Gender therapy for kids built on ‘shaky foundations’

‘We’ve all let young people down’: author

A robust British review found guidelines for the treatment of children with gender dysphoria ignored standards and are based on flimsy foundations, delivering a “very hard message for people to accept,” the editor of the influential BMJ said in conversation this week with the doctor who led the review.

Pediatrician Hilary Cass’s much-anticipated report found no reliable evidence on which to base gender-affirming care for youth; the rationale for blocking puberty in young children remains unclear and muddled and that the use of cross-sex hormones in teens under 18 presents numerous unknowns.

All in, “I think we’ve all let young people down,” Cass said in her interview with BMJ editor Kamran Abbasi.

British Prime Minister Rishi Sunak said the findings of the review, released Wednesday, underscore the need for “extreme caution” on gender treatments. England has now launched a “Cass-style” inquiry into adult gender dysphoria clinics.

Whether the report will have any bearing on gender-affirming care in Canada is debatable. The Alberta government announced in January that it would introduce strict new rules around health care for transgender minors, including banning puberty blockers for those under the age of 16 and banning all chest and genitalia surgeries for minors in the province.

Conservative party Leader Pierre Poilievre has also backed a ban on puberty blockers. While Alberta is the provincial jurisdiction that has gone furthest regarding transgender health care, provincial politicians in Saskatchewan and New Brunswick have instituted rules to limit social transitioning — perhaps using a new name or pronouns — in schools without parental consent.

Here’s what to know about the landmark report, four years in the making.

What’s the Cass review and what did it do?

Launched in 2020, the Cass review was commissioned by England’s National Health Service.

Chaired by Cass, a past president of Britain’s Royal College of Paediatrics and Child Health, the independent review was tasked with trying to understand reasons behind a remarkable exponential surge in referrals to a London gender clinic known as Tavistock, especially referrals for children born female, and to recommend ways to improve care for gender-questioning kids. After her review launched, a government inspection report found care at Tavistock irresponsible and inadequate.

In her interim report in 2022, Cass said a “fundamentally different” model was needed. Tavistock closed last weekend, to be replaced by a network of regional clinics.

Cass, in her interim report, also raised concerns around the use of puberty blockers and warned against routine use of the drugs. Earlier this year, England announced that children will no longer be routinely prescribed puberty blockers at publicly funded gender clinics.

What did Cass’ final report find?

It found that there’s no tidy or single explanation for the increase in children presenting as trans or gender diverse, but rather “broad agreement that it is a result of complex interplay between biological, psychological and social factors.”

The evidence reviews, led by the University of York in England, were not about “defining what it means to be trans” or undermining the validity of trans identities, Cass said in her foreword, but about the best healthcare approach going forward.

Cass said published studies suffer from “remarkably weak evidence,” that results are “exaggerated or mispresented” by people on both sides of the debate over transgender health care to bolster their own viewpoint.

Cass found that there is no solid evidence on the longterm outcomes of any of the interventions.

Despite an approach to care built on “shaky foundations,” Cass said the toxicity of the debate has been exceptional.

“There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media and where name-calling echoes the worst bullying behaviour. This must stop,” Cass wrote.

What did Cass say about puberty blockers?

That many doctors tossed out the usual practice of taking a cautious approach when implementing new findings. In fact, she found, “quite the reverse happened” when it came to gender care for children.

“Based on a single Dutch study, which suggested that puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence, the practice spread at pace to other countries,” she wrote.

The rationale was that pausing puberty early would help youth “pass” better in adulthood — by not developing distinctively male or female voices or facial structures, for example — and buy them time to reflect on their gender identity without their body changing in ways they found distressing.

But the systematic review on puberty blockers found no evidence the drugs improve body image or dysphoria, and “very limited evidence” that they improve mental health. Concerns have been raised that the drugs might temporarily or permanently disrupt adolescent brain maturation, “which could have a significant impact on the young person’s ability to make complex risk-laden decisions, as well as having possible longer-term neuropsychological consequences,” according to the Cass report.

The introduction of puberty blockers was rapidly followed “by a greater readiness to start masculinizing/ feminising hormones in mid-teens,” Cass said.

But Cass said adult gender clinics “thwarted” efforts by York researchers to collect follow-up data on outcomes for 9,000 people who had been under the care of Tavistock when they were younger.

Crucially, guidelines developed by the highly influential World Professional Association of Transgender Healthcare — guidelines that inform gender-affirming care in Canada — were found to “lack developmental rigour.”

So, what is Cass recommending?

Broadly, the review recommends children receive a “holistic” assessment of their needs, including screening for conditions such as autism spectrum disorder, and individualized care plans. The review recommends puberty blockers only be available to children enrolled in research trials and that “extreme caution” be used in prescribing cross-sex hormones to youth under the age of 18, with a clear rationale as to why the child can’t wait until 18.

What are doctors in Canada saying?

The Canadian Paediatric Society continues to support the use of puberty blockers.

“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,” the Ottawa-based group said in an email to the National Post.

While it wouldn’t comment on the Cass review specifically, the organization said it supports “an individualized, affirming and non-directive approach to treating gender diverse children and youth.”

“As with all areas of medicine, new and emerging evidence is evaluated as it becomes available. The CPS is committed to upholding the highest standard of care for children in Canada and continue to monitor the scientific knowledge base in the treatment of gender-diverse children and youth.”