The Cass Review: Still Not a Silver Bullet

The Cass Review is an investigation into the UK National Health Service treatment of adolescents diagnosed with gender dysphoria. It was released in early April and recommends a strict restriction on the prescription of puberty blockers while calling into question the idea of medicalization generally. It was conducted by renowned UK pediatrician Hillary Cass. I have been reluctant to write on it because I knew that I wouldn't read it. My impulse was to recommend taking The WPATH Files: Another Beginning of the End?, replacing every mention of WPATH Files with The Cass Review. Although every detail would be wrong, the conclusion would remain. "The sterilization of children will not end because of more and better information, although that is critical. It will only end when the concept of gender is destroyed, thoroughly and completely." There have already been multiple systematic reviews of the evidence for treating the diagnosis of gender dysphoria with synthetic hormones. All make clear that there is no high quality evidence to support treating a psych disorder by cosmetically changing the body. None have impacted the distribution of puberty blockers and hormones outside the countries where the reviews have taken place. None have stopped the practice altogether in their home country. Although they all restrict the use of puberty blockers, not one prohibits them outright. All the reviews leave open the possibility that there may be children who would benefit from having their puberty stopped. This remains the largest issue with this avenue to stopping adolescent transition. 

Since I am not a medical professional, I am not supposed to say that there is no evidence to support what is called medical transition, but there isn't. I would love to be proved wrong. It would make the concept less monstrous and evil. I won't be, and you don't need medical training to know why. Rather than start with the assumption that there might be a medical, rather than psychological need behind what is called gender dysphoria, start with the question of what it is. What exactly is being treated in this cohort of adolescents that calls for a collective diagnosis or protocol? From my understanding, the delivery of medical treatment is meant to be individualized. Yet, inexplicably, the treatment for every child diagnosed or self-diagnosed with gender dysphoria is the same. If adolescents are given a treatment with no differentiation one would expect that, at least, the condition being treated was exactly the same pathology in everyone receiving the treatment. However, unlike an illness like leukemia or even schizophrenia, the origins and progression of gender dysphoria is so individual that it is questionable if two individuals with the same diagnosis are experiencing the same pathology. For example, individuals who found that transition failed to help them realized that what they had diagnosed as dysphoria was actually autism, OCD, internalized homophobia, trauma from abuse or other issues.

The problem is that the diagnosis frames the discord as between the self concept of the individual and his sexed body, when the issue is between his self concept and the social expectations he assumes of his sexed body. The clue is in the diagnosis itself, humans don't have a gender, society does. If a girl likes trucks, that desire is inherent to her. The idea that liking trucks is typically masculine or that it makes her a boy is a lesson only learned from her society. Based on this alone we should prohibit any physical treatment of individuals on the basis of this discord. Based on what we have known for years, these treatments, especially for adolescents, should be viewed as unethical to the point of criminal. We know that the vast majority of adolescents internalizing discord with their bodies grow out of that discord through the process of puberty. We also know that long term studies have shown that suicide increases with each stage of transition, making it the opposite of healthcare. What makes this worse is that adolescent transition only started because the results for adults was so poor. Rather than question their assumption that modifying the body would address psychological distress, they decided the problem was the failure of adults to pass as the opposite sex and they needed to modify the body sooner. Starting with the androgynous adolescent body would make it easier to appear as the opposite sex. Despite what they bring to the conversation, this speaks to the inherent weakness of The Cass Review and the Swedish and Finnish reviews before it. They all keep alive the possibility that there might be children who would benefit from having their puberty blocked because each sought evidence for a broken premise, rather than use their evidence to question the underlying premise.

Knowing that the vast majority of children experiencing discord with their body grow out of it with puberty, what would be the clear marker of a child that would benefit from skipping puberty for an entirely aesthetic effect? Would it cause more damage to a child who continues to feel discord to go through puberty and full development, or induce the equivalent of an endocrine disorder that increases the risk of osteoporosis, stroke, heart attack and cancer? Is it better to treat a child for "gender dysphoria" or the direct cause of discord with his body, whether autism, anorexia, or past abuse? Is gender dysphoria useful as a diagnosis or is it iatrogenic, and induced in the patient through the association of multiple pathologies as gender dysphoria? If a review started with these questions it would never conclude that puberty blockers should only be administered in a trial. It would conclude that they should not be administered at all.

The Cass Review started by looking at the evidence behind adolescent medical transition because it had been administered through the NHS without evidence. Cass was thorough, careful, and narrowly focused on the question of evidence. It took four years to complete. The activists attacked it as political and called it harmful to trans children without reading a word of it. They understand clearly that adolescent transition is not about evidence. If it was, it would never have begun. The people who want to stop the sterilization of children and see the Cass Review as another silver bullet should heed the example of the activists. That which was started absent evidence can only be stopped through amassed political power. Stopping adolescent sterilization means prohibiting the practice, instituting direct punishment for unethical doctors performing it, extending the statute of limitations for medical malpractice, and making medical associations liable for best practices promoted counter to the evidence. There is no need to review evidence to support these goals.