The Cass Review Into Gender Identity Services for Children - Part 3

Proving opponents of medical treatment for trans children wrong

Fun fact - if you misspell the word “trans” on a stock photo website, you are treated to a lot of delightful photos of railways. Photo by Kadir Celep on Unsplash

This is part 3 of my series looking at the Cass review into gender identity services for children in the UK. You can find the other parts here (I will update as I add sections):

- Introduction

- Part One

- Part Two

- Part Three

- Part Four

- Part Five

- Part Six

- Part Seven

The Cass review into gender identity services for children has made a lot of waves due to the controversy over treating kids with hormones, and also the general discomfort that society has with any subject approaching gender. Nothing sparks controversy like what The Teens are up to these days.

If you look at the review, and the reporting on it, in detail, there’s something very strange. Despite the noise, there’s one huge take-home from the Cass review that appears to have been largely ignored. The review made many recommendations that have been celebrated by anti-treatment campaigners - people who lobby for governments to ban hormones and medications for trans youth - but oddly enough, it also proved them wrong.

Some of the main arguments AGAINST using hormones and medications for transgender children are contradicted by the Cass review. Barely anyone has noticed, because the review mentions this fact once in a single paragraph, and most of the data is relegated to Appendix 8.

Let’s dig in.

Treatment Is Too Quick

There are, broadly, two models of care that have been proposed for children with gender dysphoria. The traditional model, pioneered in the 60s and 70s, combines a mix of psychiatric and psychological therapy for children with the very occasional use of medications, mostly for older teens. This traditional model was used in clinics that covered the span of what could reasonably be called evidence-based practice to places that are now considered to be examples of conversion therapy.

The other main model is usually called Gender Affirming Care (GAC). Where the traditional model paints gender dysphoria as a condition in and of itself, GAC views dysphoria as simply a sign that an individual is unhappy with their gender, which is something that can be remedied. The process is less about “fixing” children, and more about acknowledging their gender choices and providing tools - psychological help, medication, etc - to assist with whatever decisions they want to make about their gender and life.

One of the biggest criticisms of GAC is that there is too much of a focus on medication. This is, in fact, where much of the controversy comes from. Kids aren’t just getting drugs, they’re getting them too quickly, too often, and without proper forethought. Many online commentators imply that GAC clinicians provide drugs to any child who has any gender confusion without so much as a psychological evaluation, or even basic mental health support.

As part of the Cass review, the team commissioned an epidemiological study looking at the treatment of trans kids in the UK. I’ve discussed this study before, in Part One. This study looked at the clinical records of children who attended UK gender clinics from 2009-2021. Among other things, they looked at two key questions:

1. How long did it take children, on average, to be referred to an endocrinologist who would then prescribe hormones/puberty blockers?

2. What proportion of children who attended the gender identity services were prescribed puberty blockers and/or hormones?

What the review found is quite shocking. In total, the study looked at 3,306 children, about 95% of the children who had ever used a gender service in their dataset. Of these kids, 27% received a referral to endocrinology services, of whom just over 81.5% received puberty blockers, hormones, or both. That means that of the 3,306 kids who went to gender services in the UK, about 730 (22%) received some form of medical treatment, and 2,576 had no medication prescribed for their transition/gender related care.

The number of appointments is also interesting. The chart the Cass review contains is below. On average, children had 6.7 appointments before being referred to endocrinology (the median is 6). The review notes that this was after waiting for years on the waitlist for an initial consultation. In addition, a referral to endocrinology was not instant, with further weeks and months on the waitlist to see an endocrinologist. Furthermore, as the review points out, many patients did not immediately get treatment when seen by the endocrinology team:

“the first intervention was not necessarily the first appointment, where treatment was recommended there were often a number of appointments required to determine the patients’ suitability for treatment (e.g., DEXA scans and blood tests prior to commencing puberty blocker treatment).” (page 9, Appendix 8)

Pictured: the distribution of the number of appointments before children were referred to endocrinology to possibly receive puberty blockers or hormones.

Now, it’s important to note that some of these numbers are a bit complex. For example, some children declined treatment entirely from the gender services. Other kids stopped engaging, and were lost to follow-up. If you exclude all of this type of patient, the proportion of kids referred to endocrinology jumps up a little bit, to 31%. In addition, some portion of the children were never referred to endocrinology because they “aged out” of the service - they hit 18 years of age, and were referred to an adult clinic instead.

Nevertheless, these figures completely contradict the narrative that children were ever getting medical assistance with transition too quickly. If anything, the medical services in the UK were far too slow to be useful. The report notes that a waiting time before the initial consultation of three years was not unusual, and that this was just the start of the journey. The median age that kids got puberty blockers was 15, which is perhaps not surprising when you consider that most children waited years after first expressing their gender concerns to even talk to a specialist who could prescribe the drugs. Perhaps that’s why in the sample of 3,306 children analyzed in the Cass review fewer than 21 (<0.5%) reported detransitioning - to even get to the first step of treatment, a patient had to be incredibly motivated to continue with their transition.

Moral Panic

What’s most remarkable about this finding is that it’s only noted in the review in one paragraph and Appendix 8. This is not a minor point - it’s a damning rebuttal of the reasons most commentators have given for banning medical treatments for transgender children.

Even worse is how the review treats this data. We know that very few kids got medications without numerous appointments, but we know little else. One of the central points that the Cass review makes is that trans children often have mental health issues and that these should be treated. The review implies that treating depression, anxiety, and other mental health issues can for some children resolve their gender dysphoria.

But the review doesn’t even look at their own data to look into this question. Did kids who went to gender clinics in the UK also see psychologists? Psychiatrists? What % of them, and for how long? If the % is large, what does that mean for the theory that being depressed/anxious/autistic can make children trans? What use is recommending psychological assistance if most trans children already see at least one mental health professional? Is it possible that the UK’s own data contradicts the theories proposed by the Cass review? We simply don’t know.

Instead of reviewing this data, the review simply notes that many children who were discharged without medical treatment from the gender identity clinics were referred to adult gender services, and that:

“Since it is common for people attending an adult GDC to receive masculinising/ feminising hormones, it is all the more critical to get follow-up data to better understand the outcomes for those who are referred to adult GDCs and those who are not.”

So, after not receiving medical treatment as children - something the review is concerned about - some portion of these people then went on to receive medications as adults. This is, of course, beyond the scope of the Cass review, but it’s also bizarre speculation. It’s not clear why the review is concerning itself with adult gender clinics, nor why it’s a problem if adults see specialists for transition-related care.

It seems that we can entirely dismiss the moral panic about children getting hormones and other drugs far too quickly. At least in the UK, this appears to be entirely untrue. It was incredibly rare for children to have fewer than 4 appointments before even being referred to see a specialist for assessment of whether drugs were the right choice, and as the review notes in most of these cases those children had already been prescribed puberty blockers by an external physician anyway.

What we can’t do is make any other statements about this patient population, because despite having access to clinical records, appointment information, and disease codes, the review doesn’t seem to have had any interest in these important questions. They’ve proven anti-treatment campaigners wrong, but there’s virtually no discussion of any of this in the document.

This should be a key point. A chapter of the review. “Common arguments against giving transgender children medications are wrong”. Instead, it’s a footnote. That raises all sorts of red flags. Why were these key findings shunted to an appendix and largely ignored?

The data in the Cass review proves many of the most vocal critics of transition-related care wrong. While there may be issues with how gender-affirming care was rolled out in the UK - subscribe if you’re interested in my pieces on that topic - it’s important to note that some of the main arguments used against GAC appear to be very simply incorrect.