Commentary
The Latest Attack on the Cass Review Comes Up Short
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Since the publication of the Cass Review, an exhaustive review of gender medical services in the United Kingdom that found “remarkably weak evidence” to support the use of puberty blockers and hormone treatments for gender-distressed children, many who are committed to so-called “gender-affirming care” have attempted to downplay its findings.
The latest salvo comes from an article that argues the Cass Review “transgresses medical law, policy, and practice, which puts it at odds with mainstream U.S. expert guidelines.”
The article, published in The New England Journal of Medicine (NEJM), is titled “The Future of Gender-Affirming Care — A Law and Policy Perspective on the Cass Review,” and is authored by Daniel G. Aaron, M.D., J.D., and Craig Konnoth, J.D.
The scope of the article is limited to procedural critiques. The authors specifically criticize the Cass Review on the grounds that it “lacked peer review, transparency of authorship, and equitable selection of nonauthor contributors.”
Yet these criticisms are misguided, and many of the supporting arguments lack coherence.
One of the article’s central critiques of the Cass Review is that it fails to adequately prevent “antitransgender bias” in “invitations to oversee and participate in the report.”
There is evidence of antitransgender bias in invitations to oversee and participate in the report. At the outset, the Cass Review’s terms of reference for its assurance group (advisory body) stated that it “deliberately does not contain subject matter experts or people with lived experience of gender services.” In other words, GAC experts and GAC patients were generally excluded from roles in overseeing the report. The clinicians interviewed for the report, for their part, are described as “self-selecting,” indicating that Cass and her colleagues did not attempt to filter out people with antitransgender bias. Indeed, according to the Review, a third of health professionals whom the authors chose to interview agreed that “there is no such thing as a trans child.”
This argument is flawed for several reasons.
First, as the cited source in the NEJM article notes, the updated terms of reference for the Cass Review’s assurance group clarify that “members are independent of NHS England and NHS Improvement and of providers of gender dysphoria services, and of any organisation or association that could reasonably be regarded as having a significant interest in the outcome of the Review.” In other words, the purpose of these terms is to prevent people who already perform child sex change procedures from influencing the review’s conclusions.
This makes sense. To include them would be to simply allow in a party with a significant bias – though not the kind of bias with which the authors are so concerned.
The authors’ position seems to be that the Cass Review is remiss for not allowing individuals with obvious conflicts of interest to steer its conclusions. That is hardly a convincing argument.
Second, the authors equate “antitransgender bias” with the position that a child cannot be transgender. This statement is simply not true. A position on whether a child can adequately understand their gender identity in no way implies prejudice against transgender individuals.
And third, if eliminating antitransgender bias meant only permitting healthcare professionals who believe that children can be transgender to provide input for the review, then the review would include only people already predisposed to endorsing so-called “gender-affirming care” for minors. The existence of transgender children presupposes, at the very least, the legitimacy of theoretical procedures to “affirm” that child’s transgender identity.
The authors also criticize the evidentiary standards of the Cass Review as too high, arguing that randomized controlled trials (RCTs) are not the standard by which research supporting so-called “gender-affirming care” should be conducted.
Nowhere in the authors’ critique of the Cass Review’s evidentiary standards is there an argument that the evidence for puberty blockers and cross-sex hormones to treat gender-distressed children is robust.
Rather, the authors point to the fact that many drugs used in pediatric medicine have been “prescribed off-label on the basis of limited evidence.”
This is comparing apples to oranges. Off-label use of, say, acetaminophen and off-label use of Lupron have vastly different potential harms. The off-label use of certain drugs without robust evidence does not necessarily imply that all off-label uses of all drugs without robust evidence should be permitted – or why have pharmaceutical regulatory bodies at all? Puberty blockers, for instance, have potential side effects including diminished bone density, cognitive impairment, and increased risk of infertility.
The off-label use of a drug to treat a serious illness that endangers a child is not comparable to the off-label use of a drug that lacks evidence of its effectiveness and, in fact, is demonstrably dangerous itself. There is no proof that gender transition drugs are the correct treatment for gender dysphoria – the evidence in fact shows the opposite – and referencing the off-label use of other drugs does not change this fact.
Moreover, the central criticism of the use of puberty blockers and cross-sex hormones to treat gender dysphoria isn’t procedural – in the sense that these drugs haven’t checked the right FDA boxes – but substantive: the evidence supporting their efficacy is weak, and they have known harms and unknown long-term risks. Nothing in the NEJM article contests that criticism.
The authors launch another critique at the Cass Review for lack of transparency in authorship, and for not submitting the report’s conclusions to peer review. Indeed, the authors assert that the Cass Review would have violated U.S. federal law requiring peer review for government-funded scientific information that will impact policy decisions.
First, peer review does not guarantee accuracy, nor does its absence imply inaccuracy: as Do No Harm has previously revealed, many of the peer-reviewed studies used to support child sex change interventions on minors are themselves rife with methodological flaws. And, as we’ve seen with the NEJM itself, too often, peer review can be an instrument of ideological enforcement.
Second, the authors’ apparent implication that a review published in the U.K. might possibly fail to comply with U.S. regulatory standards somehow calls its conclusions into question is absurd.
And finally, the authors assert that the Cass Review serves to help enforce the “gender binary,” and that “similar calls for higher standards are not applied to cisgender young people receiving gender-affirming care.”
This is a simple category error; it’s misleading to equate treatments aimed at ensuring proper hormonal development with “gender-affirming care.”
Boys who have decreased testosterone, for example, may need hormone treatments for proper bone and muscle development. It would be incorrect to dismiss the purpose of this treatment as an effort to affirm their maleness.
Addressing the harms associated with improper development is conceptually different from a child who wishes to change their appearance to match the opposite sex or appear more androgynous.
All in all, the authors rely on these faulty premises to lodge their procedural complaints while hurling accusations of antitransgender bias.
And that’s not very convincing.