Cass Report on Child Transition: Ethical Limits to the Pursuit of Knowledge

By Theodore Dalrymple

Hundreds of doctors in Britain have resigned from the nation’s top medical association because of its refusal to accept the conclusions of the Cass report, an inquiry into medical services for transgender patients chaired by Dr. Hilary Cass, a respected pediatrician.

It is obvious on reading the report that the inquiry attempted to be fair and even-handed, but wherever ideology reigns there can be no successful propitiation of extremists.

In essence, the Cass report found that there was little good evidence to support the treatments that supposedly transgender children and adolescents were receiving. Even the natural history or evolution of the condition was not known. The reason for the recent explosion in the number of cases is still a matter of speculation. Is it a case of pent-up demand, previously unrecognized because of under-reporting due to prejudice, now melting away, or of a kind of social contagion promoted by social media and reinforced by the increased attention that those claiming to be transgender receive?

If the latter, even the idea of a natural history or evolution of the condition is false or non-applicable. One can talk sensibly of the evolution of, say, Parkinson’s disease or multiple sclerosis (even though both conditions vary in their symptomatology and rate of progression), but not of a condition that is fundamentally of social and psychological origin, and which will therefore vary according to what I am tempted to call fashion, but perhaps I should call social conditions.

The fact is that the increase is of too recent origin for anyone to be able to say what the long-term consequences for individual or society may be, and if it is true that social or psychological fashion has played a large part in the increase in the number of cases, and that the fashion may change, it may be impossible forever to estimate with certainty the effects of any treatment or non-treatment. And this itself poses grave ethical questions, especially where the treatment of children is concerned.

If, for example, supposedly transgender children tended to grow out of their gender confusion, then to treat them at all would be quite wrong. Alternatively, if their gender confusion were a manifestation or symptom of another underlying condition, then the correct approach would be to treat that condition rather than the gender confusion, and to do so would be like offering minor painkillers to a person with pneumonia.

It is curious that most of the British clinics that treated transgender adults who began their transition as children initially refused to cooperate with the Cass inquiry, for example, by releasing their anonymized clinical data to it. This naturally raised suspicions that the clinics had something to hide; perhaps they could not release the data because they had no data to release. In other words, that medical professionals were forging ahead, playing with children’s futures, without knowing what they were doing. And if true, this, of course, would be the height of irresponsibility, to put it no higher. All one can say is that it will end up in the courts, and because of Britain’s largely socialized medical system, it will be the taxpayer who will foot the bill, which might well run into the hundreds of millions or billions, considering the potential scope of the damage caused to many young lives.

The Cass report called for a moratorium on the use of puberty-blocking drugs on pre-pubertal children, until more is known. But how can more ever be known by means and methods that are ethical? You cannot experiment on pre-pubertal children, giving them drugs of unknown long-term effects for a condition that is not fatal, and, indeed, whose outcome is not even known. They could not give their informed consent because of their age; neither could their parents because the risks are unknown. This is not like experimental treatment for an illness with an invariably fatal outcome, say acute leukemia, where there is (or was, now that such leukemia is eminently treatable) nothing to lose. To perform properly controlled studies on the effects of puberty-blocking drugs would, in effect, be to enter Dr. Mengele country, albeit with intentions not quite so malign.

This implies that there are some ethical limits to the pursuit of knowledge, and that it is better to remain in ignorance than to acquire it by unjustified or even cruel means. This is itself an argument not without its dangers, for in the 18th century the great Doctor Johnson argued against vivisection because he thought that the evil of the means of obtaining knowledge in this way outweighed the value of the knowledge obtained and would do so even if the knowledge obtained were useful—which at the time it largely was not.

Alas, this is not so. I write this near the town where was born Léopold Ollier, the great 19th-century French orthopedic surgeon who first developed the bone graft. This technique has relieved enormous human suffering, but its development required animal experimentation, and when I read Ollier’s original experiments, I cannot but conclude that his animal subjects must have suffered, often horribly. Bernard Shaw, the great playwright who won the Nobel Prize for literature, was another opponent of vivisection, who said that vivisectors were, ex officio, sadists, but this was obvious nonsense: Ollier was a very humane man, almost worshipped by his patients for the suffering he had alleviated in them.

But giving puberty-blockers to pre-pubertal children is in quite another category. Ollier performed his experiments on rabbits, not on children; moreover, the suffering of his human patients was so obvious (as can be seen from the photographs of those he treated and succored) that experimentation on them—like all new treatments, bone-grafting was at first experimental—was justified. Ollier was not driven by ideology but by common humanity.

The vast increase not only in the numbers of children claiming to be transgender, but treated with drugs of unknown long-term effects, can really only be explained by the sudden grip of ideology; and since the people who were in its grip were both educated and intelligent, this is an illustration of how education and intelligence are no defense against the spread of fashionable foolishness (call it what you will), and on the contrary may actually conduce to it, insofar as the educated and intelligent are better able to rationalize what they do.

First published in the Epoch Times