I keep hearing from anti-trans activists that this major review of the literature on the efficacy of transgender treatments, the Cass Report, confirms their position, which I don’t understand. What I’ve read of the report isn’t very overwhelming at all. Rather than wading into almost 400 pages of text, though, I thought this succinct summary of the whole thing was very good.
A systematic review collects all the published research in an area and ranks the research based on how likely it is to be reliable. The weakest form of evidence are case reports, where a doctor formally writes up an anecdote about a patient. The strongest form of evidence are randomized controlled trials where patients are randomly assigned to some type of medication or intervention, or to no intervention, or to a placebo, and the groups are compared to see how an intervention compares to alternatives/no treatment/placebo. Systematic reviews of several interventions for trans youth were undertaken by the University of York including puberty blockers, cross sex hormones, social transition, and psychosocial support measures.
The results of each of the systematic reviews was to characterize the overall evidence as weak, which was the Report’s most significant finding and has been widely reported. When looking more granularly at the York papers, a pattern appears of some papers showing a psychological benefit of the intervention, a smaller number showing no change positive or negative, and no papers showing any psychological harm. For example, in the systematic review of the evidence on puberty blockers, several included studies suggested psychological benefits to treatment in a range of areas, while a smaller number of studies found no significant impact. This was summarized in both the papers and the Report as “weak evidence” but could also be accurately described as “weak evidence (in favor of treatment).”
That the evidence was weak is not an indictment of the report — by their nature, case reports are necessarily weak. The alternative is to do controlled experimentation on human children, which is going to be even more problematic! The weak evidence is what we have, and that evidence says that, for the sake of the children, we should be treating kids.
The report itself actively endorses the use of puberty blockers, as well as other treatments, in addition to further studies of their effects. However, it takes a very conservative position on when young people should be allowed to take them, and even discouraged social transitioning in young children.
A full programme of research should be established to look at the characteristics, interventions and outcomes of every young person presenting to the NHS gender services.
The puberty blocker trial previously announced by NHS England should be part of a programme of research which also evaluates outcomes of psychosocial interventions and masculinising/ feminising hormones.
So I don’t get it. Why are the trans haters treating this as a vindication of their position? What I’m seeing is a cautious, conservative review that is compelled by the evidence to give cautious, conservative recommendations in favor of some degree of treatment, and I don’t care how much Helen Lewis and The Atlantic strain to twist it into a condemnation of American policy.
As usual, expect the issue to continue to be unresolved as ideology is used to torment trans kids further.
This sentence seems to sum it up.
None of the studies found that there was any psychological harm to the children.
Some of the papers showed a psychological benefit from the interventions.
This could be summarized as likely to help some children and not harm any children.
It’s not like they have a particularly robust or healthy relationship with evidence in general, so why should they be any different here? Also, they’re the sort of people who hear “the evidence for X is weak” as “X is completely made-up!”
Anyway, most of them haven’t read it either, but are only reading summaries from other people who share their preconceptions. How accurate do you imagine those summaries are? How many of those providing them have actually read the report themselves, or even a moderately accurate summary of it?
This meta analysis doesn’t exist in a vacuum.
There have been lots of studies on Trans people and their medical treatments.
A recent study found that the regret level of Trans people who have undergone surgery is 1%. This is very low.
Half of all people in the USA regret getting married and 8% regret having children.
If my only hobby were raving bigotry in the face of all the evidence then I’d probably just assume all the studies say what I want them to also.
My biggest problem with the Cass Report, though, is that it does not speak out as forcefully as necessary against the transphobes who blight our culture at the moment. It has some guarded and mild language about “not letting this be a culture war issue”, but given that the root of all our problems with transphobia comes from politically motivated right wing agitators this is insufficient. The biggest obstacle to the health and wellbeing of trans people today is this network of suppurating bigots, and to pretend that isn’t the case is a dereliction of duty for someone writing a report into the state of trans healthcare.
No, that is not the only summary you need. There is a far more in depth one here:
https://www.tandfonline.com/doi/full/10.1080/26895269.2024.2328249
There’s info and links on more problems here:
https://www.erininthemorning.com/p/cass-met-with-desantis-pick-over
The report is rife with awfulness. It starts from the premise of cis-supremacy. It cites a far-right youtuber at §2.18 who uploads loads of anti-trans propaganda. The cover is even fucking AI-generated (look at the fingers!)
I am fucking begging cis people to stop treating us like we have a disease and need to be “cured”. It would do all of them a service to read Whipping Girl by Julia Serano before even drawing a breath to say what they think about trans people.
This Cass report is new and people are still studying it.
Here is one opinion from Canada.
This Cass report doesn’t really change anything.
For various reasons we don’t always have “high quality” studies of various treatments in medicine.
Which doesn’t mean we don’t treat patients.
We look at the evidence we have and make informed decisions based on that and previous experience and use that for treatment decisions.
There are good reasons why there isn’t a lot of “high quality” clinical trial data for Trans medicine in children.
.1. Ethics.
These are children we are talking about, not mice or lab rats.
You often can’t randomize them into control and treatment groups, if one of those groups is possibly or likely to harm children included in that group.
What are you going to do? Count the number of suicides in children who don’t get puberty blockers and go through puberty versus those who receive blockers?
.2. How are you going to blind these trials?
What the researchers have been doing instead is using case reports, surveys, and interviews.
To call these “low quality” is misleading.
They aren’t the best evidence but they aren’t useless either. It is still data.
A lot of physicians who treat Trans people aren’t impressed with the Cass report.
They are calling it biased against Trans people and Trans medical care.
The idea that doctors who have been the primary gatekeepers for trans healthcare and have forced us to jump through hoops and “prove” ourselves for hormones and gender-affirming surgeries that are awarded to cis people without issue know better than ACTUAL TRANS PEOPLE is beyond ridiculous. I’m so fucking tired of me and my loved ones and community and all trans people around the world pathologized and treated as lesser than cis people and our healthcare and basic rights and humanity held hostage by them. If what you wrote were the only issues you have with the Cass report and you think it is mild rather than actively damaging and harmful PZ, I am BEGGING you to read Whipping Girl, talk to actual trans people about this stuff, and to not even for a second give cis people a hint of authority over our lives.
I believe you! I read the Cass report after reading Helen Lewis’s tortured explication of it, and was mainly relieved that it wasn’t as, shall we say, British as she made it sound. But still, Cass made it as conservative as she possibly could, despite all the evidence saying the opposite.
This Cass report isn’t going to change anything.
.1. It is already being attacked by all the other medical groups involved in Trans health care.
.2. Dr. Cass herself is overstating her case here.
Calling Trans medicine as being built on “shakey foundations” is just wrong.
It’s built on data from hundreds of studies.
The data could be better as right now this health care is new and a work in progress.
We are designing studies to get that data right now. It will take time.
Claiming Trans health care is build on “shakey foundations” doesn’t mean that it is wrong or harmful. It means we could use some more data.
In the end, all that new data might be an incremental improvement and that is it.
.3. For obvious reasons, we aren’t going to be doing a lot of Randomized Controlled Clinical Trials.
This is comparable, in a way, to how anti-vaxxers insist that new vaccines are not tested against placebo-controlled randomized trials and how that is proof the vaccines are dangerous. What people who parrot this line are missing is some basics of how scientific research in practice actually works, they’re simply relying on an overly simplistic grade-school understanding of how scientific research is conducted. The standard research design for new medicines when it gets to human trials is not merely placebo-controls but what are called active-controls. There’s still a control condition, but instead of it being against a saline injection or sugar pill, it’s against the currently accepted standard treatment/inoculation regime. It is this way because the comparison of interest is not “does this new thing do better than nothing” but “does this new thing work at least as well as the current standard of care.”
Likewise, the TERFs’ call for a double-blind RCT for trans-affirming health care as the only way to get real evidence that trans-affirming care is positive is beyond the pale fucking ignorant of how scientific research works in practice. How do you possibly double-blind anyone to whether or not they get called by their preferred pronouns or are permitted to dress in the clothes they feel matches their gender identity?
Internal validity of research is certainly important, but ecological validity is also pretty damned important to a lot of scientific research. Human-subjects oriented fields – from medicine to linguistics – do not study phenomena that could possibly exist absent an influential ecological context. Prioritizing context-less research designs as the gold standard of evidence is just wrong. Science operates best on the basis of a varied suite of research designs with different emphases on internal and external validity. Science operates best by integrating the findings from these disparate and diverse research designs. Science also does some of its best work by recognizing the limitations of certain designs or analytical approaches to address certain research questions.
But we all know that goal of TERFs is, like the goal of anti-vaxxers, not to champion good science. It’s to use an incorrect understanding of science as a cudgel to beat down everyone who disagrees with them.
I’ve linked to this article about Prof. Stephen Whittle once before – short and well worth reading. I won’t try to summarize Whittle’s mixed assessment of the Cass report.
The Cass Report may be being exaggerated by transphobes, but as others have pointed out, it is still deeply flawed and uses poor arguments essentially to camouflage transphobia as thoughtful concern.
The report uses evidence-weighting scales designed to assess the effect of simple interventions (e.g. one or a few given medications) on easily measurable outcomes (e.g. blood pressure) that involve large numbers of study participants. Some of the larger meta-analyses have huge sample sizes (this one has n > 30 million). This is not applicable to transgender health care where the numbers are much smaller than, say, hypertension, where the interventions are more complex, and where the outcomes are harder to measure.
Despite this, there have been a number of well-conducted RCTs on gender-affirming care, and they consistently show reductions in dysphoria and suicidality compared to placebo. And we’re talking huge effect sizes here, such as ‘60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month follow-up’.
Just to put this into perspective, here’s a review of FDA drug approvals for 2022:
So, yes, this is US rather than UK drug regulation, and many of those drugs were approved with weak evidence bases because they’re for cancers and other serious conditions that have no effective alternatives. But gender dysphoria and secondary suicidality are also serious conditions with no effective alternatives, and the hormones used in gender care have been known and studied for decades.
The Cass Report is essentially Hill & Knowlton-style FUD for the conservative UK government — talk about weak evidence and needing more studies as a pretext to refusing treatment to people with severe depression and dying by suicide. If Cass really gave a flying **** about trans people, the concusion would be ‘the evidence is not as strong as we would like, but what evidence we have shows important benefits with gender-affirming care at very low risk; accordingly, gender-affirming care should be available to anyone who requests it while we continue to build the evidence base, and we should be prepared to change or abandon care strategies as evidence changes.’
I’m not going to fisk the report, but I can tell you from reading parts of it that Cass has on several occasions misrepresented the evidence, especially on rates of detransitioning, and clearly finds it impossible to accept the reasons the infamous Bell v Tavistock decision was overturned on appeal.
Cass is directly responsible for closing England’s only public gender clinic for young people and children. One of her criticisms was that the waiting times were too long…well now they’re infinite. She told the Guardian this week ‘She is not even sure that future clinics should have gender in the name, noting that we should “move away from just calling these gender services because young people are not just defined by their gender”’ (I assume she is also going to recommend closing all women’s health clinics forthwith). She thinks that only a minority of young trans people should ever be allowed hormonal care, because apparently making recommendations on weak evidence is OK when she does it. She intimated to the Guardian that doctors who offered affirming care could possibly face disciplinary proceedings, while generously acknowledging ‘it is not her job to comment,’ which apparently does not count as a comment. She accused gender clinics of malicious secrecy because they wouldn’t give her unfettered access to patient files — yes, the data would be deidentifed, but as a working paediatrician she should know full well that even deidentified data sharing requires consent. She demanded all gender clinics immediately stop taking appointments for patients under 18 — that’s right, she demanded that they shouldn’t even be accepting appointments. If you’re 14 and suicidal, just wait four years to see an adult clinic, or see doctors with no expertise in gender care because we’re closing all those clinics!
If you want to read what actual trans people think of the Cass Report, this is a good place to start.
Also, while dismissing gender-affirming care because there aren’t enough RCTs, the Cass Report includes qualitative research from interviews…so apparently non-RCT evidence is good enough to report when it suits them.
The more I read about Hilary Cass and this report the more appalled I become.
This is absurd and it is just wrong.
Where does she think puberty blockers come from and why do we use them?
These are very old drugs.
These are “.. gonadotropin-releasing hormone (GnRH) agonists, which suppress the natural production of sex hormones, such as androgens (e.g. testosterone) and estrogens (e.g. estradiol).”
They’ve been in use for a number of indications since the 1980s. That is 40 or so years.
Hilary Cass is simply flat out lying here.
FWIW, puberty blockers are used because they are also reversible.
When you stop taking them, puberty then starts up.
They are really flat out lying here again.
There are a number of studies published that show favorable outcomes for using puberty blockers in Trans medical care.
What Hilary Cass just did was arbitrarily label these studies low quality and throw them out.
Meanwhile what she and the Transphobe do is use low quality studies of their own and pretend they are the definitive studies. When they aren’t just making stuff up.
The Cass report is worthless Transphobic garbage.
This is from a BBC interview with Hilary Cass.
This is just wrong and she is lying.
We have hundreds of studies and decades of experience with treating Trans people.
We don’t know everything but we know a lot.
She is making the mistake that because we don’t know everything, we should do nothing.
She doesn’t know that.
She has no data on these points whatsoever.
It is simply as assertion without proof or data and may be dismissed without proof or data.
@Hex #5,
Just took a look at that, and yeah, it’s pretty damning. Cass judges that the evidence for medical intervention is not as strong as we would like (something you could say about just about any treatment) and then concludes “so we should use other approaches instead,” which is a completely unjustified leap. Is there stronger evidence for any other approach–including doing nothing? If not, then we should continue medical intervention while, of course, also continuing the research into its efficacy.
And using unlabeled AI-generated pictures of trans youth is just silly.
Why the hatred for the choices other people make about how they live their own lives?
This is worth a listen
https://www.abc.net.au/listen/programs/healthreport/gender-puberty-blockers-hormones-evidence/103689784
Why are the trans haters treating this as a vindication of their position?
For the same reason they’re citing the Tavistock ruling, and for the same reason US gun-rights advocates cite the Heller ruling: it’s a bluff. And if the Cass report is almost 400 pages, that makes it a somewhat harder bluff to call.
So thanks, PZ, for bringing this to our attention.
My biggest problem with the Cass Report, though, is that it does not speak out as forcefully as necessary against the transphobes who blight our culture at the moment.
If the Cass report is supposed to be about the safety or efficacy of gender-affirming medical/mental-health care, then it has to stick to that narrow slice of the overall issue. If they’d said anything about the bigotry and culture-war part, the transphobes would scream bloody murder about how “partisan” and “polemical” and “unscientific” it was.
Read every comment by raven in this thread. They’re all right on the money.
One of the best reviews of the “Cass Review” I’ve read is by Gender GP. They’re a private service for trans healthcare in the UK, so could be considered biased. But I can’t see anything to fault in their discussion of all the problems in the Cass Review.
I had high hopes this Cass would be a person of integrity and do an honest review of the evidence that forms the international consensus on trans healthcare. But alas, it has become crystal clear that the “Review” was a sham. The institutionally transphobic NHS in the UK simply doesn’t want to provide trans healthcare. But they needed an excuse to ignore the international consensus. So they commissioned an “independent” review that set an impossibly high bar for evidence, used that to throw out literally 98% of the evidence, and then claim that since there’s no evidence the international consensus can be ignored. Then the NHS can say we’re stopping trans healthcare because the Cass Review said so! It seems to have been nothing more than an exercise in manufacturing a reason to stop trans healthcare.
I think this cartoon by Katy Montgomerie (who is herself trans) sums the whole thing up perfectly:
https://pbs.twimg.com/media/GKy3CkCW4AE9hA2?format=jpg&name=large
https://www.tandfonline.com/doi/full/10.1080/26895269.2023.2218357
The board of inquiry was deliberately set up to exclude any participation by trans people and deliberately sought out the views of anti-trans groups; for example, Cass met with the freak show that masquerades as medical authorities in the state of Florida under Ron de Santis. The report isn’t so much as to be read critically, as to be cited by government uncritically in service of continuing the same horrific policies that have led to multiple people dying on NHS multi-year waiting lists for a first consultation.
There are so many things wrong with the document that if I were to start it would be difficult to avoid overflowing the comment length. One particularly terrible recommendation, which amounts almost to a justification for conversion therapy, is that for pre-pubescent children the possibility of exploring social transition should generally be resisted except under medical supervision.
Pre-pubescent children are typically androgynous. Social transition for such a gender dysphoric child amounts to possibly using a different name, pronouns, and finding them different clothing, which can happen years before a medical intervention is required. The frequent story from trans adults in the UK when consulting their GPs ranges from the minority that are supportive, to a majority that disapprove of their being trans, to those who express outright hostility (with the possibility of some malpractice thrown in, such as refusing to continue medication prescribed by other doctors). The policy requiring medical supervision for what is in many cases a change in social status also fails to take into account that most GPs will neither have received any medical training with respect to trans medicine, nor will have viewed obtaining such knowledge as part of the ongoing refreshment of their skills. The Cass report is basically a justification for medical mistreatment on the one hand, while pushing trans children toward conversion therapy sneakily rebadged as ‘exploratory therapy’.
@PZ:
Further down in the very page you linked, there is a section on the recommendations of the Cass Report:
I would say that those recommendations could well be roughly summarized as “medically, treat being trans as a bad thing”, which is certainly something that trans haters would consider to be vindicating.
It is downright baffling how Cass apparently thinks one would take her as “scientific” and “objective” if she meets with one of the biggest fascists /his staff , that are out there, who has focused all his efforts on eradicating those she claims to “investigate”
The institutionally transphobic NHS in the UK simply doesn’t want to provide trans healthcare. But they needed an excuse to ignore the international consensus.
More to the point, I suspect the NHS needed an excuse to do what they may have felt they had no choice but to do: cave to a baying mob of mindless haters in a time of spineless incompetent right-wing Tory misrule. Judging by the trolls I’ve seen screaming about trans people on the ‘Tubes, they seem utterly divorced from reality and totally uncaring about facts, reason or consequences; and have been whipped up into endless implacable hate by a steady diet of lies and disinformation.
And the interest-groups feeding them all this disinformation won’t be stopping in the UK either. They’re planning to use the momentum they got in the UK to get the same results in other countries. (So, again, thanks, PZ, for posting about this and providing a place for fact-checking and commentary.)
This is an example of how Hilary Cass flat out lies.
Actually there is in fact published evidence on the effect of social transitioning in children on their mental health.
Hilary Cass simply throws out any studies that don’t agree with her biased and bigoted views of Trans people.
She in fact, threw out or ignored most of the medical studies on Trans people and their health care.
@27 if most major psychological , biological, medical and anthropological societes and even the WHo disgrees with you, you should maybe start reflecting, but she does not seem to be too eager about ethics, science , let alone “freedom” and wellbeing, as no conservative ever
She in fact, threw out or ignored most of the medical studies on Trans people and their health care.
Whaddaya expect? She was chosen to head that project for the explicitly stated reason that she had absolutely no connection, knowledge, training, stake or experience in trans healthcare. And she brought with her lots of other people whose lack of qualification was their sole qualification to be there. Which is absolutely consistent with right-wingers’ well-known hatred of experts, expertise, knowledge and knowledgeable people. As a character in a William Gibson novel said, they don’t know shit about anything and hate everyone who does.