Five initial thoughts on the Cass Review

Years in the making, the Cass Review chaired by U.K.-based pediatrician Dr. Hilary Cass was released in April 2024. During the time since it was commissioned in 2020, much seems to have happened. Various restrictions on medical care have already been placed in certain jurisdictions around the world, typically by politicians and government agencies. Even before the report was released, there have been bans on the prescription of puberty-suppressing hormones outside of clinical research protocols. Quoting a recent CBC News article, “That's a move away from the standard of care supported by many international medical bodies, including the Canadian Pediatric Society (CPS), the American Academy of Pediatrics and World Professional Association for Transgender Health.”One can try to wade through this report, or not. The summary statement making headlines is that a systematic review of evidence has found “a lack of high-quality research” that puberty blockers can help young people with gender dysphoria. So here are my initial thoughts about that and the report in general: We don’t need the Cass Report to tell us that the system is brokenThe report bemoans the long waiting lists, the lack of broader mental health provisions, the lack of awareness and support for youth on the autism spectrum, etc. Apparently, the wait for initial consultation for gender dysphoria and potential medical transition in the U.K. can be as long as five years. What has not been well publicized is that while the barriers/bans increase in the NHS, private clinics are managing the health of transgender folks who can afford it. We don’t need the Cass Report to tell us that we need to continue to do researchIf randomized controlled trials (RCTs) are the gold standard for medical research, we may never be able to achieve this in transgender youth research. For example, it would take less than a few months to easily know if you were on placebo or a puberty blocker. These medications stop the progression of pubertal changes within weeks; they are exceedingly efficient and effective. It is sometimes impossible to do RCT on pregnant patients, yet we still treat them with the best standard of care that we have based on the best evidence and clinical experience. Trans healthcare providers welcome research findings and encourage more research of the highest quality. And while we are waiting for this research, we will continue to provide the best possible care, using the best standards of care and guidelines we have, based on the best medical evidence we have to work with. This is what we are doing right now in Canada. I can’t speak for other countries and jurisdictions around the world who might have a far different reality than us. The real dilemma is . . . Doing nothing can be doing harm The unfortunate reality is that the Cass review might have the opposite effect from what it actually states. Trans youth may not get any medical care at all. I don’t believe this was the intent of this review or the wish of Dr. Cass. If a patient must be enrolled in a research protocol to access any care at all (including counselling and mental health services) this could be damning if the waiting lists are years. The most controversial issue continues to be around puberty blockers (medication which pediatricians have used for decades for precocious puberty without any outcry from . . . anyone actually). Not all trans youth need puberty blockers. For those who don’t work in this clinical area, it might be surprising to know that their use is rather limited, very specific and generally short-lived. There are standards of care for their use and the side-effects are known and usually managed appropriately. When used appropriately, they are considered fully reversible therapies. Again, we have been using them quite aggressively for decades; the medical science is not “new.”Is the Cass Review biased? The report would have us believe that all clinicians want the best for their young patients but have been let down by a lack of evidence. And this, we must all cease and desist, at least until age 25 when the brain is fully mature or we have much better evidence-based medicine. Dr. Cass has been dubbed the “voice of sanity” as she welcomes an “unhurried, holistic, therapeutic, safe and effective” approach. The international LGBTQ+ and transgender community has already exploded with the assertion that the report was commissioned by an anti-trans/trans-phobic government and is thus inherently flawed from the start. They emphasize that Dr. Cass included and excluded similar studies subjectively based on outcome rather than design. They also note that giving this report a platform will provide the ultra-right wing “more ammunition” when findings are magnified and taken out of context. Even if this medical review has attempted to be balanced and comprehensive, trans youth will be caught in the cross-fire once again when any seemingly negative statement is further politicized by states, provinces and countries hungry for “evidence” to support their polarized position. I already hear my own Premier quoting this review as ‘medical proof’ to justify upcoming Alberta legislation. The answer searching for a problem now ‘proven’ by this review. Clinicians know what they see The oddest part of all of this for me, personally, is the vitriol behind the attacks on the medical care of trans youth. I don’t often use puberty blockers, but when I do they can be life changing and perhaps even life-saving. This is not a perfect science, but I see improvements in anxiety and mood and general mental and physical health in the vast majority of patients. This is my personal clinical observation over two decades. I know what I see. This observation is supported by the clinical evidence we do have available to us now.There is so much more that could be said. Our Canadian approach to the medical management of transgender and gender diverse youth is much more moderate than other countries in the world. The Cass review showcases all the struggles with the U.K. and the NHS while attempting to review the qualitative and quantitative scientific data that we have. So, did they succeed? How much harm may come from this publication and what will he the broader ramifications for all trans youth? Dr. Ted Jablonski is a performing artist and writer who has retired his family practice to focus on sexual medicine and transgender health in Southern Alberta with two feet still on the front-line trenches of acute primary care.

Five initial thoughts on the Cass Review

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