Cass Review and Long-Term Dutch Study on Gender Identity Put Major Dents in Youth Gender-Affirming "Care"

A year ago, I illustrated how the practice of gender-affirming care was not an evidence. The evidence base was weak enough where the United Kingdom's National Health Service (NHS) banned puberty blockers for adolescents earlier this year. Last month, the proponents of youth gender-affirming care took a couple of additional hits to the credibility of their argument. 

The first is the Cass Review, which is a four-year study commissioned by the NHS. Hilary Cass, who is the author of the Cass Review, is a former President of the Royal College of Pediatrics and Child Health, as well as a premier pediatrician in the United Kingdom. What Cass did with the Cass Review was write and release a 400-page report on gender identity services for young people. Just to highlight some findings:

• Many youth referred to gender-identity services are dealing with other issues, whether it is neglect, trauma, or abuse. 
• There is no good evidence on long-term outcomes of interventions to manage gender-related distress. 
• Puberty blockers do not "buy them time to think" or "reduce suicide risk," both of which have been used as justifications for such a practice. Nor did hormone treatment reduce the elevated risk of death by suicide in this population. 
• The rationale for early puberty suppression remains unclear, with weak evidence regarding the impact on gender dysphoria, mental, or psychosocial health. The effect on cognitive and psychosocial development remains unknown. 
• For most young people, a medical pathway will not be the best way to manage their gender-related distress.

That was not the only bombshell dropped in recent weeks. There is also a long-term Dutch study that tracked 2,772 adolescents into early adulthood (Rawee et al., 2024). 11 percent had expressed "gender non-contentedness." This figure dropped to 4 percent by age 24-26. These findings have two implications. One is that questioning one's gender is not uncommon during one's adolescence. The second is that most adolescents get over adulthood and become gender-conforming. The main takeaway is that these results oppose rushing adolescents into gender-affirming care. 

Why do I find this issue so irksome? Because clinical practice was divorced from the clinical evidence base. This was a practice allowed to take place for a decade in the United Kingdom without robust data to support the practice. In the process, children have been harmed and thousands were complicit in that harm. Those who claimed they were helping people with advocacy of such a service were doing nothing of the kind. 

We need to take the politics out of medical practice. I thought this was a lesson that should have been learned from the pandemic when public health officials ignored evidence-based practice, cost-benefit analyses, and simple common sense. However, it looks like there is still work that needs to be done in that arena. I hope that these studies put the global medical community back on the path of recommending practices that have a strong evidence based versus the ones that are simply steeped in political ideology.