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The Protocol
The Review
00:46:07
The heated debate is not limited to the U.S. In England, a pediatrician tasked with figuring out how the country’s health care system should provide the care finds that the evidence is “remarkably weak.” One major medical group argues that’s missing the point — and repeating history.
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- [00:02]
Azine Qureshi
So can we just start by having you introduce yourself, what your title is and how you were selected to do this review?
- [00:13]
Hilary Cass
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 Pediatrics and Child Health. And so that gives me a fairly high profile role in policy. And having just started my retirement, the phone went and NHS England asked if I might be interested in taking on this role.
- [00:49]
Azine Qureshi
What a peaceful, calm way to start your retirement.
- [00:54]
Hilary Cass
Yes. The plans to learn how to play the saxophone and how to play bridge kind of went to the wall.
- [01:02]
Azine Qureshi
Well, so this kind of connected to my next question. I was just wondering, when you were first asked to conduct this review, I mean, did you have any idea of what you were walking into and how contentious this space is?
- [01:18]
Hilary Cass
So I obviously had some idea of how contentious it was. It's become more toxic in the time since I took it on in the first instance.
- [01:28]
Austin Mitchell
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. The clinic was part of the Tavistock Centre in London. It was called the Gender Identity Development Service, or jids. And over the past decade, as the demand surged and the patient population changed, a rift had formed among the staff. Some of the providers voiced concerns about the clinic's years long wait list and the pressure they felt to quickly approve kids for blockers and hormones. They felt there wasn't enough time to help kids work through their issues. But they said their concerns were dismissed by other providers and by higher ups at jids. Some of them said they were labeled as transphobic for speaking up. Eventually, 10 of these providers went to a senior figure outside the clinic who interviewed them about their experiences and filed a whistleblower report concluding that JIDS was, quote, not fit for purpose. That led the clinic to conduct an internal investigation which ultimately came to the opposite conclusion. That's when the whistleblower report was leaked to the public, drawing national attention. A few months after that, the National Health Service brought in Cass. She had never worked with trans kids, but that was actually part of the reason she was chosen. The NHS felt that her lack of involvement in the field made her well positioned to lead an independent review of the care and offer recommendations for how England should move forward with services. Over the next four years, Cass conducted the most comprehensive review of the evidence in the field to date.
- [03:25]
Azine Qureshi
What are your top takeaways from the report?
- [03:30]
Hilary Cass
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.
- [03:47]
Austin Mitchell
And what she concluded.
- [03:48]
Azine Qureshi
A damning new report has found that.
- [03:50]
Austin Mitchell
Children seeking gender care on the NHS.
- [03:52]
Azine Qureshi
Have been let down by a lack.
- [03:53]
Austin Mitchell
Of research and evidence called into question the very basis for the care, including the Dutch protocol.
- [04:00]
Hilary Cass
She says that for most young people, a medical pathway will not be the.
- [04:05]
Austin Mitchell
Best way to manage their gender related distress. And handed opponents of the care in the US their strongest weapon yet is remarkably weak evidence.
- [04:14]
Azine Qureshi
For what? Remarkably weak evidence.
- [04:16]
Hilary Cass
Remarkably weak evidence.
- [04:18]
Austin Mitchell
From the New York Times, I'm Austin Mitchell. This is the protocol with azine Qureshi, part 5, the review.
- [04:35]
Azine Qureshi
For people who don't know what you're talking about when you say the quality of evidence is low, you found that the quality of evidence in this space is. Is remarkably low. Can you just explain what that means?
- [04:50]
Hilary Cass
Yes. So there are.
- [04:53]
Austin Mitchell
In her nearly 400 page report, Cass spelled out in detail exactly how she came to her results. She wrote that she commissioned a team of researchers at the University of York to conduct systematic reviews of the evidence in the field. They pooled together all of the studies they could find and rated them based on how strong a connection could be drawn between the treatment and. And the outcome.
- [05:17]
Hilary Cass
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 actually. There weren't any randomized controlled trials, but we still.
- [05:31]
Austin Mitchell
Cass said there weren't any studies in the field that compared a group that was given treatment to a similar group that wasn't chosen at random, which is the strongest way to show that a treatment caused an outcome. These kinds of studies, known as randomized controlled trials or RCTs, can be challenging to do in pediatrics, largely because there are so many ethical and logistical issues around doing research with children.
- [05:58]
Hilary Cass
Even so, other kinds of studies that aren't RCTs can give us really good information, but they have to be well conducted.
- [06:07]
Austin Mitchell
There were dozens of other studies the review looked at, many of which reported some positive outcomes for patients, but most were found to have weaknesses.
- [06:17]
Hilary Cass
The assessment of studies looks at things like, do they follow up for long enough, do they lose a lot of patience 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.
- [06:37]
Austin Mitchell
Cass said that they didn't follow patients for long enough to properly assess the outcomes of the treatment. Two of the most important studies in the field that did follow patients over time were the landmark 2011 Dutch paper and a later study from the Tavistock Clinic that tried to replicate it. With the Dutch research, which had found that puberty blockers led to positive psychological outcomes, Cass said some of the study's methods could have biased the results. She pointed to the risk of selection bias, one of the issues that Ana Lou de Vries herself had noted at the time the study was published.
- [07:16]
Hilary Cass
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'd, you know, done best on the puberty blockers.
- [07:27]
Austin Mitchell
Cass noted that the group of kids included in the study had been part of a larger cohort, but the Dutch only chose to follow the first 70 kids, who then moved on to hormones. She said that meant they might have picked the kids who were responding best to the blockers. She also pointed out the Dutch patients were all getting therapy through the course of the study, so it was hard to separate the effects of that treatment from the effects of the puberty blockers. As for the other study, the one that came out of the Tavistock Clinic, it had similar limitations, but also it ultimately failed to replicate the Dutch result. While most patients reported being very happy with the treatment, on average, the study found no change in their psychological functioning. Roughly a third of them improved after going on the blockers and a third were doing worse. And even though the clinic had preliminary results by 2015, they didn't publish their findings until 2021.
- [08:31]
Hilary Cass
And 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.
- [08:47]
Austin Mitchell
On top of all the concerns about the quality of the studies, Cass said many of them were also outdated, given all the ways the patient group had changed.
- [08:56]
Hilary Cass
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. And it doesn't tell us the best way to manage this newer presenting group.
- [09:26]
Azine Qureshi
Right, right. And I want to get to the issues of the population change that you were describing, but just sticking to the evidence for a little bit longer. Dr. Kass, you have a tremendous amount of experience in pediatrics. Can you talk about just what clinicians do in areas with low evidence? Because there are other areas of medicine, particularly in pediatrics, where doctors have to figure out a way to practice without high quality evidence.
- [09:59]
Austin Mitchell
Youth gender medicine is by no means alone in having a shortage of strong evidence. Research suggests that about half of all medical interventions are supported by low or very low quality evidence.
- [10:12]
Azine Qureshi
Is there a way in which this field is different?
- [10:15]
Hilary Cass
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 organizations that does them in this country, just found it was strikingly lower than other areas, even in paediatrics. 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 to those young people in adulthood.
- [11:07]
Austin Mitchell
But even Cass stressed that what was important was not just her finding that the evidence was remarkably weak.
- [11:14]
Hilary Cass
We have a polarized political environments.
- [11:18]
Austin Mitchell
It was about how exceptionally toxic the debate in this field had become. She wrote, quote, there are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name calling echoes the worst bullying behavior. She said that this polarized situation wasn't helping the kids who were caught in the middle of the that the evidence was being politicized and misrepresented by people on all sides. Opponents argued that the evidence showed children were being hurt, while advocates argued that the evidence showed the treatment saved lives, when in fact what the evidence actually showed was we don't know.
- [12:13]
Azine Qureshi
But something else I've observed and heard a lot from prominent doctors in the US at least is this idea that part of the reason that they're hesitant to engage criticisms of the evidence is because they know it'll be used to further limit care and that they feel very confident in their experience as clinicians, you know, like that they know this will be beneficial to kids because they don't need high quality evidence to know what they've seen over and over with their own eyes in their own exam rooms, which is that this treatment can be life saving and help kids thrive. And it's about this firsthand experience and reconciling that with the data. I Guess just as an expert who hasn't treated these kids but was brought in to independently assess this field of medicine, how do you weigh a body of evidence against this kind of firsthand clinical experience, which is also important.
- [13:12]
Hilary Cass
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, you know, both clinical perspectives and that's why in the end, you can't just rely on your clinical experience.
- [13:41]
Austin Mitchell
And I think for her review, Cass and her team met with over a thousand people. And it wasn't just clinicians who had differing ideas about whether the treatment helped. She also met with parents, young adults who had gotten care and kids who were currently seeking it. And she found that within all these groups there was a range of experiences.
- [14:01]
Hilary Cass
And certainly I've spoken to young adults who are clearly thriving for, you know, a medical pathway has been the right thing for them, them. And I've also spoken to young adults where it was the wrong decision, where they have regret, where they've de transitioned. 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.
- [14:30]
Azine Qureshi
The concern that you raise and that many other European health bodies have raised is not just about the low quality of evidence. It's also about the rapid increase in kids who are seeking this care over the last 10 years, most of whom are female at birth and are in their later teens, 15, 16. As is often the case in this space, I often hear two very different stories about why this is happening. On the one hand, there's a positive story about social acceptance, that there have always been this many trans people and now there's just a language to understand and kids feel more free to be and express who they are. The other story is a more fearful one, that this is a contagion driven in large part by social media, that this is disproportionately impacting vulnerable girls. How do you think about the causes for this rise?
- [15:25]
Hilary Cass
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. 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. 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, you know, across the world. Just social acceptance just doesn't happen in that way so dramatically. So that doesn't make sense as the full answer. 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. 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.
- [16:48]
Austin Mitchell
Cass dedicated multiple chapters of her review to looking at the newer group of patients coming into clinics. She wrote that the dramatic increase in patients who were born female was, quote, unlike trans presentations in any prior historical period. And she speculated about how their use of social media and exposure to pornography online could be contributing to their distress around their bodies.
- [17:14]
Hilary Cass
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, feel that they're meeting the sort of social media stereotypes that are expected of girls, and puberty feels pretty hideous. 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, 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. So it really.
- [18:31]
Austin Mitchell
Cass warned that especially given the complexities of the new group of patients seeking care, a focus on shorter term outcomes and patient reports of satisfaction might miss how to best serve patients in the long term. And that even the original reasons for providing the care laid out by the Dutch needed to be revisited.
- [18:52]
Hilary Cass
Peggy Cohen Kattenis 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's really difficult, can be 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.
- [19:18]
Austin Mitchell
Now, Cass said that the idea of puberty blockers providing time to think about whether to medically transition, a prospect that felt so promising to the Dutch, had been challenged by the evidence since. She pointed to the Tavistock study, which found no change in psychological functioning from the blockers. And yet every patient but one had chosen to continue on to hormones.
- [19:41]
Hilary Cass
There's no evidence that it buys time to think.
- [19:44]
Austin Mitchell
So she wrote that starting on blockers might actually influence a child's gender identity development.
- [19:50]
Hilary Cass
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. 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. And that's why we've said that. We haven't said, stop this completely. In the uk, we said, let's have a proper trial to look at both who benefits and whether there's any harms. And sometimes.
- [20:27]
Austin Mitchell
Ultimately, Cass said in her report, until there was better research about which kids would benefit and which would not, there is not a reliable evidence base upon which to make clinical decisions. She recommended that puberty blockers only be prescribed as part of clinical trials and only after patients have had a thorough assessment period. When it came to hormones, she said the option to provide them at the age of 16 would still be available, but recommended extreme caution. She also recommended that the country move to a new service model by opening a network of regional centers that could increase capacity while providing more holistic and personal care for young people. These centers, she said, should focus on psychological therapies to relieve immediate distress. Her recommendation was adopted by England's National Health Service. The NHS shut down the Tavistock Clinic and opened two new centers with more planned.
- [21:29]
Azine Qureshi
You know, as part of this reporting, I've also been reaching out to major medical groups in the United States to see how they've responded to your findings.
- [21:37]
Austin Mitchell
But in the us, major medical groups downplayed the review. The American Academy of Pediatrics sent a statement to the Times that didn't engage with the review's findings. Instead, the group's president defended the AAP's own guidelines for care, saying they were grounded in evidence and science. So much of what we're seeing right now in the United States is not grounded in evidence and science, he wrote. Politicians have inserted themselves into the exam room, which is dangerous for both physicians and for families. The Endocrine Society told the Times that the CASS review did not contain any new research that would contradict its own recommendations.
- [22:22]
Azine Qureshi
I think for a lot of people this is kind of dizzying. We have medical groups in the US and the uk, they're looking at the same facts that the same scientific literature and yet they're coming to very different conclusions about both what that says and what should be done. What do you make of those responses?
- [22:42]
Hilary Cass
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. And it wouldn't be too much of a problem if people were saying this is clinical and 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.
- [23:37]
Austin Mitchell
In the weeks following Azine's conversation with Cass, one medical group in particular doubled down in their rejection of Cass's findings and their defense of the evidence. WPATH and its American branch issued a statement saying that puberty blockers and hormones are, quote, helpful and often life saving and that that conclusion was based on, quote, research and consensus based evidence.
- [24:08]
Marcus
Hey Marcus, how are you?
- [24:09]
Marcy Bowers
I'm fine. How things are. Yeah, I'm here.
- [24:12]
Marcus
Oh, hi. Hi. Sorry.
- [24:14]
Austin Mitchell
The group's president at the time was Dr. Marcy Bowers.
- [24:18]
Marcy Bowers
I'm about, I'm about at the end of my rope with this stuff, as I say, so.
- [24:39]
Azine Qureshi
We will meet in person.
- [24:40]
Marcy Bowers
Okay, that sounds good. I know you want to get this right. I know you. I really do feel that in my heart.
- [24:49]
Austin Mitchell
Dr. Marci Bowers may be the most well known surgeon working in trans medicine in the us. She's developed some of the leading techniques in gender affirming surgery and helped to open surgery programs at a number of hospitals around the world. In 2020, she became the president of WPATH.
- [25:08]
Marcus
Would you be comfortable recording this call or would you prefer not to?
- [25:14]
Marcy Bowers
Yeah, you know, I. You know they have this. Yeah, I. You know what? I do, I do, I do know you, and I do trust you, and I do want you to get it right, but I will say that, yeah, so go ahead if you want to do that. But the first thing I have to say about gender affirming care, though, is that it is like the Holocaust. There are not two sides to the story. And everyone who reports on this issue seems to feel the need to present two sides to the story. Now, beneath that, there's lots of nuance. What age, you know, how early we intervene, how thorough the mental health evaluation. But the thing that unifies every person who is knowledgeable in. Hillary Cass has never worked with a trans person, so that's really an important exclusion, is that gender affirming care is overwhelmingly efficacious. So there are not two sides to this issue. There really are not. There are subtleties, but there are not two sides. And. All right, that was my long winded intro. I just was. It was pent up. I haven't talked in so long and I just said I kind of had it, you know, I've just kind of had it.
- [26:51]
Marcus
Can we talk about Hillary cast for a minute? I mean, she is obviously, undoubtedly an extremely important figure in this space. I mean, her.
- [27:01]
Marcy Bowers
Why. But why, why, why is she important? Why is she the authority?
- [27:08]
Marcus
I mean, you're gonna have to ask the NHS that. They, they asked her to conduct the review. She, she's. I mean, she's had a long career in pediatrics, but not obviously with kids with gender dysphoria.
- [27:22]
Hilary Cass
But.
- [27:22]
Marcy Bowers
Well, there you go, full stop, right? Full stop. There you go.
- [27:26]
Marcus
You know, why, why is she important? I mean, she's important because her recommendations have just been adopted by the NHS in England and Scotland. And.
- [27:38]
Marcy Bowers
And yet you see the tens of thousands of members of the Endocrine Society, the American Academy of Pediatrics, the AMA and the apa, all with extensive experience treating this population, why are they somehow biased and she is not?
- [28:02]
Marcus
Well, I think that's. I mean, that's very confusing for people that we have health experts in major health groups in the us, major health groups in the uk, in Sweden, looking at the same data, the same scientific literature that does not respect geographic boundaries. We're looking at the same studies in this small field and reaching very different conclusions. And I think that's a really legitimate question to ask is why is that.
- [28:32]
Marcy Bowers
Happening regardless of who. Yeah, why is it happening? Because, you know, it feels like the same environment that enabled Paul McHugh to shut down, effectively shut down all the research in the United States for 35 years when they shut the Hopkins clinic in 1979.
- [28:58]
Austin Mitchell
For Marcy, the Cass review was part of a larger pattern in the history of trans medicine. One of the first places to provide surgeries and conduct research on treatment for trans adults in the US was the Johns Hopkins Gender Identity Clinic. It opened in the 1960s, and its work got a number of other universities and research institutions to start treating and studying trans patients as well. But in 1975, a man named Paul McHugh took over as head of the university's department of psychiatry. He viewed trans people as suffering from a psychiatric disorder. He once wrote that when providers give in to what he called the folly of transgenderism, they abandon the role of protecting patients from their symptoms and become little more than technicians working on behalf of a cultural force. Under his leadership, the department published a study on the outcomes for a small group of surgery patients looking at what they called observable and objective measurements of well being, like housing, education, and careers. The study, published in 1979, found that patients reported being satisfied with the procedures. But the researchers characterized those feelings as subjective and concluded that gender surgery offered no, quote, objective advantage to their well being. The study was widely denounced by providers in the field. Still, that year, Johns Hopkins closed the clinic. Other university based programs in the US soon shut down as well.
- [30:54]
Marcy Bowers
Trans people were not felt to be objective enough to judge the outcome of their own well being. I mean, that's what's so preposterous. And this is a force we've been battling ever since. So now we have suddenly in the last 10 years, universities, institutions, putting money towards this. And guess what happens? The same phenomenon, an outsider who, for whatever personal or political or religious or whatever their trans skepticality is about, you know, they want to shut it all down.
- [31:38]
Marcus
Can I ask Marquis? I mean, something you said is that we need to be listening to trans people on this. I mean, Dr. Kass kind of says that too. And she did talk to young trans people.
- [31:55]
Marcy Bowers
I know, I understand that young adults.
- [31:58]
Marcus
And older trans people, like she says very clearly in her report, and even clearer I felt in our interview that there are absolutely kids who benefit from these treatments. And the question that we need to be asking ourselves right now is do we have enough evidence to be able to tell accurately who those kids are?
- [32:19]
Marcy Bowers
Okay, well, the evidence is there and it isn't her level of evidence. You know, she dismissed what she didn't like and she. And this is just what they did back in, you know, in the original Hopkins stuff, all the arguments, they're all the same. I mean, Just to show you her, you know, how does she come up with describing the onset due to things like pornography? How does she speculate that as a responsible pediatrician? How does she use an endpoint like getting a job in a world that is discriminatory? How do you measure. Get out of the house and call that the kind of scientific endpoint that we should be looking at? What about self reporting? This is what she won't listen to.
- [33:14]
Marcus
So you're saying, like, satisfaction, People being happy with the choice that they made.
- [33:21]
Marcy Bowers
A. Zane, I wish you could have been in my clinic last week. Two individuals who came about a year after their surgery. These girls were. When I first met them, they couldn't even look me in the eye. They could barely lift their head. They were barely alive. Their parents had deep circles under their eyes. They were doing poorly in school. They were, you know, it's all the cliche. I mean, it's a. Luckily, they hadn't taken their lives because they had supportive parents and they had access to treatment, but they went through surgery. And these girls are different. They are alive. And the personality that comes up, that is something that Dr. Kass has never seen. That is something that seeing once she would change her mind, her skepticism would melt. And that is what the aap, the apa, and the AMA all know.
- [34:33]
Marcus
I mean, I sort of asked her about this, too, Marci, this, you know, how to weigh clinical experience, what, you know, doctors like yourself see with their own eyes in the exam room versus the evidence, like when the evidence is not crystal clear. And she gave a pretty nuanced answer. She said it does absolutely does matter. But she also heard from doctors in this space who had legitimate concerns. And there isn't clear clinical consensus in this space that there are people who are worried about the new cohort that she's talking about. And.
- [35:17]
Marcy Bowers
Those are two separate things. But let's just say this is how medicine has always been conducted, is that you first treat the patient based on a hypothesis and your breadth of knowledge and what available science there is there. This is how innovation comes in any field. And then you can look back and record evidence of what you found. This is why it's so clear in the minds of so many, is that there is a vast amount of experience and a vast amount of deep understanding of this population.
- [35:59]
Marcus
Even with the teenagers that are the focus of her report.
- [36:05]
Marcy Bowers
Well, that's now. This is now the update here, but let me get to that. But this is the problem with the, you know, with the Hopkins shutdown of all the major US academic institutions. Remember, after Hopkins closure in 1979, Transcare continued, but where did it continue? It continued in the hands of private practitioners like Stanley Biber, my predecessor, because these patients didn't go away, they needed care. And he didn't look at studies, he didn't look at guidelines or data because there was none. He treated the patient first, he took the basic responsibility of medicine and that is to treat the patient first. Now what's going on now? You know, this what, you know, what the skeptics call social contagion. And then the flip from birth identified males to birth identified females, you know, that's the stuff that we have to drill down on and that's the stuff that requires the WPATH standards to be really re adhered to. But remember, we lost 35 years from this Hopkins closure, so expecting it to all return. And 80% of the literature in, in trans medicine has been published in the last 10 years. I mean, that's the number I've heard many, many times. It's astounding how much is actually published. So for it to be dismissed by a haughty old retired pediatrician who frankly doesn't know the population and hasn't seen the light in the eye return to the patients they treat, that's what, that's what really, that's what makes it in a way fatally flawed. Not that it can't be learned from, not that she had mal intent, it's just that it's going to make it harder for people and it's going to lead to more misery and it's being picked up by, and misrepresented and taken out of context, but by the conservative states that want to just, you know, be done with trans people altogether.
- [38:27]
Marcus
Is that your biggest concern with, with this report? That it's wielded politically in this moment by, you know, especially by Republicans who are already intent on banning this care?
- [38:40]
Marcy Bowers
I really don't care about the Republicans. My concern is with doing the right thing for the, for the children and adolescents and families that this affects. That's what I'm interested in. And when reports come out that show this, you know, two sided thing and the skepticism and the fact there's no evidence, this just adds fuel to their fire. Instead of saying, instead of saying, instead of saying, instead of saying that this is, you know, this is a nascent field, relatively speaking, and that it is, you know, its research has been essentially squelched for the last 35 years because of a similar backlash in 1979. This is Johns Hopkins 2.0.
- [39:27]
Marcus
Right. And so the research that everyone's saying we need, it's just becoming less likely.
- [39:34]
Azine Qureshi
That we're going to get it.
- [39:36]
Marcy Bowers
And it's all there because it doesn't lie. The truth really doesn't lie. The research and the data is certainly coming.
- [40:00]
Azine Qureshi
You lead one of the biggest studies in the country.
- [40:03]
Austin Mitchell
Of all the research happening in the U.S. one of the most anticipated studies was being led by Dr. Joe Olson Kennedy.
- [40:11]
Azine Qureshi
I know it's been, I think, like nine years since you got the grant, eight years since you started enrolling patients.
- [40:18]
Austin Mitchell
She'd been working on it ever since she got the big federal Grant back in 2015, the same year she had that debate with Laura Edwards Leeper at the gender conference. The grant had already produced multiple studies into youth gender medicine in the U.S. but a study that Joe was leading on psychological outcomes from puberty blockers hadn't yet published.
- [40:40]
Azine Qureshi
A lot of people have said, where is this study? We want the evidence to make the case for this care.
- [40:45]
Austin Mitchell
It promised to be the largest longitudinal study of its kind in the country.
- [40:49]
Azine Qureshi
Can you tell me a little bit about how the study is going?
- [40:53]
Hilary Cass
Sure.
- [40:54]
Joe Olson Kennedy
Well, I think first of all, Azine.
- [40:55]
Austin Mitchell
Talked to Joe as she was writing up her results.
- [40:58]
Joe Olson Kennedy
And here's the reality. They're in really good shape when they come in, and they're in really good shape after two years.
- [41:06]
Austin Mitchell
And so she'd found that on average, puberty blockers led to no change in psychological functioning for kids. She said that was unsurprising because on the whole, the kids were already doing well when they started. They had supportive parents and they knew they'd be receiving treatment.
- [41:24]
Joe Olson Kennedy
They never expected to go through the wrong puberty.
- [41:27]
Austin Mitchell
Nevertheless, the results made it another longitudinal study to fail to get the same positive results as the Dutch. And when Azeen asked her why she hadn't yet published the results.
- [41:39]
Joe Olson Kennedy
Now, to be quite frank, your manuscripts have to be so airtight. There's not even room for postulation anymore. Right.
- [41:48]
Azine Qureshi
Like you, because of the political environment.
- [41:51]
Joe Olson Kennedy
Yes.
- [41:52]
Austin Mitchell
She said it had to do with politics.
- [41:55]
Azine Qureshi
I mean, are you worried that people will say there was no change, therefore this didn't replicate the Dutch and it gets used against you or against the care?
- [42:07]
Joe Olson Kennedy
No, I think what is more, and I want to reframe, like, it's not necessarily worry, it's just care. It's care and concern about this information being interpreted to fit a narrative that isn't real. And so what concerns me is that people get their information on formally called Twitter and it's One sentence that says intervention after two years doesn't change outcomes, and then it's used in court against, well, we shouldn't use blockers because it doesn't impact them. It takes more than one sentence to talk about, well, what does that mean? I do not want our work to be weaponized. It has to be exactly on point, clear and concise, and that takes time.
- [43:05]
Austin Mitchell
In the months that followed that conversation, and as the US Presidential campaign heated up, the politics and the science only became more entangled. Jo came under criticism not just for the results of her study, but for but for sitting on them. Elon Musk amplified the criticisms on X. Zhou denied that the delay was because of politics and claimed the Times misrepresented her in its coverage. The Cass Review drew more direct attacks from US Providers. In a scathing critique co authored by Joe, Cass was accused of misusing data and ignoring the positive outcomes reported in many of the studies she identified as weak. The critique noted that the Cass Review was already being cited in legal battles in the U.S. those legal battles exposed internal documents from WPATH that showed the group acknowledging some of the same problems with the evidence that Cass did. All of us, the lead author of the group's guidelines, said, are painfully aware that there are many gaps in research to back up our recommendations. While we value clinical expertise, he wrote, the battle for legitimacy is being fought in controlled studies. He said that adding more convincing evidence would be critical to combating the attacks.
- [44:36]
Marcy Bowers
Can I ask you a question about.
- [44:39]
Austin Mitchell
The state of medical evidence at the present time? Not long after the evidence would be in front of the Supreme Court, we saw the Cass report, which found a complete lack of high quality evidence showing where the justices appeared likely to rule that given the uncertainty, the decision to ban the care should be left up to the states. But then, in January 2025, as President Trump took office, the care and the kids receiving it were pulled into something much larger and more existential.
- [45:21]
Marcy Bowers
As of today, it will henceforth be the official policy of the United States government that there are only two genders, male and female.
- [45:43]
Austin Mitchell
Next time in Part six, the now.
- [46:00]
Marcus
It.