Tell me if you’ve heard of this before: a government responds to the noise around gender-affirming care by setting up an independent review board. This board is tasked with reviewing the evidence, and coming up with guidelines that will inform government policy about the process.
It sure sounds an awful lot like the Cass Review, doesn’t it? The report which has been repeatedly used to deny health care to transgender people, despite withering critiques from the scientific community.
Our concern here is that the Review transgresses medical law, policy, and practice, which puts it at odds with all mainstream U.S. expert guidelines. The report deviates from pharmaceutical regulatory standards in the United Kingdom. And if it had been published in the United States, where it has been invoked frequently, it would have violated federal law because the authors failed to adhere to legal requirements protecting the integrity of the scientific process.
The Review calls for evidentiary standards for GAC that are not applied elsewhere in pediatric medicine. Embracing RCTs as the standard, it finds only 2 of 51 puberty-blocker and 1 of 53 hormone studies to be high-quality. But more than half of medicines used in pediatrics have historically been prescribed off-label on the basis of limited evidence. Physicians have noted that requiring robust evidence for pediatric use of every drug would greatly limit drug treatments for children, who are already considered by researchers to be “pharmaceutical orphans.” Indeed, Cass has herself admitted that RCTs are probably infeasible in the GAC setting; “they’re difficult studies to design because you can’t blind people,” she notes, since patients will see bodily changes when given GAC-related pharmaceuticals.
Daniel G. Aaron and Craig Konnoth, “The Future of Gender-Affirming Care — A Law and Policy Perspective on the Cass Review,” New England Journal of Medicine 392, no. 6 (February 6, 2025): 526–528.
Cass Review commentary positions non-affirmative approaches as “neutral,” contrasting them to affirmative approaches that are framed as “ideological.” There is no recognition of the ideology underpinning approaches that deny the existence or validity of trans children. Cass Review reports do not consider the harms of approaches that deny or reject a trans child’s identity (…). Instead, Cass Review reports provide a sympathetic description of non-affirming professionals, centering the pressure they feel under to adopt an affirmative approach …
A significant indication of cisnormative bias can be seen in the absence of recognition of the existence of trans children across all Cass Review reports. A review expected to define best practices for trans children’s healthcare chooses to entirely avoid the word trans when referring to the children or adolescents who access UK Children’s Gender Services. Whilst including seven references to “transgender adults,” the interim report does not include even one reference to a trans child, adolescent or young person. Trans children are instead reduced to definition as “gender questioning children and young people” (Report 5, p. 11) or “children and young people needing support around their gender” (Report 5, p. 7). This framing conflates trans children, including those who have socially transitioned and are settled and confident in their affirmed identity, with children who are questioning their gender. This conflation erases the existence of trans children.
Cal Horton, “The Cass Review: Cis-Supremacy in the UK’s Approach to Healthcare for Trans Children,” International Journal of Transgender Health (March 14, 2024): 1–25.
When governments start weighing in on health care practice, the results are almost always terrible.
[… pause for dramatic effect …]