, rather than just saying, Okay, we're going to ditch that specific bit of the guidance. Which I'm sure educators will really appreciate that political tug of war.

So according to the telegraph on 16 May, Labor had declined to commit to keeping for new sex education guidance for schools, and both Keertama the party leader, and Bridget Philipson, the shadow education secretary, fell short of promising that the guidance unveiled by the education secretary would be kept if they were to win office.

The health secretary did stress the importance of age appropriate teaching and also saying that it was important to provide different laboratory facilities based on bilateral called sex, which is a bit iffy there. She wants to look carefully at what the government is setting out. It's a draft consultation and lesser consultation. There's always a consultation. It's always bloody is.

If it goes the way of everybody or most people who write into it, say, Hey, look, this is a shit idea, and you shouldn't do it, they'll still bloody do it. Yes, I've just finished reading it. So it sounds like they haven't committed to keeping the guidance or following through with the guidance if once they come in, so they could just leave it dead in the water or say, No, we're not going to. Yeah. We're not going to make that change.

You're going to make that change. But the problem is you have to see whether labor makes the decision for themselves. And at the moment, it's becoming very difficult to trust labor with our own education or lives or anything. Yeah. With that, I suppose the fact they're not committing to anything for fucking ones. Yeah, is a glint of something. Even if it's Correct and nothing. Yeah, that's infuriating, isn't it? But on the subject of the election, we've got a whole episode planned for it.

So within the next few weeks, obviously, the election is only a few weeks away, so our next episode is going to focus on it. We're going to have a look at the manifestos. We're going to have a think about who should we vote for annoyingly, in some places, it might be necessary to vote tactically, which might mean that in some places, the way to stop the tories which is the most important thing. The way to stop them might be unfortunately, hold your nose and vote for labor.

Which sucks, and there should be a better alternative, but there isn't because we're in the worst timeline, and the UK just needs to die as a concept. Now we're getting on to the whole idea of nationhood and states, which also needs to die as a concept, but don't get me started on that. So yes, look forward to that an episode, all about the election. Won't that be fun? As if we hadn't done enough writing as it is. Yeah. Yeah. Keyboards just about cooled down.

What if we had just some nice little story about a nice play that was going on in theater or about Abigail Forn or Star Wars or trans actors appearing in doctor who now we have to talk about the new Section 28 for trans people. Yeah. Okay. Um, Yeah, worst timeline. Worst for. They always blame the CAS review on this.

But this is an example on the wide reaching implications of the CAS review, and this is regardless of whether the people who made the decisions read them properly or with good intentions. It's used as an excuse to make our lives worse, regardless or not of the contents. And what we have found out from Czi Green is the effect that this will have on Transids including the effective ban on puberty blockers. We are going to have to issue a content warning again for suicide.

On 2 May, Susie Green, ex heads of mermaids put out a tweet stating that since Lebelv Tavistock ruling, 16 children have died from suicide. A year prior, the number was one child. Further on from this, she asked, how many more kids must die before a direct correlation between denial of services and death by suicide is recognized and stated that the fo concern, and what about the children is a smokescreen for bigotry.

The UK is ignoring all the evidence that proves gender affirmative care saves lives. And this is what is at stake with this CAS review. Now, all of this is terrifying. And we know that there are going to be some trans kids who do listen to this podcast. Thank you guys and gals and non binary pals. And we just want to say this. We are worried and angry for you. Every adult in the room is worried too, trans OS, and we are fighting to make sure you get the best care that you can get.

We and so many others are working to at least try to make sure we can keep you safe and defend your health care. The battle might appear to be lost, especially with an incoming labor government saying they'll stick with the cast report as a roadmap, but this is just one battle in a much larger culture war, and we will never stop fighting for your rights and ours, to be us, to be ourselves to be free. And if you haven't already, let us radicalize you to get involved.

Change only comes when people work towards it. You can find or form mutual aid groups. You can write to your MP, stage protests and get your SIS friends to join us in solidarity. Join an anarchist collective, make protest start and staple it to a cabinet ministers clothes. There are so many options. We're with you. We love you, and there's always still hope. We have to believe that. We want to thank all of the people who helped us with the reporting on this review.

It has been one of our most complex productions we've ever had. So we just want to thank Ky, Lucy, Milo, and Rowan from what we've been calling our consultation team for their analysis piece when the report first came out and for speaking with us on the pod and trans safety network for assisting them and providing them with some fantastic intel on the connections the cast report had with conversion therapist.

And we want to thank the folks who wish to remain anonymous for speaking with us about the NHS care and the information around. And finally, we want to thank doctor Cora Sergeant, doctor Rubeswlh, doctor Natasha Kennedy, and doctor al Horton for their fantastic insights that they all had and for helping advise us when we were doing all of this writing and for speaking with us on the part. And we really appreciate it.

And hopefully, we have all kept you all informed and up to speed on what this infernal report was. And with this information we've given you, help you fight this. And whilst this cultural war wages on, we can help provide you with the information to fight it.