Imagine a comprehensive review of research on a treatment for children found “remarkably weak evidence” that it was effective. Now imagine the medical establishment shrugged off the conclusions and continued providing the same unproven and life-altering treatment to its young patients.

This would indeed be really hard to imagine, because treatment for children is remarkably effective.

This is where we are with gender medicine in the United States.

If you believe the lying New York Times, sure.

It’s been three months since the release of the Cass Review, an independent assessment of gender treatment for youths commissioned by England’s National Health Service. The four-year review of research, led by Dr. Hilary Cass, one of Britain’s top pediatricians, found no definitive proof that gender dysphoria in children or teenagers was resolved or alleviated by what advocates call gender-affirming care, in which a young person’s declared “gender identity” is affirmed and supported with social transition, puberty blockers and/or cross-sex hormones. Nor, she said, is there clear evidence that transitioning kids decreases the likelihood that gender dysphoric youths will turn to suicide, as adherents of gender-affirming care claim. These findings backed up what critics of this approach have been saying for years.

“The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” Cass concluded. Instead, she wrote, mental health providers and pediatricians should provide holistic psychological care and psychosocial support for young people without defaulting to gender reassignment treatments until further research is conducted.

After the release of Cass’s findings, the British government issued an emergency ban on puberty blockers for people under 18. Medical societies, government officials and legislative panels in Germany, France, Switzerland, Scotland, the Netherlands and Belgium have proposed moving away from a medical approach to gender issues, in some cases directly acknowledging the Cass Review. Scandinavian countries have been moving away from the gender-affirming model for the past few years. Reem Alsalem, the United Nations special rapporteur on violence against women and girls, called the review’s recommendations “seminal” and said that policies on gender treatments have “breached fundamental principles” of children’s human rights, with “devastating consequences.”

But in the United States, federal agencies and professional associations that have staunchly supported the gender-affirming care model greeted the Cass Review with silence or utter disregard.

Good. Yang et al. made a greater contribution to science when they discovered how wombats produce cube-shaped feces. For that, they were awarded the Ig Nobel Prize. For her contribution in 21st century race science, Hilary Cass has been awarded the blood sacrifice of thousands of transgender children.

There’s been no response from the Department of Health and Human Services, whose website says that “gender-affirming care improves the mental health and overall well-being of gender diverse children and adolescents” and which previously pushed to eliminate recommended age minimums for gender surgery. Nor has there been a response from the American Medical Association, which also backs gender-affirming care for pediatric patients.

When I reached out to H.H.S. officials, they declined to speak on the record. The A.M.A. referred me to the American Academy of Pediatrics and the Endocrine Society. The Endocrine Society, the primary professional organization of endocrinologists, told me, “the Cass Review does not contain any new research that would contradict the recommendations made in” the society’s own guidelines. (Cass’s mandate was to assess the quality and importance of existing research.)

Cass Review is good science because I agree with it. Endocrine Society is bad science because I disagree with it.

When the NPR station WBUR interviewed Cass, it asked the American Academy of Pediatrics for a response to the review. The pediatricians’ group issued a statement that said nothing about the Cass Review. Instead, it denounced what it characterized as “politically infused public discourse” and promised to stay the course, conducting its own research review, which it agreed to do last year under intense pressure. In later comments to The Times, Dr. Ben Hoffman, the group’s president, said it reviewed the Cass report and “added it to the evidence base undergoing a systematic review.” Notably, in assessing 23 international guidelines on gender care, the Cass Review rated the research underlying the American Academy of Pediatrics guidelines among the least rigorous.

Why are their scientists taking time to do science Why can't they just make shit up like my scientists?!

The World Professional Association for Transgender Health, an advocacy organization based in the United States whose standards of gender care are closely followed domestically, said Cass was not qualified to judge because she had not practiced gender medicine herself. (To ensure independence, the National Health Service chose Cass for precisely this reason.)

Truly, people in this country have had enough of experts.

WPATH also said its own standards are “based on far more systematic reviews” than the Cass report. But four years ago, WPATH apparently blocked publication of a Johns Hopkins systematic review it had commissioned that also found scant evidence in favor of the gender-affirming approach. Recently released emails show that WPATH leaders told researchers that their work should “not negatively affect the provision of transgender health care in the broadest sense.”

In other words, the United States continues to put ideology ahead of science.

American medicine, Cass told The Times in May, is “out of date.” She said not a single American medical association or governmental official had reached out to discuss her report. “I think that’s where you’re misleading the public,” Cass said. “You need to be honest about the strength of the evidence and say what you’re going to do to improve it.”

It really is out of date. Why are we still using spironolactone? Where the fuck are the gene treatments?

Why would our government and medical institutions continue to frame gender-affirming care as medically necessary and lifesaving despite Cass’s assessment? Especially given growing concerns about the risks and irreversible consequences of gender interventions for youths, including bone density loss, possible infertility, the inability to achieve orgasm and the loss of functional body tissue and organs including breasts, genitals and reproductive organs?

Think of the children's orgasms and reproductive function!

When you consider our polarized politics, the outsize influence of advocacy groups and the particularities of our medical system, America has a lot invested in holding its ground.

THE POLITICAL STAKES

In Britain, both the Labour and the Tory parties quickly accepted the Cass Review’s findings. But in the United States, the issue is held hostage to each political party’s tendency to bend to its extremes. Republicans are beholden to religious and social conservatives. Democrats have bowed to transgender advocacy groups. The result is a struggle between those who believe they are trying to “save” children from transgenderism and those trying to “protect” children from transphobes.

Not beating the clueless allegations here.

Public opinion, on the other hand, is more moderate. While most Americans believe in transgender legal protections and anti-discrimination laws, there is decidedly less public support for what transgender activists more broadly promote as trans rights. For example, they view it as discriminatory to bar trans women from female sports teams. But there is significant evidence that trans women athletes have a competitive advantage of male hormones and musculature, and 69 percent of Americans believe they should play on teams that match their biological sex. Similarly, activists think trans women should be allowed in any female space, but should trans women who are still physically male be allowed in women’s prisons or refuges for vulnerable women like domestic abuse centers and rape crisis centers? Activists and those who agree with them also think school officials should be able to protect children by not telling their parents that they are transitioning, but parents say they have a right to know.

People's feelings matter when they agree with me

The Biden administration has essentially ceded the issue to the progressive wing of the Democratic Party, incorporating gender-affirming protocols into Department of Health and Human Services policy. Moreover, recently revealed emails indicate that President Biden’s assistant secretary of health, Dr. Rachel Levine, a pediatrician and transgender woman, successfully pushed WPATH to remove age requirements from its guidelines for gender medicine before their publication, because — mixing political and public health concerns — she thought supporters of gender treatment bans might cite them to show that the procedures are harmful. (WPATH’s draft guidelines had originally recommended age minimums of 14 for cross-sex hormones, 15 for mastectomies, 16 for breast augmentation or facial surgery and 17 for genital surgeries or hysterectomies.)

Critical support to Dr. Levine for pushing WPATH to rescind its cissexist guidelines. If cis girls are allowed to go through puberty at 12 or younger, why can't trans girls?

Republicans have in turn seized on transgender rights and medicine as a potent culture war issue. This makes it challenging for progressives, liberals and moderates to take any stand on gender issues that might be in line with a party that has become so associated with extreme positions. Some Republicans have even pushed for policies that would regulate adult transitions or would amount to outright discrimination.

Guys if we move right we'll pick up republican voters trust me trust me trust me trust me

AN IDEOLOGICAL IMPASSE

America’s current policies are based on transgender advocates’ belief that all people have an innate sense of their “gender identity” irrespective of their sex. Sex, according to this belief, is merely “assigned” at birth, whereas a person’s chosen gender is the primary determinant of one’s true identity.

Famously transgender advocates all agree on what gender and sex is.

In this view, it is society’s and medicine’s job to affirm the gender that children say is theirs and to help them to socially, medically and sometimes surgically align their bodies accordingly. As advocates often put it, children know who they are.

Well you take for granted that cis kids do!

Gender-affirming care can include social transition (allowing kids to change their name, appearance and pronouns, for example, in schools and other public settings), prescribing medicine to stall puberty and administering cross-sex hormones. The off-label use of puberty blockers is intended to give children time to think about their gender before their bodies go through sexual development. If they proceed with cross-sex hormones, their bodies, particularly if they’re male, can then more closely resemble that of the opposite sex. Surgery, including mastectomies, facial reconstruction and removal of male genitalia, is a possible final step.

And puberty blockers are the compromise treatment. Cis kids get to go through puberty when their bodies tell them to, while trans kids at best get to Think About It for several years until the Government or Daddy and Mommy say it's Okay.

Any effort to question or slow this process for a minor diagnosed with gender dysphoria or distress, or to treat a child’s anxiety or depression first, is often denounced as gatekeeping — preventing children from living out their true identity. Such efforts, activists believe, are attempts to reduce the number of visible trans people.

It's stalling for time. The Purpose of a System Is What It Does. Stall for time. Force the kids into corrective puberty. Get them to kill themselves. If they don't, well they're gonna have a harder time to pass. Maybe someone else will do it?

Instead of accepting normal gender nonconformity in kids (e.g., effeminate boys and tomboy girls) — and perhaps an early sign of same-sex attraction — advocates of gender ideology are more likely to view it as an indication of probable transness.

It's okay just to be an effeminate boy. Society loves those by the way. (can we get a people's joker emote please)

All of this frames gender treatments as ethically and medically necessary.

Yes.

THE AMERICAN MEDICAL DILEMMA

The Cass Review concluded that gender dysphoria is real and can cause significant distress, but that it is often temporary. Research has shown it tends to resolve with puberty and sexual maturation. Many kids who experience gender distress during childhood or adolescence grow out of it and are often gay or bisexual.

The Cass Review recommends a more holistic approach to treating gender dysphoria in kids. This involves untangling gender discomfort from common pre-existing conditions like autism spectrum disorder and A.D.H.D. and treating it alongside frequent comorbidities, which include anxiety, self-harm and eating disorders. A mental health counselor can help children with any difficulties during puberty and in coming to terms with their sexual orientation — without pathologizing either.

Vaccines cause transgenderism.

The goal throughout is to help. This includes working with kids to understand the causes of their gender dysphoria, relieve its symptoms, help resolve it or, in a case that proves persistent, consistent and insistent, help kids understand the pros and cons of pursuing gender reassignment for when they enter adulthood.

Trans activists warn that this approach is akin to the way the medical establishment wrongly treated same-sex attraction for years, as a mental illness. But then, no one ever needed to take hormones or have surgery to accept a same-sex attraction.

It's different this time!!!!!

It’s hard to imagine another clinical protocol in which such serious medical decisions, with potential risks and permanent consequences, are so heavily grounded in a young patient’s self-diagnosis. In this light, gender transition treatments for minors can even be considered unethical.

If you think about it, being gay is unethical too. They could catch the gay virus!!! We're just looking out for you.

This is not to say that doctors are in any way trying to harm children. Nor that all doctors and mental health professionals necessarily believe in every aspect of gender-affirming care or interpret it the same way. Many members of professional organizations, and many Americans, have embraced gender-affirming care because it has been portrayed as the most compassionate approach for an often marginalized group.

Already the gender-affirmation model is taught in leading medical schools, and all the major professional medical organizations in the United States have officially embraced it in their guidelines, a fact often cited by advocates as evidence of their validity.

This wholesale adoption of gender-affirming care is also a result of the differences between a centralized public health system like Britain’s and a privatized, diffuse health care system like ours. “Doctors are paid for each intervention, and thus have an incentive to give patients what they ask for,” The Economist noted in a recent editorial urging the United States to catch up with recent developments in gender medicine.

American healthcare is incentivized to make people transition? HAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHA

Given how entrenched the gender-affirmating model has become, reversing course won’t be easy. If the medical profession turns away from the notion that transitioning young people is necessary and lifesaving, it could open itself up to malpractice suits. Consider that in Britain, a lawsuit by a gay girl named Keira Bell against Britain’s leading gender clinic instigated the investigation that led to the Cass Review.

“I’m already hearing from the boards of directors and trustees of some hospital systems who are starting to get nervous about what they’ve permitted,” Erica Anderson, a former president of the U.S. Professional Association for Transgender Health and a transgender woman, told the British Medical Journal in May. In recent years, a number of detransitioners in the United States have brought suit charging malpractice or the failure to provide informed consent. If American doctors admit their approach was wrong, it’s going to be a costly and politically explosive practice to undo.

Not content with the repeal of affirmative action, they're trying to do the same thing to trans healthcare

A BETTER PATH FORWARD

In the absence of an official response to the Cass Review or updated guidance from our medical or governmental institutions, a number of trans activists and L.G.B.T.Q. advocacy groups have baselessly accused Cass of bias and of assuming right-wing talking points. One activist criticized her for meeting with a pediatrician who worked with Gov. Ron DeSantis in Florida, an emphatic adversary of trans advocates. But that was just one of more than 1,000 meetings she held with various experts and stakeholders from all perspectives as part of her review.

“I have faced criticism for engaging with groups and individuals who take a social justice approach and advocate for gender affirmation, and have equally been criticized for involving groups and individuals who urge more caution,” Cass remarked in her report.

You should face a lot more than criticism.

Some critics have dissected Cass’s methodology and assumptions while grudgingly accepting some of her findings; others have attacked her personally. Some even cynically labeled Cass’s advocacy of psychotherapy akin to wholly discredited gay-conversion therapy.

Other gender medicine advocates and activists found Cass’s criteria for including and evaluating studies unreasonably high. Her criteria disqualified guidelines and smaller studies that many American advocates prefer to cite as evidence. (Cass found many of the guidelines used circular referencing in which they cite one another’s recommendations to help bolster their respective claims.)

The clear objective in all of these cases has been to discredit Cass and sideline her conclusions.

Such efforts are typical in the United States, where doctors, mental health professionals, parents and other caregivers who disagree with the widely practiced protocols are attacked and feel intimidated.

Vilifying well-intentioned professionals on social media must stop, Cass wrote. “Polarization and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse, and in the long run will also hamper the research that is essential to finding the best way of supporting them to thrive.”

Freeing gender treatment from political ideology and instituting evidence-based guidelines would allow parents to trust doctors to provide the best care for their kids. It would also enable parents to trust their medical team to consider other potential interventions in those rare instances in which a child’s gender distress is consistent, insistent and persistent. And it would eliminate any basis for extreme measures like legal bans.

A child's body is a matter for its parents and the state. NOT for itself.

It’s bound to be hard for many Americans to reconsider what they’ve heard for years as being settled science and a proven path of treatment, especially for a group that has faced considerable prejudice and political attack. Most people truly want to do what’s best for kids who are in any way suffering.

But there is no basis to rush putting kids on an irreversible path of medicalization. With children’s health and well-being at stake, effective, evidence-based and compassionate health care must be accepted. It’s one thing to pursue a medical path not knowing whether it’s effective; it’s quite another to persist on that path with no solid evidence to support it.

Despite the personal or professional costs to admitting its errors, it is time for people in the American medical and political establishments to open their minds and listen to those doctors who have fully examined the evidence.