Dr. Hilary Cass
Appearances
The Protocol
The Review
I mean, let me put a hypothetical situation to you that you're a girl in early puberty who may be struggling with their sexual identity, who may have been anxious about some of the things they've seen in terms of early access to pornography, doesn't fit in socially, doesn't feel that they're meeting the sort of social media stereotypes that are expected of girls and puberty feels pretty hideous.
The Protocol
The Review
And then somebody stops the puberty. I think you may well feel a huge sense of relief and a temporary improvement in your mental health just because you've taken that away. But is that necessarily the right pathway for addressing those things or are there other ways? So, yes, you might see a temporary improvement there.
The Protocol
The Review
But we need to know what it is that you're treating and whether to some extent we're treating the normal anxieties of puberty in some of these young people. So yes, you can put someone on a medical pathway, but if at the end of it they can't get out of their bedroom, they don't have relationships, they're not in school or in work, you know, you haven't done the right thing by them.
The Protocol
The Review
Peggy Cohen-Katenis, who first thought about this, her first thought was that young trans adults were doing poorly because they couldn't pass in adulthood, because particularly if you've gone through a male puberty, it can be really difficult to pass in later life. And so that was her first thought as to why one should do this. And her second thought was that it might buy time to think. Now...
The Protocol
The Review
we need to be really clear about what we're trying to achieve with this particular treatment. Does it help some young people to pass in later life? And the answer is, you know, yes, it may well do. And so it may be that there is a much smaller group of young people for whom this is the right treatment. And we need to understand which those young people might be.
The Protocol
The Review
And that's why we've said that we haven't said stop this completely in the UK. We've said, let's have a proper trial to look at both who benefits and whether there's any harms.
The Protocol
The Review
Yes. So my name's Hilary Cass. I'm chair of the Independent Review into Services for Gender Questioning Young People. And I was selected because I have previously been a president of the Royal College of Paediatrics and Child Health. And so that gives me a fairly high profile role in policy and
The Protocol
The Review
Yeah, so I think to continue to say that the evidence is good when numerous systematic reviews have shown that it isn't is surprising. I think it is important to say that where there is weak evidence, you do your best in terms of clinical consensus and then you try and strengthen the evidence.
The Protocol
The Review
And 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 and saying the evidence is good. And I think that's where you're misleading the public. You need to be honest about the strength of the evidence and say what you're going to do to improve it.
The Protocol
The Review
So the most important concern for me is just how poor the evidence base is in this area. And some people have questioned, did we set a higher bar for this group of young people? We absolutely didn't.
The Protocol
The Review
She says that for most young people, a medical pathway will not be the best way to manage their gender-related distress.
The Protocol
The Review
From the New York Times, I'm Austin Mitchell. This is The Protocol with Azeen Qureshi. Part 5. The Review.
The Protocol
The Review
People were worried that we throw out anything that wasn't a randomized controlled trial, which is the gold standard for study design. We didn't.
The Protocol
The Review
Even so… Other kinds of studies that aren't RCTs can give us really good information, but they have to be well-conducted.
The Protocol
The Review
The assessment of studies looks at things like, do they follow up for long enough? Do they lose a lot of patients during the follow-up period? Do they have good comparison groups? And the reason the studies are weak is because they failed on one or more of those areas that I've just described.
The Protocol
The Review
And having just started my retirement, the phone went and NHS England asked if I might be interested in taking on this role.
The Protocol
The Review
The Dutch team picked the first 70 people who were ready to go on to the next stage, so they were in some ways picking the people who, you know, done best on the puberty blockers.
The Protocol
The Review
Publishing negative results is really important. And so that perpetuated, because they went on to routinely prescribing, people might have assumed that they'd got positive results. So failure to publish is a problem again.
The Protocol
The Review
The group of young people presenting now who are predominantly birth-registered girls presenting in teenage years are very different from the original group of young people who are predominantly birth-registered boys presenting from early childhood. And so even the research that we have, weak as it is, was mainly about that other group.
The Protocol
The Review
Yes, the plans to learn how to play the saxophone and how to play bridge kind of went to the wall.
The Protocol
The Review
Yeah, it has been treated differently up till now. So the University of York, which is kind of the home of systematic reviews, one of the key organisations that does them in this country, just found it was strikingly lower than other areas, even in paediatrics.
The Protocol
The Review
I think what's unique for me is that if we do give a potentially life-changing treatment to a young person and we don't have good evidence about it, then the responsible thing to do is that you must follow them up into adulthood. And really, I can't think of any other situation where we do give life-altering treatments and we just don't have enough understanding about what's happening there.
The Protocol
The Review
So I obviously had some idea of how contentious it was. It's become more toxic in the time since I took it on.
The Protocol
The Review
Yeah. So I have spoken to very many clinicians in the US, in Europe and in the UK who also have many years experience and have come to a different conclusion. So you have both clinical perspectives. And that's why in the end, you can't just rely on your clinical experience. And I think
The Protocol
The Review
Certainly, I've spoken to young adults who are clearly thriving for, you know, a medical pathway has been the right thing for them. And I've also spoken to young adults where it was the wrong decision, where they have regret, where they've detransitioned. And the critical issue is trying to work out how we can best predict who's going to thrive and who is not going to do well in
The Protocol
The Review
Yeah, so there's always two views because it's never a simple answer and probably elements of both of those things apply. Although actually the environment doesn't seem to have got friendlier to trans people. It seems to be a lot more hostile at the moment. And that's a real worry to me for those young people who are going to go on and have a trans identity. Yeah.
The Protocol
The Review
But having said that, it doesn't really make sense to have such a dramatic increase in numbers that has been really exponential. It's been like a vertical line going up that's happened in a really narrow time frame across the world. Just social acceptance just doesn't happen in that way so dramatically anymore. So that doesn't make sense as the full answer.
The Protocol
The Review
But equally, those who say, oh, this is just social contagion are also not taking account of how complex and nuanced this is and how many different factors are impacting it. Having said all of that, I think that there are many things that we need to think about that are different for girls growing up in Gen Z. It's a very, very different world and it's quite tough.