Religion is a Mental Illness

Gender medicine in the US: how the Cass review failed to land

A landmark investigation with bearing on the future of gender identity services for children and adolescents has been pivotal in the UK—and

The BMJ

A landmark investigation with bearing on the future of gender identity services for children and adolescents has been pivotal in the UK—and largely ignored by US medical organisations and media. Jennifer Block reports on how America has resisted the push for a more holistic approach

The newly released Cass review on transgender care for under 18s has had a seismic effect across the United Kingdom and Europe. Scotland and Wales promptly followed the NHS in England in ceasing the prescription of puberty “blocking” drugs outside of research protocols. The UN special rapporteur on violence against women and girls, Reem Alsalem, called the independent inquiry’s findings and recommendations “seminal” and stated that policies on gender treatments have “breached fundamental principles” of children’s human rights, with “devastating consequences.” Some charities and clinicians are disappointed with last month’s final review report. But the tone of major print and broadcast media in the UK has shifted: outlets that have previously reported criticism of gender services as transphobic now note how, as the Guardian reported, “the lack of high quality research, highlighted by Cass, has been a subject of growing unease among doctors.”

The review by Hilary Cass, paediatrician and former president of the Royal College of Paediatrics and Child Health, was commissioned by the NHS and built on the findings of Cass’s 2022 interim report. Then, she found that the evidence underpinning the treatment intensive, “gender affirming” model of care for distressed young people was “limited” and “inconclusive.” The final report is even clearer: “The reality is that we have no good evidence on the long term outcomes of interventions to manage gender related distress.”

But in the United States, where the gender affirming model is the norm, the effect of Cass’s four year investigation and final report isn’t yet obvious. “Unfortunately, Cass does not seem to be penetrating the public consciousness,” says Zhenya Abbruzzese, cofounder of the four year old Society for Evidence Based Gender Medicine (SEGM), a group of researchers and clinicians that has pushed for systematic reviews and an evidence based approach.

Of the eight systematic reviews that Cass commissioned, two looked at nearly two dozen professional guidelines and found that most lack “developmental rigour.”23 More concerning, Cass exposed how they are built on “circularity,” drawn from years old versions of guidelines issued by the World Professional Association for Transgender Health (WPATH) and the Endocrine Society, each of which refer to the other rather than to high quality evidence. “This approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor,” writes Cass. Neither group responded to The BMJ.

The American Academy of Paediatrics (AAP) and the Endocrine Society have stood by their guidelines. The Cass review “does not contain any new research that would contradict” them, the Endocrine Society said in a statement.4 WPATH issued an email statement that Cass “is rooted in the false premise that non-medical alternatives to care will result in less adolescent distress,” and added on 17 May that its own guidelines were “based on far more systematic reviews [than] the Cass review.”5 As The BMJ reported last year,6 WPATH’s own systematic review, one of an unknown number commissioned for the eighth version of its Standards of Care—just two were published—concluded that the strength of the evidence to support the mental health benefits of hormones was “low” and that it was “impossible” to conclude how they affect suicide risk.

Under pressure from some members, the AAP announced last year that it would commission an independent systematic review of the evidence for the affirmative model—at the same time that it reconfirmed its 2018 statement in support.7The BMJ obtained a new resolution dated 1 April that asks the organisation to “issue an interim update to the 2018 policy statement based on the best available evidence to date.”

“The time has passed for yet another systematic review,” says Julia Mason, an Oregon paediatrician and member of SEGM who has submitted several resolutions, including the April 2024 one, to AAP for more evidence based guidance. “We now have a dozen high quality reviews (eight Cass, two NICE, one Swedish, one German) all pointing to significant issues with the purely affirmative model of care,” she says. “Parents and their children are being misled in clinics all over the country. There is no evidence that giving puberty blockers followed by hormones and surgery is lifesaving care, and there is mounting evidence that the harms might outweigh the advantages.” The AAP did not respond to The BMJ’s request for comment.

The American Psychological Association, American Psychiatric Association, and American College of Obstetricians and Gynecologists, which have position statements in support of the affirmative model, have remained silent about Cass. Only the psychology group responded to The BMJ, saying that it is studying the Cass report, but “we stand by the statement.”

Not all relevant professional groups have joined the consensus. Scot Glasberg, past president of the American Society of Plastic Surgeons, now president of the Plastic Surgery Foundation, told The BMJ that the organisation will issue “trustworthy, high quality” guidelines, but “like Dr Cass, we’ve found that the literature is of low quality and low value to dictate surgical care . . . We are trying to be very measured and not get into the difficulty that some of the other organisations have gotten into.” The American Academy of Family Physicians sought to develop a clinical practice guideline in 2020 but hasn’t yet produced one.8 The organisation declined to comment.

Some people in the psychology community are emboldened by Cass to break their silence, even if it means facing hostility from their peers. Brooke Laufer is a clinical psychologist based outside of Chicago and among the 300 clinicians who’ve joined the organisation Therapy First, which promotes psychotherapy as first line treatment for gender exploration. She told The BMJ that she is a politically liberal feminist who has “marched in Pride marches.” Recently, she posted about the Cass review to a listserv of therapists and was reprimanded by several members for promoting “misinformation” and “hate speech.” In February, another listserv member who posted about a Therapy First webinar was met with eight separate complaints to the state medical board.

Laufer says that the American Psychological Association should “gather its integrity and put out a statement that says we’re taking the Cass report seriously and we recommend puberty blockers to be paused unless it’s in the context of a clinical trial.” She adds: “What’s at stake are human lives and a generation of kids. This is about standing up and being adults and saying sorry, we got some of this wrong.”

The American Psychiatric Association met in New York this month for its annual conference. It had just one panel discussion on the topic of gender medicine, about “promoting public policy for evidence based transgender care,” focused on the negative effects of state legislation restricting treatments. In stark contrast, the European Society for Child and Adolescent Psychiatry released a new policy statement on safeguarding gender distressed youth from “experimental and unnecessarily invasive treatments with unproven psychosocial effects.”9

US media and the political landscape in general are notoriously polarised. Trusted LGBT+ advocacy groups have been unequivocal about the merits of the affirming model. GLAAD, which journalists founded in the 1980s to combat “grossly defamatory” media reporting about HIV/AIDS, protested the New York Times’s coverage of gender medicine, which has included the voices of former patients who feel they’ve been harmed. Last year, GLAAD parked a truck outside the paper of record’s offices: its electronic billboard stated, “The science is settled.”

Some hoped that Cass would offer an impartial beacon. And a few legacy and left leaning newsrooms covered the report in earnest—Reuters, the New York Times, the Nation, NBC, and the Economist. The Wall Street Journal’s editorial board said that the review “shows wisdom and humility on treatment of young people, in contrast to the ideological conformity in US medical associations.” The Washington Post and Boston Globe also ran opinions that amplified Cass to argue for a more precautionary path forward.

But many outlets historically aligned with advocacy positions have held back on any ink. STAT News, which “delivers trusted and authoritative journalism about health, medicine, and the life sciences,” has so far ignored Cass (as well as The BMJ’s request for comment). So has CNN. Jesse Singal, one of the first American journalists to expose the potential harms of youth gender treatment, reported on his Substack that the legacy news network had recycled the pronouncement that “gender affirming care is medically necessary, evidence based care” in 35 separate articles over the past two years, practically verbatim.10 (CNN did not explain, and did not respond to a query from The BMJ.) “Many outlets dug themselves into a deep hole on this issue by simply acting as stenographers and megaphones for activist groups rather than doing their jobs,” wrote Singal.

Singal has also called out Scientific American for not covering the Cass report, while on 20 April running a question and answer piece with a prominent advocate of gender affirming care titled “Anti-trans efforts use misinformation, epistemological violence, and gender essentialism.” The oldest continuously published magazine in the US, Scientific American, has run several articles favourable to the affirmative model in recent years. In “Why anti-trans laws are anti-science,” written in 2021 and republished in 2023, the magazine’s editors stated that it is “unscientific and cruel” to claim that treatments are “unproven and dangerous” or that “legislation is necessary to protect children.” According to a 2022 article, “What the science on gender affirming care for transgender kids really shows,” data “consistently show that access to gender affirming care is associated with better mental health outcomes.” “Decades of data support the use and safety of puberty pausing medications,” declared one 2023 piece.11

The magazine’s editor in chief, Laura Helmuth, has promoted these pieces on Twitter/X with declarations like, “The research is clear, and all the relevant medical organisations agree”; policies that restrict treatments are “dangerous, cruel, bigoted, and contrary to all the best scientific and medical evidence.” She’s also disparaged inquiries on the subject. In a February 2023 tweet, Helmuth included gender affirming care among a list of “things we don’t need to be both-sidesing, be ‘objective,’ or be ‘just asking questions!’ about.” Neither Helmuth nor the magazine’s publisher, Springer Nature, responded to a detailed email referencing the articles and more than 15 tweets.

US reporting in the main is sympathetic with, if not following the lead of, authoritative sources such as the US Department of Health and Human Services (HHS), which informs that “research demonstrates that gender affirming care improves the mental health and overall wellbeing of gender diverse children and adolescents” and calls puberty blockers “reversible.”12 On 24 April, a congressman confronted Xavier Becarra, secretary of the department, about these statements, holding up a thick printed copy of the Cass review. “I can assure you that we look at all studies,” said Becarra. “When we talk about a standard of care, it’s not something we make up. It’s based on what the major medical associations [say].” The US Department of Health and Human Services did not respond to The BMJ’s request for comment.

Rachel Levine, US assistant secretary for health, told National Public Radio in October 2022 that “there is no argument among medical professionals . . . about the value and importance of gender affirming care.” Yale paediatrician Meredithe McNamara, who coauthored a November 2022 commentary in the New England Journal of Medicine titled “Protecting transgender health and challenging science denialism,” told PBS NewsHour the same month, “The evidence base is strong.” McNamara has called puberty blockers “one of the most compassionate things that a parent can consent to for a transgender child,”11 and in testimony to the US Congress, warned that when gender affirming care “is interrupted or restricted, suicide, depression, anxiety, disordered eating, and poor quality of life follow.”13

In professional training, journalists have been led to interpret dissent as part of a “misinformation climate,” as in a two part Poynter Institute webinar called “Transgender coverage: avoiding rhetoric to deliver meaningful journalism,” recorded on 18 April and 2 May. Cass’s final review no doubt qualified as “medical and peer reviewed research findings”—one of the learning goals—yet it went unmentioned in all three hours of discussion. McNamara, the only medical speaker, listed the mental health benefits of gender treatments and showed a chart of five “misinformation themes,” among them “low quality evidence” and “guidelines are not trustworthy.” In part two, when asked about European countries restricting treatment, Jo Yurcaba, a reporter for NBC Out, the LGBTQ section of NBC News, told attendees that “transition related care is highly politicised in Europe, in the same way it is in the US.” These webinars were required viewing for reporters applying for an $11 500 grant for journalists interested in covering transgender issues. A spokesperson for Poynter, which also publishes the fact checking site Politifact, told The BMJ that it “strives to present an accurate, current, and well rounded overview” for journalists in training and that, by 9 April when Cass’s final report was released, “our curriculum and learning objectives had been set and our subject matter experts had prepared their materials.”

So far, outspoken thought leaders have not reconciled their statements with the growing list of systematic reviews that stand in contradiction. In an emailed response to The BMJ, McNamara said that she “noted with great interest, the systematic reviews that the Cass review relied on deemed several of the studies it assessed as ‘moderate’ in quality.” Although other advocates have seized on this apparent discrepancy, it is a known feature of systematic reviews: individual studies within a body of evidence might be rated moderate, yet when taken as a whole, that evidence may still be, as Cass put it, “remarkably weak.”

Some prominent activists attempted to discredit other aspects of Cass, both the review and the person. Alejandra Caraballo, a Harvard Law School instructor with more than 160 000 followers on X, posted in advance of the report’s release that it had “disregarded nearly all studies,” a claim that Cass called “misinformation.” The activist Erin Reed, who has a quarter of a million followers between X and Substack and is a go-to media source, accused Cass of having “collaborated on a trans care ban in Florida.” Cass spoke with a clinical member of the state’s board of medicine as part of her review. On the Majority Report, a podcast with 1.5 million subscribers, Reed said that Cass represents “the playbook for how to ban trans care.”

For science reporters and editors who have repeatedly delivered the “science is settled” boilerplate, these denunciations offer a tempting way around correcting the record. A 10 May article in Mother Jones took that route, casting the report as a political document: “It’s like the DeSantis administration wrote it.”

Medical leaders and media professionals “should engage with the content,” says Abbruzzese, which she notes is in English, freely accessible, and transparent in its rigour. “What the Cass review did was evaluate the gender clinic model of care and concluded that, when delivered in this exceptionalised way, every child who walks through the door is viewed as a trans child who is there to be medically transitioned. Cass concluded that model is fundamentally flawed because these children’s significant pre-existing mental health problems are effectively ignored in the false expectation that transition will cure them.”

“The Cass report is going to stand the test of time,” says Erica Anderson, a clinical psychologist and former president of the US Professional Association for Transgender Health. “I’m already hearing from the boards of directors and trustees of some hospital systems who are starting to get nervous about what they’ve permitted. So I think that’s going to accelerate change within American healthcare.”

In the face of criticism, Cass has been unwavering: “It wouldn’t be too much of a problem if people were saying ‘This is clinical consensus, and we’re not sure.’ But what some organisations are doing is doubling down on saying the evidence is good,” she told the New York Times. “And I think that’s where you’re misleading the public.”

Hilary Cass Says U.S. Doctors Are ‘Out of Date’ on Youth Gender Medicine

Dr. Hilary Cass published a landmark report that led to restrictions on youth gender care in Britain. U.S. health groups said it did not cha

nytimes.com

After 30 years as one of England’s top pediatricians, Dr. Hilary Cass was hoping to begin her retirement by learning to play the saxophone.

Instead, she took on a project that would throw her into an international fire: reviewing England’s treatment guidelines for the rapidly rising number of children with gender distress, known as dysphoria.

At the time, in 2020, England’s sole youth gender clinic was in disarray. The waiting list had swelled, leaving many young patients waiting years for an appointment. Staff members who said they felt pressure to approve children for puberty-blocking drugs had filed whistle-blower complaints that had spilled into public view. And a former patient had sued the clinic, claiming that she had transitioned as a teenager “after a series of superficial conversations with social workers.”

The National Health Service asked Dr. Cass, who had never treated children with gender dysphoria but had served as the president of the Royal College of Pediatrics and Child Health, to independently evaluate how the agency should proceed.

Over the next four years, Dr. Cass commissioned systematic reviews of scientific studies on youth gender treatments and international guidelines of care. She also met with young patients and their families, transgender adults, people who had detransitioned, advocacy groups and clinicians.

Her final report, published last month, concluded that the evidence supporting the use of puberty-blocking drugs and other hormonal medications in adolescents was “remarkably weak.” On her recommendation, the N.H.S. will no longer prescribe puberty blockers outside of clinical trials. Dr. Cass also recommended that testosterone and estrogen, which allow young people to develop the physical characteristics of the opposite sex, be prescribed with “extreme caution.”

Dr. Cass’s findings are in line with several European countries that have limited the treatments after scientific reviews. But in America, where nearly two dozen states have banned the care outright, medical groups have endorsed the treatments as evidence-based and necessary.

The American Academy of Pediatrics declined to comment on Dr. Cass’s specific findings, and condemned the state bans. “Politicians have inserted themselves into the exam room, which is dangerous for both physicians and for families,” Dr. Ben Hoffman, the organization’s president, said.

The Endocrine Society told The New York Times that Dr. Cass’s review “does not contain any new research” that would contradict its guidelines. The federal health department did not respond to requests for comment.

Dr. Cass spoke to The Times about her report and the response from the United States. This conversation has been edited and condensed for clarity.

What are your top takeaways from the report?

The most important concern for me is just how poor the evidence base is in this area. Some people have questioned, “Did we set a higher bar for this group of young people?” We absolutely didn’t. The real problem is that the evidence is very weak compared to many other areas of pediatric practice.

The second big takeaway for me is that we have to stop just seeing these young people through the lens of their gender and see them as whole people, and address the much broader range of challenges that they have, sometimes with their mental health, sometimes with undiagnosed neurodiversity. It’s really about helping them to thrive, not just saying “How do we address the gender?” in isolation.

You found that the quality of evidence in this space is “remarkably weak.” Can you explain what that means?

The assessment of studies looks at things like, do they follow up for long enough? Do they lose a lot of patients during the follow-up period? Do they have good comparison groups? All of those assessments are really objective. The reason the studies are weak is because they failed on one or more of those areas.

The most common criticism directed at your review is that it was in some way rigged because of the lack of randomized controlled trials, which compare two treatments or a treatment and a placebo, in this field. That, from the get-go, you knew you would find that there was low-quality evidence.

People were worried that we threw out anything that wasn’t a randomized controlled trial, which is the gold standard for study design. We didn’t, actually.

There weren’t any randomized controlled trials, but we still included about 58 percent of the studies that were identified, the ones that were high quality or moderate quality. The kinds of studies that aren’t R.C.T.s can give us some really good information, but they have to be well-conducted. The weakness was many were very poorly conducted.

There’s something I would like to say about the perception that this was rigged, as you say. We were really clear that this review was not about defining what trans means, negating anybody’s experiences or rolling back health care.

There are young people who absolutely benefit from a medical pathway, and we need to make sure that those young people have access — under a research protocol, because we need to improve the research — but not assume that that’s the right pathway for everyone.

Another criticism is that this field is being held to a higher standard than others, or being exceptionalized in some way. There are other areas of medicine, particularly in pediatrics, where doctors practice without high-quality evidence.

The University of York, which is kind of the home of systematic reviews, one of the key organizations that does them in this country, found that evidence in this field was strikingly lower than other areas — even in pediatrics.

I can’t think of any other situation where we give life-altering treatments and don’t have enough understanding about what’s happening to those young people in adulthood. I’ve spoken to young adults who are clearly thriving — a medical pathway has been the right thing for them. I’ve also spoken to young adults where it was the wrong decision, where they have regret, where they’ve detransitioned. The critical issue is trying to work out how we can best predict who’s going to thrive and who’s not going to do well.

In your report, you are also concerned about the rapid increase in numbers of teens who have sought out gender care over the last 10 years, most of whom were female at birth. I often hear two different explanations. On the one hand, there’s a positive story about social acceptance: that there have always been this many trans people, and kids today just feel freer to express who they are. The other story is a more fearful one: that this is a ‘contagion’ driven in large part by social media. How do you think about it?

There’s always two views because it’s never a simple answer. And probably elements of both of those things apply.

It doesn’t really make sense to have such a dramatic increase in numbers that has been exponential. This has happened in a really narrow time frame across the world. Social acceptance just doesn’t happen that way, so dramatically. So that doesn’t make sense as the full answer.

But equally, those who say this is just social contagion are also not taking account of how complex and nuanced this is.

Young people growing up now have a much more flexible view about gender — they’re not locked into gender stereotypes in the way my generation was. And that flexibility and fluidity are potentially beneficial because they break down barriers, combat misogyny, and so on. It only becomes a challenge if we’re medicalizing it, giving an irreversible treatment, for what might be just a normal range of gender expression.

What has the response to your report been like in Britain?

Both of our main parties have been supportive of the report, which has been great.

We have had a longstanding relationship with support and advocacy groups in the U.K. That’s not to say that they necessarily agree with all that we say. There’s much that they are less happy about. But we have had an open dialogue with them and have tried to address their questions throughout.

I think there is an appreciation that we are not about closing down health care for children. But there is fearfulness — about health care being shut down, and also about the report being weaponized to suggest that trans people don’t exist. And that’s really disappointing to me that that happens, because that’s absolutely not what we’re saying.

I’ve reached out to major medical groups in the United States about your findings. The American Academy of Pediatrics declined to comment on your report, citing its own research review that is underway. It said that its guidance, which it reaffirmed last year, was “grounded in evidence and science.”

The Endocrine Society said “we stand firm in our support of gender-affirming care,” which is “needed and often lifesaving.”

I think for a lot of people, this is kind of dizzying. We have medical groups in the United States and Britain looking at the same facts, the same scientific literature, and coming to very different conclusions. What do you make of those responses?

When I was president of the Royal College of Pediatrics and Child Health, we did some great work with the A.A.P. They are an organization that I have enormous respect for. But I respectfully disagree with them on holding on to a position that is now demonstrated to be out of date by multiple systematic reviews.

It wouldn’t be too much of a problem if people were saying “This is clinical consensus and we’re not sure.” But what some organizations are doing is doubling down on saying the evidence is good. And I think that’s where you’re misleading the public. You need to be honest about the strength of the evidence and say what you’re going to do to improve it.

I suspect that the A.A.P., which is an organization that does massive good for children worldwide, and I see as a fairly left-leaning organization, is fearful of making any moves that might jeopardize trans health care right now. And I wonder whether, if they weren’t feeling under such political duress, they would be able to be more nuanced, to say that multiple truths exist in this space — that there are children who are going to need medical treatment, and that there are other children who are going to resolve their distress in different ways.

Have you heard from the A.A.P. since your report was published?

They haven’t contacted us directly — no.

Have you heard from any other U.S. health bodies, like the Department of Health and Human Services, for example?

No.

Have you heard from any U.S. lawmakers?

No. Not at all.

Pediatricians in the United States are in an incredibly tough position because of the political situation here. It affects what doctors feel comfortable saying publicly. Your report is now part of that evidence that they may fear will be weaponized. What would you say to American pediatricians about how to move forward?

Do what you’ve been trained to do. So that means that you approach any one of these young people as you would any other adolescent, taking a proper history, doing a proper assessment and maintaining a curiosity about what’s driving their distress. It may be about diagnosing autism, it may be about treating depression, it might be about treating an eating disorder.

What really worries me is that people just think: This is somebody who is trans, and the medical pathway is the right thing for them. They get put on a medical pathway, and then the problems that they think were going to be solved just don’t go away. And it’s because there’s this overshadowing of all the other problems.

So, yes, you can put someone on a medical pathway, but if at the end of it they can’t get out of their bedroom, they don’t have relationships, they’re not in school or ultimately in work, you haven’t done the right thing by them. So it really is about treating them as a whole person, taking a holistic approach, managing all of those things and not assuming they’ve all come about as a result of the gender distress.

I think some people get frustrated about the conclusion being, well, what these kids need is more holistic care and mental health support, when that system doesn’t exist. What do you say to that?

We’re failing these kids and we’re failing other kids in terms of the amount of mental health support we have available. That is a huge problem — not just for gender-questioning young people. And I think that’s partly a reflection of the fact that the system’s been caught out by a growth of demand that is completely outstripping the ability to provide it.

We don’t have a nationalized health care system here in the United States. We have a sprawling and fragmented system. Some people have reached the conclusion that, because of the realities of the American health care system, the only way forward is through political bans. What do you make of that argument?

Medicine should never be politically driven. It should be driven by evidence and ethics and shared decision-making with patients and listening to patients’ voices. Once it becomes politicized, then that’s seriously concerning, as you know well from the abortion situation in the United States.

So, what can I say, except that I’m glad that the U.K. system doesn’t work in the same way.

When asked after this interview about Dr. Cass’s comments, Dr. Hoffman, the A.A.P.’s president, said that the group had carefully reviewed her report and “added it to the evidence base undergoing a systematic review.” He also said that “Any suggestion the American Academy of Pediatrics is misleading families is false.”

What Does Quality of Evidence Mean?

Gender clinician Jack Turban misunderstands key concepts in evidence-based medicine.

City Journal

On Wednesday, the Dartmouth Political Union hosted a debate on sex and gender between MIT philosopher Alex Byrne, University of California at San Francisco psychiatrist Jack Turban, and Aston University emerita neuroscientist Gina Rippon.

An interesting moment came when Byrne asked Turban what he thought of the recently published Cass Review, the 388-page comprehensive report on youth gender medicine, authored by British physician Hilary Cass and her colleagues. Turban claimed that the report found “moderate” quality evidence for “gender-affirming care,” and that, contrary to its reception, the review’s findings did not lend support to restrictions on puberty blockers and other medical interventions for pediatric gender dysphoria.

Turban’s characterization is at odds with that of Cass and her team. Cass’s report, published alongside seven new systematic evidence reviews on several issues associated with youth gender transition, concludes that the evidence for the safety and efficacy of puberty blockers and cross-sex hormones as treatments for gender-related distress in adolescents is “remarkably weak.” Youth gender medicine, Cass writes in the prestigious British Medical Journal, “is built on shaky foundations.”

Here, I want to respond to Turban’s comments about evidence quality in the Cass Review. These issues are technical but important for those following the debate over pediatric gender medicine.

First, some background. Jack Turban is one of the nation’s most prominent defenders of pediatric sex-trait modification (“gender-affirming care”). He has garnered a reputation outside of his circle of followers for pursuing agenda-driven research, evading scientific debate, launching ad hominem attacks on scientific critics, and misrepresenting research findings—including his own.

In a recent deposition in a lawsuit over Idaho’s Vulnerable Child Protection Act, which bans sex-trait modification in minors, Turban demonstrated under oath his lack of understanding of, or failure to be honest about, basic principles of evidence-based medicine (EBM). He seemed unaware, for example, that systematic reviews of evidence are meant not only to assess the available research but also to score the quality of that research. Gordon Guyatt, a professor of health research methods, world-renowned expert in EBM, and a founder of the field, has said that when it comes to systematic reviews, Turban has shown he “does not understand what it’s all about.”

The studies Turban and other gender clinicians cite in support of “gender-affirming care” often suffer from high risk of bias and show inconsistent findings regarding mental-health outcomes. Further, these studies often are conducted by gender clinicians with ideological, professional, and even financial stakes in administering drugs and surgeries to minors.

The benefit of systematic reviews is that they do not take authors’ conclusions at face value. Instead, they allow independent experts in research methods and evidence evaluation to scrutinize studies’ designs and conclusions. The research on youth gender medicine interventions generally lacks adequate follow-up time, has high drop-out rates, fails to control for potential confounding factors, and regards as homogeneous a patient population with significantly different clinical presentations.

Because systematic reviews are EBM’s gold standard for furnishing clinicians and guideline developers with reliable information, it’s necessary to respond directly to Turban’s claim in the Dartmouth debate that the new systematic reviews associated with the Cass report found “moderate quality” evidence that puberty blockers improve mental health. (I will focus here on the puberty blockers review, although the analysis applies to the cross-sex hormone review as well.)

Turban’s claim is false, for three reasons. First, he ignores the crucial distinction in EBM between quality of studies and quality of evidence—an admittedly non-obvious distinction, but one that any competent clinician who opines on EBM issues should comprehend. Second, he fails to distinguish between the mental-health and non-mental-health-related research cited in the report. Third, he ignores the fact that the authors of the systematic reviews used a scoring tool that already sets a lower bar for evaluating research. In effect, the reviewers (and the Cass team) performed affirmative action for youth-gender-medicine research and still found it wanting.

Quality of Studies v. Quality of Evidence. To evaluate the quality of studies on puberty suppression, the authors of the systematic review used a modified version of the Newcastle–Ottawa Quality Assessment Scale (NOS), a tool for evaluating nonrandomized studies. Studies assessed by the scale receive one of three grades: low, moderate, or high. Of the 50 studies on puberty suppression the authors identified as relevant, 24 (including one by Turban) were excluded for being low quality. Of the remaining 26, one was determined to be high quality, and 25 moderate quality. Turban’s confusion is therefore understandable: wouldn’t the finding that most of the research is moderate quality mean that the evidence overall is moderate quality?

Not exactly. In EBM, “quality of study” refers to a given study’s risk of bias. “Risk of bias” is a technical term, which Cochrane defines as “systematic error, or deviation from the truth, in results.” To give an obvious example, if you want to test the effects of puberty blockers on mental health and give them to patients who are already receiving psychotherapy, any positive outcomes may be attributable to the drugs, the therapy, or some combination of the two. A study design that is incapable of isolating the effects of puberty blockers from confounding variables like psychotherapy is at high risk of bias.

Quality of evidence, on the other hand, refers to the confidence we can have in our estimate of an intervention’s effect, based on the entire body of information. Quality of studies (based on risk of bias) is one factor that determines quality of evidence; others include publication bias (when, for example, a journal declines to publish an unfavorable study); inconsistency (when studies addressing the same question come to significantly different results); indirectness (when the studies do not directly compare interventions of interest in populations of interest, or when they do not report outcomes deemed important for clinical decisions); and imprecision (when studies are subject to random error, often due to small sample sizes).

Gender medicine research, and youth gender medicine research in particular, suffers from these problems. To give one example, inapplicability is a form of indirectness in which the subjects of a study are different from the patients to whom an intervention is being offered. The gold standard of research in youth gender medicine is the Dutch study. That study suffers from high risk of bias, but it is also inapplicable to the majority of minors now seeking “gender-affirming care” because it was done on patients with a different clinical presentation than the group responsible for the sudden and dramatic rise in gender dysphoria diagnoses and referrals: teen girls with no prepubertal history of gender issues and with high rates of psychiatric and/or neurocognitive challenges.

Turban’s claim that the systematic reviews on puberty blockers and cross-sex hormones found “moderate” quality evidence is therefore incorrect. The reviews found moderate and a few high-quality studies, but they did not find moderate quality evidence. In fact, the University of York authors of the systematic reviews did not even evaluate the quality of evidence using widely accepted and standardized tools such as Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Instead, they summarized their findings in narrative form. “There is a lack of high-quality research assessing puberty suppression in adolescents experiencing gender dysphoria/incongruence,” they wrote. “No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development. Bone health and height may be compromised during treatment.”

Quality With Regard to What Outcomes? Turban’s second mistake is to suggest that the “moderate-quality evidence” was about “improvements in mental health.” A look at the chart included in the systematic review on puberty blockers, however, reveals that of the 25 moderate-quality studies, most appear in four columns: puberty suppression (17 studies), physical health (14), bone health (5), and side effects (3) (most studies examine more than one domain). Many of the studies do not examine mental-health outcomes.

It’s not possible for me to give a detailed account here of what each of the moderate-quality studies examined, but a few examples should be enough to show why Turban’s suggestion is misleading. One moderate-quality study included in the “puberty suppression” category tested whether Histrelin implants (a puberty blocker) are still effective at disrupting the puberty-inducing mechanism of the pituitary gland after one year. Another moderate-quality study, in the “physical health” category, was about the effects on body composition (in terms of height and lean mass) from sudden withdrawal of sex hormones in late-pubertal adolescents. Neither study examined participants’ mental-health outcomes.

Lowering the Bar for “Gender-Affirming Care.” To assess the strength of various studies, the University of York systematic review authors used a scoring tool specifically designed for nonrandomized studies. Such studies already face a higher risk of bias, since their proctors do not randomly assign comparable participants into treatment and control groups. The field of youth gender medicine lacks even a single randomized controlled study—the gold standard for testing causal claims about the safety and efficacy of medical interventions.

I asked Yuan Zhang, an assistant clinical professor of health research methods, evidence, and impact at McMaster University, home of EBM, for his impression of the Cass-linked systematic review’s methods. “With regard to the question of the effects of puberty blockers on mental health, even if the University of York team had done a quality of evidence scoring, it would not have been better than low quality.” Zhang is referring to the lowest score on GRADE. “If you want to produce credible evidence of cause and effect, for instance in order to be able to say that puberty blockers are responsible for improvement in mental health, there is no alternative to a randomized controlled trial.”

Advocates of puberty blockers like Turban argue that conducting a RCT in the gender-medicine context would be unethical, as we already know that puberty blockers are “medically necessary” interventions and that withholding them would cause harm. Of course, this claim assumes the very thing that’s in dispute. Proponents also argue that conducting a double-blinded RCT would be impossible, as there is no way to hide from participants (and their physicians) whether puberty blockers or placebos were being administered. This second objection is more reasonable, but it’s possible to design a non-blinded RCT with active comparators. Non-puberty-suppressed participants can be given antidepressants or psychotherapy, for instance. The passage of time alone may have an effect on mental health (a phenomenon known as “regression to the mean”).

As James Cantor, a psychologist and author of important articles and expert reports on gender medicine, told me, “Even if one accepted, for arguments’ sake, that RCTs couldn’t be done, it still wouldn’t justify barreling ahead as if they had been done and always showed unmitigated success.” The reason should be obvious: drugs and surgeries pose real and potentially serious risks to a person’s physical and mental health. Because in this case they are being given to adolescents who are physically healthy, the burden is on proponents of hormonal interventions to prove their safety and efficacy.

How do reviewers assess the quality of non-randomized studies, which inherently are more prone to bias? The most common tool is “Risk of Bias in Non-randomized Studies—Interventions” (ROBINS-I). It’s not clear why the authors of the Cass systematic reviews chose not to use this tool, but one possible reason is that ROBINS-I is very rigorous in assessing risk of bias in non-randomized research. Applying it to existing gender-medicine research would likely have resulted in all available studies being found to be at “serious” or “critical” risk of bias.

The NOS, which the Cass researchers used, has separate scoring scales for pre-post, cohort, and cross-sectional studies. Pre-post studies examine the effects of an intervention in a single cohort with no comparator group. Cohort studies follow a group of patients over a period of time but also lack adequate controls. Cross-sectional studies capture data at a single point in time, through methods such as surveys or medical-chart reviews.

The only high-quality study of puberty blockers included in the systematic review was a cross-sectional study from the Netherlands. A cross-sectional design is definitionally incapable of ascertaining causal relationships, so how could this study come out above other types of nonrandomized studies? The answer is that the NOS scale scores each type of study differently. A high-quality cross-sectional study means that it is high quality for cross-sectional design, not high quality for nonrandomized research in general.

Turban’s misperceptions about quality in medical research lead to similarly misguided policy conclusions. He claimed in the Dartmouth debate, for example, that moderate-quality evidence “is not particularly unusual in medicine,” adding, “I can’t think of another example in medicine where you have that quality of evidence, and you ban the care. The report also doesn’t say to ban care.”

Turban is correct that this area of medicine has been singled out for special treatment, but not in the way he thinks. Indeed, Hilary Cass, author of the Cass Review, claims that pediatric gender medicine has been “exceptionalised”—too many clinicians in this field have “abandoned normal clinical approaches to holistic assessment” and instead deferred to their patient’s self-diagnosis and desire for medical intervention. No other area of medicine has been allowed to proceed so quickly, with so little evidence, on such vulnerable patients, and with such little follow-up.

Advocates like Turban point out that many medical treatments and protocols in pediatrics are still used despite low-quality evidence. This fact, they claim, shows that gatekeepers are prejudicially motivated to restrict gender transition. An influential Yale report from 2022, for example, cited the recommendation against giving children aspirin for fevers due to risk of developing Reye’s syndrome—a progressive and potentially fatal neurological disease—despite there being only low-quality evidence linking aspirin to Reye’s.

A rule of thumb in EBM is that strong recommendations require strong evidence. In some cases, however, low-quality evidence can justify strong recommendations. Examples of such “discordant recommendations” are when the alternative to nontreatment is death, and when alternative interventions can achieve the same effects with less risk. The Yale team conveniently neglected to mention that kids can be given Tylenol, which isn’t linked to Reye’s, instead of aspirin.

When Turban says that moderate-quality evidence is “not particularly unusual” in medicine, he is thus misleading his audience on two counts. First, he falsely implies that the quality of evidence (rather than of studies) is moderate, and confuses NOS’s use of “moderate” with the use of this term in GRADE (where quality of evidence is at issue). Second, he suggests that puberty blockers fall under one of the exceptional scenarios in EBM where discordant recommendations are appropriate.

It’s noteworthy that this marks a shift in Turban’s public position, which has been that “the body of research indicates that these interventions result in favorable mental health outcomes.” In his expert witness reports, Turban has claimed that “Existing research shows gender-affirming medical treatments for adolescents with gender dysphoria are consistently linked to improved mental health.” Yet at Dartmouth, he appeared to make a different claim: the evidence is not strong, but it’s common practice in pediatrics to offer medical interventions based on uncertain evidence.

As for banning “care,” Turban is correct that the Cass Review does not recommend a blanket prohibition on puberty blockers. But if Cass’s recommendations were to be implemented in the U.S., most of the kids currently getting them would no longer be eligible, and those who would be eligible would be able to receive them only as part of research. Turban, like other gender clinicians, has conveniently but disingenuously latched on to age restriction laws (“bans”) as a way to avoid acknowledging this important implication.

Advocates of hormonal interventions frame the choice as one between only two alternatives: their own “affirmative” approach or total prohibition. They then use Europeans’ allowance for at least some instances of pubertal suppression as evidence that European countries have rejected the prohibitionist approach, and that, by implication, they agree with advocates’ “affirming” approach.

The only real disagreement between health-care authorities in places like England, Sweden, and Finland, and those in U.S. red states is whether these drugs should be allowed within research settings and administered in exceptional cases. England’s National Health Service has officially ended the routine use of puberty blockers for adolescents with gender dysphoria. Turban, by contrast, has seemed to agree that these drugs should be given out for free, on-demand, without parental consent.

At Dartmouth, Turban warned against “conflating very technical terms from the grading scale, like for medical evidence, with lay terminology saying it’s all low-quality evidence.” I agree. But Turban appears not to understand the technical terms. Perhaps someone should explain them to him in lay terminology.

Dr Hilary Cass 'surprised by homophobia' during review of gender identity services

The chair of the Cass Review has told MSPs she was "surprised" by persistent levels of homophobia as well as transphobia during her review…

The Herald

The chair of the Cass Review has told MSPs she was "surprised" by persistent levels of homophobia as well as transphobia during her review into gender identity services, as she noted that a "very high percentage" of the young people seeking help are same-sex attracted.

Giving evidence to Holyrood's Health and Social Care Committee, Dr Hilary Cass said it was easy to see "how the two things could get conflated".

She added: "This may have been naive, but one of the things that I was surprised about in conducting this review is how much homophobia there still is as well as transphobia, so we do have to support people in being able to express and understand their sexuality as well as their gender identity."

Dr Cass, whose 388-page report published in April concluded that the evidence for prescribing puberty blockers and hormone treatments to under-18s with gender distress was "remarkably weak", said that it is unclear how many patients have gone on to de-transition in adulthood due to the lack of long-term follow-up studies and because individuals who regret it "don't necessarily come back to the NHS".

She said: "That is a significant problem, but I think it's more subtle than that because for example I spoke to a young adult who started to transition very early - male to female.

"She's doing well, she had puberty blockers at the earliest stage, she had feminising hormones at the earliest stage and she passes very well as a woman, but with hindsight she knows she was a boy with intense internalised homophobia and was gay.

"But at this point in her life she's clearly not going to de-transition."

When the first NHS gender identity service was established at London's Tavistock clinic in 1989, it saw fewer than 10 children per year - mostly birth-registered males who identified as female.

Between 2018 and 2022, it was receiving thousands of referrals a year for under-18s, 73% of whom were birth-registered females.

The Sandyford clinic in Glasgow - Scotland's only NHS gender identity service for children and adolescents - has experienced a similar shift and surge in demand, with more than 1000 under-18s waiting for their first appointment with waiting times of over four years and a majority of the demand coming those seeking female-to-male transition.

Dr Cass told MSPs that the changing profile of this cohort meant it was even harder to draw conclusions from existing evidence about the long-term consequences of puberty blockers.

She added that this group of young patients also had to be considered "within the broader context of what's happening to adolescence in Gen Z" - those born between the mid-1990s and the early 2010s.

Dr Cass said: "We know that there are very high rates of depression and anxiety, there are stresses that previous generations didn't have growing up in terms of social media, and expectations on young people that arise from that early exposure to pornography.

"We don't know what any of those do to how you might present your [gender] distress.

"Certainly for some young people, that distress or feeling that you don't fit what you perceive to be the expected gender norms may manifest through questioning your gender identity.

"That's why we have to take this as a new cohort and not rely on previous research, and work with young people to help them unpick all of those things that may have led to that gender distress."

The Sandyford clinic has suspended the prescription of puberty blockers and cross-sex hormones to any new patients under-18 following the publication of the Cass Review, but the restriction only applies to the NHS.

Dr Cass told MSPs that she had "really deep concerns" about private providers continuing to provide drugs off-label, and said that self-medication by young people was "happening way more than we would wish".

The Cass Review recommended a ban on puberty blockers to under-16s except within the context of clinical trials, and advised "extreme caution" in administering cross-sex hormones to 16 and 17-year-olds. 

A clinical trial into puberty blockers is currently under development in England, and is expected to incorporate sites in Scotland and internationally. 

Dr Cass told MSPs that the review's findings had been distorted by "significant misinformation", including the false claim that 98% of studies into puberty blockers and hormone treatments had been disregarded and only randomised control trials were included. 

"Both of those things are wrong," she said. 

Of the 102 research papers identified for puberty blockers and hormone treatments, none were randomised control trials but two were rated high quality and around 50 of moderate quality.

These were all included in the analysis. 

Weaknesses tended to include follow-up periods which were too short, patients dropping out over time, or inappropriate control groups, said Dr Cass. 

"It was a very poor literature compared to most other literature, including in children's healthcare practice, so that was quite striking," she said. 

Dr Cass stressed that medical transition was "a really important option" for youngsters whose trans identity would be long-term and enduring, but the difficult is correctly distinguishing those individuals from patients whose distress is rooted in other factors such as unhappiness with their sexuality, undiagnosed neurodiversity, family breakdown, and mental health. 

She said: "Medical transition does not come without costs in terms of effects on sexual function, fertility, knowns and unknowns about long term bone health, the limitations of surgery...it's a high cost to pay if, in the longer term, you don't [have a stable trans identity]. 

"Picking that sweet point where you have a high level of certainty that you're giving the treatment to the right people is very important.

"And the group that we have least understanding about is the group that we are most commonly seeing now in clinic, which is birth-registered females who are presenting in adolescence for whom there may be a range of other factors driving their gender-related distress."

Blind to autism

The Cass review picks up an Australian gender clinic not screening for autism

genderclinicnews.com

England’s Cass review has revealed that the fast-growing gender clinic of an Australian children’s hospital does not screen new patients for autism.

In an international survey commissioned by the British paediatrician Dr Hilary Cass, one of five unnamed Australian clinics reported that it does not screen for autism because it claims such screening is “not accurate in [the] trans population.”

Clues in survey responses suggest this is the gender clinic at the Queensland Children’s Hospital in Brisbane, which also has the quickest fast-track to puberty blockers for children as young as age 8-9.

Patient numbers there reportedly rose from 190 in 2017 to 922 in 2022. In 2019, the Queensland clinic had more than 200 minors on puberty blockers1. Also in 2019, a concerned member of the public asked the clinic how many girls with autism were on blockers and was told no such data was kept.

Two other Australian gender clinics in the Cass-commissioned survey—identifiable as those at the Royal Children’s Hospital Melbourne (RCH) and the Perth Children’s Hospital [PCH]—use the Social Responsiveness Scale (SRS) to screen for autism traits.

The results of this screening test do not amount to a formal diagnosis but can identify children for referral to an autism specialist for diagnosis. A 2019 study stated2 that the PCH gender clinic “does not have capacity and resources to formally diagnose [autism].”

Youth gender clinics in Denmark, Finland and the Netherlands use the Autism Diagnostic Observation Schedule for screening, according to the Cass survey.

The over-representation of minors with (sometimes undiagnosed) autism in gender clinic caseloads internationally is a key concern in the debate3. One theory is that gender confusion may be a product of children with autism being immature and desperate to fit in, having rigid and concrete styles of thinking, and obsessional interests.

RCH in Melbourne has reported that 16 per cent of a patient sample had autism4. The prevalence of autism in the general population of Australian children is thought to be less than three per cent.

A psychologist whose daughter attended the Queensland gender clinic told GCN that in her experience “the psychological assessment was not thorough, and no history of trauma5 was taken.”

“If they are not digging deeper to carefully screen for trauma and neurodivergence and treating these issues, then they are applying very poor science,” she said.

Clinical psychologist Dr Vanessa Spiller pointed out that screening for autism was recommended by the first clinical guideline for co-occurring autism spectrum disorder (ASD) and gender dysphoria in adolescents.

“Diagnosing [gender dysphoria] can be complex in adolescents with ASD due to ASD-related weaknesses in communication, self-awareness, and executive function6,” the 2016 guideline by Strang et al says.

Dr Spiller told GCN that in her opinion, it would be negligent for a gender clinic not to take into account the effect of autism and its impairments on a minor’s capacity to make decisions and give informed consent to medical treatment.

Last month’s Cass report says England’s new regional services to replace the London-based Tavistock gender clinic should include autism specialists in their multidisciplinary teams, and standard assessment of new referrals should screen for autism and other neurodevelopmental conditions.

A Cass-commissioned evaluation of international treatment guidelines includes the 2018 “Australian standards of care” document issued by RCH in Melbourne and used across Australia’s youth gender clinics.

The Cass researchers note that the RCH guideline is among the majority of guidelines in which the recommended domains for assessment do not include neurodiversity or autism7.

Australia’s Health Minister Mark Butjler has played down the relevance of the Cass report, saying that “the clinical pathways are different in the UK from Australia.”

Last month, Western Australia’s Liberal leader Libby Mettam, who is in opposition, cited the influence of the Cass report when announcing a policy to prohibit puberty blockers, cross-sex hormones and trans surgery under the age of 16, pending a comprehensive review.

“The need for urgent action is compounded by the rapidly growing number of children being diagnosed and treated for gender dysphoria in [Western Australia],” Ms Mettam said. “Our review will also inquire into why we are seeing this rise in diagnosis.

“There are currently more than 100 children and adolescents being treated at Perth Children’s Hospital with either puberty blockers or cross-sex hormones, with the youngest aged 11.

“When experts are telling us the potential permanent side effects of these treatments can include infertility, sexual dysfunction, obesity, heart and liver disease, blood clots and atrophy of the genitals, we need to investigate.”

In line with England’s Cass report, Scotland and Wales have announced restrictions on puberty blockers.

In Canada, Alberta’s premier Danielle Smith said the Cass report vindicated her province’s plans to prohibit blockers and cross-sex hormones for minors aged 15 and under. She said she had spoken to Dr Cass to better understand her report.

“If we want to take a science-based approach, we’ve got to use the best information available,” Ms Smith told the National Post.

In the US, South Carolina has moved closer to becoming the 25th state to restrict medicalised gender change for minors.

The Cass report cites research suggesting that those who identify as transgender or non-binary are three to six times more likely to be autistic than the general population.

“These findings are echoed by clinicians who report seeing teenage girls who have good cognitive ability and are articulate, but are struggling with gender identity, suicidal ideation and self-harm,” the report says.

“In some of these young people the common denominator is undiagnosed autism, which is often missed in adolescent girls.

“Despite often being highly articulate, intelligent and skilled in many areas, autistic young people have difficulties with social communication and peer relationships, which may make it difficult for them to feel accepted and ‘fit in’.”

In her book on the scandal at England’s Tavistock gender clinic, journalist Hannah Barnes recounts how some staff were “stunned” by the clinic’s poor data collection when this was revealed in court proceedings brought by detransitioner Keira Bell.

“[The clinic] could not even tell the High Court how many of the young people put on blockers were autistic,” Ms Barnes writes in Time to Think.

“Some staff feared that they could perhaps be unnecessarily medicating autistic children. Less than two per cent of children in the UK are thought to have an autism spectrum disorder. Yet, according to [the Tavistock], ‘around 35 per cent of referred young people present with moderate to severe autistic traits’.”

In 2020, the regulatory Care Quality Commission (CQC) inspected the clinic.

Ms Barnes writes: “In a sample of records of young people referred for puberty blockers, the CQC found that more than half referred to autism spectrum disorder or attention deficit hyperactivity disorder. Yet, the regulator noted, [the Tavistock] generally did not record how many patients had a diagnosis or a suspected diagnosis of autism spectrum disorder. ‘Records did not demonstrate consideration of the relationship between autism spectrum disorder and gender dysphoria’ or that the needs of autistic patients had been ‘fully investigated’.”

“It wasn’t that anyone thought that it was not possible to be both autistic and trans, but clinicians openly questioned whether the over-representation of autistic young people [at the Tavistock] warranted pause for thought and a change in practice.”

substackcdn.com

The psychologist whose daughter was seen by the Queensland gender clinic told GCN that in her opinion the approach to assessment there “put the cart before the horse.”

“Gender dysphoria is similar to other psychological conditions disproportionately affecting teen girls and young women, in that we see obsessional rumination related to identity, appearance and the changing body,” she said.

“But it’s the tip of the iceberg. Underneath the presenting issues, we almost always find neurodivergence and/or trauma and/or anxiety disorders, and shame. [The Queensland gender clinicians] are, in my opinion, missing everything under the waterline.”

The psychologist, whose daughter in time re-embraced her birth sex, was sceptical about the clinic’s stated reason for not doing autism screening.

“What is about this so-called ‘adolescent trans population’ that means standard [autism] assessments used the world over with young people are not suitable for these young folk?”

Clinical psychologist Dr Spiller said the Queensland clinic might be correct in claiming that autism screening tools have no norms for trans-identified individuals.

“[But] if you took this argument to its logical conclusion, it would be impossible to assess or diagnose anyone who identifies as transgender with anything—a learning disorder, depression, anxiety, intellectual disability and so on, because there are ‘no norms’ for them,” she said.

“It is accepted practice to use the tools you have available and to use clinical judgment and observations until new tools are created, if necessary. 

“Ethically, it would be deemed a greater risk or harm to not diagnose someone, even with poor tools—it would stop kids from getting support in schools, early intervention, and [funding under Australia’s National Disability Insurance Scheme]. That would be considered discriminatory.

“The underlying brain areas impacted by autism are universal and include deficits in adaptive functioning (social skills, self-care skills), executive functioning, communication and sensory issues—regardless of gender identity.”

“The [approach of the Dutch pioneers of paediatric gender transition] differs from the [Tavistock’s] approach in having stricter requirements about provision of psychological interventions. For example, under the Dutch approach, if young people have gender confusion, aversion towards their sexed body parts, psychiatric co-morbidities or autism spectrum disorder (ASD) related diagnostic difficulties, they may receive psychological interventions only, or before, or in combination with medical intervention. Of note, in 2011, the Amsterdam team were reporting that up to 10 per cent of their referral base were young people with ASD.”—Dr Hilary Cass, interim report, February 2022

In 2018 de-identified case notes, psychiatrist Dr Brian Ross from the Queensland gender clinic discusses the overlap between youth gender dysphoria and autism spectrum disorder (ASD).

“Individuals with ASD have the same rights as other individuals to appropriate assessment and treatment of gender-related concerns,” Dr Ross says.

He cites several possible reasons for minors with autism identifying as trans or gender-diverse, including the wish “to find a community or tribe” or the belief it will be “safer to change gender” after sexual assault.

He suggests a girl with autism might identify as a boy because she thinks “boys are logical, girls are complicated and unkind in ways I don’t understand.”

And boys with autism might identify as a girl because they are “shy, submissive and introverted, don’t like dirt on their hands, [are] vulnerable and prefer intellectual pursuits.”

Dr Ross adds a warning that “these psychosocial explanations do not explain that for a socially disabled adolescent, the choice of another gender [at] variance to their biological assigned gender could in fact worsen underlying ASD factors.”

He describes three gender clinic patients with autism—

W, a nine-year-old female. Diagnosed with autism at the age of three. Wore boys’ clothes from age of four. “Solitary non-imaginary play with a preference to be a ‘dog’ where he would bark like a dog and seek affection by rubbing himself against others like a dog.” Could not fit in with peers. Mother thought her daughter might have identified as a boy because she lacked the more advanced language and social skills of her female peers.

Mother concerned that puberty blockers might deny her child the positive effects of her natural oestrogen and “disadvantage her child’s true gender journey.” Dr Ross reassured mother that the clinic had allowed W to enter early puberty to expose the child to oestrogen and the resulting intensification of gender dysphoria favoured the early use of puberty blockers. With natural sex hormones suppressed, W would have “a better ability to explore and experience his gender identity without the distress of his gender dysphoria.”

L, a 13-year-old female. Identifies as a boy. Father diagnosed with brain tumour when she was five months old. “Observed to not socially function in a socially appropriate [way] at school or in the family.” Few friends. “Acknowledges that he is becoming socially avoidant and experiences increasing anxiety in some social situations.” Special interest in the history of Prussia and American statesman Alexander Hamilton.

Diagnosed with autism spectrum disorder (ASD) at the gender clinic after speech therapist noticed language impairments. “Delay in detection of ASD may have arisen with the preoccupation with the father’s illness and death throughout this child’s development.” L describes four personas inside her head: “C, a gay man with HIV who is angry; R, an angel-like character who is protective of all the other personas; V1, a man who likes sex; and V, who is wanting a physical form, such as his own physical body, to express himself.” Dr Ross says L presents “as a socially odd ASD transgendered adolescent who discusses his issues in the psychodrama of his various personas” but is not psychotic or suffering from dissociative identity disorder (once known as multiple personality).

S, a 12-year-old male. Initial psychology screening suggested autism features. “Wanted to be a girl because they are kinder and seem to have and hold more friends than boys that he found rejected him after a period of time… [His] desire to be a girl arose from his need to have friends and be accepted in the context of his lifelong social skills deficits and impaired social functioning… [He] was unable to articulate any other benefits of his desire to be female [and] was not able to describe any revulsion of his male body.” Dr Ross concludes that S meets the diagnostic criteria for ASD level 1 (or Asperger’s syndrome) and does not have gender dysphoria.

GCN put questions to the office of Queensland Health Minister Shannon Fentiman and Children’s Health Queensland.

'Cass Review' author: More 'caution' advised for gender-affirming care for youth

A groundbreaking review out of the UK finds “poor” or “low quality” evidence for using puberty blockers and hormones to help gender-distress

wbur.org

Puberty blockers and hormones are sometimes used to help gender-distressed children.

But a new groundbreaking review from the UK says the science behind that practice is far from settled.

"The studies that the team looked at, well the quality was disappointingly poor, none of them really effectively reproduced results in seeing improvements in mental health," Dr. Hilary Cass, the review's author, said.

Today, On Point: Dr. Hilary Cass gives her first U.S. broadcast interview.

MEGHNA CHAKRABARTI: In April, a long-awaited report from Britain's National Health Service concluded that for most gender-distressed young people, quote, "A medical pathway will not be the best way to manage their distress," end quote. That is the result of an almost four-year long, 388-page systematic review of all available studies on the use of puberty blockers and cross sex hormones in adolescents.

The report is called the "Cass Review: An independent review of gender identity services for children and young people." It was commissioned by Britain's National Health Service, and it found that the evidence base for medicalized treatment of adolescent gender distress was quote, "Inadequate and poor."

This comes as the number of young people seeking clinical help for gender distress continues to grow. And unlike a decade or two ago, most of these people are adolescent natal girls. Many often suffer from concurrent mental health issues or autism. Dr. Hilary Cass led the review. She's one of the UK's most respected pediatricians and former chair of the British Academy of Childhood Disability and former president of the Royal College of Pediatricians and Child Health.

She granted On Point her first U.S. broadcast interview. You'll hear responses from American clinicians later in the show. But first, to the Cass interview. I began by asking Dr. Cass to describe what her team's review found regarding the quality of medical evidence for using puberty blockers in gender-distressed young people.

HILARY CASS: The quality was disappointingly poor. One of the significant reasons is that they just didn't follow up for long enough, particularly for young people who were taking masculinizing and feminizing hormones. Another problem is that many of the studies didn't take account of the fact that this is a really, what we call heterogeneous, so a mixed population of young people who were very different from each other.

And that population has changed in recent years, from predominantly birth registered boys presenting quite early, to predominantly birth registered girls presenting in the teenage years. Now, within that group are young people with autism, there are young people who may have other complex mental health issues.

There are young people who may have had a series of traumatic events in early childhood. So you can't take the results of how somebody does if they are presenting as a child, and have had consistent long-term gender incongruence from say, when they were four or five. They may not have the same response to medication as somebody who is presenting considerably later.

So you can't put all of these young people into the same treatment group and say they're all going to respond in exactly the same way to this kind of approach.

CHAKRABARTI: Okay. So more specifically then, in the systematic review of studies relating to the use of puberty blockers. We should say that puberty blockers do have quite a well-established evidence base for use in some situations, right?

For example, children with precocious puberty, so they are an accepted treatment for certain things.

CASS: Absolutely right, but it's really important to say that it's a very different thing to take a young person whose hormones are going through the normal increases that you expect to see in puberty. And pausing that. Because during puberty, all sorts of things are going on. Your brain is developing very rapidly. You're developing what's called your executive functioning, which is how you do some complex problem solving, complex judgment abilities, and you're also developing your sexuality. And we just don't know what happens if you put brakes on all of that.

CHAKRABARTI: Specifically, in the review report, there's a discussion that there are claims, actually from quite well-respected bodies, including here in the United States, that providing puberty blockers as a form of treatment and care for gender questioning youth, they're prescribed as treatment because they can alleviate gender dysphoria, they can improve mental health of young people who are genuinely suffering.

Did the review find an evidence base for those goals or aims?

CASS: Okay, so that's a really important question. And the Dutch found that there were some improvements in mental health of those young people, but it didn't affect the dysphoria. In the UK, we attempted to reproduce that using exactly the same approaches as the Dutch.

And disappointingly, the team did not find improvements in mental health. In fact, some young people got worse, some made no changes. And that's the sort of result you might expect from a treatment that's not particularly effective for those outcomes. There may be a group of young people who do have early gender incongruence, for whom this might be the right treatment, particularly that group of birth registered boys who will develop irreversible changes of male puberty.

But just to go back to the systematic reviews, the other studies that the team looked at, none of them really effectively reproduced the Dutch results of seeing robust improvements in mental health.

CHAKRABARTI: To be clear, the report states, quote, that the University of York concluded, and that's the group that did the review.

CASS: That's right.

CHAKRABARTI: That there is insufficient or inconsistent evidence about the effects of puberty suppression on psychological or psychosocial health.

CASS: Correct. And we also have to think about which young people have been receiving puberty blockers, because certainly in the UK, as time has gone on, the young people who were most likely to receive puberty blockers are most commonly aged around 15.

And by 15, obviously, you've gone through most of puberty. So instead of really thinking, okay, how are we going to manage the distress that these young people are feeling? Somehow, we've got locked into puberty blockers as the totemic treatment that young people feel. If they don't get onto puberty blockers, they're not going to get onto a medical pathway.

But actually, there are many different ways in which we can manage distress and anxiety in a 15-year-old that don't involve puberty blockers. And yet we've somehow stopped short of trying those, just because puberty blockers have become so widely believed to be effective.

CHAKRABARTI: This is a really important point that's been brought up by the Cass Review. About did the focus on trying to provide medical forms of therapy perhaps overshadow other forms of care.

CASS: Yes.

CHAKRABARTI: So I want to read to you this is from 2022. And this is from the United States Department of Health and Human Services Office of Population Affairs, and they stated that, quote, "Research demonstrates that gender-affirming care improves the mental health and overall well-being of gender diverse children and adolescents," end quote.

Now I should say that they're speaking about gender-affirming care overall and not just exclusively medical treatments. But there's a gap there, though, between what seems to be the conclusions of the Cass Review vs. that statement, which is not uncommon from the United States.

CASS: We spoke to young adults directly through the review, and we also had some qualitative research, so some researchers talking to young adults, as well.

And one of the things that they said is, I wish I'd known when I was younger that there were more ways of being trans or expressing my identity than just a binary medical pathway. And so a lot of what the focus of our review has been on is saying, what do we do to help these young people to thrive?

And how do we give them the widest range of options that also don't foreclose for them?

CHAKRABARTI: I just want to recap. So the systematic review found that there's insufficient evidence, or inconclusive evidence, about the effect of puberty blockers on mental and psychosocial health or in the alleviation of gender dysphoria.

There's also the question of, there have been competing claims about whether puberty blockers have negative impact on a young person's bone health.

CASS: Again, those results were inconclusive, and we need to follow people up for much, much longer.

CHAKRABARTI: So, Dr. Cass, one thing that the review notes very clearly at the top is the rapid rise, and actually the exponential rise, in the number of young people, adolescents, in particular, seeking treatment for gender dysphoria.

In fact, you have a chart here that shows that around 2013, 2014, every year, essentially, the numbers spike up higher and it's more, many more adolescent girls. What do you think, or what did the review seem to find in terms of what may be driving that rapid rise?

CASS: That's a really good question.

So we looked at what we understand about the biology, but obviously, biology hasn't changed suddenly in the last 10 years. So then we tried to look at what has changed? And one is the overall mental health of teenage girls in particular, although boys, to some degree. And that may also be driven by social media, by early exposure to pornography and a whole series of other factors that are happening for girls.

It's a tough time to grow up. But secondly, a much more fluid approach to how young people see gender. They see gender much more flexibly than, say, my generation did. So for some young people, gender becomes the main anxiety for them and the way in which they focus their distress. And just as an example, a colleague of mine described a not infrequent sequence of events. Which is a young person comes to clinic, a birth registered female is identifying as male.

And the gender is massive for them. The first thing she may do for that young person is put them on the pill to stop their periods. That's a much more straightforward intervention than puberty blockers. If she's binding her breasts, it's really important that she does it safely. So the nurse in the clinic will show her how to do that safely.

And then often, by the next visit, the distress, the anxiety just ramps down. And the next time they see her, it's not that the dysphoria has gone away, but it's just slipped into the background. And then they can talk about whatever the other things are that are bothering them, which might be sexuality.

It might be an eating disorder. It might be anything else. And over time, they may go on to have a trans identity, or they may decide that the issue was around their sexuality or a series of other issues. Sometimes it just resolves, and they stop seeing all of their distress through that gender lens.

CHAKRABARTI: You're back with On Point. Let's now continue my conversation with Dr. Hilary Cass.

About cross sex hormones, again, because I'm very focused on understanding the evidence base, right? Or lack thereof.

CASS: Sure.

CHAKRABARTI: Regarding cross sex hormones, the systematic review authors said there is a lack of high-quality research assessing the actual outcomes of cross sex hormones.

CASS: Yes, because we need to follow up for much longer than a year or two to know if you continue to thrive on those hormones in the longer term. And we also need to know, are those young people in relationships? Are they getting out of the house? Are they in employment? Do they have a satisfactory sex life?

What are the things that matter to them, and are they achieving those things?

CHAKRABARTI: So once again, the answer is, we don't know. There's insufficient evidence or poor-quality studies, which aren't enough to make informed guidelines for families and practitioners.

CASS: That's right.

CHAKRABARTI: By the time young people are seeking out help for gender dysphoria, they are quite distressed, right?

And as the report says, "It is well established that children and young people with gender dysphoria are at increased risk of suicide." But then the report adds this, "But suicide risk appears to be comparable to other young people with a similar range of mental health challenges." So first of all, what's the evidence for that?

And why is that important to understand?

CASS: So how do we know if this is down to the gender-related distress? Or is it because they also have an eating disorder, or they're depressed or a whole raft of other issues? And because a majority of these young people have all of these issues, then what you need to do is compare to what the population rates are of suicidality in young people who have all of those other issues, but are not gender questioning.

And that's where you find that the rates are fairly comparable. So we can't say that it is the gender questioning or the gender incongruence that's giving you additional suicide risk. And so the second part is, does the gender-affirming treatment pathway reduce that suicidality? But such data as we have shows that we can't detect a difference in the suicide rates before and after treatment.

CHAKRABARTI: So the systematic review then though really combed over all of the studies essentially that are cited when people say that gender-affirming treatment helps save lives. That's not an overstatement on my part. Because Admiral Rachel Levine, who is the Assistant Secretary of Health and Human Services in the United States, in fact, has said that gender-affirming care is, quote, "Quite literally suicide prevention care."

So I'm sure you've heard similar things in the UK, but the review concluded that in a majority of studies that looked at a reduction in suicidality, the studies report that there was a reduction, but there were problems with those studies in terms of they didn't control for the presence of those psychiatric comorbidities that you talked about. And then there was another study that showed that suicidality and self-harm decreased, but out of the 109 eligible participants, only 11 of them had actually completed the questionnaire on suicidality and self-harm.

CASS: What is the important practical issue here? And that is that we have to provide holistic care for these young people.

And what we need to try and do is pick out young people who we think are at risk and say, what are all the things we need to get in place to support this young person's risk? It may be helping with their eating disorder. It may be that they are in difficult family circumstances. There's a whole raft of things that we may need to think about.

And it's much more important to say on an individual basis, how do we manage this person's risk, than just assuming that gender-affirming care is going to be the answer.

CHAKRABARTI: So Dr. Cass, this brings us back to where we began. And that is, you and the independent review team undertook the world's largest systematic review of all of the evidence and studies related to care for gender dysphoric or gender-questioning young people.

It's interesting to me that the world's largest and most influential body that provides guidance for trans care, the World Professional Association for Transgender Health, or WPATH, in their most recent standards of care document, they said that the number of studies is still low and there are few outcome studies that follow youth into adulthood.

Therefore, a systematic review regarding outcomes of treatment in adolescence is not possible. Yet, is that not what the Cass Review did? A systematic review?

CASS: Yes, and actually, so did WPATH. So WPATH commissioned a systematic review from John Hopkins, which is obviously one of the most credible organizations in the U.S., but then they didn't refer to that in the youth part of their guidance. And that was one of the reasons that when our team rated the various guidelines, they rated the WPATH guidelines relatively poorly in terms of the rigor of their development process. Because there were points within the chapter on children and youth where the WPATH team suggested that there was strong evidence and there wasn't.

CHAKRABARTI: They do conclude that the evolving science has shown clinical benefit for transgender youth and then they cite three different studies that they claim supports the assertion of clinical benefit, but the Cass Review points out that one of those studies cited was that original Dutch protocol that we talked about, that deals with a completely different cohort of young people.

Then there's another study that had a one year follow up showing actually very modest changes for young people. And also, I think your team thought the study was too low quality and didn't even include it in your review. And then, most remarkably, the third study that WPATH cites is one that the Cass Review said is a study protocol and does not even include any results.

CASS: Yes, so you have read this extremely carefully, probably better than most of the UK commentators. I think the problem is that there has been an echo chamber of guidelines. So one of the things that the York team did was they looked at where guidelines had followed each other, and they found that most of the guidelines, there was a circularity between the Endocrine Society, WPATH, and a series of other guidelines.

CHAKRABARTI: Dr. Cass, I just want to quote some of the criticisms that have been made of the report. For example, the World Professional Association for Transgender Health that we just mentioned, they issued an email statement saying the report is, quote, "Rooted in the false premise that non-medical alternatives to care will result in less adolescent distress."

And they criticized some of the recommendations from the report, which they claim would, quote, "Severely restrict access to physical health care for gender-questioning young people." Your response to that?

CASS: So we've not taken a position that any form of care is best, but what we have said is that it is important that all young people get access to evidence-based, non-medical interventions that address the full range of their difficulties.

So this group of young people, if they are depressed, if they're anxious, if they need an autism diagnosis, all of those things should be put in place. We don't know which young people may benefit from medical care. And we have proposed that every young person who walks through the door should be included in some kind of proper research protocol so that we can follow them up and we can get those answers over time. So that we don't continue in this black hole of not knowing what's best.

CHAKRABARTI: So Dr. Cass, I just have two more questions for you. You write in the report that gender-questioning young people have been failed by the medical establishment, by the NHS in England. In order to recover from that failure. What does the report recommend change for the treatment of young people?

CASS: I think first and foremost, seeing them as a young person and not as somebody who is gender-questioning, or with a gender problem or a gender issue, they are a young person first. And I think one problem has been just seeing them through a gender lens.

I think we need to re empower professionals to not be afraid. And in the long term, I think if young people could walk through the same door, that doesn't have to be labeled gender. But is a clinic for young people to talk about a range of issues, whether it's their mental health, their sexual health, their sexuality and their gender.

And they could see somebody who would really see them as a whole person, then I think they would get a much better deal.

CHAKRABARTI: Dr. Cass, I just would like to read the last sentence of the review. You write, quote, "I am aware that this report would generate much discussion, and that strongly held views will be expressed. While open and constructive debate is needed, I would urge everybody to remember the children and young people trying to live their lives, and the families and carers and clinicians doing their best to support them. All should be treated with compassion and respect."

CHAKRABARTI: For those children and families and clinicians listening to this interview now, Dr. Cass, what would you tell them? What thought would you leave them with?

CASS: I think the most important thing is keep your options open. I'd say what some of the young adults said, it's not as urgent as it feels. Take your time. Think about all the possibilities open to you. Talk to other young people, but try not to rush.

CHAKRABARTI: Dr. Hilary Cass, she led the team that recently published the independent review of gender identity services for children and young people. It's a massive report that was published at the behest of the National Health Services in England. Dr. Cass, thank you so much for joining us.

CASS: Thank you.

The Cass Effect

A landmark report properly emphasises the application of science, not slogans, in establishing treatment protocols for trans-identified chil

Quillette

[A] systematic review… found multiple studies demonstrating that puberty blockers exert their intended effect in suppressing puberty, and also that bone density is compromised during puberty suppression. However, no changes in gender dysphoria or body satisfaction were demonstrated. There was insufficient/inconsistent evidence about the effects of puberty suppression on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk, or fertility. Moreover, given that the vast majority of young people started on puberty blockers proceed from puberty blockers to masculinising/feminising hormones, there is no evidence that puberty blockers buy time to think, and some concern that they may change the trajectory of psychosexual and gender identity development.

struggling with gender identity, suicidal ideation and self-harm. In some of these young people, the common denominator is undiagnosed autism, which is often missed in adolescent girls. Others may go on to receive a diagnosis of emotionally unstable personality disorder (EUPD) when they enter adult services.

As a case study, the debate over trans rights demonstrates how tiny cliques of radicalised actors can seize the commanding heights of policy simply by policing the use of language.

Calling All Major Medical Associations

What they should learn about LGB kids and gender-affirming care from the Cass Review

lgbtcouragecoalition.substack.com

“Every major medical association supports gender-affirming care.” You’ve likely heard this talking point from activist organizations defending gender medicine for children and adolescents: puberty blockers, cross-sex hormones, and sometimes surgery to treat gender dysphoria.

I don’t deny that American medical associations—advocacy groups that support clinicians—take this position. But I do argue that the position is not rooted in science or reality, and that it can harm the very patients it purports to help—especially gender nonconforming and gay and lesbian young people. 

Now, a nearly 400-page report, commissioned by England’s National Health Service, backs these assertions up. 

The Cass Review, which took four years to complete, comes in response to complaints about the only public youth gender clinic in England and Wales, Gender Identity Development Service, or GIDS, which was shut down last year—that they were fast-tracking kids into irreversible medical interventions, and that the culture of fear prevented concerned clinicians from speaking up. Cass and her team needed to understand the current landscape to come up with a plan to fix it. So they listened to trans people, detransitioners, therapists who feel pressure to affirm, doctors who passionately support these treatments, and many others with differing opinions. They also commissioned systematic reviews of the evidence about both psychological and medical interventions.

Here’s just some of what they found: 

• No one had followed up with the 9,000 children who’d gone through the service—and, shockingly, the adult gender clinic would not share the data about how they fared later. 

• There was no clinical consensus about how to treat them. “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 evidence to support medical transition for youth was “remarkably weak.” “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” Cass admitted. That includes the evidence around the use of puberty blockers, which the NHS has now largely banned, and their effects on bone health, brain development, and fertility.

• Of great importance is what some of that stronger evidence showed: a correlation between child-onset gender dysphoria and later homosexuality. “The majority of these children [in the studies] became same-sex attracted, cisgender adults,” Cass writes. In the one Dutch study upon which all gender medicine is based, 89 percent of the young people who transitioned “were same-sex attracted to their birth-registered sex, with most of the rest being bisexual. Only one patient was exclusively heterosexual.” 

Some parents had told Cass that their children had “been through a period of trans identification before recognising that they were cisgender same-sex attracted. Similar narratives were heard from cisgender adults.” Among the studies cited in the Review is one of almost 3,000 adolescents, whose high amount of “gender non-contentedness” in early adolescence had declined by early adulthood—but that non-contentedness “was also more often associated with same-sex attraction.” 

LGBT Courage Coalition co-founders Jamie Reed and Aaron Kimberly both experienced gender dysphoria as girls and adolescents. Both grew up to be same-sex attracted. Aaron went on to transition as an adult; Jamie went on to marry a trans man. My child is as gender nonconforming as Jamie and Aaron were—but no one can predict her future based on that. And perhaps her lack of gender dysphoria is related to growing up in a time and place and family in which that gender nonconformity is completely accepted, without anyone trying to make meaning from it.

Of great import to me as a parent is that most kids in the original cohort studied in the Netherlands were likely gay. But the medicines they received were the same as those once given to gay adults to punish them or cure them of their sexual proclivities. Somehow, these treatments are touted as being safe and effective for “LGBTQ+ kids,” but the reality is that they can sterilize and remove sexual function from same-sex attracted people—something they’ve been fighting for decades to stop.

Instead of talking openly about these hugely important issues with youth gender medicine, those who advocate for it have insisted on “no debate.” But debate we must. Because today, many more kinds of kids seek these interventions. There has been an “exponential change in referrals over a particularly short five-year timeframe,” Cass reports, with girls quite suddenly making up the bulk of patients, instead of boys—a shift that cannot be explained by increasing social acceptance. Meanwhile, children and adolescents “are on a developmental trajectory that continues to their mid-20s”—that is, it’s hard to make grand decisions during this long period of growth and change.

The youth cohort sheltered beneath the umbrella of “trans” is actually a heterogeneous group, and the inconvenient truth is that no one knows the best way to help them thrive. No one knows who they will grow up to be or how they will identify in adulthood. Nor does anyone know the benefits or harms of social transition, in which children adopt the gender identity that doesn’t correspond with their sex. “However, those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway,” Cass notes. That is, it is not a neutral intervention, but rather an active one that seems to increase the likelihood of medicalizing later. 

Cass states clearly that “For the majority of young people, a medical pathway may not be the best way” to achieve self-actualization. She supports expanding psychological support for those young people, and strict and standardized evaluations, in line with what several other European countries are doing. She demands long-term follow-up not only of anyone who will transition in the future, but of those who already have.

The World Professional Association for Transgender Health, an advocacy and activist organization that appointed itself the generator of “standards of care”—and which England and other European countries are increasingly rejecting—directed people toward an opinion piece called “The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children.” In other words, they dismiss the whole thing as bigotry. But Cass dismissed their own standards of care as lacking “developmental rigor.”

The NHS thanked Cass for her work and suggested that it may have international influence. I hope so, too. The report makes clear that the American affirmative model was a departure from a more cautious approach, and that even the cautious approach was based on substandard evidence—that modifying secondary sex characteristics in adolescents, or transitioning children to live as the opposite (or neither) sex was never fully supported by any high-quality research and became more about social justice than evidence. But medicine, Cass reminds us, is in fact evidence based. The issue is “about what the healthcare approach should be, and how best to help the growing number of children” with gender distress. It is not about ideology.

We don’t have the same system in America. We don’t have the kind of centralized healthcare and state agencies to craft guidelines that all must follow. Here, we battle it out in the legislature, state by state, red against blue, based on moral worldviews more than evidence. So how will the Cass Review influence our toxic gender culture war? How will they affect the medical associations that craft guidelines and create policy statements?

I queried the American Academy of Pediatrics, which recently reaffirmed its commitment to the affirmative model; the American Psychiatric Association; and the American Psychological Association, which have pro-affirmation models statements of their own. Only the latter responded, and I spent over an hour talking to APA Senior Advisor, Psychology in the Public Interest, Clinton Anderson. He admitted to the low quality of evidence and said that there’s a fundamental tension between those who view transition as a social justice issue and those who advocate for a more cautious, evidence-based approach. Where does the APA land? “Our concern has been largely about a human rights issue, and the way this is treatment has become politicized in our system and used as a punishment against people for being different,” Anderson told me. “And that I think has to be seen as the biggest issue.”

I disagree. But I will say that Anderson listened to my points more than anyone at these institutions ever has. I urged him to take a closer look at the Cass Review, and to listen to those who’ve been hurt, not just those who feel they’ve been helped. Maybe, just maybe, he heard me. Maybe, just maybe, these associations hear the science-minded and nuanced words of the Cass Review.

The Cass review of gender identity services marks a return to reason and evidence – it must be defended | David Bell

Its author has had to fend off criticism and misinformation, but the report offers hope for a realistic conversation, says consultant psychi

the Guardian

As the dust settles around Hilary Cass’s report – the most extensive and thoroughgoing evidence-based review of treatment for children experiencing gender distress ever undertaken – it is clear her findings support the grave concerns I and many others have raised. Central here was the lack of an evidential base of good quality that could back claims for the effectiveness of young people being prescribed puberty blockers or proceeding on a medical pathway to transition. I and many other clinicians were concerned about the risks of long-term damaging consequences of early medical intervention. Cass has already had to speak out against misinformation being spread about her review, and a Labour MP has admitted she “may have misled” Parliament when referring to it. The review should be defended from misrepresentation.

The policy of “affirmation” – that is, speedily agreeing with a child that they are of the wrong gender – was an inappropriate clinical stance brought about by influential activist groups and some senior gender identity development service (Gids) staff, resulting in a distortion of the clinical domain. Studies indicate that a majority of children in the absence of medical intervention will desist – that is, change their minds.

The many complex problems that affect these young people were left unaddressed once they were viewed simplistically through the prism of gender. Cass helpfully calls this “diagnostic overshadowing”. Thus children suffered thrice over: through not having all their problems properly addressed; by being put on a pathway for which there is not adequate evidence and for which there is considerable risk of harm; and lastly because children not unreasonably believed that all their problems would disappear once they transitioned. It is, I think, not possible for a child in acute states of torment to be able to think through consequences of a future medical transition. Children struggle to even imagine themselves in an adult sexual body.

Some claim that low numbers of puberty blockers were prescribed. Cass quotes figures showing around 30% of Gids patients in England discharged between April 2018 and 31 December 2022 were referred to the endocrinology service, of whom around 80% were prescribed puberty blockers; the proportion was higher for older children. But these numbers are likely to be an underestimate, as 70% of children were transferred to adult services once they were 17, and their data lost, as very regrettably they were not followed up. This is one of the most serious governance problems of Gids – also specifically addressed by the judges in Keira Bell v Tavistock. Six adult gender clinics refused to cooperate and provide data to Cass. However, having come under considerable pressure, they have now relented.

It is often claimed that puberty blockers were not experimental, as there is a long history of their use. They had been used in precocious puberty (for example where a child, sometimes because of a pituitary abnormality, develops secondary sexual characteristics before the age of eight) and in the treatment of prostate cancer. But they had not been prescribed by Gids to children experiencing gender dysphoria before 2011. The lack of long-term evidence underlies the decision of the NHS to put an end to their routine prescription for children as a treatment for gender dysphoria – that is, for those whose bodies were physically healthy.

The attempts of Gids clinicians to raise concerns about safeguarding and the medical approach were ignored or worse.The then medical director heard concerns but did not act; ditto the Speak up Guardian and the Tavistock and Portman NHS foundation trust management. I was a senior consultant psychiatrist, and it was in my role as staff representative on the trust council of governors that a large number of the Gids clinicians approached me with their grave concerns. This formed the basis of the report submitted to the board in 2018. The trust then conducted a “review” of Gids, based only on interviewing staff. The CEO stated that the review did not identify any “failings in the overall approach taken by the service in responding to the needs of the young people and families who access its support”. I was threatened with disciplinary action. When the child safeguarding lead, Sonia Appleby, raised her concerns before the trust’s review, the trust threatened her with an investigation; and its response, as an employment tribunal later confirmed, damaged her professional reputation and stood in the way of her safeguarding work.

Characterising a child as “being transgender” is harmful as it forecloses the situation and also implies that this is a unitary condition for which there is unitary “treatment”. It is much more helpful to use a description: that the child suffers from distress in relation to gender/sexuality, and this needs to be carefully explored in terms of the narrative of their lives, the presence of other difficulties such as autism, depression, histories of abuse and trauma, and confusion about sexuality. As the Cass report notes, studies suggest that a high proportion of these children are same-sex attracted, and many suffer from homophobia. Concerned gay and lesbian clinicians have said they experienced homophobia in the service, and that staff worked in a “climate of fear”.

It is misleading to suggest that I and others who have raised these concerns are hostile to transgender people – we believe they should be able to live their lives free of discrimination, and we want them to have safe, evidence-based holistic healthcare. What we have opposed is the precipitate placing of children on a potentially damaging medical pathway for which there is considerable evidence of risk of harm. We emphasised the need, before taking such steps, to spend considerable time exploring this complex and multifaceted clinical presentation. Young people and clinicians routinely refer to “top surgery” and “bottom surgery”, terms that serve to seriously underplay these major surgical procedures, ie double mastectomy, removal of pelvic organs and fashioning of constructed penis or vagina. These procedures carry very serious risks such as urinary incontinence, vaginal atrophy, cardiovascular complications and many others we are only beginning to learn about. There is a very serious risk of sexual dysfunction and sterility.

There are no reliable studies (for children or adults) that could support claims of low levels of regret. The studies often quoted (eg Bustos et al 2021) have been criticised for using inadequate and erroneous data. The critical issue here is the fact that children and young people who were put on a medical pathway were not followed up. Studies suggest that the majority of detransitioners, a growing population, who are having to deal with the consequences of having been put on a medical pathway, do not return to the clinics as they are very fearful of the consequences. The fact that there are no dedicated NHS services for detransitioners is symptomatic of the NHS’s lack of concern for this group. Many live very lonely and isolated lives.

Those who say a child has been “born in the wrong body”, and who have sidelined child safeguarding, bear a very heavy responsibility. Parents have been asked “Do you want a happy little girl or a dead little boy?” Cass notes that rates of suicidality are similar to rates among non-trans identified youth referred to child and adolescent mental health services (CAMHS). Indeed, the NHS lead for suicide prevention, Prof Sir Louis Appleby, has said “invoking suicide in this debate is mistaken and potentially harmful”.

It has been suggested that the Cass report sought to “appease” various interests, with the implication that those who have promoted these potentially damaging treatments have been sidelined. But in reality, it is those of us who have raised these concerns who have been silenced by trans rights activists who have had considerable success in closing down debate, including preventing conferences going ahead. Doctors and scientists have said that they have been deterred from conducting studies in this area by a climate of fear, and faced great personal costs for speaking out, ranging from harassment to professional risks and even, as Cass has experienced, safety concerns in public.

The pendulum is already swinging towards a reassertion of rationality. Cass’s achievement is to give that pendulum a hugely increased momentum. In years to come we will look back at the damage done to children with incredulity and horror.

David Bell is a retired psychiatrist and former president of the British Psychoanalytic Society

Final report – FAQs – Cass Review

cass.independent-review.uk

Following publication of the final report there have been a number of questions and points for clarification about the findings and recommendations. We have collated those questions, along with our answers, on this page.

No, the approach to the assessment of study quality was the same as would be applied to other areas of clinical practice – the bar was not set higher for this Review.

Clarification:

The same level of rigour should be expected when looking at the best treatment approaches for this population as for any other population so as not to perpetuate the disadvantaged position this group have been placed in when looking for information on treatment options.

The systematic reviews undertaken by the University of York as part of the Review’s independent research programme are the largest and most comprehensive to date. They looked at 237 papers from 18 countries, providing information on a total of 113,269 children and adolescents.

All of the University of York’s systematic review research papers were subject to peer review, a cornerstone of academic rigour and integrity to ensure that the methods, findings, and interpretation of the findings met the highest standards of quality, validity and impartiality.

No. There were no randomised control studies identified in the systematic reviews, but other types of studies were included if they were well designed and conducted.

Clarification:

The Review commissioned the University of York to undertake an independent research programme to ensure the work of the Review and its recommendations were informed by the most robust existing evidence. This included a series of systematic reviews which brought together, analysed and evaluated existing evidence on a range of issues relating to the care of gender-questioning children and young people, including epidemiology, treatment approaches and international models of current practice.

Randomised control trials are considered the gold standard in relation to research, but there are many other study designs that can give valuable information. Explanatory Box 1 (pages 49-51 of the final report) discusses in more detail the different kinds of studies that can be used, and how to decide if a study is poorly designed or biased.

Blinding is a separate issue. It means that either the patient or the researcher does not know if the patient is getting an active treatment or a ‘control’ (which might be another treatment or a placebo). Patients cannot be blinded as to whether or not they are receiving puberty blockers or masculinising / feminising hormones, because the effects would rapidly become obvious. Good RCTs can be conducted without blinding.

The University of York’s systematic review search did not identify any RCTs, blinded or otherwise, but many other studies were included. Most of the studies included were called ‘cohort studies’. Well-designed and executed high quality cohort studies are used in other areas of medicine, and the bar was not set higher for this review; even so the quality of the studies was mostly only assessed as moderate.

No. Studies were identified for inclusion in the synthesis (conclusions) of the systematic reviews on puberty blockers and masculinising/feminising hormones on the basis of their quality. This was assessed using a standard quality assessment tool appropriate to the types of study identified.  All high quality and moderate quality reviews were included in the synthesis of results. This totalled 58% of the 103 papers.

Clarification:

The Newcastle-Ottawa scale (a standard appraisal tool) was used to compare the studies. This scores items such as participant selection, comparability of groups (how alike they are), the outcomes of the studies and how these were assessed (data provided and whether it is representative of those studied). High quality studies (scoring >75%) would score well on most of these items; moderate quality studies (scoring >50% – 75%) would miss some elements (which could affect outcomes); and low-quality studies would score 50% or less on the items the scale looked at. A major weakness of the studies was that they did not have adequate follow-up – in many cases they did not follow young people for long enough for the long-term outcomes to be understood.

Because the ranking was based on how the studies were undertaken (their quality and execution), low quality research was removed before the results were analysed as the findings could not be completely trusted. Had an RCT been available it would also have been excluded from the systematic review if it was deemed to be of poor quality.

The puberty blocker systematic review included 50 studies. One was high quality, 25 were moderate quality and 24 were low quality. The systematic review of masculinising/feminising hormones included 53 studies. One was high quality, 33 were moderate quality and 19 were low quality.

All high quality and moderate quality reviews were included, however as only two of the studies across these two systematic reviews were identified as being of high quality, this has been misinterpreted by some to mean that only two studies were considered and the rest were discarded. In reality, conclusions were based on the high quality and moderate quality studies (i.e. 58% of the total studies based on the quality assessment). More information about this process in included in Box 2 (pages 54-56 of the final report)

No.  The Review has not commented on the use of masculinising/feminising hormones on people over the age of 18. This is outside of the scope of the Review. The Review has not stated that Gillick competence should be overturned.

The Review has recommended that:

“NHS England should ensure that each Regional Centre has a follow through service for 17-25-year-olds; either by extending the range of the regional children and young people’s service or through linked services, to ensure continuity of care and support at a potentially vulnerable stage in their journey. This will also allow clinical, and research follow-up data to be collected.”

This recommendation only relates to people referred into the children and young people’s service before the age of 17 to enable their care to be continued within the follow-through service up to the age of 25.

Clarification:

Currently, young people are discharged from the young people’s service at the age of 17, often to an adult gender clinic. Some of these young people have been receiving direct care from the NHS gender service (GIDS as was) and others have not yet reached the top of the waiting list and have “aged out” of the young people’s service before being seen.

The Review understands that this is a particularly vulnerable time for young people. A follow-through service continuing up to age 25, would remove the need for transition (that is, transfer) to adult services and support continuity of care and continued access to a broader multi-disciplinary team. This would be consistent with other service areas supporting young people that are selectively moving to a ‘0-25 years’ service to improve continuity of care.

The follow-through service would also benefit those seeking support from adult gender services, as these young people would not be added to the waiting list for adult services and, in the longer-term, as more gender services are established, capacity of adult provision across the country would be increased.

People aged 18 and over, who had not been referred to the NHS children and young people’s gender service, would still be referred directly to adult clinics.

No. Puberty blocker medications are used to address a number of different conditions. The Review has considered the evidence in relation to safety and efficacy (clinical benefit) of the medications for use in young people with gender incongruence/gender dysphoria.

The Review found that not enough is known about the longer-term impacts of puberty blockers for children and young people with gender incongruence to know whether they are safe or not, nor which children might benefit from their use.

Ahead of publication of the final report NHS England took the decision to stop the routine use of puberty blockers for gender incongruence / gender dysphoria in children.  NHS England and National Institute for Health and Care Research (NIHR) are establishing a clinical trial to ensure the effects of puberty blockers can be safely monitored. Within this trial, puberty blockers will be available for children with gender incongruence/ dysphoria where there is clinical agreement that the individual may benefit from taking them.

Clarification:

Puberty blockers have been used to suppress puberty in children and young people who start puberty much too early (precocious puberty). They have undergone extensive testing for use in precocious puberty (a very different indication from use in gender dysphoria) and have met strict safety requirements to be approved for this condition. This is because the puberty blockers are suppressing hormone levels that are abnormally high for the age of the child.

This is different to stopping the normal surge of hormones that occur in puberty. Pubertal hormones are needed for psychological, psychosexual and brain development, and there is not yet enough information on the risks of stopping the influence of pubertal hormones at this critical life stage.

When deciding if certain treatments should be routinely available through the NHS it is not enough to demonstrate that a medication doesn’t cause harm, it needs to be demonstrated that it will deliver clinical benefit in a defined group of patients.

Over the past few years, the most common age that young people have been receiving puberty blockers in England has been 15 when most young people are already well advanced in their puberty. The new services will be looking at the best approaches to support young people through this period when they are still making decisions about longer-term options.

The Review has advised that a more cautious approach around social transition needs to be taken for pre-pubertal children than for adolescents and has recommended that:

“When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience.”

Parents are encouraged to seek clinical help and advice in deciding how to support a child with gender incongruence and should be prioritised on the waiting list for early consultation on this issue. This should include discussion of the risks and benefits and the voice of the child should be heard. It will be important that flexibility is maintained, and options remain open.

Clarification:

Although the University of York’s systematic review found that there is no clear evidence that social transition in childhood has positive or negative mental health outcomes, there are studies demonstrating that for a majority of young children presenting with gender incongruence, this resolves through puberty. There is also evidence from studies of young people with differences of sex development (DSD) that sex of rearing seems to have some influence on eventual gender outcome, and it is possible that social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence. Living in stealth from early childhood may also lead to stress, particularly as puberty approaches.

There is relatively weak evidence for any effect of social transition in adolescence. The Review recognises that for adolescents, exploration is a normal process, and rigid binary gender stereotypes can be unhelpful. Many adolescents will go through a period of gender non-conformity in terms of outward expressions (e.g. hairstyle, make-up, clothing and behaviours). They also have greater agency in how they present themselves and in their decision-making.

Young people and young adults have spoken positively about how social transition helped to reduce their gender dysphoria and feel more comfortable in themselves. They identified that space to talk about socially transitioning and how to handle conversations with parents/carers and others would be helpful. The Review has therefore advised that it is important to try and ensure that those already actively involved in the young person’s welfare provide support in decision making and that plans are in place to ensure that the young person is protected from bullying and has a trusted source of support.

Further detail can be found in Chapter 12 of the Final Report.

Yes, the Review has been underpinned by an extensive programme of proactive engagement, which is described in Chapter 1 of the report. The Review has met with over 1000 individuals and organisations across the breadth of opinion on this subject but prioritised two categories of stakeholders:

• People with relevant lived experience (direct or as a parent/carer) and organisations working with LGBTQ+ children and young people generally.
• Clinicians and other relevant professionals with experience of and/ or responsibility for providing care and support to children and young people within specialist gender services and beyond.

A mixed-methods approach was taken, which included weekly listening sessions with people with lived experience, 6-weekly meetings with support and advocacy groups throughout the course of the Review, and focus groups with young people and young adults.

Reports from the focus groups with young people with lived experience are published on the Review’s website and the learning from these sessions and the listening sessions are represented in the final report.

The Review also commissioned qualitative research from the University of York, who conducted interviews with young people, young adults, parents and clinicians. A summary of the findings from this research is included as appendix 3 of the final report.

Whilst the Review’s terms of reference do not include consideration of the proposed legislation to ban conversion practices, it believes that no LGBTQ+ group should be subjected to conversion practice. It also maintains the position that children and young people with gender dysphoria may have a range of complex psychosocial challenges and/or mental health problems impacting on their gender-related distress. Exploration of these issues is essential to provide diagnosis, clinical support and appropriate intervention.

The intent of psychological intervention is not to change the person’s perception of who they are but to work with them to explore their concerns and experiences and help alleviate their distress, regardless of whether they pursue a medical pathway or not. It is harmful to equate this approach to conversion therapy as it may prevent young people from getting the emotional support they deserve and make clinicians fearful of providing this group of children and young people the same care as is afforded to other children and young people.

No formal science-based training in psychotherapy, psychology or psychiatry teaches or advocates conversion therapy. If an individual were to carry out such practices they would be acting outside of professional guidance, and this would be a matter for the relevant regulator.

Belgium and Netherlands call for puberty blocker restrictions following Cass Review

Britain has become the fifth European nation to restrict the use of the drug to under 18s

The Telegraph

Belgium and the Netherlands have become the latest countries to question the use of puberty blockers on children after the Cass Review warned of a lack of research on the gender treatment’s long-term effects.

Britain has become the fifth European nation to restrict the use of the drug to under 18s after initially making them part of their gender treatments.

Their use was based on the “Dutch protocol” - the term used for the practice pioneered in the Netherlands in 1998 and copied around the world, of treating gender dysphoric youth using puberty blockers.

The NHS stopped prescribing the drug, which is meant to curb the trauma of a body maturing into a gender that the patient does not identify with this month.

In Belgium, doctors have called for gender treatment rules to be changed.

“In our opinion, Belgium must reform gender care in children and adolescents following the example of Sweden and Finland, where hormones are regarded as the last resort,” the report by three paediatricians and psychiatrists in Leuven said.

Figures from the Netherlands and the United Kingdom show that more than 95 per cent of individuals who initiated puberty inhibition continue with gender-affirming treatments,” the report by P Vankrunkelsven P, K Casteels K and J De Vleminck said.

“However, when young people with gender dysphoria go through their natural puberty, these feelings will only persist in about 15 per cent.”

The report was published after a 60 per cent rise in the number of Belgium teenagers taking the blockers to stop the development of their bodies. In 2022, 684 people between the ages of nine and 17 were prescribed the drug compared to 432 in 2019, the De Morgen newspaper reported in 2019.

Pressure is also building in the neighbouring Netherlands to look again at their use. The parliament has ordered research into the impact of puberty blockers on adolescent’s physical and mental health.

The Telegraph understands that the Amsterdam Center of Expertise on Gender Dysphoria, where the Protocol originated, is set to make a statement on the use of puberty blockers next week.

“I too thought that the Dutch gender care was very careful and evidence-based. But now I don’t think that any more,” Jilles Smids, a postdoctoral researcher in medical ethics at Erasmus University in the Netherlands, told The Atlantic.

Attitudes in the Netherlands have hardened against trans rights, with a bill to make it easier for people to legally change their gender being held up in parliament.

The Cass Review said that the NHS had moved away from the restrictions of the original Dutch Protocol, and researchers in Belgium have also demanded those restrictions be reintroduced.

Belgium is regarded as one of the most trans-friendly countries in Europe. A minister in the government is transgender and people have been able to legally change their gender without a medical certificate for the past five years.

But the hard-Right Vlaams Belang party is currently leading the polls ahead of national and European elections in June.

It has called for “hormone therapy and sex surgery to be halted for underage patients until clear and concrete research has been carried out.”

In March, a report in France described sex reassignment in minors as potentially “one of the greatest ethical scandals in the history of medicine”.

Conservative French senators plan to introduce a bill to ban gender transition treatments for the under-18s.

On Monday, the Vatican’s doctrine office published a report that branded gender surgery a grave violation of human dignity on a par with euthanasia and abortion.

Finland was one of the first countries to adopt the Dutch Protocol but realised many of its patients did not meet the Protocol’s strict eligibility requirements for the drugs.

It restricted the treatment in 2020 and recommended psychotherapy as the primary care.

Sweden restricted hormone treatments to “exceptional cases” two years later. In December, Norwegian authorities designated the medicine as “under trial”, which means they will only be prescribed to adolescents in clinical trials.

Denmark is finalising new guidelines limiting hormone treatments to teenagers who have had dysphoria since early childhood.

In 2020, Hungary passed a law banning gender changes on legal documents.

“The import and the use of these hormone products are not banned, but subject to case by case approval, however, it is certain that no authority would approve such an application for people under 18,“ a spokesperson told the Telegraph.

In August, Russia criminalised all gender reassignment surgery and hormone treatments.

On August 7, 1948, at the end of a week-long session organized by Lysenko and approved by Stalin, the Academy of Agricultural Sciences announced that Lysenkoism would henceforth be taught as "the only correct theory." Soviet scientists were required to denounce any work that contradicted Lysenko, and criticism was denounced as "bourgeois" or "fascist".

Andrew Doyle: So the Gay Men's Network official response to the Cass review is now live, it is subtitled "Towards a Vision of Post-Gender Gay Rights," and it describes the Cass review as a devastating account of an unprecedented homophobic medical scandal in the NHS and private health sphere. And here to discuss it, I'm joined by Dennis Kavanagh, the lawyer and director of the Gay Men's Network. Welcome Dennis.

So, let's start with your report from the Gay Men's Network. What is your response, in a nutshell, to the Cass review?

Dennis Kavanagh: Our response is basically this. That this is a sad day for the gay rights movement. Cass is a reality check and it's shown us that for decades now, homosexuality has in effect been medicalized at the NHS. You and I've spoken before about the fact that 90% of the kids at the Tavistock were same sex attracted.

Doyle: Which has been confirmed by the Cass review.

Kavanagh: Precisely that. So, we say this. We say this is a shocking indictment of gay politics and of the gay rights movement generally. Particularly in view of the fact that the very people who should have been protecting gay youth, principally Stonewall, weren't just abandoned, didn't just abandon their post, they joined the opposition forces, when they should have been standing up for these kids.

Doyle: And what do you think their response will be now? I know Stonewell put out a kind of unclear statement, sort of saying we accept the findings of the Cass review. But it wasn't that clear, was it?

Kavanagh: They've had two statements. They put out a tweet saying that they accepted the Cass review. Their own supporters then turned on them fairly viciously to express their displeasure with it. They've now released a longer statement in which they're scrabbling around in the Cass review for crumbs of hope, saying, well it's not a blanket ban on puberty blockers because there're still a possibility of a clinical trial, for example.

But Stonewall need to get real on this. This is over now. Dr. Cass has called time on this homophobic medical scandal. The sitting Secretary of State, the shadow Secretary of State for Health have accepted Cass. It's time for Stonewall to do the same, actually show some leadership and some concern for gay youth.

I would make this point if I may, Andrew. That statement from Stonewall, it didn't have the word gay or lesbian in it once. That's a powerful indication there.

Doyle: Okay, well it might be worth just reading out what Stonewall said they said, "Dr. Cass has not called for adolescents to have their right to their Identity or autonomy removed. Nor did Dr. Cass recommend the blanket ban on social transitioning for children of any age. Most significantly, Dr. Cass did not support unilateral 'outing' of trans young people by schools. There are clear gaps between recommendations and practical policy, and we're already hearing early reports of Dr Cass's analysis of - and recommendations about - social transitioning being used to challenge trans people's right to Identity."

But it's interesting as you say, Dennis, they don't mention the key issue here, which is their failure to stand up for gay and lesbian youth.

Kavanagh: Yeah, and what a gloss on the Cass report that is. If you look at what the Cass report actually says that social transitioning, says where this occurs, there should be reference to a clinician almost immediately because it's not a neutral act. You won't find that in the Stonewall response, because Stonewall don't seem to care about concretizing cross-sex ideation, predominantly among homosexual young population.

Doyle: But they have bought into this idea that everyone is born with a gender identity and that that might be misaligned to the body. So, this is a belief system that is now so embedded in Stonewall, isn't it time that Stonewall was just no longer taken seriously?

Kavanagh: I entirely agree. In 2015, Stonewall added the T to the LGB under the leadership of Ruth Hunt, who promised everyone she wasn't going to do that but performed a vault fast. Which is why she's now facing, in the wake of this medical scandal, she's now facing a petition started by the author Simon Edge, which is coming up on, I think, 16,000-odd signatures, a petition to remove her from the House of Lords.

Doyle: I know you say that it's time's up now thanks to Cass, but isn't it going to be tough? And the reason I say that is there are still so many prominent gay and lesbian celebrities and groups and politicians, who are saying that they're standing up for Stonewall, who are standing up for the idea that kids may have a misaligned soul and body. And actually, given the prominence of those people, maybe voices like yours are the minority here.

Kavanagh: Well, that may or may not be the case, but what matters here is not the weight of numbers. What matters here is who is right about safeguarding these children. And if I'm one voice in 100, I don't care, if I'm right. I do think Stonewall are losing purchase in the public sphere, though. I do think politicians are beginning to realize that something has gone very, very seriously wrong here. It is heartening to see a cross-party consensus of serious politicians from the main, the larger parties embracing Cass and saying that a post-Cass NHS should effectively entirely rid itself of this poisonous ideology.

Doyle: And will it be taken up by the politicians? I mean, I know Alicia Kearns was adding an amendment to the criminal justice bill to try and ban what she calls "trans conversion therapy," but actually Cass specifically refers to this, saying that actually, this should not be mistaken, this should not be confused in the way that she's doing. She doesn't name Alicia Kearns, but she says that it is a common confusion.

Kavanagh: Yeah, and we've drawn this to Alicia Kearns's attention. We actually produced a briefing notes at Gay Men's Network on that amendment to the criminal justice bill. We've drawn Dr. Cass's comments to her attention. So far, we've heard absolutely nothing. Miss Kearns seems to think it's fine to speak over and speak for gay men, when gay men are telling her, look there's a problem with this piece of legislation and it has the capacity to harm gay boys.

Doyle: What I don't understand is so many of these people, they all agree that Section 28 was this terrible thing and the idea of the so-called promotion of homosexuality in schools, it should never have happened. And here they are presiding over something which is arguably even worse.

Kavanagh: Yeah, I agree it is an absurd situation and it is Orwellian, frankly, for them to be introducing such homophobic legislation and then telling us that it's a gay conversion ban. As we've discussed before, that is precisely the opposite of what it is. What it is, is state sanctioned conversion by gender and criminal penalties for doctors that don't go along with it. We call upon Alicia Kearns to withdraw this silly homophobic amendment, and we call on the Scottish government to scrap their proposed piece of legislation, which is even worse than the Kearns amendment.

Doyle: Is it time to divide LGB and T?

Kavanagh: Yes. Our interests have been demonstrated now to be entirely contrary to each other. And look, we are different protected characteristics, right. The those who have the gender reassignment characteristic under the Equality Act, good luck to them, and they of course should have rights in law. No one's opposed to that. But this force-teaming, this marriage cannot work, and it's become an abusive relationship.

Doyle: I don't understand because I saw Jeremy Corbyn speak this week, saying that there is no LGB without the T. How can it be the case that gay people who want to organize in their own interests should be connected automatically to the belief in a gender identity, which is a completely separate thing to sexual orientation? Does he not, has he not even talked to people about this, or attempted to understand?

Kavanagh: It's just another straight man telling us how to organize. How dare? How dare he stand up and say, you gays, you can't organize unless you force-team with a bunch of other people that I, a straight man, have chosen for you? Jeremy Corbyn has no right to say that to us. He doesn't understand this issue. He doesn't understand that our interests are sometimes contradictory, as is demonstrated by this global homophobic medical scandal.

Doyle: Now I wanted to ask you about an open letter that has been put together by James Esses, who's a campaigner, and this is a letter which has a number of signatories including yourself, and I should say for complete transparency, including myself. And this is calling on the government to have a full investigation into the impact of gender identity ideology in all aspects of public life. Can you tell us a bit more about that?

Kavanagh: Sure, I can tell you I'm one of the three directors of Gay Men's Network, all three of us have signed this and we support James's efforts here. We also call for a public inquiry in our consultation response. We invite ministers to consider their powers under Section One of the 2005 Inquiries Act, which is established to deal with areas of public concern. Well, what more could be of public concern than a medical scandal where the harm is disproportionately visited on defenceless children? If that's not a matter of public concern, I don't know what is. We need to get gender ideology out of the public sphere. We've got an NHS calling, insulting women by calling them uterus-havers. We've got the BBC teaching kids there's 100 genders. We've got the CPS introducing-- or proposing, two-tier prosecution standards in the case of sex by deception, which we've discussed in the past. We got Kemi Badenoch saying, across the floor of the Commons, I was told by my officials, her civil servants, that I shouldn't meet with Keira Bell, and we know that that meeting had a fundamental effect on that minister.

Doyle: That's a detransitioner.

Kavanagh: That's right. Keira Bell, who heroically and courageously brought the case of Bell and Tavistock a judicial review. So, we support James's call for there to be a public inquiry. This ideology has run riot. None of us voted for it. None of us got a say in this. And yet, it seems to have infested all areas of public life. We're sick of it because, as we can see with Cass, this is not an academic debate, right. It's not the Judith Butlers and the gendercrats and, you know, the Stonewall's CEOs at their black-tie dinners who pay the price for this. Who pays the price? Vulnerable kids. Autistic kids. Kids that are looked after. This is not okay. We need to deal with this.

Doyle: And you make the point about it not being democratic. It is in both parties. You know, this is the-- we can't vote this out. There's no way. So, is it likely that a public consultation or investigation will happen?

Kavanagh: Well, we shall see. We're making the case for it, that's all we can do for the time being. James has amassed a very impressive list of signatories from all sides of the House. We've got to get real about this. This is a medical scandal without equal. This was gay conversion 2.0 at the Tavistock. Lives have been ruined by this. Evidence from the Mayo Clinic in America just last week suggests that boys given puberty blockers have testicular atrophy, so the tissue in the testicles is degrading, and an increased cancer risk. That's where "gender" has led us to. There's going to-- heaven forbid, but it does seem likely that we're going to end up with some boy walking around now, probably in America going to end up with cancer in his testicles because of these clowns and what they unleashed on defenceless children.

Doyle: Finally, Dennis, could you tell us where we can read your full response to the Cass review?

Kavanagh: Sure. The full response is available at www.gaymensnetwork.com under Letters and Resources.

Doyle: Dennis Kavanagh, thanks ever so much for joining me.

Activist-Blogger Erin Reed Can't Stop Telling Falsehoods About Gender Medicine

Even when fact checked, Erin Reed, who has a popular Substack and X account, has repeatedly made demonstrably false claims about England's C

benryan.substack.com

Calling the assertion “completely wrong”, Cass said that it was “unforgivable” for people to undermine her report by spreading “straight disinformation”. The physician, 66, who has spoken about the toxic debate around the issue, also revealed that she had been sent “vile” abusive emails and been given security advice to help keep her safe. Of her critics, Cass said: “I have been really frustrated by the criticisms, because it is straight disinformation. It is completely inaccurate.

• Two systematic literature reviews, conducted by the University of York on behalf of the Cass Review and published by the BMJ the same day as the Cass Review, examined puberty blockers and cross-sex hormones as treatments for gender distress in minors.
• Between them, these two reviews examined 103 studies. Using a validated scoring method, they identified two high-quality papers, 58 moderate-quality papers, and 43 low-quality papers.
• Only the high-quality and moderate-quality papers were included in the review papers’ syntheses.
• When reaching their ultimate conclusions—essentially that the evidence base was largely unreliable and inconclusive, although there was some evidence that hormones were associated with psychological benefits—the review papers leaned on the high-quality papers, but did not discount the moderate-quality papers.

• Cass considered all these papers in her own analysis and did not simply disregard or discard any of them, as I reported on Substack last week.
• That said, the central purpose of an evidence-based medicine approach is to discern which studies are more likely to provide reliable results and which are less likely to do so. This is meant to keep false study results, such as those driven by bias, from influencing medical practices. Reed and other activists mischaracterize this effort as capricious and biased, one that starts with a desired outcome and then reverse engineers it.
• Discernment of study quality is particularly important, evidence-based medicine experts have insisted, when caring for the particularly vulnerable population of gender-distressed children. And it is of paramount importance, these experts say, to prioritize higher quality research when devising treatment guidelines for this group, considering that children cannot consent to their own care and may lose their fertility and sexual function as a result of treatment with puberty blockers and cross-sex hormones.

• The report did not, as Reed claimed, “call for restrictions” on social transition. It advised that families observe “caution” when considering the social transition of a child.
• The Cass Review did not “[advocate] for the blocking” of trans young adults receiving cross-sex hormones,” as Reed claimed. It advised a review of young-adult gender services, suggesting that the problems that have plagued the pediatric clinic may be similar in young-adult care.
• The theory of rapid-onset gender dysphoria has not been “discredited”, as she claimed. It remains a hypothesis under investigation by researchers.
• Systematic literature reviews are considered the gold-standard source of scientific evidence. They are not mere “reviews”, as she wrote—in scare quotes meant to dismiss them.

1. Reed falsely claimed that the Cass Review was crafted with a predetermined conclusion. In fact, as I mentioned, Dr. Cass commissioned seven independent systematic literature reviews on various facets of pediatric gender medicine from the University of York. Their findings informed Cass's conclusions.
2. Reed falsely claimed the systematic literature reviews were “highly susceptible to subjectivity.” The reviews used a validated scoring method, the Newcastle-Ottawa scale (NOS), and two independent reviewers each. The paper on the NOS scale to which Reed linked in her Substack actually states much more modestly that there is apparent “room for subjectivity in the NOS tool.”
3. She falsely claimed the Cass Review disregarded all research not deemed high quality.
4. She falsely claimed that the theory that gender dysphoria and trans identity may be influenced by social contagion has been "debunked". This remains an open question subject to ongoing research.
5. She makes the misleading suggestion about the YouTube footnote.
6. She falsely claims that the Cass Review asserts that rates of detransition are high. In fact, Cass states that the detransition rate is “unknown due to the lack of long term follow-up.”

The long, hard road to Cass

How whistleblowers, detransitioners and gender-critical activists took on trans ideology – and won.

spiked-online.com

How did people emerge from the hysteria of the witch trials? What must it have felt like to live through the period when supposed witches were suddenly revealed to be ordinary women? What did the accusers say when it became clear that these supposed agents of Satan were simply adult human females? Did they feel guilt and try to make amends? Did they shirk their responsibility? Or did they double down?

The reactions to the publication of the Cass Review last week might give us some idea. The activists, medical professionals and celebrities who championed the trans cause have been confronted with the horror they helped create. Dr Hilary Cass’s report into the NHS’s treatment of gender-confused kids has radically transformed the trans debate, exposing ‘gender-affirming care’ as a dangerous experiment. Now, the disciples of trans ideology are scrambling to save face.

The most common reaction from cheerleaders of trans ideology has been to meekly plead ignorance. One such case is that of Dr Adam Rutherford, geneticist, science communicator and president of Humanists UK – an organisation that in recent years has made a hard turn away from science and rationality in favour of worshipping the cult of gender identity. Yet when he was invited to comment on the Cass Review by Sex Matters director Maya Forstater on X, Rutherford said: ‘It’s not something I know much about.’ Really? It’s somewhat difficult to believe that Rutherford has somehow missed seeing this bit of hugely significant medical news.

This is mirrored by the bleating entreaties for ‘nuance’ from television presenter Kirstie Allsopp. For the past few years, Allsopp has smeared gender-critical views as transphobic. Now she is attempting to rewrite history by claiming that it has always ‘been possible to debate these things and those saying there was no debate are wrong’. We all know this isn’t true. As JK Rowling correctly points out, ‘one of the gender ideologues’ favourite slogans is “no debate”’.

Perhaps the most egregious response of all has come from former Stonewall CEO Baroness Ruth Hunt. It was Hunt who oversaw the charity’s transformation from a gay-rights charity to an LGBT lobby group, with the emphasis firmly on the T. It was under her watch that Stonewall tried to silence warnings about the dangers of experimental puberty blockers. Yet last week, Hunt told The Times that she had simply ‘trusted the experts’ on puberty blockers and cross-sex hormones, so she couldn’t possibly be held accountable. Given that Stonewall itself was deferred to as an ‘expert’ organisation on the issue of gender-affirming care, it is hard to accept Hunt’s projection of innocence. She was hardly some misled ingénue.

Even more deranged and delusional are those who have dismissed the Cass Review as ‘unscientific’. Apparently, Cass’s four years of research and the reams of data she gathered are simply a pretext for promoting a ‘transphobic’ narrative. This rejection of reason is perhaps most eloquently demonstrated by the hyperbolic hashtag, #CassKillsKids, which has been tweeted out by the likes of broadcaster and trans activist India Willoughby. But this position is so patently untrue that only a small minority of the most committed zealots seem to be defending it.

The fact is, it is incredibly difficult for trans activists to obscure their roles in this scandal. Many of them must now be aware that they cheered on a gruesome, ideologically motivated experiment on children. After all, the facts are now indisputable.

In measured tones and meticulous detail, Cass’s report reveals what was really going on inside the NHS’s Gender Identity Development Service (GIDS). She concludes that the ‘gender affirming’ medical treatments it provided, like puberty blockers and cross-sex hormones, are based on ‘wholly inadequate’ evidence. Doctors are usually cautious when adopting new treatments, but Cass says ‘quite the reverse happened in the field of gender care for children’. Instead, thousands of children were put on an unproven medical pathway. Worse still, medical professionals seemed largely uninterested in uncovering the side effects and long-term risks of these drugs. Cass says that all but one adult gender clinic refused to share patient data that would allow her team to study how childhood transitioners fared as adults. This made it virtually impossible to research the potential longer-term consequences of transitioning.

The implications of the review are so grave that politicians have had no choice but to act. On Monday, health secretary Victoria Atkins gave an excoriating speech to parliament, laying out the changes in policy that have already been made and those still to come. She reiterated that NHS England would no longer be able to prescribe puberty blockers for children with gender dysphoria outside of clinical trials. She also promised a crackdown on private prescriptions, as well as an urgent review on clinical policy for prescribing cross-sex hormones. Vitally, she also announced that NHS trusts that initially refused to cooperate with the review will now share their data, hopefully opening the door for further research. These developments were all sorely needed.

Atkins also made a point of thanking the clinicians, academics, activists and journalists who raised the alarm. She acknowledged that they had ‘risked their careers’ to do so. She told her fellow politicians that it should trouble each of them that the NHS ‘was overtaken by a culture of secrecy and ideology that was allowed to trump evidence and safety’.

Finally, politicians are taking these concerns seriously. Until very recently, they did not want to know. Back in May 2019, I was one of a handful of people to attend the First Do No Harm meeting at the House of Lords. There, in a tiny cramped room, we listened to clinicians and campaigners who were desperately worried about the goings on in the GIDS Tavistock clinic in London.

First Do No Harm was organised by campaigner Venice Allan and Let Women Speak founder Kellie-Jay Keen (aka Posie Parker), with the aim of bringing together journalists, politicians and medical experts. It was chaired and spon.sored by Labour peer Lord Lewis Moonie, who himself had a background in psychology and clinical pharmacological research. Among the attendees was psychoanalyst Marcus Evans. He had resigned from his post as a governor at the Tavistock clinic in February that year, citing concerns about the influence of lobby groups on clinical practice.

Despite this wealth of knowledge and expertise, First Do No Harm went largely ignored by politicians. Invitations were sent out to every member of parliament. But, aside from Moonie, the only politicians in attendance were Baroness Tanni Grey-Thompson and Conservative MP David Davies. As Evans explained at the time: ‘No one would basically attend, they’d be threatened that they would have the whip withdrawn if they attended… the silencing of opposition in this area is unbelievable.’

There was certainly a cost for Moonie. After over 40 years in the Labour Party, he was told by party general secretary Jenny Formby that his membership would be at risk if he proceeded with the event. So he resigned. Five years on, and the concerns of Moonie, a small band of whistleblowing clinicians and tenacious campaigners have finally been acknowledged.

While First Do No Harm was the first public meeting bringing concerned voices together, staff within GIDS had already been sounding the alarm for some time. It was all the way back in 2004 that Susan Evans, wife of Marcus, first spoke out about the ‘precipitous referral’ of gender-confused children on to a medical pathway. As a clinical nurse at the Tavistock, she tried to raise the possibility that there were alternatives to medically transitioning children. But she was advised that GIDS would be unable to attract patients without offering puberty blockers. Evans resigned in 2007.

Today, Evans tells me that, while she is relieved about the findings of the Cass Review, she is frustrated to see ‘what happened at GIDS described as a debate between two sides’:

‘I wanted to ensure that kids were receiving a thorough assessment and that as a team there would be a more holistic exploration… That’s not a toxic debate, that is clinical discussion and that’s what a responsible clinician ought to do. All I ever did was raise ordinary but important clinical and safeguarding concerns and questions. I was inquisitive.’

Thankfully, there were still some other inquisitive clinicians out there. In 2018, Dr David Bell, consultant psychiatrist and staff governor at the Tavistock, wrote an internal report that slammed GIDS for promoting a model of uncritical gender affirmation. He blamed trans lobby groups like Mermaids and Stonewall for infecting the organisation. He also explained that many of the young patients seeking to medically transition would otherwise grow up to be lesbian, gay or bisexual. For this, senior management at GIDS threatened Bell with disciplinary action, in an attempt to silence him.

Shortly afterwards, in 2019, clinical psychologist Kirsty Entwistle, who had previously worked at the GIDS satellite clinic in Leeds, penned an open letter, echoing similar concerns. She warned that patients were falsely being told that puberty blockers were ‘fully reversible’ and that accusations of transphobia were stifling important medical and safeguarding discussions.

GIDS was desperate to silence anyone who expressed doubts about how clinics were operating. One such whistleblower was Sonia Appleby, who was a social worker and safeguarding lead at the Tavistock. In 2016, Appleby began to raise concerns about the shambolic record-keeping and the potential over-prescription of puberty blockers. For this, she was bullied and monstered by management, and shunned by GIDS director Dr Polly Carmichael. Carmichael apparently told her team that Appleby had ‘an agenda’ and discouraged staff from sharing any safeguarding concerns with her. In a small act of justice, in 2021 Appleby was awarded £20,000 in damages for the appalling way she was treated at the Tavistock.

Many of the stories from those who spoke out chime with one another. They talk about being alarmed that children’s underlying issues were being systematically overlooked. GIDS was more interested in prescribing medical treatments than in helping children who were suffering from homophobic bullying, mental-health issues, sexual abuse or other traumas. When questions were asked about the safety of puberty blockers and hormones, staff faced an atmosphere where clinical curiosity was discouraged. In all, between 2016 and 2019, a total of 35 clinicians left the Tavistock, with many citing concerns about children being over-diagnosed. Meanwhile, management ignored all these concerns and children continued to be prescribed puberty blockers.

It was shortly after Carmichael’s appointment in 2011 that GIDS began its first trial of puberty blockers. Before the research had even concluded, these drugs, which have also been used to chemically castrate sex offenders, were made more widely available to children. In 2014, the minimum prescription age was dropped from 16 to 11. Some private clinics even started prescribing them to children as young as nine.

GIDS management, it seemed, was remarkably unbothered by the lack of evidence for puberty blockers. In 2016, Carmichael told a World Professional Association for Transgender Health conference in Amsterdam that they were crucial for trans-identified kids and ‘incredibly successful’. But in the same speech, she admitted that ‘actually, the Dutch are the only team really who have published long-term perspective studies about this. So there is very little data available.’ Indeed, as Carmichael admits, virtually the only bit of evidence ever referenced in support of puberty blockers is a piece of flawed research from the Netherlands. It was later revealed that the findings from GIDS’s own puberty-blocker trial were far from reliable.

It was left to those on the outside to bring public attention to what was happening at GIDS. Yet, just as with the silencing of clinicians, those outside the medical profession were also smeared as transphobic for questioning the new wisdom about so-called trans kids.

One of the earliest groups to demand an evidence-based approach was Transgender Trend, which was founded by Stephanie Davies-Arai in 2015. She and her organisation were almost instantly hounded and derided by trans extremists. A children’s book published by Transgender Trend was even compared to ‘terrorist propaganda’. But this smear campaign wouldn’t stop the truth from being revealed. Transgender Trend soon attracted the attention of Oxford professor Michael Biggs. In 2019, he published a report with the organisation, showing that the use of puberty blockers did not reduce the mental distress experienced by patients – a conclusion now backed up by Cass.

This reality became impossible to ignore, especially as ‘detransitioners’ began to speak out. The existence of people who regretted their decision to transition proved to be a thorn in the side of the trans movement and a powerful testimony against so-called trans healthcare. In November 2019, a women’s rights group called Make More Noise hosted the first panel discussion of detransitioners in the UK, giving them an opportunity to share their stories with journalists. With testosterone-cracked voices and mastectomy scars, these young women embody the harms of gender medicine. They were the ‘data’ that the clinicians at GIDS had overlooked.

Detransitioners fought to make themselves heard. In 2020, a high-profile legal challenge by detransitioner Keira Bell against the Tavistock prompted NHS England to commission the Cass Review. Leading paediatrician Dr Hilary Cass was then tasked with finding out what was really happening at GIDS.

Detransitioner Sinead Watson, who, as a young adult, took medical steps to present as male, is one of those who gave evidence to the Cass Review researchers. She tells me: ‘They asked about my story, how I was evaluated, how quickly, about the side effects of [testosterone] and about the surgery. They asked how I was helped to deal with the regret when I sought out support from the NHS, and seemed genuinely surprised I had received no help.’

It truly is a scandal that children and youngsters were put on a pathway to medicalisation and then promptly abandoned. There are now calls for a public inquiry, and it looks like adult services will also now face their own Cass-style review. But the problem with the trans ideology is that it extends far beyond medicine. It is a mind virus that has infected almost every British institution.

Certainly, there can never be true justice for detransitioners. They will continue to carry the mistakes of the medical establishment, and the failure of the government, on their bodies. It also seems unlikely that any of the whistleblowers who were vilified for raising the alarm will receive apologies or retractions. Trans cheerleaders will continue to deny any complicity. No doubt the GIDS management and healthcare professionals who tried to suppress the truth will be able to slink off to lucrative careers elsewhere.

Still, the Cass Review has revealed that the witches were right. Its publication ought to mark a historical turning point, and serve as a reminder that truth can win out. We must remember all this when the next hysterical mania sweeps over society.

On April 9, the long-awaited Cass Review detonated in England. Its effects have been felt around a world torn asunder by the politicized subject of gender. The 388-page report, which was supported in part by six independent systematic literature reviews that were published by the BMJ, scrutinized the science behind pediatric gender-transition treatment.

Cass found that the practice of prescribing puberty blockers and cross-sex hormones to minors was based on “remarkably weak evidence.”

In the report’s fallout, furious clouds of misinformation have formed, fueled by people who doubtfully have read much—or any—of the report or the BMJ papers. These people have falsely claimed that Cass only accepted randomized controlled trials, or RCTs, as evidence to consider in her massive report.

I write this article as the same lone warrior who battled monkeypox misinformation (and made a typo doing it) two years ago. I write in hopes of setting the record straight on a few key points. I write as a dismayed middle-aged man who remains, at his heart, the same frustrated child who always did the reading before class, and who was forced to sit and listen to those who hadn’t done their homework dominate the discussion.

The following is a distillation of various fact-checking tweet threads I’ve published regarding the Cass Review. Individual tweets are hyperlinked throughout the text if you would care to refer to, comment upon, or retweet them.

To learn about the specifics of the Cass Review, you can check out my coverage in The New York Sun, my tweet thread about that article, and my thread about the report.

This particular article will be devoted to the dying art of fact checking.

Many advocates of gender-distressed young people are furious that systematic literature reviews, they argue, set the evidentiary bar too high. They say these reviews forbid the acceptance of lots of promising findings from perfectly good studies on pediatric gender-transition treatment.

Others say those evidence-based-medicine standards of assessing the strength versus weaknesses of research are vital to prevent research that makes erroneous claims from impacting health policy and sending it astray.

They note that the stakes are high when it comes to pediatric gender-transition treatment, in particular considering the drugs in question may impact fertility and sexual function. Fertility, they say, is a human right. And since children cannot consent to their own care, the adults responsible for their care—parents or guardians and doctors—need to be especially sure before they consent to or provide drugs that could take a child’s fertility.

Here’s the question: Where does the pediatric gender-dysphoria care field go from here, now that Cass has said the evidence is weak and uncertain (as have multiple previous systematic literature reviews)? Should it accept the claim of GLAAD, the LGBTQ media watchdog group, that the “science is settled,” and that puberty blockers and cross-sex hormones should be widely provided to gender-distressed children?

Or should the pediatric gender-medicine field follow the lead of Cass and England, and of Scandinavian nations, re-classifying pediatric gender-transition treatment as experimental and, accordingly, restricting it to clinical trials only Then, if the results of those clinical trials are favorable, it is possible that those European nations will change course again and broaden access to puberty blockers and cross-sex hormones for minors? Perhaps then they would be satisfied that the evidence is strong enough?

Here in the US, we have a split-screen system, quite unlike the European nations:

• 23 red states have passed bans of pediatric access to puberty blockers and cross-sex hormones for gender distress. Many are tied up in the courts. The Supreme Court will almost surely settle the matter.
• Blue states support liberal access to such medications.

The major US medical societies, in particular the American Academy of Pediatrics and the Endocrine Society, along with the medical/activist group WPATH, all support liberal access to pediatric gender-transition treatment. This is in stark contrast to Cass/England’s approach.

So wide is the gulf between Cass and WPATH that after Cass supported forbidding puberty blockers and cross-sex hormones to minors, WPATH said that the majority of gender-dysphoric adolescents would fare better on such medications than with the holistic mental-health care Cass advises and that is now policy in England.

At stake here is the question of how scientific research is translated into health policy.

• Who gets to decide, and what methods do they use to assess the research?
• What is the best way to do this, to ensure that the best possible care is provided to vulnerable young people?

The most important question is this: How can patients, families and healthcare and mental-health providers be provided the most robust and informative information possible to guide their shared decision-making as they weigh the risks versus benefits of treatment?

Cass says that WPATH’s guidelines are weak. WPATH countered in their recent statement by asserting that they, WPATH, are the subject-matter experts on pediatric gender-transition treatment, not Cass. The American Academy of Pediatrics, meanwhile, has been sued, along with the author of its 2018 policy statement backing pediatric gender-transition treatment and the overall “affirmative” model of care, in a medical-malpractice suit that I covered for The New York Sun.

Cass does indeed state that randomized-controlled trials are the gold-standard of scientific studies. Meanwhile, many claim that an RCT for gender-transition treatment would be unethical to conduct among children, because the preponderance of evidence indicates the treatment is safe and effective. (Others vigorously dispute that such a trial would be unethical and that such evidence is trustworthy—hence, they say, the need for an RCT.) Furthermore, it is not possible to blind such a study, because the effects of the drugs (i.e., suppressed puberty or cross-sex puberty) are too obvious.

However, neither of the two systematic literature reviews on which Cass was partially based—one about puberty blockers, the other about cross-sex hormones to treat gender distress in minors—place RCTs as the bar that the 103 studies they assessed needed to meet. Rather, they used a validated assessment tool known as the Newcastle-Ottowa scale, which is designed to assess the strength of observational studies.

This is how one of the papers described the scale:

Neither of the studies deemed high quality by the reviews were RCTs.

And so, the widespread claims that the Cass Review set an impossibly high bar to reach by demanding only RCTs, discarding 101 out of 103 studies of pediatric gender-transition treatment, are: FALSE

Let’s examine how Dr. Hilary Cass and her team did factor in the systematic literature reviews about puberty blockers and cross-sex hormones.

One systematic literature review examined puberty-blockers for gender distressed kids. It examined 50 studies, and included in its synthesis one high-quality study and 25 moderate-quality studies. It did not simply ignore the 24 low-quality studies.

The other systematic lit review examined cross-sex hormone use for gender distress in minors. It examined 53 studies, and included in its synthesis one high-quality study and 33 moderate-quality studies. But it did not simply ignore the 19 low-quality ones.

What about the Cass Review? How did it make use of the two systematic lit reviews? The claim that Cass simply discarded the 101 moderate/low-quality studies and only looked at the two high-quality studies is: FALSE

She folded the analyses of the 103 studies into her report.

Let’s zoom in to the 388-page Cass review. To see where she first folds in the findings of the systematic literature review of cross-sex hormones, go to page 183. Here is how she introduces that paper:

Cass includes in her report the following chart from the lit-review paper on cross-sex hormones, which breaks down all the studies it analyzed and what outcomes they addressed. Cass is pointing out key areas where more research is needed, in particular about fertility outcomes. So you can see that this report is about way more than just the narrow question of treatment efficacy. It’s about the whole field of pediatric gender medicine and the research apparatus behind it.

On page 184 of the Cass Review, she goes into considerable detail about the findings of the systematic literature review about cross-sex hormones. She does not solely focus on the one high-quality study, although she does certainly highlight it. She refers to all 53 studies.

The review discusses the findings of the systematic literature review on cross-sex hormones for minors amid discussions of lots of other individual papers about pediatric gender-transition treatment. The review also folds in the findings from the systematic literature review about puberty blockers for gender distressed minors (p. 175).

Cass includes the following chart from the review paper on puberty blockers for gender-distressed kids, which breaks down the outcomes examined by the 50 studies. It points to areas where much more research is needed, especially about…fertility.

From page 176 to 177, Cass has lots to say about the specifics of the puberty blocker systematic literature review. She does not restrict her discussion to the one high-quality study included in the review.

The Review includes 15 pages of footnotes of studies, guidelines, and other sources on which the report is based. The report is not solely based on two studies.

In sum, those who say Cass and the lit reviewers simply discarded 101 studies are incorrect. However, because the quality of the study findings was overwhelmingly weak, Cass was indeed very limited in which studies she could rely on in assessing safety and efficacy in particular.

Cass sums up the matter as follows in her introduction:

The Canadian Broadcasting Corporation published an article quoting doctors repeating, and failing to challenge, the false claim that the Cass Review disregarded any studies about pediatric gender-transition treatment that were not randomized controlled trials. The article made various other false or misleading claims, such as that puberty blockers are at least believed to be safe and reversible. Sallie Baxendale’s recent scholarship, along with Cass’s findings, have shown how neither of those claims are known to be true. Much more research is needed.

Continuing a running theme in our culture of late, hundreds of academics have signed a letter protesting the Cass Review that strongly suggests they have not read the review or the systematic literature reviews on which it is partly based. Their letter falsely claims the Cass Review “does not include a proper systematic literature review since it disregards most research evidence because it fails to reach the impossibly high bar of a double-blind trial.”

The letter was spearheaded by transfeminist sociologist Natacha Kennedy and her colleagues at the Feminist Gender Equality Network.

Numerous accounts on X (formerly Twitter) broadcast the false claim that the Cass Review and two of the systematic literature reviews on which it was based simply discarded 101 of 103 studies on pediatric gender-transition treatment. This includes the British singer Billy Bragg, Dr. David Gorski (who also falsely claimed that Cass referred to so-called rapid-onset gender dysphoria in her report) and activist Substacker Erin Reed:

In her most recent Substack published April 18, Erin Reed continued to further the falsehood that Cass “disregarded” all but high-quality studies. She also made false or misleading claims about: the subjectivity of the systematic literature review’s scoring system; the ongoing debate over whether gender dysphoria is influenced by social contagion; the false notion that the Cass Review aligned itself with an anti-trans propagandist; and the detransition rate.

In a lengthy YouTube video, British political activist and pundit Owen Jones (who once interviewed me about monkeypox when I was very swollen and bald from chemo) repeatedly made the false assertion that the Cass Review excluded all non-RCTs.

Jones also falsely claimed that none of England’s pediatric-gender-clinic patients were sped through the assessment process. The Cass Review shows that at a minimum, hundreds of children were referred to endocrinology after no more than four assessment appointments.

Jones also repeatedly said that the rate of detransitioning—people who after taking cross-sex hormones stop the medications and revert to identifying as their biological sex—is about 1 percent, saying that long-term studies show this. This despite the fact that Cass said in her report that because of a lack of long-term follow-up, the detransition rate is unknown.

From what I can estimate, the first person to have pushed the false claim that Cass simply discarded 98 percent of the available studies about pediatric gender-transition treatment was trans activist and attorney Alejandra Caraballo.

The key problem is that Caraballo cited the wrong systematic literature reviews in a viral tweet about the Cass Review.

Five hours before the Cass Review was published on April 9, Caraballo tweeted a screenshot of what appeared to be the new systematic literature reviews that would be published alongside the Cass report. But these screenshots were actually from the so-called NICE reviews—from 2020.

The tweet quickly racked up hundreds of thousands of views and has 850K to date.

The NICE reviews of the pediatric use of puberty blockers and cross-sex hormones for gender distress relied on the GRADE system, which with rare exceptions only gives high-quality ratings to randomized controlled trials.

Caraballo apparently did not yet have a copy of the final Cass Review report at this time. If Caraballo had waited until the new systematic literature reviews on which it was partly based, Caraballo would have seen that they did not throw out all but RCTs.

I am quite certain Caraballo did not have access to the Cass Review’s final report before the embargo lifted (at 7:01pm ET April 9), because shortly before the embargo was set to lift, Caraballo tweeted what was quite apparently thought to be the Cass report. But the link was to the review papers, not the report. As you can see, I told Caraballo on April 9 that the tweet had not, as claimed, linked to the Cass Review:

And of course amid all this, uber-popular debunking podcaster Michael Hobbes, who once hosted a show called You’re Wrong About, weighed in.

This reminds me of the time Hobbes hate tweeted about the feature in The Atlantic that I wrote about carpal tunnel syndrome and spent half the summer researching. He dismissed it with a wave of the hand. It was obvious he had not read it.

I will leave you, dear reader, with one small, yet mighty request:

PLEASE DO THE READING.

Benjamin Ryan is an independent journalist, specializing in science and health care coverage. He has contributed to The New York Times, The Guardian, NBC News and The New York Sun. Ryan has also written for the Washington Post, The Atlantic, The Nation, Thomson Reuters Foundation, New York, The Marshall Project, PBS, The Village Voice, The New York Observer, the New York Post, Money, Men's Journal, City & State, Quartz, Out and The Advocate. 

Learn more about Ryan’s work on his website, and follow him on X @benryanwriter.

"The amount of energy needed to refute bullshit is an order of magnitude bigger than that needed to produce it." -- Brandolini's Law

Hilary Cass warned of threats to safety after ‘vile’ abuse over NHS gender services review

The paediatrician, who has been advised to stop using public transport, describes ‘straight disinformation’ about report

the Guardian

The doctor behind a landmark review of the NHS’s gender identity services for children and young people has said fears had been raised about her personal safety amid online abuse after the report’s release.

Dr Hilary Cass told the Times she wished to address the “disinformation” circulating about the findings and recommendations handed down by the Cass review when it was published on 10 April.

She said she had received online abuse in the wake of the report and had been advised to stop using public transport.

The report said the evidence base for gender medicine in young people had been thin and children had been let down by a “toxic” public discourse around gender.

Cass told the Times: “I have been really frustrated by the criticisms, because it is straight disinformation. It is completely inaccurate.

“It started the day before the report came out when an influencer posted a picture of a list of papers that were apparently rejected because they were not randomised control trials.

“That list has absolutely nothing to do with either our report or any of the papers.”

Referring to the online abuse she had received, she said: “There are some pretty vile emails coming in at the moment, most of which my team is protecting me from, so I’m not getting to see them.”

She added: “I’m not going on public transport at the moment, following security advice, which is inconvenient.”

The report said the now shuttered Gender Identity Development Service (Gids) at the Tavistock and Portman NHS Foundation Trust, the only NHS gender identity development service for children in England and Wales, used puberty blockers and cross-sex hormones despite “remarkably weak evidence” that they improved the wellbeing of young people and concern they may harm health.

The report recommended that young people struggling with their gender identity should be screened to detect neurodevelopmental conditions and there should be an assessment of their mental health, because some who seek help with their gender identity may also have anxiety or depression, for example.

When the report was released, Cass stressed that her findings were not intended to undermine the validity of trans identities or challenge people’s right to transition, but rather to improve the care of the fast-growing number of children and young people with gender-related distress.

NHS England has since announced a second Cass review-style appraisal of adult gender clinics. Cass confirmed to the Times that she would not take part in the adult report after the abuse she suffered in recent weeks.

She said: “You heard it right here: I am not going to do the adult gender clinic review.”

Who Counts as an Expert?

A transgender activist at Harvard Law School is fact-checked in an academic journal.

City Journal

"If someone doesn't value evidence, what evidence are you going to provide to prove that they should value it? If someone doesn’t value logic, what logical argument could you provide to show the importance of logic?" -- Sam Harris

The US needs a bipartisan, open-minded gender medicine commission - The Boston Globe

The comprehensive Cass report in England points to a way out of the political impasse over youth gender treatments.

BostonGlobe.com

A thoughtful, comprehensive review just released in Britain points to a way out of the political impasse over youth gender treatments.

The toxicity of the culture war over youth gender medicine is well known to most of us. What’s less well understood is how that poisonous climate affects the very cohort being argued about — and those who care for them.

An exhaustive, level-headed 388-page report, commissioned by the National Health Service in England and released last week, warns: “Polarisation and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse.”

The Cass Review, led by Dr. Hilary Cass, examines the events and evidence (or lack thereof) that led to the closing of the UK’s only public youth gender clinic, the Gender Identity Development Services. GIDS opened in 1989 and at first served only 10 clients per year, mostly males who received psychological therapy; few medically transitioned. By 2016, GIDS was seeing nearly 1,800 clients a year, and multiple concerned clinicians there were blowing the whistle about the poor quality of the care. For years, their complaints mostly fell on deaf ears.

This document allows them to be heard. It is exceptional in many ways, including its scope. Cass spoke to many different and competing stakeholders, including disagreeing clinicians, “transgender adults who are leading positive and successful lives,” and “people who have detransitioned, some of whom deeply regret their earlier decisions.”

Cass reaches back into the history of youth gender medicine, formalized in the late 1990s in the Netherlands. She observes that the entire practice is “based on a single Dutch study which suggested that puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence.”

Recent scrutiny of the Dutch research revealed that the methodology was too flawed to support that conclusion. The Dutch approach involved something different from what has become the norm in the United States and was the norm at GIDS for a time. The Dutch doctors and psychologists offered youths extensive evaluation over long periods of time, discouraged social transition before puberty, and limited interventions to a carefully selected cohort who’d suffered from lifelong gender dysphoria, didn’t have other serious mental health issues, and lived in supportive families.

In America, this approach became denigrated as “gatekeeping,” and we veered toward a model known as “affirming.” We shifted from treating gender dysphoria to affirming a trans identity, letting a child’s feelings lead the way, and allowing social transition at any age. Here, manifesting one’s gender identity separate from natal sex was eventually seen as a civil right, rather than as a series of psychological and medical interventions — a model that influenced GIDS. But science doesn’t work that way. “Although some think the clinical approach should be based on a social justice model,” writes Cass, the National Health Service “works in an evidence-based way.”

That social justice / civil rights framing has made it harder to reckon with what Cass calls the “exponential rise” in adolescent patients starting around 2014, and a reversal in the sex ratio. Once it was mostly natal males who transitioned, but now it is mostly natal females, many of whom had no history of gender distress but did suffer from other mental health issues.

As for the evidence about how to treat these patients and others who havesought care, Cass concludes: “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.” Individual studies may make claims about the efficacy of social transition, puberty blockers, or hormones, but they are too biased and low quality to draw conclusions from.

The National Health Service had already recently declared that puberty blockers would no longer be used for young people with gender dysphoria, “because there is not enough evidence of safety and clinical effectiveness.” The Cass Review confirms this, noting that “bone density is compromised during puberty suppression” and that doctors don’t know enough about the effects on “psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk, or fertility.” No evidence proved that blockers provided “time to think,” as many proponents of affirmation claim, but there is “concern that they may change the trajectory of psychosexual and gender identity development.”

As for the claim that these interventions prevent suicide, Cass reports that “the evidence found did not support this conclusion.”

Perhaps most important, Cass notes that “clinicians have told us they are unable to determine with any certainty which children and young people will go on to have an enduring trans identity.” That is, in contrast to the affirmative model’s claim that “children know themselves,” the few high-quality studies we have suggest that gender dysphoria in kids most often resolves during puberty, as they develop and mature and gain a deeper understanding of the interplay between gender and sexuality. Many grow up to be gay.

These findings fly in the face of claims by activist groups that the science is settled and that gender-affirming care is “evidence-based” and “lifesaving.” But the findings also don’t negate the fact that some young people are deeply grateful to have transitioned.

Cass isn’t calling for a complete ban on youth gender interventions, like the bans many Republican states have enacted. Nor is she arguing for removing barriers to these interventions and making them more accessible without parental knowledge or consent, as many Democrats advocate. Her recommendation is to expand services but root them in holistic psychological care, making sure all other mental health issues are attended to. She is suggesting the end of the specialized gender clinic model, where gender dysphoria is viewed as the root of all distress.

Without that broader approach to treatment, she says, directly addressing the thousands of youths distressed about their gender, “you are not getting the wider support you need in managing any mental health problems, arranging fertility preservation, getting help with any challenges relating to neurodiversity, or even getting counselling to work through questions and issues you may have.”

The Cass Review offers 32 recommendations, including exercising “extreme caution” when prescribing cross-sex hormones to those 16 and younger and having provisions for people considering detransition. Cass calls for long-term follow-up of those who have transitioned or sought care and a commitment to lifelong care for both those who transition and those who detransition. In contrast, Democrats have blocked attempts to pass detransition care bills and amendments that would require insurers to cover reconstructive surgeries, hormone treatments, and other assistance for detransitioners who want to live as their natal sex again, in whatever way is possible after permanent changes. Detransitioners are often left with nowhere to go to attend to their bodies or their minds — as the case used to be for trans people (and may be the case again).

Increasingly, some providers are so intimidated by the noise around this issue that they don’t want to attend to kids with gender issues at all. But these young people, as Cass says, “must have the same standards of care as everyone else.”

In America, the main problem with the issue of how best to treat kids with gender distress is that it has become intertwined with politics. Some who object to the affirmative model or question it fear the personal and professional repercussions of being cast as a bigot. Some who support the affirmative model in red states that are criminalizing the care fear being jailed. “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,” Cass writes. “This must stop.”

As someone writing a book about the youth gender culture war, I couldn’t agree more. Polarization, the stifling of debate, and invective-flinging have left many families ill informed, making decisions in the dark and often based on fears of suicide that are unsupported by evidence. How can there truly be informed consent when there is so little unambiguous information, when there are more unknowns than knowns? And what do we do in the face of uncertainty? Argue and legislate, or gather data? It doesn’t help when our federal government contributes to the faux certainty, declaring that gender-affirming care is “suicide prevention” or “well-established medical practice” — arguments the Cass Review eviscerates.

For much of Europe, our government’s digging in on these treatments rather than investigating them more fully is just another way America has gone astray. Countries such as Finland and Sweden have analyzed the evidence and crafted more cautious guidelines, with psychological support as the baseline intervention.

We, too, need new, evidence-based guidelines. We need follow-up from all youth who transitioned, those who detransitioned, and those who desisted — meaning they stopped identifying as transgender without medically transitioning. We need to speak with multiple and competing stakeholders, and we need Democrats and Republicans to listen to those who’ve been helped and those who’ve been hurt; we need bipartisanship, not polarization. We need to push past politics and create an environment where robust scientific debate is not only tolerated but celebrated.

The National Health Service itself applauded Cass’s work, writing that it “will not just shape the future of health care in this country for children and young people experiencing gender distress but will be of major international importance and significance.” Let’s use the report to call for a ceasefire in the American gender culture war. We need our own Cass Review.