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Top pediatrician whose landmark report got puberty blockers banned in the UK says US guidelines for transgender youth medicine are 'out of date'
A leading pediatrician has warned that guidance to give potent hormone-warping drugs to children who want to change gender is 'out of date,' following a major review of the safety of puberty blockers.
Dr Hillary Cass, a renowned British doctor, whose landmark 'Cass Report' got puberty blockers restricted in the UK, said US guidelines on treating gender-confused children is 'misleading.'
Her report, a systematic review of 300 scientific papers and surveys on gender-affirming care that included more than 113,000 kids from 18 countries, concluded the evidence for using the drugs on transgender children was of 'poor quality' and 'not reliable.'
Based on her findings, the pediatrician believes American medical organizations providing recommendations for the treatment of trans youth 'need to be honest about the strength of the evidence' supporting the use of puberty blockers in minors and make improvements to their guidelines.
Dr Hilary Cass' landmark review of studies into puberty blockers for teens with gender dysphoria ran counter to standard orthodoxy held by American doctor groups, which she said are out of step with science
A 2023 YouGov survey of 1,000 adults across Republican and Democrat states found that Americans were largely against gender-affirming procedures for children
The Cass Report ran counter to conclusions by American physician groups like the American Academy of Pediatrics, which she told the New York Times a ‘fairly left-leaning organization’ whose guidance is ‘misleading the public.'
In an interview with the Times, Dr Cass criticized the general orthodoxy among physician groups in the US, particularly that which tells doctors to accept what teens say about their gender dysphoria at face value, hastily setting them down a course of lifelong - and potentially irreversible - medical treatments without examining the full person.
She said: ‘You can put someone on a medical pathway, but if at the end of it they can’t get out of their bedroom, they don’t have relationships, they’re not in school or ultimately in work, you haven’t done the right thing by them.
‘So it really is about treating them as a whole person, taking a holistic approach, managing all of those things and not assuming they’ve all come about as a result of the gender distress.’
Dr Cass’ influential review said two things could be true at once: a widespread ‘social contagion’ of gender dysphoria and social acceptance has encouraged more teens to come out as trans.
The landmark review was commissioned by the UK's National Health Service, which has taken a much more conservative stance when it comes to transition care for youth compared to the US, going so far as to ban puberty blockers for teens.
Published last month, the report concluded in the vast majority of cases, while puberty blockers are meant to give a child more ‘time to think’ about their gender identity and what they need, ‘no changes in gender dysphoria or body satisfaction were demonstrated.’
She said: ‘The assessment of studies looks at things like, do they follow up for long enough? Do they lose a lot of patients during the follow-up period? Do they have good comparison groups?
'All of those assessments are really objective. The reason the studies are weak is because they failed on one or more of those areas.’
America has been accused of falling behind other countries when it comes to gender-affirming care.
In the UK, Sweden, France, Australia and the Netherlands, puberty blockers are restricted from use in minors, but in the US there are no age limits.
Puberty blockers were originally developed to suppress the hormones of minors who started puberty too early, but in the US they are prescribed off-label for people who seek to transition genders.
Advocates say they are life-saving for a suicide-prone group, but critics say puberty blockers taken too young are dangerous, and suggest therapy and counseling instead.
In the US, groups such as the AAP have called this kind of care medically necessary.
But Dr Cass added: ‘They are an organization that I have enormous respect for. But I respectfully disagree with them on holding on to a position that is now demonstrated to be out of date by multiple systematic reviews.'
Following her report, dr cass received immense criticism and even threats. One of the most common complaints was that the review was biased toward a certain conclusion due to a lack of randomized controlled trials, the gold standard for study design that randomly assigns groups to a treatment or a placebo to compare the two.
But those are difficult to conduct when it comes to studying gender-affirming care, in part due to the ethical concerns about depriving one group of gender-dysphoric youth placed in the placebo group of what they argue is necessary healthcare.
It would also take researchers years to glean usable data regarding the long-term physical and mental health effects of drugs that delay puberty and hormone therapies to give trans youth secondary sex characteristics, which have been shown to be irreversible.
Dr Cass said she did not omit randomized trials because there were none to include in the first place. Yet they still included about 58 percent of the studies they identified on the subject, which were of moderate quality or better.
High-quality studies have been peer-reviewed, include a subject population that represents a general population, and make conclusions that match the evidence.
Too little is known, she said, about the long term effects of puberty blockers and hormone treatments later on. By delaying puberty, a young teen is also delaying brain development to a certain extent during a crucial time of their life.
A study conducted by University College London earlier this year looked at 25 girls being treated with puberty blockers and found there was an average drop of seven points in their IQs.
Dr Cass said: ‘I can’t think of any other situation where we give life-altering treatments and don’t have enough understanding about what’s happening to those young people in adulthood.
'I’ve spoken to young adults who are clearly thriving — a medical pathway has been the right thing for them. I’ve also spoken to young adults where it was the wrong decision, where they have regret, where they’ve detransitioned.’
Gender dysphoria diagnoses are on the rise nationwide.
Data from 2020 showed that about 300,000 children aged between 13 and 17 (1.4 per cent) in the US identified as transgender.
That is double the number estimated to be transgender in 2017 in a previous report by the same researchers, though they used different estimates.
Overall, there are were an estimated 1.6million transgender people in the United States in 2020, up about three per cent from the estimate of 1.55million in 2017.
A report by the health data analytics firm shows the rate of gender dysphoria increased in every state except South Dakota from 2018 to 2022.
Greater social acceptance and increased awareness about the condition on the part of doctors can partly explain the increase in cases.
Dr Cass said: 'Young people growing up now have a much more flexible view about gender — they’re not locked into gender stereotypes in the way my generation was.
'And that flexibility and fluidity are potentially beneficial because they break down barriers, combat misogyny, and so on.
'It only becomes a challenge if we’re medicalizing it, giving an irreversible treatment, for what might be just a normal range of gender expression.'