Podcast Summary: The Protocol - Episode: The Review
Introduction
The Protocol, a six-part podcast series by The New York Times, delves into the complex and contentious story of medical treatment for transgender young people in the United States. In the episode titled "The Review," released on June 5, 2025, host Azine Qureshi engages with Hilary Cass, chair of the Independent Review into Services for Gender Questioning Young People, to unpack the findings and implications of a significant report scrutinizing the care provided to transgender youth.
1. The Genesis of the Independent Review
Hilary Cass's Appointment and Background
The episode begins with Azine Qureshi introducing Hilary Cass, who explains her role and qualifications:
Hilary Cass [00:01]: "My name's Hilary Cass. I'm chair of the Independent Review into Services for Gender Questioning Young People. I was selected because I have previously been a President of the Royal College of Pediatrics and Child Health... NHS England asked if I might be interested in taking on this role."
Cass highlights that her selection was partly due to her retirement status and lack of prior involvement in transgender youth care, positioning her as an independent figure to lead the review.
2. The Crisis at the Gender Identity Development Service (GIDS)
Background of GIDS and Whistleblower Reports
The podcast provides a historical context of the turmoil within England's Gender Identity Development Service (GIDS), part of the Tavistock Centre in London:
Austin Mitchell [01:27]: "When Dr. Hilary Cass got a call from England's national health service in 2019, the country's only youth gender clinic was in crisis... Some providers voiced concerns about the wait list and the pressure to approve blockers and hormones quickly. These concerns were dismissed, labeling dissenting staff as transphobic."
A whistleblower report emerged, alleging that GIDS was "not fit for purpose," leading to national attention and the commissioning of Cass's independent review.
3. Key Findings of Cass's Independent Review
a. Weaknesses in the Evidence Base
Cass underscores the fundamental issue of insufficient evidence supporting current transgender youth treatments:
Hilary Cass [03:30]: "The most important concern for me is just how poor the evidence base is in this area."
She emphasizes that the low quality of available research does not meet higher standards set for other medical groups, challenging the legitimacy of current treatment protocols.
b. Assessment of Existing Studies
The review meticulously evaluated existing studies, revealing significant methodological flaws:
Austin Mitchell [05:16]: "There weren't any randomized controlled trials... These kinds of studies... can be challenging to do in pediatrics... But, other kinds of studies... have to be well conducted."
Cass points out that many studies lacked long-term follow-up, had high patient dropout rates, or insufficient comparison groups, undermining their reliability.
c. Population Changes and Their Implications
A notable shift in the demographics of patients seeking gender care prompted Cass to explore underlying causes:
Hilary Cass [08:56]: "The group of young people presenting now... are very different from the original group... It doesn't tell us the best way to manage this newer presenting group."
She highlights the exponential rise in predominantly female-born teenagers seeking care, suggesting that factors like social media and online exposure to pornography might contribute to their distress.
d. Clinical Practice Amidst Low Evidence
Cass draws parallels with other medical fields where clinicians operate with limited evidence but asserts that transgender youth treatment is uniquely precarious:
Hilary Cass [11:07]: "If we do give a potentially life-changing treatment to a young person and we don't have good evidence about it... you must follow them up into adulthood."
She advocates for rigorous long-term studies to ascertain the efficacy and safety of treatments like puberty blockers and hormones.
4. Polarization and Public Debate
Cass on the Toxicity of the Debate
Cass comments on the increasingly hostile environment surrounding transgender youth care:
Hilary Cass [11:18]: "There are few other areas of healthcare where professionals are so afraid to openly discuss their views... where people are vilified on social media."
She criticizes both opponents and advocates for misrepresenting the evidence, stating that the true state of affairs remains uncertain.
5. Reactions from the Medical Community
Responses from Major Medical Organizations
Following the release of Cass's report, major medical groups in the United States responded dismissively:
Austin Mitchell [21:37]: "The American Academy of Pediatrics sent a statement... defended their guidelines... The Endocrine Society told the Times that the CASS review did not contain any new research that would contradict its own recommendations."
This lack of engagement reflects a broader resistance within the medical community to Cass's findings.
Interview with Marcy Bowers of WPATH
The podcast features an interview with Marcy Bowers, president of the World Professional Association for Transgender Health (WPATH), who vehemently opposes Cass's conclusions:
Marcy Bowers [24:38]: "Gender affirming care is like the Holocaust. There are not two sides to the story... Gender affirming care is overwhelmingly efficacious."
Bowers dismisses Cass's review, arguing that it lacks understanding of the transgender population and echoes historical biases in trans medicine.
She further criticizes Cass for not having direct experience with transgender patients:
Marcy Bowers [27:37]: "Hillary Cass has never worked with a trans person... that's a real important exclusion."
Bowers reinforces the notion that clinical experience should supersede Cass's evidence-based critique, emphasizing anecdotal successes in her practice.
6. The U.S. Research Landscape and Political Influences
Delayed Publication and Political Interference in Research
Cass's review also touches on the challenges faced by researchers like Dr. Joe Olson Kennedy, who conducted a significant longitudinal study on puberty blockers but faced delays in publication due to political pressures:
Joe Olson Kennedy [41:27]: "They have to do exact point, clear and concise... I do not want our work to be weaponized."
The study, which failed to replicate positive outcomes from the Dutch protocol, highlights the tension between scientific integrity and political agendas.
Legal Battles and Supreme Court Involvement
The report's findings became a focal point in legal arenas, influencing Supreme Court considerations:
Austin Mitchell [44:38]: "As President Trump took office, the care and the kids receiving it were pulled into something much larger and more existential."
By January 2025, political shifts culminated in official policy changes, restricting gender recognition:
Austin Mitchell [45:43]: "As of today, it will henceforth be the official policy of the United States government that there are only two genders, male and female."
7. Implications and Future Directions
Recommendations for Policy and Practice
Cass advocates for cautious and evidence-based approaches moving forward:
- Clinical Trials for Puberty Blockers: Only prescribe as part of controlled studies.
- Selective Hormone Treatments: Continue available at age 16 but with extreme caution.
- Regional Care Centers: Establish centers focused on holistic and personalized psychological therapies.
These recommendations aim to balance the immediate mental health needs of transgender youth with the imperative for robust scientific validation.
Adoption by the NHS
England's National Health Service (NHS) embraced Cass's recommendations, leading to the closure of the Tavistock Clinic and the establishment of new regional centers prioritizing psychological support over immediate medical interventions.
Conclusion
"The Review" episode of The Protocol presents a deep dive into the ongoing debate surrounding transgender youth care. Through Hilary Cass's independent review, listeners gain insight into the contentious interplay between scientific evidence, clinical experience, and political influences shaping the future of transgender healthcare. The episode underscores the urgent need for high-quality research and balanced discourse to ensure the well-being of transgender young people amidst a polarized societal landscape.
Notable Quotes:
- Hilary Cass [03:30]: "The most important concern for me is just how poor the evidence base is in this area."
- Marcy Bowers [24:38]: "Gender affirming care is like the Holocaust. There are not two sides to the story."
- Marcy Bowers [27:37]: "Hillary Cass has never worked with a trans person... that's a real important exclusion."
- Joe Olson Kennedy [41:27]: "I do not want our work to be weaponized."
Disclaimer: This summary is based on a fictional transcript and is intended for illustrative purposes only.