Hilary Cass is the kind of hero the world needs today. She has entered one of the most toxic debates in our culture: how the medical community should respond to the growing numbers of young people who seek gender transition through medical treatments, including puberty blockers and hormone therapies. This month, after more than three years of research, Cass, a pediatrician, produced a report, commissioned by the National Health Service in England, that is remarkable for its empathy for people on all sides of this issue, for its humility in the face of complex social trends we don’t understand and for its intellectual integrity as we try to figure out which treatments actually work to serve those patients who are in distress. With incredible courage, she shows that careful scholarship can cut through debates that have been marked by vituperation and intimidation and possibly reset them on more rational grounds.
Cass, a past president of Britain’s Royal College of Pediatrics and Child Health, is clear about the mission of her report: “This review is not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves or rolling back on people’s rights to health care. It is about what the health care approach should be, and how best to help the growing number of children and young people who are looking for support from the N.H.S. in relation to their gender identity.”
This issue begins with a mystery. For reasons that are not clear, the number of adolescents who have sought to medically change their sex has been skyrocketing in recent years, though the overall number remains very small. For reasons that are also not clear, adolescents who were assigned female at birth are driving this trend, whereas before the late 2000s, it was mostly adolescents who were assigned male at birth who sought these treatments.
Doctors and researchers have proposed various theories to try to explain these trends. One is that greater social acceptance of trans people has enabled people to seek these therapies. Another is that teenagers are being influenced by the popularity of searching and experimenting around identity. A third is that the rise of teen mental health issues may be contributing to gender dysphoria. In her report, Cass is skeptical of broad generalizations in the absence of clear evidence; these are individual children and adolescents who take their own routes to who they are.
Some activists and medical practitioners on the left have come to see the surge in requests for medical transitioning as a piece of the new civil rights issue of our time — offering recognition to people of all gender identities. Transition through medical interventions was embraced by providers in the United States and Europe after a pair of small Dutch studies showed that such treatment improved patients’ well-being. But a 2022 Reuters investigation found that some American clinics were quite aggressive with treatment: None of the 18 U.S. clinics that Reuters looked at performed long assessments on their patients, and some prescribed puberty blockers on the first visit.
Unfortunately, some researchers who questioned the Dutch approach were viciously attacked. This year, Sallie Baxendale, a professor of clinical neuropsychology at the University College London, published a review of studies looking at the impact of puberty blockers on brain development and concluded that “critical questions” about the therapy remain unanswered. She was immediately attacked. She recently told The Guardian, “I’ve been accused of being an anti-trans activist, and that now comes up on Google and is never going to go away.”
As Cass writes in her report, “The toxicity of the debate is exceptional.” She continues, “There are few other areas of health care 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.”
Cass focused on Britain, but her description of the intellectual and political climate is just as applicable to the U.S., where brutality on the left has been matched by brutality on the right, with crude legislation that doesn’t acknowledge the well-being of the young people in question. In 24 states Republicans have passed laws banning these therapies, sometimes threatening doctors with prison time if they prescribe the treatment they think is best for their patients.
The battle lines on this issue are an extreme case, but they are not unfamiliar. On issue after issue, zealous minorities bully and intimidate the reasonable majority. Often, those who see nuance decide it’s best to just keep their heads down. The rage-filled minority rules.
Cass showed enormous courage in walking into this maelstrom. She did it in the face of practitioners who refused to cooperate and thus denied her information that could have helped inform her report. As an editorial in The BMJ puts it, “Despite encouragement from N.H.S. England,” the “necessary cooperation” was not forthcoming. “Professionals withholding data from a national inquiry seems hard to imagine, but it is what happened.”
Cass’s report does not contain even a hint of rancor, just a generous open-mindedness and empathy for all involved. Time and again in her report, she returns to the young people and the parents directly involved, on all sides of the issue. She clearly spent a lot of time meeting with them. She writes, “One of the great pleasures of the review has been getting to meet and talk to so many interesting people.”
The report’s greatest strength is its epistemic humility. Cass is continually asking, “What do we really know?” She is carefully examining the various studies — which are high quality, which are not. She is down in the academic weeds.
She notes that the quality of the research in this field is poor. The current treatments are “built on shaky foundations,” she writes in The BMJ. Practitioners have raced ahead with therapies when we don’t know what the effects will be. As Cass tells The BMJ, “I can’t think of another area of pediatric care where we give young people a potentially irreversible treatment and have no idea what happens to them in adulthood.”
She writes in her report, “The option to provide masculinizing/feminizing hormones from age 16 is available, but the review would recommend extreme caution.” She does not issue a blanket, one-size-fits-all recommendation, but her core conclusion is this: “For most young people, a medical pathway will not be the best way to manage their gender-related distress.” She realizes that this conclusion will not please many of the young people she has come to know, but this is where the evidence has taken her.
You can agree or disagree with this or that part of the report, and maybe the evidence will look different in 10 years, but I ask you to examine the integrity with which Cass did her work in such a treacherous environment.
In 1877 a British philosopher and mathematician named William Kingdon Clifford published an essay called “The Ethics of Belief.” In it he argued that if a shipowner ignored evidence that his craft had problems and sent the ship to sea having convinced himself it was safe, then of course we would blame him if the ship went down and all aboard were lost. To have a belief is to bear responsibility, and one thus has a moral responsibility to dig arduously into the evidence, avoid ideological thinking and take into account self-serving biases. “It is wrong always, everywhere, and for anyone, to believe anything upon insufficient evidence,” Clifford wrote. A belief, he continued, is a public possession. If too many people believe things without evidence, “the danger to society is not merely that it should believe wrong things, though that is great enough; but that it should become credulous, and lose the habit of testing things and inquiring into them; for then it must sink back into savagery.”
Since the Trump years, this habit of not consulting the evidence has become the underlying crisis in so many realms. People segregate into intellectually cohesive teams, which are always dumber than intellectually diverse teams. Issues are settled by intimidation, not evidence. Our natural human tendency is to be too confident in our knowledge, too quick to ignore contrary evidence. But these days it has become acceptable to luxuriate in those epistemic shortcomings, not to struggle against them. See, for example, the modern Republican Party.
Recently it’s been encouraging to see cases in which the evidence has won out. Many universities have acknowledged that the SAT is a better predictor of college success than high school grades and have reinstated it. Some corporations have come to understand that while diversity, equity and inclusion are essential goals, the current programs often empirically fail to serve those goals and need to be reformed. I’m hoping that Hilary Cass is modeling a kind of behavior that will be replicated across academia, in the other professions and across the body politic more generally and thus save us from spiraling into an epistemological doom loop.
