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@benryanwriter: NEWS: Alabama Attorney General submits motion for summary judgment in District Court case over ban on pediatric gender-trans

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NEWS: Alabama Attorney General submits motion for summary judgment in District Court case over ban on pediatric gender-transition treatment.

The document offers a scathing @WPATH's credibility, based on subpoenaed documents, dismissing it as an "activist interest group." 🧵

This summarizes the Alabama Attorney General's assessment of @WPATH, based on a trove of subpoenaed internal communications that have been unsealed this week, plus more yet to be unsealed: "In short, neither the Court nor Alabama need treat WPATH as anything other than the activist interest group it has shown itself to be. The Constitution allows States to reject WPATH’s model of “care” and protect vulnerable minors from life-altering transitioning “treatments.” The Court should grant Defendants summary judgment."

The AL AG's motion for summary judgment borrows liberally from the UK Cass Review to portray the scientific literature on gender-transition treatment as weak and unreliable. It also relies on the words of @WPATH's president, Dr. Marci Bowers: "Asked whether 'reasonable people could conclude that there is not enough evidence to support the safety or clinical effectiveness of puberty blockers,' Bowers replied: 'There’s not enough high level evidence. Yes, you can – you can – you can say that.'”

The AL AG also points to Dr. Eli Coleman, the chair of @WPATH's Standards of Care 8 trans-care guidelines, when arguing that a 12-year-old cannot assent to gender-transition treatment that may make them infertile: “at their age – they would not know what they want."

The Alabama AG posits what has become a highly contested argument that most gender dysphoric young children will desist and stop identifying as transgender during adolescence.

The Alabama Attorney General argues in its motion for summary judgment in District Court regarding suit over the state's pediatric gender-transition ban: “Minors, and often their parents, are unable to comprehend and fully appreciate the risk and life implications, including permanent sterility, that result from the use of puberty blockers, cross-sex hormones, and surgical procedures." Thus, “the decision to pursue a course of hormonal and surgical interventions to address a discordance between the individual’s sex and sense of identity should not be presented to or determined for minors who are incapable of comprehending the negative implications and life-course difficulties attending to these interventions.”

The plaintiffs suing Alabama over its ban of pediatric gender-transition treatment rely on guidelines by @WPATH and the Endocrine Society. The AL Attorney General points to the Cass Review to characterize them as "unreliable and methodologically unrigorous."

The Alabama AG again refers to the Cass Review when characterizing what Cass called "circularity" in the WPATH and Endocrine Society's pediatric gender-transition treatment guidelines, but which the AG refers to as laundering.

The Alabama AG argues that the major medical associations that back the gender-affirming care model for children do not, in fact, explicitly endorse @WPATH or the Endocrine Society's treatment guidelines per se. 

When @WPATH's Dr. Eli Coleman couldn't get the @AmerMedicalAssn to back WPATH's Standards of Care 8 guidelines for trans care, he emailed his colleagues in a fury and said the AMA is run by “white cisgender heterosexual hillbillies from nowhere."

The Alabama AG criticizes @WPATH for not seeking to prevent intellectual conflicts of interest from biasing its Standards of Care 8, meaning the guidelines were made by those "professionally engaged in performing, researching, or advocating for the practices under review."

Activists have made much of the fact that Hilary Cass was appointed by the NHS to conduct a review of pediatric care for gender dysphoric children despite no experience with such patients. But that is why she was chosen, because she lacked that intellectual conflict of interest. 

WPATH, the AL AG asserts, leaned into intellectual conflicts of interest when crafting the SoC8. Its president, Dr Marci Bowers, says she made more than $1 million from such surgeries last year and said it was "absolutely...important for someone to be an advocate" for gender-transition treatment to sit on the guideline committee.

Despite the fact that the head of WPATH's Standards of Care 8 trans treatment guidelines, Dr. Eli Coleman, said that most of those who contributed to them had financial and/or nonfinancial conflicts of interest, WPATH denied this in public.

Despite asserting that they were creating the Standards of Care 8 according to evidence-based medicine principles, WPATH did not do so. Dr. Eli Coleman, who headed the effort, said, "we were not able to be as systematic as we could have been (e.g. we did not use GRADE explicitly)

WPATH admitted using the term "recommend," which per the principles of evidence-based medicine is reserved for treatments backed by strong evidence with few downsides and a high degree of acceptance among providers and patients, to describe treatments with low-quality evidence.

The systematic literature reviews that @WPATH commissioned from Johns Hopkins and that it subsequently largely buried found "little to no evidence about children and adolescents" with respect to gender-transition treatment. HHS acknowledged this in Sept 2020.

WPATH denied Johns Hopkins the requisite independence for conducting and publishing the systematic literature reviews on trans care that the organization commissioned.

Social justice lawyers told @WPATH that evidence-based reviews of the science behind gender transition treatment for children would put the organization "in an untenable position in terms of affecting policy or winning lawsuits."

WPATH, the Alabama AG alleges, were "explicit in their desire to tailor SOC-8 to ensure cover-age for practically any 'embodiment goal' a patient has by labelling it 'medically necessary.' That label was given to a staggeringly broad list of treatments, seemingly without regard to the evidence base."

Biden Admin health official Rachel Levine put political pressure on WPATH to remove the age restrictions for gender-transition treatments in the Standards of Care 8.

After the @AmerAcadPeds threatened to withhold support for the SoC8 and to come out against it if @WPATH didn't remove the age limits on gender-transition treatment, WPATH relented and then fabricated a story for the public about why they did so.

WPATH's Dr. Eli Coleman said trans health care is "not only under attack by politicians, but by:” (1) “academics and scientists who are naturally skeptical,” (2) “parents of youth who are caught in the middle of this controversy,” (3) “increasing number of regret cases” who “blame clinicians for allowing them[] to transition,” and (4) “continuing pres-sure in health care to provide evidence-based care.”

Erica Anderson, former USPATH head, told me how she locked horns with her WPATH colleagues after telling @AbigailShrier that some care of gender dysphoric kids was "sloppy." Anderson wanted more openness with journalists, USPATH wanted a moratorium on talking to the press. Anderson lost that battle.

One author of the SoC8 adolescent chapter said: "My fear is that if WPATH continues to muzzle clinicians and relay the message to the public that they have no right to know about the debate, WPATH will become the bad guy and not the trusted source."

In public, WPATH denies that social contagion may contribute to gender dysphoria in minors and that rapid-onset gender dysphoria may be a real phenomenon, but in private they are more circumspect, the Alabama Attorney General asserts.

The Scandal Goes All the Way to the White House—But It’s Deeper than Levine

What the New York Times left out of their recent reporting.

realityslaststand.com

WPATH leadership went to great lengths to suppress systematic reviews (SR) commissioned from Johns Hopkins because the reviews’ conclusions did not support the WPATH plans to recommend wide access to hormones and surgeries for all those who desired them. The evidence suppression was achieved via a 2-prong strategy. First, WPATH forced JHU to withdraw the manuscripts that were already submitted for publication as they did not meet the desired conclusions. Next, WPATH instituted a new policy whereby WPATH would have to approve all future publications by JHU.

WPATH developed an approval checklist, which required that the authors must have the “intention to use the Data for the benefit of advancing transgender health in a positive manner,” the content approval must involve SOC8 chapter leads, and the review must include “at least one member of the transgender community in the design, drafting of the article, and the final approval of the article.”

Two levels of WPATH approval were required before JHU could submit a publication: first, the proposal which includes the conclusion had to be approved; and then, the actual manuscript draft, with WPATH retaining the rights to alter content.

Only the reviews passing both levels of approval could be submitted by JHU for publication—and they had to carry a specific disclaimer that “the authors are solely responsible for the content of the manuscript, and the manuscript does not necessarily reflect the view of WPATH in the publication.”

There is a lack of current evidence-based guidance for care of children and adolescents who identify as transgender, particularly regarding the benefits and harms of pubertal suppression, medical affirmation with hormone therapy, and surgical affirmation. While these are some existing guidelines and standards of care,2, 5-6 most are derived from expert opinion or have not been updated recently so a comprehensive evidence review is currently not available.

The EPC Program will not develop a new systematic review because we found protocols for two systematic reviews that addresses portions of the nomination, and an insufficient number of primary studies exist to address the remainder of the nomination.

Biden Officials Pushed to Remove Age Limits for Trans Surgery, Documents Show

Newly released emails from an influential group issuing transgender medical guidelines indicate that U.S. health officials lobbied to remove

nytimes.com

Newly released emails from an influential group issuing transgender medical guidelines indicate that U.S. health officials lobbied to remove age minimums for surgery in minors because of concerns over political fallout.

Health officials in the Biden administration pressed an international group of medical experts to remove age limits for adolescent surgeries from guidelines for care of transgender minors, according to newly unsealed court documents.

Age minimums, officials feared, could fuel growing political opposition to such treatments.

Email excerpts from members of the World Professional Association for Transgender Health recount how staff for Adm. Rachel Levine, assistant secretary for health at the Department of Health and Human Services and herself a transgender woman, urged them to drop the proposed limits from the group’s guidelines and apparently succeeded.

If and when teenagers should be allowed to undergo transgender treatments and surgeries has become a raging debate within the political world. Opponents say teenagers are too young to make such decisions, but supporters including an array of medical experts posit that young people with gender dysphoria face depression and worsening distress if their issues go unaddressed.

In the United States, setting age limits was controversial from the start.

The draft guidelines, released in late 2021, recommended lowering the age minimums to 14 for hormonal treatments, 15 for mastectomies, 16 for breast augmentation or facial surgeries, and 17 for genital surgeries or hysterectomies.

The proposed age limits were eliminated in the final guidelines outlining standards of care, spurring concerns within the international group and with outside experts as to why the age proposals had vanished.

The email excerpts released this week shed light on possible reasons for those guideline changes, and highlight Admiral Levine’s role as a top point person on transgender issues in the Biden administration. The excerpts are legal filings in a federal lawsuit challenging Alabama’s ban on gender-affirming care.

One excerpt from an unnamed member of the WPATH guideline development group recalled a conversation with Sarah Boateng, then serving as Admiral Levine’s chief of staff: “She is confident, based on the rhetoric she is hearing in D.C., and from what we have already seen, that these specific listings of ages, under 18, will result in devastating legislation for trans care. She wonders if the specific ages can be taken out.”

Another email stated that Admiral Levine “was very concerned that having ages (mainly for surgery) will affect access to care for trans youth and maybe adults, too. Apparently the situation in the U.S.A. is terrible and she and the Biden administration worried that having ages in the document will make matters worse. She asked us to remove them.”

The excerpts were filed by James Cantor, a psychologist and longstanding critic of gender treatments for minors, who used them as evidence that the international advisory group, referred to as WPATH, was making decisions based on politics, not science, in developing the guidelines.

The emails were part of a report he submitted in support of Alabama’s ban on transgender medical care for minors. No emails from Admiral Levine’s staff were released. Plaintiffs are seeking to bar Dr. Cantor from giving testimony in the case, claiming that he lacks expertise and that his opinions are irrelevant.

Admiral Levine and the Department of Health and Human Services did not respond to requests for comment, citing pending litigation.

Dr. Cantor said he filed the report to expose the contents of the group’s internal emails obtained by subpoena in the case, most of which remain under seal because of a protective order. “What’s being told to the public is totally different from WPATH’s discussions in private,” he said.

Dr. Marci Bowers, a gynecologic and reconstructive surgeon and the president of WPATH, rejected that claim. “It wasn’t political, the politics were already evident,” said Dr. Bowers. “WPATH doesn’t look at politics when making a decision.”

In other emails released this week, some WPATH members voiced their disagreement with the proposed changes. “If our concern is with legislation (which I don’t think it should be — we should be basing this on science and expert consensus if we’re being ethical) wouldn’t including the ages be helpful?” one member wrote. “I need someone to explain to me how taking out the ages will help in the fight against the conservative anti-trans agenda.”

The international expert group ultimately removed the age minimums in its eighth edition of the standards of care, released in September 2022. The guidelines reflected the first update in a decade and were the first version of the standards to include a dedicated chapter on medical treatment of transgender adolescents.

The field of gender transition care for adolescents is relatively new and evidence on long-term outcomes is scarce. Most transgender adolescents who receive medical interventions in the United States are prescribed puberty blocking drugs or hormones, not surgeries.

But as the number of young people seeking such treatments has soared, prominent clinicians worldwide have disagreed on issues such as the ideal timing and criteria for the medical interventions. Several countries in Europe, including Sweden and Britain, have recently placed new restrictions on gender medications for adolescents after reviews of the scientific evidence. In those countries’ health systems, surgeries are only available to patients 18 and older.

The email documents were released by the U.S. District Court for the Middle District of Alabama, in a challenge to the Alabama ban brought by civil rights groups including the National Center for Lesbian Rights and the Southern Poverty Law Center on behalf of five transgender adolescents and their families.

Transgender rights groups have turned to the courts to block laws, like Alabama’s, that have been approved in more than 20 Republican-controlled states since 2021, but the courts have been split in their rulings.

On Monday, the Supreme Court announced that it would hear a challenge to Tennessee’s ban on youth gender medicine, which makes it a felony for doctors to provide any gender-related treatment to minors, including puberty blockers, hormones and surgeries. The petition, filed by the Department of Justice, cited the WPATH guidelines among its primary “evidence-based practice guidelines for the treatment of gender dysphoria.”

Additional emails cited in the new court filings suggest that the American Academy of Pediatrics also warned WPATH that it would not endorse the group’s recommendations if the guidelines set the new age minimums.

In a statement on Tuesday, Mark Del Monte, chief executive of the American Academy of Pediatrics, pointed out that the medical group, which represents 67,000 U.S. pediatricians, had not endorsed the international guidelines because it already had its own in place.

He said the academy had sought to change the age limits in the guidelines because the group’s policies did not recommend restrictions based on age for surgeries.

Last summer, the pediatrics academy reaffirmed its own guidelines, issued in 2018, but said that it was commissioning an external review of the evidence for the first time.

The numbers for all gender-related medical interventions for adolescents have been steadily rising as more young people seek such care. A Reuters analysis of insurance data estimated that 4,200 American adolescents started estrogen or testosterone therapy in 2021, more than double the number from four years earlier. Surgeries are more rare, and the vast majority are mastectomies. or top surgeries. In 2021, Reuters estimated that 282 teenagers underwent top surgery that was paid for by insurance.

Gender-related surgeries for minors have been a focal point for some politicians. Gov. Ron DeSantis, Republican of Florida, has argued that surgeons should be sued for “disfiguring” children. In Texas, where parents of transgender children have been investigated for child abuse, Gov. Greg Abbott, a Republican, has called genital surgeries in adolescents “genital mutilation.”

The final WPATH guidelines state that distress about breast development in particular has been associated in transgender teenagers with higher rates of depression, anxiety and distress.

“While the long-term effects of gender-affirming treatments initiated in adolescence are not fully known, the potential negative health consequences of delaying treatment should also be considered,” the guidelines state.

“Gender-affirming surgery is valued highly by those who need these services — lifesaving in many cases,” Dr. Bowers said.