The Cass Review: Final Report
10th April 2024
The Cass Review: Final Report
GIRES Statement following the publication of the CASS Report
Based on the peer-reviewed evidence published in reputable academic articles and the guidance published by the Endocrine Society and World Professional Society for Transgender Health the Gender Identity Research and Education Society (GIRES) has consistently endorsed a cautious affirmative approach to caring for people of all ages who experience atypical gender identity development. The Cass Review and NHS England have chosen to ignore most of that evidence and guidance.
Affirmative approaches, in the last few years, have been conflated with the medicalisation of young people. This is however a misrepresentation: affirmative approaches refer to being supportive of a child’s needs and expressions – some children might not ever need medical treatment, and yet will need to be approached in a non-judgmental way. Even the provision of puberty blockers is not affirmative in the new meaning that the word has taken: blockers in fact do not cause any permanent alteration of the body and are used in the treatment of precocious puberty.
The Cass Review and NHS England have decided to ignore the above guidance as well as significant important peer-reviewed literature, either because it did not satisfy the GRADE method of appraisal (which is unsuitable in areas of care that concern quality of life and health measures to be assessed in the long term) or because they only accepted studies that looked into puberty blockers and gender-affirming hormones separately, when instead disentangling the effects of the two forms of treatment is often not scientifically possible.
Of note, many other pediatric medications that are routinely used in pediatric care, do not and cannot have the level of evidence that Cass and NHS England demand. Anti-psychotic medications and many others have comparable if not lower levels of evidence.
In this area of care, as in any other area of care, treatment is to be provided if and when the risks of not offering treatment are worse than the risks of offering it. Doctors have a duty to consider not only the side effects and the benefits of interventions but also, obviously, the risks of leaving patients without treatment. On occasions, it is best not to treat, because the side effects of treatment would outweigh the benefit. But nobody would deny that clinicians have a duty to offer medical and surgical treatment, which might be risky and cause harm and suffering if leaving patients without those treatments were to cause patients greater risks of harm and suffering. The decision to treat, and the decision not to treat, are seldom, if ever, neutral. These decisions need to rest both on existing evidence, but also on consideration of the circumstances of the patients, of available alternatives, and likely or predictable outcomes in the short and long term of both options (treating and not treating).
Professor Simona Giordano’s book provides very full lists of relevant scientific references:Children and Gender Ethical issues in the clinical management of transgender and gender diverse youth, from early years to late adolescence: Oxford University Press 2023
Dr Ruth Pearce, Lecturer in Community Development at the University of Glasgow, and a researcher on trans healthcare, has written an article titled: What’s Wrong with The Cass Review, a round up of commentary and evidence: https://ruthpearce.net/2024/04/16/whats-wrong-with-the-cass-review-a-round-up-of-commentary-and-evidence/
Academics have published a number of critiques focussed on both the methodological issues and the inconsistencies in the report.