Advocates Say a Controversial Report on Healthcare for Trans Kids Is “Fundamentally Flawed”
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International medical organizations and transgender activists are roundly condemning a new U.K. report on gender-affirming care for minors, saying the report ignores years of research to propagate “harmful” misinformation.
On Tuesday, the “Cass Review” — a 398-page report helmed by pediatrician Dr. Hilary Cass and commissioned by the National Health Service (NHS) — was published online, immediately kicking up a stir in the U.K. for its conclusions and recommendations about gender-affirming care. In its analysis of existing literature, the review determined that evidence supporting treatment like puberty blockers is “shaky” and urged “extreme caution” in allowing minors to medically transition. The NHS confirmed on Wednesday that it will initiate a review of its hormone replacement therapy (HRT) and puberty blocker policies as a result of the report.
Shortly after its publication, numerous medical organizations released statements heavily criticizing the Cass Review, especially because of how Cass and her research team evaluated and disqualified existing research. The report asserts that most studies of puberty blockers and hormone therapy in trans youth are unreliable because they are not double-blind studies — studies in which two groups of subjects receive either a placebo or a drug to be tested, with neither the subjects nor researchers knowing which group is which. Because little to no double-blind data is available, the Cass Review asserts, no firm conclusions can be drawn on the safety or effectiveness of gender-affirming care.
As many medical professionals have observed, “randomized control studies” (RCTs) with double-blind cohorts are sometimes unethical or impossible to implement for lifesaving treatment, such as chemotherapy or abortion-related medication. (One famously sarcastic illustration of this point took the form of a 2018 study that professed to use a control group to determine whether parachutes would prevent injury or death when skydiving.) In the case of hormone therapy and puberty blockers, a double-blind study would also be logistically unfeasible, as any placebo groups would quickly realize they were not receiving actual medicine. Nevertheless, the Cass Review disregarded or downgraded the perceived quality of dozens of studies on the mental and physical effects of HRT and puberty blockers in youth, based on researchers’ assertions that those studies “lack[ed] blinding and [had] no control group.”
The review “neglects a vast amount of evidence on the benefits of gender-affirming medical treatment for trans youth,” researcher Dr. Hane Maung wrote in a statement for the U.K.-based trans health advocacy group GenderGP on Friday. Cass’s demand for randomized trials “indicates a serious misunderstanding of the roles and limitations” of those studies, Maung wrote, accusing the report’s authors of “dismissing relevant evidence” and “mak[ing] claims and recommendations that are not informed by any evidence at all.” (Notably, the Cass Review also wholly disregarded any studies not written in English.)
TransActual, another trans healthcare advocacy organization based in the U.K., called the Cass Review “fundamentally flawed” in a statement this week, heavily criticizing researchers for disqualifying studies “on the spurious grounds [they do] not meet unobtainable levels of proof.”
“Cass has tried valiantly to mask the double standards which are applied to trans-related healthcare,” representatives from TransActual wrote. “However, these double standards and the shoddiness of the Report’s contents are starkly revealed under scrutiny.”
The Cass Review has also come under fire for numerous statements and conclusions that range from specious to bizarre. Researchers discuss youth social media use and exposure to pornography at length, demanding research into a supposed link between “consumption of online pornography and gender dysphoria,” and promoting the mythical “social contagion” model of trans identity promoted by anti-trans advocates like Abigail Shrier. Without providing evidence, researchers claim to have “heard accounts of female students forming intense friendships with other gender-questioning or transgender students at school, and then identifying as trans themselves.”
Elsewhere in the study, Cass claims that “[f]or many centuries transgender people have been predominantly trans females, commonly presenting in adulthood.” No evidence is provided for this statement, TransActual noted in its response, “as no such evidence exists.” The report also claims there is no evidence that gender-affirming care reduces suicidality, asserting instead that suicides in trans communities are “related to a range of other complex psychosocial factors and to mental illness.” As a result, the Review asserts, trans youth who have not received puberty blockers face “more pressing issues” than being approved for HRT.
In an emailed statement on Friday, the World Professional Association for Transgender Health (WPATH) rejected the Cass Review’s findings, particularly around mental health and treatment efficacy. “The foundation of the Cass report is rooted in the false premise that non-medical alternatives to care will result in less adolescent distress,” representatives for the organization wrote. “[P]olicies which severely restrict access to physical healthcare, and focus almost exclusively on mental healthcare for a population which the [World Health Organization] does not regard as inherently mentally ill, are harmful and have no place in medicine where clinical guidelines exist.”
The author said on X that celebs who stood by trans rights can “save their apologies.”
Some trans advocates expressed concern that the Cass Review was linked to broader far-right activism, especially from the U.S., in part due to Cass’ alleged ties to the working group that helped establish harsh care restrictions in Florida in 2022. Although the report will likely affect the rights of trans youth in the U.K., it is still unclear whether it will influence policy abroad. Right-wing figures in the U.S. celebrated the report’s release, including the influential anti-LGBTQ+ group Alliance Defending Freedom, which falsely claimed gender-affirming care is “unproven and dangerous” and lauded Cass for her findings regarding the “remarkably weak evidence” and role of pornography. But medical organizations in Australia this week said they do not plan to implement the report’s recommendations, citing its narrow focus on current NHS policy and misguided stance on the research process.
“The Cass review recommendations are at odds with the current evidence base, expert consensus, and the majority of clinical guidelines around the world,” said Dr. Portia Predny, Vice President of The Australian Professional Association for Trans Health (AusPATH). “Our guidelines for gender-affirming care for young people already prioritize holistic, individualized and person-centered care with the involvement of multidisciplinary teams of clinicians with all kinds of areas of expertise, to help and support young people to navigate their gender journey.”
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