In contrast to signed articles, which reflect the opinion of the author, editorials reflect the opinion of the editorial board of The Reproductive Times.

Briefing: Controversies surrounding gender affirming medical care for children and teenagers were expected to abate following publication of the Cass Review in the U.K., widely lauded as a unique and fair product of four years of work. Instead, the report has reinflamed the controversy, driven by political ideologies rather than evidence and common sense. We here discuss this subject as an example of how damaging the intrusion of politics is to the practice of medicine and how it often leads to the suspension of all logical thinking.

One would assume that the negative effects on public health and society from how government and medical experts managed the COVID-19 pandemic would have been convincing enough to warn everybody about allowing national politics to enter medical practice. Current schisms in society, likely the most profound since the early 1930s in Europe and the McCarthy period in the late 1940s and early 1950s in the U.S., however, even outbid the obvious. And when- and where-ever this happens, medicine and society appear to suspend all common sense.

This is, of course, best seen in the national debate over abortions and the question of when human life begins. A central issue in the upcoming November elections, this is not today’s subject of discussion, but, undoubtedly, will become a theme of the VOICE sometime in the near future. Today’s subject is another highly politicized subject, gender-affirming medical care in children and adolescents, unsurprisingly also an issue in the upcoming elections. Moreover, it has recently become subject of intense conflict (one can no longer call it a debate) within the medical field. And, as with in the abortion debate, political extremism appears to rule the day.

It from the start is important to note that we, here, are not addressing gender-affirming care in adults. The subject of this editorial is exclusively gender-affirming care in young children and adolescents up to age 18 years. In other words, the subject here is such care for minors who society–for good and logical reasons–has throughout history limited in their ability to make medical decisions without parental input.

It does not take much scientific insight to understand that our brains must mature before they allow us to make (more or less) logical decisions. This is why in practically all states a school nurse under law must call parents for permission before giving their child a Tylenol capsule for headache, and physicians need to get parental consent before performing an appendectomy on a child.

But now, a recently passed law in California prohibits schools and school districts from adopting parental notification policies requiring teachers (or other school employees, like nurses, and psychologists) to inform parents if their under-age child asks to use a name or pronoun different from the one given at birth or if they engage in activities and use of spaces designed for the other sex.1 In other words, under current California law, the above-noted school nurse must get consent from parents to give their child a Tylenol for headache but may be prohibited from communicating with the child’s parents that their child suddenly demonstrates clinical signs of gender dysphoria. One cannot but wonder, where is the common sense?

With the rapidly increasing demand for gender-affirming medical care, very quickly a provider industry arose around it. And while it started with offerings to adults, it quickly expanded to gender-affirming care for children and adolescents. Moreover, it went far beyond just name changes and pronouns, including serious medical treatments with potential lifelong irreversible effects, including puberty blockers and major surgical procedures, often advocated by and offered at major medical centers and prominent academic institutions.

And here is one paradox: At a time when the medical field decries “medicalized female genital mutilation” in an unsigned formal editorial in The Lancet,2 the British Medical Association (BMA) called for the lifting of a ban on puberty blockers for transitioning children with gender dysphoria (under age 18) in the U.K. which the British High Court had upheld.3

All of this, of course, has been happening after the publication of the initially widely-lauded Cass Review which had warned that the use of puberty blockers and hormones for patients under the age of 18 really relied only on a “shaky foundation.” 4 The report was based on four years of gathering available evidence and did not claim that there was evidence that puberty blockers did cause permanent and often irreversible damage to individuals so-treated as children (as claimed by some) but specifically noted that convincing evidence in favor of such treatment did not so far exist. Contrast that to the statement of the chair of council of the BMA who in support of the BMA’s motion noted that the ban on puberty blockers was “unsubstantiated” and “discriminatory.”2

The difference between these two statements offers an excellent example for an often-overlooked paradox at such controversial medical decision points: medical ethics demand that treatments not be allowed to enter routine clinical practice unless previously validated in their claimed effectiveness and relative safety. In practical terms this means that whoever wishes to introduce new treatments into routine clinical practice has the obligation to first demonstrate the treatments’ effectiveness as well as safety.

Prof. Hilary Cass, MD, a British pediatrician and former president of The Royal College of Pediatrics and Child Health was Chair of the Cass Review. The Review’s conclusions not only affected British transgender practice in children and young adolescents but changed practice in almost all European countries. Originally published on April 10, 2023, the report was politically endorsed in the U.K. by the two leading political parties - Conservative and Labour - and by several medical societies. Regarding the behavior of individual physicians, the final document noted in diplomatic language that “some professionals were overshadowed by an unhelpful polarized debate around conversion practice.”

This is usually done in properly designed prospectively randomized studies, where participants are appropriately consented about the fact that the treatments they are receiving are part of a study and have not yet been established as effective and/or safe. Within this context, the Cass Review correctly pointed out that for the use of puberty blockers in children, appropriate evidence for effectiveness and/or safety currently still does not exist. A recommended ban on unrestricted use of puberty blockers in children and adolescents under the age of 18, therefore, was clinically as well as ethically the correct recommendation. The Cass Review document, moreover, did not attempt to prevent or prohibit such treatments–and, indeed, encouraged them–if offered under controlled experimental protocols with appropriate informed consents.

Contrast this logical position of the Cass Review with the above-noted statement of the BMA spokesperson: he, of course, was unable to offer clinical validation and safety data in favor of puberty blockers in children and, therefore, resorted to the oldest trick in medicine proponents of unproven treatments–starting with snake-oil salesmen–have utilized for centuries, transferring the responsibility of establishing proof of utility and safety from the proponent to the opponent of a given treatment.

Accusing the Cass Review of having no (or not sufficient) data to prove that puberty blockers do not work and/or may cause long-term harm to so-treated children and adolescents, the BMA spokesperson resorted to exactly the above-described switch and bait tactic of snake-oil salesmen in selling their wears to an ignorant public, completely ignoring the fact that the responsibility for proof of efficacy and safety lies exclusively with proponents of puberty blockers (and other gender-affirming treatments).

To see such irresponsible behavior from only too often poorly informed physicians and/or obviously economically interested parties is, of course, not surprising, considering that this trick has been around since medicine has existed as a definable professional activity. But to hear it from a representative of a highly regarded medical society like the BMA is nothing but astonishing and deeply regrettable. It can only be explained by politization of the BMA, a process which in recent years, unfortunately, also has involved several prominent medical societies in the U.S., including, regrettably, societies in the reproductive field.

As effective as the Cass Review was in affecting clinical practice in Europe, it received much less attention in the U.S., even though the case load involving children and adolescents in the U.S. increased more rapidly than in Europe and also involved much more frequently the irreversible surgical removal of body parts. Nevertheless, in contrast to Europe, one heard almost no critical medical voices and saw almost no articles in the medical literature questioning these aggressive medical practices involving children and adolescents.

One exception has been for some time the journalist Jesse Singal, who came to the attention of the public regarding this subject already in 2018 when he wrote a cover story on the subject for The Atlantic.5 And he deserves credit for not letting go to this day. He, indeed, just published another highly informative series of two articles on the subject on August 19, 2024, and September 1, 2024 (corrected), in his newsletter on Substack, in which he accused the Yale University “Integrity Project” of spreading misinformation about the Cass Review document.6,7 And more on the subject is coming because he just announced he was taking most of September off from his newsletter to finish a book on the subject.

Jesse Singal is a Princeton University-educated American journalist who has written for *New York* magazine, *The New York Times*, and *The Atlantic* and publishes a successful newsletter on *Substack*. He first addressed the issue of gender affirming treatments in 2018 in a cover story in *The Atlantic* under the title “When Children Say They’re Trans,” which at the time received considerable attention. He is now finishing a book on the subject.

Singal correctly pointed out in his writing that, if something was publicly written on the subject, it often only involved online political activists and their followers on the pro-intervention side and, therefore, did not represent objective information. As an example, he now recently presented in detail a (non-peer-reviewed) white paper published by a group of Yale University physicians (and one lawyer), paradoxically called “The Integrity Project,” which, as he well demonstrated in his scathing review, demonstrated little integrity in criticizing the Cass Review.6,7

In the two-part series of articles under the title, “Yale’s ‘Integrity Project’ Is Spreading Misinformation About the Cass Review and Youth Gender Medicine,” he quite devastatingly demonstrated the often naked self-interests that have driven this field–especially involving many of its surgical operatives, often strongly supported by their institutions, as gender-transitioning surgeries have become big business in the U.S.

Demonstrating a little black humor, he noted in the subheading to the first part of his article, that his writing “will not increase the reader’s confidence in highly credentialed (medical) experts,” a very relevant point to be made, especially after the world’s recent COVID experience.

**A demonstration in the U.K. against the ban on puberty blockers. Source: Jesse Singal. *Substack.* September 1, 2024. 7**

And then there was Lydia Polgreen, a columnist at The New York Times (where else, of course?), who on August 18, 2024, went to war against the Cass Review. Under the heading, “The Strange Report Fueling The War on Trans Kids,” her conclusion regarding the Cass Review was that it was presented “as a supposedly scientific document but, in fact, was subjective and political.” 8

But this description is, indeed, a very good conclusion of her unusually long article (The New York Times allotted her two full pages of the paper). How Polgreen described the Cass Review, indeed, revealed itself as a highly biased, subjective, and politicized product: exactly what Singal referred to when making the point that whatever was published on the subject in the media was usually biased toward political activists and their followers on the pro-intervention side.

The Cass Review, of course, is not a perfect document; but that is not for lack of trying. Because scientific truth constantly changes, perfection is difficult to achieve. The Cass Review is, however, as good a document as its subject currently allows. And on top of that, it is excellent evidence for the increasing politicization of medicine, because why else would the very liberal “newspaper of record” dedicate two full pages to a political (rather than science) writer to cover this subject and trash a detailed, scientifically-conducted medical review that took four years to perform?

Lydia Polgreen, a columnist at The New York Times, used to be editor-in-chief at the *HuffPost*. Source: *The New York Times.*

Here is just one example of why political writers for scientific topics may not be the best of all choices (there, of course are several more examples in her unusually long piece): one of Polgreen’s criticisms of the Cass Review was that it unfairly criticized the lack of available data on puberty blockers. And in support of her argument, she claimed (what else?) that this was discriminatory since so many other medical treatments also are constantly introduced into medical practice without sufficient prior validations.

She, of course, is correct that too many medical treatments (including in reproductive medicine) are introduced into routine medical practice without proper prior validation studies, and this is deplorable. Her argument, however, also demonstrates her lack of knowledge about ethical ground rules in medicine, especially since she cited as an example, treatments in the past given to very immature neonates without knowing potential outcomes of such treatments.

To compare risk-benefit between trying to save the life of a very immature neonate and offering minors potentially irreversible life-changing treatments, is simply absurd. Moreover, when very immature neonates were treated with experimental treatments, this usually happened with informed consent from the parents. Comparing giving puberty blockers to children with treating very premature infants to give them an opportunity for life, therefore, makes simply no sense and can only be explained by either complete ignorance about ethical human research or very obvious political biases. Which of the two explanations in this case applied really does not matter because both are unacceptable. Accusing the Cass Review “of fueling war on trans kids,” therefore, must be seen as highly inappropriate and as an indisputable example of the politization of medicine, in this case in the alleged “paper of record,” The New York Times.

There, moreover, exists yet another very good reason why the Cass Review should be considered an important document, and that reason is that the Review simply makes sense. It is logical in its arguments, while its opponents, very obviously, are not! Similar sentiments were recently also expressed by 900 U.K.-based physicians who signed a letter urging the BMA to abandon its announced inquiry into the Cass Review.9

What the New York Times article, however, also demonstrates is that bringing politics into health care may increasingly occur by intent. Regarding the abortion issue, this has, of course, already been obvious for many years. The similarities between the abortion debate and controversies surrounding gender-affirming care come further into focus through a recent report by Jennifer Block in The Free Press on August 7, 2024, in which she reports that Planned Parenthood apparently has started a new business: The nation’s largest abortion provider is now also one of the largest suppliers of the hormone testosterone to transitioning women.10

References

1. Associated Press. July 16, 2024. https://www.npr.org/2024/07/16/nx-s1-5041437/california-bans-school-rules-requiring-parents-notification-of-childs-pronoun-change#:~:text=Hourly%20News-,California%20bans%20school%20rules%20notifying%20parents%20of%20kids'%20pronoun%20change,person%20without%20the%20child's%20permission.

2. Editorial. The Lancet August 3, 2024. The lancet 2024;404:405

3. Feinman J. BMJ 2024;386:q1722

4. Cass Review. https://cass.independent-review.uk/home/publications/final-report/

5. Jesse Singal. The Atlantic. July/August 2018. https://www.theatlantic.com/magazine/archive/2018/07/when-a-child-says-shes-trans/561749/

6. Singal J. Substack, August 19, 2024. https://jessesingal.substack.com/p/yales-integrity-project-is-spreading

7. Singal J. Substack (Corrected) September 1, 2024. https://jessesingal.substack.com/p/yales-integrity-project-is-spreading-ba7

8. Polgreen L. The New York Times. August 18, 2024. https://www.nytimes.com/2024/08/13/opinion/cass-report-trans-kids.html

9. Feinmann J. BMJ 2024;386. Doi: https://doi.org/10.1136/bmj.q1772

10. Block J. The Free Press. August 7, 2024. https://www.thefp.com/p/how-did-planned-parenthood-become