The Cass Review - Intro
The biggest review into healthcare for transgender youth
This is the introduction to 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):
Two weeks ago, the biggest review into healthcare for transgender youth came out. The Cass review, named for the head of the project Dr Hilary Cass, a leading pediatrician in the UK, was tasked with looking into the question of why there was a large increase in the number of children attending NHS gender clinics for treatment. Basically, the government wanted to know why more kids were coming in saying that they felt like their birth registered gender was off, and what the best thing to do for these kids might be.
The review was, in a word, extensive. The actual process of conducting the review took nearly four years, with some interim findings coming out in 2022 but most of the results only just coming out in the final report. The report itself is 388 pages long, including 15 pages of references and numerous appendices, and discusses many hundreds of scientific papers. In addition, as part of the review, the UK government commissioned a series of studies from York university which included 8 systematic reviews, an online survey, and an epidemiological study of gender dysphoria in the UK.
In total, you could fill several books with all of this information. I think it’s fair to say that this is, in many ways, the most comprehensive review on gender-related care for children that has so far been conducted anywhere in the world. Broadly speaking, the review recommends that children do not get any medical assistance with transitioning genders - puberty blockers should be banned entirely, and hormone therapy should be largely reserved for adults. There is, it argues, too little evidence to use any of these therapies in kids, and therefore they should be mostly discontinued until we have run a series of randomized clinical trials to see if they are really as effective as advocates claim. This is all, unsurprisingly, very controversial.
Critics say that the review was biased, excluded a whole host of important research, and failed to engage with the very community it claims to serve. Proponents argue that the review has proven beyond any doubt that there is no evidence for hormones, puberty blockers, and the like, and that giving any medical assistance to children for transition is therefore entirely unethical.
I disagree with both of these arguments. The actual scientific studies that formed the basis of the Cass review - the systematic reviews in particular - were generally quite good. I cannot find any serious, discrediting problems with much of the data underlying the report. The argument that the review is completely inadequate because it discarded all of the studies which were not randomized clinical trials is simply incorrect. There are notable strengths to the review, which are important to understand before ignoring the findings entirely.
Conversely, there are clear errors in the review. Not only are there large conceptual gaps, there are numeric and scientific mistakes that call into question some of the key arguments made in the document. There are places where the authors have relied on extremely low-quality science to make expansive pronouncements, and other places where more high-quality research is almost entirely ignored. In addition, one of the main findings of the review is that the central belief of many opponents to medical care for trans children - that kids are getting hormones and puberty blockers with no assessment in staggering numbers - is simply false. Somehow, this finding has barely been touched on in the report, even though it is a pretty important finding.
In short, pretty much everyone I have seen commenting on the Cass review is to some extent wrong. It’s a bit depressing, really - people who oppose any medical care for transgender individuals have taken up the review as a perfect document with no flaws, while those who object to the findings seem intent on promoting untrue claims about perceived weaknesses in the report.
All of this complexity is far too much to fit into a single article. I could try, but you’d all get bored and stop reading halfway through. This is the internet, after all. So I’m going to be writing a series of pieces looking at the Cass review - the good, the bad, and the serious scientific concerns that may undermine the findings and recommendations.
As ever, I’m not a particularly useful voice in this conversation. I’m a cis man who has no major stake in the game. I’m an expert in scientific evidence and epidemiology, but that doesn’t make me special. I can’t speak to the ideological arguments, the general vibe, or how all of this data is going to be used. All I can do - all I ever really do - is discuss the scientific merits of the arguments involved, and whether the evidence really supports the contentious conclusions.