In March, Britain’s National Health Service announced it will no longer routinely prescribe puberty blockers to gender questioning young people under the age of 18. In her first U.S. broadcast interview, pediatrician Dr. Hilary Cass explains the NHS's new approach to gender-affirming care.
of gender health services for children in England, commissioned by Britain’s National Health Service. Former president of the Royal Society of Pediatrics and Child Health.Statement from the American Academy of PediatricsHILARY CASS: The quality was disappointingly poor, and there's a number of reasons for that. One of the significant reasons is that they just didn't follow up for long enough, particularly for young people who were taking masculinizing and feminizing hormones.
They may not have the same response to medication as somebody who is presenting considerably later. And I think the other thing to say is that young people present, in many different ways, in how they present their gender identity. So the commonest group now, or the most rapidly growing group, rather, isAnd we have even less research on what the right approach is for those young people.
CHAKRABARTI: Okay. More specifically, in the systematic review of studies relating to the use of puberty blockers, we should say that puberty blockers do have quite a well-established evidence base for use in some situations, right? For example, children with precocious puberty. Or there's also some adult cases where puberty blockers can be used, right?CASS: Absolutely right. Yes. So, in the UK, they are what's called licensed in children, if you have precocious puberty.
So that was the first part of the thinking. And she had a second key thought that if you could pause puberty, it would just buy young people more time to think and to work out who they were, understand their identity. So those are the two things that she originally thought would be advantages of this treatment.
But just to go back to the systematic reviews, the other studies that the team looked at, none of them really effectively reproduced the Dutch results of seeing robust improvements in mental health.," and that's the group that did the review.CHAKRABARTI:"That there is insufficient or inconsistent evidence about the effects of puberty suppression on psychological or psychosocial health.
CHAKRABARTI: This is a really important point that's been brought up by the Cass Review. About did the focus on trying to provide medical forms of therapy, perhaps overshadow other forms of care.
CHAKRABARTI: I just want to recap. So that the systematic review found that there's insufficient evidence or inconclusive evidence about the effect of puberty blockers on mental and psychosocial health or in the alleviation of gender dysphoria.
CASS: Yeah, and that's one of the really tricky questions to understand. Because we need to view this in the broader context of what's happening to adolescents and adolescent girls in particular, across most English speaking, most of the English-speaking world. And they do have higher rates of anxiety, of depression, of self-harm, of suicidal ideation, of distress about body image.
CHAKRABARTI: So Dr. Cass, one thing that the review notes very clearly at the top, which is true both in the UK and elsewhere around the world, including the United States, is the rapid rise, and actually the exponential rise in the number of young people, adolescents in particular, seeking treatment for gender dysphoria.
CASS: What's different about children and adolescents is that they are evolving and developing and how a young person feels at any point in their life is real. It's as real as it is for any adult, but I think the important thing is that young people are in a developing state, and how you feel at seven and ten and 20 may be quite different.
It's probably worth saying that for birth registered females, the male hormones work fast, and there are significant irreversible effects in terms of dropping your voice, developing facial hair and other effects. And so within a few months, you do have significant irreversible effects. Whereas for birth registered boys, estrogen takes longer to take effect, and the effects are easier to reverse.
Are they getting out of the house? Are they in employment? Do they have a satisfactory sex life? What are the things that matter to them? And are they achieving those things? And as the report says, it is well established that children and young people with gender dysphoria are at increased risk of suicide. But then the report adds this,But suicide risk appears to be comparable to other young people with a similar range of mental health and psychosocial challenges." So first of all, what's the evidence for that and why is that important to understand?
So it can be hard to make sense of the data, but such data as we have shows that people do commit suicide, both after they've had gender-affirming treatment, and before they've had gender-affirming treatment. And we can't detect a difference in the suicide rates before and after treatment. CASS: Yeah, this is one of the things which makes this so difficult. So if you look at the abstract of that particular paper, it said there was a tendency for suicidality to reduce. Or, some words to that effect, but if such a small percentage actually completed the questionnaire, what does that mean about all those that didn't complete it?
CHAKRABARTI: The report also cites another potential challenge is that it's not necessarily that care providers have wanted to overlook the other problems, but the focus from the beginning, whether by virtue of the medical culture, or even what the family and young person desire for themselves, has been on the gender dysphoria versus the other potential comorbidities.
But the review concludes that social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence. For this reason, a more cautious approach needs to be taken for children than for adolescents. Elaborate on that, Dr. Cass. So if it wasn't for the medical intervention, I think this would not be such a challenging issue for us.
In the UK, certainly, our philosophy is that parents are well intentioned towards their children, unless you've got very good reasons to suspect that might not be the case. And secrets between children and their families living a different life at school from at home is challenging. A young person thrives best with the support of their family.
And we've gone over some of the conclusions about lack of evidence for puberty blockers, similarly for hormones, lack of evidence to say with certainty if gender-affirming care reduces suicidality. These are very specific and concrete conclusions in terms of evidence. So there was a disconnect between the systematic review that they commissioned, and the conclusions that they reached.of care, they do conclude that the evolving science has shown clinical benefit for transgender youth, who receive their gender-affirming treatments in multidisciplinary gender clinics.
CHAKRABARTI: Okay. Dr. Cass, it's now been a month since the independent review was first made public. And of course, there's been quite a bit of response to it. 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 the 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.
CASS: It certainly was a concern that might be the case in the UK. I'm really pleased to say that in the UK, both of the main parties, the main political parties here have accepted the findings of the report and said we shouldn't be politicizing this. Because this is about trying to decide the best clinical care for young people, and it shouldn't be political.
And that, in some, that changed belief set is positive in many ways. Because certainly if younger people have a much more flexible view of how gender can be expressed, that breaks down gender stereotypes. It maybe breaks down misogyny. There's lots that's good about that more flexible view, but it doesn't necessarily mean that you have to treat it medically.
CASS: I think first and foremost, seeing them as a young person and not as somebody who is gender questioning, or with a gender problem or a gender issue.
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