Transgender advocates are incensed over an independent 400-page review of medical research on gender-affirming care for youth that claims there is not enough data to conclude gender-affirming care is good for trans kids.
The review, commissioned by England’s National Health Service (NHS), declared that there’s “insufficient evidence about the risks and benefits” of social transitioning, puberty blockers, and hormone replacement therapy — including the claim that they reduce suicidality among gender-distressed youths.
The review’s lead author, pediatrician Hilary Cass, said some evidence suggests that gender-affirming care can benefit certain adolescent patients’ mental health. But trans advocates have accused Cass of bending to conservative political forces in the United Kingdom and excluding hundreds of studies affirming the benefits of gender-affirming care.
Trans healthcare advocates in the U.S. worry politicians will use the review to justify state bans on gender-affirming care.
The review calls for more research and a holistic national approach that assesses each young patient’s underlying mental and physical health needs before suggesting medical treatment. It found that current research on gender-affirming care has been “exaggerated or misrepresented by people on all sides of the debate to support their viewpoint” and has also been used to vilify medical professionals on social media. This behavior “must stop,” Cass wrote, in order to find the best way to aid young people struggling with “gender incongruence.”
The review looked at global treatment guidelines, numerous peer-reviewed analyses of research data, and years’ worth of interviews — including talks with medical service providers, gender-distressed young people, their families, and detransitioned individuals.
Cass then concluded that a majority of 20 oft-cited studies — including ones promoted by the World Professional Association of Transgender Healthcare (WPATH) — were of “poor quality” or unreliable. The WPATH, an internationally recognized body for trans healthcare guidance, has cited these studies as the basis of its recommendation to treat gender dysphoria with gender-affirming medical care.
Trans journalist Erin Reed eviscerated Cass’s findings, saying the report included concepts rejected by more than 60 mental health organizations, including the American Psychological Association.
“It is important to note that gender affirming care saves lives, and there is plenty of evidence to show for it,” Reed wrote, citing numerous studies proving that such care significantly reduces suicidality. She added, “The largest and most influential medical organizations support trans care.”
The Cass Review’s key findings: More research is needed
After an analysis of 20 pediatric gender care guidelines, The Cass Review could only recommend the Finnish and Swedish guidelines for treating gender dysphoria. In 2020, Finland’s health agency recommended psychotherapy as the primary treatment for adolescent gender dysphoria. In 2022, Sweden restricted hormone treatments for trans youth to only “exceptional cases.”
The Cass review explained this doesn’t mean that Finland and Sweden are the “best approaches,” but only the ones most supported by current medical research data, which is very strict about defining the populations being treated and tracking their health outcomes.
Transgender advocate Julia Serano wrote that the Cass review excluded over 100 medical studies and literature reviews that show gender-affirming care to be effective.
Trans activist Allison Chapman, along with many others, accused the review of excluding studies on hormone replacement therapy and puberty blockers “solely because” the studies weren’t “blind” — that is, they informed researchers which participants were receiving both treatments rather than letting them evaluate the outcomes without that knowledge. Excluding those studies is “bad science and transphobic,” Chapman wrote.
Reed also noted that Cass dismissed the studies for using standards “that are unattainable and not required of most other pediatric medicine.”
Review spouts widely debunked “social contagion” theory
“Young people’s sense of identity is not always fixed and may evolve over time,” the review said. “Whilst some young people may feel an urgency to transition, young adults looking back at their younger selves would often advise slowing down.”
American medical practitioners typically will treat children for gender dysphoria if they find a young person’s declaration of trans identity has been “insistent, persistent, and consistent.” That is, a truly transgender child must repeatedly and continuously assert their trans identity over many years, not just a brief period.
“There remains diversity of opinion as to how best to treat these… young people,” the review stated. “The [research] evidence is weak and 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.”
The review even discouraged allowing children to socially transition, which essentially just means letting them dress how they want and use the name and pronouns that make them feel most comfortable. It claimed that kids who “present with gender incongruence at a young age are most likely to desist before puberty, although for a small number, the incongruence will persist” and that social transitioning “may change the trajectory of gender identity development” and make young people “more likely to proceed to a medical pathway” rather than to consider non-medical approaches to their needs.
Noting the recent increase in young U.K. patients seeking treatment for gender dysphoria, the review noted, “There is no simple explanation for the increase in the numbers of predominantly young people” identifying as transgender, “but there is broad agreement that it is a result of a complex interplay between biological, psychological and social factors.”
It noted that various psychosocial factors may drive trans identification in youth, including an increased societal acceptance of varied gender expression and gender non-congruent people, media challenges to past generations’ gender expectations, and the manifestations of other mental health challenges that express themselves as gender-related distress.
The increase in youth gender distress “needs to be considered within the context of poor mental health and emotional distress amongst the broader adolescent population, particularly given their high rates of co-existing mental health problems and neurodiversity,” the review stated.
Chapman slammed Cass for a statement to The Guardian pushing the above “social contagion” theory, in which Cass said social media may be causing more kids to think they’re trans. “Absolutely absurd statement that is not backed in facts, or studies,” Chapman said. “This is clearly a biased review that was driven by transphobic opinions and not facts.”
Reed also affirmed that the theory of trans identity as a social contagion and the existence of so-called rapid onset gender dysphoria have been widely discredited.
Review discourages use of hormonal treatments
The review said medical providers in the U.K. should use “extreme caution” when prescribing puberty blockers to trans youth under the age of 18.
“Moderate-quality evidence suggests mental health may be improved during [gender-affirming care] treatment, but robust study is still required,” the report added, somewhat contradicting the view of major American medical and mental health organizations that consider gender-affirming medical care as effective and necessary for reducing mental anguish and suicide risk among trans youth.
“The focus on the use of puberty blockers for managing gender-related distress has overshadowed the possibility that other evidence-based treatments may be more effective,” the review said, noting that other interventions are not the same as “conversion therapy” that seeks to change people’s gender identity from trans to cisgender.
“The intent of psychosocial 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 or not the young person subsequently proceeds on a medical pathway,” the review stated, recommending “a much more holistic offer of care.”
Activist Adi Aliza called these recommendations “terrifying.”
“Restricting access to life-saving treatments like puberty blockers and hormone therapy will have far-reaching and devastating impacts on their mental and emotional well-being,” she wrote on X. “The review’s insistence on ‘more research’ serves only to stall and deny crucial care in the hopes that trans identities will simply fade away. This cruel tactic further exacerbates the hostile environment trans people already endure.”
The review may help U.S. lawmakers justify bans on gender-affirming care
Trans advocates are understandably worried that the review may be cited by Republican politicians in the U.S. to justify bans against gender-affirming healthcare for trans youth. Currently, 22 states restrict such care; some even threaten doctors with prison time or loss of medical licensing for providing it.
The American Academy of Pediatrics, the American Medical Association, the American Psychological Association, and other major medical associations have all found gender-affirming care to be safe and essential to the overall well-being of trans youth. A recent survey by the National Center for Transgender Equality (NCTE) found 97% of transgender people who undergo gender-affirming surgery express increased satisfaction with their lives.
Additionally, a 2015 NCTE survey found that only 8% of nearly 28,000 respondents had de-transitioned, and some of these respondents hadn’t had gender-affirming surgeries. Of this 8% (representing 2,240 individuals), 62% said they only de-transitioned temporarily — that is, 1,389 people had de-transitioned temporarily. This means that only 851 trans-identified survey respondents had permanently de-transitioned — about 3% of all trans respondents — and some of them had detransitioned in response to transphobia.
Laurence Webb, a representative from the English trans-advocacy organization Mermaids, said that recent transphobic politics in the U.K. – including activism from extreme transphobic groups – may have affected the Cass Review’s findings.
“The intention with the Cass review is to be neutral, but I think that neutral has maybe moved,” Webb told The New York Times. “Extremist views have become much more normalized.”
Many have accused the study of being fueled by anti-trans activists whose ultimate goal is to erase trans people completely.
“The long term plan for the NHS utilizing the Cass Review is to ban gender-affirming care up to [age] 25,” queer civil rights lawyer Alejandra Caraballo wrote via X. “They’re going to force 18-25 into wrap around care that will deny access to hormones. This was never [about] kids. They don’t want trans people to exist period.”
If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat at 988lifeline.org. The Trans Lifeline (1-877-565-8860) is staffed by trans people and will not contact law enforcement. The Trevor Project provides a safe, judgement-free place to talk for youth via chat, text (678-678), or phone (1-866-488-7386). Help is available at all three resources in English and Spanish.
