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equallyshaw · 1 year

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the medicated series feat. jamie drysdale pt 3

warnings: nothing.

word Count: 2.39k

- The Medicated Series: features OC's with medical issues such as depression, anxiety, physical disabilities such as MS or Rheumatoid Arthritis as well as any other autoimmune disease such as Crohn's, endometriosis, infertility, etc. (not an autoimmune but you get it).

- one more part after this🥹

← part two - epilogue →

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three years had passed. a college degree completed, graduation, early success in her ms treatment, a proposal, a dog adopted, a small surfer house- a mere two houses down from the beach and no trevor as a roommate anymore. as well as the sudden passing of her and ej's father. which meant, he would not be there on her big day or any big day of her's in the future.

sofia had come a long way with jamie, he was there every step that he could be. though, ej made sure of that 24/7. she was completely still and living in the moment. she had obstacles still no doubt, but jamie loved her. he loved every moment that he had with her, sometimes drifting off to what the future may hold. and what it might not hold. some days the two of them sat in silence, as they both grieved the life that may never be. her grieving for her own and him for her. so when he proposed the previous year, she was had a moment of shock before feeling calm. this was meant to happen, she knew it, jamie knew it, trevor and ej knew it, plus the few other friends and family that had come out to southern california to see the proposal. so when she turned around to a group of cheers, she clutched her heart and smiled widely at jamie. tears brimming her eyes and his. her family and friends greeted her, with ej wrapping her in a bear hug and spun her around. jamie looked over as soon as he heard her laugh, he'd know that laugh anywhere. in a heart beat.

sofia walked out towards where jamie was standing with his back towards her. her hands shook as she walked up towards him, just buzzing with butterflies. she stood a few feet from him, and began to laugh. the photgrapher and videographer caught this moment on camera, getting his reaction as well. "whats so funny?" jamie asked wanting to turn around but he was waiting for her signal. she threw her head back, "i dont know." she said on the verge of tears. "whew, okay. dont wanna ruin my makeup that took an hour." she said laughing with the photgrapher who had captured the whole thing. "can i turn around now?" he asked, getting impatient.

she nodded, "yes you may." she smiled and he turned around slowly. his eyes grew wide, and he brought a hand to his mouth. he clasped his eyes shut and tried not to cry. "oh hun." she said grabbing his hands. "dont cry bubba." she said, "youre gonna make me cry." she frowned and he smiled sniffiling. "god you look gorgeous..beautiful. i dont have any big words to use." he said stepping back and admiring the dress, and his soon to be bride. he shook his head in awe, she was better than he had imagined. he pulled her in and spun her around, her laughing contagious. he dipped her, before kissing her cheek. they stood up, "i thought you were gonna try to kiss me there." she smiled, leaning in closer. he smirked, "that would defeat the purpose of our first kiss today." he said looking down at her lips before looking into her eyes. "alrighty james- time for me to go." she smiled beginning to walk off. jamie stared at her until she stepped inside but before she did, "my name's not james!" he yelled and she giggled. trevor walked out a bit too soon, "oh daaaaamn! you look good!" he said stepping back like jamie did and admired her for a second before looking at jamie, "you see this! she cleaned up nicely." trevor joked pointing at Sofia. sofia stuck her tongue out before stepping inside and found her mom.

jamie stood next to trevor who was his best man, charlie his older brother, who was his second best man (per mason), mason himself. her bridesmaids went first along with trevor's fiance who was her maid of honor. who she had met their freshman year at university. it was a match made in heaven, according to trevor.

sofia stood facing ej, who stared at her. he knew how much she wanted their father there, and so when she asked him to walk her down the aisle, he knew how hard it was. he grinned, putting his arm out for her to take it. she smiked, taking in a huge breath. "you ready?" he asked softly and she nodded. everybody stood up, as she walked out into the open. everybody took in her classic updo and classic dress, paired with a beautiful bouquet of peonies. sofia smiled at the two parties the first few steps, before coming eye to eye with jamie. she saw the tears that he tried to wipe away. the sun, the atmopshere, the timeless decor and the fact that he was about to marry his best friend and partner for life, made him emotional. she smiled widely at him, as they now only stood a few feet away. ej and jamie shook hands. ej turned back around and kissed her temple before stepping next to his wife jackie, and the landeskogs. she took jamie's hand and rubbed her thumb on his. "hi." she mouthed. he blushed, "hi." he mouthed back and they now stood face to face for the two parties to see.

jamie placed his hands softly on her cheeks, pulling her in for first kiss as partner's for life. she blushed into the kiss, grasping his hands with her own. they pulled apart, and rested their foreheads against one anothers before grabbing one another's hands and turning towards the crowd. she took the flowers, raising it to cheers. they began the descent down the aisle, and as they passed eliza and cale, the two quickly embraced eachother, a friendly hand finding one another. "thankyou. thankyou for everything." sofia smiled widely, and eliza smiled pulling her in for a quick hug. "go on!" she smirked, pushing the new bride playfully. sofia and jamie walked down the path, greeting different family and friends before heading off for some private time before they took photos.

sofia laid down on the bed that the two had in their private villa for the evening. tomorrow, they would be heading out to southern italy and then to paris. "im exhausted." she mused, turning over onto her stomach. "me too." he grinned, laying down on his back and looked down towards her. she smiled, and scooted herself up to kiss him. "i love you james drysdale." she grinned before standing up. "my names not james, mrs drysdale!" he said playfully, while pulled her onto him. she giggled, "mrs. drysdale huh?" she said coyly. "i like the sound of that." she mused, pecking him. he pulled her back down for another one, and another and another. she pulled back, "you know you gotta blame tyler for that name, he's the one that said it that night i met you two. remember?" she quizzed and got up to grab some champagne. he nodded, standing up as well. "trevor just looooves to pull my leg huh?" he joked sipping some of the glass she had given him. "yeah, for sure." she smiled. she walked over towards the window and looked down at beautiful laguna beach. "i just love it here." she sighed, leaning back into jamie. "i know me too." he smiled, placing a kiss on her head. "promise me that even if you get traded...we get a off season home here?" she asked looking up at him now. he smiled nodding, "ofcourse. anything for you." he smiled. the door opened and all they heard was claws scratching the floor. "ozzie!!" they both said excitedly and looked down to find their irish setter jumping. after the two moved into their now home, they adopted a small enough dog that even of her bad days and when she was alone, eliza could still take care of it and still function. ozzie was perfect for her, for them.

sofia and jamie held eachother in their arms, as the two sat next to one another, listening to Trevor speak. multiple times she hid her face in his chest out of embarresment or she could not contain her laughing. after trevor finished, it was sofia's. sofia as soon as they planned the wedding, wanted to do something that was not common and that was give a speech. the two had exchanged vows at the ceremony, some private words before and after. and now sofia was saying something little for the crowd. a public ancedote for their closest.

"james drysdale." she simply stated, garnering laughs from the people that knew about the inside joke. "you did this bro!" jamie joked pointing at trevor who playfully defended himself. "alright alright, yes! we can thank trevor for the mix up of jamie's name. i just love it too much to get rid of it now. i even contemplated putting it on the invitations but jamie said no." she said playfully frowning, earning a laugh from the crowd. "where do i begin?" she started...giggling herself. "my my my, trevor zegras ofcourse had to measle his way into mine and victoria's life all those years ago our sophmore year of school. mr knock off kurt russell himself." she paused, laughing at another inside joke which half the hockey room knew from his time in the nhl. "but yeah he decided he was gonna come bother us when we were eating some fish and chips after surfing in redondo beach and he was SO annoying. and then he called his friend over, and i was internally cringing. i was praying to the universe, that i could somehow leave but vic said 'no'." sofia began again, "then jamie begrudgingly came over and introduced himself to us. i actually choked on my coffee when he did. no like actually choked." she said as the crowd laughed.

jamie looked down embarrassed, because he knew what was next. "and then i proceeded to cough it all up on jamie...and trevor with that gigantic laugh here decided that it was the funniest thing on the planet." sofia playfully glared. "i was absolutley mortified! victoria and trevor exchanged numbers as jamie stood their staring into space, and i sat there thinking: is he really not gonna give me his number? well ok, there goes my self esteem." she said shrugging. trevor laughed his wicked laugh, remembering the full scene replaying it in his mind. "a few weeks later, turned into a month and i was down in newport beach and with ej as he was visiting anahiem for a game, and i decided that i was gonna get mr big foot over here to atleast attempt to surf. i got him to but it was not graceful." she smirked, as ej rolled his eyes. "he kept falling and falling. and after some time, he headed for the beach. i watched him up the shore and took in the waves that were crashing into me. and i kid you not i had a literal jumpscare seeing this guy come up next to me. i quickly looked around for trevor because at the time i could not stand that dude.

jamie see's me looking around and goes, "wow, that hurts my self esteem. i remember whipping my head towards him and glaring so hard. i hadn't realized i whispered that when i had first met him." the crowd laughed as she covered her mouth. "i glared at him, before rolling my eyes and began to paddle back out. but no, jamie said nope. youre gonna continue talking to me." she smiled looking over at jamie, who's mind was currently replaying the scene. "he called for me, and as soon as i went to stand up to you know- cruise the wave, i quickly lost my balance. and therefore to this day i dont surf with him ! but!" she segued, with the crowd eating it all up. "but! that day i learned how much of a sweetie pie he was, one that would not take "im fine" as an answer even after 25 minutes. nor was he intimidated by my big bad older brother who had faced him the previous night. nor did he judge my addiction of 1980's movies and froyo. nor my cat who fell in love with him the very moment they met. just like ester, i fell in love too. that was his final game of the year and he spent a month of his offseason with me as i finished my finals and spring semester. he accepted my okay ability of surfing, which for the record- has improved very much. he took in my ability to finish madlibs in about 90 seconds even if it does not make sense. or the fact that i have nespresso pods that will last me for the next year or two." she paused looking back at jamie. "you gave me your heart from the very first day you met me-- well the second time you met me." she grinned causing him to blush. "jamie, you gave me your word from the very beginning that you'd be there for me through thick and thin and you have done just that. even before this thing." she joked throwing up her left hand, her ring twinkling.

"even though i have seriously embarrased you in front of people that will no doubt use the info to taunt you on the ice..its all out of love. i promise." she mused, she looked towards the crowd, "promise me you wont go too hard?" she quizzed, while walking over towards the three hockey tables. they all agreed, laughing and hollering. "now, with all that said. i love you so very very much jamie. thankyou for being my biggest supporter, best friend, and fish and chips partner. i love you my love." she smiled as she walked back over towards him. he walked over towards her, taking her hand so they could do their first dance as husband and wife. "thought you weren't gonna go so hard?" he joked and she giggled. "only for you jamie." she smiled up at her blue eyed boy, "only for you." she mused and he grinned before kissing her deeply. and passionately.

•

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hope you all enjoyed!!

@jamiedrysdale: married the absolute love of my life yesterday. here’s to being your partner for life, my love.

123k likes, 2.9k comments

Tag: sofiadrysdale

@trevorzegras: BEST WEDDING EVER…!

@sofiadrysdale; even better than urs??

@victoriadiaz: seriously z??? RuDe

@jackhughes: congrats J! So glad I could be apart of your day

@masonmctavish: a wicked night!

@sofiadrysdale: can’t wait to take in the world with you, Thankyou for everything 🫶🏻

@jamiedrysdale: me too- you have no idea 🥹

@ozziedrysdale: mama and papa got married

@jamiedrysdale: love u oz

@sofiadrsydale: love u my sweet bug!

@calemakar: had an amazing time yesterday! Thankyou for having us.

@jamiedrysdale: ofcourse! So grateful for you and E!

@erik6johnson: may or may not be hungover still

@sofiadrysdale: EJ!!!!!!

@trevorzegras: same ej same…bar in ten?

@erik6johnson: already there

@anahiemeucks: crying. Sobbing.

•

@sofiadrysdale: instagram handle has been changed…it feels official.

Tag: jamiedrysdale

13.9k likes, 788 comments

@victoriadiaz: yes! The insta handle has been changed !!!!

@mel.landeskog: ofcourse! insta matters the most

@elizamakar: sof!!! Still sobbing

@sofiadrysdale: now I’m sobbing

@gabelandeskog: little sof isn’t so little anymore 😭😭

@erik6johnson: youre telling me

@jackiejohnson: he’s been crying for months now

@jamiedrysdale: insta handle looks good 😏

@sofiadrysdale: I think so too !

@anahiemducks: congrats!! Our ducks family is growing 🫶🏻🫶🏻

@sofiadrysdale: love you guys!!

@calemakar: I think I want some fish and chips. You around?

@sofiadrysdale: the one time u want some I’m not there 😭😭

@sofiadrsydale: I think I need to make a scene to get this plane to turn around

@jamiedrysdale: fish and chips?!!! Why didn’t you say something at the party?!

@trevorzegras: screaming crying throwing up

•

@trevorzegras has posted to public: wedding of the century

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Hope you guys enjoyed!! Please like and reblog :)

Tags: @fallinallincurls @nicoleloveshockey @hockeyboysarehot @slutforfreddy @jayrami3 @nolanmoylee @hockey-lover-22

#jamie drysdale #jamie drysdale x oc #Jamie Drysdale M Series #jamie drysdale fic #nhl #hockey #nhl fic #hockey fic #trevor zegras #Anaheim ducks #erik johnson

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drugrehabscentersblog · 2 months

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Discover Relief and Renewal at Our depression anxiety treatment center within the Drug Rehab Center. Struggling with depression and anxiety can feel overwhelming, but you don't have to face it alone. Our specialized program offers comprehensive treatment designed to address both conditions, providing you with the tools and support you need to reclaim your life.

#addiction treatment programs #california alcohol rehab #drug rehab centers in san diego #Depression Anxiety Treatment Center

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straightuptreatment98 · 1 year

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Common sign you need anxiety therapy?

Are feeling butterflies in stomach because your final exams are just about to start and you are not prepared, or before your job interview you have started sweating and shivering? Stomach emptiness, sweating and shivering just before an evaluation process are the fear of failures. This fear of failure however are common and almost every individual around the world passes through this feeling but when such feeling start damaging your overall personality and carrier then you need professional treatment for your condition. Some common sings when you need Google to search ‘anxiety treatment near me in California’ are underneath:-

Determination

Every goal needs full dedication and efforts to achieve but distraction due to mood swing, laziness or any hurdle, most of us get fail to achieve it. Meditation only can keep anyone focused and let them to achieve the set target. Since mediation is an exercise to keep the mind calmed and focused you can take sessions of anxiety therapy online California and start meditating at your home or workplace.

Infuriation

Usually, cause of irritation is hormonal imbalance but sometimes work load, time-mismanagement leads to the anger and irritation which results into the frustration and rapid frustration turns into anger and depression. Depression leads to the severe mental and health issues. So it’s good to make the balance in personal and professional life through OCD treatment. In order to cure such mental state you can search for OCD treatment for adults near me in California along with kids’ treatment as well.

Fear of failure

Everyone has a fear of failure. Even though the fear is good to keep progressive but for certain limitations and once fear starts severely hampering the life then you have to cure it. However, the simple to overcome a fear is to just face it and think about worst and good result of your aim. It can keeps you motivated but sometimes it is not possible and not for all. As a result you can consult with professional anxiety treatment experts and get solution of your anxiety issue from well-trained professional experts.

Social Anxiety

An extreme and persistent dread of being observed and evaluated by others is known as social anxiety disorder. The fear of social situations may appear uncontrollable to those who suffer from social anxiety disorder since it is so acute. Fears to go for office, school, or carrying out daily activities are the common instance of social anxiety. Through group anxiety therapy you can overcome your fear to face the crowd. These type of anxiety issues can be cured by group anxiety therapy.

There are two way to treat mental and health issues. One is therapy and second is through medicine. Anxiety therapists in California like Straight Up treatment use both type of treatment ways to cure the mental state of disturbance. As per the metal state evaluation through various test it diagnoses the anxiety level and decide that only therapy is enough or anxiety is chronic and requires both therapy and medication.

#anxiety treatment near me in California #Anxiety therapists in California #OCD treatment for adults near me in California

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magicaltear · 1 year

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An Outside Chance Masterlist

⇤ Previous Chapter Chapter 9 Next Chapter ⇥

Chapter 9: The Truth

As promised, JARVIS texted Stephen an address later that same afternoon. It led to a Japanese restaurant located a stone's throw away from Tony’s mansion on the East Pacific Coast Highway, which promised a splendid view of the ocean. It was also deemed the most expensive restaurant in the Malibu area, not that Stephen was surprised by that at all.

For the second time that day, Stephen changed out of his comfortable robes and fit himself into a tailored suit. The three-piece was a classic black color, and he wore a necktie Christine had gifted him for his birthday once that was the same blue-green color as his eyes.

The ache in his hands had lessened after soothing them in hot water for almost an hour, but the treatment had irritated his scars. Swollen red lines ran down the bed of his fingernails to converge into a network of scars around his wrists. Stephen was tempted to wear gloves to dinner, but he refused to cower in front of Tony. He already knew about the car accident and Stephen’s inability to perform surgeries. Stephen wasn’t about to feel ashamed over something he had already taken years to make peace with, no matter how painful the reminder could be.

Surprisingly, the only problem remaining was none other than the Cloak of Levitation.

“I promise you, I’ll be fine,” Stephen said for what felt like the hundredth time. “It’s only dinner.”

The Cloak shook its collar and squared firmly against him in his penthouse bedroom.

“If there’s any trouble, I’ll open a portal for you. I promise,” he insisted to no avail.

Annoyed, he turned away from the Cloak and slipped on his Sling Ring. His fingers were still too sensitive for it, but he would bear with the pain for the few seconds it would take him to open a portal. However, the Cloak wrapped around his wrist the moment he lifted his hand to begin the spell, effectively stopping his movements. Stephen gave an aggravated sigh.

“We really need to talk about your separation anxiety,” he told it. “I know it must have been scary not knowing if we would reunite in this universe, and I’m sorry I didn’t think to go for you sooner, but we must work through this if we want to be prepared for what lies ahead. We can start small tonight. It’s only dinner, no more than a couple of hours.”

Slowly, the Cloak’s grip on his wrist slackened and released him. It hovered in front of him, doing its best to keep still. Stephen smiled warmly at it and finally drew a portal open by the parking lot of the restaurant.

“I’ll see you soon,” he promised and slipped through back to California.

He asked for a reservation under JARVIS’ name at the lavish reception and followed the hostess to a private area of the restaurant. Their table sat right next to the large windows, which were open to allow the salty breeze inside. Tony hadn’t arrived yet, so Stephen settled in to wait with a whiskey on the rocks. The distant rumble of the ocean soothed his frayed nerves, and he lost track of time going over the books on shielding that Wong had lent him by pulling up the pages in his memory.

Forty-five minutes later, it occurred to him that there was a high chance he could be stood up. It was such a foreign concept to him now, having not worried over such a thing for many years—even since before his original accident, seeing how busy he had been at the hospital to go on any sort of dates.

A soft kind of disappointment settled somewhere inside his ribcage, but Stephen still couldn’t bring himself to feel any shame or embarrassment over his situation. If it came down to it, he’d dine on his own and maybe order some extra food to gift Wong now that he had the money to spoil his friend.

Thankfully, none of that was necessary.

Continue reading on AO3 here!

#tear-chan writes #marvel #doctor strange #iron man #ironstrange #the avengers #stephen strange #tony stark #ao3 #fanfic #an outside chance #oh look! finally an update

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ayutherapy · 1 year

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Natural Solutions for Stress Relief in California.

Find peaceful, natural stress relief, healthier ways to relax, and an anxiety relief center in California. Ayurveda wellness center can help you restore calm and promote good health. Our products are safe, effective, and free of harmful chemicals. Call us: +1 925-575-8700 For more details: https://ayutherapy.com/contact-ayutherapy-ayurveda-wellness-center/

#Anxiety relief center California #natural solutions for stress relief California #Stress relief center California #Acne treatment center California

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weedstrainsdispensary · 3 months

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Exploring the Healing Power of Hybrid Strains: A Journey into Cannabis Wellness

Welcome to the world of holistic healing and well-being through the lens of our California-based weed dispensary, dedicated to providing top-notch hybrid strains. At our dispensary, we take pride in our commitment to helping patients worldwide find low-cost cannabis solutions for anxiety, pain, and mental health disorders. In this blog post, we'll delve into the therapeutic benefits of hybrid strains, discuss their unique characteristics, and guide you on the path to discovering the perfect hybrid strain for your needs.

Understanding Hybrid Strains:

Hybrid cannabis seeds are the result of crossbreeding indica and sativa plants, combining the best of both worlds to create a diverse range of effects. The goal is to strike a balance between the relaxing and calming properties of indicas and the energizing and uplifting qualities of sativas. This balance makes hybrid strains versatile and suitable for various therapeutic purposes.

Buy Hybrid Strain: A Gateway to Holistic Wellness:

Tailored for Anxiety Relief: Hybrid strains offer a nuanced approach to anxiety relief. The calming influence of indica strains, coupled with the mood-enhancing effects of sativas, can provide a sense of tranquility without inducing sedation. Explore our collection to find the ideal hybrid strain that suits your anxiety management needs.

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[Godzilla Glue:

Balanced hybrid with a focus on anxiety relief.

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Energetic hybrid designed for daytime use.

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#Hybrid strains for sale #buy hybrid strain #hybrid cannabis seeds

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brostateexam · 1 year

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At about the time her daughter reached the age of 12, American health executive Laurie saw her once confident, happy child turning into someone she barely recognized. At first, she thought a bad case of adolescent angst was to blame.

Initially, her daughter had trouble sleeping and grappled with episodes of self-loathing and anxiety, but by the time she was 14, she had started cutting herself and was having suicidal thoughts.

Without Laurie knowing, she had been sneaking away her confiscated smartphone and spending hours online at night, trawling through posts about self-harm and eating disorders on social media platforms.

"One day she said to me: 'Mom, I'm going to hurt myself badly if I don't get help,'" Laurie said as she described the mental health crises that have plagued her daughter for the last two years, disrupting her education and devastating the family's finances.

She asked to use only her first name in order to protect the identity of her daughter.

Paying for her daughter's care - therapists, a psychiatrist, and multiple residential treatment facilities across the country - has nearly bankrupted Laurie, who recently sold her house in California and moved to a cheaper home in another state.

In August, she filed a lawsuit on behalf of her daughter against the social media platforms she blames for the ordeal: Instagram, Snapchat and TikTok.

The case is one of dozens of similar U.S. lawsuits which argue that, when it comes to children, social media is a dangerous product - like a car with a faulty seat-belt - and that tech companies should be held to account and pay for the resulting harms.

#long reads #*eating disorder #*suicide

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randomfoggytiger · 1 year

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X-Files Collector’s Edition: Christmas and Emily’s Fate

Christmases... what do they mean for our intrepid heroes? Umm... ghosts and death, particularly the death of Scully’s daughter. So! We’re celebrating with an assortment of fics dealing with Scully and Mulder’s hopes and dreams: the good, the bad, and the mostly merry AUs.

Loose Chronological order below~!

Mainly Canon-Compliant

Amatia‘s (mulderscreek) The Seventh Day (mulderscreek)

““Her three-month mark was almost up, and I knew that once she reached that mark, they would drop her, as they'd dropped all the others, from the Project. Fill her full of mind-wiping dope, plant the chip, and unhook the baby, therefore setting off the chip's timeclock.

For three months, Clone 1-SDK had lived in a tank of nutrient fluid, connected to her mother by the alien umbilical cord, and some wires that wound around it. The moment that alien cord was severed, the chip was activated so that if it was removed, the cancer would begin. Clone 1-SDK was also programmed, programmed so that if her treatment was stopped, a different form of cancer would begin.””

Scully’s captivity draws to its close as her soulless captors-- along with none other than Alex Krycek-- is there to prep her and her baby for the next stage of their unwitting lives.

@foxanddanapetrie‘s (Ao3) Don’t Let Her Get Hurt This Time

““She has a daughter. Mulder has envisioned just about every scenario of their life together. Scully and him dating, them getting married, them having kids - a daughter, a son maybe. Adopting a kid they might have stumbled across on a case. He’s imagined them buying a house - in the city or in the country. He thinks about what they’d decorate their house with. He’s decided that he’ll let her decorate. Probably with some things from her mother’s house. He’s imagined her as a mom, him as a dad watching their kids open Christmas presents while she holds a mug of tea to keep her hands warm. But he never imagined this.

He’s driving 20 over the speed limit in the 1992 rental car he snagged for cheap on his way out of the airport. He doesn’t care if anything happens to it.””

Mulder speeds to Scully and Emily, making wild plans of their future together. His hopes and anxieties only increase after he meets her.

@kateyes224‘s (Ao3)

Things You Said - Chapter 2

““It took three days, but she finally stopped hanging up as soon as she heard my voice. Something was wrong, I could hear it in the crushing silence on the other end of the line before a =click= signaled that the call was dead and I was left staring at the receiver, dumbfounded, growing angrier by the second at the interminable drone of the dial tone....

When had she ever not had words for me?””

Mulder’s hurt and dread builds after Scully’s aborted call; but it vanishes when she finally loops him into the tragedy unfolding in California.

Unnamed

““Scully thought, not for the first time, how gravely serious her daughter was. How little she smiled. Emily lifted a small hand to Scully’s face. “It’s okay, I’ve been to the hospital before. My mommy used to tell me secrets on the way. Tell me a secret.” Scully swallowed hard, closing her eyes before meeting Mulder’s gaze again in the rear view mirror. She tried to smile at Emily, brushing the girl’s damp hair back from her face. “Okay…well, you know my friend, Mulder?”

Emily nodded silently. “He doesn’t like anybody to know this, but his real name is Fox.”

Emily’s forehead scrunched. “Fox? Like Robin Hood?” This time, Scully’s smile was genuine as she heard Mulder chuff a laugh from the front seat.””

Emily wakes in the car on the way to the hospital; and Scully bonds with her while very aware of Mulder’s quiet vigilance.

Donna’s (Gossamer, mulderscreek)

I’m On My Way (Gossamer)

““She was definitely not okay. "An X-file?" He tried to make his tone light, but knew, at least with this woman, he had failed.

"Apparently so."

That stopped him again. For her to admit something like that . . . his stomach hurt.””

Mulder’s fairly relaxing Christmas is turned upside down by Scully’s tearful call.

His Emily Thoughts (Gossamer)

““Emily was a special needs child. He'd done his research. The child would never be well, would probably not live to a ripe old age. And Scully would be hurt again. The question was should she endure the hurt now or later. Either way, it was inevitable and that thought was devastating to him.

And he would not be there to help her. Oh, he'd be there as much as she allowed, but this was Scully. She would want to take on this burden and not admit she needed any help. His help.””

Mulder’s stomach is in knots as he sits on the Scully couch-- feeling ominous about the future and hurt thinking he’d be shut out either way.

Feeling Safe (Gossamer)

““Safe. A strange word, especially now, but it seemed to be the correct description for what she was feeling. She was watching his hands gripping the steering wheel - so strong, his fingers lean and tanned. He wasn't looking at her, concentrating instead on the road, but she knew he was totally aware of her. He was trying to give her the space he thought she wanted. For that she was grateful, much more solicitousness and she would explode.

That was why she has chosen to ride with him.””

Mulder is driving her home, and Scully feels safe-- so much so that she plans to fall apart with him once she arrives back at her place.

After Emily (Gossamer)

““He took the stairs down to the basement, ignoring the elevator. He was in a hurry. The door was open and the light on. That startled him and he slowed. Who would be here this late? For sure they didn't belong.””

Mulder is pulled up short by the sight of Scully crying in the office after closing hours. He understands, and assures her she is not alone.

XP1′s Still Waters

““I’m not expressing...myself...correctly. Or very well. Or even…” He sighed and brought his hands to her biceps, stepped a bit closer. He whispered to her so closely his words stirred what loose strands of hair she had at her crown. “I...I need you to know that there’s...meaning...behind this, what I’m saying, or, asking...that this isn’t…”

She put a hand to his chest and patted once, then rubbed. He wasn’t sure who the touch was meant to console. He couldn’t watch a child die, he thought, and ... he could not watch her do the same. He bit his lip to still some of the depths of his feelings. His breathing was ragged, but she moved closer, rubbed the tension he was putting on his jaw.

“I know.” she told him, tipping her head up. The tip of her nose brushed his chin. “I know you. I know.” His jaw clenched and the lids of his eyes were hot with the promise of tears.

“Relax”. She asked of him. He tried, took a breath. “Relax.” she repeated, and so he was, after a moment.””

Mulder is brimming with anger and stress in the wake of his custody testimony; and desperation for solutions leads him to propose to Scully. He is appalled that she rejects: not at her rejection so much as his perception of her defeat. In a beautiful moment of absolute honesty, Scully lays out for him the sad realities of Emily’s impending demise, using her pain to save all three of them.

The characterization and dialogue in this piece is next-level. Mulder’s speech is phrased exactly how he’s acted on-screen; and Scully’s gentle honesty, while hard for her to admit, saves her and Mulder and Emily from more pain.

Highly recommend reading!

Fialka‘s Soliloquy 01 - Bill Scully

““You took one of my sisters, then you almost took the other. Now she's sitting on the couch, crying her heart out, and what do you do? You just sit there, talking about nothing. Oh, you say, but she's not crying. That's what I mean. You don't know her. Dana doesn't cry with tears. She cries with silence. Mom knows that. Lookat her over there, fixing coffee for all of us. She's waiting.””

Bill internally directs his hatred at Mulder, darkly reminiscing about all the times he’d taken up for his sister. He settles into simmering resentment that she shuts all but her partner out.

stellar_dust’s (Ao3) Family (Ao3)

““Wait! I need to need to take a sample, we've got to get this analyzed ..." her voice trailed off as she searched frantically in her pockets for a vial.

"Scully, no." Mulder reached out and grasped her hand, stilling it. "Don't do this to yourself ... let her go."

She closed her eyes and took a deep breath, heaved it out, swallowing. He was right. "All right." She nodded. "Give me give me one more second.””

Mulder stops Scully from taking a sand sample from the coffin, kindly affirming her choices and reflecting more deeply on the ones that his parents had made.

@baronessblixen‘s (Ao3)

Unnamed Prompt #24

““She's had to say goodbye to Emily before she had the chance to properly say hello. Baby Matthew might never know he had a cousin named Emily, once.

"I should go inside," she says, opening her eyes and biting her bottom lip. Inside, they'll look at her, pity her, watch her with curious eyes when she holds her nephew. She is not ready. What will she see once she turns to Mulder? Is that how he’s going to look at her, too?””

Scully is in the throws of grief after Emily’s death, and dreads walking back inside seeing everyone’s pity and sadness. Mulder understands and knows how to support.

Unnamed Prompt for cuddle fic

“““I’m sorry, Mulder. I didn’t meanto-” Scully’s voice is dull, is teary, is too much. Mulder listens with hisear close to the answering machine. Another click – the message is over. He rewindsthe message again and again. Something is wrong. The lights still off, Muldergrabs his coat again. The food on the table is forgotten, as are the files. Hisonly thought is Scully.””

Mulder receives a morbid, unfinished call from Scully on New Years, and rushes over. She just wanted company for the first holiday after her daughter’s death.

Dashing Through the Snow

““"Scully, look." Maybe it's because his voice is full of wonderment that she does follow the direction of his finger. The park across the street looks like a tiny winter wonderland with its snow-touched trees and meadows. That's not what Mulder means to show her, though. Scully watches as children of all ages sled down a small hill and she'll blame the cold wind for it, her eyes start watering.

"We need to get back to work, Mulder." She doesn't want to see this.””

Mulder helps Scully navigate her complicated pain around children; and the two end up borrowing one of the park kiddies’ sleds.

@frogsmulder/Brynstein‘s “I’m right where I belong” (Ao3)

““In unison, they make their way to her couch, like they’ve always done it like this: him entertaining a little three year old whilst her mother cooks up a feast of spaghetti bolognaise fit for kings; telling her stories of mothman and bigfoot whilst she drew her interpretations with the crayon in her chubby toddler hand. And of course the Mr Potato head impressions that had her in fits of giggles and rolling around on the floor much to her mother’s delight. Like he didn’t play the part of domestic husband, washing the plates and dishes and cleaning up the crayons, whilst Scully had bathed her daughter and put her to bed.””

A happier reality with Emily alive and love blossoming is followed up immediately by the harsh reality of Scully’s loss and their mutual pain.

Piper’s Pajamas

““I stand against the wall, silently bearing witness to this ritual of closure. I don't respond to her statement - somehow I don't think that she expected me to. There's really no reason for me to be here. As experienced as I am in self-torture, today Scully is beating me by a mile. All I do is keep vigil as she stubbornly insists on boxing up the clothing that she bought in such blind hope for Emily, now about to be worn by some Goodwill kid who doesn't know even know how lucky she is to be alive.””

Mulder silently witnesses Scully’s grief as she packs up Emily’s clothes for donation, both knowing that her death crushed both of their dreams.

Alanna’s Fortress

““We're on a freeway, heading somewhere. Driving around in circles, mimicking our souls. Cars zip around us but I barely notice the road. I need to touch her, to make sure she is still there inside her shell -- that she hasn't slipped away from me altogether. So I reach my right hand over and lay it gently on the back of her hand, painfully contracting my arm muscles so that I might not hurt or startle her. She turns toward me and the traffic is sparse so I hazard a quick glance at her, my eyes meeting hers.

And then her hand moves under mine and her palm meets my own, her fingers twining into mine.””

Shattered Mulder decides to keep driving so he and Scully can have time to bind up their compounding wounds. He is relieved he opens up on their Tijuana detour, heartbreakingly honest though it may be.

@greekowl87/@darkesttimelinestuff ‘s (Ao3) Drabbles Collection - Chapter 2

““He hugged her tightly, ignorant of the potential older brother danger as she cried harder. He closed his eyes, wishing and willing to take all of her pain away.

“I just wanted a chance, Mulder.””

A case keeps Scully longer in San Diego; and finally she breaks. Mulder comforts her in her purgatory.

@the-spooky-alien ‘s Day 10 of Fictober ““''Sometimes I think it would be better if you stayed away from me.'' It sounds weak in the air between them. Every words shake under the weight of his guilt. His eyes never leave the road. She wishes he would look at her.”” Scully insists Mulder pull over so that she can instantly squash his self-loathing; however, she still can’t fully admit why she chose him.

Diana Alexander‘s Introspections

““After my cancer was cured, I had to get used to actually *living* again. I was so prepared to meet Death with stubborn will blazing in my eyes, and a straight spine that I hadn't really prepared myself for the chance that there would be a cure that would keep me in this world a little while longer. I was lost for a long time afterwards, and now, at Christmas, I get the biggest blow since I discovered the cancer that was lodged in my head.””

Scully had been prepared to lose the fight to cancer; but can’t seem to recover from the painful loss of her daughter. She retreats internally to lick her wounds.

@starbuck09256‘s (Ao3) Hope

““Everytime she closes her eyes she sees a scared little face begging her to stop the tests. She sees Mulder clutching yellow flowers too tightly as his own sorrow for her pours from his eyes. He knows what this tiny child was to her. He knows that she wanted another life another path, not because of him or their quest. But because fate had chosen her to live on, she had been returned survived the incurable and yet her destiny wasn’t to find the joys that she had forsaken it was as if she was being punished for fighting.””

Mulder barges into Scully’s apartment, refusing to let her shut him out. His comfort and common sense make all the difference.

Sheryl Martin’s

Tradition

““Dropping the suitcase by the stairs, she walked into the kitchen and put the kettle on; making a mental note to call Dana in a few hours and see how she was feeling. She had looked pretty rough in the car. Hadn't slept a wink on the flight, although she had put her head down on Mulder's shoulder for most of the time. He hadn't said a word, just put his hand atop hers and looked quickly over for approval. A smile was all he needed, and a slight nod of her head. He'd take care of her as best he could. And she had faith in him.””

Maggie adds Emily to the family Bible because she was her granddaughter no matter what.

A Mother’s Thoughts

““Whatever the mystery behind her existence, she was still my grandchild - maybe the one I'll miss the most. But no matter how much I talk to the priest; how many candles I light and prayers I say for all of them, I still don't understand why. Specifically, why me. Why Dana. Why Fox.””

Maggie’s pain over their combined familial loss in Emily’s death bleeds into her doubts and constant questions to God. It’s a hard road trying to trust in His plan.

Gillian Leigh‘s (mulderscreek) Sleepless Roads

““Stepping into the living room, she stopped short of saying her daughter's name a third time when she found her sitting on the couch, sound asleep with her laptop open on her lap. There was a large postal manila envelope on the couch beside her marked with the words "Films Included: Do Not X-Ray". A quick glance at the screen of the laptop showed her that her daughter had been researching adoption. Puzzled, she gently shook Scully's shoulder to wake her.””

Maggie is the quiet glue keeping Scully together; but she makes time to drop in on Mulder and make sure he’s getting some sleep. She convinces her daughter not to shut him out; but isn’t privy to the bigger bombshell that Scully reveals to Mulder later.

@i-gaze-at-scully‘s (Ao3)

Chapter One: Protect

““On a plane to California, Mulder considers briefly if the ova he carries in his pocket should be allowed past airport security. He’s a federal agent, so no one really ever asks, but he wonders. He turns the cylinder over in his pocket, the smooth surface spinning, spinning under his fingertips. She has no idea. Tens of thousands of feet in the air and he knows he’s about to drop the biggest bomb on the person he cares most about in this world. He hopes it is the right decision.””

Mulder’s developing thoughts throughout the episode crescendo in love and happiness when he finds a cure for little Emily. He assures Scully she won’t be raising her alone.

All I Want for Christmas (Ao3)

““Scully is not a last minute shopper. She has all her gifts purchased, wrapped, and packed by 9 AM, December 24. She’ll drive to Annapolis on Christmas morning, early to beat the traffic, and spend the day accepting her mother’s well-intentioned pity. Dana, could you help me in the kitchen? Dana, would you ask Tara to grab your brother? I want to take a picture of you two. Maggie knows.

Mulder, Mulder knows too.””

Scully is so grateful that Mulder distracted her from the painful reminder of last Christmas that she gets him an extra special gift.

Mystic‘s Beautiful Release

““Her eyes stung as she wiped at them and looked back to the window, not able to sleep without dreaming about Emily.

She sometimes wondered just why the girl had affected her so much. How she'd been able to become attached so quickly to her.

She tried to stop herself from thinking her name, but it didn't work. It had etched into her mind as had countless other moments and names in her life. She could only make Emily go away by thinking of Mulder and that brought her pain too. ””

Mulder and Scully finally make that next step when a case stirs up a painful Emily reminder.

AUs

Jennifer Brady’s December

““Scully brought my world down in the simple words she spoke. "Mulder, I need you," Maybe those were'nt her *exact* words, but that's what I heard. You know me, when Scully needs anything that I can provide, I'm all over it. So here I am, out the front door, heading to my partner's side.

I really would'nt have it any other way.””

The devastation of Emily’s death pushes Mulder and Scully closer together.

Maidenjedi’s Would That I Could Travel Both

““She went to California a single lady in her thirties. Hard not to think about her age and her marital status in one sentence like that; she'd been thinking too much about families and love and her place in the world. And then Bill and Tara were standing outside the terminal waiting for Dana and Maggie, Tara as big as a house and a year younger than her sister-in-law. It was a lot to take.””

Amidst many assorted AUs, Scully leaves the FBI to become Emily’s mom, much to Mulder’s resigned and pained disappointment.

@leiascully‘s (Ao3) Unnamed

““Under observation, they spend several days with Emily. Mulder promises to take her to Disneyland in the summer. Her face lights up. The social worker smiles and makes notes on her clipboard.””

Mulder and Scully rush into marriage to adopt Emily and quit the FBI. Fortunately for them, Mulder is independently wealthy and ready to re-prioritize his life.

@scapegrace74-blog‘s (Ao3) Wraith

““Perplexed and perhaps a bit put off by the fact that Scully was entertaining a guest in her pajamas with no make-up, he made his way cautiously to the kitchen. An empty cereal bowl and a half-drunk glass of orange juice were laid out on the table, but there was no other sign of occupation.

Scully stood by the doorway, her bloodshot eyes shining brightly, and gestured toward the empty kitchen chair.

“Mulder, I’d like you to meet Lily.””

Scully is gradually descending into madness-- or Mulder thinks so, until he arrives barely in time to see a wraith drowning her.

Donna’s (Gossamer, mulderscreek)

Trick or Treat (Gossamer)

““This wasn't happening. He wasn't having a conversation with Emily, Scully's Emily. Even if . . . if Emily had lived, she'd be older. And she hadn't lived. Okay, the body had been stolen, but she had been dead. He'd been there.

"For Halloween."

"Oh." This was not happening. Who was this little girl, and where were her parents?””

Mulder is shocked to see Emily’s spirit within eyesight everytime he tries to meet up with Diana. The little girl has some sage advice for him and his relationship with Scully.

jeri‘s (mulderscreek) Ersatz Matriarch

““Scully studied the paper carefully. "Do you think it's really over? Could we possibly lead normal lives?"

"Only one way to find out." He dropped the sheet and held her hands tightly in his own. "Marry me, Scully. I mean, like next week. Before the boys are born."

Scully blinked. "What?””

Mulder and Scully decide to use their downtime under Kersh to pursue IVF-- after faking a marriage at the clinic and failing at their first round, they scrounge up a successful surrogate and begin the rocky road to parenthood (while being deluged with weird X-File info about the pregnancy from Marita, congratulating a newly-married Byers, and avoiding Bill’s newest tantrum.) Skinner even manages to make their New Years the best yet.

sohmer‘s discrete edges

““i'm not unhappy, she thinks suddenly. mulder coughs beside her and she blinks several times in rapid succession in an attempt to refocus her vision. her surroundings click into place.

the thought comes again, louder. it hurts her like vertigo, like ice on naked skin. not unhappy, she tells herself. discomfort comes to mind, or perhaps loneliness. i hadn’t felt lonely with emily.””

Scully’s repressed pain over Emily builds and builds after a trip to Skinner’s Christmas Party. Mulder bides his time, slowly peeling the words out of her.

@ghostbustermelanieking/skuls‘s (Alt. Ao3)

Christmas Ficlets - Chapter 2

““She's felt sick on and off these past weeks, growing dizzy and nauseous and eventually having to lean over the sink the night before, but she never expected this. Never thought she'd actually faint at work.

One minute, she's standing by a festoon of Christmas decorations in the hallway (the FBI has Christmas decorations?) and arguing the authenticity of Mulder's toxic slime theory, and the next, her vision is spotted and her legs are weak, the room spinning as she falls and darkness falling like a curtain.””

Requiem--Scully faints at the office; but the panic that gripped her and Mulder melts with their shocking pregnancy news. They barely contain themselves before telling Emily back home.

where the love light gleams

““William wants to know about their mother. “Did you ever know her?” he asks Emily one day, shoving away the copy of Peter Pan. He’s been asking questions tiredly for the past couple of weeks, and she’s been avoiding them, doesn’t want to let him down.

She thinks she had parents, a long time ago, but they can’t be William’s parents because they died. She remembers that. And her mother always told her she was adopted, so that must mean she has a different mother somewhere. She thinks she remembers someone who sat with her on the floor and colored, who whispered things about how they might live together someday. She thinks that the woman had bright hair like her, eyes and freckles like hers and William’s.””

In an alternate universe, Emily was shuffled off to a compound run by the CSM; soon to be joined by a captured William. Following the few and vague memories she has to rely on, the two are able to escape and try to find a way to West Virginia (with help from an unnamed woman who seems to recognize them.)

Lapsed_Scholar’s Family Stories

“““It’s Picture Day next week,” explains Emily, still serious. “Mrs. Martin gave us forms. I want to be pretty for the picture, so I need a pretty dress.”

“You look pretty every day, sweetheart. You don’t need a special dress for that.” She’s trying to reassure, but Emily looks up at her, small face conveying disapproval, so she hurries to clarify, “But picture day is a special occasion, and a special occasion does deserve a special dress.”

She’s still fairly new to this—parenting. She wonders if parents who have more experience are more prepared for these conversations, or if it’s something that you always just sort of fumble through.””

This series deals with Mulder and Scully navigating the uncharted waters of parenting Emily-- as new parents, then as parents on the run with their children, then as parents of a teen girl with a rambunctious little brother. But they wouldn’t trade it for the world.

Wheeeeeew! That’s over! Hope you all have a merry feast of angsty fics~.

Enjoy!

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religion-is-a-mental-illness · 1 year

Text

By: Jennifer Block

Published: Feb 23, 2023

More children and adolescents are identifying as transgender and are being offered medical treatment, especially in the US—but some providers and European authorities are urging caution because of a lack of strong evidence. Jennifer Block reports

Last October the American Academy of Pediatrics (AAP) gathered inside the Anaheim Convention Center in California for its annual conference. Outside, several dozen people rallied to hear speakers including Abigail Martinez, a mother whose child began hormone treatment at age 16 and died by suicide at age 19. Supporters chanted the teen’s given name, Yaeli; counter protesters chanted, “Protect trans youth!” For viewers on a livestream, the feed was interrupted as the two groups fought for the camera.

The AAP conference is one of many flashpoints in the contentious debate in the United States over if, when, and how children and adolescents with gender dysphoria should be medically or surgically treated. US medical professional groups are aligned in support of “gender affirming care” for gender dysphoria, which may include gonadotrophin releasing hormone analogues (GnRHa) to suppress puberty; oestrogen or testosterone to promote secondary sex characteristics; and surgical removal or augmentation of breasts, genitals, or other physical features. At the same time, however, several European countries have issued guidance to limit medical intervention in minors, prioritising psychological care.

The discourse is polarised in the US. Conservative politicians, pundits, and social media influencers accuse providers of pushing “gender ideology” and even “child abuse,” lobbying for laws banning medical transition for minors. Progressives argue that denying access to care is a transphobic violation of human rights. There’s little dispute within the medical community that children in distress need care, but concerns about the rapid widespread adoption of interventions and calls for rigorous scientific review are coming from across the ideological spectrum.

The surge in treatment of minors

More adolescents with no history of gender dysphoria—predominantly birth registered females—are presenting at gender clinics. A recent analysis of insurance claims by Komodo Health found that nearly 18 000 US minors began taking puberty blockers or hormones from 2017 to 2021, the number rising each year. Surveys aiming to measure prevalence have found that about 2% of high school aged teens identify as “transgender.” These young people are also more likely than their cisgender peers to have concurrent mental health and neurodiverse conditions including depression, anxiety, attention deficit disorders, and autism.6 In the US, although Medicaid coverage varies by state and by treatment, the Biden administration has warned states that not covering care is in violation of federal law prohibiting discrimination. Meanwhile, the number of private clinics that focus on providing hormones and surgeries has grown from just a few a decade ago to more than 100 today.

As the number of young people receiving medical transition treatments rises, so have the voices of those who call themselves “detransitioners” or “retransitioners,” some of whom claim that early treatment caused preventable harm. Large scale, long term research is lacking, and researchers disagree about how to measure the phenomenon, but two recent studies suggest that as many as 20-30% of patients may discontinue hormone treatment within a few years. The World Professional Association for Transgender Health (WPATH) asserts that detransition is “rare.”

Chloe Cole, now aged 18, had a double mastectomy at age 15 and spoke at the AAP rally. “Many of us were young teenagers when we decided, on the direction of medical experts, to pursue irreversible hormone treatments and surgeries,” she read from her tablet at the rally, which had by this time moved indoors to avoid confrontation. “This is not informed consent but a decision forced under extreme duress.”

Scott Hadland, chief of adolescent medicine at Massachusetts General Hospital and Harvard Medical School, dismissed the “handful of cruel protesters” outside the AAP meeting in a tweet that morning. He wrote, “Inside 10 000 pediatricians stand in solidarity for trans & gender diverse kids & their families to receive evidence-based, lifesaving, individualized care.”

Same evidence, divergent recommendations

Three organisations have had a major role in shaping the US’s approach to gender dysphoria care: WPATH, the AAP, and the Endocrine Society (see box). On 15 September 2022 WPATH published the eighth edition of its Standards of Care for the Health of Transgender and Gender Diverse People, with new chapters on children and adolescents and no minimum age requirements for hormonal and surgical treatments. GnRHa treatment, says WPATH, can be initiated to arrest puberty at its earliest stage, known as Tanner stage 2.

The Endocrine Society also supports hormonal and surgical intervention in adolescents who meet criteria in clinical practice guidelines published in 2009 and updated in 2017. And the AAP’s 2018 policy statement, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents, says that “various interventions may be considered to better align” a young person’s “gender expression with their underlying identity.” Among the components of “gender affirmation” the AAP names social transition, puberty blockers, sex hormones, and surgeries. Other prominent professional organisations, such as the American Medical Association, have issued policy statements in opposition to legislation that would curtail access to medical treatment for minors.

These documents are often cited to suggest that medical treatment is both uncontroversial and backed by rigorous science. “All of those medical societies find such care to be evidence-based and medically necessary,” stated a recent article on transgender healthcare for children published in Scientific American. “Transition related healthcare is not controversial in the medical field,” wrote Gillian Branstetter, a frequent spokesperson on transgender issues currently with the American Civil Liberties Union, in a 2019 guide for reporters. Two physicians and an attorney from Yale recently opined in the Los Angeles Times that “gender-affirming care is standard medical care, supported by major medical organizations . . . Years of study and scientific scrutiny have established safe, evidence-based guidelines for delivery of lifesaving, gender-affirming care.” Rachel Levine, the US assistant secretary for health, told National Public Radio last year regarding such treatment, “There is no argument among medical professionals.”

Internationally, however, governing bodies have come to different conclusions regarding the safety and efficacy of medically treating gender dysphoria. Sweden’s National Board of Health and Welfare, which sets guidelines for care, determined last year that the risks of puberty blockers and treatment with hormones “currently outweigh the possible benefits” for minors. Finland’s Council for Choices in Health Care, a monitoring agency for the country’s public health services, issued similar guidelines, calling for psychosocial support as the first line treatment. (Both countries restrict surgery to adults.)

Medical societies in France, Australia, and New Zealand have also leant away from early medicalisation. And NHS England, which is in the midst of an independent review of gender identity services, recently said that there was “scarce and inconclusive evidence to support clinical decision making” for minors with gender dysphoria and that for most who present before puberty it will be a “transient phase,” requiring clinicians to focus on psychological support and to be “mindful” even of the risks of social transition.

“Don’t call them evidence based”

“The brief history of guidelines is that, going back more than 30 years ago, experts would write articles and so on about what people should do. But formal guidelines as we think of them now were seldom or non-existent,” says Gordon Guyatt, distinguished professor in the Department of Health Research Methods, Evidence, and Impact at McMaster University, Ontario.

That led to the movement towards developing criteria for what makes a “trustworthy guideline,” of which Guyatt was a part. One pillar of this, he told The BMJ, is that they “are based on systematic review of the relevant evidence,” for which there are also now standards, as opposed to a traditional narrative literature review in which “a bunch of experts write whatever they felt like using no particular standards and no particular structure.”

Mark Helfand, professor of medical informatics and clinical epidemiology at Oregon Health and Science University, says, “An evidence based recommendation requires two steps.” First, “an unbiased, thorough, critical systematic review of all the relevant evidence.” Second, “some commitment to link the strength of the recommendations to the quality of the evidence.”

The Endocrine Society commissioned two systematic reviews for its clinical practice guideline, Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: one on the effects of sex steroids on lipids and cardiovascular outcomes, the other on their effects on bone health. To indicate the quality of evidence underpinning its various guidelines, the Endocrine Society employed the GRADE system (grading of recommendations assessment, development, and evaluation) and judged the quality of evidence for all recommendations on adolescents as “low” or “very low.”

Guyatt, who co-developed GRADE, found “serious problems” with the Endocrine Society guidelines, noting that the systematic reviews didn’t look at the effect of the interventions on gender dysphoria itself, arguably “the most important outcome.” He also noted that the Endocrine Society had at times paired strong recommendations—phrased as “we recommend”—with weak evidence. In the adolescent section, the weaker phrasing “we suggest” is used for pubertal hormone suppression when children “first exhibit physical changes of puberty”; however, the stronger phrasing is used to “recommend” GnRHa treatment.

“GRADE discourages strong recommendations with low or very low quality evidence except under very specific circumstances,” Guyatt told The BMJ. Those exceptions are “very few and far between,” and when used in guidance, their rationale should be made explicit, Guyatt said. In an emailed response, the Endocrine Society referenced the GRADE system’s five exceptions, but did not specify which it was applying.

Helfand examined the recently updated WPATH Standards of Care and noted that it “incorporated elements of an evidence based guideline.” For one, WPATH commissioned a team at Johns Hopkins University in Maryland to conduct systematic reviews.3435 However, WPATH’s recommendations lack a grading system to indicate the quality of the evidence—one of several deficiencies. Both Guyatt and Helfand noted that a trustworthy guideline would be transparent about all commissioned systematic reviews: how many were done and what the results were. But Helfand remarked that neither was made clear in the WPATH guidelines and also noted several instances in which the strength of evidence presented to justify a recommendation was “at odds with what their own systematic reviewers found.”

For example, one of the commissioned systematic reviews found that the strength of evidence for the conclusions that hormonal treatment “may improve” quality of life, depression, and anxiety among transgender people was “low,” and it emphasised the need for more research, “especially among adolescents.” The reviewers also concluded that “it was impossible to draw conclusions about the effects of hormone therapy” on death by suicide.

Despite this, WPATH recommends that young people have access to treatments after comprehensive assessment, stating that the “emerging evidence base indicates a general improvement in the lives of transgender adolescents.” And more globally, WPATH asserts, “There is strong evidence demonstrating the benefits in quality of life and well-being of gender-affirming treatments, including endocrine and surgical procedures,” procedures that “are based on decades of clinical experience and research; therefore, they are not considered experimental, cosmetic, or for the mere convenience of a patient. They are safe and effective at reducing gender incongruence and gender dysphoria.”

Those two statements are each followed by more than 20 references, among them the commissioned systematic review. This stood out to Helfand as obscuring which conclusions were based on evidence versus opinion. He says, “It’s a very strange thing to feel that they had to cite some of the studies that would have been in the systematic review or purposefully weren’t included in the review, because that’s what the review is for.”

For minors, WPATH contends that the evidence is so limited that “a systematic review regarding outcomes of treatment in adolescents is not possible.” But Guyatt counters that “systematic reviews are always possible,” even if few or no studies meet the eligibility criteria. If an entity has made a recommendation without one, he says, “they’d be violating standards of trustworthy guidelines.” Jason Rafferty, assistant professor of paediatrics and psychiatry at Brown University, Rhode Island, and lead author of the AAP statement, remarks that the AAP’s process “doesn’t quite fit the definition of systematic review, but it is very comprehensive.”

Sweden conducted systematic reviews in 2015 and 2022 and found the evidence on hormonal treatment in adolescents “insufficient and inconclusive.”24 Its new guidelines note the importance of factoring the possibility that young people will detransition, in which case “gender confirming treatment thus may lead to a deteriorating of health and quality of life (i.e., harm).”

Cochrane, an international organisation that has built its reputation on delivering independent evidence reviews, has yet to publish a systematic review of gender treatments in minors. But The BMJ has learnt that in 2020 Cochrane accepted a proposal to review puberty blockers and that it worked with a team of researchers through 2021 in developing a protocol, but it ultimately rejected it after peer review. A spokesperson for Cochrane told The BMJ that its editors have to consider whether a review “would add value to the existing evidence base,” highlighting the work of the UK’s National Institute for Health and Care Excellence, which looked at puberty blockers and hormones for adolescents in 2021. “That review found the evidence to be inconclusive, and there have been no significant primary studies published since.”

In 2022 the state of Florida’s Agency for Health Care Administration commissioned an overview of systematic reviews looking at outcomes “important to patients” with gender dysphoria, including mental health, quality of life, and complications. Two health research methodologists at McMaster University carried out the work, analysing 61 systematic reviews and concluding that “there is great uncertainty about the effects of puberty blockers, cross-sex hormones, and surgeries in young people.” The body of evidence, they said, was “not sufficient” to support treatment decisions.

Calling a treatment recommendation “evidence based” should mean that a treatment has not just been systematically studied, says Helfand, but that there was also a finding of high quality evidence supporting its use. Weak evidence “doesn’t just mean something esoteric about study design, it means there’s uncertainty about whether the long term benefits outweigh the harms,” Helfand adds.

“Evidence itself never tells you what to do,” says Guyatt. That’s why guidelines must make explicit the values and preferences that underlie the recommendation.

The Endocrine Society acknowledges in its recommendations on early puberty suppression that it is placing “a high value on avoiding an unsatisfactory physical outcome when secondary sex characteristics have become manifest and irreversible, a higher value on psychological well-being, and a lower value on avoiding potential harm.”

WPATH acknowledges that while its latest guidelines are “based upon a more rigorous and methodological evidence-based approach than previous versions,” the evidence “is not only based on the published literature (direct as well as background evidence) but also on consensus-based expert opinion.” In the absence of high quality evidence and the presence of a patient population in need—who are willing to take on more personal risk—consensus based guidelines are not unwarranted, says Helfand. “But don’t call them evidence based.”

An evidence base under construction

In 2015 the US National Institutes of Health awarded a $5.7m (£4.7m; €5.3m) grant to study “the impact of early medical treatment in transgender youth.” The abstract submitted by applicants said that the study was “the first in the US to evaluate longitudinal outcomes of medical treatment for transgender youth and will provide essential evidence-based data on the physiological and psychosocial effects and safety” of current treatments. Researchers are following two groups, one of participants who began receiving GnRHa in early puberty and another group who began cross sex hormone treatment in adolescence. The study doesn’t include a concurrent no-treatment control group.

Robert Garofalo, chief of adolescent medicine at the Lurie Children’s Hospital in Chicago and one of four principal investigators, told a podcast interviewer in May 2022 that the evidence base remained “a challenge . . . it is a discipline where the evidence base is now being assembled” and that “it’s truly lagging behind [clinical practice], I think, in some ways.” That care, he explained, was “being done safely. But only now, I think, are we really beginning to do the type of research where we’re looking at short, medium, and long term outcomes of the care that we are providing in a way that I think hopefully will be either reassuring to institutions and families and patients or also will shed a light on things that we can be doing better.”

While Garofalo was doing the research he served as “contributor” on the AAP’s widely cited 2018 policy statement, which recommends that children and adolescents “have access to comprehensive, gender-affirming, and developmentally appropriate health care,” including puberty blockers, sex hormones, and, on a case-by-case basis, surgeries.

Garofalo said in the May interview, “There is universal support for gender affirming care from every mainstream US based medical society that I can think of: the AMA, the APA, the AAP. I mean, these organisations never agree with one another.” Garofalo declined an interview and did not respond to The BMJ’s requests for comment.

The rush to affirm

Sarah Palmer, a paediatrician in private practice in Indiana, is one of five coauthors of a 2022 resolution submitted to the AAP’s leadership conference asking that it revisit the policy after “a rigorous systematic review of available evidence regarding the safety, efficacy, and risks of childhood social transition, puberty blockers, cross sex hormones and surgery.” In practice, Palmer told The BMJ, clinicians define “gender affirming” care so broadly that “it’s been taken by many people to mean go ahead and do anything that affirms. One of the main things I’ve seen it used for is masculinising chest surgery, also known as mastectomy in teenage patients.” The AAP has told The BMJ that all policy statements are reviewed after five years and so a “revision is under way,” based on its experts’ own “robust evidence review.”

Palmer says, “I’ve seen a quick evolution, from kids with a very rare case of gender dysphoria who were treated with a long course of counselling and exploration before hormones were started,” to treatment progressing “very quickly—even at the first visit to gender clinic—and there’s no psychologist involved anymore.”

Laura Edwards-Leeper, a clinical psychologist who worked with the endocrinologist Norman Spack in Boston and coauthored the WPATH guidelines for adolescents, has observed a similar trend. “More providers do not value the mental health component,” she says, so in some clinics families come in and their child is “pretty much fast tracked to medical intervention.” In a study of teens at Seattle Children’s Hospital’s gender clinic, two thirds were taking hormones within 12 months of the initial visit.

The British paediatrician Hilary Cass, in her interim report of a UK review into services for young people with gender identity issues, noted that some NHS staff reported feeling “under pressure to adopt an unquestioning affirmative approach and that this is at odds with the standard process of clinical assessment and diagnosis that they have been trained to undertake in all other clinical encounters.”

Eli Coleman, lead author of WPATH’s Standards of Care and former director of the Institute for Sexual and Gender Health at the University of Minnesota, told The BMJ that the new guidelines emphasised “careful assessment prior to any of these interventions” by clinicians who have appropriate training and competence to assure that minors have “the emotional and cognitive maturity to understand the risks and benefits.” He adds, “What we know and what we don’t know has to be explained to youth and their parents or caregivers in a balanced way which really details that this is the evidence that we have, that we obviously would like to have more evidence, and that this is a risk-benefit scenario that you have to consider.”

Joshua Safer, director of the Center for Transgender Medicine and Surgery at Mount Sinai Hospital in New York and coauthor of the Endocrine Society guidelines, told The BMJ that assessment is standard practice at the programme he leads. “We start with a mental health evaluation for anybody under the age of 18,” he says. “There’s a lot of talking going on—that’s a substantial element of things.” Safer has heard stories of adolescents leaving a first or second appointment with a prescription in hand but says that these are overblown. “We really do screen these kids pretty well, and the overwhelming majority of kids who get into these programmes do go on to other interventions,” he says.

Without an objective diagnostic test, however, others remain concerned. The demand for services has led to a “perfunctory informed consent process,” wrote two clinicians and a researcher in a recent issue of the Journal of Sex and Marital Therapy, in spite of two key uncertainties: the long term impacts of treatment and whether a young person will persist in their gender identity. And the widespread impression of medical consensus doesn’t help. “Unfortunately, gender specialists are frequently unfamiliar with, or discount the significance of, the research in support of these two concepts,” they wrote. “As a result, the informed consent process rarely adequately discloses this information to patients and their families.”

For Guyatt, claims of certainty represent both the success and failure of the evidence based medicine movement. “Everybody now has to claim to be evidence based” in order to be taken seriously, he says—that’s the success. But people “don’t particularly adhere to the standard of what is evidence based medicine—that’s the failure.” When there’s been a rigorous systematic review of the evidence and the bottom line is that “we don’t know,’” he says, then “anybody who then claims they do know is not being evidence based.”

Sidebar:

The origins of paediatric gender medicine in the United States

The World Professional Association for Transgender Health (WPATH) began as a US based advocacy group and issued the first edition of the Standards of Care in 1979, when it was serving a small population of mostly adult male-to-female transsexuals. “WPATH became the standard because there was nobody else doing it,” says Erica Anderson, a California based clinical psychologist and former WPATH board member. The professional US organisations that lined up in support “looked heavily to WPATH and the Endocrine Society for their guidance,” she told The BMJ.

The Endocrine Society’s guidance for adolescents grew out of clinicians’ research in the Netherlands in the late 1990s and early 2000s. Peggy Cohen-Kettenis, a Utrecht gender clinic psychologist, collaborated with endocrinologists in Amsterdam, one of whom had experience of prescribing gonadotrophin releasing hormone analogues, relatively new at the time. Back then, gender dysphoric teens had to wait until the age of majority for sex hormones, but the team proposed that earlier intervention could benefit carefully selected minors.

The clinic treated one natal female patient with triptorelin, published a case study and feasibility proposal, and began treating a small number of children at the turn of the millennium. The Dutch Protocol was published in 2006, referring to 54 children whose puberty was being suppressed and reporting preliminary results on the first 21. The researchers received funding from Ferring Pharmaceuticals, the manufacturer of triptorelin.

In 2007 the endocrinologist Norman Spack began using the protocol at Boston Children’s Hospital and joined Cohen-Kettenis and her Dutch colleagues in writing the Endocrine Society’s first clinical practice guideline. When that was published in 2009, puberty had been suppressed in just over 100 gender dysphoric young people.

American Academy of Pediatrics (AAP) committee members began discussing the need for a statement in 2014, four years before publication, says Jason Rafferty, assistant professor of paediatrics and psychiatry at Brown University, Rhode Island, and the statement’s lead author. “The AAP recognised that it had a responsibility to provide some clinical guidance, but more importantly to come out with a statement that said we need research, we need to integrate the principles of gender affirmative care into medical education and into child health,” he says. “What our policy statement is not meant to be is a protocol or guidelines in and of themselves.”

Claiming it's "evidence-based" doesn't mean it's good evidence.

#Jennifer Block #pediatric transition #gender ideology #queer theory #medical transition #medical malpractice #medical scandal #medical corruption #gender affirming #affirmation model #affirmation #affirmative therapy #puberty blockers #wrong sex hormones #cross sex hormones #religion is a mental illness

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