An independent review of gender-related medical care for minors and young adults submitted Wednesday to the U.K.’s National Health Service found that previous studies on the topic are of “poor quality” and there is “very limited evidence on the longer-term outcomes” associated with medicalized transition.
“This is an area of remarkably weak evidence, and yet results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint,” Hilary Cass, who led the review, wrote in the introduction. “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.”
NHS England commissioned the Independent Review of Gender Identity Services for Children and Young People in 2020. (In the report, “young adult” refers to an individual between ages 18 and 30.)
The report, sometimes dubbed the “Cass Report” or “Cass Review,” indicates that the number of children and young people presenting to the NHS Gender Identity Service (GIDS) has increased since 2009 and had an “exponential rise” in 2014.
From 2009 to 2016, the number of adolescent females referred to GIDS rose from 15 to 1071, and the number of female children referred rose from two to 138. Meanwhile, the number of adolescent males rose from 24 to 426, and the number of male children rose from ten to 131. Prior to 2009, GIDS saw fewer than 50 children a year, and even fewer underwent medical procedures.
“A common explanation put forward is that the increase in presentation is because of greater acceptance,” the report states. “While it certainly seems to be the case that there is much greater acceptance of trans identities, particularly among younger generations, which may account for some of the increase in numbers, the exponential change in referrals over a particularly short five-year timeframe is very much faster than would be expected for normal evolution of acceptance of a minority group.”
The report recommends that children and young people referred to the NHS for gender-related services receive a “holistic assessment” that includes screening for “neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment.”
“The focus on the use of puberty blockers for managing gender-related distress has overshadowed the possibility that other evidence-based treatments may be more effective,” the report states. The interim report, released in February 2022, did not provide guidance on hormone treatments “due to gaps in the evidence base.”
The new report cites studies performed by the University of York which show that puberty blockers did suppress puberty, but also compromised bone density and found “no changes in gender dysphoria or body satisfaction.” The available evidence does not suggest that hormone treatment reduced the risk of death by suicide, according to the Cass Report.
Currently, NHS practitioners have the option to provide masculinizing or feminizing hormones to patients ages 16 and older. The report recommends “an extremely cautious clinical approach and a strong clinical rationale” for masculinizing or feminizing hormone treatments administered to someone under 18.
The report also notes a possible increase in the number of individuals treated with hormones who then de-transition, although the percentage is unknown given the lack of long-term follow-up studies.
The report recommends a “tiered approach” to intervention which “addresses urgent risk,” alleviates mental-health issues so the young person can “make complex decisions,” and develops a plan that may involve “any combination of social, psychological and physical interventions.” It also encourages distinguishing between pre- and post-pubertal children.
“The current evidence base suggests that children who present with gender incongruence at a young age are most likely to desist before puberty, although for a small number the incongruence will persist,” reads the report. “Parents and families need support and advice about how best to support their children in a balanced and non-judgemental way.”
The Cass Report was informed by systematic reviews, research, NHS data, meetings with policymakers, and “lived experience” conveyed in focus groups, among other resources.
“Although some think the clinical approach should be based on a social justice model, the NHS works in an evidence-based way,” reads the report.