Cass Review

{{silver}}[[File:Cass Review Cover.png|right|thumb|165px|The cover of the final published version of the Cass Review (2024), featuring an [[AI]]-generated image of a kid with wonky hands bolted to a wall.]]
{{gender}}
The '''Independent Review of Gender Identity Services for Children and Young People''', more commonly known as the '''Cass Review''' or '''Cass Report''', is a 388-page government report on the provision of [[gender-affirming care]] to young people in the [[United Kingdom]].<ref name="cassreview">{{cite news |last=|first=|date=April 2024|title=The Cass Review: Independent Review of Gender Identity Services for Children and Young People | work= | publisher= | url=https://cass.independent-review.uk/home/publications/final-report/|location= | access-date=}}</ref><ref name="polgreen1">{{cite news |last=Polgreen |first=Lydia |date=August 13, 2024|title=The Strange Report Fueling the War on Trans Kids | work=[[The New York Times]] | publisher= | url=https://archive.ph/IYM6U|location= | access-date=}}</ref> Commissioned by the [[NHS]] as an "independent review" headed by paediatrician Hilary Cass, the report took four years to produce but ultimately alleged weak evidence quality in the field (along with a slew of other insinuations). This was then used to justify [[#Political context and impact|swift, sweeping policy changes]] (including a ban on [[Transgender glossary#GnRH agonists|puberty blockers]]) after its release in April 2024.<ref name="horton2">{{cite news |last=Horton |first=Cal |last2=Pearce | first2=Ruth |date=August 7, 2024|title=The U.K.'s Cass Review Badly Fails Trans Children | work=Scientific American | publisher= | url=https://www.scientificamerican.com/article/the-u-k-s-cass-review-badly-fails-trans-children/}}</ref><ref name="SPWS24"/>{{rp|10}} Despite its flaws, and even if this could've been implied by its rhetorical innuendo, the Cass Review doesn't outright call for a ban on any of the options that doctors and their patients might pursue.<ref name="mcnamara1"/>{{rp|4–7}} This was further stated by Cass in a Q&A with The Kite Trust.<ref>(April 10, 2024). [https://thekitetrust.org.uk/our-statement-in-response-to-the-cass-review-report/ "Our Statement in Response to the Cass Review Report"]. ''The Kite Trust''.</ref> Nonetheless, it has been met with uncertainty or criticism for various reasons; it's sometimes been cited as an example of [[policy-based evidence making]],<ref>[https://ghostarchive.org/archive/29yd2 Tweet by Jolyon Mauham (@JolyonMaugham) Archived.]</ref><ref>[https://ghostarchive.org/archive/hO91I Tweet by TransSafetyNow (@DadTrans). Archived.]</ref><ref>[https://ghostarchive.org/archive/iQqfd Tweet by Mark Boylan (@MarkBoylanEd). Archived.]</ref> which may be plausible given that the then-ruling [[Conservative Party (UK)|Conservative Party]]'s minister Kemi Badenoch announced the review only came into existence due to the government's "[[gender-critical]]" intervention.<ref name="badenoch1"/>

As it was a [[Review article|review]] (and the final report was not itself subject to traditional [[peer review]]<ref name="JAHSep24">{{Cite journal |last=Budge |first=Stephanie L. |last2=Abreu |first2=Roberto L. |last3=Flinn |first3=Ryan E. |last4=Donahue |first4=Kelly L. |last5=Estevez |first5=Rebekah |last6=Olezeski |first6=Christy L. |last7=Bernacki |first7=Jessica M. |last8=Barr |first8=Sebastian |last9=Bettergarcia |first9=Jay |last10=Sprott |first10=Richard A. |last11=Allen |first11=Brittany J. |date=September 2024 |title=Gender Affirming Care Is Evidence Based for Transgender and Gender-Diverse Youth |url=https://linkinghub.elsevier.com/retrieve/pii/S1054139X24004397 |journal=Journal of Adolescent Health |doi=10.1016/j.jadohealth.2024.09.009 |issn=1054-139X}} Freely readable [https://www.researchgate.net/publication/384108341_Gender_affirming_care_is_evidence-based_for_transgender_and_gender_diverse_youth on ResearchGate].</ref> although that matters less than one may think), it didn't itself produce new [[evidence]].<ref name="SPWS24"/>{{rp|6}} Other reviews of transgender healthcare have been conducted. ''Prior'' to Cass, one review in this area of medicine was Cornell University's 2018 review by the What We Know Project.<ref>(2018). [https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people/ "What does the scholarly research say about the effect of gender transition on transgender well-being?"]. ''What We Know Project'', Cornell University.</ref> Out of nearly sixty studies considered by that review, the Cass Review and its associated systematic reviews for some reason found occasion to reference precisely zero of the same papers. This may be unsurprising as a critical appraisal found Cass's systematic reviews had a high risk of bias and "inappropriate exclusion of studies … the authors excluded 48% and 36% of studies for puberty blockers and [[hormone replacement therapy]] (HRT), respectively".<ref name="CriticalAppraisal"/>{{rp|5}}

''After'' Cass, a separate 1,051-page review was published in 2024/2025, authorized by the largely-[[Mormon]]<ref>Lee Davidson (January 14, 2021). [https://www.sltrib.com/news/politics/2021/01/14/latter-day-saints-are/ "Latter-day Saints are overrepresented in Utah’s Legislature, holding 9 of every 10 seats"]. ''The Salt Lake Tribune''.</ref> conservative legislature of the U.S. state of [[Utah]].<ref name="Fox13Utah"/> The Mormon Church generally opposes gender transition,<ref>Matt Lavietes (August 21, 2024). [https://www.nbcnews.com/nbc-out/out-news/mormon-transgender-restrictions-lds-church-rcna167582 "Mormon church issues new restrictions on transgender members"]. ''NBC''.</ref> yet despite the cultural and political context, this review nevertheless returned different findings from the Cass report,<ref name="AssignedUtah">Evan Urquhart (May 27, 2025). [https://www.assignedmedia.org/breaking-news/plentiful-data-no-regret-utah-review "Plentiful Data, No Regret: What the Utah Review on Youth Trans Care Found"]. ''Assigned Media''.</ref> concluding: "Overall, there were positive mental health and psychosocial functioning outcomes".<ref name="Fox13Utah">Emily Anderson Stern (May 22, 2025). [https://www.fox13now.com/news/local-news/utah-lawmakers-own-study-found-gender-affirming-care-benefits-trans-youth-will-they-lift-the-treatment-ban "Utah lawmakers’ own study found gender-affirming care benefits trans youth. Will they lift the treatment ban?"]. ''FOX 13''.</ref><ref name="Utah2025Review">(2024/2025). [https://le.utah.gov/AgencyRP/reportingDetail.jsp?rid=636 "Systematic Medical Evidence Review of Hormonal Transgender Treatment Report"]. Utah State Legislature, and the University of Utah College of Pharmacy's Drug Regimen Review Center.</ref> Regarding evidence quality, the Utah review struck a different tone from Cass: "The conventional wisdom among non-experts has long been that there are limited data on the use of GAHT [gender-affirming hormone therapy] in pediatric patients with GD [gender dysphoria]. However, results from our exhaustive literature searches have led us to the opposite conclusion."<ref name="AssignedUtah"/><ref name="Utah2025Review"/>

The Cass Review has, predictably given some of its content and background, been well-received by [[transphobia|anti-trans]] [[lobby]] groups and activists.<ref name="polgreen1" /> Outside the [[echo chamber]] inhabited by transphobes, it has been [[#Scientific response and general criticism|roundly criticised]] by major medical organisations for its limitations and [[#Methodological issues and unsupported claims|serious methodological flaws]].<ref name="CriticalAppraisal"/><ref name="mcnamara1"/><ref name="PCH1">{{Cite journal |last=Vandermorris |first=Ashley |last2=Metzger |first2=Dan |last3=Vyver |first3=Ellie |last4=Harrison |first4=Megan |last5=Harvey |first5=Johanne |date=October 10, 2024 |others=Canadian Pediatric Society |title=Response to the Letter to the Editor on the Canadian Paediatric Society statement on gender-affirming care |url=https://academic.oup.com/pch/advance-article/doi/10.1093/pch/pxae066/7816713 |journal=Paediatrics & Child Health |language=en |doi=10.1093/pch/pxae066 |issn=1205-7088}}</ref><ref name="horton2" /> Criticism of the Cass Review has come from expert groups all around the world,<ref name="wpath1" /><ref>Xander Elliards (May 15, 2025). [https://www.thenational.scot/news/25166820.international-study-tears-cass-review-trans-healthcare-uk/ "International study tears into Cass Review of trans healthcare in UK"]. ''The National''.</ref> including [[Germany]],<ref name="LemkinGerman">(March 9, 2025). [https://www.lemkininstitute.com/single-post/new-german-swiss-and-austrian-guidelines-recommend-trans-youth-care-slam-cass-review "New German, Swiss, And Austrian Guidelines Recommend Trans Youth Care, Slam Cass Review"]. ''The Lemkin Institute''. [https://register.awmf.org/de/leitlinien/detail/028-014 (See the German-language guidelines here)].</ref> [[Canada]],<ref name="canada1"/><ref name="PCH1"/> [[Japan]],<ref>(August 2024). [https://www.jspn.or.jp/uploads/uploads/files/activity/gid_guideline_no5.pdf "性別不合に関する診断と治療のガイドライン（第 5 版）" / "Guidelines for the diagnosis and treatment of gender dysphoria (5th ed.)"]. The Japanese Society of Psychiatry and Neurology. {{quotebox|WPATH (The World Professional Association for Transgender Health)のStandards of Care (SOC) 第8版 (2022） 10)でも、Cass Reviewよも多くのsystematic reviewをもとに有用性、限界や副作用について記述している。 ["The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) 8th Edition (2022) 10) also describes the usefulness, limitations and side effects based on many more systematic reviews than the Cass Review."]}} [https://whatthetrans.com/japans-transgender-treatment-guidelines-receive-update/ (See here for an English-language discussion of this statement by the society.)]</ref> [[Switzerland]],<ref name="LemkinGerman"/> the [[United States]],<ref>Xander Elliards (January 20, 2025). [https://www.thenational.scot/news/24870246.cass-review-transgresses-medical-law-policy-us-experts-claim/ "Cass Review 'transgresses medical law and policy', US experts claim"]. ''The National''.</ref><ref>Erin Reed (May 13, 2024). [https://www.losangelesblade.com/2024/05/13/american-academy-of-pediatrics-responds-to-cass-reject-bans/ "American Academy of Pediatrics responds to Cass, reject bans"]. ''The Los Angeles Blade''.</ref><ref name="JAHSep24"/> [[Australia]],<ref name="RANZCP"/><ref>[https://equalityaustralia.org.au/cass-review-out-of-line-with-medical-consensus-and-lacks-relevance-in-australian-context/ "Cass Review out-of-line with medical consensus and lacks relevance in Australian context"]. ''Equality Australia''. {{quotebox|'The Cass review recommendations are at odds with the current evidence base, expert consensus and the majority of clinical guidelines around the world,' said Dr Portia Predny, Vice President of The Australian Professional Association for Trans Health (AusPATH).}}</ref><ref>Holly Payne (August 20, 2024). [https://www.medicalrepublic.com.au/why-queensland-didnt-copy-the-uk-approach-to-transgender-care/109942 "Why Queensland didn't copy the UK approach to transgender care"]. ''The Medical Republic''.</ref><ref name="MJA25">{{Cite journal |last=Moore |first=Julia K |last2=Rayner |first2=Cate |last3=Skinner |first3=S Rachel |last4=Wynne |first4=Katie |last5=Cavve |first5=Blake S |last6=Fraser |first6=Brodie |last7=Ganti |first7=Uma |last8=McAllister |first8=Claire |last9=Meyerowitz-Katz |first9=Gideon |last10=Nguyen |first10=Tram |last11=Ravine |first11=Anja |last12=Ross |first12=Brian |last13=Russell |first13=Darren B |last14=Saunders |first14=Liz A |last15=Siafarikas |first15=Aris |date=2025 |title=Cass Review does not guide care for trans young people |url=https://onlinelibrary.wiley.com/doi/10.5694/mja2.70035 |journal=Medical Journal of Australia |volume=223 |issue=7 |pages=331–337 |doi=10.5694/mja2.70035 |issn=1326-5377 |pmid=41055349}}</ref> [[Latin America]],<ref name="SPWS24"/> [[New Zealand]],<ref name="RANZCP"/><ref name="nz1"/> [[Ireland]],<ref>Han Tiernan (April 19, 2024). [https://gcn.ie/irish-academics-letter-criticising-cass-review/ "Over 130 Irish academics sign open letter criticising Cass Review on transgender healthcare"]. ''GCN''.</ref> [[South Africa]],<ref>Jenna-Lee de Beer-Procter and Pierre Brouard (June 13, 2024). [https://www.spotlightnsp.co.za/2024/06/13/why-affirming-treatment-for-gender-questioning-youth-matters-in-sa/ "Why affirming treatment for gender questioning youth matters in SA"]. ''Spotlight''.</ref> the [[Netherlands]],<ref>(April 18, 2024). [https://www.amsterdamumc.org/nl/vandaag/een-reactie-van-amsterdam-umc-op-de-cass-review-over-transgenderzorg.htm "Een reactie van Amsterdam UMC op de Cass review over transgenderzorg" / "A response from Amsterdam UMC to the Cass review on transgender care"]. Amsterdam University Medical Center.</ref> [[Poland]],<ref>{{Cite journal |last1=Gawlik-Starzyk |first1=Aneta |last2=Dora |first2=Marta |last3=Baran |first3=Dorota |last4=Szostakiewicz |first4=Łukasz |last5=Trofimiuk-Müldner |first5=Małgorzata |last6=Müldner-Nieckowski |first6=Łukasz |last7=Bielska-Brodziak |first7=Agnieszka |last8=Adamczewska-Stachura |first8=Milena |last9=Antosz |first9=Aleksandra |last10=Bajszczak |first10=Katarzyna |last11=Barg |first11=Ewa |last12=Barteczka-Eckert |first12=Barbara |last13=Chodecka |first13=Aleksandra |last14=Cichoń |first14=Lena |last15=Dobiała |first15=Ewa |date=2025 |title=Framework guidelines for the process of caring for the health of adolescent transgender (T) and non-binary (NB) people experiencing gender dysphoria — the position statement of the expert panel |url=https://journals.viamedica.pl/endokrynologia_polska/article/view/104289/81774 |journal=Endokrynologia Polska |language=en |volume=76 |issue=1 |pages=1–28 |doi=10.5603/ep.104289 |issn=2299-8306}} {{quotebox|One of the overt criteria that the NHS followed in choosing Hilary Cass was her complete lack of experience in working with people with gender incongruence and dysphoria, which was to ensure her independence and impartiality. However, in practice it resulted in an unprecedented situation in healthcare when a non-expert in the field was invited to develop expert recommendations. The common thread of many objections to the Cass report is the multifaceted downplaying of the importance of the voices of adolescents and their families, clinical practice, the scientific knowledge base, and national and global recommendations, while misleading the public that a complete lack of clinical experience in a given field is a guarantee of reliability. As a multidisciplinary team of experts and patients, we consider such a trend to be harmful and completely contrary to the interests of adolescents in need of help.}}</ref> [[Austria]],<ref name="LemkinGerman"/> and some within the United Kingdom itself.<ref name="bma1"/><ref>[https://web.archive.org/web/20250116111616/https://bagis.co.uk/position-process-statements/ "Position & Process Statements"]. The British Association of Gender Identity Specialists.</ref> Experts in [[France]] and New South Wales also released reviews later in 2024 that took a different stance from Cass, though these did not critique the Cass Review directly.<ref>{{Cite journal |last=Brezin |first=François |last2=Busiah |first2=Kanetee |last3=Leroy |first3=Clara |last4=Fiot |first4=Elodie |last5=Bensignor |first5=Candace |last6=Amouroux |first6=Cyril |last7=Caquard |first7=Marylène |last8=Cartault |first8=Audrey |last9=Castets |first9=Sarah |last10=Delcour |first10=Clémence |last11=Devernay |first11=Marie |last12=Feigerlova |first12=Eva |last13=Hoarau |first13=Marie |last14=Lebon-Labich |first14=Béatrice |last15=Lambert |first15=Anne-Sophie |date=2024-11-17 |title=Endocrine management of transgender adolescents: Expert consensus of the french society of pediatric endocrinology and diabetology working group |url=https://www.sciencedirect.com/science/article/pii/S0929693X24001763 |journal=Archives de Pédiatrie |doi=10.1016/j.arcped.2024.08.003 |issn=0929-693X}}</ref><ref>Veronica Esposito (December 23, 2024). [https://www.assignedmedia.org/breaking-news/cass-report-vs-france-research "Cass vs France"]. ''Assigned Media''.</ref><ref>Patricia Karvelas (September 6, 2024). [https://www.abc.net.au/news/2024-09-06/gender-affirming-care-still-safe-effective-and-reversible-review/104322428 "Puberty blockers a 'safe, effective and reversible' form of gender-affirming care, finds review triggered by Westmead Hospital investigation"]. ''ABC''.</ref> Many of the key critiques of the Cass Review are articulated below.

==Rigging the game==
{{cquote|One senior [[psychiatrist]] at a [[gender identity]] clinic in England told a national newspaper in the UK that the failure to include those with personal or professional experience “had concerned many within the field.” They said: “The {{w|terms of reference}} stated that the Cass Review ‘deliberately does not contain subject matter experts or people with lived experience of gender services’ and Dr. Cass herself was explicitly selected as a senior clinician ‘with no prior involvement … in this area.’ Essentially, [[ignorance]] of [[gender dysphoria]] medicine was framed as a virtue. I can think of no comparable medical review of a process where those with experience or expertise of that process were summarily dismissed.” WPATH and USPATH agree completely.|||{{wpl|World Professional Association for Transgender Health}} (WPATH)<ref>(May 17, 2024). [https://www.wpath.org/media/cms/Documents/Public%20Policies/2024/17.05.24%20Response%20Cass%20Review%20FINAL%20with%20ed%20note.pdf?_t=1716075965 "WPATH and USPATH Comment on the Cass Review"] ''World Professional Association for Transgender Health''.</ref>}}

===Hand-picked from a shortlist of one===
The NHS announced in January 2020 that it was establishing an "independent expert group" chaired by {{wpl|Hilary Cass}} to "support a review of puberty suppressants and [[Hormone replacement therapy|cross-sex hormones]]" in paediatric [[gender transition|gender care]].<ref name="nhs2">{{cite news |last= |first= |date=January 30, 2020 |title=Update on gender identity development service for children and young people | work= | publisher=NHS England | url=https://www.england.nhs.uk/2020/01/update-on-gender-identity-development-service-for-children-and-young-people/|location= | access-date=}}</ref> In September 2020, the NHS announced that Cass would also head this review, which it billed as an "independent review into gender identity services for [[children]] and young people."<ref name="nhs1">{{cite news |last= |first= |date=September 22, 2020 |title=NHS announces independent review into gender identity services for children and young people | work= | publisher=NHS England | url=https://www.england.nhs.uk/2020/09/nhs-announces-independent-review-into-gender-identity-services-for-children-and-young-people/|location= | access-date=}}</ref> Both press releases hailed her as "Dr Hilary Cass OBE, former President of the Royal College of Paediatrics and Child Health."<ref name="nhs2" /><ref name="nhs1" /> They didn't mention that Cass lacks clinical experience or expertise in caring for [[transgender|trans]] youth.<ref name="wpath1" />

The World Professional Association for Transgender Health condemned Cass's appointment as occurring "without any transparent or competitive process" in a statement released after the review's publication in 2024.<ref name="wpath1" /> A freedom-of-information (FOI) request that same year revealed that Cass was the ''only'' candidate considered for the job (from a "shortlist" of one).<ref>(July 11, 2024). [https://www.whatdotheyknow.com/request/cass_review_chair_selection_figu#incoming-2698487 "FOICRM (NHS ENGLAND - X24), NHS England"]. ''{{w|WhatDoTheyKnow||''.}}</ref><ref name="foi">[https://ghostarchive.org/archive/44Z7A Twitter thread by @ReactiveAshley] with screenshot of response to the FOI request. Archived.</ref>

[[Conservative Party|Tory]] minister {{wpl|Kemi Badenoch||,}} a [[DeSantis]]<ref>Heather Stewart (April 30, 2023). [https://www.theguardian.com/us-news/2023/apr/30/ron-desantis-backs-kemi-badenochs-war-on-woke "Florida's rightwing governor Ron DeSantis backs Kemi Badenoch's 'war on woke'"]. ''The Guardian''.</ref> and [[Rupert Murdoch|Murdoch]] darling,<ref>Chloe Chaplain (October 2, 2023). [https://inews.co.uk/news/politics/kemi-badenoch-met-rupert-murdoch-on-new-york-trip-2657929 "Tory leadership hopeful Kemi Badenoch met Rupert Murdoch on New York trip"]. ''The i Paper''.</ref><ref>Stefan Boscia (October 2, 2023). [https://www.politico.eu/article/kemi-badenoch-secret-meeting-rupert-murdoch-united-kingdom-conservatives/ "Tory rising star Kemi Badenoch held secret talks with Rupert Murdoch"]. ''Politico''.</ref> proudly admitted in a June 2024 [[Twitter|tweet]] that political manipulation paved the way for Cass.<ref name="badenoch1">[https://archive.is/vlBmc Archived tweet by Kemi Badenoch]. Transcript: {{quotebox|'''Quoted poster''' (@ripx4nutmeg): "On Real Time with [[Bill Maher]], [[Abigail Shrier]] is asked why England has taken a global lead when it comes to banning puberty blockers for children confused about their gender{{sic}}.

She says that there are two reasons: A centralised [[NHS]] and [[JK Rowling]]'s support for [[Trans-exclusionary radical feminist|gender critical feminists]]"<br><br>'''Kemi Badenoch''' (@KemiBadenoch): "The third reason was having gender-critical men and women in the UK government, holding the positions that mattered most in Equalities and Health.  

You only need to look at what the [[SNP]] did in Scotland to see what would have happened had we not intervened.

The Cass Review would **never** have been commissioned under a [[Labour Party|Labour]] govt. Labour did not want to know.

We had incredible opposition from the system on everything. It was when the ministers changed that everything changed."}}</ref> According to Badenoch, the review wouldn't have been commissioned under a [[Labour Party|Labour]] government, and it was "when the ministers changed" that her party no longer faced "opposition from the system."<ref name="badenoch1" /> She said a decisive factor in the production of the Cass Review was "having [[gender-critical]] men and women in the UK government, holding the positions that mattered most in Equalities and Health."<ref name="badenoch1" /> Cass was not-coincidentally awarded a life peerage in the [[House of Lords]] by transphobe and outgoing Prime Minister [[Rishi Sunak]] in July 2024.<ref name="peerage1">{{cite news |last=Prinsley|first=Jane|date=July 5, 2024|title=Sunak elevates Jewish doctor Hilary Cass to House of Lords in final act of premiership | work=The Jewish Chronicle | publisher= | url=https://www.thejc.com/news/politics/sunak-elevates-jewish-doctor-hillary-cass-in-final-act-of-premiership-arbphnb3|location= | access-date=}}</ref><ref name="peerage2">{{cite news |last=Wilson|first=Matthew X.|date=July 8, 2024|title=Hilary Cass Given a Seat in the House of Lords | work=[[National Review]] | publisher= | url=https://www.nationalreview.com/corner/hilary-cass-given-a-seat-in-the-house-of-lords/|location= | access-date=}}</ref> The aforementioned Badenoch took credit, saying she "managed to get Dr Hilary Cass a peerage", and that if she were made Tory leader, would offer [[J. K. Rowling]] one, too.<ref>Amy Watson (October 17, 2024). [https://www.scotsman.com/news/politics/kemi-badenoch-i-would-give-jk-rowling-peerage-for-her-gender-stance-4828951 "Kemi Badenoch: I would give JK Rowling peerage for her gender stance"]. ''The Scotsman''.</ref><ref>Christopher McKeon (October 17, 2024). [https://www.independent.co.uk/news/uk/jk-rowling-talktv-nhs-conservative-party-house-of-lords-b2630853.html "I would give JK Rowling a peerage for gender stance, says Kemi Badenoch"]. ''The Independent''.</ref>

The Cass Review appears to have engaged in [[Burning the evidence|questionable handling of public records]] from an early stage.<ref name="missingdrafts1">[https://ghostarchive.org/archive/Rq4kh Tweet thread by @ReactiveAshley]</ref><ref name="missingdrafts2">(9 January 2025). [https://www.whatdotheyknow.com/request/cass_final_report_drafts#incoming-2880095 "FOICRM (NHS ENGLAND - X24), NHS England"]. ''{{w|WhatDoTheyKnow||''.}}</ref><ref name="reactive1">{{cite news |author=Reactive Ashley |date=February 9, 2025 |title=Did the Cass Review shred the truth? | work=What the Trans?! | publisher= | url=https://whatthetrans.com/did-the-cass-review-shred-the-truth/|location= | access-date=}}</ref> Medium blogger "Reactive Ashley" filed an FOI request seeking "internal drafts" spanning October 2020 to 
April 2024.<ref name="missingdrafts2" />  The response: "NHS England did not receive snapshots or drafts," as this fell "outside of the review's data handling policy."<ref name="missingdrafts2" /> "Reactive Ashley" subsequently told the {{w|Information Commissioner's Office}} that "a large collection of public records may have been concealed or destroyed."<ref name="reactive1" />

===Engagement with anti-LGBT perspectives===
[[File:Hilary Cass 2024.jpg|thumb|right|350px|Hilary Cass discussing criticism of her report, April 2024.]]

The Review consulted many non-experts, and many sources who were explicitly, self-admittedly in denial that transgender minors, the topic of the review, ''exist at all'' (32 percent of those surveyed).<ref name="mcnamara1"/>{{rp|10}} Cass herself was presented as impartial and thus especially fit to carry out the review.<ref name="horton">{{cite journal |last1=Horton |first1=Cal |last2= |first2= |date=2024 |title=The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children |url=https://www.tandfonline.com/doi/full/10.1080/26895269.2024.2328249 |journal=International Journal of Transgender Health |volume= |issue=|pages= |doi= | ISSN=1434-4599}}</ref> The interim report released by the NHS in February 2022 described her as having "no prior involvement or fixed views" amidst an alleged clinical "polarisation" on trans healthcare.<ref name="cass-interim">{{cite news |last= |first= |date=February 2022 |title=Independent review of gender identity services for children and young people: Interim report | work= | publisher=NHS England | url=https://cass.independent-review.uk/wp-content/uploads/2022/03/Cass-Review-Interim-Report-Final-Web-Accessible.pdf
|location= | access-date=}}</ref> However, according to a white paper released in August 2024 by Max Davie and Lorna Hobbs, clinicians working in child and adolescent gender care in the UK, she was "known by colleagues to oppose medical transition" at the time of her appointment.<ref name="davie">{{cite journal |last1=Davie |first1=Max |last2=Hobbs |first2=Lorna |date=2024 |title=Cass: the good, the bad, the critical |url=https://web.archive.org/web/20240807205716/https://docs.google.com/document/d/e/2PACX-1vQXUWs7GU9FX02LypDp9YltRfmtRVAAn9L9CIdKuuU2kHqz_z2BBttO3nJD4Wsau5EIHuHiapFCOTQ5/pub |journal= white paper|volume= |issue=|pages= |doi= | ISSN=}}</ref><ref name="davie2">{{cite news |last=Brown|first=Rivkah|date=August 8, 2024|title=The Government's Impartial Trans Healthcare Reviewer Isn't so Impartial, Colleagues Claim | work=Novara Media | publisher= | url=https://novaramedia.com/2024/08/08/the-governments-impartial-trans-healthcare-reviewer-wasnt-so-impartial-colleagues-claim/|location= | access-date=}}</ref><ref name="reed2">{{cite news |last=Reed|first=Erin|date=August 8, 2024|title=Colleagues Allege Cass Recommended Book Comparing Transition To The Holocaust | work=| publisher= | url=https://www.erininthemorning.com/p/colleagues-allege-cass-recommended|location= | access-date=}}</ref>

Davie and Hobbs' paper included a footnote stating that  Cass had "strongly recommended" the anti-trans book ''[[Abigail Shrier#Irreversible Damage|Irreversible Damage: The Transgender Craze Seducing Our Daughters]]''.<ref name="davie" /><ref name="davie2"/><ref name="reed2" /><ref name="hansford2">{{cite news |last=Hansford|first=Amelia|date=August 10, 2024|title=Dr Hilary Cass denies claim that she recommended 'gender-critical' book to colleagues | work=PinkNews| publisher= | url=https://www.thepinknews.com/2024/08/10/hilary-cass-recommended-book-to-former-colleagues/|location= | access-date=}}</ref><ref name="davie3">[https://archive.is/Zr5Z2 Twitter thread with screenshots of the original and updated footnote]</ref> Screenshots of this footnote were widely shared on social media.<ref name="hansford2" /> Davie updated the paper to clarify that Cass called him to "discuss [his] potential involvement" in the review "towards the end of 2020."<ref name="davie" /><ref name="davie3" /> In Davie's recollection, Cass "expressed concerns about {{wpl|Gender Identity Development Service|GiDS}} practice" during this conversation, finding it "shocking" that "97% of children" prescribed puberty blockers progressed to HRT.<ref name="davie3" /><ref name="davie3" /> When Davie countered that this was likely due to "accurate triage," Cass reportedly "recommended that [he] read ''Irreversible Damage''."<ref name="davie" /><ref name="davie3" /> Davie claimed that he first became "aware of Dr Cass's scepticism about the GiDS model" when they collaborated on a {{wpl|National Institute for Health and Care Excellence|NICE}} project.<ref name="davie" /><ref name="davie3" /> Cass dismissed the ''Irreversible Damage'' anecdote as "baseless and wholly untrue" in response to a request for comment from ''PinkNews''.<ref name="hansford2" /> In the statement, she denied having ever read the book and asserted that "the suggestion that I recommended it to anyone is fabrication," noting that she had "already been reviewing the evidence for six months" at the time of its publication.<ref name="hansford2" /> Davie later removed (but did not retract) the [[anecdote]] from the paper, stating that "Dr Cass obviously saw [it] as an attack" and that he and Hobbs had set out to "robustly critique the review, not make [[ad hominem|personal attacks]]."<ref name="davie4">[https://x.com/maxdavie/status/1822866379709485076 Twitter thread by Max Davie (@maxdavie)]. Archived copies of constituent tweets: [https://archive.is/vjPRc 1], [https://archive.is/CCsV3 2], [https://archive.is/HPLZw 3], [https://archive.is/bDKrE 4], [https://archive.is/fOouq 5], [https://archive.is/yAiGU 6], [https://archive.is/higm6 7], [https://archive.is/h2cjr 8].</ref>

Cass' statement to ''PinkNews'' raised new questions. It suggests that Cass believes her work on the Cass Review began in January 2020. It also implies that she has been aware of ''Irreversible Damage'' since its American release. The book was initially released by [[Regnery Publishing]] in June 2020.<ref>[https://www.amazon.com/Irreversible-Damage-Transgender-Seducing-Daughters/dp/1684510317 Listing] for the hardback edition of Irreversible Damage on Amazon.</ref> It was not published in the UK until December 2020.<ref>[https://swiftpress.com/book/irreversible-damage/ Listing] for Irreversible Damage on the Swift Press website.</ref><ref group=note>The [[LGB Alliance]] told its followers to "buy the book" and "tell everyone [they] know" in a [https://ghostarchive.org/archive/F2tyB June 2020 tweet]. It seems likely that imported American copies were already in circulation in the UK by that time. It's also possible that people may have received {{w|Advance copy|advance copies}} of the Swift Press edition prior to its publication.</ref> Regnery is a right-wing imprint that mainly sacrifices trees for pundits like [[Ann Coulter]] and [[Dennis Prager]].<ref name="davie2" /><ref name="RLSBM">{{cite news |last=Lovell |first=Rose |date=April 10, 2024 |title=Abigail Shrier's Irreversible Damage: A Wealth of Irreversible Misinformation | work=Science-Based Medicine | publisher=| url=https://sciencebasedmedicine.org/abigail-shriers-irreversible-damage-a-wealth-of-irreversible-misinformation/|location= | access-date=}}</ref> Regnery also has a history of endorsing [[anti-science]] junk such as [[Peter Duesberg]]'s ''Inventing the AIDS Virus'' (1996).<ref name="nybooks1">{{cite news |last=Horton|first=Richard|date=May 23, 1996|title=Truth and Heresy About AIDS | work=The New York Review of Books| publisher= | url=https://web.archive.org/web/20160305011057/https://www.nybooks.com/articles/1996/05/23/truth-and-heresy-about-aids/|location= | access-date=}}</ref> UK publisher Swift Press has cultivated a similar reputation for "standing up to [[groupthink]]."<ref name="swiftpress1">{{cite news |last=Kerridge|first=Jack|date=February 15, 2022|title=Meet the small publishers standing up to groupthink | work=The Telegraph| publisher= | url=https://archive.is/YEfcC|location= | access-date=}}</ref> The author of ''Irreversible Damage'', Abigail Shrier, is a [[conservative]] [[Pundit|opinion columnist]].<ref name="nordberg1">{{cite news |last=Nordberg|first=Anna|date=February 27, 2024|title=Who's Making the Kids Cry? | work=Slate| publisher= | url=https://slate.com/human-interest/2024/02/abigail-shrier-bad-therapy-book-unfortunately-liberal-parenting-can-be-highly-mockable.html|location= | access-date=}}</ref><ref name="sarahjones1">{{cite news |last=Jones|first=Sarah|date=March 19, 2021|title=Fake Feminists Fight the Equality Act | work=Intelligencer| publisher= | url=https://slate.com/human-interest/2024/02/abigail-shrier-bad-therapy-book-unfortunately-liberal-parenting-can-be-highly-mockable.html|location= | access-date=}}</ref> [[Natalie Wynn]] characterised Shrier's book as "essentially to transmasculine people what ''[[Janice Raymond|The Transsexual Empire]]'' was to trans women."<ref name="wynn1">"[https://youtu.be/7gDKbT_l2us?t=2522 J.K. Rowling]" by [[Natalie Wynn|ContraPoints]] on [[YouTube]]</ref> The book centres on [[Littman 2018 ROGD study|Lisa Littman's debunked hypothesis]] that peer pressure and [[social media]] are "seducing" [[Sex assignment at birth|AFAB]] teens into identifying as trans boys.<ref name="eckert1">{{cite news |last=Eckert| first=AJ |date=July 4, 2021 |title=Irreversible Damage to the Trans Community: A Critical Review of Abigail Shrier’s Irreversible Damage (Part One) | work=[[Science-Based Medicine]] | publisher=| url=https://sciencebasedmedicine.org/irreversible-damage-to-the-trans-community-a-critical-review-of-abigail-shriers-book-irreversible-damage-part-one/|location= | access-date=}}</ref>{{efn|Shrier made a number of extreme and scientifically-unsupported claims in ''Irreversible Damage''. For example, she recommended that parents with trans sons prevent them from accessing smartphones,<ref name="IDTTCSOD"/>{{rp|236}} suggesting they go "to great lengths to physically move [[misgendering|their daughters]] away from the schools, the peer groups, and the online communities" that supported their gender expression and identity.<ref name="IDTTCSOD"/>{{rp|240–242}} Shrier also [[Nazi analogies|compared gender transition]] to trauma inflicted on [[Jewish]] children during the [[Holocaust]].<ref name="IDTTCSOD">{{Cite book |last=Shrier |first=Abigail |title=Irreversible Damage: The Transgender Craze Seducing Our Daughters |date=2020 |publisher=Regnery Publishing, a division of Salem Media Group |isbn=978-1-68451-046-7 |location=Washington, DC}}</ref>{{rp|113–114}}}}

Cass has followed [[Graham Linehan]], [[LGB Alliance]], and {{wpl|Transgender Trend}} online, among other anti-trans activists and organisations.<ref>[https://archive.is/9NJle Archived screenshots of Cass's Twitter follows by Erin Reed (@erininthemorning)]</ref><ref>[https://archive.is/0hirm Archived screenshots of Cass's Twitter follows by @TS_Erica_S]</ref><ref>[https://archive.is/eUj4a Archived screenshot of Cass's Twitter follows by @shadell131]</ref> In 2022 she met with Patrick Hunter of the anti-trans [[SPLC]]-designated hate group<ref>[https://www.splcenter.org/hate-map?state=ID&ideology=anti-lgbt "Hate Map: Idaho, Anti-LGBTQ Groups"]. ''Southern Poverty Law Center''.</ref> [[Society for Evidence-Based Gender Medicine|SEGM]] to discuss a stitched-up report used to ban gender-affirming care in [[Florida]].<ref name="reed1">{{cite news |last=Reed |first=Erin |date=April 10, 2024 |title=Cass Met With DeSantis Pick Over Trans Ban: Her Review Now Targets England Trans Care | work= | publisher=| url=https://www.erininthemorning.com/p/cass-met-with-desantis-pick-over|location= | access-date=}}</ref><ref name="zinnia1">{{cite news |last=Jones |first=Zinnia |date=November 29, 2023 |title=New trial exhibits in Doe v. Ladapo: DOH worked with Genspect leaders Stella O’Malley and Joe Burgo in July 2022; Hilary Cass met SEGM’s Patrick Hunter to discuss Florida’s anti-trans report; [...<nowiki>]</nowiki> | work=Gender Analysis | publisher=| url=https://genderanalysis.net/2023/11/new-trial-exhibits-in-doe-v-ladapo-doh-worked-with-genspect-leaders-stella-omalley-and-joe-burgo-in-july-2022-hilary-cass-met-segms-patrick-hunter-to-discuss-floridas-ant/|location= | access-date=}}</ref> Hunter also belongs to the {{w|Catholic Medical Association}},<ref name="reed1" /><ref name="zinnia1" /> an [[anti-abortion]], [[homophobia|anti-gay]]<ref>{{cite book|last=Keefe |first=J. |year=2003 |title=Homosexuality |series=New Catholic Encyclopedia |volume=7 |edition=2nd |publisher=Gale |page=67 |isbn=978-0-7876-4011-8}}</ref><ref>{{Cite book |url=https://www.cathmed.org/assets/files/HH%20Selection.pdf |title=Homosexuality and Hope: Questions and Answers About Same-Sex Attraction |publisher=Catholic Medical Association}})</ref><ref>{{Cite book |url=https://www.cathmed.org/assets/files/Same_Sex_Marriage.pdf |title=Same Sex Marriage |date=November 20, 2013 |publisher=Catholic Medical Association}} [https://www.cathmed.org/resources/same-sex-marriage/ (Non-PDF landing page)].</ref> organisation that opposes gender transition because, according to their interpretation, it "violates the teachings of the [[Roman Catholic Church|Church]]."<ref>[https://files.eqcf.org/wp-content/uploads/2023/12/180-P-Trial-Exhibit-43-47.pdf "Case 4:23-cv-00114-RH-MAF Document 180 Filed 11/06/23"]. United States District Court for the Northern District of Florida, Tallahassee Division</ref>{{rp|33–34}} Cass was due to speak at a cancelled 2022 teleconference for trainee child psychiatrists in the UK alongside Lisa Littman, Transgender Trend founder Stephanie Davies-Arai, [[Genspect]]{{efn|Genspect is also designated a hate group by the SPLC.<ref>[https://www.splcenter.org/hate-map?state=CA&ideology=anti-lgbt Hate Map: California, Anti-LGBTQ Groups] ''Southern Poverty Law Center''.</ref>}} founder {{wpl|Stella O'Malley||,}} and anti-trans columnist [[Helen Joyce]].<ref name="ormond2">{{cite news |last=Somerville |first=Ewan |date=March 19, 2022 |title=Great Ormond Street cancels trainee doctor conference over trans ‘safety’ complaints | work=[[The Telegraph]] | publisher=| url=https://archive.is/coVz7|location= | access-date=}}</ref><ref name="ormond1">{{cite news |last=Hayward |first=Eleanor |date=March 26, 2022 |title=Gender event off after trans activists attack 'extreme' views | work=[[The Times]] | publisher=| url=https://archive.is/cSMPG|location= | access-date=}}</ref>

===Exclusion of trans-friendly perspectives===
With a transphobe specially recruited as its lead author, the Cass Review [[cherry-picking|systematically excluded]] input from expert clinicians, trans people, and other stakeholders.<ref name="wpath1" /><ref name="horton" /><ref name="SPWS24"/>{{rp|8}} In a paper in the ''International Journal of Transgender Health'', Cal Horton observed that "[The Review], by design, prioritized [[cis]] professionals with no experience in trans healthcare."<ref name="horton" /> In Horton's assessment, people consulted by Cass were chosen for their "absence of trans specific knowledge experience, including exclusion of those with lived experience of being trans."<ref name="horton" /> The original {{wpl|terms of reference}} for the Review explicitly stated it "deliberately does not contain subject matter experts or people with lived experience of gender services."<ref name="horton" /> This was later amended to a [[vague]] note on the exclusion of parties with a "significant interest in the outcome of the Review" ({{IdEst}}, trans people concerned about their access to care).<ref name="horton" /> Cat Burton, who was consulted as director of the Gender Identity Research & Education Society (GIRES), concluded that "it was obvious that the review had been written before we started."<ref>[https://archive.is/sWWGl Tweet by Cat Burton (@CatBurton_UK). Archived.]</ref>

The Cass Review convened several focus groups of "former, current and potential future service users" in Spring 2023.<ref name="cassreview2">{{cite news |last=|first=|last2=| first2=|date=2023|title=Lived Experience Focus Groups | work= | publisher=The Cass Review | url=https://archive.ph/6MHW4|location= | access-date=}}</ref> The stated aim was to "understand [the] experiences" of trans youth and to "capture their thoughts and ideas about what they need and want from services and how they would want to access them."<ref name="cassreview2" /> Multiple participants in these focus groups have expressed that they felt pressure to "[[transmedicalism|'prove' to clinicians that they were transgender]]."<ref name="polgreen1" /> One stated that clinicians had "probed [them] so hard" for "'alternative' reasons" for their transness, including "childhood [[PTSD|trauma]], with emphasis on [[rape|sexual assault]]."<ref name="polgreen1" /> This is an [[truthiness|alternative fact]] propagated by anti-trans advocates,<ref name="eberstadt">{{cite news |last= Eberstadt |first= Mary |last2=| first2=|date=July 16, 2021|title=Might Trauma Affect Gender Identity? | work=Newsweek | publisher= | url=https://www.newsweek.com/might-trauma-affect-gender-identity-opinion-1608073|location= | access-date=}}</ref><ref name="stockbauer">{{cite news |last= Stockbauer |first= Joy |last2=| first2=|date=March 23, 2023|title=Erin Brewer Explains the Connection Between Childhood Trauma and Gender Dysphoria | work=The Washington Stand | publisher= | url=https://washingtonstand.com/news/erin-brewer-explains-the-connection-between-childhood-trauma-and-gender-dysphoria|location= | access-date=}}</ref> like [[Genspect]]<ref name="genspect1">{{cite news |last= Wiley Haynes |first= Laura |last2=| first2=|date=February 15, 2023|title=Gender Identity Through the Lens of Developmental Trauma | work= | publisher=[[Society for Evidence-Based Gender Medicine#Genspect| Genspect]] | url=https://web.archive.org/web/20230318235331/https://genspect.org/gender-identity-through-the-lens-of-developmental-trauma/|location= | access-date=}}</ref> and [[Parents of ROGD Kids]].<ref name="PORKDysphoriaCauses">"[https://web.archive.org/web/20230613070800/https://www.parentsofrogdkids.com/other-causes-for-gender-dysphoria Other Known Causes for Gender Dysphoria]". ''Parents of ROGD Kids'', via the Wayback Machine.</ref>

The full membership of the Cass Review's advisory board remains unknown.<ref name="board1">{{cite news |last=Urquhart|first=Evan|date=April 15, 2024|title=What's in the Cass Report? | work=Assigned Media | publisher= | url=https://www.assignedmedia.org/breaking-news/whats-in-the-cass-report|location= | access-date=}}</ref><ref name="board2">{{cite news |last= |first= | date=April 15, 2024|title=The Cass Review Needs To Be Thrown Out Entirely. This Is Why. | work=What The Trans?! | publisher= | url=https://whatthetrans.com/cass-review/|location= | access-date=}}</ref> Richard Byng and Richard Stephens of [[SEGM]] are known members.<ref>[https://ghostarchive.org/archive/ddATA Twitter thread by TransSafetyNow (@DadTrans)]</ref><ref name="segm-board">{{cite news |last=|first=|date=|title=April 25, 2022 meeting with the HHS | work=| publisher=Office of Information and Regulatory Affairs | url=https://mobile.reginfo.gov/public/do/eoDownloadDocument?pubId=&true&documentID=136692|location= | access-date=}}</ref> [[Finland|Finnish]] child [[psychiatry|psychiatrist]] Riittakerttu Kaltiala is another.<ref name="kaltiala1">{{cite news |last= Urquhart |first= Evan |last2= Kalliomäki | first2= Esa |date=July 30, 2024|title='Don't Forget Your Homework' | work=Assigned Media | publisher= | url=https://www.assignedmedia.org/breaking-news/transgender-youth-speak-about-finland-transpoli|location= | access-date=}}</ref><ref name="kaltiala2">[https://web.archive.org/web/20240731184314/https://riittakerttu.fi/memberships/ CV on Kaltiala's professional website]</ref> Kaltiala established Finland's youth gender program, which has been accused of "grueling assessments, mockery, [[misgendering]], and intrusive personal questions."<ref name="kaltiala1" /> A 15-year-old transmasculine patient reported being grilled on his [[masturbation|masturbatory habits]] and told to report back after experimenting as "homework."<ref name="kaltiala1" /> Kaltiala decried youth transition in Finland's leading medical journal in 2011.<ref name="kaltiala1" /><ref name="kaltiala3">{{cite news |last= Urquhart |first= Evan |last2= | first2= |date=May 22, 2024|title=Undark Examination of SEGM Includes Errors and Misinfo | work=Assigned Media | publisher= | url=https://www.assignedmedia.org/breaking-news/undark-segm-misleading-distorted|location= | access-date=}}</ref> One of the few studies [[#Throwing out the majority of research|rated as "high quality" by the Cass Review]] was a 2020 paper by Kaltiala ''et al.'' concluded that medical transition does not "improve functioning and relieve psychiatric comorbidities" in young patients.<ref name="mcnamara1" /><ref name="kaltiala4">{{Cite journal |last=Kaltiala |first= Riittakerttu |last2=Heino |first2=Elias |last3=Työläjärvi |first3=Marja |last4=Suomalainen  4 |first4=Laura |date=April 2020 |title=Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria |url=https://pubmed.ncbi.nlm.nih.gov/31762394/ |journal=Nordic Journal of Psychiatry. |volume=74 |issue=3 |pages=213-219 |doi= |issn=0803-9488 }}</ref> In 2022, Kaltiala testified in support of Florida's ban on gender-affirming care for minors,<ref name="kaltiala5">{{cite news |last=Ghorayshi|first=Azeen|date=November 4, 2022|title=Florida Restricts Doctors From Providing Gender Treatments to Minors | work=[[The New York Times]] | publisher= | url=https://web.archive.org/web/20240410014011/https://www.nytimes.com/2022/11/04/health/florida-gender-care-minors-medical-board.html|location= | access-date=}}</ref> and she personally introduced Cass to anti-trans [[Traditionalist Catholic]] activist [[#Engagement with anti-LGBT perspectives|Patrick Hunter]].<ref name="zinnia1" />

The final version of the Cass Review does not name any of its authors.<ref name="aaron-konnoth">{{Cite journal |last=Aaron |first=Daniel G. |last2=Konnoth |first2=Craig|date=January 15, 2025|title=The Future of Gender-Affirming Care — A Law and Policy Perspective on the Cass Review |url=https://www.nejm.org/doi/10.1056/NEJMp2413747 |journal=New England Journal of Medicine |volume=392 |issue=6 |pages= |doi= |issn=0028-4793}}</ref> This contravenes "international publication standards" as outlined in a 2025 paper published in the ''New England Journal of Medicine'' (NEJM).<ref name="aaron-konnoth" /> The paper's authors, Daniel G. Aaron and Craig Konnoth, concluded that the Cass team "cannot convincingly claim that the intensity of debate" over transgender issues requires them to shield their names, given that the authors of the {{w|WPATH}} standards are known."<ref name="aaron-konnoth" /> They further found "evidence of antitransgender bias in invitations to oversee and participate in the report."<ref name="aaron-konnoth" />

==Scientific response and general criticism==
===Opposition from major medical groups===
[[File:BMA House.JPG|thumb|right|250px|Headquarters of the British Medical Association.]]
The Cass Review has been widely criticised by medical bodies outside [[Transgender_glossary#TERF_Island|TERF Island]] since its April 2024 release.<ref name="horton2" /> WPATH, in a joint statement with its American counterpart USPATH, determined that the Cass Review "relies on selective and inconsistent use of evidence, and its recommendations often do not follow from the data presented in the systematic reviews."<ref name="wpath1">{{cite news |last= |first= |date=May 17, 2024 |title=WPATH and USPATH Comment on the Cass Review | work= | publisher=WPATH & USPATH | url=https://www.wpath.org/media/cms/Documents/Public%20Policies/2024/17.05.24%20Response%20Cass%20Review%20FINAL%20with%20ed%20note.pdf}}</ref> {{wpl|PATHA}} of [[New Zealand]] held that the Review makes several "harmful recommendations" and "ignores the [[scientific consensus|consensus]] of major medical bodies around the world."<ref name="nz1">{{cite news |last=|first=|date=April 11, 2024 |title=Cass Review out of step with high-quality care provided in Aotearoa | work= | publisher=PATHA | url=https://web.archive.org/web/20250326175658/https://patha.nz/News/13341582}}</ref> The {{wpl|American Academy of Pediatrics||,}} the {{wpl|Endocrine Society||,}} the {{wpl|Canadian Pediatric Society||,}} and the {{wpl|Royal Australian and New Zealand College of Psychiatrists}} have all rejected the Cass Review's findings and recommendations.<ref name="acap1">{{cite news |last=Reed |first=Erin |date=May 13, 2024 |title=Endocrine Society And American Academy Of Pediatrics Respond To Cass, Reject Bans | work= | publisher= | url=https://www.erininthemorning.com/p/endocrine-society-and-american-academy|location= | access-date=}}</ref><ref name="canada1">{{cite news |last=Johnson |first=Lisa |date=April 15, 2024 |title=What Canadian doctors say about new U.K. review questioning puberty blockers for transgender youth | work=CBC News | publisher= | url=https://www.cbc.ca/news/health/puberty-blockers-review-1.7172920|location= | access-date=}}</ref><ref name="RANZCP">{{cite news |last=|first=|date=May 29, 2024|title=A letter from members regarding the Cass Review and the College's response | work= | publisher=The Royal Australian & New Zealand College of Psychiatrists | url=https://www.ranzcp.org/news-analysis/a-letter-from-members-regarding-the-cass-review-and-the-college-s-response|location= | access-date=}}</ref> The Endocrine Society's statement noted that the Cass Review "does not contain any new research that would contradict" existing clinical guidelines on gender-affirming care for minors.<ref name="endosociety">{{cite news |last=|first=|date=|title=Statement From Endocrine Society | work= | publisher=Endocrine Society | url=https://www.scribd.com/document/730290510/Statement-From-Endocrine-Society#fullscreen&from_embed|location= | access-date=}}</ref> 

A report produced by several researchers for Yale's Integrity Project concluded that the Cass Review "levies unsupported assertions about gender identity, gender dysphoria, standard practices, and the safety of gender-affirming medical treatments," and the systematic reviews it relies upon "have serious methodological flaws, including the omission of key findings in the extant body of literature."<ref name="mcnamara1">{{cite journal |last1=McNamara |first1=Meredithe |last2=Baker |first2=Kellan | last3=Connelly |first3=Kara | last4=Janssen |first4=Aron | last5=Olson-Kennedy |first5=Johanna | last6=Pang |first6=Ken C. | last7=Scheim |first7=Ayden | last8=Turban |first8=Jack | last9=Alstott |first9=Anne |date=2024 |title=An Evidence-Based Critique of 'The Cass Review' on Gender-affirming Care for Adolescent Gender Dysphoria |url=https://law.yale.edu/sites/default/files/documents/integrity-project_cass-response.pdf |journal= Yale's Integrity Project|volume= |issue=|pages= |doi= | ISSN=}}</ref><ref name="abcnews1">{{cite news |last=Alfonseca |first= Kiara|date=July 9, 2024|title=New report critiques UK transgender youth care research study | work=ABC News | publisher= | url=https://abcnews.go.com/Health/yale-releases-report-critical-uk-transgender-youth-care/story?id=111639373|location= | access-date=}}</ref><ref name="teenvogue1">{{cite news |last=Jaime |first= Angie|date=July 3, 2024|title=Yale Report Slams Cass Review: 'Misrepresents Data' on Transgender Youth | work=Teen Vogue | publisher= | url=https://www.teenvogue.com/story/yale-report-slams-cass-review-misrepresents-data-on-transgender-youth|location= | access-date=}}</ref>

In July 2024, the {{wpl|British Medical Association}}<ref group="note">The [[#Throwing out the majority of research|systematic reviews]] produced for the Cass Review were published in ''Archives of Disease in Childhood''. This is one of several journals belonging to the BMJ Group, publisher of the BMA's trade magazine, the ''[[The BMJ|British Medical Journal]]'', which maintains editorial independence. This editorial independence has grown increasingly apparent in recent years, as the ''BMJ'' has become an [[The BMJ#Trans healthcare|outlet for fringe ideas]] on trans healthcare, while the BMA's policy positions have reflected scientific consensus.</ref> broke ranks with the UK's institutional transphobia,<ref>{{cite web |title=Combating rising hate against LGBTI people in Europe |url=https://assembly.coe.int/LifeRay/EGA/Pdf/TextesProvisoires/2021/20210921-RisingHateLGBTI-EN.pdf |publisher=Council of Europe}} {{quotebox|In the United Kingdom, anti-trans rhetoric … has also been gaining baseless and concerning credibility, at the expense of both trans people's civil liberties and women's and children's rights. … UK hate crime statistics show a sharp increase in transphobic crimes since 2015 – though only 1 in 7 victims report them to an authority. … It is also becoming increasingly difficult for individuals and organisations to publicly affirm young trans people without being subject to hostility and disproportionate questioning from wider society. The 'gender-critical' movement … has played a significant role in this process, notably since the 2018 public consultation on updating the Gender Recognition Act 2004 for England and Wales. In parallel, trans rights organisations have faced vitriolic media campaigns, in which trans women especially are vilified and misrepresented. … There is also a concerning, growing account of parents who (due to difficulties in accessing timely public health care) pursue private health care on behalf of their child, being investigated by State authorities.}}</ref><ref>{{Cite journal |last=Fae |first=Jane |date=2022 |title=Facts that get in the way |url=https://journals.sagepub.com/doi/abs/10.1177/09564748221121455 |journal=British Journalism Review |volume=33 |issue=3 |pages=9–11 |doi=10.1177/09564748221121455 |issn=0956-4748}}</ref><ref>Madeline Fitzgerald (June 29, 2022). [https://www.usnews.com/news/best-countries/articles/2022-06-29/how-anti-trans-feminism-took-hold-in-the-u-k "The Roots of Anti-Trans Feminism in the U.K."]. ''U.S. News & World Report''. {{quotebox|At large, the truth is that TERFs and gender critical feminists are a small minority within U.K. feminism. They do not represent or reflect the views of U.K.-based feminists as a whole, and most U.K. based feminists reject their ideas and arguments, and consider them outdated or harmful. This does not mean they have no influence or impact, however. The trouble is that even though they are a minority, they are a vocal one, and they often have their views platformed by the media, including mainstream media. It is interesting that TERFs or gender critical feminists often say that they are being silenced by what they sometimes call the ‘trans lobby.’ Yet, even though they are indeed a small minority, their views and arguments are being platformed by many outlets just as much and sometimes more than the views of trans-affirming feminists and trans activists, and their arguments have also carried a lot of impact on policy decisions, especially in relation to the proposed GRA reforms.}}</ref><ref>Rachel Muller-Heyndyk (June 19, 2018). [https://www.hrmagazine.co.uk/content/news/transphobia-rife-among-uk-employers/ "Transphobia rife among UK employers"]. ''HR Magazine''.</ref> announcing it planned to "undertake an evaluation of the Cass Review" by the year's end.<ref name="bma1">{{cite news |last=|first=|date=July 31, 2024|title=BMA to undertake an evaluation of the Cass Review on gender identity services for children and young people | work= | publisher=British Medical Association | url=https://www.bma.org.uk/bma-media-centre/bma-to-undertake-an-evaluation-of-the-cass-review-on-gender-identity-services-for-children-and-young-people|location= | access-date=}}</ref> The statement cited international and domestic concerns over "weaknesses in the methodologies used in the Review and problems arising from the implementation of some of the recommendations."<ref name="bma1" /> The UK's anti-trans commentariat were predictably outraged.<ref name="whelan1">{{cite news |last=Whelan|first=Emma|date=August 1, 2024|title=The militant BMA is becoming an enemy of the people | work=[[The Telegraph]] | publisher= | url=https://archive.is/gryOZ|location= | access-date=}}</ref><ref name="sodha1">{{cite news |last=Sodha|first=Sonia|date=August 4, 2024|title=The BMA's stance on puberty blockers defies the key principle of medicine: first, do no harm | work=[[The Guardian]] | publisher= | url=https://archive.is/EQub4|location= | access-date=}}</ref><ref name="sapper1">{{cite news |last=Sapper|first=Paul|date=August 6, 2024|title=The BMA's shameful support for puberty blockers | work=[[Spiked]] | publisher= | url=https://archive.is/jgpaX|location= | access-date=}}</ref>

===AI-generated and "borrowed" images===
[[File:CassReportAISlop.png|right|thumb|220px|An [[AI]]-generated Adobe stock image of a pink-haired "[[non-binary gender|non binary]] teen" featured in the Cass Review.<ref name="ai-images1" />]]
The Cass Review drew criticism for using [[AI]]-generated images throughout its final published version.<ref name="ai-images1">{{cite news |last=Roscoe |first= Jules|date=April 15, 2024|title=Review Used By UK to Limit Gender Affirming Care Uses Images of AI-Generated Kids | work=404 Media | publisher= | url=https://www.404media.co/uk-gender-affirming-care-ai-generated-children/|location= | access-date=}}</ref><ref name="woods-ai">{{cite news |last=Woods|first=Mel|date=April 16, 2024|title=How AI image generators fail queer and trans people | work=Xtra! | publisher= | url=https://xtramagazine.com/video/how-ai-image-generators-fail-queer-and-trans-people-264700|location= | access-date=}}</ref><ref name="heggestad">{{cite news |last=Heggestad|first=Jon|date=May 16, 2024|title=Who does queer AI 'art' actually represent? | work=Xtra! | publisher= | url=https://xtramagazine.com/culture/ai-art-gay-queer-representation-265329 |location= | access-date=}}</ref><ref name="ai-images2">{{cite news |last=Hansford |first= Amelia|date=April 16, 2024|title=Cass report used AI-generated image of gender non-conforming child | work=PinkNews | publisher= | url=https://www.thepinknews.com/2024/04/16/cass-report-ai-generated-pictures/|location= | access-date=}}</ref> A member of Cass's team confirmed the use of Adobe stock images to both ''PinkNews'' and ''404 Media''.<ref name="ai-images1" /><ref name="ai-images2" /> In a statement to ''404 Media'', the team member explained that, given the "sensitive and contentious" nature of the report, a "conscious" effort was made to avoid "images that could identify any individuals."<ref name="ai-images1" /> 

[[machine learning|Machine learning]] tends to reproduce the [[garbage in, garbage out|biases and flaws of its training model]].<ref name="tiku1">{{cite news |last=Tiku |first= Nitasha|last2=Schaul|first2=Kevin|last3=Chen|first3=Szu Yu|date=November 1, 2023|title=These fake images reveal how AI amplifies our worst stereotypes | work=[[The Washington Post]] | publisher= | url=https://archive.is/KepUB|location= | access-date=}}</ref> Reece Rogers of ''Wired'' found that AI tools such as {{w|Midjourney}} "universally" produce "stereotypical depictions of LGBTQ culture" in a 2024 investigation.<ref name="rogers1">{{cite news |last=Rogers |first= Reece|date=April 2, 2024|title=Here's How Generative AI Depicts Queer People | work=Wired | publisher= | url=https://www.wired.com/story/artificial-intelligence-lgbtq-representation-openai-sora/|location= | access-date=}}</ref> According to Rogers' report, the AI slop machine envisions [[gay]] men as "fashionable dressers with killer abs," [[lesbianism|lesbians]] with "nose rings and stern expressions," and [[bisexuality|bi]] and [[non-binary gender|non-binary]] people with "textured" purple hair.<ref name="rogers1" /> This is consistent with a 2023 study that found AI outputs represent LGBT people as "less human, more stereotyped and more sexualized."<ref name="ungless1">{{cite journal |last1=Ungless |first1=Eddie L. |last2=Ross|first2=Björn |last3=Lauscher|first3=Anne |date=2023 |title=Stereotypes and Smut: The (Mis)representation of Non-cisgender Identities by Text-to-Image Models|url=https://aclanthology.org/2023.findings-acl.502/ |journal=Findings of the Association for Computational Linguistics |volume=|issue=|pages=7919–7942 |doi= | }}</ref> Another study from 2023 found images of non-binary people produced by {{w|Stable Diffusion}} were "farthest from [the] baseline depiction of 'person'" as a white man.<ref name="ghosh1">{{cite journal |last1=Ghosh |first1=Sourojit |last2=Caliskan|first2=Aylin |date=2023 |title=‘Person’ == Light-skinned, Western Man, and Sexualization of Women of Color: Stereotypes in Stable Diffusion|url=https://aclanthology.org/2023.findings-emnlp.465.pdf |journal=Findings of the Association for Computational Linguistics |volume=|issue=|pages=6971–6985 |doi= | }}</ref> The study's lead author, Sourojit Ghosh, told ''404 Media'' that stereotype-laden AI images contribute to the "historic trend" of mainstream LGBT erasure, and implicitly tell young people "there is a 'correct' way to present oneself as trans/nonbinary."<ref name="ai-images1" /> Mel Woods of ''Xtra!'' echoed this view, warning that such images "flatten down experiences and identities into stereotypes, and suggest there's only one way to be trans."<ref name="woods-ai" /> Nonethless, Abigail Anthony of ''[[National Review]]'' wrote a bizarre defense of Cass's use of AI images, though she conceded that the cover art has "creepy fingers."<ref name="ai-images3">{{cite news |last=Anthony |first= Abigail|date=April 18, 2024|title=Cass Report AI Images: Patients Aren't Poster Children | work=[[National Review]] | publisher= | url=https://www.nationalreview.com/corner/cass-report-ai-images-patients-arent-poster-children/|location= | access-date=}}</ref>  

The Cass Review also allegedly "[[plagiarism|borrowed]]" the chart presented as "Figure 11" ([[#A brief rundown of everything Cass gets wrong|see below]]) from [[Society for Evidence-Based Gender Medicine|SEGM]]'s website without attribution.<ref name="klotz1">{{cite news |last=Klotz |first=Frieda |date=May 20, 2024 |title=Pediatric Transgender Care and the Contentious Rise of SEGM | work=Undark| publisher= | url=https://undark.org/2024/05/20/pediatric-transgender-care-contentious-segm/|location= | access-date=}}</ref> The only modification was the [[Image manipulation|removal of SEGM's logo]] from the lower right corner.<ref name="klotz1" /> SEGM co-founder Zhenya Abbruzzese<ref group=note>Evgenia "Zhenya" Abbruzzese is [https://www.dailydot.com/debug/maia-poet-mother-segm/ reportedly] the mother of terminally-online [[Transgender glossary#Detransition|detransitioner]] Maia Poet. The younger Abbruzzese [https://nypost.com/2025/02/20/us-news/i-decided-to-detransition-after-living-in-israel-on-oct-7/ told] the ''[[New York Post]]'' in February 2025 that she decided there are "more important things in life than my gender dysphoria" because she was living as a trans man in [[Israel]] on [[Hamas#October_7th_attacks|October 7, 2023]], and would've attended the Nova Music Festival if she and her friends could've afforded tickets and secured transportation.</ref> commented in an ''Undark'' interview that the group were "both surprised and pleased" to discover their chart in the Cass Review.<ref name="klotz1" /> The Review's teal-and-orange colour scheme was seemingly inspired by SEGM's graphics.<ref>Compare to the selection of charts featured on the [https://segm.org main page of the SEGM websites] below the self-congratulatory "SEGM in Media" section.</ref>

==Methodological issues and unsupported claims==
{{cquote|That the Review asserts that the quality of evidence on which current practice is based is inadequate and then goes on to make recommendations that are based on a lower level of evidence is striking and concerning.|||Vandermorris ''et al.''<ref name="PCH1"/>}}
{{cquote|The Cass Review's internal contradictions are striking. It acknowledged that some trans young people benefit from puberty suppression, but its recommendations have made this currently inaccessible to all. It found no evidence that psychological treatments improve gender dysphoria, yet recommended expanding their provision. It found that NHS provision of GAMT (GnRHa, oestrogen or testosterone) was already very restricted, and that young people were distressed by lack of access to treatment, yet it recommended increased barriers to oestrogen and testosterone for any trans adolescents aged under 18 years. It dismissed the evidence of benefit from GAMT as "weak", but emphasised speculative harms based on weaker evidence. The harms of withholding GAMT were not evaluated. The Review disregarded studies observing that adolescents who requested but were unable to access GAMT had poorer mental health compared with those who could access GAMT.|||Moore ''et al.''<ref name="MJA25"/>}}
[[File:YaleCassExponential.png|thumb|right|The Integrity Project's critical notes on a graph presented in the Cass Review.<ref name="mcnamara1"/>{{rp|16}}<ref name="cassreview" />{{rp|85}} The chart doesn't show an "exponential" increase in GIDS referrals as claimed, but rather linear growth with levelling off, followed by a decrease and an illusory spike caused by double-counting.<ref name="mcnamara1"/>{{rp|16}} This chart was [[#Scientific response and general criticism|seemingly "borrowed"]] from [[Society for Evidence-Based Gender Medicine|SEGM]] without credit.<ref name="klotz1" />]]
===A brief rundown of everything Cass gets wrong===
The Cass Review and the systematic reviews it drew on repeatedly violated conventional standards of [[evidence]] evaluation;<ref name="PCH1"/><ref name="mcnamara1"/>{{rp|8, 28–33}} violated what can be surmised of its own standards of evidence evaluation;<ref name="mcnamara1"/>{{rp|2}} made some completely unsupported or disproven assertions;<ref name="PCH1"/><ref name="mcnamara1"/>{{rp|19–26}}<ref name="CriticalAppraisal"/>{{rp|10–11}}<ref name="SPWS24"/>{{rp|8}}<ref name="Grijseels68">{{Cite journal |last=Grijseels |first=D. M. |date=2024-06-08 |title=Biological and psychosocial evidence in the Cass Review: a critical commentary |url=https://www.tandfonline.com/doi/full/10.1080/26895269.2024.2362304 |journal=International Journal of Transgender Health |pages=1–11 |doi=10.1080/26895269.2024.2362304 |issn=2689-5269}}</ref> botched the use of [[Technobabble#Genuine jargon|technical terminology]];<ref name="mcnamara1"/>{{rp|8, 15–17}} misrepresented/misinterpreted its own presented data;<ref name="mcnamara1"/>{{rp|15–18, 20–21}} claimed to oppose [[conversion therapy]] while uncritically and favorably citing papers "proposing methods that claim to suppress transgender identity";<ref name="mcnamara1"/>{{rp|20–21}} failed to rigorously define or explain its standards or reasoning for evidence quality;<ref name="mcnamara1"/>{{rp|8, 28–33}} failed to seriously consider other factors recommended for evaluation in the care of trans patients by e.g. a {{w|GRADE approach||,}} such as risk-benefit ratios,<ref name="mcnamara1"/>{{rp|8–10}}{{efn|Quoting McNamara ''et al.'': "The Review does not consider the harms of not offering gender-affirming medical care to a young person with gender dysphoria. The most concrete and tangible effect of not providing treatment is the development of permanent physical characteristics that do not align with a person’s gender. These include voice deepening, hair growth, breast tissue development, final height, or body habitus. The Review ignores the significant psychological pain suffered by patients with gender dysphoria, for whom these permanent physical changes are highly distressing. The Review also ignores the consequences for teens who, left untreated, must present to the world a physical appearance that is at odds with their own identity. In adulthood, these physical effects can be ameliorated to some degree with costly and invasive treatments such as surgery, hair removal, and speech therapy. These treatments do not erase the intervening years of psychological distress. The Review also selectively identifies the purported harms of treatment while failing to engage with the harms of no treatment. For example, the Review theorizes that those who have been treated with puberty-pausing medications and wish to pursue vaginoplasty may have a more challenging postoperative course. But the Review does not consider how puberty-pausing medications prevent development of unwanted breast tissue and can prevent the later need for mastectomy, which is a commonly sought surgery by transgender adults."<ref name="mcnamara1"/>{{rp|9–10}}}}<ref name="SPWS24"/>{{rp|8}}<ref name="JAHSep24"/> which can be important especially given the limits for achievement of "[[Gold standard (science)|gold standard]]" evidence in many types of medicine.<ref name="ScienceAlert90">{{w|Jeremy Howick}} (September 3, 2020). [https://www.sciencealert.com/around-90-percent-of-your-medical-treatments-isn-t-backed-by-high-quality-evidence "Only 1 in 10 Medical Treatments Is Backed by High-Quality Evidence, Study Finds"]. ''The Conversation'' (via ScienceAlert).</ref><ref name="mcnamara1"/>{{rp|10–12}}<ref name="BaT24"/>

They failed to contextualize transgender medicine within wider pediatric medicine (in such a way as to create an implicit [[Double standard|double-standard]]);<ref name="mcnamara1"/>{{rp|12–15}} misrepresented the careful and considered deployment of transgender medicine as instead careless (which ran against the review's own data);<ref name="mcnamara1"/>{{rp|18–19}} oversimplified some nuanced findings;<ref name="mcnamara1"/>{{rp|9}} framed patients' advancement from social transition to medical transition [[Correlation does not imply causation|as though the former ''caused'' the latter]], rather than this being a demonstration that the patients are genuinely transgender;<ref name="mcnamara1"/>{{rp|19–20}} and [[confirmation bias|cited papers]] based on [[Statistics#Sampling_bias|surveys from anti-transgender websites]] while [[cherry picking|ignoring or underplaying major findings]] from certain papers that were based on much more rigorous methodologies,<ref name="mcnamara1"/>{{rp|22–23}}<ref name="JAHSep24"/> including even some papers that the Cass Review's own systematic reviews rated as "moderate" or "high" quality.<ref name="mcnamara1"/>{{rp|37–38}} Basically, this means the final report failed to reference certain positive evidence for trans medicine that the review's own evidence-evaluators found.<ref name="SPWS24"/>{{rp|9–10}}

===Throwing out the majority of research===
[[File:International tidyman.svg|thumb|right|215px|Hilary Cass throws out studies that don't confirm her thesis (artistic interpretation).]]
{{cquote|'''Steven Novella:''' If you decide after you look at the evidence what the threshold is--

'''Cara Santa Maria:''' Well, that's [[p-hacking|''p''-hacking]]. It's the equivalent of ''p''-hacking. It's not hacking the ''p'', it's hacking something else. It's hacking the threshold. It's [[Post hoc, ergo propter hoc|post hoc determination]].

'''Steven Novella:''' Or [[ad hoc]]. So rather than: 'here are the established methods that we use to evaluate whether or not the threshold of evidence has been met. And we're going to apply that established standard to this body of evidence.' They did not do that. They violated standard practice.|||''[[The Skeptics' Guide to the Universe]]'', Episode #995<ref>(August 3, 2024). [https://www.theskepticsguide.org/podcasts/episode-995 ''The Skeptics' Guide to the Universe'', Episode #995].</ref>{{rp|39:54–1:08:10}}<ref>[https://sgutranscripts.org/wiki/SGU_Episode_995 SGU Episode 995: transcript] ''The Skeptics' Guide to the Universe''.</ref>}}
The Cass Review's biggest methodological flaw is its nearly-wholesale dismissal of the existing body of scientific research supporting [[gender transition|gender-affirming care]].<ref name="mcnamara1" /><ref name="aaron-konnoth" /><ref name="tannehill1">{{cite news |last=Tannehill |first=Brynn |date=April 15, 2024 |title=The Cass Review heralds how all trans medicine will die | work=Los Angeles Blade | publisher= | url=https://archive.is/VbLzl|location= | access-date=}}</ref><ref name="riedel1">{{cite news |last=Riedel |first=Samantha |date=April 12, 2024 |title=Advocates Say a Controversial Report on Healthcare for Trans Kids Is 'Fundamentally Flawed'| work=Them | publisher= | url=https://www.them.us/story/cass-review-nhs-trans-youth-healthcare-report|location= | access-date=}}</ref> Cass recruited researchers at the University of York to carry out seven {{wpl|systematic review|systematic reviews}} (SRs) of the available scientific literature for use in the review.<ref name="mcnamara1" /> McNamara ''et al.'' (2024) found that the York authors {{wpl|Preregistration (science)|preregistered}} their intent to assess study quality in all seven SRs using the Mixed Methods Appraisal Tool (MMAT).<ref name="mcnamara1" /> However, they ultimately switched to a version of the Newcastle-Ottawa Scale (NOS) with "several adaptations" introduced by themselves for half<ref name="CriticalAppraisal">{{Cite journal |last=Noone |first=Chris |title=Critically Appraising the Cass Report: Methodological Flaws and Unsupported Claims |journal=BMC Medical Research Methodology |date=2025-05-10 |url=https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/s12874-025-02581-7 |doi=10.1186/s12874-025-02581-7 |last2=Southgate |first2=Alex |last3=Ashman |first3=Alex |last4=Quinn |first4=Éle |last5=Comer |first5=David |last6=Shrewsbury |first6=Duncan |last7=Ashley |first7=Florence |last8=Hartland |first8=Jo |last9=Pashdag |first9=Joanna}}</ref>{{rp|5}} of the SRs, which McNamara ''et al.'' judged to be "a divergence from standard practices designed to [[confirmation bias|minimize bias]] in systematic reviews" and "not a minor one." This switch was not explained or acknowledged in the SRs.<ref name="mcnamara1" />{{rp|28–29}}{{efn|It's hard to know if this is the reason, but the MMAT's 2018 user guide recommendation says, "Excluding studies with low methodological quality is usually discouraged."<ref>[https://web.archive.org/web/20181123102525/http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/fetch/127916259/MMAT_2018_criteria-manual_2018-08-01_ENG.pdf "Mixed Methods Appraisal Tool (MMAT) Version 2018: User Guide"]. McGill University.</ref>{{rp|1}}}}

The SRs excluded all research [[Fun:English-only movement|not published in English]] and {{w|grey literature}} from consideration.<ref name="mcnamara1" />{{rp|33}}<ref name="aaron-konnoth" /> Of the 103 studies reviewed by the SRs, "only 2 of 51 puberty-blocker and 1 of 53 hormone studies [were found] to be high-quality."<ref name="aaron-konnoth" /> The [[The BMJ|BMJ Group]] put out a press release boasting about this fact after the SRs were published in ''Archives of Disease in Childhood''.<ref name="bmj1">{{cite news |last= |first= |date=April 10, 2024 |title=Evidence for puberty blockers and hormone treatment for gender transition wholly inadequate | work= | publisher=BMJ Group | url=https://bmjgroup.com/evidence-for-puberty-blockers-and-hormone-treatment-for-gender-transition-wholly-inadequate/|location= | access-date=}}</ref> Applying ROBIS, a tool recommended by {{w|Cochrane (organisation)|Cochrane}} for evaluating risk of bias in systematic reviews, all of the seven systematic reviews used by the Cass Review were determined to be at a high risk of bias on every single measure (of four measures) — except for one that was low risk of bias on a single measure.<ref name="mcnamara1"/>{{rp|31–32}}<ref name="CriticalAppraisal"/>{{rp|3–6}} This was "driven by unexplained protocol deviations, ambiguous eligibility criteria, inadequate study identification, and the failure to integrate consideration of these limitations into the conclusions derived from the evidence syntheses."<ref name="CriticalAppraisal"/>{{rp|1}}

In laymen's terms, this means the Cass Review applied incomprehensible standards to its evaluation of evidence, seemingly [[cherry picking|picking-and-choosing]] what studies to include and exclude on an arbitrary or selective basis. This is ''worse'' than the explanation that the Review dismissed everything but [[double-blind]] [[randomized controlled trial]]s (RCTs) as "low quality." That misconception has made its way into media coverage and popular commentary.<ref name="tannehill1" /><ref name="riedel1" /> RCTs have limitations and may be [[morality|ethically questionable]] or practically infeasible in certain fields, including [[chemotherapy]], [[abortion]] medication, and gender care.<ref name="mcnamara1" />{{rp|12-13}}<ref name="riedel1" /><ref group="note">This doesn't disqualify RCTs from being used in the listed fields with appropriate ethical safeguards. When testing the effectiveness of a treatment, a [[placebo]] is generally used as a [[experimental control|control]] in RCTs. However, when RCTs are done for new treatments for which withholding of treatment would be considered unethical, the control group usually consists of a currently proven treatment instead. Cancer treatment is a perfect example. RCTs are common in cancer research. However, instead of using a placebo for the control group (as withholding treatment for a disease with such a high rate of death would be unethical), the control group generally receives the same kind of treatment they would expect from your average hospital. It's still an RCT, but the C is slightly different, with no ethical qualms.</ref> As McNamara ''et al.'' explain, "the presence or absence of 'high-quality evidence' alone should not be used to decide whether to offer treatment" with proven benefits, since "RCTs specifically are ill-suited to studying the effects of many interventions" on trans people's well-being.<ref name="mcnamara1" />{{rp|12}} In the case of puberty blockers, it would be impossible to successfully conduct a double-blind RCT on their efficacy in treating [[gender dysphoria]] in trans adolescents, as the [[placebo]] [[experimental control|cohort]] would realise their lot upon experiencing unwanted body changes (e.g. breast development in trans boys).<ref name="mcnamara1" />{{rp|12-13}}<ref name="riedel1" /><ref name="ashley1">{{cite journal |last1=Ashley |first1=Florence |last2=Tordoff |first2=Diana M. |last3=Olson-Kennedy |first3=Johanna |last4=Restar |first4=Arjee J. |date=2024 |title=Randomized-controlled trials are methodologically inappropriate in adolescent transgender healthcare |url=https://www.tandfonline.com/doi/full/10.1080/26895269.2023.2218357 |journal=International Journal of Transgender Health |volume=25 |issue=3|pages=407-418  |doi= | ISSN=1434-4599}}</ref> Half of the drugs used in pediatric medicine are prescribed "{{w|Off-label use|off-label}} on the basis of limited evidence."<ref name="aaron-konnoth" /> This is due to a general lack of pharmaceutical research focusing on children.<ref name="aaron-konnoth" /> The overall prevalence of pediatric RCTs has declined or stagnated since the 1980s for various reasons.<ref name="cohen1">{{cite journal |last1=Cohen |first1=Eyal |last2=Uleryk |first2=Elizabeth |last3=Jasuja |first3=Monica |last4=Parkin|first4=Patricia C. |date=February 2007 |title=An absence of pediatric randomized controlled trials in general medical journals, 1985-2004 |url=https://www.jclinepi.com/article/S0895-4356(06)00288-5/fulltext |journal=Journal of Clinical Epidemiology |volume=60 |issue=2|pages=118-123  |doi= | ISSN=0895-4356}}</ref><ref name="beasant1">{{cite journal |last1=Beasant |first1=L. |last2=Brigden |first2=A. |last3=Parslow |first3=R. M. |last4=Apperley| first4=H. |last5=Keep| first5=T. |last6=Northam |first6=A. |last7=Wray |first7=C.|last8=King |first8=H. |last9=Langdon |first9=R. |last10=Mills |first10=N. |last11=Young |first11=B. |last12=Crawley |first12=E. |date=June 2019 |title=Treatment preference and recruitment to pediatric RCTs: A systematic review |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6430075/ |journal=Contemporary Clinical Trials Communications |volume=14 |issue=|pages=  |doi= | ISSN=2451-8654}}</ref><ref name="groff1">{{cite journal |last1=Groff |first1=Michael L. |last2=Offringa |first2=Martin |last3=Emdin |first3=Abby |last4=Mahood| first4=Quenby |last5=Parkin| first5=Patricia C. |last6=Cohen |first6=Eyal |date=December 2020 |title=Publication Trends of Pediatric and Adult Randomized Controlled Trials in General Medical Journals, 2005–2018: A Citation Analysis |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7765242/ |journal=Children |volume=7 |issue=22|pages=  |doi= | ISSN=2227-9067}}</ref>

The Cass Review's recommendations were changed without notice in December 2024 (including in the original PDF) from supporting an [[informed consent|informed-consent framework]] to waffling that this "model may be used" while doctors consider "[[conversion therapy|different treatment options]] [[bullshit|that may meet the patient's needs]]."<ref name="reactive2">{{cite news |author=Reactive Ashley (as Not Ashley) |date=February 4, 2025 |title=The Cass Review secretly changed its final report. | work= | publisher= | url=https://medium.com/@notashley/the-cass-review-claimed-it-didnt-support-conversion-therapy-oops-now-it-does-a8516ba70c34|location= | access-date=}}</ref>

===Weird, ridiculous, and harmful assertions===
[[File:An unidentified young girl with a toy pram filled with dolls ATLIB 330374.png|right|thumb|240px|The Cass Review suggests little girls like dollies for biological reasons.]]
* '''Toy preferences are biological''': The Cass Review claims children's "toy preferences, play, and physicality" are "influenced by biological and social factors."<ref name="cassreview" />{{rp|98}} It asserts that "there is evidence for [strong] prenatal and postnatal hormonal influence" in girls' apparent preference for dolls and boys' preference for trucks,<ref name="cassreview" />{{rp|100–101}} but that this is somehow ''not'' also the case for gender identity<ref name="cassreview" />{{rp|101,115}} despite there being evidence for that,<ref>{{Cite book |last=Swaab |first=Dick F. |title=Sexual differentiation of the human hypothalamus: Relationship to gender identity and sexual orientation |date=2021 |series=Handbook of Clinical Neurology |volume=181 |pages=427–443 |url=https://linkinghub.elsevier.com/retrieve/pii/B9780128206836000312 |publisher=Elsevier |language=en |doi=10.1016/b978-0-12-820683-6.00031-2 |isbn=978-0-12-820683-6 |last2=Wolff |first2=Samantha E.C. |last3=Bao |first3=Ai-Min|quote=All the genetic, postmortem, and in vivo scanning observations support the neurobiological theory about the origin of gender dysphoria, [[Transgender#Brains|i.e., it is the sizes of brain structures, the neuron numbers, the molecular composition, functions, and connectivity of brain structures]] that determine our gender identity or sexual orientation. There is no evidence that one's postnatal social environment plays a crucial role in the development of gender identity or sexual orientation.}}</ref> including evidence mentioned in the Cass Review itself (though it frames prenatal sex hormones in this case as "environmental influences" for some reason).<ref name="cassreview" />{{rp|115–116}} It cites a 2015 study by Melissa Hines,<ref name="cassreview" />{{rp|101}} who also co-authored a 2002 study claiming "sexually differentiated object preferences" in vervet [[monkey]]s.<ref name="pearce1">{{cite news |last=Pearce |first=Ruth |date=April 15, 2024 |title=What's wrong with the Cass Review? A round-up of commentary and evidence | work=| publisher= | url=https://ruthpearce.net/2024/04/16/whats-wrong-with-the-cass-review-a-round-up-of-commentary-and-evidence/|location= | access-date=}}</ref><ref name="hines1">{{cite journal |last1=Alexander |first1=Gerianne M. |last2=Hines|first2=Melissa |date=2002 |title=Sex differences in response to children's toys in nonhuman primates (Cercopithecus aethiops sabaeus)|url=https://www.sciencedirect.com/science/article/pii/S1090513802001071 |journal=Evolution and Human Behavior |volume=23 |issue=6|pages=467-479  |doi= | ISSN=1090-5138}}</ref> In other words, it claimed that male vervets showed greater interest in a "car and a ball" while females preferred the "doll and [cooking] pot," a finding that [[anthropomorphism|assumes animals understand the purpose of human-made objects]].<ref name="pearce1" /><ref name="hines1" /> A later, smaller study with rhesus macaques had different findings from Hines's,<ref>{{Cite journal |last=Pittet |first=Florent |last2=Heng |first2=Victoria |last3=Atufa |first3=Jala |last4=Bliss-Moreau |first4=Eliza |date=2023 |title=Monkeys do not show sex differences in toy preferences through their individual choices |url=https://bsd.biomedcentral.com/articles/10.1186/s13293-023-00489-9 |journal=Biology of Sex Differences |volume=14 |issue=1 |pages=3 |doi=10.1186/s13293-023-00489-9 |issn=2042-6410 |pmid=36737809}}</ref> so it might even depend on the species of primate. (Humans are most closely related to bonobos and chimpanzees, which differ behaviorally, being matriarchal and patriarchal respectively.<ref>Adam Omary (August 17, 2022). [https://www.psychologytoday.com/us/blog/natured-nurture/202208/what-primates-can-teach-us-about-gender "What Primates Can Teach Us About Gender"]. ''Psychology Today''.</ref><ref>Jose Yong (April 4, 2023). [https://theconversation.com/bonobos-and-chimps-what-our-closest-relatives-tell-us-about-humans-202265 "Bonobos and chimps: what our closest relatives tell us about humans"]. ''The Conversation''.</ref>)
* '''Cautiously consult the doctor for fashion advice''': Cass says, "The approach taken to social transition is very individual but it is broadly understood to refer to social changes to live as a different gender such as altering hair or clothing, name change and/or use of different pronouns. … Social transition may not be thought of as an intervention or treatment, because it is not something that happens in a healthcare setting and it is within the agency of an adolescent to do for themselves. However, in an NHS setting it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning and longer-term outcomes. … Clinical involvement in the decision-making process should include advising on the risks and benefits of social transition as a planned intervention, referencing best available evidence."<ref name="cassreview" />{{rp|158-165}} We alternatively advise: doctors, barbers, and fashionistas all use sharp pointy objects, yet one must be careful about confusing them for one another.
* '''Porn makes kids trans?''': The Cass Review suggests "more investigation into consumption of online [[pornography]] and [[gender dysphoria]] is needed."<ref name="cassreview" />{{rp|110}} The only source it cites to prove [[Just asking questions|the supposed need for such research]] is a 2024 commentary by Karin Nadrowski.<ref name="cassreview" />{{rp|110}} Nadrowski argues that exposure to violent, degrading porn may induce transness in AFAB youth by increasing "[[TERF_glossary#Pornsick|shame and fear of becoming a woman]]," claiming that "working through" patients' sexual trauma "may correct false beliefs about [[sexism|gender inequality]] and therefore might alleviate gender dysphoria."<ref name="nadrowski1">{{cite journal |last1=Nadrowski |first1=Karin | date=2024 |title=A New Flight from Womanhood? The Importance of Working Through Experiences Related to Exposure to Pornographic Content in Girls Affected by Gender Dysphoria|url=https://www.tandfonline.com/doi/full/10.1080/0092623X.2023.2276149#abstract |journal=Journal of Sex & Marital Therapy |volume=50 |issue=3|pages=293-302  |doi= | ISSN=1090-5138}}</ref> Nadrowski, a clinical psychiatrist and [[Transgender glossary#Detransition|detransitioner]], belongs to a pro-[[conversion therapy]] lobby group.<ref name="reed4">{{cite news |last=Reed |first=Erin |date=May 15, 2024 |title=Opinion: No, Dr. Cass, Porn Will Not Make You Trans | work=| publisher= | url=https://www.erininthemorning.com/p/opinion-no-dr-cass-porn-will-not|location= | access-date=}}</ref><ref name="nadrowski2">{{cite news |last=|first=|date=2024 |title=Pornography and the Flight from Sexuality from a Psychodynamic Perspective | work=| publisher=Therapy First | url=https://www.therapyfirst.org/event/pornography-and-the-flight-from-sexuality-from-a-psychodynamic-perspective/|location= | access-date=}}</ref> Cass stated in a May 2024 interview with [[NPR]] that "early exposure to pornography" may drive trans identification among AFABs.<ref name="reed4" /><ref name="nadrowski3">{{cite news |last=Steinsiek |first=Alyssa |date=May 10, 2024 |title=TWIBS: Cass Says Porn Makes You Trans | work=Assigned Media| publisher= | url=https://www.assignedmedia.org/breaking-news/cass-says-porn-makes-you-trans|location= | access-date=}}</ref><ref name="nadrowski4">{{cite news |last=Scheimer |first=Dorey |last2=Chakrabarti |first2=Meghna |last3=Skoog |first3=Tim |date=May 8, 2024 |title='The evidence was disappointingly poor': The full interview with Dr. Hilary Cass | work=WBUR| publisher= | url=https://www.wbur.org/onpoint/2024/05/08/nhs-hilary-cass-review-gender-transgender-care?s=09|location= | access-date=}}</ref>
* '''[[Tumblr]] makes kids trans'''?: The Cass Review stops short of endorsing the debunked concept of [[Gender dysphoria#Rapid onset gender dysphoria|rapid-onset gender dysphoria]] (ROGD) as fact.<ref group="note">It does cite a 2021 survey by Lisa Littman, author of the [[Littman 2018 ROGD study|earlier paper proposing ROGD]], in a section on respondents' stated reasons for detransitioning.</ref> However, the Review makes a point of [[concern trolling]] that some of the parents it consulted were worried about online "influencers," who they believe have exerted "a substantial impact on their child's beliefs and understanding of their gender."<ref name="cassreview" />{{rp|120}}<ref group="note">The sentence initially attributes these concerns to "gender-questioning young people and their parents" before the Review tips its hand with "their child."</ref> It does this after spending several pages fretting over whether [[social media]] and smartphones have increased the incidence of depression, [[sleep]] disorders, and body-image issues among young people.<ref name="cassreview" />{{rp|109-111}} The notion that trans identities are spread via "social contagion" has been popularised by [[Abigail Shrier]]'s ''Irreversible Damage''.<ref name="eckert1" /> A colleague of Hilary Cass has alleged that she "[[#Engagement with anti-LGBT perspectives|strongly recommended]]" this book to him in 2020.<ref name="davie3" />
[[File:OurDutyProtest.jpg|thumb|right|240px|"Under 25? [[Conversion therapy|Therapy only]]." The UK anti-trans group Our Duty calling for restrictions on adult access to gender care in 2020.]]
*'''24-year-olds are children''': The Cass Review states that there are "different issues involved in considering gender care for children and young people than for adults."<ref name="cassreview" />{{rp|26}} In the following sentence, it claims that a person's "developmental trajectory [...] continues to their mid-20s," which it maintains "needs to be considered" in regards to supposed "determinants of gender incongruence."<ref name="cassreview" />{{rp|26}} In a later section, it states that brain maturation progresses into the mid-20s, and that "gender and sexual identity may continue to evolve" during this time.<ref name="cassreview" />{{rp|193}} Cass thus relies on the fallacious idea that human brains aren't fully developed or mature until age 25.<ref name="chu1">{{cite news |last=Chu |first=Jay C. |date=November 27, 2022|title=The Myth of the 25-Year-Old Brain | work=Slate| publisher= | url=https://slate.com/technology/2022/11/brain-development-25-year-old-mature-myth.html|location= | access-date=}}</ref> This notion, rooted in neurological research showing that white matter in the prefrontal cortex generally increases into the 20s, has become a [[pop psychology|pop-psych]] [[oversimplification|explanation]] for everything from [[school shooting]]s to {{w|Leonardo DiCaprio}}'s love life.<ref name="chu1" /> The Cass Review proposes creating a "follow-through service" for NHS gender patients aged 17 to 25.<ref name="cassreview" />{{rp|224}} It suggests this would "remove the need for transition at this vulnerable time."<ref name="cassreview" />{{rp|224}} It's unclear whether this refers to the oft-abrupt transfer from GIDS to adult services or the process of gender transition.<ref name="maung1">{{cite news |last=Maung |first=Hane |date=April 12, 2024|title=Response to the Cass Review | work=| publisher=GenderGP| url=https://www.gendergp.com/response-to-the-cass-review/|location= | access-date=}}</ref> Anti-trans lobby groups [[Society for Evidence-Based Gender Medicine#Genspect|Genspect]]<ref name="rodriguez1">{{cite news |last=Rodriguez|first=Matthew |date=August 19, 2022|title=Transphobes Are Attacking Doctors, Ellis Green Is the First Transmasc Olympian, and Pennsylvania Helps LGBTQ+ Youth: This Week in Queer News | work=Them| publisher=| url=https://www.them.us/story/this-week-in-queer-news-boston-childrens-hospital-ellia-green-libsoftiktok|location= | access-date=}}</ref><ref name="oconnell1">{{cite news |last=O'Connell |first=Kit |date=July 22, 2022|title=There Is No Legitimate ‘Debate’ Over Gender-Affirming Healthcare | work=The Texas Observer| publisher=| url=https://www.texasobserver.org/emily-bazelon-transgender-healthcare-debate-new-york-times/|location= | access-date=}}</ref> and Our Duty<ref name="ourduty1">{{cite news |last=|first=|date=December 1, 2020|title=Keira Bell Judgment – First Impressions | work=| publisher=Our Duty| url=https://ourduty.group/2020/12/01/keira-bell-judgment-first-impressions/|location= | access-date=}}</ref> support bans on gender-affirming care for under-25s. Genspect director Alasdair Gunn advised "focus[ing] relentlessly" on the "problem" of under-25s transitioning for strategic reasons in chatlogs leaked in 2023.<ref name="piper1">{{cite news |last=Piper|first=Ernie |date=July 30, 2023|title=EXCLUSIVE: 'Focus relentlessly on under 25': Leaked chats reveal influential gender-critical group’s plan to use children to push for bans on transitioning | work=The Daily Dot| publisher=| url=https://www.dailydot.com/debug/genspect/|location= | access-date=}}</ref>
* '''Time-traveling census of medievals''': The review asserts without any citation or evidence that most trans people "for many centuries" were transfeminine.<ref name="cassreview" />{{rp|114}} By the nature of this topic and the way records disappear over time, it's virtually impossible to know whether this is the case, but accounts of historical transmasculine people across nationalities are not hard to find.<ref name="maung1"/> Taken on its own, this unproven assertion appears silly and inconsequential, but given that this helps purport a "sudden surge" of young transmasculine people in the 2010s/2020s, it's likely intended to pile on more shaky support for the "ROGD" narratives mentioned above.
* '''Autistic people cannot know themselves''': The Cass Review states that research has found "transgender and gender-diverse individuals are three to six times more likely to be [[autism|autistic]]" than cis people.<ref name="cassreview" />{{rp|93}} The cited study, Warrier ''et al.'' (2020), did indeed reach this conclusion.<ref name="warrier1">{{cite journal |last1=Warrier |first1=Varun | last2=Greenberg |first2=David M. | last3=Weir |first3=Elizabeth | last4=Buckingham |first4=Clara | last5=Smith |first5=Paul | last6=Lai |first6=Meng-Chuan |last7=Allison |first7=Carrie |last8=Baron-Cohen |first8=Simon |date=August 2020 |title=Elevated rates of autism, other neurodevelopmental and psychiatric diagnoses, and autistic traits in transgender and gender-diverse individuals|url=https://pubmed.ncbi.nlm.nih.gov/32770077/ |journal=Nature Communications |volume=11 |issue=1 |pages= |doi= | ISSN=2041-1723}}</ref> At least one other paper supports a link between gender variance and [[Autism rights_ movement#Neurodiversity|neurodivergence]].<ref name="strang1">{{cite journal |last1=Strang |first1=John F. | last2=Kenworthy |first2=Lauren | last3=Dominska |first3=Aleksandra | last4=Sokoloff |first4=Jennifer | last5=Kenealy |first5=Laura E. | last6=Berl |first6=Madison |last7=Walsh |first7=Karin |last8=Menvielle |first8=Edgardo |last9=Slesaransky-Poe |first9=Graciela |date=2014 |title=Increased Gender Variance in Autism Spectrum Disorders and Attention Deficit Hyperactivity Disorder|url=https://link.springer.com/article/10.1007/s10508-014-0285-3 |journal=Evolution and Human Behavior |volume=43 |issue=|pages=1525–1533 |doi= | ISSN=0004-0002}}</ref> The trouble lies in the Review's suggestion that issues with sensory processing and emotional expression mean autistic trans kids cannot be trusted to accurately articulate "how they are feeling about their internal sensations, their gender identity and their [[sexual identity]]."<ref name="cassreview" />{{rp|93}} It uncritically repeats a 2011 study's assertion that "it can be [[gaslighting|complicated to disentangle]]" whether autistic trans kids' [[gender dysphoria|dysphoria]] "evolves from a general feeling of being just 'different' or a whether a [[transmedicalism|true 'core' cross-gender identity exists]]."<ref name="cassreview" />{{rp|68}}<ref name="devries1">{{cite journal |last1=de Vries |first1=Annelou L. C. | last2=Steensma |first2=Thomas D. | last3=Doreleijers |first3=Theo A. H. | last4=Cohen-Kettenis |first4=Peggy T. | date=August 2011 |title=Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study|url=https://pubmed.ncbi.nlm.nih.gov/20646177/ |journal=The Journal of Sexual Medicine |volume=8|issue=8|pages=2276-2283 |doi= | ISSN=1743-6095 }}</ref> The Nadrowski paper more bluntly opines that the "[[ableism|reduced mentalization capacities]]" of AFAB autistics make them more vulnerable to being [[bullshit|transed by porn]].<ref name="nadrowski1" /> The Cass Review recommends screening young [[NHS]] gender patients for "neurodevelopmental conditions, including autism spectrum disorder."<ref name="cassreview" />{{rp|148}} Its claims are part of a [[J. K. Rowling#Link between autism and gender variance|wider ableist assault]] on autistic people's right to self-determination. Trans autistics have reported being delayed or blocked in accessing care by clinicians.<ref name="white1">{{cite news |last=White |first=Bryony |date=November 16, 2016 |title=The Link Between Autism and Trans Identity | work=The Atlantic| publisher= | url=https://www.theatlantic.com/health/archive/2016/11/the-link-between-autism-and-trans-identity/507509/|location= | access-date=}}</ref> Several U.S. states restricted or banned gender-affirming care for autistics in 2023.<ref name="rummler1">{{cite news |last=Rummler |first=Orion |last2=Luterman |first2=Sara |date=May 30, 2023 |title=Anti-trans laws are targeting autistic youth and those with mental health conditions | work=The 19th| publisher= | url=https://19thnews.org/2023/05/trans-laws-autistic-youth-mental-health/|location= | access-date=}}</ref> In October 2024, an exploratory analysis found autistic people who transitioned were just as likely to persist,<ref>{{Cite journal |last=Real |first=André Gonzales |last2=Russell |first2=Stephen T. |date=2024-10-01 |title=Why Do Adolescents and Young Adults Discontinue Gender-Affirming Medical Treatments? There Is No Simple Answer |url=https://www.jahonline.org/article/S1054-139X(24)00340-9/fulltext |journal=Journal of Adolescent Health |language=English |volume=75 |issue=4 |pages=525–527 |doi=10.1016/j.jadohealth.2024.07.009 |issn=1054-139X |pmid=39293889 |quote=Importantly, neither clinical diagnosis of autism nor self-identified autistic identity were significantly associated with a greater likelihood for discontinuation.}}</ref> a hint they might well know their own gender identity after all.
====Post-review commentary====
* '''If you criticize my review, you're like anti-vaxxers:''' Two months after publication, the review's eponymous Hilary Cass compared those who criticized the review to members of the [[anti-vaccination movement]] who argue vaccines are unsafe.<ref>Susan Wichgers (June 26, 2024). [https://www.trouw.nl/verdieping/critici-noemen-kinderarts-hilary-cass-anti-trans-gelukkig-weet-ik-zelf-wat-de-waarheid-is~bc5a9a3f/ "Critici noemen kinderarts Hilary Cass anti-trans. 'Gelukkig weet ik zelf wat de waarheid is'"]. ''Trouw''. [https://archive.ph/vQBMT (Archived version)].</ref> Despite this statement, trans people's trust for the [[COVID-19 vaccine]] was very similar to the general population.<ref>McNaghten A, Brewer NT, Hung M, ''et al.'' (February 4, 2022). [https://www.cdc.gov/mmwr/volumes/71/wr/mm7105a3.htm "COVID-19 Vaccination Coverage and Vaccine Confidence by Sexual Orientation and Gender Identity — United States, August 29–October 30, 2021"]. MMWR Morb Mortal Wkly Rep 2022;71:171–176. U.S. CDC. 71(5);171–176.</ref> The playbook used by the Cass Review {{sl|Puberty blocker ban|and British government}} of "methodolatry"/[[FUD]] with regards to trans medicine is actually more similar to the rhetoric of anti-vaxxers than the other way around.<ref>Erin Reed (September 16, 2024). [https://www.erininthemorning.com/p/florida-releases-anti-vax-guidance "Florida Releases Anti-Vax Guidance Using Same Argument From Trans Care Bans"]. ''Erin In The Morning''.</ref> This is further supported by [[Robert F. Kennedy Jr.]] (RFK Jr.), the ''de facto'' "face" of the anti-vaccination movement,<ref>(March 26, 2021). [https://www.bbc.com/news/technology-56536390 "Covid vaccine: Social media urged to remove 'disinfo dozen'"]. ''BBC News''. {{quotebox|The Instagram account of campaigner Robert F Kennedy Jr - perhaps the best-known anti-vaccine influencer[…].}}</ref><ref>{{Cite journal |last=Yang |first=Y. Tony |date=2025-01-11 |title=The perils of RFK Junior's anti-vaccine leadership for public health |url=https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02603-5/fulltext |journal=The Lancet |language=English |volume=405 |issue=10473 |pages=122 |doi=10.1016/S0140-6736(24)02603-5 |issn=0140-6736 |pmid=39708828}}</ref> parroting the review's (wrong<ref name="chu1"/>) rhetoric on brain maturity just weeks after its publication.<ref>Robert F. Kennedy Jr. (May 7, 2024). [http://archive.today/2025.05.28-034733/https://x.com/RobertKennedyJr/status/1787660506850885800 "The more I learn, the more troubled I have become about giving puberty blockers to youth. … The prefrontal cortex, responsible for skills like planning, prioritizing, and making good decisions, doesn't fully mature until the early to mid-20s."] Twitter.</ref> As U.S. HHS Secretary, RFK Jr. oversaw a similar "review" against trans healthcare in 2025,{{efn|RFK Jr's HHS now has a reputation for using [[ChatGPT]] AI generation in their "scientific reviews", for what that's worth.<ref> Lauren Weber and Caitlin Gilbert (May 29, 2025). [http://archive.today/2025.05.30-222603/https://www.washingtonpost.com/health/2025/05/29/maha-rfk-jr-ai-garble/ "White House MAHA Report may have garbled science by using AI, experts say"]. ''The Washington Post''.</ref><ref>Adrianna Rodriguez and Ken Alltucker (May 29, 2025). [https://www.usatoday.com/story/news/politics/2025/05/29/rfk-jr-maha-report-citation-errors/83925319007/ "White House blames 'formatting' for errors in RFK Jr.'s MAHA report. Authors push back."] ''USA Today''.</ref>}}<ref>Geoff Mulvihil, Carla K. Johnson, and Amanda Seitz (May 1, 2025). [https://www.pbs.org/newshour/health/trumps-hhs-urges-therapy-for-transgender-youth-departing-from-broader-gender-affirming-health-care "Trump's HHS urges therapy for transgender youth, departing from broader gender-affirming health care"]. ''PBS''.</ref> spread similar anti-autistic [[stereotype]]s to the Cass Review,<ref>Ana Faguy (April 25, 2025). [https://www.bbc.com/news/articles/cd6jlvq59njo "Love on the Spectrum cast questions RFK Jr's comments about autistic people"]. ''BBC News''.</ref> and commissioned [[David Geier]]{{efn|In some kind of supreme [[irony]], the Geier family had a history of trying to "cure" autism they purported was caused by vaccines, with puberty blockers.<ref name="The74Geier"/> This was called "[[Lupron therapy]]", and unlike trans medicine where hormone-blocking is the goal in-itself, they had unrelated [[bullshit]] reasons for doing this tied up in a mix of anti-vaccine and anti-autistic tropes.}} to oversee his autism/vaccines "study".<ref name="The74Geier">Beth Hawkins (April 11, 2025). [https://www.yahoo.com/news/head-rfk-jr-vaccine-study-201913530.html "Head of New RFK Jr. Vaccine Study Practiced Unlicensed Medicine on Autistic Kids"]. ''The74'', via Yahoo! News.</ref><ref>Kathleen Seidel (May 10, 2025). [https://sciencebasedmedicine.org/david-geier-mail-order-pharmacist/ "David Geier, Mail Order Pharmacist"]. ''Science-Based Medicine''.</ref>
* '''Take antidepressants instead?:''' In an interview, Cass suggested, without offering evidence, that an alternative could be "medications for anxiety and depression that might be just as or more effective than puberty blockers."<ref>(May 7, 2024). [https://x.com/HolyroodDaily/status/1787780402217685322 "Dr Hilary Cass says the issue of puberty blockers has become 'almost totemic'."] ''Hollyrood'', via Twitter.</ref><ref>(May 7, 2024). [https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15847 "Health, Social Care, and Sport Committee / 15th Meeting 2024, Session 6 / Gender Identity Services for Children and Young People"]. Scottish Parliament.</ref>{{rp|11-12}} This most likely refers to [[SSRIs]]; the NHS states "SSRIs aren't usually recommended for children and young people under the age of 18. This is because there's evidence of an increased risk of self-harm and thoughts about suicide in this age group."<ref>[https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/medicines-and-psychiatry/ssri-antidepressants/considerations/ "Cautions - Selective serotonin reuptake inhibitors (SSRIs)"]. ''NHS''.</ref> The [[FDA]] had these drugs labeled with warnings for that reason, though they nevertheless aren't outright banned for use by minors (imagine that).<ref>(March 19, 2022). [https://www.mayoclinic.org/diseases-conditions/teen-depression/in-depth/antidepressants/art-20047502 "Antidepressants for children and teens"]. ''Mayo Clinic''.</ref> Using SSRIs for gender dysphoria itself is nonsensical and not supported by evidence, since untreated gender dysphoria is characterized by a stressful disconnect which in turn ''inflames'' depression/anxiety, rather than the other way around.<ref>{{Cite journal |last=Colizzi |first=Marco |last2=Costa |first2=Rosalia |last3=Pace |first3=Valeria |last4=Todarello |first4=Orlando |date=2013 |title=Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style |url=https://pubmed.ncbi.nlm.nih.gov/23574768 |journal=The Journal of Sexual Medicine |volume=10 |issue=12 |pages=3049–3058 |doi=10.1111/jsm.12155 |issn=1743-6109 |pmid=23574768}}</ref><ref>Jessica Nye, PhD (April 21, 2021). [https://www.psychiatryadvisor.com/news/anxiety-depression-similar-among-socially-transitioned-transgender-children-as-their-cisgender-peers/ "Anxiety, Depression Similar Among Socially Transitioned Transgender Children as Their Cisgender Peers"]. ''Psychiatry Advisor''.</ref><ref>Amelia Hansford (May 10, 2024). [https://www.thepinknews.com/2024/05/10/sorry-dr-cass-trans-healthcare-is-about-more-than-just-suppressing-anxiety/ "Sorry Dr Cass, trans healthcare is about more than just suppressing anxiety"]. ''PinkNews''.</ref>
* '''Deviation from the norm shall be exploitable''': Sayeth Cass, a measure for whether hormone replacement therapy works for trans people should be to ask in follow-up, "Are they in employment?".<ref>(May 10, 2024). [https://www.losangelesblade.com/2024/05/10/transition-should-be-measured-by-employment-not-satisfaction/ "Transition should be measured by 'employment,' not satisfaction"]. ''The Los Angeles Blade''.</ref> To name one of the more obvious criticisms of this, many employers in the UK discriminate against trans people in hiring and will even explicitly admit to it in firm surveys,<ref>{{Cite journal |last=Drydakis |first=Nick |date=2025-03-14 |title=Employment discrimination against transgender women in England |url=https://www.emerald.com/insight/content/doi/10.1108/IJM-09-2023-0528/full/html |journal=International Journal of Manpower |language=en |volume=46 |issue=1 |pages=58–74 |doi=10.1108/IJM-09-2023-0528 |issn=0143-7720}}</ref><ref>Rachel Muller-Heyndyk (June 19, 2018). [https://www.hrmagazine.co.uk/content/news/transphobia-rife-among-uk-employers/ "Transphobia rife among UK employers"]. ''HR Magazine''.</ref><ref>(June 18, 2018). [http://archive.today/2019.05.22-121637/https://www.crosslandsolicitors.com/site/hr-hub/transgender-discrimination-in-UK-workplaces "Transphobia rife among UK employers as 1 in 3 won't hire a transgender person"]. ''Crossland Employment Solicitors''.</ref> even despite the fact this is brazenly illegal under the {{w|Equality Act 2010||.}}

==Political context and impact==
===Puberty blocker ban===
[[File:Wes Streeting Official Cabinet Portrait, July 2024 (cropped).jpg|thumb|right|200px|Health Secretary Wes Streeting.]]
{{cquote|The BMA has been critical of proposals to ban the prescribing of puberty blockers to children and young people with gender dysphoria, calling instead for more research to help form a solid evidence base for children’s care&nbsp;– not just in gender dysphoria but more widely in paediatric treatments. The Association believes clinicians, patients and families should make decisions about treatment on the best available evidence, not politicians.|||British Medical Association<ref name="bma1"/>}}
Puberty blockers were banned for [[gender dysphoria]] patients under 16{{efn|This is the legal threshold for minors giving [[informed consent]] to medical treatments in the UK under the principle of {{wpl|Gillick competence||.}} However, since most adolescents go through puberty well before ages 16 to 18, restricting blocker access to older teens represents a total ban for most patients in practice. Blockers are completely useless<ref>Camille Bains (February 8, 2024) [https://www.thestar.com/life/health-wellness/puberty-blockers-cant-be-started-at-18-when-youth-have-already-developed-experts/article_9f2b2eaa-8e99-525e-82c9-0c1273992f3b.html Puberty blockers can't be started at 18 when youth have already developed: experts]. ''Toronto Star'' (The Canadian Press).</ref> to trans kids who've already been through puberty. They will not allow a trans girl to ungrow facial hair. Keira Bell, the plaintiff in ''Bell v Tavistock'', is a political detransitioner like {{wpl|Chloe Cole||.}} Bell was prescribed blockers at 16 and underwent top surgery at 20.}} in the UK following the High Court's decision in ''{{wpl|Bell v Tavistock}}'' in December 2020.<ref name="bell1">{{cite news |last= |first= |date=December 1, 2020 |title=Puberty blockers: Under-16s 'unlikely to be able to give informed consent' | work=BBC News| publisher=| url=https://www.bbc.com/news/uk-england-cambridgeshire-55144148.amp|location= | access-date=}}</ref><ref name="bell2">{{cite news |last=Parson |first=Vic |date=December 1, 2020 |title=Trans kids must understand risks of hormone therapy to receive life-saving puberty blockers, judge rules in landmark case | work=PinkNews| publisher=| url=https://www.thepinknews.com/2020/12/01/puberty-blockers-keira-bell-high-court-transgender-teenagers-gids/|location= | access-date=}}</ref> The decision was overturned by the Court of Appeal in the September 2021.<ref name="bell3">{{cite news |last=Lawrie |first=Eleanor |date=September 17, 2021 |title=Ruling limiting under-16s puberty blockers overturned | work=BBC News| url=https://www.bbc.com/news/uk-58598186|location= | access-date=}}</ref> In May 2024, shortly before the dissolution of Parliament ahead of [[2024 United Kingdom general election|that year's general election]], [[Conservative Party|Tory]] health secretary Victoria Atkins announced a ban on new blocker prescriptions for dysphoria patients under 18.<ref name="atkins1">{{cite news |last=|first=|date=May 29, 2024 |title=New restrictions on puberty blockers | work=| publisher=Department of Health and Social Care| url=https://www.gov.uk/government/news/new-restrictions-on-puberty-blockers|location= | access-date=}}</ref><ref name="atkins2">{{cite news |last=Perry |first=Sophie |date=May 30, 2024 |title=UK government bans private puberty blocker prescriptions for trans youth | work=PinkNews| publisher=| url=https://www.thepinknews.com/2024/05/30/uk-government-puberty-blockers-restrictions-trans/|location= | access-date=}}</ref><ref name="atkins3">{{cite news |last=Stone |first=Gemma |date=May 30, 2024 |title=Cowardly bully Victoria Atkins MP banned puberty blockers as Parliament dissolves | work=Trans Writes| publisher=| url=https://transwrites.world/victoria-atkins-mp-banned-puberty-blockers/|location= | access-date=}}</ref><ref name="atkins4">{{cite news |last=Reed |first=Erin |date=May 31, 2024 |title=UK Secretary Uses Emergency Powers To Criminalize Possession Of Puberty Blockers | work=| publisher=| url=https://www.erininthemorning.com/p/uk-secretary-uses-emergency-powers|location= | access-date=}}</ref> The surprise move exploited an emergency legal mechanism that was last invoked in 1999 to ban a [[Herbal supplement|poisonous herb]] (''[[Aristolochia]]'') used in [[traditional Chinese medicine]] following two deaths.<ref name="atkins3" /><ref name="atkins4" /><ref name="atkins5">{{cite news |last=Norton |first=Cherry |date=July 28, 1999|title=Chinese herb banned after two deaths | work=[[The Independent]]| publisher=| url=https://www.independent.co.uk/news/chinese-herb-banned-after-two-deaths-1109298.html|location= | access-date=}}</ref> TransActual and the Good Law Project quickly mounted a legal challenge of Atkins' ban, arguing she hadn't shown a "serious danger to health" that justified emergency action.<ref name="transactual1">{{cite news |last=|first=|date=June 6, 2024|title=Press release: TransActual to challenge ban on puberty blockers in court | work=| publisher=TransActual| url= https://transactual.org.uk/blog/2024/06/06/press-release-transactual-to-challenge-ban-on-puberty-blockers-in-court/|location= | access-date=}}</ref><ref name="ruling2">{{cite news |last=Siddique|first=Haroon|date=July 29, 2024|title=Puberty blockers ban imposed by Tory government is lawful, high court rules | work=[[The Guardian]]| publisher=| url= https://www.theguardian.com/society/article/2024/jul/29/puberty-blockers-ban-tory-government-lawful-high-court-rules|location= | access-date=}}</ref> A judge held that Atkins' use of emergency powers was "lawful" in late July.<ref name="ruling1">{{cite news |last=|first=|date=July 29, 2024|title=Puberty blockers ban is lawful, says High Court | work=[[BBC News|BBC News]]| publisher=| url= https://www.bbc.com/news/articles/c4ng3gz99nwo|location= | access-date=}}</ref><ref name="ruling2" /> 

The ban would've automatically expired in September 2024 given the mechanism's emergency intent.<ref name="atkins1" /><ref name="atkins2" /><ref name="atkins3" /> {{w|Wes Streeting}} announced his plan to make the ban permanent within days of his instalment as health secretary under the newly-elected [[Labour Party|Labour]] government in early July.<ref name="streeting1">{{cite news |last=Hansford |first=Amelia |date=July 12, 2024|title=Labour's Wes Streeting 'to make trans puberty blocker ban permanent' | work=[[The Independent]]| publisher=| url= https://www.thepinknews.com/2024/07/12/wes-streeting-puberty-blockers/|location= | access-date=}}</ref><ref name="streeting2">{{cite news |last=Searles |first=Michael |date=July 12, 2024|title=Labour moves to ban puberty blockers permanently | work=[[The Telegraph]]| publisher=| url= https://t.co/zRaSjZlFDR|location= | access-date=}}</ref> The "temporary" ban was extended on August 22.<ref name="streeting3">{{cite news |last=|first=|date=August 22, 2024 |title=Puberty blockers temporary ban extended | work=| publisher=Department of Health and Social Care| url=https://www.gov.uk/government/news/puberty-blockers-temporary-ban-extended|location= | access-date=}}</ref>{{efn|This time with the added cruelty of closing two loopholes that allowed 1) importation of blockers prescribed and supplied in the [[European Union]] and 2) UK doctors to take over existing prescriptions from the EU. Jolyon Maugham has stated that these oversights suggest that Atkins' ban was drafted in "great haste."<ref>[https://ghostarchive.org/archive/mcQ6x Jolyon Maughum on Twitter. Archived.]</ref> Streeting chose to extend the ban on the day it was announced.<ref name=streeting5>[https://ghostarchive.org/archive/zply0 Rubecela on Twitter (@Rubecela52). Archived.]</ref>}} [[Sinn Féin]] implemented the ban in [[Northern Ireland]] soon after.<ref name="n-ireland1">{{cite news |last=Tighe |first=Mark |date=August 24, 2024|title=Sinn Féin criticised for backing UK puberty blocker ban — as HSE announces review of move | work=Irish Independent| publisher=| url= https://www.independent.ie/irish-news/sinn-fein-criticised-for-backing-uk-puberty-blocker-ban-as-hse-announces-review-of-move/a303206876.html |location= | access-date=}}</ref><ref name="n-ireland2">{{cite news |last=Fox |first=Matt |date=August 22, 2024|title=Puberty blocker ban extended to Northern Ireland | work=[[BBC|BBC News]]| publisher=| url= https://www.bbc.com/news/articles/cwy3l8pnld9o |location= | access-date=}}</ref> The "temporary" ban was extended a second time in November.<ref name="streeting4">{{cite news |last=|first=|date=November 6, 2024 |title=Extension to temporary ban on puberty blockers | work=| publisher=Department of Health and Social Care| url=https://www.gov.uk/government/news/extension-to-temporary-ban-on-puberty-blockers|location= | access-date=}}</ref><ref name="2ndextension-1">{{cite news |last=Hurley |first=Lee |date=November 7, 2024|title=UK puberty blocker ban extended | work=| publisher=| url= https://hleehurley.substack.com/p/uk-puberty-blocker-ban-extended?utm_campaign=post&utm_medium=web |location= | access-date=}}</ref> The ban was made indefinite in December in all regions of the UK.<ref name="permban1">{{cite news |last=Lavietes |first=Matt |date=December 11, 2024|title=Britain bans puberty blockers for transgender minors | work=[[MSNBC|NBC News]]| publisher=| url= https://www.nbcnews.com/nbc-out/out-politics-and-policy/britain-bans-puberty-blockers-transgender-minors-rcna183839 |location= | access-date=}}</ref><ref name="permban2">{{cite news |last=Triggle |first=Nick |date=December 11, 2024|title=Puberty blockers for under-18s banned indefinitely | work=[[BBC|BBC News]]| publisher=| url=https://www.bbc.com/news/articles/cly2z0gx3p5o  |location= | access-date=}}</ref><ref name="permban3">{{cite news |last=|first=|date=December 10, 2024|title=Puberty blockers to be banned indefinitely in NI | work=[[BBC|BBC News]]| publisher=| url=https://www.bbc.com/news/articles/clyxr43e2m7o |location= | access-date=}}</ref><ref name="permban4">{{cite news |last=|first=|date=December 11, 2024|title=Scotland to follow UK under-18 puberty blocker ban | work=[[BBC|BBC News]]| publisher=| url= https://www.bbc.com/news/articles/cdr0xrpzjzko# |location= | access-date=}}</ref> It will be "reviewed" in 2027 following the ([[policy-based evidence making|presumably pre-written]]) findings of a government-run "[[torture|clinical trial]]" that kids seeking GAC in the UK will be funnelled into going forward.<ref name="permban5">{{cite news |last=Barrie|first=Robert|date=December 12, 2024|title=UK indefinitely bans puberty blockers for teenagers due to 'unacceptable risk' | work=Pharmaceutical Technology| publisher=| url= https://www.pharmaceutical-technology.com/news/uk-indefinitely-bans-puberty-blockers-for-teenagers-due-to-unacceptable-risk/?cf-view |location= | access-date=}}</ref> As of September 2024, the Cass Review had reportedly been cited for bans in ten U.S. states and one [[Canada|Canadian]] province, despite this seeming to go beyond even the review's own published recommendations.<ref name="SPWS24"/>{{rp|10}}<ref name="alberta1">{{cite news |last=Skulski |first=Chelan |last2=Romero|first2=Diego |date=April 15, 2024|title=Alberta committed to reviewing treatment of trans youth, Smith says in exclusive interview | work=CTV News| publisher=| url= https://edmonton.ctvnews.ca/alberta-committed-to-reviewing-treatment-of-trans-youth-smith-says-in-exclusive-interview-1.6848209 |location= | access-date=}}</ref>

Blockers remain legal in the UK for the treatment of {{w|precocious puberty}} ({{IdEst}}, [[hypocrisy|they're fine for cis kids]], [[discrimination|but not for trans kids]]).<ref name="precocious">{{cite news |last=Livingston |first=Eve |date=July 17, 2024|title=Puberty blockers: what are they and why are they in the news? | work=The Bureau of Investigative Journalism| publisher=| url= https://www.thebureauinvestigates.com/stories/2024-07-17/puberty-blockers-what-are-they-and-why-are-they-in-the-news/ |location= | access-date=}}</ref><ref name="SPWS24">Ojeda ''et al.'' (September 2024). [https://www.researchgate.net/publication/384324303_Afirmacion_de_genero_y_evidencia_en_torno_al_suicidio_Aportes_para_el_debate_publico "Afirmación de género y evidencia en torno al suicidio: Aportes para el debate público"] ["Gender affirmation and evidence surrounding suicide: Contributions to public debate"]. ''Sexuality Policy Watch'' (in Spanish).</ref>{{rp|6}} In a letter to a Labour constituent, Streeting claimed that suppressing "abnormally high" hormone levels in young children has been "extensively tested" and meets "strict safety guidelines," but that "[[Appeal to nature|stopping the normal surge of hormones]]" at puberty might be bad for nebulous reasons involving "psychological and [[brain]] development."<ref name="streeting6">[https://ghostarchive.org/archive/zqVLA Twitter post by Paul Ilett (@Paul_Ilett). Archived.]</ref> A subsequent FOI request offered no answer as to whether Streeting had examined evidence or consulted experts on the safety of precocious puberty treatment before making these claims.<ref name="streeting5"/> According to an academic paper in the ''Journal of Paediatrics and Child Health'':
{{cquote|The same puberty blockers have been utilised since 1981 for treating central precocious puberty, and their use is now considered safe and effective, with no known severe long-term adverse effects. They have been licensed for central precocious puberty based on relatively short open-label studies with small groups of patients because it was impossible and unethical to perform more robust studies (i.e., randomised controlled trials). Limited evidence exists, for example, on their psychological outcomes in children with central precocious puberty. If we aspire to the same scientific rigour as Cass review then, by the transitive property, we may well consider ceasing the prescription of puberty blockers also in children with precocious puberty. … <br>Puberty blockers have been the standard of care for many years in different countries when applied in well-staffed certified centres with high-quality multi-professional teams, and it is very unusual in the history of medicine that a time-honoured treatment, with a good safety record, even if based on non-randomised trials and experts' opinion, is simply banned, while waiting for better evidence.|||Ludovica Barbi and Gianluca Tornese (2024)<ref name="BaT24">{{Cite journal |last=Barbi |first=Ludovica |last2=Tornese |first2=Gianluca |date=August 17, 2024 |title=The Brexit in adolescent gender dysphoria care? |url=https://onlinelibrary.wiley.com/doi/10.1111/jpc.16651 |journal=Journal of Paediatrics and Child Health |language=en |doi=10.1111/jpc.16651 |issn=1034-4810}}</ref>}}

====NHS-funded puberty blocker trials====
In 2025, it was confirmed that Britain's NHS would fund an attempt at randomized controlled trials (RCTs) for puberty blockers to "provide better evidence" about the treatment. Cass supports the trial, which is called the "Puberty Suppression and Transitional Healthcare with Adaptive Youth Services (PATHWAYS)" trial.<ref name="BBCPathwaysConfirm">(November 2025). [https://www.bbc.com/news/articles/c2k4jg0wkj4o "New puberty blockers trial to begin after UK ban"]. ''BBC News''.</ref><ref name="SMCPathways1">[https://www.sciencemediacentre.org/expert-reaction-to-pathways-trial-of-puberty-suppression-in-young-people-with-gender-incongruence-having-received-all-necessary-regulatory-and-ethics-approval/ "expert reaction to PATHWAYS trial of puberty suppression in young people with gender incongruence having received all necessary regulatory and ethics approval"]. ''Science Media Centre''.</ref> It will be conducted by King's College London, cost £10 million, last two years, and will require participants to undergo about thirteen hours of medical assessments.<ref name="AaronTrials">Aaron Sugg (November 24, 2025). [https://www.attitude.co.uk/news/nhs-puberty-blocker-study-concern-trans-13-hours-assessments-504615/ "NHS puberty blocker trial criticised as young people face 13 hours of assessments and 50 forms"]. ''Attitude''.</ref><ref>[https://fundingawards.nihr.ac.uk/award/NIHR167530 "PATHWAYS: Puberty suppression And Transitional Healthcare with Adaptive Youth Services"]. ''The National Institute for Health and Care Research''.</ref>

Conservative Party leader Kemi Badenoch objected to the trials, as she opposes puberty blockers use in all cases pertaining to gender transitioning, even in research trials.<ref>Aine Fox (November 25, 2025). [https://www.the-independent.com/news/uk/home-news/wes-streeting-kemi-badenoch-health-secretary-nhs-conservative-b2872166.html "Kemi Badenoch calls on Wes Streeting to stop puberty blocker trial"]. ''The Independent''.</ref> TransActual's health director, Chay Brown, likewise objected, calling the trials biased as anti-trans and unethical. Brown noted the apparent association between the trial's deputy chief investigator and the group [[SEGM]].<ref name="AaronTrials"/> Several clinicians and experts question whether such an RCT would in principle be ethical or feasible.<ref name="BaT24"/><ref>{{Cite journal|title=Is puberty delaying treatment 'experimental treatment'?|url=https://pmc.ncbi.nlm.nih.gov/articles/PMC7430465/|journal=International Journal of Transgender Health|date=2020|issn=2689-5277|pmid=33015663|pages=113–121|volume=21|issue=2|doi=10.1080/26895269.2020.1747768|first=Simona|last=Giordano|first2=Søren|last2=Holm}} {{blockquote|In the case of puberty delay with GnRHa it is, however, practically impossible to conduct a RCT, and it might be unethical to try to do it. There are two main practical problems that preclude conducting a RCT.}}</ref><ref name="ScienceAlert90"/> Professor Rod Mitchell states that the trial design cannot truly determine any long-term effects on physical health, and that a longer-term study with the same group of participants would ideally be conducted to study this.<ref name="SMCPathways1"/>

(The "{{sl|Throwing out the majority of research}}" section contains some further discussion about these types of RCTs, and why it's likely infeasible for the attempted RCTs to produce "high quality" evidence under currently proposed designs.)

===Alleged suicide coverup===
Barrister {{wpl|Jolyon Maugham}} revealed in June 2024 that multiple [[whistleblower]]s had come forward with allegations of a "huge increase" in trans youth deaths since ''Bell v Tavistock''.<ref name="maugham1">[https://ghostarchive.org/archive/u8Vlj Twitter thread by Jo Maugham (@JolyonMaugham)]</ref> According to one [[whistleblower]], there were 16 deaths of trans youth on the [[NHS]] waiting list in the three years after ''Bell'', in contrast to only a single death in the seven years before the decision.<ref name="maugham1" /> This whistleblower brought these alarming numbers to the attention of Hilary Cass and a director of the Tavistock clinic.<ref name="maugham1" /> When Maugham contacted Cass about the whistleblower's claims, a representative replied pointing him to a section of the Cass Review that references "deaths of patients," but attributes [[suicide]]s to those with "multiple comorbidities and/or complex backgrounds."<ref name="maugham1" /> A second whistleblower alleged that Tavistock staff who planned to expose the numbers in an open letter were threatened with "disciplinary proceedings and being reported to their regulatory bodies."<ref name="maugham1" />

Maugham's revelations prompted the UK government to hastily commission an "independent review" from University of Manchester [[psychiatry]] professor Louis Appleby.<ref name="appleby1">{{cite news |last=Appleby |first=Louis |date=July 19, 2024|title=Review of suicides and gender dysphoria at the Tavistock and Portman NHS Foundation Trust: independent report | work=| publisher=Department of Health & Social Care| url=
https://www.gov.uk/government/publications/review-of-suicides-and-gender-dysphoria-at-the-tavistock-and-portman-nhs-foundation-trust/review-of-suicides-and-gender-dysphoria-at-the-tavistock-and-portman-nhs-foundation-trust-independent-report|location= | access-date=}}</ref><ref name="appleby2">{{cite news |last= |first=|date=July 20, 2024|title=Puberty blocker curb has not led to suicide rise – reviews | work=BBC News| publisher=| url=
https://www.bbc.com/news/articles/c9x8j5p0992o|location= | access-date=}}</ref>{{efn|Professor Appleby, an expert on suicide prevention,<ref>[https://www.gov.uk/government/people/louis-appleby Professor Louis Appleby] ''Gov.uk''.</ref> allegedly follows {{w|Rosie Duffield}} on Twitter. Duffield is a stridently anti-trans<ref>[https://medium.com/@transylvania/rosie-duffield-is-a-transphobic-bigot-ff40aa248c7a Rosie Duffield is a transphobic bigot.] by Lexi Bowen (Jun 9, 2024) ''Medium''.</ref> Labour MP caught face-palming in response to SNP MP Kirsty Blackman mentioning a trans constituent's suicidal thoughts in a parliamentary speech.<ref>[https://www.thepinknews.com/2023/06/14/trans-people-joanna-cherry-rosie-duffield/ Gender critical MPs condemned for ‘grim’ response to mention of trans suicide in parliament] by Amelia Hansford (Jun 14 2023) ''PinkNews''.</ref> Appleby also reportedly follows several 
"transphobic troll accounts"<ref>[https://archive.is/hlbgz Just out of interest why does the esteemed professor & dismisser of suicide prof appleby follow transphobic troll accounts like this?] by @waslottie (8:50 PM · Jul 19, 2024) ''Twitter'' (archived from 28 Nov 2024 02:44:33 UTC).</ref> with names such as "Unafraid Woman."}} Appleby's review concluded that "the data do not support the claim" of a "large rise in suicide" among Tavistock patients.<ref name="appleby1" /><ref name="appleby2" /> In response, Maugham pointed out that that Appleby's review examined suicides among "current and former {{wpl|Gender Identity Development Service|GIDS}} patients," while the whistleblowers' claims concerned those stuck in waiting-list limbo.<ref name="appleby2" /><ref>[https://archive.is/OGz9F Twitter thread by Jo Maugham (@JolyonMaugham)] with [https://archive.is/tdTM5 associated] [https://archive.is/yrcQy images.] All archived.</ref> Trans people seeking gender-affirming care through the NHS face years-long waitlists.<ref name="waiting1">{{cite news |last=Riedel |first=Samantha |date=August 7, 2024|title=U.K. Trans Youth Wait an Average of Two Years for Gender-Affirming Care | work=Them| publisher=| url=https://www.them.us/story/nhs-trans-youth-waitlist-two-years-gender-affirming-care|location= | access-date=}}</ref><ref name="waiting2">{{cite news |last=Cowan |first=Michael | last2=Cole | first2= Hollie |date=March 20, 2024|title=Transgender patients could face years-long wait for NHS treatment | work=[[BBC|BBC News]]| publisher=| url=https://www.bbc.com/news/uk-68602939e|location= | access-date=}}</ref> In August 2024, a 17-year-old trans man who spent four years on the GIDS waiting list without an appointment told ''[[The Guardian]]'' that trans youth were "being used for political gain and treated as an intellectual exercise, rather than as human beings."<ref name="waiting3">{{cite news |last=Brooks |first=Libby |date=August 15, 2024|title=
'I've had to become my own doctor': trans young people on life after the Cass review | work=[[The Guardian]]| publisher=| url=https://www.theguardian.com/society/article/2024/aug/15/ive-had-to-become-my-own-doctor-trans-young-people-on-life-after-the-cass-review|location= | access-date=}}</ref> Another young trans person who resorted to DIY hormone therapy after waiting five years stated that she "had to become [her] own doctor."<ref name="waiting3" /> The Labour government directed kids "unsure how the ban applies to their circumstances" to a list of crisis hotlines in its August 22 announcement.<ref name="streeting3" /><ref name="crisisletter1">{{cite news |last=|first=|date=May 31, 2024|title=Letter to patients, parents, and guardians | work=| publisher=NHS Arden & Greater East Midlands| url=https://www.ardengemcsu.nhs.uk/media/3979/nhs-england-letter-31052024.pdf|location= | access-date=}}</ref> Caroline Litman filed a FOI request to learn her daughter {{w|Alice Litman|Alice's}} widely-reported suicide was ''not'' included in Appleby's review.<ref name="litman1">[https://archive.is/LtS7T Archived post by Caroline Litman on Bluesky]</ref><ref group="note">{{w|Alice Litman}}, a 20-year-old trans woman from Brighton, took her life in May 2022 after spending 1,023 days on the waiting list without a first appointment. Her death prompted an inquiry in which a [https://www.independent.co.uk/news/uk/family-good-law-project-surrey-royal-college-of-general-practitioners-gps-b2429355.html coroner determined] that languishing on a waiting list for nearly three years "contributed to a decline in her mental health." The coroner concluded that Alice's transition from children's to adult services was "[https://www.bbc.com/news/uk-england-sussex-67100724 non-existent]," remarking that, "it seems to me that shortly after Alice turned 18, she was offered a 'coping strategies' course in a quite frankly half-hearted final offer of some kind of support."</ref> Cass told ''[[News UK#The Times|The Times]]'' in December 2024 that it was "irresponsible for people to shroud-wave" over trans youth suicides.<ref name="cass-suicides1">{{cite news |last=Hayward |first=Eleanor |date=December 13, 2024|title=MPs wrong to claim puberty blockers ban is discrimination, Cass says | work=[[News UK#The Times|The Times]]| publisher=| url=https://archive.is/4jONF|location= | access-date=}}</ref><ref name="hurley2">{{cite news |last=Hurley |first=Lee |date=December 14, 2024|title=Hilary Cass accuses critics of 'shroud-waving' over trans youth harm | work=Trans Writes| publisher=| url=https://transwrites.world/hilary-cass-trans-suicide/|location= | access-date=}}</ref> This merely insults people as "irresponsible" for criticizing the government's policy that resulted in deaths.

In a 2024 survey by researcher Natacha Kennedy, parents of trans youth in the UK reported that their children experienced "sharply declining mental health, increased depression, social isolation, anxiety, stress, self-harm, attempts to avoid school and suicide ideation" following the blocker ban.<ref name="nkennedy1">{{cite journal |last1=Kennedy |first1=Natacha |date=2024 |title=Children of Omelas: Effects of the UK Puberty Blocker Ban |url=https://feministgenderequality.network/wp-content/uploads/2024/10/Children_of_Omelas_Effects_of_the_UK_Pub.pdf?x56530 |journal=white paper |volume= |issue=|pages= |doi= | ISSN=}}</ref> This is consistent with other past research into the impacts of anti-LGBT government policy on mental health.<ref name="JAHSep24"/> Another 2024 study found a 72% increase of suicide attempts among trans and [[non-binary]] youth (TGNB) following the enactment of anti-trans legislation in several U.S. states.<ref name="wilsonlee1">{{cite journal |last1=Lee |first1=Wilson Y. |last2=Hobbs |first2= J. Nicholas |last3=Hobaica |first3= DeChants |last4=Price |first4= Myeshia N. |last5=Nath |first5= Ronita |date=2024 |title=State-level anti-transgender laws increase past-year suicide attempts among transgender and non-binary young people in the USA |url=https://www.nature.com/articles/s41562-024-01979-5.epdf |journal=Nature Human Behaviour |volume= |issue=|pages= |doi=10.1038/s41562-024-01979-5 | ISSN=2397-3374}}</ref> The American study noted "the lack of an observable {{w|Anticipatory anxiety|anticipatory effect}} in the time periods leading up to the enactment of the laws," proposing that this may be due to the long, bureaucratic legislative process "diffus[sing] the effects the bill debates had on the mental health of TGNB young people."<ref name="wilsonlee1" /> Clinicians have also expressed concerns over the impact of anti-trans laws on the treatment of eating disorders (EDs) among trans youth.<ref name="szabo1">{{cite news |last=Szabo |first=Liz |date=December 21, 2024|title=Bans on transgender care for minors may complicate eating disorder treatment | work=[[MSNBC|NBC News]]| publisher=| url=https://www.nbcnews.com/nbc-out/out-health-and-wellness/transgender-care-bans-minors-eating-disorder-treatment-rcna184817|location= | access-date=}}</ref> These young people may fall into "harmful eating behaviors" to "make their bodies conform to a masculine or feminine ideal," with trans boys in particular seeking to end [[menstruation]] or delay its onset through malnutrition.<ref name="szabo1" />

==See also==
*[[American College of Pediatricians]]
*''[[The BMJ]]''
*[[Genspect]]
*[[Littman 2018 ROGD study]]
*[[Precautionary principle]]
*[[SEGM]]
*[[Jesse Singal]]

==External links==
*[https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/s12874-025-02581-7 "Critically Appraising the Cass Report: Methodological Flaws and Unsupported Claims"], BMC Medical Research Methodology
*[https://law.yale.edu/yls-today/news/white-paper-addresses-key-issues-legal-battles-over-gender-affirming-health-care "White Paper Addresses Key Issues in Legal Battles over Gender-Affirming Health Care"], Yale Integrity Project [https://law.yale.edu/sites/default/files/documents/cass-response-7.11.24.pdf (PDF)]
*[https://www.bma.org.uk/bma-media-centre/bma-to-undertake-an-evaluation-of-the-cass-review-on-gender-identity-services-for-children-and-young-people "BMA to undertake an evaluation of the Cass Review on gender identity services for children and young people"], British Medical Association
*[https://www.researchgate.net/publication/384108341_Gender_affirming_care_is_evidence-based_for_transgender_and_gender_diverse_youth Gender Affirming Care Is Evidence Based for Transgender and Gender-Diverse Youth], Journal of Adolescent Health
*[https://www.researchgate.net/publication/384324303_Afirmacion_de_genero_y_evidencia_en_torno_al_suicidio_Aportes_para_el_debate_publico Gender affirmation and evidence surrounding suicide: Contributions to public debate], Sexuality Policy Watch (in Spanish)
*[https://ruthpearce.net/2024/04/16/whats-wrong-with-the-cass-review-a-round-up-of-commentary-and-evidence/ "What's wrong with the Cass Review? A round-up of commentary and evidence"], Dr. Ruth Pearce
*[https://www.tandfonline.com/doi/full/10.1080/26895269.2024.2362304 "Biological and psychosocial evidence in the Cass Review: a critical commentary"], International Journal of Transgender Health
*[https://www.medicalbrief.co.za/cass-review-slammed-by-transgender-youth-associations/ "Cass Review slammed by transgender associations"], MedicalBrief
*[https://www.cbc.ca/news/health/puberty-blockers-review-1.7172920 "What Canadian doctors say about new U.K. review questioning puberty blockers for transgender youth"], CBC News
*[https://fair.org/home/media-boosted-anti-trans-movement-with-credulous-coverage-of-cass-review/ "Media Boosted Anti-Trans Movement With Credulous Coverage of 'Cass Review'"], Fairness & Accuracy In Reporting
*[https://www.theskepticsguide.org/podcasts/episode-995 Episode #995 (news item 3 at 39:54–1:08:10)], [[The Skeptics' Guide to the Universe]]
*[https://archive.ph/ps827 "The U.K.'s Cass Review Badly Fails Trans Children"], [[Scientific American]]
*[https://www.assignedmedia.org/breaking-news/tag/Cass+Report Posts tagged "Cass Report"], at Assigned Media

==Notes==
{{reflist|2|group=note}}

==References==
{{reflist|2|80%}}

[[Category:Ableism]]
[[Category:British politics]]
[[Category:Documents]]
[[Category:Medicine]]
[[Category:Moral panics]]
[[Category:Propaganda]]
[[Category:Transphobia]]
[[Category:United Kingdom]]

Categories: Ableism, British politics, Documents, Medicine, Moral panics, Propaganda, Transphobia, United Kingdom