England may be the third country to withdraw from a “gender-affirming” treatment pathway because of recommendations from a long-awaited report.
In April, the country published the Cass Review, the “most comprehensive summary on transgender-youth medicine,” psychologist Erica Anderson, who identifies as transgender and has a doctorate in clinical psychology, told The Epoch Times.
The review, chaired by Dr. Hilary Cass, British honorary physician, consultant in pediatric disability, and former president of the Royal College of Paediatrics and Child Health, stated that there is insufficient evidence to demonstrate the long-term benefits of medicalizing children who want to identify as a different gender. Instead, the review recommends focusing on psychotherapy.
For some clinicians and researchers, this recommendation was a long time coming. Others are concerned that it potentially threatens medicalization—currently the primary treatment—for gender-incongruent youths.
The National Health Service (NHS) England, which commissioned the report in 2020, stated that it would be committed to following through on the recommendations.
“[The Cass Review] final report will not just shape the future of healthcare in this country for children and young people experiencing gender distress but will be of major international importance and significance,” the statement read.
‘End of the Era’
The review team commissioned researchers at the University of York to conduct systematic reviews of these papers and get feedback by interviewing young gender-incongruent children, their parents, and clinicians.
The University of York disclosed that it interviewed 12 young people who were part of voluntary organizations or the UK’s Gender Identity Development Service (GIDS), along with 12 parents. The university researchers also interviewed clinicians at the UK’s gender identity clinics.
The review found insufficient and inconclusive evidence demonstrating the effectiveness and benefits of gender reassignment treatments for children. Additionally, many of these children are on the autism spectrum and share mental comorbidities often overshadowed by the medicalization model.
Dr. Cass hence advised cautionary psychological interventions while also leaving room for children to explore their identities.
The report also mentioned that while medicalization comprising puberty blockers, cross-sex hormones, and surgery, known as the “Dutch Protocol,” was invented in the Netherlands in the 1990s, the concept of “gender affirmation”—accepting children’s gender identity at face value—actually originated in the United States and then spread internationally.
As a result of the review, children under 18 in England will not be treated using such protocol but with the same level of care as other youths with mental health struggles. Finland and Sweden made similar changes in 2023.
Puberty blockers and hormones will only be made available to those 16 years old and older under the context of research-controlled conditions. Therefore, experimentation of such treatment on minors will be hindered.
Top Findings and Suggestions
The report found that, unexpectedly, most current influential guidelines have been determined based on board consensus instead of science.Most of the current guidelines were influenced by two American standards of care: the 2012 World Professional Association of Transgender Healthcare (WPATH) and the Endocrine Society 2009.
Both relied on a consensus process among professionals to decide on the best treatment for gender dysphoria and were built upon one another. WPATH members were co-sponsors of the Endocrine Society guidelines. WPATH’s 2012 standards of care adopted the Endocrine Society’s consensus-based recommendations but did not refer to WPATH’s own systematic review data, which found inconclusive evidence of the benefits of hormone therapy.
The recommendations from these guidelines were then referred to by subsequent guidelines, snowballing into what we now see.
The Cass Review is not about “rolling back on people’s rights to healthcare,” Dr. Cass wrote in the review’s foreword. “It is about what the healthcare approach should be.”
1. Psychotherapy Is Recommended
Effectiveness and risks: Due to low quality and poor reporting of interventions in transgender children, the review couldn’t form a proper conclusion about the effectiveness of psychotherapy.However, there is evidence that psychotherapy can help address mental health conditions, such as depression and anxiety, common among transgender youths, and hormone interventions often overshadow these therapies. The review highlighted that psychotherapy is not the same as conversion therapy, as it is not about changing a child’s perception of who they are but exploring the cause of their concerns and experiences and helping alleviate distress.
2. Partial Social Transitioning Is Preferred
Effectiveness and risks: The systematic reviews did not show clear evidence of the positive or negative effects social transitioning has on mental health. Social transition generally refers to a person making only social changes, including altering hair and clothing and changing names and pronouns, instead of medical changes to live as a different gender.The review noted that many children grow out of gender dysphoria by adulthood but that those who socially transition often medically transition, meaning that they continue to have gender dysphoria.
3. Hormonal Treatments Not Recommended Except Under Research Conditions
Effectiveness and risks: The review showed no significant improvements in gender dysphoria symptoms or body satisfaction from medicalization. While some reports showed short-term improvement in mood when patients began hormonal treatment, the magnitude of such improvement was small.Hormonal treatment, which refers to the use of puberty blockers and cross-sex hormones, is not recommended for minors due to the permanence of its effects. Children 16 or older may instead be enrolled in high-quality research studies on experimental treatments.
Evidence about the effects of puberty suppression on psychological well-being, cognitive and bone development, and cardio-metabolic risk or fertility was found to be inconsistent and insufficient.
Evidence also did not support the claim that hormonal treatment reduced the risk of suicide.
The report did not discuss recommendations and changes to guidelines on gender-reassignment surgeries since, unlike children in the United States, minors in the United Kingdom typically cannot undergo these.
A Sudden Shift
Since the mid-2010s, England’s Tavistock Centre, the only publicly funded gender-based clinic serving children in England, has seen a sudden acceleration of trans-identifying youths, with the majority having no typical indications of gender dysphoria. There has also been an increasing correlation between gender dysphoria and other mental comorbidities, including being on the autism spectrum, depression, anxiety, and adverse childhood experiences.
The same has been observed in the United States.
“We need to be very careful since we have so many autistic people wanting to change their sex,” said Dr. Levine, one of the first professionals to work with gender dysphoric and transgender children and adults.
“It is a repudiation of maleness or femaleness and we need to understand the motives for this.”
Dissent and Silence
The review has received highly divided responses.Medical associations that recommend medicalization have remained largely silent, with the most vocal dissidents being transgender advocates.
“There were quite a number of studies [among the 103] that were considered to be moderate quality, and those were all included in the analysis,” she said. “So nearly 60 percent of the studies were actually included in what’s called the synthesis.”
On the side of the quiet medical institutions, WPATH was the only major organization that released a media statement. However, the press release cannot be found on its website and was primarily spread through screenshots on social media platform X, formerly known as Twitter.
“The foundation of The Cass Report is rooted in the false premise that non-medical alternatives to care will result in less adolescent distress for most adolescents and is based on a lack of knowledge of and experience working with this patient population,” WPATH claimed.
A clinician with WPATH, who was one of the first to support youth with “gender-affirming” medical treatment in the United States, told The Epoch Times that she was sad and disappointed by WPATH’s response.
“I feel like they are stuck in the 2000s,” said the clinician, who requested not to be named. “They are still of the mindset that if someone experiences gender dysphoria, medical intervention should always be the first line of recommended treatment.”
When the first gender clinics began opening in the United States, most of the children she saw were extreme cases in which their gender dysphoria and mental health problems appeared to be clearly linked to the children’s gender incongruence. For the most part, these children improved when given medical treatment and after proper assessment.
However, the demographic of patients has since changed, and cases have become more complicated.
“I think that a lot of people are honestly not even looking at the document and studying it with a critical eye to determine if it’s something that we can take seriously,” she said.
Uncertain Future in the US
The Cass Review noted that the United States is the main force driving gender medicalization.Clinicians interviewed said it would be impossible for the United States to have something like the Cass Review since individual states make many health care decisions. In contrast, health care is centralized in the UK.
While national boards and clinician associations seem to support the gender-reassignment model on a consensus basis, 23 states have passed bills to ban hormonal treatment for children, though only 18 bills are currently in effect.
Despite political and governmental differences, patient demographics are very similar in the United States and the UK. Therefore, according to the WPATH clinician, the Cass Review should be relevant to the United States.
Nevertheless, owing to this divide, a fruitful discussion is difficult. Clinical and research psychologist Amy Tishelman, previously the director of clinical research at Boston Children’s Hospital’s Gender Multispecialty Service and lead author of WPATH’s Standard of Care 8 for children, said that clinicians and researchers with reservations about the state of transgender medicine in the United States may be reluctant to go public with their statement out of the fear that their words would be used to drive legislation they disagree with.
On the other hand, Dr. Paul McHugh, a distinguished service professor of psychiatry at Johns Hopkins University School of Medicine and a longtime critic of gender-reassignment medicine, believes that support and advocacy for gender-reassignment care have become somewhat of a social phenomenon or craze.
“America is prone to this,” he said. “We get very enthusiastic—run very high demonstrating that we’re freeing people from the bigotries and mistreatment that [we’ve] had.”
Owing to this, “people are having a knee-jerk reaction because if there’s anything that has even the smallest flavor of not being completely affirming of gender-questioning youth, it’s considered transphobic by some on one extreme,” the WPATH clinician added.
“Some people in the U.S. say things like, ‘Kids know who they are; just accept what they say about their gender,’” said psychologist Erica Anderson, who specializes in treating gender-confused youth. “One of my criticisms of some of my colleagues is that it seems like they forgot everything that they’ve learned before they started working on gender issues with young people.
“We need to do a proper evaluation, and we can’t dismiss all the other things that are going on with young people in service of attention to gender issues,” the psychologist said.
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