She Who Must Be Named

A year ago today, the landmark Cass Review shook the foundations of gender-related care for children and young people. Yet, the review and its author have been ignored in Newfoundland and Labrador.

Dr. Hilary Cass

Harry Potter’s arch-enemy, Lord Voldemort, was so dreaded among the wizards of Hogwarts that they wouldn’t dare utter his name for fear of summoning disaster.

For the past year, it’s as if Newfoundlanders and Labradorians have been living in a bizarro version of J.K. Rowling’s fantasy world. Instead of a power-mad sorcerer, however, it is a dignified and compassionate English doctor who has assumed the mantle of She-Who-Must-Not-Be-Named.

You wouldn’t sense much of a threat looking at Hilary Cass, a distinguished paediatrician who has dedicated her life to the well-being of children. Her career includes a stint as president of England’s Royal College of Paediatrics and Child Health. And in 2014, she was named to the Order of the British Empire.

Given Dr. Cass’s reputation, she was a natural choice in 2020 to head an independent review of England’s Gender Identity Development Services (GIDS). Whistleblowers and a high-profile lawsuit had laid bare the centre’s irresponsible approach to gender-related care for minors.

GIDS had rushed children and young people toward puberty blockers and cross-sex hormones, putting them at risk for long-term side-effects. Some would go on to sex trait surgeries such as mastectomies.

Since around 2009, there has been explosion throughout the western world of young people presenting at clinics with gender dysphoria - that is, distress stemming from a discrepancy between their natal sex and their gender identity.

The demographics of young people experiencing gender dysphoria also changed dramatically - from mostly natal males who experienced gender incongruence since early childhood to mostly natal females whose incongruence didn’t arise until adolescence.

Meanwhile, a debate rages over whether this sudden shift is rooted in biology and greater social acceptance or in mental illness and peer influence.

Of particular concern is research noted in the Cass Review suggesting children and young people presenting with gender dysphoria have higher rates of conditions such as autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), anxiety, depression, eating disorders, self-harm, and adverse childhood experiences such as neglect, abuse or having been placed in foster care.

In many cases, GIDS clinicians were too willing to follow the lead of troubled young people diagnosing themselves as trans. But puberty blockers, cross-sex hormones and surgeries didn’t solve the underlying problems of those with serious mental health issues.

The emphasis was on affirmation rather than exploration.

The Cass Review led to the closure of GIDS, but its impact was felt far beyond England. In addition to investigating GIDS, Cass and a team of researchers from the University of York examined international standards for treating minors with gender dysphoria. And found them wanting.

Consequences

• The Cass Review found “no evidence that puberty blockers improve body image or dysphoria, and very little evidence for positive mental health outcomes.”
  

• Subsequently, the entire United Kingdom - England, Scotland, Wales and Northern Ireland - banned the routine prescription of puberty blockers for people under 18 experiencing gender dysphoria, except in clinical trials. And, just this month, the Republic of Ireland enacted its own ban.
  

• As systematic reviews in Finland (2020) and Sweden (2022) had done earlier, the Cass Review cast serious doubt on the legitimacy of standards of care endorsed by the World Professional Association for Transgender Health (WPATH) - the same standards followed by clinicians in Newfoundland and Labrador.
  

• The review found that WPATH had not followed international standards for guideline development.
  

• It ranked WPATH’s guidelines as low in “rigour of development.” Specifically, it alleged WPATH did not sufficiently search for evidence, was unclear about the link between its recommendations and supporting evidence, and did not sufficiently ensure that “health benefits, side-effects and risks had been considered in formulating (its) recommendations.”
  

• The Cass Review found that WPATH engaged in the ethically questionable practice of “circular referencing.” The 8th version of WPATH’s guidelines (WPATH 8) cited many national and regional guidelines in supporting its own - even though those other guidelines had themselves been heavily influenced by WPATH 7. “The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor,” wrote Dr. Cass.
  

• WPATH has been embroiled in scandal for most of the past year. Internal documents uncovered during a U.S. trial revealed it suppressed research it commissioned by Johns Hopkins University. It also succumbed to political pressure to eliminate minimum age requirements for “gender-related hormones and surgeries” in its latest standards of care.
  

• The Cass Review and the scandals involving WPATH have had a profound impact in jurisdictions outside of the United Kingdom in the past year. For example, the Cass Review has played a pivotal role in court cases and the public debate over gender-related care in the United States, where so far 26 states have banned such care for those under the age of 18.
  

• Influenced by the Cass Report, Australia has recently initiated an independent review of the evidence base for providing puberty blockers and cross-sex hormones to adolescents. The Australian state of Queensland has suspended the use of puberty blockers and cross-sex hormones for people under the age of 18.

The WPATH guidelines, indeed the entire gender-affirming approach, have been challenged by the findings of the Cass Review. Yet, online searches yield no mention of Dr. Cass or her review by Newfoundland and Labrador journalists, clinicians or legislators in the past year.

Why not?

I can’t speak for other journalists, for doctors or for government. But I do know people who are afraid to discuss the issue openly for fear of losing friends, family or their jobs. They feel they will be accused being transphobic and shunned for it.

In the introduction to her team’s final report, Dr. Cass spoke about the toxicity within the debate over gender-related care for minors.

"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 behaviour,” Dr. Cass said. “This must stop.”

But it didn’t.

After her team released its final report, Dr. Cass herself was subjected to online harassment and threats. Things got so bad that she was advised by security not to use public transportation. Weary of it all, Dr. Cass later declined to head an inquiry into gender-related care for adults.

While I am not aware of such extreme intimidation here in Newfoundland and Labrador, people are still afraid to speak frankly about the issue. In such an atmosphere, the citizens of this province have not been provided with all the information they need to make informed judgments and decisions about gender-related care for minors.

So, starting today, on the first anniversary of the final Cass Report’s release, this newsletter will explore those aspects gender-related care that have been under-reported or untold in this province.

My aim is a free, informed and respectful public discourse about gender-related care for minors.

My bare-minimum hope is that people in this province will no longer be afraid to say someone’s name out loud.

See also Background: The Cass Effect

Coming Soon: When It’s Your Own Child: A Mother’s Story

Note: The public domain photo of Dr. Cass was borrowed from the final report of the Independent Review into Gender Development Services (2024).