0:00

Do you have a tagline? No,

0:13

I was, that's part of the reason why

0:15

earlier I was like, do you have a

0:17

tagline? Wait, you should do your SaaS Report

0:19

one. Do your SaaS Report one, finally. Why would

0:21

I do it again? We

0:24

gotta stop keeping our little outtakes, because

0:26

we can't use our like, B-grade

0:29

or B-list taglines. Hi everybody,

0:31

and welcome to Maintenance Phase,

0:33

the podcast that has its

0:35

notifications turned off on social

0:37

media after this week's episode.

0:40

Oh yeah, we did hear from

0:42

the anti-trans brain trust, as well

0:44

as the smoothie truthers. Thank

0:47

you for your feedback. So this is like,

0:50

somewhere halfway between

0:53

like a bonus episode and like an episode

0:55

episode, I feel really bad

0:57

that like, we sort of shortchanged the cast

0:59

report in our Rapid Ons That Gender Dysphoria

1:01

episode, because we wanted to focus on the way

1:03

that this specific narrative has like, taken over all

1:05

these institutions of the US and the UK. So

1:07

that's what we focused on in the cast report,

1:10

but of course the cast report is like, 400

1:12

pages long. Listening back

1:14

to that episode, I was like, we went

1:16

really easy on the cast report. Like, I think

1:18

we tried to get across how like, it's basically

1:20

just like, a smorgasbord of anti-trans

1:22

talking points. But it's also just like, fairly

1:25

bad on other things. And it includes a

1:27

lot of other just sort of bullshit. And

1:29

so we wanted to break this out and

1:31

do like, its own little episode. Also,

1:33

I have COVID and I feel like shit. Bloody.

1:35

I don't know how detailed this is going to

1:37

be because I'm very tired and my throat is

1:39

sore. But we're going to do our

1:42

best. We're going to read a bunch of excerpts. I'm mostly

1:44

going to make Aubrey read them because her throat works. Not

1:46

to brag, but my throat works. So

1:51

again, I mean, I guess we should preface this by

1:54

just saying, like, if you're not on like, fighting about

1:56

transphobia Twitter, you may not have

1:58

seen the release of the worth

10:00

engaging with. As we've said, this is a

10:02

small field and they're not treating that many

10:04

patients. You could interview every single person who's

10:07

providing this care in the UK, it would

10:09

not be that hard. So that's

10:11

like the first like beyond red,

10:13

like bright red, like magenta flag.

10:16

And the second issue is the

10:19

nature of the engagement with actual

10:21

trans people. So we do know that

10:25

Hilary Cass met with like pro trans groups

10:27

like mermaids and there's other NGOs that work

10:29

with trans youth in the UK. So they

10:31

have not been completely cut out of the

10:33

process. Although we have heard from some of

10:35

the people who were in these quote unquote

10:37

listening sessions who say that they're like pull

10:39

quotes and their messages were like taken

10:41

out of context and included in the report or basically

10:43

that what they said was ignored.

10:46

Was there a through line with those comments?

10:48

Was there like a theme of people being

10:50

like, they didn't include this and I said

10:52

this thing? Like was there was there alignment

10:55

in the this thing? Yeah, so basically, it

10:57

was a bunch of people who said, you

10:59

know, I told the cast review positive things

11:02

about my own transition and positive things about

11:04

my care. And they took my words and

11:06

use them as ammunition for this care being

11:08

given out too easily. So here I saved

11:11

one of them. These are these are what's

11:13

known as pull quotes. It's like when you

11:15

have one of these PDF documents, it's kind

11:17

of nicely laid out, you have these larger

11:20

font quotes that are sort of highlighted as

11:22

like one of the core messages. So

11:25

just imagine you're seeing this like with

11:27

no context at all. That

11:29

is what I am seeing. Oh, yeah, good point. I am.

11:34

Imagine not knowing the name and circumstances of the

11:36

person who's saying this. There's

11:40

not only one route or one set way

11:42

to transition or to be trans. They

11:45

might want just hormones or just surgery.

11:47

People are different with different experiences, presentations

11:49

and bodies. It's fine for that

11:51

to be the case. It's okay to have

11:54

different plans for your medical transition. Yeah, I mean,

11:56

sure. I don't know. Different people are different. Yeah.

11:58

So okay, then I'm going to say. you,

12:01

this is from a very interesting

12:03

article that comes out afterwards called,

12:05

Critically Appraising the CAS Report, Methodological

12:07

Flaws and Unsupported Claims. While it

12:09

seems that this participant is advocating

12:11

for increased availability of care options

12:13

for trans people, this quote directly

12:15

informs the section which suggests, quote,

12:17

it is important to inform people

12:19

that medical transition is not the

12:21

only option, and that choosing not

12:23

to go down that route does

12:25

not invalidate their identity. The

12:28

report then reframes this response as evidence

12:30

for the need to reduce the number

12:32

of medical transitions. Again, they're implying that

12:34

people are being pushed into medical transition,

12:36

right, as if that's the only option

12:38

when they've provided no evidence of this

12:41

being the case. Again, 75% of

12:43

people who went to this UK gender clinic did

12:46

not get puberty blockers or

12:48

hormones. So we already live in a world

12:50

where people are not being pushed into this

12:52

kind of care and are not being told,

12:54

the only way that you'll ever be happy

12:57

is if we medicalize you. That's not happening.

12:59

This is so similar, the rhetoric here feels

13:01

so similar to the rhetoric around crisis pregnancy

13:03

centers. Yeah, yeah, yeah, totally. You got to

13:05

go in and hear someone tell you and

13:08

show you pictures and do all of this

13:11

stuff to make you feel even

13:13

worse about an already complicated decision.

13:15

Also, timeshares. Also,

13:18

how they get you to buy timeshares. I

13:20

just want to sit down with you for one

13:22

hour. I just want you to know this is

13:24

not your only option. It's really an investment. You

13:26

could have a timeshare. There

13:29

is like on one side of this,

13:31

there's problems with the process of consulting

13:33

trans people that the way that the

13:35

quotes are used is just kind of

13:37

odd in the report. But then there's

13:39

also, we don't know who else was

13:41

consulted for this. So there's no information

13:43

about who wrote the cast report. There's

13:45

no information about which other groups they

13:47

sat down with. They do include on

13:49

the website of like, yes, we sat

13:51

down with these pro trans groups. But

13:53

I think they're doing that as like

13:55

a box ticking exercise to prevent criticism

13:57

because they know trans people are. with,

34:00

yeah, this is like a big

34:02

community of people who need resources

34:05

and need support now.

34:07

Yeah. So like, what's your

34:09

actual theory of change here? What do you

34:11

think needs to happen? Right. And

34:13

when you ask that question, the answer you get is, don't

34:16

call it conversion therapy, but a description

34:18

of conversion therapy, right? Again, sort of

34:20

on its face, this seems like a

34:22

completely legitimate process where for

34:25

these evidence reviews, what they do

34:27

is they're trying to stratify the

34:29

studies according to quality. So this is something

34:31

that you often see in meta-analyses. It's like,

34:33

you got like, you know, 1,500 studies, you

34:35

got to like put them into tranches and

34:37

be like, well, these kind of suck. And

34:39

so we can just like spend

34:42

less time looking at them. These are medium,

34:44

these are high. Let's sort of weight the

34:46

high quality ones a little bit better. This

34:48

is like a totally normal process. And there's

34:51

all kinds of objective criteria that are supposed

34:53

to be content neutral that you can use

34:55

when you're determining, okay, is this high quality

34:57

evidence? Is this medium quality evidence or low

34:59

quality? Right? The thing that

35:01

is weird about the approach that is taken for

35:04

the CAS report is first of

35:06

all, they constantly conflate the

35:08

term quality with like the

35:11

academic definition and the

35:13

layperson definition. So when me and you hear

35:15

like, this is a low quality study, we're

35:17

like, oh, that means it sucks. Right.

35:20

And in academia, in the context

35:22

of these meta-analyses, low quality means

35:25

it's low certainty. How

35:27

much can we conclude from

35:29

this study? This is the

35:31

aspartame classification stuff. Exactly. Everybody's

35:33

like, it definitely gives you cancer.

35:35

And you're like, no, they reclassified

35:38

the strength of the evidence. Exactly.

35:40

And the way that the report and

35:43

CAS herself talk about the evidence is

35:46

constantly using the colloquial

35:48

form. So in the report and

35:50

in interviews, CAS herself

35:52

has said that this field is

35:54

based on remarkably weak evidence. But

35:58

that's not what the reviews found. much

48:00

better. There's not a lot of studies. I

48:02

think that's by far the greatest weakness in this field.

48:04

There just aren't that many studies on like our kids

48:06

doing better after they take puberty blockers. But

48:08

from what we do know, it appears

48:10

that like they either do the same

48:13

or they do better. Any like good

48:15

faith summary of that would be like,

48:17

yeah, it's promising enough that we should

48:19

probably keep giving this to kids, right?

48:22

We don't have an increase in any

48:24

of these negative symptoms. I don't know,

48:26

Mike. I don't trust anything that improves

48:28

children's mental health. It's

48:31

also funny with puberty blockers too, because the

48:34

evidence on puberty blockers is not as strong

48:36

as it is on hormones. But some of

48:38

that is mostly just because like puberty blockers

48:40

don't actually do anything. Like there's

48:42

some studies that are like kids are just

48:44

as gender dysphoric after taking puberty blockers as

48:46

before. And it's like, well, yeah,

48:48

their bodies didn't change. The whole point is that

48:50

you don't feel comfortable with your body and puberty

48:53

blockers pause your development, but they don't

48:55

change it. So the review also uses

48:57

that as kind of an excuse to be like,

48:59

oh, well, they don't even have that much of

49:01

an effect. It's like the point was never that

49:03

they would have an effect on gender dysphoria. The

49:05

point was that they would buy you time so

49:07

that you can really think about whether you want

49:09

to stay in this identity and then go

49:12

through with something more irreversible. So

49:14

it's again like holding them to this kind

49:16

of weird standard. And even by this standard,

49:18

they are actually showing improvements in

49:21

mental health markers. Yeah. The point of

49:23

puberty blockers is to avoid a wrong

49:25

gender puberty. The point is not to

49:28

alleviate dysphoria. The point is

49:30

to avoid making dysphoria worse. So

49:32

this gets worse when we get

49:34

to hormones. So hormones

49:36

are like a bigger deal. It's like a

49:38

more irreversible intervention. But again,

49:41

we only have five studies that look

49:43

at the mental health effects of

49:45

trans kids taking hormones. Gotcha. There's

49:48

the University of York makes a table where they

49:50

break out every single result. So they stratify by

49:52

like depression. What did the study say? Anxiety. What

49:55

did the study say? And so I am going to send

49:57

you the list of bullet points since there's only five. And

52:00

they're fucking ignoring it. Wait,

52:03

but then this is the one that fucking killed me.

52:05

Aubrey, here's the next paragraph. Now I'm

52:07

the one who's flagging this sucks.

52:11

There were inconsistencies regarding suicidality

52:13

and or self-harm, with three

52:15

of four studies reporting an

52:17

improvement and one no change.

52:20

Three studies found kids are less suicidal.

52:22

One study found nothing. Who

52:24

could possibly say, what

52:26

effect this has on suicidality? Come

52:28

the fuck on. So it's like

52:30

if you had a pill that it was like,

52:32

oh yeah, three studies that it made you taller. One

52:35

study said it did nothing. Oh, we

52:37

can't say anything about whether it makes you taller

52:39

or shorter. Yeah, totally. I know someone recently who

52:41

started antidepressants for the first time and they were

52:43

like, I don't know if I'm going to keep

52:46

taking these. I don't feel any different. And I

52:48

was like, well, do you get feedback from people in

52:50

your life? And this person was like, oh,

52:53

my partner says they've never been more in love

52:55

with me. And my friends are all super happy

52:57

about it. And I was like, so

52:59

there's a pill that you can take where

53:01

you feel no different. But people in your

53:04

life love and appreciate you more. That's like

53:06

my that's like my beard. My face itches.

53:08

But all of my grinder messages end with

53:10

sir. No, you hate it. But it's fucking

53:12

hot. So we could easily spend like three

53:15

fucking hours talking about like the specific studies

53:17

and the follow ups and more of this

53:19

criteria stuff. But it's like any

53:21

sort of zoomed out good faith

53:23

look at the evidence around this issue.

53:25

Finds like, yes, methodological issues. None of

53:27

these studies are perfect. You can nitpick

53:29

about any single study you want to. But

53:32

overall, we find nearly

53:35

unanimous benefits to gender

53:37

affirming care for kids to

53:40

the extent that we don't find that we typically

53:42

find no change. We don't find

53:44

harms in any of these studies. And

53:46

I think it would be one thing if

53:48

we you know, these studies might find kind of

53:50

short term benefits. But then we do

53:52

find five years down the line. We find

53:54

regret rates of you know, 50 70

53:56

percent like people are falling off of these drugs as

53:59

they become adults. in droves, but we don't

54:01

see that either. We see study after study after

54:03

study with regret rates, even with like three year

54:05

follow ups of less than 5%, which

54:08

is not typical of like the

54:10

medical system. Usually regret rates are

54:12

much higher than that for various routine procedures.

54:15

So sorry, on what basis

54:18

are we saying that there's

54:20

weak evidence for this care and

54:22

fucking banning it by law and

54:24

sending doctors to jail for providing

54:26

it? I love it that you

54:28

say we could talk about this for three hours after

54:31

we have recorded for, I'm gonna say 12 hours

54:33

on this topic. I'm

54:36

gonna limit myself. You're like, look man, we can

54:38

go on. I'm not

54:40

gonna spend two entire months of my podcast

54:43

producing words about this

54:45

report. So another

54:49

thing that's missing from this

54:51

report is any good faith

54:53

overview of the alternatives to

54:55

gender affirming care. One

54:57

of the things that Cass report refuses to

54:59

engage with is the fact that kids going

55:02

through puberty, if they already have gender dysphoria,

55:04

is extremely upsetting and that's also irreversible. And

55:06

so either way a kid is going

55:08

to go through something irreversible. That

55:10

the option of them not going through anything irreversible

55:12

is not on the table. So you

55:15

basically need to decide you have a binary choice

55:17

of like, do they go through one puberty

55:19

or the other? And all

55:22

of the data on conversion

55:24

practices, we're not even gonna get into it

55:27

because it's so fucking dire. The approach that

55:29

this document proposes and that the NHS it

55:31

appears is now going to be built around

55:34

is basically giving them therapy. Not

55:36

necessarily like gender therapy, but like

55:39

kind of classic my kid

55:41

is struggling type of therapy like things like

55:43

CBT, right? Or like maybe you put them

55:46

on antidepressants or maybe you deal with their

55:48

anxieties. Basically you're acting as if

55:50

the trans identity is an output of

55:52

these other mental illnesses. And so you're

55:55

treating those mental illnesses directly. So

55:57

the CAS review also. commissioned

56:00

a University of York systematic

56:03

review of psychotherapeutic

56:06

interventions for trans kids. Our

56:09

friend, the health nerd Gideon Meyerowitz

56:12

Katz, he has been doing this

56:14

accidental deep dive into the Cass Report. He's

56:16

an epidemiologist. It was supposed to be one

56:19

article and then it became a series of

56:21

three articles and now it's up to seven

56:23

because like so many other people who look

56:25

into this, you're like, wait a minute, I

56:27

can't fucking believe what they're doing here. Yeah,

56:29

yeah, yeah, yeah. The first thing that he

56:32

noticed was that they're using

56:34

a totally different standard of quality than they

56:36

use in all of the other reviews. There's

56:39

like the one that they're using the other reviews

56:41

is called the Newcastle Ottawa Scale and

56:43

then without saying why, they switched

56:46

to something called the mixed methods

56:48

appraisal tool when it comes to

56:50

therapy interventions. I don't

56:52

think there's a clear view of like which

56:55

standard is better, but it's really fucking weird

56:57

to say that, oh, we have

56:59

these like very high standards of quality. We

57:01

have this objective marker of like whether these

57:03

are high or low quality studies and then

57:06

as soon as we get to therapy, as

57:08

soon as we get to something that doesn't

57:10

include puberty blockers and hormones, they're like, oh

57:12

yeah, we're using a different standard and they

57:14

don't say why. And so under the quality

57:16

rubric that they are using, these are the

57:18

studies that they have considered high enough quality

57:20

to be included in the analysis. So

57:23

Gideon lists them out. I'm not going to read all of them, but I'm

57:25

going to read the first one. One of

57:27

them is a case study of attachment

57:29

based therapy on a single transgender teen.

57:32

Astonishingly, this was the study considered to

57:34

be the highest quality of the research

57:36

that you ever reviewed. Are you fucking

57:38

kidding me? A fucking case study. A

57:40

literal N of one? I'm

57:44

going to flip a fucking table, Mike. But

57:46

then they also include a study of eight

57:48

trans teens that looks at whether having a

57:51

therapist affirm their identity helps them. There's

57:54

a study of 41 trans teens

57:56

who take an online mindfulness training.

57:58

There's a study of two children.

58:00

who downloaded Headspace on their parents.

58:04

And also the one larger study that they

58:07

include is a study of 201 adolescents that

58:09

followed them over

58:11

one year and it compares trans

58:13

kids who got therapy to trans

58:16

kids who got therapy and puberty

58:18

blockers. And it says,

58:20

well, the kids who got therapy were doing

58:22

better a year later, so therapy works. But

58:25

Gideon points out the kids who got therapy

58:27

and puberty blockers were doing even better than

58:29

that. Sorry, is this a high

58:31

quality study or not? If we're trusting this study,

58:34

then we should be giving them therapy and puberty

58:36

blockers, not just therapy. You're going full internet. Make

58:38

it make sense. Not

58:42

you using the mixed method analysis

58:44

tool. The math isn't mathing. And

58:49

so here is an excerpt from

58:52

Gideon's latest post on this. These

58:54

findings are, in a word, mixed. Most

58:57

of these papers are undeniably low quality,

59:00

and as with the low quality literature

59:02

for other aspects of health care for

59:04

trans teens, don't really add much to

59:06

the literature. In addition,

59:08

the results were pretty contradictory. While

59:10

some of these psychological interventions found

59:13

that trans teens reported better mental

59:15

health, some of the studies

59:17

showed the opposite effect. One trial

59:19

of traditional psychological care for trans

59:21

youth found that it might make

59:23

depression worse. In addition,

59:25

this review found no data whatsoever

59:28

looking at interventions aimed at improving

59:30

gender dysphoria. The entire point

59:32

of the document. The majority

59:35

of the studies looked at traditional

59:37

psychological therapy in a subgroup of

59:39

transgender children. We already know that

59:41

CBT is useful for depression. All

59:44

this review shows is that traditional

59:46

psychological therapies may not be effective

59:48

for transgender teens, which also casts

59:50

doubt on one of the speculative

59:52

arguments of the cast review that

59:54

bad mental health turns children trans.

59:56

At best, we could say that psychological

59:58

interventions could theoretically be useful. have benefits

1:00:01

for trans teens, but that

1:00:03

they seem less effective than medical assistance.

1:00:06

In addition, the data is so weak

1:00:08

that there's very little you can reasonably

1:00:10

say about them at all. The reason

1:00:12

I wanted to zoom in on this

1:00:14

is that if you're someone who engages

1:00:16

with the things that these kind of

1:00:18

allegedly I'm not transphobic but transphobic people

1:00:20

say, is the thuddingly

1:00:23

obvious double standards. Right? When

1:00:25

it comes to any study

1:00:27

that affirms that puberty blockers and

1:00:29

hormones work for kids, they're like, well, you

1:00:31

know, the dropout rate was like 7%. And

1:00:34

you know, the questionnaire studies, they didn't

1:00:36

use the right scale to measure gender

1:00:38

dysphoria. And like they pretend to have

1:00:41

these extremely exacting scientific standards about the

1:00:43

methodology, right? And they will nitpick you

1:00:45

to death. But when it

1:00:47

comes to anything that goes against the consensus

1:00:49

that gender-affirming care works, they're like, oh yeah,

1:00:51

bring in a study with like a 50%

1:00:54

dropout rate. Bring in a study that

1:00:56

interviews fucking parents about the subjective experience

1:00:59

of their kids. Bring in a study

1:01:01

where the fucking conclusions of the study are in

1:01:03

the consent form. They don't give a shit. Yeah.

1:01:05

And to have someone look at this and be

1:01:08

like, what the fuck are they doing over there?

1:01:10

Yeah, totally. Totally. It's like so cathartic. This

1:01:12

section is called Mike Feels Validated. Yeah. It's

1:01:15

like, yeah, because I feel like I'm screaming

1:01:17

into the void because it's so hard to

1:01:19

get people to engage with this stuff on

1:01:22

the merits. Yeah. This is bad work. This

1:01:24

is shoddy work. And it's really obvious how

1:01:26

motivated it is. And it's really obvious what it is

1:01:28

motivated by, right? What they're trying to do is throw

1:01:31

out any evidence that shows

1:01:33

that this care helps children. And they're

1:01:36

trying to validate these other

1:01:38

approaches that are just not related to

1:01:40

the issue at hand. We're

1:01:42

at the point now where like

1:01:44

it's just time to close this

1:01:47

debate. What?

1:01:50

Oh, no, I downloaded an Airhorn

1:01:52

app. It

1:01:55

doesn't sound like an Airhorn. It's like a

1:01:57

fog horn. Yeah. It's

1:02:01

like not good. Wait, hang on. Let me do

1:02:03

a different one. I got to use a phone.

1:02:05

Wait, say your closing line again. Until we get

1:02:08

some real evidence, it's time to close the debate.

1:02:12

What was that? That's a cheering. I

1:02:15

can barely even hear that. Yeah! He's

1:02:17

right! That's what

1:02:19

the people are

1:02:22

saying. I mean, I could have done this. Oh

1:02:25

no, that burst. That's worse. Eventually I won't even

1:02:27

need you, Aubrey. Look,

1:02:29

you have the app on your phone. That's

1:02:32

true. I can just... It does most of

1:02:34

what I do. I have some bad news,

1:02:36

Aubrey. I wouldn't be needing you. Oh, I'm

1:02:38

being replaced by AI!