Editor's note: This statement has been adjusted to reflect the fact that the German guideline for adolescent transgender care is still under review. We request that you use the following version.

WPATH AND USPATH COMMENT ON THE CASS REVIEW

May 17, 2024

The recently published Cass Review is the result of a four-year investigation initiated by the United Kingdom’s National Health Service England (NHSE) into the scientific basis of treating transgender youth and the experiences of those involved in transgender care in the UK. It contains 32 recommendations for a reorganization of transgender care for youth in England and Wales. The review took place after concerns arose around the increase in referrals, the evidence base for gender-affirming medical care, and the functioning of the NHS Tavistock Clinic’s Gender Identity Development Service (GIDS), the only national care service with a long history of clinical experience and knowledge, which had operated since 1989 and was closed in March 2024. To date there are no new services in operation, and there will be none in the foreseeable future, despite what NHS England or Hillary Cass may claim. WPATH and USPATH are extremely concerned that this has left young transgender and gender diverse (TGD) people and families with little opportunity to obtain transgender care. This is a devastating situation for transgender youth and their families, whose rights are breached as they are being denied medically necessary care. We believe this to be a complete breach of the seven core values enshrined in the NHS Constitution.

Overall, WPATH and USPATH remain deeply concerned about the facts regarding the Cass Review’s process and content, as well as its consequences for the provision of care for trans and gender diverse youth. Here are some of the reasons:

1. NHS England, which commissions and finances specialist medical services, including trans health care for youth and adults in England, appointed Hillary Cass in 2020 without any transparent or competitive process. Hillary Cass is a pediatrician with hardly any clinical experience or expertise in providing transgender healthcare for young people. Furthermore, Hillary Cass lacks significant research qualifications or research expertise in transgender health. Yet, the Cass Review purports to make “evidence-based” recommendations based on six systematic reviews carried out by the University of York in the UK, which do not contain any new research that would contradict the recommendations made in professional consensus guidelines of the American Academy of Pediatrics (AAP), the Endocrine Society, and WPATH to name a few.
2. The Cass Review is hailed by some as an “independent” review, referring to the fact that Hillary Cass had negligible prior knowledge or clinical experience of trans and gender diverse youth or indeed transgender medicine and surgery. One senior psychiatrist at a gender identity clinic in England told a national newspaper in the UK that the failure to include those with personal or professional experience “had concerned many within the field.” They said: “The terms of reference stated that the Cass Review ‘deliberately does not contain subject matter, experts or people with lived experience of gender services’ and Dr. Cass herself was explicitly selected as a senior clinician ‘with no prior involvement … in this area.’ Essentially, ignorance of gender dysphoria medicine was framed as a virtue. I can think of no comparable medical review of a process where those with experience or expertise of that process were summarily dismissed.” WPATH and USPATH agree completely.
3. In contrast to what the Cass Review recommends, WPATH and USPATH firmly stand by the Standards of Care for the Health of Transgender and Gender Diverse People – version 8, which was published in 2022—and based on far more systematic reviews that the Cass Review—in collaboration with The School of Evidence-based Practice Center at Johns Hopkins University and considers that the (research and consensus-based) evidence is such to recommend that providing medical treatment including puberty-blocking medication and hormone therapy is helpful and often life-saving for young TGD people, while withholding such treatment may lead to increased gender dysphoria and adversely affect psychological functioning. Of note, many countries have reacted critically regarding the Cass Review, disagreeing with its unfounded medical opinion to severely limit the use of puberty-blocking medication and hormone therapy for TGD young people. These countries include Canada, the Netherlands, Belgium, Germany, Austria, Switzerland, and many states in the United States. In Germany, a new guideline on adolescent transgender care has been drafted (in collaboration with Austria and Switzerland) and is currently under review by 27 professional societies. As drafted, this guideline does not restrict puberty blockers and is in broad accordance with the WPATH SOC8 recommendations in its adolescent chapter. The Cass Review appears to be an outlier, ignoring more than three decades of clinical experience in this area as well as existing evidence showing the benefits of hormonal interventions on the mental health and quality of life of gender diverse young people (1-9).  
4. WPATH and USPATH also have serious concerns regarding the ethics of the provision of puberty-blocking agents for young TGD people in the United Kingdom in the context of a research protocol only. Care and treatment that is consensus- and expert-based occurs in many areas of medicine, including pediatrics. The use of a randomized blinded control group, which would lead to the highest quality of evidence, is ethically not feasible.  It is ethically problematic to induce people to participate in a research project as the only way to access a type of care that is evidence based, widely recognised as medically necessary, and often reported as lifesaving. There is no role in modern medicine for such practices, which are not commensurate with providing the highest standard of care for young people, as the Cass Review allegedly advocates for.

Regardless of what Dr. Cass’ intentions may or may not have been, the Cass Review process itself intentionally and explicitly excluded any oversight from patients and their families and trans healthcare experts, and its content is not supported by a robust methodology. The Cass Review relies on selective and inconsistent use of evidence, and its recommendations often do not follow from the data presented in the systematic reviews. The Cass Review deprives young trans and gender diverse people of the high-quality care they deserve and causes immense distress and harm to both young patients and their families.

Editor's note: This statement has been adjusted to reflect the fact that the German guideline for adolescent transgender care is still under review.

References

1. de Vries AL, McGuire JK, Steensma TD, Wagenaar ECF, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics 2014;134:696-704.
2. Mahfouda S, Moore JK, Siafarikas A, Zepf FD, Lin A. Puberty suppression in transgender children and adolescents. Lancet Diabetes Endocrinol 2017;5:816-26.
   doi: 10.1016/S2213-8587(17)30099-2 pmid: 28546095
3. Mahfouda S, Moore JK, Siafarikas A, etal. Gender-affirming hormones and surgery in transgender children and adolescents. Lancet Diabetes Endocrinol 2019;7:484-98.
   doi: 10.1016/S2213-8587(18)30305-X pmid: 30528161
4. Turban JL, King D, Kobe J, Reisner SL, Keuroghlian AS. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One 2022;17:e0261039. doi: 10.1371/journal.pone.0261039 pmid: 35020719
5. Turban JL, King D, Carswell JM, Keuroghlian AS. Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics 2020;145:e20191725.
   doi: 10.1542/peds.2019-1725 pmid: 31974216
6. van der Miesen AIR, Steensma TD, de Vries ALC, Bos H, Popma A. Psychological functioning in transgender adolescents before and after gender-affirmative care compared with cisgender general population peers. J Adolesc Health 2020;66:699-704.
   doi: 10.1016/j.jadohealth.2019.12.018 pmid: 32273193
7. Kuper LE, Stewart S, Preston S, Lau M, Lopez X. Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy. Pediatrics 2020;145:e20193006.
   doi: 10.1542/peds.2019-3006 pmid: 32220906
8. Achille C, Taggart T, Eaton NR, etal. Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. Int J Pediatr Endocrinol 2020;2020:8. doi: 10.1186/s13633-020-00078-2 pmid: 32368216
9. Chen D, Berona J, Chan YM, Ehrensaft D, Garofalo R, Hidalgo MA, Rosenthal SM, Tishelman AC, Olson-Kennedy J. Psychosocial Functioning in Transgender Youth after 2 Years of Hormones. N Engl J Med. 2023 Jan 19;388(3):240-250. doi: 10.1056/NEJMoa2206297. 

www.wpath.org

https://www.wpath.org/uspath

Click here to download a pdf of the statement.