Cass Review does not guide care for trans young people

Abstract

The Independent review of gender identity services for children and young people, or Cass Review¹ (the Review), was commissioned by England's National Health Service (NHS) following increased referrals to the NHS Gender Identity Development Service (GIDS), criticisms of GIDS, and the Bell v Tavistock case involving one young person who regretted gender-affirming medical treatment (GAMT).² The Review's April 2024 final report recommended that puberty suppression with gonadotrophin-releasing hormone analogues (GnRHa) should only be available to transgender (trans) adolescents in a clinical trial, which has not commenced. The United Kingdom Government subsequently prohibited the supply of GnRHa as GAMT for minors,³ making it unlawful for trans adolescents to commence GnRHa treatment. Other Review recommendations restrict the provision of oestrogen and testosterone for individuals over the age of 16 years, and conceptualise social affirmation of trans children as a potentially harmful intervention.¹

Worldwide, the Review has received criticism from expert professional organisations^4-7 and in the peer-reviewed literature^8-12 for its disregard of international expert consensus,¹³ methodological problems, and conceptual errors. UK trans community advocates have raised issues of justice and human rights.¹⁴ The UK Government cited the Review in guidance empowering schools to misgender trans students and breach their confidentiality.¹⁵ In response, the Royal College of Paediatrics and Child Health stated that this disregarded Gillick competence, contradicted guidance from the National Institute for Health and Care Excellence (NICE) to use chosen name and pronouns,¹⁶ and placed young people at risk of abuse.¹⁵

The Cass Review's internal contradictions are striking. It acknowledged that some trans young people benefit from puberty suppression, but its recommendations have made this currently inaccessible to all. It found no evidence that psychological treatments improve gender dysphoria, yet recommended expanding their provision. It found that NHS provision of GAMT (GnRHa, oestrogen or testosterone) was already very restricted, and that young people were distressed by lack of access to treatment,¹ yet it recommended increased barriers to oestrogen and testosterone for any trans adolescents aged under 18 years. It dismissed the evidence of benefit from GAMT as “weak”, but emphasised speculative harms based on weaker evidence. The harms of withholding GAMT were not evaluated. The Review disregarded studies observing that adolescents who requested but were unable to access GAMT had poorer mental health compared with those who could access GAMT.^17-21 Despite finding that detransition and regret appear uncommon,¹ the Review's recommendations appear to have the goal of preventing regret at any cost.

The Review, and the UK Government, have taken the position that GAMT, an established treatment with observational evidence of early and medium term benefits and acceptable safety,²² should be actively withheld from trans adolescents due to lack of high certainty evidence of very long term efficacy and safety. Few treatments for any condition meet this criterion, and it is difficult to name another field in which regulators impose such a benchmark.²³ Much health care in other areas of medicine is guided by evidence of similar or lesser strength.²³

In Australia, gender-affirming care for trans young people is recognised as best practice,²⁴ despite some vocal opposition. The National Health and Medical Research Council is currently reviewing the Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents²⁵ and developing updated guidelines. The conceptualisation of gender diversity which informs gender-affirming care is summarised in the Box.

The gender-affirming model of care⁵⁸ is highly acceptable to young people and families,³⁸ and quickly superseded previous unsuccessful efforts to repress gender-diverse identity.^{22, 59} Gender-affirming care recognises that each person should be supported to live in the gender that is most authentic to them; trans, gender-diverse and non-binary individuals are accepted as they are.²² This involves listening to the young person. Gender-affirming care includes support for the young person's requests for social affirmation (eg, chosen name, pronouns, school accommodations, documents).¹³ Gender-affirming care can also include the option of GAMT (puberty suppression, oestrogen, testosterone) for the minority who need and request it.¹³ Gender-affirming care, as described in authoritative guidelines,^{13, 25, 60} is person- and family-centred, holistic, multidisciplinary, and ethically sound.⁶¹

Responding to patient need, public paediatric gender-affirming services have developed in all Australian states. Gender-affirming care providers include general practitioners, private specialists and community allied health providers, particularly in regional and remote settings.¹³

Best practice gender-affirming care involves comprehensive multidisciplinary biopsychosocial assessment before any GAMT.^{13, 25} Coexisting conditions such as depression, anxiety, eating disorders, autism and attention deficit hyperactivity disorder (ADHD) can be addressed as needed alongside gender-affirming care.¹³ Family, school and community acceptance are supported.²⁵ Social affirmation steps are personal and family decisions, not clinical interventions.¹³

GAMT is not used before the start of puberty.¹³ Although only a minority of trans adolescents commence any GAMT,⁶² some experience it as essential, even life-saving.⁵⁷ The risks and benefits of a treatment are weighed up against the risks and benefits of not having, or delaying, the treatment; and alternatives are discussed.¹³ Frank discussion of treatment effects (irreversible and reversible), risks, fertility implications, unknowns, and the possibility of regret⁴¹ are essential for informed consent. Treatment decisions are collaborative, between the young person, their parents or caregivers and clinicians.¹³

If eligible according to guidelines,^{13, 25, 60} largely reversible puberty suppression with GnRHa may be provided from Tanner stage 2–3. For adolescents who request GnRHa but are not yet Gillick-competent, parents can provide informed consent.⁶³ Partially irreversible sex hormone treatment (oestrogen, testosterone) may be provided to Gillick-competent older adolescents and young adults, whose identity and treatment wishes have been consistent for a long time.¹³ Legal requirements for consent differ between states. Gender-affirming genital surgery is not provided for minors in Australia.²⁵

Many of the Review's 32 recommendations align with current Australian best practice. For example, there is consensus that care should be individualised, family-centred, medical-led and multidisciplinary, and it should ensure treatment of coexisting conditions; that GAMT should be provided with a clear rationale and informed consent; and that fertility impacts should be addressed.^{1, 13, 25} However, other Review recommendations are incompatible with person-centred care and unsubstantiated by evidence.

The Review described social transition (social affirmation) as an “active intervention” which is “a cause of concern for many people”, despite acknowledging the observational longitudinal and cross-sectional evidence of good mental health outcomes in children and adolescents supported to socially affirm their gender.^{55, 58, 64, 65} The child's wish to express their gender identity is incorrectly framed as a clinical problem.⁶⁶ Disturbingly, the Review speculatively conceptualised the continuation of trans identity into adulthood as a potential harm of social transition.^{1, 67} It ignored the profound distress, family conflict and school refusal that often occur when a trans child's insistently expressed identity is not respected.⁶⁷ The Review recommended that families considering social transition for prepubertal children should be “seen as early as possible by a clinical professional with relevant experience”, raising concerns that families could be exposed to repressive or conversion practices.

The Review recommended that puberty suppression for trans young people should only occur in a research trial of unspecified methodology, without discussing the questionable ethics of compulsory research,⁶⁸ the impossibility of blinding due to obvious GAMT effects, or the harms of allocation to a non-treatment group.⁶⁹ Although research-only provision of GnRHa was signalled in the Review's Interim Report in 2022,⁷⁰ no such trial has commenced to date.

The Review recommended that oestrogen and testosterone for trans 16- and 17-year-olds should be prescribed only with “extreme caution”, after approval by a “national multidisciplinary team”. The Review's audit of the NHS paediatric gender service found that of 3306 patients, after long waiting times, only 22% were prescribed any GAMT following assessment,¹ indicating that hormonal treatments were already restricted to a minority of patients. The rationale for increasing restrictions is unclear.

A Cass Review-commissioned systematic review⁷¹ identified only ten studies analysing psychosocial interventions for young people “experiencing gender dysphoria or incongruence”, none of which reported on relief of gender dysphoria. Nine were rated low quality. One small study with only eight trans participants, was rated moderate quality. The Review concluded that there was a “lack of evidence” for psychosocial treatments in this patient population. Despite this finding, the Review recommended the expansion of “psychological and psychosocial interventions” for young people referred to gender services, while withholding GAMT.¹

Paradoxically, although the Review advocated for individualised care, its blanket recommendations, and their consequences in UK trans health care provision to date, prevent the exercise of patient choice, parental responsibility, and clinical judgement.

Good medicine is guided by the values of the patient, not those of a clinician, politician or commentator.⁹⁹ A patient's goal of achieving optimal quality of life as a trans person requires respect.³⁸

A body of short and medium term observational quantitative and qualitative evidence informs paediatric gender-affirming care and GAMT.²² Further research in paediatric trans populations must be co-designed and ethically conducted.^{68, 78}

The Cass Review, lacking expertise and compromised by implicit stigma and misinformation, does not give credible evidence-based guidance. We are gravely concerned about its impact on the wellbeing of trans and gender-diverse people.

Open access publishing facilitated by The University of Melbourne, as part of the Wiley – The University of Melbourne agreement via the Council of Australian University Librarians.

We acknowledge the positionality of the authors and the other acknowledged contributors as an important consideration in shaping our approach to this topic. Some authors and acknowledged contributors are health professionals working in gender-affirming health care for transgender (trans) young people, and in other fields. Some authors and acknowledged contributors are research professionals in the area of trans health, and in other fields. Their professional backgrounds include adolescent medicine, clinical ethics, endocrinology, epidemiology, general practice, infant mental health, medical genetics, paediatrics, population health, psychiatry, psychology, sexual health, and speech pathology. Many of the authors and other acknowledged contributors are investigators of the Australian Research Consortium for Trans Youth and Children. In relation to identities and experiences, some are trans, gender-diverse and non-binary, and some are cisgender (not trans); some are queer and some are straight. The authors and acknowledged contributors are from a range of cultural and language backgrounds; some are early career and some are senior. This project is motivated by the research team's commitment to promoting respectful, person-centred and evidence-informed health care for trans and gender-diverse people of all ages.

Julia Moore is on the Policy Committee of the Australian Professional Association for Trans Health (AusPATH), is a member of the World Professional Association for Transgender Health (WPATH) and the International Society for Sexual Medicine, is an investigator of the Australian Research Consortium for Trans Youth and Children (ARCTYC), and is a Fellow of the Royal Australian and New Zealand College of Psychiatrists (RANZCP). Cate Rayner is a member of AusPATH, WPATH and the Australian Association of Adolescent Health (AAAH), is an investigator of ARCTYC, and is a Fellow of the Royal Australasian College of Physicians (RACP). S Rachel Skinner is a member of WPATH, AusPATH and AAAH, is an investigator of ARCTYC, and is a RACP Fellow. Katie Wynne is an Executive Board Member of AusPATH, a member of WPATH, is an investigator of ARCTYC, and is a Fellow of the RACP and of the Royal College of Physicians (London). Blake Cavve is a member of AusPATH and WPATH, and is an investigator of ARCTYC. Brodie Fraser is a member of the Aotearoa Trans Health Research Network, and is on the editorial review board of the International Journal of Qualitative Methods. Uma Ganti is a RACP Fellow. Claire McAllister is a member of AusPATH and a RANZCP Fellow. Gideon Meyerowitz-Katz is a volunteer on the committee of Australian Skeptics. Tram Nguyen is a Member of AusPATH, is an investigator of ARCTYC, and is a RANZCP Fellow. Anja Ravine is a member of AusPATH and WPATH, is an investigator of ARCTYC, and is a RACP Fellow. Brian Ross is a RANZCP Fellow. Darren Russell is a Board Member of AusPATH, a member of WPATH, is an investigator of ARCTYC, a Fellow of the Australasian Chapter of Sexual Health Medicine of the RACP, and a Fellow of the Royal Australian College of General Practitioners. Liz Saunders is a member of AusPATH and a member of the Australian Psychological Society. Aris Siafarikas is a RACP Fellow, is an investigator of ARCTYC, and is on the editorial board of the journal Nutrients. Ken Pang is a member of AusPATH and WPATH, is a Primary Chief Investigator of ARCTYC, a RACP Fellow, and is an associate editor of the journal Transgender Health.

Not commissioned; externally peer reviewed.

Moore JK: Conceptualization, investigation, writing – original draft, writing – review and editing. Rayner C: Conceptualization, investigation, writing – original draft, writing – review and editing. Skinner SR: Conceptualization, investigation, writing – original draft, writing – review and editing. Wynne K: Investigation, writing – original draft, writing – review and editing. Cavve BS: Investigation, writing – original draft, writing – review and editing. Fraser B: Investigation, writing – original draft, writing – review and editing. Ganti U: Conceptualization, writing – review and editing. McAllister C: Writing – review and editing. Meyerowitz-Katz G: Conceptualization, investigation, writing – review and editing. Nguyen T: Writing – review and editing. Ravine A: Conceptualization, investigation, writing – review and editing. Ross B: Conceptualization, writing – review and editing. Russell DB: Writing – original draft, writing – review and editing. Saunders LA: Conceptualization, writing – review and editing. Siafarikas A: Conceptualization, writing – review and editing. Pang KC: Conceptualization, investigation, writing – original draft, writing – review and editing.