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Cass Review deemed 98% of gender-affirming hormone studies too low-quality

Cass Review deemed 98% of gender-affirming hormone studies too low-quality

Jamie Wareham
Jamie Wareham
TL;DR: After a four-year investigation, the long-awaited review into transgender children's gender identity services has been revealed to critiques of flawed methodology. The review has links to practitioners of so-called ‘conversion therapy', and deemed 98% of studies related to gender-affirming care of too low quality to do anything more that inform the synthesis (a summary, based on sources). While some recommendations have been welcomed, there are fears about suggestions to reduce access to current provisions for trans people up to the age of 25. International experts, the LGBTQIA+ sector and trans users of the services have largely decried its methodology and approach.

When the Cass Review was first announced, and even during the four-year process of its being written and interim reports being released, the LGBTQIA+ sector approached it cautiously and optimistically. They hoped it could bring about meaningful progressive change. That all changed on Wednesday when it was released.

Despite advance briefings suggesting a more nuanced approach, it became clear to many that the authors had been captured by gender-critical and patriarchal rhetoric while using what has now widely been decried as flawed methodology, without speaking to trans or non-binary experts or clinicians experienced in providing gender-affirming care - PATHA

Specifically, the report led by paediatrician Dr Hillary Cass, which includes references to boys playing with trucks and girls playing with dolls, and downgraded 98% of studies submitted to it that showed gender-affirming care and hormones helped transgender people leading to them being less weighted in the report - Alejandra Caraballo

The Cass Review said it applied robust methodological concepts to this process by insisting all studies were double-blinded — a clinical concept you may understand as testing drugs alongside placebos. Dr Cass later said claims 98% were excluded was “completely incorrect” but that they were instead only considered of “moderate” quality leading to 60% being used to form part of the “synthesis” — BBC

For many, the issue with doing this with gender-affirming care studies is it would have required young people to be forced not to transition despite that being their wish.

Most LGBTQIA+ people will recognise this as a form of ‘conversion therapy', a pseudo-scientific practice condemned as a form of torture by international medical bodies. The practice attempts to 'cure' people of their gender identity or sexuality by requiring them to live in or practise an identity that is not their own, sometimes under the pressure of physical and emotional punishment.

The UK government has promised to ban it for the last five years. But after a series of delays and U-turns, in the same week this report was released, reports suggest it has now dropped those plans. This is likely at least partly a result of warnings given by Dr Cass about the ‘risks' of criminalising professionals based on her report's recommendations - Guido

It was revealed ahead of its release that some of those writing the report have direct links to a group that advocates for the practice of so-called ‘conversion therapy’ - something they didn't declare. Dr Hillary Cass herself met with 'Don't Say Gay' architect Ron De Santis staffers who went on to ban trans healthcare in Florida - Trans Safety Network

In the context of the Cass Review, this is crucial. It recommends a new service for 17-25 year olds is set up, which will have a focus on considering alternative reasons for their gender-related distress, such as eating disorders, neurodivergence, or social acceptance. It’s an approach journalist Sasha Baker argues "offers all the harm of conversion therapy, with the convenient excuse that transition may be considered if all other avenues have been exhausted" - Dazed

Gender-affirming care has been shown, in a number of studies, namely those excluded from the Cass Review, to lower the risk of suicidal ideation, suicide and self-harm. For want of a better phrase, this care ‘saves lives’ - Columbia University

Dr Cass said on the More or Less: Behind the Stats podcas, however, that the quality rating wasn't just to do with the double-blind issue, saying, there are many other areas where that would apply like acupuncture. However for that she argued "people would know exactly what treatment that they were getting," and so these could be considered high quality.

However, the Evidence review of Gender-affirming hormones for children and adolescents with gender dysphoria, which fed into the report as one of the evidence sets, repeatedly lists downgrade reasons on these studies or the reason for "lack of blinding and no control group".

Still, the report's conclusions, widely reported by the mainstream and international media, say young people have been "let down" by the NHS allowing them to access puberty blockers despite what it says is "remarkably weak evidence" they improve wellbeing.

Studies backed by a strong methodology do show this, but they were deemed low-quality. Meanwhile, the already-announced ban on puberty blockers for trans youth for "safety" reasons doesn't extend to their use in cisgender children - QueerAF

What are the Cass Review's key recommendations?

The Cass Review's key recommendations and reflections include some that the trans community and wider LGBTQIA+ sector have been speaking about for many years:

  • A major expansion in care for trans, non-binary, gender diverse and gender questioning youth and young people is needed - Trans Actual CIC
  • There needs to be mental health provision for those using gender identity services - Diva
  • More neurodiversity assessments should be part of the process and care pathway - Gay Times
  • Long waiting lists, seeing some people waiting a decade for a first appointment, are unacceptable

In the LGBTQIA+ sector, there is a recognition that some of the report's recommendations, therefore, could help young transgender people - particularly the recommendation of a decentralised approach and improving "unhurried, holistic, therapeutic, safe and effective" care for young people and their families. Most of the largest LGBTQIA+ sector voices have only offered interim responses to the report while promising to respond with the complete picture once they have it - Mermaids on Sky News

So there are positives in the recommendations, but they come with a huge caveat: if the report is implemented in its entirety we will see an overall reduction in gender-affirming care and access to hormones for under-25s.

The real concern from transgender analysts and expert clinicians is not about the report's broader recommendations but about how and by whom it will be used - and what for.

The day after the report was released - while most of the sector were still digesting its 32 recommendations and 388 pages - a review into adult gender care was quietly announced. It’s already expected to take the same format and approach as the Cass Review - The Guardian

Prime Minister Rishi Sunak, speaking about the report, said transitioning was "not a neutral act". Meanwhile, Labour shadow Health Secretary Wes Streeting, who is gay and used to work for Stonewall, remarked after the review’s release that he regretted his previous statements that trans women are women, and described the review as a humbling moment for many - The Sun

For many commentators, including respected trans journalist Freddy McConnell, this could be part of a broader movement in political and media circles to use the Cass Review as a "Trojan horse" to begin an assault on any form of transgender and gender affirming healthcare - including for adults - The Guardian

Analysis: Whatever its intention The Cass Review has already become a weapon to harm transgender people with

The bigger picture at play here is that the Cass Review is fodder for the anti-trans movement's bias. Meanwhile, as the Trans Solidarity Alliance conclude, the report “works for cis people who are upset by the idea of a trans child existing” - but it is ultimately a model of care that fails trans children.

In Dr Hillary Cass's attempt to play some kind of peacemaker and listen to 'all sides,' anti-trans bias has become threaded through the report's findings, methodology, and, therefore, conclusions. This will allow a powerful, co-ordinated anti-trans lobby to weaponize the report - and they’ve already started - Amnesty International

This is something Cass herself warns against, saying the toxicity of the debate has led to children being "used as a football"

It’s an admirable sentiment - but Cass’s review has already itself become another boot for media, politicians and lobbyists to kick the trans community with.

My take:

Information is everything. It helps us reach and justify conclusions. But the information ecosystem is failing us.

This week, when the Cass Review was released, news outlets rushed to cover the story, highlighting the report's conclusions without taking time to consider whether the report could be flawed.

In doing so, it amplified and solidified to the wider public the report's key conclusions without balancing it against the evidence it excluded to reach them.

While much of the news media zoned in on that conclusion, trans activists, healthcare experts and the LGBTQIA+ sector combed through it line by line to show it was another official report captured by harmful, prejudiced rhetoric.

Crucially, despite a four-year process, it still failed to find any smoking gun of widespread regret among trans folks who transition. It instead had to rely on a methodology that allowed it to deem any data about how gender-affirming care helps trans people as too low quality. Whether your analysis means that led to it being ignored or excluded is by the by - it was downgraded.

It's not enough to know what the Cass Review says. We need to understand why it reached those conclusions. When we do, we can see it for what it is rather than what it's been reported as.

At QueerAF, we'll always take stock - and deliver accountability journalism with our unique slow news approach, so you understand why.

We think that approach is essential so you have the information you need to fight back against anti-LGBTQIA+ rhetoric.

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22/04/2024, 8pm BST: This article previously reported that Dr. Cass "excluded" a number of studies from the Cass Review. She later said they had informed the report but were not rated as high quality.