OPINION
DAVID
BROOKS
The Courage to Follow the Evidence on Transgender
Care
April 18,
2024
David
Brooks
By David
Brooks
https://www.nytimes.com/2024/04/18/opinion/transgender-care-cass-report.html
Opinion
Columnist
Hilary Cass
is the kind of hero the world needs today. She has entered one of the most
toxic debates in our culture: how the medical community should respond to the
growing numbers of young people who seek gender transition through medical
treatments, including puberty blockers and hormone therapies. This month, after
more than three years of research, Cass, a pediatrician, produced a report,
commissioned by the National Health Service in England, that is remarkable for
its empathy for people on all sides of this issue, for its humility in the face
of complex social trends we don’t understand and for its intellectual integrity
as we try to figure out which treatments actually work to serve those patients
who are in distress. With incredible courage, she shows that careful
scholarship can cut through debates that have been marked by vituperation and
intimidation and possibly reset them on more rational grounds.
Cass, a
past president of Britain’s Royal College of Pediatrics and Child Health, is
clear about the mission of her report: “This review is not about defining what
it means to be trans, nor is it about undermining the validity of trans
identities, challenging the right of people to express themselves or rolling
back on people’s rights to health care. It is about what the health care
approach should be, and how best to help the growing number of children and
young people who are looking for support from the N.H.S. in relation to their
gender identity.”
This issue
begins with a mystery. For reasons that are not clear, the number of
adolescents who have sought to medically change their sex has been skyrocketing
in recent years, though the overall number remains very small. For reasons that
are also not clear, adolescents who were assigned female at birth are driving
this trend, whereas before the late 2000s, it was mostly adolescents who were
assigned male at birth who sought these treatments.
Doctors and
researchers have proposed various theories to try to explain these trends. One
is that greater social acceptance of trans people has enabled people to seek
these therapies. Another is that teenagers are being influenced by the
popularity of searching and experimenting around identity. A third is that the
rise of teen mental health issues may be contributing to gender dysphoria. In
her report, Cass is skeptical of broad generalizations in the absence of clear
evidence; these are individual children and adolescents who take their own
routes to who they are.
Some
activists and medical practitioners on the left have come to see the surge in
requests for medical transitioning as a piece of the new civil rights issue of
our time — offering recognition to people of all gender identities. Transition
through medical interventions was embraced by providers in the United States
and Europe after a pair of small Dutch studies showed that such treatment
improved patients’ well-being. But a 2022 Reuters investigation found that some
American clinics were quite aggressive with treatment: None of the 18 U.S.
clinics that Reuters looked at performed long assessments on their patients,
and some prescribed puberty blockers on the first visit.
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Unfortunately,
some researchers who questioned the Dutch approach were viciously attacked.
This year, Sallie Baxendale, a professor of clinical neuropsychology at the
University College London, published a review of studies looking at the impact
of puberty blockers on brain development and concluded that “critical
questions” about the therapy remain unanswered. She was immediately attacked.
She recently told The Guardian, “I’ve been accused of being an anti-trans
activist, and that now comes up on Google and is never going to go away.”
As Cass
writes in her report, “The toxicity of the debate is exceptional.” She
continues, “There are few other areas of health care where professionals are so
afraid to openly discuss their views, where people are vilified on social media
and where name-calling echoes the worst bullying behavior.”
Cass
focused on Britain, but her description of the intellectual and political
climate is just as applicable to the U.S., where brutality on the left has been
matched by brutality on the right, with crude legislation that doesn’t
acknowledge the well-being of the young people in question. In 24 states
Republicans have passed laws banning these therapies, sometimes threatening
doctors with prison time if they prescribe the treatment they think is best for
their patients.
The battle
lines on this issue are an extreme case, but they are not unfamiliar. On issue
after issue, zealous minorities bully and intimidate the reasonable majority.
Often, those who see nuance decide it’s best to just keep their heads down. The
rage-filled minority rules.
Cass showed
enormous courage in walking into this maelstrom. She did it in the face of
practitioners who refused to cooperate and thus denied her information that
could have helped inform her report. As an editorial in The BMJ puts it,
“Despite encouragement from N.H.S. England,” the “necessary cooperation” was
not forthcoming. “Professionals withholding data from a national inquiry seems
hard to imagine, but it is what happened.”
Cass’s
report does not contain even a hint of rancor, just a generous open-mindedness
and empathy for all involved. Time and again in her report, she returns to the
young people and the parents directly involved, on all sides of the issue. She
clearly spent a lot of time meeting with them. She writes, “One of the great
pleasures of the review has been getting to meet and talk to so many
interesting people.”
The
report’s greatest strength is its epistemic humility. Cass is continually
asking, “What do we really know?” She is carefully examining the various
studies — which are high quality, which are not. She is down in the academic
weeds.
She notes
that the quality of the research in this field is poor. The current treatments
are “built on shaky foundations,” she writes in The BMJ. Practitioners have
raced ahead with therapies when we don’t know what the effects will be. As Cass
tells The BMJ, “I can’t think of another area of pediatric care where we give
young people a potentially irreversible treatment and have no idea what happens
to them in adulthood.”
She writes
in her report, “The option to provide masculinizing/feminizing hormones from
age 16 is available, but the review would recommend extreme caution.” She does
not issue a blanket, one-size-fits-all recommendation, but her core conclusion
is this: “For most young people, a medical pathway will not be the best way to
manage their gender-related distress.” She realizes that this conclusion will
not please many of the young people she has come to know, but this is where the
evidence has taken her.
You can
agree or disagree with this or that part of the report, and maybe the evidence
will look different in 10 years, but I ask you to examine the integrity with
which Cass did her work in such a treacherous environment.
In 1877 a
British philosopher and mathematician named William Kingdon Clifford published
an essay called “The Ethics of Belief.” In it he argued that if a shipowner
ignored evidence that his craft had problems and sent the ship to sea having
convinced himself it was safe, then of course we would blame him if the ship
went down and all aboard were lost. To have a belief is to bear responsibility,
and one thus has a moral responsibility to dig arduously into the evidence,
avoid ideological thinking and take into account self-serving biases. “It is
wrong always, everywhere, and for anyone, to believe anything upon insufficient
evidence,” Clifford wrote. A belief, he continued, is a public possession. If
too many people believe things without evidence, “the danger to society is not
merely that it should believe wrong things, though that is great enough; but
that it should become credulous, and lose the habit of testing things and
inquiring into them; for then it must sink back into savagery.”
Since the
Trump years, this habit of not consulting the evidence has become the
underlying crisis in so many realms. People segregate into intellectually
cohesive teams, which are always dumber than intellectually diverse teams.
Issues are settled by intimidation, not evidence. Our natural human tendency is
to be too confident in our knowledge, too quick to ignore contrary evidence.
But these days it has become acceptable to luxuriate in those epistemic
shortcomings, not to struggle against them. See, for example, the modern
Republican Party.
Recently
it’s been encouraging to see cases in which the evidence has won out. Many
universities have acknowledged that the SAT is a better predictor of college
success than high school grades and have reinstated it. Some corporations have
come to understand that while diversity, equity and inclusion are essential
goals, the current programs often empirically fail to serve those goals and
need to be reformed. I’m hoping that Hilary Cass is modeling a kind of behavior
that will be replicated across academia, in the other professions and across
the body politic more generally and thus save us from spiraling into an
epistemological doom loop.
David
Brooks has been a columnist with The Times since 2003. He is the author, most
recently, of “How to Know a Person: The
Art of Seeing Others Deeply and Being Deeply Seen.” @nytdavidbrooks
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