Where American and British Doctors Agree on Pediatric Gender Medicine
The highly publicized United Kingdom report on pediatric gender care doesn’t recommend banning puberty blockers or gender-affirming hormones for adolescents.
Gender-affirming medical care for transgender youth is back in the news following Donald Trump’s executive order calling for a ban on this medical care for anyone under the age of nineteen. His executive order came less than a month after the U.S. Supreme Court heard oral arguments on whether bans on this care violate the Equal Protection Clause of the U.S. Constitution. The Trump executive order was blocked this week by a Maryland federal judge. This came just days after another judge in Washington similarly issued an opinion blocking the order.
A topic that came up in Supreme Court filings, and agin when the Trump administration tried to defend its executive order, is the United Kingdom’s National Health Service Report, “Independent review of gender identity services for children and young people,” often referred to as the Cass Report, referencing the lead author of the report, Dr. Hilary Cass. Many have inappropriately used it as justification to ban gender-affirming medical care for adolescent gender dysphoria (a clinical term for distress from one’s gender identity not aligning with one’s sex assigned at birth). They suggest that it recommends banning treatments like pubertal suppression and gender-affirming hormones for minors. The report recommends no such thing.
Rhetoric from the lead author of the report, Dr. Hilary Cass, has admittedly been charged. In an interview with The New York Times, she alleged that American doctors are “out of date” when it comes to the treatment of adolescent gender dysphoria. As someone who’s published some of the latest peer-reviewed research in this field, I take obvious issue with that statement and have many qualms with the report. However, what’s most interesting to me are the places where the Cass Report and mainstream medical guidelines for the treatment of adolescent gender dysphoria agree.
First and foremost, neither the Cass Report nor mainstream American medicine believe that gender-affirming medical care (puberty blockers, estrogen, and testosterone) should be banned for adolescent gender dysphoria. As Dr. Cass said in her interview with The New York Times, “there are young people who absolutely benefit from a medical pathway, and we need to make sure those young people have access.” While Cass recommends that youth in the U.K. access puberty blockers exclusively through clinical trials, and most American doctors think this isn’t feasible or ethical, everyone is on the same page that puberty blockers should not be completely banned, as nearly half of U.S. state legislatures have done, against the recommendation of every major American medical organization. Similarly, the Cass Report acknowledges that gender-affirming hormones like estrogen or testosterone may be considered at age sixteen, though it does recommend an “extremely cautious approach and a strong clinical rationale.” The Cass Report further notes, “for some, the best outcome will be transition” and that medical teams caring for transgender youth should include endocrinologists “for the subgroup for whom medical treatment may be considered appropriate.”
Second, both the Cass Report and American medical guidelines, in line with Cass’s comments about a “strong clinical rationale,” recommend a comprehensive mental health evaluation prior to an adolescent starting any gender-affirming medical intervention. The Endocrine Society Guidelines and the World Professional Association for Transgender Health Standards of Care are the guidelines American physicians follow when treating transgender youth. Both require such mental health evaluations prior to medical interventions for minors, much like the Cass Report recommends. As I recently explained in The Journal of the American Academy of Child & Adolescent Psychiatry, these mental health evaluations involve collecting a history of the young person's gender identity, screening for other mental health conditions, explaining distinctions between gender identity and sexual orientation, and ensuring that both parents and adolescents understand all the risks, benefits, and potential side effects of treatment, among many other topics. Both American physicians and the Cass Report agree that, following these assessments, medical interventions will be appropriate for some, but not all transgender adolescents, and these evaluations are helpful for identifying both medical and non-medical ways to support young people. The Cass Report emphasizes that this assessment should include, “co-develop[ing] a plan for addressing gender issues, which may involve any combination of social, psychological, and physical interventions, depending on the clinical scenario.”
The Cass Report and American doctors agree that gender-affirming medical interventions like pubertal suppression and hormones are only one potential part of a treatment plan for transgender youth. It’s also essential to work with a young person’s environment to make sure they are supported and not being bullied. It’s vital to ensure families are having open and effective communication around gender.
It's also important to make sure any co-existing mental health conditions are properly treated. As a psychiatrist at an academic medical center, I see patients with complex mental health presentations. Some adolescents with gender dysphoria experience other co-existing conditions, including autism spectrum disorder, obsessive compulsive disorder, major depressive disorder, and social anxiety disorder, to name just a few. Despite the misconception that transgender youth are rushed into medical interventions and that other potential mental health conditions are ignored, the WPATH guidelines note that prior to any gender-affirming medical interventions being started, other co-existing mental health conditions must be reasonably well controlled. They also note that for some complex clinical presentations (e.g., co-occurring autism spectrum disorder), a longer and more thorough assessment may be needed to identify all the best avenues of support for young people. The Cass Report reads, “for those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems such as family breakdown, barriers to participation in school life or social activities, bullying and minority stress” and guidelines from WPATH and The Endocrine Society are in clear agreement.
At the end of the day, I maintain optimism that physicians around the world want what’s best for transgender youth, and for them to have happy thriving lives. I hope politicians and policymakers will take note of the important common ground between the Cass Report and mainstream American and international medical organizations. Attempts to ban gender-affirming medical care are not in alignment with this consensus.
Jack Turban MD is a pediatric psychiatrist and author of the book Free to Be: Understanding Kids & Gender Identity.