In the autumn of 2019, Hilary Dawn Cass OBE, a renowned British physician in pediatric disability agreed to conduct a review of international research into puberty blockers for NHS England.
She expected it to be a short, straightforward task, “I thought it would be couple of afternoons a month for six months and then I could go home and get on with my retirement,” she said, laughing wryly, on the morning before the publication of her review into gender identity services.
Had she known that she volunteered to a gargantuan task, she might have backed out from the project that became one of the most controversial evidence-review projects in recent medical history.
After more than four years of work and research, the final report was published on April 10, 2024.
400 pages written in a calmly clinical tone, except a few sentences here or there, when she could no longer hide her anger about how NHS England has cared for a generation of vulnerable children. “We’ve let them down because the research isn’t good enough and we haven’t got good data”, she concluded.
Among others, the report declared that child gender services have been “built on shaky foundations” with “remarkably weak evidence” to support treatments. While the review stops short from explicitly stating that puberty blockers cause more mental health issues, it highlights the complexity of mental health issues faced by individuals seeking gender identity support, to which hormone treatment might not be the best option. It also mentions that young people dealing with gender-related distress often have other mental health challenges, thus “a medical pathway will not be the best way to manage their gender-related distress”.
The report notes that while there has been a considerable amount of research published in this field, systematic evidence reviews have demonstrated the poor quality of many of these studies. This means that there is not a reliable evidence base upon which to make clinical decisions, neither can children and their families make informed choices regarding their care.
The recommendations include a more holistic approach to care, aligned with standard NHS practices, focusing on individualized assessment and support for young people. This includes expanding service capacity, conducting comprehensive assessments, providing evidence-based treatments, and establishing separate pathways for pre-pubertal children.
The U.K. is not the first and very likely not the last European country to start to restrict gender treatments for children.
In 2020, Finland’s health agency restricted the care by recommending psychotherapy as the primary treatment for adolescents with gender dysphoria. Two years later, Sweden restricted hormone treatments, then Norway designated youth gender medicine as a “treatment under trial”, meaning hormones will be prescribed only to adolescents in clinical trials and Denmark involved new guidelines.
But the Cass Review might allow for an even more balanced approach to the issue.
Cass called the phenomenon a “system failure”.
In the U.K., the exponential rise in referrals to gender clinics, particularly among girls, started around 2014. In 2010-2011 less than 250 patients were referred to such institutions, usually only a few a year and most of them were boys. In 2021-2022 more than 5,000 (twenty times more). And mostly girls.
Though trans-advocacy groups hailed the “greater awareness” and “less social stigma”, that doesn’t answer the sudden rise and the gender proportions.
They didn’t like Hilary Cass’s answer.
In fact, one such organization, TransActual stated that “The Cass Review is bad science and should not be taken seriously by policymakers”. (Side note: what about health care professionals? Why the immediate focus on politicians?) TransActual called on the LGBTQI+ sector, academics and trans allies everywhere to denounce the report, its recommendations, and the clear anti-trans bias in its methodology, joining those speaking out from Professional Association for Transgender Health Aotearoa (PATHA) and the Feminist Gender Equality Network (FGEN).
Other left-wing NGOs started an online campaign spreading falsifications about the report, claiming Cass “frames trans people” as “not real” but “having a mental health disorder.” which is clearly not true.
Yet, most of them just kept silent. Just like most of the liberal media. The “Politico family” decided to simply “forget” the topic, so did Boston Globe, while The Washington Post ran a short article, focusing on the critics of the review. The New York Times chose a different path, trying to emphasize that the proposed steps in the U.K., just like the steps taken by the previously mentioned European states were “just restrictions” and “not bans”, unlike in the U.S
But the rest is silence.
Probably because the review did point at quite a few questionable practices.
Starting with the “secrecy” around outcomes.
When accepting the job, Hilary Cass was tasked with conducting a vital and comprehensive study into the outcomes of all the 9,000 children and adolescents treated at the Tavistock and Portman gender identity development service (Gids) clinics between 2009 and 2020.
During the press conference at the publication of the review, she noted that her efforts to take a look at those medical records were often “thwarted”. She found it “unbelievably disappointing” that the research study she had hoped to conduct had been blocked by the adult gender clinics, as six out of the seven refused to contact the patients for permission on her behalf. (Side note: if the results are so stellar and convincing as those clinics claim, why the secrecy in anonymous research – unless of course, they are not.)
Another crucial point of the review is the conclusion that “the toxicity of the debate has been so great that people have become afraid to work in this area”, and medical professionals experienced a sense of fear “of being called transphobic if you take a more cautious approach”.
Secrecy doesn’t end with failing to share patients’ results. In an interview to the New Statesman, Cass explained that a 2016 Gids study (that failed to prove that children benefited from being treated with puberty blockers) was not published and the treatment of children continued as if it had never happened.
The consequence of this rising nervousness among clinicians was, that, over the past 15 years, many children who just began exploring their gender (which Cass describes as “a normal process” in adolescence, not necessarily requiring any medical input) have been prematurely diverted towards chronically oversubscribed specialist clinics, and left sitting on waiting lists for years, without any support.
And this wasn’t the end of Cass’s observations.
While people from all areas of healthcare have expressed their worries for years about the negative effects of social media on the well-being of children and adolescents, it has been mostly a taboo to claim (or to even talk about the possibility) that the very same media that can prompt teenagers to try to commit suicide (remember the Blue Whale Challenge, anyone?) or can fuel eating disorder echo chambers, might also influence their self-identification or can trigger negative self-worth feelings. If young people can “being radicalized by very harmful content without even knowing it” and can end up anorexic, why couldn’t they “self-diagnose” themselves as transgender?
Hilary Cass tried to break that taboo.
“Biology hasn’t changed in the last few years so it’s not that that’s changed things … we do have to think very seriously about the impact of social media, not just in terms of influencers, but about the effect of long hours on social media”, adding, “there was some very dangerous influencing going on. Some of them give them very unbalanced information. Some were told parents would not understand so that they had to actively separate from their parents or distance their parents; … (while) … all the evidence shows that family support is really key to people’s wellbeing”.
And so on.
The report has 400 pages, and it is hardly a “politically motivated paper” as its opponents claimed, immediately accusing the Sunak government of weaponizing the issue of gender identity as part of a “culture war electoral strategy”. It focuses on the patients and on looking for solutions how people who are really in need of it, could get better treatment.
While Hilary Class didn’t point fingers, labeling the situation a “system failure”, if anyone has made a political issue of the topic were politicians, health care practitioners and self-identified experts on the liberal side, eagerly promoting the subject, ostracizing anybody (from politicians to writers like J.K. Rowling) who dared to express a different opinion.
The very same side that is now curiously silent in the wake of the review. (
Or maybe, after the latest decision of the ECHR, they might have decided to “switch” to a more convenient topic, finally allowing the necessary expert debate and in-depth research on the issue of gender-treatment to happen. One can only hope that the excesses in “climate change politics” will be also revealed by an impartial review, before it becomes too late.
