Biden issues new statement opposing trans surgeries for youth

[Davie]

Breaking: Biden issues new statement opposing trans surgeries for youth and even only mentions “mental healthcare” for trans youth, which is often used by anti-trans activists to mean conversion therapy and nothing else. Statement here: “These are deeply personal decisions and we believe these surgeries should be limited to adults,” a White House spokesperson said in an emailed statement. “We continue to support gender-affirming care for minors like mental health care and respect the role of parents, families, and doctors in these decisions.” The full story is at the 19th News. This is about as bad a statement from the administration as you can get for trans youth." —Erin Reed

 

[KathyLauren]

Aw, geez!  That means he considers the election a lost cause unless he can poach enough Republican voters to make a difference in November.  He sold out for votes. 

[Vidanjali]

Just now, KathyLauren said:

Aw, geez!  That means he considers the election a lost cause unless he can poach enough Republican voters to make a difference in November.  He sold out for votes. 

 

 

That was my first thought. It seems to have come out of left field as Biden has previously been explicitly supportive of trans youth, at least verbally. On a web search, I saw that Erin Reed quoted the NYT and said she'd be reporting. Then I read this article which details some nuance.

 

"According to reports from the Times and Fox News, the White House gave a brief statement in opposition to surgery for trans youth in response to news articles detailing conversations between the World Professional Association for Transgender Health (WPATH) and staff for Dr. Rachel Levine, the assistant secretary of the Department of Health and Human Services. 

 

The Times reported in late June that Levine’s staff pressed WPATH to remove its proposed lower age limits for adolescent surgeries out of concern of political backlash, as WPATH updated its longstanding guidelines on transgender health care for medical professionals. WPATH had proposed lowering age recommendations for masculinizing top surgeries to 15 years old, and lowering the recommended age for genital surgeries to 17 years old. 

 

In the final WPATH guidelines published in 2022, no age recommendations were given for surgeries for trans youth. 

 

WPATH said that it removed those minimum ages for providing gender-affirming care “to reflect that one-size-fits-all health care models, especially transgender care, are not accurate or appropriate for every individual person.” WPATH said that medical professionals had expressed concern “that the listing of ages would lead to further limitations to care by creating or reinforcing arbitrary boundaries to care and/or by ignoring possible contributing health factors including mental health, family support, or other individual health needs.

 

In response to WPATH’s request for HHS feedback on a draft of its forthcoming standard of care, Adm. Levine shared her view with her staff that publishing the proposed lower ages for gender transition surgeries was not supported by science or research and could lead to an onslaught of attacks on the transgender community,” the HHS said in an emailed statement. Levine, a four-star admiral in the U.S. Public Health Service Commissioned Corps, is the highest-ranking transgender official in the Biden administration.  

The HHS did not respond specifically to questions regarding the White House signaling its opposition to gender-affirming surgery for trans youth."

 

https://19thnews.org/2024/07/white-house-statement-gender-affirming-surgery-minors/

 

Then, for example, when I searched for "WPATH and Dr. Rachel Levine", the first return was a NY Post (a conservative tabloid) article claiming Dr. Levine was pressuring WPATH to remove age limits for trans youth surgery. So I can see why they issued a statement although we would have liked to have seen something not so explicitly lacking in affirmation.

 

https://nypost.com/2024/06/26/us-news/biden-administration-official-rachel-levine-pressured-medical-experts-to-remove-age-limit-guidelines-for-transgender-surgery/

 

Not wild about the whole" breaking news" but at least we can be assured it didn't actually come out of left field nor is it necessarily pandering to conservative voters, despite the uncanny timing.

[Ivy]

This is really slimy

We have no friends.

I wasn't expecting much - now I'm expecting nothing.

 

Well, you chose your path and you walk it.  Nobody said it would be fun.

[VickySGV]

Just now, Vidanjali said:

Not wild about the whole" breaking news" but at least we can be assured it didn't actually come out of left field nor is it necessarily pandering to conservative voters, despite the uncanny timing.

With those details, it does in fact seem that this is an "out of context" thing going on here and may not be the damage it seems like, considering the "leaked" nature of some of the information.  The well may not have the poison in it that it seems at first.

[Ivy]

Ok.  I posted before @Vidanjali's post came up. 

I do remember Dr. Levine's statements.  And I had no problem with them.

 

But I still don't trust these people.  They'll throw use under the bus in a heartbeat.

 

It is coming to a question of how much will you compromise for the illusion of acceptance. 

 

I have more to say, but it would probably be offensive.

 

[Ivy]

I suppose, considering the latest SCOTUS statements, there is little point in anything.  

 

I just think of the Phenix.  

 

But you got to work with what you have left.

 

Trans people have always existed.  What ever they say doesn't - can't - change that.

[Carolyn Marie]

What I find distressing is the emphasis by everyone involved in this, whether friend or foe, on gender affirmation surgery for minors!  It is something that happens for perhaps 1-2 percent of all trans youth who desire transition, and even that may be an exaggeration.  It is brought up by the right because they always focus on extreme examples as a way of riling up their base, not because it is a frequent occurrence.  It is simply a non-issue.

 

Hardly anyone brings up HRT and hormone blockers, even though that is by far the more common occurrence.  One reason is that cisgender young people are also prescribed cross gender hormones or blockers because it is sometimes medically necessary, so eliminating it for trans youth would also eliminate it for cisgender youth.  If they didn't do that, they would (rightly) be accused of discrimination.  So it's best just to leave it unmentioned.

 

Everyone probably wishes we would just go away.  While we can't and won't do that, it would be nice if we could fade into the background like we largely were 8+ years ago. It isn't such a great thing finding our community in the news every damn day.

 

Carolyn marie

[KayC]

It would be nice to get some clarification from the Administration ... but regardless, it's still going to be a politicized issue all the way through the election. 
This is not my BIG fear ... that fear would be that the 'R's take total control next year and we ALL lose our care options.

[Davie]

This move by the Biden administration concerns only 1%–2% of youth surgeries, so why would they risk alienating the many votes of the whole supportive LGBT+ community for this? Biden's main problem with his own voters is that he often refuses to stand up and advocate for his own principles—that's why his support is so soft. But he's just done that again. Perhaps the backlash from this new ruling will turn him back towards better support, but how can we trust him? How?

There's this:

Human Rights Campaign President Kelley Robinson issued a strong rebuke on Tuesday of the Biden-Harris administration’s position opposing gender affirming surgeries for minors.

The New York Times reported on June 28 that the White House, which broadly supports making medical interventions available for transgender youth, had expressed opposition to surgeries for patients under 18, having previously declined to take a specific position on the question.

“Health care decisions for young people belong between a patient, their family, and their health care provider. Trans youth are no exception,” Robinson responded. 

 

Wake up, Biden! Stand up or lose your base votes to an insane fascist.

 

[Vidanjali]

Just now, Davie said:

Wake up, Biden! Stand up or lose your base votes to an insane fascist.

 

Here's a question, though. If an individual were turned off by this Biden admin statement so much so that they no longer wanted to vote for him, is the alternative candidate really someone they'd perceive as more trustworthy? If their predilection for Biden were in fact eroded over this issue, maybe they'd just not vote at all which is in effect similar to voting for the alternative.

 

I agree the public needs clarification on this. Especially the facts on how uncommon trans minor surgery actually is & what trans youth healthcare actually entails. I'd like to see the Biden admin state what they DO support with respect to trans youth and the trans population at large. The present concern here seems to be the optics of this statement and the further ignorance is has the potential to inflame.

[Vidanjali]

I took it for granted that I would not be able to read the NYT article related to this because of the paywall. Today I clicked on it and found I'm able to read it. I don't know why, I don't subscribe. Here it is in case anyone is interested to read it. It does provide more context and detail.

 

June 24, 2024 by Azeen Ghorayshi who covers the intersection of sex, gender and science for The Times.

 

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 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.

 

https://www.nytimes.com/2024/06/25/health/transgender-minors-surgeries.html

 

[Davie]

Thanks@Vidanjalifor the update that reveals the complexity of this issue. Particularly, Dr. Marci Bowers on surgeries:  "Gender-affirming surgery is valued highly by those who need these services—lifesaving in many cases,” Dr. Bowers said. Good for her.  

[Ivy]

It is unbelievable how many people feel entitled to poke into transgender people's personal business.

[VickySGV]

Thank you @Vidanjali for that insertion in this one.  Dr. Bowers actually was my surgeon back in 2013, as patient nine hundred something (very close to, but not her 1,000th patient who I guess was just a few weeks later.)  Now that I see what is really being referred to in the core of this article, I am really rolling my eyes about the whole thing.  I was actually part of an online study group of Trans Health Care Professionals of the proposed Standards Of Care V8 back at the time they were out for professional collegial review prior to publication. I was in the discussion about 98% as simply a nosy neighbor listener and reader with a relevant professional degree to the group's thoughts. A fly on their wall so to speak.  I do remember one of my IRL friends in the group mentioning Dr. Levine's comments as a medical colleague and NOT as a political officer of any rank, but the folks I was hanging out with had their own reasons for not including the age guidelines, which were mostly of the view that other medical phenomena which occur over an age spectrum should be the guidelines such as the Tanner Scale of Sexual Maturity a couple of other professional "scales" of assessment and not legal age.  Levine and Bowers and many others were considered to be colleagues in the profession with their own say and background for adding to the conversation, which it was at that point.  I did not see the "politics" or even a relation to any political POV, however, the discussions took place AFTER the politicization of the Covid 19 Vaccine and Pandemic in 2019 and 2020 which had been well marked with political injection into medical science and treatment protocols, and thus Levine's involvement is equated to the prior years of interference and pressure from a government, especially from those whose beliefs were supported during the Covid years and are now at odds with the winner of the 2020 election.

[Vidanjali]

Just now, VickySGV said:

Thank you @Vidanjali for that insertion in this one.  Dr. Bowers actually was my surgeon back in 2013, as patient nine hundred something (very close to, but not her 1,000th patient who I guess was just a few weeks later.)  Now that I see what is really being referred to in the core of this article, I am really rolling my eyes about the whole thing.  I was actually part of an online study group of Trans Health Care Professionals of the proposed Standards Of Care V8 back at the time they were out for professional collegial review prior to publication. I was in the discussion about 98% as simply a nosy neighbor listener and reader with a relevant professional degree to the group's thoughts. A fly on their wall so to speak.  I do remember one of my IRL friends in the group mentioning Dr. Levine's comments as a medical colleague and NOT as a political officer of any rank, but the folks I was hanging out with had their own reasons for not including the age guidelines, which were mostly of the view that other medical phenomena which occur over an age spectrum should be the guidelines such as the Tanner Scale of Sexual Maturity a couple of other professional "scales" of assessment and not legal age.  Levine and Bowers and many others were considered to be colleagues in the profession with their own say and background for adding to the conversation, which it was at that point.  I did not see the "politics" or even a relation to any political POV, however, the discussions took place AFTER the politicization of the Covid 19 Vaccine and Pandemic in 2019 and 2020 which had been well marked with political injection into medical science and treatment protocols, and thus Levine's involvement is equated to the prior years of interference and pressure from a government, especially from those whose beliefs were supported during the Covid years and are now at odds with the winner of the 2020 election.

 

Care to write an op ed to the NYT? Seriously. The holes in the context are gaping from many angles.

 

Indeed, when the contentious Dr. Cantor says, “What’s being told to the public is totally different from WPATH’s discussions in private”, he is not wrong, however his deliberate omissions further muddy the big picture.

 

And what you explain about age-unrelated metrics such as sexual maturity scales helps to clarify this which was reported in the 19thnews.org article: "In response to WPATH’s request for HHS feedback on a draft of its forthcoming standard of care, Adm. Levine shared her view with her staff that publishing the proposed lower ages for gender transition surgeries was not supported by science or research and could lead to an onslaught of attacks on the transgender community.” I suspect that when people read "not supported by science or research" they may tend to err on the side of jumping to the conclusion that it means trans healthcare as a whole is not supported by science or research when really the matter is far more nuanced.

 

What I am not clear on is whether these "leaks" refer to interactions of Dr. Levine with WPATH before or after she joined the Biden administration - or do they intersect, and in that case, can it be parsed?

 

I must say also, please be careful, anyone, who gets into depth reading about this. There is at least one publication which I came across which was so incredibly cruel and petty in their reporting on this issue, and which included outright lies, even lies which were supposedly cited where the citation did not corroborate the lie. A mess. It left me a bit haunted, which I hope will pass soon enough. So, trigger warning on any deep dives on this. Much love, all.

[VickySGV]

Just now, Vidanjali said:

“What’s being told to the public is totally different from WPATH’s discussions in private”,

 

The discussions in private lead up to, and are distilled on what is published to the ignorant masses who are not medically or otherwise trained in a science field.  That dude is twistier than the Angeles Crest Highway a few miles from me.  

[Vidanjali]

Human Rights Campaign President Kelley Robinson issued the following statement in response to this recent Biden admin statement:

“Health care decisions for young people belong between a patient, their family, and their health care provider. Trans youth are no exception.

The Biden administration is flat wrong on this. It’s wrong on the science and wrong on the substance. It’s also inconsistent with other steps the administration has taken to support transgender youth. The Biden administration, and every elected official, need to leave these decisions to families, doctors and patients–where they belong. Although transgender young people make up an extremely small percentage of youth in this country, the care they receive is based on decades of clinical research and is backed by every major medical association in the U.S. representing over 1.3 million doctors. The administration has committed to fight any ban on healthcare for transgender youth and must continue this without hesitation–the entire community is watching.

No parent should ever be put in the position where they and their doctor agree on one course of action, supported by the overwhelming majority of medical experts, but the government forbids it.”

 

https://www.hrc.org/press-releases/hrc-president-on-harmful-statement-from-biden-administration-wrong-on-the-science-and-wrong-on-the-substance

[Davie]

Just now, Vidanjali said:

No parent should ever be put in the position where they and their doctor agree on one course of action, supported by the overwhelming majority of medical experts, but the government forbids it.”

Ah. Thanks for this @Vidanjali

[Ivy]

[awkward-yet-sweet]

On 7/3/2024 at 2:38 AM, Carolyn Marie said:

What I find distressing is the emphasis by everyone involved in this, whether friend or foe, on gender affirmation surgery for minors!  It is something that happens for perhaps 1-2 percent of all trans youth who desire transition, and even that may be an exaggeration.

 

Exactly.  There's a handful of cases that get a ton of media attention, like Chloe Cole.  I feel bad for those folks, but those cases are usually examples of medical malpractice or at least doctors who weren't cautious.  Sane, reasonable doctors simply aren't doing operations on minors.  Certainly not without really good reasons, like dealing with an intersex condition. 

 

One on hand, Republicans are going crazy about the handful of sensational cases....it is disingenuous and nutty.  On the other hand, I don't see it as an issue for elected leaders to affirm the belief that doing surgical alteration of minors is simply not OK....a viewpoint that the majority of professionals would agree with. 

 

On 7/3/2024 at 1:48 PM, VickySGV said:

I did not see the "politics" or even a relation to any political POV, however, the discussions took place AFTER the politicization of the Covid 19 Vaccine and Pandemic in 2019 and 2020 which had been well marked with political injection into medical science and treatment protocols, and thus Levine's involvement is equated to the prior years of interference and pressure from a government, especially from those whose beliefs were supported during the Covid years and are now at odds with the winner of the 2020 election.

 

There's plenty of fallout from injecting the government into the Covid crisis.  When folks wanted to use the government for mandating masks, closures, and even attempting vaccine mandates... medicine became highly political, and it will remain that way as long as government has the power to either mandate or restrict our options.  That bell can't be unrung now.

 

I'm continually amazed at the actions of both "left" and "right" when they use the government as a tool for advantage.  Why are those who sowed the seed surprised when in a different season they reap a harvest of the same thing?   

[Ivy]

I'm not terribly upset about the responses to covid.  Nobody knew much about it at the time.  People were freaking out.  The "public health" people were doing the best they knew how.  We know a lot more now.  We didn't know much at the time.  

The fact is, a lot of people did die.  And it was worse in urban areas.  Of course it was - a lot of people in a small area.  It didn't't have much to do with which party was in charge.

 

We have become incredibly stupid in this ridiculous politicizing of everything.  

[Carolyn Marie]

I'm going to get ahead of the curve on this discussion, and just say let's NOT diverge into a discussion of government mandates of any kind.  Doesn't belong on this thread.  and 

 

Carolyn Marie

[Davie]

Trans Legislators, LGBT Orgs Urge Biden To Reconsider Anti-Trans Statement: "A Betrayal"

On Tuesday, the Biden administration released a statement targeting surgery and other care for trans youth. Now, transgender and nonbinary state legislators are pushing back. —Erin Reed
 

Last week, the Biden Administration seemed to falter on transgender healthcare issues, releasing and revising multiple statements opposing gender-affirming surgery for transgender youth and prioritizing "mental healthcare" over other forms of care. The statements were a reaction to a misleading story from The New York Times regarding Admiral Rachel Levine's comments on WPATH guidelines for transgender youth. Now, a group of twelve transgender and nonbinary legislators have released an open letter to the Biden Administration, calling the statement "a betrayal" and urging for clarification that the administration would continue to oppose bans on gender-affirming care.

     “These are personal decisions, made on a case-by-case basis, by the young individuals, their families, and their medical providers. Yet anti-equality state legislators have passed bans on this healthcare in half the country,” the legislators state in the letter. Many of them work in states that have targeted transgender healthcare, such as Representatives Mauree Turner (Oklahoma), James Roesener (New Hampshire), Gerri Cannon (New Hampshire), Alissandra Murray (New Hampshire), Zooey Zephyr (Montana), and SJ Howell (Montana).

“The statement his administration shared with news outlet The 19th this week stands as a shocking repudiation of that promise. By stating that some forms of healthcare for transgender people should be limited solely to adults, the administration is surrendering the health care of young transgender people as something to be negotiated in the political domain, rather than something that needs to be carefully considered and decided by the medical community, by the parents of transgender youth, and by the youth themselves.”

[Davie]

Erin Reed —
The White House has just issued a "clarifying statement" on trans care. The new statement: - Opposes bans - Still has harmful anti-surgery language - Says decisions should be left to patients, families, doctors, not politicians. 

 

https://substackcdn.com/image/fetch/w_800,h_800,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F1e534736-e598-4ab8-abe1-a9c342029934_1296x684.png