Did America Just Get Its Own Cass Review?

HHS's report on youth gender medicine

Gender-affirming care is “evidence-based,” “life-saving,” “medically-necessary” and “safe.” So say activists, advocacy groups, and medical associations that represent the interests of their clinician members. Kids with gender identity issues, and their parents, have heard that the science is settled; that almost half of trans kids will try to take their own lives; and that kids know themselves. Hence: affirmation or death.

Based on such assertions, families must make difficult decisions about whether or not to affirm, and socially and medically transition a child.

How would that decision-making process differ if we had an official government document to sum up not just the state of the evidence, but the many other issues hovering around these interventions? A document that educated the public about the concept of gender identity; the overlap between gender nonconforming children and later homosexuality; the struggle to understand the reality of treatment when it’s couched in vague language like “top surgery” and “gender-affirming hormones?”

What if we had our own version of England’s Cass Review, a nonpartisan report commissioned by the NHS that concluded there is “no good evidence on the long-term outcomes of interventions to manage gender-related distress?” What guidelines would we create, what advice would parents and patients get?

Maybe Americans will finally have a chance to find out, thanks to a stipulation in President Trump’s Executive Order 14187, released on January 28, 2025: “Protecting Children from Chemical and Surgical Mutilation.”

True, Trump’s EO doesn’t read as particularly nonpartisan. But along with asserting that “medical professionals are maiming and sterilizing a growing number of impressionable children under the radical and false claim that adults can change a child’s sex through a series of irreversible medical interventions,” the order required that, within 90 days, “the Secretary of Health and Human Services (HHS) shall publish a review of the existing literature on best practices for promoting the health of children who assert gender dysphoria, rapid-onset gender dysphoria, or other identity-based confusion.” The Secretary—Robert Kennedy, Jr.—should “use all available methods to increase the quality of data” to treat these kids.

Okay, it’s 93 days later, not 90, but today we have that review: “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices.” (Hilary Cass had four years for hers). There’s no MAGA language peppering its pages, though it is also not quite as neutral in tone. I’d call it an anthology of arguments against gender-affirming care, or what they refer to as pediatric medical transition (PMT), in language regular people might be able to process. Or perhaps the world’s longest informed consent form. It could help families ask questions about gender-affirming care they were told never to ask.

As ordered, the document evaluates the research literature. Because health authorities in multiple European countries have already conducted systematic evidence reviews—which evaluate not just the conclusions of studies, but their quality and reliability—the report includes an “umbrella review”: a review of those reviews.

The overall takeaway from reports conducted in Sweden, Finland, England and other countries: the impact of social transition, puberty blockers, cross-sex hormones, and surgeries are “poorly understood.” The certainty of evidence is “very low,” meaning study findings can’t be mapped onto the larger population outside the study, and that the actual outcomes may be quite different from whatever conclusions drawn. When you hear of a study that suggests gender-affirming care improves mental health, its methodology may be so flawed, its data so biased, that those assertions may not be true.

Mostly, what the Review communicates is how little reliable information we have. It is a comprehensive list, to borrow from Donald Rumsfeld, of known unknowns.

The Review makes clear that we don’t know much about the long-term impacts of these interventions on cancer, sexual function, fertility, bone health, and heart health. We don’t know much about harms, making evaluation of risks versus benefits nearly impossible.

The lack of quality evidence chronicled here isn’t news. What’s different about this report is the inclusion of chapters on language, ethics, and therapy—chapters either never written or excised in WPATH’s latest so-called “standards of care.” The posing of questions raised by that low-certainty evidence—questions about what’s actually being treated, issues of informed consent, and the ethics of the offerings of the gender-affirmation industry—that’s what’s new, and certainly what’s been missing from the debate (if we can call the culture war a debate).

Here, for instance, is an interesting tidbit. How do we know if treatments are safe or effective, when the changes they create—the benefits—would be considered harms in any other situation?

That goal of cross-sex hormones and sex trait-modification surgeries is, ostensibly, “to induce changes in the secondary sex characteristics that resemble those typical of the opposite sex.” Testosterone in women, for instance, leads to “facial and body hair, cystic acne, male pattern scalp hair distribution, clitoral growth, changes in musculature, thickening of vocal cords leading to voice deepening, and alterations in fat deposition.” Were a woman taking an antidepressant to improve psychological functioning, these would be considered adverse side-effects. In gender medicine, they are the goal—ostensibly to match a “gender identity,” which the report points out is “A person’s deeply felt, internal, intrinsic sense of their own gender,” and therefore a circular definition.

When harms are interpreted as benefits, how do we measure harm? Well, we don’t. We hear that there are no harms, but mostly because they haven’t been studied, and detransition isn’t considered an adverse effect—though it should be.

There’s much more of interest in the Review, which we’ll discuss in more depth on Informed Dissent this week, but I urge people to read it. Though it’s 409 pages, a lot of that includes citations and the occasional David Foster Wallace-style footnote; it’s not as long to read as you might think. And I’ve been heartened to see some mainstream outlets not flat-out dismissing it. Many of them note that the Review urges leading with therapy, though some of trying to frame that as pushing conversion therapy, and others continue to insist that medical associations—advocacy groups for clinicians—still believe in “gender affirming healthcare for transgender youth.” To me, the use of these phrases show that reporters haven’t digested what the Review is trying to teach us: to scrutinize the idea of “gender affirming care” of “transgender children” and of adolescent sex-changes as healthcare.

It would be foolish to think that this document will convert the unconverted. Commanded by Trump, from a government organization headed by a vaccine-denier, amid the mass dismantling of government funding for science, this isn’t much of a backdrop for claims of impartiality or truth-seeking. Supporters of GAC interpreted Trump’s order as just another partisan battle in the “war on trans kids,” and dismissed this report as biased and “junk science” before it even came out. One medical group has already pronounced it “dangerous.” The authors of the report have chosen to remain anonymous, because they want the focus to remain on their findings, not their politics. I’m aware of their identities and can avow that they are a politically diverse group. And, as Carol Tavris writes in her brilliant book, Mistakes Were Made (But Not by Me)—which everyone should read—“You keep the message separate from the messenger.”

The authorship shouldn’t—it must not—matter, because this report is the closest our country has gotten to our version of the Cass Review, the most comprehensive and prismatic look at what should be a scientific controversy and instead flattened into a culture war.

Yet even the Cass Review fell prey to politicization in polarized America—variably ignored or impugned, unable to sway the staunch supporters of PMT, or lead medical associations and liberal politicians to concede that it required reform. When activists say this is the US Cass Review, they mean it as an insult.

The Review writers weren’t tasked with making recommendations or creating guidelines. Their job was to evaluate the evidence, and they took it upon themselves to paint a picture of the issues obscured behind the facade of a culture war. This report may not satisfy our desire for conclusions about the benefits and harms of gender-affirming care, but it certainly exposes the desperation of some researchers to preserve it no matter what happens.