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The Cass Review is a 370-page document commissioned by the UK’s National Health Service which purports to examine the evidence base for gender-affirming medical treatment (GAMT) for trans young people. Though hailed by some politicians and media outlets as a serious work, it has been discredited in the New England Journal of Medicine and the Medical Journal of Australia; was the topic of a damning 40-page critique by gender-medicine specialists working with Yale University; and has been sharply criticised by peak medical bodies worldwide.

 

What’s so wrong with the Cass Review?

 

It has an agenda – to severely limit access to GAMT – and distorts the truth to achieve that agenda.

Still, like any good piece of disinformation, it is not entirely made up of lies.

 

The Cass Review was commissioned in response to a manufactured scandal at the UK’s Gender Identity Development Service (GDIS), a department of the Tavistock Clinic. In the 2010s, there was a surge of new patients in youth gender clinics across the world, and patient numbers at GIDS increased sharply. At the same time, the UK, under Tory Prime Minister David Cameron, implemented so-called “austerity” measures that gutted public services including the NHS. As a result, some trans young people waited five years for an appointment at GIDS. During this time, since the NHS considered psychologists and counsellors outside of GIDS unqualified to work with trans patients, these young people received no mental-health support through the public system.

 

Imagine you’re a psychologist who has treated hundreds of trans young people. A young person arrives after a five-year wait, having known they were trans for even longer. Maybe they socially transitioned at five and they’re now fifteen. Their distress is intense, their parents are 100% supportive, and you see no reason not to refer them to endocrinology immediately, especially since you have so many more young people waiting for treatment.

 

The problem is, since GIDS is stretched to near breaking point, an inexperienced psychologist fresh out of university is doing a buddy shift with you, and that young physician, who knows nothing about trans children, is horrified. Rumours spread that GIDS is “fast tracking children to a medical pathway”. Eventually, the story hits the infamously transphobic UK press, who quote a lawyer confidently predicting that “up to 1000 families” might sue the Tavistock. In the end, one family sues, the family of famous “detransitioner” Kiera Bell. But one is enough. Puberty blockers are banned through the NHS and Hilary Cass is commissioned to investigate GIDS.

 

It’s here that the Cass Review is strongest, in identifying what went wrong at GIDS. Yes, trans youth should have access to a multidisciplinary treatment team and a holistic model of care, just as it says in the WPATH (and AusPATH) Standards of Care. Yes, it would be better if GIDS had multiple hubs across the UK and if doctors throughout the NHS were trained in GAMT. And yes, five years is way too long for anyone to be on a waiting list, let alone a trans young person who is in a race against puberty.

 

Why does the Cass Review matter in Australia?

 

How is any of this relevant to Queensland, where the only justification the government seems to have for banning care is the Cass review? After all, we already have a holistic model of care; the Queensland Children’s Gender Service (QCGS) follows a multi-disciplinary approach; and in late 2024, the outgoing Labour state government funded the QCGS to both expand regionally and hire more staff in order to avoid long waitlists. It’s for these reasons that Australian LGBTQIA+ advocates sometimes say that the Cass review is “not relevant in an Australian context”. They’re correct, but they don’t go far enough, because Hilary Cass’s other recommendations are not just irrelevant, they’re dangerous.

 

Still, even the worst of Cass’s recommendations are not entirely based on falsehoods. For instance, Cass claims that, according to the GRADE system (a method of rating the reliability of evidence that is used in guideline development by organisations like the World Health Organisation and the Center for Disease Control and Prevention), the evidence for the use of puberty blockers as a treatment for gender dysphoria is “low to very low quality”. This is true, to an extent, and when WPATH commissioned a similar review it produced a similar result. But what Cass neglects to mention is that many of the medical treatments we trust and rely on are based on a similar “low” standard of evidence, including most paediatric treatments. After all, the GRADE system prioritises randomised controlled trials, and RCTs are not generally undertaken for children, since in most cases the treatments in question have already been found safe and effective for adults. In such cases, it is seen as unethical to deny some children crucial treatment while providing it to others.

 

There is another issue too: that puberty blockers, these days, are not intended to improve gender dysphoria, or to improve mental health. They are intended to pause puberty, in order to prevent the catastrophic decline in mental health that will probably occur in a trans child forced to go through their endogenous puberty. But how can we measure their effectiveness at this, without forcing some trans young people to go through puberty and measuring their decline in mental health? Do puberty blockers prevent suicide? To answer that question, we can either believe trans young people when they tell us they would rather die than go through puberty, or we can do as the UK is doing: (1) ban blockers except for a small number of young people included in our study; (2) give half those young people blockers and the other half a placebo; and (3) count how many die.

 

You might ask, “What’s all the fuss about?” Surely Cass must have found evidence of serious harm to insist on such a dangerous and unethical course of action? But that’s the problem with the Cass Review.

 

In the words of the UK’s Trans Safety Network: “We believe there to be systemic biases in the ways that the review prioritises speculative and hearsay evidence to advance its own recommendations while using highly stringent evidence standards to exclude empirical and observational data on actual patients.”

 

Think on that for a moment. On the one hand, Cass employs the most stringent standards possible to assess those studies that support GAMT for trans young people. On the other hand, she applies no standards at all to the half-baked theories of potential harms with which she justifies denying children care.

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For example, blockers may “lock in a trans identity”, she claims, causing kids to grow up trans who otherwise would have grown up cis. This theory, often paraphrased by anti-trans activists as “Puberty is the cure”, stems from the debunked 80% “desistance” theory, which claims that 80% of trans young people will cease identifying as trans if you deny them GAMT. To justify this, Cass cites the infamous 2015 Ristori and Steensma literature review, which looked at studies of young people treated in various gender clinics from the 1970s to the early 2010s.

 

But we have no evidence that the young people in those studies were actually trans. Indeed, it is highly likely that most of them were not trans, since those studies stem from a time before the diagnosis of gender dysphoria existed, instead relying on an early diagnosis of “gender identity disorder”. To obtain a diagnosis of gender identity disorder, a child did not need to identify as a gender other than their gender presumed at birth; they did not even need to want to be another gender. All those boys (and they were overwhelmingly boys) had to do was to display some stigmatised so-called “effeminate” behavioural traits, such as playing with dolls, having female friends, or being “too close” with their mothers.

 

In addition, in the 20th century and even into the early 2000s, it was commonplace for gender clinics to practice what we would now call conversion therapy. Children were punished for feminine behaviours and rewarded for masculine ones. So, it seems likely that even many trans children in those studies disavowed their identities in order to avoid such treatment. After all, the stated aim of the most prominent of those clinics (Toronto’s CAMH clinic, run by Kenneth Zucker) was to “reduce the number of transsexual outcomes”.

 

A lesson in disinformation

 

You might ask, “But why?” Why is the Cass Review so misleading? Is Hilary Cass evil, or just stupid?

 

Cass believes the end justifies the means. She knows she is cooking the figures, surely! But she’s been convinced that she is doing so in order to “save the children”.

 

And here’s where this story gets truly dark.

 

The Cass Review, and everything that has happened since its release, is the result of a decade-long disinformation campaign designed to deny trans young people treatment.

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It began circa 2016, with Lisa Littman’s junk-science theory “rapid-onset gender dysphoria” (ROGD), which theorised that the increase in referrals to youth gender clinics was the result of a so-called “social contagion”. Next, the trans-hostile Pediatric and Adolescent Gender Dysphoria Working Group brought together future leaders of the anti-trans movement and disgraced former so-called experts such as Zucker and Ray Blanchard to promote “ROGD”. Later, several group members went on to create the fake grassroots movement that would seek to legitimise their fringe ideas.

 

Between them, this handful of outlier physicians created the several semi-fictional organisations, most of them existing online and in name only, that now promote anti-trans disinformation. Of these orgs, the most dangerous is SEGM (the so-called Society for Evidence-Based Gender Medicine), which the Southern Poverty Law Center (who, until Trump’s second term, tracked extremist groups for the FBI) refers to as “the hub of the anti-LGBTQ pseudo-science network” and has designated an anti-LGBTQ hate group.

 

But let’s get back to the Cass Review. Hilary Cass, who was chosen for her role specifically because she had no experience in GAMT, was assisted in preparing the Review by a so-called “clinical expert group” (AKA the NHS Working Group on Gender Dysphoria), the membership of which was kept secret. Or at least, it was intended to be kept secret. But three members of that group revealed their identities in the minutes of a meeting with the Florida Health Board during preparations to ban GAMT in Florida in 2022. Of those three physicians, two were members of SEGM (both are listed on SEGM’s website) and the third was Finnish psychiatrist Riittakerttu Kaltiala, who has spoken at SEGM conferences and rewritten the Finnish Standards of Care for trans young people to align with SEGM’s beliefs.

 

(Incidentally, the authors of the Trump administration’s HHS Review into gender dysphoria treatments were recently revealed, and all nine of them are either well-known anti-trans campaigners or affiliated with SEGM. One is a founding member of SEGM. None have any proven track record treating trans patients.)

 

Junk science, junk reviews

 

In short, the Cass Review shows the moment when junk science and anti-trans ideology captured the NHS, and used that achievement as a springboard to spread worldwide.

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As to the Queensland Government’s recent actions, they are an obvious attempt to reproduce conditions in the UK. The manufactured controversy at the Cairns Sexual Health Service is our Tavistock Clinic, and the resultant Vine Review is our Cass Review. But there is no place for junk science in the treatment of Queensland’s young people. Before the ban, the Queensland Children’s Gender Service was renowned worldwide as the gold standard in paediatric gender care. It can reach that standard again, if the government listens to experts and not to anti-trans propaganda.

 

Current status

 

The Vine Review, led by Professor Ruth Vine, has been commissioned by the Queensland government to examine “the evidence and ethical considerations surrounding the use of puberty suppression (Stage 1) and gender affirming (Stage 2) hormone therapies to treat children with gender dysphoria in the public health system”.

 

The Queensland government has stated that “the evidence supporting the use of these therapies is contested” as a key driver of their “independent” review. The review page states that they want to examine the medical evidence, as well as understanding “the impacts from a social, psychological, legal and ethical perspective.”

 

However, there is already a wealth of scientific and medical evidence both in Australia and abroad, not to mention recent reviews in both NSW and Queensland, plus a separate and comprehensive federal review currently underway. Despite this the Crisafulli government is ignoring this, leaving countless vulnerable young people without vital, evidence-based medical care while they wait for yet another unnecessary review.

 

We will keep you updated on the progress and outcomes of the Vine Review in due course.

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