Evidence in favor of hormone inhibitors and cross-sex hormone usage for minors is “remarkably weak” and should be dismissed in most cases of children with gender dysphoria, according to a four-year study published Tuesday by National Health Service England.
The highly-anticipated Cass Review, written by pediatrician Dr. Hilary Cass, was released weeks after the government-funded National Health Service announced it would no longer offer hormone blockers at gender clinics. Cass recommended these clinics conduct a more “holistic assessment” to consider factors in the rise of children with gender dysphoria, such as mental health issues.
“This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment,” she wrote in the study.
“For the majority of young people, a medical pathway may not be the best way to achieve this,” the study concluded. “For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems such as family breakdown, barriers to participation in school life or social activities, bullying and minority stress.”
However, those in favor of transgender hormone usage and sex-alteration surgery promote medical pathways as a means of addressing mental health problems.
A Stanford-led study suggested that “transgender people who began hormone treatment in adolescence had fewer thoughts of suicide, were less likely to experience major mental health disorders and had fewer problems with substance abuse than those who started hormones in adulthood.”
But Cass described research used to promote hormone blockers and transgender hormone usage as “remarkably weak.”
“This is an area of remarkably weak evidence, and yet results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint,” she wrote. “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.”
Laurence Webb, a representative from transgender youth advocacy organization Mermaids, warned some activists may weaponize the findings of the study.
“The intention with the Cass review is to be neutral, but I think that neutral has maybe moved,” Webb told The New York Times. “Extremist views have become much more normalized.”
Cass issued a direct criticism of the World Professional Association of Transgender Healthcare, whose standards of care for transgender people are commonly cited by U.S. courts and medical associations.
“The findings of the series of systematic reviews are disappointing,” Cass wrote about her study in a published medical journal editorial. “They suggest that the majority of clinical guidelines have not followed the international standards for guideline development.”
“The World Professional Association of Transgender Healthcare (WPATH) has been highly influential in directing international practice, although its guidelines were found by the University of York’s appraisal to lack developmental rigour and transparency,” she continued.
The study recommended England use “extreme caution” when offering transgender hormone usage for young people.
“NHS England should review the policy on masculinising/feminising hormones,” Cass wrote. “The option to provide masculinising/feminising hormones from age 16 is available, but the Review would recommend extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18.”
The study covered research on social transitioning for minors, which is when someone begins to identify publicly as a different gender. Cass concluded there was “no clear evidence” on the impact of this practice.
“The systematic review showed no clear evidence that social transition in childhood has any positive or negative mental health outcomes, and relatively weak evidence for any effect in adolescence,” she wrote. “However, those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway.”
