The toxicity of the culture war over youth gender medicine is well known to most of us. What’s less well understood is how that poisonous climate affects the very cohort being argued about — and those who care for them.
An exhaustive, level-headed 388-page report, commissioned by the National Health Service in England and released last week, warns: “Polarisation and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse.”
The Cass Review, led by Dr. Hilary Cass, examines the events and evidence (or lack thereof) that led to the closing of the UK’s only public youth gender clinic, the Gender Identity Development Services. GIDS opened in 1989 and at first served only 10 clients per year, mostly males who received psychological therapy; few medically transitioned. By 2016, GIDS was seeing nearly 1,800 clients a year, and multiple concerned clinicians there were blowing the whistle about the poor quality of the care. For years, their complaints mostly fell on deaf ears.
This document allows them to be heard. It is exceptional in many ways, including its scope. Cass spoke to many different and competing stakeholders, including disagreeing clinicians, “transgender adults who are leading positive and successful lives,” and “people who have detransitioned, some of whom deeply regret their earlier decisions.”
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Cass reaches back into the history of youth gender medicine, formalized in the late 1990s in the Netherlands. She observes that the entire practice is “based on a single Dutch study which suggested that puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence.”
Recent scrutiny of the Dutch research revealed that the methodology was too flawed to support that conclusion. The Dutch approach involved something different from what has become the norm in the United States and was the norm at GIDS for a time. The Dutch doctors and psychologists offered youths extensive evaluation over long periods of time, discouraged social transition before puberty, and limited interventions to a carefully selected cohort who’d suffered from lifelong gender dysphoria, didn’t have other serious mental health issues, and lived in supportive families.
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In America, this approach became denigrated as “gatekeeping,” and we veered toward a model known as “affirming.” We shifted from treating gender dysphoria to affirming a trans identity, letting a child’s feelings lead the way, and allowing social transition at any age. Here, manifesting one’s gender identity separate from natal sex was eventually seen as a civil right, rather than as a series of psychological and medical interventions — a model that influenced GIDS. But science doesn’t work that way. “Although some think the clinical approach should be based on a social justice model,” writes Cass, the National Health Service “works in an evidence-based way.”
That social justice / civil rights framing has made it harder to reckon with what Cass calls the “exponential rise” in adolescent patients starting around 2014, and a reversal in the sex ratio. Once it was mostly natal males who transitioned, but now it is mostly natal females, many of whom had no history of gender distress but did suffer from other mental health issues.
As for the evidence about how to treat these patients and others who have sought care, Cass concludes: “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.” Individual studies may make claims about the efficacy of social transition, puberty blockers, or hormones, but they are too biased and low quality to draw conclusions from.
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The National Health Service had already recently declared that puberty blockers would no longer be used for young people with gender dysphoria, “because there is not enough evidence of safety and clinical effectiveness.” The Cass Review confirms this, noting that “bone density is compromised during puberty suppression” and that doctors don’t know enough about the effects on “psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk, or fertility.” No evidence proved that blockers provided “time to think,” as many proponents of affirmation claim, but there is “concern that they may change the trajectory of psychosexual and gender identity development.”
As for the claim that these interventions prevent suicide, Cass reports that “the evidence found did not support this conclusion.”
Perhaps most important, Cass notes that “clinicians have told us they are unable to determine with any certainty which children and young people will go on to have an enduring trans identity.” That is, in contrast to the affirmative model’s claim that “children know themselves,” the few high-quality studies we have suggest that gender dysphoria in kids most often resolves during puberty, as they develop and mature and gain a deeper understanding of the interplay between gender and sexuality. Many grow up to be gay.
These findings fly in the face of claims by activist groups that the science is settled and that gender-affirming care is “evidence-based” and “lifesaving.” But the findings also don’t negate the fact that some young people are deeply grateful to have transitioned.
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Cass isn’t calling for a complete ban on youth gender interventions, like the bans many Republican states have enacted. Nor is she arguing for removing barriers to these interventions and making them more accessible without parental knowledge or consent, as many Democrats advocate. Her recommendation is to expand services but root them in holistic psychological care, making sure all other mental health issues are attended to. She is suggesting the end of the specialized gender clinic model, where gender dysphoria is viewed as the root of all distress.
Without that broader approach to treatment, she says, directly addressing the thousands of youths distressed about their gender, “you are not getting the wider support you need in managing any mental health problems, arranging fertility preservation, getting help with any challenges relating to neurodiversity, or even getting counselling to work through questions and issues you may have.”
The Cass Review offers 32 recommendations, including exercising “extreme caution” when prescribing cross-sex hormones to those 16 and younger and having provisions for people considering detransition. Cass calls for long-term follow-up of those who have transitioned or sought care and a commitment to lifelong care for both those who transition and those who detransition. In contrast, Democrats have blocked attempts to pass detransition care bills and amendments that would require insurers to cover reconstructive surgeries, hormone treatments, and other assistance for detransitioners who want to live as their natal sex again, in whatever way is possible after permanent changes. Detransitioners are often left with nowhere to go to attend to their bodies or their minds — as the case used to be for trans people (and may be the case again).
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Increasingly, some providers are so intimidated by the noise around this issue that they don’t want to attend to kids with gender issues at all. But these young people, as Cass says, “must have the same standards of care as everyone else.”
In America, the main problem with the issue of how best to treat kids with gender distress is that it has become intertwined with politics. Some who object to the affirmative model or question it fear the personal and professional repercussions of being cast as a bigot. Some who support the affirmative model in red states that are criminalizing the care fear being jailed. “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour,” Cass writes. “This must stop.”
As someone writing a book about the youth gender culture war, I couldn’t agree more. Polarization, the stifling of debate, and invective-flinging have left many families ill informed, making decisions in the dark and often based on fears of suicide that are unsupported by evidence. How can there truly be informed consent when there is so little unambiguous information, when there are more unknowns than knowns? And what do we do in the face of uncertainty? Argue and legislate, or gather data? It doesn’t help when our federal government contributes to the faux certainty, declaring that gender-affirming care is “suicide prevention” or “well-established medical practice” — arguments the Cass Review eviscerates.
For much of Europe, our government’s digging in on these treatments rather than investigating them more fully is just another way America has gone astray. Countries such as Finland and Sweden have analyzed the evidence and crafted more cautious guidelines, with psychological support as the baseline intervention.
We, too, need new, evidence-based guidelines. We need follow-up from all youth who transitioned, those who detransitioned, and those who desisted — meaning they stopped identifying as transgender without medically transitioning. We need to speak with multiple and competing stakeholders, and we need Democrats and Republicans to listen to those who’ve been helped and those who’ve been hurt; we need bipartisanship, not polarization. We need to push past politics and create an environment where robust scientific debate is not only tolerated but celebrated.
The National Health Service itself applauded Cass’s work, writing that it “will not just shape the future of health care in this country for children and young people experiencing gender distress but will be of major international importance and significance.” Let’s use the report to call for a ceasefire in the American gender culture war. We need our own Cass Review.
Lisa Selin Davis is the author of “Housewife: Why Women Still Do It All and What to Do Instead.”