Last week, Dr. Hilary Cass, chair of the independent review of Gender Identity Services for children and young people, released her final report. The review was spurred by widespread controversy over the Gender Identity Development Service at the country’s Tavistock clinic. While other jurisdictions – notably Finland and Sweden – had done comprehensive reviews of their pediatric transitioning programs, their conclusions received little press in Canada and the English-speaking world.
This Cass Review is the most important document on the topic of medical transitioning for minors in the English-speaking world. And its findings and recommendations are striking.
Medical Transitioning in the UK
The review highlights how the UK’s gender identity services went about their work with an utter disregard for the scientific method and medical caution. The Gender Identity Development Service (GIDS) was established in 1989 and, for several decades, saw very few patients. Most of these patients were pre-pubescent boys with acute gender dysphoria. The service usually provided counselling, not medical treatments. In 2011, following a novel approach to treating gender dysphoria pioneered in the Netherlands, GIDS decided to begin prescribing puberty blockers to children as a part of a research program – a medical trial. Essentially, the Gender Identity Development Service didn’t know whether prescribing puberty blockers to try to give children time to explore their gender identity would be better than just counselling, so they decided to do the rational thing to find out: start a medical trial.
But they never finished this early intervention study. In fact, GIDS didn’t even collect the data they were supposed to. Instead, they ploughed ahead with prescribing puberty blockers and then cross-sex hormones to more and more children and adolescents without ever actually learning whether this was in their young patients’ best interest. In essence, they expanded their medical trial to thousands of children without looking back to see whether the treatment was working.
When this came to light, the National Health Service commissioned Dr. Hilary Cass to review the entire model of gender care in the UK. GIDS dug through its patient consultation notes and follow-up with patients to find the data needed to evaluate the Service’s medical transitioning program. When the results were finally published in 2021, they found that “there were no statistically significant changes reviewed in gender dysphoria or mental health outcome measures whilst on puberty blockers.”
“…there were no statistically significant changes reviewed in gender dysphoria or mental health outcome measures whilst on puberty blockers.” – Cass Report
Examining All of the Evidence
But the Cass Review didn’t just want to see how children had fared under the care of GIDS. Cass commissioned six independent systematic reviews of all available evidence of medical transitioning for minors to see if medical transitioning could ever reliably improve health and well-being. Systematic reviews are the highest quality academic evidence available because they collect all the studies done on an issue and combine, compare, and analyze their results. This allows researchers to learn from other time periods, other places, and other methods of study.
These systematic reviews all reached the same conclusion: there is no high-quality evidence to support medical transitioning for minors.
For example, the University of York’s systematic review concluded:
- “there is insufficient and/or inconsistent evidence about the effects of puberty suppression on psychological or psychosocial health” (176);
- “[there is] no evidence that puberty blockers improve body image or dysphoria, and very limited evidence for positive mental health outcomes” (p. 179); and
- “the evidence for the indicated uses of puberty blockers and masculinising/feminising hormones in adolescents are unproven and benefits/harms are unknown” (194).
Medical transitioning for minors was a failure. The overview of the review’s key findings states that “for most young people, a medical pathway will not be the best way to manage their gender-related distress.” Puberty blockers and cross-sex hormones would not be offered to minors under the age of 16. Even for adolescents over age 16, the Review recommends “extreme caution.”
These systematic reviews all reached the same conclusion: there is no high-quality evidence to support medical transitioning for minors.
The Cass review also found that the World Professional Association for Transgender Health (WPATH)’s Standards of Care – the clinical guidelines predominantly followed in Canada – were not based on high quality evidence. In fact, WPATH’s Standards of Care didn’t even bother to reference its own systematic review of the literature on medical transitioning but claimed instead that a “systematic review regarding outcomes of treatment in adolescents is not possible” (131). But it was possible. The Cass Review produced six. WPATH completed one but ignored it.
It appears that the commitment of WPATH and other bodies to “gender affirming care” was ideological, not evidence-based. The Cass Review found that few medical bodies around the world were willing to admit the lack of evidence to support medical transitioning.
Evidence is Evidence, No Matter What Country You’re In
Following the publication of the Cass Review, the CBC solicited responses from Canadian doctors on the findings of the Review. These doctors and the Canadian Pediatric Society – who have not bothered to publicly assess all the available evidence in systematic reviews or craft standards of care specific to Canada – think they know the evidence on medical transitioning for minors better. These Canadian bodies continue to stand by the practice of medical transitioning for minors, despite the lack of high-quality evidence supporting the practice and even while many countries, and the province of Alberta, are restricting the availability of puberty blockers and cross-sex hormones to minors.
“…if no high quality evidence for medical transitioning is established in the coming years – that medical transitioning for minors is the great medical scandal of our time.” – Dr. J. Edward Les
Of course, Canadian doctors are not a monolithic group. Some doctors, such as Dr. J. Edward Les, have decried Canada’s direction on the issue. Dr. Les points out that there have been numerous examples in the last hundred years alone of medical consensuses leading to horrible practices that incapacitated, addicted, or even killed thousands of people. He’s afraid – rightly, if no high quality evidence for medical transitioning is established in the coming years – that medical transitioning for minors is the great medical scandal of our time.
That’s why Let Kids Be exists. As a country, we need to be humble when mistakes have been made and be courageous to correct our mistakes. Thus far, only the political arm in Alberta has been humble and courageous enough to ban medical transitioning for minors. Other provincial governments and our medical establishments need to follow suit.
Will you take action and help us make this a reality?