Cass review: how has report affected care for transgender young people? - The Guardian 2/7/25

One can tell if medical reviews are high quality: their evidence and recommendations are accepted and acted upon (copied) widely outside the jurisdiction in which they were originally proposed.

The international mood to adopt Cass' ideas is slight.

On principle I never block anyone on social media. I want to see what the buggers are up to.

I'm really not: then it would be the 'echo chamber' that it's always accused of being!

Thank you to everyone who's posted such informative and accurate evidence in response to the comic claim that Cass is a self published piece of paper 😂😂
I know it's tedious having to continually respond to untruths and fantasies - but the advantage is that women get to share peer reviewed evidence and ethical approaches in response to the toddler level insults thrown about by transactivists.

And Kennedy's 'study' is a collection of anecdotes.

It is remarkable to see a philosophical belief being treated medically and being supposedly supported by this study. It really shows the deficit in critical thinking ability of those who post it as if it somehow convincing and robust evidence.

It also doesn't look further into perhaps why these children and parents are so distressed. It doesn't track the misinformation that those children and parents have read which has fed the distress. The deliberate misrepresentations as we have seen over and over from Aidap are just an example of what these parents and their children are reading without any balance.

Yet, I doubt that the posters who post this paper even stop and think about the misinformation that has caused this situation. I can only assume that it is because they don't actually care about integrity of evidenced discussion.

TLDR: If someone considers Kennedy's paper a great example of quality evidence, while trying to discredit Dr Cass and team (and the many other countries' independent teams that found the same thing with regards to the evidence), it shows a disconnect in the definition of what is quality evidence and what is not.

Readers Note:

This 'paper' starts from a highly questionable place.

"On the last day of parliament before the general election in 2024, the government imposed a ban on puberty-blockers, criminalizing their use for young trans people. The incoming Labour government of Keir Starmer continued this ban and subsequently made it permanent, enforcing it with a criminal sanction of up to two years in prison. This has made the UK an international outlier, countries as diverse as Spain, France, Norway, Denmark, Poland, Germany, Japan, South Africa, The Netherlands, Switzerland, Belgium, Mexico, Canada, Australia, New Zealand and many others routinely prescribe puberty blockers for young people with gender incongruence. Puberty-blockers have been used to treat young trans people since the 1990s, meaning that there are now trans people in early middle age who were prescribed them. Puberty-blockers provide young trans people with the time to think and make a decision about their future when they are more mature and regarded as legally competent to do so. Their effects are fully reversible. Puberty-blockers suspend puberty, and that is all they do. They are also prescribed in the UK for precocious (ie early) puberty and for people with prostate cancer and endometriosis."

For a start, France, Norway, Denmark, Canada, New Zealand and I believe, even Germany, have all had independent teams that have stated that there is low evidence that puberty blockers and other treatments lead to a improved outcome for children and young people.

"Puberty-blockers provide young trans people with the time to think and make a decision about their future when they are more mature and regarded as legally competent to do so. Their effects are fully reversible."

This is just propaganda in view of all that is now known about these drugs. It is very dangerous misinformation.

For a start for female people, bone density issues are significant for any female person who takes puberty blockers and then moves on to taking testosterone. This is in keeping too with the adult outcomes of girls being prescribed PBs for precocious puberty. Decades later, those women report bone density issues and joint and connective tissue issues. Teeth falling out, osteoporosis, jaws dislocating and a huge range of damage to organs.

This is known. Yet it is dismissed by male people who seem to have far too heavy investment in spreading the propaganda.

Here is one study that shows that "Their effects are fully reversible" is dangerous misinformation.

Bone Health in the Transgender Population
Published online 2019 Jul 2.

Micol S. Rothman and Sean J. Iwamoto

www.ncbi.nlm.nih.gov/pmc/articles/PMC6709704/

Also unknown are the long-term effects of puberty blockade, the effect of changes in body composition and the optimal type, timing, dosage, and route of administration of GAHT for bone outcomes.

Conclusion
The results of the studies that reported impact on the critical outcomes of gender dysphoria and mental health (depression, anger and anxiety), and the important outcomes of body image and psychosocial impact (global and psychosocial functioning), in children and adolescents with gender dysphoria are of very low certainty using modified GRADE. They suggest little change with GnRH analogues from baseline to follow-up.

And

GnRH analogues are frequently employed to provide puberty blockade in adolescents with gender incongruence or gender dysphoria. From their use in other medical conditions such as prostate cancer, their deleterious effects on the bone are well known, although these have the potential to be reversible if treatments are stopped or add back therapies can be given

And

However, Z-scores in the trans boys also showed an expected drop during GnRHa treatment. Similarly, they did not fully make up their bone loss as Z-scores at age 22 were still lower than baseline

Meaning, the authors acknowledge little is known about the lasting effects of puberty blockers. In this study, they propose some positive effect from cross sex hormones for females but ths results show that it doesn’t really make up the loss from puberty blockers.

PLUS

Just adding this piece about bone density for young transitioners here:

https://segm.org/the_effect_of_puberty_blockers_on_the_accrual_of_bone_mass

1st May 2021

Dr Michael Biggs (an advisor to SEGM) has been calling for the release of data from the Tavistock’s experiment since 2019. A subset of the data were finally released following the judicial review into puberty suppression at the Tavistock clinic. Biggs’ reanalysis has just been published in the Journal of Paediatric Endocrinology and Metabolism. It finds that after two years on GnRHa, the Z-scores for a significant minority of the children had declined to a level that should trigger clinical concern.

PLUS

www.svtplay.se/video/33358590/uppdrag-granskning/mission-investigate-trans-children-avsnitt-1

The latest from Sweden on the effects of puberty blockers on Leo and others.

As the poster who posted this initially states:

A trans child, Leo was treated for puberty blockers for 4 years. Leo ended up with osteoporosis (significantly below any normal bone density interval), fractures in the back, constant pain and worse mental state.

The journalist also found an additional 12 cases in Stockholm only where children had serious side effects (bone fractures, deep regret from voice changes, injuries, deteriorating mental health and significant weight gains). Leo’s case was not reported and not one of these.

That doesn't even cover this warning:

New FDA warning for PBs:

publications.aap.org/aapnews/news/20636/Risk-of-pseudotumor-cerebri-added-to-labeling-for?autologincheck=redirected

The Food and Drug Administration (FDA) has added a warning about the risk of pseudotumor cerebri (idiopathic intracranial hypertension) to the labeling for gonadotropin-releasing hormone (GnRH) agonists that are approved for the treatment of central precocious puberty in pediatric patients. These products include Lupron Depot-Ped (leuprolide acetate), Fensolvi (leuprolide acetate), Synarel (nafarelin), Supprelin LA (histrelin) and Triptodur (triptorelin).

The new warning includes recommendations to monitor patients taking GnRH agonists for signs and symptoms of pseudotumor cerebri, including headache, papilledema, blurred or loss of vision, diplopia, pain behind the eye or pain with eye movement, tinnitus, dizziness and nausea.

And

Six cases were identified that supported a plausible association between GnRH agonist use and pseudotumor cerebri. All six cases were reported in birth-assigned females ages 5 to 12 years. Five were undergoing treatment for central precocious puberty and one for transgender care. The onset of pseudotumor cerebri symptoms ranged from three to 240 days after GnRH agonist initiation.

Just a reminder : SEGM has a page with links to studies. This is a great archive.

It covers treatment, and side effects, mental health, suicide, even social transitioning.

https://segm.org/studies

Can I just make reference to the 'you haven't got a doctorate in x biology' and then referencing a delusional man who co-authors papers with himself and who has ZERO doctorate in any biology'.

On whether it's 100% social contagion, I'm very much leaning that way. I don't in theory rule out the possibility of 'true trans' existing, but every case I know of has something else going on, whether it's fetishism, body dysmorphia, internalised homophobia/misogyny, autism or some combination of the above. I think to demonstrate the existence of 'true trans' you'd need at least one example where there aren't confounding factors, and I don't know of any.

In some ways it doesn't matter. I think Cass assumes (at least in principle) the existence of 'true trans', and Jesse Singal certainly does, and the value of their contribution is that, even coming from that standpoint, they give a strong empirical case for how weak the evidence base is.

I'd be really interested in early accounts of the idea of transition spreading. One book I read years ago, and keep meaning to revisit, is Rudolph Grey's Nightmare of Ecstasy. It's an oral history of the B-movie director Ed Wood, and was the basis for the very entertaining Tim Burton movie starring Johnny Depp, but the book has so much more in it.

Wood was a very odd character, but I feel that if he got into a time machine in the 1950s and came to the present day, we'd know him. From Grey's account he looks very much like an early AGP, a heterosexual crossdresser who moved a lot in gay circles (and seems to have been accepted by an underground gay culture that was a safe haven for transvestite fetishists), and who was fascinated to the point of obsession with Christine Jorgensen.

I feel that if he were alive today, Wood would almost certainly be asserting a trans identity, albeit Jorgensen was a classic case of transing the gay away and Wood looks like the other thing.

You can then see the idea of transition percolating through bits of gay and transvestite culture and gradually gathering steam. There's an oddly pivotal role played by Wood's friend, actor and drag queen Bunny Breckinridge (Bill Murray in the movie), who wanted to surgically transition and pursued it quite actively until life got in the way. Bunny somehow knew Gore Vidal, who borrowed his name for his 1968 novel Myra Breckinridge, which was the first big pop-culture treatment of transsexualism.

(Vidal hated the 1970 movie, but there's some camp fun to be had from it. You can tell it's a male fantasy because the transwoman is played by Raquel Welch.)

That all may seem like an eccentric detour for anyone who's not interested in schlocky B-movies from decades ago, but I'm really interested in exploring the cultural spaces where the idea of transition incubated. Very little of this appears in approved trans history, which for all its 'queer' radicalism really doesn't want to be associated with old-time camp and schlock.

@RedToothBrush you post with such clarity and I have learnt a lot from your posts.

The Cass review, and the Finland guidelines, are based on systematic reviews of evidence, differently from Wpath, American endocrinology society and American academy of pediatrics.
It's interesting to note that Wpath commissioned some systematic reviews to the John Hopkins, but then blocked their publication. The American academy of pediatrics commissioned a review one or two years ago, but that has not even been registered (a first step for a review of that type is the registration of search terms).

Systematic reviews have defined and standardized ways to rate the evidence and to combine the data from different sources.

Way back in the late 2000s I began to come to this conclusion, fairly early on.

My brother gave us information about being trans, from a trans charity. This dates back before the activism took over and in places it was very different in tone to what it became.

One of those things that jumped out at me was that the instance was 1 in 10,000 was trans. That figure was one that has rattled around my brain for nearly twenty years now. This would mean it would be extremely unlikely that you would know someone similar in your close social circle.

And yet another boy who was in the same class as my brother, and lived on the same street as us and we knew very well and were part of the same social circle and had already transitioned (I was friends with his sister). Not only that but it became apparent that there was a third boy in a different year group but was known to them that also transition.

The numbers didn't stack up with that 1 in 10000 stat and it was another of those key things that led me to questioning it all.

Your head flips to 'why'. Already it struck me as not being 'just the same as being Gay' very early for a number of different reasons, one of which was because it looked like a cluster rather than just spontaneous.

This bothered me, particularly when considering starting a family. There is the question over genetics and whether there's something in the family. But this wouldn't fully explain a cluster on its own. There would have to be a social element to why anyone predisposed genetically would end up in the same area and all know each other.

Then there's environmental. When it affects multi people on the same street, your mind wanders to the possibility that there's potential exposure to something or there's something in the water. Not knowing if that's a possibility is unnerving.

Remember I also had my own issues over very much resenting being a girl rather than a boy and having been told by my parents that we'd been born 'the wrong way round'.

But it's ultimately been the social element that's been the most unavoidable point.

Ultimately if there's some social element it best explains a cluster affect. It would pull certain groups together in terms of socio-economics and social groups. Or you have bubbles of social contagion. Or both.

I've thought a lot about the common themes between my family and this other family. There's a few things - both families are slightly odd, socially awkward and both had high achieving kids. I am now aware that my friends kids have been diagnosed as autistic and my son is diagnosed as ADHD and there's several members who are almost certain undiagnosed as autistic. This was something that way back when I didn't know or considered.

Then there's the element of both families being very rigid on gender stereotypes. My family, I wouldn't say were obviously homophobic but there's certainly things both my parents said and did in relation to concerns that my brother was 'not manly' enough and was too effeminate. The other family were more or less openly homophobic for reasons I won't go into and it had already caused issues within the family by the time the son transitioned.

When you start to add all these together, it starts to become increasingly difficult to dismiss as pure spontaneous coincidence. I don't believe in completely random coincidence as a general rule.

Then as you started to see the huge glaring cataclysm inconsistencies in logic, as the activism spiralled it has become much more obvious over the years how much of a role social contagion has played. The whole level of effort to create the cognitive dissonance between 'its not a mental health issue' and 'if you don't allow transition, people kill themselves' was quite the reach. It is simply not coherent as a position. This combined with my own experience with my brother and the level of active militancy and cultlike behaviour that was going on.

Significantly both families were early adopters of the internet at home and early online communities, fantasy and gaming.

Over the years as the links between social media bubbles, autism and homophobia have been more obvious, it's much easier to process and understand that why. There's far too many coincidences. It became apparent that those coincidences between the two families oddly was being replicated and they very much fitted into a very clear narrow demographic. One that's not possible if being trans is just spontaneous within the population.

The Cass Report ultimately has put this all down on paper in a coherent fashion - telling those caught up in it, what we already ultimately had witnessed. It wasn't unconscious bias - it's an independent scientific report saying what we'd observed on a bigger scale. And this report has gone against all the perceived wisdoms and that isn't an easy thing to dismantle. I've spent years trying to educate, take the emotional side out of it and be ultra rational and to question and requestion everything. It keeps revisiting the same key points and they are just unavoidable at this point. They aren't just an elephant in the room, there can be seen from outer space.

So many people have been so badly let down by the failure to critically think about this, it's scary. It is in itself indicative of its time.

So reporting in with the score at half time:

• Cass got off to a strong start with 8 papers in the BMJ's Disease in Childhood journal - 6 systematic reviews of the medical evidence, plus 2 of international clinical guidelines.

• Just before the whistle AidaP attempted a fightback with 1 paper in the Journal of Gender Studies - although apparently unaware of the 8 goals already conceded.

Who knows what might happen in the second half?

Maybe Gender Studies' notoriously impenetrable peer review barrier might be starting to crumble, and the floodgates will opened.

Should have RTWT before saying "there are loads of peer reviewed articles resulting from the Cass Review".

It is a piece of research - systematic reviews are a kind of research. But don't worry, it has several spin off reviews that are in peer reviewed journals.

Thanks @Helleofabore ! What a great paper

It's a systematic review. Do you have an alternative systematic review or meta analysis to recommend, which includes risk of bias and study quality?
Or do you not know what those terms mean, rather like Jack Turban?

On that aspect of coaching this paper is well worth a read.

journals.sagepub.com/doi/full/10.1177/26344041211010777

Published April 22, 2021
Kasia Kozlowska, Georgia McClure et al

Australian children and adolescents with gender dysphoria: Clinical presentations and challenges experienced by a multidisciplinary team and gender service

Part of the conclusion

Our findings indicate that engagement with families, a trauma-informed model of mental health care, and ongoing discourse pertaining to the effects of unresolved trauma and loss need to be part of all gender dysphoria clinics and the services with which they collaborate. Because of their impact on subjective well-being and the development of the self, specific loss and trauma events present crucial opportunities for both long-term psychotherapy and more immediate, targeted treatments. The move to a more comprehensive, holistic model of care—one that takes into account the individual’s developmental history and the experiences that make up that history—has also been echoed in the work of other clinician-researchers (D’Angelo, 2020a; Entwistle, 2019; Giovanardi et al., 2018; Kozlowska et al., 2021; Williamson, 2019).

Our study found that the children and families who came to the clinic had clear, preformed expectations: most often, children and families wanted a diagnosis of gender dysphoria to be provided or confirmed, together with referral to endocrinology services to pursue medical treatment of gender dysphoria. Parents (vs. children) also largely came with the same expectations, though they were more likely to be interested in incorporating holistic (biopsychosocial) elements, including treatment of mental health comorbidities, family support/therapy, and long-term psychotherapy for the child. It was our impression that these expectations had been shaped by the dominant sociopolitical discourse—the gender affirmative model. It will be interesting to track the expectations of children and families in the years to come as sociopolitical discourses become more varied and diverse and as the voices are heard of both those who have done well and those who not done well via the medical pathway.

Our study also found that despite the high rates of family conflict, relationship breakdowns, parental mental illness, and maltreatment (see Table 3)—and our own clinical perspective that both individual and family work were indicated for the majority of families—few families rated themselves as being in a clinically severe range on self-report (SCORE-15). Coupled with the dominant sociopolitical discourse—the gender affirmative model that prioritizes the medical treatment pathway—it is not surprising that the large majority of children and families were not motivated to engage in or to remain engaged in ongoing therapy. These data bring three important phenomena into focus. First, when children and families were given the space and structure to tell the child’s developmental story—nested in the story of the family—they were able to identify and provide a detailed narrative of the key issues that had contributed to the child’s presentation and distress. Without this space and structure, the issues remain undeclared and unaddressed. Second, some families—but also some clinicians—function within a non-holistic (non-biopsychosocial) framework where the child’s developmental experiences are disconnected from their clinical presentation. This non-holistic framework is likely to promote a healthcare delivery model that dehumanizes the child (by not examining the child’s and family’s lived experience) and that promotes medical solutions (correcting the identity/body mismatch) for a problem that is much more complex. Third, as noted earlier, our experience suggests that, insofar as the gender affirmative model is taken as equivalent to medical intervention, clinicians (including ourselves) who work in gender services are coming under increasing pressure to put aside their own holistic (biopsychosocial) model of care, and to compromise their own ethical standards, by engaging in a tick-the-box treatment process. Such an approach does not adequately address a broad range of psychological, family, and social issues and puts patients at risk of adverse future outcomes and clinicians at risk of future legal action.

Absolutely. You see it all over Reddit and the like, where kids are coached to make claims to their clinical team in order to get blockers or hormones or surgery.

They know the diagnostic criteria, know the triggers for referral, and just say it.

I know Aida’s thoughts on this are amusing but equally is this what trans reddit/other TRA communities think? that Dr Cass just took it upon herself to do this

also as we know TRA include a large number of ppl with IT knowledge/skills, theyre clearly all over SEO because when you Google the Cass review the first thing that comes up is transactual comment piece on it

The several systematic reviews commissioned by Dr Cass and peer reviewed are published here:
https://adc.bmj.com/pages/gender-identity-service-series

Here are international reviews that all indicated that there was low quality evidence that medical treatments for children are improving those children’s lives. Which was the finding of the Cass report:

NICE finding

arms.nice.org.uk/resources/hub/1070905/attachment

The summary of the conclusion is

Conclusion

The results of the studies that reported impact on the critical outcomes of gender dysphoria and mental health (depression, anger and anxiety), and the important outcomes of body image and psychosocial impact (global and psychosocial functioning), in children and adolescents with gender dysphoria are of very low certainty using modified GRADE. They suggest little change with GnRH analogues from baseline to follow-up.

Canada

https://nationalpost.com/news/canada/transgender-treatments-for-kids
https://archive.ph/fLMxA

"The Canadian team combed the available evidence, pooling the results of research on puberty blockers and gender affirming hormones for children and youth up to age 26. They graded the evidence using a scoring system co-developed by Dr. Gordon Guyatt, a celebrated McMaster scientist who coined the phrase evidence-based medicine.

Article content

After screening 6,736 titles and abstracts involving puberty blockers, only 10 studies were included in their review. While children who received puberty blockers compared to those who don’t score higher on “global function” — quality of life, and general physical and psychological wellbeing — the evidence was of “very low certainty.” Very low, meaning researchers have “very little confidence in the effect estimate” and that the true effect “is likely to be substantially different from the estimate of effect.”

The studies also provided low certainty of evidence on the impact of puberty blockers on depression. While they may decrease depression in “male-to-female participants,” they didn’t decrease depression scores in the female-to-male group. “We are very uncertain about the causal effect of the (drugs) on depression,” the researchers wrote.

“Most studies provided very low certainty of evidence about the outcomes of interest thus, we cannot exclude the possibility of benefit or harm,” they said."

Here are the studies referenced in the article from McMaster University

https://adc.bmj.com/content/archdischild/early/2025/01/24/archdischild-2024-327909.full.pdf

And

https://adc.bmj.com/content/archdischild/early/2025/01/24/archdischild-2024-327921.full.pdf

New Zealand

https://www.health.govt.nz/news/additional-safeguards-for-puberty-blockers

Publication date: 21 November 2024
The Ministry of Health is today releasing an evidence brief and position statement on the use of puberty blockers for gender identity issues and outlining a more cautious approach to their use.
The evidence brief shows a lack of good quality evidence to back the effectiveness and safety of puberty blockers when used for this purpose.

France

The latest from National Academy of Medicine, France. They have issued a press release about treatment for gender disphoria in children and adolescents.

SEGM have translated it, but also linked up the original version.

segm.org/France-cautions-regarding-puberty-blockers-and-cross-sex-hormones-for-youth

Sweden

http://genderreport.ca/the-swedish-u-turn-on-gender-transitioning/

I could also find and link up the same findings for Finland, Norway, Denmark and I believe Germany if I found them. All had teams, iirc, who made the same statement about low quality of evidence as the Cass Report.

I believe there must come a time when it has to be admitted that if a slew of independent country’s teams all found the same low quality of evidence as Dr Hilary Cass, that anyone declaring Cass debunked is just deliberately spreading falsehoods.

It was published in the Journal of Gender Studies, not a scientific journal. Peer review isn’t the scientific process.

You appear to be very, very confused about academic research and what science and the scientific process are.

The suicide myth seems to have appeared at around the same time as the invention of "trans children".

It seems they had to up the ante a bit when they started to promote the idea that children could be transsexual. If you're going to suggest that children are a part of a sexually motivated movement you've got to have a pretty good reason for doing so.

Readers Note:

It was admitted under oath in Skrmetti in the Supreme Court by ACLU lawyer Strangio that suicides are thankfully rare in young people with transgender identities.

https://x.com/leorsapir/status/1864793635406963173?s=46

So, posters describing medical treatments as ‘life saving’ are spreading harmful and dangerous misinformation.

I was wondering if I should make a new thread for this but I'll put it here cause it kind of fits.
"In 2022, it emerged that a senior consultant at the centre had admitted that its treatments were not backed by “robust evidence” and that they largely relied on self-diagnosis, with clinicians “basically just going on what they [the patient] tell you”."
It's almost as if the self-indulgent gibberish they publish in The Journal of Gender Studies and similar publications is of absolutely no use to clinicians in addressing their patients' issues.

https://www.thetimes.com/article/d73ec83b-71ed-4b8f-ba8b-6c046eff5900?shareToken=40facafce102e49f3e476f76ce3f6297