alt=Valerie HudsonA 388-page bomb just dropped in the U.K., and reverberations will be felt around the world. The long-awaited final Cass Review — commissioned by the National Health Service on gender-related medical treatment — has just been published. Dr. Hilary Cass, the author of this independent review, is one of Britain’s preeminent pediatricians and formerly the president of the Royal College of Paediatrics and Child Health.
The Cass Review is painstaking in its detail and comprehensive in its scope. Its findings have already caused the U.K.’s Council for Psychotherapy to cease its advocacy for an uncritically affirming stance for those with gender dysphoria. In anticipation of the final report, last month the U.K. banned the NHS from providing puberty blockers, cross-sex hormones or surgery to minors. A law prohibiting private clinics from offering these practices is also in the works.
What does the Cass Review say?
Overall, it finds the evidence for the use of puberty blockers and cross-sex hormones as treatment for gender dysphoria to be quite weak.
With regard to puberty blockers, the review “found no evidence that puberty blockers improve body image or dysphoria, and very limited evidence for positive mental health outcomes, which without a control group could be due to placebo effect or concomitant psychological support.”
Additionally, the use of puberty blockers was not only associated with significant loss in bone density, but the review found evidence that “brain maturation may be temporarily or permanently disrupted by the use of puberty blockers, which could have a significant impact on the young person’s ability to make complex risk-laden decisions, as well as having possible longer-term neuropsychological consequences.”
The effects of puberty blockers may not, then, be reversible. In fact, the review notes, “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.”
With regard to the use of cross-sex hormones, similar conclusions are reached: “There is a lack of high-quality research assessing the outcomes of hormone interventions in adolescents with gender dysphoria/incongruence, and few studies that undertake long-term follow up. No conclusions can be drawn about the effect on gender dysphoria, body satisfaction, psychosocial health, cognitive development, or fertility. Uncertainty remains about the outcomes for height/growth, cardiometabolic and bone health.”
Noting the lack of evidence as to benefits and harms, the author concludes that it is unethical to prescribe these medications to anyone under the age of 18, and possibly unethical to prescribe them to anyone younger than their mid-20s, when full executive reasoning has been achieved.
Proponents of gender-altering medical treatment have argued that treatment lowers the risk of suicide among gender dysphoric young people but Cass does not find this to be the case. The report says: “[I]t is well established that children and young people with gender dysphoria are at increased risk of suicide, but suicide risk appears to be comparable to other young people with a similar range of mental health and psychosocial challenges. Some clinicians feel under pressure to support a medical pathway based on widespread reporting that gender-affirming treatment reduces suicide risk. This conclusion was not supported by the systematic review. In summary, the evidence does not adequately support the claim that gender-affirming treatment reduces suicide risk.”
Given no real evidence of any improvement with use of puberty blockers and cross-sex hormones in gender dysphoric children, and given the clear gaps in the research literature, the review concludes that there can be no informed consent on the part of either parents or patients to this treatment. Without the possibility of informed consent, it is patently unethical for doctors to prescribe such treatments.
The Cass Review also weighs in on the issue of social transition, which has been a source of conflict between schools and parents in the U.K.
While U.K. schools are prepared to socially transition a child — and to do so without informing parents — the Cass Review asserts that social transition is consequential, especially for younger children. The review notes, “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. For this reason, a more cautious approach needs to be taken for children than for adolescents.” For this reason, the U.K. government has recently issued guidance to stop schools from socially transitioning children.
The concept of “conversion therapy” also needs to be rethought, according to the Cass Review. Given the significantly higher rate of mental health comorbidities of gender dysphoric children compared to controls, it is important that mental health professionals be allowed to investigate whether a child’s gender dysphoria may be relieved through psychological interventions. Proposed bans on “conversion therapy” might stifle such needed therapy.
Furthermore, the review insists that detransitioning support also be provided by the NHS since, according to Cass, the number of detransitioners appears to be increasing.
All in all, the Cass Review is an important achievement. It will be the foundation for an almost 180-degree turn in how the National Health Service treats gender dysphoric children. It is also a massive repudiation of the care guidelines put forward by WPATH, the World Professional Association of Transgender Healthcare. The guidelines have been unjustifiably influential given their “lack [of] developmental rigour,” as the review politely puts it.
But the report represents more, at least to Americans. It is a gauntlet thrown down to U.S. professional organizations, such as the American Medical Association, the American Academy of Pediatrics and the American Psychological Association, all of which have uncritically adopted the clearly unethical WPATH approach. It is also a gauntlet thrown down to the Biden administration, which has followed suit.
With the publication of the Cass Review, American institutions must rethink their approach to the treatment of gender dysphoric children. That approach is now clearly seen to be wrong, and can no longer be ethically justified.
I’m planning on mailing a copy of the review to the U.S. Department of Health and Human Services, care of Dr. Rachel Levine.
Valerie M. Hudson is a university distinguished professor at the Bush School of Government and Public Service at Texas A&M University and a Deseret News contributor. Her views are her own.