Hilary Cass, Superwoman

Cass's sole focus on the children has sucked the oxygen from all who want to push medicalization

A funny thing happened recently in Britain. In the matter of a week – or even less – that gender-affirming care should not involve medicalization has become conventional wisdom. When the “final report” first came out, there was a feeling in some quarters whether it could actually be enforced. A week later, those misgivings seem misplaced.

Politicians on either side of the spectrum agree. As do the supposed “centrists.” And Stonewall. And PinkNews. All of (normal) Britain now seems to agree with Health Secretary Victoria Atkins that the “fashionable cultural values” that had “overtaken evidence, safety, and biological reality… must now stop.” And for that, we have the magnificent Dr. Hilary Cass and her team to thank.

The news around it has mostly been highlighting the sensational bits – oh, look, gender medicine is built on shaky foundations; oh, look, the WPATH and Endo Society just referenced each other's shoddy studies, which were picked up by other studies which cross-referenced each other – all of that is true, and they need to be brought out in the open to end this medically-assisted destruction of children.

But more importantly, for the Brits – and if they are listening, for people anywhere – it is the most comprehensive roadmap for treating these vulnerable children. The Cass Review team brings the focus back on the children who were, for the longest period of time, treated as political and cultural pawns for adults to preen and pose.

Rather than a pediatrician being frightened out of their common sense, instincts, and medical training the moment they hear the magic word "gender," the Cass Review hands the reins back to them and says: trust yourself. As the pediatrician, you know the child, her family, and her surroundings best. You know what has been going on in her life ever since her health was entrusted to your care. You have also seen many other children like her and have the professional and personal knowledge honed over decades about how children grow up to be successful adults. None of that knowledge suddenly goes out of the window the moment you hear that dreaded word. Rather, Dr. Hilary Cass, the pediatrician, encourages them to use the combined total of their knowledge, wisdom, and experience to explore what else is happening in her life. Bring in the psychologist if necessary. Look at the child holistically. Thanks to the enormous amount of time she has spent online, she has self-diagnosed to believe certain things about herself. Your job is not to negate her feelings or disregard them. In fact, respect those feelings and treat her as a complete person, not just a single-dimensional caricature. After all, she is vulnerable, and she is looking for help. 

This is certainly not the moment to write a referral to GIDS and get her shunted to that ever-expanding waiting list, but to treat her holistically. Is she feeling discomfort about her gender? Of course, she is. And yes, hormones are still a theoretical possibility. However, with extremely limited evidence of benefits¹ from the systematic reviews commissioned by the Review and an increasing evidence base of harm, the chances of them being routinely prescribed are minimal.

Practically speaking, post-Cass, if hormones are to be prescribed to a young adult in the UK for the treatment of their gender dysphoria, there better be a fucking shitload of documented medical history to know what has been tried and what has or hasn’t worked. Even after that, the patients are followed carefully to see if there is any evidence of meaningful progress (and in the meantime, the NHS has been asked to commission studies to find out the actual results among adults who have been on hormones for years now – is there any evidence that they are faring any better?)

The report is divided into five main sections – the Review’s approach to the work it undertook; an overview of the history of the gender identity service at NHS, the changing patient demographics and the rise in the referral rate; understanding the new patient cohort; the recommended clinical approach for treating these patients; and the proposed new service model – and the last two sections are the most voluminous.

The roadmap for the clinical approach and service model are comprehensive and unimpeachable. Dr. Cass is a pediatrician. For her, there is neither any left nor right side of the issue. There’s no social justice approach or “ban the medicalization” approach. For a lifelong pediatrician, there are simply children who are suffering and who have been left languishing on waiting lists without being cared for. And for them, she will follow the evidence and seek advice from every stakeholder. As she explains in her report, the origins of their distress are individualized and complex; therefore, their treatment is individualized, complex, and nuanced. She gives these children and their very real suffering the attention and respect they deserve. It would have been very easy for her to recommend opening many clinics that hand out puberty blockers and cross-sex hormones after an initial perfunctory meeting like that is done in the “specialized pediatric gender clinics” on the other side of the pond and be done with it. Those pesky waiting lists are taken care of (“Everybody gets hormones from now on!”), the parents are relieved, the activists are appeased, and the politicians can sigh relief that a crisis has been averted (and claim victory before the elections) – nobody cares about the children anyway. But Dr. Cass would have none of that. And so she loudly calls out the “polarisation and stifling of debate” that does “nothing to help the young people caught in the middle of a stormy social discourse and in the long run…hampers the research that is essential to finding the best way of supporting them to thrive.”

Equally important is the report's tenor – always reasoned and lest anyone forget, always focused on the patient. There is not a single word of incitement or anger. Even her appearance in the media (for anyone who wants an overview of the evidence and her recommendations, this half-an-hour interview with The BMJ is a very good primer) resembles the boring aunt who would just talk about the things she knows and would rather be left alone at other times, thank you very much.

No wonder the capitulation of the activists and ideologists has been so complete. If they whine, they come across as the narcissists they are, focused on their ego rather than the wellbeing of vulnerable children. And for those who want to malign her report with malicious lies, she has this to say: “If you deliberately try to undermine a report that has looked at the evidence of children’s healthcare, then that’s unforgivable. You are putting children at risk by doing that.”

Thanks to Dr. Hilary Cass, who probably deserves a Nobel prize in medicine and peace, the horrifying chapter of gender-affirming medical mutilation of children is history in the UK.

What about the reaction to the Cass Review in the US? Lisa Selin Davis wrote a thoughtful article a few days back in the Boston Globe. I agree with her sentiments completely, except for the last sentence, “We need our own Cass Review.” What more can we do than what Cass already has? A grading of the quality of existing guidelines from different countries? Check. A review of the existing services in other countries? Check. A systematic review of the characteristics of the children who are getting referred to gender identity clinics or that of the care pathways that exist for them? Check and check, respectively. An extensive systematic review of what we know from the published medical literature, whether it is the impact of social transition, suppressing puberty, or cross-sex hormones? Check, check, and check. 

The only thing the Cass review could not do very well was analyze the existing data of the 9,000 children that have already gone through the system because the clinics did not hand it over to the researchers. Under the directive from the UK government, the NHS has now been ordered to do that. Contrast that with the situation in the US, where we do not have any long-term medicalization and outcome data about our transgender community because we lack a nationalized electronic health records system. When a patient leaves a clinic, it is as if they cease to exist in the clinic’s medical records, much like the archived data of a customer who has stopped shopping in a retail store. (The NHS will have some problems conducting this data analysis because of its decision to issue a different patient identifier for a person after their transition; it is perhaps not a straightforward exercise, but the health records before transition and post-transition can be attributed to the same person by linking their old and new identifiers. It can be done.) In the US, when a patient leaves one private clinic for another, there is no way to link one privately issued medical ID from one clinic with another issued by another clinic that maintains their own medical records. Even if the patient takes the initiative, data portability between two systems is technically and administratively impossible for all practical purposes – the best you can do is to scan the historical records without any meaningful integration.

We also need to realize that the US medical system has no incentive to gather long-term data about these patients. Our healthcare system is philosophically averse to collecting long-term patient data – why gather long-term data that could uncover new cans of worms and new legal liabilities? “Success,” therefore, is measured as a patient who has checked out and not sued the clinic before the statute of limitations expired. There is also another reason why long-term data collection does not work for the US medical system. Knowing what works and what does not will prevent much of the unnecessary spending not backed by evidence. It is no wonder healthcare costs so much more in the US than in other OECD countries while delivering worse outcomes.

The best that we can do under these circumstances is something like the underwhelming study from Chen et al. (2023) in NEJM (which, as this brilliant Reddit post pointed out, is actually a poster child of not intervening with cross-sex hormones) or the utterly disastrous “study” by Tordoff et al. (2022) in JAMA. The former has data for a sample of 315 for 24 months (losing nearly 100 by the end of the study), and the latter – well, the less said about it, the better (that NPR covered it fawningly is an eternal blot on Science Friday). Incidentally, the results of these two studies have already been incorporated in one of the eight systematic reviews that came out along with the Cass review.

What will a new “review” from the US add besides confusion and obfuscation? Even if we want to start now, it will be at least a decade before we have a good-sized cohort from whom we have collected data for an extended period of time (remember, drop-off is very high by default in a medical system without a universal patient identifier: a patient can leave town or decide to visit another clinic). An entire generation of vulnerable children cannot wait ten years (and possibly much longer) before being told that they were mistreated by experimental interventions during their formative years, with lifelong consequences. It might suit the medical industry well – lifelong customers! – but not the children.

All that we should do if we do not want to harm these children  – not that I am holding my breath – is to incorporate the recommendations of the Cass Review in its entirety. The US should consider itself lucky. The good doctor has done the homework. We just need to turn in her work and claim it as our own.

1. One emerging criticism of the Cass Review is that it had artificially set the bar of evidence too high. That, as the editorial from the BMJ Editor-in-Chief makes very clear, is complete nonsense. “In fact, the reality is different: studies in gender medicine fall woefully short in terms of methodological rigour; the methodological bar for gender medicine studies was set too low, generating research findings that are therefore hard to interpret. The methodological quality of research matters because a drug efficacy study in humans with an inappropriate or no control group is a potential breach of research ethics. Offering treatments without an adequate understanding of benefits and harms is unethical. All of this matters even more when the treatments are not trivial; puberty blockers and hormone therapies are major, life altering interventions.”