The mind of the world’s largest assessment into children’s attention has said that female medication is “built on weak foundations”.
Dr. Hilary Cass, the paediatrician commissioned to perform a review of the companies the NHS offers to children and young people who question their gender identification, said that while doctors tend to be cautious when implementing new discoveries in new medical specialties, “quite the change happened in the field of female care for children.”
Cass gave the University of York a task to carry out a number of assessments for her assessment.
The current status and growth of suggestions and recommendations for treating gender dysphoria in children and young people were examined in two documents. The scientists discovered that the majority of the 23 scientific guidelines being reviewed were no fact-based or separate.
A second report on puberty filters found that of 50 research, only one was of high quality.
Also, of 53 studies included in a third report on the use of testosterone treatment, only one was of sufficiently high quality, with little or just contradictory evidence on important outcomes.
Here are the main findings of the reviews:
Clinical guidelines
Growing numbers of children and young people who have gender dysphoria are being referred to specialist gender services. There are various guidelines that describe the best way to handle these children and adolescents ‘ clinical care.
The York researchers examined the quality and development of published guidelines or clinical recommendations for treating gender dysphoria in children and young people up to the age of 18 in the first two papers.
They examined a total of 23 guidelines that were published in various nations between 1998 and 2022. After 2010, all but two publications were made.
According to the researchers, the majority of them lacked “an independent and evidence-based approach and information about how recommendations were developed.”
Few guidelines had their recommendations based on a systematic review of empirical evidence, and they lack transparency in how they were developed. Only two of the York academics’ findings indicated that they had spoken with children and young people directly during their development.
The researchers wrote that “healthcare services and professionals should take into account the poor quality and interrelated nature of published guidance to support the management of children and adolescents who experience gender dysphoria and incongruence.”
Cass stated in a letter to the British Medical Journal (BMJ) that while medicine was typically based on the pillars of integrating the best available research evidence with clinical expertise, patient values and preferences, she “found that in gender medicine those pillars are built on shaky foundations.”
She claimed that the World Professional Association of Transgender Healthcare (WPATH) had been “highly influential in directing international practice,” despite the University of York’s evaluation finding that its guidelines lacked developmental rigor and transparency.
In the foreword to her report, Cass claimed that “quite the reverse happened in the field of gender care for children,” while doctors tended to be cautious in implementing new findings.
She cited a single Dutch medical study as an example of how “puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence” was used to “spread at pace to other countries.” Subsequently, there was a “greater readiness to start masculinizing/feminizing hormones in mid-teens”.
She continued,” Some practitioners have abandoned traditional clinical approaches to holistic assessment, making this group of young people’s exceptionalization in comparison to other young people with similarly complex presentations. They deserve very much better”.
A lack of reliable sources of information was a key issue in this area of medicine, as both papers repeatedly demonstrated.
She added,” The closing of this knowledge gap would be a great help for the young people wanting to make informed decisions about their treatment.”
Cass argued that the NHS should implement a “full programme of research” that examines the characteristics, interventions, and outcomes of each and every young person who applies to gender services, with consent frequently sought for enrollment in a study that followed them into adulthood.
Her review identified gender medicine as” an area of remarkably weak evidence,” with study findings also being “exaggerated or misrepresented by people on all sides of the debate to support their viewpoint.”
There should be research into psychosocial interventions and the use of the masculinizing and feminizing hormones testosterone and oestrogen, the review concluded in addition to a puberty blocker trial that could be conducted by December.
Hormone Treatment
Many transgender people seeking medical assistance during their transition opt for hormone therapy to masculinize or feminize their bodies, a practice that has been prevalent among transgender adults for decades.
The Cass review acknowledges that while these medications come with long-term risks and side effects, the benefits for many outweigh the drawbacks. “It is a well-established practice that has transformed the lives of many transgender people,” the Cass review notes.
For assigned females at birth, the process involves testosterone administration, leading to changes such as facial hair growth and voice deepening. On the other hand, for assigned males at birth, it entails estrogen intake to induce changes like breast development and increased body fat. Some of these changes may be irreversible.
However, in recent years, a growing number of adolescents have started taking these cross-sex or gender-affirming hormones, with the majority of those prescribed puberty blockers subsequently transitioning to such medications.
The increasing use of these hormones among young people has raised concerns about their impact on various aspects, from mental health to sexual functioning and fertility.
To ascertain the known and unknown risks, benefits, and potential side effects of such hormones on young individuals, researchers at the University of York conducted a review of the evidence, analyzing 53 previously published studies.
With the exception of one study examining side effects, the quality of research in all others was rated as moderate or poor. The researchers found limited evidence for the effects of such hormones on transgender adolescents, including outcomes like gender dysphoria and body satisfaction.
Inconsistent results were found regarding the effects of these hormones on growth, height, bone health, and cardiometabolic indicators such as BMI and cholesterol markers. Furthermore, fertility in assigned females at birth was not assessed in any study, and only one study examined fertility in assigned males at birth.
These findings align with other systematic reviews indicating insufficient and/or inconsistent evidence regarding the risks and benefits of hormone treatments in this population.
However, the review did uncover some evidence suggesting that masculinizing or feminizing hormones may enhance the psychological well-being of young transgender individuals. Three out of five studies reported improvements in suicidality and/or self-harm after 12 months of treatment, with one study showing no change. An analysis of five studies also indicated that hormone therapy could alleviate depression, anxiety, and other mental health issues in adolescents.
However, pinpointing the exact role of these hormones remains challenging. The authors note that most studies included adolescents who underwent puberty suppression, making it difficult to isolate the effects of hormones alone. They emphasize the need for comprehensive research on psychological health with long-term follow-up.
The Cass review recommends that NHS England reassess its current policy on masculinizing or feminizing hormones, suggesting caution even though the option to provide such medications at age 16 exists. They advocate for clear clinical justification for not waiting until individuals reach 18 before making recommendations.
Puberty Blockers
The use of treatments to halt adolescents from undergoing puberty began in the UK a decade ago.
These drugs, although historically utilized to treat precocious puberty (when puberty starts at a very young age), started being used off-label in children with gender dysphoria or incongruence in the late 1990s. Originating from the Netherlands, the rationale behind puberty blockers was to afford young individuals more time to contemplate and potentially ease their transition in later stages of life.
Contrary to this expectation, data from gender clinics, as reported in the Cass review, indicate that the majority of those who underwent puberty suppression subsequently proceeded to undergo masculinizing or feminizing hormone therapy, suggesting that puberty blockers did not necessarily provide ample time for reflection.
Researchers at the University of York identified 50 papers investigating the effects of these drugs on adolescents with gender dysphoria or incongruence, aiming to comprehend the broader impacts of puberty blockers. Among these papers, only one was deemed of high quality, with an additional 25 considered moderate quality. The analysis disregarded 24 papers deemed too weak.
Fewer reports explored whether the drugs achieved their intended effects and how effectively puberty was suppressed.
Of the two studies examining body satisfaction and gender dysphoria, neither yielded significant findings. According to the York team, there was “very limited” evidence supporting the mental health benefits of puberty blockers.
Overall, the researchers concluded that “no conclusions” could be drawn regarding the impact on gender dysphoria, mental and psychosocial health, or cognitive development, although some evidence suggested that bone health and height might be compromised during treatment.
As per the Cass review, puberty blockers do not seem to facilitate the transition of transgender individuals into later stages of life, particularly if these drugs do not contribute to increased height in adulthood. For transgender women considering vaginoplasty (the creation of a vagina and vulva), the decision to halt irreversible changes like voice deepening and facial hair growth must be weighed against the necessity for penile growth.
In March, NHS England announced that puberty blockers would no longer be routinely prescribed to children with gender dysphoria. Instead, their use will be limited to a trial, which, according to the Cass review, should be part of a larger study assessing the effects of masculinizing and feminizing hormone therapy.
