England may be the third country to withdraw from a “gender-affirming” treatment pathway due to recommendations from a long-awaited report.
In April, the country published the Cass Review, “most comprehensive summary on transgender-youth medicine,” psychologist Erica Anderson, who identifies as transgender and has a doctorate in clinical psychology, told The Epoch Times.
The review, chaired by Dr. Hilary Cass, British honorary physician, consultant in pediatric disability, and former president of the Royal College of Paediatrics and Child Health, stated that there is insufficient evidence to demonstrate the long-term benefits of medicalizing children who want to identify as a different gender. Instead, the review recommends focusing on psychotherapy.
For some clinicians and researchers, this recommendation was a long time coming. Others are concerned that it potentially threatens medicalization—currently the primary treatment—for gender-incongruent youths.
The National Health Service (NHS) England, which commissioned the report in 2020, stated it would be committed to following through on the recommendations.
“[The Cass Review] final report will not just shape the future of healthcare in this country for children and young people experiencing gender distress but will be of major international importance and significance,” the statement read.
Eight days after the Cass Review’s release, Scotland’s health boards announced a pause on new prescriptions for puberty blockers and cross-sex hormones as they gather evidence to support the safety and clinical effectiveness of these medications.
‘End of the Era’
The Cass Review is based on the work of 237 papers, including 214 studies, 21 guidelines, and two position statements, which covered data of over 113,000 children and young people. The authors also analyzed anonymized data from over 3,700 children diagnosed with gender dysphoria, survey responses from professionals, and numerous interviews and testimonies from stakeholders of the issue.
The review team commissioned researchers at the University of York to conduct systematic reviews of these papers and get feedback by interviewing young gender-incongruent children, their parents, and clinicians.
The University of York disclosed that it interviewed 12 young people who were part of voluntary organizations or the UK’s Gender Identity Development Service (GIDS), along with 12 parents. The university researchers also interviewed clinicians at the UK’s gender identity clinics.
Additionally, Dr. Cass also interviewed numerous transgender youths, adults, parents of these children, advocacy groups, psychologists, pediatricians, and related clinicians, both British and international, though the number of interviewees was undisclosed. She also wanted to do a follow-up with 9,000 patients referred to England’s Tavistock Centre, but that could not be done due to the lack of cooperation from all but one adult clinic.
The review found insufficient and inconclusive evidence demonstrating the effectiveness and benefits of gender reassignment treatments for children. Additionally, many of these children are on the autism spectrum and share mental comorbidities often overshadowed by the medicalization model.
Dr. Cass hence advised cautionary psychological interventions while also leaving room for children to explore their identities.
The Society for Evidence Based Gender Medicine (SEGM), a medical group that advocates for evidence-driven research on transgender care, stated that for England, the review marked “the end of the era of a highly medicalized approach to the treatment of young people with gender-related distress,” which has come to be known as “gender-affirming” care.
The report also mentioned that while medicalization comprising puberty blockers, cross-sex hormones, and surgery, known as the “Dutch Protocol,” was invented in the Netherlands in the 1990s, the concept of “gender affirmation”—accepting children’s gender identity at face value—actually originated in the United States and then spread internationally.
As a result of the review, children under 18 in England will not be treated using such protocol but with the same level of care as other youths with mental health struggles. Finland and Sweden made similar changes in 2023.
Puberty blockers and hormones will only be made available to 16-year-olds and older under the context of research-controlled conditions. Therefore, experimentation of such treatment on minors will be hindered.
“So as the Cass report made clear, they can design a study, but the study has to be approved by a larger body that passes on its ethics,” said Dr. Stephen Levine, clinical professor of psychiatry at Case Western Reserve University.
Top Findings and Suggestions
The report found that, unexpectedly, most current influential guidelines have been determined based on board consensus instead of science.
Most of the current guidelines were influenced by two American standards of care: the 2012 World Professional Association of Transgender Healthcare (WPATH) and the Endocrine Society 2009.
Both relied on a consensus process among professionals to decide on the best treatment for gender dysphoria and were built upon one another. WPATH members were co-sponsors of the Endocrine Society guidelines. WPATH’s 2012 standards of care adopted the Endocrine Society’s consensus-based recommendations but did not refer to WPATH’s own systematic review data, which found inconclusive evidence of the benefits of hormone therapy.
The recommendations from these guidelines were then referred to by subsequent guidelines, snowballing into what we now see.
The Cass Review is not about “rolling back on people’s rights to healthcare,” Dr. Cass wrote in the review’s foreword. “It is about what the healthcare approach should be.”
The review presented the following findings and recommendations.
1. Psychotherapy Is Recommended
Effectiveness and risks: Due to low quality and poor reporting of interventions in transgender children, the review couldn’t form a proper conclusion about the effectiveness of psychotherapy.
However, there is evidence that psychotherapy can help address mental health conditions, such as depression and anxiety, common among transgender youths, and hormone interventions often overshadow these therapies. The review highlighted that psychotherapy is not the same as conversion therapy, as it is not about changing a child’s perception of who they are but exploring the cause of their concerns and experiences and helping alleviate distress.
2. Partial Social Transitioning Is Preferred
Effectiveness and risks: The systematic reviews did not show clear evidence of the positive or negative effects social transitioning has on mental health. Social transition generally refers to a person making only social changes, including altering hair and clothing and changing names and pronouns, instead of medical changes to live as a different gender.
The review noted that many children grow out of gender dysphoria by adulthood but that those who socially transition often medically transition, meaning that they continue to have gender dysphoria.
While it is unknown whether social transitioning contributes to gender dysphoria, the review authors speculated that a partial transition may be more advantageous and offer greater flexibility to help children explore and express their gender identities.
3. Hormonal Treatments Not Recommended Except Under Research Conditions
Effectiveness and risks: The review showed no significant improvements in gender dysphoria symptoms or body satisfaction from medicalization. While some reports showed short-term improvement in mood when patients began hormonal treatment, the magnitude of such improvement was small.
Hormonal treatment, which refers to the use of puberty blockers and cross-sex hormones, is not recommended for minors due to the permanence of its effects. Children 16 or older may instead be enrolled in high-quality research studies on experimental treatments.
Evidence about the effects of puberty suppression on psychological well-being, cognitive and bone development, and cardio-metabolic risk or fertility was found to be inconsistent and insufficient.
Evidence also did not support the claim that hormonal treatment reduced the risk of suicide.
The report did not discuss recommendations and changes to guidelines on gender-reassignment surgeries since, unlike children in the United States, minors in the United Kingdom typically cannot undergo these.
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