April 12, 2024
Most readers have probably heard that the Cass Review’s final report is out. You can read it here. For context, the “Independent Review of Gender Identity Services for Children and Young People” (the “Cass Review”) was commissioned in 2020 by NHS England. It was led by Dr. Hilary Cass, a retired consultant pediatrician and former president of the Royal College of Paediatrics and Child Health. Dr. Cass published an interim report in February 2022.
These are the key points from the interim report:
The rapid increase in the number of children requiring support and the complex case-mix means that the current clinical model, with a single national provider, is not sustainable in the longer term.
We need to know more about the population being referred and outcomes. There has not been routine and consistent data collection, which means it is not possible to accurately track the outcomes and pathways that children and young people take through the service.
There is lack of consensus and open discussion about the nature of gender dysphoria and therefore about the appropriate clinical response.
Because the specialist service has evolved rapidly and organically in response to demand, the clinical approach and overall service design has not been subjected to some of the normal quality controls that are typically applied when new or innovative treatments are introduced.
The final report is even more damning in its evaluation of the use of puberty blockers and opposite-sex hormones in minors and young adults. Its overview of key findings notes that:
There is no simple explanation for the increase in the numbers of predominantly young people and young adults who have a trans or gender diverse identity, but there is broad agreement that it is a result of a complex interplay between biological, psychological and social factors. This balance of factors will be different in each individual.
There are conflicting views about the clinical approach, with expectations of care at times being far from usual clinical practice. This has made some clinicians fearful of working with gender-questioning young people, despite their presentation being similar to many children and young people presenting to other NHS services.
An appraisal of international guidelines for care and treatment of children and young people with gender incongruence found that that no single guideline could be applied in its entirety to the NHS in England.
While a considerable amount of research has been published in this field, systematic evidence reviews demonstrated the poor quality of the published studies, meaning there is not a reliable evidence base upon which to make clinical decisions, or for children and their families to make informed choices.
The strengths and weaknesses of the evidence base on the care of children and young people are often misrepresented and overstated, both in scientific publications and social debate.
The controversy surrounding the use of medical treatments has taken focus away from what the individualised care and treatment is intended to achieve for individuals seeking support from NHS gender services.
The rationale for early puberty suppression remains unclear, with weak evidence regarding the impact on gender dysphoria, mental or psychosocial health. The effect on cognitive and psychosexual development remains unknown.
The use of masculinising / feminising hormones in those under the age of 18 also presents many unknowns, despite their longstanding use in the adult transgender population. The lack of long-term follow-up data on those commencing treatment at an earlier age means we have inadequate information about the range of outcomes for this group.
Clinicians are unable to determine with any certainty which children and young people will go on to have an enduring trans identity.
For most young people, a medical pathway will not be the best way to manage their gender-related distress. For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems.
Innovation is important if medicine is to move forward, but there must be a proportionate level of monitoring, oversight and regulation that does not stifle progress, while preventing creep of unproven approaches into clinical practice. Innovation must draw from and contribute to the evidence base.
The findings of the final report are generally being celebrated by those in the UK who think that sex is real and that it sometimes matters. The group Sex Matters (co-founded by Maya Forstater and Helen Joyce) says: “This is a breakthrough. It’s a huge step forward, with multiple implications that will be hugely consequential.” But the group also notes that there are areas where it could have been better.
Naturally, there has been virtually no coverage of this in the mainstream US media, even though minors and young adults continue to be prescribed these harmful hormones at exorbitant rates. A 2022 study conducted by Komodo Health Inc. and published by Reuters found that there are thousands of children in the US on puberty blockers and even more taking opposite-sex hormones.
The final report of the Cass Review is an important step. The UK NHS will no longer prescribe these harmful chemicals for minors and young adults, and the governing health authority has taken steps to ensure that private providers won’t do it either. It remains to be seen whether any of this will have an effect in the US. This post explores the importance and limits of this news for the broader effort to stop the abolition of sex.
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