". . . and having done all . . . stand firm." Eph. 6:13


‘Remarkably Weak Evidence’: Groundbreaking U.K. Report Slams Puberty Blockers

April 11, 2024

A wide-ranging overview of the transgender medical treatment for minors, conducted over four years by a world-renowned pediatric specialist, found “no evidence that gender-affirmative treatments reduce” suicide, “remarkably weak evidence” for the use of puberty blockers or cross-sex hormones for youth who identify as transgender, and no reason to believe that childhood feelings of transgenderism predict whether anyone will experience “longstanding gender dysphoria in the future.” But “toxic” discourse and “point-scoring” have made it impossible to serve children’s best interests.

The report advises government officials to hold transgender clinics “to the same standards as other services seeing children and young people.” Instead of immediately setting young people on a medical pathway of puberty blockers, hormone injections, and potential surgery, doctors should implement a “holistic” plan to treat the multiple mental illnesses and psychological comorbidities trans-identifying people often suffer from, the report says.

“For the majority of young people, a medical pathway may not be the best way,” the report concludes.

The groundbreaking new report, commissioned by the British government in 2020, shatters many of the most widely-believed tropes of the transgender movement.

Dame Hilary Cass, a former president of the Royal College of Paediatrics and Child Health as well as a Member of Parliament, released her 388-page report on Wednesday morning. The Cass Review contains 32 recommendations to reform transgender services from the ground up, placing the minor’s full mental health ahead of transgender ideology.

The report’s comprehensive review of all literature about efforts to transition children found the “gender-affirming care” model flawed or unsupported at every turn.

‘Weak’ or ‘No Evidence’ for Transgender Ideology: Cass Report

“This is an area of remarkably weak evidence,” says the report. “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.” Yet advocates on “opposing sides” of the issue began “pointing to research to justify a position, regardless of the quality of the studies.” To this day, “there continues to be a lack of high-quality evidence in this area.”

‘No Evidence’ Transgender Interventions Reduce Suicide

“Tragically deaths by suicide in trans people of all ages continue to be above the national average, but there is no evidence that gender-affirmative treatments reduce this. Such evidence as is available suggests that these deaths are related to a range of other complex psychosocial factors and to mental illness,” the report found. Cass reaffirmed, “It has been suggested that hormone treatment reduces the elevated risk of death by suicide in this population, but the evidence found did not support this conclusion.”

The higher rate of suicide among trans-identifying youth stem from other psychological conditions, the report implies. Children referred to gender clinics have suicide rates ranging from 27% to 55% — far “higher than for the general adolescent population, but similar to non-trans identified youth referred to child and adolescent mental health services.”

Trans-Identifying Youths Suffer from Complex Mental Illnesses, and Childhood Trauma/Abuse

Psychologists need to look at the psychological portrait, and history of abuse, suffered by many children showing up at transgender clinics, Cass said. “Many young people with gender dysphoria are presenting with combinations of” conditions including “depression and anxiety,” “eating disorders and self-harm,” and “more specialist mental health conditions such as functional tic-like behaviours, BDD [Body Dysmorphia Disorder] and functional neurological conditions.”

Trans-identified minors also experienced numerous childhood traumas that may impact their mental health. Overall, “relatively few studies reported on adverse childhood experiences (ACEs), but those that did demonstrated high rates among children and young people referred to gender services,” including:

  • “combined neglect or abuse (11-67%)
  • “physical abuse (15-20%)
  • “sexual abuse (5-19%)
  • “emotional abuse (14%)
  • “maternal mental illness or substance abuse (53% and 49%)
  • “paternal mental illness or substance abuse (38%)
  • “exposure to domestic violence (23-25%)
  • “death or permanent hospitalisation of parent (8-19%)
  • “loss of parent through abandonment resulting in adoption (1-18%), foster care (1-12%) or children’s home placement (0.5-5%).”

Coming from a broken home also increased, as a review of the first 124 underage transgender cases in the NHS/GIDS found “just over a quarter of all referrals had spent some time in care and nearly half of all referrals had experienced living with only one parent.”

Social media use and online pornography may contribute to underlying mental health issues and gender dysphoria, the report implies at times. Since watching porn increases “bodily dissatisfaction,” experts believe “more investigation into the consumption of online pornography and gender dysphoria is needed.” Cass also cited concerns about “excessive smart phone usage and social media.”

Tragically, the report notes that parents say transgender ideology had led to “diagnostic overshadowing,” where physicians overlook all other mental health conditions with the assumption that treating gender dysphoria will cause them to disappear.

‘Toxic’ Rhetoric, Transgender Ideology Harms Children

Dame Cass told the media a “toxic” debate focused on “point-scoring” has made it all-but impossible for mental health professionals to engage in a child-centered debate of scientific data. “It’s frustrating when debate is so toxic, and you feel that there are some really important societal issues that mainly impact adults, and children are caught up in this,” said Cass. “Point-scoring that’s going on just means that we can’t talk openly about what the right thing for them is.”

“That’s been really, really frustrating,” she told the media.

That toxic discourse has marched in tandem with the rise of extreme gender ideology, which many other physicians believe has led to a social contagion of transgender ideology.

When the National Health Service founded the Gender Identity Development Service (GIDS) run by the Tavistock and Portman NHS Foundation Trust in 1989, GIDS saw fewer than 10 minors a year who identified as transgender. Yet the NHS began following the so-called “affirmative” or Dutch model in 2011, making it routine practice in 2014. In the last decade, the rate has exploded by 2,000% — from 250 trans-identifying youth in the 2011-2012 year to 5,000 a decade later in a nation of 67 million people.

NHS England knew as early as 2019 that the evidence that gender transition procedures benefit minors is “weak.” The U.K. government commissioned Dame Cass to produce the report in 2020.

Cass punctured transgender activists’ claims that feelings of gender dysphoria will inevitably persist, worsening the child’s emotions and potentially leading to suicide. Being diagnosed with gender dysphoria “is not reliably predictive of whether that young person will have longstanding gender dysphoria in the future.”

But transgender medical interventions have real health risks. Puberty blockers pose “potential risks to neurocognitive development, psychosexual development and longer-term bone health,” the Cass Review observed. The report noted little evidence that social transition — allowing children to dress as the opposite sex and change their name or pronouns — had any long-term positive impact on children, or negative impact. But Cass reported that those who socially transition at a young age are far more likely to proceed to the medical pipeline of hormones and surgery.

“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 behavior. This must stop,” wrote Cass. “Polarization and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse, and in the long run will also hamper the research that is essential to finding the best way of supporting them to thrive.”

The Cass Review: Put Children’s Mental Health First

Overall, the Cass Review recommends that the transgender industry be held “to the same standards as other services seeing children and young people.” Doctors should implement a “holistic” approach to young people who identify as transgender, screening and treating them for a full range of mental health issues. That means “screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment.” Doctors should exercise “extreme caution” in distributing cross-sex hormones to anyone under the age of 18, said the report.

Psychologists have balked at examining the whole psychological picture of trans-identifying minors due in part to threats of recriminations for engaging in “conversion therapy.” Mental health professionals have reported fearing prosecution by transgender activists, who convinced the U.K. government to undertake an ongoing investigation into banning so-called “conversion therapy” for unwanted transgender identity, as well as same-sex attraction.

Dame Cass found that “clinicians working with this population have expressed concerns about the interpretation of potential legislation on conversion practices and its impact on the practical challenges in providing professional support to gender-questioning young people. This has left some clinical staff fearful of accepting referrals of these children and young people.” The report, which repeatedly opposes so-called “conversion therapy,” says professionals must be free to treat patients’ underlying mental health problems, regardless of whether the cured patient may choose to continue or desist from a transgender identity. “Any ambiguity could serve to further disadvantage these children and young people rather than support them.”

“It is now clear that the professional ban on conversion therapy is harming children. This ban needs to end,” said Andrea Williams, chief executive of the U.K.-based Christian Concern. Last week, the U.K. Council for Psychotherapy (UCKP) withdrew its signature from the Memorandum of Understanding (MoU), a professional agreement not to help patients suffering from unwanted gender confusion. “We welcome the UKCP withdrawing its signature from the MoU on Conversion Therapy. Other organisations need to follow. Clinicians cannot be pressured into adopting an affirmative approach through the threat of accusations of ‘conversion practices.’ It is time for the government to drop entirely all plans to introduce new legislation to outlaw so-called ‘conversion practices.’” 

“We are letting this generation down by failing to help and support them in a holistic way to accept their bodies and feel comfortable and confident as themselves,” said Alliance Defending Freedom International Director of Advocacy Robert Clarke.

Transgender Clinics Shun Accountability

The absence of good evidence stems in part from the transgender industry’s decision to stonewall researchers. Six of the U.K.’s seven adult transgender clinics steadfastly refused to study the sustained outcomes of “gender-affirming health treatment” (GAHT) on the 9,000 minors who transferred from pediatric clinics into their facilities. The University of York stated its reason for refusing to participate: “Taking part in a study of this kind could call into question the integrity of clinic staff and the relationships they have with patients.”

The Cass Review advises that all transgender clinics should cooperate with data-collection and analysis programs. The current NHS interferes with this since, when someone asks to change their gender identity, the NHS changes that person’s tracking number. That may erase previous mental health diagnoses and makes it impossible to assess whether the transgender interventions improved or harmed the patient, Cass noted.

The NHS may also need to “specifically provide detransition pathways” separately from so-called “gender-affirming” services, particularly as detransitioners say they are uncomfortable returning to the same doctors who fast-tracked them for injections and/or surgery.

Doctors “have expressed concerns about being pressurised to prescribe hormones,” said the Cass Review. Lawmakers should also crack down on private clinics that more freely distribute cross-sex hormones outside the NHS and work on legislation and “statutory solutions that would prevent inappropriate overseas prescribing.” 

Whistleblowers Vindicated but ‘Terribly Sad’

One of the foremost whistleblowers, Dr. Daniel Bell, remarked that he felt vindicated but “terribly sad” by the Cass Review’s findings.

“This is the most thorough, extensive review of gender services for children ever undertaken anywhere in the world, and the results are very clear that the so-called affirmation model … has been completely the wrong clinical stance,” Bell told the media on Wednesday. “The right clinical stance is neutrality, exploration, understanding all the other multiple problems these children have that are being expressed through distress about their gender.”

Bell noted that, in 2018, he brought out “many, very serious concerns” about transgender medical interventions, “and all those concerns … have been borne out by the Cass Review.”

“There’s lots of work to do with detransitioners, and I’m really pleased Cass mentions them in the report. These are the kids that changed their mind and [have] to live the rest of their lives with the irreversible consequences of medical and often surgical treatment. And they need special care, as well,” he said.

British Government: Expect ‘Fundamental Change’ in Minor Transgender Treatment

U.K. government officials said the Cass Review will lead to “fundamental change” in the way they deal with minors diagnosed with gender dysphoria.

“I welcome the publication of the Cass Report today, something that we commissioned,” because “children’s wellbeing is uppermost in our mind,” said Prime Minister Rishi Sunak, a member of the Conservative Party, on Wednesday morning. The report is “very much in alignment with our way of thinking, which is to exercise extreme caution on these issues, because we simply don’t know the long-term consequences and impacts.”

U.K. Home Secretary Laura Farris told Sky News presenter Kay Burleigh on Wednesday morning, “You can expect to see a fundamental change in direction that comes after this.” Farris hailed Cass as “a top consultant pediatrician, and no one has ever looked at it with this kind of comprehensive, sensitive, and multidisciplinary eye before.”

She highlighted steps the government had taken after Cass published an interim report in 2022. NHS England announced in March that there is “not enough evidence to support the safety or clinical effectiveness of puberty-suppressing hormones, or to make the treatment available at this time.” Henceforth, it would restrict puberty blockers to children taking part in clinical trials. 

“The Tavistock Clinic is no longer,” she noted. “A child who is questioning their gender will be given a holistic package of support: mental health support, neurodivergence support … and not just funneled down an irreversible pathway where they may find that they reach adulthood,” and then “wonder how on Earth they were ever allowed to take those steps.”

Labour Party Leader: Cass Review ‘Very Troubling’

Both leading parties agreed children and teens need greater protections from the predatory transgender industry. Labour Party Shadow Home Secretary Yvette Cooper called the report “very troubling” and said that “Labour accepts all of its recommendations. I think they should be implemented now as swiftly as possible, and we would like to work with the government on doing that.”

She also denied that schools should socially transition children without their parents’ consent. “Parents obviously need to be involved in something like this.”

“I hope that this report really is a watershed moment for the NHS, NHS gender services, because the report is clear. It’s basically talking about evidence, focusing on evidence, focusing on children’s welfare,” said Cooper. The Cass Review shuns “getting caught up in culture wars” in favor of “looking at wider issues around mental health” and childhood wellbeing.

Transgender Activists Call on Politicians to ‘Resist’ Some of the Cass Review’s Recommendations

Mermaids, a U.K.-based transgender pressure group, said it is “concerned that some of the language in the report is open to misinterpretation” and “could be used to justify additional barriers” to transgender medical procedures.

Dame Cass did not claim the U.K. government had misinterpreted her interim report’s recommendations.

Despite the evidence, some transgender activists called on politicians to “resist” some of the report’s findings. The group called on the NHS to “resist pressures from those who seek to limit access to healthcare” and “provide gender services which are timely [and] supportive.”

Trans activists also point to some recommendations that the government reduce “unmanageably long wait lists” for those filling transgender clinics, as well as requiring training for all NHS employees so they can work with trans-identifying young people “effectively.”

Cass said she, unlike the young people she saw, had no regrets about investigating transgender ideology. “If people ask me would I do this again, the answer is yes, because I’ve become more and more passionate as time has gone on about wanting to see things change for this group of young people,” she said.

Evangelicals: ‘This Is a Grace and Truth Moment’

Christians say her conclusions broadly support the Bible’s teaching on gender — and believers must rise to the occasion, stated British evangelical leaders.

“[W]hile the Cass Review obviously doesn’t contain a theological section, its conclusions are largely consistent with the biblical picture,” said Peter Lynas of the Evangelical Alliance. “God created human beings in His image, both male and female. Man and woman are distinct, possessing equal value, made to glorify Him and together reflect His image. The human body, and therefore biological sex, is an intrinsic part of human identity. Cross-gender identification is problematic because it distorts the creational order of male and female.”

“This is a grace and truth moment. We need to pray with grace for those directly affected. Many have been misled in terms of their own treatment or how to support their loved ones,” said Lynas. “But there is also a moment of truth. This conversation is one of the most critical in our culture — evidence has been ignored in favour of ideologies — with terrible consequences for those involved.”

“Cass opens up the space for some fascinating missional conversations,” concluded Lynas of the British evangelical organization. “My prayer is that we are brave and kind enough to seize the moment.”

Ben Johnson is senior reporter and editor at The Washington Stand.