Latest news with #HilaryCass
Mint
03-07-2025
- Health
- Mint
A landmark study of gender medicine is caught in an ethics row
ONE REASON that transgender medicine is such a fraught topic is that there is little evidence behind the arguments. When Hilary Cass, a British paediatrician, reviewed the field for an influential report published in 2024, she noted that most of the science underlying the prescription of puberty blockers and cross-sex hormones to teenagers (an approach called 'gender-affirming care") was 'remarkably weak". One of her recommendations was that doctors and scientists should try to gather some better data. Britain's National Health Service (NHS) forbade the prescription of puberty blockers following Dr Cass's report, except as part of a clinical trial designed to explore whether they are genuinely beneficial. One such clinical trial, called PATHWAYS, is being led by researchers at King's College London. Originally scheduled for 2024, it is now supposed to begin later this year. Running a clinical trial to settle the question might seem like a straightforward good idea. Its conclusions would be read around the world, as many countries are grappling with how best to regulate gender medicine. But a chorus of campaigners, including doctors' groups and parents' organisations, argue that the trial would be impractical, unethical and should not be allowed to go ahead. As their name suggests, puberty blockers act on the brain to stop the release of sex hormones such as testosterone in males and oestrogen in females. When given to children with gender dysphoria, the drugs are supposed both to relieve psychological distress and buy patients 'time to think": to pause puberty while they consider if they want to go ahead with opposite-sex hormones (and possibly surgery) designed to make them more closely resemble the opposite sex. The trial plans to follow teenagers on puberty blockers for two years, with regular assessments of their 'physical, social and emotional health". The trial has yet to receive ethical approval, and only bare-bones information about its design is available (King's College London told The Economist that it would not comment until the study had been approved). But even that is enough to worry critics. Some of the opposition comes from groups that are strongly in favour of gender-affirming care. The World Professional Association for Transgender Health, which writes guidelines for gender-affirming care, disagrees with Dr Cass on the lack of evidence for puberty blockers, and argues that it is unethical to limit them to participants in clinical trials. Those doubtful of the merits of the gender-affirming approach are also sceptical. One frequently cited objection is that a clinical trial of puberty blockers seems hard to square with medical rules that require extra protections for trials involving children. David Bell, a psychiatrist and former board member of the Tavistock and Portman NHS Trust, which ran the biggest gender clinic in England and Wales until it was shut down in 2024, said in an article published in January that British law requires that trials minimise risks to a child's 'state of development"—something with which puberty blockers are specifically designed to interfere. Many (though not all) doctors argue that, to be ethical, a clinical trial requires researchers to be in a state of 'equipoise": genuinely uncertain as to whether a treatment will be helpful or harmful. Louise Irvine, who helps run the Clinical Advisory Network on Sex and Gender, a group of medics who believe that gender-affirming care poses serious risks to patients, argues that what little evidence does exist for puberty blockers suggests they can cause harm. One study published in 2020, for instance, found significant decreases in bone-mineral density in children given puberty blockers. Reports from patients prescribed one such medication called Lupron for precocious puberty (in which puberty begins too early), rather than gender dysphoria, talk of serious problems with joints and skeletons in young adulthood. Animal trials, meanwhile, suggest that blocking the production of sex hormones may hinder brain development in adolescence. One study in humans, again in children with precocious puberty rather than gender dysphoria, followed 25 female patients for three years and found an average decline in IQ of seven points. (Other studies have not found a detrimental effect.) And although puberty blockers are intended merely as a 'pause button", Dr Cass had concerns that children who take them almost always go on to further treatment. Data from the Tavistock suggest over 90% of children prescribed the drugs will go on to take cross-sex hormones—testosterone for females and oestrogen for males. If those are prescribed early enough in puberty, they can cause irreversible sterility. The Tavistock data also suggest that the psychological effects of puberty blockers are hit-and-miss, with 34% of children seeing their mental health worsen and 29% seeing it improve. For Dr Irvine, all this is enough to tilt the balance away from equipoise—and thus from running the trial. Others worry about the practicalities. The best clinical trials are blinded, in which neither doctors nor patients know who is receiving the treatment and who is not. But the effects of puberty blockers are dramatic enough to make blinding impossible. What's more, children with gender dysphoria have higher-than-normal rates of anxiety, depression and autism-spectrum disorders, all of which can muddy a trial's results. The Bayswater Support Group, an organisation for parents of gender-dysphoric children, argues that two years is too short a follow-up time for a treatment with lifelong effects. Those practical worries can themselves shade into ethical problems, says Dr Irvine, who points out that, since all clinical trials expose patients to a risk of harm, they can be justified only if they add usefully to the sum of medical knowledge. 'If you've designed a bad trial that can't answer the question, it would be unethical to run it," she says. Not everyone is opposed. Gordon Guyatt is an expert in evidence-based medicine at McMaster University in Ontario, Canada who has taken an interest in the subject. He argues that the possibility of producing useful data should weigh heavily on the ethical scales, even if the trial is imperfect. 'If it were to prove feasible it would be unethical not to do [a trial]," he says, 'because there is such polarisation, and the lack of high quality evidence is…making it hard to move forward." There are options besides testing the drugs in humans. Stephanie Davies-Arai, who runs Transgender Trend, a campaigning group sceptical of gender-affirming care, thinks more animal studies should be done. Another idea is to make use of the fact that puberty blockers have been given to gender-dysphoric children for many years already. A 'data-linkage" study would look at the modern health records of those who had been given puberty blockers as teenagers, to see what had happened to them later in life. (A previous attempt to do just such a study was thwarted when British gender clinics refused to co-operate). For now, the trial looks likely to go ahead. By the time a trial has been funded, says Dr Irvine, ethical approval is usually routine. But then again, few attract this much publicity and controversy. Curious about the world? To enjoy our mind-expanding science coverage, sign up to Simply Science, our weekly subscriber-only newsletter.
The Guardian
02-07-2025
- Health
- The Guardian
Cass review: how has report affected care for transgender young people?
At the heart of the controversy about how to meet the needs of young people questioning their gender has been the huge rise in referrals to the Tavistock – previously the only dedicated clinic in England and Wales treating children with gender dysphoria. The clinic was closed one month before the Cass review into youth gender identity services, commissioned by NHS England and led by the British paediatrician Hilary Cass, which found that children had been 'let down' by the NHS amid a 'toxic' public discourse. Her report recommended a significant shift in treatment away from medical intervention towards a more holistic approach to care, including therapy and treatment for coexisting mental ill health, neurodivergence or family issues, and to be provided by a network of regional hubs rather than concentrated in one location. Fourteen months later and the exponential rise in referrals for NHS care has halted, with figures showing a sharp reduction from up to 280 referrals a month at the Tavistock to between 20 and 30 a month this year, a 10th of the earlier rate. James Palmer, the medical director for specialised services at NHS England, who is responsible for implementing the recommendations of Cass, suggests a number of factors are behind the decrease. Young people can now only be referred for the youth gender service through mental health or paediatric specialists, rather than by a GP. Palmer also believes the reduction is partly because of the 'change in philosophy' brought in by Cass about hormone treatments. Her review concluded there was 'remarkably weak evidence' that puberty blockers (prescribed to give young people experiencing distress and dysphoria about their bodies time to consider their next move) and cross-sex hormones (which masculinise or feminise people's appearances) improve young people's wellbeing and there was concern they may harm health. Cass prompted a temporary ban on the use of puberty-blocking drugs, which was extended indefinitely by the health secretary, Wes Streeting, last December. Cross-sex hormones may be prescribed to 16- to 18-year-olds in rare cases but in practice none have been since the review. 'There's also an impact – completely immeasurable – of the change in stance in this country and around the world,' Palmer adds. The Cass review was clear, he argues, that even social transition is 'not a neutral act' and better information is needed about the outcomes for children who do so, as well as support for parents and schools. 'But there is also an impact from the global political environment which has become less accepting of trans people and gender-questioning young people.' Palmer, a neurosurgeon by background, says waiting times for the new hubs are 'still really significant' and that it will take up to three years to work through the 'substantial backlog' inherited from the Tavistock, and services are continuing to face heavy criticism from young people and their parents. According to NHS England the waiting list for the new hubs peaked in December 2024 at more than 6,400, and has been reduced to just over 6,000. There are now three regional centres open in London, Bristol and north-west England, with the capacity to see about 25 patients a month, and a fourth is expected to open in the east of England this year. Once all seven regional hubs have opened, Palmer says 'we will get to where we want, which is that individuals, as soon as that [gender] incongruence starts to be truly persistent, even at a young age, will be able to get access to an NHS service'. While opinion still differs on how best to meet the needs of this vulnerable group of young people, critics of what Palmer describes as a 'change in philosophy' argue that the fall in referrals to NHS services masks the true numbers seeking intervention, with many families turning to private providers and the hidden economy to access drugs to help them live as a different gender. Palmer accepts the long waits for help 'affect how individuals approach their care and, of course, some take desperate steps to go to unregulated providers and seek hormones'. A clinical trial of puberty blockers, which was recommended by Cass, is being set up by an independent research team at King's College London, which is taking it through ethical and regulatory approvals. An expert panel will report to Streeting in July after considering a similar ban on cross-sex hormones for 16- to 18-year-olds, with initial signals that further restriction is likely. The Guardian spoke to a range of parents about their concerns over their children's treatment since the Cass report was published. Some said they felt more hopeful since Cass's emphasis on evidence-based care, and were pleased to see underlying issues highlighted in her report – such as bullying, neurodiversity, emerging same-sex attraction and trauma – being addressed first in regular sessions with a psychologist. Others said this culture change had not reached adult services, where older teenagers were being treated, adding they were the same cohort subjected to the same societal factors that were reviewed by Cass. Some parents were particularly frustrated that other European countries had conducted similar reviews of the evidence base for hormone treatments but came to different conclusions that supported their use for young people. They also worried that staff at the new hubs did not appear to be very experienced in gender care, with what they felt was limited understanding of how time-critical decisions about hormone treatment can be. Pathways to gender-affirming hormones, for example, although technically still available were simply not discussed. One family reported that they were warned at a hub that accessing hormone treatment privately could trigger a safeguarding referral by their GP and even a police report. Another said it was unfair that NHS England had moved 200 young people already receiving puberty blocking or gender-affirming treatment at the Tavistock to a Nottingham clinic where their hormone treatment was continuing, while other youngsters were not offered that option. For 18-year-old Ben, who lives in the Midlands with his family and is about to start a degree at a Russell Group university, there is 'definitely value' in holistic support, as prioritised by Cass. But he says talking therapies lose their value if young people feel they are having to 'prove themselves' deserving of access to hormones. Ben joined the youth services waiting list at the age of 14, but was transferred to the adult NHS waiting list earlier this year after he turned 18, never having had an appointment. Instead his family accessed puberty blockers and then testosterone from an online clinic. 'I can understand that for someone who has not been in my position this is obviously a massive decision for a young person to make, and it is necessary to have safeguards in place, but to completely remove access to hormones is going to have a negative impact on many young people for the rest of their lives. 'Whilst using unregulated private providers has more risks than accessing healthcare through the NHS, risk is much greater where young trans people are left without any access to healthcare at all, as is the case for many who are unable to pay for private healthcare.' Some young people formerly treated at the new hubs have found their way to the private Gender Plus, a clinic that treats young people as well as adults, and is the only service in the UK able to prescribe cross-sex hormones to 16- to 18-year-olds, in line with NHS England guidance through its Care Quality Commission-registered hormone clinic. Its director, Dr Aidan Kelly, said: 'I'm hearing there's a huge drop-out rate [from the new hubs], which doesn't surprise me because the evidence base for group therapy helping young people with gender dysphoria is weaker than that for hormone interventions. They feel that the NHS has given up on them and so they are just waiting to age up into the adult service.' The adult service is under review by NHS England, in response to detailed concerns raised by Cass following her youth review, including 'out of control' waiting lists, inadequate consent processes, and limited explanation of the risks involved in treatment. In 2024, Gender Plus's first full year, it took 874 referrals, 343 of whom were under 18, and it has expanded to sites in London, Birmingham, Leeds and Dublin, with 20 staff, many of whom formerly worked at NHS gender services. Of those aged 16 to 18, 61% were prescribed gender-affirming hormones after completing an average six months of assessment. Gender Plus is facing a judicial review at the end of June, brought by the former NHS gender specialist Sue Evans, who also instigated proceedings against the Tavistock in 2019, challenging the CQC's decision to grant registration to the Gender Plus hormone clinic in January 2024, and the subsequent decision to award the clinic an outstanding rating in December 2024 after its first inspection. Kelly suggests NHS England is assuming by denying young people access to medical pathways, they 'will simply give up'. 'There's no evidence of that happening and in fact there is evidence that it does harm.' Last year, the Guardian reported on experts warning that growing numbers of under-18s were turning to the medicines hidden economy. Some of those young people are becoming politically active. In March, the activist group Trans Kids Deserve Better disrupted a Guardian event with Streeting, highlighting that he had not consulted with trans youth before making decisions about their treatment but had spoken to other groups that oppose gender-affirming care. NHS England says that the more cautious approach approved by Cass includes regular appointments with a clinician, and a suite of therapy options, one to one, in groups and with family, as well as treatment for coexisting mental health issues, including medication if necessary. In building the new services, efforts have been made to let clinicians get on with their day job away from the media spotlight. But Palmer says he worries that 'the polarised debate in the newspapers' does not recognise there are many young people 'who are really impacted by the dysphoria and distress that can follow gender incongruence and need access to the care of an NHS service'.
Telegraph
27-06-2025
- Health
- Telegraph
The British Medical Association has just shown its contempt for science
The British Medical Association hasn't gone out of its way to court public affection lately – the 11 strikes the BMA has held since 2022 resulted in about 1.5 million cancelled appointments, though they also resulted in an astonishing increase in its members' pay. And it's a safe bet that patients won't be edified to learn that they're now 'energised' at the prospect of yet another strike. But if the doctors' union is disastrously out of touch on strikes, it turns out that it's even more remote from public opinion on the contentious trans issue. The Cass Review recommended an almost complete ban on puberty blockers for children. Well, the man who led the BMA's opposition to the Report, Tom Dolphin, has now been made chairman of the BMA's council, its governing body. The appointment followed what looks like a coup by the 69 member board which ousted the previous incumbent, Professor Philip Banfield. Dr Dolphin tabled an emergency motion last July that led to the union rejecting the Cass report. It announced it would be publishing its own review instead. But alas, nothing has so far appeared. Let's remember that Hilary Cass, the author of the report, found that 'there is no good evidence' that puberty blockers for young people are safe to use and that 'it is unusual for us to give a potentially life-changing treatment to young people and not know what happens to them in adulthood'. And it seems that in fact many doctors agreed. When the BMA council bypassed debate to reject the Cass review after it ran out of time to discuss the motion at the annual meeting, there were four attempts by members to have an open debate on the review. More than 1,500 doctors, the majority of them BMA members, signed a 'Not in Our Name' open letter to the BMA council, criticising the 'very undemocratic' decision to reject Lady Cass's findings. But rather than respond to members' concerns, the BMA council has now elected Tom Dolphin to lead the organisation. It's not out to please, is it? Dr Dolphin's view on this issue can be judged by his position three years ago, when he posted photos of himself getting ready for a Trans Pride march, saying: 'About to set off to let London know that trans rights are human rights!' Mind you, he didn't focus on this when he accepted his new position, observing that the last three years 'has been a period of huge change for the BMA which has seen doctors realise the power that they have as trade union members to change their working lives … for the better. The fight to restore doctors' pay and pensions continues.' More militancy then. You have to ask: are doctors really best led by a man who takes such a radical approach to giving life-altering drugs to children confused about their gender? I'd say it's proof that the BMA isn't an organisation that patients or the Government can take seriously.
Western Telegraph
01-05-2025
- Politics
- Western Telegraph
Generation will be lost to poor mental health without safeguards on tech
Baroness Hilary Cass said the impact of smart devices on children's sleep, attention span, and education is 'not just a moral problem but an economic timebomb'. The independent crossbencher called for teachers to receive dedicated training on the issue, in addition to education for parents, as peers debated the Children's Wellbeing and Schools Bill. Independent crossbencher Lady Cass (Yui Mok/PA) Then-Dr Hilary Cass previously led a landmark review into gender services for young people, which found children had been let down by a lack of research and evidence on the use of puberty blockers and hormones. Speaking during the Bill's second reading debate on Thursday, she told the Lords: 'Any legislation addressing the subject of safeguarding children, and opportunity, and safety in schools, cannot possibly ignore the impact of digital technology on the lives of children and young people.' Lady Cass argued it's not just 'deliberate harm', such as cyber bullying, emotional abuse, sexual abuse, exploitation and grooming that children are at risk of. 'That's just the tip of the iceberg, there are multiple other risks associated with digital technology that have been discussed in this House, including adverse affects of learning, attention, sleep, educational attainment and mental health. 'And addictive apps are particularly a problem, especially for boys,' she said. We are looking at losing a generation to poor mental health and to even more young adults being unable to contribute to the workforce Lady Cass Lady Cass continued: 'This is not just an issue of whether we ban smartphones in schools, there's a wide array of possible actions that can be part of a strategic, multi-faceted approach to the problem. 'For example, RSE (relationships and sex education) is compulsory in schools, and yet there is no requirement to teach young people how to manage the digital technology that occupies so many hours of their lives. 'Nor indeed to include appropriate training for the staff that are teaching our infants or older children. 'There's insufficient consideration of the impact of loss of safe place spaces, which would give children alternative recreational activities to spending time on their digital devices. 'There's no focus on providing education and advice to parents on how to manage access to technology so that they can facilitate their children's learning and development. 'So I very much hope that the Government will be receptive to a range of amendments that will address these deficits in the Bill, and thus gift our children with a safer, healthier future. 'Without such measures we are looking at losing a generation to poor mental health and to even more young adults being unable to contribute to the workforce. 'So this is not just a moral problem, but an economic timebomb that we can ill afford.'
Yahoo
01-05-2025
- Health
- Yahoo
Generation will be lost to poor mental health without safeguards on tech
A generation of young people will be lost to poor mental health if safeguards on digital technology are not brought forward, a top paediatrician has warned. Baroness Hilary Cass said the impact of smart devices on children's sleep, attention span, and education is 'not just a moral problem but an economic timebomb'. The independent crossbencher called for teachers to receive dedicated training on the issue, in addition to education for parents, as peers debated the Children's Wellbeing and Schools Bill. Then-Dr Hilary Cass previously led a landmark review into gender services for young people, which found children had been let down by a lack of research and evidence on the use of puberty blockers and hormones. Speaking during the Bill's second reading debate on Thursday, she told the Lords: 'Any legislation addressing the subject of safeguarding children, and opportunity, and safety in schools, cannot possibly ignore the impact of digital technology on the lives of children and young people.' Lady Cass argued it's not just 'deliberate harm', such as cyber bullying, emotional abuse, sexual abuse, exploitation and grooming that children are at risk of. 'That's just the tip of the iceberg, there are multiple other risks associated with digital technology that have been discussed in this House, including adverse affects of learning, attention, sleep, educational attainment and mental health. 'And addictive apps are particularly a problem, especially for boys,' she said. Lady Cass continued: 'This is not just an issue of whether we ban smartphones in schools, there's a wide array of possible actions that can be part of a strategic, multi-faceted approach to the problem. 'For example, RSE (relationships and sex education) is compulsory in schools, and yet there is no requirement to teach young people how to manage the digital technology that occupies so many hours of their lives. 'Nor indeed to include appropriate training for the staff that are teaching our infants or older children. 'There's insufficient consideration of the impact of loss of safe place spaces, which would give children alternative recreational activities to spending time on their digital devices. 'There's no focus on providing education and advice to parents on how to manage access to technology so that they can facilitate their children's learning and development. 'So I very much hope that the Government will be receptive to a range of amendments that will address these deficits in the Bill, and thus gift our children with a safer, healthier future. 'Without such measures we are looking at losing a generation to poor mental health and to even more young adults being unable to contribute to the workforce. 'So this is not just a moral problem, but an economic timebomb that we can ill afford.'
