Tell The American Academy of Pediatrics We Know About The Cass Review
And we are going to raise hell about it
We are forwarding this email from a network of sex realist organizations.
IMPORTANT!! CALL TO ACTION: January Littlejohn is heading up a letter writing campaign to the American Academy of Pediatrics to put pressure on them to acknowledge the Cass Review. We need full participation, even sending an email anonymously (create a proton email in 30 seconds).
If your child was affected or you know someone who has been please personalize with a bit of that story.
Do BEFORE COB MAY 6, 2024 in order to have the biggest impact, but don't let that date stop if you cannot make it in time. If we can flood their office with letters from parents, we can get media to cover this, particularly if they don't respond. Instructions and sample letters are below. Please use the sample letters as a template and make them into your own original letter OR you can use the talking points to write your own letter. We have also attached a CASS Review summary you can attach to your emails. Feel free to add your personal story like I did as well. SHARE THIS FAR AND WIDE.
Email addresses:
Dr. Benjamin D. Hoffman: benjyhoffman@gmail.com
Dr. Susan Kressly: skresslymd@gmail.com
Dr. Sandy Chung: sandychungaap@gmail.com
Dr. Margaret Fisher: Margaret.Fisher@RWJBH.org
Mark Del Monte, JD: mdelmonte@aap.org
CC: AAPcampaign@proton.me (so that January can have an accurate count of emails.)
Letter Version 1
Dear ___________,
You would be aware of the recent review of current practices in pediatric gender medicine carried out in the United Kingdom. These reviews are the largest and most comprehensive to date in the area of pediatric gender medicine. The team looked at 237 papers from 18 countries, providing information on a total of 113,269 children and adolescents. The review team was headed by Dr. Hilary Cass, a pediatrician whose research and interests include autistic spectrum disorders, cognitive impairment due to epilepsy, children with visual loss, and care of children with multiple disabilities. In 2015, Dr. Cass received an OBE for services to child health and was subsequently appointed chair of the British Academy of Childhood Disability.
Over the last four years, Dr. Cass and her team conducted an exhaustive literature review, resulting in a nearly 400-page report accompanied by nine studies (six of which were systematic reviews of evidence).
Just like you, Dr. Cass is a pediatrician, and just like you, she is concerned about the well-being of the children who are suffering from gender dysphoria. As she points out in the very beginning, the report 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 healthcare.” Rather, it is about “what the healthcare approach should be, and how best to help the growing number of children and young people who are looking for support in relation to their gender identity.”
I understand your desire to help these children – you became a pediatrician because you care for the children entrusted under your care. That means you also change your care protocols based on the latest evidence. For example, for many years, doctors who genuinely cared for their patients suffering from pain routinely prescribed FDA-approved opioids like Oxycontin and other semi-synthetic narcotic analgesics. However, they stopped prescribing these opioids once the evidence behind them was shown to be dubious.
So, I can understand why pediatricians all over the country started prescribing puberty blockers and cross-sex hormones for children, even though the FDA did not approve them for treating gender dysphoria. Their decision would have become even easier after the AAP released its guidelines in 2018 and reaffirmed them in 2023.
The Cass Review and the accompanying systematic reviews show conclusively that with gender medicine, the current medical model is “built on shaky foundations.” Or, in the words of the editor-in-chief of the British Medical Journal: “The evidence base for interventions in gender medicine is threadbare, whichever research question you wish to consider – from social transition to hormone treatment.”
What is especially concerning for the AAP is that when its 2018 guidelines were evaluated, they were arguably the lowest-rated among all the 23 guidelines evaluated by Dr. Cass and her team (as per the AGREE II, an instrument used to assess the quality of practice guidelines). AAP’s guidelines received just 12% on the rigor of development and 6% on their applicability (scores higher than 75% were considered good).
Equally concerning, while the availability of so many guidelines might indicate consensus, Dr. Cass’s review team found that the WPATH 2012 and the Endocrine Society 2009 guidelines have heavily influenced the rest. They cite each other to create a false sense of consensus, and the other guidelines cite them. In the words of Dr. Cass, “The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.” You can see the scores of the 23 guidelines and the intricate web of each citing each other in one of the systematic reviews published along with the Cass Review (see the enclosed pages).
Only two guidelines – from the medical boards of Sweden and Finland – scored highly in this systematic review (and these two started from scratch, using neither the WPATH nor Endocrine Society guidelines). Perhaps unsurprisingly, both countries now have limited access to either puberty blockers or cross-sex hormones only in clinical research settings. Routine prescription to children for these unapproved drugs is not allowed in six European countries because of a lack of evidence of their benefits and concern about long-term harms.
In 2020, Finland started recommending psychotherapy as the primary treatment for adolescents with gender dysphoria and now recommends hormones only in exceptional circumstances. In 2022, Sweden restricted hormones only in clinical trials; in 2023, Norway did the same. Denmark currently limits hormone treatments only to transgender adolescents who have experienced dysphoria since early childhood. Rounding up the list, England and Scotland have now followed in the Nordic countries' footsteps. To quote Dr. Cass, “For most young people, a medical pathway will not be the best way to manage their gender-related distress.”
Recall that all these countries had started cross-sex hormones as a treatment for gender dysphoria much earlier than the United States. Their evidence is also much better than ours because they have much better longitudinal data about their patients thanks to the national patient health records.
I can understand why you believed the guidelines from the AAP. But now that the diligent and exhaustive guidelines have come out from the UK, after four years of painstaking research, and have shown the AAP guidelines to be particularly poor, I am sure you will appreciate that continuing with this mode of treatment would not only negligent and unethical, exposing providers to legal liability.
What is the AAP waiting for beyond this exhaustive set of guidelines and reviews that covers even the most recent studies conducted in the United States? Does the AAP consider the Cass Review lacking in some ways? If so, it should publish its objections clearly and with specificity. Every day that goes by in this state of limbo is another day where the AAP appears to prioritize its own survival over children’s health.
The AAP should remember that medicine is neither a political nor a civil rights issue. It is the practice of humane, evidence-based care for ailing patients: nothing more, nothing less. Dr. Hilary Cass and her team took four years to come out with a definitive review of everything we know about gender medicine for children and young adults. US medical bodies would do well to review this work and issue a statement. Failure in this regard will cast America’s medical sciences as outliers and raise questions about its ethics and motivations.
Now that we know it has wholly botched up its first set of guidelines, the AAP should not waste more time and should endorse the Cass Review and its policies. The professional reputation of American medicine – and the lives of tens of thousands of children – are at stake.
As a pediatrician, you will also doubtless appreciate how Dr. Cass emphasizes that the people who know the children best – the pediatricians – should be at the heart of providing the holistic care that all children deserve. I am confident that you agree and urge you to bring up the issue with the AAP. As Dr. Cass mentioned in her foreword of the Cass Review, what happened in gender medicine is an inversion of how medicine is practiced. I also hope you will read the entire review. If you are short on time, please at least peruse its summary on pages 12-45 or the attached PDF of key content.
Warmly yours,
<name (optional)>
NOTE: You might have come across news about individuals and organizations spreading misinformation about the Report. As a pediatrician, you will appreciate Dr. Cass’s response: “If you deliberately try to undermine a report that has looked at the evidence of children’s healthcare, then that’s unforgivable. You are putting children at risk by doing that.” You might also find the FAQs published by her team to combat this misinformation helpful.
_____________________
Parent letter
Dear _________,
I am a parent of trans-identified child. I am writing to urge you to acknowledge the Final Report of the Cass Review released on April 10, 2024.
Parents of gender dysphoric youth expect you to fulfill your mission, which is “to attain the optimal physical, mental, and social health and well-being of infants, children, adolescents, and young adults.” Your mission includes the protection of gender dysphoric and trans-identified youth, and you are failing them unless you acknowledge the significant policy shift taking place around the rest of the world. Notably, the UK has shut down their only remaining gender clinic, and England, Scotland, and Wales are no longer permitting the use of puberty blockers and cross sex hormones for youth diagnosed with gender dysphoria.
Parents of gender dysphoric youth have been fighting for our children in silence for years while your organization has continued to follow low quality evidence and promote puberty blockers, hormones and surgeries for our children. This must end. This issue should not be political, and we implore you to let the evidence lead your policies on the issue, not politics.
Thank you for your time.
Sincerely,
<name (optional)>
_________________
Letter using key Cass Conclusions
Dear ___________,
I am writing to ask you to please follow your policy on best practices for treating gender dysphoric youth, and make immediate changes to conform with the findings of the Cass Review released April 10, 2024.
Key conclusions from the Cass Review:
“Exploration of identity is a completely natural process during childhood and adolescence and rarely requires clinical input.”
“While a considerable amount of research has been published in this field, systematic evidence reviews demonstrated the poor quality of the published studies, meaning there is not a reliable evidence base upon which to make clinical decisions, or for children and their families to make informed choices.”
“The rationale for early puberty suppression remains unclear, with weak evidence regarding the impact on gender dysphoria, mental or psychosocial health. The effect on cognitive and psychosexual development remains unknown.”
“The use of masculinising / feminising hormones in those under the age of 18 also presents many unknowns, despite their longstanding use in the adult transgender population. The lack of long-term follow-up data on those commencing treatment at an earlier age means we have inadequate information about the range of outcomes for this group.”
“Clinicians are unable to determine with any certainty which children and young people will go on to have an enduring trans identity.”
“For most young people, a medical pathway will not be the best way to manage their gender-related distress. For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems.”
In light of these findings, please revise your guidelines immediately, and follow the evidence and what most other countries are doing, which is to stop promoting the use of puberty blockers, hormonal and surgical interventions to treat gender dysphoria. Our children deserve ethical, evidence-based treatment.
Sincerely,
<name (optional)>
______________
Talking points if you wish to compose your own letter:
The Final Report from the Cass Review was published on April 10, 2024
Consequently, England’s National Health Service has closed their only youth gender clinic.
England, Scotland, and Wales no longer permit the use of puberty blockers and cross sex hormones for youth diagnosed with gender dysphoria.
Prior to the Cass Review, health authorities in Finland, Sweden, Norway, and Denmark restricted the use of puberty blocker and cross sex hormones in youth.
Access to mastectomies and genital surgeries for gender dysphoria was never widely available in Europe. Mastectomies were available in the Netherlands after age 16. In other countries surgeries were largely restricted to age 18 and older.
The Cass Review revealed that social, hormonal, and surgical transition is supported by “remarkably weak evidence, and yet results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint. The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.”
Key conclusions from the Cass Review
“Exploration of identity is a completely natural process during childhood and adolescence and rarely requires clinical input.”
“While a considerable amount of research has been published in this field, systematic evidence reviews demonstrate the poor quality of the published studies, meaning there is not a reliable evidence base upon which to make clinical decisions, or for children and their families to make informed choices.”
“The rationale for early puberty suppression remains unclear, with weak evidence regarding the impact on gender dysphoria, mental or psychosocial health. The effect on cognitive and psychosexual development remains unknown.”
“The use of masculinising / feminising hormones in those under the age of 18 also presents many unknowns, despite their longstanding use in the adult transgender population. The lack of long-term follow-up data on those commencing treatment at an earlier age means we have inadequate information about the range of outcomes for this group.”
“Clinicians are unable to determine with any certainty which children and young people will go on to have an enduring trans identity.”
“For most young people, a medical pathway will not be the best way to manage their gender-related distress. For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems.”
The American Academy of Pediatrics
In August 2023, the AAP leadership reaffirmed their 2018 policy that emphasized social, hormonal, and surgical transition as the preferred treatment for gender dysphoria.
The AAP also said in August 2023 that it would conduct an independent systematic review. The status of this review is unknown. There is zero possibility that this review will find high quality evidence that supports claims that youth will benefit from social, hormonal, or surgical transition.
AAP CEO and Vice President Mark Del Monte, in announcing these things, also said that AAP leadership was “confident the principles presented in the original policy remain in the best interest of children.”
Statements / Asks / Demands
Dr. Cass recognizes the “toxicity of the debate” as it relates to the proper treatment for youth with gender dysphoria.
“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 behaviour. This must stop.”
—Foreward of the Cass Review
The AAP must play a role. Its leadership can decrease the toxicity, stop the name calling and vilification, and promote reason debate and decision making. Youth and young adults deserve better leadership. They deserve better, safer, ethical and evidence-based care.
The AAP must recognize the Cass Review and changes that are occurring in many European countries.
The AAP mission is “to attain the optimal physical, mental, and social health and well-being of infants, children, adolescents, and young adults.” The AAP mission includes gender dysphoric and trans-identified youth.
The AAP's continued support of social, hormonal, and surgical transition is unconscionable and cannot be defended. A public statement is necessary and policy changes are needed.