The American Academy of Pediatrics (AAP) annual convention is an opportunity for pediatricians to network, exchange ideas and learn. Unfortunately, when it comes to youth gender medicine, misinformation was on the 2024 conference agenda. As a keynote speaker, the AAP chose U.S. Department of Health and Human Services Assistant Secretary for Health Rachel Levine, the highest-ranking transgender official in the Biden administration.

Levine’s invitation should cause concern to American families who want to know that the nation’s largest pediatrician group values evidence-based medicine. Levine has supported a misinformation campaign that has turned the U.S. into an international outlier in the use of the “gender-affirming” model of care, which recommends hormones and surgeries rather than psychotherapy as the first-line treatment for adolescent distress around puberty. 

Emails recently unsealed in a lawsuit revealed that in 2022, Levine pressured the World Association for Transgender Health to remove age minimums for gender surgeries from its “standards of care.”

Since 2017, a Manhattan Institute analysis of health insurance claims has shown, that more than 5,000 teenage girls had their breasts amputated as part of a “gender-affirming” procedure designed to help them achieve a male look. This includes 50 to 179 girls who were 12-and-a-half years old or younger at the time of surgery.  

These figures represent an undercount, as they do not include procedures performed at large health care systems like Kaiser Permanente (which is currently being sued by two young women who underwent “top surgery”). Yet these surgeries do not seem to pose a problem for those like Levine who believe the theory that “trans kids know who they are.”  

Levine’s invitation ought to also be a concern to AAP members who worry that homophobia and regressive sex stereotypes are a large component of what underlies “gender affirming” treatments. Incredibly, children who do not fit sex stereotypes and same-sex attracted adolescents are now given the idea they are “trans” and encouraged to perceive hormones and surgeries as a solution to the substantial difficulties that society imposes on gender non-conforming young people. It is unwise to promote this speculative narrative, since neither data nor logic supports the concept of a “trans child.”

What we need is open, respectful, and fact-based public dialogue regarding these issues. Unfortunately, that will not occur at the AAP’s primary peer-reviewed journal, Pediatrics. This formerly high-quality journal has been used to cheerlead for the “gender-affirming care” scheme rather than to provide a forum for rigorous scholarly debate. This distortion of science conveniently helps insulate the AAP from criticism and is a prime example of how ideological activism, even if well-meaning, destroys trust in medicine.   

Until recently, these large numbers of gender dysphoric teens would have been unheard of. I was in medicine for two decades without encountering a single trans-identified youth. Youth with other types of body-related distress were common, but only in the last decade did any substantial number claim they had been born in the wrong body and request hormones and surgeries to become their “authentic selves.”

What has occurred to cause young people so much distress with their biological sex? How did they come to believe so strongly in irreversible treatments with scant supporting evidence? 

Rather being humble and accurate about what we know and don’t know regarding how to approach these young people, those within AAP have condemned anyone who advocates for a cautious, evidence-based approach as “anti-trans.” They even attempted to have their conference moved out of Florida due to erroneous and self-aggrandizing perception that “hate” is why so many across the world recommend against these treatments.

Levine’s invitation to be keynote was not the only dubious milestone for the AAP this year. The AAP also promised to conduct a systematic review of the evidence for so-called “gender-affirming care” over 13 months ago. There is no indication that the review has begun.

Systematic reviews, the gold standard in medical evidence analysis, are the reason a growing number of countries now classify puberty blockers and cross-sex hormones as “an experimental practice” and impose restrictions on their use. The AAP has refused to answer questions from journalists on the matter and excluded voices urging caution from its convention.

AAP is now under investigation by state attorneys general and, along with the author of its 2018 policy statement on “gender-affirming care,” is a named defendant in a lawsuit by a young woman who says she suffered irreparable harm because of the APP’s fraudulent recommendations.

In his book, “Blind Spots, When Medicine Gets It Wrong, and What It Means for Our Health,” Marty Makary reveals many examples of the harms of medical hubris and groupthink. One is the AAP’s reckless 2000 guidelines on peanut avoidance. Without supporting evidence, the AAP put its institutional credibility behind untested theories. When parents followed the AAP’s bad advice to avoid giving infants and young children peanuts, there was an increase in the number and severity of peanut allergies. The U.S. now leads the world in peanut allergies, which are almost unheard of in much of the world. 

The AAP quietly reversed this foolishness in 2017 but failed to learn from the episode. In 2018, it concocted its even more harmful and less evidence-based statement promoting gender-affirming care. The statement, written by a single physician with minimal clinical experience, has been thoroughly debunked and was rated unfit for use by a recent systematic review of guideline quality. The Cass Review, the most comprehensive review of youth gender medicine to date, found the AAP recommendations to be among the world’s worst.

Most embarrassing for AAP, in June, private emails unsealed as part of a lawsuit showed that even the discredited leadership at World Association for Transgender Health had said the AAP recommendations have “a very weak methodology, [and were] written by [a] few friends who think the same.” 

As a psychiatrist, I have seen firsthand how “gender-affirming” treatment approaches cause harm to vulnerable youth. Gender-affirming care is well-intended activism posing as medical treatment. It has torn families apart and eroded public trust in our medical system.

Contrary to the slogans, these treatments are not lifesaving. The AAP’s decision to invite Levine as keynote speaker and its continued lack of transparency regarding the evidence for its recommendations signal that the AAP continues to prioritize misguided advocacy over science.  

Kristopher Kaliebe is a psychiatrist and expert on youth gender medicine and professor in the Psychiatry Department at the University of South Florida.

Oh CAPTAIN, My CAPTAIN

Southern Poverty Law Centre's legal hopes rest on an international smear campaign

voidifremoved.co.uk

I think we need a more detailed defense that we can use that can respond to academic critics and that can be used in the many court cases that will be coming up. […] we know that some of the studies we have cited in support of our recommendations will be torn about by organizations such as the Society for Evidence Based Gender Medicine.

Most recently, members of the newly designated hate group, Society for Evidence-Based Gender Medicine, helped advise the Cass Review in the United Kingdom,

Notably, SEGM’s funding streams include the same groups that fund the Heritage Foundation, the Alliance Defending Freedom, and the Family Research Council, far-right organizations capitalizing on Christian nationalism.

a large part of SEGM’s funding in 2020 came through a $100,000 donation from the Edward Charles Foundation … Analyses of additional financial records from 2021 reveal that SEGM’s total revenue nearly quadrupled from the previous year to nearly $800,000, and that funding appears to have come primarily from donor advised funds. The largest contribution, which came from Fidelity Investments Charitable Gift Fund, totals over $350,000. Notably, Fidelity and Vanguard Charitable Endowment Program (which also donated to SEGM in 2021) have a history of directing money to anti-LGBTQ+ groups, such as the Alliance Defending Freedom and the Family Research Council. … [In 2020] In addition to Heritage Foundation, that year, the Charles Koch Institute contributed […] $1.3 million to the Edward Charles Foundation (which funded SEGM that year).

The donor, a 68-year-old woman from California who asked to remain anonymous because she feared harassment, described herself as a non-religious feminist who had supported Barack Obama and Hillary Clinton.

• In 2020/21 the Fidelity Investments Charitable Gift Fund gave SEGM $363,500, while also giving SPLC $4,065,459. 
• In 2020/21 Vanguard gave SEGM $22,000 and SPLC 45 times more: $1,084,650
• In 2020/21, The American Online Giving Foundation gave SEGM just $15,201 and SPLC over 130 times more: $1,995,272

The BMA turns away from rejecting the Cass Report

The doctors’ union has voted to retain a neutral position on the issue.

New Statesman

The British Medical Association (BMA) has reversed its decision to call for a pause in implementing the recommendations of the Cass Review, the New Statesman can reveal. It follows intense criticism of the doctors’ union after this publication exposed its discussions regarding the rejection of the findings of Dr Hilary Cass’s independent review into gender identity services for children and young people.

Informed by seven new systematic evidence reviews, and more than a thousand conversations with trans young people, clinicians and others, Cass concluded in April that gender medicine was built on “shaky foundations” and “an area of remarkably weak evidence”. The reality, she wrote in her report, is that there is “no good evidence on the long-term outcomes of [hormonal] interventions to manage gender-related distress”.

Yet, on 16 July, the New Statesman revealed that a motion had been tabled by the BMA council – the executive body of the doctors’ union – which called for the BMA  to “lobby… to oppose the implementation of the recommendations made by the Cass Review”. It also described Cass’s recommendations as having been “driven by unexplained study protocol deviations, ambiguous eligibility criteria, and exclusion of trans-affirming evidence”. The motion had originally called for the BMA to “disavow” the Cass Review too, though this wording was changed to “publicly critique” when the vote took place the next day. Sources have confirmed since that 45 of the 69 voting members of the BMA’s council took part in those votes. Less than half of them – 21 – voted to oppose supporting the Cass Review (11 voted against; 13 abstained). By comparison, 29 members voted to critique it. 

In a press release that followed, the BMA also criticised the government’s ban on new prescriptions of puberty blockers to those aged under 18 (for the purpose of treating gender-related distress). NHS England had already confirmed in March that puberty blockers would no longer be prescribed on the NHS for the treatment of gender-related distress, because of a lack of evidence over their safety and clinical effectiveness. Instead, they would only be prescribed as part of clinical research. The ban meant that others could not continue prescribing routinely as well, and was judged lawful by the High Court in July. The Health Secretary, Wes Streeting, has extended the ban until the end of November, and to cover Northern Ireland

An open letter condemning the BMA’s stance followed, gaining more than 1,500 signatures, around 1,000 of which were from BMA members. The BMA was the only major medical group in the UK to consider rejecting Cass. Supportive statements have been issued by the Royal College of GPs, the Royal College of Psychiatrists, the Academy of Medical Royal Colleges and the Association of Clinical Psychologists. Many BMA members were dismayed, some resigning their membership in protest. Signatories to the letter accused the union of failing to follow an evidence-based approach to medicine. The letter, shown first to the New Statesman, criticised the process behind the BMA’s decision as “opaque and secretive” and said the motion did “not reflect the views of the wider membership, whose opinion you did not seek”.

After months of criticism and negative press coverage, it would seem the BMA has now listened. Earlier this week, the BMA’s council members voted to “retain a neutral position on the recommendations of the Cass Review… while a BMA task and finish group undertakes its own evaluation”.  

Dr David Strain, chair of the BMA’s board of science is leading the union’s “critique” of the Cass Review, which is still going ahead. “I have no preconceptions and have every intention to lead our evaluation from a position of neutrality,” he said. “As a geriatrician, I do not treat children and young people for gender dysphoria, and so the first phase of my review will be to listen to people with lived experience and a range of healthcare professionals working in this area.” Strain explained that his group would also review the actions taken in the name of the Cass Review. “I do not know, nor do I pre-empt, what we will conclude,” he added.

Some of those who were critical of the BMA’s earlier stance are relieved. Dr Louise Irvine, who organised the open letter condemning the original motion, told the New Statesman, “I welcome the BMA’s decision to reverse its opposition to the Cass Review and adopt a position of neutrality. Its previous position… has damaged the reputation of the union and its commitment to evidence-based medicine. I hope this change can help the BMA to earn it back.”

The BMA has previously said that it hopes to have completed its review by the end of the year.

Progressives’ Drive for Equity Is Leading Them Astray on Medical Gender Transition for Minors | National Review

It’s understandable to want to help troubled kids. But the evidence simply isn’t there that unproven drugs and surgeries are what they need.

National Review

It’s understandable to want to help troubled kids. But the evidence simply isn’t there that unproven drugs and surgeries are what they need.

In our drive to eliminate health inequities, my fellow liberal Democrats and I are eager to help children who identify as transgender. This compassionate urge has led our state, Oregon, to fast-track Medicaid coverage of medical transition services for kids, including puberty-blockers, cross-sex hormones, and surgical removal of breasts and genitals. Yet I’m deeply concerned that in the push for equity, Oregon has ignored evidence, to the point of jeopardizing children’s health. I know from experience that my state can do better to ensure that kids get medically necessary care.

Oregon has long been a national and even international model for evidence-based medicine. I personally encountered my state’s strong commitment to medical science after my two young sons were diagnosed with autism in the late 2000s. At the time, few autism treatments were covered by insurance or Medicaid anywhere in America, so I worked with state leaders and a broader coalition to right that wrong. One key hurdle was Oregon’s Health Evidence Review Commission (HERC), which determines what treatments Medicaid covers and strongly influences the coverage of private health-insurance plans.

HERC held us to its customary high standards for quality of evidence. We organized testimony from some of the world’s leading experts on autism and submitted reams of peer-reviewed journal articles, all of which were rigorously scrutinized by HERC’s experts. We prevailed only after the U.S. Agency for Healthcare Research and Quality published a groundbreaking systematic review that supported the effectiveness of behavioral interventions for autistic children. In 2014, HERC approved Medicaid coverage of such treatments for children like mine. HERC’s wise focus on evidence steered patients and physicians away from risky and unproven interventions that were popular at the time, some of which, such as chelation therapy, reportedly killed autistic children. To this day, I’m grateful for the commission’s high standards.

Yet HERC hasn’t upheld the same standards for gender medicine. To its credit, the commission began looking at this issue in 2012, before gender dysphoria was on the social radar. At the time, based primarily on studies of adults over the age of 30, it concluded that there was “very poor evidence” of benefits of medical interventions for patients. Even so, HERC decided in 2014 to provide comprehensive Medicaid coverage for puberty-blockers, cross-sex hormones, and surgeries for anyone, including children, who identifies as transgender. In a strange departure from its own rules, HERC didn’t run these policies through its evidence-based-guidelines subcommittee. In my fight for autism coverage, that subcommittee was the most important part of the process.

I’m confident the commissioners were trying to help people in what was then a unique situation. At the time, in 2015, the state estimated that very few patients would choose medical transition: according to NPR, “at least 175” patients per year, of all ages. NPR quoted HERC’s medical expert as estimating that the combined total cost for this coverage would be “up to $200,000 — for the whole state.” Yet by 2019, more than 7,500 Oregonians were receiving such treatment, at a cost of over $20 million per year. Based on my analysis of state data, hundreds of children have received some combination of puberty-blockers, cross-sex hormones, and surgeries. None of these procedures have gone through clinical trials to demonstrate their safety and effectiveness, and in the case of hormones, children are receiving drugs that haven’t been approved for such use by the FDA.

Amid this exponential rise, HERC in 2023 commissioned a thorough review of the latest studies. The draft report, which I obtained via a freedom-of-information request, found that the evidence was still very limited. For youth, the investigators reported that they were unable to find any systematic reviews — the key evidence we had to provide for autism coverage — with “extractable data” showing benefits of transgender treatments for children. The report also noted that many lower-quality studies can’t be applied to patients who seek a rapid gender-affirming transition, which is typically the case with children. The report was essentially Oregon’s version of the Cass Report, which the United Kingdom released in April.

Yet Oregon’s report was never finalized, and HERC staff didn’t even present their draft to the body’s 13 commissioners. Instead, after the state passed a law requiring the coverage of “accepted standards of care” for transgender treatments, HERC quickly endorsed guidelines from an advocacy group — without any analysis of the contents. The guidelines are highly aggressive yet based on low-quality evidence. Today, preteen Oregonians can be put on powerful chemicals without FDA approval, before moving on to surgeries as adolescents. These interventions can irreversibly alter their bodies and leave them less likely or even unable to have children of their own later in life. The risks to their physical and mental health are high and, crucially, not justified by existing proof of benefit.

Equity cannot be achieved by ignoring evidence and stripping away consumer protections from historically underserved people. While I deeply sympathize with the goal of helping struggling kids, we can’t accept shortcutting medical ethics — and we didn’t accept it a decade ago, with autism coverage. The ethical path is for HERC to define “accepted standards of care” based on the best science. Medicine is supposed to follow the evidence because health and well-being hang in the balance. The stakes are especially high for children. If we truly want to be equitable, Oregon will stop undermining children’s right to evidence-based medical care.

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Research into trans medicine has been manipulated

Court documents offer a window into how this happens

The Economist

In April Hilary Cass, a British paediatrician, published her review of gender-identity services for children and young people, commissioned by NHS England. It cast doubt on the evidence base for youth gender medicine. This prompted the World Professional Association for Transgender Health (WPATH), the leading professional organisation for the doctors and practitioners who provide services to trans people, to release a blistering rejoinder. WPATH said that its own guidelines were sturdier, in part because they were “based on far more systematic reviews”.

Systematic reviews should evaluate the evidence for a given medical question in a careful, rigorous manner. Such efforts are particularly important at the moment, given the feverish state of the American debate on youth gender medicine, which is soon to culminate in a Supreme Court case challenging a ban in Tennessee. The case turns, in part, on questions of evidence and expert authority.

Court documents recently released as part of the discovery process in a case involving youth gender medicine in Alabama reveal that WPATH's claim was built on shaky foundations. The documents show that the organisation’s leaders interfered with the production of systematic reviews that it had commissioned from the Johns Hopkins University Evidence-Based Practice Centre (EPC) in 2018.

From early on in the contract negotiations, WPATH expressed a desire to control the results of the Hopkins team’s work. In December 2017, for example, Donna Kelly, an executive director at PATH, told Karen Robinson, the EPC's director, that the WPATH board felt the EPC researchers “cannot publish their findings independently”. A couple of weeks later, Ms Kelly emphasised that, “the [WPATH] board wants it to be clear that the data cannot be used without WPATH approval”.

Ms Robinson saw this as an attempt to exert undue influence over what was supposed to be an independent process. John Ioannidis of Stanford University, who co-authored guidelines for systematic reviews, says that if sponsors interfere or are allowed to veto results, this can lead to either biased summaries or suppression of unfavourable evidence. Ms Robinson sought to avoid such an outcome. “In general, my understanding is that the university will not sign off on a contract that allows a sponsor to stop an academic publication,” she wrote to Ms Kelly.

Months later, with the issue still apparently unresolved, Ms Robinson adopted a sterner tone. She noted in an email in March 2018 that, “Hopkins as an academic institution, and I as a faculty member therein, will not sign something that limits academic freedom in this manner,” nor “language that goes against current standards in systematic reviews and in guideline development”.

Eventually WPATH relented, and in May 2018 Ms Robinson signed a contract granting WPATH power to review and offer feedback on her team’s work, but not to meddle in any substantive way. After WPATH leaders saw two manuscripts submitted for review in July 2020, however, the parties’ disagreements flared up again. In August the WPATH executive committee wrote to Ms Robinson that WPATH had “many concerns” about these papers, and that it was implementing a new policy in which WPATH would have authority to influence the EPC team’s output—including the power to nip papers in the bud on the basis of their conclusions.

Ms Robinson protested that the new policy did not reflect the contract she had signed and violated basic principles of unfettered scientific inquiry she had emphasised repeatedly in her dealings with WPATH. The Hopkins team published only one paper after WPATH implemented its new policy: a 2021 meta-analysis on the effects of hormone therapy on transgender people. Among the recently released court documents is a WPATH checklist confirming that an individual from WPATH was involved “in the design, drafting of the article and final approval of [that] article”. (The article itself explicitly claims the opposite.) Now, more than six years after signing the agreement, the EPC team does not appear to have published anything else, despite having provided WPATH with the material for six systematic reviews, according to the documents.

No one at WPATH or Johns Hopkins has responded to multiple inquiries, so there are still gaps in this timeline. But an email in October 2020 from WPATH figures, including its incoming president at the time, Walter Bouman, to the working group on guidelines, made clear what sort of science WPATH did (and did not) want published. Research must be “thoroughly scrutinised and reviewed to ensure that publication does not negatively affect the provision of transgender health care in the broadest sense,” it stated. Mr Bouman and one other coauthor of that email have been named to a World Health Organisation advisory board tasked with developing best practices for transgender medicine.

Another document recently unsealed shows that Rachel Levine, a transwoman who is assistant secretary for health, succeeded in pressing WPATH to remove minimum ages for the treatment of children from its 2022 standards of care. Dr Levine’s office has not commented. Questions remain unanswered, but none of this helps WPATH’s claim to be an organisation that bases its recommendations on science. 

Medical institutions must treat the Cass review as a significant event and act upon it

Publication of the Cass review in April 2024 was a seminal moment in contemporary medicine. Hilary Cass, a consultant paediatrician, was com

The BMJ

Publication of the Cass review in April 2024 was a seminal moment in contemporary medicine. Hilary Cass, a consultant paediatrician, was commissioned by NHS England to report independently on “the services provided by the NHS to children and young people who are questioning their gender identity or experiencing gender incongruence.” The background was an increase in referrals—of mainly “birth registered females in early teenage years”—to gender identity clinics from 2014 at an “exponential rate.”

The conclusions of the Cass review should not be surprising to anyone who has watched the promotion of medical interventions as necessary or curative in young people with gender dysphoria. As Cass states, there is a “lack of evidence” on the long term impact of hormonal prescriptions in young people, for example. Work now begins on how to design better, more evidence based, holistic services. The conclusion that services “must operate to the same standards as other services seeing children and young people with complex presentations and/or additional risk factors” is astonishing, in that it needed to be said. We need, says the report “a different approach to healthcare, more closely aligned with usual NHS clinical practice.” In other words, this suggests that the approach the NHS has taken with respect to gender dysphoria has been at odds with the usual, evidence based approach taken elsewhere. This should be deeply discomfiting. As the dust settles, and we reflect on the report’s conclusions, we should ask why this has happened.

There are multiple potential explanations. One is alluded to clearly by Cass: “the toxicity of the debate is exceptional,” she writes. Indeed. I know many senior medics who were concerned about the lack of evidence for interventions, but felt their reputation and job would be under threat if they spoke up. Anonymous personal attacks online is one thing; personal abuse from senior medics for raising clinical concerns is quite another. When considered in the context of whistleblowing more broadly, medicine clearly has an ongoing problem.

But when it comes to large, well funded, professional medical organisations, there is even less excuse. The job of medical institutions is in large part to remember the mistakes of history. These organisations should respond with care, consider evidence, uncertainty, and the recurrent tendency of well meaning medicine to do harm with good intentions. Popularity should be resisted over the need for evidence and caution. This requires strong leadership. Shutting down, or trying to shut down debate about serious clinical uncertainties—as has happened—is unacceptable.

This has not been helped by the multiple lobby groups, welcomed by many institutions to influence their policy making in this area. The same rules that we would normally use to guard relationships with any other pressure group—be it promoters of disease “awareness campaigns” or party politicians looking for support—seem to have dissolved against social pressure to achieve a compliance badge on a website.

The other explanation for what has happened that I think pertinent is this. Doctors, quite rightly, have been afraid to make the same mistakes as medicine did when homosexuality was treated as an illness in the 1950s. Then, electric shocks, desensitisation, hormones, and psychotherapy were attempted to be used to “treat” homosexuality—shamefully. What medicine did then was to intervene—ineffectively and harmfully—in something that was not a disease and should not have come under a medical purview. As Cass states, for most young people experiencing gender dysphoria, it is temporary; it is often associated with neurodiversity; it mainly resolves over time, and medical intervention does not benefit the majority. There is a comparison, but it is in favour of medicine backing off from prescriptions and surgery, and understanding why a phenomenon might be happening, why it is being seen in a medical context, and what is the best and least harmful way to respond to such expressed and profound distress.

I urge major medical institutions to treat the Cass review as a significant event, and consider what they have contributed, both negative and positive, to the damning conclusions. Was speaking up in their organisation possible, and welcomed? Did people raising concerns have fair hearings, or were they attacked or dismissed? Did the organisation enable rational debate, or instead attempt to shut it down? Did the organisation acknowledge uncertainty and the potential for harm in current practice? I don’t expect any of that to be easy. But without understanding what has happened, we will only be ready to make the same mistakes again, just in a different set of circumstances.

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@benryanwriter: NEWS: Alabama Attorney General submits motion for summary judgment in District Court case over ban on pediatric gender-trans

threadreaderapp.com

NEWS: Alabama Attorney General submits motion for summary judgment in District Court case over ban on pediatric gender-transition treatment.

The document offers a scathing @WPATH's credibility, based on subpoenaed documents, dismissing it as an "activist interest group." 🧵

This summarizes the Alabama Attorney General's assessment of @WPATH, based on a trove of subpoenaed internal communications that have been unsealed this week, plus more yet to be unsealed: "In short, neither the Court nor Alabama need treat WPATH as anything other than the activist interest group it has shown itself to be. The Constitution allows States to reject WPATH’s model of “care” and protect vulnerable minors from life-altering transitioning “treatments.” The Court should grant Defendants summary judgment."

The AL AG's motion for summary judgment borrows liberally from the UK Cass Review to portray the scientific literature on gender-transition treatment as weak and unreliable. It also relies on the words of @WPATH's president, Dr. Marci Bowers: "Asked whether 'reasonable people could conclude that there is not enough evidence to support the safety or clinical effectiveness of puberty blockers,' Bowers replied: 'There’s not enough high level evidence. Yes, you can – you can – you can say that.'”

The AL AG also points to Dr. Eli Coleman, the chair of @WPATH's Standards of Care 8 trans-care guidelines, when arguing that a 12-year-old cannot assent to gender-transition treatment that may make them infertile: “at their age – they would not know what they want."

The Alabama AG posits what has become a highly contested argument that most gender dysphoric young children will desist and stop identifying as transgender during adolescence.

The Alabama Attorney General argues in its motion for summary judgment in District Court regarding suit over the state's pediatric gender-transition ban: “Minors, and often their parents, are unable to comprehend and fully appreciate the risk and life implications, including permanent sterility, that result from the use of puberty blockers, cross-sex hormones, and surgical procedures." Thus, “the decision to pursue a course of hormonal and surgical interventions to address a discordance between the individual’s sex and sense of identity should not be presented to or determined for minors who are incapable of comprehending the negative implications and life-course difficulties attending to these interventions.”

The plaintiffs suing Alabama over its ban of pediatric gender-transition treatment rely on guidelines by @WPATH and the Endocrine Society. The AL Attorney General points to the Cass Review to characterize them as "unreliable and methodologically unrigorous."

The Alabama AG again refers to the Cass Review when characterizing what Cass called "circularity" in the WPATH and Endocrine Society's pediatric gender-transition treatment guidelines, but which the AG refers to as laundering.

The Alabama AG argues that the major medical associations that back the gender-affirming care model for children do not, in fact, explicitly endorse @WPATH or the Endocrine Society's treatment guidelines per se. 

When @WPATH's Dr. Eli Coleman couldn't get the @AmerMedicalAssn to back WPATH's Standards of Care 8 guidelines for trans care, he emailed his colleagues in a fury and said the AMA is run by “white cisgender heterosexual hillbillies from nowhere."

The Alabama AG criticizes @WPATH for not seeking to prevent intellectual conflicts of interest from biasing its Standards of Care 8, meaning the guidelines were made by those "professionally engaged in performing, researching, or advocating for the practices under review."

Activists have made much of the fact that Hilary Cass was appointed by the NHS to conduct a review of pediatric care for gender dysphoric children despite no experience with such patients. But that is why she was chosen, because she lacked that intellectual conflict of interest. 

WPATH, the AL AG asserts, leaned into intellectual conflicts of interest when crafting the SoC8. Its president, Dr Marci Bowers, says she made more than $1 million from such surgeries last year and said it was "absolutely...important for someone to be an advocate" for gender-transition treatment to sit on the guideline committee.

Despite the fact that the head of WPATH's Standards of Care 8 trans treatment guidelines, Dr. Eli Coleman, said that most of those who contributed to them had financial and/or nonfinancial conflicts of interest, WPATH denied this in public.

Despite asserting that they were creating the Standards of Care 8 according to evidence-based medicine principles, WPATH did not do so. Dr. Eli Coleman, who headed the effort, said, "we were not able to be as systematic as we could have been (e.g. we did not use GRADE explicitly)

WPATH admitted using the term "recommend," which per the principles of evidence-based medicine is reserved for treatments backed by strong evidence with few downsides and a high degree of acceptance among providers and patients, to describe treatments with low-quality evidence.

The systematic literature reviews that @WPATH commissioned from Johns Hopkins and that it subsequently largely buried found "little to no evidence about children and adolescents" with respect to gender-transition treatment. HHS acknowledged this in Sept 2020.

WPATH denied Johns Hopkins the requisite independence for conducting and publishing the systematic literature reviews on trans care that the organization commissioned.

Social justice lawyers told @WPATH that evidence-based reviews of the science behind gender transition treatment for children would put the organization "in an untenable position in terms of affecting policy or winning lawsuits."

WPATH, the Alabama AG alleges, were "explicit in their desire to tailor SOC-8 to ensure cover-age for practically any 'embodiment goal' a patient has by labelling it 'medically necessary.' That label was given to a staggeringly broad list of treatments, seemingly without regard to the evidence base."

Biden Admin health official Rachel Levine put political pressure on WPATH to remove the age restrictions for gender-transition treatments in the Standards of Care 8.

After the @AmerAcadPeds threatened to withhold support for the SoC8 and to come out against it if @WPATH didn't remove the age limits on gender-transition treatment, WPATH relented and then fabricated a story for the public about why they did so.

WPATH's Dr. Eli Coleman said trans health care is "not only under attack by politicians, but by:” (1) “academics and scientists who are naturally skeptical,” (2) “parents of youth who are caught in the middle of this controversy,” (3) “increasing number of regret cases” who “blame clinicians for allowing them[] to transition,” and (4) “continuing pres-sure in health care to provide evidence-based care.”

Erica Anderson, former USPATH head, told me how she locked horns with her WPATH colleagues after telling @AbigailShrier that some care of gender dysphoric kids was "sloppy." Anderson wanted more openness with journalists, USPATH wanted a moratorium on talking to the press. Anderson lost that battle.

One author of the SoC8 adolescent chapter said: "My fear is that if WPATH continues to muzzle clinicians and relay the message to the public that they have no right to know about the debate, WPATH will become the bad guy and not the trusted source."

In public, WPATH denies that social contagion may contribute to gender dysphoria in minors and that rapid-onset gender dysphoria may be a real phenomenon, but in private they are more circumspect, the Alabama Attorney General asserts.

America’s Medical Establishment Is in Denial on the Dangers of Gender Transition | National Review

Influential U.S. medical bodies are ignoring findings abroad that puberty-blockers and hormonal treatments for children and teens lack suppo

National Review

Influential U.S. medical bodies are ignoring findings abroad that puberty-blockers and hormonal treatments for children and teens lack supporting evidence.

On this side of the Atlantic, the Cass Review has fallen on deaf ears.

Dr. Hilary Cass released her final report for England’s National Health Service two months ago, clearly demonstrating that puberty-blockers and hormonal treatments for trans-identified children and teens lack supporting evidence. NHS England has now banned puberty-blockers in clinical care and will be restricting their use to research settings. Yet U.S. medical leaders have responded with silence, inaction, or both, proving that the physical and emotional well-being of youth has taken a back seat to social and political agendas.

The American Academy of Pediatrics (AAP) is a case in point. Since the Cass Review’s release, the AAP has refused to recognize the problematic nature of its policy that promotes hormonal and surgical treatments of trans-identified minors. This is critical because the AAP is arguably one of the most powerful institutions supporting this unproven and controversial treatment. The AAP uses its authority and trust to influence legislative debate, judicial proceedings, and parental decisions nationwide.

Initially, the AAP declined to comment on the Cass Review. A month after its release, Dr. Cass gave her first U.S. interview to NPR. It was only then that the AAP released a short statement that defended irreversible hormonal and surgical treatments, wrongly claiming they are “grounded in evidence and science.” The AAP claims its policy enjoys “strong consensus” and is “medically necessary and appropriate.”

The AAP is increasingly isolated in its claims. Health-care authorities, clinicians, and researchers in England, Scotland, Wales, Finland, Sweden, Norway, Denmark, France, and — as of last week — Germany and Switzerland have reviewed the evidence, recognized the harms, and come to the exact opposite conclusions of the AAP.

The AAP’s only other response to the Cass Review came in the New York Times. Reacting to another interview with Cass, in which she called the U.S. approach “out of date,” the AAP maintained that it was not misleading families. In a letter to the editor, the AAP’s president disputed that the evidence is weak and promised that “Dr. Cass’s conclusions will be considered” in the academy’s own review of evidence, which was announced last August. Why is the AAP waiting to consider the Cass Review when other countries are acting to protect children now?

That promised evidence review raises additional concerns. The AAP’s announcement of the review was accompanied by a reaffirmation of its existing policy, strongly suggesting that the review will reach the AAP’s predetermined conclusions — an approach contrary to good scientific practice.

Other signs indicate that the AAP review process is compromised. In April, I joined 14 fellow academy members in submitting a resolution requesting that AAP leadership update its 2018 policy to reflect the fact that every European review has shown that poor evidence supports these treatments. We also asked the AAP to disclose the protocol and methodology for its promised evidence review. Such transparency is standard and critically necessary. Yet nearly a year after the review’s announcement, the AAP has not provided this basic information.

This is the fifth year that members like me have petitioned the AAP to review its policy, yet our resolution has already died. It failed to gain sponsorship from AAP committees or chapters, a necessary step. Some AAP leaders have told me privately that they support these resolutions, but they face pressure from the academy’s leaders to steer clear. As such, regular AAP members have been effectively silenced.

These actions reflect a group driven by a political agenda rather than a group seeking medical excellence based on evidence. Patients, parents, and policy-makers need the AAP to engage honestly with the facts. The critical question remains: What will it take to restore the American Academy of Pediatrics to its medical mission?

England’s experience offers valuable lessons. A young woman who regretted her testosterone treatment and mastectomy joined a lawsuit and judicial review of the NHS treatment policy. Soon after, the Cass Review began its work, which eventually revealed the dramatic rise in patient volumes, lack of patient safeguarding, the harm and regret that was occurring, and the “threadbare” evidence, as described by the British Medical Journal’s editor in chief, that is used to justify this care.

The AAP should be wary of lawsuits. Last fall, a 20-year-old woman sued the author of the AAP’s gender-treatment policy after he treated her with testosterone, beginning when she was 14. Her lawsuit accuses the AAP and the policy’s author of “civil conspiracy, fraud, [and] medical malpractice.”

This lawsuit is likely the first of many. The AAP’s guidelines promote hormonal and surgical treatments for youths with gender distress, and tens of thousands of minors have undergone this unproven protocol. I have met dozens who regret what was done to them — puberty-blockers, hormones, mastectomies, hysterectomies, and castrations. They and many others now face lifelong physical problems, loss of sexual function, and infertility. It is right for these youths to seek justice from the people who pushed them down this road.

Much of the blame can be laid at the feet of the American Academy of Pediatrics. The Cass Review should have served as a wake-up call for the AAP and other prominent medical institutions. What a shame that the only way to spur necessary change seems to be the continued suffering of children, teens, and young adults.

Gender medicine in the US: how the Cass review failed to land

A landmark investigation with bearing on the future of gender identity services for children and adolescents has been pivotal in the UK—and

The BMJ

A landmark investigation with bearing on the future of gender identity services for children and adolescents has been pivotal in the UK—and largely ignored by US medical organisations and media. Jennifer Block reports on how America has resisted the push for a more holistic approach

The newly released Cass review on transgender care for under 18s has had a seismic effect across the United Kingdom and Europe. Scotland and Wales promptly followed the NHS in England in ceasing the prescription of puberty “blocking” drugs outside of research protocols. The UN special rapporteur on violence against women and girls, Reem Alsalem, called the independent inquiry’s findings and recommendations “seminal” and stated that policies on gender treatments have “breached fundamental principles” of children’s human rights, with “devastating consequences.” Some charities and clinicians are disappointed with last month’s final review report. But the tone of major print and broadcast media in the UK has shifted: outlets that have previously reported criticism of gender services as transphobic now note how, as the Guardian reported, “the lack of high quality research, highlighted by Cass, has been a subject of growing unease among doctors.”

The review by Hilary Cass, paediatrician and former president of the Royal College of Paediatrics and Child Health, was commissioned by the NHS and built on the findings of Cass’s 2022 interim report. Then, she found that the evidence underpinning the treatment intensive, “gender affirming” model of care for distressed young people was “limited” and “inconclusive.” The final report is even clearer: “The reality is that we have no good evidence on the long term outcomes of interventions to manage gender related distress.”

But in the United States, where the gender affirming model is the norm, the effect of Cass’s four year investigation and final report isn’t yet obvious. “Unfortunately, Cass does not seem to be penetrating the public consciousness,” says Zhenya Abbruzzese, cofounder of the four year old Society for Evidence Based Gender Medicine (SEGM), a group of researchers and clinicians that has pushed for systematic reviews and an evidence based approach.

Of the eight systematic reviews that Cass commissioned, two looked at nearly two dozen professional guidelines and found that most lack “developmental rigour.”23 More concerning, Cass exposed how they are built on “circularity,” drawn from years old versions of guidelines issued by the World Professional Association for Transgender Health (WPATH) and the Endocrine Society, each of which refer to the other rather than to high quality evidence. “This approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor,” writes Cass. Neither group responded to The BMJ.

The American Academy of Paediatrics (AAP) and the Endocrine Society have stood by their guidelines. The Cass review “does not contain any new research that would contradict” them, the Endocrine Society said in a statement.4 WPATH issued an email statement that Cass “is rooted in the false premise that non-medical alternatives to care will result in less adolescent distress,” and added on 17 May that its own guidelines were “based on far more systematic reviews [than] the Cass review.”5 As The BMJ reported last year,6 WPATH’s own systematic review, one of an unknown number commissioned for the eighth version of its Standards of Care—just two were published—concluded that the strength of the evidence to support the mental health benefits of hormones was “low” and that it was “impossible” to conclude how they affect suicide risk.

Under pressure from some members, the AAP announced last year that it would commission an independent systematic review of the evidence for the affirmative model—at the same time that it reconfirmed its 2018 statement in support.7The BMJ obtained a new resolution dated 1 April that asks the organisation to “issue an interim update to the 2018 policy statement based on the best available evidence to date.”

“The time has passed for yet another systematic review,” says Julia Mason, an Oregon paediatrician and member of SEGM who has submitted several resolutions, including the April 2024 one, to AAP for more evidence based guidance. “We now have a dozen high quality reviews (eight Cass, two NICE, one Swedish, one German) all pointing to significant issues with the purely affirmative model of care,” she says. “Parents and their children are being misled in clinics all over the country. There is no evidence that giving puberty blockers followed by hormones and surgery is lifesaving care, and there is mounting evidence that the harms might outweigh the advantages.” The AAP did not respond to The BMJ’s request for comment.

The American Psychological Association, American Psychiatric Association, and American College of Obstetricians and Gynecologists, which have position statements in support of the affirmative model, have remained silent about Cass. Only the psychology group responded to The BMJ, saying that it is studying the Cass report, but “we stand by the statement.”

Not all relevant professional groups have joined the consensus. Scot Glasberg, past president of the American Society of Plastic Surgeons, now president of the Plastic Surgery Foundation, told The BMJ that the organisation will issue “trustworthy, high quality” guidelines, but “like Dr Cass, we’ve found that the literature is of low quality and low value to dictate surgical care . . . We are trying to be very measured and not get into the difficulty that some of the other organisations have gotten into.” The American Academy of Family Physicians sought to develop a clinical practice guideline in 2020 but hasn’t yet produced one.8 The organisation declined to comment.

Some people in the psychology community are emboldened by Cass to break their silence, even if it means facing hostility from their peers. Brooke Laufer is a clinical psychologist based outside of Chicago and among the 300 clinicians who’ve joined the organisation Therapy First, which promotes psychotherapy as first line treatment for gender exploration. She told The BMJ that she is a politically liberal feminist who has “marched in Pride marches.” Recently, she posted about the Cass review to a listserv of therapists and was reprimanded by several members for promoting “misinformation” and “hate speech.” In February, another listserv member who posted about a Therapy First webinar was met with eight separate complaints to the state medical board.

Laufer says that the American Psychological Association should “gather its integrity and put out a statement that says we’re taking the Cass report seriously and we recommend puberty blockers to be paused unless it’s in the context of a clinical trial.” She adds: “What’s at stake are human lives and a generation of kids. This is about standing up and being adults and saying sorry, we got some of this wrong.”

The American Psychiatric Association met in New York this month for its annual conference. It had just one panel discussion on the topic of gender medicine, about “promoting public policy for evidence based transgender care,” focused on the negative effects of state legislation restricting treatments. In stark contrast, the European Society for Child and Adolescent Psychiatry released a new policy statement on safeguarding gender distressed youth from “experimental and unnecessarily invasive treatments with unproven psychosocial effects.”9

US media and the political landscape in general are notoriously polarised. Trusted LGBT+ advocacy groups have been unequivocal about the merits of the affirming model. GLAAD, which journalists founded in the 1980s to combat “grossly defamatory” media reporting about HIV/AIDS, protested the New York Times’s coverage of gender medicine, which has included the voices of former patients who feel they’ve been harmed. Last year, GLAAD parked a truck outside the paper of record’s offices: its electronic billboard stated, “The science is settled.”

Some hoped that Cass would offer an impartial beacon. And a few legacy and left leaning newsrooms covered the report in earnest—Reuters, the New York Times, the Nation, NBC, and the Economist. The Wall Street Journal’s editorial board said that the review “shows wisdom and humility on treatment of young people, in contrast to the ideological conformity in US medical associations.” The Washington Post and Boston Globe also ran opinions that amplified Cass to argue for a more precautionary path forward.

But many outlets historically aligned with advocacy positions have held back on any ink. STAT News, which “delivers trusted and authoritative journalism about health, medicine, and the life sciences,” has so far ignored Cass (as well as The BMJ’s request for comment). So has CNN. Jesse Singal, one of the first American journalists to expose the potential harms of youth gender treatment, reported on his Substack that the legacy news network had recycled the pronouncement that “gender affirming care is medically necessary, evidence based care” in 35 separate articles over the past two years, practically verbatim.10 (CNN did not explain, and did not respond to a query from The BMJ.) “Many outlets dug themselves into a deep hole on this issue by simply acting as stenographers and megaphones for activist groups rather than doing their jobs,” wrote Singal.

Singal has also called out Scientific American for not covering the Cass report, while on 20 April running a question and answer piece with a prominent advocate of gender affirming care titled “Anti-trans efforts use misinformation, epistemological violence, and gender essentialism.” The oldest continuously published magazine in the US, Scientific American, has run several articles favourable to the affirmative model in recent years. In “Why anti-trans laws are anti-science,” written in 2021 and republished in 2023, the magazine’s editors stated that it is “unscientific and cruel” to claim that treatments are “unproven and dangerous” or that “legislation is necessary to protect children.” According to a 2022 article, “What the science on gender affirming care for transgender kids really shows,” data “consistently show that access to gender affirming care is associated with better mental health outcomes.” “Decades of data support the use and safety of puberty pausing medications,” declared one 2023 piece.11

The magazine’s editor in chief, Laura Helmuth, has promoted these pieces on Twitter/X with declarations like, “The research is clear, and all the relevant medical organisations agree”; policies that restrict treatments are “dangerous, cruel, bigoted, and contrary to all the best scientific and medical evidence.” She’s also disparaged inquiries on the subject. In a February 2023 tweet, Helmuth included gender affirming care among a list of “things we don’t need to be both-sidesing, be ‘objective,’ or be ‘just asking questions!’ about.” Neither Helmuth nor the magazine’s publisher, Springer Nature, responded to a detailed email referencing the articles and more than 15 tweets.

US reporting in the main is sympathetic with, if not following the lead of, authoritative sources such as the US Department of Health and Human Services (HHS), which informs that “research demonstrates that gender affirming care improves the mental health and overall wellbeing of gender diverse children and adolescents” and calls puberty blockers “reversible.”12 On 24 April, a congressman confronted Xavier Becarra, secretary of the department, about these statements, holding up a thick printed copy of the Cass review. “I can assure you that we look at all studies,” said Becarra. “When we talk about a standard of care, it’s not something we make up. It’s based on what the major medical associations [say].” The US Department of Health and Human Services did not respond to The BMJ’s request for comment.

Rachel Levine, US assistant secretary for health, told National Public Radio in October 2022 that “there is no argument among medical professionals . . . about the value and importance of gender affirming care.” Yale paediatrician Meredithe McNamara, who coauthored a November 2022 commentary in the New England Journal of Medicine titled “Protecting transgender health and challenging science denialism,” told PBS NewsHour the same month, “The evidence base is strong.” McNamara has called puberty blockers “one of the most compassionate things that a parent can consent to for a transgender child,”11 and in testimony to the US Congress, warned that when gender affirming care “is interrupted or restricted, suicide, depression, anxiety, disordered eating, and poor quality of life follow.”13

In professional training, journalists have been led to interpret dissent as part of a “misinformation climate,” as in a two part Poynter Institute webinar called “Transgender coverage: avoiding rhetoric to deliver meaningful journalism,” recorded on 18 April and 2 May. Cass’s final review no doubt qualified as “medical and peer reviewed research findings”—one of the learning goals—yet it went unmentioned in all three hours of discussion. McNamara, the only medical speaker, listed the mental health benefits of gender treatments and showed a chart of five “misinformation themes,” among them “low quality evidence” and “guidelines are not trustworthy.” In part two, when asked about European countries restricting treatment, Jo Yurcaba, a reporter for NBC Out, the LGBTQ section of NBC News, told attendees that “transition related care is highly politicised in Europe, in the same way it is in the US.” These webinars were required viewing for reporters applying for an $11 500 grant for journalists interested in covering transgender issues. A spokesperson for Poynter, which also publishes the fact checking site Politifact, told The BMJ that it “strives to present an accurate, current, and well rounded overview” for journalists in training and that, by 9 April when Cass’s final report was released, “our curriculum and learning objectives had been set and our subject matter experts had prepared their materials.”

So far, outspoken thought leaders have not reconciled their statements with the growing list of systematic reviews that stand in contradiction. In an emailed response to The BMJ, McNamara said that she “noted with great interest, the systematic reviews that the Cass review relied on deemed several of the studies it assessed as ‘moderate’ in quality.” Although other advocates have seized on this apparent discrepancy, it is a known feature of systematic reviews: individual studies within a body of evidence might be rated moderate, yet when taken as a whole, that evidence may still be, as Cass put it, “remarkably weak.”

Some prominent activists attempted to discredit other aspects of Cass, both the review and the person. Alejandra Caraballo, a Harvard Law School instructor with more than 160 000 followers on X, posted in advance of the report’s release that it had “disregarded nearly all studies,” a claim that Cass called “misinformation.” The activist Erin Reed, who has a quarter of a million followers between X and Substack and is a go-to media source, accused Cass of having “collaborated on a trans care ban in Florida.” Cass spoke with a clinical member of the state’s board of medicine as part of her review. On the Majority Report, a podcast with 1.5 million subscribers, Reed said that Cass represents “the playbook for how to ban trans care.”

For science reporters and editors who have repeatedly delivered the “science is settled” boilerplate, these denunciations offer a tempting way around correcting the record. A 10 May article in Mother Jones took that route, casting the report as a political document: “It’s like the DeSantis administration wrote it.”

Medical leaders and media professionals “should engage with the content,” says Abbruzzese, which she notes is in English, freely accessible, and transparent in its rigour. “What the Cass review did was evaluate the gender clinic model of care and concluded that, when delivered in this exceptionalised way, every child who walks through the door is viewed as a trans child who is there to be medically transitioned. Cass concluded that model is fundamentally flawed because these children’s significant pre-existing mental health problems are effectively ignored in the false expectation that transition will cure them.”

“The Cass report is going to stand the test of time,” says Erica Anderson, a clinical psychologist and former president of the US Professional Association for Transgender Health. “I’m already hearing from the boards of directors and trustees of some hospital systems who are starting to get nervous about what they’ve permitted. So I think that’s going to accelerate change within American healthcare.”

In the face of criticism, Cass has been unwavering: “It wouldn’t be too much of a problem if people were saying ‘This is clinical consensus, and we’re not sure.’ But what some organisations are doing is doubling down on saying the evidence is good,” she told the New York Times. “And I think that’s where you’re misleading the public.”

Casting Evidence Aside

The Biden administration’s new Title IX guidance disregards the research on pediatric gender distress.

City Journal

In its recent Title IX guidance, the U.S. Department of Education’s Office for Civil Rights redefines the 1972 law to ban discrimination on the basis of “gender identity” in federally funded education programs. In doing so, it showed willful disregard for scientific research on pediatric gender transition and for the findings of the Cass Review, a 388-page report and the most comprehensive to date on youth gender medicine.

OCR also ignored legal precedent. It said that its Title IX rule was a response to Bostock v. Clayton County, a 2020 Supreme Court decision that involved employment discrimination under Title VII of the Civil Rights Act. OCR thus acted without regard for the vast differences between employment (which involves adults) and education (which involves primarily children). And it disregarded entirely the Bostock Court’s explicit statement that it was “proceed[ing] on the assumption that ‘sex’ . . . refer[s] only to biological distinctions between male and female” and consequently that its ruling does “not purport to address bathrooms, locker rooms, or anything else of the kind.”

The Republican response has been swift. Several red states have publicly condemned the update, and more than 20 have filed lawsuits. Much of the criticism has rightly focused on how creating “gender identity” rules will undermine women’s safety and opportunities by eliminating single-sex spaces and forcing the integration of male athletes into female sports.

The new rule effectively forces schools to facilitate so-called social transitions—recognizing trans-identifying students by their chosen “gender”—regardless of students’ age, familial circumstances, or medical and mental-health background. Schools won’t need to get parental consent; in fact, the rule effectively compels them to secure students’ consent before disclosing information about their social transition to their parents. It does so by recognizing students’ right to privacy from not just their school, but their own parents.

These new changes bring the Department of Education into conflict with the findings and recommendations of the recently published Cass Review. Immediately following the Review’s publication, Kamran Abbasi, editor-in-chief of the British Medical Journal, acknowledged that the evidence base for gender medicine—“from social transition to hormone treatment”—is “threadbare.” He called the report “an opportunity to pause, recalibrate, and place evidence informed care at the heart of gender medicine.”

The Biden administration has declined that opportunity. Its new Title IX rules implicitly reject the report’s findings and further illustrate Democrats’ indifference to the rising chorus of international skepticism about pediatric gender medicine and early social transition.

Advocates of social transition make two arguments for the practice. First, they insist that social transition improves mental health in “trans kids” and that failing to “affirm” a child’s “gender identity” can be psychologically damaging. Second, and somewhat in tension with the first claim, proponents argue that using students’ preferred names and pronouns, and granting them access to their preferred sex-specific facilities and activities, is no big deal. It’s not a psychological intervention at all, they claim, but merely a show of “respect” and “inclusion.”

Like physical medicine, psychological interventions can be beneficial or harmful. Iatrogenesis—treatment-induced illness—exists in physical and mental-health care alike. For this reason, any intervention requires careful diagnosis, weighing of costs and benefits, consideration of alternatives, and informed consent, which, in the case of minors, comes from those legally responsible for their wellbeing.

In her report, Cass writes that social transition “in an NHS setting” is “an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning and longer-term outcomes.” Cass and her team recommend that, for children, mental-health professionals advise parents “on the risks and benefits of social transition as a planned intervention, referencing best available evidence.” (Keep in mind that Cass’s recommendation assumes mental-health professionals will not automatically “affirm” a child’s feelings about gender.)

While Cass claims that social transition “is within the agency of an adolescent to do for themselves,” this needs to be clarified. A student may request new pronouns, wear clothing typical of the opposite sex, or want to use the other sex’s bathrooms, but a trans-identifying child has not socially transitioned unless adults in positions of authority treat the child as though he were what he claims to be. For very young children who don’t understand what pronouns are or how gender-related behaviors like dress and haircuts relate to one’s status as boy or girl, the “request” for social transition is inferred by adults from the child’s behavioral cues. In other words, by definition, social transition is something done to kids—not something they do to themselves.

If, as established, social transition is an active psychological intervention, the next question is: Does it help? The Biden DOE, which in 2021 encouraged schools to “use the name a student goes by, which may be different from their legal name, and pronouns that reflect a student’s gender identity,” thinks so. The department’s position mirrors that of the World Professional Association for Transgender Health, which, in its Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, says, “Research indicates social transition and congruent gender expression have a significant beneficial effect on the mental health of [trans-identifying] people.”

This isn’t true, according to the Cass report. Cass and her team commissioned seven systematic reviews of evidence and medical guideline quality from experts at the University of York, one of which dealt specifically with the question of social transition. The findings of that review, Cass writes, support “none of the WPATH [SOC] 8 statements in favour of social transition in childhood.”

Cass also notes that “social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence.” In other words, if all adults in positions of authority in a boy’s life consistently treat him as if he is a girl, he will be more likely to believe that he really is a girl. While data on the relationship between social transition and gender-identity outcomes is limited, the possibility that social transition solidifies a cross-sex identity is supported by desistance literature. A 2018 paper by University of Toronto psychologist Kenneth J. Zucker suggests that 67 percent of children who meet the diagnostic threshold of gender dysphoria outgrow those feelings by adulthood, typically during puberty. Of those below the diagnostic threshold, 93 percent desisted.

Crucially, the kids in those studies had not been socially transitioned in the way gender transition advocates now recommend. Compare these high rates of desistence to those from a 2022 study of a group of socially transitioned children, which found that 97.5 percent had not come to terms with their sex at the end of a five-year follow-up period. Though this study did not follow the kids all the way through adolescence, it suggests that social transition can lock in a child’s cross-gender beliefs and feelings that otherwise are likely to remit. Most of the children in this study were receiving medical interventions, including puberty blockers, by its end.

Cass and her team thus recommend caution. They instruct parents to socially transition a young child, if at all, only after consulting a clinician, and they counsel clinicians to prefer partial social transition (e.g., letting the child wear cross-sex clothes while maintaining his name and pronouns) to full social transition. For adolescents, they argue that “exploration” of identity “is a normal process” and “rigid binary gender stereotypes can be unhelpful.” (Of course, trans identities often rely on such stereotypes.)

While gender ideology critics may find it disappointing that Cass allows for social transition in some cases, it’s important to remember that her approach is pragmatic. She acknowledges the reality that parents, teachers, and clinicians only have so much control over a teen’s life. Whatever parents do, they should never make it harder for their kids to “return” to their sex (i.e., desist) after having declared themselves trans. The important thing is “keeping options open.”

Finally, and perhaps most importantly, Cass emphasizes that there is no way of knowing which gender non-conforming or trans-identified kids, if any, will experience a lifetime of suffering if they are denied social or medical interventions. By contrast, getting it wrong means severe and potentially permanent iatrogenic harm. Clinicians have no diagnostic tool that can distinguish a child or adolescent who is destined to endure a lifetime of agony from one going through a phase. Normal distress over puberty, inability to accept oneself as gay, ongoing mental health challenges, and (in young children) simple confusion can all manifest symptoms consistent with the current definition of “gender dysphoria.” For this reason, Cass has warned of “diagnostic overshadowing.”

But even if a diagnostic test for “true trans” existed, there is no good evidence that the long-term benefits of early intervention outweigh the risks. And even if they did, it is doubtful that a young teen could understand the tradeoffs and give informed consent.

It is a mark of arrogance that the Office of Civil Rights took none of these facts—many well-known prior to the publication of Cass’s final report—into account when formulating its new Title IX rules. The agency couches its rules in absolutist “rights talk” and imposes highly inflexible requirements on schools.

The new regulations will force schools to accommodate a student who requests social transition, regardless of the student’s age, level of cognitive and emotional maturity, family circumstances, or mental-health challenges, and with or without a mental-health professional’s diagnosis or input from parents. Notably, the rules favorably cite two policy documents—an advisory from the California DOE and an administrative regulation from Nevada’s Washoe County School District—that endorse blanket social transition policies at school without requiring parental notification.

As one of us (Sapir) has pointed out in the past, legal rules like the new Title IX regulation generate considerable legal uncertainty for school districts. In their desire to avoid expensive and embarrassing civil rights lawsuits and OCR investigations, and on the advice of their risk-averse lawyers, school officials and boards find it in their interest to defer to the very advocacy organizations that, either on their own or through allies in their network, can initiate legal proceedings against the school. A self-interested administrator will thus adopt, say, GLSEN’s model policy on transgender accommodation, in the expectation that doing so will send a signal of compliance to the powerful ACLU. Unlike the Biden administration, neither GLSEN nor the ACLU are accountable to voters. Both can adopt radical policies far afield from what even an ideologically driven Department of Education can hope to achieve. This is essentially a racket underwritten by the federal government.

Following OCR’s logic to its conclusion, a school with a parental-notification policy could be guilty of “hostile environment harassment,” as defined in the new Title IX regulations. After all, some would argue, such a policy could be “subjectively and objectively offensive and . . . so severe or pervasive that it limits or denies a person’s ability to participate in or benefit from the recipient’s education program or activity.” Indeed, though the regulatory update goes into effect in August, the Office for Civil Rights has already cited this rationale to launch an investigation against a school district for its parental-notification policy.

The Biden administration, in its Title IX guidance and elsewhere, has stretched the term “abuse” beyond its obvious connotation to include failing to “affirm” a child’s gender identity. Proponents of the administration’s position claim that trans-identified students are at high risk of rejection and could face abuse at home if they are “outed” to their families, but we’ve noted serious problems with this argument. In effect, so has England’s National Health Service, which recommended last September that fit parents should always be involved in the decision-making process regarding social transition in school.

Indeed, mental-health outcomes for gender-distressed youth are better when they have supportive relationships with their family. “Outcomes for children and adolescents are best,” Cass writes, “if they are in a supportive relationship with their family. For this reason parents should be actively involved in decision making unless there are strong grounds to believe that this may put the child or young person at risk.” Secret social-transition policies—which Parents Defending Education estimates are in effect in 18,878 schools in the United States, affecting close to 11 million students—establish an adversarial dynamic between parents and children.

The Cass Review contrasts an “evidence-based” approach to managing gender-related confusion and distress with a “social justice model,” in which considerations of evidence are secondary to political goals. The Biden administration’s Title IX rules, which subordinate the interests of vulnerable children to those of powerful interest groups in the Democratic coalition, clearly belong in the second category. 

My name is Dr Jill Simons. I'm a board-certified pediatrician and the executive director for the American College of Pediatricians. Today I'm here alongside my colleagues representing the Coalition of co-signers of the Doctors Protecting Children Declaration. Our coalition consists of physicians together with nurses, behavioral health clinicians, other health professionals, scientists, researchers and public health and policy professionals. And we have serious concerns about the physical and mental health effects of the current protocols promoted for the care of children and adolescents in the United States who express discomfort with their biological sex.

This declaration was authored by the American College of Pediatricians, but really it was developed from the expertise of hundreds of doctors researchers and other healthcare workers and leaders wh, for years have been sounding the alarm on the harmful protocols that continue to be promoted by the medical organizations in the United States. Despite recent revelations from the leaked WPATH Files and the recent release of the final report from the Cass Review, these medical organizations have not changed course.

So, we are calling on these medical organizations of the United States, including the American Academy of Pediatrics, the Endocrine Society, the Pediatric Endocrine Society, the American Medical Association, the American Psychological Association and the American Academy of Child and Adolescent Psychiatry to follow the science and their European colleagues and immediately stop the promotion of social affirmation, puberty blockers, cross-sex hormones and surgeries for children and adolescents who experience distress over their biological sex.

In our declaration, we affirm that sex is a dimorphic, innate trait defined in relation to an organism's biological role in reproduction: male and female this genetic signature is present in every nucleated somatic cell in the body and is not altered by drugs or surgical interventions. Consideration of these innate differences is critical to the practice of good medicine and to the development of sound policy for children and adults alike. Medical decision-making should be based upon an individual's biological sex. It should respect biological reality and the dignity of the person by compassionately addressing the whole person.

We are here defying the claims made by these medical organizations in the US that those of us who are concerned are a minority and that their protocols are consensus. They are not consensus, and we are speaking in a loud unified voice: enough.

Doctors Protecting Children Declaration SIGN THE DECLARATION "Therefore, given the recent research and the revelations of the har

Doctors Protecting Children

• Desistance is the norm without affirmation as documented by Zucker in his article “The Myth of Peristence”. (1) Zucker, KJ. The myth of persistence: Response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender nonconforming children” by Temple Newhook et al. International Journal of Transgenderism. 2018: 19(2), 231–245. Published online May 29, 2018.http://doi.org/10.1080/15532739.2018.1468293 [1]
• In the “largest sample to date of boys clinic-referred for gender dysphoria,” there was a desistance rate of 87.8%. (2) Singh D, Bradley SJ and Zucker KJ. A Follow-Up Study of Boys With Gender Identity Disorder. Front Psychiatry. 2021;12:632784. doi: 10.3389/fpsyt.2021.632784
• The pro-affirmation Endocrine Society Guidelines (2017) admit: “…the GD/gender incongruence of a minority of prepubertal children appears to persist in adolescence.” (3) Hembree, W., Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline J Clin Endocrinol Metab. 2017; 102:1–35.
• A longitudinal study from the University of Groningen in the Netherlands followed 2772 adolescents (recruited from a psychiatric clinic) from age 11 years through 22 – 26 years. “In early adolescence 11% of participants reported gender non- contentedness. The prevalence decreased with age and was 4% at the last follow-up (around age 26).” Even in this psychiatric patient study group for which interventions were not addressed, but “gender affirmation” is most likely, gender non-contentedness (essentially gender noncongruence) decreased substantially from early adolescence to young adulthood.(4) Rawee P, Rosmalen JGM, Kalverdiijk L and Burke SM. Development of gender non-contentedness during adolescence and early adulthood. Archives of Sexual Behavior. 2024; https://doi.org/10.1007/s10508-024-02817-5

• The two Dutch studies that form the foundation for treatment guidelines as documented in the WPATH “Standards of Care” guidelines version 7 (SOC 7) had serious flaws.[3]
• These studies did show that the appearance of secondary sex characteristics in adolescents and young adults could be changed by hormonal and surgical interventions, but they failed to demonstrate meaningful long-term improvement in psychological well-being.
• Scientific concerns with these studies also include a lack of a control group, small sample sizes, significant numbers of patients lost to follow up, and the elimination of patients who experienced significant mental illness from entering the studies.
• It is concerning that the Dutch studies did not address complications and adverse outcome in the adolescent cohort that underwent transition. These complications included new onset diabetes, obesity and one death.[4]

• The Cass Review was released on April 10, 2024, as an “independent review of gender identity services for children and young people”. The following points are from Cass’s final report:[5]
• Commissioned by the National Health Service (NHS) England, and chaired by Dr. Hilary Cass, the 388-page report utilized systematic reviews, qualitative and quantitative research, as well as focus groups, roundtables and interviews with international clinicians and policy makers.
• As part of the evaluation, they reviewed the research on social transition, puberty blockers, and cross-sex hormones.
• Social transition
• “The systematic review showed no clear evidence that social transition in childhood has any positive or negative mental health outcomes, and relatively weak evidence for any effect in adolescence.
• However, those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway.”
• Puberty blockers
• “The systematic review undertaken by the University of York found multiple studies demonstrating that puberty blockers exert their intended effect in suppressing puberty, and also that bone density is compromised during puberty suppression. However, no changes in gender dysphoria or body satisfaction were demonstrated [emphasis added].”
• “There was insufficient/inconsistent evidence about the effects of puberty suppression on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk or fertility.”
• “Moreover, given that the vast majority of young people started on puberty blockers proceed from puberty blockers to masculinizing/ feminizing hormones, there is no evidence that puberty blockers buy time to think, and some concern that they may change the trajectory of psychosexual and gender identity development.”
• Cross-sex hormones
• “The University of York carried out a systematic review of outcomes of masculinising/feminising hormones.” They concluded, “There is a lack of high-quality research assessing the outcomes of hormone interventions in adolescents with gender dysphoria/incongruence, and few studies that undertake long-term follow-up. No conclusions can be drawn about the effect on gender dysphoria, body satisfaction, psychosocial health, cognitive development, or fertility.”
• “Uncertainty remains about the outcomes for height/growth, cardio-metabolic and bone health.”
• The Cass Review further stated, “Assessing whether a hormone pathway is indicated is challenging. A formal diagnosis of gender dysphoria is frequently cited as a prerequisite for accessing hormone treatment. However, it is not reliably predictive of whether that young person will have longstanding gender incongruence in the future, or whether medical intervention will be the best option for them.”
• A 2024 German systematic review on the evidence for use of puberty blockers (PB) and cross-sex hormones (CSH) in minors with gender dysphoria (GD) also found “The available evidence on the use of PB and CSH in minors with GD is very limited and based on only a few studies with small numbers, and these studies have problematic methodology and quality. There also is a lack of adequate and meaningful long-term studies. Current evidence doesn’t suggest that GD symptoms and mental health significantly improve when PB or CSH are used in minors with GD.”[6]  

• Youth who are socially affirmed are more likely to progress to using puberty blockers and cross-sex (masculinizing or feminizing) hormones.
• “Social transition is associated with the persistence of gender dysphoria as a child progresses into adolescence.”[7]
• “Gender social transition of prepubertal children will increase dramatically the rate of gender dysphoria persistence when compared to follow-up studies of children with gender dysphoria who did not receive this type of psychosocial intervention and, oddly enough, might be characterized as iatrogenic.”[8]
• Puberty blockers permanently disrupt physical, cognitive, emotional and social development.
• Side effects listed in the Lupron package insert include emotional lability, worsening psychological illness, low bone density, impaired memory, and the rare side-effect of pseudotumor cerebri (brain swelling).[9]
• A coalition of physicians and medical organizations from around the world submitted a petition to the Commissioner of the U.S. Food and Drug Administration requesting urgent action be taken to eliminate the off-label use of GnRH (growth hormone) agonists in children.[10]
• Testosterone use in females and estrogen use in males are associated with dangerous health risks across the lifespan including, but not limited to, cardiovascular disease, high blood pressure, heart attacks, blood clots, stroke, diabetes, and cancer.[xi],[12]
• Genital surgeries affect future fertility and reproduction.

• “The WPATH Files reveal that the organization does not meet the standards of evidence-based medicine, and members frequently discuss improvising treatments as they go along.”
• “Members are fully aware that children and adolescents cannot comprehend the lifelong consequences of ‘gender-affirming care’ and, in some cases due to poor health literacy, neither can their parents.”
• In addition, developmentally challenged and mentally ill individuals were being encouraged to “transition”, and treatments were often improvised.

• The constitution of the National Health Service in England will be updated to state, “We are defining sex as biological sex.”[15]
• The European Society of Child and Adolescent Psychiatry issued a document titled “ESCAP statement on the care for children and adolescents with gender dysphoria: an urgent need for safeguarding clinical, scientific, and ethical standards.”
• In this paper, they stated, “The standards of evidence-based medicine must ensure the best and safest possible care for each individual in this highly vulnerable group of children and adolescents. As such, ESCAP calls for healthcare providers not to promote experimental and unnecessarily invasive treatments with unproven psycho-social effects and, therefore, to adhere to the “primum-nil-nocere” (first, do no harm) principle”.[16]

• In a letter to the British newspaper, The Guardian, sixteen psychologists, some of whom worked at the Tavistock Center for Gender Identity Development Service, acknowledged the role clinical psychologists played in placing children on an “irreversible medical pathway that in most cases was inappropriate.”[17]
• In the United States, a group of psychiatrists, physicians and other health care workers wrote an open Letter to the American Psychiatric Association (APA), calling on the APA to explain why it glaringly ignored many scientific developments in gender-related care and to consider its responsibility to promote and protect patients’ safety, mental and physical health.[18]

• The American Psychological Association states it is the largest association of psychologists worldwide. The organization released a policy statement in February 2024 stating, “The APA opposes state bans on gender-affirming care, which are contrary to the principles of evidence-based healthcare, human rights, and social justice.”[19]
• The Endocrine Society responded to the Cass Review by reaffirming their stance. “We stand firm in our support of gender-affirming care…. NHS England’s recent report, the Cass Review, does not contain any new research that would contradict the recommendations made in our Clinical Practice Guideline on gender-affirming care.”[20]
• The American Academy of Pediatrics (AAP) Board of Directors in August 2023, voted to reaffirm their 2018 policy statement on gender-affirming care. They did decide to authorize a systematic review but only because they were concerned “about restrictions to access to health care with bans on gender-affirming care in more than 20 states.”[21]
• Of note, Dr. Hilary Cass called out the AAP for “holding on to a position that is now demonstrated to be out of date by multiple systematic reviews.”[22]

The Pride movement has nothing to be proud of

The LGBT lobby has betrayed gay youngsters in the name of gender ideology.

spiked-online.com

This year’s Pride Month has rarely seemed so pointless. After all, only the truly shameless in the LGBT activist set could feel any pride in 2024 – a year in which the rainbow-flag fliers’ betrayal of gay youngsters in the name of gender ideology was laid bare.

The publication of the Cass Review in April exposed the scandal of the NHS’s treatment of ‘gender confused’ kids. It showed how the NHS’s Gender Identity Development Services (GIDS) subjected troubled, often gay youngsters to life-altering hormones, drugs and treatments. Yet when these same-sex-attracted young people needed a gay movement, it failed them. Stonewall, its principal representative, actively cheered on those encouraging gay youngsters to believe they were born in the wrong body. Former Stonewall CEO Ruth Hunt even warned parents that half their gender-distressed children would commit suicide without puberty blockers. At the same time, leading sections of the gay movement turned on anyone questioning the trans agenda.

You won’t see any reflection on this betrayal of gays and lesbians during Pride Month. There will be no recognition that by embracing gender ideology, the gay-rights movement of today has undermined the gay rights of tomorrow. Instead, an unholy alliance of corporates, trade unions and parading gendercrats will spend weeks celebrating their supposed virtue, while remaining oblivious to the absurdity and growing unpopularity of the movement they represent.

Don’t let the ubiquitous Pride flag fool you over the coming weeks into thinking this is a successful movement. How strong can a ‘gay rights’ movement be if it has allowed its next generation to be chemically castrated? How strong can a movement be that has allowed lesbians like Kathleen Stock or Julie Bindel to be deplatformed, harassed and sacked for standing up to gender ideology?

The new ‘Progress Pride’ flag tells the story of the movement’s corruption. A new trans chevron makes an ugly incursion from the left, with an ‘intersex-inclusive’ purple circle placed on top of it (despite some intersex activists asking not to be included). This is more of a logo now and less of a flag. It symbolises the hostile takeover of the gay-rights movement by gender-identity ideology.

Pride was once our answer to shame. The riposte to being kicked out of your home for coming out. The retort to everyday incidents of homophobia, which are now thankfully a thing of the past in the UK and the West.

Today’s Pride is different. It is not a response to a sense of shame. It is a false pride born of shamelessness. A pride fuelled by the self-righteous embrace of the cause of trans rights. Think of Stonewall CEO Nancy Kelley calling lesbians ‘sexual racists’ in 2021 for not wanting to have sex with biological males. Think of those happily suppressing moderate gay voices for warning that ‘conversion-therapy bans’ simply criminalise ordinary therapy for gender-confused youth. Or how Stonewall did everything in its power to hound gender-critical barrister Allison Bailey out of a job.

If one must take pride in anything during Pride Month, I prefer to find it in the spirited and steadfast work of women and gay people in the UK who, against all the odds, have taken on gender ideology and its champions within the gay movement. Organisations like LGB Alliance and the Gay Men’s Network, which I direct, have done sterling work in defending gay rights from the predations of gender ideology. It has been tough. We have had to battle against an elite consensus. It wasn’t that long ago that both Theresa May and, later, Sir Keir Starmer were promising Pink News that gender self-identification would become law. Now, in part thanks to the efforts of gay-rights activists and gender-critical feminists, the sitting and shadow secretaries of state for health and social care are committed to implementing the findings of the Cass Review.

Pride, the holy month of the rainbow, is now a thoroughly rudderless affair. Its foolish embrace of the specious cause of trans rights has cost it dear. This increasingly silly party now takes place against the backdrop of a generation-defining medical scandal that Pride and its backers endorsed. Even Stonewall seems cowed. It certainly seems less keen to pronounce that transing a two-year-old is a good idea than it was just a few years ago.

Pride should parade its way into irrelevance. The gay-rights activism of the future will need to look very different.

Dennis Kavanagh is a director of Gay Men’s Network.

Eager to ‘Affirm,’ Yet Unwilling to Debate

A prominent South Carolina doctor and transgender rights activist has made a great show of calling England’s Cass Review “a sham at best”—bu

Quillette

In April, Dr Hilary Cass, a former president of Britain’s Royal College of Paediatrics and Child Health, published the most comprehensive scientific analysis of paediatric sex-trait modification procedures to date. These procedures, often described as components of “gender-affirming care” (GAC), serve to align a child’s physical features with his or her claimed “gender identity” through (typically irreversible) hormone regimes and surgeries, which often lead to sterility and other serious medical side effects. The Cass Review, as it is commonly known, reported that the evidence base supporting the use of such procedures was “remarkably weak.” Moreover, while it’s been widely claimed that hormone treatments reduce the elevated risk of death by suicide among trans-identified children, Dr Cass found that the available evidence “did not support this conclusion.”

The response to Dr Cass’s findings has been dramatic. England’s National Health Service, which commissioned the report, expressed gratitude to Dr Cass and committed to implementing her recommendations. These include prioritising psychotherapy for gender-distressed youth, and phasing out the use of puberty blockers as part of England’s publicly funded healthcare system. Following the publication of the Cass Review, Scotland and Wales joined numerous other European jurisdictions—many of which have conducted their own reviews, and reached similar conclusions—in restricting the use of puberty blockers and cross-sex hormones to treat minors. Several international bodies have also issued policy statements praising the Cass Review for its thoroughness and lack of bias.

However, while these international authorities are reforming their policies in accordance with the latest scientific evidence, medical organisations in North America have generally remained steadfast in their support of GAC. The American Academy of Pediatrics and the Endocrine Society, for instance, both recently issued statements defending their support of GAC practices as “grounded in evidence and science,” and “based on a thorough review of medical evidence, author expertise, rigorous scientific review, and a transparent process.”

Despite these assertions, however, no major medical organisation or scientific publication has (to my knowledge) published a detailed rebuttal of the findings contained in the Cass Review. The only ostensible exception is an article from the International Journal of Transgender Health‚ the official journal of the World Professional Association for Transgender Health (WPATH), whose author, Cal Horton, is a self-described “researcher & intersectional feminist… upholding a defiantly non-binary reality (they/them),” as well as a “specialis[t] in trans inclusion and Applied Trans Studies.” By means of what is grandly presented as a qualitative “inductive and deductive reflexive thematic analysis,” the author denounces the Cass Review as “an example of cis-supremacy, within a cis-dominant healthcare system lacking accountability to trans communities.” Interpret that as you will.

As the global trend shifts away from “gender-affirming care,” one might expect that proponents of GAC would be eager to publicly defend their practices, and to set out the facts and arguments that, as they see it, Dr Cass and her many international counterparts have ignored or misinterpreted. Specifically, one might imagine that they’d revisit the policy of “no debate” that has long been enforced within the trans activist community (typically on the stated grounds that the very act of debate would serve to invalidate, or even threaten, the existence of transgender individuals).

And yet, this hasn’t happened. Just the opposite: It appears that the definitive nature of Dr Cass’s report has caused defenders of GAC to become even more skittish about publicly defending their practices.

Last week on X (formerly known as Twitter), South Carolina-based doctor Michael O’Brien dismissed the Cass Review as a “sham.” As a paediatrician and outspoken advocate of GAC who’s made a name for himself on X by aggressively criticising anyone expressing divergent views, he may be fairly described as an influential American voice when it comes to treating gender-distressed youth—and therefore a worthy candidate for inclusion in any debate on the subject.

Following Dr. O’Brien’s outburst, I joined with my Manhattan Institute colleague Dr Leor Sapir, a gender-medicine expert, in inviting Dr O’Brien to participate in a good-faith scientific exchange on my Substack, Reality’s Last Stand, which provides regular editorial coverage of the issues Dr Cass examined. We offered to donate $250 to a children’s hospital of Dr O’Brien’s choice if he agreed to participate in the discussion. Our hope was that he would elaborate on his claim that Dr Cass had produced a “sham,” complete with data and scientific citations.

Dr O’Brien responded as follows: “I help kids and families with shared, evidence-based, complex medical decisions. [Dr Sapir is] a non-expert corporate pawn looking to make a quick buck. My answer is: f*** no.” He then blocked us both from seeing any of his future posts, and continued to justify his refusal to engage in the discussion on the grounds that it would somehow benefit us financially. (Since this time, Dr O’Brien has switched his X account to protected mode.)

This effort at deflection is nonsensical for several reasons. Firstly, as noted above, Dr Sapir and I had each pledged $250 of our own money to a children’s hospital in return for his participation. Secondly, I promised that the written debate would not be published behind a paywall, so as to ensure it received the largest possible audience without providing me with any direct financial benefit. I also indicated that I would donate any incidental revenue from new Substack subscriptions, as well as donations related to the debate, to the children’s hospital of Dr O’Brien’s choice. 

As our public exchange garnered attention, other X users started making their own financial pledges to encourage scientific debate on this issue. Dr Eithan Haim, a Dallas-based surgeon, pledged $500, for instance. Dr Emma Hilton, a developmental biologist at the University of Manchester (and Quillette author), pledged £100.

As I saw this as an important opportunity to open up a dialogue on this subject, in defiance of trans activists’ oddly dogmatic “no debate” policy, I even started a GoFundMe campaign to raise funds for the children’s hospital of Dr O’Brien’s choosing. The stated condition was clear, however: Dr O’Brien would provide a detailed critique of the Cass Review, outlining his reasons for dismissing it as “a sham at best,” and engage with at least one rebuttal from Dr Sapir.

Launched on 23 May, the GoFundMe campaign attracted more than $5,000 in pledges in just two hours. By the morning of the 24th, contributions had exceeded $10,000. That evening, a surprise $5,000 donation from J.K. Rowling, coupled with her encouragement to others to contribute, propelled the total beyond $20,000. On 29 May, we reached our goal of $30,000.

That’s over $30,000 to a children’s hospital of Dr O’Brien’s choice if this paediatrician agrees to engage in a scientific discussion about the Cass Review and GAC—a discussion that one might expect Dr O’Brien to regard as an urgent imperative given his fervent advocacy of GAC, his (presumably informed) opinion that the Cass Review is “a sham,” and his (presumed) fear that “trans kids” (as he describes them) are at mortal risk of being denied GAC on the basis of Dr Hilary Cass’s views. Assuming Dr O’Brien is able to debunk the Cass Review (in keeping with his sweeping denunciation of its validity), what would be the downside—for him or anyone else?

Although the fundraiser has garnered significant attention (one presumes he is familiar with Rowling as both an author and advocate), Dr O’Brien has yet to revisit his previously stated refusal to participate. Alas, today I will therefore be forced to refund over $30,000 in donations that would otherwise go to a children’s hospital so that children of all types, including those “trans kids” Dr O’Brien purports to care so deeply about, can receive better medical care. To do otherwise would violate the representations I made as part of the GoFundMe campaign.

However, I strongly encourage donors to consider personally reallocating their contributions to a children’s hospital of their choice—or to one of several organisations working diligently to inform doctors, parents, and policymakers about the risks associated with GAC. Among the organisations leading these efforts are the LGBT Courage Coalition, the Society for Evidence-Based Gender Medicine, Genspect, Do No Harm, and Therapy First.

I believe that all children and adolescents, gender-distressed or otherwise, deserve evidence-based care. And I’m sure Dr O’Brien shares this goal. I hope that this fundraiser will prompt gender-affirming doctors to reassess the logic of their extreme “no debate” policy, and ultimately abandon it. Open discussion of the science is the only way to ensure children receive the evidence-based care they need and deserve.

Trans activism is holding proper health care to ransom after Cass Rev…

archive.ph

The Cass Review of gender medicine in England, released this week, captures a medical establishment waking up to a major scandal.

Thousands of transgender and gender-questioning English children have been exposed to harmful interventions under the medical treatment model called “gender-affirming care”.

This failure was caused by medical authorities who abandoned traditional safeguards in the face of pressure from international trans activist groups. Many other countries are now starting to acknowledge similar failures, led by Sweden and Finland.

Gender confusion is a normal part of adolescence that is likely to resolve without treatment in the overwhelming majority of cases. The gender-affirming care described in the review trapped gender-confused kids on a treadmill from which few escaped, leading from social transition, through puberty blockers, to hormone treatment and surgery in many cases.

As widely publicised when puberty blockers were banned in England a few weeks ago, these treatments have significant side-effects, including fractured bones, infertility and severe sexual dysfunction, which can be lifelong.

Cass makes it impossible for Australian authorities to continue to ignore warnings that Aussie kids and their families face the same systemic problems and clinical risks the English, Swedes and Finns are now scrambling to correct.

The explosive growth in gender-questioning patients and gender-affirming services in Australia closely retraces the English trajectory. But we started a few years later, so there is time to learn from England’s mistakes.

English medical authorities were forced to awaken by years of testimony from clinical whistleblowers, traumatised patients, and their families. The Cass Review followed books, media attention and legal cases, describing a health service heavily influenced by trans activist groups who infiltrated clinical units as patient advocates and supports.

Health staff reported they felt pressured to ignore signs of medical and mental illness in order to focus exclusively on gender, a process called diagnostic overshadowing. Even more damning, Cass reveals that gender-affirming providers ignored their own research, rapidly expanding access to dangerous medications such as puberty blockers even after finding there were no benefits.

The usual health system safeguards failed to detect this violation of the first principle of medicine: do no harm. Instead, problems were only identified because individual patients and staff had the courage to speak out over strong social and bureaucratic pressure to remain silent.

As well as ignoring their own research, English gender services actively refused to co-operate with official efforts to analyse existing data. This prevented investigators from getting a better picture of who was being treated, what was being done to them, and what the outcomes were.

While speculative, it seems unlikely that services would have refused to participate in research if they were confident it would show patients were significantly more helped than harmed by gender-affirming treatment.

Although these advance warnings should be good news for the health and safety of gender-questioning Australian kids and their families, our gender services do not seem to be listening. Instead, in many cases, they are making up for lost time by implementing more aggressive versions of the practices being shut down in England because of risks to patients.

For example, the Cass Review explicitly identifies “informed consent” models, similar to one being rolled out in Victoria, as incompatible with responsible medical practice. This type of model is grounded in political activist theory more than medicine. It views assessment of the gender identity of gender-confused teens as an illegitimate form of “gatekeeping” designed to control patient behaviour, instead of a medical safeguard protecting their health.

Under this model the doctor’s only role is to confirm that patients understand proposed treatments. Once confirmed, doctors must deliver any treatment the patient requests, without further assessment.

This contradicts the traditional medical approach, in which a comprehensive assessment, including the assessment of gender identity, is a non-negotiable feature of competent and ethical treatment of gender dysphoria. Even more concerning is that the “informed consent” model in Victoria is reportedly being extended to allow GPs to medicate transgender kids without specialists, going well beyond the safe limits recommended by Cass.

It may seem strange that Australia’s gender services are so keen to implement and go beyond risky treatments being shut down all over the world, but it is consistent with what is known about the gender-affirming care movement. This is a well-organised, well-funded international network of clinicians and activists committed to advancing a specific agenda.

Those interested in the details should seek out the report compiled by publisher Thomson-Reuters for gay rights organisation iglyo in 2019 called Only Adults?

In brief, the report compares international efforts to overcome strong public dislike of trans activist goals such as legislation enshrining the right to unconstrained gender self-identification in law, replacing biological sex with gender as the basis of legal rights, and the elimination of barriers such as lower age limits for non-traditional gender identities and treatments.

Based on case studies across Europe, the report recommends trans activists take a strategic approach to achieve their goals. Reflecting on evidence that increased public awareness of trans ideology tends to increase public resistance to it, the report recommends avoiding scrutiny by limiting contact with media and focusing efforts on influencing key decision-makers rather than attempting to change public opinion.

A core part of the strategy relies on establishing gender self-identification legislation as a legal foot in the door that can be leveraged to achieve many other trans activist goals.

The stakes are high, and not just for trans people. A case in Federal Court this week provides a perfect example, where a woman, Sally Grover, is defending her right to define for herself what a woman-only space means. The other party is a transgender woman, Roxanne Tickle, who is effectively claiming transgender women should have all the same rights as biological women, and be able to enforce those rights in court.

The rapid expansion of gender-affirming care, despite the limited evidence of benefits and the certain knowledge of harms, is consistent with this type of strategy. High-quality healthcare relies upon the integrity of the medical authorities who write the blueprints used by hospitals and health services to build their clinical services. This can work very well when the blueprints are written by independent experts who exercise methodological rigour focused purely on patient health outcomes. It can be deeply problematic when the small committees that write the blueprints are co-opted by people with ulterior motives.

Unfortunately, as confirmed by the Cass Review, the blueprints used to create gender services in Australia (endorsed by the WPATH and AusPATH organisations) scored very low on both methodological rigour (26 per cent and 19 per cent respectively) and editorial independence (17 per cent and 14 per cent).

Close examination of these blueprints suggests the primary goal of gender-affirming care in Australia is not to improve the health of gender-confused kids but to ensure they have the right to gender self-identification, and that public health services affirm that identity with support, resources, and medical and surgical interventions.

The rapid expansion of gender-affirming care to increasing numbers of gender-confused kids in Australia, despite the gaps in knowledge, represents a significant failure of leadership. While the reflex is often to blame politicians for systemic failures, medicine’s claim to expert authority in matters of health suggests political solutions will not be possible until the medical profession in Australia follows England’s lead and initiates a comprehensive review of gender medicine.

Why the Medical Profession Abandoned Good Practice for the Depathologization Movement

Guilt over the pathologization of homosexuality led psychiatrists to turn a blind eye to the failures of "gender-affirming care"

genspect.substack.com

It often takes many years before strongly positive research findings are incorporated into practice. … Quite the reverse happened in the field of gender care for children.

• Why did gender services expand so rapidly despite the lack of evidence that they would benefit patients?
• Who were the decision-makers who endorsed the creation and expansion of gender services?
• What additional safeguards are necessary to ensure that medical decision-makers are not influenced by political goals?

Support for Stonewall crumbles after Cass review

The LGBT rights charity has come under intense scrutiny for its stance on trans rights, with the NHS and other public bodies reviewing their

thetimes.co.uk

A decade ago, as same-sex marriage became legal, Stonewall was riding high.

Lauded for its key role in pushing for equal rights and campaigning prowess, it was helping government departments and schools expand their diversity offering and become more welcoming to all.

Now, the NHS has distanced itself and other public bodies are reviewing their associations with the charity, as the fallout from a landmark report on gender identity shines a spotlight on the organisation.

Stonewall, Britain’s most well-known LGBT rights charity, has come under intense scrutiny for its stance on trans rights since the publication of the report by Dr Hilary Cass.

Campaigning for transgender people became a key part of Stonewall’s offering from 2015, including backing the prescription of “puberty blockers” for transgender teenagers.

The Times revealed last week that the charity had tried to suppress early warnings to schools about the shaky evidence base, telling teachers to shred a resource pack which highlighted potential dangers.

But Cass found that children experiencing gender distress and wanting to transition had been let down by a lack of research and “remarkably weak” evidence on medical interventions.

She said studies had been “exaggerated or misrepresented by people on all sides of the debate to support their viewpoint” and there was a “toxicity” in discussions, with young people being caught in “stormy social discourse”.

Critics have put some of the blame for that at Stonewall’s door.

Baroness Hunt of Bethnal Green, who ran Stonewall between 2014 and 2019, said in an interview with The Times that she had never attempted to shut down debate and that her only regret was trusting the “experts”. She said she did not recognise the characterisation of Stonewall as being a bullying campaign group.

But one source close to the charity said it was Stonewall’s increasing stance of “demanding” change rather than campaigning and enabling progress to be made that had caused issues.

They said: “What Stonewall does now is ‘we demand you agree with this, we demand you agree with that, we demand the next thing’, and it just doesn’t enable that bigger principle which is ‘what support should we be giving to some young people and vulnerable young adults so that they can make the best decisions for their life?’”

They added: “Some people think it shouldn’t be campaigning on trans rights at all, I think that’s up to it and that’s not my point. My point is that actually it just didn’t build broad alliances and it absolutely did no debate.”

Responding to the report, Stonewall said Cass’s recommendations could “make a positive impact” if implemented properly.

But in a review of the recommendations published on Thursday it said hormones and puberty blockers should still be prescribed to children and young people in a “timely manner” — against Cass’s recommendations — if supported by a medical practitioner. In a sign that the charity’s influence is waning, The Times understands NHS England has distanced itself from the organisation, cancelling conference tickets and a planned membership of the charity’s Diversity Champions Scheme.

An NHS spokesperson said: “After consideration, NHS England took the decision to not renew its membership with Stonewall last year.”

Other quangos which The Times revealed last month had kept their memberships, despite a government diktat to withdraw from the scheme, are now reviewing their associations.

Sport England had been part of the Diversity Champions Scheme, which brought in £3.9 million for Stonewall last year. But a spokesman told The Times: “We have reviewed the partnership and Sport England will not be renewing membership.

“As a public body which scrutinises how we spend every penny of public funds, this decision has been taken with value for money as our primary concern.”

Historic England had also paid £3,000 a year for the scheme. It said it was also reviewing whether to renew its membership “based on a value-for-money test” with the Stonewall partnership due to end this month.

Arts Council England, which had a three-month membership which ended in October, is also no longer part of the scheme.

Other government departments have also withdrawn from the scheme over the years, and Kemi Badenoch, the women and equalities minister, said last year: “We have engaged with numerous LGBT groups, but the fact of the matter is that many of them support self-ID.

“That is not this government’s policy. Stonewall does not decide the law in this country.”

A government source added: “Stonewall has gone from being a leading civil rights organisation, to the leading pusher of the dangerous trans ideology that led to the outrageous events documented in the Cass Review.”

They said the government had “made it clear that Stonewall’s divisive schemes aren’t welcome in Whitehall” but that some arms-length bodies and civil society groups still handed over funds. “This needs to stop,” they said.

Stonewall was contacted for comment.