O n this side of the Atlantic, the Cass Review has fallen on deaf ears.
Dr. Hilary Cass released her final report for England’s National Health Service two months ago, clearly demonstrating that puberty-blockers and hormonal treatments for trans-identified children and teens lack supporting evidence. NHS England has now banned puberty-blockers in clinical care and will be restricting their use to research settings. Yet U.S. medical leaders have responded with silence, inaction, or both, proving that the physical and emotional well-being of youth has taken a back seat to social and political agendas.
The American Academy of Pediatrics (AAP) is a case in point. Since the Cass Review’s release, the AAP has refused to recognize the problematic nature of its policy that promotes hormonal and surgical treatments of trans-identified minors. This is critical because the AAP is arguably one of the most powerful institutions supporting this unproven and controversial treatment. The AAP uses its authority and trust to influence legislative debate, judicial proceedings, and parental decisions nationwide.
Initially, the AAP declined to comment on the Cass Review. A month after its release, Dr. Cass gave her first U.S. interview to NPR. It was only then that the AAP released a short statement that defended irreversible hormonal and surgical treatments, wrongly claiming they are “grounded in evidence and science.” The AAP claims its policy enjoys “strong consensus” and is “medically necessary and appropriate.”
The AAP is increasingly isolated in its claims. Health-care authorities, clinicians, and researchers in England, Scotland, Wales, Finland, Sweden, Norway, Denmark, France, and — as of last week — Germany and Switzerland have reviewed the evidence, recognized the harms, and come to the exact opposite conclusions of the AAP.
The AAP’s only other response to the Cass Review came in the New York Times. Reacting to another interview with Cass, in which she called the U.S. approach “out of date,” the AAP maintained that it was not misleading families. In a letter to the editor, the AAP’s president disputed that the evidence is weak and promised that “Dr. Cass’s conclusions will be considered” in the academy’s own review of evidence, which was announced last August. Why is the AAP waiting to consider the Cass Review when other countries are acting to protect children now?
That promised evidence review raises additional concerns. The AAP’s announcement of the review was accompanied by a reaffirmation of its existing policy, strongly suggesting that the review will reach the AAP’s predetermined conclusions — an approach contrary to good scientific practice.
Other signs indicate that the AAP review process is compromised. In April, I joined 14 fellow academy members in submitting a resolution requesting that AAP leadership update its 2018 policy to reflect the fact that every European review has shown that poor evidence supports these treatments. We also asked the AAP to disclose the protocol and methodology for its promised evidence review. Such transparency is standard and critically necessary. Yet nearly a year after the review’s announcement, the AAP has not provided this basic information.
This is the fifth year that members like me have petitioned the AAP to review its policy, yet our resolution has already died. It failed to gain sponsorship from AAP committees or chapters, a necessary step. Some AAP leaders have told me privately that they support these resolutions, but they face pressure from the academy’s leaders to steer clear. As such, regular AAP members have been effectively silenced.
These actions reflect a group driven by a political agenda rather than a group seeking medical excellence based on evidence. Patients, parents, and policy-makers need the AAP to engage honestly with the facts. The critical question remains: What will it take to restore the American Academy of Pediatrics to its medical mission?
England’s experience offers valuable lessons. A young woman who regretted her testosterone treatment and mastectomy joined a lawsuit and judicial review of the NHS treatment policy. Soon after, the Cass Review began its work, which eventually revealed the dramatic rise in patient volumes, lack of patient safeguarding, the harm and regret that was occurring, and the “threadbare” evidence, as described by the British Medical Journal’s editor in chief, that is used to justify this care.
The AAP should be wary of lawsuits. Last fall, a 20-year-old woman sued the author of the AAP’s gender-treatment policy after he treated her with testosterone, beginning when she was 14. Her lawsuit accuses the AAP and the policy’s author of “civil conspiracy, fraud, [and] medical malpractice.”
This lawsuit is likely the first of many. The AAP’s guidelines promote hormonal and surgical treatments for youths with gender distress, and tens of thousands of minors have undergone this unproven protocol. I have met dozens who regret what was done to them — puberty-blockers, hormones, mastectomies, hysterectomies, and castrations. They and many others now face lifelong physical problems, loss of sexual function, and infertility. It is right for these youths to seek justice from the people who pushed them down this road.
Much of the blame can be laid at the feet of the American Academy of Pediatrics. The Cass Review should have served as a wake-up call for the AAP and other prominent medical institutions. What a shame that the only way to spur necessary change seems to be the continued suffering of children, teens, and young adults.