Hormonal treatment
In what was likely a disappointment to many, the interim report did not provide definitive advice on the use of puberty blockers and feminising or masculinising hormones. Instead, Cass advised that recommendations will be developed as the review’s research programme progresses. In particular, the report expresses the need for more long term data to assuage safety concerns regarding these hormonal interventions. Although additional data in this area are undoubtedly needed, the decision to delay recommendations pending more information on potential unknown side effects is problematic for several reasons.
Firstly, it ignores more than two decades of clinical experience in this area as well as existing evidence showing the benefits of these hormonal interventions on the mental health and quality of life of gender diverse young people.
No it doesn’t ignore this. It points out this this two decades has been done in an evidence-limited zone, with the purported evidence not being as good as it’s made out to be. None of the published evidence looks beyond a year. There is also published evidence that there is no psychological improvement from puberty blockers. This basically boils down to “we see kids who seem happy in our clinic, so it must work!” even though they have no idea how they go in their 20s.
Secondly, it will take many years to obtain these long term data.
But you just said there was two decades of clinical experience! Why weren’t you doing the proper studies during that time? And what’s wrong with it taking “many years” for something so significant?
Finally, Cass acknowledges that when there is no realistic prospect of filling evidence gaps in a timely way, “professional consensus should be developed on the correct way to proceed.” Such consensus already exists outside the UK. The American Academy of Pediatrics, the Endocrine Society, and the World Professional Association for Transgender Health have all endorsed the use of these hormonal treatments in gender diverse young people,101112 but curiously these consensus based clinical guidelines and position statements receive little or no mention in the interim report.
Because quite sensibly, Cass has elected to approach from afresh, to look at it from a primary point of view. When this is done it’s clear the guidelines and recommendations from organisations with conflicts of interest are lacking in evidence.
Indeed, there is no evidence, as yet, that the Cass review has consulted beyond the UK. This inward looking focus may be a reflection of how England’s gender identity service has come to chart its own path in this field. For example, its current use of puberty blockers diverges considerably from international best practice. In particular, NHS England mandates that any gender diverse person under the age of 18 years who wishes to access oestrogen or testosterone must first receive at least 12 months of puberty suppression.13 However, many young people in this situation will already be in late puberty or have finished their pubertal development, by which time the main potential benefits of puberty suppression have been lost.11 Moreover, using puberty blockers in such individuals is more likely to induce unwanted menopausal symptoms such as fatigue and disturbed mood.14 For these reasons, puberty suppression outside the UK is typically reserved for gender diverse young people who are in early or middle puberty, when there is a physiological reason for prescribing blockers.
Acknowledgment that puberty blockers cause mood disturbance in older children, so say it’s better to give them younger. No acknowledgement of mood disturbance at this age though.
Another possible reason exists for the Cass review appearing to have neglected international consensus around hormone prescribing. While the interim report often mentions the need to “build consensus,” Cass seems keen to find a way forward that ensures “conceptual agreement” and “shared understanding” across all interested parties, including those who view gender diversity as inherently pathological. Compromise can be productive in many situations, but the assumption that the middle ground serves the best interests of gender diverse children and young people is a fallacy. Where polarised opinions exist in medicine—as is true in this case—it can be harmful to give equal credence to all viewpoints, particularly the more extreme or outlying views on either side. Hopefully Cass will keep this in mind when preparing her final report.
This final paragraph is remarkable. It’s essentially saying “don’t listen to the bigots, their concern is false”. Basically ignore the detransitioners, there is no middle ground, affirmative care is the only way.
These are Australian clinicians, totally enmeshed in the affirmative model. I think they are feeling extremely threatened by the likelihood that facts and stories from detransitioners will expose everything they’ve done.
I imagine Dr Cass will be in no way swayed from listening to everyone who needs to be listened to.