Money talks
Paediatrician Hilary Cass pushes back against gender clinicians who stand to profit
Who benefits?
British paediatrician Hilary Cass has highlighted the financial conflict of interest among American gender clinicians critical of her landmark report, which urges a less medicalised treatment approach to gender-distressed minors.
“I do worry that some of the people, certainly in the US, who’ve been most critical of my review are the ones who have private practices and are therefore financially conflicted in some of their comments on not following a cautious approach,” Dr Cass said.1
She advised England’s National Health Service to end routine treatment with puberty blockers—they are restricted to a possible future clinical trial—and to exercise “extreme caution” with any prescription of cross-sex hormones for minors.
Speaking during a July 2 webinar on whether her recommendations are relevant to Australia, Dr Cass also expressed concern about reports of scientific misconduct by the World Professional Association for Transgender Health (WPATH) and she denounced activist disinformation about her 2020-24 review as “unbelievably frustrating”.
“Too much of the debate over this topic [of medicalised gender change] focuses on the legal, political and philosophical questions, too little on the empirical ones that matter most. Such as: Do these treatments benefit most kids who receive them? If so, by how much? And if only some kids benefit, how can the others be identified before starting life-altering treatments such as hormones and surgery?”—Columnist Megan McArdle, opinion article, The Washington Post, 2 July 2024
Path to error
In the Australian webinar, Dr Cass warned that an “affirmation-only” approach by gender clinics would lead to more frequent misdiagnosis of distressed minors whose real problems would be left untreated.
She was responding to a question during the webinar—organised by psychiatrist Professor Philip Morris of the National Association of Practising Psychiatrists (NAPP)—about how to reconcile the need for differential diagnosis with the child-led gender-affirming approach.
“If you go down an affirmation-only path, then you can’t guard against [misdiagnosis],” Dr Cass said.
“You have to take a more wholistic view of the young person, and a pure affirmative approach—meaning that you don’t explore or do a broad assessment—is going to lead you to make more mistakes.”
The Australian Professional Association for Trans Health (AusPATH), whose members include transgender activists as well as gender clinic staff in children’s hospitals across the country, expressed concern that Dr Cass’s interim report “questioned” the affirmative approach and “talked about” various possible “causes” of gender incongruence.
AusPATH endorses the 2018 gender-affirming treatment guidelines issued by the Royal Children’s Hospital (RCH) Melbourne and used by Australia’s paediatric gender services.2
Critics of the gender-affirming approach, among them detransitioners, argue that the true causes of what is presented as gender distress may include mental health issues, awkward same-sex attraction, autism, and a history of family dysfunction, sexual abuse or trauma. On this view, a young person’s condition may get worse after social or medical gender change because the underlying problems go untreated.
AusPATH says it does “not support ‘exploratory therapy’ which is often used as a euphemism for conversion therapy” that would lead a child to re-identify with birth sex.3
In the NAPP webinar, Dr Cass said: “There is a huge conflation in the minds of some people between [on the one hand] proper exploratory and evidence-based psychological care and [on the other] conversion therapy.”
“The intent of psychosocial intervention is not to change the person’s perception of who they are. It’s to work with them to explore their concerns and experiences and alleviate distress—regardless of whether or not they subsequently proceed on a medical pathway.”
Video: Surgeon Eithan Haim explains why he turned whistleblower at Texas Children’s Hospital—a decision that has him facing up to ten years’ prison
Political fix
During the webinar, Dr Cass was asked about the revelation that WPATH had abandoned minimum ages for trans surgery in its 8th edition standards of care (SOC-8) as a result of political pressure from Dr Rachel Levine, the second most senior health official of the US Biden Administration.
In her answer, Dr Cass spoke of a related scandal in which WPATH had commissioned multiple systematic reviews and then sought to suppress awkward results which showed there was scant evidence supporting gender-affirming care for minors. This has reached a large international audience as a June 27 news report in The Economist, under the heading “Research into trans medicine has been manipulated.”
Dr Cass told the webinar audience that reports of these scandals were “concerning” and “obviously, we need to understand the background.”
She noted there were systematic reviews—the gold standard for judging the quality of evidence in healthcare—that WPATH “didn’t allow to be published” and the organisation had misrepresented the results of a review which had been cleared for release.
“So, the chapter on adolescents [in SOC-8] claims that the evidence base is strong. The one review that was reported showed that the evidence base is weak. So, there are real methodological problems about WPATH,” she said.
“If what we’re hearing [at The Trevor Project] is correct—and it’s entirely possible it isn’t—we’re extremely concerned about the age minimums I believe are in the new SOC-8 standards. If what we’ve seen is accurate, this could have disastrous consequences for the work to protect basic healthcare for transgender youth… I know we’re on the same side, and I’m hoping we can talk this through a bit.”—Staffer at the LGBTQ lobby The Trevor Project, subpoenaed email to WPATH (whose president sits on The Trevor Project’s board), 2 September 2022
Video: Journalist Lisa Selin Davis discusses the latest WPATH scandal with psychotherapists Sasha Ayad and Stella O’Malley
Guides that mislead
The Cass review commissioned guideline evaluation experts at the University of York to rate gender dysphoria treatment guidelines internationally—including the 2018 RCH Melbourne document, which scored 19 per cent for the rigour of its development and 14 per cent for independence.
Australia’s Health Minister Mark Butler has been briefed by departmental officials on the poor performance of the Australian guideline, but appears not to have mentioned it in his public commentary on the Cass review, which he suggests has little local relevance.
In Tuesday’s webinar, Dr Cass said: “International guideline development has for the most part not followed standard evidence-based approaches and WPATH has influenced most other international guidelines.”
“[It’s an] echo chamber of international guidelines that sort of copy and paste off each other.”4
She said the reasons for guidelines rating poorly in the University of York evaluation included the failure to undertake a systematic review of the evidence, lack of clarity about the quality of evidence said to support treatment advice, and a lack of editorial independence involving “copying and pasting off other guidelines.”
“The only guidelines that have taken an independent and evidence-based approach are the Swedish (2022) and the Finnish (2020) guidelines,” she said.
She said those two documents stood out because they advised “a cautious approach to treatment”, taking account of the weak evidence base and the unprecedented rise of chiefly female adolescents in gender clinics when the classic gender dysphoria patient had been boys in early childhood.
Dr Cass, who had planned to devote her retirement to pottery and the saxophone before she was appointed to head a review exposing her to toxic identity politics, told Tuesday’s webinar audience that she was not much bothered by being trolled on social media.
“The thing that I find exhausting is the disinformation,” she said. “For example, one thing that started before the report was even released, was the claim that we had ignored 98 per cent of the published literature.”
“That’s just manifestly untrue. The systematic reviewers [at the University of York] discussed all the literature, but included it when they synthesised all the moderate- and high-quality papers, which was nearly 60 per cent of the [literature].”
At a June 25 parliamentary forum in Sydney, the visiting US detransitioner Chloe Cole highlighted the financial value of a medical model presented to the public as “a human rights issue”. She said: “Within the healthcare system, this is a billion-dollar industry. This is highly profitable. The longer they have patients on these treatments, the further that [patients] go into it, especially the younger that they go into it, the more money it generates for these doctors or for these hospitals, and for pharmaceutical companies as well, because [the treatment] creates more and more problems within the body. You’re directly interfering with these children’s development and the function of the bodies of these patients. And we’re creating patients who are basically slaves to medicine.”
At the Queensland Children’s Hospital, the gender-affirming treatment model is mandated in a formal “work instruction” to staff—and not only to those who work in its large gender clinic. Under the heading of assessment, the document includes a child’s “history of gender identity development and gender expression”, but it does not suggest the possibility that an opposite-sex identity might be an artefact of underlying disorders or difficulties. It asserts that “being transgender, non-binary or gender diverse is part of the natural spectrum of human diversity.”
In her report, Dr Cass points out that anti-conversion therapy legislation—of the kind found in some Australian jurisdictions—may have the perverse effect of denying care to young people. She said: “The reluctance of clinicians to engage in the clinical care of gender-questioning children and young people [has been recognised]. Clinicians [say] this stems from the weak evidence base, lack of consistent professional guidance and support, and the long-term implications of making the wrong judgement about treatment options. In addition, concerns were expressed [during the review] about potential accusations of conversion practice when following an approach that would be considered normal clinical practice when working with other groups of children and young people. Throughout the review, clinicians working with this population have expressed concerns about the interpretation of potential legislation on conversion practices and its impact on the practical challenges in providing professional support to gender-questioning young people. This has left some clinical staff fearful of accepting referrals of these children and young people.”
In her report, Dr Cass said: “Early versions of two international guidelines, the Endocrine Society 2009 and World Professional Association for Transgender Healthcare (WPATH) SOC-7 guidelines influenced nearly all the other guidelines. These two guidelines are also closely interlinked, with WPATH adopting Endocrine Society recommendations, and acting as a co-sponsor and providing input to drafts of the Endocrine Society guideline. WPATH SOC-8 cited many of the other national and regional guidelines to support some of its recommendations, despite these guidelines having been considerably influenced by WPATH SOC-7. The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.”
I find it difficult to rationalise the position of the RACP on the Affirmative model of gender ‘care’ of children diagnosed with gender dysphoria.
On the 5th of March 2020 it was stated thus:
"The RACP strongly supports expert clinical care that is non-judgemental, supportive and welcoming for children, adolescents and their families"
Note: No reference to the need for ‘evidence’
On May 14th 2024 I wrote to the President-elect and Board Chair of the RACP questioning the ‘strong support’ for an untrialled, irreversible and sterilising procedures in children .
The response I received was not extensive but did include the following:
Due to the current evidence-gap the RACP does not have a position on clinical care that involves the use of hormone therapy in children and adolescents with gender dysphoria.
Due to the multidisciplinary needs of individuals experiencing gender dysphoria, the RACP advice is that the Federal Government should develop a nationally consistent framework, through an evidence-based process.
I would have thought that given the acknowledgment of an ‘evidence gap’ the advice should be to cease such interventions until such time as evidence was available, or at the very least, until a mechanism to recruit evidence was put in place.
Thanks Guy, I just thought it would be of relevance to our statutory regulatory body of AHPRA’s position in the ( slow but likely inexorable) challenge to GAC ( specifically for minors) here in Australia for the effect of the closure of GIDS at Tavistock to have reverberated through the UK’s equivalent body. We were to understand that there were a number of class actions underway in the UK and would be of interest to see if the targets of the litigants extended beyond individual clinicians and the GIDS body. Legal nets are usually cast wide, so who would be surprised if their relevant colleges and their statutory regulatory body were not to become deemed culpable , and therefore targeted through historical inaction? I just thought Dr Cass might have discussed such detail, given it might have relevance here, where our courts historically follow British legal precedence. From Bernard’s reply , my question remains.