The newly released Cass Review on transgender care for young people has been pivotal in the UK, where the prescription of puberty "blocking" drugs outside of research protocols has now ceased.
But in the United States, where the treatment-intensive, "gender affirming" model of care is the norm, the impact of Cass's four-year investigation and final report has been largely ignored, finds journalist Jennifer Block in The BMJ today.
The review concluded that the evidence on use of puberty blockers and hormones for children and teens experiencing gender related distress is wholly inadequate and called for a more holistic approach to care.
It also found that links between the evidence and medical guidance are often unclear, and largely informed by the World Professional Association for Transgender Health and Endocrine Society guidelines, which themselves lack scientific rigour.
"This approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor," wrote Cass.
Yet the American Academy of Pediatrics (AAP) and Endocrine Society have stood by their guidelines, while the American Psychological Association, American Psychiatric Association, and American College of Obstetricians and Gynecologists have remained largely silent about Cass.
"Unfortunately, Cass does not seem to be penetrating the public consciousness," says Zhenya Abbruzzese, cofounder of the Society for Evidence-Based Gender Medicine (SEGM), a group of researchers and clinicians that has pushed for systematic reviews and an evidence-based approach.
Oregon paediatrician and SEGM member, Julia Mason, adds: "Parents and their children are being misled in clinics all over the country. There is no evidence that giving puberty blockers followed by hormones and surgery is lifesaving care and there is mounting evidence that the harms outweigh the advantages."
Not everyone has joined the consensus, notes Block. Scot Glasberg, past president of the American Society of Plastic Surgeons, now president of the Plastic Surgery Foundation, told The BMJ that the organisation will issue "trustworthy, high quality" guidelines, but "like Dr Cass, we've found that the literature is of low quality and low value to dictate surgical care .. We are trying to be very measured and not get into the difficulty that some of the other organisations have gotten into."
Similarly, The Wall Street Journal editors said the review "shows wisdom and humility on treatment of young people, in contrast to the ideological conformity in U.S. medical associations," while The Washington Post and Boston Globe ran opinions that amplified Cass to argue for a more precautionary path forward. But many outlets, including STAT News, CNN, and Scientific American, which have run many articles favourable to the affirmative model, have so far ignored Cass.
So far, outspoken thought leaders have not reconciled their statements with the growing list of systematic reviews that stand in contradiction, adds Block.
Yale paediatrician Meredithe McNamara has called puberty blockers "one of the most compassionate things that a parent can consent to for a transgender child," and in testimony to the US Congress, warned that when gender-affirming care "is interrupted or restricted, suicide, depression, anxiety, disordered eating, and poor quality of life follow."
Alejandra Caraballo, a Harvard Law School instructor with more than 160,000 X followers, also tweeted in advance of the report's release last month that it had "disregarded nearly all studies," a claim that Cass called "misinformation."
But Erica Anderson, a clinical psychologist and former president of USPATH, says the Cass report is going to "stand the test of time." "I'm already hearing from the boards of directors and trustees of some hospital systems who are starting to get nervous about what they've permitted. So I think that's going to accelerate change within American healthcare."
In the face of criticism, Cass has been unwavering: "It wouldn't be too much of a problem if people were saying 'This is clinical consensus and we're not sure.' But what some organizations are doing is doubling down on saying the evidence is good," she told the New York Times. "And I think that's where you're misleading the public."
