The British doctor whose landmark report got puberty blockers restricted in the UK has urged similar caution be taken in the US, in her first American interview.
Dr Hilary Cass’ 400-page report, which took more than three years to complete, found the evidence for using the drugs on transgender children was of ‘poor quality’ and ‘not reliable.’
The findings resulted in the UK’s National Health Service (NHS) restricting hormone drugs for people under 18, an outcome that has made Dr Cass the subject of viscous bullying – leaving her too scared to use public transportation.
Now, in her first discussion of the report on an American platform, Dr Cass is urging doctors to allow transgender children to go through their natural puberty to ‘leave their options open.’
Dr Cass received major backlash, previously saying she has been the recipient of online bullying and threats, adding she cannot even use public transportation anymore because she is being threatened over her report
She highlighted the irreversible effects of puberty blockers in some patients, suggested other stressors could be causing children’s gender anxiety and highlighted the many unknown side effects of starting the drugs too young.
Speaking on the On Point podcast, Dr Cass said: ‘The more we can let young people go through their typical puberty, and work out their identity and leave their options open as long as possible, the more likely it is that they will make the best possible decision.’
Because a wrong decision could mean permanent change, especially for young girls taking male hormones, which can cause irreversible voice dropping and facial hair growth within months.
However, Dr Cass added: ‘It’s really important to say that there may be a group of young people who do have early gender incongruence for whom this might be the right treatment,’ such as young boys who would experience irreversible changes of male puberty.
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.
Dr Cass, former president of the Royal College of Pediatrics and Child Health, Britain’s premier body for pediatricians, was commissioned by the NHS in 2020 to investigate whether it is medically sound to provide gender-confused children with puberty blockers and cross-sex hormones
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.
Dr Cass said: ‘Just giving hormones without supporting people is not helpful. An adult trans person said to me the other day, “If you just get the hormones, that does not make years of dysphoria go away, and you need some therapeutic support, as well.”‘
She continued: ‘Somehow, we’ve got locked into puberty blockers as the totemic treatment that young people feel that if they don’t get on that pathway, if they don’t get onto puberty blockers, they’re not going to get onto a medical pathway [to transition].’
While there are many different ways in which doctors can address gender anxiety in children that don’t involve drugs, Dr Cass said ‘we’ve somehow stopped short of trying those just because puberty blockers have become so widely believed to be effective.’
She added she has spoken with people in the trans community who said they wish they knew when they were younger there are more options and more ways of expressing identity than just taking a medical approach.
‘So a lot of what the focus of our review has been on is saying what do we do to help these young people to thrive, and how do we give them the widest range of options that also don’t foreclose for them,’ the doctor said.
Keeping options open is a major point Dr Cass stressed.
She gave an example of adolescent girls, who are more at risk for self harm, depression and suicidal ideation.
While going through puberty, they may feel distress over the changes in their bodies, leading them to question their identity: ‘And then you go on puberty blockers.
‘That may absolutely be the right decision, but conversely, you have very little experience of your own puberty and probably very little basis on which you might change your mind because you feel good on your testosterone.
‘We have absolutely no way of knowing whether we have changed the trajectory for those young people. It’s a huge unknown.’
The hormones may ease gender distress to a degree the girls are able to discuss other issues that may be causing anxiety.
Over time, they may identify as trans, but they may determine their anxiety was about another issue entirely and not want to transition anymore.
Dr Cass, former president of the Royal College of Pediatrics and Child Health, Britain’s premier body for pediatricians, was commissioned by the NHS in 2020 to investigate whether it is medically sound to provide gender-confused children with puberty blockers and cross-sex hormones.
Her report was a systematic review, considered the ‘gold standard’ in research, of 300 scientific papers and surveys encompassing studies of more than 113,000 kids from 18 countries.
Systematic reviews find every relevant study on a particular topic and then re examine the study methodology, type and duration of research and scrutinize the validity of the studies’ results.
It is the world’s largest systematic review on the topic to date.
Dr Cass said the review found the support for using a medicalized approach for gender-confused children ‘was disappointingly poor’ because the studies ‘didn’t follow up for long enough, particularly for young people who were taking masculinizing and feminizing hormones, because it’s not enough to just follow up for a couple of years.’
Overall, the review recommended children and adolescents don’t go on a medicalized approach to gender discomfort because their sense of self is constantly evolving and the decision for drugs may be premature.
Dr Cass said during the podcast: ‘We’ve not taken a position that any form of care is best, but what we have said is that it is important that all young people get access to evidence based, non-medical interventions that address the full range of their difficulties.
‘This group of young people, if they are depressed, if they’re anxious, if they need an autism diagnosis, all of those things should be put in place.
‘We don’t know which young people may benefit from medical care, and we have proposed that every young person who walks through [a clinic] door should be included in some kind of proper research protocol, so that we can follow them up and we can get those answers over time.’
Along with unconvincing evidence, a major flaw in the studies was lack of long-term follow up and diverse set of subjects that didn’t represent different ages or varying types of gender dysphoria presentations, and didn’t include enough people with mental health conditions or trauma.
Dr Cass said this was a problem because people who are presenting their gender confusion differently respond to medications differently.
She said: ‘You can’t put all of these young people into the same treatment group and say they’re all going to respond in exactly the same way to this kind of approach.’
The NHS requested the review after a former patient of a UK gender clinic sued a facility, the Gender Identity Development Services (GIDS), in 2020, claiming she had not been challenged enough before being prescribed puberty blockers at 16 years old.
The UK’s highest court then ruled children, specifically under 16 years old, could not always realize the long-term consequences of taking puberty blocks.
The NHS requested the review after a former patient of a UK gender clinic sued a facility, the Gender Identity Development Services (GIDS), in 2020, claiming she had not been challenged enough before being prescribed puberty blockers at 16 years old
Practices at the UK’s only clinic for minors experiencing gender distress, GIDS, were coming under increasing scrutiny just before the lawsuit after former patients and whistleblowing staff claimed children were being rushed onto medications like puberty blockers despite concerns over their use.
An internal report found one-fourth of the clinic’s doctors had concerns over whether they could provide safe, evidence-based care for young people as patients at the clinic skyrocketed – increasing from a few dozen in 2010 to more than 3,000 in 2021.
One of Dr Cass’ main takeaways is that children should ‘keep their options open’ as young people are constantly evolving.
She added: ‘I think all we can recommend is caution and keeping options open.’
And just as the sweeping review was being published, a separate study found the majority of gender-confused children grow out of that feeling by the time they are fully grown adults.’
Results from that study showed at the start of the research, around one-in-10 children (11 percent) expressed being distressed about their gender to varying degrees.
But by age 25, just one-in-25 (4 percent) said they ‘often’ or ‘sometimes’ were discontent with their gender.
Citing the study, Dr Cass said: ‘It’s not about saying there shouldn’t be gender-affirming care. It’s just, when is the right time to embark on that gender-affirming care? And most particularly, when is it safe to embark on the components of that care that might be hardest to reverse?’
