Cass Review

Review of gender identity services in England

Logo of the Cass Review

The Independent Review of Gender Identity Services for Children and Young People (commonly, the Cass Review) was commissioned in 2020 by NHS England and NHS Improvement[1] and led by Hilary Cass, a retired consultant paediatrician and the former president of the Royal College of Paediatrics and Child Health.[2] It dealt with gender services for children and young people, including transgender youth and those with gender dysphoria in England.

The final report was published on 10 April 2024,[3] and it was endorsed by both the Conservative and Labour parties though LGBT+ Labour criticised it. The Green Party initially supported the review, but ceased following condemnation from LGBTQ members. LGBTQ advocacy groups in the UK and internationally have criticised the review.[4][5][6]

The review's recommendations were largely welcomed by UK medical organisations, though some noted criticisms of the review and called for their consideration.[7][8][9] The British Medical Association called to publicly critique the review and later initiated an independent review of it.[10][11] The British Association of Gender Identity Specialist and UK's Association of LGBTQ+ Doctors and Dentists criticised the review.[12][13] Medical organisations outside the UK, international medical organisations, and other countries' clinical practice guidelines have criticised its methodology, findings, and recommendations.[14][15][16] Following high profile media coverage, Cass expressed concern that misinformation about the review had spread online and elsewhere.[17][18][19]

The review led to a UK ban on prescribing puberty blockers to those under 18 experiencing gender dysphoria (with the exception of existing patients or those in a clinical trial).[20] The Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust was closed in March 2024 and replaced in April with two new services, which are intended to be the first of eight regional centres.[21] In August, the pathway by which patients are referred to gender clinics was revised and a review of adult services commissioned.[22] In September, the Scottish government accepted the findings of a multidisciplinary team that NHS Scotland had set up to consider how the Cass Review's recommendations could best apply there.[23] In England a delayed clinical trial into puberty blockers is planned for 2025.[24][25]

## Background

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See also: Gender Identity Development Service

The number of referrals to GIDS by sex assigned at birth in each financial year from 2009/2010 to 2019/2020.

The Gender Identity Development Service (GIDS) was the specialist clinic nationally commissioned by NHS England to provide care to transgender and gender diverse children, including those with gender dysphoria. In the years leading up to the Cass Review, several GIDS staff members voiced concerns over the evidence base for the treatments being given and the extent of prior assessment.[26][27][28] At the same time, professional disagreements over the strength of evidence for treatments provided to children and young people, such as puberty blockers, was growing.[29][30] The case of Bell v Tavistock also explored issues of informed consent.[31][32][33] Several systematic reviews had found the evidence base supporting these treatments to be poor,[34][35][36] and European countries, such as Finland and Sweden, limited the use of puberty blockers and other hormone treatments for this patient cohort, citing a lack of evidence supporting their use.[37][38][39] In January 2021, the Care Quality Commission (CQC) gave GIDS an "inadequate" rating (the lowest one possible).[40][41] These issues led to GIDS becoming controversial and gaining extensive news coverage.[42]

The Cass Review was commissioned by NHS England in September 2020, following a significant increase in referrals to the Gender Identity Development Service[a] and a shift in the service from a psychosocial and psychotherapeutic model to one that included hormonal treatment.[b][c] Hilary Cass, a former president of the Royal College of Paediatrics and Child Health (RCPCH), was asked by NHS England and NHS Improvement's Quality and Innovation Committee to chair an independent review with the aim of improving gender identity services for children and young people.[50] The Cass Review's final report stated the concerns which led to its creation included very long waiting lists, of over two years per patient; an "exponential" increase in the number of children and young people requesting gender-affirming care from the NHS; a change towards earlier medical treatment in this patient cohort;[d] and concerns that there was insufficient evidence to justify the treatments being given.[e]

## Methodology

[edit]

The Cass Review was an independent service review which made policy recommendations for services offered to children and young people questioning their gender identity or experiencing gender incongruence in the NHS.[54] Dr. Cass chaired the review and authored its recommendations and reports, independently of any medical bodies or consensus-building process. An assurance group was appointed but was not involved in the preparation of recommendations. No external review or prior consultation was performed before publishing. An advisory board was also established, but the composition and contributions of the group are not documented.[55]

The Cass Review commissioned several independent systematic reviews from the University of York's Centre for Reviews and Dissemination,[f] which were published in Archives of Disease in Childhood.[57][58][59][60] Whether the research questions were decided by the York Team or Cass Review is unclear.[61]

The systematic reviews covered:[62][63]

* Characteristics of children and adolescents referred to specialist gender services[64]
* Impact of social transition in relation to gender for children and adolescents[65]
* Psychosocial support interventions for children and adolescents experiencing gender dysphoria or incongruence[66]
* Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence (puberty blockers)[67]
* Masculinising and feminising hormone interventions for adolescents experiencing gender dysphoria or incongruence (transgender hormone therapy)[68]
* Care pathways of children and adolescents referred to specialist gender services[69]
* Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence[70][71]

The reviews of puberty blockers and gender-affirming hormones excluded qualities deemed to be low quality. The review of psychosocial interventions included all studies regardless of quality.[61] The reviews examined English-language studies of minors,[g] and the quality of studies was assessed using the Mixed Methods Appraisal Tool and a modified version of the Newcastle–Ottawa scale,[73][74] though certainty-of-evidence ratings were not provided for individual outcomes.[75]

Additionally, focus group interviews with patients, clinicians, and a review of previous treatment courses for children and adolescents with gender incongruity in the NHS were conducted.[61][76][77]

## Interim report

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A statue of Sigmund Freud in front of the Tavistock Centre, at which the GIDS was based.

The interim report of the Cass Review was published without peer-review in March 2022.[75] It said the rise in referrals had led to staff being overwhelmed, and recommended the creation of a network of regional hubs to provide care and support to young people. The report said the clinical approach used by the Gender Identity Development Service (GIDS) "has not been subjected to some of the usual control measures" typically applied with new treatments, and raised concerns about the lack of data collection by GIDS.[78][79][80] While most children referred to GIDS did not receive endocrine treatment, there was insufficient detail provided about their broader needs when they did.[81]

The report said that while the GIDS approach to hormone interventions was initially based on the Dutch protocol, there were "significant differences" in the current NHS approach.[82] For example, the report said there were no clear guidelines for when to provide psychological support before or instead of medical treatment, endocrinologists administering puberty blockers did not attend multidisciplinary meetings, and there was insufficient capacity to increase (or even maintain) appointments once adolescents received puberty blockers.[83]

The interim report said GPs and other non-GIDS staff felt "under pressure to adopt an unquestioning affirmative approach" to children unsure of their gender. The report also said that diagnosis of gender-related distress sometimes led to "diagnostic overshadowing", where comorbidities such as poor mental health – which were usually managed by local services – were overlooked.[84] The report suggested that long wait times to access GIDS had resulted in increased distress for patients and their families, as well as less time for exploration – since patients arrived having already begun social transition and with expectations of a rapid assessment process.[85] In response, the Tavistock and Portman NHS Foundation Trust said "being respectful of someone's identity does not preclude exploration", and that it agreed "support should be holistic, based on the best available evidence" without making assumptions about "the right outcome for any given young person".[86]

The interim report further said there were "gaps in the evidence" over the use of puberty blockers. A public consultation was held and a further review of evidence by NICE said there was "not enough evidence to support the safety or clinical effectiveness of puberty suppressing hormones to make the treatment routinely available at this time". Subsequently, NHS England stopped prescribing them to children.[87][88][89]

In April 2022, Health Secretary Sajid Javid told MPs that services in this area were too affirmative and narrow, and "bordering on ideological".[90] In November 2022, the World Professional Association for Transgender Health (WPATH) – along with regional groups ASIAPATH, EPATH, PATHA, and USPATH – issued a statement criticising the NHS England interim service specifications based on the interim report.[14]

## Final report

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The final report of the Cass Review was published on 10 April 2024, alongside a series of systematic reviews and a survey carried out by the University of York, encompassing the patient cohort, service pathways, international guidelines, social transitioning, puberty blockers, hormone treatments, and psychosocial treatments.[62][91]

### Findings

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#### Lack of research in the field

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The quality of studies on puberty blockers and gender-affirming hormone therapy in adolescents.

The report states that the existing evidence for both endocrine (puberty blockers and hormone therapy) and non-endocrine treatments (psychosocial interventions) in children and adolescents with gender incongruence is weak.[h]

#### Increase in referrals

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Cass Review Figure 11: Child and Adolescent Referrals for Gender Dysphoria (UK, GIDS)

The report found no clear explanation for the rise in the number of children and adolescents with gender dysphoria, but said there was broad agreement for attribution to a mix of biological and psychosocial factors. The report's suggested influences included a lower threshold for medical treatment, social media-related mental health consequences, abuse, access to information regarding gender dysphoria, struggles with emerging sexual orientation, and early exposure to online pornography. The report considered a rise in acceptance of transgender identities to be insufficient to explain the increase on its own.[94][64]

#### Social transition

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Main article: Social transitioning

A systematic review evaluated 11 studies assessing the outcomes of social transition in minors using a modified version of the Newcastle-Ottawa scale and considered nine to be low quality and two to be moderate quality.[73][65] The report said that insufficient evidence was available to assess whether social transition in childhood has positive or negative effects on mental health, and that there was weak evidence for efficacy in adolescence. It also said that sex of rearing seems to influence gender identity, and suggested that early social transition may "change the trajectory" of gender identity development in children.[95]

The report said that although social transition was not usually seen as a treatment, it should be considered an "active intervention". It suggests taking "a more cautious approach" for social transition for children than for adolescents, and said pre-pubertal children undergoing social transition should be seen "as early as possible" by an experienced clinician.[96][97][98]

#### Puberty blockers

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Main article: Puberty blocker

The report said the evidence base and rationale for early puberty suppression remains unclear, with unknown effects on cognitive and psychosexual development. A systematic review examined 50 studies on the use of puberty blockers using a modified version of the Newcastle–Ottawa scale and rated one as high quality, 25 as moderate quality, and 24 as low quality.[67] The review concluded that the lack of evidence means no conclusions can be made regarding the impact on gender dysphoria and mental health, but did find evidence of bone health being compromised during treatment. The review suggested puberty blockers did not provide children and young people with "time to think", since nearly all patients who went on blockers later proceeded with hormone therapy.[99][67][100] For youth assigned male at birth, the report states that blockers taken too early can make a later penile inversion vaginoplasty more difficult due to insufficient penile growth.[101] The report states one of the benefits of puberty blockers is preventing the irreversible changes of a lower voice and facial hair.[102]

#### Hormone therapy

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Main article: Transgender hormone therapy

The report said many unknowns remained for the use of hormone treatment among under-18s, despite longstanding use among transgender adults, with poor long-term follow-up data and outcome information on those starting younger. A systematic review evaluated 53 studies on transgender hormone therapy using a modified version of the Newcastle-Ottawa scale, and rated one study as high quality, 33 as moderate quality and 19 as low quality. Overall, the review found some evidence that hormone treatment improves psychological outcomes after 12 months, but found insufficient evidence regarding physical benefits and risks. The review said hormone therapy should be available from 16 years old, but that there should be a "clear clinical rationale" for the prescription of hormone therapy for anyone under 18.[103][68][104]

#### Psychosocial intervention

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A systematic review assessed ten studies on the efficacy of psychosocial support interventions in transgender minors using the Mixed Methods Appraisal Tool and rated one as medium quality, and nine as low quality. The review said that no robust conclusions can be made and more research is needed.[66][105]

The report said the evidence for psychosocial interventions was "as weak as research on endocrine treatment".[106] It recommended that psychosocial interventions also form part of a research programme, along with endocrine interventions.[103]

#### Clinical pathways

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Cass Review Figure 34: Outline of medical pathway at start of Review

The report said that clinicians cannot be certain which children and young people will have an enduring trans identity in adulthood, and that for most, a medical pathway will not be the most appropriate. When a medical pathway is clinically indicated, wider mental health or psychosocial issues should also be addressed. Due to a lack of follow-up, the number of individuals who detransitioned after hormone treatment was unknown.[107][page needed]

The Cass Review attempted to work with the Gender Identity Development Service and the NHS adult gender services to "fill some of the gaps in follow-up data for the approximately 9,000 young people who have been through GIDS to develop a stronger evidence base." However, despite encouragement from NHS England, "the necessary cooperation was not forthcoming."[108][109]

#### International guidelines

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Cass Review Table 6: Critical appraisal domain scores

A systematic review assessed 23 regional, national and international guidelines covering key areas of practice, such as care principles, assessment methods and medical interventions. The review said most guidelines lacked editorial independence and developmental rigour, and were nearly all influenced by the 2009 Endocrine Society guideline and the 2012 WPATH guideline, which were themselves closely linked. The Cass review questioned the guidelines' reliability, and concluded that no single international guideline regarding transgender care could be applied in its entirety to NHS England.[110][70][71]

#### Conflicting clinical views

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The report said there were conflicting views among clinicians regarding appropriate treatment. It suggested that disputes over language such as "exploratory"[111] and "affirmative"[112] approaches meant it was difficult to establish neutral terminology. Some clinicians avoided working with gender-questioning young people.[113] The report said some professionals were concerned about being accused of conversion therapy, and were likewise concerned about the impact of legislation to ban conversion therapy.[114][115]

### Recommendations

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The report made 32 recommendations covering areas including assessment of children and young people, diagnosis, psychological interventions, social transition, improving the evidence base underpinning medical and non-medical interventions, puberty blockers and hormone treatments, service improvements, education and training, clinical pathways, detransition and private provision.[116]

Recommendations included:

* Care provision:
* A designated medical practitioner who takes personal responsibility for the safety of children receiving care.[117]
* Individualised care plans, including mental health assessments and screening for neurodivergent conditions such as autism.[118]
* The use of standard psychological and pharmacological treatments for co-occurring and associated conditions like anxiety and depression.[119]
* That children and families considering social transition should be seen as soon as possible by a relevant clinical professional.[120]
* Longstanding gender dysphoria must be a prerequisite for medical transition, but is not the only criteria in deciding whether to allow a transition.[103]
* There should be a clear clinical rationale for the prescription of masculinising/feminising hormone therapy below the age of 18, and no masculinising/feminising hormone therapy below the age of 16.[103]
* Every case considered for medical transition must be discussed by a national multi-disciplinary team.[103]
* All minors should be offered fertility counselling and preservation prior to embarking upon a medical pathway.[103]
* A separate pathway should be established for the treatment of pre-pubertal children, who are ideally to be treated as early as possible.[121]
* Changing how the NHS provides care:
* The development of a regional network of centres, and continuity of care for 17–25 year olds.[122][50]
* The DHSC should direct NHS gender clinics to participate in the data linkage study, with the resulting research being overseen by NHS England's Research Oversight Board.[123]
* A multi-site service network should be developed as soon as possible, and the National Provider Collaborative to oversee the multi-disciplinary team should be established without delay.[124]
* To increase the available workforce, joint contracts should be used for health providers across a wide array of NHS services; and requirements for gender services should be built into the workforce planning for adolescent health services.[125]
* NHS England should develop a formal training program and competency framework for gender services, including a module on the holistic mental assessment framework.[126]
* Similar changes should be considered for adult gender services over the age of 25.[127]
* NHS England should "ensure there is provision for people considering detransition", which may require separate services.[128]
* The DHSC and NHS England should consider the implications of private healthcare on any future requests by patients for treatment under the NHS.[129]
* The DHSC should work to define the dispensing responsibilities of pharmacists receiving private prescriptions, and work to halt the sourcing of transition medication obtained through prescriptions acquired in Europe.[129]
* Future research:
* The establishment of a full program of research which will carefully study the characteristics, interventions, and outcomes of every person seen by NHS gender services.[103]
* A central evidence and data resource for gender services should be established, with specifically defined datasets for both local and national services.[126]
* National infrastructure should be put in place to manage continual data collection on gender services, including through the ages of 17 to 25.[126][127]
* A unified research strategy shall be established to ensure the most meaningful data and numbers are collected.[130]
* A living systematic review over all of this research should be collected.[121]
* The NHS should establish requirements for the collection of data from patients of NHS gender services.[131]

## Implementation by NHS England

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NHS England responded positively to the interim and final reports. As of April 2024[update] they have implemented a number of measures.[21] In response to the interim report, in March 2024 NHS England announced that it would no longer prescribe puberty blockers to minors outside of use in clinical research trials, citing insufficient evidence of safety or clinical effectiveness.[132][133] GIDS closed in March 2024,[21] being replaced by the new NHS Children and Young People's Gender Services.[134][135][136] Two new services, located in the north-west of England and in London, opened in April 2024, and are intended to be the first of up to eight regional services.[21] These will follow a new service specification for the "assessment, diagnosis and treatment of children and young people presenting with gender incongruence".[21] Puberty suppressing hormones are no longer routinely available in NHS youth gender services.[21] New patients that have been assessed as possibly benefiting from them will be required to participate in a clinical trial that is being set up by the National Institute for Health and Care Research.[60][137] A new board, chaired by Simon Wessely will encourage further research in the areas highlighted in the review as having a weak evidence base.[21]

On August 7, 2024, NHS England announced a status update for young people being considered for referral to specialist gender services, including the publication of a new pathway specification.[138] Referrals will only be accepted from an NHS-commissioned paediatric or children's mental health service instead of general practitioners and other professionals,[138][139][140] and those considering social transition should be seen quickly by a clinical professional with relevant experience. NHS England will also "explore the issues around a detransition pathway by October 2024".[141]

In April 2025, James Palmer, NHS England's national medical director for specialised services, said the NHS had not issued any new prescriptions of gender affirming hormones to minors in the year since the report's publication, even though they have not been banned, with the NHS instead prioritising "holistic care". Palmer said these new services only have 30 referrals per month, compared to 5,000 per year at GIDS. One paediatric mental health expert said this was due to the increased complexity of the new referral process and families seeking treatment elsewhere — such as by acquiring hormones on the black market or abroad.[140]

The clinical trial on puberty blockers for children and young people, due to start late 2024, has now been delayed to 2025.[24][25]

In February 2025, the National Institute for Health and Care Research (NIHR) revealed that the NHS had commissioned a £10.7 million clinical trial on puberty blockers which is planned to last until 2031. The trial, called "Pathways", will consist of four parts and be led by Emily Simonoff, a head professor of child and adolescent psychiatry at the King's College London. The trial will involve children being given puberty blockers while having their physical, social and emotional well-being monitored over the span of two years, including regular brain scans to track whether puberty blockers impact their thinking and brain development. Other studies will involve monitoring the well-being of children attending new NHS gender clinics who do not receive puberty blockers. The children also must have the permission of their parents and doctors to participate in the trial. Additionally, the children in the trial will continue to receive psychosocial support and researchers will talk to children about their experiences living with gender dysphoria and the care they receive, as well as getting the opinions of parents and staff. Cass welcomed the news, saying the trial "aims to fill some of the gaps in our knowledge about the outcomes of different interventions".[25][142]

## Reception within the United Kingdom

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### Response from UK political parties and public bodies

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Conservative Prime Minister at the time Rishi Sunak said that the findings "shine a spotlight" on the need for a cautious approach to child and adolescent gender care.[143][144] In their manifesto for the 2024 United Kingdom general election, the Conservatives promised to implement the Cass Review recommendations.[145]

Wes Streeting, the Labour shadow Health Secretary at the time, welcomed the final report, saying it was "a watershed moment for the NHS's gender identity services". Both Streeting and then Shadow Home Secretary Yvette Cooper said Labour would implement the report's recommendations in full.[146] In its statement, LGBT+ Labour urged their party to "exercise caution in responding to the review", saying that while it got things right, it had "received credible criticism from trans advocacy groups and researchers".[147]

In April 2024, the Green Party of England and Wales released a statement on the review. This was withdrawn an hour later, after the LGBTIQA+ Greens threatened to remove support for their party's leaders. The withdrawal was criticised by gender-critical members.[148]

The Equality and Human Rights Commission, a non-departmental public body, described the Cass Review as a "vital milestone" and called for all service providers to fully implement its recommendations.[149]

### Response from devolved governments

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The Scottish Government said it would "take the time to consider the findings" of the review.[150] Humza Yousaf, First Minister of Scotland and Scottish National Party (SNP) leader at the time, said the review would be given "utmost consideration", that "all recommendations" made by it would be considered, and that decisions on changes to treatments as a result of the review would be made by clinicians rather than politicians.[151][152]

The Scottish Greens, then a part of the Scottish Government, criticised the review at its initial publication.[153] Patrick Harvie, co-leader of the Scottish Greens, said he'd seen "far too many criticisms" of the review for him to say it was a "valid scientific document".[154][155][156] Harvie's comments were controversial and widely critcised,[157][158][155] and the resulting tension with the SNP has been cited as a factor in the collapse of the Bute House Agreement.

The Welsh Senedd initially voted against a motion tabled by the Welsh Conservatives Shadow Social Justice Minister to accept the findings of the Cass Review in full. Subsequently, the Senedd voted unanimously to pass an amended motion noting "NHS England has concluded there is not enough evidence to support the safety or clinical effectiveness of puberty suppressing hormones for the treatment of gender dysphoria in children and young people" and "the Welsh Government will continue to develop the transgender guidance for schools taking account of the Cass review and stakeholder views".[159]

Citing the Cass Review findings, in August 2024 the Northern Ireland Executive agreed to the extension of the ban on the private sale and supply of puberty blockers to Northern Ireland.[160] This was supported by all parties in the Executive at the time apart from the Alliance Party.[161]

### Response from health bodies in the United Kingdom

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In April 2024, the British Psychological Society (BPS) said they supported "the report's primary focus of expanding service capacity across the country" and acknowledged that "while psychological therapies will continue to have an incredibly important role to play in the new services, more needs to be done to assess the effectiveness of these psychological interventions." BPS president Roman Raczka said the review was "thorough and sensitive", and welcomed the recommendation for a consortium of relevant bodies to develop better trainings and upskill the workforce.[7] Rob Agnew, chair of the BPS's Sexualities Section, described it as "bad news for our trans youth" and said it was "out of step with better quality, more comprehensive reviews".[162]

The Royal College of Psychiatrists (RCP) welcomed the report. They supported the emphasis on a holistic and person-centred approach and research to improve the evidence basis for treatment protocols. They said that some of its trans members, and the wider trans community, had concerns about availability of treatments while awaiting research, said there was "a strong view that the report makes assumptions in areas such as social transition and possible explanations for the increase in the numbers of people who have a trans or gender diverse identity, which contrasts with the more decisive statements about treatment approaches", and called for direct and comprehensive involvement of those with lived experience.[163]

The Royal College of Paediatrics and Child Health (RCPCH) said they would take the time to review the recommendations in full and said that data collected had identified a lack of confidence by paediatricians and GPs to support this patient group, which the RCPCH pledged to address by developing new training.[164] In August 2024, the RCPCH acknowledged there had been some academic criticism of the Cass Review and a call to pause the implementation of recommendations, but that "pausing the implementation of the Cass report recommendations would be a backwards step for Gender Identity Services, as this will again delay care and therefore risks causing further harm to this patient population". They stated they were engaged with NHS England and as a part of this would "encourage NHSE to consider emerging criticisms of any chosen approach, as would be the case in the delivery of any other children's health service."[165]

In July 2024, the Royal College of General Practitioners updated its position statement on the role of the GP in transgender care in response to the Cass Review. They advise that, for patients under 18, GPs should not prescribe puberty blockers outside of clinical trials, and the prescription of gender-affirming hormones should be left to specialists. The GCGP says it will fully implement the Cass Review recommendations. They specifically highlight recommendations for continuity of care for 17–25 year olds, and the need for additional services for those people considering detransition.[166]

The same month Vassili Crispi, a member of the governing council of the British Medical Association (BMA) and member of its LGBTQ+ network, brought a motion calling for the BMA to initiate an evidence-based critique of the review's methodology and oppose the governments legislative approach. He later stated the Cass Review was commissioned, funded, and published "by an openly gender-critical government", representing a conflict of interest.[167] The BMA, which represents 190,000 doctors, passed the motion calling for the organisation to "publicly critique" the Cass Review and oppose the implementation of its "unsubstantiated recommendations". After the motion was leaked to journalist Hannah Barnes, more than 1,500 doctors (including nearly 1,000 BMA members) signed an open letter to the BMA which criticised the council for "going against the principles of evidence-based medicine and against ethical practice".[168][169] In September 2024, the BMA council voted to instead maintain a neutral position on the issue until the completion of its own evaluation of the Cass Review.[10][170]

The Academy of Medical Royal Colleges (AoMRC) released a statement in August 2024 in support of the report's recommendations, stating that "further speculative work risks greater polarisation", and that "our focus should be on implementing the recommendations of the Cass Review".[9]

#### Response from LGBTQ health bodies in the UK

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In April 2024, the British Association of Gender Identity Specialists (BAGIS) said it was "deeply troubled by some of the content of the Cass Review and the potential impact thereof". In December 2024, BAGIS also said it was "dismayed" to see the Department for Health and Social Care's "indefinite ban" on puberty blockers for under-18s, stating: "The Cass Review finds that puberty blockers have clearly defined benefits in narrow circumstances, which is inconsistent with a legislative ban".[12]

In July 2024, the UK's Association of LGBTQ+ Doctors and Dentists (GLADD) criticised the British Medical Journal's coverage of the Cass Review, stating that some recommendations could be beneficial while others could create new barriers to care for transgender youth. It also criticised "The weaponisation of the Cass review against trans people" by political parties and campaigners.[171] In October, GLADD released an official response to the review, stating they were broadly supportive of its recommendations but were "concerned with what we believe to be an ingrained bias against the autonomy of trans people throughout the narrative text" which had also been noted by others. Of the 32 recommendations of the Cass Review, GLADD supported 15, and said that it could support a further 14 with provisos, could not support two, and was neutral on one. GLADD also said the Cass Review "may implicitly pathologise trans and non-binary identities" or "perpetuate stigmatisation of this population", including in its discussions of social transition, the suggestion that gendered toy preference is biologically deterministic, and the language used regarding masculinising/feminising hormones as a negative or undesirable outcome.[13]

### Hilary Cass's response

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In an interview given the week after the release of the final report, Cass described receiving abusive emails and said she was given security advice to avoid public transport.[17] She said that "disinformation" had frequently been spread online about the report. Cass said deliberate attempts "to undermine a report that has looked at the evidence of children's healthcare" were "unforgivable" and put children at risk.[17] There were widespread misleading claims from critics of the report that it had dismissed 98% of the studies it collected and all studies which were not double-blind experiments.[18] Cass described these claims as being "completely incorrect". Although only 2% of the papers collected were considered to be of high quality, 60% of the papers, including those considered to be of moderate quality, were considered in the report's evidence synthesis.[63][172][173] Cass criticised Labour MP Dawn Butler for repeating inaccurate claims that the review had dismissed more than 100 studies during a debate in the House of Commons.[174][175][176] After talking with Cass, Butler used a point of order to admit her mistake and correct the record in Parliament, stating the figure came from a briefing she had received from Stonewall.[177][18]

In a May 2024 interview with The New York Times, Hilary Cass said:

> I think there is an appreciation that we are not about closing down health care for children. But there is fearfulness — about health care being shut down, and also about the report being weaponized to suggest that trans people don't exist. And that's really disappointing to me that that happens, because that's absolutely not what we're saying.[19]

She also said that the review was not about defining what trans means or rolling back healthcare, stating: "There are young people who absolutely benefit from a medical pathway, and we need to make sure that those young people have access — under a research protocol, because we need to improve the research — but not assume that that's the right pathway for everyone."[19]

In a May 2024 interview with WBUR-FM, Cass responded to WPATH's criticism about prioritising non-medical care, saying the review did not take a position about which is best. Cass hoped that "every young person who walks through the door should be included in some kind of proper research protocol" and for those "where there is a clear, clinical view" that the medical pathway is best will still receive that, and be followed up to eliminate the "black hole of not knowing what's best". Responding to claims that the review assumed a trans outcome was the worst outcome for a child, Cass emphasised that a medical pathway, with lifetime implications and treatment, required caution but "it's really important to say that a cis outcome and a trans outcome have equal value".[178]

## Global reception

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Professional organisations and transgender health providers have widely criticised the Review's findings.[179][4]

### Global health bodies

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The Endocrine Society responded to the report by reaffirming their support for gender-affirming care for minors and saying that their current policies supporting such treatments are "grounded in evidence and science".[180] The Endocrine Society said the Review "does not contain any new research that would contradict the recommendations made in our Clinical Practice Guideline on gender-affirming care" and concluded "Banning evidence-based medical care based on misinformation takes away the ability of parents and patients to make informed decisions.".[180]

The World Professional Association for Transgender Health (WPATH) released an email statement saying the report is "rooted in the false premise that non-medical alternatives to care will result in less adolescent distress" and further criticised recommendations which "severely restrict access to physical healthcare, and focus almost exclusively on mental healthcare for a population which the World Health Organization does not regard as inherently mentally ill".[181][182] An official statement expanded on these concerns, saying Hilary Cass had "negligible prior knowledge or clinical experience" and that "the (research and consensus-based) evidence" suggests medical treatments such as puberty blockers and hormone therapy were "helpful and often life-saving". It questioned the provision of puberty blockers only in the context of a research protocol: "The use of a randomized blinded control group, which would lead to the highest quality of evidence, is ethically not feasible."[183]

In 2022, WPATH, ASIAPATH, EPATH, PATHA, and USPATH, responding to the NHS policy changes arising from the Interim Report, had stated they "makes assumptions about transgender children and adolescents which are outdated and untrue" including "the supposition that gender incongruence is transient in pre-pubertal children", arguing it "quotes selectively and ignores newer evidence about the persistence of gender incongruence in children" in addition to noting issues with the older studies.[14] They further said the statement "the primary intervention for children and young people... is psychosocial (including psychoeducation) and psychological support and intervention" was alarming. They said "this 'psychotherapeutic' approach, which was used for decades before being superseded by evidence-based gender-affirming care, has not been shown to be effective. Indeed, the denial of gender-affirming treatment under the guise of 'exploratory therapy' has caused enormous harm to the transgender and gender diverse community and is tantamount to 'conversion' or 'reparative' therapy under another name".[14]

International transgender healthcare bodies,[14] other international organisations,[184][185] researchers,[186] and politicians[185][187] have also criticised the recommendation that children and young people accessing puberty blockers should be required to sign up to a research trial.[183][186][14]

### Australia and New Zealand

[edit]

The Royal Australian and New Zealand College of Psychiatrists rejected calls for an inquiry into trans healthcare following the release of the Cass Review, characterising it as one review among several in the field. They emphasised that, "assessment and treatment should be patient centred, evidence-informed and responsive to and supportive of the child or young person's needs and that psychiatrists have a responsibility to counter stigma and discrimination directed towards trans and gender diverse people."[188]

The Professional Association for Transgender Health Aotearoa (PATHA), a New Zealand professional organisation, said the Cass Review made "harmful recommendations" and was not in line with international consensus. It suggested that "Restricting access to social transition is restricting gender expression, a natural part of human diversity". It also said trans or non-binary people were not included in the Cass Review's planning and decision-making – including clinicians experienced with affirmative care – while several people involved in the review had "previously advocated for bans on gender-affirming care" in the U.S., and had "promoted non-affirming 'gender exploratory therapy', which is considered a conversion practice". PATHA criticised the exclusion of those with clinical and lived experience of gender-affirming care from "its decision-making, conclusions, or findings" and the exclusion of trans people from the review's Governance Assurance Group "on the basis of potential bias".[189][5]

A joint statement by Equality Australia, signed by the Australian Professional Association for Trans Health (AusPATH) and PATHA among others, said the review "downplays the risk of denying treatment to young people with gender dysphoria and limits their options by placing restrictions on their access to care".[189][190][191]

### Canada

[edit]

The Canadian Pediatric Society responded that "Current evidence shows puberty blockers to be safe when used appropriately, and they remain an option to be considered within a wider view of the patient's mental and psychosocial health."[192] Members of the Canadian Pediatric Society's Adolescent Health Committee stated "there are significant limitations, biases, and inaccuracies within the Review", that "the Review has been noted to include incorrect citations of evidence (6) and inaccurate, sometimes scientifically disproven speculations", and concluded "The Cass Review is a critique, authored by a single individual, presenting a perspective on current practices in a particular context, and it will inform care. It does not, however, purport to be 'the new international standard of care', and it should not be treated as such."[193]

### Europe

[edit]

In June 2024, the European Society for Child and Adolescent Psychiatry (ESCAP) issued a statement which referred to the Cass Review systematic reviews along with previous reviews conducted in the UK, Sweden, Finland and Germany which also found a lack of evidence for the safety or efficacy of puberty blockers and cross-sex hormones to treat minors with gender dysphoria. ESCAP stated that "there is an urgent need to apply widely endorsed clinical, scientific, and ethical standards to the care of children and adolescents with gender dysphoria", called for healthcare providers "not to promote experimental and unnecessarily invasive treatments with unproven psycho-social effects", and insisted on the importance of "respect for all kinds of different views and attitudes" in professional debate.[194]

In September 2024, in reference to the NHS' planned implementation of this recommendation that puberty blockers be restricted to clinical trials, as well as a similar protocol in Sweden, a thematic report prepared by the Council of Europe Committee of Experts on Sexual Orientation, Gender Identity and Expression, and Sex Characteristics (ADI-SOGIESC) said: "There are ethical implications of only offering treatment to a small group of patients, potentially violating the fundamental ethical principles governing research ... as for many young people the only way to receive treatment is to participate in the trial, therefore calling into question whether consent can be constituted as free and informed in these situations".[184][185]

### Germany, Austria, and Switzerland

[edit]

In 2025 a collaboration of Germany, Austria, and Switzerland, led by the Association of the Scientific Medical Societies in Germany, produced new clinical practice guidelines on transgender healthcare which criticised the Cass Review's methodology, conclusions, and lack of transparency. The guidelines stated there are "no proven effective treatment alternative without body-modifying medical measures for a [person with] permanently persistent gender incongruence" and criticised the potentially harmful recommendation of psychotherapy for distress related to gender dysphoria as no studies in the review showed a reduction in dysphoria through psychotherapy. It further criticised the Cass Review's lack of involvement from medical professional societies, its "assurance group" being explicitly uninvolved in the development of recommendations, and the presence of an "advisory board" whose composition and contributions weren't documented.[61][195]

### Japan

[edit]

In August 2024, the Japanese Society of Psychiatry and Neurology [ja] published updated guidelines on the treatment of gender dysphoria. The guidelines considered the Cass Review, describing it as specific to the unique situation in the UK, noted criticism of the Cass Review by other international organisations, and stated that the WPATH SOC8 considered more systematic reviews. The guidelines further said it is "self-evident" that, unless puberty is suppressed, development of sex characteristics are irreversible in AMAB individuals. The society stated they will continue to track and recommend prescriptions of puberty blockers in Japan to minors and expand to tracking discontinuations and switches to hormone therapy.[16][196]

### Netherlands

[edit]

The Amsterdam University Medical Center said it agrees with the goals of reducing wait times and improving research, but disagrees that the research-base for puberty blockers is insufficient, stating that puberty blockers have been used in trans care for decades. It stated they did not consider it ethical to mandate youth who desire puberty blockers to be registered in research trials, that it was worrying that after closing GIDS youth seeking trans healthcare were deprived of care, and that it "regrets that this situation arose for patients in England."[197]

### Poland

[edit]

A Polish Framework guidelines for the process of caring for the health of adolescent transgender (T) and non-binary (NB) people experiencing gender dysphoria was released in 2024 which said the Cass Review "caused a stir in public opinion and immediate harsh criticism from the medical and patient communities worldwide" and criticised Cass being chosen for her lack of experience in trans healthcare. It stated "the common thread of many objections to the Cass report is the multifaceted downplaying of the importance of the voices of adolescents and their families, clinical practice, the scientific knowledge base, and national and global recommendations, while misleading the public that a complete lack of clinical experience in a given field is a guarantee of reliability."[198]

### United States

[edit]

The American Academy of Pediatrics responded to the report by reaffirming its support for gender-affirming care for minors and saying that their current policies supporting such treatments are "grounded in evidence and science".[180] The American Psychological Association stated they were studying the Cass report but "stand by" their position statement in support of gender-affirming care.[199]

In May 2025, the United States Department of Health and Human Services under President Donald Trump released a report in compliance with a January executive order forbidding the government from supporting gender transitions under 19.[200] The report expressed support for the Cass Review and its findings, which it cited extensively, calling it the "most comprehensive" and "most influential" evaluation of youth gender affirming care to date.[201][202]

## Reception by academics and researchers

[edit]

Some academics in the UK agreed with the Cass Review's findings stating a lack of evidence;[203][108][204] others, both in the UK[205] and internationally, disagreed with the report's methodology and findings.[192][206][207]

Several scholars and organisations have criticised the Cass Review's conclusions and the evidence base used to support them.[59][208] Researchers Cal Horton and Ruth Pearce have said of the Cass Review, "its most controversial recommendations are based on prejudice rather than evidence".[208] Cal Horton criticised the Interim Report and other documents for prioritising research on aetiology of trans identities, saying: "Research into the causation of trans identities has a pathologized history, running parallel to efforts to prevent or cure transness."[209] Cal Horton also criticised the Interim Report's support of exploratory therapy and its use of the terminology of "desistance".[209]

Various scholars also criticised the emphasis on high and moderate quality evidence, saying that paediatric care often relies on low quality evidence in other areas; that in downgrading qualitative research, the patient voice was minimised; and that the highest quality evidence (such as from randomised controlled trials) may be difficult or unethical to obtain in this area.[186][179][209][better source needed]

Academics have also criticised unsupported claims that social transition and puberty blockers may "change the trajectory of psychosexual and gender identity development" and that youth who transition may lose the opportunity to experience adulthood as a gender they don't identify with.[citation needed]

In September 2024, a commentary was published in Journal of Adolescent Health arguing that other scholars had made "lengthy and nuanced rebuttals to the Cass report". The commentary says that Cass' conclusions generally focus on "limiting or minimizing medical gender-affirming care (GAC) for youth" and that she "minimizes the robust data and the potential negative impact of increasing barriers for an already disenfranchised group". The commentary states that "GAC for youth is well supported by evidence" and that concerns about the evidence base and the need for more research "do not warrant removal of access to this important care". The commentary further suggests that randomised controlled trials (RCT) would not be ethically feasible for young people experiencing gender dysphoria.[210]

In November 2024, over 200 educational psychologists signed an open letter addressed to education secretary Bridget Phillipson. The letter expressed concerns about the "processes and findings of the Cass review" and the impact of the Cass Review on children and young people in education.[211] That same month, the healthcare division of the RAND Corporation (a US-based research institute), released its own systematic review into treatments for trans and gender expansive young people, in which it described several similarities and differences between its own approach and that of the Cass Review.[i] The report rated the existing evidence base as having low and very low certainty, but also found the treatments to be low risk and with little evidence of side-effects, regret, or dissatisfaction.[j] It said the Cass Review was "highly comprehensive", but said its findings may have limited applicability outside the context of the NHS.[k]

On 9 May 2025 a critical evaluation of the Cass report and its seven commissioned reviews was published in BMC Medical Research Methodology. Using an independent Risk of Bias (ROBIS) tool, the evaluation identified a "high risk of bias" in all seven reviews as well as "methodological flaws", "unsubstantiated claims", and "misrepresentation of evidence".[215][216]

### Yale Law School Integrity Project

[edit]

In July 2024, The Integrity Project at Yale Law School released a white paper which said the Cass Review had "serious flaws".[217][218][219] The white paper, co-authored by a group of eight legal scholars and medical researchers, suggests that the Cass Review "levies unsupported assertions about gender identity, gender dysphoria, standard practices, and safety of gender-affirming medical treatments, and it repeats claims that have been disproved by sound evidence". It concluded that the review "is not an authoritative guideline or standard of care, nor is it an accurate restatement of the available medical evidence on the treatment of gender dysphoria."[217][218]

The white paper criticised the review's recruitment for focus groups, which included individuals who were not clinicians and who had unclear expertise, and said that the review "is not an accurate restatement of the available medical evidence on the treatment of gender dysphoria".[186][217] In reference to one question, where a third of respondents agreed with the statement "There is no such thing as a trans child", the authors write: "Denying the existence of transgender people of any age is an invalid professional viewpoint. The involvement of those with such extreme viewpoints is a deeply concerning move for a document that issues recommendations on clinical care."[186][220] The Yale Integrity Project white paper suggested that what the Cass Review referred to as the "exponential change in referrals" to youth gender services was not actually exponential, and that the recorded growth could be the result of double counting data points. Further, the paper criticises the Cass Review for suggesting that "peer and socio-cultural influence" are driving the increase in referrals, a claim which originates from a single article that has been heavily corrected for numerous well-documented fatal flaws.[186] The Cass Review also suggested that the provision of gender-affirming care appeared "rushed, careless, and common", though its data showed waiting times for assessment were over two years and only 27% of patients seen during the review were referred to endocrinology for consideration of medical intervention.[179][186] The Yale Integrity Project also criticised the review's discussions of evidence quality, since it introduces the GRADE approach and uses its terminology but does not evaluate evidence using the GRADE framework, and "takes the unusual step of elevating its own assessment of evidence quality above the considerations that guideline developers value".[186]

## Reception by advocacy organisations

[edit]

Amnesty International criticised "sensationalised coverage" of the review, stating it was "being weaponised by people who revel in spreading disinformation and myths about healthcare for trans young people".[221][222]

### LGBTQ organisations

[edit]

The International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA), international LGBTQ student organisation IGLYO, and Transgender Europe released a joint statement which criticised the Cass Review's "poor and inconsistent use of evidence, pathologising approaches, and exclusion of service users and trans healthcare experts", as well as the review's exclusion of service users and trans healthcare experts.[4] ILGA and Transgender Europe also raised concerns about "pathologizing approaches" and the use of language like "gender questioning" to refer to transgender youth.[4]

Trans youth charity Mermaids and the LGBTQ+ charity Stonewall endorsed some of the report's recommendations, such as expanding service provisions with the new regional hubs, but raised concerns the review's recommendations may lead to barriers for transgender youth in accessing care.[5]

In October 2024, 100 LGBTQ+ organisations and activists signed a letter to Wes Streeting expressing a "deep lack of confidence" in the Review. Concerns included Cass's selection without consideration of other candidates, "secrecy" regarding the report's commissioning, and "explicit exclusion of any trans people from involvement in the Governance Assurance Group, on the basis of potential bias". It described the review as "an absurd spectacle" with extensively documented technical failings and said, "There is a real concern, therefore, that the review promotes an inherently flawed approach to determining the efficacy and safety of clinical support for trans healthcare".[6][223]

Trans advocates have criticised the Cass Review for its alleged connections with anti-trans activism.[224][225] LGBTQ advocates specifically criticised meetings between Cass, members of her team, and members of Florida governor Ron DeSantis' medical board, which restricted transgender healthcare in Florida.[226][227] Cass met with board member Patrick Hunter, a member of the Society for Evidence-Based Gender Medicine (SEGM) and Catholic Medical Association.[228][229] Hunter and Cass exchanged materials and Cass was invited to present to the board.[230][231]

### Unions

[edit]

In June 2024, the University and College Union's (UCU) national executive committee unanimously passed a motion criticising the review's methodology, sourcing and claims.[l] This was met with criticism from some academics and union members, who said the move "risks making the union appear anti-scientific".[232] The UCU brought a version of the motion to the Trades Union Congress (TUC) LGBT+ conference, where it was carried without opposition.[233]

### Reception by gender-critical organisations

[edit]

See also: 21st-century anti-trans movement in the United Kingdom

Gender-critical organisations including Sex Matters and Genspect welcomed the report. Stella O'Malley of Genspect said that if a conversion therapy ban were to criminalise any exploration into why a child identifies as trans, it "would ban the very therapy that Cass is saying should be prioritised".[234][235]

## Subsequent government actions in the UK

[edit]

### Ban on puberty blockers

[edit]

#### Private prescription

[edit]

In May 2024, then Health Secretary Victoria Atkins implemented an emergency three-month ban on the prescription of puberty blockers by medical providers outside of the NHS.[m] It went into effect on 3 June 2024 and was set to expire on 3 September 2024. The ban restricted their use to those already taking them, or within a clinical trial. In July, this ban was challenged by campaign groups TransActual and the Good Law Project who brought a legal case arguing the ban was unlawful.[236] On 29 July 2024, the High Court of Justice ruled that the ban was lawful.[237][20][238]

The Health Secretary Wes Streeting welcomed the decision as "evidence led", and said efforts were being made to set up a clinical trial to "establish the evidence on puberty blockers".[20][238] Following the ruling, TransActual announced they would not appeal the decision due to limited funds and the unlikelihood of an appeal being heard before the ban expires.[239]

On 22 August 2024, the government extended the emergency ban until 26 November 2024. The ban was also extended to cover Northern Ireland, following agreement from the Northern Ireland Executive and came into effect on 27 August 2024.[240][241][242] On 6 November 2024 the ban was extended again to 31 December 2024.[243] On 11 December 2024, the ban was renewed indefinitely and is set to be reconsidered in 2027.[185][244]

#### Commission on Human Medicines review

[edit]

In January 2025, the Commission on Human Medicines (CHM) delivered a report on the proposed permanent restriction of the use of puberty blockers for children and young people. The review stated that both "Baroness Cass and the independent CHM found that there is a lack of evidence for the efficacy of these medicines in the treatment of gender incongruence and/or gender dysphoria, and that there is currently an unsafe prescribing environment." The report recommended an indefinite ban until prescriptions could be deemed safe, with legislation to be reviewed in 2027. According to the report, the proposed ban was opposed by the Royal College of General Practitioners, the British Medical Association and the Royal College of Psychiatrists.[245][246]

#### Ban on cross-sex hormones

[edit]

In May 2025, Government lawyers confirmed that Wes Streeting was "actively reviewing" a potential ban on prescription of cross-sex hormones to under-18s, with an expert panel due to deliver a report on the matter in July.[247][248]

### Adult clinics

[edit]

The Cass Review did not cover adult care, but in April 2024, NHS England said it would also initiate a review of adult gender clinics.[249] NHS England National Director of Specialised Commissioning John Stewart sent a letter to Cass stating that it would review the use of transgender hormone therapy in adults in a similar manner as was done for puberty blockers in the Cass Review.[250][251][252]

In May 2024, Cass wrote to NHS England to pass on the feedback regarding adult care from clinicians who had approached her during the review process. Clinicians across the country in adult gender services had expressed concern about both the clinical practice and model of care. Some clinicians in other settings, especially general practice, had raised concerns about the treatment of patients under their care.[253] On 7 August, NHS England included a response to the adult care letter in a status report for the under-18s services.[254]

On 8 August, they stated the review of adult services would be led by Dr. David Levy, medical director for Lancashire and South Cumbria integrated care board, to assess "the quality (i.e. effectiveness, safety, and patient experience) and stability of each service, but also whether the existing service model is still appropriate for the patients it is caring for"; and that Dr. Levy would work with a group of "expert clinicians, patients and other key stakeholders, including representatives from the CQC, Royal Colleges and other professional bodies and will carefully consider experiences, feedback and outcomes from clinicians and patients, past and present". The first onsite visits are planned to start in September 2024. The findings will be used to support an updated adult gender service specification which will then be liable to engagement and public consultation. Unlike the Cass Review, the review of adult gender services is expected to be completed within months, rather than years.[22][255][256]

In December 2024, it was reported that a number of GPs had begun refusing or withdrawing hormone treatment from adult trans patients, for reasons including insufficient funds, the Cass Review, and the Royal College of GPs' response to the Cass Review – despite the Cass Review only applying to youth services.[257]

### NHS Scotland

[edit]

On 18 April 2024, NHS Scotland announced that it had paused prescribing puberty blockers to children referred by its specialist gender clinic.[258] The chief medical officer of Scotland set up a multidisciplinary clinical team to assess how the Cass Review's 32 recommendations might be applied to NHS Scotland. Their Cass Review – implications for Scotland: findings report was published in July 2024 and found that the majority of recommendations were applicable to NHS Scotland to a varying degree, with some modification dealing with differences in the Scottish health service. They recommended that the use of puberty blockers be paused until clinical trials are begun. NHS Scotland will participate in the forthcoming UK study.[259] That report was fully accepted by the Scottish government in September. Among the changes recommended are that the gender identity service for children and young people should be moved to a paediatric setting and more than one service offered across the regions. In common with other specialities, a referral to these services will now have to come from a clinician.[23]

### Department for Education

[edit]

In May 2024, the UK government released a draft of new Relationships, Sex and Health Education (RSHE) guidelines. The guidelines would ban lessons on the "contested theory of gender identity" and emphasised that any instruction on transgender people must focus on the legality of transitioning and the fact one has to be 18 to legally change their gender. A press release accompanying the guidelines stated that "In light of the Cass Review, it is important that schools take a cautious approach to teaching about this sensitive topic and do not use any materials that present contested views as fact, including the view that gender is a spectrum."[260][261]

## See also

[edit]

* 21st-century anti-trans movement in the United Kingdom
* Bell v Tavistock
* Evidence-based medicine
* Time to Think
* Transgender health care
* Transgender rights in the United Kingdom
* Trump administration HHS gender dysphoria report
* LGBTQ rights in the United Kingdom
* Transgender history in the United Kingdom

## Endnotes

[edit]

1. ^ Between 2009–10 and 2019–20, the number of referrals increased from 77 to more than 2,700.[43][44][45][46]
2. ^ Over time, the service adopted international standards from the Dutch Protocol and the WPATH and the Endocrine Society guidelines.[47][48]
3. ^ "Before 2011, Gids would give puberty blockers to children only once they had turned 16. But as gender clinics around the world began providing blockers to those who had just begun puberty, reports grew of UK children going overseas to buy the drugs. And in 2011, a medical study was approved through which younger children could access these drugs...In 2014, despite the patchwork of information about the study – which was still running – a change in Gids' policy was approved by NHS England: children with gender dysphoria, who were just beginning puberty, could now be eligible for blockers."[49][43][50]
4. ^ According to Cass: "In 2011, a study began to evaluate the impact of administering puberty blockers to younger children. By 2014, when the study had just finished recruiting its final participants, GIDS lowered the age at which young people could be referred for treatment with blockers from 16 to those in the early stages of puberty. There was no lower age limit as such, but it meant in some instances that children of nine or 10 could now be eligible to be referred for this medical intervention."[51]
5. ^ Between 2019 and 2020, issues were raised about services and the evidence base for treatments in reports by the Royal College of General Practitioners (RCGP), an NHS England Policy Working Group, and the National Institute for Health and Care Excellence (NICE).[52][53]
6. ^ The Centre for Reviews and Dissemination is one of three bodies funded by the National Institute for Health and Care Research (NIHR) to provide a systematic review service to the NHS.[56]
7. ^ The systematic reviews considered studies of patients up to 18 years old, although young adults up to 30 were included in the qualitative research to discuss their prior experiences.[72]
8. ^ On medical treatments: "When the Review started, the evidence base, particularly in relation to the use of puberty blockers and masculinising or feminising hormones, had already been shown to be weak"; and that after the examination of over 100 pieces of potential evidence, that "there continues to be a lack of high-quality evidence in this area".[92] On psychosocial treatments: "A problem, that has become increasingly apparent as the Review has progressed is that research on psychosocial interventions and longer-term outcomes for those who do not access endocrine pathways is as weak as research on endocrine treatment. This leaves a major gap in our knowledge about how best to support and help the growing population of young people with gender-related distress in the context of complex presentations.[93]
9. ^ According to the report: "The systematic reviews conducted for the Cass Review used similar methods to our work, with some variations—for example, the reviews were restricted to studies with participants age 18 and younger, excluded case studies and non-English studies, used different risk-of-bias assessment tools, excluded studies meeting less than 50 percent of bias assessment criteria from syntheses in the hormonal intervention reviews, and did not provide certainty-of-evidence ratings for outcomes (Taylor, Mitchell, Hall, Langton, et al., 2024; Taylor, Mitchell, Hall, Heathcote, et al., 2024)."[212]
10. ^ According to the report: "Our review found that the available evidence suggests low risks of harmful outcomes from gender-affirming interventions, such as regret, dissatisfaction, side effects, or complications. Potential harms, such as bone health and fertility effects of hormonal interventions, warrant ongoing clinical and research attention because of the very low certainty of evidence available, as well as limited evidence for adjunctive interventions that mitigate those harms (e.g., fertility preservation). Nevertheless, these interventions have not shown the serious risks of harm that would suggest the need for policies to restrict the interventions. The low regret rate—though again based on very low certainty of evidence—is consistent with a meta-analysis (Bustos et al., 2021), primarily of adult literature, that found that regret rates were under 2 percent for gender-affirming surgery (i.e., the most intensive TGE-affirming intervention). That finding continues to be replicated (e.g., Bruce et al., 2023). By comparison, a systematic review that explored a variety of other surgical procedures unrelated to gender dysphoria (Wilson, Ronnekleiv-Kelly, and Pawlik, 2017) found an average regret rate of 14 percent."[213]
11. ^ According to the report: "As one example, the Cass Review did not include evidence for gender-affirming surgery because the National Health Service had already restricted that intervention to individuals age 18 or older. In contrast, we sought to provide evidence summaries that practice and policy decisionmakers could more broadly consider across diverse contexts."[214]
12. ^ The motion said the review has "serious methodological flaws", "provides no evidence for the 'new approach' it recommends", and is based on "selective use of evidence and promotion of unevidenced claims".[232]
13. ^ NHS England had already announced it would no longer prescribe puberty blockers to minors outside of clinical trials in March 2024.[88][133]

## References

[edit]

1. ^ "NHS commissioning » Independent review into gender identity services for children and young people". NHS England (Primary source). Archived from the original on 9 April 2024. Retrieved 9 April 2024.
2. ^ "The Chair – Cass Review". Cass Independent Review (Primary source). Archived from the original on 9 April 2024. Retrieved 9 April 2024.
3. ^ Parry, Josh; Pym, Hugh (10 April 2024). "Hilary Cass: Weak evidence letting down children over gender care". BBC News (News). Archived from the original on 27 April 2024. Retrieved 28 April 2024.
4. ^ a b c d "Joint statement: Trans children and young people in schools deserve safety and understanding". ILGA, Transgender Europe, and IGLYO. 2 September 2024. Retrieved 2 January 2025.
5. ^ a b c "How LGBTQIA+ charities are responding to the Cass review". Gay Times (News). 11 April 2024. Archived from the original on 11 April 2024. Retrieved 11 April 2024.
6. ^ a b Hansford, Amelia (18 October 2024). "LGBTQ+ experts criticise Cass Review in open letter to Wes Streeting". Retrieved 2 January 2025.
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* Smith 2024
* RCPCH 2024
* RCGP 2024

9. ^ a b "Academy statement: Implementation of the Cass Review". Academy of Medical Royal Colleges (Statement). Archived from the original on 1 August 2024.
10. ^ a b "BMA takes 'neutral position' on gender review". BBC News. 27 September 2024. Archived from the original on 28 September 2024. Retrieved 28 September 2024.
11. ^ "BMA to undertake an evaluation of the Cass Review on gender identity services for children and young people" (Press release). British Medical Association. 31 July 2024. Archived from the original on 31 July 2024. Retrieved 31 July 2024.
12. ^ a b "Position & Process Statements: Initial BAGIS statement on the Cass Review". BAGIS. Archived from the original on 16 January 2025. Retrieved 21 December 2024.
13. ^ a b "GLADD Response to the Cass Review" (PDF). The Association of LGBTQ+ Doctors and Dentists (GLADD). 28 October 2024. Archived from the original (PDF) on 12 February 2025.
14. ^ a b c d e f "WPATH, ASIAPATH, EPATH, PATHA, and USPATH Response to NHS England in the United Kingdom (UK): Statement regarding the Interim Service Specification for the Specialist Service for Children and Young People with Gender Dysphoria (Phase 1 Providers) by NHS England" (PDF) (Press release). 25 November 2022. Archived (PDF) from the original on 14 April 2024. Retrieved 13 April 2024.
15. ^

* WPATH; EPATH (10 October 2023). "30.10.23 EPATH - WPATH Joint NHS Statement Final" (PDF). WPATH (Press release). Archived from the original on 11 April 2024. Retrieved 14 April 2024.
* "Cass Review' author: More 'caution' advised for gender-affirming care for youth". WBUR-FM. 8 May 2024. Archived from the original on 9 May 2024. Retrieved 9 May 2024.
* PATHA 2024
* Reed 2025
* Vandermorris et al. 2024, pp. 415–416
* Gawlik-Starzyk et al. 2025, p. 5

16. ^ a b "Seibetsu fu gō ni kansuru shindan to chiryō no gaidorain (dai 5-ban)" 性別不合に関する診断と治療のガイドライン (第 5 版) [Guidelines for the diagnosis and treatment of gender dysphoria (5th ed.)] (PDF). The Japanese Society of Psychiatry and Neurology (in Japanese). August 2024. pp. 16–18\. Archived (PDF) from the original on 1 October 2024. Retrieved 29 September 2024.
17. ^ a b c Beal, James (19 April 2024a). "Hilary Cass: I can't travel on public transport after gender report". The Times. Archived from the original on 20 April 2024. Retrieved 20 April 2024.
18. ^ a b c "It's misleading to say 100 studies were not included in the Cass Review". Full Fact. 20 May 2024. Retrieved 13 December 2024.
19. ^ a b c Ghorayshi, Azeen (13 May 2024). "Hilary Cass Says U.S. Doctors Are 'Out of Date' on Youth Gender Medicine". The New York Times. Archived from the original on 13 May 2024. Retrieved 13 May 2024.
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### Works cited

[edit]

* Aaron, Daniel G.; Konnoth, Craig (15 January 2025). "The Future of Gender-Affirming Care — A Law and Policy Perspective on the Cass Review". New England Journal of Medicine. 392 (6): 526–528\. doi:10.1056/NEJMp2413747. ISSN 0028-4793. PMID 39813640.
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* Beal, James (23 April 2024b). "Cass author condemns 'misinformation' spread by trans lawyer". The Times. Archived from the original on 22 April 2024. Retrieved 23 April 2024.
* Campbell, Denis; Gentleman, Amelia; Vinter, Robyn (10 April 2024). "Thousands of children unsure of gender identity 'let down by NHS', report finds". The Guardian (News). Archived from the original on 3 July 2024. Retrieved 10 April 2024.
* Cass, Hilary (10 March 2022). "Interim report – Cass Review". The Cass Review. Archived from the original on 13 January 2023. Retrieved 15 January 2023.
* Cass, Hilary (10 April 2024). "Final Report – Cass Review". The Cass Review. Archived from the original on 9 April 2024. Retrieved 10 April 2024.
* Gawlik-Starzyk, Aneta; Dora, Marta; Baran, Dorota; Szostakiewicz, Łukasz; Trofimiuk-Müldner, Małgorzata; Müldner-Nieckowski, Łukasz; Bielska-Brodziak, Agnieszka; Adamczewska-Stachura, Milena; Antosz, Aleksandra; Bajszczak, Katarzyna; Barg, Ewa; Barteczka-Eckert, Barbara; Chodecka, Aleksandra; Cichoń, Lena; Dobiała, Ewa (2025). "Framework guidelines for the process of caring for the health of adolescent transgender (T) and non-binary (NB) people experiencing gender dysphoria — the position statement of the expert panel". Endokrynologia Polska. 76 (1): 1–28\. doi:10.5603/ep.104289. ISSN 2299-8306. PMID 40071796.
* Horton, Cal (14 March 2024). "The Cass Review: Cis-supremacy in the UK's approach to healthcare for trans children". International Journal of Transgender Health: 1–25\. doi:10.1080/26895269.2024.2328249. ISSN 2689-5269.
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* "RCPCH responds to publication of the final report from the Cass Review" (Press release). Royal College of Paediatrics and Child Health. 10 April 2024. Archived from the original on 21 May 2024. Retrieved 18 May 2024.
* Reed, Erin (12 March 2025). "New German, Swiss, and Austrian guidelines recommend gender-affirming care, slam Cass Review". The Advocate. Retrieved 24 March 2025.
* Smith, Lade (22 April 2024). "Detailed response to The Cass Review's Final Report" (Press release). Royal College of Psychiatrists. Archived from the original on 16 May 2024. Retrieved 18 May 2024.
* Vandermorris, Ashley; Metzger, Dan; Vyver, Ellie; Harrison, Megan; Harvey, Johanne (1 September 2024). "Response to the Letter to the Editor on the Canadian Paediatric Society statement on gender-affirming care". Paediatrics & Child Health. 29 (6): 415–416\. doi:10.1093/pch/pxae066. ISSN 1205-7088. PMC 11557130\. PMID 39539773.
* Xian, Sophia; Dietz, Elizabeth; Fabi, Rachel (15 January 2025). "Trans Experiences In Healthcare: Testimonial Injustice in Clinical Practice". Voices in Bioethics. 11. doi:10.52214/vib.v11i.13149. ISSN 2691-4875.

## External links

[edit]

* Official website