Hilary Cass and Those Uncomfortable Questions: The Orthodoxy of Transgender Medicine

Hilary Cass, a Scottish pediatrician has done a courageous thing: She has insisted on critically evaluating the science behind current medical practice.

Dr. Hilary Cass

And not just any medical practice, a practice which in the commercial medical system of the United States has become a mighty industry, and in the socialized national health systems of Scandinavia, the Netherlands, France and the United Kingdom has skyrocketed into a huge cost and some would say, burden, for those publicly funded systems: Transgender Clinics.

Her report was commissioned and prompted owing to the explosion in demand for transgender care seen across Europe. Some have asked, "Where have all these kids been, until now?" Tens of thousands of children from age 10 to 18 have been brought to clinic by their parents with the chief complaint: I do not feel like a girl, although I was born a girl. I'm in the wrong body. I am the wrong sex for what I am.

This is called "gender dysphoria."

This complaint is not new, but what is new is the vast numbers of children presenting for care.

Some have claimed these kids were always out there in the real world, but like homosexuals, they were in the closet, afraid to report the torment they were going through.

Unlike homosexuals, however, these children are not seeking to be simply left alone; these children are patients because they are presenting themselves asking doctors to help them, and this help takes the form of powerful hormones and, ultimately for some, reconstructive surgery and castration.

More than fifty years ago, patients with a variety of abnormalities in production of various hormones, usually testosterone or its downstream products, were described, and some of these people were born with "ambiguous genitalia" which could not be clearly called either scrotum or vulva, penis or clitoris. Some were born with normal appearing female external genitalia, i.e. vulva, clitoris, but who in fact did not have female internal genitalia (i.e. uterus, ovaries). But these patients could be understood biochemically and ultimately, genetically. 

The current wave of patients presenting to transgender clinics have no such biochemical or genetic abnormalities yet identified.

Curiously, Dr. Cass notes, over the past decade most of the flood of patients have been requesting female to male transition, which was not the case twenty years ago.

When she looked at the data to try to ascertain the fates of kids who had been "transitioned" to the opposite gender, it was not clear, but it appeared many if not most of the preadolescents treated at the clinics had, by age 18, reverted to identifying as the gender they had originally been designated at birth, mostly female.

Simply put, these children had "outgrown" their problem or "got over it." (Not Dr. Cass's words)

I was particularly interested in this report because this whole phenomenon has been such an anomaly in medicine: It is the only session at the Endocrine Society meetings where scientific method, open inquiry and challenging the data and conclusions presented were shouted down and treated as heresy, blasphemy really. To question what was being done in the Transgender Clinic was to declare yourself as one of "them," the censorious world of bigots who, blinded by hate and intolerance, refused to acknowledge the suffering of this cohort of patients.

Paul McHugh, MD

In fact, this reaction was not new or confined to the Endocrine Society: Dr. Paul McHugh was vilified at Johns Hopkins after he questioned the Transgender Clinic programs which included surgery to transform female to male and male to female. Medical students refused to even speak with  him. At Johns Hopkins!

McHugh arrived at Hopkins in 1975  to assume the chair of the Department of Psychiatry, and one of the first things he was asked to do was to integrate psychiatry into the Hopkins Transgender Clinic, which included  plastic surgery, gynecology, urology and endocrinology.  And, being a scientist, he sat down to review the data and one thing leapt out at him: The patients at the clinic were committing suicide (or making serious attempts, not just gestures) at a rate exceeding 45%.  He asked: if you had a program in cardiology or surgery which had a 45% death rate, would you not pause that operation to re-evaluate it? 

Galelio

Hopkins had been doing sex reassignment surgery since 1966, but it was hoping to ramp it up in 1975. McHugh withdrew psychiatry from the program. By 1979, the Hopkins sex reassignment surgery program was discontinued. 

In 2017, McHugh wrote an amicus brief in a Supreme Court case outlining his objections: 

--Policy Should Not be Used to Enforce Bad Medicine — Treating Gender Dysphoria Through Social Transition and Mandatory Gender Affirmation Rests on Unreliable Testimonials

-- Social Transition Encourages a Gender Dysphoric Person to Indulge in a Falsehood, Which does not Address the Root Issues Causing Clinical Distress and Makes it Harder for the Mind to Accept Reality

--Hormone Therapy has not been Proven Beneficial, and there are Harmful Consequences to Artificially Manipulating the Body

--Surgical Intervention has not Proven Beneficial, and there are Harmful Consequences to Surgically Altering Healthy Bodies

--There is Insufficient Scientific Evidence to Support Treating Gender Dysphoric Children as if They are the Opposite Sex

-- Gender Dysphoric Children Suffer from a Psychological Disorder that Can Be Resolved through Therapy in Many Cases

--Gender Affirmation and Medical Intervention for Gender Dysphoric Children is Not Helpful, and Can be Harmful

--Protocols Calling for Social Affirmation, Hormone Treatment, and Sex Reassignment Surgery are a Reflection of Ideology and Activism, Not Evidence Based Medicine

 His basic argument was, and is still, that gender dysphoria is analogous to anorexia nervosa, where a 90 pound woman who is 5'7" looks in the mirror and says, "I'm so FAT!" She has a single "wrong idea" and the child with gender dysphoria is similarly afflicted. He was arguing that the doctors in the Clinic were participating in confirming that wrong idea to the patient and to the patient's family. 

Attending the Endocrine Society meetings some years ago, I went to a session on "Androgen Abuse Syndrome" where cases of men who looked like the Incredible Hulk, with huge musculature, visited clinics asking for testosterone injections because they looked in the mirror and saw themselves as 98 pound weaklings. In Dutch clinics,  patients signed contracts to taper themselves off exogenous testosterone, run on the model of their opiate addiction clinics and their anorexia nervosa clinics. 

My next session was the Transgender Medicine session, where the speakers readily admitted the suicide rates in their clinics had always exceeded 40%, and showed no signs of declining--which they attributed not to anything they might be doing to their patients, but to the pressures society puts on transgender people. 

The doctors in these clinics were using doses of testosterone which were 4-5 times higher than I had ever used to treat males.  I was stunned, and I texted the man from University of Michigan who had led the "Androgen Abuse" session, and he replied, "There is nothing wrong with that, because these doses are being used in gender affirming therapy."

So in one patient, we've got him signing contracts to taper himself off testosterone, and in another patient we are giving patients orders of magnitude higher doses to affirm their new gender.

One case presented was a male to female (still with penis and testicles) and the lesbian partner who wanted expensive IVF treatments to get pregnant. Nobody asked, wait, what kind of sex are they having?

Another case of a female to male was being given testosterone in 5 times the usual dose because menstruation had not been ablated and the monthly menstrual flow was undermining the patient's new identity as a male.

We are not talking science here. We are talking faith.

The problem with complaining about Transgender Clinics is you immediately find yourself grouped with Marjorie Taylor Greene and the "there are only two genders" crowd, or with Abigail Shrier, who wrote a screed calling Transgender Medicine part of a "craze," doing irreparable harm to young people. 

What doctors crave is a pathway to the truth, and the way there is, and always has been, the dispassionate, rigorous pathway and in the case of transgender medicine, this has been discarded by the medical profession, until now, until Dr. Cass published her report.