There’s Just Not Scientific Evidence That Gender Medicine for Teens Should Be Restricted
Reading Time: 8 minutesA controversial and lengthy scientific review isn’t totally wrong. But it contains several key flaws—and should definitely not be used as evidence to fuel bans., The evidence in the Cass Review simply doesn’t support bans on gender medicine.
The Cass Review into gender identity services in the U.K. has been a topic of much contention. If you believe the supporters of the review, it was a solid document that took a uniquely scientific approach to evaluating interventions like puberty blockers and hormones for children and found the evidence for them wanting. If you believe the review’s detractors, it was a biased political exercise that did nothing more than parrot anti-trans rhetoric in service of doing terrible things to transgender children.
I don’t agree with either of these positions, as an epidemiologist who fact-checks news about science. The review is complex, and contains both scientifically rigorous aspects and some really egregious oversights. People tend to want simple answers, but these rarely exist for such complex questions—and whether a new kind of medical care for children has more benefits than downsides is very complex.
The Cass Review, named for Hillary Cass, the pediatrician who conducted it, was commissioned after a court case (which eventually failed) raised fears about the gender services—which are clinics run to provide care for transgender and gender-diverse children—in the U.K. People were worried that clinicians were providing drugs like puberty blockers and hormones without the proper assessment, and that a rise in referrals meant that thousands of cisgender children would now be forced to live as adults with permanent body issues caused by inappropriate medications they’d been given as teens.
After four years and a very contentious interim report, the Cass Review came out. That was in the spring, but I think it’s worth continuing discuss it, because debates over care for trans kids aren’t going away any time soon. Twenty-four states in the U.S. have some kind of ban on such care. Former President Donald Trump has stoked fears around access to gender medicine by claiming that kids are undergoing surgeries at school (this is not true). After Taylor Swift endorsed Kamala Harris and Tim Walz, who has put protections in place around trans health care in Minnesota, she was labeled as an ‘extremist’ when it comes to gender.
Maybe you know that language is, well, kind of extreme. But maybe you also think that, given the Cass Review’s findings, parts of the U.S. are now, by continuing to offer medical care for trans kids, ignoring the science, as Pamela Paul suggested this summer in the New York Times.
The Cass Review, though, shouldn’t be used to restrict access to trans care for children. It’s simply too flawed to tell us whether interventions like puberty blockers and hormones are harmful, or that they don’t work.
At nearly 300 pages (before appendixes), it’s difficult to summarize quickly. It’s impossible to go over all of the details in one short piece. I have been writing a lengthy series looking at the review from a scientific standpoint, and even after 20,000 or so words, there is still more to cover.
But, broadly speaking, the review made five major points:
As complex as all this is, there are some things that are pretty easy to untangle. For example, the report does not convincingly show that there has been an ‘exponential increase’ in children with gender dysphoria in the U.K. attributable to some combination of social media, influencers, and mental health problems generally. It also ignores the most obvious explanation for the rise in referrals for gender identity services—a change in the diagnosis.
We know that making the criteria to fit a diagnosis broader will always result in more people getting that diagnosis. We have decades of evidence showing that this has happened for everything from high blood pressure to autism. In late 2013, the American Psychiatric Association changed the diagnosis in the Diagnostic and Statistical Manual of Mental Disorders from Gender Identity Disorder, a very strict and narrow definition, to the much broader Gender Dysphoria. At the same time, the Royal College of Psychiatrists in the U.K. released guidelines discussing this new diagnosis. The review never checks to see whether this might have caused the massive increase in the number of children being diagnosed. Given that 2014 and 2015 had the biggest single-year increases in the number of diagnoses and referrals to specialist clinics, it seems quite likely that the changing diagnostic criteria had a lot to do with the increase in numbers. The changing diagnostic criteria doesn’t have anything to do with social media or mental health, and it doesn’t mean that more kids will definitely get medical interventions. It just means that the main way we measure dysphoria—kids going to see medical professionals—becomes easier to access, and therefore the diagnosis becomes more common.
Further, the review takes a very hard stance on medications used to help children with gender issues. Puberty blockers are given so that kids can have time to think about whether they are trans before the irreversible changes of puberty take hold, and hormones are given to much older teens (usually 16-plus) who do want to permanently transition genders. The review effectively recommends a ban on all of these medications until more studies can be done, arguing that the evidence behind them is insufficient, and that they have potential harms that we haven’t fully investigated yet.
In doing so, the review’s authors obliquely recommend psychological therapies as the only choice for trans youth in the U.K. But the review found no evidence at all for these therapies. Much of the evidence generated for the Cass Review was done by York University through a series of systematic reviews, which are studies that aggregate all the evidence on a topic into one place. The York systematic review into psychosocial and psychological interventions did not find a single study that even looked at the question of whether psychological interventions can help with gender dysphoria. The study that the York team rated highest in this area was a case study of a single transgender teen—hardly the sort of evidence that you want to be basing clinical decisions on.
This is the sort of problem that the Cass Review is rife with. Evidence that supports gender-affirming care (like that for puberty blockers and hormones) is treated with enormous suspicion. It’s not just that more research should ideally be done—the recommendations read as if the findings from that future research are already known, and that those findings are very bad. Meanwhile, evidence that stands against such care is usually assumed to be fine, regardless of how weak it truly is. Large studies showing benefits for puberty blockers and hormones are mostly ignored because they are weak data (which is true—but it doesn’t mean they’re worthless). And yet, a single psychiatrist’s opinion is used to imply that pornography may be making young girls trans. The primary reason that the review gives for recommending a ban on puberty blockers is that these drugs may cause issues with psychosexual development, but the citation used to support this is an opinion piece describing a short series of laboratory experiments where rats and mice had their sexual organs removed. The Cass Review never discusses how or why this relates to human children.
There are many stark omissions in the review. For one thing, it never once discusses the potential harms of going through cisgender puberty for transgender children. The use of hormones and puberty blockers in the U.K. is described as inappropriate, despite the review’s own data showing that only a small proportion of children who were referred to clinics ever got these drugs.
This is just a brief look at the scientific issues with the Cass Review. I have written more extensively elsewhere with criticisms of the review, as have others. But the point is that there are quite a few serious errors in analysis, and omissions. And yet, the document is now one of the main pieces of evidence being used by right-wing groups in the U.S. and elsewhere to deny treatment to trans children and adults.
Possibly the worst thing about all this is that one of the key takeaways of data in the review might be that gender medicine in the U.K. was actually very conservative. There was no apparent mass inappropriate prescription of puberty blockers and hormones to children—instead, according to the Cass Review, the average child had more than six appointments with the clinics before even being referred for assessment to see if they could get these drugs. On average it took more than five years from when a child was initially referred to when they were approved to take the medications, and nearly six years until they started them. The data tells a story of careful, reasonable care, in stark counterpoint to the fears of culture warriors online.
A very interesting counterpoint to the Cass Review has recently come out of the Australian state of Queensland. The state commissioned an independent review into their gender services, similar to the U.K.’s. This review basically accepted all the conclusions of the Cass Review that related to service provision and research—that is, service happens on a relatively slow timeline, and the research supporting it is somewhat weak—but none of the ones that related to banning medications and health care services. Instead of shuttering services and banning drugs, the state has made no change to medication prescriptions and has actually doubled the funding to their clinics, increasing clinics in rural areas. That kind of extra support could help kids get more help figuring out what the best option for them would be.
It is important to note that the review didn’t get everything wrong, and that some of the criticisms of it are just incorrect. There was a viral myth that the authors had dismissed 98 percent of the evidence in their report based on a misreading that too many people repeated without question. The review was not perfect, but neither did the authors simply discard most of the data on gender identity out of hand.
The evidence for puberty blockers and hormones is undoubtedly weaker than the evidence we use for most other medical procedures. A common argument against the Cass Review is that the evidence supporting antidepressants for kids is terrible, but even then, we have dozens of fairly good trials looking into the question. The question about antidepressants is more about whether those good trials show enough of a benefit to use the drugs, not whether they have any benefit at all. For puberty blockers, we have studies that simply do not provide us with good information about the questions we want answered. But the important thing to remember here is that bad data leaves us not with knowledge of the best thing to do, but with uncertainty. It seems that whether you think the data supports medical transition or not depends on whether you think medical transition is a positive outcome in the first place.
The point is that the Cass Review’s most contentious recommendations are not scientific—they are opinions. The authors believe, without evidence, that puberty blockers are so harmful that transgender children should never have access to them (there is no ban for cisgender children). Hormones are similarly mysteriously problematic. According to the review, even social transition is potentially more harmful than it is helpful.
None of these opinions are based on hard facts. The key scientific finding of most of the review was that we are uncertain about treatments, but that’s true of half of medicine, if to varying degrees. In most cases, we deal with uncertainty by recommending less intensive stuff first, and then moving on to more potentially harmful things later, informing patients of the risks along the way. In the case of psychological treatments and medications for depression in children and adolescents, the guidelines generally recommend first trying the psychological therapies we know have a clearer benefit, then moving on to medicines if those don’t work. The Cass Review could have recommended a similar approach to gender medicine, but instead went with one that has instead been held up to support outright bans on services for transgender children.
While there are some useful findings from the review, the main conclusion seems to be that it is a document rife with issues. It is not a reasonable justification for restrictions on care. It is extremely worrying that it will now be used to define the course of children’s lives.
Reference: https://slate.com/technology/2024/10/cass-review-uk-gender-medicine-bans-teens.html
Ref: slate
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