Calling All Major Medical Associations

What they should learn about LGB kids and gender-affirming care from the Cass Review

“Every major medical association supports gender-affirming care.” You’ve likely heard this talking point from activist organizations defending gender medicine for children and adolescents: puberty blockers, cross-sex hormones, and sometimes surgery to treat gender dysphoria.

I don’t deny that American medical associations—advocacy groups that support clinicians—take this position. But I do argue that the position is not rooted in science or reality, and that it can harm the very patients it purports to help—especially gender nonconforming and gay and lesbian young people. 

Now, a nearly 400-page report, commissioned by England’s National Health Service, backs these assertions up. 

The Cass Review, which took four years to complete, comes in response to complaints about the only public youth gender clinic in England and Wales, Gender Identity Development Service, or GIDS, which was shut down last year—that they were fast-tracking kids into irreversible medical interventions, and that the culture of fear prevented concerned clinicians from speaking up. Cass and her team needed to understand the current landscape to come up with a plan to fix it. So they listened to trans people, detransitioners, therapists who feel pressure to affirm, doctors who passionately support these treatments, and many others with differing opinions. They also commissioned systematic reviews of the evidence about both psychological and medical interventions.

Here’s just some of what they found: 

· No one had followed up with the 9,000 children who’d gone through the service—and, shockingly, the adult gender clinic would not share the data about how they fared later. 

· There was no clinical consensus about how to treat them. “Clinicians who have spent many years working in gender clinics have drawn very different conclusions from their clinical experience about the best way to support young people with gender-related distress,” Cass wrote.

· The evidence to support medical transition for youth was “remarkably weak.” “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” Cass admitted. That includes the evidence around the use of puberty blockers, which the NHS has now largely banned, and their effects on bone health, brain development, and fertility.

· Of great importance is what some of that stronger evidence showed: a correlation between child-onset gender dysphoria and later homosexuality. “The majority of these children [in the studies] became same-sex attracted, cisgender adults,” Cass writes. In the one Dutch study upon which all gender medicine is based, 89 percent of the young people who transitioned “were same-sex attracted to their birth-registered sex, with most of the rest being bisexual. Only one patient was exclusively heterosexual.” 

Some parents had told Cass that their children had “been through a period of trans identification before recognising that they were cisgender same-sex attracted. Similar narratives were heard from cisgender adults.” Among the studies cited in the Review is one of almost 3,000 adolescents, whose high amount of “gender non-contentedness” in early adolescence had declined by early adulthood—but that non-contentedness “was also more often associated with same-sex attraction.” 

Photo by Wesley Tingey on Unsplash

LGBT Courage Coalition co-founders Jamie Reed and Aaron Kimberly both experienced gender dysphoria as girls and adolescents. Both grew up to be same-sex attracted. Aaron went on to transition as an adult; Jamie went on to marry a trans man. My child is as gender nonconforming as Jamie and Aaron were—but no one can predict her future based on that. And perhaps her lack of gender dysphoria is related to growing up in a time and place and family in which that gender nonconformity is completely accepted, without anyone trying to make meaning from it.

Of great import to me as a parent is that most kids in the original cohort studied in the Netherlands were likely gay. But the medicines they received were the same as those once given to gay adults to punish them or cure them of their sexual proclivities. Somehow, these treatments are touted as being safe and effective for “LGBTQ+ kids,” but the reality is that they can sterilize and remove sexual function from same-sex attracted people—something they’ve been fighting for decades to stop.

Instead of talking openly about these hugely important issues with youth gender medicine, those who advocate for it have insisted on “no debate.” But debate we must. Because today, many more kinds of kids seek these interventions. There has been an “exponential change in referrals over a particularly short five-year timeframe,” Cass reports, with girls quite suddenly making up the bulk of patients, instead of boys—a shift that cannot be explained by increasing social acceptance. Meanwhile, children and adolescents “are on a developmental trajectory that continues to their mid-20s”—that is, it’s hard to make grand decisions during this long period of growth and change.

The youth cohort sheltered beneath the umbrella of “trans” is actually a heterogeneous group, and the inconvenient truth is that no one knows the best way to help them thrive. No one knows who they will grow up to be or how they will identify in adulthood. Nor does anyone know the benefits or harms of social transition, in which children adopt the gender identity that doesn’t correspond with their sex. “However, those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway,” Cass notes. That is, it is not a neutral intervention, but rather an active one that seems to increase the likelihood of medicalizing later. 

Cass states clearly that “For the majority of young people, a medical pathway may not be the best way” to achieve self-actualization. She supports expanding psychological support for those young people, and strict and standardized evaluations, in line with what several other European countries are doing. She demands long-term follow-up not only of anyone who will transition in the future, but of those who already have.

The World Professional Association for Transgender Health, an advocacy and activist organization that appointed itself the generator of “standards of care”—and which England and other European countries are increasingly rejecting—directed people toward an opinion piece called “The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children.” In other words, they dismiss the whole thing as bigotry. But Cass dismissed their own standards of care as lacking “developmental rigor.”

The NHS thanked Cass for her work and suggested that it may have international influence. I hope so, too. The report makes clear that the American affirmative model was a departure from a more cautious approach, and that even the cautious approach was based on substandard evidence—that modifying secondary sex characteristics in adolescents, or transitioning children to live as the opposite (or neither) sex was never fully supported by any high-quality research and became more about social justice than evidence. But medicine, Cass reminds us, is in fact evidence based. The issue is “about what the healthcare approach should be, and how best to help the growing number of children” with gender distress. It is not about ideology.

We don’t have the same system in America. We don’t have the kind of centralized healthcare and state agencies to craft guidelines that all must follow. Here, we battle it out in the legislature, state by state, red against blue, based on moral worldviews more than evidence. So how will the Cass Review influence our toxic gender culture war? How will they affect the medical associations that craft guidelines and create policy statements?

I queried the American Academy of Pediatrics, which recently reaffirmed its commitment to the affirmative model; the American Psychiatric Association; and the American Psychological Association, which have pro-affirmation models statements of their own. Only the latter responded, and I spent over an hour talking to APA Senior Advisor, Psychology in the Public Interest, Clinton Anderson. He admitted to the low quality of evidence and said that there’s a fundamental tension between those who view transition as a social justice issue and those who advocate for a more cautious, evidence-based approach. Where does the APA land? “Our concern has been largely about a human rights issue, and the way this is treatment has become politicized in our system and used as a punishment against people for being different,” Anderson told me. “And that I think has to be seen as the biggest issue.”

I disagree. But I will say that Anderson listened to my points more than anyone at these institutions ever has. I urged him to take a closer look at the Cass Review, and to listen to those who’ve been hurt, not just those who feel they’ve been helped. Maybe, just maybe, he heard me. Maybe, just maybe, these associations hear the science-minded and nuanced words of the Cass Review.