This month saw the publication of “the largest review ever undertaken in the field of transgender health.” Led by Dr. Hilary Cass, a former president of the UK’s Royal College of Paediatrics, it was commissioned by Britain’s National Health Service (NHS) with the stated goal of figuring out “how best to help the growing number of children and young people who are looking for support from the NHS in relation to their gender identity.” The findings of this four-year review were written up in a 388-page report which is, as The Economist puts it, “damning of practices that were commonplace in England until recently and remain widespread in other countries, notably America.”
This article will not focus on theological or pastoral reflection, important as such reflection undoubtedly is, nor will it mount a case against the foundations of transgender ideology—a case that is increasingly being made even by secular philosophers and public intellectuals. My aim is simply to show that the Cass report discredits four widely believed claims. This article will demonstrate: first, that adolescent gender dysphoria does not predict lifelong experience; second, that puberty blockers don’t merely “buy time” to think; third, that puberty blockers and cross-sex hormones are not “life-saving” medicines; and fourth, that the exponential rise in trans identity in recent years is not explained by greater societal acceptance. Finally, it will suggest how the Cass report might help us all have better conversations, especially with those with whom we deeply disagree on questions of trans identity.
1. Adolescent gender dysphoria does not predict adult identification.
Trans identity is often presented as an innate reality, which must not be questioned. The claim is that children or adolescents who experience gender dysphoria simply are trans, and must therefore be allowed to make decisions on that basis. But according to the Cass report, gender dysphoria in childhood “is not reliably predictive of whether that young person will have longstanding gender incongruence in the future, or whether medical intervention will be the best option for them” (29).
Indeed, far from gender dysphoria in minors reflecting an immutable reality, the large majority of people who experience it in childhood or adolescence will no longer do so in adulthood. As Cass reports, a review of studies “found persistence rates of 10–33% in cohorts who had met formal diagnostic criteria at initial assessment” (67). In other words, at least two-thirds of those who reported gender dysphoria as children no longer experienced it in adulthood. Most grew up to be same-sex attracted adults, who identified with their biological sex (67). (In line with much secular academic research, the Cass report uses the term “same-sex attracted.”)
At least two-thirds of those who reported gender dysphoria as children no longer experienced it in adulthood.
2. Puberty blockers don’t merely ‘buy time to think.’
Puberty blockers are routinely prescribed to adolescents on the grounds that they just “press pause” on sexual development and buy young people “time to think.” This claim is made in middle school health classes across America today. But as the Cass report notes, “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” (32). Strikingly, “the vast majority of young people started on puberty blockers proceed from puberty blockers to masculinising/feminising hormones” (32). Furthermore, puberty-blockers may negatively affect important physical aspects such as cognitive development and fertility (32).
So, why are they so widely prescribed?
In 2011, a team of Dutch scientists published study of 70 patients who had received early treatment with puberty blockers between 2000 and 2008. The minimum age for inclusion in the study was twelve, and kids had to have “suffered from life-long gender dysphoria that had increased around puberty, be psychologically stable without serious comorbid psychiatric disorders that might interfere with the diagnostic process, and have family support” (68). Given the “poor mental health outcomes for the adult transgender population, much of which was attributed to minority stress and difficulty ‘passing’ in their expressed gender” (68), the logic was that prescribing puberty blockers to prepubescent and adolescent kids would enable them to live more successfully in adulthood, since they would ultimately look more like the sex with which they wanted to identify. Since taking puberty blockers was seen as simply “pressing pause” the rationale was also that prescribing them would give young people time to think, before making a high-stakes decision about cross-sex hormones.
The same year that the Dutch study was published, a UK-based study started trialing the use of puberty blockers on kids who reported gender dysphoria. Preliminary results from the study in 2015–2016 did not demonstrate benefit. Rather than just being a neutral step, this trial found that 98 percent of kids who were prescribed puberty blockers went on to take cross-sex hormones (71). But the results of the study were “not formally published until 2020, at which time it showed there was a lack of any positive measurable outcomes” (68).
Meanwhile, on the basis of what became known as “the Dutch protocol,” from 2014 onwards in Europe and America, puberty blockers were routinely prescribed to kids, even though many of them “would not have met the inclusion criteria of the original protocol,” including “patients with no history of gender incongruence prior to puberty, as well as those with neurodiversity and complex mental health presentations” (73).
Advocates for prescribing puberty blockers claim they ease gender dysphoria and improve body image and psychological well-being. But the systematic review of literature on which the Cass report draws “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” (179). It also found that “bone density is compromised during puberty suppression” and that there was “insufficient/inconsistent evidence about the effects of puberty suppression on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk or fertility” (32).
In light of the potential risks regarding a range of health outcomes, the UK’s National Health Service was advised in July 2023 that puberty blockers should only be offered to minors participating in scientific research (32). The UK subsequently became the fifth European country to halt its use of puberty blockers for trans-identifying youth outside of carefully controlled scientific studies.
The UK became the fifth European country or region to halt its use of puberty blockers for trans-identifying youth outside of very controlled scientific studies.
3. Puberty blockers and cross-sex hormones are not ‘life-saving’ medicines.
Puberty blockers and cross-sex hormones are frequently billed as life-saving interventions. Parents of trans-identifying kids are often asked, “Would you rather have a living daughter or a dead son?” or vice versa. “It has been suggested that hormone treatment reduces the elevated risk of death by suicide in this population,” the Cass report observes, “but the evidence found did not support this conclusion.” (33)
Far from confirming the mental health benefits of puberty blockers, the preliminary findings from the UK’s 2011 early intervention study suggested that puberty blockers can make the mental health of some young people worse, not better. The study “did not demonstrate improvement in psychological wellbeing, and in fact some birth-registered females had a worsening of ‘internalising’ problems (depression, anxiety) based on parental report.” Troublingly, “in response to the Youth Self Report Scale, there was a significant increase after one year on treatment in adolescents scoring the statement ‘I deliberately try to hurt or kill myself” as ‘sometimes true’, especially among birth-registered females’” (70–71).
So, why is it so widely believed that puberty blockers are life-saving?
The Cass report explains that “There are many reports that puberty blockers are beneficial in reducing mental distress and improving the wellbeing of children and young people with gender dysphoria,” and these have been used to put doctors “under pressure to continue prescribing such treatments on the basis that failing to do so will put young people at risk of suicide.” But the systematic review on which the Cass report draws found that “the quality of these studies is poor” (179).
One of the difficulties in studying gender therapy outcomes is that so many young people who are referred to gender clinics have other challenges. A review of referrals across multiple countries concluded, “These children show higher than expected levels of ASD, ADHD, anxiety, depression, eating disorders, suicidality, self harm, and ACEs” (97). For instance, researchers in Finland found that “more than three-quarters of the referred adolescent population needed specialist child and adolescent psychiatric support due to problems other than gender dysphoria, many of which were severe, predated and were not considered to be secondary to the gender dysphoria” (91). Meanwhile, studies have found that trans-identifying people are “three to six times more likely to be autistic” than their peers (93).
Young people referred to gender services are also disproportionately likely to have gone through “adverse childhood experiences.” For instance, studies have found that about half of all kids referred for gender services had been affected by maternal mental illness or substance abuse, while almost a quarter had been exposed to domestic violence (94).
Many trans-identifying youth have mental health challenges aside from their gender dysphoria—and these other needs are often neglected.
When it comes to suicidal ideation and attempts, the rates among trans-identifying youth are higher than in the general population. But rather than this being driven by lack of societal acceptance for trans people or failure to provide “gender affirming medicines” (as is often claimed) it is largely accounted for by the other mental health challenges. A recent study looking at international data, “reviewed all gender clinic referred adolescents between 1996 and 2019 (2,083) and compared them to age-matched controls (16,643).” The study found that, “Although the suicide rate in the gender-referred youth was higher than in the general population, this difference levelled out when specialist-level mental health treatment was taken into account” (96). The Cass report concludes: “Overall, it is difficult to draw firm conclusions because the absolute risk of suicide in the population of gender dysphoric youth and in the control population was very low, so numbers were thankfully small” (96).
The popular narrative is that trans-identifying kids are suffering because they are trans and that “gender affirming medicine” coupled with societal acceptance will resolve their mental health challenges and prevent them from committing suicide. The truth is that many trans-identifying young people have mental health challenges aside from their gender dysphoria—and these other needs are often neglected. The Cass report concludes, “the evidence does not adequately support the claim that gender affirming treatment reduces suicide risk” (187).
4. The exponential rise in trans identity is not explained by greater societal acceptance.
In the last 15 years, both in the UK and across the Western world, the number of minors being referred to gender clinics has grown exponentially, and the male-female ratio has flipped. In the UK, “In 2009, 15 female adolescents were referred to the UK’s gender clinic and 24 adolescent males. But in 2016, 1,071 adolescent females and 426 adolescent males were referred.” Indeed, “From 2014 referral rates to GIDS began to increase at an exponential rate, with the majority of referrals being birth-registered females presenting in early teenage years” (85). By 2022, GIDS was receiving more like 5,000 referrals, though poor record-keeping makes it hard to say exactly (85).
The Cass report notes that greater societal acceptance is a “common explanation put forward” to explain this increase in referrals. But while there is clearly “much greater acceptance of trans identities, particularly among younger generations, the exponential change in referrals over a particularly short five-year timeframe is very much faster than would be expected for normal evolution of acceptance for a minority group.” Moreover, the report observes that greater societal acceptance “does not adequately explain the switch from birth-registered males to birth-registered females, which is unlike trans presentations in any prior historical period” (26).
So, what has driven this exponential growth and the switch from boys to girls?
The Cass reports notes that, “Peer influence during this stage of life is very powerful” (122). It points to the influence of social media on trans-identifying kids and the evidence that social media is associated with a range of mental health challenges:
A systematic review of 20 studies found that use of social media was associated with body image concerns and disordered eating (Holland & Tiggermann, 2016). Numerous other studies implicate smartphone and social media use in mental distress and suicidality among young people, particularly girls, with a clear dose-response relationship (Abi-Jaoude et al., 2020); that is, the more hours spent online the greater the effect. (110)
In addition to the influence of social media, “the Review has heard accounts of female students forming intense friendships with other gender-questioning or transgender students at school, and then identifying as trans themselves” (122).
The timeline for the explosion of trans identity among young people in the West supports the hypothesis that social media has played a key role. In the UK, the “recorded prevalence of gender dysphoria in people aged 18 and under increased over 100-fold between 2009 and 2021,” the report notes. “This increase occurred in two phases; a gradual increase between 2009 and 2014, followed by an acceleration from 2015 onwards” (87). So, the “inflection point for the increase in referrals in the UK was in 2014, with similar timing in several other countries” (88). This maps onto the time when it became normative for adolescents in the West to have unlimited access to smartphones and social media. At this point, as social psychologist Jonathan Haidt puts it in his new book The Anxious Generation, “girls’ mental health began to collapse” (165). Indeed, as the Cass report observes, “The increase in presentations to gender clinics has to some degree paralleled this deterioration in child and adolescent mental health” (111).
The timeline for the explosion of trans identity among young people in the West supports the hypothesis that social media has played a key role.
In sum, the exponential increase in adolescents in the West identifying as transgender is not a reflection of the fact that the same proportion of the population has always “been trans,” and that more young people are now able to come out because of greater societal acceptance. Rather, it is in large part due to the influence of social media, which has simultaneously harmed the mental health of Gen Z—especially girls—and encouraged adolescents to attribute their loneliness, depression, and anxiety to a mismatch between their true identity and their sexed bodies.
What Now?
Writing for The Atlantic, journalist Helen Lewis calls the Cass report “a model for the treatment of fiercely debated social issues: nuanced, empathetic, evidence-based” and observes that “it has taken a political debate and returned it to the realm of provable facts.” This focus on the facts means that the Cass report can point us to solid scientific ground amid a marshland of misinformation regarding care for trans-identifying youth. It also offers a basis for more fruitful conversations between people who profoundly disagree on questions of trans identity, but who share a desire to care well for young people who struggle with gender dysphoria or currently identify outside their biological sex. For instance, if you (like me) have kids in public schools in the United States, the Cass report could be a strong foundation for requesting that those schools stop telling kids in health class that puberty blockers “just press pause.”
While many of the claims about trans-identifying youth are unsupported by the evidence, we must also recognize that these young people are a vulnerable group and that they need care—albeit not in the form of medical interventions with potentially life-long consequences. For kids who have been led to trans identity by social media, it’s important that we take time to listen carefully to how they feel. They may be suffering from depression, anxiety, or concerns about their bodies driven by their online experiences. If we are parents, it is worth considering putting real boundaries around social media use or removing it completely from our children’s lives in light of the well-documented negative effects on adolescent mental health.
The Cass report can point us to solid scientific ground amid a marshland of misinformation.
While gender dysphoria in adolescence does not predict adult experience, it is important that we recognize that it can be very painful and distressing. Sadly, a small proportion of people will battle with these feelings all their lives. Acknowledging the reality of this experience does not require agreeing that a trans-identifying boy truly is a girl, or vice versa. But it does mean being willing to listen to people about their feelings.
We must also not forget that some children are born with a disorder of sexual development or intersex condition, which means their bodies do not straightforwardly conform to either male or female norms. These children often get caught in the crossfire. Christian parents with kids in this situation are having to make difficult medical decisions for their children within a wider culture that wants to use them to justify the validity of trans identity and a Christian culture within which some people mock the idea that someone could have valid questions when it comes to their sex. We need to educate ourselves about physical disorders of sexual development so that we do not oversimplify this conversation and fail to support those families.
In conclusion, when it comes to trans-identifying youth, the Cass report has given us a valuable basis for more fruitful conversations, whether with the children in our lives or with our neighbors, colleagues, friends, or public-school administrators. If we are followers of Jesus, we must speak the truth in love. Dr. Cass has given us a better handle on the truth when it comes to some specific questions of medical research regarding trans identity. It’s down to us to bring the love.
Is there enough evidence for us to believe the Gospels?
In an age of faith deconstruction and skepticism about the Bible’s authority, it’s common to hear claims that the Gospels are unreliable propaganda. And if the Gospels are shown to be historically unreliable, the whole foundation of Christianity begins to crumble.
