Jan Bergstra & Laurens Buijs
Amsterdam Gender Theory Research Team
A long-awaited review of transgender care for children and young adults as provided by Britain’s NHS National Health Service was released this week. The conclusions are scathing: diagnostics fall short, treatments lack evidence-base. In particular, hormone treatments and puberty blockers are under heavy fire: “thousands of children abandoned,” headlines The Guardian .
The study was conducted under the direction of respected pediatrician Dr. Hilary Cass (University of York), who worked on it for 3.5 years. She stresses that her research does not recommend ending trans care for young people; she wants it to be improved. The investigation comes after a series of scandals in transgender health care in the UK, after a whistleblower went public in 2020 about abuses at the Tavistock gender clinic.
Read more about transgender health care scandals in the UK and abroad:
Leaked WPATH files show significant doubt among medical professionals about gender transition
Dr. Cass examined the NHS’sGender Identity Development Service (GID) program that treated about 9,000 children with an average age of 14 between 2009 and 2020. The Guide program has since been shut down and replaced with a program that focuses on psychological counseling of the young, without medical-pharmaceutical intervention.
The report recommends that better diagnostics are needed. It points out that there is often a mix of everything among young people struggling with incongruent gender identity. A complex home situation, learning disabilities as well as issues such as autism, ADHD or depression.
Despite the fact that the cause of adolescent gender dysphoria is often complex and there is still much uncertainty about proper treatment, the infamous Tavistock clinic in London and Leeds (now closed) began prescribing many more puberty blockers starting in 2014. According to Dr. Cass, careful evidence-base for this policy is lacking.
Dr. Cass highlights the role of toxic debate and woke’s destructive effect on scandal in British transgender care for young people. She notes that critics on program over the years have been quickly dismissed as transphobic and canned, preventing a healthy academic free debate about the pros and cons of the Guide approach.
The Guardian also spoke with some of the doctors involved in the Guide program. They stress that puberty inhibitors and hormones can certainly be helpful, even in some specific (very small) groups of adolescents, but that diagnostics need to be much better. They also fear a “backlash” against all trans care, threatening to throw the baby out with the bathwater.
Dr. Cass notes in her report that she and her university (University of York) experienced “coordinated opposition” to her research by the NHS. She was denied access to patient health data, despite repeated requests.
The report notes how starting in 2010 there was an explosion in applications to Guide, especially from young girls. This was a remarkable change in trend: traditionally, more boys and men asked for gender transition. Despite the fact that there was every reason to investigate whether this rise was caused by societal hype and whether that calls for a different approach, that did not happen.
Dr. Cass points out the role of the Internet and social media. According to her, young girls have been irresponsibly incited en masse via social media by influencers to adopt non-binary or transgender identities and engage in gender transition. Young people were sometimes even pressured by them to distance themselves from family.
Transgender health care is under great pressure worldwide due to a series of scandals brought forward by whistleblowers beginning in 2020. The Netherlands plays a major role in the international scandal, as our country set an important standard for transgender care worldwide, especially care for transgender youth, starting in the 1990s with the so-called Dutch protocol .
The Dutch protocol is now under fire worldwide, and the Netherlands is rapidly losing its once widely respected position in international transgender care (see also AGTRT-BF66). Incidentally, Amsterdam’s 2020 research does mention the Cass report as being of high quality. This contrasts with the vast majority of other research on gender transition in young people, which Dr. Cass finds downright weak.
Transgender health care is and will continue to be essential, including for young people. Incongruent gender identity is sometimes accompanied by very severe psychological suffering, and for some, gender transition is the only solution. There is still a case for intervention at the beginning of puberty in specific groups of young people. But the diagnostics and evidence-base of care urgently needs to improve, that much is now clear.
Key findings
of the Cass report:
- No good evidence base on either side of the debate (both for and against transgender care for youth), especially lack of long-term data. This is especially true of hormone treatments and adolescent puberty blockers, but there is also little evidence on the effectiveness of things like therapy.
- Transgender care is the subject of a particularly toxic debate. On one side are groups that speak out loud and clear for more and more progressive care for transgender youth, on the other are groups that speak out vehemently against any form of medicalization. The polarization between the groups is so intense that no proper dialogue is possible.
- Starting in 2014, the British NHS increasingly prescribed adolescent puberty blockers, despite lack of evidence.
- As of 2010, the profile drastically changed of individuals presenting to NHS gender clinics: initially, these were primarily adult males (AMAB: assigned male at birth) with a desire to become a woman, meanwhile the vast majority of them (73%) teenage girls (AFAB: assigned female at birth) with a desire to become male or non-binary (what we prefer to call neutral).
- The increase in teenage girls signing up is linked to the use of social media and increasing mental health problems among this group.
- Many young people who present to the NHS with incongruent gender identity also suffer from a variety of other neuro-psychological problems such as depression, anxiety, body dysmorphia, eating disorders, autism spectrum disorders (ASD) or attention deficit hyperactivity disorder (ADHD).
- In some of the young people who present with an incongruent gender identity, the gender dysphoria disappears naturally over the years; in another, it does not.
- Most of the young people had already begun “social transitioning” when they registered with the NHS: in other words, they had already changed their names and pronouns. The report highlights that such transition is profound while no good research exists on whether it is desirable and helpful in the treatment of gender dysphoria and if so how. It is recommended that parents be involved in choosing whether or not to have their child go through a social transition, and that a professional be involved as soon as possible.
- In the future, young people should be better screened for neurodevelopmental problems and mental health. Puberty inhibitors and hormone treatments can no longer be used to “buy time” as proponents have often said until now; they set in motion a permanent transition process in terms of psychosexual development and gender identity development, which, moreover, can be accompanied by serious side effects .