A Reckoning Over Gender Treatment 

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Perceptive Morning Dispatch readers have probably noticed at some point in the last four-and-a-half years that this newsletter is not interested in fanning the flames of the culture wars and getting readers riled up as they start their days. We made a promise at the outset that we’d do our best to separate the signal from the noise and distill the goings-on in the world into something worth your time every morning. There have been a handful of exceptions—times where we thought we could add clarity—but for many years, the battle over the appropriate treatment of minors seeking to change their gender has been filled with more heat than light. It’s possible that may be beginning to change. 

More than three-and-a-half years ago, the United Kingdom’s National Health Service (NHS) commissioned the “Independent Review of Gender Identity Services for Children and Young People.” That study—which has come to be known as the Cass Review, named Dr. Hilary Cass, the chair of the project and the former president of the Royal College of Paediatrics and Child Health—was published last week, and the review provided a welcome and evidence-based respite from an otherwise toxic conversation with its wide-ranging examination of studies and research undergirding gender-transition treatment and the clinical practices for delivering that treatment. 

The nearly 400-page U.K. report could signal a sea change for Europe in the debate over the future of gender-transition treatment for children and young people, providing a case study in the dangers of letting cultural pressures influence medical treatment. But it’s unclear if the takeaways will translate across the pond, where many of those cultural pressures have led to the public conversation being dominated by the most extreme voices on either side of the debate.

The conclusions of Cass’ report were striking. “The rationale for early puberty suppression remains unclear, with weak evidence regarding the impact on gender dysphoria, mental or psychosocial health,” the review found. It confirmed what some medical professionals and researchers had been arguing for years: There isn’t high-quality research showing that treatment delaying the onset of puberty is actually helping young people seeking a gender transition. “This is an area of remarkably weak evidence, and yet results of studies are exaggerated or

misrepresented by people on all sides of the debate to support their viewpoint,” Cass wrote in the report. “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender related distress.”  

The report included a variety of recommendations to improve care but concluded that “for most young people, a medical pathway will not be the best way to manage their gender-related distress.” Consequently, the NHS reversed its decade-long practice of prescribing puberty-suppressing hormones (PSH) to children with gender dysphoria—“a marked incongruence between one’s experienced/expressed gender and assigned gender of at least six months duration, as manifested” in delineated criteria, according to the Diagnostic and Statistical Manual of Mental Disorders. “We have concluded that there is not enough evidence to support the safety or clinical effectiveness of PSH to make the treatment routinely available at this time,” the NHS said last month. PSH treatment will still be available for participants in clinical trials and at private clinics, although some British lawmakers are now pushing for a ban across the board.

To understand the significance of these shifts, it’s important to appreciate how gender-transition treatment has evolved in Europe. In the late 1990s, researchers in the Netherlands helped pioneer such treatment for young people experiencing gender dysphoria in what became known as the “Dutch Protocol.” Treatment involved puberty-blocking drugs for children and teenagers with gender dysphoria, followed by cross-sex hormone treatment—providing biological males with estrogen and biological females with testosterone—and then, for some, transition surgery. A key 2011 Dutch study found positive results among 70 young people who received PSH treatment and a follow-up study in 2014 that tracked 55 of those people who subsequently underwent transition surgery and demonstrated that gender dysphoria “was alleviated and psychological functioning had steadily improved.”

But the Cass Review highlighted some significant issues with the 2011 study. For example, some of the study participants didn’t complete questionnaires after their treatments designed to assess their improvement, potentially biasing the results towards individuals who decided to come forward with positive outcomes. Plus, all the patients saw psychiatrists or psychologists during the PSH treatment, making it difficult to isolate the positive outcomes to the effects of the drugs.  

What’s more, subsequent research found that young people who experienced gender dysphoria as well as separate psychiatric issues reported no improvement in their well-being after taking PSH. Cass argued in The British Medical Journal that the early research showed success in a “small number of birth-registered males” but that the current population of people seeking gender treatment in the U.K. are largely “birth-registered”—or biological—females, and there is not sufficient evidence showing that that cohort benefits from PSH treatment. “It is unusual for us to give a potentially life-changing treatment to young people and not know what happens to them in adulthood,” Cass told BBC last week. 

The review led to the closure of the NHS’ Gender Identity Development Service (GIDS)—the largest children’s gender treatment clinic in the world—last month. In the early 2010s, GIDS became ground zero for the shift in the population of young people seeking gender treatment away from largely biological males who experienced gender dysphoria before puberty toward biological females experiencing gender distress. Most of those patients were seeking treatment after puberty had begun, and many had a host of separate diagnoses, often depression and anxiety. That change also coincided with the rollout of PSH treatment for young people. 

In 2011, the NHS conducted a trial of puberty blockers in young people with gender dysphoria—an “early intervention”—but the preliminary results of the study showed no benefits. “The results of the study were not formally published until 2020, at which time it showed there was a lack of any positive measurable outcomes,” the Cass Review noted. “Despite this, from 2014 puberty blockers moved from a research-only protocol to being available in routine clinical practice and were given to a broader group of patients who would not have met the inclusion criteria of the original protocol.” Some former GIDS staff had previously criticized the service for making assessments and recommending PSH treatment before psychological treatment or support had been offered. The Cass Review interviewed GIDS staff and found that some felt “under pressure to adopt an unquestioning affirmative approach and that this is at odds with the standard process of clinical assessment and diagnosis that they have been trained to undertake in all other clinical encounters.” 

Still, the Cass Review and the closing of GIDS are not without their critics among transgender advocates and some medical professionals. Mermaids, a British transgender charity, worried that the changes could heighten wait times for young people seeking care. GenderGP, an online gender clinic, criticized the report for an “inadequate” literature review that did not take into account evidence from non-randomized control studies. 

But the review’s findings are consistent with growing efforts by European medical experts and policymakers to roll back hormonal and transition treatment for young people. Last year, an independent Norwegian health board recommended that gender-transition treatment for minors be designated as “experimental.” In 2022, France’s National Academy of Medicine recommended practitioners delay using puberty blockers and cross-sex hormones, concluding it was “appropriate to extend the psychological treatment phase as much as possible.” Sweden issued guidance in 2022 to restrict treatment for minors to the rarest cases, and in 2020, the Finnish Health Authority issued new guidelines prioritizing psychotherapy as the first-line treatment. As a result of the Cass Review, some doctors in Belgium and the Netherlands are now calling for restrictions on the use of puberty blockers.

Europe’s moves stand in contrast to the U.S., where leading medical bodies recommend an affirmative model of treatment that holds “a child of any age may be cognizant of their authentic identity and will benefit from a social transition at any stage of development.” Last summer, the American Academy of Pediatrics reaffirmed its commitment to this model of treatment, which is also supported by the World Professional Association of Transgender Healthcare (WPATH). U.S. Assistant Secretary for Health Rachel Levine—the first openly transgender person to hold a position requiring Senate confirmation—reflected the position of many gender-affirming care advocates in April 2022: “There is no argument among medical professionals—pediatricians, pediatric endocrinologists, adolescent medicine physicians, adolescent psychiatrists, psychologists, etc.—about the value and the importance of gender-affirming care.” 

While “gender-affirming care” can include social and therapeutic support, Levine’s framing belied the genuine disagreements among doctors and practitioners about medical interventions. “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 report also said that WPATH’s guidelines for care “lack developmental rigor.” 

Like the U.K., the U.S. is also seeing a growing number of young biological females who don’t have a long history of gender dysphoria seeking gender treatment. Yet they’re being treated through a model based on research that’s applicable to a different cohort. “The population has changed drastically,” Laura Edwards-Leeper, the former head of the Child and Adolescent Committee for WPATH, told the New York Times earlier this year. Edwards-Leeper founded the first pediatric gender clinic in the U.S. in 2007. “You have to take time to really assess what’s going on and hear the timeline and get the parents’ perspective in order to create an individualized treatment plan,” she said. “Many providers are completely missing that step.”

In 2022, Reuters surveyed 18 gender treatment clinics in the U.S. and found that none of them employed the month-long psychological screenings conducted by the researchers in the Dutch studies that provided the foundation for the affirmative care model. Seven of the clinics said they can prescribe based on a single visit “if they don’t see any red flags and the child and parents are in agreement.” The clinics said waiting months to treat children puts them at unnecessary risk of harm. 

While in the U.K. lawmakers from both the Labour and Conservative parties seem ready to support reforms to gender care, U.S. efforts to place additional restrictions on gender-transition treatment are largely led by Republican lawmakers at the state level. A number of red-leaning states have restricted—or outright banned—certain gender-transition treatments for minors, and GOP lawmakers in additional states are pointing to the Cass Review as justification for doing the same. The battle over such state laws is currently playing out in the courts to varying effect. The Supreme Court ruled this week that Idaho could enforce its ban on treatment for minors with a handful of exceptions, but on Tuesday, a state court in Ohio temporarily blocked the state’s ban from going into effect.

The debate will no doubt continue apace in the near future, but likely not without continued risk to the debaters. “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behavior,” Cass wrote. 

“This must stop,” she added. “Polarization and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse, and in the long run will also hamper the research that is essential to finding the best way of supporting them to thrive.”