The Cass Review Is Coming
MoH's advice for GP's has gone AWOL as trans New Zealanders fret about what unannounced changes could be forced upon them at a moment's notice
This coalition government is being deceptive again.
I know, we’re all surprised. It’s so out of character for them.
In 2023, well before the start of this government’s term, the Ministry for Health was asked to write a report clarifying the recommended guidelines for prescribing puberty blockers to transgender teens. This would be — or would have been — a welcome help for GPs who are struggling with the diversity of care their role requires in 2024, and who frequently lack the knowledge to properly treat and prescribe for gender diversity and for mental health-related conditions.
Puberty blockers are prescribed to those experiencing gender dysphoria and/or who believe they are transgender, upon their request and in consultation with their doctor and usually their parents. They are also prescribed to cisgender children who develop “precocious puberty” (who start puberty early). They are essentially a pause button on puberty, stopping the production of hormones to temporarily delay the development of sex-specific characteristics. This treatment can buy teenagers time; time to figure out their gender identity or give them a chance to wait until they’re older before they go on hormone treatment or resume puberty as normal.
As hormone treatment can be a big change for an individual and can create irreversible results, this opportunity for teenagers to grow and develop (sometimes literally: the treatment can help with idiopathic short stature due to evening outgrowth spurts) before making this decision for themselves can provide a valuable opportunity for trans teens to get their head around what’s happening (and also their sometimes-hesitant or uncertain families).
What’s the deal with hormone blockers and treatment?
Hormone blockers are considered safe and effective treatment for teens struggling with their gender identity, with potential short-term puberty-associated side effects listed as things like mood swings, changes in appetites, muscle aches, and changes in breast tissue. It can also cause other manageable and low-risk side effects like fatigue and headaches.
There has been some difficulty in studying the long-term effects of puberty blockers, in part because of the difficulty in following patients over such a long time. The long-term safety and efficacy of puberty blockers do raise some potential issues: bone density can be affected; there are some questions around fertility; and there have been observed psychological side effects, some of which can be very serious. However, these should be taken in the context of what the treatment is, and in the context of treatment alternatives.
Estrogen hormones, the treatment for male-to-female trans people, also cause bone density loss (as does being female, especially during menopause), and both estrogen and testosterone treatment can affect future fertility and are more likely to than hormone blockers. Psychological side effects are even more common with psychological medication like anti-depressants (according to the Cass Review these would be considered alternate treatments for teenagers struggling with gender dysphoria and associated symptoms). As someone who’s been on more than my fair share of anti-depressants, they are certainly no walk in the park.
Trans teens are prescribed hormones, but puberty blockers are important to make sure less of them do so when they aren’t ready for it, or may not be trans.
By far, most people who “change their mind” do so to a different gender from their birth gender (e.g. ftm trans person transitioning to non-binary). This is a pretty typical part of the trans experience.
Anti-depressants are much more commonly prescribed to teens than both hormones and puberty blockers; they come with more risks than puberty blockers and they have considerably more evidence that they are being inappropriately prescribed by GPs. However, you don’t have activists protesting against their prescribing to adolescents because it is recognised as a complicated health/mental health matter best handled by the field of medicine, and between patients and their GP or their treatment teams. No one would ever consider banning the prescription of anti-depressants to teens or adults across the board because there is conflicting evidence on the efficacy of anti-depressants vs placebo, or because they cause an increased risk of suicide, both of which are very genuine and significant issues with these drugs.
The danger of not treating gender dysphoria is an increased risk of suicide.
It is generally well accepted, from both studies and from speaking to trans or non-binary individuals, that receiving gender-affirming care is beneficial for dysphoria symptoms and for a person’s overall mental health. While there have been few long-term studies on the mental health effects of teens who receive hormone blockers, literature certainly supports the benefits of treatment. For example, this study found the likelihood of suicidality to be greatly reduced in people who had been on puberty blockers, supporting previous studies that draw other positive connections between gender-affirming treatment and improved mental health outcomes.
It’s worth noting at this point that puberty blockers and hormone treatments are not the “default treatment” issued for trans youth (or even trans people). While 121,882 children and adolescents have been diagnosed with gender dysphoria in the US from 2017-2022, only 17,600 of them received any sort of medical hormone treatment, blockers or otherwise. This is because many trans people transition only socially (or only socially as teenagers/at first), and teens who seek medical intervention are usually those with the most significant symptoms and issues; i.e. with worse dysphoria, and often with more certain/fixed gender identities, or at least with stronger indicators.
It reflects the reality that appropriate treatment is being prescribed and taken up with discretion; and like all medical and especially mental health treatment, it is something that should be the decision of the patient and their treating doctor, not the decision of some guy who listened to a ZM commentator go off about how little they understand of the world on their drive to work.
Trans healthcare has better rates of regret than any other equivalent care across the board. According to one study, 98% of transgender teens who begin puberty suppression treatment continue onto gender affirming care. This ratio would suggest that, in the Netherlands at least where this study was based, puberty blockers are being prescribed appropriately — perhaps even underprescribed. This follows other data that suggests rates for discontinuation and reversal of treatment are significantly lower in gender treatments than they are for other non-gender medical interventions. For example, confirmation surgeries have a regret rate of less than 1%; breast surgeries on cisgender patients have a regret rate of up to 47.1%. This reflects the high social barrier to coming out as transgender, as well as barriers to accessing to medical care including transphobia, cost of treatment, etc.
This is the established science of transgender medical care, a field that has existed in America since 1966 when John Hopkins University opened their Gender Clinic. While there are relatively fewer studies that directly address hormone treatment and puberty blockers for adolescents as medical treatment in adolescents is relatively rarer than in adults, the wider field of transgender medicine is well-studied with many demonstrated, established known outcomes for transgender transition-focussed healthcare, including the benefits of holistic gender-affirming care and the harm that can be caused to children whose gender expression is not supported and accepted1.
The Cass Review
The Cass Review is a report into transgender healthcare for under 18s, commissioned by the previous UK conservative government for the NHS. It was written by Baroness Hillary Cass, a retired pediatrician selected specifically for the role and whose previous research includes transitional care from youth to adult services and working with disabled young people. She was selected to do this review despite having no actual gender-related experience. One of the people involved in the methodology has been accused of participating in conversion therapy practices, and the report itself recommended the removal of trans people from the protections of UK Conversion Therapy Ban so as to protect practitioners who “work with trans people”, which the government acquiesced on. The conversion therapy ban they passed protected only GLB people.
The review has received criticism from many transgender healthcare and rights organisations inside and outside the UK. The largest flaw identified with the review is in the weighting of the different studies, with 98% of studies being downgraded.
Some notable criticisms:
Despite advance briefings suggesting a more nuanced approach would be taken, 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
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 stafferswho went on to ban trans healthcare in Florida - Trans Safety Network
It’s an approach that "offers all the harm of conversion therapy, with the convenient excuse that transition may be considered if all other avenues have been exhausted" - Dazed, Journalist Sasha Baker
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
LGBTQ+ site wearequeeraf.com records what Dr Cass has said about the methodology used.
Dr Cass said on the More or Less: Behind the Stats podcast 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 out, 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 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
Many LGBTQ+ and transgender health clinics elected not to share patient records with Dr Cass, leading to further questions about the validity of the evidence.
As a result of Dr Cass’s findings that there was no conclusive evidence supporting the safety or efficacy of trans hormones, the NHS has ceased all hormone treatment for transgender children and teenagers. Cisgender children and teenagers continue to be able to access these treatments.
Despite this controversy, Dr. Cass is currently conducting a similar review into the treatment of transgender adults.
Trying to follow up on information for this review and its methodology was, honestly, weird as all hell. Even before I found the site wearequeeraf.com, which has a good overview of the issues with the studies and with Dr Cass and her team, I ran into the same confusion they did regarding the BBC interview that Dr Cass gave on misinformation and the “toxicity” of the debate.
As a side note, it’s a well-established fact that top execs of the BBC have been sympathetic to the TERF agenda for many years now. Much of the rest of the UK’s media is owned by Rupert Murdoch. But even by those standards, this debate was strangely covered in this BBC interview with Dr Cass.
The questions the BBC puts to Cass are seriously mis-relayed, inserting the supposed misinfo into them and making the asker seem ignorant and like they’re spreading false accusations, when the question put to Cass was worded entirely differently to what was being said, inserting in the misinformation into the question by using the word “disregarded” instead of “downgraded”. The confusion of critics seems to be based on Cass’s own words and her claims about the study. Despite this, rather than clarifying what she said, she only discusses how “you can’t have double-blind placebo trials” with hormones because the patients will know they’re not on them. She does not address at all the higher weighting for blind studies and how the most useful and detailed studies are ones with control groups at all, or the ethical and practical reasons why these studies wouldn’t be done.
The interview came across very strongly as someone trying to spin a narrative from both interviewer and interviewee, a narrative that relied upon demonising or dismissing any supposed criticisms rather than attempting to shed light on the review or explain things to the public.
Looking further around the internet, she didn’t seem to have many good explanations in other (mainstream) interviews or media, though a notable number of her speaking events since the review have been for organisations associated with anti-science misinformation and/or are widely considered transphobic. These fringe groups have hailed this report as a victory, and the right-wing pressure group the Free Speech Union has promoted it nationally and internationally. Their New Zealand-wide tour of Graham Linehan (the transphobic former television comedy writer who now makes his career off of being cancelled) was timed for when the Cass review was released, and this was discussed at length at events up and down the country.
As a pediatrician who specialises in disability and autism, Dr Cass will have met and treated many gender-diverse patients in her time. This is because gender diversity has a higher occurrence in autistic people than in the general population. Autistic people are also more likely to be non-binary than allistic trans people. As an autistic person who’s been in rooms of 10- ish autistic people where maybe two people in the room had pronouns you could guess ahead of time, I can confirm this is pretty accurate.
Many theories have been postulated for why autistic people are so much more likely to be gender diverse, with the likely explanation being a mix of several of the most well-supported theories:
Autistic people have hyper-masculinised brains (this would also help explain why assigned-female-at-birth autistic people are slightly more likely to be trans and nonbinary than assigned-male-at-birth people are)
Autistic people feel less constrained by social norms, such as norms that dictate gender
Autistic people are more likely to “not fit in” which makes them more drawn to marginalised groups and identities
Autistic people are more likely to have a particularly “diverse” brain structure and chemistry in other ways (e.g. ADHD, depression) and this extends to gender diversity/gender dysphoria too
Autistic people struggle with the changes of puberty more than allistic people
Autistic people place greater importance on identities and understanding their identities, giving them a different perspective or deeper insight on gender
The experience of unmasking also involves unmasking enforced gendered behaviour that does not match internal gender identity
Autistic people are less likely to see the world “through the eyes of others” which creates a disconnect between theirs and other’s perceptions of their gender
What radical feminists and, notably, the Free Speech Union (including in New Zealand) promote is that autistic people are uniquely vulnerable to gender confusion and “trans propaganda” due to being autistic — the implication being we “don’t understand” or have gotten bamboozled by the militant trans people converting us.
This matches with reported autistic experiences that gender identity is often invalidated by the people around them because of their autism.
It’s mind-boggling that this review is the opinion of a single person who is not even involved in trans healthcare, given the weight that has been placed on it and the agency that’s been stripped from thousands of trans youth. This should have been an expert panel at minimum.
The review itself acknowledges that the effects of stopping transition are also not well studied; despite that, this is the recommendation that has been given and followed for every single trans youth in the UK. It does not consider the suicide risk increase that may result from this.
The Missing Ministry of Health Review
The Ministry of Health’s review was due out in November 2023. This was pushed out at the last minute to April 2024, with MoH saying it wanted to take time to develop a position statement to accompany it setting out the next steps. The Cass report was released two weeks before the new April due date.
It is now September 2024 and the MoH review has still not been released. MoH instead commissioned PATHA (Professional Association of Transgender Health Aotearoa) to create a resource that GPs can “refer to answer their questions and to learn more. It will also provide tools to support GPs who want to learn to prescribe hormone therapy.”
The Spin-Off reports:
“The decision to draft an evidence brief followed the ministry’s scrubbing of official advice about the safety of puberty blockers from its website in 2022. Emails released to Newsroom showed a line stating puberty blockers were “a safe and fully reversible medicine” was removed in the hope it “creates fewer queries”.
It’s expected New Zealand’s new guidelines on puberty blockers will be, at least in part, informed by the release of a similar report in the UK that was led by Dr Hilary Cass.”
In May 2024, Dr Bourne, who is in charge of the report and is the ministry’s chief medical officer for clinical community and mental health, met with Dr Cass who provided, according to him, “valuable insights into their process”.
Bourne has claimed, in comments released alongside the documents to the Spin-off, that the delay wasn’t unusual due to the “rapidly developing clinical issues”.
Where that leaves us
It is frightening for trans people that this uncertainty follows Winston Peters speaking out about gender-affirming healthcare on the campaign trail, proposing to ban transgender women from using women’s restrooms and force trans people to compete as their assigned sex in sports, promises that made it into the coalition agreement.
It is frightening for trans autistic people, who have already experienced the government’s sudden and highly-criticised decision to cut disability funding eligibility in a way that especially impacted autistic people, that was then followed up with blow after blow to the disability system.
It is frightening to think about how much money this government could save — or thinks it can save — by not purchasing puberty blockers, and how much money clearly matters to them over the wellbeing of New Zealanders.
It is alarming that both the Cass Review and this government have a history of making decisions without consultation with or consideration for the people they affect.
It’s alarming that cisgender people are allowed to undergo cosmetic or medically necessary treatments with the same side effects, but trans people and their doctors need to prove over and over again in every system how important it is for them to receive this treatment, despite them saying loudly and proudly how helpful they find it.
And it’s especially alarming how many people out there are willing to lie to get their way on this.
Selected Sources/Further Reading:
https://transactual.org.uk/advocacy/critiques-of-the-cass-review/
https://growinguptransgender.com/2022/04/06/the-failure-of-the-cass-review/
News Sources:
https://www.wearequeeraf.com/cass-review-excluded-98-of-gender-affirming-studies-to-reach-its-conclusion/
BBC Interview: Gender care report author attacks 'misinformation': https://www.bbc.com/news/health-68863594?ref=wearequeeraf.com2
https://www.sciencemediacentre.co.nz/2024/04/10/review-of-evidence-for-puberty-blockers-and-hormone-treatment-in-youth-expert-reaction/
https://www.gisborneherald.co.nz/column/cass-review-had-biased-unsound-methodology?amp=1
Studies:
The lived experiences of gender dysphoria in autistic adults
Children and adolescents with Gender Identity Disorder referred to a paediatric medical center