'Cass Review' author: More 'caution' advised for gender-affirming care for youth

Find our full interview with Dr. Hilary Cass here. 

Puberty blockers and hormones are sometimes used to help gender-distressed children.

But a new groundbreaking review from the UK says the science behind that practice is far from settled.

"The studies that the team looked at, well the quality was disappointingly poor, none of them really effectively reproduced results in seeing improvements in mental health," Dr. Hilary Cass, the review's author, said.

Today, On Point: Dr. Hilary Cass gives her first U.S. broadcast interview.

Hilary Cass, pediatrician. Led the independent scientific review of gender health services for children in England, commissioned by Britain’s National Health Service. Former president of the Royal Society of Pediatrics and Child Health.

Laura Edwards-Leeper, clinical psychologist, specializes in work with gender diverse and transgender children, adolescents, and adults. Member of the American Psychological Association Task Force that developed practice guidelines for working with transgender individuals.

Amy Tishelman, clinical and research psychologist, and a research associate professor at Boston College in the Department of Psychology and Neuroscience. International lead in the development of new global standards of care for prepubescent children for the World Association of Transgender Health (WPATH).

Part I

MEGHNA CHAKRABARTI: In April, a long-awaited report from Britain's National Health Service concluded that for most gender-distressed young people, quote, "A medical pathway will not be the best way to manage their distress," end quote. That is the result of an almost four-year long, 388-page systematic review of all available studies on the use of puberty blockers and cross sex hormones in adolescents.

The report is called the "Cass Review: An independent review of gender identity services for children and young people." It was commissioned by Britain's National Health Service, and it found that the evidence base for medicalized treatment of adolescent gender distress was quote, "Inadequate and poor."

This comes as the number of young people seeking clinical help for gender distress continues to grow. And unlike a decade or two ago, most of these people are adolescent natal girls. Many often suffer from concurrent mental health issues or autism. Dr. Hilary Cass led the review. She's one of the UK's most respected pediatricians and former chair of the British Academy of Childhood Disability and former president of the Royal College of Pediatricians and Child Health.

She granted On Point her first U.S. broadcast interview. You'll hear responses from American clinicians later in the show. But first, to the Cass interview. I began by asking Dr. Cass to describe what her team's review found regarding the quality of medical evidence for using puberty blockers in gender-distressed young people.

HILARY CASS: The quality was disappointingly poor. One of the significant reasons is that they just didn't follow up for long enough, particularly for young people who were taking masculinizing and feminizing hormones. Another problem is that many of the studies didn't take account of the fact that this is a really, what we call heterogeneous, so a mixed population of young people who were very different from each other.

And that population has changed in recent years, from predominantly birth registered boys presenting quite early, to predominantly birth registered girls presenting in the teenage years. Now, within that group are young people with autism, there are young people who may have other complex mental health issues.

There are young people who may have had a series of traumatic events in early childhood. So you can't take the results of how somebody does if they are presenting as a child, and have had consistent long-term gender incongruence from say, when they were four or five. They may not have the same response to medication as somebody who is presenting considerably later.

So you can't put all of these young people into the same treatment group and say they're all going to respond in exactly the same way to this kind of approach.

CHAKRABARTI: Okay. So more specifically then, in the systematic review of studies relating to the use of puberty blockers. We should say that puberty blockers do have quite a well-established evidence base for use in some situations, right?

For example, children with precocious puberty, so they are an accepted treatment for certain things.

CASS: Absolutely right, but it's really important to say that it's a very different thing to take a young person whose hormones are going through the normal increases that you expect to see in puberty. And pausing that. Because during puberty, all sorts of things are going on. Your brain is developing very rapidly. You're developing what's called your executive functioning, which is how you do some complex problem solving, complex judgment abilities, and you're also developing your sexuality. And we just don't know what happens if you put brakes on all of that.

CHAKRABARTI: Specifically, in the review report, there's a discussion that there are claims, actually from quite well-respected bodies, including here in the United States, that providing puberty blockers as a form of treatment and care for gender questioning youth, they're prescribed as treatment because they can alleviate gender dysphoria, they can improve mental health of young people who are genuinely suffering.

Did the review find an evidence base for those goals or aims?

CASS: Okay, so that's a really important question. And the Dutch found that there were some improvements in mental health of those young people, but it didn't affect the dysphoria. In the UK, we attempted to reproduce that using exactly the same approaches as the Dutch.

And disappointingly, the team did not find improvements in mental health. In fact, some young people got worse, some made no changes. And that's the sort of result you might expect from a treatment that's not particularly effective for those outcomes. There may be a group of young people who do have early gender incongruence, for whom this might be the right treatment, particularly that group of birth registered boys who will develop irreversible changes of male puberty.

But just to go back to the systematic reviews, the other studies that the team looked at, none of them really effectively reproduced the Dutch results of seeing robust improvements in mental health.

CHAKRABARTI: To be clear, the report states, quote, that the University of York concluded, and that's the group that did the review.

CASS: That's right.

CHAKRABARTI: That there is insufficient or inconsistent evidence about the effects of puberty suppression on psychological or psychosocial health.

CASS: Correct. And we also have to think about which young people have been receiving puberty blockers, because certainly in the UK, as time has gone on, the young people who were most likely to receive puberty blockers are most commonly aged around 15.

And by 15, obviously, you've gone through most of puberty. So instead of really thinking, okay, how are we going to manage the distress that these young people are feeling? Somehow, we've got locked into puberty blockers as the totemic treatment that young people feel. If they don't get onto puberty blockers, they're not going to get onto a medical pathway.

But actually, there are many different ways in which we can manage distress and anxiety in a 15-year-old that don't involve puberty blockers. And yet we've somehow stopped short of trying those, just because puberty blockers have become so widely believed to be effective.

CHAKRABARTI: This is a really important point that's been brought up by the Cass Review. About did the focus on trying to provide medical forms of therapy perhaps overshadow other forms of care.

CASS: Yes.

CHAKRABARTI: So I want to read to you this is from 2022. And this is from the United States Department of Health and Human Services Office of Population Affairs, and they stated that, quote, "Research demonstrates that gender-affirming care improves the mental health and overall well-being of gender diverse children and adolescents," end quote.

Now I should say that they're speaking about gender-affirming care overall and not just exclusively medical treatments. But there's a gap there, though, between what seems to be the conclusions of the Cass Review vs. that statement, which is not uncommon from the United States.

CASS: We spoke to young adults directly through the review, and we also had some qualitative research, so some researchers talking to young adults, as well.

And one of the things that they said is, I wish I'd known when I was younger that there were more ways of being trans or expressing my identity than just a binary medical pathway. And so a lot of what the focus of our review has been on is saying, what do we do to help these young people to thrive?

And how do we give them the widest range of options that also don't foreclose for them?

CHAKRABARTI: I just want to recap. So the systematic review found that there's insufficient evidence, or inconclusive evidence, about the effect of puberty blockers on mental and psychosocial health or in the alleviation of gender dysphoria.

There's also the question of, there have been competing claims about whether puberty blockers have negative impact on a young person's bone health.

CASS: Again, those results were inconclusive, and we need to follow people up for much, much longer.

CHAKRABARTI: So, Dr. Cass, one thing that the review notes very clearly at the top is the rapid rise, and actually the exponential rise, in the number of young people, adolescents, in particular, seeking treatment for gender dysphoria.

In fact, you have a chart here that shows that around 2013, 2014, every year, essentially, the numbers spike up higher and it's more, many more adolescent girls. What do you think, or what did the review seem to find in terms of what may be driving that rapid rise?

CASS: That's a really good question.

So we looked at what we understand about the biology, but obviously, biology hasn't changed suddenly in the last 10 years. So then we tried to look at what has changed? And one is the overall mental health of teenage girls in particular, although boys, to some degree. And that may also be driven by social media, by early exposure to pornography and a whole series of other factors that are happening for girls.

It's a tough time to grow up. But secondly, a much more fluid approach to how young people see gender. They see gender much more flexibly than, say, my generation did. So for some young people, gender becomes the main anxiety for them and the way in which they focus their distress. And just as an example, a colleague of mine described a not infrequent sequence of events. Which is a young person comes to clinic, a birth registered female is identifying as male.

And the gender is massive for them. The first thing she may do for that young person is put them on the pill to stop their periods. That's a much more straightforward intervention than puberty blockers. If she's binding her breasts, it's really important that she does it safely. So the nurse in the clinic will show her how to do that safely.

And then often, by the next visit, the distress, the anxiety just ramps down. And the next time they see her, it's not that the dysphoria has gone away, but it's just slipped into the background. And then they can talk about whatever the other things are that are bothering them, which might be sexuality.

It might be an eating disorder. It might be anything else. And over time, they may go on to have a trans identity, or they may decide that the issue was around their sexuality or a series of other issues. Sometimes it just resolves, and they stop seeing all of their distress through that gender lens.

Part II

CHAKRABARTI: You're back with On Point. Let's now continue my conversation with Dr. Hilary Cass.

About cross sex hormones, again, because I'm very focused on understanding the evidence base, right? Or lack thereof.

CASS: Sure.

CHAKRABARTI: Regarding cross sex hormones, the systematic review authors said there is a lack of high-quality research assessing the actual outcomes of cross sex hormones.

CASS: Yes, because we need to follow up for much longer than a year or two to know if you continue to thrive on those hormones in the longer term. And we also need to know, are those young people in relationships? Are they getting out of the house? Are they in employment? Do they have a satisfactory sex life?

What are the things that matter to them, and are they achieving those things?

CHAKRABARTI: So once again, the answer is, we don't know. There's insufficient evidence or poor-quality studies, which aren't enough to make informed guidelines for families and practitioners.

CASS: That's right.

CHAKRABARTI: By the time young people are seeking out help for gender dysphoria, they are quite distressed, right?

And as the report says, "It is well established that children and young people with gender dysphoria are at increased risk of suicide." But then the report adds this, "But suicide risk appears to be comparable to other young people with a similar range of mental health challenges." So first of all, what's the evidence for that?

And why is that important to understand?

CASS: So how do we know if this is down to the gender-related distress? Or is it because they also have an eating disorder, or they're depressed or a whole raft of other issues? And because a majority of these young people have all of these issues, then what you need to do is compare to what the population rates are of suicidality in young people who have all of those other issues, but are not gender questioning.

And that's where you find that the rates are fairly comparable. So we can't say that it is the gender questioning or the gender incongruence that's giving you additional suicide risk. And so the second part is, does the gender-affirming treatment pathway reduce that suicidality? But such data as we have shows that we can't detect a difference in the suicide rates before and after treatment.

CHAKRABARTI: So the systematic review then though really combed over all of the studies essentially that are cited when people say that gender-affirming treatment helps save lives. That's not an overstatement on my part. Because Admiral Rachel Levine, who is the Assistant Secretary of Health and Human Services in the United States, in fact, has said that gender-affirming care is, quote, "Quite literally suicide prevention care."

So I'm sure you've heard similar things in the UK, but the review concluded that in a majority of studies that looked at a reduction in suicidality, the studies report that there was a reduction, but there were problems with those studies in terms of they didn't control for the presence of those psychiatric comorbidities that you talked about. And then there was another study that showed that suicidality and self-harm decreased, but out of the 109 eligible participants, only 11 of them had actually completed the questionnaire on suicidality and self-harm.

CASS: What is the important practical issue here? And that is that we have to provide holistic care for these young people.

And what we need to try and do is pick out young people who we think are at risk and say, what are all the things we need to get in place to support this young person's risk? It may be helping with their eating disorder. It may be that they are in difficult family circumstances. There's a whole raft of things that we may need to think about.

And it's much more important to say on an individual basis, how do we manage this person's risk, than just assuming that gender-affirming care is going to be the answer.

CHAKRABARTI: So Dr. Cass, this brings us back to where we began. And that is, you and the independent review team undertook the world's largest systematic review of all of the evidence and studies related to care for gender dysphoric or gender-questioning young people.

It's interesting to me that the world's largest and most influential body that provides guidance for trans care, the World Professional Association for Transgender Health, or WPATH, in their most recent standards of care document, they said that the number of studies is still low and there are few outcome studies that follow youth into adulthood.

Therefore, a systematic review regarding outcomes of treatment in adolescence is not possible. Yet, is that not what the Cass Review did? A systematic review?

CASS: Yes, and actually, so did WPATH. So WPATH commissioned a systematic review from John Hopkins, which is obviously one of the most credible organizations in the U.S., but then they didn't refer to that in the youth part of their guidance. And that was one of the reasons that when our team rated the various guidelines, they rated the WPATH guidelines relatively poorly in terms of the rigor of their development process. Because there were points within the chapter on children and youth where the WPATH team suggested that there was strong evidence and there wasn't.

CHAKRABARTI: They do conclude that the evolving science has shown clinical benefit for transgender youth and then they cite three different studies that they claim supports the assertion of clinical benefit, but the Cass Review points out that one of those studies cited was that original Dutch protocol that we talked about, that deals with a completely different cohort of young people.

Then there's another study that had a one year follow up showing actually very modest changes for young people. And also, I think your team thought the study was too low quality and didn't even include it in your review. And then, most remarkably, the third study that WPATH cites is one that the Cass Review said is a study protocol and does not even include any results.

CASS: Yes, so you have read this extremely carefully, probably better than most of the UK commentators. I think the problem is that there has been an echo chamber of guidelines. So one of the things that the York team did was they looked at where guidelines had followed each other, and they found that most of the guidelines, there was a circularity between the Endocrine Society, WPATH, and a series of other guidelines.

CHAKRABARTI: Dr. Cass, I just want to quote some of the criticisms that have been made of the report. For example, the World Professional Association for Transgender Health that we just mentioned, they issued an email statement saying the report is, quote, "Rooted in the false premise that non-medical alternatives to care will result in less adolescent distress."

And they criticized some of the recommendations from the report, which they claim would, quote, "Severely restrict access to physical health care for gender-questioning young people." Your response to that?

CASS: So we've not taken a position that any form of care is best, but what we have said is that it is important that all young people get access to evidence-based, non-medical interventions that address the full range of their difficulties.

So this group of young people, if they are depressed, if they're anxious, if they need an autism diagnosis, all of those things should be put in place. We don't know which young people may benefit from medical care. And we have proposed that every young person who walks through the door should be included in some kind of proper research protocol so that we can follow them up and we can get those answers over time. So that we don't continue in this black hole of not knowing what's best.

CHAKRABARTI: So Dr. Cass, I just have two more questions for you. You write in the report that gender-questioning young people have been failed by the medical establishment, by the NHS in England. In order to recover from that failure. What does the report recommend change for the treatment of young people?

CASS: I think first and foremost, seeing them as a young person and not as somebody who is gender-questioning, or with a gender problem or a gender issue, they are a young person first. And I think one problem has been just seeing them through a gender lens.

I think we need to re empower professionals to not be afraid. And in the long term, I think if young people could walk through the same door, that doesn't have to be labeled gender. But is a clinic for young people to talk about a range of issues, whether it's their mental health, their sexual health, their sexuality and their gender.

And they could see somebody who would really see them as a whole person, then I think they would get a much better deal.

CHAKRABARTI: Dr. Cass, I just would like to read the last sentence of the review. You write, quote, "I am aware that this report would generate much discussion, and that strongly held views will be expressed. While open and constructive debate is needed, I would urge everybody to remember the children and young people trying to live their lives, and the families and carers and clinicians doing their best to support them. All should be treated with compassion and respect."

CHAKRABARTI: For those children and families and clinicians listening to this interview now, Dr. Cass, what would you tell them? What thought would you leave them with?

CASS: I think the most important thing is keep your options open. I'd say what some of the young adults said, it's not as urgent as it feels. Take your time. Think about all the possibilities open to you. Talk to other young people, but try not to rush.

CHAKRABARTI: Dr. Hilary Cass, she led the team that recently published the independent review of gender identity services for children and young people. It's a massive report that was published at the behest of the National Health Services in England. Dr. Cass, thank you so much for joining us.

CASS: Thank you.

CHAKRABARTI: We spoke with Dr. Cass late last week, and there's significantly more of that interview which you can hear in its entirety in the On Point podcast feed. As a British report, the Cass Review did make several recommendations to the UK's National Health Service. The NHS is now no longer offering puberty blockers to children under the age of 18, except in cases where a young person presents long-term gender dysphoria, and all other possible mental health issues are being cared for.

And in those cases, the NHS says it will provide puberty blockers through care that is rigorous and closely monitored. So what, if any, are the lessons the Cass Review can provide for the care of gender-questioning young people in the United States? To answer that, we're joined by Laura Edwards-Leeper.

She's a long-time clinical psychologist who works with gender diverse young children. She was founding psychologist of the first interdisciplinary clinic in the United States that treats trans youth. That's the Gender Management Service, or GeMS, at Boston Children's Hospital, though she's no longer with the clinic.

Dr. Edwards-Leeper, welcome.

LAURA EDWARDS-LEEPER: Thank you for having me.

CHAKRABARTI: And Dr. Amy Tishelman also joins us. She's currently a research associate professor in psychology and neuroscience at Boston College. Prior to that, for years, she was Director of Clinical Research in the Behavioral Health, Endocrinology, and Urology program at Boston Children's Hospital and also with the Gender Multispecialty Service, or GeMS, although she's no longer at Children's Hospital.

But Dr. Tishelman, welcome to you.

AMY TISHELMAN: Thank you.

CHAKRABARTI: One of the important things in this conversation is, Dr. Cass, Dr. Tishelman, Dr. Edwards-Leeper, these are all professionals who have, dedicated their careers to the care of gender questioning young people. So it's not the issue of a trans identity that we're talking about here, it's just how to achieve that best care.

And I just felt like it was important to say that. Dr. Edwards-Leeper, look, do you think that young people, and particularly the young, natal girls or adolescents who have been the source of the recent growth in people seeking care, that many of them were put on a medical treatment pathway that didn't necessarily need it.

EDWARDS-LEEPER: I think that the mental health concerns back when I started doing this work were really a result of being in the wrong body, the social stigma that surrounded trans people at that time. And once medical interventions were started, the mental health issues really did improve for the large majority of patients I worked with.

That has changed drastically in the last 15 years or so, where the mental health issues occur for young people prior to there ever being any gender distress. And it's so critical to do comprehensive assessments that are very individualized. I think to your question, these days, if that isn't being done, then I do worry that there are young people being treated medically who shouldn't be.

CHAKRABARTI: Dr. Tishelman, I'd love to hear your addition to that.

TISHELMAN: I would like to thank you for mentioning that we work with transgender youth. I'm very hesitant about being on this show, because I don't want anything I say to be taken to support bans on medical care. And I worry about how politics has infused this field in a way that I think can be detrimental to all youth.

I also think there's been equivalence of gender-affirming care with medical intervention, and that's problematic. Gender-affirming care can be psychosocial care alone. It can be psychosocial and medical intervention. Or in some cases, medical intervention alone. The research that we have out there right now doesn't really track very well whether multiple interventions are co-occurring. And whether those youth who are doing better are youth who are, have access both to medical and mental health interventions. And I think we need to move to an individualized approach in trying to understand what each child needs.

CHAKRABARTI: What you're describing is this disconnect between the ongoing need to build a better evidence base, versus the spike in the number of people seeking that care. Dr. Edwards-Leeper, how do you think we got to that place? That young people, adolescent girls in particular, they're experiencing a lot of different things. But for some reason, for many of them, much of how they interpret those feelings is coming through that gender lens.

EDWARDS-LEEPER: This is another super important question that we need research to really answer. And so part of it, I think is, even though we are in 2024, there still are a lot of expectations around gender for young people, that some are just very uncomfortable with. But that in combination with the internet and social media, from what I see in my clinical practice, that has been huge.

Just the kinds of things that the young people are watching online, and learning about related to transitioning and it being something that can greatly help them. Certainly, for some, it can be, I think, lifesaving and give them a lot of hope, if they are someone who will benefit from medically transitioning.

But for others who are distraught and experiencing significant mental health issues and trying to understand why they feel so different and so miserable, then in some of these cases, it just doesn't. Because it doesn't fix the underlying mental health issues.

TISHELMAN: And I'd like to support what Laura is saying.

I think that because of the numbers of youth coming forward, there may be a pressure to fast forward things. And I think that's opposite of what we need to do. And so I strongly support the idea that licensed mental health clinicians make decisions for themselves about what their patients need, without having to report to medical providers and justify that. And think the way hierarchies in hospitals happen, a lot of times, medical providers set up the systems and make the final decisions about clinics that they run.

Part III

CHAKRABARTI: We have heard from parents whose children are gender questioning, and the different paths that they're all taking, or the questions that they have and how to do the best they can for their kids.

So here's a few of those voices.

(LISTENER MONTAGE)

Our pediatrician was totally uncomfortable with our questions and referred us to his partner, who immediately offered hormone treatment.

I would love information on therapists who are not forced to tell my son whatever he wants to hear about his gender. I would love to hear about doctors who study every aspect of a person's health before they prescribe hormones and surgery.

We've known our child, since she was very young, telling us who she is, and not only telling us who she is, but being so depressed at such a, like, young age. The decision that we have to make is hard. Her having to go through male puberty would be an absolute nightmare.

I remember, Wyatt, when you transitioned to a new pronoun and a new name. And you finally had the haircut that you wanted, people commented all the time on how there was a light in your eyes and you had life in you, and I saw it, it was like a 180 transition.

So I'm a lot happier than I would be if I were still living as the gender I previously was. Sometimes it's something I forget about, which I'm lucky to have the option of I can just live my life without thinking about it.

I have a transgender son. His dad is not accepting of him and we are just trying to figure out how he can start T. And he wants to do top surgery, but he cannot do anything without his father's permission. And the biggest question that we are navigating right now is legal question.

My child was 12. I was concerned about my child's depression, their withdrawal from things they'd previously enjoyed, the fact that their transition came out of the blue, very suddenly, during lockdown. I had concerns about my child being on the spectrum, but the social worker we saw wasn't concerned about any of that. She just recommended we go ahead and start hormone therapy, ASAP.

CHAKRABARTI: So those are just some of the parents that we have heard from. People are Desperately seeking guidance that they can trust. And one of the first things that the family hears upon appointment No. 1, again we have been told directly this by many families, they're told by the clinician, do you want a living son or a dead daughter?

Given the fact that now we have established that there is an inadequate evidence base for making that kind of broad claim regarding suicidality, how did we get to a place where clinicians are saying this repeatedly to families?

EDWARDS-LEEPER: This is one of the most frustrating things for me, I have to tell you, and it sounds like you've talked to many families who've experienced this, and I have, as well. And I'm not entirely sure how we got to this place, but so many seem to be in sort of an echo chamber, where they will not even entertain these conversations or these considerations, and so somehow that has led the field, at least in the United States, somehow we've just spiraled into an inability to critically think, and I do think the political scene is a huge part of that problem.

There's so much fear among providers and among the trans community that care may be taken away, and I understand that fear. I have that fear myself, and the bans are horrible. I'm not in favor of that. But we can't stop engaging in these conversations, or critically thinking or thinking about the wellbeing of children as a whole, not just related to their gender, simply because we're afraid of these bans.

I don't think that's going to get us anywhere.

CHAKRABARTI: Now, we reached out to the American Academy of Pediatrics, and they sent us a statement from their president, Dr. Ben Hoffman, that stands by their guidance. It says, quote, "The AAP's gender-affirming care policy, like all our standing guidance, is grounded in evidence and science. The politically infused public discourse is getting this wrong and it's impacting the way that doctors care for their patients. Physicians must be able to practice medicine that is informed by their medical education, training, experience, and available evidence freely and without threat of punishment."

That's part of the AAP's statement.

The Endocrine Society also sent us a lengthy statement, which includes, "We stand firm in our support of gender-affirming care. Transgender and gender diverse people deserve access to needed and often lifesaving medical care." They say the NHS England's recent report, the Cass Review, "Does not contain any new research that would contradict the Endocrine Society's recommendations."

CHAKRABARTI: Dr. Tishelman and Dr. Edwards-Leeper, both of you were involved in different chapters for the World Professional Association of Transgender Health's 8 Standards of Care. And those chapters, as we heard earlier in the show, Dr. Cass and her review, they say were not adequately founded in robust evidence.

Dr. Tishelman, I'd first like to get your response to that.

TISHELMAN: I was the lead author of the Standards of Care for Children, not for adolescents, and Laura actually was one of the participants. We deliberately organized the authors to represent diversity of opinions. I expected there would be a lot of friction, but in fact there wasn't a whole lot of conflict. There was a lot of consensus about what we should end up with. But I agree with Dr. Cass, and we wrote it in our chapter that there wasn't a lot of research. In fact, there wasn't enough research to found the chapter on an evidence base, but we said that directly in the chapter.

I think the issue is, what do you do when there's a dearth of research, and that happens a lot in a lot of clinical areas. As an example, psychopharmacology for children. A lot of times children were given psychopharmacological interventions and there wasn't any research and still isn't on the effect on the developing brain.

We don't have as much research as we need on gender affirming psychosocial interventions, which is all that can occur with young children, or medical interventions for adolescents. But that means we need to be cautious, but also not do nothing.

CHAKRABARTI: Okay. So then Dr. Edwards-Leeper, since you were involved in the chapter on adolescence, would love to hear your thoughts on this.

EDWARDS-LEEPER: I think the part that has me more perplexed and concerned is the statements that have come out by these organizations. Like you mentioned, WPATH, AAP, the Endocrine Society, that doesn't feel to me in line so much with the chapters that we wrote. And makes me question if those who have written those statements have read the Cass Review to really understand how the areas of caution are basically what we wrote in the chapters.

And as we keep saying in this today, that the lack of evidence doesn't mean to never pursue medical intervention, or never to recommend medical intervention for young people. It just means that we need to address the mental health issues first and approach each case individually. That's a very important thing to recognize, and I'm not sure why these organizations are so resistant to that.

Let me put it also this way. There's a deeply held feeling amongst many in the trans community that the recommendation for caution can also basically lead to transphobia, right? It can lead people down the path of not getting the kind of care that they need. And I think that's one of the criticisms that has been levied on the Cass Review.

TISHELMAN: I think it's a valid concern. We know that adults report having been harmed as children by not getting the care they need. Who, many of whom have been traumatized by being negated. And still, there's a lot of rhetoric in the United States and elsewhere that there's no such thing as being transgender. And that idea that it's all a mental health problem and that there aren't real, there isn't a real transgender community can be harmful.

CHAKRABARTI: I would actually love to hear Dr. Tishelman, the points that you disagree with the Cass Review on, if you'd like to share those.

TISHELMAN: Yeah, I don't think we can mandate that all children who socially transition have mental health treatment in our country, because we don't have a national health service.

There's tremendous problems with access to mental health care for all youth.

CHAKRABARTI: Okay, so let me just jump in here because Dr. Tishelman is bringing up a really good point. I actually discussed this with Dr. Cass. It's in our elongated version of that interview in our podcast feed. The Cass Review contains a section about social transitioning.

The Cass Review recommends exercising caution and having full parental buy in, and mental health services available for young people who seek to socially transition in any way.

This topic in and of itself is a huge topic that we could spend several hours talking about. What I took away from the Cass Report regarding the younger children is that maybe we need to be thinking about social transition as somewhat of an intervention in and of itself, even though it's not medical. But it does, in some ways, set children on a path, that if not approached in a very careful way, could be difficult for them to get off.

EDWARDS-LEEPER: But it's also critical for children who fall in that category to be reminded that they can change course at any point, should they ever feel differently. The adolescent social transition piece is a whole [other] ballgame. I think the main one probably being the schools not knowing how to best support the young people when they want to change their name and or pronouns but don't want their parents to know.

I will tell you that what I have seen over and over in my clinical practice is how withholding information from parents is really very rarely in the child's best interest. Because 99% of the time, these young people have significant mental health issues and so by not sharing the gender distress with parents, it also often means not sharing the rest of the mental health picture.

And it ends up tearing families apart. Parents feel that they've been left out of the loop. Many times, the parents are very supportive of their child's gender questioning, but simply want to be involved in their care. And so I do agree with Dr. Cass. And what she speaks about in the report regarding the adolescence, that it really needs to involve the parents.

CHAKRABARTI: Okay. So it was said very eloquently before that it is part of the profoundly unfortunate, that politics have infused this issue as much as it has. I wonder if you would see a similar misfortune in terms of advocacy having infused this situation as much as it has.

TISHELMAN: I do have mixed feelings about advocacy. I will say as an old person and a feminist, when I started college, women couldn't get a credit card without a man signing off, advocacy on the part of the gay and lesbian communities has made a huge impact in quality of life. And so I think we need to recognize the importance of different advocacy groups being able to voice their needs and push things forward.

CHAKRABARTI: Again, the critical role that advocates played in terms of advancing HIV/AIDS research. That's another example here.

TISHELMAN: Huge. It's important. Just diminishing the importance of advocacy, I don't think is a good idea, but we also need to be able to say things that some advocates may not want to hear.

There's so much backlash. I just think it's important, and I have an obligation, especially as the lead of the child chapter.

CHAKRABARTI: Backlash from where?

TISHELMAN: With the internet and social media, there are people who have very passionate feelings and are very scared and traumatized, who may get angry at some of the things that either Laura or I are saying, and feel that we're not advocating enough for their communities.

And I understand that, but I also think it's really problematic. Because we need to have good debate and we should be listening to one another, at least for people who have the best interests of youth in mind.

EDWARDS-LEEPER: I would just add that it is terrifying. There's no other way to put it from my perspective to engage in these conversations publicly.

That is honestly the reason I have been vocal. Because I do care about the well-being of trans children. Tremendously, that's what my career is focused on, but I also care about the well-being of gender distressed, cisgender children. And to only focus on one group and not both, I think is harmful.

Young people are in a state of mental health crisis, and we can't pretend like that's not a piece of what's going on for a lot of the gender-distressed kids coming in these days.

CHAKRABARTI: Do you think, and Dr. Tishelman, I'll start with you, that there are changes that need to be made, let's stick with clinicians, how they approach care for young people who come to them?

TISHELMAN: I would like to call for gender clinics around the United States now to put some resources into facilitating research. We really don't have time to waste, because until we understand the outcomes, it's going to be years and years. And the more we put off collecting data on outcomes, the more we're not going to understand how to characterize youth coming forward now, what they need.

EDWARDS-LEEPER: In addition to putting more resources into research, from my perspective, the focus these days really needs to be on the mental health needs first, as the Cass Report points out. And that means that the majority of providers within these clinics need to be mental health providers and need to be offering the kind of thorough assessment. And then, ongoing support for the young people.

TISHELMAN: One final point I would say is we're talking about assessments, but we really don't have research on what assessments are effective. Right now, we don't have a research basis for making those decisions, but at least we could bring together a diversity of sophisticated clinicians who do believe that transgender youth exist, to come up with some guidelines about what we mean by assessment.

CHAKRABARTI: That is so remarkable. We don't even know yet what the best assessments are, let alone we don't have an evidence base to know what the best treatments are.

TISHELMAN: No.

CHAKRABARTI: And we have, thousands and thousands of different individuals who are seeking that treatment. That brings me to my last question and Dr. Edwards-Leeper, I'm going to turn this to you. Nobody wants to wait for the slow process of medical science to unfold while their children are feeling deep distress now. So for all the parents listening out there right now, Dr. Edwards-Leeper, what is your most sincere advice to them about how should they manage on a day-to-day basis all of the uncertainties that we've been discussing when it comes to caring for their most precious things in their lives?

EDWARDS-LEEPER: I can't tell you how much empathy I have for these parents that are going through this. To be caught up in this political and polarized field right now is ripping families apart and just causing so much distress for the young person, but for the parents and for the families as a whole. So what I recommend, that they ask the potential provider if they've read the Cass Review.

And get the provider's perspective. See if it aligns with what their take is and if it feels like someone who is going to approach their child's care in a more nuanced and individualized way. Basically, just interview the providers ahead of time to find someone who they feel like will be a good fit for their child.

TISHELMAN: Can I say one thing? I just want to, I agree with you, Laura, but I want to clarify something. There isn't going to be any one approach that fits all. And so these need to be individual decisions. There is, every single family, every single child is unique.

CHAKRABARTI: With that, I'm afraid we have run out of time.

So Dr. Amy Tishelman, currently research associate professor in psychology and neuroscience at Boston College, thank you so much for joining us today.

TISHELMAN: Thank you so much for having us. It's been really a pleasure.

CHAKRABARTI: And Dr. Laura Edwards-Leeper, long time clinical psychologist who also specializes in work with gender diverse young people. Thank you so much for being with us.

EDWARDS-LEEPER: Thank you for having me.

CHAKRABARTI: And once again, you can find our interview with Dr. Hilary Cass in its entirety in our podcast feed, and on our website. Also at the website, statements from WPATH, the Endocrine Society, and the American Academy of Pediatrics.