U.K. Report Calls into Question Youth Gender-Transition Treatments

Happy Wednesday! As soon as we saw this headline yesterday—“Circus Elephant Gets Loose, Goes for Stroll Through Butte”—we knew we had to let you know about it.

But we’ll let you guess the elementary school-level punchline we came up with.

Quick Hits: Today’s Top Stories

• White House National Security Adviser Jake Sullivan announced new sanctions against Iran on Tuesday in response to Tehran’s multi-wave aerial attack on Israel over the weekend. The sanctions specifically target Iran’s missile and drone program, and are aimed at holding “the Iranian government accountable for its malicious and destabilizing actions,” Sullivan said, adding that the U.S. will also enact sanctions against entities supporting the Islamic Revolutionary Guard Corps and Iran’s Defense Ministry. Lt. Gen. Herzi Halevi, Israel’s military chief, vowed on Monday the Israel Defense Forces will respond to Iran’s attack, but officials have not yet given an indication of how or when such retaliation will occur. Israel’s war cabinet will reportedly meet today for the third time this week to discuss next steps.
• The House Select Committee on the Chinese Communist Party (CCP) released a report Tuesday that suggested China is leveraging the U.S. fentanyl crisis for strategic and economic gain, including by subsidizing the production and export of illegal fentanyl and permitting its open sale online.* The bipartisan committee—led by Republican Chairman Mike Gallagher and Democratic Ranking Member Raja Krishnamoorthi—recommended the creation of a task force to combat the global illicit fentanyl trade, providing enhanced resources for law enforcement and intelligence agencies, and aggressively sanctioning entities involved with the trade, among other measures. Gallagher, however, is resigning from Congress at the end of the week after deciding not to run for reelection. 
• Record rainfall in the Gulf states of the Arabian Peninsula this week caused flash flooding that killed at least 17 people in Oman and wreaked havoc throughout the region. The intense rainfall—which forced the closure of the Dubai airport—equaled what the United Arab Emirates typically sees in the entire year.
• The Supreme Court heard oral arguments on Tuesday in a case concerning the constitutionality of the felony charges against a participant in the January 6 riot. The defendant—a former Pennsylvania police officer who entered the Capitol building on January 6, 2021—faces charges under a federal law that punishes anyone who “obstructs, influences, or impedes any official proceeding, or attempts to do so.” The justices seemed divided Tuesday over whether the law should cover the behavior exhibited by those who participated in the January 6 riot. The Supreme Court’s ruling in the case—expected later this summer—could affect the prosecutions of more than 300 people charged for their actions that day.
• GOP Rep. Thomas Massie of Kentucky on Tuesday joined Rep. Marjorie Taylor Greene of Georgia as a co-sponsor on her motion to vacate the speaker, which could force a vote on House Speaker Mike Johnson’s ouster. Massie—who sits on the powerful House Rules Committee—said the speaker was going for the “Triple Crown” in pushing Ukraine aid, last month’s omnibus spending bill, and the recent reauthorization of Section 702 of the Foreign Intelligence Surveillance Act. Massie urged Johnson to resign preemptively, but the speaker said Tuesday he will not step down and seemed to have the support of many of his House Republican colleagues.
• Republican impeachment managers from the House of Representatives formally delivered two articles of impeachment against Homeland Security Secretary Alejandro Mayorkas to the Senate on Tuesday, related to Mayorkas’ handling of the southern border. The House approved the articles in a narrow 214-213 vote in February, and senators are expected to be sworn in as jurors in the impeachment trial later today. It’s unlikely, however, that the proceedings will last long in the Democratic-controlled Senate, where a two-thirds majority is needed for a conviction and Democratic senators are angling for an expedited vote to dismiss the charges. 
• Seven of 12 jurors—plus six alternates—were seated on Tuesday in the second day of jury selection in former President Donald Trump’s criminal trial related to alleged hush-money payments to porn star Stormy Daniels. The judge overseeing the trial issued a stern warning to Trump against making intimidating remarks to any of the jurors after observing the former president “gesture” and make “audible” remarks toward a member of the panel. “I won’t tolerate that,” Judge Juan Merchan said. “I will not have any jurors intimidated in this courtroom. I want to make that crystal clear.” 
• One American News Network (OAN) on Tuesday reached a confidential settlement in a defamation case filed against them by Smartmatic, a company that specializes in electronic voting systems. The case, filed in 2021, stemmed from OAN’s broadcast of false election fraud claims involving Smartmatic that the company argued damaged its reputation. In the lawsuit, Smartmatic notes that it only provided election services to Los Angeles County in the 2020 election. Smartmatic also has pending litigation against Fox News and Newsmax for their related coverage. 
• Former Florida Gov. Bob Graham died at the age of 87, his family announced Tuesday. The Democrat, who also served as a U.S. senator, was a vocal critic of former President George W. Bush and the invasion of Iraq. He suffered a debilitating stroke in 2020. 

A Reckoning Over Gender Treatment 

Perceptive Morning Dispatch readers have probably noticed at some point in the last four-and-a-half years that this newsletter is not interested in fanning the flames of the culture wars and getting readers riled up as they start their days. We made a promise at the outset that we’d do our best to separate the signal from the noise and distill the goings-on in the world into something worth your time every morning. There have been a handful of exceptions—times where we thought we could add clarity—but for many years, the battle over the appropriate treatment of minors seeking to change their gender has been filled with more heat than light. It’s possible that may be beginning to change. 

More than three-and-a-half years ago, the United Kingdom’s National Health Service (NHS) commissioned the “Independent Review of Gender Identity Services for Children and Young People.” That study—which has come to be known as the Cass Review, named Dr. Hilary Cass, the chair of the project and the former president of the Royal College of Paediatrics and Child Health—was published last week, and the review provided a welcome and evidence-based respite from an otherwise toxic conversation with its wide-ranging examination of studies and research undergirding gender-transition treatment and the clinical practices for delivering that treatment. 

The nearly 400-page U.K. report could signal a sea change for Europe in the debate over the future of gender-transition treatment for children and young people, providing a case study in the dangers of letting cultural pressures influence medical treatment. But it’s unclear if the takeaways will translate across the pond, where many of those cultural pressures have led to the public conversation being dominated by the most extreme voices on either side of the debate.

The conclusions of Cass’ report were striking. “The rationale for early puberty suppression remains unclear, with weak evidence regarding the impact on gender dysphoria, mental or psychosocial health,” the review found. It confirmed what some medical professionals and researchers had been arguing for years: There isn’t high-quality research showing that treatment delaying the onset of puberty is actually helping young people seeking a gender transition. “This is an area of remarkably weak evidence, and yet results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint,” Cass wrote in the report. “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender related distress.”  

The report included a variety of recommendations to improve care but concluded that “for most young people, a medical pathway will not be the best way to manage their gender-related distress.” Consequently, the NHS reversed its decade-long practice of prescribing puberty-suppressing hormones (PSH) to children with gender dysphoria—“a marked incongruence between one’s experienced/expressed gender and assigned gender of at least six months duration, as manifested” in delineated criteria, according to the Diagnostic and Statistical Manual of Mental Disorders. “We have concluded that there is not enough evidence to support the safety or clinical effectiveness of PSH to make the treatment routinely available at this time,” the NHS said last month. PSH treatment will still be available for participants in clinical trials and at private clinics, although some British lawmakers are now pushing for a ban across the board.

To understand the significance of these shifts, it’s important to appreciate how gender-transition treatment has evolved in Europe. In the late 1990s, researchers in the Netherlands helped pioneer such treatment for young people experiencing gender dysphoria in what became known as the “Dutch Protocol.” Treatment involved puberty-blocking drugs for children and teenagers with gender dysphoria, followed by cross-sex hormone treatment—providing biological males with estrogen and biological females with testosterone—and then, for some, transition surgery. A key 2011 Dutch study found positive results among 70 young people who received PSH treatment and a follow-up study in 2014 that tracked 55 of those people who subsequently underwent transition surgery and demonstrated that gender dysphoria “was alleviated and psychological functioning had steadily improved.”

But the Cass Review highlighted some significant issues with the 2011 study. For example, some of the study participants didn’t complete questionnaires after their treatments designed to assess their improvement, potentially biasing the results towards individuals who decided to come forward with positive outcomes. Plus, all the patients saw psychiatrists or psychologists during the PSH treatment, making it difficult to isolate the positive outcomes to the effects of the drugs.  

What’s more, subsequent research found that young people who experienced gender dysphoria as well as separate psychiatric issues reported no improvement in their well-being after taking PSH. Cass argued in The British Medical Journal that the early research showed success in a “small number of birth-registered males” but that the current population of people seeking gender treatment in the U.K. are largely “birth-registered”—or biological—females, and there is not sufficient evidence showing that that cohort benefits from PSH treatment. “It is unusual for us to give a potentially life-changing treatment to young people and not know what happens to them in adulthood,” Cass told BBC last week. 

The review led to the closure of the NHS’ Gender Identity Development Service (GIDS)—the largest children’s gender treatment clinic in the world—last month. In the early 2010s, GIDS became ground zero for the shift in the population of young people seeking gender treatment away from largely biological males who experienced gender dysphoria before puberty toward biological females experiencing gender distress. Most of those patients were seeking treatment after puberty had begun, and many had a host of separate diagnoses, often depression and anxiety. That change also coincided with the rollout of PSH treatment for young people. 

In 2011, the NHS conducted a trial of puberty blockers in young people with gender dysphoria—an “early intervention”—but the preliminary results of the study showed no benefits. “The results of the study were not formally published until 2020, at which time it showed there was a lack of any positive measurable outcomes,” the Cass Review noted. “Despite this, from 2014 puberty blockers moved from a research-only protocol to being available in routine clinical practice and were given to a broader group of patients who would not have met the inclusion criteria of the original protocol.” Some former GIDS staff had previously criticized the service for making assessments and recommending PSH treatment before psychological treatment or support had been offered. The Cass Review interviewed GIDS staff and found that some felt “under pressure to adopt an unquestioning affirmative approach and that this is at odds with the standard process of clinical assessment and diagnosis that they have been trained to undertake in all other clinical encounters.” 

Still, the Cass Review and the closing of GIDS are not without their critics among transgender advocates and some medical professionals. Mermaids, a British transgender charity, worried that the changes could heighten wait times for young people seeking care. GenderGP, an online gender clinic, criticized the report for an “inadequate” literature review that did not take into account evidence from non-randomized control studies. 

But the review’s findings are consistent with growing efforts by European medical experts and policymakers to roll back hormonal and transition treatment for young people. Last year, an independent Norwegian health board recommended that gender-transition treatment for minors be designated as “experimental.” In 2022, France’s National Academy of Medicine recommended practitioners delay using puberty blockers and cross-sex hormones, concluding it was “appropriate to extend the psychological treatment phase as much as possible.” Sweden issued guidance in 2022 to restrict treatment for minors to the rarest cases, and in 2020, the Finnish Health Authority issued new guidelines prioritizing psychotherapy as the first-line treatment. As a result of the Cass Review, some doctors in Belgium and the Netherlands are now calling for restrictions on the use of puberty blockers.

Europe’s moves stand in contrast to the U.S., where leading medical bodies recommend an affirmative model of treatment that holds “a child of any age may be cognizant of their authentic identity and will benefit from a social transition at any stage of development.” Last summer, the American Academy of Pediatrics reaffirmed its commitment to this model of treatment, which is also supported by the World Professional Association of Transgender Healthcare (WPATH). U.S. Assistant Secretary for Health Rachel Levine—the first openly transgender person to hold a position requiring Senate confirmation—reflected the position of many gender-affirming care advocates in April 2022: “There is no argument among medical professionals—pediatricians, pediatric endocrinologists, adolescent medicine physicians, adolescent psychiatrists, psychologists, etc.—about the value and the importance of gender-affirming care.” 

While “gender-affirming care” can include social and therapeutic support, Levine’s framing belied the genuine disagreements among doctors and practitioners about medical interventions. “Clinicians who have spent many years working in gender clinics have drawn very different conclusions from their clinical experience about the best way to support young people with gender-related distress,” Cass wrote. The report also said that WPATH’s guidelines for care “lack developmental rigor.” 

Like the U.K., the U.S. is also seeing a growing number of young biological females who don’t have a long history of gender dysphoria seeking gender treatment. Yet they’re being treated through a model based on research that’s applicable to a different cohort. “The population has changed drastically,” Laura Edwards-Leeper, the former head of the Child and Adolescent Committee for WPATH, told the New York Times earlier this year. Edwards-Leeper founded the first pediatric gender clinic in the U.S. in 2007. “You have to take time to really assess what’s going on and hear the timeline and get the parents’ perspective in order to create an individualized treatment plan,” she said. “Many providers are completely missing that step.”

In 2022, Reuters surveyed 18 gender treatment clinics in the U.S. and found that none of them employed the month-long psychological screenings conducted by the researchers in the Dutch studies that provided the foundation for the affirmative care model. Seven of the clinics said they can prescribe based on a single visit “if they don’t see any red flags and the child and parents are in agreement.” The clinics said waiting months to treat children puts them at unnecessary risk of harm. 

While in the U.K. lawmakers from both the Labour and Conservative parties seem ready to support reforms to gender care, U.S. efforts to place additional restrictions on gender-transition treatment are largely led by Republican lawmakers at the state level. A number of red-leaning states have restricted—or outright banned—certain gender-transition treatments for minors, and GOP lawmakers in additional states are pointing to the Cass Review as justification for doing the same. The battle over such state laws is currently playing out in the courts to varying effect. The Supreme Court ruled this week that Idaho could enforce its ban on treatment for minors with a handful of exceptions, but on Tuesday, a state court in Ohio temporarily blocked the state’s ban from going into effect.

The debate will no doubt continue apace in the near future, but likely not without continued risk to the debaters. “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 behavior,” Cass wrote. 

“This must stop,” she added. “Polarization and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse, and in the long run will also hamper the research that is essential to finding the best way of supporting them to thrive.” 

Worth Your Time

• Writing for Christianity Today, Andy Olsen told the story of a nation and a people who feel like they’re facing the end times. “Pastor Frederic Nozil has learned to keep his head down,” Olsen said of one Haitian minister watching his country deteriorate. “He schedules church activities to wrap up before a mandatory curfew. He will cut a prayer service short if he has a bad feeling about a police vehicle he noticed on the street. Some of his congregation risk their lives crossing gang checkpoints on their way to the church, the Centre Chrétien International Maison d’Adoration, so he knows to expect a smaller turnout. Ministry looks different, he figures, at the end of the world. ‘We are living in an eschatological time,’ Nozil said. That’s how it felt in the early hours of March 18. It was a Monday, and the bespectacled minister should have been recovering from the usual slate of Sunday demands. Instead, he shut himself in his home for two days straight as heavy gunfire echoed through the hills.”
• For Reason magazine, Ronald Bailey explored a new progress movement counteracting the voices of pessimism. “All these projects direct people’s attention to Gapminder, Human Progress, Our World in Data, and other efforts that comprehensively document how much progress is still being made today,” he wrote. “These changes include increasing average life expectancy, cutting extreme poverty, reducing childhood mortality, increasing wealth, supplying greater access to education, and empowering women’s rights. Yet merely pointing out the facts of progress isn’t enough to persuade a lot of folks. It would be great, says [Progress Network founder Zachary] Karabell, if it worked just to tell people, ‘You should all just read the data and change your views.’ But it usually doesn’t.” These efforts, Bailey explained, are instead about a narrative of progress. “‘You can’t throw facts in the face of people’s emotions, or at least you’ve got to be very careful about how you do that,’ says Karabell. ‘You can’t tell people that they should feel better just because the data tells them they should.’ [Roots of Progress founder Jason] Crawford agrees: ‘Narratives have a lot of power and they have more power than charts and graphs.’”

Presented Without Comment

National Review: NPR Suspends Longtime Editor after Scathing Exposé on Left-Wing Bias

Also Presented Without Comment

Bloomberg: [Democratic Sen.] Bob Menendez Poised to Blame His Wife in Bribery Case Defense 

Also Also Presented Without Comment 

Republican Sen. Tom Cotton: “I encourage people who get stuck behind the pro-Hamas mobs blocking traffic: take matters into your own hands to get them out of the way. It’s time to put an end to this nonsense.”

Toeing the Company Line

• How will Israel respond to Iran’s attack? Are Americans actually less polarized than social media makes it seem? Will Mike Johnson’s speakership survive? Declan was joined by David Daoud, Will, Drucker, and Charles to discuss all of this and more on last night’s Dispatch Live (🔒). Members who missed the conversation can catch a rerun—either video or audio-only—by clicking here. 
• In the newsletters: Nick explored the lessons learned from the “rolling disaster” of efforts to oust House Speaker Mike Johnson. 
• On the podcasts: Jonah is joined on The Remnant by our old friend Nancy French to discuss her new book, Ghosted: An American Story. 
• On the site: Jonah unpacks President Biden’s “take the win” argument against Israeli retaliation and Kevin writes about the rise of the “MAGA Democrat,” starting with Pennsylvania congressional candidate Mike O’Brien.

Let Us Know

Do you think we’ll look back on the Cass Review in five or ten years as a tipping point in the debate over gender-transition treatment for minors?

Clarification, April 17, 2024: This newsletter originally mislabeled the name of the Select Committee on the Chinese Communist Party.